ASSESSMENT Subjective: Nahihirapan ako huminga, may plema amg ubo ko as claimed.

DIAGNOSIS Ineffective airway clearance related to increased mucus production as manifested by crackles upon auscultation.

PLANNING y After 4 hours of nursing intervention, the patient will be able to demonstrate behaviors to improve airway clearance e.g. coughing and expectorate secretions.

INTERVENTION y Assist patient to assume position of comfort. Elevate head of the bed. Encouraged patient to lean on overbed, table or sit on the edge of the bed. Auscultate breath sounds and assessair movrement. Encouraged or assist client with abdominal or pursed lip breathing exercises. Instruct the client to increase fluid intake within level of cardiac tolerance. Provuide warm liquids. Recommend intake of fluids between instead y

RATIONALE Elevate head of the bed to facilitate respiratory function by use of gravity.

EVALUATION y Goal partially unmet. After 4 hours of nursing intervention, the patient will not able to demonstrate behaviors to improve airway clearance e.g. coughing and expectorate secretions.

Objective: y With crackles upon auscultation. Presence of productive cough. With use of accessory muscles. Respiratory rate above noramal range of 34 breaths per minute.

To ascertain status and note progress.

Provides client with some means to cope or control dyspnea and reduce air trapping.

Hydration helps decrease viscosity of secretions. Facilitating expectoration using warm liquids may decrease bronchospasm. Fliuds during meals can increase gastric

during meals.

distention and poressure on the diaphragm.

Keep enviromental pollution to a distress e.g. dust, smoke, feather pillows, according to individual situation. Observe characteristics of cough, like persistent or hacking or moist. Assist with measure to improve effectiveness of cough effort. Administer bronchodilators if prescribed.

Precipitation of allergic type on inspiratory reactions that can trigger on exarcebate onset of acutec episode.

Coughing is the most effective in an upright position or head down position after chest percussion.

Broncxhodilators relieve bronchospasm by altering smooth muscles tone and reduce airway obstruction by allowing oxygen

distribution throughout the lungs and improving alveolar ventilation.

ASSESSMENT

DIAGNOSIS Impaired gas exchange related to alveolar capillary changes and ventilation perfusion imbalance.

PLANNING y After 4 hours of nursing intervention the client would be able to maintain clear lung felds and remain free of signs of respiratory distress.

INTERVENTION y Administered supplemental oxygen judiciously , using approriate delivery method. y

RATIONALE Use to correct or prevent worsening of hypoxemia, improved survival and quality life. Supplemental oxygen can be provided by excerbations only or as a long term therapy.

EVALUATION y Goal unmet. After 4 hours of nursing intervention the client would be able to maintain clear lung felds and remain free of signs of respiratory distress

Objective: y Tachypneic with respiratory rate of 34 breaths per minute With oxygen inhalation via nasal cannula at 2-3 liters per minute. With use of accessory muscles upon breathing.

Monitor vital signs and cardiac rhythm.

Tachycardia, dysrthmias, and changes in blood. Pressure can affect of systemic hypoxemia and cardiac function. Useful in evaluating the degree or respiratory distress.

y y With crackles upon auscultation. Pale in appearance y

Assess of respiratory rate, depth, and note use of accessory muscles and pursed lip breathing. Position client in semi-fowlers position.

Research indicate that 45 degree position facilitates breathing and

reduces the risks of pneumonia. y Auscultate breath sounds noting the areas or decrease airflow and adventitious sounds. y Breathsounds may be faint because of decrease airflow or areas considilation. Presence of wheezes may indicate bronchospasm or retained secretions. Changes in clients mental status can be an early sign of impaired gas exchange. Weight loss in a client with COPD has a negative effect on the course of the disease , resulting in a loss of muscle mass and in the respiratory muscles which can lead to respiratory failure.

Monitor clients behavior and mental status for the onset restlessness.

Assess nutritional status including serum albumin level and body maxss index.

ASSESSMENT Subjective: hirap ako sa pagtulog dahil sa hirap kong paghinga as claimed. Objective: y Use of accessory muscles in breathing Presence of productive cough With crackles upon auscultation Tachpneic

DIAGNOSIS Ineffective breathing pattern related to chronic airflow limitation as evidenced by use of accessory muscles in breathing and respiratory of 34 breaths per minute.

PLANNING y After 4 hours of nursing intervention the patient will be able to demonstrate an effective breathing pattern.

INTERVENTION y Place patient in high fowlers position y

RATIONALE Positioning the patient in high fowlers position helps breathe normally because the lungs expands much better. Proper ventilation can help the patient to breathe properly decrease difficulty in gasping air. A normal respiratory rate an adult without dyspnea is 12-16. With secretions in the airway the respiratory rate will increase. This technique can help increase sputum clearance and decrease cough spasm. Controlled coughing uses diaphragmatic muscles, making the cough more forceful and effect

EVALUATION y Goal partially unmet. After 4 hours nursing intervention the patient wasnt able to demonstrate an effective breathing pattern.

Provide proper ventilation

Monitor the respiratory rate, depth, and effort every two hours or as necessary.

y y

y Respiratory rate above normal range 34 breaths per minnute.

Discuss and teach the patient the importance of performing coughing and deep breathing exercise.

ASSESSMENT Subjective : Paputol-putol ang tulog ko mayat maya ay may pumapasok as claimed. Objective: y Presence of eye bags Weakness and restlessness Yawning Dark circle around the eyes

DIAGNOSIS Disturbed sleeping pattern related to interruptions for therapeutics, monitoring and other generated awakening and excessive stimulation (noise, lighting).

PLANNING y After 6 hours of nursing intervention the patient will achieve optimal amount of sleep as evidenced by verbalization of feeling rested.

INTERVENTION y Assess the sleep pattern disturbances that are associated with the enviroment. Observe and obtain feedbacks regarding of the unusual sleeping pattern, bed time routine and the usual number of hours of sleep and rest. Do as much as possible wtihout waking up the client and do as much as possible while the client is still awake. Explain necessity of disturbances for monitoring vital signs and care hospitalized. y

RATIONALE High percentage of sleep disturbances can affect the recovery of the patient.

EVALUATION y Goal unmet after 6 hours of nursing intervention the patient wasnt able to improve sleeping pattern.

To determine usual sleeping pattern and to compare if there are any improvements on the sleeping pattern of the patient.

y y

To aviod disturbances during sleep and to also maximize the slee and rest of the client. For the client tp have an understanding of the importance of care being done to him and minimize the complaints

ASSESSMENT Objective: y Increase in laboratory results such as,BUN createnine and uric acid. Pale in appearance Increased urine specific gravity

DIAGNOSIS

PALNNING Short term: After 4 hours of nursing intervention the patient will be able to maintain a normal specific gravity. Long term: After 1 day of nursing intervention the patient will be able to identify risk factors that exacerbate decrease tissue perfussion and will modify lifestyle appropriately.

INTERVENTION y Monitor and document intake and output every hour until output exceeds 30ml/hour, then every 2-4 hours. y

RATIONALE If patient has no history of renal disease, urine output is a good indicator of tissue perfussion. Decreased or absent of urine output usually indicates poor renal perfussion Concentrated urine may indicate poor kidey function and dehydration. Dependent edema may indicate a lakc of kidney function. To notes deviation from normal. Rising levels may indicate decreased kidney function.

EVALUATION Short term: Goal unmet.After 4 hours of nursing intervention the patient will be able to maintain a normal specific gravity. Long term: Goal unmet.After 1 day of nursing intervention the patient will be able to identify risk factors that exacerbate decrease tissue perfussion and will modify lifestyle appropriately.

Altered tissue renal perfussion related to glomerular malfunction as evidenced by increased laboratory results such as BUN, createnine, and urine specific gravity.

Document urine color, and characteristic. Report changes. Assess for dependent edema

Observe voiding patterns. Monitor urine specific gravity and serum electrolytes, BUN nad createnine levls. Monitor hemodynamics status and vital signs. Notify

Increased from baseline may indicate fluid overload caused by

physicians if changes. y Allow for frequent rest periods. Refer patient to a dietitian for a special diet for renal impairment. y

lack of kidney fuction. To enable patient to nconserved energy.

To help patient avoid foods that increased demands on the kidneys.

ASSESSMENT

DIAGNOSIS Risk for infection related to external factors.

PLANNING After 4 hours of nursing intervention the patients fluid and protein intake remaina at specifis level.

INTERVENTION y Monitor WBC count as ordered. Report eleavtion or depressions.

RATIONALE y Elevated total WBC counts indicate infections. Markedly decreased WBC count may indicate decreased production resulting from extreme debilitation on severe lack of vitamins and amino acids. Hand washing prevents spread of pathogens to other objects or foods.

EVALUATION Goel unmet.After 4 hours of nursing intervention the patients fluid and protein intake remaina at specifis level.

Objective: y Increase in laboratory results such as, WBC,and urine spefic gravity. y Weak and Pale in appearance Tachpneic

Help patient wash hands before and after using bathroom, bed pan or urinal. Offer oral hygiene to patient every 4 hours.

To prevent colinization of bacteria and reduced risk of descending infection. Convinient disposal encourages expactorations, reduces spread of infection. This prevents drying and irritation of respiratory mucosa,

Provide tissues and disposal bags fpr expectorated sputum.

Use of sterile water for humidification or

nebeulization

impaired ciliary action, and thickening of secretions within respiratory tract. y To help thin mucus secretions.

Encouraged fluyid intake of 3,000 to 4,000 ml daily, unless contraindicated. Ensure adequate nutritional intake. Offer high-protein supplements unless contraindicated. Teach patient that about: good handwashing technique, factors that increased infection of sign and symptoms.

To help stabilized weight, muscle tone and mass, and aids wound healing.

These measure allow patient to participate care and help patient modify lifestyle to maintain optimum helath level.