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1.

Impaired gas exchanged

Abnormal ABGs/arterial pH (Compensated Respiratory Alkalosis) Abnormal breathing & using of accessory muscle(25 cpm) Dyspnea Restlessness; Irritability Tachycardia After 30 mins. to 1 hour of nursing intervention the patient will demonstrate improved ventilation and adequate oxygenation of tissues by ABGs levels within normal limits and absence of symptoms of respiratory distress

Assess for restlessness and changes in level of consciousness Assess for presence of dyspnea and tachycardia Monitor lung sounds Monitor oxygen saturation through pulse oximeter or ABGs as necessary Teach patient in frequent position change and deepbreathing/coughing exercises Maintain adequate I/O for mobilization of secretions, but avoid fluid overload Administer O2 as ordered Administer medication as indicated

After 30 mins to 1hour of nursing intervention the patient demonstrates improved ventilation and adequate oxygenation of tissues by ABGs levels within normal limits and absence of symptoms of respiratory distress and all intervention is subjected for continuity until full recovery of the patient

2. Ineffective breathing pattern

Dyspneic: RR= 25 cpm shallow breathing pattern Use of accessory muscle upon breathing

After 1 hour of nursing intervention the patient breathing pattern will be normalized and maintained as evidenced by normal respiratory rate and pattern

Asses RR and depth by listening to lung sounds saturation via pulse oximeter Assess response to increase level of activities Assess skin color and oxygen positioning the patient in high-fowlers position as indicated *oxygen therapy administration

After 1 hour of nursing intervention the patient breathing pattern normalized and maintained as evidenced by respiratory rate and pattern of 19 cpm, but every intervention is subjected for continuation until full recovery of the patient

3. Ineffective tissue perfusion related to decrease in hemoglobin for oxygen

Low hemoglobin count = 92.0 Pale skin Delayed capillary refill Dyspneic Weak pulse in lower extremities

After 1 day of nursing intervention the patient must demonstrate increased in perfusion

Identify changes related to systemic and/or peripheral alterations in circulation Investigate reports of chest pain/ angina note precipitating factors, changes in characteristic of pain episodes Evaluate for signs of infection especially when immune system is compromised Administer medication as prescribed

After 1 day of nursing intervention the patient demonstrate increased in perfusion the same time when decreased cardiac output is relieved but some interventions is subjected for continuity to promote the intensity of care for full recovery

4. Risk for aspiration related to depressed gag reflex

Cannot tolerate solid foods Weak gag reflex

After 30 minutes of nursing intervention the patient were able to experience no aspiration as evidenced by noiseless respiration.

Assess clients ability to swallow and strength of gag reflex Elevate client to highest or best possible position for eating and drinking Provide a rest period prior to feeding time Minimize use of sedative/ hypnotics whenever possible Provide health teaching about the effect of aspiration on the lungs

After 30 minutes of nursing intervention the patient was able to response to intervention and action performed. experience no aspiration as evidenced by noiseless respiration.

5. Altered Sensory Perception

s/ss: Changes in usual response to stimuli Confusion forgetfulness

Independent: Asses degree of sensory or perceptual impairment Maintain a reality- oriented relationship and environment Provide quiet, non distracting environment when indicated Provide simple outing that provide pleasurable sensory stimuli that reduce suspiciousness Promote balanced physiologic functions using colourful, arm dancing with music

After 8 hours of nursing intervention the client was able to demonstrate improved/ appropriate response to stimuli and control factors that contribute to alternatives in perceptual abilities

6. Constipation related to insufficient physical activity

Immobility Low oral fluid intake Low fiber diet

After 1 hour of nursing intervention the patient must establish/ regain normal of bowel functioning.

Note color, odor, consistency, amount and frequency of stool Auscultate abdomen for presence, location and characteristics of bowel sounds. Instruct a diet of balanced fiber and bulk and fiber supplements Promote adequate fluid intake, including high fiber, fruit juices, suggest drinking warm, stimulating fluids. Administer stool softeners, mild stimulants as ordered Provide sitz bath after stools for soothing effect to rectal area

After 1 hour of nursing intervention the patient was able to establish normal of bowel functioning.

7. Self care deficit related to physical limitations

Impraired ability to perform ADLs Aging

After 8 hours of nursing intervention the client must performs self care activities within level of own ability. Identify and uses personal /community resources that can provide resistence.

Independent: Identify hygienic needs and provide assistance as needed with care of hair/ nails/ skin and brushing teeth Be attentive to non verbal physiologic symptoms. Be alert of underlying meaning of verbal statements Supervise but allow as much autonomy as possible. Assist with neat dressing provide with colourful clothes

After 8 hours of nursing intervention the client performs self care activities within level of own ability. Identify and uses personal /community resources that can provide resistence.