High Risk for infection r/t knowledge deficit: illness,

information misinterpretation
Subjective: "Na-admit ta adda kanu infection ditoy
reproductive na."
Objective: not using of personal protective equipment
Planning
Short Term Goal: will able to participate in learning process
Long Term Goal: Demonstrate lifestyle changes
Assessment
1. Assess client's knowledge about the disease (simplify
explanation on client)
2. Determine clients learning style (i.e. visual aids) (to
facilitate learning or recall)
3. Explain the disease process (s/s, causes) (increase
knowledge and reduce anxiety)
4. Discuss the uses of medications
5. Provide calm & quiet environment (to promote relaxation)
6. Initiated the ff.: use of PPE (protect and/or avoid, minimize
exposure to other pathogens)
:increase intake of nutritious foods (promote wellness
:increase intake of food rich in vit C (to boost immunity)
:exercise and have adequate rest periods (to regain strength)

Risk for Deficient fluid volume r/t excessive lossess

through normal route
Subjective: "Nagsarsarwa ak ken nagburis ak, nabanog ti
riknak."
Objective: fatigue, weakness, sunken eye balls, skin non
resilient
Interventions
Establish rapport (gain pts' trust)
Monitor and record v/s (obtain baseline data)
Assessed for skin resiliency (note for any signs of dehydration)
Made self available by staying at bedside (provide timely
support)
Positioned on bed comfortably
Fixed linens and keep clothes clean and dry (to provide comfort
& keep pt warm)
Encourage the ff.
:increase fluid intake up to 3L per day (prevent dehydration &
electrolyte imbalance)
:eat nutritious foods (to regain strength)
:bed rest
:verbalize feelings and concerns
Administer medications prescribed (such as probiotics, to
promote growth of normal flora)

Ineffective Breathing pattern r/t decreased lung

expansion (accumulation of air/liquid)
-dyspnea
-tachypnea
-respiratory depth changes
-use of accessory muscles
-impaired development of the chest
-cyanosis
-abnormal blood gas analysis
Goal: effective breathing pattern
Outcomes: showed normal breathing pattern / effective w/
normal blood gas analysis free cyanosis and signs of hypoxia
symptoms
Nursing interventions
Identify the etiology or trigger factor - evaluation of respiratory
function (rapid breathing, cyanosis, changes in v/s)
Auscultation of breath sounds
Note the position of the trachea and chest dev'p, review
fremitus
Maintain a comfortable position, usually HOB elevated
Give O2 via nasal cannula/mask
When the cheat tube is installed:
Check the vacuum container, liquid limit
Observe air bubbles on bottle container
Hose clamp on the bottom of the drainage in the event of
leak
Keep an eye on the 'ebb' and flow of water reservoir
Note the character/number of chest tube drainage.

Ineffective airway clearance

D> Productive cough, difficulty of breathing w/ crackles upon
auscultation, use of accessory muscles
A> ACHS, monitored respirations and auscultated breath
sounds; positioned to High Fowler's to promote lung expansion
& airway clearance; bronchial tapping done; offered warm water
to liquefy thick secretions
R> Able to breathe w/o difficulty, decreased in coughing
episodes
Elevated Blood Pressure
D> Blood pressure taken as ____mmHg
A> Assessed current health status; monitored BP, medications
given; instructed to report signs of high BP such as dizziness,
nape pain, and headache for prompt intervention, encouraged
to eat fruits and vegetables and to avoid coffee and chocolate,
to avoid sodium products such as canned foods and instant
noodles and fatty foods like deep fried meat (DASH diet low fat
low salt high fruits)
R> BP taken as ____mmHg
F: Venoclysis
D: Above IVF dislodged and removed
A: Above IVF of D5LRS 1L x 8 hours inserted aseptically on
right hand by NOD and regulated accordingly
R: IVF infusing well

Rest and Sleep

D> Restlessness, appears weak, lethargic
A> Assessed current health status; assisted to position
comfort; reiterated importance of houring adequate rest
periods; minimized controllable noise for comfortable sleep;
facilitated on deep breathing exercises and relaxation
techniques conducive to sleep, listening of music
R> Able to have adequate rest and sleep at least 5 hours w/n
the shift

Nutrition: imbalance less than body requirements

>receiving statement
D> "Damdama ak nga mangan", lack of interest in foods, eats
25% of food served
A> Assessed current health status, evaluated total daily food
intake; instructed on small frequent feeding diet; reiterated
importance of well balanced and encourage to eat nutritious
foods for health promotion; made self available for any possible
concerns
R> Able to consume 75% of food served

Deficient Diversional Activity

D> Disinterest on moving or doing exercises, inattentiveness,
avoids eye contact
A> Noted impact of disability/illness in lifestyle to provide
comparative baseline for assessments and interventions;
made self available for any possible concerns; reiterated
importance of participating in activities like morning exercises
to prevent from muscle fatigue and immobility; provide a
clean and comfortable environment to promote comfort and
increase desire to participate; encouraged to verbalize
feelings and concerns to lessen burden; encouraged on
diversional activities such as reading magazines, listening to
music and encouraged on deep breathing exercises to
promote relaxation.
R> Able to participate actively on any given activities.

Infection control
D> Fixator on right leg, swelling on the right foot
A> Observed aseptic technique during interventions, reiterated
the importance of keeping the fixator clean and dry, encouraged
the ff.: proper hand washing before and after handling things,
intake of Vit C rich foods such as lemon, oranges, and other
citrus foods to boost immune system, and protein rich foods
such as eggs and meat to promote wound healing, advised to
report untoward signs such as foul smell and yellowish
discharges
R> Enumerated ways of keeping fixator clean and dry, no signs
of complication or infection

Fatigue
D> "Agkakapsut ak; kasla awan pigpigsak", appears weak,
needs minimal assistance in doings ADL's
A> Assessed environmental factors contributing to fatigue,
assisted with self care needs, planned interventions to allow
adequate rest periods, promoted overall health measures
such as adequate fluid intake; instructed to limit activities that
requires excessive use of energy; encouraged intake of
nutritious foods, high sugar foods and beverages, verbalize
feelings and concerns, regular light exercise as tolerated
R> Improved sense of energy after rendering interventions

Risk for fluid volume deficit (Hypovolemia)

S/s: acute weight loss, decreased skin turgor, oliguria,
concentrated urine, orthosthatic HPN, fatigue, tachycardia,
hyperthermia, polidipsia, delayed caplliary refill, decreased
CVP, cold, pale and clammy skin, anorexic, nauseous, muscle
cramps, dry mucosa membranes
A> Monitor v/s, skin turgor, capilliary refill, weight, and hourly I
and O, check for diarrhea, vomiting and excessive urination
(polyuria) - may cause further fluid loss; check ___ for
concentration, WOF: decreased cerebral perfusion, decreased
perioheral perfusion, low CVP
Med mgn't: correction of factors, fever and diarrhea, increase
oral intake, iv therapy,

Nausea related to anesthetic

D: States she's nauseated. Vomited 100ml clear fluid at 2255
A: Given Compazine 1mg IV at 2300.
R: Reports no further nausea at 2335. No further vomiting.

Ineffective breathing pattern r/t decreased lung volume

capacity as evidence by tachypnea; presence of crackles
on both lung

Acute pain related to surgical incision

D: Reports pain as 7/10, grimaces and groans with
movement BP 154/88. Had received PO analgesic at 2200.
A: Given morphine 1mg IV at 2335. Repositioned on left
side.
R: Reports pain as 1/10 at 2355. BP 138/82.

fields and dyspnea

Subjective: dyspnea
Objective: the pt manifested the ff.:
Tachypnea
Presence of crackles on both lung fields upon auscultation
Use of accessory muscles

Risk for infection related to incision sites

D: Incision site in front of left ear extending down and around
the ear and into neck14 cm in length--without dressing.
Jackson-Pratt drain in left neck below ear secured in place
with suture.
A: Assess site and emptied drain. Taught patient S&S of
infection.
R: No swelling or bleeding; bruising below left ear noted. JP
drained 20mL bloody drainage. States understanding of
teaching.
Delayed surgical recovery
D: C/O dizziness after trying to get OOB to use the bathroom.
A: Assisted patient back in bed and with use of bedpan by
CNA. Taught how to dangle legs and get OOB slowly. Taught
coughing and deep breathing exercises, turning in bed, and
use of anti-embolism stockings.
R: Voided 200mL in bedpan. Did cough and deep breathing
appropriately. Lungs clear bilaterally. Anti-embolism stockings
on.

Rr of 28
Cyanosis
Orthopnea
Diaphoresis
Planning: short term: after three hours of nursing interventions
the pt will demonstrate appropriate coping behaviors and
methods to improve breathing pattern.
Long term: after 1 to 2 days of nursing interventions the pt
would be able to apply techniques that would improve breathing
pattern and be free from signs and symptoms af respiratory
distress
Nursing interventions:
established rapport; monitor and record v/s
Assessed breath sounds, rr, depth, and rhythm
Elevate head of the pt
Provide relaxing environment
Administer supplemental O2 as ordered
Assist client in the use of relaxation technique
Administer prescribed medications as ordered: maximize
respiratory effort w/ good posture and effective use of accessory
muscle.