Вы находитесь на странице: 1из 2


Nursing Diagnosis/ Cues Justification

Ineffective breathing pattern related to This has been the prioritized problem because
decreased lung expansion breathing pattern is important when it comes to
ranking of problems. The sooner this problem
Objective: gets resolved the lesser the complications like
• The respiratory rate is 25 the patient respiratory acidosis that could lead to a crisis.
seems to be in distress.
• Dyspnea and orthopnea noted
• Alteration in depth of breathing
• Nasal flaring noted
• Upon the test of lung excursion the patient
the excursion wasn’t full
• The patient was apprehensive

• The patient stated “medyo nahihirapan
akong huminga, lalong lalo na pag
nakahiga ako”.
• He also added “nag-aalala na ko tingin
hindi na to normal”

Acute pain related to presence of tubes and This has to be the second prioritized problem
drains next to breathing pattern because pain can
affect the treatment and cooperation of the
Objective: patient it can also adhere his difficulty of
• Guarding behavior, protective gestures, breathing due to panic. It also limits his
positioning to avoid pain movements as stated by the client, thus
• Facial mask of pain slowing down his recovery.

• The patient mentioned “hindi ako
makagalaw kasi masakit yung
pinapasukan ng tubo ko”

• The patient rated the pain as 10 in the
scale of 1-10 where 10 it the highest and 1
is the lowest.

Impaired physical mobility related to The patient’s inability to move could slow down
discomfort at surgical site his recovery. It could also cause some
problems like pneumonia and muscle atrophy.
• Inability to move or change position when
lying in bed
• Needs assistance when sitting down
• Demonstrates guarding behavior at
surgical site
• The patient verbalized “hindi ako
makagalaw kasi masakit yung
pinapasukan ng tubo ko”
• He also added “natatakot din ako
matanggal yung tubo kaya ayoko gumalaw

Risk for infection related to invasive The fact that the patient has incision site would
procedure make him more vulnerable in developing
infection directly to his systemic circulation and
Objective: in his thorax and lungs.
• Chest tube attached to the patient.