CUES/DATA

Subjective: Isa talaga sa malaking pagbabago sakin ay yung madali nakong mapagod at hingalin, di na ko makapag-side car at makagawa ng ilang bagay. as verbalized by the client. Objective: - Increased heart rate and respiratory rate response to minimal activity. - Exertional discomfort

NURSING DIAGNOSIS
Activity intolerance related to inadequate oxygen supply, as evidenced by easy fatigability

RATIONALE
- This nursing diagnosis is not life threatening and doesnt need immediate attention, however, it can affect the bodys normal functioning. (Fundamentals of Nursing 7th edition by Kozier et al. p. 1068) -Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. Activity intolerance may also be related to emotional states such as depression or lack of confidence to exert one's self.

GOALS and OBJECTIVES

After 30 minutes of intervention, 1. The patient will maintain activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue. 2. Patient will verbalize and use energyconservation techniques.

INTERVENTIONS
Independent 1. Determine patient's perception of causes of fatigue or activity intolerance. These may be temporary or permanent, physical or psychological. 2. Establish guidelines and goals of activity with the patient and caregiver. (Avoid any kind of heavy work) 3. Encourage adequate rest periods, especially before meals, exercise sessions, and ambulation.

RATIONALE
Assessment guides treatment.

EVALUATION
The goals and objectives have been partially met as evidenced by: 1. The patient still experienced shortness of breath during activities. 2. Patient verbalized and used energyconservation techniques.

Motivation is enhanced if the patient participates in goal setting. Rest between activities provides time for energy conservation and recovery. Heart rate recovery following activity is greatest at the beginning of a rest period. Patients with limited activity tolerance need to prioritize tasks. Muscles that are deconditioned consume more oxygen and place an additional burden on the lungs. Through regular, graded exercise, these muscle groups become more conditioned, and the patient can do more without getting as short of breath.

4. Refrain from performing nonessential activities. 5. Support patient in establishing a regular regimen of exercise according to the patients level of functioning. Example is exercise through walking.

CUES/DATA
Subjective: Wala akong ganang kumain, kaya nga nabawasan talaga timbang ko mula 83kg naging 72.73kg nalang ako sa loob ng 2 buwan as verbalized by the client. Objective: -Thin -Signs of weakness

NURSING DIAGNOSIS
Imbalanced Nutrition: Less than Body Requirements related to loss of appetite as evidenced by weight loss

RATIONALE
- This condition needs to be addressed immediately for the client to be able to gain enough strength in performing her usual activities. -The body obtains energy in the form of calories from carbohydrates, protein and fat. The body uses energy for voluntary activities such as walking and involuntary activities such as breathing. (Fundamentals of Nursing 7th edition by Kozier et al.)

GOALS and OBJECTIVES

Immediately after intervention, the patient will verbalize and demonstrate selection of foods or meals that will achieve a cessation of weight loss.

INTERVENTIONS
1. Discuss eating habits, including food preferences. 2. Discourage beverages that are caffeinated or carbonated before meals. 3. Review and reinforce the following to patient or caregivers: o The basic four food groups, as well as the need for specific minerals or vitamins. -Vitamin C (Helps the immune system to produce antibodies) -calcium (help relief for tuberculin lesions -vitamin B6(combats toxic effect of INH) o Importance of maintaining adequate caloric intake; an average adult needs 1800 to 2200 kcal/ day. o Foods high in calories and protein that will promote weight gain and nitrogen balance (e.g., small frequent meals of foods high in calories and protein) *Perform health teaching according to clients level of understanding.

RATIONALE
To appeal to clients likes or dislikes. These may decrease appetite and lead to early satiety. Patients may not understand what is involved in a balanced diet.

EVALUATION
The goals and objectives have been fully met as the patient verbalizes and demonstrates selection of foods or meals that will achieve a cessation of weight loss.

CUES/DATA
Subjective: Nahirapan ako huminga lalo pagnapapagod ako, khit konting galaw lang ay hinihingal na ako as verbalized Objective: -Altered chest excursion - Use of accessory muscles - Cough - Tachypnea

NURSING DIAGNOSIS
Ineffective Breathing Pattern Decreased lung expansion secondary to PTB

RATIONALE
-

GOALS and OBJECTIVES

Immediately after intervention, the patient will - maintaine normal Respiratory Status - verbalize demonstrate understanding on breathing techniques - Patients breathing pattern is maintaine

INTERVENTIONS
Independent 1. ssess respiratory rate and depth by listening to lung sounds. 2. Monitor breathing patterns: Tachypnea (increase in respiratory rate) 3. Assess position patient assumes for normal or easy breathing 4. Monitor ABGs as appropriate; note changes. -

RATIONALE
Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. Specific breathing patterns may indicate an underlying disease process or dysfunction.

EVALUATION
The goals and objectives have been fully met as the patient verbalizes and demonstrates - maintained normal Respiratory Status - verbalized demonstrated understanding on breathing techniques - Patients breathing pattern is maintained as evidenced by eupnea

5. Pace and schedule activities providing adequate rest periods. 6. Teach patient when to inhale and exhale while doing strenuous activities

creasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient begins to fail, the respiratory rate decreases and PaCO2 begins to rise. his prevents dyspnea resulting from fatigue. Appropriate breathing techniques during exercise are important in maintaining adequate gas exchange.

CUES/DATA
Objective: - incision - indwelling cathether exposure to pathogens

NURSING DIAGNOSIS
Risk for InfectionInade quate primary defenses: broken skin secondary to thoracentesis

RATIONALE
-

GOALS and OBJECTIVES

Immediately after intervention, the patient will - Patient remains free of infection - recognize infection early to allow for prompt treatment - verbalize demonstrate understanding infection control -

INTERVENTIONS
Independent - Assess for presence, existence of, and history of risk factors such as open wounds and abrasions; chest thoracotomy tube Monitor white blood count (WBC). Maintain or teach asepsis for dressing changes and wound care, catheter care and handling Encourage coughing and deep breathing; consider use of incentive spirometer. Dependent 1. Administerantimicrobial (antibiotic) drugs as ordered. -

RATIONALE
present a break in the bodys normal first lines of defense. Rising WBC indicates bodys efforts to combat pathogens:very low WBC (neutropenia <1000 mm3) indicates severe risk for infection because patient does not have sufficient WBCs to fight infection. NOTE: In elderly patients, infection may be present without an increased WBC. These measures reduce stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia. these agents are either toxic to the pathogen or retard the pathogens growth. Ideally, the selection of the drug is based on cultures from the infected area

EVALUATION
The goals and objectives have been fully met as the patient verbalizes and demonstrates - Patient remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes. - recognized infection early to allow for prompt treatment - verbalized demonstrated understanding infection control

CUES/DATA
Subjective data: -Mga apat na oras lng ata ako nakakatulog sa gabi tapos paputol-putol pa, kumikirot parin kasi yung sa loob eh as verbalized

NURSING DIAGNOSIS
Sleep deprivation related to pain and discomfort secondary to thoracotomy tube

RATIONALE

GOALS and OBJECTIVES

Short term goal:After 15 minutes of nursing intervention, the client will be able to identify appropriate interventions to promote sleep as manifested by: -Explaining atleast two management in promoting sleep. -Verbalize understanding of sleep disorder -shows decrease in being irritable Long term goal: After 1day of nursing intervention, the client will be able to establish a normal sleeping pattern as evidenced by: -reports decrease feeling of discomfort

INTERVENTIONS
Independent: -assess sleep pattern -Position client in a comfortable position -provide comfort measures such as quiet environment and dim light

RATIONALE

EVALUATION
After 15 minutes of nursing intervention, the client will be able to identify appropriate interventions to promote sleep as manifested by: Explaining atleast two management in promoting sleep. -Verbalize understanding of sleep disorder -shows decrease in being irritable Long term goal:

-to provide comparative baseline to alleviate discomfort and promote sleep To distract attention on pain, reduce tension and to promote non pharmacological management -verbalizing concerns may promote relaxation

Objective data: -appears restless -pain scale of 7/10 -irritability -frequent yawning during assessment -guarding behavior

-encourage the client to express concerns when unable to sleep

-investigate anxious feelings

-to help determine basis and appropriate anxietyreduction techniques

After 1day of nursing intervention, the client will be able to establish a normal sleeping pattern as evidenced by: -reports decrease feeling of discomfort

Dependent: -Prescribe sedatives as ordered

-to induce sleep

CUES/DATA
Subjective Data: simula kaninang paggicing ko linalagnat na ako as verbalized by the patient. Objective Data: -Febrile, T= 37.9 C -warm to touch with flushing -PR=87 bpm -RR=28cpm -Patient looks pale and weak in appearance

NURSING DIAGNOSIS
Increased in body temperature related to inflammatory response secondary to infection

RATIONALE

GOALS and OBJECTIVES

After 30 minutes of effective nursing intervention, the patients temperature will : -Demonstrate temperature within normal range, from 38.1 C to 36.5C -37.5C -Demonstrate behaviors to monitor and promote normothermia. -Skin is cool to touch and less flushness -Identify underlying cause/contributing factors and importance of treatment, as well as signs/symptoms requiring further interventions. -Verbalized -understanding of specific interventions to prevent hyperthermia

INTERVENTIONS
Independent: -Monitor core temperature q 1 . -Note presence or absence of sweating as body attempts to increase heat loss by evaporation.

RATIONALE

EVALUATION
After 30 minutes of effective nursing intervention, goal is met. Patients temperature is already in the normal range; T=37.1 C Demonstrated behaviors to monitor and promote normothermia. Skin is cool, absence of flushing.

-Temperature of 38.9-41.1C suggest acute infectious disease process. -Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat. -To support circulating volume and tissue perfusion. -To reduce metabolic demands/oxygen consumption. -Heat is loss by evaporation and conduction. -Heat is loss by convection, radiation and conduction. -to prevent dehydration

-Increase oral fluid intake. -Promote bed rest, encourage relaxation skills and diversional activities. -Provide TSB as needed -Promote surface cooling, loosen clothing and cool environment - -Discuss importance of adequate fluid intake and protein diet Collaborative: -Administer medications as indicated to treat underlying cause, such as: -Paracetamol 325mg/tab 1 tab q 6 -Administer replacement fluids and electrolytes to support circulating volume and tissue

-To treat underlying cause

The patient, together with his significant others understands causes of the disease and is ready to practice specific interventions to prevent hyperthermia

-To support circulating

perfusion

volume and tissue perfusion.