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University of Pangasinan Phinma Education Network Name: Mr.

EVX Age: 61 years old Diagnosis: Community Acquired Pneumonia

Assessment Problem: Difficulty breathing Subjective: Nahihirapan po akong huminga., as verbalized by the client. Objectives: RR: 38 cycles/minute PR:102 beats/minute with positive wheezes at right lower thorax. use of accessory muscles in breathing pale in appearance

Nursing Diagnosis

Nursing Analysis

Goals and Outcomes

Nursing Interventions
Independent: 1. Evaluate the clients vital capacity 2. Assist the client in a semi-fowlers position 3. Emphasize adequate rest 4.Encourage adequate oral fluid intake of 2000 ml per day 5.Have standby oxygen Dependent: 6. Administer mucolytics as prescribed. 7. Administer antibiotics, as ordered and monitor for side effects 8. Administer bronchodilator as recommended.

Rationale

Evaluation The goal was met.

Impaired gas exchange related to alveolar capillary membrane changes such as pneumoconiosis as evidenced by difficulty of breathing, respiratory rate of 38 cycles per minute, pulse rate of 102 beats per minute, positive crackles at right lower thorax, harsh breath sounds at the right chest area, use of accessory muscles and pale in appearance.

The presence of puss and accumulation of excessive pleural cavity lessens the range of lung expansion thereby decreasing the amount of air that enters the lungs

Goal: After 8 hours of intervention, the client will be able to demonstrate improved ventilation and oxygenation of tissues within clients normal limits. Outcomes: After the interventions, the client will be able to show: clear breath sounds eliminate dyspnea prevent the used of accessory muscles respiratory rate of <25 cycles per minute relaxation to condition

1. To assess respiratory insufficiency 2. Facilitate easier breathing 3. Promotes comfort 4. Helps liquefy secretions 5.For emergency use

After 8 hours of intervention, the client was able to show adequate gas exchange such as: clear breath sounds no dyspneic episodes free breathing without use of accessory muscles respiratory rate of 19 cycles per minute. relaxed and lighten face

6. Decreases mnusus viscosity 7. Avoids further multiplication of microorganisms. 8. Helps enhance passage of air to the airway

ACTUAL NURSING DIAGNOSIS

University of Pangasinan Phinma Education Network Name: Mr. EVX Age: 61 years old Diagnosis: Community Acquired Pneumonia

Assessment Problem: Activity Intolerance Subjective: Hindi ako makagalaw ng magisa kelangan ko pa ng alalay., as verbalized by the client. Objectives: RR: 23 cycles per minute Shortness of breath after repositioning Noted body weakness Difficulty maintaining balance Observed body malaise and discomfort Facial grimace

Nursing Diagnosis

Nursing analysis

Goals and Outcomes

Nursing Interventions

Rationale

Evaluation Goal was met.

Activity intolerance related to bed rest or immobility as evidence by shortness of breath after repositioning, RR: 23 cycles per minute, noted body weakness, difficulty maintaining balance, observed body malaise and discomfort and facial grimace.

Activity intolerance is due to lessen movement, refusal of the client to go out of bed and decreased exercise and range of motion. Thus, it results to decreased circulation and muscle strength.

Goal: After 2 days of intervention, the client will be able to identify techniques in enhancement of activity tolerance. Outcomes: After the nursing interventions, the client will show: eupnea after repositioning increased body strength balance stability decreased muscle pain and comfort good facial gestures

Independent: 1. Evaluate current limitations/ degree of muscle strength 2. Assess emotional/psychologic factors affecting the current situation 3. Adjust activities depending on clients tolerance 4.Perform ROM exercise as necessary 5.Plan care with rest periods between activities Dependent: 6. Assist with activities with the use of assistive device as recommended 1. Provides comparative baseline 2. Determines whether this factor aggravates underlying cause 3. prevents overexertion 4. Helps increase clients muscle strength 5.Reduces fatigue

After 2 days of intervention, the client was able to shoe activity tolerance and manifests: eupnea after moving increased body strength balance stability decreased muscle pain and comfort good facial gestures

6. Protects client from injury

ACTUAL NURSING DIAGNOSIS

University of Pangasinan Phinma Education Network Name: Mr. EVX Age: 61 years old Diagnosis: Community Acquired Pneumonia

Assessment Problem: Fever Subjective: Pakiramdam ko po ang init-init ng katawan ko. , as verbalized by the patient. Objectives: T= 38.7C Skin warm to touch Flushed Skin Teary eyes Dry mucus membrane Total WBC = 16.9x10 /L

Nursing Diagnosis

Nursing Analysis

Goal and Outcomes

Nursing Interventions

Rationale 1. Promotes heat loss by evaporation and conduction


2. Promotes heat loss by radiation and conduction 3. Promotes heat loss by convection

Evaluation Goal was met. After 8 hours of intervention the client was able to have: T= 36.9C Verbalized feeling of comfort Relaxed attitude towards other people Perspiration in moderate amount

Hyperthermia related to decreased ability of the body to perspire and illness as evidenced by temperature of 38.7C, skin warm to touch, flushed skin, teary eyes, dry mucus membrane and total WBC of 16.9x10 /L.

Fever is a systemic manifestation of the body when there is an ongoing infection. There is this bodys defense mechanism wherein the production of white blood cells increases resulting to Leukocytosis.

Goal: After 8 hours of intervention, the client will maintain core temperature within normal range. Outcomes: After the said interventions, the client will manifest: T= 36.5-37.4C Cool feeling Relaxed Attitude

Independent: 1. Perform Cool/ Tepid Sponge Bath to the client 2. Promote surface cooling by means of loosening of dressing 3. Provide cool environment and/or fans 4.Discuss importance of adequate fluid intake

4. Prevents further dehydration

Dependent: 5. Administer Good perspiration medications like Paracetamol or diazepam as ordered 6. Administer medications such as antibiotics like Cefuroxime

5. Controls shivering and prevents seizure occurrence

6. Treats underlying cause of infection inside the body

ACTUAL NURSING DIAGNOSIS

University of Pangasinan Phinma Education Network Name: Mr. EVX Age: 61 years old Diagnosis: Community Acquired Pneumonia Nursing Diagnosis Assessment

Nursing Analysis

Goal and Outcomes

Nursing Interventions

Rationale

Evaluation

Problem: Anxiety Subjective: Kelan ako aalis dito? Feeling ko lahat iniiwasan ako., as verbalized by the patient. Objectives: RR: 36 cycles per minute Restless Difficulty Sleeping Disturbed thoughts and feelings Facial grimace Excessive perspiration

Moderate anxiety related to threat to or change in health status and economic status as evidenced by respiratory rate of 36 cycles per minute, restless, difficulty sleeping, disturbed thoughts and feelings, facial grimace and excessive perspiration.

Anxiety is caused by strong will of the client to get out immediately of the hospital premises due to lack of money to pay their bills. Another is the belief of the client that he is being isolated and being prevented by others because of his disease.

Goal: After 1 day of interventions, the client will be able to appear relaxed and report anxiety is reduced to a manageable level. Outcomes: After the said interventions, the client will have: A normal range of respiratory rate of 16-20 cycles per minute An enough sleep of at least 8 hours A good and consistent dream A right decision for the problems that causes anxiety

Independent: 1. Observe behavior indicative of level of anxiety 2. Provide accurate information about the situation

Goal was met. 1. Can give a clue to the clients level of anxiety 2. Helps client to identify what is reality based After 1 day of interventions, the client was able to have: RR= 17 cycles per minute A sleep from 9am to 6pm A concrete sleep A decision that will help him solve his problem in his bills such as PHILHEALTH.

3. Moderate anxiety 3. Assist client to use anxiety for coping with heightens awareness the situation, if helpful and permits the client to focus on dealing with problems 4. It may interfere 4. Be aware of the with the ability of defense mechanism the client to deal the client used with problem Dependent: 5. Helps reduce the 5. Give antianxiety medications as ordered anxiety level felt by the client 6. Refer to physician for drug management program/ alteration of prescription regimen 6. Sometimes drugs often causing symptoms of anxiety

ACTUAL NURSING DIAGNOSIS

University of Pangasinan Phinma Education Network Name: Mr. EVX Age: 61 years old Diagnosis: Community Acquired Pneumonia

Assessment

Nursing Diagnosis

Nursing Analysis

Goal and Outcomes

Nursing Interventions

Rationale

Evaluation

Problem: Nutrition related anxiety Subjective: Paano ko maibabalik ang dati kong lakas?,as verbalized by the client. Objectives: Attentiveness Possess positive outlook Implies interest to the topic Good awareness regarding health condition

Readiness for enhanced nutrition related to be developed as evidenced by attentiveness, positive outlook, implies interest to the topic and good awareness regarding health condition.

Interest of the patient to enhance his nutrition is due to the fact the he need to live not for just on his own but also to his family. Although, that may be another factor in the part of the client to get well and not anymore a heavy load to his family.

Goal: After 3 days of intervention, the client will demonstrate behaviours to attain appropriate weight. Outcomes: After the said interventions, the client will be able to have: weight gain of 3-5 lbs. Regular eating habits Have a diet of nutritious foods such as fruits and vegetables

Independent: 1. Assess clients knowledge of current nutritional needs and ways client is meeting these needs 2. Assess eating patterns and food/fluid choices 3. Evaluate for influence of cultural factors 4. Review safe preparation and storage of food

Goal was met. 1. Provides baseline for further teaching or interventions After 3 days of interventions, the client was able to have: A weight gain of 3.5 lbs. Regular eating habits Include fruits and vegetables as part of his diet

2. Helps identify specific strengths and weaknesses 3. Determines what client considers to be normal diet 4. Avoids food borne illnesses

5. Encourage variety 5. Encourages client and moderation in in efforts for dietary plan healthy choices Dependent: 6. Consult with and refer to dietitian 6. For further recommendations.

ACTUAL NURSING DIAGNOSIS

University of Pangasinan Phinma Education Network Name: Mr. EVX Age: 61 years old Diagnosis: Community Acquired Pneumonia

ACTUAL NURSING DIAGNOSIS