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ASSESSMENT Subjective: medyo nahihirapan ako huminga siguro dahil sa plema ko. As verbalized by the patient.

DIAGNOSIS Ineffective airway clearance R/T excessive mucus

PLANNING After 4 hrs. Of continuous nursing interventions the patient verbalize relief difficulty in breathing

INTERVENTION Monitor respirations and breath sounds, noting rate and sounds Assisted the patient on comfortable position/ semi fowler

RATIONALE

EVALUATION After 4 hrs. Of continuous nursing interventions the patient verbalized relief of DOB

Objective: -use of accessory muscle -weak in appearance - with inhalation via nasal cannula

Indicative of respiratory distress and or accumulation of secretions Promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions. To maximize effort

Teach pt. deep breathing and coughing exercises Advised the patient to avoid straneous activities and promote rest

Prevent/reduces fatigue

Vital signs taken and recorded

For baseline data

ASSESSMENT Subjective: nahihirapan na nga ako huminga madalas pa akong hinihingal Objective: -Labored breathing -Has Difficulty in breathing when lying on his back -discomfort

DIAGNOSIS Ineffective breathing pattern R/T presence of secretions in lungs that labor breathing

PLANNING After 4 hours of nursing intervention the patient will establish an effective breathing pattern

INTERVENTION

RATIONALE

EVALUATION

Evaluate cough and presence of secretions Elevate head of bed or have the client sit up in chair as appropriate Encourage adequate rest periods Maintain calm attitude while dealing with client Teach the client on deep breathing exercises Vital signs taken and recorded

Indicating possible After 4 hours of nursing obstruction intervention the goal has been met as evidenced To promote physiological and by : patient will psychological ease established an of maximal effective inspiration breathing pattern To limit fatigue To limit level of anxiety

For baseline data

ASSESSMENT Subjective: nanghihina ako ngayon kaya nga andito lang ako sa kama nakaupo kaya hindi ko makaya yung gusto ko mang gawin Objective: -weak appearance - fatigue

DIAGNOSIS Activity Intolerance R/T generalized weakness

PLANNING After 4 hours of nursing intervention the client will demonstrate a measurable increase in tolerance to activity without DOB and fatigue.

INTERVENTION

RATIONALE

EVALUATION After 4 hours of nursing intervention the client demonstrated a measurable increase in tolerance to activity without DOB and fatigue.

Establish rapport with the patient Explain importance of rest in treatment plan Assist client with activity Promote comfort measures on the activity Vital signs taken and recorded

To establish trust and cooperation To reduce fatigue To prevent over exertion To protect client from injury

For baseline data

-discomfort -pallor

Encourage pt. to maintain positive attitude

To enhance sense of well being