ASSESSMENT

NURSING DIAGNOSIS (RATIONALE)

PLAN >OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

OBJECTIVE DATA >BP: 110/70mmHg >RR: 40breaths/min >PR: 103bpm >Pale in appearance >Limited ROM >Easily irritated >Anxious >Facial grimace upon sudden movement >pain scale: 6/10 SUBJECTIVE DATA >Makulog ngani lalo pag nagaabo tapos pagnaglulunok masakitun ta makulog, as verbalized by the patient.

Acute pain realted to injuring agent as manifested by guarding behavior (Pleural effusion is excess fluid that accumulates between the two pleural layers, the fluid-filled space that surrounds the lungs. An excessive amount of such fluids limits the expansion of the lungs during ventilation that causes pain.)

Within the 6 hours of nursing intervention and implementation, the patients pain scale will be lowered to 4/10. >to report pain as controlled >to verbalize nonpharmacological methods that provide relief >to demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation

1. Assess level of anxiety by monitoring vital sign 2. Encourage SO to provide therapeutic touch such as light massage in the extremities or back rub. 3. Encourage patient to a bed rest with fowler position / semi-fowler position. 4. Provide environmental modifications that can reduce anxiety by: -Perform a calm manner to the client -Ensuring a quiet environment by always closing the door of the room -Regulating the room temperature -Changing patients bed linen 5. Instruct and encourage the client with the use of relaxation technique such as deep breathing, imaging and music.

1. These can point the patients level of anxiety as to mild, moderate, severe or panic and identify physical responses associated with both medical and emotional conditions 2. It is a way to divert attention of the client from pain being felt. 3. Fowlers position promotes venous return of the blood. 4. To provide comfort and makes her environment more relax which decreases sympathetic response of a client. 5. To distract attention and reduce tension

After 4 hrs. of nursing intervention, the clients pain has been reduced from 6/10 to 4/10

___Met ___Partially met ___Unmet

ASSESSMENT

NURSING DIAGNOSIS (RATIONALE)

PLAN >OBJECTIVES

INTERVENTION 1. Monitor respirations and breath sounds, noting rate and sounds 2. Elevate head of bed and change position every 2 hours and when necessary 3. Keep environment allergen free by changing the linens and keeping the door of the patients room close at all times 4. Encourage deep breathing and coughing exercise 5. Assist with the use of respiratory devices and treatment such as nebulizers and oxygen therapy

RATIONALE

EVALUATION

OBJECTIVE DATA >BP: 110/70mmHg >RR: 40breaths/min >PR: 103bpm >Pale in appearance >Limited ROM >Facial grimace upon sudden movement such as coughing >pain scale: 6/10

Ineffective airway clearance related to weakness and poor cough effort

(Due to limited lung expansion during ventilation, pleural effusion causes impairment in the gas exchange that leads to SUBJECTIVE DATA inadequate oxygen >Nanruruluya ngani ang supply in the body that pagmati ko nunyan tapos results to easy nasasakitan pa ko fatigability) maghangos, as verbalized by the patient. >Makulog ngani lalo pag nagaabo, as verbalized by the patient.

Within the 6 hours of nursing intervention and implementation, the patient will demonstrate reduction of congestion with breath sounds clear >to verbalize and demonstrate understanding of therapeutic and nontherapeutic management >to demonstrate behaviors to improve or maintain clear airway

1. It is an indicative of respiratory distress and/or accumulation of secretions 2. To take advantage of the gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments. 3. To prevent further complication or congestion

After 6 hrs. of nursing intervention, the patient has demonstrate reduction of congestion with breath sounds clear (RR: 31 breaths/min) ___Met ___Partially met ___Unmet

4. To maximize effort 5. These therapies or modalities may be required to acquire and maintain adequate airways, improve respiratory function and gas exchange