problem: dob assessment s: “hindi siya makahinga

8/14/2019 Problem: DOB ASSESSMENT S: hindi Siya Makahinga

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oxygen inhalationvia canula @ 3 lpm

Dullness on chest area

Dx: Ineffectivebreathing pattern r/tdecrease lungexpansion asmanifested by DOBsecondary to pleuraleffusion

-performing DBE andpursed lip breathing

-participate intreatment regimenwith a level of ability

to be able to identifypotential complicationand initiate action

mucus/cougheffectively

Evaluate client coughand gag reflex andswallowing ability

Review diagnosticsresult and themedications prescribesuch as:

Tx : Assist patient toassume position of comfort

Assist patientfrequent DBE

Note cyanosis/change

To determine abilityto protect own airway

Basis for planningintervention

Proper positioningfacilitate respiratoryfunction by use of

gravity

DBE facilitatemaximum expansionof lung

Accumulation of secretion can impaircirculation/oxygenation of vital organs andtissues

And Use of accessorymuscles

Modification:

-Performing DBE andpursed lip breathing

-Proper bodypositioning( highfowlers)

-participate intreatment regimen

-Maintain bed rest


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in skin color includingmucus membraneand nail beds

Encourage purse lipbreathing duringexhalation

Promote bed rest

Loosen clothing fromchest, neck andabdominal area

Provide psychologicalsupport

Maintain chestdrainage

Creates resistanceagainst out flowingair to preventcollapse

Reduce oxygenconsumption anddemands

To facilitate breathingand lung expansion

Allay anxiety

Dyspnea is caused byexcessive

accumulation of fluidin lungs, mainataingchest drainage helps


4/13

Edx : DemonstrateDBE and purse lipbreathing

Encourage expressionof feeling

Instruct SO to reduceclothing and changeinto loosely clothes

Instruct SO to provide

/maintainquiet/relaxingenvironment

in alleviating dyspnea

For maximum lungexpansion andfacilitate normal flowof air

Reduce anxiety thatmay increase oxygendemand

To facilitate breathingand lung expansion

For effective bed rest


5/13

PROBLEM: Colon Cancer MetastasisASSESSMENT EXPLANATION GOAL INTERVENTION RATIONALE EVALUATION

O>weakness

>diagnosed withcolon cancer

>decreased bowelsounds(7)

>history of longterm alcoholabuse

Colon Ca cell growth

neovascularization andlymphangiogenesis(development of new lymphaticvessels)invasion of the host stroma, blood

vessels, and lymphatic system

survival in the circulation

STO:

After 8 hours of the nursingintervention thepatient will:

Verbalizeunderstanding of individual risk

Dx

1. Determinepresence of condition as listedin Risk factors,noting whether

problempm isacute or chronic.

>Influences choiceof intervention

Goal is met if thepatient will:

Verbalizeunderstanding of individual riskfactors that

contribute topossibility of liverdamage/failure.And


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>lab-aminotransaspartate liquid-increased(20.1U/L)

A> Risk forimpaired liverfunction relatedcolon cancermetastasis

arrest in small blood vessels

extravasation(migration out of blood vessels)into the parenchyma of organs

continuous proliferation, whichdepends on establishing anadequate blood supply(angiogenesis)

lymphatic and vascular systemshave numerous connections thatallow disseminating tumor cells topass rapidly from Colon to liver

risk for impairment of liverfunction

Source:http://scienceweek.com/2006/sw060106-3.htm

factors thatcontribute topossibility of liverdamage/failuresuch as.

a.drugsb.possiblemetastasis of colon cancer

c. history of longterm alcoholabuse

LTO:

After 3 days of nursingintervention thepatient will:

>Demonstratebehaviors, lifestylechanges to reducerisk factors andprotect self frominjury such as:

>be free fromsigns of liver

2.Review result of laboratorytests/diagnosticstudies

3.Identifysymptoms thatwarrants promptnotification of health careprovider

Tx

1.Assist medicaltreatment of underlyingcondition

2. Refer tospecialist/livertreatment center,as indicated

>that indicatepresence of hepatotoxiccondition and needfor medicaltreatment

>indicators severeliver dysfunction,possible organfailure

>To support organfunction andminimize liverdamage

>May be beneficialfor person withchronic liver diseasewhendecompensating orclient with hepatitisand other coexistingcondition ortolerance to

demonstratebehaviors, lifestylechanges to reducerisk factors andprotect self frominjury.

Goal is partiallymet if the patient:

Have compliancewith his medication.But do notdemonstratebehaviors, lifestyle

changes thatreduce risk factorsand protect himself from injury.

Goal is unmet if the patient:

Manifest positiveimpairment of his

liver function.
http://scienceweek.com/2006/sw060106-3.htmhttp://scienceweek.com/2006/sw060106-3.htmhttp://scienceweek.com/2006/sw060106-3.htmhttp://scienceweek.com/2006/sw060106-3.htm


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failure asevidenced by:

a. liver functionstudies withinnormal levels

b. absence of jaundice

c. hepaticenlargement

d. altered mentalstatus

3.Maintainpatients reverseisolation

Edx

1.Stress importantof drinking oravoiding alcohol

2. Discuss safe

use/concern aboutclients medicationregimen

3.Stress necessityof follow-up careand adhere totherapeuticregimen

treatment due toside effects

>Immunocompromise patient arevulnerable to other

opportunisticinfection

>To reduceincidence of cirrhosis/severity of liver damage/failure

>Known to causehepatotoxicity,either alone orcombination, or inoverdose situation

>For faster recoveryand prevention of the occurrence of liver dysfunction

Modification:

-avoiding alcohol

-follow medicationregimen

-have follow-upcare and adhere totherapeuticregimen


8/13

PROBLEM: Stress within the FamilyASSESSMENT EXPLANATION GOAL INTERVENTION RATIONALE EVALUATION

O

>anxious

>poor communicationon other members of the family

>feeling of grief

> inability to acceptor receive neededhelp

Since the patienthave been confined inthe hospital most of the time and moneyof the family wasconsumed for hismedicines and otherhospital expenses.the patient wasdiagnosed with stageIII colon cancer, someof the family are

anticipating his neardeath which leads tostress in the entire

STO: After 8 hours of nursing interventionsclient will be able to:

a. Expresshis feelingsfreely.

LTO: after two days

of nursinginterventions thepatient will be able

DX:

Note components of familypresence of extended andothers

Identify patterns of

Helps patient and caregiverknow who isavailable toassist with careand support

Provides informationabout

Goal is met if patient will:

-Express his feelingfreely

-The patient is able todemonstrateinvolvement inproblem solvingprocesses directed atappropriate solutionsfor the problem


9/13

Nsg. Dx.

Risk for interruptedfamily process r/tsituational condition

family that maycause interruptedfamily process.

to:

a.Demonstrateinvolvement inproblem

solvingprocessesdirected atappropriatesolutions forthe problem

communicationin the family

and patterns of interactionbetween thefamily

members

Assess role

expectations of familymembers andencouragediscussionabout them

effectivenessof communication, and identifiesproblems thatmay interfere

with familysability to assistpatient andadjustpositively onthe treatmentof cancer

Each person may see thesituation onown individualmanner, andclearidentificationand sharing of theseexpectationspromoteunderstanding

Provide clues

about

Goal is partiallymet if patient will:

Express his feelingfreely but in able tocope with his anger.

Goal is unmet if patient will:

-in able to meetemotional needs of family members

- Inability to accept orreceive needed help

- Inappropriate orpoorly communicatedfamily rules

Modification:

Identify communityresources that maybe helpful in dealingwith particular

situations (e.g.,telephone hotlines,self-help groups,


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Assess energy direction eg.Are efforts atresolution or

problemsolvingscattered

Note cultural or

religious belief

TX:

listen to

expression of helplessness

interventionsthat maybeappropriate toassist patientand family indirecting

energies in amore effectivemanner.

Affectspatient or SOreaction todiagnoses,treatment andoutcomes of

cancer

Helplessfeeling maycontribute todifficultyadjusting todiagnoses of cancer andcooperatingwith treatmentregimen

educationalopportunities, socialservice agencies, andcounseling centers).Groups that cometogether for mutual

support orinformation exchangecan be beneficial inhelping family reachgoals.


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Deal withfamilymembers in awarm, caring,respectful way.Provideinformationand reinforceas necessary.

Acknowledgethe difficulty of the situation

EDX:

Encourage appropriateexpressions of

providesfelling of sympathy andpromotes

individualssense of worthandcompetence inability tohandle currentsituation

Communicates acceptance

of the realitythe patient andthe family arefacing

Feelings of anger are to beexpected whenindividuals aredealing with

the difficult orpotentially fatalillness of


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anger withoutreachingnegatively onthem

Encourageuse of previoussuccessfulcopingbehaviors

cancer.Appropriateexpressionenablesprogresstowards

resolution of the stages of the grievingprocess.

Most peoplehavedeveloped

effectivecoping skillsthat can beuseful with thecurrentsituation


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problem: dob assessment s: “hindi siya makahinga

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