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Describes the clients perceived

pattern of health and well-beingand how health is managed.

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Habits

Actual or potential problems

needs for modifications

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has no health problems except

for severe pain in stomachcaused by gastrointeritis.

doesnt have anyallergieusually eating pattern 3 timesa day

graded her health 6 out of 10.

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usually eating pattern 3 timesa day

graded her health 6 out of 10.

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Describes the clients pattern offood and fluid consumption relative

to metabolic need and patternindicators of local nutrient supply.

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The adequacy of local nutrientsupplies is evaluated.

Actual or potential problems

related to fluid balance

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tissue integrity

host defenses

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weighs 40 kg ( 88lbs )usually eats fish and doesnt like

aeting vegetables Regular intake of vitamin C.

can finish 6 glass of water in aday.

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no dental problems

lost of appetitenauseated

discomfort in eating due tofrequent vomitting

lose weight 38 kg ( 83. 6 lbs )

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Describes the patterns ofexcretory function(bowel,

bladder, skin).

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defacates everyday comfortablyregularly urinates ( light yellow

)doesnt have any infection

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frequent defacation ( liquidizebowel

excessive perspirationdark yellow urine

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Describes the pattern of exercise,

activity, leisure and recreation

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active and responsive

eats a lot

likes to play with friends

frequent vomiting

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feels weak

always feels tired and tensed

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Describes sensory-perceptualand cognitive patterns.

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6th grade student

Does well in schoolComprehensive

Normal sensory functions

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Dread mind about going back toschool after hospiatalization

Responds normally

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Describes patterns of sleep, rest

and relaxation.

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Sleeps well continuously from

8pm to 7 amSleeps at afternoon

Sleep deprivationNot physically rested andrelaxed

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Describes the clients self-concept pattern and perceptions

of self.

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Good body posture and gaitCheerful person

Contented with herself

Easily get annoyed

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Anxious

Depressed

Poor body posture and gait

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Describes the clients pattern ofrole participation and

relationships.

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Friendly

ExtrovertPlayful with her siblings

Lonely

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Distantness from her academicgroup

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Describes the clients patterns ofsatisfaction and dissatisfaction with

sexuality and reproductive pattern.

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Cooperate and interact with the

same and opposite sexStarted her menstrual periodwhen she was 11 years old

Withdrawn with opposite sex

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Describes the clients general

coping pattern and theeffectiveness of the pattern interms of stress tolerance

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Cheerful person

Forget problems by engaging insome social activities (e.g.sports)

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Anxious: My stomach hurts

Answers the nurse by nodding

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Describes the patterns of values,

beliefs (including spiritual), andgoals that guide the clientschoices or decisions

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Roman CatholicFamily Cantered

Trust God he can handle thepain

Accompanied by her mother

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Is a visual tool in which ideas or data are

enclosed in circles or boxes of some shape

and relationships between these are

indicated by connecting lines or arrows.

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Is an infection of the lowerrespiratory tract most

commonly due to bacterial orviral pathogens

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and much less commonly theresult of invasion of fungi,

parasites or other org.

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A 35 y/0 man

possible ofbacterial

pneumonia

FeverSore throatRunny noseCoughSever shakingSevere sweatingOverweight

Dullness to percussion of left lateral posterior chestT = 39C PR = 130 bpm RR = 28 cpmHeld left chest when coughingProduce very little thick rusty colored sputumRales heard over auscultation

Ineffectiveairway

clearance r/taccumulatio

n ofsecretions in

lungs

Alteredbreathingpattern r/t

inhalation ofhazardous

chemicals

Ineffective health

maintenance r/tdeficient

knowledgeregarding self

care and treatmentof disease

Chestpain r/tlungconsolidation

w/in 2 3 daysPatient will:Have productive coughHave lungs clear toauscultationHave normalrespirationsExcrete large amount ofsputum

Give prescribed parental fluidsAuscultate lungs q4hTake VS q4hInstruct patient in coughing anddeep breathing techniques tofacilitate removal of secretionsPosition client in fowlers or semi-fowlersIncrease fluid intakeMonitor amt. and color of sputum

After 4 5 weeksPatient will:Patients consolidated lung

will be clearResonance to percussion ofleft posterior chestVerbalize alleviation ofpain

Patient will have enoughrest and sleep

Ask patient to rate pain or discomfort on a scaleof 0 -10 ( 0 =no pain/ discomfort, 10 = worst pain)Observe for nonverbal cues of discomfort,especially inthose unable to communicate effectivelyNotify physician if pain is not relievedAttend to comfort needs and other activities toassistrelaxationProvide information about pain, such as itscauses, how longit will last, and anticipated discomforts fromproceduresAdminister penicillin G as prescribed byphysician

w/in 3 4 daysPatient must:Patient maintainseffective breathingpattern as evidencedby respiratory rate 12to 20 bpm and clearand equal lungsoundsPatient mustincrease awarenessabout the risks ofsmoking

Maintain fowlers / semi fowlers positionEncourage deep breathing andcoughing after deepbreathing, as neededAssist the patient inrepositioning q3hAuscultate lungs q4hEducate patient about risk ofcigarette smokingEncourage Pt to increase fluidintake

Use of correct

breathing/coughing techniqueafter instructionPatient must develop and followstrategies to maximize healthIdentify potential health riskscreated by lifestyle

Instruct Pt in breathing and coughingtechniques. Remind to perform, and assistq3hAdvice Pt to limit alcohol intake and avoidcigarette smokingEncourage discussion of preventive healthmeasures specific to patient needs, such asdietary changes, cessation of smoking, stressreduction and implementation of exerciseprogram

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A 35 y/0 man possible ofbacterial pneumonia

Sore throatRunny noseCoughSever shakingSevere sweatingOverweight

Dullness to percussion of left lateral posterior chestT = 39C PR = 130 bpm RR = 28 cpmHeld left chest when coughingProduce very little thick rusty colored sputumRales heard over auscultation

Ineffective airwayclearance r/t

accumulation of

secretions in lungs

Altered breathing patternr/t inhalation of

hazardous chemicals

Ineffective healthmaintenance r/t deficient

knowledge regarding selfcare and treatment of disease

Chest pain r/t lung

consolidation

Ineffective airway

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Ineffective airwayclearance r/t accumulation

of secretions in lungs

w/in 2 3 daysPatient will:Have productive coughHave lungs clear to auscultation

Have normal respirationsExcrete large amount of sputum

Goal

Give prescribed parental fluidsAuscultate lungs q4hTake VS q4hInstruct patient in coughing and deep breathingtechniques to facilitate removal of secretionsPosition client in fowlers or semi- fowlersIncrease fluid intakeMonitor amt. and color of sputum

Nursing Interventions

Ch t i /t l

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Chest pain r/t lungconsolidation After 4 5 weeksPatient will:

Patients consolidated lung will be clearResonance to percussion of left

posterior chestVerbalize alleviation of painPatient will have enough rest and sleep

Goal

Ask patient to rate pain or discomfort on a scale of 0 -10 ( 0 =

no pain/ discomfort, 10 = worst pain)Observe for nonverbal cues of discomfort, especially inthose unable to communicate effectivelyNotify physician if pain is not relievedAttend to comfort needs and other activities to assistrelaxationProvide information about pain, such as its causes, how longit will last, and anticipated discomforts from proceduresAdminister penicillin G as prescribed by physician


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w/in 3 4 daysPatient must:Patient maintains effective breathingpattern as evidenced by respiratory rate

12 to 20 bpm and clear and equal lungsoundsPatient must increase awareness aboutthe risks of smoking

Goal

Maintain fowlers / semi fowlers positionEncourage deep breathing and coughing after deepbreathing, as neededAssist the patient in repositioning q3hAuscultate lungs q4h

Educate patient about risk of cigarette smokingEncourage Pt to increase fluid intake


Altered breathing patternr/t inhalation of

hazardous chemicals

Ineffective health

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Use of correct breathing/coughingtechnique after instructionPatient must develop and followstrategies to maximize healthIdentify potential health riskscreated by lifestyle

Goal

Instruct Pt in breathing and coughing techniques.Remind to perform, and assist q3hAdvice Pt to limit alcohol intake and avoid cigarettesmokingEncourage discussion of preventive health measuresspecific to patient needs, such as dietary changes,cessation of smoking, stress reduction andimplementation of exercise program


Ineffective healthmaintenance r/t deficient

knowledge regarding selfcare and treatment of disease

Documents

BACON B