nutrition planning: upon discharge, the client will be in his ideal form based o

n Bmi
pakidagdag sa assessment ung initial BMI nung patient. kahit anung number un bas
ta dapat below 25
Ineffective breathing pattern Planning: within 8 hours, the client will show sig
ns
of improved breathing pattern as manifested by signs of eupnea
(absence of adventitious sounds, equal lung sounds, normal RR) and decreased eff
ort in breathing
(absence of orthopnea, absence of the use of accessory muscles)
INtervention: Gather baseline vital signs (rationale: to allow and provide a b
asis for comparison for the
improvement of the patient's condition)
INtroduce yourself to the client (rationale: this will decrease
anxiety on the part of the
client and will ensure that the client is in a relaxed state during treatment [a
nxiety will increase oxygen demand]
place the client is a position of comfort (rationale: the client
alone will be the one to determine his
or her most comfortable position, in this case, a high folwer or orthopneic posi
tion is preferrable)
modify the clients environment and overall ambiance of the room.
(rationale: the airway
reacts to extremes of temperature, too warm or cold may cause contraction of the
airway, furthering the complication.
instruct the client to avoid fresh fruits and or flowers and ass
ist the client and watchers in cleaning
clients room from dust.. (rationale: allergens cause constriction of the airway
and may aggravate the condition of the client
instruct the client to perform pursed lip breathing (rationale:
pursed lip breathing increases the
duration of the exhalaltion, thus allowing more time for the lungs to expel exce
ss c02 from the body)
Monitor the clients 02 saturation (rationale: 02 saturation dete
rmined then extent of hypoxia
by the patient caused by the ineffective breathing pattern, the current 02 sat d
ictates the treatment plan)
administer 02 per doctors order (rationale: because of the impa
irment in the amount of o2 that the client inhales,
providing oxygenation will aid in preventing hypoxia)
adminsiter medications as ordered i.e, bronchodilators and corti
costeroids (rationale: medications
provide immediate relief of physical symptoms especially when the client is at a
critical state of hypoxia)
assess placement of the ET tube. (rationale: during the course o
f therapy the client may move and dislodge
tube. regular assessment ensures that both lung fields are well-oxygenated to pr
event lung collapse)
Intervention for imbalanced nutrition:
take baseline data from the client, specifically anthropometric
measurements such as height and weight.
(Rationale: height and more importantly weight is a sensitive indicator of nouri
shment and is used in different measurements
to determine sustenance)
determine client's overall status i.e, the presence of fever, di
sease (rationale: disease increases the
bodys metabolism to fight off disease, and may aggravate the clients current sta

tus)
modify the clients environment by controlling the temperature of
the room (rationale: a cold room increases
the body need to increase body heat, which requires energy from food.
assist with feeding the client through ngt ensuring that the pro
per steps are followed before feeding
(rationale: following the assigned schedule of feeding of the client ensures tha
t he receives proper noursihment throughout
the day)
assess the clients
S