Problem: DOB

ASSESSMENT EXPLANATION GOAL INTERVENTION RATIONALE EVALUATION

S: “hindi siya Patient was STO: after 8 hours of Dx: Monitor Indicative of Goal will be met if:
makahinga ng diagnosed to have nursing intervention, respirations and respiratory distress
maayos” as colon cancer. Cancer patient will be able breath sounds, noting Patient’s breathing
verbalized by SO cells may reached the to: rate and sounds pattern is maintained
lungs through the as evidenced by
blood stream. Cancer a. Maintain patent eupnea, normal skin
cells then irritates the airway with To rate dyspnea with color, and regular
O:  Dyspnea breath sound Note the respiratory
pleura.Irritated tissue presence/degree of aid in quantifying and
 Tachypnea (RR:26 makes extra fluid clear tracking changes in rate/pattern.
b. Verbalize dyspnea
) which eventually respiratory distress Goal will be
causes fluid build up understanding partially met if:
 decreased tactile preventing lungs from of the health
Fremitus inflating during teaching given Patient’s refrain from
to improve To increase amount using accessory
breathing this causes
 pale in airway such as: of thick secretions muscle but still
dyspnea.
appearance -DBE and suggest development experiencing
Decrease amount and of secondary problem
pursed-lip tachypnea.
 non productive characteristic of eg. DHN, infection,
breathing
Cough sputum/secretions peripheral edema,
-proper body
 Nasal flaring positioning local hemorrhage
Goal will be unmet
if:
 Respiratory depth
changes Patient’s breathing
LTO: after 24 hours
of nursing pattern is not
 Altered chest Expectoration maybe
intervention, the maintained as
excursion difficult when
patient will be able to evidenced by
 Use of accessory secretion is thick Dyspnea, Tachypnea,
demonstrate behavior
muscles to improve airway Nasal flaring
Note the ability to
such as: expectorate
 oxygen inhalation -performing DBE and mucus/cough To determine ability And Use of accessory
via canula @ 3 lpm pursed lip breathing effectively to protect own airway muscles

 Dullness on chest -participate in

area treatment regimen
with a level of ability Evaluate client cough Modification:
to be able to identify and gag reflex and
Basis for planning -Performing DBE and
Dx: Ineffective potential complication swallowing ability intervention pursed lip breathing
breathing pattern r/t and initiate action
decrease lung -Proper body
expansion as Review diagnostics positioning( high
manifested by DOB result and the fowlers)
secondary to pleural medications prescribe
such as: -participate in
effusion treatment regimen
Proper positioning
facilitate respiratory -Maintain bed rest
function by use of
gravity
Tx: Assist patient to
assume position of
comfort DBE facilitate
maximum expansion
of lung

Assist patient
frequent DBE Accumulation of
secretion can impair
circulation/oxygenatio
n of vital organs and
tissues
Note cyanosis/change
in skin color including
mucus membrane
and nail beds Creates resistance
against out flowing
air to prevent
collapse

Encourage purse lip

breathing during Reduce oxygen
exhalation consumption and
demands

Promote bed rest

To facilitate breathing
and lung expansion

Loosen clothing from

chest, neck and
abdominal area Allay anxiety

Provide psychological
support
Dyspnea is caused by
excessive
accumulation of fluid
Maintain chest in lungs, mainataing
drainage chest drainage helps
 in alleviating dyspnea

For maximum lung

expansion and
facilitate normal flow
of air

Edx: Demonstrate
DBE and purse lip Reduce anxiety that
breathing may increase oxygen
demand

Encourage expression To facilitate breathing

of feeling and lung expansion

Instruct SO to reduce
clothing and change For effective bed rest
into loosely clothes

Instruct SO to provide

/maintain
quiet/relaxing
environment
PROBLEM: Colon Cancer Metastasis
ASSESSMENT EXPLANATION GOAL INTERVENTION RATIONALE EVALUATION

O>weakness Colon Ca cell growth STO: Dx Goal is met if the

patient will:
>diagnosed with neovascularization and After 8 hours of 1. Determine >Influences choice
colon cancer lymphangiogenesis the nursing presence of of intervention Verbalize
(development of new lymphatic intervention the condition as listed understanding of
>decreased bowel vessels) patient will: in Risk factors, individual risk
sounds(7) invasion of the host stroma, blood
noting whether factors that
vessels, and lymphatic system Verbalize
>history of long problempm is contribute to
understanding of acute or chronic. possibility of liver
term alcohol survival in the circulation
individual risk damage/failure.And
abuse
>lab-aminotrans arrest in small blood vessels factors that 2.Review result of >that indicate demonstrate
aspartate liquid- contribute to laboratory presence of behaviors, lifestyle
increased(20.1 extravasation possibility of liver tests/diagnostic hepatotoxic changes to reduce
(migration out of blood vessels)
U/L) damage/failure studies condition and need risk factors and
into the parenchyma of organs
such as. for medical protect self from
continuous proliferation, which treatment injury.
a.drugs
A> Risk for depends on establishing an 3.Identify
adequate blood supply >indicators severe
impaired liver b.possible symptoms that liver dysfunction,
(angiogenesis)
function related metastasis of warrants prompt possible organ Goal is partially
colon cancer lymphatic and vascular systems colon cancer notification of failure met if the patient
metastasis have numerous connections that health care :
allow disseminating tumor cells to c. history of long provider
pass rapidly from Colon to liver term alcohol Have compliance
abuse with his medication.
But do not
risk for impairment of liver Tx demonstrate
function behaviors, lifestyle
LTO: 1.Assist medical >To support organ
treatment of function and changes that
Source:
After 3 days of underlying minimize liver reduce risk factors
http://scienceweek.com/2006/s
nursing condition damage and protect himself
w060106-3.htm
intervention the from injury.
patient will:

>Demonstrate 2. Refer to >May be beneficial

behaviors, lifestyle specialist/liver for person with Goal is unmet if
changes to reduce treatment center, chronic liver disease the patient:
risk factors and as indicated when Manifest positive
protect self from decompensating or impairment of his
injury such as: client with hepatitis liver function.
and other coexisting
>be free from condition or
signs of liver tolerance to
failure as treatment due to Modification:
evidenced by: side effects
-avoiding alcohol
a. liver function >Immunocompromi
studies within 3.Maintain se patient are -follow medication
normal levels patient’s reverse vulnerable to other regimen
isolation opportunistic
b. absence of -have follow-up
infection care and adhere to
jaundice
therapeutic
c. hepatic regimen
enlargement Edx >To reduce
incidence of
d. altered mental 1.Stress important cirrhosis/severity of
status of drinking or liver damage/failure
avoiding alcohol
>Known to cause
2. Discuss safe hepatotoxicity,
use/concern about either alone or
client’s medication combination, or in
regimen overdose situation

3.Stress necessity >For faster recovery

of follow-up care and prevention of
and adhere to the occurrence of
therapeutic liver dysfunction
regimen
PROBLEM: Stress within the Family
ASSESSMENT EXPLANATION GOAL INTERVENTION RATIONALE EVALUATION

O Since the patient STO: After 8 hours of DX: Goal is met if

have been confined in nursing interventions patient will:
>anxious the hospital most of client will be able to: Note Helps patient
the time and money components of and caregiver -Express his feeling
>poor communication a. Express family know who is freely
on other members of of the family was
consumed for his his feelings presence of available to
the family freely. extended and assist with care -The patient is able to
medicines and other demonstrate
>feeling of grief hospital expenses others and support
involvement in
.the patient was problem solving
> inability to accept diagnosed with stage
or receive needed processes directed at
III colon cancer, some appropriate solutions
help of the family are LTO: after two days
of nursing Provides for the problem
anticipating his near
death which leads to interventions the information
patient will be able Identify about
stress in the entire
patterns of
Nsg. Dx. family that may to: communication effectiveness Goal is partially
cause interrupted in the family of met if patient will:
Risk for interrupted family process. a. and patterns of communication
family process r/t Demonstrate interaction , and identifies Express his feeling
situational condition involvement in between the problems that freely but in able to
problem family may interfere cope with his anger.
solving members with family’s
processes ability to assist
directed at patient and Goal is unmet if
appropriate adjust patient will:
solutions for positively on
the problem the treatment -in able to meet
of cancer emotional needs of
family members

- Inability to accept or
Each person receive needed help
Assess role may see the
expectations of situation on - Inappropriate or
family own individual poorly communicated
members and manner, and family rules
encourage clear
discussion identification
about them and sharing of Modification:
these
expectations Identify community
promote resources that may
understanding be helpful in dealing
with particular
situations (e.g.,
telephone hotlines,
Provide clues
self-help groups,
about
 interventions educational
that maybe opportunities, social
Assess energy appropriate to service agencies, and
direction eg. assist patient counseling centers).
Are efforts at and family in Groups that come
resolution or directing together for mutual
problem energies in a support or
solving more effective information exchange
scattered manner. can be beneficial in
helping family reach
goals.
Affects
patient or SO
reaction to
diagnoses,
treatment and
Note cultural or outcomes of
religious belief cancer

Helpless
feeling may
contribute to
difficulty
adjusting to
TX: diagnoses of
cancer and
listen to
cooperating
expression of
with treatment
helplessness
regimen
 provides
felling of
sympathy and
promotes
individuals
sense of worth
and
Deal with competence in
family ability to
members in a handle current
warm, caring, situation
respectful way.
Provide
information
and reinforce Communicat
as necessary. es acceptance
of the reality
the patient and
the family are
Acknowledge facing
the difficulty of
the situation

Feelings of
anger are to be
expected when
individuals are
EDX:
dealing with
Encourage the difficult or
appropriate potentially fatal
expressions of illness of
anger without cancer.
reaching Appropriate
negatively on expression
them enables
progress
towards
resolution of
the stages of
the grieving
process.

Most people
have
developed
effective
coping skills
that can be
Encourage useful with the
use of previous current
successful situation
coping
behaviors