Describes the clients perceived pattern of health and well-being and how health is managed.

Habits Actual or potential problems needs for modifications

has no health problems except

for severe pain in stomach caused by gastrointeritis. doesnt have any allergie usually eating pattern 3 times a day graded her health 6 out of 10.

usually eating pattern 3 times

a day graded her health 6 out of 10.

Describes the clients pattern of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply.

The adequacy of local nutrient supplies is evaluated.

Actual or potential problems

related to fluid balance

tissue integrity host defenses

weighs 40 kg ( 88lbs )

usually eats fish and doesnt like

aeting vegetables Regular intake of vitamin C. can finish 6 glass of water in a day.

 no dental problems
lost of appetite

nauseated
discomfort in eating due to

frequent vomitting lose weight 38 kg ( 83. 6 lbs )

Describes the patterns of excretory function(bowel, bladder, skin).

defacates everyday comfortably

regularly urinates ( light yellow

) doesnt have any infection

frequent defacation ( liquidize

bowel excessive perspiration dark yellow urine

Describes the pattern of exercise, activity, leisure and recreation

active and responsive eats a lot likes to play with friends frequent vomiting

feels weak always feels tired and tensed

Describes sensory-perceptual and cognitive patterns.

6th grade student

Does well in school

Comprehensive
Normal sensory functions

Dread mind about going back to

school after hospiatalization Responds normally

Describes patterns of sleep, rest and relaxation.

Sleeps well continuously from

8pm to 7 am Sleeps at afternoon Sleep deprivation Not physically rested and relaxed

Describes the clients selfconcept pattern and perceptions of self.

Good body posture and gait

Cheerful person
Contented with herself

Easily get annoyed

Anxious Depressed Poor body posture and gait

Describes the clients pattern of role participation and relationships.

Friendly
Extrovert

Playful with her siblings

Lonely

Distantness from her academic

group

Describes the clients patterns of satisfaction and dissatisfaction with sexuality and reproductive pattern.

Cooperate and interact with the

same and opposite sex Started her menstrual period when she was 11 years old Withdrawn with opposite sex

Describes the clients general coping pattern and the effectiveness of the pattern in terms of stress tolerance

Cheerful person
Forget problems by engaging in

some social activities (e.g. sports)

Anxious: My stomach hurts Answers the nurse by nodding

Describes the patterns of values, beliefs (including spiritual), and goals that guide the clients choices or decisions

Roman Catholic

Family Cantered
Trust God he can handle the

pain Accompanied by her mother

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.

Is an infection of the lower respiratory tract most commonly due to bacterial or viral pathogens

and much less commonly the result of invasion of fungi, parasites or other org.

Chest pain r/t lung consolida tion

After 4 5 weeks Patient will: Patients consolidated lung will be clear Resonance to percussion of left posterior chest Verbalize alleviation of pain Patient will have enough rest and sleep 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 in those unable to communicate effectively Notify physician if pain is not relieved Attend to comfort needs and other activities to assist relaxation Provide information about pain, such as its causes, how long it will last, and anticipated discomforts from procedures Administer penicillin G as prescribed by physician

A 35 y/0 man possible of bacterial pneumonia

Fever Sore throat Runny nose Cough Sever shaking Severe sweating Overweight Dullness to percussion of left lateral posterior chest T = 39C PR = 130 bpm RR = 28 cpm Held left chest when coughing Produce very little thick rusty colored sputum Rales heard over auscultation

Ineffective health maintenance r/t deficient knowledge regarding self care and treatment of disease

Instruct Pt in breathing and coughing techniques. Remind to perform, and assist q3h Advice Pt to limit alcohol intake and avoid cigarette smoking Encourage discussion of preventive health measures specific to patient needs, such as dietary changes, cessation of smoking, stress reduction and implementation of exercise program

Use of correct breathing/coughing technique after instruction Patient must develop and follow strategies to maximize health Identify potential health risks created by lifestyle

Ineffective airway clearance r/t accumulatio n of secretions in lungs

Altered breathing pattern r/t inhalation of hazardous chemicals

w/in 3 4 days Patient must: Patient maintains effective breathing pattern as evidenced by respiratory rate 12 to 20 bpm and clear and equal lung sounds Patient must increase awareness about the risks of smoking Maintain fowlers / semi fowlers position Encourage deep breathing and coughing after deep breathing, as needed Assist the patient in repositioning q3h Auscultate lungs q4h Educate patient about risk of cigarette smoking Encourage Pt to increase fluid intake

Give prescribed parental fluids Auscultate lungs q4h Take VS q4h Instruct patient in coughing and deep breathing techniques to facilitate removal of secretions Position client in fowlers or semifowlers Increase fluid intake Monitor amt. and color of sputum

w/in 2 3 days Patient will: Have productive cough Have lungs clear to auscultation Have normal respirations Excrete large amount of sputum

A 35 y/0 man possible of bacterial pneumonia

Ineffective airway clearance r/t accumulation of secretions in lungs

Sore throat Runny nose Cough Sever shaking Severe sweating Overweight Dullness to percussion of left lateral posterior chest T = 39C PR = 130 bpm RR = 28 cpm Held left chest when coughing Produce very little thick rusty colored sputum Rales heard over auscultation

Ineffective health maintenance r/t deficient knowledge regarding self care and treatment of disease

Chest pain r/t lung consolidation

Altered breathing pattern r/t inhalation of hazardous chemicals

Ineffective airway clearance r/t accumulation of secretions in lungs

Goal

w/in 2 3 days Patient will: Have productive cough Have lungs clear to auscultation Have normal respirations Excrete large amount of sputum

Nursing Interventions

Give prescribed parental fluids Auscultate lungs q4h Take VS q4h Instruct patient in coughing and deep breathing techniques to facilitate removal of secretions Position client in fowlers or semi- fowlers Increase fluid intake Monitor amt. and color of sputum

Chest pain r/t lung consolidation

Goal

After 4 5 weeks Patient will: Patients consolidated lung will be clear Resonance to percussion of left posterior chest Verbalize alleviation of pain Patient will have enough rest and sleep

Nursing Interventions 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 in those unable to communicate effectively Notify physician if pain is not relieved Attend to comfort needs and other activities to assist relaxation Provide information about pain, such as its causes, how long it will last, and anticipated discomforts from procedures Administer penicillin G as prescribed by physician

Altered breathing pattern r/t inhalation of hazardous chemicals

Goal

Nursing Interventions

w/in 3 4 days Patient must: Patient maintains effective breathing pattern as evidenced by respiratory rate 12 to 20 bpm and clear and equal lung sounds Patient must increase awareness about the risks of smoking

Maintain fowlers / semi fowlers position Encourage deep breathing and coughing after deep breathing, as needed Assist the patient in repositioning q3h Auscultate lungs q4h Educate patient about risk of cigarette smoking Encourage Pt to increase fluid intake

Ineffective health maintenance r/t deficient knowledge regarding self care and treatment of disease

Goal

Use of correct breathing/coughing technique after instruction Patient must develop and follow strategies to maximize health Identify potential health risks created by lifestyle

Nursing Interventions

Instruct Pt in breathing and coughing techniques. Remind to perform, and assist q3h Advice Pt to limit alcohol intake and avoid cigarette smoking Encourage discussion of preventive health measures specific to patient needs, such as dietary changes, cessation of smoking, stress reduction and implementation of exercise program