Date Problems encountered (actual and resolved)

Actual problems that are identified are and have been resolved last
July 23, 2009 Aug.1, 2009:

First is ineffective airway clearance. As evidence by relatives

verbalization “ Inuubo pa rin siya.” And based on the assessment done
(+) productive cough, (+)Wide eyed and (+)Restlessness Because of the
necessary nursing interventions that have been done the pt maintained a
patent airway.

Second is disturbed sleep pattern. As evidence by verbalization of

the husband of the pt “onti lang ang tulog niya mga 2 hours at paputol-
putol” And based on the assessment done that there are (+) sunken
eyeballs and weakness. It should be the second priority because the
client is experiencing a insufficient time or period of sleep. The
necessary nursing interventions should be done for the client to be able
to maintain a comfortable environment. After doing so, the client
verbalized improvement in sleep pattern and can sleep now from 4-8
hours.

Third is is impaired physical mobility. It should be identify for

the client to have sufficient energy to endure or complete required or
desired daily activities. The problem was evidence by verbalization of
the pt husbands “di nga siya pwedeng tumayo sabi ni Dok” and
positive immobility, weakness, Doctors order of CBR. And (+)
Tracheostomy based on the assessment done. Because of the necessary
nursing interventions that have been formulated the client was able to
do simple task.

And Forth impaired skin integrity. As positively evidence by skin

disruption of skin surface and as verbalized by the husband of the pt
“Di pa magaling ung suagat niya gawa ng pag papaopera niya sa
lalamunan” and(+) Floppy skin,76 yrs old and (+) Tracheostomy.
Necessary nursing interventions should be done; and after doing so the
client’s wound becomes dry and clean.

Aug 1, 2009 There is a potential problem that had been identified during our
contact with the client and this is risk for infection due to the disruption
of the skin which is the primary defense. Necessary nursing
interventions should be done to prevent infection and complications.