Problem # 1: Productive cough

Assessment:
Cues:
Subjective: Patient’s statement:“inuubo ako simula pa noong Mayo”
“ang tigas ng plema ko, nahihirapan akong ilabas ito”

Objective: (+)wheezes and (+)crackles upon auscultation

;RR:22(NV:12-20);PR 98(NV:60-100);(+) green, thick sputum with
scanty blood ; chest PA shows primary Koch’s infection.

Nursing Diagnosis: Ineffective airway clearance r/t accumulation

of thick copious secretions

Rationale:

Goal: After 2hrs. of nursing intervention, the patient will

expectorate or clear secretions readily.

The patient will maintain airway patency within the shift.

Intervention:
Independent:
1. Assessed respirations and breath sounds, noting rate and
sounds. Indicative of respiratory distress and/or accumulation
of secretions.(Doenges, 2008:78)
2. Assess mental status during periods when airway is obstructed.
Lack of oxygen for even short periods can affect cerebral
oxygenation, resulting in changes in mental status and LOC.
(Rodgers, 2007:243)
3. Encouraged deep-breathing and coughing exercises. To maximize
effort.(Doenges, 2008:79)
4. Increased fluid intake to at least 2000ml/day within cardiac
tolerance. Hydration can help liquefy viscous secretions and
improve secretion clearance.(Doenges, 2008:79)
5. Placed patient in semi- or high-Fowler’s position.
Positioning helps maximize lung expansion and decreases
respiratory effort.(Doenges, 2002:184)
6. Established intravenous access. Ensures a route for rapid-
acting medications.(Rodgers, 2007:243)
7. Monitor the patient for signs of aspiration into lungs:
abnormal breath sounds, fever, and increased secretions.
Frequently foreign objects are in the airway, some particles may
be aspirated in the lungs and may cause aspiration pneumonia;
monitoring the patient allows detection of early symptoms that
may require further treatment. (Rodgers, 2007:243)

Dependent:
1. Administered Combivent neb.every 8hrs.as ordered
2. Give levofloxacin 500mg 1tab ODx7days as ordered.

Evaluation: Goal met. The patient was able to expectorate/clear

secretions readily after 2hrs.of NI.
The patient was able to maintain airway patency within the shift.

Problem # 2: Abdominal Pain

Assessment:
Cues:
Subjective: patient’s stated:”masakit yung sa may bandang kaliwa,
sa baba ng tiyan ko kapag nararamdaman kong dudumi ako.”
“sumasakit siya tuwing nararamdaman ko na dudumi ako, yung parang
pinipiga sa loob, unti-unti naman siyang nawawala pag hindi na
ako nadudumi.”
Pain scale of 7/10 in a 1-10 point scale.

Objective: grimacing, restlessness,irritable, RR:22(NV:12-20),

Doctor’s diagnosis of Sigmoid Adenocarcinoma

Nursing Diagnosis: Acute pain r/t pressure on nerve endings.

Rationale: Compression of the epithelial lining of the intestine
causes the tissue to stretch and exposes the nerve endings to the
intestine contents and stimulates pain (Smeltzer, 2008: 34)

Goal: Within the shift, the patient will verbalize that the pain
is reduced from 7/10 to 0-4/10 in a scale of 1/10.

Intervention:

Independent:

1.Assessed pain, character, location, severity, and duration;

used a pain rating scale. Pain assessment can provide clues
about diagnosis, and be used to determine treatment required.
(Rodgers, 2007:604)
2. Accepted client’s description of pain. Acknowledged the pain
experience and convey acceptance of client’s response to pain.
Pain is subjective experience and cannot be felt by others.
(Doenges, 2008:500)
3. Monitored v/s every 4hrs. Slight increase of RR could be
resulted from the possibility of patient’s reaction towards
pain.(Kozier, 2008)
4. Provided non-pharmacological measures.(E.g. back rub, massage,
repositioning). Promotes relaxation and helps refocus attention.
(Rodgers, 2007: 604).
5.Encouraged use of stress management skills/ diversional
activities. (E.g.deep-breathing techniques, music, therapeutic
touch). Enables patient to participate actively in non drug
treatment of pain and enhances sense of control.(Doenges,
2002:817)
6. Allowed patient to air out response to pain. Promotes
relaxation and helps focus attention (Rodgers, 2007: 604).
7.Review client’s previous experiences with pain and methods
found in the past. May be helpful or unhelpful for management
pain control. (Doenges, 2008:501)
8. Observe non verbal cues/ pain behaviors (E.g. how client
walks, holds body, sits, etc.)Observations may/may not be
congruent with verbal reports .(Doenges, 2008:500)

Evaluation: Goal met. The patient verbalized that the pain was
reduced to 2/10 from 7/10.

Problem # 3: Constipated
Assessment:
Cues:
Subjective: Patient’s stated:”sa isang linggo,minsan isa hanggang
dalawang beses lang ako nakakadumi, parang dumi lang ng kambing,
maliliit na kulay itim”
“hirap akong dumumi, sumasakit kasi yung tyan ko kapag
nararamdaman ko na nadudumi ako.”

Objective: hard formed stool, straining with defecation,

abdominal tenderness, and distention.

Nursing Diagnosis: Constipation r/t obstruction secondary to

Sigmoid Adenocarcinoma
Rationale:

Goal: Within the shift, the patient will establish normal pattern
of bowel functioning.

The patient will demonstrate behaviors or lifestyle changes to

prevent recurrence of the problem as evidenced by verbalization
of changing to a healthy lifestyle after 2hrs.of NI.

Intervention:

Independent:
1. Noted color, odor, consistency, amount and frequency of stool.
Provides a baseline for comparison, promotes recognition of
changes.(Doenges, 2008:197)
2. Determined fluid intake. To evaluate client’s hydration
status. (Doenges, 2008:197)
3. Noted activity level and exercise pattern. Sedentary
lifestyle may affect elimination patterns.(Doenges, 2008:197)
4. Palpated abdomen for presence of distention, masses.
(Doenges, 2008:197)
5. Encourage a diet of balanced fiber and bulk. To improve
consistency of stool and facilitate passage through colon.
(Rodgers , 2007:606)
6. Promoted adequate fluid intake, including high fiber fruit
juices. To promote passage of soft stool. (Doenges, 2008:197)
7. Encouraged activity/ exercise within limits of individual
ability. (Doenges, 2008:197)

Dependent:
1. Administer lactulose 30cc H-S as ordered.

Evaluation: Goal not met. The patient did not establish normal
pattern of bowel functioning.
Goal met: The patient was able demonstrate behaviors or lifestyle
changes to prevent recurrence of the problem as evidenced by
verbalization of changing to a healthy lifestyle after 2hrs.of
NI.
Problem # 4: Impaired urinary elimination
Assessment:
Cues:
Subjective: patient stated: “simula kaninang alas sais ng umaga,
naka pitong beses na ako umihi”
“hindi nga ako makatulog ng maayos dahil dito sa pag ihi ko, sa
tuwing naiihi ako, nagigising talaga ako, bumabangon at umiihi.”

Objective:

Nursing Diagnosis: impaired urinary elimination r/t anatomical

obstruction.
Rationale:

Goal: After 2hrs. of NI, the patient will be able to verbalize

understanding of condition.

The patient will achieve normal elimination pattern or

participate in measures to correct/ compensate for defects within
the shift.

Intervention:

Independent:
1. Assessed for signs and symptoms of bladder infection.(Doenges,
2008: 749)
2. Identify conditions that may be present, such as urinary tract
infection.
3. Determined client’s usual daily fluid. Noted condition of skin
and mucous membranes, color o urine. (Doenges, 2008:723)
4.Review medication regimen (Doenges, 2008:723)

Evaluation: Goal met. After 2hrs. of NI, the patient was able to
verbalize understanding of condition.
Goal not met.
The patient was not able achieve normal elimination pattern or
participate in measures to correct/ compensate for defects within
the shift.

Problem # 5: disturbed sleeping pattern

Assessment:
Cues:
Subjective: patient stated: “hindi nga ako makatulog ng maayos
dahil dito sa pag ihi ko, sa tuwing naiihi ako, nagigising talaga
ako, bumabangon at umiihi.”
“pagising gising talaga ako kasi hindi ko mapigilan yung pag ihi
ko, matutulog ako, tapos maya maya gigising nanaman para lng
umihi, hindi ko na alam ang gagawin ko”
“hindi ako makatulog kagabi kasi mainit”

Objective: restlessness, irritability, slowed reaction

Nursing Diagnosis: Sleep deprivation r/t prolonged discomfort

Rationale:

Goal: The patient will report improvement in sleep/rest pattern

within the shift.

Intervention:

Independent:
1. Determined presence of physical or psychological stressors.
(Doenges, 2008:631)
2. Noted Medical diagnosis that affect sleep. (Doenges, 2008:632)
3. Noted environmental factors that affect sleep. (Doenges,
2008:632)
4. Determined client’s usual sleep pattern. (Doenges, 2008:632)
5. Observed physical signs of fatigue. (Doenges, 2008:632)
6. Recommended quiet activities such as, listening to soothing
music. (Doenges, 2008:632)
7. Provided calm, quiet environment and manage controllable
sleep-disrupting factors