nutrition planning: upon discharge, the client will be in his
ideal form based on Bmi pakidagdag sa assessment ung initial BMI
nung patient. kahit anung number un basta dapat below 25Ineffective
breathing pattern Planning: within 8 hours, the client will show
signs of improved breathing pattern as manifested by signs of
eupnea (absence of adventitious sounds, equal lung sounds, normal
RR) and decreased effort in breathing(absence of orthopnea, absence
of the use of accessory muscles) INtervention: Gather baseline
vital signs (rationale: to allow and provide a basis for comparison
for theimprovement 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 [anxiety will increase oxygen demand] place the
client is a position of comfort (rationale: the client alone will
be the one to determine hisor her most comfortable position, in
this case, a high folwer or orthopneic position 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 assist the client and watchers in cleaningclients 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 excess c02 from the body) Monitor the
clients 02 saturation (rationale: 02 saturation determined then
extent of hypoxiaby the patient caused by the ineffective breathing
pattern, the current 02 sat dictates the treatment plan) administer
02 per doctors order (rationale: because of the impairment in the
amount of o2 that the client inhales, providing oxygenation will
aid in preventing hypoxia) adminsiter medications as ordered i.e,
bronchodilators and corticosteroids (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 of therapy the client may move and
dislodgetube. regular assessment ensures that both lung fields are
well-oxygenated to prevent 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 nourishment and is used in different
measurements to determine sustenance) determine client's overall
status i.e, the presence of fever, disease (rationale: disease
increases the bodys metabolism to fight off disease, and may
aggravate the clients current status) 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 proper steps are followed before feeding
(rationale: following the assigned schedule of feeding of the
client ensures that he receives proper noursihment throughout the
day) assess the clients S
