Date: January 8, 2015 Time: 6:00 pmEvaluated by: Mary Carolene Saur and Ylron John Tapar

System ROS Mode of Assessment

Ideal Observed Significance

A. General/Overall Health Status

“Okay naman ang pakiramdam ko.” As verbalized by the patient.

Inspection There should be no sign of pain. Appearance is clean and neatly dressed according to the environment. The patient should exhibit body symmetry. No obvious deformity and a well appearance.

No sign of pain. Appearance is clean and neatly dressed. No sign of discomfort.

B. Integument (skin, hair, nail)

“Wala ako nararamdaman na kakaiba sa balat ko per hindi ako nakakapag suklay ng buhok.” As verbalized by the patient.

Inspection The skin varies from whitish pink to brown color depending on the patient’s race. Skin should be dry with a minimum of perspiration. The nail surface should be smooth and slightly rounded or flat. Skin should be dry with minimum perspiration.

Patient’s skin is dry. No sign of alopecia but dandruff or flakes is visible from his head and on his shoulder. Nail beds are clean no splintering or brittle edges.

Dryness of head may be caused by cold air, combined with overheated rooms which can causes itchiness. Not enough shampooing may cause the flakes or improper use of shampoo.

C. Head “Hindi nasakit ang ulo ko.” As verbalized by the patient.

Inspection and palpitation.

Generally round and proportional to the body. No swelling, lesions, tenderness noted upon palpation.

No occurrence of swelling, lesions and tenderness. Patient didn’t complain of any pain during palpitation.

D. Eyes “Malinaw naman mga mata ko” as verbalized by the patient.

Inspection and palpation

Eyes are evenly place and in line with each other. Sclera is white; conjunctiva is pink. Eyelids should appear symmetrical. The pupils should be completely black, round and equal diameter.

Eyes are symmetrical; pupils are deep dark, and sclera appears to be white.

No presence of swelling or any lesions.

No presence of discharge or cloudiness.

E. Ears “Wala naman problema sa pandinig ko.” as verbalized by the patient.

Inspection and palpation

Patient should be able to hear and respond well to our questions. The position of the ears should be proportional to the head.

Ears are symmetrical and there’s no appearance of lesions or skin discoloration.

The ear pinna is align from the outer canthus of the eye to the occiput.

Review of System/Physical Assessment

The patient did not complain of pain or tenderness during palpation.

F. Nose and Sinuses “Wala na ako sipon. Nakakahinga naman ako ng maayos” as verbalized by the patient.

Inspection and palpation

No evidence of swelling around the nose, eyes, and sinuses. Located symmetrically in the midline of the face.

Nostrils are patent; patient can perform normal breathing. No swelling or tenderness felt during palpation at the site of the sinuses.

G. Mouth and Throat “Hindi naman nangangati lalamunan ko, medyo dry lang ang labi ko.” as verbalized by the patient.

Inspection The lips should be moist and pink with no evidence of lesions or inflammation. The throat is normally pink and vascular and without swelling or lesions.

The patient’s lips are slightly violet and dry. There’s no sign of inflammation. The throat is pink; there’s no sign of inflammation.

Lips are dry from dehydration, which is due to lack of oxygen in the blood.

H. Neck “Hindi naman sumasakit ang leeg ko.” as verbalized by the patient.

Inspection and palpitation

There should not be any sign of mass and lumps. Symmetrical and no distention.

The patient’s neck is normal no nodules and lesions found. No pain experienced during palpation of the neck.

I. Breast and Axillary “Normal lahat.” as verbalized by the patient.

Inspectionpalpation

There should not be lumps or nodules. Breast is symmetry -no breast edema-no swelling -no discharges-no lesions-lympnodes are not palpable-lympnodes are movable

J. Respiratory “May konting ubo parin ako.” as verbalized by the patient.

Inspection and vital signs

There should be no difficulty of breathing. The respiratory rate should be between 12-20 cycles per minute. No wheezing, difficulty breathing or chest pain.

-no barrel chest -no pectus carinatum -no pectus excavatum-no kyphosis-shoulders are in the same height-no masses-no use of accessory muscle(+) sputum productionthin watery sputum(+)cracklesRR- 20

Crackles are due to water @ the lung parenchyma

K. Cardiovascular “Medyo mataas ang blood Vital signs and Blood pressure should not be over 120/80 and Patient has a blood pressure of Abnormal increase of blood

pressure ko.” as verbalized by the patient.

inspection not lower than 90/60. Heart rate should range around 60-100 beats per minute.

130/90.No pulsation @ aortic,pulmonic,tricuspid,mitralRadial pulse is palpated

pressure is because of the constriction of the small arterioles.

L. Gastrointestinal “Wala nasakit sa tyan ko.” As verbalized by the patiet.

Inspection and Palpation

It should be no presence of tenderness and masses.

Theres no retractions -for respiration the abdomen rise during inhalation and falls dung exhalation.

- No masses or nodules presented

M. Urinary “Hindi ako nahihirapan umihi.” As verbalized by the patient.

Inspection and patient’s urinalysis

results.

No difficulty elimination urine. Urinalysis normal value: yellow color, clear, pH level 4.5 – 8, negative protein and glucose.

Patient has a normal input and output. Urinalysis came out normal with the result of yellow urine, clear, pH level of 7.0., negative protein and glucose in the urine.

N. Genitalia “Normal lang din.” As verbalized by the patient.

Inspection Skin is free of lesions and inflammation. No abnormal discharge or masses.

There’s no lesions, rash or inflammation. Patient denied any abnormal discharge or masses.

O. Musculoskeletal “Minsan sumamasakit yung tuhod ko pag nakatayo ng matagal.” as verbalized by the patient.

Inspection Muscle and joints should not have difficulty moving.

Knee hurts after walking or standing up for a long time. No stiffness, swelling, cramps, or weakness is felt in any part of the body.

Due to degenerative process and decrease muscle strength in lower extremities related to activity intolerance.

P. Neurologic “Wala naman ako nararamdaman na kakaiba.” As verbalized by the patient.

Inspection and interview

No history of abnormal motor function, sensory function, and mental status.

No history of seizure disorder, stroke, fainting or blackouts. No abnormalities in the patient’s mental status.

Q. Endocrine “Wala naman ako nararamdaman na symptoms ng diabetes.”

Inspection Normal Findings:WBC 5.0-10RBC 4.0-5.5Hemoglobin 120-160

No signs of abnormalities.

R. Hematologic “Hindi naman ako madali magka-bruise o magkasugat sa bibig.” As verbalized by the patient.

Laboratory Results and inspection

No bleeding tendency of skin or mucous membrane, excessive bruising, lymph nodes swelling, exposure to toxic agents or radiation.

Patient appears to be normal. No evidence of abnormal excessive thirst, hunger, or urine production. No abnormal hair distribution and no signs of nervousness.

July 15, 2015

Procedure Indication Normal value/ Findings

Actual Findings

Implication Nursing Responsibilities

CLINICAL CHEMISTRY SECTION- BLOOD 7/15/15HbA1c Glycated Hemoglobin or

Glycohemoglobin is a test that shows how well your diabetes is being

controlled. It is an average of the blood sugar control over the past 2 to 3

months and is used along with home blood sugar monitoring to make adjustment to diabetes medicine.

4. 3 – 6.4 % 6.4 % Hemoglobin A1c levels between 4. 3 % to 6.4 %, Hemoglobin A1c levels between 5.7% and 6.4% indicate increased risk of

diabetes, and levels of 6.5% of higher indicate diabetes.

Take a sample of blood by inserting a needle into a vein in the arm or pricking the tip of

the finger with a small pointed lancet.

CLINICAL CHEMISTRY SECTION- BODY FLUIDS – 7/15/15Fasting blood

sugarPatient must fast for 8 hours 4-10 – 5.90

mmol/L7.71 Having a higher level fasting blood

glucose indicates that the possibility for you to have diabetes is greater.

>Explain to the patient that he may experience slight discomfort.

>Alert the patient of the symptoms or hypoglycemia, weakness, nervousness and hunger.

Creatinine Waste product from the normal breakdown 58-110 mmol/L 102 A normal result of creatinine test means the kidneys are absorbing the creatinine

and it is cleared from the body.

>Tell patient that medication will have to be stopped for 24 hours before the procedure.>Check urine output in 24 hours.

SGPT(Serum Glutamic

pyruvic transaminase)

It is measured to see if the liver is damaged or diseased. Low levels of SGPT are

normally found in the blood. But when liver is damaged or diseased it releases SGPT in the blood stream which makes SGPT go up. Keep track of the effects of medicines that

can damage the liver.

21-72 U/L 164(2x done)

A high result of SGPT test may indicate that the liver is very damage. The damage can be due to the amount of medications

consumed, liver disease, arrhosis and hepatitis.

>Explain the procedure to the patient.>Notify the patient that blood will be drawn from vein; there might be a mild bruising.

Cholesterol This is to identify the amount of cholesterol that is in your body. High amount of

cholesterol can build up in the walls of the arteries and hardens,

0-5.2 mmol/L

2.42 Cholesterol levels are normal which means there is no plaque buildup in the arteries, which lessens the risk for heart

attack and stroke.

>Have cholesterol check every 5 years. People who are at risk for heart attack may

need to be checked more often.

High Density High levels are better. Low HDL 0-1.55mmol.L 0.84 Normal HDL can result to low risk of >To Help boost HDL advice patient to be

Lipoprotein cholesterol put you in higher risk for heart disease. “Good cholesterol” It transport

cholesterol from blood to liver where it is secreted by the body.

having heart disease. The more LDL that can be transported from blood to liver to

be excreted by the body

active, lose extra weight, stop smoking and choose better fats.

Low Density Lipoprotein

“Bad Cholesterol” This test can identify the amount of plaque buildup. Measure a

person’s overall risk of having a heart attack or stroke.

0-3.9 mmol.L

1. 33 Normal LDL result can indicate that there’s low amount of plaque buildup in the body. The lower the LDL the better.

>Recommend to avoid food high in saturated fats and trans fats.

Triglycerides The buildup of fatty deposits in artery walls that increases the risk for heart attack and

stroke.

0-1.69 mmol/L 0.44 Low amount of triglycerides is expected to decrease the risk for heart attack or stroke. Small amount of triglycerides

indicates that there’s low buildup of fatty deposit in the artery which will make the

blood flow nicely.

>Advice Patient to decrease sugar consumption, eat low fat diet, add omega-3 fatty acids in their diet and exercise to avoid

increase level of triglycerides.

Uric acid Determines how much uric acid is present in your blood. The rest can help determine how well your body produces and removes

uric acid.

208-506 ummol/L

350 Patient D.V has normal uric acid which means it is easily dissolved in the blood, filtered through the kidneys and expelled

in the urine.

>Advice patient to refrain from any food or drink for hours before the test.

URINALYSIS URINE 7/15/15Color To assess our overall health to diagnose

medical condition and to monitor medical condition.

Light yellow to amber brown

Yellow Yellow urine is normal. >Ask patient if taking any medications, vitamins, supplements because some drugs

can affect the result of the urinalysis.Transparency Determines the freshness of the urine. Clear or Cloudy Clear Freshly voided urine is transparent or

clear. Cloudy urine may be caused by crystals, deposits, white cells or red cells.

Reaction pH The pH level of the urine can determine if you have an infection, if alkaline, it can

indicate infection.

4.5-8 7.0 Urine PH level is at normal, no infection occurs

Protein Protein in the urine can indicate proteinuria some disease that can cause this are renal

disease, fever, CHF, HPN and others.

0-trace Negative No protein in the urine, which means no kidney disease or kidney damage.

Glucose Glucose level is important to identify diabetes. Diabetes may lower or false the

glucose tends in the urine.

0-trace Negative Negative glucose in the protein may indicate that the patient doesn’t have

diabetes.Specific Gravity Specific Gravity with increase with the

amount of dissolved particles in it.1.005 to 1.125 1.015 Valves that remain1.010 regardless of

fluid intake, occurs in chronic glomerulonephritis with extreme renal

damage.RBC RBC in the urine may indicate infection or

inflammation of the urinary tract infection.0-3 0-2/HPF Normal RBC count can simplify that the

patient does not have any inflammation or infection.

Epithelial cells In urinary tract conditions such as Rare Rare amount of epithelial cells implies

infections, inflammation and malignancies, more epithelial cells are present.

that there is less chance of infection in the urinary tract.

BODY FLUIDS 7/15/15Red blood cells If RBC is low (anemia) The body may not

be getting the oxygen it needs. If it’s too high there’s a chance that it will clamp together and block the blood vessels

(Capillaries)

4.50-6.00 x10^12/L

5.20 There’s a normal amount of RBC in the body, which may imply that the body is

getting the consistent amount of oxygen it needs.

>Explain the procedure to the patient.>Explain the possible results.

Hematocrit Measures the amount of space (volume) red blood cells take up in the blood. Shows if

anemia or polycythemia is present.

0.40-0.54% 0.48 There’s normal amount of hematocrit, which means the patient is not suffering of

anemia or polycythemia.Hemoglobin Measures the amount of hemoglobin in

blood and is a good measure of the bloods ability to carry oxygen throughout the body.

120.00-160.00g/L

157 The amount of hemoglobin in the blood is normal which makes oxygen distribution

throughout the body easy.White blood Cells Gives information about the immune

system. Too many or too low can help find and infection, an allergic or toxic reaction to

medicine or chemicals.

4.50-10.00x 10^9/L

6.9 The white blood cells level is normal and this implies that the body is producing enough WBC that will help fight off

infections.Lymphocytes Crucial to the immune system. There are T

cells, B-cells and killer cells. These cells act to recognize antigens produces antibodies,

or even to kill cells that could cause damage.

0.20-0.40 0. 38 There’s a normal amount of lymphocytes in the patients’ blood, which will help kill cells that may cause damage to the body.

Monocytes Response to inflammation signals, they can move quickly to sites of infection in the

tissues and divide into macrophages to elicit an immune person.

0.00-0.07 0.10 An increased percentage of monocytes may indicate chronic inflammatory

disease, parasitic, infection, tuberculosis and viral infection

Eosinophil Help protect body from harmful bacteria, as well as in parasites that can steal important

nutrients from your body.

0.00-0.05 0.06 Slightly high amount of eosinophil may imply that there’s stress, inflammation, a fever from virus, disease that results from abnormal activity of the immune system.

IV. Problem List

A. Actual or Active

Problem No. Problem (Chief Complain) Date Identified Date Resolved

1Ineffective Airway Clearance July 16, 2015 July 16, 2015

2Increase Blood Pressure July 16, 2015 July 16, 2015

3Self Care Deficit July 16, 2015 July 16, 2015

A. High Risk or Potential

Problem No. Problem Date Identified

1Risk for Activity Intolerance July 16, 2015

2Risk for Mild Anxiety July 16, 2015

3Risk for Fall July 16, 2015

Date:

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

NCP: Ineffective Airway Clearance

Subjective:

“May konting ubo parin ako.” as verbalized by the patient.

Objective:

Wheezing Rapid and

shallow breathing

Noisy breathing

Cough every 2 minutes

Phlegm production: white, watery and thin

Ineffective airway clearance related to presence of phlegm production.

The inflammation and increased secretions make it difficulty to maintain a patent airway, which is caused by decrease ability to expel the excessive mucous produced that will lead to extensive obstruction of the airway.

ST:After 6 hours of nursing intervention the patient will:

Maintain airway patency

Expectorate secretions easily

Demonstrate reduction of congestion with clear breath sounds, noiseless respiration

Demonstrate behaviors to improve or maintain clear airway.

Monitor respirations and breath sounds (eg. Wheezes)

Evaluate patient’s cough/gag reflex and swallowing ability.

Maintain high backrest during rest and sleep.

Increase OFI

Encourage deep-breathing and coughing exercises

Auscultate breath sounds to identify adventitious sounds.

Encourage/provide opportunities for rest

Indication of respiratory distress and/or accumulation of secretion

Determines ability to protect own airway

To open/maintain open airway when resting and sleeping

Helps in thinning of secretion and easier expectoration

Liquefy viscous secretion

To maximize effort

To ascertain status and note progress

Prevents/reduces fatigue

ST:After 6 hours of nursing intervention patient was able to:

Maintain airway patency

Expectorate secretions easily

Demonstrate reduction of congestion with noiseless respiration

Understand and demonstrate behaviors to improve or maintain clear airway.

Date: July 16, 2015

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

“Hindi ko alam bat lagi mataas ang blood pressure ko?” as verbalized by the patient.

Objective:

Vital signs: BP: 130/90

mmHg PR: 84 bpm 20 cpm 35.7 C

Request for information

Knowledge deficit related to lack of information about the disease process and self-care.

Increase blood pressure means high tension in the artery. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. Normal blood pressure is below 120/80; BP between 120/80 and 139/89 is called prehypertension and blood pressure of 140/90 or above is high. The increase in blood pressure can lead to many conditions like heart disease, renal disease or stroke.

ST: After 6 hours of

nursing intervention, the patient will be able to gain knowledge of his disease and show positive response.

Understand and perform necessary lifestyle changes and participate in treatment regimen.

Ascertain level of knowledge, including anticipatory needs

Determine client’s ability, readiness and barriers to learning.

Define and state the limits of desired BP. Explain hypertension and its effect on the heart, blood vessels, kidney and brain.

Assist patient in identifying modified risk factors like diet high in sodium, saturated fats and cholesterol

Advice to have check ups as often as needed and importance of following treatment regime.

Encourage patient to decrease or eliminate caffeine, soda or chocolates.

Provide active role for client in learning process.

Provide mutual goal setting and learning contracts.

Individual may not be physically, emotionally, or mentally capable at this time.

Provides basis to understand how BP can increase, clarifies that increase in BP can exist without symptoms.

These factors has been shown to contribute to hypertension

Lack of cooperation is common reason for failure of antihypertensive therapy.

Caffeine is a cardiac stimulant and may adversely affect cardiac function

Promotes sense of control over situation and is means for determining the client is assimilating and using new information.

Clarifies expectations of teacher and learner

ST: After 6 hours

of nursing intervention, the patient gained knowledge about this health condition and showed a positive attitude towards it.

Patient is able to perform lifestyle changes in participation to his treatment regimen.

NCP – Increase Blood Pressure

Date: July 16, 2015

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

“Hindi pa ako nakakaligo ngayong araw.” As verbalized by the patient.

Objective:

Discomfort Unfixed

hair Presence of

dandruffs Dry body

skin

Self-care deficit related to lack of motivation in performing proper hygiene.

Having good hygiene is essential to live a healthy life. Washing your hands, cleaning your self after a long day will help decrease the risk of getting disease, infections and bacteria.

ST: After 6 hours of

nursing intervention the patient will identify at least 3 reasons why hygiene is an importance to the health.

Verbalize knowledge of health care practices

Initiate and perform self-care activities within level of own ability

Explain the importance of proper bathing and hair brushing to the patient

Perform and assist with meeting clients needs when he is unable to meet his own needs for example personal care assistance

Plan time for listening to the client’s feelings and concern

To provide appropriate way of doing the procedure

Enhances commitment to plan and helps patient to be motivated

To discover barriers to participation in regimen and to work on problem solution.

ST: After 6 hours of

nursing intervention the patient was able to identify 3 reasons why proper hygiene is important.

Patient was able to verbalize his knowledge of the health care practices

Patient was able to perform self-care activities within level of own ability.

NCP – Lack of Proper Hygiene

Date: July 16, 2015

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME

Subjective:

“Hindi na ako masyado nageexercise.” as verbalized by the patient.

Objective:

Weak lower extremities

Irritability Facial

grimaceVital signs

BP: 130/90 PR: 84bpm RR: 20 cpm T: 35.7 C

Risk for activity intolerance related to prolonged bed rest.

Most activity intolerance is related to generalized weakness and deliberation secondary to acute or chronic illness and or disease.

Adequate exercise is important to prevent getting ill.

Regular physical activity will help control our weight, improve our mood, boosts energy, and promotes better sleep.

Lack of physical activity can lead to obesity.

ST: Participate

willingly in necessary/desired activities

Verbalize understanding of potential loss of ability in relation to existing condition

Identify alternative ways to maintain desired activity level.

INDIVIDUAL: Ask patient about usual level

of energy

Encourage active ROM exercises

Provide positive atmosphere while acknowledging difficulty of the situation for patient

Determine current level and physical condition with observation, exercise tolerance

Discuss with patient the relationship of illness or debilitating condition

COLLABORATIVE: Implement physical

therapy/exercise program in conjunction with the client and other team members for example physical and or occupational therapist.

INDIVIDUAL: To identify potential

problems and/or patient’s perception of energy and ability to perform needed or desired activities

To maintain muscle strength and joint ROM

Helps minimize frustrations and increase energy

Provides baseline for comparison and opportunity to track changes.

Understanding these relationships can help with acceptance of limitations.

COLLABORATIVE: Coordination of

program increases likelihood of success.

ST: Patient will b e

able to participate willingly in desired activities

Patient will verbalize his understanding about potential loss of ability in relation to existing condition

Patient will identify alternative ways to maintain desired activity level.

NCP – Risk for Activity Intolerance

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME

Subjective:

“Hindi ko na nakikita yung mga anak ko.” As verbalized by the patient.

Objective:

Irritability Stressed Worried Expressed

concerns due to change in life events.

Dry lips Sleep

disturbance

Risk for mild anxiety related to loss of presence from the family members.

Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal with threat.

ST: Appear relaxed

and report that anxiety reduced to a manageable level

Verbalize awareness of feelings of anxiety

Demonstrate problem-solving skills

Use resources/support system effectively

INDIVIDUAL: Provide accurate information

about the situation Listen helpful resources and

people including available hotline or crisis manager.

Review strategies, such as role-playing and use of visualizations to practice anticipated events.

Encourage patient to develop and exercise or activity program

Provide opportunities for the patient to make simple decision

Encourage expressions of feelings (fear, sadness, etc.) acknowledge anxiety.

Provide calm, peaceful setting and privacy as appropriate.

INDIVIDUAL: Helps client identify

what is reality based. To provide

ongoing/timely support

Useful for being prepared for/dealing with anxiety-provoking situations

May save to reduce level of anxiety by relieving tension

Enhances sense of control

Enhances trust and therapeutic relationship

Promotes relaxation and ability to deal with situations.

ST: Patient will be

able to be relaxed and at ease, verbalized feelings of anxiety, demonstrate problem-solving skills and use resources system effectively.

NCP – Risk for Mild Anxiety

Date: July 16, 2015

ASSESSMENT NURSING DIAGNOSIS

INFERENCE PLANNING INTERVENTION RATIONALE EXPECTED OUTCOME

Subjective:

Objective:

Lowered side rails

Irritable Decreased

lower extremity strength

Limited ROM

Risk for falls related to impaired physical mobility.

Increase susceptibility to falling that may cause physical harm.

ST: Verbalize

understanding of individual risk factors that contribute to possibility of falling.

Modify environment as indicated to enhance safety

Be free of injury

INDIVIDUAL: Assess muscle straight, gross

and fine motor coordination Review history of prior falls Advice patient to always

keep side rails up Assess mood, coping

abilities, personally styles

COLLABORATIVE:

Refer to rehab team, physical or occupational therapist as appropriate

INDIVIDUAL: To predict current

risk for falls

Promote safety

Individuals and temperament typical behavior, stressors, and level of self-esteem can affect attitude towards safety issues, resulting in carelessness or increased risk-taking without consideration of consequences.

COLLABORATIVE:

To improve patient’s balance, strength or mobility.

ST: Patient will be

able to verbalize his understanding about the risk factors that contributes to the possibility of falls.

Patient will be able to avoid injury.

NCP – Risk for Fall

COMPLIANCE CONTENT

Medication Advice patient to take blood pressure medications exactly as directed. Don’t skip doses. Missing doses can cause your blood pressure to get out of control.

Avoid medications that contain heart stimulants, including over the counter drugs. Check for warnings about high blood pressure on the label. Check with your doctor before taking decongestant some decongestants can worsen high blood pressure. Always take your antibiotics as directed. Explain the side affects of the medication and state their importance.

Environment Encourage patient to provide adequate rest periods and observe and promote personal hygiene. Instruct patient not to do strenuous activity for him to gain back his normal strength. Advice patient to maintain a healthy weight. Exercise at least three hours in a week. Recommend patient to breath warm and moist air to help loosen mucus. Loosely place a warm; we wash cloth over your nose and mouth.

Treatment Continue taking medications as directed. Take deep breaths. Deep breathes help open the airway. Take two deep breaths and cough two or three times every hour. Coughing helps get mucus

out of the body. Drink liquids as directed. Liquids help make mucus thin and easier to get out of your body. Advice patient to lay with their head lower that the chest several times a day and tap the chest area to help loosen mucus.

Health teaching Advice patient to get at least eight hours of sleep every night. Avoid heavy lifting and strenuous activities after discharge. Recommend to patient to control their stress by doing stress management techniques. This will help decrees high blood pressure. Demonstrate and explain hand-washing procedure to decrease the risk of acquiring bacteria.

Out-patient Further inpatient care includes monitoring of changes in vital signs, mucous production, and reinforcement of dietary advice, practice energy-saving techniques and so simple activities.

Have regular check ups to monitor progress of heath and wellness. Encourage patients to consult doctor or go to the nearest hospital if there’s any problem.

Diet Recommend DASH diet to reduce hypertension. Advice to cut back on salt and canned foods. Limit alcohol consumption and limit drinks that contain caffeine. Eat foods riche in vitamin C and increase fluid intake.

Discharge Health Teaching Plans