PROBLEM PRIORITIZATION

Nursing Diagnosis/ Cues Justification Ineffective breathing pattern related to decreased lung expansion

Objective: The respiratory rate is 25 the patient

seems to be in distress. Dyspnea and orthopnea noted Alteration in depth of breathing Nasal flaring noted Upon the test of lung excursion the patient

the excursion wasn’t full The patient was apprehensive

Subjective: The patient stated “medyo nahihirapan

akong huminga, lalong lalo na pag nakahiga ako”.

He also added “nag-aalala na ko tingin hindi na to normal”

This has been the prioritized problem because breathing pattern is important when it comes to ranking of problems. The sooner this problem gets resolved the lesser the complications like respiratory acidosis that could lead to a crisis.

Acute pain related to presence of tubes and drains

Objective: Guarding behavior, protective gestures,

positioning to avoid pain Facial mask of pain

Subjective: The patient mentioned “hindi ako

makagalaw kasi masakit yung pinapasukan ng tubo ko”

Measurement: The patient rated the pain as 10 in the

scale of 1-10 where 10 it the highest and 1 is the lowest.

This has to be the second prioritized problem next to breathing pattern because pain can affect the treatment and cooperation of the patient it can also adhere his difficulty of breathing due to panic. It also limits his movements as stated by the client, thus slowing down his recovery.

Impaired physical mobility related to discomfort at surgical site

Objective: Inability to move or change position when

lying in bed Needs assistance when sitting down Demonstrates guarding behavior at

surgical siteSubjective:

The patient’s inability to move could slow down his recovery. It could also cause some problems like pneumonia and muscle atrophy.

The patient verbalized “hindi ako makagalaw kasi masakit yung pinapasukan ng tubo ko”

He also added “natatakot din ako matanggal yung tubo kaya ayoko gumalaw galaw.”

Risk for infection related to invasive procedure

Objective: Chest tube attached to the patient.

The fact that the patient has incision site would make him more vulnerable in developing infection directly to his systemic circulation and in his thorax and lungs.