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providing support / care and have great impact on client’s quality of life. 
 Discussed specific pathology and individual potentials to SO. 
Rationale- aids in establishing realistic expectations and promotes understanding of current situation and needs. 
 Reviewed current restrictions and discussed potential resumption of activities to SO. 
Rationale- Promotes understanding, provides hope for future and creates expectation of resumption of more normal life 
 Discussed plans for meeting self-care needs to SO 
Rationale- varying levels of assistance may be required evaluation and modification to meet individual needs. 
 Reviewed importance of balanced diet to SO 
Rationale- improves general well-being and may provide energy for life activities. 
Evaluation 
 Goal met. After 8 hours of duty patient’s SO manifests increased knowledge and awareness about meningitis. 
Date: 
Subjective cues 
 no subjective cues noted 
Objective cues 
 Presence of bad breath (halitosis) 
 Patient is on NGT feeding 
 With O2 inhalation at 2-4 L/min 
 Glasgow Coma Scale of 6 
• Eye opening – no response – 2 
• Motor response – extends abnormally – 2 
• Verbal response – no response – 2 
 On Intravenous Fluid at 60-70 microgtts/min 
Nsg. Dx. 
 Poor oral hygiene r/t low level of consciousness as evidenced by halitosis 
Planning 
 After 10 minutes of duty, patient will have improved oral hygiene 
Intervention 
Independent: 
 Performed oral care (using toothpaste and brushed teeth) 
Rationale- to minimize bacteria accumulation in the mouth that can cause certain oral disease. 
Dependent: 
 Refer to physician 
Rationale- identify further needs or treatments 
Evaluation 
 Goal met. After 10 minutes of rendering nursing care, bad breath is absent and oral cavity is cleansed. 
1 
Subjective cues 
 “magpaaso man siya kay murag maglisod usahay pagginhawa” as verbalized by SO 
Objective cues 
 V/S: 
 With O2 inhalation at 2-4 L/min 
 Wheezing sound noted upon auscultation 
 Audible rales heard at left base upon auscultation 
 Breathing pattern shallow and rhythmic upon inspection 
 Glasgow Coma Scale of 6 
• Eye opening – no response – 2 
• Motor response – extends abnormally – 2 
• Verbal response – no response – 2 
 On NGT feeding 
 On Intravenous Fluid at 60-70 microgtts/min 
Nsg. Dx. 
 Ineffective airway clearance r/t increased sputum production as evidenced by abnormal breath sounds and dyspnea 
Planning 
 After 2 hours of duty patient will manifest comfort in breathing and normal breathing pattern 
Intervention 
Independent 
 Elevated head of bed to semi-Fowler’s and changed position to side lying every 2 hours 
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