RESULT OF INTERVIEW WITH SIGNIFICANT FINDINGSA. Interaction PatternsAccording to the daughter of Aling Adela named Pat-pat, her mother is always busy at work. They (children) are always in-charged for planningactivities at home. Sometimes if they are planning to go out as family, Aling Adela is not interested to join, she instead advises her children to becareful and take extra responsible.B. Economic PatternsAling Adela is the only one who supports and works for her family. Her husband died a couple of years ago from emphysema. Aling Adela works as"laundry woman" in their neighborhood. And sometimes work as extra in the farm during harvest of rice. The client wakes up as early as 4:00AM andwork until 6:00PM. Her eldest daughter Tin-tin admitted that the income of her mother is not sufficient to support them in their everyday needs as welas other expenses such as payment for food and education.C. Cognitive PatternsAling Adela just finished Grade 5 and has difficulty understanding her present condition. She sometimes cries at the corner and always thinks whatwould happen to her family if she suddenly passed away.List of Possible Nursing DiagnosesIneffective Airway ClearanceImpaired Gas ExchangeIneffective CopingActivity IntoleranceAnxietyIneffective Breathing PatternRisk of InfectionImpaired Social InteractionKnowledge DeficitAnticipatory GrievingNursing Diagnosis #2_Subjective, Objective, Measurement:Impaired Role PerformanceHopelessnessImpaired skin IntegrityPRIORITIZATION OF PROBLEM AND CLUSTERED CUES/CLUES:Nursing Diagnosis #1 (Problem and Etiology qualifier secondary to/related to)Subjective, Objective, Measurement:_PowerlessnessManagement, ineffective therapeutic regimenImpaired Oral mucus membraneSelf care deficitNursing Diagnosis #3_Subjective, Objective, Measurement:Example: Ineffective airway clearance related to foreign body in airway as evidenced by:Objective:Ineffective cough Nursing Care Plan FormulationInstructions:1. Refer to the clinical situation given below;2. Cluster all cues/clues and make a list of prioritized nursing diagnoses;3. Formulate a Nursing Care Plan with at least three prioritized (3) diagnoses: Apply PES (Problem, Etiology, Signs & Symptoms fo each nursingdiagnosis)BIOGRAPHIC DATA:Name of Client: Adela B. CruzAddress: 22 Halcion St., Brgy. Panatag, Mandaluyong CityAge: 46Educational Attainment: Grade 5 (Elementary Level)Civil Status: WidowReligion: Roman CatholicAdmitting Diagnosis: AsthmaChief Complaint: Difficulty of breathingAttending Physician: Jaycee H. Santos, MDHISTORY OF PRESENT ILLNESS: On April 3, 2021 Aling Adela experienced difficulty of breathing. She was accompanied by her neighbor atZapanta Maternity Hospital and was given nebulization and unrecalled medications, 3 days PTA. Then she was brought again to San Jose DistrictHospital due to difficulty of breathing and cough.RESULT OF PHYSICAL ASSESSMENT (as of April 5, 2021): Client is wearing a "daster", she hasn't taken a bath for 2 days. Client stands 5'1"and weighs 50 kilograms. Her hair is not combed. Client cannot perform her activities of daily living.Vital signs take as follows:BP120/80 mm HgRR-32 bpmPR-88 bpmT-37.2 °CMrs. Cruz's skin is brown in color, no lesion but texture is rough and dry. The nurse recalls that according to Kozier, Fundamentals of Nursingpage 702 implies that the degree to which the skin protects the underlying tissues from injury depends on the general health of the cells, theamount of the subcutaneous tissue, and the dryness of the skin. Skin that is poorly nourished and dry is less easily protected and none vulnerableto injury. Adela was also complaining "my skin is itchy, when I scratch it, it whitens out".• Examination of the skull shows no palpable mass, no lesions, hair are very distributed and black in color with some white strands. Facialexpression due to difficult and labored breathing, there is flaring of nares and dryness of the mucus membrane.• Chest examination revealed crackles upon auscultation and she uses her accessory muscles of respiration to breathe, forcing the shouldergirdle upward and causing the supraclavicular fossae to retract on inspiration. Abdominal muscles also aid in her breathing.• Upper and lower extremities are symmetrical, no lesion, able to do simple extension, flexion, and no audible clicks heard during joint movement.Active range of motion exercises are not performed because it aggravates the difficulty of breathing.

Question

RESULT OF INTERVIEW WITH SIGNIFICANT FINDINGSA. Interaction PatternsAccording to the daughter of Aling Adela named Pat-pat, her mother is always busy at work. They (children) are always in-charged for planningactivities at home. Sometimes if they are planning to go out as family, Aling Adela is not interested to join, she instead advises her children to becareful and take extra responsible.B. Economic PatternsAling Adela is the only one who supports and works for her family. Her husband died a couple of years ago from emphysema. Aling Adela works as&#34;laundry woman&#34; in their neighborhood. And sometimes work as extra in the farm during harvest of rice. The client wakes up as early as 4:00AM andwork until 6:00PM. Her eldest daughter Tin-tin admitted that the income of her mother is not sufficient to support them in their everyday needs as welas other expenses such as payment for food and education.C. Cognitive PatternsAling Adela just finished Grade 5 and has difficulty understanding her present condition. She sometimes cries at the corner and always thinks whatwould happen to her family if she suddenly passed away.List of Possible Nursing DiagnosesIneffective Airway ClearanceImpaired Gas ExchangeIneffective CopingActivity IntoleranceAnxietyIneffective Breathing PatternRisk of InfectionImpaired Social InteractionKnowledge DeficitAnticipatory GrievingNursing Diagnosis #2_Subjective, Objective, Measurement:Impaired Role PerformanceHopelessnessImpaired skin IntegrityPRIORITIZATION OF PROBLEM AND CLUSTERED CUES/CLUES:Nursing Diagnosis #1 (Problem and Etiology qualifier secondary to/related to)Subjective, Objective, Measurement:_PowerlessnessManagement, ineffective therapeutic regimenImpaired Oral mucus membraneSelf care deficitNursing Diagnosis #3_Subjective, Objective, Measurement:Example: Ineffective airway clearance related to foreign body in airway as evidenced by:Objective:Ineffective cough Nursing Care Plan FormulationInstructions:1. Refer to the clinical situation given below;2. Cluster all cues/clues and make a list of prioritized nursing diagnoses;3. Formulate a Nursing Care Plan with at least three prioritized (3) diagnoses: Apply PES (Problem, Etiology, Signs & Symptoms fo each nursingdiagnosis)BIOGRAPHIC DATA:Name of Client: Adela B. CruzAddress: 22 Halcion St., Brgy. Panatag, Mandaluyong CityAge: 46Educational Attainment: Grade 5 (Elementary Level)Civil Status: WidowReligion: Roman CatholicAdmitting Diagnosis: AsthmaChief Complaint: Difficulty of breathingAttending Physician: Jaycee H. Santos, MDHISTORY OF PRESENT ILLNESS: On April 3, 2021 Aling Adela experienced difficulty of breathing. She was accompanied by her neighbor atZapanta Maternity Hospital and was given nebulization and unrecalled medications, 3 days PTA. Then she was brought again to San Jose DistrictHospital due to difficulty of breathing and cough.RESULT OF PHYSICAL ASSESSMENT (as of April 5, 2021): Client is wearing a &#34;daster&#34;, she hasn't taken a bath for 2 days. Client stands 5'1&#34;and weighs 50 kilograms. Her hair is not combed. Client cannot perform her activities of daily living.Vital signs take as follows:BP120/80 mm HgRR-32 bpmPR-88 bpmT-37.2 °CMrs. Cruz's skin is brown in color, no lesion but texture is rough and dry. The nurse recalls that according to Kozier, Fundamentals of Nursingpage 702 implies that the degree to which the skin protects the underlying tissues from injury depends on the general health of the cells, theamount of the subcutaneous tissue, and the dryness of the skin. Skin that is poorly nourished and dry is less easily protected and none vulnerableto injury. Adela was also complaining &#34;my skin is itchy, when I scratch it, it whitens out&#34;.• Examination of the skull shows no palpable mass, no lesions, hair are very distributed and black in color with some white strands. Facialexpression due to difficult and labored breathing, there is flaring of nares and dryness of the mucus membrane.• Chest examination revealed crackles upon auscultation and she uses her accessory muscles of respiration to breathe, forcing the shouldergirdle upward and causing the supraclavicular fossae to retract on inspiration. Abdominal muscles also aid in her breathing.• Upper and lower extremities are symmetrical, no lesion, able to do simple extension, flexion, and no audible clicks heard during joint movement.Active range of motion exercises are not performed because it aggravates the difficulty of breathing.

Accepted Answer

Case summary:

The Patient is a 46-year-old woman named Adela B. Cruz who was admitted to the…