Daily

Patient
Assignment
By:
Irish Eunice A. Felix
PATIENT'S PROFILE
NAME: Patient E

AGE: 72 years olds

ADDRESS: 296 Zavalla St. Brgy, Kanluran. Sta Rosa City Laguna

SEX: Male

CIVIL STATUS: Widowed

RELIGION: Roman Catholic

BIRTHDAY: March 28, 1948

CHIEF COMPLAINT: Dyspnea, fatigue and dry cough

VITAL SIGNS MONITORING

Date/Time Blood Pressure Pulse Rate Respiratory Rate Temperature
(Day 1)
11-17-20 130/80 mmHg 92 bpm 19 cpm 35.2 °C
2:00 pm
4:00 pm 110/70 mmHg 89 bpm 19 cpm 36 °C
8:00 pm 110/70 mmHg 90 bpm 18 cpm 35.8 °C
(Day 2)
11-18-20
1:00 pm
4:00 pm
8:00 pm
(Day 3)
11-24-20
1:00 pm
4:00 pm
8:00 pm
(Day 4)
11-25-20
1:00 pm
4:00 pm
8:00 pm
(Day 5)
12-01-20
 1:00 pm
4:00 pm
8:00 pm
(Day 6)
12-02-2020
1:00 pm
4:00 pm
8:00 pm
(Day 7)
12-08-2020
1:00 pm
4:00 pm
8:00 pm
(Day 8)
12-09-2020
1:00 pm
4:00 pm
8:00 pm

Daily Medications
Meds Time Time Time
(Dosage,Route of administration, frequency)
Co-Amoxiclav 625mg/tab orally BID 6:00 am 6:00 pm
for 7 days (November 17, 2020)
Levopront Bottle 30ml/1-tsp TID for 5 6:00 am 12:00 nn 6:00 pm
days orally (Nov 17, 2020)

Nursing Care and Management

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective Short term: Independent: After 30
"Nahihirapan airway After 30 minutes- minutes-1 hour
akong huminga clearance 1 hour of nursing  Assess airway  Prioritize the of nursing
dahil sa plema related to intervention, the for patency. maintaining of intervention, the
kong hindi ko persistent client will be able the airway. patient was able
mailabas” as cough and to: to:
verbalized by phlegm  Maintain  Auscultate the  RR and rhythm  Patient was
the patient. airway lungs for the changes are able
patency. presence of early warning expectorate
Objective:  Expectorate normal and signs of the
 Productive the mucus or adventitious impending sputum or
dry cough sputum that breath sounds. respiratoy mucus and
 Dyspnea resides in her difficulties. patient
bronchioles. shows a
  Place client in  To promote lung non
Long term: semi-or high – expansion and desruptive
Vital signs After 3 days of fowlers productive and
BP: 130/80 nursing position. Assist coughing . continuous
mmHg intervention the client with breathing.
RR: 19 cpm client will be able coughing and
PR: 92 bpm to: deep breathing After 3 days of
T: 35.2°C  Maintain exercise. nursing
normal intervention the
breathing  Ask the patient  For the secretion client was able
without any to cough and to move up to to:
signs of deep breathe tracheobronchial  Maintain
repiratory for atleast 3-6 tree. normal
distress and times. breathing
free the without any
upper  Maintain fluid  High fluid intake signs of
respiratory intake helps thin repiratory
tract from secretions. distress and
phlegm. free the
 Auscultate the  To rule out if upper
lungs for the bronchial sounds respiratory
presence of and crackles are tract from
normal and present. phlegm.
adventitious
breath sounds.

 Note the  Unusual

presence of appearance may
sputum; be a result of an
Evaluate the infection, White
color , odor and is normal, Yellow
consistency. or greenish is a
sign of an
infection, Brown
is a sign that
there is a
bleeding, and
Red is a sign of a
fresh blood.

DRUG STUDY
DRUG NAME INDICATION ACTION CONTRAINDICATION ADVERSE REACTION NURSING
RESPONSIBILITY
Brand Name: Used to treat The combination patients with a  Nausea Baseline
Co-Amoxiclac many different of amoxicillin and history of allergic  Vomiting Assessment:
infections clavulanic acid reactions to any  Headache Question for
Generic caused by is used to treat penicillin. It is also  Diarrhea history of
Name: bacteria, such certain infections contraindicated in  Gas allergies, esp.
Amoxicillin or as , pneumonia, caused by patients with a Stomach pain penicillins,
Clavulanate ear infections, bacteria, previous history of  Skin rash or cephalosporins,
bronchitis, including cholestatic renal impairment.
Route, Dosage urinary tract infections of the jaundice/hepatic itching
& Frequency: infections, and ears, lungs, sinus, dysfunction  White patches in
625mg/tab infections of skin, and urinary associated with your mouth or Intervention/
orally BID for the skin. tract. Amoxicillin amoxicillin/ throat evaluation
7 days is in a class of clavulanate  Vaginal yeast Promptly report
medications potassium. infection (itching rash diarrhea
called penicillin- or discharge) (fever, abdominal
like antibiotics. It pain, mucus and
works by stopping blood in stoolmay
the growth of indicate
bacteria. antibiotic-
associated
colitis). Be alert
for signs of
superinfection,
including fever,
vomiting,
diarrhea, black
"hairy" tongue,
ulceration or
changes of oral
mucosa, anal/
genital pruritus.

Brand Name: For the Paracetamol may Excessive mucus GI Tract: nausea;  Give with
Levopront symptomatic cause analgesia discharge and vomiting; heartburn; meals if GI
relief of cough. by inhibiting CNS limited mucociliary abdominal upset occurs;
Generic prostaglandin function. Severe discomfort; diarrhea.  Give after
name: synthesis. The liver impairment. CNS: exhaustion, meals if
Levodropro- mechanism of faintness; drooling or
pizine morphine is somnolence, nausea
believed to clouding of occurs.
Route, Dosage involve decreased consciousness  Ensure
& Frequency: permeability of (stupor); numbness; patient voids
Levopront the cell dizziness; headache. before
Bottle membrane to CVS: palpitations. receiving
30ml/1-tsp sodium, which Hypersensitivity each dose if
TID for 5 days results in reactions may occur urinary
orally diminished in predisposed retention is a
transmission of patients because problem.
pain impulses Levopront contains  Take this
therefore parabens. drug exactly
analgesia. as Rx.
Allergic skin reactions  Report
were observed in difficult or
very rare cases. painful
Consult the physician urination,
or the pharmacist in constipation
the event other side rapid or
effects appear. pounding
heartbeat,
confusion,
eye pain.
FDAR (Focus Charting)
DATE/TIME FOCUS DATA/ACTION/RESPONSE
Day 1 Difficulty of D: Subjective:
breathing due to "Nahihirapan akong huminga dahil sa plema kong
November 17, 2020 hindi ko mailabas” as verbalized by the patient.
cough and phlegm
1:00 pm Objective:
 Productive dry cough
 Dyspnea with elevated shoulders
 Restlessness

Vital signs
BP: 130/80 mmHg
RR: 19 cpm
PR: 92 bpm
T: 35.2°C

A: - Assess airway for patency.

- Assess the respiratory function, such as breath
sounds, rate, rhythm, and depth.
- Ask the patient to cough and deep breathe
for atleast 3-6 times.
- Maintain fluid intake.
- Auscultate the lungs for the presence of normal
and adventitious breath sounds.
- Note the presence of sputum;
Evaluate the color, odor and consistency.
- Give cough suppressants drugs as
physician's order.

R: -Patient was able expectorate the remaining

sputum or mucus and patient shows a continuous
breathing.