ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Nahihirapan huminga si lola dahil sa plema, as verbalized by the patient relative. Objective: productive cough sputum is thick and brownish in color crackles DOB Deep breathing irritability

Ineffective Airway Clearance related to presence of Secretions secondary to Community acquired pneumonia

After 2 hours of nursing interventions, the clients respiration will improve and difficulty of breathing will be Relieved.

Monitor RR, taking note of the depth and rate, BP, PR Auscultate lung fields, noting presence of adventitious breath sounds Elevate head of bed to high fowlers

To establish baseline data and monitor changes To determine possible bronchospasm or obstruction To facilitate breathing and lung expansion To facilitate in the expulsion of mucus

After 2 hours of nursing intervention, goal was not met as evidenced by an increase in the depth and rate of respirations due to an increase in difficulty of breathing.

Provide health teachings regarding coughing and deep breathing exercise. Encourage client to increase fluid intake to about 2000 mL Administer medications such as expectorants as ordered

To liquefy secretions

To reduce bronchospasm and mobilize secretions

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective : Nanghihina si lola as verbalized by the patient relative. Objective: Ineffective cough Restlessness Use of accessory muscles when breathing Loss of appetite Poor muscle tone

Imbalanced nutrition: less than body requirements related to inadequate intake of nutritious foods secondary to underlying disease as evidenced by loss of appetite and body weakness.

OBJECTIVE: After 5 hours of nursing intervention, the patient will regain body strength and loss of appetite will be relieved. GOAL: At the end of the nursing rotation, the patient will demonstrate behaviours, to regain or and or maintain appropriate weight.

Determine clients ability to chew, swallow, and taste food. Assess drug interactions, disease effects, allergies. Auscultate bowel sounds. Note characteristics of stool (color, amount, frequency etc.) Evaluate total daily food intake. Obtain diary of calorie intake, patterns and times of eating. Emphasize importance of well-balanced nutritious intake.

To determine factors that can affect ingestion and digestion of nutrients. To determine factors that may affect appetite, food intake or absorption. To evaluate degree of deficit

After 5 hours of nursing intervention, the patient regained body strength and loss of appetite has been relieved.

V/s

BP- 140/80 mm/Hg T -36.6 C P- 102 bpm R -41 cpm

To reveal possible cause of malnutrition/change s that could be made in clients intake. To promote wellness

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Subjective : none Objective: V/S BP: 140/80 mmHg T: 36.6 C P: 100 bpm R: 44 cpm With AB With ET DOB Restlessness Irritability

Impaired gas exchange related to ventilation perfusion imbalance.

After 8 hours of nursing intervention the patient will be able to: 1. Demonstrate improved ventilation and adequate oxygenation of tissues by HBGs within clients normal limits. 2. Participate in treatment regimen (e.g., breathing exercises, effective coughing, and use of oxygen) within level of ability/situation. 3. Verbalize understanding of causative factors and appropriate intervention.

Independent: 1. Elevated head of bed/position client appropriately, provide airway adjuncts and suction as indicated. 2. Encouraged frequent deep breathing/ coughing exercises. 3. Auscultated breath sounds noting crackles, wheezes

Independent: 1. To maintain airway

Goal -Met: After 8 hours of nursing intervention the patient was able to demonstrate improved ventilation and

2. Promotes optimal chest expansion and drainage of secretions.

adequate oxygenation of tissues by HBGs within clients normal limits.

3. Reveals presence of pulmonary congestion/ collection of secretion, indicating need for further intervention.

Collaborative: 1. Assisted with procedures as individually indicated (e.g., transfusion, phlebotomy, bronchoscopy.

Collaborative: 1. To improve respiratory function/ oxygen-carrying capacity.

Drug Name

Mechanism of Action

Indication

Contraindication

Side Effects/ Adverse Effects

Nursing Responsibilities

Brand Name: Salbutamol Generic Name : Albuterol Classification : Bronchodilator (respiratory smooth muscle relaxant), betaagonists.

Chemical Effect: Albuterol may reduce chemical mediator release from pulmonary mast cells and improve ability of cilia to clear mucus.

To relieve bronchospasm associated with acute or chronic asthma, bronchitis, or other reversible obstructive airway diseases. Also used to prevent exerciseinduced bronchospasm.

-Contraindicated in patients hypersensitive to drug or its ingredients. -Use cautiously in patients with CV disorders (including coronary insufficiency and hypertension), hyperthyroidism, or diabetes mellitus and in those who are unusually responsive to adrenergics. -Use extendedrelease tablets cautiously in patients with GI narrowing.

-CNS: tremor, nervousness, dizziness, insomnia, headache, hyperactivity, weakness, CNS stimulation, malaise. -CV: tachycardia, palpitations, hypertension. -EENT: dry and irritated nose and throat with inhaled form, nasal congestion, epistaxis, hoarseness. -GI: heartburn, nausea, vomiting, anorexia, altered taste, increased

-Drug may decrease sensitivity of spirometry used for diagnosis of asthma. -When switching patient from regular to extended-release tablets, remember that a regular 2-mg tablet every 6 hours is equivalent to an extendedrelease 4-mg tablet every 12 hours. -Syrup contains no alcohol or sugar and may be taken by children as young as age 2.

Therapeutic Effect: Albuterol is a direct-acting agent that relaxes smooth muscle walls of the bronchi, uterus, and skeletal muscle vascular bed.

appetite. -Metabolic: hypokalemia. -Musculoskeletal: muscle cramps. -Respiratory: bronchospasm, cough, wheezing, dyspnea, bronchitis, increased sputum. -Other: hypersensitivity reactions.

-In children, syrup may rarely cause erythema multiforme or Stevens-Johnson. -The HFA form uses the propellant hydrofluroalkane (HFA) instead of chlorofluorocarbon s. -Alert: Patient may use tablets and aerosol together. Monitor these patients closely for signs and symptoms of toxicity.

Drug Name

Mechanism of Action

Indication

Contraindication

Side Effects/ Adverse Effects

Nursing Responsibilities

Brand Name: Duphalac Generic Name : Lactulose Classification :

Drug passes unchanged into colon where bacteria breaks it down into organic acids that increase the osmotic pressure & slightly acidity colonic contents w/c increase stool softening action.

-constipation -prevention &treatment of portal-systemic encephalopathy

-low galactose diet -Intestinal obstruction

-Abdominal discomfort associated w/flatulence/cramps -prolonged use/large doses may result in diarrhea w/excessive loss of water & electrolytes.

-do not administer if pt. has already pass out stool-give laxative syrup w/ water, juice or milk to increase palatability -do not give other laxativesreplace fluid loss -monitor serum ammonia levels &blood glucose levels.

Drug Name

Mechanism of Action

Indication

Contraindication

Side Effects/ Adverse Effects

Nursing Responsibilities

Brand Name: Fluimucil Generic Name : Acetylcysteine Classification : Mucolytic Agent

-Nausea, rhinorrhea, bronchospasm especially in asthmatics, stomatitis, and urticaria.

-Mucolytic Adjuvant therapy for abnormal, viscid, or inspissated mucus secretion in acute and chronic broncho pulmonary disease (pneumonia, asthma, TB).

-Contraindicated with hypersensitivity to acetylcysteine; use caution and discontinue if bronchospasm occurs.

> Fever, drowsiness, tachycardia, hypotension, flushing, ear pain, eye pain, nausea, vomiting.

> Drug smell strongly of sulfur. Mixing oral form with juice or cola improve sits taste. >Monitor coughs type and frequency. >Warn patient that drug may have a foul taste or smell that some patients find distressing.

IX. DRUG STUDY X. NURSING CARE PLAN