Nursing Care Plan

Name of Patient: L. M. Age: 82 yrs. Old Chief Complaint: Difficulty of Breathing Admitting Physician: Dr. Abayon

Assessment

Nursing Diagnosis
Ineffective airway clearance related to increased production of bronchial secretions as evidenced by shortness of breath.

Rationale
Precipitating Factors: Predisposing Factors Asthma - Age Presence of - Nutrition Bronchial Secretions

Desired Outcome

Nursing Intervention

Justification

Evaluation

The patient verbalized Ndi ko mayo kaginhawa

After 40 hours of nurse client interaction, my patient will be able to: After 30 mins: 1. Verbalize understanding of the disease process and treatment regimen. After 40 hours: 1. Normal respiration as evidenced and by absence of dyspnea

Independent: - Elevated head of the bed for about 30 degrees and ask the client to assume dorsal recumbent position. - Encouraged deep breathing exercises - Kept environmental pollution to a minimum - Monitored respiratory patterns, including rate, depth, and effort.

- Difficulty of Breathing noted. - Accessory muscles during respiration were used. - Orthopnea noted. -Vital Signs of BP- 160/90 mmHg T- 32. 1 P- 74 bpm R- 28 cpm Strength: Strong Family Support Risk Related Factors: - Asthma

Decreased oxygenation to the tissues of the body Body compensates to the decreased oxygen Body increases pulse rate and respiratory rate Difficulty of breathing (rapid and shallow)

-Elevation of the bed facilitates respiratory function by use of gravity. It also decreases pressure on the abdomen when assuming the position. - Promote chest expansion -Precipitators of allergic type of respiratory reactions that can trigger or exacerbate onset of acute episode. - Assesses the condition of the client - helps in giving adequate oxygen to the client - assess the condition of the client

Reference:
Nurses Pocket Guide 9th Edition

adventitious

breath sounds (wet crackles). 2. Normal cpm 3. Absence of bronchial secretions 4. Normal chest x-ray results breathing

Dependent: -Gave supplemental oxygen as ordered (2LPM via nasal cannula) Collaborative: Obtained blood specimen for Arterial Blood Gas study

pattern: RR = 12-20

Reference:
http//:www.Wikipedia.com

Drug Study

Generic Name

Dosage and Route of Administration

Mechanis m of Action
y

Indication

Contraindication

Adverse Effects

Nursing Consideration

Hydrocortisone
Brand Names:
Ala-Cort, Ala-Scalp, Cetacort, Colocort, Cortef, Cortenema, Hi-Cor, Hycort_, Hytone, Stie-Cort, Synacort, Texacort Cream, gel, lotion, ointment, solution: various strengths Injection: 25 mg/ml, 50 mg/ml; 100 mg/ vial, 250 mg/vial, 500 mg/vial, 1,000 mg/vial Intrarectal aerosol foam: 90 mg Oral suspension: 10 mg/5 ml Retention enema: 100 mg/60 ml Spray (topical): 1% Tablets: 5 mg, 10 mg, 20 mg
Suppresses inflammatory and immune responses, mainly by inhibiting migration of leukocytes and phagocytes and decreasing inflammatory mediators

Classification:
Short-acting corticosteroid

Replacement therapy in adrenocortical insufficiency; hypercalcemia due to cancer; arthritis; collagen diseases; dermatologic diseases; autoimmune and hematologic disorders; trichinosis; ulcerative colitis; multiple sclerosis; proctitis; nephrotic syndrome;aspiratio n pneumonia Itching and inflammation caused by skin conditions

Hypersensitivity to drug, alcohol, bisulfites, or tartrazine (with some products) Systemic fungal infections Concurrent use of other immunosuppressan t corticosteroids Concurrent administration of livevirus vaccines

CNS: headache, nervousness, depression, euphoria, personality changes, psychoses, vertigo, paresthesia meningitis, increased intracranial pressure, seizures CV: hypotension, hypertension, thrombophlebitis, heart failure, shock, EENT: cataracts, glaucoma, increased intraocular pressure, epistaxis GI: nausea, vomiting, esophageal candidiasis or ulcer, abdominal distention, dry mouth, rectal bleeding Hematologic: purpura Metabolic: sodium and fluid retention, hypokalemia, hypocalcemia, hyperglycemia, hypercholesterolemia, amenorrhea, growth retardation, diabetes mellitus Musculoskeletal: osteoporosis, aseptic joint necrosis,muscle pain or weakness

 Instruct patient to take daily P.O. dose with food by 8 A.M.  Urge patient to immediately report unusual weight gain, face or leg swelling, epigastric burning, vomiting of blood, black tarry stools, irregular menstrual cycles, fever, prolonged sore throat, cold or other infection, or worsening of symptoms.  Tell patient using topical form not to apply occlusive dressing unless instructed by prescriber.  Advise patient to discontinue topical drug and notify prescriber if local irritation occurs.  Instruct patient to eat small, frequent meals and to take antacids as needed to minimize GI upset.

Drug Study

Generic Name

Dosage and Route of Administration

Mechanism of Action

Indication

Contraindication

Adverse Effects

Nursing Consideration

Amlodipine

Brand Name:
Amlodipine

Injection: 10 mg/ml Oral solution: 10 mg/ml, 40 mg/5 ml Tablets: 20 mg, 40 mg, 80 mg

Classification:
Calcium Channel Blocker

Inhibit calcium influx through membranes of cardiac and smooth-muscle cells; this action depresses automaticity and conduction velocity in cardiac muscle, reducing myocardial contractility. Also decrease depolarization rate, atrial conduction, and total peripheral resistance.

Hypertensi on, angina pectoris, vasospastic (Prinzmeta l s) angina, supraventr iculartachy arrhythmia s, rapid ventricular rate in atrial flutter or fibrillation

Contraindicated in hypersensitivity to drug, sick sinus syndrome, secondor third-degree atrioventricular block (unless patient has artificial pacemaker in place), and systolic pressure below 90 mm Hg Use cautiously in severe renal or hepatic impairment, advanced aortic stenosis, cardiogenic shock (unless associated with supraventricular tachyarrhythmias), history of serious ventricular arrhythmias or heart failure, concurrent use of I.V. beta-adrenergicblockers, elderly patients, pregnant or breastfeeding patients.

CNS: headache, abnormal dreams, anxiety, confusion, dizziness, syncope, drowsiness, nervousness, paresthesia, tremor, asthenia, psychiatric disturbances CV: peripheral edema, chest pain, hypotension, palpitations, bradycardia, tachycardia, arrhythmias, heart failure EENT: blurred vision, disturbed equilibrium, tinnitus, epistaxis GI: nausea, vomiting, diarrhea, constipation, dyspepsia, dry mouth, anorexia GU: dysuria, nocturia, polyuria, sexual dysfunction, gynecomastia Hematologic: anemia, leukopenia, thrombocytopenia Metabolic: hyperglycemia Musculoskeletal: joint stiffness,muscle cramps Respiratory: cough, dyspnea Skin: rash, dermatitis, pruritus, urticaria, flushing, diaphoresis, photosensitivity reaction, erythema multiforme, Stevens-Johnson syndrome Other: gingival hyperplasia, altered taste, weight gaininjectionsite

 Monitor blood glucose and electrolyte levels, fluid intake and output, and liver and kidney function tests.  Assess vital signs, ECG, weight, and blood pressure in both arms (with patient lying down, sitting, and standing).

Breath sounds
Breath sounds are the noises produced by the structures of the lungs during breathing. Considerations The lung sounds are best heard with a stethoscope. This is called auscultation. Normal lung sounds occur in all parts of the chest area, including above the collarbones and at the bottom of the rib cage. Using a stethoscope, the doctor may hear normal breath sounds, decreased or absent breath sounds, and abnormal breath sounds. Absent or decreased sounds can mean:
y

There are several types of abnormal breath sounds. The 4 most common are:
y y y y

airflow in the windpipe (trachea) or in the back of the throat.

Rales Rhonchi Stridor Wheezing

Glasgow Coma Score Eye Opening (E) 4=Spontaneou s 3=To voice 2=To pain 1=None Verbal Response (V) 5=Normal conversation 4=Disoriente d conversation 3=Words, but not coherent 2=No words......only sounds 1=None Motor Response (M) 6=Normal 5=Localizes to pain 4=Withdraws to pain 3=Decorticate posture 2=Decerebrat e 1=None Total = E+V+M

Rales are small clicking, bubbling, or rattling sounds in the lung. They are believed to occur when air opens closed air spaces. Rales can be further described as moist, dry, fine, and coarse. Rhonchi are sounds that resemble snoring. They occur when air is blocked or becomes rough through the large airways. Wheezes are high-pitched sounds produced by narrowed airways. They can be heard when a person breathes out (exhales). Wheezing and other abnormal sounds can sometimes be heard without a stethoscope. Stridor is a wheeze-like sound heard when a person breathes. Usually it is due to a blockage of

y y y

Air or fluid in or around the lungs (pneumonia, heart failure, pleural effusion) Increased thickness of the chest wall Over-inflation of a part of the lungs (emphysema can cause this) Reduced airflow to part of the lungs