DIAGNOSTIC RESULTS

Result Normal
Reason for Patient Values
(↓ or ↑) Range
Na+ 129mmol/L ↓ 135-148 Resulted from inadequate
sodium intake caused by
profuse loss bowel
movement and inadequate
fluid intake.
K+ 3.7mmol/L 3.50-5.30 WNL
Creatinine 137.02µmol/L 71.0-133.0 Resulted from fluid volume
deficit caused by loss bowel
movement

CHEST X Ray Results

Impression:
> Minimal PTB both upper lobes w/ fibrosis stable
> Bilateral Pneumonia
> Calcified Pleural Plaque ® and Granuloma’s Bilateral Stable
> Pulmonary Emphysema
> Bilateral Pleurodiaphragmatic Adhesion
> Atheromatous Aorta.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS RATIONALE GOAL NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective airway Chronic cough and After 8 hours of nursing  Independent: After 8hrs of nursing
clearance r/t sputum production interventions the client 1. Position the client in an upright 3. An upright or semi-Fowler’s intervention, Goal
The patient verbalizes increased production often precede the will be able to: or semi-Fowler’s position. position facilitates in lung partially met:
“Nabudlayan ako mag of thick and viscous development of 1. Demonstrate effective 2. Encourage to take in fluids and expansion.
ginhawa.” secretions airflow limitation. coughing and clear promote hydration. 4. This liquefies secretions for Client demonstrates
The mucus- breath sounds. 3. Using touch on the shoulder, easy expectoration. effective coughing as
Objective: producing bronchial 2. Maintain patent coach the client to slow 5. The nurses’ presence, evidenced by
wall hypertrophy and airway at all times. respiratory rate demonstrating reassurance, and help in expectoration of
> RR- increased in number 3. Relate methods to slow respirations; making eye controlling the client’s secretions.
23bpm(slightly consequently the enhance secretion contact with the client; and breathing can be very Crackles and
tachypneic) Definition: increase mucus removal. communicating in a calm, beneficial in decreasing wheezing were
> Abnormal A state in which an secretions affect the 4. Identify and avoid supportive fashion. anxiety. decreased in all lung
breathe sounds individual is unable to flow of air and specific factors that 4. Note pattern of respiration. fields.
(wheeze, clear secretions from exchange of gas inhibit effective airway The client was able to
crackles) respiratory tract to and may predispose clearance. 6. Symptoms may be masked breathe with ease as
> Cough with maintain airway the client to plugging 5. Monitor respiratory rate, depth, by chronic respiratory evidenced by a
sputum patency. and infection. Long and ease of respiration. conditions common among decreased in
standing infection older adults. respiratory rate from
> Decrease
results in destruction 23 to 20 breath per
respiratory
Reference: of lung tissue. With 7. Understanding the minute.
excursion.
infection, the 6. Note abdominal breathing, use underlying cause of patient’s
Nurses’ Pocket Guide amount of sputum of accessory muscles, nasal particular ventilatory problem
By: Doenges,Marilyn becomes more flaring, retractions, irritability, is essential to the care of
4th edition page 67 copious and confusion, or lethargy. patient
purulent. 8. These symptoms signal
Breathlessness on increasing respiratory
exertion occurs with difficulty and increasing
increasing severity. hypoxia.
• Collaborative:
1. Administer medications as 1. This drug relaxes bronchial
indicated: and
> Salbutamol(Ventolin) 2. This relaxes smooth muscles
through nebulization of the bronchial tree and
pulmonary blood vessels.
 > Theophylline(Asmasolo CNS stimulation(including
n) the respiratory center)

3. This drug stimulates beta-

receptors thus producing
relaxation of bronchial
smooth muscles.
> Bambuterol(Bambec) 4. To facilitate the demand of
oxygen in the body. And help
in dyspnea.

2. Administer O2 inhalation 2lpm

via nasal cannula.
NURSING CARE PLAN
 CUES NURSING DIAGNOSIS RATIONALE GOAL NURSING INTERVENTIONS RATIONALE EVALUATION
• Independent
1. Ascertain patient’s
beverage preferences, and
set up a 24-hr schedule for
fluid intake. Encourage 1. Relieves thirst and discomfort
foods with high fluid of dry mucous membranes and
content. augments parenteral
2. Monitor urinary output. replacement.
Measure/estimate fluid
After 8 hours of nursing
losses from all sources. 2. Fluid replacement needs are
interventions the client
based on correction of current
will be able to:
deficits and ongoing losses. A
1. Maintain fluid volume
decreased urinary output may
at a functional level.
indicate insufficient renal
2. Verbalize
perfusion/hypovolemia, or
understanding of
polyuria can be present,
FVD results from causative factors and
3. Monitor for sudden/marked requiring more aggressive fluid
loss of body fluid purpose of
elevation of BP, replacement.
intake. FVD can therapeutic
Fluid volume deficit restlessness, moist cough, 3. Too rapid a correction of fluid
develop from intervention.
r/t Diarrhea dyspnea, basalar crackles, deficit may compromise the
inadequate intake 3. Demonstrate After 8 hours of
Subjective: frothy sputum. cardiopulmonary system,
alone if the behaviors participate nursing interventions
4. Weigh daily and compare especially if colloids are used in
decreased intake is and correct fluid loss Goal partially met:
The patient verbalizes with 24-hr fluid balance. general fluid replacement.
prolonged. Cause of as indicated. • Maintain fluid
“gatubig akon pamus- Mark/measure edematous 4. Although weight gain and fluid
FVD includes volume at a
on.” areas, e.g., abdomen, intake greater than output may
abmormal fluid functional level as
limbs. not accurately reflect
losses. Such as, evidenced by
Objective: intravascular volume, e.g., third-
vomiting, nausea, stable vital signs,
Definition: space fluid accumulation cannot
diarrhea, sweating moist mucous
Hyperactive bowel The state in which an be used by the body for tissue
or inability to gain membranes, good
sounds individual perfusion, these measurements
access to fluid. skin turgor, and
Poor skin turgor experiences vascular, provide useful data for
Dry skin cellular or 5. Evaluate patient’s ability to comparison. prompt capillary
Edema at the left leg intracellular swallow. 5. Impaired gag/swallow refill.
and left forearm. deutoration (in reflexes, anorexia/nausea, oral  Demonstrate
excess of needs or discomfort, and changes in level behaviors to
monitor and
Sodium(129 replacement of consciousness/
correct deficit as
mmol/L) capabilities due to cognition are among the factors
appropriate.
failure of regulatory that affect patient’s ability to
Creatine(137.02 mechanisms. 6. Provide skin and mouth replace fluids orally.
mmol/L) care. Bathe every other day 6. Skin and mucous membranes
using mild soap. Apply are dry, with decreased elasticity,
Reference: lotion as indicated. because of vasoconstriction and
reduced intracellular water. Daily
Nurses’ Pocket Guide bathing may increase dryness.
By: Doenges,Marilyn 7. Turn frequently, massage 7. Tissues are susceptible to
4th edition skin, and protect bony breakdown because of
prominences. vasoconstriction and increased
cellular fragility.
• Collaborative
1. Monitor laboratory studies 1. Depending on the avenue of
 Filamer Christian College
College of Nursing
Roxas City

DRUG STUDY

Name of Patient: ________________________ _ Age/Sex: _______________________ Attending Physician: ___________________

Area/ Bed No.: ___________________________ Impression: ____________________ Date: ________________________________

Name of Drug Method of Mechanism of Action Adverse Reaction Special Consideration Nursing Responsibilities Rationale
Administration
Generic Name: Route: Directly relaxes smooth Hypotension, tachycardia, Cardiac, pulmonary and 1. Monitor VS. Measure 1. Expected clinical
muscles of the bronchial arrhythmias renal diseases, diabetes. intake and output. effects include
Theophylinne PO tree and pulmonary blood Concurrent use of improvement in
Brand Name: Timing: vessels. It also exhibits xanthenes. quality of pulse and
CNS stimulation respiration.
Asmasolon 8-6 (including the respiratory 2. Warn patient of side 2. Dizziness is a
center), cardiac effects. (dizziness) common side effect at
stimulation, coronary the start of therapy.
vasodilation, diuresis, and 3. Determine dosage by 3. Individuals
increases gastric acid monitoring response, metabolizes xanthenes
secretion. These actions tolerance, pulmonary at different rates.
are believed to be due to functions and serum Toxicity with levels
inhibition of levels. (should ranged above 20 mcg/ml
phosphodiesterase, thus from 10-20 mcg/ml)
reducing intracellular 4. Administer drug with
hydrolysis of cyclic AMP. full glass of water after 4. G.I. symptoms may be
Classification: Dosage: Indications: Side Effects: Contraindications: meals. relieved by taking oral
Prevention to treatment of Dizziness, drowsiness Hypersensitivity to drug with full glass of
Anti-asthmatic and COPD 1 tab(130mg) reversible bronchospasm xanthine compounds water before meal,
Preparation associated with asthma or although food in
Available forms: Frequency: chronic obstructive stomach delays
pulmonary disease. absorption.
Tablet, Capsule, Elixir, BID
Syrup, Injection
 Filamer Christian College
College of Nursing
Roxas City

DRUG STUDY

Name of Patient: ________________________ _ Age/Sex: _______________________ Attending Physician: ___________________

Area/ Bed No.: ___________________________ Impression: ____________________ Date: ________________________________

Name of Drug Method of Mechanism of Action Adverse Reaction Special Consideration Nursing Responsibilities Rationale
Administration
Generic Name: Route: A prodrug of the Tremor, Headache, Tonic Hyperthyroidism which is 1. Caution patient not to 1. to avoid
adregnergic beta-receptor muscle cramps, not yet under adequate take any prescription hypersensitivity to
Bambuterol PO agonist terbutaline, palpitations control. Severely impaired and OTC drugs unless ordered drugs
wwhich predominantly renal function. Liver prescribed by the
stimulates beta-receptors cirrhosis physician.
thus producing relaxation 2. Instruct Patient if 2. to avoid further
of bronchial smooth hypersensitivity complications.
Brand Name: Timing: muscle, inhibition of the reaction occurs during
release of the endogenous the medication,
Bambec 12 spasmogens, inhibition of immediately notify the
edema caused by physician.
endogenous mediators and
increased mucociliary
clearance. Inhibits plasma
cholinesterase.
Classification: Dosage: Indications: Side Effects: Contraindications:
Bronchial Asthma, Hypersensitivity to
Anti-asthmatic 1 tab Chronic bronchitis, salbutamol, cardiac
Emphysema and other arrhythmia associated
lung diseases where with tachycardia caused
Available forms: Frequency: bronchospasm is a by digitalis intoxication.
complicating factor.
Tablet OD

Filamer Christian College

College of Nursing
Roxas City

DRUG STUDY

Name of Patient: ________________________ _ Age/Sex: _______________________ Attending Physician: ___________________

Area/ Bed No.: ___________________________ Impression: ____________________ Date: ________________________________
 Name of Drug Method of Mechanism of Action Adverse Reaction Special Consideration Nursing Responsibilities Rationale
Administration
Generic Name: Route: Relaxes bronchial and Bronchospasm, OccuNeb has not been 1. Monitor VS, measure 5. Expected clinical
enterine smooth muscle by Hypersensitivity reactions studied for treating acute and record effects include
Salbutamol Neb acting on beta-adrenergic bronchospasms. intake/output. improvement in
receptors quality of pulse and
respiration.
2. Warn patient of side 6. Dizziness is a
Brand Name: Timing: effects.(dizziness) common adverse
reaction at start of
Ventolin Stat therapy.

Classification: Dosage: Indications: Side Effects: Contraindications:

Relief of bronchospasm in Tremor, nervousness, Patient with
Anti-asthma/ 1 neb bronchial asthma, chronic dizziness, insomnia, hypersensitivity to drug or
Bronchodilator bronchitis, emphysema, headache, weakness, its ingredients.
obstructive pulmonary tachycardia and irritated
disease. nose and throat, nasal
Available forms: Frequency: congestion, nausea,
increased sputum, cough
Nebule muscle cramps.