HA NOI MEDICAL UNIVERSITY

ADVANCED NURSING PROGRAM

NURSING CARE PLAN

STUDENT : LE PHUONG THAO

GROUP : 41 CLASS: Y4Q

UNIT : Respiratory center

DATE OF CARE : 25/12/2018 (12th day after admission)

PATIENT’S FULL NAME : Hoang Thai Hoc

UNIT: Respiratory center

ADMISSION DATE: 13/12/2018

AGE/GENDER : 83/ Female

ALLERGIES : no allergies

SOCIAL SUPPORT: Hoang Van Hiep

Phone number: 0979338093

ADDRESS : Huong Son-Ha Tinh

Reason for hospitalization:

bloody cough
Medical diagnosis:

Respiratory failure, Pneumonia has not ruled out recurrent TB, medullary
dysfunction.
Present history:

2 weeks before hospital admission, the patient appeared to have a productive cough
and blood with a small amount, fever, the highest fever up to 39 degrees. Patients
with fatigue, shortness of breath with mild chest pain. The patient was treated for 3
days in the hospital in Ha Tinh province but was less well supported. After that, the
patient was transferred to Bach Mai Hospital.

Medical history:

a. Patient history

Patients with pulmonary tuberculosis were treated 3 years ago with an 8-

month regimen.

b. Family history

No metabolic disorder has been found.

Focus assessment:

1. Admission condition(13/12/2018)

- alert, G=15 point

- cough that produce sputum and blood

- fever

- pale skin and mucosa

- no hemorrhage under the skin, no tumor, no ulcer

- Normal lung sounds, rales in the upper part of the right lung
 -

- no hepatomegaly

- Vital signs: Pulse: 102pbm

BP:118/70mmHg

RR:22 pbm

Temperature: 39oC

SpO2=95%

2. Current assessments (25/12/2018)

a. general conditions:

- alert, G=15 point

- fatigue

- pale mucous and membrane

- no hemorrhage under the skin

- no tumor, no ulcer

- Vital signs: Pulse: 100pbm

BP:130/80mmHg

RR:22 pbm

Temperature: 37oC

- Weight: 50 kg Height: 160 cm

BMI= 19.5 (normal)

b. Cardiovacular system

- Heart rate: 100bpm.

- Blood pressure: BP: 130/80mmHg

 - pale skin,mucous membrane.

- Capillary refill: <2s

c. Respiratory system:

- Respiratory rate: 22 bpm,

- Cough reduced

- Right chest pain when coughing

- Not difficult to breathe

- Lungs have scattered rales

d. Gastrointestinal system

- Abdomen: symmetric, no tumor, no scar.

- Soft, no distention

- Eating by mouth, no vomiting

- stool: yellow, normal

e. Musculoskeletal system

normal

f. Genitourinary system

no has abnormal

Laboratory test

LABORATORY REFERENCE Result RATIONALE/EXPLANATIO

TEST VALUE N

RANGES (ABNORMAL VALUES

ONLY)
WBC 4.0 – 10.0 Gl 4.71
Neutrophils % 45 – 75% 58.1
Lymphocytes % 25 – 45% 21.5
Monocytes % 0 – 8% 16.5
Eosinophils % 0 – 8% 1.0
Basophils % 0 – 1% 0.4
Neutrophils # 1.8 – 7.5G/l 2.74
Lymphocytes # 1.0 – 4.5G/l 1.01
Monocytes # 0 – 0.8G/l 0,78
Eosinophils # 0 – 0.8G/l 0,05
Basophils # 0 – 0.1G/l 0,02
RBC 4.5-5.9 T/l 2.88
HGB 135 – 175g/l 93
HCT 0.41-0.53 l/l 0.291
MCV 80 – 100Fl 100.8
MCH 26 – 34pg 32.1
MCHC 315 – 363g/l 319
Platelets 150 – 400G/l 267
Basic Metabolic
Panel:
Na 133-147 mmol/l 138
K 3.4 – 4.5 4.2
mmol/l
Cl 94 – 111 99
mmol/l
Ure 2.5-6.1 mmol/l 3.1
Creatinine 45-90 µmol/l 65
 Glucose 4.0-6.0 mmol/l 7.71
AST <37 U/L 20
ALT <41 U/L 20
CK 26-140 U/L 87
CK-MB <24 U/L 14
CRP <0.5 mg/dL 14.555 Risk of infection
Coagulation: ‘
Prothombin S 14.2
PT % 70 – 140 % 70.1
PT-INR 1.25
Acid lactic 0.5-2.2 mmol/l 2.34

Arterial blood gas

LABORATORY TEST REFERENCE VALUE Result

RANGES
pH 7.35 – 7.45 7.46
PCO2 35 – 45 mmHg 39
PO2 83 - 108 mmHg 95
HCO3 mmol/L 27,7

OTHER DIAGNOSTICS OR SIGNIFICANT INFORMATION (x-rays, MRI,

other studies):

 images of lesions in the upper lobe and middle lobe of the right lung

 abscess monitoring

NURSING PROCESS

date of care: 25/12/21018

12th day after admission
Diagnosis 1: ineffective breathing pattern related to
failure
Nursing intervention
1. Inspect thorax for symmetry
of respiratory movement
2. Observe breathing pattern:
nasal flaring, pursed-lip
breathing or prolonged
expiratory phase and use of
accessory muscles
3. Assess emotional response
4. Place patient in semi-
fowlers position
5. Encourage sustained deep
breaths by:
 Using demonstration:
highlighting slow
inhalation, holding end
inspiration for a few
seconds, and passive
exhalation
 Utilizing incentive
spirometer
 Requiring the patient to
yawn
6. Provide respiratory
medications and oxygen,
per doctor’s orders.
respiratory
Rationale
1. Determines adequacy of
breathing
2. Identifies increased work of
breathing
3. Detects use of hyperventilation
as a causative factor
4. To have a maximum lung
expansion
5. These techniques promotes deep
inspiration, which increases
oxygenation and prevents
atelectasis. Controlled breathing
methods may also aid slow
respirations in patients who are
tachypneic. Prolonged
expiration prevents air trapping.
6. Beta-adrenergic agonist
medications relax airway
smooth muscles and cause
bronchodilation to open air
passages.
7. This facilitates adequate
clearance of secretions.
8. This is to clear blockage in
airway.
 7. Maintain a clear airway by 9. Encourage frequent rest periods
encouraging patient to and teach patient to pace
mobilize own secretions activity.
with successful coughing.

8. Suction secretions, as
necessary.

9. Encourage frequent rest

periods and teach patient to
pace activity.

Descride outcome:

 Patient’s oxygen saturation will be 90-100% throughout hospitalization.

 Patient’s respiratory rate will be 12-20 breaths per minute throughout
hospitalization

Diagnosis 2: Impaired Gas Exchange related to increased sputum secretions

Nursing intervention Rationale

1. Position patient with head of 1. Upright position or semi-Fowler’s

bed elevated, in a semi-
Fowler’s position as
tolerated.
2. Regularly check the patient’s
position so that he does not
slump down in bed
position allows increased thoracic
capacity, full descent of
diaphragm, and increased lung
expansion preventing the
abdominal contents from
crowding.

3. Turn the patient every 2 2. Slumped positioning causes the

hours. Monitor mixed
venous oxygen saturation
closely after turning. If it
drops below 10% or fails to
return to baseline promptly,
abdomen to compress the
diaphragm and limits full lung
expansion.
3. Turning is important to prevent
complications of immobility, but
 turn the patient back into a
supine position and evaluate
oxygen status.
4. Maintain an oxygen
administration device as
ordered, attempting to
maintain oxygen saturation
at 90% or greater.
5. Help patient deep breathe
and perform controlled
coughing. Have patient
inhale deeply, hold breath for
several seconds, and cough
two to three times with
mouth open while tightening
the upper abdominal muscles
as tolerated.
6. Suction as necessary.
7. Administer medications as
prescribed.
Describe outcome:
 Patient manifests resolution of symptoms of respiratory distress.
diagnosis 3: Fatigue related to decreased hemoglobin and diminished oxygen-
carrying capacity of the blood.
Nursing intervention
1. Assess vital signs
2. Obtain client descriptions of
fatigue
3. Ask client to rate fatigue
4. Assess the patient’s ability to
in critically ill patients with low
hemoglobin levels or decreased
cardiac output, turning on either
side can result in desaturation.
4. Supplemental oxygen may be
required to maintain PaO2 at an
acceptable level.
5. This technique can help increase
sputum clearance and decrease
cough spasms. Controlled
coughing uses the diaphragmatic
muscles, making the cough more
forceful and effective.
6. Suction clears secretions if the
patient is not capable of
effectively clearing the airway.
Airway obstruction blocks
ventilation that impairs gas
exchange.
Rationale
1. To evaluate fluid status and
cardiopulmonary response to
activity
2. To assist in evaluating impact on
client’s life
 perform ADLs, instrumental
activities of daily living
(IADLs), and demands of
daily living (DDLs).
5. limiting strenuous activity,
Establish realistic activity
goals with client and
encourage forward movement
6. Make the patient aware about
the signs and symptoms of
overexertion with activity.
Describe outcome:
 Patient will report improved sense of energy
Diagnosis 4: Imbalanced Nutrition: Less Than Body Requirements
Nursing intervention
1. Measure intake and output
accurately; Monitor weight
daily
2. eat according to the diet of
the hospital
3. Provide covered container
for sputum and remove at
frequent intervals. Assist and
encourage oral hygiene after
emesis, after aerosol and
postural drainage treatments,
and before meals.
4. Maintain adequate nutrition
3. To determine degree of
fatigability
4. Fatigue can restrict the patient’s
ability to participate in self-care
and do his or her role
responsibilities in the family and
society, such as working outside
the home.
5. Changes in heart rate, oxygen
saturation, and respiratory rate
will reflect the patient’s
tolerance for activity.
Rationale
1.
2.
3. Eliminates noxious sights,
tastes, smells from the patient
environment and can reduce
nausea.
4. To replenish lost nutrients.
5. Milk products may increase
sputum production.
6. These measures may enhance
intake even though appetite
may be slow to return.
 to offset hypermetabolic
state secondary to infection.
Ask the dietary department
to provide a high-calorie,
high-protein diet consisting
of soft, easy-to-eat foods.
5. Consider limiting use of milk
products
6. Provide small, frequent
meals, including dry foods
and foods that are appealing
to patient.

Describe outcome:
 Demonstrate increased appetite.
 Maintain/regain desired body weight.

Diagnosis 5: Acute Pain related to persistent coughing

Nursing intervention
1. Assess pain characteristics:
sharp, constant, stabbing.
Investigate changes in
character, location, or
intensity of pain.
2. Monitor vital signs.
3. Provide comfort measures:
back rubs, position changes,
massage. Encourage use of
relaxation and breathing
exercises.
4. Offer frequent oral hygiene.
5. Administer analgesics and
antitussives as indicated.
Rationale
1. Chest pain, usually present to
some degree with pneumonia,
may also herald the onset of
complications of pneumonia,
such as pericarditis and
endocarditis.
2. Changes in heart rate or BP
may indicate that patient is
experiencing pain, especially
when other reasons for changes
in vital signs have been ruled
out.
3. Non-analgesic measures
administered with a gentle
touch can lessen discomfort and
augment therapeutic effects of
analgesics.

Describe outcome:
 control of pain.
 Demonstrate relaxed manner, resting,sleeping and engaging in activity
appropriately.
Diagnosis 6: Risk for Infection
Nursing intervention
1. Monitor vital signs closely,
especially during initiation of
therapy.
2. Instruct patient concerning
the disposition of secretions:
raising and expectorating
versus swallowing; and
reporting changes in color,
amount, odor of secretions.
3. Demonstrate and encourage
good hand washing
technique.
4. Change position frequently.
5. Limit visitors as indicated.
6. Encourage adequate rest
balanced with moderate
activity. Promote adequate
nutritional intake.
Describe outcome:
4. Mouth breathing and oxygen
therapy can irritate and dry out
mucous membranes,
potentiating general discomfort.
Rationale
1. During this period of time,
potentially fatal complications
may develop.
2. Although patient may find
expectoration offensive and
attempt to limit or avoid it, it is
essential that sputum be
disposed of in a safe manner.
Changes in characteristics of
sputum reflect resolution of
pneumonia or development of
secondary infection.
3. Effective means of reducing
spread or acquisition of
infection.
4.
5. Reduces likelihood of exposure
to other infectious pathogens.
6. Facilitates healing process and
enhances natural resistance.
  Achieve timely resolution of current infection without complications.
 Identify interventions to prevent secondary infection.
Diagnosis 7: Deficient Knowledge
Nursing Interventions
1. Discuss debilitating aspects of
disease, length of
convalescence, and recovery
expectations. Identify self-care
and homemaker needs.
2. Reinforce importance of
continuing effective coughing
and deep-breathing exercises.
3. Emphasize necessity for
continuing antibiotic therapy
for prescribed period.
4. Outline steps to enhance
general health and well-being:
balanced rest and activity, well-
rounded diet.
5. Identify signs and symptoms
requiring notification of health
care provider: increasing
dyspnea, chest pain, prolonged
fatigue, weight loss, fever,
chills, persistence of productive
cough, changes in mentation.
6. Instruct patient to avoid using
antibiotics indiscriminately.
Describe outcome:
 Verbalize understanding of condition, disease process, and prognosis.
Rationale
1. Information can enhance coping
and help reduce anxiety and
excessive concern. Respiratory
symptoms may be slow to
resolve, and fatigue and
weakness can persist for an
extended period. These factors
may be associated with
depression and the need for
various forms of support and
assistance.
2.
3.
4. Increases natural defense, limits
exposure to pathogens.
5. Prompt evaluation and timely
intervention may prevent
complications.
6. This may results in upper
airway colonization with
antibiotic resistant bacteria. If
the patient then develops
pneumonia, the organisms
producing the pneumonia may
require treatment with more
toxic antibiotics.
  Verbalize understanding of therapeutic regimen.
 Initiate necessary lifestyle changes.
 Participate in treatment program.

Medicine

Name of drug Dose and route Effects of drugs Side effects of drugs
administration

Tienam 500mg 4

Tavanic 500mg 2
– 100ml

Mucosolvan 3 tablets
30mg
ỏal

Laevolac 15ml 2

Oral