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
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
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)
DRUG STUDY
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 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
DRUG STUDY