University of San Carlos

College of Nursing
Cebu City

NURSING CARE PLAN

Name of Patient: Arreglado, Bernardo Patient’s Health Profile: Received Pt. lying in bed, conscious and dyspneic with
Age: 77 Sex: M D5LR @ 20-30gtts./min infusing well @ Right Arm w/
O2 @ 2L.
Occupation: Farmer Initial Complaint: Cough
Date of Admission: 02/27/10
Status: Married Religion: Roman Catholic Diagnosis / Impression: Community Acquired Pneumonia

Needs / Nsg Dx Cues Scientific Analysis Objectives Nursing Rationale Evaluation

Interventions

* Physiologic Need *PATHOPHYSIOLOGY OF
* Ineffective PNEUMONIA*
Breathing Pattern r/t. - The invading organism causes
to inflammation of the symptoms, in part, by provoking
lung tissue. an overly exuberant immune
response in the lungs. The small
S: “Katong usa ka blood vessels in the lungs
simana, gihubak na (capillaries) become leaky, and
siya og mayo nya protein-rich fluid seeps into the
naglisod og ginhawa” alveoli. This results in a less
as verbalized by the functional area for oxygen-carbon
daughter of the dioxide exchange. The patient
patient. becomes relatively oxygen
deprived, while retaining
O: Dyspnea potentially damaging carbon
Coughs dioxide. The patient breathes
Appears weak faster and faster, in an effort to
After 4 hours of - Encourage an - To help secretions be - The client was able to
student-nurse client increase in fluid intake readily expelled. utilize different ways
interaction, the client - Position the client in - To expand the lungs to and actions in
will be able to: high fowlers facilitate in effective maintaining and
breathing. breathing effectively
1.) Identify the ways - Teach client in - To facilitate a wide such as the use of deep
in increasing breathing performing deep exchange of gases. breathing exercise and
effectivity. breathing exercise. utilizing the right
2.) Return - Administer meds - As counter-measures position. The client was
Demonstrate Deep (bronchodilators & for bronchospasms. able to follow accurately
Breathing exercise. etc.) prn. and perform correctly
3.) Give the - Monitor vital signs - To be able to assess deep breathing exercise.
importance of and treat complications At first it was hard for
manifesting an arising from tachypnea. him as it automatically
effective breathing - Have client breathe - To correct stimulates coughing
pattern. into paper bag hyperventilation reflex but was able to
adapt. The client
Nasal Flaring bring in more oxygen and blow off - Maintain a caring - To limit level of verbalize “nindot ning
more carbon dioxide. and calm attitude in anxiety. maka.tarong tag
-http://science.jrank.org/pages/5 dealing with the ginhawa kay mas
358 patient makabuhat og lihok ko
- Suction airway as - To promote and nya dili ko magluya
*Own Analysis* needed maintain a patent airway prime.”
- Assess the nasal - To ensure the correct
- Ineffective breathing pattern cannula patency flow of O2
occurs when there is presence of - Encourage adequate - To decrease the
spasms and inflammation of the rest metabolic demands of
lung tissue and parenchyma, these the body.
results in inability of the pt to - Encourage client to - So’s not to aggravate
move air in and out of the lungs as conserve energy the already dyspneic
needed to maintain adequate tissue state of the client.
oxygenation and perfusion.
 University of San Carlos
College of Nursing
Cebu City

DRUG STUDY

Name of Drug: Classification Mechanism of Route & Dosage Contraindications Side Effects Nursing Responsibilities
Generic Name Action
Brand Name
Contraindi
Generic Name: Analgesic; Unknown. Though 500 mg 1 tab q4h cated in patients Anemia, jaundice, -Alert. Many OTC products
Antipyretic to produce PRN for fever hypersensitive to rash, urticaria. contain acetaminophen; be aware
- Acetaminophen analgesia by drug or its of this when calculating total daily
blocking generation components. dose.
Brand Name: of pain impulses,
by inhibiting - Use liquid form for children and
- Calpol prostaglandin patients who have difficulty
- Abenol †◊ synthesis in the swallowing.
- Acephen CNS or the
synthesis or action - Use cautiously in patients with
of other substances history of chronic alcohol use
that sensitize pain because hepatotoxicity has
receptors to occurred after therapeutic doses.
mechanical or
chemical
stimulation. Relieve
fever by central
action in the
hypothalamic heat-
regulating center.
 University of San Carlos
College of Nursing
Cebu City

DRUG STUDY

Name of Drug: Classification Mechanism of Route & Dosage Contraindications Side Effects Nursing Responsibilities
Generic Name Action
Brand Name
Contraindi
Generic Name: Anti-infective A second Adults and cated in patients Phlebitis, - Alert: Don’t confuse drug with
drug; generation children age 13 hypersensitive to Thrombophlebitis, other cephalosporins that sound
- cefuroxime Cephalosporins cephalosporin that and older: 250-mg drug or other diarrhea, hemolytic alike.
sodium inhibits cell-wall tab P.O. b.i.d. for cephalosporins. anemia
synthesis, 10 days. - Absorption of cefuroxime axetil
Brand Name: promoting osmotic Children ages 3 is enchanced by food.
instability; usually months to12
- Kefurox bactericidal years: 30 - Obtain specimen for culture and
- Zinacef mg/kg/day oral sensitivity tests before giving first
suspension P.O. in dose. Therapy may begin pending
two divided doses results..
for 10 days.
 University of San Carlos
College of Nursing
Cebu City

DRUG STUDY

Name of Drug: Classification Mechanism of Route & Dosage Contraindications Side Effects Nursing Responsibilities
Generic Name Action
Brand Name
Contraindi
Generic Name: Respiratory Relaxes bronchial, Adults and cated in patients Tremor, nervousness, -Alert. Don’t confuse albuterol
Drugs; uterine and vascular children age 12 hypersensitive to headache, with atenolol or Albutein or
- salbutamol Bronchodilators smooth muscle by and older: drug or its hyperactivity, Flomax with Volmax
stimulating beta 2 Oral Tables: 2-4 components. tachycardia,
Brand Name: receptors.. mg P.O. t.i.d. or palpitations, nausea - Albuterol may decrease
q.i.d. Maximum 8 sensitivity of spirometry used for
- Aerolin mg q.i.d. diagnosis of asthma.
- Rotacaps Children ages 6 to
- Volmax 12: - Syrup may be taken by children
Oral Tables: 2 mg as young as age 2; it contains no
P.O. t.i.d. or q.i.d. alcohol or sugar.
Maximum, 12 mg
b.i.d.