F > Hyperthermia  Encouraged to loosen clothing and straighten

linens for comfort.

D > Received patient sitting on bed with bottle #  Instructed to increase calorie intake.
1D5NSS 1 liter @ 30gtts/min. at the level of 9:15pm > Above IVF consumed and followed-up with
350cc, hooked at the right basalic vein, infusing bottle #2 D5NSS 1 liter regulated at 30gtts/min.
well. 9:30pm > Cefuroxime 750mg given IVTT.
 warm to touch 10:00pm > Vital signs rechecked and recorded.
 flushed skin
 diaphoresis on forehead R > Patient was able to maintain temperature
 T- 38.5°C; PR- 110bpm; RR- 38cpm; BP- within normal range, T- 36.9 °C.
160/60mmHg  with the same IVF at the level of 930cc.
 Endorsed to staff asleep, with the latest V/S of:
A > Bedside care done. T- 36.9 °C; PR- 100bpm; RR- 38cpm; BP-
 Vital signs taken and recorded. 170/70mmHg
 IVF checked and maintained on prescribed
rate. F > Ineffective airway clearance
 TSB done.
 Instructed significant other to continue tepid D > Received patient sitting on a chair with bottle #
sponge bath. 3 PNSS 1 liter regulated at 30gtts/min. at the level
 Temperature rechecked – 37.6°C. of 90cc, hooked at the left metacarpal vein,
 Instructed patient to increase fluid intake. infusing well.
 Instructed significant other not to leave patient  with O2 inhalation via nasal cannula regulated
alone. at 1L/min.
 Kept back dry.  RR—28cpm
6:00pm > Ambroxol 30mg 1 tab given p.o  diaphoresis on forehead
 Demonstrated how to perform deep breathing  pale looking
exercises.  sweating
 Comfort measures performed such as back
rubbing. A > Bedside care done.
 Encouraged to assume different positions on  Vital signs taken and recorded.
bed.
  IVF checked and maintained on prescribed
rate.
 Instructed significant other to keep patient’s
back dry.
 Demonstrated how to perform deep breathing
exercises and pursed lip breathing.
6:00pm > Nebulization with Salbutamol 1 nebule done.
6:15pm > Above IVF consumed and followed – up with
bottle #4 D50.3NaCl 1 liter at KVO rate.
 Encouraged to be in complete bed rest with
bedside commode.
 Instructed significant other not to leave patient
alone.
 Advised t keep patient well ventilated to
facilitate breathing.
 Positioned comfortably in bed.
9:30pm > Cefuroxime 750mg given IVTT.
 Instructed patient and significant other to
prepare soft diet eg. Lugao.
10:00pm > Vital signs rechecked and recorded.
R > Patient was able to maintain effective airway
clearance and had no complaints of difficulty of
breathing.
 with the same IVF at the level of 920cc.
 Endorsed to staff asleep, with the latest V/S of:
T- 36.7 °C; PR- 87bpm; RR- 25cpm; BP-
120/80mmHg
F > Sleep disturbance
D > Received patient sitting on bed awake, with
bottle # 2 PNSS 1 liter regulated at 10gtts/min. at
the level of 350cc, hooked at the left metacarpal
vein, infusing well.
 weak
 restless
 irritable
 T- 37.1°C; PR- 86bpm; RR- 24cpm; BP-
130/90mmHg
A > Bedside care done.
5:00pm > Vital signs taken and recorded.
 IVF checked and maintained on prescribed
rate.
 Determined presence of physical and
environmental stressors affecting sleep.
 Encouraged to have adequate rest periods.
 Advised to increase fluid intake.
 Advised to regularly change clothing when wet.
6:00pm > Distinguished beneficial bedtime habit such
and drinking milk rather than drinking late
evening coffee.
 Encouraged to restrict caffeine and avoid eating
large evening meals.
 Instructed to perform adequate physical
exercise during the day.
 Suggested to abstain frequent daytime naps.
 Instructed to keep back dry.
  Advised to do relaxation technique such as
deep breathing exercise.
8:00pm > Kept comfortable.
 Reminded on S/E.
10:00pm > Vital signs rechecked and recorded.
R > After 4hrs. of nursing interventions the patient
was able to sleep comfortably in bed.
 with the same IVF at the level of 190cc.
 Endorsed to staff asleep, with the latest V/S of:
T- 36.6 °C; PR- 85bpm; RR- 23cpm; BP-
110/80mmHg
F > Body malaise
D > Received patient lying on bed awake, with
PNSS 1 liter regulated at 15gtts/min. at the level of
220cc, hooked at the right cephalic vein, infusing
well.
 weak as seen
 restless at times
 irritable
 slowed movement
 needs assistance in doing ADL’s
 T- 36.2°C; PR- 90bpm; RR- 30cpm; BP-
160/80mmHg
A > Bedside care done such as fixing linens and
pillows.
5:00pm > Vital signs taken and recorded.
 IVF checked and maintained on prescribed
rate.
6:00pm > Isosorbide mononitrate 30mg given p.o
 Encouraged to have adequate bedrest.
 Advised to regularly change clothing when wet.
 Emphasized the importance of maintaining
proper hygiene.
 Encouraged significant other to assist patient in
performing ADL’s.
 Instructed to keep back dry.
7:20pm > Repeat hemoglobin result attached to chart.
 Advised to do relaxation technique such as
deep breathing exercise.
 Instructed to move slowly and steadily.
 Encouraged to perform active range of motion.
 Provided divertional activities by encouraging
conversation to significant others.
 Instructed on complete bed rest.
 Keptcomfortable.
 Instructed on diabetic diet.
10:00pm > Vital signs rechecked and recorded.
R > After 4hrs. of nursing interventions the patient
was able to demonstrate ways to conserve
energy.
 with the same IVF at the level of 130cc.
 Endorsed to staff awake, with the latest V/S of:
T- 36.4°C; PR- 88bpm; RR- 28cpm; BP-
150/70mmHg

F > Ineffective airway clearance
D > Received patient sitting on bed awake, with
PNSS 1 liter regulated at KVO rate at the level of
900cc, hooked at the right metacarpal vein,
infusing well.
 with O2 inhalation regulated at 1L/min. at the
level of 500psi
 pale looking
 restless
 with non-productive cough
 T- 36.2°C; PR- 112bpm; RR-20cpm; BP-
120/80mmHg
A > Bedside care done.
 Vital signs taken and recorded.
 IVF checked and maintained on prescribed rate.
 Auscultated lung fields for alteration in breath
sounds.
5:30m > Referred to Dr. Talan with order carried out.
 Demonstrated to perform effective coughing.
6:00pm > Salbutamol 2ml given thru nebulization.
 Cefuroxime 750mg given IVTT.
 Medication started: glimeperide 2mg and
Multivitamins with Fe 1cap given p.o
 Humulin N 10units administered
subcutaneously at deltoid area.
 Encouraged to do deep breathing exercises.
 Encouraged position of comfort.
 Advised to have adequate bed rest.
 Instructed to keep back dry as always.
 Instructed to increase fluid intake at least 8-10
glasses of water a day.
8:30pm > O2 off temporarily.
 Encouraged to eat nutritious food to maximize
energy production; reminded on soft diet.
 Instructed patient and significant other to
secure materials for OR use.
 Monitored for signs of respiratory distress.
10:00pm > Vital signs rechecked and recorded.
R > After 4hrs. of nursing interventions the patient
was able to maintain effective airway clearance
and had no complaints of respiratory distress.
 with the same IVF at the level of 650cc.
 Endorsed to staff awake, with the latest V/S of:
T- 36.4°C; PR- 108bpm; RR- 19cpm; BP-
130/80mmHg
F > Dizziness
D > Received patient lying on bed asleep, with
PNSS 1 liter regulated at 15gtts/min at the level of
930cc, hooked at the left metacarpal vein, infusing
well.
 “Sige rako malipong.”
 weak
 pale looking
 needs assistance in getting out of bed
 T- 36.7°C; PR- 67bpm; RR-20cpm; BP-
170/100mmHg

A > Bedside care done.
 Vital signs taken and recorded.
 IVF checked and maintained on prescribed rate.
 BP monitored every hour.
8:30pm > Referred to Dr. Talan for IV to follow with
order carried out.
6:00pm > Cefuroxime 750mg given IVTT.
 Encouraged to have adequate rest periods to
prevent fatigue.
 Advised significant other to keep patient’s back
dry.
 Encouraged to eat nutritious foods to maximize
energy production; with low salt, low fat diet.
 Encouraged position of comfort.
 Advised to wear loose and thin clothing.
 BP rechecked – 180/110mmHg.
8:00pm > Clonidine 150mg 1tab given sublingual.
 Instructed to secure Lozartan + HCTZ 50mg HPN
med maintenance.
 Encouraged significant other to assist patient in
doing ADL’s.
 Advised significant other not to leave patient
alone.
10:00pm > Vital signs rechecked and recorded.
R > After 4hrs. of nursing interventions the patient
was able to comfortably position self on bed with
less complaint of dizziness.
 with the same IVF at the level of 590cc.
 Endorsed to staff awake, with the latest V/S of:
T- 36.9°C; PR- 71bpm; RR- 21cpm; BP-
150/90mmHg
F > Noncompliance to therapeutic regimen
D > Received patient sitting on bed awake and
responsive upon interaction, without IVF.
 unable to secure medication
 refuse for IVF insertion
 T- 37.2°C; PR- 82bpm; RR-21cpm; BP-
130/90mmHg
A > Bedside care done.
 Vital signs taken and recorded.
 IVF checked and maintained on prescribed rate.
6:00pm > U/A result referred to Dr. Barrosa with order
carried out.
6:15pm > Referred to Dr. Kho – not around.
 Allopurinol 100mg 1tab given p.o.
 Determined who manages the medication
regimen and ascertained whether they know
the indication of the medication.
 Ascertained how client remembers to take
medication and how many doses hve been
missed and the possible effects if not taken
regularly.
 Identified factors that interfere with taking
medication or lead to lack of compliance to
treatment eg. financial constraints.
 Noted length of illness.
  Encouraged client to maintain self-care
activities and providing for assistance when
necessary.
 Provided health teaching:
- Instructed to keep back dry always.
- Advised to change to clean clothing.
- Instructed to wear loose clothing.
- Reminded to increase fluid intake.
 Advised to secure medication.
 Reminded patient and significant other on soft
diet.
10:00pm > Vital signs rechecked and recorded.
R > She was able to verbalize the importance of
securing medications.
 Endorsed to staff awake, with the latest V/S of:
T- 37.4°C; PR- 80bpm; RR- 20cpm; BP-
100/80mmHg
Name of patient: Migduyan, Myrna
F > Dizziness
D > Received patient sitting on bed, coherent,
responsive, oriented to time, place, and date, with
IVF of bottle #2 D5LR 1liter at the level of 700cc,
hooked at the right metacarpal vein regulated at
30gtts/min., infusing well.
 pale looking
 with limited range of motion
 Can’t tolerate to move out of bed without
assistance
 Needs assistance in doing ADL’s
 T- 35.2°C; PR- 76bpm; RR-20cpm; BP-
100/70mmHg
A > Vital signs taken and recorded.
 Bedside care done.
 IVF checked and maintained on prescribed
rate.
6:00pm > Omeprazole 20mg 1tab given p.o..
 Assumed position of comfort for patient.
 Encouraged to have adequate rest periods.
 Instructed to move out of bed slowly and
steadily.
 Advised to eat nutritious foods which are high
in iron such as kalamunggay and meat.
 Instructed significant other to assist patient in
doing ADL’s eg. eating and urinating.
 Advised to drink adequate fluid intake.
 Safety measures rendered such as putting
linens on sides.
 Advised to secure medication.
10:00pm > Vital signs rechecked and recorded.
 Reminded on U/A and S/E.
R > After 4hrs. of nursing interventions the patient
she was able to demonstrate ways to conserve
energy.
 with the same IVF at the level of 90cc
 Endorsed to staff awake, with the latest V/S of:
T- 36.8°C; PR- 80bpm; RR- 20cpm; BP-
100/80mmHg
Generic name : Isosorbide mononitrate
Dosage and route: 30mg, p.o
Classification : anti-anginals
Indication : acute angina attack (sublingual and
chewable tablets of Isosorbide dinitrate only); for
prevention in situations likely to cause angina attack
Action : not completely known; thought to
reduce cardiac oxygen demand by decreasing preload and
afterload; drug also may increase blood flow through the
collateral coronary vessels.
Contraindications:
 Contraindicated with hypersensitivity or
idiosyncrasy to nitrates and in those with
severe hypotension.
 Use cautiously in patients with blood
volume depletion (such as diuretic therapy)
or mild hypotension.
Nursing Considerations:
 Monitor blood pressure and intensity of
drug response.
 Caution pt. to take drug regularly as
prescribed and to keep it accessible at all
times.
 Tell pt. to take tablets sublingually.
 Caution pt. to avoid alcohol because it may
worsen low blood pressure effects.
 Instruct pt. to store drug in a cool place, in
a tightly closed container and away from
the light.
Generic name : Omeprazole
Brand name : Flazomel
Dosage and route: 20mg, 1tab BID, p.o
Classification : anti-ulcer
Action : suppresses gastric acid secretion by
inhibiting the parietal cells; blocks the final step of acid
production
Adverse effects :
 Headache, dizziness, vertigo, insomnia
 Rash, urticaria, dry skin
Nursing Considerations:
 Take as directed (before meal)
 Do not crush or chew capsules
 One may experience anorexia; small
frequent meals may help to maintain
adequate nutrition.
 Report changes in urination or pain on
urination.
Generic name : Allopurinol  Report any unusualties such as rash,
painful urination, blood in urine or
Brand name : Zyloprim stool, and muscle weakness.

Dosage and route: 100mg, 1tab, p.o Generic name : Cefuroxime

Classification : anti-gout agent Brand name : Betcef

Indication : prevention of attacks of gouty arthritis Dosage and route: 750mg, q8h, IVTT
and nephropathy
Classification : anti-bacterial
Action : inhibits xanthine oxidase, the enzyme
responsible for the conversion of hypoxanthine to Indication :
xanthine to uric acid. Allopurinol is metabolized to
oxypurinol whch is also an inhibitor of xanthine oxidase, Action : inhibits third and final stage of
acts on purine catabolism, reducing the production of uric bacterial cell wall synthesis, thus killing the bacteria
acid without disrupting the biosynthesis of vital purines.
Contraindication : - hypersensitivity to cephalosporins
Adverse effects : and related antibiotic
 Headache, dizziness, nausea, vomiting,
and abdominal pain Adverse effects :
 Pruritus, chills
Nursing Considerations:  Abdominal discomfort
 Take as directed (preferably before
meal) Nursing Considerations:
 Maintain hydration, at least 2liters of  Determine history of hypersensitivity.
water a day.  Report onset of loose stools.
 Avoid alcohol, OTC medication and  Monitor manifestations of
additional Vitamin C without consulting hypersensitivity.
prescriber.  Inspect IV injection site for phlebitis.
 Do skin testing prior to administration.
Generic name : Salmeterol xinafoate  Alert pt. to prevent exercise induced
bronchospasm.
Brand name : Salbutamol

Dosage and route: 2ml, q6h, thru nebulization Generic name : Ephedrine sulfate

Classification : bronchodilator Brand name : Ambroxol

Indication : to prevent bronchospasm in pt. with Dosage and route: 30mg, 1tab TID, p.o
nocturnal asthma or reversible obstructive airway disease
who had regular short-acting beta-agonist. Classification : bronchodilator

Action : Indication :

Contraindication : - patient with known hypersensitivity Action : stimulates alpha and beta receptors;
to drug and its components direct and indirect acting sympathometic

Adverse effects : Contraindication : - patient with known hypersensitivity

 headache to drug and its components
 palpitation
 nasopharyngitis Adverse effects :
 Insomnia
Nursing Considerations:  Palpitation
 Assess patient’s respiratory condition  Dryness of nose and throat
before starting the therapy.  Nausea and vomiting
 Be alert for adverse reaction and drug
interaction. Nursing Considerations:
 Don’t give drug for acute  Obtain history of pt’s underlying
bronchospasm. condition before starting therapy, and
 If headache occurs, give mild analgesic reassess regularly.
as ordered.
  Be alert for adverse reactions and drug
interactions.
 Warn pt. not to take OTC drugs.
 Instruct pt. to notify prescriber if
adverse reaction occurs.
 Caution pt. not to perform hazardous
activities if adverse CNS reactions occur.
Generic name : Insulin, Isophane (NPH)
Brand name : Humulin N
Dosage and route: 10units, BID, s.c
Classification : antidiabetic agent; hormone substitute
Indication : control of hyperglycemia in patient
with Type 1 and 2 DM
Action : increases glucose transport across
muscle and fat cell membrane to reduce glucose level
Contraindication : - in patients with history of systemic
allergic reaction to pork when porcine-derived products
are used or hypersensitivity to any component of
preparation
- During episodes of hypoglycemia
Adverse effects :
 Blurred vision
 Dry mouth
 Rash, urticaria, pruritus, swelling

Drug interactions: drug-drug; ACE inhibitors, Clonidine
Nursing Considerations:
 Advise pt. not to change orders in which
insulins are mixed or brand of insulin,
syringe or needle.
 Advise pt. not to smoke within 30mins.
After insulin injection because smoking
decreases amount of insulin absorbed
subcutaneously.
 Advise pt. to avoid vigorous exercise
immediately after insulin injection,
especially in the area where injection
was given because it decreases
absorption and risk of high glucose
episodes.
 Make sure that pt. knows that drug
relieves symptoms but doesn’t cure the
disease.
Generic name : Glimepiride
Brand name : Amaryl
Dosage and route: 2mg, OD, p.o
Classification : antidiabetic agent
 Indication : to lower glucose level in patients with  Make sure that pt. knows that drug
Type 2 DM whose hyperglycemia can’t be managed by relieves symptoms but doesn’t cure the
diet and exercise alone disease.

Action : lowers glucose level, possibly by Generic name : Clonidine

stimulating the release of insulin from functioning
pancreatic beta cells and may lead to increase sensitivity Brand name : Catapres
of peripheral tissues to insulin
Dosage and route: 150mg, 1tab, SL
Contraindication : - in patients hypersensitive to drug and
in those with diabetic ketoacidosis, which should be Classification : anti-hypertensive
trated with insulin
Indication : hypertension, used alone or as part of
Adverse effects : combination therapy
 Dizziness, asthenia, headache
Action : stimulates alpha-2 receptors and
Drug interactions: drug-drug; beta-blockers, may mask inhibit the central vasomotor centers, decreasing
symptoms of hypoglycemia sympathetic outflow to the heart, kidneys, and peripheral
vasculature and lowering peripheral vascular resistance,
Nursing Considerations: blood pressure and heart rate.
 Tell pt. to take drug with first meal of
the day. Contraindication : - hypersensitivity to Clonidine or any
 Teach pt. to carry candy or other simple adhesive layer components of the transdermal system
sugars to treat mild episodes of low
glucose level. Adverse effects :
 Advise pt. to avoid alcohol which lowers  Drowsiness, sedation, dizziness
glucose level.  Headache, fatigue
 Advise pt. to consult prescriber before  agitation, depression
taking any OTC products.
Nursing Considerations:
 Instruct pt. to take drug as ordered.
  Advise pt. that stopping drug abruptly
may cause severe rebound high blood
pressure.
 Tell pt. to take the last dose
immediately before bedtime.
 Inform pt. that dizziness upon standing
can be minimize by rising slowly from a
sitting or lying position and avoiding
sudden position changes.
Generic name : Salbutamol sulfate
Brand name : Acro--vent
Dosage and route: 1neb 2.5ml, thru nebulization
Classification : bronchodilator
Indication : to prevent and relieve bronchospasm
Action : relaxes smooth muscle by stimulating
beta2-receptor, thereby causing bronchodilation and
vasodilation
Contraindication : - hypersensitivity to drug
Adverse effects :
 Dizziness, insomnia, hypertension, chest
pain, dry and irritated throat
 Nausea and vomiting, anorexia, dry
mouth, heart burn, tooth discoloration
Interactions : drug-drug - beta adrenergic blockers
Drug-food – caffeine containing food
and beverage
Nursing Considerations:
 Instruct pt. in proper way of using the
nebulizer.
 Advise pt. to clean the mouthpiece in a
warm soapy water every week.
 Advise pt. to limit intake of caffeine
containing foods and beverages and to
avoid herbs unless prescriber approves.
 Caution pt. to avoid driving and other
hazardous activities until he knows how
drug affects concentration and
alertness.
Generic name : Cefuroxime
Brand name : Harox
Dosage and route: 750mg, IVTT
Classification : anti-infectives
Indication : lower respiratory tract infection
Action : second generation cepholosporins that
inhibit cell wall synthesis, promoting osmotic instability,
usually bactericidal
 Planning: Within 8hrs. of rendering nursing interventions, the
Contraindication : - hypersensitivity to penicillin patient will be able to identify ways to soothe dry cough by
expectorating secretions.
Adverse effects :
 Headache, dizziness, lethargy, Nursing Interventions:
paresthesias
Independent Rationale
Nursing Considerations: 1. Assess respiratory rate. - provides basis confirming the
 Assess pt.’s infection before therapy presence of shortness of
and regularly thereafter breath
 Ask pt. about previous reaction to 2. Recheck breath sounds - identifies consolidation that
cephalosporin or penicillin and presence of secretions. causes the obstruction and
 Do not double dose the drug if there are shortness of breath
lapses in taking the medication. 3. Position pt. in high/semi- - take advantage of gravity
 Tell pt. to take full course of therapy. fowlers position. decreasing pressure on
 Advise pt. to take drug with food. diaphragm and enhancing
Cues: drainage of secretions on
O > RR of 30cpm different lung segments
> weak 4. Provide back tapping. - can promote expectoration
> adventitious sound heard upon auscultation; crackles of secretions
> with dry cough 5. Encourage for slow deep - assist pt. in relaxing
respirations. respiratory muscles
Nursing diagnosis: Ineffective airway clearance related to 6. Encourage to perform - expels enough carbon
retained secretions in the bronchi deep breathing and pursed dioxide in the lungs and inhale
lip breathing exercises. sufficient oxygen, promoting
Scientific basis : A part of the respiratory function is the good ventilation
exchange of gases, where the bronchi is the gateway of 7. Demonstrate technique of - aids in proper expectoration
passage for gas travelling to the alveoli where gas exchange effective coughing. of secretions
happens. As the passage way for proper respiration is 8. Encourage to provide - warm liquids can aid in
obstructed by retained secretions, the travelling of gas in the warm liquids than cold ones. mucus liquefaction more than
tract is impaired. cold ones.
9. Encourage pt. and - increase intake of fluid can Scientific basis : Pain usually is viewed in the context of
significant other to allow pt. help liquefy the mucus tissue integrity. In the presence of invading pathogens, the GIT
minimal but increase fluid secretion compensates by increasing peristaltic movement in an
intake. attempt to get rid of the invaders. Noceciptive stimulation
10. Encourage adequate - limits fatigue and improves that activates with fibers can cause a response known as
sleep periods. condition neurogenic inflammation that produces vasodilation and an
11. Provide good ventilation - so as not to aggravate the increase release of chemical mediator to which the receptors
of environment, limiting pt.’s condition respond
allergens.
Dependent Planning: Within 8hrs. of rendering nursing interventions, the
1. Administer Salbutamol - relaxes smooth muscle by patient will be able to verbalize pain is reduced from 6/10 to
sulfate (Acro-vent) 1neb stimulating beta2-receptor, 2/10.
2.5ml, thru nebulization. thereby causing
bronchodilation and Nursing Interventions:
vasodilation
Independent Rationale
Evaluation: After 8hrs. of rendering nsg. Interventions the 1. Monitor/ document - variation of appearance and
patient was able to identify ways to soothe dry cough like characteristics of pain, noting behavior of pt. present a
deep breathing exercises and increasing fluid intake. verbal reports, non-verbal challenge in assessment
cues, and hemodynamic
Cues: response.
S > “Sakit pa gihapon ilihok akong lawas.” Painscale of 2. Encourage pt. to report - pain is perceived and
6/10 type and intensity of pain tolerated individually; it is
O > grimace using pain scale. also a subjective experience;
> pallor provides baseline for
> guarding behavior on abdomen comparison to aid in
> diaphoresis determining effectiveness of
> restless care
3. Observe for crying, - non-verbal cues may
Nursing diagnosis: Acute abdominal pain related to increase
irritability, restlessness,sleep indicate indicate pain
peristaltic movement due to bacterial invation
disturbance exerienced
4. Provide comfort measures,
eg. back rubbing, assist self-
care activities
5. Encourage to perform deep
breathing exercises and
splinting
6. Instruct to put ice pack on
the area.
7. Instruct to report increasing
pain immediately.
8. Encourage to have
divertional activities eg.
frequent communication to
SO.
9. Provide a quiet, calm,restful
environment
10. Encourage adequate rest.
Dependent
1. Administer analgesic as
ordered.
Cues:
S > “Magsige paman ko og ubo.”
O > crackles upon auscultation
> RR- 38cpm
> restless
- promotes relaxation and
redirect attention
- promotes relaxation
- provides non-
pharmacological relief of
pain;
- prompt assessment and
intervention may be given
- redirects feeling of pain
- external stimuli may
aggravate pain and anxiety
- provision of comfort
- prevents the synthesis of
prostaglandin from smooth
muscles, inhibiting the
stimulation of receptor to
synthesize pain
> difficulty of vocalizing
> grimace
Nursing diagnosis: Ineffective airway clearance related to
productive cough
Scientific basis : Presence of retained secretions in respiratory
tract impedes airflow. And inability to clear secretions results to
ineffectivity of airway clearance.
Planning: Within 8hrs. of rendering nursing interventions, the
patient will be able to identify ways to expectorate secretions.
Nursing Interventions:
Independent Rationale
1. Assess respiratory rate. - provides basis confirming the
presence of shortness of breath
2. Recheck breath sounds - identifies consolidation that
and presence of secretions. causes the obstruction and
shortness of breath
3. Position pt. in high/semi- - take advantage of gravity
fowlers position. decreasing pressure on
diaphragm and enhancing
drainage of secretions on
different lung segments
4. Provide back tapping. - can promote expectoration of
secretions
5. Encourage for slow deep - assist pt. in relaxing
respirations. respiratory muscles
6. Encourage to perform - expels enough carbon dioxide
deep breathing and pursed in the lungs and inhale
lip breathing exercises.
7. Demonstrate technique
of effective coughing.
8. Encourage to provide
warm liquids than cold
ones.
9. Encourage pt. and
significant other to allow pt.
minimal but increase fluid
intake.
10. Encourage adequate
sleep periods.
11. Provide good
ventilation of environment,
limiting allergens.
Dependent
1. Administer Ambroxol
30mg 1tab, TID p.o
sufficient oxygen, promoting
good ventilation
- aids in proper expectoration
of secretions
- warm liquids can aid in mucus
liquefaction more than cold
ones.
- increase intake of fluid can
help liquefy the mucus
secretion
- limits fatigue and improves
condition
- so as not to aggravate the
pt.’s condition
- inhibits phosphodiesterase,
the enzyme that degrades
cAMP, thereby relaxing
smooth muscle of bronchial
airway and pulmonary blood
vessels