medical management to conclusion
DESCRIPTION
HypokalTRANSCRIPT
V. THE PATIENT AND HIS CARE
A. Medical Management
a. IVF
MEDICAL
MANAGEMENT /
TREATMENT
DATE ORDERED
DATE
PERFORMED
DATE CHANGED
GENERAL
DESCRIPTION
INDICATION(S)
OR
PURPOSES
CLIENT’S
RESPONSE
TO TREATMENT
Plain Normal Saline
Solution
(PNSS)
Ordered:
09-12/07
Performed:
09/12/07 to
09/19/07
Plain normal saline
solution contain
308 mosm/L (Na,
154 MEq/L, Cl, 154
mCq/L) has pH of
4.5 to 7.0 and is
usually supplied in
volumes of lL,
SODCC, 250cc and
100cc
It is used to treat
increase in random
blood sugar of the
client. To
administer
medication and
nutrients to the
body
No negative
reaction
NURSING RESPONSIBILITIES
Before
Check doctor’s order
Check for ordered IVF (name and volume)
Check for cloudiness and expiration date of IVF
Check for patency of tubing
Explain procedure and the purpose of management to SO
During
Clean site of injection and observe aseptic technique
Support’s patient’s hand
Check IV tubing for presence of air
Check integrity of infusion
Monitor and adjust IV flow rate appropriate to the needs of patient
After
Document the IVF on the chart
Change IVF bottle if empty
MEDICAL MANAGEMENT/
TREATMENT
DATE ORDERED
DATE PERFORMED
DATE CHANGED
GENERAL DESCRIPTION
INDICATION/PURPOSE
CLIENT’S RESPONSE TO TREATMENT
D5W DO: 9/19/07
DP: 9/19/07
DC: 9/20/07
Hypotonic solution that exerts less osmotic pressure with that of plasma. Administration of liquid generally causes dilution of plasma solute concentration and forces water movement into cells and reestablish intracellular and extracellular equilibrium.
Administered as a carrying medium for the patient’s intravenous medication
The patient did not experience any discomfort other than the IV insertion and medication administration upon the course of this IV therapy.
NURSING RESPONSIBILITIES:
- Explain the need for IV infusion
- Check if the IV infusion is infusing well
- Regulate and monitor flow rate as ordered
MEDICAL
MANAGEMENT/
TREATMENT
DATE ORDERED
DATE
PERFORMED
DATE CHANGED
GENERAL
DESCRIPTION
INDICATION(S)
OR
PURPOSES
CLIENT’S
RESPONSE
TO THE
TREATMET
Oxygen Inhalation
via nasal cannula @
2-3 lpm
Ordered:
09/12/07
Performed
09/12/07 to
09/19/07
changed
09/20/07
Used in
administering
oxygen. It can be a
cannula, facial
mask or Tran
tracheal that is
inserted directly to
the trachea.
It is used for clients
who have difficulty
ventilating all areas
with lungs, those
whose gas
exchange is
impaired or people
with heart failure
may require oxygen
therapy to prevent
hypoxia
The client was
able to show
progress in
respiration and
there was relief of
difficulty of
breathing.
NURSING RESPONSIBILITIES
Before
Explain to the client what you are going to do, why it is necessary,
and how he or she can cooperate.
Discuss how the effects of the oxygen therapy will be used in
further planning of treatments or care
Assess the patient regularly
Inspect equipment regularly
During
Wash hands and observe infection control measures / procedures
Turn on oxygen at the prescribed rate and ensure proper
functioning
Put the cannuia over the client’s face with the outlet prongs fitting
into the nares and the elastic band around the head
Make sure that the air delivered to the patient is humidified
Set flow rate prescribed
After
Closely monitor patient’s respiratory status
Monitor flow rate
NAME OF DRUG
GENERIC NAME
BRAND NAME
DATE ORDERED
DATE PERFORMED
DATE CHANGED
ROUTE OF ADMIN
DOSAGE AND FREQUENCY OF ADMIN
INDICATIONS OR PURPOSES
(PT CENTERED)
SPECIFIC FOOD TAKEN
CLIENT’S RESPONSE TO
THE MEDICATION
Furosemide(Lasix)
Cefixime(Zefral)
Butamirate Citrate (Sinecod)
Aldazide
Acetylcysteine(Broncoflem)
Sept. 17, 2007Sept. 17-19, 2007Sept. 20, 2007
Sept. 19, 2007Sept. 19, 2007(to discharge)Sept. 20, 2007
Sept. 12, 2007Sept. 12-20, 2007Sept. 20, 2007
Sept. 17, 2007Sept. 17-20, 2007Sept. 20, 2007
PO: 200mg 1 tab OD
PO: 200mg/cap BID
PO: 2 tab/ day
25mg/tab BID
PO: 600 mg/sachet OD
(Loop Diuretic)>tx of edema.
(Anti-infective)>secondary infections of respiratory tract dses.
(Antitussive)>acute cough of any etiology
(Anti-hypertensive)>essential HPN or edema.
(Mucolytic)>acute/ chronic resp. tract
Rice, soup, apple, water, veggies.
Rice, apple, water, meat, veggies.
Rice, meat, water, banana.
Rice, soup, apple, water.
Cup noodles, rice, banana, water.
>the pt did not encounter any side effect of the drug.
>the pt. did not experience any side effect of the drug.
>the pt. did not manifest any side effects.
>the pt did not manifest any side effects.
>the pt did not manifest any side effects.
Ceftriaxone(Eurosef)
Enalapril(Acebitor)
Roxithromycin(Guamil)
Vit. B Complex
Sept. 13, 2007Sept. 13-20, 2007Sept. 20, 2007
Sept. 12, 2007Sept. 12-19, 2007Sept. 20, 2007
Home Medicine
Sept. 12, 2007Sept. 12-20, 2007Home Medicine
Sept. 12, 2007Sept. 12-20, 2007
1g/IV q12 ANST
PO: 2.5 mg/tab BID
PO:300 mg OD
PO: 1tab OD
infections abundant with mucus secretions.
(Anti- infectives)>serious lower respiratory tract infections.
(Anti-hypertensive)>HPN
(Anti-infective)>tx of upper and lower resp. tract infection.
(Multivitamins)>daily supplement
Rice, meat, water.
Lugaw, apple, water.
Rice, banana, soup, water.
Rice, banana, soup, water.
>the pt did not manifest any side effect of the drug.
>the pt did not manifest any side effect of the drug.
>the pt did not manifest any side effects.
>the pt did not manifest any side effects of the drug.
NURSING RESPONSIBILITIES:
Furosemide:
Before:
>Assess the pt. for tinnitus and hearing loss.
>Monitor for renal, cardiac, neurologic, GI, pulmonary manifestations of
hypokalemia.
>Monitor electrolytes, also include BUN, blood pH, ABG’s.
>Assess BP before and during therapy.
During:
>Give in morning to avoid interference to sleep.
>Drug may be crushed before administering.
After:
>Teach pt. to take medication early in the day to prevent nocturia.
>Instruct pt. to the medicine with food or milk.
>Caution pt. to rise slowly from sitting or reclining, orthostatic hypotension
might occur.
>Instruct pt to continue taking the medication even if feeling better.
Cefixime and Ceftriaxone:
Before:
>Assess pt for s/sx of infection including characteristics of wounds, sputum,
urine and stool.
>Obtain C & S before beginning drug therapy to identify if correct tx has
been initiated.
>Identify urine output
>Monitor bleeding and growth of infection.
During:
>Give for 10 days to ensure organism death and prevent superinfection.
>Give with food if needed for GI symptoms.
>Give after C & S is completed.
After:
>Teach pt to report sore throat, bruising, bleeding, and joint pain. It may
indicate blood discarias.
>Advise pt to contact prescriber if there is loose foul stool and furring of
tongue occur.
>Advise pt to notify prescriber if diarrhea with blood or pus occurs.
Butamirate Citrate:
Before:
>Verify doctor’s order
>Explain importance and purpose of the medicine.
>Assess pt. for hypersensitivity
During:
>Identify pt first.
>Administer only exact amt. of dosage.
>Tell the pt. to swallow the medication fully.
After:
>Tell the client that he may experience a little bit of dizziness and avoid
driving after administration.
>Tell the pt to take the medication in instructed intervals.
Acetylcysteine:
Before:
>Assess cough first.
>Assess characteristics, rate, rhythm of respiration, increased dyspnea and
sputum.
>Monitor VS, cardiac status including checking for dysrhythmias, increased
rate and palpitations.
During:
>Give decreased dosage to elderly pts.
>Use only if suction machine is available.
After:
>Tell the pt to avoid driving or any other hazardous activities until stabilized
with this medication.
>Teach the pt that unpleasant odor will decrease after repeated use.
Aldazide:
Before:
>Verify doctor’s order.
>Explain to the pt the importance of the drug.
>Explain to the client possible side effects of drug.
>Assess pt for hypersensitivity.
During:
>Be sure to identify the client first.
>Administer only desired dose to the pt.
>Always check the medication before administration.
After:
>Tell the pt to change position in a slow manner, orthostatic hypotension
might occur.
>If adequate diuresis doesn’t occur after 3 days increase dose.
Enalapril:
Before:
>Monitor BP and pulse frequently.
>Monitor frequency of prescription refills to determine adherence.
>Monitor CBC especially WBC with differential prior to initiation of therapy.
>Assess urine protein prior and periodically during therapy.
During:
>Monitor CBC during therapy
>Do not confuse Enalapril to Eldepryl.
After:
>Instruct pt to take medication as directed as the same day and time each
day even feeling better.
>Caution pt to avoid salt substitutes or foods containing high levels of
potassium or sodium.
>Instruct pt to notify physician if rash, mouth sores, sore throat,
fever/swelling of hands & feet, chest pain and DOB occurs.
>Emphasize importance of follow-up checkup.
Roxithromycin:
Before:
>Verify doctor’s order
>Explain importance of medicine
>Assess pt for hypersensitivity
>Assess for hepatic or renal impairment.
During:
>Check medication first before administration.
>Administer only exact dose as ordered.
>Take the medication before meals.
After:
>Assess for allergic reactions
>Assess for n/v.
>Tell the pt. to complete days of medication; superinfection may occur.
Vitamin B Complex:
Before:
>Verify Doctor’s order.
>Explain the importance and purpose of the drug.
>Assess pt for hypersensitivity.
During:
>Identify the pt first before administration.
>Check medication first before administration.
>Administer only exact dose as ordered.
After:
>Tell the pt to continue taking the medication for better results.
>Explain the benefits he will get for taking the medication for
encouragement.
TYPE OF DIET DATE ORDERED
DATE PERFORMED
DATE CHANGED
GENERAL DESCRIPTION
INDICATIONS OR PURPOSES
SPECIFIC FOODS TAKEN
CLIENT’S RESPONSE
NPO (Nothing Per Orem)
DAT with limited Fluid Intake to 1L/ day.
DAT (Diet as Tolerated)
Sept. 12, 2007Sept. 12, 2007Sept. 12, 2007
Sept. 13, 2007Sept. 13-18, 2007Sept. 19, 2007
Sept. 19, 2007Sept. 20, 2007
>this diet requires no food intake by mouth including water.
>this diet permits the client to eat a regular diet but with limitation of fluid.
It is adequate in all nutrients accdg. to the standards and is used for pts. requiring to no dietary
>to prevent abdominal distention thus preventing irritation.
>to supply the client enough energy he needs at the same time limiting fluid intake to lessen fluid excess in the body.
>to give the client all the nutrients he needs in able to nourish a healthy body.
>no food was taken.
>cup noodles, rice, veggies, meat, a little amt. of water.
>he was given a complete meal composed of meat, rice, veggies, and a glassful of water.
>the pt felt hungry and demanded for food.
>the pt was satisfied with the meal.
>the pt was satisfied with the meal.
modification. It contains bet. 2500 to 3000 calories daily.
NURSING RESPONSIBILITIES:
Before:
>Verify doctor’s order. Discuss importance of ordered diet.
>Cite examples of food under diet ordered. Ask patient’s preference that
may be included in their diet list.
>Remind the client of proper handwashing.
During:
>Assist pt. for comfortable position.
>Identify the pt. Verify the meal served in the tray.
>Assess if there is a need for assistance during meal.
After:
>Monitor how much meal and fluids were taken.
>Monitor client’s reaction and compliance with diet.
>Instruct SO to increase fruit juices and milk in diet for nourishment.
TYPE OF EXERCISE
DATE ORDEREDDATE
PERFORMEDDATE CHANGED
GENERAL DESCRIPTION
INDICATIONS OR PURPOSES
CLIENT’S RESPONSE
Bed Rest
Sitting
Walking
Sept. 12, 2007Sept. 12-16, 2007
Sept. 12, 2007Sept. 12-16, 2007
Sept. 17, 2007Sept. 17, 2007(to discharge)
>this exercise makes the pt lie on bed the whole time and other activities are prohibited to be done.
>makes the pt sit in the bed for a specific purpose.
>make the pt ambulate in close range.
>makes the pt conserve energy to prevent too much O2 consumption.
>provides pt comfort from dizziness and coughing when is supine position.
>to give the pt a little activity to move his legs and exercise a bit.
>the pt was comfortable in bed but got a little bored.
>the pt did not complain and is relieved from coughing and dizziness.
>the pt felt a little bit tired when he walked.
VI. NURSING MANAGEMENT
1. NURSING CARE PLANS
Problem1: Ineffective airway clearance related to retained secretions as evidenced by productive cough
with reddish sputum and dyspnea
ASSESSMEN
T
NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
OBJECTIVE
S
NURSING
INTERVENTIO
NS
RATIONALE EXPECTED
OUTCOME
S > “maguku
ku”as
verbalized by
the pt.
O > The pt.
manifested
> pt. appears
weak
> with
productive
Ineffective
airway
clearance
related to
retained
secretions
as
evidenced
by
productive
cough with
In Pleural
Effusion, there
would be
disruption of
equilibrium
across pleural
membrane.
Therefore,
there would
be increase in
fluid from
Short term:
After 4
hours of
nursing
intervention
s, the
patient will
demonstrate
improvemen
t in airway
patency as
1. Monitor and
record vital
signs
2. Auscultate
breath sounds
3. Assess rate,
rhythm and
depth of
1. To establish baseline
data
2. To note for possible
adventitious breath
sounds
3. To note for irregular
patterns of respiration
Short term:
The patient
shall have
demonstrated
improvement
in airway
patency as
evidenced by
patient having
non-
productive
cough
with
reddish
sputum
> with
dyspnea
experienced
when
assuming
supine
position
> with chest
tightening
experienced
when in
supine
position
> used
accessory
muscles to
reddish
sputum
and
dyspnea
interstitial
spaces of lung
via visceral
pleura.
Defects in
function of
lymphatic
vessels in
visceral pleura
to remove
fluid occurs.
Therefore,
there would
be fluid
accumulation
and retained
secretions in
the lungs.
Thus, airway
patency would
evidenced
by patient
having non-
productive
cough.
Long term:
After 4 days
of nursing
intervention
s, the pt. will
establish
airway
patency as
evidenced
by patient
free from
dyspnea and
respirations
4. Assess use
of accessory
muscles
5. Note ability
of patient to
expectorate
sputum
effectively
6. Assess
tactile and
vocal fremitus
7. Note
4. Accumulation of
secretions and inability
to clear airways may
lead to use of accessory
muscles and increased
work of breathing.
5. Expectoration may be
difficult when secretions
are very thick as a result
of infection or
inadequate hydration.
6. Decreased or absent
fremitus may be
associated with and fluid-
filled tissue
7. Blood-tinged or frankly
cough.
Long term:
The patient
shall have
established
airway
patency as
evidenced by
patient free
from dyspnea
and
productive
cough.
breath when
positioned
flat in bed
> with
limited ROM
> with
disturbance
of sleep
> have
sedentary
lifestyle
> with
bipedal
pitting edema
> no pain
perceived
- the pt. may
manifest:
>
be affected
and there
would be
ineffective
airway
clearance.
productive
cough.
character of
sputum and
presence of
hemoptysis
8.Place client
in semi- or
high- fowler’s
position.
9. Encourage
patient to do
deep slower
breathing and
pursed-lip
breathing
exercise
10. Instruct
bloody sputum results
from tissue breakdown in
the lungs or from
tracheobronchial
ulceration and may
require further
evaluation.
8. Positioning helps
maximize lung expansion
and decreases
respiratory effort.
9. To promote movement
of secretions into larger
airways for
expectoration.
restlessness
>listlessness
> difficulty of
sleeping
> irritability
> diaphoresis
patient to
increase oral
fluid intake
11. Instruct SO
to do CPT
when the
patient
coughed
12. Keep
patients back
dry
13. Maintain
calm attitude
14. Provide
10. To mobilize
secretions
11. To facilitate
expulsion of secretions.
12. To prevent
evaporation of sweat
from the patient’s back
13. To provide relaxation
and limit level of anxiety
rest periods
15. Provide
quiet
environment
16. Perform
quiet
conversations
17. Instruct pt.
to change
position
frequently
18. Encourage
pt. to assume
comfortable
position when
14. To allow the body to
regain its energy
15. To promote an
environment conductive
to recovery
16. To promote relaxing
conversations
17. To provide comfort
and to prevent stasis of
secretions
18. Client may be
resting or
sleeping
19. Advise pt.
to eat
nutritious food
20.Administer
medications as
indicated:
a. mucolytic
agents
b.
Bronchodilator
s
comfortable with head of
bed elevated, sleeping in
a chair, or leaning
forward on overhead
table with follow support
19. To provide nutrition
with adequate amount of
vitamins and minerals
a.Reduces the thickness
ans stickiness of
pulmonary secretions to
facilitate clearance
b. Increases lumen size
of the tracheobronchial
tree, thus decreasing
c.
Corticosteriods
resistance to airflow and
improving oxygen
delivery
c. May be useful in the
presence of extensive
involvement with
profound hypoxemia and
when inflammatory
response is life
threatening.
Problem 2: Ineffective Breathing Pattern related to decrease lung expansion as evidenced by dyspnea and orthopnea
ASSESSMEN
T
NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
OBJECTIVE
S
NURSING
INTERVENTIO
NS
RATIONALE EXPECTED
OUTCOME
S >
“Magkasakit
ku
mangisnawa
at mangku ku
patye maka
flat ku”, as
verbalized by
the pt.
O > The pt.
manifested
> pt. appears
slightly weak
> with
dyspnea
experienced
when
assuming
supine
Ineffective
Breathing
Pattern
related to
decrease
lung
expansion
as
evidenced
by dyspnea
and
orthopnea
In Pleural
Effusion, there
would be
disruption of
equilibrium
across pleural
membrane.
Therefore,
there would
be increase in
fluid from
interstitial
spaces of lung
via visceral
pleura.
Defects in
function of
lymphatic
vessels in
visceral pleura
Short-term:
After 4
hours of
nursing
intervention
s, pt will be
able to
demonstrat
e improved
breathing
pattern with
resolving
signs of
hypoxia as
evidenced
by pt
sleeping in
side lying
position
1. Monitor and
record vital
signs
2. Auscultate
breath sounds
3. Note rate
and depth of
respirations
4. Assess
environmental
, social,
cultural, and
educational
factors that
may influence
teaching plan
1. To establish baseline
data
2. To note for possible
adventitious breath
sounds
3. To note for irregular
patterns of respiration
4. To identify appropriate
measures related to the
presenting
manifestations of the
patient
Short-term:
The patient
shall have
demonstrated
improved
breathing
pattern with
resolving
signs of
hypoxia as
evidenced by
pt. sleeping in
side lying
position
Long-term:
The patient
shall have
position
> with chest
tightening
experienced
when in
supine
position
> used
accessory
muscles to
breath when
positioned
flat in bed
> with limited
ROM
> with
disturbance
of sleep
> have
sedentary
to remove
fluid occurs.
Thus, there
would be
reduction in
pressure in
pleural space
and there
would be
inability of
lung to
expand
causing
dyspnea or
shortness of
breath and
orthopnea.
There would
be also
increase in
Long term:
After 4 days
of nursing
intervention
s, the pt.
will
establish
effective
breathing
pattern
without
signs of
hypoxia as
evidenced
by pt able to
tolerate
sleeping in
supine
position
5. Assess
cognitive
function and
emotional
readiness to
learn
6. Assess
tactile and
vocal fremitus
7. Note chest
excursion and
position of
trachea
8. Maintain
calm attitude
5. To determine
readiness to learn on the
part of the client.
6. Decreased or absent
fremitus may be
associated with and fluid-
filled tissue
7. To know if chest
excursion is unequal until
lung re-expands. Trachea
may deviate away from
affected side
8. To provide relaxation
and limit level of anxiety
established
effective
breathing
pattern
without signs
of hypoxia as
evidenced by
pt. able to
tolerate
sleeping in
supine
position
lifestyle
> with
productive
cough
with
reddish
sputum
> with
bipedal
pitting edema
> no pain
perceived
- the pt. may
manifest:
>
restlessness
> difficulty of
sleeping
> irritability
hydrostatic
pressure in
lungs which
also cause
orthopnea.
When there is
difficulty of
breathing and
orthopnea,
there would
be decreased
lung
expansion
resulting to
ineffective
breathing
pattern.
9. Encourage
deep, slower
breathing and
pursed lip
breathing
10. Promote
proper bed
positioning as
to semi-
fowler’s
position
11. Provide
rest periods
12. Provide
quiet
environment
9. To assist client in
“taking control” of the
situation
10. To promote an
increase in lung
expansion
11. To allow the body to
regain its energy
12. To promote an
environment conductive
> diaphoresis
13. Keep
patients back
dry
14. Perform
quiet
conversations
15. Instruct pt.
to change
position
frequently
16. Encourage
pt. to assume
comfortable
position when
resting or
sleeping
to recovery
13. To prevent
evaporation of sweat
from the patient’s back
14. To promote relaxing
conversations
15. To provide comfort
and to prevent stasis of
secretions
16. Client may be
comfortable with head of
bed elevated, sleeping in
a chair, or leaning
17. Advise pt.
to eat
nutritious food
18. Encourage
resting as
needed during
activity
avoiding
overexertion
as mush as
possible
19. Instruct pt.
to alternate
heavy with
light tasks
20. Discuss
purpose and
forward on overhead
table with follow support
17. To provide nutrition
with adequate amount of
vitamins and minerals
18. To limit fatigue and
to decrease oxygen
demand and
consumption
19. To promote energy
conservation
method of
administration
for each
medication
21. Instruct
patient to
avoid central
nervous
system (CUS)
depressants
20. To improve
information for the
patient
21. To present from
further depressing the
respiratory system.
Problem 3: Disturbed sleep pattern related to shortness of breath when assuming supine position AEB impairment of normal sleep pattern.ASSESSMEN
TNURSING
DIAGNOSISSCIENTIFIC EXPLANATI
ON
OBJECTIVES NURSING INTERVENTI
ON
RATIONALE EXPECTED OUTCOME
S> “magkasakit ku mipatudtud nabengi” as verbalized by the patient.
O> pt. appears weak.
Disturbed sleep pattern r/t shortness of breath when assuming spine position AEB impairment of normal sleep
As a result of shortness of breath of the pt. he becomes more focused on how to breath properly than to relax thus making him
Short Term:After 4 hrs of nursing interventions the pt. will report increase in self well being and feeling rested.
>monitor and record VS.
>auscultate breath sounds.
>identify
>to obtain baseline data.
>to assess any adventitious breath sounds.
>to
Short Term:After 4 hrs of nursing interventions the pt. shall have reported increase in self well being and feeling
>with disturbance of sleep.
>experiencing DOB when assuming supine position.
>slept for only 4 hrrs.
>with limited ROM.
>with bipedal pitting edema.
>have sedentary lifestyle.
>with easy fatigability upon exertion.
pattern. anxious and disturbing his sleep pattern.
Long Term:After 2-3 days of N.I. the pt. will have regular sleeping pattern AEB long hours of sleep.
presence of factors that interferes with sleep.
>assess sleep disturbances that are associated with underlying illness.
>determine client’s expectations of adequate sleep and frequency.
>observe physical signs of fatigue.
>arrange care to provide uninterrupted periods for
determine possible causes of sleep disturbance.
>to see if the illness contributed to the sleep disturbance.
>to know what the pt. expects in adequate sleeping.
>to know when the client gets exhausted.
>to give the pt. more time to rest and sleep.
rested
Long Term:After 2-3 days of N.I. the pt. would have a regular sleeping pattern AEB long hours of sleep
>no pain perceived.
rest and allowing longer periods of sleep.
>provide quiet envt. And comfort measures.
>instruct to limit fluid intake in the evening.
>instruct pt. to drink milk before going to bed.
>instruct pt. to assume comfortable position when resting.
>perform quiet
>to make the client comfortable with the environment.
>to reduce chance of nocturia.
>to help facilitate sleep.
>to make the pt. comfortable with his position.
>to avoid disturbance and creation
converstations.
of noise.
Problem 4: Activity Intolerance Level III r/t general weakness AEB easy fatigability
ASSESSMENT NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
OBJECTIVES NURSING
INTERVENTIO
NS
RATIONALE EXPECTED
OUTCOME
S>
“Mangalambut
ku.” as
verbalized by
the patient.
Activity
Intoleranc
e Level III
r/t general
weakness
In pleural
effusion, an
abnormal
volume of
fluid
Short term:
- After 4
hours of NI,
the patient
will
1. Establish
rapport.
1. To obtain
cooperation
and trust from
the patient.
Short term:
- After 4
hours of NI,
the patient
shall have
O> The patient
manifested:
Appears
weak
With ease
fatigability
upon
exertion
With limited
ROM
Have
productive
cough with
reddish
sputum
Have
sedentary
lifestyle
AEB easy
fatigability
accumulates
in the pleural
space causing
shortness of
breath and
cough. When
there is
shortness of
breath, there
would be
alteration in
O2 supply and
demand.
The level
of O2
determines
the body’s
ability to
oxygenate
demonstrate
increase in
tolerance to
activity AEB
patient
walking at a
distance of
3-4 meters
without
experiencing
fatigue and
dyspnea
thereafter.
Long Term
- After 4
days of NI,
the patient
will
demonstrate
2. Monitor and
record VS.
3. Auscultate
client’s breath
sounds.
4. Identify
client’s
response to
activities.
5. Note reports
on dyspnea
and increased
weakness.
2. To establish
baseline data.
3. To note any
adventitious
breath sounds
present.
4. To note any
reaction like
dyspnea or
fatigue during
and after
activities.
5. To establish
client needs
and facilitates
choice and
demonstrated
increase in
tolerance to
activity AEB
patient
walking at a
distance of 3-4
meters
without
experiencing
fatigue and
dyspnea
thereafter.
Long Term
- After 4
days of NI, the
patient shall
have
With
dyspnea
experienced
when doing
strenuous
activities
With bipedal
pitting
edema
The patient
may manifest:
Heart rate
above
normal
range
Compensato
ry
tachypnea
tissues,
especially at
times of
increased
oxygen
demand.
When there is
alteration in
O2 supply and
demand, it
means that
the RBCs are
not properly
oxygenated.
RBC
transports O2
to tissues in
order to
oxygenate
them. Thus, a
tolerance in
doing
activities of
daily living,
like the
patient
taking a bath
without
assistance
and without
experiencing
fatigue or
dyspnea
thereafter.
6. Assess
client’s ability
to stand and
walk.
7. Provide
quiet
environment
and calm
activities.
8. Provide rest
interventions.
6. To
determine the
patient’s
capabilities
and facilitates
choice of
interventions.
7. To provide
an
environment
conducive to
energy
regeneration.
8. To allow
the body to
regain its
demonstrated
tolerance in
doing
activities of
daily living,
like the
patient taking
a bath without
assistance and
without
experiencing
fatigue or
dyspnea
thereafter.
Sign and
symptoms of
decreased
cardiac
output
Restlessness
diaphoresis
decrease in O2
would mean a
decrease in o-
xygenation of
tissues
necessary for
metabolism in
producing
ATP, a
precursor of
energy.
Reduced
energy is
termed as
weakness and
is directly
related to
decrease
tolerance to
activities.
periods.
9. Perform
quiet
conversations.
10. Keep
patient’s back
dry.
11. Provide
CPT when
patient coughs.
12. Provide
back rub.
energy.
9. To promote
relaxing
conversations.
10. To prevent
evaporation of
sweat from
the patient’s
back.
11. To
facilitate
expulsion of
sputum.
12. It
stimulates
nerve fibers
13. Instruct
patient to
engage in
relaxation and
diversional
activities.
14. Instruct
patient to
change
position
frequently.
15. Instruct the
patient to
assume
which allow
the client to
feel
comfortable.
13. This
reduces stress
and excess
stimulation,
promoting
rest.
14. To
promote
relaxation and
prevent
immobility.
comfortable
position when
resting or
sleeping.
16. Explain
importance of
rest in
treatment plan
and necessity
for balancing
activities with
rest.
15. Client may
be
comfortable
with HOB
elevated,
sleeping on a
chair, or
leaning
forward on
over bed table
with pillows.
16. Bed rest is
maintained
during acute
phase to
decreased
metabolic
demands thus
conserving
17. Regulate
IVF as ordered.
18. Assist with
self care
activities as
necessary.
Provide for
progressive
energy for
healing.
Activity
restrictions
thereafter are
determined by
patient’s
response to
activity and
resolution of
respiratory
insufficiency.
17. To
maintain
hydration of
the patient.
18. Minimizes
exhaustion
increase in
activities.
19. Instruct
patient to take
medicines on
time.
and help
balance O2 –
supply and
demand.
19. To follow
proper
treatment
regimen.
Problem 5: Fatigue r/t general weakness AEB decreased in performance in doing activities of
daily living
ASSESSMENT NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
OBJECTIVES NURSING
INTERVENTIO
NS
RATIONALE EXPECTED
OUTCOME
S> The pt.
verbalized:
“Yun nga yung
problema ko,
Fatigue r/t
general
weakness
AEB
In pleural
effusion, an
abnormal
volume of
Short term:
- After 4
hours of NI,
the patient
1. Monitor and
record VS.
2. Auscultate
1. To establish
baseline data.
2. To note any
Short term:
- After 4
hours of NI,
the patient
yung madali
akong
mapagod.”
O> The patient
manifested:
Have
productive
cough with
reddish
sputum
Experienced
DOB and
feels tired
after
walking
Experienced
DOB when
assuming
decreased
in
performan
ce in doing
activities
of daily
living
fluid
accumulates
in the pleural
space causing
shortness of
breath and
cough. When
there is
shortness of
breath, there
would be
alteration in
O2 supply and
demand. The
level of O2
determines
the body’s
ability to
oxygenate
tissues,
will in
desired
activities at
level of
ability such
as walking
towards the
comfort room
instead of
voiding in a
urinal beside
the bed.
Long Term
- After 4
days of NI,
the patient
will perform
activities of
daily living
client’s breath
sounds.
3. Assess
which problem
bothers the
patient.
4. Determine
the patient’s
ability to
participate in
activities.
5. Assess the
presence and
degree of sleep
disturbance.
adventitious
breath sounds
present.
3. To prioritize
problems
experienced
by the
patient.
4. to assess
the patient’s
ability to
mobilize.
5. To assess
contributing
factors to
fatigue.
shall have
demonstrated
increase in
tolerance to
activity AEB
patient
walking at a
distance of 3-4
meters
without
experiencing
fatigue and
dyspnea
thereafter.
Long Term
- After 4
days of NI, the
patient shall
supine
position
No pain
perceived
With
disturbance
of sleep
Appears
weak
With ease
fatigability
upon
exertion
With limited
ROM
Have
sedentary
lifestyle
With bipedal
pitting
especially at
times of
increased
oxygen
demand.
When there is
alteration in
O2 supply and
demand, it
means that
the
erythrocytes
are not
properly
oxygenated.
RBC
transports O2
to tissues in
order to
oxygenate
and will
participate
with
improved
sense of
energy AEB
patient
feeling less
tired after
doing an
activity.
6. Note client’s
belief of what
is causing the
fatigue.
7. Note daily
energy
patterns.
8. Note the
need for
individual
assistance.
9. Provide
adequate rest
periods.
6. To assist
factors that
contribute to
the fatigue.
7. To
determine
peak energy
level, pattern,
or timing of
activity.
8. To know
when to assist
the client
whenever
needed.
9. To allow
the body to
have
demonstrated
tolerance in
doing
activities of
daily living,
like the
patient taking
a bath without
assistance and
without
experiencing
fatigue or
dyspnea
thereafter.
edema
The patient
may manifest:
Sign and
symptoms of
decreased
cardiac
output
Heart rate
above
normal
range
Listlessness
Compensato
ry
tachypnea
Diaphoresis
Frequent
them. Thus, a
decrease in O2
would mean a
decrease in o-
xygenation of
tissues
necessary for
metabolism in
producing
ATP, a
precursor of
energy. A
reduced
energy is
termed as
weakness,
and if the
body is weak,
it becomes
easily
10. Encourage
patient to do
whatever
possible
activities like
walking.
11. Instruct
methods to
conserve
energy like
sitting instead
of standing.
12. Assist in
self-care
needs.
regain its
energy.
10. To assist
the patient
cope with
fatigue.
11. To avoid
excessive
usage of
energy.
12. Minimizes
exhaustion
urination exhausted,
and this is
termed as
fatigue. 13. Provide
quiet
environment.
14. Perform
quiet
conversations.
15. Instruct
patient to
engage in
relaxation and
diversional
activities.
16. Keep
and helps
balance
oxygen supply
and demand.
13. To provide
environment
conducive to
energy
regeneration.
14. To
promote
relaxing
conversations.
15. This
reduces stress
and excess
stimulation,
promoting
patient’s back
dry.
17. Provide
back rub.
18. Provide
CPT when
patient coughs.
19. Instruct the
patient to
assume
comfortable
position when
rest.
16. To prevent
evaporation of
sweat from
the patient’s
back.
17. It
stimulates
nerve fibers
which allow
the client to
feel
comfortable.
18. To
facilitate
expulsion of
resting or
sleeping.
20. Advise
patient to eat
nutritious food.
21. Assist
client in
performing
activities.
22. Provide
comfort
measures,
such as
sputum.
19. Client may
be
comfortable
with HOB
elevated.
20. To provide
foods with
proper
vitamins and
minerals by
the body to
regain energy.
stretching
linens.
23. Regulate
IVF as ordered.
24. Instruct
patient to take
medications on
time.
23. To
maintain
hydration of
the patient.
24. To comply
with proper
treatment
regimen.
Problem 6: Impaired physical mobility classification 3 related to weakness as evidenced by inability to purposely move within
the physical environment and limited ROM
ASSESSMEN
T
NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
OBJECTIVES NURSING
INTERVENTIO
NS
RATIONALE EXPECTED
OUTCOME
S >
“Magkasakit
ku gagalo,
Impaired
physical
mobility
In Pleural
Effusion, an
abnormal
Short-term:
After 4 hours
of nursing
1. Monitor and
record vital
signs
1. To establish baseline
data
Short-term:
The patient
shall have
tatalakad
tsaka
lalakad”, as
verbalized by
the pt.
O > The pt.
manifested
> pt. appears
slightly weak
> the patient
needs
someone to
assist him
whenever he
walks.
>with easy
fatigability
upon
exertion.
classificatio
n 3 related
to
weakness
as
evidenced
by inability
to
purposely
move within
the physical
environmen
t and
limited ROM
volume of
fluid
accumulates
in the pleural
space causing
shortness of
breath and
cough. When
there is
dyspnea,
there would
be alteration
in oxygen
supply and
demand. The
level of
oxygen
determines
the body’s
ability to
interventions,
the patient
will be able to
demonstrate
techniques
that enable
resumption of
activities as
evidenced by
patient
change
positions at
least every 2
hrs.
Long term:
After 4 days
of nursing
interventions,
the pt. will
2. Assess
functional
abilty and
extent of
impairment
initially and on
a regular basis
3. Determine
degree of
immobility
4. Change
positions at
least every 2
hr (supine,
side lying).
5. Position in
2. identifies strength
and deficiencies and
may provide
information regarding
recovery.
3. To assess functional
ability
4. To reduce risk of
ischemia or injury
demonstrated
techniques
that enable
resumption of
activities as
evidenced by
patient
change
positions at
least every 2
hrs.
Long-term:
The patient
shall have
maintained
strength and
function of
affected or
> with
limited ROM
> with
dyspnea
experienced
when
assuming
supine
position
> c chest
tightening
experienced
when in
supine
position
> used
accessory
muscles to
breath when
positioned
oxygenate
tissues
especially at
times of
increased
oxygen
demand.
When there is
alteration in
oxygen and
demand, it
means that
the
erythrocytes
are not
properly
oxygenated.
RBC
transports
oxygen to
maintain
strength and
function of
affected or
compensator
y body part
as evidenced
by patient
able to do
activities of
daily living.
prone position
once or twice
a day if client
can tolerate
6. Use arm
sling when
client is in
upright
position as
indicated
7. Evaluate
the use of
positional aids:
a. place pillow
under axilla to
abduct arm
b. elevate arm
5. Helps maintain
functional hip
extension.
6. Use of sling may
reduce risk of shoulder
subluxation and
shoulder-hand
syndrome
7.
a.prevents adduction of
shoulder and flexion of
elbow
compensatory
body part as
evidenced by
patient able
to do
activities of
daily living.
flat in bed
> with
disturbance
of sleep
> have
sedentary
lifestyle
> with
productive
cough
with reddish
sputum
> no pain
perceived
> c bipedal
pitting
edema
-the pt. may
manifest:
tissues in
order to
oxygenate
them. Thus, a
decrease in
oxygen would
mean a
decreased in
oxygenation
of tissues for
their
metabolism in
producing
ATP, a
precursor of
energy. A
reduced
energy is
termed as
weakness
and hand
c. place hard
hand-rolls in
palm with
fingers and
thumb
opposed
d. place knee
and hip in
extended
adduction
e. Maintain leg
in neutral
position with
trochanter roll
8. Observe for
b. promotes venous
return and helps
prevent edema
formation.
c.hard cones decrease
the stimulation of finger
flexion, maintaining
finger and thumb in
functional position.
d.maintains functional
position
e. prevents external hip
rotation.
>
restlessness
> gait
changes
>postural
instability
> irritability
> diaphoresis
may cause
impaired
physical
mobility.
color edema
and other
signs of
compromised
circulation
9. Inspect skin
regularly,
particularly
over bony
prominence
10. Maintain
calm attitude
11. Provide
rest periods
12. Provide
quiet
8. Edematous tissue is
more easily
traumatized and heals
more slowly
9. Pressure points over
bony prominences are
most at risk for
decreased perfusion/
ischemia
10. To provide
relaxation and limit
level of anxiety
11. To allow the body to
environment
13. Keep
patients back
dry
14. Perform
quiet
conversations
15. Advise pt.
to eat
nutritious food
16. Encourage
resting as
needed during
activity
regain its energy
12. To promote an
environment
conductive to recovery
13. To prevent
evaporation of sweat
from the patient’s back
14. To promote relaxing
conversations
15. To provide nutrition
with adequate amount
of vitamins and
minerals
avoiding
overexertion
as mush as
possible
17. Instruct pt.
to alternate
heavy with
light tasks
18.Encourage
exercises such
as quadriceps/
gluteal
exercise,
squeezing
rubber ball,
extension of
fingers and
16. To limit fatigue and
to decrease oxygen
demand and
consumption
17. To promote energy
conservation
18. Minimizes muscle
atrophy, promotes
circulation and helps
prevent contractures.
legs/ feet
19.Assist to
develop sitting
balance; assist
to sit on edge
of the bed,
having client
use the strong
arm to support
body weight
and strong leg
to move and
standing
balance.
20. Administer
muscle
relaxants,
antispasmodic
19. Aids in retaining
neuronal pathways,
enhancing
propioception and
motor response.
s as indicated
20. May be required to
relieve spaciticity in
affected extremities
2. ACTUAL SOAPIER’S
September 17, 2007
S > “Mangalambut ku” as verbalized by the pt
O > Received pt on a sitting position, awake, coherent, conscious, c an IVF of
PNSS IL @ 550cc level regulated at 30-31 gtts/min inserted at ® cephalic
vein.
> the pt. appears weak
> with easy fatigability upon excretion
> the pt has productive cough with reddish sputum
> with limited ROM
> have sedentary lifestyle
> with dyspnea experienced when doing strenuous activities
> with bipedal pitting edema
> no pain perceived
> with vital signs taken and recorded as follows: T: 36oC / axillary P=86bpm
R=20bpm BP:140/100 mmHg
A > Activity intolerance level III related to general weakness as evidenced by
easy fatigability
P > After 4 hours of nursing interventions, the pt will demonstrate increase in
tolerance to activity as evidenced by walking at a distance of 3-4 meters c
out experiencing fatigue and DOB thereafter
I > established rapport
> monitored and recorded v/s q 1o
> auscultated breath sounds
> Identified client’s response to activities
> noted reports or dyspnea and increased weakness
> assessed the client’s ability to stand and walk
> provided quiet environment and calm activities
> provided rest penods
> performed quiet conversations
> kept pits back dry
> provided CPT when pt coushed
> provided back rub
> instructed pt. to engage in relaxational and diversional activities
> instructed so not to feed the pt. because of NPO status
> instructed pt. to change position frequently
> instructed pt. to assume comfortable position when resting or sleeping
> assisted the pt. in going to the toilet
> due meds given
> IVF regulated
> needs attended
> endorsed
E > Goat met as evidenced by pt. walked towards the comfort room which is
more than 4 meters away from his bed c experiencing fatigue or DOB
thereafter
September 18, 2007
S > “Yun nga ang problema ko, yung madali akong mapagod”, as verbalized
by the pt.
O > Received pt. on a sitting position, awake, coherent, conscious, c an IUF
of PNSS IL @ 750cc level regulated at 30-31 gtts/min inserted at ® cephalic
vein infusing well.
> the pt. appears weak
> easy fatigability upon exertion
> experienced DOB and feels tired after walking
> with limited ROM
> with bipedal pitting edema
> have sedentary lifestyle
> experienced DOB when assuming supine position
> productive cough c reddish sputum
> no pain perceived
> with disturbance of sleep
> with vital signs taken and recorded as follows: T: 36.5oC / axillary, P: 89
bpm,
R = 19 bpm BP = 130/190 mmHg
A > Fatigue related to general weakness as evidenced by decrease in
performance in doing activities of daily living.
P > After 4 hours of nursing interventions, the pt. will participate in desired
activities at level of ability such as walking towards the comfort room instead
of voiding on a urinal beside the bed
I > monitored and recorded v/s q 4o
> auscultated breath sounds
> assessed which problem bother the pt. (easy fatigability vs difficulty of
sleeping)
> determined the pts. Ability to participate in activities
> assessed the presence and degree of sleep disturbance
> noted client’s belief about what is causing the fatigue
> noted daily energy patterns.
> note the need for individual assistance
> provided adequate rest periods
> encourages pt to do whatever possible activities like walking
> instructed methods to conserve energy like sitting instead of standing
> assisted c self care needs
> provided quiet environment
> performed quiet conversation
> instructed pt. to engage in diversional and relaxational activities
> kept pts back day
> provided back nub
> provided CPT when pt. coughed
> instructed pt. to assume comfortable position when resting or sleeping
> instructed pt. to limit fluid intake as ordered
> inserted O2 nasal cannula 2-3 lpm to nostrils as demanded by the pt.
> advised pt. to eat nutritious food
> regulated IUF
> stretched bed linens
> due meds given
> needs attended
> endorsed
E> Goal met as evidenced by pt. walked towards the comfort room instead of
voiding on a urinal beside the bed
September 18, 2007
S > “Magkasakit ku mipatudtud nabengi” as verbalized by the pt.
O > Received pt. on a sitting position, awake, coherent, conscious, c an IVF of
PNSS IL @ 750cc level regulated at 30-31 gtts/min inserted at ® cephalic
vein infusing well
> the pt. appears weak
> with disturbance of sleep last night
> experienced DOB when assuming supine position
> slept for only 4 hours last night
> with limited ROM
> with bipedal pitting edema
> have sedentary lifestyle
> with easy fatigability upon exertion
> no pain perceived
> with vital signs taken and recorded as follows. T:36.5 oC / axillary,
P:89bpm, R = 19 bpm
BP = 130 / 90 mmtlg
A > Disturbed sleep pattern related to shortness of breath when assuming
supine position as evidenced by impairment of normal sleep pattern
P > After 4 hours of nursing interventions, the pt. will report increase in
sense of well-being and feeling rested
I > monitored and recorded v/s q 4o
> auscultated breath sounds
> identified presence of factors that interferes sleep
> assessed sleep pattern disturbances tat are associated with underlying
illness
> observed and obtained feedback from client regarding usual bedtime,
routines, number of hours of sleep, time of arising, and environmental needs
> determined client’s expectations of adequate sleep
> identified circumstances that interrupt sleep and frequency
> observed physical signs of fatigue
> arranged care to provide for uninterrupted periods for rest, especially
allowing for longer periods of sleep at night when possible
> explained necessily of disturbances for vital signs monitoring and other
care when client is hospitalized.
> provided quiet environment and comfort measures
> instructed to limit fluid intake in evening
> instructed pt. to drink milk before going to bed
> recommended midmorning nap
> performed quiet conversations
> provided adequate rest
> provided CPT when pt. coughed
> instructed pt to assume comfortable position when resting or sleeping
> inserted O2 nasal cannula 2-3 lpm to nostnls as descended by the pt.
> acused pt. to eat nutritions food
> regulated IVF
> stretched bed linens
> due meds given
> needs attended
> endorsed
E > Goal met as evidenced by pt. reported increase in sense of well-being
and feeling rested
September 19, 2007
S > “Magkasakit ku mangisnawa patye maka-falat ku” as verbalized by the
pt.
O > Received pt. on a sitting position, awake, coherent, conscious, IV out.
> pt. appears slightly weak
> with dypnea experienced when assuming supine position
> with chest hightening experienced when in supine position
> used accessory muscles to breath when positioned flat in bed
> with limited ROM
> with disturbance of sleep
> have sedentany lifestyle
> with productive cough with reddish sputum
> with bipedal pitting edema
> no pain perceived
> with v/s taken and recorded as follows: T = 36.4oC / axillany P= 86 bpm,
,R = 21bpm ,BP = 110/70 mmltg
A > Ineffective breathing pattern related to decrease lung expansion as
evidenced by dyspnea.
P > after 4 hours of nursing interventions, the pt. will be able to demonstrate
improved breathing pattern with resolving signs of hypoxia as evidenced by
pt. sleeping in side lying position.
I > monitored and recorded v/s g 4o
> auscultated breath sounds
> noted rate and depth of respirations
> assessed environmental, social, cultural, and educational factors that may
influence teaching plan
> assessed cognitive function and emotional readiness to learn
> assessed tactile and vocal fremitus
> maintained calm attitude
> encouraged deep, slower breathing and pursed-lip, breathing exercise
> promoted proper bed positioning as to semi fowler’s position.
> provided rest periods
> provided quiet environment
> instructed pt. to limit fluid intake IL / day as ordered
> kept pts. back dry
> performed quiet conversation
> instructed pt. to change position frequently
> encouraged pt. to assume comfortable position when resting or sleeping
> advised pt. to eat nutritious food
> encouraged resting as needed during activities avoiding over exertion as
much as possible
> instructed pt to alternate heavy c light tasks
> due meds given
> regulated IVF
> needs attended
> endorsed
E > Goal met as evidenced by the pt demonstrated improved breathing
pattern with resolving signs of hypoxia as evidenced by pt sleeping in side-
lying position
September 19, 2007
S > “Pabawas de ing danum a painum da kanaku” as verbalized by the pt.
O > Received pt. on a sitting position, awake, coherent, conscious, IV out
> pt appears slightly weak
> ordered to limit fluid intake upto IL/day only
> the pt. is not having proper hydration from IV line because it was removed
> the IV line was removed and was not replaced for 4 hours
> with dyspnea when assuming supine position
> with chest tightening experienced in supine position
> with limited ROM
> have sedentary lifestyle
> with productive cough with reddish sputum
> with bipedal pitting edema
> no pain perceives
>with v/s taken and recorded as follows : T = 36.4oC / axillary P = 86bpm,
R=21bpm, BP=110/70 mmltg
A > Risk for imbalanced fluid volume related to decrease fluid intake
P > after 4 hours of nursing interventions, the pt will be hydrated as
evidenced by IV line inserted with DSW and properly regulated at 15gtts/min
I > monitored and recorded v/s q 4o
> auscultated breath sounds
> noted client’s age, level of consciousness / mentation
> assessed vain turgor
> assessed for clinical signs of dehydration
> assessed other etiological factors present
> established individual needs / replacement schedule
> monitored I/O balance being aware of insensible losses
> monitored changes in vital signs
> discussed individual risk factors / potential problems
> monitored increasing lethargy, hypotension, muscle cramping
> maintained fluid restrictions
> provided rest periods
> instructed pt. to limit fluid intake to IL/day as ordered
> kept pts. back dry
> provided quiet environment
> provided small, frequent meals
> obtained baseline weight
> above IVF consumed, hooked DSW 500cc x 15 gtts / min as follow-up as
ordered
> due meds given
> regulated IVF
> needs attended
> endorsed
E > Goal meat as evidenced by pt. is hydrated AEB IV line inserted with DSW
and properly regulated at 15gtts/min
VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL
1. Client Daily Progress Chart (from admission to discharge)
DAYS ADMISSI
ON
09-12-07
13 14 15 16 17 18 19 DISCHAR
GE
09-20-07
NURSING
PROBLEMS
Ineffective airway
clearance related
to retained
secretions as
evidenced by
productive cough
with reddish
sputum and
dyspnea
Ineffective Breathing
Pattern related to
decrease lung
expansion as
evidenced by dyspnea
Disturbed sleep
pattern related to
shortness of breath
when assuming
supine position as
evidenced by
impairment of
normal sleep pattern
Activity intolerance
level III related to
general weakness as
evidenced by easy
fatigability
Fatigue related to
general weakness as
evidenced by
decrease in
performance of
doing activities in of
daily living
Impaired physical
mobility
classification 3
related to weakness
as evidenced by
inability to purposely
move within the
physical
environment and
limited ROM
DAYS ADMISSI
ON
09-12-07
13 14 15 16 17 18 19 DISCHAR
GE
09-20-07
VITAL SIGNS
Temp
PR
RR
BP
36.8%
75
28
140/100
36.3oC
80
28
130/10
0
36
82
28
140/10
0
36.5o
C
74
24
140/9
0
37oC
77
26
130/10
0
36oC
86
20
140/100
36.5o
C
89
19
130/9
0
36.4
86
21
110/7
0
36oC
80
24
120/70
DIAGNOSTIC
/LABPROCEDURE
S
Hematology
a) Hemoglobin
b) Hematocrit
153g /dL
46%
9.1 g /L
c) White blood
cells
d) Neutrophils
e) Lymphocytes
f) Platelet count
.78
0.20/mm3
180 g IL
Hematology
a) White blood
cells
b) Neutrophills
c) Lymphocyles
d)
9.7g /L
0.75
0.25/
mm3
Chest
Ultrasound
There is
face
flowing
pleural
effusion,
® Hemi
thorax
DAYS ADMISSIO
N
13 14 15 16 17 18 19 DISCHARG
E
Urinalysis
a) Color
b) Transparency
c) Albumin
d) Reaction
e) Specific Gravity
f) Pus cells
g) Red blood cells
Dark
Yellow
Clear
Trace
Acidic
1.030
0-1 / HPF
h) Epithelial cells 1.2 / HPF
few
Thoracentesis
1st:
2nd ;
500cc
were
withdrawn
500cc of
fluid
withdrawn
Pleural Fluid
Analysis
a) Color
b) Transparency
c) RBC
d) WBC
e) Neutrophils
f) Lymphocytes
g) CHON
Dark
Yellow
Turbid
43,762/
mm3
706/mm3
6
94
h) LDH 3.9%
3230 U/L
DAYS ADMISSIO
N
13 14 15 16 17 18 19 DISCHARG
E
Electrocardiogr 1. Normal
aphy (ECG) sinus
Rhythm
2.
Incomplete
® bundle
branch
back
3.
Anterocept
al wall
ischemia
Chest x-ray - suspicious
cardiomega
ly with
pulmonary
congestion
and right
minimal
pleural
effusion
-
Pneumonia,
bilateral
cannot be
rived out
would
suggest
clinical
correlation
and follow
up
examinatio
n
Blood
Chemistry
a) RBS
b) BUN
c) Creatinine
d) LDH (Lactose
Dehydrogenises)
e) Total CHON
f) SGOT
g) SGPT
h) NA
10.11
mmol/L
5.0 mmol /L
98.3
mmol/L
866.1 IU/L
63.6 gm/L
2 3.9 IU/L
31.1 IU/L
i) K 13 g
mmol/L
4.0 mmol/L
CT Scan Opacit
y in
the
right
middle
and
lower
lobes
as well
as in
the left
lung
consid
er
pneum
onic
proces
s
recom
mend
follow-
up
study
DAYS ADMISSIO
N
13 14 15 16 17 18 19 DISCHARG
E
MEDICAL
MANAGEMENT
IVF
a.) PNSS IL
b.) D5W
Oxygen
Inhalation
DAYS ADMISSIO
N
13 14 15 16 17 18 19 DISCHARG
E
DRUGS
a) Furosemide
(Diuspec)
b) Cefixime
(Zefral)
c) Butamirale
Citrate
(Sinecod)
d) Aldazide
e)
Acetylcysteine
(Brencoflem)
f) Ceftriaxone
(Euroset)
g) Enalapril
(Acebitor)
h)
Roxithromycin
(Guamil)
i) Vitamin B.
Complex
DAYS ADMISSIO
N
13 14 15 16 17 18 19 DISCHARG
E
DIET
a) NPO
(nothing per
orem)
b) DAT
(Diet as tolerated)
with limited
fluid intake
to
IL/day
c) DAT
(Diet as
tolerated)
ACTIVITY EXERCISE
a) Bed Rest
b) Sitting
c) Walking
2. DISCHARGE PLANNING
a. General Condition of Client upon discharge
The client is in sitting position, conscious, and coherent with D5W
500cc x 15gtts/min @ 250cc level infusing well on the left cephalic vein. The
patient appears slightly weak and with difficulty of breathing upon exertion.
He has affective productive with reddish sputum. He is now feeling better and
can eat any food that he wants. He is full of enthusiasm and can do activities
of daily living without experiencing difficulty of breathing and fatigue
thereafter. Vital signs were taken and recorded as follows: T = 36oC
P=90bpm R=24bpm and BP: 120/70mmltg.
b. METHOD
M – Reinforced instruction to pt. that he must take the following
medicines at home:
> Furosemide 20mg ITAB BID
> Cefixime 200mg ICAP BID
> Enalapril 2.5mg TAB BID
> Roxithromycin 30mg OD To consume
E – Encouraged patient to perform activities of daily living as tolerated
T – Emphasized the importance of compliance to treatment regimen
and health teachings given
H – Encouraged pt. to do deep breathing and pursed-lip breathing
exercise
- Encouraged pt. to have adequate rest periods
- Encouraged pt. to engage in relaxational and diversional activities
- Instructed pt. to engage in relaxational and diversional activities
- Instructed pt. to alternate heavy tasks c light tasks
- Encouraged pt. to assume comfortable position when resting or
sleeping
O – Instructed pt. to comeback for follow-up check-up on October 1,
2007
D – Instructed pt. to eat nutritious foods
III. CONCLUSION
“Character cannot be developed in ease and quiet. Only through
experience of trial can the soul be strengthened, vision cleared,
ambition inspired, and success achieved.” --
Helen Keller
There is an adage that learning never ceases. Through this, the
world tells us that learning will always take its toll upon us. We are
being screwed around with the thought that we could never escape
learning, similar to that of change. Yet, there is quite a significant
difference between those that we learned in our early years, and with
the information we will be gathering once we’ll be required and tasked
to harness our skills.
The knowledge we reap today is supposed to benefit us in our
journey towards the next step. Perhaps it is even more correct if we
refer it to be the next “leap”, since the world we will be facing after all
of these is quite unnerving. Either way, all the education we have gone
in the past or so will jut aid us in our battles against life: life as an
adult, life as a person; and in our case, life as a nurse.
This case study is still part of the never-ending education.
Perhaps, through this study, we will only be learning a part of the
profession that lies ahead of us. But we believed that it is the
assimilation of these “bits” of information that actually makes a
successful, effective, downright and caring nurse.
The fact still remains that this study provides insufficient
information regarding a specific disease condition; but what makes this
piece of work important to us is that through this, we have been
supplied with at least the basic care, if not more of the disease. These
“basics”, so to speak, are the media by which optimum care is
provided to a client. These ‘basics” are the essentials by which a nurse
is tagged as a “nurse”.
