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Introduction
Bronchitis is an acute inflammation of the air passages within the lungs. It occurs
when the trachea (windpipe) and the large and small bronchi (airways) within the lungs
become inflamed because of infection or other causes.
The thin mucous lining of these airways can become irritated and swollen. The cells that
make up thislining may leak fluids in response to the inflammation. Coughing is a reflex
thatworks to clear secretions from the lungs. Often the discomfort of a severe cough
leads you to seek medical treatment. Both adults and children can get bronchitis.
Bronchitis can either be of brief duration (acute) or have a long course (chronic). Acute
bronchitis is usually caused by a viral infection but can also be caused by a bacterial
infection and can heal without complications. Chronicbronchitis is a sign of serious lung
disease that may be slowed but cannot be cured. This form is found almost exclusively
in adult smokers. Bronchitis in children is often misdiagnosed as asthma.
Acute bronchitis is most prevalent in winter. It is most often caused by a viral infection
and may be accompanied by a secondary bacterial infection. Acute bronchitis resolves
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within two weeks, although the cough may persist longer. Acute bronchitis, like any
upper airway inflammatory process, can increase a child's likelihood of developing
pneumonia.
Acute bronchitis is one of the more common illnesses affecting preschool and
school-age children. It is more commonly diagnosed among children under age five
than any other age group. It occurs more often in young males. It can occur anytime but
is more frequent during the winter months. In otherwise healthy children complications
are few.
Acute bronchitis usually begins with the symptoms of a cold, such as a runny
nose, sneezing, and drycough. However, the cough soon becomes deep and painful.
Coughing brings up a greenish yellow phlegm or sputum. These symptoms may be
accompanied by a fever of up to 102F (38.8C). Wheezing after coughing is common.
In uncomplicated acute bronchitis, the fever and most other symptoms, except the
cough, disappear after three to five days. Coughing may continue for several weeks.
Acute bronchitis is often complicated by a bacterial infection, in which case the fever
and a general feeling of illness persist. To be cured, the bacterial infection should be
treated with antibiotics..
Physical findings of acute bronchitis vary with the age of the child, and the stage of the
disease, but may include the following:
y runny nose
y dry, hacking unproductive cough that may change to a loose cough with
increased mucus
y sore throat
y back and other muscle pains
y chills and low grade fever
y headache and general malaise (feeling unwell)
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Objective of the Study
This study aims to understand more about the pathophysiologic event
of the disorder experienced by the patient. In this way we can enhance our
learning through actual assessment of the client in the clinical area. And
incorporate the theories in the book to the actual setting. The main goals of
this study are the following:
Provide appropriate nursing intervention and attend to the patients
specific needs.
Discuss to the patient, family members or significant others the
simple and understandable way of the disease process, and the
causative and risk factors of it.
Provide training and instructions to patient and family members
regarding the therapeutic management in alleviating this disease
condition such as breathing and coughing exercises, positioning,
chest tapping, pursed-lip breathing, and healthy lifestyle.
Apply the nursing process in the actual setting.
Broaden our knowledge and skills as a health care provider.
Achieve the best outcome and progress of the patients health
condition.
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Scope and limitation of the study
The study was conducted throughout our medical ward exposure at PGH
Velez and was only limited to the patient admitted at the medical ward
department. The study was done for 3 days which is approximately more or
less 20 hours all in all to be specific. The study only encompasses the health
condition of the patient that was been assessed and determined in the actual
setting on that given span of time.
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Patients Profile
Name: Mrs. Ana (not his real name)
Age: 53 yrs. Old
Date of birth: June 5, 1957
Address: Macasandig
Sex: Female
Religion: Roman Catholic
Civil status: Married
Nationality: Filipino
Height: 5 ft
Weight: 138 Ibs
Educational attainment: College graduate
Occupation: Government employee
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Health History
Family and Personal Health History
Pt. was a diagnosed case of pneumonia last 2000.
Is hypertensive with no maintenance of medications
had cough
paternal side none
maternal side hypertension
History of Present Illness
Pt complains about fever, on and off productive cough with yellowish
secretion. Few weeks prior to admission, pt has been having cough which
subsided, but 3 days PTA recurrence of cough associated with undocumented
fever. She took Azithromycin which was prescribed by Dr. Ucab, a relative
physician. Persistence of condition thus prompted admission.
Chief Complaint
Fever and cough
Previous illness
Pneumonia (2000)
Gallstone removal (2010)
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Developmental data
Mrs. Ana belongs to the middle adult stage. In which we can correlate the possible
manifestations of behaviors to the following developmental theories.
1) Robert Havighursts Developmental Task Theory in middle adult
According to Havighursts, the person in this stage assists teenage
children to become responsible and happy adults, achieving adult social and
civic responsibility, reaching and maintaining satisfactory performance in ones
occupational career, develops adult leisure time activities. And accept and
adjust to the physiological changes of middle age. And these characteristics
really manifested to my patient since she really works hard just to sustain his
family regardless w/ his condition. And they had a close bonding with her
daughters and wife as they keep on teasing each other at the hospital. And I
conclude that mrs. Ana was able to accept and adjust to the physiologic needs
of middle age.
2) Ericksons theory in middle adult
The middle adult is in a period of generativity versus stagnation. The tasks are
accepting middle age changes, and reevaluate ones goals and
accomplishments. Adults who do not achieve these tasks tend to focus on
themselves, becoming overly concerned w/ their own physical and emotional
health needs. I can see that mrs. Ana has achieve this stage because she
always think of the hospital expense that her family will be paying, thats why
she wanted to go home. He doesnt think of his self alone.
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Doctors order and Rationale
DATE/TIME Doctors Order Rationale
January 11,
2011
4:00 pm
S: Cough and fever
O: Harsh breath sounds (occasional wheeze)
A: to consider Acute Bronchitis, Hypertension
P: Pls. admit under Dr. Gamolo
- Secure consent to care & management
- Low fat, low salt diet
- IVF: PNSS 1L @ 10gtts/m
- LABS:
y CBC
y UA
y Na+, K
+
y 12 L ECG
y CXR PA
y FBS, lipid profile
- Medications:
y Paracetamol
y Fluimucil 600mg 1cap in glass of
- For initiation of care.
- To prevent further increase in
blood pressure
- An isotonic solution that
expands the extracellular fluid
volume. To provide water,
electrolytes & nutrients to
meet daily requirements in the
pt.s hospital stay.
- To examine hematologic
condition for any instability.
- To examine urine for any
abnormalities
- To monitor serum Na+ & K+
levels for any disturbances.
- To provide information about
the electrical activity of the
myocardium.
- To examine patients lung
status & support the
underlying diagnosis.
- To check blood glucose levels
- To relieve fever
- A mucolytic given to thin
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5:35 pm
7:00 pm
water
y Nebulizer w/ Combivent 1neb now,
then q 6hrs
- Monitor vital signs q 4hrs & record
- I and O q shift
- Pls. inform attending physician
- Refer accordingly
- Start Kenaxef 1gram IV q 12hrs ANST
- Duavent 1 neb q 6hrs
- Start Zenith 500mg 1tab OD, P.O
- Replace Combinant neb to Duavent 1neb q
6hrs
- Pls. follow up maintenance meds of patient
and continue
mucus & help remove mucus
secretions.
- To relieve bronchospasms
- To watch for any deviations
from normal
- To determine the proportion of
intake and output
- To report pts condition
- For continuous care
- Antimicrobial used to treat
bronchitis
- An anti-infective
- To go on w/ the pts
maintenance of meds
January 12,
2011
- Lipitor 80mg 1tab OD, P.O
- Rely CXR result
- Discontinue Azithromycin
- An antilipemics used to
decrease LDL cholesterol
- to provide basis for care
- to withdraw meds
January 13,
2011
- Nasatidera 1cap TID
- Amlodipin 5mg 1tab OD, P.O
- P
- An antianginals given to pt to
decrease myocardial
contractility and oxygen
demands and dilates coronary
arteries and arterioles.
January 14,
2011
- IVF TF: PNSS 1L @ 10 gtts/m - An isotonic solution that
expands the extracellular fluid
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- MGH
- Home meds
volume. To provide water,
electrolytes & nutrients to
meet daily requirements in the
pt.s hospital stay.
- Advised to go home
- To hasten recovery.
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Drug study
1)Paracetamol
Generic name: Paracetamol
Brand Names: Biogesic
Classification: Analgesic/Antipyretic
Mechanism of Action
Paracetamol possesses prominent antipyretic and analgesic effects. Its anti-inflammatory activity is weak and has no clinical significance. The mechanism of actionis related to depression of the prostaglandin synthesis by inhibition of the specific cellcyclooxygenase, and depression of the thermoregulatory center in the medullaoblongata. Inhibits prostaglandins in CNS, but lacks anti-inflammatory effects inperiphery; reduces fever through direct action on hypothalamic heat-regulating center.
Indications
The preparation is indicated in diseases manifesting with pain and fever:headache, toothache, mild and moderate postoperative and injury pain, hightemperature, infectious diseases and chills (acute catarrhal inflammations of the upperrespiratory tract, flu, small-pox, parotitis, etc.).
Contraindications
Paracetamol should not be used in hypersensitivity to the preparation and in
severe liver diseases.
Adverse reactions
In rare cases hypersensitivity reactions, predominantly skin allergy (itching andrash), may appear. Long-term treatment with high doses may cause a toxic hepatitiswith following initial symptoms: nausea, vomiting, sweating, and discomfort.Occasionally a gastrointestinal discomfort may be seen.
Nursing Responsibilities
The preparation should be used with care in patients with liver and renal diseases. The
treatment with Paracetamol may change the laboratory tests of uric acid and bloodglucose analysis. In severe renal failure the interval between two consecutive takingsshould not be shorter than 8 hours.
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2) Acetylcysteine
Generic name: Acetylcysteine
Brand Names: Fluimucil
Classification: Mucolytic
Mechanism of Action
Muculytic that reduces the viscosity of pulmonary secretions
Indications
For abnormal viscid and thickened mucous secretions
Contraindications
Use cautiously in elderly or debilitated patients with severe respiratoryinsufficiency
adverse reactions
fever, drowsiness, tachycardia, dyspnea and rash
Nursing Responsibilities
Bronchial tapping and monitor for bronchospasm
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3) Duavent
Generic name: Ipratropium + salbutamol
Brand Names: Duavent
Classification: Bronchodilator
Mechanism of Action
A Bronchodilator used for Treatment of obstructive airway diseases.
Indications
Management of reversible bronchospasm associated obstructive airway disease.Patient with chronic obstructive pulmonary disease on a regular enhaled bronchospasmand who required a 2nd bronchodilator.
Contraindications
Hypertrophic obstructive cardiomyopathy or tachyarrhythmia. Hypersensitiviity toatropine and its derivatives
adverse reactions
Headache, pain, influenza, chest pain, nausea.Bronchitis, dyspnea, coughing,pneumonia, bronchospasm pharyngitis, sinusitis, rhinitis, edema, fatigue,hypertension,dizziness, nervousness, paresthesia, tremor, dyspepsia, vomiting,arrhythmia, palpitation, tachycardia, arthralgia, angina, increased sputum, tasteperversion and UTI/dysuria, allergic-type reactions.
Nursing Responsibilities
Drugs should be given only if the potential benefit justifies thepotential risk to the foetus.
Position patient on high back rest position. Do back tapping after you nebulize the patient. do not give a food immediately it can cause vomiting
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4) Azithromycin
Generic name: Azithromycin
Brand Names: Zithromax
Classification: Anti-infective
Mechanism of Action
A macrolide anti-biotic that is a derivative of erythromycin. It Binds to the 50ssubunit of bacterial ribosomes blocking protein synthesis.
Indications
Acute bacterial exacerbation of COPD caused by Haemophilus influenzae,Moroxella catarrhalis, or Streptococcus pneumoniae; uncomplicated skin and skin-structure infection caused by Staphylococcus aureus, Streptococcus pyogenes, or S.agalactiae; second line therapy of pharyngitis or tonsillitis caused by S. pyogenes.
Contraindications
Contraindicated in patients hypersensitive to erythromycin or other macrolides.
Adverse reactions
nausea and vomiting, headache, dizziness, fatigue, diarrhea, dyspepsia,abdominal pain, anorexia
Nursing Responsibilities
Monitor patient for super infection. Instruct patient to take medication as prescribed even if he feels better. Instruct patient that if hypersensitivity occurs during the medication
immediately notify the physician.
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5) Atorvastatin
Generic name: Atorvastatin
Brand Names: Lipitor
Classification: Antilipidemic (cholesterol reducer)
Mechanism of Action
Atorvastatin inhibits the rate-determining enzyme located in hepatic tissue thatproduces mevalonate, a small molecule used in the synthesis of cholesterol and othermevalonate derivatives. This lowers the amount of cholesterol produced which in turnlowers the total amount of LDL cholesterol. Atorvastatin is a competitive inhibitor ofHMG-CoA reductase.
Indications
For management as an adjunct to diet to reduce elevated total-C, LDL-C, apo B,and TG levels in patients with primary hypercholesterolemia and mixed dyslipidemia.
Contraindications
Use cautiously in pregnant patients, those with liver disease, alcoholics and patientswith uncontrolled seizures
Adverse reactions
Rash, itchy skin, hair loss. Abdominal cramps, constipation, diarrhea, flatus,heartburn,
Nursing Responsibilities
Instruct patient to avoid eating foods that are high in fat or cholesterol.Atorvastatin will not be as effective in lowering your cholesterol if you do not follow acholesterol-lowering diet plan, and to avoid drinking alcohol while taking atorvastatin.Alcohol can raise triglyceride levels, and may also damage your liver while you aretaking atorvastatin.
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Anatomy and physiologic review of the respiratory system
The respiratory system is composed of the upper and lower respiratory
tracts. Together, the two tracts are responsible for ventilation (the movement of
air in and out of the airways). The upper tract known as the upper airway warms
and filters inspired air so that the lower respiratory tract (the lungs) can
accomplish gas exchange. The gas exchange involves delivering oxygen to the
tissues through the blood stream and expelling waste gases, such as carbon
dioxide, during expiration.
Anatomy of the Upper respiratory Tract: Upper Airway
Nose
Sinuses and Nasal passages
Pharynx, tonsils and adenoids
Larynx
Trachea
Anatomy of the lower respiratory Tract: Lungs
Pleura
Mediastinum
Lobes
Bronchi and bronchioles
Alveoli
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The respiratory system consists of all the organs involved in breathing. These include the nose,
pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it
brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us
get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx,
trachea and bronchi all work like a system of pipes through which the air is funneled down into our
lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon
dioxide is pushed from the blood out into the air. When something goes wrong with part of the
respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we
need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include
breathlessness, cough, and chest pain.
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Functions of the respiratory system
Certain vital tissues such as those of the brain and the heart cannot
survive for long without a continuing supply of oxygen. However, as a result of
oxidation in the body tissues, carbon dioxide is produced and must be
removed from the cells tp prevent build up of acid waste products. The
respiratory system performs this function by facilitating life-sustaining process
such as oxygen transport, respiration and ventilation, and gas exchange.
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Pathophysiology
Inflammation
Bradykinin, histamine, prostaglandin
Increased capillary permeability
Fluid cellular exudation
Edema of mucous membrane
Hyper secretion of mucus
Persistent of cough
Bronchitis
ACUTE BRONCHITIS
It is inflammation of the main air
passages to the lungs. Bronchitis may be
short-lived (acute) or chronic, meaning
that it lasts a long time and often recurs.
Predisposing Factors:
y Age 53 yrs old
y Recurrent
respiratory tractinfections
Precipitating
Factors:
y Cough
y
Bacterialinfection
y Air
pollutants
Signs & symptoms noted:
Fever
Fatigue
Productive cough
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EENT:
[X] Impaired vision [ ] blind[ ] pain redden [ ] drainage
[ ] gums [] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion teeth[ ] assess eyes ears nose[ ] throat for abnormality [] no problemRESP:
[ ] asymmetric [ ] tachypnea [ ] barrel chest[ ] apnea [ ] rales [X] cough
[ ] bradypnea [] shallow [ ] rhonchi
[X] Sputum [ ] diminished [X] dyspnea[] orthopnea [ ] labored [ ] wheezing
[] pain [ ] cyanotic
Assess resp. rate, rhythm, pulse bloodBreath sounds, comfort [X] no problemCARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [] edema [X] fatigue[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate rhythm, pulse, bloodPressure, circ., fluid retention, comfort
[ ] No problemGASTROINTESTINALTRACT:
[ ] obese [ ] distention [ ] mass[ ] dyspagea [ ] rigidity [ ]pain
Assess abdomen, bowel habits, swallowing
Bowel sounds, comfort [X] no problemGENITO URINARYAND GYNE
[ ] pain [ ] urine [ ] color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturiaAssess urine frequency, control, color, odor, comfort
gyne bleeding [ ] discharge [X] no problemNEURO:
[ ] paralysis [ ] stuporus [] unsteady [ ] seizure
[ ] lethargic [ ] comatose [] vertigo [ ] treamors
[ ] confused [ ] vision [X] gripAssess motor, function, sensation, LOC, strengthGrip, gait, coordination, speech [] no problemMUSCULOSKELETAL and SKIN:
[ ] appliance [ ] stiffness [ ] itching [ ] petechie[X] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] wound [ ] flushed
[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic [] moistassess mobility, motion gait, alignment, joint function
Skin color, texture, turgor, integrity [] no problem
NURSING SYSTEM REVIEW CHART
Name:Mrs. Ana Date: January13, 2011
PR: 76 bpm BP: 140/90 mmHg Temp: 37.9C Height: 5 ft Weight: 138 Ibs
An [X] is placed in the area of abnormality. Comment at the space provided. Indicate the location of the problem in
the figure using [X].
Used of eyeglasses,
blurry vision
Productive cough w/
thick yellowish
secretions
BP -140/90 mmHg
,
- Loss of
appetite
- Weak in
appearance
- Fatigability
- has fever
T- 37oc
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SUBJECTIVE OBJECTIVE
COMMUNICATION
[ ] hearing loss
[X] visual changes
[ ]denied
[X] glasses [ ]languages
[ ] contact lens [ ] hearing aide
R L
Pupil size:2 mm
Reaction: Sluggishly reactive
OXYGENATION:
[ ]dyspnea
[ ]smoking history
[X] cough
[X]sputum
[]denied
Resp. [X]regular []irregular
Describe: Respiratory cycle is normal RR=16cpm.
Not dyspneic and chest excursion is symmetrical.
R: Right lung is symmetrical with the left lung.
L: left lung is symmetrical with the right lung.
CIRCULATION
[ ]chest pain
[ ] leg pain
[] numbness of extremities
[X] denied
Heartrhythm [X] regular [ ] irregular
Ankle Edema: none
Carotid Radial Dorsal pedis femoral
R: + 67 + +
L: + 65 + +
Comments: Pulses are palpable but kind of a weak.
NUTRITION:
Diet: low salt, low fat diet
[ ] N [ ] V
Character
[ ] recent change in weight
and appetite
[X]dentures []none
Full partial with patient
Upper [] [X] []
Lower [] [X] []
Comments: halap-
halap na ako
panan.aw as
verbalized by
patient.
Comments:gahi
pa gihapon ako
ubo, ug naay
plemas, as
verbalized by the
patient.
Comments: ok
raman wala man koy
nabatian as
verbalized by the
patient.
Comments:ok
raman, gana man
gihapon ko mu
kaon, as verbalized
by the patient.
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[ ] swallowing difficulty
[X]denied
ELIMINATION
Usual bowel pattern urinary frequency
formed, softl stool_ ___6x/day___
[]constipation [ ]urgency
remedy: [ ]dysuria
Date of last BM [ ] hematuria
__1/11/11_ [ ] incontinence
[ ] diarrhea [ ] polyuria
Character: [] foly in place
[X] denied
Comments: Bowel sounds: normoactive
yellowish Urine Abdominal distention
Odor , malodorous Present [ ] yes [X] No
. Urine (color,consistency,
odor)
MGT. OFHEALTH & ILLNESS:
[ ] alcohol [X]denied
(amount frequency)
NA
[X] SBE last Pap smear:
LMP:2 yrs ago
Briefly, describe the patients ability to follow
treatments (diet, meds, etc.) for chronic health
problems (if present).
The patient follows religiously to the treatment and
submissive to treatment care.Pt. is not an alcoholic drinker
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SKIN INTEGRITY:
[ ] dry Comment: ok raman la
[ ] other man koy nabatian nga
[X] denied deperensiya as verbalized
by the patient.
[ ] dry [ ] cold [] pale[ ] flushed [X] warm[] moist [ ] cyanotic*rashes, ulcers, decubitus (describe size, location,
drainage)
ACTIVITY/SAFETY:
[ ] convulsion
[] dizziness
[] Limited motion
OfJointsLimitation inAbility to[ ] ambulate[ ] bathe self
[ ] other[X] denied
[ ] LOC and orientation: patient is weak in
appearance but still oriented
Gait: [ ] walker [ ] cane [X] other[ ] steady [] unsteady
[ ] sensory and motor losses in face orExtremities: No sensory and motor losses on face
or extremities noted.
[ ] ROM limitations: there were no ROM
limitations noted.
COMFORT/SLEEP/
AWAKE:
[ ] pain (location)
(Frequency)
(Remedies)
[ ] nocturia[X]sleep difficulties
[ ] denied
[ ] facial grimaces[ ] guarding[ ] other signs of pain :
[ ] siderail release form signed (60+ years)
No siderails released
COPING:Occupation: Government employeeMembers ofhousehold: 4Most supportiveperson: husband
Observed non-verbal behavior: patient is irritablePhone number that can be reached anytime: It is
kept confidential.
Comments:la may
problema, maka lihok-lihok
raman ko, as verbalized by
the patient.
Comments:mag mata-
mata lge k okay ping-ot
ako ilong, as verbalized
by the patient.
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Nursing CarePlan
CUES NURSINGDIAGNOSIS
SPECIFICOBJECTIVES
NURSINGINTERVENTIONS
RATIONA
Subjective:
Ping-ot kayo ako
ilong, as
verbalized by the
patient.
Objective:
- Productivecough w/thickyellowishsecretion
- Has colds
Ineffective Airwayclearance r/tincreased mucus
production asmanifested byProductive cough(yellow sputum)and congested
nose
At the end of 8
hours, the client
will be able to
expectorate
secretions readily
and demonstrate
behaviours to
improve andmaintain clear
airway.
Independent:
Keep environmentallergen free, fromdust and smoke.
Instruct DBE andcoughing
exercises.
Instruct pt. Onincrease fluidintake.
o .
Place pt onmoderate highbackrest.
Provide chesttapping
To maintaienvironmeairway.
To mobiliz
To liquefy
For total luexpansion
To dislodgsecretions
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CUES NURSING
DIAGNOSIS
SPECIFIC
OBJECTIVES
NURSING
INTERVENTIONS
RATIONA
Subjective:
luya pa ako
paminaw, as
verbalized by the
patient.
Objective:
- Weak in
appearance
- Complainsof fatigue
Activityintolerance r/t togeneralized bodyweakness as
At the end of 8hours, the clientwill be able tolearn how toconserve energyand verbalize relieffrom fatigue
Independent:
Evaluate the pt.scurrent activitytolerance
Adjust activity andreduce intensity oftask that maycause undesiredphysiological
changes Increase exerciseand activity levelsgradually
Teach methods toconserve energysuch as sitting thanstanding whiledressing
Assist the pt. whiledoing ADLs andGive the pt. info.That providesevidence ofprogress
Provide coopbaseline
To prevent ov
Enhance acti
Helps minimienergy
Prevent the pand to sustaimotivation
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CUES NURSING
DIAGNOSIS
SPECIFIC
OBJECTIVES
NURSING
INTERVENTIONS
RATIONA
Subjective:
gi tugnaw ko, as
verbalized by the
patient.
Objective:
- Warm totouch
- Febrile T-38
0C
Ineffectivethermoregulationr/t increased bodytemperature
After 30 minutes ofcontinuous TSB,the pt.stemperature willdecrease from 380C to 37.5C and
below
Independent:
Monitor VS
Increase fluid intake
Maintain bed rest
Provide sufficientclothing
Perform TSB
Administerantipyretics asordered
Serves as ba
To help cool temperature
To decrease that produce
Facilitate com
Facilitate heameans of evaHelps lower twithin norma
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Actual Nursing Management (SOAPIE)
S Ping-ot kayo ako ilong as verbalized by the patient.
o- Received awake lying on bed w/ ongoing IVF of PNSS 1L @ 120 cc level regulated
@ 10 gtts/m, infusing well- Has colds
A Ineffective airway clearance related to congested nose
P To improve airway patency
I
1) Pt was instructed to increase fluid intake
2) Instructed to expectorate mucus secretions rather than swallowing it.3) Taught on pursed lip breathing and deep breathing exercise.
4) Placed on moderate high back rest
5) Due meds given
E The pt was able to verbalize improvement of airway patency.
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S gahi pa gihapon ako ubo, ug naay plemas, as verbalized by the patient.
O- Received awake lying on bed w/ ongoing IVF of PNSS 1L @ 120 cc level regulated
@ 10 gtts/m, infusing well
- Weak in appearance
- Productive cough noted w/ yellowish secretions.
A Ineffective airway clearance related to thick mucus secretions
P The pt will be able to expectorate excessive mucus secretions properly
I
1) Instructed on coughing exercise
2) Chest tapping done
3) Instructed on postural drainage
4) Nebulization done
5) Placed on moderate high back rest
E The pt was able to expectorate copious secretions.
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S kapoy pa ako lawas, luya pa, as verbalized by the patient.
O
- Un comb hair
- Un groomed- Weak in appearance
A Self-care deficit related to body weakness and fatigability
P The client will be able to do self-care activities progressively and will look fresh, cool andclean.
I
1) Watcher was instructed to provide Oral mouth care every after meal.
2) Provide CBB to pt to make patient fresh and tidy.
3) Comb patients hair for good grooming
4) Provide a towel under patients neck to prevent clothing from mouth secretions.
5) Patient was kept cool and dry.
E After giving the interventions, the client became fresh and clean and well groomed.
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Referrals and Follow-up
The patient and watcher was instructed and informed to have a Follow-up
health check at OPD after 1 week of discharge, or to seek an immediate
consultation to any health clinics if signs of respiratory distress occurs. This is
to check for changes and progress in the clients health status, and be
intervened as early as possible to prevent further complications.
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Evaluation
Mrs. Ana is currently still on the road to progress, and getting his strength
back to hasten recovery. She still have productive cough. Medical
interventions were already implemented and he is receiving various home
medication drugs to alleviate sign and symptoms experienced and achieve
maximum progress and recovery. Goals and objectives are expected to be
met during the upcoming days of hospital stay.
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Bibliography
y Brunner & Suddarths textbook ofMedical-Surgical Nursing by Suzanne
C. Smeltzer & Brenda G. Bare, 10th ed. vol. 1, pp.569-586)
y 26th edition , Nursing2006 Drug handbook by Lippincott Williams &
Wilkins
y http://www.livestrong.com/ls_images/disease/0-999/23-
17099.jpg?v=1220483504
y http://www.answers.com/topic/bronchitis