Professional Documents
Culture Documents
PRESENTATION
The urethra is the tube through which urine passes from the
bladder to the exterior of the body. The female urethra is around 2
inches long and ends inferior to the clitorisand superior to the vaginal
opening. In males, the urethra is around 8 to 10 inches long and ends
at the tip of the penis. The urethra is also an organ of the male
reproductive system as it carries sperm out of the body through the
penis.
The flow of urine through the urethra is controlled by the
internal and external urethral sphincter muscles. The internal urethral
sphincter is made of smooth muscle and opens involuntarily when
the bladder reaches a certain set level of distention. The opening of
the internal sphincter results in the sensation of needing to urinate.
The external urethral sphincter is made of skeletal muscle and may
be opened to allow urine to pass through the urethra or may be held
closed to delay urination.
Maintenance of Homeostasis
The kidneys maintain the homeostasis of several important
internal conditions by controlling the excretion of substances
out of the body.
Inside each kidney are around a million tiny structures called nephrons.
The nephron is the functional unit of the kidney that filters blood to produce urine.
Arterioles in the kidneys deliver blood to a bundle of capillaries surrounded by a
capsule called a glomerulus. As blood flows through the glomerulus, much of the
bloods plasma is pushed out of the capillaries and into the capsule, leaving the
blood cells and a small amount of plasma to continue flowing through the capillaries.
The liquid filtrate in the capsule flows through a series of tubules lined with filtering
cells and surrounded by capillaries. The cells surrounding the tubules selectively
absorb water and substances from the filtrate in the tubule and return it to the
blood in the capillaries. At the same time, waste products present in the blood are
secreted into the filtrate. By the end of this process, the filtrate in the tubule has
become urine containing only water, waste products, and excess ions. The blood
exiting the capillaries has reabsorbed all of the nutrients along with most of the
water and ions that the body needs to function.
Storage and Excretion of Wastes
ECG, TSH, free T3 and T4 are the minimum indicated laboratory investigations, with renal and adrenal function also
recommended. It is important to note that this disorder is autosomal dominant in two-thirds of cases; with male preponderance when providing
genetic counselling.11 The basic guidelines to follow when caring for the patient include control of plasma potassium, avoidance of large glucose
and salt loads (which promote intracellular shift), maintenance of body temperature, acidbase balance, and cautious use of neuromuscular
blocking agents.12,13 The specific treatment of hypokalemic FPP is oral potassium supplementation, repeated at 15-30 minute intervals
depending on the response of the ECG, serum potassium level, and muscle strength. Replenishment may be done intravenously if the patient is
vomiting or unable to swallow. Prophylaxis against recurrent periodic attacks has been successful with a wide variety of treatment modalities
including spironolactone and acetazolamide.
Pneumonia is an infection that inflames the air sacs in one or both lungs.
The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm
or pus, fever, chills, and difficulty breathing. A variety of organisms, including
bacteria, viruses and fungi, can cause pneumonia.
Pneumonia can range in seriousness from mild to life-threatening. It is
most serious for infants and young children, people older than age 65, and people
with health problems or weakened immune systems.
The signs and symptoms of pneumonia vary from mild to severe,
depending on factors such as the type of germ causing the infection, and your age
and overall health. Mild signs and symptoms often are similar to those of a cold or
flu, but they last longer.
Many germs can cause pneumonia. The most common are bacteria and
viruses in the air we breathe. Your body usually prevents these germs from infecting
your lungs. But sometimes these germs can overpower your immune system, even if
your health is generally good. Pneumonia is classified according to the types of
germs that cause it and where you got the infection.
Community-acquired pneumonia
Community-acquired pneumonia is the most common type of pneumonia. It
occurs outside of hospitals or other health care facilities. It may be caused by:
Causes
Pneumonia can affect anyone. But the two age groups
at highest risk are:
Children who are 2 years old or younger
People who are age 65 or older
Other risk factors include:
ANATOMY AND PHYSIOLOGY
Being hospitalized. You're at greater risk of pneumonia if you're in a hospital intensive care unit, especially if you're on a machine that helps you
breathe (a ventilator).
Chronic disease. You're more likely to get pneumonia if you have asthma, chronic obstructive pulmonary disease (COPD) or heart disease.
Smoking. Smoking damages your body's natural defenses against the bacteria and viruses that cause pneumonia.
Weakened or suppressed immune system. People who have HIV/AIDS, who've had an organ transplant, or who receive chemotherapy or long-
term steroids are at risk.
Pneumonia is an infection of the lung, and can be caused by nearly any
class of organism known to cause human infections, including bacteria, viruses,
fungi, and parasites. In the United States, pneumonia is the sixth most common
disease leading to death, and the most common fatal infection acquired by already
hospitalized patients. In developing countries, pneumonia ties with diarrhea as the
most common cause of death.
Pneumonia is suspected in any patient who presents with fever, cough,
chest pain, shortness of breath, and increased respirations (number of breaths per
minute). Fever with a shaking chill is even more suspicious, and many patients cough
up clumps of mucus (sputum) which may appear streaked with pus or blood. Severe
pneumonia results in the signs of oxygen deprivation, including blue appearance of
the nail beds (cyanosis).
Bacterial pneumonia prior to the discovery of penicillin antibiotics was a
virtual death sentence. Today, antibiotics, especially given early in the course of the
disease, are very effective against bacterial causes of pneumonia. Erythromycin and
tetracycline improve recovery time for symptoms of mycoplasma pneumonia, but do
not eradicate the organisms. Amantadine and acyclovir may be helpful against
certain viral pneumonias.
The lungs constitute the largest organ in the respiratory system. They play an important
role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide.
The lungs expand and contract up to 20 times per minute taking in and disposing of those gases.
Air that is breathed in is filled with oxygen and goes to the trachea, which branches off
into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the
breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three
lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of
elastic, spongy tissue.
Within the lungs, the bronchi branch out into minute pathways that go through the
lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called
alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels.
The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in
carbon dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs.
Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered
membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid
between the layers. The fluid allows the membranes to easily slide over each other during
breathing.
Baseline Data
I. Biographical Data
Name of the Patient: Patient M.
Address: P-2,Mauswagon, Maningcol Ozamiz City
Gender: Female
Birth date: August 03,1993
Race or Ethnic Background: Pure Bisaya
Primary and secondary languages (Spoken and read): Can
speak and read Filipino and Visayan
Marital Status: Single
Religious or Spiritual Practices: IFI
Educational Level: High school level
Occupation: None
Significant others or support persons: Mother
II. Reasons for Seeking Health Care
Prior to admission, patient had difficulty in
ambulation and difficulty of breathing.
Admission Dx: Acute Renal Failure Secondary to
Hypokalemia with Periodic Paralysis; R/O Gullian
Barre Syndrome.
Admission Date: August 14,2017; 3:36 pm
Actions done: ( Immediate )
Intubated ET size 7 @ level 16
Diazepam cup IVTT stat
Inserted Met. 12 and open to drain
Fast drip PNSS 200 cc
16F with PNSS 1 L @ 30gtts/min.
III. Initial Assessment
Blood Pressure: 90/60 mmHg
Respiratory Rate: 28 cpm
Heart Rate: 70 bpm
Temperature: 37. 0 C
Oxygen Saturation: 99 %
Height:
Weight:
BMI:
Tubes: none
Intravenous Fluid and date of Insertion:
Onset (When did it begin) August 14,2017 August 14,2017 August 16,2017
Grandparents Illness and Patient doesnt remember their ages but they died due to
longevity katigulangon
Lifestyle and health Practices Profile
Description of Typical day Kuan ,kaning naa raman ko sa balay, magtabang-tabang
sa akong mama ug panlaba, hinlo ug bisan unsa pa as
verbalized by the patient.
Nutrition and Weight Management Patient doesnt want to eat acidic foods.
Sleep and Rest Usually sleep at 11 pm and wake up at around 6 am.
Substance use None
Stress levels and Coping styles Mag-ampo lang sa Ginoo, mao rana as verbalized by the
patient.
Environment Theyre currently living in Maningcol Ozamiz City and its
not that polluted.
Physical Assessment
1ST DAY
Integumentary System Assessment The clients skin is uniform in color with a
Inspect general skin colorInspect skin skin color of medium brown. Skin is warm
integrityInspect for skin lesion and to touch. The skin is intact, a little bit of
ulcersInspect for skin odorAssess for scars in the lower extremities. Phlebitis
edemaAssess skin moistureAssess skin noted in the right plantar ( midfoot).
thicknessAssess skin textureAssess for skin
temperature
Nails Assessment The clients fingernails are short and
Inspect nail grooming and cleanlinessInspect clean with no nail color. With no linear
nail color and markingsInspect nail shapeAssess markings. Clients nail has a shape of
nail texture and consistency, whether nail plate convex curve. It is smooth and is intact.
is attach to nail bedTest capillary refill When nails pressed between the fingers,
the nails return to usual color in less than
2 second. Toe nails are with nail color
(pink) , partially clean.
Hair Assessment The hair of the client is brown-black and
Inspect the scalp and hair for general color and is uniform in color. It is thick with an
condition.Inspect and palpate the hair and the evenly distributed amount of hair. Hair is
scalp for cleanliness, dryness, oiliness, parasites dry and has dirty scalp, has a little bit of
and lesionsInspect amount and distribution of dandruff and with lice. No axillary hair.
scalp, body, axillae, and pubic hair
Head and Face Assessment The clients head is round and
Inspect for head sizeInspect for involuntary symmetrical with no involuntary
movementCheck the temporal arteryCheck the movements. Temporal artery is not
temporomandibular joint distended. No tenderness upon palpation.
Its just that her face likely manifests
Cushings syndrome ( moonfaced).
Neck Assessment The neck is in midline position with no
Inspect for the neck position, symmetry, lump visible masses. The trachea is place in
and massesInspect movement of the neck midline of the neck. The thyroid gland is
structureInspect the cervical vertebraeInspect not visible on inspection and the glands
the range of motionInspect the tracheaInspect ascend during swallowing but are not
the thyroid glandInspect for lymph nodes visible. Lymph nodes are palpable on the
right side of the neck.
Eyes Assessment The clients eyes are positioned and
Inspect for the position and alignment of the aligned in the eye socket. The bulbar
eyeball in the eye socket Inspect the bulbar conjunctiva is pinkish. Anicteric sclera.
conjunctiva and scleraInspect the lacrimal Patient can see clearly. Her eyelashes are
apparatusInspect the cornea and lensInspect short, eyelids have a little dark spots.
the iris and pupilInspect the optic discInspect
the retinal vesselsCheck distant visual
acuityCheck for visual fields for gross peripheral
testInspect the eyelids and eyelashes
Ears Assessment The auricles are symmetrical and have
Inspect the auricle, tragus and mastoid the same color with the facial skin. The
processInspect the external auditory auricles are aligned with the outer
canalInspect the tympanic membraneInspect canthus of the eye. No discharges are
for any discharges and discolorationPerform noted.
Whisper testPerform Weber testPerform Rinne
test
Mouth, Tongue, and Teeth Assessment The clients teeth are a little bit yellowish.
Inspect the teeth and gums(Note the number Gums are pinkish. Client has the ability to
of teeth, color and condition)Inspect the buccal taste.
mucosaInspect and palpate the tongueAssess
the ventral surface of the tongueCheck the
anterior tongues ability to tasteInspect the
hard and soft palate and uvula
Nose and Sinuses Assessment The nose appeared symmetric, straight
Check the external structureCheck the patency and uniform in color. Nasal flaring noted.
of airflow through the nostrilsCheck the No tenderness noted.
internal structureInspect the frontal and
maxillary sinusesCheck for nasal discharges
Throat Assessment I wasnt able to assess.
Inspect the tonsils appearanceInspect the posterior
pharyngeal wall Check the patency of the airflow
Note the odor
Thoracic and Lungs Assessment The clients face is round and the lips light
Inspect the face, lips and chestAssess for breath pink. The chest wall is intact with symmetrical
soundsInspect for shape of the sternumInspect slope expansion. The client exerts effort in
of the ribsObserve quality and pattern of inspiration. The sternum is midline. No
respirationCheck for tenderness and massesCheck tenderness and masses upon palpation.RR= 28
anterior chest expansion cpm Hyperventilation occurs prior to
admission.
Breast and LymphaticAssessment Breast is symmetric with no masses upon
Inspect size and symmetry Inspect color and palpation. Nipples are firm with brownish color
textureInspect superficial venous patternInspect the of the areola. No discharges noted.
areolaInspect the nipplesCheck for tenderness and
massesInspect and palpate the axillae
Abdominal Assessment The skin color is lighter than the skin color. No
Observe the color of the skinInspect for scars and scars and striae noted. No lesions and rashes
striaeAssess for lesions and rashesInspect the noted. No masses and tenderness upon
umbilicus, its appearance and locationAssess palpation.
abdominal symmetryInspect abdominal
movementCheck bowel soundsCheck internal
organsCheck for masses and abdominal tenderness
Heart and neck vessels Jugular vein is not distended. Murmur noted. No
Observe and evaluate jugular venous pulseCheck the visible pulsations in the aortic and pulmonic areas.
carotid arteriesCheck the apical pulseCheck for the extra A blood pressure of 90/60 mmHg.
heart soundsCheck blood pressure
Peripheral vascular Assessment The clients hands, finger and arms are warm to
Inspect the fingers, hands, arms, and temperatureInspect touch. The client has the ability to raise her both
the capillary refill timeCheck the brachial pulses, femoral arms, and legs. The capillary refill time is within 2
pulses, popliteal pulse, posterior tibial pulse and dorsalis second. No varicosities noted.
pedis pulsePerform Allen testInspect the superficial
inguinal lymph nodesInspect for varicosities and
thrombophlebitits
Male/Female GenitaliaMale: She has menstruation. August 17,2017 is her
Inspect the base of the penis and pubic hairInspect the first day.
skin of the shaftInspect the foreskinInspect the size,
shape an position of the scrotumCheck urethral
dischargesCheck for inguinal lymph nodes and hernia
Female:Inspect for mons pubisObserve and palpate
inguinal nodesInspect the labia majora and
perineumInspect the labia minora, clitoris, urethral
meatus and vaginal opening inspect the size of the
vaginal opening of the angle of the vaginaInspect the
cervixInspect the vaginal wall
Anus and rectum Assessment No masses in the peri-anal area. Defecate once
Inspect for the peri-anal area(Note for lumps, ulcers, with black brown in color. No other discharges
lesions, rashes and redness)Check the rectumInspect for noted.
the stool characteristicInspect for any other discharges
Musculoskeletal Assessment The extremities are symmetrical in
Inspect size, shape, color and color and size. No heat and
symmetryCheck for edema, heat, tenderness, nodules noted. Only the
tenderness, pain and nodulesCheck for right plantar (midfoot) is swollen.
ROMObserve and assess gaitObserve the The client can move her both legs.
cervical, thoracic and lumbar curves from
the side, then from behindCheck ROM of
cervical spine, thoracic and lumbar
spineCheck ROM of elbows, wrist, hands,
fingers, hips, ankles and feet
Neurologic Assessment A GCS scoring of 15.
Assess GCSCheck 12 cranial nervesAssess
movement, balance, coordination,
sensation and reflexesCheck involuntary
movementsEvaluate gait and
balanceAssess for sensory system
GORDONS FUNCTIONAL HEALTH PATTERNS
Demographic Data
Name: Patient M. Age: 24 years old
Sex: Female Civil Status: Single
Address: P-2, Mauswagon, Maningcol Ozami City
Birthdate: August 3,1993
Religion: IFI
Occupation: None
Date of Admission: August 14,2017
E. Actions taken since symptoms started. Have your actions helped? How can we be most
helpful?
N/A
Hyperventilation
Decreased (Metabolic acidosis)
Difficulty of
breathing
COMPLICATIONS
Cardiac Complications
Cardiac dysrhythmias. Tachycardia, hypertension
Muscular Complications
Muscle fibers break down, Paralysis
Diabetic Complications
Hyperglycemia and
Other complications
Hypokalemia can also lead to metabolic acidosis, respiratory
acidosis, renal cystic disease and hepatic encephalopathy.
OR EVEN DEATH
Disruption of Precipitating Factor:
Predisposing Factor: mucociliary -Smoking
- Age: ____ activity -Alcohol
- Gender: ____ intoxication
Multiplication of
microorganisms in the
bronchi and/or alveoli
Fever
Coughing
Inflammatory reaction
Producing exudates in
the alveoli
Chest pain
Interferes with
diffusion of O2 & CO2
Pathophysiology of Pneumonia
Dyspnea
Medical management
Management Date General Description Indication Clients Response
Ordered
D5LR 08-14- 1 liter 20 gtts/mmin MOA: restores Fluid & Rehydrated
17 fluid and electrolyte balances, Electrolyte
produces diuresis, and acts as replenishment
alkalizing agent
PNSS infused 08-14- 1 liter PNSS ; 90 cc PNSS infused Fluid & Stabilized potassium
with 20 mEq 17 with 20 mEq of potassium chloride Electrolyte level in the blood.
KCl MOA: Restores fluid and electrolytes replenishment
balances, for potassium
supplementation of the body.
CBC 08-14- A (CBC) gives important information Bleeding and Segmenters: 87.25 %
17 about the kinds and numbers of Inflammation IncreasedLymphocyt
cells in the blood, especially , , and es: 6.90 % Decreased
.
CHEST X-RAY 08-14- Diagnostic x rays are useful in To identify Reveals right lobar
AP 17 detecting abnormalities within the abnormalities. pneumonia
body. They are a painless, non-
invasive way to help diagnose
problems such as broken bones,
tumors, dental decay, and the
presence of foreign bodies.
Urinalysis 08-14- Urinalysis is the physical, chemical, Acute renal Pus cells: 2-3/hpfEpithelial cell:
17 and microscopic examination of urine. failure few/hpfBacteria: few/hpf
It involves a number of tests to detect
and measure various compounds that
pass through the urine.
Impression:
Right Lobar pneumonia
Urinalysis (August 16,2017)
Color Yellow
Transparency Slightly cloudy
Specific Gravity 1.015
Ph 6.5
Pus cells 2-3 /hpf
Epithelial Cells Few/hpf
Bacteria Few/hpf
Sodium Level 08-14-17 Acute renal failure August 14,2017 : 142.90
mmol/LAugust 21,2017: 137.50
mmol/L
Potassium Level 08-14-17 Acute Renal August 14,2017: 1.94 mmol/L
Failure August 15,2017- 2.56 mmol/L
Ausgut 16,2017: 3.12 mmol/L
August 17,2017: 3.59 mmol/L
August 21,2017: 3.83 mmol/L
Calcium Level 08-14-17 Acute renal failure August 14,2017 : 3.12 mmol/L
BUN 08-14-17 Acute renal failure August 14,2017: 23.18 mg/dl
(increase)
CREATININE 08-14-17 Acute renal failure August 14,2017: 1.255mg/dl
(increase)
ARTERIAL BLOOD GAS 08-14-17 Oxygen Saturation Fully Compensated Metabolic
of the blood. Acidosis
August 17,2017 Immunology
August 23,2017
Gram stain; Culture and Sensitivity
Specimen: Blood
Comment: After 24 hours of incubation
Organism: No growth
10 NURSING DIAGNOSIS: ARF
Subjective: Fatigue At the end 1.Discuss therapy regimen relating 1.To Identify At the end of 8 hours
Walay kusog related to of 8 hours to individual causative factors and causative factors nursing interventions, the
ang akong decreased nursing help client-SO(s) to understand 2.That indicate the client was able to:
lawas, galuya potassium intervention relationship of fatigue to illness. need to alter 1. Reported a little
jud tanan level in the s, the client 2. Instruct the client in ways to activity level. improvement in sense of
akong pamati, body. will be able monitor responses to activity and 3.To have baseline energy.
dili nako to: significant signs-symptoms. data. 2. Identified basis of fatigue
malihok-lihok 1. Report 3. Promote overall health 4.Presence of and individual areas of
akong mga tiil improved measures. anemia and control.
ug kamot as sense of 4. Provide supplemental oxygen, as hypoxemia reduces
verbalized by energy. indicated. oxygen available
the patient. 2. Identify 5. Assist client to identify for cellular uptake
Objective:Diffi basis of appropriate coping behaviors. and contributes to
culty in fatigue and 6. Encourage client to do whatever fatigue.
ambulationBo individual possible such as, self-care, sit-up in 5.Promote sense of
dy weakness areas of chair, go for walk, interact with control and
control. family, and play games. improves self-
3. Perform 7. Encourage nutritionally dense, esteem.
activities of easy to prepare and consume 6. Increase activity
daily living foods and avoidance of caffeine level, as tolerated.
and and high-sugar foods and 7. To promote
participate beverages. energy.
in desired 8. Refer to comprehensive 8. To improve
activities at rehabilitation program, physical stamina, strength
level of and occupational therapy for and muscle tone to
ability. programed daily exercises and enhance sense of
activities. well-being.
ASSESSMENT NURSING DESIRED INTERVENTION(S) RATIONALE EVALUATION
DIAGNOSIS OUTCOME
Subjective: Impaired At the end of 8 1.Encourage verbalizations of 1. To promote At the end of 8 hours
Wala juy tissue hours nursing feelings and expectation self-function nursing interventions,
umoy akong integrity interventions, regarding g condition and and the client was able to:
kalawasan as related to the client will be potential for recovery of identification. 1.Verbalized
verbalized by decreased able to:Verbalize structure and function. 2. To reduce understanding of
the patient. potassium understanding pain or condition and causative
Objective:Bod level in the of condition and 2.Discuss importance of early discomfort factors.
y weakness body. causative detection and reporting of and to 2. Demonstrated
factors.2. changes in condition or any improve behaviors and lifestyle
Display unusual physical discomforts quality of life. changes to promote
progressive or changes in pain 3. To optimize healing and prevent
improvement in characteristics. healing complications or
wound or lesion potential. recurrence.
healing. 3. 3.Emphsize needs for 4. To limit
Demonstrate adequate nutritional and metabolic
behaviors and fluid intake. demands,
lifestyle changes maximize
to promote 4.Stress importance of energy
healing and follow-up care, ass available for
prevent appropriate. healing, and
complications or meet comfort
recurrence. 5.Encourage adequate needs.
periods of rests and sleep. 5. To promote
6. Promote early mobility, circulation and
assist with or encourage prevent
position changes, active or excessive
passive and assistive tissue
exercises. pressure.
PNEUMONIA
ASSESSMENT NURS DESIRED INTERVENTION with RATIONALE EVALUATI
INGDI OUTCOME ON
AGN
OSIS
Subjective:Patient Impaired gas exchange After nursing - Note respiratory rate, - Provides insight into the
complaints of difficulty in related to altered oxygen interventions, the depth, use of accessory work of breathing and
breathing. supply as evidenced by patient will be muscles, pursed-lip adequacy of alveolar
Objective:Use of difficulty of breathing. able breathing; areas of ventilation. - Affects
accessory muscle when to;Demonstrate pallor/cyanosis, such as ability to clear airways of
breathingNasal improved peripheral versus secretion - All vital signs
flaringUse of oxygen ventilation and central or general are impacted by changes
therapy adequate duskiness.- Note in oxygenation.- Elevation
oxygenation of character and or upright position
tissues by ABGs effectiveness of cough facilitates respiratory
within client's mechanism.- Monitor function by gravity.- to
usual parameters vital signs and cardiac clear or maintain open
and absence of rhythm. - Elevate head airway, when client is
symptoms of of bed and position unable to clear secretions,
respiratory client approximately. - or improve gas diffusion
distress.Verbalize Provide airway when client is showing
understanding of adjuncts and suction, disaturation of oxygen by
causative factors as indicated. - oximetry or ABGs.- for
and appropriate Maintain adequate mobilization of secretions,
interventions input and output. - but avoid fluid overload.-
Participate in Administer medications generally used to prevent
treatment as indicated. and control symptoms,
regimen within reduce frequency and
level of ability or severity of exacerbations,
situation and improve exercise
tolerance.
ASSESSMENT NUR DESIRED INTERVENTION with RATIONALE EVALUAT
SING OUTCOME ION
DIAG
NOSI
S
Subjective:Naglisod ko Ineffective airway clearance After nursing - Assess level of - Information is essential
related to neuromuscular interventions, the consciousness/cogniti for identifying potential for
ug ginhawa as verbalized
dysfunction. patient will be able on and ability to airway problems, providing
by the patient.
to;Maintain airway protect own airway. - baseline level of care
Objective:Use of
patency.Expectorat Monitor respirations needed, and influencing
accessory muscle when
e/clear secretions and breath sounds, choice of interventions.-
breathingRR-28 cpmNasal
readily.Demonstrat noting rate and indicative of respiratory
flaring
e sounds.- Position distress and/or
absence/reduction head appropriate for accumulation of
of congestion with age and condition. - secretions.- to open or
breath sounding Suction nose, mouth maintain open airway
clear, noiseless and trachea, as airway in an at-rest or
respirations, and necessary. - Elevate compromised individual.- to
improved oxygen head of bed, clear airway when
exchange.Verbalize encourage early excessive or viscous
understanding of ambulation, or secretions are blocking
causes and change client's airway or client is unable to
therapeutic position every 2 cough or swallow
management hours. - Encourage effectively.- to take
regimen.Demonsta deep breathing and advantage of gravity
rte behaviors to coughing exercises or decreasing pressure on the
improve or splint-chest/incision.- diaphragm and enhancing
maintain clear Administer drainage of/ventilation to
airway.Identify analgesics, as different lung secretions.-
potential prescribed. to maximize effort. - to
complications and relax smooth respiratory
how to initiate musculature, reduce airway
appropriate edema, and mobilize
preventive or secretions.
corrective actions.
ASSESSMENT NUR DESIRED OUTCOME INTERVENTION with RATIONALE EVALUATION
SING
DIA
GNO
SIS
Subjective: Nag-lisod ko Ineffective breathing After nursing - Note emotional - Anxiety may be causing
ug ginhawa adtung paadmit pattern related to interventions, the responses. - Assess for or exacerbating acute or
palang ko as verbalized by neuromuscular dysfunction; patient will be able concomitant chronic
the patient. Objective:- hyperventilation as to;Establish a normal, pain/discomfort.- hyperventilation.- this
Patient used accessory evidenced by used of effective respiratory Administer oxygen at may restrict respiratory
muscles to breath as accessory muscles to breath. pattern as evidenced lowest concentration effort.- for management
observed. by absence of cyanosis indicated and of underlying pulmonary
and other prescribed respiratory condition, respiratory
signs/symptoms of medications.- distress, or cyanosis.- to
hypoxia, with ABGs Encourage assist client in "taking
withing clients normal slower/deeper control" of the situation.
or acceptable respirations, use of - to evaluate breathing
range.Verbalize pursed-lip technique, sounds and secretions.-
awareness of causative and so on.- Auscultate to verify maintenance/
factors.Initiate needed and percuss chest.- improvement of O2
lifestyle Monitor pulse saturation.- to limit level
changes.Demonstrate oximetry, as indicated. of anxiety. - to promote
appropriate coping - Maintain calm relaxation and reduce
behaviors. attitude in dealing with anxiety.- to promote
client and SOs.- Assist deeper respirations and
client in the use of cough.- to limit fatigue. -
relaxation techniques.- to prevent worsening the
Medicate with condition and for it not
analgesics, as to re-occur.- this may
prescribed.- Encourage cause abdominal
adequate rest periods.- distention and impair
Avoidance of known breathing efforts.
irritants, allergens, and
etc. - Avoid
overeating/gas forming
foods.
DRUGS STUDY
DRUG ROUTE/DOS INDICATIO MECHANISM CONTRAINDICAT SIDE EFFECTS NURSINGRESPONSIBILIT
NAME AGE/FREQU N OFACTION ION Y/ PATIENT TEACHING
ENCY
GenericNa 1tab TID/PO IV Maintain acid Hyperkalemi CNS: confusion, Assessment:Assess signs
me: Treat balance and a and severe weaknessGI: and symptoms of
Potassium ment/ electrophysiolo renal Abdominal pain. hyperkalemiaMonitor
Chloride Preve gic balance of impairment Diarrhea, nausea pulse, bp and ECGLab
Brand ntion the cell. Use and testsImplementation:
Name: of Contraction of cautiously vomitingLocal: Administer with or after
Pharmacol potass smooth muscle, in: DM , irritation IV meals to decrease GI
ogic Class: ium cardiac, and cardiac siteNeuro: irritations.Patient/ Family
Therapeuti deplet skeletal. disease, paralysis, TeachingExplain to the
cClass: ion Therapeutic renal paraesthesia patient the purpose of
effect: impairment the
Replacement, medication.Encourage
prevention of compliance of
deficiency.. recommended
diet.Instruct patient to
report dark tarry stools,
weakness, fatigue. Notify
physicians for nausea and
vomiting and
diarrhea.Emphasize to
monitor serum levels.
DRUG NAME ROUTE/DO INDICATION MECHANISM CONTRAINDICAT SIDE EFFECTS NURSINGRESPONSIBILITY/
SAGE/FRE OFACTION ION PATIENT TEACHING
QUENCY
GenericName 40mg IVTT GERD/ Binds to an Hypersensit Adverse reactions: CNS: PO: Administer doses before
: q 24H maintenan enzyme on ivity; dizziness, drowsiness, meals, preferably in the
OMEPRAZOL ce of gastric Metabolic fatigue, headache, morning. Maybe concurrently
E Brand healing in parietal cells alkalosis weakness. CV: Chest pain used with antacids.Patient/
Name:Losec, erosive in presence and GI: Abdominal pain, Family TeachingInstruct
Prilosec esophagiti of acidic hypocalcemconstipation, diarrhea, patient to take medication as
Pharmacologi s. gastric pH, ia (Zegerid flatulence, nausea and directed. Take missed meds as
c Duodenal preventing only)Use vomiting Derm: itching, rash soon as remembered.May
Class:Proton ulcers.Sho the final Cautiously Misc. allergic reactions cause dizziness. Avoid
pump rt-term transport of in: Liver driving.Advice patient to
inhibitors treatment hydrogen disease avoid alcohol, aspirin, foods
TherapeuticCl of active ions into the (dosage that can make GI
ass:antiulcer benign gastric reduction irritation.Advice patient to
agents gastric lumen. may be report onset of black, tarry
Pregnancy: ulcer.Path necessary) stools, diarrhea, abdominal
Category C ologic pain; or persistent headache
hypersecr to health care professional
etory promptly.
conditions
.Reduction
of risk of
bleeding
critically ill
patients.
DRUG NAME ROUTE/DOSAGE INDICATION MECHANISMOFACTIO CONTRAINDICATION SIDE EFFECTS NURSINGRESPONSIBILITY/
/FREQUENCY N PATIENT TEACHING
Generic Name: 1 gm IVTT q12H Treatm Bind to bacterial Contraindicated CNS: seizures (high Assess patient for signs
Ceftriaxone ANST ent of cell wall in: doses).GI: and symptoms of infection
Brand Name: the membrane, Hypersensitivity Pseudomembranous prior to and throughout
Rocephin followin causing cell to cephalosporins; colitis, diarrhea, therapy.Before initiating
PharmacologicC g death. Serious cramps, nausea, therapy, obtain a history
lass THIRD infectio hypersensitivity to vomiting.Derm: to determine previous use
GENERATIONCE ns penicillins.Use rashes, of and reactions to
PHALOSPORIN caused Cautiously in: urticaria.Hematagranu penicillins or
TherapeuticClas by Renal impairment locytosis, bleeding cephalosporins. Persons
s: ANTI- suscepti (dose adjustments (increase with with a negative history of
INFECTIVESPRE ble necessary); cefotetan and penicillin sensitivity may
GNANCY organis History of GI cefoxitin), still have an allergic
CATEGORY B ms: disease, especially eosinophilia, hemolytic response.Observe patient
Urinary colitis; Geri: anemia, neutropenia, for signs and symptoms of
Tract Dosage hrombocytopenia.Loca anaphylaxis (rash,
Infectio adjustment due to l: pain at IM site, pruritus, laryngeal edema,
n age-related phlebitis at IV wheezingDiscontinue the
decrease in renal site.Misc: allergic drug and notify physician
function may be reactions including or other health care
necessary; may anaphylaxis and serum professionalimmediately if
also be at increase sickness, these symptoms occur.
risk for bleeding superinfection.. Keep thromepinephrine,
with cefotetan or an antihistamine,and
cefoxitin; OB: resuscitation equipment
Pregnancy and close by in the event of an
lactation (have anaphylactic
been used safely). reaction.Instruct patient to
report signs of
hypersensitivity.).
DRUG ROUTE/DOSAGE/F INDIC MECH CONTRAINDICATION SIDE EFFECTS NURSINGR
NAME REQUENCY ATION ANISM ESPONSIBIL
OFACT ITY/
ION PATIENT
TEACHING
Generic amp IVTT STAT This drug is A benzodiazepine Contraindicated in CNS- drowsiness, Warn patient to avoid
Name:Diazepam prescribed to that probably patients dysarthria, slurred activities that require
Brand Name: treat:AnxietyMuscl potentiates hypersensitive to speech, tremor, alertness and good
Valium e Spasm Adjunct effects of GABA , drug or soy fatiqueCV- collapse, coordination until
Pharmacologic treatment for depresses the protein or in bradycardia, effects of drugs are
Class:Benzodiaze seizure disorder CNS, and patients hypotensionEENT- unknownInstruct
pine Therapeutic suppresses the experiencing blured vision, patient to avoid alcohol
Class:Anxiolytic spread of seizure shockContraindica nystagmus and while taking drugNotify
activity ted in patients diplopiaGI- diarrhea, pt. that smoking may
with acute constipation and decrease drugs
closure nauseaGU- effectivenessInstruct
glaucomaUse incontinence and urine pts caregiver on the
cautiously in retentionHematologic- proper use of diastat
patients with liver neutropeniaRespirator rectal gel
or renal y- resp. depression and
impairment, apneaSkin- rash and
depression, and phlebitis at injection
history of siteOther- Altered
substance abuse libido
DRUG NAME ROUTE/DOSAG IN MECHANIS CONTRAINDICATION SIDE EFFECTS NURSINGRE
E/FREQUENCY DI M SPONSIBILIT
CA OFACTION Y/ PATIENT
TI TEACHING
O
N
Generic Name: gm q8H This drug is Inhibits ell wall Contraindicated CNS- headache, Instruct patient to
Piperacillin ANST (-) prescribed synthesis during in patients insomnia, fever, report adverse
Tazobactam to bacterial hypersensitive seizures, anxietyCV- reactions
Brand Name: treat:Moder multiplication to drug or other arrhythmia, chest promptlyTell patient
Piperacillin ate to penicillinsUse pain, edema, to alert a health care
Pharmacologic severe cautiously in hypertension, professional about
Class:Extended nosocomial patients with tachycardiaEENT- discomfort at the IV
Spectrum pneumonia bleeding RhinitisGI- diarrhea, site
Penicillin Beta- caused by tendencies, constipation, nausea,
Lactamase piperacillin- uremia, pseudomembranous
Inhibitor resistant hypokalemia, colitis, abdominal
Therapeutic and allergies to pain, Stool changes,
Class:Antibiotic other drugs, vomitingGU-
especially candidiasis and
cephalosporins, intestinal
because of nephritisHematologic
possible cross- - leukopenia,
sensitivity neutropenia,
anemiaRespiratory-
DyspneaSkin- Pruritus
and rashOther-
Anaphylaxis
DRUG NAME ROUTE/DOSAGE/FREQ INDICATIO MECHANISM CONTRAINDICATIO SIDE EFFECTS NURSING
U E N C Y N O F A C T I O N N RESPONSI
BILITY/
PATIENT
TEACHIN
G
Generic Name:Salbutamol + This drug is Depressed CNS ( Contraind HeadacheDizzi Instruct pt. not to
Salbutamol + Ipatropium neb 1 prescribed to GABA ) Inhibitory icated in nessNauseaDry drive or any
Ipatropium neb q8H treat and prevent: neurotransmitter. patients mouthTremors activities that
neb Brand Symptoms of and Relaxed the muscles hypersens ConstipationM require alertness
Name: caused by around the airways itive to uscle because this drug
Pharmacologic ongoing lung so that they open up drug crampsChest can cause
Class:Ipratropi disease and you can breathe Inform painConfusion dizziness and
um more easily. the Rash vision
Therapeutic physician changesInstruct
Class:Broncho first pt. to limit
dilator history of alcohol intake
elevated
BP, heart
disease,
glaucoma
, difficulty
urination,
and
seizure
before
using the
medicatio
n
Discharge Summary
ATTENDING PHYSICIAN:
FINAL DIAGNOSIS:
CHIEF COMPLAINT Prior to admission, the patient had difficulty in ambulation and
difficulty of breathing.
ARF
Discharge Planning
Medicine:
Continue medication
Treatment
Medication as prescribed:
Health Teaching
Nutrition. A referral to nutritionist is made because of the
dietary changes required.
Problems to report. The patient and family should know what
the problems to report to the healthcare provider are.
Follow-up Examinations. The importance of follow-up examinations
and treatment is stressed to the patient and family because of
changing physical status and renal functions.
Prognosis