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Bataan Peninsula State University

Institute of Nursing & Midwifery
Orani Campus,
Campus of Courtesy



Presented by:
Group 18 – MTW
Santos, John Kenneth
Galicia, Lorryleen
Lagman, Kimberly
Cruz, Lindon
Torres, Michelle
Bautista, Renae
Sapno, Lovely
Mungcal, Precious Kate
Macatulad, Reymark
Gabon, Jesusa
Cortez, Jennifer
Bronchitis Overview

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

• The cells that make up this lining may leak fluids in response to
the inflammation.

• Coughing is a reflex that works 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. Symptoms are
similar for both.

• Infants usually get bronchiolitis, which involves the smaller
airways and causes symptoms similar to asthma.
Bronchitis Causes

Bronchitis occurs most often during the cold and flu season, usually
coupled with an upper respiratory infection.

• Several viruses cause bronchitis, including influenza A and B,
commonly referred to as "the flu."

• A number of bacteria are also known to cause bronchitis, such as
Mycoplasma pneumoniae, which causes so-called “walking

• Bronchitis also can occur when you inhale irritating fumes or
dusts. Chemical solvents and smoke, including tobacco smoke,
have been linked to acute bronchitis.

• People at increased risk both of getting bronchitis and of having
more severe symptoms include the elderly, those with weakened
immune systems, smokers, and anyone with repeated exposure
to lung irritants.

Bronchitis Symptoms

Acute bronchitis most commonly occurs after an upper respiratory
infection such as the common cold or a sinus infection. You may see
symptoms such as fever with chills, muscle aches, nasal congestion,
and sore throat.

• Cough is a common symptom of bronchitis. The cough may be
dry or may produce phlegm. Significant phlegm production
suggests that the lower respiratory tract and the lung itself may
be infected, and you may have pneumonia.

• The cough may last for more than two weeks. Continued forceful
coughing may make your chest and abdominal muscles sore.
Coughing can be severe enough at times to injure the chest wall
or even cause you to pass out.

• Wheezing may occur because of the inflammation of the airways.
This may leave you short of breath.

When to call the doctor

Although most cases of bronchitis clear up on their own, some people
may have complications that their doctor can ease.

• Severe coughing that interferes with rest or sleep can be
reduced with prescription cough medications.

• Wheezing may respond to an inhaler with albuterol (Proventil,
Ventolin), which dilates the airways.

• If fever continues beyond four to five days, see the doctor for a
physical examination to rule out pneumonia.

• See a doctor if the patient is coughing up blood, rust-colored
sputum, or an increased amount of green phlegm.

When to go to the hospital
• If the patient experiences difficulty breathing with or without
wheezing and they cannot reach their doctor, go to a hospital's
emergency department for evaluation and treatment.

Exams and Tests

Doctors diagnose bronchitis generally on the basis of symptoms and a
physical examination.

• Usually no blood tests are necessary.

• If the doctor suspects the patient has pneumonia, a chest x-ray
may be ordered.

• Doctors may measure the patient's oxygen saturation (how well
oxygen is reaching blood cells) using a sensor placed on a finger.

• Sometimes a doctor may order an examination and/or culture of
a sample of phlegm coughed up to look for bacteria.

Self-Care at Home

• By far, the majority of cases of bronchitis stem from viral
infections. This means that most cases of bronchitis are short-
term and require nothing more than treatment of symptoms to
relieve discomfort.

• Antibiotics will not cure a viral illness.

• Experts in the field of infectious disease have been warning for
years that overuse of antibiotics is allowing many bacteria to
become resistant to the antibiotics available.

• Doctors often prescribe antibiotics because they feel pressured
by people's expectations to receive them. This expectation has
been fueled by both misinformation in the media and marketing
by drug companies. Don't expect to receive a prescription for an
antibiotic if your infection is caused by a virus.

• Acetaminophen (Feverall, Panadol, Tylenol), aspirin, or ibuprofen
(Motrin, Nuprin, Advil) will help with fever and muscle aches.

• Drinking fluids is very important because fever causes the body
to lose fluid faster. Lung secretions will be thinner and easier to
clear when the patient is well hydrated.

• A cool mist vaporizer or humidifier can help decrease bronchial

• An over-the-counter cough suppressant may be helpful.
Preparations with guaifenesin (Robitussin, Breonesin, Mucinex)
will loosen secretions; dextromethorphan-the "DM" in most over
the counter medications (Benylin, Pertussin, Trocal, Vicks 44)
suppresses cough.
Medical Treatment

Treatment of bronchitis can differ depending on the suspected cause.

• Medications to help suppress the cough or loosen and clear
secretions may be helpful. If the patient has severe coughing
spells they cannot control, see the doctor for prescription
strength cough suppressants. In some cases only these stronger
cough suppressants can stop a vicious cycle of coughing leading
to more irritation of the bronchial tubes, which in turn causes
more coughing.

• Bronchodilator inhalers will help open airways and decrease

• Though antibiotics play a limited role in treating bronchitis, they
become necessary in some situations.

• In particular, if the doctor suspects a bacterial infection,
antibiotics will be prescribed.

• People with chronic lung problems also usually are treated with

• In rare cases, the patient may be hospitalized if they experience
breathing difficulty that doesn't respond to treatment. This
usually occurs because of a complication of bronchitis, not
bronchitis itself.


• The patient should follow up with their doctor within a week after
treatment for bronchitis—sooner if your symptoms worsen or do
not improve.

• Call the doctor's office if any new problems occur.


• Stop smoking.

• Avoid exposure to irritants. Proper protection in the workplace is
vital to preventing exposure.

• The dangers of secondhand smoke are well documented.
Children should never be exposed to secondhand smoke inside
the home.


Nearly all cases of acute bronchitis clear up completely over time.

• In the case of bronchitis caused by exposure to respiratory
irritants, all the patient may need to do is keep away from the
cause of irritation.

• Smoking cessation is recommended to prevent development of
chronic bronchitis or other chronic lung disease such as
emphysema. Chronic bronchitis, as its name suggests, can cause
symptoms for prolonged periods and lead to other debilitating
lung conditions.
Name: Mrs. E.M.
Address: Banawang, Bagac, Bataan
Phone no: NN
Age: 51 y/o
Birthdate: June, 5 1958
Birthplace: San Fernando, La Union
Gender: Female
Marital Status: Married
Nationality: Filipino
Religion: Catholic
Occupation: Housewife
Physical Assessment

Technique Normal Findings Abnormal

Skin Inspection • Skin is brown and • None
generally equal
• No edema
• Good skin turgor
• No lesion
Palpation • Temp. is warm &

Nails Inspection • Clean, smooth • None
• Pink to light
brown nail beds

Hair Inspection • No lesion • None
• No dandruff
• Even in

Head Inspection • Symmetrical in • None
movement &
• Face is
• Normocephalic

Eyes Inspection • Symmetrical in • Pale conjunctiva
• Sclera is white &
• Brisk reaction to

Ears Inspection • Equal in size
• Symmetrical
• No swelling or

Nose Inspection • Symmetrical
• No inflammation
Palpation • Air can be felt in
both nares
Technique Normal Findings Abnormal

Mouth & Throat Inspection • Tongue is at • Cracked lips
midline • Tongue is pale
• Dental caries
• Missing tooth

Neck Inspection • Symmetrical with • None
normal ROM
• No jugular vein
• Trachea is visible
at the midline
Palpation • No nodule
• Lymph nodes are
not palpable

Breast & Axilla Inspection • One breast is • None
slightly larger
• No nipple
Palpation discharge
• No masses
• No lymph nodes

Chest Inspection • Normal contour
Palpation • Tactile fremitus • Limited chest
Auscultation • Bronchial breath excursion

Heart Auscultation • S1 & S2 heard • None

Abdomen Inspection • Color is
consistent with
the body
• No lesion or any
• Bowel sounds is
normo- active
• No tenderness

Genitals Interview • No swelling or • None
• No foul smell
• No infestation

Extremities Inspection • Norma hair • Limited ROM
• No edema
• No swelling
• Capillary refill
around 1-3
Human Respiratory System

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.

The Upper Airway and Trachea

When you breathe in, air enters your body through your nose or
mouth. From there, it travels down your throat through the larynx (or
voice box) and into the trachea (or windpipe) before entering your
lungs. All these structures act to funnel fresh air down from the outside
world into your body. The upper airway is important because it must
always stay open for you to be able to breathe. It also helps to moisten
and warm the air before it reaches your lungs.

The Lungs


The lungs are paired, cone-shaped organs which take up most of
the space in our chests, along with the heart. Their role is to take
oxygen into the body, which we need for our cells to live and function
properly, and to help us get rid of carbon dioxide, which is a waste
product. We each have two lungs, a left lung and a right lung. These
are divided up into 'lobes', or big sections of tissue separated by
'fissures' or dividers. The right lung has three lobes but the left lung
has only two, because the heart takes up some of the space in the left
side of our chest. The lungs can also be divided up into even smaller
portions, called 'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each
other by membranes. There are about 10 of them in each lung. Each
segment receives its own blood supply and air supply.

How they work

Air enters your lungs through a system of pipes called the
bronchi. These pipes start from the bottom of the trachea as the left
and right bronchi and branch many times throughout the lungs, until
they eventually form little thin-walled air sacs or bubbles, known as the
alveoli. The alveoli are where the important work of gas exchange
takes place between the air and your blood. Covering each alveolus is
a whole network of little blood vessel called capillaries, which are very
small branches of the pulmonary arteries. It is important that the air in
the alveoli and the blood in the capillaries are very close together, so
that oxygen and carbon dioxide can move (or diffuse) between them.
So, when you breathe in, air comes down the trachea and through the
bronchi into the alveoli. This fresh air has lots of oxygen in it, and some
of this oxygen will travel across the walls of the alveoli into your
bloodstream. Traveling in the opposite direction is carbon dioxide,
which crosses from the blood in the capillaries into the air in the alveoli
and is then breathed out. In this way, you bring in to your body the
oxygen that you need to live, and get rid of the waste product carbon
Blood Supply

The lungs are very vascular organs, meaning they receive a very
large blood supply. This is because the pulmonary arteries, which
supply the lungs, come directly from the right side of your heart. They
carry blood which is low in oxygen and high in carbon dioxide into your
lungs so that the carbon dioxide can be blown off, and more oxygen
can be absorbed into the bloodstream. The newly oxygen-rich blood
then travels back through the paired pulmonary veins into the left side
of your heart. From there, it is pumped all around your body to supply
oxygen to cells and organs.

The Work of Breathing

The Pleurae

The lungs are covered by smooth membranes that we call
pleurae. The pleurae have two layers, a 'visceral' layer which sticks
closely to the outside surface of your lungs, and a 'parietal' layer which
lines the inside of your chest wall (ribcage). The pleurae are important
because they help you breathe in and out smoothly, without any
friction. They also make sure that when your ribcage expands on
breathing in, your lungs expand as well to fill the extra space.

The Diaphragm and Intercostal Muscles

When you breathe in (inspiration), your muscles need to work to
fill your lungs with air. The diaphragm, a large, sheet-like muscle which
stretches across your chest under the ribcage, does much of this work.
At rest, it is shaped like a dome curving up into your chest. When you
breathe in, the diaphragm contracts and flattens out, expanding the
space in your chest and drawing air into your lungs. Other muscles,
including the muscles between your ribs (the intercostal muscles) also
help by moving your ribcage in and out. Breathing out (expiration)
does not normally require your muscles to work. This is because your
lungs are very elastic, and when your muscles relax at the end of
inspiration your lungs simply recoil back into their resting position,
pushing the air out as they go.

The Respiratory System Through the Ages

Breathing for the Premature Baby

When a baby is born, it must convert from getting all of its
oxygen through the placenta to absorbing oxygen through its lungs.
This is a complicated process, involving many changes in both air and
blood pressures in the baby's lungs. For a baby born preterm (before
37 weeks gestation), the change is even harder. This is because the
baby's lungs may not yet be mature enough to cope with the
transition. The major problem with a preterm baby's lungs is a lack of
something called 'surfactant'. This is a substance produced by cells in
the lungs which helps keep the air sacs, or alveoli, open. Without
surfactant, the pressures in the lungs change and the smaller alveoli

This reduces the area across which oxygen and carbon dioxide
can be exchanged, and not enough oxygen will be taken in. Normally,
a fetus will begin producing surfactant from around 28-32 weeks
gestation. When a baby is born before or around this age, it may not
have enough surfactant to keep its lungs open. The baby may develop
something called 'Neonatal Respiratory Distress Syndrome', or NRDS.

Signs of NRDS include tachypnoea (very fast breathing),
grunting, and cyanosis (blueness of the lips and tongue). Sometimes
NRDS can be treated by giving the baby artificially made surfactant by
a tube down into the baby's lungs.

The Respiratory System and Ageing

The normal process of ageing is associated with a number of changes
in both the structure and function of the respiratory system. These

• Enlargement of the alveoli. The air spaces get bigger and lose
their elasticity, meaning that there is less area for gases to be
exchanged across. This change is sometimes referred to as
'senile emphysema'.
• The compliance (or springiness) of the chest wall decreases, so
that it takes more effort to breathe in and out.
• The strength of the respiratory muscles (the diaphragm and
intercostal muscles) decreases. This change is closely connected
to the general health of the person.

All of these changes mean that an older person might have more
difficulty coping with increased stress on their respiratory system, such
as with an infection like pneumonia, than a younger person would.
Generic Name: Amoxicillin
Brand Name: Amoxil, Trimox
Classification: Antibiotic

Mechanism of Action
Inhibits bacterial cell wall mucopeptide synthesis.

Used to treat many different types of infections caused by
bacteria, such as ear infections, bladder infections, pneumonia,
gonorrhea, and E. coli or salmonella infection.

Hypersensitivity to penicillins, cephalosporins, or imipenem. Not
used to treat severe pneumonia, empyema, bacteremia, pericarditis,
meningitis, and purulent or septic arthritis during acute stage.

Adverse Reaction:
Agitation; anxiety; behavioral changes; confusion; convulsions;
dizziness; headache; hyperactivity; insomnia.
Acute generalized exanthematous pustulosis; erythema multiforme;
erythematous maculopapular rashes; exfoliative dermatitis;
mucocutaneous candidiasis; Stevens-Johnson syndrome; toxic
epidermal necrolysis; urticaria.
Diarrhea (2%); nausea (1%); black, hairy tongue; hemorrhagic
pseudomembranous colitis; tooth discoloration; vomiting.
Crystalluria; vulvovaginal mycotic infection.
Agranulocytosis; anemia; eosinophilia; hemolytic anemia; leukopenia;
thrombocytopenia; thrombocytopenic purpura.
Acute cytolytic hepatitis; cholestatic jaundice; hepatic cholestasis;
increased ALT and AST.
Anaphylaxis; hypersensitivity vasculitis.
Serum sickness–like reactions.

Nursing Responsibilities
Periodically assess renal, hepatic, and hematopoietic function
during prolonged therapy. Patients diagnosed with gonorrhea should
have a serologic test for syphilis at the time of treatment and a follow-
up serologic test after 3 months.
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 action is related to depression of the
prostaglandin synthesis by inhibition of the specific cell
cyclooxygenase, and depression of the thermoregulatory center in the
medulla oblongata. Inhibits prostaglandins in CNS, but lacks anti-
inflammatory effects in periphery; reduces fever through direct action
on hypothalamic heat-regulating center.

The preparation is indicated in diseases manifesting with pain
and fever: headache, toothache, mild and moderate postoperative and
injury pain, high temperature, infectious diseases and chills (acute
catarrhal inflammations of the upper respiratory tract, flu, small-pox,
parotitis, etc.).

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 and rash), may appear. Long-term treatment with high
doses may cause a toxic hepatitis with 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 blood glucose analysis. In severe renal
failure the interval between two consecutive takings should not be
shorter than 8 hours. The treatment with the preparation is not
advisable during the first trimester of the pregnancy. In nursing women
the preparation should be used with strictly observation of the
therapeutic dose and duration of the treatment.
Generic Name: Ambroxol
Brand Name: Mucosulvan
Classification: Expectorant/Antibiotic

Mechanism of Action
When administered orally onset of action occurs after about 30
minutes. The breakdown of acid mucopolysaccharide fibers makes the
sputum thinner and less viscous and therefore more easily removed by
coughing. Although sputum volume eventually decreases, its viscosity
remains low for as long as treatment is maintained.

All forms of tracheobronchitis, emphysema with bronchitis
pneumoconiosis, chronic inflammatory pulmonary conditions,
bronchiectasis, bronchitis with bronchospasm asthma. During acute
exacerbations of bronchitis it should be given with the appropriate

There are no absolute contraindications but in patients with
gastric ulceration relative caution should be observed.

Adverse Reaction
Occasional gastrointestinal side effects may occur but these are
normally mild.

Nursing Responsibilities
Observe respiratory rate and obtain baseline data. Check drug
interactions if taking other medications.
It is advisable to avoid use during the first trimester of pregnancy.
Generic Name: Metoprolol
Brand Name: Lopressor, Toprol-XL
Classification: Beta blocker

Mechanism of Action
Blocks beta receptors, primarily affecting CV system (decreases
heart rate, decreases contractility, decreases BP) and lungs (promotes

Metoprolol is used to treat angina (chest pain) and hypertension
(high blood pressure). It is also used to treat or prevent heart attack.

You should not use this medication if you are allergic to metoprolol,
or if you have a serious heart problem such as heart block, sick sinus
syndrome, or slowheart rate. If you have any of these other conditions,
you may need a dose adjustment or special tests to safely use
 pheochromocytoma; or
 problems with circulation (such as Raynaud's syndrome);
 congestive heart failure;
 asthma, bronchitis, emphysema;
 diabetes;
 low blood pressure; depression;
 liver or kidney disease;
 a thyroid disorder; or
 myasthenia gravis.

Adverse Reaction
Hypotension; edema; flushing; bradycardia (3%); palpitations; CHF;
arterial insufficiency; peripheral edema.
Headache; fatigue; dizziness (10%); depression (5%); lethargy;
drowsiness; forgetfulness; sleepiness (10%); vertigo; paresthesias.
Rash (5%); facial erythema; alopecia; urticaria; pruritus (5%).
Dry eyes; visual disturbances.
Nausea; vomiting; diarrhea (5%); dry mouth; gastric pain; constipation;
heartburn; flatulence.
Impotence; urinary retention; difficulty with urination.
Shortness of breath (3%); bronchospasm; dyspnea; wheezing.
Increased hypoglycemic response to insulin; may mask hypoglycemic
signs; muscle cramps; asthenia; systemic lupus erythematosus; cold

Nursing Responsibilities
In patients with angina pectoris or coronary artery disease (CAD),
metoprolol may cause exacerbation of angina, occurrence of MI, and
ventricular arrhythmias. Monitor patients closely. Because CAD is
common and often unrecognized, it may be prudent not to discontinue
beta-blocker therapy abruptly in patients being treated for
Nursing Care Plan

Assessment Diagnosi Planning Interven Rationa Evalua
s tions le tion

Subjective:  Ineffect  After 8  Monito  Serve
 “Nahihirapa ive hours r Vital s as
n akong airway of signs basel
huminga” clearan continu ine
as ce r/t es nsg.  Place data
verbalized. increas Interve the pt.  To
ed ntions in facilit
Objective: product the pt. fowler’ ate
 Received ion of will be s or maxi
awake lying bronchi able to semi- mum
on bed with al mainta fowler’ lung
an ongoing secreti in s expa
IVF of PLRS ons as airway positio nsion
1 L at 350 manife patenc n  Impro
cc level sted by y  Teach ves
regulated at Body Expect
  the pt. ventil
10 gtts, malaise orate how to ation
infusing secreti
 Wheez do and
well at right ons
es upon proper helps
auscult  Maintai deep in
 Conscious/c ation n RR of breath mobil
oherent at ing izing
 Product
 DOB w/ an ive least and secre
RR of 35 cough 20-25 coughi tions
bpm noted. (yellow from ng w/o
 Body to the exerci causi
malaise green initial se ng
noted sputum 35  Avoid fatigu
 Wheezes  Restles bpm expos e
upon sness  Learn ure to  To
auscultation  Chest and irritant avoid
 Productive pain perfor s such allerg
cough  Discom m as ic
(yellow to fort breathi cigaret reacti
green ng and te on
 Facial
sputum coughi smoke
 Restlessnes e ng ,
s noted exercis aeroso  To
 Chest pain e. l and ascer
noted  Verbali fumes tain
 Discomfort zed  Auscul statu
noted relief tate s and
 Facial form breath note
Grimace dyspne sounds progr
noted a.  Increa ess
se  Helps
fluid liquef
intake y
 Suctio tions
n as  To
ordere clear
d airwa
 Provid y
e  Provi
oxyge de
n adeq
inhalat uate
ion as amou
ordere nt of
d oxyg
 Admini en
ster  Will
medic help
ation loose
as n
ordere secre
d tions
Nursing Care Plan

Assessment Diagnosis Plannin Interven Ration Evalua
g tions ale tion

Subjective:  Activity  After  Evalua  Provi
 “Ang bigat intolerance 10 te the de
ng r/t to hour pt.’s coop
pakiramda generalized s of curren erati
m ko” as body nursi t ve
verbalized weakness ng activit base
as inter y line
Objective: manifested venti tolera
 Received by ons nce  To
awake lying  Conscious/c the  Adjust prev
on bed with oherent pt. activit ent
an ongoing will y and over
 Body
IVF of PLRS parti reduc exer
1 L at 340 cipat e tion
cc level e intensi
 Difficulty
regulated willin ty of
moving left
at 10 gtts, gly task
arm noted
infusing in that
 Facial  Enh
well at right nece may
grimace ance
arm. ssary cause
noted activ
 Conscious/c activ undesi ity
oherent  Pallor noted
ity red toler
 Body  Complains
 Will physio ance
malaise of fatigue
be logical
noted able chang  Help
 Difficulty to es s
moving left mov  Increa mini
arm noted e her se mize
 Facial left exerci wast
grimace arm se and e of
noted with activit ener
 Pallor noted ease y gy
 Complains  Lear levels
of fatigue n gradu
how ally
to  Teach  Prev
cons metho ent
erve ds to the
ener conser pt.
gy ve from
 Verb energ injur
alize y such y
relief as  To
from sitting sust
fatig than ain
ue standi the
ng pt.’s
while moti
dressi vatio
ng n
 Assist
the pt.
 Give
the pt.
ce of
Nursing Care Plan

Assessment Diagnosi Planni Intervent Rational Evalua
s ng ions e tion

Subjective:  Ineffect  Afte  Monitor  Serve
 “Giniginaw ive r8 VS s as
ako” as thermo hour baseli
verbalized regulati s of  Increas ne
on r/t cont e fluid data
increas inuo intake  To
Objective: ed us help
 Received body TSB, cool
 Maintai
awake lying temper the down
n bed
on bed with ature pt.’s core
an ongoing as tem temp
IVF of PLRS 1 manifes pera eratur
L at 320 cc ted by ture e
 Provide
level Warm will
 sufficie  To
regulated at to decr nt decre
10 gtts, touch eas clothin ase
infusing well e
 Flushed g meta
at right arm. fro
face  Perfor bolis
 Conscious/co m m
 Febrile m TSB
herent 38.2 that
with a
 Warm to temper to produ
 Admini
touch noted ature of 37.5 ce
 Flushed face 38.2°C °C heat
noted  Facilit
etics as
 Febrile with a ordered ate
temperature comfo
of 38.2°C rt

 Facilit
s of
 Helps
Nursing Care Plan

Assessment Diagnosis Planni Intervent Rational Evalua
ng ions e tion

Subjective:  Acute  Afte  Monitor  Pain
 “Sumasakit pain r/t r 10 VS alters
ang dibdib at localize hour  Perfor VS
braso ko” as d s of m pain  To
verbalized inflamm nsg. assess rule
Objective: ation inter ment out
 As vent (COLD devel
 Received
manifes ions SPA) opme
awake lying
ted by the every nt of
on bed with
 Headac pt.’s time compl
an ongoing
he pain pain icatio
 Restless scal occurs ns by
L at 300 cc
ness e knowi
 Difficult will ng
regulated at
y decr  Encour allevi
10 gtts,
moving ease age ating
infusing well
left arm from verbali and
at right arm.
7 to zation precip
 Conscious/co  Chest
4 of itatin
herent pain
 The feeling g
 Headache  Pain
pt. of pain factor
 Restlessness scale of
will s
 Difficulty 7 out of
verb  Pain
moving left 10  Instruc
alize is
arm  Facial t use of
relie subje
 Chest pain grimace relaxati
f ctive
 Pain scale of from on
exercis &
7 out of 10 pain can’t
 Facial  Will e such
as be
grimace dem asses
onst listenin
g to sed
rate throu
use music
of  Provide
rela quiet
xati and
on calm
environ  Prom
skill otes
s ment
 Encour
te rest
 Admini
sic as
d  Noisy
 Preve

 To
Nursing Care Plan

Assessmen Diagnos Plannin Interventi Rational Evaluati
t is g ons e on

Subjective:  Altere  After  Monitor  For
 “wala d 4 vital baselin
akong nutriti hours signs e data
ganang on of  Weight  Monitor
kumain” less nursin on nutritio
than g regular nal
Objective: body interv basis state
requir ention and
 Refusal
emen s, effectiv
to eat
ts R/T patien  Discuss eness
 Poor loss t’s eating of
muscle of appeti habits interve
tonicity appet te will includin ntions
 Body ite as be g food  To
weakness evide impro preferen appeal
noted nced ved: ces. to
 Restlessn by from  Serve client
ess dysfu 2 likes
nctio tables foods and
nal poons that are dislikes
eatin to at not
g least contrain  To
patter 5 dicated. stimula
n. tables  Serves te the
poons foods appetit
per that are e
meal. palatabl
e and  To
attractiv stimula
e. te the
 Prevent appetit
and e
e  May
unpleasa have
nt odors. negativ
e effect
 Emphasi on
ze the appetit
importan e/eatin
ce of g
well  Promot
balance e
d wellnes
nutrition s