University of San Carlos College of Nursing Cebu City NURSING CARE PLAN Name of Patient: Arreglado, Bernardo Age

: 77 Sex: M Occupation: Farmer Date of Admission: 02/27/10 Status: Married Religion: Roman Catholic Needs / Nsg Dx Cues * Physiologic Need * Ineffective Breathing Pattern r/t. to inflammation of the lung tissue. S: “Katong usa ka simana, gihubak na siya og mayo nya naglisod og ginhawa” as verbalized by the daughter of the patient. O: Dyspnea Coughs Appears weak Scientific Analysis *PATHOPHYSIOLOGY OF PNEUMONIA* - The invading organism causes symptoms, in part, by provoking an overly exuberant immune response in the lungs. The small blood vessels in the lungs (capillaries) become leaky, and protein-rich fluid seeps into the alveoli. This results in a less functional area for oxygen-carbon dioxide exchange. The patient becomes relatively oxygen deprived, while retaining potentially damaging carbon dioxide. The patient breathes faster and faster, in an effort to Patient’s Health Profile: Received Pt. lying in bed, conscious and dyspneic with D5LR @ 20-30gtts./min infusing well @ Right Arm w/ O2 @ 2L. Initial Complaint: Cough Diagnosis / Impression: Community Acquired Pneumonia Objectives After 4 hours of student-nurse client interaction, the client will be able to: 1.) Identify the ways in increasing breathing effectivity. 2.) Return Demonstrate Deep Breathing exercise. 3.) Give the importance of manifesting an effective breathing pattern. Nursing Interventions - Encourage an increase in fluid intake - Position the client in high fowlers - Teach client in performing deep breathing exercise. - Administer meds (bronchodilators & etc.) prn. - Monitor vital signs - Have client breathe into paper bag Rationale - To help secretions be readily expelled. - To expand the lungs to facilitate in effective breathing. - To facilitate a wide exchange of gases. - As counter-measures for bronchospasms. - To be able to assess and treat complications arising from tachypnea. - To correct hyperventilation Evaluation - The client was able to utilize different ways and actions in maintaining and breathing effectively such as the use of deep breathing exercise and utilizing the right position. The client was able to follow accurately and perform correctly deep breathing exercise. At first it was hard for him as it automatically stimulates coughing reflex but was able to adapt. The client

. -http://science. .To limit level of anxiety.jrank.Assess the nasal cannula patency .Nasal Flaring bring in more oxygen and blow off more carbon dioxide. .To decrease the metabolic demands of the body.So’s not to aggravate the already dyspneic state of the client.Encourage adequate rest .Encourage client to conserve energy . these results in inability of the pt to move air in and out of the lungs as needed to maintain adequate tissue oxygenation and perfusion.To promote and maintain a patent airway .Suction airway as needed .Ineffective breathing pattern occurs when there is presence of spasms and inflammation of the lung tissue and parenchyma.” .To ensure the correct flow of O2 . verbalize “nindot ning maka.tarong tag ginhawa kay mas makabuhat og lihok ko nya dili ko magluya 358 *Own Analysis* .Maintain a caring and calm attitude in dealing with the patient .

Acephen Classification Mechanism of Action Route & Dosage Contraindications Side Effects Nursing Responsibilities Analgesic. Though 500 mg 1 tab q4h to produce PRN for fever analgesia by blocking generation of pain impulses.Abenol †◊ . urticaria. jaundice. Relieve fever by central action in the hypothalamic heatregulating center. Antipyretic Unknown. .Use cautiously in patients with history of chronic alcohol use because hepatotoxicity has occurred after therapeutic doses.Calpol . Many OTC products contain acetaminophen.Use liquid form for children and patients who have difficulty swallowing. drug or its components. . . be aware of this when calculating total daily dose. Contraindi cated in patients Anemia. -Alert.Acetaminophen Brand Name: . hypersensitive to rash. by inhibiting prostaglandin synthesis in the CNS or the synthesis or action of other substances that sensitize pain receptors to mechanical or chemical stimulation.University of San Carlos College of Nursing Cebu City DRUG STUDY Name of Drug: Generic Name Brand Name Generic Name: .

. Children ages 3 months to12 years: 30 mg/kg/day oral suspension P.i. usually bactericidal Contraindi Adults and cated in patients children age 13 hypersensitive to and older: 250-mg drug or other tab P.Absorption of cefuroxime axetil is enchanced by food.Alert: Don’t confuse drug with other cephalosporins that sound alike. diarrhea. for cephalosporins.O. b.cefuroxime sodium Brand Name: .O. .. hemolytic anemia .Zinacef Classification Mechanism of Action Route & Dosage Contraindications Side Effects Nursing Responsibilities Anti-infective A second drug. Phlebitis. . Therapy may begin pending results. promoting osmotic instability.Obtain specimen for culture and sensitivity tests before giving first dose.d. Thrombophlebitis. generation Cephalosporins cephalosporin that inhibits cell-wall synthesis. in two divided doses for 10 days.Kefurox .University of San Carlos College of Nursing Cebu City DRUG STUDY Name of Drug: Generic Name Brand Name Generic Name: . 10 days.

salbutamol Brand Name: ..d. Tremor. Maximum.i.d. or q.Aerolin . Adults and children age 12 and older: Oral Tables: 2-4 mg P. uterine and vascular Bronchodilators smooth muscle by stimulating beta 2 receptors. Maximum 8 mg q.d. tachycardia.i. Side Effects Nursing Responsibilities Respiratory Relaxes bronchial. . hyperactivity.i.d.Syrup may be taken by children as young as age 2. palpitations.University of San Carlos College of Nursing Cebu City DRUG STUDY Name of Drug: Generic Name Brand Name Generic Name: . Drugs. t. or q. nervousness.O. Children ages 6 to 12: Oral Tables: 2 mg P. 12 mg b.i.d.i.Volmax Classification Mechanism of Action Route & Dosage Contraindications Contraindi cated in patients hypersensitive to drug or its components.i.d. nausea -Alert. t. headache.O.Rotacaps .Albuterol may decrease sensitivity of spirometry used for diagnosis of asthma. Don’t confuse albuterol with atenolol or Albutein or Flomax with Volmax . . it contains no alcohol or sugar.