Professional Documents
Culture Documents
Assessment / Assessment
Shortness of breath and cough that has never stopped since the last 8 months.
• Medical history before being admitted to health history before admitted to hospital:
Asthma
• Assessment of focus data and diagnostic supporting data (lab, xray, etc.) / Focus
assessments and diagnostic tests (lab, xray, etc):
o TTV: BP: 100/65 mmHg P : 108 x / minute T:
38 o C
RR : 36 x / minute SpO 2 : 92%
o Chest: Hear: adynamic precardium, normal rate, regular rhytm.
2. Current therapy:
Normally:
- OBH = 3x1 a day - Leukocytes = 5000 - 10,000 / mm 3
- Amoxicilin = 3x500 mg - Erythrocytes = 4.5 - 5.5 million / mm 3
- Kotrimoxazol = 3x1 - IED / BBS = (0 - 10 mmhour)
- Vitamin B - Hb = (13-16 gr%) (12-14 gr%)
- Frixity = 2 x 1/2 a day
-
Nursing diagnosis according to priority : (actual, risk, etiology-
symptoms) Nursing Diagnose based on priority: (actual, risk, etiology-
symptoms)
1. The pattern of ineffective breathing is related to increased production of secretion
3. Pattern disturbance 1. Monitor the general Hours: 09.00 S: After it's done
bd sleep often condition of the patient 1. Monitor the general 2x 24 hours of treatment
wake up at night and TTV condition of the patient patient said
day. 2. Assess Sleep Patterns. and time of the building
4. Assess the factors that Patient Response: at night
cause TTV: BP: 100/65 mmHg P: usually can be 4 to 5
sleep disorder (cough) 108 x / minute last night he only
5. create a comfortable RR: 25 x / minute T: 38 o wake up 3 times. Patient
atmosphere, C SpO 2 : 92% say wake up
Reduce or eliminate 2. Review Sleep Patterns. the morning is much more
distractions immediately.
environment and sleep O: patient's face
disorders. Patient response: Fresh plasticity, no
6. Limit visitors during the The patient said before the looks pale RR: 25
period pattern x / minute Pulse: 98x
optimal rest (eg after he slept well he slept from /minute
eat). the hour A: The problem is
7. Ask clients to limit 10:00 p.m. resolved
fluid intake at night and 2. Assess the factors that in part
urinate before going to cause P: Intervention
bed. sleep disorder (cough) next.
8.. Advise or give care Patient response:
in the evening (eg The patient says the
hygiene) patient has experienced it
personal, linen and coughing 8 months ago
nightgowns and coughing it up
clean). getting worse at night.
9. Collaboration 4. Provide a comfortable
doctor atmosphere, reduce it
for or eliminate environmental
drug administration .. distractions and
sleep disorders.
Rational : Patient response:
1. Knowing awareness, The patient feels that
and conditions atmosphere
the body is normal or silent, makes him feel
not. more
2. To find out the ease in comfortable.
sleep. 5. Limit visitors during the
4. To identify causes period
actual sleep disturbance optimal rest (eg after
5. To monitor how far it eat).
can be
be calm and relax.
6. To help relaxation when Patient Response:
sleep. Patients agree to reduce
Rational : the amount
1. Knowing awareness, visitors, because he feels
and conditions he needs it lenty of time to
the body is normal or rest.
not. 6. Ask clients to limit their
2. To find out the ease in intake
sleep. liquid at night and urinate
4. To identify causes before sleeping.
actual sleep disturbance Patient Response:
5. To monitor how far it The patient does what is
can be said
be calm and relax. the nurse she only drank 1
6. To help relaxation when glass before
sleep. dinner and 1 glass after
meals
night.
Hours: 16.00
7. Advise or give care
in the evening (eg
hygiene)
personal, linen and
nightgowns
clean)
Patient response:
The patient wants to be
helped to take a warm bath
and
ask us to do bed makeing.
Collaboration:
Doctor collaboration for drug
administration