Denice Ezra Dela Cruz BSN-3

I. Nursing Care Plan

Assessment Diagnosis Planning Intervention Evaluation

Subjective: Ineffective breathing After 4 hours of nursing >Established rapport Goal partially met:
“Ga guot akoang pattern related to intervention the patient After 4 hours of nursing
dughan unya ga lisod smooth muscle will demonstrate an > Monitor vs evaluation the patient
kog hinga” as verbalized constriction of the improved ventilation will demonstrate
by the patient. bronchioles. and adequate > Promote bed rest decreased signs of
oxygenation of tissues respiratory distress
Objectives: and absenceof signs of > Increase fluid intake
respiratory distress
>Encouraged patient to
> shallow breathing
have diversional activities
> restlessness such as watching movie
>patient is anxious and
irritable > Encouraged patient to
intake of non-irritating
V/S: liquids
Temp- 36.5
PR- 80 > Encouraged patient to
RR- 27 report pain.
BP- 130/90
> Assist patient to
comfortable position.

>medication given as
prescribe by the
physician.

>Encourage deep
breathing exercises
 II. Drug Study

Name of Classification Dosage Indication Contraindication Adverse Reaction Nursing Considerations

Drugs
Generic: Bronchodilator 8 mg P.O To prevent or >Contraindicated CNS: tremor, >Drugs may decrease
Albuterol s b.i.d treat in patients nervousness, sensitivity of spirometry
sulfate bronchospasm hypersensitive to headache, used for diagnosis of
in patients drug or its hyperactivity, asthma.
with ingredients. insomnia, dizziness, >Syrup contains no alcohol
Brand name: reversible weakness, CNS or sugar and may be taken
Salbutamol obstructive >Use cautiously in stimulation, malaise. by children as young as ages
airway disease patients with CV CV: tachycardia, of 2
disorders(including palpitations, >In children, syrup may
coronary hypertension, chest rarely cause erythema
insufficiency and pain, multiform or Steven-
hypertension) lymphadenopathy. Johnson syndrome.
Hyperthyroidism EENT: conjunctivitis, >Monitor patient for
or diabetes otitis media, dry and effectiveness. Using drug
mellitus and in irritated nose and alone may not adequate to
those who are throat (with inhaled control asthma in some
unusually form), nasal patients. Long –term control
responsive to congestion, medications may be needed.
adrenergics. epistaxis,
hoarseness,
>Use extended- pharyngitis, rhinitis.
release tablets GI: nausea, vomiting,
cautiously in heartburn, anorexia,
patients with GI altered taste,
narrowing increased appetite.
GU: UTI.
 III. Sample Chart
FOCUS
“Ga guot akoang dughan unya
ga lisod kog hinga”
Ineffective breathing pattern
related to smooth muscle
constriction of the
bronchioles.
DATA ACTION RESPONSE
> shallow breathing >Established rapport Goal partially met: After 4
> restlessness hours of nursing evaluation
>patient is anxious and > Monitor vs the patient will demonstrate
irritable decreased signs of respiratory
> Promote bed rest distress
V/S: > Increase fluid intake
Temp- 36.5
>Encouraged patient to have
PR- 80
diversional activities such as
RR- 27 watching movie
BP- 130/90
> Encouraged patient to intake of
non-irritating liquids
> Encouraged patient to report
pain.
> Assist patient to comfortable
position.
>medication given as prescribe
by the physician.
>Encourage deep breathing
exercises