CHAPTER VIII

NURSING CARE PLAN

ASSESSMENT EXPLANATION GOALS AND INTERVENTION RATIONALE EVALUATION
OF THE OBJECTIVES
PROBLEM
S> >Patient STO: After 8 >Auscultate breath >Some degree of STO: After 3
“Nahihirapan started hours of sounds. Note bronchospasm is present hours of
akong huminga” smoking at a nursing adventitious with obstructions in airway nursing
young age. intervention, breath sounds such and may or may not be intervention,
>”Naninikip Due to the patient will: as wheezes, manifested in adventitious patient is
itong dibdib prolonged >Able to crackles, or breath sounds, such as, able to
ko” exposure to expectorate rhonchi. scattered, moist crackles; expectorate
respiratory secretions. faint sounds with secretions.
O> Smoking Hx irritants, expiratory wheezes; or (Fully met)
>Productive the patient LTO: After 3 absent breath sounds.
Cough with developed days of >Assess and LTO: After 3
yellowish COPD. Thus nursing monitor >Tachypnea is usually days of
sputum causing an intervention, respiratory rate. present to some degree and nursing
>irritable inflammation patient will: Note inspiratory- may be pronounced on intervention,
>Shallow, fast in her >Maintain to-expiratory admission, during stress, patient
breathing bronchial Airway Patency ratio. or during concurrent acute maintained
>(+) wheezes, airways with clear infections. Respirations airway
crackles upon together with breath sounds. may be shallow and rapid, patency with
auscultation an increase with prolonged expiration clear breath
>Respiratory in production in comparison to sounds.
rate of 25-30 of sputum, >Assist client to inspiration. (Partially
cycles per causing maintain a met)
minute difficulty in comfortable
>Unable to breathing. position to >Elevation of the head of
expectorate The increase facilitate the bed facilitates
secretions. in the breathing by respiratory function using
production of elevating the head gravity; however, client in
secretions of the bed, severe distress will seek

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Nursing Dx: coupled with leaning on or over the position that most
Ineffective narrowing and bed table, or eases breathing
Airway inflammation sitting on the
Clearance of the edge of the bed.
related to airways lead >Administer >It relaxes the smooth
accumulation to a nursing salbutamol per muscle in the lungs and
of phlegm to diagnosis of nebulization as opens airways to improve
the bronchial ineffective ordered. breathing. 
area. airway
clearance >Facilitate back >To break up the mucus in
tapping after the lungs in order to make
nebulization. it easier for the patient
to cough them up.

>Encourage and
assist with >Provides client with some
abdominal or means to cope up with and
pursed lip control dyspnea and reduce
breathing air-trapping.
exercises.
>Inhaled anticholenergic
>Assist with agents are now considered
respiratory the first-line drugs for
treatments, such clients with stable COPD
as spirometry and because studies indicate
chest they have a longer duration
physiotherapy. of action with less
toxicity potential, whereas
still providing the
> Encourage effective relief of the
increased fluid beta-antagonists.
intake. >Fluids help minimize
mucosal drying and maximize
ciliary action to move

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 secretions.

ASSESSMENT EXPLANATION GOALS AND INTERVENTION RATIONALE EVALUATION

OF THE OBJECTIVES
PROBLEM
S> “Hindi ako >Patient is STO> After 8 > Assess and record > Useful in evaluating the STO> After 8
nakakahinga ng diagnosed hours of respiratory rate, degree of respiratory hours of
maayos kung with COPD, nursing depth. Note use of distress or chronicity of nursing
walang oxygen because of intervention, accessory muscles, the disease process intervention:
support.” this proper patient will: pursed-lip >the patient
lung >Sustain breathing, inability was able to
O> Shallow, expansion is respiratory to speak or converse > Oxygen delivery may be sustained
fast breathing greatly rate within > Elevate head of improved by upright respiratory
affected due normal range: bed, assist patient position and breathing rate within
to the damage RR: 12-20cpm. to assume position exercises to decrease normal range:
>Respiratory of the to ease work of airway collapse, dyspnea, RR: 12-20cpm.
rate of 25-30 alveolar LTO> After 3 breathing. Include and work of breathing. (Fully met
cycles per sacs. Thus days of periods of time Note: Recent research
minute. causing air- nursing in prone position as supports use of prone LTO> After 3
trapping, intervention, tolerated. Encourage position to increase Pao2 days of
>Productive where old air patient will: deep-slow or pursed- nursing
Cough with does not get > Be able to lip breathing as intervention:
yellowish out of the have a normal individually needed > Cyanosis may be >The patient
sputum lungs forcing O2 saturation or tolerated. peripheral (noted in was able to
>O2 saturation little to no and no signs nailbeds) or central (noted have a normal
in the low 85- amount of new of difficulty >Assess and around lips/or earlobes). O2 saturation
90 percent. air comes in. of breathing. routinely monitor Duskiness and central and no signs

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(without O2 Where oxygen skin and mucus cyanosis indicate advanced of difficulty
supply) finds it membrane color. hypoxemia of breathing.
difficult to (Partially
Nursing Dx: come in and > Breath sounds may be met)
Impaired Gas CO2 has a > Auscultate breath faint because of decreased
Exchange difficulty sounds, noting areas airflow or areas of
related to going out. of decreased airflow consolidation. Presence of
alveolar- Thus leading and adventitious wheezes may indicate
capillary to a nursing sounds bronchospasm or retained
membrane diagnosis of secretions. Scattered moist
changes Impaired Gas crackles may indicate
Exchange interstitial fluid or
cardiac decompensation
>Administer
salbutamol per >It relaxes the smooth
nebulization as muscle in the lungs and
ordered. opens airways to improve
breathing. 
>Facilitate back
tapping after >To break up the mucus in
nebulization. the lungs in order to make
it easier for the patient
> Evaluate sleep to cough them up.
patterns, note > Multiple external stimuli
reports of and presence of dyspnea may
difficulties and prevent relaxation and
whether patient inhibit sleep
feels well rested.
Provide quiet
environment, group
care or monitoring
activities to allow
periods of
uninterrupted sleep;

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 limit
stimulants such
as caffeine;
encourage position
of comfort

POTENTIAL PROBLEM

ASSESSMENT EXPLANATION OF GOALS AND INTERVENTION RATIONALE EVALUATION

THE PROBLEM OBJECTIVES
S>”Hindi ako >The patient is STO> After 8 >Evaluate >Establishes STO>After 8 hours
makagalaw having hours of nursing client’s client’s of nursing
masyado, medyo difficulty in intervention, response to capability and intervention:
nahihirapan ako” moving because patient will: activity. Note needs and > Manifest no
she is already >Manifest no reports of facilitates signs of
O>Needs weakened by her signs of dyspnea, choice of respiratory
assistance in illness. respiratory increased interventions distress like
moving and distress like weakness and nasal flaring,
positioning COUGH-> nasal flaring, fatigue, and using of
OBSTRUCTION IN using of changes in vital accessory
>Needs AIRWAYS -> LOW accessory signs during and >Reduce stress muscles. (Fully
assistance in O2 SUPPLY-> LOW muscles. after activities and excess met)
performing ADL’s PRODUCTION OF >Provide a quiet stimulation,

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>Easy ATP -> ACTIVITY LTO> After 3 days environment and promoting rest LTO> After 3 days
fatigability INTOLERANCE of nursing limit visitors of nursing
>Unable to intervention, during acute intervention:
tolerate walking patient will: phase as > Patient will be
for at least 2 >Patient will indicated. able to report
meters. report Encourage use of >Bedrest is the ability to
the ability to stress maintained during perform required
>Dyspnea perform required management and acute phase to activities of
activities of diversional decrease daily living.
>Productive daily living. activities as metabolic (Partially met)
Cough appropriate demands, thus
>Explain conserving energy
importance of for healing.
Nursing Dx: rest in Activity
Risk for treatment plan restrictions
Activity and necessity thereafter are
Intolerance for balancing determined by
related to activities with individual client
imbalance rest response to
between oxygen activity and
supply and resolution of
demand respiratory
insufficiency

>Client may be
comfortable with
>Assist client head of bed
to assume elevated,
comfortable sleeping in a
position for chair, or leaning
rest and sleep forward.

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 DRUG STUDY

DRUG MODE OF ACTION SIDE EFFECTS NURSING CONSIDERATIONS

GENERIC NAME: CV: Palpitations,  Monitor BP for
Amlodipine -Selectively blocks flushing, tachycardia, therapeutic
calcium ion reflux across peripheral or facial effectiveness. BP
BRAND NAME: cell membranes of cardiac edema, bradycardia, chest reduction is
Norvasc and vascular smooth pain, postural greatest after peak
CLASSIFICATION: muscle without changing hypotension levels of amlodipine
Cardiovascular agent, serum calcium CNS: Light-headedness, are achieved 6-9 h
calcium channel blocker concentrations. fatigue, headache following oral
DOSAGE: GI: Abdominal pain, doses. Monitor for
 2.5mg nausea, anorexia, S&S of dose-related
 5mg constipation, dyspepsia, peripheral or facial
 10mg dysphagia, diarrhea, edema that may not
flatulence, vomiting be accompanied by
ROUTE: Urogenital: Sexual weight gain, rarely,
Oral dysfunction, nocturia severe edema may
Respiratory: Dyspnea cause
Skin: Flushing, rash discontinuation of
Other: Arthralgia, drug.
cramps, myalgia

DRUG MODE OF ACTION SIDE EFFECTS NURSING CONSIDERATIONS

GENERIC NAME: - The mechanisms of Nausea, vomiting & other  Do not give this
N-Acetylcysteine action for GI symptoms, generalized drug if the patient
BRAND NAME: acetylcysteine’s urticarial accompanied by has hypersensitivity
Solmucol well-known mucolytic mild fever, hypotension, to this drug.
CLASSIFICATION: effects are wheezing, dyspnea, and  This medication
Mucolytic different. In stomatitis should be diluted
DOSAGE: particular, when with water.
600 mg + ½ glass of water inhaled,
 Stop using this drug
acetylcysteine (and
when there is
ROUTE: its metabolic

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OD HS byproduct cysteine) inflammation of the
exerts its mucolytic mouth.
action through its
free sulfhydryl
group, which reduces
the disulfide bonds
in the mucus matrix
and lowers mucus
viscosity. This
action increases
with increasing pH
and is most
significant at pH 7
to 9.

DRUG MODE OF ACTION SIDE EFFECTS NURSING CONSIDERATIONS

GENERIC NAME: - Atorvastatin acts CNS: Headache, asthenia  WARNING: Withhold
Atorvastatin primarily in the GI: Flatulence, abdominal atorvastatin in any
BRAND NAME: liver, where pain, cramps, acute, serious
Lipitor decreased hepatic constipation, nausea, condition (severe
CLASSIFICATION: cholesterol dyspepsia, heartburn, infection,
Dyslipidaemic Agent concentrations liver failure hypotension, major
DOSAGE: stimulate the Respiratory: Sinusitis, surgery, trauma,
20mg upregulation of pharyngitis severe metabolic or
hepatic low density Other: Rhabdomyolysis endocrine disorder,
ROUTE: lipoprotein (LDL) with acute renal failure, seizures) that may
G-tube receptors which arthralgia, myalgia suggest myopathy or
increases hepatic serve as risk factor
uptake of LDL. for development of
renal failure.
 Ensure that patient

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 has tried cholesterol-
lowering diet regimen
for 3–6 mo before
beginning therapy.
 Administer drug
without regard to
food, but at same time
each day.
 Consult dietitian
about low-cholesterol
diets.


DRUG MODE OF ACTION SIDE EFFECTS NURSING CONSIDERATIONS

GENERIC NAME: - Ceftriaxone works HYPERSENSITIVITY: rash - Assess patient’s
Ceftriaxone by inhibiting the previous sensitivity
BRAND NAME: mucopeptide HEMATOLOGIC: reaction to
Forgram synthesis in the eosinophilia, thrombocytosis and l penicillin or other
CLASSIFICATION: bacterial cell eukopenia cephalosporins.
3rd generation wall. The beta- - Assess patient for
cephalosporin lactam moiety of GASTROINTESTINAL: diarrhea signs and symptoms of
DOSAGE: Ceftriaxone binds infection before and
450mg TIV q12 to HEPATIC: elevations of SGOT  during the treatment.
carboxypeptidases, - Obtain C&S before
ROUTE: endopeptidases, and RENAL: elevations of the BUN  beginning drug
IV transpeptidases in therapy to identify
the bacterial CENTRAL NERVOUS SYSTEM: headache if correct treatment
cytoplasmic or dizziness were reported has been initiated.
membrane. These - Report signs such as

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enzymes are epistaxis or other
involved in cell- occasionally forms of unexplained
wall synthesis and bleeding.
cell division. By GENITOURINARY: moniliasis - Monitor hematologic,
binding to these or vaginitis were reported electrolytes, renal
enzymes. occasionally and hepatic function.

MISCELLANEOUS: diaphoresis and

flushing were reported
occasionally

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