ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

SUBJECTIVE: Ineffective SHORT TERM: 1. Establish rapport with the 1. To gain patient’s trust and SHORT TERM:
“nahihirapan ako huminga Breathing After 1-2 hours of patient. cooperation. The client has
lalo na pag tapos ng Pattern nursing 2. Monitor for the patient’s vital 2. To obtain data for comparison. verbalized
exercise at kapag Related to intervention, signs. 3. To note any presence or character understanding and
nakahiga” as verbalized by Respiratory patient will be able 3. Auscultate chest. of breath sounds and presence of demonstrate proper
the patient. Muscle fatigue to verbalize 4. Elevate HOB as appropriate. secretions. deep breathing
as evidenced understanding and 5. Maintain calm attitude while 4. To promote technique to facilitate
OBJECTIVE: by Dyspnea. demonstrate proper dealing with the client. physiologic/psychologic ease of proper oxygenation to
 Occasional deep breathing 6. Instruct the client to do deep maximal inspiration. alleviate
expiratory wheeze technique to breathing exercise after 5. To limit the level of anxiety. hyperventilation.
on forced facilitate proper demonstrating proper 6. Deep breathing exercise increases
expiration oxygenation to technique. oxygen intake and can help LONG TERM:
 Blood pressure of alleviate 7. Keep environment allergen alleviate dyspnea. The client has
134/78 mm hyperventilation. free. (dust, feather pillows, 7. Presence may trigger allergic maintained normal
 Respiratory rate is smoke, pollen) response that may cause further breathing pattern.
30. LONG TERM: 8. Medicate with analgesics as increase in mucus secretion.
 Dyspnea After 2-3 days of ordered. 8. To promote deeper respiration and
 Chest radiograph is nursing 9. Refer for any abnormal cough.
read as normal. intervention, changes in the body. 9. To medically manage any
 Cough, ineffective patient will 10. Assess client knowledge of complication
or absent of establish normal contributing causes treatment 10. to ascertain level of client’s
sputum breathing pattern. plan and specific medication. knowledge.
11. Encourage the client to have
adequate rest periods 11. To limit fatigue.
between activities.
 DRUG ORDER
GENERIC NAME:
Budesonide
BRAND NAME:
Pulmicort respules,
Pulmicort turbuhaler ,
Rhinocort Turbuhaler.
CLASSIFICATION:
Corticosteroid
ROUTE:
Inhalation route
DOSAGE:
Previously on inhaled
corticosteroids: Initially,
200-400 mcg twice daily,
maximum dose, 800 mcg
bid (4 inhalations).
FREQUENCY:
10-12 hours apart
MECHASNISM OF INDICATIONS CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILTY
ACTION S
Anti-inflammatory - Management of Inhalation contraindicated CNS: Headache, dizziness, - WARNING: taper
effect: local symptoms of seasonal or with hypersensitivity to lethargy, fatigue, systemic steroids carefully
administration into nasal perennial allergic drug or for relief of acute paresthesia’s, nervousness. during transfer to
passages maximizes rhinitis in adults and asthma or bronchospasm. inhalational steroids; deaths
beneficial effects on children; nonallergic DERMATOLOGIC: rash, from adrenal insufficiency
these tissues, while perennial rhinitis inn Use cautiously with TB, edema, pruritis, alopecia. have occurred.
decreasing the adults. systemic infections, - Arrange for use of
likelihood of adverse lactation. ENDOCRINE: HPA decongestant nose drops to
effects from systemic - Turbuhaler maintenance suppression, Cushing’s facilitate penetration if
absorption. treatment of asthma as syndrome with overdosage edema, excessive secretions
prophylactic therapy in and systemic absorption. are present.
adults and children > 6 - Prime unit before use for
yr and for patients GI: Nausea, dyspepsia, dry pulmocort turbuhaler; have
requiring corticosteroids mouth. patient rinse mouth after
for asthma inhalation each use.
suspension. LOCAL: Nasal irritation, - Use aerosol within 6
fungal infection. months of opening. Shake
- Maintenance treatment well before each use.
and prophylaxis therapy RESPIRATORY: epis - Store respules upright and
of asthma in children 12 taxis, rebound congestion, protected from light; gently
months to 8 years old. pharyngitis, cough. shake before use; open
envelopes should be
OTHER: Chest pain, discarded after 2 weeks.
asthenia, moon face, acne,
bruising, back pain.