UNIVERSITY OF CEBU LAPU-LAPU AND MANDAUE

A.C Cortes Avenue, Looc, Mandaue City

College of Nursing

Clinical Case Scenario 6

Submitted By: Jeenam Alyssa M. Espina

 NURSING CARE PLAN
Instructor/
Relevant Nursing Intervention/
Nursing Diagnosis Outcome Identification Evaluation Receptors
Assessment Data Rationale
Assessment
1. Educate the patient in the following: Criteria Score
1. Ineffective airway Subjective Cues: After 8 hours of SN-   After 8 hours of SN- Ng. Diagnosis _____
 Dyspnea Assessment
clearance related to Client interaction, the Client interaction, the
Data ______
chronic obstructed Objective Data: patient will :  Optimal positioning (sitting position) patient was able to : Outcomes _________
pulmonary disease as  Abnormal Ng. Interventions ____
evidenced by wheezing breath sounds (  Patient will maintain  Use of pillow or hand splints when coughing  Patient maintained Evaluation _________
ronchi, clear, open airways  Use of abdominal muscles for more forceful clear, open airways Timeliness _________
wheezing) as evidence by cough as evidenced by
normal breath normal breath Total Score ________
sounds, normal rate  Use of quad and huff techniques sounds, normal rate Average __________
and depth of  Use of incentive spirometry and depth of
(Signature of
respirations, and respirations, and Instructor/Preceptor)
ability to effectively Rationale: The proper sitting position and ability to effectively
cough up secretions splinting of the abdomen promote effective cough up (Assessment Date)
after treatments and coughing by increasing abdominal pressure secretions after
deep breaths. and upward diaphragmatic movement. treatments and
Controlled coughing methods help mobilize deep breaths.
secretions from smaller airways to larger
airways because the coughing is done at
varying times. Ambulation promotes lung
expansion, mobilizes secretions, and lessens
atelectasis.

2. Position the patient upright if tolerated.

2. Impaired gas exchange
 related to chronic
condition (COPD) as
evidenced by Alveolar-
capillary membrane
changes (inflammatory
effects)
Regularly check the patient’s position to
prevent sliding down in bed.
Rationale: Upright position limits abdominal
contents from pushing upward and inhibiting
lung expansion. This position promotes better
lung expansion and improved air exchange.

3. Perform nasotracheal suctioning as necessary,

3. Activity intolerance
related to Exhaustion
associated with
interruption in usual
sleep pattern because
of discomfort, excessive
coughing, and dyspnea 4. Instruct the patient to take several deep
especially if cough is ineffective.
Rationale: Suctioning is needed when patients
are unable to cough out secretions properly
due to weakness, thick mucus plugs, or
excessive or tenacious mucus production.
breaths before and after nasotracheal
suctioning procedure and use supplemental
oxygen, as appropriate.
Rationale: Hyperoxygenation before, during,
and after suctioning prevents hypoxia.

5. Provide oral care every 4 hours.

Rationale: Oral care freshens the mouth after

respiratory secretions have been expectorated.
 PHARMACOLOGIC NURSING STUDY
Instructor/
Outcome
Assessment Nursing Diagnosis Nursing Intervention Evaluation Preceptor’s
Identification
Assessment
Criteria Score
Medical History: Infection related to After 8 hours of SN- 1. Monitor vital signs closely, especially during After 8 hours of SN- *Assessment ______
inflammatory process as Client interaction initiation of therapy; Client interaction *Mt Diagnosis _____
Physical Exam: evidenced by increased patient will: Rationale: During this period of time, patient will: *Outcome
mucus secretions - Demonstrate techniques potentially fatal complications (hypotension, - Demonstrated Identification____
 General :Elderly , lifestyle changes to shock) may develop techniques , *Nursing
male, looks older
promote safe 2. Encourage adequate rest balanced with lifestyle changes to Intervention _____
environment promote safe
than stated age moderate activity. Promote adequate environment * Evaluation ______
nutritional intake; *Timeliness _______
 HEENT: Mildly
Rationale: Facilitates healing process and _________________
icteric, pupils enhances natural resistance.
equally round 3. Investigate sudden change in condition, such Total Score _______
as increasing chest pain, extra heart sounds, Ave: ____________
and reactive to
altered sensorium, recurring fever, changes in
light and
sputum characteristics; _________________
accommodation Rationale: Delayed recovery or increase in Signature of
 Neck: Supple severity of symptoms suggests resistance to Instructor/Preceptor
antibiotics or secondary infection. )
 Resp: Coarse
breath sounds,
rhonchi and _________________
wheezes heard Date of Assessment
 throughout
 Cardio: Regular
rate and rhythm,
no murmurs,
rubs, or gallops.
 Abd: Slightly
distended
 Ext: No edema
 Skin: Excoriated,
otherwise normal
 Neuro: Slightly
altered, but
baseline

Radiology:

 Chest X-ray
showed focal
consolidation in
the right lower
love, suggestive
of pneumonia.
Micro:

•Blood culture: No
growth at 48 hours

•System culture:

Gram stain:

-4t squamous epithelial

cells,

-4t segmented
neutrophils, no organisms

•Pneumococcal

-Urinary Antigen: Positive

-Legionella Urinary
Antigen : Negative
Ceftriaxone
 Administer the drug as soon as possible after
Therapeutic class: After 8 hours of SN- the diagnosis has been made After 8 hours of SN-
Antibiotics Deficient Knowledge Client interaction, the R:to improve effectiveness of the antiviral Client interaction,
related to drug therapy patient will: activity the patient will:
Pharmacologic class:  Demonstrate  Demonstrated
Third-generation effectiveness of  Ensure good hydration effectiveness of
cephalosporins comfort and safety R: to decrease the toxic effects on the kidneys. comfort and
measures and safety measures
Mechanism of compliance with the  Provide safety precautions (e.g., use of side and compliance
Action: regimen. rails, appropriate lighting, orientation, with the
Semisynthetic third assistance) if CNS effects occur regimen.
generation R: to protect the patient from injury
cephalosporin
antibiotic.
Preferentially binds to
one or more of the
penicillin-binding
proteins (PBP) located
on cell walls of
susceptible
organisms. This
inhibits third and final
stage of bacterial cell
wall synthesis, thus
killing the bacterium.
ADVERSE
REACTIONS

Gl:
pseudomembranous
colitis, diarrhea.
Hematologic:
eosinophilia,
thrombocytosis,
leukopenia.
Skin: pain, induration,
tenderness at
injection site, rash.
Other:
hypersensitivity
reactions, serum
sickness, anaphylaxis.

Vancomycin
Brand Name:
Firvanq, Vancocin

Therapeutic Class:
Antibiotics
Pharmacologic class:
Glycopeptides
ACTION

Hinders bacterial cell-

wall synthesis, dam
aging the bacterial
plasma membrane
and making the cell
more vulnerable to
osmotic pressure.
Also interferes with
RNA synthesis.

ADVERSE
REACTIONS

CNS: fever, pain,

headache, fatigue.
CV: hypotension,
thrombophlebitis at
injection site.

EENT: ototoxicity,
tinnitus.

GI:
pseudomembranous
colitis, nausea, ab
dominal pain,
vomiting, diarrhea,
flatulence.
GU: nephrotoxicity.

Hematologic:
leukopenia,
neutropenia,
eosinophilia.

Metabolic:
hypokalemia (P.O.).

Respiratory:
dyspnea, wheezing.
Skin: red-man
syndrome (with rapid
I.V. infusion).

Other: anaphylaxis,
chills, superinfection.

Tobramycin

Brand Name:
Aktob, Tobrex

tobramycin sulfate
Bethkis, Kitabis Pak,
TOBI, TOBI Podhaler

Therapeutic class:
Antibiotics
Pharmacologic class:
Aminoglycosides
Mechanism of
Action:
Generally bactericidal.
Inhibits protein
synthesis by binding
directly to the 30S
riboso mal subunit.

ADVERSE
REACTIONS

CNS: seizures,
headache, lethargy,
confusion,
disorientation, fever,
dizziness, vertigo.
EENT: blurred vision
(ophthalmic); hear ing
loss, tinnitus,
ototoxicity,
hoarseness,
pharyngitis.

GI: vomiting, nausea,

diarrhea.

GU: nephrotoxicity,
possible increase in
urinary excretion of
casts.
Hematologic:
anemia, eosinophilia,
leukopenia,
thrombocytopenia,
agranulocytosis.

Metabolic:
electrolyte
imbalances.
Musculoskeletal:
muscle twitching.
Skin: rash, urticaria,
pruritus, dermatitis,
pain at injection site.

Respiratory:
bronchospasm.

Piperacillin sodium
tazobactam sodium

Brand Name:
Zosyn

Therapeutic class:
Antibiotics
Pharmacologic class:
Extended-spectrum
penicillins-beta-
lactamase inhibitors
ADVERSE
REACTIONS

CNS: headache,
insomnia, fever,
seizures, agitation,
anxiety, dizziness,
pain.
CV: arrhythmia, chest
pain, edema,
HTN,tachycardia.

EENT: rhinitis.

GI: diarrhea,
constipation, nausea,
pseudomembranous
colitis, abdominal
pain, dyspepsia, stool
changes, vomiting,
oral candidiasis.

GU: candidiasis,
interstitial nephritis.

Hematologic:
leukopenia,
neutropenia,
thrombocytopenia,
anemia, eosinophilia.

Respiratory:
dyspnea.
Skin: pruritus, rash.

Other: anaphylaxis,
hypersensitivity
reactions,
inflammation,
phlebitis at I.V. site.

NURSES NOTES
Date/Time Notes Instructor/Preceptor’s
Assessment
5/28/21 Criteria Score
0730H F (Focus) - Activity intolerance related to exhaustion associated with interruption in usual sleep pattern *Quality of Documentation
because of discomfort, excessive coughing, and dyspnea ______
*Fundamental Rule of
Documentation
 D (Data) – Patient received on bed awake, coherent, with O2 at 4L via nasal cannula __________
____________________________
A (Action) – Total Score _____
- Nursing rounds done Average _______
- Encouraged patient to verbalized feelings
- Maintain head or neck in midline position, provide small pillow for support. ___________________________
1200H - Administered ceftriaxone 2 g IM (Signature of
- Assist patient to assume comfortable position for rest and sleep. Instructor/Preceptor)

R (Response) – Report/demonstrate a measurable increase in tolerance to activity with absence of dyspnea ____________________________
and excessive fatigue, and vital signs within patient’s acceptable range. (Assessment Date)

REFLECTION

Based on Gibbs’ model of reflection:

This scenario gives us information that health awareness is vital to a human life and we should take care of ourselves. It also gives ideas to health practitioner on how to manage
a case that has crucial situation and needs immediate attention. Reading this scenario made me imagine that we should take care ourselves from numerous points of view like
For each disease process there is an effect on other systems, and each of these effects must be taken into account when treating the patient. The good and bad about the
experience is that the more time I overthink the higher possible it is for me to answer my module wrong. But with the help of the e-books and books that I actually have with me
and classmates I get to answer my module on time and hopefully correctly. The patient’s right to confidentiality and privacy must also be taken to consideration and right to
information regarding his condition must not be forgotten also. And observe proper therapeutic communication with the patient and not give false hope.