OUR LADY OF THE RULE

MATERNITY
AND GENERAL HOSPITAL

Submitted by:

Kriz Lin Kyle S. Go

Submitted to:

Ms. Ayana Christina P. Abarquez, RN

 CONTENTS OF THE RLE WRITTEN REQUIREMENTS

General Objectives

After 3 days exposure at Our Lady of the Rule Maternity and General Hospital being aided with the

concept of Nursing Care of the client with high-risk labor and delivery of her family, I will be able to gain the

exact knowledge, enhance my skills and develop a positive attitude towards the care of the clients.

Specific Objectives

After 3 days of exposure at Our Lady of the Rule Maternity and General Hospital I will be able to:

1. Be oriented to the physical setup, rules and policies, and the staff.

2. Establish rapport with the client.

3. Communicate effectively with patients, families, and other relevant persons by:

- Listening and interpreting information

- Demonstrating non-judgmental behavior.

- Evaluating the interaction between members of the family

- Discussing information at the appropriate intellectual level for all ages and conditions.

4. Obtain pertinent information about the patient

5. Perform an appropriate physical examination (IPPAO).

6. Perform common procedures (V/S) using appropriate instruments and materials.

7. Elicit and interpret pertinent events from the patient, family, and other sources.

8. Identify nursing problems and formulate a nursing care plan.

9. Formulate management plans for short and long-term care.

10. Apply appropriate interventions to the client

11. Evaluate the effectiveness of the nursing interventions.

 HEALTH HISTORY FORMAT

Student Name: Kriz Lin Kyle S. Go

Area of Assignment: General Ward
Date & Time of Interview: 02/16/2023 2:51 PM

I. Biographical and Demographic Data

Name: Alexander Louis Gimarangan Sarino

Gender: Male
Birth Date: 07/28/2013
Birth Place: LLC
Age: 9 years old
Address: Purok Kalabasa, Panglag, Consolacion, Cebu
Contact Number: 09632167282
Educational Level: Elementary
Marital Status: Child
Occupation: N/A
Nationality: Filipino
Religion: Roman Catholic
Source of Data: Father of patient
Contact Person in Case of Emergency: Eufemia Panfoja
Health Insurance: Philhealth and company insurance
Date & Time of Admission: 02/16/2023 , 8AM
Attending Physician: Dr. Corazon Ouano
Diagnosis: Dyspnea

Chief Complaint: Patient’s guardian verbalized “Giubo, sip-on akong anak 1 week na mag wala-wala. Hubak siguro”

II. Current Health (History of present illness)

Character: Coughing with phlegm

Onset: 1-week recurring cough, day prior to admission patient experienced dyspnea, situation is better after admission.
Location: Chest
Duration: Lasts for 30 mins
Severity: Patient rates severity 5 out of 10
Pattern: Patient feels better when taking Salbutamol
Associated factors: Other symptoms include a runny nose. Does not interfere with daily activities and the patient is still
able to go to school.

A case of Mr. Alexander Sarino, 9 years old, a resident of Purok Kalabasa, Panglag, Consolacion, admitted for the
first time at Our Lady of the Rule Maternity and General Hospital last February 16, 2023 because of Dyspnea.

1 week prior to admission, patient experienced a recurring cough. Patient rated severity as 5 (10 is the highest
and 1 is the lowest). Day prior to admission, patient experienced dyspnea which prompted the parents to seek
consultation at Our Lady of the Rule Maternity and General Hospital and was advised for admission.

III. Past Health History

Previous Hospitalization: Check up last month due to recurring cough at Consolacion Family Clinic
Birth Problems: No birth problems
Childhood Illnesses: Gets cough and colds easily
Immunizations: Immunized with MMR, Hepa B, Varicella
Surgeries: No surgeries
Accidents: No accidents
Pain: No pain
Allergies: Poultry
Treatments: No treatments
Medications: Salbutamol for previous cough
 IV. Family Health History (With Genogram)

Legend:

Male Patient X

Female Asthmatic A

Deceased Male Cancer C

Deceased Female Diabetic D

Hypertensive H

Narrative Report:
Alexander Sarino is the son of Maxjun O. Sarino. The asthmatic condition runs in his father’s family. On his
father’s side, his grandfather passed away, but his grandmother is still living and suffers from asthma and hypertension.
On his mother’s side, both grandparents are living and experiencing no ailments. His father has 3 male siblings and 3
female siblings. On the other hand, his mother has 1 male sibling and 1 female sibling. Alexander is an only child.

V. Psychosocial history

o Lifestyle - Use of mobile phone, sedentary lifestyle

o Personal styles - wakes up, goes to school, does homework, and uses mobile phone
o Personal strengths
ADL: goes to school, use mobile phone most of the time, draw, and write
Diet: Egg, chicken, corned beef, drinks 8 glasses of water a day
Medication & Substances Use: None
Elimination: Defecates once a day, urinates five times a day
Sleep & Rest: Gets 8 hours of uninterrupted sleep, sometimes naps during the day
Exercise: None
Occupation: N/A
Leisure: Drawing, writing
Religious Observations: no specific religious beliefs
Environment: comfortable home and neighborhood, patient stays at home most of the time
Stressors & Coping Strategies: Patient uses his mobile phone to relax.
Roles & Relationships: Patient does not have a specific role in the household in terms of chores. Patient is
the only child in the family and is given comfort and care by parent.
Self-Concept: Perceives himself as kind
Self-Care Responsibilities: Patient practices basic hygiene like taking a bath everyday, changes clothes,
and brushes teeth. Patient does not come in for regular check ups unless needed.
VI. Gordon’s Functional Health Pattern (11 health patterns)

HEALTH PATTERN ASSESSMENT

Health Perception / Health Management Pattern Alexander has no history of chronic illness. His father
reported that he was immunized with MMR, Varicella,
TDAP, Hepa B.

Nutritional / Metabolic Pattern
Client has a good appetite. Food intake: 2-3 times a
day with snacks. Fluid intake: estimated 8 glasses of
water per day. Client has allergies to poultry and no
allergies with drugs. Has no difficulties with eating and
swallowing.

Elimination Pattern Client defecates regularly at least once daily. No

problem associated with bladder or urination.

Activity / Exercise Pattern Client has no regular exercise regime. During his
leisure time, client draws and write. Client uses his
mobile phone most of the time when out of school.

Cognitive / Perceptual Pattern Client has good sensory and auditory adequacy. No
difficulties in learning. Oriented.

Sleep / Rest Pattern Client has 8 hours of sleeping pattern and sometimes
fits in a nap during the day.

Self-perception / Self-concept Pattern Client perceives himself as kind. Shows positive

attitude towards others.

Role / Relationship Pattern The client plays as the only child in the family. His
parent provide him with comfort and care.

Sexuality / Reproductive Pattern The client is circumcised

Coping / Stress Tolerance Pattern Client uses mobile phone to relax.

Value / Belief Pattern Not applicable

VII. Review of Systems (IPPAO)

General Survey:
A case of Mr. Alexander Sarino, 9 years old, male, child and a Filipino citizen was admitted to Our Lady of the
Rule Maternity and General Hospital last February 16, 2023 due to dyspnea. Patient is conscious with the
following vital signs: T= 37.4 , O2=99, RR=29, PR=112, BP= 120/90

Skin:
- Medium complexion noted
- No lesion noted
- No signs of poor skin turgor
Nails
- Pinkish nails noted
- Short & presence of dirt noted
- Smooth in texture
- Good capillary refill
Eyes
- Eye pain due to prolonged use of mobile phone
- White sclera and pink conjunctiva with no drainage noted
Thorax and Lungs
- Patient reported shortness of breath for 30 minutes before admission
- Reports coughing up phlegm
- Wheezing, crackles noted
VIII. Anatomy & Physiology (of the affected part)

This will show a drawing of the organ affected related to the diagnosis of the patient.

Dyspnea is the medical term for difficulty breathing or shortness of breath. It is a symptom of many conditions that
affect the respiratory system. Shortness of breath can range from mild and temporary to serious and long-lasting. It is
sometimes difficult to diagnose and treat dyspnea because there can be many different causes. It is a common problem.
Around 1 in every 4 people who visit emergency services have dyspnea.
Dyspnea can happen due to overexertion, spending time at high altitudes, or as a symptom of several conditions.
Signs that a person is experiencing dyspnea include:

● shortness of breath after exertion

● labored breathing
● tightness in the chest
● rapid, shallow breathing
● feelings of being smothered or suffocated
● heart palpitations
● wheezing
● coughing
An episode of dyspnea is not always directly related to an individual’s health. A person can feel short of breath
after intense exercise when traveling to a high altitude or through major temperature changes. However, dyspnea usually
relates to health problems. Sometimes, it is just a case of inactivity, and exercise can improve symptoms. However,
dyspnea can be a sign of a serious health issue. If shortness of breath starts suddenly, it is an acute case of dyspnea.

Acute dyspnea could be due to: asthma, anxiety, pneumonia, cardiac disease, foreign objects obstructing airways, allergic
reactions, anemia, etc.

Most cases of shortness of breath are due to heart or lung conditions. Your heart and lungs are involved in transporting
oxygen to your tissues and removing carbon dioxide, and problems with either of these processes affect your breathing.

IX. A. Laboratory Results

Date Type of Exam Patient’s Results Normal Values Significance/Interpretation

WBC: 21.85 WBC: 4.00 - 12.00

RBC: 5.1 RBC: 3.50 - 5.20
NORMAL
12/16/23 HEMATOLOGY HG: 15.1 HG: 12.0 - 16.0
HCT: 43.5 HCT: 35.0 - 49.0
PLT: 381 PLT: 150 - 450

Color: Color:

Yellow Yellow
NORMAL
12/16/23 URINALYSIS
Transparency: Transparency:

Clear Clear
 B. Diagnostic Tests
Criteria Patients result Normal Findings Significance

CHEST XRAY:
PA FUR taken as OPD

RAPID ANTIGEN NEGATIVE

X. Drug Study

Mechanism of Adverse
Drug Name Classification Indication Contraindication Nursing responsibilities
Action reaction

o Generic Antibiotic Bactericidal: Lowers Contraindicated CNS: Before

Name Cephalosporin Inhibits respiratory with allergy to Headache, Do skin testing into the
synthesis of infections cephalosporins dizziness, intradermal area
Ceftriaxone bacterial cell caused by or penicillins. lethargy
Sodium wall causing cell Streptococcu Use cautiously Protect drug from light
death s pneumonia, with renal GI: Nausea,
o Brand Name Staphylococc failure, vomiting, Do not mix ceftriaxone
us aureus, lactation, diarrhea, with other antimicrobial
Rocephin Haemophilus pregnancy anorexia, drug
influenza, E. pseudomemb
o Actual coli, ranous colitis During
dosage, route, Enterobacter Use a separate syringe
frequency aerogenes. HEMATOLOG when giving this drug
IC:
Actual Dosage: Intra-abdomi bone marrow Have Vitamin K available
nal infections depression - in case of
caused by E. dec. WBC, hypoprothrombinemia
Route: IVTT coli, platelets, occurs
Klebsiella HCT
Frequency: q12h pnemoniae After
LOCAL: pain, Discontinue if
inflammation hypersensitivity occurs
of IV site
Monitor blood levels in
OTHER: patients taking this drug.
superinfection
s,
disulfiram-like
reaction with
alcohol

Mechanism of Nursing
Drug Name Classification Indication Contraindication Adverse reaction
Action responsibilities

o Generic Belongs to the Ipratropium is a Management Hypertrophic Edema, fatigue, Check the
Name class of nonselective of reversible obstructive hypertension, physician's order.
adrenergics in competitive bronchospasm cardiomyopathy dizziness,
Ipratropium combination with antimuscarinic or nervousness, Follow the 14 rights
Salbutamol anticholinergics agent. It causes tachyarrhythmia paresthesia, of medication
bronchodilation tremor, Position patient on
o Brand Name by blocking the dysphonia, high back rest
action of insomnia, position
Duavent acetylcholine-in diarrhea, dry
duced mouth, Do back tapping
o Actual stimulation of dyspepsia, after you nebulize
dosage, guanyl cyclase, vomiting, the patient
route, hence reducing arrhythmia,
frequency formation of palpitation Do not give food
cyclic immediately, may
Actual Dosage: guanosine cause vomiting
1 neb monophosphate
at
Route: Inhalation parasympatheti
c site.
Frequency: q6h x Salbutamol
48hrs activates adenyl
cyclase, the
enzyme that
stimulates the
production of
 cyclic
adenosine

Mechanism of Nursing
Drug Name Classification Indication Contraindication Adverse reaction
Action responsibilities

o Generic Pharmacologic Enters target -Replacement Concentrations CNS: Before

Name Class cells and binds therapy in - Allergy to any Vertigo, - Assess for
Adrenal cortical to cytoplasmic adrenal cortical component of headache, contraindications.
Hydrocortisone steroid receptor; initiates insufficiency the drug paresthesias, - Assess body weight,
Corticosteroid many complex - Fungal seizures, skin color,
o Brand Name Glucocorticoid reactions that - Allergic infections psychosis V/S, urinalysis, serum
are responsible states – severe - Amebiasis CV: Hypotension, electrolytes,
Cortef,, Therapeutic for its or - Hepatitis B shock, HPN X-rays, CBC.
Hydrocortone, Class anti-inflammator incapacitating - Vaccinia or and heart failure - Arrange for
Cortenema Hormone y, allergic varicella secondary to increased dosage
immunosuppress conditions -Antibiotic-resist fluid retention, when
o Actual ive ant thromboembolism, patient is subject to
dosage, (glucocorticoid), - Hematologic infections unusual stress.
route, and saltretaining disorders -Immunosuppres Dermatologic: - Do not give live
frequency (mineralocorticoi sion Thin, fragile vaccines with
d) actions. Some skin, petechiae, immunosuppressive
Actual Dosage: actions may be - Ulcerative Precaution ecchymoses, doses of
100ML undesirable, colitis - Kidney disease purpura, striae hydrocortisone.
depending on - Liver disease - Observe the 15
Route: IVTT drug use. - Cirrhosis EENT: Cataracts, rights of drug
- Hypothyroidism glaucoma, administration.
Frequency: q24h x - Recent GI increased IOP During
5 days surgery - Give daily before
- Active or latent Endocrine: 9am to mimic
peptic Amenorrhea, normal peak diurnal
ulcer irregular mens, corticosteroid
- Inflammatory growth levels.
bowel retardation, - Space multiple
disease decreased doses evenly
- Hypertension carbohydrate throughout the day.
- Heart failure tolerance and - Use minimal doses
- Convulsive DM,hyperglycemi for minimal
disorders a duration to minimize
adverse effects.
GI: Peptic or - Do not give IM
esophageal ulcer, injections if patient
pancreatitis, has
abdominal thrombocytopenic
distention, purpura.
nausea, vomiting, - Taper doses when
increased appetite discontinuing
and weight high-dose or
gain long-term therapy.
After
Hematologic: Na - Monitor client for at
and fluid least 30
retention, minutes.
hypocalcemia, - Educate client on
increased blood the side effects of
sugar, the medication and
increased serum what to expect.
cholesterol, - Instruct client to
decreased T3 and report pain at
T4 levels injection site.
- Instruct client to
Hypersensitivity: take drug exactly
Anaphylactoid or as prescribed.
hypersensitivity - Dispose of used
reactions materials properly.
- Document that drug
Musculoskeletal: has been
Muscle given.
weakness,
and loss of
muscle mass,
osteoporosis,
spontaneous
fractures
 Mechanism of Nursing
Drug Name Classification Indication Contraindication Adverse reaction
Action responsibilities

o Generic Therapeutic: It enhances Adjuvant Should not be There are no Monitor for S&S of
Name Mucolytic pulmonary therapy in used in patients such harmful aspiration of excess
surfactant patients with known to be side effects of the secretions, and for
Ambroxol Pregnancy production and abnormal, hypersensitive to medicine. It is bronchospasm
Hydrochloride Category A stimulates viscid, or ambroxol or usually well (unpredictable);with
ciliary activity. inspissated other tolerated. In hold drug and notify
o Brand Name mucous components of some cases, physician
These actions secretions in the formulation. nausea and immediately if either
Mucosolvan and result in acute and vomiting might occurs.
Mucoangin improved chronic There are no occur.
mucus flow and bronchopulmo absolute Lab tests: Monitor
o Actual transport nary diseases, contraindications ABGs, pulmonary
dosage, (mucociliary and in but in patients functions and pulse
route, clearance). pulmonary with gastric oximetry as
frequency complications ulceration indicated.
Enhancement of cystic relative caution
Actual Dosage: of fluid fibrosis and should be Have suction
6ml secretion and surgery, observed. apparatus
mucociliary tracheostomy, immediately
Route: PO clearance and available. Increased
facilitates atelectasis. volume of
Frequency: BID x expectoration respiratory tract fluid
5 days and eases may be liberated;
cough. suction or
endotracheal
aspiration may be
necessary to
establish and
maintain an open
airway.

Report difficulty with

clearing the airway
or any other
respiratory distress

Mechanism of Nursing
Drug Name Classification Indication Contraindication Adverse reaction
Action responsibilities

o Generic Classification: Inhibits To manage Hypersensitivity CNS: Assessment & Drug

Name Glucocorticoid inflammatory symptoms of to budesonide or Amnesia, Effects:
cells seasonal or its components, asthenia, benign
Budesonide Anti-asthmatic, and mediators, perennial renal septal intracranial Do not use more
antiinflammatory possibly by allergic rhinitis; ulcers or nasal hypertension, often
o Brand Name decreasing To prevent or surgery or change in mood, than prescribed; do
influx into nasal provide trauma; status dizziness, not
Pulmicort passages, maintenance asthmaticus or fatigue, fever, stop without
Flexhaler bronchial walls, therapy in other acute headache consulting
or the chronic asthma your health
o Actual intestines. As a bronchial episodes. ENDO: Adrenal care provider.
dosage: 1 result, asthma; insufficiency,
neb nasal or airway Nebulized decreased blood It may take several
inflammation inhalation; To cortisol level, days
Route: Inhalation decreases. Oral reduce growth to achieve good
inhalation remission in suppression in effects;
frequency: q12h x form also patients with children do not stop if effects
48h inhibits mucus active mild to hypercorticism are
secretion in moderate not immediate.
airways, distal RESP:
decreasing the ulcerative Bronchospasm, Use decongestant
amount and colitis increased cough, nose
viscosity of extending up respiratory tract drops first if
sputum. infection nasal passages are
blocked.
SKIN: Allergic or
contact
dermatitis,
maculo-papular
rash, pruritus,
purpura, rash
urticaria
 Mechanism of Nursing
Drug Name Classification Indication Contraindication Adverse reaction
Action responsibilities

o Generic Adrenergics Selectively Maintenance Contraindicated CNS: Tremor, Assessment and

Name activates beta 2 treatment for to patients with headache Drug Effects:
adrenergic COPD hypersensitivity
Salmeterol receptors, including to drug or any of CV: subjective Assess patient’s
senafoate and which results in chronic its components. palpitations and respiratory condition
Fluticasone bronchodilation bronchitis and cardiac before starting
and blocks the emphysema. Caution to arrhythmias, therapy.
o Brand Name release of patients who are
allergic unusually MS: arthralgia, Assess peak flow
Seretide mediators from responsive to readings before
the mast cells in sympathomimeti Others: starting therapy and
o Actual the respiratory cs and patients hypersensitivity periodically
dosage: 2 tract with coronary reactions, thereafter.
puffs artery oropharyngeal
route: Inhalation insufficiency. irritation, Be alert for adverse
hoarseness,oral reactions and drug
frequency: BID candidiasis, reactions
paradoxical
bronchospasm Don’t give drug for
acute
bronchospasm.

Tell patient to take

the drug at about
12-hour intervals
even if he is feeling
better.

XI. Problem List

● Ineffective breathing pattern related to presence of thick mucus secretions, as evidenced by dyspnea.
● Impaired Gas Exchange related to altered oxygen supply (obstruction of airways by mucus secretion) as
evidenced by wheezes upon auscultation

XII. Nursing Care Plan

Defining Nursing Scientific Goal of Care Intervention Rationale Evaluation

Characteristic Diagnosis Analysis
s

Objective: Ineffective Presence of Patient will 1. Establish 1. To gain pt.’s Patient

-wheezing breathing secretions can demonstrate rapport. trust. demonstrates
upon pattern plug the pursed-lip pursed-lip
inspiration related to airway, thereby breathing and 2. assess pt.’s 2. To obtain breathing and
and presence of decreasing the diaphragmatic condition baseline data diaphragmatic
expiration thick mucus amount of breathing. breathing.
-dyspnea secretions, oxygen 3. VS monitor and 3. Serve to
-coughing as available for Patient will record track Patient
evidenced gas exchange manifest signs important manifests signs
by dyspnea. in the lungs. of decreased 4. Auscultate changes of decreased
And inability to respiratory breath sounds respiratory
maintain clear effort AEB and assess airway 4. to check for effort AEB
airway. This absence of pattern the presence absence of
obstruction is dyspnea of adventitious dyspnea
further 5. Elevate head of breath sounds
heightened by Patient will the bed and change Patient
bronchospasm verbalize position of the pt. 5. To minimize verbalized
due to the understanding every difficulty in understanding
contraction of of causative 2 hours. breathing of causative
the factors and factors and
smooth demonstrate 6. Encourage deep demonstrate
muscles in behaviors that breathing and 6. To maximize behaviors that
the bronchi. would improve coughing effort for would improve
This breathing exercises. expectoration. breathing
is caused by pattern pattern
parasympathet 7. Demonstrate 7. To decrease
ic diaphragmatic and air trapping
stimulation of pursed-lip breathing. and for efficient
the breathing.
muscarinic2
receptors as 8. Encourage 8. To prevent
well fatigue.
 as by chemical increase in fluid
mediators intake 9. To prevent
released in situations that
response to 9. Encourage will aggravate
the opportunities for rest the condition
presence of and
allergen. limit physical 10. To mobilize
activities. secretions.
Source:
Nursing, O. R. 10. Reinforce low
F. (n.d.). 11.2 salt, low fat diet
Basic as ordered.
Concepts of
Oxygenation –
Nursing Skills.
Pressbooks.
https://wtcs.pre
ssbooks.pub/n
ursingskills/ch
apter/11-2-basi
c-concepts-of-
oxygenation/

Defining Nursing Scientific Goal of Care Intervention Rationale Evaluation

Characteristic Diagnosis Analysis
s

Objective: Impaired Entry of Short term Independent: Short term

RR: 28 Gas noxious goal: 1.Monitor skin and 1.Duskiness goal:
PR: 112 Exchange particles or mucous membrane and
-wheezes related gases After 2 hours color central After 2 hours
upon to altered to the lungs of nursing cyanosis of nursing
auscultation oxygen ↓ intervention the indicate intervention
-with pulse supply Release of client: 2.Elevate head of the advanced the client:
oximeter (obstruction mediators -Demonstrate bed, assist patient to hypoxemia -Demonstrate
of airways by ↓ improved assume position to d
secretion) as Abnormal ventilation and ease work of 2.Oxygen improved
evidenced by inflammation adequate breathing delivery ventilation and
wheezes of the oxygenation of may be adequate
upon lungs tissues 3.Suction when improved oxygenation of
auscultation ↓ needed by upright tissues
Chronic -Decrease suctioning
inflammation respiratory rate 4.Auscultate breath -decreased
↓ from 28cpm to sounds, noting areas 3.Suctioning is respiratory
Scar tissue 20 cpm of decreased air-flow required when rate from
formation or presence of cough is 28cpm to 20
↓ Long term adventitious sound ineffective cpm
Narrowing of goal for
airway lumen After 3 days of 5.Palpate for expectoration Long term
↓ nursing fremitus of secretions goal:
Airflow intervention the
limitations client: 6.Provide quiet 4.Presence of After 3 days of
↓ -Manifest environment to allow wheezes may nursing
Impaired gas absence the patient to relax indicate intervention
exchange of wheezes bronchospasm/ the client:
↓ upon Collaborative: retained -Manifested
wheezes auscultation 1.Monitor pulse secretions absence of
-Attain normal oximetry and ABGs wheezes upon
breathing 5.Decrease of auscultation
pattern vibratory - Attained
of 20 cpm tremors normal
suggest fluid breathing
collection or air pattern
tapping of 20 cpm

6.External
stimuli
may prevent
relaxation or
inhibit
sleep
 Collaborative
1.to identify if
hypoxia is
present

XIII. Readings: related to the diagnosis of the patient (updates)

Physicians have noted dyspnea in severely ill asthmatic patients to be associated with fright or panic; in more
stable patients dyspnea may reflect characteristics including lung function, personality and behavioral traits. This study
evaluates the symptom of dyspnea in 32 asthmatic patients twice: first when acutely ill and again after an initial response
to therapy. Spirometry was performed, dyspnea quantified (Borg scale), and panic assessed with a specialized measure
of acute panic (the acute panic inventory (API)) in the 32 patients before and again after treatment. After treatment,
questionnaires to evaluate somatization and panic disorder were also administered. When acutely ill, both the API and all
spirometric measures (PEFR; FEV1; IC) correlated with dyspnea. Multiple linear regression showed that measures of the
API, the peak expiratory flow rate, and female sex taken together accounted for 41% of dyspnea in acute asthma. After
treatment, the API again predicted dyspnea while spirometric data did not. Those subjects who described themselves as
having chronic panic disorder reported high grades of dyspnea after treatment also. We conclude that interpretations of
the self-report of asthma differ between acutely ill and stable asthmatic patients.

Bibliography
Lavietes, M. H. (2015). The Interpretation of Dyspnea in the Patient with Asthma. Pulmonary Medicine, 2015, 1–4.
https://doi.org/10.1155/2015/869673

Discharge Planning Guide

F = Ineffective breathing pattern related to presence of thick mucus secretions, as evidenced by dyspnea

D = Received patient conscious, coherent, and afebrile

= With recurring cough for 1 week
= Wheezing is heard from a distance
= With O2 inhalation via NC @ 2LPM

A = Assessed general health status

= Assessed patient’s needs and performed hand hygiene before handling patient
= Monitored v/s and charted
= Monitored respiratory patterns, including rate, depth, and effort
= Medication given as ordered
= Encouraged increase fluid intake
= Ensured safety
= Maintained well-ventilated environment
= Encouraged deep breathing exercises

M = the parents of the client must know the name, action, purpose, dose, route of administration of each drug the
child is taking.

E = parents must provide the child with a clean and safe environment for their child

T = the family knows the purpose and action of any treatment.

H = the family is taught how to administer drugs and treatments when necessary.

O = the family knows the times, dates, and location of appointments as well as acquiring available telephone
numbers of referred physicians and agencies.

D = Diet should include a good source of protein at least twice a day to help maintain strong respiratory muscles.
Limit simple carbohydrates and salty foods.

R = Patient reports he feels better

= Absence of wheezing
= Increased fluid intake
 Kriz Lin Kyle S. Go BSN2-B1

Drug Study

Mechanism of Nursing
Drug Name Classification Indication Contraindication Adverse reaction
Action responsibilities

o Generic Antihistamine Montelukast inhibits Prevents Hypersensitivity -Fatigue Check physician’s

Name bronchoconstriction wheezing and to Montelukast; -Fever order.
due to antigen shortness of Severe asthma -Abdominal pains,
Montelukast challenge. breath attacks. -Trauma, and Follow rights of
-Headache medication
o Brand
Name Assess respiratory
status
Zykast
Instruct patient not
o Actual to reduce or
dosage: 1 discontinue other
tab asthma medications
without consulting
route: PO HCP.

frequency:
ODHS

Nursing
Drug Name Classification Mechanism of Action Indication Contraindication Adverse reaction
responsibilities

o Generic Mucolytic - Acetylcysteine, Treatment of Fluimucil -Vomiting, 1. Monitor the

Name Used in the active ingredient of respiratory granules and -Diarrhea, effectiveness of
treatment of FLUIMUCIL, exerts affections tablets are -Abdominal pain, therapy and advent
Acetylcysteine wet cough an intensive characterized contraindicated -Nausea of adverse/allergic
mucolytic-fluidifying by thick and in patients -Rash, effects.
o Brand action on mucous viscous suffering from -Pyrexia
Name and mucopurulent hypersecretions phenylketonuria -Decreased blood 2. Instruct patient in
secretions by due to the pressure appropriate use and
Fluimucil depolymerizing the aspartame adverse effects to
mucoprotein content. report
o Actual complexes and the Children below
dosage: nucleic acids which 2 years of age 3. Perform chest
confer viscosity to physiotherapy to
route: the vitreous and loosen secretions
purulent component for elimination.
frequency: of the sputum and
other secretions

Mechanism of Nursing
Drug Name Classification Indication Contraindication Adverse reaction
Action responsibilities

o Generic Pharmacologic Reduce airway Hydrocortisone - Concurrent Long-term BASELINE

Name Class inflammation, reduces administration of therapy: ASSESSMENT
Hydrocortisone Corticosteroid improve airway discomfort, live virus vaccine Hypocalcemia,
responsiveness itching, swelling, hypokalemia, Obtain baseline
o Brand Therapeutic , and shorten and inflammatory -Systemic fungal muscle wasting weight, B/P, serum
Name Class the duration of by cooling down infections (esp. arms, legs), glucose, cholesterol,
Solu-cortef Anti-inflammatori the your body's osteoporosis, electrolytes. Screen
es (steroidal) exacerbation immunological -Concurrent use of for infections
o Actual reaction. It can other Abrupt including fungal
dosage: also be used to immunosuppressa withdrawal after infections, TB, viral
100mg replace the nt corticosteroids long-term skin lesions.
natural stress therapy:
route: IVTT hormone cortisol -Insomnia,
in patients who -Headache, --Monitor the patient
frequency: q8h don't have -Nausea, for any sign of
enough of it. -Vomiting, respiratory infection;
-Increased blood continued use of
glucose steroids during
acute infection can
lead to serious
complications
related to the
depression of the
inflammatory and
immune responses
 Adverse Nursing
Drug Name Classification Mechanism of Action Indication Contraindication
reaction responsibilities

o Generic Andrenergics Selectively activates Regular Hypersensitivity to -Upper 1.Assess patient for
Name beta 2 adrenergic treatment of sympathomimetics, respiratory tract severe allergic
receptors, which reversible tachydysrhythmias, infections reaction notify
Salmeterol results in obstructive severe health care
senafoate and bronchodilation and airways cardiac disease, -Throat irritation professional
Fluticasone blocks the release of disease monotherapy immediately if these
allergic mediators (ROAD) treatment of -Hoarseness, occur.
o Brand from the mast cells including asthma, milk voice changes,
Name in the respiratory asthma where protein, primary and trouble 2. Follow Doctor’s
tract use treatment in speaking prescription
Seretide combination status asthmaticus, accordingly
therapy acute -Thrush (fungal
o Actual (bronchodilator bronchospasm infections in 3. Tell the patient to
dosage: 2 and inhaled your mouth or keep this drug in a
puff corticosteroids) throat) dry place away from
is appropriate heat and sunlight.
route: INH -Bronchitis
4. Assess patient
frequency: BID -Cough respiratory condition
starting therapy
-Headache
5. Inform the patient
-Nausea and to not use drug if
vomiting acute
bronchospasm
occurs.

6. Instruct the
patient in how to
use inhaler, to use it
once daily at the
same time each day

F = Ineffective airway clearance r/t thick mucus secretions AEB RR of 29cpm

D = Received patient on bed, conscious, coherent, and afebrile. Px verbalized “hangakon rako usahay dili na
kaayo pareha pag una”
= Px is on 2LPM of oxygen via NC
= With productive cough as px is able to expel mucus occasionally
= Wheezing heard from a distance

A = Performed hand hygiene before handling patient

= Assessed general health status
= Positioned px comfortably
= Assessed patient’s needs
= Monitored v/s, I&O and charted
= Encouraged increase fluid intake
= Promoted rest

R = Goals met