Mindanao State University

COLLEGE OF HEALTH SCIENCES

Marawi City

NAME OF STUDENT: Section E1 CLINICAL INSTRUCTOR: PROF. NORHANIE A. ALI

AREA OF ASSIGNMENT: Medicine Ward DATE SUBMITTED: 06/06/2023.

NURSING ASSESSMENT I

PATIENT’S NAME: PATIENT X ADDRESS: RAGAYAN, POONA BAYABAO (GATA), LANAO DEL SUR AGE: 59yrs old
SEX: FEMALE RELIGION: ISLAM CIVIL STATUS: WIDOW OCCUPATION: NONE

FREQUENCY AMOUNT PERIOD/DURATION

1. Tobacco X X X

2. Alcohol X X X

3. OTC- drug/nonprescription drug (Biogesic, Neozep and PRN 500mg 26yrs

Mefenamic)

A. CHIEF OF COMPLAINTS:

“Margn a kapakaginaw akn saman aya ka pitaro rakn pn o doctor a pagilay rakn na and kon pn oto a asthma akn” as verbalized by patient

B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational
responsibilities, affected diagnoses}.

This is a case of a 59-year-old female from Ragayan, Poona Bayabao (Gata), Lanao del sur. According to her, May 21 st of 2023 when the patient caught a cold associated
with a persistent cough, she thought that it is just a normal cold that can be treated in a just few days by drinking lots of water and using an Over the counter drugs such as Biogesic or Paracetamol
unfortunately her cold and cough has worsen to the point that she experienced shorter of breathing. On May 28 th, prior to admission the patient had shortness of breathing. On May 30 th, the patient
cannot tolerate the pain that she experiencing that make her think that it is the last day of her life, exactly 9:12 in the evening they arrived in Emergency room at Amai pakpak medical center and
Immediately they assessed her vital signs her Respiratory rate is quit abnormal because it is 44cpm and Oxygen Saturation of 89%, doctors first suspect her that she has covid since she have most
common symptoms but after they swab her, and the result came out negative after further laboratories and examinations they confirmed it that the patient has a Bronchial Asthma Acute Exacerbation.

A. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits,
birth and developmental history, nutrition- for pedia)
 The patient has been hospitalized due to hypertension and no report of injuries. The patient has never undergone for any minor or major surgery and reported that she experienced
chicken fox and measles during her childhood days, and she also added that she had completed her immunization. The patient has a health maintenance for her hypertension and no reports
any major illness, no allergies, taking OTC drugs as needed and losartan every morning, she likes cleaning around the house and loves to stroll around not for just fun but to have an
exercise as well, she is G8P7.

Heredo- familial Diseases:

Diabetes X
Heart Diseases X
Hypertension X
Cancer X
Asthma X
Epilepsy X
Mental Illness X
Rheuma/Arthritis X
Others (pls. specify) X

Acquired Diseases:
Hypercholesterolemia X
Kidney Disease X
Tuberculosis X
Alcoholism X
Drug Addiction X
Hepatitis A X
B X
C X
Others (pls. specify)
FAMILY HISTORY GENOGRAM
Patient
Daughter
Son
Husband (Deceased)

B. PATIENT’S PERCEPTION OF:

 1. Present Illness

“Margn a kapakaginaw akn saman aya ka pitaro rakn pn o doctor a pagilay rakn na and kon pn oto a asthma akn” as verbalized by patient
2. Hospital Environment

“Mapiya mambo ka pkatabangan iran so madakl a kikinanglan na pakalibre tapn sa bayad ogaid na aya say abo sakit na so mga kakaba a mangaito a na didn kada” as verbalized by the
patient.
C. SUMMARY OF INTERACTION

The Patient is cooperative and has an understanding to everything. She entertains the student nurse and answers every question you ask. She was always smiling when you were
talking to her. She never get tired or irritated while you were asking personal questions perhaps she will answer you very detailed.

PHYSICAL EXAMINATION
Name: Patient X Date: June 02,2023
Chief of Complaints: Difficulty of breathing Height: 144 cm Weight: 50 kg
Vital signs: T: 36.4℃ RR:23cpm PR:67bpm O2Sat:95% BP:130/90mmHg Pain score:6/10 BMI: 23.6 kg/m2

Received patient sitting at the bed with on-going IVF of patient on right metacarpal. Patient is alert, conscious, and
oriented to time, place and people surrounding. Patient is cooperative and enjoy the company of the student nurses
GENERAL especially when you were asking a questions personal or not she will answer it clearly and detailed, patient is well
groomed, nails was clean cut, hair is combed properly and tucked in.
 Head: Head is normochepalic and has no lesions, lumps, or masses. Hair has a visible gray in some part but not
completely gray
HEENT Eyes: Eyebrows are symmetric and black in color, but few are turning in white. Eyelashes are evenly distributed. Eyelids
are swollen. No presence of discharges is noted.
Ears: Ears are symmetric. There is no presence of tenderness, lesions, and discharges.
Nose: nasal flaring is noted and a nasal discharge.
Throat: No presence of swelling and masses.

INTEGUMENTARY Senile turgor is noted due to aging, patient has no lesion or masses in the body and no discoloration.

Pulse rate is 67 bpm with blood pressure of 130/90 mmHg. Chest expansion is equal. Patient has no history of any cardiovascular
CARDIOVASCULAR
problem.

RESPIRATORY Respiratory rate of patient is 23 cpm and saturation of oxygen at 95% via room air. No oxygen therapy is used. Wheezes at right
lung field and crackles is heard as Auscultated. Patient also has a persistent cough

GASTROINTESTINAL Patient has a complete incisor, canine and premolars but she only have 6 molars, mouth appear healthy and moist, no abdominal
pain, no loss in appetite, has normal sound of bowel movement and can defecate without using any kind laxative.
 NEUROLOGICAL Sense Smelling and touching is functioning well, Vision is no longer 20/20, no sign of cataract, PERRLA, hearing is intact as
well. Patient is Alert and conscious around her surrounding

MUSCULOSKELETAL Deterioration of vertebral support and body weakness is noted due to aging but can walk, sit and eat without assistance.

Menarche starts on 15 years age and the patient is G8P7, Menopause at the age of 50 years old, no history of any cervical
REPRODUCTIVE diseases.

EXCRETORY The patient verbalized that she voids 3 to 6 times a day, and no burning is felt in every void and no foul odor is smelled.

NURSING ASSESSMENT II

Name: PATIENT X Age 59____ Sex F____

Admitting Chief Complaint DOB
Impression/Diagnosis Bronchial Asthma Acute Exacerbation.
Date/Time of Admission May 30, 2023 Inclusive Dates of Care _ _
Diet: No diet is recommended but eats vegetables, rice and fish Allergies None
Type of Operation (if any)

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

DAY 1 DAY 2

1.ACTIVITIES- REST The patient was usually doing a house The patient shows body weakness, The patient shows body weakness, The patient shows body weakness
hold chores and stroll around, and rest and tiredness. She spends most of and tiredness. She spends most of but can walk from bed to comfort
 a. Activities after luhor prayer for an hour and sleep the time in bed. And sleeps all the the time in bed. And sleeps all the room. She rests most of the time and
b. Rest every 9:30pm and wake up 4:00am time due to tiredness and Shortness time due to tiredness and shortness sleeps every 8:00pm to 4:00am.

c. Sleeping pattern of breathing. of breathing.

2.NUTRITIONAL- The patient has no diet restrictions. The patient loses her appetite, she The patient has no appetite, but she The patient has no diet restrictions.
METABOLIC She eats three times a day and drinks always depends on IVF most of the doesn’t have any restriction in food, She eats three times a day and
a. Typical intake (food, 5-7glasses of water a day. She was not time. Weight gradually loss and but she usually eats soft food such drinks 4 to 5 glasses of water a day.
fluid)
taking any vitamins but takes some received medication through IVTT, as porridge, weight is the same She received medication through
b. Diet OTC drugs like Paracetamol as except for his maintenance losartan when she was admitted, and she IVTT, except for his maintenance
c. Diet restrictions needed. The patient has a maintenance and the other prescribed received medication through IVTT, losartan and the other prescribed
d. Weight of losartan for her hypertension. Azithromycin received it through PO and nib Azithromycin received it through
e. Medications/supplement oral and she also received it through oral and she also received it through
food nebulizer. nebulizer.

3. ELIMINATION Frequent urination color is yellow. Patient voids 3 a day and urination Patient voids 3 a day and urination Patient voids 3 a day and urination
a. Urine (frequency, color, Usually voids 3 to 6 times a day and color are yellow. Since her color are yellow. Since her color are yellow. Since her

transparency) defecates once every day characterized admission no burn felt or foul smell. admission no burn felt or foul smell. admission no burn felt or foul smell.
with a stool color of brown and intact Also reported that she defecates Also reported that she defecates Also reported that she defecates
stool form. No burning felt or foul every other day since her admission. every other day since her admission. every other day since her admission.
smell
b. Bowel (frequency, color,
consistency)

4. EGO INTEGRITY Patient is content in her life, whenever The patient shows tiredness and The patient shows tiredness and Patient’s believe that only Allah
a. Perception of self she feels lonely or have a problem that body weakness. She just seeking body weakness. She just seeking knows when she will get back at

b. Coping Mechanism
c. Support System
d. Mood/Affect
she faced, she is praying much more Allah’s mercy and guidance. Her Allah’s mercy and guidance. Her home and she prays a lot to ease the
and ask Allah’s guidance. Her family family supports her and is always by family supports her and is always pain she feel, her family is the
support her especially her daughters her side, especially his by her side, especially his primary support and she doesn’t get
and sons, she is not moody and doesn’t granddaughter who always stays by granddaughter who always stays by irritated in hospital instead she was
 get angry or irritated in small things her side ever since admission. her side ever since admission. thankful that the doctor and nurses
instead she smiles a lot. helping her.

5. NEURO-SENSORY
a. Mental state
b. Condition of five senses:
(sight, hearing, smell,
taste,
touch)
Patient has no history of any mental
illness and disorders. The patient is
conscious, coherent, and oriented to
time, date, place, and persons.
The patient’s five senses are intact.
Patient has no history of any mental
illness and disorders. The patient is
conscious, coherent, and oriented to
time, date, place, and persons.
Patient's sense of light, smell,
hearing, and touch function well.
Patient has no history of any mental
illness and disorders. The patient is
conscious, coherent, and oriented to
time, date, place, and persons.
Patient's sense of light, smell,
hearing, and touch function well.
Patient has no history of any mental
illness and disorders. The patient is
conscious, coherent, and oriented to
time, date, place, and persons.
The patient’s five senses are intact.

6. OXYGENATION Vital signs are not taken and no history T=36.2°C T=36.4°C T=35.6°C
a. Vital signs of respiratory problem.
P= 90 bpm P= 65 bpm P= 92 bpm
Temperature
R=44 cpm R= 23 cpm R= 22 cpm
Respiratory rate
BP= 140/90 mmHg BP= 130/90 mmHg BP= 130/80 mmHg
Heart rate
Blood pressure
b. Lung sounds Patient’s experienced shortness of Patient’s experienced shortness of Patient’s experienced shortness of
c. History of Respiratory breathing, Wheezing and Crackles breathing, Wheezing and Crackles breathing, Wheezing and Crackles
Problems are noted. Patient is suspect of are noted. are noted
COVID.

7. PAIN-COMFORT The patient feels shortness of Patient having trouble breathing The Patient still feel shortness of The Patient still feel shortness of
a. Pain (location, onset, breathing, fever, and productive cough radiating at the back and pain feels breathing but the pain is no longer breathing but the pain is no longer

character, intensity, 3 days prior to admission. No comfort like someone’s choking her that felt like before, with pain score of felt like before, with pain score of
duration, reported. makes her difficult to breath
 associated symptoms, properly. 6/10. 4/10.
aggravation)

The patient received oxygen therapy The patient was nebulized. The patient was nebulized.
b. Comfort
measures/Alleviation stat to alleviate the pain and make
her breath properly.

c. Medications

8. HYGIENE AND Patient takes a bath thrice a week. She Patient can't take bath as usual to Patient can't take bath as usual to Patient can't take bath but received
ACTIVITIES usually does household chores and routine process. The patient can't do routine process. The patient can't do tepid sponge bath. She can sit, eat,
OF DAILY LIVING strolls around the neighborhood. usual ADLs and shows tiredness usual ADLs and shows tiredness and walk without assistance.
and body weakness. and body weakness.

9. SEXUALITY Menarche starts on 15 years age and Menarche starts on 15 years age and Menarche starts on 15 years age and Menarche starts on 15 years age and
the patient is G8P7, Menopause at the the patient is G8P7, Menopause at the patient is G8P7, Menopause at the patient is G8P7, Menopause at

a. female (menarche, age of 50 years old, patient is widow the age of 50 years old, patient is the age of 50 years old, patient is the age of 50 years old, patient is
menstrual and no history of cervical disease. widow and no history of cervical widow and no history of cervical widow and no history of cervical
cycle, civil status, number disease. disease. disease.
of
children, reproductive
status)
b. male (circumcision, civil
status, number of children)
 SUMMARY OF INTRAVENOUS FLUID

DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED
 05-30-2023 – 9:18pm PNSS 1L 80cc/hr 8hrs 05-31-2023 – 5:18am

05-31-2023 – 5:18am PNSS 1L 80cc/hr 8hrs 06-01-2023 – 1:18am

06- 01-2023 – 1:18am PNSS 1L 80cc/hr 8hrs 06-01-2023 – 9:18pm

8hrs
06-01-2023 – 9:18pm PNSS 1L 80cc/hr 06-02-2023 – 5:18am

DRUG STUDY

BRAND NAME Prescribed and Mechanism

GENERIC NAME Recommended dosage, Of
CLASSIFICATION frequency, route of Action Indication Contraindication Adverse Nursing Responsibilities
administration Reaction
BRAND NAME Prescribed: 1 tab + 1/2 Blocks the Losartan is used to  Allergy to ARBs - CNS:  Follow the rights of
100mg vasoconstrictor and treat high blood prevent severe dizziness, medication before
Cozaar aldosterone-secreting hypersensitivity fatigue, administration
pressure
Frequency: every 8 hours effects of angiotensin reactions headache,
GENERIC NAME (hypertension). It is  Assess for the mentioned
Route: OD II at various receptor also used to lower insomnia,
LOSARTAN sites, including  Renal and hepatic weakness contraindications to this drug
the risk of strokes in impairment - can to prevent potential adverse
vascular smooth
CLASSIFICATION patients with high alter metabolism CV: chest pain, effects
muscle and the
blood pressure. and excretion of edema,
Pharmacotherapeutic: adrenal glands,  Obtain baseline status for
drugs which can hypotension
increase the risk weight, vital signs, overall skin
Angiotensin II receptor
of toxicity EENT: nasal condition and laboratory tests
antagonist
congestion like renal and hepatic function
Clinical: Antihypertensive test and serum electrolyte to
ENDO:hypogl assess patient’s response to
ycemia, weight therapy
gain
 Monitor patient’s BP closely to
GI: diarrhea, evaluate effectiveness of
abdominal therapy
pain, nausea
 Assess and monitor fluids and
GU: impaired electrolytes level
renal function
 Instruct patient to notify
MS: back pain, physician if there are signs of
myalgia allergic reaction occurs such as
difficulty breathing, swelling
in the face, lips, tongue or
throat

BRAND NAME Prescribed and Mechanism

GENERIC NAME Recommended dosage, Of
CLASSIFICATION frequency, route of Action Indication Contraindication Adverse Nursing Responsibilities
administration Reaction
BRAND NAME Prescribed: 1 dose The short term effects Used for the control Hypersensitivity to CNS:  Follow the rights of
of corticosteroids are of asthma in persons drug or for relief of headache, medication before
Pulmicort Turbuhaler Frequency: Every 12 decreased acute asthma or dizziness, administration
requiring continuous,
hours vasodilation and bronchospasm, lethargy,
GENERIC NAME prolonged treatment.  Monitor respiratory status and
Route: Inhalation permeability of fatigue,
Budesonide neb capillaries, as well as Use cautiously with paresthesias, lung sounds
decreased leukocyte TB and systemic nervousness
CLASSIFICATION infections.  Assess pulmonary function
migration to sites of tests periodically during and
inflammation. Dermatologic:
Corticosteroid after a transfer from systemic
Rash, edema,
pruritus, to inhalation corticosteroids.
alopecia  Monitor signs and symptoms
GI: Nausea, of hypersensitivity reactions
dry mouth periodically during therapy

Local: nasal  Advise patient to take

irritation, medication as directed.
fungal  Advise patient not to
infection discontinue medication
Respiratory: without consulting health care
Epistaxis, professional.
rebound  Advise patient to stop using
congestion medication and notify health
Other: chest care professional immediately
pain, acne, if signs and symptoms of
moon face, hypersensitivity reactions
bruising and occur.
back pain

BRAND NAME Prescribed and Mechanism

GENERIC NAME Recommended dosage, Of
CLASSIFICATION frequency, route of Action Indication Contraindication Adverse Nursing Responsibilities
administration Reaction
BRAND NAME Prescribed: 3 doses Ipratropium is a Treatment of chronic Hypersensitivity to Hypersensitivit  Follow the rights of
nonselective obstructive salbutamol, y reactions, medication before
Combivent Respimat, Frequency: Every 5 mins competitive pulmonary disease ipratroprium or paradoxical administration.
DuoNed then q8 antimuscarinic agent. (COPD) in those fenoterol, atroprine or bronchospasm,  Monitor therapeutic
GENERIC NAME Route: Inhalation It causes patients who are its derivatives. ocular effectiveness.
bronchodilation by currently on a regular complications,  Monitor for: S&S of fine
Salbutamol + Ipratropium blocking the action of bronchodilator who serious
tremor in fingers, which may
acetylcholine-induced continue to have hypokalemia,
CLASSIFICATION interfere with precision
stimulation of guanyl bronchospasms and gastrointestinal
cyclase, hence require a second mobility handwork; CNS stimulation,
Therapeutic Classification:
reducing formation of bronchodilator. disturbances, particularly in children 2–6 y,
Bronchodilator
cyclic guanosine ECG changes, tachycardia, GI symptoms.
monophosphate urinary Report promptly to physician.
(cGMP) at retention.  Lab tests: Periodic ABGs,
Pharmacologic
Classification: parasympathetic site. pulmonary functions, and
Cardiac
Anticholinergic Agent; pulse oximetry.
Salbutamol activates Disorders:
Beta2-Adrenergic Agonist  Instruct patient on proper
adenyl cyclase, the palpitations,
inhalation technique according
enzyme that tachycardia
to product directions
stimulates the
production of cyclic Eye disorders:
 Advise the patient that using
adenosine-3’, 5’- Accommodatio
the ‘blow by’ technique is not
monophosphate n disorders
recommended
(cAMP). Increased Gastrointestina
cAMP leads to l disorders: dry
activation of protien mouth, nausea
kinase A, which
inhibits Nervous
phosphorylation of system
myosin and lowers disorders:
intracellular ionic Ca headache
concentrations,
resulting in smooth
muscle relaxation.

BRAND NAME Prescribed and Mechanism

GENERIC NAME Recommended dosage, Of
CLASSIFICATION frequency, route of Action Indication Contraindication Adverse Nursing Responsibilities
administration Reaction
BRAND NAME Prescribed: 600mg 1 Decreases viscosity Treatment of Hypersensitivity to CNS:  Follow the rights of
sachet+1/2 glass of water of respiratory tract respiratory affections acetylcysteine; patients dizziness, medication before
Acetylcysteine secretions and characterized by at risk of gastric drowsiness administration
Frequency: BID Q12H promote their thick and viscous hemorrhage.
GENERIC NAME GI: nausea,  Instruct patient to follow
Route: oral removal by breaking hypersecretions;
N-acetylcysteine disulfide bonds. In acute and chronic vomiting, directions exactly
acetaminophen bronchitis and its stomatitis,
CLASSIFICATION hepatotoxicity  Warn the patient that the drug
overdose, it protects exacerbation, may have a foul taste or foul
Mucolytic the liver from injury pulmonary Respiratory: smell that may be distressing
by restoring emphysema, bronchospasms
glutathione levels or mucoviscidosis and , rhinorrhea,  Assess patient’s history of
by acting as alternate bronchiectasis. burning underlying condition, cough:
substrate for Antidote in sensation in type, frequency, and character
acetaminophen poisoning caused by upper  Assess respiratory function
metabolism. paracetamol, carbon respiratory (lung sound, dyspnea) and
tetrachloride, arsenic, passages, color, amount and consistency
metallic mercury epistaxis of secretions before and
inhalation, yellow
immediately following
phosphorus and for
treatment to determine
cyclophosphamide
effectiveness of therapy
induced hemorrhagic
cystitis  For maximum effect, instruct
patient to cough to clear the
airway
 Explain the importance of
using drug as directed

BRAND NAME Prescribed and Mechanism

GENERIC NAME Recommended dosage, Of
CLASSIFICATION frequency, route of Action Indication Contraindication Adverse Nursing Responsibilities
administration Reaction
BRAND NAME Prescribed: 4.5gm Inhibits the cell wall Moderate to sever History of allergic CNS: fever  Follow the rights of
during bacterial pneumonia caused by reactions to any of the headache, medication before
Piptaz Frequency: every 8 hours multiplication piperacilin-resistant, penicillins, insomnia, administration
GENERIC NAME Route: IV beta-lactmase- cephalosporins or B- seizures,
producing strains of lactamase inhibitors agitation,  Obtain history of
Piperacillin + tazobactam S, aureus or by anxiety, hypersensitivity to penicillins,
piperacillin dizziness, pain cephalosporins or other drugs
tazobactam prior to administration
susceptible CV:
CLASSIFICATION  Lab tests: C&S prior to first
arrhythmia,
chest pain, dose of the drug; start drug
Antiinfective; antibiotic
edema, pending results
hypertension,  Monitor hematologic status
tachycardia with prolonged therapy
EENT: rhinitis  Monitor patient carefully
GI: diarrhea, during the first 30 mins after
constipation, initiation of the infusions for
nausea, signs of hypersensitivity.
abdominal  Monitor patient for diarrhea
pain, stool and initiate therapeutic
changes, measures as needed
vomiting
 Monitor patient for
Respiratory: superinfection
dyspnea
 Tell patient to report adverse
Skin: Rash and reactions or signs of
pruritus superinfections promptly
 Instruct patient to report
discomfort at IV insertion site

BRAND NAME Prescribed and Mechanism

GENERIC NAME Recommended dosage, Of
CLASSIFICATION frequency, route of Action Indication Contraindication Adverse Nursing Responsibilities
administration Reaction
BRAND NAME Dosage: 1 g Inhibits synthesis of Serious UTI and Contraindicated in Headache,  Follow the rights of
bacterial cell wall, lower respiratory patients hypersensitive dizziness, medication before
Ceptaz Route:IV causing cell death tract infection; skin; to drugs or other phlebitis, administration
GENERIC NAME Frequency: every 8 hours gynecologic; CNS cephalosporins. nausea and
infection vomiting,  Assess for liver and renal
Ceftazidime diarrhea, dysfunction
abdominal  Obtain specimen for culture
CLASSIFICATION
cramps, rushes and sensitivity tests before
Antiinfectives and pain giving first dose.
 Ask patient if he or she has
allergies to penicillin and
cephalospirin
 For IM administration, inspect
deep into a large muscle
 Monitor CBC, BMP and renal
function periodically
 Monitor I&Os. Observe for
daily pattern of bowel activity,
stool consistency.
 Instruct patient to report any
signs of hypersensitivity
reactions

BRAND NAME Prescribed and Mechanism

GENERIC NAME Recommended dosage, Of
CLASSIFICATION frequency, route of Action Indication Contraindication Adverse Nursing Responsibilities
administration Reaction
BRAND NAME 30cc Osmotic effect of Relief of constipation  Contraindicated to  GI:  Follow the rights of
organic acids causes patients on low- flatulence; medication before
Cephulac laxative action, which galactose diet belching; administration
GENERIC NAME moves water from abdominal
plasma to intestines,  Contraindicated in disturbanc  Assess patient for abdominal
Lactulose softening stools and patients with GI es; pain distention, presence of bowel
stimulates peristalsis obstruction or and sounds, and normal pattern of
CLASSIFICATION perforation, toxic bowel function
by pressure from distention;
water content to colitis, diarrhea,
megacolon,  Assess color, consistency and
stool. hypernatr amount of stool produced
nausea and emia
vomiting or acute  Promote fluid intake during
surgical abdomen  Bulking drug therapy for constipation
forming
laxatives  Monitor body weight of the
may cause patient
intestinal
 Monitor for signs of
obstructio
hypotension, tachcardia,
n,
andioedema, hyperkalemia and
impaction
hypernatremia
or
esophagea  Encourage patient to use other
l forms of bowel regulation,
obstructio such as increasing bulk in diet,
ns increasing fluid intake and
increasing mobility
 Caution patients that this
medication may cause
belching, flatulence or
abdominal cramping
 Tell patient to notify the
physician if diarrhea persists
more than 24-48 hours.
Diarrhea is a sign if over-
dosage.
BRAND NAME Prescribed and Mechanism
GENERIC NAME Recommended dosage, Of
CLASSIFICATION frequency, route of Action Indication Contraindication Adverse Nursing Responsibilities
administration Reaction
BRAND NAME Dosage: 250/10 mcg Selectively activates Maintenance Contraindicated to CNS: tremor,  Follow the rights of
MDI 2 puffs BID q12 beta 2 adrenergic treatment for COPD patients with headache medication before
Seretide receptors, which including chronic hypersensitivity to administration
Route: inhalation results in bronchitis and drug or any of its CV: subjective
GENERIC NAME palpitations  Assess patient’s respiratory
Frequency: BID bronchodilation and emphysema components.
Salmeterol + Fluticasone blocks the release of and cardiac condition before starting
allergic mediators Caution to patients arrhythmias therapy
CLASSIFICATION who are usually
from the mast cells in MS: arthralgia  Be alert for adverse reactions
the respiratory tract. responsive to
Adrenergics and drug reactions
sympathomimetics and Others:
patients with coronary hypersensitivit  Advise patient to notify health
artery insufficiency y reactions, care professional if fever,
oropharyngeal chills, change in sputum color,
irritation, increased cough or increased
hoarseness, in breathing problems occur
oral
candidiasis,  Instruct patient to use dust-
paradoxical proof covers on the mattress
bronchospasm. and pillows.

ANATOMY AND PHYSIOLOGY

Larynx - The primary function of the larynx in humans and other

vertebrates is to protect the lower respiratory tract from aspirating
food into the trachea while breathing. It also contains the vocal cords
PATHOPHYSIOLOGY
 MEDICAL MANAGEMENT
Ideal Medical Management

 The treatment of choice for Bronchial Asthma Acute Exacerbation is to administer the following drugs:
  Bronchodilators (beta-2 agonists and anticholinergics)
 Epinephrine
 Ipratropium
 Systemic Corticosteroids
 Antibiotics
 Nebulizer treatment relaxes the breathing muscles and permits air to flow more easily in and out of the lungs. It also helps to loosen mucous in the lungs. Both of these benefits
of nebulizer treatment help to decrease and prevent wheezing, shortness of breath, coughing, and tightness in the chest.

 Hospitalization generally is required if patients have not returned to their baseline within 4 hours of aggressive emergency department treatment. Criteria for hospitalization
vary, but definite indications are:
 Failure to improve
 Worsening fatigue
 Relapse after repeated beta-2 agonist therapy
 Significant decrease in PaO2 (to < 50 mm Hg)
 Significant increase in PaCO2 (to > 40 mm Hg)
 A significant increase in PaCO2 indicates progression to respiratory failure.
 Noninvasive positive pressure ventilation (NIPPV) may be needed in patients whose condition continues to deteriorate despite aggressive treatment, to alleviate the work
of breathing.
 Endotracheal intubation and mechanical ventilation allow the provision of sedation to further alleviate the work of breathing, but the routine use of neuromuscular
blocking agents should be avoided because of possible interactions with corticosteroids that can cause prolonged neuromuscular weakness.
 Bronchial thermoplasty is a minimally invasive treatment for severe asthma. It's a way to open airways. The procedure uses gentle heat to shrink the smooth muscles in lungs -- the
ones that tighten during asthma attacks and make it hard to breathe.

Actual Management

Actual medical management for the patient started on June 6, 2023

 Monitor vital signs q4h.

 Monitor for abnormal events.
 Continue IVF and medications.
 Provide safety and comfort measures.
 Prescribed medications are:

➢ Budesonide neb q12hr

➢ Salbutamol + Ipratropium neb q8hr
➢ N-Acetylcysteine 600 mg BID
➢ Hydrocortisone 200mg IV q8hr
➢ Azithromycin 500 mg 1 tab OD
➢ Losartan 1 tab OD
Administered Plain NSS IVF 1L, 80 cc/hr.

NURSING MANAGEMENT

IDEAL ACTUAL
 Obtain health history
 Assess the vital signs every 2 to 4 hours.
 Physical examination
 Prescribed medications were administered to the patient in accordance to the
 Administration of IV fluid and medications (Oral, intramuscular, or intravenous
doctor’s instruction. These include:
antibiotics)
 Teach the patient how to cough, deep breathe, and use an incentive spirometer - Losartan 100mg 1tab OD
- Lactulose 30cc
 Encourage mobilization of secretion through ambulation, coughing, and deep - Erythromycin 500mg 1tab OD
breathing. - Budesonide neb 1doss q12
- Salbutamol + Ipratropium q8
 Ensure adequate fluid intake to liquefy secretions and prevent dehydration caused - N-acetylcysteine 600mg BID q12
by fever and tachypnea.
 Assist the patient to assume a position of comfort elevate the head of the bed, and
 Instruct the patient to complete the full course of prescribed antibiotics and have the patient lean on an overbed table or sit on the edge of the bed
explain the effect of meals on drug absorption.  Demonstrate effective coughing and deep-breathing exercise

 Encourage rest, avoidance of bronchial irritant, and a good diet to facilitate  Relive pain by encouraging bed rest and relaxation.
recovery.
 Intake and Output (I&O) was also monitored
 Encourage deep slow or pursed lip breathing as individually tolerated or  Encouraged to drink plenty of water
indicated.  Patient was advised to increase fluid intake and to drink clean, drinking water.
 In every session of care, student nurse on duty communicated with the patient in a
calming voice and answers all questions asked by the patient and S.O in a delicate
way.
 Patient is kept monitored for any unusualities.
Continuity of Care is ensured in every endorsement.

NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective breathing pattern After 8 hours of providing Independent After 8 hours of providing
“Margn a kapakaginawa related to alteration of normal nursing interventions, the  Monitor respiratory status  Monitor closely for nursing interventions, the
akn” as verbalized by the O2:CO2 ratio secondary to patient will be able to: changes in respiratory patient was able to:
patient asthma as evidenced by status to intervene quickly
shortness of breath and Short-term  Verbalize understanding
accessory muscle use  Verbalize understanding of  Help the patient identify  Identifying triggers helps of potential triggers of
potential triggers of asthma their triggers prevent asthma asthma exacerbations
Objective: exacerbations exacerbations.  Display an effective
- Shortness of breath breathing pattern
- Wheezing Long terms  Encourage slower/deeper  To assist client in taking evidenced by a
- Nasal flaring  Display an effective respirations control of the situation respiratory rate and
- Accessory muscle use breathing pattern evidenced rhythm within normal
by a respiratory rate and  Provide/encourage use of  To facilitate deeper limits.
With initial vital signs: rhythm within normal adjuncts, such as respiratory effort  Initiate needed lifestyle
T: 36.4 °C limits. incentive spirometer or changes
PR: 67bpm peak flow meter
 Initiate needed lifestyle
RR: 24cpm
changes
BP: 130/90 Dependent  Bronchodilators help relax
O2 Sat: 95%  Administer the muscles around the
bronchodilators and airways. Inhaled
corticosteroids as ordered corticosteroids reduce
inflammation and mucus
Inter-dependent
 Refer for general exercise  To maximize client’s level
program as indicated of functioning
 NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Activity intolerance may be After 8 hours of providing Independent After 8 hours of providing
“Kyalbod ako dukawan related to imbalance nursing interventions, the  Ask client/SO about usual  To identify potential nursing interventions, the
igira”, as verbalized by the between oxygen supply and patient will be able to: level of energy problems and/or patient, were able to:
patient. demand secondary to asthma perception of client’s
as evidenced by fatigue and Short-term energy and ability to  Verbalize understanding
exertional dyspnea  Identify negative factors perform needed or of potential loss of ability
Objective: affecting activity tolerance desired activities in relation to existing
- Dyspnea on exertion and eliminate or reduce their  Identify factors that could condition
- Fatigue effects when possible block/affect the desired  To have baseline data  Participate willingly in
- Inability to play, eat, or level of activity necessary/desired
complete tasks Long terms activities
 Use identified techniques to  Monitor for emotional  Demonstrate a decrease
With initial vital signs: enhance activity tolerance factors affecting activity  Asthma flare-ups can be in physiologic signs of
T: 36.4  Participate willingly in frightening intolerance
PR: 67bpm necessary/desired activities  Encourage progressive
RR: 24cpm  Demonstrate a decrease in activity  The patient should limit
BP: 130/90 mmHg physiologic signs of their sedentary time and
O2 Sat: 95% intolerance alternate between rest and
activity to improve their
tolerance
 Discuss and plan with
client & SO relationship  Understanding this can
between illness or help with acceptance of
debilitating conditions limitations or reveal
and ability to perform opportunity of changes.
desired activities

Dependent
 Give medication, as  To minimize symptoms
ordered. and provide well-being

Inter-dependent  To develop individually

 Provide referral to other appropriate therapeutic
disciplines as indicated regimen
 CUES Dx Objectives Interventions Rationale Evaluation

Subjective Ineffective Short Term Goal: Take the vital signs of the For baseline date After 40 minutes of nursing
“Di ako pakaginawa Breathing Patter After 40 minutes of patient intervention, the patient was able to
piya-piya related to nursing intervention, To ensure the comfort of the patient perform deep breathing exercise
watakulay”, as inflammation and the patient will be Perform bed care
verbalized by the swelling to the able to perform deep
patient lungs as evidenced breathing exercise To ensure that supply of oxygen is
by dyspnea Check the placement of the being properly breathe by the patient
“I can’t properly Long Term Goal: cannula and state of oxygen
breathe my dear After 8 hours of flow rate
child”, as verbalized nursing intervention, Respiratory rate is a fundamental vital After 8 hours of nursing
by the patient the patient will be Note the rate and depth of the sign that sensitive to different intervention, the patient was be able
able to display small respiration for 1 minute pathological conditions to display small improvements that
Objective: improvements that showed an effective breathing
The vital signs were will show an Auscultate the lung fields. Wheezing is a common finding with pattern as evidenced by a
taken as follows: effective breathing asthma as the airways are constricted respiratory rate and rhythm within
T: 37.3 pattern as evidenced from inflammation. normal limits
P: 70 bpm by a respiratory rate Monitor ABG
RR: 28 cpm and rhythm within Respiratory acidosis occurs from
O2: 90% normal limits severe asthma and can develop into,
BP: 130/70mmHg respiratory failure prolonged.
-Application of O2 Avoid overfeeding
therapy noted Abdominal distention can interfere
-Dyspnea noted with breathing
-Facial Grimace Instruct on peak flow meters
noted Peak flow meters can be used daily to
-Discomfort noted monitor how well air is moving in and
-BM+ Teach and encourage the patient out of the lungs
-U/O= 500ml to do deep breathing and
relaxation technique Promotes more effective breathing and
airway management

Administer bronchodilator and

corticosteroid as prescribed
Bronchodilator make breathing easier
 by relaxing the muscles in the lungs
and widening the airway. Inhaled
corticosteroid reduced inflammation
and mucus

Encourage the patient to To ensure lung expansion and comfort

maintain comfortable position

Educate and provide relevant To ensure the understanding of the

information to the patient and patient regarding her condition
SO regarding the condition of
the patient including the drugs
involved
 NURSING CARE PLAN

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUAT

DIAGNOSIS ION
Subjective: Chest pain relate to After 8 hours of providing Take the vital signs of the patient For baseline date After 30 minutes of
“Masakit so rareb akn sa swollen lungs as nursing interventions, the nursing
wata”, as verbalized by the evidenced by patient will be able to: intervention, the
patient grimace face To ensure the comfort of the patient patient was able to
Short Term Goal: Perform bed care verbalized her
“I’m having a chest  After 30 minutes of understanding
patient”, as verbalized by nursing intervention, the regarding her
the patient patient will be able to conditions
show and verbalize her Check the placement of the cannula and To ensure that supply of oxygen is
Objectives: understanding regarding state of oxygen flow rate being properly breathe by the patient
The vital signs taken as her conditions  After 8 hours of
follows nursing
T: 36.9 Long-term goal: Ask the patient to verbalize the To know the characteristic of the pain intervention,
P: 78  After 8 hours of nursing characteristic and let her rate the level of of the patient and also the level of pain. the patient pain
R: 18 intervention, the patient her pain in which 10 is the highest and 1 Thus, we will be able to know the was subside
BP: 110/90 pain will subside is the lowest; 10=severe pain; proper management that will be done
O2: 99 1=tolerable

-Application of O2 therapy Determine the past illness that might To determine the other factors that
noted contributed in her current condition contributes to her condition thus,
-Dyspnea noted accurate nursing intervention will be
-Facial Grimace noted executed
-Discomfort noted
-BM+ Note the rate and depth of the respiration Respiratory rate is a fundamental vital
-U/O= 500ml for 1 minute sign that sensitive to different
pathological conditions
Auscultate the lung fields. Wheezing is a common finding with
asthma as the airways are constricted
from inflammation

Monitory ABG ABGs reflect conditions that influence

the respiratory, circulatory, and
metabolic systems.
 Note the presence and characteristic of Cough that is persistent and constant
cough can interfere with breathin

Avoid overfeeding Abdominal distention can interfere

with breathing which may trigger chest
pain

Teach and encourage the patient to do Promotes more effective breathing and
deep breathing and relaxation technique airway management

Administer bronchodilator and Bronchodilator make breathing easier

corticosteroid as prescribed by relaxing the muscles in the lungs
and widening the airway

Administer analgesic as prescribed Inhaled corticosteroid reduced

inflammation and mucus

 To alleviate chest pain or make it

tolerable

DISCHARGE PLAN
NAME: Patient X DATE OF DISCHARGE: June 2023
CONDITION UPON DISCHARGE Nature: Home per request ( ) Discharge against medical advice ( )

 Give adequate instruction about the importance of following medication and dietary regimens.
Medications for Maintenance:
1. MEDICATIONS 1.Salbutamol 4 mg, TID, Inhalation
2.Prednisone 40 mg, OD, PO
3.Ciclesonide 160 mcg, BID, PO
4. Salmeterol + Fluticasone 250/10 mcg MDI 2 puffs BID q12

 Exercise as your provider recommends. Some people have coughing or wheezing only during or after
physical activity. This is called exercise-induced asthma. Even though exercise may trigger an asthma
2. EXERCISE attack, exercise is still important. Some ways to prevent an asthma attack during exercise include:
 Start with a long, slow warm-up to the activity.
 It may be necessary to use a rescue inhaler before you start exercise.
 Always have a rescue inhaler with you during exercise.
 Promote rest and pursed lip breathing exercise.
 Do active range of motion with slow progressions infrequency and provide assistance if needed.
 Mediterranean diet, one based on eating plenty of healthy fats (like olive oil), fish, whole grains, and
fruit, fits the bill
3. DIET  Stay hydrated. Staying hydrated with plenty of fluids such as water, juice, and tea can help alleviate
asthma symptoms.
 Avoid sulfites. Sulfites can trigger asthma symptoms in some people. Used as a preservative, sulfites can
be found in wine, dried fruits, pickles, fresh and frozen shrimp, and some other foods.
 Teach patient and family about asthma (chronic inflammatory).
 Teach patient and family about the purpose and action of medications.
4. HEALTH TEACHING  Teach the patient and family about the triggers to avoid and how to do so.
 Teach the patient and family about proper inhalation technique.
 Instruct patient and family about peak-flow monitoring.
5. SCHEDULE FOR THE NEXT VISIT Follow-up check-up:
June 13, 2023, at APMC