SPECIFIC PATHOPHYSIOLOGY

NON- MODIFIABLE MODIFIABLE FACTORS

FACTORS
PRECIPITATING FACTORS
 Chronic alcoholism at age 16
 Age (1992-2018)
 Low socioeconomic
 Family history  Cigarette Smoking
 Deficient knowledge
HPN: Mother, Father  at age 16 (1992-2018) 6-7 PACK
 Stress
CANCER: Auntie (Leukemia) YEARS
 Multiple Partners
 Other sexually transmitted  NSAIDS (Celecoxib)
infection (HPV)

Damaged or mutation to cell’s DNA

Imbalances between oncogene and

suppressor gene

Estrogen promote growth to

abnormally dividing cell

Increases cell cycle causing more

cellular proliferation

Dysplasia

Abnormal cell production overtime

Healthy cells in the cervix developed

changes ( mutation) in their DNA

Anemia
NSG. DIAGNOSIS
Ineffective tissue perfusion
r/t decreased hemoglobin
Further compression of
bloodvessels and tissues in the
cervix
Ruptured small surrounding
capilliaries
Excessive vaginal bleeding
NSG. DIAGNOSIS
Risk for deficient fluid volume r/t
excessive vaginal bleeding
Accumulating abnormal cells form a
mass (tumor)
Cancer cells invade nearby tissue
Invasion to column-shaped glandular
cells that line the cervical canal
Adenocarcinoma
STAGE 4 Extended beyond the true
pelvis or involment of the bladder or
rectral mucosa( biopsy- proven)
Inflammation of the pelvic area
involving bladder
Cancer cell and surrounding tissues
compresses the urethra
Hydronephoris
NSG. DIAGNOSIS
Acute pain r/t pressure from swollen
kidney
Exposure to bacteria, dead
Ischemic pain
cells, discharge
Foul smelling discharge Pelvic pain
NSG. DIAGNOSIS NSG. DIAGNOSIS
Risk for infection r/t presence of Acute pain r/t cervical mass
pathogenic microorganisms
NURSING INTERVENTION NURSING
INTERVENTION
 Establish rapport
 Monitor patient’s vital  Establish rapport
signs  Monitor patient's vital
 Assess color of discharge signs
note abnormalities  Assess level of pain from
 Promote rest and cessation 1 to 10 (OLDCART)
of intercourse  Allow patient to verbalize
 Promote teaching about feelings
vaginal care.
 DIAGNOSTIC EXAM
 CBC
March 10, 2023
Hemoglobin (80g/L)
Hematoctrit (0.24)
 Physical Assessment:
Pallor in color
NSG. MANAGEMENT
 Monitor Vital Sign
 Establish rapport
 Provide supplemental
oxygen therapy as
needed
 Educate energy-
conservation
techniques.
 Assist the client in
developing a schedule
for daily activity and
rest.
PHARMACOLOGIC
MANAGEMENT
March 10, 2023
 BT 2u PRBC
NSG. CONSIDERATIONS
Blood Transfusion
 Follow 14 rights
 Monitor VS
 Check the patient's blood
type and cross-match it
with the blood product to
ensure compatibility.
 Monitor for any signs of
adverse reactions, such as
fever, chills, itching, rash,
or difficulty breathing
 Promote safety
NURSING INTERVENTION DIAGNOSTIC EXAM NSG. MANAGEMENT NURSING
 Establish rapport March 11,2023 (IJ CATHETERIZATION INTERVENTION
 Monitor patient’s vital signs,  UTZ INSERTION)
especially BP and HR. Left kidney size: globularly  Provide comfort
 Ask patient to keep count on Before the procedure:
enlarged (11.7 x 8.5 x 6.1 cm PT:  Monitor Vital signs  Provide quiet
used pads 1.6cm  Explain the procedure to the patient environment
 Assess bleeding
Hydronephrosis: Severe and obtain informed consent.  Instruct the client to
 Promote rest and cessation of
intercource March 11,2023  Ensure that the patient has an empty avoid sexual intercourse
 Allow patient to verbalize  Blood test bladder before the procedure.  Administer med as
feelings Creatinine: 1971.9 ↑umol/L  Position the patient in a supine ordered
position with the head turned
 Asses for signs of DHN.
slightly away from the side of the IJ
catheter insertion.
NSG. MANAGEMENT PHARMACOLOGIC
 Monitor VS  Use sterile technique throughout the
MANAGEMENT
 Establish rapport procedure
March 11, 2023
 Assess the patient’s I&O and fuid  Use ultrasound guidance
DIAGNOSTIC EXAM  Tramadol 50mg PRN
balance  Watch for signs of complications
March 10, 2023  Paracetamol 500mg TID Q6
 Apply a sterile dressing to the
 Encourage the patient to rest and PRN for pain
 CBC insertion site once the catheter is in
use comfort measures
Hemoglobin (80g/L↓)  Monitor patient for sign of place.
Hematoctrit (0.24↓)  Document the procedure
infection or obstruction such as
 Physical Assessment: Pallor fever, chills and pain, such as heat After the procedure: NSG. CONSIDERATIONS
in color  Monitor the patient's vital signs,
and cold therapy, positioning and
March 10, 2023 relaxation techniques  Assess the patient's pain level and Opioid Analgesic ( Tramadol)
 PT (439 normal) administer pain medication as  Follow 14 rights
March 11, 2021 ordered.
 Monitor VS
 PT (249 normal) PHARMACOLOGIC  Observe the dressing for any signs  Inform the client that drug
March 13, 2023 of drainage or wetness.
MANAGEMENT can cause N/V and dizziness
 Ensure the sterile dressing remains
 PT (145↓) March 10, 2023  Advised the patient to avoid
intact and dry. alcohol while taking the
 Omeprazole 40mg IV
 Change the dressing according medication
 Paracetamol 500mg TID PRN S/P
 Encourage the patient to move and  Promote safety measures
Insertion of IJ Catheter
ambulate Be careful not to dislodge Analgesic (Paracetamol)
March 11, 2023 the catheter or cause trauma to the
 Hemodialysis  Follow 14 rights
insertion site.  Monitor VS
PHARMACOLOGIC  Flush the catheter according to  Assess for allergy
MANAGEMENT facility policy to maintain patency.  Promote safety measures
March 11, 2023 SURGICAL MANAGEMENT  Encourage the patient to drink
 Tranexamic acid 500mg IV fluids and eat a balanced diet
 Insertion of IJ Catheter (March
Q6
11, 2023)
NSG. CONSIDERATIONS
Antifibrinolytics (Tranexamic
Acid)
 Follow 14 rights
 Monitor VS
 Monitor for signs of clotting
 Promote safety measures
 Cancer cell continuous to penetrate to
cervical tissue

Decreased blood flow in DIAGNOSTIC EXAM

Obstructive uropathy Affects surrounding blood vessles to  Blood test
the kidney
X`x`x` further grow March 11,2023
Creatinine: 1971.9 ↑umol/L
BUN: 48.50 ↑mmol/L
NSG. DIAGNOSIS Ionized Calcium 1.10↓mmo/L
Decreased GFR Cancer cells travel to the adjacent Phosphorus 3.67↑mmol/L
Acute pain r/t mass in the
organ Serum potassium
urinary bladder
7.73↑mmol/L
Serum Magnesium 3.25↑
mg/dL
DIAGNOSTIC EXAM Rapid growth of tissue in the bladder
Oliguria
March 11,2023
 UTZ
Whole abdomen ultrasound ACUTE KIDNEY INJURY
(8.9 x 8.1 x9.1 cm) (Post-Renal Injury)
NSG. DIAGNOSIS March 11,2023 Bladder mass formation
Impaired Urinary  Blood test
Elimination r/t decreased Creatinine: 1971.9 ↑umol/L
GFR BUN: 48.50 ↑mmol/L
Decreased blood flow to the kidneys ↓
DIAGNOSTIC EXAM O2
March 10, 2023 NSG. MANAGEMENT
 History Taking  Monitor VS
 Urine output: 300ml  Establish rapport
 Assess the patient’s Damaged to tubules, glumerolus and
I&O and fuid balance interstitium
 Encourage the patient
PHARMACOLOGIC to rest and use comfort
MANAGEMENT measures
 Monitor patient for Ischemia/ Necrosis
 Insertion of IFC sign of infection or
March 10, 2023 obstruction such as
Urine output: 300ml fever, chills and pain,
March 11, 2023 such as heat and cold Death of epithelial cells
Urine output: N/A therapy, positioning
March 12, 2023 and relaxation
Urine output: N/A techniques
March 13, 2023
Urine output: 1,030 ml Obstruction in the tubules
 PHARMACOLOGIC
MANAGEMENT Decreased GFR
 Insertion of IFC
March 10, 2023
Urine output: 300ml
March 11, 2023
Urine output: N/A
March 12, 2023 Progressive loss of kidney function
Urine output: N/A
March 13, 2023
Urine output: 1,030 ml

Chronic Kidney Disease

(ESRD)

Inability of the kidney

to produce urine Decreased Erythropoietin Failure of the kidney to Elevated levels of urea
secretion regenerate bicarbonate and nitrogenous waste
products
Bipedal Edema Oliguria Decreased alkaline in the
Reduced RBC production body
production by bone marrow
Brain tissue damage
NSG. DIAGNOSIS NSG. DIAGNOSIS
Fluid volume excess r/t Impaired Urinary Metabolic Acidosis
decreased GFR Elimination r/t decreased
GFR Anemia
Uremic Encephalopathy
Kussmaul’s Breathing
DIAGNOSTIC EXAM
DIAGNOSTIC EXAM
 Pitting test (+2 NSG. DIAGNOSIS
 History Taking
2mm) March 11, Ineffective tissue
 Urine output: NSG. DIAGNOSIS
2023) 300ml March 10, perfusion r/t decreased Ineffective breathing pattern
023 hemoglobin r/t increased metabolic Confusion Seizure
NSG. MANAGEMENT acidosis
 Monitor VS NSG. MANAGEMENT DIAGNOSTIC EXAM
 Monitor daily weight,  Monitor VS  CBC DIAGNOSTIC EXAM NSG. DIAGNOSIS
abdominal girth and  Monitor daily NSG. DIAGNOSIS
March 10, 2023 March 10, 2023 Risk for injury r/t cerebral
I&O weight, abdominal Altered mental status r/t
Hemoglobin (80g/L)  ABG Test dysfunction
 Restrict Na and fluid girth and I&O inflammation of the brain
Hematoctrit (0.24) PH: 7.402 (normal)
intake  Restrict Na and fluid  Physical Assessment: PCo2: 6.1 ↓
 Consult dietitian for intake Pallor in color Hco3: 3.7 ↓
proper diet  Consult dietitian for
proper diet
 PHARMACOLOGIC NSG. DIAGNOSTIC EXAM
MANAGEMENT NSG. MANAGEMENT DIAGNOSTIC EXAM
MEDICAL MANAGEMENT  Glasgow coma
 Furosemide 40mg IV  Monitor VS  Physical Examination
MANAGEMENT  Monitor Vital Sign scale (GCS test)
 Maintain good  Createnine 1971.9
Q12  Insertion of IFC  Provide supplemental
 Hemodialysis respiratory function Score 11 March umol/L ↑
Urine output: 300ml oxygen therapy as  BUN 48.50 mmol/L ↑
 Protect the client from 10, 2023
March 10, 2023 needed March 10, 2023
injury  Physical
 Educate energy-
NSG. conservation
 Restore electrolyte Examination
CONSIDERATIONS balance especially K.
techniques. March 10, 2023 NSG. MANAGEMENT
 Promote energy
 Assist the client in  Plain CT Scan of the
Diuretics (Furosemide) conservation
developing head March 11,  Monitor Vital signs
 Follow 14 rights a schedule for daily 2023  Monitor GCS
 Monitor VS activity and rest.  Keep lights open.
 Monitor I/O MEDICAL
 Provide safe
 Monitor serum K MANAGEMENT
NSG. environment.
 Monitor weight March 11, 2023  Assist patient with
MEDICAL  Sodium Bicarbonate MANAGEMENT
 Promote safety MANAGEMENT  Monitor Vital signs frequent position
650mg 1 tab TID changes.
March 11, 2023  Hemodialysis  Regular neurological
 Blood Transfusion 2u assessments can help  Implement fall
PRBC identify changes in precautions as
 Hemodialysis mental status and appropriate
NSG.
cognitive function.  Promote airway
CONSIDERATIONS clearance. Turn head to
 Promote sleep and
NSG. rest side during seizure
Alkanizing agent activity.
CONSIDERATIONS (Na HC03)  Maintain quiet and
 Follow 14 rights calm environment to
Blood Transfusion  Monitor VS help reduce
 Follow 14 rights  Monitor I/O confusion
PHARMACOLOGIC
 Monitor VS  Assess the patient’s  Assess for changes in
MANAGEMENT
 Check the patient's electrolyte levels level of
consciousness,  Diazepam 5mg IV
blood type and cross-  Monitor the patient's
orientation, speech, PRN
match it with the blood respiratory status, as
product to ensure and motor function. March 10, 2023
alkalinizing agents can
compatibility. cause respiratory  Hemodialysis
 Monitor for any signs of alkalosis, which can lead
adverse reactions, such to hyperventilation NSG.
as fever, chills, itching,  Instruct the patient to PHARMACOLOGIC
CONSIDERATIONS
rash, or difficulty avoid taking sodium MANAGEMENT
breathing bicarbonate with acidic Benzodiazepines
 Osmotic Diuretics
 Promote safety foods or beverages, as this (Diazepam)
(Mannitol)
can reduce its  Follow 14 rights
effectiveness.
March 11, 2023  Monitor VS especially
RR
 Promote safety
NSG.  Assess for risk for
CONSIDERATIONS substance abuse
 The medication should
Diuretics be tapered gradually
 Follow 14 rights  Provide comfort
 Monitor VS
 Monitor I/O
 Monitor serum Na
 Monitor weight

Inability to maintain electrolytes
Unable to excrete
potassium
Hyperkalemia
NSG. DIAGNOSIS
Fatigue r/t increased
potassium in the blood
DIAGNOSTIC EXAM
 Blood Test
Serum Potassium 4.5 ↑
mmol/ L
March 11, 2023
NSG. MANAGEMENT
 Educate the client on
low potassium diet
 Monitor I & O
 Monitor VS
 Follow ECG closely
to look for peaked T
waves
 Check blood glucose
when administering
insulin
PHARMACOLOGIC
MANAGEMENT
 D50 1 vial + 5 units
HR for 3 doses q 8
hrs
March 11, 2023
NSG. CONSIDERATIONS
Short- acting insulin
(Humulin R)
 Follow 14 rights
 Monitor VS
 Monitor glucose level
 Assess for hypoglycemia
 Promote safety
NSG. MANAGEMENT Nausea/ Vomiting post
(HEMODIALYSIS) HD
Before the procedure:
 Assess the patient's vital signs
 Monitor for any signs of complications NSG. DIAGNOSIS
such as hypotension, bleeding, or Risk for fluid volume
infection. deficit r/t loss of body
Inability to excrete  Monitor the patient's vascular access
Failure to regulate fluids
site (central venous catheter) for
magnesium phosphate balance patency, signs of infection, or bleeding
 Administer anticoagulation therapy as
ordered by the healthcare provider to DIAGNOSTIC EXAM
Hyperhosphatemia prevent clotting of the dialysis circuit.  Physical Assessment
Hypermagnesemia  Monitor for signs of bleeding or  Weight
complications related to anticoagulation
NSG. DIAGNOSIS therapy.
NSG. DIAGNOSIS Risk for injury r/t bone  Monitor for signs of fluid overload or
electrolyte imbalances.
Fatigue r/t decreased fragility
 Provide patient comfort measures NSG.
acetylcholine during the hemodialysis session, such as
adjusting the patient's position or
MANAGEMENT
DIAGNOSTIC EXAM
 Blood Test temperature, and providing distractions
DIAGNOSTIC EXAM such as TV or music.  Monitor VS
Serum phosphorus
 Blood Test  Follow strict infection control measures,  Establish rapport
3.67↑mmol
Serum Magnesium 3.25 ↑ including hand hygiene, use of personal  Monitor I/O
March 11, 2023
mg/dL protective equipment, and proper  Provide mouth care
March 11, 2023 disinfection of equipment and surfaces.  Monitor for fluid and
NSG.  Educate the patient on their electolyte
MANAGEMENT hemodialysis treatment, including the imblanances
purpose of the treatment, the risks and  Promote safety
NSG. MANAGEMENT  Monitor VS benefits, and how to care for their measures
 Monitor VS  Sodium rich food diet vascular access site.  Administer
 Monitor I & O  Safety precautions After the procedure: medicaion as ordered
 Monitor the patient's vital signs,
 Check patellar reflex  Check weight every
including blood pressure, heart rate,
regularly day to monitor fluid
respiratory rate, and oxygen saturation.
 Encourage bed rest volume status  Adjust the patient's diet and fluid intake PHARMACOLOGIC
 Monitor for any sign accordingly.
of seizure MANAGEMENT
 Assess the vascular access site for any
 Metoclopromide
signs of bleeding, infection, or
PHARMACOLOGIC 10mg IV
hematoma formation
MANAGEMENT  Assess the patient's pain level and March 12, 2023
 Sevelamer 800mg provide pain relief medication if needed.
TID  Encourage the patient to drink fluids to
NSG.
March 11, 2023 replace any fluid loss that occurred
during hemodialysis. CONSIDERATIONS
 Educate the patient on self-care Prokinetic Agents
NSG. CONSIDERATIONS measures to reduce the risk of  Follow 14 rights
complications after hemodialysis  Monitor VS
Phospahate binder treatment
 Ensure that the patient knows when  Monitor adverse
 Follow 14 rights
their next hemodialysis treatment is effect such as
 Monitor VS
scheduled and what to expect during the restlesness and
 Monitor serum phosphorus treatment.
drowsiness
level  Provide protein supplement (ProHeal
 Provide safety
 Monitor serum calcium 500ccx12 OD)
 Provide comfort
levels
 Provide safety
 Persistent injury to kidney
The kidney became highly Leakege of large particles Fluid shifts to interstitial space tubules
permeable (RBC) in the urine
Accumulation of fluid in the Activation of RAAS MEDICAL MANAGEMENT
Specific protein being peritoneal cavity March 10, 2023
excreted in urine (Albumin) Hematuria  Nicardipine drip 10 mg in
90 cc PNSS titrate by 5
Ascites Hypertension cc/hr q 15 mins
Proteinuria March 11, 2023
NSG. DIAGNOSIS  Amlodipine 5mg OD
Acute pain r/t kidney failure NSG. DIAGNOSIS Increased workload of the heart  Coralan 5mg 1 tab BID
NSG. DIAGNOSIS Excess fluid volume r/t organ
failure
Excess fluid volume r/t
decreased kidney function DIAGNOSTIC EXAM
 Urinalysis
Cardiomegaly
DIAGNOSTIC EXAM NSG.
TNTC/HPF March 10, 2023
DIAGNOSTIC EXAM March 11, 2023 CONSIDERATIONS
 Urinalysis  BUN NSG. DIAGNOSIS
48.50 ↑ mmol/ L Risk for decreased Cardiac
March 11, 2023 Calcium channel blocker
NSG. MANAGEMENT Crea: 1971.9↑ mmol/L output r/t compromised (Nicardipine, Amlopdipine)
Protein ++  Whole Abdomen UTZ contractility  Follow 14 rights
 Monitor VS Ascites: Minimal to moderate  Monitor VS
NSG. MANAGEMENT  Establish rapport  Monitor renal and hepatic
 Provide emotional DIAGNOSTIC EXAM
function
 Monitor VS support NSG. MANAGEMENT Hypertension:  Advice patient to take
 Monitor daily weight,  Provide pain management  Sphymomanometer
drugs before meals
 Monitor I/O, volume color  Monitor VS BP: 200/100mmHg
abdominal girth and  Tell patient to rise slowly
and consistency  Monitor daily weight, March 10, 2023
I&O  Admisniter medication as from sitting or lying
abdominal girth and I&O
 Monitor patient’s prescribed Cardiomegaly:
 Restrict Na and fluid intake
protein level  Chest X-Ray Selective If-channel
 Assess breath sounds for
 Restrict Na and fluid Cardiomegaly w/ congestive inhibitors ( Coralan)
presence of crackles and
intake changes  Follow 14 rights
congestion
 Assess breath sounds for  Monitor VS
 Consult dietician for proper
presence of crackles and  Advised to take the
PHARMACOLOGIC diet
congestion medicaiton with food
MANAGEMENT NSG. MANAGEMENT
 Consult dietician for  Promote bed rest
proper diet March 11, 2023 PHARMACOLOGIC
 Tranexamic acid 500mg IV  Monitor VS  Provide comfort
MANAGEMENT  Establish rapport
Q6 March 11, 2023  Educate about lifestyle
 Furosemide 40mg IV Q12 modification such as
PHARMACOLOGIC
NSG. CONSIDERATIONS  Ketoanalouges 2 Tabs TID dietary changes, regular
MANAGEMENT
 Hemodialysis exercise can improve
March 11, 2023
 Hemodialysis Antifibrinolytics (Tranexamic hypertension control
March 13, 2023 Acid)  Encourage the patient to
 Nephro HD  Follow 14 rights sit in fowler’s positon.
 Monitor VS  Monitor for complication
 Monitor for signs of of hypertension.
clotting
 Promote safety measures
 CHRONIC KIDNEY CERVICAL CANCER
DISEASE (ESRD) STAGE 4

Cancer cells inhibit the activation

Kidneys are not functioning
of T- cells
properly

Build up of waste product in the Decreased antibodies

body

Weakened Immune System

Inhaling respiratory pathogens

Pathogens colonized the alveoli in lobe

of the lungs

Stimulates pyretic effect Activation of inflammatory response

Fever Acts on the brain that regulates

Macrophages will try to engulf pathogens
metabolism and appetite
by secreting Interleukin 1 and TNF alpha
(Hypothalamus)

NSG. DIAGNOSIS
Hyperthermia r/t inflammatory Decreased appeite
response

NSG.
CONSIDERATIONS
Analgesic (Paracetamol)
 Follow 14 rights
 Monitor VS
 Assess for allergy
 Promote safety measures
Antibiotic (Ceftriaxone)
 Follow 14 rights
 Monitor VS
 Take medication with
meals
 Administer after negative
skin test
DIAGNOSTIC EXAM
 Thermometer
 March 10, 2023: (38°C) Anorexia Hypoglycemia
 WBC 17.73↑
 Segmenters: 0.90↑
 Lymphocytes: 0.8↓
 Monocytes: 0.02↓
 Eosinophils: 0.00↓ NSG. DIAGNOSIS
 March 11, 2023 Risk for injury r/t alteration in
 WBC 18.15↑ consciousness
 Segmenters: 0.87↑
 Lymphocytes: 0.7↓
 Eosinophils: 0.00↓ DIAGNOSTIC EXAM
 March 13, 2023  Hemaglucotest
 WBC 13.36↑
 Segmenters: 0.87↑
NSG. MANAGEMENT
 Lymphocytes: 0.9↓
 Eosinophils: 0.00↓  Monitor VS
 Establish rapport
NSG. MANAGEMENT  Monitor blood glucose levels
regularly
 Monitor VS  Assess the patient's level of
 Monitor for potential consciousness
complications such as  Educate the patient and
seizure, dehydration and family members about the
infection signs and symptoms of
 Establish rapport hypoglycemia
 Loosen or remove excess
 Encourage patients to
clothing and covers
 Provide a tepid bath or maintain a healthy diet
sponge bath  Monitor for complications
 Provide comfort measures such as seizures, loss of
such as keeping the patient’s consciousness, and cognitive
room cool and well- impairment.
ventilated
PHARMACOLOGIC
PHARMACOLOGIC MANAGEMENT
MANAGEMENT  D5050 IV
March 10, 2023  Heraclene Forte (Vitamin
 Paracetamol 300mg IV q4 b12)
PRN
 March 13, 2023
 Ceftriaxone 2g IV OD NSG. CONSIDERATIONS
Vitamin
 Follow 14 rights
 Monitor VS
 Advise the patient to avoid
caffeine
 Promote safety
 Interleukins binds to smooth
muscle of the bronchioles causing
bronchospasm
DOB/ Tachycardia
NSG. DIAGNOSIS
Ineffective breathing pattern r/t
bronchospasm
DIAGNOSTIC EXAM
March 10, 2023
 Physical assessment (Use of
accessory muscle)
 VS: RR: 36 (16-20 CPM)
NSG. MANAGEMENT
 Monitor VS
 Establish rapport
 Assess patient’s anxieety level
and level of consciousness
 Place the client on comfortable
position that facilitates
breathing such as sitting up,
leaning forward or using
pillows to prop up the head and
chest
 Teach the client breathing
techniques such as pursed- lip
or diapgragmatic breathing
 Provide emotional support and
reasssurance
PHARMACOLOGIC
MANAGEMENT
March 10, 2023
 Salbutamol Neb q4
 Hydrocortisone 100mg IV q8
March 12, 2023
 Shift to Pulmudual 1 Neb
Increases permeability of
capillaries surrounding alveoli
Congestion takes place due to
vasodilation and circulatory
permeability
Exudation of RBC, fluids WBC
and Fiber
RBC breakdown
Macrophages clear pus from the
infected area
Activates productive cough
NSG. DIAGNOSIS
Ineffective airway clearance r/t
inflammation of the alveoli
DIAGNOSTIC EXAM
March 12, 2023
 Chest Xray
Pulmonary congestion
NSG. DIAGNOSIS
Impaired gas exchange r/t fluid
filled alveoli
DIAGNOSTIC EXAM
March 12, 2023
 Chest Xray
There is also mild diminution of the
pulmonary congestion.
NSG. MANAGEMENT
 Monitor VS
 Establish rapport
 Assess the patient's
respiratory status and
response to treatment.
 Position the patient in an
upright position or elevate the
head of the bed to reduce the
pressure on the lungs and
facilitate breathing.
 Encourage coughing and deep
breathing exercises to help
clear secretions from the
lungs.
 Provide adequate hydration to
thin the mucus and promote
its clearance.
 Encourage the patient to rest
and conserve energy to reduce
oxygen demand.
Pulmonary Consolidation
/ Bibasilar rales
NSG. DIAGNOSIS
Ineffective airway clearance r/t
accumulation of mucus
DIAGNOSTIC EXAM
March 10, 2023
 Chest Xray
Pulmonary consolidation versus
beginning right lower lobe atelectasis.
 Auscultation
NSG. MANAGEMENT
 Monitor VS
 Establish rapport
 Assess the patient's respiratory
status and response to treatment.
 Position the patient in an upright
position or elevate the head of the
bed to reduce the pressure on the
lungs and facilitate breathing.
 Encourage coughing and deep
breathing exercises to help clear
secretions from the lungs.
 Provide adequate hydration to thin
the mucus and promote its
clearance.
 Encourage the patient to rest and
conserve energy to reduce oxygen
demand.
 NSG. CONSIDERATIONS NSG. MANAGEMENT PHARMACOLOGIC PHARMACOLOGIC
MANAGEMENT MANAGEMENT
Bronchodilators (Salbutamol,  Monitor VS March 12, 2023
March 12, 2023
Pulmodual)  Establish rapport  Pulmodual 1 Neb  Pulmodual 1 Neb
 Follow 14 rights  Hemodialysis  Hemodialysis
 Educate patient on good
 Monitor VS
forcefull coughing techniques
 Educate the patient on proper
using the abdominal muscles.
inhalation technique
 Monitor for sign of
 Educate patient on good NSG. CONSIDERATIONS NSG. CONSIDERATIONS
forcefull coughing techniques
hyperglycemia
using the abdominal muscles Bronchodilators (Pulmodual)
 Monitor for sign of muscle Bronchodilators (Pulmodual)
 Encourage the patient to  Follow 14 rights
weakness  Follow 14 rights
hydarated  Monitor VS
 Assess HR and ECG  Monitor VS
 Encourage to  Educate the patient on proper
ambulate/reposition every two  Educate the patient on proper
inhalation technique inhalation technique
hours  Monitor for sign of
 Elevate the head of the bed by  Monitor for sign of
hyperglycemia hyperglycemia
propping up on pillows  Monitor for sign of muscle
 Encourage patient to  Monitor for sign of muscle
weakness weakness
Gargle/drink warm liquids to  Assess HR and ECG
sooth the throat  Assess HR and ECG
 Perform chest physio therapy
 Provide frequent oral care (every
four hours)

PHARMACOLOGIC
MANAGEMENT
March 10, 2023
 Salbutamol Neb q4
 Hydrocortisone 100mg IV q8
March 12, 2023
 Shift to Pulmudual 1 Neb

NSG. CONSIDERATIONS
Bronchodilators (Salbutamol,
Pulmodual)
 Follow 14 rights
 Monitor VS
 Educate the patient on proper
inhalation technique
 Monitor for sign of
hyperglycemia
 Monitor for sign of muscle
weakness
 Assess HR and ECG
Corticosteroids (Hydrocortisone)
 Follow 14 rights
 Monitor VS
 Educate the client about
infection control
 The medication should be
tapered gradually
 Promote safety