Medical Management To Conclusion

V.
THE PATIENT AND HIS CARE

A. Medical Management
a. IVF
DATE ORDERED
INDICATION(S)
MEDICAL
DATE
GENERAL
OR
CLIENTS
MANAGEMENT /
PERFORMED
DESCRIPTION
PURPOSES
RESPONSE
TREATMENT
DATE CHANGED
Plain Normal Saline
Ordered:
Plain normal saline It is used to treat
Solution
09-12/07
solution
(PNSS)
TO TREATMENT
308
contain increase in random
mosm/L
(Na, blood sugar of the
Performed:
154 MEq/L, Cl, 154 client.
09/12/07 to
mCq/L) has pH of administer
09/19/07
4.5 to 7.0 and is medication

usually supplied in nutrients
volumes
of
lL, body
SODCC, 250cc and

100cc
To
and
to
the
No negative
reaction
NURSING RESPONSIBILITIES
Before
Check doctors order
Check for ordered IVF (name and volume)
Check for cloudiness and expiration date of IVF
Check for patency of tubing
Explain procedure and the purpose of management to SO
During
Clean site of injection and observe aseptic technique
Supports patients hand
Check IV tubing for presence of air
Check integrity of infusion
Monitor and adjust IV flow rate appropriate to the needs of patient
After
Document the IVF on the chart
Change IVF bottle if empty
MEDICAL
MANAGEMENT/
TREATMENT
D5W
DATE
ORDERED
DATE
PERFORMED
DATE
CHANGED
DO: 9/19/07
DP: 9/19/07
DC: 9/20/07
GENERAL
DESCRIPTION
INDICATION/PURP
OSE
CLIENTS
RESPONSE TO
TREATMENT
Hypotonic solution
that exerts less
osmotic pressure with
that of plasma.
Administration of
liquid generally
causes dilution of
plasma solute
concentration and
forces water
movement into cells
and reestablish
intracellular and
extracellular
equilibrium.
Administered as a
carrying medium for
the patients
intravenous
medication
The patient did

not experience
any discomfort
other than the IV
insertion and
medication
administration
upon the course of
this IV therapy.
NURSING RESPONSIBILITIES:
-
Explain the need for IV infusion
Check if the IV infusion is infusing well
Regulate and monitor flow rate as ordered
MEDICAL
DATE ORDERED
GENERAL
INDICATION(S)
CLIENTS
MANAGEMENT/
DATE
DESCRIPTION
OR
RESPONSE
TREATMENT
PERFORMED
PURPOSES
TO THE
DATE CHANGED
TREATMET
Oxygen Inhalation
Ordered:
Used
in It is used for clients The
via nasal cannula @
09/12/07
administering
2-3 lpm
Performed
oxygen. It can be a ventilating all areas progress
09/12/07 to
cannula,
who have difficulty able

facial with
or
lungs,
to
those respiration
09/19/07
mask
changed
tracheal
09/20/07
inserted directly to impaired or people breathing.
that
the trachea.
Tran whose
client
show
in
and
gas there was relief of
is exchange
with
was
heart
is difficulty
failure
may require oxygen

therapy to prevent
hypoxia
of
NURSING RESPONSIBILITIES
Before
Explain to the client what you are going to do, why it is necessary,
and how he or she can cooperate.
Discuss how the effects of the oxygen therapy will be used in
further planning of treatments or care
Assess the patient regularly
Inspect equipment regularly
During
Wash hands and observe infection control measures / procedures
Turn on oxygen at the prescribed rate and ensure proper functioning
Put the cannuia over the clients face with the outlet prongs fitting
into the nares and the elastic band around the head
Make sure that the air delivered to the patient is humidified
Set flow rate prescribed
After
Closely monitor patients respiratory status
Monitor flow rate
NAME OF
DRUG
GENERIC
NAME
BRAND NAME
Furosemide
(Lasix)
Cefixime
(Zefral)
Butamirate
Citrate
(Sinecod)
Aldazide
Acetylcysteine
(Broncoflem)
DATE
ORDERED
DATE
PERFORMED
DATE
CHANGED
ROUTE OF
ADMIN
DOSAGE AND
FREQUENCY
OF ADMIN
Sept. 17, 2007

Sept. 17-19,
2007
Sept. 20, 2007
PO: 200mg 1
tab OD
Sept. 19, 2007

Sept. 19, 2007
(to discharge)
Sept. 20, 2007
PO: 200mg/cap
BID
Sept. 12, 2007

Sept. 12-20,
2007
Sept. 20, 2007
Sept. 17, 2007
Sept. 17-20,
2007
Sept. 20, 2007
INDICATIONS
OR PURPOSES
(PT
CENTERED)
SPECIFIC
FOOD TAKEN
CLIENTS
RESPONSE TO
THE
MEDICATION
(Loop Diuretic)
>tx of edema.
Rice, soup,
apple, water,
veggies.
>the pt did not

encounter any
side effect of
the drug.
(Anti-infective)
>secondary
infections of
respiratory tract
dses.
Rice, apple,
water, meat,
veggies.
>the pt. did not

experience any
side effect of
the drug.
PO: 2 tab/ day
(Antitussive)
>acute cough
of any etiology
Rice, meat,
water, banana.
>the pt. did not

manifest any
side effects.
25mg/tab BID
(Antihypertensive)
>essential HPN
or edema.
Rice, soup,
apple, water.
>the pt did not

manifest any
side effects.
PO: 600
mg/sachet OD
(Mucolytic)
>acute/ chronic
resp. tract
Cup noodles,
rice, banana,
water.
>the pt did not

manifest any
side effects.
Sept. 13, 2007

Sept. 13-20,
2007
Sept. 20, 2007
Ceftriaxone
(Eurosef)
infections
abundant with
mucus
secretions.
1g/IV q12 ANST
Sept. 12, 2007

Sept. 12-19,
2007
Sept. 20, 2007
PO: 2.5 mg/tab

BID
Roxithromycin
(Guamil)
Home Medicine
PO:300 mg OD
Vit. B Complex
Sept. 12, 2007

Sept. 12-20,
2007
Home Medicine
Enalapril
(Acebitor)
(Antiinfectives)
>serious lower
respiratory tract
infections.
(Antihypertensive)
>HPN
(Anti-infective)
>tx of upper
and lower resp.
tract infection.
Sept. 12, 2007

Sept. 12-20,
2007
PO: 1tab OD
(Multivitamins)
>daily
supplement
Rice, meat,
water.
>the pt did not

manifest any
side effect of
the drug.
Lugaw, apple,
water.
>the pt did not

manifest any
side effect of
the drug.
Rice, banana,
soup, water.
>the pt did not

manifest any
side effects.
Rice, banana,
soup, water.
>the pt did not

manifest any
side effects of
the drug.
Furosemide:
Before:
>Assess the pt. for tinnitus and hearing loss.
>Monitor for renal, cardiac, neurologic, GI, pulmonary manifestations of
hypokalemia.
>Monitor electrolytes, also include BUN, blood pH, ABGs.
>Assess BP before and during therapy.
During:
>Give in morning to avoid interference to sleep.
>Drug may be crushed before administering.
After:
>Teach pt. to take medication early in the day to prevent nocturia.
>Instruct pt. to the medicine with food or milk.
>Caution pt. to rise slowly from sitting or reclining, orthostatic hypotension
might occur.
>Instruct pt to continue taking the medication even if feeling better.
Cefixime and Ceftriaxone:
Before:
>Assess pt for s/sx of infection including characteristics of wounds, sputum,
urine and stool.
>Obtain C & S before beginning drug therapy to identify if correct tx has
been initiated.
>Identify urine output
>Monitor bleeding and growth of infection.
During:
>Give for 10 days to ensure organism death and prevent superinfection.
>Give with food if needed for GI symptoms.
>Give after C & S is completed.
After:
>Teach pt to report sore throat, bruising, bleeding, and joint pain. It may
indicate blood discarias.
>Advise pt to contact prescriber if there is loose foul stool and furring of
tongue occur.
>Advise pt to notify prescriber if diarrhea with blood or pus occurs.
Butamirate Citrate:
Before:
>Verify doctors order
>Explain importance and purpose of the medicine.
>Assess pt. for hypersensitivity
During:
>Identify pt first.
>Administer only exact amt. of dosage.
>Tell the pt. to swallow the medication fully.
After:
>Tell the client that he may experience a little bit of dizziness and avoid
driving after administration.
>Tell the pt to take the medication in instructed intervals.
Acetylcysteine:
Before:
>Assess cough first.
>Assess characteristics, rate, rhythm of respiration, increased dyspnea and
sputum.
>Monitor VS, cardiac status including checking for dysrhythmias, increased
rate and palpitations.
During:
>Give decreased dosage to elderly pts.
>Use only if suction machine is available.
After:
>Tell the pt to avoid driving or any other hazardous activities until stabilized
with this medication.
>Teach the pt that unpleasant odor will decrease after repeated use.
Aldazide:
Before:
>Verify doctors order.
>Explain to the pt the importance of the drug.
>Explain to the client possible side effects of drug.
>Assess pt for hypersensitivity.
During:
>Be sure to identify the client first.
>Administer only desired dose to the pt.
>Always check the medication before administration.
After:
>Tell the pt to change position in a slow manner, orthostatic hypotension
might occur.
>If adequate diuresis doesnt occur after 3 days increase dose.
Enalapril:
Before:
>Monitor BP and pulse frequently.
>Monitor frequency of prescription refills to determine adherence.

>Monitor CBC especially WBC with differential prior to initiation of therapy.
>Assess urine protein prior and periodically during therapy.
During:
>Monitor CBC during therapy
>Do not confuse Enalapril to Eldepryl.
After:
>Instruct pt to take medication as directed as the same day and time each
day even feeling better.
>Caution pt to avoid salt substitutes or foods containing high levels of
potassium or sodium.
>Instruct pt to notify physician if rash, mouth sores, sore throat,
fever/swelling of hands & feet, chest pain and DOB occurs.
>Emphasize importance of follow-up checkup.
Roxithromycin:
Before:
>Verify doctors order
>Explain importance of medicine
>Assess pt for hypersensitivity
>Assess for hepatic or renal impairment.
During:
>Check medication first before administration.
>Administer only exact dose as ordered.
>Take the medication before meals.

After:
>Assess for allergic reactions
>Assess for n/v.
>Tell the pt. to complete days of medication; superinfection may occur.
Vitamin B Complex:
Before:
>Verify Doctors order.
>Explain the importance and purpose of the drug.
>Assess pt for hypersensitivity.
During:
>Identify the pt first before administration.
>Check medication first before administration.
>Administer only exact dose as ordered.
After:
>Tell the pt to continue taking the medication for better results.
>Explain the benefits he will get for taking the medication for
encouragement.
TYPE OF DIET
NPO
(Nothing Per
Orem)
DATE
ORDERED
DATE
PERFORMED
DATE
CHANGED
GENERAL
DESCRIPTION
Sept. 12, 2007

Sept. 12, 2007
Sept. 12, 2007
DAT with limited Sept. 13, 2007

Fluid Intake to
Sept. 13-18,
1L/ day.
2007
Sept. 19, 2007
DAT
(Diet as
Tolerated)
Sept. 19, 2007

Sept. 20, 2007
INDICATIONS
OR PURPOSES
SPECIFIC
FOODS TAKEN
CLIENTS
RESPONSE
>this diet
requires no food
intake by mouth
including water.
>to prevent
abdominal
distention thus
preventing
irritation.
>no food was

taken.
>the pt felt
hungry and
demanded for
food.
>this diet
permits the
client to eat a
regular diet but
with limitation
of fluid.
>to supply the

client enough
energy he
needs at the
same time
limiting fluid
intake to lessen
fluid excess in
the body.
>cup noodles,
rice, veggies,
meat, a little
amt. of water.
>the pt was
satisfied with
the meal.
It is adequate in
all nutrients
accdg. to the
standards and
is used for pts.
requiring to no
dietary
>to give the

client all the
nutrients he
needs in able to
nourish a
healthy body.
>he was given

a complete
meal composed
of meat, rice,
veggies, and a
glassful of
water.
>the pt was
satisfied with
the meal.
modification. It
contains bet.
2500 to 3000
calories daily.
Before:
>Verify doctors order. Discuss importance of ordered diet.
>Cite examples of food under diet ordered. Ask patients preference that
may be included in their diet list.
>Remind the client of proper handwashing.
During:
>Assist pt. for comfortable position.
>Identify the pt. Verify the meal served in the tray.
>Assess if there is a need for assistance during meal.
After:
>Monitor how much meal and fluids were taken.
>Monitor clients reaction and compliance with diet.
>Instruct SO to increase fruit juices and milk in diet for nourishment.
TYPE OF
EXERCISE
DATE ORDERED
DATE
PERFORMED
DATE CHANGED
GENERAL
DESCRIPTION
INDICATIONS OR
PURPOSES
CLIENTS
RESPONSE
Bed Rest
Sept. 12, 2007

Sept. 12-16, 2007
>this exercise
makes the pt lie on
bed the whole time
and other activities
are prohibited to be
done.
>makes the pt
conserve energy to
prevent too much
O2 consumption.
>the pt was
comfortable in bed
but got a little
bored.
Sitting
Sept. 12, 2007

Sept. 12-16, 2007
>makes the pt sit

in the bed for a
specific purpose.
>provides pt
comfort from
dizziness and
coughing when is
supine position.
>the pt did not

complain and is
relieved from
coughing and
dizziness.
Walking
Sept. 17, 2007

Sept. 17, 2007
(to discharge)
>make the pt
ambulate in close
range.
>to give the pt a

little activity to
move his legs and
exercise a bit.
>the pt felt a little

bit tired when he
walked.
VI. NURSING MANAGEMENT

1. NURSING CARE PLANS
Problem1: Ineffective airway clearance related to retained secretions as evidenced by productive cough
with reddish sputum and dyspnea
ASSESSMEN
NURSING
SCIENTIFIC
OBJECTIVE
NURSING
DIAGNOSI
EXPLANATIO
INTERVENTIO
S
S > maguku Ineffective
N
In Pleural
Short term:
NS
1. Monitor and
RATIONALE
EXPECTED
OUTCOME
1. To establish baseline
data
Short term:
kuas
airway
Effusion, there
After 4 hours record vital
verbalized by
clearance
would be
of nursing
the pt.
related to
disruption of
intervention
retained
equilibrium
s, the
2. Auscultate
2. To note for possible
improvement
O > The pt.
secretions
across pleural
patient will
breath sounds
adventitious breath
in airway
manifested
as
membrane.
demonstrate
sounds
patency as
> pt. appears
evidenced
Therefore,
improvemen
weak
by
there would
t in airway
3. Assess rate,
3. To note for irregular
patient having
> with
productive
be increase in
patency as
rhythm and
patterns of respiration
non-
productive
cough with
fluid from
evidenced
depth of
signs
The patient
shall have
demonstrated
evidenced by
productive
cough
reddish
interstitial
by patient
respirations
cough.
with
sputum
spaces of lung
having non-
reddish
and
via visceral
productive
4. Assess use
4. Accumulation of
sputum
dyspnea
pleura.
cough.
of accessory
secretions and inability
Long term:
muscles
to clear airways may
The patient
> with
Defects in
dyspnea
function of
lead to use of accessory
shall have
experienced
lymphatic
muscles and increased
established
when
vessels in
work of breathing.
airway
assuming
visceral pleura After 4 days
supine
to remove
of nursing
5. Note ability
5. Expectoration may be
evidenced by
position
fluid occurs.
intervention
of patient to
difficult when secretions
patient free
> with chest
Therefore,
s, the pt. will expectorate
are very thick as a result
from dyspnea
tightening
there would
establish
sputum
of infection or
and
experienced
be fluid
airway
effectively
inadequate hydration.
productive
when in
accumulation
patency as
supine
and retained
evidenced
6. Assess
6. Decreased or absent
position
secretions in
by patient
tactile and
fremitus may be
> used
the lungs.
free from
vocal fremitus
associated with and fluid-
accessory
Thus, airway
dyspnea and
muscles to
patency would productive
Long term:
patency as
cough.
filled tissue
7. Note
7. Blood-tinged or frankly
breath when
be affected
positioned
cough.
character of
bloody sputum results
and there
sputum and
from tissue breakdown in
flat in bed
would be
presence of
the lungs or from
> with
ineffective
hemoptysis
tracheobronchial
limited ROM
airway
ulceration and may
> with
clearance.
require further
disturbance
evaluation.
of sleep
8.Place client
> have
in semi- or
8. Positioning helps
sedentary
high- fowlers
maximize lung expansion
lifestyle
position.
and decreases
> with
9. Encourage
respiratory effort.
bipedal
patient to do
9. To promote movement
pitting edema
deep slower
of secretions into larger
> no pain
breathing and
airways for
perceived
pursed-lip
expectoration.
breathing
- the pt. may
exercise
manifest:
>
10. Instruct
restlessness
patient to
>listlessness
increase oral
10. To mobilize
> difficulty of
fluid intake
secretions
sleeping
> irritability
11. Instruct SO
> diaphoresis
to do CPT
when the
patient
11. To facilitate expulsion
coughed
of secretions.
12. Keep
patients back
dry
12. To prevent
evaporation of sweat
13. Maintain
from the patients back
calm attitude
13. To provide relaxation
14. Provide
and limit level of anxiety
rest periods
15. Provide
14. To allow the body to
quiet
regain its energy
environment
15. To promote an
environment conductive
16. Perform
to recovery
quiet
conversations
16. To promote relaxing
17. Instruct pt.
conversations
to change
position
frequently
17. To provide comfort

and to prevent stasis of
18. Encourage
secretions
pt. to assume
comfortable
position when
18. Client may be
resting or
comfortable with head of
sleeping
bed elevated, sleeping in

a chair, or leaning
19. Advise pt.
forward on overhead
to eat
table with follow support
nutritious food
19. To provide nutrition
20.Administer
with adequate amount of
medications as vitamins and minerals

indicated:
a. mucolytic
agents
a.Reduces the thickness
b.
ans stickiness of
Bronchodilator
pulmonary secretions to
facilitate clearance
b. Increases lumen size
of the tracheobronchial
tree, thus decreasing
c.
resistance to airflow and
Corticosteriods improving oxygen

delivery
c. May be useful in the
presence of extensive
involvement with
profound hypoxemia and
when inflammatory
response is life
threatening.
Problem 2: Ineffective Breathing Pattern related to decrease lung expansion as evidenced by dyspnea and
orthopnea
ASSESSMEN
NURSING
SCIENTIFIC
OBJECTIVE
NURSING
DIAGNOSI
EXPLANATIO
INTERVENTIO
RATIONALE
EXPECTED
OUTCOME
S
Ineffective
N
In Pleural
Short-term:
NS
1. Monitor and
Magkasakit
Breathing
Effusion, there
After 4
record vital
data
ku
Pattern
would be
hours of
signs
mangisnawa
related to
disruption of
nursing
at mangku ku
decrease
equilibrium
intervention
2. Auscultate
2. To note for possible
demonstrated
patye maka
lung
across pleural
s, pt will be
breath sounds
adventitious breath
improved
flat ku, as
expansion
membrane.
able to
sounds
breathing
verbalized by
as
Therefore,
demonstrat
3. Note rate
the pt.
evidenced
there would
e improved
and depth of
3. To note for irregular
resolving
by dyspnea be increase in
breathing
respirations
patterns of respiration
signs of
O > The pt.
and
fluid from
pattern with
manifested
orthopnea
interstitial
resolving
4. Assess
> pt. appears
spaces of lung
signs of
environmental
4. To identify appropriate
pt. sleeping in
slightly weak
via visceral
hypoxia as
, social,
measures related to the
side lying
> with
pleura.
evidenced
cultural, and
presenting
position
dyspnea
Defects in
by pt
educational
manifestations of the
experienced
function of
sleeping in
factors that
patient
when
lymphatic
side lying
may influence
assuming
vessels in
position
teaching plan
supine
visceral pleura
S>
Short-term:
The patient
shall have
pattern with
hypoxia as
evidenced by
Long-term:
The patient
shall have
position
to remove
Long term:
5. Assess
established
> with chest
fluid occurs.
After 4 days
cognitive
5. To determine readiness effective
tightening
Thus, there
of nursing
function and
to learn on the part of
breathing
experienced
would be
intervention
emotional
the client.
pattern
when in
reduction in
s, the pt.
readiness to
without signs
supine
pressure in
will
learn
of hypoxia as
position
pleural space
establish
> used
and there
effective
6. Assess
accessory
would be
breathing
tactile and
6. Decreased or absent
tolerate
muscles to
inability of
pattern
vocal fremitus
fremitus may be
sleeping in
breath when
lung to
without
associated with and fluid-
supine
positioned
expand
signs of
7. Note chest
filled tissue
position
flat in bed
causing
hypoxia as
excursion and
7. To know if chest
> with limited
dyspnea or
evidenced
position of
excursion is unequal until
ROM
shortness of
by pt able to trachea
lung re-expands. Trachea
> with
breath and
tolerate
may deviate away from
disturbance
orthopnea.
sleeping in
affected side
of sleep
There would
supine
8. Maintain
> have
be also
position
calm attitude
sedentary
increase in
evidenced by
pt. able to
8. To provide relaxation
and limit level of anxiety
lifestyle
hydrostatic
9. Encourage
> with
pressure in
deep, slower
9. To assist client in
productive
lungs which
breathing and
taking control of the
cough
also cause
pursed lip
situation
with
orthopnea.
breathing
reddish
When there is
sputum
difficulty of
10. Promote
> with
breathing and
proper bed
bipedal
orthopnea,
positioning as
10. To promote an
pitting edema
there would
to semi-
increase in lung
> no pain
be decreased
fowlers
expansion
perceived
lung
position
expansion
- the pt. may
resulting to
11. Provide
manifest:
ineffective
rest periods
>
breathing
restlessness
pattern.

12. Provide
> difficulty of
quiet
sleeping
environment
> irritability
regain its energy

12. To promote an
environment conductive
> diaphoresis
to recovery
13. Keep
patients back
dry
13. To prevent
14. Perform
quiet
conversations

conversations
15. Instruct pt.

to change
position
15. To provide comfort
frequently
and to prevent stasis of

secretions
16. Encourage
pt. to assume
comfortable
16. Client may be
position when
comfortable with head of
resting or
bed elevated, sleeping in
sleeping
a chair, or leaning
forward on overhead
17. Advise pt.
table with follow support
to eat
nutritious food
18. Encourage
with adequate amount of
resting as
vitamins and minerals
needed during
18. To limit fatigue and to
activity
decrease oxygen
avoiding
demand and
overexertion
consumption
as mush as
possible
19. Instruct pt.
to alternate
heavy with
19. To promote energy
light tasks
conservation
20. Discuss
purpose and
method of
20. To improve
administration
information for the
for each
patient
medication
21. Instruct
patient to
avoid central
nervous
21. To present from
system (CUS)
further depressing the
depressants
respiratory system.
Problem 3: Disturbed sleep pattern related to shortness of breath when assuming supine position AEB
impairment of normal sleep pattern.
ASSESSMEN
NURSING
SCIENTIFIC OBJECTIVES
NURSING
RATIONALE
EXPECTED
T
DIAGNOSIS
EXPLANATI
INTERVENTI
OUTCOME
ON
ON
S>
magkasakit
ku
mipatudtud
nabengi as
verbalized by
the patient.
O> pt.
appears
weak.
Disturbed
sleep pattern
r/t shortness
of breath
when
assuming
spine
position AEB
impairment
of normal
sleep
As a result of
shortness of
breath of the
pt. he
becomes
more focused
on how to
breath
properly than
to relax thus
making him
Short Term:
After 4 hrs of
nursing
interventions
the pt. will
report
increase in
self well
being and
feeling
rested.
>monitor and
record VS.
>to obtain
baseline
data.
>auscultate
breath
sounds.
>to assess
any
adventitious
breath
sounds.
>identify
>to
Short Term:
After 4 hrs of
nursing
interventions
the pt. shall
have
reported
increase in
self well
being and
feeling rested
pattern.
>with
disturbance
of sleep.
>experiencin
g DOB when
assuming
supine
position.
>slept for
only 4 hrrs.
>with limited
ROM.
anxious and
disturbing his
sleep
pattern.
Long Term:
After 2-3
days of N.I.
the pt. will
have regular
sleeping
pattern AEB
long hours of
sleep.
presence of
factors that
interferes with
sleep.
>assess sleep
disturbances
that are
associated
with
underlying
illness.
determine
possible
causes of
sleep
disturbance.
Long Term:
After 2-3
days of N.I.
the pt. would
have a
>to see if the regular
illness
sleeping
contributed
pattern AEB
to the sleep
long hours of
disturbance.
sleep
>with bipedal
pitting
edema.
>determine
clients
expectations
of adequate
sleep and
frequency.
>to know
what the pt.
expects in
adequate
sleeping.
>have
sedentary
lifestyle.
>observe
physical signs
of fatigue.
>to know
when the
client gets
exhausted.
>arrange care
to provide
uninterrupted
periods for
>to give the

pt. more time
to rest and
sleep.
>with easy
fatigability
upon
exertion.
>no pain
perceived.
rest and
allowing
longer periods
of sleep.
>provide
quiet envt.
And comfort
measures.
>instruct to
limit fluid
intake in the
evening.
>instruct pt.
to drink milk
before going
to bed.
>instruct pt.
to assume
comfortable
position when
resting.
>perform
quiet
>to make the

client
comfortable
with the
environment.
>to reduce
chance of
nocturia.
>to help
facilitate
sleep.
>to make the
pt.
comfortable
with his
position.
>to avoid
disturbance
and creation
converstation
s.
of noise.
Problem 4: Activity Intolerance Level III r/t general weakness AEB easy fatigability
ASSESSMENT
NURSING
SCIENTIFIC
OBJECTIVES
DIAGNOSI
EXPLANATIO
INTERVENTIO
NS
Short term:
NURSING
RATIONALE
EXPECTED
OUTCOME
S>
Activity
In pleural
Mangalambut
Intoleranc
effusion, an
ku. as
e Level III
abnormal
hours of NI,
and trust from
hours of NI,
verbalized by
r/t general
volume of
the patient
the patient.
the patient
the patient.
weakness
fluid
will
- After 4
1. Establish
1. To obtain
Short term:
rapport.
cooperation
- After 4
shall have
AEB easy
accumulates
demonstrate
2. Monitor and
2. To establish
demonstrated
fatigability
in the pleural
increase in
record VS.
baseline data.
increase in
space causing
tolerance to
shortness of
activity AEB
3. Auscultate
3. To note any
activity AEB
Appears
breath and
patient
clients breath
adventitious
patient
weak
cough. When
walking at a
sounds.
breath sounds
walking at a
With ease
there is
distance of
present.
distance of 3-4
fatigability
shortness of
3-4 meters
upon
breath, there
without
4. Identify
4. To note any
without
exertion
would be
experiencing
clients
reaction like
experiencing
With limited
alteration in
fatigue and
response to
dyspnea or
fatigue and
ROM
O2 supply and
dyspnea
activities.
fatigue during
dyspnea
Have
demand.
thereafter.
and after
thereafter.
O> The patient

manifested:
tolerance to
meters
activities.
productive
cough with
The level
reddish
of O2
sputum
determines
Have
Long Term
- After 4
5. Note reports
5. To establish
Long Term
days of NI,
on dyspnea
client needs
the bodys
the patient
and increased
and facilitates
days of NI, the
sedentary
ability to
will
weakness.
choice and
patient shall
lifestyle
oxygenate
demonstrate
interventions.
have
- After 4
With
tissues,
tolerance in
dyspnea
especially at
doing
6. Assess
6. To
tolerance in
experienced
times of
activities of
clients ability
determine the
doing
when doing
increased
daily living,
to stand and
patients
activities of
strenuous
oxygen
like the
walk.
capabilities
daily living,
activities
demand.
patient
and facilitates
like the patient
With bipedal
When there is
taking a bath
choice of
taking a bath
pitting
alteration in
without
interventions.
without
edema
O2 supply and
assistance
demand, it
and without
The patient
means that
experiencing
may manifest:
the RBCs are
demonstrated
assistance and
7. To provide
without
7. Provide
an
experiencing
fatigue or
quiet
environment
fatigue or
not properly
dyspnea
environment
conducive to
dyspnea
Heart rate
oxygenated.
thereafter.
and calm
energy
thereafter.
above
RBC
activities.
regeneration.
normal
transports O2
range
to tissues in
8. To allow the
Compensato
order to
body to regain
ry
oxygenate
8. Provide rest
tachypnea
them. Thus, a
periods.
its energy.
Sign and
decrease in O2
9. To promote
symptoms of
would mean a
relaxing
decreased
decrease in o-
9. Perform
cardiac
xygenation of
quiet
output
tissues
conversations.
Restlessness
necessary for
evaporation of
diaphoresis
metabolism in
sweat from
conversations.
10. To prevent
producing
10. Keep
the patients
ATP, a
patients back
back.
precursor of
dry.
energy.
11. To
Reduced
facilitate
energy is
11. Provide
expulsion of
termed as
CPT when
sputum.
weakness and
patient coughs.
is directly
12. It
related to
12. Provide
stimulates
decrease
back rub.
nerve fibers
tolerance to
which allow
activities.
the client to
feel
comfortable.
13. Instruct
13. This
patient to
reduces stress
engage in
and excess
relaxation and
stimulation,
diversional
promoting
activities.
rest.
14. Instruct
patient to
14. To
change
promote
position
relaxation and
frequently.
prevent
immobility.
15. Instruct the

patient to
assume
15. Client may
comfortable
be
position when
comfortable
resting or
with HOB
sleeping.
elevated,
sleeping on a
chair, or
leaning
forward on
over bed table
16. Explain
with pillows.
importance of
rest in
16. Bed rest is
treatment plan
maintained
and necessity
during acute
for balancing
phase to
activities with
decreased
rest.
metabolic
demands thus
conserving
energy for
healing.
Activity
restrictions
thereafter are
determined by
patients
response to
activity and
resolution of
respiratory
17. Regulate
insufficiency.
IVF as ordered.
17. To
maintain
18. Assist with
hydration of
self care
the patient.
activities as
necessary.
18. Minimizes
Provide for
exhaustion
progressive
and help
increase in
balance O2
activities.
supply and
demand.
19. Instruct
patient to take
medicines on
time.
19. To follow
proper
treatment
regimen.
Problem 5: Fatigue r/t general weakness AEB decreased in performance in doing activities of
daily living
ASSESSMENT
NURSING
SCIENTIFIC
OBJECTIVES
DIAGNOSI
EXPLANATIO
INTERVENTIO
NS
Short term:
NURSING
RATIONALE
EXPECTED
OUTCOME
S> The pt.
Fatigue r/t
In pleural
verbalized:
general
effusion, an
Yun nga yung
weakness
abnormal
hours of NI,
problema ko,
AEB
volume of
the patient
2. Auscultate
2. To note any
the patient
yung madali
decreased
fluid
will in
clients breath
adventitious
shall have
akong
in
accumulates
desired
sounds.
breath sounds
demonstrated
mapagod.
performan
in the pleural
activities at
present.
increase in
ce in doing
space causing
level of
- After 4
1. Monitor and
1. To establish
Short term:
record VS.
baseline data.
- After 4
hours of NI,
tolerance to
O> The patient
activities
shortness of
ability such
3. Assess
3. To prioritize
activity AEB
manifested:
of daily
breath and
as walking
which problem
problems
patient
living
cough. When
towards the
bothers the
experienced
walking at a
Have
there is
comfort room patient.
by the
distance of 3-4
productive
shortness of
instead of
patient.
meters
cough with
breath, there
voiding in a
4. Determine
reddish
would be
urinal beside
the patients
4. to assess
experiencing
sputum
alteration in
the bed.
ability to
the patients
fatigue and
Experienced
O2 supply and
participate in
ability to
dyspnea
DOB and
demand. The
activities.
mobilize.
thereafter.
feels tired
level of O2
after walking
determines
days of NI,
5. Assess the
Experienced
the bodys
the patient
presence and
5. To assess
Long Term
DOB when
ability to
will perform
degree of sleep contributing
assuming
oxygenate
activities of
disturbance.
supine
tissues,
daily living
position
especially at
and will
6. Note clients
No pain
times of
participate
belief of what
6. To assist
demonstrated
perceived
increased
with
is causing the
factors that
tolerance in
With
oxygen
improved
fatigue.
contribute to
doing
Long Term
without
- After 4
- After 4
factors to
days of NI, the
fatigue.
patient shall
have
disturbance
demand.
sense of
the fatigue.
of sleep
When there is
energy AEB
7. Note daily
Appears
alteration in
patient
energy
7. To
like the patient
weak
O2 supply and
feeling less
patterns.
determine
taking a bath
With ease
demand, it
tired after
peak energy
without
fatigability
means that
doing an
level, pattern,
assistance and
upon
the
activity.
or timing of
without
exertion
erythrocytes
8. Note the
activity.
experiencing
With limited
are not
need for
8. To know
fatigue or
ROM
properly
individual
when to assist
dyspnea
Have
oxygenated.
assistance.
the client
thereafter.
sedentary
RBC
whenever
lifestyle
transports O2
needed.
With bipedal
to tissues in
9. Provide
pitting
order to
adequate rest
9. To allow the
edema
oxygenate
periods.
body to regain
them. Thus, a
activities of
daily living,
its energy.
The patient
decrease in O2
10. Encourage
may manifest:
would mean a
patient to do
10. To assist
decrease in o-
whatever
the patient
Sign and
xygenation of
possible
cope with
symptoms of
tissues
activities like
fatigue.
decreased
necessary for
walking.
cardiac
metabolism in
output
producing
11. Instruct
Heart rate
ATP, a
methods to
above
precursor of
conserve
11. To avoid
normal
energy. A
energy like
excessive
range
reduced
sitting instead
usage of
Listlessness
energy is
of standing.
energy.
Compensato
termed as
ry
weakness,
12. Assist in
tachypnea
and if the
self-care
Diaphoresis
body is weak,
needs.
Frequent
it becomes
exhaustion
urination
easily
and helps
exhausted,
balance
and this is
oxygen supply
termed as
and demand.
fatigue.
13. Provide
12. Minimizes
quiet
13. To provide
environment.
environment
conducive to
energy
regeneration.
14. Perform
quiet
14. To
conversations.
promote
15. Instruct
relaxing
patient to
conversations.
engage in
15. This
relaxation and
reduces stress
diversional
and excess
activities.
stimulation,
promoting
16. Keep
rest.
patients back
dry.
16. To prevent
evaporation of
17. Provide
sweat from
back rub.
the patients
back.
17. It
stimulates
nerve fibers
18. Provide
which allow
CPT when
the client to
patient coughs. feel

comfortable.
19. Instruct the
patient to
18. To
assume
facilitate
comfortable
expulsion of
position when
sputum.
resting or
sleeping.
19. Client may

be
20. Advise
comfortable
patient to eat
with HOB
nutritious food.
elevated.
20. To provide
foods with
21. Assist
proper
client in
vitamins and
performing
minerals by
activities.
the body to
regain energy.
22. Provide
comfort
measures,
such as
stretching
linens.
23. Regulate
IVF as ordered.
24. Instruct
23. To
patient to take
maintain
medications on
hydration of
time.
the patient.
24. To comply
with proper
treatment
regimen.
Problem 6: Impaired physical mobility classification 3 related to weakness as evidenced by inability to

purposely move within the physical environment and limited ROM
ASSESSMEN
NURSING
SCIENTIFIC
DIAGNOSI
EXPLANATIO
INTERVENTIO
S
Impaired
N
In Pleural
Short-term:
NS
1. Monitor and
Short-term:
Magkasakit
physical
Effusion, an
After 4 hours
record vital
data
The patient
ku gagalo,
mobility
abnormal
of nursing
signs
tatalakad
classificatio
volume of
interventions,
tsaka
n 3 related
fluid
the patient
lalakad, as
to
accumulates
verbalized by
weakness
the pt.
as
S>
OBJECTIVES
NURSING
RATIONALE
EXPECTED
OUTCOME
shall have
demonstrated
2. Assess
2. identifies strength
techniques
will be able to functional
and deficiencies and
that enable
in the pleural
demonstrate
abilty and
may provide
resumption of
space causing
techniques
extent of
information regarding
activities as
evidenced
shortness of
that enable
impairment
O > The pt.
by inability
breath and
resumption of
initially and on
patient
manifested
to
cough. When
activities as
a regular basis
change
there is
evidenced by
> pt. appears purposely
recovery.
evidenced by
positions at
slightly weak
move within dyspnea,
patient
3. Determine
3. To assess functional
least every 2
> the patient
the physical
there would
change
degree of
ability
hrs.
needs
environmen
be alteration
positions at
immobility
someone to
t and
in oxygen
least every 2
assist him
limited ROM supply and
whenever he
demand. The
walks.
level of
>with easy
hrs.
Long-term:
4. Change
positions at
4. To reduce risk of
The patient
Long term:
least every 2
ischemia or injury
shall have
oxygen
After 4 days
hr (supine,
maintained
fatigability
determines
of nursing
side lying).
strength and
upon
the bodys
interventions,
exertion.
ability to
the pt. will
5. Position in
> with
oxygenate
maintain
prone position
5. Helps maintain
compensatory
limited ROM
tissues
strength and
once or twice
functional hip
body part as
> with
especially at
function of
a day if client
extension.
evidenced by
dyspnea
times of
affected or
can tolerate
experienced
increased
compensator
function of
affected or
patient able to
do activities of
when
oxygen
y body part
6. Use arm
daily living.
assuming
demand.
as evidenced
sling when
supine
When there is
by patient
client is in
6. Use of sling may
position
alteration in
able to do
upright
reduce risk of shoulder
> c chest
oxygen and
activities of
position as
subluxation and
tightening
demand, it
daily living.
indicated
shoulder-hand
experienced
means that
when in
the
7. Evaluate
supine
erythrocytes
the use of
position
are not
positional aids:
> used
properly
a. place pillow
accessory
oxygenated.
under axilla to
a.prevents adduction of
muscles to
RBC
abduct arm
shoulder and flexion of
breath when
transports
positioned
oxygen to
b. elevate arm
flat in bed
tissues in
and hand
> with
order to
disturbance
oxygenate
c. place hard
prevent edema
of sleep
them. Thus, a
hand-rolls in
formation.
> have
decrease in
palm with
c.hard cones decrease
syndrome
7.
elbow
b. promotes venous
return and helps
sedentary
oxygen would
fingers and
the stimulation of finger
lifestyle
mean a
thumb
flexion, maintaining
> with
decreased in
opposed
finger and thumb in
productive
oxygenation
cough
of tissues for
d. place knee
their
and hip in
sputum
metabolism in
extended
d.maintains functional
> no pain
producing
adduction
position
perceived
ATP, a
> c bipedal
precursor of
e. Maintain leg
pitting
energy. A
in neutral
edema
reduced
position with
e. prevents external hip
energy is
trochanter roll
rotation.
with reddish
functional position.
-the pt. may
termed as
manifest:
weakness
8. Observe for
>
may cause
color edema
restlessness
impaired
and other
8. Edematous tissue is
> gait
physical
signs of
more easily
changes
mobility.
compromised
traumatized and heals
circulation
more slowly
>postural
instability
> irritability
9. Inspect skin
> diaphoresis
regularly,
particularly
over bony
9. Pressure points over
prominence
bony prominences are

most at risk for
10. Maintain
decreased perfusion/
calm attitude
ischemia
11. Provide
10. To provide
rest periods
relaxation and limit

level of anxiety
12. Provide
quiet
environment
regain its energy

12. To promote an
13. Keep
environment
patients back
conductive to recovery
dry
14. Perform
13. To prevent
quiet
conversations

15. Advise pt.
conversations
to eat
nutritious food
16. Encourage
resting as
with adequate amount
needed during
of vitamins and
activity
minerals
avoiding
overexertion
16. To limit fatigue and
as mush as
to decrease oxygen
possible
demand and
consumption
17. Instruct pt.

to alternate
heavy with
light tasks
17. To promote energy
18.Encourage
conservation
exercises such
as quadriceps/
gluteal
exercise,
squeezing
18. Minimizes muscle
rubber ball,
atrophy, promotes
extension of
circulation and helps
fingers and
prevent contractures.
legs/ feet
19.Assist to
develop sitting
balance; assist
to sit on edge
of the bed,
having client
19. Aids in retaining
use the strong
neuronal pathways,
arm to support
enhancing
body weight
propioception and
and strong leg
motor response.
to move and
standing
balance.
20. Administer
muscle
relaxants,
antispasmodic
s as indicated
20. May be required to
relieve spaciticity in
affected extremities
2. ACTUAL SOAPIERS
September 17, 2007
S > Mangalambut ku as verbalized by the pt

O > Received pt on a sitting position, awake, coherent, conscious, c an IVF of
PNSS IL @ 550cc level regulated at 30-31 gtts/min inserted at cephalic
vein.
> the pt. appears weak
> with easy fatigability upon excretion
> the pt has productive cough with reddish sputum
> with limited ROM
> have sedentary lifestyle
> with dyspnea experienced when doing strenuous activities
> with bipedal pitting edema
> no pain perceived
> with vital signs taken and recorded as follows: T: 36 oC / axillary P=86bpm
R=20bpm BP:140/100 mmHg
A > Activity intolerance level III related to general weakness as evidenced by
easy fatigability
P > After 4 hours of nursing interventions, the pt will demonstrate increase in
tolerance to activity as evidenced by walking at a distance of 3-4 meters c
out experiencing fatigue and DOB thereafter
I > established rapport
> monitored and recorded v/s q 1o
> auscultated breath sounds
> Identified clients response to activities
> noted reports or dyspnea and increased weakness
> assessed the clients ability to stand and walk
> provided quiet environment and calm activities
> provided rest penods
> performed quiet conversations
> kept pits back dry

> provided CPT when pt coushed
> provided back rub
> instructed pt. to engage in relaxational and diversional activities
> instructed so not to feed the pt. because of NPO status
> instructed pt. to change position frequently
> instructed pt. to assume comfortable position when resting or sleeping
> assisted the pt. in going to the toilet
> due meds given
> IVF regulated
> needs attended
> endorsed
E > Goat met as evidenced by pt. walked towards the comfort room which is
more than 4 meters away from his bed c experiencing fatigue or DOB
thereafter
September 18, 2007
S > Yun nga ang problema ko, yung madali akong mapagod, as verbalized
by the pt.
O > Received pt. on a sitting position, awake, coherent, conscious, c an IUF of
PNSS IL @ 750cc level regulated at 30-31 gtts/min inserted at cephalic vein
infusing well.
> easy fatigability upon exertion
> experienced DOB and feels tired after walking
> with limited ROM
> experienced DOB when assuming supine position
> productive cough c reddish sputum
> no pain perceived
> with disturbance of sleep
> with vital signs taken and recorded as follows: T: 36.5 oC / axillary, P: 89
bpm,
R = 19 bpm
BP = 130/190 mmHg
A > Fatigue related to general weakness as evidenced by decrease in

performance in doing activities of daily living.
P > After 4 hours of nursing interventions, the pt. will participate in desired
activities at level of ability such as walking towards the comfort room instead
of voiding on a urinal beside the bed
I > monitored and recorded v/s q 4o
> assessed which problem bother the pt. (easy fatigability vs difficulty of
sleeping)
> determined the pts. Ability to participate in activities
> assessed the presence and degree of sleep disturbance
> noted clients belief about what is causing the fatigue
> noted daily energy patterns.
> note the need for individual assistance

> provided adequate rest periods
> encourages pt to do whatever possible activities like walking
> instructed methods to conserve energy like sitting instead of standing
> assisted c self care needs
> provided quiet environment
> performed quiet conversation
> instructed pt. to engage in diversional and relaxational activities
> kept pts back day
> provided back nub
> provided CPT when pt. coughed
> instructed pt. to assume comfortable position when resting or sleeping
> instructed pt. to limit fluid intake as ordered
> inserted O2 nasal cannula 2-3 lpm to nostrils as demanded by the pt.
> advised pt. to eat nutritious food
> regulated IUF
> stretched bed linens
> due meds given
> needs attended
> endorsed
E> Goal met as evidenced by pt. walked towards the comfort room instead of
voiding on a urinal beside the bed
September 18, 2007

S > Magkasakit ku mipatudtud nabengi as verbalized by the pt.
O > Received pt. on a sitting position, awake, coherent, conscious, c an IVF of
PNSS IL @ 750cc level regulated at 30-31 gtts/min inserted at cephalic vein
infusing well
> with disturbance of sleep last night
> experienced DOB when assuming supine position
> slept for only 4 hours last night
> with limited ROM
> with easy fatigability upon exertion
> no pain perceived
> with vital signs taken and recorded as follows. T:36.5
C / axillary,
P:89bpm, R = 19 bpm
BP = 130 / 90 mmtlg
A > Disturbed sleep pattern related to shortness of breath when assuming
supine position as evidenced by impairment of normal sleep pattern
P > After 4 hours of nursing interventions, the pt. will report increase in sense
of well-being and feeling rested
> identified presence of factors that interferes sleep
> assessed sleep pattern disturbances tat are associated with underlying
illness
> observed and obtained feedback from client regarding usual bedtime,
routines, number of hours of sleep, time of arising, and environmental needs
> determined clients expectations of adequate sleep
> identified circumstances that interrupt sleep and frequency
> observed physical signs of fatigue
> arranged care to provide for uninterrupted periods for rest, especially
allowing for longer periods of sleep at night when possible
> explained necessily of disturbances for vital signs monitoring and other
care when client is hospitalized.
> provided quiet environment and comfort measures
> instructed to limit fluid intake in evening
> instructed pt. to drink milk before going to bed
> recommended midmorning nap
> performed quiet conversations
> provided adequate rest
> provided CPT when pt. coughed
> instructed pt to assume comfortable position when resting or sleeping
> inserted O2 nasal cannula 2-3 lpm to nostnls as descended by the pt.
> acused pt. to eat nutritions food
> regulated IVF
> stretched bed linens
> due meds given
> needs attended
> endorsed
E > Goal met as evidenced by pt. reported increase in sense of well-being
and feeling rested
September 19, 2007

S > Magkasakit ku mangisnawa patye maka-falat ku as verbalized by the
pt.
O > Received pt. on a sitting position, awake, coherent, conscious, IV out.
> pt. appears slightly weak
> with dypnea experienced when assuming supine position
> with chest hightening experienced when in supine position
> used accessory muscles to breath when positioned flat in bed
> with limited ROM
> with disturbance of sleep
> have sedentany lifestyle
> with productive cough with reddish sputum
> no pain perceived
> with v/s taken and recorded as follows: T = 36.4 oC / axillany P= 86 bpm,
,R = 21bpm ,BP = 110/70 mmltg
A > Ineffective breathing pattern related to decrease lung expansion as
evidenced by dyspnea.
P > after 4 hours of nursing interventions, the pt. will be able to demonstrate
improved breathing pattern with resolving signs of hypoxia as evidenced by
pt. sleeping in side lying position.
I > monitored and recorded v/s g 4o
> noted rate and depth of respirations
> assessed environmental, social, cultural, and educational factors that may
influence teaching plan
> assessed cognitive function and emotional readiness to learn
> assessed tactile and vocal fremitus
> maintained calm attitude
> encouraged deep, slower breathing and pursed-lip, breathing exercise
> promoted proper bed positioning as to semi fowlers position.
> provided rest periods
> instructed pt. to limit fluid intake IL / day as ordered

> kept pts. back dry
> performed quiet conversation
> instructed pt. to change position frequently
> encouraged pt. to assume comfortable position when resting or sleeping
> advised pt. to eat nutritious food
> encouraged resting as needed during activities avoiding over exertion as
much as possible
> instructed pt to alternate heavy c light tasks
> due meds given
> regulated IVF
> needs attended
> endorsed
E > Goal met as evidenced by the pt demonstrated improved breathing
pattern with resolving signs of hypoxia as evidenced by pt sleeping in sidelying position
September 19, 2007

S > Pabawas de ing danum a painum da kanaku as verbalized by the pt.
O > Received pt. on a sitting position, awake, coherent, conscious, IV out
> pt appears slightly weak
> ordered to limit fluid intake upto IL/day only
> the pt. is not having proper hydration from IV line because it was removed
> the IV line was removed and was not replaced for 4 hours
> with dyspnea when assuming supine position
> with chest tightening experienced in supine position
> with limited ROM
> with productive cough with reddish sputum
> no pain perceives
>with v/s taken and recorded as follows : T = 36.4oC / axillary P = 86bpm,
R=21bpm, BP=110/70 mmltg
A > Risk for imbalanced fluid volume related to decrease fluid intake
P > after 4 hours of nursing interventions, the pt will be hydrated as
evidenced by IV line inserted with DSW and properly regulated at 15gtts/min
> noted clients age, level of consciousness / mentation
> assessed vain turgor
> assessed for clinical signs of dehydration
> assessed other etiological factors present
> established individual needs / replacement schedule
> monitored I/O balance being aware of insensible losses
> monitored changes in vital signs
> discussed individual risk factors / potential problems
> monitored increasing lethargy, hypotension, muscle cramping
> maintained fluid restrictions
> provided rest periods
> instructed pt. to limit fluid intake to IL/day as ordered
> kept pts. back dry

> provided small, frequent meals
> obtained baseline weight
> above IVF consumed, hooked DSW 500cc x 15 gtts / min as follow-up as
ordered
> due meds given
> regulated IVF
> needs attended
> endorsed
E > Goal meat as evidenced by pt. is hydrated AEB IV line inserted with DSW
and properly regulated at 15gtts/min
VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL

1. Client Daily Progress Chart (from admission to discharge)
DAYS
ADMISSI
13
14
15
16
17
18
19
ON
GE
09-12-07
NURSING
09-20-07
PROBLEMS
Ineffective airway
clearance related
to retained
secretions as
evidenced by
productive cough
with reddish
sputum and
dyspnea
Ineffective Breathing
Pattern related to
DISCHAR
decrease lung
expansion as
evidenced by dyspnea
Disturbed sleep
pattern related to
shortness of breath
when assuming
supine position as
evidenced by
impairment of
normal sleep pattern
Activity intolerance
level III related to

general weakness as
evidenced by easy
fatigability
Fatigue related to
general weakness as
evidenced by
decrease in
performance of doing
activities in of daily
living
Impaired physical
mobility
classification 3
related to weakness
as evidenced by
inability to purposely
move within the
physical environment
and limited ROM
DAYS
ADMISSIO
N
13
14
15
16
17
18
19
DISCHAR
GE
09-12-07
09-20-07
VITAL SIGNS
36.8%
36.3oC
36
36.5o
37oC
36oC
36.5o
36.4
36oC
PR
75
80
82
77
86
86
80
RR
28
28
28
74
26
20
89
21
24
BP
140/100
130/10
140/10
24
130/10
140/100
19
110/7
120/70
140/9
130/9
Temp
0
DIAGNOSTIC
/LABPROCEDURE
S
Hematology
153g /dL
a) Hemoglobin
46%
b) Hematocrit
9.1 g /L
c) White blood
.78
cells
d) Neutrophils
e) Lymphocytes
f) Platelet count
0.20/mm3
180 g IL
9.7g /L
Hematology
0.75
a) White blood
0.25/mm
cells
b) Neutrophills
c) Lymphocyles
d)
Chest
Ultrasound
There is
face
flowing
pleural
effusion,
Hemi
thorax
DAYS
ADMISSIO
13
Dark
b) Transparency
Yellow
c) Albumin
Clear
d) Reaction
Trace
e) Specific Gravity
Acidic
f) Pus cells
1.030
g) Red blood cells
0-1 / HPF
h) Epithelial cells
1.2 / HPF
few
Thoracentesis
1st:
500cc were
withdrawn
2nd ;
500cc of
fluid
withdrawn
15
16
17
18
19
DISCHARG
E
Urinalysis
a) Color
14
Pleural Fluid
Analysis
Dark Yellow
a) Color
Turbid
b) Transparency
43,762/m
c) RBC
m3
d) WBC
706/mm3
e) Neutrophils
f) Lymphocytes
g) CHON
h) LDH
6
94
3.9%
3230 U/L
DAYS
Electrocardiogr
aphy (ECG)
ADMISSIO
13
N
1. Normal
sinus
2.
Incomplete
bundle
branch
back
3.
Anterocept
al wall
ischemia
Chest x-ray
15
16
17
18
19
DISCHARG
E
Rhythm
14
- suspicious
cardiomega
ly with
pulmonary
congestion
and right
minimal
pleural
effusion
Pneumonia,
bilateral
cannot be
rived out
would
suggest
clinical
correlation
and follow
up
examinatio
n
Blood
Chemistry
a) RBS
10.11
mmol/L
b) BUN
c) Creatinine
d) LDH (Lactose
Dehydrogenises)
5.0 mmol /L
98.3
mmol/L
866.1 IU/L
e) Total CHON
f) SGOT
63.6 gm/L
g) SGPT
2 3.9 IU/L
h) NA
31.1 IU/L
i) K
13 g
mmol/L
4.0 mmol/L
CT Scan
Opacit
y in
the
right
middle
and
lower
lobes
as well
as in
the left
lung
consid
er
pneum
onic
proces
s
recom
mend
followup
study
DAYS
ADMISSIO
13
14
15
16
17
18
19
DISCHARG
E
MEDICAL
MANAGEMENT
IVF
a.) PNSS IL
b.) D5W
Oxygen
Inhalation
DAYS
ADMISSIO
13
14
15
16
17
18
19
DISCHARG
E
DRUGS
a) Furosemide
(Diuspec)
b) Cefixime
(Zefral)
c) Butamirale
Citrate
(Sinecod)
d) Aldazide
e)
Acetylcysteine
(Brencoflem)
f) Ceftriaxone
(Euroset)
g) Enalapril
(Acebitor)
h)
Roxithromycin
(Guamil)
i) Vitamin B.
Complex
DAYS
ADMISSIO
13
14
15
16
DIET
17
18
19
DISCHARG
E
a) NPO
(nothing per
orem)
b) DAT
(Diet as tolerated)
with limited
fluid intake
to
IL/day
c) DAT
(Diet as
tolerated)
ACTIVITY EXERCISE
a) Bed Rest
b) Sitting
c) Walking
2. DISCHARGE PLANNING
a. General Condition of Client upon discharge
The client is in sitting position, conscious, and coherent with D5W
500cc x 15gtts/min @ 250cc level infusing well on the left cephalic vein. The
patient appears slightly weak and with difficulty of breathing upon exertion.
He has affective productive with reddish sputum. He is now feeling better and
can eat any food that he wants. He is full of enthusiasm and can do activities
of daily living without experiencing difficulty of breathing and fatigue
thereafter. Vital signs were taken and recorded as follows: T = 36 oC P=90bpm
R=24bpm and BP: 120/70mmltg.
b. METHOD
M Reinforced instruction to pt. that he must take the following
medicines at home:
> Furosemide
20mg
ITAB
BID
> Cefixime
200mg
ICAP
BID
> Enalapril
2.5mg
TAB
BID
> Roxithromycin
30mg
OD
To consume
E Encouraged patient to perform activities of daily living as tolerated

T Emphasized the importance of compliance to treatment regimen
and health teachings given
H Encouraged pt. to do deep breathing and pursed-lip breathing
exercise
- Encouraged pt. to have adequate rest periods
- Encouraged pt. to engage in relaxational and diversional activities
- Instructed pt. to engage in relaxational and diversional activities
- Instructed pt. to alternate heavy tasks c light tasks
- Encouraged pt. to assume comfortable position when resting or
sleeping
O Instructed pt. to comeback for follow-up check-up on October 1,

2007
D Instructed pt. to eat nutritious foods
III. CONCLUSION
Character cannot be developed in ease and quiet. Only through

experience of trial can the soul be strengthened, vision cleared,
ambition inspired, and success achieved.
--
Helen Keller
There is an adage that learning never ceases. Through this, the
world tells us that learning will always take its toll upon us. We are
being screwed around with the thought that we could never escape
learning, similar to that of change. Yet, there is quite a significant
difference between those that we learned in our early years, and with
the information we will be gathering once well be required and tasked
to harness our skills.
The knowledge we reap today is supposed to benefit us in our
journey towards the next step. Perhaps it is even more correct if we
refer it to be the next leap, since the world we will be facing after all
of these is quite unnerving. Either way, all the education we have gone
in the past or so will jut aid us in our battles against life: life as an
adult, life as a person; and in our case, life as a nurse.
This case study is still part of the never-ending education.
Perhaps, through this study, we will only be learning a part of the
profession that lies ahead of us. But we believed that it is the
assimilation of these bits of information that actually makes a
successful, effective, downright and caring nurse.
The fact still remains that this study provides insufficient
information regarding a specific disease condition; but what makes this
piece of work important to us is that through this, we have been
supplied with at least the basic care, if not more of the disease. These
basics, so to speak, are the media by which optimum care is
provided to a client. These basics are the essentials by which a nurse

is tagged as a nurse.

Medical Management To Conclusion

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V.

THE PATIENT AND HIS CARE

Plain Normal Saline

Plain normal saline It is used to treat

contain increase in random

(Na, blood sugar of the

154 MEq/L, Cl, 154 client.

mCq/L) has pH of administer

4.5 to 7.0 and is medication

SODCC, 250cc and

The patient did

Explain the need for IV infusion

Check if the IV infusion is infusing well

Regulate and monitor flow rate as ordered

in It is used for clients The

via nasal cannula @

oxygen. It can be a ventilating all areas progress

who have difficulty able

inserted directly to impaired or people breathing.

gas there was relief of

may require oxygen

Sept. 17, 2007

Sept. 19, 2007

Sept. 12, 2007

>the pt did not

>the pt. did not

PO: 2 tab/ day

>the pt. did not

>the pt did not

>the pt did not

Sept. 13, 2007

Sept. 12, 2007

PO: 2.5 mg/tab

Sept. 12, 2007

Sept. 12, 2007

>the pt did not

>the pt did not

>the pt did not

>the pt did not

Cefixime and Ceftriaxone:

>Monitor frequency of prescription refills to determine adherence.

>Take the medication before meals.

Sept. 12, 2007

DAT with limited Sept. 13, 2007

Sept. 19, 2007

>no food was

>to supply the

>to give the

>he was given

Sept. 12, 2007

Sept. 12, 2007

>makes the pt sit

>the pt did not

Sept. 17, 2007

>to give the pt a

>the pt felt a little

VI. NURSING MANAGEMENT

After 4 hours record vital

2. To note for possible

O > The pt.

> pt. appears

3. To note for irregular

secretions and inability