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HA NOI MEDICAL UNIVERSITY

ADVANCED NURSING PROGRAM

NURSING CARE PLAN

STUDENT : LE PHUONG THAO

GROUP : 41 CLASS: Y4Q

UNIT : Respiratory center

DATE OF CARE : 25/12/2018 (12th day after admission)

PATIENT’S FULL NAME : Hoang Thai Hoc

UNIT: Respiratory center

ADMISSION DATE: 13/12/2018

AGE/GENDER : 83/ Female

ALLERGIES : no allergies

SOCIAL SUPPORT: Hoang Van Hiep

Phone number: 0979338093

ADDRESS : Huong Son-Ha Tinh

Reason for hospitalization:

bloody cough
Medical diagnosis:

Respiratory failure, Pneumonia has not ruled out recurrent TB, medullary
dysfunction.
Present history:

2 weeks before hospital admission, the patient appeared to have a productive cough
and blood with a small amount, fever, the highest fever up to 39 degrees. Patients
with fatigue, shortness of breath with mild chest pain. The patient was treated for 3
days in the hospital in Ha Tinh province but was less well supported. After that, the
patient was transferred to Bach Mai Hospital.

Medical history:

a. Patient history

Patients with pulmonary tuberculosis were treated 3 years ago with an 8-


month regimen.

b. Family history

No metabolic disorder has been found.

Focus assessment:

1. Admission condition(13/12/2018)

- alert, G=15 point

- cough that produce sputum and blood

- fever

- pale skin and mucosa

- no hemorrhage under the skin, no tumor, no ulcer

- Normal lung sounds, rales in the upper part of the right lung
-

- no hepatomegaly

- Vital signs: Pulse: 102pbm

BP:118/70mmHg

RR:22 pbm

Temperature: 39oC

SpO2=95%

2. Current assessments (25/12/2018)

a. general conditions:

- alert, G=15 point

- fatigue

- pale mucous and membrane

- no hemorrhage under the skin

- no tumor, no ulcer

- Vital signs: Pulse: 100pbm

BP:130/80mmHg

RR:22 pbm

Temperature: 37oC

- Weight: 50 kg Height: 160 cm

BMI= 19.5 (normal)

b. Cardiovacular system

- Heart rate: 100bpm.

- Blood pressure: BP: 130/80mmHg


- pale skin,mucous membrane.

- Capillary refill: <2s

c. Respiratory system:

- Respiratory rate: 22 bpm,

- Cough reduced

- Right chest pain when coughing

- Not difficult to breathe

- Lungs have scattered rales

d. Gastrointestinal system

- Abdomen: symmetric, no tumor, no scar.

- Soft, no distention

- Eating by mouth, no vomiting

- stool: yellow, normal

e. Musculoskeletal system

normal

f. Genitourinary system

no has abnormal

Laboratory test

LABORATORY REFERENCE Result RATIONALE/EXPLANATIO


TEST VALUE N

RANGES (ABNORMAL VALUES


ONLY)
WBC 4.0 – 10.0 Gl 4.71
Neutrophils % 45 – 75% 58.1
Lymphocytes % 25 – 45% 21.5
Monocytes % 0 – 8% 16.5
Eosinophils % 0 – 8% 1.0
Basophils % 0 – 1% 0.4
Neutrophils # 1.8 – 7.5G/l 2.74
Lymphocytes # 1.0 – 4.5G/l 1.01
Monocytes # 0 – 0.8G/l 0,78
Eosinophils # 0 – 0.8G/l 0,05
Basophils # 0 – 0.1G/l 0,02
RBC 4.5-5.9 T/l 2.88
HGB 135 – 175g/l 93
HCT 0.41-0.53 l/l 0.291
MCV 80 – 100Fl 100.8
MCH 26 – 34pg 32.1
MCHC 315 – 363g/l 319
Platelets 150 – 400G/l 267
Basic Metabolic
Panel:
Na 133-147 mmol/l 138
K 3.4 – 4.5 4.2
mmol/l
Cl 94 – 111 99
mmol/l
Ure 2.5-6.1 mmol/l 3.1
Creatinine 45-90 µmol/l 65
Glucose 4.0-6.0 mmol/l 7.71
AST <37 U/L 20
ALT <41 U/L 20
CK 26-140 U/L 87
CK-MB <24 U/L 14
CRP <0.5 mg/dL 14.555 Risk of infection
Coagulation: ‘
Prothombin S 14.2
PT % 70 – 140 % 70.1
PT-INR 1.25
Acid lactic 0.5-2.2 mmol/l 2.34

Arterial blood gas

LABORATORY TEST REFERENCE VALUE Result

RANGES
pH 7.35 – 7.45 7.46
PCO2 35 – 45 mmHg 39
PO2 83 - 108 mmHg 95
HCO3 mmol/L 27,7

OTHER DIAGNOSTICS OR SIGNIFICANT INFORMATION (x-rays, MRI,


other studies):

 images of lesions in the upper lobe and middle lobe of the right lung

 abscess monitoring

NURSING PROCESS

date of care: 25/12/21018


12th day after admission

Diagnosis 1: ineffective breathing pattern related to respiratory


failure
Nursing intervention Rationale
1. Inspect thorax for symmetry 1. Determines adequacy of
of respiratory movement breathing

2. Observe breathing pattern: 2. Identifies increased work of


nasal flaring, pursed-lip breathing
breathing or prolonged
3. Detects use of hyperventilation
expiratory phase and use of
as a causative factor
accessory muscles
4. To have a maximum lung
3. Assess emotional response
expansion
4. Place patient in semi-
5. These techniques promotes deep
fowlers position
inspiration, which increases
5. Encourage sustained deep oxygenation and prevents
breaths by: atelectasis. Controlled breathing
methods may also aid slow
 Using demonstration:
respirations in patients who are
highlighting slow
tachypneic. Prolonged
inhalation, holding end
expiration prevents air trapping.
inspiration for a few
seconds, and passive 6. Beta-adrenergic agonist
exhalation medications relax airway
smooth muscles and cause
 Utilizing incentive bronchodilation to open air
spirometer passages.
 Requiring the patient to 7. This facilitates adequate
yawn clearance of secretions.
6. Provide respiratory 8. This is to clear blockage in
medications and oxygen, airway.
per doctor’s orders.
7. Maintain a clear airway by 9. Encourage frequent rest periods
encouraging patient to and teach patient to pace
mobilize own secretions activity.
with successful coughing.

8. Suction secretions, as
necessary.

9. Encourage frequent rest


periods and teach patient to
pace activity.

Descride outcome:

 Patient’s oxygen saturation will be 90-100% throughout hospitalization.


 Patient’s respiratory rate will be 12-20 breaths per minute throughout
hospitalization

Diagnosis 2: Impaired Gas Exchange related to increased sputum secretions

Nursing intervention Rationale

1. Position patient with head of 1. Upright position or semi-Fowler’s


bed elevated, in a semi- position allows increased thoracic
Fowler’s position as capacity, full descent of
tolerated. diaphragm, and increased lung
2. Regularly check the patient’s expansion preventing the
position so that he does not abdominal contents from
slump down in bed crowding.

3. Turn the patient every 2 2. Slumped positioning causes the


hours. Monitor mixed abdomen to compress the
venous oxygen saturation diaphragm and limits full lung
closely after turning. If it expansion.
drops below 10% or fails to 3. Turning is important to prevent
return to baseline promptly, complications of immobility, but
turn the patient back into a in critically ill patients with low
supine position and evaluate hemoglobin levels or decreased
oxygen status. cardiac output, turning on either
4. Maintain an oxygen side can result in desaturation.
administration device as 4. Supplemental oxygen may be
ordered, attempting to required to maintain PaO2 at an
maintain oxygen saturation acceptable level.
at 90% or greater. 5. This technique can help increase
5. Help patient deep breathe sputum clearance and decrease
and perform controlled cough spasms. Controlled
coughing. Have patient coughing uses the diaphragmatic
inhale deeply, hold breath for muscles, making the cough more
several seconds, and cough forceful and effective.
two to three times with 6. Suction clears secretions if the
mouth open while tightening patient is not capable of
the upper abdominal muscles effectively clearing the airway.
as tolerated. Airway obstruction blocks
6. Suction as necessary. ventilation that impairs gas
7. Administer medications as exchange.
prescribed.

Describe outcome:
 Patient manifests resolution of symptoms of respiratory distress.

diagnosis 3: Fatigue related to decreased hemoglobin and diminished oxygen-


carrying capacity of the blood.

Nursing intervention Rationale

1. Assess vital signs 1. To evaluate fluid status and


2. Obtain client descriptions of cardiopulmonary response to
fatigue activity

3. Ask client to rate fatigue 2. To assist in evaluating impact on


client’s life
4. Assess the patient’s ability to
perform ADLs, instrumental 3. To determine degree of
activities of daily living fatigability
(IADLs), and demands of 4. Fatigue can restrict the patient’s
daily living (DDLs). ability to participate in self-care
5. limiting strenuous activity, and do his or her role
Establish realistic activity responsibilities in the family and
goals with client and society, such as working outside
encourage forward movement the home.
6. Make the patient aware about 5. Changes in heart rate, oxygen
the signs and symptoms of saturation, and respiratory rate
overexertion with activity. will reflect the patient’s
tolerance for activity.

Describe outcome:
 Patient will report improved sense of energy

Diagnosis 4: Imbalanced Nutrition: Less Than Body Requirements

Nursing intervention Rationale

1. Measure intake and output 1.


accurately; Monitor weight 2.
daily
3. Eliminates noxious sights,
2. eat according to the diet of tastes, smells from the patient
the hospital environment and can reduce
3. Provide covered container nausea.
for sputum and remove at 4. To replenish lost nutrients.
frequent intervals. Assist and
5. Milk products may increase
encourage oral hygiene after
sputum production.
emesis, after aerosol and
postural drainage treatments, 6. These measures may enhance
and before meals. intake even though appetite
may be slow to return.
4. Maintain adequate nutrition
to offset hypermetabolic
state secondary to infection.
Ask the dietary department
to provide a high-calorie,
high-protein diet consisting
of soft, easy-to-eat foods.
5. Consider limiting use of milk
products
6. Provide small, frequent
meals, including dry foods
and foods that are appealing
to patient.

Describe outcome:
 Demonstrate increased appetite.
 Maintain/regain desired body weight.

Diagnosis 5: Acute Pain related to persistent coughing


Nursing intervention Rationale
1. Assess pain characteristics: 1. Chest pain, usually present to
sharp, constant, stabbing. some degree with pneumonia,
Investigate changes in may also herald the onset of
character, location, or complications of pneumonia,
intensity of pain. such as pericarditis and
2. Monitor vital signs. endocarditis.
3. Provide comfort measures: 2. Changes in heart rate or BP
back rubs, position changes, may indicate that patient is
massage. Encourage use of experiencing pain, especially
relaxation and breathing when other reasons for changes
exercises. in vital signs have been ruled
out.
4. Offer frequent oral hygiene.
3. Non-analgesic measures
5. Administer analgesics and administered with a gentle
antitussives as indicated. touch can lessen discomfort and
augment therapeutic effects of
analgesics.
4. Mouth breathing and oxygen
therapy can irritate and dry out
mucous membranes,
potentiating general discomfort.
Describe outcome:
 control of pain.
 Demonstrate relaxed manner, resting,sleeping and engaging in activity
appropriately.
Diagnosis 6: Risk for Infection

Nursing intervention Rationale

1. Monitor vital signs closely, 1. During this period of time,


especially during initiation of potentially fatal complications
therapy. may develop.
2. Instruct patient concerning 2. Although patient may find
the disposition of secretions: expectoration offensive and
raising and expectorating attempt to limit or avoid it, it is
versus swallowing; and essential that sputum be
reporting changes in color, disposed of in a safe manner.
amount, odor of secretions. Changes in characteristics of
3. Demonstrate and encourage sputum reflect resolution of
good hand washing pneumonia or development of
technique. secondary infection.

4. Change position frequently. 3. Effective means of reducing


spread or acquisition of
5. Limit visitors as indicated.
infection.
6. Encourage adequate rest
4.
balanced with moderate
activity. Promote adequate 5. Reduces likelihood of exposure
nutritional intake. to other infectious pathogens.
6. Facilitates healing process and
enhances natural resistance.

Describe outcome:
 Achieve timely resolution of current infection without complications.
 Identify interventions to prevent secondary infection.
Diagnosis 7: Deficient Knowledge

Nursing Interventions Rationale

1. Discuss debilitating aspects of 1. Information can enhance coping


disease, length of and help reduce anxiety and
convalescence, and recovery excessive concern. Respiratory
expectations. Identify self-care symptoms may be slow to
and homemaker needs. resolve, and fatigue and
2. Reinforce importance of weakness can persist for an
continuing effective coughing extended period. These factors
and deep-breathing exercises. may be associated with
depression and the need for
3. Emphasize necessity for
various forms of support and
continuing antibiotic therapy
assistance.
for prescribed period.
2.
4. Outline steps to enhance
general health and well-being: 3.
balanced rest and activity, well- 4. Increases natural defense, limits
rounded diet. exposure to pathogens.
5. Identify signs and symptoms 5. Prompt evaluation and timely
requiring notification of health intervention may prevent
care provider: increasing complications.
dyspnea, chest pain, prolonged 6. This may results in upper
fatigue, weight loss, fever, airway colonization with
chills, persistence of productive antibiotic resistant bacteria. If
cough, changes in mentation. the patient then develops
6. Instruct patient to avoid using pneumonia, the organisms
antibiotics indiscriminately. producing the pneumonia may
require treatment with more
toxic antibiotics.

Describe outcome:
 Verbalize understanding of condition, disease process, and prognosis.
 Verbalize understanding of therapeutic regimen.
 Initiate necessary lifestyle changes.
 Participate in treatment program.

Medicine

Name of drug Dose and route Effects of drugs Side effects of drugs
administration

Tienam 500mg 4

Tavanic 500mg 2
– 100ml

Mucosolvan 3 tablets
30mg
ỏal

Laevolac 15ml 2

Oral