April Grace P.

Lopez BSN1B Case: A 70 year old man was rushed in the emergency room with chief complaint of difficulty of breathing. Upon history taking the nurse found out that the old man has a body weakness for a week, low grade fever for a week and productive cough for more than two weeks. Initial vital signs are BP: 130/90 mmHg, RR: 30cpm, PR: 90bpm and Temp:38C/ axilla. ASSESSMENT Subjective: Nahihirapan ako huminga. as verbalized by the patient. Objective: V/S: BP: 130/90 mmHg PR: 90 bpm RR: 30 bpm Temp: 38 C Dyspnea Use of accessory muscle when breathing. Nasal flaring Irritable Presence of productive cough. DIAGNOSIS Ineffective Airway clearance related to secretions in the bronchi as evidenced by dyspnea. PLANNING At the end of the shift the patient will manifest a decrease in respiratory rate from 30 to 22 bpm. INTERVENTION Monitored vital signs. Assessed respiratory function, e.g., breath sounds, rate, and use of accessory muscles and secretion characteristics and amount. Positioned patient in semior high Fowlers position. Assessed airway patency. RATIONALE To have baseline data. Noted chest movement; use of accessory muscles during respiration. EVALUATION At the end of the shift the patient manifested a decreased in respiratory rate from 30 to 22 bpm.

Maintained patient on moderate high back rest. Checked for obstructions: accumulation of secretions.

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DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: May lagnat din ako mga isang linggo na. As verbalized by the patient. Objective: febrile temperatur e of 38 C flushed skin warm to touch

Hyperthermia related to disturbance of the hypothalamus due to production of pyrogen, secondary to bacterial infection in the respiratory tract.

After 6hrs of nursing intervention the patient will manifest a decrease in temperature from 38 to 37.5 C.

> Monitor vital signs >To have baseline especially temp. data. >Provided surface cooling such as TSB and removing of extra clothing. >Promoted rest and comfort providing bed rest. >To promote core cooling by helping reduce body temperature.

After 6hrs of nursing intervention the patient manifested a decrease in temperature from 38 to 37.5 C. GOAL MET

>To reduce metabolic demands that may contribute to further complications. >To prevent dehydration because increase in body temperature causes fluid loss such as sweating. >Paracetamol are classified as analgesics and antipyretic which acts on the hypothalamus to regulate normal body temperature.

>Encouraged increase in fluid intake.

> Administered paracetamol as ordered.