Bataan Peninsula State UniversityInstitute of Nursing & Midwifery

Orani Campus,Campus of Courtesy

CASE STUDY

Of

Acute Bronchitis

Presented by:Group 18 – MTW

Santos, John KennethGalicia, LorryleenLagman, Kimberly

Cruz, LindonTorres, MichelleBautista, RenaeSapno, Lovely

Mungcal, Precious Kate

Macatulad, ReymarkGabon, JesusaCortez, Jennifer

Bronchitis Overview

Bronchitis is an acute inflammation of the air passages within the lungs. It occurs when the trachea (windpipe) and the large and small bronchi (airways) within the lungs become inflamed because of infection or other causes.

The thin mucous lining of these airways can become irritated and swollen.

The cells that make up this lining may leak fluids in response to the inflammation.

Coughing is a reflex that works to clear secretions from the lungs. Often the discomfort of a severe cough leads you to seek medical treatment.

Both adults and children can get bronchitis. Symptoms are similar for both.

Infants usually get bronchiolitis, which involves the smaller airways and causes symptoms similar to asthma.

Bronchitis Causes

Bronchitis occurs most often during the cold and flu season, usually coupled with an upper respiratory infection.

Several viruses cause bronchitis, including influenza A and B, commonly referred to as "the flu."

A number of bacteria are also known to cause bronchitis, such as Mycoplasma pneumoniae, which causes so-called “walking pneumonia”.

Bronchitis also can occur when you inhale irritating fumes or dusts. Chemical solvents and smoke, including tobacco smoke, have been linked to acute bronchitis.

People at increased risk both of getting bronchitis and of having more severe symptoms include the elderly, those with weakened immune systems, smokers, and anyone with repeated exposure to lung irritants.

Bronchitis Symptoms

Acute bronchitis most commonly occurs after an upper respiratory infection such as the common cold or a sinus infection. You may see symptoms such as fever with chills, muscle aches, nasal congestion, and sore throat.

Cough is a common symptom of bronchitis. The cough may be dry or may produce phlegm. Significant phlegm production suggests that the lower respiratory tract and the lung itself may be infected, and you may have pneumonia.

The cough may last for more than two weeks. Continued forceful coughing may make your chest and abdominal muscles sore. Coughing can be severe enough at times to injure the chest wall or even cause you to pass out.

Wheezing may occur because of the inflammation of the airways. This may leave you short of breath.

When to call the doctor

Although most cases of bronchitis clear up on their own, some people may have complications that their doctor can ease.

Severe coughing that interferes with rest or sleep can be reduced with prescription cough medications.

Wheezing may respond to an inhaler with albuterol (Proventil, Ventolin), which dilates the airways.

If fever continues beyond four to five days, see the doctor for a physical examination to rule out pneumonia.

See a doctor if the patient is coughing up blood, rust-colored sputum, or an increased amount of green phlegm.

When to go to the hospital

If the patient experiences difficulty breathing with or without wheezing and they cannot reach their doctor, go to a hospital's emergency department for evaluation and treatment.

Exams and Tests

Doctors diagnose bronchitis generally on the basis of symptoms and a physical examination.

Usually no blood tests are necessary.

If the doctor suspects the patient has pneumonia, a chest x-ray may be ordered.

Doctors may measure the patient's oxygen saturation (how well oxygen is reaching blood cells) using a sensor placed on a finger.

Sometimes a doctor may order an examination and/or culture of a sample of phlegm coughed up to look for bacteria.

Self-Care at Home

By far, the majority of cases of bronchitis stem from viral infections. This means that most cases of bronchitis are short-term and require nothing more than treatment of symptoms to relieve discomfort.

Antibiotics will not cure a viral illness. Experts in the field of infectious disease have been warning for

years that overuse of antibiotics is allowing many bacteria to become resistant to the antibiotics available.

Doctors often prescribe antibiotics because they feel pressured by people's expectations to receive them. This expectation has been fueled by both misinformation in the media and marketing by drug companies. Don't expect to receive a prescription for an antibiotic if your infection is caused by a virus.

Acetaminophen (Feverall, Panadol, Tylenol), aspirin, or ibuprofen (Motrin, Nuprin, Advil) will help with fever and muscle aches.

Drinking fluids is very important because fever causes the body to lose fluid faster. Lung secretions will be thinner and easier to clear when the patient is well hydrated.

A cool mist vaporizer or humidifier can help decrease bronchial irritation.

An over-the-counter cough suppressant may be helpful. Preparations with guaifenesin (Robitussin, Breonesin, Mucinex) will loosen secretions; dextromethorphan-the "DM" in most over the counter medications (Benylin, Pertussin, Trocal, Vicks 44) suppresses cough.

Medical Treatment

Treatment of bronchitis can differ depending on the suspected cause.

Medications to help suppress the cough or loosen and clear secretions may be helpful. If the patient has severe coughing spells they cannot control, see the doctor for prescription strength cough suppressants. In some cases only these stronger cough suppressants can stop a vicious cycle of coughing leading to more irritation of the bronchial tubes, which in turn causes more coughing.

Bronchodilator inhalers will help open airways and decrease wheezing.

Though antibiotics play a limited role in treating bronchitis, they become necessary in some situations.

In particular, if the doctor suspects a bacterial infection, antibiotics will be prescribed.

People with chronic lung problems also usually are treated with antibiotics.

In rare cases, the patient may be hospitalized if they experience breathing difficulty that doesn't respond to treatment. This usually occurs because of a complication of bronchitis, not bronchitis itself.

Follow-up

The patient should follow up with their doctor within a week after treatment for bronchitis—sooner if your symptoms worsen or do not improve.

Call the doctor's office if any new problems occur.

Prevention

Stop smoking.

Avoid exposure to irritants. Proper protection in the workplace is vital to preventing exposure.

The dangers of secondhand smoke are well documented. Children should never be exposed to secondhand smoke inside the home.

Outlook

Nearly all cases of acute bronchitis clear up completely over time.

In the case of bronchitis caused by exposure to respiratory irritants, all the patient may need to do is keep away from the cause of irritation.

Smoking cessation is recommended to prevent development of chronic bronchitis or other chronic lung disease such as emphysema. Chronic bronchitis, as its name suggests, can cause symptoms for prolonged periods and lead to other debilitating lung conditions.

Name: Mrs. E.M.

Address: Banawang, Bagac, Bataan

Phone no: NN

Age: 51 y/o

Birthdate: June, 5 1958

Birthplace: San Fernando, La Union

Gender: Female

Marital Status: Married

Nationality: Filipino

Religion: Catholic

Occupation: Housewife

Physical Assessment

Technique Normal Findings Abnormal Findings

Skin Inspection

Palpation

Skin is brown and generally equal

No edema Good skin turgor No lesion Temp. is warm &

cool

None

Nails Inspection Clean, smooth Pink to light

brown nail beds

None

Hair Inspection No lesion No dandruff Even in

distribution

None

Head Inspection Symmetrical in movement & position

Face is symmetrical

Normocephalic

None

Eyes Inspection Symmetrical in position

Sclera is white & glossy

PERRLA Brisk reaction to

light

Pale conjunctiva

Ears Inspection Equal in size Symmetrical No swelling or

discharges

Nose Inspection

Palpation

Symmetrical No inflammation Air can be felt in

both nares

Technique Normal Findings Abnormal Findings

Mouth & Throat Inspection Tongue is at midline

Cracked lips Tongue is pale Dental caries

present Missing tooth

Neck Inspection

Palpation

Symmetrical with normal ROM

No jugular vein distention

Trachea is visible at the midline

No nodule Lymph nodes are

not palpable

None

Breast & Axilla Inspection

Palpation

One breast is slightly larger

No nipple discharge

No masses No lymph nodes

palpated

None

Chest InspectionPalpation

Auscultation

Normal contour Tactile fremitus Bronchial breath

sounds

Limited chest excursion

Heart Auscultation S1 & S2 heard upon auscultation

None

Abdomen Inspection Color is consistent with the body

No lesion or any abnormal findings

Bowel sounds is normo- active (13/min)

No tenderness

Genitals Interview No swelling or discharges

No foul smell No infestation

None

Extremities Inspection Norma hair distribution

No edema No swelling Capillary refill

around 1-3 seconds

Limited ROM

Human Respiratory System

The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain.

The Upper Airway and Trachea

When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voice box) and into the trachea (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must

always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs.

The Lungs

Structure

The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply.

How they work

Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Traveling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

Blood Supply

The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs.

The Work of Breathing

The Pleurae

The lungs are covered by smooth membranes that we call pleurae. The pleurae have two layers, a 'visceral' layer which sticks closely to the outside surface of your lungs, and a 'parietal' layer which lines the inside of your chest wall (ribcage). The pleurae are important because they help you breathe in and out smoothly, without any friction. They also make sure that when your ribcage expands on breathing in, your lungs expand as well to fill the extra space.

The Diaphragm and Intercostal Muscles

When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in, the diaphragm contracts and flattens out, expanding the space in your chest and drawing air into your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not normally require your muscles to work. This is because your lungs are very elastic, and when your muscles relax at the end of

inspiration your lungs simply recoil back into their resting position, pushing the air out as they go.

The Respiratory System Through the Ages

Breathing for the Premature Baby

When a baby is born, it must convert from getting all of its oxygen through the placenta to absorbing oxygen through its lungs. This is a complicated process, involving many changes in both air and blood pressures in the baby's lungs. For a baby born preterm (before 37 weeks gestation), the change is even harder. This is because the baby's lungs may not yet be mature enough to cope with the transition. The major problem with a preterm baby's lungs is a lack of something called 'surfactant'. This is a substance produced by cells in the lungs which helps keep the air sacs, or alveoli, open. Without surfactant, the pressures in the lungs change and the smaller alveoli collapse.

This reduces the area across which oxygen and carbon dioxide can be exchanged, and not enough oxygen will be taken in. Normally, a fetus will begin producing surfactant from around 28-32 weeks gestation. When a baby is born before or around this age, it may not have enough surfactant to keep its lungs open. The baby may develop something called 'Neonatal Respiratory Distress Syndrome', or NRDS.

Signs of NRDS include tachypnoea (very fast breathing), grunting, and cyanosis (blueness of the lips and tongue). Sometimes NRDS can be treated by giving the baby artificially made surfactant by a tube down into the baby's lungs.

The Respiratory System and Ageing

The normal process of ageing is associated with a number of changes in both the structure and function of the respiratory system. These include:

Enlargement of the alveoli. The air spaces get bigger and lose their elasticity, meaning that there is less area for gases to be exchanged across. This change is sometimes referred to as 'senile emphysema'.

The compliance (or springiness) of the chest wall decreases, so that it takes more effort to breathe in and out.

The strength of the respiratory muscles (the diaphragm and intercostal muscles) decreases. This change is closely connected to the general health of the person.

All of these changes mean that an older person might have more difficulty coping with increased stress on their respiratory system, such as with an infection like pneumonia, than a younger person would.

Bronchitis

AmoxicillinGeneric Name: AmoxicillinBrand Name: Amoxil, TrimoxClassification: Antibiotic

Mechanism of ActionInhibits bacterial cell wall mucopeptide synthesis.

IndicationUsed to treat many different types of infections caused by

bacteria, such as ear infections, bladder infections, pneumonia, gonorrhea, and E. coli or salmonella infection.

ContraindicationHypersensitivity to penicillins, cephalosporins, or imipenem. Not

used to treat severe pneumonia, empyema, bacteremia, pericarditis, meningitis, and purulent or septic arthritis during acute stage.

Adverse Reaction:CNS:Agitation; anxiety; behavioral changes; confusion; convulsions; dizziness; headache; hyperactivity; insomnia.Dermatologic: Acute generalized exanthematous pustulosis; erythema multiforme; erythematous maculopapular rashes; exfoliative dermatitis; mucocutaneous candidiasis; Stevens-Johnson syndrome; toxic epidermal necrolysis; urticaria.GI: Diarrhea (2%); nausea (1%); black, hairy tongue; hemorrhagic pseudomembranous colitis; tooth discoloration; vomiting.Genitourinary:Crystalluria; vulvovaginal mycotic infection.Hematologic-Lymphatic: Agranulocytosis; anemia; eosinophilia; hemolytic anemia; leukopenia; thrombocytopenia; thrombocytopenic purpura.Hepatic: Acute cytolytic hepatitis; cholestatic jaundice; hepatic cholestasis; increased ALT and AST.Hypersensitivity: Anaphylaxis; hypersensitivity vasculitis.Miscellaneous: Serum sickness–like reactions.

Nursing ResponsibilitiesPeriodically assess renal, hepatic, and hematopoietic function

during prolonged therapy. Patients diagnosed with gonorrhea should have a serologic test for syphilis at the time of treatment and a follow-up serologic test after 3 months.

ParacetamolGeneric name: ParacetamolBrand Names: BiogesicClassification: Analgesic/Antipyretic

Mechanism of ActionParacetamol possesses prominent antipyretic and analgesic

effects. Its anti-inflammatory activity is weak and has no clinical significance. The mechanism of action is related to depression of the prostaglandin synthesis by inhibition of the specific cell cyclooxygenase, and depression of the thermoregulatory center in the medulla oblongata. Inhibits prostaglandins in CNS, but lacks anti-inflammatory effects in periphery; reduces fever through direct action on hypothalamic heat-regulating center.

IndicationsThe preparation is indicated in diseases manifesting with pain

and fever: headache, toothache, mild and moderate postoperative and injury pain, high temperature, infectious diseases and chills (acute catarrhal inflammations of the upper respiratory tract, flu, small-pox, parotitis, etc.).

ContraindicationsParacetamol should not be used in hypersensitivity to the

preparation and in severe liver diseases.

Adverse reactionsIn rare cases hypersensitivity reactions, predominantly skin

allergy (itching and rash), may appear. Long-term treatment with high doses may cause a toxic hepatitis with following initial symptoms: nausea, vomiting, sweating, and discomfort. Occasionally a gastrointestinal discomfort may be seen.

Nursing ResponsibilitiesThe preparation should be used with care in patients with liver

and renal diseases. The treatment with Paracetamol may change the laboratory tests of uric acid and blood glucose analysis. In severe renal failure the interval between two consecutive takings should not be shorter than 8 hours. The treatment with the preparation is not advisable during the first trimester of the pregnancy. In nursing women the preparation should be used with strictly observation of the therapeutic dose and duration of the treatment.

AmbroxolGeneric Name: AmbroxolBrand Name: MucosulvanClassification: Expectorant/Antibiotic

Mechanism of ActionWhen administered orally onset of action occurs after about 30

minutes. The breakdown of acid mucopolysaccharide fibers makes the sputum thinner and less viscous and therefore more easily removed by coughing. Although sputum volume eventually decreases, its viscosity remains low for as long as treatment is maintained.

IndicationAll forms of tracheobronchitis, emphysema with bronchitis

pneumoconiosis, chronic inflammatory pulmonary conditions, bronchiectasis, bronchitis with bronchospasm asthma. During acute exacerbations of bronchitis it should be given with the appropriate antibiotic.

ContraindicationThere are no absolute contraindications but in patients with

gastric ulceration relative caution should be observed.

Adverse ReactionOccasional gastrointestinal side effects may occur but these are normally mild.

Nursing ResponsibilitiesObserve respiratory rate and obtain baseline data. Check drug

interactions if taking other medications.It is advisable to avoid use during the first trimester of pregnancy.

MetoprololGeneric Name: MetoprololBrand Name: Lopressor, Toprol-XLClassification: Beta blocker

Mechanism of ActionBlocks beta receptors, primarily affecting CV system (decreases

heart rate, decreases contractility, decreases BP) and lungs (promotes bronchospasm).

IndicationMetoprolol is used to treat angina (chest pain) and hypertension

(high blood pressure). It is also used to treat or prevent heart attack.

ContraindicationYou should not use this medication if you are allergic to metoprolol,

or if you have a serious heart problem such as heart block, sick sinus syndrome, or slowheart rate. If you have any of these other conditions, you may need a dose adjustment or special tests to safely use metoprolol:

pheochromocytoma; or problems with circulation (such as Raynaud's syndrome); congestive heart failure; asthma, bronchitis, emphysema; diabetes; low blood pressure; depression; liver or kidney disease; a thyroid disorder; or myasthenia gravis.

Adverse ReactionCardiovascular:Hypotension; edema; flushing; bradycardia (3%); palpitations; CHF; arterial insufficiency; peripheral edema.CNS: Headache; fatigue; dizziness (10%); depression (5%); lethargy; drowsiness; forgetfulness; sleepiness (10%); vertigo; paresthesias.Dermatologic: Rash (5%); facial erythema; alopecia; urticaria; pruritus (5%).EENT: Dry eyes; visual disturbances.GI:Nausea; vomiting; diarrhea (5%); dry mouth; gastric pain; constipation; heartburn; flatulence.Genitourinary: Impotence; urinary retention; difficulty with urination.Respiratory: Shortness of breath (3%); bronchospasm; dyspnea; wheezing.Miscellaneous: Increased hypoglycemic response to insulin; may mask hypoglycemic signs; muscle cramps; asthenia; systemic lupus erythematosus; cold extremities.

Nursing ResponsibilitiesIn patients with angina pectoris or coronary artery disease (CAD),

metoprolol may cause exacerbation of angina, occurrence of MI, and ventricular arrhythmias. Monitor patients closely. Because CAD is common and often unrecognized, it may be prudent not to discontinue beta-blocker therapy abruptly in patients being treated for hypertension.

Nursing Care Plan

Assessment Diagnosis

Planning Interventions

Rationale

Evaluation

Subjective: “Nahihirapa

n akong huminga” as verbalized.

Objective: Received

awake lying on bed with an ongoing IVF of PLRS 1 L at 350 cc level regulated at 10 gtts, infusing well at right arm.

Conscious/coherent

DOB w/ an RR of 35 bpm noted.

Body malaise noted

Wheezes upon auscultation

Productive cough (yellow to green sputum

Restlessness noted

Chest pain noted

Discomfort noted

Facial Grimace noted

Ineffective airway clearance r/t increased production of bronchial secretions as manifested by

Body malaise

Wheezes upon auscultation

Productive cough (yellow to green sputum

Restlessness

Chest pain

Discomfort

Facial Grimace

After 8 hours of continues nsg. Interventions the pt. will be able to maintain airway patency

Expectorate secretions

Maintain RR of at least 20-25 from the initial 35 bpm

Learn and perform breathing and coughing exercise.

Verbalized relief form dyspnea.

Monitor Vital signs

Place the pt. in fowler’s or semi-fowler’s position

Teach the pt. how to do proper deep breathing and coughing exercise

Avoid exposure to irritants such as cigarette smoke, aerosol and fumes

Auscultate breath sounds

Increase fluid intake

Suction as ordered

Provide oxygen inhalation as ordered

Administer

Serves as baseline data

To facilitate maximum lung expansion

Improves ventilation and helps in mobilizing secretions w/o causing fatigue

To avoid allergic reaction

To ascertain status and note progress

Helps liquefy secretions

To clear airway

Provide adequate amount of oxygen

Will

medication as ordered

help loosen secretions for easy expulsion.

Nursing Care Plan

Assessment Diagnosis Planning

Interventions

Rationale

Evaluation

Subjective: “Ang bigat

ng pakiramdam ko” as verbalized

Objective: Received

awake lying on bed with an ongoing IVF of PLRS 1 L at 340 cc level regulated at 10 gtts, infusing well at right arm.

Conscious/coherent

Body malaise noted

Difficulty moving left arm noted

Facial grimace noted

Pallor noted Complains

of fatigue

Activity intolerance r/t to generalized body weakness as manifested by

Conscious/coherent

Body malaise noted

Difficulty moving left arm noted

Facial grimace noted

Pallor noted Complains

of fatigue

After 10 hours of nursing interventions the pt. will participate willingly in necessary activity

Will be able to move her left arm with ease

Learn how to conserve energy

Verbalize relief from fatigue

Evaluate the pt.’s current activity tolerance

Adjust activity and reduce intensity of task that may cause undesired physiological changes

Increase exercise and activity levels gradually

Teach methods to conserve energy such as sitting than standing while dressing

Assist the pt. while doing ADLs

Give the pt. info. That provides evidence of

Provide cooperative baseline

To prevent over exertion

Enhance activity tolerance

Helps minimize waste of energy

Prevent the pt. from injury

To sustain the pt.’s motivation

progress

Nursing Care Plan

Assessment Diagnosis

Planning

Interventions

Rationale

Evaluation

Subjective: “Giniginaw

ako” as verbalized

Objective: Received

awake lying on bed with an ongoing IVF of PLRS 1 L at 320 cc level regulated at 10 gtts, infusing well at right arm.

Conscious/coherent

Warm to touch noted

Flushed face noted

Febrile with a temperature of 38.2°C

Ineffective thermoregulation r/t increased body temperature as manifested by

Warm to touch

Flushed face

Febrile with a temperature of 38.2°C

After 8 hours of continuous TSB, the pt.’s temperature will decrease from 38.2 to 37.5°C

Monitor VS

Increase fluid intake

Maintain bed rest

Provide sufficient clothing

Perform TSB

Administer antipyretics as ordered

Serves as baseline data

To help cool down core temperature

To decrease metabolism that produce heat

Facilitate comfort

Facilitate heat loss by means of evaporation

Helps lower temperature within normal range

Nursing Care Plan

Assessment Diagnosis Planning

Interventions

Rationale

Evaluation

Subjective: “Sumasakit

ang dibdib at braso ko” as verbalized

Objective: Received

awake lying on bed with an ongoing IVF of PLRS 1 L at 300 cc level regulated at 10 gtts, infusing well at right arm.

Conscious/coherent

Headache Restlessness Difficulty

moving left arm

Chest pain Pain scale of

7 out of 10 Facial

grimace

Acute pain r/t localized inflammation

As manifested by

Headache

Restlessness

Difficulty moving left arm

Chest pain

Pain scale of 7 out of 10

Facial grimace

After 10 hours of nsg. interventions the pt.’s pain scale will decrease from 7 to 4

The pt. will verbalize relief from pain

Will demonstrate use of relaxation skills

Monitor VS

Perform pain assessment (COLDSPA) every time pain occurs

Encourage verbalization of feeling of pain

Instruct use of relaxation exercise such as listening to music

Provide quiet and calm environment

Encourage adequate rest period

Administer analgesic as ordered

Pain alters VS

To rule out development of complications by knowing alleviating and precipitating factors

Pain is subjective & can’t be assessed through observation alone

Promotes relaxation and diverts attention from pain

Noisy environment stimulates irritation

Prevent fatigue

To

maintain tolerable level of pain

Nursing Care Plan

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation

Subjective: “wala

akong ganang kumain”

Objective: Refusal

to eat Poor

muscle tonicity

Body weakness noted

Restlessness

Altered nutrition less than body requirements R/T loss of appetite as evidenced by dysfunctional eating pattern.

After 4 hours of nursing interventions, patient’s appetite will be improved: from 2 tablespoons to at least 5 tablespoons per meal.

Monitor vital signs

Weight on regular basis

Discuss eating habits including food preferences.

Serve favorite foods that are not contraindicated.

Serves foods that are palatable and attractive.

Prevent and minimize unpleasant odors.

Emphasize the importance of well balanced nutrition diet

For baseline data

Monitor nutritional state and effectiveness of interventions

To appeal to client likes and dislikes

To stimulate the appetite

To stimulate the appetite

May have negative effect on appetite/eating

Promote wellness