Problem: Difficulty in sleeping Patient: R.

E Date: 11-16-09 ASSESSMENT Subjective: hindi ako makatulog ng maayos dahil nahihirapan akong huminga, as verbalized by the patient. Objective: Use of accessory muscle. Dyspnea Weak looking With contraption s, IVF of D5W x KVO V/S taken as follows: T: 36.7 PR: 57 RR: 25 Bp: DIAGNOSIS Sleep pattern disturbed related to inability to assume usual sleep position due to dyspnea. PLANNING To help the patient be able to have a good sleep within 1-2 hours of Nursing Intervention. INTERVENTION Independent: Provide quiet environmen t RATIONALE this provides a conducive environmen t for the client to relax. this soothes and relaxes the client Caffeine inhibits sleep EVALUATION Goal met. The patient was able to have a good sleep within 1-2 hours of Nursing Intervention .

Provide comfort measures (back rub) Recommend Limiting intake of caffeine and chocolate prior to sleep. Dependent: Administer Oxygen 2-3 LPM as per doctors order

To make patient comfortable and be able to sleep well.

100/80

Problem: Dyspnea

Assessment S> Marigatannak nga umanges as verbalized by the patient. O > uses accessory muscles on breathing with body weakness moaning irritable cold and clammy skin V/S: BP- 120/90 PR- 118 bpm (N= 60-100bpm) RR- 30 breaths/min (12-20 breaths/min) Temp- 35.6 C

Diagnosis Ineffective airway clearance related to decrease energy and increase fatigue with predisposin g factors present

Planning Intervention That the pts: Diagnostics: breathing To monitor pattern vital signs will go back to its normal state after To assess 1-2 hours airway for of nursing patency interventio ns

Rationale As a baseline date for the following interventions that will be done.

Evaluation

Therapeutics: To place the patient in Fowlers or high-Fowlers position. Encourage frequent positions.

Goal partially met. The patient verbalized that his breathing pattern is slightly goes back to its normal state after 1-2 hours of Maintaining airway is the nursing first priority intervention. especially in cases of trauma, acute neurological decompensation , or cardiac arrest. The upright position promotes lung expansion and improves air exchange;

Contraptions: O2 via nasal cannula running at 1-2 Lpm With IVF of D5W 1/2L x KVO

Educative: To explain effects of smoking, including second hand smokes to the patient and to the family members. To tell the family members to provide adequate rest periods for the patient by letting the patient sleep and by not talking to the patient too much. Collaborative: To dminister prescribed medications as ordered, and monitor the effects.

position changes facilitate movement secretions.

the of

Chemical irritants and allergens can increase mucus production and bronchospasm.

Rest reduces metabolic demands, fatigue, and the work of breathing, promoting a more effective breathing pattern.

- If the infecting organism is resistant to the prescribed antibiotic, little improvement may be seen with treatment. Bronchodilators help maintain open airways but may

To administer oxygen as ordered.

have adverse effects such as anxiety and restlessness. > Oxygen therapy increases the alveolar oxygen concentration and facilitates its diffusion across the alveolar-capillary membrane, reducing hypoxia and anxiety

Brand Name Capoten

Generi c Name Captopr il

General Action 25 mg 1 Antihypert tab TID ensive: angiotensi nconverting enzyme (ACE) inhibitor

Dosage

Contraindicati on Heart block

1. Observe for drop in BP within 3 hrs of initial dose if on diuretic Caution: Dizziness, therapy and low-salt diet. If BP Leukemia, cough, falls rapidly, place supine; have chronic nocturia, saline infusion available. obstructive impotence, 2. Report occurrences of bruising, pulmonary rash, polyuria, petechiae, and/or bleeding. This disease, renal hyperkalemia, may indicate a severe reaction to or thyroid taste an angiotensin antagonist such as disease disturbance captopril 3. Explain to the client that Adverse dizziness and light-headedness Effects: may occur during the first week of captopril therapy. If dizziness Oliguria, persists, the health care provider urticaria, should be notified. severe 4. Inform the client to take hypotension captopril 1 hr before a meal. Food decreases 35% of captopril

Adverse/Side Effects Side Effects:

Nursing Responsibilities

absorption. 5. Inform the client that the taste of food may be diminished during the first month of drug therapy.

Brand Name Lasix

Generic Name Furosemid e

Dosage 40 mg IV

General Action Loop (high ceiling) diuretic

Contraindicati on Presence of severe electrolyte imbalances, hypovolemia, anuria, hypersensitivity to sulfonamides, hepatic coma.

Adverse/Side Effects Side Effects: Nausea, diarrhea, electrolyte imbalances, vertigo, cramping, rash, headache, weakness, ECG changes, blurred vision, photosensitivity Adverse Effects: Severe

Nursing Responsibilities 1. Recognize the furosemide is highly protein-bound and can displace other protein-bound drugs such as Warfarin (Coumadin). 2. Assess vital signs, serum electrolytes, weight, and urine output for baseline levels. 3. Check the half-life of furosemide. With a short halflife, the drug can be repeated or given more than once a day. 4. Check onset of action for furosemide, orally and intravenously (IV). If the drug is

dehydration; marked hypotension

given IV, the urine output should be increase in 5 to 20 minutes. If urine output does not increase, notify the health Life Threatening: care provider. Severe renal Renal failure, disorder may be present. thrombocytopenia 5. Monitor urinary output to , agranulocytosis determine body fluid gain or loss. Urinary output should be at least 25ml/hr or 600ml/24 hrs. 6. Check the clients weight to determine fluid loss or gain. A loss of 2.2 to 2.5 pounds is equivalent to a fluid loss of 1 liter. 7. Monitor vital signs. Be alert of marked decrease in blood pressure. 8. Administer IV furosemide slowly; hearing loss may occur if rapidly injected. 9. Observe for signs and symptoms of hypokalemia (<3.5 mEq/L), such as muscle weakness, abdominal distention, leg cramps, and/or cardiac dysrhythmias. 10. Check serum potassium levels, especially when a client is taking digoxin. Hypokalemia enhances the action of digitalis causing digitalis toxicity. 11. Instruct the client to arise slowly to prevent dizziness resulting from fluid loss.

12. Suggest taking furosemide at mealtime or with food to avoid nausea. 13. If the client tells that he/she only eats pasta and does not eat fruits and vegetables, the nurse may have two options: to encourage the client to eat fruits and vegetables or to contact the health care provider so that an adequate potassium supplement would be prescribed to overcome potassium loss. 14. Emphasize the importance of the client taking a potassium supplement with the potassium-wasting diuretic. In addition, advise the client of consequences and dangers of not taking potassium supplements or lack of appropriate diet while taking potassium-wasting diuretics.

Brand Name Aspirin

Generic Name ASA

Dosage 80mg OD 1 tab

General Action Antipyretic Analgesic (nonopioid) Antiinflammatory Antirheumati c Antiplatelet Salicylate NSAID

Contraindication Contraindicated with allergy to salicylates or NSAIDs (more common with nasal polyps, asthma, chronic urticaria); allergy to tartrazine (cross-sensitivity to aspirin is common); hemophilia, bleeding ulcers, hemorrhagic states, blood coagulation defects, hypoprothrombin emia, vitamin K deficiency (increased risk of bleeding). with impaired renal function

Adverse/Side Effects Acute aspirin toxicity: Respiratory alkalosis, hyperpnea, tachypnea, hemorrhage, excitement, confusion, asterixis, pulmonary edema, seizures, tetany, metabolic acidosis, fever, coma, CV collapse, renal and respiratory failure (dose related, 2025 g in adults, 4 g in children) Aspirin intoleranc e Exacerbation of bronchospasm , rhinitis (with nasal polyps,

Nursing Responsibilit ies Take extra precautio ns to keep this drug out of the reach of children; this drug can be very dangerous for children. Use the drug only as suggeste d; avoid overdose . Avoid the use of other over-thecounter drugs while taking this drug. Many of these drugs contain aspirin,

asthma, rhinitis) GI: Nausea, dyspepsia, heartburn, epigastric discomfort, anorexia, hepatotoxicity

and serious overdose can occur. Take the drug with food or after meals if GI upset occurs. Do not cut, crush, or chew sustained -release products. Over-thecounter aspirins are equivale nt. Price does not reflect effective ness. You may experien ce these side

effects: Nausea, GI upset, heartbur n (take drug with food); easy bruising, gum bleeding (related to aspirin's effects on blood clotting). Report ringing in the ears; dizziness, confusion ; abdomin al pain; rapid or difficult breathing ; nausea, vomiting, bloody stools.

Generic Name Digoxin

Brand Name Lanoxin 200 mg (0.2 mg) twice daily for 4 days.

Action Alone or in combination with other agents / diuretics vasodilators in the treatment of CHF.

Mechanism of Action Initiate the face of myocardial contraction prolongs refractory period of the AV node.

Adverse Effect / Side Effect CNS: fatigue weakness, headache, blurred vision, yellow vision

Nursing Responsibilities BP should be monitored periodically in patients receiving IV digoxin. Monitor ECG throughout IV administration and throughout therapy. Notify physician of bradycardia occur. Assess any sound pulse and BP before administration and during peak administration . Monitor for chest pain. Observe for period bronchospasm .

Salbutamol

Ventolin 1 nebule now then every 8 hours.

Management of reversible due to asthma or COPD.

To prevent or treat bronchospasm in patients with reversible obstructive airway disease

CNS: nervousnes s, insomnia, headache GI: nauseas, vomiting