Sie sind auf Seite 1von 34

Bataan Peninsula State University

Institute of Nursing & Midwifery

Orani Campus, Campus of Courtesy


Acute Bronchitis
Santos, John Kenneth Galicia, Lorryleen Lagman, Kimberly Cruz, Lindon Torres, Michelle Bautista, Renae Sapno, Lovely Mungcal, Precious Kate

Presented by: Group 18 MTW

Macatulad, Reymark Gabon, Jesusa Cortez, 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 shortterm 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.


The patient should follow up with their doctor within a week after treatment for bronchitissooner if your symptoms worsen or do not improve. Call the doctor's office if any new problems occur.


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 Skin Inspection

Normal Findings Skin is brown and generally equal No edema Good skin turgor No lesion Temp. is warm & cool Clean, smooth Pink to light brown nail beds No lesion No dandruff Even in distribution Symmetrical in movement & position Face is symmetrical Normocephalic Symmetrical in position Sclera is white & glossy PERRLA Brisk reaction to light Equal in size Symmetrical No swelling or discharges Symmetrical No inflammation Air can be felt in both nares

Abnormal Findings None













Pale conjunctiva




Inspection Palpation

Technique Mouth & Throat Inspection

Normal Findings Tongue is at midline

Abnormal Findings Cracked lips Tongue is pale Dental caries present Missing tooth None




Symmetrical with normal ROM No jugular vein distention Trachea is visible at the midline No nodule Lymph nodes are not palpable One breast is slightly larger No nipple discharge No masses No lymph nodes palpated Normal contour Tactile fremitus Bronchial breath sounds

Breast & Axilla

Inspection Palpation



Inspection Palpation Auscultation

Limited chest excursion



S1 & S2 heard
upon auscultation




Color is consistent with the body No lesion or any abnormal findings Bowel sounds is normo- active (13/min) No tenderness No swelling or discharges No foul smell No infestation Norma hair distribution No edema No swelling Capillary refill around 1-3 seconds None





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.


Amoxicillin Generic Name: Amoxicillin Brand Name: Amoxil, Trimox Classification: Antibiotic Mechanism of Action Inhibits bacterial cell wall mucopeptide synthesis. Indication Used to treat many different types of infections caused by bacteria, such as ear infections, bladder infections, pneumonia, gonorrhea, and E. coli or salmonella infection. Contraindication Hypersensitivity 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 sicknesslike reactions. Nursing Responsibilities Periodically 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 followup serologic test after 3 months.

Paracetamol Generic name: Paracetamol Brand Names: Biogesic Classification: Analgesic/Antipyretic Mechanism of Action Paracetamol 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 antiinflammatory effects in periphery; reduces fever through direct action on hypothalamic heat-regulating center. Indications The 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.). Contraindications Paracetamol should not be used in hypersensitivity to the preparation and in severe liver diseases. Adverse reactions In 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 Responsibilities The 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.

Ambroxol Generic Name: Ambroxol Brand Name: Mucosulvan Classification: Expectorant/Antibiotic Mechanism of Action When 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. Indication All 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. Contraindication There are no absolute contraindications but in patients with gastric ulceration relative caution should be observed. Adverse Reaction Occasional gastrointestinal side effects may occur but these are normally mild. Nursing Responsibilities Observe 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.

Metoprolol Generic Name: Metoprolol Brand Name: Lopressor, Toprol-XL Classification: Beta blocker Mechanism of Action Blocks beta receptors, primarily affecting CV system (decreases heart rate, decreases contractility, decreases BP) and lungs (promotes bronchospasm). Indication Metoprolol is used to treat angina (chest pain) and hypertension (high blood pressure). It is also used to treat or prevent heart attack. Contraindication You 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 Reaction Cardiovascular: 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 Responsibilities In 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 Diagnosi s
Ineffect ive airway clearan ce r/t increas ed product ion of bronchi al secreti ons as manife sted by Body malaise Wheez es upon auscult ation Product ive cough (yellow to green sputum Restles sness Chest pain Discom fort Facial Grimac e


Interven tions
Monito r Vital signs Place the pt. in fowler s or semifowler s positio n Teach the pt. how to do proper deep breath ing and coughi ng exerci se Avoid expos ure to irritant s such as cigaret te smoke , aeroso l and fumes Auscul tate breath sounds Increa se fluid intake Suctio n as ordere d Provid e oxyge n inhalat ion as ordere d Admini ster

Rationa le
Serve s as basel ine data To facilit ate maxi mum lung expa nsion Impro ves ventil ation and helps in mobil izing secre tions w/o causi ng fatigu e To avoid allerg ic reacti on To ascer tain statu s and note progr ess Helps liquef y secre tions To clear airwa y Provi de adeq uate amou nt of oxyg en Will

Evalua tion

Nahihirapa n akong huminga as verbalized. 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/c oherent DOB w/ an RR of 35 bpm noted. Body malaise noted Wheezes upon auscultation Productive cough (yellow to green sputum Restlessnes s noted Chest pain noted Discomfort noted Facial Grimace noted


After 8 hours of continu es nsg. Interve ntions the pt. will be able to mainta in airway patenc y Expect orate secreti ons Maintai n RR of at least 20-25 from the initial 35 bpm Learn and perfor m breathi ng and coughi ng exercis e. Verbali zed relief form dyspne a.

medic ation as ordere d

help loose n secre tions for easy expul sion.

Nursing Care Plan

Assessment Diagnosis Plannin g
After 10 hour s of nursi ng inter venti ons the pt. will parti cipat e willin gly in nece ssary activ ity Will be able to mov e her left arm with ease Lear n how to cons erve ener gy Verb alize relief from fatig ue

Interven tions
Evalua te the pt.s curren t activit y tolera nce Adjust activit y and reduc e intensi ty of task that may cause undesi red physio logical chang es Increa se exerci se and activit y levels gradu ally Teach metho ds to conser ve energ y such as sitting than standi ng while dressi ng Assist the pt. while doing ADLs Give the pt. info. That provid es eviden ce of

Ration ale
Provi de coop erati ve base line To prev ent over exer tion

Evalua tion

Ang bigat ng pakiramda m ko as verbalized 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/c oherent 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/c oherent Body malaise noted Difficulty moving left arm noted Facial grimace noted Pallor noted Complains of fatigue

Enh ance activ ity toler ance Help s mini mize wast e of ener gy

Prev ent the pt. from injur y To sust ain the pt.s moti vatio n

progre ss

Nursing Care Plan

Assessment Diagnosi s
Ineffect ive thermo regulati on r/t increas ed body temper ature as manifes ted by Warm to touch Flushed face Febrile with a temper ature of 38.2C

Planni ng
Afte r8 hour s of cont inuo us TSB, the pt.s tem pera ture will decr eas e fro m 38.2 to 37.5 C

Intervent Rational ions e

Monitor VS Increas e fluid intake Maintai n bed rest Provide sufficie nt clothin g Perfor m TSB Admini ster antipyr etics as ordered Serve s as baseli ne data To help cool down core temp eratur e To decre ase meta bolis m that produ ce heat Facilit ate comfo rt Facilit ate heat loss by mean s of evapo ration Helps lower temp eratur e within norm al range

Evalua tion

Giniginaw ako as verbalized

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/co herent Warm to touch noted Flushed face noted Febrile with a temperature of 38.2C

Nursing Care Plan

Assessment Diagnosis Planni ng
Afte r 10 hour s of nsg. inter vent ions the pt.s pain scal e will decr ease from 7 to 4 The pt. will verb alize relie f from pain Will dem onst rate use of rela xati on skill s

Intervent Rational ions e

Monitor VS Perfor m pain assess ment (COLD SPA) every time pain occurs Pain alters VS To rule out devel opme nt of compl icatio ns by knowi ng allevi ating and precip itatin g factor s Pain is subje ctive & cant be asses sed throu gh obser vation alone Prom otes relaxa tion and divert s attent ion from pain Noisy enviro nmen t stimul ates irritati on Preve nt fatigu e To

Evalua tion

Sumasakit ang dibdib at braso ko as verbalized 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/co herent Headache Restlessness Difficulty moving left arm Chest pain Pain scale of 7 out of 10 Facial grimace


Acute pain r/t localize d inflamm ation As manifes ted by Headac he Restless ness Difficult y moving left arm Chest pain Pain scale of 7 out of 10 Facial grimace

Encour age verbali zation of feeling of pain Instruc t use of relaxati on exercis e such as listenin g to music Provide quiet and calm environ ment Encour age adequa te rest period Admini ster analge sic as ordere d

maint ain tolera ble level of pain

Nursing Care Plan

Assessmen Diagnos t is Subjective:
wala akong ganang kumain Altere d nutriti on less than body requir emen ts R/T loss of appet ite as evide nced by dysfu nctio nal eatin g patter n.

Plannin g
After 4 hours of nursin g interv ention s, patien ts appeti te will be impro ved: from 2 tables poons to at least 5 tables poons per meal.

Interventi ons
Monitor vital signs Weight on regular basis Discuss eating habits includin g food preferen ces. Serve favorite foods that are not contrain dicated. Serves foods that are palatabl e and attractiv e. Prevent and minimiz e unpleasa nt odors. Emphasi ze the importan ce of well balance d nutrition diet

Rational e
For baselin e data Monitor nutritio nal state and effectiv eness of interve ntions To appeal to client likes and dislikes To stimula te the appetit e To stimula te the appetit e May have negativ e effect on appetit e/eatin g Promot e wellnes s

Evaluati on

Refusal to eat Poor muscle tonicity Body weakness noted Restlessn ess