MEDICATION TABLET PARACETAMOL Group Contain Dosage Frequency Date On Date Off Route Indication Special Precaution Side

Effect Drug Interaction : Analgesics and Antipyretics : Paracethamol : 500 mg : BD : 22/8/2011 : 23/8/2011 : Oral : Relief of pain and fever : Renal and hepatic impairment : Hematological, skin reactions, other allergic reactions. : Alcohol, oral anticoagulant, chloramphenicol, aspirin, phenobarb, liver enzyme inducers, hepatotoxic

TABLET SINGULAIR Group Dosage Generic name Frequency Date On Date Off Route Indication : Anti Inflammatory : 5 MG : Montelukast sodium : On night : 22/08/2011 : 23/08/2011 : Oral : singulair is indicate in adults and pediatric patient 2 year of age and order for the relief of the time and night time symptoms of seasonal allergic rhinitis Contraindication Special Precaution : : Not for treatment of acute asthma attacks. Not to be abruptly substitute for inhaled or oral corticosteroids. Pregnancy Lactation Side Effect : Abdominal pain, headache, hypersensitivity reactions, hallucinations, drowsiness, GI & sleep disturbance,Myalgia. Rarely, increased bleeding tendency, bruishingoedema

TABLET PREDNISOLONE Group Dosage Generic name Frequency Date On Date Off Route Indication : Anti histamine : 10 mg : xepasone : TDS : 22/8/2011 : 24/8/2011 : Oral : suppression of inflammatory and allergic disorder including asthma, serum sickness, drug sensation, rheumatoid and urticaria Contraindication : contraindicated for patients with peptic ulcer, osteoporosis psychoses, epilepsy, diabetic mellitus, tuberculosis, herpes zoster, herpes simlplex and other viral infections. Special Precaution : in patient subjected to unusual stress, increased dosage of rapidly acting corticosteroid s before, during and after the stressfull situation is indicated. When large doses are given, it is advisable to take meals and antacids between meals to prevent peptic ulcer. Side Effect : stomach ulcer and bleeding, nervous and hormone disturbance, muscle and bone damage, and eyes changes

SYMBICORT PUFF GroUP DosagE Generic name Frequency Date On Date Off Route Indication Contraindication Special Precaution Side Effect : Corticosteroid : : Budesonide : 2 puff BD : 22/8/2011 : continue at home : oral : asthamathic : : :

I/V UNASYN Group Dosage Generic name Frequency Date On Date Off RoutE Indication : Antibiotic : 1.5 gm : sulbactam sodium/ ampicillin sodium : TDS : 22/8/2011 : continue at home : intraveneous : indicated patient upper and lower respiratory tract infections Including sinusitis, otitis media and epiglottis Contraindication : contraindicated in individuals with a history of an allergic reaction to any of the penicillin. Special Precaution : as with any antibiotic preparation, constant observation for signs of over growth of non susceptible organism. For example fungi, is essential. Side Effect : serious and occasionally fatal hypersensitivity (anaphylactic) reaction have been reported in patients on penicillin

TABLET UNASYN Group Dosage Generic name Frequency Date On Date Off Route Indication Contraindication : Antibiotic : : sultamicillin : : 22/8/2011 : continue at home. : Oral : : contraindicated in individuals with a history of an allergic reaction to any of the penicillin. Special Precaution : serious and occasionally fatal hypersensitivity(anaphylactic) reaction have been reported in patients on penicillin therapy including sultamicillin. Before have experience severe reactions when treated with chepalosporins. Side Effect : hypersensitivity reactions(hyperergic reactions) skin and mucosal reactions of varying extend and severity (itching, redness, vesiculation). local tissue swelling(urticarial oedema)

I/V HYDROCORTISONE Group Dosage Generic name Frequency Date On Date Off Route Indication Contraindication Special Precaution : anti-inflammatory : 200 mg : solu-cortef : STAT : 22/8/2011 : 22/8/2011 : intraveneous : Endocrine disorders, rheumatic disorder,allergic, respiratory diseases. : systemic fungal infections known hypersensitivity to components : in patients on corticosteroid therapy subjected to unusual stress ,increased dosage or rapidly acting corticosteroid before, during and after the stressful situation indicated Side Effect : peptic ulcer,bone and muscle damage, suppression of growth in children.

ATROVENT(NEBULLIZER) Group Dosage Generic name Frequency Date On Date Off Route Indication Contraindication Special Precaution Side Effect : : : : : : : : : : : Nausea, vomiting, lost appetite, irritating throat, it will cough secrete out the mucus.

VENTOLIN(NEBULLIZER) Group Dosage Generic name Frequency Date On Date Off Route Indication Special Precaution Side Effect : Anti-asthmatic : 1ml : salbutamol : 4 hourly : 22/8/2011 : 23/8/2011 : via mask : : : nausea, vomiting, dry mouth, dizziness, palpitation,

NURSING CARE PLAN

1. INEFFECTIVE BREATHING PATTERN: SHORTNESS OF BREATHING

DUE TO BRONCHOSPASM. 2. ALTERATION IN BODY TEMPERATURE:HYPERTHERMIA RELATED TO INFLAMMATION. 3. ALTERATION IN COMFORT:COUGH DUE TO HYPERSCRETION. 4. ALTERATION IN EMOTIONAL STATUS:ANXIETY DUE TO NEW ENVIRONMENT 5. KNOWLEDGE DEFICIT DUE TO HOME CARE MANAGEMENT OF ASTHMA

DATE: 22/8/2011 TIME: 1800H NURSING DIAGNOSIS: INEFFECTIVE BREATHING PATTERN: SHORTHNESS OF BREATHING DUE TO BRONCHOSPASM. SUPPORTING DATA: NON-VERBAL 1.Facial expression: i. ii. iii. patient look tired pale look difficulty in breathing

2. Verbal:
i.

patient complain SOB

3. Goal: Long term Short term : Patient will be able breathing easily during hospitalization. : Patient will be able breathing easily and no complain of after 2 hour after intervention was given. NURSING INTERVENTION Assess patient characteristic of respiration status example: rate,tachynoea, wheezing and rhythm. Provide baseline data and changes airway resistance, bronchospasm use for nursing intervention. I: during assessment I noticed that patient look fatigue and tired after A&E department give nebulizer. 1) Monitor vital sign patient, especially blood pressure. To detect abnormalities to patient. I: I monitor vital sign, to detect any changes at patient, and if any changes I will inform to the staff nurse and staff nurse will inform doctor. 2) Administered nebulizer as doctor order. To treat of bronchospasm. I: I serve nebulizer via mask to MR.V, then I explain to him about this procedure and he understands. 4) Teach patient a proper way deep breathing exercise after nebulizer

 To give lungs expansion, and give clear airway. I:I taught MR.V deep breathing exercise for him split out the secretion 5) Maintain patient position in semifowlers 45-60 Provide needed rest and give patient relax and easy to breath. I: I put MR.V in semifowlers position, and I ask him, whether he comfortable not, and I explain to him the purpose. 6) Give turbuhaler to the patient e.g.symbicort as orderd by doctor. Act to dilate bronchi, relief bronchospasm in reversible airway obstruction. or

I:I taught MR.V how to use symbicort puff to relief his discomfort in breathing. 7) Inform doctor if any complication to patient. To plan further intervention. I:I didnt inform doctor because patient no complain of, and patient look alert.

DATE: 22/8/2011 TIME: 2100H EVALUATION EVIDENCE : Patient able to breath easily after and hours intervention given : Patient no complains of about SOB, patient looks stable.

DATE: 22/8/2011 TIME: 1800H NURSING DIAGNOSIS : ALTERATION IN BODY TEMPERATURE: HYPERTHERMIA RELATED TO INFLAMMATION.

SUPPORTING DATA: NON-VERBAL 1.Facial expression: iv. v. patient look tired pale

2. Verbal:
i.

patient complain of fever 1/7, and temperature on admission 37.5

3. Goal:

Long term Short term

: Patient temperature will be reduce during hospitalization. : Patient temperature 37.5 will be reduce 37 after intervention given.

NURSING INTERVENTION. 1) Asses patient general condition such as flushing face, skin warm to touch and lethargic. As a baseline data to plan further intervention. I: I assess patient and patient looks flushing face but still can alert when I communicate with him. 2) Monitor vital signs especially temperature every 2 hourly. To determine what are nursing intervention were carry out, I: I monitor MR.V temperature to determine any changes in temperature. 3) Provide tepid sponging to patient if temperature is still not reduce more than 38.5 To reduce heat via evaporation. I: I will do tepid sponging if patient temperature more than 38, but patient temperature still maintain 37. 4) Advise patient to wear thin clothes and remove blanket. To promote heat loss from body. I: I explain to patient why we must wear thin clothes and remove blanket and he understand my explanation. 5) Avoid patient to do exercise. Doing exercise will increase the amount body heat produce I: I advise patient why he do not do any exercise and MR.V verbalised. 6) Advise patient to rest in bed (RIB) To minimise activity and make patient get enough rest. I: I advise patient to rest in bed, so that patient can get enough rest. 7) Serve medication paracetamol 500mg as ordered by doctor. To reduce the temperature.

I: I serve medication as ordered by doctor to MR.V, and I explain to him action of this medication, to reduce the temperature. 8) Inform doctor if temperature still not reduce. To carry out next intervention for patient. I:I didnt inform doctor, because patient temperature below than 37, and patient look stabil.

DATE: 23/8/2011 TIME: 0800H EVALUATION: Patient temperature reduce until 37 after intervention given. EVIDENCE: :NON-VERBAL: 1) Patients condition no flushing and pale, and patient looks cheerful. Verbal: 1) Patient no complain of fever, and look stabil

DATE: 22/8/2011 TIME: 1800H Nursing diagnosis: Alteration in body comfort related to cough. Supporting data: 1) Mr. A complaint having cough with secretion since 2 days. 2) Mr. A complaint that he feels uncomfortable. GOAL: LONG TERM: SHORT TERM: Nursing intervention: 1) Assess patient condition e.g. characteristic of cough, frequency, productive or nonproductive. As a baseline data to plan an appropriate nursing intervention I: I assess Mr. A when he coughing. 2)promote comfortable condition as patient desire. E.g. fowlers position; 90. for better lung expansion and easy to cough out the secretion. I:I position Mr. A in fowlers position for him easy to cough out the secretion. 3) Monitor patient vital sign especially in pulse and respiration. severe cough may indicate increasing in pulse and respiration. I: I monitor patient vital sign by doing hourly observation until the vital sign normal range. reduce to

5) Encourage patient to drink adequate fluids e.g. 1-2Lper day. to soothe he throat.

I: I advise Mr. A to drink 1-2L of water everyday. 6) Promote clean and conducive environment. to reduce cough reflex. I: I ensure that Mr. A is in clean and conducive environment. 7) Advise patient do not take any cold and oily food. to reduce throat irritation. I: I advise Mr. A to avoid taking cold and oily food. 8) Inform doctor if patient cough still persist. for further treatment I: I Didnt inform doctor, because my patient no more complain of about cough.

DATE: 23/8/2011 TIME: 1000H NURSING DIAGNOSIS: ALTERATION IN EMOTIONAL STATUS:ANXIETY DUE TO NEW ENVIRONMENT SUPPORTING DATA: NON-VERBAL: 1) Patient looks anxious when I interview.

GOAL: Patient will not anxious with new environment after intervention given.

NURSING INTERVENTION:

1) Assess patient emotional status. As base line data to plan for further intervention. I: I assess patient emotional status during my interview session. 2) Orientate patient to another patient with same condition. Orientation will make patient feel comfortable in the environment of the ward I: I will tell him about the other patient, so that he not feels comfortable. 3) Encourage family member to come for visit every day. This visit will divert patient from feel separation anxiety. I: I tell her family member especially the mother, to accompany him. 4) Advise patient to watch their favourite channel. I: I tell MR.V to watch favourite channel, so that he will not feel anxious. 5) Give a ward orientation such as doctors round, meal times and ward nurse. To reduce patient anxiety. I: I explain to him one by one, then he will know about situation in hospitalization. DATE: 23/8/2011 TIME: 1500H EVALUATION: MR.V not anxious about new environment, after my orientation to him. EVIDENCE: Patient look cheerful, verbal to communicate when I ask him.

DATE: TIME: NURSING DIAGNOSIS: KNOWLEDGE MANAGEMENT OF ASTHMA SUPPORTING DATA: NON-VERBAL: NIL VERBAL : Patient ask me regarding the management asthma DEFICIT DUE TO HOME CARE

NURSING INTERVENTION:

1) Assess patient level of knowledge, how far he knows about asthma attack. To obtain baseline data for further intervention. I: I ask patient regarding disease of asthma, I want to know level of knowledge my patient 2) Emphasis doctor misunderstanding explanation using simple word and avoid

for better understanding

3) Teach patient how to use inhaler. To avoid patient from do mistake I: I teach patient how to use inhaler, but my patient use symbicort, so I teach him how to use this turbuhaler. 4) Give patient pamphlet regarding the asthma To add patient knowledge and easy to refer when he still confuse I: I give to my patient pamphlet regarding the asthma, and I explain to patient what their explanation in that pamphlet. 4) Tell to the family member about asthma, when asthma attack, and how to control it. To prepare if anything happen when asthma attack they not to panics. I: I tell to the family members my patient how to take care him when asthma attacks. It must be faster to take action, example make sure MR.V always bring the inhaler anywhere.

5) Tell patient if still not understand he can ask me again. To make patient not confused I: I tell patient if he still not understand, then he understand what I tell him. DATE: 23/8/2011 TIME: 1800H EVALUATION: Patient can understand what I explain to him, and he ask me when he confused during the session. EVIDENCE: he not ask me again after all I explain to him. And he can perform to me how to use the turbuhaler with the correct procedure.