PA TOOL (Medicine Ward)

Revised 2022
Mindanao State University

COLLEGE OF HEALTH SCIENCES
Marawi City
Name of Students: B3 STUDENTS Clinical Instructor: DR. JONAID M. SADANG, RN, RM, LPT, MAN, PHD H.C., DSCN
PANARA-AG, JOEHARA MACAUROG
Area of Assignment: MEDICINE WARD Date Submitted: November 08, 2022
NURSING ASSESSMENT I
PATIENT’S PROFILE
Name: XXX Address: WAWALAYAN CALOCAN, MARAWI CITY, LANAO DEL SUR Age: 71 YEARS OLD
Sex: MALE Religion: ISLAM Civil Status: MARRIED Occupation: NONE
HABITS
Frequency Amount Period/Duration
1. Tobacco x x x
2. Alcohol x x x
OTC-drugs/ non-prescription drugs PRN 500mg 3 days, prior to admission
(Paracetamol for fever)
A. CHIEF COMPLAINT
Dyspnea
B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and
vocational responsibilities, affected diagnoses}.
Patient, a 71-year-old married male, first felt DOB in October 19 as he was swiping their floor for dusts but did not seek immediate medical attention as he expected hid DOB to go away
in days. But, only until October 26 did, he felt it is no longer manageable at home. During the admission, patient was experiencing DOB with an intensity of 8/10 that lasted for 7 days.
Patient articulated that performing daily tasks would aggravate his illness and that he alleviates it by resting and through medications (Nebulizer, Piptaz, and Salmeterol for the inhaling
device). During admission, patient was also experiencing occasional productive cough, shortness of breath, wheezing, and lack of energy. Patient had been treated for Chronic Obstruction
of Pulmonary Disease for the past two months. Patient cannot do social responsibilities as he feels immediate DOB when doing so. Patient also has no other illness that could have been
affected.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications,
habits, birth and developmental history, nutrition- for pedia)
Patient was already diagnosed with Chronic Obstruction of Pulmonary Disease in Acute Exacerbation. The patient stated that his illness was due to inspiration of strong chemical. In 1980,
their home was close to a factory making muriatic acid and an explosion happened causing strong chemicals in the air. He had been hospitalized twice for the past two months. He was first
admitted for DOB in August 20-24, 2022, the second time was also due to DOB in September 24-29, and the third time was also due to DOB in October 26-still admitted. Patient has no
injuries. He had undergone cataract surgery on his left eye in 2015 and the right eye in 2016. He does not carry any infectious disease. Patient had not been immunized with Pneumococcal
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vaccine and Covid vaccine. Patient has Hypertension and Diabetes Milletus II and has allergies on chicken and green beans. For his HTN, he uptakes Losartan in the morning and
Amlodipine in the evening. He also has medications for his Diabetes Mellitus, Glimepiride in the morning and Gliclazide in the evening. Patient is a non-smoker and non-alcoholic person.
FAMILY HISTORY WITH GENOGRAM
Acquired Diseases: Heredo- familial Diseases:

Hypercholesterolemia  Diabetes 
Kidney Disease  Heart Diseases 
Tuberculosis  Hypertension 
Alcoholism  Cancer 
Drug Addiction  Asthma 
Hepatitis A  Epilepsy 
B  Mental Illness 
C  Rheuma/Arthritis 
Others (pls. specify) Others (pls. specify)
D. PATIENT’S PERCEPTION OF:

1.Present Illness
“Aya bo a problema akn na maregen a kapakaginawa akn” as verbalized by the patient.
2.Hospital Environment
“Malo miyakaluwag (so facilities), mapiya den. Ago so mga nurses na excellent so service iran” as verbalized by the patient.
E. SUMMARY OF INTERACTION
Patient was cooperative had barrier in communicating as he had difficulties in hearing. Thus, taking the assessment longer as the student nurses had to explain the questions twice. The
patient was very responsive that he sometimes diverts the topic to another so the SNs had to redirect the topic to what is being asked. The pt also had difficulty vocalizing his insights due
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to DOB – he can’t talk continuously as he had a hard time breathing but not too extremely. Overall, p atient was responsive, cooperative, and openly shared about his illness and other
essential details needed.
PHYSICAL EXAMINATION
Name: XXX Date: October 28. 2022

Chief Complaint: Dyspnea Height: 157 cm or 1.57 m Weight: 71 kg
Vital Signs: Temp: 36.7 C RR: 31 cpm PR: 71 bpm O2Sat: 90% BP: 110/70 mmHg Intensity Score (DOB): 8/10 BMI: 45.22 (Extreme Obesity)
GENERAL
The patient was received conscious and in high-fowler’s position with no I.V, only heplock hooked at left hand patent and intact. Pt was interactive and
independently answered all inquiries of the student nurses.
HEENT H: Headaches are felt occasionally, head size is normocephalic, bald spots noted, white hairs present, no bruises, no abnormal bumps and swelling, the
circumference is circular with no deformities, no sounds in the head upon auscultation, no soft areas, facial feature is asymmetrical and is masculine, facial skin
color is light brown, frontal is wider, parietal is hard, occipital area is flat, not-so-sharp mandible, maxilla aligned with mandible, zygomatic bone is not protruding,
no acromegaly, moderate amount of facial hairs, no presence of reddened cheeks, no hydrocephalus, nor craniofacial anomalies, and no moon face observed,.
E: No enlargement of the eye, noticeable weakness in eyes, myopia present, no astigmatism, eyebrows correspond in facial expression, eyelids are normal, no
protrusion of eyeballs, visual acuity of both eyes is different, left eye is moderately blurry than the right one, ocular movement is good, pt is not wearing contact
lenses and artificial eye, no conjunctivitis, no hordeolum, no iritis, presence of cataracts, pupil in right eye constricts normally, pupil in the left eye constricts lesser
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and reacts to light 0.001sec late, left eye had undergone through cataract surgery in 2015 whilst the right eye was in 2016.
E: Left lateralization is suspected, no malignant lesions, no buildup of cerumen in ear canals, no otitis externa, no polyp, no exostosis, no red and bulging
membrane, no indication of blood resulted from trauma, no ruptures, no infections, no scars, and no white spots &streaks.
N: Occasional epistaxis, pt can smell well but with no recognition of the object, nose is patent, no nasal drainage, flaring of the nose present, and little presence of
mucous.
T: Lips are close to pallor, dental caries present, gums are a bit pale, teeth are all cut upper parts are gone due to dental caries, tartar present, plaque present, no
tonsilitis & stomatitis, no parotitis, no glossitis, no herpes simplex zoster, no angioedema, no leukoplakia, no candidiasis, no dysphagia, no throat pain, no masses,
no distention, tongue is healthy, floor of the mouth is normal, salivary glands are noticed. Neck muscles are flexible with no swelling/bumps, pulsation is present,
and no enlargement of the lymph.
Skin has glimpse of redness, dark skin areas in neck, armpits, and ankles. Saggy skin associated with old age, warts (kulogo) present, macules present, skin in
fingers do not recoil, bald spots noted, white hairs present, pale conjunctiva, warm to touch, good skin turgor, no lesion, no cyanosis, no jaundice, no erythema, no
INTEGUMENTARY birthmarks, no vitiligo, mild swelling in hands, no papule, no plaques, no nodules, no pustules, no vesicles, no cysts, no wheals, scratch marks present, no ruptured
vesicles, no lichenification, no scales, no crusts, no skin ulcer, no fissures, no keloid, no excoriation, no contact dermatitis, no psoriasis, no hives, no scabies, and
no tinea corporis
Hypertension II with a blood pressure of 150/90 mmHg; Presence of Diabetes Milletus II with glucose level of 587 and is constant from morning to lunch without
eating and when insulin is not given; murmurs present, increased heart rate, irregular rhythm, hypoxemia as evidenced by the metabolic acidosis in ABG, and chest
CARDIOVASCULAR
pain present. Pt intakes Losartan in the morning and Amlodipine in the evening for his HTN. For his DM II, Glimepiride is taken in the morning and Gliclazide in
the evening.
Adventitious breath sound of wheezing, dyspnea observed evidenced with RR of 31 cpm and intensity score of 8/10, chest discomfort, tachypnea present, patient
takes longer to exhale for 3 seconds, barrel chest, shortness of breathing observed, chest discomfort of 6/10, abnormal breath sounds (Ronchi), productive cough,
RESPIRATORY prolonged exhalation of 3secs, excessive greenish sputum, diminished and low-pitched breath sounds, sonorous or sibilant wheezes, and inaudible bronchophony,
egophony, & whispered pectoriloquy. Frequent infections observed, fine inspiratory crackles, no surface anomalies, no pigeon chest, no funnel chest, no thoracic
kyphoscoliosis, absence of paradoxical movement,
Increased thirst and hunger, skin is flabby, soft, and non-tender. No dullness upon percussion when percussed in the fecal area, no tympany percussed, obesity
GASTROINTESTINAL observed, no fibroids and other masses, no ascitic fluid, no epigastric hernia, liver is normal, left-lower quadrant pain associated with frequent urination, normal
spleen, normal gallbladder, and no aortic aneurysm.
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Pt is conscious, alert, and oriented with the time, place, environment, and the people. Pt is irritable, has frequent mood changes, and no noticeable spinal
deformities. Impaired olfactory nerve as pt can’t recognize objects even if smelled well; impaired optic nerve as pt can barely see from afar; impaired oculomotor
nerve as pt has different pupil constrictions in the eyes (right eye constricts normally than the left eye), pt can lift his eyelids and control eye movements; normal
trochlear nerve as pt can contract one eye muscle and vice versa; trigeminal nerve is normal but pt feels numbness/can’t feel through touching objects due to his
NEUROLOGICAL hypertension II but, pt can sense pain and temperature, pt can clench his jaw for biting and chewing; abducens nerve is normal, facial nerve functions well as pt can
smile, frown, and close his eyes; acoustic nerve is impaired as pt has left lateralization; vestibulocochlear nerve is normal as pt can maintain balance;
glossopharyngeal nerve is normal as patient has gag reflex; vagus nerve is normal; spinal nerve is normal as pt can freely move his head, neck, and shoulder
muscles; and hypoglossal nerve is normal though patient can barely talk due to shortness of breath. Pt does not have eye tics, no amyotrophic lateral sclerosis, and
no abnormal gaits. Overall, pt can speak and respond well to people.
Pt is extremely obese according to the BMI, pt has hand tremors, body malaise observed, unintended weight loss was articulated by the pt, fatigue noticed,
numbness or tingling in the hands or feet. Pt can perform all skeletal muscle movements: abduction, adduction, circumduction, inversion, eversion, extension,
MUSCULOSKELETAL flexion, pronation, supination, protraction, retraction, and rotation. No flattening of the lumbar curve is noticed, no kyphosis, no lumbar lordosis, no scoliosis, no
arthritis, no ganglion, hammer toe present, no hallux valgus. Pt’s upper extremity muscle strength score is 4/5 and, lower extremity muscle strength score is 4/5.
Overall, pt has noticeable body weakness, chest discomfort, and difficulty of breathing.
REPRODUCTIVE Patient has increased risk for infection, erectile dysfunction, decreased libido, and ejaculation problems.
The patient has normal urination of 5x a day but still urinates frequently without excessive drinking of water; pt usually urinates 300mL with yellowish substance.
EXCRETORY
Pt defecates daily with yellowish, normal texture of stool.
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NURSING ASSESSMENT II
Name: XXX Age: 71 Years Old

Admitting Chief Complaint: Dyspnea Sex: Male
Impression/Diagnosis: COPD in Acute Exacerbation Inclusive Dates of Care: October 26, 2022 – October 28, 2022
Date/Time of Admission: October 26, 2022, 7:16 PM Allergies: Chicken and Green Beans
Diet: Low Sodium and Low Sugar Diet Type of Operation (if any): None
CLINICAL APPRAISAL
NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL
DAY 1 DAY 2
Patient has no work and staying at Patient is limited of tasks and can’t Patient is limited of tasks and can’t
Patient is limited of tasks and can’t
1.ACTIVITIES- REST home. Patient can rest any time but do any activities. Patient rests any do any activities. Patient rests any
do any activities. Patient rests any
a. Activities has irregular sleeping pattern. He time and has an improved sleeping time and has an improved sleeping
time and still with irregular sleeping
begins to sleep at 10PM but pattern. He can now sleep at an pattern. He can now sleep at an
pattern of sleeping at 10PM, wakes
b. Rest suddenly wakes up at 12MN and average of 6-8hrs every night and average of 6-8hrs every night and
up at 12MN, and can no longer go
can no longer go back to sleep until only wakes up when there are only wakes up when there are
back to sleep. Only 2 hours of deep
c. Sleeping pattern morning. Only 2 hours of deep medications that are needed to be medications that are needed to be
sleep.
sleep. taken. taken.
Patient eats what the hospital Patient eats what the hospital Patient eats what the hospital
provides and sometimes eats provides and sometimes eats provides and sometimes eats
2.NUTRITIONAL- METABOLIC
Patient consumes rice and more of biscuits/bread for his snacks. He is biscuits/bread for his snacks. He is biscuits/bread for his snacks. He is
a. Typical intake (food, fluid)
vegetables. Also, patient likes to still in his strict diet, low sugar, and still in his strict diet, low sugar, and still in his strict diet, low sugar, and
have banana and milk as snacks too. sodium diet. Patient weighs 71kg. sodium diet. Patient weighs 71kg. sodium diet. Patient weighs 71kg.
b. Diet
Patient has a strict diet of low sugar Medication taken include Medication taken include Medication taken include
and sodium due to his DM II. Hydroxyzine, Salbutamol, Hydroxyzine, Salbutamol, Hydroxyzine, Salbutamol,
c. Diet restrictions
Patient’s weight is 74 kg and has Hydrocortisone, Omeprazole, Hydrocortisone, Omeprazole, Hydrocortisone, Omeprazole,
drug maintenance such as Losartan Piperacillin Tazobactam, Piperacillin Tazobactam, Piperacillin Tazobactam,
d. Weight
and Amlodipine for hypertension, Acetylcysteine, Ipratropium Acetylcysteine, Ipratropium Acetylcysteine, Ipratropium
Gliclazide and Glimepiride for his Bromide Salbutamol, Budesonide, Bromide Salbutamol, Budesonide, Bromide Salbutamol, Budesonide,
e. Medications/supplement
diabetes. Losartan, and Insulin Glargine. Losartan, and Insulin Glargine. Losartan, and Insulin Glargine.
food
Medications for his HTN and DM Medications for his HTN and DM Medications for his HTN and DM
are still maintained. are still maintained. are still maintained.
Patient reported that he urinates
3.ELIMINATION
regularly at least 6 times and Patient urinates at least 5 times a Patient urinates at least 5 times a
a. Urine (frequency, color,
defecates regularly twice a day. day and defecates once. Urine color Patient urinates at least 3 times a day and defecates once. Urine color
transparency)
Urine color was clear yellow, and is yellowish, and the stool is in day and hasn’t defecate. Urine color is yellowish, and the stool is in
the stool was firm and soft, normal texture, consistency yellow is yellowish. normal texture, consistency yellow
b. Bowel (frequency, color,
consistency in between light to dark color. color.
consistency)
brown color.
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4.EGO INTEGRITY
Patient stated that he is very calm in
a. Perception of self
coping up with everything. He relies
Patient stated that he is very calm
on his family especially his wife. He Patient stated that he is very calm Patient stated that he is very calm
b. Coping Mechanism but when in pain, he appears to be
had stated that every time he gets and in good mood, he relies on his and in good mood, he relies on his
low mood and slightly irritated. He
angry, he diverts his attention to wife. wife.
c. Support System relies on his wife.
other things, and sometimes drink
water help him calm.
d. Mood/Affect
Patient stated that he has good Patient stated that he has good Patient stated that he has good Patient stated that he has good
5.NEURO-SENSORY
mental state, patient oriented to mental state, patient oriented to mental state, patient oriented to mental state, patient oriented to
a. Mental state
person, place, time, and situation, person, place, time, and situation, person, place, time, and situation, person, place, time, and situation,
has a sharp memory; the right eye has a sharp memory; the right eye has a sharp memory; the right eye has a sharp memory; the right eye
b. Condition of five senses:
can see properly but the left eye is can see properly but the left eye is can see properly but the left eye is can see properly but the left eye is
(sight, hearing, smell,
blurry, sense of smell and touch are blurry, sense of smell and touch are blurry, sense of smell and touch are blurry, sense of smell and touch are
taste, touch)
intact. intact. intact. intact.
6.OXYGENATION
a. Vital Signs
T: 36.7 ℃ T: 36.2 ℃ T: 36.8 ℃
Temperature
RR: 31 cpm RR: 28 cpm RR: 24 cpm
Respiratory Rate Patient’s S.O. reported that vital
HR: 71 bpm HR: 78 bpm HR: 83 bpm
Heart Rate signs cannot be monitored since
BP: 110/70 mmHg BP: 110/80 mmHg BP: 120/80 mmHg
Blood Pressure they don’t know how, and they
SPO2: 90% SPO2: 93% SPO2: 96%
don’t have equipment too. He has a
a. Lung sounds respiratory problem since 2009.
Patient has an abnormal breath Patient has an abnormal breath Patient has an improved breath
sound (Ronchi) upon auscultating. sound (Ronchi) upon auscultating. sound (lessened wheezing)
b. History of Respiratory
Problems
7.PAIN-COMFORT
a. Pain (location, onset,
character, intensity,
Patient experiences chest discomfort
duration, Patient stated that he can manage Pt’s chest discomfort is lightly Pt’s chest discomfort is lightly
with an intensity score of 6/10
associated symptoms, the pain if it’s moderate. He sits up alleviated with an intensity score of alleviated with an intensity score of
associated with DOB. Discomfort
aggravation) in upright position and asks the S.O. 5/10 associated with DOB. Pt is 3/10 associated with DOB. Pt is
aggravates when pt is in a semi-
to intensely percuss his back to given Salbutamol, Ipratropium given Salbutamol, Ipratropium
fowler’s position. Patient is given
b. Comfort alleviate his pain. Bromide, and Hydrocortisone. Bromide, and Hydrocortisone.
salbutamol.
measures/Alleviation
c. Medications
8.HYGIENE AND ACTIVITIES Patient stated that he takes a bath Patient has not taken a bath since Patient’s hygiene is maintained by a Patient’s hygiene is maintained by a
OF DAILY LIVING every day, trim nails, and brushes admission due to his condition. tepid sponge bath with the help of tepid sponge bath with the help of
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teeth regularly. Inability to perform
Still unable to perform daily
daily activities due to the SO. the SO and help him brush his teeth.
activity.
breathlessness.
9.SEXUALITY
a. Female (menarche,
menstrual cycle,
civil status, number of
children, reproductive The patient has circumcised, The patient has circumcised, The patient has circumcised, The patient has circumcised,
status) married, and has 10 children married, and has 10 children married, and has 10 children married, and has 10 children
b. Male (circumcision, civil

Status, number of
children)
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LABORATORY AND DIAGNOSTIC PROCEDURES
DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

October 26, 2022 HEMATOLOGY
Complete Blood Count
WBC 15.81 x10^9/L H 5.0-10.0  Leukocytosis may be caused by bacterial
RBC 4.03 x10^9/L 4.0-5.5 infection suspected in the lungs.
Hemoglobin 12.10 L 14.0-18.0  Altered hemoglobin may be caused by onset the
of medication.
Hematocrit 0.35 L 0.40-0.50  Altered hematocrit may be caused by onset the
of medication.
Differential Count
Neutrophils 82 % H 50-70  High neutrophils try to neutralize the WBC.
Lymphocytes 11 % L 20-40  Low lymphocytes indicate bacterial infection.
Monocyte 6%H 1-5  Monocytosis indicates chronic infection.
Eosinophil 0% 0-5
Basophil 0% 0.01
Red Indices
MCV 86.40 80-96
MCH 30.00 27-31
MCHC 34.80 33-36
Platelet
Platelet Count 241.00 140-340
Blood Typing
Blood Typing A
Rh Positive
October 26, 2022 CHEMISTRY

Arterial Blood Gas
pH 7.329 mmHg 7.310 - 7.410
pC02 28.4 mmHg L 41.0 – 51.0  Decreased PaCO2 reflects alveolar
hyperventilation.
p02 97 mmHg 80 – 105
Base Excess -11 mmol/L L (-) 2 – 3  Low base excess indicates that there is a lower-
than-normal amount of HCO3– in the blood.
HC03 14.9 mmol/L L 23 – 28  Low bicarbonate indicates metabolic acidosis.
 Low CO2 means the body is removing too
9
Total CO2 16 mmol/L L 24 – 29 much CO2.
S02 97 % 95 – 98
Hemoglobin A1C 9.8 % < 6.5

Blood Urea Nitrogen 18.20 mg/dL 10 – 50
Creatinine 1.17 mg/dL 0.6 – 1.3
Blood Uric Acid 4.10 mg/dL 3.4 – 7.0
October 26, 2022 ELECTROLYTES

NA 136 mmol/dL 135 – 155
K 4.4mmol/dL 3.5 – 5.3
Ionized Calcium 1.20 mmol/dL 1.10 – 1.30
SGPT/ALT 49.00 IU Up to 40
SGOT/AST 24.00 U/L 5 - 34
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SUMMARY OF INTRAVENOUS FLUID
DATE/TIME STARTED INTRAVENOUS FLUID VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CLOSED
NONE NONE NONE NONE NONE
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SUMMARY OF MEDICATIONS
MEDICATIONS
DATE REMARKS
(DOSAGE, FREQUENCY, AND ROUTE)
October 26, 2022 Salbutamol Ipratropium bromide (neb q 15min x3 doses then q6hrs) Administered and given on the exact time indicated.
Budesonide (neb Q12) Administered and given on the exact time indicated.
Hydrocortisone (250mg IV now then 100mg IV Q8) Administered and given on the exact time indicated.
Omeprazole (40mg OD) Administered and given on the exact time indicated.
October 27, 2022 Salbutamol Ipratropium bromide (neb q 15min x3 doses then q6hrs) Administered and given on the exact time indicated.
Budesonide (1neb q12) Administered and given on the exact time indicated.
Piperacillin Tazobactam (4.5mg tab q8 ANSTC) Administered and given on the exact time indicated.
N-Acetylcysteine (600mg tab + ½ H2O OD) Administered and given on the exact time indicated.
October 28, 2022 Budesonide (1neb q12) Administered and given on the exact time indicated.
N-Acetylcysteine (600mg tab + ½ H2O OD) Administered and given on the exact time indicated.
October 29, 2022 Budesonide (1neb q12) Administered and given on the exact time indicated.
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DRUG STUDY
PRESCRIBED AND
BRAND NAME, RECOMMENDED
GENERIC NAME, DOSAGE, MECHANISM ADVERSE
INDICATIONS CONTRAINDICATIONS NURSING RESPONSIBILITIES
& FREQUENCY, OF ACTION REACTIONS
CLASSIFICATION ROUTE, OF
ADMINISTRATION
Brand Name: Acute Adrenal Inhibits Systemic: Hypersensitivity to Long-term Before Administration
Hydrocortisone Insufficiency accumulation of Management of hydrocortisone. Fungal, Therapy:  Ask if pt is allergic to hydrocortisone,
IV: Adults, Elderly: inflammatory cells adrenocortical tuberculosis, viral skin Hypocalcemia, aspirin, tartrazine (a yellow dye in some
Generic Name: 100 mg IV bolus, then at inflammation insufficiency, anti- lesions; serious infections, hypokalemia, processed foods and drugs), or any other
Anusol HC Caldecort 50–75 mg q6h for 24 sites, phagocytosis, inflammatory, IM administration in muscle wasting drugs.
Colocort Cortaid hrs, then taper slowly. lysosomal enzyme immunosuppressive idiopathic (esp. arms, legs),  Ask what prescription and nonprescription
SOLU-Cortef Children: 1–2 mg/kg release, synthesis . thrombocytopenia purpura. osteoporosis, medications pt is taking, especially
Cortenema IV bolus, then 150– and/or release of spontaneous anticoagulants.
Cortizone-10 250 mg/day in divided mediators of Topical: Cautions: Thyroid fractures,  Assess for fungal infection.
Preparation H doses q6–8h. Infants: inflammation. Inflammatory dysfunction, cirrhosis, amenorrhea,  Assess if pregnant, plan to become
Hydrocortisone 1–2 mg/kg/dose IV Reverses increased dermatoses, hypertension, osteoporosis, cataracts, pregnant, or breast-feeding.
Proctocort Westcort bolus, then 25–150 capillary adjunctive treatment thromboembolic tendencies glaucoma, peptic  Ask if scheduled for surgery.
mg/day in divided permeability. of ulcerative colitis, or thrombophlebitis, HF, ulcer, HF.  If pt has a history of ulcers or take large
Classification doses q6–8h. atopic dermatitis, seizure disorders, diabetes, doses of aspirin or other arthritis
Pharmacotherapeutic Therapeutic inflamed respiratory tuberculosis, Abrupt medication, limit your consumption of
: Adrenal Anti-Inflammation, Effect: hemorrhoids. untreated systemic Withdrawal After alcoholic beverages while taking this
corticosteroid. Immunosuppression Prevents/suppresses infections, renal/hepatic Long-Term drug. Hydrocortisone makes your stomach
Clinical: IV, IM: Adults, cell-mediated Off-Label: impairment, acute MI, Therapy: Nausea, and intestines more susceptible to the
Glucocorticoid. Elderly: 100–500 immune reactions. Management of myasthenia gravis, fever, headache, irritating effects of alcohol, aspirin, and
mg/dose at intervals Decreases/prevents septic shock. glaucoma, cataracts, sudden severe joint certain arthritis medications. This effect
of 2 hrs, 4 hrs, or 6 tissue response to Treatment of increased intraocular pain, rebound increases your risk of ulcers.
hrs. Children: 1–5 inflammatory thyroid storm. pressure, elderly, inflammation,
mg/kg/day in divided process. immunocompromised fatigue, weakness, During Administration:
doses q12h. patients. lethargy, dizziness,  Monitor signs of hypersensitivity
PO: Adults, Elderly: orthostatic reactions or anaphylaxis, including
15–240 mg q12h. hypotension. pulmonary symptoms (tightness in the
Children: 2.5–10 throat and chest, wheezing, cough,
mg/kg/day in divided dyspnea) or skin reactions (rash, pruritus,
doses q6–8h. urticaria).
 Notify physician immediately if these
Dosage in reactions occur.
Renal/Hepatic  Assess any muscle or joint pain.
Impairment
No dose adjustment.
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After Administration:
 Monitor signs of thrombophlebitis (lower
extremity swelling, warmth, erythema,
tenderness) and thromboembolism
(shortness of breath, chest pain, cough,
bloody sputum).
 Notify physician and request objective tests
(Doppler ultrasound, lung scan, others) if
thrombosis is suspected. Monitor and
report signs of peptic ulcer, including
heartburn, nausea, vomiting blood, tarry
stools, and loss of appetite.
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DRUG STUDY
PRESCRIBED AND
RECOMMENDED
BRAND NAME,
DOSAGE, MECHANISM ADVERSE
GENERIC NAME, & INDICATIONS CONTRAINDICATIONS NURSING RESPONSIBILITIES
FREQUENCY, OF ACTION REACTIONS
CLASSIFICATION
ROUTE, OF
ADMINISTRATION
Brand Name: Acute Stimulates beta2 - Treatment or Hypersensitivity to Excessive Before Administration
Albuterol Bronchospasm, adrenergic prevention of albuterol. Severe sympathomimetic  Monitor respiratory rate, oxygen
Exacerbation of receptors in lungs, bronchospasm due hypersensitivity to milk stimulation may saturation, and lungs sounds before and
Generic Name: Asthma resulting in to reversible protein (powder for produce after administration.
Salbutamol relaxation of obstructive airway inhalation). palpitations, ectopy,  If more than one inhalation is ordered,
Inhalation: Adults, bronchial smooth disease, prevention tachycardia, chest wait at least 2 minutes between
Classification elderly, children Older muscle. of exercise-induced Cautions: Hypertension, pain, and slight inhalations.
than 12 years: (Acute, bronchospasm. cardiovascular disease, increase in B/P  Use a spacer device to improve drug
Pharmacotherapeutic Severe): 4–8 puffs Therapeutic hyperthyroidism, diabetes, followed by delivery, if appropriate.
: Sympathomimetic q20min up to 4 hrs, Effect: Relieves HF, convulsive disorders, substantial decrease,
(adrenergic agonist). then q1–4h as needed. bronchospasm and glaucoma, hypokalemia, chills, diaphoresis, During Administration:
Children 12 years and reduces airway arrhythmias. blanching of skin.  Relieve GI upset. Administer oral drug
Clinical: younger: (Acute, resistance. Too-frequent or with food or milk to relieve GI irritation if
Bronchodilator. Severe): 4–8 puffs excessive use may GI upset is a problem. Monitor drug
q20min for 3 doses, lead to decreased response.
then q1–4h as needed. bronchodilating
effectiveness and After Administration:
Nebulization: Adults, severe, paradoxical  Monitor for muscle pain or weakness,
elderly, children older bronchoconstriction. muscle cramps, or a heartbeat that does
than 12 years: (Acute, not feel normal.
Severe): 2.5–5 mg
q20min for 3 doses,
then 2.5–10 mg q1–4h
or 10–15 mg/hr
continuously.
Children 12 years and
younger: 0.15 mg/kg
q20min for 3 doses
(minimum: 2.5 mg),
then 0.15–0.3 mg/kg
q1–4h as needed.
15
DRUG STUDY
PRESCRIBED AND MECHANISM ADVERSE

RECOMMENDED OF ACTION REACTIONS
BRAND NAME,
DOSAGE,
FREQUENCY,
CLASSIFICATION
ROUTE, OF
ADMINISTRATION
Brand name: Rhinitis Inhibits Nasal: (Rx): Hypersensitivity to Acute Before Administration
Budesonide accumulation of Management of budesonide, primary hypersensitivity  BLACK BOX WARNING: Taper systemic
Intranasal: (Rx): inflammatory cells; seasonal or treatment of status reaction (urticaria, steroids carefully during transfer to
Generic name: Adults, Elderly, controls rate of perennial allergic asthmaticus, acute episodes angioedema, inhalational steroids; deaths from adrenal
Entocort EC Pulmicort Chidren 6 years and protein synthesis; rhinitis in adults of asthma. Not for relief of severe insufficiency have occurred.
Flexhaler Pulmicort Older: 1 spray (32 decreases and children 6 yrs acute bronchospasms. bronchospasm)  Arrange for use of decongestant nose drops
Rhinocort Allergy mcg) in each nostril migration of and older. occurs rarely. to facilitate penetration if edema, excessive
Rhinocort Aqua Uceris once daily. Maximum: polymorphonuclea Cautions: Thyroid disease, secretions are present.
4 sprays in each r leukocytes (OTC): Relief of hepatic impairment, renal  Prime unit before use for Pulmicort
Classification nostril once daily for (reverses capillary hay fever, other impairment, cardiovascular Turbuhaler; have patient rinse mouth after
Pharmacotherapeutic adults and children 12 permeability and upper respiratory disease, diabetes, each use.
: Glucocorticosteroid. yrs and older; 2 sprays lysosomal allergies. glaucoma, cataracts,  Use aerosol within 6 mo of opening. Shake
Clinical: Anti- in each nostril once stabilization at myasthenia gravis, pts at well before each use.
inflammatory, daily for children 6– cellular level). Nebulization, Oral risk for osteoporosis,  Store Respules upright and protected from
antiallergy. 11 yrs. Inhalation: seizures, GI disease, post light; gently shake before use; open
Therapeutic Maintenance or acute MI, elderly envelopes should be discarded after 2 wk.
Intranasal: (OTC): Effect: Relieves prophylaxis  Do not use more often than prescribed; do
Adults, Elderly, symptoms of therapy for asthma. not stop without consulting your health
Children 6 years and allergic rhinitis, care provider.
Older: 2 sprays in asthma, Crohn’s Off-Label:  It may take several days to achieve good
each nostril once disease. Treatment of effects; do not stop if effects are not
daily. May decrease to vasomotor rhinitis. immediate.
1 spray in each nostril
once daily. During Administration:
 Use decongestant nose drops first if nasal
Bronchial Asthma passages are blocked.
 Prime unit before use for Pulmicort
Nebulization: Turbuhaler; rinse mouth after each use.
Children 12 mos-8
years: Previous After Administration:
therapy with  Pt may experience these side effects: Local
bronchodilators irritation (use your device correctly), dry
alone): 0.5 mg/day as mouth (suck sugarless lozenges).
single dose or 2  Report sore mouth, sore throat, worsening
16
divided doses. of symptoms, severe sneezing, exposure to
Maximum: 0.5 chickenpox or measles, eye infections.
mg/day. (Previous
therapy with inhaled
corticosteroids): 0.5
mg/day as single dose
or 2 divided doses.
Maximum: 1 mg/day.
(Previous therapy of
oral corticosteroids): 1
mg/day as single dose
in 2 divided doses.
Maximum: 1 mg/day.
Oral Inhalation:
(Pulmicort Flexhaler):
Adults, Elderly:
Initially, 360 mcg 2
times/day. Maximum:
720 mcg 2 times/day.
Children, 6 years and
Older: 180 mcg 2
times/day. Maximum:
360 mcg 2 times/day.
17
DRUG STUDY
PRESCRIBED AND
RECOMMENDED
BRAND NAME,
CLASSIFICATION
ROUTE, OF
ADMINISTRATION
Brand Name: Anxiety Competes with Antiemetic, Hypersensitivity to Hypersensitivity Before Administration
Hydroxyzine Note: Initiate elderly histamine for treatment of hydrOXYzine. Early reaction  WARNING: Determine and treat
dose at the lower end receptor sites in GI anxiety/agitation, pregnancy; subcutaneous, (wheezing, underlying cause of vomiting. Drug may
Generic Name: of recommended tract, blood antipruritic. intravenous administration; dyspnea, chest mask signs and symptoms of serious
Apo-Hydroxyzine, dosage. PO: Adults, vessels, respiratory pts with prolonged QT tightness) may conditions, such as brain tumor, intestinal
Atarax, Novo- Elderly: 50–100 mg 4 tract. Therapeutic interval. occur. QT interval obstruction, or appendicitis.
Hydroxyzin, Vistaril times/day or 37.5–75 Effect: Produces prolongation,  Do not administer parenteral solution
mg/day in divided anxiolytic, Cautions: Narrow-angle torsades de pointes subcutaneously, IV, or intra-arterially;
Classification doses. anticholinergic, glaucoma, prostatic have been tissue necrosis has occurred with
Pharmacotherapeutic antihistaminic, hypertrophy, bladder neck reported. Acute subcutaneous and intra-arterial injection,
: Histamine H1 Pruritus analgesic effects; obstruction, asthma, generalized and hemolysis with IV injection.
antagonist. PO: Adults, Elderly: relaxes skeletal COPD, elderly. exanthematous  Give IM injections deep into a large
Clinical: 25 mg 3–4 times/day. muscle; controls pustulosis (AGEP) muscle: In adults, use upper outer quadrant
Antihistamine, Children 6 years and nausea, vomiting. may occur. of buttocks or midlateral thigh; in children
antianxiety, older: 50–100 mg/day use midlateral thigh muscles; use deltoid
antispasmodic, in divided doses. area only if well developed.
antiemetic, antipruritic Children younger than
6 years: 50 mg/day in During Administration:
divided doses.  Administer this drug as prescribed. Avoid
Dosage in excessive dosage.
Renal/Hepatic  Pt may experience these side effects:
Impairment Dizziness, sedation, drowsiness (use
No dose adjustment. caution if driving or performing tasks that
Change dosing require alertness); avoid alcohol, sedatives,
interval to q24h in pts sleep aids (serious overdosage could
with primary biliary result); dry mouth (frequent mouth care,
cirrhosis. sucking on sugarless lozenges may help).
 Report difficulty breathing, tremors, loss
of coordination, sore muscles, or muscle
spasms.
18
DRUG STUDY
PRESCRIBED AND
RECOMMENDED
BRAND NAME,
CLASSIFICATION
ROUTE, OF
ADMINISTRATION
Brand name: Active Duodenal Inhibits hydrogen- Short-term Hypersensitivity to Pancreatitis, Before Administration
Omeprazole Ulcer potassium treatment (4–8 omeprazole, other proton hepatotoxicity,  Assess respiratory status, including
PO: Adults, Elderly: adenosine wks) of erosive pump inhibitors. interstitial respiratory rate and rhythm.
Generic name: 20 mg/day for 4–8 triphosphatase esophagitis Concomitant use with nephritis occur  Note evidence of cough, hoarseness, and
Apo-Omeprazole Losec wks. (H+ /K+ ATP (diagnosed by products containing rarely. May epistaxis, to monitor for potential adverse
pump), an enzyme endoscopy), rilpivirine. increase risk of C. effects of the drugs.
Classification Symptomatic GERD on the surface of symptomatic difficile infection.  Advise patient to avoid alcohol and foods
Pharmacotherapeutic PO: Adults, Elderly, gastric parietal gastroesophageal Cautions: May increase that may cause an increase in GI irritation.
: Benzimidazole. Children Weighing 20 cells. reflux disease risk of fractures,  Instruct patient to report bothersome or
Clinical: Proton pump kg or more: 20 (GERD) poorly gastrointestinal infections. prolonged side effects, including skin
inhibitor mg/day for up to 4 Therapeutic responsive to other Hepatic impairment, pts of problems (itching, rash) or GI effects
wks. 10–19 kg: 10 Effect: Increases treatment. H. Asian descent. (nausea, diarrhea, vomiting, constipation,
mg/day. 5–9 kg: 5 gastric pH, pylori–associated heartburn, flatulence, abdominal pain).
mg/day. reduces gastric duodenal ulcer (with
acid production. amoxicillin and During Administration:
Erosive Esophagitis clarithromycin).  Administer this drug as prescribed. Avoid
PO: Adults, Elderly, excessive dosage.
Children Weighing 20 Long-term  Pt may experience these side effects:
kg or more: treatment of Dizziness, sedation, drowsiness (use
Treatment: 20 mg/day pathologic caution if driving or performing tasks that
for 4–8 wks. Children hypersecretory require alertness); avoid alcohol,
1-16 years weighing conditions, sedatives, sleep aids (serious overdosage
10-19 kg: 10 mg/day. treatment of active could result); dry mouth (frequent mouth
Weighing 5-9 kg: 5 duodenal ulcer or care, sucking on sugarless lozenges may
mg/day. Children 1-11 active benign gastric help).
mos weighing 10 kg ulcer. Maintenance
or more: 10 mg/day. healing of erosive After Administration:
Weighing 5-9 kg: 5 esophagitis.  Monitor improvements in GI symptoms
mg/day. Weighing 3-4 (gastritis, heartburn, and so forth) to help
kg: 2.5 mg/day. OTC, short-term: determine if drug therapy is successful.
Maintenance: Adults, Treatment of  Assess dizziness that might affect gait,
Elderly, Children frequent, balance, and other functional activities.
Weighing 20 kg or uncomplicated  Report balance problems and functional
more: 20 mg/day for heartburn occurring limitations to the physician and caution
19
up to 12 mos 2 or more days/wk. the patient and family/caregivers to guard
(including treatment against falls and trauma.
period). Asian Off-Label:  Monitor other CNS side effects
patients, Children Prevention/treatmen (drowsiness, fatigue, weakness,
weighing 10-19 kg: 10 t of NSAID-induced headache), and report severe or prolonged
mg/day. Weighing5–9 ulcers, stress ulcer effects.
kg: 5 mg/day. prophylaxis in  Monitor any chest pain and attempt to
critically ill pts. determine if pain is drug induced or
caused by cardiovascular dysfunction
(e.g., angina that occurs during exercise).
20
DRUG STUDY
PRESCRIBED AND
RECOMMENDED
BRAND NAME,
DOSAGE, MECHANISM CONTRAINDICATION ADVERSE
GENERIC NAME, & INDICATIONS NURSING RESPONSIBILITIES
FREQUENCY, OF ACTION S REACTIONS
CLASSIFICATION
ROUTE, OF
ADMINISTRATION
Brand Name: IV: Inhibits bacterial Indicated to treat Contraindications: Frequent diarrhea, Before Administration
Zosyn ADULTS, cell wall synthesis bacterial infections Hypersensitivity to headache,  Always wash hands thoroughly and
ELDERLY: 4.5 g q6– by binding to in different parts of piperacillin/tazobactam, constipation, disinfect equipment (whirlpools,
Generic Name: 8h or 3.375 g q6h. PCN-binding the body. any penicillin. nausea, insomnia, electrotherapeutic devices, treatment
Piperacillin/ Maximum: 18 g daily. proteins, which rash. Occasional: tables, and so forth) to help prevent the
Tazobactam inhibit the final Cautions: History of Vomiting, spread of infection.
Note: step of allergies (esp. dyspepsia,  Use universal precautions or isolation
Classification: Extended Infusion: peptidoglycan cephalosporins, beta- pruritus, fever, procedures as indicated for specific
Pharmacotherapeutic: ADULTS, synthesis. lactamase inhibitors), renal agitation, patients.
Penicillin. CLINICAL: ELDERLY: 3.375–4.5 impairment, preexisting candidiasis,  Monitor signs of allergic reactions and
Antibiotic. g over 4 hrs q8h. Therapeutic seizure disorder dizziness, anaphylaxis, including pulmonary
Effect: abdominal pain, symptoms (tightness in the throat and
Bactericidal. edema, anxiety, chest, wheezing, cough dyspnea) or skin
Tazobactam: dyspnea, rhinitis. reactions (rash, pruritus, urticaria).
Inactivates  Notify physician immediately if these
bacterial beta- reactions occur.
lactamase.  Assess pt if he/she has kidney disease, a
Therapeutic bleeding or blood clotting disorder, low
Effect: Protects levels of potassium in your blood, cystic
piperacillin from fibrosis, a history of allergies, if you are
enzymatic on a low-salt diet, or if you are allergic to
degradation, a cephalosporin antibiotic
extends its
spectrum of During Administration:
activity, prevents  Instruct patient to notify physician
bacterial immediately if signs of the following
overgrowth. occur: Superinfection (black, furry
overgrowth on tongue; vaginal itching or
discharge; loose or foul-smelling stools).
 Watch for seizures; notify physician
immediately if patient develops or
increases seizure activity.
21
 Monitor signs of allergic reactions and
anaphylaxis, including pulmonary
symptoms (tightness in the throat and
chest, wheezing, cough dyspnea) or skin
reactions (rash, pruritus, urticaria). Notify
physician or nursing staff immediately if
these reactions occur.
 Assess muscle aches and joint pain
(arthralgia) that may be caused by serum
sickness. Notify physician if these
symptoms seem to be drug-related rather
than caused by musculoskeletal injury, or
if muscle and joint pain are accompanied
by allergic-like reactions (fever, rashes,
etc.)
 Monitor signs of blood dyscrasias such as
leukopenia and neutropenia (fever, sore
throat, signs of infection) or
thrombocytopenia (bruising, nose bleeds,
and bleeding gums). Report these signs to
the physician.
 Assess dizziness and confusion that might
affect gait, balance, and other functional
activities (See Appendices C, D). Report
balance problems and functional
limitations to the physician and nursing
staff and caution the patient and
family/caregivers to guard against falls
and trauma.
 Monitor injection site for pain, swelling,
and irritation. Report prolonged or
excessive injection site reactions to the
physician.
22
DRUG STUDY
PRESCRIBED AND
RECOMMENDED
BRAND NAME,
DOSAGE, MECHANISM CONTRAINDICATION ADVERSE
GENERIC NAME, & INDICATIONS NURSING RESPONSIBILITIES
FREQUENCY, OF ACTION S REACTIONS
CLASSIFICATION
ROUTE, OF
ADMINISTRATION
Brand Name: 21-hour regimen: PO: Decreases the PO: Antidote for the Patient with asthma, CNS: drowsiness. Before Administration
Acetadote, Mucomyst, Initially, 150 mg/kg in buildup of a management of history of bronchospasm, CV: vasodilation.  If treating acetaminophen overdose, make
Mucosil 200 mL of diluent via hepatotoxic potentially atopy; decreased cough EENT: rhinorrhea. sure patient understands the purpose of
infusion over 1 hour, metabolite in hepatotoxic reflex (e.g. frail patient), Resp: drug therapy, and that the patient should
Generic Name: followed by 50 mg/kg acetaminophen overdosage of predisposition to bronchospasm, consult the physician before resuming use
I.V. Acetylcysteine in 500 mL of diluent overdosage. acetaminophen gastrointestinal bronchial/tracheal of products containing acetaminophen.
infused over the next (should be haemorrhage [e.g. irritation, chest  When used as a mucolytic, counsel
Classification: 4 hours and then 100 IV: Decreases the administered within oesophageal varices, peptic tightness, patient on proper inhalation techniques,
Pharmacotherapeutic: mg/kg in 1,000 mL of buildup of a 24 hr of ingestion). ulcer] (oral). Patient increased and advise patient not to exceed the
Therapeutic: antidotes diluent infused over hepatotoxic requiring fluid restriction secretions. recommended dose or frequency of
(for acetaminophen the next 16 hours. metabolite in IV: Antidote for the or who weighs ≤40 kg GI: nausea, inhalations. Contact physician
toxicity), mucolytics Treatment may be acetaminophen management of (IV). vomiting, immediately if bronchospasm or other
continued using the overdosage. potentially stomatitis. respiratory symptoms are increased by
same dose and rate as hepatotoxic Derm: pruritus, drug inhalation.
the 3rd infusion Inhalation: overdosage of rash, urticaria,  Instruct patient and family/caregivers to
depending on the Degrades mucus, acetaminophen clamminess. report other troublesome side effects such
individual clinical allowing easier (should be Misc: allergic as severe or prolonged drowsiness, chills,
evaluation. Refer to mobilization and administered within reactions fever, nasal inflammation, or GI problems
specific product expectoration. 8–10 hr of (primarily with (nausea, vomiting, irritation in/around the
guidelines for further ingestion). IV), including mouth).
dosing information. Therapeutic anaphylaxis,
Effects: PO: Inhalation: ANGIOEDEMA, During Administration:
Prevention or Mucolytic in the chills, fever.  When implementing airway clearance
lessening of liver management of techniques, attempt to intervene when the
damage following conditions drug has produced maximum mucolytic
acetaminophen associated with thick effects. Peak responses typically occur 5–
overdose. Inhaln: viscid mucous 10 min after inhalation.
Lowers the secretions.
viscosity of After Administration:
mucus. Unlabeled Use:  Monitor signs of angioedema, including
Prevention of rashes, raised patches of red or white skin
radiocontrast- (welts), burning/itching skin, swelling in
induced renal the face, and difficulty breathing. Notify
dysfunction (oral). physician of these signs immediately.
23
 Monitor other signs of allergic reactions
and anaphylaxis, especially after IV
administration. Signs include pulmonary
chest, wheezing, cough, dyspnea) and
skin reactions (rash, pruritus, urticaria).
Notify physician or nursing staff
immediately if these reactions occur.
 Monitor signs of bronchospasm and
respiratory irritation, including wheezing,
cough, dyspnea, increased secretions, and
tightness in the chest and throat. Report
excessive or prolonged respiratory
problems to the physician.
 When used as a mucolytic, assess the
quantity and consistency of sputum to
help document whether this drug is
successful in reducing the viscosity of
respiratory secretions.
24
DRUG STUDY
PRESCRIBED AND
RECOMMENDED
BRAND NAME,
CLASSIFICATION
ROUTE, OF
ADMINISTRATION
Brand Name: Initial dose: 50 mg Blocks the Alone or with other Losartan use is CNS: dizziness, Before Administration
Cozaar orally once a day. vasoconstrictor agents in the contraindicated with the fatigue, headache,  Assess blood pressure periodically and
Maintenance dose: 25 and aldosterone- management of use of aliskiren in diabetes insomnia, weakness. compare to normal values to help
Generic Name: to 100 mg orally in 1 secreting effects of hypertension. mellitus. It is also CV: chest pain, document antihypertensive effects. Report
Losartan to 2 divided doses. angiotensin II at Treatment of contraindicated in edema, hypotension. low blood pressure (hypotension),
various receptor diabetic hypersensitivity to losartan EENT: nasal especially if patient experiences dizziness
Classification: sites, including nephropathy in or any of its components. congestion. Endo: or syncope.
Therapeutic: vascular smooth patients with type 2 hypoglycemia,  Assess peripheral edema using girth
antihypertensives muscle and the diabetes. weight gain. GI: measurements, volume displacement, and
Pharmacologic: adrenal glands. Prevention of diarrhea, abdominal measurement of pitting edema. Report
angiotensin II receptor stroke in patients pain, dyspepsia, increased swelling in feet and ankles or a
antagonists Therapeutic with hypertension nausea. GU: sudden increase in body weight due to
Effects: Lowering and left ventricular impaired renal fluid retention.
of blood pressure hypertrophy. function. F and E:  Monitor symptoms of high plasma
in hypertensive hyperkalemia. MS: potassium levels (hyperkalemia),
patients. back pain, myalgia. including bradycardia, fatigue, weakness,
Decreased Misc.: numbness, and tingling. Notify physician
progression of ANGIOEDEMA, because severe cases can lead to life-
diabetic fever. threatening arrhythmias and paralysis.
nephropathy.
Decreased During Administration:
incidence of stroke  If treating diabetic neuropathy, establish
in patients with baseline electroneuromyography values at
hypertension and the beginning of drug treatment whenever
left ventricular possible.
hypertrophy  Periodically reexamine these values to
(effect may be less monitor peripheral nerve function and
in black patients). document whether drug therapy delays the
progression of neuropathic disease.
 Monitor signs of hypoglycemia,
especially during and after exercise.
 Assess dizziness that might affect gait,
25
balance, and other functional activities.
Report balance problems and functional
limitations to the physician and caution
the patient and family/caregivers to guard
against falls and trauma.
 Assess any muscle pain or back pain to
rule out musculoskeletal pathology; that
is, try to determine if pain is drug-induced
rather than caused by anatomical or
biomechanical problems.
 Monitor signs of angioedema, including
rashes, raised patches of red or white skin
(welts), burning/itching skin, swelling in
the face, and difficulty breathing. Notify
physician immediately of these signs.
 Watch for and report signs of impaired
renal function, including decreased urine
output, cloudy urine, or sudden weight
gain due to fluid retention.
 Assess body weight periodically and
report.
26
DRUG STUDY
PRESCRIBED AND
RECOMMENDED
BRAND NAME,
CLASSIFICATION
ROUTE, OF
ADMINISTRATION
Brand Name: subcutaneous solution Lowers blood Control of Endo: Before Administration
Basaglar KwikPen, (100 units/mL; 300 glucose by hyperglycemia in hypoglycemia.  Advise patient about symptoms of
Lantus, Lantus Solostar units/mL; yfgn 100 stimulating patients with Local: hyperglycemia (confusion, drowsiness;
Pen, Semglee, Toujeo, units/mL) glucose uptake in diabetes mellitus. lipodystrophy, flushed, dry
Lantus OptiClik skeletal muscle Concentrated pruritus, erythema,  Monitor signs of hypoglycemia,
Cartridge, Toujeo Max and fat, inhibiting regular insulin U- swelling. Misc: especially during and after exercise.
SoloStar, Semglee hepatic glucose 500: Only for use allergic reactions, Common neuromuscular symptoms
Prefilled Pen, Semglee production. Other in patients with including include anxiety; restlessness; tingling in
(Vial), Semglee actions of insulin: insulin anaphylaxis. hands, feet, lips, or tongue; chills; cold
(Prefilled Pen) inhibition of requirements >200 sweats; confusion; difficulty in
lipolysis and units/day. concentration; drowsiness; excessive
Generic Name: proteolysis, Unlabeled Use: hunger; headache; irritability;
Insulin Glargine enhanced protein Treatment of nervousness; tremor; weakness; unsteady
synthesis. hyperkalemia. gait. Report persistent or repeated
Classification: episodes of hypoglycemia to the
Therapeutic: Therapeutic physician.
antidiabetics, hormones Effects: Control of
Pharmacologic: hyperglycemia in  Encourage patient to monitor blood
pancreatics diabetic patients. glucose before and after exercise and to
adjust insulin dose accordingly based on
exercise duration and intensity.
 Emphasize the importance of adhering to
nutritional guidelines and the need for
periodic assessment of glycemic control
(serum glucose and glycosylated
hemoglobin levels) throughout the
management of diabetes mellitus.
During Administration:
 Implement aerobic exercise and
endurance training programs to maintain
optimal body weight, improve insulin
sensitivity, and reduce the risk of
macrovascular disease (heart attack,
27
stroke) and microvascular problems
(reduced blood flow to tissues and organs
that causes poor wound healing,
neuropathy, retinopathy, and
nephropathy).
 Assess blood pressure. A sudden or
sustained increase in blood pressure
(hypertension) may indicate problems in
diabetes management and should be
reported to the physician.
 Do not apply physical agents (heat, cold,
electrotherapeutic modalities) or massage
at or near the injection site; these
interventions will alter insulin absorption
from subcutaneous tissues.
 Monitor signs of allergic reactions and
anaphylaxis, including pulmonary
chest, wheezing, cough, dyspnea) or skin
reactions (rash, pruritus, urticaria). Notify
physician immediately if these reactions
occur.
 Provide a source of oral glucose (fruit
juice, glucose gels/tablets, etc.) to treat
mild hypoglycemia. Call for emergency
assistance if symptoms persist or in cases
of severe hypoglycemia. Emergency
treatment typically consists of IV glucose,
glucagon, or epinephrine.
 Assess body weight periodically. Changes
in weight may necessitate changes in
insulin dose.
 Assess injection site for redness, swelling,
or other reactions. Make sure patient
understands the need to rotate injections
sites to prevent local damage and
lipodystrophy.
28
ANATOMY AND PHYSIOLOGY
HEALTHY RESPIRATORY SYSTEM AFFECTED RESPIRATORY SYSTEM
29
The Organs Involved in the Respiratory System and Their Function/s: How A Respiratory System Is Affected by a COPD?
 Mouth and Nose: Openings that pull air from outside your body into your respiratory  The airways and tiny air sacs in the lungs lose their ability to stretch and shrink back.
system.  The walls between many of the air sacs are destroyed.
 Sinuses: Hollow areas between the bones in your head that help regulate the temperature  The walls of the airways become thick and inflamed (irritated and swollen).
and humidity of the air you inhale.  The airways make more mucus than usual, which can clog them and block air flow.
 Pharynx (throat): Tube that delivers air from your mouth and nose to the trachea
(windpipe). With COPD, the airways in your lungs become inflamed and thicken, and the tissue where
 Trachea: Passage connecting your throat and lungs. oxygen is exchanged is destroyed. The flow of air in and out of your lungs decreases. When
 Bronchial tubes: Tubes at the bottom of your windpipe that connect into each lung. that happens, less oxygen gets into your body tissues, and it becomes harder to get rid of the
 Lungs: Two organs that remove oxygen from the air and pass it into your blood. waste gas carbon dioxide. As the disease gets worse, shortness of breath makes it harder to
 Diaphragm: Muscle that helps your lungs pull in air and push it out. remain active. Sometimes referred to as either chronic bronchitis or emphysema, most people
 Ribs: Bones that surround and protect your lungs and heart. will have symptoms of both conditions, so health professionals prefer to call the disease
 Alveoli: Tiny air sacs in the lungs where the exchange of oxygen and carbon dioxide takes COPD. However, some doctors think that chronic bronchitis may be present even though a
place. person does not have the airway obstruction characteristic of COPD.
 Bronchioles: Small branches of the bronchial tubes that lead to the alveoli.
 Capillaries: Blood vessels in the alveoli walls that move oxygen and carbon dioxide. Source: American Lung Association, 2022. Retrieved from https://www.lung.org/lung-health-
 Lung lobes: Sections of the lungs — three lobes in the right lung and two in the left lung. diseases/lung-disease-lookup/copd/learn-about-copd.
 Pleura: Thin sacs that surround each lung lobe and separate your lungs from the chest wall.
 Cilia: Tiny hairs that move in a wave-like motion to filter dust and other irritants out of
your airways.
 Epiglottis: Tissue flap at the entrance to the trachea that closes when you swallow to keep
food and liquids out of your airway.
 Larynx (Voice Box): Hollow organ that allows you to talk and make sounds when air
moves in and out.
Gas Exchange Process

The lungs (purple structures within the thoracic cage) are organs that act as the site for gas
exchange. Each lung is conical in shape, very elastic, and spongy in texture. The left lung is
divided into two lobes: upper and lower. The right lung is divided into three lobes: superior,
30
middle, and inferior.
Within each lung is a respiratory tree, comprised of the bronchi and its branching subdivisions
—the primary bronchi, which branches into the secondary bronchi, which branches into the
tertiary bronchi, which branches into the bronchioles.
The bronchi deliver oxygen-rich air to the lungs, where gas exchange occurs in tiny air sacs
called alveoli. Exhaled air (oxygen-poor and carbon dioxide–rich) go the reverse way—from
the ends of the bronchioles and back up.
31
Alveoli are tiny air sacs in the lungs—1.5 million per lung!—encased within capillary
networks. Oxygen diffuses from the alveoli into the capillaries, which carry it out of the lungs
and to the rest of the body; carbon dioxide diffuses into the alveoli and is then exhaled out of
the body. The respiratory membrane is the barrier through which oxygen and carbon dioxide
are exchanged.
In pulmonary circulation—circulation between the heart and lungs—the vasculature is flipped.

While normally arteries bring oxygenated blood away from the heart to the rest of the body, the
pulmonary arteries take deoxygenated blood away from the heart to the lungs for
replenishment. The pulmonary veins, likewise, return oxygenated blood to the heart from the
lungs.
32
Source: VisibleBody, 2022. Retrieved from https://www.visiblebody.com/blog/anatomy-and-
physiology-gas-exchange
33
PATHOPHYSIOLOGY (ACTUAL)
Precipitating Factors: Predisposing Factors:

IRRITANTS
Smoking Genetic
Environment Family history
Passive smoking Age
Working with chemicals and dusts INFLAMMATION
 MUCUS-SECRETING GLANDS THICKENED BRONCHIAL WALLS

 GOBLET CELLS
FURTHER NARROWED BRONCHIAL LUMEN

 MUCUS PRODUCTION
DAMAGED ALVEOLI ADJACENT TO THE BRONCHIOLES

MUCUS-LODGED AIRWAY
ALVEOLAR MACROPHAGES ALTERED FUNCTION
 CILIARY FUNCTION
AIRFLOW OBSTRUCTION  SUSCEPTIBILITY TO RESPIRATORY

INFECTION
COPD
RESPIRATORY INFECTION
34
Precipitating Factors: IRRITANTS Predisposing Factors:
Environment Age
Working with chemicals and dusts
CHRONIC BRONCHITIS EMPHYSEMA
 MUCUS-SECRETING GLANDS THICKENED BRONCHIAL WALL DESTRUCTION OF

 GOBLET CELLS WALLS  DEAD SPACE
OVERDISTENDED ALVEOLI
SORE OR SCRATCHY THROAT. FEELING

THE NEED TO COUGH. PRODUCTIVE
COUGH. NONPRODUCTIVE OR DRY FURTHER NARROWED BRONCHIAL
COUGH. WHEEZING. TROUBLE SLEEPING. LUMEN  CAPILLARY BED SIZE IMPAIRED GAS EXCHANGE
CONGESTION IN THE NASAL PASSAGES
AND AIRWAYS
INTERIOR OF A VESSEL, CAPILLARY BED IS AN HYPERCAPNIA HYPOXEMIA

 MUCUS PRODUCTION SUCH AS THE CENTRAL INTERWOVEN NETWORK OF
SPACE IN AN ARTERY, VEIN CAPILLARIES THAT SUPPLIES
OR CAPILLARY THROUGH AN ORGAN.
WHICH BLOOD FLOWS.
MUCUS-CLODGED AIRWAY
PULMONARY
HYPERTENSION
AGITATION . DIFFICULTY  RESISTANCE TO
BREATHING DAMAGED ALVEOLI ADJACENT TO
PULMONARY BLOOD FLOW
THE BRONCHIOLES
 CILIARY FUNCTION
RIGHT-SIDED
HEART FAILURE
CILIA MOVE MICROBES AND ALVEOLI ARE TINY AIR RIGHT VENTRICLE MAINTAINS
DEBRIS UP AND OUT OF THE SACS AT THE END OF THE
BRONCHIOLES BP IN PULMONARY ARTERY
AIRWAYS
ALVEOLAR MACROPHAGES
AIRFLOW OBSTRUCTION ALTERED FUNCTION
CHOKING OR GAGGING. SUDDEN

VIOLENT COUGHING. VOMITING.
NOISY BREATHING OR WHEEZING. MACROPHAGES ARE SPECIALISED
STRUGGLING TO BREATHE. CELLS INVOLVED IN THE DETECTION,
TURNING BLUE. PHAGOCYTOSIS AND DESTRUCTION OF
BACTERIA AND OTHER HARMFUL
ORGANISMS.
DUE TO IMPAIRED GAS HYPOXEMIA OR

EXCHANGE HYPOXEMIA
 SUSCEPTIBILITY TO
RESPIRATORY INFECTION
35
MEDICAL MANAGEMENT
IDEAL MANAGEMENT MANAGEMENT DONE
Independent: October 26, 2022
 IV fluid: IV fluid administration help maintain fluid for the patient and allow quick access in case that is needed. Managements:
 NPO For now
Dependent:  Heplock
 Antibiotics have been shown to be of some benefit to patients with increased dyspnea, increased sputum production,  Monitor V/S every 4 hours
and increased sputum purulence.  Monitor I&O every shift
 Indications for hospitalization for acute exacerbation of COPD include severe dyspnea that does not respond to initial
therapy, confusion or lethargy, respiratory muscle fatigue, paradoxical chest wall movement, and peripheral edema. Medications:
 Budesonide neb, 1 neb q 12
Collaborative:  Salbutamol + Ipratropium bromide neb q6
 Optimization of bronchodilator medications is first-line therapy and involves identifying the best medications taken  Hydrocortisone 100 mg IV q8
on regular schedule for a specific patient. (Short-acting & long-acting bronchodilator inhalers)  Omeprazole 40 mg IV OD
 A short trial course of oral corticosteroids may be prescribed for patients to determine whether pulmonary function
improves, and symptoms decrease. October 27, 2022
 Upon arrival of the patient in the emergency room, supplemental oxygen therapy is administered, and rapid Managements:
assessment is performed to determine if the exacerbation is life-threatening.  Heplock
 Monitor V/S every 4 hours
Drugs to be administered:  Monitor I&O every shift
 Bronchodilators  Facilitate the pending labs
 Corticosteroids  CBG monitoring
Other medications: Medications:

 Alpha1-antitrypsin augmentation therapy  Budesonide neb, 1 neb q 12
 Antibiotic agents  Salbutamol + Ipratropium bromide neb q6
 Mucolytic agents  Hydrocortisone 100 mg IV q8
 Antitussive agents  Omeprazole 40 mg tab OD
 Vasodilators  Piperacillin – tazobactam 4.5 mg tab q 8
 Narcotics  N-Acetylcysteine 600mg tab + ½ H20 OD
 Vaccines  HRI resume dose 8u sc if CBG >180 mg/dl
10u sc if CBG> 250mg/dl
Management of Exacerbation 12u sc if CBG>300 mg/dl
 Roflumilast
October 28, 2022
Source: NHS, 2022. Retrieved from https://www.nhs.uk/conditions/chronic-obstructive- Medications:
pulmonary-disease-copd/treatment/#:~:text=For%20most%20people%20with%20COPD,  Hydrocortisone 250mg IVTT now then 100mg IVTT q8
such%20as%20salbutamol%20and%20terbutaline.  Omeprazole 40mg IVTT OD
 Salbutamol + Ipratropium bromide neb now then q6.
 PIP-TAZ 4.5mg tab q8
36
SURGICAL MANAGEMENT
Bullectomy is a procedure in which 20% - 30% of the most diseased portions of the lungs are removed. Patients with one or a No surgical management performed.
few giant bullae, (enlarged air sacs within the lungs that look like balloons and occupy one-third to one-half of the lung area)
may be candidates for a VATS (video-assisted thoracic surgery) bullectomy. In a bullectomy, a surgeon removes the bullae,
allowing surrounding healthier lung tissue to expand and work more efficiently.
Preoperative Evaluations
Bullectomy surgery is major surgery. You will need to undergo several tests before surgery in order to determine if the
procedure is right for you and to make the procedure as safe as possible. You may require some or all of the following:
 Blood tests
 Electrocardiogram (ECG)
 Pulmonary function tests (breathing tests)
 CT scans (CAT Scan)
 Nuclear lung scan
 Exercise testing
Preoperative Surgery
 Do not eat or drink anything including water, after midnight the night before the procedure unless instructed
otherwise by your surgeon. Leave jewelry and other valuables at home.
 Cognitive interventions: the interventions were conducted in the form of "one-to-one" interviews, including
preoperative preparation, etiology, surgical and anesthetic procedures, intraoperative cooperation, as well as
postoperative precautions and methods to prevent complications. At the same time, a "Health Education Manual on
Spontaneous Pneumothorax due to Ruptured Alveoli" was drawn up and distributed to patients and their families to
raise their awareness.
 Psychological intervention: by understanding the patients' personality characteristics, attitude towards the disease,
and psychological reactions through communication, the nursing staff used feedback to encourage them to talk about
their concerns and doubts, vent their negative emotions, relieve their psychological pressure, as well as informing
them of the significance of maintaining a good state of mind for disease regression.
 Instructed them on deep breathing exercises, abdominal breathing, and effective coughing, as well as performing
preoperative training for 10-15 min/time, 2 times/d. In addition, their favorite music was played to divert their
attention and relieve their pain.
Intraoperative Surgery
 The temperature of the operating room was maintained at an appropriate level (24-25°C). • The patient was assisted
to assume the surgical position, and the operative field was fully exposed.
 The nursing staff should smile and shake hands with the patient to provide moral support and care, eliminate tension,
and ease discomfort.
 Patients were encouraged to take deep breaths to relieve tension.
Postoperative Surgery
37
 The patient was assisted with dressing and slowly wheeled to the ward with a pillow to elevate the head. When the
patient was awake, the nursing staff informed him of the operation, explained the key points of postoperative care,
and assisted him in choosing a comfortable and appropriate position. If vital signs were stable, the patient could be
assisted to assume a semi-sitting or sitting position to facilitate the drainage of pleural fluid.
 According to the patient's specific recovery situation, the nursing staff would give a small amount of warm water to
drink and observe the patient for symptoms such as nausea and vomiting. If tolerated, the patient was given a small
amount of liquid food to eat. If the patient had any special conditions, the nursing staff should promptly report to the
attending physician for symptomatic treatment.
 The patient was given oral analgesic medication or analgesic pump as prescribed by the doctor to promptly relieve
pain, and the surgical incision and drainage were checked to determine the cause of the pain. The negative pressure
attraction was adjusted appropriately according to the degree of pain.
 The nursing staff should fix the drainage tube properly, strengthen the monitoring of the drainage tube, observe the
negative pressure of the water seal bottle, and check for air leakage in time to ensure normal drainage. They were also
required to strictly follow the principle of aseptic operation and regularly change the sterile drainage bottle and sterile
solution to avoid obstruction, twisting, and slipping of the catheter. In addition, the nursing staff should closely
monitor the flow and color of the drainage fluid. The water column was required to fluctuate within a range of 4-
6cm. The liquid level should be 60-100cm below the mouth of the drainage tube, and the long tube should be
submerged 3-4cm into the liquid level without reversal.
 According to the patient's recovery, the patient was instructed to perform deep breathing exercises, abdominal
breathing, and effective coughing to keep the airway open.
Source: LHSC, 2022. Retrieved from https://www.lhsc.on.ca/thoracic-surgery/bullectomy.
Lung Volume Reduction Surgery (LVRS) is a surgical procedure wherein lung tissue is resected from patients with COPD,
particularly those with severe emphysema. the procedure is usually done through 3 different techniques: (1) via open
sternotomy, (2) via video-assisted thorascopic surgery or (3) via thoracotomy.
 Pulmonary function tests
 Six-minute-walk test
 Arterial blood gas
 CT scans of the lungs
 Electrocardiography
 Echocardiogram
 Cardiopulmonary exercise test
 Assessment to determine if patient is a candidate for surgical intervention
 Communication between interdisciplinary team members involved in patient care
 Formulation of appropriate preoperative management/ exercise training program
 Preoperative exercise training to reduce possible complications after surgery
38
 Educate the patient
 Possible risks/complications and how to avoid them
 Postoperative pain management
 Mobilization after surgery
 Lung expansion techniques
 Energy conservation techniques
 Psychological Support
 Nutritional Support
 Continuing the assessment of the patient's physiologic and psychologic status
 Promoting safety and privacy
 Preventing wound infection
 Promoting healing
 Assessment of postoperative patient
 Formulation of appropriate postoperative management/ exercise training program
 Postoperative pain management
 Mobilization of postoperative patient
 Postoperative exercise training
 Psychological support
 Nutritional support
Source: Physiopedia, 2022. Retrieved from https://www.physio-pedia.com/Lung_Volume_Reduction_Surgery#:~:text=Lung

%20Volume
%20Reduction%20Surgery%20(LVRS,or%20(3)%20via%20thoracotomy.
Lung Transplantation is a surgical procedure to replace a diseased or failing lung with a healthy lung, usually from a
deceased donor. A lung transplant is reserved for people who have tried medications or other treatments, but their conditions
haven't sufficiently improved.
 A chest X-ray/CT scan
 Lung perfusion scan
 Lung function tests (spirometry)
 24-hour ECG (electrocardiogram) – also known as a Holter monitor
 Coronary angiography
 Twelve lead ECG (electrocardiogram)
 Heart scan (echocardiogram)
 Right heart catheter studies
39
 Stress test (exercise ECG or myocardial perfusion scan)
 MRI Scan
 Induction of anesthesia
 Invasive arterial blood pressure monitoring is required as hemodynamics can deteriorate rapidly in these patients.
 Temperature monitoring is mandatory as hypothermia exaggerates pulmonary vascular resistance (PVR)
 Orotracheal intubation options for selective lung ventilation include a double-lumen endotracheal tube or a single-
lumen tube with a bronchial blocker, if a double-lumen tube cannot be passed successfully.
 Initial ventilator parameters are adjusted according to the arterial blood gas (ABG) to maintain low arterial CO2
tension and prevent hypoxemia.
 Preemptive management strategies that include meticulous and continuous cardiorespiratory monitoring, prompt
initiation of vasoactive pharmacotherapy, volume administration, and institution of extracorporeal support are of
critical importance during specific phases of intraoperative care.
 During these intraoperative phases of care (described below), there is a high risk of hemodynamic instability, lung
derecruitment, worsening ventilation/perfusion mismatch, and alveolar hypoventilation leading to hypoxemia and
hypercarbia in varying degrees of severity.
 The goals of perioperative ventilator support in lung transplantation rely on providing adequate minute ventilation
while preventing oxygen toxicity, barotrauma, and volutrauma.
 Initial postoperative care for all lung transplant recipients is provided on the intensive care unit. Interventions specific
to the care of the lung transplant patient will include, but are not limited to, the following:
 Ventilator management
 INO weaning protocol
 Hemodynamic management and fluid administration protocol
 Flexible bronchoscopy is performed on all patients prior to extubation to facilitate tracheobronchial toilet and to
evaluate the integrity of the airways.
 Chest tube removal is started in POD#1 once criteria are met (no air leak, total serosanguineous drainage <200 mL/24
h, and/or <20 mL/h for the three consecutive hours prior to planned removal).
 Nutritional support
 DVT prophylaxis will be initiated per hospital protocol (subcutaneous heparin 5000 units every 8 h).
 Physical therapy consultation will be completed within 48 h of transplantation; early mobility is the goal.
Source: InTechOpen, 2019. Retrieved from https://www.intechopen.com/chapters/66282.
40
NURSING MANAGEMENT
Independent: October 26, 2022
Achieving Airway Clearance: Independent:
 The nurse must appropriately administer bronchodilator and corticosteroid and become  Monitor vital signs every 4 hrs.
alert for potential side effects.  Encourage deep breathing/coughing/pursed lip breathing exercise
 The nurse instructs the patient in directed or controlled coughing, which is more effective  Assessment done; checked for any discomfort
and reduces fatigue associated with undirected forceful coughing. Directed coughing  Encourage relaxation exercises such as deep breathing exercise and pursed lip breathing
consist of a slow maximal inspiration followed by breath holding for several seconds and exercise.
two to three coughs.  Encourage adequate rest periods
 Provide bedside care
Improving Breathing Patterns:  Monitor patient’s daily intake and output.
 Inspiratory muscle training and breathing retraining may help improve breathing patterns/  Assist client to maintain a comfortable position to facilitate breathing elevating the head of
 Training in diaphragmatic breathing reduces the respiratory rate, increases alveolar bed, leaning on over-bed table, or sitting on edge of bed.
ventilation, and sometimes help expel as much air as possible during expiration.
 Pursed-lip breathing helps slow expiration, prevent collapse of small airways, and control Dependent:
the rate and depth respiration.  Administer prescribed medication, for example: bronchodilator and corticosteroid.
To Improve Activity Tolerance

 The nurse evaluates the patient’s activity tolerance and limitations and uses education
strategies to promote independent activities of daily living. The patient may be a October 27, 2022
candidate for exercise training to strengthen the muscles of the upper and lower Independent:
extremities and to improve exercise tolerance and endurance. The use of walking aids  Monitor vital signs every 4 hrs.
may be recommended to improve activity levels and ambulation.  Encourage deep breathing/coughing/pursed lip breathing exercise
 Assessment done; checked for any discomfort
Monitor and Managing Potential Complication:  Encourage relaxation exercises such as deep breathing exercise and pursed lip breathing
 The nurse monitors for cognitive changes (personality and behavioral changes, memory exercise.
impairment), increasing dyspnea and tachypnea which may indicate increasing  Encourage adequate rest periods
hypoxemia and impending respiratory failure.  Provide bedside care
 The nurse instructs the patient about signs and symptoms of respiratory infection that  Monitor patient’s daily intake and output.
may worsen hypoxemia and reports changes in the patient’s physical and cognitive status  Assist client to maintain a comfortable position to facilitate breathing elevating the head of
to primary provider. bed, leaning on over-bed table, or sitting on edge of bed.
 The nurse also instructs the patient to report any signs of infection, such as a fever or
change in sputum color, character, consistency, or amount. Any worsening of symptoms Dependent:
also suggests infection and must be reported.  Administer prescribed medication, for example: bronchodilator and corticosteroid.
 To prevent infection, the nurse encourages the patient with COPD to be immunized
against influenza and pneumococcal pneumonia, because patient is prone to respiratory Collaborative:
infection. In addition, because each patient reacts differently to external exposure O2 Therapy
(significant air pollution, high or low temperature, high humidity, strong smells), the
nurse must assess the patients actual and potential triggers that cause bronchospasm so
that avoidance or a treatment plan can be established. October 28, 2022
41
Independent:
Dependent:  Monitor vital signs every 4 hrs.
 The nurse prescribed medications.  Encourage deep breathing/coughing/pursed lip breathing exercise
 Assessment done; checked for any discomfort
Collaborative:  Encourage relaxation exercises such as deep breathing exercise and pursed lip breathing
 Monitor serial chest x-ray, ABG and ECG exercise.
 Administer supplemental oxygen judiciously via nasal cannula, mask or mechanical  Encourage adequate rest periods
ventilator and titrate as indicated by ABG results and client tolerance.  Provide bedside care
 Monitor patient’s daily intake and output.
 Assist client to maintain a comfortable position to facilitate breathing elevating the head of
bed, leaning on over-bed table, or sitting on edge of bed.
Dependent:
Source: Brunner, L. S., Suddarth, D. S., Smeltzer, S. C. O., & Bare, B. G. (2004).  Administer prescribed medication, for example: bronchodilator and corticosteroid.
Brunner & Suddarth's Textbook of Medical-Surgical Nursing (15th edition.). Lippincott
Williams & Wilkins. Collaborative:
 O2 Therapy
42
DISCHARGE PLAN
Name: XXX Date of Discharge: October 30, 2022

Condition Upon Discharge: Not Fully Recovered Nature: () Home Per Request ( ) Discharge Against Medical Advice
 Advise patient to continue medication as prescribed by the physician.

 Instruct the patient to store drugs in proper place.
 Instruct the patient to take meds on time to its proper administration
route.
 Encourage patient to complete antibiotics as prescribed.
MEDICATION
 Instruct patient to check labels and expiration date before purchasing the
drug.
 Advise patient to strictly follow the duration of his medication – how
long should he take the meds.
 Instruct patient not to skip meds.
 Encourage patient on deep breathing exercises
 Instruct the patient to have enough rest and sleep for fast recovery.
EXERCISE  Go for a 10-minute walk
 Encourage patient to do daily tasks but do not exert too much as it can
trigger his illness again.
 Restrict from eating green beans and chicken.
 Encourage high potassium diet.
 Encourage patient to eat low-fat diet.
 Encourage patient to increase fluid intake.
DIET
 Encourage low-sodium and low-sugar diet.
 Encourage pt to eat lots of green and lessen eating white rice (for HTN).
 Eat adequately and slowly chew to keep him from overeating (as slow
chewing will make him digest the food better and keep him full).
 Health teaching about chronic obstructive pulmonary disease.
 Identify the signs and symptoms of chronic obstructive pulmonary
disease.
 The importance of eating healthy foods and decreasing salt in the diet.
 Maintain airway patency.
HEALTH TEACHING
 Assist with measures to facilitate gas exchange.
 Enhance nutritional intake.
 Prevent complications, slow progression of condition.
 Provide information about disease process/prognosis and treatment
regimen.
43
 Encourage the patient to visit again to the doctor and explain the
importance.
SCHEDULE FOR NEXT VISIT  Instruct patient to report follow up check-up if necessary.
 Instruct patient to seek medical care.
 Encourage pt to immediately seek medical care if DOB is felt again.
NURSING CARE PLAN
NURSING
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
44
Subjective: Ineffective airway After the 8 hours of Independent: After 8 hours of
The client verbalized clearance r/t nursing intervention,  Demonstrate deep-breathing exercise to  Deep breathing facilitates maximum expansion nursing intervention,
“Mar’gan a kap’lgta excessive sputum the patient will be able client an encourage him to do it of the lungs and smaller airways. Splinting the patient is able to:
rakn ago pkargenan production A/E by to: frequently. reduces chest discomfort, and upright position  Have an open
ako guminawa” dyspnea and  Maintain clear, favors deeper, more forceful cough effort. airway.
abnormal breath open airways.  To mobilize secretions.  Normal breath
Objectives: sounds (that has  Have normal breath  Encourage fluid intake.  To facilitate sputum secretion. sounds, normal
 Dyspnea noticeable wheezes sounds, normal RR,  Perform chest physiotherapy  Tachypnea, shallow respirations, and RR, SPO2, and
 Productive cough during expiration; and depth of  Assess rate and depth of respirations asymmetric chest movement are frequently depth of
 yellowish sputum ronchi). respirations and chest movement. Monitor for signs present because of discomfort of moving chest respirations.
 Wheezing  Have a normal of respiratory failure (e.g., cyanosis and wall of fluid in lung.  Notice changes in
 Abnormal breath SPO2. severe tachypnea.  Thick purulent sputum indicates infection. sputum color
sounds (presence  Clear sputum  Note amount, color, and consistency of  Have normal
of wheezes when  Effectively cough sputum  Decreased airflow in areas consolidated with breath sounds (no
exhaling; ronchi) up secretions after  Auscultate lung fields, noting areas of fluid. Bronchial breath sounds (normal over wheezing).
 Prolonged treatments and deep decreased or absent airflow and bronchus) can also occur in consolidated areas.  Maintain position
exhalation breaths. adventitious breath sounds, such as Crackles, rhonchi, and wheeze are heard on without being
 Abnormal  Demonstrate crackles and wheezes. inspiration and expiration in response to fluid uncomfortable.
respiratory rate, increased air accumulation, thick secretions, and airway
rhythm, and depth exchange. spasm or obstruction.
 Excessive  Recognize the  Elevate head of bed, change position  Keeping the head elevated lowers diaphragm,
secretions significance of frequently. promoting chest expansion, aeration of lung
 Hypoxemia changes in sputum segments, and mobilization and expectoration
to include color, of secretions to keep the airway clear.
Vital Signs: character, amount, Dependent:
T: 36.7 and odor.  Administer medications, as indicated,  Aids in reduction of bronchospasm and
PR: 89 bpm  Maintain position for example mucolytics, expectorants, mobilization of secretions.
RR: 31 cpm without being bronchodilators, and analgesics.
BP: 110/70 mmHg uncomfortable.
SPO2: 92%
 Provide supplemental fluids such as IV,  Fluids are required to replace losses, including
and humidified oxygen. insensible, and aid in mobilization of
secretions.
Collaborative:
 Note of serial chest x-rays, ABGs, and  Follows progress and effects of disease process
pulse oximetry reading and therapeutic regimen and facilitates
necessary alterations in therapy.
NURSING CARE PLAN
NURSING
DIAGNOSIS
45
Subjective: Ineffective After the 8 hours of nursing Independent: After the 8 hours of
“Di ako maka breathing intervention:  Assess airway for patency.  Maintaining patent airway is always the first nursing intervention:
pamaypas sa mathey pattern r/t  Patient will be able to priority, especially in cases like trauma, acute  Patient have
ka psakaan ako” as narrowing of have relaxed breathing at neurological decompensation, or cardiac arrest. relaxed breathing
verbalized by the bronchioles normal rate and depth and  Auscultate lungs for presence of normal  Abnormal breath sounds can be heard as fluid at normal rate and
patient. A/E by by absence of dyspnea. or adventitious breath sounds. and mucus accumulate. This may indicate depth and absence
tachypnea  Patient’s respiratory rate ineffective airway clearance. of dyspnea.
Objectives: remains within  Assess respirations. Note quality, rate,  A change in the usual respiration may mean  Patient’s
 Metabolic acidosis established limits. pattern, depth, flaring of nostrils, respiratory compromise. An increase in respiratory rate is
 Abnormal breath  Patient’s ABG levels dyspnea on exertion, evidence of respiratory rate and rhythm may be a within normal
sounds (presence return to and remain splinting, use of accessory muscles, and compensatory response to airway obstruction. range.
of wheezes when within established limits. position for breathing.  Patient’s ABG
exhaling; ronchi)  Patient indicates, either  Maintain a clear airway.  Encouraging the patient to mobilize their own levels within
 Abnormal verbally or through secretions via effective coughing facilitates normal range.
respiratory rate, behavior, feeling adequate clearance of secretions.  Patient is feeling
rhythm, and depth comfortable when comfortable when
 Dyspnea breathing.  Keep away from a high oxygen  Suctioning helps to clear the blockages in the breathing.
 Excessive  Patient reports feeling concentration in patients with chronic airway.  Patient feels rested
secretions rested each day. obstructive pulmonary disease (COPD). each day.
 Hypoxemia  Patient performs  Suction secretions, as necessary.  Hypoxia triggers the drive to breathe in the  Patient performs
 Prolonged diaphragmatic pursed-lip chronic CO2 retainer patient. When diaphragmatic
exhalation breathing. administering oxygen, close monitoring is pursed-lip
 Patient demonstrates critical to avoid hazardous risings in the breathing.
Vital Signs: maximum lung expansion patient’s PaO2, leading to apnea.  Patient
T: 36.7 with adequate ventilation.  Place patient with proper body  A sitting position permits maximum lung demonstrates
PR: 89 bpm alignment for maximum breathing excursion and chest expansion. maximum lung
RR: 31 cpm pattern. expansion with
BP: 110/70 mmHg  Encourage sustained deep breaths.  These techniques promote deep inspiration, adequate
SPO2: 92% Techniques include (1) using which increases oxygenation and prevents ventilation.
demonstration: highlighting slow atelectasis. Controlled breathing methods may
inhalation, holding end inspiration for a also aid slow respirations in tachypneic
few seconds, and passive exhalation; (2) patients. Prolonged expiration prevents air
utilizing incentive spirometer and (3) trapping.
requiring the patient to yawn.
 Encourage diaphragmatic breathing for  This method relaxes muscles and increases the
patients with chronic disease. patient’s oxygen level.
 Note for changes in HR, BP, and  Increased work of breathing can lead to
temperature. tachycardia and hypertension.
 Note presence of sputum; evaluate its  Unusual appearance of secretions may be a
quality, color, amount, odor, and result of infection, bronchitis, chronic smoking,
consistency. or other condition. A discolored sputum is a
sign of infection; an odor may be present.
46
 Submit a sputum specimen for culture  Labored breathing may be a sign of respiratory
and sensitivity testing, as appropriate. infection that needs an appropriate treatment of
antibiotics.
 Use pulse oximetry to monitor oxygen  Pulse oximetry is used to detect changes in
saturation; assess arterial blood gases oxygenation. Oxygen saturation should be
(ABGs) maintained at 90% or greater. Alteration in
ABGS may result in increased pulmonary
secretions and respiratory fatigue.
Dependent:
 Provide respiratory medications and  Beta-adrenergic agonist medications relax
oxygen, per doctor’s orders. airway smooth muscles and cause
bronchodilation to open air passages.
 Avoid high concentrations of oxygen in  Hypoxia triggers the drive to breathe in the
patients with COPD. chronic CO2 retainer patient. When
administering oxygen, close monitoring is
critical to avoid uncertain risings in the
patient’s PaO2, leading to apnea.
 Ambulate patient as tolerated with  Ambulation can further break up and move
doctor’s order three times daily. secretions that block the airways.
Collaborative:
 Consult a dietitian for dietary  COPD may cause malnutrition which can affect
modifications. breathing patterns. Good nutrition can
strengthen the functionality of respiratory
muscles.
 Educate patient about medications:
indications, dosage, frequency, and  Incorporate review of the metered-dose inhaler
possible side effects. and nebulizer treatments, as needed. This
information promotes safe and effective
 Refer the patient for evaluation of medication administration.
exercise potential and development of  Exercise promotes conditioning of respiratory
individualized exercise program. muscles and the patient’s sense of well-being.
47
NURSING CARE PLAN
NURSING
DIAGNOSIS
Subjective: Impaired gas After 8 hours of nursing Independent: After 8 hours of
The client verbalized exchange r/t intervention:  Assess respiratory rate, depth, and  Rapid and shallow breathing patterns and nursing intervention:
“Mar’gan a kap’lgta emphysema  Patient will be able to effort, including the use of accessory hypoventilation affect gas exchange (Gosselink  Patient maintained
rakn ago pkargenan A/E by maintain optimal gas muscles, nasal flaring, and abnormal & Stam, 2005). Increased respiratory rate, use optimal gas
ako guminawa” abnormal ABG exchange as evidenced by breathing patterns. of accessory muscles, nasal flaring, abdominal exchange as
usual mental status, breathing, and a look of panic in the patient’s evidenced by usual
Objectives: unlabored respirations at eyes may be seen with hypoxia. mental status,
 Metabolic acidosis 12-20 per minute,  Assess the lungs for areas of decreased  Any irregularity of breath sounds may disclose unlabored
 Hypoxemia oximetry results within ventilation and auscultate presence of the cause of impaired gas exchange. The respirations at 12-20
 Hypoxia normal range, blood gases adventitious sounds. presence of crackles and wheezes may alert the per minute,
 Hypercapnia within normal range, and nurse to airway obstruction, leading to or oximetry results
 Abnormal breath baseline HR for patient. exacerbating existing hypoxia. Diminished within normal
sounds (Ronchi)  Patient will be able to breath sounds are linked with poor ventilation. range, blood gases
 Dyspnea maintain clear lung fields  Monitor for signs of hypercapnia.  Signs of hypercapnia include headaches, within normal
 Body malaise and remains free of signs Hypercapnia is the buildup of carbon dizziness, lethargy, reduced ability to follow range, and baseline
of respiratory distress. P dioxide in the bloodstream. instructions, disorientation, and coma. HR for patient.
Vital Signs:  Patient will be able to  Note blood gas (ABG) results as  Increasing PaCO2 and decreasing PaO2 are  Patient maintained
T: 36.7 verbalize understanding of available and note changes. signs of respiratory acidosis and hypoxemia. clear lung fields and
PR: 89 bpm oxygen and other As the patient’s condition deteriorates, the remains free of
RR: 31 cpm therapeutic interventions. respiratory rate will decrease, and PaCO2 will signs of respiratory
BP: 110/70 mmHg  Patient will be able to increase. Some patients, such as those with distress.
SPO2: 92% participate in procedures to COPD, have a significant decrease in  Patient verbalized
optimize oxygenation and pulmonary reserves, and additional understanding of
in management regimen physiological stress may result in acute oxygen and other
within level of respiratory failure. therapeutic
capability/condition.  Assess the home environment for  Help the patient adjust the home environment interventions.
 Patient will be able to irritants that impair gas exchange. as necessary (e.g., installing an air filter to  Patient participated
manifest resolution or decrease dust). Irritants in the environment in procedures to
absence of symptoms of decrease the patient’s effectiveness in optimize
respiratory distress. accessing oxygen during breathing. oxygenation and in
 Position patient with head of the bed  Upright or semi-Fowler’s position allows management
elevated, in a semi-Fowler’s position increased thoracic capacity, total descent of the regimen within
(head of the bed at 45 degrees when diaphragm, and increased lung expansion level of
supine) as tolerated. preventing the abdominal contents from capability/condition.
crowding.  Patient manifested
 Slumped positioning causes the abdomen to resolution or
 Regularly check the patient’s position compress the diaphragm and limits full lung absence of
48
so that they do not slump down in bed. expansion. symptoms of
 If the patient has unilateral lung disease,  Gravity and hydrostatic pressure cause the respiratory distress.
position the patient correctly to promote dependent lung to become better ventilated and
ventilation-perfusion. perfused, which increases oxygenation. The
good side should be down when the patient is
positioned on the side (e.g., lung with
pulmonary embolus or atelectasis should be
up).
 Turning is important to prevent complications
 Turn the patient every 2 hours. Monitor of immobility, but in critically ill patients with
mixed venous oxygen saturation closely low hemoglobin levels or decreased cardiac
after turning. If it drops below 10% or output, turning on either side can result in
fails to return to baseline promptly, turn desaturation.
the patient back into a supine position
and evaluate oxygen status.  Ambulation facilitates lung expansion,
 Encourage or assist with ambulation as secretion clearance and stimulates deep
per the physician’s order. breathing.
 The partial pressure of arterial oxygen has been
 Consider positioning the patient prone shown to increase in the prone position,
with upper thorax and pelvis supported, possibly because of greater diaphragm
allowing the abdomen to protrude. contraction and increased ventral lung regions’
Monitor oxygen saturation and turn function. Prone positioning improves
back if desaturation occurs. Do not put hypoxemia significantly.
in a prone position if the patient has
multisystem trauma.  This technique can help increase sputum
 Help patient deep-breathe and perform clearance and decrease cough spasms.
controlled coughing. Have the patient Controlled coughing uses the diaphragmatic
inhale deeply, hold breath for several muscles, making the cough more forceful and
seconds, and cough two to three times effective.
with mouth open while tightening the
upper abdominal muscles as tolerated.  This technique promotes deep inspiration,
 Encourage slow deep breathing using an which increases oxygenation and prevents
incentive spirometer as indicated. atelectasis.
Dependent:  Suction clears secretions if the patient is not

 Suction as necessary. capable of effectively clearing the airway.
Airway obstruction blocks ventilation that
impairs gas exchange.
 Administer humidified oxygen through  The type depends on the etiological factors of
appropriate device (e.g., nasal cannula the problem (e.g., antibiotics for pneumonia,
49
or face mask per physician’s order); bronchodilators for COPD, anticoagulants,
watch for the onset of hypoventilation thrombolytics for pulmonary embolus,
as evidenced by increased somnolence analgesics for thoracic pain).
after initiating or increasing oxygen
therapy.
 Administer medications as prescribed.  A patient with chronic lung disease may need a
hypoxic drive to breathe and hypoventilate
during oxygen therapy.
Collaborative:
 Instruct patient to limit exposure to  This is to reduce the potential spread of
persons with respiratory infections. droplets between patients.
 Instruct family in complications of  Knowledge of the family about the disease is
disease and importance of maintaining a critical to prevent further complications.
medical regimen, including when to call
physician.
 Support the family of a patient with  Severely compromised respiratory functioning
chronic illness. causes fear and anxiety in patients and their
families. Reassurance from the nurse can be
helpful.
50

PA TOOL (Medicine Ward)

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Revised 2022

Mindanao State University

Acquired Diseases: Heredo- familial Diseases:

D. PATIENT’S PERCEPTION OF:

Name: XXX Date: October 28. 2022

Name: XXX Age: 71 Years Old

b. Male (circumcision, civil

DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

October 26, 2022 CHEMISTRY

Hemoglobin A1C 9.8 % < 6.5

October 26, 2022 ELECTROLYTES

NONE NONE NONE NONE NONE

PRESCRIBED AND MECHANISM ADVERSE

HEALTHY RESPIRATORY SYSTEM AFFECTED RESPIRATORY SYSTEM

Gas Exchange Process

In pulmonary circulation—circulation between the heart and lungs—the vasculature is flipped.

Precipitating Factors: Predisposing Factors:

 MUCUS-SECRETING GLANDS THICKENED BRONCHIAL WALLS

FURTHER NARROWED BRONCHIAL LUMEN

DAMAGED ALVEOLI ADJACENT TO THE BRONCHIOLES

ALVEOLAR MACROPHAGES ALTERED FUNCTION

AIRFLOW OBSTRUCTION  SUSCEPTIBILITY TO RESPIRATORY

 MUCUS-SECRETING GLANDS THICKENED BRONCHIAL WALL DESTRUCTION OF

SORE OR SCRATCHY THROAT. FEELING

INTERIOR OF A VESSEL, CAPILLARY BED IS AN HYPERCAPNIA HYPOXEMIA

CHOKING OR GAGGING. SUDDEN

DUE TO IMPAIRED GAS HYPOXEMIA OR

Other medications: Medications:

Source: LHSC, 2022. Retrieved from https://www.lhsc.on.ca/thoracic-surgery/bullectomy.

Source: Physiopedia, 2022. Retrieved from https://www.physio-pedia.com/Lung_Volume_Reduction_Surgery#:~:text=Lung

Source: InTechOpen, 2019. Retrieved from https://www.intechopen.com/chapters/66282.

To Improve Activity Tolerance

Name: XXX Date of Discharge: October 30, 2022

 Advise patient to continue medication as prescribed by the physician.

Dependent:  Suction clears secretions if the patient is not

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