CLIENT INFORMATION

Name: A.G.F.
Chief Complaint: Matagal ng inuubo ni daddy
halos 3 taon na as verbalized of the clients care-
giver

Age: 79 y/o
Date of Admission:
September 8, 2011
Role: Father , Husband
Gender: Male
Family Support: Diagnosis: Chr onic Br onchitis
SUBJECTIVE DATA

OBJECTIVE DATA
Vital Signs
Pulse Rate = 104 bpm
Respiratory Rate = 25 bpm
Blood Pressure = 110/80 mmHg
Weight = 58 kg
BMI = 18.3
Osteorized Food = 330 cc
Productive cough with
whitish sputum (5-10 ml)
Chest Retractions
Fast Breathing (when
walking)
Wheezing
Use of accessory muscle
sternocleidomastoid
Exertional dyspnea when
walking
Shortness of breath (when
walking)
Slight clubbing of finger
nails and toe nails
Left sided body weakness

Male pattern baldness
Easy fatigability

DIAGNOSTICS
Hemoglobin = 120 g/L
Hematocrit = 0.28 g/L
Red cell count = 2.85 x 10
12/L
WBC = 11.40 x 10 g/L
Neutrophils = 0.84
pH = 7.33
PaCO
2
= 47
HCO
3
= 27
NURSING PROBLEM

Ineffective airway clearance
EXPECTED OUTCOME


Within 1 hour and 20 minutes of nurs-
ing intervention, the clients caregiver
has able to maintain patent airway
from Respiratory Rate of 25 to 20
breaths per minute and exhibited im-
proved airway.

NURSING PROBLEM


Ineffective breathing pattern

EXPECTED OUTCOME
Within 1 hour and 30 minutes of nurs-
ing interventions, the clients caregiver
has able to establish effective breath-
ing pattern with Respiratory Rate of
25 to 20 bpm and exhibited improved
breathing pattern and demonstrated
understanding the proper regimen for
adequate breathing pattern.

NURSING PROBLEM


Imbalanced Nutrition: Less than body
requirements






EXPECTED OUTCOME
Within 30 minutes 1 hour of nursing
intervention and health teaching, the
health caregiver has followed the man-
agement in the nutritional needs of the
client and complied on the interven-
tions of the nutritional needs of the
client.
INTERVENTIONS
Elevate head of the bead to
a moderate high back rest


Suction as needed
Perform chestphysiotherapy
like vibration
Perform the nebulization to
the client
Maintain patent airway
Wean the client gradually
from PEG feeding

Monitor daily measurement
of osteorized food intake
and nutritional needs for the
client
Continuous monitoring
clients weight
Monitor laboratory values
and fluid and electrolytes
results
Note respiratory rate, depth
and use of accessory mus-
cles and pursed lip breath-
ing
Administer oxygen therapy
(2-3 L/min)

TEACHINGS
Encourage the client of
proper breathing and cough-
ing such as splinting
Encourage to increase fluid
intake
Emphasize in the im-
portance of well-balanced
nutritional intake

PHARMACOLOGY
Administer salbutamol
(ventolin) 2.5 mg
Acetylcysteine (Flumucil)
200 mg
Multivitamis with Iron
(Iberet) 10 cc
Methycobal (Mecobalamin)
500 mg