A Case Study on

INTRODUCTION
A. BACKGROUND OF THE STUDY
Asthma is a chronic disease of the airways that causes airway
hyperresponsiveness, mucosal edema and mucus production. This
inflammation, ultimately leads to recurrent episodes of asthma symptoms:
cough, chest tightness, wheezing and dyspnea. (Medical-Surgical Health
Nursing Volume 1 by Smeltzer and Bare page 587). It is a multifactorial disease
process associated with genetic, allergic, environmental, infectious, emotional,
and nutritional components. Because of their symptomatology the majority of
individuals with asthma experience a significant number of missed work or
school days. This can create a severe disruption in quality of life, often leading
to depressive episodes. It also disrupts the lives of caregivers and family
members of the affected individual. Asthma patients who have increased
symptomatology at night (a significant portion) also tend to have disturbed
sleep patterns and impaired daytime attention, concentration, and memory.
B. RATIONALE FOR CHOOSING THE CASE
I choose the case of bronchial asthma because it would help me to have a
focus study regarding this casemore nursing care would be given. Added to
that, I choose the client because of the fact that he is cooperative in the sense
that he always try to answer the questions asked in his full knowledge and try
to verbalize anything that he wants to say.

I. NURSING HEALTH HISTORY

A. DEMOGRAPHIC PROFILE
Name: Faisal Younis
Age: 30 years old
Sex: Male
Civil Status: Married
Address: Tabuk, KSA
Date Admitted: November 2, 2014
Time Admitted: 9:00 AM
B. CHIEF COMPLAINT AND HISTORY OF PRESENT ILLNESS
Three days prior to admission, the patient has already suffering from slight
difficulty of breathing that is usually relieved when resting. Two hours prior
to admission, the patient still suffering from difficulty of breathing with
continuous cough and cannot be relieved even when resting. This prompted
him to seek medical help at King Khalid Civilian Hospital and thus
recommended for admission.

C. PHYSICAL ASSESSMENT
GENERAL

NORMS

ACTUAL FINDINGS

APPEARANCE

INTERPRETATION AND
ANALYSIS

1. Posture/Gait

Relaxed, erect
Slouched/bent
posture; coordinated posture
movement
Older adults (middle
age) assume a
stooped forward
bent posture, hips
and knees are some
what flexed. Arms
are raised because
arms are bent at the
elbow

Interpretation: Not
normal
Analysis:
This observation is
most seen with
dyspnea, advance
chronic lung disease
and air trapping,
acute and chronic

2. Skin Color

Healthy appearance Pallor; weakness;

Skin color may be
obvious illness
pink, tan, brown,
olive or yellowish
depends on the race.
With a normal
supply of oxygen, the
nail beds, the tongue
and the lips appear
pinkish-red in color

Interpretation: Not
normal
Analysis:
Skin color and
temperature
particularly that of
the lips and nail beds.
The color of the lips
and nail beds is an
indicator of tissue
perfusion (passage of
blood through the
vessels) Pale,
cyanotic, cool and
moist skin may be a
sign of circulatory
problems. The color
and appearance of
the skin and nails may
reflect insufficient
delivery of
oxygenated blood to

GENERAL

NORMS

ACTUAL FINDINGS

INTERPRETATION AND
ANALYSIS
the tissue because of
respiratory
dysfunction (

APPEARANCE

3. Personal
Hygiene/
Grooming

Clean, neat

No foul body odor,

neat

Interpretation:
Normal
Analysis:
Personal hygiene is
the self care by which
people attend to such
functions as bathing,
toileting, general
body hygiene, and
grooming. Hygiene is
highly personal
matter determined by
individual values and
practices. It involves
care of the skin, hair,
nails, teeth, oral and
nasal cavities, eyes,
ears, and perinealgenital areas. Hygiene
is the observance of
health rules relating
to these self-care

4. Nutritional
Status

The state of nutrition

is often reflected in a
persons
appearance.
Although the most
obvious physical sign
of good nutrition is a
normal body weight
with to respect to
height, body frame,
and age, other

Malnourished;
general
appearance is
listless, appears
acutely or
chronically ill

Interpretation: Not
Normal
Analysis:
Loss of weight may be
generalized as a
result of inadequate
caloric intake or may
be seen in loss of
muscle mass with
disorders that affect
protein synthesis.

GENERAL

NORMS

ACTUAL FINDINGS

INTERPRETATION AND
ANALYSIS
Nutritional problems
in the elderly often
occur or are
precipitated by such
illnesses as
pneumonia and
urinary tract
infections. Acute and
chronic diseases may
affect the metabolism
and utilization of
nutrients, which
already are altered by
the aging

5. Age
Adulthood ages
Appropriateness ranges from 25 to 66
years. According to
Erik Eriksons Theory,
the central task is
generativity versus
stagnation. The
indicators of positive
resolution are
creativity,
productivity and
concern for others.
The indicators of
negative resolution
are self-indulgence,
self-concern, lack of
interests and
commitments.

The age of the

client is 56 years
old. As a middle
adult, she has
concern with
others, talks with
the patients in the
same ward

Interpretation:
Normal
Analysis:
Erikson believes that
the greater the task
achievement, the
healthier the
personality of the
person

6. Verbal
Behavior

The client has

logical sequence of

Interpretation:
Normal

APPEARANCE
tissues can serve as
indicators of good
nutritional status
and adequate intake
of specific nutrients;
these include the
hair, skin, teeth,
gums, mucous
membranes, mouth
and tongue, skeletal
muscles, abdomen,
lower extremities,
and thyroid gland.
General appearance
is alert and
responsive

Understandable,
moderate pace;

GENERAL
APPEARANCE

7. Non-verbal
behavior

NORMS

INTERPRETATION AND
ANALYSIS
exhibition of thought though, has a sense Analysis:
association; logical
of reality and able Verbal
sequence; make
to understand
communication is
sense; has sense of
largely conscious
reality
because people
choose the words
they use. The words
use varies among
individuals according
to culture,
socioeconomic
background, age and
education. Countless
possibilities exist for
the way ideas are
exchanged. An
abundance of words
can be used to form
messages
No distress noted in
facial expression; the
clients affect/mood
is appropriate to
situation

ACTUAL FINDINGS

The clients
affect/mood is
appropriate in the
situation.

Interpretation:
Normal
Analysis:
Nonverbal
communication
includes gestures,
body movement, use
of touch and physical
appearance,
adornment.
Nonverbal behavior is
controlled less
consciously than
verbal behavior

MEASUREMENTS

NORMS

ACTUAL FINDINGS

INTERPRETATION AND
ANALYSIS

Temperature

Normal adult
temperature axillary:
35.8 C to 37.0 C

As of November 20
2006
8:00pm 36.5 C

Interpretation: Normal
Analysis:
Normal adult
temperature ranges
from 35.8 C to 37.0
C. it is not uncommon
for adult/elderly
persons to have body
temperature less than
36.4 C because
normal temperature
drops as persons ages.

Pulse Rate

The normal pulse

8:00pm 80 beats
rate of an adult: 60per minute
100 beats per minute

Interpretation: Normal
Analysis:
The normal range of
the pulse in an adult is
60 to 100 beats per
minute. As the age
increases, the pulse
rate gradually decrease

Respiratory
Rate

The normal
8:00pm 21
respiratory rate of an breaths per minute
adult: 12-20 breaths
per minute

Interpretation: Not
Normal
Analysis:
Normal breathing is
automatic and
involuntary. At rest,
the normal adult
respiratory rate is 12
to 20 breaths per
minute. Respiratory
rate changes with age.
Tachypnea is an
abnormally fast

MEASUREMENTS

Blood
Pressure

BODY PARTS

Skin

NORMS

Systolic
Diastolic
90-140

ACTUAL FINDINGS

8:00pm
mmHg

130/70

60-90

NORMS

Varies from light to

deep brown; from
ruddy pink; from
yellow overtones to
olive

ACTUAL FINDINGS

Pallor

INTERPRETATION AND
ANALYSIS
respiratory rate
(usually above 20
breaths per minute in
adult)
Interpretation: Normal
Analysis:
In adults, the trend is
toward gradually
increasing systolic and
diastolic blood
pressure with aging. In
part, this trend is due
to increased
systematic vascular
resistance, reflecting
arterial narrowing and
decreased vessel
elasticity due to
atherosclerotic vessel
disease. The increase
in systolic pressure is
proportionally greater
than the increase in
diastolic pressure

INTERPRETATION AND
ANALYSIS
Interpretation: Not
Normal
Analysis:
Pallor is the result of
inadequate circulating
blood or hemoglobin
and subsequent
reduction in tissue

BODY PARTS

Mouth/ Oral
Cavity
Lips

Thorax
Anterior
Thorax

NORMS

-Uniform pink color

-Soft, moist, smooth
texture
-Symmetry of
contour
-Ability to purse lips

-Quite rhythmic and

effortless
respirations

ACTUAL FINDINGS

- lips has visible

margins
- symmetrical
- pale in color
- no edema

-tachypnea
-wheezes at right
lung field

INTERPRETATION AND
ANALYSIS
oxygenation
Interpretation: Not
Normal
Analysis:
Pallor is the result of
inadequate circulating
blood or hemoglobin
and subsequent
reduction in tissue
Interpretation: Not
Normal
Analysis:
Dyspnea is a sign of
serious disease of the
airway, lungs, or heart.
(www.medterms.com)
Tachypnea may be
necessary for a
sufficient gas-exchange
of the body
(www.wrongdiagnosis.
com)
Possible cause of air
passing through a
constricted bronchus
as a result of secretion,
swelling or tumor

D. LABORATORY AND DIAGNOSTIC EXAMINATION

DIAGNOSTIC
EXAM
Urinalysis

NORMS

ACTUAL RESULTS

INTERPRETATION AND ANALYSIS

Reference Values
Color: light straw
to dark amber
Appearance: clear
Odor: aromatic
pH: 4.5-8.0
Specific Gravity:
1.005-1.030
Protein: 2-8
mg/dl; negative
reagent strip test;
trace
Glucose: negative
Ketones: negative
(Handbook of
Laboratory and
Diagnostic Test
with Nursing
Inplication, 5th
edition, pg. 343)

Actual Findings
Color: Yellow
Appearance:
slightly hazy
Odor: aromatic
pH: acidic
Specific Gravity:
1.015
Protein: trace
Glucose: negative
Microscopic
Examination:
RBC: 2-3/hpf
Pus: 3-5/hpf
Epithelial cells:
many
Mucus threads:
light
Bacteria: few

Interpretation: The urine

color, appearance, pH and
microscopic examination
are considered not normal
while the odor, specific
gravity, protein and
glucose are considered
normal.
Analysis:
Color of the urine
changes can results from
diet, drugs and many
diseases (pg. 395,
Diagnostic Test). Color is
affected by concentration
of urine. Tea colored urine
is due to blood in the
urine. Bright yellow urine
may be secondary to
vitamin intake. Dark yellow
urine is a sure indicator
that there is dehydrated
indicated and that the fluid
consumption must be
increased. When water
loose from the body
exceeds water intake, the
kidneys need to consume
water making the urination
more concentrated with
waste products and
subsequently dark in color.
Yellow colored urine is
possible of pyuria, and
infection. (Medical Surgical

Microscopic
Examination:
RBC: 0-2/high
power field
WBC: 0-5/high
power field
Epithelial cells: 05/high power field
(Handbook of
Diagnostic Test,
3rd edition, pg.
329)

DIAGNOSTIC
EXAM

NORMS

ACTUAL RESULTS

INTERPRETATION AND ANALYSIS

Nursing by Bare and
Smeltzer pg.1263) Turbid
urine may contain red or
white cells, bacteria, fat or
chyle and may reflect renal
infection (pg. 395,
Diagnostic Test, 2004 by
Lippincott Williams and
Wilkins). Urine turbidity
may result from urinary
tract infections (pg. 180, A
Manual of Laboratory and
Diagnostic Test, 7th
edition). A normal pH is 7.
A pH < 7 indicates acid
urine and > 7 indicates
alkaline urine. Acid urine
ph is associated with renal
tuberculosis, pyrexia,
phenylketonuria,
alkaptonuria and acidosis.
(Diagnostic Tests, A
Prescribers Guide to
Selection and
Interpretation by
Lippincott Williams and
Wilkins, p.395) Due to
carbohydrate
malabsorption, fat
malabsorption and
disaccharides deficiency. (A
Manual of Laboratory and
Diagnostic Tests, 7th
edition by Lippincott
William and Wilkins,
p.279)Normally, freshly
voided urine has a faint
odor owing to the

DIAGNOSTIC
EXAM

NORMS

ACTUAL RESULTS

INTERPRETATION AND ANALYSIS

presence of volatile acids.
It is not generally
offensive. Fresh urine from
most persons has a
characteristic aromatic
odor (pg. 396, Diagnostic
Test). Specific gravity is an
indication of the relative
proportions of dissolved
solid components to the
total volume of the
specimen and reflects the
relative degree of
concentration or dilution
of the specimen.
(www.intensivecaring.com)
In a healthy renal and
urinary tract system, urine
contains no protein or only
trace amount (pg. 191, A
Manual of Laboratory and
Diagnostic Test). Sugar,
usually absent from the
urine, may appear under
normal conditions (pg. 329,
Handbook of Diagnostic
Test, 3rd edition)
Red blood cells in the
urine can be due to
vigorous exercise or
exposure to toxic
chemicals. Bloody urine
can also be a sign of
bleeding in the
genitourinary tract as a
result of systemic bleeding
disorders, various kidney
diseases, bacterial

DIAGNOSTIC
EXAM

NORMS

ACTUAL RESULTS

INTERPRETATION AND ANALYSIS

infections, parasitic
infections including
malaria, obstructions in
the urinary tract, scurvy,
subacute bacterial
endocarditis, traumatic
injuries, and tumors.
A high number of white
blood cells in the urine is
usually a symptom of
urinary tract infection. A
large number of cells from
tissue lining (epithelial
cells) can indicate damage
to the small tubes that
carry material into and out
of the kidneys.
(www.healthatoz.com)

Hematology

Reference Values:
Neutrophils: 0.400.60
Lymphocytes:
0.20-0.40
(Diagnostic
Testing and
Nursing
Implications, 4th
edition)

Actual Findings:
Interpretation: Not normal
Neutrophils: 0.79 Analysis:
Lymphocytes: 0.13
Increase in Neutrophils:
severe bacterial disease,
diabetic acidosis,
infarctions, increase in
acute, severe
inflammation,
malignancies (Diagnostic
Testing and Nursing
Implications, 4th edition)
Decreased
in
Lymphocytes:
indicates
lymphopenia.
(Medical Surgical Nursing
by Bare and Smeltzer pg.
876)
Possible cause of sepsis
and
immunodeficiency

DIAGNOSTIC
EXAM

NORMS

ACTUAL RESULTS

INTERPRETATION AND ANALYSIS

disease.
(Fundamentals of Nursing
by Kozier pg. 759)

A.

Conclusion and Recommendations

Reducing exposure to allergens that can trigger broncho-constriction
and inflammation is an important preventive measure. Nurses can be
instrumental in working with the client and family to identify individual asthma
triggers and motivate the family to restructure the environment to limit
allergen exposure.
E. ANATOMY AND PHYSIOLOGY
The respiratory system is situated in the thorax, and is responsible for
gaseous exchange between the circulatory system and the outside world. Air
is taken in via the upper airways (the nasal cavity, pharynx and larynx)
through the lower airways (trachea, primary bronchi and bronchial tree) and
into the small bronchioles and alveoli within the lung tissue.
The respiratory system is an intricate arrangement of spaces and
passageways that conduct air from outside the body into the lungs and finally
into the blood as well as expelling waste gasses. This system is responsible for
the mechanical process called breathing, with the average adult breathing
about 12 to 20 times per minute.
When engaged in strenuous activities, the rate and depth of breathing
increases in order to handle the increased concentrations of carbon dioxide
in the blood. Breathing is typically an involuntary process, but can be
consciously stimulated or inhibited as in holding your breath.

Nostrils/Nasal Cavities
During inhalation, air enters the nostrils and passes into the nasal cavities
where foreign bodies are removed, the air is heated and moisturized before
it is brought further into the body. It is this part of the body that houses our
sense of smell.
Sinuses
The sinuses are small cavities that are lined with mucous membrane
within the bones of the skull.
Pharynx
The pharynx or throat carries foods and liquids into the digestive tract and
also carries air into the respiratory tract.
Larynx
The larynx or voice box is located between the pharynx and trachea. It is
the location of the Adam's apple, which in reality is the thyroid gland and
houses the vocal cords.
Trachea
The chest and conducts air between the larynx and the lungs.
Lungs
The lungs are the organ in which the exchange of gasses takes place. The
lungs are made up of extremely thin and delicate tissues. At the lungs, the
bronchi subdivides, becoming progressively smaller as they branch through
the lung tissue, until they reach the tiny air sacks of the lungs called the
alveoli. It is at the alveoli that gasses enter and leave the blood stream.
The lungs are divided into lobes; The left lung is composed of the upper lobe,
the lower lobe and the lingula (a small remnant next to the apex of the
heart), the right lung is composed of the upper, the middle and the lower
lobes.
Bronchi
The trachea divides into two parts called the bronchi, which enter the
lungs.
Bronchioles
The bronchi subdivide creating a network of smaller branches, with the
smallest one being the bronchioles. There are more than one million
bronchioles in each lung.
Alveoli
The alveoli are tiny air sacks that are enveloped in a network of capillaries.
It is here that the air we breathe is diffused into the blood, and waste gasses
are returned for elimination.

F. PATHOPHYSIOLOGY/SCHEMATIC DIAGRAM OF THE DISEASE

The underlying pathology of asthma is reversible and diffuse airway
inflammation. The inflammation leads to obstruction from the following:
swelling of the membranes that line the airways (mucosal edema), reducing
the airway diameter; contraction of the bronchial smooth muscle that
encircles the airways (bronchospasm), causing further narrowing; and
increased mucus production, which diminishes airway size and may entirely
plug the bronchi.
The bronchial muscles and mucus glands enlarge; thick tenacious sputum
is produced; and the alveoli hyperinflate. Some patients may have airway
subbasement membrane fibrosis. This is called airway remodeling and
occurs in response to chronic inflammation. The fibrotic changes in the
airway lead to airway narrowing and potentially irreversible airflow
limitation.
Cells that play a key role in the inflammation of asthma are mast cells,
Neutrophils, eosinophils, and lymphocytes. Mast cells, when activated,
release several chemicals called mediators. These chemicals, which include
histamine, bradykinin, prostaglandins and leukotrienes, perpetuate the
inflammatory response, causing increased blood flow, vasoconstriction, fluid
leak from vasculature, attraction of white blood cells to the area and
bronchoconstriction. Regulation of these chemicals is the aim of much of the
current research regarding pharmacologic therapy for asthma.
Further, alpha- and beta2-adrenergic receptors of the sympathetic
nervous system are located in the bronchi. When the alpha-adrenergic
receptors are stimulated, bronchoconstriction occurs; when the beta2adrenergic receptors are stimulated, bronchodilation results. The balance
between alpha and beta2 receptors is controlled primarily by cyclic adenosine
monophosphate (cAMP). Alpha-adrenergic receptor stimulation results in a
decrease in cAMP, which leads to an increase of chemical mediators released
by the mast cells and bronchoconstriction. Beta2-receptor stimulation results
in increased levels of cAMP, which inhibits the release of chemical mediators
and causes bronchodilation. (Medical-Surgical Nursing Volume 1 by Smeltzer
and Bare page 588)

Figure 1-1 Pathophysiology of Asthma

Predisposing Factors
Atopy
Female Gender

Causal Factors
Exposure to indoor and
outdoor allergens
Occupational sensitizers

Contributing Factors
Respiratory infections
Air pollution
Active/passive smoking
Other (diet, small size at birth)

Inflammation

Hyperrensponsiveness of
airways

Risk Factors for exacerbations

Allergens
Respiratory infections
Exercise and hyperventilation
Weather changes
Exposure to sulfur dioxide
Exposure to food, additives,
medications

Airflow limitation

Symptoms
Wheezing
Cough
Dyspnea
Chest tightness

G. DRUG STUDY
GENERIC NAME

ALBUTEROL

ACTION

BRAND NAME

Synthetic
Salbutamol
sympathomime
tic amine and
moderately
selective
beta2adrenergic
agonist with
comparatively
long action.
Acts more
prominently on
beta2
receptors
(particularly
smooth
muscles of
bronchi,
uterus, and
vascular supply
to skeletal
muscles) than
on beta1
(heart)
receptors.
Minimal or no
effect on
alpha-

CLASSIFICATION

INDICATION

autonomic
nervous system
agent; betaadrenergic agonist
(sympathomimeti
c); bronchodilator
(respiratory
smooth muscle
relaxant)

To relieve
bronchospasm
associated with
acute or
chronic
asthma,
bronchitis, or
other
reversible
obstructive
airway
diseases. Also
used to
prevent
exerciseinduced
bronchospasm.

CONTRAINDICATIONS

Pregnancy
(category C),
lactation. Use of
oral syrup in
children
<2 y.

SIDE EFFECTS/
ADVERSE
REACTIONS

NURSING
RESPONSIBILITY

Body as a
Whole:
Hypersensitivit
y reaction.
CNS: Tremor,
anxiety,
nervousness,
restlessness,
convulsions,
weakness,
headache,
hallucinations.
CV:
Palpitation,
hypertension,
hypotension,
bradycardia,
reflex
tachycardia.
Special Senses:
Blurred vision,
dilated pupils.
GI: Nausea,
vomiting.
Other: Muscle
cramps,
hoarseness

Assessment & Drug

Effects
Monitor
therapeutic
effectiveness which
is indicated by
significant subjective
improvement in
pulmonary function
within 6090 min
after drug
administration.
Monitor for: S&S
of fine tremor in
fingers, which may
interfere with
precision handwork;
CNS stimulation,
particularly in
children 26 y,
(hyperactivity,
excitement,
nervousness,
insomnia),
tachycardia, GI
symptoms. Report
promptly to
physician.

GENERIC NAME

ACTION

adrenergic
receptors.
Inhibits
histamine
release by mast
cells.

BRAND NAME

CLASSIFICATION

INDICATION

CONTRAINDICATIONS

SIDE EFFECTS/
ADVERSE
REACTIONS

NURSING
RESPONSIBILITY
Lab tests: Periodic

ABGs, pulmonary
functions, and pulse
oximetry.
Consult physician
about giving last
albuterol dose
several hours before
bedtime, if druginduced insomnia is a
problem.
Patient & Family
Education
Review directions
for correct use of
medication and
inhaler
Avoid contact of
inhalation drug with
eyes.
Do not increase
number or frequency
of inhalations
without advice of
physician.
Notify physician if
albuterol fails to
provide relief
because this can
signify worsening of

GENERIC NAME

ACTION

BRAND NAME

CLASSIFICATION

INDICATION

CONTRAINDICATIONS

SIDE EFFECTS/
ADVERSE
REACTIONS

NURSING
RESPONSIBILITY
pulmonary function
and a reevaluation of
condition/therapy
may be indicated.
Note: Albuterol
can cause dizziness
or vertigo; take
necessary
precautions.
Do not use OTC
drugs without
physician approval.
Many medications
(e.g., cold remedies)
contain drugs that
may intensify
albuterol action.

CEFUROXIME
SODIUM

Semisynthetic
secondgeneration
cephalosporin
antibiotic with
structure
similar to that
of the
penicillins.
Resistance
against betalactamase-

Kefurox,
Zinacef

antiinfective;
antibiotic; secondgeneration
cephalosporin

Infections
caused by
susceptible
organisms in
the lower
respiratory
tract, urinary
tract, skin, and
skin structures;
also used for
treatment of
meningitis,

Hypersensitivity
to cephalosporins
and related
antibiotics;
pregnancy
(category B),
lactation

Body as a
Whole:
Thrombophleb
itis (IV site);
pain, burning,
cellulitis (IM
site);
superinfection
s, positive
Coombs' test.
GI: Diarrhea,
nausea,

Assessment & Drug

Effects
Determine history
of hypersensitivity
reactions to
cephalosporins,
penicillins, and
history of allergies,
particularly to drugs,
before therapy is
initiated.
Lab tests: Perform

GENERIC NAME

ACTION

producing
strains exceeds
that of first
generation
cephalosporins
. Antimicrobial
spectrum of
activity
resembles that
of cefonicid.
Preferentially
binds to one or
more of the
penicillinbinding
proteins (PBP)
located on cell
walls of
susceptible
organisms. This
inhibits third
and final stage
of bacterial cell
wall synthesis,
thus killing the
bacterium.
Partial crossallergenicity
between other
beta-lactam
antibiotics and

BRAND NAME

CLASSIFICATION

INDICATION

gonorrhea, and
otitis media
and for
perioperative
prophylaxis
(e.g., openheart surgery),
early Lyme
disease.

CONTRAINDICATIONS

SIDE EFFECTS/
ADVERSE
REACTIONS
antibioticassociated
colitis. Skin:
Rash, pruritus,
urticaria.
Urogenital:
Increased
serum
creatinine and
BUN,
decreased
creatinine
clearance.

NURSING
RESPONSIBILITY
culture and
sensitivity tests
before initiation of
therapy and
periodically during
therapy if indicated.
Therapy may be
instituted pending
test results. Monitor
periodically BUN and
creatinine clearance.
Inspect IM and IV
injection sites
frequently for signs
of phlebitis.
Report onset of
loose stools or
diarrhea.
Monitor for
manifestations of
hypersensitivity.
Discontinue drug and
report their
appearance
promptly.
Monitor I&O rates
and pattern:
Especially important
in severely ill
patients receiving
high doses. Report

GENERIC NAME

ACTION

cephalosporins
has been
reported.

BRAND NAME

CLASSIFICATION

INDICATION

CONTRAINDICATIONS

SIDE EFFECTS/
ADVERSE
REACTIONS

NURSING
RESPONSIBILITY
any significant
changes.
Patient & Family
Education
Report loose stools
or diarrhea
promptly.
Report any signs or
symptoms of
hypersensitivity

A. NURSING CARE PLAN

CUES

NURSING DIAGNOSIS

ANALYSIS/ HEALTH
IMPLICATION

INTERACTION
The client
verbalized, Hindi
ko mailabas ang
plema ko ngayon
Nakakahinga
naman ako pero
medyo hirap

Ineffective airway
clearance related
to secretions in
the bronchi

IMMEDIATE
CAUSE
Secretions in the
bronchi

OBSERVATION
Difficulty
vocalizing
Wheezes at right
lung field
Pale
MEASUREMENT
Respiratory Rate:
21 breaths per
minute

INTERMEDIATE
CAUSE
Contraction of the
bronchial smooth
muscle that
encircles the
airways
(bronchospasm)
ROOT CAUSE
Diffuse airway
inflammation
HEALTH
IMPLICATION
Retained
secretions
increased the
work breathing
and may
contribute to
atelectasis and
hypoxemia.
(Fundamentals of

GOALS AND
OBJECTIVES

NURSING
INTERVENTIONS

RATIONALE

EVALUATION

GOAL:
After 8 hours of
shift, Mrs.
Ventura will be
able to
expectorate/ clear
secretions readily
OBJECTIVES
(1) Provide and
teach the client
the importance of
adequate
hydration

a. Encourage fluid
(2,0003,000ml/day)
within level of
cardiac tolerance

b. Monitor clients
input and output

Adequate
hydration thins
secretions, which
prevents mucus
from plugging
airways.
(Fundamentals of
Nursing by Craven
and Hirnle, 4th
edition page 861)
Evaluate
hydration status
of client
(Fundamentals of
Nursing by Craven
and Hirnle, 4th
edition page 861)

EFFECTIVENESS
1. Was the client
able to promote
systemic fluid
hydration?
yes __no why?
2. Was the client
able to cough to
mobilize the
secretions
yes __no why?
3. Was the client
able to be monitor
regarding to his
respiratory
functioning?
yes __no why?

CUES

NURSING DIAGNOSIS

ANALYSIS/ HEALTH
IMPLICATION
Nursing by Craven
and Hirnle, 4th
edition page 828)
Shallow
respirations
inhibit both
diaphragmatic
excursion and
lung distensibility.
The result of
inadequate chest
expansion is
pooling of
respiratory
secretions, which
ultimately harbor
microorganisms
and promote
infection
(Fundamentals of
Nursing by Kozier,
7th edition page
1301)
Mucus that is
hard to
expectorate
promotes
infection because
the bacteria it
traps have time to
multiply. Mucous
plugs in the

GOALS AND
OBJECTIVES

NURSING

RATIONALE

EVALUATION

INTERVENTIONS
Milk products
tend to thickens
secretions
c. Avoid milk and
milk products

a. Deep breathing
every 2 hours
(2) Position and
encourage client
to cough to
promote
mobilization of
secretions

b. Huff coughing

To facilitate lung
aeration, thereby
preventing
atelectasis and
pneumonia
(Fundamentals of
Nursing by Kozier,
7th edition page
903)
Prevent airway
collapse
(Fundamentals of
Nursing by Craven
and Hirnle, 4th
edition page 861)
This technique
helps keep your
airway open while
moving secretions
up and out of the
lungs.
(Fundamentals of
Nursing by Kozier,
7th edition page
1303)

EFFICIENCY
Was the
interventions done
within the time
frame?
yes __no why?
APPROPRIATENESS
Were the
interventions
suitable to the
client?
yes __no why?

ACCESSIBILITY
Were the
interventions
acceptable to the
client?
yes __no why?
ADEQUACY
Were the
interventions
adequate to meet
the clients needs?
yes __no why?

CUES

NURSING DIAGNOSIS

ANALYSIS/ HEALTH
IMPLICATION
airways can lead
to atelectasis and
decreased
oxygenation
(Fundamentals of
Nursing by Craven
and Hirnle, 4th
edition page 827)

GOALS AND
OBJECTIVES

NURSING

RATIONALE

INTERVENTIONS

c. Assist client to a
sitting position
with head slightly
flexed, shoulders
relaxed, and
knees flexed

Lying flat causes

the abdominal
organs to shift
toward the chest,
crowding the
lungs and making
it more difficult to
breathe
(Fundamentals of
Nursing by Kozier,
7th edition page
1327)
Permits deep
inspiration and
forceful
abdominal
contractions
necessary for
coughing
(Fundamentals of
Nursing by Craven
and Hirnle, 4th
edition page 861)
Provide basis for
evaluating
adequacy of
ventilation
(Fundamentals of
Nursing by Kozier,
7th edition page

EVALUATION

CUES

NURSING DIAGNOSIS

ANALYSIS/ HEALTH
IMPLICATION

GOALS AND
OBJECTIVES

NURSING

RATIONALE

INTERVENTIONS
1327)

a. Monitor rate,
rhythm, depth,
and effort of
respirations
(3) Respiratory
monitoring

b. Monitor clients
ability to cough
effectively

Respiratory tract
infections alter
the amount and
character of
secretions. An
ineffective cough
compromises
airway clearance
and prevent
mucus from being
expelled
(Fundamentals of
Nursing by Kozier,
7th edition page
1327)
A variety of
respiratory
therapy
treatments may
be used to open
constricted
airways and
liquefy secretions
(Fundamentals of
Nursing by Kozier,
7th edition page
1328)

EVALUATION

CUES

NURSING DIAGNOSIS

ANALYSIS/ HEALTH
IMPLICATION

GOALS AND
OBJECTIVES

NURSING
INTERVENTIONS
c. Institute
respiratory
therapy
treatments (e.g.
nebulizer) as
needed

RATIONALE

EVALUATION