Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective STG: Independent STG:

“nahihirapan breathing pattern After 5 hours of • Assess • Flaring of the After 5 hours of
akong huminga” related to mucus nursing respiratory nostrils, nursing
as verbalized by obstruction as intervention the quality, rate, dyspnea, use intervention the
the patient. manifested by patient will be depth, effort of accessory patient was able
thick green able to and pattern. muscles, to demonstrate
Objective: mucus/ sputum demonstrate tachypnea and normal/ effective
discharge. normal/ effective /or apnea are breathing pattern
• use of breathing pattern all signs of
accessory severe distress LTG:
muscle for LTG: that require After 3 days of
breathing, After 3 days of immediate nursing
nasal flaring nursing intervention. intervention the
• thick mucus intervention the • Auscultate patient was able
discharge patient will be chest, noting • Regularly to verbalize
able to verbalize presence/ scheduled awareness about
awareness about character of evaluation also disease process,
disease process, breath sounds helps treatment
treatment and presence determine regimen, and
regimen, and of secretions. areas of good prognosis.
prognosis. air exchange
and provides a
baseline to
evaluate
resolution of
Pneumothorax
• Note chest .
excursion and
position. • Chest
excursion is
• Assess unequal until
fremitus. lung re-
expands.
 • Voice and
tactile
fremitus
(vibration) is
reduced in
• Assess for fluid filled/
concomitant consolidated
pain and tissue.
discomfort.
• Presence of
pain and
• Assist Patient discomfort
with coughing may reveal
and deep limit
breathing respiratory
techniques effort.
(positioning,
incentive • Assist patient
spirometry, to improve
frequent lung
position expansion, the
changes). productivity of
the cough and
mobilize
• Encourage secretions.
slower/ deeper
respirations
and use of
pursed lip
technique. • To assist client
in “taking
• Maintain calm control” of the
attitude while situation.
dealing with
the patient.
• Provide • To limit the
information level of
about disease anxiety.
process,
treatment
regimen, and
prognosis. • To promote
wellness
• Maximize
respiratory
effort with
good posture
and effective
use of • To promote
accessory wellness
muscles.

Dependent
• Medicate with
analgesics as
appropriate
• To promote
Collaborative deeper
• Assist in respiration and
necessary cough
testing (lung
volume/ flow
studies) • To diagnose
severity/
presence of
lung disease
 NURSING
CLASS PRECAUTIONS SIDE EFFECTS
INDICATIONS CONTRAINDICATION RESPONSIBILITIES

RANITIDINE Antiulcerative, H2 receptor Intractable Patients Patients with GI Diarrhea, dizziness, • Remind patient
antagonist duodenal ulcer, hypersensitive malignancy, severe tiredness, taking drug once
maintenance to drug, hepatic renal & hepatic headache & rash, daily to take it h.s.
dysfunction,
therapy for healing impairment, reversible
impaired kidney
duodenal ulcer, function. pregnancy, lactation, confusional states,
• Instruct patient to
GERD, erosive history of acute hypersensitivity
take drug without
esophagitis, relief porphyria, history of reactions, fever, regard to meals.
of occasional peptic ulcer, chronic arthralgia, myalgia,
heartburn, acid lung disease, blood & CV
indigestion and diabetes, disorders. • Urge patient to
sour stomach. immunocompromised. avoid cigarette
smoking because it
may increase
gastric acid
secretion and
worsen disease.