Santiago, Niña Kristine M.

BSN3-Y1-6

FDAR1

Patient name: Richardo M.

Age: 34

Birthday: December 25, 1988

Date/time Focus Documentation, Action, and Response
September 25, 2023 Impaired gas exchange due to Documentation: “nahihirapan ako huminga, masakit sa bandang chest.” The patient stated.
pneumothorax caused by blunt chest
Time: 12:30 PM trauma The patient is using his accessory muscles when breathing.
He is also holding his chest while trying to breathe deeply.
Unequal breathing sound

VS: O2 sat: 83
RR: 30
PR- 120
BP: 100/60
Temp: 37.5

Action: A chest tube was inserted to treat a simple pneumothorax which can drain excess
fluid.

Response: chest drainage has drained 400mL of light red fluid during the first 6 hours of
insertion, there are still no changes to the patients VS and breathing, the patient will be
observed thoroughly for the next hours.
Santiago, Niña Kristine M.

BSN3-Y1-6

FDAR2

Patient: Teressa S.

Age: 20

Birthday: May 28, 2003

Date/ time Focus Documentation, Action, And Response

Date: September 26, 2023 Trouble in breathing caused by Bacterial Pneumonia Documentation: “I am having trouble in breathing and my chest hurts” Teresa stated.

Time: 10:00 AM Persistent cough

Fatigue
Use of accessory muscle
VS: Temp: 38.7 C
BP: 130/80
RR: 25
PR: 98
O2 sat: 90

Action: encourage patient to drink plenty of fluids to help thin the mucus.
Administer mucolytic as prescribed by the attending physician

Response: The patient is coughing with thin phlegm

Niña Kristine M Santiago

Drug study 1: Albuterol Sulfate

Drug Classification Action Indication Contraindications and Adverse reaction Nursing considerations
cautions
Albuterol Sulfate Therapeutic class: Relaxes bronchial, To prevent or treat bronchospasm CNS: tremor, • Drug may decrease
in patients with reversible
Bronchodilators uterine, and vascular obstructive airway disease.
• Contraindicated in nervousness, sensitivity of spirometry
Other name: smooth muscle by patients headache, hyper- used for diagnosis of
Airomir, ProAir digihaler, Pharmacologic stimulating beta2 Tablets (extended release) hypersensitive to drug activity, insomnia, asthma.
ProAir HFA, ProAir class: receptors. Adults and children older than age 12: or its ingredients. dizziness, • Syrup contains no alcohol
4 to 8 mg PO every 12 hours.
RespiClick, ProAir Adrenergic beta-2 Route. PO Maximum, 32 mg daily. • Use cautiously in weakness, CNS or sugar and may be taken
Ventolin HFA, VoSpire agonists patients with CV stimulation, by children as young as age
Onset: 15.30 min Children ages 6 to 12: 4 mg PO every
ER disorders (including malaise 2.
Peak: 2-3 hr 12 hours. Maximum, 24 mg daily
coronary insufficiency • In children, syrup may
Forms and dosage: Duration: 4-8 hr and . CV: tachycardia, rarely cause erythema
Tablets
Route: PO (extended) Adults and children older than age 12: HTN), palpitations, HTN, multiform or SUS.
Onset unknown 2 to 4 mg PO tid. or qid
Route: inhalation hyperthyroidism, or chest pain, • Monitor patient for
Peak 6 hr Maximum, 32 mg daily
diabetes mellitus. and lymphadenopathy, effectiveness. Using drug
Aerosol: Duration 12 hr Children ages 6 to 12:2 mg PO tid. in those who are edema. alone may not be adequate
Route: Inhalation Maximum, 24 mg daily.
Inhalation Aerosol: unusually responsive to control asthma in some
(aerosol)
100mcg/actuation, Solution for inhalation to adrenergic. EENT: patients. Long-term control
108mcg/actuation Onset: 5-15 min • Use extended- conjunctivitis, otitis medications may be needed
Adults and children age 12 and older:
Peak: 30-120 min 2.5 mg by nebulizer, given over 5 to 15 release tablets media, dry and
Duration: 3-4 h minutes, tid. or qid.
Powder: cautiously in patients irritated nose and Alert: Drug may cause
Route: Inhalation
108mcg/actuation To prepare solution, use 0.5 mL of
with GI narrowing. throat (with paradoxical bronchospasm.
(powder) 0.5% solution diluted with 2.5 mL of Dialyzable drug: inhaled form), Monitor patient closely;
Solution: NSS. Unknown. nasal congestion, discontinue drug
0.021%(0.63 mg/ 3mL), Onset: rapid Or, use 3 mL of 0.083% solution. Overdose: epistaxis, immediately and use
Children ages 2 to 12 weighing more
0.042%(1.25mg/3mL), Peak: 30min than 15 kg: 2.5 mg by nebulizer given hoarseness, alternative therapy if
0.083%(2.5mg/3mL), over S to. Exaggeration of pharyngitis, paradoxical bronchospasm
0.5mg/mL, 1mg/mL, Duration: 3-4 h 15 minutes tid. or qui.d., with adverse reactions, rhinitis. occurs.
subsequent doses adjusted to seizures, angina,
2mg/mL, 0.5% response. Don't exceed 2.5 mg t.i.d. or Bronchospasm with inhaled
(5mg/mL) q.i.d.
hypotension, Gl: nausea, formulations frequently
HTN, tachycardia, vomiting, occurs with first use of new
Half-life: Oral, 5 to 6
Children ages 2 to 12 weighing 15 kg arrhythmias, heartburn, canister or vial.
hours; inhalation aerosol,
Route: Oral or legs: nervousness, anorexia, altered O Alert: Patient may use
6 hours; inhalation 0.63 mg or 1.25 mg by nebulizer given headache, tremor, dry taste, increased tablets and aerosol together.
powder, 5 hours. over Sto 15 minutes tid. or gid, with
Syrup: subsequen doses adjusted to mouth, palpitations, appetite. Monitor these patients
2mg/5mL response, Don't exceed 2.5 mg t.i.d. or nausea, dizziness,
qui.d. fatigue, malaise,
 sleepless-ness, GU: UTI. Metabolic: closely for signs and
Tablets: Syrup hypokalemia, cardiac hypokalemia. symptoms of toxicity.
Adults and children older than age
2mg, 4mg arrest. Musculoskeletal: • Look alike-sound alike:
14:2 to 4 mg POt.i.d. or q.i.d.
Maximum, 32 mg daily. muscle cramps, Don't confuse albuterol with
Tablets (extended back pain. atenolol or Albutein.
release) Children ages 6 to 14:2 mg PO t.i.d or
q.i.d.
4mg, 8mg Maximum, 24 mg daily. Respiratory:
bronchospasm,
Children ages 2 to 5: imitially. 0 1 cough, wheezing,
mg/kg
t.i.d. Starting dose shouldn’t exceeed dyspnea,
Maximum, 12 mg daily. bronchitis,
increased sputum
Inhalation aerosol
Adults and children age 4 and older: 1
to 2 inhalations every 4 to 6 hours as . Other:
needed. hypersensitivity
reactions, flulike
Regular use for maintenance therapy
to con. trol asthma symptoms isn't syndrome, cold
recommended Adjust-a-dose: For symptoms.
elderly patients and those sensitive to
sympathomimetic amines, 2 mg
POt.i.d. or q.i.d. as oral tablets or
syrup.
Maximum, 32 mg daily.

Inhalational powder
Adults and children age 4 and older: 2
inhalations every 4 to 6 hours. In some
patients, 1 inhalation every 4 hours
may be sufficient.
• To prevent exercise-induced bron-
chospasm
Adults and children age 4 and older: 2
inhale. tions 15 to 30 minutes before
exercise.

> Adjuvant therapy for acute

treatmento moderate to severe
hyperkalemia
Adults: 10 to 20 mg via nebulization
over 10 minutes, given in combination
with other recommended therapy.

Niña Kristine Santiago

BSN3-Y1-6

Drug study 2: Azithromycin

Drug Classification Action Indication Contraindications and Adverse reaction Nursing considerations
cautions
Azithromycin Therapeutic class: Antibiotics Binds to the SOS subunit of Acute bacterial worsening Contraindicated in patients CNS: fatigue, headache, Monitor patient for
bacterial ribo-somes, of COPD caused by hypersensi. ive to azithro somnolence, dizzi-ness. superinfection. Drug may
Pharmacologic class: blocking protein synthesis; Haemophilus influenzae, mycin, erythromycin, or other CV: chest pain, palpitations. cause overgrowth of
Other name: Macrolides bac-teriostatic or EENT: eye irritation nonsusceptible bacteria or
AzaSite, Zithromax bactericidal, depending on acolide or ketolide antibiotics (ophthalmic). fungi.
concentration.
Community-acquired and in those mil history of Gl: abdominal pain, anorexia, Alert: Monitor patient for
pneumonia caused by C. cholestatic jaundice or hepatic diarrhea, nausea, vomiting, CDAD, which may range in
AVAILABLE FORMS Route: PO pneumoniae, H. infuenzae, dysfunction from prior use of pseu-domembranous colitis, severity from mild diarrhea to
tasks that re known. azithromycin, dyspepsia, flatulence, melena. fatal colitis.
Injection: 500 mg Onset: unknown CU: candidiasis, nephritis, Alert Consider full risk profile
Ophthalmic solution: 1% Peak: 2-5 hours prescriber me prep- vaginitis. when choosing appropriate
Serious cases of allergic
Duration: unknown M. pneumonia, or S. reactions, includ. ing Hepatic: cholestatic jaundice. antibiotic therapy. Alternative
pneumoniae angioedema, anaphylaxis, Skin: photosensitivity macrolide or fluoroquinolone
Powder for oral reactions, rash, pain at class drugs also have the
SJS, toxic epidermal
suspension: 100 mg/S mL, Route: IV ophthalmic necrolysis, and DRESS injection site, pruritus. Others potential to cause OT. interval
200 mg/5 mL; 1,000 Onset: unknown Children age 6 months and syndrome have been reported, angioedema. prolongation and other
mg/single-dose packet Peak: unknown older: 10 mg/g oral some with fatalities. Prolonged significant
adverse effects.
Duration: unknown suspension PO (maximum observation and symptomatic
treatment may be necessary. Monitor patient for allergic and
Tablets: 250 mg, 500 mg, of 500 mg) as a single dose skin reac-tions. Discontinue
600 mg Half life: about 3 days on day 1, followed by 5 drug if reactions occur. Be
Infantile hypertrophic pyloric aware that allergic symptoms
mg/kg (maximum of 250 stenosis has been reported may recur when symptomatic
mg) daily on days 2 after the use of azithromycin in therapy is discontinued;
through 5. neonates (treatment up to 42 patient may require prolonged
days of life). monitoring and treatment.
Monitor patient for jaundice,
Don't use oral drug in patients hepatotoxi-city, and hepatitis.
with pneumonia or in those Discontinue drug immediately
with moderate to severe if signs and symptoms
illness or risk factors (such as (yellowing of skin or sclera,
cystic fibrosis, nosocomially abdominal pain, nausea,
acquired infections, known or vomit-ing, dark urine) occur.
suspected bacteremia; Alert: Exacerbation and new
hospitalized, elderly, or onset of myasthenia gravis
debilitated patients; or patients have occurred with
with immunodeficiency or azithromycin use.
functional asplenia).
Use cautiously in patients with
impaired hepatic function or
myasthenia gravis.

Alert Drug is not indicated for

prophylatis of bronchiolitis
obliterans syndrome in
patients undergoing
hematopoietic stem cell
tansplantation (GISCT). Long-
term, expse nay increase the
risk or hematologie malil-
nancy relapse and death.
O Aiert Use cautiously in
patients aside creased risk for
torsades a p pointes and he
arhythmias, including those
with known prolonged QT
interval, history of torsades de
pointes, congenital long QT
syndrome, bradyarchythmias,
uncompensated HI, uh,
corrected hypokaleria or
hypomagnesel. clinically
significant bradycardia.
Santiago, Niña Kristine M

BSN3-Y1-6

NCP 1

Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation

Short-term goals Long-term goals
S: “nahihirapan ako Impaired gas exchange due After 1 hour of After a week of 1. Insertion of chest 1. Inserting a CTT Chest drainage has drained
huminga,naninikip ang to pneumothorax and interventions the patient medication tube can drain the 400mL of light red fluid
dibdib ko” hemothorax caused by will be able to: 2. Promote effective excess fluid during the first 6 hours of
O: Nasal Flaring blunt chest trauma gas exchange around the lungs insertion, there are still no
Use of accessory muscle Improve oxygen saturation Secretions will be 3. Manage pain and 2. Encourage the changes to the patients VS
Restlessness removed discomfort patient to sit on and breathing, the patient
Productive cough Promote effective 4. Prevent respiratory a semi fowlers will be observed
breathing pattern trauma and position for a thoroughly for the next
VS: O2 sat: 83 Patient’s will heal from infection better lung hours.
pneumothorax and expansion
RR: 30 hemothorax
PR- 120

BP: 100/60

Temp: 37.5
Santiago, Niña Kristine M

BSN3-Y1-6

NCP2

Assessment Nursing diagnosis Planning Nursing intervention Rationale Intervention

Short term goals Long term goals
S: “nilalamig po ako, at Ineffective airway clearance Improve airway patency After week of medication 1. Perform 1. Nebulization can Patient demonstrates
hirap huminga, cause by continues patient will be able to: nebulization, promote airway improved airway
napapadalas din ang pag coughing due to Maintain proper fluid encourage the clearance, upon clearance
ubo ko” as stated by the community acquired volume Demonstrate improved patient to cough coughing sputum
patient pneumonia ventilation and after. or other secretions
Improve tolerance to oxygenation 2. Auscultate the chest can be release.
O: use of accessory muscle activity and lungs of the 2. Upon percussion
Purulent sputum Patient will maintain patient and percuss. the patient may
Ineffective cough optimal gas exchange cough after to
Decreased breath sounds Measures to prevent release excess
over affected area complications Patient will demonstrate secretions.
Cough with little sputum behaviors to achieve
production airway clearance

VS: Patient will display patent

Temp: 38.2c airway with breath sound
O2 sat: 90 clearing; absence of
dyspnea as evidenced bt
keeping a patent airway