Acute Respiratory

Failure
NCMB 418 RLE: Group 2
Table of Contents
01
PATHOPHYSIOLOGY OF THE DISEASE

02 IMPORTANCE OF DIAGNOSTIC TEST

03 DRUG STUDY

04 NURSING CARE PLAN

 Case Scenario
A 55-year-old white female, not married, presented to the emergency department with
acute onset shortness of breath. Symptoms began approximately 2 days before and had
progressively worsened with no associated, aggravating, or relieving factors noted. She
had similar symptoms approximately 1 year ago with an acute, chronic obstructive
pulmonary disease (COPD) exacerbation requiring hospitalization. She uses BiPAP
ventilatory support at night when sleeping and has requested to use this in the emergency
department due to shortness of breath and wanting to sleep.

She denies fever, chills, cough, wheezing, sputum production, chest pain, palpitations,
pressure, abdominal pain, abdominal distension, nausea, vomiting, and diarrhea. She
reports difficulty breathing at rest, forgetfulness, mild fatigue, feeling chilled, requiring
blankets, increased urinary frequency, incontinence, and swelling in her bilateral lower

extremities that are new-onset and worsening. Subsequently, she has not ambulated from bed for several days except to use the
restroom due to feeling weak, fatigued, and short of breath. There are no known ill contacts at home. Her family history includes
significant heart disease and prostate malignancy in her father. Social history is positive for smoking tobacco use at 30 pack years.

She quit smoking 2 years ago due to increasing shortness of breath. She denies all alcohol and illegal drug use. There are no known
foods, drugs, or environmental allergies. Past medical history is significant for coronary artery disease, myocardial infarction, COPD,
hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus, peripheral vascular disease, tobacco usage, and obesity. Past
surgical history is significant for an appendectomy, cardiac catheterization with stent placement, hysterectomy, and nephrectomy.
Her current medications include fluticasone-vilanterol 100-25 mcg inhaled daily, hydralazine 50 mg by mouth, 3 times per day, hydrochlorothiazide
25 mg by mouth daily, albuterol-ipratropium inhaled every 4 hours PRN, levothyroxine 175 mcg by mouth daily, metformin 500 mg by mouth twice
per day, nebivolol 5 mg by mouth daily, aspirin 81 mg by mouth daily, vitamin D3 1000 units by mouth daily, clopidogrel 75 mg by mouth daily,
isosorbide mononitrate 60 mg by mouth daily, and rosuvastatin 40 mg by mouth daily.

Physical Exam: Initial physical exam reveals temperature 97.3ºF, heart rate 74bpm, respiratory rate 24cpm, BP 104/54mmHg, BMI 40.2, and O2
saturation 90% on room air.

Appearance: Extremely obese, acutely ill-appearing female. Well-developed and well-nourished with BiPAP in place. Lying on a hospital stretcher
under 3 blankets.

HEENT:
● Head: Normocephalic and atraumatic
● Mouth: Moist mucous membranes
● Macroglossia
● Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Bilateral periorbital edema present.
● Neck: Neck supple. No JVD present. No masses or surgical scarring.
● Throat: Patent and moist

Cardiovascular: Normal rate, regular rhythm, and normal heart sound with no murmur. 2+ pitting edema bilateral lower extremities and strong
pulses in all four extremities.

Pulmonary/Chest: No respiratory status distress at this time, tachypnea present, (+) wheezing noted, bilateral rhonchi, decreased air movement
bilaterally. Patient barely able to finish a full sentence due to shortness of breath.

Abdominal: Soft. Obese. Bowel sounds are normal. No distension and no tenderness

Skin: Skin is very dry

Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses
Initial evaluation to elucidate the source of dyspnea was performed and included CBC to establish if an infectious or anemic source was
present, CMP to review electrolyte balance and review renal function, and arterial blood gas to determine the PO2 for hypoxia and any
major acid-base derangement, creatinine kinase and troponin I to evaluate the presence of myocardial infarct or rhabdomyolysis, brain
natriuretic peptide, ECG, and chest x-ray. Considering that it is winter and influenza is endemic in the community, a rapid influenza assay
was obtained as well.

Laboratory and Diagnostics: Her CBC showed largely unremarkable and non-contributory to establish a diagnosis. CMP showed creatinine
elevation above baseline from 1.08 base to 1.81, indicating possible acute injury. EGFR at 28 is consistent with chronic renal disease.
Calcium was elevated to 10.2. However, when corrected for albumin, this corrected to 9.8 mg/dL. Mild transaminitis is present as seen in
alkaline phosphatase, AST, and ALT measurements which could be due to liver congestion from volume overload.

Initial arterial blood gas with pH 7.491, PCO2 27.6, PO2 53.6, HCO3 20.6, and oxygen saturation 90% on room air, indicating respiratory
alkalosis with hypoxic respiratory features. Creatinine kinase was elevated along with serial elevated troponin I studies. In the setting of
her known chronic renal failure and acute injury indicated by the above creatinine value, a differential of rhabdomyolysis is determined.

Influenza A and B: Negative

ECG: Normal sinus rhythm with non-specific ST changes in inferior leads. Decreased voltage in leads I, III, aVR, aVL, aVF.

Chest X-ray

Findings: Bibasilar airspace disease that may represent alveolar edema. Cardiomegaly noted. Prominent interstitial markings noted. Small
bilateral pleural effusions

Radiologist Impression: Radiographic changes of congestive failure with bilateral pleural effusions greater on the left compared to the
right
CONCEPT MAP
 Pathophysiology Diagnostic Tests
Acute respiratory failure is a sudden ● CBC (unremarkable, thus non-contributory to diagnosis)

deterioration of the gas exchange function of

55-year-old white female ● CMP (creatinine elevation 1.08 – 1.81 = possible for acute
injury)
EGFR (28 = chronic renal disease)
the lung and indicates failure of the lungs to ●
● Calcium (10.2, corrected for Albumin 9.8 mg/dl)
provide adequate oxygenation to the blood. It ● Mind Transaminitis (present, as seen in alkaline
phosphatase, AST, ALT) which could be due to liver
involves decrease in PaO2 (hypoxemia) and congestion from volume overload
decrease in PaCO2 (hypocapnia) whereas the ● ABG (respiratory alkalosis with hypoxic respiratory
features) Creatinine Kinase (increased)
ventilation or perfusion mechanisms in the lung ● Serial Troponin 1 (increased)
● Rhabdomyolysis (determined)
are impaired. ● Influenza A & B (negative)
● ECG (normal sinus rhythm with non-specific ST changes in
inferior leads) decreased voltage in leads I, III, aVR, aVF

Significant
● Chest X-Ray (bibasilar airspace disease = may represent
alveolar edema) cardiomegaly, prominent interstitial
Diagnosis markings, small bilateral effusion
● Radiology (CHF with bilateral effusions greater than on the

Data
left)

ACUTE RESPIRATORY FAILURE

Medications
Medical/Surgical History ● Fluticasone-vilanterol 100-25 mcg inhaled daily
● Medical history ● Hydralazine 50 mg by mouth, 3 times per day
○ CAD ● Hydrochlorothiazide 25 mg by mouth daily
○ MI ● Albuterol-ipratropium inhaled every 4 hours PR
○ COPD ● Levothyroxine 175 mcg by mouth daily
○ Hypertension, Hyperlipidemia ● Metformin 500 mg by mouth twice per day
○ Hypothyroidism ● Nebivolol 5 mg by mouth daily
○ DM, PVD ● Aspirin 81 mg by mouth daily
● Surgical history ● Vitamin D3 1000 units by mouth daily
○ Appendectomy, cardiac catheterization ● Clopidogrel 75 mg by mouth daily 11. isosorbide
with stent placement, hysterectomy, and ● Mononitrate 60 mg by mouth daily
nephrectomy. ● Rosuvastatin 40 mg by mouth daily.
 Impaired Gas Exchange related to
excess fluid in interstitial space as Ineffective Airway Clearance related to Ineffective breathing pattern related to
evidenced by shortness of breath, airway spasm hyperventilation as evidenced by
tachypnea, dyspnea at rest, abnormal as evidenced by
dyspnea, tachypnea, hypoxia, 90% O2
blood gas w/ hypoxia, 90% 02 sat and wheezing, bilateral rhonchi, decreased
sat, ABG: respiratory alkalosis, and she
bibasilar airspace disease that may air movement bilaterally, dyspnea,
smoking tobacco use at 30 pack years uses BiPAP ventilatory
represent alveolar edema.

RR: 24 cpm, 90% O2 saturation, (+)

wheezing, bilateral rhonchi, decreased air tachypnea, dyspnea, unable to finish a full
RR:24rpm; ABG: respiratory alkalosis w/ movement bilaterally, shortness of breath, sentence due to SOB, hypoxia,ABG:
hypoxia; tachypnea; dyspnea at rest; and difficulty breathing at rest, smoking
wheezing respiratory alkalosis

Independent: Independent
- Ensure patent airway and adequate gas exchange
by positioning the patient with head of the bed Independent:
-Position the client in a relaxed and comfortable
elevated in a semi-fowler’s position position that can also facilitate effective breathing.
- Assess level of consciousness/cognition and
- Assess rate, rhythm, and depth of respirations. ability to protect own airway.
-Teach the patient about pursed-lip breathing,
abdominal breathing, performing relaxation
- Timely monitor respirations and auscultate
- Assess level of consciousness and mentation techniques, performing relaxation techniques
breath sounds, noting rate and sounds.
changes. Advise SO to report promptly changes in
the patient’s condition. -Note rate and depth of respirations, counting for 1
- Assist client to maintain a comfortable position
full minute, if rate is irregular.
to facilitate breathing by elevating the head of
- Monitor vital signs, including oxygen saturation
bed, leaning on over-bed table, or sitting on
-Assess for the use of accessory muscle and nasal
edge of bed.
- Review pertinent diagnostic data (e.g., ABGs) and flarings
chest radiography
- Encourage and assist with abdominal or
-Assess ABG levels and 02 saturation-Encourage
pursed-lip breathing exercises.
-Regularly check the patient’s position so that they frequent rest periods and teach the patient to pace
do not slump down in bed. activity.
- Increase fluid intake to 3000 mL/day within
cardiac tolerance. Provide warm or tepid liquids.
-Encourage frequent position changes and -Encourage small frequent meals.
Recommended intake of fluids between, instead
deep-breathing and coughing exercises.
of during, meals.
 - Keep environment allergen free Dependent
-Pace activities and schedule rest periods to prevent - Provide health education and assist in operating
fatigue. Assist with ADLs. Dependent: the BiPAP ventilator.

-Schedule nursing care to provide rest and minimize - Administer medications such as prescribed by the
Administer medications, as indicated
fatigue. primary physician.
- Bronchodilator like fluticasone and
-Emphasize the importance of nutrition
vilanterol

- Adrenergic agonist like Collaborative

Dependent -Collaborate with other healthcare professionals in
-Encourage slow deep breathing using an incentive
Albuterol/ipratropium
caring and monitoring for the patient such as
spirometer as indicated. medical technologists and radiologists.

- Administer drug as indicated upon doctor’s order. Collaboration: -Consult a dietitian for dietary modifications.
- Collaborate with radtech, medtech; monitor and
- Assist and provide close monitoring while using the graph serial ABGs, pulse oximetry, and chest
BiPAP machine. x-ray.
Expected Outcome/s:

COLLABORATIVE - Establish a normal, effective respiratory

pattern as evidenced arterial blood
- Refer to med tech for lab test monitoring. Expected Outcome/s:
gasses (ABGs) within client’s normal or
acceptable range and absence of s/sx
- Maintain airway patency of hypoxia
Expected outcome:

- Demonstrate absence/reduction of - manifest resolution or absence of

- Demonstrate improved ventilation and
congestion with breath sounding clear, symptoms of respiratory distress.
adequate oxygenation of tissues by ABGs
within normal range and be free of symptoms noiseless respirations, and improved
oxygen exchange (e.g., /pulse oximetry - Patient demonstrates maximum lung
of respiratory distress.
results within client norms) expansion with adequate ventilation.
- Patient participates in procedures to optimize
- Will demonstrate increased airway - Patient indicates, either verbally or
oxygenation and in management regimen
clearance through behavior, feeling comfortable
within level of capability/condition.
when breathing.
- Manifest resolution or absence of symptoms - Identify and avoid specific factors that
inhibits effective airway clearance. - When patient carries out ADLs,
of respiratory distress.
breathing pattern remains normal.
Pathophysiology
of the Disease
Modifiable:
● Medical history
○ CAD
○ MI
Non -modifiable:
○ COPD
● Smoking tobacco usage for 2 years
○ Hypertension
● Family hx
○ Hyperlipidemia Allergens enter the upper respiratory tract
○ Heart disease
○ Hypothyroidism
○ DM
○ PVD Stimulation and activation of B Lymphocytes
● Obese (40.2 BMI)

B Lymphocytes produces Immunoglobulin E

IgE antibodies attached to mast cells and

basophils in the bronchial walls

Mast cell degranulation, releases inflammation

mediators, oxidative stress, & cytokines

Triggers vasodilation and increases vascular EGFR 28

permeability
Decreased voltage in leads I, III,
aVR, aVL, aVF. Disruption of surfactant Creatinine elevation: 1.81
Legend:
Disease process
Predisposing factor
V/Q mismatch Intrapulmonary shunting Alveolar hypoventilation Signs and symptoms
Diagnostic tests
Signs and
Hypoxemia Reduces diffusion gradient to venous blood &
symptoms
impairs O2 uptake
Disease process
Diagnostic tests
Hypoxemic (O2 deficiency in inspiring air) Peripheral circulatory failure
 Diminishing blood flow to the Proteins and large molecules are lost into the Decreased level of consciousness
underventilated alveoli interstitial fluid

Reduced respiratory drive forgetfulness

Impaired diffusion that affects O2 transport Mild transaminitis

Inspiratory muscle fatigue

Decreases the oncotic pressure gradient

Constriction to the supplying vessels

Fatigued, dyspnea
Fluid shifting from the vasculature and to the
Edema
alveoli
Excess hyperventilation
Decreased
Small Bilateral Pleural Effusion Wheezing Bilateral air
ronchi movement
Reduced CO2 released from bilaterally
underventilated alveoli
(Hypocapnia) - Bibasilar airspace
disease
- Bilateral pleural
ABG: pH 7.491, PCO2 27.6, effusions greater on the
left compared to the Bilateral periorbital edema Swelling bilateral of lower Incontinence
HCO3 20.6 right. extremities

Bronchi narrowed and

Lack of oxygen perfusion Increased need for oxygenated Hypertension
preclude normal ventilation of blood flowing to the tissue
the alveoli

COPD Decrease O2 saturation Shortness of breath,

Increased RR (24 cpm) tachypnea
(90% on air room)

Respiratory cells are damaged PO2 53.6,

Decrease ventilation secondary to airway lung
Bibasilar airspace disease
disease

Vascular occlusion
Small bilateral pleural effusion Decreased in alveolar and CO2

Decreased amount of gases in the blood

Cardiomegaly noted

Gas exchange failure manifested by hypoxemia Prominent interstitial markings

ACUTE RESPIRATORY Respiratory Alkalosis with

Hypoxic respiratory features
FAILURE
Importance of
Diagnostic Test
 RESULT/FINDINGS IMPORTANCE

COMPLETE BLOOD COUNT (CBC) ● Her cbc showed largely ● To establish if an infectious source or
unremarkable and anemia is present.
● A complete blood count is a blood test used to
non-contributory to establish a
evaluate your overall health and detect a wide diagnosis ● Using a small amount of blood, a CBC can
range of disorders, including anemia and help detect various health conditions and
infection (Mayo Clinic, 2020) disorders It also allows the providers to
screen for disease and plan and adjust
treatment if needed.

Comprehensive Metabolic Panel (CMP) ● CMP showed creatinine elevation ● To review electrolyte imbalance, renal
above baseline from 1.08 base to function, and blood sugar.
● A comprehensive metabolic panel is a group of
1.81 indicating possible acute
blood tests. They provide an overall picture of injury. ● Since the result is elevated, her healthcare
your body's chemical balance and metabolism. provider will likely have the patient
Metabolism refers to all the physical and undergo additional tests to confirm or rule
chemical processes in the body that use out a specific diagnosis.
energy.(UCSF Health, 2019)

Arterial Blood Gas (ABG) ● Initial arterial blood gas with pH ● To obtain information about patient
7.491, PCO2 27.6, PO2 53.6, ventilation (pCO2), oxygenation (pO2) and
● A blood gas analysis used as a diagnostic tool to
HCO3 20.6, and oxygen saturation acid base balance.
assess the acid-base status of the patient 90% on room air, indicating ● Arterial blood gas to determine the
● Helps provide further information in analyzing the respiratory alkalosis with hypoxic PO2 for hypoxia
partial pressures of gas in the blood respiratory features. ● This information is crucial to adequate
treatment of her respiratory illness. Since
her ABG is not within normal,, they can be
significant clues to respiratory problems as
well as needed changes in ventilator or
oxygen settings.
 RESULT/FINDINGS IMPORTANCE

Creatine kinase and troponin I ● Creatinine kinase was elevated along ● To evaluate the presence of myocardial
● They are both proteins that are more with serial elevated troponin I studies. infarct or rhabdomyolysis
frequently found in the skeletal and heart
● In the setting of her known renal failure
muscles of your body than in the brain.
due to her nephrectomy and acute injury
Increased blood levels of troponin and indicated by the above creatinine value, a
creatine kinase can cause health issues differential of rhabdomyolysis can be
like heart attacks. determined and elevated troponin I
indicates proteins are released when the
heart muscle has been damaged

ELECTROCARDIOGRAM (ECG) ● Normal sinus rhythm with non-specific ST ● The goal is to determine or detect the
● An electrocardiogram records the electrical changes in inferior leads. Decreased cause of chest pain and evaluate
Voltage in leads I, III, aVR, aVL, aVF problems that may be heart-related, such
signals in the heart. It's a common and
as severe tiredness, shortness of breath,
painless test used to quickly detect heart
as well as identify irregular heartbeats
problems and monitor the heart's health. (Hopkins Medicine, 2021).
(Mayo Clinic, 2022)

Chest X-Rays ● Bibasilar airspace disease that may ● Used to help diagnose the cause of her
● produce images of your heart, longs, blood represent alveolar edema. cardiomegaly breathing difficulties and edema. This will
noted. Prominent interstitial markings also help with her treatment plan and
vessels, airways and, the bones of your
noted. Small bilateral pleural effusions monitor treatment.
chest and spine. Chest X-rays can also
● Radiologist impression; Radiographic
reveal fluid in or or around lungs or air changes of congestive failure with bilateral
surrounding a lung. (Mayo Clinic, 2022) pleural effusions greater on the left
compared to the right.
 RESULT/FINDINGS IMPORTANCE

Estimated Glomerular filtration rate ● eGFR at 28 is consistent with ● To determine how well her
● is a test that measures your level of kidney function and chronic renal disease kidneys are working and help
determines your stage of kidney disease. (National with the treatment plan
Kidney Foundation, 2020) also measures your kidneys’ including managing
ability to filter toxins or waste from your blood ( Cleveland hypertension and blood sugar
Clinic, 2021) levels

Liver Function Test ( AST, ALT, ALP) ● Mild transaminitis is present as ● To monitor and measure the
seen in alkaline phosphatase, severity of a disease and
● ALT is an enzyme found in the liver that helps convert AST and ALT measurements monitor possible side effects of
proteins into energy for the liver cells. When the liver is which could be due to liver medication.
damaged, ALT is released into the bloodstream and congestion from Volume
levels increase. (Mayo Clinic, 2021) overload.

● AST is an enzyme that helps metabolize amino acids.

Like ALT, AST is normally present in blood at low levels.
An increase in AST levels may indicate liver damage or
disease (Mayo Clinic, 2021)

● ALP is an enzyme found in the liver and bone and is

important for breaking down proteins. Higher-than-normal
levels of ALP may indicate liver damage or disease
(Mayo Clinic, 2021)
Drug Study
 Name of Mechanism of Indication and Nursing
Contraindications Side Effects
Drug Action Rationale Consideration
Generic Name: Stimulates beta2 Maintenance Possible Possible Side Before
fluticasone and -adrenergic receptors treatment of Contraindications: Effects: Administration
vilanterol in lungs, resulting in bronchial asthma. ● cardiovascula ● Throat
relaxation of r disease, irritation, ● history of skin
Brand Name: bronchial smooth Rationale: ● diabetes ● hoarseness, disorder,
Breo Ellipta muscle. ● dry mouth, asthma,
The patient use ● cough, rhinitis
Classifications: Therapeutic Effect: this drug for ● temporary ● hypersensitivi
Bronchodilator Relieves prophylactic wheezing, ty, esp. milk
Anti-inflammat bronchospasm and therapy to prevent products or
ory reduces airway asthma attacks lactose
resistance. and treatment for ● Assess rate,
her COPD. depth,
rhythm, type
Dosage, of respiration;
Frequency and quality/rate
Route: of pulse.
100 mcg/25 ● Assess lung
mcg inhaled sounds for
daily rhonchi,
wheezing,
rales.
N M C S
I o
a e i
n n During Administration
m c d t d
e ha i r e ● Monitor rate, depth, rhythm, type of respiration; quality/rate of pulse
a Do not shake or prime before use
n c
●
i ● Put mouthpiece between lips, breathe deeply and slowly through the mouth, remove inhaler, and
o i a
n
E
t hold breath for 3–4 seconds.
f s d f
i
m i f After Administration
o c
D n e
a ● Pts receiving bronchodilators by inhalation concomitantly with steroid inhalation therapy should
r o t c
use bronchodilator several min before corticosteroid aerosol (enhances penetration of steroid
ug f a i t into bronchial tree).
n o s ● Do not change dose/schedule or stop taking drug; must taper off gradually under medical
d n
Ac s supervision.
t ● Maintain strict oral hygiene.
R
i a ● Rinse mouth with water immediately after inhalation (prevents mouth/throat dryness, oral
on t fungal infection).
i ● Increase fluid intake (decreases lung secretion viscosity).
o
n
a
l
e
 Name of Mechanism of Indication and Nursing
Contraindications Side Effects
Drug Action Rationale Consideration

Generic Name: Direct vasodilating Management of Possible Possible Side Before

Hydralazine effects on arterioles. moderate to Contraindications: Effects: Administration
severe There is no ● Headache
Brand Name: Therapeutic Effect: hypertension contraindication ● anorexia ● Obtain B/P,
Apresoline indicated in the pt ● nausea pulse
Decreases B/P,
Rationale: ● vomiting immediately
systemic vascular case
Classifications: The patient uses diarrhea before each
Vasodilator resistance. this drug to lower ● palpitations dose, in
Antihypertensi her blood pressure ● tachycardia addition to
ve since she has a ● angina regular
hypertension. pectoris. monitoring
Dosage, (be alert to
Frequency and fluctuations).
Route:
PO 50 mg, 3 During
times per day Administration

● Monitor B/P,
pulse. Monitor
for headache,
palpitations,
tachycardia
N M C S
I o
a e i
n n
m c d t d
e ha i r e
n c a
i
o i a
n
E
f s t f
d
i
m i f
o c
D n e After Administration
a
r o t c
ug f a i t ● Assess for peripheral edema of hands, feet.
n o s ● To reduce hypotensive effect, go from lying to standing slowly.
d n
Ac s
● Report muscle/joint aches, fever (lupus-like reaction), flu-like symptoms.
t
R
i a
on t
i
o
n
a
l
e
 Name of Mechanism of Indication and Nursing
Contraindications Side Effects
Drug Action Rationale Consideration

Generic Name: Inhibits sodium Treatment to Possible Possible Side Before

hydrochlorothi reabsorption in distal edema in HF Contraindications: Effects: Administration
azide renal tubules, ● diabetes ● Increased
Rationale: urinary ● Check vital
causing excretion of
Brand Name: The patient uses frequency signs, esp.
Apo-Hydro sodium, potassium, this drug to treat (diminishes B/P for
hydrogen ions, water. her increased with hypotension,
Classifications: urinary frequency, continued before
: Sulfonamide Therapeutic Effect: incontinence , and use) ● Assess for
derivative Promotes diuresis; 2+ pitting edema ● urine volume signs of
Thiazide reduces B/P. bilateral lower ● Potassium hypokalemia
diuretic extremities. depletion. ● Assess muscle
● Orthostatic strength,
Dosage, hypotension mental status.
Frequency and ● headache ● Note skin
Route: ● GI temperature,
PO 25 mg daily disturbances moisture.
● photosensitiv ● Obtain
ity. baseline
weight.
● Assess I&O.
N M C S
I o
a e i
n n During Administration
m c d t d
e ha i r e ● Monitor I &O
n c a
i ● monitor B/P, vital signs,. daily weight.
o i a
n
E ● Note extent of diuresis.
f s t f
d
i
m i f After Administration
o c
D n e
a
r o t c ● Evaluate skin turgor, mucous membranes for hydration status.
ug f a i t ● Evaluate for peripheral edema.
n o s ● Watch for changes from initial assessment (hypokalemia may result in weakness,
d n tremor, muscle cramps, nausea, vomiting, altered mental status, tachycardia;
Ac s
t hyponatremia may result in confusion, thirst, cold/clammy skin).
R ● Potassium supplements are frequently ordered. Check for constipation (may occur
i a with exercise diuresis).
on t ● Expect increased frequency (diminishes with continued use), volume of urination.
i ● To reduce hypotensive effect, go from lying to standing slowly.
o
● Eat foods high in potassium, such as whole grains (cereals), legumes, meat,
n
bananas, apricots, orange juice, potatoes (white, sweet), raisins.
a
l ● Protect skin from sun, ultraviolet light (photosensitivity may occur).
e
 Name of Mechanism of Indication and Nursing
Contraindications Side Effects
Drug Action Rationale Consideration

Generic Name: Stimulates beta2 Treatment of Possible Possible Side Before

Albuterol/ipratro -adrenergic receptors bronchospasm Contraindications: Effects: Administration
pium in lungs, resulting in ● ,cardiovascular ● Headache,
Rationale: disease ● restlessness, ● Assess lung
relaxation of
Brand Name: ● diabetes ● nervousness, sounds, pulse,
Combivent bronchial smooth The patient uses this ● tremors, B/P, color,
Respimat muscle. drug to treat her ● nausea, characteristic
shortness of breath ● dizziness, s of sputum
Classifications: Therapeutic Effect: and for COPD ● pharyngitis, noted.
adrenergic Relieves exacerbation since ● B/P changes ● Offer
agonist bronchospasm and this drug is for including emotional
Bronchodilator reduces airway
bronchospasm. hypertension support (high
● heartburn, incidence of
Dosage, inhaled resistance.
● transient anxiety due to
every 4 hours wheezing. difficulty in
PRN ● Dry, irritated breathing and
mouth or sympathomim
throat; etic response
● cough, to drug).
● bronchial
irritation.
N M C S
I o
a e i
n n During Administration
m c d t d
e ha i r e ● Monitor rate, depth, rhythm, type of respiration; quality and rate of pulse; EKG;
n c a
i ,glucose; ABG determinations.
o i a
n
E ● Shake container well before inhalation.
f s t f
d Prime prior to first use. A spacer is recommended for use with MDI.
i ●
m i f
o c ● Wait 2 min before inhaling second dose (allows for deeper bronchial penetration).
D n e
a
r o t c After Administration
ug f a i t
n o s ● Rinse mouth with water immediately after inhalation (prevents mouth/throat
d n
Ac s dryness)
t ● Assess lung sounds for wheezing (bronchoconstriction), rales.
R
i a
on t
i
o
n
a
l
e
 Name of Mechanism of Indication and Nursing
Contraindications Side Effects
Drug Action Rationale Consideration

Generic Name: Levothyroxine Treatment of Possible Possible Side BASELINE

Levothyroxine sodium, a synthetic hypothyroidism Contraindications: Effects: ASSESSMENT
form of thyroxine, is
●Hypersensitivity to ● Dry skin Obtain baseline
metabolized into
levothyroxine ● GI intolerance weight, vital signs.
Brand Name: N/I triiodothyronine.Both ●Acute MI ● Rash Signs/ symptoms of
Rationale:
Possible: levothyroxine sodium diabetes mellitus,
Euthyrox The patient has a ●Uncorrected adrenal ● Urticaria
and triiodothyronine diabetes insipidus,
past medical insufficiency ● Pseudotumor adrenal insufficiency,
diffuse into cell
history of cerebri hypopituitarism may
nucleus and bind to Cautions:
hypothyroidism. become intensified.
Classifications: thyroid receptor
Levothyroxine is ● Elderly pts
Synthetic Thyroid proteins attached to INTERVENTION/EVAL
used by the ● Angina pectoris
Hormone (T4) the deoxyribonucleic UATION
patient to replace ● Hypertension, other
acid (DNA) and exert
thyroxine as her cardiovascular ● Monitor apical pulse
their physiologic
thyroid gland disease for rate, rhythm
Dosage, effects by controlling
cannot produce it. ● Adrenal insufficiency (Withhold is pulse
Frequency and DNA transcription Myxedema rate is >100 bpm and
Route: and protein ● Diabetes mellitus report to the
175 mcg by synthesis. Its main physician). Observe
and insipidus
mouth daily pharmacologic for tremors, anxiety.
● Swallowing
activity is to increase ● Assess appetite,
disorders
the rate of cell sleep pattern.
metabolism.
N M C S
I o
a e i
n n
m c d t d
e ha i r e
n c a
i
o i a
n
E PATIENT/FAMILY TEACHING
f s t f
d
i ● Administer in the morning on an empty stomach, 30 min before food.
m i f
o c ● Administer before breakfast to prevent insomnia.
D n e Tablets may be crushed.
a ●
r o t c ● Take 4 hrs apart from antacids, iron, calcium supplements.
ug f a i t ● Do not discontinue drug therapy; replacement for hypothyroidism is lifelong.
n o s ● Follow-up office visits, thyroid function tests are essential.
d n
Ac s
● Take medication at the same time each day, preferably in the morning.
t ● Monitor pulse for rate, rhythm; report irregular rhythm or pulse rate over 100 beats/ min.
R Do not change brands
i a
●
Promptly report chest pain, weight loss, anxiety, tremors, insomnia.
on t
●

i
o
n
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 Name of Mechanism of Indication and Nursing
Contraindications Side Effects
Drug Action Rationale Consideration

Generic Name: Metformin decreases Management of Possible Possible Side BASELINE

Metformin blood glucose levels type 2 diabetes Contraindications: Effects: ASSESSMENT
by decreasing hepatic mellitus.
●Hypersensitivity to ● GI disturbances Obtain CBC, renal
glucose production
Rationale: metformin. (diarrhea, nausea, function test, fasting
Brand Name: N/I decreasing the
Metformin is given ●Severe renal vomiting, abdominal serum glucose, Hgb
Possible: intestinal absorption
to the patient that disease/dysfunction bloating, flatulence, A1c
Glucophage of glucose, and INTERVENTION/EVALU
has diabetes ●Acute or chronic anorexia)
increasing insulin ATION
mellitus to help metabolic acidosis ● Vitamin B12
sensitivity by
control the deficiency ●Monitor fasting serum
Classifications: increasing peripheral Cautions:
glucose uptake and amount of glucose glucose, Hgb A1c,
Anti-diabetic
Agent utilization. in the blood as it renal function, CBC.
●Heart failure
lowers the glucose Monitor serum folic
●Hepatic impairment
production in the acid and B12, renal
●Excessive
liver and decrease function tests for
Dosage, acute/chronic
the amount of evidence of early
Frequency and alcohol intake lactic acidosis.
Route: glucose she
●Be alert to conditions
500 mg by mouth absorbs after
that alter glucose
twice a day eating.
requirements: fever,
.
increased activity,
stress
N M C S
I o
a e i
n n
m c d t d
e ha i r e PATIENT/FAMILY TEACHING
n c a
i
o i a
n
E ● Take with meals to avoid gastrointestinal problems.
f s t f ● Instruct take metformin at the same time, if missed take as soon as possible and, do not double
d
i doses.
m i f
o c ● Do not cut or crush extended-release tablets
D n e
a ● Educate about signs of vitamin B12 deficiency: fatigue, decreased level of energy, paleness,
r o t c numbness, tingling sensation in arms and legs, difficulty with walking or balance.
ug f a i t ● Prescribed diet is principal part of treatment; do not skip, delay meals.
n o s ● Educate to eat foods that are high in fiber and vitamin B12: eggs, meat, poultry, milk products,
d n
Ac s
green leafy vegetables.
t ● Educate the patient that diabetes requires lifelong control.
R
i a
● Avoid alcohol.
on t
● Report persistent headache, nausea, vomiting, diarrhea or if skin rash, unusual
bruising/bleeding, change in color of urine or stool occurs: medication toxicity.
i
● Do not take dose for at least 48 hrs after receiving IV contrast dye with radiologic testing.
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 Name of Mechanism of Indication and Nursing
Contraindications Side Effects
Drug Action Rationale Consideration

Generic Name: Blocks the Management of Possible Possible Side BASELINE ASSESSMENT
Contraindications: Effects: Assess baseline
Nebivolol stimulation of beta-1 hypertension.
renal/hepatic function
adrenergic receptor
●Severe bradycardia ● Decrease BP tests. Assess B/P, apical
sites which decrease Rationale:
●Overt cardiac failure ● Decrease heart rate pulse immediately
Nebivolol is used
Brand Name: N/I the force and rate of Cardiogenic shock ● Dizziness
before drug
Possible: Bystolic contraction of the to lower the blood administration
pressure of the ●Heart block greater ● Fatigue (Withhold if HR is <60
heart, with
patient which than first degree ● Nausea bpm and withhold if BP
consequent
decreases the risk ●Severe hepatic ● Headache is ≤ 90/60 mmHg
reduction in arterial
Classifications: impairment ● Impotence withhold medication,
for adverse
Beta-adrenergic blood pressure and ● Diarrhea contact physician).
blocker, in cardiac load. In cardiovascular
Cautions: INTERVENTION/EVALUATI
events. ● Insomnia
Anti-hypertensiv addition, it blocks ● Diabetes mellitus
ON
e Measure B/P near end of
the release of renin ● Acute exacerbation dosing interval
which results to of coronary artery (determines whether
vasodilation. disease
B/P is controlled
throughout day). Monitor
Dosage, B/P for hypotension.
Frequency and Assess pulse for quality,
Route: 5 mg by irregular rate,
mouth daily bradycardia. Question
for evidence of
headache
N M C S
I o
a e i
n n
m c d t d
e ha i r e
n c a
i
o i a
n
E PATIENT/FAMILY TEACHING
f s t f
d
i ● Monitor B/P, pulse before taking medication.
m i f
o c ● The dose should be taken preferably at the same time of the day
D n e Nebivolol Tablets may be taken before, during or after the meal, but, alternatively, you can take
a ●
r o t c it independently of meals. The tablet is best taken with some water.
ug f a i t ● Compliance with therapy regimen is essential to control hypertension.
n o s ● Do not use nasal decongestants, OTC cold preparations (stimulants) without physician’s
d n
Ac s
approval.
t ● Restrict salt, alcohol intake.
R Do not crush, split, chew tablets
i a
●
Do not stop treatment abruptly
on t
●

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 Name of Mechanism of Indication and Nursing
Contraindications Side Effects
Drug Action Rationale Consideration

Generic Name: Irreversibly inhibits As platelet Possible Possible Side BASELINE

Aspirin cyclooxygenase aggregation Contraindications: Effects: ASSESSMENT
● Do not use Aspirin if
enzymes (COX-1, inhibitor in the
●Hypersensitivity to ● GI upset there is smell of
COX-2) which reduces prevention of
salicylate ● Heartburn strong vinegar odor in
Brand Name: N/I thromboxane A2 transient ischemic ●NSAID ● Drowsiness the medicine bottle.
Possible: Aspen, synthesis by platelets attacks (TIAs) and ●Asthma ● Nausea ● Assess if there is
Ecotrin therefore reduces myocardial ●Rhinitis ● Vomiting history of GI bleed,
platelet activation infarction ●Inherited or acquired peptic ulcer disease,
● Hepatotoxicity
and aggregation bleeding disorders OTC use of products
● Hemolysis
Classifications: ● Bleeding that may contain
Anticoagulant Cautions: aspirin
Rationale: Patient ● Platelet/ bleeding ● Anemia
has a history of disorders INTERVENTION/EVALU
myocardial ● Severe renal/hepatic ATION
infarction and impairment ● Monitor urinary pH
peripheral ● Dehydration (sudden acidification,
Dosage, pH from 6.5 to 5.5, may
vascular disease, ● Erosive gastritis
Frequency and result in toxicity).
Route: 81 mg by using Aspirin, it ● Peptic ulcer disease
Assess skin for
mouth daily prevents heart ● Sensitivity to
evidence of
attack and stroke tartrazine dyes. ecchymosis.
N M C S
I o
a e i
n n
m c d t d
e ha i r e PATIENT/FAMILY TEACHING
n c a
i
o i a
n
E ● Swallow enteric -coated tablets whole. Do not crush or chew enteric-coated tablets.
f s t f ● May give with water, milk, meals if GI distress occurs.
d
i
m i f ● Sit upright for at least 10 minutes after taking the medicine.
o c ● Instruct patient to use soft or electric toothbrush and other measure to prevent bleeding
D n e
a ● Monitor input and output as decrease in output may indicate renal failure
r o t c ● Monitor for dark-colored urine that may indicate Hepatotoxicity
ug f a i t ● Assess skin color and presence of lesions as this may indicate hepatotoxicity, allergy, and bleeding.
n o s ● Observe patient for signs and symptoms of bleeding such as easy bruising, bleeding in the gums,
d n
Ac s
and nosebleeds
t ● Store aspirin away from heat and moisture.
R
i a
● Avoid alcohol.
on t
● Report tinnitus or persistent abdominal GI pain, bleeding.
● Monitor for signs and symptoms of drug allergy such as difficulty of breathing, pruritus or itchy skin,
i
and rashes
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 Name of Mechanism of Indication and Nursing
Contraindications Side Effects
Drug Action Rationale Consideration

Generic Name: Calcitriol: Stimulates Vitamin D with Possible Possible Side BASELINE
vitamin D3 calcium transport in calcium is used to Contraindications: Effects: ASSESSMENT
(Drisdol, intestines, resorption treat or prevent ● Sarcoidosis. ● Chest pain,
Calciferol, in bones, and tubular bone loss ● High amount feeling short ● Obtain
cholecalciferol, reabsorption in (osteoporosis). of phosphate of breath; baseline
1,25-Dihydroxy kidney; suppresses Vitamin D is also ● Growth serum
in the blood.
cholecalciferol, parathyroid hormone used with other problems (in calcium,
and (PTH) secretion/ medications to ● High amount a child taking phosphorus,
ergocalciferol.) synthesis. treat low levels of of calcium in cholecalcifer alkaline
Doxercalciferol: calcium or the blood. ol); or. phosphatase,
Brand Name: Regulates blood phosphate caused ● Excessive ● Early signs of creatinine,
Calciferol, calcium levels, by certain amount of vitamin D iPTH.
Drisdol stimulates bone disorders overdose
vitamin D in
growth, suppresses weakness, INTERVENTION/EVAL
Classifications: the body. UATION
PTH metallic taste
Fat-soluble secretion/synthesis. ● Kidney in your
vitamin Ergocalciferol: stones. mouth, ● Monitor
Promotes active ● Decreased weight loss, serum,
Dosage, absorption of kidney muscle or urinary
Frequency and calcium and bone pain, calcium
function.
Route: phosphorus, constipation, levels, serum
1000 units by increasing serum nausea, and phosphate,
mouth daily levels to allow bone vomiting. magnesium,
creatine,
N mineralization; I C S INTERVENTION/EVALUATION
mobilizes nd o
a calcium and n
i
i ● Monitor serum, urinary calcium levels, serum phosphate, magnesium, creatine,
m phosphate t d
c alkaline phosphatase, BUN determinations (therapeutic calcium level: 9–10
e from bone, r e mg/dl), iPTH measurements.
increases a a
reabsorption t i ● Estimate daily dietary calcium intake.
o n
E Encourage adequate fluid intake.
of calcium and i ●
f phosphate by d f Monitor for signs/symptoms of vitamin D intoxication.
o ●
renal tubules.
n
i f
D Paricalcitol: c e PATIENT/FAMILY TEACHING
Suppresses a
r PTH a t c
● Adequate calcium intake should be maintained.
ug secretion/synt n i t
● Dietary phosphorus may need to be restricted (foods high in phosphorus include
hesis. d o s
n beans, dairy products, nuts, peas, whole-grain products).
Therapeutic s ● Oral formulations may cause hypersensitivity reactions.
Effect: Ra
● Avoid excessive doses.
Essential for t
absorption, i
utilization of o
calcium,
phosphate,
n
control of PTH a
levels. l
e
 Name of Mechanism Indication and
Contraindications Side Effects Nursing Consideration
Drug of Action Rationale

Generic Inhibits Use during a Possible Possible Side BASELINE ASSESSMENT

Name: binding of percutaneous Contraindications: Effects:

● Perform platelet counts before drug
Clopidogrel enzyme coronary ● Patients therapy, q2days during first wk of
adenosine intervention (PCI) with a ● bleeding treatment, and weekly thereafter
until therapeutic maintenance dose
Brand Name: phosphate for acute coronary known more easily is reached.
Plavix (ADP) to its syndrome (ACS) hypersensit than ● Abrupt discontinuation of drug
and stable ivity to therapy produces elevated platelet
platelet normal count within 5 days.
Classificatio ischemic heart clopidogrel
receptor and nosebleeds
ns: disease Primary or any INTERVENTION/EVALUATION
Antiplatelet
subsequent ● bruising
prevention of component
ADP-mediated more easily Monitor platelet count for evidence
thromboembolism of the ●
Dosage, activation of a of thrombocytopenia.
atrial fibrillation. product. or bleeding Assess BUN, serum creatinine,
Frequency glycoprotein ●
● Patients that takes bilirubin, AST, ALT, WBC, Hgb, Hct,
and Route: complex. with active ● Check for signs/symptoms of hepatic
longer to insufficiency during therapy.
75 mg by pathologica
mouth daily Therapeutic stop
l bleeding PATIENT/FAMILY TEACHING
Effect: including GI
● diarrhea
Inhibits bleeding ● stomach ● It may take longer to stop bleeding
platelet during drug therapy.
and pain ● Report any unusual bleeding.
aggregation. intracranial ● indigestion ● Inform physicians, dentists if
clopidogrel is being taken, esp.
bleeding. or before surgery is scheduled or
heartburn before taking any new drug.
 Name of Mechanism Indication and Side
Contraindications Nursing Consideration
Drug of Action Rationale Effects

Stimulates Possible Possible Side BASELINE ASSESSMENT

Generic Isosorbide
Name: intracellular mononitrate is Contraindications: Effects:
● Significant ● Abnorma ● Record onset, type (sharp, dull, squeezing),
Isosorbide cyclic guanosine indicated for the radiation, location, intensity, duration of anginal
anemia. l heart pain; precipitating factors (exertion, emotional
Mononitrate monophosphate prevention and ● Methemoglob sound. stress).
management of inemia, a type ● Absence ● If headache occurs during management therapy,
Therapeutic administer medication with meals.
Brand angina pectoris of blood of or
Name: Effect: due to coronary
disorder. decrease
INTERVENTION/EVALUATION
Relaxes vascular ● A heart in body
Ismo artery disease. attack. moveme
smooth muscle ● Assist with ambulation if light-headedness,
The onset of ● Hypertrophic nt. dizziness occurs.
Classifications: of arterial, cardiomyopat Arm,
action of oral ● ● Assess for facial/neck flushing.
Antianginal venous hy. back, or ● Monitor number of anginal episodes, orthostatic
isosorbide B/P.
vasculature. ● A hemorrhage jaw pain.
Decreases mononitrate is not in the brain. Black,
Dosage, ● PATIENT/FAMILY TEACHING
preload, sufficiently rapid ● Low blood tarry
Frequency
afterload. to be useful in pressure. stools. Do not chew/crush sublingual, extended-release,
and Route: Abnormal Bladder
●
aborting an acute ● ● sustained-release forms.
60 mg by absorption of pain. ● Take sublingual tablets while sitting down.
anginal episode. food Bleeding ● Rise slowly from lying to sitting position, dangle
mouth daily ● legs momentarily before standing (prevents
nutrients in after dizziness effect).
the defecatio ● Take oral form on empty stomach (however, if
gastrointestin n. headache occurs during management therapy,
take medication with meals).
al tract. ● Blood in ● Dissolve sublingual tablet under tongue; do not
● High pressure the urine swallow.
within the or stools. ● Avoid alcohol (intensifies hypotensive effect).
● If alcohol is ingested soon after taking nitrates,
skull. ● Body possible acute hypotensive episodes (marked
aches or drop in B/P, vertigo, pallor) may occur.
pain. ● Report signs/symptoms of hypotension, angina.
 Name of Mechanism Indication and
Contraindications Side Effects Nursing Consideration
Drug of Action Rationale

Generic Name: Interferes Rosuvastatin is Possible Possible Side BASELINE ASSESSMENT

Rosuvastatin with used together Contraindications: Effects:
● Untreated ● Constipatio Obtain dietary history,
cholesterol with a proper ●
decreased n
Brand Name: biosynthesis diet to lower bad esp. fat consumption.
level of ● Stomach
Crestor by inhibiting cholesterol (LDL) thyroid pain
● Question for possibility
conversion of and triglycerides hormones ● Dizziness of pregnancy before
Classifications the enzyme ● Dehydration ● Difficulty initiating therapy
(fats) in the
: HMG-CoA to ● Alcoholism falling (Pregnancy Category X).
Antihyperlipid blood, and to a asleep or
mevalonate, a ● ● Assess baseline lab
emic increase your hemorrhage staying
precursor to results: serum
good cholesterol in the brain asleep
cholesterol. cholesterol, triglycerides,
Dosage, (HDL). It is also ● Liver failure ● Depression
● Liver ● Joint pain hepatic function tests.
Frequency and Therapeutic used to treat
problems ● Headache
Route: Effect: adults who ● Acute kidney ● Memory INTERVENTION/EVALUATION
40 mg by Decreases cannot control failure loss or
mouth daily LDL, VLDL, their cholesterol ● Bloody forgetfulnes ● Monitor serum
plasma levels by diet urine. s cholesterol, triglycerides
triglyceride and exercise for therapeutic response.
levels; alone. ● Lipid levels should be
increases HDL monitored within 2–4 wks
concentration of initiation of therapy or
change in dosage.
N M C S ● Monitor hepatic function tests. Hepatic function tests should be performed at 12 wks
I o
a e i following initiation of therapy, at any elevation of dose, and periodically (e.g., semiannually)
n n
thereafter.
m c d t d
e ha r e ● Monitor CPK if myopathy is suspected.
i
a Monitor daily pattern of bowel activity, stool consistency.
n c
●
i ● Assess for headache, sore throat.
o i a
n
E
t ● Be alert for myalgia, weakness.
f s d f
i
m i f PATIENT/FAMILY TEACHING
o c
D n e
a
r o t c ● Use appropriate contraceptive measures (Pregnancy Category X).
ug f a i t ● Periodic lab tests are an essential part of therapy.
n o s ● Maintain an appropriate diet (an important part of treatment).
d n Report unexplained muscle pain, tenderness, weakness, esp. if associated with fever,
Ac s
●
malaise.
t
R
i a
on t
i
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Nursing Care
Plan
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired Gas Exchange Short Term: Independent Independent Short Term:
r/t excess fluid in Within 8 hrs of Nursing Within 8 hrs of Nursing
Intervention the Patient Intervention the Patient was
She reports difficulty interstitial space as will:
- Ensure patent airway and - Elevation or upright position
able to:
of breathing at rest evidenced by shortness adequate gas exchange by facilitates respiratory function
-Demonstrate improved -Demonstrate improved
positioning the patient with by gravity, allows increased
of breath, tachypnea, ventilation and adequate head of the bed elevated in a thoracic capacity, total descent ventilation and adequate
Objective: dyspnea at rest, and oxygenation of tissues by semi-fowler’s position of the diaphragm, and oxygenation of tissues by
ABGs within normal range increased lung expansion ABGs within normal range
ABG result: abnormal and be free of symptoms and be free of symptoms of
- dyspnea at rest preventing the abdominal
blood gas w/ hypoxia, of respiratory distress. contents from crowding. respiratory distress.
- bilateral rhonchi adventitious breath
sound, O2 saturation -Patient participates in - Assess rate, rhythm, and - Alveolar hypoventilation and -Patient participates in
procedures to optimize depth of respirations. associated hypoxemia lead to procedures to optimize
- wheezing 90% on room air, and oxygenation and in respiratory failure. oxygenation and in
Bibasilar airspace management regimen management regimen within
-Bibasilar airspace - Decreased level of
disease that may within level of - Assess level of consciousness level of capability/condition.
disease that may capability/condition. and mentation changes. Advise consciousness
represent alveolar represent alveolar SO to report promptly changes can be an indirect
Long Term:
edema. edema. in the patient’s condition. measurement of impaired
Long Term: oxygenation Within 24 hours of nursing
Within 24 hours of nursing intervention, the patient was
- RR: 24 rpm: intervention, the patient able to:
- Monitor vital signs, including - To check for improvement
tachypnea will: -manifest resolution or
oxygen saturation
-manifest resolution or absence of symptoms of
-O2 saturation 90% absence of symptoms of - to evaluate lung mechanics,
- Review pertinent diagnostic respiratory distress.
on room air. data (e.g., ABGs) and chest capacities, and function.
respiratory distress.
radiography
__Goal met
__Goal partially met
-Regularly check the patient’s -Slumped positioning causes __Goal not met
position so that they do not the abdomen to compress the
slump down in bed. diaphragm and limits full lung
expansion.
 -Encourage frequent position changes and deep-breathing and coughing exercises. This promotes optimal chest expansion, mobilization of
secretions, and oxygen diffusion

-Encourage adequate rest and limit activities to within client tolerance. Promote a calm, -This helps limit oxygen needs and consumption.
restful environment.
-Activities will increase oxygen consumption and should be
-Pace activities and schedule rest periods to prevent fatigue. Assist with ADLs. planned, so the patient does not become hypoxic.

-The hypoxic patient has limited reserves; inappropriate activity

-Schedule nursing care to provide rest and minimize fatigue. can increase hypoxia.
As D -Emphasize the importance of nutrition -Improves stamina and reducing the work of breathing.
s i P Dependent
e a l Dependent -This technique promotes deep inspiration, which increases
-Encourage slow deep breathing using an incentive spirometer as indicated. oxygenation and prevents atelectasis.
s gn an
s o n
- For compliance to existing medication
- Administer drug as indicated upon doctor’s order.

m s i - To ensure that the machine is properly working and effectively

en i ng
- Assist and provide close monitoring while using the BiPAP machine. Aids the patient’s breathing.

t s COLLABORATIVE
COLLABORATIVE
- To check improvements on
- Refer to med tech for lab test monitoring. ABG’s, creatinine levels and electrolytes.
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Ineffective Airway Short term: Independent: Independent: Short term:
Clearance related to Within 8 hrs of Nursing Within 8 hrs of Nursing
Intervention the Patient - Assess level of - This information is essential Intervention the Patient was
- She reports airway spasm
will able to: consciousness/cognition for identifying potential for able to:
difficulty of as evidenced by and ability to protect own airway problems, providing
breathing at rest wheezing, bilateral airway. baseline level of care
- Maintain airway - Maintain airway
rhonchi, decreased air needed, and influencing
patency patency
Objective: movement bilaterally, choice of interventions.
- Demonstrate - Demonstrate
dyspnea, smoking absence/reductio - Timely monitor - To ascertain current status absence/reductio
- Adventitious tobacco use at 30 pack n of congestion n of congestion
respirations and and note effects of
breath sounds with breath with breath
years auscultate breath sounds, treatment in clearing
(Wheezing, sounding clear, sounding clear,
noting rate and sounds. airways.
rhonchi) noiseless noiseless
- Decreased air respirations, and - Assist client to maintain a - Elevation of the head of the respirations, and
movement improved oxygen comfortable position to bed facilitates respiratory improved oxygen
bilaterally exchange (e.g., facilitate breathing by function using gravity; exchange (/pulse
- History of COPD /pulse oximetry elevating the head of bed, however, client in severe oximetry results
- Smoking 30 packs results within leaning on over-bed table, distress will seek the within client
for years client norms) or sitting on edge of bed. position that most eases norms)
breathing. Supporting arms
Vital signs: Long term: and legs with table, pillows, Long term:
and so on helps reduce
Within the hospital stay Within the hospital stay
muscle fatigue and can aid
- O2 Saturation: patient will be able to: patient was be able to:
chest expansion.
90% - Encourage and assist with
- Will demonstrate abdominal or pursed-lip - Provides client with some - Will demonstrate
increased airway breathing exercises. means to cope with and increased airway
clearance control dyspnea and reduce clearance
- Identify and air-trapping. - Identify and avoid
avoid specific - Increase fluid intake to specific factors
factors that 3000 mL/day within - Hydration helps decrease that inhibits
inhibits effective cardiac tolerance. Provide bronchospasm. Fluids during effective airway
airway clearance. warm or tepid liquids. meals can increase gastric clearance.
Recommended intake of distention and pressure on
fluids between, instead of the diaphragm.
during, meals.
 Intervention Rationale
- Keep environment allergen free - To avoid any contributory factors in the condition
of patient

Dependent: Dependent:

Administer medications, as indicated - Inhaled anticholinergic agents are now

- Bronchodilator like fluticasone and vilanterol considered the first-line drugs for clients
with stable COPD because studies indicate
they have a longer duration of action with
As D - Adrenergic agonist like Albuterol/ipratropium
less toxicity potential E
s i P - Adrenergic receptors in lungs, resulting in
relaxation of bronchial smooth muscle. v
e a l a
Collaboration:
s gn an - Collaborate with radtech, medtech; monitor and graph serial ABGs, pulse oximetry, and Collaboration: l
- Establishes baseline for monitoring progression or
s o n chest x-ray.
regression of disease process and complications. ua
m s i Note: Pulse oximetry readings detect changes in
saturation as they are happening, helping to t
en i ng identify trends possibly before client is
symptomatic.
i
t s on
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective breathing Short Term: Independent Independent Short Term:

Within 8 hrs of Nursing -Position the client in a relaxed -A semi to high fowler's Within 8 hrs of Nursing
pattern related to Intervention the Patient and comfortable position that position permits maximum Intervention the Patient will:
She reports difficulty
hyperventilation as will: can also facilitate effective lung excursion and chest - Establish a normal,
of breathing at rest breathing. expansions
evidenced by - Establish a effective
normal, respiratory pattern
Objective: tachypnea, dyspnea, effective -Teach the patient about -These measures allow the as evidenced
respiratory pursed-lip breathing, patient to participate in arterial blood
ABG: respiratory abdominal breathing, maintaining health status and
- RR: 24 rpm: pattern as gasses (ABGs)
alkalosis with hypoxic evidenced
performing relaxation improve ventilation.These
within client’s
tachypnea techniques, performing techniques promote deep
respiratory features, O2 arterial blood
relaxation techniques inspiration, which increases
normal or
-O2 saturation 90% gasses (ABGs) acceptable range
saturation 90% on within client’s
oxygenation and prevents
and absence of
on room air. atelectasis. Controlled
room air, and the use of normal or breathing methods may also s/sx of hypoxia
acceptable aid slow respirations in
- dyspnea BiPAP ventilator
range and tachypneic patients. Prolonged
absence of s/sx expiration prevents air __Goal met
-Initial arterial blood of hypoxia trapping.
gas with pH 7.491, __Goal partially met
PCO2 27.6, PO2 53.6, -Note rate and depth of -The average rate of __Goal not met
HCO3 20.6 indicating respirations, counting for 1 full respiration for adults is 10 to
respiratory alkalosis minute, if rate is irregular. 20 breaths per minute. It is
with hypoxic important to take action when
respiratory features. there is an alteration in
breathing patterns to detect
-She uses BiPAP early signs of compromise on
the respiratory system.
ventilatory support
at night when
-Assess for the use of Work of breathing increases
sleeping accessory muscle and nasal greatly as lung compliance
flarings decreases. These can signify
-Patient barely able
increase respiratory effort.
to finish a full
sentence due to
-Assess ABG levels and 02 -This monitors oxygenation and
shortness of breath
saturation ventilation status
 Planning Intervention Rationale Evaluation
Long Term: -Encourage frequent rest periods and teach the -Extra activity can worsen shortness of Long Term:
Within 24 hours of nursing patient to pace activity. breath. Ensure the patient rests between Within 24 hours of nursing
intervention, the patient will: strenuous activities. intervention, the patient will:
-manifest resolution or absence -manifest resolution or
of symptoms of respiratory -Encourage small frequent meals. -This prevents crowding of the diaphragm absence of symptoms of
distress. respiratory distress.
Dependent
-Patient demonstrates Dependent -This helps patient to breathe more easily -Patient demonstrates
As D maximum lung expansion - Provide health education and assist in operating the
BiPAP ventilator.
either while sleeping or when patient
experience sudden onset of symptoms. Assist
maximum lung expansion
s i with adequate ventilation. and provide close monitoring while using the
BiPAP machine. Ensure correct settings.
with adequate ventilation.

e a -Patient indicates, either -Patient indicates, either

-This is to help aid s/sx and promote
s gn verbally or through behavior, - Administer medications such as prescribed by the pharmacological regimen to achieve optimal verbally or through
s o primary physician. health.
feeling comfortable when behavior, feeling
breathing. comfortable when
m s -When patient carries out Collaborative
Collaborative
breathing.
en i ADLs, breathing pattern -Collaborate with other healthcare professionals in -For the administration of diagnostic and -When patient carries out
caring and monitoring for the patient such as medical
t s remains normal. laboratory tests. ADLs, breathing pattern
technologists and radiologists.
-Good nutrition can strengthen the remains normal.
-Consult a dietitian for dietary modifications. functionality of respiratory muscles.

__Goal met
__Goal partially met
__Goal not met
References
Pathophysiology:
● Hinkle, Janice L. and Kerry H. Cheever. BRUNNER & SUDDARTH’S TEXTBOOK OF Medical-Surgical Nursing 14th Edition. Philadelphia:
Wolters Kluwer.
● Silbernagl, S., & Lang, F. (2000). Color Atlas of Pathophysiology. Stuttgart: Georg ThiemeVerlag.

Diagnostic Tests:
● https://www.mayoclinic.org/tests-procedures/complete-blood-count/about/pac-20384919
● https://www.ucsfhealth.org/medical-tests/comprehensive-metabolic-panel
● https://medlineplus.gov/lab-tests/creatine-kinase/
● https://medlineplus.gov/lab-tests/troponin-test/
● https://www.mayoclinic.org/tests-procedures/ekg/about/pac-20384983
● https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/electrocardiogram
● https://www.radiologyinfo.org/en/info/chestrad
● https://www.kidney.org/content/kidney-failure-risk-factor-estimated-glomerular-filtration-rate-egfr#:~:text=The%20estimated%20glomerular%
20filtration%20rate,%2C%20body%20size%2C%20and%20gender.
● https://my.clevelandclinic.org/health/diagnostics/21593-estimated-glomerular-filtration-rate-egfr
● https://www.mayoclinic.org/tests-procedures/liver-function-tests/about/pac-20394595

Drug Study:
● Kizior, R. J., & Hodgson, B. B. (2013). Saunders Nursing Drug Handbook 2014. Elsevier.
● Kizior, R. J., & Hodgson, K. J. (2020). Saunders Nursing Drug Handbook 2021. Elsevier Health Sciences.
●
Nursing Care Plan:
● Carpenito-Moyet, L. J., & Carpenito, L. J. (2013). Handbook of Nursing Diagnosis. Wolters Kluwer Health/Lippincott Williams & Wilkins.
● Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales. F. A.
Davis Company.
● Wayne, G. (2022, March 19). Ineffective Breathing Pattern – Nursing Diagnosis & Care Plan. Nurseslabs. Retrieved September 23, 2022,
from https://nurseslabs.com/ineffective-breathing-pattern/
● Wayne, G. (2022, May 8). Impaired Gas Exchange Nursing Diagnosis & Care Plan. Nurseslabs. Retrieved September 23, 2022, from
https://nurseslabs.com/impaired-gas-exchange/
GROUP 2 RLE NCMB 418

● BERONGOY, CHRISTIAN JAY

● CONCLARA, SARAH
● CUSTODIO, JEHERSON ART
● DUEY, LORIE MAE
● ESPLEGUIRA, AIRA
● LANDERO, JANELLA MAEGAN
● MARCELO, JANIEL CYNTH
● MACARUBBO, PRINCESS ALLIAH
● PEMPENA, NIKKA SHAINE