1.

Study of the Illness Condition

ASSESSMENT ANATOMY PHYSIOLOGY PATHOPHYSIOLOGY ANALYSIS
(1) The system involved is (1) The principal organs (2) Shortness of breath or difficulty in
Subjective: the respiratory system: of the respiratory Below is the breathing is common for patient with
 Complaints system are the nose, pathophysiology and life COPD, because of repeated inhalation
of acute pharynx, trachea, threatening pathway. of irritants results to inflammation
shortness of bronchi, and lungs. (1) When irritants response with defensive cells along
breath Respiratory consists come contact with inflammatory chemicals from the
 Symptoms of 2 zones, the with the immune system. Thus, narrowing the
started 2 conducting zone, bronchioles and air passage. Moreover, inflammatory
days before and respiratory alveolus, there chemicals may also impair alveolar
and had zone. Conducting would be walls and destroy air sacs.
progressively zone are organs that inflammation and
worsened serves only for mucous (3) As stated above, COPD reduces air
with no airflow while the hypersecretion, flow into the lungs, making breathing
associated, latter is for gas and ciliary difficult and labored. It also reduces the
aggravating, exchange. Within disfunction. Thus, oxygen supply your whole body
or relieving the lungs, air flows an obstruction of receives. Without enough oxygen, your
factors along a one-way airflow occurs. body will feel tired and exhausted, thus,
 Had similar (2) The organ involve is the pathway from When airflow is increases body fatigue and
symptoms lungs, specifically, bronchi to obstructed, restlessness.
approximatel bronchioles and bronchioles to abnormal gas
y 1 year ago alveolus: alveoli. The exchange may (4) COPD in most cases results to
with acute incoming air stops in occur leading to systemic effects such as hypertension
COPD the alveoli, shortness of and heart diseases. In the patient’s
 Reported exchanges oxygen breath. This may condition, may manifest a weak
difficulty with the blood also lead to heart,causing fluids to build up in the
breathing, stream through systemic effects body and making the kidney work to get
rest, mild alveolar wall, and such as heart rid of the excess fluid.
fatigue, and then flows back out disease and
increased as carbon dioxide. pulmonary References:
urinary hypertension. (1) Agarwal AK, Raja A, Brown BD.
frequency. References: Chronic Obstructive Pulmonary
References: Disease. [Updated 2021 Dec 10]. In:
Objective: (1) Saladin, K. S., Gan, (1) MacNee W. StatPearls [Internet]. Treasure Island
 Shortness of C. A., & Cushman, (2016). (FL): StatPearls Publishing; 2022 Jan-.
breath H. N. (2018). Pathology, Available from:
  restlessness References: Anatomy & pathogenesis, https://www.ncbi.nlm.nih.gov/books/NB
(1) Saladin, K. S., Gan, C. A., physiology: The and K559281/
History: & Cushman, H. N. (2018). unity of form and pathophysiology. (2) Brooks M. FDA Clears Olodaterol
 family history Anatomy & physiology: function. BMJ : British (Striverdi Respimat) for COPD.
of heart The unity of form and Medical Journal, Medscape Medical News. Available at
disease and function. 332(7551), 1202– http://www.medscape.com/viewarticle/8
hypertension (2) RUDRAX Chest Clinic, 1204. 29248. Accessed: 19/4/2022.
 positive COPD(2021), [a blog], (3) Son YJ, Kwon BE. Overactive Bladder
smoking of accessed at: is a Distress Symptom in Heart Failure.
tobacco use https://drdipakviradia.com/ Int Neurourol J. 2018 Jun;22(2):77-82.
at 20 years copd/ doi: 10.5213/inj.1836120.060. Epub
 quit smoking 2018 Jun 30. PMID: 29991228; PMCID:
3 years ago PMC6059908.
due to
increasing
shortness of
breath
 no allergies
 history of
non-suicidal
injury when
teenager.
Pathophysiology and Life-threatening Pathway of the Patient:

Factors

Long term Smoking Genes

Mucous hypersecretion,
and ciliary dysfunction

Inflammation

Obstruction of airflow

Difficulty in breathing

Gas exchange abnormalities

Fatigue

Adverse Systemic Effects

Heart Diseases Hypertension Pneumonia

Increased Urinary
Frequency
2. Nursing Care Plan
ASSESSMENT NURSI PLANNING IMPLEMENTATION EVALUATION
NG
DIAGNOSI OBJECTIV INTERVENTION RATIONALE
S E OF
CARE

Subjective Cues: Impaired After 8 hours Observe rate, rhythm, and Provides insight into RR-30, Rhythmic, The patient
 Complaints gas of nursing depth. the work of shallow or decreased demonstrated
of acute exchange intervention, breathing and depth. improved
shortness of related to the patient adequacy of breathing and
breath obstructed will alveolar ventilation. ventilation, and
 Symptoms airway as demonstrate free from
started 2 evidenced improved Assist the patient to a three- To maximize Assisted the patient in respiratory
days before by difficulty breathing & point position, (bending respiratory effort. a sitting position to do distress. Although
and had in breathing. ventilation of forward while supporting self tripod breathing some breathing
progressivel and free of by placing one hand on each technique. Patient exercises needs
y worsened respiratory knee) demonstrated easier some practices,
with no distress breathing. the patient noted
associated, its significance.
aggravating, Demonstrate patient the purse- To prolong Demonstrated purse-
or relieving lip method. expiration, and lip method. The
factors produce positive- patient improved
 Reported end expiratory breathing along with
difficulty pressure(PEEP). tripod position. RR-
breathing, 27, and depth is
rest, mild slightly increased.
fatigue, and
increased Elevate the head or position Elevation or upright The patient prefers
urinary the client appropriately. position facilitates fowler’s when in bed.
frequency. respiratory Patient verbalized ‘it’s
function by gravity; easier to breathe this
however, client in way.’
Objective Cues: severe distress will
 Shortness of seek position of
breath comfort.
 Restlessness
while
Encourage frequent position Promotes optimal Client does deep
breathing.
changes, deep-breathing chest expansion, breathing exercises,
exercises, or directed coughing mobilization of but there is no
secretions, and improvement.
oxygen diffusion Practicing may be
needed. Though,
directed coughing is
effective to the
patient.

Encourage adequate rest and Promote a calm, The patient had

limit activities to within client restful environment. interrupted sleep due
tolerance. Facilitates relaxation to shortness of breath
and oxygen needs. and coughing.

Encourage expectoration of Thick, tenacious, Medicine and

sputum; suction when needed. copious secretions equipment are ready
are a major source for expectoration, as
of impaired gas well as patient’s
exchange in small verbal consent is
airways. noted.

Provide humidified oxygen as Administering Hospital humidifier

ordered. humidified oxygen has already been
prevents drying out used according to
the airways, patient’s condition
decrease convective
moisture losses,
and improves
 compliance.

ASSESSMENT NURSI PLANNING IMPLEMENTATION EVALUATION

NG
DIAGNOSI OBJECTIV INTERVENTION RATIONALE
S E OF
CARE

Subjective Cues: Ineffective After 8 hours Assess level of Essential Identifying Patient is restless but The patient
 Reported airway of nursing consciousness/cognition and and assessing conscious, can talk, demonstrated
difficulty clearance intervention, ability to protect own airway. potential for airway but is interrupted positive behaviors
breathing, related to the patient problems and easily due to effort to by using
restlessness, restlessnes will influencing choice of clear throat. breathing
mild fatigue, s as demonstrate medical techniques as the
and evidenced behaviors to intervention. patient already
increased by difficulty improve did the
urinary in breathing. restlessness Evaluate respiratory rate/depth Provides insight into RR-30, Rhythmic, techniques
frequency. and maintain and breath sounds. the work of shallow or decreased before, and is
clear airway breathing and depth. eager to do it
adequacy of again. Moreover,
Objective Cues: alveolar ventilation. the restlessness
 Shortness of of the patient
breath
Evaluate amount and type of Excessive and/or Patient has excessive lessened after
 Restlessness
secretions being produced. sticky mucus can mucous production, few hours of
while
breathing. completely with COPD, the sleep and intake
obstruct or make it patient’s cough of water.
difficult to maintain function is impaired.
 effective airways,
especially if client
has impaired cough
function

Position head appropriate for to open or maintain Patient prefers

age and condition/disorder. open airway in at- fowler’s position as it
rest or compromised is easier to promote
individual excretion of mucous
when cough reflex is
made.

Suction when indicated and to clear airway when Since excessive

assist procedures when secretions are mucous is presented
necessary. blocking airways by the patient,
suctioning is allowed
by the patient.

Keep the environment free of allergies may trigger Humidifier is being

irritants such as smoke, dust, acute cough used in the room,
or feather episodes and doors, windows
are closed to
minimize entry of
dust.

Demonstrate patient the purse- To prolong Due to excessive

lip method. expiration, and mucous, purse-lip
produce positive- method is
end expiratory demonstrated to the
pressure(PEEP). patient to promote
breathing and
relaxation.
 Assist the patient to a three- To maximize Patient is informed
point position, (bending respiratory effort. and practiced tripod
forward while supporting self position before.
by placing one hand on each
knee)

Encourage rest and sleep. Promote a calm, Restlessness has

restful environment. lessened by relaxing
Facilitates relaxation or maximizing bed
and oxygen needs. time rest by the
patient.

Increase fluid intake to 3000 Hydration helps

mL per day within cardiac decrease the The patient is taking
tolerance. Provide warm or viscosity of at least 3000mL and
tepid liquids. Recommend the secretions, verbalized that it
intake of fluids between, facilitating helped her breathe.
instead of during, meals. expectoration. Using
warm liquids may
decrease
bronchospasm.
Fluids during meals
can increase gastric
distension and
pressure on the
diaphragm.

Reference/s:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2018). Nursing diagnosis manual: Planning, individualizing, and documenting client care. Philadelphia,
PA: F.A. Davis.
In Herdman, T. H., In Kamitsuru, S., & North American Nursing Diagnosis Association,. (2018). NANDA International, Inc. nursing diagnoses: Definitions
& classification 2018-2020.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. Philadelphia:
F.A. Davis Co.

Page 4 of 7
4. Drug Study
GENERIC NAME: Fluticasone MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
REACTION
Direct local effect as a potent vasoconstrictor,
anti-inflammatory. Side Effects Baseline Assessment:
Therapeutic Effect: Prevents, and controls  Throat irritation  Establish history of skin
inflammation.  Hoarseness of voice disorder, asthma, rhinitis.
 Dry mouth and cough  Question hypersensitivity
BRAND NAME: Breo Ellipta INDICATION:  Temporary wheezing  Question medical history
 Management of nasal symptoms  Nasal burning
 Management of seasonal allergic rhinitis  Stinginess Intervention/Evaluation
 Treatment to nasal polyps  Rhinorrhea  Monitor RR, Depth,
DRUG ILLU  Relief of upper respiratory allergies  Altered sense of taste Rhythm and pulse
 Maintenance of bronchial asthma as  Assess lung sounds
prophylactic theraphy  Assess oral mucous
membrane
 Assess for response in
irritation

Patient/Family Teaching
 Patients receiving
bronchodilators by
inhalation concomitantly
with steroid inhalation
STRATION: therapy should use
bronchodilator several
CLASSIFICATION: CONTRAINDICATION: min before corticosteroid
PHARMACOTHERAPEUTIC:  Hypersensitivity to fluticasone aerosol
Corticosteroid.
 CLINICAL: Anti-inflammatory,  Hypersensitivity to milk proteins  Do not change dose/
antipruritic.  Primary treatment to status asthmaticus schedule or stop taking
 Acute exacerbation asthma drug; must taper
off gradually under
DOSAGE/FREQUENCY/ROUTE:
medical supervision
Intranasal: ADULTS, ELDERLY:  Maintain strict oral
Initially, 200 mcg (2 sprays in each hygiene
nostril once daily or 1 spray in each  rinse mouth with water
nostril q12h). Maintenance: 1 spray in after using
each nostril once daily. May increase  increase fluid intake
to 100 mcg (2 sprays) in each nostril.  clear nasal passages
Maximum: before using
200 mcg/day.  notify physician if there is
no effect/irritation persists
GENERIC NAME: Losartan MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
REACTION
Blocks vasoconstrictor, aldosterone-secreting
effects of angiotensin II, inhibiting binding of Side Effects Baseline Assessment:
angiotensin II to AT1 receptors.  Upper respiratory tract  Obtain BP, apical pulse
Therapeutic Effect: Causes vasodilation, infection and other regular
decreases peripheral resistance,  Dizziness monitoring routine
decreases B/P.  Diarrhea  Obtain medical history
 Cough
BRAND NAME: Prestan INDICATION:  Insomnia Intervention/Evaluation
 treatment of hypertension  Dyspepsia  Maintain hydration
DRUG ILLU
 treatment for diabetic nepropathy  Heartburn  Assess evidence of upper
 prevention of stroke  Backpain respiratory tract infection
 Muscle cramps  Monitor BP and pulse
 Myalgia  Assist with ambulation if
 Nasal congestion dizziness occurs
 Sinusitis
 Depression Patient/Family Teaching
 Avoid tasks that require
Adverse Effects: alertness and motor skills
 Overdosage may manifest  Report any sign of
as hypotension respiratory illness
 Do not take
STRATION: decongestants
 do not stop taking
CLASSIFICATION: CONTRAINDICATION: medication
PHARMACOTHERAPEUTIC:  hypersensitivity to losartan  limit salt intake.
Angiotensin  concomitant use of aliskerin
II receptor antagonist.
CLINICAL:
 Antihypertensive.

DOSAGE/FREQUENCY/ROUTE:

PO: ADULTS, ELDERLY: Initially, 50

mg once daily. Maximum: May be
given once or twice daily, with total
daily doses ranging from 25–100 mg.
CHILDREN 6–16 YRS: Initially, 0.7
mg/kg (maximum: 50 mg) once daily.
Adjust dose to BP response.
Maximum: 100 mg/day.

Reference/s:
Kizior RJ, Hodgson KJ. Saunders Nursing Drug Handbook 2021 / Robert J. Kizior, Keith J. Hodgson. Elsevier; 2021.