VII.

DIAGNOSTIC TEST RESULTS & SIGNIFICANCE

NAME OF TEST NORMALVALUE RESULTS SIGNIFICANCE

Complete Blood Count
RBC: 4-6 x 10/L 4.28
Purpose: CBC is ordered to aid in the Hct: 0.37- 0.47 0.36
detection of anemias; hydration Hgb: 110- 160 gm/L 111
status; and as part of routine WBC: 5-10 x 10 /L 11.3
hospital admission test. The Lymphocytes:0.25-0.35 0.25
differential WBC is necessary for Segmenters: 0.50-0.65 0.74
determining the type of infection. Eosinophil: 0.01-0.06 0.01
Increased segmenters (mature
neutrophils) reflect a bacterial
infection since this are the
body’s first line of defense
against acute bacterial
invasion.
Lymphocytes are decreased
during early acute bacterial
infection and only increase
late in bacterial infections but
continue to function during
the chronic phase.
VI. DRUG STUDY
 Generic/ Brand Mechanism of Action Indication/ Adverse Nursing
Name Classification Reaction Responsibility
Salbutamol Stimulates beta-2 -Bronchodilators Fast, irregular, Assessment
receptors of -Relief of pounding, or Assess cardio-
bronchioles by bronchospasm in racing heartbeat respiratory function:
increasing levels of bronchial asthma, or pulse, BP, heart rate and
cAMP which relaxes chronic bronchitis, shakiness in the rhythm and breath
smooth muscles to emphysema and other legs, arms, sounds
produce reversible, obstructive hands, or feet, Determine history of
bronchodilatation. Also pulmonary diseases. trembling or previous medication
cause CNS stimulation, Also useful for treating shaking of the and ability to self
cardiac stimulation, bronchospasm in hands or feet medicate to prevent
increase dieresis, patients with co- additive.
skeletal muscle existing heart disease Monitor for evidence of
tremors, and increased of hypertension. allergic reaction and
gastric acid secretion. paradoxical
Longer acting than bronchospasm.
isoproterenol.
Prednisone Immediately and -Steroids problems with Assessment
completely converted -Allergic and your vision; Obtain baseline weight,
to active prednisolone inflammation swelling, rapid BP, and electrolyte
in the liver. The anti- conditions, i.e., in weight gain, levels and monitor
inflammatory effects bronchial asthma and feeling short of periodically during
maybe due to inhibition skin disorders, breath; severe therapy.
of prostaglandin ophthalmic diseases, depression, Assess patient’s
synthesis. It also rheumatic disorders, unusual thoughts condition before
inhibits the migration of organ transplant, or behavior, therapy and regularly
leukocytes and neoplastic GI and seizure thereafter to monitor
macrophages to the nervous disorders. In (convulsions); drug effectiveness.
site of inflammation as conditions responsive bloody or tarry Monitor for possible
well as inhibits to glucosesteroid stools, coughing drug induced adverse
phagocytosis and therapy, as in up blood. reactions.
lososomal enzyme adrenocortical Monitor plasma cortisol
release. insufficiency. levels during long term
therapy.
Hydrocortisone Glucocorticoid with anti The topical burning, itching, Assess patient’s
inflammatory effect corticosteroids irritation, condition before
because of its ability to constitute a class of dryness, starting therapy and
inhibit prostaglandin primarily synthetic folliculitis, reassess regularly.
synthesis, inhibit steroids used as anti- hypertrichosis, Monitor patients
migration of inflammatory and anti- acneiform weight, BP, glucose and
macrophages, pruritic agents. eruptions, electrolyte levels.
leukocytes, and hypopigmentatio Monitor weight, input
fibroblasts at sites of n, perioral and output ratio, urine
inflammation, dermatitis, output and increasing
phagocytosis and allergic contact edema.
lysosomal enzyme dermatitis, Assess carefully for
VIII. NURSING CARE PLAN (ACTUAL)

CUES/DATA NURSING SHORT/LONG INTERVENTION RATIONALE EVALUATION

DIAGNOSIS TERM
OBJECTIVES
Subjective: Ineffective After 8 hours of -Monitor vital -to serve as a Goals are
“ Ubo ako ng ubo breathing Nursing signs baseline data partially met.
at hindi pattern Intervention, the After 8 Hours
makahinga ng related to patient’s breathing -to prevent of Nursing
maayos.”, as painful / pattern is -Avoidance of further irritation. interventions,
verbalized by the ineffective effectively irritants; smoking the patient’s
client. cough. maintained as allergens, and breathing
evidenced by: industrial pattern was
Objective: 1) eupnea chemicals -to thin mucus improved as
(+) dyspnea 2) minimal/no and make it evidenced by
(+) facial complaints -Increased based easier to eupnea and
grimace of dyspnea fluid intake expectorate. minimal
Pain scale: complaints of
7/10 -to improve air dyspnea
Respiratory Rate: -Deep breathing circulation and
13 bpm exercise breathing.

-if not indicated,

-position the a sitting position
client with proper allows for good
alignment for lung excursion
optimal and chest
breathing pattern expansion

-encourage the -this promotes

patient to clear airway patency
her own
secretions with
effective
coughing.
 Interdependent:
-Use of Meds:
Bronchodilators,
expectorants &
liquifying agents.
NURSING CARE PLAN (POTENTIAL)

CUES/DATA NURSING SHORT/LONG INTERVENTION RATIONALE EVALUATION

DIAGNOSIS TERM
OBJECTIVES
Objective: Risk foe Activity After 8 hours of -Observe and -close monitoring n/a
(+) inability to Intolerance r/t nursing document serves as a guide
perform or begin imbalance intervention, the response to for optimal
activity between oxygen client will be able activity progression of
(+)Abnormal supply and to maintain activity.
Heart Rate demand activity level
(+) Exertional within -Refrain from -patients with
discomfort or capabilities as performing limited activity
dyspnea evidenced by: nonessential intolerance need
1) normal procedures to prioritize tasks
heart rate
2) absence of -establish -motivation is
shortness guidelines and enhanced if the
of breath, goals of activity patient
weakness with the patient participates in
and and caregiver goal setting.
fatigue.
3) Patient -encourage -provides energy
verbalizes adequate rest conservation and
and uses periods recovery.
energy-
conservati -this promotes a
on -encourage sense of
techniques physical activity autonomy while
consistent with being realistic
the patient’s about
needs. capabilities.

-encourage -
verbalization of acknowledgemen
feelings t that living with
regarding activity
limitations intolerance is
both physically
and emotionally
difficult aids
coping