TRINITY UNIVERSITY OF ASIA

St. Luke’s College of Nursing

Name: Sanchez, Racelle Kaye D. Date: May, 18 2022

Section: 1NU04

CASE 1
C.S. is a 49-year-old male who goes to the health care provider because he is experiencing heartburn more frequently and it is keeping him
awake at night. He had asthma as a child. He is currently taking Mylanta as needed for heartburn.

Has had occasional heartburn about once a week for a few years, but in the last couple of months it has become more frequent and is now
occurring almost daily. Describes the pain as a burning pain in his sternal area that is relieved by drinking milk or taking Mylanta. Pain worsens
after he goes to bed and he has been having difficulty sleeping Denies any nausea or vomiting

Vital Signs

Temperature 98.4° F, Pulse 78, Respirations 16, Blood Pressure 124/70 Height 6’0”,weight 270 lbs Physical exam normal, no abdominal pain or
tenderness noted

Assessment Nursing Goal Nursing Rationale Expected Outcomes

Diagnosis Intervention

SUBJECTIVE CUES Chronic pain SHORT TERM INDEPENDENT INDEPENDENT GOAL MET
- Has had occasional related to acidic Within 2 hours of 1. Identify 1. These conditions After 1 month of
heartburn about once a irritation of nursing interventions, contributing factors can cause, precipitate, nursing interventions,
week for a few years, but mucosa as the patient will be to the pain and exacerbate the patient:
the last couple of months it evidenced by able to report relief persistent pain
has become more frequent reports of from pain

and is now occurring
almost daily
- Describes the pain as a
burning pain in his sternal
area that is relieved by
drinking milk or taking
Mylanta
- Pain worsens after he
goes to bed and he has been
having difficulty sleeping
- Denies any nausea or
vomiting
OBJECTIVE CUES
● Temperature = 98.4
F (36.9 C)
● Pulse = 78 bpm
● Respirations = 16
cpm
● Blood Pressure =
124/70 mmHg
● Height = 6’0”
● Weight = 270 lbs
(122.47 kg)
TRINITY UNIVERSITY OF ASIA
St. Luke’s College of Nursing
frequent LONG TERM - Was free from any
occurrences of Within 1 month of 2. Evaluate client’s 2. Individuals with occurrences of
heartburn nursing interventions, pattern of coping, and external locus of heartburn
the patient will be locus of control control may take little
able to: (internal or external) or no responsibility - Demonstrated and
for pain management initiated behavioral
- Be free from any modifications of
occurrences of lifestyle and appropriate
heartburn 3. Note lifestyle 3. Major effects of use of therapeutic
effects of pain chronic pain on the interventions
- Demonstrate and client’s life can
initiate behavioral include weight loss or - Achieved and
modifications of gain, sleep maintained an adequate
lifestyle and disturbances, and etc. body weight from 270
appropriate use of lbs to 180 lbs
therapeutic 4. Evaluate for 4. Psychological
interventions presence of/suspected factors may include - Verbalized increased
psychological (and are not limited sense of control and
- Achieve and disorders to) eating disorders. enhanced enjoyment of
maintain an adequate life
body weight from 5. Discuss pain 5. It may be that
270 lbs to 180 lbs management goals while pain cannot be
and review patient resolved, it can be
- Verbalize increased expectations versus significantly reduced
sense of control and reality. or managed to the
enhanced enjoyment degree that client can
of life participate in desired
or needed life
activities, improving
quality of life
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Physical Examination: DEPENDENT DEPENDENT

1. Administer 1. Provides analgesic
- Normal acetaminophen (e.g. effect
- No abdominal pain Tylenol) as
or tenderness noted prescribed

2. Administer proton 2. Increases

pump inhibitor drugs gastric pH, reduces
(e.g., omeprazole) as gastric acid
prescribed production.

COLLABORATIVE COLLABORATIVE
1. Refer the patient to 1. For proper diet and
dietitian more comprehensive
treatment for the
patient’s condition

Source/s:

Aprn Bc, M. D. E., Crrn, M. M. R. M. F., & Bsn Rn, A. M. C. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
(Fifteenth ed.). F.A. Davis Company.

Bs, R. K. J., RPh, & Ccrn, H. K. R. B. (2020). Saunders Nursing Drug Handbook 2021, 1e (1st ed.). Saunders.

Cherney, K. (2020, April 9). Antacid Treatment for GERD. Healthline. https://www.healthline.com/health/gerd/antacids
 TRINITY UNIVERSITY OF ASIA
St. Luke’s College of Nursing

Seltzer, C., MD. (2018, November 27). BMI Chart for Men & Women: Is BMI Misleading? BuiltLean. https://www.builtlean.com/bmi-chart/

Vera, M. B. (2022, March 18). 7 Gastroesophageal Reflux Disease (GERD) Nursing Care Plans. Nurseslabs.
https://nurseslabs.com/gastroesophageal-reflux-disease-gerd-nursing-care-plans/

Case 2

E.M., a 5-month-old female, presents to the emergency department (ED) with respiratory distress, hypoxia, and fever. Her parents state that she
has had mild cold symptoms for a few days. She has fed poorly over the last few days with a decreased number of wet diapers. You take her vital
signs and complete an initial assessment.

Vital Signs

Blood pressure 130/72 mm Hg

Respiratory rate 83 breaths/min Heart rate 188 beats/min

Temperature 38.4 ° C (101.1° F) SaO2 88% on room air

Weight 8 kg

Assessment Nursing Diagnosis Goal Nursing Rationale Expected Outcomes

Intervention

SUBJECTIVE CUE Ineffective Airway SHORT TERM INDEPENDENT INDEPENDENT GOAL MET
Her parents Clearance related to After 2 hours of 1.Monitor and note 1. To assist in 1. After implementing a
 TRINITY UNIVERSITY OF ASIA
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verbalized, “For a Respiratory distress nursing intervention, the patient’s vital creating an accurate series of nursing
few days, my baby is secondary to the patient will be signs. diagnosis and interventions, goals are
still sick and not pneumonia as able to maintain monitor the met. The patient was able
eating anything.” evidenced by airway patency and effectiveness of to:
hypoxia, mild cold improved airway medical treatment. - Demonstrate
symptoms, and SpO2 clearance as proper breathing.
level of 88% evidenced by having - Assess and - Pulse - Maintain clear
a respiratory rate monitor the oximetry is a and open airways
between 30 - 60 bpm, oxygen helpful tool as evidenced by
OBJECTIVE CUES oxygen saturation of saturation to detect normal breath
95% and above, and using pulse alterations in
sound, normal
● BP – 130/72 the patient will oximetry. oxygenation
respiratory rate.
mmHg demonstrate ease of initially.
breathing. - Maintain normal
● RR – 83 bpm
oxygen
● HR – 188
- Assess - In most saturation.
bpm
airway cases, - Show free from
● T – 38.4 C
patency. maintaining mild cold
● O2 sat – 88% airway symptoms and
● Difficulty LONG TERM patency is a fever.
breathing After 2 days of priority. - Demonstrate
● Poor activity nursing intervention, proper eating and
is noted the patient will be - Auscultate - Abnormal uses wet diapers
able to maintain an lungs for breath sounds adequately.
effective breathing normal and may indicate
pattern and free from adventitious that there is
mild cold symptoms sounds. fluid and
as evidenced by mucus
relaxed breathing at accumulation
normal rate and
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St. Luke’s College of Nursing

depth, demonstrate - Assess - Change in the

good activity, and fed respirations respiration
properly. and note for may indicate
its rate, that the
quality, respiratory
pattern, system is
depth, and compromised
use of .
accessory
muscles.

2. Elevate the head of 2. Proper positioning

the bed and assist the helps improve the
patient in a Semi – expansion of the
Fowler’s position. lungs, enabling the
patient to breathe
more effectively.

3. Monitor the arterial 3. Arterial Blood Gas

blood gases (ABG). monitors the patient’s
oxygenation and
ventilation status.

4. Assess the 4. Airway clearance

hydration status of is impaired with poor
the patient (skin hydration and
turgor, mucous subsequent secretion
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membranes, tongue). thickening.

5. Instruct parents or 5. Hydration

guardians about the facilitates easy
need for adequate elimination of
fluid intake even after secretions.
hospital discharge.

DEPENDENT DEPENDENT
1. Suction secretions 1. Suctioning helps
and nebulize as the patient to cough
needed. out secretions
properly due to
weakness and mucus
production.

2.Administer 2. A variety of
medications as medications are
prescribed, such as prepared to manage
antibiotics, specific problems.
bronchodilators, Most promote
expectorants, noting clearance of airway
effectiveness and side secretions and may
effects. reduce airway
resistance.
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COLLABORATIVE COLLABORATIVE
1. Coordinate with a 1. Chest
therapist for chest physiotherapy
physiotherapy and includes the
nebulizer techniques of postural
management as drainage and chest
needed and indicated. percussion to
mobilize secretions
from smaller airways
that cannot be
eliminated by means
of coughing or
suctioning.

Source/s:

Acute Respiratory Distress Syndrome ARDS for nurses. (2022, March 7). NurseStudy.net.
https://nursestudy.net/ards-nursing-diagnosis/

Wayne, G., BSN, & R.N. (2016, August 22). Ineffective Airway Clearance – Nursing Diagnosis & Care Plan. Nurseslabs.
https://nurseslabs.com/ineffective-airway-clearance/#nursing_interventions_for_ineffective_airway_clearance