SAN PABLO COLLEGES
COLLEGE OF NURSING
NURSING CARE PLAN
Patient’s Name: GINA CARPIO
Nursing Diagnosis: Impaired Gas Exchange r/t changes associated with the condition of alveolar-capillary changes and increased pulmonary resistance as evidenced by abnormal breathing
pattern (dyspnea) and irritability
Reference: NANDA 16TH Edition (Doenges, Moorhouse, Murr) -Pulmonary Hypertension, p.1200
ASSESSMENT
PLANNING/GOAL
Desired Outcome
Pertinent Data:
Patient will:
Subjective:
● “Hindi ako makahinga nang
maayos, malabo rin ang akin
paningin at palaging masakit
ang ulo ko pagkagising” as
verbalized by the patient.
Objective:
● RR: 25 bpm (Tachypnea)
● HR: 120 bpm (Tachycardia)
● Arterial ph: 7.23 (Acidosis)
● PaCO2: 50 mmhg
● BP: 150/100
● Confusion, Irritable mood
●
Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by
arterial blood
gases (ABGs)
within client’s
unusual
parameters and
absence of
symptoms of
respiratory
distress
IMPLEMENTATION
Nurse will:
RATIONALE
Reason for the
intervention
Why:
●
Note the presence of
conditions that can
cause or be
associated in some
way with gas
exchange problems.
●
To assess
causative/contributing
factors
●
Note respiratory rate,
depth, use of
accessory muscles,
pursed-lip breathing,
and areas of
pallor/cyanosis, such
as peripheral
(nailbeds) versus
central (circumoral) or
general duskiness.
●
To provide insight into
the work of breathing,
adequacy of alveolar
ventilation, and
potential for
pulmonary and
cardiac compromise
EVALUATION
Expected
Outcome
Positive result
The patient was able:
●
Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by
arterial blood
gases (ABGs)
within client’s
unusual
parameters and
absence of
symptoms of
respiratory
distress
GOAL MET
Yes
No
●
Observe for dyspnea
on exertion or
gasping, changing
positions frequently,
and tendency to
assume the
three-point position
(bending forward
while supporting self
by placing one hand
on each knee.
●
To ease breathing
●
Encourage frequent
position changes and
deep-breathing and
coughing exercises.
Use incentive
spirometer, chest
physiotherapy, and
intermittent
positive-measure
breathing, as
indicated
●
To promote optimal
chest expansion,
mobilization of
secretions, and oxygen
diffusion.
●
Assess the level of
consciousness and
mentation changes
●
A decreased level of
consciousness can be
an indirect
measurement of
impaired oxygenation,
but also impairs one's
ability to protect the
airway that leads to a
further effect in
oxygenation)
●
Note client reports of
restlessness and
headache on arising.
Assess for energy
level and activity
intolerance, noting
reports or evidence of
fatigue, weakness,
and problems with
sleep
●
Symptoms mentioned
are associated with
diminished
oxygenation
●
Elevate the head of
the bed and position
the client
appropriately.
●
Elevation or upright
position facilitates
respiratory function by
gravity.
●
Provide airway
adjuncts and suction,
as indicated.
●
To clear or maintain
open airway, when
client is unable to
clear secretions, or to
improve gas diffusion
when the client is
showing desaturation
of oxygen by oximetry
or ABGs
●
Administer
medications as
indicated (e.g.,
inhaled and systemic
glucocorticosteroids,
antibiotics,
bronchodilators,
methylxanthines, and
vasodilators)
●
To prevent and control
symptoms, reduce
frequency and severity
of exacerbations, and
improve exercise
tolerance.
●
Verbalize
understanding
of causative
factors and
appropriate
interventions
●
Review other
pertinent laboratory
data (e.g., ABGs, CBC,
chest x-rays)
●
To monitor the
progress of the client
●
Discuss implications
of smoking related to
the illness or
condition each visit.
Encourage the client
and significant
other(s) to stop
smoking.
Instruct the caregiver
to avoid the use of a
face mask in an
elderly emaciated
client
●
To reduce health risks
and/or prevent further
decline in lung
function
●
Mask can increase the
client’s agitation
●
Instruct the client to
keep the environment
allergen and pollutant
free
●
To reduce the irritant
effect of dust and
chemicals on airways.
●
Instruct the client to
maintain fluid intake,
but avoid fluid
overload
●
Fluid intake: for
mobilization of
secretions
Fluid overload: may
increase pulmonary
congestion
Instruct the use of
relaxation and
stress-reduction
techniques, as
appropriate.
●
●
●
Participate in a
treatment
regimen (e.g,
breathing
exercises,
●
●
To promote effective
breathing.
●
Verbalize
understanding of
causative factors
and appropriate
interventions
●
Participate in a
treatment
regimen (e.g,
breathing
exercises,
effective
coughing, use of
oxygen) within
the level of
ability or
situation
⮚
●
Reinforce the need
for adequate rest,
while encouraging
activity and exercise
(upper and lower
extremity strength
and flexibility training,
endurance)
●
To decrease dyspnea
and improve quality of
life
●
Emphasize the
importance of
nutrition
●
To improve stamina
and reduce the work
of breathing
●
Discuss home oxygen
therapy and safety
measures, as
indicated.
●
To ensure the client’s
safety, especially when
used in the very
young, fragile elderly,
or when cognitive or
neuromuscular
impairment is present.
If the client goal was not met, briefly describe why and what step would be taken next:
effective
coughing, use of
oxygen) within
the level of
ability or
situation
SAN PABLO COLLEGES
COLLEGE OF NURSING
DRUG STUDY
Reference: Nursing Drug Handbook 2021 (Saunders)
Patient Name: GINA CARPIO
Generic- Brand Name
Generic Name: Atenolol
Brand Name: Tenormin
Route/Dosage
● Oral: ADULTS:
Initially, 25–50 mg
once daily. After
1–2 wks, may
increase dose up to
100 mg once daily.
● ELDERLY: Usual
initial dose, 25
mg/day.
●
Classification/Indication
CLASSIFICATION:
Beta-Adregenic blocker
(Anti-hypertensie,
Antiarrhythmic, antianginal)
INDICATION:
● Reduces heart rate
and blood pressure
and decreases
myocardial
contractility
Side Effects/ Adverse Reaction
Side Effects:
Atenolol is generally well tolerated, with mild and
transient side effects.
Frequent: Hypotension manifested as cold
extremities, constipation or diarrhea, diaphoresis,
dizziness, fatigue, headache, and nausea.
Occasional: Insomnia, flatulence, urinary
frequency, impotence or decreased libido,
depression.
Rare: Rash, arthralgia, myalgia, confusion
(esp. in the elderly), altered taste.
Nursing Consideration
●
●
●
●
Adverse Reaction:
● Overdose may produce profound bradycardia
and hypotension.
● Abrupt withdrawal may result in diaphoresis,
palpitations, headache, and tremors.
● May precipitate HF, MI in pts with cardiac
disease; thyroid storm in pts with
thyrotoxicosis; peripheral ischemia in pts
with existing peripheral vascular disease.
● Hypoglycemia may occur in previously
controlled diabetes.
● Thrombocytopenia (unusual bruising,
bleeding) occurs rarely.
●
●
Assess B/P, apical pulse
immediately before drug is
administered (if pulse is 60/min
or less, or systolic B/P is less than
90 mm Hg, withhold medication,
contact physician).
Monitor B/P for hypotension,
pulse for bradycardia, respiration
for difficulty in breathing, ECG.
Monitor daily pattern of bowel
activity, stool consistency.
Assess for evidence of HF:
dyspnea (particularly on exertion
or lying down), nocturnal cough,
peripheral edema, distended
neck veins.
Monitor I&O (increased weight,
decreased urinary output may
indicate HF). Assess extremities
for pulse quality, changes in
temperature (may indicate
worsening peripheral vascular
disease).
Assist with ambulation if dizziness
occurs.
Patient Teaching
●
●
●
●
●
●
●
●
●
Do not abruptly discontinue
medication.
Compliance with therapy
essential to control
hypertension, angina.
To reduce hypotensive effect,
go from lying to standing
slowly.
Avoid tasks that require
alertness, motor skills until
response to drug is
established.
Advise diabetic pts to monitor
blood glucose carefully (may
mask signs of hypoglycemia).
Report dizziness, depression,
confusion, rash, unusual
bruising/bleeding.
Outpatients should monitor
B/P, pulse before taking
medication, following correct
technique.
Restrict salt, alcohol intake.
Therapeutic antihypertensive
effect noted in 1–2 wks.
SAN PABLO COLLEGES
COLLEGE OF NURSING
DRUG STUDY
Generic- Brand Name
Generic Name: Clonidine
Brand Name: Catapres
Route/Dosage:
● PO: ADULTS:
(Immediate-Release):
Initially, 0.1 mg twice a day.
Increase by 0.1 mg/day at
wkly intervals.
Dosage range:0.1–0.8
mg/day in 2 divided doses.
Maximum: 2.4 mg/day.
Usual dose range: 0.1–0.2
mg twice daily.
ELDERLY: Initially, 0.1 mg at
bedtime. May increase
gradually.
Classification/Indication
CLASSIFICATION: Alpha-androgenic
agonist, Anti-hypertensive
Side Effects/ Adverse Reaction
Side Effects:
● Dry mouth
● Drowsiness
● Dizziness
● Sedation
● Constipation.
INDICATION:
● Used alone or together with
other medicines to treat
high blood pressure
Adverse Reaction:
(hypertension)
● Overdose produces profound
hypotension, irritability,
bradycardia, respiratory
depression, hypothermia, miosis
(pupillary constriction),
arrhythmias, apnea.
● Abrupt withdrawal may result in
rebound hypertension
associated with nervousness,
agitation, anxiety, insomnia,
paresthesia, tremor, flushing,
diaphoresis.
● May produce sedation in pts
with acute CVA.
Nursing Consideration
●
●
●
Obtain B/P immediately before
each dose is administered, in
addition to regular monitoring
(be alert to B/P fluctuations).
Monitor daily pattern of bowel
activity, stool consistency.
If cloNIDine is to be withdrawn,
discontinue concurrent
beta-blocker therapy several
days before discontinuing
cloNIDine (prevents cloNIDine
with drawal hypertensive
crisis). Slowly reduce cloNIDine
dosage over 2–4 days.
Patient Teaching
●
●
●
●
●
Sugarless gum, sips of water
may relieve dry mouth.
Avoid tasks that require
alertness, motor skills until
response to drug is
established.
To reduce hypotensive
effect, rise slowly from lying
to standing.
Skipping doses or
voluntarily discontinuing
drug may produce severe
rebound hypertension.
Avoid alcohol.
SAN PABLO COLLEGES
COLLEGE OF NURSING
DRUG STUDY
Generic- Brand Name
Generic Name: Hydralazine
Brand Name: Apresoline
Route/Dosage:
PO: ADULTS, ELDERLY: Initially, 10
mg 4 times/day for first 2–4 days.
May increase to 25 mg 4 times/day
balance of first wk. May increase by
10–25 mg/dose gradually q2–5 days
to 50 mg 4 times/day.
Usual range: 100–200 mg/day in
2–3 divided doses.
IV, IM: ADULTS, ELDERLY: Initially,
10–20 mg/dose q4–6h. May
increase to 40 mg/dose.
Classification/Indication
CLASSIFICATION: Vasodilator
INDICATION:
● Management for moderate
to severe hypertension
Side Effects/ Adverse Reaction
Nursing Consideration
Side Effects:
Occasional: Headache, anorexia, nausea,
vomiting, diarrhea, palpitations,
tachycardia, angina pectoris.
Rare: Constipation, ileus, edema,
peripheral neuritis (paresthesia),
dizziness, muscle cramps, anxiety,
hypersensitivity reactions (rash, urticaria,
pruritus, fever, chills, arthralgia), nasal
congestion, flushing, conjunctivitis.
BASELINE ASSESSMENT
● Obtain B/P, pulse
immediately before each
dose, in addition to
regular monitoring (be
alert to fluctuations).
INTERVENTION/EVALUATION
● Monitor B/P, pulse.
● Monitor for headache,
palpitations,
tachycardia.
● Assess for peripheral
edema of hands, feet.
Adverse Reaction:
● High dosage may produce lupus
erythematosus–like reaction
(fever, facial rash, muscle/joint
aches, glomerulonephritis,
splenomegaly).
● Severe orthostatic hypotension,
skin flushing, severe headache,
myocardial ischemia, cardiac
arrhythmias may develop.
● Profound shock may occur with
severe overdosage.
Patient Teaching
●
●
●
To reduce the hypotensive
effect, go from lying to
standing slowly.
Report muscle/joint aches,
fever (lupus-likereaction),
flu-like symptoms.
Limit alcohol use.
SAN PABLO COLLEGES
COLLEGE OF NURSING
HEART FAILURE & DEEP VEIN THROMBOSIS
NCP & DRUG STUDY
NCM 112
submitted by:
Kristele Anne B. Abinsay