Patient #5: Acute Respiratory Failure

F, 48

DIAGNOSIS ANALYSIS GOAL NURSING RATIONALE EVALUATION

INTERVENTIONS
The patient was able to
Ineffective Respiratory The patient will breath without difficulty.
breathing pattern failure can be be able to 1. Obtain For comparison
seen with a breathe more baseline of result, and to
O: change in easily and data and determine
The patient is respiratory rate, without any refer effectiveness of
lying restlessly on change in difficulty abnormal the intervention
her bed. normal vital given.
abdominal and signs.
The client has thoracic This provides
slow deep patterns for 2. Place maximum lung
respirations. inspiration and patient in expansion for
expiration, a semi- the patient and
The patient change in depth fowler’s facilitates
appears to be of ventilation position. better way of
pale. (Vt), and breathing.
respiratory
S: alternans. 3. Ensure The appropriate
The patient Breathing that amount of
complains of pattern changes oxygen oxygen is
difficulty of may occur in a delivery continuously
breathing. multitude of system is delivered so
The patient asks cases from applied to that the patient
for some air. hypoxia, heart the does not
failure, and/or patient. desiderate.
M: pain, cognitive
BP 140/90 impairment and 4. If
RR 24 anxiety, ineffective
PR 89 metabolic . Report
Temp 36.8 abnormalities to the
like DM nurse in
charge.
Drug Name Dosage Classification Indication Contraindication Side Effects Nursing Responsibilities

Paracetamol 1.2 mL antipyretics, Mild pain Hypersensitivity to Hema: hemolytic anemia, BEFORE:
q 4 hr nonopioid Fever acetaminophen or neutropenia, leukopenia, ~ Advise parents or
PRN analgesics phenacetin; use with pancytopenia. caregivers to check
od alcohol. Hepa: jaundice concentrations of liquid
Metabolic: hypoG preparations. Errors have
GI: HEPATIC FAILURE, resulted in serious liver
HEPATOTOXICITY damage.
(overdose)GU: renal failure (high ~ Assess fever; note
doses/chronic use). presence of associated
Derm: rash, urticaria. signs (diaphoresis,
tachycardia, and
malaise).
DURING:
~ Adults should not take
acetaminophen longer
than 10 days and children
not longer than 5 days
unless directed by health
care professional.
~ Advise mother or
caregiver to take
medication exactly as
directed and not to take
more than the
recommended amount.
AFTER:
~ Advise patient to
consult health care
professional if discomfort
or fever is not relieved by
routine doses of this drug
or if fever is greater than
39.5°C (103°F) or lasts
longer than 3 days.

Omeprazole 20mg Antisecretory Short-term Contraindicated with - CNS: Headache, dizziness, - Administer before
tab OD agent treatment of hypersensitivity to asthenia, vertigo, meals. Caution
active duodenal omeprazole or its insomnia, apathy, anxiety, patient to swallow
Proton pump ulcer; First-line components; paresthesias, dream capsules whole—
inhibitor therapy in Use cautiously with abnormalities not to open, chew,
treatment of pregnancy, lactation. - Dermatologic: Rash, or crush them.
heartburn or inflammation, urticaria, - Arrange for