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NURSING CARE PROCESS

ASSESSMENT NURSINGDIAGNOSIS

RATIONALE GOAL NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective cues:Nahihirapan nasiya humingadahil sa plemahindi niyamailabas, grabenakasi ang ubo niyaneh as verbalizedby his mother

Objective cues:>difficulty of

breathing

>Wheezes on

both lung fields

>productive cough

whitish color

Ineffective airwayclearance related

to ineffective

cough and

retained

secretions.

The inflammatoryresponse to

infection causes

tissue edema and

exudates formation

in the lungs, the

inflammatory

response can

narrow andpotentially obstruct

bronchial passages

and alveoli.

Short Term:

After 4 hours of

nursing

interventions, the

client will be able

to maintain airway

patency.

Long Term:

After 1 day ofnursingintervention, the

client will be

able to

expectorate

retainedsecretions and

maintain normal

>Assessedrespiratory

movements and use

of accessory

muscles.

>Monitored vital

signs especially the

RR.

>Auscutated the

lung sounds, noting

areas of decreased

ventilation and

presence of

adventitious sounds.

>Use of accessorymuscles to breathe

indicates an abnormal

increase in work of

breathing.

>To obtain baseline

data.)

>Bronchial lung

sounds are commonly

heard over areas of

lung density or

consolidation.

Crackles are heard

when fluid is present.

The client

maintained airway

patency as

evidenced by

expectorating clea

secretions readily

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>nasal flaring

>restlessness

breathing

pattern.

>Monitored chest x

ray reports.

>Encouraged clientto increase fluid

intake.

>Advised the

realtives elevate the

head of bed at least

30 degrees.

>Assisted on

nebulizer treatment.

Nebulization done

as per doctors order

every 12 hours.

>These determine

progression of disease

process.)

>Hydration helpsdecrease the viscosity

of secretions,

facilitating

expectorations.

>Positioning facilitates

chest expansion and

respiratory efficiency

by reducing pressure

of abdominal organs

on diaphragm.

> Relaxes bronchial

and uterine smooth

muscle by acting on

betaadrenergic

receptors.

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>Chest tapping

performed after

each nebulization.

>Instructed the

client to have oral

care after each

nebulization.

>Provided

supplemental fluids

>Chest physiotherapy

helps to aid

immobilization of

secretions.

>Discharges from the

nebulizer are often foul

tasting and smelling.

>Fluids are regulated

to replace losses and

aid immobilization

secretions.

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ASSESSMENT NURSINGDIAGNOSIS

RATIONALE GOAL NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective Data:

Tatlong araw ngpabalik-balik anglagnat ng anak ko,hindimaganda angpakiramdamnya kayapinunta ko nasiya ditoas verbalized byhis mother

Objective Data:

T=38.7 C

Hyperthermiarelated toinflammatoryresponse.

Increase in body

temperature

greater than

normal range.

Entry of thepathogen in

circulatory system|

Regulation of toxinsin the body

|Release of pyrogen

|Stimulation of the

hypothalamus|

Increase oralteration of

thermoregulation|

Increase in bodytemperature

|Hyperthermia

After 2 hours of

effectivenursing intervention,

the patients

temperature will

decrease:

>Demonstratetemperature withinnormal range, from38.7 C to 36.5C-37.5C

>Demonstratebehaviors tomonitor andpromotenormothermia.

>Skin is cool totouch and lessflushness

>Identify underlyingcause/contributing

factors andimportance oftreatment, as well

Independent:

>Monitor coretemperature q 1 .

>Note presence orabsence ofsweatingas body attempts toincrease heat lossby evaporation.

>Increase oral fluidintake.

>Promote bed rest,encouragerelaxation skills and

>Temperature of38.9-41.1Csuggest acuteinfectiousdisease process.

>Evaporation isdecreased byenvironmentalfactors of highhumidity and highambienttemperature aswell as bodyfactorsproducing lossof ability tosweat.

>To supportcirculatingvolume andtissue perfusion.

>To reducemetabolicdemands/oxygenconsumption.

After 2 hours ofeffective nursingintervention, goalis met.

> Patientstemperature isalready in thenormal range;T=___ C

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treat underlyingcause, such as:

-Paracetamol325mg/tab 1 tab q6

>Administerreplacementfluids andelectrolytes tosupportcirculatingvolume andtissue perfusion

causes

>To supportcirculatingvolume andtissue perfusion

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ASSESSMENT NURSINGDIAGNOSIS

RATIONALE GOAL NURSINGINTERVENTION

RATIONALE EVALUATION

Subjective Data:

Madalas siyangdumumi halos tatlohangang limangbesesasverbalized by hismother.

Objective cues:

> Frequent waterystools

>Increasedperistalsis

Diarrhea related topresence of toxinsdue to poorpersonal hygiene.

Diarrhea is thepassage of looseand waterystools (morethan 3 bowelmovements perday) oftenassociated withgassiness,bloating, andabdominal pain.It may also beaccompanied bynausea,vomiting, andfever. Diarrhearesults to loss ofbody fluids andsalts leading todehydration ofvarying severity.Severedehydration maycause deathespecially inchildren

After 4 hoursof nursinginterventions,the patientwill reportreduction infrequency ofstools.

Independent:

> Observe andrecord stoolfrequency,characteristics,amount andprecipitatingfactors.

> Promote bed rest

> Provide bedsideCommode

> Identify foods and

> Helpsdifferentiateindividual diseaseandassesses severityofepisode

> Rest decreasesintestinal motilityandreduces metabolicrate.

> Urge to defecatemay occur withoutwarning anduncontrollable,increasing riskof incontinenceor falls if facilities

After 4 hours ofnursinginterventions, thepatient was able toreport reduction infrequency ofstools.

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fluids thatprecipitatediarrhea.

> Restart oral fluidintake gradually.Offer clear liquidshourly, and avoidcold fluids.

> Encourage to eatfoods like bananaand apple

> Avoid foods thatare oily, spicy andcaffeine.

Collaborative:> Administer anti-diarrheals as

prescribed by thephysician.

are not close athand

> Avoidingintestinalirritants

promotesintestinal rest

> Provides colonrest by omittingor decreasingstimulus of foods orfluids. Gradualconsumption ofliquids may preventcramping and

recurrence ofdiarrhea. Coldfluids can increaseintestinal motility.

> Fruits that arestool formed

> Foods that mayprecipitate gastriccramping

> Decreases G.I

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motility orperistalsis anddiminishesdigestivesecretions torelieve cramping

and diarrhea.

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DRUG STUDY

DRUG DOSAGE Mechanism ofAction

Indication Contraindication Side Effects NursingResponsibilities

Generic Name:Gentamicin Sulfate

BrandName:Garamycin

Child :IV/IM 67.5mg/kg/d in 34divideddosesIntrath ecal>3 mo, 12 mgpreservative freeq.d.

Chemical Effect:

>

Aminoglycoside;

actively transported

across the bacterial

cell membrane,

binds to a specific

receptor protein on

the 30 S subunit ofbacterial

ribosomes, and

interferes with an

initiation complex

between mRNA

(messenger RNA)

and the 30 S

subunit, inhibiting

protein synthesis.

DNA may be

misread, thusproducing

nonfunctional

Parenteral userestricted totreatment ofserious infectionsof GI,respiratory, andurinary tracts, CNS,bone, skin, and softtissue (includingburns) when otherless toxic

antimicrobialagents areineffective or arecontraindicated.Has been used incombination withother antibiotics.Also usedtopically for primaryand secondary skininfections and forsuperficial

infectionsof external eye andits adnexa.

History ofhypersensitivity toor toxic reactionwith anyaminoglycosideantibiotic. Safe useduring pregnancy(category C) orlactation is notestablishedBacterial and fungal

corneal ulcers havedeveloped duringtreatment withgentamicinophthalmicpreparations.

The most

frequently reported

adverse reactions

are ocular burning

andirritation upon drug

instillation,

>upset stomach

>vomiting

>fatigue

>pale skin

> Lab tests:Perform C&S andrenal function priorto first dose andperiodically duringtherapy; therapymay begin pendingtest results.

>Determinecreatinine

clearance andserum drugconcentrations atfrequent intervals,particularly forpatients withimpaired renalfunction,infants (renalimmaturity), olderadults, patientsreceiving high

doses ortherapy beyond 10d, patients with

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necrotic

enteritises may

absorb appreciable

quantities of the

drug. After IM

administration to

dogs and cats,

peak levels occur

from 1/2 to 1 hour

later.

Subcutaneous

injection results in

slightly delayed

peak levels and

with more

variability than after

IM injection.

Bioavailability from

extravascular

injection

(IM or SQ) is

greater than 90%.

60 min IVinfusion. Draw blood

specimens for troughlevels just before the

next IMor IV dose. Use

nonheparinized tubesto collect blood.