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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.