NURSING CARE PLAN

ASSESSMENT DATA (Subjective & Objective Cues) Problem # 1 SUBJECTIVE: “Sakit akong tiyan ug kalipongon ko”, as stated by the px

NURSING DIAGNOSIS (Problem and Etiology) Nausea related to gastric pain as manifested by body malaise

GOALS AND OBJECTIVES After 1 hour of nursing intervention the patient will be able to: Be free of nausea Manage chronic nausea, as evidenced by acceptable level of dietary intake

NURSING INTERVENTIONS AND RATIONALE INDEPENDENT: 1. Assess for presence of conditions of the GI tract. Dietary changes may be sufficient to decrease frequency of nausea 2. Check vital signs for children and older clients and note sign of dehydration. Nausea may occur in the presence of postural hypotension/fluid volume deficit 3. Have client try dry foods such as crackers and toast before rising when it occurs in the morning or throughout the day 4. Encourage client to eat small meals spaced throughout the day instead of large meals so stomach

EVALUATION Goals Met After 1 hour of nursing intervention the patient able to be free of nausea, had managed chronic nausea, and maintained weight.

OBJECTIVES:   pallor weakness pain scale: 6/10  Maintain weight as possible

Administer antiemetic on regular schedule before/ during and after administration of antineoplastic agents to prevent/ control side effects of medication NURSING CARE PLAN .doesn’t feel excessively full COLLABORATIVE: 1.

as well as signs/ symptoms requiring further NURSING INTERVENTIONS AND RATIONALE INDEPENDENT: 1. decreased level of platelet as nursing intervention the    Warm to touch . Assist with internal cooling methods to treat malignant hyperthermia to promote rapid core cooling 3. within normal range  Be free of complications such as irreversible brain and acute renal failure  Identify underlying cause/ contributing factors and importance of treatment. Discuss importance of adequate fluid intake to prevent dehydration COLLABORATIVE: 1.ASSESSMENT DATA (Subjective & Objective Cues) Problem # 2 SUBJECTIVE: “Sakit akong ulo usahay mao ng malipong na dayon ko”. orally as ordered EVALUATION Goals Met After 30 minutes of nursing interventions patient able to maintained normal body core temperature. Administer antipyretics such as Paracetamol. Monitor laboratory studies such as CBC’s. urinalysis and coagulation profile 2. Promote surface cooling by means of undressing. as stated by the px OBJECTIVES: Body temp: 37. 8°C Flushed skin NURSING DIAGNOSIS (Problem and Etiology) Hyperthermia related to manifested by increased body temperature  GOALS AND OBJECTIVES After 30 minutes of patient will be able to: Maintain core temp. cool environment and fans and tepid sponge baths 2. glucose. been free of complications and had demonstrated behaviors that monitored and promoted normothermia.

evaluation  Demonstrate behaviors to monitor and promote normothermia NURSING CARE PLAN ASSESSMENT DATA (Subjective & Objective NURSING DIAGNOSIS (Problem and Etiology) GOALS AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION .

00 (Reference Value150.Cues) Risk for infection related to Problem #3 Objective cues: >latest CBC result of HCT count is 46.5 % (34. frequency) Generic Name: MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG NURSING RESPONSIBILITIES/ PRECAUTIONS Thought to produce ♥ Fever reduction ♥ Hypersensitivity to ♥ Hematologic: hemolytic ♥ Monitor for s/s of: . DRUG STUDY DRUG ORDER (Generic name. route. *Dependent: 4)Administer/monitor medication regimen as prescribed. patient resistance against infection will be maintained/regained as evidenced by: >rise of WBC count to the normal range of 5. dosage. 2)cleanse insertion sites with cotton bals 3) Instructing mother to cleanse the nipple woth water before and after breastfeeding.00390. brand name.000 >improved nutritional status >absence of other nosocomial infections RATIONALE Independent: 1) Stress proper hygiene techniques to the SO.00010.00 X10 ٨ 9/L) altered immune response secondary to Dengue Hemorrhagic Fever At the end 8 hours shift.000 >improved nutritional status >absence of other nosocomial infections Goals partially met. After 8 hours shift of intervention.00010.10-44 %) >Platelet 135. patient resistance against infection had been maintained/regained as evidenced by: >rise of WBC count to the normal range of 5. classification.

g. leucopenia ♥ pancytopenia. ♥ The drug should not be taken with other medication (e. especially in individuals with poor nutrition or who have ingested alcohol over prolonged periods o poisoning.paracetamol Brand Name: Biogesic Classification: Antipyretic Dosage: 500mg (250mg/5ml) 10ml Route: PO (syrup) Frequency: Q4 if temp > 37. ♥ This medication should not be used without medical direction for: .5 analgesia by blocking pain impulses of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. ♥ Temporary relief of mild to moderate pain ♥ Generally as substitute for aspirin when the later is no tolerated acetaminophen or phenacin ♥ Long term alcohol use (may cause hepatotoxicity) ♥ anemia. usually from accidental ingestion or suicide attempts o Potential abuse from psychological dependence (withdrawal has been associated with restless and excited responses). neutropenia ♥ Hepatic: jaundice ♥ Metabolic: hypoglycemia ♥ Skin: rash. The drug may relieve fever through central action in the hypothalamic heatregulating center. urticaria Children < 3 years old unless directed by a physician ♥ Malnutrition ♥ Thrombocytopenia ♥ Arthritic or rheumatoid conditions affecting children < 12 years old hepatotoxicity. even with moderate acetaminophen doses. overdosing and chronic use can cause liver damage without consulting a physician ♥ Advise client not to self medicate for pain more than 10 days (5 days in children) without consulting a physician. cold preparations) containing acetaminophen without medical advice.

fever persisting longer than 3 days. fever over 39. or recurrent fever.5 ーC (103ーF). ♥ Do not give children more than 5 doses in 24 hrs unless prescribed by a physician DRUG ORDER MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS NURSING RESPONSIBILITIES/ PRECAUTIONS .

Generic: Ranitidine Brand: Zantac Classification: Antacids Dosage: 25 mg Route: IVTT Frequency: Q8h Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells. neutropenia. thrombocytopenia Misc: hypersensitivity reactions ♥ assess for abdominal pain and frank or occult blood in the stool. emesis or gastric aspirate ♥ may cause increase in serum transaminases and serum creatinine ♥ may cause false positive results for urineprotein. resulting in inhibition of gastric acid secretion ♥ short term treatment of active duodenal ulcers and benign gastric ulcers ♥ maintenance therapy for duodenal and gastric after healing of active ulcers ♥ some products contain alcohol and should be avoided in patients with known intolerance CNS: confusion. drug-induced hepatitis. ♥ renal impairment diarrhea. drowsiness. nausea ♥ hepatic impairment ENDO: gynecomastia acute porphyria Hemat: anemia. hallucinations CV: arrythmias GI: constipation. test with sulfosalicylic acid ♥ inform patient that this may cause dizziness and drowsiness inform patient that increased fluid and fiber intake and exercise may minimize constipation . dizziness.

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