VII.

DRUG STUDY DRUG Date ordered: August 04, 2010 Generic name: Dexamethasone Brand name: -Classification: Anti inflammatory Glucocorticoid Dosage: 1.8 mg IV q6 INDICATION ACTION SIDE/ADVERSE EFFECTS  CNS: euphoria, insomnia, psychotic behavior, pseudotumor cerebri, vertigo, headache, paresthesia, seizures, depression.  CV: hypertension, edema, arrythmias, thromboembolism.  EENT: cataracts, glaucoma.  GI: peptic ulceration, GI irritation, increased appetite, pancreatitis, nausea, vomiting.  GU: increase urine glucose, and calcium levels  Metabolic: hypokalemia, hyperglycemia  Musculoskeletal: muscle weakness  Skin: Delayed wound healing  Other: Susceptibility to infections. NURSING CONSIDERATION 1. Determin e whether patient is sensitive to other corticosteroids 2. Most adverse reactions to corticosteroids are dose-or durationdependent. 3. For better results and less toxicity, give once daily dose in morning. 4. Give oral dose with food when possible. Patient may need drugs to prevent GI irritation. 5. Give I.M injection deeply into gluteal muscle. Rotate injection sites to prevent muscle atrophy. Avoid subcutaneous PATIENT TEACHINGS 1. Tell patient not to stop drug abruptly or without prescriber’s consent. 2.Instruct patient to take drug with food or milk. 3.Teach patient signs and symptoms of adrenal insufficiency; fatigue, muscle weakness, join pain, fever, anorexia. 4.Warn patient on long term therapy about cushingoid effects(moon face, buffalo hump) 5.Warn patient about easy bruising. 6.Advise patient to avoid exposure to infections (such as

Specific The patient was given Adjunctive treatment dexamtehasone 1.8 mg in bacterial meningitis. through IV every 6 hours to decreases General inflammation, mainly by Cerebral edema stabilizing leukocyte Allergic and lysosomal membranes; inflammatory suppresses immune conditions response; stimulates Shock bone marrow; and Tuberculosis influences protein, fat meningitis and carbohydrate metabolism.

injection because atrophy and sterile abscesses may occur. 6. Alwats adjust to lowest effective dose 7. Monitor patient weight, blood pressure, and electrolyte levels. 8. Monitor patient for cushingoid effects, including moon face, buffalo hump, thinning of hair.

measles and chickenpox) and to notify prescriber if such exposure occurs.

SIDE/ADVERSE EFFECTS  Allergic Reactions  Disturbances of vestibular function  Facial Parathesia  Nausea and Vomiting NURSING CONSIDERATION 1. Evaluate patient’s hearing before therapy. 3. Encourage to take adequate amount of fluids. brucellosis ACTION The patient was given Streptomycin 300 mg OD M-W-F to treat and destroy bacteria in body by inhibiting protein synthesis in bacterial cell by binding directly by 30S ribosomal subunit. preferably water. . Monitor for dehydration 5. causing inaccurate peptide sequence to form in protein chain. 3. 2010 Generic Name: Streptomycin Brand Name: -Classification: Antituberculosis agent Dosage: 300 mg OD M-W-F ANST INDICATION Specific mycobacterial infections General Part of combination therapy of active tuberculosis. used in combination with other agents for treatment of streptococcal or enterococcal endocarditis. 4. Assess the patient for any previous adverse or sensitivity reaction 2. Emphasize the need for blood testing. tularemia. Monitor the patient’s intake-output ratio. resulting in bacterial death. Instruct the patient’s watcher to report adverse reaction to nurse at once. 2. plague. rash. Assess for any allergic reaction. PATIENT TEACHINGS 1.DRUG Date ordered: August 4.

2010 Generic Name: Meropenem Brand Name: -Classification: Antibiotic Dosage: 500mg TIV q8⁰ ANST INDICATION Specific For pneumonia and meningitis General Treatment of infection caused by single or multiple susceptible bacteria sensitive to meropenem. Pneumonia including hospital acquired. 3. Advise watcher to report loose stool to prescriber. 2. gynecological and skin and soft tissue infection. meningitis. neutropenia. The bactericidal interferes with bacterial cell wall replication of susceptible organism which it readily penetrates the cell wall of the most gram positive and gram negative bacteria to reach penicillinbinding protein targets where it inhibits cell wall synthesis to render the cell wall osmoticaly unstable. Monitor patient’s fluid balance and weight carefully. SIDE/ADVERSE EFFECTS  Seizure. intraabdominal infections. septicemia. . In patients with CNS disorders such as bacterial meningitis drug may cause seizures.DRUG Date ordered: August 4. headache and pain  Pseudomembranous colitis  Apnea  Anaphylaxis  Thrombophlebhitis NURSING CONSIDERATION 1. urinary tract. ACTION The patient was given Meropenem 500mg TIV q8⁰ to inhibit bacterial growth and replication. If seizures occur stop drug infusion. PATIENT TEACHINGS 1. 2. Instruct the patient’s watcher to report adverse reaction to nurse at once.

To prevent tubercle bacilli in those exposed to tuberculosis (TB) or those with positive skin test results whose chest x-rays and bacteriologic study results indicate non progressive TB. . 2010 Generic Name: Isoniazid Brand Name: -Classification: Antituberculosis agent Dosage: 200mg/5ml: 3ml OD PO INDICATION Actively growing tubercle bacilli. ACTION The patient was given Isoniazid 200mg/5ml: 3ml OD to treat or inhibit synthesis of meningococcal infection and bacterial growth. bactericidal.DRUG Date ordered: August 4. SIDE/ADVERSE EFFECTS  Seizures  Toxic Enchepalopathy  Memory impairment  Unusual weakness or fatigue  Yellow skin or eyes  Dark urine NURSING CONSIDERATION 1. Always give drug with other antituberculitics to prevent development of resistant organisms 2. Notify health care providers if signs and symptoms of liver impairment occur. Instruct patient to take drug exactly as prescribed. warn about stopping drug without prescriber’s consent 2. Explain the importance of taking the drug at the right time and amount. It may inhibit cell wall biosynthesis by interfering with lipid and DNA synthesis. Monitor hepatic function for changes 3. Give pyridoxine specially to malnourished patients PATIENT TEACHINGS 1. 4. Take drug before meals 3.

which impairs mos) of short-course antiRNA TB treatment. Monitor hepatic function. non-mycobacterial infections. bactericidal leprosy in combination with other antibiotics/chemotherapeutic agents. Warn patient that the drug can turn urine into red to orange. 2.DRUG Date ordered: August 4. 2010 Generic Name: Rifampicin Brand Name: -Classification: Antituberculosis agent Dosage: 200mg/5ml: 4. brucellosis in combination with a tetracycline . 2. For DNA-dependent RNA continuation phase (for 4 polymerase.5ml OD to treat or inhibit General synthesis of Maintenance treatment of all meningococcal forms of pulmonary and infection and bacterial extra-pulmonary growth by inhibiting tuberculosis (TB). PATIENT TEACHINGS 1. 3. Advise patient to avoid alcohol during drug therapy. Give the drug one hour before taking. The patient was given Rifampicin 200mg/5ml: 4. 3. visual disturbances. exudative conjunctivitis NURSING CONSIDERATION 1.5ml OD PO INDICATION Specific Prevention of meningococcal meningitis ACTION SIDE/ADVERSE EFFECTS  Headache. drowsiness. Watch out for and report to prescribe signs and symptoms of hepatic impairment 4. fatigue. behavioral changes and dizziness  Shock. Instruct patients who cannot tolerate capsules on an empty stomach to take the drug with one full glass of water. TB and synthesis. Monitor client’s hepatic functions.

anxiety. but that ice applied to site may help alleviate discomfort. depression. 3. fatigue. Therapy may begin pending results. including otitis media ACTION SIDE/ADVERSE EFFECTS  CNS: neuropathy. 2. 2. Tell patient or patient’s significant other to report adverse reactions promptly. Instruct patient to report discomfort at I. NURSING CONSIDERATION 1. bacterial or fungal superinfection may occur. leukopenia  Musculoskele tal: arthralgia The client was given Penicillin G sodium 650. . anemia.000”u” IV every 4 hours after negative skin test which inhibits cellGeneral wall synthesis during Moderate to severe systemic bacterial multiplication. Obtain specimen for culture and sensitivity tests before giving first dose. lethargy. 2010 Generic name: Pencillin G sodium Brand name: -Classification: Anti-infective Dosage: 650. infection. especially for PATIENT TEACHINGS 1. ask patient about allergic reactions to penicillin. enterocolitis. Observe patient closely. Warn patient receiving I. vomiting. 3. Assess neurologic status. ischemic colitis  GU: neuropathy  HEMA: Hemolytic anemia.  CV: thrombophlebitis  GI: Nausea. seizures. dizziness.000 u IV q4 ANST(-) INDICATION Specific Pneumoccocal respiratory infections. 4. confusion.DRUG Date ordered: August 05.V site.M injection that the injection may be painful. Before giving drug. hallucinations. With large doses and prolonged therapy.

Tell patient to take prescription drug with a snack. Look for blood in emesis. diarrhea. acne. 3. conjuctival redness. ACTION SIDE/ADVERSE EFFECTS  CNS: dizziness. Oral suspension must reconstituted and shaken before use. dry mouth. PATIENT TEACHINGS 1. paresthesia. Assess patient for abdominal pain. . tinnitus  Musculosketal: bone and muscle pain.  CV: palpitations  GI: nausea. 2. 3. inhibiting gastric acid secretion and stabilizing pepsin. vain irritation. Inform patient that pain relief may not begin until several days after therapy starts. or gastric aspirate. Tell the patient that drug is most effective when at bedtime. OTHER: hypersensitivity reactions. parietal cells. DRUG Date ordered: August 05. asthenia. With prescriber’s knowledge. dry skin. NURSING CONSIDERATION 1. The patient was given Famotidine 5mg through IV every 12 hours as a phrophylaxis for General duodenal ulcer by Hospitalized patient who blocking action of cannot take oral drug or histamine at histamine 2have an intractable ulcers or receptor sites in gastric hypersecretory conditions. let patient take antacids together. 2. stool.  SKIN: Flushing. Monitor blood urea nitrogen and creatinine levels in patient with renal impairment. desired. anorexia  EENT: orbital edema. 4. headache. seizures and decreasing level of consciousness. constipation. pain at injection sure. anaphylaxis. 2010 Generic name: Famotidine Brand name: -Classification: -Histamine 2-receptor agonist -Anti ulcer drug Dosage: 5mg IV q12 INDICATION Specific Prophylaxis of duodenal ulcers.

nausea. pepsin. OTHER: altered taste. pain at injection site. flatulence. Reconsitu te drug before instillation through a nasogastric tube. Instruct patient to continue prescribed regimen to ensure complete healing. 2010 Generic name: Sucralfate Brand name: Carafate Classification: Anti ulcer agent Dosage: 1gm/tab ½ tabs through NGT q6 after each lavage INDICATION ACTION Short term (up to 8 weeks) The patient was given treatment of duodenal ulcer. Monitor patient for severe. 3. persistent constipation. 2. SIDE/ADVERSE EFFECTS  CNS: dizziness. especially at begining of therapy when pain is severe. dry mouth. vomiting. Tell the patient or parents of the patient to take sucralfate on an empty stomach . . Drug is minimally absorbed and causes few adverse reactions. Pain and other ulcer signs and symptoms may subside DRUG Date ordered: August 05. rash  OTHER: facial swelling.  RESP: Respiratory difficulty  SKIN: pruritus. indigestion. NURSING CONSIDERATION 1. headache. gastrric discomfort. inhibiting gastric secretion. diarrhea. 5. Flush tube with water to ensure passage into stomach. 1 hour before each meal and at bedtime. hypersensitivity reactions. Advise patient to report abdominal pain or blood in stools or vomit. PATIENT TEACHINGS 1. vertigo  GI: constipation. fever. Sucralfate ½ gram per tablet through NGT every 6 hours after lavage as a short term treatment for duodenal ulcer which acts by combining with gastric acid to form protective coating on ulcer surfaces. and bile salts. 2. sleepiness.

ALT. Drug is as effective as cimetidine in healing duodenal ulcer. 2. neutropenia. which fever dissipates heat and lowers body SIDE/ADVERSE EFFECTS  HEMATOLOGIC: thrombocytopenia. hemolytic anemia. urticaria. pro-time. dark urine clay colored stools. urticaria  OTHER: hypersensitivity reactions (such as fever) PATIENT TEACHINGS 1. pancytopenia. 5. 2010 INDICATION Specific Fever ACTION The client was given Paracetamol 125mg through Iv every 4 Generic name: General hours for fever to cause Acetaminophen Mild to moderate pain relief by inhibition of caused by headache. DRUG Date ordered: August 14. Fever Classification: reduction may result Analgesic. .hypersensitivity reaction. 3. backache. leucopenia. 3. within first few weeks of therapy. parents. Monitor liver and renal functions. Antacids may be used while taking drug. AST. Advice patient.  HEPATIC: jaundice. 2. Inform patient with chronic alcoholism that drug may increase risk of severe liver damage. common in CNS. toothache subsequent blockage of pain impulses. Assess allergic reactions such as rash. but separate doses by 30 minutes. Drug contains aluminum but isn’t classified as an antacid. or other caregivers to contact prescriber if fever ot other symptoms persist despite takinf recommended amout of drug. itching. muscle prostaglandin synthesis Brand name: ache. 4. Antipyretic from vasodilation and increased peripheral Dosage: blood flow in 125mg IV q4 for hypothalamus. Assess hepatotoxicity. with Paracetamol cold. bilirubin. Monitor patient with renal insufficiency for aluminum toxicity. hepatotoxicity  METABOLIC: hypoglycemic coma  SKIN: rash. NURSING CONSIDERATION 1.

and electrolyte levels (especially sodium and potassium. 2010 Generic name: Mannitol Brand name: -Classification: Diuretic Dosage: 60 cc IV q4 x 30 min with BP precaution INDICATION Reduction of increased intracranial pressure associated with cerebral edema. DRUG Date ordered: August 14.) PATIENT TEACHINGS 1. fluid balance. especially those related to the drugs. . legs or chest. diarrhea. pressure by increasing the hypotension. such as increase shortness of breath or pain in back. Monitor renal function tests. Monitor IV site carefully to avoid. seizures with BP precaution to decrease intracranial  CV: Chest pain.temperature. tests. extravasation and tissue necrosis. filtrate. 2. dry mouth. Advised patient to report pain at infusion site as well as adverse reactions. Central venous pressure. Mannitol 60cc through IV headache. osmotic pressure of tachycardia. urinary output. which inhibits tubular reabsorption of  EENT: Blurred water and electrolytes and vision increases urinary output. Teach patient about importance of monitoring exact urinary output. 2.  GI: nausea. 3. vomiting. review all other significant and life threatening adverse reactions and interactions. SIDE/ADVERSE EFFECTS The patient was given  CNS: dizziness. glomerular vascular overload. ACTION NURSING CONSIDERATION 1. and behaviors mentioned above. As appropriate.

especially those related to the drugs and tests mentioned above. 4. As appropriate. including pulmonary edema. 2010 Generic Name: Phenobarbital INDICATION Specific Treatment of generalized tonic-clonic and cortical focal seizures. Tell patient drug may cause thirst or dry mouth. Depressant and SIDE/ADVERSE EFFECTS       Dizziness Headache Hypotension Bradycardia GI disturbances Allergic reaction NURSING CONSIDERATION 1. hypokalemia  RESP: pulmonary congestion. 4. hypernatremia. water intoxication. urinary retention  METABOLIC: dehydration. PATIENT TEACHINGS 1.  OTHERS: chills. thirst. Monitor the patient before and after therapy to know the effectiveness of the drug. water intoxication and heart failure. Assess for evidence of circulatory overload. review all other significant and life-threatening adverse reactions and interactions. fever. Advice the mother to check prescriptions and refills because Phenobarbital is DRUG Date ordered: August 17. GU: polyuria. Watch for excessive fluid loss and signs and symptoms of hypovolemia and dehydration.  SKIN: rash. but that frequent mouth care should case these symptoms. Emphasize that fluid restrictions are necessary. edema and tissue necrosis. 3. metabolic acidosis. 3. emergency control of acute convulsions ACTION The patient is given Phenobarbital PO q12° to help free from seizure activity. urticaria. .

3.) As a sedative. Avoid taking antacids. 2. urinary tract. Advice mother to turn patient q2° to prevent orthostatic hypotension. Assess the patient for signs and symptoms of infection before and during treatment. skin and soft tissue. preanesthetic sedation.  Sedation and depression may occur 2. abdominal cavity (e. 4. prostatitis. Assess seizure activity: type. location. DRUG Date ordered: August 17. . 2010 Generic Name: Ciprofloxacin Brand Name: -Classification: Antibiotic: INDICATION Infections of the respiratory tract. 4.g. Do not take with alcohol for it can increase the chances of the adverse effects. Instruct patient to take drug on the length of time ordered. 2. middle ear. it may also interfere with the transmission of impulses from the thalamus to the brain cortex. gonorrhea. eyes. 2. bones SIDE/ADVERSE EFFECTS         Nausea Diarrhea Rash Allergic reactions Sleep disorders Thrombophlebitis Photosensitivity Renal impairment NURSING CONSIDERATION 1. peritonitis). 3. Assess for barbiturate toxicity: cold clammy skin. PATIENT TEACHINGS 1. genital organs including adnexitis. duration and character. Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria. available in different forms. Assess for drug induced adverse reactions. cyanosis. Avoid activities that require alertness for phenobarital induce sleepiness. paranasal sinuses. Advise mother to report occurrence of any adverse reaction. infections of the GIT or biliary tract. anticonvulsant effects may be realted to its ability to increase and/or mimic the inhibitory activity of GABA on nerve impulses (depress CNS synaptic transmission and increase seizure activity threshold in the motor cortex.Brand Name: -Classification: Barbiturates Dosage: 60mg ½ tab q12° PO General Short term treatment of insomnia. Assess the patient for any previous sensitivity reaction. ACTION The patient was given Ciprofloxacin ½ tab q12° to help inhibit or possibly destroy the microorganism in the clients body. kidneys and/or. 3.

LIST OF PRIORITY PROBLEMS 1. malaise. infections or imminent risk of infections (prophylaxis) in patients whose immune system has been weakened (e. 4. Impaired skin integrity 5. sepsis. 4. Hyperthermia 3. Risk for aspiration . Assess for the client’s renal function before and during therapy vitamin or mineral supplements within 6 hours before or 2 hours after you take ciprofloxacin. pain. 3. Advise patient to report itching. swelling. Ineffective cerebral tissue perfusion 2.fluoroquinolones Dosage: 500mg ½ tab q12° PO and joints. Assess the patient for any allergic reaction or anaphylaxis. VIII. patients on immunosuppressants or have neutropenia). Selective intestinal decontamination in immunosuppressed patients. Acute uncomplicated UTI (acute cystitis). redness.g. Imbalanced Nutrition: Less than body requirements 4. Uncomplicated UTI including acute uncomplicated pyelonephritis.

Objective cues: Nursing Diagnosis Ineffective cerebral tissue perfusion related to compression of cerebral arteries secondary to increased intracranial pressure (ICP) Rationale Increased intracranial pressure can be due to a rise in cerebrospinal fluid pressure. It can also be due to increased pressure within the brain matter caused by a mass (such as a tumor). . bleeding into Goals and Objectives After 4 hours of continuous nursing interventions. Interventions Independent: -Monitoring the vital signs of the patient .Vital signs within client’s normal range.no seizure episodes . the goal was PARTIALLY MET as evidenced by : . Knowledge of vital Rationale Evaluation After 4hours of continuous intervention.Vital signs within client’s normal range. the patient will show signs of increased tissue perfusion as evidenced by : . NURSING CARE PLAN Cues/data Subjective: “Hindi niya na maigalaw ang ulo at mga paa niya para din siyang naninigas” As verbalized by the patient’s mother.IX.Assessment of vital signs is an important component of the physical therapy examination and should be included in the examination of all patients.

and reducing metabolic demands on the body. improving peripheral blood flow. which is chronic in nature. signs allow the nurse to understand a patient’s physiologic status and is helpful in determining appropriate goals interventions needed by the patient. -Provide information on normal tissue perfusion and possible impairments on the patient’s mother. it can have devastating effects on the patient. . If the decreased perfusion is acute and protracted. Diminished tissue perfusion. invariably results in tissue or organ -Monitor the LOC -Avoid measures that will trigger increase of ICP of the patient such as straining. -Monitoring the LOC will give the nurse a baseline data.-hydrocephaluscommunicating -increased ICP -restlessness -changes in pupillary reactions(nonreactive) -presence of NGT -use of accessory muscles to breath -extremity weakness -muscle rigidity the brain and cerebral artery compression. -Elevation of the head will promote venous outflow from the brain due to the force of gravity and this will help in the decrease of the ICP of the patient. -Avoiding these measures will help the decrease of ICP of the patient and to avoid the further decrease of cerebral blood flow of the patient which can be fatal. Management is directed at removing vasoconstricting factor(s). the patient’s response to medications. Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient. positioning the neck of the patient in flexion and head flat. . helps in determining the status of the patient. -Avoiding the patient to have seizures Reduced arterial Long-term goal: blood flow causes decreased nutrition mental status of the and oxygenation at patient(alert) the cellular level.Elevate the patients head or the HOB of the patient about 30 – 45 degrees.

660) -http://en.Having the cooperation of the patient’s mother will help in the monitoring of the patient and early assessment facilitates prompt treatment. org/wiki/I ntracranial_pressure -Explain all procedures and equipments to the patient mother.damage or death. Nursing and health professions. increase or return -observe seizure precaution for the patient:  Provide dim light  Side rails  Avoid exposure to electricfan  Avoid noise . .(p. -Instruct patient’s mother to inform the nurse immediately of symptoms of decreased perfusion persist.to avoid progression of seizure and the risk for injury of patient. -Explaining the procedures and equipments may reduce the anxiety of the patient’s mother on the unknown and this will also help in the establishment cooperation with the mother .Educating the mother will give the mother the idea if the patient is experiencing any abnormalities and this will also establish cooperation with the mother. . REFERENCES: -Mosby’s pocket dictionary of medicine.wikipedia.

by Dooenges.200) . Moorhouse and Murr (p. 708) -Nursing Care plans by Gulanick and Myers(p. -to avoid patient on having seizures which can result from cerebral edema or ischemia and to reduce increase ICP. Avoid jarring of the bed DEPENDENT: -Administer anticonvulstants and osmotic diuresis prescribed by the doctor when it is needed. REFERENCES: -Nurse’s Pocket guide 11th edition.

For example. Objective data:  Flush skin  Warm to touch Nursing Diagnosis Hyperthermia related to infection secondary to meningitis Rationale The child may develop fever as a symptom of a wide variety of illnesses as well as from infections. noting the level of consciousnes s and orientation. certain blood disorders and inflammatory disorders (eg juvenile arthritis) may cause fever. reaction to stimuli of pupils Rationale Evaluation After 4 hours of nursing intervention The goal was not met as evidence by the body temperature of the patient is still 39°C  To know if its increasing or decreasing  Central hypertension or .Cues / Data Subjective cues: “ Mainit siya tapos ilang araw na hindi bumaba ang lagnat niya” as verbalized by his mother. Goals and Objectives After 4 hours of nursing intervention the patient body temperature will reduce to 37°C Interventions Independent:  Assess for neurological response.

However. electrolyte.7°C  RR: 26  BP 140/100  PR:144 Fever can also be caused by sunstroke and some childhood immunisations. T: 39. but ventilatory effort may eventually impaired by seizure. most episodes of fever are caused by viral infections.  Monitor core temperature. vomiting and diarrhea.wou nd and insensible loses  Monitor laboratorial studies such as ABGs. dehydration.  Monitor BP and heart and rhythm  Monitor respiration  Monitor/ record all sources of fluid loss such as urine. hypermetaboli c rate (shock and acidosis)  Oliguria and/or renal failuremay occur due to hypotension. shock  It may reveal tissue degeneration . cardiac and liver enzyme  Promote peripheral/pos tural hypotension occurs  Hyperventilati on may initially be present.

Nutritional status can be affected by disease or injury states social factors Goals and Objective After 4 hours of nursing intervention. goals fully met as evidenced by: . cool and environment  Encourage TSB Dependent:  Administer medication o (para cetam ol)  Cool environment can or helps the body temperature to decrease  Could lower down the body temperature  To rapid decrease body temperature Cues / Data Subjective Data: “Nangayayat na nga sya ngayon eh” as verbalized by the mother Objective data: -Iron Deficiency Nursing Diagnosis Imbalanced Nutrition: Less than Body Requirements related to inability to ingest food Rationale Adequate nutrition is necessary to meet the body’s demands.surface cooling by means of undressing. Rationale 1. Provide most appropriate position to enhance movement of formula by gravity and peristalsis and to prevent vomiting or aspiration Evaluation After 4 hours of nursing intervention. the patient will experience gradual balanced nutrition as manifested by: -complying to the feeding time of the Intervention 1.complied time of feeding -health teaching was . Place the child in position of comfort for feeding.

12.03 MCH ↓23.9 Kg present weight -BMI 10.63 Hematocrit ↓27. and contamination of food that may 3. storage of food. Promotes information to ensure stable weight and gains proportionate to growth provided to the parents.68 MCV ↓74. Teach parent about caloric needs for age of -provide parents child and in weight information about the and height 3.4 Kg upon admission.09 .74 Hemoglobin ↓8. hand wash before preparing or handling food. 2.8 -Underweight patient -giving of prescribed supplement or vitamin if available 2. Prevent spoiling appropriate nutrition. Teach parent cause about proper gastrointestinal preparation and symptoms.20. measurement. .09 MCHC ↓31.Anemia as evidenced by laboratory results: RBC count ↓3.

color.” As verbalized by the patient’s mother.neuromascular impairment VS Taken: BP: 140/100 RR: 26 PR: 144 TEMP: 39. duration of problem and changes over time *inspect skin on a daily basis *Assess skin routinely. and institute treatment immediately *Provide adequate clothing/covers.Cues/Needs O Subjective data: “Namamalat na yung bandang ari niya at sa may pwet.immobility/inactivity . intervention thus the goal is partially met *To prevent complications *To monitor progress or healing *enhanced circulation to compromised tissue *this may indicate particular vulnerability *Reduces likelihood of progression to skin breakdown *To prevent vasoconstriction *To maintain general good health and skin turgor *promoting hygienic procedures is a key in infection prevention .redness . Brunner & Suddarth”s Goals and Objectives After 4hrs.disruption of the epidermis . Including age at onset. protect from drafts *Emphasize importance of adequate nutritional/fluid intake * stress proper hand hygiene to all care givers and other infection control procedures Rationale Evaluation The patient able to maintain physical well being after the given 4hrs. noting moisture. and elasticity *Observe for reddened/blanched areas or skin rashes. of given intervention the patient will maintain physical well-being Long-term goal: Timely wound healing Interventions Independent: *client teaching * obtain a history of condition. Objective data: .7˚ C Nursing Diagnosis Impaired skin integrity r/t physical immobilization Rationale Decreased muscle strength ↓ Body weakness ↓ Irritability ↓ Physical immobility ↓ Risk for skin integrity *Medical-Surgical Nursing 11th Edition.

Cues/Needs OBJECTIVE: ➢ Improper NGT feeding Nursing Diagnosis Risk for aspiration related to knowledge deficit. Patient’s factor for aspiration. inhalation Goals and Objectives After hours of nursing intervention the patient will be able to: Interventions Independent  Monitor level of Rationale Evaluation consciousness. Auscultate breath sounds for development of crackles and/or rhonchi. . often witnessed.   Assess cough and gag reflexes.  Assess pulmonary status for clinical evidence of aspiration. risk of aspiration is decreased as a result of ongoing  A depressed assessment and cough or gag reflex increases early intervention. Patient maintains patent airway. Aspiration pneumonitis represents chemical damage to the tracheobronchial tree caused by acute. Rationale Aspiration is defined as the inhalation of either oropharyngeal or gastric contents into the lower airways.  Aspiration of Keep suction setup available  small amounts can occur without coughing or sudden onset of respiratory distress. Although these two entities are managed differently.  Patient’s risk of aspiration is decreased as a result of ongoing assessment and early intervention. especially in patients with decreased levels of consciousness. they are often interchangeably referred to as aspiration pneumonia. Inhalation of these contents can lead to aspiration pneumonia and aspiration pneumonitis. After hours of nursing intervention  A decreased the Goal was MET level of by: Patient was able consciousness is to maintain patent a prime risk airway. the risk of aspiration.

of regurgitated gastric contents in patients with an acute change in mental status.  positioning of patients with swallowing difficulties is of primary importance during feeding or eating.  This protects Position patient at 90degree angle. usually unwitnessed. Comatose patients need frequent turning to facilitate drainage of secretions. Use cushions or pillows to maintain position.   This is necessary to maintain a patent airway. inhalation of small amounts of oropharyngeal contents leading to an infectious process. Aspiration pneumonia results from chronic. Position patients who have a decreased level of consciousness on their sides. whether in bed or in a chair or wheelchair. . Proper positioning can decrease the risk of aspiration.  Proper Maintain upright position for 30 to 45 minutes after feeding.  the airway.

 This removes residuals and reduces pocketing of food that can be later aspirated. use a right side-lying position after feedings to facilitate passage of stomach contents into the duodenum. If the head of the bed cannot be elevated because of the patient’s condition.  The upright position facilitates the gravitational flow of food or fluid through the alimentary tract. Provide oral care after meals. .

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