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GOAL AND NURSING

NURSING DIAGNOSIS ANALYSIS RATIONALE EVALUATION


OBJECTIVES INTERVENTIONS

Activity Intolerance (Level Specific Implication: Goal:


IV) By December 6, 2008 the
Insufficient client will have improved
related to: physiological or tolerance of activity and
psychological energy to progress toward an optimum
Reduced cardiac output and endure or complete level of physical activity
enforced bed rest required or desired daily tolerance.
activities.
As evidenced by: (Nursing Pocket Guide, Objectives:
11th Edition by Doenges After 45 minutes of Supplemental
Subjective: et.al) appropriate nursing Developmental
intervention, the client will Facilitative
• Verbalization of Immediate Cause: be able to:
“nanghihina at Altered Heart
parang pagod na Contractility Discussion spans the
pagod ako” 1. Exhibit ability to pace entire range of health
• Inability to perform Intermediate Cause: activity. care prevention,
simple activities like Risk for Inflammation of 2. Confirm the underlying maintenance, recovery
walking myocardial wall cause of present activity and rehabilitation. It
• Lack of desire in intolerance. promotes interaction
activity Root Cause: 3. Verbalize Improvement and enhances
Suspected Bacterial in fatigue. knowledge.
• Grasping for breath
Infection 4. Eliminate bacterial
• Guarding area of the infection. (Introduction to person
chest 5. Exhibit no difficulty in centered nursing by:
• Fatigue breathing. Lindberg, p.1083)
6. Maintain body
Objective: temperature within the
normal range. Discussion encourages
• Rapid heart rate 7. Steadily increase participation by learner.
• Pallor skin activity level to include (F.O.N, Kozier. p. 461)
• Dyspnea climbing one flight of
• Variation in blood stairs without chest pain Demonstration is
or without ECG particularly useful for
pressure reading changes, while the heart
• Palpitations rate remains under 90 psychomotor learning.
• Dysrythmia beats/min. Explaining a skill while
• Elevated slowly demonstrating it
temperature leads to taking clients
• ECG changes through the procedure
for the first few times.

(Fundamentals of
Nursing 4th edition by
Ruth Craven, p.369)

Generic/ Trade Dosage/ Classificati


Indication Contra-Indication Side Effects Nursing Responsibilities
Name Frequency on

Adults Pregnancy • Analgesic-antipyretic • Contraindicated CNS: Headache Assessment


Generic Name: PO or PR Category B in patients with with allergy to
Acetaminophen By suppository, aspirin allergy, acetaminophen. CV: Chest pain, dys- History: Allergy to acet-
325-650 mg q4-6 hemostatic • Use cautiously pnea, myocardial aminophen, impaired hep-
Brand Name: hr or PO, 1,000mg disturbances, with impaired damage when doses atic function, chronic alco-
Paracetamol tid to qid. Donot bleeding diatheses, of 5–8 g/day are in- holism, pregnancy, lacta-
excedd 4g/day upper GI disease, gested daily for sever- tion
gouty arthritis al weeks or when
Pediatric Patients • Arthritis and doses of 4 g/day are Physical: Skin color, le-
PO or PR ingested for 1 year sions; T; liver evaluation;
rheumatic disorders
Doses may be CBC, liver and renal func-
involving
repeated 4-5 GI: Hepatic toxicity tion tests
musculoskeletal pain
times/day; do not and failure, jaundice
(but lacks clinical
excedd five doses Interventions
significant
in 24 hr; give PO
antirheumatic and
GU: Acute kidney • Do not exceed the re-
or by suppository. failure, renal tubular commended dosage.
anti inflammatory
necrosis • Consult physician if
effects) needed for children <
• Common cold, flu, Hematologic: Meth- 3 yr; if needed for
other viral and emoglobinemia--cy- longer than 10 days; if
bacterial infections anosis; hemolytic an- continued fever,
and pain and fever. emia--hematuria, severe or recurrent
• Unlabeled use: anuria; neutropenia, pain occurs (possible
Prophylactic for leukopenia, serious illness).
children receiving pancytopenia, throm- • Avoid using multiple
DPT vaccination to bocytopenia, hy- preparations contain-
induce incidence of poglycaemia ing acetaminophen.
fever and pain Carefully check all
Hypersensitivity: OTC products.
Rash, fever • Give drug with food if
GI upset is noted.
• Discontinue drug if
hypersensitivity reac-
tions occur.
• Treatment of over-
dose: Monitor serum
levels regularly, N-
acetylcysteine should
be available as a spe-
cific antidote; basic
life support measures
may be necessary.

Teaching points
• Do not exceed recom-
mended dose; do not
take for longer than
10 days.
• Take the drug only for
complaints indicated;
not an anti-inflammat-
ory agent.
• Avoid the use of other
OTC preparations.
They may contain
acetaminophen, and
serious overdosage
can occur. If you need
an OTC preparation,
consult your health
care provider.
• Report rash, unusual
bleeding or bruising,
yellowing of skin or
eyes, changes in void-
ing patterns.

Generic Name: Adults Pregnancy • Contraindicated CNS: Headache,


Esomeprazole • Healing of Category B with dizziness, asthenia,
Assessment:
Magnesium erosive hypersensitivity vertigo, insomia,
History: Hypersensitivity
esophagitis: to omeprazole, apathy, anxiety,
to any proton pum inhibit-
Trade Name: 20-40mg PO esomeprazole, paresthesias, dream
or; hepatic dysfunction;
Nexuim IV daily for 4- • GERD- treatment of or other proton abnormalities.
pregnancy, lactation
8wk. An heartburn and other pump inhibitor. Physical: Skin lesions; T
additional 4- related symptoms • Use cautiously Dermatologic: Rash,
reflexes, affect; urinary
8wk course of • Erosive esophagitis with hepatic inflammation,
output, abdominal examin-
therapy can short-term (4-8wk) dysfunction, urticaria, pruritus,
ation; respiratory ausculta-
be considered treatment for healing pregnancy, alopecia, dry skin.
tion, LFTs
for patients and symptom relief. lactation.
who have not Also used for GI: Diarrhea,
Interventions
healed. maintenance therapy abdominal pain,
*Warning: Arrange for
• Maintenance following healing of nausea, vomiting,
further evaluation of pa-
of healing of erosive esophagitis constipation, dry
tient after 4 wk of therapy
erosive • Short-term treatment mouth, tongue
for gastroesophageal re-
esophagitis: of GERD with a atrophy, flatulence
flux disorders. Sympto-
20mg daily. history of erosive matic improvement does
• Symptomatic esophagitis bi IV Respiratory: URI
not rule out gastric cancer.
symptoms, sinusitis,
GERD: 20 route for up to 10 cough, epistaxis • If administering ant-
mg daily for 4 days, when oral acids, they may be ad-
wk. An therapy is not ministered concomit-
additional 4- possible. antly with
wk course of • As part of esomeprazole.
therapy can combination therapy • Administer IV for
be considered for treatment of maximum of 10 days;
if symptoms duodenal ulcer also switch to oral form as
have not associated with soon as possible.
resolved. Helicobacter pylori • Ensure that the patient
• Short-term • Reduction in swallows capsule
treatment of occurrence of gastric whole; do not crush,
GERD when ulcers associated with or chew; patients hav-
oral therapy is continous NSAID use ing difficulty swal-
not possible: in patients at risk (60 lowing may sprinkle
20-40 mg IV yr or above, history in applesauce or dis-
by injection of gastric ulcers) for perse in tap water, or-
over at least 3 developing gastric ange or apple juice, or
min or IV ulcers yogurt; do not crush
infusion over or chew pellets.
10-30 min. • Obtain baseline liver
• Duodenal function tests and
ulcer: 40 monitos periodically
mg/day PO during therapy.
for 10 days • Maintain supportive
with 1,000 treatment as appropri-
mg PO bid ate for underlying
ampicillin and problem.
500 mg PO
• Provide additional
bid
comfort measures to
clarithromyci
alleviate discomfort
n.
from GI effects and
• Reduction of
headache.
risk of gastric
• Establish safety pre-
ulcers with
cautions if dizziness
NSAID use:
or other CNS effects
20-40 mg PO occur (use side rails,
daily for 6 accompany patient)
mo.
Teaching Points:
Pediatric Patients • Take the drug at least
Safety and 1 hour before meals.
efficacy not Swallow the capsules
established whole; do not chew or
crush. If youcannot
Patients with swallow the capsule,
hepatic it can be opened and
dysfunction sprinkled in apple-
Do not exceed sauce or disperse in
20mg/day in tap water, orange or
patients with apple juice, or yogurt;
severe hepatic do not crush or chew
dysfunction. pellets. This drug will
need to be taken for 4-
8wks, at which time
your condition will be
reevaluated.
• Arrange to have regu-
lar medical follow-up
visits while you are
using this drug.
• Maintain all of the
usual activities and re-
strictions that apply to
your condition. If this
becomes difficult,
consult your health
care provider.
• Report severe head-
ache, worsening of
symptoms, fever,
chills, darkening of
the skin, changes in
the color of urine or
stool.