NAME : Patient ABCD EFGH AGE : 86 y/o DATE OF BIRTH : December 30, 1922 GENDER : Male ADDRESS : San Pedro, Laguna PRIMARY DIALECT SPOKEN: Tagalog ETHNIC GROUP : None RELIGION : Roman Catholic OCCUPATION : Pensioner (retired government employee) HIGHEST EDUC’L ATTAINMENT: High School MARITAL STATUS : Widow


MEDICAL AND FAMILY HISTORY According to the daughter of the patient, the patient have had suffered from right CVA five years ago causing him bedridden for a long period of time. She also said that, her father have suffered from respiratory arrest many times prior his confinement to the hospital.

A month ago, they rushed their father who has complaint of difficulty of breathing with temperature increased to more than 38.0º C to East Avenue Medical Center thru hospital referral. The daughter of the patient said that their late mother died of pulmonary arrest. She reiterated that her maternal side has history of hypertension and diabetes mellitus. On the other hand, she reclaimed that her paternal side has a medical history of cardiopulmonary problems. Her eldest sister attested that one of her children has hypertension and asthma. Also she said that their youngest brother is diabetic.


SEPT. 15, 2009 (8:00am) Pulse Rate : 82 bpm Blood Pressure : 110/80 mmHg Respiratory Rate : 27 cpm Temperature : 37.3 º C

SEPT. 15, 2009 (7:00am) Pulse Rate : 76 bpm Blood Pressure : 120/70 mmHg Respiratory Rate : 33 cpm Temperature : 37.8º C

SEPT. 15, 2009 (9:00am) Pulse Rate : 66 bpm Blood Pressure : 110/80 mmHg Respiratory Rate : 33 cpm Temperature : 37.8 º C SEPT. 15, 2009 (11:00am) Pulse Rate : 83 bpm Blood Pressure : 110/70 mmHg Respiratory Rate : 39 cpm Temperature : 38.0º C V. MEDICATION Frequency TID q6h BID

SEPT. 15, 2009 (10:00am) Pulse Rate : 78 bpm Blood Pressure : 110/70 mmHg Respiratory Rate : 36 cpm Temperature : 38.2 º C SEPT. 15, 2009 (12:00nn) Pulse Rate : 81 bpm Blood Pressure : 110/80 mmHg Respiratory Rate : 34 cpm Temperature : 38.1º C

Medications 1. NaCl Tab 2. N – Acetylcystein 600mg 3. Clindamycin 30mg Cap NGT

Time 8:00am; 2pm 8:00am; 2pm; 8pm; 2am 12:00 nn

Remark Not administered Not administered Done at 12:10 nn


NURSING CARE PLAN DIAGNOSIS Risk for infection r/t compromised immune system. INFERENCE Sepsis is a clinical term to describe symptomatic bacteremia, with or without organ dysfunction. Sustained bacteremia, in contrast to transient bacteremia, may result to a sustained febrile PLANNING After 8 hours of nursing interventions, will achieve timely healing and free from further infections. INTERVENTION Independent: • Provide isolation and monitor visitors as indicated; RATIONALE • Body substance isolation should be used for all infectious patients. Reserve isolation/ restriction may be needed to protect the immunosuppres sed patient. EVALUATION After 8 hours of nursing interventions, the patient was able to achieve timely healing and free from further infections.

ASSESSMENT Subjective Data: “Lagi syang nilalagnat. Kapag hinihipo mo sya mararamdaman mong mainit talaga katawan nya.” (He always gets sick. When you touch him you will really feel that his temperature is increased.), as

verbalized by the patient’s daughter. Objective data: • • • • Increased body temperature Flushed skin Increased respiratory rate V/S taken as follows:

response that may be associated with organ dysfunction. Septicemia refers to the active multiplication of the bacteria into the bloodstream that result in an overwhelming infection.

Wash hands before and after each care activity;

Reduces risks of cross contamination because gloves may have noticeable defects, get torn or damaged during use. Prevents spread of infection via airborne droplets. May provide clue to portal entry, type of primary infecting organisms, as well as early identification of secondary infection. Prevents introduction of bacteria, reducing risks of nosocomial infection.

Limit use of invasive devices or procedures as possible; Inspect wounds or site of invasive devices, paying attention to parenteral lines; Maintain sterile technique when changing dressings, suctioning, or providing site care; Provide tepid sponge bath and avoid use

SEPT. 15, 2009 (7am) T: 37.8 º C P: 76 bpm R: 33 cpm BP: 120/70 mmHg SEPT. 15, 2009 (8am) T: 37.3 º C P: 82 bpm R: 27 cpm BP: 110/80 mmHg SEPT. 15, 2009 (9am) T: 37.8 º C P: 66 bpm R: 33 cpm BP: 110/80 mmHg

Used to reduce fever

SEPT. 15, 2009 (10am) T: 38.2 º C P: 78 bpm R: 36 cpm BP: 110/70 mmHg SEPT. 15, 2009 (11am) T: 38.0º C P: 83 bpm R: 39 cpm BP: 110/70 mmHg SEPT. 15, 2009 (12nn) T: 38.1º C P: 81 bpm R: 34 cpm BP: 110/80 mmHg

alcohol; • Observe for chills and profuse diaphoresis; • Chills often precede temperature spikes in presence of generalized infection. May reflect inappropriate anti-biotic therapy or overgrowth of secondary infection. Identification of portal entry and organism causing the septicemia is crucial effective treatment

Monitor signs for deterioration of condition or failure to improve in therapy.

Collaborative: • Obtain specimens of urine, blood, sputum, wound as indicated for gram stain, and sensitivity;

Administer anti-biotic as prescribed.

To prevent further spread of infection.

VI. DRUG STUDY 1. Clindamycin 300 mg

a. Phamacologic class: b. Therapeutic class:

Lincosamide Anti – infective

• •

To reduce development of bacterial resistance and maintain drug efficacy, use only to prevent and treat infections that are proven and strongly suspected to be caused by bacteria. Diarrhea, colitis, and pseudomembranous colitis may first appear up to the end of clindamycin therapy. Inhibits protein synthesis in susceptible bacteria at level of 50S ribosomes, thereby inhibiting peptide bond formation and causing cell death. Bacterial vaginosis (phosphate) Chlamydia trachomatis infection in females. CNS toxoplasmosis in AIDS patients Pneumocystis jiroveci pneumonia Rosacea (lotion) Hypersensitivity to drug or lincomycin Renal or hepatic impairment Known alcohol intolerance Pregnant patient Neonates diarrhea that is watery or bloody; fever, chills, body aches, flu symptoms; nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes); urinating less than usual or not at all; or fever, sore throat, and headache with a severe blistering, peeling, and red skin rash.

c. Actions:
• • • • • •

d. Off-label uses:

e. Contraindication: f. Precautions:
• • • •

• g. Adverse reaction:
• • • • • • •

h. Nursing responsibilities:
In patients with renal insufficiency, assess creatinine level before giving first dose and at least once a week during prolonged therapy. Monitor drug blood closely. Watch for s/s of serious adverse reactions, including GI problems, jaundice, and hypersensitivity reactions.

2. N – Acetylcystein 600 mg a. Phamacologic class: Antidote; b. Therapeutic class: mucolytic • Decrease viscosity of secretions; • Promoting secretions removal thru vomiting

c. Actions: • Treatment of acute chronic bronchopulmonary disease d. Contraindication: • cautioned for patients with asthma • hypersensitivity to drugs (except w/ antidotal use.) e. Precautions: • Renal or hepatic disease • Elderly patients f. Adverse reaction: • Flushing, fever, stomatitis, nausea, vomiting, rhinorrhoea, bronchospasm, anaphylactoid reactions, rashes. Rarely, blurred vision, bradycardia, syncope, thrombocytopenia, convulsions. Potentially Fatal: Rarely, respiratory or cardiac arrest. g. Nursing responsibilities: • Monitor respiration, cough, and character of secretions • Instruct the patient to report worsening cough and other respiratory symptoms. • Advise patient to mix oral form with juice or cola to mask bad taste and odor. 3. Sodium Chloride (NaCl) Tab a. Phamacologic class: Electrolyte supplement b. Therapeutic class: Sodium replacement c. Actions: • Replaces deficiencies of sodium and chloride and maintains these electrolytes at adequate level. d. Contraindication: • Normal or elevated electrolyte levels (with 3% and 5% NaCl • Fluid retention e. Precautions: • Renal impairment • Heart failure • Edema • Sodium retention • Surgical patients f. Adverse reaction: • Fluid and electrolyte disturbances • Aggravation of existing metabolic acidosis • Pulmonary edema • Local tenderness g. Nursing responsibilities: • Monitor electrolyte levels

• • •

Watch for s/s of pulmonary edema or worsening heart failure Carefully monitor v/s, fluid balance, weight, and cardiovascular status Instruct patient to report DOB, pain, tenderness, and swelling at injection site

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