VII.

DRUG STUDY

DRUG INDICATION ACTION SIDE/ADVERSE EFFECTS NURSING PATIENT

CONSIDERATION TEACHINGS
Date ordered: Specific The patient was given  CNS: euphoria, insomnia, 1. Determine whether 1. Tell patient not to
August 04, 2010 Adjunctive treatment dexamtehasone 1.8 mg psychotic behavior, patient is sensitive stop drug abruptly
Generic name: in bacterial meningitis. through IV every 6 pseudotumor cerebri, vertigo, to other or without
Dexamethasone hours to decreases headache, paresthesia, corticosteroids prescriber’s
General inflammation, mainly by seizures, depression. 2. Most adverse consent.
Brand name: Cerebral edema stabilizing leukocyte reactions to 2. Instruct patient to
-- Allergic and lysosomal membranes;  CV: hypertension, edema, corticosteroids are take drug with
Classification: inflammatory suppresses immune arrythmias, dose-or duration- food or milk.
Anti inflammatory conditions response; stimulates thromboembolism. dependent. 3. Teach patient
Glucocorticoid Shock bone marrow; and 3. For better results signs and
Tuberculosis influences protein, fat  EENT: cataracts, glaucoma. and less toxicity, symptoms of
Dosage: meningitis and carbohydrate give once daily adrenal
1.8 mg IV q6 metabolism.  GI: peptic ulceration, GI dose in morning. insufficiency;
irritation, increased appetite, 4. Give oral dose with fatigue, muscle
pancreatitis, nausea, food when weakness, join
vomiting. possible. Patient pain, fever,
may need drugs to anorexia.
 GU: increase urine glucose, prevent GI 4. Warn patient on
and calcium levels irritation. long term therapy
 Metabolic: hypokalemia, 5. Give I.M injection about cushingoid
hyperglycemia deeply into gluteal effects(moon face,
muscle. Rotate buffalo hump)
 Musculoskeletal: muscle injection sites to 5. Warn patient about
weakness prevent muscle easy bruising.
 Skin: Delayed wound healing atrophy. Avoid 6. Advise patient to
 Other: Susceptibility to subcutaneous avoid exposure to
infections. injection because infections (such as
atrophy and sterile measles and
abscesses may chickenpox) and to
 occur. notify prescriber if
6. Alwats adjust to such exposure
lowest effective occurs.
dose
7. Monitor patient
weight, blood
pressure, and
electrolyte levels.
8. Monitor patient for
cushingoid effects,
including moon
face, buffalo hump,
thinning of hair.
 DRUG INDICATION ACTION SIDE/ADVERSE EFFECTS NURSING PATIENT
CONSIDERATION TEACHINGS

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

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

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

Date ordered: Specific The patient was given  Headache, fatigue, 1. Give the drug one 1. Warn patient that
August 4, 2010 Prevention of Rifampicin drowsiness, hour before taking. the drug can turn
meningococcal meningitis 200mg/5ml: 4.5ml behavioral changes 2. Monitor hepatic urine into red to
Generic Name: OD to treat or inhibit and dizziness function. orange.
Rifampicin General synthesis of  Shock, visual 3. Watch out for and 2. Instruct patients
Maintenance treatment of all meningococcal disturbances, report to prescribe who cannot
Brand Name: forms of pulmonary and infection and bacterial exudative signs and tolerate capsules
-- extra-pulmonary growth by inhibiting conjunctivitis symptoms of on an empty
tuberculosis (TB). For DNA-dependent RNA hepatic impairment stomach to take
Classification: continuation phase (for 4 polymerase, which impairs 4. Monitor client’s the drug with one
Antituberculosis agent mos) of short-course anti- RNA hepatic functions. full glass of
TB treatment. TB and synthesis; bactericidal water.
Dosage: leprosy in combination with 3. Advise patient to
200mg/5ml: 4.5ml other avoid alcohol
OD PO antibiotics/chemotherapeutic during drug
agents; non-mycobacterial therapy.
infections; brucellosis in
combination with a
tetracycline
 DRUG INDICATION ACTION SIDE/ADVERSE NURSING PATIENT
EFFECTS CONSIDERATION TEACHINGS
1. Before giving drug, 1. Tell patient or
Date ordered: Specific The client was given  CNS: neuropathy, ask patient about patient’s
August 05, 2010 Pneumoccocal respiratory Penicillin G sodium seizures, lethargy, allergic reactions to significant other to
infections, including otitis650,000”u” IV every 4 hallucinations, penicillin. report adverse
Generic name: media hours after negative skin anxiety, confusion, reactions
Pencillin G sodium test which inhibits cell- depression, 2. Obtain specimen for promptly.
General wall synthesis during dizziness, fatigue. culture and
Brand name: Moderate to severe systemic bacterial multiplication. sensitivity tests 2. Instruct patient to
-- infection.  CV: before giving first report discomfort
Classification: thrombophlebitis dose. Therapy may at I.V site.
Anti-infective  GI: Nausea, begin pending
vomiting, results. 3. Warn patient
Dosage: enterocolitis, receiving I.M
650,000 u IV q4 ischemic colitis 3. Observe patient injection that the
ANST(-) closely. With large injection may be
 GU: neuropathy doses and prolonged painful, but that
 HEMA: Hemolytic therapy, bacterial or ice applied to site
anemia, anemia, fungal may help alleviate
leukopenia superinfection may discomfort.
occur.
 Musculoskeletal:
arthralgia 4. Assess neurologic
status, especially for
 OTHER: seizures and
hypersensitivity decreasing level of
reactions, consciousness.
anaphylaxis, pain at
injection sure, vain
irritation.
 DRUG INDICATION ACTION SIDE/ADVERSE NURSING PATIENT
EFFECTS CONSIDERATION TEACHINGS
Date ordered: Specific The patient was given  CNS: dizziness, 1. Assess patient for 1. Tell the patient
August 05, 2010 Prophylaxis of duodenal Famotidine 5mg through headache, abdominal pain. that drug is most
ulcers. IV every 12 hours as a paresthesia, Look for blood in effective when at
Generic name: phrophylaxis for asthenia. emesis, stool, or bedtime.
Famotidine General duodenal ulcer by gastric aspirate.
Hospitalized patient who blocking action of  CV: palpitations 2. Inform patient
Brand name: cannot take oral drug or histamine at histamine 2- 2. Oral suspension that pain relief
-- have an intractable ulcers or receptor sites in gastric  GI: nausea, must reconstituted may not begin
Classification: hypersecretory conditions. parietal cells, inhibiting diarrhea, and shaken before until several days
-Histamine 2-receptor gastric acid secretion and constipation, dry use. after therapy
agonist stabilizing pepsin. mouth, anorexia starts.
-Anti ulcer drug 3. Monitor blood urea
 EENT: orbital nitrogen and 3. Tell patient to
Dosage: edema, creatinine levels in take prescription
5mg IV q12 conjuctival patient with renal drug with a
redness, tinnitus impairment. snack, desired.

 Musculosketal: 4. With prescriber’s

bone and muscle knowledge, let
pain. patient take
antacids together,
 SKIN: Flushing, especially at
acne, dry skin. begining of
therapy when
 OTHER: altered pain is severe.
taste, fever, pain
at injection site, 5. Advise patient to
hypersensitivity report abdominal
reactions. pain or blood in
stools or vomit.
 DRUG INDICATION ACTION SIDE/ADVERSE NURSING PATIENT
EFFECTS CONSIDERATION TEACHINGS
Date ordered: Short term (up to 8 weeks) The patient was given  CNS: dizziness, 1. Reconsitute drug 1. Tell the patient
August 05, 2010 treatment of duodenal ulcer. Sucralfate ½ gram per headache, sleepiness, before instillation or parents of the
tablet through NGT vertigo through a patient to take
Generic name: every 6 hours after nasogastric tube. sucralfate on an
Sucralfate lavage as a short term  GI: constipation, Flush tube with empty stomach ,
treatment for duodenal diarrhea, dry mouth, water to ensure 1 hour before
Brand name: ulcer which acts by flatulence, gastrric passage into each meal and at
Carafate combining with gastric discomfort, stomach. bedtime.
acid to form protective indigestion, nausea,
Classification: coating on ulcer vomiting. 2. Drug is minimally 2. Instruct patient to
Anti ulcer agent surfaces, inhibiting absorbed and continue
gastric secretion,  RESP: Respiratory causes few adverse prescribed
Dosage: pepsin, and bile salts. difficulty reactions. regimen to
1gm/tab ensure complete
½ tabs through NGT q6  SKIN: pruritus, rash 3. Monitor patient for healing. Pain and
after each lavage severe, persistent other ulcer signs
 OTHER: facial constipation. and symptoms
swelling, may subside
hypersensitivity 4. Drug is as within first few
reaction. effective as weeks of therapy.
cimetidine in
healing duodenal 3. Antacids may be
ulcer. used while taking
drug, but
5. Drug contains separate doses by
aluminum but isn’t 30 minutes.
classified as an
antacid. Monitor
patient with renal
insufficiency for
aluminum toxicity.
 DRUG INDICATION ACTION SIDE/ADVERSE NURSING PATIENT
EFFECTS CONSIDERATION TEACHINGS
Date ordered: Specific The client was given  HEMATOLOGIC: 1. Assess allergic 1. Advice patient,
August 14, 2010 Fever Paracetamol 125mg thrombocytopenia, reactions such as parents, or other
through Iv every 4 hemolytic anemia, rash, urticaria. caregivers to
Generic name: General hours for fever to cause neutropenia, contact prescriber
Acetaminophen Mild to moderate pain relief by inhibition of leucopenia, 2. Assess if fever ot other
caused by headache, muscle prostaglandin synthesis pancytopenia. hepatotoxicity; symptoms persist
Brand name: ache, backache, common in CNS, with  HEPATIC: jaundice, dark urine clay despite takinf
Paracetamol cold, toothache subsequent blockage of hepatotoxicity colored stools, recommended
pain impulses. Fever  METABOLIC: itching. amout of drug.
Classification: reduction may result hypoglycemic coma 2. Inform patient
Analgesic, Antipyretic from vasodilation and  SKIN: rash, urticaria 3. Monitor liver and with chronic
increased peripheral  OTHER: renal functions, alcoholism that
Dosage: blood flow in hypersensitivity ALT, AST, drug may
125mg IV q4 for hypothalamus, which reactions (such as bilirubin, pro-time. increase risk of
fever dissipates heat and fever) severe liver
lowers body damage.
temperature. 3. As appropriate,
review all other
significant and
life threatening
adverse reactions
and interactions,
especially those
related to the
drugs, tests, and
behaviors
mentioned above.
 DRUG INDICATION ACTION SIDE/ADVERSE NURSING PATIENT
EFFECTS CONSIDERATION TEACHINGS
Date ordered: Reduction of increased The patient was given  CNS: dizziness, 1. Monitor IV site 1. Teach patient
August 14, 2010 intracranial pressure Mannitol 60cc through IV headache, seizures carefully to avoid, about importance
associated with cerebral with BP precaution to extravasation and of monitoring
Generic name: edema. decrease intracranial  CV: Chest pain, tissue necrosis. exact urinary
Mannitol pressure by increasing the hypotension, 2. Monitor renal output.
osmotic pressure of tachycardia, function tests, 2. Advised patient
Brand name: glomerular vascular overload. urinary output, to report pain at
-- filtrate, which inhibits fluid balance, infusion site as
tubular reabsorption of  EENT: Blurred Central venous well as adverse
Classification: water and electrolytes and vision pressure, and reactions, such as
Diuretic increases urinary output.  GI: nausea, electrolyte levels increase shortness
vomiting, diarrhea, (especially of breath or pain
Dosage: dry mouth. sodium and in back, legs or
60 cc IV q4 x 30 min potassium.) chest.
with BP precaution  GU: polyuria, 3. Watch for 3. Tell patient drug
urinary retention excessive fluid may cause thirst
loss and signs and or dry mouth.
 METABOLIC: symptoms of Emphasize that
dehydration, water hypovolemia and fluid restrictions
intoxication, dehydration. are necessary, but
hypernatremia, 4. Assess for that frequent
metabolic acidosis, evidence of mouth care
hypokalemia circulatory should case these
overload, symptoms.
 RESP: pulmonary including 4. As appropriate,
congestion. pulmonary review all other
edema, water significant and
 SKIN: rash, intoxication and life-threatening
urticaria. heart failure. adverse reactions
 OTHERS: chills, and interactions,
fever, thirst, edema especially those
 and tissue necrosis. related to the
drugs and tests
mentioned above.

DRUG INDICATION ACTION SIDE/ADVERSE NURSING PATIENT

EFFECTS CONSIDERATION TEACHINGS

Date ordered: Specific The patient is given  Dizziness 1. Monitor the 1. Advice the
August 17, 2010 Treatment of generalized Phenobarbital PO q12°  Headache patient before mother to check
tonic-clonic and cortical to help free from  Hypotension and after therapy prescriptions
Generic Name: focal seizures; emergency seizure activity.  Bradycardia to know the and refills
Phenobarbital control of acute  GI disturbances effectiveness of because
convulsions Depressant and  Allergic reaction the drug. Phenobarbital is
Brand Name: anticonvulsant effects  Sedation and 2. Assess seizure available in
-- General may be realted to its depression may activity: type, different forms.
Short term treatment of ability to increase occur location, 2. Do not take
Classification: insomnia; preanesthetic and/or mimic the duration and with alcohol for
Barbiturates sedation. inhibitory activity of character. it can increase
GABA on nerve 3. Assess for drug the chances of
Dosage: impulses (depress CNS induced adverse the adverse
60mg ½ tab q12° PO synaptic transmission reactions. effects.
and increase seizure 4. Assess for 3. Avoid activities
activity threshold in the barbiturate that require
motor cortex.) As a toxicity: cold alertness for
sedative, it may also clammy skin, phenobarital
interfere with the cyanosis. induce
transmission of sleepiness.
impulses from the 4. Advice mother
thalamus to the brain to turn patient
cortex. q2° to prevent
orthostatic
hypotension.
 DRUG INDICATION ACTION SIDE/ADVERSE NURSING PATIENT
EFFECTS CONSIDERATION TEACHINGS

Date ordered: Infections of the The patient was given  Nausea 1. Assess the 1. Advise mother
August 17, 2010 respiratory tract, middle Ciprofloxacin ½ tab  Diarrhea patient for any to report
ear, paranasal sinuses, eyes, q12° to help inhibit or  Rash previous occurrence of
Generic Name: kidneys and/or, urinary possibly destroy the  Allergic reactions sensitivity any adverse
Ciprofloxacin tract, genital organs microorganism in the  Sleep disorders reaction. reaction.
including adnexitis, clients body.  Thrombophlebitis 2. Assess the 2. Instruct patient
Brand Name: gonorrhea, prostatitis,  Photosensitivity patient for signs to take drug on
-- abdominal cavity (e.g. Inhibits bacterial  Renal impairment and symptoms of the length of
infections of the GIT or DNA gyrase thus infection before time ordered.
Classification: biliary tract, peritonitis), preventing replication and during 3. Avoid taking
Antibiotic: skin and soft tissue, bones in susceptible bacteria. treatment. antacids,
fluoroquinolones and joints; sepsis, 3. Assess the vitamin or
infections or imminent risk patient for any mineral
Dosage: of infections (prophylaxis) allergic reaction supplements
500mg ½ tab q12° PO in patients whose immune or anaphylaxis. within 6 hours
system has been weakened 4. Assess for the before or 2
(e.g. patients on client’s renal hours after you
immunosuppressants or function before take
have neutropenia). and during ciprofloxacin.
Selective intestinal therapy 4. Advise patient
decontamination in to report
immunosuppressed itching, malaise,
patients. Acute redness, pain,
uncomplicated UTI (acute swelling.
cystitis). Uncomplicated
UTI including acute
uncomplicated
pyelonephritis.
VIII. LIST OF PRIORITY PROBLEMS

1. Ineffective cerebral tissue perfusion

2. Hyperthermia

3. Imbalanced Nutrition: Less than body requirements

4. Impaired skin integrity

5. Risk for aspiration

IX. NURSING CARE PLAN

Cues/data Nursing Diagnosis Rationale Goals and Interventions Rationale Evaluation

Objectives

Subjective: Ineffective cerebral Increased intracranial After 4 hours of Independent: After 4hours of
“Hindi niya na tissue perfusion pressure can be due continuous nursing - Assessment of vital continuous
maigalaw ang ulo at related to to a rise in interventions, the -Monitoring the vital signs is an important intervention, the goal
mga paa niya para compression of cerebrospinal fluid patient will show signs of the patient component of the was PARTIALLY
din siyang cerebral arteries pressure. It can also signs of increased physical therapy MET as evidenced
naninigas” As secondary to be due to increased tissue perfusion as examination and by :
verbalized by the increased pressure within the evidenced by : should be included in - Vital signs within
patient’s mother. intracranial brain matter caused - Vital signs within the examination of client’s normal
pressure (ICP) by a mass (such as a client’s normal all patients. range.
Objective cues: tumor), bleeding into range. Knowledge of vital - no seizure episodes
-hydrocephalus- the brain and -Avoiding the signs allow the nurse
communicating cerebral artery patient to have to understand a
-increased ICP compression. seizures patient’s physiologic
-restlessness status and is helpful
-changes in pupillary Reduced arterial Long-term goal: in determining
reactions(non- blood flow causes appropriate goals
reactive) decreased nutrition mental status of the -Monitor the LOC interventions needed
-presence of NGT and oxygenation at patient(alert) by the patient.
-use of accessory the cellular level. -Monitoring the LOC
muscles to breath Management is will give the nurse a
-extremity weakness directed at removing baseline data, helps
-muscle rigidity vasoconstricting in determining the
factor(s), improving -Avoid measures that status of the patient,
peripheral blood will trigger increase the patient’s
flow, and reducing of ICP of the patient response to
metabolic demands such as straining, medications.
on the body. positioning the neck -Avoiding these
Decreased tissue of the patient in measures will help
perfusion can be flexion and head flat. the decrease of ICP
transient with few or of the patient and to
minimal - Elevate the patients avoid the further
consequences to the head or the HOB of decrease of cerebral
health of the patient. the patient about 30 blood flow of the
If the decreased – 45 degrees. patient which can be
perfusion is acute fatal.
and protracted, it can -Elevation of the
have devastating head will promote
effects on the patient. -Provide information venous outflow from
Diminished tissue on normal tissue the brain due to the
perfusion, which is perfusion and force of gravity and
chronic in nature, possible impairments this will help in the
invariably results in on the patient’s decrease of the ICP
tissue or organ mother. of the patient.
damage or death. - Educating the
mother will give the
mother the idea if the
patient is
-Explain all experiencing any
REFERENCES: procedures and abnormalities and
-Mosby’s pocket equipments to the this will also
dictionary of patient mother. establish cooperation
medicine, Nursing with the mother.
and health -Explaining the
professions.(p.660) procedures and
-http://en.wikipedia. equipments may
org/wiki/I reduce the anxiety of
ntracranial_pressure the patient’s mother
on the unknown and
-Instruct patient’s this will also help in
mother to inform the the establishment
nurse immediately of cooperation with the
symptoms of mother
decreased perfusion - Having the
persist, increase or cooperation of the
return patient’s mother will
help in the
-observe seizure monitoring of the
precaution for the patient and early
patient: assessment facilitates
 Provide dim prompt treatment.
light - to avoid
 Side rails progression of
 Avoid seizure and the risk
exposure to for injury of patient.
electricfan
 Avoid noise
 Avoid jarring
of the bed

DEPENDENT:
-Administer
anticonvulstants and
osmotic diuresis -to avoid patient on
prescribed by the having seizures
doctor when it is which can result
needed. from cerebral edema
or ischemia and to
reduce increase ICP.

REFERENCES:
-Nurse’s Pocket
guide 11th edition, by
Dooenges,
Moorhouse and Murr
(p. 708)
-Nursing Care plans
by Gulanick and
Myers(p.200)
 Cues / Data Nursing Diagnosis Rationale Goals and Interventions Rationale Evaluation
Objectives
Subjective cues: Hyperthermia The child may After 4 hours of Independent: After 4 hours of
“ Mainit siya tapos related to infection develop fever as a nursing intervention  Assess for  To know if nursing intervention
ilang araw na hindi secondary to symptom of a wide the patient body neurological its increasing The goal was not
bumaba ang lagnat meningitis variety of illnesses temperature will response; or decreasing met as evidence by
niya” as verbalized as well as from reduce to 37°C noting the the body temperature
by his mother. infections. For level of of the patient is still
example, certain consciousnes 39°C
blood disorders and s and
Objective data:
inflammatory orientation,
 Flush skin disorders (eg  Central
reaction to
 Warm to juvenile arthritis) hypertension
stimuli of
touch may cause fever. or
pupils
 T: 39.7°C Fever can also be peripheral/pos
 Monitor core
 RR: 26 caused by sunstroke tural
temperature,
 BP 140/100 and some childhood hypotension
 PR:144 immunisations. occurs
 Monitor BP
However, most
and heart and
episodes of fever are
rhythm
caused by viral
 Hyperventilati
infections.
 Monitor on may
respiration initially be
present, but
ventilatory
 Monitor/ effort may
record all eventually
sources of impaired by
fluid loss seizure,
such as hypermetaboli
urine; c rate (shock
vomiting and and acidosis)
diarrhea;wou
 nd and
insensible  Oliguria
loses and/or renal
failuremay
 Monitor occur due to
laboratorial hypotension,
studies such dehydration,
as ABGs, shock
electrolyte,
cardiac and  It may reveal
liver enzyme tissue
degeneration
 Promote
surface  Cool
cooling by environment
means of can or helps
undressing; the body
cool and temperature to
environment decrease
 Could lower
 Encourage down the
TSB body
Dependent: temperature
 Administer
medication
o (para  To rapid
cetam decrease body
ol) temperature
 Cues / Data Nursing Rationale Goals and Objective Intervention Rationale Evaluation
Diagnosis
Subjective Data: Imbalanced Adequate nutrition is After 4 hours of 1. Place the child in 1. Provide most After 4 hours of
“Nangayayat na nga Nutrition: Less than necessary to meet nursing intervention, position of appropriate nursing intervention,
sya ngayon eh” as Body Requirements the body’s demands. the patient will comfort for position to enhance goals fully met as
verbalized by the related to inability Nutritional status experience gradual feeding. movement of evidenced by:
mother to ingest food can be affected by balanced nutrition as formula by gravity
disease or injury manifested by: and peristalsis and - complied time of
Objective data: states social factors to prevent vomiting feeding
-complying to the or aspiration
-Iron Deficiency feeding time of the -health teaching was
Anemia as patient 2. Promotes provided to the
evidenced by information to parents.
laboratory results: -giving of prescribed ensure stable
RBC count ↓3.74 supplement or 2. Teach parent weight and gains
vitamin if available about caloric proportionate to
Hemoglobin ↓8.63 needs for age of growth
-provide parents child and in weight
Hematocrit ↓27.68 information about the and height 3. Prevent spoiling
appropriate nutrition. measurement. and contamination
MCV ↓74.03 of food that may
3. Teach parent cause
MCH ↓23.09
about proper gastrointestinal
MCHC ↓31.09 preparation and symptoms.
storage of food;
- 20.4 Kg upon hand wash before
admission, 12.9 Kg preparing or
present weight handling food.

-BMI 10.8
-Underweight
 Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation
Diagnosis Objectives

O Subjective data:
“Namamalat na yung
bandang ari niya at sa may
pwet.” As verbalized by the
patient’s mother.
Objective data:
- disruption of the
epidermis
- redness
- immobility/inactivity
- neuromascular
impairment
VS Taken:
BP: 140/100
RR: 26
PR: 144
TEMP: 39.7˚ C
Impaired skin Decreased muscle After 4hrs. of given Independent: The patient able to
integrity r/t strength intervention the *client teaching *To prevent maintain physical
physical ↓ patient will maintain complications well being after the
immobilization Body weakness physical well-being given 4hrs.
↓ * obtain a history of intervention thus
Irritability Long-term goal: condition, Including age *To monitor the goal is partially
↓ Timely wound at onset, duration of progress or healing met
Physical immobility healing problem and changes
↓ over time
Risk for skin integrity
*inspect skin on a daily *enhanced
*Medical-Surgical basis circulation to
Nursing 11th Edition; compromised tissue
Brunner & *Assess skin *this may indicate
Suddarth”s routinely, noting particular
moisture, color, and vulnerability
elasticity
*Observe for *Reduces likelihood
reddened/blanched of progression to
areas or skin rashes, skin
and institute breakdown
treatment
immediately

*Provide adequate *To prevent

clothing/covers; vasoconstriction
protect from drafts
*Emphasize *To maintain
importance of general good health
adequate and skin turgor
nutritional/fluid
intake

* stress proper hand *promoting hygienic

hygiene to all care procedures is a key
givers and other in infection
infection control prevention
procedures

* proper technique when *frequent change of

cleaning the patients wound dressing will
skin is needed prevent infection

*encourage turning *to promote good

position of the patient circulation that
every 2hours contribute to faster
healing and avoid
friction and pressure

*put calamine *hygienic purposes

lotion/powder and to promote
faster healing

Dependent: *Relieves pain felt

* give the proper by
medications as directed the patient
by the physician
*Nursing Care
 Plans;7th
Edition;Doenges,Mo
orehouse,Murr

Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation

Diagnosis Objectives

OBJECTIVE: Risk for Aspiration is defined After hours of Independent After hours of
aspiration as the inhalation of nursing intervention nursing intervention
➢ Improper NGT feeding related to the patient will be  Monitor level of  A decreased the Goal was MET
either oropharyngeal
consciousness. level of
knowledge or gastric contents able to: consciousness is by: Patient was able
deficit. into the a prime risk to maintain patent
lower airways. factor for airway. Patient’s
Inhalation of these aspiration. risk of aspiration is
 Patient  Assess cough and
contents can lead to maintains patent decreased as a
aspiration pneumonia gag reflexes.
airway. result of ongoing
and  A depressed
 Patient’s risk of assessment and
cough or gag
aspiration aspiration is
reflex increases early intervention.
pneumonitis. decreased as a
the risk of
Although these two result of  Assess pulmonary
aspiration.
entities are managed ongoing status for clinical
differently, they are assessment and evidence of
early aspiration.  Aspiration of
often interchangeably
intervention. Auscultate breath small amounts
referred to as
sounds for can occur
aspiration development of
pneumonia. without
crackles and/or coughing or
Aspiration rhonchi. sudden onset of
pneumonitis respiratory
represents chemical distress,
damage to the especially in
tracheobronchial tree  Keep suction setup patients with
caused available  decreased levels
by acute, often of
consciousness.
witnessed, inhalation  Position patients
of regurgitated gastric who have a
contents in patients decreased level of  This is
with an consciousness on necessary to
acute change in their sides. maintain a
mental status. patent airway.
Aspiration
pneumonia results
 This protects
from chronic, usually the airway.
unwitnessed, Proper
inhalation of small positioning can
amounts of decrease the
 Position patient at risk of
oropharyngeal
90-degree angle, aspiration.
contents leading to an whether in bed or in
infectious process. Comatose
a chair or patients need
wheelchair. Use frequent turning
cushions or pillows to facilitate
to maintain position. drainage of
secretions.
 Maintain upright
position for 30 to 45  Proper
minutes after positioning of
feeding. patients with
swallowing
difficulties is of
primary
importance
 during feeding
or eating.

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

 This removes
residuals and
reduces
pocketing of
food that can be
later aspirated.