NURSING CARE PLAN

Name: FDE Date Admitted: September 10, 2020

Age: 14 years old Chief Complaints:
Sex: Female Diagnosis: Mild Anaphylaxis, Rhinosinusitis
Civil Status: Single Attending Physician: DR. Michael James Dominguez
Address: Bago, Buenavista, Bohol Ward/Area: Pedia Ward

ASSESSMENT NURSING BACKGROUND PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
Ineffective airway Anaphylactic  also After 8 hours of  Assess the - It will Goal met
Subjective Cues: clearance related to known nursing intervention patient for provide
“ Ga lisud kog allergy secondary to as distributive the patient is will any important After 8 hours of
ginhawa, ping-ot Anaphylaxis shock, or vasogenic able to breathe in previous information nursing intervention
akong ilong” As shock is a life- ease. history of of the , the patient is will
verbalized by the threatening allergic anaphylaxis patient’s able to breathe in
patient. reaction that is or allergic past ease.
caused by reaction. medical
a systemic antigen- history, thus
Objective Cues: antibody immune  Place the can give the
-Occasional cough response to a patient in a nurse and
noted foreign substance Fowler’s overview on
-Difficulty of (antigen) position/se how to
breathing introduced into the mi fowler’s handle the
-Nasal Congestion body. It position situation.
with moderate clear is characterized by a
discharge smooth muscle cont - Allows the
-Watery eye raction, massive  Check patient to
-Fatigue vasodilation and airway improve its
Vital signs: increased capillary clearance breathing
permeability capacity to
BP= 110/60 mmHG triggered by a  Administer the
PR=84bpm release of oxygen if maximum.
RR=14bpm histamine. It occurs necessary
T=36.5 degrees within seconds to - Any airway
centigrade minutes after obstruction
contact with an  Assess if the should be
antigenic patient is removed.
substances and responding
progresses rapidly well to the - Improves
to respiratory medication. body
distress, vascular oxygenation
collapse, systemic  Monitor .
shock, and possibly patient’s
death if emergency oxygen - If the
treatment is not saturation patient is
initiated. Causative by using a not
agents include pulse responding
severe reactions to oximeter to the first
a sensitive shot, the
substance such as a doctor
drug, vaccine, food  Once the might order
(e.g., eggs, milk, patient is another
peanuts, shellfish), stable, in shot after
insect venom, dyes depth 15 mins.
or contrast media, medical
or blood products. history is - A 98-100%
necessary. oxygen
saturation is
needed to
make sure
that the
patient is
getting
enough
oxygen in
his/her
body.

- To
understand
and
document
the
patient’s
medical
history , you
 help to
assure that
you and the
patient
health care
providers
provide the
most
appropriate
and
effective
treatment
and support
for the
patient
illnesses
and health
conditions
so that they
maintain
the best
possible
health.
Subjective Cues: Impaired skin Rash is a symptom After 8 hours of >Recommended >To reduce risk of After 8 hours of
“ Katol pod akong integrity related to that causes the nursing intervention keeping nails short. dermal injury when nursing intervention
tibuok lawas” as alteration in skin as affected area of skin the patient will be severe itching is the patient will be
verbalized by the manifested by to turn red and able to demonstrate present able to demonstrate
patient presence of rashes blotchy, and to behaviours/ >Kept the area behaviours/
on chest. swell. A rash may techniques to affected clean and >To prevent further techniques to
Objective Cues: cause spots that are prevent skin dry invasion of prevent skin
-Itching bumpy, scaly, flaky, breakdown microorganism breakdown
-Rashes on chest or filled with pus.
and extremities five Rashes can vary in >Removed wet/ >Moisture
after eating shrimp location, pattern wrinkled linens potentiates skin
and peanut sauce and extent and may breakdown
-Warm and Dry occur in any area of
the body. A chest >Instructed patient >To prevent skin
Vital signs: rash can have a not to use tight irritation
BP= 110/60 mmHG variety of causes, clothings
PR=84bpm and it may indicate >Administered >To decrease
RR=14bpm something occurring triderm as ordered. irritable itching
T=36.5 degrees around the chest
centigrade itself or suggest a
systemic (body-
wide) condition.