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NCP

Scientific Goals and Nursing
Cues Problem Rationale Evaluation
Reason objectives Intervention

Subjective: Risk for Wounds Goal:  Assess signs  Fever Goal met:
infection involving At the end of and symptoms may indicate
related to injury to soft hospitalization, of infection infection. Patient was
Objective: jejunoctomy tissue can patient will not especially free from any
surgery vary from manifest any temperature. signs and
 T-36.3°C secondary to minor tears to signs and symptoms of
 Weak in impaired severe symptoms of  It serves infections as
appearance skin integrity crushing infection  Emphasize as a first line manifested by
 Clean and injuries. The the importance of defense absence of
intact decision to of handwashing against fever.
abdominal suture a Objective: technique. infection.
dressing wound
depends on After 30 minutes  Maintain
the nature of of nursing aseptic  Regular
the wound the intervention, the technique when wound
time since the patient will be changing dressing
injury was able to dressing/caring promotes fast
sustained the understand the wound. healing and
degree of importance of drying of
contamination being free of  Keep area wounds.
. infection around wound
clean and dry.  Wet area
Reference: Within the shift, can be lodge
Brunner & patient will be area of
 Emphasized
Suddarth’s able to identify bacteria
necessity of
Textbook of ways to reduce taking
Medical- risk for infection. antibiotics as  Prematur
Surgical ordered. e
Nursing 11th The patient will discontinuati
edition by be able to on of
Smeltzer, demonstrate treatment
Bare, Hinkle, different ways of when client
Cheever protecting begins to feel

oneself in well may preventing result in infection. ceftraxone synthesis of ory to dizziness. with any other bacterial cell infection cephalosporin lethargy. antimicrobial wall. bacteria GI: Nausea. anorexa patients with . return of infection. DRUG STUDY DRUG DOSE. ceftriaxone media. acute or penicillin. renal failure. causing s. cautiously with diarrhea. paresthsias drug. blood levels in UTI. celldeath. > Monitor l otitis > Use vomiting. TION ACTION ON ION AND EFFECTS/ADVER RESPONSIBILIT FREQUEN CAUTIONS SE EFECTS ITES CY Cefuroxi 750 mg >Antibiotic >Bactericidal: >Lower Contraindicate CNS: >Do not mix me TIV inhibits respirat d with allergy Headache. CLASSIFICA MECHANISM OF INDICATI CONTRAINDICAT SIDE NURSING ROUTE.

iron. GI: transient . > Avoid decreased acohol while platelets. Skin pregnancy. CLASSIFICA MECHANISM INDICAT CONTRAINDICA SIDE NURSING ROUTE. Local: Pain. GU: severe renal ea. drug and for 3 Hypersensitivit days after y: tanging because from rash to severe fever to reactions anaphylaxis often occur. s. folate levels needed for cell or cobalt. Gonorrh lactation. disulfiram- like reaction with alcohol. taking this decreased Hct. abscess at infection site Other: Superinfection s. hct. with structur Bone marrow renal and e depression – hepatic infection decreased impairment. function and is vitamin B12 heart failure. Vit. WBC count. B12. count. DRUG DOSE. TION OF ACTION ION TION AND EFFECTS/ADVE RESPONSIBILI FREQUE CAUTIONS RSE EFECTS TITES NCY Vitamin 1 amp Vitamins >A coenzyme >Pernici Contraindicate CV: BEFORE: B TIV and that ous d with peripheral Determine complex Minerals stimulate anemia hypersensitive vascular reticulocyte metabolic to thrombosis. Nephrotoxicity impairment and Skin Hematologic: and pt.

before hematopoiesis. history before synthesis. systemic anaphylactoid elimination will reactions with reduce parenteral effectiveness of administration vitamin. transitory administration exanthema. urticaria.replication. Obtain a sensitivity test and myelin Skin: itching. B12 from light. Avoid I. Leber’s Respi: beginning and disease. Don’t mix parenteral preparation in same syringe with other drugs. vitamin B12 routinely. AFTER: Protect Vit. nucleoprotein edema. drug is lost through excretion. Early diarrhea. pulmonary therapy. faster anaphylaxis. pain or DURING: Don’t give large burning at doses of injection site. administration Other: bec. Monitor patient for .V. . Don’t refrigerate or freeze.

Give potassium supplements. . as needed.hypokalemia for first 48 hours. as anemia correct itself.

Jieneth May (head nurse) BSN113 – G51 . Enjay D. Nursing Care Plan And Drug Study (Leadership and Management) Submitted by: Fabros. (staff) Submitted to: Enriquez.