ACTUAL NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Intervention Evaluation

Subjective Fluid volume deficit related Short term goal Encourage client to Short term goal
“Nararamdaman ko din na to active fluid volume loss After 1-2hours of nursing increase oral fluid intake After 1-2 hours of nursing
nanghihina ako at para (diarrhea) intervention, the client will intervention, the client
bang palage ako walang maintain adequate fluid Provide meticulous oral maintained adequate fluid
lakas” Verbalized by volume loss through fluid care volume versus active fluid
patient hydration and monitoring loss as evidenced by an
of intake and output Check voiding and record increase in oral fluid intake
Objective amount from 500 ml to 1000ml
 Decrease urine Long term goal with moistened mucous
output 25cc/hr After 8 hours of nursing Promote a quiet membrane, good skin
 Decrease oral fluid intervention, the client will environment and bed rest turgor and increase urine
intake(400-500ml) have an increase in energy output of 30cc/hr-goal
 Poor Skin turgor levels and prevent further Regularly assess client for partially met
 Pale nail beds complication as evidence changes in conditions
 Pale palpebral by patient’s verbalization Long term goal
 Slightly pale nasal of an increase energy level Strictly monitor I/O
and buccal mucosa After 8 hours of nursing
 Dry and Cracked intervention., the client
lips reported a slight increase
 Thready/weak in energy level and absence
pulse of complication as
verbalized by the patient.
-goal partially met.
 Therapeutic Action
Classification
Metronidazole is selectively absorbed by
anaerobic bacteria and
Classification: sensitive protozoa. Once
Antipotozoal taken up by anaerobes, it
is non-enzymatically
reduced by reacting with
reduced ferredoxin,
which is generated by
pyruvate oxido-
reductase. Many of the
reduced nitroso
intermediates will form
sulfinamides and
thioether linkages with
cysteine-bearing
enzymes, thereby
deactivating these critical
enzymes.
Contraindication Toxicity Effect Indications Safety Dosage
Check with your Along with its needed Amebiasis. Flagyl For amebiasis
physician if you have effects, a medicine may (metronidazole) is infections:
cause some unwanted indicated in the
any of the following: effects. Although not all of treatment of acute Adults and
these side effects may occur, intestinal amebiasis teenagers—500 or
Conditions: if they do occur they may (amebic dysentery) and 750 milligrams (mg)
Alcohol Intoxication, need medical attention. amebic liver abscess. 3 times per day for
Lower Seizure Check with your doctor In amebic liver abscess,
5 to 10 days.
Threshold, immediately if any of the Flagyl (metronidazole)
Any Disorder of the following side effects occur: therapy does not Children—Dose is
Brain, Numbness, obviate the need for based on body
More common aspiration or drainage of
Tingling or Pain of weight and must be
 Agitation pus.
Hands or Feet,  Back pain
determined by your
Meningitis Not  Blindness Anaerobic Bacterial doctor. The dose is
Caused by an  Changes in speech Infections. Flagyl usually 35 to 50
Infection, patterns (metronidazole) is milligrams (mg) per
Severe Liver  Depression indicated in the
kilogram (kg) of
 Dizziness treatment of serious
Disease, Seizures,  Drowsiness infections caused by body weight per
Decreased  Eye pain susceptible anaerobic day, divided and
Neutrophils a Type  Fever bacteria. Indicated given in 3 doses, for
 surgical procedures
of White Blood Cell, Hallucinations 10 days.
 Headache should be performed in
Habit of Drinking conjunction with Flagyl
 Irritability
Too Much Alcohol (metronidazole)
 Lack of
coordination therapy. In a mixed
Allergies:  Mood or mental aerobic and anaerobic
changes infection, antimicrobials
NITROIMIDAZOLES appropriate for the
 Nausea
treatment of the aerobic
 Seizures
infection should be used
 Shakiness and
in addition to Flagyl
unsteady walk
(metronidazole) .
 Slurred speech
 Stiff neck or back
 Trouble speaking
 CNS For dermatologic
Cefuroxime Inhibits synthesis of An allergic reaction : Headache,dizziness, 750mg TIV q 8
bacterial cell wall, causing (difficulty breathing; infections, caused
lethargy,paresthesias
Classification cell death closing of the throat; GI by S.aureus, S.
Antibiotic swelling of the lips, : Nausea, vomiting, diarrhea, pyogenes
face, or tongue;
anorexia, abdominal pain, Fights bacteria in
flatulence, the body.
hives; or a rash). pseudomembranous colitis,
Rash, redness or liver toxicity
Is used to treat
itching. Hematologic many different
Severe nausea, : Bone marrow types of bacterial
depression:decreased WBC, infections.
vomiting, or diarrhea decreased platelets,
decreased Hct
GU
: Nephrotoxicity
Hypersensitivity
:Ranging from rash to fever
to anaphylaxis, serum
sickness reaction
Other
:Super infections,disulfiram-
like reaction with alcohol
 Assessment Nursing Diagnosis Planning Intervention Evaluation
Subjective Ineefective cerebral tissue After 8 hours of nursing Monitor After 8 hours of nursing
“napansin ko na hindi perfusion related to intervention the patient temperature.Administer intervention.the patient
normal ang laki ng ulo ng arterial or venous blood will demonstrate TSB in presence of fever. was able to demonstrate
anak ko” verbalized by flow improved vital signs and improved vital signs of
mother absence of signs of Monitor Intake/Output increase icp
increased ICP
Objective Maintained head or neck
REstlessnesss in midline or in neutral
Irritability position
Changes in vital signs
V/S Taken as follow Provide rest periods
T=37.5 between care of activities
P=90 and limit duration of
R=22 procedures

Decrease extraneous
stimuli and provide
comfort measures as back
massafe,quiet
environment genile touch.

Help patient avoid or limit

coughing,cring vomiting
and straigning of stool

Elevate The Head of bed

gradually to 15-30 degress
as tolerated or indicated

Administer diuretics as
indicated
 Therapeutic Action Contraindication Toxicity Effect Indication Safety dosage
Classification
Ampicillin Inhibits bacterial cell wall  Hypersensitivity Treatment of Usual Pediatric Dose
Call your doctor at for Bacterial
Classification synthesis by binding to one or to penicillins. once if you have a UTI, otitis media, Endocarditis
Systemic Anti- more of the penicillin binding Infectious serious side effect sinusitis,bronchitis, Prophylaxis
infectives proteins (PBPs); which in turn such as: uncomplicated
mononucleosis. Low to moderate risk:
inhibits the final  Use cautiously  fever, sore community-acquired 50 mg/kg IV or IM 30
minutes before
transpeptidation step of with renal throat, and pneumonia,Haemophil procedure.
headache with
peptidoglycan synthesis in disorders. a severe
us influenzae
High risk: 50 mg/kg
bacterial cell walls, thus blistering, infections and plus gentamicin 1.5
inhibiting cell wall peeling, and invasives almonellosis mg/kg, both
red skin rash; intramuscularly or IV
biosynthesis. Bacteria  diarrhea 30 minutes before
eventually lyse due to ongoing that is watery or procedure. Follow
activity of cell wall autolytic bloody; with ampicillin 25
 fever, chills, mg/kg IV or IM, or
enzymes (autolysins and body aches, flu amoxicillin 25 mg/kg
murein hydrolases) while cell symptoms; orally, 6 hours after
initial dose.
wall assembly is arrested.  easy
bruising or Usual Pediatric Dose
bleeding, for Meningitis
unusual
weakness; Neonates:
 urinating < 7 days, birthweight
less than usual < 2000 g: 50 mg/kg
or not at all; IV every 12 hours.
 agitation, < 7 days, birthweight
confusion, > 2000 g: 50 mg/kg
unusual IV every 8 hours.
thoughts or > 7 days, birthweight
behavior; or < 1200 g: 50 mg/kg
IV every 12 hours.
 seizure > 7 days, birthweight
(black-out or 1200 to 2000 g: 50
convulsions). mg/kg IV every 8
hours.
> 7 days, birthweight
> 2000 g: 50 mg/kg
IV every 6 hours.

Infants and children:

50 to 100 mg/kg IV
every 6 hours.
Maximum dose 12
g/day.

Ampicillin should be
given in combination
with another
antibiotic, depending
on the nature of the
infection.

Usual Pediatric Dose

for Skin or Soft Tissue
Infection

IV: 6.25 to 12.5

mg/kg every 6 hours
(maximum 12 g/day).

Oral: 6.25 to 12.5

mg/kg every 6 hours
(maximum 2 to 3
g/day).
 0.5 to 2 g/kg IV
Mannitol Increases osmotic pressure of  Active  To reduce infusion as15% to
25% solution given
Classification plasma in glomerular filtrate, intracranial intracranial over 30 to60
Diuretics inhibiting tubularre absorption bleeding pressure and minutesMannitol
(Osmitrol)
of water and electrolytes (except during brain mass 150cc IV q8
(including sodium and craniotomy)
potassium).  Test dose for
 Anuria marked
These actions enhance water secondary to oliguria or
flow from various tissues and severe renal suspected
ultimately decrease disease inadequate
intracranial and intraocular renal function
pressures; serum sodium level  Progressive
rises while potassium and heart failure,  To prevent
blood urea levels fall pulmonary oliguria during
.Also protects kidneys by congestion, cardiovascular
preventing toxins from renal damage, and other
forming and blocking tubules or surgeries
renaldysfunctio
n after  Acute oliguria
mannitol
therapy begins  To reduce
intraocular
 Severe pressure
pulmonary
congestion or  To promote
pulmonary diuresis in
edema drug toxicity

 Irrigation
 Severe during
dehydration transurethral
resection of
prostate
(TURP)