ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

INDEPENDENT: INDEPENDENT:
SUBJECTIVE: Ineffective Within 7-8 1. Position head midline 1. To open or maintain After 7-8 hours
“Inuubo ako at airway hours of with flexion appropriate open airway in at- of proper nursing
nahihirapan ako clearance proper nursing for condition. rest or compromised intervention the
huminga” as related to intervention 2. Encourage the client to individual. patient was able
verbalized by the excessive the patient will do deep breathing and 2. Incision to maximize to have patent
patient. mucus as be able to have coughing exercise. effort. airway as
evidenced by patent airway 3. Suction as indicated: 3. Stimulates cough or manifested by:
OBJECTIVE: productive as manifested frequent coughing, mechanically clears
 Dyspnea cough. by: adventitious breath airway in patient -RR within
 Presence of sounds, desaturation who is unable to do normal range.
yellowish -RR within related to airway so because of -Demonstrated
sputum. normal range. secretions. ineffective cough or reduction of
 Tachycardia -Demonstrate 4. Auscultate breath decreased level of congestion with
 Inability to do reduction of sounds and assess for air consciousness. clear breath
activities of congestion movement. 4. To ascertain status sounds
daily living. with clear 5. Maintain adequate and note progress.
 Temperature: breath sounds. hydration by forcing 5. Fluids, especially
39 °C fluids to at least 3000 warm liquids, aid in
 HR: 112 BPM mL/day unless mobilization and
contraindicated (e.g., expectoration of
 RR: 30 CPM
heart failure). Offer secretions
 BP: 110/70
warm, rather than cold,
mmHg
fluids.
DEPENDENT: DEPENDENT:
1. Administer 1. Bronchodilators are
bronchodilator as medications used to
ordered. facilitate respiration
by dilating the
airways.
ASSSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Nutrition: Within 2-3 INDEPENDENT: INDEPENDENT: After 2-3 days of

“Bigla nalang Imbalanced, days of proper 1. Note real, exact 1. These anthropomorphic proper nursing
bumaba ang less than the nursing weight; do not assessments are vital that intervention the
timbang ko” as body intervention estimate. they need to be accurate. patient was able
verbalized by the requirements the patient will 2. Take a nutritional These will be used as basis to:
patient. related to lack be able to: history with the for caloric and nutrient
of information participation of requirements. - Demonstrated
OBJECTIVE: as evidenced - Demonstrate significant others. 2. Family members may progressive
by weight progressive 3. Promote proper provide more accurate weight gain
 Loss of loss. weight gain positioning. details on the patient’s toward goal.
weight toward goal. 4. Offer high protein eating habits, especially if - Verbalized
with - Verbalize supplements based patient has altered understanding of
adequate understanding on individual needs perception. causative factors
food of causative and capabilities. 3. Elevating the head of bed 30 when known and
intake. factors when 5. Consider the degrees aids in swallowing necessary
 Weaknes known and possible need for and reduces risk for intervention.
s necessary enteral or parenteral aspiration with eating.
 Poor intervention. nutritional support 4. Such supplements can be
muscle with the patient, used to increase calories and
tone family, and protein without conflict with
 Weight caregiver, as voluntary food intake.
of 72 appropriate. 5. Nutritional support may be
kgs, it 6. Offer liquid energy recommended for patients
went supplements and who are unable to maintain
down to multivitamins 1 nutritional intake by the oral
58 kgs capsule a day route.
over a 6. Energy supplementation has
year. COLLABORATIVE: been shown to produce
1. Ascertain healthy weight gain.
body weight for age COLLABORATIVE:
and height. Refer to 1. Experts like a dietician can
a dietitian for determine nitrogen balance
complete nutrition as a measure of the
assessment and nutritional status of the
methods for patient.
nutritional support.
PATIENT CHARTING DATE AND TIME:
12/07/21 7:00 AM-3:30 PM
“Inuubo ako at nahihirapan ako huminga” as verbalized.

 Dyspnea
 Presence of yellowish sputum.
 Tachycardia
 Inability to do activities of daily living.

Within 7-8 hours of proper nursing intervention the client will be able to have patent airway as manifested
by:
-RR within normal range.
-Demonstrate reduction of congestion with clear breath sounds.
7:00 AM- Positioned head midline with flexion appropriate for condition.
8:00 AM- Encouraged the client to do deep breathing and coughing exercise.
9:00 AM- Suctioned as indicated: frequent coughing, adventitious breath sounds, desaturation related to
airway secretions.
10:00 AM- Auscultated breath sounds and assess for air movement.
11:00 AM- Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless contraindicated
(e.g., heart failure). Offer warm, rather than cold, fluids.
2:00 PM- Administered bronchodilator as ordered.

 RR within normal range.

 Demonstrated reduction of congestion with clear breath sounds.
 Able to consume food served.
 Endorsed

ROMERO, DEINIELLE INGRID M. SN

PATIENT CHARTING: DATE AND TIME:
12/07/21 7:00 AM- 3:30 PM
“Bigla nalang bumaba ang timbang ko” as verbalized by the patient.

 Loss of weight with adequate food intake.

 Weakness
 Poor muscle tone
 Weight of 72 kgs, it went down to 58 kgs over a year.
Within 2-3 days of proper nursing intervention the patient will be able to:
- Demonstrate progressive weight gain toward goal.
- Verbalize understanding of causative factors when known and necessary intervention.
7:00 AM- Noted real, exact weight; do not estimate.
8:00 AM- Taken a nutritional history with the participation of significant others.
10:00 AM- Promote proper positioning.
12:00 PM- Offered high protein supplements based on individual needs and capabilities.
1:00 PM- Considered the possible need for enteral or parenteral nutritional support with the patient,
family, and caregiver, as appropriate.
2:00 PM- Offered liquid energy supplements and multivitamins 1 capsule a day.
3:00 PM- Ascertained healthy body weight for age and height. Refer to a dietitian for complete nutrition
assessment and methods for nutritional support.

 Demonstrated progressive weight gain toward goal.

 Verbalized understanding of causative factors when known and necessary intervention.
 Have weight within 10% of ideal body weight.
 Able to consume food served.
 Endorsed

ROMERO, DEINIELLE INGRID M. SN

 Name of Drug Classification Mechanism of Action Indication Contraindications Side Effects Nursing Responsibilities
of Drug
Generic Name: Therapeutic: Bind to bacterial cell wall Treatment of Hypersensitivity to GI: Before:
membrane, causing cell cephalosporins and
Cefuroxime Anti-infectives It is effective for Diarrhea,
death related  Determine history
the treatment of antibiotics; nausea, antibiotic-
penicillinase- pregnancy of hypersensitivity reactions
Trade Name: Pharmacologic producingNeisseria (category B), associated colitis.
Therapeutic Effects: to cephalosporins,
: lactation.
Ceftin
Bactericidal action gonorrhoea(PPNG) penicillins, and history of
Second
. Skin:
generation allergies, particularly to
Cephalosporins Effectively treats Ra sh , drugs, before therapy is
bone and joint
Content: pruritus, urticaria. initiated.
infections,
Pregnancy bronchitis,  Lab tests: Perform
Catergory B
meningitis, Urogenital: culture and sensitivity tests
gonorrhea, otitis
Maximum Dose: media, Increased serum before initiation of therapy
pharyngitis/tonsilliti creatinine and
BUN, decreased and periodically during
s, sinusitis, lower
creatinine therapy if indicated.
respiratory tract clearance.
Minimum Dose: infections, skin and Therapy may be instituted
soft tissue
pending test results.
infections, urinary Hemat:
tract infections, and Monitor periodically BUN
is used for surgical Hemolytic anemia
Availability: and creatinine clearance.
prophylaxis,
Tablets: 125mg, 250mg, reducing or
500mg MISC:
eliminating
Powder for injection: infection. Anaphylaxis
750mg, 1.5g, 7.5g
Premixed containers:
750 mg/50ml, 1.5g/50ml During:

 Inspect IM and IV
injection sites frequently for
Source:
signs of phlebitis.
Davis Drug Guide for
 Monitor for
Nurses 10th Edition
manifestations
of hypersensitivity (see
Appendix F). Discontinue
drug and report their
appearance promptly.
 Monitor I&O rates and
pattern: Especially
important in severely ill
patients receiving high
doses. Report any
significant changes.
 Report onset of loose
stools or diarrhea. Although
pseudomembranous colitis
(see Signs & Symptoms,
 Appendix F) rarely occurs,
this potentially life-
threatening complication
should be ruled out as the
cause of diarrhea during
and after antibiotic therapy.
After:

 Instruct patient to take

medication around the
clock at evenly spaced
times and to finish the
medication completely,
even if feeling better
 Advise patient to report
signs of superinfection and
allergy
 Instruct patient to notify
health professional if fever
and diarrhea develop