VIII.

DRUG STUDY

Drug Dosage Mechanism of Indication & Side Effects & Adverse Nursing Responsibilities
Action Contraindication Effects

1-26-2020 ● Monitor renal,

Generic Name: (6PM, Inhibits cell-wall Indication: Side Effects: hepatic, and
12PM) synthesis during ● Septicemia ● N/V, Diarrhea,mild haematologic function
Ampicillin 278mg TIV bacterial rashes periodically; observe
q6 multiplication signs and symptoms
1-26-2020 Contraindication: of anaphylaxis during
Brand Name: (6AM, ● Patients with Adverse Effects: 1st dose
12PM,
hypersensitivity ● Hypersensitivity ● Monitor sodium level
Omnipen 6PM, ● WOF signs and
to penicillins reactions
12MN) symptoms of
295mg TIV ● Anaphylaxis
hypersensitivity
q6
● Tell the caregiver to
Functional Class:
2-1-2020 report episodes of
Aminopenicillins (6AM) diarrhea
295mg TIV ● Notify prescriber if the
OD patient manifests
rashes
Chemical Class:

Beta-lactam
penicillin
antibiotics
Drug Dosage Mechanism of Indication & Side Effects & Adverse Nursing Responsibilities
Action Contraindication Effects

1-26-2020 ● Monitor urinalysis,

Generic Name: (8PM) Inhibits protein Indication: Side Effects: urine output, BUN,
15mg TIV synthesis by ● Septicemia ● N/V, stomach upset, serum creatinine.
Gentamicin OD binding directly to loss of appetite, and ● Weight and assess
30s ribosomal ● injection site hearing prior to
2-1-2020
subunit resulting reactions (pain, initiation, during and
(8AM) Contraindication:
Brand Name: 15mg TIV in a defective irritation, and after treatment in
● Hypersensitivity
OD bacterial cell redness). patients at risk for
to gentamicin
Garamycin membrane; ototoxicity.
and other
2-10-2020 bactericidal. ● Ask the caregiver to
(8AM) aminoglycosides
● Patients who report any adverse
15mg TIV Adverse Effects:
OD have reactions
Functional Class: ● Hearing loss, muscle
pre-existing ● Monitor IVF properly
twitching, seizure,
Aminoglycoside 2-16-2020 hypomagnesemi changes in urine
antibiotics (8AM)
a amount, edema
15mg TIV
OD

2-16-2020
(8PM)
18mg TIV
OD
Drug Dosage Mechanism of Indication & Side Effects & Adverse Effects Nursing Responsibilities
Action Contraindication

Generic Name: 2-1-2020 Inhibits cell wall Indication: Side Effects ● Monitor renal function,
Cefotaxime (8AM, synthesis, ● Septicemia ● N/V, diarrhea CBC w/ differential.
4PM, promoting osmotic ● Injection site Observe for signs and
Brand Name: 12MN) instability; Contraindication: reactions (swelling, symptoms of
Claforan 195mg bactericidal ● Hypersensitivit redness, pain, anaphylaxis during 1st
TIV q8 y to soreness, or a hard dose
Functional Class: cefotaxime or lump), ● Check for IV line patency
Third generation- 2-8-2020 other ● loss of appetite, and appearance of
cephalosporin (6AM, cephalosporin injection site
antibiotics 12PM, s. ● Stomach pain ● Tell caregiver to report
6PM, ● Patient w/ Adverse Effects: any sign of irritation at
12MN) history of IV site
195mg penicillin ● Rash (maculopapular ● Advise caregiver to
TIV q8 allergy or erythematous), report loose stools or
pruritus, fever, diarrhea
2-14-202 eosinophilia;
0 (6AM, inflammation,
12PM, phlebitis,
6PM, thrombophlebitis (IV);
12MN) pain
195 TIV
OD

2-16-202
0
(6AM,
12PM,
6PM,
12MN)
220mg
TIV OD
X. Nursing Care Management

ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTION RATIONALE OUTCOME

OBJECTIVE: Ineffective airway SHORT-TERM GOAL Independent: SHORT-TERM GOAL

clearance related to Goal met.
Productive Cough retained secretions After 10 minutes of Monitored Indicative of
nursing intervention, respiration and respiratory distress
Crackles the patient will be breath sounds and/or accumulation
able to maintain of secretions
Supraclavicular patent airway as
Retraction manifested by
normal breath Suctioned nose, To clear airway when
Chest x-ray shows sounds and no mouth, and trachea excessive or viscous
bilateral pneumonia retractions as necessary secretions are
blocking the airway

This will help open or

Raised the head
maintain open airway
slightly
and improve
LONG-TERM GOAL breathing
LONG-TERM GOAL
After 1 hour of To keep the mucus Goal met.
Kept the patient
nursing intervention, flowing and easy to
hydrated by
the patient will be cough up. Fluids help
instructing the
able to demonstrate minimize mucosal
mother to breastfeed
absence of mucus drying and maximize
secretions and ciliary action to move
maintain normal secretions
breathing Dependent:

Administered oxygen To aid in breathing

 Collaborative:

Coordinated with a Chest physiotherapy

respiratory therapist includes the
for chest techniques of
physiotherapy and postural drainage and
nebulizer chest percussion to
management as mobilize secretions
indicated from smaller airways
that cannot be
eliminated by means
of coughing or
suctioning

ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTION RATIONALE OUTCOME

SUBJECTIVE: Hyperthermia related SHORT-TERM GOAL Independent: SHORT-TERM GOAL

to bacterial Goal met.
Patient’s mother infiltration. Within 1 hour of Encouraged surface To decrease
state that “mainit proper nursing cooling by means of temperature by
siya” intervention we will TSB means through
able to lower the evaporation and LONG-TERM GOAL
patient’s body conduction Goal met.
temperature from
OBJECTIVE: 38 ˚C to 37 ˚C

Skin is warm to touch

Changed clothing to To promote heat loss
Temperature: 38˚C loose and
LONG-TERM GOAL comfortable ones
WBC Count:
After an 8 hours of
23.2 (normal nursing intervention Established and
value:5-10) the client was able to maintain cool and To promote heat loss
maintain core comfortable
CSF WBC: temperature within environment
80 /cu mm (normal normal range of
value:1-9/cu mm) 36.5˚C to 37.5˚C

Maintain fluid intake To prevent

as tolerated. dehydration and
avoid fluid overload
because of risk of
cerebral edema.

Dependent :

Administered
paracetamol 2.8 mL To relieve fever and
every 4 hours as facilitate fast
ordered by the recovery
physician.

Collaborative :

Referred to Medical To indicate presence

Technologies for the of infection and
monitoring of dehydration.
hematologic tests
and other pertinent
 lab records.

ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTION RATIONALE OUTCOME

OBJECTIVE: Interrupted SHORT-TERM GOAL Independent: SHORT-TERM GOAL

breastfeeding related Goal met.
The newborn is to infant illness After 1 hour of Encouraged To determine efforts
diagnosed with a nursing intervention, discussion of needed to continue
disease the mother will be current/previous breastfeeding while
able to identify and breastfeeding circumstances LONG-TERM GOAL
demonstrate experience/s interrupting process Goal met.
techniques to sustain is resolved
Mother is unable to lactation until
provide breast milk breastfeeding is
to newborn reinitiated
continuously
Discussed proper use
To promote the
and choice of
continuity of
LONG-TERM GOAL supplemental
breastfeeding in all
nutrition and
acceptable methods
After 1 week of alternate feeding
nursing intervention method if needed
and 15 minutes of
health teaching,
mutually satisfactory
Reviewed techniques To provide optimal
feeding regimen with
for expression and nutrition and
infant content after
storage of breast milk promote
feedings and gaining
continuation of
weight appropriately breastfeeding
will be achieved process

Recommended using
expressed breast milk
instead of formula or This prevents
at least partial permanent
breastfeeding for as interruption in
long as mother and breastfeeding,
child are satisfied decreasing the risk of
premature weaning

Encouraged the
mother to obtain
adequate rest,
To sustain adequate
maintain fluid and
milk production and
nutritional intake,
breastfeeding
continue her prenatal
process
vitamins, and
schedule breast
pumping every 3
hours while awake,
as indicated

Dependent:

Administered D5IMB
360 cc to run 15cc x
 24hrs as ordered by To keep the patient
the physician hydrated

Collaborative:

Referred to support
This will help in
groups and
monitoring the
community resources
continuity of the
if needed
mother to breastfeed
her child

ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTION RATIONALE OUTCOME

SUBJECTIVE: Risk for unstable SHORT-TERM GOAL Independent: SHORT-TERM GOAL

glucose level related Monitored the To assess for signs of Goal partially met
to insufficient dietary After an 8 hours patient's vital signs. hypoglycemia Patient attained a
OBJECTIVE: intake. nursing intervention glucose level of 105
the patient will be mg/dL
Blood Chemistry: able to attain a Breastfeed the To aid in normalizing
Random blood sugar: glucose level within patient as per blood glucose level LONG-TERM GOAL
80 mg/dL (normal satisfactory range of demand. Goal met.
value 110- 110- 145mg/dL
145mg/dL)
LONG-TERM GOAL

After 5 days of Dependent:

nursing intervention
the patient will be Monitored blood This is due to risk for
able to maintain a sugar level of the hypoglycemia of a
glucose level within patient prior to the patient undergoing
satisfactory range of procedure. NPO prior to the
110- 145mg/dL procedure.

Administered D5IMB To aid in normalizing

360 cc to be given at blood glucose level
15cc/hr for 24 hours

Collaborative:

Referred to the
lactation consultant For modification in
for dietary needs the patient’s food
based on the intake that will
individual situation. contribute in
stabilizing the blood
glucose level.
ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTION RATIONALE OUTCOME

SUBJECTIVE Risk for injury related SHORT-TERM GOAL Independent : SHORT-TERM GOAL
to episodes of seizure Goal partially met.
The parent stated secondary to the After 3 hours of Encouraged surface To decrease After 3 hours of
that the patient had disease condition. nursing intervention cooling by means of temperature by nursing intervention
1 episode of seizure the patient will be TSB means through the patient was able
of less than 5 able to : evaporation and to :
seconds having an -Be free from injury conduction.
upward rolling of the -Attain normal body To provide support -Patient attain lower
eyeball. temperature and prevent any level of potassium as
gradually from injury to the child. evidence of having
OBJECTIVE 38˚C to 37˚C 5.30 mmol/L
-Normalize
Body temperature: electrolyte balance Avoid restraining the Prevents injury
38 ˚C with normal range as child or putting during seizure which
Blood Chem: evidence of having anything in his or her is a complication of
Potassium: 5.42 potassium level of mouth and provide meningitis.
mmol/L 3.5 – 5.5 mmol/L gentle support to
head arms.
LONG-TERM GOAL
Goal met
Assess and record To facilitate the
seizure activity and reduction of
LONG-TERM GOAL location. Note the potassium levels and
duration of seizures, may prevent
After an 8 hours of parts of the body recurrence of
nursing intervention involved, site of hyperkalemia.
and 15 minutes of onset and
health teaching with progression of
the family, they will seizure and remove
be able to verbalize objects/toys from
understanding of bed.
individual factors that
contribute to the Identified and
possibility of injury. discontinued dietary
sources of potassium,
such as beans, dark
leafy greens, fish,
avocados, and
bananas for the
breastfeeding
mother.

Dependent :

Administered To relieve fever and

paracetamol 2.8 mL facilitate fast
every 4 hours as recovery
ordered by the
physician

Monitored laboratory Evaluate therapy

results, such as needs and
serum potassium and effectiveness.
arterial blood gasses,
as indicated.

Collaborative:

Referred to a physical
To identify high- risk
or occupational
task in addition to
therapist, as
appropriate. providing therapies
as indicated