ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Impaired airway Short term goal: Independent: Independent: At the end of the
• “Galisod ug clearance and After 2 hours of • Patient should take 30 • To treat severe respiratory nursing
ginhawa akong anak, breathing nursing interventions, to 50 mg erythromycin tract infections. interventions,
duha ka adlaw na pattern related patient’s temperature daily in 2-4 divided for 14 goals were met,
nag ubo-ubo, unya to bronchial will reduce, mild days as per doctor’s patient had
init.” as verbalized secretions and cough, and reddish order. maintained airway
by the patient’s decreased cheek will subside. patency, absence
mother. airway patency • Maintain good • Good ventilation plays an of cough, and
• 5 years old male as evidenced by Long term goal: ventilation. important part on child’s improved oxygen
child. dyspnea. After 7-14 days of progress and prognosis. saturation.
nursing intervention,
the patient will • Teach parents to keep • Keeping the child away
Objective: show/maintain the child away from from stress maintains good
• Rapid cough patent airway and stress. atmosphere for the patient.
• Nasal flaring with absence of dyspnea.
rhinorrhea • Promote bed rest. • Helps in gaining energy.
• Reddish cheeks
• Difficulty breathing • Encourage increase of • Keeps from being
• VS taken as fluid intake. dehydrated and moistens
follows: the pharynx.
- T: 38.1 • Encourage Tepid • Reduces hot temperature.
degrees Sponge Bath (TSB).
Celsius • Identify and avoid • Helps in preventing
- P: 120 specific factors that certain factors that may
bpm inhibit effective airway lead serious complications.
- R: 25 clearance.
cpm
- OS: 94% Dependent:
• Position the client to Dependent:
optimize respiration. • To achieve comfort in his
position.
• Promote effective
coughing. • Prevents other people
 from acquiring the same
• Educate about disease.
breathing. • To achieve comfort in
• Monitor respiratory breathing.
patterns, including rate, • To see if the patient’s
depth, and effort. condition is improving.
 DRUG STUDY - ERYTHROMYCIN
DRUG NAME PRESCRIBED MECHANIS INDICATION CONTRAI ADVERSE REACTIONS NURSING RESPONSIBILITIES
DOSAGE AND M OF NDICATION
ROUTE OF ACTION
ADMINISTRATION
GENERIC NAME: AVAILABLE Binds with • To treat mild Astemizole, • Gastrointestinal • Question for history of
Erythromycin FORMS: the 50S to severe cisapride, disturbances, such allergies (particularly
Erythromycin is ribosomal respiratory dihydro- as diarrhea, nausea,  erythromycins), hepatitis.
BRAND NAME: available subunit of tract ergotamine, abdominal pain, Receive full medication
Erythrocin in enteric-coated t the 70S infections. ergotamine, and vomiting, are history and screen for
ablets, slow- ribosome in • Pertussis lovastatin, very common interactions.
CLASSIFICATION release capsules, many types • Intestinal pimozide, because • Monitor daily pattern of
: oral suspensions, of aerobic, amebiasis simvastatin, or erythromycin is bowel activity, stool
Macrolide, ophthalmic anaerobic, • Pelvic terfenadine a motilin agonist consistency.
antibiotic, anti- solutions, gram- inflammatory therapy; • CNS: Fatigue, •Assess skin for rash.
acne ointments, gels, negative, disease hypersensitivity fever, malaise, •Assess for hepatotoxicity
enteric-coated and gram- • Conjunctivitis to erythromycin, weakness (malaise, fever, abdominal
capsules, non positive. • Pneumonia other macrolide • EENT: Hearing pain, GI disturbances).
enteric-coated This action • Urogenital antibiotics, loss, oral candidiasis •Be alert for
tablets, non inhibits infections or their • Allergic reactions superinfection: fever,
enteric-coated RNA • components. range vomiting, diarrhea, anal/
capsules, and dependent Nongonococcal from urticaria to  genital pruritus, oral
injections. protein urethritis or anaphylaxis. mucosal changes
synthesis in uncomplicated • Topical: Dry skin (ulceration, pain,
ROUTES AND bacterial urethral, (50%). erythema).
DOSES: cells, endocervical, • Ophthalmic: •Check for phlebitis (heat,
•PO: causing or rectal Sensitivity reaction pain, red streaking over
(Base): them to infections. with increased vein).
CHILDREN: 30–50 die. • Legionnaire’s irritation, burning, •Monitor for high-dose
mg/kg/day in 2–4 disease itching, hearing loss.
divided doses. • Prevent inflammation. PATIENT/FAMILY
Maximum: 2 rheumatic • Other: Fluid TEACHING
g/day. fever overload (from I.V. • Continue therapy for full
(Ethylsuccinate): • Prevent infusion), injection- length of treatment.
 CHILDREN: 30–50 bacterial site inflammation • Doses should be evenly
mg/kg/day in endocarditis in and phlebitis spaced.
divided doses. patients with • Take medication with 8
Maximum: 4 penicillin oz water 1 hr before or 2
g/day. allergy who hrs following food or
NEONATES: 10 plan dental or beverage.
mg/kg/dose q8– upper • Ophthalmic: Report
12h. respiratory burning, itching,
•IV: tract surgery inflammation.
CHILDREN, • Topical: Report
INFANTS: 15–20 excessive skin dryness,
mg/kg/day divided itching, burning.
q6h. Maximum: 4 • Improvement of acne
g/day. may not occur for 1–2
NEONATES: 10 mos; maximum benefit
mg/kg/dose q8– may take 3 mos; therapy
12h. may last mos or yrs.
• Use caution if using
other topical acne
preparations containing
peeling or abrasive
agents, medicated or
abrasive soaps, cosmetics
containing alcohol (e.g.,
astringents, aftershave
lotion).
rosacea or psoriasis
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Risk for infection Short term goal: Dependent: Dependent: After all the
“Napaso akong related to loss of After 30 minutes of • Use gowns, gloves, • Prevents exposure to nursing
bagtak sa tambutso skin barrier as nursing intervention, masks, and careful infectious organisms. interventions, the
kay napiit ko evidenced by patient’s burn will be aseptic technique during patient’s wound
pagtumba dayon environmental covered, and the direct wound care and will be free from
sige ra siya ug nana, exposure. patient will verbalize offer sterile or newly purulent exudate
dili nako katulog.” As relief from pain and washed bed linens or and be afebrile,
verbalized by a 15 Disturbed reduced anxiety. gowns. free from
year old patient. sleeping pattern • Apply Povidone-iodine • A broad spectrum infection, and will
related to (Betadine) topical agent antimicrobial topical agent be able to perform
Objective: excessive Long term goal: prescribed by the doctor. that kills bacteria on activities of daily
• Drainage in the drainage as After 2-3 weeks, the wounds. living (ADLs).
open wound. evidenced by children will be free • Administer other • Tissue destruction and
• 2nd degree burn second degree of infection during medications as altered defense
• VS taken as burn. healing process and appropriate: Subeschar mechanisms increase risk of
follows: will be able to clysis or systemic developing tetanus or gas
T: 37.6 degrees perform activities of antibiotics; Tetanus gangrene, especially in deep
Celsius daily living (ADLs) toxoid or clostridial burns such as those caused
HR: 80 antitoxin, as appropriate. by electricity.
RR: 17 cpm • Encourage verbalization • Provides outlet for
BP: 115/85 about pain. emotions and helps the
PS: 8/10 child cope.
• Cover the area with a • To protect the wound
sterile gauze pad from bacteria.
• Keep biosynthetic burn • Helps reduce the number
dressing dry. of bacteria introduced to
the burn site.
• Examine wound daily, • To identify signs of
document changes in infection and presence of
appearance, quantity of healing.
drainage, and odor.
• Obtain routine cultures • Allows early recognition
and sensitivities of and specific treatment of
 wounds and/or drainage. wound infection.

Dependent:
• Promote uninterrupted
sleep with use of
medications.
• Sleep deprivation can
increase pain perception.

DRUG STUDY – POVIDONE - IODINE

DRUG NAME PRESCRIBED MECHANISM OF ACTION INDICATIONS CONTRA ADVERSE NURSING
DOSAGE AND INDICATIONS REACTIONS RESPONSIBILITIES
ROUTE OF
ADMINISTRATION
GENERIC NAME: • 1 application Povidone-iodine is a • Prevention • Iodine Severe • Caution should
Povidone-iodine prior to surgery combination of iodine and of infection in hypersensitivity angioedema / be exercised in
for ophthalmic a water soluble polymer minor burns • Thyroid anaphylactoid patients with
BRAND NAME: prep solution known as and skin disease reactions history of
Betadine • 3 polyvinylpyrrolidone. The abrasion • Ocular cyanosis
serious burns or
applications/day antimicrobial action of (cuts and exposure renal failure
deep puncture
CLASSIFICATION for up to 7 days povidone-iodine occurs scraps). • Burns, renal renal tubular
: for topical after iodine disassociates • Use as an impairment necrosis wounds, any
Antiseptics and products. from the complex. Once in antiseptic • Children, allergy, during
Disinfectants, the free form, iodine hand scrub infants Moderate pregnancy, and
Excluding Hand ROUTE: rapidly penetrates prior to • Caesarean erythema breastfeeding.
Products Topical microbial cell membranes surgery. section, labor, hyperthyroidism • Stop treatment
Ocular and interacts with • Ophthalmic neonates, hypothyroidism if redness,
Ophthalmic
Antiseptics proteins, nucleotides, and solution obstetric hypotension swelling or
Vaginal anti- fatty acids in the before delivery, sinus tachycardia irritation
infectives cytoplasm and cytoplasmic surgery pregnancy develops.
membrane. This • Surgical • Breast- metabolic • Avoid contact
interaction ultimately infection feeding acidosis with patient’s
results in rapid cell death. prophylaxis. eyes.
Povidone-iodine has a Mild
wide antimicrobial ocular irritation
spectrum with activity skin irritation
against gram-positive and vomiting
gram-negative bacteria, diarrhea
fungi, protozoa, tubercle nausea
bacilli, viruses, and
bacterial spores. Data
show that povidone-iodine
is bactericidal, fungicidal,
and virucidal.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Gum infection Short term goal: Independent: Independent: After all nursing
“Sakit kayo akong related to poor After 30 minutes of • Patient should take • Nonsteroidal anti- interventions,
ngipon, muapil ug oral hygiene. nursing intervention, 200mg ibuprofen orally inflammatory drugs goals were met.
sakit akong ulo.” As patient will verbalize (NSAIDs) have been shown The patient is
verbalized by the relief of pain. to be effective at reducing
able to
patient. pain
understand the
Long term goal:
“Gahi mangud nig After 1 hour of Dependent: Dependent: importance of
ulo bataa ma’am, nursing intervention, • Instruct patient to have • Dental checkup can having healthy
gahi kayo the patient will be a dental checkup identify dental problem. teeth and is
patoothbrushon.” As able to demonstrate immediately. willing for dental
verbalized by the the proper ways to do checkup.
patient’s mother. oral hygiene and will • Educate patient about • Right knowledge helps
have willingness in the importance of oral prevent possible dental
Objective: dental care. hygiene. problems.
• Frequent touching • Educate patient about • Adequate nutrition is vital
of the cheeks the importance of to healthy teeth and body.
• VS taken as maintaining healthy diet
follows: despite dentition
- T: 37.6 problems
degrees • Educate the patient • Checkups help identify
Celsius regarding the importance dental problems early.
- P: 80 bpm of dental checkups and
- R: 18 follow-ups.
- PS: 6/10
 DRUG STUDY - IBUPROFEN
DRUG NAME PRESCRIBED MECHANISM INDICATION CONTRA ADVERSE NURSING
DOSAGE AND OF ACTION S INDICATIONS REACTIONS RESPONSIBILITIES
ROUTE OF
ADMINISTRATION
GENERIC PO: Reversibly • Patent For all forms CNS: Aseptic • Advise patient to take
NAME: CHILDREN 12 YRS inhibits COX-1 Ductus except ibuprofen meningitis, CVA, medication with food or
Ibuprofen AND OLDER, and COX-2 Arteriosus lysine: dizziness, immediately after meals to
ADOLESCENTS: enzymes, • Rheumatoid- Angioedema, headache, alleviate gastrointestinal
200–400 mg q4- resulting in and osteo- asthma, nervousness, upset.
BRAND
6h prn. Maximum decreased arthritis bronchospasm, seizures • Advise patient not to
NAME:
daily dose: 1,200 formation of • Cystic nasal polyps, CV: Fluid take the medication in
Motrin, Advil mg/day. prostaglandin fibrosis rhinitis, or retention, heart higher dosages or for a
CHILDREN 6 MOS precursors. • Orthostatic urticaria caused failure, longer duration than
Classification: AND OLDER: Therapeutic hypotension by hypertension, MI, advised.
NSAIDs, dosage depends Effect: • Dental Pain hypersensitivity to peripheral edema, • Instruct patient to
antipyretic, on the weight. Produces • Minor Pain aspirin or other tachycardia consult prescriber if he
analgesic, IV: analgesic, anti- NSAIDs; EENT: Amblyopia, needs to take drug for
anti- CHILDREN 12–17 inflammatory hypersensitivity to epistaxis, more than 3 days for fever
inflammatory YRS: 400 mg q4– effects; ibuprofen or its stomatitis, or 10 days for pain.
6h prn. Maximum: decreases components; pain tinnitus • Notify phenylketonuric
2,400 mg/ day. fever with coronary GI: Abdominal patients that Motrin
CHILDREN 6 artery bypass cramps, chewable pills contain
MOS–11 YRS: 10 graft (CABG) distention, or aspartame.
mg/ kg q4–6h prn. surgery; For pain; anorexia; • Inform the patient that
Maximum dose: ibuprofen lysine: constipation; the entire therapeutic
400 mg. bleeding diarrhea; effect of arthritis may take
Maximum: 40 (especially active diverticulitis; up to two weeks or longer
mg/kg up to 2,400 intracranial dyspepsia; to manifest.
mg/day hemorrhage or dysphagia; • Urge patient to avoid
gastrointestinal elevated liver taking two different
bleeding), enzymes; NSAIDs at the same time.
coagulation epigastric • Instruct the patient to
defects, discomfort; abstain from alcohol,
congenital heart esophagitis; aspirin, and corticosteroids
disease in whom flatulence; while on ibuprofen.
patency of the gastritis; • Inform that ibuprofen
patent ductus gastroenteritis; may negate the effect of
arteriosus is gastroesophageal aspirin.
necessary for reflux disease; GI • Advise patient to report
satisfactory bleeding, flu-like symptoms, rash,
pulmonary or hemorrhage, signs of GI bleeding,
systemic blood perforation, or swelling, vision changes,
flow (pulmonary ulceration; and weight gain.
atresia, severe heartburn; • Urge parents to tell
coarctation of the hemorrhoids; prescriber promptly if child
aorta, severe hepatic failure; receiving drug develops
tetralogy of hepatitis; hiatal headache, high fever,
Fallot), hernia; nausea, persistent
hypersensitivity to indigestion; diarrhea, severe persistent
ibuprofen or its melena; nausea; sore throat, or vomiting or
components, stomatitis; hasn’t been drinking fluids.
known or vomiting • Advise parents to consult
suspected GU: Cystitis, a doctor before
infection or hematuria, renal administering OTC
necrotizing failure (acute) ibuprofen to a child with
enterocolitis, HEME: asthma, bleeding issues,
significant renal Agranulocytosis, heart or kidney disease,
impairment, anemia, aplastic high blood pressure,
thrombocytopeni anemia, ulcers, or a need for
a eosinophilia, diuretic medication.
hemolytic anemia, • Caution pregnant patient
leukopenia, not to take NSAIDs during
neutropenia, last trimester because they
pancytopenia, may cause premature
prolonged closure of the ductus
bleeding time, arteriosus.
thrombocytopenia • Explain that ibuprofen
RESP: may cause serious
Bronchospasm, cardiovascular problems;
dyspnea, advise patient to seek
wheezing medical assistance if chest
pain, edema, shortness of
SKIN: Blisters, breath, slurred speech,
erythema limb swelling, weight gain,
multiforme, or weakness occur.
photosensitivity, • Emphasize the necessity
pruritus, rash, of obtaining immediate
Stevens–Johnson medical assistance if
syndrome, toxic patients experience
epidermal stomach or epigastric pain,
necrolysis, black or tarry stools,
urticaria indigestion, or vomiting
blood or coffee grounds.
Other: • Alert patient to rare but
Anaphylaxis, serious skin reactions.
angioedema, flu- Urge him to seek
like symptoms, immediate medical
hypokalemia, attention for blisters,
weight gain fever, itching, rash, or
other indications of
hypersensitivity.