NURSING CARE PLAN

CLIENT: Mr. H
CARE PLAN BY: GLAIZA SAVELLA Patient will participate in activities that reduce cardiac workload.
ASSESSMENT DIAGNOSIS SCIENTIFIC GOAL INTERVENTION RATIONALE EVALUATION
BACKGROUND
S> “Nagrigat la Excess Fluid The Patient is 38 years old November 21, 2022 INDEPENDENT: May 10, 2022
garud iti Volume female with edema in Shift 7-3 Shift 7-3
agsikogen related to the face and upper and 7:00AM-3:00PM 1) Review patient’s 1) Such 10:00 AM
nayunan Cardiac lower extremities Short term goal: history to determine information can Level of attainment:
paylang met ti dysfunction as After 8 hours of the probable cause assist to direct  Goal met.
panagumbal toy evidenced by Weakened heart muscle effective nursing management. Short term goal:
of the fluid
bagik” edema in intervention; History may  The patient was
imbalance. include
O> the face and  The patient able to
 Presence upper and Fluid build up due to fluid will increased fluids demonstrate a
of edema lower retention demonstrate a or sodium reduction of
in the extremities and reduction of 2) Monitor and record intake. edema through
face and verbalization edema through input and output physical
upper of “Nagrigat la physical closely. examination.
Patient develops edema
and garud iti examination.  Patient
lower agsikogen  Patient 2) Dehydration verbalized
extemitie nayunan verbalizes may be the awareness of
Excess Fluid Volume result of fluid
s. paylang met ti related to Cardiac awareness of 3) Monitor and note causative
panagumbal causative shifting even if factors and
dysfunction as evidenced by BP and HR. overall fluid
toy bagik”. edema in the face and upper factors and behaviors
4) Assess urine output intake is
and lower extremities and behaviors essential to
essential to in response to adequate. correct fluid
verbalization of “Nagrigat la diuretic therapy.
garud iti agsikogen nayunan correct fluid excess.
5) Assess for crackles 3) Sinus
paylang met ti panagumbal excess.  Patient
tachycardia and
toy bagik”.  Patient in the lungs, explained
increased BP are
explains changes in measures that
evident in early
measures that respiratory pattern, can be taken to
stages.
can be taken to treat or prevent
shortness of breath, 4) To determine if
treat or prevent fluid volume
 fluid volume and orthopnea. the body has excess.
excess. 6) Elevate edematous responded to the  Patient was able
 Patient extremities, and diuretic. to describe
describes 5) These signs are symptoms that
handle with care.
symptoms that caused by an indicate the
indicate the accumulation of need to consult
need to consult fluid in the with health care
with health 7) Check for excessive lungs. provider.
care provider. response to 6) Elevation
diuretics. increases
venous return to
the heart and, in
8) Explain the need to
turn, decreases
use antiembolic edema.
stockings or Edematous skin
bandages, as is more
ordered. susceptible to
injury.
7) Significantly
increased
response to
diuretics may
lead to the fluid
deficit.
8) These aids help
promote venous
return and
minimize fluid
accumulation in
the extremities.
DEPENDENT:
1) DIURETIC 1) EXPLANATIO
N

2) Restriction of
sodium aids in
decreasing fluid
2) Limit sodium intake as retention
prescribed.
 DRUG STUDY
(Cefuroxime)
NAME OF INDICATIONS CONTRAINDICATION MECHANISM OF ACTION SIDE EFFECTS NURSING RESPONSIBILITIES
DRUG S
Generic name:  Pharyngitis and • Contraindicated in o Cefuroxime is a beta- o Diarrhea o Monitor patient for signs and
Cefuroxime tonsillitis patients lactam antibiotic. By symptoms of superinfection and
hypersensitive to binding to specific o Pain, redness, diarrhea and treat appropriately.
Brand name:  Serious lower drug or other penicillin-binding swelling, or
Ceftin respiratory tract cephalosporins. proteins (PBPs) located bleeding near the o Monitor signs of allergic
infection, UTI, inside the bacterial cell place where reactions and anaphylaxis,
Classification: skin or skin- • Use cautiously in wall, it inhibits the third cefuroxime was including pulmonary symptoms.
Cephalosporin structure patients and last stage of injected. Notify physician or nursing staff
antibiotics infections, bone or hypersensitive to bacterial cell wall immediately if these reactions
joint infection, penicillin because synthesis. Cell lysis is o Seizures occur.
Dosage: septicemia, of possibility of then mediated by
250 mg meningitis, and cross-sensitivity bacterial cell wall o Rash o Drug may increase INR and risk
gonorrhea. with other beta- autolytic enzymes such of bleeding.
Frequency: o Hives
lactam antibiotics. as autolysins; it is
Every 12 hours
possible that cefuroxime
 Mild to moderate • According to the o Swelling of the o Shake suspension well before
Route: interferes with an
acute bacterial CDC, oral autolysin inhibitor. face, throat, tongue, measuring dose. Suspension may
PO exacerbations of lips, and eyes. be stored at room temperature or
cephalosporins
chronic bronchitis aren't refrigerated, but must be
recommended to o Difficulty discarded after 10 days.
 Acute bacterial treat gonococcal swallowing or
maxillary sinusitis infections. breathing. o Instruct parent to give oral
suspension with food.
 Otitis media • According to o Hoarseness
clinical practice o Decreased urination
guidelines,
 Uncomplicated o Swelling in legs and
cefotaxime or
skin and skin- ceftriaxone should feet.
structure infection be used to treat
o Peeling, blistering,
childhood bacterial
 Uncomplicated or shedding skin
meningitis and
UTI pneumococcal and o A return of fever,
meningococcal sore throat, chills, or
 Uncomplicated
meningitis caused
 gonorrhea by penicillin- other signs of
resistant strains and infection.
 Early Lyme Haemophilus
disease Impetigo influenzae type b o Hearing loss, if you
meningitis. are being treated for
meningitis
• Use cautiously in
patients with
history of colitis
and in those with
renal insufficiency.

• Drug may cause

CDAD and
pseudomembranou
s colitis ranging
from mild to life-
threatening, which
can occur even 2
months after
therapy.

• Some
cephalosporins
have been
associated with
seizures in patients
with renal
impairment when
the dosage wasn't
reduced. If drug-
associated seizures
occur, discontinue
drug and treat with
anticonvulsant
therapy if
indicated.