Maria Kimber S.

Pineda
Bsn2b
Patient Name: Cipriano, Stacey
Room: 403
Date Admitted: March 28, 2023
Admitting Diagnosis: To consider Cerebrovascular
Drug Study:

Medication Date Classification Indication Mechanism of Contraindicatio Side effect Patient’s Nursing
Ordered/ Action n /Adverse Response Responsibilities
Given or effect
Taken/
Discontinued

Generic: Date Analgesic and Paracetamol This drug works Those having an This drug's side This Prior:
Paracetamol Ordered:  antipyretic is as an analgesic allergic reaction effects and lessens the  Check the
(Syrup) March 11, drugs commonly (pain reliever) to paracetamol or adverse effects pain and patient’s
2023 recognized and anti-pyretic any other include allergic the body
Brand: as a pain (fever reducing) medicine, as well reactions such as temperature temperature
Biogesics Date Given:  reliever and agent that as liver or kidney rash and swelling, of the  Take into
March 11, fever exhibits disorders, should as well as patient consideration
Route of 2023 reducer. It minimal avoid taking flushing, low returns to that this drug
Administration:  is widely interactions with paracetamol. blood pressure, its normal is not for
Oral used to treat other and fast range.  regular use
mild to pharmaceutical heartbeat, as well with any
Dosage:  moderate compounds. as blood form of liver
250mg/5ml pain, such Paracetamol abnormalities disease
as (acetaminophen) such as During:
Frequency: headaches, works upon the thrombocytopenia  Take with
Q4 toothaches, brain to block (low number of food or milk
  or sprains, prostaglandin platelet cells) and to minimize
and to production. leukopenia (low GI upset
reduce number of white  Report
fevers blood cyanosis,
caused by cells)paracetamol shortness of
illnesses syrup. breath and
such as abdominal
colds and pain as these
flu. are signs of
toxicity
After:
 Monitor
CBC, liver,
and renal
functions
 Advise the
patient to
report if pain
still persists.

Nursing Care Plan ( Priority 1)

Assessment Nursing Rationale Planning Nursing Intervention  Rationale Evaluation/

 Diagnosis   Possible Outcome

Subjective Ineffectiv An increase in SHORT TERM INDEPENDENT :  INDEPENDENT: SHORT TERM

cue: e Airway the number of GOAL:   Institute  To prevent spread and GOAL: 
Clearance breaths per After a 30 minutes isolation protect the patient from After the nursing
“Nahihirapan related to minute may of nursing precautions. other infectious processes. intervention, the
po minsan decreased indicate that a intervention, the  Suction as  Stimulates cough or breathing pattern was
yung anak energy, person is patient’s breathing needed. mechanically clears airway improved and
kung fatigue as having pattern will be who is unable to cough relieved.
huminga” evidenced difficulty improved and  Assist and effectively.
verbalized by cough breathing or is relieved. monitor effects  Humidify the airway to thin Goal Met
by the not obtaining of nebulizer secretions and facilitate
mother enough LONG TERM treatment liquefaction and
oxygen. Color GOAL:  Monitor serial expectoration of secretions.
Objective shifts. A bluish After 8 hours of chest x-rays,  Follows progress and effects
cues: color visible nursing ABGs, and and extent of pneumonia. LONG TERM
Lethargy around the intervention, pulse oximetry Oxygen saturation should be GOAL:
PR:83 mouth, on the secretions will be readings. at 90% or greater. After 8 hours of
RR: 38 inside of the mobilized, and nursing intervention,
Oxygen lips, or on the airway patency the airway patency
Saturation: fingernails will be maintained DEPENDENT: DEPENDENT: was maintained free
92% may occur free from  Administer  Used to combat microbial from secretions.
Cough when a person secretions antimicrobials pneumonias.
is not obtaining as prescribed.
Laboratory enough GOAL
Chest x-ray: oxygen.  Administer To help loosen the mucus on the PARTIALLY MET.
Bilateral nebulization as airway, and to decrease resistance
interstitial needed. in the respiratory airway.
pneumonia

Priority 2
 Assessment Nursing Rationale Planning Nursing Intervention  Rationale Evaluation/
Diagnosis   Possible
Outcome

Subjective Elevated A fever is a SHORT TERM INDEPENDENT: INDEPENDENT: SHORT

Cues: body temporary rise GOAL:  Monitor vital signs and  It will serve as TERM 
temperature in body After 2 hours of take notes for the baseline data, and After 2 hours of
“Nilalagnat related to temperature. It's nursing presence of chills for comparison of nursing
siya nang bacterial one part of an intervention, the any fluctuations in intervention,
tatlong araw infection as overall response patient’s  Monitor fluid intake and vital signs. patient's
na” as evidenced by from the body's temperature will urine output   Fluid resuscitation temperature
verbalized by temperature immune system. decrease to may be required to decreased to
the mother. of 38.5 C A fever is normal range  Raise the bedside rails correct dehydration 36.8 C 
usually caused (36.5 - 37.5)
by an infection.  Check for rashes,itchy  To provide patients Goal Met
Objective redness and swollen safety even without
cues: the presence of
LONG TERM DEPENDENT: seizure
Temperature: GOAL:  Administer paracetamol  To know if there any LONG TERM
38.5 C After 12 hours of as prescribed by the signs of allergic After nursing
RR: 38 nursing physician  reaction of drugs  intervention
intervention, the patient’s vital
patient's signs returned to
temperature will COLLABORATIVE   It reduce high normal range;
be maintained  Monitor Hematologic temperature Temperature of
within the normal test & other pertinent lab
36.8 C
range of 36.5°C- records  Indicate presence of
37.5° C. infection &
dehydration
 Assessment Nursing Rationale Planning Nursing Intervention  Rationale Evaluation/
Diagnosis   Possible Outcome

Subjective Activity Activity Short Term Goal: Independent: Independent: Short Term Eval:
Cue: Intolerance intolerance  After 6 hours of -Explain to the child and -Promotes understanding of After 6 hours of
 “ Palagi lang related to bed can be intervention the parents the purpose of the need to conserve energy intervention the client
siyang tulog at rest as described as client will have an activity restriction. and rest to help in recovery. was able to
nanghihina” as evidenced by insufficient ability to participate in activities
verbalized by expressed physiological participate -Instruct parents and -Prevents fatigue and of daily living such as
the mother weakness and or activities of daily children to rest when promotes recovery. walking, and talking
fatigue psychological living. feeling tired. with parents.
Objective energy to -If patients are comfortable,
Cues: complete -Provide comfort they are likely to recover Goal Met
required or measurement such as quicker and have better health
-Weak in desired daily Long Term Goal: elevated head. outcomes. A negative
appearance activities. After 2 days of environment delays healing.
-Fatigue Activity nursing  
- Pale lips intolerance is intervention, the Dependent: Dependent: Long Term Eval:
a common client will have an - Administer medication - It is important for After 2 days of
side effect of increased ability to as ordered by the controlling chronic nursing intervention,
heart failure perform activities physician conditions, treating temporary the client was able to
and can be of daily living, conditions, and overall long- performed activities of
related to such as playing term health and well-being daily living, such as
generalized games, changing -Note treatment-related playing games,
weakness and her own clothes, factors ,such as side changing her own
difficulty and absences of effects/interaction of clothes, and absence
resting and body weakness. medication of body weakness.
sleeping.  

Priority 3