Assessment Diagnosis Planning Interventions Evaluation

Subjective: Hyperthermia related to After 8 hours of sufficient Independent: After 8 hours of sufficient
inflammatory process, as nursing intervention nursing interventions the
“Nagbalik2 ija hilanat ug evidenced by increasing patient’s core - Monitor core patient’s core
pirme nagluja” as body temperature. temperature will decrease temperature by temperature was
verbalized by the SO to 37.5 and maintain it. appropriate route (Rectal decreased to 37.5 and
and tympanic route) ; To maintin it.
Objective: ensure the accurate
temperature of the
- Fatigue patient and to monitor it.
- Warm skin - Monitor Heart rate and
rhythm and respiration; To
V/S taken as follows: record the abnormalities
Temp: 38.2C of his status.
PR: 130 bpm - Monitor and report all
RR: 27bpm sources of fluid losses; To
BP: 80/60mmHg avoid dehydration of the
02sat: 99% patient.
- Monitor respirations.
- Monitor blood pressure,
noting hypotension.

Dependent:

-Administer
chlorpromazine or
diazepam as ordered by
 the doctor; To avoid
Shivers and siezures.
-Administer antipyretics,
orally or rectally as
ordered by the doctor; To
avoid liver failure into
pedias.
-Provide supplemental
oxygens; to offset
increased oxygen demans
and consumption.
Collaboration:
Provide High calorie diet,
enteral nutrition, or
parenteral nutrition ; To
meet increased metabolic
demands.

Assessment Diagnosis Planning Interventions and Evaluation

rationale
Subjective: Acute pain on joints After 8 hours of sufficient Independent: After 8 hours of sufficient
“Sakit ako mga joints” as related to migratory nursing intervention nursing intervention
verbalized by the patient. inflammation of joints. patient will report that -Monitor skin color and patient was reported that
pain is relieved with relief temperature and vital pain is relieved and was
Objective: on its face and will be signs; which are usually be scaled to 2/10.
scaled to 2/10. altered in acute pain.
- Pain scale: 7/10 -Determine factors in
- Warm skin client’s lifestyle; that can
V/S taken as follows: affect responses to
Temp: 38.2C analgesics.
PR: 130bpm -Provide Comfort
RR: 27bpm measures ( Hot and Cold
BP: 80/70mmHg compress) To ease the
O2Osat= 99% pain of the patient.
Identify ways to avoid or
minimize pain.

Dependent:

- Administer analgesics as
indicated to maximun
dosage; To maintain
acceptable level of pain.
- Note clients attitude
toward pain and use of
pain medications; Client
may have beliefs
 restricting use of
medications.

Collaboration:

Collaborate in treatment
of underlying condition or
disease processes causing
pain .

Generic Brand Drug Prescribed Mechanism Indication Contraindication Adverse Nursing

Name name Classification dosage of action Reaction Implication
cefTRIAXone Therapeutic IV- add Inhibits cell UTI: Lower Contraindicated GI: diarrhea Tell patient
sodium class: 2.4ml wall respiratory to patient Skin: Pain, Rash to report
Antibiotics dilluent to synthesis tract hypersensitive Hematologic: adverse
Pharmacologic the 250mg promoting Acute to drug or other Thrombocytosi reaction.
class: Third vial, 4.8ml to osmotic bacterial cephalosporins. s Instruct
generation the 500mg instability; otitis media. patient to
cephalosporins vial, 9.6ml to usually Acute otitis report
the 1g vial, bactericidal. media. discomfort
and 19.2ml at IV
to the 2g insertion
vail. site.
Route: IV
Onset:
immediate
Peak:
immediate
Duration:
unknown
Generic Name Brand Drug Prescribed Mechanism Indication Contraindication Adverse Nursing
name Classification dosage of action Reaction Implication
acetaminophe Artisol Therapeutic Children Thought to Mild pain Contraindicated CNS: Tell patient to
n forte, class: ages 9 to 10 produce or fever. in patients anxiety, consult
Fortolin, Analgesics weighing analgesia by Mild to hypersensitive headache, prescriber
Ofirmev, Pharmacologic 27.3 kg to inhibiting moderate to drug IV form insomniaGI: before giving
Pediatrix, class: Para- 32.6kg : prostaglandin pain with is nausea, drug to
Taminol, aminophenol 400 mg PO and other adjunctive contraindicated vomitting. children
Tylenol derivatives every 4 substances opioid in patients with Respi: younger than
hours p.r.n that sensitize analgesics sever acute liver Abnormal age 2.
Maximum 5 pain fever. disease or breath Many OTC and
dose a day. receptors. severe hepatic sounds, prescription
Route: PO Drug may impairment. dyspnea. produvts
Onset: 1 hr relive fever Use cautiously contain
Peak: 30 through on patient with acetaminophen
min- central action any type liver be aware of
60mins in the disease. this when
Duration: 4- hypothalamic calculating
6 hrs heat- total dose.
regulating
center.
Generic Brand Drug Prescribed Mechanism of Indication Contraindication Adverse Nursing
Name name Classification dosage action Reaction Implication
Omeprazole Losec Therapeutic Children Inhibits proton Symptomatic Use cautiously CNS: Give patient
class: Anti ages 1 to 1 pump activity GERD in patients with dizziness, instruction
ulcer drug. to 16 by binding to without hypokalemia headache on how to
Pharmacologic weighing 20 hydrogen esophageal and respiratory GI: take oral
class: PPI kg or more: potassium lesion. alkolosis and in Abdominal suspension.
20 mg PO adenosine Erosive patients on low pain, Teach
daily for up thriposphatase esophagitis sodium diet. diarrhea, patient to
to 4 weeks. , located at Dudenal constipation. recognize
Route: PO secretory ulcer. Respi: Cough and report
Onset: 1 hr surface of Helicobacter signs and
Peak: 30 gastric parietal pylori symptoms of
min- 2hr cells, to infection and low
Duration: 3 suppress doudenal magnesium
days gastric adic ulcer disease. levels.
secretion.
Generic Brand Drug Prescribed Mechanism of Indication Contraindication Adverse Nursing
Name name Classification dosage action Reaction Implication
Aspirin Asaphen, Therapeutic Children Thought to Mild pain Use cautiously in CNS: Tell patient
Asatab, Class: NSAIDS Ages 2 to produce analgesia or fever. patients with GI Headache, whos
Bayer Pharmacologic 11 and exert its anti- Suspected lesions, unstable Dizziness, allergic to
Aspirin, Class: weighing inflammatory Acute MI. angina, Lethargy tartranic to
Durlaza, Salicylates. less than effect by Acute hypoprothrombinemia CV: avoid
Entrophen, 50kg: 10 to inhibiting ischemic Vitamin K defiency, Hypotension, aspirin.
Novasen, 15mg PO prostaglandin and Stroke. tthrombocytopia. Tachycardia Advise
Rivasa or PR every other substance Avoid use in patient Skin: Rashes patient to
4 hours that sinsitize pain with sever hepatic take drug
P.R.N. receptors. impairment. with food,
Routes: PO milk,
Onset: 5- antacid or
30 Mins large glass
Peak: 1-2hr of water to
Duration: reduce GI
1-4 hrs. reaction.
 GENOGRAM

CYSTS
HYPERTENSION SURGER HEALTHY DIABETTI
Y S

-GRANDFATHER

-GRANDMOTHER

-MOTHER
HEALT
-FATHER HY

-PATIENT

-BROTHER

-SISTER