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NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) OBJECTIVES RATIONALE

Goals Met
Problem # 1 Nausea related to gastric After 1 hour of nursing INDEPENDENT:
After 1 hour of nursing
SUBJECTIVE: pain as manifested by body intervention the patient 1. Assess for presence of conditions
intervention the patient
“Sakit akong tiyan ug kalipongon malaise will be able to: of the GI tract. Dietary changes may
able to be free of
ko”, as stated by the px be sufficient to decrease frequency
nausea, had managed
 Be free of nausea of nausea
chronic nausea, and
OBJECTIVES: 2. Check vital signs for children and
maintained weight.
 Manage chronic older clients and note sign of
 pallor nausea, as dehydration. Nausea may occur in
evidenced by the presence of postural
 weakness acceptable level of hypotension/fluid volume deficit
dietary intake 3. Have client try dry foods such as

 pain scale: 6/10 crackers and toast before rising


 Maintain weight as when it occurs in the morning or
possible throughout the day
4. Encourage client to eat small
meals spaced throughout the day
instead of large meals so stomach
doesn’t feel excessively full

COLLABORATIVE:
1. Administer antiemetic on regular
schedule before/ during and after
administration of antineoplastic
agents to prevent/ control side
effects of medication

NURSING CARE PLAN


ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Subjective & Objective Cues) (Problem and Etiology) OBJECTIVES RATIONALE

Goals Met
Problem # 2 Hyperthermia related to After 30 minutes of INDEPENDENT:
After 30 minutes of
SUBJECTIVE: decreased level of platelet as nursing intervention the 1. Promote surface cooling by
nursing interventions
“Sakit akong ulo usahay mao ng manifested by increased patient will be able to: means of undressing; cool
patient able to
malipong na dayon ko”, as body temperature environment and fans and tepid
maintained normal
stated by the px  Maintain core temp. sponge baths
body core temperature,
within normal range 2. Assist with internal cooling
been free of
OBJECTIVES:  Be free of methods to treat malignant
complications and had
complications such hyperthermia to promote rapid core
demonstrated
 Body temp: 37. 8°C as irreversible brain cooling
behaviors that
and acute renal 3. Discuss importance of adequate
monitored and
 Flushed skin failure fluid intake to prevent dehydration
promoted
 Identify underlying
normothermia.
 Warm to touch cause/ contributing COLLABORATIVE:

factors and 1. Monitor laboratory studies such as

importance of CBC’s, glucose, urinalysis and

treatment, as well as coagulation profile

signs/ symptoms 2. Administer antipyretics such as


requiring further Paracetamol, orally as ordered
evaluation
 Demonstrate
behaviors to monitor
and promote
normothermia

NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING EVALUATION


(Subjective & Objective (Problem and Etiology) OBJECTIVES INTERVENTIONS AND
Cues) RATIONALE
Risk for infection related to At the end 8 hours shift, Independent: After 8 hours shift of
Problem #3 altered immune response patient resistance against 1) Stress proper hygiene intervention, patient
Objective cues: secondary to Dengue infection will be techniques to the SO. resistance against infection
>latest CBC result of HCT Hemorrhagic Fever maintained/regained as 2)cleanse insertion sites had been
count is 46.5 % (34.10-44 evidenced by: with cotton bals maintained/regained as
%) >rise of WBC count to the 3) Instructing mother to evidenced by:
>Platelet 135.00 normal range of 5,000- cleanse the nipple woth >rise of WBC count to the
(Reference Value150.00- 10,000 water before and after normal range of 5,000-
390.00 X10 ٨ 9/L) >improved nutritional status breastfeeding. 10,000
>absence of other *Dependent: >improved nutritional status
nosocomial infections 4)Administer/monitor >absence of other
medication regimen as nosocomial infections
prescribed. Goals partially met.

DRUG STUDY
NURSING
DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS OF RESPONSIBILITIES/
(Generic name, brand ACTION THE DRUG PRECAUTIONS
name, classification,
dosage, route,
frequency)

Generic Name: Thought to produce ♥ Fever reduction ♥ Hypersensitivity to ♥ Hematologic: hemolytic ♥ Monitor for s/s of:
paracetamol analgesia by blocking acetaminophen or anemia, leucopenia hepatotoxicity, even with
pain impulses of ♥ Temporary relief of phenacin moderate acetaminophen
Brand Name: prostaglandin in the mild to moderate ♥ pancytopenia, doses, especially
Biogesic CNS or of other pain ♥ Long term alcohol use neutropenia in individuals with poor
substances that (may cause nutrition or who have
Classification: sensitize pain ♥ Generally as hepatotoxicity) ♥ Hepatic: jaundice ingested alcohol over
Antipyretic receptors to substitute for prolonged periods
stimulation. The drug aspirin when the ♥ Children < 3 years old ♥ Metabolic: o poisoning, usually from
Dosage: may relieve fever later is no tolerated unless directed by a hypoglycemia accidental ingestion or
500mg through central physician suicide attempts
(250mg/5ml) action in the ♥ Skin: rash, urticaria o Potential abuse from
10ml hypothalamic heat- ♥ Malnutrition psychological dependence
regulating center. (withdrawal has been
Route: ♥ Thrombocytopenia associated with restless and
PO excited responses).
(syrup) ♥ Arthritic or rheumatoid ♥ The drug should not be
conditions affecting taken with other
Frequency: children < 12 years old medication (e.g. cold
Q4 if temp > 37.5 preparations) containing
acetaminophen without
medical advice;
overdosing and chronic
use can cause liver
damage without
consulting a physician
♥ Advise client not to self
medicate for pain more
than 10 days (5 days in
children) without
consulting a physician.
♥ This medication should
not be used without
medical direction for:
fever persisting longer
than 3 days, fever over
39.5 ーC (103ーF), or
recurrent fever.
♥ Do not give children
more than 5 doses in 24
hrs unless prescribed by
a physician

NURSING
DRUG ORDER MECHANISM OF
INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS RESPONSIBILITIES/
ACTION
PRECAUTIONS
Generic: Inhibits the action of ♥ short term ♥ some products contain CNS: confusion, ♥ assess for abdominal
Ranitidine histamine at the H2 treatment of active alcohol and should be dizziness, drowsiness, pain and frank or occult
receptor site located duodenal ulcers and avoided in patients with hallucinations blood in the stool, emesis
Brand: primarily in gastric benign gastric ulcers known intolerance CV: arrythmias or gastric aspirate
Zantac parietal cells, GI: constipation,
resulting in inhibition ♥ maintenance ♥ renal impairment diarrhea, drug-induced ♥ may cause increase in
Classification: of gastric acid therapy for duodenal hepatitis, nausea serum transaminases and
Antacids secretion and gastric after ♥ hepatic impairment ENDO: gynecomastia serum creatinine
healing of active acute porphyria Hemat: anemia,
Dosage: ulcers neutropenia, ♥ may cause false
25 mg thrombocytopenia positive results for urine-
Misc: hypersensitivity protein; test with
Route: reactions sulfosalicylic acid
IVTT
♥ inform patient that this
Frequency: may cause dizziness and
Q8h drowsiness inform patient
that increased fluid and
fiber intake and exercise
may minimize
constipation