NURSING CARE PROCESS

ASSESSMENT NURSING DIAGNOSIS RATIONALE GOAL NURSING INTERVENTION >Assessed respiratory After 4 hours of nursing interventions, the client will be able to maintain airway patency. >Monitored vital signs especially the RR. Long Term: >Auscutated the After 1 day of nursing intervention, the client will be able to expectorate retained secretions and maintain normal lung sounds, noting areas of decreased ventilation and presence of >Bronchial lung sounds are commonly heard over areas of lung density or consolidation. >To obtain baseline data.) movements and use of accessory muscles. RATIONALE EVALUATION

Subjective cues: Nahihirapan na siya huminga dahil sa plema hindi niya mailabas, grabe na kasi ang ubo niyan eh as verbalized by his mother Objective cues: >difficulty of breathing

Ineffective airway The inflammatory clearance related to ineffective cough and retained secretions. response to infection causes tissue edema and exudates formation in the lungs, the inflammatory response can narrow and potentially obstruct bronchial passages and alveoli.

Short Term:

>Use of accessory muscles to breathe indicates an abnormal increase in work of breathing.

The client maintained airway patency as evidenced by expectorating clear secretions readily.

>Wheezes on both lung fields

>productive cough whitish color

adventitious sounds. Crackles are heard when fluid is present.

>nasal flaring

breathing pattern.

>Monitored chest x ray reports.

>These determine progression of disease process.)

>restlessness

>Encouraged client to increase fluid intake.

>Hydration helps decrease the viscosity of secretions, facilitating expectorations.

>Advised the realtives elevate the head of bed at least 30 degrees.

>Positioning facilitates chest expansion and respiratory efficiency by reducing pressure of abdominal organs on diaphragm.

>Assisted on nebulizer treatment. Nebulization done

> Relaxes bronchial and uterine smooth muscle by acting on

as per doctors order beta adrenergic every 12 hours. receptors.

>Chest tapping performed after each nebulization.

>Chest physiotherapy helps to aid immobilization of secretions.

>Instructed the client to have oral care after each nebulization.

>Discharges from the nebulizer are often foul tasting and smelling.

>Provided supplemental fluids

>Fluids are regulated to replace losses and aid immobilization secretions.

ASSESSMENT

NURSING DIAGNOSIS Hyperthermia related to inflammatory response. Increase in body temperature greater than normal range.

RATIONALE

GOAL

NURSING INTERVENTION Independent:

RATIONALE

EVALUATION

Subjective Data: Tatlong araw ng pabalik-balik ang lagnat ng anak ko, hindi maganda ang pakiramdam nya kaya pinunta ko na siya dito as verbalized by his mother Objective Data: T= 38.7 C

Entry of the pathogen in circulatory system | Regulation of toxins in the body | Release of pyrogen | Stimulation of the hypothalamus | Increase or alteration of thermoregulation | Increase in body temperature | Hyperthermia

After 2 hours of >Monitor core effective nursing intervention, temperature q 1 . the patients temperature will decrease: >Demonstrate temperature within normal range, from 38.7 C to 36.5C -37.5C >Demonstrate behaviors to monitor and promote normothermia. >Skin is cool to touch and less flushness >Identify underlying cause/contributing factors and importance of treatment, as well >Note presence or absence of sweating as body attempts to increase heat loss by evaporation.

>Temperature of 38.9-41.1C suggest acute infectious disease process. >Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat. >To support circulating volume and tissue perfusion.

After 2 hours of effective nursing intervention, goal is met.

> Patients temperature is already in the normal range; T=___ C

>Increase oral fluid intake.

>To reduce >Promote bed rest, metabolic encourage demands/oxygen relaxation skills and consumption.

as signs/symptoms requiring further interventions. >Verbalized understanding of specific interventions to prevent hyperthermia

diversional activities. >Provide TSB as needed >Heat is loss by evaporation and conduction. >Heat is loss by Convection radiation and conduction. >To promote wellness

>Promote surface cooling, loosen clothing and cool environment >Review specific risk factors/causes, signs and symptoms with the interventions required

>Discuss importance of adequate fluid intake and protein diet Collaborative: >Administer medications as indicated to

>To prevent dehydration

>To treat underlying

treat underlying cause, such as: -Paracetamol 325mg/tab 1 tab q 6 >Administer replacement fluids and electrolytes to support circulating volume and tissue perfusion

causes

>To support circulating volume and tissue perfusion

ASSESSMENT

NURSING DIAGNOSIS Diarrhea related to presence of toxins due to poor personal hygiene.

RATIONALE

GOAL

NURSING INTERVENTION Independent: > Observe and record stool frequency, characteristics, amount and precipitating factors. > Promote bed rest

RATIONALE

EVALUATION

Subjective Data: Madalas siyang dumumi halos tatlo hangang limang beses as verbalized by his mother. Objective cues: > Frequent watery stools >Increased peristalsis

Diarrhea is the passage of loose and watery stools (more than 3 bowel movements per day) often associated with gassiness, bloating, and abdominal pain. It may also be accompanied by nausea, vomiting, and fever. Diarrhea results to loss of body fluids and salts leading to dehydration of varying severity. Severe dehydration may cause death especially in children

After 4 hours of nursing interventions, the patient will report reduction in frequency of stools.

> Helps differentiate individual disease and assesses severity of episode

After 4 hours of nursing interventions, the patient was able to report reduction in frequency of stools.

> Provide bedside Commode

> Rest decreases intestinal motility and reduces metabolic rate.

> Identify foods and

> Urge to defecate may occur without warning and uncontrollable, increasing risk of incontinence or falls if facilities

fluids that precipitate diarrhea.

are not close at hand > Avoiding intestinal irritants promotes intestinal rest

> Restart oral fluid intake gradually. Offer clear liquids hourly, and avoid cold fluids.

> Encourage to eat foods like banana and apple > Avoid foods that are oily, spicy and caffeine. Collaborative: > Administer antidiarrheals as prescribed by the physician.

> Provides colon rest by omitting or decreasing stimulus of foods or fluids. Gradual consumption of liquids may prevent cramping and recurrence of diarrhea. Cold fluids can increase intestinal motility. > Fruits that are stool formed

> Foods that may precipitate gastric cramping

> Decreases G.I

motility or peristalsis and diminishes digestive secretions to relieve cramping and diarrhea.

DRUG STUDY
DRUG DOSAGE Mechanism of Action Indication Contraindication Side Effects Nursing Responsibilities

Generic Name: Gentamicin Sulfate Brand Name:Garamycin

Child :IV/IM 67.5 mg/kg/d in 34 divided dosesIntrath ecal >3 mo, 12 mg preservative free q.d.

Chemical Effect:

> Aminoglycoside; actively transported across the bacterial cell membrane, binds to a specific receptor protein on the 30 S subunit of bacterial ribosomes, and interferes with an initiation complex between mRNA (messenger RNA) and the 30 S subunit, inhibiting protein synthesis. DNA may be misread, thus producing nonfunctional

Parenteral use restricted to treatment of serious infections of GI, respiratory, and urinary tracts, CNS, bone, skin, and soft tissue (including burns) when other less toxic antimicrobial agents are ineffective or are contraindicated. Has been used in combination with other antibiotics. Also used topically for primary and secondary skin infections and for superficial infections of external eye and its adnexa.

History of hypersensitivity to or toxic reaction with any aminoglycoside antibiotic. Safe use during pregnancy (category C) or lactation is not established Bacterial and fungal corneal ulcers have developed during treatment with gentamicin ophthalmic preparations. The most frequently reported adverse reactions are ocular burning and irritation upon drug instillation,

>upset stomach >vomiting >fatigue >pale skin

> Lab tests: Perform C&S and renal function prior to first dose and periodically during therapy; therapy may begin pending test results. >Determine creatinine clearance and serum drug concentrations at frequent intervals, particularly for patients with impaired renal function, infants (renal immaturity), older adults, patients receiving high doses or therapy beyond 10 d, patients with

proteins; polyribosomes are split apart and are unable to synthesize protein.

nonspecific conjunctivitis, conjunctival epithelial defects, and conjunctival hyperemia.

fever or extensive burns, edema, obesity. > Note: Dosages are generally adjusted to maintain peak serum gentamicin concentrations of 4 10 g/mL, and trough concentrations of 12 g/mL. Peak concentrations above 12 g/mL and trough concentrations above 2 g/mL are associated with toxicity. > Draw blood specimens for peak serum gentamicin concentration 30 min1h after IM administration, and 30 min after completion of a 30

Therapeutic Effect: > Gentamicin, like the other aminoglycosides is not appreciably absorbed after oral or intrauterine administration, but is absorbed from topical administration (not skin or urinary bladder) when used in irrigations during surgical procedures. Patients receiving oral aminoglycosides with hemorrhagic or Other adverse reactions which have occurred rarely are allergic reactions, thrombocytopenic purpura, and hallucinations.

necrotic enteritises may absorb appreciable quantities of the drug. After IM administration to dogs and cats, peak levels occur from 1/2 to 1 hour later. Subcutaneous injection results in slightly delayed peak levels and with more variability than after IM injection. Bioavailability from extravascular injection (IM or SQ) is greater than 90%.

60 min IV infusion. Draw blood specimens for trough levels just before the next IM or IV dose. Use nonheparinized tubes to collect blood.