NURSING CARE PLAN 3

PATIENTS NAME: JHUNRY QUISADA MEDICAL DIAGNOSOS: ACUTE OTITIS MEDIA

ASSESMENTS/CUES/EV NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

IDENCES

Subjective Cues: Risk for infection related to After 4 hours of nursing Teach family members Good hygiene After 4 hours of
knowledge deficit about intervention the parents to cover mouths and prevents spread nursing intervention
Wala mi kabalo kung infection in children. will express noses when of pathogens. the parents
unsaon namu sia pag understanding of sneezing or expressed
atiman as verbalized by measure to lead fewer coughing and to understanding of
the mother. to infections wash hands measure to lead
frequently. Have fewer to infections.
parents isolate sick
children. Physical well-
Objective Cues: Encourage optimal being helps the
nutrition, rest, and body fight
Palpitation exercise. disease.
Dry mouth
Headaches Elevated position
Nausea and/or Position bottle-fed
prevents injection
diarrhea infants upright when of milk and
Restlessness feeding. Do not prop pathogens into
Pacing bottles. the eustachian
Pupil dilation tube.

Fewer irritants
Eliminate allergens
and allergens
and upper
may decrease
respiratory irritants
susceptibility to
such as tobacco,
respiratory
smoke, and dust.
infections.
Second hand
smoke
 contributes to
higher incidence
of otitis media.

NURSING CARE PLAN 2

PATIENTS NAME: JHUNRY QUISADA MEDICAL DIAGNOSOS: ACUTE OTITIS MEDIA

ASSESMENTS/CUES/EV NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

IDENCES
Subjective Cues: Disturbed Sensory After 8 hours of nursing Identify name and Identification After 8 hours of nursing
Perception: auditory interventions the patient purpose when when entering the interventions the
Dili kayo sia kadungog conductive disorder related to will be able to do the entering client's room. room helps the patient shall able to do
as verbalized by his the sound of the organ. following: client feel secure the following:
parents. Demonstrates and decreases Demonstrated
understanding by a social isolation. understanding by a
verbal, written, or verbal, written, or
signed response signed response
Demonstrates relaxed Converse with and Demonstrated relaxed
Objective cues: body movements and touch client frequently Appropriate touch body movements
facial expression during care if frequent can decrease and facial expression
Head Tilting Explains plan to modify touch is within client's social isolation. Explained plan to
Cupping hands lifestyle to cultural norm. modify lifestyle to
around ears accommodate visual accommodate visual
Social avoidance or hearing impairment or hearing
or withdrawal Remains free of Reduce noise in the impairment
Irritability physical harm client environment So that speaker Remained free of
Difficulty of resulting from does not have to physical harm
learning or decreased balance or complete to be resulting from
following directions a loss of vision, Provide good lighting heard. decreased balance
Dizziness hearing, or tactile when the client relies or a loss of vision,
sensation on the lips. This enhances the hearing, or tactile
Maintains contact with patients use of lip sensation
appropriate reading, facial Maintained contact with
community resources expressions and appropriate
Speaking clearly and gesturing. community
firmly on the client resources
without the need to
shout This prevents
humiliation
NURSING CARE PLAN 1

PATIENTS NAME: JHUNRY QUISADA MEDICAL DIAGNOSOS: ACUTE OTITIS MEDIA

ASSESMENTS/CUE NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
S/EVIDENCES DIAGNOSIS

Subjective Cues: Acute Pain After 1 hour of nursing INDEPENDENT: Goal was met. After
related to interventions, the client Establish rapport to the client To enhance the clients 1 hour of nursing
Sumasakit ang inflammation will: cooperation toward nursing interventions, the
kaliwang tenga ko, of the middle Report pain as Assess the clients current health management client reported pain
as verbalized by the ear tissue reduced. status To provides data about the as reduced and
client. proper management of the said verbalized
Verbalize Determine pain characteristics patient nonpharmacologic
nonpharmacologic through clients description To establish baseline for techniques
Objective Cues: methods that Use pain rating scale assessing improvement/ that provide relief.
provide relief. appropriate for age changes.
Positioning to Monitor skin color and vital To assess level of pain
avoid pain signs
Encourage to increase fluid To note any changes in bodys
Irritable
Facial grimace intake behavior towards pain
Provide quiet environment and To decrease susceptibility to
Pain rated as7
adequate rest infection
out 10
To promote
V/S
PR-120 Encourage to listen to music, nonpharmacological pain
have focused breathing, management
beats/min
socializing to others or other To distract attention and
RR-26
diversion activities reduce tension towards pain
breaths/min
Temp- 37.1 C Provide comfort and safety

DEPENDENT:
To prevent any injury may
Administer analgesics as
happen
ordered by the physician
To lessen the pain

NURSING CARE PLAN 4

PATIENTS NAME: JHUNRY QUISADA MEDICAL DIAGNOSOS: ACUTE OTITIS MEDIA

ASSESMENTS/CUES/EV NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
IDENCES

Subjective Cues: Risk for Caregiver Role Strain After 8 hours of nursing Determine the Many parents After 8 hours of
related to chronic disease. intervention the parents parents ability to can treat nursing intervention
Wala nam kabqlo unsa will express confidence manage condition. children at the parents
amua sunod buhaton as about treating the child Provide frequent home. expressed
verbalized by his Father. and state that stress is information and Knowledge of confidence about
reduce. feedback. condition allows treating the child and
parents to make state that stress is
informed reduced.
decisions and to
manage
Objective Cues: condition
Encourage effectively.
Expressions of Active
parental input in
helplessness managing care. participation
Feelings of increases
inadequacy confidence and
Crying ability to
Difficulty concentrating manage
Rumination Listen carefully to condition.
Inability to problem- parental Reacting
solve expressions of empathically
Preoccupation frustration and encourages
fatigue and try to parents to
understand communicate.
parents feelings.

NURSING CARE PLAN 5

PATIENTS NAME: JHUNRY QUISADA MEDICAL DIAGNOSOS: ACUTE OTITIS MEDIA

ASSESMENTS/CUES/EV NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
IDENCES

Subjective Cues: Risk for Altered Growth and After 2 days of nursing Assess hearing ability Monitoring detects After 2 days of
Development related to interventions the child frequently. hearing loss early nursing interventions
Mahadlok mi basin hearing loss will have normal the childshall have
madala niya nga sakit hearing. The child will normal hearing. The
hangtud sia mudako as have normal motor and child shall have
verbalized by his parents. language development. Assess motor and Early detection of normal motor and
language developmental language
development at delays can lead to development.
each health care appropriate
visit intervention.
Objective Cues:

Expressions of
helplessness
Feelings of
inadequacy
Difficulty
concentrating
Inability to problem-
solve
Feelings of
helplessness and
discomfort

DRUG STUDY
 DRUG CLASSIFICA MECHANISM OF INDICATIONS CONTRAINDICATION SIDE EFFECTS NURSING
TION ACTION RESPONSIBILITIES

GENERIC NAME: Central Unknown. May Ibuprofen Contraindicated in CNS; Headache, Tell patient to take with meals or
nervous inhibit Contains the active patients hypersensitive dizziness, milk to reduce adverse GI
Ibuprofen system prostaglandin ingredient to drug and in those nervousness, reactions.
agent; synthesis, to ibuprofen with angioedema, aseptic meningitis.
NSAID (cox- produce anti- , which belongs to syndrome of nasal Note: Drug is available at OTC.
BRAND NAME: 1); inflammatory, a group of polyps, or bronco CV: Peripheral Instruct patient not to
analgesic; analgesic, and medicines called spastic reaction to edema, fluid exceed1.2 g daily, not to give
Advil, Apo- antipyretic antipyretic non-steroidal anti- aspirin or other retention, edema to children younger than age
Ibuprofen, Motrin, effects. inflammatory drugs NSAIDs. . 12, and not to take for
Excedrin IB, Pregnancy (NSAIDs).It works EENT: Tinnitus extended periods ( longer
Genpril, Haltran, Category: B by blocking the Contraindicated in than 3days for fever or longer
Ibu-tab, Medipren, action of a pregnant women. GI: Epigastric than 10 days for pain) without
Menadol, Midol substance in the distress, nausea, consulting prescriber.
IB,Motrin, body called Use cautiously inpatients occults blood loss,
Rufen,Trendar cyclo- oxygenase with GIdis orders, peptic ulceration, Tell patient that full therapeutic
history of peptic ulcer diarrhea, effect for arthritis may be
DOSE, TIMING, disease, cardiac constipation, delayed for 2 to 4weeks.
ROUTE: decompensating, abdominal pain, Although pain relief occurs at
hypertension, asthma, bloating, GI fullness, low dosage levels,
Children ages 6 or intrinsic coagulation dyspepsia, inflammation doesnt improve
months to 12 defects flatulence, heart at dosages less than 400 mg
years; burn, decreased q.i.d.
If childs appetite.
temperature is Teach patient to watch for and
below102.5 GU: Acute renal report to prescriber
F(39.2 C),give 5 failure, azotemia, immediately signs and
mg/kg P.O. q 6 to cystitis, hematuria symptoms of GI bleeding,
8hours. including blood in vomit, urine,
or stool
or coffee ground vomit, and
black, tarry stool.
Warn patient to avoid
hazardous activities
 DRUG STUDY

DRUG CLASSIFICATION MECHANISM INDICATIONS CONTRAINDICATION SIDE EFFECTS NURSING

OF ACTION RESPONSIBILITIES

GENERIC NAME: Antipyretic, Non- Antipyretic: 1. Analgesic- This drug is CNS: Headache 1. Do not exceed the
Opioid Analgesic This drug antipyretic in contraindicated to recommended dosage.
Acetaminophen Pregnancy reduces fever patients with patients who are CV: Chest pain,
Category B by acting aspirin allergy, allergic or dyspnea, myocardi 2. Consult physician if
directly on the hemostatic hypersensitive to al damage when needed for children < 3
BRAND NAME:
hypothalamic disturbances, acetaminophen. Use doses of 58 g/day yr; if needed for longer
heat-regulating bleeding this drug cautiously are ingested daily than 10 days; if continued
Suppositories: Abenol
center to cause diatheses, upper with impaired hepatic for several weeks fever, severe or recurrent
, Acephen
vasodilation and GI disease, gouty function, chronic or when doses of 4 pain occurs (possible
sweating, which arthritis alcoholism, g/day are ingested serious illness).
Oral: Tapanol,
helps dissipate pregnancy, lactation. for 1 yr
Tempra, Tylenol,
heat. 2.Arthritis and 3. Avoid using multiple
Aceta, Apacet, Atasol,
Genapap, Genebs, rheumatic GI: Hepatic preparations containing
Liquiprin, Panadol Analgesic: disorders toxicity and acetaminophen. Carefully
Site and involving failure, jaundice check all OTC products.
mechanism of musculoskeletal
action unclear. pain (but lacks GU: Acute kidney 4. Give drug with food if
clinically failure, renal GI upset occurs.
significant tubular necrosis
antirheumatic 5. Discontinue drug if
and anti- Hematologic: hypersensitivity reactions
inflammatory Methemoglobinemi occur.
effects) acyanosis;
hemolytic anemia 6. Treatment of overdose:
DOSE, TIMING, 3. Common cold, hematuria, anuria; Monitor serum levels
ROUTE: flu, other viral neutropenia, regularly, N-acetyl
and bacterial leukopenia, cysteine should be
PO or PR infections with pancytopenia, available as a specific
Doses may be pain and fever thrombocytopenia, antidote; basic life
repeated 45 hypoglycemia support measures may
times/day; do not be necessary.
exceed five doses in Hypersensitivity:
24 hr; give PO or by Rash, fever
suppository.
40 mg.

DRUG STUDY

DRUG CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATION SIDE EFFECTS NURSING

ACTION RESPONSIBILITIES
GENERIC NAME: Antibiotics Interferes with Respiratory Marked liver CNS: fatigue, Assess for infection
(Antibacterial) bacterial growth by tract, renal GIT parenchymal damage; hallucinations, (vital signs;
Sulfamethoxazole inhibiting bacterial Osteomyelitis, severe renal headache, insomnia, appearance of
, Trimethoprim, Pregnancy Risk folic acid synthesis pneumocystis impairment; pregnancy. mental depression wound, sputum,
Co-trimoxazole Category: through carina Hypersensitivity. urine, and
C; D competitive pneumonia, GI: hepatic necrosis, stool;WBC) at
if used near term antagonism of toxoplasmosis, nausea, vomiting, beginning and during
PABA. action diarrhea, stomatitis therapy.
BRAND NAME: mycetoma,
acute GU: crystalluria Obtain specimens for
Bactrim brucellosis, no culture and
cardiosis Derm: toxic epidermal sensitivity before
necrolysis, rashes, initiating therapy.
photosensitivity
DOSE, TIMING, Inspect IV site
ROUTE: Hemat: frequently. Phlebitis
agranulocytosis, is common.
Tab 2 tab Fore leukopenia,
tab. 1 tab infant & megaloblastic anemia, Monitor CBC and
children TM 6 mg thrombocytopenia urinalysis periodically
&SMZ 30 mg/kg during therapy
body wt daily. To Local: phlebitis at IV
be given in bid. site
Gonorrhea 5 tab
bid or 2 forte Misc: allergic reactions
tab bid for 1 day. including erythema
multi
form, Stevens -
Johnson syndrome,
fever

DRUG STUDY
 DRUG CLASSIFICATION MECHANISM OF INDICATIONS SIDE EFFECTS NURSING RESPONSIBILITIES
ACTION

GENERIC MACROLIDE More active Pyodermas, acne GI: Nausea, vomiting, Report onset of GI symptoms after PO
NAME: ANTIBIOTIC against gram- vulgaris, and external abdominal cramping, administration to physician. These are
positive organisms ocular infections, Diarrhea, heartburn, dose related; if symptoms persist after
Erythromycin than against gram- including neonatal anorexia. dosage reduction, physician may
negative chlamydial prescribe drug to be given with meals in
organisms due to conjunctivitis and Body as a Whole: spite of impaired absorption.
its superior gonococci Fever, eosinophilia, Observe for S&S of super infection by
penetration into ophthalmic. urticarial, skin eruptions, overgrowth of non-susceptible bacteria
gram-positive fixed drug eruption, or fungi. Emergence of resistant
organisms anaphylaxis. Super staphylococcal strains is highly
BRAND NAME: infections by no predictable during prolonged therapy.
susceptible bacteria, Monitor for S&S of hepatotoxicity.
Apo-Erythro Base yeasts, or fungi. Premonitory S&S include: Abdominal
pain, nausea, vomiting, fever,
Special Senses: leukocytosis, and eosinophilia; jaundice
Ototoxicity: reversible may or may not be present. Symptoms
bilateral hearing loss, may appear a few days after initiation of
tinnitus, vertigo. drug but usually occur after 12 wk of
continuous therapy. Symptoms are
DOSE, TIMING, Digestive: (Estolate) reversible with prompt discontinuation of
ROUTE: Cholestatic hepatitis erythromycin.
syndrome. Monitor for ototoxicity that appears to
2% ointment ( develop most frequently in patients
Topical Skin: (topical use) receiving 4 g/dor more, older adults,
Apply 0.51 cm Erythema, female patients, and patients with
ribbon in lower desquamation, burning, kidney or liver dysfunction. It is
conjunctiva sacs tenderness, dryness or reversible with prompt discontinuation of
shortly after oiliness, pruritus. drug.
birth) Report any ototoxic effects including
dizziness, vertigo, nausea, tinnitus,
roaring noises, hearing impairment
DRUG STUDY
 DRUG CLASSIFICATION MECHANISM OF INDICATIONS CONTRAINDICATION SIDE EFFECTS NURSING
ACTION RESPONSIBILITIES

GENERIC NAME: Anti-infective Drug Prevents bacterial Treatment of Hypersensitivity to Nausea Advise the patients
cell wall synthesis infection of penicillins, Vomiting family to take the
amoxicillin during replication. respiratory tract, cephalosparins, or Diarrhea medication with meals
Bactericidal skin &skin imipenem. Not used to Rash for better absorption&
structures, treat severe Pruritus to reduce GI
genitourinary pneumonia, empyema, Urticaria discomfort.
tract, otitis bacteremia, Instruct the patients
media, pericarditis, meningitis family to take
BRAND NAME: meningitis, and purulent or septic medication as
septicemia, arthritis during acute prescribed even after
Amoxil sinusitis, stage feeling better and not
bacterial . to double dose.
endocarditis Teach the patients
prophylaxis family to report sore
DOSE, TIMING, throat, bruising,
ROUTE: bleeding and joint pain,
this may indicate blood
A 2.5 ml is given dyscrasias.
TID for 7 days Advise patients family
to watch out for
perineal itching, fever,
malaise, redness, pain,
swelling, drainage,
rash, diarrhea, change
in cough, sputum or
furry tongue, this may
indicate super
infection.
Advise patients family
to report bloody,
mucoid diarrhea which
may indicate
pseudomembranous
colitis