NURSING CARE PROCESS

ASSESSMENT NURSING DIAGNOSIS

RATIONALE GOAL NURSING INTERVENTION

RATIONALE EVALUATION

Subjective cues:

“Nahihirapan nasiya humingadahil sa plemahindi niyamailabas, grabe nakasi ang ubo niyaneh” as verbalized by his mother

Objective cues:

>difficulty of

breathing

>Wheezes on

both lung fields

>productive cough

– whitish color

Ineffective airway

clearance related

to ineffective

cough and

retained

secretions.

The inflammatory

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:

After 4 hours of

nursing

interventions, the

client will be able

to maintain airway

patency.

Long Term:

After 1 day of nursing intervention, the

client will beable toexpectorateretainedsecretions andmaintain normal

>Assessed

respiratory

movements and use

of accessory

muscles.

>Monitored vital

signs especially the

RR.

>Auscutated the

lung sounds, noting

areas of decreased

ventilation and

presence of

adventitious sounds.

>Use of accessory

muscles to breathe

indicates an abnormal

increase in work of

breathing.

>To obtain baseline

data.)

>Bronchial lung

sounds are commonly

heard over areas of

lung density or

consolidation.

Crackles are heard

when fluid is present.

The client

maintained airway

patency as

evidenced by

expectorating clear

secretions readily.

>nasal flaring

>restlessness

breathingpattern.

>Monitored chest x

– ray reports.

>Encouraged client

to increase fluid

intake.

>Advised the

realtives elevate the

head of bed at least

30 degrees.

>Assisted on

nebulizer treatment.

Nebulization done

as per doctor’s order

every 12 hours.

>These determine

progression of disease

process.)

>Hydration helps

decrease the viscosity

of secretions,

facilitating

expectorations.

>Positioning facilitates

chest expansion and

respiratory efficiency

by reducing pressure

of abdominal organs

on diaphragm.

> Relaxes bronchial

and uterine smooth

muscle by acting on

beta – adrenergic

receptors.

>Chest tapping

performed after

each nebulization.

>Instructed the

client to have oral

care after each

nebulization.

>Provided

supplemental fluids

>Chest physiotherapy

helps to aid

immobilization of

secretions.

>Discharges from the

nebulizer are often foul

tasting and smelling.

>Fluids are regulated

to replace losses and

aid immobilization

secretions.

ASSESSMENT NURSING DIAGNOSIS

RATIONALE GOAL NURSING INTERVENTION

RATIONALE EVALUATION

Subjective Data:

“Tatlong araw ng pabalik-balik anglagnat ng anak ko, hindimaganda ang pakiramdamnya kayapinunta ko nasiya dito”as verbalized by his mother

Objective Data:

T= 38.7 °C

Hyperthermia related to inflammatory response.

Increase in body temperature greater than normal range.

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 effectivenursing intervention, the patient’s temperature will decrease:

>Demonstrate temperature withinnormal range, from38.7 °C to 36.5°C-37.5°C

>Demonstrate behaviors tomonitor andpromotenormothermia.

>Skin is cool to touch and less flushness

>Identify underlying cause/contributingfactors andimportance oftreatment, as well

Independent:

>Monitor core temperature q 1 °.

>Note presence or absence of sweatingas body attempts toincrease heat lossby evaporation.

>Increase oral fluid intake.

>Promote bed rest, encouragerelaxation skills and

>Temperature of 38.9-41.1°Csuggest acuteinfectiousdisease process.

>Evaporation is decreased byenvironmentalfactors of highhumidity and high ambienttemperature aswell as bodyfactorsproducing lossof ability tosweat.

>To support circulatingvolume andtissue perfusion.

>To reduce metabolicdemands/oxygenconsumption.

After 2 hours ofeffective nursingintervention, goal is met.

> Patient’s temperature isalready in thenormal range;T=___ °C

as signs/symptomsrequiring furtherinterventions.

>Verbalized understanding of specificinterventions topreventhyperthermia

diversionalactivities.

>Provide TSB as needed

>Promote surface cooling, loosen clothing and coolenvironment

>Review specific riskfactors/causes, signs and symptoms withthe interventionsrequired

>Discuss importance of adequate fluidintake andprotein diet

Collaborative: >Administer medications asindicated to

>Heat is loss by evaporation and conduction.

>Heat is loss by Convectionradiation and conduction.

>To promote wellness

>To prevent dehydration

>To treat underlying

treat underlyingcause, such as:

-Paracetamol 325mg/tab 1 tab q 6° >Administer replacementfluids andelectrolytes tosupportcirculatingvolume andtissue perfusion

causes

>To support circulatingvolume andtissue perfusion

ASSESSMENT NURSING DIAGNOSIS

RATIONALE GOAL NURSING INTERVENTION

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 related to presence of toxins due to poor personal hygiene.

Diarrhea is thepassage of looseand waterystools (morethan 3 bowelmovements perday) oftenassociated withgassiness,bloating, andabdominal pain.It may also beaccompanied bynausea,vomiting, andfever. Diarrhearesults to loss ofbody fluids andsalts leading todehydration ofvarying severity.Severedehydration maycause deathespecially inchildren

After 4 hours of nursing interventions,the patientwill reportreduction infrequency ofstools.

Independent:

> Observe andrecord stoolfrequency,characteristics,amount andprecipitatingfactors.

> Promote bed rest

> Provide bedside Commode

> Identify foods and

> Helps differentiateindividual disease andassesses severity ofepisode

> Rest decreasesintestinal motility andreduces metabolic rate.

> Urge to defecate may occur withoutwarning anduncontrollable,increasing riskof incontinenceor falls if facilities

After 4 hours ofnursing interventions, the patient was able toreport reduction infrequency of stools.

fluids thatprecipitatediarrhea.

> Restart oral fluid intake gradually.Offer clear liquidshourly, and avoidcold fluids.

> Encourage to eatfoods like bananaand apple

> Avoid foods thatare oily, spicy andcaffeine.

Collaborative:> Administer anti-diarrheals asprescribed by thephysician.

are not close at hand

> Avoidingintestinalirritantspromotesintestinal rest

> Provides colonrest by omittingor decreasingstimulus of foods or fluids. Gradualconsumption ofliquids may preventcramping and recurrence of diarrhea. Cold fluids can increase intestinal motility.

> Fruits that are stool formed

> Foods that mayprecipitate gastriccramping

> Decreases G.I

motility orperistalsis anddiminishes digestivesecretions 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 6–7.5 mg/kg/d in 3–4 divided dosesIntrath ecal >3 mo, 1–2 mgpreservative 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 proteins;

Parenteral use restricted to treatment of serious infections of GI,respiratory, and urinary tracts, CNS, bone, skin, and soft tissue (includingburns) when other less toxic antimicrobial agents are ineffective or arecontraindicated. Has been used in combination with other antibiotics. Also usedtopically for primary and secondary skin infections and for superficial infectionsof 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 andirritation upon drug instillation, nonspecific

>upset stomach >vomiting >fatigue >pale skin

> Lab tests: Perform C&S and renal function prior to first dose andperiodically during therapy; therapy may begin pending test results.

>Determine creatinine clearance and serum drug concentrations atfrequent intervals, particularly for patients with impaired renal function,infants (renal immaturity), older adults, patients receiving high doses ortherapy beyond 10 d, patients with fever or extensive

polyribosomes are split apart and are unable to synthesize protein.

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 necrotic

conjunctivitis, conjunctival epithelialdefects, and conjunctival

hyperemia.

Other adverse reactions which have occurred rarely are allergic reactions, thrombocytopenic purpura, and hallucinations.

burns, edema,obesity.

> Note: Dosages are generally adjusted to maintain peak serum gentamicinconcentrations of 4– 10 g/mL, and trough concentrations of 1–2 g/mL.Peak concentrations above 12 g/mL and trough concentrations above 2g/mL are associated with toxicity.

> Draw blood specimens for peak serum gentamicin concentration 30 min–1hafter IM administration, and 30 min after completion of a 30–60 min IV

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

infusion. Draw blood specimens for trough levels just before the next IMor IV dose. Use nonheparinized tubes to collect blood.