Drug Study- Dexamethasone 4z6qq

VII. DRUG STUDY DRUG Date ordered: August 04, 2010 Generic name: Dexamethasone Brand name: -Classification: Anti inflammatory Glucocorticoid Dosage: 1.8 mg IV q6

INDICATION

ACTION

Specific The patient was given Adjunctive treatment dexamtehasone 1.8 mg in bacterial meningitis. through IV every 6 hours to decreases General inflammation, mainly by Cerebral edema stabilizing leukocyte Allergic and lysosomal membranes; inflammatory suppresses immune conditions response; stimulates Shock bone marrow; and Tuberculosis influences protein, fat meningitis and carbohydrate metabolism.

SIDE/ADVERSE EFFECTS  CNS: euphoria, insomnia, psychotic behavior, pseudotumor cerebri, vertigo, headache, paresthesia, seizures, depression.  CV: hypertension, edema, arrythmias, thromboembolism.  EENT: cataracts, glaucoma.  GI: peptic ulceration, GI irritation, increased appetite, pancreatitis, nausea, vomiting.  GU: increase urine glucose, and calcium levels  Metabolic: hypokalemia, hyperglycemia  Musculoskeletal: muscle weakness  Skin: Delayed wound healing  Other: Susceptibility to infections.

NURSING CONSIDERATION 1. Determin e whether patient is sensitive to other corticosteroids 2. Most adverse reactions to corticosteroids are dose-or durationdependent. 3. For better results and less toxicity, give once daily dose in morning. 4. Give oral dose with food when possible. Patient may need drugs to prevent GI irritation. 5. Give I.M injection deeply into gluteal muscle. Rotate injection sites to prevent muscle atrophy. Avoid subcutaneous

PATIENT TEACHINGS 1. Tell patient not to stop drug abruptly or without prescriber’s consent. 2.Instruct patient to take drug with food or milk. 3.Teach patient signs and symptoms of adrenal insufficiency; fatigue, muscle weakness, pain, fever, anorexia. 4.Warn patient on long term therapy about cushingoid effects(moon face, buffalo hump) 5.Warn patient about easy bruising. 6.Advise patient to avoid exposure to infections (such as

injection because atrophy and sterile abscesses may occur. 6. Alwats adjust to lowest effective dose 7. Monitor patient weight, blood pressure, and electrolyte levels. 8. Monitor patient for cushingoid effects, including moon face, buffalo hump, thinning of hair.

measles and chickenpox) and to notify prescriber if such exposure occurs.

DRUG

INDICATION

Date ordered: August 4, 2010

Specific mycobacterial infections

Generic Name: Streptomycin

General Part of combination therapy of active tuberculosis; used in combination with other agents for treatment of streptococcal or enterococcal endocarditis, plague, tularemia, brucellosis

Brand Name: -Classification: Antituberculosis agent Dosage: 300 mg OD M-W-F ANST

ACTION The patient was given Streptomycin 300 mg OD M-W-F to treat and destroy bacteria in body by inhibiting protein synthesis in bacterial cell by binding directly by 30S ribosomal subunit, causing inaccurate peptide sequence to form in protein chain, resulting in bacterial death.

SIDE/ADVERSE EFFECTS  Allergic Reactions  Disturbances of vestibular function  Facial Parathesia  Nausea and Vomiting

NURSING CONSIDERATION 1. Assess the patient for any previous adverse or sensitivity reaction 2. Assess for any allergic reaction; rash. 3. Monitor the patient’s intake-output ratio. 4. Monitor for dehydration 5. Evaluate patient’s hearing before therapy.

PATIENT TEACHINGS 1. Instruct the patient’s watcher to report adverse reaction to nurse at once. 2. Encourage to take adequate amount of fluids, preferably water. 3. Emphasize the need for blood testing.

DRUG Date ordered: August 4, 2010 Generic Name: Meropenem Brand Name: -Classification: Antibiotic Dosage: 500mg TIV q8⁰ ANST

INDICATION Specific For pneumonia and meningitis General Treatment of infection caused by single or multiple susceptible bacteria sensitive to meropenem. Pneumonia including hospital acquired, septicemia, neutropenia, intraabdominal infections, meningitis, urinary tract, gynecological and skin and soft tissue infection.

ACTION The patient was given Meropenem 500mg TIV q8⁰ to inhibit bacterial growth and replication. The bactericidal interferes with bacterial cell wall replication of susceptible organism which it readily penetrates the cell wall of the most gram positive and gram negative bacteria to reach penicillinbinding protein targets where it inhibits cell wall synthesis to render the cell wall osmoticaly unstable.

SIDE/ADVERSE EFFECTS  Seizure, headache and pain  Pseudomembranous colitis  Apnea  Anaphylaxis  Thrombophlebhitis

NURSING CONSIDERATION 1. In patients with CNS disorders such as bacterial meningitis drug may cause seizures. 2. If seizures occur stop drug infusion. 3. Monitor patient’s fluid balance and weight carefully.

PATIENT TEACHINGS 1. Instruct the patient’s watcher to report adverse reaction to nurse at once. 2. Advise watcher to report loose stool to prescriber.

DRUG Date ordered: August 4, 2010 Generic Name: Isoniazid Brand Name: -Classification: Antituberculosis agent Dosage: 200mg/5ml: 3ml OD PO

INDICATION

ACTION

Actively growing tubercle bacilli. To prevent tubercle bacilli in those exposed to tuberculosis (TB) or those with positive skin test results whose chest x-rays and bacteriologic study results indicate non progressive TB.

The patient was given Isoniazid 200mg/5ml: 3ml OD to treat or inhibit synthesis of meningococcal infection and bacterial growth. It may inhibit cell wall biosynthesis by interfering with lipid and DNA synthesis; bactericidal.

SIDE/ADVERSE EFFECTS  Seizures  Toxic Enchepalopathy  Memory impairment  Unusual weakness or fatigue  Yellow skin or eyes  Dark urine

NURSING CONSIDERATION 1. Always give drug with other antituberculitics to prevent development of resistant organisms 2. Monitor hepatic function for changes 3. Give pyridoxine specially to malnourished patients

PATIENT TEACHINGS 1. Instruct patient to take drug exactly as prescribed; warn about stopping drug without prescriber’s consent 2. Take drug before meals 3. Notify health care providers if signs and symptoms of liver impairment occur. 4. Explain the importance of taking the drug at the right time and amount.

DRUG Date ordered: August 4, 2010 Generic Name: Rifampicin Brand Name: -Classification: Antituberculosis agent Dosage: 200mg/5ml: 4.5ml OD PO

INDICATION Specific Prevention of meningococcal meningitis

ACTION

The patient was given Rifampicin 200mg/5ml: 4.5ml OD to treat or inhibit General synthesis of Maintenance treatment of all meningococcal forms of pulmonary and infection and bacterial extra-pulmonary growth by inhibiting tuberculosis (TB). For DNA-dependent RNA continuation phase (for 4 polymerase, which impairs mos) of short-course antiRNA TB treatment. TB and synthesis; bactericidal leprosy in combination with other antibiotics/chemotherapeutic agents; non-mycobacterial infections; brucellosis in combination with a tetracycline

SIDE/ADVERSE EFFECTS  Headache, fatigue, drowsiness, behavioral changes and dizziness  Shock, visual disturbances, exudative conjunctivitis

NURSING CONSIDERATION 1. Give the drug one hour before taking. 2. Monitor hepatic function. 3. Watch out for and report to prescribe signs and symptoms of hepatic impairment 4. Monitor client’s hepatic functions.

PATIENT TEACHINGS 1. Warn patient that the drug can turn urine into red to orange. 2. Instruct patients who cannot tolerate capsules on an empty stomach to take the drug with one full glass of water. 3. Advise patient to avoid alcohol during drug therapy.

DRUG Date ordered: August 05, 2010 Generic name: Pencillin G sodium Brand name: -Classification: Anti-infective Dosage: 650,000 u IV q4 ANST(-)

INDICATION Specific Pneumoccocal respiratory infections, including otitis media

ACTION

The client was given Penicillin G sodium 650,000”u” IV every 4 hours after negative skin test which inhibits cellGeneral wall synthesis during Moderate to severe systemic bacterial multiplication. infection.

SIDE/ADVERSE EFFECTS  CNS: neuropathy, seizures, lethargy, hallucinations, anxiety, confusion, depression, dizziness, fatigue.  CV: thrombophlebitis  GI: Nausea, vomiting, enterocolitis, ischemic colitis  GU: neuropathy  HEMA: Hemolytic anemia, anemia, leukopenia  Musculoskele tal: arthralgia

NURSING CONSIDERATION 1. Before giving drug, ask patient about allergic reactions to penicillin. 2. Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin pending results. 3. Observe patient closely. With large doses and prolonged therapy, bacterial or fungal superinfection may occur. 4. Assess neurologic status, especially for

PATIENT TEACHINGS 1. Tell patient or patient’s significant other to report adverse reactions promptly. 2. Instruct patient to report discomfort at I.V site. 3. Warn patient receiving I.M injection that the injection may be painful, but that ice applied to site may help alleviate discomfort.

 OTHER: hypersensitivity reactions, anaphylaxis, pain at injection sure, vain irritation. DRUG Date ordered: August 05, 2010 Generic name: Famotidine Brand name: -Classification: -Histamine 2-receptor agonist -Anti ulcer drug Dosage: 5mg IV q12

INDICATION Specific Prophylaxis of duodenal ulcers.

ACTION

The patient was given Famotidine 5mg through IV every 12 hours as a phrophylaxis for General duodenal ulcer by Hospitalized patient who blocking action of cannot take oral drug or histamine at histamine 2have an intractable ulcers or receptor sites in gastric hypersecretory conditions. parietal cells, inhibiting gastric acid secretion and stabilizing pepsin.

SIDE/ADVERSE EFFECTS  CNS: dizziness, headache, paresthesia, asthenia.  CV: palpitations

seizures and decreasing level of consciousness.

NURSING CONSIDERATION 1. Assess patient for abdominal pain. Look for blood in emesis, stool, or gastric aspirate.

 GI: nausea, diarrhea, constipation, dry mouth, anorexia

2. Oral suspension must reconstituted and shaken before use.

 EENT: orbital edema, conjuctival redness, tinnitus

3. Monitor blood urea nitrogen and creatinine levels in patient with renal impairment.

 Musculosketal: bone and muscle pain.  SKIN: Flushing, acne, dry skin.

PATIENT TEACHINGS 1. Tell the patient that drug is most effective when at bedtime. 2. Inform patient that pain relief may not begin until several days after therapy starts. 3. Tell patient to take prescription drug with a snack, desired. 4. With prescriber’s knowledge, let patient take antacids together,

especially at begining of therapy when pain is severe.

 OTHER: altered taste, fever, pain at injection site, hypersensitivity reactions.

DRUG Date ordered: August 05, 2010 Generic name: Sucralfate Brand name: Carafate Classification: Anti ulcer agent Dosage: 1gm/tab ½ tabs through NGT q6 after each lavage

INDICATION

ACTION

Short term (up to 8 weeks) The patient was given treatment of duodenal ulcer. Sucralfate ½ gram per tablet through NGT every 6 hours after lavage as a short term treatment for duodenal ulcer which acts by combining with gastric acid to form protective coating on ulcer surfaces, inhibiting gastric secretion, pepsin, and bile salts.

SIDE/ADVERSE EFFECTS  CNS: dizziness, headache, sleepiness, vertigo  GI: constipation, diarrhea, dry mouth, flatulence, gastrric discomfort, indigestion, nausea, vomiting.  RESP: Respiratory difficulty  SKIN: pruritus, rash  OTHER: facial swelling,

5. Advise patient to report abdominal pain or blood in stools or vomit. NURSING CONSIDERATION 1. Reconsitu te drug before instillation through a nasogastric tube. Flush tube with water to ensure age into stomach.

PATIENT TEACHINGS 1. Tell the patient or parents of the patient to take sucralfate on an empty stomach , 1 hour before each meal and at bedtime.

2. Drug is minimally absorbed and causes few adverse reactions.

2. Instruct patient to continue prescribed regimen to ensure complete healing. Pain and other ulcer signs and symptoms may subside

3. Monitor patient for severe, persistent constipation.

hypersensitivity reaction.

DRUG Date ordered: August 14, 2010

INDICATION Specific Fever

ACTION

The client was given Paracetamol 125mg through Iv every 4 Generic name: General hours for fever to cause Acetaminophen Mild to moderate pain relief by inhibition of caused by headache, muscle prostaglandin synthesis Brand name: ache, backache, common in CNS, with Paracetamol cold, toothache subsequent blockage of pain impulses. Fever Classification: reduction may result Analgesic, Antipyretic from vasodilation and increased peripheral Dosage: blood flow in 125mg IV q4 for hypothalamus, which fever dissipates heat and lowers body

SIDE/ADVERSE EFFECTS  HEMATOLOGIC: thrombocytopenia, hemolytic anemia, neutropenia, leucopenia, pancytopenia.  HEPATIC: jaundice, hepatotoxicity  METABOLIC: hypoglycemic coma  SKIN: rash, urticaria  OTHER: hypersensitivity reactions (such as fever)

4. Drug is as effective as cimetidine in healing duodenal ulcer. 5. Drug contains aluminum but isn’t classified as an antacid. Monitor patient with renal insufficiency for aluminum toxicity. NURSING CONSIDERATION 1. Assess allergic reactions such as rash, urticaria. 2. Assess hepatotoxicity; dark urine clay colored stools, itching. 3. Monitor liver and renal functions, ALT, AST, bilirubin, pro-time.

within first few weeks of therapy. 3. Antacids may be used while taking drug, but separate doses by 30 minutes.

PATIENT TEACHINGS 1. Advice patient, parents, or other caregivers to prescriber if fever ot other symptoms persist despite takinf recommended amout of drug. 2. Inform patient with chronic alcoholism that drug may increase risk of severe liver damage.

temperature.

DRUG Date ordered: August 14, 2010 Generic name: Mannitol Brand name: -Classification: Diuretic Dosage: 60 cc IV q4 x 30 min with BP precaution

INDICATION Reduction of increased intracranial pressure associated with cerebral edema.

ACTION

SIDE/ADVERSE EFFECTS The patient was given  CNS: dizziness, Mannitol 60cc through IV headache, seizures with BP precaution to decrease intracranial  CV: Chest pain, pressure by increasing the hypotension, osmotic pressure of tachycardia, glomerular vascular overload. filtrate, which inhibits tubular reabsorption of  EENT: Blurred water and electrolytes and vision increases urinary output.  GI: nausea, vomiting, diarrhea, dry mouth.

3. As appropriate, review all other significant and life threatening adverse reactions and interactions, especially those related to the drugs, tests, and behaviors mentioned above.

NURSING CONSIDERATION 1. Monitor IV site carefully to avoid, extravasation and tissue necrosis. 2. Monitor renal function tests, urinary output, fluid balance, Central venous pressure, and electrolyte levels (especially sodium and potassium.)

PATIENT TEACHINGS 1. Teach patient about importance of monitoring exact urinary output. 2. Advised patient to report pain at infusion site as well as adverse reactions, such as increase shortness of breath or pain in back, legs or chest.

 GU: polyuria, urinary retention  METABOLIC: dehydration, water intoxication, hypernatremia, metabolic acidosis, hypokalemia  RESP: pulmonary congestion.  SKIN: rash, urticaria.  OTHERS: chills, fever, thirst, edema and tissue necrosis.

DRUG Date ordered: August 17, 2010 Generic Name: Phenobarbital

INDICATION Specific Treatment of generalized tonic-clonic and cortical focal seizures; emergency control of acute convulsions

ACTION The patient is given Phenobarbital PO q12° to help free from seizure activity. Depressant and

SIDE/ADVERSE EFFECTS      

Dizziness Headache Hypotension Bradycardia GI disturbances Allergic reaction

3. Watch for excessive fluid loss and signs and symptoms of hypovolemia and dehydration. 4. Assess for evidence of circulatory overload, including pulmonary edema, water intoxication and heart failure.

NURSING CONSIDERATION 1. Monitor the patient before and after therapy to know the effectiveness of the drug.

3. Tell patient drug may cause thirst or dry mouth. Emphasize that fluid restrictions are necessary, but that frequent mouth care should case these symptoms. 4. As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above. PATIENT TEACHINGS 1. Advice the mother to check prescriptions and refills because Phenobarbital is

Brand Name: -Classification: Barbiturates

General Short term treatment of insomnia; preanesthetic sedation.

Dosage: 60mg ½ tab q12° PO

DRUG Date ordered: August 17, 2010 Generic Name: Ciprofloxacin Brand Name: -Classification: Antibiotic:

INDICATION Infections of the respiratory tract, middle ear, paranasal sinuses, eyes, kidneys and/or, urinary tract, genital organs including adnexitis, gonorrhea, prostatitis, abdominal cavity (e.g. infections of the GIT or biliary tract, peritonitis), skin and soft tissue, bones

anticonvulsant effects may be realted to its ability to increase and/or mimic the inhibitory activity of GABA on nerve impulses (depress CNS synaptic transmission and increase seizure activity threshold in the motor cortex.) As a sedative, it may also interfere with the transmission of impulses from the thalamus to the brain cortex. ACTION The patient was given Ciprofloxacin ½ tab q12° to help inhibit or possibly destroy the microorganism in the clients body. Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria.

 Sedation and depression may occur

2. Assess seizure activity: type, location, duration and character. 3. Assess for drug induced adverse reactions. 4. Assess for barbiturate toxicity: cold clammy skin, cyanosis.

SIDE/ADVERSE EFFECTS

NURSING CONSIDERATION

       

Nausea Diarrhea Rash Allergic reactions Sleep disorders Thrombophlebitis Photosensitivity Renal impairment

1. Assess the patient for any previous sensitivity reaction. 2. Assess the patient for signs and symptoms of infection before and during treatment.

available in different forms. 2. Do not take with alcohol for it can increase the chances of the adverse effects. 3. Avoid activities that require alertness for phenobarital induce sleepiness. 4. Advice mother to turn patient q2° to prevent orthostatic hypotension. PATIENT TEACHINGS 1. Advise mother to report occurrence of any adverse reaction. 2. Instruct patient to take drug on the length of time ordered. 3. Avoid taking antacids,

fluoroquinolones Dosage: 500mg ½ tab q12° PO

and ts; sepsis, infections or imminent risk of infections (prophylaxis) in patients whose immune system has been weakened (e.g. patients on immunosuppressants or have neutropenia). Selective intestinal decontamination in immunosuppressed patients. Acute uncomplicated UTI (acute cystitis). Uncomplicated UTI including acute uncomplicated pyelonephritis.

VIII. LIST OF PRIORITY PROBLEMS 1. Ineffective cerebral tissue perfusion 2. Hyperthermia

3. Imbalanced Nutrition: Less than body requirements 4. Impaired skin integrity 5. Risk for aspiration

3. Assess the patient for any allergic reaction or anaphylaxis. 4. Assess for the client’s renal function before and during therapy

vitamin or mineral supplements within 6 hours before or 2 hours after you take ciprofloxacin. 4. Advise patient to report itching, malaise, redness, pain, swelling.

IX. NURSING CARE PLAN Cues/data

Nursing Diagnosis

Rationale

Subjective: “Hindi niya na maigalaw ang ulo at mga paa niya para din siyang naninigas” As verbalized by the patient’s mother.

Ineffective cerebral tissue perfusion related to compression of cerebral arteries secondary to increased intracranial pressure (I)

Increased intracranial pressure can be due to a rise in cerebrospinal fluid pressure. It can also be due to increased pressure within the brain matter caused by a mass (such as a tumor), bleeding into

Objective cues:

Goals and Objectives After 4 hours of continuous nursing interventions, the patient will show signs of increased tissue perfusion as evidenced by : - Vital signs within client’s normal range.

Interventions

Rationale

Evaluation

- Assessment of vital signs is an important component of the physical therapy examination and should be included in the examination of all patients. Knowledge of vital

After 4hours of continuous intervention, the goal was PARTIALLY MET as evidenced by : - Vital signs within client’s normal range. - no seizure episodes

Independent: -Monitoring the vital signs of the patient

-hydrocephaluscommunicating -increased I -restlessness -changes in pupillary reactions(nonreactive) -presence of NGT -use of accessory muscles to breath -extremity weakness -muscle rigidity

the brain and cerebral artery compression.

-Avoiding the patient to have seizures

Reduced arterial Long-term goal: blood flow causes decreased nutrition mental status of the and oxygenation at patient(alert) the cellular level. Management is directed at removing vasoconstricting factor(s), improving peripheral blood flow, and reducing metabolic demands on the body. Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient. If the decreased perfusion is acute and protracted, it can have devastating effects on the patient. Diminished tissue perfusion, which is chronic in nature, invariably results in tissue or organ

-Monitor the LOC

-Avoid measures that will trigger increase of I of the patient such as straining, positioning the neck of the patient in flexion and head flat. - Elevate the patients head or the HOB of the patient about 30 – 45 degrees.

-Provide information on normal tissue perfusion and possible impairments on the patient’s mother.

signs allow the nurse to understand a patient’s physiologic status and is helpful in determining appropriate goals interventions needed by the patient. -Monitoring the LOC will give the nurse a baseline data, helps in determining the status of the patient, the patient’s response to medications. -Avoiding these measures will help the decrease of I of the patient and to avoid the further decrease of cerebral blood flow of the patient which can be fatal. -Elevation of the head will promote venous outflow from the brain due to the force of gravity and this will help in the decrease of the I of the patient.

damage or death.

REFERENCES: -Mosby’s pocket dictionary of medicine, Nursing and health professions.(p.660) -http://en.wikipedia. org/wiki/I ntracranial_pressure

-Explain all procedures and equipments to the patient mother.

-Instruct patient’s mother to inform the nurse immediately of symptoms of decreased perfusion persist, increase or return -observe seizure precaution for the patient:  Provide dim light  Side rails  Avoid exposure to electricfan  Avoid noise

- Educating the mother will give the mother the idea if the patient is experiencing any abnormalities and this will also establish cooperation with the mother. -Explaining the procedures and equipments may reduce the anxiety of the patient’s mother on the unknown and this will also help in the establishment cooperation with the mother - Having the cooperation of the patient’s mother will help in the monitoring of the patient and early assessment facilitates prompt treatment. - to avoid progression of seizure and the risk for injury of patient.

 Avoid jarring of the bed DEPENDENT: -ister anticonvulstants and osmotic diuresis prescribed by the doctor when it is needed.

-to avoid patient on having seizures which can result from cerebral edema or ischemia and to reduce increase I. REFERENCES: -Nurse’s Pocket guide 11th edition, by Dooenges, Moorhouse and Murr (p. 708) -Nursing Care plans by Gulanick and Myers(p.200)

Cues / Data Subjective cues: “ Mainit siya tapos ilang araw na hindi bumaba ang lagnat niya” as verbalized by his mother. Objective data:  Flush skin  Warm to touch

Nursing Diagnosis

Rationale

Hyperthermia related to infection secondary to meningitis

The child may develop fever as a symptom of a wide variety of illnesses as well as from infections. For example, certain blood disorders and inflammatory disorders (eg juvenile arthritis) may cause fever.

Goals and Objectives After 4 hours of nursing intervention the patient body temperature will reduce to 37°C

Interventions Independent:  Assess for neurological response; noting the level of consciousnes s and orientation, reaction to stimuli of pupils

Rationale

 To know if its increasing or decreasing

 Central hypertension or

Evaluation After 4 hours of nursing intervention The goal was not met as evidence by the body temperature of the patient is still 39°C

 T: 39.7°C

 RR: 26  BP 140/100  PR:144

Fever can also be caused by sunstroke and some childhood immunisations. However, most episodes of fever are caused by viral infections.

 Monitor core temperature,  Monitor BP and heart and rhythm  Monitor respiration  Monitor/ record all sources of fluid loss such as urine; vomiting and diarrhea;wou nd and insensible loses  Monitor laboratorial studies such as ABGs, electrolyte, cardiac and liver enzyme  Promote

peripheral/pos tural hypotension occurs

 Hyperventilati on may initially be present, but ventilatory effort may eventually impaired by seizure, hypermetaboli c rate (shock and acidosis)  Oliguria and/or renal failuremay occur due to hypotension, dehydration, shock  It may reveal tissue degeneration

surface cooling by means of undressing; cool and environment  Encourage TSB Dependent:  ister medication o (para cetam ol)

Cues / Data Subjective Data: “Nangayayat na nga sya ngayon eh” as verbalized by the mother Objective data: -Iron Deficiency

Nursing Diagnosis Imbalanced Nutrition: Less than Body Requirements related to inability to ingest food

Rationale

Goals and Objective

Adequate nutrition is necessary to meet the body’s demands. Nutritional status can be affected by disease or injury states social factors

After 4 hours of nursing intervention, the patient will experience gradual balanced nutrition as manifested by: -complying to the feeding time of the

Intervention 1. Place the child in position of comfort for feeding.

 Cool environment can or helps the body temperature to decrease  Could lower down the body temperature

 To rapid decrease body temperature

Rationale

Evaluation

1. Provide most appropriate position to enhance movement of formula by gravity and peristalsis and to prevent vomiting or aspiration

After 4 hours of nursing intervention, goals fully met as evidenced by: - complied time of feeding -health teaching was

Anemia as evidenced by laboratory results: RBC count ↓3.74 Hemoglobin ↓8.63 Hematocrit ↓27.68 MCV ↓74.03 MCH ↓23.09 MCHC ↓31.09 - 20.4 Kg upon ission, 12.9 Kg present weight -BMI 10.8 -Underweight

patient -giving of prescribed supplement or vitamin if available

2. Promotes information to ensure stable weight and gains proportionate to growth

2. Teach parent about caloric needs for age of -provide parents child and in weight information about the and height 3. Prevent spoiling appropriate nutrition. measurement. and contamination of food that may 3. Teach parent cause about proper gastrointestinal preparation and symptoms. storage of food; hand wash before preparing or handling food.

provided to the parents.

Cues/Needs

Nursing Diagnosis

Rationale

Goals and Objectives

O Subjective data: “Namamalat na yung bandang ari niya at sa may pwet.” As verbalized by the patient’s mother.

Impaired skin integrity r/t physical immobilization

Decreased muscle strength ↓ Body weakness ↓ Irritability ↓ Physical immobility ↓ Risk for skin integrity

After 4hrs. of given intervention the patient will maintain physical well-being

Objective data: - disruption of the epidermis - redness - immobility/inactivity - neuromascular impairment VS Taken: BP: 140/100 RR: 26 PR: 144 TEMP: 39.7˚ C

*Medical-Surgical Nursing 11th Edition; Brunner & Suddarth”s

Long-term goal: Timely wound healing

Interventions Independent: *client teaching * obtain a history of condition, Including age at onset, duration of problem and changes over time *inspect skin on a daily basis *Assess skin routinely, noting moisture, color, and elasticity

Rationale

*To prevent complications *To monitor progress or healing

*enhanced circulation to compromised tissue *this may indicate particular vulnerability

*Observe for reddened/blanched areas or skin rashes, and institute treatment immediately

*Reduces likelihood of progression to skin breakdown

*Provide adequate clothing/covers; protect from drafts

*To prevent vasoconstriction

*Emphasize importance of adequate nutritional/fluid intake

*To maintain general good health and skin turgor

* stress proper hand hygiene to all care givers and other infection control procedures

*promoting hygienic procedures is a key in infection prevention

Evaluation The patient able to maintain physical well being after the given 4hrs. intervention thus the goal is partially met

Cues/Needs OBJECTIVE: ➢ Improper NGT feeding

Nursing Diagnosis

Rationale

Goals and Objectives

Risk for aspiration related to knowledge deficit.

Aspiration is defined as the inhalation of either oropharyngeal or gastric contents into the lower airways. Inhalation of these contents can lead to aspiration pneumonia and aspiration pneumonitis. Although these two entities are managed differently, they are often interchangeably referred to as aspiration pneumonia. Aspiration pneumonitis represents chemical damage to the tracheobronchial tree caused by acute, often witnessed, inhalation

After hours of nursing intervention the patient will be able to:

Patient maintains patent airway.  Patient’s risk of aspiration is decreased as a result of ongoing assessment and early intervention. 

Interventions Independent  Monitor level of

consciousness.

 Assess cough and

gag reflexes.

 Assess pulmonary

status for clinical evidence of aspiration. Auscultate breath sounds for development of crackles and/or rhonchi.

Keep suction setup available 

Rationale

Evaluation

After hours of nursing intervention  A decreased the Goal was MET level of by: Patient was able consciousness is to maintain patent a prime risk airway. Patient’s factor for aspiration. risk of aspiration is decreased as a result of ongoing  A depressed assessment and cough or gag reflex increases early intervention. the risk of aspiration.  Aspiration of

small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with decreased levels of consciousness.

of regurgitated gastric contents in patients with an acute change in mental status. Aspiration pneumonia results from chronic, usually unwitnessed, inhalation of small amounts of oropharyngeal contents leading to an infectious process.

Position patients who have a decreased level of consciousness on their sides. 

 This is

necessary to maintain a patent airway.  This protects

Position patient at 90degree angle, whether in bed or in a chair or wheelchair. Use cushions or pillows to maintain position. 

Maintain upright position for 30 to 45 minutes after feeding. 

the airway. Proper positioning can decrease the risk of aspiration. Comatose patients need frequent turning to facilitate drainage of secretions.  Proper

positioning of patients with swallowing difficulties is of primary importance during feeding or eating.



Provide oral care after meals. 

The upright position facilitates the gravitational flow of food or fluid through the alimentary tract. If the head of the bed cannot be elevated because of the patient’s condition, use a right side-lying position after feedings to facilitate age of stomach contents into the duodenum.

 This removes

residuals and reduces pocketing of food that can be later aspirated.