NURSING CARE PLAN
NURSING CARE PLAN: Potential
ASSESSMENT DIANOSIS PLANNING INTERVENTION RATIONALE EVALUATION
1. Monitor VS 1. To assess Goal was met:
Subjective Cues: Ineffective STG: every 2 hrs. baseline data. STG: After 4
“Maglisod sya og Airway After 4 hours hours of
ginhawa tungod sa Clearance of nursing 2. Encourage 2. Promotes nursing
iya ubo” as related to intervention, patient maximal lung intervention,
verbalized by the thick the client will to position high function. the client had
mother. tenacious be able to back rest been able to
secretions cough positon. cough
Objective Cues: and airway effectively and effectively and
- Inability to cough obstruction as clear own 3. Turn patient 3.Repositioning clear own
effectively manifested by secretions every 2 hrs and promotes secretions.
- shallow shallow as needed. drainage of
respirations respiration, .LTG: pulmonary LTG: After 5
- febrile tachypnea After 5 days of secretions and days of
- anxiety and fever nursing enhances nursing
- restlessness intervention, ventilation to intervention,
- adventitious the client will decrease the client
breath sounds maintain potential of maintained
- tachypnea patency of atelectasis. patency of
- use of accessory airway and will airway and
muscle while have clear 4. Teach client to 4. To help thin had clear
breathing breath maintain secretions. breath sounds.
sounds. adequate
hydration by
drinking at least
8-10 glasses of
fluid/day ( if not
contraindicated).
5. Administer 5.To improve
bronchodilators ventilation and
as ordered. maximizes air
exchange.
NURSING CARE PLAN: Potential
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATION
N
Subjective Impaired oral After 5 hours of 1. Advice mother to 1. To Goal was met:
continue with the completely
Cues: mucous nursing antibiotics as
After 5 hours of
destroy the
‘’ Naglisod sya membrane intervention, prescribed by the bacteria and
nursing
mokaon kay related to the clients doctor even if also to prevents intervention, the
sakit iyang infectious mother will symptoms subside. the resistance patient’s mother
tutunlan” as process as verbalize the of the bacteria was able to
verbalized by evidenced by understanding from the verbalize the
antibiotic.
the mother. inflamed of etiology and 2. Advise mother to understanding
tonsils management of avoid giving sweets 2. Bacteria of the etiology
tonsillitis of her and cold beverage proliferate faster and
Objective child. to the patient. in sweet management of
Cues: environment. the tonsillitis.
3. Encourage
- reddened After applying mother to do tepid
tonsils the health sponge bath in 3. Tepid sponge
- Vital signs teachings given case fever persists. bath decreases
take as follows: to the mother, the body’s
T= 37.5 the patient’s temperature
through
PR= 120 condition will conduction.
RR= 32 improve and
recurrence of 4. Promote oral 4. Without
the infection fluid intake. proper nutrition
will be avoided. and hydration
the oral mucosa
is more
vulnerable to
damage and
this will also
prevent
dehydration.
5. Advise mother to 5. This relieves
make patient gargle the patient’s
with a solution of sore throat
warm water and although this is
salt. only short-lived.
NURSING CARE PLAN: Actual
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATION
N
Subjective Hyperthermia After 4 hours 1. Monitor the 1. To assess Goal Met:
Cues: related to acute of nursing vital signs. the baseline After 4 hours
‘’ Gihilantan infection by interventions, data. of nursing
sya ganeha microorganisms. the mother 2. Encourage 2. Tepid interventions,
kadlawon” as will verbalized mother to do sponge bath the mother
verbalized by that the tepid sponge decreases the was
the mother. temperature bath in case body’s verbalized
will maintain fever persists temperature that the
within the through temperature
Objective normal range conduction. was maintain
Cues: of 37.2 from within the
-Flushed skin 38.1. normal range
-Warm to touch 3. Promote oral 3. To prevent of 37.2 from
-Restlessness fluid intake. from 38.1.
-Vital sign dehydration
taken as 4.Administered
follows: paracetamol as 4. Paracetamol
ordered. are classified
T- 38.1 as analgesics
PR- 110 and antipyretic
RR- 28 which acts on
BP- 110/90 the
hypothalamus
to regulate
normal body
temperature.
5. Promote rest 5.T o reduce
and comfort metabolic
providing bed demands that
rest. may contribute
to further
complications.
NURSING CARE PLAN: Actual
ASSESSMEN DIAGNOSIS PLANNING INTERVENTI RATIONALE EVALUATION
T ON
Subjective Imbalance After 4 hours 1.Monitor or 1.Many
Cues: Nutrition less of nursing explore psychological,
“ Ngluya siya than body intervention, attitudes psychosocial,
ky dli ganahan requirements the patient will toward eating and cultural
mokaon” as related to be able to: and food. factors
verbalized by difficulty of determine the
the patient. swallowing. -Verbalized type, amount,
and and
Objectives demonstrate appropriates of
Cues: selection of food consumed.
-Pale skin foods or 2. Provide 2. Attention to
-Sunken eyes meals that will companionshi the social
-Dry skin achieve a p during aspects of
- Weight loss cessation of mealtime. eating is
weight loss. important in
both the
hospital and
home setting.
DRUG STUDY
Classificatio Dosage Action Indication Contraindication Side Nursing responsibilities
n effect
Generic 500 MG Bacterial Treatment Contraindicated to Assess for allergies
name: action for patients with to penicillin,cephalosporins,
• ROUTE: against infections allergies to or other allergens and renal
ampicillin IVTT sensitive caused by penicillin’s, disorders
Brand name: organisms susceptible cephalosporin’s, Culture infected area
• Inhibits strains of or other allergen before treatment; reculture
Ampicin synthesis H.influenza area if response is not
of bacterial as expected.
cellwall,
causing ell Check IV site carefully for
death. signs of thrombosis or drug
reaction.
Teach SO to report
patient’s pain or discomfort
at sites, unusual bleeding
or bruising, mouth sores,
rash, hives, fever, itching,
severe diarrhea, difficulty
breathing.
DRUG STUDY
Classificatio Dosage Action Indication Contraindication Side effect Nursing
n responsibilities
Generic PO It relieves Hypersensitivi Nervousnes Assess lung
name: (Adults nasal ty to s sounds, PR
and congestion adrenergic Restlessnes and BP
Albuterol Children and reversible amines s before drug
more bronchospasm Tremor administratio
Brand name: than 12 by relaxing the Hypersensitivi Headache n and during
years): smooth ty to Insomnia peak of
Salbutamol 2-4 mg muscles of the fluorocarbons Chest pain medication.
3-4 times bronchioles. Palpitations Observe fore
a day or The relief from Angina paradoxical
4-8 mg nasal Arrhythmias spasm and
of congestion Hypertensio withhold
extended and n medication
dose bronchospasm Nausea and and notify
tablets is made vomiting physician if
twice a possible by Hyperglyce condition
day. the following mia occurs.
mechanism Hypokalemi If
that takes a administerin
place when g medication
Salbutamol is through
administered. inhalation,
allow at
least 1
minute
between
inhalation of
aerosol
medication.
Advise the
patient to
rinse mouth
with water
after each
inhalation to
minimize dry
mouth.
Inform the
patient that
Albuterol
may cause
an unusual
or bad taste.
DRUG STUDY
Classificatio Dosage Action Indication Contraindicatio Side effect Nursing
n n responsibilitie
s
Generic 2.5 ml Decreases Relief of Contraindicated Drowsiness Asses
name: fever by mild to to patients who Nausea and patients fever
Route: inhibiting the moderate have vomiting and pain
Paracetamol Oral of effect of pain hypersensitivity Abdominal
pyrogens on Intolerance to pain Assess
Brand name: Frequency the Treatmen tartrazine , Hepatotoxicit allergic
: hypothalamu t of fever alcohol, table y reaction
Calpol Q 4hours s hear sugar, Hepatic
regulating sarccharin, seizure Teach patient
centers and Allergy to Hemolytic to recognize
hypothalamic acetaminophen anemia signs of
reaction . Coma and voerdose
leading to death
sweating and Jaundice
vasodilation. Rash
Urticarial
DRUG STUDY
Classificatio Dosage Action Indication Contraindication Side Nursing
n effect responsibilities
DRUG STUDY
Classificatio Dosage Action Indication Contraindication Side Nursing
n effect responsibilities
DRUG STUDY
Classificatio Dosage Action Indication Contraindication Side Nursing
n effect responsibilities
