NURSING CARE PROCESS

ASSESSMENT NURSING RATIONALE GOAL NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

Subjective cues: Ineffective airway The inflammatory Short Term: >Assessed >Use of accessory
The client
“Nahihirapan na clearance related response to respiratory muscles to breathe
maintained airway
siya huminga
to ineffective infection causes After 4 hours of movements and use indicates an abnormal
dahil sa plema patency as
hindi niya cough and tissue edema and nursing of accessory increase in work of
evidenced by
mailabas, grabe
retained exudates formation interventions, the muscles. breathing.
na expectorating clear
kasi ang ubo niyan secretions. in the lungs, the client will be able
secretions readily.
eh” as verbalized
inflammatory to maintain airway >Monitored vital >To obtain baseline
by his mother
response can patency. signs especially the data.)
Objective cues: narrow and RR.
>difficulty of potentially obstruct Long Term:
breathing bronchial passages >Auscutated the >Bronchial lung
and alveoli. After 1 day of lung sounds, noting sounds are commonly
nursing
>Wheezes on areas of decreased heard over areas of
intervention, the
both lung fields ventilation and lung density or
client will be presence of consolidation.
able to
>productive cough expectorate adventitious sounds. Crackles are heard
– whitish color retained when fluid is present.
secretions and
maintain normal
>nasal flaring >Monitored chest x >These determine
 – ray reports. progression of disease
>restlessness breathing process.)
pattern.

>Encouraged client >Hydration helps

to increase fluid decrease the viscosity
intake. of secretions,
facilitating
expectorations.

>Advised the >Positioning facilitates

realtives elevate the chest expansion and
head of bed at least respiratory efficiency
30 degrees. by reducing pressure
of abdominal organs
on diaphragm.

>Assisted on > Relaxes bronchial

nebulizer treatment. and uterine smooth
Nebulization done muscle by acting on
as per doctor’s order beta – adrenergic
every 12 hours. receptors.
>Chest tapping >Chest physiotherapy
 performed after helps to aid
each nebulization. immobilization of
secretions.

>Instructed the >Discharges from the

client to have oral nebulizer are often foul
care after each tasting and smelling.
nebulization.

>Provided >Fluids are regulated

supplemental fluids to replace losses and
aid immobilization
secretions.

ASSESSMENT NURSING RATIONALE GOAL NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data: Hyperthermia Entry of the Independent:
related to pathogen in After 2 hours of After 2 hours of
“Tatlong araw ng inflammatory circulatory system effective >Monitor core >Temperature of effective nursing
pabalik-balik ang response. | nursing intervention, temperature q 1 °. 38.9-41.1°C intervention, goal
lagnat ng anak ko, Regulation of toxins the patient’s suggest acute is met.
hindi Increase in body in the body temperature will infectious
maganda ang temperature | disease process.
decrease:
pakiramdam greater than Release of pyrogen
nya kaya normal range. | >Note presence or >Evaporation is
>Demonstrate
pinunta ko na Stimulation of the absence of decreased by > Patient’s
temperature within
siya dito” hypothalamus sweating environmental temperature is
normal range, from
as verbalized by | as body attempts to factors of high already in the
38.7 °C to 36.5°C
his mother Increase or increase heat loss humidity and high normal range;
-37.5°C
alteration of by evaporation. ambient T=___ °C
Objective Data: thermoregulation temperature as
>Demonstrate
| well as body
behaviors to
T= Increase in body factors
monitor and
38.7 °C temperature producing loss
promote
| of ability to
normothermia.
Hyperthermia sweat.
>Skin is cool to
>To support
touch and less
>Increase oral fluid circulating
flushness
intake. volume and
tissue perfusion.
>Identify underlying
cause/contributing
>To reduce
factors and
>Promote bed rest, metabolic
importance of
encourage demands/oxygen
treatment, as well
relaxation skills and consumption.
as signs/symptoms
diversional
requiring further
activities.
interventions.
 >Heat is loss by
>Verbalized >Provide TSB as evaporation and
understanding of needed conduction.
specific
interventions to >Heat is loss by
prevent >Promote surface Convection
hyperthermia cooling, loosen radiation and
clothing and cool conduction.
environment
>To promote
>Review specific wellness
risk
factors/causes,
signs and
symptoms with
the interventions
required

>Discuss
importance of
adequate fluid >To prevent
intake and dehydration
protein diet

Collaborative:

>Administer
medications as >To treat
indicated to underlying
treat underlying causes
cause, such as:
-Paracetamol
325mg/tab 1 tab q
6°
>To support
>Administer circulating
replacement volume and
fluids and tissue perfusion
electrolytes to
support
circulating
volume and
tissue perfusion
 ASSESSMENT NURSING RATIONALE GOAL NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

Subjective Data: Diarrhea related to Diarrhea is the After 4 hours Independent:

presence of toxins passage of loose of nursing After 4 hours of
due to poor and watery interventions, > Observe and > Helps nursing
“Madalas siyang personal hygiene. stools (more the patient record stool differentiate interventions, the
dumumi halos tatlo than 3 bowel will report frequency, individual disease patient was able to
hangang limang movements per reduction in characteristics, and report reduction in
beses” as day) often frequency of amount and assesses severity frequency of stools.
verbalized by his associated with stools. precipitating of
mother. gassiness, factors. episode
bloating, and
Objective cues: abdominal pain. > Promote bed rest
It may also be
accompanied by > Rest decreases
> Frequent watery
nausea, intestinal motility
stools
vomiting, and and
fever. Diarrhea reduces metabolic
>Increased
results to loss of > Provide bedside rate.
peristalsis
body fluids and Commode
salts leading to
dehydration of > Urge to defecate
varying severity. may occur without
Severe warning and
dehydration may uncontrollable,
cause death increasing risk
especially in of incontinence
children > Identify foods and or falls if facilities
fluids that are not close at
precipitate hand
diarrhea.
> Avoiding
intestinal
irritants
> Restart oral fluid promotes
intake gradually. intestinal rest
Offer clear liquids
hourly, and avoid
cold fluids. > Provides colon
rest by omitting
or decreasing
stimulus of foods or
fluids. Gradual
consumption of
liquids may prevent
cramping and
recurrence of
> Encourage to eat diarrhea. Cold
foods like banana fluids can increase
and apple intestinal motility.

> Avoid foods that > Fruits that are

are oily, spicy and stool formed
caffeine.

Collaborative: > Foods that may

> Administer anti- precipitate gastric
diarrheals as cramping
prescribed by the
physician.
> Decreases G.I
motility or
peristalsis and
diminishes
digestive
secretions to
relieve cramping
and diarrhea.
 DRUG STUDY

DRUG DOSAGE Mechanism of Indication Contraindication Side Effects Nursing

Action Responsibilities

Generic Name: Child :IV/IM 6–7.5 Chemical Effect: Parenteral use History of >upset stomach > Lab tests:
Gentamicin Sulfate mg/kg/d in 3–4 restricted to hypersensitivity to Perform C&S and
divided treatment of or toxic reaction >vomiting renal function prior
Brand dosesIntrath ecal > serious infections with any to first dose and
Name:Garamycin >3 mo, 1–2 mg Aminoglycoside; of GI, aminoglycoside >fatigue periodically during
preservative free actively transported respiratory, and antibiotic. Safe use therapy; therapy
q.d. urinary tracts, CNS, during pregnancy >pale skin may begin pending
across the bacterial
bone, skin, and soft (category C) or test results.
cell membrane,
tissue (including lactation is not
binds to a specific burns) when other established >Determine
receptor protein on less toxic Bacterial and fungal creatinine
the 30 S subunit of antimicrobial corneal ulcers have clearance and
bacterial agents are developed during serum drug
ribosomes, and ineffective or are treatment with concentrations at
interferes with an contraindicated. gentamicin frequent intervals,
initiation complex Has been used in ophthalmic particularly for
between mRNA combination with preparations. patients with
other antibiotics. impaired renal
(messenger RNA)
Also used The most function,
and the 30 S topically for primary infants (renal
frequently reported
subunit, inhibiting and secondary skin immaturity), older
adverse reactions
protein synthesis. infections and for adults, patients
are ocular burning
DNA may be superficial receiving high
and
misread, thus infections doses or
of external eye and irritation upon drug therapy beyond 10
producing
its adnexa. instillation, d, patients with
nonfunctional
 fever or extensive
proteins; nonspecific burns, edema,
polyribosomes are conjunctivitis, obesity.
split apart and are conjunctival
> Note: Dosages
unable to epithelial
are generally
synthesize protein. defects, and
adjusted to
conjunctival maintain peak
serum gentamicin
hyperemia. concentrations of
Therapeutic Effect: 4– 10 g/mL, and
Other adverse trough
> Gentamicin, reactions which concentrations of
like the other have occurred 1–2 g/mL.
aminoglycosides is rarely are allergic Peak
reactions, concentrations
not appreciably
thrombocytopenic above 12 g/mL and
absorbed after oral
purpura, and trough
or intrauterine hallucinations. concentrations
administration, but
above 2
is absorbed from g/mL are
topical associated with
administration (not toxicity.
skin or urinary
bladder) when used > Draw blood
in irrigations during specimens for peak
surgical serum gentamicin
procedures. concentration 30
min–1h
after IM
Patients
administration, and
receiving oral 30 min after
aminoglycosides completion of a 30–
with hemorrhagic or
 60 min IV
necrotic infusion. Draw blood
enteritises may specimens for trough
absorb appreciable levels just before the
next IM
quantities of the
or IV dose. Use
drug. After IM
nonheparinized tubes
administration to to collect blood.
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%.