NURSING CARE PLAN ASSESSMENT

S-ADDA PAY BASSIT TI PANATENG KEN UYEK KO

DIAGNOSIS
INEFFECTIVE AIRWAY CLEARANCE RELATED TO INCREASED NASAL DISCHARGES

PLANNING
AFTER LESS THAN 1 HOUR OF NURSING INTERVENTION THE CLIENT WILL BE KNOWLEDGEABLE IN MANAGING HIS DISCOMFORTS RELATED TO HIS NASAL DISCHARGES

IMPLEMENTATION
REPOSITIONED TO SEMI FOWLERS

RATIONALE
TO FACILITATE PROPER CIRCULATION AND HEALING ON THE AFFECTED EXTREMITY TO PROMOTE COMFORT AND PREVENT PAIN DUE TO IMMOBILITY

EVALUATION
GOAL MET.

Purulent nasal discharges noted Complaints of nasal congestion Non productive cough noted No signs of respiratory distress

ASSISTED IN NEBULIZATION

INSTRUCTED ON HOW TO CLEAR NASAL SECRETIONS PROPERLY ADVISED TO USE CLEAN HANKERCHIEF RATHER THAN TISSUE PAPER

TO PROMOTE MOBILTY AND PREVENT PAIN CAUSED BY THE IMMOBILITY.

ADVISED TO DISPOSE OF USED TISSUES CLOTHS ASEPTICALLY TO PREVENT INFECTION ADVISED TO INSTRUCTED TO SUPPORT AFFECTED EXTREMITY DURING MOBILIZATIONS INCLUDING ADLs INSTRUCTED TO PERFORM EXERCISES AS TOLERATED ADVISED TO KEEP SURGICAL BANDAGE DRY AND FREE FROM MOISTURE ENCOURAGED TO EAT FOOD RICH IN PROTEIN,IRON, AND VITAMIN C

FOR NUTRITIONAL ASSISTANCE IN BOOSTING HEALING PROCESS IN THE AFFECTED SYSTEM OF THE PATIENTS BODY TO ASSESS AND GIVE IMMEDIATE NURSING INTERVENTIONS TO SPECIFIC SUBJECTIVE DATAS

ENCOURAGED TO REPORT ANY UNTOWARD PAINS

DOCTORS ORDER
Tramadol Hydrochloride

DRUG CLASSIFICATION
Pharmacologic class: Synthetic, centrally active analgesic Therapeutic class: Analgesic

INDICATION

CONTRAINDICATIONS

SIDE EFFECTS

NURSING CONSIDERATION
Reassess patient's level of pain at least 30 minutes after administration. Monitor CV and respiratory status. Withhold dose and notify prescriber if respirations are shallow or rate is below 12 breaths/minute. Monitor bowel and bladder function. Anticipate need for stimulant laxative. For better analgesic effect, give drug before onset of intense pain. Monitor patients at risk for seizures. Drug may reduce seizure threshold. In the case of an overdose, naloxone may also increase risk of seizures. Monitor patient for drug dependence. Drug can produce dependence similar to that of codeine and thus has

Moderate to moderately severe chronic pain

Contraindicated in patients hypersensitive to drug or other opioids, in patients with severe renal impairment, breast-feeding women, suicidal patients, and in those with acute intoxication from alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic drugs. Contraindicated in patients with significant respiratory depression or acute or severebronchial asthma or hypercapnia in unmonitored settings or where resuscitative equipment isn't available. Alert: Serious hypersensitivity reactions can occur, usually after the first dose. Patients with history of anaphylactic reaction to codeine and other opioids may be at increased risk. Use extended-release forms cautiously in elderly patients, especially those age 75 and

CNS: dizziness, headache, somnolence, vertigo, seizures, anxiety, asthenia, CNS stimulation, confusion, coordination disturbance, euphoria, malaise, nervousness, sleep disorder. CV: vasodilation. EENT: visual disturbances. GI: constipation, nausea, vomiting, abdominal pain, anorexia, diarrhea, dry mouth, dyspepsia, flatulence. GU: menopausal symptoms, proteinuria, urinary frequency, urine retention. Musculoskeletal: hypertonia. Respiratory: respiratory depression.

older.

Skin: diaphoresis, pruritus, rash.

potential for abuse.