MEDICAL MANAGEMENT

a. Medical Orders and Rationale

DOCTORS ORDER

RATIONALE

Start D5 0.3NaCL 500ml @ 100cc/hr

Labs:

CBC

Urinalysis

SE

For further management and treatment of

condition
To provide easy digestion of food without
experiencing pain upon digestion
To provide access for intravenous
medications.
To screen the patients blood component and
to detect any abnormalities. This also serves
as a baseline data to evaluate effectiveness of
blood transfusions.
To screen the patients urine components and
to detect any abnormalities.
To screen the patients feces & to detect any
abnormalities

NURSING MANAGEMENT
b. Actual Nursing Management
Priority number 1

Productive cough
Inability to expectorate secretions
Restlessness

Ineffective Airway Clearance related to productive cough

Short Term: At the end of 8 hours, the patient will be able to maintain airway
patency.

1. Elevated head of the bed by putting pillow under the head/changed position
frequently.
To enhance drainage and ventilation to different lung segments
2. Monitored infant for feeding intolerance, abdominal distention and
emotional stress.
May compromise airway.
3. Encouraged mother to hydrate infant frequently.
To loosen the secretions
4. Positioned appropriately and discouraged use of oil-based products around
the nose.
To prevent vomiting with aspiration to lungs
Dependent:
5. Administered Ambroxol as prescribed.
To loosen the secretions
The goal has been met; the patient was able to maintain airway patency.

Priority number 2

O
A

Cool extremities
Sunken eyes
Dry skin
Watery stool
Persistent vomiting
Weight (Before = 7 kgs; Now = 6.5 kgs)

Fluid volume deficit related to excessive losses through GI tract secondary to

diarrhea

Short term: At the end of 8 hours, the patient will be able to restore fluid and
electrolyte imbalances

Encouraged the mother to give oral fluid intake.

To increase fluid intake
2. Monitored intake and output balance.
To ensure accurate picture of fluid status
3. Observed for excessively dry skin and mucous membranes, decreased skin
turgor, slowed capillary refill.
Indicates excessive fluid loss/resultant dehydration
4. Weighed daily
Indicator of overall fluid and nutritional status
5. Monitored vital signs
To note the changes in heart rate and respiration
Dependent:
6. Provided supplement fluids as indicated D5LR 500cc @ 28cc/hr
Fluids may be given in this manner if patient is unable to take oral
fluid

Goal has been met; at the end of 8 hours, the patient was able to restore fluid and
electrolyte imbalances

Priority number 3
O

Hyperactive bowel sounds

3-5 loose liquid stools per day

Diarrhea related to irritation of the GI tract

Short Term: at the end of 8 hours, the patient will reestablish and maintain
normal pattern of bowel functioning.

1. Weighed infants diaper.

To determine the amount of output and fluid replacement
needs
2. Encouraged oral fluid intake containing electrolytes.
To maintain fluid and electrolyte balance
3. Provided prompt diaper changes and gentle cleansing
Because, skin breakdown can occur quickly when diarrhea
is present
4. Did auscultation of abdomen.
To check for presence, location, and characteristics of
bowel sounds.
Dependent:
5. Administered antidiarrheal medications as prescribed.
To treat infectious process and decrease motility and
minimize fluid losses