drug study- dexamethasone

VII. DRUG STUDY

DRUG INDICATION ACTION SIDE/ADVERSE EFFECTS NURSING CONSIDERATION

PATIENT TEACHINGS

Date ordered: August 04, 2010

Generic name: Dexamethasone

Brand name: --

Classification:Anti inflammatory

Glucocorticoid

Dosage:1.8 mg IV q6

SpecificAdjunctive treatment in bacterial meningitis.

GeneralCerebral edemaAllergic and inflammatory conditionsShockTuberculosis meningitis

The patient was given dexamtehasone 1.8 mg through IV every 6 hours to decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat and carbohydrate metabolism.

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.

1. Determine whether patient is sensitive to other corticosteroids

2. Most adverse reactions to corticosteroids are dose-or duration-dependent.

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 injection because atrophy and sterile abscesses may

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, join 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 measles and

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.

chickenpox) and to notify prescriber if such exposure occurs.


PATIENT TEACHINGS

Date ordered:August 4, 2010

Generic Name:Streptomycin

Brand Name:--

Classification:Antituberculosis agent

Dosage:300 mg OD

M-W-FANST

Specificmycobacterial infections

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

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.

Allergic Reactions Disturbances of vestibular

function Facial Parathesia Nausea and Vomiting

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.

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.


PATIENT TEACHINGS


Generic Name:Meropenem

Brand Name:--

Classification:Antibiotic

Dosage:500mg TIV q8⁰

ANST

SpecificFor pneumonia and meningitis

GeneralTreatment of infection caused by single or multiple susceptible bacteria sensitive to meropenem. Pneumonia including hospital acquired, septicemia, neutropenia, intra-abdominal infections, meningitis, urinary tract, gynecological and skin and soft tissue infection.

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 penicillin- binding protein targets where it inhibits cell wall synthesis to render the cell wall osmoticaly unstable.

Seizure, headache and pain

Pseudomembranous colitis

Apnea Anaphylaxis Thrombophlebhitis

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.

1. Instruct the patient’s watcher to report adverse reaction to nurse at once.

2. Advise watcher to report loose stool to prescriber.

DRUG INDICATION ACTION SIDE/ADVERSE EFFECTS

NURSING CONSIDERATION

PATIENT TEACHINGS


Generic Name:Isoniazid

Brand Name:--


Dosage:200mg/5ml: 3ml

OD PO

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.

Seizures Toxic

Enchepalopathy Memory

impairment Unusual

weakness or fatigue

Yellow skin or eyes

Dark urine

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

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.



PATIENT TEACHINGS


Generic Name:Rifampicin

Brand Name:--


Dosage:200mg/5ml: 4.5ml

OD PO

SpecificPrevention of meningococcal meningitis

GeneralMaintenance treatment of all forms of pulmonary and extra-pulmonary tuberculosis (TB). For continuation phase (for 4 mos) of short-course anti-TB treatment. TB and leprosy in combination with other antibiotics/chemotherapeutic agents; non-mycobacterial infections; brucellosis in combination with a tetracycline

The patient was given Rifampicin 200mg/5ml: 4.5mlOD to treat or inhibit synthesis of meningococcal infection and bacterial growth by inhibiting DNA-dependent RNApolymerase, which impairs RNAsynthesis; bactericidal

Headache, fatigue, drowsiness, behavioral changes and dizziness

Shock, visual disturbances, exudative conjunctivitis

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.

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.



PATIENT TEACHINGS


Generic name: Pencillin G sodium

Brand name: --

Classification:Anti-infective

Dosage:650,000 u IV q4

ANST(-)

SpecificPneumoccocal respiratory infections, including otitis media

GeneralModerate to severe systemic infection.

The client was given Penicillin G sodium 650,000”u” IV every 4 hours after negative skin test which inhibits cell-wall synthesis during bacterial multiplication.

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

Musculoskeletal: arthralgia

OTHER: hypersensitivity reactions, anaphylaxis, pain at injection sure, vain irritation.

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 seizures and decreasing level of consciousness.

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.



PATIENT TEACHINGS


Generic name: Famotidine

Brand name: --

Classification:-Histamine 2-receptor

agonist-Anti ulcer drug

Dosage:5mg IV q12

SpecificProphylaxis of duodenal ulcers.

GeneralHospitalized patient who cannot take oral drug or have an intractable ulcers or hypersecretory conditions.

The patient was given Famotidine 5mg through IV every 12 hours as a phrophylaxis for duodenal ulcer by blocking action of histamine at histamine 2-receptor sites in gastric parietal cells, inhibiting gastric acid secretion and stabilizing pepsin.

CNS: dizziness, headache, paresthesia, asthenia.

CV: palpitations

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

EENT: orbital edema, conjuctival redness, tinnitus

Musculosketal: bone and muscle pain.

SKIN: Flushing, acne, dry skin.

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

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

2. Oral suspension must reconstituted and shaken before use.

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

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.

5. Advise patient to report abdominal pain or blood in stools or vomit.



PATIENT TEACHINGS


Generic name: Sucralfate

Brand name: Carafate

Classification:Anti ulcer agent

Dosage:1gm/tab

½ tabs through NGT q6 after each lavage

Short term (up to 8 weeks) treatment of duodenal ulcer.

The patient was given 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.

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, hypersensitivity reaction.

1. Reconsitute drug before instillation through a nasogastric tube. Flush tube with water to ensure passage into stomach.

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

3. Monitor patient for severe, persistent constipation.

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.

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. Instruct patient to continue prescribed regimen to ensure complete healing. Pain and other ulcer signs and symptoms may subside within first few weeks of therapy.

3. Antacids may be used while taking drug, but separate doses by 30 minutes.



PATIENT TEACHINGS


Generic name: Acetaminophen

Brand name: Paracetamol

Classification:Analgesic, Antipyretic

Dosage:125mg IV q4 for

fever

SpecificFever

GeneralMild to moderate pain caused by headache, muscle ache, backache, common cold, toothache

The client was given Paracetamol 125mg through Iv every 4 hours for fever to cause relief by inhibition of prostaglandin synthesis in CNS, with subsequent blockage of pain impulses. Fever reduction may result from vasodilation and increased peripheral blood flow in hypothalamus, which dissipates heat and lowers body temperature.

HEMATOLOGIC: thrombocytopenia, hemolytic anemia, neutropenia, leucopenia, pancytopenia.

HEPATIC: jaundice, hepatotoxicity

METABOLIC: hypoglycemic coma

SKIN: rash, urticaria OTHER:

hypersensitivity reactions (such as fever)

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.

1. Advice patient, parents, or other caregivers to contact 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.

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.



PATIENT TEACHINGS


Generic name: Mannitol

Brand name: --

Classification:Diuretic

Dosage:60 cc IV q4 x 30 min with BP precaution

Reduction of increased intracranial pressure associated with cerebral edema.

The patient was given Mannitol 60cc through IV with BP precaution to decrease intracranial pressure by increasing the osmotic pressure of glomerularfiltrate, which inhibits tubular reabsorption of water and electrolytes and increases urinary output.

CNS: dizziness, headache, seizures

CV: Chest pain, hypotension, tachycardia, vascular overload.

EENT: Blurred vision

GI: nausea, vomiting, diarrhea, dry mouth.

GU: polyuria, urinary retention

METABOLIC: dehydration, water intoxication, hypernatremia, metabolic acidosis, hypokalemia

RESP: pulmonary congestion.

SKIN: rash, urticaria.

OTHERS: chills, fever, thirst, edema

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.)

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.

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.

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

and tissue necrosis. related to the drugs and tests mentioned above.



PATIENT TEACHINGS


Generic Name:Phenobarbital

Brand Name:--

Classification:Barbiturates

Dosage:60mg ½ tab q12° PO

SpecificTreatment of generalized tonic-clonic and cortical focal seizures; emergency control of acute convulsions

GeneralShort term treatment of insomnia; preanesthetic sedation.

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

Depressant and 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.

Dizziness Headache Hypotension Bradycardia GI disturbances Allergic reaction Sedation and

depression may occur

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

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.

1. Advice the mother to check prescriptions and refills because Phenobarbital is 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


Generic Name:Ciprofloxacin

Brand Name:--

Classification:Antibiotic:

fluoroquinolones

Dosage:500mg ½ tab q12° PO

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 and joints; 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.

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.

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.

3. Assess the patient for any allergic reaction or anaphylaxis.

4. Assess for the client’s renal function before and during therapy

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, 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.

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

IX. NURSING CARE PLAN

Cues/data Nursing Diagnosis Rationale Goals and Objectives

Interventions Rationale Evaluation

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

Objective cues:-hydrocephalus-communicating-increased ICP-restlessness-changes in pupillary reactions(non-reactive)-presence of NGT-use of accessory muscles to breath-extremity weakness-muscle rigidity

Ineffective cerebral tissue perfusion

related to compression of

cerebral arteries secondary to

increased intracranial

pressure (ICP)

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 the brain and cerebral artery compression.

Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Management is directed at removing vasoconstricting factor(s), improving peripheral blood flow, and reducing metabolic demands on the body. Decreased tissue

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.-Avoiding the patient to have seizures

Long-term goal:

mental status of the patient(alert)

Independent:

-Monitoring the vital signs of the patient

-Monitor the LOC

-Avoid measures that will trigger increase of ICP of the patient such as straining, positioning the neck of the patient in

- 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 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

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

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 damage or death.

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

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.

-Explain all procedures and equipments to the patient mother.

-Instruct patient’s mother to inform the nurse immediately of

the decrease of ICP 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 ICP of the patient.- 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

http://en.wikipedia/

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 Avoid jarring

of the bed

DEPENDENT:-Administer anticonvulstants and osmotic diuresis prescribed by the doctor when it is needed.

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.

-to avoid patient on having seizures which can result from cerebral edema or ischemia and to reduce increase ICP.

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 Nursing Diagnosis Rationale Goals and Objectives


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 T: 39.7°C RR: 26 BP 140/100 PR:144

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

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

Independent: Assess for

neurological response; noting the level of consciousness and orientation, reaction to stimuli of pupils

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

To know if its increasing or decreasing

Central hypertension or peripheral/postural hypotension occurs

Hyperventilation may initially be present, but ventilatory effort may eventually impaired by seizure, hypermetabolic rate (shock and acidosis)

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

nd and insensible loses

Monitor laboratorial studies such as ABGs, electrolyte, cardiac and liver enzyme

Promote surface cooling by means of undressing; cool and environment

Encourage TSB

Dependent: Administer

medicationo (para

cetamol)

Oliguria and/or renal failuremay occur due to hypotension, dehydration, shock

It may reveal tissue degeneration

Cool environment can or helps the body temperature to decrease

Could lower down the body temperature

To rapid decrease body temperature

Cues / Data NursingDiagnosis

Rationale Goals and Objective Intervention Rationale Evaluation

Subjective Data:“Nangayayat na nga sya ngayon eh” as verbalized by the mother

Objective data:

-Iron Deficiency 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 admission, 12.9 Kg present weight

-BMI 10.8 -Underweight

Imbalanced Nutrition: Less than Body Requirements related to inability

to ingest food

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 patient

-giving of prescribed supplement or vitamin if available

-provide parents information about the appropriate nutrition.

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

2. Teach parent about caloric needs for age of child and in weight and height measurement.

3. Teach parent about proper preparation and storage of food; hand wash before preparing or handling food.

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

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

3. Prevent spoiling and contamination of food that may cause gastrointestinal symptoms.

After 4 hours of nursing intervention, goals fully met as evidenced by:

- complied time of feeding -health teaching was 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.

Objective data:- disruption of the

epidermis- redness- immobility/inactivity- neuromascular

impairment

VS Taken:

BP: 140/100RR: 26PR: 144TEMP: 39.7˚ C

Impaired skin integrity r/t

physical immobilization

Decreased musclestrength

↓Body weakness

↓Irritability

↓Physical immobility

↓Risk for skin integrity

*Medical-SurgicalNursing 11th Edition;

Brunner &Suddarth”s

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

Long-term goal:Timely wound healing

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 skinroutinely, notingmoisture, color, andelasticity

*Observe forreddened/blanchedareas or skin rashes,and institutetreatmentimmediately

*Provide adequateclothing/covers;protect from drafts

*To prevent complications

*To monitor progress or healing

*enhanced circulation to compromised tissue*this may indicateparticularvulnerability

*Reduces likelihoodof progression to skinbreakdown

*To preventvasoconstriction

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

*Emphasizeimportance ofadequatenutritional/fluidintake

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

* proper technique when cleaning the patients skin is needed

*encourage turning position of the patient every 2hours

*put calamine lotion/powder

Dependent:* give the proper medications as directed by the physician

*To maintain general good health and skin turgor

*promoting hygienic procedures is a key in infection prevention

*frequent change of wound dressing will prevent infection

*to promote good circulation that contribute to faster healing and avoid friction and pressure

*hygienic purposes and to promote faster healing

*Relieves pain felt bythe patient

*Nursing Care

Plans;7thEdition;Doenges,Moorehouse,Murr

Cues/Needs Nursing Diagnosis

Rationale Goals and Objectives


OBJECTIVE:

➢ Improper NGT feeding

Risk for aspiration related to knowledge

deficit.

Aspiration is defined as the inhalation of either oropharyngeal or gastric contents into thelower airways. Inhalation of these contents can lead to aspiration pneumonia andaspiration pneumonitis. Although these two entities are managed differently, they areoften interchangeably referred to as aspiration pneumonia.Aspiration pneumonitis represents chemical damage to the

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.

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.

A decreased level of consciousness is a prime risk factor for aspiration.

A depressed cough or gag reflex increases the risk of aspiration.

Aspiration of small amounts can occur without coughing or sudden onset of respiratory distress, especially in

After hours of nursing intervention the Goal was MET by: Patient was able to maintain patent airway. Patient’s risk of aspiration is decreased as a result of ongoing assessment and early intervention.

tracheobronchial tree causedby acute, often witnessed, inhalation of regurgitated gastric contents in patients with anacute change in mental status. Aspiration pneumonia results from chronic, usuallyunwitnessed, inhalation of small amounts of oropharyngeal contents leading to aninfectious process.

Keep suction setup available

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

Position patient at 90-degree 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.

patients with decreased levels of consciousness.

This is necessary to maintain a patent airway.

This protects 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

Provide oral care after meals.

during feeding or eating.

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 passage of stomach contents into the duodenum.

This removes residuals and reduces pocketing of

food that can be later aspirated.

drug study- dexamethasone

Documents