ASSESMENT DIAGNOSIS SCIENTIFICEXPLANATION

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“Okay na sya, bka nga daw pwede n kami maka-uwi” as verbalized by the mother

Objective:- received pt. awake lying on bed ĉ ongoing IVF of #5 D5IMB 500cc to run for 12ox31gtts/min @450cc level, infusing well @ left hand - ĉ standby 02 @ bedside- conscious and coherent-ambulatory- ĉ dry cough- ĉ good skin turgor-ĉ good capillary refill in 2-3 secs- on DFA ĉ SAP- ĉ poor appetite, consumed ¼ of the food served- voiding freely

Readiness for Enhanced

Therapeutic Regimen related to normal health

status.

When the systems in the

body respond well to medications

and treatments it results to good

health. Thus, our body is ready to regain its normal

functioning.

Within the 8˚ shift, the client will maintain

normal health status and

remain free from possible

complications.

Independent:

- establish rapport

- assess the client/SO’s level of understanding of therapeutic regimen

- help client’s needs and potential problems- identify contributing factors that may need to be improve now or in the future- provide suggestions to the client/SO for sources of support that will help reinforce enhanced behaviors - monitor vital signs

- provide health teachings such as: increase oral fluid intake

- to facilitate cooperation as well as to gain pt’s trust

- to assure accuracy and completeness of knowledge based for future learning- to maintain high-level of well-being

- to prevent possible complications

- to broaden ideas that the pt may already have in order to reinforce positive behaviors

- to note changes that can affect the pt’s condition

- to promote optimum wellness

Goal met. Within the 8˚

shift, the client maintained

normal health status and

remained free from

possible complications.And the client went home.

- not dyspneic (RR 30 CPM)- afebrile

emphasize the importance of proper hygiene advise the SO to constantly change the shirt of the client whenever playing advise SO to avoid exposing the client to crowded and smoking areas Dependent:

- to give due medications- instructed on home meds

- to facilitate easy recovery- to serve as a guide in doing self-medication that promotes independence

DRUG STUDYBRAND NAME

GENERIC NAME

DOSAGE ACTION INDICATION CONTRAINDICATION PRECAUTION NURSINGCONSIDERATIONS

Tempra Paracetamol 120mg/15, 6ml q4o for To

>37.8

Decreases fever by

inhibiting the

Relief of mild-to-moderate pain;

treatment of

Hypersensitivity; intolerance to

tartrazine, alcohol,

Pts. with impaired kidney or liver

function. Pts. with

Assess pt.’s fever or pain. Assess allergic

effects of pyrogens on

the hypothalamic

heat regulating centers and by

a hypothalamic action leading

to sweating and

vasodilation. Relieves pain by inhibiting

prostaglandin synthesis at the CNS but

does not have anti-

inflammatory action

because of its minimal effect on peripheral prostaglandin

synthesis.

fever. table sugar, saccharin. alcohol dependence.

reactions. Monitor liver and renal functions. Check input and output ratio. Assess for chronic poisoning.

BRAND NAME

GENERIC NAME

DOSAGE ACTION INDICATION CONTRAINDICATION PRECAUTION CONSIDERATIONS

Loviscol Carbocisteine 100mg/15, 5ml TID

Reduces the viscosity of bronchial

secretions and

Acute and chronic disorders of the upper and lower respiratory tract

Active peptic ulcer. Concomitantly

administration with antitussive

History of peptic ulcer and

hypothyroidism. It is not

Obtain pt’s history of cough before therapy and reassess after giving

facilitates expectoration

associated with the secretion and

formation of excessive and viscid mucus

(chronic sinusitis, otitis, and all

forms of tracheobronchitis,

emphysema, bronchitis, and

chronic inflammatory lung

disease)

recommended during the first

trimester of pregnancy

the drug Assess cough: type, frequency, character, including sputum: provide adequate hydration to 2L/day to decrease viscosity of secretions Monitor for possible adverse reactions: CNS: drowsiness, dizziness GI: nausea, vomiting, abdominal pain Discuss on detail all information regarding the drug