nursing care plan
TRANSCRIPT
ASSESSMENT NURSING
DIAGNOSISSCIENTIFIC DEFINITION
OBJECTIVES NURSING INTERVENTION
RATIONALE EXPECTED OUTCOMES
S>
O> patient may manifested:>Diminished adventitious breathing sound rales and ronchi sound.>Cough w/ excessive sputum>difficulty in vocalizing > wide eyes > restless
“Ineffective airway clearance related to retained secretion.”
>It is due to inability to clear secretion or obstructions from the respiratory tract to maintain a clear clearance
Short term:After 4hr of nursing intervention the patient will demonstrate behavior to improve and maintain clear airway
Long term:After days of nursing intervention the patient will expectorate clear secretion
>Establish rapport
>maintain respiratory and breathing sound
>Evaluate patient’s cough gag reflex and swallowing ability
>position the patient head appropriately for the condition
>suction naso / tracheal PRN
>elevate the head and bed change position in every 2hr
> encourage deep breathing coughing exercise;
>to gain the trust of the patient> indicative of respiratory distress and accumulation of secretion > to determine ability to protect own airway>to open or maintain open airway in at rest or compromise individual>to clear airway when excessive or viscous secretions are blocking airway > to enhance drainage of
Short term: The patent should maintained airway patency.
Long tem:The patient should identified potential complications and how to initiated appropriate preventive action.
> increase fluid intake
>Ascultate the breath sounds and assess the air movement
ventilation to different lung segment.>to minimize effort Hydration can help liquefy viscous secretions and improve secretion clearance> to ascertain status and rate progress.
ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC DEFINITION
OBJECTIVES NURSING INTERVENTION
RATIONALE EXPECTED OUTCOMES
S>
O> Patient manifested:>restlessness>irritability>hypoxia>abnormal breath sounds(rales)> nasal flaring
“Impaired gas exchanged related to alveolar capillary membrane changes”
Excess or deficit in Oxygenation and carbon dioxide elimination at the alveoli capillary membrane may be an entity of
Short term:After 4hr of nursing intervention the patient will participate in treatment regimen such as deep breathing
> Evaluate pulse oumetry to determine oxygenation, evaluate lung volumes and force vital capacity> Elevate head of bed / position the patient
>To assess the respiratory insufficiency >To maintain airway
> To provide optimal chest expansion and
Short term:
The patient should participate in treatment regimen such as deep breathing exercise within level of ability.
its own, but also may be result of other pathology w/ an interrelatedness between airway clearance and breathing patterns.
exercise w/ in level of activity.
Long term:After 3 days of nursing intervention the patient will demonstrate, improve ventilation and adequate oxygenation of tissues by ABG’s within patient normal limits and absence of symptoms of respiratory distress.
appropriately and and provide airway adjust and suction as indicated.> Encourage frequent position changes, deed breathing and coughing exercise.>Monitor for carbon dioxide narcoses> Maintain adequate I/O, avoid fluid overload.>Encourage rest and limit activities and promote calm restful environment.>provide psychological, support, active listen question concerns. > Keep environment allergen/ pollutant free.
drainage of secretion.
>Help limit oxygen needs/ consumption
>To reduce anxiety.
> To reduce irritant effect of dust and chemicals on airway.
Long term:
> The patient should demonstrated improved ventilation and adequate oxygenation of tissues by ABG’s within patient’s normal limits and absence of symptoms of respiratory distress.
ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC DEFINITION
OBJECTIVES NURSING INTERVENTION
RATIONALE EXPECTED OUTCOMES
S>
O> patient manifested: >fatigue ness
> abnormal heart rate, blood pressure response to activity
> Electro cardiographic orange reflecting arrtmythmias or ischemia.
“Activity intolerance related ton imbalance between oxygen supply and demand secondary to CAP.”
It is due ton insufficient physiological or psychological energy to induce or complete required or desired daily activities.
Short term:
After 4hr of nursing intervention, the patient will able to identify techniques to enhance activity tolerance.
Long term:
After 3 days of nursing intervention, the patient will participate willingly in increase activities.
>Note of factors contributing to fatigue.>Evaluate patients actual and perceive limitations degree of deficit in light of usual status. > Note patient reports of weakness, fatigue, pain, difficulty accomplishing tasks and or insomnia.>Ascertain necessary use of equipment >Assess emotional and psychological factors affecting the current situation.>provide positive atmosphere while acknowledging difficulty of the situation for the
>Fatigue effects both the patient actual and perceive activity to participate the activities.>To provides comparative baseline and provides information about needed educations regarding quality of life.>Symptoms may be result of / or contribute to intolerance of activity,> To determine current status and needs associate with
Short term:
The patient should identified techniques to enhanced activity intolerance.
Long term:
The patient should participate willingly in necessary /desired activities.
patient.>Assist with activity, provide and monitor patient’s use of assistive devices such as wheel chairs, or oxygen tank.> promote comfort measures and provide relief for pain.
participation in needed desired activies.> Stress, or depression may be increasing the effect of an illness and may result of being force into activities. >Helps to minimize frustration and rechanel energy.>To protect patient from injury.>to enhance ability to participate in activities.
GENERIC NAME: Ipratropin Bromide
BRAND NAME: Combinent, Duoneb
GENERAL ACTION: Anticholinergic, Bronchodilator
SPECIFIC ACTION: An Anticholinergic that blocks the action of Acetylcholine at Parasympathetic
site in Bronchial smooth muscle.
INDICATION: Maintain treatments of bronchospasm due to chronic obstructive pulmonary
disease (COPD).
CONTRAINDICATION: History of hypersensitivity to atropine, soya lecithin or related food products
such as soybean and peanuts. Narrow-angle Glaucoma, Prostatic Hypertrophy,
Bladder Neck Obstruction.
DOSSAGE: For: Inhalation: maximum; 12 inhalation per day
For: Nebulatization:500mcg 3-4 times a day
For: Intranasal: 2 sprays per nostril 2-3times a day
SIDE EFFECTS: Cough, dry lips, headache, nausea, dry nose, and mouth, nasal irritation,
Dizziness, transient increased bronchospasm, Hypotension Insomnia, Diarrhea,
or Constipation.
NURSING
IMPLICATION:
>offer emotional support, high evidence of anxiety due to difficulty breathing,
sympathomimetic response to drugs.
>Monitor rate, depth, rhythm, type of respiratory, quality, rate of pulse.
>Assess lung sounds for bronchi, wheezing and rales.
>Increase fluid intake to decrease living secretion viscosity.
>Avoid excessive use of caffeine derivatives such as chocolates, coffee, and
cocoa.
GENERIC NAME: Hydrocortisone
BRAND NAME: Cortisporin
GENERAL ACTION: Narcotic Analgesic
SPECIFIC ACTION: Adrenal Cortical Steroid that inhibits accumulation of inform of corticosteroid
response in skill, pagosytosis.
INDICATION: Management of adrenocortical insuffiency, relief of inflammation of
corticosteroid respordermatosis, adjunctive treatment of ulcerative colitis,
status asthmaticus shock.
CONTRAINDICATION: Fungal, tuberculosis, or viral skin lesions, serious infections, Hyperthyroidism,
cirrhosis, ulcerative colitis, hypertension, osteoporosis, thromboembolic
tendencies, CHF, seizure disorders, thrombophebitis, peptic ulcer, diabetes.
DOSSAGE: IVF: 100mg IV bolus; 300mg/day in divided in every 8hr.
IM: 15-240mg every 12hr
PO: 15-240mg every 12hr
SIDE EFFECTS: Long therapy may cause hypocalcaemia, muscle wasting, osteoporosis,
amenorrhea, cataracts, glaucoma, peptic ulcer disease and CHF.
NURSING IMLICATION: >obtain baseline values for weight, BP, Blood glucose, serum cholesterol,
electrolytes.
>Assess for edema, and infection, sore throat, fever, vague symptoms.
>notify physician of fever, sore throat, muscle aches, muscle aches, sudden
weight gain or swelling.
>Do not take aspirin or many medication without consulting physician.
>Limit caffeine and avoid alcohol.
GENERIC NAME: Cefuroxime Sodium
BRAND NAME: Kefurox, Zinacef, Ceftin
GENERAL ACTION: Antireflective, Antibiotic, Second-generation Cephalosporin.
SPECIFIC ACTION: It inhibits third and final stage of bacterial cell wall synthesis, thus killing the
bacterium. Partial cross-allergenicity between other betalactam antibiotic and
cephalosporine has been reported.
INDICATION: For infection caused by susceptible organism in the lower respiratory tract,
skin, and skin structures, also used for treatment of meningitis, gonorrhea and
Otitis media and preoperative prophylaxis (”ex. Open-heart surgery) early
Lyme disease.
CONTRAINDICATION: Hypersensitivity to cephalosporin and related antibiotics ,pregnancy category
B.
DOSSAGE: Tablet: 250mg every 12hr, for 10 days.
Suspension:20mg/kg/day in 2 divided doses
IM;IV: 750mg every 8hr and 1.5g every 8hr
SIDE EFFECT: Diarrhea, loose stools, nausea and vomiting abdominal pain, decreased H and
H.
NURSING IMPLICATION: >Determine history of hypertensensetivity reactions to cephalosporin’s,
penicillin and history of allergies
particularly to drugs before therapy initiated.
>Inspect IM and IV injection sites for phlebitis.
> Report insect of lose stool or diarrhea.
A.2.DRUGS
GENERIC NAME: Propoxyphene Hcl.
BRAND NAME: Darvocet-N 100, Propacet 100
GENERAL ACTION: Narcotic and nonarcotic analgesic
SPECIFIC ACTION: Decreased fever by a hypothalamic effect leading to sweating and vasodilation and inhibits the
effects of pryrogens on the hypothalamic heat-regulating centers.
INDICATION: Relief of mild fever to moderate pain, either when pain is alone or when accompanied by fever.
CONTRAINDICATION: Hypersensitivity to propoxyphene or acetaminophen, use in those suicidal or addiction prone.
DOSSAGE: Usual: tablet, 100mg propoxyphene napsylate and 650mg acetaminophen every 4 hours
SIDE EFFECTS: Drowsiness, Dizziness, nausea and vomiting, sedation, Constipation, abdominal pain, lever
dysfunction, cholestatic jaundice, lightheadedness, headache, weakness, minor visual disturbances,
skin rashes, and hallucination.
NURSING IMPLICATION: >assess for depression, suide ideation, excessive alcohol use, drug addiction prone, precludes drug
use.
>take as directed, do not exceed prescribed dose.
>do not perform an activity that requires mental alertness until drug effects realized.
>may cause dizziness, nausea and vomiting, lie down and rest if these occur to relieve symptom.
>avoid alcohol and CNS depressant during therapy.
GENERIC NAME: Acetaminophen and codeine phosphate
BRAND NAME: Tylenol with codeine-II
GENERAL ACTION: Non-narcotic/ Narcotic analgesic combination
SPECIFIC ACTION: It causes analgesia by inhibiting CNS prostaglandin synthesis. The mechanism of morphine is to
involve decreased permeability of the cell membrane to sodium, which result in dimished
transmission of pain impulses and therefore analgesia.
INDICATION: Relief mild to moderately severe pain.
CONTRAINDICATION: Renal insufficiency, anemia. Those with cardiac or pulmonary disease are more susceptible to
acetaminophen toxicity.
DOSSAGE: Elixir (oral solution): 15ml(360mg acetaminophen and 36mg codeine phosphate) q 4hr.
Tablet: acetaminophen 200-1000mg is a single dose,4000mg is the maximum. Codeine,15-60mg is
the single dose, 360 is the maximum dose q 4hr.
SIDE EFFECTS: Lightheadedness, dizziness, sedation, shortness of breath, nausea and vomiting. Respiratory
depression (high doses of codeine)
NURSING IMPLICATION: >take directed with a full glass of water. May take with food or milk if GI upset.
>do not drive or perform activities that require mental alertness until drug effect realized may cause
dizziness and drowsiness.
>store away from bedside and out of reach of children.
>report any adverse side effects of lack of desired effects.
GENERIC NAME: Hydrocortisone
BRAND NAME: Cortisporin
GENERAL ACTION: Narcotic Analgesic
SPECIFIC ACTION: Adrenal Cortical Steroid that inhibits accumulation of inform of corticosteroid response in skill,
pagosytosis.
INDICATION: Management of adrenocortical insuffiency, relief of inflammation of corticosteroid
respordermatosis, adjunctive treatment of ulcerative colitis, status asthmaticus shock.
CONTRAINDICATION: Fungal, tuberculosis, or viral skin lesions, serious infections, Hyperthyroidism, cirrhosis, ulcerative
colitis, hypertension, osteoporosis, thromboembolic tendencies, CHF, seizure disorders,
thrombophebitis, peptic ulcer, diabetes.
DOSSAGE: IVF: 100mg IV bolus; 300mg/day in divided in every 8hr.
IM: 15-240mg every 12hr
PO: 15-240mg every 12hr
SIDE EFFECTS: Long therapy may cause hypocalcaemia, muscle wasting, osteoporosis, amenorrhea, cataracts,
glaucoma, peptic ulcer disease and CHF.
NURSING IMLICATION: >obtain baseline values for weight, BP, Blood glucose, serum cholesterol, electrolytes.
>Assess for edema, and infection, sore throat, fever, vague symptoms.
>notify physician of fever, sore throat, muscle aches, muscle aches, sudden weight gain or swelling.
>Do not take aspirin or many medication without consulting physician.
>Limit caffeine and avoid alcohol.
IIE.C. Nursing Management
Nursing Care Plan, Postoperative Care
ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC DEFINITION
OBJECTIVES NURSING INTERVENTION
RATIONALE EXPECTED OUTCOMES
S>
O> patient manifested:
>a febrile>weakness>difficulty in
“Disturbed body image related to loss or alteration of the breast.”
>it is due to MRM, procedure that involves removal of entire breast, tissue, including the
Short term:
After 12hr of nursing intervention the patient will verbalize feelings
>determine whether condition is permanent / no expectation for resolution.
>evaluate level of patient knowledge
>there is always that can be done to enhance acceptance.
>which may indicate
Short term:
The patient was able to verbalized feelings regarding the changes in image.
Long tem:
vocalizing emotion > irritability> restless>sad facial expression.>missing body part the left breast.
nipple-areola complex.
regarding change in image.
Long term:
After 2weeks of nursing intervention the patient will verbalize relief of anxiety and adaptation to actual/ altered body image.
of and anxiety related to the situation, observe emotional changes.
>note sign of grieving/indicators of severe or prolonged depression.
>determine ethnic background and cultural/religious perceptions and consideration.
>observe interaction of patient to the SOs.
>note addictive substance/alcohol > encourage patient to look and touch the affected body part.
>help patient to select and used clothing or bra and
acceptance or no acceptance of situation.
> to evaluate needs for counseling and or medication
>may influence how individual deals with what happen.
>distortion of body image may be unconsciously reinforced by the family members, or secondary gain issue may interfere with progress.
>may reflect dysfunctional coping. >begin to
The patient should verbalized relief of anxiety and adaptation to actual altered body image.
makeup.
incorporate body image.
> To minimize body changes and enhances appearance.
ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC DEFINITION
OBJECTIVES NURSING INTERVENTION
RATIONALE EXPECTED OUTCOMES
S>
O> Patient manifested:
> A febrile >Headache >restlessness>irritability>hypoxia>Diaphoretic
“pain and discomfort related to surgical procedure”
>Unpleasant sensory and emotion experience arising from actual or potential tissue damage.
Short term:
After 12hr of nursing intervention the patient will decrease pain from score of 5 to 3 in pain scale.
>assess patient condition associated with long term pain, example slow healing traumatic injuries/surgery. >discuss use of nicotine, sugar, caffeine, white
>to identify patient with potential for pin lasting beyond normal healing used. > Some holistic practitioner believes these
Short term:
The patient should decreased pain from score of 5 to 3 in the pain scale.
Long term:
> The patient should
>Pain scale scored are 5
Long term:
After 3 days of nursing intervention the patient will report the decreased and state pain/discomforts management strategies are effective.
flour as appropriate.
>evaluate pain behaviors..>assess degree of personal maladjustment of the patient, such as isolationism, anger, irritability, lost of work time.. > Maintain adequate I/O, avoid fluid overload.
>Encourage rest and limit activities and promote calm restful environment.>provide psychological, support, active listen question concerns. > apply pain managements, as appropriate,
items need to be eliminated from the patient diet.
> may be exaggerated because patient perception of pain is not believe or because patient believes caregivers discounting reports of pain. >Help limit oxygen needs/ consumption
>To reduce anxiety.
> Medically intervention, as indicated, in all aspects of long term
report the decreased and stated pain/discomforts management strategies are effective.
extended-relief pain medication.
>assist patient to learn breathing techniques
>provide comfort measures such as listening music’s and watching TV.
>be alert to changes in pain of the patient.
pain. >To assist in muscle and generalized relaxation.
>to limit focusing the pain.
>may indicated a new physical problem.
ASSESSMENT NURSING DIAGNOSIS
SCIENTIFIC DEFINITION
OBJECTIVES NURSING INTERVENTION
RATIONALE EXPECTED OUTCOMES
S>
O> Patient may manifested:
>fatigue>febrile>weakness>redness at the incision site
“Risk for infection related to inadequate primary defenses due to traumatized tissue/surgical incision.”
>it is due to MRM, procedure that involves removal of entire breast, tissue, including the nipple-areola complex and
Short term:
After 12hr of nursing intervention, the patient will able to verbalize understanding of individual
>monitor sign and symptom of infection of inflammations. >encourage patient to perform proper hygiene/sterile techniques.
>to avoid contamination.
>to reduce risk of cross contamination. >to maintain clean, dry, and intact wound
Short term:
The patient should verbalized understanding of individual causative/risk factor to prevent infection.
> skin rashes
Patient Manifested:
>irritability/discomfort>moderate pain>intact/dry dressing of the incision site.
may be the pathogens’ can inter the entire wound or surgical incision and causes infections.
causative/risk factor to prevent infection.
Long term:
After 1week of nursing intervention, the patient will maintain clean, dry, and intact surgical incisions and achieve timely wound healing.
> instruct patient to maintain clean, dry and do not expose the wound.
>change surgical/ other wound dressings, as indicated, using proper technique of changing and disposing contaminated material. > administer and monitor medication regimen.
>encourage patient in adequate fluid intake.
> promote comfort measures and provide relief for pain.
>encourage patient to drink and take food rich in
dressing to prevent infection.
>to determine effectiveness of the therapy and presense of side effects.
>to increased the immune system
Long term:
The patient should maintain clean, dry, intact surgical incision and achieved timely wound healing.
vitamin C.
Indications and Usage for DiprivanDiprivan Injectable Emulsion is an IV sedative-hypnotic agent that can be used for both induction and/or maintenance of anesthesia as part of a balanced anesthetic technique for inpatient and outpatient surgery in adult patients and pediatric patients greater than 3 years of age. Diprivan Injectable Emulsion can also be used for maintenance of anesthesia as part of a balanced anesthetic technique for inpatient and outpatient surgery in adult patients and in pediatric patients greater than 2 months of age. Diprivan Injectable Emulsion is not recommended for induction of anesthesia below the age of 3 years or for maintenance of anesthesia below the age of 2 months because its safety and effectiveness have not been established in those populations.
ContraindicationsDiprivan Injectable Emulsion is contraindicated in patients with a known hypersensitivity to Diprivan Injectable Emulsion or its components, or
when general anesthesia or sedation are contraindicated.INDICATION DOSAGE AND ADMINISTRATION
Induction of General Anesthesia
Healthy Adults Less Than 55 Years OF Age: 40 mg every 10 seconds until induction onset (2 to 2.5 mg/kg).Elderly, Debilitated, or ASA III/IV Patients: 20 mg every 10 seconds until induction onset (1 to 1.5 mg/kg).
Cardiac Anesthesia: 20 mg every 10 seconds until induction onset (0.5 to 1.5 mg/kg).Neurosurgical Patients: 20 mg every 10 seconds until induction onset (1 to 2 mg/kg)
INDICATION DOSAGE AND ADMINISTRATIONPediatric Patients - healthy, from 3 years to 16 years of age: 2.5 to 3.5 mg/kg administered over 20-30 seconds.
See PRECAUTIONS− Pediatric Use: and CLINICAL PHARMACOLOGY− Pediatric patients)
Maintenance of General Anesthesia:
InfusionHealthy Adults Less Than 55 Years of Age: 100 to 200 µg/kg/min (6 to 12 mg/kg/h).
Elderly, Debilitated, ASA III/IV Patients: 50 to 100 μg/kg/min (3 to 6 mg/kg/h).Cardiac Anesthesia: Most patients require:
Primary Diprivan Injectable Emulsion with Secondary Opioid − 100 − 150 µg/kg/minLow-Dose Diprivan Injectable Emulsion with Primary Opioid − 50 - 100 µg/kg/min
(See CLINICAL PHARMACOLOGY, Table 5)Neurosurgical Patients: 100 to 200 µg/kg/min (6 to 12 mg/kg/h).
Pediatric Patients - healthy, from 2 months of age to 16 years of age:125 to 300 µg/kg/min (7.5 to 18 mg/kg/h)
Following the first half hour of maintenance, if clinical signs of light anesthesia are not present, the infusion rate should be decreased. (See PRECAUTIONS− Pediatric Use: and CLINICAL PHARMACOLOGY− Pediatric patients)
Propofol side effects pain, swelling, blisters, or skin changes where the medicine was injected;
seizure (convulsions);
weak or shallow breathing; or
fast or slow heart rate.
Less serious side effects may include: nausea;
cough;
slight burning or stinging around the IV needle;
mild itching or skin rash;
numbness or tingly feeling;
confusion, agitation, anxiety;
muscle pain; or
discolored urine.
INDICATION
FORANE (isoflurane, USP) may be used for induction and maintenance of general anesthesia. Adequate data have not been developed to establish its application in obstetrical anesthesia.
SIDE EFFECTS
Adverse reactions encountered in the administration of FORANE (isoflurane, USP) are in general dose dependent extensions of pharmacophysiologic effects and include respiratory depression, hypotension and arrhythmias.
Shivering, nausea, vomiting and ileus have been observed in the postoperative period.
CONTRAINDICATION
Known sensitivity to FORANE (isoflurane, USP) or to other halogenated agents. Known or suspected genetic susceptibility to malignant hyperthermia
IndicationSynera† is indicated for use on intact skin to provide local dermal analgesia for superficial venous access and superficial dermatological procedures such as excision, electrodessication and shave biopsy of skin lesions ().
Side effects
Systemic adverse effects of lidocaine and tetracaine are similar in nature to those observed with other amide and ester local anesthetic agents, including CNS excitation and/or depression (light- headedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression and arrest). Excitatory CNS reactions may be brief or not occur at all, in which case the first manifestation may be drowsiness merging into unconsciousness. Signs of CNS toxicity may start at plasma concentrations of lidocaine as low as 1000 ng/mL. The plasma concentrations at which tetracaine toxicity may occur are less well characterized; however, systemic toxicity with tetracaine is thought to occur with much lower plasma concentrations compared with lidocaine. The toxicity of co-administered local anesthetics is thought to be at least additive. Cardiovascular manifestations may include bradycardia, hypotension and cardiovascular collapse leading to arrest.
CONTRAINDICATION
Synera† is contraindicated in patients with a known history of sensitivity to lidocaine, tetracaine, or local anesthetics of the amide or ester type. Synera is also contraindicated in patients with para-aminobenzoic acid (PABA) hypersensitivity and in patients with a known history of sensitivity to any other component of the product.