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VII.

DRUG STUDY DRUG Date ordered: August 04, 2010 Generic name: Dexamethasone Brand name: -Classification: Anti inflammatory Glucocorticoid Dosage: 1.8 mg IV q6 INDICATION ACTION SIDE/ADVERSE EFFECTS 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. NURSING CONSIDERATION 1. Determin e whether patient is sensitive to other corticosteroids 2. Most adverse reactions to corticosteroids are dose-or durationdependent. 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 PATIENT TEACHINGS 1. Tell patient not to stop drug abruptly or without prescribers 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

Specific The patient was given Adjunctive treatment dexamtehasone 1.8 mg in bacterial meningitis. through IV every 6 hours to decreases General inflammation, mainly by Cerebral edema stabilizing leukocyte Allergic and lysosomal membranes; inflammatory suppresses immune conditions response; stimulates Shock bone marrow; and Tuberculosis influences protein, fat meningitis and carbohydrate metabolism.

injection because atrophy and sterile abscesses may 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.

measles and chickenpox) and to notify prescriber if such exposure occurs.

DRUG Date ordered: August 4, 2010 Generic Name: Streptomycin Brand Name: -Classification: Antituberculosis agent Dosage: 300 mg OD M-W-F ANST

INDICATION Specific mycobacterial infections General Part of combination therapy of active tuberculosis; used in combination with other agents for treatment of streptococcal or enterococcal endocarditis, plague, tularemia, brucellosis

ACTION 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.

SIDE/ADVERSE EFFECTS Allergic Reactions Disturbances of vestibular function Facial Parathesia Nausea and Vomiting

NURSING CONSIDERATION 1. Assess the patient for any previous adverse or sensitivity reaction 2. Assess for any allergic reaction; rash. 3. Monitor the patients intake-output ratio. 4. Monitor for dehydration 5. Evaluate patients hearing before therapy.

PATIENT TEACHINGS 1. Instruct the patients 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.

DRUG Date ordered: August 4, 2010 Generic Name: Meropenem Brand Name: -Classification: Antibiotic Dosage: 500mg TIV q8 ANST

INDICATION Specific For pneumonia and meningitis General Treatment of infection caused by single or multiple susceptible bacteria sensitive to meropenem. Pneumonia including hospital acquired, septicemia, neutropenia, intraabdominal infections, meningitis, urinary tract, gynecological and skin and soft tissue infection.

ACTION The patient was given Meropenem 500mg TIV q8 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 penicillinbinding protein targets where it inhibits cell wall synthesis to render the cell wall osmoticaly unstable.

SIDE/ADVERSE EFFECTS Seizure, headache and pain Pseudomembranous colitis Apnea Anaphylaxis Thrombophlebhitis

NURSING CONSIDERATION 1. In patients with CNS disorders such as bacterial meningitis drug may cause seizures. 2. If seizures occur stop drug infusion. 3. Monitor patients fluid balance and weight carefully.

PATIENT TEACHINGS 1. Instruct the patients watcher to report adverse reaction to nurse at once. 2. Advise watcher to report loose stool to prescriber.

DRUG Date ordered: August 4, 2010 Generic Name: Isoniazid Brand Name: -Classification: Antituberculosis agent Dosage: 200mg/5ml: 3ml OD PO

INDICATION 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.

ACTION 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.

SIDE/ADVERSE EFFECTS Seizures Toxic Enchepalopathy Memory impairment Unusual weakness or fatigue Yellow skin or eyes Dark urine

NURSING CONSIDERATION 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

PATIENT TEACHINGS 1. Instruct patient to take drug exactly as prescribed; warn about stopping drug without prescribers 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.

DRUG Date ordered: August 4, 2010 Generic Name: Rifampicin Brand Name: -Classification: Antituberculosis agent Dosage: 200mg/5ml: 4.5ml OD PO

INDICATION Specific Prevention of meningococcal meningitis

ACTION

SIDE/ADVERSE EFFECTS Headache, fatigue, drowsiness, behavioral changes and dizziness Shock, visual disturbances, exudative conjunctivitis

NURSING CONSIDERATION 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 clients hepatic functions.

PATIENT TEACHINGS 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.

The patient was given Rifampicin 200mg/5ml: 4.5ml OD to treat or inhibit General synthesis of Maintenance treatment of all meningococcal forms of pulmonary and infection and bacterial extra-pulmonary growth by inhibiting tuberculosis (TB). For DNA-dependent RNA continuation phase (for 4 polymerase, which impairs mos) of short-course antiRNA TB treatment. TB and synthesis; bactericidal leprosy in combination with other antibiotics/chemotherapeutic agents; non-mycobacterial infections; brucellosis in combination with a tetracycline

DRUG Date ordered: August 05, 2010 Generic name: Pencillin G sodium Brand name: -Classification: Anti-infective Dosage: 650,000 u IV q4 ANST(-)

INDICATION Specific Pneumoccocal respiratory infections, including otitis media

ACTION

SIDE/ADVERSE EFFECTS 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 Musculoskele tal: arthralgia

The client was given Penicillin G sodium 650,000u IV every 4 hours after negative skin test which inhibits cellGeneral wall synthesis during Moderate to severe systemic bacterial multiplication. infection.

NURSING CONSIDERATION 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

PATIENT TEACHINGS 1. Tell patient or patients 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.

OTHER: hypersensitivity reactions, anaphylaxis, pain at injection sure, vain irritation. DRUG Date ordered: August 05, 2010 Generic name: Famotidine Brand name: -Classification: -Histamine 2-receptor agonist -Anti ulcer drug Dosage: 5mg IV q12 INDICATION Specific Prophylaxis of duodenal ulcers. ACTION SIDE/ADVERSE EFFECTS 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.

seizures and decreasing level of consciousness.

The patient was given Famotidine 5mg through IV every 12 hours as a phrophylaxis for General duodenal ulcer by Hospitalized patient who blocking action of cannot take oral drug or histamine at histamine 2have an intractable ulcers or receptor sites in gastric hypersecretory conditions. parietal cells, inhibiting gastric acid secretion and stabilizing pepsin.

NURSING CONSIDERATION 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.

PATIENT TEACHINGS 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 prescribers knowledge, let patient take antacids together,

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

especially at begining of therapy when pain is severe. 5. Advise patient to report abdominal pain or blood in stools or vomit. NURSING CONSIDERATION 1. Reconsitu te 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. PATIENT TEACHINGS 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

DRUG Date ordered: August 05, 2010 Generic name: Sucralfate Brand name: Carafate Classification: Anti ulcer agent Dosage: 1gm/tab tabs through NGT q6 after each lavage

INDICATION

ACTION

Short term (up to 8 weeks) The patient was given treatment of duodenal ulcer. Sucralfate 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.

SIDE/ADVERSE EFFECTS 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.

4. Drug is as effective as cimetidine in healing duodenal ulcer. 5. Drug contains aluminum but isnt classified as an antacid. Monitor patient with renal insufficiency for aluminum toxicity. NURSING CONSIDERATION 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.

within first few weeks of therapy. 3. Antacids may be used while taking drug, but separate doses by 30 minutes.

DRUG Date ordered: August 14, 2010

INDICATION Specific Fever

ACTION

The client was given Paracetamol 125mg through Iv every 4 Generic name: General hours for fever to cause Acetaminophen Mild to moderate pain relief by inhibition of caused by headache, muscle prostaglandin synthesis Brand name: ache, backache, common in CNS, with Paracetamol cold, toothache subsequent blockage of pain impulses. Fever Classification: reduction may result Analgesic, Antipyretic from vasodilation and increased peripheral Dosage: blood flow in 125mg IV q4 for hypothalamus, which fever dissipates heat and lowers body

SIDE/ADVERSE EFFECTS HEMATOLOGIC: thrombocytopenia, hemolytic anemia, neutropenia, leucopenia, pancytopenia. HEPATIC: jaundice, hepatotoxicity METABOLIC: hypoglycemic coma SKIN: rash, urticaria OTHER: hypersensitivity reactions (such as fever)

PATIENT TEACHINGS 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.

temperature.

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.

DRUG Date ordered: August 14, 2010 Generic name: Mannitol Brand name: -Classification: Diuretic Dosage: 60 cc IV q4 x 30 min with BP precaution

INDICATION Reduction of increased intracranial pressure associated with cerebral edema.

SIDE/ADVERSE EFFECTS The patient was given CNS: dizziness, Mannitol 60cc through IV headache, seizures with BP precaution to decrease intracranial CV: Chest pain, pressure by increasing the hypotension, osmotic pressure of tachycardia, glomerular vascular overload. filtrate, which inhibits tubular reabsorption of EENT: Blurred water and electrolytes and vision increases urinary output. GI: nausea, vomiting, diarrhea, dry mouth.

ACTION

NURSING CONSIDERATION 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.)

PATIENT TEACHINGS 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.

GU: polyuria, urinary retention METABOLIC: dehydration, water intoxication, hypernatremia, metabolic acidosis, hypokalemia RESP: pulmonary congestion. SKIN: rash, urticaria. OTHERS: chills, fever, thirst, edema and tissue necrosis.

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.

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 related to the drugs and tests mentioned above. PATIENT TEACHINGS 1. Advice the mother to check prescriptions and refills because Phenobarbital is

DRUG Date ordered: August 17, 2010 Generic Name: Phenobarbital

INDICATION Specific Treatment of generalized tonic-clonic and cortical focal seizures; emergency control of acute convulsions

ACTION The patient is given Phenobarbital PO q12 to help free from seizure activity. Depressant and

SIDE/ADVERSE EFFECTS Dizziness Headache Hypotension Bradycardia GI disturbances Allergic reaction

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

Brand Name: -Classification: Barbiturates Dosage: 60mg tab q12 PO

General Short term treatment of insomnia; preanesthetic sedation.

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. ACTION The patient was given Ciprofloxacin tab q12 to help inhibit or possibly destroy the microorganism in the clients body. Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria.

Sedation and depression may occur

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.

DRUG Date ordered: August 17, 2010 Generic Name: Ciprofloxacin Brand Name: -Classification: Antibiotic:

INDICATION 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

SIDE/ADVERSE EFFECTS Nausea Diarrhea Rash Allergic reactions Sleep disorders Thrombophlebitis Photosensitivity Renal impairment

NURSING CONSIDERATION 1. Assess the patient for any previous sensitivity reaction. 2. Assess the patient for signs and symptoms of infection before and during treatment.

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 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,

fluoroquinolones Dosage: 500mg tab q12 PO

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.

3. Assess the patient for any allergic reaction or anaphylaxis. 4. Assess for the clients renal function before and during therapy

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 Subjective: Hindi niya na maigalaw ang ulo at mga paa niya para din siyang naninigas As verbalized by the patients mother. Objective cues: Nursing Diagnosis Ineffective cerebral tissue perfusion related to compression of cerebral arteries secondary to increased intracranial pressure (ICP) Rationale 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 Goals and Objectives After 4 hours of continuous nursing interventions, the patient will show signs of increased tissue perfusion as evidenced by : - Vital signs within clients normal range. Interventions Independent: -Monitoring the vital signs of the patient - 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 Rationale Evaluation After 4hours of continuous intervention, the goal was PARTIALLY MET as evidenced by : - Vital signs within clients normal range. - no seizure episodes

-hydrocephaluscommunicating -increased ICP -restlessness -changes in pupillary reactions(nonreactive) -presence of NGT -use of accessory muscles to breath -extremity weakness -muscle rigidity

the brain and cerebral artery compression.

-Avoiding the patient to have seizures

Reduced arterial Long-term goal: blood flow causes decreased nutrition mental status of the and oxygenation at patient(alert) the cellular level. Management is directed at removing vasoconstricting factor(s), improving peripheral blood flow, and reducing metabolic demands on the body. Decreased tissue 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

-Monitor the LOC

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

signs allow the nurse to understand a patients 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 patients response to medications. -Avoiding these measures will help 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.

damage or death.

REFERENCES: -Mosbys pocket dictionary of medicine, Nursing and health professions.(p.660) -http://en.wikipedia. org/wiki/I ntracranial_pressure

-Explain all procedures and equipments to the patient mother.

-Instruct patients mother to inform the nurse immediately of 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

- 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 patients mother on the unknown and this will also help in the establishment cooperation with the mother - Having the cooperation of the patients 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.

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

-to avoid patient on having seizures which can result from cerebral edema or ischemia and to reduce increase ICP. REFERENCES: -Nurses Pocket guide 11th edition, by Dooenges, Moorhouse and Murr (p. 708) -Nursing Care plans by Gulanick and Myers(p.200)

Cues / Data 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

Nursing Diagnosis Hyperthermia related to infection secondary to meningitis

Rationale 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.

Goals and Objectives After 4 hours of nursing intervention the patient body temperature will reduce to 37C

Interventions Independent: Assess for neurological response; noting the level of consciousnes s and orientation, reaction to stimuli of pupils

Rationale

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

To know if its increasing or decreasing

Central hypertension or

T: 39.7C

RR: 26 BP 140/100 PR:144

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

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 nd and insensible loses Monitor laboratorial studies such as ABGs, electrolyte, cardiac and liver enzyme Promote

peripheral/pos tural hypotension occurs

Hyperventilati on may initially be present, but ventilatory effort may eventually impaired by seizure, hypermetaboli c rate (shock and acidosis) Oliguria and/or renal failuremay occur due to hypotension, dehydration, shock It may reveal tissue degeneration

surface cooling by means of undressing; cool and environment Encourage TSB Dependent: Administer medication o (para cetam ol)

Cool environment can or helps the body temperature to decrease Could lower down the body temperature

To rapid decrease body temperature

Cues / Data Subjective Data: Nangayayat na nga sya ngayon eh as verbalized by the mother Objective data: -Iron Deficiency

Nursing Diagnosis Imbalanced Nutrition: Less than Body Requirements related to inability to ingest food

Rationale Adequate nutrition is necessary to meet the bodys demands. Nutritional status can be affected by disease or injury states social factors

Goals and Objective After 4 hours of nursing intervention, the patient will experience gradual balanced nutrition as manifested by: -complying to the feeding time of the

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

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

Evaluation After 4 hours of nursing intervention, goals fully met as evidenced by: - complied time of feeding -health teaching was

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

patient -giving of prescribed supplement or vitamin if available

2. Teach parent about caloric needs for age of -provide parents child and in weight information about the and height 3. Prevent spoiling appropriate nutrition. measurement. and contamination of food that may 3. Teach parent cause about proper gastrointestinal preparation and symptoms. storage of food; hand wash before preparing or handling food.

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

provided to the parents.

Cues/Needs O Subjective data: Namamalat na yung bandang ari niya at sa may pwet. As verbalized by the patients mother. Objective data: - disruption of the epidermis - redness - immobility/inactivity - neuromascular impairment VS Taken: BP: 140/100 RR: 26 PR: 144 TEMP: 39.7 C

Nursing Diagnosis Impaired skin integrity r/t physical immobilization

Rationale Decreased muscle strength Body weakness Irritability Physical immobility Risk for skin integrity *Medical-Surgical Nursing 11th Edition; Brunner & Suddarths

Goals and Objectives After 4hrs. of given intervention the patient will maintain physical well-being Long-term goal: Timely wound healing

Interventions 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 skin routinely, noting moisture, color, and elasticity *Observe for reddened/blanched areas or skin rashes, and institute treatment immediately *Provide adequate clothing/covers; protect from drafts *Emphasize importance of adequate nutritional/fluid intake * stress proper hand hygiene to all care givers and other infection control procedures

Rationale

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

*To prevent complications *To monitor progress or healing

*enhanced circulation to compromised tissue *this may indicate particular vulnerability *Reduces likelihood of progression to skin breakdown

*To prevent vasoconstriction *To maintain general good health and skin turgor

*promoting hygienic procedures is a key in infection prevention

Cues/Needs OBJECTIVE: Improper NGT feeding

Nursing Diagnosis Risk for aspiration related to knowledge deficit.

Rationale Aspiration is defined as the inhalation of either oropharyngeal or gastric contents into the lower airways. Inhalation of these contents can lead to aspiration pneumonia and aspiration pneumonitis. Although these two entities are managed differently, they are often interchangeably referred to as aspiration pneumonia. Aspiration pneumonitis represents chemical damage to the tracheobronchial tree caused by acute, often witnessed, inhalation

Goals and Objectives After hours of nursing intervention the patient will be able to:

Interventions Independent
Monitor level of

Rationale

Evaluation

consciousness.

Patient maintains patent airway. Patients risk of aspiration is decreased as a result of ongoing assessment and early intervention.

Assess cough and

gag reflexes.

Assess pulmonary

status for clinical evidence of aspiration. Auscultate breath sounds for development of crackles and/or rhonchi.

After hours of nursing intervention A decreased the Goal was MET level of by: Patient was able consciousness is to maintain patent a prime risk airway. Patients factor for aspiration. risk of aspiration is decreased as a result of ongoing A depressed assessment and cough or gag reflex increases early intervention. the risk of aspiration.
Aspiration of

Keep suction setup available

small amounts can occur without coughing or sudden onset of respiratory distress, especially in patients with decreased levels of consciousness.

of regurgitated gastric contents in patients with an acute change in mental status. Aspiration pneumonia results from chronic, usually unwitnessed, inhalation of small amounts of oropharyngeal contents leading to an infectious process.

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

This is

necessary to maintain a patent airway.


This protects

Position patient at 90degree angle, whether in bed or in a chair or wheelchair. Use cushions or pillows to maintain position.

the airway. Proper positioning can decrease the risk of aspiration. Comatose patients need frequent turning to facilitate drainage of secretions.
Proper

Maintain upright position for 30 to 45 minutes after feeding.

positioning of patients with swallowing difficulties is of primary importance during feeding or eating.

Provide oral care after meals.

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 patients 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.

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