Nursing Care Plan Problem: Impaired Ventilation Assessment |Nursing Diagnosis |Planning |Intervention |Rationale |Evaluation | |Subjective: |Impaired spontaneous ventilation |Within 8hrs of nursing |Independent: | | | |“Gi ubo/sipon siya before na |related to accumulation of upper |interventions the pt won’t | | |After 8hrs of nursing | |disgrasya.
Pagka disgrasya naka inum |airways secretions secondary to VA|exhibit signs of respiratory |Assess pt’s condition |To know and determine pt’s need |interventions the pt’s | |siya ug mga dugo niya mao nang | |distress or infection | | |temperature has risen to | |gibutangan siya ana (tracheostomy) | | | |To establish baseline data –Temp. |38.
0C but isn’t showing | |para ma suyop to ky mag lisud man | | |Assess and monitor client’s temperature. |above 37. 5? C may suggest acute |signs of respiratory | |siya ginhawa.. As verbalized by the | | | |infectious disease process. |distress | |mother. | | | | | | | | | | |To facilitate breathing |Goal Partially Met | |Objective: | | Elevate head of bed and align head in the middle | | | |Increased use of accessory muscles | | | | | | | | | |Raise side rails |For safety measures | | |Irritable | | | | | | | | | |Provide TSB |Water applied to skin causes the pores| | |Restlessness | | | |to open allowing excess heat to | | | | | | |escape. Evaporation creates cooling | | |Creatinine and SGPT(ALT) Result: | | | |process. | | |0. 60mg/dL –below | | | | | | |55. 0 U/L –higher | | | | | | | | | |Independent: | | | |CBC Result higher than normal range: | | | | | | |WBC 14. 9 | | |Administered medications as prescribed by AP | | | | | | |Tramadol 50mg IVTT q8 PRN |Pain reliever | | |Vital Signs: | | |Cefuroxime 750mg IVTT q8 | | | |T 38. 0C | | |Salbutamol 1neb q6 |2nd gen. arenteral cephalosporin | | |P 77 | | | |antibiotic | | |R 23 | | | |Bronchodilator | | | | | | | | | | | | | | | | | | | | | | | | | | |IVF PNLR @ 30gtts/min as ordered by AP | | | | | | | | | | | | | |Collaboration: |To replenish fluid losses during | | | | | | |evaporation of fluid in the body. | | | | |Creatinine and SGPT(ALT), CBC sent out to Medtech| | | | | | |Lab as ordered by AP | | | | | | | |To determine possible infection. | | Drug Study Cefuroxime 750mg IVTT q8 Powder for injection: 750mg, 1. 5g, 7. 5g Premixed containers: 750 mg/50ml, 1. g/50ml Source: Davis Drug Guide for Nurses 10th Edition Therapeutic: Anti-infectives Pharmacologic: Second generation Cephalosporins Pregnancy Catergory B Bind to bacterial cell wall membrane, causing cell death Therapeutic Effects: Bactericidal action Treatment: It is effective for the treatment of penicillinaseproducingNeisseria gonorrhoea(PPNG). Effectively treats bone and joint infections, bronchitis, meningitis, gonorrhea, otitis media, pharyngitis/tonsilliti s, sinusitis, lower respiratory tract infections, skin and soft tissue infections, urinary tract infections, and is used for surgical prophylaxis, reducing or eliminating infection.
Hypersensitivity to cephalosporins and related antibiotics; pregnancy (category B), lactation. GI: Diarrhea, nausea, antibiotic- associated colitis. Skin: Rash , pruritus, urticaria. Urogenital: Increased serum creatinine and BUN, decreased creatinine clearance. Hemat: Hemolytic anemia MISC: Anaphylaxis Before: Determine history of hypersensitivity reacti ons to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Lab tests: Perform culture and sensitivity tests before initiation of therapy and periodically during therapy if indicated. Therapy may be instituted pending test results. Monitor periodically BUN and creatinine clearance. During:
Inspect IM and IV injection sites frequently for signs of phlebitis. Monitor for manifestations of hypersensitivity Tramadol 50mg IVTT q8 PRN Therapeutic: Analgesics (centrally acting) Actions: Physiologic Mechanism • Decreased pain. Pharmacologic Mechanism • Binds to mu-opioid receptors. • Inhibits reuptake of serotonin and norepinephrine in the CNS. Indication: • Moderate to moderately severe pain Nursing Care • Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. • Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended doses. • Assess bowel function routinely.
Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects. • Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously received opioids for more than 1 wk; may cause opioid withdrawal symptoms. • Prolonged use may lead to physical and psychological dependence and tolerance, although these may be milder than with opioids. This should not prevent patient from receiving adequate analgesia. Most patients who receive tramadol for pain d not develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve pain. Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined aspirin 650mg/codeine 60 mg for acute postoperative pain. • Monitor patient for seizures. May occur within recommended dose range. Risk increased with higher doses and inpatients taking antidepressants (SSRIs, tricyclics, or Mao inhibitors), opioid analgesics, or other durgs that decrese the seizure threshold. • Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some, but not all, of the symptoms of overdose. Treatment should be symptomatic and supportive. Maintain adequate respiratory exchange. • Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and pneumonia.