VIII.

PATHOPHYSIOLOGY (book and client based)

 IX. NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS

Subjective data: Hyperthermia At the end of Provide proper Proper

r/t exposure thirty minutes, ventilation. ventilation may
Mainit po ang to hot the patient will reduce the
pakiramdam ko environment maintain a core temperature of
as verbalize by the patient.
temperature
the patient within normal.
Dysrhythmias
Monitor heart are common due
Objective data: rate and to electrolyte
rhythm. imbalance,
T= 37.9 o dehydration, and
C direct effects of
Skin is hyperthermia on
warm to blood and
touch cardiac tissue.
RR= 20
Heat loss by
convention.
 Promote
surface cooling
by means of Ensuring
cool patients safety
environment prevents other
and/or fans. problems.
Self-care
awareness help
in the prevention
and control of
Promote client hyperthermia.
safety.

Encourage
patients
participation in
ways to protect
oneself from
excessive Adequate fluid
exposure to hot intake prevents
environment. dehydration.

Instruct These may

client/SO to indicate prompt
increase fluid interventions.
intake.

Review sings
and symptoms
 of Identifying the
hyperthermia. possible
causative factors
helps
prevent/control
the occurrence of
infection.

Note risk
factors for the Visible sings of
occurrence of infection enable
infection. the management
of more severe
infections.
The skin is our
primary defense
against
infectious
diseases.
Observe for
localized sings
Objective data: for infection at
insertion sites.
Decreased At the end of
immunity 30 minutes, the
client will Assess skin
Risk for verbalize conditions Hand washing
understanding around technique is a
infection r/t
of individual insertion sites first-line defense
IV therapy of pins, wires,
causative and against
and tongs, nosocomial
risk factors.
noting infections.
inflammation
and drainage.
 Stress proper
hand washing
techniques by Care for the skin
all caregivers integrity
and SOs of the prevents the
patient. occurrence of
infection.

Instruct
client/SO in
techniques to
protect the
integrity of the
skin.
Subjective Fluid At the end of Assessed Provides
data: volume the shift, the vital signs baseline data
deficit patient will be and degree and information;
Nagsuka siya at related to able to: of hydration this is also
nagtae, as and level of important in the
increase
verbalized by her - Achieve consciousnes evaluating
metabolic s clients condition
mother demand adequate
an success of
and hydration as intervention
insensible evidenced by
Objective data: fluid loss good skin
through turgor, moist
Dry vomiting mucous
Adequate fluids
mucous and membranes
membran will replace fluid
increased and lips, no Encouraged
es and lost through
body alteration in adequate insensible water
lips
temperatu mentation fluid intake loss due to hyper
Sunken
as tolerated metabolic state
eyeballs re
by the and vomiting
patient.
Instructed SO
to provide
fluids in the
bedside

Regulation of
Regulated fluid is critical in
IVF according maintaining
to specified adequate
flow rates circulating fluids
basing on the to recover for the
physicians amount of water
order loss through
fever and
vomiting
 Urine output
serves as an
Monitored important
frequency of parameter in
urination and assessing clients
amount of ability to
excreted conserve fluids
urine
DRUG STUDY

Classification / Nursin
Generic Name Trade Name Frequency/ Route Mechanism of Contraindication Adverse Effect Considera
Action Health Teac

Pantoprazole Pantoloc 40mg/PO Pharmacologic Class: C/I: Hypersensitivity. Headache, abdominal Advise patient t
Sodium gastric acid pump Lactation. pain, diarrhea, alcohol, produc
inhibitors eructation, flatulence, containing aspir
hyperglycemia NSAIDs, and fo
may cause an in
Use cautiously in
in GI irritation.
Therapeutic Class: pregnancy and children
antiulcer agents (safety not established).

Advise patient t
onset of black, t
stools; diarrhea
abdominal pain
health care prof
promptly.
 Nursin
Classification /
Generic Name Trade Name Frequency/ Route Contraindication Adverse Effect Considera
Mechanism of Action
Health Teac

Amlodipine Norvasc 10mg/PO Cardiovascular agent Patient with known Headache, Report sig
besylate hypersensitivity to edema of the swelling of f
Calcium channel amlodipine lower extremities extremities
blocker
Take care to
Antihypertensive support
agent standing or w
due to p
dose
dizziness

Report shortn
breath palp
irregular hea
 Classification / Nursin
Generic Name Trade Name Frequency/ Route Mechanism of Contraindication Adverse Effect Considera
Action Health Teac

Ciprofloxacin Ciprobay 500mg/PO Gastrointestinal Drugs that inhibits Nausea, Assess patie
drug peristalsis. Pregnant vomiting, rash, previous sen
and lactating headache, reaction
Action: inhibits mothers. dizziness, fever
bacterial DNA Assess patie
gyrase thus any s/s of in
preventing during or
replication in treatment
susceptible bacteria
Assess for a
reaction
 Nursin
Generic Frequency/ Classification /
Trade Name Contraindication Adverse Effect Considera
Name Route Mechanism of Action
Health Tea

Bacillus Erceflora PO/2X a day Anti-diarrheals Not for use in No known side Monitor Vita
clausii immunocompromised effects of patient
Action: Contributes to
patients (cancer patients
the recovery of the Monitor fo
on chemotherapy,
intestinal microbial untoward
patients taking
flora altered during and sympto
immunosuppressant erceflora.
the course of
meds)
microbial disorders
of diverse origin.
It produces various
vitamins, particularly
group B vitamins
thus contributing to
correction of vitamin
disorders caused by
antibiotics &
chemotherapeutic
agents. Promotes
normalization of
intestinal flora.

Genogram
 Mothers Side Fathers Side
LOLA (+)
LOLO LOLO LOLA (+)
(+) DM (+)

HPN

SISTER SISTER DAD SISTER BROTH BROTH SISTER SISTER

DM
ER ER
MOM SISTER

BROTHER

PATIENT JG

SISTER

LEGEND
SISTER
LOLA (+) PATIENT JG

DM DM
MOM
 - Diabetes Mellitus - Diabetes Mellitus - patient JG

- Hypertension - Spouse
LOLO
(+)
DAD
HPN

Laboratory and Diagnostic Exam

Date: 02/14/17
 LABORATORY TEST Result Normal Values Significance

Potassium 4.07 3.5-5.1 mmol/L -within normal range

Creatinine 74.40 53-106 mmol/L -within normal range

Hemoglobin 136 120-150 g/L -within normal range

Hematocrit 0.42 0.38-0.48 -within normal range

White blood cell 10.0 5.0-10x10/L -within normal range

-If you have stomach or

bowel problems, you
may not be able to
absorb the magnesium
0.23 (LOW) 0.77-1.03 mmol/L you take in.

Magnesium Magnesium may not be

absorbed properly due
to alcohol use, diarrhea,
or laxative use.

Increased excretion of
magnesium from your
body

Ionized calcium 0.93 9 (LOW) 1.15-1.33 mmol/L

-malabsorption of
calcium
-a vitamin D
deficiency