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Date identified: March 02, 2017 Within 2 days of student nurse- Independent: After 8 hours of student nurse-patient
patient interaction the patient will be 1. Assessed the rate and depth of respirations and chest interaction:
Ineffective Airway Clearance able to: movement.
related to retained secretions R: To monitor the clients health state and to Day 1 (March 2, 2017)
secondary to pneumonia as - Demonstrate behaviors which will investigate any further complications.
evidenced by unproductive cough. improve clear airway such huffing Respiration Rate = 21 cpm
and doing breathing exercises. 2. Monitored for signs of respiratory failure such as Crackles heard over lung fields
- Maintain airway patency through cyanosis and severe tachypnea. Verbalized, Im having difficulty spitting
effective coughing and R: Tachypnea, shallow, respirations, and asymmetric out ate"
Scientific Basis: The inflammation
expectoration of secretions. chest movement are frequently present because of
and increased secretions make it Day 2 (March 3, 2017)
- Demonstrate absence or discomfort of moving chest wall or fluid in lung.
difficult to make a patent airway,
reduction of congestion with
which is caused by decreased ability Respiration rate = 28 cpm
breath sounding clear, noiseless 3. Auscultated lung fields, noting areas of decreased or
to expel the excessive mucus Crackles still heard over lung fields
respirations, and improved absent airflow and adventitious breath sounds such as
produced that will lead to extensive Use of accessory muscles not noted
oxygen exchange crackles and wheezes.
obstruction of the airway. Verbalized, I can spit it out na ate"
R: Decreased airflow occurs in areas consolidated with
fluid. Bronchial breath sounds can also occur in
consolidated areas. Crackles, rhonchi, and wheezes
Source: Smeltzer, S., Bare, B., are heard in inspiration and expiration in response to
Hinkle, J. & Cheever, K. (2010). fluid accumulation, thick secretions, airway spasms or
Medical surgical nursing (12th ed.). obstructions.
Philadelphia, PA: Lippincott Williams
& Wilkins. 4. Elevated head of bed and change position frequently.
R: Keeping the head elevated lowers diaphragm,
promoting chest expansion, aeration of lung segments,
and mobilization and expectoration of secretions to
keep the airway clear.
Collaborative:
Date identified: March 02, 2017 Desired outcome: Independent: After 8 hours of student nurse-patient
interaction:
Hyperthermia related to release of Within 2 days nursing intervention, 1. Identified underlying cause.
pyrogens as a response to infection patients temperature will reduce to R: to assess contributing factors
secondary to pneumonia as within normal range and vital signs Day 1 (March 2, 2017)
2. Monitored core temperature
manifested by elevated body will be stable.
R: to evaluate the degree of hyperthermia Patients temperature increased to
temperature of 38.3C/axilla, skin
warm to touch. 38.6 C/axilla and vital signs were
3. Monitored blood pressure
R: central hypertension or peripheral/postural stable
hypotension can occur.
Scientific Basis: Fever is the most Day 2 (March 3, 2017)
common sign of a systemic 4. Monitored heart rate and rhythm
response. It is caused by R: dysrhythmias are common due to electrolyte Patient temperature decreased from
endogenous pyrogens released from imbalance, dehydration and direct effects of 38.3C/axilla to 38.0C/axilla and vital
hyperthermia on blood on cardiac tissue. signs were stable
neutrophils and macrophages. These
substances reset the hypothalamic 5. Monitored respirations and auscultated breath sounds
thermostat, which controls body R: hyperventilation, adventitious breath sounds may
temperature and produce fever. initially be present.
Collaborative:
1. Administered Paracetamol 500mg PRN
R: to relieve fever through central action in the
hypothalamic heat regulating center of the brain.
Collaborative:
Date Identified: March 2, 2017 Desired Outcome: 1. Assessed vital signs especially for pulse and Actual outcome:
blood pressure. Watched for changes.
Risk for bleeding related to Within 2 days of student nurse R: an increase of pulse and blood pressure can Within 8 hours of student nurse and
production of antibodies in and patient interaction, the patient indicate loss of circulation and covert bleeding. patient interaction:
response to dengue virus will be free from bleeding injury
secondary to dengue fever 2. Monitored platelet count.
R:low platelets denotes severe bleeding DAY 1 (March 2, 2017)
Cues:
- Positive NS1 test 3. Monitored skin color and presence of bruises. Petechiae found on the upper right
- Decreased platelet count of R: Bruises indicate ruptured underlying blood arm
126 10e3/L (no= 440-140 vessels.
10e3/L)
4. Checked for unusual color of stool and urine.
Scientific Basis: NS1 R: urine that appears dark or smoky may indicate DAY 2 (March 3, 2017)
antigen test (nonstructural protein bleeding in the urinary tract. Black tarry stools
1), is a test for dengue, introduced Petechiae still noted on the upper
may indicate bleeding in the upper GI tract and
in 2006. It allows rapid detection hematochezia or presence of blood may indicate right arm
on the first day of fever, before Laboratory findings for fecalysis -
bleeding in the lower GI tract.
antibodies appear some 5 or more occult blood testing came out positive
days later. A positive result of NS1 5. Encouraged to report for severe headache and
antigen test implies that there is dizziness.
an active infection caused by the R: Headache or changes in neurological status
dengue virus inside the clients can indicate intracranial bleeding.
body. A dengue virus attacks the
liver spleen and suppresses the 6. Encouraged to eat foods rich in Vitamin K such as
bone marrow. Bone marrow avocado, banana and sweet potato.
suppression causes a decreased R: Vitamin K can help and promote to thicken
production of the blood cells blood and increase clotting ability.
especially the platelets. The
platelets are the ones responsible 7. Maintained a safe environment for the patient
for maintaining the integrity of the such as raising side rails.
blood vessels, if there is a R: to prevent bleeding due to a fall
decreased production of these
blood cells, the blood vessels may 8. Kept sharp objects away from patient
disrupt which leads to bleeding. R: to avoid acquiring wounds
Source: Lemone, P. & Burke, K. 6. Aid the patient if he or she is unable to eat without
(2004). Medical surgical nursing: assistance, and encourage the family to assist with
Critical thinking in clients care (3rd feedings if necessary
ed.). Upper Saddle River, NJ: R: Dehydrated patients are weak and unable to meet
Pearson Prentice Hall. prescribed intake independently
Collaborative:
Date identified: March 2, 2017 Within 2 days of student nurse-patient Independent: After 8 hours of student nurse-patient
interaction, the patient would be able to: 1 Assisted in ambulating. interaction, the patient was able to:
Activity Intolerance related to the R: phenobarbital causes drowsiness.
interference of nerve transmission - Perform ADLs with minimal Day 1 (March 2, 2017)
secondary to the intake of assistance like feeding, toileting, 2 Performed passive ROM of both right and left lower
bathing, dressing and ambulation. extremities.
Phenobarbital as manifested by
lethargic condition and a score of 4/5 R: To prevent muscle atrophy Rest and sleep but still appears tired
- Maintain/ increase muscle strength
on all extremities for muscle strength 3 Provided a conducive environment for sleep and rest and exhausted.
and function of affected
compensatory body part. such as providing well ventilation, organizing
(no=5/5)
materials and minimize the noise Signs and symptoms of fatigue noted
R: To provide comfort and enhance relaxation such as weakness and slowed
Scientific Basis: Phenobarbital acts
movements.
on GABA receptors, increasing
4 Kept necessary things within reach.
synaptic inhibition. This has the effect R: To preserve oxygen and energy consumption
of elevating seizure threshold and Day 2 (March 3, 2017)
reducing the spread of seizure 5 Instructed Significant others to stay at the bedside
activity from a seizure focus. As it always Demonstrated increased tolerance to
acts on GABA receptors, it depresses R: To address immediate help and concerns needed. activity.
the sensory cortex, Was able to rest and sleep well.
decreases motor activity, 6 Scheduled nursing activities like morning care, vital Was able to stand with assistance.
signs monitoring. ROM was still limited
alters cerebellar function, and
R: To provide adequate rest periods.
produces drowsiness, sedation, and
hypnosis. Day 3 (March 4, 2017)
7 Scheduled nursing activities like morning care, vital
Source: Hodgson, B. & Kizior, R. signs monitoring. Was able to do her usual activities
R: To provide adequate rest periods. such as drawing and making her
(2016). Saunders nursing drug
handbook. St. louis, MO: W.C. assignments.
Saunders Co.
Was able to sleep and rest well.
Date identified: March 2, 2017 Within 2 days of 8 hours student 1. Assessed for presence of physical or psychological After 8 hours of student nurse-patient
nurse-patient interaction, the patient stressors such as pain and current illness. interaction:
Disturbed sleeping pattern related will be able to: R: Worry over personal problems or situations can
to frequent monitoring by the disrupt sleep. Day 1 (March 2, 2017)
healthcare provider secondary to Sleep and rest with enough
The patient reported that she was
hospital admission with a time 2. Explained rationale of nursing intervention such as
unable to sleep well and was easily
verbalization of I feel distracted by Statements of feeling well frequent monitoring.
R: Reduces anxiety of patient concerning frequent aroused because of intermittent
the people going in and out of the rested monitoring of health care providers.
room. Report improvement in quality interruption of rest periods.
of sleep and pattern
Scientific Basis: Sleep is required to 3. Discussed relaxation techniques such as listening to
provide energy for physical and music. Day 2 (March 3, 2017)
mental activities. R: Decreases anxiety and may be used to facilitate
resting and sleeping The patient appeared well rested and
Interruption/disruption in the
had an adequate hours of sleep with a
individuals pattern of sleep and
4. Provided quiet and comfortable environment such verbalization of I slept well today.
wakefulness may be temporary or
chronic which may result in both as using night light rather than overhead light
subjective distress and apparent whenever possible, keeping beepers and alarms on
impairment in functional abilities. low volume and keeping the door closed.
Sleep patterns can be affected by R: Conducive environment helps patient to relax,
environment, especially in hospital rest, and sleep.
care units. These patients experience
5. Scheduled activities to be done.
sleep interruptions/disturbances
R: Provides enough time to rest and sleep
secondary to the noisy and frequent
monitoring and treatments. 6. Explore other sleep aids (warm bath or milk)
R: To promote wellness
Source: Flaughter, M. (n.d.). The
importance of sleep: Promoting 7. Encourage client to urinate just before bedtime
restful sleep in patients as well as the R: To reduce discomfort and promote wellness
nurses who care for them. Retrieved
from http://nursing.advanceweb.com.