University of Perpetual Help- Dr. Jose G. Tamayo Medical University Sto.

Nio, Bian, Laguna College of Nursing NURSING CARE PLAN

Date: January 4, 2011 Name: Baby SA Age / Gender: 5 months/ Male

Medical Diagnosis: Bronchopneumonia Nursing Diagnosis: Ineffective airway clearance related to retained secretions as manifested by RR of 67 cpm, ineffective coughing and crackles heard on both lung fields. Short Term Goal: At the end of the nursing intervention, the patient will be able to improve airway patency as evidence by decrease of RR from 67cpm to 40- 50cpm. Long Term Goal: After hospitalization, the patient will be able to maintain airway patency as evidenced by absence of symptoms of respiratory distress.
CUES PROBLEM SCIENTIFIC REASON INTERVENTIONS RATIONALE EVALUATION

Subjective: Inuubo pa rin siya at hirap huminga, as verbalized by the patients mother. Objective: RR of 67 cpm Crackles heard on both lung fields Ineffective coughing reflex

Ineffective Airway Clearance

Inability to clear secretionsor obstructions from the respiratory tract to maintain a clear airway. (NANDA, 12th Edition pp. 80)

Independent: Establish therapeutic nursepatient relationship Observe for signs and symptoms of infection.

To gain patients trust and cooperation and to avoid patients anxiety. To identify infectious process and promote timely intervention.

 Assess clients family for knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures. Monitor vital signs especially the respirations and breath sounds. Auscultate breath sounds and assess air movement. Assist with the use of respiratory devices and treatments such as nebulizer. Position appropriately and elevate head part.

Modalities to manage secretions and improve airflow vary according to clients diagnosis.

This may be indicative of respiratory distress and/or accumulation of secretions. To ascertain status and note progress. To identify infectious process and promote timely intervention. To take advantage of the gravity decreasing pressure on the diaphragm and enhancing

drainage of/ ventilation to the different lung segments. Prevents/ reduces fatigue.

Encourage/ provide opportunities for rest; limit activities to level of respiratory tolerance. Encourage familys verbalization of feelings about the present condition. Dependent: Assist with the use of respiratory devices and treatments such as nebulizer.

To evaluate familys concerns and response regarding the condition and intervention done. To acquire and maintain adequate airways, improve respiratory function and gas exchange

University of Perpetual Help- Dr. Jose G. Tamayo Medical University Sto. Nio, Bian, Laguna College of Nursing NURSING CARE PLAN
Date: January 5, 2011 Name: Baby SA Age / Gender: 5 months/ Male

Medical Diagnosis: Bronchopneumonia Medical Diagnosis: Bronchopneumonia Nursing Diagnosis: Hyperthermia related to exposure to pathogens as manifested by 37.9o C temperature, flushed skin and chilling Short Term Goal: At the end of the nursing intervention, the patients temperature will lower into normal range measurable from 37.9o C to 37o C. Long Term Goal: After hospitalization, the patient will be able to maintain the normal range of temperature from 36.5o C to 37.2o C and be free from any complications.
CUES PROBLEM SCIENTIFIC REASON INTERVENTIONS RATIONALE EVALUATION

Subjective Cue: Mainit siya, as verbalized by the patients mother. Objective Cues: Temperature of 37.9oC RR of 67 cpm Flushed skin; warm to touch

Hyperthermia

Body temperature elevated above normal range (NANDA, 12th Edition pp. 439)

Independent: Establish nursepatient relationship

Identify the cause of elevation in body temperature which

To gain the trust and cooperation of the patient and to promote comfort while doing the intervention To assess the contributing factors

is infection To obtain baseline data and to evaluate the degree of hyperthermia To promote heat loss by evaporation and conduction. To assist with the measures of restoring normal body temperature To support circulating volume and tissue perfussion To promote patients wellness

Monitor the vital signs especially the temperature Promote surface cooling by means of tepid sponge bath Discuss the importance of adequate fluid intake if tolerated Review the specific risk factors like nausea and vomiting and those that client can control such as self treatment of underlying disease process

University of Perpetual Help- Dr. Jose G. Tamayo Medical University Sto. Nio, Bian, Laguna College of Nursing DRUG STUDY

Mechanism of Action Brand Name: Interferes with cell Saloxin wall synthesis of Generic Name: susceptible Ampicillin organisms, Sulbactam preventing Classification: bacterial Anti-infectives multiplication, it penicillin also renders the Dosage and cell wall Frequency: 350mg osmotically ANST(-) q8 unstable and burst Route: TIV due to osmotic pressure. Deactivated by beta-lactamase, an enzyme

Name of Drug

Indications Treatment of respiratory tract and soft tissue infections, bacterial meningitis, septicemia and gonococcal infections caused by susceptible microorganisms, prophylaxis in rape victims and for bacterial endocarditis.

Contraindications Hypersensitivity to penicillins, cephalosporins or imipenem. Oral form not used to treat severe pneumonia, emphysema, bacteremia, pericarditis and purulent or septic arthritis during acute stage.

Side Effects Thrombophlebitis at injection site, dizziness, fatigue, insomnia, reversible hyperactivity, neurotoxicity, urticaria, skin rashes, itchy eyes, laryngospasm, diarrhea, neuropathy, increased BUN and creatinine, decreased Hgb, Hct, RBC, WBC.

Nursing Considerations -Assess patients condition before therapy. -examine turbinate and look for evidence of nasal septal ulcers. -Assess for active infection and determine if immunocompromised. -Assess onitor for possible drug induced adverse reactions3

produced by resistant bacteria.

University of Perpetual Help- Dr. Jose G. Tamayo Medical University Sto. Nio, Bian, Laguna College of Nursing DRUG STUDY

Name of Drug Brand Name: Flixotide Generic Name: Fluticasone Classification: Dermatological Topical Costicosteroids Dosage and Frequency: neb 1cc BID Route: Nasal/ inhalation

Mechanism of Action Glucocorticoid with a high topical antiinflammatory potency. It has a strong affinity for and agonist activity at human glucocorticoid receptors.

Indications It is used for inhalation for the prophylaxis of asthma: also is administered by nasal spray in the prophylaxisand treatment of allergic rhinitis. It is applied topically in the treatment of various skin disorders.

Contraindications Prirmary treatment of severe acute asthmatic attacks or status asthmaticus when intensive measures are required. When applied topically: Rosacea, acne vulgaris, perioral dermatitis, perianal and genital pruritus. Cutaneous viral infections e.g herpes simplex, chicken pox.

Side Effects Candidiasis or dryness of mouth and throat. Hoarseness. Paradoxical bronchospasm. Cutaneous hypersensitivity reactions. Possible systemic effects include suppression of adrenal function, growth retardation in children and adolescents,

Nursing Considerations -Obtain patients history and hypersensitivity to floucinonide and other drugs. -Assess daily affected skin before and during therapy. -Note degree of implementation and pruritus.

Children <1 yr. known hypersensitivity to fluticasone propionate or any ingredient in the formulation.

decrease in bone mineral density, cataract and glaucoma. Unpleasant taste and smell. Epistaxis when applied topically: local burning and pruritus, atrophic skin changes, secondary infection and allergic contact dermatitis, hypercorticism in children and infants. Exacerbation of signs and symptomsof dermatoses.

University of Perpetual Help- Dr. Jose G. Tamayo Medical University Sto. Nio, Bian, Laguna College of Nursing DRUG STUDY

Mechanism of Action Brand Name: Stimulates Beta 2 Ventolin receptors of Generic Name: bronchioles by Salbutamol increasing levels Classification: which relaxes Sympathomimetics smooth muscles to respiratory Drug` produce Dosage and bronchodilation. Frequency: 1 neb + Also cause CNS 1cc PNSS BID stimulation, cardiac Route: stimulation, Nasal/ inhalation increase in diuresis, skeletal muscle tremors and increase gastric acid secretions.

Name of Drug

Indications Relief of bronchospasm in bronchial asthma, chronic bronchitis, emphysema and other reversible obstructive pulmonary disease.

Contraindications Hypersensitivity to salbutamol, also to atropine and its derivatives. Threatened abortion during first or second trimester.

Nursing Considerations Fine skeletal -Assess cardiomuscle tremors, leg respiratory function, cramps, BP, heart rate and palpitations, rhythm, and breath tachycardia, sounds. hypertension, -Determine history headache, nausea, of previous meds vomiting, dizziness, and ability to self hyperactivity, medicate. insomnia, -Monitor for hypotension, evidenceof allergic heartburn, action and epistaxis, cough.. paradoxical bronchospasm.

Side Effects

University of Perpetual Help- Dr. Jose G. Tamayo Medical University Sto. Nio, Bian, Laguna College of Nursing DRUG STUDY

Name of Drug Brand Name: Ambroxol HCl Generic Name: Ambrolex Classification: Mucokinetics/ expectorants Dosage and Frequency: 0.5 ml Route: PO

Mechanism of Action Increases lung concentration of antibiotics when given concomitantly.

Indications Acute and chronic disorder of the respiratory tract associated with pathologically thickened mucus and impaired mucus transport.

Contraindications

Side Effects Mild gastrointestinal disturbances.

Nursing Considerations Special precaution on early month of pregnanacy.

University of Perpetual Help- Dr. Jose G. Tamayo Medical University Sto. Nio, Bian, Laguna College of Nursing DRUG STUDY

Name of Drug Brand Name: Generic Name: Gentamycin Classification: antiinfectives Dosage and Frequency:350 mg OD Route: TIV

Mechanism of Action Destroys gramnegative bacteria by irreversibly binding to 3OS subunit of bacterial ribosomes and blocking protein synthesis, resulting in misreading of genetic code and separation of ribosomes from messenger RNA.

Indications

Contraindications

Side Effects Respiratory: apnea, GI: nausea and vomiting, stomatitis, increases salivation, anorexia, anemia, raches, weight loss, infection, irritation,pain.

Serious infections Hypersensitivity to caused by drug or another pseudomonas amino glycosides. aeruginosa scherichia coli, proteus, klebsiella, serratia, enterobacter, citro bacter or staphylococcus species.

Nursing Considerations -Watch for signs and symptoms of hypesensitivity reactions. -Assess fluid intake. -Monitor CBC,BUN level and clearance.