DS
Content
VII. MEDICATIONS, IV INFUSIONS, BLOOD TRANSFUSIONS, TREATMENTS GIVEN Generic/ Trade Name Cefuroxime (Kepox) Dosage/ Frequency 300 mg IV q 8h Classification Antiinfective; Antibiotic; Second Generation Cephalosporin Indication It is effective for the treatment of penicillinaseproducing Neisseria gonorrhoea (PPNG). Effectively treats bone and joint infections, bronchitis, meningitis, gonorrhea, otitis media, pharyngitis/tonsillitis, sinusitis, lower respiratory tract infections, skin and soft tissue infections, urinary tract infections, and is used for surgical prophylaxis, reducing or eliminating infection To relieve mild to moderate pain due to things such as headache, muscle and joint pain, backache and period pains. It is also used to bring Contraindication Hypersensitivity to cephalosporin and related antibiotics; pregnancy (category B), lactation. Side Effects Body as a Whole: Thrombophlebitis (IV site); pain, burning, cellulitis (IM site); super infections, positive Coombs' test. GI: Diarrhea, nausea, antibioticassociated colitis. Skin: Rash, pruritus, urticaria. Urogenital: Increased serum creatinine and BUN, decreased creatinine clearance. Nursing Responsibilities •Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. • Inspect IM and IV injection sites frequently for signs of phlebitis. • Report onset of loose stools or diarrhea. Although pseudomembranous colitis. • Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes. Assessment & Drug Effects • Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in
Paracetamol
300 mg IV q4h
Non-opioid analgesic
Hypersensitivity to acetaminophen or phenacetin; use with alcohol.
Side effects are rare with paracetamol when it is taken at the recommended doses. Skin rashes, blood
down a high temperature. For this reason, paracetamol can be given to children after vaccinations to prevent postimmunisation pyrexia (high temperature). Paracetamol is often included in cough, cold and flu remedies .
disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for a long time. One advantage of paracetamol over aspirin and NSAIDs is that it doesn't irritate the stomach or causing it to bleed, potential Side effects of aspirin and NSAIDs
Ranitidine (Zantac)
30 mg IV q6h
Therapeutic: Anti-ulcer agents Pharmacologic: Histamine H2 antagonists
•Treatment and prevention of heartburn, acid indigestion, and sour stomach.
Contraindicated in: •Hypersensitivity, Cross-sensitivity may occur; some oral liquids
• CNS: Confusion, dizziness, drowsiness, hallucinations, headache
individuals with poor nutrition. Patient & Family Education • Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects. • Do not selfmedicate children for pain more than 5 d without consulting a physician. • Do not use for fever persisting longer than 3 d, fever over 39.5° C (103° F), or recurrent fever. • Do not give children more than 5 doses in 24 h unless prescribed by physician. • Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. • Nurse should know
contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in: • Renal impairment • Geriatric patients (more susceptible to adverse CNS reactions) • Pregnancy or Lactation
Tranexamic Acid
½ amp q8h
Anti-fibrinolytic
Prevent excessive bleeding
1. In patients with acquired defective color vision, since this prohibits measuring one
that it may cause false-positive results for urine protein; test with sulfosalicylic acid. • GI: • Inform patient that Altered taste, it may cause black tongue, constipation, dark drowsiness or dizziness. stools, diarrhea, • Inform patient that drug-induced hepatitis, nausea increased fluid and fiber intake may minimize • GU: Decreased sperm constipation. count, impotence • Advise patient to report onset of black, tarry stools; • ENDO: fever, sore throat; Gynecomastia diarrhea; dizziness; rash; confusion; or • HEMAT: hallucinations to Agranulocytosis, health car Aplastic Anemia, professional neutropenia, promptly. thrombocytopenia • Inform patient that medication may • LOCAL: temporarily cause Pain at IM site stools and tongue to appear gray black. • MISC: Hypersensitivity reactions, vasculitis • Nausea • Check for doctor’s order • Vomit • vision changes • Perform ANST prior to • dizziness admission • CV: Arrhythmias
endpoint that should be followed as a measure of toxicity 2. In patients with subarachnoid hemorrhage. Anecdotal experience indicates that cerebral edema and cerebral infarction may be caused by CYKLOKAPRON in such patients. 3. In patients with active intravascular clotting. Injectable form: Shock, coma, acute alcohol intoxication, depressed vital signs, obstetrical patients, infants <30 d of age. Tablet form: Infants <6 mo of age, acute narrow-angle glaucoma, untreated openangle glaucoma;
• diarrhea
• Should not be given if positive skin test • Slow IV push • Inform the patient about the possible side effect of the drug • Advise patient to report any discomfort on the IV insertion site • Provide safety
DIAZEPAM (dye-az'e-pam) ApoDiazepam, Diastat, Diazemuls , EPam , Meval , Novodipam , Valium, Valrelease, Vivol
Status Epilepticus Adult: IV/IM 5–10 mg, repeat if needed at 10–15 min intervals up to 30 mg, then repeat if needed q2– 4h Child: IV/IM <5 y, 0.2–0.5 mg slowly
CENTRAL NERVOUS SYSTEM AGENT; BENZODIAZEPINE ANTICONVULSANT; ANXIOLYTIC
Drug of choice for status epilepticus. Management of anxiety disorders, for short-term relief of anxiety symptoms, to allay anxiety and tension prior to surgery, cardioversion and endoscopic procedures, as an amnesic, and treatment for restless legs. Also
Body as a Whole: Throat and chest pain. CNS: Drowsiness, fatigue, ataxia, confusion, paradoxic rage, dizziness, vertigo, amnesia, vivid dreams, headache, slurred speech, tremor; EEG changes, tardive
• Monitor for
adverse reactions. Most are dose related. Physician will rely on accurate observation and reports of patient response to the drug to determine lowest effective maintenance dose. • Monitor for therapeutic effectiveness.
q2–5min up to 5 mg; >5 y, 1 mg slowly q2–5min up to 10 mg, repeat if needed q2–4 h Anxiety, Muscle Spasm, Convulsions, Alcohol Withdrawal Adult: PO 2– 10 mg b.i.d. to q.i.d. or 15–30 mg/d sustained release IV/IM 2–10 mg, repeat if needed in 3– 4h Geriatric: PO 1–2 mg 1–2 times/d (max: 10 mg/d) Child: PO >6 mo, 1–2.5 mg b.i.d. or t.i.d.
used to alleviate acute withdrawal symptoms of alcoholism, voiding problems in older adults, and adjunctively for relief of skeletal muscle spasm associated with cerebral palsy, paraplegia, athetosis, stiff-man syndrome, tetanus.
during or within 14 d of MAO inhibitor therapy. Safe use during pregnancy (category D) and lactation is not established.
dyskinesia. CV: Hypotension, tachycardia, edema, cardiovascular collapse. Special Senses: Blurred vision, diplopia, nystagmus. GI: Xerostomia, nausea, constipation, hepatic dysfunction. Urogenital: Incontinence, urinary retention, gynecomastia (prolonged use), menstrual irregularities, ovulation failure. Respiratory: Hiccups, coughing, laryngospasm. Other: Pain, venous thrombosis, phlebitis at injection site.
Maximum effect may require 1–2 wk; patient tolerance to therapeutic effects may develop after 4 wk of treatment. • Observe necessary preventive precautions for suicidal tendencies that may be present in anxiety states accompanied by depression. • Observe patient closely and monitor vital signs when diazepam is given parenterally; hypotension, muscular weakness, tachycardia, and respiratory depression may occur. • Lab tests: Periodic CBC and liver function tests during prolonged therapy.
TREATMENT/ INFUSION D5IMB Balanced Multiple Maintenance Solution with 5% Dextrose
CLASSIFICATION Hypertonic Solution
INDICATION Slow administration essential to prevent overload (100 mL/hr) -Water intoxication -Severe sodium depletion
CONTRAINDICATION phlebitis, peripheral edema, cellular dehydration
D5 0.3% NaCl
Hypertonic Solution
• Management of severe sodium chloride depletion when rapid electrolyte restoration is essential • Management of severe symptoms of hyponatremia including seizures, coma, and focal neurologic signs
IMPORTANT IMPLICATIONS
•
•
Fluid balance, serum electrolyte concentrations (sodium, potassium, bicarbonate, chloride, magnesium), and acid-base balance should be monitored closely Use with caution if congestive heart failure, liver cirrhosis, severe renal failure, urinary tract
NURSING RESPONSIBILITIES • Do not administer unless solution is clear and container is undamaged. • Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin. • Do not administer unless solution is clear and container is undamaged.
obstruction, or in patients receiving drugs that can cause sodium retention, such as corticosteroids
VI. LABORATORY AND DIAGNOSTIC EXAMINATION RESULTS Date November 11, 2010 Procedure Hemoglobin Hematocrit RBC Neutrophils BUN Creatinine ESR Urinalysis a. Color b. WBC c. Specific Grav. d. Sugar e. Reaction (pH) Norms 120 – 150 .40-.50 4.2 – 5.4 x 10 0.55 – 0.62 1.7 – 8.3 63 – 97 0 – 2 mm/hr Pale yellow to amber Negative or rare 1.015-1.025 Negative 4.5-8.0 Result 130 .41 4.3 .77 4.8 57 26 mm/hr Yellow TMTC; Epithelial-moderate 1.025 Negative Acidic Interpretation and Analysis Normal Normal Normal Elevated; may be due to acute infection Normal Decreased; indication of a problem with renal function. Elevated; Indication of an inflammation Normal Elevated; may be a sign of infection Normal Normal Normal
HERMANO, Geovanni Rai D. BSN 207 XI. Nursing Care Plan Nursing Diagnosis Impaired Physical Mobility related to neuromuscular impairment As evidenced by: S: >”Hindi siya makatulong sa mga gawaing bahay dahil hindi siya makatayo o makagalaw.” as verbalized by the mother. > “Kapag may Analysis
Scientific Implication: Problems and disabilities related to CP range from very mild to very severe. Their severity is related to the severity of the brain damage. They may be very subtle, noticeable only to medical professionals, or may be obvious to the parents and other caregivers.
Goal/ Objectives
Goal: After 2 weeks of Nursing intervention, the client will have adequate mobility to perform activities of daily living to maximum potential.
Nursing Intervention
Rationale
Evaluation
Objectives: INDEPENDENT: 1. After 10 minutes • Carry out and of nursing teach family to intervention, the perform stretching client’s family will exercise on be able to apply affected limb. stretching exercises on affected areas. • Demonstrate the
• To prevent muscle contractures.
The client’s family was able to apply the stretching exercises to their child.
Immediate cause: 2. After 10 minutes
• To increase
The client/family
masakit sa kanya, parang umuungol siya, kasi pag tinatanong ko, sumasagot naman.” as verbalized by the mother. O: > atrophy > Malposition of body part, foot drop > Atonic muscles > Flaccidity, weakness, spasticity or sudden involuntary muscle contraction > Muscle strength is +1 >Limited range of motion > Limited ability to perform fine motor skills > Persistence of primitive reflexes
Cerebral palsy is caused by an injury to the brain before, during, or shortly after birth. Root cause: Failure of the brain to develop properly (developmental brain malformation) and Neurological damage to the child's developing brain.
of nursing intervention, the client/family will be able to demonstrate the use of assistive devices. 3. After 10 minutes of nursing intervention, the client will be able to decrease possible complications.
proper uses of assistive device such as wheelchair and wrist splints.
mobility.
was able to demonstrate the proper use of assistive device.
• Position the client in semi-fowler’s or semi upright position.
• To decrease the chance of aspiration and facilitate the mobilization of food and fluids through esophagus.
The client maintained Semifowler’s position and was able to decrease possible complications.
4. After 10 minutes of nursing intervention, the client will be able to display joint movement.
• Encourage to play • To promote joint exercises that movement and to involve joint promote movement and achievement of promote fine and developmental motor skill milestones. acquisition and repetition. DEPENDENT: • To minimize pain • Administering and decrease medications spasticity. intended to decrease pain and muscle spasticity as prescribed.
The client displays joint movement.
5. After 10 minutes of nursing intervention, the client will be able to minimize pain and spasticity.
The client minimized pain and spasticity.
Nursing Diagnosis Hyperthermia related to illness / PUD
Analysis
Goal/ Objectives
GOAL: After 4 hours of nursing interventions, the client will maintain core temperature within normal range. OBJECTIVES: 1. After 10 minutes of nursing intervention, the client’s family will be able to recognize underlying cause and importance of treatment, as well as the signs and symptoms requiring further evaluation or intervention. 2. After 1 hour of nursing intervention, the client will be able to demonstrate behaviors to monitor
Nursing Intervention
Rationale
Evaluation
Scientific implication: • Increased Heat conservation (Vasoconstriction/ As evidenced by: behaviour S: > “Dinala changes). naming siya dito • Increased Heat production sa hospital kasi ang taas ng lagnat (involuntary muscular niya.” as contractions)
INDEPENDENT: • Identify underlying cause and note for the chronological and developmental age of the client.
•
To provide adequate knowledge.
The client was
able to recognize underlying cause and importance of treatment, as well as the signs and symptoms requiring further evaluation or intervention.
verbalized by the mother. > “Mainit siya, pabalik-balik ang lagnat niya, mamaya bababa, tapos tataas na naman mamaya.” as verbalized by
Immediate cause: Elevated thermoregulatory set point. Root cause: Trauma or illness(cerebral palsy) that affects
• Render Tepid sponge bath.
•
To decrease temperature by means through evaporation
The client was able to maintain normal temperature.
the mother. O: >Temp: 38.9°C > warm to touch > Flushed skin
hypothalamus.
and promote normal temperature.
• Wrap extremities with cotton blankets.
and conduction. • To minimize shivering.
• Monitor core temperature and vital signs. • Monitor and record all fluid loss such as urine, vomiting, etc. and note presence/ absence of sweating as body attempts to increase heat loss by evaporation, conduction, and diffusion.
3. After 1 hour of nursing intervention, the client will be able to decrease possible complications.
•
To evaluate effects and degrees of hyperthermi a.
To monitor or potentiates fluid and electrolyte loses.
•
DEPENDENT: • Administer medications such as antipyretics as ordered.
• Provide supplemental oxygen. • To help in lowering the temperature and to control shivering and seizures.
The client was able to minimized possible complications.
To offset increased Oxygen demands and consumption.
•
Paracetamol
300 mg IV q4h
Non-opioid analgesic
Hypersensitivity to acetaminophen or phenacetin; use with alcohol.
Side effects are rare with paracetamol when it is taken at the recommended doses. Skin rashes, blood
down a high temperature. For this reason, paracetamol can be given to children after vaccinations to prevent postimmunisation pyrexia (high temperature). Paracetamol is often included in cough, cold and flu remedies .
disorders and acute inflammation of the pancreas have occasionally occurred in people taking the drug on a regular basis for a long time. One advantage of paracetamol over aspirin and NSAIDs is that it doesn't irritate the stomach or causing it to bleed, potential Side effects of aspirin and NSAIDs
Ranitidine (Zantac)
30 mg IV q6h
Therapeutic: Anti-ulcer agents Pharmacologic: Histamine H2 antagonists
•Treatment and prevention of heartburn, acid indigestion, and sour stomach.
Contraindicated in: •Hypersensitivity, Cross-sensitivity may occur; some oral liquids
• CNS: Confusion, dizziness, drowsiness, hallucinations, headache
individuals with poor nutrition. Patient & Family Education • Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects. • Do not selfmedicate children for pain more than 5 d without consulting a physician. • Do not use for fever persisting longer than 3 d, fever over 39.5° C (103° F), or recurrent fever. • Do not give children more than 5 doses in 24 h unless prescribed by physician. • Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. • Nurse should know
contain alcohol and should be avoided in patients with known intolerance. Use Cautiously in: • Renal impairment • Geriatric patients (more susceptible to adverse CNS reactions) • Pregnancy or Lactation
Tranexamic Acid
½ amp q8h
Anti-fibrinolytic
Prevent excessive bleeding
1. In patients with acquired defective color vision, since this prohibits measuring one
that it may cause false-positive results for urine protein; test with sulfosalicylic acid. • GI: • Inform patient that Altered taste, it may cause black tongue, constipation, dark drowsiness or dizziness. stools, diarrhea, • Inform patient that drug-induced hepatitis, nausea increased fluid and fiber intake may minimize • GU: Decreased sperm constipation. count, impotence • Advise patient to report onset of black, tarry stools; • ENDO: fever, sore throat; Gynecomastia diarrhea; dizziness; rash; confusion; or • HEMAT: hallucinations to Agranulocytosis, health car Aplastic Anemia, professional neutropenia, promptly. thrombocytopenia • Inform patient that medication may • LOCAL: temporarily cause Pain at IM site stools and tongue to appear gray black. • MISC: Hypersensitivity reactions, vasculitis • Nausea • Check for doctor’s order • Vomit • vision changes • Perform ANST prior to • dizziness admission • CV: Arrhythmias
endpoint that should be followed as a measure of toxicity 2. In patients with subarachnoid hemorrhage. Anecdotal experience indicates that cerebral edema and cerebral infarction may be caused by CYKLOKAPRON in such patients. 3. In patients with active intravascular clotting. Injectable form: Shock, coma, acute alcohol intoxication, depressed vital signs, obstetrical patients, infants <30 d of age. Tablet form: Infants <6 mo of age, acute narrow-angle glaucoma, untreated openangle glaucoma;
• diarrhea
• Should not be given if positive skin test • Slow IV push • Inform the patient about the possible side effect of the drug • Advise patient to report any discomfort on the IV insertion site • Provide safety
DIAZEPAM (dye-az'e-pam) ApoDiazepam, Diastat, Diazemuls , EPam , Meval , Novodipam , Valium, Valrelease, Vivol
Status Epilepticus Adult: IV/IM 5–10 mg, repeat if needed at 10–15 min intervals up to 30 mg, then repeat if needed q2– 4h Child: IV/IM <5 y, 0.2–0.5 mg slowly
CENTRAL NERVOUS SYSTEM AGENT; BENZODIAZEPINE ANTICONVULSANT; ANXIOLYTIC
Drug of choice for status epilepticus. Management of anxiety disorders, for short-term relief of anxiety symptoms, to allay anxiety and tension prior to surgery, cardioversion and endoscopic procedures, as an amnesic, and treatment for restless legs. Also
Body as a Whole: Throat and chest pain. CNS: Drowsiness, fatigue, ataxia, confusion, paradoxic rage, dizziness, vertigo, amnesia, vivid dreams, headache, slurred speech, tremor; EEG changes, tardive
• Monitor for
adverse reactions. Most are dose related. Physician will rely on accurate observation and reports of patient response to the drug to determine lowest effective maintenance dose. • Monitor for therapeutic effectiveness.
q2–5min up to 5 mg; >5 y, 1 mg slowly q2–5min up to 10 mg, repeat if needed q2–4 h Anxiety, Muscle Spasm, Convulsions, Alcohol Withdrawal Adult: PO 2– 10 mg b.i.d. to q.i.d. or 15–30 mg/d sustained release IV/IM 2–10 mg, repeat if needed in 3– 4h Geriatric: PO 1–2 mg 1–2 times/d (max: 10 mg/d) Child: PO >6 mo, 1–2.5 mg b.i.d. or t.i.d.
used to alleviate acute withdrawal symptoms of alcoholism, voiding problems in older adults, and adjunctively for relief of skeletal muscle spasm associated with cerebral palsy, paraplegia, athetosis, stiff-man syndrome, tetanus.
during or within 14 d of MAO inhibitor therapy. Safe use during pregnancy (category D) and lactation is not established.
dyskinesia. CV: Hypotension, tachycardia, edema, cardiovascular collapse. Special Senses: Blurred vision, diplopia, nystagmus. GI: Xerostomia, nausea, constipation, hepatic dysfunction. Urogenital: Incontinence, urinary retention, gynecomastia (prolonged use), menstrual irregularities, ovulation failure. Respiratory: Hiccups, coughing, laryngospasm. Other: Pain, venous thrombosis, phlebitis at injection site.
Maximum effect may require 1–2 wk; patient tolerance to therapeutic effects may develop after 4 wk of treatment. • Observe necessary preventive precautions for suicidal tendencies that may be present in anxiety states accompanied by depression. • Observe patient closely and monitor vital signs when diazepam is given parenterally; hypotension, muscular weakness, tachycardia, and respiratory depression may occur. • Lab tests: Periodic CBC and liver function tests during prolonged therapy.
TREATMENT/ INFUSION D5IMB Balanced Multiple Maintenance Solution with 5% Dextrose
CLASSIFICATION Hypertonic Solution
INDICATION Slow administration essential to prevent overload (100 mL/hr) -Water intoxication -Severe sodium depletion
CONTRAINDICATION phlebitis, peripheral edema, cellular dehydration
D5 0.3% NaCl
Hypertonic Solution
• Management of severe sodium chloride depletion when rapid electrolyte restoration is essential • Management of severe symptoms of hyponatremia including seizures, coma, and focal neurologic signs
IMPORTANT IMPLICATIONS
•
•
Fluid balance, serum electrolyte concentrations (sodium, potassium, bicarbonate, chloride, magnesium), and acid-base balance should be monitored closely Use with caution if congestive heart failure, liver cirrhosis, severe renal failure, urinary tract
NURSING RESPONSIBILITIES • Do not administer unless solution is clear and container is undamaged. • Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin. • Do not administer unless solution is clear and container is undamaged.
obstruction, or in patients receiving drugs that can cause sodium retention, such as corticosteroids
VI. LABORATORY AND DIAGNOSTIC EXAMINATION RESULTS Date November 11, 2010 Procedure Hemoglobin Hematocrit RBC Neutrophils BUN Creatinine ESR Urinalysis a. Color b. WBC c. Specific Grav. d. Sugar e. Reaction (pH) Norms 120 – 150 .40-.50 4.2 – 5.4 x 10 0.55 – 0.62 1.7 – 8.3 63 – 97 0 – 2 mm/hr Pale yellow to amber Negative or rare 1.015-1.025 Negative 4.5-8.0 Result 130 .41 4.3 .77 4.8 57 26 mm/hr Yellow TMTC; Epithelial-moderate 1.025 Negative Acidic Interpretation and Analysis Normal Normal Normal Elevated; may be due to acute infection Normal Decreased; indication of a problem with renal function. Elevated; Indication of an inflammation Normal Elevated; may be a sign of infection Normal Normal Normal
HERMANO, Geovanni Rai D. BSN 207 XI. Nursing Care Plan Nursing Diagnosis Impaired Physical Mobility related to neuromuscular impairment As evidenced by: S: >”Hindi siya makatulong sa mga gawaing bahay dahil hindi siya makatayo o makagalaw.” as verbalized by the mother. > “Kapag may Analysis
Scientific Implication: Problems and disabilities related to CP range from very mild to very severe. Their severity is related to the severity of the brain damage. They may be very subtle, noticeable only to medical professionals, or may be obvious to the parents and other caregivers.
Goal/ Objectives
Goal: After 2 weeks of Nursing intervention, the client will have adequate mobility to perform activities of daily living to maximum potential.
Nursing Intervention
Rationale
Evaluation
Objectives: INDEPENDENT: 1. After 10 minutes • Carry out and of nursing teach family to intervention, the perform stretching client’s family will exercise on be able to apply affected limb. stretching exercises on affected areas. • Demonstrate the
• To prevent muscle contractures.
The client’s family was able to apply the stretching exercises to their child.
Immediate cause: 2. After 10 minutes
• To increase
The client/family
masakit sa kanya, parang umuungol siya, kasi pag tinatanong ko, sumasagot naman.” as verbalized by the mother. O: > atrophy > Malposition of body part, foot drop > Atonic muscles > Flaccidity, weakness, spasticity or sudden involuntary muscle contraction > Muscle strength is +1 >Limited range of motion > Limited ability to perform fine motor skills > Persistence of primitive reflexes
Cerebral palsy is caused by an injury to the brain before, during, or shortly after birth. Root cause: Failure of the brain to develop properly (developmental brain malformation) and Neurological damage to the child's developing brain.
of nursing intervention, the client/family will be able to demonstrate the use of assistive devices. 3. After 10 minutes of nursing intervention, the client will be able to decrease possible complications.
proper uses of assistive device such as wheelchair and wrist splints.
mobility.
was able to demonstrate the proper use of assistive device.
• Position the client in semi-fowler’s or semi upright position.
• To decrease the chance of aspiration and facilitate the mobilization of food and fluids through esophagus.
The client maintained Semifowler’s position and was able to decrease possible complications.
4. After 10 minutes of nursing intervention, the client will be able to display joint movement.
• Encourage to play • To promote joint exercises that movement and to involve joint promote movement and achievement of promote fine and developmental motor skill milestones. acquisition and repetition. DEPENDENT: • To minimize pain • Administering and decrease medications spasticity. intended to decrease pain and muscle spasticity as prescribed.
The client displays joint movement.
5. After 10 minutes of nursing intervention, the client will be able to minimize pain and spasticity.
The client minimized pain and spasticity.
Nursing Diagnosis Hyperthermia related to illness / PUD
Analysis
Goal/ Objectives
GOAL: After 4 hours of nursing interventions, the client will maintain core temperature within normal range. OBJECTIVES: 1. After 10 minutes of nursing intervention, the client’s family will be able to recognize underlying cause and importance of treatment, as well as the signs and symptoms requiring further evaluation or intervention. 2. After 1 hour of nursing intervention, the client will be able to demonstrate behaviors to monitor
Nursing Intervention
Rationale
Evaluation
Scientific implication: • Increased Heat conservation (Vasoconstriction/ As evidenced by: behaviour S: > “Dinala changes). naming siya dito • Increased Heat production sa hospital kasi ang taas ng lagnat (involuntary muscular niya.” as contractions)
INDEPENDENT: • Identify underlying cause and note for the chronological and developmental age of the client.
•
To provide adequate knowledge.
The client was
able to recognize underlying cause and importance of treatment, as well as the signs and symptoms requiring further evaluation or intervention.
verbalized by the mother. > “Mainit siya, pabalik-balik ang lagnat niya, mamaya bababa, tapos tataas na naman mamaya.” as verbalized by
Immediate cause: Elevated thermoregulatory set point. Root cause: Trauma or illness(cerebral palsy) that affects
• Render Tepid sponge bath.
•
To decrease temperature by means through evaporation
The client was able to maintain normal temperature.
the mother. O: >Temp: 38.9°C > warm to touch > Flushed skin
hypothalamus.
and promote normal temperature.
• Wrap extremities with cotton blankets.
and conduction. • To minimize shivering.
• Monitor core temperature and vital signs. • Monitor and record all fluid loss such as urine, vomiting, etc. and note presence/ absence of sweating as body attempts to increase heat loss by evaporation, conduction, and diffusion.
3. After 1 hour of nursing intervention, the client will be able to decrease possible complications.
•
To evaluate effects and degrees of hyperthermi a.
To monitor or potentiates fluid and electrolyte loses.
•
DEPENDENT: • Administer medications such as antipyretics as ordered.
• Provide supplemental oxygen. • To help in lowering the temperature and to control shivering and seizures.
The client was able to minimized possible complications.
To offset increased Oxygen demands and consumption.
•
