Patient #1: Vehicular accident patient
Male, 22
DIAGNOSIS
Ineffective airway
clearance related to
increased production of
bronchial secretions
secondary to fluid shift to
extravascular
compartment.
Cues:
-The patient has a
tracheostomy
- the patient use to point
his throat
ANALYSIS GOAL NURSING RATIONALE EVALUATION
INTERVENTIONS
Due to trauma that The patient will be – Assessed – Provides a basis The patient has obtain
has occurred over the able to have effective respiratory rate. for evaluating effective airway
ribs, an intense airway clearance adequacy of clearance
inflammatory after the intervention ventilation.
response occurred. within the hours of
Exudation of plasma, the shift. – Use of accessory
leukocytes, – Noted chest muscles of
infiltration of mast movement; use respiration may
cells, growth factors of accessory occur in response
and inflammatory muscles during to ineffective
leukocytes occurs in respiration. ventilation.
effect. These fluid and
exudates crosses the – Auscultated – Crackles indicate
permeable membrane breath sounds; accumulation of
of the pleurae causing noted areas with secretions and
it to accumulate in presence of inability to clear
this membranous adventitious airways.
space. Instead of the sounds.
lungs being able to
function normally, – Documented – Expectorations
these fluids inhibit the respiratory may be different
lungs to expand secretions: when secretions
anteroposteriorly thus character and are very thick.
causing ineffective amount of
breathing and sputum.
discomfort for the
patient. – Positioning helps
– Maintained maximize lung
patient on expansion.
moderate high
back rest.
– Checked for
obstructions:
accumulation of
 – To maintain
adequate airway
patency.
– Duration should
be limited to
secretions. reduce hazard of
hypoxia, damage
– Suctioned airway mucosa
patient limited and impair cilia
to 5-sec action.
duration. – Increases lumen
size of the
tracheobronchial
tree, thus
decreasing
resistance to
airflow and
improving oxygen
delivery.

Drug Name Dosage Classification Indication Contraindication Side Effects Nursing

Responsibilities
100mg q8 IVP Analgesic Used to treat Health CNS: sedation, – Should the check
moderate to professionals have dizziness or the patients name,
Tramadol moderately severe not yet fully vertigo, head ache, the correct route,
pain and most endorsed of its use confusion, dosage, and
types of neuralgia, on a large scale for dreaming , frequency of the
including these disorders, sweating, anxiety medicine that
trigeminal although it may be and seizures should be given
neuralgia. It has used when other
been suggested that treatments have CV: Hypotension,
tramadol could be failed (under the tachycardia,
effective for supervision of a bradycardia
alleviating psychiatrist).
symptoms of
 depression,
anxiety, and
phobias.
Metronidazole 500 g TIV q8 Asymptomatic and Blood dyscrasias; (> 1%) Body as a – Discontinue
symptomatic active CNS whole: therapy
trichomoniasis in disease; 1st hypersensitivity immediately if
females and males; trimester of (rash, urticaria, symptoms of CNS
acute intestinal pregnancy pruritus, flushing), toxicity develop.
amebiasis and (category B), fever, fleeting joint – Lab tests: obtain
amebic liver lactation. pains, overgrowth total and
abscess; of Candida. CNS: differential WBC
preoperative CAUTIOUS USE vertigo, headache, counts before,
prophylaxis in Coexistent ataxia, confusion, during, and after
colorectal surgery, candidiasis; second irritability, therapy, esp. if
elective and third trimesters depression, second course is
hysterectomy or of pregnancy restlessness, necessary.
vaginal repair, and (category B); weakness, fatigue, – Monitor for S&S
emergency alcoholic liver paresthesias, of Na retention,
appendectomy. IV disease. sensory neuropathy esp. in patients on
metronidazole is (rare). GI: nausea, corticosteroid
used for the vomiting, therapy or with a
treatment of serious epigastric distress, history of CHF.
infection caused by diarrhea, – Monitor patients in
susceptible constipation, dry lithium for
anaerobic bacteria mouth, proctitis, elevated lithium
in intraabdominal anorexia, levels.
infections, skin abdominal cramps, – Report appearance
infections, metallic/bitter taste. of candidiasis or its
gynecologic Urogenital: becoming more
infections, pulyuria, dysuria, prominent with
septicemia, and for pyuria, therapy to
preoperative and incontinence, physician
postoperative cystitis, decreased immediately.
prophylaxis, libido, dyspareunia, – Repeat feces exam,
bacterial vaginosis. dryness of vagina usually up to 3 mo,
Topical: Rosacea. and vulva, sense of to ensure that
pelvic pressure. amebae have been
Special senses: eliminated.
Nasal congestion.
CV: ECG changes
 (flattening of T
wave).

Pantoprazole 40g TIV OD Gastric acid pump Short-term Hypersensitivity to (>1%) GI: diarrhea, – Monitor for and
inhibitor; belongs treatment of pantoprazole or flatulence, immediately report
to a class of erosive esophagitis other PPIs; severe abdominal pain. S&S of
antisecretory associated with hepatic CNS: Headache, angioedema or
compounds. GERD. insufficiency, insomnia. Skin: severe skin
Gastric acid cirrhosis. rash. reaction.
secretion is – Lab tests: urea
decreased by CAUTIOUS USE breath test 4-6 wks
inhibiting the H+, Mild to moderate after completion of
K+-ATPase enzyme hepatic therapy.
system responsible insufficiency;
for acid production. pregnancy
(category B).
lactation. Safety
and effectiveness in
children <18 years
are not established.
Ceftriaxone 1g Bactericidal: Perioperative Contraindicated CNS: head – Perform skin test
Prophylaxis with allergy to ache,dizziness, before
IV Inhibits synthesis cephalosporin or lethargy,parestesia administering to
of Bacterial cell penicillins or detect if the patient
q12 wall, causing cell GI: nausea,
penicillins is allergic to the
death vomiting, drug
abdominal pain, – Assess for patient’s
flatulence, liver history of liver and
toxicity renal depression,
GU: nephrotoxicity lactation and
pregnancy
Hematologic: bone – Have vitamin K
marrow depression available in case
hperprothombinem
Hypersensitivity: ia occurs
ranging from rash,
fever to – Discontinue if
anaphylaxis hypersensitivity
occurs
Local: pain, Inform the
inflammation at IV patient about
site the side effects.

– Instruct patient to
avoid alcohol
while taking the
drug and for 3 days
because severe
reactions often
occur