VIII.

Nursing Care Plan

Nursing Diagnosis Goal Intervention Evaluation

Subjective: Short term: Assessed Short term:

Medyu manguku characteristics of
kupa at ating plema After 6 hours of sputum After 6 hours of
as verbalized by the nursing intervention nursing intervention
patient. the patient will Vital signs taken the patient
demonstrate behaviors and recorded demonstrated
to improved and behaviors to
Objective: maintained clear auscultated improved and
with good skin airway breath sound maintained clear
turgor airway. Goal met
on and off encouraged deep
reproductive breathing
cough Long term: exercise
crackles Long term:
encouraged to
breathe sound After 4 days of
increase fluid
heard upon nursing intervention After 4 days of
intake
auscultation the patient will nursing intervention
with body verbalize absence of the patient will
encouraged SO
malaise secretion and maintain verbalized absence of
to do back
muscle pain on clear airway secretion and maintain
tapping to the
both clear airway. Goal met
patient
extremities
Demonstrated
pursed-slip
Ineffective airway
techniques
clearance related to
retained secretions
VII. Drug Study

Name of Drug Classification Indication Contraindication Adverse Effects Nursing

Consideration

Generic Name Antigout drug Gout and Contraindicated CNS: headache, Administer drug
Allopurinol Hyperurice with allergy to drowsiness, following meals
mia allopurinol, blood peripheral
dyscrasias neuropathy, neuritis Encouraged
Brand Name parethesias patient to drink
Purinol use cautiously with 2.5-3Liters of
Mechanism of liver disease, renal GI: Nausea and water per day to
Action failure, pregnancy vomiting, diarrhea, decrease the risk
Dosage Inhibits the lactation. abdominal pain, of renal stone
100mg 1 Tablet enzyme gastriris, development
responsible for the hepaomegaly,
conversion of cholestatic jaundice Check urine
Frequency purines to uric alkalinity-urates
acid, thus reducing GU: exacerbation crystallize in acid
BID the production of of gout and renal urine sodium
uric acid with a calculi, renal failure bicarbonate or
decrease in serum potassium citrate
and sometimes in Hematologic: may be ordered to
urinary uric acid Anemia alkalinize urine
levels, relieving Leukopenia
the signs and Thrombocytopenia
symptoms of gout Bone marrow
depression
 Name of Drug Classification Indication Contraindication Adverse Effects Nursing
Consideration

Generic Name Antibiotic drug Infections hypersensitivity to Thrombophlebitis Determine history

Cefuroxime Second generation caused by the drugs and IV site pain, of
Sodium Cephalosporin susceptible related antibiotics burning hypersensitivity
organism in to cephalosporin,
Mechanism of the lower pregnancy lactation Diarrhea, nausea penicillin and
Brand Name Action respiratory antibiotic history of
Zinacef Semisynthetic tract. cautiously use associated colitis allergies,
second generation history of allergy particularly to
cephalosporin particularly to drugs before
Dosage antibiotic with drugs, penicillin therapy is
1.5g Injection structure similar sensitivity, renal initiated.
to that of the insuffiency
penicillin.
Frequency Resistance against history of colitis or
ta-lactamase other GI disease
Every 8 hours producing strains potent diuretics.
exceeds that
antimicrobial
spectrum of
activity resembles
that of cefonicid.
Preferentially
binds to one or
more of the
penicillin binding
proteins(PBP)
located on cell
wall synthesis
thus killing the
bacterium .partial
cross allergenicity
between other
lactam antibiotics
and cephalosporin
has been reported.
Name of Drug Classification Indication Contraindication Adverse Effects Nursing
Consideration
Electrolyte and
Generic water balance Hypokalemia Contraindicated Dermatologic Get the history
Name agent, with allergy to : rash allergy to tartrazine
Potassium replacement tartrazine aspirin aspirin, Severe renal
Chloride solution. (tartrazine found in GI: nausea and impairment,
Mechanism of some preparations vomiting , untreated addisons
Action marketed as (Kaon- diarrhea disease,
Brand Name Principal Cl Klorcon) abdominal Hyperkalemia,
Kalium Durule intracellular discomfort, GI Adynamia
cation, essential Severe renal obstruction, GI episodica,hereditaria
for maintenance impairment with bleeding, GI , acute dehydration,
Dosage of intracellular oliguria, ulceration or heat cramps, GI
500mg 1Tablet isotonicity, anuria.Azotemia, perforation disorders that delay
transmission of untreated addisons passage in the GI
nerve impulses. disease, Hematologic: tract, cardiac
Frequency contraction of Hyperkalemia, Hyperkalemia disorders and
cardiac skeletal Adynamia ECG changes lactation
TID and smooth episodica,hereditari
muscles a, acute
maintenance of dehydration, heat
normal kidney cramps, GI
 function and for disorders that delay
enzyme activity passage in the GI
place a tract.
prominent role
in both use catiously with
formation and cardiac disorders
corrections of
imbalances in
acid-base
metabolism.

Body Part Assessed Technique Used Actual Finding Interpretation

Skin Inspection Skin color Dark skin Normal

Palpation Skin is smooth with fair skin turgor Normal
 Head Inspection Normocephalic Normal
Evenly distributed hair, no dandruff, lesions nor Normal
infection
Eyes
Palpation Sinuses non-tender Normal

Inspection Symmetrical eyelids Normal

Pinkish conjuctiva Normal
Anicteric sclera Normal

Body Part Assessed Technique Used Actual Finding Interpretation

Ears Inspection Normoset Normal

Palpation No discharge Normal

Non tender Normal
Nose Inspection No presence of mass or nodules Normal
Symmetrical nasal folds Normal
Nasal septum at midline Normal
Mucosa is moist, pinkish, intact and no discharge Normal
Airways patent on both nares
Non tender sinuses Normal
Palpation Normal
 Mouth Inspection Lips pinkish and dry Normal
Tongue at midline Normal
Gums and mucosa pink Normal

Pharynx Inspection Uvula at midline Normal

Tonsils not inflamed Normal

Neck Inspection Neck symmetrical with full ROM Normal

Pulmonary Inspection Symmetric Normal

Auscultation Crackles breath sounds Abnormal

Body Part Assessed Technique Used Actual Finding Interpretation

Cardiovascular Auscultation Normal heartbeats Normal

Normal
Abdomen Inspection Flat and symmetrical Normal
No lesions Normal
 Palpation No tenderness

Extremities Inspection Skin smooth Normal

Skin intact Normal
Nails convex curved Normal
Pink nail beds Normal

Palpation Skin normal temperature Normal

Motor Sensory Inspection 100% intact Normal

12 cranial nerves responsive Normal