ASSESSMEN

T NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED OUTCOMES

DIAGNOSIS DEFINITION INTERVENTION

S> “Ineffective >It is due to Short term: >Establish rapport>to gain the Short term:
airway inability to After 4hr of trust of the The patent should
O> patient may clearance clear secretion nursing >maintain patient maintained airway patency.
manifested: related to or obstructions intervention the respiratory and > indicative of
>Diminished retained from the patient will breathing sound respiratory
adventitious secretion.” respiratory demonstrate distress and Long tem:
breathing tract to behavior to >Evaluate patient’s accumulation The patient should identified
sound rales and maintain a improve and cough gag reflex of secretion potential complications and
ronchi sound. clear clearance maintain clear and swallowing > to determine how to initiated appropriate
>Cough w/ airway ability ability to preventive action.
excessive protect own
sputum >position the airway
>difficulty in patient head >to open or
vocalizing Long term: appropriately for maintain open
> wide eyes After days of the condition airway in at
> restless nursing rest or
intervention the >suction naso / compromise
patient will tracheal PRN individual
expectorate >to clear
clear secretion >elevate the head airway when
and bed change excessive or
position in every viscous
2hr secretions are
blocking
> encourage deep airway
breathing coughing > to enhance
exercise; drainage of
 ventilation to
> increase fluid different lung
intake segment.
>to minimize
>Ascultate the effort
breath sounds and Hydration can
assess the air help liquefy
movement viscous
secretions and
improve
secretion
clearance
> to ascertain
status and rate
progress.

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED

DIAGNOSIS DEFINITION INTERVENTION OUTCOMES

S> “Impaired Excess or Short term: > Evaluate pulse >To assess the Short term:
gas deficit in After 4hr of oumetry to respiratory
O> Patient exchanged Oxygenation nursing determine insufficiency The patient should
manifested: related to and carbon intervention the oxygenation, participate in treatment
>restlessness alveolar dioxide patient will evaluate lung >To maintain regimen such as deep
>irritability capillary elimination at participate in volumes and force airway breathing exercise within
>hypoxia membrane the alveoli treatment vital capacity level of ability.
>abnormal breath changes” capillary regimen such > Elevate head of > To provide
sounds(rales) membrane may as deep bed / position the optimal chest
> nasal flaring be an entity of breathing patient expansion and
its own, but exercise w/ in appropriately and drainage of
also may be level of and provide airway secretion. Long term:
result of other activity. adjust and suction
pathology w/ as indicated. >Help limit > The patient should
an > Encourage oxygen needs/ demonstrated improved
interrelatedness frequent position consumption ventilation and adequate
between Long term: changes, deed oxygenation of tissues by
airway After 3 days of breathing and >To reduce ABG’s within patient’s
clearance and nursing coughing exercise. anxiety. normal limits and absence
breathing intervention the >Monitor for of symptoms of respiratory
patterns. patient will carbon dioxide > To reduce distress.
demonstrate, narcoses irritant effect
improve > Maintain of dust and
ventilation and adequate I/O, chemicals on
adequate avoid fluid airway.
oxygenation of overload.
tissues by >Encourage rest
ABG’s within and limit activities
patient normal and promote calm
limits and restful
absence of environment.
symptoms of >provide
respiratory psychological,
distress. support, active
listen question
concerns.
> Keep
environment
allergen/ pollutant
free.
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED
DIAGNOSIS DEFINITION INTERVENTION OUTCOMES

S> “Activity It is due ton Short term: >Note of factors >Fatigue Short term:
intolerance insufficient contributing to effects both
O> patient related ton physiological After 4hr of fatigue. the patient The patient should
manifested: imbalance or nursing >Evaluate patients actual and identified techniques to
>fatigue ness between psychological intervention, actual and perceive perceive enhanced activity
oxygen energy to the patient will limitations degree activity to intolerance.
> abnormal heart supply and induce or able to identify of deficit in light of participate the
rate, blood demand complete techniques to usual status. activities.
pressure response secondary to required or enhance > Note patient >To provides
to activity CAP.” desired daily activity reports of comparative
activities. tolerance. weakness, fatigue, baseline and
> Electro pain, difficulty provides Long term:
cardiographic accomplishing information
orange reflecting tasks and or about needed The patient should
arrtmythmias or insomnia. educations participate willingly in
ischemia. Long term: >Ascertain regarding necessary /desired
necessary use of quality of life. activities.
After 3 days of equipment >Symptoms
nursing >Assess emotional may be result
intervention, and psychological of / or
the patient will factors affecting contribute to
participate the current intolerance of
willingly in situation. activity,
increase >provide positive > To
activities. atmosphere while determine
acknowledging current status
difficulty of the and needs
situation for the associate with
patient. participation
>Assist with in needed
activity, provide desired
and monitor activies.
patient’s use of > Stress, or
assistive devices depression
such as wheel may be
chairs, or oxygen increasing the
tank. effect of an
> promote comfort illness and
measures and may result of
provide relief for being force
pain. into activities.
>Helps to
minimize
frustration and
rechanel
energy.
>To protect
patient from
injury.
>to enhance
ability to
participate in
activities.
GENERIC NAME: Ipratropin Bromide
BRAND NAME: Combinent, Duoneb
GENERAL ACTION: Anticholinergic, Bronchodilator
SPECIFIC ACTION: An Anticholinergic that blocks the action of Acetylcholine at Parasympathetic site in

Bronchial smooth muscle.

INDICATION: Maintain treatments of bronchospasm due to chronic obstructive pulmonary disease

(COPD).
CONTRAINDICATION: History of hypersensitivity to atropine, soya lecithin or related food products such as

soybean and peanuts. Narrow-angle Glaucoma, Prostatic Hypertrophy, Bladder Neck

Obstruction.
DOSSAGE: For: Inhalation: maximum; 12 inhalation per day

For: Nebulatization:500mcg 3-4 times a day

For: Intranasal: 2 sprays per nostril 2-3times a day

SIDE EFFECTS: Cough, dry lips, headache, nausea, dry nose, and mouth, nasal irritation, Dizziness,

transient increased bronchospasm, Hypotension Insomnia, Diarrhea, or Constipation.

NURSING IMPLICATION: >offer emotional support, high evidence of anxiety due to difficulty breathing,

sympathomimetic response to drugs.

>Monitor rate, depth, rhythm, type of respiratory, quality, rate of pulse.

>Assess lung sounds for bronchi, wheezing and rales.

>Increase fluid intake to decrease living secretion viscosity.

 >Avoid excessive use of caffeine derivatives such as chocolates, coffee, and cocoa.

GENERIC NAME: Hydrocortisone

BRAND NAME: Cortisporin
GENERAL ACTION: Narcotic Analgesic
SPECIFIC ACTION: Adrenal Cortical Steroid that inhibits accumulation of inform of corticosteroid response in

skill, pagosytosis.
INDICATION: Management of adrenocortical insuffiency, relief of inflammation of corticosteroid

respordermatosis, adjunctive treatment of ulcerative colitis, status asthmaticus shock.

CONTRAINDICATION: Fungal, tuberculosis, or viral skin lesions, serious infections, Hyperthyroidism, cirrhosis,

ulcerative colitis, hypertension, osteoporosis, thromboembolic tendencies, CHF, seizure

disorders, thrombophebitis, peptic ulcer, diabetes.

DOSSAGE: IVF: 100mg IV bolus; 300mg/day in divided in every 8hr.

IM: 15-240mg every 12hr

PO: 15-240mg every 12hr

SIDE EFFECTS: Long therapy may cause hypocalcaemia, muscle wasting, osteoporosis, amenorrhea,

cataracts, glaucoma, peptic ulcer disease and CHF.

NURSING IMLICATION: >obtain baseline values for weight, BP, Blood glucose, serum cholesterol, electrolytes.

>Assess for edema, and infection, sore throat, fever, vague symptoms.

>notify physician of fever, sore throat, muscle aches, muscle aches, sudden weight gain or

swelling.
 >Do not take aspirin or many medication without consulting physician.

>Limit caffeine and avoid alcohol.

GENERIC NAME: Cefuroxime Sodium

BRAND NAME: Kefurox, Zinacef, Ceftin
GENERAL ACTION: Antireflective, Antibiotic, Second-generation Cephalosporin.
SPECIFIC ACTION: It inhibits third and final stage of bacterial cell wall synthesis, thus killing the bacterium.

Partial cross-allergenicity between other betalactam antibiotic and cephalosporine has been

reported.
INDICATION: For infection caused by susceptible organism in the lower respiratory tract, skin, and skin

structures, also used for treatment of meningitis, gonorrhea and Otitis media and

preoperative prophylaxis (”ex. Open-heart surgery) early Lyme disease.

CONTRAINDICATION: Hypersensitivity to cephalosporin and related antibiotics ,pregnancy category B.
DOSSAGE: Tablet: 250mg every 12hr, for 10 days.

Suspension:20mg/kg/day in 2 divided doses

IM;IV: 750mg every 8hr and 1.5g every 8hr

SIDE EFFECT: Diarrhea, loose stools, nausea and vomiting abdominal pain, decreased H and H.
NURSING IMPLICATION: >Determine history of hypertensensetivity reactions to cephalosporin’s, penicillin and

history of allergies

particularly to drugs before therapy initiated.

>Inspect IM and IV injection sites for phlebitis.

 > Report insect of lose stool or diarrhea.
A.2.DRUGS

GENERIC NAME: Propoxyphene Hcl.

BRAND NAME: Darvocet-N 100, Propacet 100

GENERAL ACTION: Narcotic and nonarcotic analgesic
SPECIFIC ACTION: Decreased fever by a hypothalamic effect leading to sweating and vasodilation and inhibits the
effects of pryrogens on the hypothalamic heat-regulating centers.
INDICATION: Relief of mild fever to moderate pain, either when pain is alone or when accompanied by fever.
CONTRAINDICATION: Hypersensitivity to propoxyphene or acetaminophen, use in those suicidal or addiction prone.
DOSSAGE: Usual: tablet, 100mg propoxyphene napsylate and 650mg acetaminophen every 4 hours
SIDE EFFECTS: Drowsiness, Dizziness, nausea and vomiting, sedation, Constipation, abdominal pain, lever
dysfunction, cholestatic jaundice, lightheadedness, headache, weakness, minor visual disturbances,
skin rashes, and hallucination.
NURSING IMPLICATION: >assess for depression, suide ideation, excessive alcohol use, drug addiction prone, precludes drug
use.
>take as directed, do not exceed prescribed dose.
>do not perform an activity that requires mental alertness until drug effects realized.
>may cause dizziness, nausea and vomiting, lie down and rest if these occur to relieve symptom.
>avoid alcohol and CNS depressant during therapy.

GENERIC NAME: Acetaminophen and codeine phosphate

BRAND NAME: Tylenol with codeine-II
GENERAL ACTION: Non-narcotic/ Narcotic analgesic combination
SPECIFIC ACTION: It causes analgesia by inhibiting CNS prostaglandin synthesis. The mechanism of morphine is to
involve decreased permeability of the cell membrane to sodium, which result in dimished
transmission of pain impulses and therefore analgesia.
INDICATION: Relief mild to moderately severe pain.
CONTRAINDICATION: Renal insufficiency, anemia. Those with cardiac or pulmonary disease are more susceptible to
acetaminophen toxicity.
DOSSAGE: Elixir (oral solution): 15ml(360mg acetaminophen and 36mg codeine phosphate) q 4hr.
Tablet: acetaminophen 200-1000mg is a single dose,4000mg is the maximum. Codeine,15-60mg is
the single dose, 360 is the maximum dose q 4hr.
SIDE EFFECTS: Lightheadedness, dizziness, sedation, shortness of breath, nausea and vomiting. Respiratory
depression (high doses of codeine)
NURSING IMPLICATION: >take directed with a full glass of water. May take with food or milk if GI upset.
>do not drive or perform activities that require mental alertness until drug effect realized may cause
dizziness and drowsiness.
>store away from bedside and out of reach of children.
>report any adverse side effects of lack of desired effects.

GENERIC NAME: Hydrocortisone

BRAND NAME: Cortisporin
GENERAL ACTION: Narcotic Analgesic
SPECIFIC ACTION: Adrenal Cortical Steroid that inhibits accumulation of inform of corticosteroid response in skill,
pagosytosis.
INDICATION: Management of adrenocortical insuffiency, relief of inflammation of corticosteroid
respordermatosis, adjunctive treatment of ulcerative colitis, status asthmaticus shock.
CONTRAINDICATION: Fungal, tuberculosis, or viral skin lesions, serious infections, Hyperthyroidism, cirrhosis, ulcerative
colitis, hypertension, osteoporosis, thromboembolic tendencies, CHF, seizure disorders,
thrombophebitis, peptic ulcer, diabetes.
DOSSAGE: IVF: 100mg IV bolus; 300mg/day in divided in every 8hr.
IM: 15-240mg every 12hr
PO: 15-240mg every 12hr
SIDE EFFECTS: Long therapy may cause hypocalcaemia, muscle wasting, osteoporosis, amenorrhea, cataracts,
glaucoma, peptic ulcer disease and CHF.
NURSING IMLICATION: >obtain baseline values for weight, BP, Blood glucose, serum cholesterol, electrolytes.
>Assess for edema, and infection, sore throat, fever, vague symptoms.
>notify physician of fever, sore throat, muscle aches, muscle aches, sudden weight gain or swelling.
>Do not take aspirin or many medication without consulting physician.
>Limit caffeine and avoid alcohol.

IIE.C. Nursing Management

Nursing Care Plan, Postoperative Care

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED OUTCOMES

DIAGNOSIS DEFINITION INTERVENTION
S> “Disturbed >it is due to Short term: >determine >there is Short term:
body image MRM, whether condition always that
O> patient related to loss procedure that After 12hr of is permanent / no can be done to The patient was able to
manifested: or alteration involves nursing expectation for enhance verbalized feelings regarding
of the removal of intervention the resolution. acceptance. the changes in image.
>a febrile breast.” entire breast, patient will
>weakness tissue, verbalize >evaluate level of >which may Long tem:
>difficulty in including the feelings patient knowledge indicate
vocalizing nipple-areola regarding of and anxiety acceptance or The patient should
emotion complex. change in related to the no acceptance verbalized relief of anxiety
> irritability image. situation, observe of situation. and adaptation to actual
> restless emotional changes. altered body image.
>sad facial > to evaluate
expression. Long term: >note sign of needs for
>missing body grieving/indicators counseling and
part the left After 2weeks of severe or or medication
breast. of nursing prolonged
intervention the depression. >may
patient will influence how
verbalize relief >determine ethnic individual
of anxiety and background and deals with
adaptation to cultural/religious what happen.
actual/ altered perceptions and
body image. consideration. >distortion of
body image
>observe may be
interaction of unconsciously
patient to the SOs. reinforced by
the family
>note addictive members, or
substance/alcohol secondary gain
 issue may
> encourage interfere with
patient to look and progress.
touch the affected
body part. >may reflect
dysfunctional
>help patient to coping.
select and used
clothing or bra and >begin to
makeup. incorporate
body image.

> To minimize
body changes
and enhances
appearance.
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED
DIAGNOSIS DEFINITION INTERVENTION OUTCOMES

S> “pain and >Unpleasant Short term: >assess patient >to identify Short term:
discomfort sensory and condition patient with
O> Patient related to emotion After 12hr of associated with potential for The patient should
manifested: surgical experience nursing long term pain, pin lasting decreased pain from score
procedure” arising from intervention the example slow beyond normal of 5 to 3 in the pain scale.
> A febrile actual or patient will healing traumatic healing used.
>Headache potential tissue decrease pain injuries/surgery.
>restlessness damage. from score of 5 > Some
>irritability to 3 in pain >discuss use of holistic Long term:
>hypoxia scale. nicotine, sugar, practitioner
>Diaphoretic caffeine, white believes these > The patient should
>Pain scale flour as items need to report the decreased and
scored are 5 appropriate. be eliminated stated pain/discomforts
Long term: from the management strategies
>evaluate pain patient diet. are effective.
After 3 days of behaviors.
nursing . > may be
intervention the >assess degree of exaggerated
patient will personal because
report the maladjustment of patient
decreased and the patient, such as perception of
state isolationism, pain is not
pain/discomforts anger, irritability, believe or
management lost of work time. because
strategies are . patient
effective. > Maintain believes
adequate I/O, caregivers
avoid fluid discounting
overload. reports of
pain.
>Encourage rest
and limit activities >Help limit
and promote calm oxygen needs/
restful consumption
environment.
>provide >To reduce
psychological, anxiety.
support, active
listen question > Medically
concerns. intervention,
> apply pain as indicated, in
managements, as all aspects of
appropriate, long term
extended-relief pain.
pain medication.
>To assist in
>assist patient to muscle and
learn breathing generalized
techniques relaxation.

>provide comfort >to limit

measures such as focusing the
listening music’s pain.
and watching TV.
>may
>be alert to indicated a
changes in pain of new physical
the patient. problem.
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EXPECTED
DIAGNOSIS DEFINITION INTERVENTION OUTCOMES

S> “Risk for >it is due to Short term: >monitor sign and >to avoid Short term:
infection MRM, symptom of contamination.
O> Patient may related to procedure that After 12hr of infection of The patient should
manifested: inadequate involves nursing inflammations. >to reduce risk verbalized
primary removal of intervention, of cross understanding of
>fatigue defenses due entire breast, the patient will >encourage patient contamination. individual
>febrile to tissue, able to to perform proper causative/risk factor to
>weakness traumatized including the verbalize hygiene/sterile >to maintain prevent infection.
>redness at the tissue/surgical nipple-areola understanding techniques. clean, dry, and
incision site incision.” complex and of individual intact wound
> skin rashes may be the causative/risk > instruct patient to dressing to
pathogens’ can factor to maintain clean, dry prevent Long term:
inter the entire prevent and do not expose infection.
Patient Manifested: wound or infection. the wound. The patient should
surgical >to determine maintain clean, dry,
>irritability/discomfor incision and >change surgical/ effectiveness intact surgical incision
t causes other wound of the therapy and achieved timely
>moderate pain infections. Long term: dressings, as and presense wound healing.
>intact/dry dressing of indicated, using of side effects.
the incision site. After 1week of proper technique
nursing of changing and >to increased
intervention, disposing the immune
the patient will contaminated system
maintain clean, material.
dry, and intact
surgical > administer and
incisions and monitor
achieve timely medication
wound healing. regimen.

>encourage patient
in adequate fluid
intake.

> promote comfort

measures and
provide relief for
pain.

>encourage patient
to drink and take
food rich in
vitamin C.
Indications and Usage for Diprivan
Diprivan Injectable Emulsion is an IV sedative-hypnotic agent that can be used for both induction and/or maintenance of anesthesia as part of
a balanced anesthetic technique for inpatient and outpatient surgery in adult patients and pediatric patients greater than 3 years of age.
Diprivan Injectable Emulsion can also be used for maintenance of anesthesia as part of a balanced anesthetic technique for inpatient and
outpatient surgery in adult patients and in pediatric patients greater than 2 months of age. Diprivan Injectable Emulsion is not recommended
for induction of anesthesia below the age of 3 years or for maintenance of anesthesia below the age of 2 months because its safety and
effectiveness have not been established in those populations.

Contraindications
Diprivan Injectable Emulsion is contraindicated in patients with a known hypersensitivity to Diprivan Injectable Emulsion or its components, or
when general anesthesia or sedation are contraindicated.
INDICATION DOSAGE AND ADMINISTRATION
Induction of General Healthy Adults Less Than 55 Years OF Age: 40 mg every 10 seconds until induction onset (2 to 2.5 mg/kg).
Anesthesia Elderly, Debilitated, or ASA III/IV Patients: 20 mg every 10 seconds until induction onset (1 to 1.5 mg/kg).
Cardiac Anesthesia: 20 mg every 10 seconds until induction onset (0.5 to 1.5 mg/kg).
Neurosurgical Patients: 20 mg every 10 seconds until induction onset (1 to 2 mg/kg)
Pediatric Patients - healthy, from 3 years to 16 years of age: 2.5 to 3.5 mg/kg administered over 20-30 seconds.
See PRECAUTIONS− Pediatric Use: and CLINICAL PHARMACOLOGY− Pediatric patients)

Maintenance of Infusion
General Anesthesia: Healthy Adults Less Than 55 Years of Age: 100 to 200 µg/kg/min (6 to 12 mg/kg/h).
Elderly, Debilitated, ASA III/IV Patients: 50 to 100 μg/kg/min (3 to 6 mg/kg/h).
Cardiac Anesthesia: Most patients require:
Primary Diprivan Injectable Emulsion with Secondary Opioid − 100 − 150 µg/kg/min
Low-Dose Diprivan Injectable Emulsion with Primary Opioid − 50 - 100 µg/kg/min
(See CLINICAL PHARMACOLOGY, Table 5)
Neurosurgical Patients: 100 to 200 µg/kg/min (6 to 12 mg/kg/h).
Pediatric Patients - healthy, from 2 months of age to 16 years of age:
125 to 300 µg/kg/min (7.5 to 18 mg/kg/h)
Following the first half hour of maintenance, if clinical signs of light anesthesia are not present, the infusion rate
should be decreased. (See PRECAUTIONS− Pediatric Use: and CLINICAL PHARMACOLOGY− Pediatric patients)

Propofol side effects

• pain, swelling, blisters, or skin changes where the medicine was injected;
• seizure (convulsions);
 • weak or shallow breathing; or
• fast or slow heart rate.
Less serious side effects may include:
• nausea;
• cough;
• slight burning or stinging around the IV needle;
• mild itching or skin rash;
• numbness or tingly feeling;
• confusion, agitation, anxiety;
• muscle pain; or
• discolored urine.
INDICATION
FORANE (isoflurane, USP) may be used for induction and maintenance of general anesthesia. Adequate data have not been developed to
establish its application in obstetrical anesthesia.

SIDE EFFECTS

Adverse reactions encountered in the administration of FORANE (isoflurane, USP) are in general dose dependent extensions of
pharmacophysiologic effects and include respiratory depression, hypotension and arrhythmias.

Shivering, nausea, vomiting and ileus have been observed in the postoperative period.

CONTRAINDICATION

Known sensitivity to FORANE (isoflurane, USP) or to other halogenated agents. Known or suspected genetic susceptibility to malignant
hyperthermia

Indication
Synera† is indicated for use on intact skin to provide local dermal analgesia for superficial venous access and superficial dermatological
procedures such as excision, electrodessication and shave biopsy of skin lesions ().

Side effects
Systemic adverse effects of lidocaine and tetracaine are similar in nature to those observed with other amide and ester local anesthetic agents,
including CNS excitation and/or depression (light- headedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus,
blurred or double vision, vomiting, sensations of heat, cold or numbness, twitching, tremors, convulsions, unconsciousness, respiratory depression
and arrest). Excitatory CNS reactions may be brief or not occur at all, in which case the first manifestation may be drowsiness merging into
unconsciousness. Signs of CNS toxicity may start at plasma concentrations of lidocaine as low as 1000 ng/mL. The plasma concentrations at
which tetracaine toxicity may occur are less well characterized; however, systemic toxicity with tetracaine is thought to occur with much lower
plasma concentrations compared with lidocaine. The toxicity of co-administered local anesthetics is thought to be at least additive. Cardiovascular
manifestations may include bradycardia, hypotension and cardiovascular collapse leading to arrest.

CONTRAINDICATION

Synera† is contraindicated in patients with a known history of sensitivity to lidocaine, tetracaine, or local anesthetics of the amide or ester type.
Synera is also contraindicated in patients with para-aminobenzoic acid (PABA) hypersensitivity and in patients with a known history of sensitivity to
any other component of the product.