NURSING CARE PLAN

Cues and Evidences

Nursing Diagnosis

Nursing Objectives

Nursing Intervention

Rationale

Evaluation

Subjective: Ubos lage daw iyang hemoglobin ingon ang doctor ug naa man gud pod ga gawas nga dugo diha sa iyang samad sa lagos as verbalized by the client live in partner .

Risk for infection related inadequate primary and secondary defenses (decrease hemoglobin and traumatized tissue)

LTO: At the end of 3 days the client would be able to remain free of symptoms of infection and demonstrate appropriate care of infection prone site STO: At the end of the first visit , we would be able to impart health teachings to the client and family member emphasizing the hygienic measure to prevent infection and SSx of infection of which to be aware of.

1. Observe and report sign of infection such as redness, warmth, discharge, and increase body temperature.

Objective: Restlessness Weakness Presence of dried blood on the face towel covered on her head noted V/s: Temp: 36.2 PR: 106 bpm RR: 26 cpm BP: 90/60mmHg

Prospective surveillance study for nasocomial infection on hematologyoncology units should include fever of unknown origin as the single most common and clinically important entity. Lab values are correlated with client history and provide a global view of client immune function and to develop an appropriate plan care for diagnosis. To formulate plan and nursing intervention to

Goal Fully met.

2. Note and report laboratory values.

Lab result: Hgb: 7.5g/dl Hct: 22.7 vol %

3. Observe for localized signs of infection at wounds.

prevent infection. 4. Stress proper hand hygiene by all caregiver and client. Collaborative: 1. Each client and family member the risk factors contributing to surgical wound infection, smoking and high BMI. 2. Refer client and family to social services and community resources. These are some factors associated with risk of surgical wound infections. First line defense against infections.

To obtain support in maintaining a lifestyle that increase immune function.

Cues and Evidences

Nursing Diagnosis

Nursing Objectives

Nursing Intervention

Rationale

Evaluation

Subjective: Dili gyud ko ganahan na mag pangarte kay tungid sa akong kahimtang As verbalized by the client

Objective: Restlessness Less eye to eye contact Facial discomfort noted V/s: Temp- 36.4 PR: 111bpm RR: 23cpm BP:90/70 mmHg

Self care deficit, dressing/grooming related discomfort and lack of motivation as manifested by inability to maintain appearance at a satisfactory level

LTO: At the end of 3 days the client would be able to dress and groom self optional potential. STO: At the end of the visit, the client would be able to maintain appearance at a satisfactory level and we methods to enhance strength during dressing and grooming.

1. Observe the client ability to dress and groom self through direct observation and noting specific deficits and their causes.

Presence of chronic diseases alter dressing routines, and understanding these routines can allow development of energy conservation method of dressing. Energy conservation increases activity tolerance and promotes self care. An established routine of walking and dressing provides a sense of normalcy and increase motivation to perform self care.

2. Plan activity to prevent fatigue while dressing and grooming.

3. Encourage client to dress appropriately for time of day. Perform dressing and grooming activities in a consistent sequence each day.

Collaborative: 1. Teach the client and family to dress the affected side first, then the unaffected side. 2. Teach the client and family to select clothes appropriate for season, temperature, and weather. Dressing the affected side first allows for easier manipulation of clothing.

Clients with altered sensation need to understand the factors that influence body temperature and the environment.

NURSING CARE PLAN

DRUG STUDY

Name of drug

Mechanism of action

indication

Side effects and Contraindications adverse effects CNS: headache CV: chest pain Dyspnea Contraindicated with allergy to acetaminophen.

Nursing Responsibilities Do not exceed the recommend ed dosage. Avoid using multiple preparations containing acetaminop hen. Carefully check the OTC products. Give drug with foods if GI upset occurs.

Patient teaching Do not take for longer than 10 days. Take the drug only for complaint s indicate; it is not an antiinflammat ory agent. Report rash, unusual bleeding or bruising, yellow of skin or eyes, changes in voiding patterns.

Generic name:

Reduces fever by acetaminophen acting (Paracetamol) directly on the hypothalamic Classification: heat Anti-pyretic regulating Analgesic center to (non-opioid) cause vasodilation Pracetamol and 500 mg tab sweating, every 4 hours which helps PRN for fever. dissipate heat. Site and mechanism of action unclear.

Analgesicantipyretic in patients with aspirin allergy, hemostatic disturbances, bleeding diatheses, upper GI disease, gouty arthritis.

Use cautiously GI: Hepatic with impaired toxicity and hepatic function, failure jaundice. chronic alcoholism and GU: acute pregnancy, kidney failure, lactation. renal tubular necrosis. Hypersensitivity: Rash, fever.

DRUG STUDY

Name of drug

Mechanism of action

indication

Side effects and adverse effects CNS: headache, dizziness

Contraindications

Nursing Responsibilities

Patient teaching

Generic name: Mefenamic Acid

Anti-pyretic Analgesic Antiinflammatory Classification: Activities Anti-pyretic related to Analgesic inhibition of Antiprostaglandin inflammatory synthesis; exact Mefenamic mechanism of Acid every 6 action area is hours RTC. not known.

Relief of moderate pain when therapy will not exceed 1 week.

Contraindicated to hypersensitivity to mefenamic GI: nausea, acid, aspirin GI pain, allergy, and as diarrhea, treatment of vomiting preoperative pain with coronary Other: artery bypass peripheral grafting. edema Use cautiously in asthmatic patient, renal or hepatic impairment, patient has a heart failure and in the pregnant and breastfeeding woman.

Give with milk or food to decrease GI upset. Monitor the level of consciousn ess.

Report any unusual happenin g.

DRUG STUDY

Name of drug

Mechanism of action

indication

Side effects and adverse effects

Contraindications

Nursing Responsibilities

Patient teaching

Generic name: Cefazolin

Treat a wide variety of bacterial Classification: infections. It Cephalosporin may also be antibiotic used before and during Cefazolin IVTT certain now ANST (-) surgeries to help prevent infections.

It will not work with viral infections. Unnecessary use or misuse of any antibiotic can lead to its decreased effectiveness.

Loss of Contraindicated appetite; mild with diarrhea; hypersensitivity nausea; of cephalosporin stomach agents. cramps; Use cautiously in vomiting. children younger than 1 month or younger than 10 years old, be cautious also to the elderly for they may be more sensitive to its effects.

any Check level Report unusual of consciousn happening. ess. Monitor vital signs.