ASSESSMENT Nursing Diagnosis Rationale Expected Outcome Nursing Intervention Justification Evaluation

ENTRY OF THE MICROORGANISM TO

Subjective: “INEFFECTIVE After 4 days of A. Independent After 4 days of
NASAL
“Nabudlayan ko AIRWAY CLEARANCE Nursing nursing intervention
mag ginhawa labi R/T INCREASED INVASION OF THE RESPIRATORY
Intervention, the >Asses the rate or depth >Tacypnea,shallow I was able to:
nagid ko gina ubo SYSTEM
SPUTUM client will be able of respirations and chest respiration and asymmetric GOAL MET:
ako”
PRODUCTION AS ACTIVATION OF THE IMMUNE to: movement. chest movement are present
RESPONSE (COUGH)
Objective: EVIDENCE BY because of discomfort. >Maintain
-weight loss PRESENCE OF INEEFECTIVE IMMUNE RESPONSE >Maintain or To promote chest expansion respiratory function
PRODUCTIVE COUGH RESULT TO Improve >Elevate the head of the bed >of lung segments and of my patient as
-poor skin turgor
-conscious and WITH GREENISH INVADING LUNG PRANCHYMA respiratory and change position mobilization and evidence by
coherent SPUTUM.” function. frequently. expectoration of secretions negative DOB.
-body weakness RELEASE OF ENDOTOXINS AND
EXOTOXINS
to clear the airway.
-loss of appetite >Demonstrate >Suction as indicated >to stimulate cough or >The client was able
MASSIVE INFLAMATION behaviours to mechanically clear the to demonstrate
Laboratory: (PNEUMONIA)
>RBS= 178mg/dl SOUCRE: NANDA achieve airway B.Collaborative airway. correct deep
(N.V=65-130mg/dl) ALTERED GAS EXCHANGE clearance. breathing exercise.
>Chest X-ray revealed
multiple abscess in the >administer medication as >Aids in the reduction of
INCREASE SPUTUM PRODUCTION
left side of the lungs. >Maintain stable indicated, expectorans or brochospasm and >the client was able
>Hemoglobin=11.3gms INEFFECTIVE AIRWAY CLEARANCE vital signs analgesics. mobilization of secretions to verbalized
(N.V=14-16gms)
>erythrocyte= 34% and to improve cough effort. understanding aboyt
(N.V=42-50%) DIFFICULTY OF BREATHING >Provide >Provide supplemental fluids >To replace losses of fluids the present health
>leukocyte=11800cum
m
information about ( I.V and Humidified oxygen) in the body and humidified condition.
(N.V=5,000- Source: John Hapkins Book the disease process oxygen is use to improve
10,000cumm) Medical Surgical Book of prognosis and breathing pattern. >The client has a
>platelet
count=200,000cumm treatment. >Monitor serial chest x- >tTo follow up the progress stable vital signs.
(N.V=150,000- rays,ABG’s,pulse oxymetry. and effects of disease to
400,000cumm) facilitates necessary
>Lymphocytes= 26%
(N.V=22-40%) SOURCE: NANDA alteration in therapy.
 B.NURSING CARE PLAN

Drug Study
GENERIC BRAND CLASSIFICATIO DOSAGE AND INDICATION MECHANISM OF SIDE EFFECTS NURSING RESPONSIBLITIES
NAME NAME N ROUTE ACTION

>amoxicilli >Novomoxin >Antibiotic >500mg PO every >infections due to >Bactericidal: >CNS:Lethargy,seizures,hallucination. >Assessment:
Haemophilus influenza Inhibits synthesis of cell wall >GI: Glossitis, Stomatitis ,Gastritis ,  History-allergies to
n 8 hours. and Streptococcus of sensitive organism causing vomiting, diarrhea, abdominal pain. penicillin.caphalosporin
trihydrate Pneuminiae. cell death. >GU: Nephritis  Physical- skin color, lesion,
>Hematologic: bowe sound
Anemia,Thrombocytopenea,neutropen >Teaching point:
ia,bleeding  Take this drug arounf the
>Hypersensitivity: clock.
Rash, fever, wheezing  Take the full course of
therapy
 This antibiotic is specific
problem and should not be
used to self treat infections.
>Zithromax >Macrolide >10mg PO as a >treatment of mild to >Bacteriostatic or bactericidal >CNS; Dizziness, headache, fatigue >Assessment:
>azithromy Antibiotic single dose on the moderate community in susceptible bacteria. >GI: Diarrhea, abdominal pain, nausea  Hypersensitivity to
cin first dat then 5 mg acquired pneumonia vomiting. azithromycin
PO on 2-5 days  Site of infections,skin color,
bowel sounds
>Teaching points:
 Take the full course of
therapy.
 Do not take with antacids.
 Report immediately of severe
or watery diarrhea and severe
vomiting