ASSESSME NURSIN PLANNING IMPLEMENTAT EVALUATIO

NT G Objective of Intervention Rationale ION N

DIAGNO Care
SIS
Subjective Fatigue At the end of Assess the To treat the Patient has a low At the end of 1
Cues: related to 1 hour of cause of approprtiate intake (190 kcal); hour of patient
the patient fatigue and source of Vital signs were intervention,
- “mga un increased intervention, monitor vital fatigue and recorded and the patient was
semana ya se basal the patient signs plan further yielded results of able to:
disuyu metabolis will be able to: regularly. interventions elevated PR (>125
kalentura m of the  the bpm) and RR (>25  The
sir” as body patient bpm) patient
verbalized secondary reports felt
by the to This help in Client was more
relief
Advice the meeting the reminded to eat
mother of inflammat of comfort
client to nutritional more frequently
the patient ory fatigue able and
maintain needs of the and encouraged to
- “Nukere se process as  Patient is
balanced body that will take bigger
le sir mobe evidenced exhibit relived
nutritionand or help relieve amounts of food.
gayot kay by s because
to take small fatigue
dwele daw se decreased capacit of the
yet frequent
new
disuyu pyes” capacity y for feeds. To improve Patient was also linen
as verbalized for physic hydration and encouraged to  Patient
by the physical al meet the drink milk and lots had a
mother of activity activit Advise the metabolic of water as thy much
the patient y client to drink needs of the physician advised more
pointing at  The lots of fluids body to do so as well. time
the left thigh patient and fruit juices resting,
of her child. verbali The patient as taking
Objective zes asked to move frequent
Cues: This is to more frequently
underst naps to
allow and and have her right
anding restore
- V/S: Encourage the support
of non- leg lifted a few energy.
 RR: client to capacity to do
pharm times.  Capacit
38 perform Range physical
acologi y for
bpm of Motion activity
c physical
 PR: (ROM) The client’s linen
metho activity
126 exercises in was changed into a
ds to was
bpm the bed new one and had a
decrea partially
- Weak & Sleep and rest cleaner linen.
se met;
Fragile Provide a are crucial in
fatigue client
- comfortable decreasing
moved
Experiences clean bed metabolic rate,
her arms
recurrent without thus relieving and
fever wrinkles and or lessens the head but
- patient has promote sleep body’s fatigue still
a swollen left and rest. refuses
thigh to move
- Malaise her left
- Diaphoresis leg
- CBC: because
 RBC of the
– 39 pain.
(lower  Patient
ed) nods her
 Hgb - head as
98 techniqu
(lower es are
ed) taught
 Hct – and
0.31 verbaliz
(lower ed to her
ed) and to
History: her
 mother.
- Was no
longer
walking even
prior to
admission

ASSESSME NURSIN PLANNING IMPLEMENTAT EVALUATI

NT G Objective of Intervention Rationale ION ON
DIAGNO Care
SIS
Subjective Deficient At the end of 30 Assess the To educate The patient is a At the end of
knowledge minutes of client’s the client in Zamboangueño 30 minutes of
Cues:
related to patient language and their own and speaks patient
the disease intervention, the ability to language and chavacano and intervention,
condition patient will be follow at their own adjusted wording the patient
- “Nusabe
as able to: instructions level of of questions. was able to:
gane yo sir, evidenced and include understanding  The
by queries  Cooperat family mother
kay dol
and e with the members as of the
hinde pa uncertaint following well as patient
y of nursing significant The patient was appear
man sila ta To prevent also urged to drink
interventio interventi others in ed
puede saka n ons teaching dryness and plenty of water interest
maintain and milk as it is ed and
cosa el hydration; also recommended
problema  Gian Advise the thus reducing by the doctor. listens
knowledg client to drink fever well to
del dimiyo The mother of the
e more oral the
anak” as regarding fluids, fruit To prevent patient was instruc
disease juices, or diarrhea and encouraged to give tions
verbalized dysentery the appetite
condition coconut water given
by the , from gastric booster given by  Mother
complicat irritation and the physician and tried to
mother of Advise the maintain reminded that hot
ions, and buy
the patient treatment client toeat a nutrition and spicy foods alcohol
modalitie soft and bland could trigger pain after
- “basta ya diet, andavoid (gastric irritation).
s getting
abla lang sila hot and spicy the
food until This is to The mother and medici
sir kay dale recovery prevent also the patient ne of
lang yo este  Shows further spread was reminded to the
interest of typhoid use alcohol before patient
toma dos on infection on and after toileting  Patient
beses na un further family and eating.
Educate the nods
instructio members as Washing hands are
dia” client on and
ns and well as others also advised to the
washing hands follow
referring to interventi mother as she is s her
ons before and after the primary
milk as eating or mother
watcher of the as they
toileting and patient and the one
verbalized use
include family who helps in
by the members alcohol
This helps in feeding the patient. before
mother of avoiding and
further The patient and the after
the patient mother are advised
infection eating.
from S. typhi to wash the fruits
that can like apples eaten
Objective
Cues: Advise the worsen the by the patient and
family member condition of to always have the
- Illiterate of and the patient the patient. utensils washed
regarding food before and after
the disease hygiene to eating. Different
conditions wash utensils for the
vegetables, mother and the
- Unease of fruits, and patient was also
the meats strictly advised as
thoroughly they use the same
complicatio before cooking utensils.
n of the and cook food
well before
disease eating
- Need for
environment
al sanitation
and isolation
protocols

History:

- Patient
plays with
her cousin
along the
city streets
unsupervise
d prior to
admission
and
appearance
of signs and
symptoms
- History of
UTI and
Pneumonia
References:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans : guidelines for individualizing client care

across the life span (10th ed.). F.A. Davis.

Swearingen, P. L., & Wright, J. D. (2019). All-in-one nursing care planning resource : medical-surgical, pediatric,

maternity, and psychiatric-mental health (5th ed.). Elsevier.

GENERIC NAME: MECHANISM OF SIDE

NURSING
OXACILLIN SODIUM ACTION: EFFECTS/ADVERSE
RESPONSIBILITY
REACTION
Semisynthetic, acid-
stable, penicillinase- Body as a
resistant isoxazolyl
 penicillin. Whole: Thrombophlebitis
(IV therapy), superinfections, Assessment & Drug
BRAND NAME: Bactocill, INDICATION: wheezing, sneezing, Effects
Prostaphlin
Primarily, infections fever, anaphylaxis.
caused by GI: Nausea,  · Inquire with the
vomiting,
penicillinase- patient about
DRUG ILLUSTRATION: flatulence, diarrhea, hepatoc
producing hypersensitivity
ellular dysfunction (elevated
staphylococci and AST, ALT, hepatitis). reactions to
penicillin-resistant penicillins,
staphylococci. May be Hematologic: Eosinophilia, cephalosporins, and
used to initiate therapy leukopenia, other allergens prior
in suspected thrombocytopenia, to the first dose.
staphylococcal granulocytopenia, agranulocy  • Lab tests: CBC
infections pending tosis; neutropenia (reported with differential,
culture and sensitivity in children). platelet count, and
test results. As with urinalysis on a
Skin: Pruritus, rash, urticaria. regular basis.
other penicillins,
serum concentrations Urogenital: Interstitial  • Hepatic
are enhanced by nephritis, transient hematuria, dysfunction
concurrent use of albuminuria, azotemia (perhaps due to
probenecid. (newborns and infants on hypersensitivity) has
high doses). been linked to IV
CLASSIFICATION CONTRAINDICATI oxacillin; it is
ON: reversible with
ANTIINFECTIVE;
medication
ANTIBIOTIC PENICILLIN; Hypersensitivity to
withdrawal.
ANTISTAPHYLOCOCCAL penicillins or
Symptoms such as
PENICILLIN cephalosporins. Safe
hives, rash, fever,
use during pregnancy
DOSAGE/FREQUENCY/ nausea, vomiting,
(category B) is not
ROUTE: abdominal
established.
discomfort,
- 700 mg IV q6r anorexia, lethargy,
 and jaundice should
be reported
immediately if they
mirror viral hepatitis
or general
indications of
hypersensitivity
(with dark yellow to
brown urine, light-
colored or clay-
colored stools,
pruritus).
 • Withhold the next
medicine dose and
notify the doctor if
hypersensitivity
reactions or
superinfections
occur.

Patient & Family

Education

 Take oral
medication
continuously and do
not miss a dose.
Unless otherwise
ordered by your
doctor, take all of
the medication given
even if you feel
 better.
 Do not breastfeed
while taking this
medication without
first consulting your
doctor.

GENERIC NAME: MECHANISM OF SIDE

Vancomycin ACTION: EFFECTS/ADVERS NURSING RESPONSIBILITY
E REACTION
Inhibits bacterial cell-
wall synthesis, blocks CNS: Headache
glycopeptides CV: Cardiac arrest,
vascular collapse Assessment & Drug Effects
BRAND NAME: Vancocin INDICATION: (rare), hypotension,
Systemic: Treatment peripheral edema  Monitor BP and heart rate
of infections caused EENT: Ototoxicity, continuously through period
DRUG ILLUSTRATION: by staphylococcal, permanent deafness, of drug administration.
streptococcal spp. tinnitus, nystagmus  Lab tests: Monitor
bacteria. GI: Nausea, urinalysis, kidney & liver
pseudomembranous functions, and hematologic
PO: Treatment of C. colitis studies periodically.
difficile–associated GU: Nephrotoxicity,  Monitor serial tests of
diarrhea and treatment increased BUN, vancomycin blood levels
of enterocolitis caused creatinine, albumin, (peak and trough) in
by S. aureus fatal uremia patients with borderline
(including MRSA). HEMA: Leukopenia, kidney function, in infants
OFFLABEL: eosinophilia, and neonates, and in
Treatment of neutropenia patients >60 y.
infections caused by INTEG: Chills,  Assess hearing. Drug may
 gram-positive fever, rash, cause damage to auditory
organisms in pts with thrombophlebitis at branch (not vestibular
serious allergies to inj site, urticaria, branch) of eighth cranial
beta-lactam pruritus, necrosis nerve, with consequent
antibiotics; treatment (red-man syndrome), deafness, which may be
of beta-lactam– skin/subcutaneous permanent.
resistant gram-positive tissue disorders  Be aware that serum levels
infections. Surgical MS: Back pain of 60–80 mcg/mL are
prophylaxis, treatment RESP: Wheezing, associated with ototoxicity.
of prosthetic joint dyspnea Tinnitus and high tone
infection. SYST: Anaphylaxis, hearing loss may precede
superinfection deafness, which may
CLASSIFICATION CONTRAINDICATI progress even after drug is
ON: withdrawn. Older adults and
ANTIINFECTIVE;
ANTIBIOTIC Hypersensitivity to those on high doses are
this product or corn especially susceptible.
DOSAGE/FREQUENCY/  Monitor I&O: Report
ROUTE: changes in I&O ratio and
pattern. Oliguria or cloudy
-300 mg IV q6r
or pink urine may be a sign
of nephrotoxicity (also
manifested by transient
elevations in BUN,
albumin, and hyaline and
granular casts in urine).

Patient & Family Education

 Notify physician promptly

of ringing in ears.
 Adhere to drug regimen
(i.e., do not increase,
 decrease, or interrupt
dosage. The full course of
prescribed drug therapy
must be completed).
 Do not breast feed while
taking this drug.

References:

Kizior, R. J., & Hodgson, K. (2021). Saunders Nursing Drug Handbook 2022. Saunders.

Skidmore-Roth, L. (2018). Mosby’s 2018 nursing drug reference. Elsevier.

Pathophysiology of Typhoid Fever

Invade small intestine mucosa and enter the

bloodstream

Taken up by macrophage & transported to

regional lymph node

S. Typhi multiply in the intestinal lymphoid

tissue

Intact with enterocytes & M cells (ileal Peyer's

patches) during 3 weeks of incubation period
(diarrhea occurs)

End of incubation period, bacilli enters

bloodstream (Bacteremia phase) - This is
where typhoid fever onset starts

Bacteria invade the gallbladder, biliary

system, and lymphatic tissue of the bowel and
multiply in high number

Then pass into the intestinal tract and

becomes a stool

Resolved through administration of antibiotics

- Vancomycin 300 mg IV q6r
- Oxacillin 700 mg IV q6r
- Pen-G 1.4 IU q6r