URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

DRUG STUDY
Name of Student: BUENCONSEJO, JIRAH Year Level and Group: BSN 3 – GROUP A

Affiliating Agency/Area: ___________________________________________ Month/Year of Exposure: ______________________

DRUG CLASSIFICATION INDICATION SIDE EFFECTS ADVERSE EFFECTS NURSING RESPONSIBILITIES

Treatment of the  diarrhea/loose  diarrhea or loose - Assess patient for infection (vital signs;
following infections due stools, stools, appearance of wound, sputum, urine, and
Generic Name: - Class of
to susceptible organisms:  abdominal pain,  nausea, stool; WBC) at beginning of and throughout
medications
Azithromycin and  abdominal pain, therapy.
called macrolide Upper respiratory tract
 nausea.  stomach upset, - Obtain specimens for culture and sensitivity
antibiotics. It infections, including
 vomiting, before initiating therapy. First dose may be
works by streptococcal pharyngitis,
Brand Name:  constipation, given before receiving results.
stopping the acute bacterial
 dizziness, - Observe for signs and symptoms of
ZITHROMAX growth of exacerbations of chronic
 tiredness, anaphylaxis (rash, pruritus, laryngeal edema,
bacteria. bronchitis and tonsillitis,
 headache, wheezing). Notify health care professional
Antibiotics such
Lower respiratory tract  vaginal immediately if these occur.
Dosage: as azithromycin
infections, including itching or dischar - Assess patient for skin rash frequently during
will not work for
bronchitis and ge, therapy. Discontinue azithromycin at first
500 mg colds, flu, or
pneumonia,  nervousness, sign of rash; may be life-threatening. Stevens-
other viral
250 mg  sleep problems Johnson syndrome or toxic epidermal
infections. Acute otitis media,
(insomnia), necrolysis may develop. Treat
Route:
Skin and skin structure  skin rash or itchin symptomatically; may recur once treatment
PO infections, g, is stopped.
 ringing in the
Frequency: Nongonococcal urethritis,
ears/hearing
cervicitis, gonorrhea, and
q.d in day 1 followed problems,
chancroid.
by 250 mg q.d. on  or
days 2-5 Prevention of decreased sense 
disseminated Mycobacte of taste or smell.
rium avium complex
 (MAC) infection in
patients with advanced
HIV infection.

MECHANISM OF ACTION CONTRAINDICATIONS

- Azithromycin - Contraindicated
binds to the 23S in patients with
rRNA of the known
bacterial 50S hypersensitivity
ribosomal to azithromycin,
subunit. It stops or any other
bacterial protein macrolide and in
synthesis by hepatic disease.
inhibiting the Use with caution
transpeptidation/ in renal failure.
translocation
step of protein
synthesis and by
inhibiting the
assembly of the
50S ribosomal
subunit.

Checked by: _________________________________ Date: ____________________

Clinical Instructor’s Name and Signature

URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

NURSING CARE PLAN (NCP)

Name of Student: BUENCONSEJO, JIRAH Year Level and Group: 2nd YEAR GROUP A

Affiliating Agency/Area: ___________________________________________ Month/Year of Exposure: ________________________

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

(at least 10)

Subjective: Problem, Etiology, Short Term Goal: Independent: Short Term Goal Evaluation
Signs S.M.A.R.T. + Evidence  Assessment
“Nahihirapan po (P.E.S.) format - Maintaining patent airway is After 1 hour of nursing
akong huminga tapos After 1 hour of nursing - Assess airway for patency. always the first priority, especially intervention, the goal was fully
ubo po ako ng ubo at Ineffective airway intervention, the: in cases like trauma, acute met. The patient:
maplema” as clearance related to neurological decompensation, or
verbalized by the pneumonia as evidenced - Patient will cardiac arrest. - Maintained clear, open
patient. by coughing with yellow maintain clear, airways as evidence by
sputum open airways as - Note for changes in HR, BP, and normal breath sounds,
evidence by -Monitor Vital Sign temperature. Increased work of normal rate and depth of
normal breath breathing can lead to tachycardia respirations, and ability to
sounds, normal and hypertension. Retained effectively cough up
rate and depth of secretions or atelectasis may be a secretions after
respirations, and sign of an existing infection or treatments and deep
ability to inflammatory process manifested breaths.
effectively cough by a fever or increased - Demonstrated increased
up secretions after temperature. air exchange
treatments and
deep breaths. -Assess respirations. Note quality, -A change in the usual respiration
- Patient will rate, pattern, depth, flaring of may mean respiratory
demonstrate nostrils, dyspnea on exertion, compromise. An increase in
increased air evidence of splinting, use of respiratory rate and rhythm may
exchange accessory muscles, and position be a compensatory response to
for breathing. airway obstruction.

-Note cough for efficacy and -Coughing is a mechanism for

productivity. clearing secretions. An ineffective
cough compromises airway
clearance and prevents mucus
Objective: INFERENCE Long Term Goal: from being expelled. Respiratory Long term Goal Evaluation
(at least 5) Scientific Explanation S.M.A.R.T.+ Evidence muscle fatigue, severe
(Diagram Form) bronchospasm, or thick and After 1 day of nursing
- Fatigue After 1 day of nursing tenacious secretions are possible intervention, the goal was fully
- Productive Pneumonia bacteria intervention, the: causes of ineffective cough. met. The client:
cough with invading the lung
yellow sputum parenchyma - Patient will -Assess for abdominal or thoracic -Pain can result in shallow - Recognized the
- Worsening recognize the pain. breathing and an ineffective significance of changes in
dyspnea significance of cough. sputum to include color,
- Decreased changes in sputum character, amount, and
activity Producing inflammatory  Therapeutic
to include color, odor.
tolerance process -Abnormal breath sounds can be
character, amount, - Identified and avoid
- Fever greater -Auscultate lungs for presence of heard as fluid and mucus
and odor. specific factors that inhibit
than 39.4 C in normal or adventitious breath accumulate. This may indicate
- Patient will identify effective airway
4 days may cause ineffective and avoid specific sounds, as in the following: ineffective airway clearance. clearance.
cough factors that inhibit
effective airway -These may indicate presence of
clearance. • Decreased or absent breath a mucous plug or other major
sounds obstruction.
compromises airway - This may indicate partial airway
clearance and prevents • Wheezing obstruction or resistance.
mucus from being - This may indicate presence of
expelled. • Coarse crackles secretions along larger airways.

-Use pulse oximetry to monitor -Pulse oximetry is used to detect

oxygen saturation; assess arterial changes in oxygenation. Oxygen
Ineffective airway blood gases (ABGs) saturation should be maintained
clearance at 90% or greater. Alteration in
ABGS may result in increased
pulmonary secretions and
respiratory fatigue.
 Educative

-Review patient’s understanding -Patient teaching will vary

of disease process. depending on the acute or chronic
disease condition as well as the
patient’s cognitive level.

-Advise the pt. to rest and limit -To promote lung expansion and
activities. decrease respiratory effort.

Dependent:
 Assessment
-To ensure the client’s safety
Check the doctor’s order upon administering medications.

 Therapeutic
-To treat the infection.
-Administer antibiotics as
prescribed.

 Educative

-Explain to the patient the good -To have knowledge about the
effects and adverse effects of administered medication.
medication.

Interdependent/Collaborative

 Assessment

-Review other pertinent -To reveal and prevent any

laboratory data (e.g., ABGs, further complications.
complete
 blood count (CBC)); chest x-rays.

 Therapeutic

- Submit a sputum specimen for

culture and sensitivity testing, as
appropriate.
 Educative
- Know if patient considers use of
herbal treatment (e.g., echinacea
for URTI, goldenseal for
- Labored breathing may be a
sign of respiratory infection that
needs an appropriate treatment
of antibiotics.
- Drug interactions with
prescribed medications and
contraindications need to be

Checked by: Date: ___________________

URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

FDAR CHART

Name of Student: BUENCONSEJO, JIRAH Year Level and Group: 2ND YEAR – GROUP A
 DATE/TIME FOCUS DATA, ACTION AND RESPONSE

DATA:
05/26/2021 Ineffective airway clearance - “Nahihirapan po akong huminga tapos ubo po ako ng ubo at maplema” as verbalized
by the patient.
- Fatigue
- Productive cough with yellow sputum
0800 - Worsening dyspnea
- Decreased activity tolerance
- Fever greater than 39.4 C in 4 days

ACTION:

- Assess airway for patency.

- Monitor Vital Sign
- Assess respirations. Note quality, rate, pattern, depth, flaring of nostrils, dyspnea on
exertion, evidence of splinting, use of accessory muscles, and position for breathing.
- Auscultate lungs for presence of normal or adventitious breath sounds
- Administer antibiotics as prescribed.
- Note cough for efficacy and productivity.
- Submit a sputum specimen for culture and sensitivity testing, as appropriate.

RESOLUTION:

- The client maintained clear, open airways as evidence by normal breath sounds,
normal rate and depth of respirations, and ability to effectively cough up secretions
after treatments and deep breaths.
0400
- Demonstrated increased air exchange