PROBLEM LIST

Name: P. J. L. S. Chief complains: Fever, cough, LBM, vomiting

Age: 11 years old Diagnosis: Acute Gastroenteritis with moderate dehydration
Ward: Medical Ward
Attending physician: Dr. J

PHYSIOLOGIC BEHAVIORAL
CUES PROBLEM RANK Actual Potential Actual Potential
Subjective Cues: Electrolyte 1 Diarrhea may be Risk for deficient Fluid Ineffective role Risk for
Imbalance related to toxins, volume possibly performance powerlessness
“ang iyang kalibanga possibly evidenced by evidenced by
kay kalit ra sad, wala at least three loose, excessive losses.
me kabalo kong unsa liquid stools a day.
iyahang nakaon pero
kalit ra sad” as
verbalized by pt. Difficulty 2 Ineffective breathing Risk for shock related Fatigue related to Risk for activity
grandfather Breathing pattern related to to hypoxia. increase in respiratory intolerance related
hypoxia as evidenced exertion as evidenced to generalize body
“Ginahapo man na by respiratory rate: 32 by rapid shallow weakness.
akoang apo, galisud cpm breathing.
siya og ginhawa” as
verbalized by the pt.
grandfather. Cough 3 Ineffective airway Risk for recent viral Self-care deficit may be Risk for ineffective
clearance related to respiratory infection Related to tiredness, as role performance
retained secretions in evidenced by reports of possibly evidenced
Objective Cues: the bronchi secondary inability to perform by health alterations
> Respiratory Rate: 25 to pneumonia. desired ADLs.
cpm

> guarding behavior

> appears weak
 NURSING CARE PLAN

Name: P. J. L. S. Chief complains: Fever, cough, LBM, vomiting

Age: 11 years old Diagnosis: Acute Gastroenteritis with moderate dehydration
Ward: Medical Ward
Attending physician: Dr.

ASSESSMENT NURSING PATHOPHYSIOLOGY EXPECTED OUTCOME NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective cues: Diarrhea may Food factors after 8 hours of nursing INDEPENDENT: After8 hours of
be related to intervention, the patient  Note the  Diarrhea in an nursing intervention,
“ang iyang toxins, will be able to: Client’s age. infant or young the goal was partially
kalibanga kay possibly child and older met. The patient was
kalit ra sad, evidenced by  Reestablish and or debilitated able to:
wala me kabalo at least three maintain normal client can cause
kong unsa loose, liquid pattern of bowel complications of  Established
iyahang nakaon stools a day. functioning. dehydration and and
The toxins cannot
pero kalit ra electrolyte maintained
be absorbed
sad” as  Demonstrate imbalance. normal pattern
verbalized by appropriate of bowel
 Note reports
pt. grandfather behavior to  Pain is often functioning.
of abdominal
assist with present with
or rectal pain
resolution of inflammatory  Still feel the
associated
causative bowel disease, pain on his
with episodes.
Hyper-peristaltic factors. irritable bowel anus area with
Decrease the syndrome, and a pain scale of
Objective Cues:
chance intestine to mesenteric 6.
> guarding
behavior absorb food. ischema.
> appears weak DEPENDENT:
 Antibiotics to
treat diarrhea.
 COLLABORATION:
Electrolyte  Collaborate  Collaboration
Imbalance with the with the
physician or physician and
other health other health
care Provider care provider
will help
improve the
overall health of
the patient.
 DRUG STUDY

Name: P. J. L. S. Chief complains: Fever, cough, LBM, vomiting

Age: 11 years old Diagnosis: Acute Gastroenteritis with moderate dehydration
Ward: Medical Ward
Attending physician: Dr. J

NAME OF THE DRUG CLASSIFICATION MODE OF ACTION INDICATION CONTRAINDICATION SIDE EFFECT NURSING REPOSIBILITIES
Generic Name: Antiulcer drugs, Inhibits proton Short-term Contraindicated in CNS: asthenia,  Assess patients for signs
Omeprazole PPIs pump activity by treatment of patients dizziness, and symptoms of
binding to active benign hypersensitive to headache. cyanocobalamin
Brand Name: hydrogen- gastric ulcers. drugs or its deficiency (weakness,
Omeprazole potassium components. GI: abdominal heart palpitations,
Magnesium adenosine pain, constipation, dyspnea, paresthesia,
triphosphatase, diarrhea, pale skin, smooth tongue,
located at secretory flatulence, nausea, CNS changes, loss of
Route and Dosage: surface of gastric vomiting, acid appetite)
25 mg IVTT parietal cells, to regurgitation.
suppress gastric  Monitor patient for signs
Frequency: acid secretion. Muscoskeletal: and symptoms of acute
back pain, interstitial nephritis.
weakness.
 Discontinue drug if signs
Respiratory: and symptoms of
Cough, URI cutaneous lupus
erythematosus or SLE
Skin: rash develop; refer patient to
the appropriate specialist
for evaluation.
 NAME OF THE CLASSIFICATION MODE OF INDICATION CONTRAINDICAT SIDE EFFECT NURSING REPOSIBILITIES
DRUG ACTION ION
Generic Name: Antibiotics, second- Inhibits cell-wall  Serious lower  Contraind CV: phlebitis,  Monitor patient
Cefuroxime generation synthesis, respiratory icated in thrombophlebitis. for sign and
cephalosporins promoting tract patients symptoms of
Brand Name: osmotic infection, UTI, hypersen GI: diarrhea, superinfection
Cefuroxime instability; skin or skin- sitive to pseudomembranous and diarrhea and
sodium usually structure drug or colitis, nausea, anorexia, treat
bactericidal. infection, other vomiting. appropriately.
Route and Dosage: bone or joint cephalosp
750 mg IVTT Q8h infection, orins. Hematologic: hemolytic
septicemia, anemia,
Frequency: meningitis, thrombocytopenia,  Don’t confuse
4 am-12 pm -8 pm and transient neutropenia, drug with other
gonorrhea. eosinophilia. cephalosporins
that sound alike.
Skin: maculopapular and
erythematous rashes,
urticaria, pain,
induration, sterile
abscesses, temperature
elevation, tissue
sloughing at IM injection
site.

Other: anaphylaxis,
hypersensitivity
reactions, serum
sickness.
 NAME OF THE CLASSIFICATION MODE OF INDICATION CONTRAINDICATIO SIDE EFFECT NURSING REPOSIBILITIES
DRUG ACTION N
Generic Name:
Albuterol Bronchodilator Relaxes the Use in the routine Patients with a  Trembling,  Assess lung
(therapeutic); smooth muscles management of history of particularly in sounds, PR and
Brand Name: adrenergics of all airways, chronic hypersensitivity to the hands. BP before drug
Salbutamol (pharmacologic) from the trachea bronchospasm any of its  Nervous administration
to the terminal unresponsive to components. tension. and during peak
Route and Dosage: bronchioles conventional  Headaches. of medication.
therapy, and in the  Suddenly
treatment of acute noticeable  Observe fore
severe asthma heartbeats paradoxical
Frequency: spasm and
(palpitations)
 Muscle withhold
cramps. medication and
notify physician if
condition occurs.

 Administer PO
medications with
meals to
minimize gastric
irritation.
 NAME OF THE CLASSIFICATIO MODE OF ACTION INDICATIO CONTRAINDICATI SIDE EFFECT NURSING REPOSIBILITIES
DRUG N N ON
Generic Name: Analgesics, Thought to produce Mild pain Contraindicated in CNS: agitation (IV), anxiety,  Assess patient fever
Paracetamol Muscle analgesia by or fever. patients fatigue, headache, insomnia, or pain: type of
Relaxants inhibiting hypersensitive to pyrexia. pain, location,
Brand Name: prostaglandin and drug. IV form is
intensity, duration,
Calpol other substances contraindicated in CV: HTN, hy- potension, peripheral
that sensitize pain patients with edema, periorbital edema, temperature, and
Route and receptors. Drug may severe hepatic tachycardia (IV). diaphoresis.
Dosage: relieve fever impairment or  Assess allergic
through central severe active liver GI: nausea, vom- iting, abdominal reactions: rash,
IVTT 250 mg action in the disease. pain, diarrhea, constipa- tion (IV). urticaria; if these
Q4h hypothalamic heat-
GU: oliguria (IV). occur, drug may
regulation center.
have to be
Frequency: Hematologic: hemolytic anemia, discontinued.
8 am- 12 pm- 4 leukopenia, neutropenia,  Teach patient to
pm- 8 pm pancytopenia, anemia. recognize signs of
chronic overdose:
Hepatic: jaundice.
bleeding, bruising,
 Metabolic: hypoalbuminemia (IV), malaise, fever, sore
hypo- glycemia, hypokalemia, throat.
hypervolemia, hypo- magnesemia,  Tell patient to notify
hypophosphatemia (IV). Mus-
prescriber for
culoskeletal: muscle spasms,
extremity pain (IV). pain/fever lasting
for more than 3
days.
Skin: rash, urticaria; infusion-site
pain (IV), pruritus.

NAME OF THE CLASSIFICA MODE OF ACTION INDICATIO CONTRAINDICATIO SIDE EFFECT NURSING REPOSIBILITIES
DRUG TION N N
Generic Name:
Azithromycin Macrolide inhibition of bacterial Used to Patients with a  Being sick  Monitor patient for
antibiotics protein synthesis, treat history of severe (vomiting) superinfection. Rug may
Brand Name: inhibition of certain hypersensitivity to cause overgrowth of
 Losing your
proinflammatory bacterial azithromycin or nonsusceptible bacteria or
Route and Dosage: appetite
cytokine production, infections, another macrolide fungi.
6.5 mL PO OD inhibition of neutrophil such as antimicrobial  Headaches
infestation, and pneumonia  Diarrhea  Monitor patient for allergic
macrophage polarization . and skin reactions.
Frequency: alteration Discontinue drug if reaction
occurs.

 Monitor patient for jaundice.

Discontinue immediately if
signs and symptoms occur.
 NAME OF THE CLASSIFICATION MODE OF INDICATION CONTRAINDICATION SIDE EFFECT NURSING REPOSIBILITIES
DRUG ACTION
Generic Name:
Ceftriaxone Antibacterial Binds to Treatment of History of Frequent:  Assess oral cavity for
bacterial cell susceptible hypersensitivity/anap Discomfort with IM white patches on
Brand Name: membranes, infections due hylactic reaction to administration, oral mucous membranes,
inhibits cell to gram-negative cefTRIAXone, candidiasis (thrush), tongue (thrush).
Route and Dosage: wall aerobic cephalosporins. mild diarrhea, mild
2 g IV drip Q24hrs synthesis. organisms, abdominal cramping,  Monitor daily pattern of
some gram- vaginal candidiasis. bowel activity, stool
positive consistency. Mild GI
organisms, Occasional: Nausea, effects may be tolerable
Frequency: serum sickness–like (increasing severity may
including
respiratory tract, reaction (fever, joint indicate onset of
GU tract pain; usually occurs antibiotic-associated
after second course colitis).
of therapy and
resolves after drug is  Monitor I&O, renal
discontinued). function tests for
nephrotoxicity, CBC.
Rare: Allergic
reaction (rash,  Be alert for
pruritus, urticaria), superinfection: fever,
thrombophlebitis vomiting, diarrhea,
(pain, redness, anal/genital pruritus,
swelling at injection oral mucosal changes
site). (ulceration, pain,
erythema).
 LABORATORY

Name: P. J. L. S. Chief complains: Fever, cough, LBM, vomiting

Age: 11 years old Diagnosis: Acute Gastroenteritis with moderate dehydration
Ward: Medical Ward
Attending physician: Dr. J

TEST (s) RESULT (s) REFERENCE VALUE (S) IMPLICATION NURISNG CONSIDERATION

Hematocrit 0.39 L Male: 0.40-0.54 g/dL Indicated an insufficient Encouraged patient to eat
Female: supply of healthy red blood foods that are high in protein
cell. and iron.
 DISCHARGE PLAN

Name: P. J. L. S. Chief complains: Fever, cough, LBM, vomiting

Age: 11 years old Diagnosis: Acute Gastroenteritis with moderate dehydration
Ward: Medical Ward
Attending physician: Dr. J

Problem Health Teaching Rationale

Hygiene: Electrolyte Imbalance PROMOTIVE:
 Daily bath  Teach the patient/family of proper  Bathing provides relaxation
 Proper hand washing/hygiene good hygiene, hand washing and comfort and it gives most
 Oral care technique. people a sense of well-being.
 Proper food sanitation and
beverages.  Advise the patient to have adequate  Hand washing technique
rest. prevents infection and spread
Activity: of microorganism
 Breathing exercise  Inform the patient and family about
 Regular exercise (walking in the the dietary modification.  To gain back the lost strength
morning) and thus allow ample time for
 Review causative factors and healing.
appropriate intervention.
Diet:  To prevent recurrence.

 Increased food intake that is high PREVENTIVE:

in potassium (banana)
 Drink plenty of water  Instruct patient to avoid eating milky  May temporarily stop
products. producing lactase the intestinal
Instruction: enzyme that digests lactose.
 Follow up check-up
 Take prescribe medication for 1  Encourage the patient to maintain  Healthy diet will keep the
disease from worsening.
week. healthy diet.

CURATIVE:
 To prevent drug resistant
 Educate patient regarding the strains or to treat client’s
importance of compliance to given condition.
medication

REHABILITATIVE:

 Instruct to return for follow up check

up  To ensure continuity of care
even and after discharge
 Instruct patient’s guardian or family
about the correct timing, dosage,
and route as well as the effects and
considerations of medication
prescribed by the physician.