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I. PATIENT AND HIS CARE A. MEDICAL MANAGEMENT
Medical Managemen
t
General Description
Indications
DATEOrdered/Performe
d
Client’s Response
IVF #1 D5LRS 1L x
8°
IVF #2 D5NM 1L x
8°
5% Dextrose in Lactated Ringer's Injection provides electrolytes and calories, and is a
source of water for hydration. It is
capable of inducing diuresis depending
on the clinical condition of the
patient. This solution also contains lactate
which produces a metabolic alkalinizing
effect. Sodium, the major cation of the extracellular fluid,
functions primarily in the control of water
distribution, fluid balance and osmotic
pressure of body fluids.
Normosol-M and 5% Dextrose injection is
nonpyrogenic and
It is indicated
for restoring
electrolytes and
replacing fluids in the
body especially in the case
of the patient who
has had dehydration
from Typhoid Fever.It also
serves as a route for
medication.
01/23/14
01/24/14
Client manifested no adverse reactions to
the treatment,
but it helped by
rehydrating the body
and providing
electrolytes and
calories.
Client manifested no adverse reactions to
the
is a nutrient replenisher. It provides water and electrolytes
(with dextrose as a readily available
source of carbohydrate) for maintenance of daily fluid and
electrolyte requirements, plus
minimal carbohydrate calories. The electrolyte
composition approaches that of the principal ions of normal plasma
(extracellular fluid).
It serves as a
maintenance of daily fluid and
electrolyte levels for
the patient. The
dextrose (sugar) restores glucose
levels and provides minimal
carbohydrate calories
treatment, but it
helped by rehydrating
the body and
providing electrolytes and calories
NURSING RESPONSIBILITIES:
Before the Procedure Check the doctor’s order regarding to what type of IVF to be used and
also its volume and rate.
Explain the procedure to the patient.
Gather all materials needed for the insertion of IVF to save time and not
to waste time for looking for other materials.
Wash hands before and after the procedure to prevent contamination
from insertion site.
During the Procedure Place patient in a comfortable position to facilitate easy insertion of IV
line and to decrease patient’s fear about the procedure.
Make sure that we give the proper IV fluid and drop rate accurately
because patient may experience fluid overload or dehydration.
Check for its patency by observing the backflow of blood upon insertion.
After the Procedure
Press the site where the needle was inserted and secure it with
micropore.
Check the site of hand where the needle is inserted if bulging is not
visible. If so, reinsertion is to be undertaken.
Advice patient to avoid scratching the site less movement of the hand
where the needle was inserted to keep it in place.
Instruct patient and significant others to inform the nurse on duty if
bulging of the site is visible, if there is back flow of blood of if IVF is not
infusing well.
Observe the IV site at least every hour for signs of infiltration or other
complications fluid or electrolyte overload and air embolism.
IVF regulation should be checked and monitored upon receiving patient.
Always check the doctor’s order for new orders regarding the IVF
supplement of the patient.
Always check if the IVF is infusing well and intact.
B. PHARMACOLOGICAL MANAGEMENT
Generic Name(brand name)
Mechanism of
Action
Date Ordered/Administ
ered
Indications
Contraindication
s
Client’s Response
to Treatmen
t
NURSING RESPONSIBILITIES
PARACETAM
OL
(biogesic)
Adult: PO 5
00 mg/tab
q4 RTC/
PRN(T>37.
5)
ANTIPYRETIC,
ANALGESICS(NON-
OPIOID)
Decreases
fever by a
hypothalam
ic effect
leading to
sweating
and
vasodilation
.
Inhibits
pyrogen
effect on
the
hypothalam
ic-heat-
regulating
01-23-14 For
temporary
relief of
pain and
discomfort
from
headache
and fever.
For
relieving
fever.
.
Hypersen
sitivity to
paraceta
mol
The
patient
didn’t
manifest
any
allergic
reaction to
Paracetam
ol. The
fever
subsided
from 38.6
to 37.3
degrees
Celsius
Before the administration of
drug
Check for medical order
Determine if patient is allergic to
the drug
Explain the procedure and
reasons for giving the drug, to
gain patient cooperation
Explain possible side effects
During drug administration
Maintain aseptic technique
Check medication, right route,
dosage, storage, etc
Stay with the patient while she
takes in the drug
Do not exceed the
recommended dosage
centers
Inhibits CNS
prostagland
in
synthesis.
After the administration of drug
Monitor any untoward effects of
the drug
Instruct SO’s to report to the
attending nurse if any unusual
effects occur
Provide comfort for the patient.
Report and record as
appropriate.
Generic Name(brand name)
Mechanism of
Action
Date Ordered/Administ
ered
Indications
Contraindications
Client’s Response
to Treatment
NURSING RESPONSIBILITIES
CIPROFLOXA
CIN
(ciprobay xr)
Adult: PO
1gm/tab
B.I.D
ANTI-BACTERIAL
Bactericidal
; interferes
with the
DNA
replication
in
susceptible
bacteria
preventing
cell
reproductio
n.
01-23-14 For Gram-
negative
bacteria like
Salmonella
typhi
Hypersensitivity.
Not to be used
concurrently with
tizanidine. Avoid
exposure to strong
sunlight or
sunlamps during
treatment.
The patient
didn’t
manifest
any allergic
reaction to
ciprofloxaci
n
Before the
administration of drug
Check for medical
order
Determine if patient is
allergic to the drug
Explain the procedure
and reasons for giving
the drug, to gain
patient cooperation
Explain possible side
effects
During drug
administration
Maintain aseptic
technique
Check medication,
right route, dosage,
storage, etc
Stay with the patient
while she takes in the
drug
Do not exceed the
recommended dosage
After the administration
of drug
Monitor any untoward
effects of the drug
Instruct SO’s to report
to the attending nurse
if any unusual effects
occur.
Report and record as
appropriate.
Generic Name(brand name)
Mechanism of
Action
Date Ordered/Administ
ered
Indications
Contraindications
Client’s Response
to Treatment
NURSING RESPONSIBILITIES
CEFTRIAXON
E
(xtenda)
Adult: IV
Inhibits
bacterial
cell wall
synthesis,
rendering
01-23-14 Typhoid
fever’s
causative
agent is
Salmonella,
Contraindicated in
patients with
known allergy to
the cephalosporin
class of antibiotics.
The patient
didn’t
manifest
any allergic
reaction to
Before the
administration of drug
Check for medical
order
Determine if patient is
inf. ST(-)
1gm q8
ANTIBACTERIAL
cell wall
osmotically
unstable
leading to
cell death.
a gram-
negative
bacilli, this
medication
inhibits this
bacteria to
multiply by
inhibiting
cell wall
synthesis.
ceftriaxone. allergic to the drug
Explain the procedure
and reasons for giving
the drug, to gain
patient cooperation
Explain possible side
effects
During drug
administration
Maintain aseptic
technique
Check medication,
right route, dosage,
storage, etc
Stay with the patient
while she takes in the
drug
Do not exceed the
recommended dosage
After the administration
of drug
Monitor any untoward
effects of the drug
Instruct SO’s to report
to the attending nurse
if any unusual effects
occur.
Report and record as
appropriate.
Generic Name(brand name)
Mechanism of
Action
Date Ordered/Administ
ered
Indications
Contraindications
Client’s Response
to Treatment
NURSING RESPONSIBILITIES
OMEPRAZOL
E
(risek)
Adult: PO
40mg/cap
HS
PROTON PUMP
Gastric-acid
pump
inhibitor;
suppresses
gastric acid
secretion at
the
secretory
surface of
the gastric
01-23-14 To decrease
further
irritation of
the gastric
mucosal
lining.
Contraindicated in
patients with
known
hypersensitivity to
substituted
benzimidazoles or
to any component
in the formulation.
The patient
didn’t
manifest
any allergic
reaction to
Omeprazole
. Verbalized
reduced
abdominal
Before the administration of drug Check for medical
order Determine if patient is
allergic to the drug Explain the procedure
and reasons for giving the drug, to gain patient cooperation
Explain possible side effects
INHIBITOR parietal
cells; blocks
the final
step of acid
production.
cramps.During drug administration
Give before food, preferably breakfast; capsules must be swallowed whole
Maintain aseptic technique
Stay with the patient while she takes in the drug
Do not exceed the recommended dosage
After the administration of drug
Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged use.
Advise patient to report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine.
Instruct SO’s to report to the attending nurse
if any unusual effects occur
Provide comfort for the patient.
Report and record as appropriate.
Generic Name(brand name)
Mechanism of
Action
Date Ordered/Administ
ered
Indications
Contraindications
Client’s Response
to Treatment
NURSING RESPONSIBILITIES
HYDROCORT
ISONE
(solu-cortef)
Adult: IV
100mg q6 x
3 doses
STEROID
Hydrocortis
one is a
short-acting
synthetic
steroid with
both
glucocortico
id and
mineralocor
ticoid
properties
that affect
nearly all
systems of
01-23-14 Hydrocortis
one is used
to reduce
inflammatio
n. It
reduces
swelling.
Contraindicated in
patients with
known
hypersensitivity to
substituted
benzimidazoles or
to any component
in the formulation.
The patient
didn’t
manifest
any allergic
reaction to
Hydrocortis
one.
Before the administration of drug Assess for
contraindications. Assess body weight,
skin color, V/S, urinalysis, serum electrolytes, X-rays, CBC.
Arrange for increased dosage when patient is subject to unusual stress.
Observe the rights of drug administration.
During drug administration
the body.
By
inhibiting
the
formation,
storage and
release of
histamine
from mast
cells, it
reduces the
effects of
an allergic
response. It
also
increases
the body’s
response to
circulating
catecholami
nes.
Give daily before 9am to mimic normal peak diurnal corticosteroid levels.
Space multiple doses evenly throughout the day.
Use minimal doses for minimal duration to minimize adverse effects.
Do not give IM injections if patient has thrombocytopenic purpura.
Taper doses when discontinuing high-dose or long-term therapy.
After the administration of drug Monitor client for at least
30minutes. Educate client on the
side effects of the medication and what to expect.
Instruct client to report pain at injection site.
Instruct client to take drug exactly as prescribed.
Dispose of used materials properly.
Document that drug has been given
C. DIET
Type of Activity
General Description
Indications/ Purpose
Date Ordered/ Performe
d
Examples of food
Client’s Response
Soft Diet A diet that is
soft in
texture, low
in residue,
easily
digested,
and well
tolerated. It
provides the
essential
nutrients in
the form of
liquids and
semisolid
foods.
A soft diet
food can
easily be
digested by
the body. As
the digestive
system of
the patient
becomes
weak during
typhoid, the
typhoid
remedies do
not
recommend
a patient to
eat any food
that may be
high in tough
fibers.
01/23/14 Soup,
eggs,
yoghurt,
breads,
cereals,
mashed
potato,
oatmeal
The patient
complied to the
given diet.
SOFT DIET
NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER
Before the Procedure
Check the doctor’s order.
Check the right client.
Be sure that the diet is properly instructed.
Explain the reason for type of diet
During the Procedure
Monitor if the client complies with the given diet.
Be sure patient is taking or eating food he/she can tolerate
After the Procedure
Assess for patient’s condition; how he responded to the diet.
A. ACTIVITY and EXERCISE
NURSING RESPONSIBILITIES
Educate client regarding his activity
Assisting client to his bathroom privileges
Explain the purpose of restrictions in activity and position in bed as
ordered.
Assist the patient to maintain the prescribed position.
Encourage the patient to adhere to ordered activity.
Accomplish necessary documentation of patient’s reaction to the ordered
activity restrictions.
Type of Activity
General Description
Indications/ Purpose
Date Ordered/ Performe
d
Client’s Response
Bed Rest
with
Bathroom
Privilege
with
assistanc
e
It is a
restriction of
a patient's
activities,
either
partially or
completely ,
but permitted
to use the
bathroom
with
assistance.
One of the
symptoms of
Typhoid Fever is
dehydration and
weakness.
Therefore,
patient must be
assisted in using
the bathroom to
prevent any
injury.
01/23/14 Patient complied
to the prescribed
activity. It
provided
assistance to
ease the effort in
using the
bathroom by
saving energy
and preventing
exhaustion.
II. NURSING CARE PLANS
NURSING PROBLEM: Hyperthermia related to infection of systemic effects of endotoxins and bacterial products of salmonella typhi
CUESNURSING
DIAGNOSISSCIENTIFIC
EXPLANATIONOBJECTIVES
NURSING INTERVENTIONS
RATIONALE EVALUATION
Subjective:
“Halos 2 weeks
nakong
nilalagnat” as
verbalized by
the patient
Objective:
Restlessne
ss
Malaise
Headache
Warm to
touch
Elavated
WBC (14.6)
Typhidot
(presence
Hyperthermi
a
related to
infection of
systemic
effects of
endotoxins
and
bacterial
products of
salmonella
typhi.
Body
temperature
elevated above
normal level
that is usually
caused by
several factors
related to
illness. As
inoculation
occurs, prolifer
ation of
bacteria follows
and
multiplication
occurs. Once
the bacteria
starts to grow
in number, it
After 4 hours
of nursing
intervention
client will be
able to
maintain
core
temperature
within
normal range
as evidenced
by:
Body
temperat
ure
reduced
lowered
to 38.6°C
to 37.5°C.
Monitor patient
temperature
degree and
patterns.
Observe for
shaking chills
and profuse
diaphoresis
Provide tepid
sponge baths
and avoid the
Fever
pattern
may aids
in
diagnosing
underlying
disease.
Chills often
precede
during
high
temperatu
re and in
presence
of
generalize
d infection.
Goal met
After 4 hours of
nursing
intervention
goals and
objectives was
met as
evidenced by
body
temperature of
37.3°C
of IgM)
V/S taken
are as
follows:
T = 38.6 °C
RR = 22
PR = 92
BP = 90/60
will soon reach
it pathogenic
level that will
result
into pyrexia or
fever as a
defense
mechanism of
the body.
use of ice
water and
alcohol.
Remove excess
clothing and
covers
Maintain bed
rest or
minimize
movement.
May help
reduce
fever. Use
of ice
water and
alcohol
may cause
chills and
can
elevate
temperatu
re
This
decreases
warmth
and
increases
evaporativ
e cooling
To reduce
metabolic
Encourage
client to
increase fluid
intake.
INDEPENDENT:
Administer
Paracetamol as
prescribed by
the physician ,
utilizing 10Rs
in giving
medication.
demands
of oxygen
consumpti
on.
If patient is
dehydrate
d or
diaphoretic
, fluid loss
contribute
s to fever.
Antipyretic
s acts on
the
hypothala
mus,
reducing
hyperther
mia.
NURSING PROBLEM: Acute Pain R/T irritation of intestinal mucosa AEB facial grimace, guarding position, restlessness,
and 7/10 pain scale secondary to Typhoid Fever
ASSESSMENTNURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
N
OBJECTIVESINTERVENTIO
NRATIONALE EVALUATION
Subjective
Cues:
“Masakit tiyan
ko.”
Objective
Cues:
(+) facial
grimace
(+)
guarding
position
(+)
restlessne
ss
7/10 Pain
Scale
Acute Pain
R/T irritation
of intestinal
mucosa AEB
facial
grimace,
guarding
position,
restlessness,
and 7/10
pain scale
secondary to
Typhoid
Fever
Once the
Salmonella
typhi that
causes typhoid
fever is
consumed, it
travels initially
through the
digestive
system.
Therefore,
causing
irritation that
will eventually
trigger
diarrhea or
constipation,
weight loss,
and abdominal
Short
Term:
After 4 hours
of nursing
interventions
, the patient
will verbalize
relief from
pain.
Long Term:
After 24
hours of
nursing
intervention,
the patient
will show
signs of
comfort and
Assess the
level of pain,
location,
duration,
intensity and
characteristi
cs of pain.
Give warm
compresses
on the area
of pain.
Provide a
quiet
environment
Changes in
the
characterist
ics of the
pain may
indicate the
spread of
disease or
any
complicatio
n.
Warm can
help ease
the pain.
Promotes
Goal met
After 4 hours of
nursing
interventions,
the patient
verbalized
reduced pain
from pain scale
of 7 to 5/10.
Reported relief
from and have
rested and slept
comfortably.
V/S taken are
as follows:
T = 38.6 °C
RR = 22
PR = 92
BP = 90/60
pain. will be able
to rest and
sleep.
and reduce
stressful
stimuli.
Place in
position of
comfort.
Provide
diversional
activities,
and
relaxation
technique
Administered
Omeprazole
as
prescribed
by the
rest that
may
alleviate
the pain
May lessen
associated
discomfort
Helps with
pain
manageme
nt by
redirecting
attention to
such
activities.
Omeprazole
is a proton
physician pump
inhibitor
which
decreases
acid
secretion to
prevent
further
irritation of
mucosa
which
contributes
to the
abdominal
pain.
NURSING PROBLEM: Activity Intolerance r/t muscle weakness
CUESNURSING
DIAGNOSISSCIENTIFIC
EXPLANATIONOBJECTIVES
NURSING INTERVENTIONS
RATIONALE EVALUATION
Subjective:
“Masaki tang
Activity
Intolerance
r/t muscle
Activity
Intolerance is
insufficient
After 2-3
hours
of nursing
Assess
patient’s level
of mobility.
This aids
defining
what pati
Goal met.
After 2-3 hours
of nursing
mga
kasukasuhan
ko,
nahihirapan
ako
gumalaw” as
verbalized
by patient.
Objective:
Febrile
(38.6)
body
weakness
restlessne
ss
increased
RR (22
cpm)
low hgb
count
(11.9g/L)
fatigue
prefers to
weakness physiological or
psychological
energy, poor
endure or
complete
required or
desired daily
activities.
Because of low
hct level there
will be decrease
oxygen being
delivered to the
tissues of the
body since the
hgb is
responsible for
the oxygenation
of tissue. As a
compensatory
mechanism, the
body will
increase its
demand of
interventions
and giving
health
teachings,
the patient
will be able
to :
Follow
energy
conservati
on
technique
s to
lessen
fatigue
Perform
ADL as
tolerated.
Assess ability
to stand and
move about
and the
degree
of assistance
necessary.
Provided
adequate rest
ent is
capable of
which is
necessary
before
setting
realistic
goals.
To
determine
current
status
and needs
associate
d
with parti
cipation in
needs
or desired
activities.
Rest
between
interventions the
patient was able
to perform
comfort measure
to minimize
energy
consumption like
refraining from
doing non
essential
procedures and
placing
frequently used
items within
reach.
lie down
on bed
oxygen by
increasing
respiratory rate
of the patient
which results
then to fatigue.
Because of this
there will be fast
consumption of
ATP leading to
weaker
contractions
thus causing
muscle
weakness and if
the patient has
muscle
weakness there
will be activity
intolerance.
periods,
especially
before meals,
other ADLs,
and
ambulation.
Instruct
patient to eat
nutritious
foods and
drink adequate
fluid intake.
Teach comfort
measure to
conserve
energy by: 1.)
Changing
position
frequently; 2.)
Placing
activities
provides
time
energy
conservati
on and
recovery.
Promotes
well-being
and
maximize
s energy
production.
This
distribute
s work to
the
different
muscles
to avoid
fatigue
frequently
used items
within reach;
3) Bedside
commode
Instruct
patient to
promote /
have
ambulation
and reposition
as necessary.
To
prevent
skin
breakdow
n and
maximize
s energy
productio
n.
NURSING PROBLEM: Risk for Imbalance Nutrition: Less than body requirements r/t loss of appetite and altered absorption of nutrients
CUESNURSING
DIAGNOSISSCIENTIFIC
EXPLANATIONOBJECTIVES
NURSING INTERVENTIONS
RATIONALE EVALUATION
Subjective:
“Minsan
wala ako
gang kumain
kasi
masyadong
masakit” as
Risk for
Imbalance
Nutrition:
Less than
body
requirements
r/t loss of
Lack of appetite
is a common
symptom of
many diseases.
Brief periods of
anorexia are life
threatening but
After 2 hours
of nursing
interventions
the patient
will be able
to:
Maintain
Assess
appetite
changes.
Frequency and
amount of
food intake
Indicates
health
status
and effect
of illness
which
require an
Goal met.
After 2 hours
of nursing
interventions the
patient was able
to verbalized
understanding of
verbalized
by patient.
Objective:
Poor skin
turgor
body
weakness
Pale
conjuncti
va
Diaphoret
ic
appetite and
altered
absorption of
nutrients
can cause
temporary
nutrition.
Prolonged
anorexia may
lead to serious
consequences
such as
malnutrition.
During reduced
food
consumption,
people use up
their stored
glycogen which
provides energy
through
glycgenolysis.
Prolonged
reduced food
consumption
may minimize or
consume all
stored glycogen
hydration
status
State
importanc
e of meal
intake to
meet
metabolic
needs
Have
adequate
amount of
food
intake
Ask SO to
provide
companionship
during meal
Suggested
liquid drinks
for
supplemental
increased
nutritional
needs and
appetite
affected
by illness
Attention
to the
social
aspects of
eating is
important
in both
hospital
and home
setting
Such
suppleme
nts can be
used to
increase
calories
the importance
of food intake to
sustain the
nutrients of the
body and for
faster recovery.
thus improper
diet occurs.
nutrition
Instruct
patient to eat
nutritious
foods high in
calories and
protein that
will promote
weight gain.
Explain to
patient that
nutritional
needs during
the course of
and
proteins
without
interfering
voluntary
food
intake.
Maintains
and
promotes
health
status
To aid in
the
understad
ing of
patient of
the
importanc
e of
nutrition
illness also
increase so it
is imperative
to take in food.
Advised
patient to take
small frequent
feedings
Administered
intravenous
fluid D5NM 1L
for faster
recovery
To
increase
energy
levels at
regular
intervals
To
maintain
hydration
status of
the
patient
NURSING PROBLEM: Deficient Fluid volume related to diarrhea.
ASSESSMENT
NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION
PLANNINGINTERVENTIO
NRATIONALE EVALUATION
Subjective
Cues:
“Nauuhaw
ako lagi
prang
nanunuyo
ang
lalamunan
ko.”
Objective
Cues:
o Dry
mucous
membrane
o Dry skin
and lips.
o Pale
Conjunctiv
a.
o Frequent
Diarrhea 3-
Risk for
deficient
Fluid volume
related to
excessive
fluid loss
through
frequent
passage of
stools
When there is
insufficient fluid
intake, and
excessive fluid
loss from and
diarrhea it
indicates
imbalance in
fluid volume in
which the body
can’t
compensate by
an adequate
intake of water.
Decreased
volume in the
intravascular
compartment is
called
hypovolemia.
Since water
moves freely
between the
After 2-4
hours of
nursing
intervention,
the client will:
o Learn ways
on how to
keep body
hydrated
o Comply
with the
prescribed
soft diet
o Demonstra
te clinical
signs of
adequate
hydration
o Assess and
document
amount,
color and
characteristi
cs of vomitus
and
diarrhea.
o Assess skin
turgor and
oral mucous
membrane;
o Provide for
changes in
dietary
intake
o Increase oral
fluids
o Determine
Fluid
replaceme
nt.
o To
evaluate
changes
as related
to fluid
status.
o To avoid
foods that
precipitat
e diarrhea
o To replace
fluid loss
After 4 hours of nursing intervention the client was able to:
o Maintain normal hydration as evidenced by moist skin
o Comply with the given diet
o Increase fluid intake
5x a day compartments,
extracellular
fluid deficit
causes
intracellular
fluid deficit
(cellular
dehydration),wh
ich leaves the
cells without
adequate water
to carry on
normal function.
o Recommend
products
such as
normal
fibers, plain
yoghurt
o Restrict solid
food intake
as indicated
o Assess
presence of
postural
hypotension,
tachycardia,
o To restore
normal
flora of
bowel
o To allow
bowel to
rest and
reduce
intestinal
workload
o To watch
out
warning
signs of
dehydrati
on