Republic of the Philippines

Department of Health
WESTERN VISAYAS SANITARIUM
Santa Barbara, Iloilo
NURSING SERVICE TRAINING OFFICE

NURSING CARE PLAN

CLUSTERED CUES NURSING RATIONALE GOALS/OUTCOME NURSING RATIONALE EVALUATION

DIAGNOSIS AND CRITERIA INTERVENTION
DEFINITION
Date: Ineffective Airway Respiratory After giving INDEPENDENT:
Time: clearance related infection triggers nursing care The - Diminished
to excessive inflammatory patient is - Help the - This action crackles noted
SUBJECTIVE: mucus production processes and expected to patient cough will facilitate - RR 21
the patient and retained inflammation is improve and and deep removal of - Breathing
verbalizes ma secretions also triggered by maintain a patent breath every secretions and pattern
plema ubo ko infectious airway as 2 hours promote improve as
bala Definition: organism and by manifested by pulmonary breathing
Ineffective airway inhalation of 1. Effective ventilation becomes
OBJECTIVE: clearance is a irritating agents. cough effortless
- Productive nursing diagnosis The inflammation 2. Absence of - Use an - To facilitate - Reduced
coughing in which there is occurs in the crackles on incentive deep amount of
noted an inability to interstitial spaces, auscultation spirometer if breathing and phlegm when
- Crackles upon clear secretions or alveoli, and often 3. Absence of available stimulate coughing
auscultation obstruction from the bronchioles. phlegm when coughing noted
- Spitting out the respiratory The process coughing - The patient
with yellowish tract to maintain a begins when 4. Diminished - Chest - Facilitate claimed daw
color phlegm clear airway organism intercostals Physiotherapy mobilization nag hagan
- Minimal penetrate the retraction of secretions hagan na ubo
laboured airway mucosa 5. Improve to easily spit ko subong
breathing and multiply in breathing out when - WBC 9- 10
- Minimal alveolar spaces. pattern coughing
intercostals To do this, they (absence of
 retractions must survive the effort and - Drink at least - Adequate
noted lungs many rate within 3 litres of fluid hydration may
- RR -28 defences against normal range) daily unless help thin
- Minimal microbial 6. WBC will another secretions and
restlessness invasion, including reduced problem make them
noted inflammatory within normal requires easier to
- WBC: 17 response. White level at least restriction remove
- CXRAY result: blood cells 10
Bilateral migrate to the 7. Repeat Chest - Restrict - Oxygen is
pneumonia area of infection X-ray result smoking flammable
causing local will reveal a within the agent and
capillary leak, resolve area smoke can be
oedema, and pneumonia an irritating
exudates. These condition. agent to the
fluids collect in patient
and around the
alveoli, and the
alveolar walls - Keep the - Presence of
thicken. environment irritant can
clean and free trigger bodys
REFERENCE: from dust inflammatory
Ignatavicious process that
Workman, Patient can worsen
Centered the patients
Collaborative condition
Approach To
Medical-Surgical DEPENDENT:
Nursing Volume - Administer - To ensure
1,2010, p.659. oxygen at _ adequate
LPM with pulmonary
strict oxygen
monitoring of concentration
flow rate to
avoid oxygen
 intoxication

- Observe sign - To prevent

of oxygen care related
intoxication complication
such as
sternal pain,
GI upset,
dyspnoea and
non
productive
cough

- Administer
the following
medications
as ordered:

1. Ceftriaxone - Indicated for

treatment of
LRTI by
inhibiting cell
wall synthesis
rendering cell
wall
osmotically
unstable,
leading to cell
death

2. Azithromycin - Indicated to
500 mg IV treat
respiratory
infection by
 binding to the
P site of 50S
bacterial
ribosomal
subunits
thereby
inhibiting
protein
synthesis;
bactericidal or
bacteriostatic
depending on
concentration
with much
greater
spectrum of
activity than
erythromycin

3. Cefuroxime - (Indication
and
mechanism of
action) ... tae
karbaw
DATE:
TIME:
SUBJECTIVE: INDEPENDENT:
patient Verbalizes Altered Nutrition, Catabolic state After giving - -
kagamay sang less than body increases because interventions the
kaon ko daw waay requirements of infection and patient:
ko gana mag related to inability stress. With 1. claim
kaon, kay pimi lng to ingests food or inadequate food improvement
abi ubo kag kalas- digest food or intake and in food intake
ay sang panabor absorb nutrients nutrients can alter 2. gain strength
ko due to biological the nutritional in doing ADL
psychological AND status of the 3. taste to food
OBJECTIVE: economic factors patient improves
- unable to
consume Definition: This is Reference:
supplied food a state of health Ignatavicious
- dry skin in which an Workman, Patient
- weakness individual is Centered
noted experiencing an Collaborative
- decrease meal intake of nutrients Approach To
enjoyment insufficient to Medical-Surgical
meet metabolic Nursing Volume
needs 1,2010, p.1392

DRUG STUDY

NAME OF DRUG CLASSIFICATION INDICATION CONTRAINDICATION ADVERSE NURSING RATIONALE

MECHANISM OF REACTION RESPONSIBILITIES
ACTION
1. ceftriaxone - It inhibits cell 1. Indicated for 1. Hypersensitivity 1. Pain 1. Observe the 1. To avoid
azithromycin wall synthesis lower to 2. Induration the 5 Rs in error in giving
rendering cell respiratory cephalosporin 3. Phlebitis after giving the medication
wall tract and penicillin IV medication
osmotically infection 2. Peristalsis- administration, 2. Perform skin 2. To determine
unstable, inhibiting 4. rash test before hypersensitivi
leading to cell preparation 5. diarrhoea giving the ty to drug
death 3. Phorphyria, 6. eosinophilia medication
unapplianced 7. casts in urine 3. Assess 3. To determine
auricular- 8. thrombocytosis patients history as an
ventricular 9. leucopenia previous indication of
block ; 10. elevation of sensitivity immediate
cardiogenic aspartate reaction to referral
shock transaminase penicillin, or before giving
(AST), alanine other medication
transaminase cephalosposri since this is
(ALT); BUN and ns. Cross- contraindicat
Creatinine sensitivity ed with
11. GI betweenpenic hypersensitivi
disturbances: illins and ty to
soft cephalosporin cephalospori
stools/diarrhea s is common n and
, nausea, penicillin
vomiting,
stomatitis, 4. Asses patient 4. To determine
glossitis. for signs and indication of
12. Hematologic symptoms of the
changes: infection medication to
Eosinophilia, before and the patient
leukopenia, during
granulocytope treatment:
nia, haemolytic fever and
anemia, WBC >
thrombocytop 10,000/mm
enia, 5. Obtain C&S 5.determine
13. Skin reaction: before resistance to
exanthema, beginning medication
allergic drug therapy
dermatitis, to identify if
pruritus, correct
urticuria, treatment has
edema, been initiated.
erythema 6. Asses for 6.to prepare
 multiforme allergic possibility and
14. Headache and reaction and chances of
dizziness anaphylaxis: delayed allergic
15. Increase in rash, urticuria, reaction
liver enzymes pruritus, chills,
16. Gallbladder fever, or joint
sludge pain
17. Oliguria angioedema
18. Crystalluria may occur a
few days after
the beginning
of therapy.
Epinephrine
and
resuscitation
equipment
should be
available for
anaphylactic
reaction
7. Assess renal 7. To monitor
function the adverse
before and reaction of
during the
therapy: urine medication
output, BUN,
and
Creatinine,
Monitor for
nephrotoxicity
8. Monitor 4. To determine
hematologic, the
electrolyte, hematologic
and hepatic adverse
 status if the reaction of
patient is in the
long term medication
therapy. and other
Hematologic reactions
bleeding:
ecchymosis,
bleeding
gums,
hematuria,
stool guiac,
CBC and Hct.
Electrolyte:
sodium,
potassium,
and chloride.
Hepatic: AST,
AT, LDH,
bilirubin,
alkaline
phosphatise,
and Coombs
test monthly :
9. Discuss the 5. To educate
treatment the patient
regimen such to encourage
as timing and involvement
duration of of the patient
the, side in her care
effects and management
advers
reaction
10. Teach the 6. To determine
patient to hematologic
report sore adverse
throat, reaction of
bruising, the
bleeding, and medication
joint pain, this
may indicate
blood dycrasia
(rare)