Assessment Nursing Diagnosis Planning Intervention Evaluation

Subjective Fluid volume deficit related Short term goal Encourage client to Short term goal
“Nararamdaman ko din na to acive fluid volume loss After 1-2hours of nursing increase oral fluid intake After 1-2 hours of nursing
nanghihina ako at para (diarrhea) intervention, the clent will intervention,the client
banf palage ako walang maintain adequate fluid Provide meticulous oral maintained adequate fluid
lakas”Verbalized by patient volume loss through fluid care volume versus active fluid
hydration and monitoring loss as evidenced by an
Objective of intake and output Check voiding and record increase in oral fluid intake
 Decrease urine amount from 500 ml to 1000ml
output 25cc/hr Long term goal with moistened mucous
 Decrease oral fluid After 8 hours of nursing Promote a quiet membrane,good skin
intake(400-500ml) intervention,the client will environment and bed rest turgor and increase urine
 PoorSkinturgor have an increase in energy output of 30cc/hr-goal
 Pale nail beds levels and prevent further Regularl assess client for partially met
 Pale palpebral complication as evidence changes in conditions
 Conjunctiva by patient’s verbalization Long term goal
 Slightly pale nasal of an increase energy level Strictly monitor I/O
and buccal mucosa After 8 hours of nursing
 Dry and Cracked intervention.,the client
lips reported a slight increase
 Thready/weak in energy level and absence
pulse of complication as
verbalized by the patient.
-goal partially met.
 Therapeutic Action Contraindication Toxicity Effect Indications Safety Dosage
Classification
Metronidazole is selectively absorbed by Check with your Along with its needed Amebiasis. Flagyl For amebiasis
anaerobic bacteria and physician if you have effects, a medicine may (metronidazole) is infections:
cause some unwanted indicated in the
Classification: sensitive protozoa. Once any of the following: effects. Although not all of treatment of acute Adults and
Antipotozoal taken up by anaerobes, it these side effects may intestinal amebiasis teenagers—500 or
is non-enzymatically Conditions: occur, if they do occur they (amebic dysentery) and 750 milligrams (mg)
reduced by reacting with Alcohol Intoxication, may need medical attention. amebic liver abscess. 3 times per day for
reduced ferredoxin, Lower Seizure 5 to 10 days.
Check with your doctor In amebic liver abscess,
which is generated by Threshold, immediately if any of the Flagyl (metronidazole)
pyruvate oxido- Any Disorder of the following side effects occur: therapy does not Children—Dose is
reductase. Many of the Brain, Numbness, obviate the need for based on body
Tingling or Pain of More common aspiration or drainage of weight and must be
reduced nitroso
 Agitation pus.
intermediates will form Hands or Feet,  Back pain
determined by your
sulfinamides and Meningitis Not  Blindness Anaerobic Bacterial doctor. The dose is
thioether linkages with Caused by an  Changes in speech Infections. Flagyl usually 35 to 50
cysteine-bearing Infection, patterns (metronidazole) is milligrams (mg) per
enzymes, thereby Severe Liver  Depression indicated in the
kilogram (kg) of
 Dizziness treatment of serious
deactivating these critical Disease, Seizures, infections caused by body weight per
 Drowsiness
enzymes. Decreased  Eye pain susceptible anaerobic day, divided and
Neutrophils a Type  Fever bacteria. Indicated given in 3 doses, for
surgical procedures
of White Blood Cell,  Hallucinations 10 days.
should be performed in
Habit of Drinking  Headache
conjunction with Flagyl
Too Much Alcohol  Irritability
(metronidazole)
 Lack of
therapy. In a mixed
coordination
Allergies: aerobic and anaerobic
 Mood or mental
infection, antimicrobials
NITROIMIDAZOLES changes
appropriate for the
 Nausea treatment of the
 Seizures aerobic infection should
 Shakiness and be used in addition to
unsteady walk Flagyl (metronidazole) .
 Slurred speech
 Stiff neck or back
 Trouble speaking
Cefuroxime Inhibits synthesis of An allergic CNS For dermatologic 750mg TIV q 8
bacterial cell wall, causing : Headache,dizziness, infections, caused
reaction (difficulty
lethargy,paresthesias
Classification cell death breathing; closing of GI by S.aureus, S.
Antibiotic the throat; swelling : Nausea, vomiting, diarrhea, pyogenes
of the lips, face, or anorexia, abdominal pain, Fights bacteria in
tongue; hives; or a flatulence, the body.
pseudomembranous colitis,
rash). liver toxicity Is used to treat
Rash, redness or Hematologic many different
itching. : Bone marrow types of bacterial
Severe nausea, depression:decreased WBC, infections.
decreased platelets,
vomiting, or diarrhea decreased Hct
GU
: Nephrotoxicity
Hypersensitivity
:Ranging from rash to fever
to anaphylaxis, serum
sickness reaction
Other
:Super infections,disulfiram-
like reaction with alcohol
 Assessment Nursing Diagnosis Planning Intervention Evaluation
Subjective Ineefective cerebral tissue After 8 hours of nursing Monitor After 8 hours of nursing
“napansin ko na hindi perfusion related to intervention the patient temperature.Administer intervention.the patient
normal ang laki ng ulo ng arterial or venous blood will demonstrate TSB in presence of fever. was able to demonstrate
anak ko” verbalized by flow improved vital signs and improved vital signs of
mother absence of signs of Monitor Intake/Output increase icp
increased ICP
Objective Maintained head or neck
REstlessnesss in midline or in neutral
Irritability position
Changes in vital signs
V/S Taken as follow Provide rest periods
T=37.5 between care of activities
P=90 and limit duration of
R=22 procedures

Decrease extraneous
stimuli and provide
comfort measures as back
massafe,quiet
environment genile touch.

Help patient avoid or limit

coughing,cring vomiting
and straigning of stool

Elevate The Head of bed

gradually to 15-30 degress
as tolerated or indicated

Administer diuretics as
indicated
 Therapeutic Action Contraindication Toxicity Effect Indication Safety dosage
Classification
Ampicillin Inhibits bacterial cell wall  Hypersensitivity Treatment of Usual Pediatric Dose
Call your doctor at for Bacterial
Classification synthesis by binding to one or to penicillins. once if you have a UTI, otitis media, Endocarditis
Systemic Anti- more of the penicillin binding Infectious serious side effect sinusitis,bronchitis, Prophylaxis
infectives proteins (PBPs); which in turn such as: uncomplicated
mononucleosis. Low to moderate risk:
inhibits the final  Use cautiously  fever, sore community-acquired 50 mg/kg IV or IM 30
minutes before
transpeptidation step of with renal throat, and pneumonia,Haemophil procedure.
headache with
peptidoglycan synthesis in disorders. a severe us influenzae
High risk: 50 mg/kg
bacterial cell walls, thus blistering, infections and plus gentamicin 1.5
inhibiting cell wall peeling, and invasives almonellosis mg/kg, both
red skin rash; intramuscularly or IV
biosynthesis. Bacteria  diarrhea that is 30 minutes before
eventually lyse due to ongoing watery or procedure. Follow
bloody; with ampicillin 25
activity of cell wall autolytic  fever, chills, mg/kg IV or IM, or
enzymes (autolysins and body aches, flu amoxicillin 25 mg/kg
murein hydrolases) while cell symptoms; orally, 6 hours after
 easy bruising initial dose.
wall assembly is arrested. or bleeding,
unusual Usual Pediatric Dose
weakness; for Meningitis
 urinating less
Neonates:
than usual or < 7 days, birthweight
not at all; < 2000 g: 50 mg/kg
 agitation, IV every 12 hours.
confusion, < 7 days, birthweight
unusual > 2000 g: 50 mg/kg
thoughts or IV every 8 hours.
behavior; or > 7 days, birthweight
 seizure (black- < 1200 g: 50 mg/kg
out or IV every 12 hours.
convulsions). > 7 days, birthweight
1200 to 2000 g: 50
mg/kg IV every 8
hours.
> 7 days, birthweight
> 2000 g: 50 mg/kg
IV every 6 hours.

Infants and children:

50 to 100 mg/kg IV
every 6 hours.
Maximum dose 12
g/day.

Ampicillin should be
given in combination
with another
antibiotic, depending
on the nature of the
infection.

Usual Pediatric Dose

for Skin or Soft Tissue
Infection

IV: 6.25 to 12.5

mg/kg every 6 hours
(maximum 12 g/day).

Oral: 6.25 to 12.5

mg/kg every 6 hours
(maximum 2 to 3
g/day).
Mannitol Increases osmotic pressure of  Active  To reduce 0.5 to 2 g/kg IV
infusion as15% to
Classification plasma in glomerular filtrate, intracranial intracranial 25% solution given
Diuretics inhibiting tubularre absorption bleeding pressure and over 30 to60
minutesMannitol
of water and electrolytes (except during brain mass (Osmitrol)
(including sodium and craniotomy) 150cc IV q8
potassium).  Test dose for
 Anuria marked
These actions enhance water secondary to oliguria or
flow from various tissues and severe renal suspected
ultimately decrease disease inadequate
intracranial and intraocular renal function
pressures; serum sodium level  Progressive
rises while potassium and heart failure,  To prevent
blood urea levels fall pulmonary oliguria during
.Also protects kidneys by congestion, cardiovascular
preventing toxins from renal damage, and other
forming and blocking tubules or surgeries
renaldysfunctio
n after  Acute oliguria
mannitol
therapy begins  To reduce
intraocular
 Severe pressure
pulmonary
congestion or  To promote
pulmonary diuresis in
edema drug toxicity

 Irrigation
 Severe during
dehydration transurethral
resection of
prostate
(TURP)