atp - ncs.docx

7/27/2019 ATP - ncs.docx

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Generic Name

Brand nameClassification

Indication

FrequencyDosage

Route

Mechanism ofaction

Side Effect/ AdverseReaction

Special Considerations

Generic name:

Paracetamol

Brand name:

Aeknil

Classification:

para – aminophenol

derivative,nonnarcotic

analgesic,antipyretic.

Indication: mild

pain or fever

Frequency: PRNTemp ≥ 37.8°C

PRN

Temp ≥38.5 °C

Dosage:100mg/mL amp

(IV)

Inhibits thesynthesis

of prostaglandin sthat may serve as

mediators of pain

and fever primarilyIn the CNS. Has no

significant anti

inflammatoryproperty or GI

toxicity.

Side effects:

hives, rash, short breath

adverse reaction:

Hematologic:Hemolytic anemia,

neutropenia, leucopenia,

pancytopenia,thrombocytopenia

Hepatic:

Liver damage, jaundice

Metabolic: Hyploglycemic

Skin: rash, urticatria

Special consideration:

Nursing Responsibilities:

Assess patient patient’s

pain or temperaturebefore and during therapy.

Be alert of adverse

reactionsand druginteractions.

Tell patient not to use drugfor marked fever (39.5°C),

fever persisting longer than3 days, or recurrent fever

unless directed by

prescriber.

Warn patient that high

doses or unsupervised long- term use can cause

hepatic damage.



Cues Diagnosis Background

Knowledge

Planning Intervention Rationale Expected

Outcome

Objective

Temp:

37.7 C

>warm totouch

Hyperthermiarelated to illness

AEB an elevated

body temperaturesecondary to acutetonsillopharyngitis

Hypothalamus isthe

thermoregulation

center of ahuman body

presence of infection

trigger of thefever, called a

pyrogen

release of

prostaglandin E2(PGE2). PGE2

then in turn actson thehypothalamus

causing heat-

creating effectsincrease heatconservation

and production

resulting

increase bodytemperature

hyperthermia.

Reference:Luckmann, Joanand Sorensen,

.Short Term:

After 8 hours shift,

the patient’stemperature willdecrease from37.7to 37.5 C.

Long Term:

Within a week of nursing

intervention the patient will

maintain histemperature withinthe normal range.

>Establishrapport.

>Monitor vitalsigns.

>Monitor andregulate IVF.

>Discuss pt’s

perceptions/fearfulfeelings. Listen to

the pt’s concerns.

>Promote bedrest, encourage

relaxation skillsand diversionalactivities.

>Provide TSB asneeded

>Administer Paracetamol PRN.

>Enhances sense of trust and nurse – client

relationship

>To asses if there isany irregularities.

>To ensure that the patient is receiving theright amount of IVFthat aids in hydration.

>Promotes

atmosphere of caringand permits

explanation/correctionof misperception.

>To reduce metabolicdemands/oxygen

consumption.

>Heat is loss byevaporation andconduction.

>Paracetamol areclassified asanalgesics andantipyretic which actson

Short Term:After the nursing

intervention, the

patient’s tempshall decreasefrom 37.7to 37.5C.

Long Term:Within a week

of intervention,the patient shall

be free from

fever.



Karen. MS-Nursing4th. ed

>Encourage toincrease OFI.

>Advise (-)DCF

the hypothalamus toregulate

normal bodytemperature.

>To prevent fromdehydration.

>To monitor signs of bleeding that may be present in stool or urine.




Knowledge

Planning Intervention Rationale Evaluation

Subjective“inuubo padin paminsan

– minsan”, asverbalized by

the patient’smother

Objective:

> inability tocougheffectively

>(+) cough

Ineffectiveairwayclearance r/t

presence of secretion in the

tracheobronchialtree.

Inability toclear secretions or

obstructionsfrom the

respiratorytract tomaintain a

clear airway.

Reference: NANDAEdit.11 p.77

Short Term:At the end of an8 hours shift the

pt will maintainairway patency

and be able toexpectorate/clear the secretions.

Long term:

Within a week of nursingintervention the

pt will be free

from cough andmaintain airwayclearance.

>Establish rapport.

>Monitor vital signs.

>Monitor and regulate

IVF.

> Monitor child for feeding intolerance.

>Keep environmentallergen free.

>Provide adequate rest.

>Position headappropriate for age/condition.

>Encourage to increaseOFI.

>Enhances sense of trustand nurse – clientrelationship

>To asses if there are any

irregularities and obtain baseline data.

>To ensure that the patient

is receiving the rightamount of IVF that aids inhydration.

>To assess if there is a presence of compromiseairway.

> To prevent further irritants that mayaggravate coughing.

> To promote wellness.

>To open or maintainopen airway in at-restindividual.

>Hydration can helpliquefy viscous secretions

and improve clearance.

Short Term:After 8 hours of nursing intervention

the patient shall havemaintain airway

patency and be able toexpectorate/clear thesecretions.

Long Term:

Within the week of nursing intervention,the patient shall be

free from cough and

maintain airwayclearance.




Knowledge

Planning Intervention Rationale Evaluation

Risk for fall Increasedsusceptibility tofalling that maycause physicalharm.

Reference:

NANDA Edit.11 p.291

Short Term:

After 8 hoursshift, the patient’smother willunderstand therisk factors thatcan contribute tofall.

Long Term:

Within the week of nursingintervention the

pt’s mother willdemonstrate

behaviors,lifestyle changesto reduce risk factor and protectthe pt from injury.

>Establish rapport.


>Monitor andregulate IVF.

>Provide a calm andquiet environment

>Discuss the need for supervision

>Maintain side rails.

>Enhances senseof trust and nurse

– clientrelationship

>To asses if thereis anyirregularities.

>To ensure thatthe patient isreceiving the right

amount of IVFthat aids in

hydration.

>Reduces stressand excessstimulation,

promoting rest

>To monitor themovements of thechild.

>To prevent thechild from falling.

Short Term:After the 8 hour shiftthe patient’s mother shall have understandthe risk factors thatcan contribute to fall

Long Term:

Within a week of intervention, the

patient’s mother shall

have demonstrated behaviors, lifestyle

changes to reducerisk factor and

protect the pt frominjury.




Knowledge

Planning Intervention Rationale Expected

Outcome

Risk for

imbalancednutrition less

than bodyrequirementsrelated to

decreasedswallowingappetitesecondary toATP

Tonsillopharyngitis

is acute infection of the pharynx or

palatine tonsils or both. Due toinfection

inflammationwould occur, thusseveral signs andsymptoms will also

be experience bythe patient. One of which is dysphagia.Or difficultyswallowing. Patient

may find it difficultto swallow foodespecially those

hard ones. The patient may also

experience loss of taste. Thus result to

poor intake of

foods making the patient at risk for

imbalancednutrition.

Short Term:

within 8 hours of nursing

intervention the patientwill be able to increaseher food and milk intake

Long Term:

Within a week of nursingintervention the patientwill be able to maintainstable weight and be freefrom any signs of

malnutrition.

>Establish rapport.


>Monitor and regulateIVF.

>Assess patient’sability to chew,swallow, and taste

foods

>Encourage patient’s

mother to let the patient eat soft diet

foods or eat smallamount of foodsfrequently

Weigh the patient on a

daily basis.>Provide a calm andquiet environment

>Discuss/implementeffective age-appropriate bedtimerituals.

>Enhances sense of

trust and nurse – clientrelationship

>To asses if there is anyirregularities.

>To ensure that the patient is receiving theright amount of IVFthat aids in hydration.

>to know other factorsthat can influence or affect ingestion of

foods.

>soft foods may not be

hard to swallow.

>to know if patient has

been gaining or loosingweight.

>Reduces stress andexcess stimulation,

promoting rest

Short Term:

within 8 hoursof nursing

intervention the patient shall beable to increase

her food andmilk intake

Long Term:Within a week of nursingintervention the

patient shall beable to maintainstable weight

and be freefrom any signs

of malnutrition.

atp - ncs.docx

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