MELANIE CLAIRE TORILLO BSN2 LEININGER

Nursing Diagnosis Rationale Intervention Rationale Evaluation

Risk for infection Inspiration and/or Independent: Goal partially met.

related to Dilation expiration that does not
and curettage. provide adequate Assess the 1. To know if there are other After 8 hours of providing
ventilation. patient's complications that have occurred. nursing care, the patient
Subjective Data: swallowing was able to depict deep
Patient verbalized Schematic Diagram: ability. 2. To obtain knowledge if there are slow breaths, but has yet
“ga sakit akun pus other factors that could implicate to reach normal
on” Respiratory Distress Educate the the problem. respiration rate.
patient on proper
Objective Data: positioning. 3. To check if gas exchange is
Difficulty of breathing
● Post implicated due to respiratory
operative Regularly monitor distress.
pain 5/10 Increase respiratory the patient for
● rate signs and 4. Assessing respiratory status is
● Respiratory symptoms of crucial as this can serve as an
rate: 37 aspiration risk, informant if the patient has
Adventitious sounds such as coughing underlying cardiovascular or
Goals: during neurological disorders (Rawlings-
After 8 hours of Ineffective breathing swallowing, Anderson & Hunter, 2008).
providing nursing pattern pocketing of food
care, the patient will in cheeks, or wet 5. To check if there are
be able to establish voice quality. abnormalities in the patient’s
an effective chest.
breathing pattern as Evaluate patient’s
evidenced by respiratory 6. Proper health education to the
relaxed breathing at status. patient's guardian can help
a normal rate. alleviate the problem.
MELANIE CLAIRE TORILLO BSN2 LEININGER

7. To help with patient’s discomfort

and improve the patient's well-
being.

Observe chest
size, shape, and
symmetry.

Perform health
teachings (e.g.
optimal positions
for effective
breathing)

Dependent:

Administer
respiratory
medications and
therapies as
ordered.
Nursing Diagnosis Rationale Intervention Rationale Evaluation
Impaired gas Shortness of Independent: Goal unmet.
exchange related to CLAIRE
MELANIE breath TORILLO
serves asBSN2
a 1. Assess for
LEININGER 1. To detect
shortness of breath cardinal symptom, respiratory changes in After 4 hours of
as evidenced by indicating rate, depth, respiratory providing nursing
decrease in respiratory distress and effort status care, the patient
hemoglobin and and the body's regularly. promptly. demonstrates an
hematocrit. response to improvement in
hypoxia and 2. Place the 2. To optimize breathing but the
Subjective Data: hypoxemia. patient in a lung expansion oxygen saturation is
● Parent semi-fowler’s and facilitate still below its normal
reports Schematic position. breathing. level.
difficulty Diagram:
breathing 3. Encourage 3. To help thin
and the child Shortness of adequate fluid respiratory
appears breath intake. secretions,
restless. making them
easier to clear
Decrease in
Objective Data:
oxygen saturation
● Hct: 30.4% 4. Continuously 4. To determine if
● Hgb: 9.9 monitor hematocrit and
g/dL Ineffective tissue oxygen hemoglobin is
● Shortness of perfusion saturation in normal
breath - levels using range or still
dyspnea pulse oximetry. below.
● O2 saturation Occurrence of
- 90% hypoxia and 5. Engage the 5. To promote
hypoxemia patient in deep lung expansion
Goals: breathing and improve
After 4 hours of Impaired gas exercises. gas exchange.
providing nursing exchange
care, the patient will Dependent:
demonstrate 6. Administer 6. To alleviate
improved gas bronchodilator constriction
exchange as and antibiotic and improve
evidenced by drugs as gas exchange
normal oxygen ordered. and
saturation levels respiration.
(SpO2 > 95%). Collaborative:
7. Collaborate 7. To adjust
with physicians treatment
and respiratory plans based on
therapists. the patient's
response and
 MELANIE CLAIRE TORILLO BSN2 LEININGER

Nursing Diagnosis Rationale Intervention Rationale Evaluation

Imbalanced Imbalance in the Independent Goal met.

nutrition: less than nutritional needs of ● Assessed ● Identify
body requirements a person occurs nutritional deficiencies After 8 hours of
related to when the history. suspected of nursing intervention
insufficient dietary individual’s Including a the the patient’s guardian
intake as evidenced metabolic and preferred possibility of was able to verbalize
by weight loss, nutritional food. intervention. “amo na sya gale
muscle weakness, demands are not ● Provide ● helps patient dapat ya pgd
and reported lack of sufficiently information to determine kaonon”, and the
appetite. supplied. regarding nutritional patient's fluid intake
poor dietary needs has increased.
Schematic habits ● To
Subjective Data: Diagram: ● Monitor determine
Guardian intake and nutritional
verbalized, Insufficient dietary output and
“Kaniwang gne sa intake ● Look for elimination
iya wala sa bi permi physical problem
gana magkaon gd signs of poor ● to determine
Decrease in
damo” nutritional if the patient
muscle mass
intake. encountering
Objective Data: ● Give and nutritional
Muscle weakening help oral deficiencies
● Patient hygiene may
appears resemble to
weak. Weight loss be sluggish
● Patient does and fatigued.
not eat that Imbalanced ● Increase
much food. nutrition: less than appetite and
Goals: body requirements oral input
After 1 hour of
nursing intervention
 MELANIE CLAIRE TORILLO BSN2 LEININGER

the patient will be

able to drink more
milk and fluids, and
verbalize the
importance of
nutrition to their
body.

Name of Drug Content Mechanism of Action Indication

azithromycin dihydrate Azithromycin dihydrate Therapeutic Class: To treat mild community-

(Rozitan) Antibiotic acquired pneumonia, otitis
media, pharyngitis,
tonsillitis, and
200mg/5mL
Pharmacologic Class: uncomplicated skin and
2 mL soft-tissue infections caused
Macrolide
by susceptible bacteria
PO
MOA:
OD
Binds to a ribosomal subunit
of susceptible bacteria,
8 AM blocking peptide
MELANIE CLAIRE TORILLO BSN2 LEININGER

translocation and inhibiting

RNA-dependent protein
synthesis. Drug concentrates
in phagocytes, macrophages,
and fibroblasts, which release
it slowly and may help move it
to infection sites.

Contraindication Adverse Effects Nursing Considerations

History of cholestatic jaundice or hepatic CNS: Aggressiveness, agitation, ● Know that azithromycin should not
dysfunction associated with prior use of anxiety, asthenia, dizziness, fatigue, be used in patients who have
azithromycin; hypersensitivity to headache, hyperactivity, malaise, undergone donor stem cell
azithromycin, erythromycin, ketolide nervousness, paresthesia, seizures, transplant for cancer of the blood
antibiotics, other macrolide antibiotics or somnolence, syncope,vertigo or lymph nodes because of an
their components increased risk for cancer relapse
CV: Arrhythmias, chest pain, edema, and possibly death.
elevated serum CK level, ●
hypotension,palpitations, prolonged QT
interval, torsades de pointes, ventricular ● Monitor elderly patients closely for
tachycardia arrhythmias because they are
more susceptible to drug effects on
EENT: Hearing loss, oral candidiasis, the QT interval.
perversion or loss of taste or ●
smell,tinnitus, tongue discoloration ● Obtain culture and sensitivity test
results, if possible, before starting
ENDO: Hyperglycemia
therapy.
GI: Abdominal pain, anorexia, ●
cholestatic jaundice, constipation, ● Use azithromycin cautiously in
diarrhea,dyspepsia, elevated liver patients with hepatic dysfunction
MELANIE CLAIRE TORILLO BSN2 LEININGER

enzymes, flatulence, hepatic necrosis or not associated with prior use of

failure, azithromycin (drug is metabolized
in the liver) or renal dysfunction
hepatitis, nausea, pancreatitis, pyloric (effects are unknown in this group).
stenosis, pseudomembranous ●
colitis,vomiting
● Give azithromycin capsules 1 hour
GU: Acute renal failure, elevated BUN before or 2 to 3 hours after food.
and serum creatinine levels, Give tablets or suspension without
nephritis,vaginal candidiasis regard to food.
HEME: Leukopenia, neutropenia,
thrombocytopenia
MS: Arthralgia
SKIN: Acute generalized
exanthematous pustulosis, erythema
multiforme,photosensitivity, pruritus,
rash, Stevens–Johnson syndrome, toxic
epidermal necrolysis, urticaria

Name of Drug Content Mechanism of Action Indication

cetirizine hydrochloride cetirizine hydrochloride Therapeutic class: To treat acute urticaria

(Allecur) Antihistamine
Pharmacologic class:
5mg/ml Histamine-1 (H-1) receptor
0.5 mL antagonist
MOA: The
PO antihistaminic activity of
MELANIE CLAIRE TORILLO BSN2 LEININGER

cetirizine is mediated via

OD selective inhibition of
8AM peripheral H1-receptors to
alleviate urticaria.

Contraindication Adverse Effects Nursing Considerations

Hypersensitivity to cetirizine, CNS: Dizziness, fatigue, feeling hot, ● Know that Quzyttir is a single-use
hydroxyzine, levocetirizine, or their headache, insomnia, injectable product for intravenous
components irritability,paresthesia, presyncope, administration only.
sedation, somnolence
EENT: Dry mouth, epistaxis,
pharyngitis, taste alteration ● Be aware that intravenous use is
not recommended in children less
GI: Abdominal pain, diarrhea, than 6 years of age with impaired
dyspepsia, nausea, vomiting hepatic or renal function.
RESP: Bronchospasm, cough
● Institute safety precautions,
SKIN: Diaphoresis because drugs can cause sedation
and somnolence.

● Monitor patient’s status after

administration to note adverse
reactions of the medicine.
MELANIE CLAIRE TORILLO BSN2 LEININGER

● Instruct the guardian of the patient

that lethargic effects are normal
when antihistamine medicines are
administered.

Name of Drug Content Mechanism of Action Indication

albuterol sulfate albuterol sulfate Therapeutic class: To prevent exercise-induced

(Nasamed) Bronchodilator bronchospasm

2mg/5mL Pharmacologic class:

5 mL Adrenergic

PO MOA:
Albuterol attaches to beta2
TID receptors on bronchial cell
membranes, which
stimulates the intracellular
8AM - 1PM - 6PM
enzyme adenylate cyclase
to convert adenosine
triphosphate (ATP) to cyclic
adenosine monophosphate
(cAMP). This reaction
decreases intracellular
calcium levels. It also
increases intracellular levels
of cAMP, as shown.
Together, these effects
MELANIE CLAIRE TORILLO BSN2 LEININGER

relax bronchial smooth

muscle cells and inhibit
histamine release.

Contraindication Adverse Effects Nursing Considerations

Hypersensitivity to albuterol or its CNS: Anxiety, dizziness, drowsiness, ● Assess for the patient's vital signs
components headache, hyperkinesia, before administration to serve as a
insomnia,irritability, nervousness, baseline after administering the
tremor, vertigo, weakness ordered drug.
● Administer pressurized inhalations
CV: Angina, arrhythmias, chest pain,
hypertension, hypotension, of albuterol during second half of
palpitations inspiration, when airways are
● open wider and aerosol distribution
EENT: Altered taste, dry mouth and is more effective.
throat, ear pain, glossitis,
hoarseness,oropharyngeal edema,
pharyngitis, rhinitis, taste perversion ● Monitor serum potassium level
because albuterol may cause
ENDO: Hyperglycemia
transient hypokalemia.
GI: Anorexia, diarrhea, dysphagia,
heartburn, nausea, vomiting, ● Be aware that drug tolerance can
GU: UTI develop with prolonged use.
MS: Muscle cramps
● Monitor for abnormal changes in
RESP: Bronchospasm, cough, the patient’s vital signs in order to
dyspnea, paradoxical halt or change medication as
bronchospasm,Pulmonary edema ordered by the physician.
MELANIE CLAIRE TORILLO BSN2 LEININGER

SKIN: Diaphoresis, flushing, pallor,

pruritus, rash, urticaria

Nursing Diagnosis Rationale Intervention Rationale Evaluation

Independent: 1. To address the risk for aspiration by Goal met.
Risk for aspiration related closely monitoring the patient's level of
to decreased level of Decreased level of
1. Assess the patient’s consciousness post-operatively to prevent After 8 hours of providing
consciousness and post- consciousness and the
level of consciousness potential airway compromise. care, the patient was able
operative status. physiological stress of surgery
and responsiveness maintain a clear airway w
compromise the patient’s ability
using a standardized 2. To mitigate the risk, implementing signs of aspiration, indica
to protect their airway,
tool like the Glasgow appropriate positioning techniques. successful prevention me
Subjective Data: increasing the likelihood of
Coma Scale. and effective managemen
aspiration.
3. To further safeguard against aspiration,
2. Educate the patient timely interventions such as suctioning
● Patient reports
and family members and oral care to prevent pooling of
feeling drowsy. Schematic Diagram: about the importance secretions.
● Patient feels of maintaining a safe
nauseated. Decreased level of swallowing 4. To ensure effective management,
● Abdominal pain consciousness environment, avoiding interdisciplinary collaboration among
scale of 6/10. large or hard-to- healthcare professionals to identify and
swallow foods, and address any signs or symptoms of
Post-operative status recognizing signs of aspiration.
Objective Data: aspiration, such as
coughing or choking.
● Patient is Potential aspiration
observed to be 3. Assess respiratory
half awake and rate, depth, and effort
restless. Risk for Aspiration regularly to detect any
MELANIE CLAIRE TORILLO BSN2 LEININGER

● Fluctuating signs of respiratory

oxygen saturation distress or aspiration
values, requiring early.
nasal cannula.
4. Keep the patient's
head elevated to at
Goals: least 30 degrees to
After 8 hours of providing reduce the risk of
nursing care, the patient aspiration during sleep
will maintain a clear airway or periods of
without signs of aspiration. decreased
consciousness.

5. Assist the patient to

maintain good upright
posture during feeding
and medication
administration.