Impaired Ventilation

Nursing Care Plan Problem Impaired respiration Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation Subjective Impaired unrehearsed ventilation Within 8hrs of nursing In bloodsucking Gi ubo/sipon siya before na related to accumulation of hurrying interventions the pt wont After 8hrs of nursing disgrasya.Pagka disgrasya naka inum airways secretions secondary to VAexhibit signs of respiratory Assess pts condition To know and determine pts need interventions the pts siya ug mga dugo niya monoamine oxidase nang distress or infection temperature has risen to gibutangan siya ana (tracheostomy) To establish baseline data Temp. 38. 0C but isnt show para ma suyop to ky mag lisud man Assess and monitor clients temperature. above 37. 5? C may suggest acute signs of respiratory siya ginhawa.. As verbalized by the infectious distemper process. distress mother. To facilitate breathing Goal Partially Met Objective Elevate head of bed and coordinate head in the middle Increased use of accessory muscles Raise side rails For guard measures Irritable Provide TSB Water applied to skin causes the pores Restlessness to open allowing excess heat to escape. evaporation creates cooling Creatinine and SGPT(ALT) Result process. 0. 60mg/dL below 55. 0 U/L higher Independent complete blood count Result higher than normal range WBC 14. 9 Administered medications as prescribed by AP Tramadol 50mg IVTT q8 PRN Pain reliever Vital Signs Cefuroxime 750mg IVTT q8 T 38. 0C Salbutamol 1neb q6 2nd gen. arenteral cephalosporin P 77 antibiotic R 23 Bronchodilator IVF PNLR 30gtts/min as ordered by AP Collaboration To replenish fluid losings during evaporation of fluid in the body. Creatinine and SGPT(ALT), CBC sent out to Medtech Lab as ordered by AP To determine possible infection. Drug Study Cefuroxime 750mg IVTT q8 Powder for injection 750mg, 1. 5g, 7. 5g Premixed containers 750 mg/50ml, 1. g/50ml microbe Davis Drug Guide for Nurses 10th Edition Therapeutic Anti-infectives Pharmacologic Second generation Cephalosporins Pregnancy Catergory B Bind to bacterial cell wall membrane, causing cell death Therapeutic Effects bactericidal action Treatment It is effective for the treatment of penicillinaseproducingNeisseria gonorrhoea(PPNG). Effectively treats bone and joint infections, bronchitis, meningitis, gonorrhea, otitis media, pharyngitis/tonsilliti s, sinusitis, lower respiratory tract infections, skin and soft tissue infections, urinary tract infections, and is used for surgical prophylaxis, reducing or eliminating infection.Hypersensitivity to cephalosporins and related antibiotics pregnancy (category B), lactation. GI Diarrhea, nausea, antibiotic- associated colitis. Skin Rash , pruritus, urticaria. Urogenital Increased serum creatinine and BUN, decreased crea tinine clearance. Hemat haemolytic anemia MISC Anaphylaxis Before Determine history of hypersensitivity reacti ons to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated. Lab tests Perform finish and sensitivity tests before initiation of therapy and sporadically during therapy if indicated. Therapy may be instituted pending test results. monitor periodically BUN and creatinine clearance. DuringInspect IM and IV injection sites frequently for signs of phlebitis. Monitor for manifestations of hypersensitivity Tramadol 50mg IVTT q8 PRN Therapeutic Analgesics (centrally acting) Actions Physiologic tool Decreased pain. Pharmacologic Mechanism Binds to mu-opioid receptors. Inhibits reuptake of serotonin and norepinephrine in the CNS. Indication Moderate to fair severe pain Nursing Care Assess type, location, and intensity of pain before and 2-3 hr (peak) by and by administration. Assess BP & RR before and periodically dur ing administration. Respiratory depression has non occurred with recommended doses. Assess bowel function routinely.Prevention of impairment should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects. Assess previous analgesic history. Tramadol is not recommended for patients dependent on opioids or who have previously received opioids for more than 1 wk may cause opioid withdrawal symptoms. Prolonged use may lead to physical and mental dependence and tolerance, although these may be milder than with opioids. This should not prevent patient from receiving adequate analgesia. Most patients who receive tramadol for pain d not develop psychological dependence. If tolerance develops, changing to an opioid agonist may be required to relieve pain. Tramadol is considered to provide more analgesia than codeine 60 mg but less than combined aspirin 650mg/codeine 60 mg for acute postoperative pain. Monitor patient for seizures. May occur within recommended dose range. Risk increased with higher doses and inpatients taking antidepressants (SSRIs, tricyclics, or Mao inhibitors), opioid analgesics, or other durgs that decrese the seizure threshold. Overdose may cause respiratory depression and seizures. naloxone (Narcan) may reverse some, but not all, of the symptoms of overdose. Treatment should be symptomatic and supportive. Maintain adequate respiratory exchange. Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and pneumonia.