IV.

Nursing Care Plan

Name: E.A.S
Date: October 25, 2019
S/O(Data) A P I E
(Focus) (Action) (Response)
Nursing Background Long Term Plan Short Term Plan Intervention Rationale Evaluation
Diagnosis Knowledge

Subjective: Rashes The rash in dengue To facilitate the Provide desired Stablish rapport To gains patient’s Goal not
“May rashes lang po fever is a maintenance of care trust and met.
ako sa braso at kamay maculopapular or fluid & cooperation
at tatlong araw na po macular confluent electrolytes Make patient
akong walang lagnat” rash over the face, Balance comfortable Facilitation of Help to control/
as verbalized by the thorax and flexes oral medication alleviate
patient surface, with islands To facilitate the Monitor vital symptoms
of skin sparing. The maintenance of signs
Objective: rash typically begins nutrition for all Monitored & Help to increase
 Rashes on day 3 and persists body cells Monitor IV regulated IVF at the amount of
 Redness 2-3 days. Fever fluids 35gtt/min body fluid
 Flushed skin typically abates with To facilitate the
 Afebrile the cessation of maintenance of Assess patient’s Encourage to To replace fluid
viremia elimination need increase oral fluid loss and to prevent
Hemoglobin: 152 intake dehydration
Hematocrit: 0.48 To maintain good
RCC: 4.61 hygiene & Instruct to avoid To monitor if there
WCC: 8.9 physical comfort dark colored food is a possible
Platelet: 60 bleeding inside
Neutrophils: 0.44 To use
Lymphocytes: 0.27 community Monitor and To have baseline
Eosinophils: 0.01 resources as an record vital signs data
Basophils: 0.02 aid to resolving
Monocytes: 0.26 problem that
arises for illness
 Date: October 26, 2019
S/O(Data) A P I E
(Focus) (Action) (Response)
Nursing Background Long Term Plan Short Term Intervention Rationale Evaluation
Diagnosis Knowledge Plan
Subjective -Risk for - This infectious - To promote safety - Monitor Monitored and To maintain hydration Goal not
“Wala namang bleeding disease is manifested through prevention patient’s IV regulated IVF at and help wash away met.
masakit sakin” as by a sudden onset of of accident, injury, fluid 30gtt/min toxin
verbalized by the fever, with severe or other trauma and
headache, muscle and through prevention - Provide Medication given To help alleviate
patient.
joint pains (myalgias of the spread of desired care symptoms
and arthralgias severe infection
Objective pain gives it the name - Make patient Instructed to avoid To monitor if there is a
>(+)rashes break bone fever or >To facilitate the comfortable dark colored food possible bleeding inside
>Redness bone crusher disease) maintenance of
>Afebrite and rashes and usually nutrition for all - Monitor vital Kept comfortable To prevent falls or
appears first on the body cells signs position injury
Hemoglobin:140 lower limbs and the
Hematocrit: 0.42 chest. There may also >To facilitate the - Assess the
RCC: 4.61 be gastritis and maintenance of patient’s need Encourage use of In the presence of
WCC: 5.8 sometimes bleeding fluid and soft bristle clotting factor
electrolyte balance toothbrush, disturbances, minimal
Platelet C: 58
avoiding straining trauma can cause
Neutrophils: 0.58 >To facilitate the for stool and mucosal bleeding
Lymphocytes: 0.27 maintenance of forceful nose
Eosinophils: 0.02 elimination blowing.
Basophils: 0.01
Monocytes: 0.12 >To understand the Monitor Hgb, Hct Indicators of anemia,
role of social and Platelet count active bleeding or
problems as severity of coagulation
influencing factors defect.
in the cause of
illness
 C. Medications (refer to Pharma format)

PARACETAMOL
Sanmol
Name of Classification: Mechanism of Action Indication and Side Effects Nursing Responsibilities
Drugs Contraindications
Generic Analgesic Paracetamol may cause Indication: Hematologic:  Observe for acute toxicity and
overdose.
Name: (Non-opoid) analgesia by inhibiting to relieve mild to thrombocytopenia,
● Caution parents or other caregivers
Paracetamol Antypyretic CNS prostaglandin moderate pain caused hemolytic not to give acetaminophen to
children
synthesis. The by headache, muscle anemia, neutropenia,
younger than age 2 without
Brand mechanism of morphine ache, backache, minor leukopenia, pancytopenia consulting prescriber first.
● Tell patient, parents, or other
Name: is believed to involve arthritis, common Hepatic: jaundice,
caregivers not to use drug
Sanmol decreased permeability cold, toothache, hepatotoxicity concurrently with other
acetaminophen-containing products.
of the cell membrane to or menstrual cramps Metabolic: hypoglycemic
● Advise patient, parents, or other
Dose: sodium, which results in or fever coma caregivers to contact prescriber if
fever or other symptoms persist
10mg IV diminished transmission Skin: rash, urticaria
despite taking recommended amount
of pain impulses Contraindication: Other: hypersensitivity of drug.
Hypersensitivity to ● Inform patients with chronic
Frequency: therefore analgesia reactions (such
alcoholism that drug may increase
Q4 drug as fever) risk of severe liver damage.
● As appropriate, review all other
significant and life-threatening
adverse reactions and interactions,
especially those related to the drugs,
tests, and behaviors mentioned
above.
CEFUROXIME
 Cefzime

Name of Drugs Classification: Mechanism of Action Indication and Side Effects Nursing Responsibilities
Contraindications
Generic Name: ANTIBIOTIC Second-generation Indication: Body as a Whole: Determine history of
CEFUROXIM cephalosporin that Treatment for surgical Thrombophlebitis (IV hypersensitivity reactions to
E inhibits cell wall prophylaxis, infection site); pain, burning, cephalosphorins, penicillin and
synthesis, promoting of the urinary and cellulitis, (IM site); history of allergies particularly to
Brand Name: osmotic instability; lower respiratory superinfection positive drugs before therapy is initited.
Cefzime usually bactericidal. tracts and skin and Coombs'test.
skin-structure Report onselt of loose stools
Dosage: infection caused by GI: Diarrhea nausea,
1 tab 500 mg Streptococcus antibiotic-associated Absorption of cefuroxime is
pneumoniae. colitis. enhance by food.
Route:
PO Contraindications: Skin Rash, pruritus, Notify prescriber about rashes or
Hypersensitive to urticaria. Urogenutal: superinfections
Frequency: drug, to penicillin Increased serum cretonne
BID because of possibility and BUN, decrease
of cross sensitivity creatinine clearance.
with other betalactam
antibiotics.