X.

DRUG STUDY
Generic Name Paracetamol Brand Name Biogesic Dosage 250mg/ 5ml 4mL q4 oral Classification Analgesic Antipyretic Indication To relieve fever and pain Contraindication Hypersensitivity Adverse Reaction Nausea, vomiting, abdominal pain Nursing Consideration
Monitor the patients vital signs especially VS plus report of pain. Observe proper dosage of medications. If the patient has fever, give medications, then check temperature every 15 minutes to note whether the fever has subside. Watch out for any adverse reactions. Assess the patients condition. Monitor vital signs. Note for the number of times the patient vomit. Note for any side effects and report it to the attending physician.

Metoclopramide Plasil

30 mg IV

Anti-emetic

To relieve vomiting

GI hemorrhage, epileptics

Nausea, vomiting, headache, dizziness, fatigue

XI. NURSING CARE PLAN

Assessment S> Hindi nya masyadong maigalaw ang paa nya, as verbalized by the patients mother. Diagnosis Impaired physical mobility related to musculoskeletal impairment as evidenced by limited ROM. Planning After 8 hours of nursing intervention, the patient will be able to slightly move the affected leg. Intervention Assess the patients condition. Monitor VS. Assess degree of pain. Position client from time to time. Administer medications as prescribed to permit maximal effort and involvement in activity. Schedule activities with adequate rest periods during the day to reduce fatigue. Provide safety measures Provide health teachings such as: Advise patient to have high fiber diet, high protein diet, vitamin C intake and increased fluid intake. Evaluation Goal met: After 8 hours of nursing intervention, the patient has been able to move slightly her affected leg

O> limited range of motion - Slowed movement - Difficulty turning -

Assessment S> Sumasakit daw yung paa nya, as verbalized by the patients mother.

Diagnosis Pain related to insertion of Steinman pin on the affected femur.

Planning After 4 hours of nursing intervention, the patient will report decrease of pain from pain scale of 8 to pain scale of 4.

O> restlessness - Irritable - Crying - Guarding behavior - Pain scale of 8

Intervention Assess the patients condition. Monitor VS plus COLDSPA. Position client from time to time. Administer medications as prescribed to permit maximal effort and involvement in activity. Encourage diversional activities like giving coloring book and materials. Provide safety measures. Encourage adequate rest periods to prevent fatigue. Provide health teachings such as: Advise patient to have high fiber diet, high protein diet, vitamin C intake and increased fluid intake.

Evaluation Goal met: After 4 hours of nursing intervention, the patient reported that there had been a decreased in pain from pain scale of 8 to 5.

Assessment S> Hindi siya makagalaw ng ayos, as verbalized by the patients mother.

Diagnosis Activity intolerance related to application of balance skeletal traction as evidenced by limited ROM.

Planning After 8 hours of nursing intervention, the patient will be able to do activities.

Intervention
Assess the patients condition. Monitor VS plus COLDSPA. Position client from time to time. Administer medications as prescribed to permit maximal effort and involvement in activity. Encourage diversional activities like giving coloring book and materials. Provide safety measures. Advise patient to do deep breathing and coughing exercise and toe pedal exercises. Encourage adequate rest periods to prevent fatigue. Provide health teachings such as: Advise patient to have high fiber diet, high protein diet, vitamin C intake and increased fluid intake.

Evaluation Goal met: After 8 hours of nursing intervention, the patient has been able to do activities.

O> restlessness - Limited ROM - Irritability

Assessment S> Hindi pa rin siya pwedeng lumakad, as verbalized by the patients mother.

Diagnosis Impaired walking related to pain on the insertion site.

Planning After 8 hours of nursing intervention, pain on the insertion site will decrease.

Intervention
Assess the patients condition. Monitor VS plus COLDSPA. Position client from time to time. Administer medications as prescribed to permit maximal effort and involvement in activity. Encourage diversional activities like giving coloring book and materials. Provide safety measures. Advise patient to do deep breathing and coughing exercise and toe pedal exercises. Encourage adequate rest periods to prevent fatigue. Provide health teachings such as: Advise patient to have high fiber diet, high protein diet, vitamin C intake and increased fluid intake.

Evaluation Goal met: After 8 hours of nursing intervention, pain on the insertion site has decreased.

O> restlessness - Limited ROM - Irritability - Steinman pin insertion on the femur

Assessment S> Di siya kumakain ng maayos,pumapayat na sya lalo, as verbalized by the patients mother.

Diagnosis Imbalance nutrition less than body requirements related to lack of interest in food.

Planning After 8 hours of nursing intervention, the patient will show interest in food.

O> restlessness - Low of weight - Irritability - Poor appetite

Intervention Assess the patients condition. Monitor VS. Have a good food service and make it appealing to the childs eye. Administer medications as prescribed. Encourage adequate rest periods to prevent fatigue. Provide health teachings such as: Advise patient to have high fiber diet, high protein diet, vitamin C intake and increased fluid intake.

Evaluation Goal met: After 8 hours of nursing intervention, pain on the insertion site has decreased.