VIII NCP

DATA

NURSING DX

OBJECTIVES

SUBJECTIVE CUES:
Bigla ako nahirapan
huminga, as
verbalized by the
patient

INEFFECTIVE
BREATHING
PATTERN

SHORT
TERM:
After 30
minutes of
nursing
intervention;
patient will
demonstrate
adequate
breathing
pattern, with
easy, unlabored
respirations

OBJECTIVE CUES:
Tachypnea
Diaphoresis
Dyspnea
Restlessness

; Patient will
demonstrate
correct
technique in
pursed-lip
breathing,
abdominal
breathing and
relaxation
techniques.

NURSING
INTERVENTIONS

RATIONALE

EVALUATION
SHORT TERM:

Provide relaxing
environment

To promote
adequate rest
periods and to
limit fatigue

Elevate patient
head

To promote lung
expansion

Assist patient in
the use of
relaxation
techniques

To maximize
oxygen available
for cellular
uptake

Teach patient on
pursed-lip
breathing,
abdominal
breathing and
relaxation
techniques

These activities
allow patient
participate in
maintatinng
health status and
ventilation

DEPENDENT:
Chest
thoracostomy
tube

To remove excess
fluid from pleural
space

The patient shall

have demonstrated
appropriate coping
behaviors and
method to improve
breathing pattern
LONG TERM :
The patient shall
have applied
techniques that
improved breathing
pattern
respiratory rate
within normal
range
effective breathing
and minimal used
of accessory
muscles during
breathing

DATA
SUBJECTIVE
CUES:
OBJECTIVE
CUES:
Presence of
chest
thoracostomy
tube at the right
midaxilliary
area
Open
environment

NURSING DX
Risk for infection
related to surgical
procedure as
evidenced by
presence of right
midaxillary chest
thoracostomy tube

OBJECTIVES
SHORT TERM:
After 30minutes of
nursing intervention
the patient will be
able to identify
behaviour and
practice to prevent
and reduce the risk
for infection

NURSING
INTERVENTIONS
INDEPENDENT
Stress and model
proper hand
washing techniques
to client and
caregiver

Reduce cross
contamination and
bacterial colonization,

EVALUATION

Maintain aseptic
technique with any
procedures. Provide
routine site care and
wound care as
appropriate

Prevent entre of bacteria

reducing risk for
infection

Inspect dressing not

characterized by
drainage

Early detection of
developing infection
provides opportunity for
timely intervention and
prevention and more
serious complication

Encourage frequent
position changes
and being out of
bed or early
ambulation as
tolerated

Limit stasis of body

fluids promotes optimal
functional organ system
and gastrointestinal tract

Monitor vital signs

To have base line data

LONG TERM:
After days of giving
nursing intervention
the client will
achieved timely
wound healing free of
signs of infection and
inflammation

RATIONALE

SHORT TERM:
The patient shall
identify behaviour
and practice in
preventing
infection
LONG TERM :
The patent shall
achieve wound
healing and free
from infection and
inflammation

specially increase
temperature
DEPENDENT:
Administer
antibiotics as
indicated

DATA

NURSING DX

OBJECTIVES

NURSING

Wide spectrum
antibiotics may be used
prohylactically or
antibiotic therapy may
be geared toward
specific organism

RATIONALE

EVALUATION

SUBJECTIVE CUES:
sumasakit yung dito
ko as verbalized by the
patient
Patient verbalized pain
scale of 6 out of 10.
OBJECTIVE CUES:
Facial grimace
Guarded behaviour
on the CTT site
Tachypnea
RR: 30
Dyspnea

ACUTE PAIN
RELATED TO
PLACEMENT OF
CHEST
THORACOSTOMY
TUBE

SHORT TERM:
After 3 hours of
nursing intervention
the patient will be
able to report a
decrease of pain.
LONG TERM:
After 2 days of
nursing interventions
the patient will be
free from pain and
demonstrate
relaxational skills.

INTERVENTIONS
Perform comfort
measures to
promote relaxation
such as
repositioning and
relaxation
techniques.

These measures
reduce muscle
tension or spasm,
and help patient
focus on non-pain
related subjects

Manipulate the
environment to
promote periods of
uninterrupted rest

Encourage and
assist client to do
deep breathing
exercises

Deep breathing
exercises contribute
to relief of pain

Encourage
verbalization and
feelings of pain

Only the client can

judge the level and
degree of pain; pain
management should
be a team approach
that includes the
client

This promotes
health, well-being,
and increased
energy level
important to pain
relief.

SHORT TERM:

The patient shal

have reported
pain is relieved
from a pain scale
of 6/10 to 3/10

LONG TERM :

The patient shal

be free from pain
as evidenced by
demonstration of
relaxation skills
and diversional
activities

DEPENDENT:
Administer
medications,
(geocet 25mg 1 tab
PRN for pain)

IX DRUG STUDY

To relieve pain

DRUG ORDER
(Generic name, brand
name, classification,
dosage, route,
frequency)
Generic Name:
Cefuroxime
Classification:
Antibiotic
Dosage:
500 mg tab
Route:
oral
Frequency:
BID

MECHANISM
OF ACTION

INDICATIONS

Bactericidal:
Inhibits
synthesis of
bacterial cell
wall, causing
cell death

Lower
respiratory
infections

CONTRAINDICATIONS

ADVERSE EFFECTS OF
THE DRUG

contraindicated with
allergy to cephalosporins
or penicillins
Use cautiously with enal
failure, lactation,
pregnancy

CNS: Headache, dizziness,

lethargy
GI: Nausea, vomiting,
diarrhea, anorexia,
abdominal pain, flatulence,
liver toxicity
GU: Nephrotoxicity
Hematologic: Bone
marrow deppression
( decreased WBC,
decreased platelets,
decreased Hct).
Hypersensitivity: Ranging
from rash to fever to
anaphylaxis, serum
sickness reaction
Local: Pain, abscess at
injection site, phlebitis,
inflammation at IV site

NURSING
RESPONSIBILITIES/
PRECAUTIONS

NR:
Culture infection, nd
arrange for sensitivity tests
before and during therapy if
expected, response is not
seen
Give oral drug with food to
decrease GI upset and
enhance absorption
Give oral drug to children
who can swallow tablets:
crushing the drug results in
a bitter, unpleasant taste