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VIII NCP

DATA NURSING DX OBJECTIVES NURSINGINTERVENTIONS

RATIONALE EVALUATION

SUBJECTIVE CUES:Bigla ako nahirapan

h!inga"# a$

%&r'ali(&) '* +h&pa+i&n+

OBJECTIVE CUES:

Ta,h*pn&aDiaphor&$i$

D*$pn&a

R&$+l&$$n&$$

INE--ECTIVEBREAT.ING

PATTERN

S.ORTTER/:

A0+&r 12

!in+&$ o0nr$ing

in+&r%&n+ion3pa+i&n+ 4ill

)&!on$+ra+&a)&5a+&

'r&a+hing

pa++&rn# 4i+h&a$*# nla'or&)

r&$pira+ion$

3 Pa+i&n+ 4ill

)&!on$+ra+&,orr&,+

+&,hni5& inpr$&)6lip

'r&a+hing#

a')o!inal'r&a+hing an)

r&la7a+ion+&,hni5&$8

Pro%i)& r&la7ing

&n%iron!&n+

El&%a+& pa+i&n+

h&a)

A$$i$+ pa+i&n+ in+h& $& o0

r&la7a+ion+&,hni5&$

T&a,h pa+i&n+ on

pr$&)6lip

'r&a+hing#a')o!inal

'r&a+hing an)

r&la7a+ion+&,hni5&$

DEPENDENT:

Ch&$+

+hora,o$+o!*

+'&

To pro!o+&

a)&5a+& r&$+

p&rio)$ an) +o

li!i+ 0a+ig&

To pro!o+& lng

&7pan$ion

To !a7i!i(&o7*g&n a%aila'l&

0or ,&lllarp+ak&

Th&$& a,+i%i+i&$

allo4 pa+i&n+

par+i,ipa+& in!ain+a+inng

h&al+h $+a+$ an)

%&n+ila+ion

To r&!o%& &7,&$$

0li) 0ro! pl&ral

$pa,&

S.ORT TER/:

Th& pa+i&n+ $hall

ha%& )&!on$+ra+&)appropria+& ,oping

'&ha%ior$ an)!&+ho) +o i!pro%&

'r&a+hing pa++&rn

LONG TER/ :

Th& pa+i&n+ $hall

ha%& appli&)+&,hni5&$ +ha+

i!pro%&) 'r&a+hing

pa++&rn

r&$pira+or* ra+&4i+hin nor!al

rang&

&00&,+i%& 'r&a+hing

an) !ini!al $&)o0 a,,&$$or*

!$,l&$ )ring'r&a+hing

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DATA NURSING DX OBJECTIVES NURSINGINTERVENTIONS

RATIONALE EVALUATION

SUBJECTIVECUES:

OBJECTIVE

CUES:Pr&$&n,& o0

,h&$++hora,o$+o!*

+'& a+ +h& righ+!i)a7illiar*

ar&a

Op&n

&n%iron!&n+

Ri$k 0or in0&,+ionr&la+&) +o $rgi,al

pro,&)r& a$&%i)&n,&) '*

pr&$&n,& o0 righ+

!i)a7illar* ,h&$++hora,o$+o!* +'&

S.ORT TER/:

A0+&r 12!in+&$ o0nr$ing in+&r%&n+ion

+h& pa+i&n+ 4ill '&a'l& +o i)&n+i0*

'&ha%ior an)pra,+i,& +o pr&%&n+

an) r&),& +h& ri$k0or in0&,+ion

LONG TER/:

A0+&r )a*$ o0 gi%ing

nr$ing in+&r%&n+ion

+h& ,li&n+ 4illa,hi&%&) +i!&l*

4on) h&aling 0r&& o0$ign$ o0 in0&,+ion an)

in0la!!a+ion

INDEPENDENT

S+r&$$ an) !o)&l

prop&r han)4a$hing +&,hni5&$

+o ,li&n+ an),ar&gi%&r

/ain+ain a$&p+i,

+&,hni5& 4i+h an*

pro,&)r&$8 Pro%i)&

ro+in& $i+& ,ar& an)4on) ,ar& a$

appropria+&

In$p&,+ )r&$$ing no+

,hara,+&ri(&) '*)rainag&

En,orag& 0r&5&n+po$i+ion ,hang&$

an) '&ing o+ o0'&) or &arl*

a!'la+ion a$

+ol&ra+&)

/oni+or %i+al $ign$

R&),& ,ro$$

,on+a!ina+ion an)'a,+&rial ,oloni(a+ion#

Pr&%&n+ &n+r& o0 'a,+&ria

r&),ing ri$k 0or

in0&,+ion

Earl* )&+&,+ion o0

)&%&loping in0&,+ionpro%i)&$ oppor+ni+* 0or

+i!&l* in+&r%&n+ion an)

pr&%&n+ion an) !or&$&rio$ ,o!pli,a+ion

Li!i+ $+a$i$ o0 'o)*0li)$ pro!o+&$ op+i!al

0n,+ional organ $*$+&!an) ga$+roin+&$+inal +ra,+

To ha%& 'a$& lin& )a+a

S.ORT TER/:Th& pa+i&n+ $hall

i)&n+i0* '&ha%ioran) pra,+i,& in

pr&%&n+ing

in0&,+ion

LONG TER/ :

Th& pa+&n+ $halla,hi&%& 4on)

h&aling an) 0r&&

0ro! in0&,+ion an)in0la!!a+ion

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DEPENDENT:

A)!ini$+&r

an+i'io+i,$ a$in)i,a+&)

$p&,iall* in,r&a$&+&!p&ra+r&

9i)& $p&,+r!

an+i'io+i,$ !a* '& $&)proh*la,+i,all* or

an+i'io+i, +h&rap* !a*

'& g&ar&) +o4ar)$p&,i0i, organi$!

DATA NURSING DX OBJECTIVES NURSING RATIONALE EVALUATION

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INTERVENTIONS

SUBJECTIVE CUES:

$!a$aki+ *ng )i+oko" a$ %&r'ali(&) '* +h&

pa+i&n+

Pa+i&n+ %&r'ali(&) pain

$,al& o0 o+ o0 ;28

OBJECTIVE CUES:

-a,ial gri!a,&

Gar)&) '&ha%ior

on +h& CTT $i+&

Ta,h*pn&a

RR: 12

D*$pn&a

ACUTE PAIN

RELATED TOPLACE/ENT O-

C.ESTT.ORACOSTO/&,+$

Thi$ pro!o+&$

h&al+h# 4&ll6'&ing#

an) in,r&a$&)

&n&rg* l&%&l

i!por+an+ +o pain

r&li&08

D&&p 'r&a+hing

&7&r,i$&$ ,on+ri'+&

+o r&li&0 o0 pain

Onl* +h& ,li&n+ ,an

>)g& +h& l&%&l an))&gr&& o0 pain3 pain

!anag&!&n+ $hol)

'& a +&a! approa,h

+ha+ in,l)&$ +h&

,li&n+

S.ORT TER/:

Th& pa+i&n+ $hal

ha%& r&por+&)pain i$ r&li&%&)

0ro! a pain $,al

o0 ?;2 +o 1?;2

LONG TER/ :

Th& pa+i&n+ $hal

'& 0r&& 0ro! paia$ &%i)&n,&) '

)&!on$+ra+ion or&la7a+ion $kill

an) )i%&r$ional

a,+i%i+i&$

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DEPENDENT:

A)!ini$+&r

!&)i,a+ion$#

@g&o,&+ =!g ; +a'

PRN 0or pain

To r&li&%& pain

IX DRUG STUD

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DRUG ORDER@G&n&ri, na! 'ran)

na! ,la$$i0i,a+ion#)o$ag ro+

0r&5&n,*

/EC.ANIS/

O- ACTION

INDICATIONS

CONTRAINDICATIONS ADVERSE E--ECTS O-T.E DRUG

NURSING

RESPONSIBILITIES?PRECAUTIONS

G&n&ri, Na!&:C&0ro7i!&

Cla$$i0i,a+ion:An+i'io+i,

Do$ag&:

22 !g +a'

Ro+&:

oral

-r&5&n,*:BID

Ba,+&ri,i)al:Inhi'i+$

$*n+h&$i$ o0'a,+&rial ,&ll

4all# ,a$ing,&ll )&a+h

Lo4&rr&$pira+or*

in0&,+ion$

,on+rain)i,a+&) 4i+hall&rg* +o ,&phalo$porin$

or p&ni,illin$U$& ,a+io$l* 4i+h &nal

0ailr la,+a+ion#pr&gnan,*

CNS: .&a)a,h )i((in&$$#l&+harg*

GI: Na$&a# %o!i+ing#

)iarrh&a# anor&7ia#a')o!inal pain# 0la+l&n,

li%&r +o7i,i+*

GU: N&phro+o7i,i+*

.&!a+ologi,: Bon&

!arro4 )&ppr&$$ion

@ )&,r&a$&) 9BC#)&,r&a$&) pla+&l&+$#

)&,r&a$&) .,+8

.*p&r$&n$i+i%i+*: Ranging

0ro! ra$h +o 0&%&r +oanaph*la7i$# $&r!

$i,kn&$$ r&a,+ion

Lo,al: Pain# a'$,&$$ a+in>&,+ion $i+ phl&'i+i$#

in0la!!a+ion a+ IV $i+&

NR:

Cl+r& in0&,+ion# n)arrang& 0or $&n$i+i%i+* +&$+$

'&0or& an) )ring +h&rap* i0&7p&,+&)# r&$pon$& i$ no+

$&&n

Gi%& oral )rg 4i+h 0oo) +o)&,r&a$& GI p$&+ an)

&nhan,& a'$orp+ionGi%& oral )rg +o ,hil)r&n

4ho ,an $4allo4 +a'l&+$:

,r$hing +h& )rg r&$l+$ ina 'i++&r# npl&a$an+ +a$+&