Impaired Ventilation

Nursing Care Plan Problem damage Ventilation valuatement Nursing Diagnosis Planning Intervention rule Evaluation Subjective Impaired spontaneous ventilation Within 8hrs of treat Independent Gi ubo/sipon siya in the lead na related to accumulation of upper berth interventions the pt wont After 8hrs of nursing disgrasya.Pagka disgrasya naka inum airways secretions secondary to VA evidence signs of respiratory Assess pts condition To know and adjudicate pts need interventions the pts siya ug mga dugo niya mao nang straiten or infection temperature has risen to gi yetangan siya ana (tracheostomy) To establish baseline data Temp. 38. 0C but isnt showing para ma suyop to ky mag lisud man Assess and monitor clients temperature. above 37. 5? C whitethorn suggest crafty signs of respiratory siya ginhawa.. As verbalized by the morbific disease process. distress mother. To facilitate breathing Goal Partially Met bearing Elevate head of bed and alig n head in the snapper Increased use of accessory muscles Raise side rails For condom measures Irritable Provide TSB Water applied to skin causes the pores Restlessness to unmortgaged allowing excess heat to escape. Evaporation creates cooling Creatinine and SGPT(ALT) settlement process. 0. 60mg/dL below 55. 0 U/L higher Independent CBC Result higher than normal range WBC 14. 9 Administered medications as incontrovertible by AP Tramadol 50mg IVTT q8 pro re nata 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 unstable losses during evaporation of fluid in the body. Creatinine and SGPT(ALT), CBC sent step to the fore to Medtech Lab as ordered by AP To determine poss ible infection. window pane Study Cefuroxime 750mg IVTT q8 Powder for injection 750mg, 1. 5g, 7. 5g Premixed containers 750 mg/50ml, 1. g/50ml showtime Davis Drug Guide for Nurses 10th Edition Therapeutic Anti-infectives Pharmacologic secant generation Cephalosporins Pregnancy Catergory B Bind to bacterial cell ring membrane, causing cell death Therapeutic Effects Bactericidal meet 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 motherhood (category B), lactation. GI Diarrhea, nausea, antibiotic- associated colitis. Skin Rash , pruritus, urticaria. Urogenital Increased seru m creatinine and BUN, decreased creatinine clearance. Hemat Hemolytic anemia MISC Anaphylaxis Before Determine history of hypersensitivity reacti ons to cephalosporins, penicillins, and history of allergies, curiously to drugs, before therapy is initiated. Lab tests Perform culture and sensitivity tests before creation 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 Mechanism Decreased pain. Pharmacologic Mechanism Binds to mu-opioid receptors. Inhibits reuptake of serotonin and norepinephrine in the CNS. Indication Moderate to moderately prankish pain Nursing Care Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. As sess BP & RR before and periodically during administration. Respiratory opinion has non occurred with recommended doses. Assess bowel function routinely.Prevention of constipation should be instituted with change magnitude 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 to a greater extent than 1 wk may cause opioid withdrawal symptoms. Prolonged use may lead to physical and psychological 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 printing 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 up and breathe deeply every 2 hr to prevent atelactasis and pneumonia.