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Subjective cues: Ineffective airway The inflammatory Short Term: >Assessed >Use of accessory
The client
“Nahihirapan na clearance related response to respiratory muscles to breathe
maintained airway
siya huminga
to ineffective infection causes After 4 hours of movements and use indicates an abnormal
dahil sa plema patency as
hindi niya cough and tissue edema and nursing of accessory increase in work of
evidenced by
mailabas, grabe
retained exudates formation interventions, the muscles. breathing.
na expectorating clear
kasi ang ubo niyan secretions. in the lungs, the client will be able
secretions readily.
eh” as verbalized
inflammatory to maintain airway >Monitored vital >To obtain baseline
by his mother
response can patency. signs especially the data.)
Objective cues: narrow and RR.
>difficulty of potentially obstruct Long Term:
breathing bronchial passages >Auscutated the >Bronchial lung
and alveoli. After 1 day of lung sounds, noting sounds are commonly
nursing
>Wheezes on areas of decreased heard over areas of
intervention, the
both lung fields ventilation and lung density or
client will be presence of consolidation.
able to
>productive cough expectorate adventitious sounds. Crackles are heard
– whitish color retained when fluid is present.
secretions and
maintain normal
>nasal flaring >Monitored chest x >These determine
– ray reports. progression of disease
>restlessness breathing process.)
pattern.
>Discuss
importance of
adequate fluid >To prevent
intake and dehydration
protein diet
Collaborative:
>Administer
medications as >To treat
indicated to underlying
treat underlying causes
cause, such as:
-Paracetamol
325mg/tab 1 tab q
6°
>To support
>Administer circulating
replacement volume and
fluids and tissue perfusion
electrolytes to
support
circulating
volume and
tissue perfusion
ASSESSMENT NURSING RATIONALE GOAL NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Generic Name: Child :IV/IM 6–7.5 Chemical Effect: Parenteral use History of >upset stomach > Lab tests:
Gentamicin Sulfate mg/kg/d in 3–4 restricted to hypersensitivity to Perform C&S and
divided treatment of or toxic reaction >vomiting renal function prior
Brand dosesIntrath ecal > serious infections with any to first dose and
Name:Garamycin >3 mo, 1–2 mg Aminoglycoside; of GI, aminoglycoside >fatigue periodically during
preservative free actively transported respiratory, and antibiotic. Safe use therapy; therapy
q.d. urinary tracts, CNS, during pregnancy >pale skin may begin pending
across the bacterial
bone, skin, and soft (category C) or test results.
cell membrane,
tissue (including lactation is not
binds to a specific burns) when other established >Determine
receptor protein on less toxic Bacterial and fungal creatinine
the 30 S subunit of antimicrobial corneal ulcers have clearance and
bacterial agents are developed during serum drug
ribosomes, and ineffective or are treatment with concentrations at
interferes with an contraindicated. gentamicin frequent intervals,
initiation complex Has been used in ophthalmic particularly for
between mRNA combination with preparations. patients with
other antibiotics. impaired renal
(messenger RNA)
Also used The most function,
and the 30 S topically for primary infants (renal
frequently reported
subunit, inhibiting and secondary skin immaturity), older
adverse reactions
protein synthesis. infections and for adults, patients
are ocular burning
DNA may be superficial receiving high
and
misread, thus infections doses or
of external eye and irritation upon drug therapy beyond 10
producing
its adnexa. instillation, d, patients with
nonfunctional
fever or extensive
proteins; nonspecific burns, edema,
polyribosomes are conjunctivitis, obesity.
split apart and are conjunctival
> Note: Dosages
unable to epithelial
are generally
synthesize protein. defects, and
adjusted to
conjunctival maintain peak
serum gentamicin
hyperemia. concentrations of
Therapeutic Effect: 4– 10 g/mL, and
Other adverse trough
> Gentamicin, reactions which concentrations of
like the other have occurred 1–2 g/mL.
aminoglycosides is rarely are allergic Peak
reactions, concentrations
not appreciably
thrombocytopenic above 12 g/mL and
absorbed after oral
purpura, and trough
or intrauterine hallucinations. concentrations
administration, but
above 2
is absorbed from g/mL are
topical associated with
administration (not toxicity.
skin or urinary
bladder) when used > Draw blood
in irrigations during specimens for peak
surgical serum gentamicin
procedures. concentration 30
min–1h
after IM
Patients
administration, and
receiving oral 30 min after
aminoglycosides completion of a 30–
with hemorrhagic or
60 min IV
necrotic infusion. Draw blood
enteritises may specimens for trough
absorb appreciable levels just before the
next IM
quantities of the
or IV dose. Use
drug. After IM
nonheparinized tubes
administration to to collect blood.
dogs and cats,
peak levels occur
from 1/2 to 1 hour
later.
Subcutaneous
injection results in
slightly delayed
peak levels and
with more
variability than after
IM injection.
Bioavailability from
extravascular
injection
(IM or SQ) is
greater than 90%.