MISSION

“MABINI COLLEGES provides quality instruction, research and extension

VISION MABINI COLLEGES, INC. service programs at all educational levels as its monumental contribution to
national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE
of EXCELLENCE in education.”
College of Nursing and Midwifery Specifically, it transforms students into:
1. God – fearing
2. Nation – loving
Daet Camarines Norte 3. Law abiding
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons

Assessment Diagnosis Planning Implementation/Rationale Evaluation

Case: pulmonary Ineffective After a series of   Establish rapport through NPI At the end of the shift the
tuberculosis airway nursing  Assess respiratory goals of the intervention
clearance intervention, the function noting breath sounds, rate, will be seen in the patient
Subjective: related to client will: rhythm, and depth, and use of as evidence by:
“nahihirapan akong thick,  Maintain a accessory muscles. (Diminished  Clients respiratory
huminga” as viscous or patent airway breath sounds may reflect rate is within normal
verbalized by the bloody  Expectorate atelectasis. Rhonchi, wheezes range RR:18bpm
patients secretions indicate accumulation of secretions
secretions  Secretions
as and inability to clear airways that
Objective: without decreased
evidenced may lead to use of accessory
 Fatigue assistance
by dyspnea muscles and increased work of  Clients restlessness
 Weakness Demonstrate a
breathing). was alleviated and
 Poor appetite behavior to
 Note ability to expectorate mucus remain calm
 Restlessness maintain patent
and cough effectively; document  Temperature is
airway clearance.
 Cough character, amount of sputum, within normal range
 Bloody sputum presence of hemoptysis.
 Clients expectorate
 Chest pain (Expectoration may be difficult when
secretions are very thick as a result secretions without
 Dyspnea assistance
of infection and/or inadequate
 Abnormal hydration). 
breath sounds:  Place patient in semi or High-
wet crackles Fowler’s position. Assist patient with
 Temperature coughing and deep-
increases from breathing exercises.(Positioning help
 MISSION
“MABINI COLLEGES provides quality instruction, research and extension
VISION MABINI COLLEGES, INC. service programs at all educational levels as its monumental contribution to
national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE
of EXCELLENCE in education.”
College of Nursing and Midwifery Specifically, it transforms students into:
1. God – fearing
2. Nation – loving
Daet Camarines Norte 3. Law abiding
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons

36c to 37.5c s maximize lung expansion and

 BP:80/60 decreases respiratory effort. Maximal
 RR:26 bpm ventilation may open atelectatic
areas and promote movement of
 PR:75bpm
secretions into larger airways for
expectoration).
 Clear secretions from mouth and
trachea; suction as necessary.
( Prevents obstruction and aspiration.
Suctioning may be necessary if
patient is unable to expectorate
secretions).
 Maintain fluid intake of at least 2500
mL/day unless contraindicated. (High
fluid intake helps thin secretions,
making them easier to expectorate).
 Humidify inspired air and oxygen.
(Prevents drying of mucous
membranes and helps thin
secretions).
 MISSION
“MABINI COLLEGES provides quality instruction, research and extension
VISION MABINI COLLEGES, INC. service programs at all educational levels as its monumental contribution to
national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE
of EXCELLENCE in education.”
College of Nursing and Midwifery Specifically, it transforms students into:
1. God – fearing
2. Nation – loving
Daet Camarines Norte 3. Law abiding
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons

Drug Action Indication Contraindication Adverse Effects Nursing Responsibility

Generic Name: Works by inhibiting Indicated inpatients with Hypersensitive to  Pain  Assess patient’s
Ceftriazone the mucopeptide neurologic complications, cephalosporin’s,  Induration
 Previous sensitivity
Brand Name: synthesis in the carditis and arthritis. It is penicillin’s and  Phlebitis
Forgram bacterial cell wall. also effective in Gram related antibiotics.  Rash reaction to penicillin or
The beta-lactam negative infections  Diarrhea
other cephalosporin’s.
Classification: moiety of Meningitis, Gonorrhea. It is  Thrombocytosis
3rd generation Ceftriaxone binds also for Bone and joint  Leucopenia  Assess patient for signs
cephalosporin. to infections, Lower  Glossitis
and symptoms
carboxypeptidases respiratory tract infections,  Respiratory super
Dosage:450mg , endopeptidases, middle ear infection, PID, infections of infection before and
TIVq12 and trans Septicemia and Urinary
during the treatment
peptidases in the Tract infections
bacterial  Obtain C&S before
cytoplasmic
beginning drug therapy
membrane. These
enzymes are to identify if correct
involved in cell-wall
treatment has been
synthesis and cell
division. By binding initiated.
to these enzymes,
 Report signs such as
Ceftriaxone results
in the formation of petechiae, ecchymotic
of defective cell
areas, epistaxis or other
walls and cell
death. forms of unexplained
bleeding.
 Monitor hematologic,
 MISSION
“MABINI COLLEGES provides quality instruction, research and extension
VISION MABINI COLLEGES, INC. service programs at all educational levels as its monumental contribution to
national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE
of EXCELLENCE in education.”
College of Nursing and Midwifery Specifically, it transforms students into:
1. God – fearing
2. Nation – loving
Daet Camarines Norte 3. Law abiding
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons

electrolytes, renal and

hepatic function.
 Assess for possible
upper infection: itching
fever
 MISSION
“MABINI COLLEGES provides quality instruction, research and extension
VISION MABINI COLLEGES, INC. service programs at all educational levels as its monumental contribution to
national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE
of EXCELLENCE in education.”
College of Nursing and Midwifery Specifically, it transforms students into:
1. God – fearing
2. Nation – loving
Daet Camarines Norte 3. Law abiding
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons

o 
 MISSION
“MABINI COLLEGES provides quality instruction, research and extension
VISION MABINI COLLEGES, INC. service programs at all educational levels as its monumental contribution to
national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE
of EXCELLENCE in education.”
College of Nursing and Midwifery Specifically, it transforms students into:
1. God – fearing
2. Nation – loving
Daet Camarines Norte 3. Law abiding
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons

Drug Action Indication Contraindication Adverse Effects Nursing Responsibility

Azithromycin Blocks o Treatment of Contraindicated with Mild to moderate  Culture site of
Class: Macrolide transpeptidatio lower respiratory hypersensitivity to nausea, vomiting, infection before
Pregnancy n by  binding infections: Acute azithromycin, abdominal pain, therapy.
Category: B to50s ribosomal bacterial erythromycin, or any dyspepsia, flatulence,  Administer on an
subunit of exacerbations of macrolide antibiotic diarrhea, cramping; empty stomach 1
Dosage susceptible COPD due to angioedema, hr. before or
500 mg tab OD organisms and Haemophilus cholestatic jaundice; 2 – 3 hr. after
disrupting RNA- influenzae, dizziness, headache, meals. Food
dependent Moraxella vertigo, somnolence; affects the
protein catarrhalis, transient elevations absorption of this
synthesis at the Streptococcus of liver enzyme value drug
chain pneumoniae;  Take the full
elongation step community- course
acquired prescribed. Do
pneumonia due not take with
to S.pneumoniae, antacids. Tablets
H.influenzae and oral
o Treatment of suspension can
lower respiratory be taken with or
infections: without food
Streptococcal  Report severe or
pharyngitis and watery diarrhea,
tonsillitis due to severe nausea or
Streptococcus vomiting, rash or
pyogenes in itching, mouth
those who cannot sores, vaginal
take penicillin’s sore
o Treatment of
 MISSION
“MABINI COLLEGES provides quality instruction, research and extension
VISION MABINI COLLEGES, INC. service programs at all educational levels as its monumental contribution to
national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE
of EXCELLENCE in education.”
College of Nursing and Midwifery Specifically, it transforms students into:
1. God – fearing
2. Nation – loving
Daet Camarines Norte 3. Law abiding
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons

uncomplicated
skin infections
due to
Staphylococcus
aureus, S.
pyogenes,
Streptococcus
agalactiae

Drug Action Indication Contraindicatio Adverse Effects Nursing Responsibility

n
 MISSION
“MABINI COLLEGES provides quality instruction, research and extension
VISION MABINI COLLEGES, INC. service programs at all educational levels as its monumental contribution to
national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE
of EXCELLENCE in education.”
College of Nursing and Midwifery Specifically, it transforms students into:
1. God – fearing
2. Nation – loving
Daet Camarines Norte 3. Law abiding
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons

Generic name: Paracetamol to relieve mild to Hypersensitivity Hematologic:  Assess patient’s fever or
Paracetamol may cause moderate pain to acetaminophen Hemolytic anemia, leukopenia, pain: type of pain,
Brand name: analgesia by due to things or phenacetin; neutropenia, pancytopenia, location, intensity,
Biogesic Dose:500 inhibiting such as use with alcohol thrombocytopenia. duration, temperature,
mg 1 tab CNS headache, Hepatic: and diaphoresis.
Route: Oral prostaglandi muscle liver damage, jaundice  Assess allergic reactions:
Frequency: q n synthesis. and joint pain, Metabolic: rash, urticaria; if these
4° The backache and hypoglycemia occur, drug may have to
Classification: mechanism period pains. Skin: bed is continued.
Analgesic ( Non- of morphine It is also used rash, urticuria  Teach patient to
opioid)Antipyreti is believed to to bring down recognize signs of chronic
c involve a high overdose: bleeding,
decreased temperature. bruising, malaise, fever, sore
permeability For this throat
of the cell reason,  Tell patient to notify
membrane to paracetamol prescriber for pain/fever
sodium, can be given lasting for more than 3
which results to children days.
in diminished after
transmission vaccinations to
of pain prevent post-
impulses immunization
there fore pyrexia (high
analgesia. temperature).
Paracetamol is
often included
in cough, cold
and flu
 MISSION
“MABINI COLLEGES provides quality instruction, research and extension
VISION MABINI COLLEGES, INC. service programs at all educational levels as its monumental contribution to
national and global growth and development.
“MABINI COLLEGES shall cultivate a CULTURE
of EXCELLENCE in education.”
College of Nursing and Midwifery Specifically, it transforms students into:
1. God – fearing
2. Nation – loving
Daet Camarines Norte 3. Law abiding
4. Earth caring
5. Productive, and
6. Locally and Globally competitive persons

Assessment Diagnosis Planning Implementation/Rationale Evaluation

Deficient At the end of intervention   Establish rapport through At the end of the shift
Subjective: “hindi pantay knowledge the guardian verbalizes the NPI the goals of the
ang mga paa niya” as proper care, causes and  Vital signs taken and intervention will be seen
verbalized by the management of the monitored in the guardian of the
grandparents of the disease  Health teaching patient as evidence by:
patients  Provide information  Verbalize
Objective: about the disease, understanding
 Awake on the bed causes and about the health
 Unstable gait complications teaching done
 Not irritable  ensure child safety
always
 T-37.5
 instruct the guardian
 PR- 100Bbpm to report any sign of
 RR-27bpm complication after the
procedure
 provide emotional and
psychological support.