Assessment Nursing Scientific Planning Intervention Rationale Evaluation

diagnosis background
Subjective: Acute pain Bacteria in Date: June 10, Independent Date: June 10,
“Idi kalman pay related to dental plaque 2024  Instruct the patient to  Warm saltwater rinses 2024
lang nasakit decaying metabolize Shift: 8 AM- 4 PM rinse their mouth with can reduce Shift: 9AM
etoy ngipen ko tooth as dietary sugars to Short Term warm saltwater inflammation and After 2 hours of
kasla adda evidenced by produce acids After 2 hours of several times a day. provide temporary nursing
tumudtudok “Idi kalman nursing relief from discomfort intervention, the
sunga umay ko pay lang Demineralizatio intervention, the by cleaning the patient was able
ipacheck- up nasakit etoy n of the enamel patient will be able affected area and to verbalize
tatta” ngipin ko to verbalize reducing bacterial satisfactory pain
kasla Decay satisfactory pain load. control from 7/10
Objective: tinutusok ti progresses and control from 7/10  Advise the patient to  Avoiding irritants and at a level of 2/10
 Facial ngipin ko reaches the at a level less than avoid hot, cold, and consuming soft foods  Verbalize
grimace sunga dentin 3 to 4. sugary foods and to can help minimize understanding
 Presence of nagdesisyon  Verbalize opt for soft foods. pain and discomfort of the
dental nak nga Bacteria and understanding associated with tooth importance of
carries on ipacheck- up acids break of the decay. maintaining
both lower tatta”, facial down the importance of  Educate the patient on  Good oral hygiene can good oral
molar teeth grimace, dentin's structure maintaining proper brushing and prevent further decay hygiene and
 Report pain presence of good oral flossing techniques. and complications, the need for
scale of 7/10 dental carries Nerve endings in hygiene and which can help dental
 Slightly on both the pulp the need for manage pain and evaluation.
elevated BP lower molar chamber exposes dental improve overall dental  Vital signs
 Tachycardia teeth, and evaluation. Dependent health. normalize, v/s
Vital signs taken reported pain Acute pain  Improve and  Administer prescribed  Analgesics can help as follows:
BP: 130/110 scale of 7/10, reduce back to pain relief manage pain  BP: 110/80
Temp: 36.9 Slightly normal vital medications or topical effectively, allowing mmHg
degrees Celsius elevated BP, signs analgesics as ordered the patient to perform  PR: 88 beats
RR: 19 Tachycardia by a healthcare daily activities with per min.
PR: 104 and vital Long Term provider. less discomfort.  Goal met.
O2 Sat: 97% signs as After 1 week of Following the
follows: nursing provider's orders Long Term
BP: 130/110 intervention, the ensures appropriate After 1 week of
Temp: 36.9 patient will be able and safe medication nursing
degrees to report pain  Facilitate a referral to use. intervention, the
Celsius relief and manage a dentist for  Professional dental patient was able
RR: 19 pain effectively evaluation and care is required to to report back
PR: 104 with minimal treatment of the tooth address the underlying again pain relief
O2 Sat: 97% medication and decay. cause of pain and to and manage pain
non- provide definitive effectively with
pharmacological treatment that nursing minimal
practice. Collaborative interventions alone medication and
 Demonstrate  Collaborate with cannot achieve non-
effective oral dentists to develop  Dentists can provide pharmacological
hygiene a comprehensive specialized care for practice
practices and treatment plan for tooth decay, working Demonstrate
seek regular the patient’s tooth together ensures that effective oral
dental care to decay. the patient receives hygiene practices
prevent future integrated care that and seek regular
issues. addresses both pain dental care to
management and prevent future
 Collaborate with dental treatment. issues. Goal met.
the healthcare  Educating patients
team to provide and their families
education on pain ensures they are
management, oral informed about
hygiene, and the managing pain,
importance of understanding
follow-up care. treatment options, and
maintaining good oral
health.
Possible Nursing Diagnosis and Medications

I. Nursing Diagnosis

 Acute Pain related to tooth decay as evidenced by patient’s verbal report of pain, discomfort,
or sensitivity in the affected tooth.
 Impaired Oral Mucous Membrane related to tooth decay as evidenced by visible signs of
decay on teeth, discomfort and presence of dental caries.
 Risk for Infection related to compromised dental health due to tooth decay as evidenced by the
presence of cavities, pain, and potential exposure of underlying tooth structures.
 Difficulty Eating related to pain and discomfort from tooth decay as evidenced by the
patient’s, reduced food intake, or difficulty chewing.
 Knowledge Deficit related to dental hygiene practices as evidenced by the patient’s lack of
understanding about the prevention and management of tooth decay.

II. Medications
 Analgesics for pain
o Ibuprofen (Advil)
o Paracetamol (Biogesic)

 Topical Analgesics for pain

o Benzocaine (Orajel)

 Antibiotics (if infection is present or suspected)

o Amoxicillin- for bacterial infections
o Clindamycin- for patients allergic to penicillin or when a different spectrum of
activity is needed.
 Antiseptic Mouth Rinses
o Chlorhexidine Gluconate (Peridex)- reduces oral bacteria and helps in managing
gingivitis and oral infections.

 Medications for Supporting Oral Health

o Fluoride Gel or Varnish- helps to strengthen tooth enamel and prevent further decay.

 Desensitizing Agents
o Potassium Nitrate Toothpaste (Sensodyne)- helps to reduce sensitivity by calming the
nerves inside the teeth.
 Assessment Nursing Scientific Planning Intervention Rationale Evaluation
diagnosis background
Subjective: Ineffective Irritant Date: June 10, Independent Date: June 10,
“maysa airway (inhalation) 2024  Teach the patient  Effective coughing can 2024
domingo isunan clearance Shift: 8 AM- 4 PM techniques for help mobilize and clear Shift: 8:30 AM
nga aguyuyek related to Inflammatory Short Term effective coughing, thick sputum from the After 30 mins. of
nga adda iti productive response After 30 mins. of such as deep breathing airways, improving nursing
plema na, ken cough as nursing followed by a strong, airway clearance. intervention, the
agkakapsot pay evidenced by Increase intervention, the controlled cough.  Adequate hydration patient was able
sunan” use of production of patient will be able  Encourage the patient helps to thin mucus to maintain a
accessory secretions to maintain a to increase fluid intake secretions, making normal breathing
Objective: muscles, normal breathing unless contraindicated. them easier to pattern, as
use of accessory presence of Airway pattern, as expectorate and evidenced by a
muscles thick sputum obstruction evidenced by a clearing the airways respiratory rate
presence of secretions respiratory rate more effectively. within the normal
thick sputum (pale yellow Ineffective within the normal  Position the patient in  An upright position can range (RR: 16
secretions (pale in color), airway range an upright or semi- enhance lung expansion cpm), verbalize
yellow in color) difficulty clearance  verbalize Fowler’s position to and assist in the understanding
difficulty maintaining understanding facilitate optimal lung drainage of secretions and adherence to
maintaining normal and adherence expansion and improve from the airways, prescribed
normal breathing to prescribed airway clearance. making it easier for the treatments and
breathing pattern, v/s as treatments and patient to breathe and self-care
pattern follows: self-care Dependent cough effectively. practices for
v/s as follows: BP: 110/80 practices for  Administer maintaining
BP: 110/80 RR: 14 maintaining medications such as  Medications can assist airway clearance,
RR: 14 Temp: 36.6 airway expectorants, in loosening and demonstrated
Temp: 36.6 PR: 78 clearance. bronchodilators, or thinning mucus, improved airway
PR: 78 O2 Sat: 96%  demonstrate corticosteroids as opening the airways, clearance as
O2 Sat: 96% and “maysa improved prescribed by the and reducing evidenced by a
lingo na ag airway healthcare provider. inflammation, all of reduction in the
cough with clearance as which contribute to use of accessory
sputum, ken evidenced by a improved airway muscles and an
agkakapsot reduction in clearance. increase in the
pa suna” as the use of  Assist with or  Diagnostic tests can effectiveness of
verbalized by accessory coordinate diagnostic provide valuable coughing. Goal
the patient. muscles and an tests, such as chest X- information about the met.
increase in the rays or sputum underlying cause of the
effectiveness cultures, as ordered by productive cough and Long Term
of coughing. the healthcare help guide appropriate After 1 week of
provider. treatment strategies. nursing
intervention, the
Long Term Collaborative patient was able
After 1 week of  Work with respiratory  Respiratory therapists to achieve
nursing therapists to provide can offer specialized sustained
intervention, the additional treatments interventions, such as effective airway
patient will be able such as chest chest physiotherapy to clearance, as
to achieve physiotherapy or help clear mucus or evidenced by
sustained effective nebulizer treatments. nebulizer treatments to clear lung
airway clearance, administer medications sounds, absence
as evidenced by directly into the of productive
clear lung sounds, airways, improving cough, and
absence of overall airway normal
productive cough, clearance. respiratory
and normal pattern. Goal
respiratory pattern. met.
Possible Nursing Diagnosis and Medications
I. Nursing Diagnosis

 Fatigue related to increased effort required for breathing and coughing as evidenced
by weakness, decreased energy levels, and difficulty performing activities of daily
living.
 Risk for Infection related to the presence of a productive cough and potential
exposure of respiratory secretions as evidenced by symptoms such as weakness,
increased sputum production.
 Impaired Physical Mobility related to weakness and fatigue as evidenced by difficulty
moving or performing activities of daily living due to decreased strength and energy.

II. Medications
 Expectorants
o Guaifenesin (Mucinex)- facilitates the removal of mucus from the respiratory
tract, improving airway clearance.
 Mucolytics
o Acetylcysteine (Mucomyst)- reduces the viscosity of mucus, aiding in its
clearance from the lungs.
 Bronchodilators
o Albuterol (Proventil)- helps open the airways, making it easier to breathe and
clear mucus.
 Antibiotics (if a bacterial infection is suspected)
o Amoxicillin- Effective against a range of bacteria that could be contributing to
respiratory symptoms.
o Azithromycin- Provides a broad-spectrum antibiotic option, especially useful
in treating respiratory infections.
 Medications for Managing Weakness and Fatigue
o Multivitamins Supplements- Supports overall health and energy levels, which
can help alleviate fatigue.
 Iron Supplements (if anemia or iron deficiency is a contributing factor)
o Ferrous Sulfate- Corrects iron deficiency, which can contribute to fatigue and
weakness.
 Steroids (if inflammation is a significant contributing factor)
o Prednisone- Reduces inflammation and can help improve respiratory function
and symptoms.
 Pain Relievers
o Ibuprofen (Advil)- Provides relief from discomfort, which can help the patient
manage coughing and associated symptoms better.
Possible Nursing Diagnosis and Medications
III. Nursing Diagnosis

 Impaired Skin Integrity related to the recent removal of the toenail and current
infection, as evidenced by the presence of pus, inflammation, and fever
 Acute Pain related to infection and inflammation in the area of the toenail removal,
as evidenced by patient-reported pain and discomfort, along with fever and visible
signs of infection.
 Hyperthermia related to the systemic response to infection as evidenced by an
elevated body temperature (fever) and the presence of pus at the site of toenail
removal.

IV. Medications

 Antibiotics
o Amoxicillin- Effective against many types of bacteria and helps to clear the
infection.
o Cephalexin- Useful for treating skin and soft tissue infections that might result
from the toenail removal.
o Clindamycin- Effective for treating infections when amoxicillin or cephalexin
are not suitable.
o Azithromycin- Provides broad-spectrum coverage and is often used in cases
where compliance with a shorter course is preferred.
 Pain Relievers (Analgesics)
o Paracetamol (Biogesic) Provides pain relief and helps to reduce fever without
anti-inflammatory effects.
o Ibuprofen (Advil)- Nonsteroidal anti-inflammatory drug (NSAID) that helps
reduce pain, inflammation, and fever.
 Anti-inflammatory Medications
o Prednisone- Helps to control severe inflammation and reduce swelling, though
typically used short-term due to potential side effects.
 Topical Antiseptics
o Chlorhexidine Gluconate (Hibiclens)- Reduces bacterial load at the wound site
and helps prevent further infection
o Neosporin (Triple Antibiotic Ointment)- Provides a barrier to bacteria and
helps to prevent infection in minor wounds.
 Fever Management
o Cool Compresses- Helps to physically lower body temperature and provide
symptomatic relief from fever.
 Assessment Nursing Scientific Planning Intervention Rationale Evaluation
diagnosis background
Subjective: Risk for Removal of Date: June 11, Independent Date: June 11,
“umay mi ipa- infection dead toenail 2024  Provide patient  Educating the patient 2024
check- up etuy related to Shift: 8 AM- 4 PM education on proper helps ensure proper Shift: 9:00 AM
saka na ta nag open wound Nail bed Short Term wound care, including self-care and adherence Short Term
nana gamin from dead exposed (open After 1 hour of cleaning, dressing to infection prevention After 1 hour of
gapo iti inikkat nail removal wound) nursing changes, and signs of strategies, which can nursing
na etuy natay na as evidenced intervention, the infection to watch for. reduce the risk of intervention, the
ng kuko, kasla by the Inflammation patient will be able complications. patient was able
agurgurigor pay presence of as natural to demonstrate an  Ensure the patient  Effective hand hygiene to demonstrate an
sunan” as pus, redness, body response understanding of understands the is a fundamental understanding of
verbalized by and swelling for initiating wound care and importance of washing practice to prevent the wound care and
the patient’s around the healing infection their hands thoroughly spread of infection
significant other nail bed, prevention with soap and water microorganisms and prevention
febrile and Leukocytes measures, as before and after reduce the risk of measures, as
Objective: “umay mi and evidenced by touching the wound or infection. evidenced by
Redness and ipa-check- up neutrophils verbalizing correct performing any wound verbalizing
swelling around etuy saka na accumulate wound care care activities. correct wound
the nail bed ta nag nana the area to techniques and care techniques
Pus (yellowish gamin gapo promote preventive Dependent and preventive
in appearance) iti inikkat na healing strategies v  Administer antibiotics strategies,
febrile etuy natay na  demonstrate or other medications as  Antibiotics are essential demonstrate
v/s as follows: ng kuko, Collection of reduced signs prescribed by the for controlling bacterial reduced signs of
Temp: 38.2 kasla localized of infection, as healthcare provider to infections and infection, as
degree Celsius agurgurigor abscesses evidenced by a prevent or treat promoting healing. evidenced by a
pay sunan” as decrease in infection. decrease in
verbalized by Failure to redness,  Schedule and facilitate redness, swelling,
the patient’s keep the swelling, and follow-up visits with  Follow-up visits allow and pus around
significant wound clean pus around the the healthcare provider for professional the nail bed. Goal
other. and dry nail bed to monitor the progress evaluation of the met.
of wound healing and wound and adjustment
Risk for infection control. of treatment plans if Long Term
infection Long Term needed. After 2 days of
After 2 days of Collaborative nursing
nursing  Work with the intervention, the
intervention, the healthcare team to  Coordination with the patient was able
patient will be able ensure comprehensive healthcare team ensures to maintain an
to maintain an care, including a holistic approach to afebrile state,
afebrile state, with infection control, pain care, addressing all with no evidence
no evidence of management, and aspects of the patient’s of systemic
systemic infection, wound care. health and improving infection, as
as evidenced by a overall treatment evidenced by a
normal body outcomes. normal body
temperature temperature
(36.6°C - 37.2°C (36.6°C),
 demonstrate demonstrate
effective effective
management of management of
any potential any potential
complications complications
associated with associated with
the nail the nail removal,
removal, including the
including the prevention of
prevention of secondary
secondary infections and
infections and maintenance of
maintenance of overall foot
overall foot health. Goal met.
health