A. THE CLIENT AND HIS CARE 1. MEDICAL MANAGEMENT a.

IVF, O2 inhalation Medical management/ treatment Date Ordered Date Performed Date Changed d/c DO: 11-07-13 PNSS IL DC: Normal saline solution is It was used by the client as 9 grams of sodium a route of administration of to elevate Clients sodium level General description Indications or purposes Clients Response to the treatment

returned to a normal level of 139.5mmol/L. There

chloride dissolved in 1 IV medications. Also it was Regulated at 10cc/hr liter of water. It is used used

clients were no noted sign of infiltration.

frequently in IV drips. It is sodium level of 133mmol/L the safest fluid to give (11/06/13) quickly large volume. 10 mEqs KCL in 50 cc PNSS for 3 cycles DO: 11-08-13 DC: 11-08-13 Potassium participates in carbohydrate range. It was given for the to a normal

Warmth was felt upon administration. There

maintenance of body fluid composition and electrolyte

utilization and protein synthesis, and is critical Time given: 11:30 am 1:50 pm 2:30 am in the regulation of

were no complaints of

balance. Clients potassium phlebitis and vessication. level was 3.32 mmol/L Weakness evident was still slight was by the

nerve conduction and muscle contraction,

which is below normal.

although

improvement acknowledged client.

particularly in the heart. Chloride, the major

extracellular closely follows

anion, the

metabolism of sodium, and changes in the

acid-base of the body are reflected by

changes in the chloride concentration. NURSING RESPONSIBILITIES: Before During After Document the IVF properly on the chart. Check for any signs of inflammation. Monitor the rate flow every hour. Clean site of insertion and observe aseptic technique. Support client hand and maintain aseptic technique. Once in place, regulate the IVF as ordered. Label IVF on the date and time started and on the infusion rate. Check doctors order. Check for ordered IVF. Check for the patency of the tubing. Explain the procedure to be done to the SO. Inform them about necessity of the treatment and the possible outcomes that could occur if the client will undergo the treatment.

Monitor the patency of the tube and the IV site Date Ordered Date Performed Date Changed d/c General description Indications or purposes Clients Response to the treatment

Medical management/ treatment

Oxygen Therapy

Date ordered: 11/07/13

Administration

of

oxygen

at Noted

labored The client responded well

concentrations greater than that in breathing, tachypnea to the oxygen therapy as room air to treat or prevent hypoxemia Periods of weakness evidenced by stabilized

Date preformed: 11/07/13 11/08/13 11/09/13 11/10/13 11/11/13

(not enough oxygen in the blood). and pale lips. Oxygen delivery systems are

breathing

pattern

and

clients breathing at ease.

classified as stationary, portable, or ambulatory. Oxygen can be

administered by nasal cannula, mask, and tent.

Regulation: 4Lpm

Nursing Responsibilities [O2 therapy]: Oxygen is flammable. "No Smoking" signs should be posed when a client is receiving oxygen. Electrical equipment must have special grounding adaptors on plugs to avoid sparks. Oxygen tanks or compressors should be turned off when not in use and oxygen valves should be checked routinely to be sure that they are secure. Oxygen levels in reserve tanks should be monitored to ensure continuous therapy. Monitor the client's condition and vital signs frequently, according to the policy of the medical setting.

The fit of the nasal cannula or mask and all of the oxygen connections should be evaluated, to ensure that no part of the system has been blocked or diverted and the oxygen is being delivered correctly, as ordered b. Drugs

I.

Anti-hypertensive drugs Name of Drug Generic Name Brand Name Date Ordered Date Taken/Given Date Changed D/C Route or Admin Dosage and Frequency of Administration RA: PO GA: Calcium Channel Blocker D: 30mg Used management clients MOA: Inhibits calcium pressure F: OD ion influx across cell ranging membrane cardiac Functional Classification, Mechanism of Action Indication(s) or Purpose(s) Clients Response to the Medication w/ actual side effects in Clients of pressure blood to Blood elevated

GN: NIfedipine

DO: 11-07-13 DC: continuous

BN: Adalat

190/100mmgH-

reading 180/100mmgH between initially recorded

during 190/100mmgH-

after admission to ward. After

depolarization, 180/100 mmgH and chest pain.

produces relaxation of coronary smooth peripheral vascular muscle and

continuously giving medication, clients BP fluctuates

vascular

between 160/100 to 130/80mmgH. Medication in relieving helped chest

smooth muscle, dilates coronary arteries, myocardial vascular increases oxygen

pain.

delivery in clients with

vasospastic angina.

Nursing responsibilities Before During After Monitor for Blood pressure and pulse Instruct not to perform activities that may require mental alertness; may cause dizziness or lightheadedness. Manage possible constipation that may be a side effect of drug Instruct client to report persistent headache, nausea, dizziness, palpitation and rash Check for pulse. If apical pulse falls below 60 bpm, hold the medication and question the order. Assess for Blood pressure. Hold if BP falls at 90/60 and below.

Name of Drug Generic Name Brand Name

Date Ordered Date Taken/Given Date Changed D/C

Route or Admin Dosage and Frequency of Administration RA: PO

Functional Classification, Mechanism of Action

Indication(s) or Purpose(s)

Clients Response to the Medication w/ actual side effects

GN: Atorvastatin

DO: 11-07-13

GA: Statins

To

prevent After giving

continuously medication,

atherosclerotic BN: Avamax DO: continuous D:40 mg MOA: Selectively F: BID HMG-CoA which

event. It also helps clients BP fluctuates inhibits in the maintenance between 160/100 to reductase, of Blood pressure as 130/80mmgH. it to it may cause

converts

HMG-CoA

to vasodilation

malevonate, a precursor for sterols. Lowers and

cholesterol lipoprotein levels

Nursing responsibilities Before During Continue dietary restrictions of saturated fat, cholesterol and alcohol. Instruct client that drug may be taken with or without meals.

After Advise client to report and unexplained muscle weakness or tenderness Monitor liver function for continuous use. Date Ordered Date Taken/Given Date Changed D/C GN: Trimetazidine DC: continuous BN: Vestar F: BID D: I tab MOA: myocardial requirements decreasing determinants demand of DO: 11-07-13 Route or Admin Dosage and Frequency of Administration RA: PO GA: Antianginal Drug The given drug to was Clients relieve subsided chest pain and after Functional Classification, Mechanism of Action Indication(s) or Purpose(s) Clients Response to the Medication w/ actual side effects

Name of Drug Generic Name Brand Name

Decrease periods of chest prevented O2 pain, and as a continuous by prophylaxis the chest pain. O2 to administration.

Nursing responsibilities Before During After Instruct the client to report if there is persistent nausea or vomiting Encourage client not to perform activities that may require mental alertness Instruct to report presence of thrombophlebitis, vertigo, and muscle spasm. Instruct client to take drug with food.

Name of Drug Generic Name Brand Name

Date Ordered Date Taken/Given Date Changed D/C

Route or Admin Dosage and Frequency of Administration RA: PO D: 10 mg F: OD

Functional Classification, Mechanism of Action

Indication(s) or Purpose(s)

Clients Response to the Medication w/ actual side effects

GN: Perindopril BN: Coversyl

DO: 11-08-13 DC: Continuous

GA: ACE Inhibitor

Arterial

After

continuously medication, BP

Hypertension and giving MOA: Converted in the liver slow into active perindoprilat, an ACE inhibitor that prevents the conversion of progression clients

to CHF. Reduction of risk of

fluctuates between to

CV 160/90

events in clients 130/80mmgH. with coronary stable artery

angiotensin Angiotensin

I to the active II, a potent

vasoconstrictor.

Low disease.

angiotensin II levels result to vasodilation and decreased aldosterone secretion. Nursing Responsibilities Before During After Teach client about orthostatic hypotension. Check for clients BP, if less than 90/60, hold and question the order

Instruct client to report lightheadedness and dizziness Monitor BP Date Ordered Date Taken/Given Date Changed D/C Route or Admin Dosage and Frequency of Administration RA: SL D:75mcg F: Stat GA: drug Centrally acting Prevention atherosclerotic events Functional Classification, Mechanism of Action Indication(s) or Purpose(s) Clients Response to the Medication w/ actual side effects of Clients 190/90 to BP of

Name of Drug Generic Name Brand Name

GN: Clonidine HCL BN: Catapress

DO: 11-07-13 11-09-13 11-12-13

160/90

in mmgH lowered to a

MOA: Stimulates central peripheral arterial range of 150/80 to alpha-adrenergic receptors sympathetic cardioaccelerator to disease inhibit acute or in 130/80 mmgH.

coronary

syndrome without and ST elevation

vasoconstrictor centers

Nursing responsibilities Before During After Monitor pulse rate and BP. Educate client about orthostatic hypotension. Check blood pressure before giving clonidine, if blood pressure falls below 90/60, hold and question the order. Check for apical pulse rate, if rate is below 60bpm, hold the drug.

Tell the client that stopping the drug abruptly can cause withdrawal symptoms such as nervousness, agitation, headache and confusion.

Name of Drug Generic Name Brand Name

Date Ordered Date Taken/Given Date Changed D/C

Route or Admin Dosage and Frequency of Administration RA: Dermal D: 5 mcg F: every 16 hours

Functional Classification, Mechanism of Action

Indication(s) or Purpose(s)

Clients Response to the Medication w/ actual side effects Clients chest pain relieved

GN: Nitrogycerin patch

DO: 11-07-13 DC: Continuous

GC: Antianginal Drug

Periods chest pain

of

MOA: Decrease myocardial O2 requirements by decreasing the determinants of O2 demand

Nursing responsibilities Before During After Apply the skin patch to a clean, dry, hairless area of the body, below your neck and above your knees or elbows. If the patch falls off, try sticking it back on. If you replace the patch with a new one, leave it on only for the rest of your wearing time. Tell the client that nitroglycerin patch can cause severe headaches, especially when you first start using it. Educate client about orthostatic hypotension. Assess the severity of chest pain.

 II.

Place Nitroglycerin patch for 12 to 14 hours and then removed. Monitor BP and pulse

Blood thinners Name of Drug Generic Name Brand Name Date Ordered Date Taken/Given Date Changed D/C Route or Admin Dosage and Frequency of Administration RA: PO GA: Antiplatelet agent Treatment of clients suffering D: 40mg MOA: receptors F: OD Blocks which APD from acute prevent coronary Functional Classification, Mechanism of Action Indication(s) or Purpose(s) Clients Response to the Medication w/ actual side effects Client experienced constipation that may be due to drug side effect. There were no noted any sign of bleeding.

GN: Clopidogrel

DO: 11-07-13 DC: Continuous

BN: Plavix

fibrinogen binding at the syndrome and site and thereby reduce reduction of the possibility of platelet atherosclerotic adhesion and aggregation. event.

Nursing responsibilities Before During Educate client to side effects such as headache, dizziness, nausea and vomiting, weakness, constipation. Instruct not to perform activities that may require mental alertness Instruct to report any sign of bleeding Assess for any sign of active bleeding. Instruct client that drug may be taken with or without meals.

After Monitor for any unusual bruising or bleeding Monitor vital signs Date Ordered Date Taken/Given Date Changed D/C Route or Admin Dosage and Frequency of Administration Functional Classification, Mechanism of Action Indication(s) or Purpose(s) Clients Response to the Medication w/ actual side effects GN: Enoxaparin DO: 11-07-13 RA: Subcutaneous BN: Clexane DC: continuous D: 0.4 mL GA: Anticoagulant Clients with high risk Client of thromboembolism. experienced mild MOA: Accelerates formation Clients with high risk discomfort of antithrombin IIB-thrombin of complex F: OD thrombin, and upon of

Name of Drug Generic Name Brand Name

hemorrage. administration

deactivates Treatment of clients drug. preventing suffering from acute syndrome of

conversion of fibrinogen to coronary fibrin. and

reduction

atherosclerotic event.

Nursing responsibilities Before During Assess for any active sign of bleeding. Ensure patency of the line.

 After III.

Check for any redness and inflammation on the intravenous site Instruct the client that may experience mild discomfort, irritation, hematoma at site.

Instruct to report unusual weakness, bruising, bleeding, black, and bloody or tarry stools immediately.

Anxiolytics Name of Drug Generic Name Brand Name Date Ordered Date Taken/Given Date Changed D/C Route or Admin Dosage and Frequency of Administration RA: PO D: 2 mg tab F: OD MOA: Potentiates action of GABA, GC: Benzodiazepine Emotional Disturbances the Client Functional Classification, Mechanism of Action Indication(s) or Purpose(s) Clients Response to the Medication w/ actual side effects experienced as

GN: Clonazepam BN: Rivotril

DO: 11-07-13 DC: Continuous

in drowsiness

possible side effect. Client was able to

inhibitory cardiovascular and

neurotransmitter, resulting in an increased and

respiratory sleep at night.

neuronal systems, CNS in emotional reactions to organic 2

inhibition depression,

especially

limbic system and reticular chronic formation disease.

consecutive sleepless nights

Nursing Responsibilities Before During Tell the client that he/she may experience these side effects: Drowsiness, dizziness, GI upset, fatigue, nervousness, depression, emotional changes, bed-wetting, urinary incontinence. Assess for hypersensitivity to benzodiazepines; impaired liver or kidney function, debilitation. Instruct to take with meals.

After Monitor liver function and blood counts periodically in clients on long-term therapy. Clients Response to the Medication w/ actual side effects GA: Anxiolytic & Emotional Disturbances the Client in periods experienced of

Name of Drug Generic Name Brand Name

Date Ordered Date Taken/Given Date Changed D/C

Route or Admin Dosage and Frequency of Administration RA:PO D: I.5mg F: stat

Functional Classification, Mechanism of Action

Indication(s) or Purpose(s)

GN: Bromazepam BN: Lexotan

DO: 11-12-13

Benzodiazepines MOA: Depress by an

CNS, the cardiovascular weakness, respiratory drowsiness. Client

probably GABA,

potentiating and

inhibitory systems, Produces emotional to organic

was able to sleep.

neurotransmitter.

skeletal muscle relaxation by reactions inhibiting spinal poly-synaptic chronic afferent pathways disease

Nursing responsibilities Before During After Keep Lexotan in a cool dry place where the temperature stays below 30C. Advise client to report side effects that include drowsiness, confusion, dizziness and unsteadiness, which may increase the risk of a fall. Ask if the client is lactose intolerant. Inform doctor if client is lactose intolerant.

Name of Drug Generic Name Brand Name

Date Ordered Date Taken/Given Date Changed D/C

Route or Admin Dosage and Frequency of Administration RA: PO D: 40 mg F: OD

Functional Classification, Mechanism of Action

Indication(s) or Purpose(s)

Clients Response to the Medication w/ actual side effects

GN: Lansoprazole BN: Prevacid

DO:11-08-13 DC: Continuous

GC: Proton Pump Inhibitor MOA: Suppresses by

To

protect of

the Client experienced the no epigastric pain. from that

gastric linings inhibiting stomach irritation

secretion

Hydrogen/potassium ATPase located enzyme in the

system may be caused secretory by oral drugs To stress

surface of the parietal cells of the stomach blocking the final step of acid production.

given. prevent

related elevation

of

BP,

and that

ulcerations

may result from decreased cardiac output.

Nursing responsibility Before Consider hypersensitivity to lansoprazole Lansoprazole should be taken 30 minutes before eating. During Do not crush, break, or open a delayed-release capsule. Swallow the pill whole. After Monitor for side effects

Name of Drug Generic Name Brand Name

Date Ordered Date Taken/Given Date Changed D/C

Route or Admin Dosage and Frequency of Administration RA: PO D: 30 cc F: HS

Functional Classification, Mechanism of Action

Indication(s) or Purpose(s)

Clients Response to the Medication w/ actual side effects

GN: Lactulose BN: Lilac

DO: 11-08-13 DC: Continuous

GA: Laxative

To

prevent Client

defecated

MOA: Causes an influx of fluid in bearing the intestinal tract by increasing due to

down once in the morning hard with formed and soft stool (11-11-13)

the osmotic pressure within the formed stool.

intestinal lumen distending the colon due to increased fluid

therefore

enhancing

intestinal

motility and secretion.

Nursing responsibility Before During After Notify physician if diarrhea occurs and persists for more than 24 hours as this could be a sign of overdose. Educate client that lactulose may take effect after 2-3 days. Advise client to drink plenty of fluids while taking lactulose. Ask the client if she has intolerance to lactose.

Name of Drug Generic Name Brand Name

Date Ordered Date Taken/Given Date Changed D/C

Route or Admin Dosage and Frequency of Administration RA: PO GA:

Functional Classification, Mechanism of Action

Indication(s) or Purpose(s)

Clients Response to the Medication w/ actual side effects

GN: Paracetamol

DO: 11-07-13

Non-narcotic

analgesic

and To help regulate Clients body temperature

antipyretic DC: continuous D: 500 mg

MOA: Unknown. Thought to produce temperature that remained at normal analgesia by blocking generation of may increase level. to the of

BN: Biogesic F: every 6 hrs.

pain impulses, probably by inhibiting due

prostaglandin synthesis in the CNS presence or the synthesis or action of other Inflammation substance that sensitize pain

receptors to mechanical or chemical stimulation. Its though to relieve fever by central action in the hypothalamic heat-regulating center. Nursing responsibility Before After o Monitor for liver function in case of prolong use Assess for clients temperature. Instruct that medication may be taken with or without meals.

c. Activity/Exercise
Type of Exercise Date Ordered Date Started Date Changed Complete bed rest without Bathroom Privileges Date continuous Nursing Responsibilities Before: After: Report any abnormal findings. Take note of the clients improvement on her health. Assessed the clients condition before introducing the exercise. Explain the type and how the exercise should be done and explain the need and purpose of the exercise. started: Date Ordered: 11-07-13 A medical treatment involving a It helps to conserve energy, period of consistent promote recovery and rest, and fatigue. It was also The client was seen in bed throughout the day and was able to regain a little bit of energy. The clients BP of 190/100 limited to to 180/100 160/100 was to General Description Indication(s) or Purpose(s) Clients Response or action to the Activity/Exercise

recumbence in bed .It is used prevent

as a treatment for an illness or required to prevent injury to client medical condition by relaxing as she experienced dizziness, the body to enhance recovery of weakness and lightheadedness. health

130/80mmgH.

During: Observe the client Provide comfort with the aid of pillows. Provide safety measures to facilitate health.

d. Diet Type of Diet Date Ordered Date Started Date Changed Low salt, Low Date Ordered: fat with Uremic diet 11/07/13 Food in this type of diet is prepared Useful effect both to in reduce people blood Fried chicken with Fries Soda General Description Indication(s) or Purpose(s) Specific Foods Taken Clients Response and/or Reaction to the diet. Although the client understands implications the and

pressure,

without added salt or hypertension and in people with any fat or sodium normal blood pressure. compound. All

indications of her diet client therapy, was the not

Date started: Continuous

processed foods rich in fat are not allowed. On the other hand, A low protein diet is helpful for reducing work pressure of the kidneys, thus slowing down kidney damage and improving the

Uremic diet aims at maintaining a balance of minerals, fluids,

electrolytes in clients who are in an advanced kidney disease stages. Uremia clients need this special diet to limit the buildup of waste products in their body. Uremic Diet requires a low-sodium diet. When you are in an advanced stage of kidney disease,

compliant with the diet recommended.

illness condition.

the kidneys fail to

remove the

excessive water, causing swellings. And sodium will worsen this

symptom. A low sodium diet will help your kidneys work better, which may delay the development of kidney disease. Low fat diet could help reduce fat buildup on the arterial lumen that could contribute to hypertension.

Nursing Responsibilities: As a nurse, our duties may include serving the diet trays at mealtime. For many clients, mealtime is the high point of the day. The clients are more apt to have a better appetite, eat more, and enjoy their food more if you prepare them for their meals before the trays arrive. Encourage SO and Client to follow dietary regimen strictly and present possible complications that may result in to. Assist the client to wash hands and face as needed. Create an attractive and pleasant environment for eating. Remove distracting articles such as an emesis basin or a urinal, and use a deodorizer to remove unpleasant odors in the room. See that the room is well lighted and at a comfortable temperature. Position the client for the meal. If allowed, elevate the head of the bed or assist the client to sit up in a chair. Clear the over-bed table to make room for the diet tray.