Generic & Brand Action Indication Contraindication Adverse Reaction Nursing Responsibility

Name, Dose,& Route

Decreases sllergic Used as anti emetic in Hypersensitivity to Orthostatic •Assess respiratory
Generic Name: response by treatment of nausea antihistamines; hypotension; status: rate, rhythm,
Dipenhydramine antagonizing the and vomiting, narrow angle palpitations; and increase in
effects of histamine particularly in the glaucoma; stenosing bradycardia; bronchial secretions,
Brand Name: causes increased heart prevention and peptic ulcer; tachycardia; reflex wheezing, and chest
Dramelin rate, vasodilation, treatment of motion symptomatic prostatic tachycardia; tightness:
secretions; significant sickness. May also be hypertrophy; extrasytoles; •Monitor input output
Dosage: CNS depressant and used as hypnotic in asthmatic attack; faintness. Drowsiness; •Monitor CBC
500 mg anticholinergic short term bladder neck •Assess cough
properties. management of obstruction. characteristic
Route: insomnia. •Assess sleep patterns
Per Orem •Asses Nausea,
vomiting, bowel
sounds, and
abdominal pain.
•Assess degree of
itching skin rashes
and inflamations
 Generic & Brand Action Indication Contraindication Adverse Reaction Nursing Responsibility
Name, Dose,& Route
Generic Name: Binds with opiate Relief of moderate to Hyper sensitivity Sedation, Drowsiness, •Monitor vital sign
Nalbuphine receptors in the CNS severe pain for pre Sweating , Nausea, after parenteral route
ascending pain operatively analgesia, Dry mouth and •Monitor for
Brand Name: pathways in the limbic Supplement to Dizziness, headache respiratory depression
Nubain system, thalamus, balanced anesthesia, and vomiting •Monitor allergic
midbrain, surgical anesthesia, reaction
Dosage: hypothalamus, obstetrical analgesia •Monitor possible
10mg altering perception of adverse reaction
Route: and emotional
IV response to pain.
Relieves pain.
 Generic & Brand Action Indication Contraindication Adverse Reaction Nursing Responsibility
Name, Dose,& Route
Generic Name: Depresses the limbic Sedation in Pre Acute narrow angle Amnesic episodes •Monitor blood
Midazolam system and reticular medication before glaucoma premature pressure, heart rate,
formation by surgical or diagnostic infants hyper rhythm, respiration
Brand Name: increasing or procedure induction sensitivity and oxygen status
Dormicum facilitating the and maintenance of •Assess apnea
Dosage: inhibitory anesthesia. respiratory depression
50mg neurotransmitter of •Assess vital signs
Route: GABA. during recovery period
IM •Assess degree of
amnesia in elderly
•Assess injection site
 Generic & Brand Action Indication Contraindication Adverse Reaction Nursing Responsibility
Name, Dose,& Route
Generic Name: For the production of For the production of Known Hypotension, •Monitor vital signs
Bupivacaine local regional local regional hypersensitivity to bradicardia, post •Monitor respiratory
anesthesia for oral anesthesia for oral local anesthesia of the spinal rate
Brand Name: surgery diagnostic and surgery diagnostic and amide type headache,allergic
Senpivac heavy therapeutic and therapeutic and reation
Dosage: obstet procedure obstet procedure
10-20ml
Route:
Epidural block
 Generic & Brand Action Indication Contraindication Adverse Reaction Nursing Responsibility
Name, Dose,& Route
Generic Name: Centrally acting Use for moderate to Hypersensitivity. Vasodilation, Dizziness •Assess patients pain
tramadol analgesic not severe pain Acute intoxication Headache,Anxiety, •Monitor for CNS
chemically related to with alcohol, Confusion, Euphoria, changes
Brand Name: opiods but binds to hypnotics, centrally Sweating, Rash, •Monitor input output
Dolotral mu opiods receptors acting analgesics Decrease hemoglobin, ratio
Dosage: and inhibits reuptake opiods Elevated liver •Monitor for possible
100mg Of norepinephrine enzymes hypertonia drug induce adverse
Route: and serotonin reaction
Per orem
 Generic & Brand Action Indication Contraindication Adverse Reaction Nursing Responsibility
Name, Dose,& Route
Generic Name: Inhibits Post Operative Sensitivity to aspirin Edema, vomiting , •Assess characteristic
Diclofenac cyclooxygenase, an indication cataract Patient undergoing Dizziness, Rash, of pain and
enzyme needed for surgery and other surgery with high risk headache, Vertigo inflammation
Brand Name: the biosynthesis of surgical intervention of hemorrhage •Check respiratory
Cataflam prostaglandin, function
Dosage: subsequent decrease •Assess for hyper
75mg in prostaglandin result sensitivity reaction
Route: to the analgesic, •Monitor hematologic
Per orem antipyretic and anti status
inflammatory effect •Assess renal status
 Generic & Brand Action Indication Contraindication Adverse Reaction Nursing Responsibility
Name, Dose,& Route
Generic Name: Inhibits histamine at Prophylaxis of GI Hypersensitivity, Bradycardia, •Use caution in
Ranitidine h2 receptor site in the hemorrhage from History of acute Headache, Fatigue, presence of renal and
gastric parietal cells, stress ulceration and porphria, long term Dizziness, Nausea and hepatic impairment
Brand Name: which inhibits gastric patient at risk of therapy vomiting •Assess potential for
Zantac and acids secretion developing acid interaction with other
Dosage: aspiration during pharmacological agent
50mg General anesthesia •Monitor AST,ALT,
Route: Serum creatinine
Per orem •evaluate result of lab
tests
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain, related After 8 hours of  Ask the patient to  To be able to know After 8 hours of
to wound at the nursing rate the pain form 1 the degree of pain. nursing intervention
gluteal area. intervention the to 10 (1 is the the patient was able
lowest and 10 is the  Establishes baseline
“ Kumikirot ang patient will able to to verbalize that the
highest.) for assessing
sugat ko” as verbalize the pain degree of pain is was
improvement/
verbalized by the is minimized/ changes lessen.
patient relieved within  Determine pain
8hours. characteristics  Avoids direct
through pt. pressure to area of
Description. injury which could
 Place foot cradle on result in
bed and encourage vasoconstriction /
Objective: use of loose fitting increased pain.
slippers when up.
Facial grimace
 Stay with client who  To reduce the anxiety
is experiencing pain of the patient.
or appears anxious.
 Maintain quiet,
comfortable  For promote
environment; relaxation for the
restrict visitors as patient.
necessary.

 Administered  Provides relief of

Analgesic discomport when
unrelieved by other
measures.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Disturbed Sleep After an hour of Independent: After an hour of efficient
Pattern related to efficient nursing nursing interventions, the
¨Di ako nakakatulog presence of illness. interventions, the Provide for adequate Although prolonged patient was able to have
ng maayos dahil sa patient will have rest. Restrict daytime physical and mental sufficient sleep.
sakit ko, ”as sufficient sleep. sleep as appropriate; activity results in
verbalized by the increase interaction fatigue, which can
patient. time between client increase confusion,
and family/ staff programmed activity
during day, then without over
reduce mental stimulation promotes
Objective: activity late in the sleep.
day.
- Restlessness Increasing confusion,
Evaluate level of disorientation and
- Visible Eye bags stress/ orientation as uncooperative
day progresses. behaviors
- Irritable (¨sundowners
Adhere to regular syndrome¨) may
- Fatigue bedtime schedule interfere with
and rituals. Tell client attaining restful
- Frequent yawning that it is time to asleep pattern.
sleep.
Reinforces that it is
Providing evening bedtime and
snack, warm milk, maintains stability of
bath, back rub/ environment.
general massage with
lotion.

Reduce fluid intake in Promotes relaxation

the evening. Toilet and drowsiness and
before retiring. helps to address skin-
Provides soft music. care needs.

Collaborative: Decreases need to

get up to go to the
Administer bath room/
medications, as incontinence during
indicated for sleep: night.
antidepressants e.g.
Paroxitine (Paxil) Reduces sensory
stimulation by
blocking out other
environmental
Sedative- hypnotics; sounds that could
e.g. Oxazepam interfere with restful
(Serax), triazolam sleep.
(Halcion)
May be effective in
treating
pseudodementia or
depression,
improving ability to
sleep.

Used sparingly, low

dose, short-acting,
rapid onset hypnotics
may be effective in
treating insomnia.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired skin After 36 hrs of ● Obtain culture ● To identify After 36 hrs of nursing
intergrity related to nursing intervention of wound pathogens intervention the patient was
¨ Mahapdi ang bahagi physical the patient will be dranaige and theraphy able to verbalized feelings
ng sugat ko¨ as immobilization as able to participate in of choice of increased self esteem
verbalized by the manifested by wound prevention measures ● soat foot in ● Local and ability to manage
patient. in the gluteal area. and tretment room germicidal situation.
program and temperature effective for
verbalized feelings of sterile water surface
Objective: increased self esteem with betadine wounds.
and ability to manage solution TID keeps clean /
● Disruption of situation. for 15mins. minimized
skin surface Dress wound cross
( epidermis) with dry contaminatio
● Distruction of sterile n.
skin layers dressing , use
( dermis) pape tape ● To reduce
● Invasion of ● use pressure on
body approprate enhance
structures pading circulation to
● Physical devices ( eg. compromised
Assessment air water tissue.
reveals wound matterss ● to promotes
in the gluteal sheep skin) circulation
area. and reduces
● Encourage risk
early associated
ambulatory / with
immobilizatio immobility.
n
Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Risk for infection After nursing care the •Stress the proper •a first line of After nursing care the
related from post patient will be able to hand washing defense against patient was able to identify
Inadequate primary operative wound identify interventions techniques. nosocomial infection interventions to prevent &
defense because of to prevent & reduce •monitor visitors •to prevent exposure reduce the risks for
broken skin the risks for infection. of client. infection.
•change dressing as •to promote fast
needed. healing
•cleanse incision site
daily with provide
iodine.
•use gloves when •to avoid transfer of
caring for the open microorganism
lesion.
•cover dressing with •to prevent
plastic when using contamination of
bed pan. wound
•maintain adequate •to avoid bladder
hydration distention.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective – Risk for imbalanced During the operation •asssess for clinical •signs of dehydration After the operation patient
Hypotension fluid volume related patient will be able to signs of dehydration signifies fluid loss was able to maintain stable
Increased heart rate to intra operative maintain stable fluid fluid volume.
Delayed capillary surgery. volume. •measure and record •to prepare for fluid
refill. intake and output management
(blood loss,urine).

•note presence of
bleeding
•calculate fluid •may be the
balance contributing factor
for fluid deficiency

•monitor blood
pressure response
•increased when
•administer IV fluids there is fluid deficit.
as prescribed
•to promote fluid
management