Submitted By: Gutierrez, Karell Eunice E.

BSN3-5 GROUP 20
NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PATHOPHYSIOLO PLANNING INTERVENTIO RATIONALE EVALUATION

GY NS

SUBJECTIVE: Fluid Volume Renal failure Within 8 · Record · Accurate After 8 hours
“Namamanas excess hours of accurate I&O is of nursing
ang mga paa related to nursing intake and necessary for intervention,
nya" patient has
Compromised Decrease blood intervention, output determining
displayed
as verbalized regulatory flow to kidneys the (I&O). renal appropriate
by mechanism patient will function and urinary output
the relative of (renal failure) display · Assess skin, fluid with specific
the patient. Decrease appropriate face, replacement laboratory
perfusion in urinary dependent needs studies near
OBJECTIVE: kidney output areas for and reducing normal; vital
- Venous with edema risk of signs within
distension laborator fluid overload patient’s
- Lower Decrease y studies · Plan oral normal range;
edema urinary output near fluid · Edema and absence of
- Patient edema.
normal; vital replacement occurs
reports of signs within with primarily in Goal Met.
body Water retention patient’s patient, within dependent
weakness normal multiple tissues
- Oliguria range; and restrictions of the body,
- Changes in Fluid volume absence of like hands
Respiratory Excess edema. Medication and feet.
Pattern
- Dyspnea · · Helps avoid
Administer/res periods
· V/S taken as trict without
follows fluids as fluids,
T: 35.9˚C indicated. minimizes
P: 48 boredom
R: 13 · Administer of limited
BP: 130/90 medication as choices,
indicated in and reduces
example; sense
· of deprivation
Antihypertensi and
ves, thirst
Metoprolol

· Antidiuretic
drugs

· Fluid
management
is usually
calculated

to replace
output
from all
sources
plus
estimated
insensible
losses

· May be
given to
treat
hypertension
by
counteracting
effects of
decreased
renal blood
flow
 and/or
circulating
volume
overload

· Given early
in
oliguric phase
of
Renal Failure
in an
effort to
convert to
nonoliguric
phase,
flush the
tubular
lumen of
debris,
reduce
hyperkalemia
, and
promote
adequate
urine volume.

Gutierrez, Karell Eunice E.

BSN3-5 GROUP 20

DRUG NAME DOSAGE ACTION INDICATION ADVERSE CONTRAINDICATI NURSING

 AND ROUTE EFFECTS ON RESPONSIBILI
TY

DIAZEPAM Status
(dye-az'e-pam) Epilepticus Psychothera Drug of Body as a Injectable Monitor for
Adult: IV/IM peutic agent choice for Whole: form: Shock, adverse
Apo- 5–10 mg, related to status Throat and coma, acute reactions.
Diazepam, repeat if chlordiazepo epilepticus. chest pain. alcohol Most are dose
Diastat, needed at xide; Managemen CNS: intoxication, related.
Diazemuls , E- 10–15 min reportedly t of anxiety Drowsiness, depressed vital Physician will
Pam , Meval , intervals up superior in disorders, fatigue, signs, obstetrical rely on
Novodipam , to 30 mg, antianxiety for short- ataxia, patients, infants accurate
Valium, then repeat and term relief confusion, <30 d of age. observation
Valrelease, if needed anticonvulsa of anxiety paradoxic Tablet form: and reports of
Vivol q2–4h nt activity, symptoms, rage, Infants <6 mo of patient
Child: IV/IM with to allay dizziness, age, acute response to
Classifications <5 y, 0.2– somewhat anxiety and vertigo, narrow-angle the drug to
: CENTRAL 0.5 mg shorter tension amnesia, glaucoma, determine
NERVOUS slowly q2– duration of prior to vivid untreated open- lowest
SYSTEM AGENT; 5min up to action. Like surgery, dreams, angle glaucoma; effective
BENZODIAZEPIN 5 mg; >5 y, chlordiazepo cardioversio headache, during or within maintenance
E 1 mg slowly xide, it n and slurred 14 d of MAO dose.
ANTICONVULSA q2–5min up appears to endoscopic speech, inhibitor therapy.
NT; ANXIOLYTIC to 10 mg, act at both procedures, tremor; EEG Safe use during Monitor for
repeat if limbic and as an changes, pregnancy therapeutic
needed q2– subcortical amnesic, tardive (category D) and effectiveness.
4h levels of and dyskinesia. lactation is not Maximum
CNS. treatment CV: established. effect may
Anxiety, for restless Hypotension require 1–2
Muscle legs. Also , wk; patient
Spasm, used to tachycardia, tolerance to
Convulsion alleviate edema, therapeutic
s, Alcohol acute cardiovascul effects may
Withdrawa withdrawal ar collapse. develop after
l symptoms Special 4 wk of
Adult: PO 2– of Senses:
10 mg b.i.d. Blurred
to q.i.d. or alcoholism, vision, treatment.
15–30 mg/d voiding diplopia,
sustained problems in nystagmus. Observe
release IV/I older adults, GI: patient closely
M 2–10 mg, and Xerostomia, and monitor
repeat if adjunctively nausea, vital signs
needed in for relief of constipation when
3–4 h skeletal , hepatic diazepam is
Geriatric: muscle dysfunction. given
PO 1–2 mg spasm Urogenital: parenterally;
1–2 times/d associated Incontinenc hypotension,
(max: 10 with e, urinary muscular
mg/d) cerebral retention, weakness,
Child: PO palsy, gynecomast tachycardia,
>6 mo, 1– paraplegia, ia and
2.5 mg athetosis, (prolonged respiratory
b.i.d. or stiff-man use), depression
t.i.d. syndrome, menstrual may occur.
tetanus. irregularitie
s, ovulation Supervise
failure. ambulation.
Respirator Adverse
y: Hiccups, reactions such
coughing, as drowsiness
laryngospas and ataxia are
m. Other: more likely to
Pain, occur in older
venous adults and
thrombosis, debilitated or
phlebitis at those
injection receiving
site. larger doses.
Dosage
adjustment
may be
 necessary.

Monitor I&O
ratio,
including
urinary and
bowel
elimination.

Gutierrez, Karell Eunice E.

BSN3-5 GROUP 20

DRUG NAME DOSAGE ACTION INDICATION ADVERSE CONTRAINDICATI NURSING

AND ROUTE EFFECTS ON RESPONSIBILI
TY

METOPROLOL Hypertension: Competitively Hypertension, Allergic: Assessment

(met oe' proe Initially, 100 blocks beta- alone or with Pharyngitis,
Contraindicated with
lole) mg/day PO in adrenergic other drugs, erythematous History: Sinus
single or receptors in especially rash, fever, sinus bradycardia bradycardia (HR
Apo-Metoprolol divided doses; the heart and diuretics sore throat, (HR < 45 < 45 beats/min),
(CAN), Betaloc gradually juxtaglomerula laryngospasm second- or third-
beats/min), second-
(CAN), Lopresor increase r Immediate- degree heart
(CAN), dosage at apparatus, release tablets CNS: Dizziness, or third- block (PR interval
Lopressor, weekly decreasing the and injection: vertigo, degree heart block > 0.24 sec),
Novometoprol intervals. influence of Prevention of tinnitus, cardiogenic
cardiogenic shock,
(CAN), Nu- Usual the reinfarction in fatigue, shock, CHF,
Metop (CAN), maintenance sympathetic MI patients emotional CHF; lactation. systolic BP <
Toprol XL dose is 100– nervous who are depression, 100 mm Hg;
450 mg/day. system on hemodynamica paresthesias, Use cautiously with diabetes or
CLASSIFICATIO these tissues lly stable or sleep diabetes or thyrotoxicosis;
N: Angina and the within 3–10 disturbances, thyrotoxicosis; asthma or COPD;
Drug classes pectoris: excitability of days of the hallucinations, asthma or COPD; lactation
Beta1-selective Initially, 100 the heart, acute MI disorientation, pregnancy
adrenergic mg/day PO in decreasing memory loss, Physical: Weight,
blocker 2 divided cardiac output Treatment of slurred speech skin condition,
Antihypertensiv doses; may be and the angina pectoris neurologic
e increased release of C V:CHF, status, P, BP,
gradually, renin, and Toprol XL only: cardiac ECG, respiratory
effective lowering BP; Treatment of arrhythmias, status, kidney
range 100– acts in the CNS stable, peripheral and thyroid
400 mg/day. to reduce symptomatic vascular function, blood
sympathetic CHF of insufficiency, and urine glucose
MI, early outflow and ischemic, claudication,
treatment: vasoconstricto hypertensive, CVA, Do not
Three IV bolus r tone. or pulmonary discontinue drug
doses of 5 mg cardiomyopathi edema, abruptly after
each at 2-min c origin hypotension long-term
intervals with therapy
careful Dermatologic: (hypersensitivity
monitoring. If Rash, pruritus, to
these are sweating, dry
tolerated, give skin catecholamines
50 mg PO 15 may have
min after the EENT: Eye developed,
last IV irritation, dry causing
dose and q 6 eyes, exacerbation of
hr for 48 hr. conjunctivitis, angina, MI, and
Thereafter, blurred vision ventricular
give a arrhythmias).
maintenance GI: Gastric Taper drug
dosage of 100 pain, gradually over 2
mg PO flatulence, wk with
bid. Reduce constipation, monitoring.
initial PO diarrhea, Ensure that
doses to 25 nausea, patient swallows
mg, or vomiting,anore the ER tablets
discontinue in x ia, whole; do not
patients who ischemic cut, crush, or
do not colitis, renal chew
tolerate the IV and them.
doses. mesenteric
arterial
thrombosis, Give oral drug
retroperitoneal with food to
fibrosis, facilitate
hepatomegaly, absorption.
acute
pancreatitis Provide continual
cardiac
GU: monitoring for
Impotence, patients
decreased receiving IV
libido, metoprolol.
Peyronie's
disease,
dysuria,
nocturia,
frequent
urination

Musculoskeleta
l: Joint pain,
arthralgia,
muscle cramp
 Nursing Problem Nursing Diagnosis Objective of Care Nursing Intervention Rationale Evaluation

Respiratory:
Bronchospasm,
Difficulty of Breathing Ineffective breathing After 15 minutes of dyspnea,
Independent: After 15 minutes of
cough,
pattern nursing interventions the 1. Assist the client in 1. To promote good nursing interventions the
bronchial
Subjective cues:
patient will be able to a sitting position
obstruction, lung and chest patient was able to breathe
“Nahihirapan akong nasal
breathe normally as expansion. normally as manifested by
huminga” as verbalized by stuffiness,
manifested by a decrease rhinitis, a decrease in RR from
the client. pharyngitisand
in RR from 30cpm to 2.Demonstrate 2. To inhale 30cpm to 19cpm and a
•
19cpm and a decrease in advice
Other:the client to do greater concentration decrease in PR from 127
Objective cues: Decreased
PR from 127 to 115 bpm. the purse lip breathing of oxygen to 115 bpm..
• RR=30cpm exercise
tolerance,
• PR=127bpm development
Dependent: GOAL MET.
of antinuclear
• BP= 3.
antibodies Administer 3. To supply
110/80mmhg (ANA),
oxygen by a nasal adequate oxygen
hyperglycemia
• Respiratory depth cannula at 2 LPM.
or saturation
changes. hypoglycemia,
elevated
• Sweating Collaborative:
serum
• Faintness 4.transaminase,
Assist for Lung
alkaline
• Asymmetrical X-ray, as ordered
phosphatase 4. To know if

chest expansion there is other lung

problem that affects
the breathing of the
client and to prevent
further problem.

GUTIERREZ, MA. NICA KAMAE Q.

N3-5