CHAPTER IV NURSING CARE PLANS

ASSESSMENT SUBJECTIVE: Namumutla ako as verbalized by the patient. OBJECTIVE:  Pale skin  Hemoglobin (74 gm/L as of Sept. 22, 2011)  Hematocrit (.234 as of Sept. 22, 2011)  Limited range of motion (within the bed)  VS:
RR- 24 bpm PR- 92 bpm BP- 80/50 mmHg Temp.- 36.6C

NURSING DIAGNOSIS Ineffective tissue perfusion related to decreased oxygen carrying capacity of blood as evidenced by weakness, pallor, and low hemoglobin

INFERENCE

PLAN After the shift, the patient will:  demonstrate adequate in oxygen level (pinkish skin, normal RR)  verbalize comfort  be free from signs of bleeding

NURSING INTERVENTIONS 1. Monitor vital signs

RATIONALE  To determine impending problems  To promote lung expansion, facilitating adequate oxygen  To decrease tissues oxygen demand  To avoid excessive use of oxygen  To increase fluid in the body  Following doctors order  To monitor bleeding  To avoid hypovolemic shock

EVALUATION After the shift:  No bleeding noted  Able to promote adequate rest as evidenced by sound sleep

NSAIDS
Hydrogen ions and pepsin

2. Position in semifowlers position 3. Promote rest

Mucosal damage and ulceration

Abdominal Pain

Bleeding

4. Minimize strenuous activities 5. Instruct to increase fluid intake 6. Maintain in soft diet 7. Emphasize avoidance of highly colored foods 8. Monitor episodes of bleeding 9. Keep comfortable

Hypotension Tachycardia Low hemoglobin

ASSESSMENT SUBJECTIVE: The patient verbalized Medyo nahihilo at namumutla ako. OBJECTIVE:  Pale skin  Dry mucous membrane  Hemoglobin (74 gm/L as of Sept. 22, 2011)  Hematocrit (.234 as of Sept. 22, 2011)  Post BT of 3 u PRBC  For BT of 2 more u PRBC  VS:
RR- 24 bpm PR- 92 bpm BP- 80/50 mmHg Temp.- 36.6C

NURSING DIAGNOSIS Fluid volume deficit related to decreased circulating blood as manifested by pallor, hypotension , and low hematocrit.

INFERENCE

PLAN After the shift, the patient will demonstrate adequate hydration as evidenced by moist mucous membrane and normal VS (BP)

NURSING INTERVENTIONS 1. Monitor vital signs

RATIONALE  To determine impending problems  To promote venous return  To promote adequate fluid in the body  Following doctors order  To monitor bleeding  To promote adequate energy to the body  To avoid hypovolemic shock  To determine needs of fluid replacement

EVALUATION Within the shift:  The BP increased from 80/50 to 90/70 mmHg  No bleeding noted

NSAIDS
Hydrogen ions and pepsin

2. Position in trendelenburgs position 3. Instruct to increase fluid intake 4. Maintain in soft diet 5. Emphasize avoidance of highly colored foods 6. Advise frequent feeding 7. Monitor episodes of bleeding 8. Monitor input and output 9. Keep comfortable

Mucosal damage and ulceration

Abdominal Pain

Bleeding

Hypotension

Pallor Dry mucous membrane

ASSESSMENT SUBJECTIVE: Sumasakit yung tiyan ko, the patient verbalized. OBJECTIVE:  Restless  With facial grimace  With abdominal guarding  Pain scale of 6 over 10  Pallor  VS:

NURSING DIAGNOSIS Altered comfort related to abdominal pain as evidenced by abdominal guarding and pain scale of 6 over 10.

INFERENCE

PLAN Within the shift, the patient will verbalized decrease of pain and demonstrate ability to sleep and rest appropriately.

NURSING INTERVENTIONS 1. Note reports of pain including location, duration and intensity 2. Position in most comfortable position 3. Maintain in soft diet 4. Emphasize avoidance of highly colored foods 5. Advise small, frequent feeding

RATIONALE  To compare previous pain symptoms  To promote comfort  Following doctors order  To monitor bleeding  Small meals prevent distention and release of gastrin that can trigger the pain  To avoid hypovolemic shock  To lessen the pain in GI and for prevention of further pain  To promote comfort

EVALUATION Within the shift the patient verbalized decreased of pain as evidenced by pain scale of 2 over 10; able to sleep comfortably; no bleeding noted

NSAIDS
Hydrogen ions and pepsin

Mucosal damage and ulceration

Abdominal Pain

RR- 24 bpm PR- 92 bpm BP- 80/50 mmHg Temp.36.6C

6. Monitor episodes of bleeding 7. Identify and limits the food that create discomfort 8. (COLLABORATIVE) administer medications as indicated and prescribed by the doctor (analgesics, antacids, etc.)

CHAPTER V DRUG STUDY

GENERIC NAME (BRAND NAME) DOSAGE, ROUTE, FREQUENCY MECHANISM OF ACTION PEAK EFFECT, DURATION NURSING RESPONSIBILITIES

CLASSIFICATION

SIDE EFFECTS

OMEPRAZOLE (famazole)

Proton pump inhibitor

20 mg, PO, BID

Suppresses gastric secretion by inhibiting hydrogen/ potassium ATPase enzyme system in the gastric parietal cell. Blocks the final step of acid production.

PEAK EFFECT 30mins3 1/2hrs

     DURATION  3-4hrs    

   

Angina  Assess history of Tachycardia hypersensitivity to Bradycardia omeprazole or any of Palpitation its components; Headache  Assess for pregnancy, Dizziness lactation Rash  Take the drug before Diarrhea meals. Swallow the abdominal capsules whole; do pain not chew, open, or acid crush regurgitatio them. This drug will n need to be taken for nausea up to 8 vomiting wk (short-term) or for constipation a prolonged period (> 5 yr in some cases). back pain  Advise patient to report any signs of adverse effect

SPIRONOLACTO NE (Aldactone)

Diuretic/ Antihypertensive

50 mg, PO, BID

Antagonizes aldosterone in the distal tubules, increasing sodium and water excretion.

PEAK EFFECT 48-72hrs DURATION unknown

   

   

headache drowsiness lethargy GI disturbance s inability to achieve or maintain erection irregular menses amenorrhe a ataxia post menopausa l bleeding

 Educate patient to avoid hazardous activity such as driving until response to drug is known.  Take with meals or milk  Avoid excessive ingestion of food high in potassium or use of salt substitutes  Diuretic effect may be delayed 2-3 days and maximum hypertensive may be delayed 23weeks  Monitor I and O ratios and daily weight, BP, serum electrolytes (K, Na) and renal function BEFORE: Assess fever; note presence of associated signs (diaphoresis, tachycardia, and malaise).

PARACETAMOL (biogesic)

Analgesic

1 tab, PO, every 6 hours

Decreases fever by inhibiting the effects of pyrogen on the hypothalamic heat regulating centers and by a

PEAK EFFECT 1-3hrs

    DURATION  3-4hrs 

stimulation drowsiness nausea vomiting abdominal pain hepatotoxi

hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have antiinflammatory action because of its minimal effect on peripheral prostaglandin synthesis

   

city rash uticaria convulsion CNS stimulation

DURING: Advise SO to take medication exactly as directed and not to take more than the recommended amount. AFTER: Advise patient to consult health care professional if discomfort or fever is not relieved by routine doses of this drug or if fever is greater than 39.5C (103F) or lasts longer than 3 days.

CIPROFLOXACI N (floxacif)

Antibacterial

500mg 1 tab, PO, every 12 hours

Inhibits bacterial DNA syrase thus preventing replication in susceptible bacteria.

 Nausea  Vomiting  Stomach pain  Heartburn  Diarrhea  Feeling an urgent need DURATION to urinate unknown  Headache  Hives PEAK EFFECT 1-2hrs (PO) immediat e (IV)

 Instruct patient not to take ciprofloxacin with dairy products such as milk or yogurt, or with calcium-fortified juice. They could make the medication less effective.  Tell patient that

 Difficulty bre athing or swallowin g  Rapid, irregular, or pounding heartbeat  Fainting  Fever  Joint or muscle pain  Unusual bruis ing or bleeding  Extremetired ness  Lack of energy of appetite  Seizures  Dizziness  Confusion

Ciprofloxacin can cause side effects that may impair his thinking or reactions.  Tell patient to be careful if he plans to drive or do anything that requires him to be awake and alert.  Instruct patient to take ciprofloxacin with a full glass of water (8 ounces).  Inform patient that Ciprofloxacin may cause swelling or tearing of a tendon, especially in the Achilles' tendon of the heel

FUROSEMIDE (piplen)

Diuretic/ Antihypertensive

40 mg tab, PO, OD

Inhibits sodium and chloride reabsorption at the proximal tubules, distal tubules, and

PEAK EFFECT 1-2hrs (PO) 1/2hr (IV)

CNS: headac he, fatigue, weakness, vertigo, paresthesias

 Assess patient for tinnitus, hearing loss, ear pain  Monitor for renal, cardiac, neiurologic, GI, pulmonary

ascending loop of Henley, leading to excretion of water together with sodium, chloride and potassium.

DURATION 6-8hrs (PO) 2hrs (IV)

CV: orthostatic hypotension, chest pain, ECG changes, circulatory collapse ELECTROLYTES: hypokalemia, hypochloremi c alkalosis, hypoagnese mia, hyperuricemi a ENDO:hypergl ycemia GI: nausea, diarrhea, dry mouth, vomiting, anorexia, pancreatitis GU: polyuria, reanl failure, glycosuria

manifestation of hypokalemia: acidic urine, decreased urine osmolality, nocturia, polyuria and polydipsia  Monitor for CNS, GI, cardiovascular, integumentary, neurologic manifestations of hypocalcemia: personality changes, anxiety, disturbances  Monitor for manifestations of hyponatremia  Monitor electrolytes Precautions: Pregnancy, DM, dehydration, severe renal disease, cirrhosis, ascites