GENERIC BRAND NURSING

DOSAGE FREQUENCY ROUTE CLASSIFICATION ACTION INDICATION CONTRAINDICATION

NAME NAME RESPONSIBILITY

Cefuroxime Ceftin, 750 mg q8 IVP Cephalosporin Decrease Less If the drug was Should the
Zinacef s or susceptible tolerated it can check the
control to beta cause diarrhea, patients name,
the lactamase nausea, vomiting, the correct
infection. and have headache, or route, dosage,
greater migraines, dizziness and frequency
activity and abdominal of the medicine
against pain. that should be
Haemophilu given.
s
Influenzae,
gonorrhea
and Lyme
disease.
GENERIC BRAND NURSING
DOSAGE FREQUENCY ROUTE CLASSIFICATION ACTION INDICATION CONTRAINDICATION
NAME NAME RESPONSIBILITY

Used to
Tramadol Tramal, 100mg q8 IVP Analgesic Treat treat Health Should the
Mabron, moderate moderate professionals have check the
Ralivia, to to not yet fully patients name,
Ryzolt, moderatel moderately endorsed of its use the correct
Tramacet, y severe severe pain on a large scale for route, dosage,
Ultracet, pain and and most these disorders, and frequency
Zamadol, most types of although it may be of the medicine
Zytram types of neuralgia, used when other that should be
neuralgia, including treatments have given
including trigeminal failed (under the
trigeminal neuralgia. supervision of a
neuralgia. It has been psychiatrist).
suggested
that
tramadol
could be
effective
for
alleviating
symptoms
of
depression,
anxiety,
and
phobias.
 GENERIC BRAND NURSING
DOSAGE FREQUENCY ROUTE CLASSIFICATION ACTION INDICATION CONTRAINDICATION
NAME NAME RESPONSIBILITY

Paracetamo Naprex 1 amp q8 IVP Analgesic, Used for Suitable Excessive use can Should check
l Antipyretic the relief substitute for damage multiple first the
of fever, aspirin & organs such as liver temperature
headaches recommende and kidney. before giving
, and d to be given the medicine
other if the fever is and after 15-
minor 38.5C and 30 mins.
aches and above. Recheck the
pains, and temperature of
is a major the patient,
ingredient should also
in check for the
numerous patients name,
cold and right route,
flu dosage and
remedies. frequency of
the medicines.
 HEALTH ASSESSMENT
Pt’s Name: Paterno Tongohan
Diagnosis: S/P Thyroidectomy

Skull
➢ normocephalic
Scalp
➢ no lesions noted
Hair
➢ gray hair
➢ thin strands
➢ no evidence of alopecia
Face
➢ heart-shaped face
➢ symmetrical
➢ with facial grimace
Eyes
➢ no ptosis, edema or lesions of lids
➢ conjunctive and sclera moist without jaundice or suffusion
 ➢ pupils equal, round, react to accommodation
Ears
➢ ear lobes are bean shaped, parallel and symmetrical
➢ no lesions noted upon inspection
Nose
➢ negative nasoaural discharge
➢ nose in midline
➢ negative nasal flaring
➢ both nares are patent
Neck
➢ straight and symmetrical
➢ negative lymph adenopathy
➢ with wound dressing at the anterior side with + reddish discharge
➢ dysphagia
Chest
➢ hyperpnea
Abdomen
➢ flat contour
Extremities
➢ both extremities are equal in size
➢ have the same contour with prominences of joints
➢ no involuntary movement
➢ can perform complete range of motion
Skin
➢ hot and dry
➢ no abnormal pigmentation
➢ with pallor
 Laboratory Examination

Hematology Result 07-20-09

ABO type “B”

Bleeding time 3’ 35”
Clotting time5’ 05”

Urinalysis 07-20-09

Color: yellow
Transparency: clear
pH: 7.0
Specific Gravity: 1.005
Epithelial cells: -
WBC: 0-1/ hpf
RBC: 0-1/ hpf
Albumin: (-)
Sugar: (-)

Thyroid Function Test 07-22-09

 TSH: 0.212 UIU/ml
T3: 1.90 nmol/L
T4: 112 nmol/L

Hematology 07-21-09

Hemoglobin: 142 g/L

Hematocrit: 0.43
WBC: 11.3x10 g/L
Segmenters: 0.55
Lymphocyte: 0.34
Eosinophils: 0.11
Platelet Count: 229x10 g/L

Blood Chemistry 07-21-09

BUN: 5.5 nmol/L

Creatinine: 86 umol/L

PATIENT’S HISTORY
Paterno Tongohan, 56 y.o. from Tanay, Rizal.
Currently working as a construction worker in Pag-asa, Talavera, Nueva Ecija.
 They are 12 in the family with 9 siblings, he’s the 7th child.
With only one child and living as a single-parent family.
Smoker with 42 packs of cigarette per year and stopped on February 2008,
and a heavy drinker of liquor beer 3x a week up to 1 case.

PAST MEDICAL HISTORY

Hemoptysis previous treated for PTB and retreated with category II

HISTORY OF PAST ILLNESS

Tentative diagnosis: Anterior Neck Mass
Final diagnosis: Diffuse Multi nodular non-toxic goiter
Nursing Nursing Nursing
Planning Rationale Evaluation
Problem Diagnosis Intervention
Objective data: Acute pain maybe ➢ to decrease ➢ Assist pt. to ➢ To promote ➢ After 8⁰ of duty
➢ with latest vital related to presence of pain within 8⁰ of turn side by good blood the pt’s pain
signs of: surgical incision duty side every 2⁰. circulation lessened as
T: 38.1 manipulation of ➢ To lower the ➢ encourage to ➢ To avoid bed verbalized by
P:70 tissues/muscles temp. at 37 ⁰C increase time of sores the pt.
R:27 sleep ➢ To be easily ➢ Goal in
➢ determine pain gain his decreasing
BP: 110/90
characteristic strength temperature is
➢ with grimace through pt. ➢ Establishes unmet.
and weak in description base line for
appearance ➢ stretching of assessing
➢ pale linens improvement or
➢ with yellowish ➢ Provide changes
feet diversional ➢ to promote skin
➢ with tachypnea
activities to the integrity
➢ with difficulty pt such as ➢ to refrain pt.
speaking listening to from anxiety,
➢ pain scale of 8 radio have depression or
as verbalize by some stress about his
the pt. conversation condition
with him or tell
him some
stories that he
may listen of.
 Goiter is the term for overactive tissue within the thyroid
gland, resulting in overproduction and thus an excess of circulating free
thyroid hormones: thyroxine (T4), triiodothyronine (T3), or both. Thyroid
hormone is important at a cellular level, affecting nearly every type of tissue
in the body.
Thyroid hormone functions as a stimulus to metabolism and is critical to
normal function of the cell. In excess, it both over stimulates metabolism and
exacerbates the effect of the sympathetic nervous system, causing "speeding
up" of various body systems and symptoms resembling an overdose of
epinephrine (adrenaline). These include fast heart beat and symptoms of
palpitations, nervous system tremor and anxiety symptoms, digestive system
hyper motility (diarrhea), and weight loss.