DAVAO DOCTORS COLLEGE

Gen. Malvar St., Davao City

DRUG STUDY

Name: Binancilan, Maryfiel Mosquera Date of Admission: Sept. 8, 2010

Age: 52 Sex: Female Civil Status: Married Room/Bed no: 559 Attending Physician: Dr. Crisostomo Serrano, Sr.

GENERI BRANDNAM CLASSIFICATIO MECHANIS INDICATIO CONTRAINDI ADVERSE DOSAGE NURSING

C NAME E N M OF N CATION REACTION RESPONSIBILIT
ACTION Y
Phenylpro Nasathera cap Nasal It constricts Nasal Patients w/ Giddiness, phenylpro  Encouraged
panolamin Decongestant, (shrinks) blood congestion coronary nausea, vomiting, panolamin patient to
e HCl + Antipyretic, vessels (veins due to thrombosis, sweating, thirst, e 25 mg. increase oral
Paracetam analgesic and arteries), common HTN, tachycardia, paracetam fluid intake
ol which reduces colds, rhinitis hyperthyroidism, precordial pain, ol 250 mg,  Instruct patient to
swelling of & sinusitis. close-angle palpitations, Give 1 avoid operating
mucous glaucoma. It difficulty in cap tid machine or
membranes in should not be micturition, driving since it
areas such as used muscular can cause
the nose and concomitantly w/ weakness & dizziness
sinuses. It or w/in 2 wk of tremors, anxiety,  Do not take
thins mucous, MAOI therapy. restlessness & phenylpropanolami
increases insomnia, ne if you have taken
lubrication of Cardiac diseases, paranoid a monoamine
the respiratory angina of effort, psychosis, oxidase inhibitor
tract (lungs, diabetes & in delusions & (MAOI)
nose and patients receiving hallucinations.  Monitor BP
throat), and digitalis & before giving
increases the antidepressants & Phenylpropanolami
removal of w/ prostate ne
mucous. enlargement.
Pregnancy.

Name: Davalos, Meriam Dorres M. Section: C Group: 26

 DAVAO DOCTORS COLLEGE
Gen. Malvar St., Davao City

DRUG STUDY

Name: Binancilan, Maryfiel Mosquera Date of Admission: Sept. 8, 2010

Age: 52 Sex: Female Civil Status: Married Room/Bed no: 559 Attending Physician: Dr. Crisostomo Serrano, Sr.

GENERI BRANDNAM CLASSIFICATIO MECHANIS INDICATIO CONTRAINDI ADVERSE DOSAGE NURSING

C NAME E N M OF N CATION REACTION RESPONSIBILIT
ACTION Y
Cefuroxime Zinnat Anti-infective: It inhibits Eradication of •Hypersensitivity CNS: headache, 500mg 1 • Advise patient to
Axetil hyperactivity,
second-generation bacterial cell gram-negative to cephalosporins hypertonia, seizures GI: tab tid immediately report
cephalosporin wall synthesis, bacilli and or penicillins nausea, vomiting, rash or bleeding
rendering cell gram-positive • Carnitine diarrhea, abdominal tendency.
pain, dyspepsia,
wall organisms; deficiency pseudomembranous • Instruct patient to
osmotically treatment of Use cautiously colitis take drug with food
unstable; serious lower in: every 8 hours as
respiratory • renal or hepatic GU: hematuria, vaginal prescribed.
candidiasis, renal
tract, urinary impairment dysfunction, acute renal • Teach patient how
tract, skin, and • pregnant or failure to recognize signs
gonococcal breastfeeding and symptoms of
infections, patients Hematologic: superinfection.
hemolytic anemia,
septicemia, • children. aplastic anemia, Instruct him to
and hemorrhage report right away.
meningitis. • Advise patient to
Hepatic: hepatic report CNS
dysfunction
changes.
Metabolic:
• As appropriate,
hyperglycemia review all other
significant and life-
Skin: toxic epidermal threatening adverse
necrolysis, erythema
multiforme, Stevens-
reactions and
Johnson syndrome interactions,
Other: allergic reaction, especially those
superinfection,anaphyla
xis
related to the drugs,
tests, and foods
mentioned above.
Name: Davalos, Meriam Dorres M. Section: C Group: 26
 DAVAO DOCTORS COLLEGE
Gen. Malvar St., Davao City

NURSING CARE PLAN

Patient’s Name: Binancilan, Maryfiel Mosquera Age: 52 Sex: Female Room/bed no: 559 Date of Admission: Sept. 8,2010
Civil Status: Married Religion: Catholic Attending Physician: Dr. Crisostomo Serrano, Sr. Diagnosis: CAP- LR, Maxillary Sinusitis

PROBLEM SCIENTIFIC GOALS NURSING RATIONALE EVALUATION

BASIS OBJECTIVE INTERVENTION
CRTERIA
S : “ Kagalkal kayo Cough results from Within the 8 hour
akong ubo ba” as irritation of the span of care, the
verbalized by the mucous membrane patient will be able to:
patient anywhere in the 
respiratory tract.
Persistent and
frequent cough can be
exhausting and can
cause pain. A cough
that worsens when
patient is supine
suggests postnasal
drip (sinusitis).
Sputum production is
the reaction of the
lungs to any
constantly recurring
irritant.
Reference: Smeltzer, et.al. Brunner
and Suddarth’s Textbook of
Medical- Surgical Nursing. 11th
Edition. 2008. Lippincott Williams &
Wilkins

Name: Davalos, Meriam Dorres M. Section: C Group: 26

 DAVAO DOCTORS COLLEGE
Gen. Malvar St., Davao City

COMPREHENSIVE ASSESSMENT

A. PERSONAL DATA

Name: Binancilan, Maryfiel M. Age: 52 Sex: Female Civil Status: Married Religion: Catholic
Address: Blk.6 Lot8 Ph.2 Roseville Subd., Lanang, Dvo. Cty Occupation: Retired Employee
Chief Complain: Shortness of breath, backpain Attending Physician: Dr. Crisostomo Serrano Sr.
Date of Admission: Sept. 8, 2010 Impression to Diagnosis: CAP- LR, Maxillary Sinusitis

B. FAMILY BACKGROUND
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C. EFFECTS/EXPECTATIONS OF ILLNESS TO FAMILY AND SELF

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D. HISTORY OF PAST ILLNESS

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E. HISTORY OF PRESENT ILLNESS

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GUIDELINES
I. Mental Status
a. state of mental consciousness
b. orientation
c. intellectual capacity
d. vocabulary level
e. attention span
f. ability to understand
II. Status of Special Senses
a. auditory perception
b. visual perception
c. speech perception
d. tactile perception
e. olfactory perception
III. Motor Ability
a. current mobility
b. posture
c. range of motion
d. muscle and nerve status
e. loss of extremities
FUNCTIONAL PATTERN
ONGOING ASSESSMENT
PATIENT DAY 1 DAY 2 DAY 3
Alert, conscious, coherent N/A
Oriented to place, time,
situation, place
Able to understand, can
operate simple math, with
good intact memory
Speaks fluently in his
preferred dialect, without
sluggishness
Able to participate in long-
term conversation
Able to understand well
Able to hear well to verbal
stimuli
Able to see clearly without
visual aids, no blurring in
vision
Able to speak fluently enough
to be understood
Able to respond and feel to
touch or pain stimulus
Able to distinguish various
odor
No limitation in mobility, can
ambulate well
With normal gait, erect
posture
Able to do active and passive
joint motion without pain and
difficulty
Nerves and motor action are
coordinated and symmetrical
Complete upper and lower
extremities
IV. Body Temperature
a. ranges
V. Respiratory Status
a. character
b. use of respiratory aids
c. interference in respiration
d. abnormal respiratory opening
VI. Circulatory Status
a. character of arterial pulse
b. apical-radial pulse
c. intravenous fluids
VII. Nutritional Status
a. condition of buccal cavity
b. digestion of food
c. weight
VIII. Elimination Status
a. bowel
b. bladder
c. abnormalities
IX. Female Reproductive Status
a. age of menarche
b. pattern of menses
Normal temp. from 36-37.5 0C
Regular inspiratory and
expiratory, with clear breath
sound, no retraction
Can breathe without difficulty,
without use of resp aids
No interference in respiration
No abnormal opening
With strong, bounding pulse,
regular in rhythm, with pr of
60-100bpm
With equal pulse, symmetrical
apical-radial pulse
No intravenous hooked to pt
With pink and moist buccal
membrane, no ulceration
noted
With regular digestive action,
with good appetite
Wt is appropriate for his
height
Able to defecate daily without
straining, with yellow-brown
feces
Voiding freely without pain,
urinate approx. 240cc/8hr of
clear-yellow urine
No abnormalities in
eliminating feces and urine
Menarche starts at10-15y.o.
Regular monthly cycle of 28

c. pregnancy
d. vaginal discharge
X. State of Skin and Appendages
a. skin
b. hair
c. nails
XI. State of Physical Comfort and rest
a. sleep/rest pattern
b. presence of pain/ discomfort
c. use of supportive aids
XII. Emotional Status
a. emotional reaction
b. body image
c. ability to relate others
XIII. Nursing Diagnosis
1. Ineffective Airway Clearance r/t retained thick copious bronchial secretion
2.
3.
days average, duration of 3-5
days, consume 3-4 pads
Nulligravid state
With clear, vaginal disharges,
not foul odor
Smooth, warm to touch, with
good skin turgor, without
lesions and abrasions
Evenly-distributed hair, shiny,
without any infestation, and
dandruff
Clean, trimmed nails, with
pink nailbed, normal
curvature, with CRT <2 secs
Able to sleep and rest at least
6-8 hours a day
No presence of pain or
discomfort
Is comfortable and can rest
without use of supportive aids
Coherent mood and affect,
able to verbalize feeling
With good self-esteem
Social, pleasant, interactive
towards other