Nursing Care Plan ASSESSMENT Subjective: Hindi ko maigalaw ang aking kaliwang kamay at medyo hindi ko rin maigalaw

ang kaliwa kong paa. Objective: Left hemi paralysis Limited range of motion !O"# $unctional level: level %&re'uires help SCIENTIFIC EXPLANATION (mpaired physical mobility related to neuromuscular impairment INFERENCE )euromuscular disorders affect the nerves that control the voluntary muscles. *oluntary muscles are the ones that can be controlled+ like in the arms and legs. ,he nerve cells+ also called neurons+ send the messages that control these muscles. -hen the neurons become unhealthy or die+ communication Long term .fter / months of continuous +effective and collaborative nursing interventions+ .fter / hours+ the patient verbali0e understanding situation or risk factors and individual treatment regimen and safety measures 3ncourage and facilitate early ambulation and other .2Ls when possible. .ssist with each initial change: dangling+ sitting in chair+ ambulation ,he longer the patient remains immobile the .fter / months of continuous +effective 2etermine the diagnosis that contributes to immobility ,o be informed about the PLANNING Short term INTERVENTION "onitor *1S RATIONALE ,o note changes and for baseline comparison. EVALUATION .fter / hours of nursing intervention the patient was able to verbali0e understanding situation or risk

situations that may factors and individual treatment restrict movements regimen and safety measures

greater the level of and collaborative nursing debilitation that will occur interventions+ patient was able to maintain position and function

between the nervous patient will

from another person.

system and muscles breaks down. .s a result+ the muscles weaken and waste away. ,he weakness can lead to twitching+ cramps+ aches and pains+ and joint and movement problems. Sometimes it also affects heart function and ability to breathe. "any neuromuscular diseases are genetic+ which means they run in families or there is a mutation in your

maintain position+ function and skin integrity 4erform passive or active !O" e5ercises to all e5tremities increased venous return+ prevents stiffness+ and maintains muscle strength and endurance ,urn and position every % hours or as needed. ,his optimi0es circulation to all tissues and relieves pressure. 4rovide safety measures side rails+ using pillow to support body part# ,o provide safety and reduce the risk of pressure ulcers

and skin integrity as 35ercise promotes evidenced by the absence of contractures+ footdrop+ decubitus and so forth

genes. Sometimes+ an immune system disorder can cause them. "ost of them have no cure. ,he goal of treatment is to improve symptoms+ increase mobility and lengthen life.

"assage back and bony prominences

(t provides comfort to the patient and promotes good circulation

6onsult with physical or occupational therapist as indicated

,o develop individual e5ercise therapy or program

!eference: http:11www7.us.elsevierhealth.com1"3!L()18ulanick16onstructor1inde5.cfm9plan:;<

ASSESSMENT

SCIENTIFIC EXPLANATION

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: =Hindi ako mapadumi. Objective: .bdominal pain+ urgency .ltered bowel sounds Left Hemi paralysis Limited !O" 6onstipated for five days

6onstipation related to insufficient physical activity

. decrease in a person>s normal fre'uency of defecation+ accompanied by difficult or incomplete passage of stool and1or passage of e5cessively hard+ dry stool. . lack of physical activity can lead to constipation. $or e5ample+ constipation often occurs after an accident or during an illness when one must stay in bed and cannot e5ercise. Lack of

.fter ? hours+ the patient will establish or return to normal patterns of bowel functioning

2etermine stool color+ consistency+ fre'uency and amount

.ssist in identifying causative and contributing factors and appropriate interventions

.fter ? hours+ the patient was able to establish or return to normal patterns of bowel functioning as evidenced by easy passage of long+ round+ and smooth brown& shaded stool with a te5ture similar to creamy peanut butter

.uscultate bowel sounds

Aowel sounds are generally decreased in constipation

3ncourage increased fluid intake+ %<@@&;@@@ ml1day within cardiac tolerance

.ssists in improving stool consistency

3ncourage to eat high&fiber rich

,o enhance easy defecation

physical activity is thought to be one of the reasons constipation is more common in older people. "oreover+ increased physical activity is more likely to stimulate bowel motility and improve the symptoms of constipation.

foods 2ecrease gastric !ecommend avoiding gas& forming foods distress and abdominal distention 4revents skin .ssist in perianal skin condition fre'uently+ noting changes or beginning breakdown $acilitates 2iscuss use of stool softeners+ mild stimulants+ bulk& forming la5atives+ or enemas as indicated. "onitor defecation when constipation is present e5coriation and breakdown

effectiveness 6onstipation is a (dentify factors e.g.+ medications+ bed rest+ diet# that may cause or contribute to constipation. 3valuate medication profile for gastrointestinal side effects. $iber absorbs water+ which adds 6onsult dietitian to provide well& balanced diet high in fiber and bulk bulk and softness to the stool and speeds up passage through the intestines common side effect of many drugs including narcotics and antacids.

!eference: http:11www.med.umich.edu17libr1aha1umconstipation.htm

ASSESSMENT SBAC36,(*3: =ayoko kumain ng walang lasa OAC36,(*3: Dpale to pinkish conjunctiva and lips Dweak looking Dfair appetite+ selective with food

DIAGNOSIS (mpaired adjustment related to health status re'uiring change in lifestyle

SCIENTIFIC EXPLANATION (nability to modify lifestyle in a manner consistent with a change in status. ,he objective of nursing care for focuses on lowering and controlling the blood pressure without adverse effects and without

PLANNING Short ,erm 8oal .fter / days of nursing intervention+ there will be an increase interest and participation on the

INTERVENTION (ndependent *ital signs monitored and recorded. A4 monitored regularly .ssist the patient in identifying modifiable risk factors like diet high in sodium+ saturated fats and

RATIONALE

EVALUATION .fter / days of

$or baseline comparison

nursing interventions the goal is met through participation and demonstration of lifestyle changes

hypertensive patients demonstration of self care and will initiate lifestyle changes that will permit adaptation to present medical situation

,hese risk factors have been shown to contribute to hypertension

preferences A4&7;@1E@ mmHg

undue cost. ,o achieve these goals+ the nurse must support and teach the patient to adhere to the treatment regimen by implementing necessary lifestyle changes like avoidance of foods high in sodium and fats and taking medications as prescribed.

cholesterol (nstruct and emphasi0e necessary care and lifestyle changes that will enhance her recovery. ,his will promote trust and will on the patient to adhere to such activities that will enhance fast recover 4lan necessary care and assistance in .2Ls with the relative 3mphasi0e the importance of ade'uate rest 3mphasi0e the Hypertension 4lanning with the relative will add more cooperation of the patient ,his will lower the patientFs A4

importance of adherence to medications 4rovide an open environment encouraging communication

needs medications to maintain the A4 in its normal range 35pression of feelings concerning impaired function is dealt with realistically

!eference: http:11www.medicinenet.com1highGbloodGpressure1article.htm

DRUG STUDY

Nursing Name o Drug 8eneric )ame: "annitol Arand )ame: Classi i!a"ion "iscellaneous $luids or 2iuretics A!"ion &increase osmotic pressure of !oute and $re'uency: (* '/ 2ose: glomerular filtrate which inhibits tubular re&absorption of water and electrolytes and increases urinary output In#i!a"ions !eduction of increased intracranial pressure associated with cerebral edema !eduction of increased ocular pressure 4romotion of diuresis in the prevention and1or treatment for oliguria or anuria due to acute renal failure Si#e E e!"s 2i00iness Headache 6onvulsions Alurred vision 2iuresis 2ry mouth Loss of hearing Con"rain#i!a"ions Hypersensitivity Severe renal disease Severe dehydration 4ulmonary congestion Res$onsi%ili"ies .ssess patientFs condition before therapy and regularly thereafter to monitor drug effectiveness .ssess for possible drug induced adverse reactions. .ssess patient for possible drug induced adverse reactions. ,each patient to recogni0e and immediately report adverse

Moni"oring Parame"ers "onitor vital signs+ 6*4+ and urine specific gravity "onitor manifestations of electrolyte imbalance .ssess A4 before and during the therapy with patient lying+ standing and sitting+ orthostatic hypotension can occur rapidly.

Osmofudin %@H

7@@ cc

reactions .sses patientFs and familyFs knowledge of drug therapy

Nursing Name o Drug 8eneric )ame: 6iticholine Arand )ame: Classi i!a"ion 6)S stimulants or )eurotonics A!"ion In#i!a"ions 6*. in acute and recovery phase. Signs and symptoms of cerebral insufficiency. !ecent cranial trauma 4arkinsonFs disease 6ytidine 2iphosphate &. derivative of choline and cytidine 6holine involved in the !oute and $re'uency: (* '7% 2ose: biosynthesis of lecithin. (t is claimed to increased blood flow and o5ygen consumption. Si#e E e!"s Shock Hypersensitivity Hypotension (nsomnia Stimulates parasympathetic action and fleeting and discreet hypotension effect Con"rain#i!a"ions Hypertonia of the parasympathetic nervous system 4regnancy and lactation Res$onsi%ili"ies 3valuate patient medical history .ssess patient condition Should not be administered to patient with hypertonia of the parasympathetic nervous system 6aution that large doses could

Moni"oring Parame"ers "onitor vital signs .ssess allergic reaction like 8( disturbances

7 gm

aggravate increase in cerebral blood flow in episodes of persistent intracranial hemorrhage. ,each patient to gain benefits and not to miss any dose

Nursing Name o Drug Classi i!a"ion In#i!a"ions Si#e E e!"s Con"rain#i!a"ions Res$onsi%ili"ies

Moni"oring Parame"ers

8eneric )ame:

6ardiovascular Statins A!"ion &(nhibits H"8&6O. reductase en0yme+

,o reduce L2L cholesterol+ apolipoprotein beta and triglycerides

.bdominal pain 6onstipation $latulence (nsomnia Headache !ashes 2i00iness "uscle cramps

Hypersensitivity to any component of the preparations

.ssess nutrition: fat + protein+ carbohydratesI nutritional analysis should be completed by dietitian before treatment is initiated

"onitor creatinine phophokinase levels due to possibility of myopathyI serum cholesterol

Simvastatin Arand )ame:

.ltovast !oute and $re'uency: Oral Od 2ose:

6hildren and lactation .ctive liver disease Bne5plained persistent elevations of serum transaminases

,o increase H2L cholesterol in the treatment of hyperlipidaemias

which reduces cholesterol production

"onitor triglycerides+ cholesterol baseline and throughout treatment

6oronary heart disease

.ssess liver function tests prior to therapy and periodically thereafter 3valuate therapeutic response and adverse reactions on a regular basis

/@ mg

.ssess

knowledge or teach patient proper use

Nursing Name o Drug 8eneric )ame: (midapril Arand )ame: Classi i!a"ion In#i!a"ions 6ardiovascular drugs ,reatment of =antihypertensive A!"ion &inhibits angiotensin converting en0ymeI !oute and $re'uency: Oral O2 2ose: reduction of angiotensin (( resulting in dilation of peripheral vessels and reduction of vascular resistance hypertension Si#e E e!"s 2ry cough Headache !ash 4alpitation $atigue 2iscomfort in the throat Con"rain#i!a"ions 4atients with known hypersensitivity to angiotensin converting en0yme inhibitors or with history of angioneorotic edema 4regnancy and lactation Res$onsi%ili"ies 3stablish baselines in renal+ liver function tests before therapy 6heck for edema .sses for patient allergic reactions .dvise patient to avoid potassium+ salt substitutes ,each patient how to take Ap

Moni"oring Parame"ers "onitor blood studies "onitor bp+ orthostatic hypotension "onitor electrolytes during the firs % weeks of therapy "onitor renal studies and symptoms

*ascor

<@ mg

and normal readings for age group

Nursing Name o Drug 8eneric )ame: 6lonidine Arand )ame: A!"ion &stimulates central& !oute and $re'uency: Oral O2 2ose: alpha adrenergic receptors to inhibit sympathetic cardioaccelareators and vasoconstrictor centers Classi i!a"ion 6ardiovascular drugs =6entrally&acting drugs In#i!a"ions "anagement of all grades of hypertension with the e5ception of H4) due to phaeochromooyto ma 4rophylactic treatment of migraine or recurrent vascular treatment of Si#e E e!"s Local skin irritation 2rowsiness 2ry mouth Headache $atigue .nore5ia .n5iety Con"rain#i!a"ions Res$onsi%ili"ies Hypersensitivity to .ssess pain+ clonidine Sick sinus syndrome location+ intensity+ character+ alleviating+ aggravation factors+ baseline and fre'uency 4erform blood studies+ neorophils+ decreased platelets 4erform renal

Moni"oring Parame"ers "onitor baselines for renal+ liver function test before therapy begins "onitor A4+ standing+ sitting+ supine+ mental status+ and heart rate.

6atapres

J< mcg

migraine $or relief of cancer pain

studies .ssess Ap and apical pulse before initial dose )ote allergic reactions

NAME OF DRUG 8eneric )ame: !anitidine Arand )ame: Kantac

CLASSIFICATION 8astrointestinal 1 hepatobiliray 2rugs H% !eceptor .ntagonists

INDICATIONS Bsed in management of gastrointestinal 8(# disorders. 4rophyla5is of 8( hemorrhage from stress ulceration and in patients at risk of developing acid aspiration during general

SIDE EFFECTS Aradycardia Headache $atigue 2epression

CONTRAINDICATIONS Hypersensitivity History of acute porphyria Long&term therapy

NURSING RESPONSI&ILITIES Bse caution in presence of renal or hepatic impairment. .ssess for potential for interactions with other pharmacological agents patient may be taking. 3valuate results of

MONITORING PARAMETERS "onitor .S,+ .L,+ Serum creatinine+ signs and symptoms of peptic ulcer disease+ occult blood with 8( bleeding. "onitor renal function to correct dos.

Me!'anism o !oute: (.* $re'uency: ' 7% A!"ion: (nhibits histamine at H% receptor site in the gastric parietal cells+ which inhibits gastric acid

!ashes 6onstipation

2ose: <@ mg

secretion.

anesthesia.

laboratory tests+ therapeutic effectiveness.