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CUES

CUES

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Published by Rosline Grajera

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Published by: Rosline Grajera on Mar 07, 2011
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01/01/2014

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CUES

NURSING DIAGNOSIS Acute pain related to physiological injuring agents;DHF

SCIENTIFIC EXPLANATION

GOALS AND OBJECTIVES

NURSING INTERVENTION Independent Perform comprehensive assessment on pain Provide calm activities; reading magazines, listening to the radio Encourage adequate rest periods Dependent Administer analgesics as ordered by the physician

RATIONALE

EVALUATION Short term goal: After 3 hours of the nursing intervention the client was: Verbalized ³hindi na ganung masyado kasakit ang tiyan ko´ Verbalize methods that provide relief

Subjective: ³Masakit ang tiyan ko´ as verbalized by the client

Dengue virus in the Short term goal: circulation After 3 hours of the nursing Decrease platelet intervention the in the circulation client will: Presence of gastric Verbalize ³hindi na acid in the stomach ganung masyado kasakit ang tiyan Risk for bleeding ko´ Gastric acids hit nerve endings Pain sensation Verbalize methods that provide relief Pain scale of 5/10 will decrease to 2/10. (-) facial grimace

To assess, baseline purposes

Objective: Pain scale 5/10 (+) epigastric pain (+) facial grimace (+) vomitus, 3x

To explore methods for alleviation

To prevent fatigue Pain scale of 5/10 will decrease to 2/10. (-) facial grimace

Long term goal: After one day of the nursing intervention the client will: (-) epigastric pain

Long term goal: After one day of the nursing intervention the client was: (-) epigastric pain

hypophosphatemia. lactation *Physical: skin color. and adsorbs both pepsin and bile acids. preventing further damage from acid. it prevents back diffusion of hydrogen ion s. epiderma Contraindication Side Effects/ Adverse Effect Nursing Responsibility Assessment *History: allergy to sucralfate. reflexes. normal output. Iselpin 500mg/tab TID Hypersensitivity to drug/class/compone nts. it has been indicated that sucralfate also stimulates the increase of prostaglandin E2. It also attaches to proteins on the surface of ulcers. . In addition. dysphagia or GI obstruction caution if renal failure. Less commonly reported include flatulence. orientation. and bile. such as albumin and fibrinogen. pepsin. pregnancy. Recently.viscous. pastelike material capable of acting as an acid buffer for as long as 6 to 8 hours after a single dose.Chapter 3: IMPLEMENTATION Drug DRF Indication Drug class(es): miscellaneo us GI agents Sucralfate systemic is used in the treatment of: y y y y Mechanism of Action Sucralfate is a locally acting substance that in an acidic environment (pH < 4) reacts with hydrochloric acid in the stomach to form a cross-linking. mucus membranes. Nursing mothers: Uncertain. to form stable insoluble complexes. and xerostomia (dry mouth). These complexes serve as protective barriers at the ulcer surface. Sucralfate. lesions. chronic y y y Duodenal Ulcer Duodenal Ulcer Prophylaxis GERD Hyperphosphat emia of Renal Failure Stomach Ulcer Stomatitis Stress Ulcer Prophylaxis The most common side effects seen are constipation and bezoar forma tion. chronic renal failure/dialysis. cephalalgia (he adache).

It is better tolerated than aspirin in patients in whom excessive gastric acid secretion or prolongation of bleeding time may be a concern. aches. even peripheral anti-inflammatory activity comparable to other NSAIDs can be observed. It has analgesic and antipyretic pr operties comparable to those of aspirin. one of which is high level of peroxides present in inflammatory lesions. bFGF. Contraindication Hypersensitivity Hepatic function Side Effects GI symptoms hypotension Nursing Responsibility Give drug with food to increase bioavailability Assess temperature 10 Rs . and gastric mucus.l growth factors (EGF). while its antiinflammatory effects are weaker. it has in recent years increasingly become a common household drug. in some circumstances. However. Mechanism of Action The main mechanism of action of paracetamol is considered to be the inhibition of cyclooxygenase (COX).[39] While it has analgesic and antipyretic p roperties comparable to those of aspirin or other NSAIDs. and recent findings suggest that it is highly selective for COX2. Available without a prescription. its peripheral anti-inflammatory activity is usually limited by several factors.7degree Celsius 500mg/tab q4 Indication Paracetamol is used for the relief of fevers. and pains associated with many parts of the body. Drug Paracetamol DRF PRN T=37.

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