NURSING CARE PLAN # 1 (ACTUAL) ASSESSMENT Actual/Abnormal cues: nakabalo na na siya ganimag sulat gamit ang wala ya nga

kamot kay tungod may dextrose siya sa pihak.. as Definition: verbalized by the patients mother Limitation in independent, purposeful Able to physical perform limited hand movement of the body or of activities. one or more Limited extremities Range of motion. Source: NURSING DIAGNOSIS RATIONALE DESIRED OUTCOME After 5 days of nursing intervention, the client will be able to: Demonstrate techniques/beha viors that enable resumption of activities. Participate in ADLs and desired activities. INTERVENTIONS INDEPENDENT: Observe movement when client is unaware of observation Assist with treatment of underlying condition(s) Assist/have client reposition self on a regular schedule as dictated by individual situation Identify/enco -to note any incongruency with reports of abilities. JUSTIFICATIONS EVALUATION After 5 days of nursing intervention, the client:

-to maximize potential for mobility and optimal function.

-to enhance circulation to tissues, reduce risk of tissue ischemia

Verbalize

understanding of situation and individual treatment

-Limits fatigue,

Strength: Good emotional and family support Positive attitude towards recovery Risk: Prolonged bedrest Long term IVF infection

Nurses Pocket Guide 9th edition By Doenges et al

regimen and safety measures. Maintain or increase strength and function of affected or compensatory body part.

urage energyconserving techniques for ADLs.

maximizing participation.

COLLABORATIVE: Collaborate with physical medicine specialist and occupational/physical therapists in providing range-of-motion exercise (active or passive). -These techniques can be helpful in rehabilitating the client

DRUG STUDY #1 Drug Generic Name: Paracetamol Brand Name: Dosage/ Frequency/ Route Mechanism of Action Indication Contraindication Adverse Effects Hematologic: thrombocytopenia, hemolytic anemia, neutropenia, leukopenia, pancytopenia Hepatic: jaundice, hepatotoxicity Metabolic: hypoglycemic coma Skin: rash, urticaria Nursing Responsibilty Observe for acute toxicity and overdose. Signs and symptoms of acute toxicity are as follows: Nausea, vomiting, anorexia, malaise, diaphoresis. Tell patient, parents, or other caregivers not to use drug concurrently with other acetaminophencontaining products. Advise patient, parents, or other caregivers to contact

Classification: Synthetic nonopioid aminophenol derivative Therapeutic class: Analgesic, antipyretic

Unclear. Pain relief may result from inhibition Mild to moderate of prostaglandin pain caused by synthesis in CNS, headache,muscle with subsequent ache, backache blockage of pain impulses. Fever reduction may result from vasodilation and increased peripheral blood flow in hypothalamus, which dissipates heat and lowers body

Hypersensitivity to drug

Use cautiously in: anemia, hepatic or renal disease elderly patients pregnant or breastfeeding patients children younger than age 2.

temperature.

Other: hypersensitivity reactions (such as fever)

prescriber if fever or other symptoms persist despite taking recommended amount of drug.

As appropriate, review all other significant and life-threatening adverse reactions and interactions.

DRUG STUDY # 2 Drug Generic Name: 10 g/ sachet Esomeprazole Magnesium Brand Name: Nexium Classification: *Proton pump inhibitor *anti-ulcer drugs PO OD Dosage/ Frequency/ Route Mechanism of Action Reduces gastric acid production by inhibiting enzyme activity in gastric parietal cells, preventing transport of hydrogen ions into gastric lumen Indication Contraindication Adverse Effects Nursing Responsibilty Monitor neurologic status, especially for dizziness, headache, paresthesia, and asthenia. Watch for signs and symptoms of EENT and respiratory infections. Assess nutritional and hydration status in light of adverse GI effects. Check for rash

Treatment of

gastroesophageal reflux disease (GERD); healing of erosive esophagitis

Helicobacter pylori

Hypersensitivity to drug or its components Use cautiously in: severe hepatic impairment children younger than age 18 (safety not established).

CNS: headache, dizziness, asthenia, vertigo, apathy, anxiety,paresthesia, insomnia, abnormal dreams EENT: sinusitis, epistaxis GI: nausea, vomiting, diarrhea, constipation, abdominal pain, flatulence, dry mouth Respiratory: upper respiratory tract infection, cough Skin: rash,

eradication to decrease risk of duodenal ulcer recurrence

Treatment of

pathological hypersecretory conditions

inflammation, urticaria, pruritus, alopecia, dry skin

and other signs of hypersensitivity.

DRUG STUDY # 3 Drug Generic Name: Furosemide Brand Name: Lasix Classification: Sulfonamide loop diuretic 16 mg IVTT Stat Dosage/ Frequency/ Route Mechanism of Action inhibit sodium and chloride reabsorption from ascending loop of Henle and distal renal tubules. Increases potassium excretion and plasma volume, promoting renal excretion Indication Contraindication Adverse Effects Nursing Responsibilty Watch for signs and symptoms of ototoxicity. Assess for other evidence of drug toxicity (arrhythmias, renal dysfunction, abdominal pain, sore throat, fever). Monitor CBC, BUN, and electrolyte, uric acid, and CO2 levels. Monitor blood

Acute pulmonary edema Hypertension

Edema caused

Hypersensitivity to drug or other sulfonamides Anuria Use cautiously in: diabetes mellitus, severe hepatic disease elderly patients pregnant or breastfeeding patients neonates.

by heart failure, hepatic cirrhosis, or renal disease

CNS: dizziness, headache, weakness, lethargy, paresthesia, drowsiness, restlessness, lightheadedness CV: hypotension, orthostatic hypotension, Tachycardia, arrhythmias EENT: blurred vision, hearing loss, tinnitus GI: nausea, vomiting, diarrhea, constipation,

of water, sodium, chloride, magnesium, hydrogen, and calcium. Reactions

dyspepsia, oral and gastric irritation, cramping, anorexia, dry mouth, acute pancreatitis GU: excessive and frequent urination, nocturia, glycosuria, oliguria Hematologic: anemia, purpura, leukopenia, thrombocytopenia, hemolytic anemia Hepatic: jaundice Metabolic: hyperglycemia, hyperuricemia, dehydration, hypokalemia, hypomagnesemia, hypocalcemia Musculoskeletal: muscle pain,muscle cramps Skin: photosensitivity, rash, diaphoresis, urticaria, pruritus, exfoliative dermatitis, Other: fever, transient

pressure, pulse, fluid intake and output, and weight. Monitor dietary potassium intake. Watch for signs and symptoms of hypokalemia.

pain at I.M. injection site

DRUG STUDY # 4 Drug Dosage/ Frequency/ Route Mechanism of Action Indication Contraindication Adverse Effects Nursing Responsibilty

Generic Name: Hydroxyzine diHCl Brand Name: Iterax Classification: Antihistamin es & Antiallergics , Anxiolytics

2mg/ml 4ml BID PRN

Hydroxyzin e diHCl is rapidly absorbed from the gastrointes tinal tract and its clinical effects are usually noted within 1530 mins after oral administrat ion. A suppressio n of activity in certain key regions of the subcortical area of the central nervous system.

Symptomatic

treatment of anxiety. Generalized anxiety disorder (GAD). As premedication to general anesthesia. Symptomatic treatment of pruritus of allergic origin.

Hypersensitivity to cetirizine & other piperazine derivatives. Intermittent acute porphyria. Pregnancy & lactation. Use cautiously on patients with Glaucoma, prostatic hypertrophy, intestinal or urinary obstruction, myasthenia, dementia, convulsions. Predisposition to cardiac arrhythmia. May impair ability to drive or operate machinery.

Anticholinergic Effects: Dry mouth.

CNS Effects: Drowsiness is usually transitory and may disappear in a few days of continued therapy or upon reduction of the dose. Involuntary motor activities including rare instances of tremor and convulsions have been reported, usually with doses considerably higher than those recommended.

Name of Drug

Dosage, Frequency, Route

Mechanism of Action

Indications

Contraindication s

Adverse Effects

Nursing Responsibility

Trade Name:

10mg/tab

Cetirizine hydrochloride

1tab OD

A long-acting, nonsedating antihistamine that selectively inhibits peripheral H1 receptors.

Contraindicated in patients Seasonal allergic hypersensitive rhinitis to drug or to hydroxyzine and in breast-feeding women.

CNS: somnolence, fatigue, dizziness, headache

Per orem Perrenial allergic rhinitis, chronic

EENT: pharyngitis Use cautiously in

Stop drug 4 days before diagnostic skin testing because antihistamines can prevent, reduce, or mask positive skin test response.

urticaria

patients with renal or hepatic impairment.

Brand Name:

GI: dry mouth, nausea, vomiting, abdominal distress

Ainix

Classification:

Antihistamine