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NURSING CARE PLAN

ASSESSMENT S- MASAKIT PA. >PAINSCALE 6 -10 >PERIORBITAL HEMATOMA NOTE ON LEFT EYE >POSITIVE TENDERNESS NOTED >GUARDING BEHAVIOR DIAGNOSIS MODERATE PAIN RELATED TO ACQUIRED PHYSICAL INJURY PLANNING
AFTER 5 HOURS OF NURSING INTERVENTION THE PAIN WILL DECREASE FROM MODERATE TO MILD

IMPLEMENTATION
REPOSITIONED COMFORTABLY

RATIONALE
TO EVALUATE AND REASSESS THE EFFECTIVENESS OF INTERVENTIONS GIVEN INFECTION CAN AGGRAVATE THE CONDITION OF THE PATIENT, INFECTION CONTROL IS A VITAL NURSING RESPONSIBILTY TO PREVENT INFECTION, REGURGITATION AND LEAKAGE OF THE ILEOSTOMY BAG

EVALUATION
GOAL MET PAINSCALE 3-10

BEDSIDE CARE DONE

APPLIED COLD COMPRESS

ENCOURAGED TO DO DIVERTIONAL ACTIVITIES

EMPHASIZED THE IMPORTANCE OF REST AND SLEEP

TO TRAIN THE DIGESTIVE FUNCTION ESPECIALLY THE PERISTALSIS OF THE PATIENT TO PREVENT GROSS INDIGESTION OF THE FOODS SERVED

>ABLE TO PERFORM ADL WITH MINIMAL ASSISTANCE

EAT FOODS RICH IN CHON, CHO, VIT C, IRON AND CALCIUM ADVISED TO

TO HELP THE PATIENTS DIGESTIVE TRACT COPE UP WITH THE SURGICAL TRAUMA

NUTRITIONAL SUPPORT TO OPTIMIZE THE AFFECTED ORGANS TO COPE UP

PHYSIOLOGICAL SUPPORT TO OPTIMIZE THE AFFECTED ORGANS TO COPE UP

INFECTION CONTROL

DOCTORS ORDER

DRUG CLASSIFICA TION

INDICATION
To treat infectious diarrhea caused by susceptible organisms (including Campylobacter jejuni, Citrobacter diversus, Citrobacter freundii, Enterobacter cloacae, Escherichia coli, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Morganella morganii, Neisseria gonorrhoeae, Proteus mirabilis, Proteus vulgaris, Providencia rettgeri, Providencia stuartii, Pseudomonas aeruginosa, Serratia marcescens, Shigella flexneri, and Shigella sonnei) and gram-positive organisms (including Enterococcus faecalis, Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pneumoniae)

CONTRAINDICA TIONS

SIDE EFFECTS
CNS: Agitation, anxiety, cerebral thrombosis, confusion, dizziness, headache, insomnia, light-headedness, migraine, nightmares, paranoia, peripheral neuropathy, restlessness, seizures, syncope, toxic psychosis CV: Angina, atrial flutter, cardiopulmonary arrest, cardiovascular collapse, hypertension, MI, orthostatic hypotension, palpitations, phlebitis, tachycardia, torsades de pointes, vasculitis, ventricular ectopy EENT: Oral candidiasis GI: Abdominal pain, constipation, diarrhea, elevated liver function test results, flatulence, GI bleeding, hepatic failure or necrosis, hepatitis, indigestion, intestinal perforation, jaundice, nausea, pancreatitis, pseudomembranous colitis, vomiting GU: Crystalluria, hematuria, increased serum creatinine level, interstitial nephritis, nephrotoxicity, renal calculi, renal failure, urine retention, vaginal candidiasis HEME: Agranulocytosis, bone marrow depression, hemolytic anemia, lymphadenopathy, pancytopenia MS: Tendinitis, tendon rupture SKIN: Erythema multiforme, exfoliative dermatitis, photosensitivity, rash, StevensJohnson syndrome, toxic epidermal necrolysis, urticaria RESP: Bronchospasm, pulmonary embolism, respiratory arrest Other: Acidosis, anaphylaxis,
angioedema,serum sicknesslike reaction

NURSING CONSIDERATION
Urge patient to complete the prescribed course of therapy, even if he feels better before its finished. Tell patient not to take drug with dairy products or calcium-fortified juices alone. Advise patient to take ciprofloxacin 2 hours before or 6 hours after antacids, iron supplements, or multivitamins that contain iron or zinc. Tell him to shake oral suspension for 15 seconds, not to chew microcapsules, and not to split, crush, or chew E.R. tablets. Encourage patient to drink plenty of fluids during therapy to help prevent crystalluria. Urge patient to avoid caffeinated products because caffeine may accumulate in the body during ciprofloxacin therapy and cause excessive stimulation. Caution patient to avoid excessive exposure to sunlight or artificial ultraviolet light because severe sunburn may result. Tell patient to notify prescriber if sunburn develops; drug will need to be stopped. Urge patient to avoid hazardous activities until CNS effects of drug are known. Advise patient to notify prescriber about changes in limb sensation or movement and about inflammation, pain, or swelling over a joint. Urge patient to rest the affected limb at the first sign of discomfort. Tell patient to stop taking drug and to notify prescriber at first sign of rash or other hypersensitivity reaction. Urge patient to report watery, bloody stools to prescriber immediately, even up to 2 months after drug therapy has ended..

CIPROFLOXACIN Chemical class: 500MG 1 CAP Fluoroquinolone BID derivative Therapeutic class: Antibiotic

Hypersensitivity to ciprofloxacin, quinolones, or their components

DOCTORS ORDER
CELECOXIB 200MG 1 CAP BID

DRUG CLASSIFICATION
Anti-inflammatory, antirheumatic

INDICATION

CONTRAINDICA TIONS
Allergic reaction (such as anaphylaxis or angioedema) to aspirin, other NSAIDs, or sulfonamide derivatives or history of aspirin-induced nasal polyps with bronchospasm; hypersensitivity to celecoxib or its components; treatment of perioperative pain after coronary artery bypass graft surgery

SIDE EFFECTS
CNS: Asceptic meningitis, cerebral hemorrhage, depression, dizziness, fever, headache, insomnia, ischemic stroke, stroke, suicidal ideation, syncope, transient ischemic attacks, vertigo CV: Aortic valve incompetence, chest pain, congestive heart failure, deep vein thrombosis, fluid retention, hypertension, MI, palpitations, peripheral edema or gangrene, sinus bradycardia, tachycardia, thrombosis, unstable angina, vasculitis, ventricular fibrillation, ventricular hypertrophy EENT: Conjunctival hemorrhage, deafness, labyrinthitis, nasopharyngitis, pharyngitis, rhinitis, sinusitis, vitreous floaters ENDO: Hyperglycemia, hypoglycemia GI: Abdominal pain, diarrhea, elevated liver function test results, esophageal perforation, flatulence, GI bleeding or ulceration, hepatic failure, ileus, indigestion, jaundice, nausea, pancreatitis, perforation of stomach or intestine, vomiting GU: Acute renal failure, interstitial nephritis, ovarian cyst, proteinuria, UTI, urinary incontinence HEME: Agranulocytosis, aplastic anemia, decreased hematocrit and hemoglobin, leukopenia, pancytopenia, prolonged APTT, thrombocytopenia MS: Arthralgia, back pain, elevated serum CK level, epicondylitis, tendon rupture RESP: Bronchospasm, cough, dyspnea, pneumonia, pulmonary embolism, upper respiratory tract infection SKIN: Erythema multiforme, exfoliative dermatitis, phototoxicity, rash, StevensJohnson syndrome, toxic epidermal necrolysis, urticaria

NURSING CONSIDERATION
Monitor patient closely for thrombotic events, including MI and stroke, because use (especially long-term use) of NSAIDs such as celecoxib increases the risk. WARNING In patient who has bone marrow suppression or is receiving antineoplastic therapy, monitor laboratory results (including WBC) and assess for infection because celecoxib antiinflammatory and antipyretic actions may mask signs and symptoms, such as fever and pain.

localized inflammation

DOCTORS ORDER

DRUG CLASSIFICATION

INDICATION

CONTRAINDICATIONS

SIDE EFFECTS

NURSING CONSIDERATION

METOCLOPRAMIDE Therapeutic class: 1 AMP IV Q8 FOR Antiemetic, upper GI N/V stimulant

chemotherapyinduced vomiting

Concurrent use of butyrophenones, phenothiazines, or other drugs that may cause extrapyramidal reactions; GI hemorrhage, mechanical obstruction, or perforation; hypersensitivity to metoclopramide or its components; pheochromocytoma; seizure disorders

CNS: Agitation, anxiety, depression, dizziness, drowsiness, extrapyramidal reactions (motor restlessness, parkinsonism, tardive dyskinesia), fatigue, headache, insomnia, irritability, lassitude, neuroleptic malignant syndrome, panic reaction, restlessness CV: AV block, fluid retention, heart failure, hypertension, hypotension, supraventricular tachycardia EENT: Dry mouth ENDO: Galactorrhea, gynecomastia GI: Constipation, diarrhea, nausea GU: Menstrual irregularities HEME: Agranulocytosis SKIN: Rash Other: Restless leg syndrome

Advise against activities that require alertness for about 2 hours after each dose. Urge patient to avoid alcohol and CNS depressants while taking metoclopramide. They may increase CNS depression. Tell patient to immediately report involuntary movements of face, eyes, tongue, or hands, including lip smacking, chewing, puckering of mouth, frowning, scowling, sticking out tongue, blinking, moving eyes, or shaking arms and legs. Explain that stopping metoclopramide may cause withdrawal symptoms that include dizziness, nervousness, and headache.