V. THE PATIENT AND HIS CARE A. Medical Management a.

Intravenous Fluids Medical Management Date Ordered, Performed, Changed General Description Indication Patient¶s Response

PNSS (0.9 NaCl ) 1L

DO: 07-12-10

Hypotonic solution To concentration free of to

maintain Patient responded and well as she did not fluid manifest any signs IVF. dehydration mucous membranes. such replace this

that has greater rehydration

water loss, patient was and symptoms of for as dry skin and

molecules that are given found inside the Also, DP: 07-12-10 cell.

medication administration.

Nursing Responsibilities: Prior to Treatment: 1. Check the physician¶s order for IV solution and explain to the client the procedure. 2. Check the potency of IV line and needle. 3. Check the type of infusion, condition of the vein and medical condition of the patient. During the Treatment: 1. Maintenance of aseptic technique. 2. Proper procedure and steps in infusing IV solution. 3. Count drops per minute in drip chamber. After the treatment: 1. Monitor IV infusion at least every 2 hour.

which may indicate infiltration of IV. drug was untoward given to the pt reactions to reduce the were noted. there may be a need to remove IV cannula and reinsert to other potential site. If any of the aforementioned manifestations is present. coolness or pallor at the site of insertion. 5. 3.2. Inspect site for pain. acid may accumulation during No . Monitor client for fluid overflow. More frequent check may be needed if a medication(s) are being infused. 4. dosage. heat and pain which may indicate phlebitis. gastric which cause gastrointestin al irritation due to other prescribed medications. Drugs Name of Drug. Adjust IV clamp as needed and recount drop per minute. swelling. 6. B. frequency of administration General Action Indication Patient¶s reaction Antisecretory Generic Name: Omeprazole DP: Brand Name: Prilosec Frequency: OD 07-12-10 Dosage: 20 mg Antiulcer Agent DO: 07-12-10 Route: Oral Proton Pump Inhibitor Drug Prevention of stress- The pt did not experience GI induces ulcer any and reduction irritation or GI of risk of GI upset irritation. swelling. Brand name Date ordered. Inspect site for redness. This feeding. Generic name. performed. changed Route.

Nursing Responsibilities: Prior to Administration: 1. nausea. 2. Brand name Date ordered. 2. fever and chills. headache. performed. dosage. vomiting and diarrhea. reflexes and affect During Administration: 1. 2. Instruct patient that she may feel side effects: Dizziness. Assess urinary output. Generic Nname. or crush them. Report severe headache. chew. 07-12-10 Brand Name: Chronulac. Name of Drug. Instruct patient to swallow capsules whole. Administer before meals. Assess for hypersensitivity to omeprazole or any of its components. worsening of symptoms. After Administration: 1.not to open. frequency of administration General Action Indication Patient¶s reaction Generic Name: Lactulose DO: 07-12-10 DP: Route: Oral Dosage: 30 cc Frequency: OD Laxative Treatment of constipation The has patient not and the of bought given because negative funds. Constilac medication . changed Route.

serum electrolytes. 2. frequency of administration General Action Indication Patient¶s reaction . 3. serum ammonia levels. bowel movements will be increased to 2-3 per day. Report diarrhea. Assess bowel sounds. Instruct patient that she may feel side effects: Abdominal fullness. performed. Do not administer other laxatives while using lactulose. After Administration: 1. Assess for allergy to lactulose 2. dosage. belching. During Administration: 1. Carefully monitor blood glucose levels. 3. Generic name. severe belching. flatulence.Nursing Responsibilites: Prior to Administration: 1. Give syrup orally with fruit juice. changed Route. Brand name Route: Generic Name: Essential Amino Acids Brand Name: Ketosteril DP: 07-13-10 DO: 07-13-10 Oral Dosage: 600 mg Frequency: BID Essential amino acids Ketoanalogs Prevention & therapy of damages due to faulty/deficie nt protein metabolism in chronic renal insufficiency Date ordered. Name of Drug. 2. water or milk to increase palatability. Make sure you have ready access to bathroom.

Nursing Responsibilities: Prior to Administration: 1. After Administration: 1. 2. Assess for allergy. Brand name Date ordered. Report seizures and other manifestations of hypercalcemia. Inform the patient about the medication about to be given. Assess for hypercalcemia before administration. During Administration: 1. dosage. Give with food if GI irritation occurs. Check if the right drug is to be given to the patient. changed Route. performed. frequency of administrati on General Action Indication Patient¶s reaction Generic Name: Ferrous Sulfate Brand Name: Date ordered: 07-13-10 Date Performed: 07-13-10 Route: Oral Dosage: 1 tab Frequency: OD Iron Preparation Elevates the serum iron concentration which then helps to form High or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron . 3. Name of Drug. Frequently assess hypercalcemia 2. Generic name. 2.

After Administration: 1. early Lyme disease Date ordered. sulphite. acute otitis media. slowly increase to build up tolerance. Give drug with meals if GI discomfort is severe. Hgb.Nursing Responsibilities: Prior to Administration: 1. serum ferritin and iron levels. UTIs. dosage. diarrhea or constipation. frequency of administration General Action Indication Patient¶s reaction . nausea. lethargy. uncomplicated skin and skin structure. Brand name Generic Name: Cefuroxime Brand Name: Ceftin Date ordered: 07-13-10 Date Performed: 07-13-10 Route: Intravenous Dosage: 750 mg Frequency: q 8 hrs Anti-infective Antibiotic secondgeneration cephalospori n Susceptible mild to moderate infections including pharyngitis/tonsillitis. rapid respirations. 2. regional enteritis. Assess lab tests: CBC. Warn patient that stool may be dark or green. 2. ulcerative colitis. changed Route. Report sever GI upset. During Administration: 1. bronchitis. Generic name. Hct. performed. vomiting. Instruct patient that she may feel side effects: GI upset. acute maxillary sinusitis.constipation. Administer to patient with an empty stomach. Assess for allergy to any ingredient. dark or green stools. peptic ulcer. normal iron balance. Name of Drug. gonorrhea. 2. 3.

frequency of administratio n General Action Indication Patient¶s reaction Date ordered: 07-13-10 Date Performed: 07-13-10 Route: Rectal suppository Dosage: 2 supp Frequency: once Laxatives Short term relief of constipation. whenever a stimulant laxative is required. Constipation. . Arrange for sensitivity test before administering drug. dosage. changed Route. 2. either chronic or of recent onset. performed. Report severe diarrhea. 2. Instruct patient that she may feel side effects: stomach upset or diarrhea. 2. fatigue. Generic name. During Administration: 1. difficulty of breathing. Name of Drug. After Administration: 1. Assess for history of renal impairment. Assess renal function tests. Brand name Generic Name: Bisacodyl Brand Name: Dulcolax Date ordered.Nursing Responsibilities: Prior to Administration: 1. Maintain aseptic technique when administering drug.

Changed Diabetic diet Date Ordered: 07-12-10 Date Performed: 07-12-10 Diet given for diabetic clients. Instruct client about the procedure. Observe aseptic techniques during procedure.Nursing Responsibilities: Prior to Administration: 1. but low in fat Hypoglycemic Patients Description Indications Specific Foods taken Patient¶s reaction . Assess for bowel distension. 2. After Administration: 1. Performed. bowel sounds and pattern of bowel elimination. C. Diet Diet Date ordered. flushing and excessive thirst. Report muscle cramps. 2. especially soluble fiber. 2. Most often recommended is high in dietary fiber. Make sure you have ready access to bathroom. During Administration: 1. sweating. Maintain patient¶s privacy during the procedure.

During the implementation of Diet: 1.Nursing Responsibilities: Prior to Implementing Diet: 1. Assess patient¶s appetite after the treatment. Refer to doctors for any noted changes in appetite and nutritional imbalance (malnutrition. 3. Check the doctor¶s order. Discuss necessary follow-up treatment and regimen to avoid recurrence of past condition. 2. etc. Discuss to the patient the importance of the diet.) . 2. 3. anorexia. obesity. 3. 4. Assess patient¶s level of hydration. Provide a variety of choices of foods. 2. Educate the patient and significant others on the right foods to be taken. Educate the patient and significant others why Diabetic diet is indicated. After the Implementation of Diet: 1. See to it that the patient adheres to the diet regimen.

Provide safety precautions like raising the side rails when necessary. . After the Implementation of Activity/Exercise: 1. Identify patient before the activity. Explain to the patient the need for the said activity/exercise. Obtain initial assessment about the progress of the activity. Nursing Responsibilities: Prior to Implementing Activity/Exercise: 1. 3. motion promotes optimal level of functioning. Check physician¶s order about the activity. 2.D. Monitor the position/activity of the client every 2 hours 2. Activity Type of Activity/ Exercise Exercise/s and activities as tolerated. or passive range living of exercises. active activities of daily planned for her. strengthening her exercise/s it activities exercises. 2. Date Ordered Date Started Date Changed DO: 07-12-10 DP: 07-12-10 It Client¶s Response General Description Indication(s) or Purpose(s) and/ or Reaction to the Activity/ Exercise may include It prepares the The patient was able patient back to to and go to tolerate the ambulation. During the implementation of Actiity/exercise: 1. Promote a quiet environment conducive for rest.

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