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DRUG NAME furosemide (Lasix) Dosage:20 mg
ACTION Specific action: DIURETIC
INDICATION Management of edema secondary to CHF. Hepatic or renal disease. Used alone or in combination with antihypertensi ves in the treatment of hypertension
CONTRAINDICATIO N Hypersensitivity
NURSING CONSIDERATION Monitor daily weight, intake and output ratios, lung sounds, skin turgor and mucous membrane. Monitor BP and pulse before and during administration. Administer medication in the morning to prevent disruption of cycle. Watch for signs of hypokalemia such as muscle weakness & cramping. Monitor elderly patients who are especially susceptible
Mechanism of action: Inhibits Frequency: q 8 the reabsorption hours with BP of Na and Cl from the loop of precautions Henle and distal Route: IV tubule Increases renal secretion of water, sodium, chloride, magnesium, hydrogen, and calcium Diuresis and subsequent mobilization of
Dizziness, headache, Cross sensitivity with hearing loss, thiazides and tinnitus, sulfonamide may hypotension, exist. diarrhea, Pregnancy, lactation constipation, rashes, photosensitivit y, metabolic alkalosis, hypovolemia
to excessive diuresis.
X. Drug Study DRUG NAME metronidazole ( Flagyl) Dosage: mg 500 ACTION Specific action: ANTIBACTERIAL Mechanism of Action: Directacting trichomonacide and amebicide that works inside and outside the intestines. It’s thought to enter the cells of microorganisms that contain nitroreductase,f orming unstable compounds that bind to DNA INDICATION Bacterial infections caused by anaerobic microorganism s CONTAINDICATIO N Contraindicated patients hypersensitive drug. ADVERSE EFFECTS NURSING CONSIDERATION Monitor liver function test results carefully in elderly patients. Take medication with food. Observe patient for edema, especially if he’s receiving corticosteroids Record number and character of stools Avoid alcoholcontaining products.
Frequency: q 8 hours Route: IV
in Headache, seizures, fever, to vertigo, ataxia, dizziness, syncope, Women in first incoordination, trimester of confusion, pregnancy. irritability, depression, Use cautiously in weakness, patients with history insomnia, and of blood dyscaria, peripheral neuropathy. CNS disorder, or retinal or visual field changes.
X. Drug Study DRUG NAME diazepam (Valium) Dosage:10 mg Frequency: q 6 hours Route: IV ACTION INDICATION CONTAINDICATIO N > Contraindicated in patients hypersensitive to drug or soy protein experiencing shock, coma, or acute alcohol intoxication (parenteral form); in pregnant women, especially in first trimester; and in children younger than 6months (oral form). ADVERSE EFFECTS CNS: drowsiness, dysarthia, slurred speech, tremor, transient amnesia, fatigue, ataxia, headache, insomnia, paradoxical anxiety, hallucinations, and minor changes in EEG patterns. CV: collapse, bradycardia, hypotension EENT: diplopia, NURSING CONSIDERATIO N Monitor periodic hepatic, renal and hematopoietic function studies in patients receiving repeated or prolonged therapy
Specific Action: MUSCLE RELAXANT Mechanism of action: A benzodiazepin e that probably potentiates the effects of GABA, depresses the CNS, and suppresses the spread of seizure activity.
> Muscle pain .
Monitor elderly patients for dizziness, ataxia, mental status CV changes. Drug should be avoided during pregnancy. Don’t mix
blurred vision, injectable nystagmus diazepam with other drugs & GI: nausea, don’t store constipation, and diarrhea parenteral with rectal solution in plastic syringes. form. Don’t withdraw drug abruptly.
X. Drug Study DRUG NAME ACTION INDICATION CONTAINDICATIO N ADVERSE EFFECTS NURSING CONSIDERATIO N
oxacillin Dosage:1am pule Frequency:q 6 hours Route: IV
Specific Action: ANTIBIOTIC Mechanism of action: Binds to bacterial cell wall, leading to cell death
Treatment of infection due to susceptible strains of penicillinase producing staphylococci
Hypersensitivity to penicillins Severe hepatic impairment Seriously ill patients who experience nausea and vomiting
Seizures, nausea, vomiting, diarrhea, hepatitis, interstitial nephritis, rashes, urticaria, blood dyscrasia.
Obtain patient to s/sx of anaphylaxis CBC, BUN, creatinine, urinalysis, LFT should be monitored periodically during therapy Administer around the clock on an empty stomach and finish the drug completely as directed. Advise the pt. to report signs of superinfection. Abnormal urinalysis results may indicate drug-induced intestinal
IX. NURSING MANAGEMENT A. Nursing Care Plans
ASSESSMENT S> “Medyo sumasakit ang sugat ko sa kanang paa.”, as verbalized by the patient. O> - Pain scale: 4 / 10 -- (+) red discoloration on the affected part - (+) swelling on the affected part - Vital Signs: T- 36.8C/A P- 88 beats/min R- 25 brpm BP- 150/90 mmHg
NURSING DIAGNOSIS Altered body comfort related to injury a.m.b. verbal complaints.
PLANNING After 8 hours of intervention, the patient will express feelings of comfort.
INTERVENTION Help patient into a comfortable position (Elevate the affected part) Maintain a restful, quiet, dim, and free of unnecessary stimuli in the environment. Manipulate the environment to promote periods of uninterrupted rest. Divert the attention of the patient. Administer antibiotics as prescribed by the attending physician. Encourage the
RATIONALE To reduce muscle tension and spasm and to redistribute pressure on body parts To promote periods of uninterrupted rest and increase energy level important to relieve pain. For efficient and fast pain relief.
EVALUATIO N Goal Met. After rendering appropriate nursing interventions , the patient verbalized feeling of comfort and alleviation of pain based on the pain scale, an improvement of 4/10 from 1/10.
To refocus the patient from pain to acceptable activity. To limit further infection
To reduce anxiety about pain.
NURSING DIAGNOSIS S> “Nilinis ko Deficient ng steel brush knowledge ang sugat ko.”, related to as verbalized by proper wound the patient. care. O> - Patient was observed scraping the affected area with his uncleaned hands
PLANNING The patient will incorporate learned skills into daily routine so as to prevent the recurrence of unhygienic behavior.
INTERVENTIO N Assess the patient’s understanding of his condition. Start Health Teachings: a. Emphasize the importance of proper handwashing before and after cleaning the wound. b. Instruct patient to use hygienic measures for cleaning the wound.
RATIONALE To determine what patient needs to know. Building on known information leads to successful learning. Handwashing is the single best way in preventing the spread of infection. To minimize the risk for further infections.
EVALUATION Goal met. The patient successfully verbalizes and demonstrates proper wound care.
ASSESSMENT S> “Tumataba yata ang isang paa ko.”, as stated by the patient. O> - (+) pedal edema on the right foot (+2 pitting edema) - (+) reddish skin discoloration on the right foot
NURSING DIAGNOSIS Impaired tissue perfusion related to impaired circulation as evidenced by the right pedal edema.
PLANNING After series of nursing intervention, there will be a reduced rate of pitting edema at the right foot.
NURSING INTERVENTIO NS Take vital signs. Assess the type of pedal edema manifested by the patient. Elevate the affected part. (pitting edema) Reduce salt intake. Administer diuretics as prescribed by the attending physician. Monitor intake
RATIONALE For baseline data. To identify the nursing interventions to be done. To promote good circulation. To prevent fluid retention. To promote excretion of excess fluid and sodium on the affected part. To determine
EVALUATION Goal met. The rate of pitting edema was minimized as evidenced by +1 pitting edema rate.
the appropriate response of the patient to diuretics.
ASSESSMENT S> “Sumasakit ang batok ko.”, as stated by the patient O> -Vital sign: P- 88 beats/min BP: 150/90 mmHg - irritable - Pain scale: 4/10
NURSING DIAGNOSIS Acute pain related to increased cerebrovascul ar pressure as evidenced by verbal report of pain on the suboccipital region
PLANNING After rendering appropriate nursing interventions, the patient will report pain is relieved.
NURSING INTERVENTIO NS Assess and rate the level of pain from 0 to 10. Encourage adequate rest periods. Provide quiet and nonstimulating environment. Encourage use of relaxation
RATIONALE To determine the appropriate nursing intervention to be rendered. To prevent fatigue. To promote nonpharmacological pain management. To distract
EVALUATIO N Goal met. The patient verbalized alleviation of pain, an improvement of 2/10 from 4/10.
techniques (e.g. deep breathing exercise). Administer diuretics as prescribed by the attending physician
attention and reduce tension.
To decrease elevated blood pressure that causes the pain.
B. OTHER NURSING INTERVENTIONS Our patient was admitted last April 2, 2009. Ideally, characteristically, the manifestations of tetanus increase in severity for about 3 days after the first sign, and sudden remain stable for the next 5 to 7 days. After about 10 days, spasm begins to occur less frequently, and by the period of 2 weeks. Although residual stiffness may persist for a prolonged period most survivors recover completely in 4 weeks. Nonspecific premonitory symptoms such as restlessness, irritability and headache are encountered occasionally, but the commonest presenting complaints are pain and stiffness in the jaw, abdomen, or back and difficulty in swallowing. As the disease progresses, stiffness gives way to rigidity , and patients often complain of difficulty in opening their mouths. In fact, trismus is the commonest manifestation of tetanus and is responsible for the familiar descriptive name of lockjaw. As more muscles are involved, rigidity becomes generalized, and sustained contractions of facial muscles produce a
characteristic expression called risus sardonicus. The intensity and the sequence of muscle involvement are quite variable. In a small proportion of patients, only local signs and symptoms develop in the region of injury. In the vast majority, however, most muscles are involved to some degree, and the signs and symptoms encountered depend upon the majority muscle group affected. Reflex spasm usually occurs within 24 to 72 hours of the first symptoms, an interval referred to as the onset time. As in the case of this incubation period. A short onset time is associated with poor prognosis. Spasms are caused by sudden intensification of afferent stimuli arising in the periphery, which increases rigidity and causes simultaneous and excessive contraction of muscles and their antagonist. Spasm maybe both painful and dangerous. As the disease progresses, minimal or unapparent stimuli produce more intense and longer-lasting spasms with increasing frequency. Respiration may be impaired by laryngospasm or tonic contraction of respiratory muscles which prevents adequate ventilation. Hypoxia may then and to irreversible central nervous system damage and death. Patients are almost invariably conscious and mentally alert at the time of admission. Lowgrade fever, profuse sweating and tachycardia are common. Deep tendon reflexes are hyperactive, and there may be labile hypertension. The physical examination should bbe undertaken with care, because reflex convulsive spasms may be precipitated easily. The wound through which Cl. Tetanus was introduced should be evaluated, and the examination would determine the extent of rigidity; the severity of trismus; the presence or absence of dysphagia and respiratory embarrassment; the frequency, intensity, and duration of convulsive spasms; and the presence of complications such as respiratory infection. But we handled the patient on his 3rd week, therefore, the time we were exposed, these signs and symptoms were not observed. But still, some nursing interventions related to what was noted during the first week were formulated ideally based on books. So these are the interventions for the related problems presented;
MUSCLE SPASM –
Begins with mild spasms in the jaw muscle (lockjaw). The spasms can also affect the chest, neck, back and abdominal muscles. Back muscle spasms often cause arching, called opisthotonos. Sometimes, the spasms affect muscles that help with breathing, which can lead to breathing problems. Muscle relaxation is the key to therapy, but mild sedation is also desirable because it reduces the effect of sensory stimuli. Tracheostomy has an important role to the management of tetanus. It prevents against laryngospasm, reduces the risk of aspiration and facilitates mechanical assistance of ventilation. While most patients with mild tetanus and some with severe disease can be managed without it,all patient should be considered candidates for tracheostomy and equipment should be available at bedside. NURSING CONSIDERATION FOR TRACHEOSTOMY: ASPIRATION PREVENTION DETECTION Evaluate patient’s ability to Assess for dyspnea, swallow. tachypnea, rhonci, crackles, excessive secretions, and Evaluate his head and fever. inflate cuff during feeding and for 30 minutes afterward. Don’t pull on the Check dressing regularly: tracheostomy tube; don’t slight bleeding is normal, allow ventilator tubing to do especially if patient has a so. bleeding disorder. If dressing adheres to wound, wet it with hydrogen peroxide and remove gently.
BLEEDING AT TRACHEOSTOMY SITE
INFECTION AT TRACHEOSTOMY SITE
Always use strict aseptic technique. Thoroughly clean all tubing. Change nebulizer or humidifier jar and all tubing daily. Collect sputum and wound drainage specimens for culture.
Check for purulent, foul smelling drainage from stoma. Be alert for other signs of infection: fever, malaise, increased white blood cell count, and local pain.
Nursing intervention for muscle spasm: • Secretions that accumulated should be removed through suctioning and postural drainage.
Seizures are disturbances in normal brain function resulting from abnormal electrical discharges in the brain, which can cause loss of consciousness, uncontrolled body movements, changes in behaviors and sensation, and changes in the autonomic system. Majority of seizures happen within the first years of life.
• • • Explore with the patient the various stimuli that may precipitate seizure activity. Discuss seizure warning signs and usual seizure pattern. Keep padded side rails up with bed in the lowest position
• • •
Padded tongue depressor should be placed between the teeth to prevent tongue biting during the convulsion.
Evaluate need for protective head gear
Loosen clothing around the neck to prevent airway obstruction.
Maintain strict bed rest if prodromal signs or aura experienced. Turn head to side or suction airway as indicated. Insert plastic bite block only if jaw are relaxed.
• Cradle head, place on soft area, or assist to floor if out of bed. • Reorient patient following seizure activity. Collaborative: • Administer medications as indicated.
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