DRUG MOA INDICATION CONTRA- ADVERSE REACTION NURSING

INDICATION CONSIDERATION

ATORVAS Inhibits HMG- Adjunct to diet ● Hypersensitivity CNS: ● Monitor patient for
TATIN CoA to decrease total to drugor its signs and symptoms of
CALCIUM reductase,which cholesterol,LDL components Amnesia, headache, hyperactivity, allergic response.
catalyzes first ,and apo- poor coordination, malaise, 2Evaluate for muscle
step in lipoprotein B ● Active hepatic paresthesia, peripheral neuropathy, weakness (a symptom
disease or drowsiness, syncope, weakness
Therapeutic cholesterol levels in boys
unexplained,persist
of myositis and
class: synthesis; and possibly
postmenarchal ent serum rhabdomyolysis).
Lipid- this action transaminase
lowering girls ages 10 to CV:
reduces 17 with familial elevations ● Be aware that
agent concentrations orthostatic hypotension, palpitations, reduction in dosage and
and nonfamilial ● Pregnancy or
of serum phlebitis, vasodilation periodic monitoring of
heterozygous breastfeeding
cholesterol and hypercholesterol creatine kinase level
EENT:
low-density emia may be considered for
lipoproteins glaucoma, eye hemorrhage, dry eyes, patients taking drugs
(LDLs) Prevention of hearing loss,tinnitus, epistaxis, that may increase
cardiovascular sinusitis. atorvastatin level.
disease in
patients without GI: ● Monitor liver
clinically function test results and
nausea, vomiting, diarrhea, blood
evident coronary
constipation, abdominal cramps,
heart disease lipid levels.
abdominal or biliary pain hematuria,
(CHD) but with
nocturia, dysuria, urinary frequency
multiple CHD
or urgency, urinary retention
risk factors
 DRUG MOA INDICATION CONTRA- ADVERSE REACTION NURSING
INDICATION CONSIDERATION

CARVEDI Blocks Hypertension ● Hypersensitivity CNS: ● Watch for signs and

LOL stimulation of to drug symptoms of
PHOSPHA cardiac Heart failure dizziness, fatigue, anxiety, hypersensitivity
TE beta1adrenergic caused by ● Uncompensated depression, insomnia, memory loss, reaction.
receptor sites ischemia or heart failure nightmares, headache, pain
Therapeutic and pulmonary cardiomyopathy ● Assess baseline CBC
class:Antih beta2-adrenergic ● Pulmonary and kidney and liver
ypertensive receptor sites. Left ventricular edema function test results.
dysfunction CV:
Shows intrinsic following ● Cardiogenic ● Monitor vital signs
shock orthostatic hypotension, peripheral
sympathomimeti myocardial (especially blood
vasoconstriction,angina pectoris,
c infarction ● Bradycardia or chest pain, hypertension, bradycardia pressure),ECG,and
activity,causing exercise tolerance.
heart block
slowing of heart EENT: Drug may alter cardiac
rate, decreased ● Severe hepatic output and cause
myocardial impairment blurred or abnormal vision, dry eyes,
ineffective airway
excitability, stuffy nose, rhinitis, sinusitis,
clearance.
reduced cardiac ● Bronchial pharyngitis
output,and asthma,bronchospa ● Weigh patient daily
sm GI:
decreased renin and measure fluid
release from nausea, diarrhea, constipation intake and output to
kidney. detect fluid retention.
GU:
● Measure blood
urinary tract infection, hematuria, glucose regularly if
albuminuria, decreased libido, patient has diabetes
erectile dysfunction, renal dys mellitus.
 DRUG MOA INDICATION CONTRA- ADVERSE REACTION NURSING
INDICATION CONSIDERATION

ELIQUIS Apixaban is used To reduce risk Active pathological unusual pain ,swelling, discomfort,  Monitor
to prevent of stroke and bleeding. unusual bruising, prolonged bleeding bleeding from
 Therapeutic serious blood any body
systemic from cuts or gums, persistent,
class: contraindicated for system as this
Anticoagul clots from embolism in
use by patients
frequent nosebleeds, pink/dark
could be fatal if
ants forming due to a patients with urine, coughing up blood, vomit that is
with severe severe
certain irregular non valvular bloody or looks like coffee grounds,  Monitor for
heartbeat (atrial atrial fibrillation hypersensitivity to severe headache, dizziness/fainting impairment
fibrillation) (AF) the drug unusual or persistent including
tiredness/weakness, bloody/black/tarry numbness,
Prophylaxis of stools, difficulty swallowing. paresthesia,
deep vein weakness,
thrombosis confusion, back
(DVT) pain,
bladder/bowel
impairment
 ASSESSMENT NURSING PLANNING NURSING INTERVENTION EVALUATION
DIAGNOSIS

Subjective: Impaired physical After 4-6 hours of the Independent: At the end of the 4-6
nursing intervention hours nursing
“Nahihirapan siya mobility related
the patient will:  Determine diagnosis that contributes
gumalaw since nga half intervention, the
to decreased muscle to immobility (e.g. fractures, hemi/
body niya ay stroke” as  Maintain para /tetra /quadriplegia). To identify patient was able to:
verbalized by the daughter strength. position and causative/contributing factors  Maintain
in law of the patient function and skin  Determine degree of immobility in position and
integrity as relation to functional level scale. To function and skin
evidenced by assess functional ability
integrity as
Objective: absence of  Ascertain that dependent client is
contractures, evidenced by
placed in best bed for situation(e.g.,
 (+) General footdrop, and correct size, support surface, and absence of
body weakness decubitus . mobility function) To promote contractures,
 Limited range  Will demonstrate mobility and enhance environmental footdrop, and
of motion techniques safety decubitus.
 (+) Paralysis of / behaviors that  Provides safety measures (side rails  Verbalize and
left side of the will enable safe up, using pillows to support body part) will to
body repositioning To provide safety demonstrate
 Slowed  Instruct client and caregiver in techniques
movement methods of moving client relative to / behaviors that
specific situation and mobility will enable safe
needs. To impart health teaching repositioning
 Encourage continuation of exercises.
To maintain and enhance gains in
strength and muscle control
Collaboration:
 Include physical and occupational
therapist and rehabilitation providers
in creating movement program.
Reference: Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales
ASSESSMENT NURSING PLANNING NURSING INTERVENTION EVALUATION
DIAGNOSIS

Objective: Risk for Impaired After 1-2 hours Independent: At the end of the 1-2
of nursing intervention hours of nursing
 Body malaise Skin Integrity related
the client and the  Assess skin routinely, noting
intervention, the client
 Limited range to altered circulation relatives will be able: moisture, color, and elasticity.
was able to:
of motion Review with client history of past
 Dry skin  To verbalize  Identify
skin problems. To indicate particular
understanding individual risk
of individual vulnerability
 Provide protection by use of pads, factors
factors that
 Verbalize
contributed to pillows, foam mattress and water
possibility understanding
bed. To increase circulation and
of skin of treatment/
limit or eliminate excessive tissue
integrity therapy
pressure regimen
impairment and
take steps to  Place the patient in a comfortable  Demonstrate
correct the position. To prevent back aches or behaviors and
situation. As muscle aches. techniques to
evidence by:  Massage bony prominences and use prevent skin
 Understanding proper positioning, turning, lifting, break down
the situation.
and transferring techniques when
 patient’s skin
remain intact moving client. To prevent friction or
 No redness shear injury
over bony
prominences

Reference: Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales

 ASSESSMENT NURSING PLANNING NURSING INTERVENTION EVALUATION
DIAGNOSIS

Objective: Impaired verbal After the nursing Independent: After nursing

intervention intervention the goal
 Difficulty communication
the patient will  Monitor vital signs. Establishes was met the client
producing related to stroke establish method of baseline data for review of existingestablished method
speech. communication in conditions of communication in
 Inability in use which needs can be  Provided an atmosphere which needs are
of facial or express of acceptance and privacy through expressed As
body speaking slowly and in a normal evidenced by :
expression. As evidence by: tone, not forcing the client to
communicate. Impaired ability to  Established eye
 Establish eye communicate spontaneously is contact while
contact while frustrating and embarrassing communicating
communicating  Taught techniques to improve with others.
with others speech by initially asking questions  Participate in
 Participate in that client can answer with a “yes” therapeutic
therapeutic or “no”. Deliberate actions can be communication
communication taken to improve speech. As the
 Establish client’s speech improves, his Goal partially met.
method of confidence will increase and she will
communication make more attempts at speaking
in which needs  Used strategies to improve the
can be client’s comprehension by using
expressed touch and behavior to communicate
calmness and adding other non–
verbal methods of communication
such as pointing or using flashcards
for basic needs. Improving the
client’s comprehension can help to
decrease frustration and increase
trust .Clients with aphasia can
correctly interpret tone of voice.
  Involved the significant others in the
plan of care. Enhances participation
and commitment to plan

Reference: Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales

 ASSESSMENT NURSING PLANNING NURSING INTERVENTION EVALUATION
DIAGNOSIS

Subjective: Decreased Cardiac After 6 hours Independent: After 6 hrs of nursing

of nursing intervention interventions, the
“mataas ang blood Output related to
the client will be able:  Monitor Blood Pressure every1-2 hours, or
pressure ko” as client had no elevation in
malignant every5 minutes during active titration
claimed by the patient  Have no blood pressure above
of vasoactive drugs. Changes in Blood normal limits and will
hypertension as elevation in
Pressure may indicates changes in patient maintain
manifested by blood pressure
above normal status requiring prompt attention blood pressure within
Objective:
decreased stroke volume limits and will  Encourage patient to decrease intake acceptable limits.
 Pale in color maintain of caffeine, cola and chocolates. Caffeine
 Skin cool and blood pressure is a cardiac stimulant and may adversely
moist to touch within affect cardiac function.
 Verbalized acceptable
light  Instruct client &family on fluid and diet
limits.
headedness on requirements and restrictions
sudden change of sodium. Restrictions can assist with
of position decrease in fluid retention and
hypertension, thereby improving cardiac
output.
 Observe skin color, temperature, capillary
refill time and diaphoresis. Peripheral
vasoconstriction may result in pale, cool,
clammy skin, with prolonged capillary
refill time.

Reference: Nurse's Pocket Guide: Diagnoses, Interventions, and Rationales