VIII.

MANAGEMENT
a. NURSING CARE PLAN
DATA NURSING DIAGNOSIS SCIENTIFIC GOAL/OBJECTIVE NURSING INTERVENTION EVALUATION
BACKGROUND
Subjective P- Acute pain Unpleasant sensory and After per shift patient - Note patient’s age, weight,
cues: E- related to disruption of emotional experience will report mild to no coexisting medical or Goal not met; Patient report mild pain
skin, tissue and muscle arising from actual or pain and appear psychological conditions, when try to move.
integrity, bonte trauma potential tissue, relaxed, able to rest or idiosyncratic sensitivity to
S- as evidenced by reports of damage or described in sleep and participate analgesics, and intraoperative
Objective acute pain terms of such damage; in activities course
Cues: suddeb or slow onset of appropriately - Review intraoperative or recovery
any intensity from mild room record for type of anesthesia
to severe with and medications previously
anticipated or administered.
predicatable end a - Evaluate pain regularly (every 2
duration of less than 6 hrs noting characteristics, location,
months and intensity (0–10 scale).
Emphasize patient’s responsibility
for reporting pain/ relief of pain
completely
- ote presence of anxiety or fear,
and relate with nature of and
preparation for procedure.
- Assess vital signs, noting
tachycardia, hypertension, and
increased respiration, even if
patient denies pain
- Encourage use of relaxation
techniques: deep-breathing
exercises,
- Analgesics
XI. DRUG STUDY
NAME AND DOSE, MECHANISM OF INDICATIONS CONTRAINDICATIO ADVERSE EFFECT NURSING
CLASSIFICATION FREQUENCY, ACTION NS RESPONSIBILITY/TIES
OF DRUG ROUTE,
DURATION OF
ADMINISTRAT
ION
Inhibits protein Treatment of skin and Hypersensitivity; Dizziness; headache; - Assess for infection
synthesis in skin structure previous vertigo; bitter taste; - Monitor bowel
clindamycin 400g PO TID susceptible bacteria infection. Res[iratory pseudomembraneous nausea and vomitig elimination
all the level of the 50 tract infectiins, and colitis; severe liver - Assess patient for
ribosomes. septicemia impairment hypersensitivity
 Tranexamic acid is a used to treat or  Allergic to tranexamic  Headache - Monitor bowel
synthetic analog of prevent excessive acid  Backache elimination
tranexamic Acid 500 mg PO TID the amino acid lysine. blood loss from major  History of seizures  Nasal sinus problem - Assess patient for
It serves as trauma, postpartum  History of venous or  Abdominal pain
an antifibrinolytic by
hypersensitivity
bleeding, surgery, arterial  Diarrhea
reversibly binding four tooth removal, thromboembolism or
to five lysine receptor  Fatigue
nosebleeds, and active
sites on plasminogen.  Anemia
heavy menstruation thromboembolic
disease
 Severe renal
impairment due to
accumulation of the
drug, dose adjustment
is required in mild or
moderate renal
impairment

For its use in reducing It is used to treat Salicylate Abdominal pain, nausea, - Monitor bowel
Celecoxib 200mg PO BID colon polyps, the painand inflammati hypersensitivity or and diarrhea. Serious elimination
celecoxib affects on in osteoarthritis, acu NSAID hypersensitivity may include heart - Assess patient for
genes and pathways te pain in who have experienced attacks, strokes, gastroin
involved in adults, rheumatoid testinal
hypersensitivity
asthma, urticaria, or
inflammation and arthritis, ankylosing other allergic reactions perforation, gastrointesti
malignant spondylitis, painful after taking aspirin or nal bleeding, kidney
transformation in menstruation other NSAIDs. failure, and anaphylaxis.
tumors, but not normal
tissues
- Monitor bowel
Omeprazole is a Treatment elimination
omeprazole 400g IV 400g IV Now selective and of gastroesophageal Hypersensitivity  Central nervous - Assess patient for
irreversible proton reflux disease, peptic reactions may include system: headache,
Now pump inhibitor. It ulcer disease,
hypersensitivity
anaphylaxis, dizziness
suppresses stomach
 acid secretion by and Zollinger–Ellison anaphylactic shock,  Respiratory: upper
specific inhibition of syndrome angioedema, respiratory tract
the H+/K+-ATPase bronchospasm, infection (
system found at the interstitial nephritis, and  : abdominal pain
secretory surface of urticaria diarrhea, nausea
gastric parietal cells. vomiting, flatulence ,
Because this enzyme acid regurgitation,
system is regarded as constipation
the acid (proton, or H+)  Neuromuscular and
pump within skeletal: back pain ,
the gastric mucosa, weakness
omeprazole inhibits  Dermatologic: rash
the final step of acid
production

Diminish mental - Assess degree of nasal

Is as a Histamine H1 antihistamine mainly alertness, or, in the stuffiness
Diphenhydramine 1 amp IV pre BT Receptor Antagonist used to treat allergies young pediatric patient, Sedation - Assess movenet
Meds cause excitation. disorder
- Asses for urticaria