Nursing Care Plan

&
Drug tabulations
Submitted by:
Kris Nielsen Amantilo
BSN1-STEM A

Submitted to:
Mr. Gino Paulo A. Buizon, RN
Nursing care plans
ASSESSMENT NURSING
ASSESSMENT NURSING PLANNING
PLANNING NURSING
NURSING RATIONALE
RATIONALE EVALUATION
EVALUATION
DIAGNOSIS
DIAGNOSIS INTERVENTION
INTERVENTION
Subjective Data:Impaired
Subjective data: Impaired VerbalShort-term: Short-term:  Independent:
Created a rapport.  Goals
To offer oneself in order to achieved:
After 4Following
hours of nursing
“Indi namon sya
“Nabudlayan kag ga sakit Swallowing Communication
related The patient Themust
patient will to
be able report Monitored
Created vital
a rapport.
signs,  gain
To offer oneself in 6 hours of intervention,
cooperation. nursing the patient
maintindihan mag
ang tutunlanstorya”
nya kungas verbalized related to cerebal
mag to behavioral findings
stop coughing andoftouching
decreased withMonitored
a focus onvital
blood  order tobaseline
Having gain data. intervention,wasthe patient
able wascoughing
to stop
by the patient.
lunok sya” as verbalized impairment
problems as as its throat frustration
after 4 hourswith
of signs, with a focus
pressure.  cooperation.
Encourages relaxationable
and to establish a method
and touching his or her
Objective
by the patient’s folks. Data: evidenced
evidenced
by by slurring communication after 6 Create
nursing intervention. on blood pressure.
a relaxing,  allows
Havingthebaseline
patient to of communication
throat. through
 Speaks slowly
hours of nursing data. on the taskwhich
of needs could be
and clearly coughing. Long-term: unhurried
Encourage the concentrate
Objective data:
 Slurring intervention.
After 24 hours of nursing patient to free
environment speakofup. To alleviate client expressed.
 eating.

 Facial grimace Difficulty putting Long-term:
intervention, the patient will distractions.  Ifannoyance
the patientand
is unable to take
words or
observed sentences be able toAfter three days of  Dependent:
demonstrate Dependent: promoteorally, it may be
anything
together.
 Touching of the throat. improvednursing interventions,
swallowing, as  IV
Give Administer
fluids andany
tube comprehension.
necessary for fluid
 Difficulty
 Gagging expressing one's evidencedthe bypatient will have feedings.
less gagging medications  replacement
To over-soothe
and nutrition.
thoughts verbally. established a method
and grimacing.
 Coughing prescribed by the the patient's
 Making use of
nonverbal cues. of communication doctor to the illness.
through which his or patient.
her needs can be
expression.
 ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective data: Deficient Short-term:  Created a rapport.  To offer oneself in order to After 8 hours of nursing
N/A Knowledge of the The patient was able  Monitored vital signs, with a gain cooperation. intervention, the patient and
risk factors for to stop coughing focus on blood pressure.  Having baseline data. family verbalized their
Objective data: developing CVD. and touching his or  Provide written activity,  After discharge, it serves as a understanding of the
 Inattention her throat after 4 medication, and essential facts visual reinforcement and a importance of diet
 Facial grimace hours of nursing instructions and schedules. reference source. modification and
 Restlessness intervention.  Encourage the patient to use  Provides memory aids and medication adherence in
 Fatigue written communications or notes promotes cognitive skill order to avoid further

 BP: 140/90 rather than relying on memory. improvement. deterioration of the client's
condition.
 Drug tabulations

Drug Order Mechanism of Action Indications Contraindications Adverse effects Nursing Responsibilities

Generic Name: Atorvastatin selectively  Reduction of risk of stroke  Hypersensitivity, active  Headache, flatulence,  Verify any medication order
Atorvastatin and competitively and heart attack in type 2 liver disease or diarrhea, nausea, and make sure it's complete.
inhibits HMG-CoA diabetes patients without unexplained persistent vomiting, anorexia,  Follow the Ten rights of
Brand Name: reductase, the enzyme evidence of heart disease elevations of serum xerostomia, angioedema, medication administration.
that catalyses the but with other CV risk transaminase, porphyria. myalgia, rash/pruritus,  Verify dosage of the drug.
Classifications: conversion of HMG- factors, and alopecia, allergy,  Verify client’s identity.
Dyslipidaemic CoA to produce revascularization infection, chest pain.  Inform client of the purpose
Agents mevalonate. The procedures in patients of the drug.
reduction of mevalonate without evidence of  Check patient’s status.
Route: Oral production results to a coronary heart disease but  Administer on time.
compensatory increase with multiple risk factors
Dosage: 80 g  Ensure patient to report
in the expression of other than diabetes.
1 tab unusualities.
LDL receptors and  Patients with CHD, to
 Document all relevant data.
stimulation of LDL reduce risks of MI,
Frequency: OD
catabolism, revascularization
consequently lowering procedures, hospitalization
LDL-cholesterol levels. for CHF, and angina
Drug Order Mechanism of Indications Contraindications Adverse effects Nursing
Action Responsibilities
Generic Name: Carvedilol is a non-  Hypertension,
Carvedilol selective β-blocker. It
reduces peripheral
Brand Name: vascular resistance by
Eodilol selective α1 receptor
blockade and  Treatment of mild
Classifications: suppresses renin-
Alpha and Beta angiotensin system
blocking agents. through non-selective
β-blockade.
Route: Oral Carvedilol has weak
membrane stabilising
Dosage: ½ tab properties and has no  Left ventricular
intrinsic
Frequency: BID
sympathomimetic
activity.
 Hypersensitivity; severe  Significant: Hypotension with or without  Verify any
alone or with chronic heart failure, syncope, bradycardia. medication order
other oral drugs, bronchial asthma or  Blood and lymphatic system disorders: and make sure it's
especially related bronchospastic Anaemia. complete.
diuretics. conditions;  Cardiac disorders: Dyspnoea, pulmonary  Follow the Ten
 Severe hepatic oedema. rights of medication
to severe CHF of impairment.  Eye disorders: Visual impairment, eye administration.
ischemic or  Patients with NYHA irritation, dry eye.  Verify dosage of the
cardiomyopathic class IV cardiac failure, drug.
 GI: Nausea, diarrhoea, vomiting, dyspepsia,
origin with 2nd or 3rd AV block, sick abdominal pain.  Verify client’s
digitalis, diuretics, sinus syndrome,  General disorders and admin site conditions: identity.
ACE inhibitors cardiogenic shock or Asthenia, fatigue.  Inform client of the
severe bradycardia.  Infections and infestations: Bronchitis. purpose of the drug.
dysfunction  Lactation.  Check patient’s
 Metabolism and nutrition disorders:
(LVD) after MI status.
Oedema, hypervolaemia, weight gain,
hypercholesterolaemia, hyperglycaemia,  Administer on time.
hypoglycaemia.  Ensure patient to
 Musculoskeletal and connective tissue report unusualities.
disorders: Pain in extremities, arthralgia.  Document all
 NS: Dizziness, headache. relevant data.
 Psychiatric disorders: Depression.
 Renal and urinary disorders: Micturition
disorders, abnormal renal function, renal
failure.
 Vascular disorders: Orthostatic hypotension,
peripheral vascular disease.
 Drug Order Mechanism of Indications Contraindications Adverse effects Nursing Responsibilities
Action
Generic Name: It is used in Indicated for use as a  diabetes.  diarrhea,  Verify any medication order
Lactulose preventing and laxative in the  appendicitis.  nausea, and make sure it's complete.
treating clinical treatment of chronic  Follow the Ten rights of
 blockage of the  vomiting,
Brand Name: portal-systemic constipation in medication administration.
Enulose, encephalopathy. Its adults and geriatric stomach or intestine.  bloating,
 Verify dosage of the drug.
Kristalose , chief mechanism of patients.  galactosemia.  gas,
Constulose, and
 Verify client’s identity.
action is  glucose-galactose  belching, and.  Inform client of the purpose of
generlac by decreasing the malabsorption.  stomach pain or discomfort. the drug.
intestinal production  Check patient’s status.
Classifications:
and absorption of
colonic acidifier  Administer on time.
. ammonia. It has also
 Ensure patient to report
Route: Oral gained popularity as
unusualities.
a potential
therapeutic agent for  Document all relevant data.
Dosage:  Verify client’s identity.
10 g/15 ml the management of
subacute clinical  Inform client of the purpose of
Frequency: BID
encephalopathy the drug.
 Check patient’s status.
 Administer on time.
 Ensure patient to report
unusualities.
 Document all relevant data
 Drug Order Mechanism of Indications Contraindications Adverse effects Nursing
Action Responsibilities
Generic Name: Losartan is a  Hypertension,  Patients  CNS: dizziness,  Verify any
Losartan competitive Nephepaticall hypersensitive asthenia, fatigue, medication
angiotensin II y in type 2 to drug headache, order and
Brand Name: receptor diabetic  Breastfeeding insomnia make sure it's
antagonist. It patients, to is not  CV: Edema, complete.
Classifications: selectively reduce risk of recommended, chest pain  Monitor
Angiotensin II blocks AT1 CVA in causes fetal  EENT: nasal patient’s BP
Antagonists receptors found patients with and neonatal congestion,  Asses patient’s
in many tissues hypertension morbidity and sinusitis, renal function
Route: Oral (e.g. vascular and left death. pharyngitis,  Follow the
smooth muscle, ventricular sinus disorder Ten rights of
Dosage: 50 mg adrenal gland), hypertrophy.
1 tab  GI: Abdominal medication
thereby pain, nausea, administration.
reducing the diarrhea,  Verify dosage
Frequency: vasoconstricting
OD dyspepsia. of the drug.
and  Musculoskeletal:  Verify client’s
aldosterone- muscle cramps, identity.
secreting effects myalgia, back or  Inform client
of angiotensin leg pain of the purpose
II. Losartan is  Respiratory: of the drug.
less likely to be cough, upper  Check
associated with respiratory patient’s
non renin- infection status.
angiotensin
effects (e.g.  Administer on
cough, time.
angioedema)  Tell patient to
due to the lack avoid salt
of effect to the substitues.
response to  Ensure patient
bradykinin. to report
unusualities.
  Document all
relevant data.

Drug Order Mechanism of Action Indications Contraindications Adverse effects Nursing

Responsibilities
Generic Name: Inhibits reabsorption of  Oral, IV: Edema  Contraindicated with  CNS: dizziness, vertigo,  Verify any
Furosemide sodium and chloride from associated with allergy to furosemide, paresthesias, xanthopsia, medication order and
the proximal and distal heart failure, sulphonamides; weakness make sure it's
Brand Name: tubules and ascending limb cirrhosis, renal  Allergy to tartrazine;  CV: orthostatic complete.
of the loop of Henle, leading disease hypertension,  Follow the Ten rights
 Anuria, severe renal
Classifications: to a sodium-rich dieresis.  IV: Acute thrombophlebitis of medication
failure;
Diuretics pulmonary edema
 Hepatic coma;  Derma: photosensitivity, administration.
 Oral: Hypertension
 Pregnancy; pruritus, urticarial, purpura  Verify dosage of the
Route: IVTT
 Lactation.  GI: nausea, anorexia, drug.
vomiting, oral and gastric  Verify client’s
Dosage: 20 mg
irritation identity.
Frequency: q8h  GU: nocturia, glycosuria,  Inform client of the
(12pm-8pm-4am) urinary bladder spasm purpose of the drug.
 Hematologic: leukopenia,  Check patient’s
anemia, thrombocytopenia status.
 Administer on time.
 Ensure patient to
report unusualities.
 Document all
relevant data.

Drug Order Mechanism of Action Indications Contraindications Adverse effects Nursing

Responsibilities
Generic Name: Are synthetic ligands for Indicated as an Patients with a known  swelling (edema), when  Verify any
Pioglitazone peroxisome proliferator- adjunct to diet and hypersensitivity to used in combination with medication order and
activated receptors exercise to improve pioglitazone or any of its sulfonylurea or insulin. make sure it's
Brand Name: (PPARs). They alter the glycemic control in components. Diabetic  low blood sugar complete.
Actos, actoplus met, transcription of genes adults with type 2 ketoacidosis or type 1 (hypoglycemia)  Follow the Ten
duetact, oseni influencing carbohydrate diabetes mellitus in diabetes, since  upper respiratory rights of medication
Classifications: multiple clinical
and lipid metabolism, pioglitazone is active only infection. administration.
Thiazolidinediones
settings. Pioglitazone
resulting in changed in the presence of insulin.  headache.  Verify dosage of the
exerts its
amounts of protein antihyperglycemic drug.
Route: IV  heart failure.
synthesis and, therefore, effect only in the  Verify client’s
metabolic changes.  sinus infection.
presence of identity.
Dosage: 15mg  fracture of bone.
endogenous insulin.  Inform client of the
 30mg
 sore throat (pharyngitis) purpose of the drug.
 45mg
 Check patient’s
status.
Frequency: OD  Administer on time.
 Ensure patient to
report unusualities.
 Document all
relevant data.

Drug Order Mechanism of Action Indications Contraindications Adverse effects Nursing

 Responsibilities
Generic Name: It is a potent It is indicated for  an infection.  High blood pressure  Verify any
Pioglitazone immunomodulatory agent the prophylaxis of  cancer or malignancy. medication order and
 Increased hair growth. 
with an increasing number of organ rejection in make sure it's
 high cholesterol.
Brand Name: clinical applications. Its kidney, liver, and heart  Swollen or inflamed complete.
allogeneic transplants.  high amount of
Neoral, Sandimmune, major mode of action gums.  Follow the Ten rights
It is always to be used triglyceride in the blood.
and Gengraf. is inhibition of the  Numbness or tingling of of medication
with adrenal  low amount of
production of cytokines magnesium in the blood. the hands or feet. administration.
Classifications: corticosteroids. The
involved in the regulation of  Verify dosage of the
drug may also be used  high levels of potassium  Other common side
Immunosuppressants T-cell activation. In drug.
in the treatment of in the blood. effects are tremors,
particular, cyclosporine chronic rejection in  Verify client’s
Route: oral  pseudotumor cerebri, a restlessness, stomach
inhibits the transcription of patients previously upset, nausea, cramps, identity.
condition with high fluid
interleukin 2. treated with other diarrhea, headache, and  Inform client of the
 Dosage: 25mg) pressure in the brain.
immunosuppressive changes in blood sugar. purpose of the drug.
 50mg)  high blood pressure.
agents.  Check patient’s
 100mg) .
status.
 Administer on time.
Frequency: BID  Ensure patient to
report unusualities.
 Document all
relevant data.
 Drug Order Mechanism of Action Indications Contraindications Adverse effects Nursing Responsibilities

Generic Name: It is an inhibitor of  It is indicated to reduce the  Active Bleeding  excessive tiredness.  Verify any medication
Clopidogrel ADP-induced platelet rate of myocardial Plavix is contraindicated in  headache. order and make sure it's
aggregation acting infarction (MI) and stroke in
patients with active  dizziness. complete.
patients
Brand Name: by direct inhibition of pathological bleeding such  Follow the Ten rights of
 nausea.
Clavix adenosine diphosphate  myocardial infarction, as peptic ulcer or medication administration.
intracranial hemorrhage.  vomiting.
(ADP) binding to its including patients who are  Verify dosage of the drug.
Classifications: to be managed medically  stomach pain.
receptor and of the Hypersensitivity  Verify client’s identity.
 antiplatelet medications subsequent ADP- and those who are to be  diarrhea.
managed with coronary Plavix is contraindicated in  Inform client of the
mediated activation of  nosebleed.
Route: oral revascularization patients with purpose of the drug.
the glycoprotein hypersensitivity (e.g.,  Check patient’s status.
GPIIb/IIIa complex. anaphylaxis) to
Dosage:  Administer on time.
 75mg
clopidogrel or any  Ensure patient to report
 300mg
component of the product
unusualities.
 Document all relevant
data.
Frequency: BID