ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Decreased Cardiac After 8 hours -Identify patients - In addition to an -After 8 hours of nursing
“Gasakit akon ulo Output related to of nursing exhibiting individual who is interventions, the client's
pag mag gulpi ko hypertension as interventions, the symptoms or at obviously at danger due blood pressure was just not
tindog”-as manifested by patient will have no risk as noted in to existing heart elevated above normal
verbalized by the increased blood elevation in Risks Factors and difficulties, cardiac ranges and would remain
patient. pressure. blood pressure above defining output concerns are a within acceptable levels.
normal limits and will Characteristics. potential.
Objective: maintain The goal was met.
-Restlesness blood pressure - Changes in blood
-Dizziness within acceptable -Check blood pressure may signal a
VS takens as limits. pressure every 1-2 change in the patient's
follows: hours or every 5 condition that needs
T-36.2 minutes during immediate care.
BP-140/90 active titration of
PR-78bpm vasoactive - Peripheral
RR-24bpm medications. vasoconstriction can
cause pale, cold,
clammy skin and a
- Observe the skin delayed capillary refill
color, time.
temperature,
capillary refill
time, and - It may reduce
diaphoresis. peripheral venous
pooling, which is
increased by
vasodilators and
prolonged sitting or
- advise keeping standing.
position changes
 - Caffeine is a cardiac
stimulant that may
impair heart function.

- Encourage the
patient to intake
lesser coffee, cola,
and chocolate.

ACTUAL

ACTUAL
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Ineffective After 4 hours -Determine the - Defining After 4 hours
NONE breathing pattern of nursing presence of Characteristics helps of nursing
related to presence interventions, the factors/conditions to demonstrate interventions, the
of cough and patient will manifest of the patient breathing patient has manifested
dyspnea. signs of decreased impairments. signs of decreased
OBJECTIVE: respiratory effort AEB respiratory effort AEB
-Abnormal absence of dyspnea -Establish Rapport -To gain patients absence of dyspnea
breathing pattern and demonstrate and Assess patient trust and obtain and demonstrate
-Dyspnea behaviors that would condition baseline data behaviors that would
-Coughing improve breathing improve breathing
pattern. -Vs monitor and -Serve to track pattern.
*VS taken as follow: record and important changes
T-35.9
BP-140/90 -Elevate head of the -To minimize
PR-75bpm bed and change difficulty in
RR-22 bpm position of the breathing
patient every 2
hours.

-Encourage -To prevent

opportunities for situations that will
rest and limit aggravate the
physical activities condition.

POTENTIAL
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: N/A Risk for Falls After 2 to 3 hours of -Identify the elements -To be aware of the -After 2 to 3 hours
related to body rendering proper that influence safety intervention that of rendering
Objective: weakness nursing intervention, requirements. will be implemented proper nursing
--unattractive the patient will be -It is useful in intervention, the
appearance free from fall -Evaluate the patient's determining the patient has been
-reduced strength in hazards. capacity to ambulate functional capacities freed from fall
the lower safely, whether with or of the client to hazards as
extremities without support design methods to evidenced by
-the absence of side equipment. improve the issue ability to explain
Rails areas the safety
precautions.
VS taken as follow: -Introduce the patient
T-35.9 to the environment
BP-140/90 thoroughly. -To familiarize the
PR-75bpm clients with the
RR-22 bpm -Ask the client's surroundings
significant others to
constantly stay with
him or her. -To ensure the
safety of clients

- Tell the patient to call - To keep the patient

for help while moving. from falling asleep
in bed.
-Install side rails,
-To lessen the
possibility of falling

Today, I experienced how student nurses and their work environment influence patient perceptions of the
quality of care. Healthcare organizations or (assigned in the Nurse Ward at Socsargen County Hospital) evaluate
 and enhance the quality of care by monitoring patient experiences. Nurses have a significant influence on patient
experiences since they spend so much time with them. To enhance patient perceptions of the quality of care,
nurses must understand the factors that affect the nursing work environment. We all know that quality is the
most important issue in healthcare, and that every patient has the right to get high quality care. One of the
primary goals of Socsargen County Hospital is to provide higher quality care in the areas of access, quality of life,
and user happiness.
I've learned that we all need to give hands-on nursing care to patients in a variety of health settings, such
as hospitals, physicians' offices, outpatient care facilities, and private homes. We also provide emotional support
and health education to the family and caregivers of our patients. Always remember that nursing is a
compassionate and caring profession. Nurses build empathy for the needs of others and a relationship with their
patients, not only execute duties or offer services.

I feel blessed because I’m here taking this course with Humility and Compassionate to my course. Nursing
is one of the most rewarding and enjoyable professions. It brings with it a wealth of medical information and
abilities that enable you to assist healing and alleviate suffering through accurate evaluation, diagnosis, and
treatment. But always remember that humility should be our constant friend.

I think I realized that as student nurses, we much value the “ Curiosity”. Finally, Ma'am Van thought that
nursing knowledge encompassed all of the nursing profession's ideas, philosophies, research, and practical
wisdom. We should never ever stop learning.

DATE MEDICATION MODE OF DOSAGE INDICATION(S) CONTRAINDICAC SIDE EFFECTS ADVERSE NURSING
ORDER ACTION ATION (S) EFFECTS RESPONSIBILITIE
ED S
Gabapentin Initial dose: Gabapentin is -suicidal -Feeling Drowsiness, -Take
has no direct 300 mg indicated as thoughts sleepy, tired dizziness, loss precautions and
GABAergic orally on monotherapy in -depression or dizzy of consult the
coordination,
action and day one, the treatment -myasthenia -Feeling sick tiredness, doctor first. If
does not block 300 mg of partial gravis, a skeletal (nausea) blurred/double the patient is
GABA uptake orally 2 seizures with muscle disorder -Being sick vision, unusual taking
or metabolism. times day and without -decreased lung (vomiting) eye gabapentin for
GN: movements, or
Gabapentin on day two, secondary function -Diarrhoea the first time,
gabapentin shaking
blocks the then 300 generalisation -chronic -Mood give the initial
[ GA-ba- (tremor) may
tonic phase of mg orally 3 in adults and obstructive changes dose at bedtime.
PEN-tin ] occur. If any of
nociception times a day adolescents pulmonary -Swollen arms these effects This is to
induced by on day aged 12 years disease and legs persist or decrease
BN:
formalin and three and above. -chronic kidney -Blurred worsen, tell dizziness and
Gralise, your doctor or
carrageenan, Maintenanc Gabapentin is disease stage 3A vision drowsiness.
Horizant, pharmacist
and exerts a e dose: 300 indicated for (moderate) -Dry mouth Monitor the
Neurontin, promptly.
potent to 600 mg the treatment -chronic kidney -Difficulty patient for
Gabarone
inhibitory orally 3 of peripheral disease stage 3B getting an symptoms of
CLASSIFICATIONS effect in times a day neuropathic (moderate) erection worsening
Gamma- neuropathic Maximum pain such as -chronic kidney -Weight gain depression,
aminobutyric pain models of dose: 3600 painful diabetic disease stage 4 increase suicidal
acid analogs mechanical mg orally neuropathy and (severe) ideation, and
hyperalgesia daily (in 3 post-herpetic -chronic kidney behavioral and
and divided neuralgia in disease stage 5 mood changes.
mechanical/th doses) adults. (failure)
ermal -Maximum -kidney disease
allodynia time Neurontin with likely
between (gabapentin) is reduction in
doses in the used to treat kidney function
3 times a pain you may
day have from
schedule shingles
should not (postherpetic
exceed 12 nerve pain). It is
hours also used with
other seizure
medicines for
partial onset
seizures in
patients 3 years
and older.

Gralise
(gabapentin) is
only used for
pain after
having shingles
(postherpetic
nerve pain). It
should not be
used for any
other medical
condition.

Horizant
(gabapentin
enacarbil) is an
extended
release tablet
used to treat
restless legs
syndrome and
 for the pain
from having
shingles
(postherpetic
nerve pain).

Generic brands
of gabapentin
capsules, USP
are used for
postherpetic
nerve pain and
for add on
therapy for
partial onset
seizures in
patients 3 years
and older
DRUG STUDY/S

DATE MEDICATION MODE OF DOSAGE INDICATION(S) CONTRAINDICAC SIDE EFFECTS ADVERSE NURSING
ORDERED ACTION ATION (S) EFFECTS RESPONSIBILITIE
 S
Algesia P The oral - Neuropathic -If you are allergic -Nausea Abdominal pain, - Routinely
Tablet dose for Pain: Algecia is to aceclofenac, -Vomiting anorexia, monitor the
works by adults is 325 indicated for paracetamol, or -Stomach constipation, effectiveness of
diarrhea,
interfering to 650 mg the treatment any of the pain dizziness, dry acetaminophen
with the every 4 to 6 of neuropathic ingredients of -Indigestion mouth, by assessing pain
GN: production hours. The pain in adults, Algesia P Tablet. -Constipation dyspepsia, levels and fever
Acetaminoph of a maximum including -If you have a fatigue, reduction. IV
en or flatulence,
chemical daily dose is neuropathic history of asthma, acetaminophen
Paracetamol headache, hot
called 4 grams. pain skin rashes, should be
flushes, HTN,
prostagland Child- the associated swelling & nasal hypoesthesia,
infused over 15
BN:
ins, which is recommende with spinal congestion after increased minutes. For
ALGECIA
responsible d dose is 10 cord injury. taking painkillers. sweating, flu- patients who are
CLASSIFICATIONS for swelling to 15 mg/kg -If you have a like symptoms, at risk for
anti-epileptic and pain. every 4 to 6 -Epilepsy: history of or insomnia, hepatotoxicity or
Paracetamo hours. Algecia is currently have nausea, renal toxicity,
drug
indicated as nervousness,
l is also stomach ulcers or the nurse should
prostatic
known to adjunctive bleeding in any disorder, closely monitor
increase therapy in part of the pruritus, rash, AST and ALT
the pain adults with digestive tract. somnolence, levels and BUN
threshold, partial -If you have a trembling & and creatinine
and hence seizures, with heart failure vomiting
reduce the or without problem, high
level of the secondary blood pressure,
sensation generalization liver or kidney-
of pain related problem
-If you are
-Generalized pregnant, this
Anxiety medicine should
Disorder: not be taken,
Algecia is especially in the
indicated for
 the treatment third trimester of
of Generalized pregnancy.
Anxiety
Disorder (GAD)
in adults.

-Fibromyalgia:
Algecia is
indicated for
the
management
of
fibromyalgia.

DATE MEDICATION MODE OF DOSAGE INDICATION(S) CONTRAINDICAC SIDE EFFECTS ADVERSE NURSING
ORDE ACTION ATION (S) EFFECTS RESPONSIBILITIE
RED S
 Betahistine -8 mg -SERC is - -Nausea, - - This drug
affects the and 16 indicated for Hypersensitivity indigestion, Gastrointestinal should be taken
histaminergic mg Meniere's to the active headaches. disorders: with food .
system: tablet: syndrome with substance or to Itching, rash, Common: Advised relatives
Betahistine acts The symptoms of any of the hives, mild nausea and to support
GN: Betahistine both as a partial dosage vertigo, excipients. gastric dyspepsia. patient’s
dihydrochloride histamine H1- for adults hearing loss Phaeochromocyt complaints -Nervous ambulation.
receptor agonist is 24-48 and tinnitus oma such as system Protect
BN:
and histamine mg which can vomiting, disorders: medication from
Serc
H3-receptor divided negatively stomach pain Common: moisture.
CLASSIFICATIONS antagonist also over the affect the and bloating. headache. Do not give this
antivertigo drug in neuronal day. ability to drive -Immune medication to
tissue, and has -24 mg and use System children.
negligible H2- tablet: machines. disorders: Swallow tablet
receptor activity. The SERC is shown Hypersensitivity whole with one
Betahistine dosage to have no or reactions, e.g. full glass of
increases for adults negligible anaphylaxis. water. Never
histamine is 48 mg effects to - take a double
turnover and divided affect the Gastrointestinal dose if you
release by over the ability to drive. disorders: Mild missed one
blocking day Keep your gastric medication. If
presynaptic H3- tablets in the complaints you missed one,
receptors and pack until it is kin and take medication
inducing H3- time to take subcutaneous immediately.s
receptor them. tissue
downregulation. . disorders:
Betahistine may Cutaneous and
increase blood subcutaneous
flow to the hypersensitivity
cochlear region reactions, in
as well as to the particular
 whole brain angioneurotic
edema,
urticaria, rash,
and pruritus.

Date Medication Mode of action Dosage Indication (s) Contraindication Side effects Adverse effects Nursing
ordered (s) Responsibility
 Inhibits Adult and Amlodipine is Amlodipine is Swelling of the CNS: headache, Assess heart rate,
calcium ion pediatric used to treat contraindicated hands, feet, somnolence, ECG, and heart
influx across Dosage: chest pain in patients ankles, or lower fatigue, dizziness. sounds, especially
cardiac and (angina) and hypersensitive legs. during exercise
smooth-muscle Tablet2.5mg other to drug. CV: edema, (see appendices
cells, dilates 5mg conditions flushing, G, H).
GN: coronary 10mg caused by -Use cautiously headache palpitations.
Amlodipine arteries and coronary in patients upset stomach Monitor BP
arterioles, and Oral artery disease. receiving other GI: nausea, frequently during
BN: Norvasc decreases BP Suspension peripheral nausea abdominal pain. initiation of
and myocardial -1mg/ml Amlodipine is vasodilators, therapy. Because
Classification: oxygen also used to especially those stomach pain Respiratory: drug-induced
Antihypertensives demand. treat high with severe pulmonary vasodilation has a
blood pressure aotic stenosis or dizziness or edema, dyspnea. gradual onset,
(hypertension). hypertrophic lightheadedness acute
Lowering cardiomyopathy Skin: pruritus, hypotension is
blood pressure with outflow drowsiness rash. rare.
may lower tract
your risk of a obstruction, and excessive Notify prescriber
stroke or heart in patients with tiredness. if signs of HF
attack. HF with reduced occur, such as
LVEF. Because swelling of hands
drug is and feet or
metabolized by shortness of
the liver, use breath.
cautiously and
in reduced
dosage in
patients with
severe hepatic
disease.

DATE MEDICATION MODE OF DOSAGE INDICATION(S) CONTRAINDICAC SIDE ADVERSE NURSING

ORDER ACTION ATION (S) EFFECTS EFFECTS RESPONSIBILITIES
ED
As an adjunct to Contraindicated - may -myalgia - Watch for signs of
Inhibits diet to reduce in patients increase -diarrhea myositis and
calcium ion elevated total-C, hypertensive to ALT,ALT , -nausea myopathy
reflux LDL-C, apo B, drug and in these and CK -alanine - (unexplained
across and TG levels with Active liver levels. aminotransfe muscle, pain,
GENERIC NAME: cardiac and and to increase disease or rase increase tenderness,
Altorvastatine smooth HDL-C in adult unexplained -hepatic weakness, malaise,
Calcium muscle patients persistent enzyme
dark urine,fever).
with primary transaminase increase
cells, Drug may need to
BRAND NAME: hypercholester elevations.
dilates be discontinued.
Liptor olemia.
coronary
arteries -Some dosage -Look alike, sound
forms contain
and alike. Don’t
Therepeutic polysorbate 80,
arterioles comprise
Class: which can cause
and atorvastatin with
Antilipemics delayed
decreases hypersensitivity. atomoxetine. Don’t
Pharmacologic BP (blood confuse Lipitor with
Class: [pressure) Loniten,Letarol or
-AMG-Con and zytec.
reductase myocardial
inhibitors oxygen
demand.
 is a second generation calcium channel blocker with antihypertensive and antianginal properties. Amlodipine inhibits the influx of
extracellular calcium ions into heart muscle (myocardial smooth muscle cells).
DATE MEDICATION MODE OF DOSAGE INDICATION(S) CONTRAINDICAC SIDE ADVERSE NURSING
ORDER ACTION ATION (S) EFFECTS EFFECTS RESPONSIBILITIES
ED
 - is a second - -Contraindicated -None
generation  patents reported
calcium hypertensive to
channel drug.
blocker wit
h
antihyperten
sive and
antianginal
GENERIC NAME: properties.
Amlodipine Amlodipine
Besylate inhibits the
influx of
BRAND NAME: extracellular
-Katerzia calcium ions
-Norvasc into heart
muscle
(myocardial
Therepeutic smooth
Class: muscle
Antihypertensive cells).

Pharmacologic
Class:
-Calcium Channel
Blocker\