LYCEUM-NORTHWESTERN UNIVERSITY

COLLEGE OF NURSING

Related Learning Experience

Alternative Activities for Clinical Practice

NURSING CARE PLAN

Assessment Planning Implementatio Rationale Evaluation

n
Subjective: Short-term Goal: Independent: -To know Short term:
“Nahihilo at After 8 hours of Assess patient condition of After 8 hours of
nahihirapan akong nursing general patient and to nursing
huminga” as intervention the condition and gain trust and intervention
verbalized by the patient will be establish rapport cooperation the patient had
client. able to Exhibit from the client to Exhibited
relevant normal relevant normal
Objective: levels of - To gather levels of
Irregular heartbeat, laboratory value Assess vital signs baseline data laboratory
Pale skin, and cold such as in value such as in
V/S: temp. 39, BP hemoglobin and Raise bedside - To provide hemoglobin
90/50, HR 120 bpm, red blood cell rails safety and red blood
O2 sat 85%. level cell level
Hgb: 6 g/dl Do bed bath and - To promote
Long-term Goal: changing of bed hygiene Long term:
Nursing Diagnosis: After 3 days of linens After 3 days of
nursing - Worsening of nursing
Deficient fluid Note patient’s symptoms may
intervention the intervention
volume related to individual reflect
patient will be the patient had
active fluid loss due physiological continued
able to maintain maintained
to gastrointestinal response to bleeding or
adequate fluid adequate fluid
bleeding bleeding inadequate
and electrolyte and electrolyte
balance. fluid balance
replacement.

Monitor intake - Provides

and output guidelines for
(I&O), and fluid
correlate with replacement.
weight changes. - Activity/
vomiting
Maintain bed increases intra-
rest; prevent abdominal
vomiting and pressure and
straining at can lead to
stool. further
bleeding.

Caffeine and
Provide carbonated
clear/bland beverages
fluids when stimulate
intake is hydrochloric
resumed. Avoid acid (HCl)
caffeinated and production,
carbonated possibly
beverages potentiating
rebleeding.

Dependent:
- Transfused all
-Facilitate in blood
blood components
transfusion that are low in
the laboratory
results.

- Histamine
(H2)-receptor
- Administer
antagonists
medications, as
may be given
indicated
parenterally
during
bleeding to
reduce HCL
acid
 production.

Collaborative: -To monitor

Monitor effectiveness of
laboratory therapy and to
studies, e.g.: Hb, monitor
Hct, RBC coun patients status.

DRUG STUDY:

Name of the Classification: Indications: Side Effects Nursing

drug: Implications:
Ferosac is a Iron-deficiency Headache,
Ferrosac form of the anemia: fever, pain, Fatigue
mineral iron. Treatment of asthenia, related to
Dosage: Iron is iron-deficiency feeling unwell, decreased
important for anemia in chronic malaise and hemoglobin
200 mg IV many kidney disease accidental and
iron (= 10 mL functions in (CKD) injury. diminished
Ferosac) the body, oxygen-
results in an especially for Contraindications: carrying
increase in the transport Adverse capacity of the
hemoglobin of oxygen in You should not Effects: blood.
which is the blood. receive this
equivalent to medication if you risk of inducing Deficient
1 unit blood Mechanism of have ever had an a minor knowledge
(= 400 mL Action: allergic reaction hypersensitivity related to the
with 150 g/L to an iron reaction that complexity of
Hb content). Ferosac is injection, or if you can include treatment,
given as an have iron flushing, lack of
injection overload (the urticaria, resources, or
through a buildup of excess pruritus, or unfamiliarity
needle placed iron) or chest and/or with the
into a vein or hemochromatosis back pressure. disease
directly into a . Severe adverse condition.
dialysis line. events (SAEs)
 You will are Risk for
receive this exceedingly infection.
injection in a rare, but the
clinic, hospital, exact Risk for
or dialysis frequency is bleeding
setting. unclear

Name of the Classification: Indications: Side Effects Nursing

drug: Implications:
Vitamins, Folic acid is signs of an
Folic Acid Water -Soluble indicated for the allergic Administer
treatment of folic reaction to orally if at all
Generic acid deficiency, folic acid: possible. With
Name: folic megaloblastic hives, rash, severe GI
acid (FOE lik Mechanism of anemia, and in itching, skin malabsorption
AS id) Action: anemias of redness; or very severe
nutritional wheezing, disease, give
Brand Name: An exogenous origins, difficult IM, IV, or
Folvit source of pregnancy, breathing; subcutaneously.
folate is infancy, or swelling of Test using
Dosage: required for childhood. your face, lips, Schilling test
nucleoprotein tongue, or and serum
Tablet: 400 synthesis and throat vitamin B12
mcg, 800 the levels to rule
mcg, 1mg maintenance Contraindications: Adverse out pernicious
Injectable of normal Effects: anemia.
solution: erythropoiesis Hypersensitivity Therapy may
5mg/mL Folic acid, to folic acid or its skin rash that mask signs of
Route: Inject/ whether given formulation is a may include pernicious
Oral by mouth or potential itchy, red, anemia while
parenterally, contraindication swollen, the neurologic
stimulates the to its blistered or deterioration
production of administration. peeling skin. continues.
red blood cells One must recall you're
 white blood that research has wheezing. you
cells, and yet to establish get tightness
platelets in hypersensitivity in the chest or
persons reactions to folic throat. you
suffering acid, but a history have trouble
of an breathing or
anaphylactic talking.
reaction from any
substance must
deter the
administration of
the offending
agent.

Name of the Classification: Indications: Adverse Effects: Nursing

drug: Implications:
Calcium- Treatment of CNS:
Generic channel essentials dizziness, Assess the
name: blocker hypertension and fatigue, patient history
Amlodipine angina. lightheadedness, of allergy to
Mechanism of lethargy amlodipine,
Brand name: Action: Contraindications: impaired
Norvasc CV: hepatic or
Inhibit calcium Allergy to peripheral renal function,
Dosage: ions from amlodipine, edema, sick sinus
entering the hepatic or renal arrhythmias syndrome,
Oral: 5 mg slow channels impairment, sick heart block or
PO Daily or select sinus syndrome, GI: CHF.
voltage heart block, nausea
sensitive areas lactation abdominal Assess for
of vascular discomfort adverse drug
smooth reactions;
muscle and report
myocardium irregular
during heartbeat,
depolarization swelling of
the hands and
feet,
shortness of
breath,
 pronounced
dizziness, and
constipation.

Monitor BP
and cardiac
rhythm.

Instruct
patient to
take drug with
meals if
abdominal
discomfort
occurs; advise
on eating
small,
frequent
meals for
nausea and
vomiting.

Name of the Classification: Indications: Side Effects: Nursing

drug: Implications:
Calcium Angina pectoris swollen
Brand name: Antagonist including Prinz hands, ankles Drug
Dilzem metal’s angina, or feet, Interactions:
Mechanism of hypertension, headaches, exacerbates
Generic Action: supraventricular feeling dizzy, AV blocks with
name: tachyarrhythmias lightheaded, digoxin;
Diltiazem Block calcium and rapid feeling tired, increases
entrance into ventricular rates weak and serum digoxin
Dosage: cardiac and in atrial flutter of generally and serum
vascular smooth fibrillation. unwell. quinidine
Oral: 180 mg muscle cells by levels as well
Daily blocking the L- Contraindications: feeling hot as
type voltage (flushing) and cyclosporine
sensitive Patients with sick redness of the levels;
calcium channel sinus syndrome skin. cimetidine
which is except in the increases
abundant in presence of a itching or diltiazem
cardiac and functioning burning on serum levels.
smooth muscle. ventricular the skin where
In smooth pacemaker. you use the Check blood
muscle, calcium cream or pressure, heart
binds to Patients with ointment. rate, and
calmodulin second- or third- cardiac
resulting in degree AV block stomach pain, monitor prior
activating except in the indigestion, to
myosin light presence of a and administering
chain kinase, an functioning constipation. diltiazem
enzyme that ventricular
phosphorylates pacemaker.
the myosin light
chain. This Patients with
phosphorylation severe
is essential for hypotension or
muscle cardiogenic shock
contraction,
thus by
decreasing
calcium levels in
the vascular
smooth muscle
these agents
lessen
contraction. In
the heart,
calcium binding
to troponin
removes the
inhibitory effect
of troponin on
the actin-
myosin
interaction thus
allowing
 contraction.
Thus, blockade
of the slow
calcium channel
by these agents
can result in
negative
inotropic effect.

Name of Classification Indications: Side Effects: Nursing

the drug: : Implications:
Lower Black, tarry stools,
Generic Antibiotic respiratory chest pain, BEFORE: Do Skin
Name: Cephalospor infections shortness of Testing into the
Ceftriaxo in caused by breath, sore intradermal area
ne Streptococcus throat, sores, Protect Drug from
Sodium pneumonia, ulcers, or white light Do not mix
Staphylococcus spots on the lips ceftriaxone with
Brand Mechanism aureus, or in the mouth, other antimicrobial
Name: of Action: Haemophilus swollen glands, drug
Rocephin influenza, E. unusual tiredness
Bactericidal: coli, or weakness DURING:
Dosage: Inhibits Enterobacter Use a separate
2 gm IV synthesis of aerogenes. syringe when
Daily bacterial cell Intra-abdominal giving this drug
wall causing infections Adverse Effects: Have Vitamin K
cell death caused by available in case of
E.coli, Klebsiella CNS: Headache, hypoprothrombine
pneumoniae dizziness, lethargy mia occurs

GI: Nausea, AFTER:

vomiting, Discontinue if
Contraindicatio diarrhea, anorexia, hypersensitivity
ns: pseudomembrano occurs Monitor
Contraindicated us colitis Blood levels in
with allergy patients taking
tocephalospori HEMATOLOC: this drug
ns or penicillins. bone marrow
Use cautiously depression–dec.
with renal WBC, platelets,
 failure, Hct
lactation,
pregnancy LOCAL:
pain,
inflammation of

IV Site OTHER:
super infections,
disulfiram-like
reaction with
alcohol

Name of the Classification: Indications: Side Effects: Nursing

drug: Implications:
beta- Tazocin EF is Diarrhea,
Tazocin lactamase active against Nausea, Obtain history
inhibitor. bacteria which Vomiting of
Generic name: cause serious hypersensitivity
Piperacillin, infections such as topenicillins,
tazobactam chest infections, cephalosporins,
Mechanism of urine infections, Adverse or other drugs
Brand Name: Action: stomach Effects: prior to
Piptaz infections, skin administration.
Piperacillin infections, Agitation,
Functional inhibits cell gynaecological Bruishing, Lab tests: C&S
Class: wall synthesis infections, cough prior to first
Antiinfective by binding to septicaemia dose of the
bacterial cell (blood drug; start
Chemical membranes. drug pending
poisoning). It is
Class: Tazobactam results.
also used to treat
Penicillin inactivates many other
bacterial beta- infections. Monitor
Dosage: lactamase. hematologic
Therapeutic Contraindications status with
2.25 gm Effect: : prolonged
Piperacillin is therapy (Hct
Route: IV
 Time: every 8 bactericidal in History of allergic and Hgb, CBC
hours susceptible reactions to any with
organisms of the penicillins, differential and
cephalosporins, platelet count)
or β-lactamase
inhibitors

Case Scenario
Mrs. Z is a 48 years old Female patient who came to A&E because of dizziness and
difficulty of breathing. Patient said “Nahihilo po ako at nahihirapan akong huminga.
Patient has history of Hypertension.Upon examinations,patient has irregular heartbeat,
pale skin and cold hands and feet. Vital signs taken was Temp = 39, BP= 90/50, HR =
120 bpm O2 Sat = 85%. Patient was placed on Oxygen support at 3L/ minute via nasal
cannula. Series of blood investigation and test was done to the patient. Blood result is,
Hemoglobin level is only 6.Ultrasound abdomen shows polyps and abnormal thickening
of the endometrium. She is diagnosed with Anemia secondary to Abdominal Uterine
Bleeding.The doctor ordered to give 2 units of Packed RBC and Ferrosac 200 mg IV 5
doses every other day and Folic Acid 5 mg PO Daily. She was charted with Amlodipine
5mg PO Daily, Diltiazem 180 mg PO Daily , Ceftriaxone 2 gm IV Daily and Tazocin 2.25
gm IV every 8 hours. Patient will be scheduled for Total Abdominal Hysterectomy
tomorrow morning. She was then transferred to the Medical-Surgical Ward for further
treatment. Do a NCP and Drug study with all the medications listed here.