Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar

COLLEGE of NURSING and ALLIED HEALTH SCIENCES

NURSING CARE PLAN

Name of Patient: Capoquian, Norieta D. Date Admitted: 11/30/22 Chief Complaint: VA Age: 57 yrs old Gender: F Civil Status: Married
Address:Mapanas, Northern Samar Ward: Surgical AP:_Dr. Siervo______

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATION

DIAGNOSIS RATIONALE INTERVENTION RATIONALE
S
Subjective: Impaired Physical Impaired physical After 4 hours of nursing .1. Encourage the 1. Once the nurse has After 4 hours of
“nagsusuol siya Mobility mobility is a intervention, patient will be patient to do as assessed the degree of nursing
pag gin common nursing able to: much as they can. immobility, they should intervention,
tatamak” as diagnosis found 2. Medicate for encourage independence patient was able
stated by the among most 1. Client will pain. aligned with the patient’s to:
client patients at one time regain/maintain mobility 3.  Schedule capabilities. This
at the highest possible activities around decreases dependence on Client
or another. It can be
level. rest periods. others and increases the regain/maintains
a temporary,
2. Client will maintain 4. Provide adaptive patient’s self-esteem. mobility at the
permanent or equipment.
position of function. highest possible
Objectives: worsening problem 5.  Promote proper 2. If pain and discomfort level.
and has the 3. Client will increase
BP: 130/90 nutrition and are a barrier, the nurse
potential to create strength/function of
hydration. can provide analgesics Client maintains
(+) skin larger issues such affected and
prior to performing position of
Inflamation as skin compensatory body parts.
exercises or planned function
breakdown, infectio 4. Client will demonstrate
ADLs. Even simple
With Left Leg ns, falls, and social techniques that enable
interventions such as a Client increases
External Fixitor isolation. resumption of activities.
heating pad or ice packs strength/function
may alleviate muscle and of affected and
joint pain and increase compensatory
movement. body parts.
 Client
demonstrates
3. Allow the patient to
techniques that
determine the best times
enable resumption
for exercise or movement
of activities.
related to their energy
levels. Do not overwhelm
or exhaust and allow
periods of rest between
activities
4. Provide equipment that
allows for maximum
movement related to the
patient’s capabilities. For
example, if bed-bound
but able to use upper
extremities, a trapeze bar
can help the patient can
pull themselves up.

5. Malnourishment
prevents recovery and
contributes to a higher
risk of functional
disability
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE INTERVENTI RATIONALE
ONS
Subjective: Impaired Skin When the skin is After 8 hours of nursing Perform wound Wound care differs After 8 hours of
“nagsusuol siya Intergrity compromised due intervention, patient will be care per depending on the type of nursing
pag gin to cuts, abrasions, able to: guidelines and skin breakdown, location on intervention, patient
tatamak” as ulcers, incisions, orders the body, and size of the were able to:
stated by the and wounds, it wound. Inadequate or
client allows bacteria to 1. Client will verbalize Continued incorrect wound care delays Client verbalizes
enter causing relief of discomfort. assessment of healing and increases relief of
infections. skin and wounds the risk for infection
Skin at risk for breakdown discomfort.
2. Client will demonstrate Repositioning should be closely monitored
Objectives: behaviors/techniques to and support of at least once a shift. Client
BP: 130/90 prevent skin boney Observed wounds should be demonstrates
prominences monitored to ensure
breakdown/facilitate behaviors/techniq
dressings are intact or that
(+) skin healing as indicated. Keep the skin skin breakdown is not ues to prevent
Inflamation clean and dry worsening, such as increased skin
3. Client will achieve Use appropriate redness. breakdown/facilit
With Left Leg timely wound/lesion devices and air ate healing as
External Fixitor mattresses Measurements of wounds
healing if present. should occur at least weekly indicated.
Encourage to monitor for progress.
nutrition and Client achieves
hydration Patients who cannot timely
reposition themselves should wound/lesion
be turned in bed on a
schedule at least every 2
healing if present
hours. Boney prominences
such as hips, knees, heels,
and elbows should be
supported with pillows or
devices to allow for proper
skin perfusion.

Consider incontinence or
increased perspiration.
Along with a turning
schedule, patients should be
assessed for any bodily
secretions. Bed linens,
clothing, and any use of
adult diapers must be kept
dry as urine, feces, and
sweat are irritating to the
skin.

Wedge pillows, waffle

boots, and gel overlays to
beds and chairs can be
effective in offloading. A
low-air loss mattress
alternates inflating and
deflating to mimic the
shifting of a patient in bed
which helps in repositioning
and relieving pressure.

Proper intake of fluids

increases oxygen and
nutrient delivery to the
wound bed by increasing the
blood volume. Intake of high
protein foods and
supplements is essential for
repairing body tissues.
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE
Subjective: Risk for infection Pin site infections After 4 hours of nursing 1. Provide sterile pin 1. May prevent After 4 hours of
“nagsusuol siya are a common intervention, patient will be or wound care cross-contamination nursing intervention,
pag gin complication of able to: according to and the possibility patient was able to:
tatamak” as external fixation protocol and of infection
stated by the that places a Client will achieve timely exercise Client achieved
client significant burden wound healing, be free of meticulous handwas 2. The presence of timely wound
on the patient and purulent drainage or erythema, hing. purulent drainage healing, be free of
healthcare system. and be afebrile. . requires wound and purulent drainage or
Such infections 2. Institute linen precautions to erythema, and be
Objectives: increase the prescribed isolation prevent cross- afebrile.
BP: 130/90 number of clinic procedures. contamination.
visits required
during a patient’s 3. IV and
(+) skin course of treatment, 3. Administer topical antibiotics
Inflamation can result in the medications, as Wide-spectrum
need for additional indicated antibiotics may be
With Left Leg treatment including used
External Fixitor antibiotics and 4. Provide wound or prophylactically or
surgery, and most bone irrigations and may be geared
importantly can apply warm or
compromise patient toward a specific
moist soaks as microorganism.
outcomes should indicated.
osteomyelitis or . Tetanus toxoid
instability result
Given
from pin loosening
prophylactically
or need for pin or
complete construct because the
removal possibility of
tetanus exists with
any open wound.
Note: Risk increases
when injury or
wound(s) occur in
“field conditions”
(outdoor, rural
areas, work
environment).

4. Local
debridement and
 cleansing of wounds
reduce
microorganisms and
the incidence of
systemic infection.
Continuous
antimicrobial drip
into bone may be
necessary to treat
osteomyelitis,
especially if the
blood supply to the
bone is
compromised

Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
 COLLEGE of NURSING and ALLIED HEALTH SCIENCES

DRUG ANALYSIS
Name of Patient: Capoquian, Norieta D. Date Admitted: 11/30/22 Chief Complaint: VA Age: 57 yrs old Gender: F Civil Status:
Married Address:Mapanas, Northern Samar Ward: Surgical AP:_Dr. Siervo______
 NAME OF SPECIFIC INDICATION CONTRAIN DRUG ADVERSE SPECIFI NURSING
DRUG ACTION DICATION INTERAC REACTION C RESPONSIBILITIES
TION PRECAU
TION
Generic Name: Effectively Semisynthetic Hypersensiti Drug: Prob Body as a History of Assessment & Drug Effects
Cefuroxime treats bone second-generation vity to enecid decr Whole: Thro allergy,
and joint cephalosporin cephalospori eases renal mbophlebitis particularl  Determine history of
Brand Name: infections, antibiotic with ns and elimination (IV site); y to drugs; hypersensitivity
Ceftin structure similar to pain, reactions to
bronchitis, related of penicillin
that of the cephalosporins,
meningitis, antibiotics; cefuroxime, burning, sensitivity;
penicillins. penicillins, and history
gonorrhea, Resistance against pregnancy thus cellulitis (IM renal
Dosage: site); of allergies, particularly
otitis media, beta-lactamase- (category B), prolonging insufficien
Adult: PO 250– pharyngitis/ superinfectio cy; history to drugs, before therapy
producing strains lactation. its action.
exceeds that of first is initiated.
500 mg tonsillitis, ns, positive of colitis
generation  Lab tests: Perform
q12h IV/IM 750 sinusitis, Coombs' or other GI
cephalosporins. culture and sensitivity
mg–1.5 g q6–8h lower test. GI: Diar disease;
Antimicrobial tests before initiation of
respiratory rhea, nausea, potent
spectrum of activity therapy and
tract antibiotic- diuretics. periodically during
resembles that of
infections, cefonicid. associated therapy if indicated.
Route: skin and Preferentially binds colitis. Skin:  Therapy may be
Intramascular soft tissue to one or more of Rash, instituted pending test
infections, the penicillin- pruritus, results. Monitor
urinary tract binding proteins urticaria. Uro periodically BUN and
infections, (PBP) located on genital: Incr
Classification: creatinine clearance.
cell walls of
ANTIINFECTIVE;  and is used eased serum  Inspect IM and IV
susceptible
ANTIBIOTIC; SE for surgical creatinine injection sites
organisms. This
COND- prophylaxis, and BUN, frequently for signs of
inhibits third and
GENERATION reducing or decreased phlebitis.
final stage of
CEPHALOSPORI bacterial cell wall creatinine  Report onset of loose
eliminating
N synthesis, thus clearance. stools or diarrhea.
infection.
killing the Although
bacterium. Partial pseudomembranous
cross-allergenicity colitis (see Signs &
between other beta- Symptoms, Appendix
lactam antibiotics F) rarely occurs, this
Reference: and cephalosporins potentially life-
Nursing Drug has been reported.
threatening
Handbook complication should be
ruled out as the cause of
STUDENT NURSE: ______ CLINICAL INSTRUCTOR: _______________________________________
 NAME OF SPECIFIC INDICAT CONTRAIN DRUG ADVERSE SPECIFIC NURSING
DRUG ACTION ION DICATION INTERACTIO REACTION PRECAUTIO RESPONSIBILITIES
N N
Generic Effective against Semisynth History of Drug: ANESTHET CNS: Neurotoxi Impaired renal Assessment & Drug
Name: a wide variety of etic hypersensitivit ICS, SKELETAL city: drowsiness, function; Effects
Amikacin gram-negative derivative y or toxic MUSCLE unsteady gait, eighth cranial
bacteria of reaction with RELAXANTS  hav weakness, (auditory)  Baseline tests:
kanamycin e additive Before initial
including Escheri an clumsiness, nerve
with broad dose, C&S;
Brand Name: chia coli, aminoglycosid neuromuscular paresthesias, impairment;
range of renal function
Amkin Enterobacter, e antibiotic. blocking tremors, preexisting
antimicrob and
Klebsiella ial activity Safety during effects; acyclovi convulsions, vertigo or
r, amphotericin peripheral vestibulocochle
Dosage: pneumoniae, mos that pregnancy dizziness,
ar nerve
Adult: IV/IM 5 t strains includes (category C), B, bacitracin, ca neuritis. Special tinnitus, or
many function (and at
–7.5 mg/kg of Pseudomonas lactation, preomycin, cep Senses: Audito dehydration;
strains regular intervals
halosporins, coli ry–ototoxicity, h
loading dose, aeruginosa, and resistant to
neonates and fever; older during therapy;
many strains infants, or use stin, cisplatin, c igh-frequency adults, closely monitor
then 7.5 other
arboplatin, met hearing loss,
of Proteus aminoglyc period premature in the older
mg/kg q12h hoxyflurane, pol complete
species, Serratia, osides. exceeding 14 infants, adult, patients
Providencia Pharmacol d is not ymyxin hearing loss neonates and with
stuartii, ogic established B, vancomycin,  (occasionally infants; documented ear
properties furosemide, eth permanent);
Route: IV/IM Citrobacter myasthenia problems, renal
freundii, are acrynic tinnitus; ringing gravis; impairment, or
Acinetobacter. Al essentially acid increase or buzzing in parkinsonism; during high
the same risk of
so effective ears; Vestibular:  hypocalcemia. dose or
as those of
against ototoxicity and dizziness, prolonged
gentamicin
penicillinase- and . Appears nephrotoxicity. ataxia. GI: Naus therapy).
non- to inhibit ea,  Monitor peak
Classification: penicillinase- protein vomiting, hepato and trough
ANTIINFECTI producing Staphy synthesis toxicity. Metabo amikacin blood
VE; AMINOGL lococcus species, in bacterial lic: Hypokalemi levels: Draw
YCOSIDE and cell and is a, blood 1 h after
ANTIBIOTIC usually IM or
against Mycobact hypomagnesemi
bactericida immediately
erium l. a. Skin: Skin
after completion
tuberculosis and rash, urticaria,
of IV infusion;
atypical pruritus,
Reference: draw trough
mycobacteria. redness. Urogen
Nursing Drug levels
ital: Oliguria,
Handbook immediately
urinary before the next
STUDENT NURSE: ______ CLINICAL INSTRUCTOR: _______________________________________
 NAME OF SPECI INDICATION CONTRAINDI DRUG ADVERSE SPECIFIC NURSING
DRUG FIC CATION INTERACTI REACTION PRECAUTI RESPONSIBILITIES
ACTIO ON ON
N
Generic Name: Effectiv Rapid-acting Hypercalcemi Drug: May GI: Constipation  Decreased Assessment & Drug
Vitmin D plus ely antacid with high a and enhance or laxative bowel Effects
Calcium relieves neutralizing hypercalciuria inotropic and effect, acid motility
sympto capacity and (e.g., toxic effects rebound, nausea, (e.g., with  Note number and
relatively consistency of
ms of hyperparathyr of digoxin; ma eructation, flatul anticholinerg
prolonged duration stools. If
Brand Name: acid oidism, gnesium may ence, vomiting, ics,
of action. constipation is a
Caltrate indigest Decreases gastric vitamin D compete for GI fecal antidiarrheal
problem,
ion and acidity, thereby overdosage, absorption; concretions. Met s,
physician may
Dosage: useful inhibiting decalcifying decreases abolic: Hyperca antispasmodi
prescribe alternate
as a proteolytic action tumors, bone absorption lcemia with cs), the older
of pepsin on gastric or combination
Adult: PO 1–2 g calcium metastases), of TETRACYCLI alkalosis, adult,
mucosa. Also therapy with a
b.i.d. or t.i.d. supplem calcium loss NES, QUINOLO metastatic lactation. magnesium
increases lower
ent. due to NES (ciproflox calcinosis, antacid or advise
esophageal
Route: Oral sphincter tone. immobilizatio acin). hypercalciuria, patient to take a
Although classified n, severe renal hypomagnesemi laxative or stool
as a nonsystemic disease, renal a, softener as
antacid, a slight to calculi, GI hypophosphate necessary.
Classification: moderate alkalosis hemorrhage or mia (when  Lab tests:
FLUID AND usually develops obstruction, phosphate intake Determine serum
ELECTROLYTIC with prolonged dehydration, is and urine calcium
BALANCE therapy. Acid
hypochloremi low). CNS: Moo weekly in patients
AGENT; REPLAC rebound, which
c alkalosis, d and mental receiving
EMENT may follow even
low doses, is ventricular changes. Uroge prolonged therapy
SOLUTION; ANT
thought to be fibrillation, nital: Polyuria, and in patients
ACID
caused by release cardiac renal calculi. with renal
of gastrin triggered disease, dysfunction.
by action of pregnancy  Record
Reference:
calcium in small (category C). amelioration of
Nursing Drug intestines. symptoms of
Handbook hypocalcemia
(see Signs &
Symptoms,
Appendix F).
 Observe for S&S
of hypercalcemia
STUDENT NURSE: ______ CLINICAL INSTRUCTOR: _______________________________________
 NAME OF SPECIFI INDICATION CONTRAIN DRUG ADVERSE SPECIFIC NURSING
DRUG C DICATION INTERACTI REACTION PRECAUTIO RESPONSIBILITIES
ACTION ON N
Generic Name: Increases Water-soluble Use of sodium Drug: Large GI: Nausea, Excessive Assessment & Drug
Vitamin C plus protectio vitamin ascorbate in doses may vomiting, doses in Effects
Zinc n essential for patients on attenuate heartburn, patients with
mechanis synthesis and sodium hypoprothombi diarrhea, or G6PD  Lab tests:
maintenance of Periodic Hct &
m of the restriction; use nemic effects abdominal cramps deficiency;
collagen and Hgb, serum
Brand Name: immune of calcium of ORAL (high hemochromato
intercellular electrolytes.
Poteen C system, ground ascorbate in ANTICOAGULA doses). Hematolo sis,
NTS; SALICYLA
 Monitor for
thus substance of patients gic: Acute thalassemia,
TES may inhibit
S&S of acute
Dosage: supportin body tissue receiving hemolytic anemia sideroblastic
hemolytic
Adult: PO/IV/IM/S g wound cells, blood digitalis. ascorbic acid (patients with anemia, sickle
vessels, anemia, sickle
C 150–500 healing. Safety during uptake by deficiency of cell anemia; cell crisis.
Necessar cartilage, bones, pregnancy leukocytes and G6PD); sickle cell patients prone
mg/d in 1–2 teeth, skin, and
y for (category C) tissues, and crisis. CNS: Head to gout or Patient & Family
doses tendons. Unlike
wound most mammals, or lactation is ascorbic acid ache or insomnia renal calculi. Education
healing humans are not may decrease (high
and unable to established elimination doses). Urogenita  High doses of
Route: Oral resistance synthesize of SALICYLATE l: Urethritis, vitamin C are
to ascorbic acid in S; chronic high dysuria, not
infection. the body; doses of crystalluria, recommended
therefore it ascorbic acid hyperoxaluria, or during
Frequency:
must be may diminish pregnancy.
hyperuricemia
consumed daily.  Take large
the effects (high
of disulfiram. doses of vitamin
Classification: doses). Other: Mi
C in divided
VITAMIN ld soreness at
amounts
injection site;
because the
dizziness and
body uses only
temporary
what is needed
faintness with at a particular
Reference: rapid IV
Nursing Drug time and
administration. excretes the rest
Handbook
in urine.
 Megadoses can
interfere with
absorption of
vitamin B12.
STUDENT NURSE: ______ CLINICAL INSTRUCTOR: _______________________________________