José Rizal University

College of Nursing & Health Sciences

School Year 2022-2023

P: NCP & Drug Study (OR/RR)

In Partial Fulfillment of the Requirement for the subject

NUR C404 | INTENSIVE NURSING PRACTICUM

Submitted by:
Arandia, Ma. Lyn

Submitted to:
Prof. Edgar Manood, RM, RN, Ph. D
Case Scenario:
Mr. Sepulvida, a 25 year old male, post-op laparotomy. Day 1 post op nil by mouth.
Initially, his vital signs were BP: 110/70, T: 36.5, PR: 85bpm, RR: 16cpm. Upon awakening, Mr. S
is quite agitated and is moving side to side. When questioned, the patient complained of
increasing abdominal pain stating “ang sakit sakit ng tiyan ko”. Upon assessment, the patient is
also diaphoretic and is in guarding behavior. Vital signs are as follows: BP: 120/80, T: 37.2, PR:
90bpm, RR: 18cpm. Mr. S rate his pain as 8/10. Doctor ordered 30 mg of ketorolac via IV.

Assessment Nursing Planning Intervention Rationale Evaluation

Diagnosis

Subjective: Acute pain After 6 hours Independent: Independent: After 6 hours

“Ang sakit related to of nursing Assess for This is to of nursing
sakit ng tiyan surgical interventions potential differentiate interventions
ko” as incision in , the patient types of pain the type of , the patient
verbalized by the will report that may be pain that the reported pain
the patient abdominal pain is affecting client is is relieved
cavity relieved or client having. It is and
Pain scale: controlled obvious that controlled
8/10 with 5/10 the client is with 5/10
pain scale experiencing pain scale
level neuropathic level
Objective: pain
Agitated
Diaphoretic Assess To determine
Guarding location of if the client is
behavior surgical site having an
infection.
Vital signs: Because
BP: 120/80 infection may
T: 37.2 be the cause
PR: 90 of pain.
RR: 18
Provide Providing
comfort comfort to
measures the client and
and teaching
encourage relaxation
use of breathing
relaxation exercises can
exercise such ease pain.
as deep
 breathing
exercise

Monitor vital Monitoring

signs q30 vital signs
minutes and q30 minutes
check to see if the
dressing medication is
working.

Dependent: Dependent:
Administer This is to
30 mg of relieve pain.
Ketorolac via
IV as per
doctor’s
order

Collaborative Collaborative
: :
Collaborate To know if
with medical there is
providers in another
pain reason for
assessment, the pain he is
including experiencing
neurological and to
and provide
psychological better
factors (pain treatment for
inventory, the client
psychological
interview) as
appropriate
when pain
persists.

DRUG STUDY

Generic Name Ketorolac

Brand/Trade Name Toradol
Dosage 30 mg
Route and Frequency IV q6hr

Drug Classification Non-Steroidal Anti-inflammatory Drugs

Mechanism of Action Reversibly inhibits cyclooxygenase-1 and -2

(COX-1 and COX-2) enzymes; analgesic, anti
inflammatory, antipyretic effects.

Indication Mild to Moderate pain (short term)

Contraindication Pregnancy 3rd trimester, hypersensitivity to

this product, salicylates, asthma, hepatic
disease, peptic ulcer disease, CV bleeding,
C-section, intracranial bleeding, perioperative
pain in CABG

Side Effects Common side effects are: Dizziness,

Drowsiness, Diarrhea, and Nausea and
Vomiting

Nursing Responsibilities ● Assess patient before administering drug.

(eg., allergies)
● Report any signs of itching, swelling in the
ankles, sore throat, easy bruising, etc.
● Monitor patient’s blood pressure
● Monitor patient’s worsening of side
effects
● Always side rails up
● Instruct patient to always ask for
assistance when ambulating
● Always ready emergency equipment in
case of hypersensitivity
● Drug vials should be protected from light