Patient Name: Arzadon, Marc Francis M.

Age: 22 Sex: M Ward/Room/Bed: Surgical Ward/Room 1/Bed 1 Diagnosis: Acute Appendicitis Date: April 14, 2023

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: “Sumasakit po Acute pain r/t distension of After 30 minutes of Independent: After 30 minutes of
‘yung tiyan ko e, kumikirot intestinal tissues s/t nursing interventions, the 1. Determine and 1. To give appropriate nursing interventions, the
po,” as verbalized by the inflammation AEB pain patient will demonstrate document presence of intervention indicated patient demonstrated
patient. scale of 7/10 and facial use of relaxation skills and possible upon the underlying relaxation skills and
grimace. diversional activities. pathophysiological and cause of pain. diversional activities.
Objective: psychological causes of
o Facial grimace After 4 hours of nursing pain. After 4 hours of nursing
o Restlessness interventions, the patient 2. Provide accurate and 2. To decrease anxiety. interventions, the patient
o Pain scale of 7/10 will verbalize that the pain honest information verbalized that the pain is
o BP: 140/100 mmHg is controlled. regarding illness to the controlled.
o PR: 133 bpm patient.
o RR: 22 cpm 3. Keep at rest in a semi- 3. To relieve abdominal
fowler’s position. tension, therefore
relieving the pain.
4. Provide quiet 4. To promote relaxation.
environment.

5. Provide diversional 5. To refocus attention and

activities such as enhancing coping
watching and listening abilities.
to music.

Dependent:
6. Administer analgesic as 6. To relieve pain.
indicated.

Delantar, Krizia Mae C., SN

 Generic Name:
Cefuroxime
Brand Name: Zinacef Mechanism of Action
Inhibits cell wall synthesis,
Drug Illustration promoting osmotic instability;
usually bactericidal.
Indication
Perioperative prophylaxis
Contraindication
➢ Contraindicated in patients
Drug Classification hypersensitive to drug or
Pharmacologic: other cephalosporins.
Second generation ➢ Use cautiously in patients
Cephalosporins hypersensitive to penicillin
Therapeutic: Antibiotics because of possibility of
cross-sensitivity with other
beta-lactam antibiotics.
➢ Use cautiously in patients
Dose/Frequency/Route
with colitis and renal
750 mg TIV q8 hrs
insufficiency.
Side Effects/
Adverse Reactions
Assessment & Drug Effects
CV: Phlebitis, thrombophlebitis
GI: Diarrhea,
pseudomembranous colitis,
nausea, anorexia, vomiting.
Hematologic: Hemolytic
anemia, thrombocytopenia,
transient neutropenia,
eosinophilia.
Skin: Maculopapular and
erythematous rashes, sterile
abscesses, temperature elevation.
Patient & Family Education
Nursing Responsibilities
• Determine history of hypersensitivity reactions to
cephalosporins, penicillin, and history of allergies,
particularly to drugs, before therapy is initiated.
• Lab tests: Perform culture and sensitivity tests before
initiation of therapy and periodically during therapy if
indicated. Therapy may be instituted pending test results.
Monitor periodically BUN and creatinine clearance.
• Inspect IM and IV injection sites frequently for signs of
phlebitis.
• Report onset of loose stools or diarrhea. Although
pseudomembranous colitis rarely occurs, this potentially life-
threatening complication should be ruled out as the cause of
diarrhea during and after antibiotic therapy.
• Monitor for manifestations of hypersensitivity. Discontinue
drug and report their appearance promptly.
• Monitor I&O rates and pattern: Especially important in
severely ill patients receiving high doses. Report any
significant changes.
• Report loose stools or diarrhea promptly.
• Report any signs or symptoms of hypersensitivity
 Generic Name:
Mechanism of Action
Metronidazole
Direct-acting trichomonacide and
Brand Name: Flagyl IV amebicide that works inside and
outside the intestines. It is thought
Drug Illustration to enter the cells of microorganisms
that contain nitro reductase,
forming unstable compounds that
bind to DNA and inhibit synthesis,
causing cell death.
Indication
To prevent postoperative infection
in contaminated or potentially
contaminated colorectal surgery.
Contraindication
➢ Contraindicated in patients
hypersensitive to drug or
Drug Classification
other nitroimidazole
Pharmacologic:
derivatives.
Nitroimidazoles
➢ Use cautiously in patients
Therapeutic: Antiprotozoals
with history of blood
dyscrasias, CNS disorder, or
retinal or visual field
changes.
➢ Use cautiously in patients
Dose/Frequency/Route who take hepatotoxic drugs
500 mg TIV q8 hrs or have hepatic disease,
alcoholism, or renal
impairment.
Side Effects/
Adverse Reactions
CNS: Headache, seizures, fever,
vertigo, ataxia, dizziness,
syncope, incoordination,
confusion, irritability,
depression, weakness, insomnia,
peripheral neuropathy.
CV: Flattened T wave, edema,
flushing, thrombophlebitis after
IV infusion.
EENT: Rhinitis, sinusitis,
pharyngitis.
GI: Nausea, abdominal pain,
stomatitis, epigastric distress,
vomiting, anorexia, diarrhea,
constipation, proctitis, dry
mouth, metallic taste.
GU: Darkened urine, Genital
Pruritus, UTI.
Hematologic: Transient
Leukopenia, neutropenia.
Musculoskeletal: Transient
joint pains.
Nursing Responsibilities
Assessment & Drug Effects
• Discontinue therapy immediately if symptoms of CNS
toxicity develop. Monitor especially for seizures and
peripheral neuropathy (e.g., numbness and paresthesia of
extremities).
• Lab tests: Obtain total and differential WBC counts before,
during, and after therapy, especially if a second course is
necessary.
• Monitor for S&S of sodium retention, especially in patients
on corticosteroid therapy or with a history of CHF.
• Monitor patients on lithium for elevated lithium levels.
• Report appearance of candidiasis or it’s becoming more
prominent with therapy to physician promptly.
• Repeat feces examinations, usually up to 3 mo., to ensure that
amebae have been eliminated.
Patient & Family Education
• Do not drink alcohol during therapy; may induce a
disulfiram-type reaction. Avoid alcohol or alcohol-containing
medications for at least 48 h after treatment is completed.
• Urine may appear dark or reddish brown (especially with
higher than recommended doses). This appears to have no
clinical significance.
• Report symptoms of candida overgrowth: Furry tongue, color
changes of tongue, glossitis, stomatitis; vaginitis, curd-like,
milky vaginal discharge; proctitis. Treatment with a
candidacidal agent may be indicated.
 Generic Name:
Acetaminophen Mechanism of Action
Thought to produce analgesia by
Brand Name: Ofirmev inhibiting prostaglandin and other
substances that sensitize pain
Drug Illustration
receptors. Drug may relieve fever
through central action in the
hypothalamic heat-regulating
center.
Indication
For mild to moderate pain and fever neutropenia, pancytopenia,
Contraindication
➢ Contraindicated in patients
hypersensitive to drug.
Drug Classification ➢ Contraindicated in patients
Pharmacologic: with severe hepatic
Para-aminophenol derivatives impairment or severe acute
Therapeutic: Analgesics liver disease.
➢ Use cautiously in patients
with G6D deficiency,
chronic malnutrition, and
severe hypovolemia.
Dose/Frequency/Route ➢ Use cautiously in patients
600 mg TIV RTC q8 hrs with long-term alcohol use
because therapeutic doses
can cause hepatotoxicity.
Side Effects/
Adverse Reactions
CNS: agitation, anxiety, fatigue,
headache, insomnia, pyrexia.
CV: HTN, hypotension,
peripheral edema, periorbital
edema, tachycardia.
GI: Oliguria
Hematologic: Hemolytic
anemia, leukopenia,
anemia.
Hepatic: Jaundice
Metabolic: Hypoalbuminemia,
hypoglycemia, hypokalemia,
hypervolemia, hypomagnesemia.
Musculoskeletal: Muscle
spasms, extremity pain
Respiratory: Abnormal breath
sounds, dyspnea, hypoxia,
atelectasis, pleural effusion,
pulmonary edema, stridor,
wheezing
Nursing Responsibilities
Assessment & Drug Effects
• Monitor for S&S of: hepatotoxicity, even with moderate
acetaminophen doses, especially in individuals with poor
nutrition or who have ingested alcohol over prolonged
periods; poisoning, usually from accidental ingestion or
suicide attempts; potential abuse from psychological
dependence (withdrawal has been associated with restless and
excited responses).
Patient & Family Education
• Do not take other medications (e.g., cold preparations)
containing acetaminophen without medical advice;
overdosing and chronic use can cause liver damage and other
toxic effects.
• Do not self-medicate adults for pain more than 10 d (5 d in
children) without consulting a physician.
• Do not use this medication without medical direction for:
fever persisting longer than 3 d, fever over 39.5° C (103° F),
or recurrent fever.
 Generic Name: Side Effects/
Nursing Responsibilities
Omeprazole Adverse Reactions
Mechanism of Action
Brand Name: Losec Inhibits proton pump activity by
binding to hydrogen-potassium
Drug Illustration
adenosine triphosphatase, located at
secretory surface of gastric parietal
cells, to suppress gastric acid secretion.
Assessment & Drug Effects
CNS: Asthenia, dizziness, headache.
• Lab tests: Monitor urinalysis for hematuria and
GI: Abdominal pain, constipation, proteinuria. Periodic liver function tests with
Indication diarrhea, flatulence, nausea, prolonged use.
For eradication Helicobacter pylori vomiting, acid regurgitation.
Patient & Family Education
Musculoskeletal: Back pain,
Contraindication weakness. • Report any changes in urinary elimination such
➢ Contraindicated in patients as pain or discomfort associated with urination,
hypersensitive to drug or its Respiratory: Cough. or blood in urine.
Drug Classification components. • Report severe diarrhea; drug may need to be
Pharmacologic: ➢ Use cautiously in patients with Skin: Rash. discontinued.
Proton Pump Inhibitors hypokalemia and respiratory
Therapeutic: alkalosis an din patients on a
Gastrointestinal Agent low-sodium diet.
➢ Long-term administration of
bicarbonate with calcium or
Dose/Frequency/Route milk can cause milk-alkali
40 mg TIV OD syndrome.