Generic Name Mechanism of Action Side effects / Adverse Nursing Responsibility

effect

Brand name Indication

Drug Illustration

Contraindication

Classification

D/F/R

DRUG STUDY

Generic Name Mechanism of Action Side effects / Adverse Nursing Responsibility

effect

Brand name Indication

Drug Illustration

Contraindication

Classification

D/F/R

DRUG STUDY
Reference
 Generic Name Mechanism of Action Side effects / Adverse Nursing Responsibility
effect
PARACETAMOL work by inhibiting an ✓Observe 14 R’s in administering
enzyme in the brain •Skin rashes, itching or medication
(cyclooxygenase) hives
responsible for producing
•Swelling of the throat,
prostaglandins, which are
tongue or face ✓Administer the medication
involved in pain according to the prescribed dosage
perception and fever. •Shortness of breath or and schedule, ensuring proper
wheezing dilution and IV administration
Brand name Indication
techniques.
Skin rash or peeling, or
Amcetam relieve mild to moderate mouth ulcers
pain and reduce fever. It is
•Breathing problems. ✓Monitor the patient for any signs
commonly used for
conditions such as of overdose or adverse effects,
•Liver problems.
Drug Illustration headaches, muscle aches, particularly liver function tests.
•Nausea, sudden weight
and fever. loss, loss of appetite and
Contraindication yellowing of the eyes
and skin can occur ✓ Educate the patient about the
importance of not exceeding the
recommended dosage and the
 known allergy or potential dangers of paracetamol
hypersensitivity to
overdose.
paracetamol or
any of its
components.

Classification

Antipyretic

D/F/R

900 mg IV (intravenous) prn

DRUG STUDY (3)

Reference/s: 2021-Nurses-Drug-Handbook-Jones-Bartlett-Learning-20th-Edition-PARACETAMOL
 Generic Name Mechanism of Action Side effects / Adverse Nursing Responsibility
effect
Ampicillin and Sulbactam Inhibits bacterial cell ✓Observe 14 R’s in administering
wall synthesis and protects GI:Diarrhea Nausea medication
against beta-lactamase Vomiting Abdominal
enzymes pain Oral or vsv Verify the patient's allergies,
gastrointestinal especially to penicillin or
Brand name Indication candidiasis (thrush) cephalosporin antibiotics, before
administration.
Skin and Allergic
Sultamicillin Used to treat various Reactions: Rash Follow the healthcare provider's
bacterial infections prescription for dosage, frequency,
Contraindication Pruritus (itching) and duration.
Urticaria (hives)
Drug Illustration Erythema multiforme Administer the medication via IV
(skin disorder) according to manufacturer
 Allergies to Severe cutaneous
guidelines.
penicillin or adverse reactions (e.g.,
severe Stevens-Johnson
Monitor the patient for any allergic
hypersensitivity. syndrome)
Hematologic System: reactions, including anaphylaxis.

Blood dyscrasias (e.g., Educate the patient about potential

leukopenia, neutropenia, side effects and when to seek
thrombocytopenia) medical attention.
Hepatic System:
Elevated liver enzymes Provide proper reconstitution of the
Hepatitis medication before administration.
Renal System:
Interstitial nephritis (a Assess the patient's clinical status
type of kidney and any changes in response to the
inflammation) medication.
Neurological System:
Headache Keep an eye out for any adverse
Local Reactions at effects and promptly report them to
Classification Injection Site: the healthcare provider.
Pain or irritation at the
Antibiotics injection site
Phlebitis (inflammation
D/F/R of the vein)
Serious Allergic
3 grams IV, Q6 Reactions:

Anaphylaxis (a severe,
life-threatening allergic
reaction)
DRUG STUDY (3)

Reference/s: 2021-Nurses-Drug-Handbook-Jones-Bartlett-Learning-20th-Edition-PARACETAMOL
 NURSING CARE PLAN (NCP)

NURSIN PLANNING
G
ASSESSMENT OBJECTIVE IMPLEMENTATION EVALUATION
DIAGNO INTERVENTION RATIONALE
OF CARE
SIS

After 8 hour nursing

Subjective cues: Impaired At the end of 8 -Assess respiratory rate, -Evaluated the patient's intervention, the objective
SO reports, “Pag- gas hours nursing depth, and ease Rationale: To promptly identify any breathing rate, depth, and of care were fully met as
admit niya dari nagkalala exchange intervention respiratory distress and initiate effort. evidenced by:
iyang condition Ma’am, related to patient will be timely interventions.
labaw iyang paglisud respiratory able to: -Inspected the skin, mucous  Achieve improved
niya ug ginahawa” distress as  Demonstra -Observe color of skin, Rationale: To detect cyanosis, an membranes, and nailbeds, tissue oxygenation
evidence te improve mucous membranes, and early sign of hypoxia, and gauge its taking note of any signs of and ventilation as
by ventilation nailbeds, severity for appropriate action. peripheral cyanosis (nailbeds) evidenced by
abnormal and noting presence of or central cyanosis (around the ABG values
ABG maintain peripheral cyanosis Rationale: To recognize cardiac mouth). consistently within
levels and ABGs (nailbeds) or compensation due to hypoxia and the acceptable
hypoxemia within central cyanosis manage cardiovascular stress. -Kept a close watch on the range and the
Objective cues: acceptable (circumoral) patient's heart rate and rhythm. absence of any
- GCS score of 3 range and Rationale: To maintain real-time symptoms
- ABG; ph 7.4 absence of awareness of oxygen saturation and -Continuously monitored the indicative of
PaC02 46.3(H), symptoms -Monitor heart rate and obtain comprehensive data for patient's oxygen saturation with respiratory
HCO3 (28.9) of rhythm. oxygen therapy management. pulse oximetry and procured distress. This
- Admitting respiratory arterial blood gases (ABGs) as includes
diagnosis: distress. required. maintaining a
Respiratory -Monitor pulse oximetry Rationale: To provide the right balanced pH and
Failure  Participate continuously and ABGs as oxygen concentration for -Delivered oxygen therapy appropriate levels
secondary to in needed. immediate and effective correction using the appropriate methods. of oxygen (PaO2)
hypoxic treatment of oxygen deficiency, improving and carbon
ischemia regimen patient outcomes. dioxide (PaCO2)
(within -Administer oxygen in the blood.
level of therapy by appropriate  Actively
ability or means participate in the
situation prescribed
treatment regimen,
including the use
of supplemental
oxygen, to the best
of the patient's
ability. This
entails adhering to
oxygen therapy
 recommendations,
following proper
techniques for
oxygen delivery,
and consistently
utilizing oxygen
as advised by the
healthcare team,
thereby
contributing to
their own recovery
and overall well-
being.

Reference: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: guidelines for individualizing client care across the life span.
Ed. 7. Philadelphia, F.A. Davis Co. pp 181-183

NURSING PLANNING
ASSESSMENT DIAGNOSI OBJECTIVE OF IMPLEMENTATION EVALUATION
INTERVENTION RATIONALE
S CARE

After 8 hour nursing

Subjective cues: Ineffective At the end of 8 - Auscultate breath Rationale: To assess respiratory -Auscultated breath sounds: intervention, the objective
SO stated pt was airway hours nursing sounds. Note status and detect any abnormal of care were fully met as
intubated on the day clearance intervention patient adventitious breath sounds, allowing early intervention. Regularly checked and evidenced by:
of admission retained will be able to: sounds recorded vital signs.
secretions as  Maintain such as wheezes, Rationale: For early detection of  After
evidenced by patent crackles, or rhonchi physiological changes and prompt Ensured secure positioning and implementing
alteration in airway with intervention to prevent provided oral care. suctioning and
respiratory rate breath - Continuously complications. respiratory care,
and sounds monitor vital signs, Kept a close watch on and the patient's
Objective cues: endotracheal clear or including heart rate, adjusted ventilator settings as airway remained
- Endotrachea intubation clearing. blood pressure, Rationale: Ensures proper tube required. patent, and breath
l in place  Effectively respiratory rate, and placement, reduces complications, sounds became
- Visible mobilize oxygen saturation. and maintains oral hygiene to Administered prescribe clear.
secretions in and clear prevent infection. medications following  Secretions were
the secretions - Monitor endotracheal healthcare provider's orders. effectively
endotracheal from the tube, including mobilized and
tube airway securing the tube, and Rationale: Maintains optimal cleared from the
- Admitting  Maintain providing oral care. oxygenation and ventilation to airway.
diagnosis: respiratory prevent respiratory issues.  Maintained
Respiratory Monitor mechanical
 Failure within the ventilation settings to respiratory rate
secondary to acceptable maintain optimal Rationale: Manages symptoms, within the
hypoxic range. oxygenation and pain, and underlying conditions, acceptable range:
ischemia ventilation. supporting the patient's well-being The patient's
and recovery. respiratory rate
Administer was consistently
medications, as within the
indicated acceptable range,
reflecting
improved
respiratory status
and secretion
management.

Reference: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: guidelines for individualizing client care across the life span.
Ed. 7. Philadelphia, F.A. Davis Co. pp 181-183

NURSING PLANNING
ASSESSMENT DIAGNOSI OBJECTIVE OF IMPLEMENTATION EVALUATION
INTERVENTION RATIONALE
S CARE

After 8 hour nursing

Subjective cues: Imbalanced At the end of 8 - Assess recent food To understand the patient's - Assessed recent food intake intervention, the objective
Nutrition: less hours nursing intake and note any nutritional status and identify any and identified eating of care were fully met as
than body intervention patient eating difficulties. eating issues that may affect difficulties. evidenced by:
requirement will be able to: nutrition.
related to  Display Evaluate weight and -Evaluated weight and body  Patient exhibited a
history of progressive body mass. To monitor changes in the patient's mass. steady and
significant weight gain nutritional status over time. appropriate
weight loss as toward goal Monitor bowel sounds - Monitored bowel sounds increase in weight,
Objective cues: evidenced by as through auscultation. To assess gastrointestinal function, through auscultation. aligning with the
- Endotrachea abnormal BMI appropriate as abnormal sounds may indicate predetermined
l in place  Demonstrat Provide regular oral issues with nutrient absorption. -Provided regular oral care, target.
- Visible e be hav care, promptly remove promptly removed secretions,  patient actively
secretions in iors and secretions, and offer a To prevent infections and and offered a designated displayed and
the lifestyle designated container aspiration, maintaining oral hygiene container for disposal. adopted
endotracheal changes to for disposal. is crucial in critically ill patients. constructive
tube regain and -Reviewed pertinent lab values. behaviors and
- Admitting maintain Review pertinent lab To identify and address any Collaborated with a clinical lifestyle
diagnosis: values. nutritional deficiencies or nutritionist to assess and
 Respiratory appropriate imbalances. customize the patient's modifications
Failure weigh Collaborate with a nutritional plan. aimed at achieving
secondary to clinical nutritionist to To create a personalized nutrition and preserving an
hypoxic assess and tailor the plan that meets the patient's specific appropriate body
ischemia patient's nutritional needs and ensures effective weight.
Lab Values: (Deviations) Values Indication
needs.- nutritional support.

CBC Complete Blood Count

RBC 44.3 L - Indicates a lower than normal red blood cell count.

This could be a sign of blood loss.

WBC 19.0 H - Indicates a higher than normal white blood cell count. This may suggest infection,
inflammation, or a response to stress from sustained injury.
Reference: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: guidelines for individualizing client care across the life span.
Artetial Blood Gas Result Artetial Blood Gas Result (deviations)
Ed. 7. Philadelphia, F.A. Davis Co. pp 181-183
(deviations)
PaCO2
PaCO2 46.3 H - This value is slightly elevated. It suggests respiratory acidosis, indicating that there might
be a buildup of carbon dioxide in the blood due to impaired ventilation or respiratory
dysfunction.
PaO2
PaO2 470.3 H- This value is significantly elevated and well above the normal range. Such high levels of
oxygen may be due to supplemental oxygen therapy.

HCO3
HCO3 28.9 H- This value is slightly elevated. It suggests a compensatory response to the respiratory
acidosis indicated by the elevated PaCO2. An increase in bicarbonate is the body's way of
trying to balance the pH by buffering excess carbon dioxide.