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DRUG STUDY

Name of the patient:Cerilla. Elvie Age: 29 Sex: F Marital Status: M Religion: RC Room/Bed: FW
Chief complaints/reason/s for Admission: abdominal pain
Medical Diagnosis/Impression: acute cholecystitis
Attending Physician: Dr. Cuarte

Generic Brand Classifica Action Indication Contraindicati Adverse Nursing


Name Name tion on Effect Consideration

Ketorola Toradol NSAID Unknown Short term Contraindication o Drowsine o Use cautiously in
c . management to ss patient with hepatic
Produces of hypersensitivity. o Headach or renal
anti moderately e impairement.
inflammat severe acute o Edema o Correct hypovolemia
ory, pain. o Hyperten before treatment
analgesic sion with torolac.
and o Nausea o Observe for
antipyreti o GI pain cuagulopathies in
c effects. those taking
o Diarrhea
o Constipat coagulants.
ion o IM administration
o Flatulenc may cause pain at
e injection site.
Dosage: Frequenc Route: o Rashes
1amp y: IVTT
TID
Nursing Care Plan
Name of the patient: Cerilla, Elvie Age: 29 Sex: F Marital Status: M Religion: RC Room/Bed: FW
Chief complaints/reason/s for Admission: abdominal pain
Date & Time of Admission: 11/24/08 @ 5pm Accompanied by/informant: mother
Medical Diagnosis/Impression: acute cholecystitis
Operation performed (if any):
Attending Physician: Dr. Cuarte
Date/time of Assessments: 11/25/08 @ 12noon Date/time of Evaluation: 11/25/08 @ 3pm

Cues & Nursing Objection Nursing Rationale Evaluation


Evidence Diagnosis Intervention
Subjective:
“init kayo ko Alteration in body As the end of my o Perform TSB. o To decrease Goal met as
maam”, as patient temperature care patient’s temp. evidence by temp
verbalized. related to infection temperature will o Promote o Heat loss by = 37.3 ° Celcuis.
Objective: secondary to be within normal surface radiation &
o Temp=37.8 acute cholecytitis range 37-37.5 ° cooling. conduction
degree Celsius as evidenced by Celsius. o To rest the
o Pale lips increase body o Provide patient.
noted. temperature (37.8 conducive
o Flushed skin ° Celsius) environment. o To reduce
noted Scientific Basis: o Encourage to metabolic
o Skin warm to Body temperature maintain bed demands.
touch. elevated above rest.
normal range. Dependent:
Reference: o Administer o To help reduce
NANDA 10th antipyretic as to body
edition. doctors order temperature.
Nursing Care Plan
Name of the patient: Rellanos, ConsueloAge: 61 Sex: F Marital Status: M Religion: RC Room/Bed: FW
Chief complaints/reason/s for Admission: epistaxis and hypertension
Date & Time of Admission: 11-24-08 @ 9:10pm Accompanied by/informant: Daughter
Medical Diagnosis/Impression: HPN urgency
Operation performed (if any):
Attending Physician: DR. Cuarte
Date/time of Assessments: 11-25-08 @ 7am Date/time of Evaluation: 11-25-08 @ 3pm

Cues & Nursing Objection Nursing Rationale Evaluation


Evidence Diagnosis Intervention
Subject:
“ naghanap akong Risk for injury At the span of o Establish o To gain trust Goal partially met
panan’aw” as related to blurring of may nursing care rapport. and as evidenced by
verbalized by the vision secondary to patient’s BP and o Safety cooperation patient BP
hypertension
patient. PR will be measures o To avoid decrease from
Scientific Basis:
decrease to its rendered. further injury. 150/100mmHg to
Objective: At risk of injury a as normal range. o Promote o To provide 140/90mmHg and
o BP= result of conducive comfort PR decrease from
150/100mmHg environmental environment 112bpm to 77bpm
o PR= 112bpm condition in o Promote rest o To conserve
o Weakness interacting with the and sleep energy
noted individuals adaptive
o Irritable noted. & defensive
Dependent
resources
Source: o Administer o To help reduce
NANDA 10th edition antihypertensiv BP and PR.
e as doctors
prescribed
DRUG STUDY
Name of the patient: Rellanos, ConsueloAge: 61 Sex: F Marital Status: M Religion: RC Room/Bed: FW
Chief complaints/reason/s for Admission: epistaxis and hypertension
Medical Diagnosis/Impression: HPN urgency
Attending Physician: Dr. Cuarte

Generic Brand Classification Action Indication Contraindicat Adverse Nursing


Name Name ion Effect Considerati
on

Captopril Capoten Antihypertensives Decrease Hypertension; Contraindicated o Dizzeness o Monitor pt’s


aldosterone Left in patients with o Headache BP and PR
frequently.
secretion, ventricular hypersensitive o Fatigue o Instruct pt to
w/c dysfunction to drug or other o Abdominal take drug 1
reduces after acute ACE inhibitors. pain hour before
sodium and myocardial o Nausea meals; food
water infarction. in the GI
o Vomiting tract may
retention
o Persistent reduce
and lowers absorption.
nonproduc
blood Compared
tive cough o
pressure. with other
ACE
inhibitors,
captopril is
the most
likely to
cause
Dosage: Frequency: Route: cough.
50mg q6 sublingual