Student Name: Jenny Lyn D.

Toquero Patient Name: EDC Generic name Dexamethas one Brand name Celestami ne Age: 71 yrs. Old Classificatio n Anti histamine Dosa ge 20mg TIV Diagnosis: Nasopharyngeal Cancer Mechanism of action Dec. inflammatory mainly by stabilizing leukocytes, lysomal membranes; suppresses immune response Indication Contra indication Systemic fungal information MAOI therapy Hypersensiti vity hypotension Side effect Nursing managem ent Give daily dose in morning Give oral dose with meal

Respiratory ocular Dermatolog ic allergies

Amlodipine

Norvasc

Antihypertens 5mg ive OD

Metrocloprom ide hydrochloride

Omepraz ole

Antiemetics

10mg TIV

A class IA antirrhytmic that dec. excitability, conduction, velocity, automaticity;&memb rane responsiveness w/ prolonged refractory period. Stimulates motility of upper GI tract; inc. lower esophageal sphincter tone and blocks dopamine receptors at the chemoreceptors trigger zone

Hypertensi on Angina CHF Myocardial ischemia

Fluid & electrolyte imbalance Musculoskel etal GI Dermatologi c Headache Edema Fatigue Abd. Pain Flushing

Monitor CBC frequently Monitor electrolyte Monitor blood pressure Monitor bowel sound Safety effectivene ss of drug havent established for therapy lasting longer 12 wks.

To reduce/ prevent nausea & vomiting from ematogenic cancer chemother apy

Hypersensiti vity to drug With pt. for who stimulate of GI motility

Anxiety Drowsiness Fatigue Hypotension

IX. Nursing Care Plan

Name: D. P. Age: 66 yrs. Old Assessment Subjective: hind naman ako mlakas kuamain pero mataba ako as patient verbalized Objective: Edema in upper extremities Changes in respiratory pattern Restlessness Dypnea Nursing Diagnosis Excess Fluid Volume related to compromised regulatory mechanism like organ failure Planning Partially Compensator Long Term Goal After 1 shift of nursing intervention the pt will reduce the excess fluid in the body Intervention Rationale Facilitate measuring of For changes that may abd. grin. indicate inc fluid retention Facilitate appropriate To prevent peaks/ rate of fluid intake. valleys in fluid level & thirst Evaluation Pt. reduce the excess fluid in the body

Facilitate weighing of the pt.

To provide comparative baseline

Facilitate elevation of ematous extremities frequently Facilitate use of lip balm & frequent oral intake

To reduce tissue pressure & risk of skin breakdown To reduce discomfort of fluid restriction

Assessment Subjective:

Planning Partially Compensator

Intervention Rationale Facilitate discussion of To appeal clients like eating habits. and dislikes

Evaluation Pt. increase her appetite

hindako makakain as Long Term Goal patient verbalized After 3 days of nursing Objective: intervention the pt will increase her appetite Loss of appetite Weakness Capillary fragility Dec. albumin: 23.2 Dec.total protein: 47.4 Nursing Diagnosis Imbalnced Nutrition less than body requirement related to inability to absorb nutrients

Facilitate weighing of the pt.

To provide comparative baseline

Facilitate promotion of pleasant, relaxing environment.

To enhance intake

Facilitate prevention of May have a negative unpleasant odors / effect on the pt. sights appetite Inhibit fluid intake at least 1 hr before meals

To reduce possibility of early satiety.

Assessment Subjective:

Planning Partially Compensator Long Term Goal

Intervention Facilitate observation of reddened/ blanched areas/ skin rashes. Facilitate adequate clothing/ covers; protect from drafts.

Rationale To reduce likelihood of progression to skin breakdown To prevent vasoconstriction

Evaluation Pt. verbalized her understanding about her condition

Objective: Hypothermia Physical immobilization Imbalanced nutritional state Changes in skin turgor Changes in pigmentation Nursing Diagnosis Risk for Impaired Skin Integrity After 1 shift of nursing intervention the pt will verbalized her understanding about her condition

Facilitate protection by To inc. circulation& means of using of limit or eliminate pads, or pillows. excessive tissue pressure. Facilitate encourage of continuation of To enhance circulation regular exercise program. Facilitate elevation of lower extremities when sitting. To enhance venous return & reduce edema formation