Assessment Diagnosis Planning Interventions Rationale Evaluation

Objective: Alteration in comfort; After 45 minutes of nursing 1. Positioned patient – for relaxation Goal met, as
intervention, comfortably on
Grimaced face Pain r/t increased evidenced by
bed.
the patient will be able
RR= 24cpm Intracranial pressure absence
to establish reduction 2. Provided cool & quiet – promotes
PR= 112bpm Secondary to CVA. environment. of facial grimace &
of pain by absence of relaxation
vital signs are normal.
3. Intermittently massaged
grimace face & v/s within
the forehead.
normal range.
– for relaxation
4. Elevated head of the bed.

5. Turned patient at
intervals.
– promote blood circulation
6. Meds given as ordered
– for relaxation

7. v/s taken and recorded.

– to reduce pain by
pharmacologic

effect

– serves as baseline
data
 NURSING CARE PLAN

Assessment Diagnosis Planning Interventions Rationale Evaluation

Objective: Altered tissue After 15mins. of nursing 1. Assessed for s/s of – Provides baseline Goal partially met,
cranial pressure & data.
BP= 140/100mmHG perfusion r/t intervention, the no episode of seizure
effects of cerebral
interruption of blood patient will be able to vasoconstriction. noted, & afebrile.

flow as evidenced by maintain tissue 2. Elevated head of the – Promotes venous

bed 30-40 degrees. return.
BP of 140/100mmHg. perfusion as manifested

by normal temperature 3. Promoted a quiet &

restful environment. – Decreased the
and (-)seizures.
need of oxygen &

glucose of brain

4. Observed signs of cells.

seizure.

– To immediately
implement
 5. Meds given as ordered. interventions
before the
occurrence.

– To control blood
pressure.

Assessment Diagnosis Planning Interventions Rationale Evaluation

Objective: Impaired physical After the shift, the 1. Repositioned client – To prevent Goal met, as
every 2 hours pressure ulcer.
Limited ROM Mobility r/t occlusion patient will be able to evidenced by

of major cerebral maintain skin integrity 2. Supported affected – To maintain maintenance of skin
body parts with pillows. position of
Decreased Muscle arteries. by absence of decubitus. function integrity by absence
& reduce risk of
strength of decubitus.
pressure ulcers.

3. Provided safety – To prevent fall may

measures like use of cause injury.
Side rails.
 4. Provided passive range – for good
of motion.
circulation

5. Taught SO exercises &

techniques to improve
balance & coordination
– to prevent further
complications.

DRUG STUDY

Name of Drug Action Contraindication Adverse Reaction Nursing Considerations Patient Teaching

Generic name: Inhibits cell wall Contraindicated to CV: phlebitis, Before administration ask the Tell the patient to take

Cefuroxime Sodium
synthesis, Patients hypersensitiveThrombophlebitis. patient if he or she is allergic to drugs as prescribed

promoting To other drugs and penicillins or cephalosporins . even after he feels better.

Brand: Zinacef oncotic Cephalosporins GI: nausea, anorexia,

 Instability usually Vomiting, diarrhea. Obtain specimen for culture & Instruct the patient to take
bacteriacidal.
Classification: Use cautiously in sensitivity test before oral form w/ food.

Anti-infectious patients Hematologic: giving first dose.

hypersensitive to Thrombocytopenia If suspension is being used tell

Category: penicillins. If doses are given patient to shake container well

Pregnancy Risk Skin: pain, therapy is prolonged before measuring dose.

category B temperature or patient is at risk.

Elevation Instruct the patient to notify

Dosage: Monitor for s/s of super prescribed about rash or

500 mg/cap q 8⁰ Infection. evidence of super infection.

Tell patient to notify prescribes

about loose stools or diarrhea.

Name of Drug Action Contraindication Adverse Reaction Nursing Considerations Patient Teaching

Generic name: Sodium chloride is the Contraindicated to GI: anorexia, nausea, Note for history o Take these tablets only as
abdominal distention
Sodium Chloride principle salt involved in patients with f hypernatremia, fluid prescribed.

the maintenance of plasma hypernatremia, fluid retention, pregnancy,

Hematologic
Classification: tonicity important for retention, pregnancy, impaired renal function, Have periodic blood tests
: hypernatremia, fluid
Electrolyte maintaining plasma value any condition when CHF, edematous or sodium and medical evaluation.
overload
promoting membrane increase sodium or retaining states lactation.

Category: stability & electrolyte chloride could be Wash hands before using
Local:
Pregnancy Risk balance detrimental, optalmic preparation.
Chemical cellulitis
category B bacteriostatic is
Tissue necrosis,
contraindicated in Report irritability, confusion,
Ulceration sloughing at
newborns because of tremor, swelling of
site of infiltration,
associated toxicity. extremities, difficulty
pain at a site of
reathing and black tarry
injection.
Use cautiously with stoo.l

impaired renal function

 CHF, edematous or no

retaining, states lactation

or surgical patients.

Name of Drug Action Contraindication Adverse Reaction Nursing ConsiderationsPatient Teaching

Generic name: Inhibits the action of Contraindicated with CNS: headache, malaise, Administer oral drug Take drug with meals at
bedtime. Therapy may
RANITIDINE histamine at the h2 allergy to ranitidine, dizziness, somnolence, with meals and at
continue for
receptors of the lactation. insomnia, vertigo. bedtime.
4-6 weeks or longer.
Classification: parietal cells of the

H2 blocker stomach, inhibiting Use cautiously with CV: tachycardia, bradycardia Decrease doses in
If you are using antacid ,
basal gastric acid impaired renal or hepatic renal and liver failure.
take it exactly
Dosage: secretion and gastric function, pregnancy. GI: constipation, diarrhea,
as prescribed being
500 mg IV q 12⁰acid secretion that is nausea and vomiting, Provide concurrent
stimulated by food, careful of the time of
abdominal pain hepatitis, antacid, therapy to
insulin, histamine, administration.
increased ALT levels. relive pain.
cholinergic agonist,

gastrin, and Report sore throat,

GU: gynecomastia, Administer IM dose
pentagastrin . fever, unusual bruising or
impotence or decrease libido undiluted, deep into
bleeding, tarry stools,
large muscle group.
confusin, hallucination,

dizziness, severe headache,

Arrange for regular
muscle or joint pain.
follow up, including

blood test to
 evaluate effects .

Name of drug Actions Contraindications Adverse effect Nursing consideration Patient teaching
Mannitol Acts by increasing Active intracranial GU: dieresis, urinary Signs of metabolic To rise slowly

osmalarity of bleeding, retention, thirst. acidosis: drowsiness. from lying and sitting position

Classification: glomelular hypersensitivity anuria,

Osmotic Diuretic filtrate which raises severe dehydration, CNS: dizziness, Signs of hypokalemia: The reason for and method of

osmotic pressure progressive heart, headache, convulsion, postural hypotension, treatment.

Dosage:75 cc of fluid in renal renal failure. rebound increase ICP malaise, fatigue,

tubules; decreases in confusion. tachycardia, leg cramps,

reabsorption weakness.

of water, electrolytes, GI: nausea and

increases in urinary
vomiting, dry mouth, Rashes
output, sodium,
diarrhea.
chloride excretion.
Hydration including skin

CV: edema, turgor, thirst, dry mucous

membranes.
thrombophlebitis,

hypotension,

hypertension,

tachycardia,

angina-like
 chest pains, fever,

chills.

EENT: loss of hearing,

blurred vision, nasal

congestion, decrease

intraocular pressure.

Name of drug Action Contraindication Adverse reaction Nursing consideration Patient teaching
Aspirin Blocks pain impulses in
Hypersensitivity to CNS: drowsiness, Give drugs with food orTake extra precautions to

CNS, inhibition of salicylates, tartrazine dizziness, confusion, after meals if GI upset keep drug out of the reach

Classification: NSAID prostaglandin synthesis:

bleeding disorders. convulsion, headache, occurs. of children, this drug can be
antipyretic action
flushing, hallucination, very dangerous for children
results from vasodilation
Dosage:80 mg/tab OD coma. Give drug with full glass
of peripheral vessels,
of
Use the drug only as
decreases platelet
water to reduce risk of
aggregation. GI: nausea and vomiting, suggested; avoid over dose;
tablet or capsule
GI bleeding, diarrhea, avoid the use of OTC drugs
lodging in the
heart burn, anorexia, while taking this drug.
esophagus.
hepatitis.

Take drug with food or after

Do not crush and
-EENT: tinnitus, meals if GI upset occurs.
ensure that patient
hearing loss.
does not chew SR

preparation.
CV: rapid pulse,

pulmonary edema.
Do not use aspirin that

has a strong vinegar

 like odor.

Name of drug Actions Contraindication Adverse effect Nursing consideration Patient teaching
GENERIC NAME: -reduces fever by Contraindicated with CNS: headache Give drug with food if GI Do not exceed

Acetaminophen acting directly on the allergy to upset occurs. recommended dosage.

hypothalamic
Acetaminophen. CV: chest pain, Do not take for longer than 10
heat-regulating center
BRAND NAME: Dyspnea. Discontinue drug if days.
to
Paracetamol Use cautiously with hypersensitivity
cause vasodilation
impaired hepatic GI: hepatic toxicity reactions occurs. Take the drug only for
and sweating which
complaints indicated;
Classification: function, chronic and failure, jaundice.
helps dissipate heat.
alcoholism, pregnancy, it is not an anti inflammatory
Analgesic/antipyretic Do not exceed
lactation.
agent.
GU: acute renal failure,recommended dosage
renal tubular necrosis
Dosage:500 mg IV
Report rash, unusual

bleeding or bruising,
yellowing

of skin or eyes changes in

voiding patterns.

Name of drug Actions Contraindication Adverse reaction Nursing consideration Patients teaching
GENERIC NAME: Exact mechanism Contraindicated with GI: anorexia, nausea Monitor urine or Do not discontinue this
medication without
Metformin hydrochloride is not understood; allergy to metformin; and vomiting, serum glucose levels
frequently to consulting your health care
possibly increases CHF, diabetes epigastric discomfort,
peripheral determine provider.
BRAND NAME: complicated by fever heart burn, diarrhea,
utilization of effectiveness of drug
Glumet severe infections, flatulence.
glucose, decreases and dosage. Monitor blood for glucose and
severe trauma,
hepatic glucose ketones as prescribe.
Classification: ketosis, acidosis coma
Production and
Antidiabetic drug
alters intestinal Do not use this drug for
pregnancy.
absorption of

glucose.
Dosage:500 mg 1 tab BID
Avoid using alcohol while taking
this drug.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Alteration in body After 15-30 1. Temperature -serves as baseline Goal met, patient’s
temperature: minutes of effective taken and recorded. data. latest temperature
“May lagnat si
hyperthermia r/t nursing is 37.4⁰C.
mommy” as
increase pyrogens intervention, the
verbalized by the
in the body as patient’s body 2. Performed TSB.
SO.
manifested by skin temperature will
warmer to touch. decrease from the -heat loss through
normal range 36.5- conduction
Objective: 37.5⁰C.
3. Instructed SO to
T=38.7⁰C
dress patient with -heat loss through
Skin warm to touch light clothing. evaporation.

4. Provided well
ventilated
-heat loss through
environment.
radiation.

5. Administered
medication as
ordered. -to decrease body
temperature
through the use of
pharmacologic
agent.
Name of Drug Action Contraindication Adverse effects Nursing
Considerations

GENERIC NAME: An interneuron Pararympathetic GI disorders somazine must not

Cithicoline communication enhancer. hypertonia be administered

It is neurotransmission level because along with Medicaments

it containing
BRAND NAME:
favors the synthesis and production Meclophenaxate.
Somazine amp
speed of dopamine

in the striatum acting then as a

Classification:
dopaminergic against through
Loop Diuretic
the inhibition or tyroninehydroxylase.

Dosage:

1gm IV q 8⁰