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S: masuol kuno
pag nag ginhawa
siya as
verbalized by the
mother
O:
>facial frimace
>diaphoretic
Diagnosis
>acute pain r/t
inflammatory
response of
alveolar tissues
secondary to
pneumonia
Scientific Rationale
Tissue injury or
infection results to
immediate vascular
response; transitory
vasoconstriction
followed
immediately by
vasodilation due to
the release of
histamine,bradykini
n and prostaglandin
which in turn leads
to increased
capillary
permeability,
hyperemia and
cellular exudation
that results to
edema and then
pain caused by
compression of
nerve endings,
release of pain
mediators
bradykinin and
prostaglandins and
eventually loss or
impaired function.
Planning
After a series of
nursing
interventions:
> Demonstrate relief
of pain as absence of
muscle tension,
absence of facial
grimace and
restlessness
Reference: Josie
QuiambaoUdan,Mastering
Fundamentals of
Nursing 3rd edition,
Intervention
>perform a comprehensive
assessment of pain to include
location, characteristic, onset,
duration, frequency,quality and
precipitating factors of pain.
Scientific Rationale
>pain is subjective experience
and must be described by the
client in order to plan
effective treatment.
>personal factors can
influence pain and pain
>reduce or eliminate factors that
tolerance. Factors that may be
precipitate or increase pain
precipitating o augmenting
experience.
pain should be reduced or
eliminated to enhance the
overall pain management
program.
>relaxation techniques help
reduce skeletal and muscle
>Elicit behaviors that are
tension which will reduce the
conditioned to produce relaxation,
intensity of the pain.music
such as deep breathing, music
therapy serves as a distracter
therapy.
from hospital noise, thereby
reducing emotional anxiety
and pain
>Instruct client to report any
>Unrelieved pain can create
improvement/exacerbation of pain.
problems such as anger,
anxiety, immobility,
>Encourage verbalization about
respiratory problems and
feelings of pain.
delay in healing.
>only the client can judge the
level and distress of pain,
pain management should be a
team approach that includes
the client.
>Provide comfort measures such as
> To promote comfort and
repositioning
alleviate pain.
And fixing the bed sheets.
Source:
Medical-Surgical Nursing, 7
th
ed. by Black, Joyce M.and
Jane Hokanson Hawks; p.
443
Clinical Instructor: JEANETTE J. ROJO, RN, MAN
Evaluation
>Patient will have relief of
pain as absence of muscle
tension, absence of facial
grimace and restlessness.
Assessment
S:
>di siya
nakakaturog
kay masuol uraura verbalized
by the mother
O:
>yawning
>crying
>wakes up
every 2 hours
Diagnosis
Fatigue related
to sleep
deprivation
secondary to
pneumonia
Scientific Rationale
> Prostaglandin due to
inflammatory reaction
as a result from the
wound, or
microorganism may
result to transmission
of pain thereby affects
mobility, mood, rest
and concentration.
Reference: Josie
QuiambaoUdan,Mastering
Fundamentals of
Nursing 3rd edition,
Planning
>after 8 hours of
nursing
interventions the
pt will be able to:
>lessen
discomforts and
obtain adequate
rest.
Intervention
>manipulated environment such
as cleaning the surroundings
and minimizing noise.
Scientific Rationale
>to promote comfort
> Clients
position may aggravate
pain felt. Positioning
properly may promote
comfort and also ensure
good circulation.
>nutrition is the
fundamental
cellular integrity
and tissue repair
>caffeine has
substances that is
known to disrupt
Evaluation
>patients discomforts will lessen and
will obtain adequate rest.
sleeping patterns
>Diversional
activities will
help the client
focus on other
things rather than
the pain felt
> To facilitate
expansion of
abdomen and to
decrease pain
Assessment
S:
>kakure danay
mag gin hawa
ini siya as
verbalized by
the mother
O:
>productive
cough noted
>difficulty in
breathing
name of drug
specific
action
generic name:
Inhibits cellwall
synthesis, of
bacterial cell
wall causing
cell death.
cefuroxime sodium
brand name:
cefuroxime axetil
classification:
second-generation
cephalosporin
route & dosage:
750mg IVTT q8h
hypersensitive
cephalosporin or
penicillin
Drug-Drug:
May increased
nephrotoxicity
with
aminoglycoside
s
Increased
bleeding effects
with oral
anticoagulants
CV: phlebitis,
thrombophlebi
tis
GI:
pseudomembr
anous colitis,
nausea,
anorexia,
vomiting,
diarrhea
hypersensitive to penicillin
nursing responsibilities
Before :
>Make sure patient is not
allergic to penicillins or cephalosporins.
>assess if any hypersensitivity
to penicillin
>Observe 10Rs of medication
administration
After:
>Discontinue if hypersensitivity
reaction occurs
Skin:
maculopapular
and pain,
induration,
temperature
elevation.
Specific action(s)
Indication
Contraindication(s)
Drug interaction
Adverse reaction
Specific
precaution
generic name:
Antipyretic:
Reduces fever by
acting directly on
the hypothalamic
heat-regulating
center to cause
vasodilatation and
sweating, which
helps dissipate heat.
Temporary
reduction of
fever.
Contraindicated with
allergy to
acetaminophen,
Potentiating:
barbiturates,
carbamazepine,
diflunical,
hydantoins,
isoniazid,
rifabutin,
rifampin,
sulfinpyrazone:
increased risk of
hepatotoxicity
Zidovudine:
increase risk of
granulocytopenia.
CNS:Headache,
dizziness, lethargy,
paresthesia,
GI:hepatic toxicity
and failure
GU:liver toxicity,
nephrotoxicity,
Hematologic:bone
marrow depression,
Hypersensitivity:,
rash, fever
Anaphylaxis, pain,
phlebitis
Use
cautiously
with impaired
hepatic
function and
renal failure
paracetamol
brand name:
tempra
ROUTE:
IVTT
DOSAGE:
400 mg
FREQUENCY
:
Q4h
CLASSIFICA
TION:
Analgesic(nonopioid),
Antipyretic
1
2
Inhibiting:
activated
charcoal,
cholestyramine,
colestipol:
decreased
acetamininophen
absorption.
Name of Student Nurse: CHRISTINA EJERCITO
Name of the
drug
Nursing responsibilities
generic name:
paracetamol
brand name:
tempra
ROUTE:
IVTT
DOSAGE:
170 mg
FREQUENCY
:
Q4h
CLASSIFICA
TION:
Analgesic(nonopioid),
Antipyretic
Antipyretic:
Reduces fever by
acting directly on
the hypothalamic
heat-regulating
center to cause
vasodilatation and
sweating, which
helps dissipate heat.
Analgesic: Site and
mechanism of action
unclear.
Temporary
reduction of
fever.
Contraindicated with
allergy to
acetaminophen,
Potentiating:
barbiturates,
carbamazepine,
diflunical,
hydantoins,
isoniazid,
rifabutin,
rifampin,
sulfinpyrazone:
increased risk of
hepatotoxicity
Zidovudine:
increase risk of
granulocytopenia.
CNS:Headache,
dizziness, lethargy,
paresthesia,
GI:hepatic toxicity
and failure
GU:liver toxicity,
nephrotoxicity,
Hematologic:bone
marrow
depression,
Hypersensitivity:,
rash, fever
Anaphylaxis, pain,
phlebitis
Use cautiously
with impaired
hepatic function
and renal failure
1.
Inhibiting:
activated
charcoal,
cholestyramine,
colestipol:
decreased
acetamininophen
absorption.
Name of Student Nurse: CHRISTINA EJERCITO
Specific action(s)
Ceftriaxone
is a
cephalosporin
antibiotic.
It works by
interfering
with the
formation of
the
bacteria's
cell wall so
that the wall
ruptures,
Indication
Lowers
respiratory
infections
caused by
Streptococcus
pneumonia,
Staphylococc
us aureus,
Haemophilus
influenza, E.
coli,
Enterobactera
erogenes.
Intraabdominal
infections
caused by
E.coli,Klebsi
ellapneumoni
ae
Contraindication(s)
Drug interaction
Adverse reaction
Specific
precaution
Contraindicated with
allergy to
cephalosporins
isoniazid,
rifabutin,
rifampin,
HEMATOLOGIC:
bone marrow
depression
dec. WBC,
platelets, Hct
LOCAL: pain,
inflammation of
IVSite
OTHER:
Super infections,
disulfiram-like
reaction with
alcohol
Use
cautiously
with impaired
hepatic
function and
renal failure
Nursing responsibilities
>perform skin testing prior to giving meds
>Do not mix ceftriaxone with other antimicrobial
drug
DURING:
>Use a separate syringe when giving this drug
>Have Vitamin K available in case
of hypoprothrombinemia occurs AFTER:
>Discontinue if hypersensitivity occurs
>Monitor Blood levels in patients taking this drug
resulting in
the death of
the bacteria.
Diagnosis
Impaired Gas
Exchange r/t
Alveolarcapillary
membrane
changes
Secondary to
pneumonia.
Scientific Rationale
> Pneumonia is an
infection in one or
both lung. It can be
caused by fungi,
bacteria, or viruses.
Pneumonia causes
inflammation in
your lungs air sacs,
or alveoli. The
alveoli fill with
fluid or pus, in
which there is
ventilationperfusion mismatch.
Reference: Josie
QuiambaoUdan,Mastering
Fundamentals of
Nursing 3rd edition,
Planning
>after 8 hours of nursing
interventions the pt will
be able to:
>Display patent airway
with breath sounds
clearing; absence of
dyspnea, cyanosis.
Intervention
>Assess respiratory rate,
depth, and ease.
>Observe color of skin,
mucous membranes, and
nailbeds, noting presence of
peripheral cyanosis (nail
beds) or central cyanosis
(circumoral)
>Monitor body temperature,
as indicated. Assist with
comfort measures to reduce
fever and chills: addition or
removal of bedcovers,
comfortable room
temperature, tepid or cool
water sponge bath.
>Elevate head and
encourage frequent position
changes, deep breathing,
and effective coughing.
>Observe for deterioration
in condition, noting
hypotension, copious
amounts of bloody sputum,
pallor, cyanosis, change in
LOC, severe dyspnea, and
restlessness.
Scientific Rationale
>Manifestations of
respiratory distress are
dependent on/and
indicative of the degree
of lung involvement and
underlying general health
status.
>Cyanosis of nail beds
may represent
vasoconstriction or the
bodys response to
fever/chills; however,
cyanosis of earlobes,
mucous membranes, and
skin around the mouth
(warm membranes) is
indicative of systemic
hypoxemia.
>High fever (common in
bacterial pneumonia and
influenza) greatly
increases metabolic
demands and oxygen
consumption and alters
cellular oxygenation.
Evaluation
>patient will display patent airway
with breath sounds clearing; absence
of dyspnea, cyanosis.
name of drug
specific
action
generic name:
tranexamic acid
brand name:
Hemostan,
Fibrinon,
Cyklokapron,
Lysteda, Transamin
classification:
antifibrinolytic
route & dosage:
Tranexamic
acid is a
synthetic
derivative of
the amino
acid lysine. It
exerts its
antifibrinolyti
c effect
through the
reversible
blockade of
lysinebinding sites
on
plasminogen
molecules.
Antifibrinolytic
drug inhibits
endometrial
plasminogen
activator and
thus prevents
fibrinolysis
and the
breakdown of
blood clots.
The
>Allergic
reaction to the
drug or
hypersensitivity
>Presence of
blood clots (eg,
in the leg, lung,
eye, brain),
have a history
of blood clots,
or are at risk for
blood clot.
Drug-Drug:
CV: phlebitis,
thrombophlebi
tis
GI:
pseudomembr
anous colitis,
nausea,
anorexia,
vomiting,
diarrhea
Skin:
maculopapular
and pain,
induration,
temperature
elevation.
1.
>Pregnanc
in bleeding
y.
pattern should
Tranexamic
be immediately
acid
reported to the
crosses the
placenta.>
Lactation.
Tranexamic
acid is
distributed
into breast
milk;
concentrati
ons reach
approximat
Unusual change
physician.
2.
plasminogenplasmin
enzyme
system is
known to
cause
coagulation
defects
through lytic
activity on
fibrinogen,
fibrin and
other clotting
factors. By
inhibiting the
action of
plasmin
(finronolysin)
the antifibrinolytic
agents reduce
excessive
breakdown of
fibrin and
effect
physiological
hemostasis.
Name of Student Nurse: CHRISTINA EJERCITO
ely 1% of
3.
The medication
the
can be taken
maternal
with or without
plasma
meals.
concentrati
on.
4.
Swallow
Tranexamic
Acid whole
with plenty of
liquids. Do not
break, crush, or
chew before
swallowing.
name of drug
specific
action
generic name:
Ranitidine
Hydrochloride
brand name:
Zantac
classification:
antisecretory (h2receptor
antagonist)
route & dosage:
>Ranitidine
blocks
histamine
H2-receptors
in the
stomach and
prevents
histaminemediated
gastric acid
secretion. It
does not
affect pepsin
secretion,
pentagastrinstimulated
factor
secretion or
serum
gastrin..
>Short-term
treatment of
active
duodenal ulcer
>Maintenance
therapy for
duodenal ulcer
hypersensitive
cephalosporin or
penicillin
Drug-Drug:
May increased
nephrotoxicity
with
aminoglycoside
s
Increased
bleeding effects
with oral
anticoagulants
CV: phlebitis,
thrombophlebi
tis
GI:
pseudomembr
anous colitis,
nausea,
anorexia,
vomiting,
diarrhea
at reduced
dosage
Skin:
maculopapular
and pain,
induration,
temperature
elevation.
hypersensit
ive to
penicillin
Age:
name of drug
specific
action
generic name:
Clonidine
brand name:
catapres
classification:
>Clonidine
hydrochloride
(Catapres) is
an
antihypertens
ive drug
that stimulate
s CNS
alpha2adrenergic
receptors,
inhibits
sympathetic
cardioacceler
ator and
vasoconstrict
or centers,
and decreases
sympathetic
outflow from
the CNS.
>Antihypertensi
ve
>Sympatholytic (
centrally acting)
Central analgesic
route & dosage:
indications
>Contraindicated with
>Hypertension
, used alone or
as part of
combination
therapy
hypersensitivity
to clonidine or any
adhesive layer
components of
the transdermal system.
Civil Status: M
drug
interaction
Drug-Drug:
Increased
bleeding effects
with oral
anticoagulants
CNS: Drowsin
ess, sedation,
dizziness, head
ache, fatigue
that tend to
diminish
within 46 wk,
dreams,
nightmares,
insomnia,
hallucinations,
delirium,
nervousness,
restlessness,
anxiety,
depression,
retinal
Use
1.
hypersensitivity to clonidine or
cautiously
with severe
coronary
insufficiency
, recent
MI, cerebrov
ascular disea
se; chronic
renal failure;
pregnancy,
lactation.
2.
discontinue abruptly;
degeneration
>CV: CHF,
discontinuing clonidine;
orthostatic
hypotension,
48 hr.
palpitations,
tachycardia, br
adycardia, Ray
nauds phenom
enon, ECG
abnormalities
manifested
as Wenckebac
h period or
ventricular trig
emin
specific
action
indications
generic name:
mefenamic acid
brand name:
Ponstel
classification:
analgesic
NSAID
route & dosage:
> Inhibits
synthesis of
prostaglandin
>Mefenamic
acid is used for
the short-term
treatment of
mild to
moderate pain
from various
conditions.
Civil Status: M
drug
interaction
Drug-Drug:
>History of
kidney or
liver
disease;blood
dyscrasias;ast
hma;diabetes
mellitus;hype
rsensitivity to
aspirin. Long
term use
increases risk
of serious
adverse
events.
Chief Complaint:
Diet: LSLF
Ward:MMW/S
nursing responsibilities
and bleeding;
nausea,
vomiting,
abdominal
exceeding 1 wk (manufacturers
cramps,
warning).
flatus,
constipation,
hepatic
toxicity.
Hematologic:
Prolonged
prothrombin
time, severe
autoimmune
hemolytic
anemia (longterm use),
leukopenia,
eosinophilia,
agranulocytos
is,
thrombocytop
enic purpura,
megaloblastic
anemia,
pancytopenia,
bone marrow
hypoplasia.
Assessment
S: masuol ak ulo
ngan kalipong
O:
>180/120mmHg
>pain at occipital
region radiating to
the neck in a scale
of 7 out of 10
Diagnosis
Increased cerebral
Planning
After a series of
nursing
interventions:
vascular pressure
> Report
secondary to
pain/discomfort is
hypertension
relieved/controlled.
Scientific Rationale
>Verbalize methods
that provide relief
Intervention
> Note clients attitude toward pain
and use of pain medications,
including any history of substance
abuse.
> Determine specifics of pain
(location, characteristics, intensity
(010 scale), onset and duration).
Note nonverbal cues.
> Encourage and maintain bed rest
during acute phase.
> Provide or recommend
nonpharmacological measures for
relief of headache such as cool
cloth to forehead; back and neck
rubs; quiet, dimly lit room;
relaxation techniques (guided
imagery, distraction); and
diversional activities.
> Eliminate or minimize
vasoconstricting activities that may
aggravate headache (straining at
stool, prolonged coughing, bending
over).
> Assist patient with ambulation as
needed.
Scientific Rationale
> To assess etiology or
precipitating contributory
factors.
> Facilitates diagnosis of
problem and initiation of
appropriate therapy.
Helpful in evaluating
effectiveness of therapy.
> Minimizes stimulation
and promotes relaxation.
> Measures that reduce
cerebral vascular pressure
and that slow or block
sympathetic response are
effective in relieving
headache and associated
complications.
> Activities that increase
vasoconstriction
accentuate the headache in
the presence of increased
cerebral vascular pressure.
> Dizziness and blurred
vision frequently are
associated with vascular
headache. Patient may
also experience episodes
of postural hypotension,
causing weakness when
ambulating.
Source:
Medical-Surgical Nursing
,7
th
ed. by Black, Joyce M.and
Jane Hokanson Hawks; p.
443
Evaluation
>patient will
demonstrate relief of
pain in a scale of 2 from
7