NURSING CARE PLAN

Lainisha Pounds 12/12/09 Patient Initials: SP, Dx: gastric adenocarcinoma

NURSING
ASSESSMENT GOALS INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective data: Imbalanced nutrition 1. Patient will 1. Encourage 1. Allow patient to 1. Met: patient
- patient’s friend related to decreased attempt to increase patient to eat increase the current consumed more
says that client eats desire to eat secondary his food/fluid frequent small amount of nutrients fluids today
one bite of food and to pain from gastro consumption within meals according to his
drinks very little. adenocarcinoma 8 hours wife
“He may get down 2. Patient will 2. Understanding 2. Met: patient
3 ice cubes.” understand the 2. Explain the of needs for acknowledged that
- Patient states physiological need for adequate nutrition will be he understood that
that he has lost over reasons for food/fluids motivation to eat he needs to drink
10lbs within the last increasing more water instead of
2 wks food/fluid intake at soda
time of discussion
Objective Data: 3. Patient will 3. Met: at the end
- Poor muscle maintain pain at a 3. Monitor 3. To ensure that of shift patient
tone tolerable level for patient’s pain level patient is not trying stated he was at a 0
- Patient only the duration of the to “tolerate” the pain level and was
drank his orange prescription time pain which is drinking water from
juice from breakfast inhibiting is his cup
- patient was in appetite
visible pain while
attempting to move

Vital Signs:
BP: 104/62
RR: 14
P: 75
T: 96.8
O2: 96
GENERIC NAME: senna TRADE NAME: senokot, senolax, gentlax, ex-lax Cramping, rectal bleeding, nausea, vomiting; product should be discontinued.
gentle, dosalax, black draught Administer: in morning or evening (oral dose) with full glass of water. Dissolve
CLASSIFICATION: laxative-stimulant granules in water or juice before administration. On empty stomach for more rapid
USES: acute constipation, bowel preparation for surgery or examination, results. Shake oral sol before giving. Evaluate: therapeutic response: decrease in
prevention of constipation in those taking opiates long term constipation. Teach: that urine, feces may turn yellow-brown to red. Not to use
DOSAGE & ROUTE: adult: PO (senokot) 1-8 tabs/day or ½ to 4 tsp of franules (1 laxatives for long-term therapy; bowel tone will be lost. That normal bowel
tsp-4ml) added to warer or juice; RECT SUPP 1-2 at bedtime; SYR 1-4tsp at movements do not always occur daily. Not to use in presence of abdominal pain,
bedtime, 7.5-15 ml (black draught) ¾ oz dissolved in 2.5 oz liquid given between nausea, vomiting. To notify prescriber if constipation unrelieved or of symptoms
2-4pm the day before procedure (X-prep). Child >27kg: PO ½ adult dose; do not of electrolyte imbalance: muscle cramps, pain, weakness, dizziness, excessive
use Black Draught for children. Child 1 mo-1yr: SYR (senokot) 1.25-2.5ml at thirst.
bedtime
SIDE EFFECTS: GI: nausea, vomiting, anorexia, cramps, diarrhea, flatulence.
GU: pink, red or brown, black urine. META: hypocalcemia, enteropathy, alkalosis,
hypokalemia, tetany
NURSING CONSIDERATIONS: assess: stool: color, consistency, amount.
Blood, urine electrolytes if product is used often. I&O ration to identify fluid loss.
Cause of constipation; fluids, bulk, exercise missing, constipating products.
GENERIC NAME: docusate sodium TRADE NAME: colace, correctol extra Bowel movements do not always occur daily. Not to use in presence of abdominal
gentle pain, nausea, vomiting. To notify prescriber if constipation unrelieved or if
CLASSIFICATION: laxative, emollient; stool softener symptoms of electrolyte imbalance occur: muscle cramps, pain, weakness,
USES: prevention of dry, hard stools dizziness, excessive thirst. Inform patient that product may take up to 3 days to
DOSAGE & ROUTE: adult: PO 50-300 mg/day (sodium) or 240mg (calcium or soften stools. Take oral prep with a full glass of water unless on fluid restrictions
potassium) prn; ENEMA 4 ml. child ?12yr: ENEMA 2 ml. child 6-12: PO 40-150 and increase fluid intake
mg/day (sodium) in divided doses. Child 3-6: PO 20-60 mg/day (sodium). Child
<3: PO 10-40 mg/day (sodium) divided doses
SIDE EFFECTS: EENT: bitter taste, throat irritation. GI: nausea, anorexia,
cramps, diarrhea. INTEG: rash.
NURSING CONSIDERATIONS: assess: cause of constipation; identify whether
fluids, bulk, or exercise are missing from lifestyle, constipating products.
Cramping, rectal bleeding, nausea, vomiting; if these symptoms occur, product
should be discontinued. Administer: swallow tabs whole, do not break, crush, or
chew. Oral sol: diluted in milk, fruit juice to decrease bitter taste. In morning or
evening (oral dose). Perform/provide: storage in cool environment; do not freeze.
Evaluate: therapeutic response: decrease in constipation. Teach: that normal
GENERIC NAME: fentanyl TRADE NAME: fentanyl, fentora, sublimaze
CLASSIFICATION: opiod analgesic
USES: controls moderate to severe pain; preoperatively, postoperatively; adjunct to general
anesthetic, adjunct to regional anesthesia; fentanyl: anesthesia as pre-medication, conscious
sedation
DOSAGE & ROUTE: anesthetic – adult: IV 25-100 mcg (0.7-2 mcg/kg) q2-3min prn.
Anesthesia supplement – adult/child >12yr: IM/IV 2-20 mcg/kg IV INF 0.025-0.25
mcg/kg/min. induction and maintenance – adult: IV BOL 5-40 mcg/kg. child 2-12: IV 2-3
mcg/kg. preoperatively – adult/child >12: IM/IV 0.05-0.1mg q30-60min before surgery.
Postoperatively – adult/child >12: IM/IV 0.05-0.1 mg q1-2hr prn. Sedation/analgesia –
adult/child >23: IV 0.5-1 mcg/kg/dose; may repeat after 30-60min. child 1-12: IV BOL 1-2
mcg/kg/dose; may repeat after 30-60min intervals; CONT IV 1-5 mcg/kg/hr after IV bol
dose. Neonates: IV BOL 0.5-3 mcg/kg/dose; CONT IV 0.5-2 mcg/kg/hr after IV bol
SIDE EFFECTS: CNS: dizziness, delirium, euphoria, sedation. CV: bradycardia, arrest,
hypo/hypertension. EENT: blurred vision, miosis. GI: nausea, vomiting, constipation. GU:
urinary retention. INTEG: rash, diaphoresis. MS: muscle rigidity. RESP: respiratory
depression, arrest, laryngospasm
NURSING CONSIDERATIONS: assess: VS after parenteral route; note muscle rigidity,
product history, hepatic and renal function tests. CNS changes: dizziness, drowsiness,
GENERIC NAME: dexamethasone sodium phosphate TRADE NAME: dalalone, decadron
phosphate, solurex
CLASSIFICATION: corticosteroid, synthetic
USES: inflammation, allergies, neoplasms, cerebral edema, septic shock, collagen disorders
DOSAGE & ROUTE: inflammation – adult: PO 0.75-9 mg/day in divided doses q6-12hr or phosphate
IM 0.5-9 mg/day divided q6-12hr, or acetate IM 4-16 mg q1-3wk. child: PO 0.024-0.34 mg/kg/day in
divided doses q6-12hr. anaphylactic shock – adult: IV (phosphate) single dose 1-6 mg/kg or IV 40 mg
q2-6hr as needed up to 72 hr. cerebral edema – adult: IV (phosphate) 10 mg, then 4-6 mg IM q6hr x 2-
4 days, then taper over 1 wk. child: loading dose 1-2 mg/kg (PO/IM/IV) then 1-1.5 mg/kg/day, max 16
mg/day divided q4-6hr for 2-4 days, then taper down q wk. bone pain (unlabeled) – adult: PO/IV 12-
20 mg/day in divided doses.
SIDE EFFECTS: CNS: depression, flushing, sweating, headache, mood changes, euphoria, psychosis,
seizures, insomnia. CV: hypertension, circulatory collapse, thrombophlebitis, embolism, tachycardia,
edema, cardiomyopathy. EENT: fungal infections, increased intraocular pressure, blurred vision,
cataracts, glaucoma. ENDO: HPA suppression, hyperglycemia, sodium, fluid retention. GI: diarrhea,
nausea, abdominal distention, GI hermorrhage, increased appetite, pancreatitis. HEMA:
thrombocytopenia, transient leukocytosis. INTEG: acne, poor wound healing, ecchymosis, petechiae,
hirsutism. MET: hypokalemia. MS: fractures, osteoporosis, weakness, arthralgia, myopathy
NURSING CONSIDERATIONS: assess: potassium, blood, urine glucose while on long-term therapy;
hypokalemia and hyperglycemia. Weight daily; notify prescriber of weekly gain >5lb. B/P q4hr, pulse;
notify prescriber of chest pain. I&O ration; be alert for decreasing urinary output, increasing edema.
Hallucinations, euphoria, LOC, pupil reaction. Allergic reactions: rash, urticaria.
Respiratory dysfunction: respiratory depression, character, rate, rhythm; notify prescriber if
respirations are < 10min. administer: by inj (IM<, IV); give slowly to prevent rigidity. Must
have emergency equipment available, opiod antagonists, 02; to be used by only those
trained; (IV) products to be used in OR, ER, ICU. IV ROUTE: IV undiluted by
anesthesiologist or diluted with 5 ml or more sterile H20 or 0.9% NaCl given through Y-
tube or 3-way stopcock at 0.1 mg or less/1-2min. perform: storeage in light-resistant area at
room temperature. Evaluate: therapeutic response: induction of anesthesia, breakthrough
cancer pain. Teach: coughing, turning, deep breathing for postoperative patients. Safety
measures: side rails, night-light, call bell within reach. CNS changes: physical dependence;
not to use with alcohol, other CNS depressants.
Plasma cortisol levels during long-term therapy (normal: 138-635 nmol/L SI units when drawn at 8am);
Prolonged use can cause cushingoid symptoms. Infections: fever, WBC even after withdrawal of
medication; product masks in fection. Potassium depletion: paresthesias, fatigue, nausea, vomiting,
depression, polyuria, dysrhythmias, weakness. Edema, hypertension, cardiac symptoms. Mental status:
affect, mood, behavioral changes, aggression. Administer: titrated dose; use lowest effective dose. IM
inj deeply in large muscle mass; rotate sites; avoid deltoid; use 21G needle. In one doe in AM to
prevent adrenal suppression; avoid SUBCUT administration, may damage tissue. With food or milk to
decrease GI symptoms. IV ROUTE – undiluted direct over 1 min or less or diluted with 0.9% NaCl or
D5W and give as an IV at prescribed rate. After shaking suspension (parenteral); do not give
suspension IV. Perform: assistance with ambulation in patient with bone tissue disease to prevent
fractures. Evaluate: therapeutic response: decreased inflammation. Teach: that ID as steroid user should
be carried. To contact prescriber if surgery, trauma, stress occurs; dose may need to be adjusted. To
notify prescriber if therapeutic response; dosage adjustment may be needed. Not to discontinue abruptly
or adrenal crisis can result. Symptoms of adrenal insufficiency: nausea, anorexia, fatigue, dizziness,
dyspnea, weakness, joint pain. To avoid OTC products: salicylates, alcohol in cough products, cold
preparations unless directed by prescriber. To teach patient all aspects of product usage, including
cushingoid symptoms; to notify health care provider of infection. Avoid exposure to chickenpox or
measles, persons with infection.
GENERIC NAME: morphine TRADE NAME: astramorph, duramorph, oms concentrate,
statex, roxanol
CLASSIFICATION: opioid analgesic
USES: moderate to severe pain
DOSAGE & ROUTE: adult: SUBCUT/IM 5-20 mg q4hr prn; PO 10-30 mg q4hr prn; EXT
REL 15-30 mg q8-12hr; RECT 10-30 mg q4hr prn; IV 4-10 mg diluted in 4-5 ml H20 for
inj, over 5 min; SUS REL caps (Kadian), EXT REL caps (avinza) give total daily dose
q24hr; for those with no tolerance to opiods, 30 mg/day; may adjust by no more than 30 mg
q4 days. Child: SUBCUT/IV 0.05-0.1 mg/kg, max 15mg; PO 0.2-0.5 mg/kg, max 15 mg;
PO 0.2-0.5 mg/kg q4-6hr (reg rel), q12hr (sus rel)
SIDE EFFECTS: CNS: drowsiness, dizziness, confusion, headache, sedation, euphoria,
insomnia, seizures. CV: palpitations, bradycardia, change in BP, shock, cardiac arrest, chest
pain, hypertension, edema, tachycardia. EENT: tinnitus, blurred vision, miosis, diplopia.
GI: urinary retention. HEMA: thrombocytopenia. INTEG: rash, urticaria, bruising, flushing,
diaphoresis, pruritus. RESP: respiratory depression, respiratory arrest, apnea.
NURSING CONSIDERATIONS: assess: pain: location, type, character; give dose before
pain becomes severe. Bowel status; constipation common. I&O ratio; check for decreasing
output; may indicate urinary retention. BP, pulse, respirations (character, depth, rate). CNS
changes; dizziness, drowsiness, hallucinations, euphoria, LOC, pupil reaction
GENERIC NAME: acetaminophen TRADE NAME: Tylenol, aceta, aspirin-free anacin,
datril, tempra, children’s feverall, aminofen
CLASSIFICATION: nonopioid analgesic, antipyretic
USES: mild to moderate pain or fever, arthralgia, dental pain, dysmenorrheal, headache,
mayalgia, osteoarthritis
DOSAGE & ROUTE: adult/child >12: PO/RECT 325-650 mg q4-6hr prn, max 4 g/day.
Child 1-12: RECT 10-15 mg/kg q4-6hr, max 5 doses/24hr. child 1-12: RECT 10-20
mg/kg/dose q4-6hr. neonate: RECT 10-15 mg/kg/dose q6-8hr. migraine – adult/adolescent:
PO 500-1000mg, max 1g/dose or max 4 g/day
SIDE EFFECTS: CNS: stimulation, drowsiness. GI: nausea, vomiting, abdominal pain;
hepatotoxicity, hepatice seizure (overdose). GU: renal failure (high, prolonged doses).
HEMA: leucopenia, neutropenia, hemolytic anemia (long-term use), thrombocytopenia,
pancytopenia. INTEG: rash, urticaria. SYST: hypersensitivity. TOXICITY: cyanosis,
anemia, neutropenia, jaundice, pancytopenia, CNS stimulation, delirium followed by
vascular collapse, convulsions, coma, death
NURSING CONSIDERATIONS: assess: hepatic studies: AST, ALT, bilirubin, creatinine
prior to therapy if long-term therapy is anticipated; may cause hepatic toxicity at doses
>4g/day with chronic use. Renal studies: BUN, urine creatinine, occult blood, albumin, if
Respiratory dysfunction: depression, character, rate, rhythm: notify prescriber if respirations
are <12/min. administer: may be given by patient: controlled analgesia. Epidural
cautiously in the geriatric patients. Kadian is not bioequivalent to other controlled release
forms. Kadian caps may be opened and sprinkled on applesauce immediately before use;
pellets in the cap should not be chewed, crushed, or dissolved, which may lead to overdose;
adjustments may need to be made when converting from another form of morphine. PO
ROUTE: do not break, crush, or chew controlled or sus rel products. With antiemetic for
nausea, vomiting. When pain is beginning to return; determine dosage interval by response;
continuous dosing is more effective than prn. IV ROUTE: after diluting with 5 ml or more
sterile H2O or NS; give 15mg or less over 4-5 min; give through Y-tube or 3-way stopcock;
may be added to IV sol, each 0.1-1mg diluted in 1 ml D5W, D10W, 0.9% NaCl, o.45%
NaCl, ringer’s sol, LR, given with inf pump titrated to patient response. Perform: storage in
light-resistant container at room temperature. Assistance with ambulation. Safety measures:
side rails, night-light, call bell within easy reach. Gradual withdrawal after long-term use.
Evaluate: therapeutic response: decrease in pain intensity. Teach: to change position
slowly; orthostatic hypotension may occur. To report any symptoms of CNS changes,
allergic reactions. That physical dependency may result form long-term use. To avoid use
of alcohol, CNS depressants. That withdrawal symptoms may occur; nausea, vomiting,
cramps, fever, faintness, anorexia.
patient is on long-term therapy; presence of blood or albumin indicates nephritis. Blood
studies: CBC, PT if patient is on long-term therapy. I&O ratio; decreasing output may
indicate renal failure (long-term therapy). For fever and pain: type of pain, location,
intensity, duration. For chronic poisoning: rapid, weak pulse; dyspnea; cold, clammy
extremities; report immediately to prescriber. Hepatoxicity: dark urine; clay-colored stools;
yellowing of skin, sclera; itching, abdominal pain; fever; diarrhea if patient is on long-term
therapy. Allergic reactions: rash, urticaria; if these occur, product may have to be
discontinued. Administer: PO ROUTE crushed or whole; chewable tabs may be chewed;
give with full glass of water. With food or milk to decrease gastric symptoms if needed.
Suspension after shaken well. Perform: storage of suppositories <80o F (27oC). evaluate:
therapeutic response: absence of pain using pain scoring; fever. Teach: not to exceed
recommended dosage, acute poisoning with liver damage may result. That acute toxicity
includes symptoms of nausea, vomiting, abdominal pain; prescriber should be notified
immediately. That toxicity may occur when used with other combination products. Not to
use with alcohol, herbals without approval of prescriber. To recognize signs of chronic
overdose, bleeding, bruising, malaise, fever, sore throat. To notify prescriber of pain or
fever lasting over 3 days.
GENERIC NAME: promethazine TRADE NAME: phenadoz, phenergan, promethazine
HCl
CLASSIFICATION: antihistamine, h1-receptor antagonist
USES: motion sickness, rhinitis, allergy symptoms, sedation, nausea, preoperative and
postoperative sedation
DOSAGE & ROUTE: nausea – adult: PO/IM/IV/RECT 12.5-25 mg q4-6hr prn. Child >2:
PO/IM/IV/RECT 0.25-0.5 mg/kg q4-6hr prn. Morning sickness – adult: PO 25mg bid, give
½-1hr before departure and q8-12hr prn. Child >2: PO/IM/RECT 12.5-25 mg bid, give 1/2
-1 hr before departure and q8-12hr prn. Allergy/rhinitis – adult: PO 12.5 mg qid, or 25 mg
at bedtime. Child >2: PO 6.25-12.5 mg tid or 25 mg at bedtime. Sedation – adult: PO/IM
25-50 mg at bedtime. Child >2: PO/IM/RECT 12.5-25 mg at bedtime.
SIDE EFFECTS: CNS: dizziness, drowsiness, poor coordination, fatigue, anxiety, euphoria,
confusion, paresthesia, neuritis, EPS, neuroleptic malignant syndrome. CV: hypo-
hypertension, palpitations, tachycardia. EENT: blurred vision, dilated pupils, tinnitus, nasal
stuffiness; dry nose, throat, mouth; photosensitivity. GI: constipation, dry mouth, nausea,
vomiting, anorexia, diarrhea. GU: urinary retention, dysuria, frequency. HEMA:
thrombocytopenia, agranulocytosis, hemolytic anemia. INTEG: rash, urticaria,
photosensitivity. RESP: increased thick secretions, wheezing, chest tightness, apnea in
neonates, infants, young children.
NURSING CONSIDERATIONS: assess: I&O ratio; be alert for urinary retention,
frequency, dysuria; product should be discontinue. CBC during long-term therapy; blood
dyscrasias may occur. Respiratory status; rate, rhythm, increase in bronchial secretions,
wheezing, chest tightness. Cardiac status: palpitations, increased pulse, hypo-hypertension,
VS. administer: avoid use with other CNS depression. PO ROUTE with meals for GI
symptoms; absorption may slightly decrease. When used for motion sickness, 30-min-1hr
before travel. IM ROUTE IM inj deep in large muscle; rotate site. IV ROUTE: do not use if
precipitate is present. Rapid administration may cause transient decrease in B/P. after
diluting each 25-50 mg/9ml of NaCl for inj; give 25mg or less/2 min. perform: hard candy,
gum, frequent rinsing of mouth for dryness. Storage in tight, light-resistant container.
Evaluate: therapeutic response:: absence of running, congested nose; rashes; absence of
motion sickness, nausea; sedation. Teach: that product may cause photosensitivity; to avoid
prolonged sunlight. To notify prescriber of confusion, sedation, hypotension, jaundice, fever.
To avoid driving, other hazardous activity if drowsy. To avoid concurrent use of alcohol
 SCHEDULED MEDICATION PRN MEDICATION
Senna 8.6mg tab Acetaminophen 325mg tab
(senna) (acetaminophen)
Dose: 17.2mg (2 tab) PO bid Dose: 650mg (2 tab) PO q6hr
Fentanyl 25mcg/hr patch Acetaminophen 650mg sup
(duragesic) (acephen)
Dose: 25 mcg/hr TOP q72hr Dose: 650mg (1 sup) PR q6hr
Docusate 100 mg/10ml cup Promethazine 25mg tab
(docusate sodium) (promethazine HCl)
Dose: 250mg (2.5 cup) PO bid Dose: 25mg (1 tab) PO q6hr (nausea/vomiting)
Morphine concentrate 20mg/cc Morphine 30mg/30ml syringe
Dose at 5mg (0.25cc) PO q1hr (morphine 1mg/ml vial P/F)
PRN for pain or dyspnea Dose: 30mg (30mg syringe) pump
Decadron 4mg PO bid
Only give Decadron IV route as ordered above if patient cannot take PO
Decadron