Daily Nursing Process Plan

NUR 248
Date of Care: 10/28/15 Pt. Initials: KM Age: 40 Room #: 270 #2 EDC: Date/Time of Delivery: 10/28/15 Gestation: 39 1/7
Pre-Delivery: G: 3 P: 2 (T: 2 P: 0 A: 0 L: 2);
Post-Delivery: G: 3 P: 3 (T: 3 P: 0 A: 0 L: 3)
Pregnancy History: 2 living children delivered via C/S, IUGR, Placenta Previa Type of Delivery: C/S
Reason: Repeat
Wt: 125 Ht: 5 2
Diet: Regular
Appetite: Good
Formula/Breast/Frequency: Breast/On demand
Admitting Diagnosis: Repeat C/S
LMP: 1/25/15
Allergies: KNDA
Surgical Procedure (C/S, Episiotomy, Laceration, Anesthesia,): C/S L-transverse, spinal with astromorph
PMH/PSH/Social/Family: (include childhood medical hx): 2 prior term C/S (2009,2011), Abnormal Pap, LEEP (2003), Prior HX of
IUGR, Placenta Previa, (-)ETOH, (-)smoking, declined amnio with current pregnancy
Labor Hx: 3 term deliveries via C/S Planned/Unplanned Pregnancy: Planned
Pre/Post Delivery weight: 56.82 kg (125 lbs) /64.09 kg (144 lbs) Weight gain: 8.64 kg (14 lbs)
Immunization Profile: no immunizations on file, Rubella titer non-immune Activity: Bedrest X 24 hours until d/c F/C then OOB as
tolerated
Vital Signs: T: 99.4 Pulse: 80 Apical: N/A RR: 18 B/P: 102/56 SaO2: 98% on RA Pain Scale: 7 on 1-10 scale
IV: Cefazolin 2g/50ml Dextrose IVPB, Peripheral IV Left forearm, 18g, 10/28/15, 08:00 (Solution, Site, Gauge, Date, Time)
Intake: 500 cc Output: 500 cc Foley Catheter: Yes, patent, draining clear, yellow urine Drains: N/A
SUBJECTIVE/OBJECTIVE ASSESSMENT: Circle and describe Clients Stressors
Include positive and significant negative findings. (GIVE DETAILED DATA)
BUBBLE HE
Safety:
B
S: Pt States I am comfortable and have everything I need
Breasts are smooth, even in color, symmetrical, soft and tender to
O: Room free of obstacles, bed in lowest position, call bell
touch. Nipples supple and pigmented. Mom is nursing on demand
within reach
and wearing a supportive nursing bra.
Mood/Affect/Emotions:
U
S: Positive mood, normal affect, some liability may be noted
Uterus is firm and at U
post-partum due to fatigue and hormone fluctuation
O: Pt appears calm with fatigue, normal affect, emotions
WNL, pleasant conversation with nurse and visitors
Neurological:
B
S: A&O X3, Responsive, answering all questions
F/C in place and patent draining clear yellow urine, I (=) O, (-) C/O
appropriately, (-) c/o headache or blurred vision
pain, bladder not distended
O: A&O X3, PERRLA, Pulse, Motor, Sensory intact in all 4
extremities, strength equal bilaterally
Respiratory:
B
S: Airway patent, no S/S of distress
(+) Bowel Sounds X 4 Quads, ABD soft, tender from surgical
O: Airway patent, no S/S of distress, L/S = and clear bi-lat,
incision X 4 quads, pt reports that she is passing gas, (-)
(-)SOB, (-)accessory muscle use, RR=18, SpO2 98% on RA
hemorrhoids, medicated for surgical pain and cramping per MD
order
Cardiovascular:
L
S: B/P stable and WNL, Pulse regular and WNL
Lochia moderate rubra, (-) foul smell
O: B/P 102/56, Pulse 80, (-) chest pain, skin pink, dry, and
warm
Peripheral Vascular:
E/I (episiotomy, laceration, incision)
S: Extremities should be pink, dry, and warm showing
C/S incision is clean, dry, and intact. Edges are well approximated
perfusion WNL
and closed with surgical glue, Dry protective dressing covering
O: Extremities appear pink, dry, and warm, (+)peripheral
incision with abdominal binder in place, (-) discharge, (-) odor, (-)
pulses in all 4 extremities, capillary refill > 2 sec in all 4
S/S of infection
extremities, flotrons in place
Epidural site (-) S/S of leakage, dressing is clean, dry and intact
Gastrointestinal:
H
S: Pt reports 7 out of 10 pain on 1-10 pain scale, pain is
Passive dorsiflexion performed (-) pain in calf or legs, (-) difference
described as achy and crampy Pt also states I have passed
in color or temperature of lower extremities, (-) redness, (-)
gas but have not yet had a bowel movement.
swelling, (-)pain upon palpation, pt encouraged to perform active
O: pt consumed all of dinner, 0 c/o N/V, (+) bowel sounds X 4 ROM exercises while on bedrest, Flotrons in place
quad, Abd soft but tender from surgical incision X 4 quads,
medicated for pain per MD order
Genitourinary:
E
S: F/C inserted prior to C/S, (-)c/o pain
Pt is calm, resting, holding newborn and conversing pleasantly with
O: F/C patent and draining yellow, clear urine, 500 cc drained
husband and nurse. Pt reports this is her third child and she is
from foley bag
comfortable giving care. Pt reports a positive support system in her

husband and family.

Gynecological History:
Birth Control: None STI's: No Hx of STIs
PAP date: 1/5/2015
Infertility: No Hx of Infertility
Musculo-Skeletal:
S: Pt still on bedrest s/p C/S
O: ROM in all extremities WNL, pt able to turn and position
on her own, (-) c/o abnormal sensation throughout body, (+)
pain in abdomen upon exertion around site of incision,
medicated per MD order with (+) effect
Skin, Hair, Nails:
S: Skin intact, hair and nails clean and intact
O: Skin intact 0 breakdown noted, hair and nails clean and
intact, some dry areas noted moisturizing cream applied

Daily Nursing Process Plan

List All Medications (Complete Order) * Include Labor & Delivery Medications. Work up at least 5
medications for the mother and 3 for the newborn. Complete Page 16 for each medication that you work up.
Mother:
Fentanyl (Sublimaze) 0.05mg/mL injection
Morphine (PF) (Duramorph) 1mg/mL injection
Lactated ringers bolus IV bolus 1000mL 500ml/hr
Oxytocin (Pitocin) 20 units in 1000mL NACL IV infusion (Post Delivery) 125mL/hr, Continuous
Cefazolin (Ancef/Kefzol) 2g/50mL Dextrose IVPB at 100mL/hr Q8H First dose on Wed 10/28/15 at 1800, for 2 doses, Postpartum,
Administer first dose 8 hours after pre op dose
Acetaminophen (Tylenol) tablet 650mg, oral, every 4 hours, PRN, mild pain (1-3)
Ibuprophen (Advil/Motrin) tablet 600mg, oral, every 6 hours, PRN, mild pain (1-3)
Morphine sulfate injection 5mg, Subcutaneous, every 3 hours, PRN, severe pain (7-10)
Oxycodone immediate release (Roxicodone) tablet 10mg orally, every 3 hours, PRN, severe pain (7-10)
Naloxone (Narcan) injection 0.2mg, Intravenous, every 2 minutes, PRN, respiratory rate less than 8 per minute
Baby:
Vitamin K injection, IM, 0.5mL within 1 hour of birth
Recombivax HB injection, IM, 0.5mL after birth with parental consent
Erythromycin Ointment 0.5% ointment, place a thin ribbon in conjunctiva of both eyes, within 1 hour of birth
Diagnostic Tests, Procedures, Treatments, Dressings:
CBC, Type and Cross, H&H
C-section, closed with surgical glue, covered with dry protective dressing and abdominal binder
18g peripheral IV, left forearm, covered with tegaderm
Foley Catheter inserted prior to C/S
Laboratory Results
Labs
Pregnancy
Values
RBC
N/A

Post Delivery Expected Values Explain Abnormal Lab Values

Values
4.39
3.70-5.30x10(6)/mcl

Hgb

N/A

11.9

11.2-15.4 gm/dL

Hct

N/A

35.6

34.0-47.0%

Platelets

N/A

234

150-400 x 10(3)/mcL

WBC

N/A

7.6

3.7-11.1 x 10(3)/mcL

Type & Rh

O+

O+

N/A

Non-reactive

Non-reactive

RPR or VDRL Non-reactive

GBS status
Rubella titre

Negative
Negative
Non-Immune Non-Immune

Negative
Immune

HepBsAg

Negative

Negative

Negative

HIV
U/A
Drug Level

Negative
Negative
Negative

Negative
Negative
Negative

Negative
Negative
Negative

Other

Mother needs MMR vaccine prior to discharge

Daily Nursing Process Plan

Client/Parent Teaching Topics (Include health education/prevention & areas of knowledge deficit in preparation
for discharge)
C-Section Care: Keep your C Section site dry. Pat dry if wet after shower. Do not use soap on incision line.
C-Section Care: Try hugging a pillow or use your hands to splint your incision to cough, sneeze or laugh.
C-Section Care: Call your physician for a fever, foul odor, discharge, redness, swelling or separation of incision line.
Lochia / Vaginal Discharge: Your lochia will change and may last up to 4-6 weeks.
Engorgement: Use warms soaks before feedings. Use ice packs between feedings to reduce swelling
Engorgement: Supplement with pumping your breasts after nursing as needed.
Rest, Fatigue and Exercise: Take naps when able (rest when your baby is napping) Allow others to help you to rest.
Rest, Fatigue and Exercise: Dont attempt any kind of exercise after a C Section until your physician says it is ok, limit
stairs
Emotional Adjustments: After your baby is born, your bodys estrogen and progesterone levels drop dramatically. This
decrease can cause noticeable changes, such as mood swings, hair loss and night sweats.
Emotional Adjustments: Postpartum Depression (PPD) - inability to take care of yourself or baby and inability to do
every day things. Treatable with counseling and medication (call your physician if you have these symptoms).
Nurses Note:
Pt KM recd at 17:30 DD s/p repeat C/S (3), G3P3 (T3, P0, A0, L3) pt is A&O X3, Breasts are symmetrical and soft,
nipples supple, Uterus is firm at U and at midline, Abdomen is soft and tender in area of c/s, (+) bowel sounds X 4
quads, (+) flatus, (-) bowel movement this shift, F/C in place and patent draining clear yellow urine; 500 cc this shift,
Lochia MR (-) odor, surgical incision is covered with dry dressing covered by abdominal binder (-) drainage, (-) odor,
clean, dry, and intact. Epidural dressing is in place clean, dry, and intact. Extremities (-) for S/S of DVT, (-) edema, (+)
pulses in all 4 extremities, (-) pain with dorsiflexion, pt appears calm and relaxed talking with family members. B/P
102/56, HR 80 and regular, RR 18, Temp 99.4 F, Spo2 98% on RA, Pt on regular diet consumed 100% of dinner tray,
KM is on bedrest until F/C is d/c; 18 gauge IV patent in peripheral L forearm antibiotics running IVPB at this time,(-)
S/S of adverse reaction.. Pt reported pain of 7 on 0-10 scale at the beginning of shift medicated with 600 mg
Ibuprophen and 10 mg Roxicodone per MD order with (+) effect, pt. states her pain level is now a 2 on 0-10 pain scale.
BBM T-98.2 F, P-50 apical, RR-50; BBM had 2X wet diapers this shift and 1 stool; baby is breastfeeding on demand, last
fed at 18:00, 15 minutes on each breast, Taught pt importance of reporting pain prior to it getting to a level 7, teaching
received well. No other significant events this shift.

Signature and Credentials: Jennifer Altenburg, Nursing Student, SCCC-Grant campus

Priority List for Mothers Nursing Diagnoses in PES Format (List min 5/max 10)
Work up 3 nursing diagnoses for mother. See page 12.
1) R/F Bleeding R/T surgical incision and postpartum complications.
2) Acute Pain R/T surgical incision AEB pt states my pain is a 7 on a pain scale 0-10.
3) R/F infection R/T surgical incision.
4) R/F constipation R/T opioid analgesics AEB hypoactive bowel sounds
5) Effective breastfeeding R/T maternal confidence AEB mom putting baby to breast with effective
LATCH
Priority List for Newborns Nursing Diagnoses in PES Format (List 5)
Work up 3 nursing diagnoses for the newborn. See page 13.

1) Ineffective thermoregulation R/T immaturity and lack of subcutaneous fat AEB need for an infant warmer
with a temp of 37 C.
2) Nutrition, Imbalanced: Less than body requirements R/T limited nutritional and fluid intake AEB
insufficient wet diapers.
3) R/F infection R/T circumcision.
4) Impaired skin integrity R/T loose stools AEB excoriation of buttocks.
5) Acute pain R/T circumcision AEB crying when surgical area is cleansed.

Daily Nursing Process Plan

Actual Nursing Diagnosis

Include Actual & Risk for.
Place in priority order in PES
format

5 Interventions for each Nursing Dx with

Scientific Rationales

Dx #1:
R/F Bleeding R/T surgical incision
and postpartum complications.

1) Assess vital signs for S/S of shock

(hypotension, decreased pulse pressure,
tachycardia, delayed cap refill, cool
clammy skin)
Rationale: Assessment findings reveal
cardiovascular status, degree of
hemorrhage, and results of therapeutic
adjustments r/t fluid replacement needs.
2) Collect blood specimen for CBC and
type and cross per agency protocol and
HCP directive.

Short Term Goal:

Patient will remain
hemodynamically stable with no S/S
of hemorrhage or shock.
GOAL MET

Rationale: This action anticipates the need

for fluid volume replacement therapy as
soon as it is available.
3) Administer prescribed fluids through
large caliber IV
Rationale: Ringers lactate or isotonic
solution is given to replace blood loss.
4) Monitor blood loss by checking lochia
and surgical incision.
Rationale: More than 3 soaked pads on one
hour are indicative of more than 500mL
blood loss.
5) Measure urine output hourly

Dx # 2:
Acute pain R/T surgical incision
AEB pt states my pain is a 7 on a
1-10 pain scale

Short Term Goal:

Within 1 hour of intervention the
patients subjective perception of
pain is at an acceptable level, AEB a
report of no more than 2-3 on a 0-10
scale; objective measures such as
grimacing are diminished or absent.
GOAL MET

Rationale: Low urine output reflects

inadequate intravascular volume and
decreased renal perfusion.
1) Assess duration and type of pain,
characteristics (intensity, quality, onset,
alleviating or aggravating factors, severity
by a standard pain scale and location.
Rationale: Characteristics and location of
pain indicate cause. Some treatments (e.g.
C/S) cause pain.
2) Monitor patient for behavioral signs of
pain and obtain a verbal report q2h.

Write One Evaluation for Each

Intervention

1) VS taken q2h remained within normal

limits.

2) CBC collected and type and cross

completed.

3) 18 gauge IV placed in L forearm,

lactated ringers running per MD order, IV
patent.
4) Lochia and surgical incision monitored
no significant blood loss.

5) Urine output is consistent with fluid

intake.

1) Pt states pain level is a 7 on a 0-10

scale, pain is crampy, constant, and
aggravated by moving

2) Pt shows no behavioral indicators of

pain, appears relaxed and calm talking to
family. Pt states my pain level is a 2 on a
0-10 scale 1.5 hours after medication.

Rationale: Changes in pain indicate

improvement in condition or development
of complications. Behavioral and
physiologic responses clarify presence of
pain when patient is unable to self-report
pain.
3) Position for comfort; promote position
changes q-30 min while patient is awake
Rationale: Frequent position changes
increase comfort and circulation and relieve
fatigue.
4) Teach and assist with appropriate

3) Pt placed in POC and instructed to

change positions every 30 minutes.

4) Taught husband how to massage patients

Pre/Post-Conference Diagnoses/Collaborative Problems: Add additional pages if necessary. Newborn

Date of Care: 10/28/15 Pt. Initials: BBM Age: 0 Days Room No.: 270 #2 Date/Time of Delivery: 10/28/15 08:56
Gender: Male
Apgar: 9/9
Birthweight: 3249 gms. 7 lbs. 2.6 oz.
Length: 48.3 cms 19 inches
T: 98.2
AP: 140
RR: 50
Skin color: Pink
Gest Age: 39 1/7
Stooling Pattern:
N/A
Voiding Pattern: wet diapers
Umbilical Site: clean, dry, intact Circumcision Site: N/A Voided after Circ: N/A
Blood Type: O
Rh: +
Coombs: Negative
Glucose Monitoring: N/A
Feeding (circle one or both): Breastfeeding / Formula Time on each breast per feeding: 15 minutes on breast, tolerated
well
Amount of Formula taken & tolerated: N/A
Frequency: N/A
Time of last feeding: 18:00
Abnormal Findings: None Sleeping: No. of hours in 24 period: N/A Neonatal Abstinence Score (if applicable): N/A
Labs
Expected
Newborn
Interpretation of Abnormal Values
Values
Values
Glucose
30-100
88
N/A
Type & Rh
N/A
O+
N/A
Total Bilirubin
5 and below
2.4
N/A
Direct/Indirect Bilirubin
0.3-1.9
0.4
N/A
Medications: Complete Page 16 for each medication. Include: Hepatitis B vaccine; Erythromycin Ointment;
Vitamin K
Pre/Post Conference Diagnoses/Collaborative Problems
Actual Nursing Diagnosis
Include Actual & Risk For
Place in priority order in PES format

5 Interventions for each Nursing Dx

Write One Evaluation for Each

Intervention

Dx #1:
Ineffective thermoregulation R/T
immaturity and lack of subcutaneous fat
AEB need for an infant warmer with a
temp of 37 C (98.6 F)

1) Assess axillary temperature at birth and

when indicated (q 4 hours).

1) Axillary temperature indicates newborns

temperature is 98.2 F.

Short Term Goal:

Client will maintain temperature in
normal range without the assistance of
warmer.
GOAL MET

Rationale: Axillary temperature is

preferred to avoid risk of rectal perforation.
Assessment provides information about
neonates temperature regulation.
2) Make sure newborn wears hat and is
wrapped in warm blankets when not in
isolate.
Rationale: Newborns lose most of their
heat through their head, so hats and warm
blankets should always be utilized when
outside the warmer.
3) Encourage skin to skin contact.
Rationale: The AAP recommends that
healthy infants be placed and remain in
direct skin to skin contact with their
mothers immediately after delivery until
the first feeding is accomplished. Such
contact provides the infant optimal
physiologic stability and warmth.
4) Maintain room temperature and avoid
rapid temperature changes with infant.
Rationale: If no heat conservation
measures are initiated, the normal term
newborns core temperature falls 0.1C per
minute, skin temperature decreases 0.3C

2) Newborn is wearing hat, onsie, and is

swaddled in facility blanket.

3) Upon birth newborn was placed on

moms chest immediately.

4) Thermostat in room reads 72 degrees F.

Dx #2: Nutrition, Imbalanced: Less than

body requirements R/T limited
nutritional and fluid intake AEB
insufficient wet diapers.

Short Term Goal: Newborn will latch

well to breast with on demand feedings.
NB will feed and void within normal
parameters.
GOAL MET

per minute. Skin temperature markedly

decreases within 10 minutes after exposure
to room air.
5)Avoid placing infant on cool surfaces or
using cold instruments in assessment (e.g.
scale, stethoscope)
Rationale: Placing the infant on a cool
surface or using cool instruments increases
heat loss by conduction.
1) Encourage early and frequent
breastfeeding
Rationale: An on-demand feeding
program facilitates each babys own
rhythm and helps the new mother establish
lactation.
2) Monitor Intake and Output per facility
flowsheet.

Rationale: Recording the newborns

caloric and fluid intake ensures adequate
hydration

Daily Nursing Process Plan continued

5) Assessment was performed in radiant

warmer with warmed instruments.

1) Newborn put to breast immediately after

birth.

2) Intake and Output is monitored on chart

keep on newborns isolate.

Actual Nursing Diagnosis

Use Actual & Risk For. Place in
priority order in PES format

5 Interventions for each Nursing Dx with

Scientific Rationales
3) Perform daily weights.
Rationale: Weight loss of up to 10% for the
term newborn is considered normal during
the first week of life. Weight loss is a result
of limited intake, loss of excess cellular
fluid, and passage of meconium.
4) Collaborate with dietician as needed

Dx #3: R/F infection R/T circumcision.

Short Term Goal: Newborn will

remain free of infection during duration
of hospital stay.
GOAL MET

Rationale: Nutritional assessment will

include parameters to measure wellness and
is an effective strategy for increasing
breastfeeding rates.
5) Teach proper Latch techniques.
Rationale: Each breastfeeding mother
should have a breastfeeding evaluation to
determine any knowledge deficits,
acknowledge any concerns, provide
instructions, and assist with breastfeeding.
1) Assess temperature every 4 hours
Rationale: Temperature of up to 38C
(100.4 F) for 48 hours after surgery is
related to surgical stress; after 48 hours
temp greater than 37.7 C (99.8 F)
suggests infection.
2) Observe penis for signs and symptoms of
infection at each diaper change (e.g.
swelling, drainage, foul smell)
Rationale: Early detection of infection can
prevent generalized sepsis from occurring.
3) Clean penis gently with warm water and
apply fresh sterile petroleum gauze with
each diaper change.
Rationale: Removes urine/feces from penis.
Excessive scrubbing may irritate the site
and provide entry for bacteria.
4) Administer local or systemic antibiotic as
ordered
Rationale: Treats infection; prevents
systemic involvement
5) Observe for appearance of white/yellow
exudate around the glans, do not remove.
Rationale: Exudate is usually noted 24-48
hours following circumcision, it is a normal
sign of the granulation (healing) process
and will disappear on its own.

Write One Evaluation for Each

Intervention
3) Newborn weighed at dinner time
each evening.

4) Newborn feeding and voiding well,

no consult needed at this time.

5) Newborn latching well.

1) Newborn temperature is 98.2 F.

2) Circumcision site is clean, dry, and

intact.

3) Penis is clean with sterile petroleum

gauze.

4) Newborn in infection free at this

time no need for antibiotics.
5) Penis has a small area of white
exudate on the glans.

NEWBORN ASSESSMENT TOOL (Due once during the course)

Student Name: Jennifer Altenburg Date & Time of Exam: 10/28/15 19:00 Babys Initials: BBM Sex: Male
Date & Time of Delivery: 10/28/15 10:38 Weeks Gestation: 39 1/7
Breast/Bottle/Both: Breast EDC: 1/25/15
TYPE OF DELIVERY
Normal Vaginal Delivery: N/A
Forcep: N/A
Vacuum: N/A
Primary C/S: N/A (Reason) Repeat C/S: Yes

CLASSIFICATION
Pre-Term: N/A
Post-Term: N/A
Term: Yes
SGA: N/A AGA: Yes LGA: N/A

VITAL SIGNS: Temp: 98.6 Apical HR: 158 Respirations: 40 ACTIVITY: Active/Alert: Lethargic: N/A
MEASUREMENTS:
Weight
3.249
Length
48.3
Head Circum 34

Gms
Cms
Cms

COLOR:
Pink: Pallor: N/A Ruddy: N/A Jaundice: N/A
Skin:
Acrocyanosis
Cyanosis
Dryness
Rash
Desquamation
Meconium stained
Petechiae

7 lb. 2.6 oz.

19
13.39

Lbs/ozs
Inches
Inches

Phototherapy: N/A
Mouth:
Lips intact
Soft Palate intact
Hard Palate intact
Symmetry
Pink mucosa
Other_____________

 Lanugo
Mongolian Spot
Other _____________
Head:
Normocep
Fontanels soft
(Circle One)
Fontanels: level depressed bulging
Molding
Cephalhematoma
Caput succedaneum
Forcep marks
Bruising
Overriding Sutures
Other_______________

Thorax:
Symmetry
Clavicles intact
Breath sounds (bilateral)
HR rhythm regular
Arrythmia
Murmur
Tachypnea
Grunting
Retractions
Other_______________

Eyes:
Conjunctiva pink
Cornea clear
Scleral hemorrhage
Other_______________

Abdomen:
Symmetry
3 vessel cord
Bowel sounds
Femoral pulses (bilateral)
Other______________

Ears:
Normal placement
Normal shape
Other_______________

Back:
Vertebral Column intact
Sacral Dimple
Other______________

Nose:
Nares Bilateral & Patent
Nasal Flaring
Milia
Other_______________

Neuro:
Lusty Cry
Tonus Normal
Stepping
Babinski
Suck
Swallow
Moro
Palmar
Plantar Grasp
Rooting
Other______________

Genitalia:
Male
Testes descended
Epispadias
Hypospadias
Hydrocele
Other ___________
Female
Vaginal Tag
Pseudomenstruation
Other___________
Extremities:

 Peripheral Pulses
Full hip rotation
Gluteal Folds
Symmetry of movement
Symmetry of limbs
Hip click
Other______________
Anus patent
Passed stool

Date/Time

Intake
Breast or bottle (amt
per feeding)

Voided

Void

Stool
(color)

*Please submit a separate sheet with the definitions of all the bolded terms and how the reflexes are performed
(separate sheet of paper typed)

NUR 248 Drug Evaluation Guide

Name: Jennifer Altenburg

Pt. Initials: KM

Date: 10/28/15

Clinical Assignment #: 270 #2

Drug Name: Cephazolin

Pregnancy Category: B

Generic Name: Ancef, Cefazolin Sodium

Classification: Antibiotic, Cephalosporin (first generation)
Action: Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin binding proteins
Indications for use: Surgical Prophylaxis
Pt. Dose: 2g/50 mL Dextrose
Route Prescribed: IVPB

Usual Dose: 250-1500mg every 6-12 hr (max 12g daily)

Alternate Routes available: IM

Schedule of Administration: Every 8 hours for 2 doses

Major Side Effects and Toxicity:
Use with caution in pt with history of pcn allergy, fever, rash, diarrhea, N/V, abdominal cramps, pain at injection
site. Cefazolin may increase the levels/effects of Fosphenytoin; Phenytoin; Vitamin K Antagonist
Nursing Implications (include patient assessments and pertinent lab data):
Asses results of C&S and pt allergy history prior to therapy. Assess anticoagulants pt may be taking for
potential interactions. Teach pt to report hypersensitivity, opportunistic infection, renal dysfunction and anemia.
Discuss specific use and S/E with patient as it related to treatment.
Contraindications and Precautions: Hypersensitivity to cefazolin sodium, any component of the formulation,
or any other cephalosporin.
Patient Education: Discuss specific use and S/E with patient as it related to treatment. Educate patient about
S/S of significant reaction. Have patient report immediately any signs of significant reaction.
Reason Why This Patient Is Taking Medication: Surgical Prophylaxis

NUR 248 Drug Evaluation Guide

Name: Jennifer Altenburg

Pt. Initials: BBM

Date: 10/28/15

Clinical Assignment #: 270 #2

Drug Name: Hepatitis B vaccine recombinant

Pregnancy Category: C

Generic Name: Recombivax HB

Classification: N/Vaccine/Immunization
Action: N/A
Indications for use: Active immunization against infection from all known subtypes of Hepatitis B virus
(HBV), primary pre-exposure prophylaxis against HBV, post-exposure prophylaxis when given with Hepatitis B
immune globulin (HBIG)
Pt. Dose: 5mcg/0.5mL

Usual Dose: 5mcg/0.5mL in a series of 3 doses over a 6 month period

Route Prescribed: Intramuscular injection in vastus lateralis

Alternate Routes available: None

Schedule of Administration: Once at birth, follow up at 3 and 6 months

Major Side Effects and Toxicity: soreness at injection site, diarrhea, irritability
Nursing Implications (include patient assessments and pertinent lab data):
Assess previous immunization history and h/o hypersensitivity
Assess for h/o latex allergy
Contraindications and Precautions:
Do not administer to individuals with a history of severe allergic or anaphylactic reactions
Hypersensitivity to yeast
Patient Education:
Patient may experience pain, redness or swelling at injection site. Educate parents about signs of significant
reaction and immediately report to prescriber severe injection site reaction.
Reason Why This Patient Is Taking Medication: To prevent Hepatits B infection and all know subtypes, to
protect newborn against disease

NUR 248 Drug Evaluation Guide

Name: Jennifer Altenburg
Date: 10/28/15
Drug Name: Tylenol

Pt. Initials: KM
Clinical Assignment #: 270 #2
Pregnancy Category: C

Generic Name: Acetaminophen

Classification: Analgesic, Antipyretic
Action: Reduces fever by acting on the hypothalamus to cause vasodilation and sweating
Indications for use: Treatment of mild-to-moderate pain and fever

Pt. Dose: 650 mg Q6H

Usual Dose: 325-650 mg Q4H, or 1000 mg Q6H

Route Prescribed: Oral

Alternate Routes available: IV, Rectal suppository

Schedule of Administration: every 6 hours

Major Side Effects and Toxicity:
Rash, nausea, anemia, hypersensitivity reactions, Excessive ETOH intake may increase the r/f acetaminopheninduced hepatotoxicity limit ETOH consumption to 3 drinks per day, rate of absorption may be decreased with
food
Nursing Implications (include patient assessments and pertinent lab data):
Assess pt for history of ETOH abuse. Ensure adult patients keep daily dose under 4g
Contraindications and Precautions:
Hypersensitivity to acetaminophen or any component of the formulation; severe hepatic impairment or severe
active liver disease
Patient Education:
Discuss specific use of drug and S/E as it relates to treatment. Pt may experience nausea. Educate pt abut signs
of significant reaction
Reason Why This Patient Is Taking Medication: Pain Relief

NUR 248 Drug Evaluation Guide

Name: Jennifer Altenburg
Date: 10/28/15
Drug Name: Advil/Motrin

Pt. Initials: KM
Clinical Assignment #: 270 #2
Pregnancy Category: C

Generic Name: Ibuprofen

Classification: Therapeutic: antipyretics, antirheumatics, nonopiod analgesics, NSAIDS
Action: Inhibits prostaglandin synthesis

Indications for use: Treatment of mild to moderate pain, fever

Pt. Dose:

600 mg

Usual Dose: 400-800 mg 3-4 daily (not to exceed 3200 mg/day

Route Prescribed: Oral

Alternate Routes available: IV

Schedule of Administration: every 6 hours mild pain (1-3)

Major Side Effects and Toxicity: GI Bleeding, constipation, diarrhea, stomach upset, exfoliative dermatitis,
Stevens - Johnson syndrome, Toxic epidermal necrosis, allergic reactions including anaphylaxis
Nursing Implications (include patient assessments and pertinent lab data):
BUN, serum creatinine, CBC, and liver function tests should be evaluated periodically
Assess pain, assess for S/S of GI bleed, assess for skin rash frequently, monitor temp, pt with
Asthma, aspirin induced allergy and nasal polyps are at increased r/f developing hypersensitivity
reactions.

Contraindications and Precautions:

Contraindicated in:
Hypersensitivity
Active GI Bleed or ulcer disease
Caution in:
Cardiovascular disease
Renal or hepatic disease
Aspirin triad patients
Chronic ETOH use/abuse
Coagulation disorders
Patient Education:
Take with a full glass of water
Take medication as prescribed
Caution that use of ibuprofen with 3+ glasses of ETOH increases r/f GI bleed
Reason Why This Patient Is Taking Medication: post-surgical pain relief
NUR 248 Drug Evaluation Guide
Name: Jennifer Altenburg

Pt. Initials: KM

Date: 10/28/15

Clinical Assignment #: 270 #2

Drug Name: Roxicodone

Pregnancy Category: C

Generic Name: Oxycodone

Classification: Therapeutic: opioid analgesic
Action: Binds to opioid receptors in the CNS. Alter the perception and response to painful stimuli, while
producing generalized CNS depression

Indications for use: Moderate to severe pain

Pt. Dose: 10 mg
Route Prescribed: Oral

Usual Dose: 5-10mg every 3-4 hours as needed

Alternate Routes available: Rectal

Schedule of Administration: Every 3 hours for severe pain (7-10)

Major Side Effects and Toxicity:
Confusion
Sedation
Respiratory Depression
Constipation
GI Upset
Overdose: opioid antagonist is required to reverse respiratory depression
Nursing Implications (include patient assessments and pertinent lab data):
Assess:
Type, location, and intensity of pain prior to and 1 hour after administration
B/P, Pulse, RR-before and periodically during administration; if RR is less than 10 assess level of
sedation
Bowel function frequently
Lab Tests:
May increase plasma and lipase levels
Toxicity:
If an opioid antagonist is required to reverse respiratory depression or coma, naloxone (Narcan)
is the antidote.
Contraindications and Precautions:
Contraindications:
Hypersensitivity to oxycodone, acetaminophen, ibuprofen
Caution:
Head trauma
Severe renal, hepatic, or pulmonary disease
H/O peptic ulcer disease
Hypothyroidism
Adrenal insufficiency
Alcoholism
Patient Education:
Instruct pt on how and when to ask for pain medication
Caution pt oxycodone is a potential drug of abuse
May cause drowsiness or dizziness
Advise pt to avoid concurrent use of ETOH or other CNS depressants with this medication
Reason Why This Patient Is Taking Medication: Severe post-surgical pain

NUR 248 Drug Evaluation Guide

Name: Jennifer Altenburg

Pt. Initials: KM

Date: 10/28/15

Clinical Assignment #: 270 #

Drug Name: Narcan

Pregnancy Category: B

Generic Name: Naloxone

Classification: Therapeutic; antidote for opioids

Action: Competitively blocks the effects of opioids, including CNS and respiratory depression, without
producing any agonist (opioid-like) effects
Indications for use: Reversal of CNS depression and respiratory depression because of a suspected opioid
overdose.
Pt. Dose: 0.2mg
obtained

Usual Dose: 0.02-0.2 mg q 2-3 minutes until response

Route Prescribed: IV

Alternate Routes available: IV, IM, SC, Nasal

Schedule of Administration: every 2 minutes until response obtained

Major Side Effects and Toxicity:
Ventricular Arrhythmias
Hypertension, Hypotension
N/V
Nursing Implications (include patient assessments and pertinent lab data):
Assess:
Monitor RR, rhythm, and depth, ECG, B/P, level of consciousness frequently
Pt receiving opioids less than 1 week are more sensitive to the effects of narcan
Assess pt for level of pain after administration, Narcan decreases respiratory depression but also
reverses analgesia.
Assess pt for S/S of opioid withdrawal
Contraindications and Precautions: Hypersensitivity
Patient Education: As medication becomes effective, explain purpose and effects of naloxone to pt.
Reason Why This Patient Is Taking Medication: Antidote if opioid pain relievers cause respiratory
depression

NUR 248 Drug Evaluation Guide

Name: Jennifer Altenburg

Pt. Initials: BBM

Date: 10/28/15

Clinical Assignment #: 270 #2

Drug Name: Vitamin K

Pregnancy Category: C

Generic Name: Phytonadione

Classification: Therapeutic: antidote, vitamins
Action: Required for hepatic synthesis of blood coagulation factors II (prothrombin), VII, IX, and X
Indications for use: Prevention of hemorrhagic disease of the newborn
Pt. Dose: 0.5 mL
Route Prescribed: IM

Usual Dose: 0.5-1 mg

Alternate Routes available: IM, SC

Schedule of Administration: 1 injection within 1 hour of birth (one dose)

Major Side Effects and Toxicity:
GI upset
Flushing, rash, uticaria
Pain at injection site
Allergic reactions
Nursing Implications (include patient assessments and pertinent lab data):
Monitor for frank and occult bleeding
Monitor for S/E and adverse reactions
Labs:
Monitor prothrombin time

Contraindications and Precautions:

Hypersensitivity
Hypersensitivity or intolerance to benzyl alcohol
Caution in impaired liver function
Patient Education:
Advise parents to report any S/S of unusual bleeding or bruising
Reason Why This Patient Is Taking Medication: This is a prophylactic injection to prevent hemorrhage in the
newborn which can occur because of low prothrombin levels in the first few days of life. The hemorrhage
potential is from the absence of gut bacterial flora which influences the production of vitamin K

NUR 248 Drug Evaluation Guide

Name: Jennifer Altenburg

Pt. Initials: BBM

Date: 10/28/15

Clinical Assignment #: 270 #2

Drug Name: Erythromycin Ointment

Pregnancy Category: B

Generic Name: Erythromycin Ointment

Classification: Therapeutic: anti-infective
Action: Suppresses protein synthesis at the level of the 50S bacterial ribosome.
Indications for use: Preventive treatment of gonorrhea in the newborn is required by law. Either bacteriostatic
or bactericidal, depending on the organisms involved or the concentration of the drug.

Pt. Dose:

0.5% 0.5 cm ribbon

Route Prescribed:

Ophthalmic ointment

Usual Dose: 0.5% 0.5-1 cm ribbon

Alternate Routes available: IV, PO

Schedule of Administration: Administer within 1 hour of birth

Major Side Effects and Toxicity:
Sensitivity reaction
May interfere with ability to focus
May cause edema and inflammation
Nursing Implications (include patient assessments and pertinent lab data):
Wash hands immediately before instillation to prevent introduction of bacteria
Do not irrigate eyes after instillation
Observe for hypersensitivity

Contraindications and Precautions:

Patient Education: Educate parents regarding side effects and signs to be reported and about the need for eye
prophylaxis

Reason Why This Patient Is Taking Medication: Preventive treatment of gonorrhea in the newborn. This is a
legal requirement to administer. The newborn may be infected by gonorrhea during delivery if the mother is
infected.