NURSING CARE PLAN

Date Cues Need Nursing Diagnosis Objective of Nursing Intervention Evaluation

and Care
Time
1/13/20 Subjective R Disturbed sleeping After 1 day of -Assess sleep pattern Goal partially met as
“ Putol E pattern related to nursing disturbances that are evidenced by:
putol akoa S interruptions for intervention the associated with the
tulog kay T therapeutics, patient will environment Patient verbalization of
taud2 naay monitoring and other achieve optimal (High percentage of “katulog ko gamay”
nurse o & generated awakening amount of sleep sleep disturbances can
doctor mag and excessive as evidenced by affect the recovery of Patient is more responsive
rounds” as S stimulation the patient)
verbalized L -Verbalization of -Do as much care as Absence of yawning
by the E Erb’s & Kozier’s feeling rested possible without
patient E Fundamentals of -Decrease the waking up the client
P Nursing presence of and do as much care
Objective (10th Edition) eyebags as possible while the
-Presence Physiologic -Absence of client is still awake
(To avoid disturbances
of eyebags Need Lack of sleep restlessness
during sleep, and to
- maximize the sleep
restlessness (Maslow’s Tiredness and rest of the client)
-yawning Hierarchy of
-Explain the
Needs)
Difficulty coping with necessity of
daily life disturbances for
monitoring vital
signs and care given
Low self esteem (For the patient to have
an understanding of
the importance of care
Feelings of worry
given to her and to also
and/or stress
minimize the
complaints)

NURSING CARE PLAN

51
Date Cues Need Nursing Diagnosis Objective of Nursing Intervention Evaluation
and Care
Time
1/13/2 Subjective: P Acute pain After 8 hours Independent: Goal met as evidenced by
0 “Sakit A related to of nursing • Monitor pain scale from 8/10 to
akoa I distention or interventions vital signs. 6/10
tiyan” as N rupture of , the patient • Monitor for
verbalized fallopian tube. will be presence and
by A relieved amount of vaginal
patient. V (Erb’s and Kozier’s bleeding.
O Fundamentals of Pain scale from • Monitor for
Objective: I Nursing 10th Edition) 8/0 decreased increase and pain
• Facial D to 6/10 and abdominal
mask A Previous ectopic pregnancy distention and
of pain. N rigidity.
Disruption of the tissue
• C especially in the fallopian
• Provide comfort
Guarding E tubes measure like
behavior. back rubs, deep
Physiologi Dysfunction of the cilia breathing.
which normally propels the
c Instruct in
fertilized ovum through the
Need tube onto the uterine cavity relaxation or
visualization
(Maslow’s Impaired tubal motility exercises.
Hierarchy Provide
Slows the movement of a
of Needs) diversional
fertilized egg through the
fallopian tube to the uterus activities.
• Provide
Fertilized egg attaches Diversional
or lodges to an area activities.
outside the uterus Collaborative:
• Administer
2-8 weeks after missed analgesics as
menstrual period, the indicated.
zygote grows large
enough

Tearing of the fallopian

52
tube

Sharp stabbing pain

Bleeding

NURSING CARE PLAN

53
Date Cues Need Nursing Diagnosis Objective of Nursing Intervention Evaluation
and Care
Time
1/13/20 Subjective S Self-care deficit in After a day of Assess patient’s Goal met as evidenced by
E hygiene related to nursing ability to bathe self
“ Dili man L activity intolerance intervention, through direct Trimmed nails
ko kaligo F the patient will observation. Nothing
kay (Erb’s and Kozier’s be able to specific deficits and Clean clothes
maglisud C Fundamentals of nursing perform their causes.
kog A 10th edition) personal (Use of observation of No unpleasant odor noted
tindog” R hygiene within function provides
As E level of own complementary Well combed hair
verbalized ability assessment data for goal
& intervention
by the D
planning)
patient E
F Instruct patient to
Objective I select bath time when
C she is rested and
Dirty I unhurried
clothes T (Hurrying may result in
noted accidents & the energy
Dorothea required for these
Long Orem activities may be
unpleasant substantial)
nails
Provide privacy
Unpleasant during
odor bathing/dressing as
appropriate
(The need for privacy is
fundamental for most
patients)

Encourage use of
clothing one size
larger
DETAILED DRUG STUDY

54
Generic Dosage Mechanism of Indication Contraindication Adverse Reaction Nursing Consideration
Name/ Frequency Action
Brand Name Route
Classificatio
n
ATROPINE Preanesthe Adjunct in Hypersensitivity CNS: Headache, • Monitor vital signs. HR
SULFATE sia Acts by symptomatic to belladonna ataxia, dizziness, is a sensitive indicator of
(a'troe-peen) Adult: selectively treatment of alkaloids; excitement, patient's response to atropine.
IV/IM/SC blocking all GI disorders synechiae; angle- irritability, Be alert to changes in quality,
Atropair , 0.2–1 mg muscarinic (e.g., peptic closure convulsions,
rate, and rhythm of HR and
Atropisol, 30–60 min responses to ulcer, glaucoma; drowsiness,
respiration and to changes in
Isopto before acetylcholine pylorospasm parotitis; fatigue,
Atropine surgery (ACh), , GI obstructive weakness; mental BP and temperature.
Child: whether hypermotilit uropathy, e.g., depression,
Classificatio IV/IM/SC excitatory or y, irritable bladder neck confusion, • Initial paradoxical
ns: <5 kg, 0.02 inhibitory. bowel obstruction disorientation, bradycardia following IV
AUTONOM mg/kg; >5 Selective syndrome) caused by hallucinations. atropine usually lasts only 1–2
IC kg, 0.01– depression of and spastic prostatic CV: min; it most likely occurs
NERVOUS 0.02 mg/kg CNS relieves disorders of hypertrophy; Hypertension or when IV is administered
SYSTEM 30–60 min rigidity and biliary tract. intestinal atony, hypotension, slowly (more than 1 min) or
AGENT; before tremor of Relaxes paralytic ileus, ventricular when small doses (less than
ANTICHOL surgery Parkinson's upper GI obstructive tachycardia, 0.5 mg) are used. Postural
INERGIC Arrhythmi syndrome. tract and diseases of GI palpitation,
hypotension occurs when
(PARA- as Antisecretory colon during tract, severe paradoxical
SYMPATH Adult: hypotonic ulcerative colitis, bradycardia, AV
patient ambulates too soon
action
OLYTIC); IV/IM 0.5– (vagolytic radiography. toxic megacolon; dissociation, after parenteral
ANTIMUSC 1 mg q1–2h effect) Ophthalmic tachycardia atrial or administration.
ARINIC prn (max: 2 suppresses Use: To secondary to ventricular
mg) sweating, produce cardiac fibrillation. GI: • Note: Frequent and
Child: lacrimation, mydriasis insufficiency or Dry mouth with continued use of eye
IV/IM salivation, and thyrotoxicosis; thirst, dysphagia, preparations, as well as
0.01–0.03 and secretions cycloplegia acute loss of taste; overdosage, can have systemic
mg/kg for from nose, before hemorrhage; nausea, vomiting, effects. Some atropine deaths
1–2 doses mouth, refraction myasthenia constipation, have resulted from systemic
Organopho pharynx, and and for gravis. Safety delayed gastric
absorption following ocular
sphate bronchi. treatment of during emptying, antral
administration in infants and
Antidote Blocks vagal anterior pregnancy stasis, paralytic
Adult: impulses to uveitis and (category C) or ileus. Urogenital: children.
IV/IM 1–2 heart with iritis. lactation is not Urinary hesitancy
55
mg q5– Preoperative established. and retention, Monitor I&O, especially in
60min until resulting Use: To dysuria, older adults and patients who
muscarinic decrease in suppress impotence. Skin: have had surgery (drug may
signs and AV salivation, Flushed, dry skin; contribute to urinary
symptoms conduction perspiration, anhidrosis, rash,
retention). Palpate lower
subside time, increase and urticaria, contact
abdomen for distention. Have
(may need in heart rate respiratory dermatitis,
up to 50 and cardiac tract allergic patient void before giving
mg) output, and secretions; to conjunctivitis, atropine.
Child: shortened PR reduce fixed-drug
IV/IM 0.05 interval. incidence of eruption. Special
mg/kg laryngospas Senses:
q10–30 min m, reflex Mydriasis,
until bradycardia blurred vision,
muscarinic arrhythmia, photophobia,
signs and and increased
symptoms hypotension intraocular
subside during pressure,
COPD general cycloplegia, eye
Adult: anesthesia dryness, local
Inhalation redness
0.025
mg/kg
diluted
with 3–5
mL saline,
via
nebulizer
3–4 times
daily (max:
2.5 mg/d)
, via
nebulizer
3–4 times
daily
Uveitis

56
DETAILED DRUG STUDY

Generic Dosage Mechanism of Indication Contraindication Adverse Reaction Nursing Consideration

Name/ Frequency Action
Brand Name Route
Classification

57
ATROPINE Preanesthesi Adjunct in Hypersensitivity CNS: Headache, • Monitor vital signs. HR is
SULFATE a Acts by symptomatic to belladonna ataxia, dizziness, a sensitive indicator of patient's
(a'troe-peen) Adult: selectively treatment of alkaloids; excitement, response to atropine. Be alert to
IV/IM/SC blocking all GI disorders synechiae; angle- irritability, changes in quality, rate, and
Atropair , 0.2–1 mg muscarinic (e.g., peptic closure glaucoma; convulsions, rhythm of HR and respiration and
Atropisol, 30–60 min responses to ulcer, parotitis; drowsiness, fatigue,
to changes in BP and temperature.
Isopto before acetylcholine pylorospasm, obstructive weakness; mental
Atropine surgery (ACh), whether GI uropathy, e.g., depression,
Child: excitatory or hypermotility, bladder neck confusion, • Initial paradoxical
Classification IV/IM/SC inhibitory. irritable bowel obstruction caused disorientation, bradycardia following IV atropine
s: <5 kg, 0.02 Selective syndrome) and by prostatic hallucinations. CV: usually lasts only 1–2 min; it
AUTONOMI mg/kg; >5 depression of spastic hypertrophy; Hypertension or most likely occurs when IV is
C NERVOUS kg, 0.01– CNS relieves disorders of intestinal atony, hypotension, administered slowly (more than 1
SYSTEM 0.02 mg/kg rigidity and biliary tract. paralytic ileus, ventricular min) or when small doses (less
AGENT; 30–60 min tremor of Relaxes upper obstructive tachycardia, than 0.5 mg) are used. Postural
ANTICHOLI before Parkinson's GI tract and diseases of GI palpitation, hypotension occurs when patient
NERGIC surgery syndrome. colon during tract, severe paradoxical
ambulates too soon after
(PARA- Arrhythmias Antisecretory hypotonic ulcerative colitis, bradycardia, AV
SYMPATHO Adult: radiography. toxic megacolon; dissociation, atrial
parenteral administration.
action
LYTIC); IV/IM 0.5–1 (vagolytic Ophthalmic tachycardia or ventricular
ANTIMUSC mg q1–2h effect) Use: To secondary to fibrillation. GI: Dry • Note: Frequent and
ARINIC prn (max: 2 suppresses produce cardiac mouth with thirst, continued use of eye preparations,
mg) sweating, mydriasis and insufficiency or dysphagia, loss of as well as overdosage, can have
Child: lacrimation, cycloplegia thyrotoxicosis; taste; nausea, systemic effects. Some atropine
IV/IM 0.01– salivation, and before acute hemorrhage; vomiting, deaths have resulted from
0.03 mg/kg secretions from refraction and myasthenia gravis. constipation, systemic absorption following
for 1–2 nose, mouth, for treatment Safety during delayed gastric ocular administration in infants
doses pharynx, and of anterior pregnancy emptying, antral and children.
Organophos bronchi. Blocks uveitis and (category C) or stasis, paralytic
phate vagal impulses iritis. lactation is not ileus. Urogenital:
Antidote Preoperative established. Urinary hesitancy Monitor I&O, especially in older
to heart with
Adult: resulting Use: To and retention, adults and patients who have had
IV/IM 1–2 decrease in AV suppress dysuria, impotence. surgery (drug may contribute to
mg q5– conduction salivation, Skin: Flushed, dry urinary retention). Palpate lower
60min until time, increase perspiration, skin; anhidrosis, abdomen for distention. Have
muscarinic in heart rate and rash, urticaria, patient void before giving
signs and and cardiac respiratory contact dermatitis, atropine.
symptoms output, and tract allergic
subside shortened PR secretions; to conjunctivitis,
(may need interval. reduce fixed-drug

58
up to 50 mg) incidence of eruption. Special
Child: laryngospasm, Senses: Mydriasis,
IV/IM 0.05 reflex blurred vision,
mg/kg q10– bradycardia photophobia,
30 min until arrhythmia, increased
muscarinic and intraocular
signs and hypotension pressure,
symptoms during general cycloplegia, eye
subside anesthesia dryness, local
COPD redness
Adult:
Inhalation
0.025 mg/kg
diluted with
3–5 mL
saline, via
nebulizer 3–
4 times daily
(max: 2.5
mg/d)
, via
nebulizer 3–
4 times daily
Uveitis

59
DETAILED DRUG STUDY

Generic Dosage Mechanism of Indication Contraindication Adverse Reaction Nursing Consideration

Name/ Frequency Action
Brand Name Route
Classification
Generic IV adults < Used for Documented >10% Assess respiratory status, pulse, and
55 yrs/old. involves a induction hypersensitivity, Hypotension (peds BP continuously throughout propofol
Propofol Induction positive and/or egg allergy, 17%; adults 3-26%) therapy. Frequently causes apnea
40mg q 10 modulation of maintenance soybean/soy allergy lasting ≥60 sec. Maintain patent
Brand name: seconds the inhibitory of Apnea lasting 30- airway and adequate ventilation.
Diprivan until function of the anaesthesia Cautions 60 sec (peds 10%;
Propofol should be used only by
induction neurotransmitte and for Drug vehicle adults 24%)
Classification achieved (2- management (emulsion) is individuals experienced in
r gama-
: 2.5mg/kg aminobutyric of refractory capable of Apnea lasting >60 endotracheal intubation, and
General total) acid (GABA) status supporting rapid sec (peds 5%; equipment for this procedure should
Anesthetics through epilepticus. growth of adults 12%) be readily available.
GABA-A microorganisms;
receptors. proper aseptic Movement (peds Assess level of sedation and level of
technique is 17%; adults 3-10%) consciousness throughout and
imperative following administration.
Injection site
Closely monitor burning/stinging/pa
When using for ICU sedation, wake-
patients with in (peds 10%;
anemia, hepatic adults 18%)
up and assessment of CNS function
impairment, should be done daily during
myxedema, or renal 1-10% maintenance to determine minimum
impairment Respiratory dose required for sedation. Maintain a
acidosis during light level of sedation during these
Risk of potentially weaning (3-10%) assessments; do not discontinue.
fatal propofol Abrupt discontinuation may cause
infusion syndrome Hypertriglyceridem rapid awakening with anxiety,
in ICU patients ia (3-10%) agitation, and resistance to mechanical
ventilation.
May cause Hypertension (peds
hypotension, 8%)
especialy if patient Monitor for propofol infusion
is hypovolemic or Rash (peds 5%; syndrome (severe metabolic acidosis,
if bolus dosing is adults 1-3%) hyperkalemia, lipemia,
used; reduction in rhabdomyolysis, hepatomegaly,
60
mean arterial Pruritus (1-3%) cardiac and renal failure). Most
pressure may frequent with prolonged, high-dose
exceed 30%; use Arrhythmia (1-3%) infusions (>5 mg/kg/hr for >48 hr) but
caution in patients has also been reported following large-
who Bradycardia (1-3%) dose, short-term infusions during
arehemodynamicall
surgical anesthesia. If prolonged
y unstable, Cardiac output
hypovelimic, or decreased (1-3%; sedation or increasing dose is required,
have abnormally concurrent opioid or metabolic acidosis occurs, consider
low vascular tone use increases alternative means of sedation.
incidence)
Use with caution in
patients with severe Tachycardia (1-3%)
cardiac disease
(<50% ejection <1%
fraction) or Arterial
hypotension; may hypotension
have more
profound adverse Anaphylaxis
cardiovascular
responses to Asystole
propofol
Bronchospasm

Cardiac arrest

Seizures

Opisthotic rxn

Pancreatitis

Pulmonary edema

Phlebitis

Thrombosis

Renal tubular
toxicity

61
62
DETAILED DRUG STUDY

Generic Dosage Mechanism of Action Indication Contraindication Adverse Reaction Nursing Consideration
Name/ Frequen
Brand Name cy
Classificatio Route
n
Generic Dosage: An antibiotic that Known or Penicillin Lethargy, hallucinations, >Assess bowel pattern before and
name: 1MG combines amoxicillin suspected hypersensitivity. seizures, glossitis, sore during treatment as pseudo
Co- q8 and clavulanic acid. amoxicillin- History of co- mouth, furry tongue, membranous colitis may occur.
Amoxiclav hours It destroys bacteria resistant amoxiclav- black “hairy tongue”,
PO by disrupting their infections associated or nausea and vomiting,
>Report hematuria or oliguria as
ability to form cell including penicillin- diarrhea, abdominal
walls. respiratory associated pain, bloody diarrhea,
high doses can be nephrotoxic.
tract, skin and jaundice or enterocolitis
soft tissue, hepatic >Assess respiratory status.
genitourinary, dysfunction.
Clavulanic acid and ear, nose >Observe for anaphylaxis.
blocks the chemical and throat
defense, known as infections. >Ensure that the patient has
beta-lactamase that Effective adequate fluid intake during any
some bacteria have against strains diarrhea attack.
against penicillin’s. of Escherichia
coli, Proteus
mirabilis,
Haemophilus
Co-amoxiclav is influenza,
active against Streptococcus
bacterial infections faecalis,
that have become Streptococcus
resistant to pneumoniae
amoxicillin. and some
beta-
lactamase-
producing
organisms.

63
DETAILED DRUG STUDY
Generic Dosage Mechanism of Action Indication Contraindication Adverse Reaction Nursing Consideration
Name/ Freque
Brand Name ncy
Classificatio Route
n
Celecoxib 400 mg Adjunctive - Hyperse CNS: Before:
OD Exhibits anti- treatment to nsitivity Dizziness, drowsiness, - Assess pt’s history of
Brand Name PRN inflammatory, decrease the to drug, headache, insomnia, allergic reaction to the
Celebrex analgesic and anti- number of sulfona fatigue drug
pyretic action due to adenomatous mides, - Monitor complete blood
inhibition of the colorectal or other CV:
count, electrolyte levels,
enzyme COX-2 polyps in NSAIDs Peripheral edema
familial - Severe creatinine clearance, and
adenomatous hepatic EENT: occult fecal blood test and
polyposis impairm Ophthalmic effects, liver function test results
ent tinnitus, pharyngitis, every 6 to 12 months
- History rhinitis, sinusitis
of During
asthma GI:
or Nausea, diarrhea, - Instruct patient to take
urticaria constipation, abdominal drug with food or milk
- Advanc pain, dyspepsia,
food or milk
ed renal flatulence, dry mouth
disease
- Teach patient to avoid
- Late Hematologic: aspirin and other NSAIDs
pregnan Decreased hemoglobin (such as ibuprofen and
cy naproxen) during therapy
- Breastfe
eding After:

- Advise patient to
immediately report bloody
stools, blood in vomit, or
signs or symptoms of liver
damage (nausea, fatigue,
lethargy, pruritus,
yellowing of eyes or skin,

64
tenderness on upper right
side of abdomen, or
flulike symptoms

65