Name of the drug Lactulose (DUPHALA C)

Date ordered

Classification Osmotic Laxative

Dose frequency route

Mechanism of action Produces osmotic effect, which increases water content in colon and enhances peristalsis. Breakdown products in colon lead to acidification of colonic contents, softening of feces, and decreased ammonia absorption from colon to systemic circulation. These effects reduce blood ammonia level in portalsystem encephalopathy.

Specific indication Adjunct in the manageme nt of portalsystemic

Side effects belching, cramps, distention, flatulence,

Nursing implication BEFORE: -Assess pt. neurologic status, pulse rate, BP, respiratory status, before giving this medication. DURING: -Give this drug with food to decreases orthostatic hypotension. AFTER: -Monitor pt. for any sign of hepatic impairment (pruritus, dark urine or stools, anorexia, jaundice, pain).

Name of the drug

Date ordered

Classification

Dose frequency route

Mechanism of action

Specific indication

Side effects

Nursing implication

Clopidogrel 11/21/12 (PLAVIX) Antiplatelet

75mg od p.o.

Inhibits platelet aggregation by blocking ADP receptors on platelets, preventing clumping of platelets.

Treatment of pt. with acute coronary syndrome.

CNS Headache, dizziness, weakness, syncope, flushing. CV Hypertension, edema DERMA. Rash, pruritus GI Nausea, GI distress, constipation, diarrhea, GI bleeding. OTHER Increase bleeding risk

BEFORE: Assess pt. for any allergy to clopidogrel. DURING: Instruct pt. to avoid tasks that require mental alertness.

AFTER: Instruct pt. to report immediately if he experience skin rash, chest pain, severe headache, and abnormal bleeding.

Name of the drug

Date ordered

Classification

Dose frequenc y route

Mechanism of action

Specific indication

Side effects

Nursing implication

Spironolacto ne (ALDACTO NE)

11/21/12

Potassium Sparing Diuretic

25mg od p.o.

Competitively blocks the effects of aldosterone in the renal tubule, causing loss of sodium and water and retention of potassium.

Adjunctive therapy in edema associated with heart failure.

CNS Dizziness, headache, drowsiness, ataxia, confusion.

BEFORE: Check serum electrolytes of the pt.

DERMA. DURING: Rash, urticarial Instruct pt. to avoid foods that GI are rich in Cramping, potassium. diarrhea, dry mouth, thirst, vomiting. AFTER: GU Emphasize to pt. Impotence and family member to report HEMA. muscle cramps, Hyperkalemia, weakness, hyponatremia, nausea, agranulocydizziness, or tosis numbness.

NURSING CARE PLAN

Assessment Subjective: dili ko ganahan mo kaun kay lud-an ko.. ako ra isuka akong kinaun as verbalized by the patient. Nursing Diagnosis Deficite Fluid Volume Nursing Goal Nursing Intervention Rationale Outcome Criteria Evaluation

Scientific Basis: Objective: -weak -pale -poor skin turgor -delayed capillary refil (5 sec.) -hematy -sunken eyes

NURSING CARE PLAN

Assessment Nursing Diagnosis Subjective: Ineffective maglisud ko ug Airway ginhawa as Clearance verbalized by the related to pt. Increase mucus secretion secondary to Pulmonary congestion. Objective: -dyspnic -cough -rales -nasal flaring -use of O2 in Scientific Basis: breathing -RR=28cpm Congestion occurs mainly in the lungs from blood blocking up into pulmonary veins Nursing Goal After 3-4 hours of comprehensive nursing intervention patient will be able to improve or maintain clear airway. Nursing Intervention Independent: -monitored respiration and breath sounds, noting rate and sounds. Rationale Outcome Criteria 3-moderate tachypnea 2-mild tachypnea 1-normal RR 3-well ventilated 2-more ventilated 1-less ventilated 3-presence of both reflexes 2-presence of mild cough and gag reflexes 1-absence of both reflexes Evaluation

-indicate respiratory distress and accumulation of secretions.

-elevated head of -to enhance bed of the pt. ventilation

-evaluated cough/gag reflex and swallowing ability.

-to determine ability to protect airway.

and capillaries. (Lippincott Manual of Nursing Practice 8th Edition)

-encouraged deep breathing exercise.

-to promote lungs expansion.

3-lungs well expanded 2-lungs less expanded 1-lungs not expanded

Dependent: --administered -to treat medication as underlying prescribed by the conditions. doctor. -administered supplemental oxygenation at its prescribed dose. -to maintain respiratory rate at its normal range. 3-more treated 2-less treated 1-not treated 3

3-moderate tachypnea 2-mild tachypnea 1-normal RR

NURSING CARE PLAN

Assessment Subjective: wa ko tarung tulog tungod sa ako ubo ug tungod nga mag kisud ko ginhawaas verbalized by the pt. Objective: -restless -irritable -yawning V/S of T-37.4 c P-128bpm R-28cpm BP170/100mmhg -# of hrs of sleep=5 hrs. Nursing Diagnosis Disturbed sleeping pattern related to shortness of breath. Nursing Goal Nursing Intervention After 8 hours of -assessed sleep rendering disturbance that nursing care, pt. are associated will identify with underlying appropriate illness. interventions to promote sleep. -provided quit environment. Rationale -to identify causative factors. Outcome Criteria 3-more identified 2-less identified 1-not identified 3-well provided 2-less provided 1-not provided 3-well avoided 2-less avoided 1-not avoided 3-well established 2-less established 1-not established Evaluation 3

Scientific Basis: - Changes in environment health and routine combined with hospital routines interferes with patient normal sleep-wake pattern. Weakness and discomfort can continue to disrupt sleep. Other factors that contribute to sleep fragmentation include stimuli that tend to awaken people in the middle of the night. Internal stimuli such as discomfort are frequent disturbances. Any

-to promote sleep.

-encouraged limit intake of fluid in the evening. -arranged care to allow for uninterrupted periods of rest.

-to reduce need for night time awakening. -to help pt establish optimal sleep pattern.

-provide comfort

illnesses that cause physical discomfort can result in sleep problems. (www.nursingscrib.com)

measure such as -to promote back rub, hand sleep. washing. --administer medication as prescribed by the doctor. -administer supplemental oxygenation at its prescribed dose.

3-well provided 2-less provided 1-not provided

-to treat underlying conditions.

3-more treated 2-less treated 1-not treated

-to maintain respiratory rate at its normal range.

3-moderate tachypnea 2-mild tachypnea 1-normal RR