NURSING CARE PLAN

Assessment Diagnosis Planning Interventions Rationale Evaluation

Objective: Alteration in comfort; After 45 minutes of nursing 1. Positioned patient - for relaxation Goal met, as
Grimaced face Pain r/t increased intervention, comfortably on evidenced by
RR= 24cpm Intracranial pressure the patient will be able bed. absence
PR= 112bpm Secondary to CVA. to establish reduction of facial grimace &
of pain by absence of 2. Provided cool & quiet - promotes vital signs are normal.
grimace face & v/s within normal environment. relaxation
range.
3. Intermittently massaged - for relaxation
the forehead.

4. Elevated head of the bed. - promote blood circulation

5. Turned patient at - for relaxation

intervals.

6. Meds given as ordered

- to reduce pain by pharmacologic
effect

7. v/s taken and recorded. - serves as baseline

data
Assessment Diagnosis Planning Interventions Rationale Evaluation
Objective: Altered tissue After 15mins. of nursing 1. Assessed for s/s of - Provides baseline Goal partially met,
BP= 140/100mmHG perfusion r/t intervention, the cranial pressure & data. no episode of seizure
interruption of blood patient will be able to effects of cerebral noted, & afebrile.
flow as evidenced by maintain tissue vasoconstriction.
BP of 140/100mmHg. perfusion as manifested - Promotes venous
by normal temperature 2. Elevated head of the return.
and (-)seizures. bed 30-40 degrees.

3. Promoted a quiet & - Decreased the

restful environment. need of oxygen &
glucose of brain
cells.

4. Observed signs of - To immediately implement

seizure. interventions
before the
occurrence.

5. Meds given as ordered. - To control blood pressure.

Assessment Diagnosis Planning Interventions Rationale Evaluation
Objective: Impaired physical After the shift, the 1. Repositioned client - To prevent Goal met, as
Limited ROM Mobility r/t occlusion patient will be able to every 2 hours pressure ulcer. evidenced by
of major cerebral maintain skin integrity maintenance of skin
Decreased Muscle arteries. by absence of decubitus. 2. Supported affected - To maintain integrity by absence
strength body parts with pillows. position of of decubitus.
function
& reduce risk of
pressure ulcers.

3. Provided safety - To prevent fall may

measures like use of cause injury.
Side rails.

4. Provided passive range - for good

of motion. circulation

5. Taught SO exercises & - to prevent further

techniques to improve balance & complications.
coordination.
 DRUG STUDY

Name of Drug Action Contraindication Adverse Reaction Nursing Considerations Patient Teaching
Generic name: Inhibits cell wall Contraindicated to CV: phlebitis, Before administration ask the Tell the patient to take
Cefuroxime Sodium synthesis, Patients hypersensitive Thrombophlebitis. patient if he or she is allergic to drugs as prescribed
promoting To other drugs and penicillins or cephalosporins . even after he feels better.
Brand: Zinacef oncotic Cephalosporins GI: nausea, anorexia,
Instability usually Vomiting, diarrhea. Obtain specimen for culture & Instruct the patient to take
Classification: bacteriacidal. Use cautiously in sensitivity test before oral form w/ food.
Anti-infectious patients Hematologic: giving first dose.
hypersensitive to Thrombocytopenia If suspension is being used tell
Category: penicillins. If doses are given patient to shake container well
Pregnancy Risk Skin: pain, therapy is prolonged before measuring dose.
category B temperature or patient is at risk.
Elevation Instruct the patient to notify
Dosage: Monitor for s/s of super prescribed about rash or
500 mg/cap q 8 Infection. evidence of super infection.

Tell patient to notify prescribes

about loose stools or diarrhea.
Name of Drug Action
Generic name: Sodium chloride is the
Sodium Chloride principle salt involved in
the maintenance of plasma
Classification: tonicity important for
Electrolyte maintaining plasma value
promoting membrane
Category: stability & electrolyte
Pregnancy Risk balance
category B
Contraindication
Contraindicated to
patients with
hypernatremia, fluid
retention, pregnancy,
any condition when
increase sodium or
chloride could be
detrimental,
bacteriostatic is
contraindicated in
newborns because of
associated toxicity.
Use cautiously with
impaired renal function
CHF, edematous or no
retaining, states lactation
or surgical patients.
Adverse Reaction Nursing Considerations Patient Teaching
GI: anorexia, nausea, Note for history o Take these tablets only as
abdominal distention f hypernatremia, fluid prescribed.
retention, pregnancy,
Hematologic impaired renal function, Have periodic blood tests
: hypernatremia, fluid CHF, edematous or sodium and medical evaluation.
overload retaining states lactation.
Wash hands before using
Local: optalmic preparation.
Chemical cellulitis
Tissue necrosis, Report irritability, confusion,
Ulceration sloughing at tremor, swelling of
site of infiltration, extremities, difficulty
pain at a site of reathing and black tarry
injection. stoo.l
Name of Drug Action Contraindication Adverse Reaction Nursing Considerations Patient Teaching
Generic name: Inhibits the action of Contraindicated with CNS: headache, malaise, Administer oral drug Take drug with meals at bedtime.
RANITIDINE histamine at the h2 allergy to ranitidine, dizziness, somnolence, with meals and at Therapy may
receptors of the lactation. insomnia, vertigo. bedtime. continue for
Classification: parietal cells of the 4-6 weeks or longer.
H2 blocker stomach, inhibiting Use cautiously with CV: tachycardia, bradycardia Decrease doses in
basal gastric acid impaired renal or hepatic renal and liver failure. If you are using antacid ,
Dosage: secretion and gastric function, pregnancy. GI: constipation, diarrhea, take it exactly
500 mg IV q 12 acid secretion that is nausea and vomiting, Provide concurrent as prescribed being
stimulated by food, abdominal pain hepatitis, antacid, therapy to careful of the time of
insulin, histamine, increased ALT levels. relive pain. administration.
cholinergic agonist,
gastrin, and GU: gynecomastia, Administer IM dose Report sore throat,
pentagastrin . impotence or decrease libido undiluted, deep into fever, unusual bruising or
large muscle group. bleeding, tarry stools,
confusin, hallucination,
Arrange for regular dizziness, severe headache,
follow up, including muscle or joint pain.
blood test to
evaluate effects .
Name of drug Actions Contraindications Adverse effect Nursing consideration Patient teaching
Mannitol Acts by increasing Active intracranial GU: dieresis, urinary Signs of metabolic To rise slowly
osmalarity of bleeding, retention, thirst. acidosis: drowsiness. from lying and sitting position.
Classification: glomelular hypersensitivity anuria,
Osmotic Diuretic filtrate which raises severe dehydration, CNS: dizziness, Signs of hypokalemia: The reason for and method of
osmotic pressure progressive heart, headache, convulsion, postural hypotension, treatment.
Dosage:75 cc of fluid in renal renal failure. rebound increase ICP malaise, fatigue,
tubules; decreases in confusion. tachycardia, leg cramps,
reabsorption weakness.
of water, electrolytes, GI: nausea and
increases in urinary vomiting, dry mouth, Rashes
output, sodium, diarrhea.
chloride excretion. Hydration including skin
CV: edema, turgor, thirst, dry mucous
thrombophlebitis, membranes.
hypotension,
hypertension,
tachycardia,
angina-like
chest pains, fever,
chills.

EENT: loss of hearing,

blurred vision, nasal
congestion, decrease
intraocular pressure.
Name of drug Action Contraindication Adverse reaction Nursing consideration Patient teaching
Aspirin Blocks pain impulses in Hypersensitivity to CNS: drowsiness, Give drugs with food or Take extra precautions to
CNS, inhibition of salicylates, tartrazine, dizziness, confusion, after meals if GI upset keep drug out of the reach
Classification: NSAID prostaglandin synthesis: bleeding disorders. convulsion, headache, occurs. of children, this drug can be
antipyretic action flushing, hallucination, very dangerous for children
Dosage:80 mg/tab OD results from vasodilation of coma. Give drug with full glass of
peripheral vessels, water to reduce risk of Use the drug only as
decreases platelet GI: nausea and vomiting, tablet or capsule suggested; avoid over dose;
aggregation. GI bleeding, diarrhea, lodging in the avoid the use of OTC drugs
heart burn, anorexia, esophagus. while taking this drug.
hepatitis.
Do not crush and Take drug with food or after
-EENT: tinnitus, ensure that patient meals if GI upset occurs.
hearing loss. does not chew SR
preparation.
CV: rapid pulse,
pulmonary edema. Do not use aspirin that
has a strong vinegar
like odor.
Name of drug Actions Contraindication Adverse effect Nursing consideration Patient teaching
GENERIC NAME: -reduces fever by Contraindicated with CNS: headache Give drug with food if GI Do not exceed
Acetaminophen acting directly on the allergy to upset occurs. recommended dosage.
hypothalamic Acetaminophen. CV: chest pain, Do not take for longer than 10
BRAND NAME: heat-regulating center to Dyspnea. Discontinue drug if days.
Paracetamol cause vasodilation Use cautiously with hypersensitivity
and sweating which impaired hepatic GI: hepatic toxicity reactions occurs. Take the drug only for complaints
Classification: helps dissipate heat. function, chronic alcoholism,
and failure, jaundice. indicated;
Analgesic/antipyretic pregnancy, lactation. Do not exceed it is not an anti inflammatory
GU: acute renal failure, renalrecommended dosage agent.
Dosage:500 mg IV tubular necrosis
Report rash, unusual
bleeding or bruising, yellowing
of skin or eyes changes in
voiding patterns.
Name of drug Actions Contraindication Adverse reaction Nursing consideration Patients teaching
GENERIC NAME: Exact mechanism Contraindicated with GI: anorexia, nausea Monitor urine or Do not discontinue this medication
Metformin hydrochloride is not understood; allergy to metformin; and vomiting, serum glucose levels without
possibly increases CHF, diabetes epigastric discomfort, frequently to consulting your health care
BRAND NAME: peripheral complicated by fever, heart burn, diarrhea, determine provider.
Glumet utilization of severe infections, flatulence. effectiveness of drug
glucose, decreases severe trauma, and dosage. Monitor blood for glucose and
Classification: hepatic glucose ketosis, acidosis coma ketones as prescribe.
Antidiabetic drug Production and
alters intestinal Do not use this drug for pregnancy.
absorption of
Dosage:500 mg 1 tab BID glucose. Avoid using alcohol while taking this drug.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Alteration in body After 15-30 minutes of 1. Temperature taken -serves as baseline data. Goal met, patients latest
May lagnat si mommy temperature: effective nursing and recorded. temperature is 37.4C.
as verbalized by the SO. hyperthermia r/t intervention, the
increase pyrogens in the patients body 2. Performed TSB. -heat loss through
Objective: body as manifested by temperature will conduction
T=38.7C skin warmer to touch. decrease from the
Skin warm to touch normal range 36.5- 3. Instructed SO to dress -heat loss through
37.5C. patient with light evaporation.
clothing.

4. Provided well -heat loss through

ventilated environment. radiation.

5. Administered
medication as ordered. -to decrease body
temperature through the
use of pharmacologic
agent.
Name of Drug Action Contraindication Adverse effects Nursing Considerations
GENERIC NAME: An interneuron Pararympathetic GI disorders somazine must not
Cithicoline communication enhancer. hypertonia be administered
It is neurotransmission level because it along with Medicaments
BRAND NAME: favors the synthesis and production speed of containing
Somazine amp dopamine Meclophenaxate.
in the striatum acting then as a
Classification: dopaminergic against through
Loop Diuretic the inhibition or tyroninehydroxylase.

Dosage:
1gm IV q 8