VIII.

NURSING CARE PLAN

Assessment Nursing Planning Intervention Rationale Evaluation

diagnosis

Subjective: Acute pain - Within 8 hours -Evaluate pain -Provides -After 8 hours of
“ Nagsakit tuy related to of doing nursing regularly (every 2 hrs information about doing
naoperaan ma’am” tissue trauma intervention, the noting characteristics, need for or intervention, the
effectiveness of
As verbalized by as evidenced pain scale of the location, and intensity patient pain scale
interventions.
the patient by pain scale of patient would (0–10 scale). decreased to 4
7/10 decrease to 3 Emphasize patient’s from 7, with
Objective: from 7, with responsibility for minimal facial
- Pain scale of minimal facial reporting pain/ relief grimace and
7, 10 as the grimace and of pain completely. guarding behavior.
highest and guarding
-Reposition as -May relieve pain
1 as the behavior.
indicated: semi- and enhance
lowest. circulation.
Fowler’s/lateral Sims
- (+) facial
grimace Encourage use of -Relieves muscle
- (+) relaxation techniques: and emotional
guarding deep-breathing tension; enhances
behavior exercises, guided sense of control and
when imagery, visualization, may improve coping
moving music. abilities.

Objective: Impaired skin Reinforce initial Protects wound

-Presence of wound integrity dressing and change from mechanical
at the operative site related to post as indicated. Use strict injury and
-(-) foul smell operation as aseptic techniques. contamination.
-(-)pus evidenced by
Inspect wound Prevents
presence of
regularly, noting accumulation of
wound.
characteristics and fluids that may
integrity. Note cause excoriation.
patients at risk for
delayed healing
Early recognition of
Assess amounts and
delayed healing or
characteristics of
developing
drainage.
complications may
prevent a more
serious
situation.Decreasing
drainage suggests
evolution of healing
process, whereas
continued drainage
or presence of
bloody or
odoriferous exudate
suggests
complications.

Equalizes pressure
Splint abdominal and on the wound,
chest incisions or area minimizing risk of
with pillow or pad dehiscence or
during coughing or rupture.
movement.
IX. DRUG STUDY

DRUG ACTION/INDICATION CONTRAINDICATION SIDE EFFECT NURSING INTERVENTION

Co- Amoxiclav Used alone, Combination shares Mild diarrhea Assess bowel pattern
(co-amoxiclav) clavulanic acid toxic potential of Nausea or vomiting before and during
antibacterial activity ampicillin. Headache treatment as
pseudomembranous
is weak. In Hypersensitivity to Skin rash or itching
colitis may occur.
A- PO 250- 500 mg combination,it penicillins;infectiou White patches in
tablet inhibits s mononucleosis your mouth or
enzyme(beta- throat - Report hematuria or
C- PO < 40 kg, 20- 40 mg lactamase)degradati Vaginal yeast oliguria as high doses
can be nephrotoxic.
/ d/ based on amoxillin on of amoxicillin infection ( itching
component and by synergism or dis charge
extends both - Assess respiratory
spectrum of activity status.
& bactericidal effect
of amoxicillin - Observe for
against many strains anaphylaxis.
of beta-lactamase
producing bacteria
- Ensure that the
resistant to patient has adequate
amoxicillin alone fluid intake during any
diarrhea attack.

Celecoxib NSAID that exhibits Severe hepatic Chest pain, -Monitor for fluid
( celecoxib-oral) anti inflammatory, impairment weakness retention and edema
( Celebrex) analgesic & hypersensitivity to shortness of especially in those
antipyretic celecoxib asthmatic breath, slurred with history of
A- PO 100- 200 mg b.I.d activities; unlike patients with speech, problems hypertension.
or 200 mg q.d ibuprofen inhibits aspirin triad; with vision or
A- PO 400 mg 1st dose prostaglandin advanced renal balance -Monitor for serious
then 200 mg same day if synthesis by disease; concurrent Black bloody or side effects and report
needed, then 200 mg inhibiting use of diuretics & tarry stools it immediately to the
b.I.d prn cyclooxygenase-2 ace inhibitors; Coughing up blood physician.
A- PO 400 mg b.I.d (COX-2) but does anemia; pregnancy or vomit that looks
not inhibit (category D) in third like coffee grounds
cyclooxygenase -1 trimesters; lactation Swelling or rapid
(COX-1) weight gain
Urinating less than
usual or not at all
Skin rash, brushing
severe tingling,
numbness pain,
muscle weakness

Losartan Angiotensin II Hypersensitivity to Dizziness, Avoid given first dose

receptor{type losartan, pregnancy insomnia, at night due to
A- PO 25-50 mg In 1-2 A}antagonist acts as [category C[first headache, increase hypotensive
risk.
divided doses (max: 100 a potent trimester] category dyspepsia muscle
mg/d); start with 25 vasoconstrictor and D[second &third cramps, back and Monitor blood
mg/d if volume depleted primary vasoactive trimester] lactation leg pain , sinusitis, pressure and pulse
hormone of the cough, respiratory frequently.
renin-angiotensin- infection.
aldosterone system. Ask the complete
health history of
patient specially any
renal disease
Check patient s/s for
angioedema.

Monitor electrolytes
specially sodium and
potassium levels, uric
acid levels and CBC

Avoid potassium rich

diet and supplements
when taken losartan
Do not breast feed
when taken losartan

Inform patients the s/s

of hypotension.

Inform HP about
pregnancy if conceived.

Take plenty of water to

avoid dehydration.

Monitor BP at drug
trough
Mefenamic Acid Anthranilic acid Hypersensitivity to Drowsiness,  Assess patient
A- PO loading dose 500 derivative. Like drug, GI insomnia, who develop
mg PO maintenance ibuprofen inhibits inflammation ,or dizziness, severe diarrhea
dose 250 mg q6h prn prostaglandin ulceration. Safety in nervousness, and vomiting
synthesis and affects children during confusion, for dehydration
platelet function .No pregnancy or headache. and electrolyte
evidence that it is lactation is not imbalance.
superior to aspirin. established.  Discontinue drug
promptly if
diarrhea, dark
stools,
hematemesis,
ecchymoses,
epistaxis, or rash
occur and do not
use again. Contact
physician.
 Notify physician if
persistent GI
discomfort, sore
throat, fever, or
malaise occur.
 Do not drive or
engage in
potentially
hazardous
activities until
response to drug
is known. It may
 cause dizziness
and drowsiness.
 Monitor blood
glucose for loss of
glycemic control if
diabetic.
 Do not breast feed
while taking this
drug without
consulting
physician.