DRUG NAME INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING

ACTION REACTION CONSIDERATION

GENERIC NAME  Emergency  Depressant  Hypersensitivity to  Dizziness.  Assess patient’s

 Phenobarbital control of acute and anti- barbiturates.  Headache. condition before
convulsions. convulsant  Porphyria.  Exacerbation of therapy and
BRAND NAME  Long-term effects may be  Pregnancy. pre-existing regularly thereafter
 treatment of related to its  Severe renal, pain. to monitor drug
generalized ability to hepatic or  Hypotension. effectiveness.
CLASSIFICATION tonic-clonic and increase respiratory  GI  Assess for seizure
 CNS cortical focal and/or mimic impairment. disturbances. activity: type,
drugs/hypnotics seizures. impulses  Allergic location, duration
and sedatives  Short treatment (depress CNS reactions and character.
of insomnia. synaptic  Monitor vital signs
DOSAGE  Preanesthetic transmission every 30 mins. For
 25mg/pptab, 1 sedation. and increase 2 hrs. after
tab PO q12 seizure potential route.
activity  Assess patient’s
threshold in family knowledge
the motor of drug therapy.
cortex).
DRUG STUDY

DRUG NAME INDICATION MECHANISM CONTRAINDICATION ADVERSE NURSING CONSIDERATION

OF ACTION REACTION

GENERIC NAME  Aerobic and  Inhibits  History of  Allergic  Assess patient’s for
 Chloramphenicol anaerobic protein hypersensitivity reactions. previous sensitivity to
bacteria synthesis in and toxic  GI other anti-infectives.
BRAND NAME Gram (+) bacteria. reactions. reactions.  Assess patient for signs
 Pediachlor bacteria. Acts  Infants <1 month.  Diarrhea. and symptoms of infection
 Anti-infective primarily by  Lactation.  Vomiting. including WBC, fever and
CLASSIFICATION regimens. binding  Trivial infection  Digital obtain baseline
 Anti-infectives  Typhoid reversibly (e.g. colds, throat paresthesia. information during
fever. to the 50s infection, treatment.
DOSAGE  Meningitis or ribosomal influenza.  Assess bowel pattern
 125 mg/5ml, other serious subunit.  Blood diseases everyday.
Give 2.5 ml PO q6º infections especially aplastic  Advise the patient’s
caused by anemia and guardian to report fever
susceptible thrombocytopenia. and bleeding.
strains of
Salmonella,
rickettsia or
Chlamydia.
 Meningeal
infection
 Bacteremia.
 Brain abscess.
 Other
diseases,
which do not
respond to
other
standard
antimicrobial
agents.
DRUG NAME INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING
ACTION REACTION CONSIDERATION

GENERIC NAME  Treatment of  Interferes  Hypersensitivity to  Hyperthermia.  Obtain patient history

 Ampicillin respiratory with cell wall penicillins,  Skin rashes. of infection before and
tract and soft synthesis of cephalosporins or  Diarrhea. during therapy to
BRAND NAME tissue susceptible imipenem.  Oliguria. assess response.
 Ampicin infection. organisms,  Urticaria.  Assess patient for sign
 Bacterial preventing  Itchy eyes. and symptoms of
CLASSIFICATION meningitis. bacterial infection. Fever, stool
 Anti-infectives  Septicemia multiplicatio and WBC.
DOSAGE and n, it also  Monitor renal function
 125 mg IV q6º gonococcal renders the by Urine output,
infections cell wall Urinalysis.
caused by osmotically  Instruct the guardian
susceptible unstable and of the patient if
microorganis burst due to diarrhea with blood or
m. osmotic pus notify physician
pressure. immediately.
Deactivated
by beta-
lactamase,
an enzyme
produced by
resistant
bacteria.
DRUG NAME INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING
ACTION REACTION CONSIDERATION

GENERIC NAME  Pyrexia of  Decreases  Hypersensitivity.  Hematological,  Assess patient’s fever.

 Paracetamol unknown fever  Intolerance to skin and other  Assess allergic
origin. inhibiting tartrazine (yellow allergic reaction: rash or
BRAND NAME  Fever and pain the effects of dye #5), alcohol, reaction. urticaria, discontinue
 Aeknil associated pyrogens on table drug.
with common the sugar,saccharin.  Check input and
CLASSIFICATION childhood hypothalami output ratio. Decrease
 Analgesics and disorders, c heat output may indicate
Antipyretic tonsillitis, regulating renal failure.
upper centers and  Assess for
DOSAGE respiratory by hepatotoxicity: Dark
 50 mg IV for tract hypothalami urine, clay-colored
T>38.5ºC PRN infections. c action stools.
 Prevention of leading to
febrile sweating and
convulsion. vasodilatatio
 Muscle pain. n. Relieves
by inhibiting
Prostaglandi
n synthesis
at the CNS
but does not
have anti-
inflammator
y action
because of
its minimal
effects on
peripheral
 prostaglandi
n synthesis.

DRUG NAME INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING

ACTION REACTION CONSIDERATION

GENERIC NAME  Pyrexia of  Decreases  Hypersensitivity.  Drowsiness  Assess patient’s fever.

 Paracetamol unknown fever  Intolerance to  Nausea  Assess allergic
origin. inhibiting tartrazine (yellow  Vomiting reaction: rash or
BRAND NAME  Fever and pain the effects of dye #5), alcohol,  Jaundice urticaria, discontinue
 Biogesic associated pyrogens on table  Urticaria drug.
with common the sugar,saccharin.  Rash  Check input and
CLASSIFICATION childhood hypothalami output ratio. Decrease
 Cyanosis
 Analgesics and disorders, c heat output may indicate
 Anemia
Antipyretic tonsillitis, regulating renal failure.
centers and  Abdominal
upper  Assess for
by pain
DOSAGE respiratory hepatotoxicity: Dark
 100mg/ml PO tract hypothalami urine, clay-colored
q4º for fever infections. c action stools.
T>38º C  Prevention of leading to  Tell guardian of the
febrile sweating and patient to recognize
convulsion. vasodilatatio signs of chronic
 Muscle pain. n. Relieves overdose: bleeding,
by inhibiting bruising, malaise,
Prostaglandi fever, sore throat.
n synthesis
at the CNS
but does not
have anti-
inflammator
y action
because of
its minimal
effects on
 peripheral
prostaglandi
n synthesis.

DRUG NAME INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING

ACTION REACTION CONSIDERATION

GENERIC NAME  Mild to  Macrolide  Hypersensitivity to  In children,  Assessment

 Clarithromycin moderate antibiotic clarithromycin, the most  Note any sensitivity to
infetions that acts by other macrolide common side erythromycin or any of
BRAND NAME caused by binding the antibiotics, or effects are the macrolide
 Biaxin susceptible 50S erythromycin. diarrhea, antibiotics.
strains of the ribosomal Clients taking vomiting,  Document onset,
CLASSIFICATION ff. subunit of pimozide. Use with abdominal severity, and
 Antibiotic, Children. susceptible ranitidine bismuth pain, rash, and characteristics of
Macrolide  Pharyngitis or organisms, citrate in those with headache symptoms
tonsillitis thus a history of acute  Obtain baseline
DOSAGE  Acute interfering porphyria. cultures, monitor CBC,
 1.5ml q12 maxillary with or liver and renal function
sinusitis or inhibiting studies
acute otitis microbial
media protein
 Uncomplicate synthesis.
d skin and Rapidly
skin structure absorbed by
infections the GI tract
 Disseminated although
mycobacterial food slightly
infections delays the
onset of
absorption
and the
formation of
the active
metabolite
but does not
 affect the
extent of
bio-
availability
DRUG NAME INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING
ACTION REACTION CONSIDERATION

GENERIC NAME  Stimulated  Aerosol for  Diarrhea  Obtain history and

 Albuterol(Salbuta • Prophylaxis beta-2 prevention of  dry mouth assess EKG and CNS
mol) and treatment receptors of exercise induced  appetite loss status
of the bronchi, bronchospasm and  Hyperkinesia  Document PFT’s, CXR,
BRAND NAME bronchospasm leading to tablets are not  Excitement and lung sounds.
 Accuneb • Inhalation bronchodilat recommended for  Nervousness  Assess symptom
solution for ion. Causes children lass than characteristics, onset,
 Tension
CLASSIFICATION acute attacks less 12 years of age. Use duration, frequency,
of  Tremor
 Symphato- tachycardia during lactation and any precipitating
bronchospasm and is  Dizziness
mimetic factors
s. longer-  vertigo
 Monitor pulmonary
DOSAGE • Prophylaxis of acting than  Weakness
status(I.e. breath
 1 cc + 1cc PNSS q exercise- isoprotereno  Drowsiness sounds, VS, peak flow,
4 induced l. Has  restlessness or ABG’s) for effects of
bronchospsm. minimal  headache the therapy
beta-1  Observe for evidence of
activity allergic responses
Available as
inhaler that
contains no
chlorofluoro
carbons
(Proventil
HFA)
DRUG NAME INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING
ACTION REACTION CONSIDERATION

GENERIC NAME  The skeletal  Hypersensitivity,  Drowsiness  Document indications

 Diazepam • Adjunct muscle acute narrow-angle  Fatigue for therapy,
therapy in relaxant of glaucoma,  Confusion  Determine any
BRAND NAME status effect of psychoses, primary  Ataxia depression or drug
 Diastat epilepticus diazepam depressive d/o in  Sedation abuse.
and severe may be due which anxiety is not  Avoid simultaneous
 Dizziness
CLASSIFICATION recurrent to a significant use of CNS
 Vertigo
 Anti anxiety drug, convulsive enhancemen symptom. depressants.
seizures,  Depression
benzodiazephine t of GABA-  Assess emotional
• Tetanus mediated  apathy
status
• IV prior to presynaptic  Lightheadedn
DOSAGE  Reduce drug gradually
cardioversion inhibition at ess
 (0.3ml) 1.5mg IV  Monitor CBC, renal
for relief of the spinal  Delirium
for active seizures and LFT’s
anxiety and level as well  Headache
 Review anxiety level
tension as in the  Lethargy
and identify any
• Relief of brain stem  Disorientation
contributing factors
anxiety and reticular  Hypoactivity
tension in formation.  Nervousness
clients  irritability
undergoing
surgical
procedures
DRUG NAME INDICATION MECHANISM OF CONTRAINDICATION ADVERSE NURSING
ACTION REACTION CONSIDERATION

GENERIC NAME • Serious  Broad spectrum • Hypersensitivity to • Ototoxicity • Document type,

 Gentamicin infections of the antibiotics aminoglycosides, • Dizziness onset and
conjunctiva or believed to long term therapy • Nystagmus characteristics of
BRAND NAME cornea inhibit protein (except • Vertigo symptoms
 Garamycin • Infections synthesis by streptomycin for • ataxia • Obtain a clinical
include bacterial binding tuberculosis) • Renal functions
CLASSIFICATION neonatal sepsis, irreversibly to Impairment studies, CBC,
 Antibiotic, bacterial ribosome s (30S • increased thirst and appropriate
Aminoglycoside septicemia, and subunit), • Headache specimens for
serious thereby • Tremor culture
DOSAGE infections of the interfering with • Lethargy • With eye d/o
 25mg OD skin, bone, and an initiation • Paresthesia note baseline
CNS (including complex • peripheral ophthalmologic
meningitis). between neuritis examinations
messenger RNA • Diarrhea • Assess for
and the 30S • weight loss tinnitus, vertigo,
subunit. This • Rarely or hearing losses
leads to • agranulocytosis during therapy.
production of
nonfunctional
proteins;
pyloribosomes
are split apart
and are unable
to synthesize
protein. Usually
bactericidal due
to deisruption of
 the bacterial
cytoplasmic
membrane.

NURSING CARE PLAN

Patient’s Name: Baby Boy X Age: 2 months

Medical Diagnosis: Pneumonia
Nursing Diagnosis: Ineffective Airway Clearance related to increased sputum production as evidenced by abnormal breath sound and cough with (+) white
sputum
Short-term Goal: After rendering 8° of nursing intervention, the patient will be able to loosen out secretions.
Long-term Goal: The patient will maintain a clear and patent airway with normal breath sounds.

SCIENTIFIC NURSING
CUES PROBLEM RATIONALE EVALUATION
REASON INTERVENTION
Independent:
Subjective: Increased sputum Pneumonia affects Goal Met
production in the both ventilation and  Monitor Vital  To monitor the
“Ngayon lang siya airway that results into diffusion. An Signs. status of the The patient has
nahirapan sa difficulty of breathing. inflammatory reaction patient and loosened out his
paghinga ng ganito” can occur in the alveoli prevent further secretions upon
as verbalized by the producing exudate that complications. suctioning.
patient’s mother. interferes with the
diffusion of oxygen and  Auscultate chest  To monitor for
carbon dioxide. Areas for breath tachypnea,
Objective: of the lung are not sounds. shallow
adequately ventilated respirations and
 (+) Crackles because of secretions abnormal breath
upon chest that cause partial sounds that are
auscultation occlusion of the frequently
 Productive bronchi or alveoli. This present because
cough will interfere with gas of discomfort
 (+) White exchange and may moving of chest
 sputum slow recovery. wall and
 Tachypneic; accumulation of
RR=96cpm fluid secretions
 Tachycardic; in the lung.
PR=182 bpm
 Cyanotic
 Instruct patient’s  Keeping the
Source: Brunner & mother to head elevated
Suddarth’s Textbook of
continue to put lowers
Medical-Surgical
Nursing, 11th edition
the baby in diaphragm,
upright position. promoting chest
expansion,
aeration of lung
segments and
mobilization and
expectoration of
secretions to
keep the airway
clear.

 Suction as  Stimulates
indicated cough or
mechanically
clears airway in
client who is
unable to do so
because of
ineffective cough
or decreased
level of
consciousness.

Dependent:

 Assist and  Facilitates

 monitor effects of liquefaction and
nebulizer removal of
treatments. secretions.

 Administer  Aids in reduction

medications as of
prescribed by the bronchospasm
physician (e.g. and mobilization
mucolytics, of secretions.
bronchodilators
and analgesics)
NURSING CARE PLAN

Patient’s Name: Baby Boy X Age: 2 months

Medical Diagnosis: Pneumonia
Nursing Diagnosis: Hyperthermia related to infectious process as manifested by an elevated temperature of 38.4°C
Short-term Goal: After rendering 8° of nursing intervention, the patient ‘s temperature will subside from 38.4°C to 37.5°C
Long-term Goal: The patient will demonstrate temperature within normal range and be free of chills.
SCIENTIFIC NURSING
CUES PROBLEM RATIONALE EVALUATION
REASON INTERVENTION
Independent:
Subjective: Elevation of Pneumonia, an Goal Partially Met
temperature above inflammation of the  Monitor Vital  To monitor the
“Ang taas na naman ng the normal range. lungs commonly Signs. status of the The patient’s
lagnat niya” as caused by bacteria. patient and temperature has
verbalized by the Parts of the lungs are prevent further subsided to 37.7°C
patient’s mother. plugged with a fiberlike complications.
fluid. Symptoms
include severe chills, a  Monitor input  Comparing
Objective: high fever, headache, and output actual and
and cough and chest anticipated
 (+) Chills pain. output may aid
 Flushed skin in evaluating
 Warm to touch degree of
 (+) Crackles complication.
upon chest
auscultation  Monitor  Room
 Febrile,T=38.4°C environmental temperature and
 Tachypneic; temperature; number of
RR=90cpm Source: Mosby Medical limit/add bed blankets should
 Tachycardic; Encylcopedia 2002 linens as be altered to
PR=185 bpm indicated. maintain near-
normal body
temperature.
  Provide tepid  TSB may help
sponge baths, reduce fever.
avoid use of Use of ice water
alcohol or alcohol may
cause chills,
actually
elevating
temperature.

Dependent:

 Administer  Aids in the

medications as reduction of
prescribed by the fever and
physician (e.g. prevents client
antipyretics and from further
analgesics) complications.
NURSING CARE PLAN

Patient’s Name: Baby Boy X Age: 2 months

Medical Diagnosis: Pneumonia
Nursing Diagnosis: Risk for fluid volume deficit related to insensible fluid loss as manifested by high grade fever, diaphoresis and rapid respiratory
rate.
Short-term Goal: After rendering 8° of nursing intervention, the patient will maintain fluid volume at a functional level.
Long-term Goal: The patient will demonstrate fluid balance as evidenced by stable vital signs, good quality pulse, normal skin turgor and moist
mucous membranes

SCIENTIFIC NURSING
CUES PROBLEM RATIONALE EVALUATION
REASON INTERVENTION

The patient is at high The respiratory rate of Independent: Goal Partially Met
risk for experiencing patients with
Objective: vascular, cellular or Pneumonia increases  Monitor Vital  To monitor the The patient has able to
intracellular because of the Signs. status of the maintain adequate fluid
 Dry skin dehydration increased workload patient and intake but still have high
 Poor skin imposed by labored prevent further fever.
turgor breathing and fever. complications.
 Diaphoresi An increased Elevated
s respiratory rate leads to temperature or
 Febrile, an increase in prolonged fever
T=38.4°C insensible fluid loss increases
 Tachypnei during exhalation and metabolic rate
c, RR=90cpm can lead to and fluid loss
dehydration. through
evaporation
Source: Brunner &
Suddarth’s Textbook of  Assess skin  Indirect
Medical-Surgical turgor and indicators of
Nursing,11th edition moisture of adequacy of fluid
mucous volume, although
membranes. oral mucous
 membranes may
be dry because
of mouth
breathing and
supplemental
oxygen.

 Note reports of  Presence of

nausea/vomiting these symptoms
reduces oral
intake.

 Monitor input and  Provides

output information
about adequacy
of fluid volume
and replacement
needs.
Dependent:

 Administer  Aids in the

medications as reduction of
prescribed by the fever and useful
physician (e.g. in reducing fluid
antipyretics) losses.

 Provide  In the presence

supplemental IV of reduced
as necessary. intake or
excessive loss,
use of parenteral
route may
correct/prevent
deficiency.
NURSING CARE PLAN

Patient’s Name: Baby Boy X Age: 2 months

Medical Diagnosis: Pneumonia
Nursing Diagnosis: Impaired Gas Exchange related to alveolar-capillary membrane changes as evidenced by tachycardia, nasal flaring and
cyanosis.
Short-term Goal: After rendering 8° of nursing intervention, the patient will maintain adequate ventilation and oxygenation as evidenced by normal skin color.
Long-term Goal: The patient will demonstrate improved ventilation and adequate oxygenation within client’s normal limits and be free of
symptoms of respiratory distress.

SCIENTIFIC NURSING
CUES PROBLEM RATIONALE EVALUATION
REASON INTERVENTION
Pneumonia affects
Subjective: There is a deficiency in both ventilation and Independent: Goal Partially Met
the oxygenation at the diffusion. An
“Nahihirapan na alveoli-capillary inflammatory reaction  Monitor Vital  To monitor the The patient has able to
siyang huminga membrane that results can occur in the alveoli Signs. status of the maintain adequate
talaga, nangingitim in impaired gas producing exudate that patient and ventilation and
na sya” as exchange interferes with the prevent further oxygenation, the
verbalized by the diffusion of oxygen and complications. patient’s skin color has
patient’s mother. carbon dioxide. Areas Tachycardia is returned to its normal
of the lung are not usually present state.
Objective: adequately ventilated as a result of
 Nasal flaring because of secretions fever/dehydration
 With o2 that cause partial but may
inhalation occlusion of the represent a
 Cyanotic bronchi or alveoli. This response to
 Febrile, will interfere with gas hypoxemia.
T=38.4°C exchange and may
 Tachypneic, slow recovery.  Observe skin  Cyanosis of nail
RR=90cpm color, mucous beds may
 Tachycardic; membranes and represent
PR=185 bpm nail beds noting vasoconstriction
Source: Brunner & presence of or the body’s
Suddarth’s Textbook of cyanosis. response to
Medical-Surgical fever/chills;
Nursing, 11th edition however cyanosis
of earlobes,
mucous
membranes and
skin around the
mouth is
indicative of
systemic hypoxia.

 Maintain bed rest  Prevents over

exhaustion and
reduces oxygen
consumption/dem
ands to facilitate
resolution of
infection.

 Elevate head and  These measures

encourage promote maximal
frequent position inspiration;
changes. enhance
expectoration of
secretions to
improve
ventilation.
Dependent:
 Administer  The purpose of
oxygen therapy oxygen therapy is
as indicated to maintain PaO2
above 90% O2
saturation.
Oxygen is
administered by
the method that
provides
appropriate
delivery within
client’s tolerance.

 Administer  Aids in the

medications as reduction of
prescribed by the bronchospasm
physician (e.g and mobilization
mucolytics, of secretions.
bronchodilators
and analgesics)

 Prepare  Intubation and

for/transfer to mechanical
critical care ventilation may
setting if be required in the
indicated event of sever
respiratory
insufficiency.
NURSING CARE PLAN

Patient’s Name: Baby Boy X Age: 2 months

Medical Diagnosis: Pneumonia
Nursing Diagnosis: Risk for injury related to occurrence/recurrence of seizure episodes secondary to prolonged heightened body temperature and
respiratory distress.
Short-term Goal: Within our 8-hour shift, the patient will be protected from possible injury in the event of occurrence/recurrence of seizure
episodes.
Long-term Goal: The patient’s condition will improve and he will be free of possible causes of seizures upon hospital discharge.

SCIENTIFIC NURSING
CUES PROBLEM RATIONALE EVALUATION
REASON INTERVENTION

The patient is at high Increase in body Independent: Goal Partially Met

risk for experiencing temperature beyond
Objective: injury due to seizure normal range may lead  Monitor Vital  To monitor the The patient temperature
episodes during to convulsion. If there Signs. status of the has subsided to 37.7°C
 Warm to convulsion attacks. is a sudden violent patient and
touch uncontrollable prevent further
 Flushed contraction of a group complications.
skin of muscles the patient
 (+) Chills is at high risk for injury.  Monitor Input and  Comparing
 Febrile, Risk for injury as a Output actual and
T=38.4°C result of environmental anticipated
 Tachypnei conditions interacting output may aid in
c, RR=90cpm with the individual’s evaluating
adaptive and defensive degree of
 Stiffness
resources. complication.
of extremities
 strabismu
 Promote safe  For the patient’s
s
physical safety and to
Source: The Mosby environment prevent patient
Medical Encyclopedia for further risk for
 injury.

 Provide client’s  Information

relative regarding giving is a
conditions that preventive
may result in measure for
increased risk for accidental
injury. injuries that may
occur.

 Secure patient’s  This will avoid

crib with soft trauma to
artifacts such as patient’s
pillows or folded extremities when
blanket. seizure episodes
occurred or
recurred.

 Instruct client’s  This will help in

relative to loosen releasing heat
out the clothes of within the body
the patient and promote in
lessening the
high temperature
of the baby.
Dependent:

 Administer  Medications will

medications as help in lowering
prescribed by the the body
physician (e.g. temperature and
analgesics and will prevent
antipyretics) further
complication.