Assessment Diagnosis Planning Nursing Intervention Implementation Evaluation

Subjective: Acute Pain After 8 hours of RLE A: Maintain bed rest in an upright  Maintained bed rest After 8 hours of RLE the client was able to:
No verbalized cue. related to eye the client will be able position or the position of head of in an upright position  Goal met: The Client was able to
trauma to: 60º. of head of 60º. maintain pain of 3 out 10
Objective:  To maintain R: Minimize stimulation and  Absence of tenderness over the left
 pain scale of 7 pain scale 3 out Provide relaxation  Used the pain scale eye, eyebrow, and cheekbone
out of 10 of 10 A: Use pain scale levels to levels to determine  Demonstrates use of
(moderate to  Demonstrate determine the dose of analgesics. the dose of nonpharmacological treatment
severe pain) use of A: Give a cold compress to reduce analgesics. such as relaxation.
 tenderness relaxation skills pain and swelling.  Provided cold  No signs of sore and red eyes
over his left  Absence of A: Acknowledge and accept the compress to reduce
eye, eyebrow, sore and red client’s pain. pain and swelling.
and eye R: Nurses have the duty to ask  Accepts client’s pain.
cheekbone  Absence of their clients about their pain and
 facial grimace tenderness believe their reports of pain.  Reduced light levels
 sore and red over the left A: Reduce lighting levels.  Teaches client the
eye eye, eyebrow, A: Teach the use of use of
 and cheekbone nonpharmacological techniques nonpharmacological
such as relaxation. techniques such as
R: Nonpharmacologic methods in relaxation.
pain management may include
physical, cognitive-behavioral
strategies, and lifestyle pain
management.

Drug Mechanism of Action Indication Contraindication Adverse Effect Nursing Responsibilities

Generic Name: Decreases hepatic Adjunct to diet to  physical weakness (asthenia) Assessment
 Allergies to
metformin glucose production, lower blood  diarrhea
biguanides  History: Allergy
hydrochloride decreases intestinal glucose with  gas (flatulence)
to metformin;
glucose absorption, and type2 (non–  an infection  symptoms of
Brand Name: Increases sensitivity to insulin- diabetes
weakness, muscle pain (myalgia)
 low blood sugar complicated by
Glucophage insulin. Indicated for the dependent)  upper respiratory tract infection
fever, severe
management of type 2 diabetes mellitus
 pituitary  low blood sugar (hypoglycemia)
infections,
Classification: diabetes mellitus; may be in patients
hormone  abdominal pain (GI complaints),
Antidiabetics/Biguanides used with diet, insulin, or severe trauma,
deficiency lactic acidosis (rare)
sulfonylurea major surgery,
 low blood levels of vitamin B-12 ketosis,
Dosage: oral hypoglycemics  decreased  nausea acidosis, coma;
500mg  vomiting type 1
function of the
850mg  chest discomfort diabetes,
adrenal gland
1000mg  chills, dizziness serious hepatic
 inadequate  bloating/abdominal distention or renal
Route: PO vitamin B12  constipation impairment,
 heartburn uremia,
Frequency: BID  excess body thyroid or
acid endocrine
impairment,
 dehydration
glycosuria,
 alcoholism hyperglycemia
associated
 alcohol with primary
intoxication renal disease,
CHF,
 a heart attack
pregnancy,
 sudden and lactation
serious  Physical: Skin
symptoms of color, lesions;
heart failure T, orientation,
called acute reflexes,
decompensate peripheral
d heart failure sensation; R,
adventitious
 liver problems sounds; liver
 fever evaluation,
 bowel sounds;
 a condition urinalysis,
where the body BUN, serum
is unable to creatinine,
maintain LFTs, blood
adequate blood glucose, CBC
flow called Interventions
shock
 Monitor urine
 excessive or serum
vomiting glucose levels
 excessive frequently to
diarrhea determine
effectiveness
 serious lack of of drug and
oxygen in the dosage.
blood  WARNING:
Arrange for
 weakened transfer to
patient insulin therapy
 sepsis during periods
of high stress
 chronic kidney (infections,
disease stage surgery,
3B (moderate) trauma).
 WARNING:
 chronic kidney
 Use IV glucose
disease stage 4 if severe
(severe) hypoglycemia
 chronic kidney occurs as a
disease stage 5 result of
(failure) overdose.
Teaching points
 kidney disease
with likely  Do not
reduction in discontinue
kidney function this
medication
without
consulting
your health
care provider.
 Monitor urine
or blood for
glucose and
ketones as
prescribed.
 Swallow
extended-
release tablets
whole; do not
cut, crush, or
 chew.
 Do not use this
drug during
pregnancy; if
you become
pregnant,
consult with
your health
care provider
for
appropriate
therapy.
 Avoid using
alcohol while
taking this
drug.
 Report fever,
sore throat,
unusual
bleeding or
bruising, rash,
dark urine,
light-colored
stools, hypo-
or
hyperglycemic
 reactions.

Sources: https://www.rxlist.com/consumer_metformin/drugs-condition.htm

https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/metformin-hydrochloride/#:~:text=Monitor%20urine%20or%20serum%20glucose,as%20a%20result%20of
%20overdose.

https://www.scribd.com/document/203194902/Drug-Study-Metformin

https://medlineplus.gov/druginfo/meds/a696005.html

https://www.webmd.com/drugs/2/drug-11285-7061/metformin-oral/metformin-oral/details/list-contraindications