DRUG MECHANISM OF ACTION/SIDE-
EFFECTS N RATIONALE
Brand name: Isordil Mechanism of Action: Produce
vasodilation (venous greater
Generic name:
than arterial). Decrease left
Isosorbide dinitrate
ventricular end-diastolic
(ISND)
pressure and left ventricular
Classification: end-diastolic volume (preload).
Therapeutic: antianginals Net effect is reduced
myocardial oxygen
Pharmacologic: nitrates
consumption. Increase
Route: SL coronary blood flow by dilating
coronary arteries and
Dosage: 5mg S/L
improving collateral flow to
Frequency: 1 hr (ASAP) ischemic regions.
then PRN q4 w/ BP
precaution Side effects:
CNS: dizziness, headache.
CV: hypotension, tachycardia,
paradoxic bradycardia,
syncope.
Dermatologic: rash, exfoliative
dermatitis.
INDICATION/CONTRAINDICATIO
Indication: Acute treatment of
anginal attacks (SL only).
Prophylactic management of
angina pectoris.
Contraindication: Contraindicated
with allergy to nitrates, severe 1. Right patient
anemia, head trauma, cerebral
hemorrhage, hypertrophic,
cardiomyopathy, narrow-angle
glaucoma, postdural hypotension.
NURSING RESPONSIBILITIES AND
Observe clients 10 rights to
administration of drugs. Rationale:
Observing the 10 rights of patients
ensures the administration of medica
to be safe:
2. Right medication
3. Right dosage
4. Right route
5. Right time
6. Right documentation
7. Right client education
8. Right to refuse
9. Right assessment
10. Right evaluation
> Check the doctor’s order
Rationale: To make sure
GI: nausea, vomiting. that the medication is given on the ba
of the order of the doctor.
GU: urinary frequency.
Misc: flushing, tolerance. > Assess location, duration, intensity
precipitating factors of anginal pain.
Rationale:
> Monitor BP and pulse routinely dur
period of dosage adjustment. Rationa
> Instruct patient to take medication
directed, even if feeling better. Ration
> Caution patient to make position
changes slowly. Rationale: To avoid
orthostatic hypotension.

> Advised patient to avoid alcoholic

beverages. Rationale: They may produ
increased hypotension.
> Inform patient that headache is a
common side effect that should decre
with continuing therapy. Rationale: Th
patient must be aware of its side effec

> Advise patient to notify health care

professional if dry mouth or blurred
vision occurs. Rationale:
 > Document and record

DRUG MECHANISM OF ACTION/SIDE- INDICATION/CONTRAINDICATIO NURSING RESPONSIBILITIES AND

EFFECTS N RATIONALE

Brand name: Rocephin Mechanism of Action: Inhibits Indication: Susceptible bacterial Observe clients 10 rights to
cell wall synthesis, promoting infections of the lower respiratory administration of drugs. Rationale:
Generic name:
osmotic instability that is tract, skin and skin structure, Observing the 10 rights of patients
Ceftriaxone
usually bactericidal. bone and joint, UTIs, meningitis. ensures the administration of medica
Classification: to be safe:
Side effects: Contraindication: Ceftriaxone is
Cephalosporin
contraindicated in patients with 1. Right patient
antibiotics CNS: headache, dizziness,
known allergy to the
lethargy 2. Right medication
Route: IVT cephalosporin group of
GI: nausea, vomiting, diarrhea, antibiotics. 3. Right dosage
Dosage: 1mg
anorexia, pseudomembranous
4. Right route
Frequency: q12 colitis
5. Right time
Hematologic: bone marrow
depression – dec. WBC, 6. Right documentation
platelets, Hct
7. Right client education
Local: pain, inflammation of IV
site 8. Right to refuse
Other: superinfections, 9. Right assessment
disulfiram-like reaction with
10. Right evaluation
alcohol
> Check the doctor’s order
Rationale: To make sure
that the medication is given on the ba
of the order of the doctor.

> Do skin testing into the intradermal

area. Rationale: To find out if the pati
is allergic to things such as insect stin
and penicillin.
> Use separate syringe when giving th
drug. Rationale: A new clean syringe
should always be used to prevent
contamination.
> Assess patient for signs and sympto
of infection before and during the
treatment. Rationale: To provide goo
palliative care in general practice.
> Obtained C&S before beginning dru
therapy. Rationale: To identify if corre
treatment has been initiated.
> Monitor hematologic, electrolytes,
renal and hepatic function. Rationale
> Advise patient to promptly report s
of adverse reactions. Rationale:
> Check the patency of the IV site and
line.
Rationale: To ensure that the line is
properly placed and the fluids will flow
into the vein as intended.
> Monitor blood levels in patients tak
this drug. Rationale:
> Instruct patient to report pain at IV
Rationale:
> Document and record
CUES NURSING GOALS AND DESIRED NURSING IMPLEMENTATION EVALUATION
DIAGNOSIS OUTCOME INTERVENTION
Subjective: Nausea related to Goal: Assess vital signs Client’s vital signs
After series of
“Nahihilo po ako” dizziness After series of nursing (pulse, respirations, are assessed. nursing
as verbalized by interventions, the and blood pressure). interventions, the
the patient. client will be able to Rationale: Helps in client was:
be free of nausea determining 1. Been free or
Objective: completely. appropriate decreased
 Client interventions. nausea
appears to Desired Outcome: sensation.
look  Client will be Assess for presence GI tract was 2. Able to
lethargic able to of condition of the GI assessed. conserve
 Feeling conserve tract. Rationale: To energy and
nauseous energy and ensure that there is reduce
 Observed to reduce no problem that will dizziness.
be dizziness. cause vomiting. 3. Able to take
experiencing  Able to take acceptable
slightly dizzy acceptable level Note Foods/substance level of
V/S taken as of dietary foods/substance that that trigger dietary
follows: intake. trigger nausea. nausea was noted. intake.
T: 38ᵒC  Vital signs will Rationale: To 4. Vital signs will
P: 120 be at normal decreased the be at normal
R: 23 bpm limits. possibility of nausea limits.
BP: 140/100 episodes upon meals.
mmHg

Promote sufficient Promoted

nutritional intake. sufficient
Rationale: The nutritional intake.
patient will need
properly balanced
intake of fats,
carbohydrates,
proteins, vitamins
and minerals to
provide energy.
Administered and
Administer and monitored
monitor response to response to
medication used to medication used
treat underlying to treat
cause of nausea. underlying cause
Rationale: of nausea.

Encourage patient to Encouraged

start intake of small patient to start
tolerate dry foods intake of small
such as crackers. tolerate dry foods.
Rationale: Dry foods
have natural
tendencies to
decrease nausea.

Provide good oral Provided good

hygiene. Rationale: oral hygiene.
To decreased bad
taste.

Provide clean Provided clean

peaceful peaceful
environment and environment and
fresh air with fan or fresh air.
open window.
Rationale: To
promote clear flow of
air in the patient’s
area. One way of
promoting
relaxation.