Assessment Diagnosis Planning Interventions Rationale Expected outcome

Subjective: SHORT TERM GOAL: INDEPENDENT: SHORT TERM GOAL:

Acute Pain related Monitor closely and document
“Masakit din daw ang headache secondary to After 1-2 hours of neurologic deterioration, and To assess for level of After 1-2 hours of nursing
ulo nya, lula or the increase intracranial nursing intervention the maintain a neurologic flow record consciousness, increased intervention the client will
drowsy ganon “as pressure and client will be able to intracranial pressure, the experience
verbalized by the compression of the brain experience location and extent reduction/relief of pain.
nurse of the patient ventricles from the tumor reduction/relief of pain. Monitor the neurological status,
tissue resulting in cause, precipitating factors, To identify the CNS function LONG TERM GOAL:
cerebral edema as LONG TERM GOAL: frequency and severity of
Objective: evidenced by abnormal headaches Within hospitalization, the
vital signs, fever and Within hospitalization, patient will:
 Abnormal vital increased intra-cranial the patient will be able Continuously monitor the vital
signs pressure to: signs and pain score regularly To identify the extent and  Displays improved
 High temperature  Displays improved severity of pain and provide well-being such as
that indicates well-being such as appropriate interventions. baseline levels for
Fever baseline levels for Place the client in High Fowler’s pulse, BP and
 increased intra- pulse, BP and position with pillows supported to To decrease CSF pressure respirations.
cranial pressure respirations. the sides. and relieve pain  Displays
 Displays improvement in
improvement in Minimize environmental stimuli mood, coping.
Vital Signs: mood, coping. like excessive lights or sounds To relieve stress and thereby  Be free from pain
 Be free from of that triggers the headache reduce headache
T:37.8 degree pain
celsius
P: 82 bpm Assess the need for surgical
R: 22 bpm intervention and prepare the client To remove the abnormal
BP: 170/100 mmHg for cranial surgery, if indicated tissue and prevent
02 Sat: 98% based on the grading of Tumor compression of nerves and
blood vessels

DEPENDENT:
Administer analgesics as
prescribed To relieve headache

Administer osmotic diuretics like

Mannitol as prescribed To remove excess fluid and
decrease ICP thereby
decreasing cerebral edema
and headache
Administer anti-seizure drugs like
Phenytoin as prescribed To treat seizure activity and
induce sleep
COLLABORATIVE:
Refer the patient to a pain
specialist as required. To enable to patient to receive
more information and
specialized care in pain
management if needed
 Assessment Diagnosis Planning Interventions Rationale Expected outcome

Subjective: SHORT TERM INDEPENDENT: SHORT TERM GOAL:

GOAL:
“Nanghina daw ang Electrolyte Imbalance related Monitor vital signs and CVP, Note Measurements are useful in After 8 hours of nursing
katawan nya after ng to hyponatremia and After 8 hours of presence/degree of postural BP. determining the degree of intervention the patient
surgery don sa hypokalemia as evidenced by nursing intervention Changes. Observe fever. fluid deficit and response to will verbalize
Health Serv” as low sodium and potassium the patient will be able replacements therapy, Fever understanding of
verbalized by the level, body weakness and to verbalize increases metabolism and electrolyte imbalances
nurse of the patient lethargy understanding of exacerbates fluid loss
electrolyte imbalances LONG TERM GOAL:
Objective: Assess level of consciousness A deficit in sodium level may
LONG TERM GOAL: and neuromuscular response lead to decreased mentation Within hospitalization,
- Body weakness to coma , as well as the patient will have
- Lethargy Within hospitalization, generalized muscle stable fluid and
- Low Serum the patient will be able weakness, cramps or electrolyte balance
Sodium and to have stable or convulsions
potassium level normal fluid and
electrolyte balance Monitor respiratory depth rate Co-occurring hypochloremia
Sodium level: may produce slow and
shallow respiration as the
May 21, 2022: 126 body compensates for
mmol/L metabolic alkalosis
May 25, 2022: 134
mmol/L Monitor urinary output. Fluid replacement needs are
Measure/estimate fluid loses from based on correction of
Potassium level: all sources current deficits and ongoing
losses.
May 25, 2022: 2.6
mmol/L Palpate peripheral pulses; note
capillary refill, skin Conditions that contribute to
color/temperature. extracellular fluid deficit can
result in inadequate organ
perfusion to all areas and
may cause circulatory
collapse/shock.

Teach family and patient about

complications of deficient fluid Fluid restriction helps to
and electrolytes prevent more buildup of fluid
in the body.

DEPENDENT:

Place the patient on fluid

restriction as per the physician’s A slow intravenous sodium
order. solution is given to raise the
sodium level in the blood
Administer a slow intravenous stream.
sodium solution as prescribed.
In case of SIADH-induced
hyponatremia, administer To block the action of the
vasopressin antagonists as vasopressin ADH.
prescribed.
 Assessment Diagnosis Planning Interventions Rationale Expected outcome
INDEPENDENT:
Subjective: SHORT TERM SHORT TERM GOAL:
GOAL: Determine real, exact body weight Weight is used as a basis for
“Mahina daw syang Imbalanced Nutrition: Less for age and height. Do not caloric and nutritional Within the shift, the
kumain” as Than Body Requirements Within the shift, the estimate requirements. patient or significant
verbalized by the related to poor oral intake patient or significant others will verbalize
nurse of the patient secondary to anorexia as others will be able to Assess the patient’s nutritional Nutritional risk screening importance and initiate
evidenced by decreased verbalize importance risk using nutritional risk tools are very useful in the behaviors or lifestyle
Objective: weight, appetite, level and initiate behaviors screening tools. everyday routine to detect changes to regain and to
consciousness and lack of or lifestyle changes to potential or manifest maintain appropriate
- Decreased response regain and to maintain malnutrition in a timely weight of the patient.
weight appropriate weight of method.
- Decreased the patient. LONG TERM GOAL:
appetite Assess patient’s nutritional status Assessment of the nutritional
- Decreased level status should be conducted By the time of discharge,
of LONG TERM GOAL: in patients identified as at the patient demonstrate
consciousness nutritional risk following the stable weight or
- Lack of By the time of screening for risk of progressive gain toward
response discharge, the patient malnutrition goal and absence of
will demonstrate signs of
Glagow Coma Scale stable weight or Ascertain etiological factors for Several factors may affect malnutrition.
Score: progressive gain decreased nutritional intake. the patient’s nutritional
toward goal and intake, so it is vital to assess
absence of signs of properly. Ambulatory patients
13 | 5-22-22 malnutrition. with nutritional problems such
as weight loss may be
experiencing difficulties
11-12 | 5-23-22
unrelated to disease

Look for physical signs of poor The patient encountering

nutritional intake. nutritional deficiencies may
resemble to be sluggish and
fatigued.

Review laboratory values that Laboratory tests play a

indicate well-being or significant part in determining
deterioration. the patient’s nutritional status

COLLABORATIVE:
Consult with dietitian and nutrition Helpful in assessing client’s
specialist nutritional needs in light of
changes in indigestion and
intestinal function, including
absorption of vitamins and
minerals
 Assessment Diagnosis Planning Interventions Rationale Expected outcome
INDEPENDENT:
Subjective: SHORT TERM GOAL:  Establish rapport listening  Friendly relationship with SHORT TERM GOAL:
carefully and attending to client’s patient and to be able to
“Minsan nakakausap Impaired Verbal After series of nursing verbal and non verbal know her concerns After series of nursing
naman sya pero hindi Communication related intervention, the client will expressions intervention, the client
maintindihan” as to loss of mental be able to communicate will communicate and
verbalized by the function and processes and participate to  Assess the degree of  This will determine the participate to
nurse of the patient secondary to loss of therapeutic disorientation to time, place, amount of reorientation therapeutic
neuronal function communication and person and situation. and intervention the communication and
Objective: responsible for memory interventions needed. patient will need. interventions needed.
and speech as
 Showing evidenced by showing LONG TERM GOAL: LONG TERM GOAL:
 Evaluate mental status, note  Evaluating the mental
decrease level of decrease level of
presence of psychotic status of the patient is
consciousness consciousness, By the time of discharge, By the time of discharge,
conditions. Assess psychological vital to determine
and impaired impaired verbal the patient will be able to the patient will build
response to communication contributing factors.
verbal communication and build reality-based reality-based cognitive
impairment, willingness to find
communication mental status cognitive process, process, stablish the
alternate means of
 Mental status examination reveals stablish the relationship, relationship, seek aid
communicating
examination loss of cognition, seek aid and support as and support as required,
 Dysphasia assessment
reveals loss of comprehension and required, remain calm remain calm and
 Assess for the presence of provides you with
cognition, disturbed thought and oriented, verbalize oriented, verbalize being
expressive dysphasia (inability to invaluable information. It
comprehension process being control of his/her control of his/her life,
cover information verbally) and allows you to establish
and disturbed life, and communicate receptive dysphasia (word the type of dysphasia and communicate
thought process effectively. meaning may be scrambled your client has, along effectively.
during the process of information with severity of it, and
by the patient’s brain). strengths and
weaknesses.
Glagow Coma Scale
Score:
 To promote positive
 Listen to the client carefully sense for leaning
13 | 5-22-22 about the thought process and
readiness to non-verbal
communication
11-12 | 5-23-22  To avoid overwhelming
 Use simple words and short the client with numerous
sentences while communicating verbal stimuli

 To avoid distraction and

 Decrease excess environmental disrupting the
stimuli communication efforts

 To make communication
 Ask simple questions that can be process simple
answered by yes or no
 To compensate for
 Make use of gestures and sign verbal communication
 language appropriate to the and for better
communication understanding

DEPENDENT  To diagnose, treat or

 Administer medication as prevent illness
prescribed

COLLABORATIVE:

 Collaborate with the speech  To help gain the

therapist speaking ability
 Assessment Diagnosis Planning Interventions Rationale Expected outcome

Subjective: SHORT TERM INDEPENDENT: SHORT TERM GOAL:

GOAL:
Risk for injury related to body Determine the client’s age, These factors play a role in Within the shift, the
Objective: weakness Within the shift, the developmental stage, health the client’s ability to keep patient or significant
patient or significant status, lifestyle, impaired themselves safe from injury. others will determine
others will be able to communication, sensory- Nurses must thoroughly the factors that
determine the factors perceptual impairment, mobility, assess each of these factors increases the risk for
that increases the risk cognitive awareness, and when formulating a plan of injury and will
Vital Signs: for injury and will decision-making ability. care or teaching the clients demonstrate behaviors
demonstrate about safety measures. to avoid injury.
behaviors to avoid
injury. Assess the client’s ability to Alterations in mobility LONG TERM GOAL:
ambulate and identify the risk for secondary to muscle
LONG TERM GOAL: falls. weakness, paralysis, poor After hospitalization, the
balance, and lack of patient remain free form
After hospitalization, coordination increase the risk the injuries
the patient will remain of falls.
free form the injuries
Check on the home environment Patients experiencing
for threats to safety. impaired mobility, impaired
visual acuity, and
neurological dysfunction,
including dementia and other
cognitive functional deficits,
are at risk for injury from
common hazards.

Assess for changes in health A change in health status

status and cognitive awareness.
COLLABORATIVE:
may increase a client’s risk of
injury. For example, a
postoperative patient may
experience confusion,
disorientation, and memory
loss putting them at risk for
falls/injury.

Coordinate with a physical Gait training in physical

therapist for strengthening therapy has been proven to
exercises and gait training to prevent falls effectively.
increase mobility. Contact Safety is accomplished from
occupational therapists for the collaborative efforts by
assistance with helping patients both individuals that provide
 perform ADLs. direct or indirect care to
clients and the healthcare
system.

Assessment Diagnosis Planning Interventions Rationale Expected outcome

Risk for Self care deficit SHORT TERM GOAL: INDEPENDENT: SHORT TERM GOAL:
Subjective:
related to impaired
mobility secondary to Within hospitalization, Assess the patient’s strength to The patient may only need Within hospitalization, the
neuronal dysfunction the patient will be able accomplish ADLs efficiently and help with some self-care patient will perform
Objective:
causing impaired function to perform activities of cautiously on a daily basis using a measures. FIM measures 18 activities of daily living as
of the extremities daily living as proper assessment tool, such as the self-care items related to independently as
independently as Functional Independence Measures eating, bathing, grooming, possible and recognize
possible, and (FIM). dressing, toileting, bladder when he or she needs
recognize when he or and bowel management, assistance
she needs assistance transfer, ambulation, and
stair climbing. LONG TERM GOAL:
LONG TERM GOAL:
Assess patient’s ability to perform To provide interventions After hospitalization, the
After hospitalization, self are based on the ability of the patient remain free form
the patient will remain patient the risk of having self
free form the risk of care deficit
having self care deficit Encourage the client in setting To promote the sense of well
realistic goals based on their ability being and satisfaction
and help them to achieve
independence care.

Provide psychological support by To gain confidence and

informing that gradually client will be facilitate feeling of self worth
able to hold responsibilities and
improve the self care ability

Educate the patient’s carer or To provide learning to the

significant other on providing carer or significant other and
appropriate assistance to the patient to ensure that the patient has
while he/she performs self-care a good amount of support
tasks. while doing ADLs at home.

Meet all the activities of daily living To meet the self care needs
and self care like bathing, oral care, and improve hygiene
perineal care etc. at the bed side

Determine the specific cause of To aid in recovery and

each deficit (e.g., visual problems, improve self care activity
weakness, cognitive impairment).

Advice the client and family Various etiological factors

members to cope up with the may need more explicit
treatment protocol and follow chemo interventions to enable self-
and therapy care.

DEPENDENT:

Administer vitamins supplements To improve cognitive

and Piracetam as prescribed function and to maintain self-
care
COLLABORATIVE:

Refer the patient to occupational

therapist. Occupational therapists are
skilled professionals in
helping clients achieve
optimal performance in their
daily activities like bathing,
dressing, and personal
hygiene tasks.
Coordinate with the physical therapy
team on how to create and initiate A customized exercise plan
an exercise program for the patient. can help the patient in terms
of increasing his/her
endurance and strength
which he/she will need when
doing self-care activities.
 Assessment Diagnosis Planning Interventions Rationale Expected outcome
SHORT TERM GOAL: SHORT TERM GOAL:
Risk for infection related Independent:
Subjective:
to craniotomy After 2 hours of After 2 hours of nursing
nursing intervention, Note the risk factors for occurrence To help the patient identify intervention, the patient
the patient or patient’s of infection in the incision the present risk factors that or patient’s significant
Objective:
significant others will may add up to the infection others will gain
be able to gain knowledge in infection
knowledge in infection control as evidenced by
control as evidenced Observe for localized signs of To evaluate if the character, discussing the wound
by discussing the infection at sites of invasive lines, presence and condition of caring
wound caring surgical incisions or wounds the present infection
.
LONG TERM GOAL:
LONG TERM GOAL: Discuss to patient the following To impart to the patient when
signs of infection – redness, the wound become infected After hospitalization the
After hospitalization swelling, increased pain, or purulent and when to sought medical patient or patient’s
the patient or patient’s drainage on the site and fever care significant others will
significant others will have the necessary
be able to have the knowledge and
necessary knowledge Make health teachings specially in information on how to be
and information on identification of environmental risk To help. The client modify or free from signs and
how to be free from factors that could add up on avoid some of the symptoms of infection
signs and symptoms of infection environmental factors
infection present which could reduce
the incidence of infection

Know the signs of itching and

scratching The patient who scratches
the wound to alleviate
extreme itching may open
the suture and increase the
risk for infection

A sterile technique reduces

Keep a sterile dressing technique the risk of infection in
during wound care. impaired tissue integrity. This
involves the use of a sterile
procedure field, sterile
gloves, sterile supplies and
dressing, sterile instruments
Dependent:
Antibiotics will help kill and
Administer antibiotics as ordered by stop the proliferation and
the physician growth of the bacteria which
could cause infection
 DRUG NAME DOSAGE AND INDICATION CONTRAINDICATION MECHANISM OF NURSING
ADMINISTRATION ACTION RESPONSIBILITIES
BRAND NAME:
40 milligrams (mg) 1 tab MICARDIS HCT * In patients who are Telmisartan blocks the * Monitor BP carefully
Telmisartan a day. (telmisartan and hypersensitive to any vasoconstrictor and after initial dose; and
hydrochlorothiazide) is component of this aldosterone-secreting periodically thereafter.
indicated for the product. effects of angiotensin II Monitor more frequently
treatment of by selectively blocking with preexisting biliary
GENERIC NAME: hypertension, to lower * In patients with anuria. the binding of obstructive disorders or
blood pressure. angiotensin II to the AT1 hepatic insufficiency.
Micardis Lowering blood * For co-administration receptor in many
pressure reduces the with aliskiren in patients tissues, such as * Monitor dialysis
risk of fatal and nonfatal with diabetes vascular smooth muscle patients closely for
cardiovascular events, and the adrenal gland. orthostatic hypotension.
CLASSIFICATION: primarily strokes and
myocardial infarctions. * Lab tests: Periodic
CARDIOVASCULAR These benefits have Hgb, creatinine
AGENT; been seen in controlled clearance, liver
ANTIHYPERTENSIVE; trials of antihypertensive enzymes.
ANGIOTENSIN II drugs from a wide
RECEPTOR variety of pharmacologic * Monitor concomitant
ANTAGONIST classes including the digoxin levels
classes to which this throughout therapy.
drug principally belongs.
* Allow between 2–4 wk
for maximum
therapeutic response.

* Do not breast feed

while taking this drug.
 DRUG NAME DOSAGE AND INDICATION CONTRAINDICATION MECHANISM OF NURSING
ADMINISTRATION ACTION RESPONSIBILITIES
GENERIC NAME:
Used for the promotion Mannitol is an osmotic
Mannitol of diuresis before There are multiple diuretic that is
1.25 g/kg IV infused * Take care to avoid
irreversible renal failure contraindications to metabolically inert in
over 30-60 minutes; extravasation. Observe
becomes established, giving mannitol, humans and occurs
may repeat q6-8hr injection site for signs of
the reduction of including: naturally, as a sugar or inflammation or edema.
BRAND NAME: intracranial pressure, sugar alcohol, in fruits
 Established anuria
the treatment of cerebral and vegetables.
due to renal disease * Lab tests: Monitor
Osmitrol edema, and the Mannitol elevates blood closely serum and urine
promotion of urinary  Pulmonary edema plasma osmolality, electrolytes and kidney
excretion of toxic or severe resulting in enhanced function during therapy.
substances. pulmonary flow of water from
congestion tissues, including the
CLASSIFICATION: brain and cerebrospinal * Measure I&O
Mannitol is also
 Active intracranial fluid, into interstitial fluid accurately and record to
indicated as add-on
Diuretics, Osmotic and plasma. As a result, achieve proper fluid
maintenance therapy for bleeding except for
Agents cerebral edema, balance.
improving pulmonary during a current
function in cystic fibrosis craniotomy elevated intracranial
patients aged 18 and pressure, and * Monitor vital signs
over who have passed  Severe dehydration cerebrospinal fluid closely. Report
the BRONCHITOL volume and pressure significant changes in
 Progressive heart may be reduced. As a BP and signs of CHF.
tolerance test (BTT). It
failure diuretic mannitol
is recommended that
patients take an orally induces diuresis * Monitor for possible
 Known mannitol
inhaled short-acting because it is not indications of fluid and
hypersensitivity
bronchodilator 5-15 reabsorbed in the renal electrolyte imbalance
minutes prior to every  Renal damage tubule, thereby (e.g., thirst, muscle
inhaled mannitol dose. caused by mannitol increasing the cramps or weakness,
osmolality of the paresthesia’s, and signs
glomerular filtrate, of CHF).
facilitating excretion of
water, and inhibiting the * Be alert to the
renal tubular possibility that a
reabsorption of sodium, rebound increase in ICP
chloride, and other sometimes occurs about
solutes. Mannitol 12 h after drug
promotes the urinary administration. Patient
excretion of toxic may complain of
materials and protects headache or confusion.
against nephrotoxicity
by preventing the
* Take accurate daily
concentration of toxic
weight.
substances in the
tubular fluid. As an
Antiglaucoma agent
mannitol elevates blood
plasma osmolarity,
resulting in enhanced
flow of water from the
eye into plasma and a
consequent reduction in
intraocular pressure. As
a renal function
diagnostic aid mannitol
is freely filtered by the
glomeruli with less than
10% tubular
reabsorption. Therefore,
its urinary excretion rate
may serve as a
measurement of
glomerular filtration rate
(GFR).

The exact mechanism of

action of inhaled
mannitol in the
symptomatic
maintenance treatment
of cystic fibrosis remains
unclear. It is
hypothesized that
mannitol produces an
osmotic gradient across
the airway epithelium
that draws fluid into the
extracellular space and
alters the properties of
the airway surface
mucus layer, allowing
easier mucociliary
clearance.
 DRUG NAME DOSAGE AND INDICATION CONTRAINDICATION MECHANISM OF NURSING
ADMINISTRATION ACTION RESPONSIBILITIES
GENERIC NAME:
Phenytoin is indicated to  Hypersensitivity to * Continuously monitor
Phenytoin treat grand mal Phenytoin is a hydantoin vital signs and
Capsule, immediate-
seizures, complex drug derivative, a first- symptoms during IV
release
partial seizures, and to generation anti- infusion and for an hour
 Sinus bradycardia convulsant drug that is
 30mg prevent and treat afterward. Watch for
BRAND NAME: seizures during or effective in the respiratory depression.
 100mg  Sinoatrial block treatment of generalized
following neurosurgery. Constant observation
Dilantin Injectable phenytoin  Second and third- tonic-clonic seizures, and a cardiac monitor
Capsule, extended- complex partial
release and Fosphenytoin, are necessary with older
which is the phosphate degree A-V block seizures, and status adults or patients with
ester prodrug epilepticus without cardiac disease. Margin
 100mg  Adams-Stokes significantly impairing
formulation of between toxic and
DRUG NAME DOSAGE
200mgAND INDICATION CONTRAINDICATION MECHANISM
neurological OF
function.  NURSING
CLASSIFICATION: phenytoin, are indicated therapeutic IV doses is
ADMINISTRATION
 300mg syndrome ACTION RESPONSIBILITIES
to treat tonic-clonic relatively small.
BRAND NAME: Phenytoin works by
Anticonvulsant status epilepticus, and • Hypersensitivity
Concurrent use with
tablet, chewable to blockade
Trimetazidine of voltage-
inhibits
for the prevention and * Instruct
Be the aware of
patient to
Vastarel 35 mg/tab
 50mg BID. Trimetazidine is trimetazidine or any dependent
beta-oxidationmembrane
of fatty
treatment of seizures delavirdine of therapeutic
to: serum
indicated for the component the sodium
acids by blocking channels
long-
occurring during concentration: 10–20
Oral suspension symptomatic treatment product responsible
chain 3-ketoacyl-CoA for
neurosurgery. • Parkinson’s
History ofdisease,
prior mcg/mL;
* Take toxic level: 30–
Trimetazidine
 125mg/5mL of stable angina pectoris increasing
thiolase, the action
which
50
withmcg/mL;
food. lethal level:
in patients inadequately parkinsonian symptoms, potential.
enhances Through this
glucose
acute hepatotoxicity 100 mcg/mL. Steady-
GENERIC NAME: Injectable solution controlled or intolerant tremors, restless leg action,
oxidation.it obstructs
In the
an
state therapeutic
* Do not levels
take in larger
 50mg/mL to first line therapies. syndrome, and other
attributable to positive
ischaemicfeedback
cell, energy that
are not achieved for
amounts at
than
Trimetazidine movement-related sustains high-frequency
obtained during glucose
least 7–10 d.
advised/prescribed.
disorders
phenytoin repetitive firing, thus
oxidation requires less
• Severe renal preventing
oxygen the spread of
consumption
* Lab tests: Periodic
impairment (creatinine the
thanseizure
in focalthe point.
beta-
serum
* Ensure that phenytoin
the
clearance <30 mL/min) oxidation process.
concentration;
treatment course CBC with is
CLASSIFICATION: • Pregnancy
differential,
completed. platelet
• Breastfeeding
count, and Hct and Hgb;
Fatty acid oxidation
serum
* Do notglucose, serum
stop the use of
inhibitors.
calcium,
this medicine and without
serum
magnesium;
consulting the and
doctor.liver
function tests.

* Observe patient
closely for neurologic
adverse effects
following IV
administration. Have on
hand oxygen, atropine,
vasopressor, assisted
ventilation, seizure
precaution equipment
(mouth gag, nonmetal
airway, suction
apparatus).

* Be aware that gingival

hyperplasia appears
 DRUG NAME DOSAGE AND INDICATION CONTRAINDICATION MECHANISM OF NURSING
ADMINISTRATION ACTION RESPONSIBILITIES
BRAND NAME:
20 milligrams (mg) once Omeprazole, according Long-term use for Hydrochloric acid (HCl) Assessment & Drug
Prilosec a day before a meal. to the FDA label Label is gastroesophageal reflux secretion into the gastric Effects
a proton pump inhibitor disease (GERD), lumen is a process
(PPI) used for the duodenal ulcers; proton regulated mainly by the * Lab tests: Monitor
following purposes: pump inhibitors (PPIs), H(+)/K(+)-ATPase of the urinalysis for hematuria
GENERIC NAME: hypersensitivity; children proton pump, expressed and proteinuria. Periodic
• Treatment of active <2 y; use of OTC in high quantities by the liver function tests with
Omeprazole duodenal ulcer in adults formulation in children parietal cells of the prolonged use.
<18 y or GI bleeding; stomach. ATPase is an Patient & Family
• Eradication of pregnancy (category C); enzyme on the parietal Education
Helicobacter pylori to use of Zegerid in cell membrane that
CLASSIFICATION: reduce the risk of metabolic alkalosis, facilitates hydrogen and * Report any changes in
duodenal ulcer hypocalcemia, vomiting, potassium exchange urinary elimination such
GASTROINTESTINAL recurrence in adults GI bleeding. through the cell, which as pain or discomfort
AGENT; PROTON normally results in the associated with
PUMP INHIBITOR • Treatment of active extrusion of potassium urination, or blood in
benign gastric ulcer in and formation of HCl urine.
adults (gastric acid).
* Report severe
• Treatment of Omeprazole is a diarrhea; drug may need
symptomatic member of a class of to be discontinued.
gastroesophageal reflux antisecretory Do not breast feed while
disease (GERD) in compounds, the taking this drug
patients 1 year of age substituted
and older benzimidazoles, that
stop gastric acid
• Treatment of erosive secretion by selective
esophagitis (EE) due to inhibition of the H+/K+
acid-mediated GERD in ATPase enzyme
patients 1 month of age system. Proton-pump
and older inhibitors such as
 omeprazole bind
• Maintenance of covalently to cysteine
healing of EE due to residues via disulfide
acid-mediated GERD in bridges on the alpha
patients 1 year of age subunit of the H+/K+
and older ATPase pump, inhibiting
gastric acid secretion for
• Pathologic up to 36 hours. This
hypersecretory antisecretory effect is
conditions in adults dose-related and leads
to the inhibition of both
basal and stimulated
acid secretion,
regardless of the
stimulus.
 DRUG NAME DOSAGE AND INDICATION CONTRAINDICATION MECHANISM OF NURSING
ADMINISTRATION ACTION RESPONSIBILITIES
BRAND NAME: .
5-31-22 | 11:33PM Potassium chloride Severe renal Supplemental Assessment & Drug
extended-release impairment; severe potassium in the form of Effects
Start KCL tablet TID. capsules are indicated hemolytic reactions; high potassium food or
for the treatment and untreated Addison's potassium chloride may * Monitor I&O ratio and
GENERIC NAME: prophylaxis of disease; crush be able to restore pattern in patients
hypokalemia in adults syndrome; early normal potassium receiving the parenteral
Potassium chloride and children with or postoperative oliguria levels. drug. If oliguria occurs,
without metabolic (except during GI stop infusion promptly
alkalosis, in patients for drainage); adynamic and notify physician.
CLASSIFICATION: whom dietary ileus; acute dehydration;
management with heat cramps, * Lab test: Frequent
ELECTROLYTIC AND potassium-rich foods or hyperkalemia, patients serum electrolytes are
WATER BALANCE diuretic dose reduction receiving potassium- warranted.
AGENT; is insufficient. sparing diuretics, Monitor for and report
REPLACEMENT digitalis intoxication with signs of GI ulceration
SOLUTION AV conduction (esophageal or
disturbance. epigastric pain or
hematemesis).

* Monitor patients
receiving parenteral
potassium closely with
cardiac monitor.
Irregular heartbeat is
usually the earliest
clinical indication of
hyperkalemia.
Be alert for potassium
intoxication may result
from any therapeutic
dosage, and the patient
may be asymptomatic.

* The risk of
hyperkalemia with
potassium supplement
increases (1) in older
adults because of
decremental changes in
kidney function
associated with aging,
(2) when dietary intake
of potassium suddenly
increases, and (3) when
kidney function is
significantly
compromised.
 DRUG NAME DOSAGE AND INDICATION CONTRAINDICATION MECHANISM OF NURSING
ADMINISTRATION ACTION RESPONSIBILITIES
BRAND NAME: .
Paracetamol is a mild Hypersensitivity to Paracetamol has a * Check the patient’s
300mg IV q4h PRN analgesic and paracetamol or any central analgesic effect serum potassium levels.
antipyretic, and is component of the that is mediated through Check for current
recommended for the product. activation of descending medications that include
GENERIC NAME: treatment of most serotonergic pathways. anticoagulants as these
painful and febrile Renal Insufficiency Debate exists about its should be used
Paracetamol conditions, for example, Anemia primary site of action, cautiously with
headache including which may be inhibition acetaminophen.
migraine, toothache, of prostaglandin (PG)
neuralgia, colds and synthesis or through an * Advise the patient that
influenza, sore throat, active metabolite Do not exceed
CLASSIFICATION: backache, rheumatic influencing cannabinoid 4gm/24hr. In adults and
pain and receptors. 75mg/kg/day in children.
CENTRAL NERVOUS dysmenorrhoea.
SYSTEM AGENT; * Do not take for >5days
NONNARCOTIC for pain in children, ten
ANALGESIC, days for pain in adults,
ANTIPYRETIC or more than three days
for fever in adults.

* Monitor CBC, liver,

and renal functions.
Assess for fecal occult
blood and nephritis.
Avoid using OTC drugs
with Acetaminophen.

* Take with food or milk

to minimize GI upset.
Report N&V. cyanosis,
shortness of breath, and
abdominal pain as these
are signs of toxicity.

* Report paleness,
weakness, and
heartbeat skips
Report abdominal pain,
jaundice, dark urine,
itchiness, or clay-
colored stools.
Phenmacetin may
cause urine to become
dark brown or wine-
colored.

* Report pain that

persists for more than 3-
5 days

* Avoid alcohol.

* This drug is not for

regular use with any
form of liver disease..

* N-acetylcysteine – For
those with more severe
or complicated
paracetamol or
acetaminophen
overdose, parenteral
administration of N-
aetylcysteine, an amino
acid, is the drug of
choice and antidote to
counteract its toxic
effects.
 DRUG NAME DOSAGE AND INDICATION CONTRAINDICATION MECHANISM OF NURSING
ADMINISTRATION ACTION RESPONSIBILITIES
BRAND NAME: .
1 gram (g) injected into Moderate-to-severe: Hypersensitivity to The bactericidal activity .
Invanz a vein or injected into a complicated intra- ertapenem; of ertapenem results * Lab tests: Perform
muscle once a day. abdominal infections, hypersensitivity to from the inhibition of cell C&S tests prior to
complicated skin and amide-type local wall synthesis and is therapy. Monitor
skin structure infections, anesthetics such as mediated through periodically liver and
GENERIC NAME community-acquired lidocaine; ertapenem binding to kidney function.
pneumonia, complicated hypersensitivity to penicillin binding
Ertapenem urinary tract infections meropenem or proteins (PBPs). In * Determine history of
(including imipenem; previous Escherichia coli, it has hypersensitivity
pyelonephritis), acute anaphylactic reaction to strong affinity toward reactions to other beta-
pelvic infections beta-lactams. PBPs 1a, 1b, 2, 3, 4 and lactams,
including postpartum 5 with preference for cephalosporins,
endomyometritis, septic PBPs 2 and 3. penicillins, or other
CLASSIFICATION: abortion, and Ertapenem is stable drugs. Discontinue drug
ANTIINFECTIVE; postsurgical gynecologic against hydrolysis by a and immediately report
BETA-LACTAM infections. Prophylaxis variety of beta- S&S of hypersensitivity.
ANTIBIOTIC of surgical site infection lactamases, including
following elective penicillinases, and * Report S&S of
colorectal surgery. cephalosporinases and superinfection or
extended spectrum pseudomembranous
beta-lactamases. colitis.
Ertapenem is
hydrolyzed by metallo- * Monitor for seizures
beta-lactamases. especially in older adults
and those with renal
insufficiency.

* Lab tests: Monitor

AST, ALT, alkaline
phosphatase, CBC,
platelet count, and
routine blood chemistry
during prolonged
 therapy.

DRUG NAME DOSAGE AND INDICATION CONTRAINDICATION MECHANISM OF NURSING

ADMINISTRATION ACTION RESPONSIBILITIES
BRAND NAME: Amlodipine may be .
5mg tab OD used alone or in Hypersensitivity to Amlodipine is * Monitor BP for
Amvasc combination with other amlodipine or any considered a peripheral therapeutic
antihypertensive and dihydropyridine calcium arterial vasodilator that effectiveness. BP
antianginal agents for antagonist; advanced exerts its action directly reduction is greatest
the treatment of the aortic stenosis because on vascular smooth after peak levels of
following conditions the drug can worsen the muscle to lead to a amlodipine are achieved
GENERIC NAME: Label: abnormal valve reduction in peripheral 6–9 h following oral
pressure gradient vascular resistance, doses.
Amlodipine • Hypertension associated with this causing a decrease in
condition; pregnant blood pressure. * Monitor for S&S of
• Coronary artery women, women of Amlodipine is a dose-related peripheral
disease childbearing potential or dihydropyridine calcium or facial edema that
CLASSIFICATION: breastfeeding mothers; antagonist (calcium ion may not be
• Chronic stable angina severe liver failure; antagonist or slow- accompanied by weight
CARDIOVASCULAR known history of shock. channel blocker) that gain; rarely, severe
AGENT; CALCIUM • Vasospastic angina inhibits the influx of edema may cause
CHANNEL BLOCKER; (Prinzmetal’s or Variant calcium ions into both discontinuation of drug.
ANTIHYPERTENSIVE angina) vascular smooth muscle
AGENT and cardiac muscle. * Monitor BP with
• Angiographically Experimental studies postural changes.
documented coronary imply that amlodipine Report postural
artery disease in binds to both hypotension. Monitor
patients without heart dihydropyridine and more frequently when
failure or an ejection nondihydropyridine additional
fraction < 40% binding sites, located on antihypertensives or
cell membranes. The diuretics are added.
contraction of cardiac
muscle and vascular * Monitor heart rate;
smooth muscle are dose-related palpitations
dependent on the (more common in
movement of women) may occur.
extracellular calcium
ions into these cells by
specific ion channels.
Amlodipine blocks
calcium ion influx across
cell membranes with
selectivity. A stronger
effect of amlodipine is
exerted on vascular
smooth muscle cells
than on cardiac muscle
cells.. Direct actions of
amlodipine on vascular
smooth muscle result in
reduced blood pressure