I.

Demographic Profile
Patient’s Name: Room #:
Age:
Sex:
Marital Status:
Religion:
Address:
Physician: Chief Complaint:
Procedure:
Admitting Diagnosis:
II. History
a. Past Medical History
b. Past Surgery History
c. Medication History
d. Family History

III. Medications:
IV. Review of Systems
Gen:
Skin:
 HEENT:
Resp:
Cardiac:
GIT:

DRUG STUDY

Drug Mechanism of Indication Routes Contraindications Side Effects Nursing

Action and Responsibilities
Dosage
Ondansetron Blocks serotonin Used to 8mg, IV  Allergic/ CNS: headache,  First dose must
effects at 5-HT3- prevent Hypersensitivity to dizziness, administer 30
receptor sites in the nausea and similar medications fatigue. minutes prior to
Drug Classification: vagal nerve vomiting that Weakness emetogenic event.
 Congenital long QT
Antiemetics terminals and the may be caused  Instruct patient to
syndrome
chemoreceptor by  With phenylketonuria CV: QT interval take ondansetron as
trigger zone in the chemotherapy, (PKU) d/t orally prolongation directed.
CNS. radiation disintegrating tablets  Advise patient to
therapy, may contain GI: constipation, notify health care
and/or post- phenylalanine diarrhea, professional
operation. abdominal pain, immediately if
  Hepatic Impairment dry mouth,  symptoms of
(daily dose not to exceed liver enzymes irregular heartbeat
8mg) occur.
 Concurrent use of
apomorphine (  risk of
severe hypotension and
loss of consciousness)

Omeprazole Binds to an Used to 40 mg,  Hypersensitivity CNS: headache,
enzyme on gastric diminish IV  Lactation dizziness,  Instruct patient to
parietal cells in the accumulation  With liver disease fatigue, notify health care
Drug Classification: presence of acidic of acid in the weakness
Anti-ulcer agent professional of
gastric pH, gastric lumen onset of black,
(Proton Pump preventing the final CV: chest pain
Inhibitor) tarry stools
transport of  Instruct patient to
hydrogen ions into GI: constipation, avoid alcohol,
the gastric lumen. diarrhea, medications
abdominal pain, containing aspirin
acid or NSAIDs, and
regurgitation foods that may
increase GI
F&E: irritation.
hypomagnesemia

Derm: itching,
rash

Dexamethasone Suppress migration Adjunctive 100 mg,  Systemic fungal CNS:  Monitor I&O
of management IV infections depression, ratios and daily
polymorphonuclear of nausea and  Administration of live euphoria, weights.
Drug Classification: leukocytes (PML) vomiting from virus vaccines headache,  Observe patient
Long-acting and reverse chemotherapy;  Immunosuppression restlessness for peripheral
corticosteroids increased capillary suppression of  Hypothyroidism edema
permeability by inflammation CV:  Check vitals signs
their anti- and hypertension at least twice a
inflammatory modification day.
effect. Suppress of the normal  Monitor daily
immune system immune GI: peptic pattern of bowel
response ulceration, activity, stool
diarrhea, consistency.
anorexia  Evaluate food
tolerance.
F&E: fluid  Monitor serum
retention (long- electrolytes
term high doses), especially for
hypokalemia hypercalcemia
and hypokalemia.
Metab: Weight  Instruct the
gain patient to avoid
alcohol and limit
MS: muscle caffeine.
wasting, Encourage patient
osteoporosis to eat a diet high
in protein,
Misc: calcium, and
cushingoid potassium, and
appearance low I sodium and
(moon face),  carbohydrates.
susceptibility to  Instruct patient on
infection correct technique
of medication
administration.
Advise patient to
take medication as
directed.
  Caution patient to
avoid
vaccinations
without first
consulting health
care professional

Metoclopramide Blocks dopamine Used to 10mg  Hypersensitivity CNS:  Assess for signs
receptors in prevent IV PRN  Hx of depression drowsiness, of depression
chemoreceptor vomiting in q8 for  Hx of seizure disorders restlessness periodically
Drug Classification: trigger zone of the chemotherapy N/W  Diabetes Mellitus (may anxiety, throughout
Antiemetic CNS. Stimulates alter response to insulin) depression therapy.
motility of the  Renal impairment  For PO,
upper GI tract and CV: arrhythmia, administer doses
accelerates gastric hypertension, 30 minutes before
emptying. hypotension meals and at
bedtime.
GI: constipation,  For IV, advise
diarrhea, dry patient to
mouth, administer IV
dose 30 min
before
administration of
chemotherapeutic
agent
 Avoid concurrent
use of alcohol and
other CNS
depressants while
taking this
medication.
Gabapentin Mechanism of Used with 100 MG  Hypersensitivity CNS: Confusion,  Administer with
action is not other 1 TAB  Renal toxicity depression, evening meal.
known. May affect medications to BID, PO  Concurrent use of dizziness, Swallow tablet
Drug Classification: transport decrease antacid drowsiness whole; do not
Anticonvulsant drug of amino acids incidences of crush, break, or
across and stabilize seizure and as EENT : chew.
neuronal neuropathic abnormal vision  Instruct patient to
membranes. pain take medication
CV : exactly as discrete
hypertension  Advice patient not
to take the
medication within
2 hr of antacid.

NURSING CARE PLAN

Identified Problem: Pain and bruises on both arms
Nursing Diagnosis: Risk for Impaired Skin Integrity related to effects of chemotherapy

Assessment Planning Implementation Evaluation

Subjective:
“Masakit akon kamot kanan
an chemotherapy.”, as
verbalized by the patient.
Objective:
Within 8 hours of nursing  Assess skin frequently for side effects of Long Term Goals:
intervention, the patient cancer therapy. Emphasize importance of Within 8 hours of nursing
will be able to: reporting open areas to caregiver. intervention, the patient was
 Verbalize  Encourage patient to avoid vigorous able to:
understanding of rubbing and scratching and to pat skin dry  Verbalized
treatment/therapy instead of rubbing. understanding of
regimen.  Turn or reposition frequently. treatment/therapy
 Demonstrate  Educate patient for expected dermatologic regimen.
 behaviors and side effects seen with chemotherapy.  Demonstrated behaviors
 Pain Scale: 3 techniques to  Apply ice pack or warm compresses per and techniques to
 Noticed presence of prevent skin protocol prevent skin breakdown
bruising left arm due breakdown  Massage bony prominences and use proper
to IV insertion. positioning, turning, lifting, and
 V/S taken as follows: transferring techniques when moving client
T: 35.7 to prevent friction or shear injury.
P: 74  Emphasize importance of adequate
R: 20 nutritional and fluid intake to maintain
BP: 110/80 general good health and skin turgor.
 Hemoglobin: 130

NURSING CARE PLAN

Identified Problem: Fatigability and weakness
Nursing Diagnosis: Fatigue related to altered body chemistry, side effects of pain and other medications, chemotherapy

Assessment Planning Implementation Evaluation

Subjective:
“Okay la man ak. Medyo
maluya ha lawaw.”, as
verbalized by the patient
Objective:
Within 8 hours of nursing
intervention, the patient
will be able to :
 Report improved
sense of energy.
 Identify basis of
fatigue and
individual areas of
 Have patient rate fatigue (using a 0 to 10 or
similar numerical scale, using a numeric
scale, if possible, the time of a day when it
is mots severe.
 Plan care to allow rest periods. Schedule
activities for patients when patient has
more energy.
 Assess patient with self-care needs. Keep
Within 8 hours of nursing
intervention, the patient was
able to:
 Report improved sense of
energy.
 Identified basis of fatigue
and individual areas of
control.
 control. bed in low position and assist ambulation.  Performed activities of
 V/S taken as follows:  Perform activities of  Encourage patient to do whatever possible daily living and participate
T: 35.7 daily living and and increase activity level as tolerated. in desired activities at
P: 74 participate in desired  Accept reality of client reports of fatigue level of ability.
R: 20 activities at level of and do not underestimate effect on client’s  Participated in
BP: 110/80 ability. quality of life. recommended treatment
 Participate in  Perform pain assessment and provide pain program.
recommended management as prescribed.
treatment program.  Encourage nutritional intake.
 Educate patient the side effects of
chemotherapy (weakness, nausea,
headache.
 Promote overall health measures (e.g.,
nutrition, adequate fluid intake, and
appropriate vitamin and iron
supplementation).

NURSING CARE PLAN

Identified Problem: Desire to manage side effects of chemotherapy

Nursing Diagnosis: Readiness of Enhanced Self-Health Management

Assessment Planning Implementation Evaluation

Subjective:
Patient stated, “Ika-napulo
ko na ini na cycle kanan
chemo. Oo gad, gusto ko
lumaban. Pero yun lang, diri
Long Term Goals:
Within 3 days of nursing
intervention, the patient
will be able to:
 Assume
responsibility for
 Ascertain client’s understanding about
health and his/her ability to maintain
health.
 Verify client’s level of understanding of
therapeutic regimen. Note specific health
goals.
Long Term Goals:
Within 3 days of nursing
intervention, the patient was
able to:
 Assumed responsibility
for managing treatment
ako sanay pa it side effects. managing  Instruct in individually appropriate regimen.
Although manageable, treatment regimen. wellness behaviors such as managing pain  Demonstrated proactive
masakit la gihap”  Demonstrate of IV and medications site by allowing to management by
proactive alleviate it with cold compress. anticipating and
“Ano akon pwede mahimo management by  In cases of nausea side effects, encourage planning for
para bagat ma wara wara it anticipating and patient to drink anti-emetic drugs for eventualities of
sakit labi na didi akon kamot planning for chemotherapy, as prescribed by the condition or potential
na usa, may bunog?” eventualities of physician. complications.
condition or  Encourage use of exercise, relaxation  Remained free of
potential skills, yoga, meditation, visualization, and preventable
Objective: complications. guided imagery to assist in management of complications,
 Remain free of stress and promote general health and well- progression of illness
 Noticed presence of preventable being. and sequelae.
bruising left arm due complications,
to IV insertion. progression of
 The patient shows illness Short term Goals:
positivity towards the and sequelae. After 5 hours of nursing
treatment. intervention, the client was able
 Patient is to verbalized understanding of
cooperative, asks Short term Goals: information gained.
question After 5 hours of nursing
 V/S taken as follows: intervention, the client
will be able to verbalize
understanding of
information gained.