Bilocura, Elva B.

March 07, 2024

BSN-3B
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION

Subjective Cues: Acute pain related to Short term: Independent: Goal met:
“Sakit kayo akoa tiyan ” as abdominal pain as evidenced After 8 hours of nursing ● Assessed for referred pain as After 8 hours of nursing
verbalized by the patient. by patient facial grimace and interventions, the patient will appropriate. interventions, the patient was able
paleness. report pain is relieved and ● Obtained patient assessment of pain to to report pain was relieved and
Pain Scale: 8/10 as patient controlled. include location, characteristics, onset and controlled.
verbalized. duration, frequency and intensity.
●Monitored skin color and temperature and
Objective Cues: vital signs.
V/S taken as follows: ● Provided comfort measures, quiet
environment and calm activities.
Temp.: 36C ● Determined and documented the
PR: 92bpm presence of possible psychological causes
RR: 32cpm of pain.
BP: 90/60mmHg
SPO2: 99% Dependent:
- facial grimace ● Note patients attitude toward pain and
-restlessness use of pain medications, including any
-paleness history of substance abuse.
● Administer analgesics, as indicated, to
maximum dosage, as needed.
● Evaluate and document patients
response to analgesia, and assist in
transitioning or altering drug regimen,
based on individual needs and protocols.
 Generic Name, Prescribed and
Brand Name, and Recommended
Drug Classification Dosage, Frequency, Mechanism of Indication Contraindications Adverse Reactions Nursing Implications
and Route of Action
Administration

Components and Capsules (delayed- Inhibits proton pump Treatment of ●Contraindicated in CNS: Asthenia, ● May increase risk of CDAD.
Generic Name: released): 10mg, activity by binding to symptomatic GERD patients hypersensitive to dizziness, headache. Evaluation for CDAD in patients
Omeprazole 20mg, 40mg hydrogen-potassium without esophageal drug or its components and GI: Abdominal pain, who develop diarrhea that doesn’t
adenosine lesions, erosive in patients receiving constipation, improve.
Powder (for triphosphatase, esophagitis(EE), rilpivirine-containing diarrhea, flatulence, ●Monitor patients for signs and
delayed-release oral located at secretory pathologic products. nausea, vomiting, symptoms of acute interstitial
Brand Name: suspension): surface of gastric hypersecretory ●Use cautiously in patients acid regurgitation. nephritis. If suspected, discontinue
2.5mg, 10mg parietal cells, to conditions (such as with hypokalemia and Musculoskeletal: drug and evaluate patient.
Losec suppress gastric Zollinger-Ellison respiratory alkalosis and in Back pain, weakness ●Monitor patients for signs and
Suspension: 2mg/ml acid secretion. syndrome), duodenal patients on a low-sodium Respiratory: Cough symptoms of low magnesium level,
Drug Classification: ulcer (short term diet. Skin: Rash such as abnormal HR or rhythm,
Antiulcer drugs Tablets (delayed- treatment), ●Risk of fundic gland palpitations, muscle spasms,
release): 20mg Helicobacter pylori polyps increases with long- tremors, or seizure.
infection and term use, especially ●Drug is unstable in gastric acid;
Route: PO duodenal ulcer beyond 1 year. less drug is lost to hydrolysis
disease, to eradicate ●Long-term administration because drug increases gastric PH.
H.pyloriwith of bicarbonate with calcium ●Evaluate for therapeutic response
clarithromycin (dual or milk can cause milk- (relief of GI symptoms). Question if
therapy), short term alkali syndrome. GI discomfort, nausea, diarrhea
treatment of active ●Use PPIs may increase occurs.
benign gastric ulcer, risk of CDAD. Consider
frequent heartburn CDAD diagnosis in
and dyspepsia. patients with persistent
diarrhea that doesn’t
improve.