Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain related to After 4 hours of nursing Establish rapport To have a good nurse After 4 hours of nursing
disruption of skin intervention, patient will client relationship interventions, the
"masakit yung buong
and tissue secondary verbalize decrease pain patient verbalized pain
tryan ko - To establish baseline
to gastrectomy intensity, patient will Monitor vital signs decreased as evidenced
data
Parang parehong participate in prevention by (-) facial grimace (-)
measures and treatment, Inspect skin on daily basis guarding behaviour
labas at loob dahil sa -To determine unusual ties
maintain physical well and observe changes
tahi at kabag" and report it to physician
Can ambulate with no
being and has ability to - Provide comfort by for prompt treatment
As verbalized by the assistance
manage situation. helping patient to sit, stand
patient -To avoid injuries or
lay on bed and go to toilet Goal partially met
accidents when patient
or walk around
ambulates
Objective: • Provide comfortable
-Calm environment helps
environment by cleaning
• Pain scale = promote likelihood of
bed and proper ventilation
decreasing pain, anxiety
• Facial grimace and discomfort
Instruct to put pillow on the
• Guarding behaviour abdomen when coughing or
-To check for diastasis
moving
Vital signs: recti and protect the area
of incision to improve
ВР = comfort
PR =
RR =
T=
NURSING CARE PLAN
DRUG STUDY
Drug name Mechanism of Action Indication/Contraindication Adverse Effects Nursing Responsibilities
Generic Name: - Interferes with bacterial cell Indication: CNS: Chills, fever, headache, Dx:
Cefuroxime wall synthesis by inhibiting the seizures
Treatment if the followingin fections a. Obtain a history to determine
Axetil/Sodium final step-in cross-linking
caused by susceptible organisms: CV: Edema previous use of and reaction to
peptidoglycan strands.
Brand Name: Respiratory tract infection, Urinary penicillin or cephalosporins
Peptidoglycans makes thecell EENT: Hearing loss, oral
Ceftin/ Zinacef tract infections, Skin to skin structure
membrane rigid and protective. candidiasis b. Assessed for signs and
infections.
Class: Second- Without it, bacterial cells symptoms of infection
rupture and die. GI: Abdominal cramps,
generation Contraindication:
diarrhea,elevated liver enzymes, c. Check doctor’s order
cephalosporine,7-
Contraindicated with allergy to hepatic failure, hepatomegaly,
aminocephalosporic Tx:
Cephalosporins or Penicillin. Use nausea, pseudomembranous
acid
cautiously with renal failure, lactation colitis, vomiting a. Give drug with food, to
Therapeutic: and pregnancyHypersensitivity to decrease GI upset and enhance
GU: Elevated BUN level,
Antibiotic cefuroxime, other cephalosporins, or absorption
nephrotoxicity, renal failure,
their components
Pharmacologic: vaginal candidiasis b. Discontinue if
hypersensitivity reaction occurs
Dosage: HEME: Eosinophilia, hemolytic
anemia, hypoprothrombinemia, c. Observe if patient took in
Route
neutropenia, thrombocytopenia, medication
unusual bleeding
Edx:
MS: Arthralgia
a. Educated that this drug is
RESP: DyspneaSKIN: specific for thisinfection and
Ecchymosis, erythemaerythema, should not be used to self-treat
multiforme, pruritus, rash, other problems.
Steven-Johnson syndrome
b. Instructed the client to swallow
Other: Anaphylaxis; Injection- tablets whole, do not crush them,
site edema, pain, and redness; take the drug with food
superinfection
c. Educated the client that they
may experience these side
effects: stomach upset or diarrhe