NURSING CARE PLAN

Patients Name:A.P.D Age:80 years old Impression/Diagnosis: Acute Urinary Retention sec. to Prostatic malignancy Nurses Name & Signature: Bulalaque, Jhanine Hosp. No.: 090022532042 Room No.: 8B-844 Physician Dr. W. Limquico

CLINICAL PORTRAIT
I. ASSESSMENT -Upon assessment patient is conscious, coherent, oriented to time, person and place, and responsible to questions being asked. -Patient skin is uniform in brown color, warm and smooth to touch. Her head is normocephalic, hair is not equally distributed and white in color. Chest wall are symmetrical no abnormalities noted. Nutrition approach is through oral. II. SIGNIFICANT FINDINGS -One day prior to admission noted difficulty in urinating associated with hematuria, no other associated signs and symptoms. III. Vital Signs taken during 1st contact: Temperature: 37.2 degrees celcius Blood Pressure:150/100 mmHg Pulse Rate:84 bpm Respirations:20 cpm

PERTINENT DATA
I. HISTORY OF PRESENT ILLNESS One day prior to admission noted difficulty in urinating associated with hematuria, no other associated signs and symptoms. II. CHIEF COMPLAINTS Patient came in due to pain in the suprapubic area and hematuria noted during urination. III. PAST HEALTH HISTORY The patient had experienced fever, cough, measles, and mumps when he was young. He had experienced hospitalization when he 1st experience UTI. Patient claimed that his immunizations when he was young are up-to-date and has no allergies from drugs and foods. IV. VITAL SIGNS Temperature: 37.1 degrees Celsius Blood Pressure:130/90 mmHg Pulse Rate:92 bpm Respirations:20 cpm V. LABORATORY REPORT HEMATOLOGY REPORT

IV. 5 Priority Nursing Problems Complete Blood Count

08-30-2011

09-02-2011

09-06-2011

 Alteration in comfort: Pain related to urinary retention sec. to prostatic malignancy Hyperthermia related to disease process Risk for infection related to catheter insertion Deficient knowledge related to the diagnosis of : cancer, urinary difficulties, and treatment modalities Disturbed sleep pattern related to interruptions of frequent monitoring.

WBC RBC Hemoglobin Hematocrit Platelet Blood Indices MCV MCH MCHC RDW PDW MPV Relative Differential Count Neutrophil (%) Lymphocytes (%) Monocyte (%) Eosinophils (%) Basophils (%) Absolute Differential Count Neutrophil (#) Lymphocytes (#) Monocytes (#) Eosinophils (#) Basophils (#)

6.90 3.24 9.6 29.2 175 90.0 29.8 33.1 13.1 15.3 8.1 87.3 7.5 4.1 0.8 0.3 6.06 0.52 0.28 0.06 0.02

6.93 3.14 9.7 28.9 180 92.0 30.9 33.6 16.2 10.9 9.8 74.5 12.1 9.7 3.6 0.1 5.16 6.84 0.67 0.25 0.01

8.40 3.14 9.5 28.4 280 90.0 30.3 33.5 12.6 14.5 9.4 80.5 11.7 5.5 2.2 0.1 6.73 0.98 0.46 0.18 0.01

HEMATOLOGY REPORT Prothrombin Time Patient Activity Result 16.0 68.0 Reference >70% Unit Sec. %

INR Control Control activity Test Creatinine

1.30 13.0 100.0

<=1.21 Sec % unit Mg/uL

CLINICAL CHEMISTRY REPORT Result Reference 2.0 0.6-1.5 URINALYSIS

Physical Characteristics Color Transparency pH Specific Gravity Chemical Characteristics Protein Glucose Ketone Urobilinogen Leukocytes Blood Bilirubin Nitrite Ascorbic Acid Microscopic Finding RBC WBC Bacteria Mucus Threads

Result Brick red cloudy 7.0 1.010 Result 30 Negative Negative 4 0.03 Positive Positive Negative Negative Result 16 4 None 6

CUES

NURSING DAIGNOSIS
Alteration in comfort: Pain related to urinary retention sec. to prostatic malignancy

SCIENTIFIC BASIS
Pain exists when the patient says it does. Pain may be either acute or chronic. Acute pain is sudden and of short duration it may be associated with a single event, such as surgery, or an acute exacerbation of a condition such as sickle cell crisis. The inflammatory response that follows the initial injury causes a sustained pained response. (Fuller, 2001, London p.12008)

GOALS & OUTCOME CRITERIA

Goals: after 8 hours of nursing intervention the patient will be able to verbalize decrease of pain and discomfort. The pt. will: 1. Verbalize a pain scale of 4/10. 2. Diminished or absent of nonverbal indicators such as: grimace, irritable and guarding behavior. 3. Will appear relax and more fit and healthy. 4. Participate in desired activities at level of activity 5. Verbalize the reduction of pain

NURSING OUTCOME & NURSING ORDERS

After 8 hours of nursing interventions, patient will be able to verbalize the relief of pain. INDEPENDENT Assess pain, noting location, characteristic, severity,(0-10 scale). Investigate and report changes in pain as appropriate.

RATIONALE

EVALUATION

S-sakit ang ako pus.on dapit as verbalized by the patient. O-Received patient lying on bed, conscious, coherent, a febrile, and responsive to questions asked with a grimaced face, guarding behaviour on the suprapubic area due to urinary obstruction. With a pain scale of 8,10 as the highest pain and 0 as no pain

After 8 hours of nursing interventions, patient was able to verbalize the pain scale of 4. Demonstrate behaviours which are less pain.

Useful in
monitoring effectiveness of medication, progression of healing. Changes in characteristic of pain may indicate developing abscess/ peritonitis, requiring prompt medical evaluation and intervention. (Doenges 7th ed. P.354)

Goal was partially met.

Provide accurate, honest information to client / SO.

Being informed about progress of situation provides emotional support, helping to decrease anxiety. (Doenges 7th ed. P.354) Gravity localizes inflammatory exudates into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position. (Doenges 7th ed. P.354)

Keep at rest in semi-Fowlers position.

DEPENDENT Encourage early ambulation. Promotes normalization of organ function; e.g., stimulates peristalsis and

passing of flatus, reducing abdominal discomfort. (Doenges 7th ed. P.354)

Provide
diversional activities.

Refocuses attention, promotes relaxation, and may enhance coping abilities. (Doenges 7th ed. P.354)

COLLABORATIVE Keep NPO/ maintain NG suction initially Decreases discomfort of early intestinal peristalsis and gastric irritation/ vomiting. (Doenges 7th ed. P.354)

Administer analgesics as indicated.

Relief of pain facilitates cooperation with other therapeutic interventions; e.g., ambulation,

 Place ice bag on

abdomen periodically during initial 2448 hr as appropriate.

pulmonary toilet. (Doenges 7th ed. P.354)

Soothes and
relieves pain trough desentization of nerve endings. Note do not use heat because it may cause tissue congestion/ increase edema formation. (Doenges 7th ed. P.354)

UNIVERSITY OF CEBU-BANILAD COLLEGE OF NURING DRUG STUDY

Patient: A.P.D Age: 80 yr.old Hospital No.:11-002-266-70-75 Room No.: 7A-715

Impression/ Diagnosis: Acute Urinary Retention sec. to Prostatic Malignancy Allergy to: NONE

Attending Physician: Dr. W. Limquico

GENERIC / BRAND NAME & CLASSIFICATION

GENERIC: folic acid

DOSE, STRENGTH & FORMULATION

ORDERED: 5 mg (PO) TIMING:

INDICATION / MECHANISM OF DRUG ACTION

INDICATIONS: To treat folic acid deficiency.

ADVERSE/ SIDE EFFECTS & DRUG INTERACTION

Adverse effect / Side effect: Allergic reaction (bronchospasm, erythema, fever, malaise, rash, pruritus) Drug Interaction:

NURSING RESPONSIBILITIES
Warning: Dont give injection form containing benzyl alcohol to neonates or immature infants.

RATIONALE

CLIENT TEACHING

BRAND: OD Folart MECHANISM OF

Analgesics, carbamazipine

Because a fatal toxic syndrome may occur with CNS, respiratory, circulatory, and renal impairment and metabolic acidosis.

Advise against
taking folic acid supplements as a substitute for proper dietary intake. Explain that good sources of folic acid include green

DURATION: CLASSIFICATION: Unknown Nutritional supplement OTHER FORMS: Tablets, I.V. infusion, I.M or subcutaneous injection

ACTION: Act as a catalyst for normal production of red blood cells, helping to prevent megaloblastic anemia, and helps maintain normal homocysteine levels. After being converted to tetrahydrofolic acid in the intestines, folic acid promotes synthesis of several enzymes, including glycine and methathionine; and metabolism of histidine, all of which are essential for normal cell structure and growth.

,estrogens(including oral contraceptives), phenolbarbital, primidone,:possibly increased folic acid requirement.

Give folic acid supplements at least 1 hour before or 4 hours after cholestyramine or sulfasalazine and dont give antacids within 1 hour before or 2 hours after giving folic acid. Know that folic acid will correct hematologic disorders in pernicious anemia, but neurologic problems will progressively worsen.

(Jones & Barlett 10th ed. P. 460) To prevent decreased absorption. (Jones & Barlett 10th ed. P. 460)

To prevent further complication. (Jones & Barlett 10th ed. P. 460)

vegetables, potatoes, cereals, and organ meats. Recommend eating raw green vegetables because heat used during cooking destroys up to 99% of folic acid in food. Explain to patients with pernicious anemia that folic acid wont affect the neurologic symptoms associated with the disease.

Mrs. Pergeline Cabahug Printed name and signature Clinical instructor

Jhanine F. Bulalaque Printed name and signature student

UNIVERSITY OF CEBU-BANILAD COLLEGE OF NURING DRUG STUDY

Patient: A.P.D Age: 80 yr.old Impression/ Diagnosis: Acute Urinary Retention sec. to Prostatic Malignancy Allergy to: NONE Hospital No.:11-002-266-70-75 Room No.: 7A-715 Attending Physician: Dr. W. Limquico

GENERIC / BRAND NAME & CLASSIFICATION

GENERIC: cefixime BRAND: Targecef

DOSE, STRENGTH & FORMULATION

ORDERED: 500 mg (PO) TIMING: TID DURATION: unknown

INDICATION / MECHANISM OF DRUG ACTION

INDICATIONS: To treat uncomplicated UTI caused by Escherichia coli and Proteus mirabilis; otitis media caused by Haemophilis influezae, Moraxella catarrhalis, or Strptococcus pyogenes; pharyngitis

ADVERSE/ SIDE EFFECTS & DRUG INTERACTION

Adverse effect / Side effect: CNS: chills, fever, headache, seizures. CV: Edema EENT: hearing loss GI: abdominal cramps, diarrhea, elevated, liver function test results, hepatic, failure, hepatitis, hepatomegaly, jaundice, nausea, oral

NURSING RESPONSIBILITIES
Use cefixime cautiously in patients with impaired renal function or a history of GI disease, especially colitis. If possible, obtain culture and sensitivity

RATIONALE

CLIENT TEACHING
Instruct patient to complete the prescribed course of therapy. Advise patient to shake oral suspension well before pouring dose and to use a calibrated device to

To prevent
further complication. (Jones & Barlett 10th ed. P. 192)

To know if the patient is

CLASSIFICATION: antibiotic

OTHER FORMS: Oral suspension, tablets, capsules.

and tonsillitis caused by S. pyogenes; acute bronchitis and acute acute exacerbations of chronic bronchitis caused by H. influenza and Streptococcus pneumonia. MECHANISM OF ACTION: Interferes with bacterial cell wall synthesis by inhibiting the final step in the in the cross linking of peptidoglycan makes cell membranes rigid and protective. Without it, bacterial cells rupture and die.

candidiasis, pseudomembranous colitis, vomiting. GU: elevated BUN level, nephrotoxicity, renal failure, vaginal candidiasis HEME: eosinophilia, haemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia, unusual bleeding MS: arthralgia RESP: dyspnea SKIN: ecchymosis, erythema, pruritus, rash, Stevens-Johnsons syndrome.

test results, as ordered, before giving the drug.

allergic to that medication or not. (Jones & Barlett 10th ed. P. 192)

Tablets shouldnt be substituted for oral suspension to treat otitis media.

Cefexime
suspension produces higher peak blood level than do tablets when administered at the same dose. (Jones & Barlett 10th ed. P. 192)

Monitor BUN and serum creatinine for early signs of nephrotoxicity. also monitor fluid intake and output. Be aware that an allergic reaction may occur a few days after therapy starts.

Decreasing urine output may indicate nephrotoxicity.

(Jones & Barlett 10th ed. P. 192)

Normal reaction when the therapy starts. (Jones & Barlett 10th ed. P. 192)

obtain an accurate dose. Instruct patient to store suspension at room temperature and to discard unused portion after 14 days. Tell patient to immediately report severe diarrhea to prescriber. Inform patient that yogurt and buttermilk can help maintain intestinal flora and decrease diarrhea. Teach patient to recognize and report signs of superinfection, such as furry tongue, perineal itching, and loose, foul smelling

Assess bowel pattern daily.

Severe diarrhea
may indicate pseudomembran ous colitis. (Jones & Barlett 10th ed. P. 192) They may indicate a blood dyscrasia. (Jones & Barlett 10th ed. P. 192)

stools.

Assess for pharyngitis, ecchymosis, bleeding, and arthralgia.

Mrs. Pergeline Cabahug Printed name and signature Clinical instructor

Jhanine F. Bulalaque Printed name and signature student

UNIVERSITY OF CEBU-BANILAD COLLEGE OF NURING DRUG STUDY

Patient: A.P.D Age: 80 yr.old Impression/ Diagnosis: Acute Urinary Retention sec. to Prostatic Malignancy Allergy to: NONE GENERIC / BRAND NAME & CLASSIFICATION
GENERIC: ofloxacin

Hospital No.:11-002-266-70-75 Room No.: 7A-715 Attending Physician: Dr. W. Limquico NURSING RESPONSIBILITIES RATIONALE CLIENT TEACHING

DOSE, STRENGTH & FORMULATION

INDICATION / MECHANISM OF DRUG ACTION

INDICATIONS: To treat pelvic inflammatory disease caused by susceptible organism.

ADVERSE/ SIDE EFFECTS & DRUG INTERACTION

ADVERSE/ SIDE EFFECTS: CNS: aggressiveness, agitation, ataxia, dizziness, drowsiness, emotional lability, exacerbation, of extrapyramidal disorders, and myasthenia gravis,

ORDERED: 200 mg (PO) TIMING:

Monitor elderly patients closely for prolonged interval QT.

BRAND: Inoflox

OD DURATION: MECHANISM OF

For I.V infusion, dilute drug in normal saline solution or D5W

Prolonged QT interval has an uncorrected electrolyte disorder. (Jones & Barlett 10th ed. P. 756) To dilute the solution. (Jones & Barlett 10th ed. P. 756)

Encourage patient to take each oral dose with a full glass of water. Advise patient to avoid hazardous activity until CNS effects of drug are known.

ACTION: unknown CLASSIFICATION: antiboitic OTHER FORMS: Tablets, I.V infusion Inhibits synthesis of the bacterial enzyme DNA gyrase by counteracting excessive supercoiling of DNA during replication or transcription. Inhibition of DNA gyrase causes rapidand slow growing bacterial cells to die.

fever, headache, incoordination, insomnia, light headedness, mania, peripheral neuropathy, psychotic, reactions, restlessness, stroke, suicidal ideation ,syncope. CV: arrhythmias, prolonged QT interval, severe hypotension, torsades de pointes, vasculitis. EENT: blurred vision, diplpoia, disturbances in taste, smell, hearing, and equilibrium. ENDO: hypergycemia, hypoglycemia, GI: abdominal cramps or pain, acute hepatic necrosis or failure, diarrhea, hepatitis, jaundice, nausea, pseudomembranous colitis and vomiting. GU: acute renal insufficiency or

to at least mg/ml ,and infuse over 60 minutes to minimize the risk of hypotension. Discard un used portion. Monitor patient closely for hypersensitivity, which may occur as early as firstdose.

Notify the prescriber immediately and expect to discontinue the drug. (Jones & Barlett 10th ed. P. 756) To prevent development of highly concentrated urine and crystalluria. (Jones & Barlett 10th ed. P. 756) It may indicate pseudomembra nous colitis. (Jones & Barlett 10th ed. P. 756)

Maintain adequate hydration.

If diarrhea develops, notify prescriber.

Tell patient to limit exposure to sun and ultraviolet light to prevent phototoxicity. Advise patient to notify prescriber immediately about burning skin, hives, itching, rash, rapid heart rate, abnormal motor or sensory function, and tendon pain. Urge patient to seek medical care immediately for trouble breathing or swallowing, which may signal an allergic reaction.

failure,interstitial nephritis, renal calculi, vaginal candidiasis. RESP: arthralgia, myalgia, tendon inflammation. SKIN: blisters, diaphoresis, erythema, photosensitivity, pruritus,rash.

Mrs. Pergeline Cabahug

Printed name and signature Clinical instructor

Jhanine F. Bulalaque
Printed name and signature student

UNIVERSITY OF CEBU-BANILAD COLLEGE OF NURING DRUG STUDY

Patient: A.P.D Age: 80 yr.old Impression/ Diagnosis: Acute Urinary Retention sec. to Prostatic Malignancy Allergy to: NONE GENERIC / BRAND NAME & CLASSIFICATION
GENERIC: tranexamic acid BRAND: TIMING: hemostan OD CLASSIFICATION: MECHANISM OF ACTION: CV: deep vein thrombosis EENT: Central retinal

Hospital No.:11-002-266-70-75 Room No.: 7A-715 Attending Physician: Dr. W. Limquico NURSING RESPONSIBILITIES RATIONALE CLIENT TEACHING

DOSE, STRENGTH & FORMULATION

INDICATION / MECHANISM OF DRUG ACTION

INDICATIONS: To treat cyclic heavy menstrual bleeding.

ADVERSE/ SIDE EFFECTS & DRUG INTERACTION

ADVERSE / SIDE EFFECTS: CNS: cerebral thrombosis, dizziness, fatigue,headache, migraine.

ORDERED: 500 mg (PO)

Tranexamic acid therapy isnt recommended for women who use hormonal contraceptives. Use tranexamic acid cautiously in patients with

It may increased risk of thromboemboli sm. (Jones & Barlett 10th ed. P. 1046) Because of possible exacerbation of

Instruct patient to swallow tranexamic acid tablets whole, without chewing or breaking them. Tell patient to seek emergency care

DURATION: Antifibrinolytic unknown OTHER FORMS: tablets

Displaces plasminogen from surface of fibrin by binding to high affinity lysine site of plasminogen. This diminishes the solution of hemostatic fibrin, which decreases bleeding.

artery and vein obstruction, feeling of throat tightness,impaired color vision, ligneous conjunctivitis, nasal and sinus congestion sinusitis, visual abnormalities GI: Abdominal pain, diarrhea, nausea vomiting GU: Acute renal cortical necrosis HEME: Anemia MS: Arthralgia, back pain, muscle cramps, and spasms, myalgia RESP:Dyspnea, pulmonary embolism, respiratory congestion SKIN: Allergic skin reaction, facial flushing Other: Anaphlaxis, multiple allergies including seasonal.

acute promyelocytic leukemia taking oral tretrinoin for remission induction.

the procoagulant effect of tretinoin. (Jones & Barlett 10th ed. P. 1046)

immediately if she has any signs of allergic reaction, especially dyspnea, a feeling of throat tightness, and facial flushing, and to stop taking drugs. Advise patient to report any changes in vision or ocular discomfort.

Mrs.Pergeline Cabahug
Printed name and signature Clinical instructor

Jhanine F. Bulalaque
Printed name and signature student

UNIVERSITY OF CEBU-BANILAD COLLEGE OF NURING DRUG STUDY Patient: A.P.D Age: 80 yr.old Impression/ Diagnosis: Acute Urinary Retention sec. to Prostatic Malignancy Allergy to: NONE GENERIC / BRAND NAME & CLASSIFICATION
GENERIC: metoprolol succinate BRAND: Betaloc Durules

Hospital No.:11-002-266-70-75 Room No.: 7A-715 Attending Physician: Dr. W. Limquico NURSING RESPONSIBILITIES RATIONALE CLIENT TEACHING

DOSE, STRENGTH & FORMULATION

ORDERED: 50 mg (PO) TIMING: PRN DURATION:

INDICATION / MECHANISM OF DRUG ACTION

INDICATIONS: To manage hypertension, alone or with other antihypertensive. To treat angina pectoris and chronic stable angina. MECHANISM OF

ADVERSE/ SIDE EFFECTS & DRUG INTERACTION

ADVERSE/ SIDE EFFECTS: CNS: anxiety, confusion, depression, dizziness, drowsiness, fatigue, hallucinations, headache, insomnia, weakness. CV: angina arrhythmias, (including AV block and bradycardia), chest pain, decreased HDL level,

Use cautiously in patients with hypertensionor angina who have congestive heart failure.

CLASSIFICATION:

Because beta blockers such as metoprolol can further depress myocardial contractility. Worsening heart failure. (Jones & Barlett 10th ed. P. 667)

Instruct patient to take metoprolol with food at the same time each day once daily for E.R. tablets. Explain that he may halve tablets but not chew or crush

Unknown Antianginal, antihypertensive, MI prophylaxis and treatment OTHER FORMS: Tablets , I.V injection

ACTION Inhibits stimulation of beta1-receptor sites, located mainly in the heart, resulting in decreased cardiac excitability, cardiac output, and myocardial oxygen demand. These effects help relieve angina. Metoprolol also helps reduce in blood pressure by decreasing renal release of renin .

increased triglyceride levels, gangrene of extremity heart failure, hypertension , and orthostatic hypotension. EENT: nasal cingestion, rhinitis, taste disturbance GI: constipation, diarrhea. Hepatitis, nausea, vomiting GU: impotence HEME: leukopenia, thrombocytopenia, MS: arthralgia, back pain, myalgia, RESP: bronchospasm, dyspnea, SKIN:diaphoresis, photosensitivity, rash, urticaria, worsening of psoriasis.

Before starting therapy for heart failure, expect to give diuretic, an ACE inhibitor, and digoxin. If patient has pheochromocyto ma, alpha blocker therapy should start first, followed by metoprolol.

To stabilize the patient. (Jones & Barlett 10th ed. P. 667) To prevent paradoxical increase in blood pressure from attenuation of beta-mediated vasodilation in skeletal muscle. (Jones & Barlett 10th ed. P. 667) To prevent further complications. (Jones & Barlett 10th ed. P. 667)

them.

Advise patient
to notify prescriber if pulse rate falls below 60 beats/ minute or is significantly lower than usual. Urge diabetic patient to check blood glucose level often during the therapy. Caution patient not to stop drug abruptly.

If patient with heart failure develops symptomatic bradycardia , expect to decrease the metoprolol dosage.

Mrs. Pergeline Cabahug

Printed name and signature

Jhanine F. Bulalaque
Printed name and signature

Clinical instructor

student

IVF STUDY
Type of Solution PNSS Classification Isotonic Content Na- 154 mEq/L Cl 154mEq/L Osmolarity 30gmomsm/L Mechanism of Action It is a type of solution that causes no change in cell volume. Capable of diluting and gives sufficient supply of hydration in the body. Source of water and electrolyte, for fluid replacement. (Mosby, 2006:743) Indication *Patients who are dehydrated *Hypovolemic patients. *Alkalosis *Hypernatremia *For fluid loss in the body. *Sodium depletion. *Saline is also helpful for irrigation. *It can be used to wash the wound. *Fluid retention. *Patients who are hypersensitive to the solution. Contraindication *Congestive Heart Failure. *Severely impaired renal function. How Supplied Baxter: 500cc Dose As directed by the physicia n. Nursing Responsibility 1. Check the pt. Chart. 2. Check the 5 rights of giving medication. 3. Note reason for therapy; monitor pts electrolyte. 4. Monitor pts vital signs, intake and output. 5. Open only the solution when ready to use. 6. Use sterile infusion set. 7. Use only if solution is clean and container is not

leaking. 8. Store at temperature not exceeding 30C

APPENDIX B

APPENDIX C

APPENDIX D