University of Luzon

College of Nursing
Dagupan City

Name Patients: _______________________________________Age: ________ Sex: __________ Ward/Area: ________________ Hospital: ______________________
Chief Complaint/s: _______________________________________ Diagnosis/ Impression: ___________________________ Date of Admission: ______________________

DRUG STUDY

GENERIC BRAND DOSAGE, INDICATI ACTION ADVERSE INTERACTION CONTRA NURSING PATIENT
NAME NAME ROUTE & ON REACTION INDICATION IMPLICATION TEACHING
FREQUENCY
Ketorolac Toradol 30 mg IV Pain Unknown. No adverse No interaction No -Don’t give drug -Teach patient
every 8 hrs for May inhibit reaction to other drug contraindication epidurally or signs and
3 doses prostagland noted like: noted like: noted like: intrathecally because symptoms of GI
in CNS: Drug-drug. of alcohol content bleeding,
synthesis, drowsiness, ACE inhibitors: Contraindicated in including blood
to produce sedation, May cause renal patients -NSAIDs may mask in vomit, urine or
anti- dizziness, impairment, hypersensitive to signs and symptoms stool; coffee
Classificati inflammato headache particularly in drug and in those of infection because ground vomit;
on: ry, CV: edema, volume with active peptic of their antipyretic and black, tarry
NSAID analgesic, hypertension, depleted ulcer disease, and anti-inflammatory stool. Tell him to
and pyretic palpitation. patient. Avoid recent GI bleeding actions. notify prescriber
effects. GI: nausea, using together or perforation, immediately if
dyspepsia, GI Antihypertens advanced renal -Serious GI toxicity, any of these
pain, ive, diuretics: impairment, including peptic ulcers occurs.
diarrhea, May decrease cerebrovascular and bleeding can
peptic effectiveness. bleeding, occur in patients
ulceration, Monitor patient hemorrhagic taking NSAIDs,
vomiting, closely diathesis, or despite lack of
constipation, Lithium: May incomplete symptom
flatulence increase lithium hemostasis and
and level. Monitor those at risk for
stomatitis patient closely renal impairment
Hematologi Methotrexate: from volume
c: purpura May decrease depletion or at
Skin: methotrexate risk of bleeding
pruritus, clearance and
rash, increased
diaphoresis toxicity. Avoid
 Other: pain using together.
at the
injection site.

Submitted by:__________________________________ Clinical Instructor: ________________________________

Date: _______________________ Date:_________________________________
University of Luzon
College of Nursing
Dagupan City

Name Patients: _______________________________________Age: ________ Sex: __________ Ward/Area: ________________ Hospital: ______________________
Chief Complaint/s: _______________________________________ Diagnosis/ Impression: ___________________________ Date of Admission: ______________________

DRUG STUDY

GENERIC BRAND DOSAGE, INDICA ACTION ADVERSE INTERACTION CONTRA NURSING PATIENT
NAME NAME ROUTE & TION REACTION INDICATION IMPLICATION TEACHING
FREQUENCY
Paracetam Aeknil 1 amp. IV fever Unknown. No adverse No interaction No Many OTC and -Tell patient that
ol every 4 hours Thought to reaction to other drug contraindicatio prescription products drug is only for
produce noted noted n noted like: contain short term use
analgesia like: like: Contraindicated in acetaminophen; be and to consult
by blocking Hematologic Barbiturates, patients aware of this when prescriber if
pain : hemolytic carbamazepine, hypersensitive to calculating total daily giving to children
impulses by anemia, hydantoins, drug. dose. for longer than 5
inhibiting neutropenia, rifampin, Use cautiously in days or adults for
Classificati synthesis of leucopenia, sulfinpyrazone: patients with long longer than 10
on: prostaglandi pancytopenia. High doses or term alcohol use days
Analgesic n in the CNS Hepatic: long term use of because -Tell patient that
Antipyreti or other Jaundice these drugs may therapeutic doses high doses or
c substances Metabolic: reduce cause unsupervised
that hypoglycemia therapeutic hepatotoxicity in long-term use can
sensitize Skin: rash, effects and these patients. cause liver
pain urticaria enhance damage.
receptors to hepatotoxic Excessive alcohol
stimulation. effects of use may increase
The drug acetaminophen. the risk of liver
may relieve Avoid using damage
fever together.
through Warfarin: May - Do not use this
central increase medication
action in the hypoprothrombine without medical
hypothalami mic effects with direction for:
c heat- long term use fever persisting
regulating with high doses of longer than 3 d,
center. acetaminophen.
fever over 39.5° C
Monitor INR
closely. (103° F), or
Lamotrigine: recurrent fever.
May decrease
lamotrigine level.
Monitor patient
for therapeutic
effects.
Submitted by: __________________________________ Clinical Instructor: ________________________________
Date: _______________________ Date:_________________________________
University of Luzon
College of Nursing
Dagupan City
Name Patients: _______________________________________Age: ________ Sex: __________ Ward/Area: ________________ Hospital: ______________________
Chief Complaint/s: _______________________________________ Diagnosis/ Impression: ___________________________ Date of Admission: ______________________

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS NOC (Nursing Outcome NIC (Nursing Intervention RATIONALE EVALUATION
(Subjective/Objective) (Nursing Problem) Classification) Classification)

SUBJECTIVE: Hyperthermia R/T GOAL: LABEL: Fever treatment After 8 hours of duty:
“Pabalik balik ang lagnat increased metabolic rate To decrease body DEF. To assist with Patient temperature
ko” as verbalized by the AEB temp. of 39.8 °C temperature & To measures to reduce body subsided to 36.8 °C
patient. promote wellness temperature.

DEF. A state in which ACTIVITIES:

an individual’s body DESIRED OUTCOME: Independent -V/S monitored until temp.
temperature is elevated After 8 hrs of duty, -Monitor V/s esp. was subsided
above normal range Patient temperature will temperature -TSB was done and
OBJECTIVE: subsided within normal demonstrated and
Warm to touch range or can be -Provide tepid sponge bath instructed his wife to
Flushed skin maintained @ continuously TSB the pt.
Weak in appearance 37 °C -Pt increased his fluid
-To serve as data baseline intake (drink 500 ml of
Febrile- 39.8 °C -Increase fluid intake
Increased Respiratory Rate- mineral water)
24/min. -Promote surface cooling by - Done by removing the
means of undressing buttons in the lower part
-To increase heat loss through of his jogging pants
evaporation and conduction -done by his wife
-Provide dry clothing and
bed linens

-Maintain bed rest -Bed rest maintained by

-To replenish lost fluid the pt.

Collaborative -Heat loss by radiation and

-Administer antipyretics conduction
(Paracetamol -Paracetamol Aeknil was
given by NOD.

-for comfort
 -To reduce metabolic
demand/oxygen consumption
and to limit heat production

-To reduce fever by its central

action on the hypothalamus

Submitted by:__________________________________ Clinical Instructor: ________________________________

Date: _______________________ Date:_________________________________
University of Luzon
College of Nursing
Dagupan City

Name Patients: _______________________________________Age: ________ Sex: __________ Ward/Area: ________________ Hospital: ______________________
Chief Complaint/s: _______________________________________ Diagnosis/ Impression: ___________________________ Date of Admission: ______________________

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS NOC (Nursing NIC (Nursing Intervention RATIONALE EVALUATION
 (Subjective/Objective) (Nursing Problem) Outcome Classification)
Classification)
LABEL: Pain Management After 8 hours of duty,
SUBJECTIVE: Acute pain R/T distention GOAL: DEF. To relived or controlled patient report lessen pain
“ Sumasakit a tiyan or rupture of fallopian Patient report pain is pain with a pain scale of 2/10
ko” as verbalized by tube AEB verbal reports, relieved or controlled
the patient guarding behaviors, and ACTIVITIES:
facial mask of pain.
- V/S monitored.
Independent
P-it remain the same DEF. Unpleasant sensory -Monitor v/s
Q-aching and emotional experience DESIRED OUTCOME: - Patient verbalized about
R- on lower quadrant arising from actual or After 8 hours of duty, -Encourage verbalization of pain.
S-6/10 potential tissue damage Patient will report feelings about pain
or described in terms of lessen pain as -Encourage relaxation
such damage -Usually altered in acute pain
evidenced by rating of techniques
1 on scale 1-10 & to serve as baseline data. - Relaxation technique
OBJECTIVE -Encourage deep breathing done by the patient
-To help determine possibility -Patient done the deep
Facial mask of pain exercise
of underlying condition breathing exercise
Guarding behaviors -Provide quite and calm
environment - Quite and calm
Irritable -Relaxes muscle and redirects environment provided
-Encourage& demonstrate attention away from painful -Coughing technique was
coughing techniques sensation not done yet.
-Provide divertional activities
-To prevent stasis of lung -Done by listening to
mucus music.
Collaborative:
-Administer pain medication

-To promote comfort

-To lessen pain and discomfort -Ketorolacwas given thru

I.V push by NOD

-Refocuses attention,
promotes relaxation, and may
enhance coping abilities
 - To produce analgesia by
blocking pain impulses by
inhibiting synthesis of
prostaglandin in the CNS or
other substances that
sensitized pain receptor to
simulation

Submitted by:__________________________________ Clinical Instructor: ________________________________

Date: _______________________ Date:_________________________________

UNIVERSITY OF LUZON
COLLEGE OF NURSING
DAGUPAN CITY
 NURSING CARE PLAN
and

DRUG STUDY

SUBMITTED BY: SUBMITTED TO:

DESIREE A. BARRIOS MRS. AMELIA V. CASING
MTW/3-11/CUISON CLINICAL INSTRUCTOR