Chapter 7

DRUG STUDY

Drugs

Action

Indication

Side effect or Adverse Reaction >No side effect noted.

Nursing Consideration Assessment: >Assess patient for epigastric or abdominal pain using the pain scale 1-10. Intervention: >Take vital signs for the baseline data. >Determine if the client has allergies to medication. >Check right patient, right dosage, right time and frequency, right route. >Give the medicine through IV slowly. >Clean the port with the antiseptic or alcohol swab. >Mix the medication and solution by gently rotating the bottle.

Generic Name: Ranitidine

Brand Name: Zantac

>Reduce gastric acid secretion and increase gastric mucous and bicarbonate production, creating a protective coating on gastric mucosa.

>Treatment and prevention of acid indigestion, and sour stomach.

Date and Time Ordered: 9/1/11 @ 1:45 pm

Dosage and Frequency: 50 mg/ amp; 1 amp. TIV every 8 hour

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Drugs

Action

Indication

Side Effect / Adverse Reaction >No side effect noted.

Nursing Consideration Assessment: >Assess vital signs and neurologic, cardiovascular and respiratory status. Intervention: >Check right patient, dosage, right time, right frequency and right route. > Clean the port with antiseptic or alcohol swab. > Mix the medication and solution by gently rotating the bottle >Inform patient that his eyes may be markedly sensitive to light

Generic Name: Hyoscine

Brand Name: Buscopan

Date and Time Ordrered: 9/1/11 @ 1:45 pm

>Acts the competitive inhibitor at post ganglionic muscarinic receptor sites of parasympathetic nervous system and on smooth muscle that respond to acetylcholine but lack cholinergic transmission from vestibular nuclei to higher Central Nervous System centers and from reticular formation to vomiting center.

>Excessive GI motility and hypertonia in irritable bowel syndrome, mild dysentery, diverticulitis, pylorospasm and cardiospasm

Dosage and Frequency: 1 amp every 8 hours

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Chapter 8

NURSING CARE PLAN

Assessment Subjective: Sumasakit ang tiyan ko, as verbalized by the patient. Objective: Numeric intensity Pain Scale of 6 out of 10. Facial grimace Irritable

9/1/11 2:00pm Vital Signs: BP:100/70 PR:110 bpm Temp:360C RR:20 cpm

Diagnosis Planning Acute pain related Short term to the disease goal: process. After40 of INFERENCE: nursing After the interventio occurrence of the n the fever the normal patient will response of the able to body against the verbalize fever is to release the relief of of the chemical pain from mediators. Then the pain increase of scale from vascular 6 to 1. permeability follows and then eruption of tiny blood vessel that causes abdominal pain.

Intervention INDEPENDENT: 1. Monitor vital signs. Rationale: To provide baseline. 2. Encourage diversional activities. Rationale:To divert attention from the pain. 3. Encourage verbalization of feelings about the pain. Rationale:To identify the severity of pain. 4. Instruct in and encourage use of relaxation techniques, such as focus breathing, imaging, CDs or tapes. Rationale: To distract attention and reduce tension.

Evaluation Short term goal: Goal met as evidenced when the patient verbalized the relief of pain from pain scales of 6 to 1.

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DEPENDENT: 1. Administer medications as prescribed by the physician. Rationale:To relieve the pain.

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Assessment Subjective: Hindi ako masyadong makakain kasi nasusuka ako, as verbalized by the patient.

Diagnosis Risk for fluid volume deficit related to fluid loss.

INFERENCE: Nausea and Objective: vomiting are not 1. irritable disease, but rather 2. restlessness are symptoms of 3. sweating many different 4. salivary conditions, such as production viral infection. 9/1/11 2:00pm Vital signs: BP:100/70 Temp:360C PR:110 bpm RR:20 cpm

Planning Intervention Short term INDEPENDENT: goal: 1. Note possible conditions of Within 4 processes that hours of may lead to nursing deficits. interventio Rationale: To assess causative factors to n the patient will the clients nausea verbalized and vomiting. the relief of GI 2. Place the discomfort patient on and Fowlers or maintain side lying adequate position Rationale: To lessen fluid the risk of aspiration. volume. 3. Eliminate smells from the environment. Rationale: To reduce gastric stimulation and vomiting response. DEPENDENT: 1. Administer IV fluids as prescribed by the physician. Rationale: To reduce fluid loss

Evaluation Short term goal: Goal met. After 4 hours of nursing interventio ns the patient verbalized the relief of nauseating symptoms.

COLLABORATIVE: 1. Provide foods that she can tolerate such as dry crackers and ice chips. Rationale: To

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provides nutrients and helps to settle the stomach.

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Assessment Subjective: Mainit po ang pakiramdam ko, as verbalized by the patient. Objective: Skin warm to touch 9/2/11 8:30 am Vital Signs: BP:100/70 PR:110 bpm Temp:380C RR:20 cpm

Diagnosis Hyperthermia related to dehydration as evidenced by skin warm to touch.

INFERENCE: Viral infection will stimulate the function of the monocytes and then the monocytes ingests the virus that triggers the pyrogen. The pyrogen gives the signal to the anterior hypothalamus which is the thermoregulator of the body. This will eventually result to an elevated thermo-regulatory set point of the body that will lead to fever.

Planning Intervention Short term INDEPENDENT: goal: 1. Monitor vital After4 signs. Rationale:To hours of provide baseline nursing interventio and to monitor n the body changes temperatur e of the 2. Monitor heart patient will rate and be rhythm. Rationale:Dysrythmi lessened a are common due from 380C to electrolyte to 36.50C. imbalance and dehydration. 3. Promote tepid sponge bath Rationale:Heat loss by evaporation and conduction 4. Remove excess clothing and covers Rationale:Decrease s body heat and increases evaporated cooling 5. Encourage patient to increase fluid intake Rationale:To promote rehydration

Evaluation Short term goal: Goal met as evidenced by lessened body temperature from 380C to36.50C.

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DEPENDENT: 1. Administer replacement fluids and electrolytes. Rationale:To support circulating volume and tissue perfusion. COLLABORATIVE: 1. Provide high calorie diet. Rationale:To meet increased the metabolic demands.

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