Precious F.

Pambid Fourth Year Section One Group A

January 6 2009

Patient Amelia Guttierez Room 202-B

Roosevelt College System

Institute of Nursing and Health Education
Sumulong Hi-way Cainta, Rizal

DRUG STUDY
GENERIC DOSAGE/FRE NURSING
NAME QUENCY CLASSIFICATIO INDICATION CONTRAINDICA SIDE EFFECTS RESPONSIBILITY
N TION
Ciprobay/C 500 mg tab Fluoroquinolo CIPRO is indicated Contraindicated (-) headache > Monitor patient’s
iprofloxaci q 12° nes for the treatment in patients (-) intake and output
n 8am – 8pm Are of infections sensitive to restlessness and observe for
antimicrobials, caused by fluoroquinolone (-) confusion sighns of crystalluria
medicines used susceptible strains s (-) edema > Tell patient to take
to treat of the designated drug as prescribed
infections microorganisms in even after he feels
caused by the conditions and better.
microorganisms patient Instruct patient to
. Physicians populations listed avoid caffeine while
prescribe these below. taking drug because
drugs for of potential
bacterial Adult Patients increased caffeine
infections in effects
many parts of Urinary Tract
the body. For Infections caused
example, they by Escherichia
are used to coli, Klebsiella
treat bone and pneumoniae,
joint infections, Enterobacter
skin infections, cloacae, Serratia
urinary tract marcescens,
infections, Proteus mirabilis,
inflammation of Providencia
the prostate, rettgeri,
serious ear Morganella
infections, morganii,
bronchitis, Citrobacter
pneumonia, diversus,
tuberculosis, Citrobacter
some sexually freundii,
transmitted Pseudomonas
diseases aeruginosa,
(STDs), and methicillin-
some infections susceptible
that affect Staphylococcus
people with epidermidis,
AIDS. Staphylococcus
saprophyticus, or
Precious F. Pambid Fourth Year Section One Group A
January 6 2009

Patient Amelia Guttierez Room 202-B

Roosevelt College System

Institute of Nursing and Health Education
Sumulong Hi-way Cainta, Rizal

NURSING CARE PLAN

Assessme Nursing Planning Implementation Rationale Evaluation
nt Diagno
sis
Subjectiv Anxiety After 1 ½ After 1 1.2
e: related hour of >Establish a > Honesty, availability, hour of
“Na-ha- to nursing therapeutic nurse/client and unconditional nursing
highblood change interventionrelationship. Be honest, consistent in intervention
ako kasi in patient responses, and patient
naiinip na health Amelia Honesty, availability, available. Show Amelia
and unconditional acceptance promotes
ako status Guttierez @ honest, consistent in trust, which is Guttierez @
umuwi” as room 202-B responses, and necessary for genuine room 202-B
as evidenc will be ableavailable. Show positive regard. was able to:
verbalize ed by to:
acceptance promote > Tension and anxiety  appear
d by the express can be released safely, relaxed
patient ed trust, which is
 Appear necessary for and physical activity and
concern relaxed genuine positive may provide emotional report
Objective about and regard. benefit to the client that
: going report through release in the anxiety
home the development of a brain of morphine like
anxiety substances was
-expresse is reduce therapeutic (endorphins) that reduced
d relationship.
to a promote sense of to a
concerns manage well-being. managea
about able >Provide activities ble level
going level. geared toward through
> Anxious clients often
home  Verbalize reduction of tension backrub
deny a relationship
-tensed awarene and anxiety can be and
between emotional
-anxious ss of released safely, and change of
problems and their
-restlessn feelings tension and decreasing position.
anxiety. Use of the
ess of anxiety (e.g., walking or  Verbalize
defense mechanisms
anxiety. physical activity may d feelings
of projection and
VS: provide emotional of anxiety
displacement are
Temperat benefit to musical through
exaggerated.
ure: 37.4 exercises,). ventilatio
Pulse n of
> Can help to limit
Rate: 76 >Encourage client to feelings
transmission of
Respirato identify true feelings about
anxiety to/from client.
ry Rate: and to acknowledge disease.
21 ownership of those
> Provides patient a
Blood feelings.
sense of control in
Pressure:
managing some
160/100
aspects of treatment.
> Maintain a calm
atmosphere and
> Provides means of
approach to client.
altering response to
anxiety.
> Provide time for
> Helps to redirect
divertional activities
attention and
appropriate for
promotes relaxation,
condition.
enhancing coping
abilities.
>Instruct patient about
deep breathing and
> Adaptive
guided imagery.
mechanisms are
necessary to cope with
> Provide routine
the situation.
 Precious F. Pambid Fourth Year Section One Group A January 6
2009
Patient Amelia Guttierez Room 202-B

Roosevelt College System

Institute of Nursing and Health Education
Sumulong Hi-way Cainta, Rizal

RELATED LEARNING EXPERIENCE ON

LEADERSHIP AND MANAGEMENT

SAMPLE CHARTING

S - “Na-ha-highblood ako kasi naiinip na ako umuwi” as

verbalized by the patient

O - Received patient awake, lying on bed

Expressed concerns about going home
Tensed
Anxious
Restlessness

A - Anxiety related to change in health status as evidenced by

expressed by concern about going home

P – After 1 ½ hour of nursing intervention Patient Amelia

Guttierez at room 202-B will be able to:

 appear relaxed and report anxiety is reduced to a manageable

level
 verbalize awareness of feelings of anxiety
I – Identify/evaluate patient’s perception of the conflict
represented by the situation this aids in defining the scope of
interventions.

Provide comfort measures like backrub and change of

position.
Provide time for rest, divertional activities appropriate for
condition like reading newspaper.

Encourage ventilation of feelings about disease, its effect on

lifestyle and future health status.

Instruct patient in relaxation and techniques e.g. deep

breathing and guided imagery.

E – After 1 1.2 hour of nursing intervention Patient Amelia

Guttierez at Room 202-B was able to:

 appear relaxed and report anxiety was reduced to manageable

level through comfort measure like backrub and change of
position.
 verbalize feelings of anxiety through encouragement given by
the nurse in ventilation of feelings about disease.

______________________
Student Head Nurses

Noted by: ____________________________

CLINICAL INSTRUCTOR
Precious F. Pambid Fourth Year Section One Group A
January 7 2009

Patient Amelia Guttierez Room 202-B

Roosevelt College System

Institute of Nursing and Health Education
Sumulong Hi-way Cainta, Rizal

DRUG STUDY
GENERIC DOSAGE/FRE NURSING
NAME QUENCY CLASSIFICATIO INDICATION CONTRAINDICATI SIDE RESPONSIBILITY
N ON EFFECTS
Kalium 1 durule TID Electrolytes and  For hypokalemia >Severe renal >renal  Some patients
Durule (8-1-6) minerals  As prophylaxis impairment insufficienc find it difficult to
during treatment > severe y swallow the large
with diuretics hemolytic >hyperkale sized KCl tablet.
 To prevent and reactions mia Administer while
treat potassium, > acute >nausea patient is sitting
deficit secondary dehydration >vomiting up or standing
to diuretics or >heat cramps >irritability (never in
corticosteroid >hyperkalemia >muscle recumbent
therapy. weakness position) to
 Also indicated Cautious use in: >difficulty prevent drug-
when potassium, >cardiac or renal in induced
is depleted by disease; swallowing esophagus.
severe vomiting, systematic Not e: none  Follow instructions
prolonged diuresis acidosis of these regarding dilution.
and diabetic side  Color in some
acidosis. ef fect s commercial oral
wer e f ound solutions fades
on t he with exposure to
pa tient . light but drug
effectiveness is
reportedly not
altered.

Precious F. Pambid Fourth Year Section One Group A

January 7 2009
Patient Amelia Guttierez Room 202-B

Roosevelt College System

Institute of Nursing and Health Education
Sumulong Hi-way Cainta, Rizal

NURSING CARE PLAN

Assessment Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Ineffective After 1 hour of > Assess >Adaptive mechanisms After 1 hour
“Akala ko individual nursing effectiveness of are necessary to of nursing
makkauwi na coping intervention coping strategies by appropriately alter intervention
ko kahapon e related to Patient Amelia observing behaviors, one’s lifestyle, deal with Patient
may inaantay unmet Guttierez at room ability to verbalize chronicity of Amelia
pa” as expectation 202-B will be able feelings and concerns hypertension and Guttierez at
manifested as to: and willingness to integrate prescribed room 202-B
by the manifested >identify participate in the therapies into activities was able to:
patient. by ineffective coping treatment plan. of daily living.
expressed behaviors and >identify
Objective: concern of consequences > Assist patient to > Recognition of ineffective
-anxious going home > verbalize identify specific stressors is the first coping
-expressed awareness of own stressors and possible step in altering one’s behaviors and
concern of coping strategies for coping response to the consequences
going home abilities/strengths with them. stressor. by means of
-tensed >demonstrate verbalization
the use of > Promote expression and
enhance coping of feelings and fears > Verbalization of promotion of
skills/methods e.g. denial and anger. concerns reduces expression of
tension. feelings and
> Provide quiet fears like
environment, and denial.
calm activities and > Decreases external
comfort measures stimuli which may > verbalize
(e.g. dry/wrinkle free aggravate anxiety and awareness of
linens, backrub). cardiac strain, and limit own coping
coping abilities. abilities by
>Assist in relaxation promotion of
techniques e.g. expression.
deep/slow breathing, >Helpful in decreasing
distraction behaviors, perception/response to >
visualization, guided anxiety. Provides a demonstrate
imagery. sense of control over the use of
the situation. effective
coping skills
by means of
deep
breathing and
guided
imagery.
 Precious F. Pambid Fourth Year Section One Group A January 6
2009
Patient Amelia Guttierez Room 202-B

Roosevelt College System

Institute of Nursing and Health Education
Sumulong Hi-way Cainta, Rizal

RELATED LEARNING EXPERIENCE ON

LEADERSHIP AND MANAGEMENT

SAMPLE CHARTING

S - “Akala ko makkauwi na ko kahapon e may inaantay pa” as

manifested by the patient.

O – Received patient awake, lying on bed

-Anxious
-Expressed concern of going home
-Tensed

A - Ineffective individual coping related to unmet expectation as

manifested by expressed concern of going home

P – After 1 hour of nursing intervention Patient Amelia Guttierez

at room 202-B will be able to:
>identify ineffective coping behaviors and consequences
> verbalize awareness of own coping abilities/strengths
>demonstrate the use of enhance coping skills/methods
 I – > Assess effectiveness of coping strategies by observing
behaviors, ability to verbalize feelings and concerns and
willingness to participate in the treatment plan.

> Assist patient to identify specific stressors and possible

strategies for coping with them.

> Promote expression of feelings and fears e.g. denial and anger.

> Provide quiet environment, and calm activities and comfort

measures (e.g. dry/wrinkle free linens, backrub).

>Assist in relaxation techniques e.g. deep/slow breathing,

distraction behaviors, visualization, guided imagery.

E – After 1 hour of nursing intervention Patient Amelia Guttierez

at room 202-B was able to:

>identify ineffective coping behaviors and consequences by

means of verbalization and promotion of expression of feelings
and fears like denial.

> verbalize awareness of own coping abilities by promotion of

expression.

> demonstrate the use of effective coping skills by means of deep

breathing and guided imagery