PATIENT NAME: PATIENT X

AGE: 64 Y/O
CASE NO. : 19756
DIAGNOSIS: INTESTINAL OBSTRUCTION
NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Goal Met
Subjective Data: Fatigue related to post-operative Within 8 hours of nursing *Establised rapport to the *To gain client's trust and *Was able to demonstrate
experience as manifested by interventions, the client patient. cooperation. improved level of energy
evidence of weakness and will: by having rest periods.
deep sleep. *Monitored vital signs and *To see trends including
Objective Data: *demonstrate improved interpreted it accurately. progress of condition or *Appeared relaxed and calm.
level of energy specifically any unusual signs.
*Vital signs: to participate in
T: 37.5oC therapeutic activities at *Provided with rest intervals *To prevent fatigue.
RR: 20 b/m level of ability with quiet environment and
PR: 79 b/m well-ventilated area.
BP: 130/70mmHg *restore energy through
rest intervals. *Provided comfort measures *To enhance self-image.
*After operation, patient such as massaging of hands
is on bed rest *vital signs will remain and forehead.
in normal range
*Flat on bed and shows *Provided patient with oppotu- *To let the patient feel you
evidence of weakness nities for expressing feelings are concerned and he's
of irritation, weakness or not alone.
*Steady and in deep sleep discomfort.
PATIENT NAME: PATIENT X
AGE: 64 y/o
CASE NO. : 19756
DIAGNOSIS: INTESTINAL OBSTRUCTION

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Goal Met
Subjective Data: Impaired skin / tissue integrity Within 8 hours of our shift, *Monitored vital signs. *To monitor patient's After 8 hours immediate post
related to mechanical interrup- immediate post operative progress. operative nursing care the
tion of the skin (presence of nursing care, the client *Monitored intake and output. *To assess risk for hypo- client manifested intact
surgical wound) will manifest intact skin volemic shock. skin integrity as evidenced by:
Objective Data: integrity as evidenced by: *Inspected wound regularly, *Early recognition of
T: 36.2oC noting characteristics and delayed healing or deve- 1.) Absence of inflammation,
RR: 20b/m 1.) absence of inflamma- integrity. Note patients at loping complications may redness, purulent discharges
PR: 80b/m tion, redness, purulent risk for delayed healing. prevent a more serious on skin or operative site
BP: 100/70mmHg discharges on skin or situation.
operative site 2.) Vital Signs remained in
(+) Surgical incision normal range: T- 37.5oC,
2.) vital signs will remain RR-20b/m, PR-79b/m,
No exudates, itchiness, and in normal range BP-130/70
redness noted.
 Doctor's Nursing
Brand Name Generic Name Indication Contraindication Adverse Effect Side Effects
Order Consideration

Ranitidine Zantac Ranitidine * Short-term treatment
50mg q8 Hydrochloride of active duodenal
slow IV ulcer
*Short-term treatment of
active, benign gastric
ulcer
*Short-term treatment for
GERD
*Maintenance therapy for
duodenal ulcer at reduced
dosage
*Pathologic hypersecretory
conditions (Zollinger-
Ellison Syndrome)
Contraindicated with CNS: headache, malaise, Common side effects Assessment:
allergy to ranitidine, dizziness, somnolence, of Zantac Injection 1. History: Allergy to ranitidine,
lactation. insomia, vertigo include injection site impaired renal or hepatic
reactions (pain, burning, function, lactation, pregnancy
Use cautiously with CV: tachycardia, brady- itching, redness, or 2. Physical: skin lesions,
impaired renal or hepatic cardia stinging), headache, orientation, vein evaluation,
function, pregnancy. dizziness, sleepiness, abdominal examination, normal
Dermatologic: rash, sleep problems output, renal function tests,
alopecia (insomnia), vertigo, CBC
constipation, or diarrhea. Intreventions:
GI: constipation, 1. Administer oral drug with
diarrhea, nausea and meals and at bedtime
vomiting, abdominal 2. Decrease doses in renal
pain, hepatitis and liver failure
3. Provide concurrent antacid
GU: impotence or therapy to relieve pain
decreased libido 4. Administer IM
 Doctor's
Brand Name Generic Name Indication
Order
Cefazolin Ancef, Kefzol Cefazolin Cefazolin for Injection USP and De Hypersensitivity to any
1 gram IV is a cephalosporin
q8 antibacterial indicated in the
treatment of the following
infections caused by
susceptible isolates of the
designated microorganisms:
Respiratory tract infections
(1.1); urinary tract infections
(1.2); skin and skin structure
infections (1.3); biliary tract
infections (1.4); bone and joint
infections (1.5); genital
infections (1.6); septicemia
(1.7); endocarditis (1.8) and
perioperative prophylaxis (1.9)
Contraindication Adverse Effect
Hematologic: Hemolytic
cephalosporin and related anemia, neutropenia,
antibiotics; pregnancy leukopenia, eosinophilia,
(category B), lactation thrombocytopenia,
thrombocytosis, impaired
platelet aggregation
Dermatologic: Rash
(maculopapular), puritis,
urticaria
Gastrointestinal: Diarrhea
Hepatic: Abnormal liver
function tests
Renal: Interstitial nephitis
Other: Anaphylaxis
Nursing
Side Effects
Consideration
Allergic reactions Assessment & Drug Effects
Confusion *Determine history of
Diarrhea hypersensitivity to cephalosporins,
Drowsiness penicillins, and other drugs,
Eosinophilia before therapy is initiated.
Fainting
Fever *Lab tests: Perform culture and
Gas sensitivity testing prior to and
Headache during therapy. Therapy may be
Heartburn initiated pending results.
Hives
Increased transaminases *Monitor I&O rates and pattern:
Injection site reactions Be alert to changes in BUN, serum
(pain, swelling, skin rash, creatinine.
or a hard lump)
Lightheadedness
Loss of appetite
Low blood pressure
(hypotension)
Low platelet count
(thrombocytopenia)
Low white blood cell
count (leukopenia,
neutropenia)
Nausea and vomiting
Oral thrush
Phlebitis
cont.: Cefazolin
Doctor's Nursing
Brand Name Generic Name Indication Contraindication Adverse Effect Side Effects
Order Consideration

Pseudomembranous colitis
Rectal itching
Seizure
Skin rash or itching
Stevens-Johnson syndrome
Stomach cramps/pain
Thrombocytosis
Tiredness
Transient elevation of
hepatic enzymes
Vaginal itching or discharge
Weakness
White patches or sores
inside the mouth or
on the lips
 Doctor's
Brand Name Generic Name Indication
Order
Omeprazole Prilosec omeprazole Short-term treatmentof
20mg activeduodenalulcer; First-
IV OD line therapy intreatment of
heartburn or symptoms of
gastroesophageal reflux
disease(GERD); Short-term
treatment of active benign
gastric ulcer; GERD,severe
erosive esophagitis, poorly
responsive symptomatic
GERD;Long-term therapy:
Treatment of pathologic
hypersecretory conditions
(Zollinger-Ellison syndrome,
multiple adenomas,
systemic mastocytosis);
Eradication of H. pylori
With amoxicillin or
metronidazole.
Contraindication Adverse Effect
Contraindicated with Significant: Hypomagnasaemia,
hypersensitivity to ome- cutaneous lupus
zole or its component; erythematosus, SLE,
Use cautiously with osteoporosis-related
pregnancy; lactation, fractures, fundic gland
polyp, carcinoma,
Clostridium difficile-
associated diarrhoea,
interstitial nephritis,
Vitamin B12 deficiency
(long-term therapy),
gastrointestinal infection
(e.g. salmonella,
Campylobacter).
Gastrointestinal disorders:
Nausea, vomiting,
diarrhoea, constipation,
flatulence, abdominal
pain.
General disorders and
administration site
conditions: Weakness,
malaise.
Hepatobiliary disorders:
Increased liver enzymes.
Nursing
Side Effects
Consideration
headache Assessment & Drug Effects
nausea
vomiting Lab tests: Monitor urinalysis for
diarrhea hematuria and proteinuria.
stomach pain Periodic liver function tests
gas with prolonged use.
constipation
fever, or
cold symptoms Patient & Family Education
(stuffy nose, sneezing,
and sore throat) Report any changes in urinary
elimination such as pain or
discomfort associated with
urination, or blood in urine.
Report severe diarrhea;
drug may need to be discontinued.
Do not breast feed while
taking this drug.
cont. omeprazole
Doctor's Nursing
Brand Name Generic Name Indication Contraindication Adverse Effect Side Effects
Order Consideration

Immune system
disorders: Urticaria.

Metabolism and
nutrition disorders:
Peripheral oedema.

Musculoskeletal and
connective tissue
disorders: Back pain.

Nervous system
disorders: Headache,
dizziness, somnolence,
paraesthesia, vertigo.

Psychiatric
disorders: Insomnia.

Respiratory,
thoracic and
mediastinal disorders:
Cough.

Skin and subcutaneous

tissue disorders:
Rash, dermatitis, pruritus.
Ketorolac
Doctor's Nursing
Brand Name Generic Name Indication Contraindication Adverse Effect Side Effects
Order Consideration

Ketorolac 30mg Toradol Ketorolac Short-term managementof Contraindicated with CNS:headache,dizziness, Headache Renal impairment, Impaired
IV q8 Tromethamine pain (up to 5 days) significant renal somnolence,insomnia, Drowsiness hearing,allergies, hepatic,
impairment, aspirin fatigue,dizziness Indigestion
allergy, recent GI bleed tinnitus,ophthalmologic Stomach or abdominal Skin color and lesions,orientation,
or perforation effects pain reflexes,peripheral sensation,
Use cautiously with Nausea clotting times, CBC,adventitious
impaired hearing; Diarrhea sounds
allergies; hepatic Dizziness
conditions Itching Be aware that patientmay be at
Swelling (edema) risk for CVevents, GI bleeding,
Increased blood urea renal toxicity, monitor accordingly
nitrogen (BUN)
Constipation Keep emergency equipment
Purpura readily available at time of initial
Increased serum dose, in case of severe
creatinine hypersensitivity reaction
Drowsiness
High blood pressure Protect drug vials from light
(hypertension)
Administer every 6 hrs to
maintain serum levels and
control pain
Metformin
Doctor's Nursing
Brand Name Generic Name Indication Contraindication Adverse Effect Side Effects
Order Consideration

Metformin Glucophage, metformin GLUCOVANCE (Glyburide GLUCOVANCE is
50gm Glucophage XR, and Metformin HCl) Tablets contraindicated in
tab BID Fortamet, is indicated as an adjunct to patients with:
Glumetza, diet and exercise to
Riomet improve glycemic control 1. Renal disease or renal
in adults with type 2 dysfunction (eg, as
diabetes mellitus. suggested by serum
creatinine levels ≥
1.5 mg/dL [males], ≥ 1.4
mg/dL [females], or
abnormal creatinine
clearance) which may
also result from
conditions such as
cardiovascular collapse
(shock), acute
myocardial infarction,
and septicemia
2. Known hypersensitivity
to metformin
hydrochloride or
glyburide.
digestive problems, Side effects of metformin * Metformin is the drug of choice
such as diarrhea, include: for overweight patients for
vomiting, and flatulence whom dieting has not controlled
a vitamin B-12 deficiency physical weakness diabetes. Can also be used in
slight weight loss (asthenia) patients who are not overweight
diarrhea and when diabetes cannot be
gas (flatulence) controlled with sulphonylurea
symptoms of weakness, treatment.
muscle pain (myalgia) * Advantages include lower
upper respiratory incidence of weight gain.
tract infection * Gastrointestinal complaints are
low blood sugar more common with higher doses.
(hypoglycemia) * To avoid lactic acidosis do not
low blood levels use in patients with even mild
of vit B-12 renal problems.
nausea * Store in a tight container in a
vomiting cool place.
chest discomfort *Side-effects are common and
chills, dizziness advice about taking the drug
bloating/abdominal with food or using slow-release
distention tablets can help
constipation
heartburn
cont. metformin
Doctor's Nursing
Brand Name Generic Name Indication Contraindication Adverse Effect Side Effects
Order Consideration

3. Acute or chronic
metabolic acidosis,
including diabetic
diabetic ketoacidosis,
with or without coma.
Diabetic ketoacidosis
should be treated with
insulin.

4. Concomitant
administration of
bosentan.

GLUCOVANCE should be
temporarily discontinued
in patients undergoing
radiologic studies
involving intravascular
administration of
iodinated contrast
materials, because use
of such products may
result in acute alteration
of renal function.
Ceftriaxone
Doctor's Nursing
Brand Name Generic Name Indication Contraindication Adverse Effect Side Effects
Order Consideration

Ceftriaxone Rocephin Ceftriaxone Lowers respiratory
1gm Sodium infections caused by
IV q8 Streptococcus pneumonia,
Staphylococcus aureus,
Haemophilus influenza, -
E. coli, Enterobacter
aerogenes.Intra
abdominal infections
caused by E.coli, Klebsiella
pneumoniae
Contraindicated with CNS: Headache,dizziness, rash, BEFORE: Do Skin Testing into
allergy to cephalosporins lethargy diarrhea, the intradermal area
or penicillins. Use nausea,
cautiously with renal GI: Nausea, vomiting, vomiting, Protect Drug from light
failure, lactation, diarrhea, anorexia, upset stomach,
pregnancy. pseudomembranous blood clots, Do not mix ceftriaxone with
colitis dizziness, other antimicrobial drug
headache,
HEMATOLOGIC: bone pain or swelling in DURING: Use a separate
marrow depression your tongue, syringe when giving this drug
dec. WBC, platelets, Hct a lump where the
medicine was injected, Have Vitamin K available in case
LOCAL: pain, inflammation sweating, of hypoprothrombinemia occurs
of IV Site vaginal itching or
discharge, AFTER: Discontinue if
OTHER: superinfections, vaginal yeast infection, hypersensitivity occurs
disulfiram-likereaction anemia,
with alcohok changes in taste, or Monitor Blood levels in patients
flushing. taking this drug
Clindamycin
Doctor's
Brand Name Generic Name Indication
Order
Clindamycin Cleocin, Clindamycin * infections caused by
300mg Clinacin, sensitive staphylococci,
IV q6 Dalacin, others streptococci, pneumococci,
bacteroides, fusibacterium,
clostridium perfringens,
and other sensitive
aerobic and anaerobic
organisms
*Endocarditis prophylaxis
for dental procedures in
patients allergic to
penicillin
* acne vulgaris
* bacterial vaginosis
* pneumocystis jiroveci
(carinii) pneumonia
* toxoplasmosis(cerebral
or ocular) immuno-
compromised patient
Nursing
Contraindication Adverse Effect Side Effects
Consideration
Contraindicated in CNS: headache nausea, * assess patients infection before
patients hypersensitive vomiting, and regularly throughout therapy
to drug or lincomycin- CV:Thrombo phlebitis diarrhea,
use cautiously in patients stomach pain, * before giving first dose, obtain
with renal or hepatic EENT: pharyngitis joint pain, specimen for culture and
disease, asthma, history vaginal itching or sensitivity test, begin therapy
of GI disease, or GI: abdominal pain, discharge, pending results.
significant allergies. Anorexia, bloody or skin rash or itching,
tarry stools, constipation, heartburn, * monitor renal, hepatic,and
diarrhea, dysphagia, sore throat, or hematopoetic functions during
esophagitis, flatulence, changes in bowel habits prolonged therapy
nausea, (especially in older
psuedomembranus adults). * be alert for adverse reactions
colitis, unpleasant or and drug interactions
bitter taste, vomiting.
* if adverse GI reactions occurs,
GU: UTI monitor patients hydration
HEMATOLOGIC: * teach patient how to store
Eosinophilia ,thrombo- oral solution
cytopenia, transient
leukopenia * tell patient to take entire
amount prescribed even after
SKIN: maculopapular he feels better
rash, urticaria
cont. clindamycin
Doctor's Nursing
Brand Name Generic Name Indication Contraindication Adverse Effect Side Effects
Order Consideration

* warn patient that I.M.

OTHER: anaphylaxis, injection may be painful
erythema, pain (I.V. use)
induration, pain; * instruct patient to report
sterile abcess (I.M.use) diarrhea and to avoid self-
threatening pseudomembranus
colitis

* tell patient receiving drug I.V.

to report discomfort at
infusion site
PATIENT NAME: PATIENT X
AGE: 64 Y/O
CASE NO. : 19756
DIAGNOSIS: INTESTINAL OBSTRUCTION

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Goal Met
Subjective Data: Risk for nosocomial infection Within 8 hours of nursing * Assess signs and symptoms * Fever mayindicate Patient was free from any
"Kagabi lang ako related to post surgical interventions, the client of infection especially infection. signs and symptoms of
naoperahan"; as incision. will: temperature. infections as manifested
verbalized by the by absence of fever.
patient. Scientific Reason: *Remain free from signs of * Emphasize the importance * It serves as a first line of
Objective Data: Wounds involving injury to soft any infection of hand washing technique defense against infection.
tissue can vary from minor tears
*Vital signs: to severe crushing injuries. * Demonstrate ability to * Maintain aseptic technique * Regular wound dressing
T: 37.5oC The decision to suture a wound care for infection-prone site when changing dressing/ promotes fast healing
RR: 20 b/m depends on the nature of the caringwound. and drying of wounds.
PR: 79 b/m wound the time since the injury *Verbalize which symptoms
BP: 130/70mmHg was sustained the degree of of infection to watch out for * Keep area around wound * Wet area can be lodge
contamination. clean and dry. area of bacteria.
*Afebrile, conscious and *Show capability to
coherent recognize symptoms of * Emphasized necessity of * Premature
infection taking antibiotics as ordered. discontinuation of
*Lying in bed, awake treatment when client
begins to feel well may
result in return of
infection.

* Encourage adequate rest. *Rest can reduce stress

and boost the immune
system.