De Guzman, Nina Ricci E.

Group: CB6

Nursing Care Plan

Assessment Nursing Rationale Planning Nursing Rationale Evaluation

Diagnosis Intervention
Subjective - risk for - malfunctioning -After 30 Independent: -After 30
Data: Deficient of IVF catheter minutes of • Assess the minutes of
Fluid Volume can affect the effective patient’s IVF nursing
related to correct order nursing catheter - to ensure if intervention,
malfunctioni of IVF and intervention, - Check for kinks there is no the patient’s IV
Objective ng of IVF proper infusion the patient’s obstruction catheter was
Data: catheter IVF will be - to check if reinserted at
 With regulated - Assess if the IVF the left metacarpal
D5LR 1L x 8° properly and catheter is still catheter is infusing well
(31-32 correctly. intact by still intact with 31-32
gtts/min) due lowering the gtts/min
on 4:55 pm bottle to check
on left arm for back flow
 at 1:30 - to infuse
pm, IV Dependent: the IVF in
catheter is - If there is no back correct
not flowing flow, refer to rate as
but the MROD for IVF ordered
regulator is regulation or
on reinsertion of IVF
Drug Study
Drugs Indication Action Side Effects/ Nursing Patient
Adverse Reaction Consideration Teaching

Cefuroxime Moderate to Interferes with CNS: headache, -Monitor patient for -Advise patient to
severe bacterial cell-wall- hyperactivity, life-threatening immediately
(Axetil) infections, synthesis and hypertonia, seizures adverse effects, report rash/
Classification: including those division by binding including bleeding
of skin, bone, to cell wall, causing GI: nausea, anaphylaxis, tendency.
anti-infective vomiting, diarrhea,
joints, urinary or cell to die. Active Stevens- Johnson
500mg (1tab) respiratory tract, against gram- abdominal pain, syndrome and - Instruct patient
gynecologic negative and gram- dyspepsia, pseudomembranous to take drug with
QID pseudomembranous food.
infection positive bacteria, colitis.
with expanded Glitis
-Monitor neurologic -Teach patient
activity against GU: hematuria, how to recognize
gram-negative status, particularly
vaginal candidiasis, for signs of signs &
bacteria. Exhibits renal dysfunction, symptoms of
minimal impending seizures.
acute renal failure. super infection.
immunosuppressant -Monitor kidney and Instruct him to
activity. Hematologic: liver function test report these right
hemolytic anemia, result and I&O away.
aplastic anemia,
hemorrhage -Monitor CBC w/ -Advise patient to
differential and report CNS
Hepatic: hepatic Prothrombin time; changes.
dysfunction watch for signs and
symptoms of blood -As appropriate,
Metabolic: review all other
hyperglycemia dyscrasias.
significant and
 Skin: toxic epidermal -Monitor life-threatening
necrolysis, erythema temperature; watch adverse reaction
multiforme, Stevens- for signs and and interaction
Johnson syndrome symptoms of especially those
superinfection. related to the
Other: allergic drugs and test.
reaction, drug fever,
superinfection,
anaphylaxis.

Ketoprofen Inflammatory Inhibits CNS: drowsiness, -Pt. who has -Advice patient to
disorders, Mild to prostaglandin headache, dizziness asthma, aspirin- take medication
(Orudis) moderate pain, synthesis, induced allergy, as directed.
including suppression of pain EENT: blurred nasal polyps are at
Classification: vision, tinnitus -May cause
antipyretics, dysmenorrhea and inflammation, increased risk for
and fever. reduction of fever. developing dizziness and
nonopiod CV: edema drowsiness.
analgesics, hypersensitivity
GI: constipation, reactions. Advice patient to
nonsteroidal avoid driving and
anti- diarrhea, dyspepsia,
nausea, vomiting, -For pt with fever other activities
inflammatory monitor temp; note requiring
agents, anorexia, discomfort,
flatulence. signs associated alertness until
1 tab BID with fever response to
GU: cystitis, (diaphoresis, medication is
Q12 hematuria, renal tachycardia, known.
failure malaise).
-Caution pt that
Derm: -For rapid initial use of ketoprofen
photosensitivity, effect, administer 30 with 3 or more
rashes min before or 2 hr glasses of
after meals. alcohol may
 -Extended-release increase risk of
capsules should be GI bleeding.
swallowed whole;
do not open and
chew.

Ascorbic Acid Treatment and Water soluble CNS: drowsiness, -use cautiously in
prevention of vitamin with fatigue, headache, recurrent kidney
(poten-cee) Vitamin C antioxidant insomnia stones.
Classification: deficiency properties;
(scurvy) with stimulates collagen GI: cramps, -Avoid rapid IV
Vitamins dietary formation and diarrhea, heartburn, infusion
supplementation enhances tissue nausea and vomiting
Vit C
. repair. GU: kidney stones
Prevention of Derm: Flushing
1 Gram common colds.
(2tabs) QD Hemat: deep vein
thrombosis,
hemolysis, sickle cell
crisis.

Local: pain at subcut

or IM sites.