NAME OF THE DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE REACTION NURSING RESPONSIBILITY

DRUG ROUTE ACTION

FREQUENCY
OF ADM.

Cefuroxime Axetil 500 mg; BID; Second-generation >Serious lower > Contraindicated in patient CV: phlebitis, thrombophlebitis > Before giving the drug, ask patient
per Orem cephalosporin that respiratory tract infection, hypersensitive to drug or other GI: diarrhea, pseudomembranous if he is allergic to penicillin or
( Zinnat) inhibits cell-wall skin/skin structure cephalosporin colitis, nausea and vomiting , cephalosporins.
Pharmacologic Class: synthesis, promoting infections, bones/joints anorexia
second Generation osmotic instability; infection. > Use cautiously in patients Hematologic: hemolytic anemia, >Obtain specimen for culture and
cephalosporin usually bactericidal. hypersensitive to penicillin thrombocytopenia, transient sensitivity tests before giving first
>uncomplicated skin and because sensitivity with other neutropenia, eosinophilia dose. Therapy may begin while
skin infection. beta- lactan antibiotics. Skin: maculopopular and awaiting results.
erythematous rashes, uticaria, pain,
indurations, sterile abscesses, > Absorption of oral drugs is
temperature elevation, tissue enhanced by food.
sloughing, at IM injection site.
> Tablets may be crushed, if
necessary, for patients who cannot
swallow tablets. Tablets may be
dissolved in small amounts of apple,
orange or grape juice or chocolate
milk. However, the drug has a bitter
taste that is difficult to mask, even
with food.

> Monitor patient for Signs and

symptoms of super infection.

> tell the patient to take drug as

prescribed even after he feels better.

> instruct the patient to take oral

forms with food

> tell the patient to notify prescribed

about rash, loose stools, diarrhea or
evidenced of super infection.
 NAME OF THE DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE REACTION NURSING RESPONSIBILITY
DRUG ROUTE ACTION
FREQUENCY
OF ADM.

Metronidazole 500 mg; BID; Direct acting >to prevent postoperative > Contraindicated in-patient CNS: headache, seizures, fever, > monitor liver function test results
per Orem trichomonocide and infection in contaminated hypersensitive to drug or other vertigo, ataxia, dizziness, syncope, in carefully in elderly patient.
(Metronidazole) amebicide that works or potentially nitroimidazole derivative to coordination, confusions, irritability,
Pharmacologic Class: inside and outside the contaminated colorectal drug or other nitroimidazole depression, weakness, insomnia, >give oral forms for meals.
Nitroimidazole intestines. It has surgery. derivatives. peripheral neuropathy.
thought to enter the > observe patient for edema,
cells of microorganisms >bacterial infections > Use cautiously in patients CV: flattened T waves, edema, especially if he’s receiving
that contain caused by anaerobic with history of blood flushing, thrombophlebitis after I.V. corticosteroids; flaggy IV RTU may
nitroreductase, forming microorganism dyscrasia, CNS disorder, or infusion. cause sodium retention
unstable compounds retinal or visual field changes.
that binds to DNA and > Intestinal amebiasis. EENT: rhinitis, sinusitis, pharyngitis > Record number and character of
inhibits synthesis, > Use cautiously in patients stools when drug is used to treat
causing cell death. who take hepatotoxic drugs or GI: abdominal ramping or pain, amebiases.
have hepatic disease or stomatitis, epigastric distress,
alcoholism. proctitis,diarrhea, constipation, > instruct patient in proper hygiene.
nausea and vomiting , anorexia, dry
mouth, metallic taste. > tell the patient to avoid alcohol and
alcohol containing drugs during and
GU: darkened urine, polyuria, for at least 3 days after treatment
dysuria, cystitis, dyspareunia, genital course.
pruritus.
> tell patient he may experience a
Hematologic:, transient leucopenia, metallic taste and have dark
neutropenia, red/brown urine.

Skin: rash > tell the patient to notify prescribed

about any neurologic symptoms.
MS: Transient joint pains

Respi: upper respiratory tract

infection
 NAME OF DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE REACTION NURSING RESPONSIBILITY
THE DRUG ROUTE ACTION
FREQUEN
CY OF
ADM.

Amlodipine 5 mg; BID; Inhibits calcium in >chronic stable > Contraindicated in-patient hypersensitive to drug CNS: headache,somnolence, fatigue, > monitor patient carefully. Some
besylate per Orem influx across cardiac angina, vasospatic light headedness, paresthesia patients, especially those with severe
and smooth muscle ells, angina (prinzmetal > Use cautiously in patients receiving other obstructive pulmonary artery disease,
(vasalat) dilates coronary arteries or variant angina) peripheral vasodilators, especially those with sever CV: edema, flushing, palpitations have developed increase frequency,
Pharmacologic and arterioles, and aortic stenosis, and in those with heart failure. duration, or severity of angina or
Class: calcium- decreased blood >hypertension Because drug is metabolized by the liver, use GI: abdominal pain, , nausea acute MI after initiation of calcium
channel blocker pressure and cautiously and in reduced dosage in-patient with channel blocker therapy or at time of
myocardial oxygen severe hepatic disease. GU: sexual difficulties dosage increase.
demand.
MS: muscle pains >monitor blood pressure frequently
during initiation of therapy. Because
Respi: dyspnea drug is induced vasodilatations has a
gradual onset, acute hypotension is
Skin: Rash, pruritus rare.

> tell the patient to notify prescribed

about any signs of heart failure
occur, such as swelling of hands and
feet or shortness of breath

> Alert: abrupt withdrawal of drug

may increase frequency and duration
of chest pain. Taper dose gradually
under medical supervision.

> Caution patient to continue taking

drug even when feeling better.
 NAME OF DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE REACTION NURSING RESPONSIBILITY
THE DRUG ROUTE ACTION
FREQUEN
CY OF
ADM.

Ranitidine 150 mg; Competitively inhibits >active duodenal > Contraindicated in-patient hypersensitive to drug CNS: headache, malaise, vertigo > Asses patient for abdominal pain.
TID; per action of histamine on and gastric ulcer) and those with acute porphyria Note for [presence of blood in
(ulcin) Orem the H2 at receptor sites EENT: blurred vision emesis, stool, or gastric aspirate.
Pharmacologic of parietal cells, >maintenance > Use cautiously in patients with hepatic
Class: H2 decreasing gastric acid therapy for dysfunction. Adjust dosage in-patient with impaired Hepatic: jaundice >drug may be added to total
receptor secretion. duodenal of gastric renal function. parenteral nutrition solutions.
antagonist ulcer Others: anaphylaxis, angio edema,
burning and itching at injection site. > instruct patient on proper use of OT
> heart burn preparation, as indicated

> Record patient to take once- daily

prescription drug at bedtime for best
result.

> instruct patient to take out regard to

meals because absorption isn’t
affected by food

> advise patient to report abdominal

pain and blood in stool and emesis

> urge patient to avoid smoking

because this may increase gastric
acid secretion and worsen disease.
 NAME OF DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE REACTION NURSING RESPONSIBILITY
THE DRUG ROUTE ACTION
FREQUEN
CY OF
ADM.

Paracetamol 500 mg; Thought to produce >mild pain or fever > Contraindicated in-patient hypersensitive to drug Metabolic: hypoglycemia > Many OTC prescription products
PRN; per analgesia by blocking > Use cautiously in patients with long-term alcohol contain acetaminophen; be aware of
(acetamenophen Orem, for pain impulses by use because therapeutic doses cause hepatotoxity in Hepatic: jaundice this when calculating total daily
) fever inhibiting synthesis of these patients. dose.
Pharmacologic prostaglandin in the Hematologic: hemolytic anemia,
Class: CNS or of other neutropenia, pancytopenia >tell patient not to use for marked
paraaminophen substances that fever (temperature higher than 103.1
ol derivative sensitize pain receptors Skin: rash, uticaria Fahrenheit/ 39.5 Celsius), fever
to stimulation. The drug persisting longer than 3 days or
may relieve fever recurrent fever unless directed by
through central action prescriber.
in the hypothalamic
heat regulating enter. > Alert! Warn patient that high doses
or unsupervised long-term use can
cause liver damage. Excessive
alcohol use may increase risk for
liver damage. Caution long-term
alcoholics to limit drug to 2/ grams/
day or less.

ASSESSMENT DIAGNOSIS RATIONALE DESIRED INTERVENTION JUSTIFICATION EVALUATON

 OUTCOME

Subjective cues: Knowledge deficit High school graduate After 4 days Independent 1.Goal met: client has able to gain the motivation to
“Ano ni tah ang akon related to the disease nurse-client 1. provide physical This allows the patient to learn as he really give attention to what I am doing.
sakit haw? “ process and surgical interaction, the comfort for the concentrate on what is being He claimed that gusto ko mag tuon sang akon
management as client will be able learner discussed or demonstrate. masakit basta mau lang ang gatudlo indi suplada
…Clients complain… evidenced by “ano nit Lack of knowledge to: According to Maslow’s theory, pareha sa imo day”
ah akon sakit haw?’ as about the nature of basic physiologic needs must be
Objective cues: client claimed disease, etiology, 1. demonstrate addressed before patient education. 2. Goal met: client really shows attentive
> curiosity physiology cause and motivation to participation in the learning process. He is so eager
>inadequate signs and symptoms. learn 2. provide a quiet This allow the patient to to know of his disease.
performance of test atmosphere without concentrate more completely
> lack of recall 2. Participate in interruption
> not on the mood to learning process, and 3. Goal met: client have do the task correctly without
follow instructions Unrecognized signs treatment regimen. 3. provide an This is especially important when any hesitation
and symptoms atmosphere of providing education to patients
Strength/ wellness: 3. perform necessary respect, openness, with different values and beliefs
procedures correctly trust and about health and illness. 4. Goal partially met: client was not that able to
>Supportive family collaboration initiate lifestyle changes as he say” dapat amat amat
Surgery 4. initiate necessary lang la pag bago indi dapat pag gulpihon”
>Good compliance lifestyle changes 4. provide Patient must have correct
with medication instruction for information to make informed
specific topics choices in their treatment, to
>Strong faith in God. Lack of care and identify when therapy adjustments
treatment for the are needed ant to recognize
Risk related factors: postoperative disease. important changes in their
condition that would lead to
>Poor financial Definition: absence/ serious outcomes.
support deficiency of cognitive
information related to
> Lack of Knowledge specific topic
5. provide positive, A positive approach allows the
constructive learner to feel good about the
reinforcement of learning accomplishments, gain
learning confidence and maintain self-
esteem while correcting mistakes.

Collaborative:
1. refer the patient These allows the patient to interact
to community with others who have similar
resources/support problems, learning needs or
groups as needs specialty resources.
 ASSESSMENT DIAGNOSIS RATIONALE DESIRED INTERVENTION JUSTIFICATION EVALUATON
OUTCOME

Subjective cues: Deficient diversional activity related to Recognize signs and symptoms of After 4 days nurse- Independent: 1.Goal met: client ‘s
“ Ka boring gid di ya depression and boredom as evidenced by “ swelling at right scrotal area. client interaction, the 1. Provide frequent A prolonged confinement attention was diverted
day, natak-an nako di kaboring gid di ya day, natak an nako do client will be able to: contact. Be certain resulting from illness or to an interest of talking
magtinir sa hospital magtinir sa hospital mau pa sa balay damu ko that patient is aware disability may cause the to his family members
kay la gid ko di maubra.” as client claimed 1. patient attention is of your presence. patient to become who is attending his
ibrahun” Admission to the hospital prior for diverted to interest depressed or to disengage needs in the hospital.
…Clients complain… surgery other than illness and from life by increasing He is now fun of
confinement the amount of time spent telling stories about his
Objective cues: sleeping or refusing past life.
> verbal expression of Definition: decrease stimulation from (or Inability to perform ADL due to visitors.
boredom interest or engagement ) recreational or leisure pain at the incision site
>desire for activity activities ( note: internal/ external factors may or 2. Provide and The patient may need 2. Goal met: client
> excessive complaint may not be beyond the individuals ontrol) Lack of activities 2. Engage in satisfying assist with specific assistance to engage in really shows a positive
> feeling of depression activities with in physical, cognitive, desired activities. outcome of the
> disinterest personal limitations. social and spiritual intervention with him.
> preoccupation with activities that can He is now engage in
illness Feeling of boredom and depression be accomplished in different activities like
the current talking, sitting together
Strength/ wellness: situation. with his daughter, and
3. perform any works performs exercises at
>Supportive family Deficient diversional activity available at the 3. provide dietary Mealtime, especially the bedside.
hospital changes if possible family and menu
>Good compliance selection become very
with medication important to the confined 3. Goal met: client
patient have do the activities
>Strong faith in God. in his own capacity
4. spend time with Engaging with the patient
Risk related factors: the patient without without focusing on
providing physical illness will divert the
>Poor financial are patient’s attention and
support help pass the time.

> Lack of Knowledge 5. explain the Patients are more likely to

benefits of engage in activity that
diversional require expenditure of
activity(e.g. energy if they see a
relaxation, positive benefit..
distraction)
Collaborative: For further fast recovery
1. collaborate with
physical,
occupational and
recreational therapy
to plan and
implement an
acceptable,
achievable activities
and programs.
 ASSESSMENT DIAGNOSIS RATIONALE DESIRED INTERVENTION JUSTIFICATION EVALUATON
OUTCOME

Subjective cues: Disturbed body Palpable mass and After 4 days nurse- Independent: 1. Goal met: client ‘has able to cope up with
“ day daw nahuya image related to swelling of right testes. client interaction, the 1. Help the patient Patient may perceive changes that are not the new changes in his body. He has now
nako magapakita repair of hernia and client will be able to: identify actual present or real, or they place an unrealistic able to talk and be open with his life.
sakon lawas bala kay marks of incision changes. value on the body structure or function.
kalapad guid sang site as evidencedby 1. Patient
akon tinay an” “day daw nahuya repair of hernia with X demonstrates enhanced 2. encourage It is worthwhile to encourage the patient to
…Clients complain… nako magpakita LAP body image and self- verbalization of separate feelings about changes in the body 2. Goal met: client is now open to what he
sakon lawas daw di esteem as evidenced positive and negative structures and functions from feelings about feels. He has over come his problems about
Objective cues: nako mag uba bala by ability to look feelings about the self worth. Expression of feelings can his body as he laimen” okey baton ko na
> verbal expression of kay kalapad guid abdominal and inguinal touch, talk about And actual change enhance the persons coping strategies. kung noh natabo sakon, gapasalamat gid k
depression and shyness sakon tinay an” as incision care for actual or okay biskan may nagbag to sa lawas ko , stil
>refusal to talk about client claimed. perceived altered body 3. Demonstrate Professional caregivers represent a buhe ko”
changes part and function. positive caring routine microcosm of society and their actions and
> excessive complaint marks of incision site activities. behaviors are scrutinized as the patient
> compensatory use of plans to return to home, work and other
concealing clothing 2. Verbalized positive activities. 3. Goal met: client have now know that he
Definition: feeling about self and has marks of incision at his abdomen and
Strength/ wellness: Feeling of depression and Express feeling about 4. Teach patient about The person experiencing a body image inguinal area.
shyness how he looks. normalcy of body changes needs now information to support
>Strong faith in God image disturbance and cognitive appraisal of the changes.
>Good compliance grief process.
with medication
>Supportive family Disturbed body image 3. Patient identifies at
least 1 thing about his 5. teach patient This compensate for the actual hanged body
. body. adaptive behaviors structures and function.

Risk related factors: Collaborative:

1. refer the patient to These allows the patient to interact with
> Lack of Knowledge community others who have similar problems, learning
>Poor financial resources/support needs or specialty resources.
support groups as needs
 ASSESSMENT DIAGNOSIS RATIONALE DESIRED INTERVENTION JUSTIFICATION EVALUATON
OUTCOME

Subjective cues: Risk for infection surgery. After 4 days nurse- Independent:
“ day diba open ang related to client interaction, the 1. Assess closed Provide information indicating incision
tinay an ni tatay?, inadequate primary client will be able to: incision site for infection of edges, healing.. 1. Goal met: client ‘did not complain of any
magka imfection mana defense: broken redness, swelling, pain in any part of his body especially in the
sa day noh?” skin, injured repair of hernia with X 1. Clients denies of pain, drainage, incision site.
…SO… tissues, body fluis LAP pain in any area. approximation.
stasis as evidenced
Objective cues: by presence of 2. position in side Facilitates drainage through wound drain
> poen surgical incision on the open abdominal and 2. Patient remains free lying or semi fowlers and prevents spread of infection upward the
incision abdominal and inguinal incision of infection, as abdomen
> presence of penrose inguinal with a evidenced by absence 2. Goal met: client undergoes wound
tube penrose drainage. of purulent drainage 3. Teach client and Promote understanding of wound healing dressing every other day that makes him
> soak dressing exposure to from wounds. folks about incision and progression to infection resolution away from infection.
microorganisms care, dressing changes
Strength/ wellness: and healing process.
Definition:
>Good compliance 3. Have a surgical 4. carefully cleanse the Prevent contamination of wound and risk 3. Goal met: client’s incision site is dry and
with medication incision that is clean perineal area of any for infection. intact. There is no presence of any redness.
>Strong faith in God risk for infections and intact without any urine or stool as client claimed that “ daw okey na day akon
>Supportive family redness, Edema, odor needed tinay an wala na mau gabasa di parehas
and drainage. sang nanligad
.
5. encourage hand Prevent transmission of microorganisms
Risk related factors: washing, medial and
surgical asepsis during
>Poor financial and without procedure
support or care as possible
> Lack of Knowledge
6. Monitor vital signs, Elevation of temperature indicates infection
esp. temperature q4h

Collaborative:
1. Monitor WBC count An increasing WBC count indicates a
body’s efforts to combat pathogens. Normal
values are 4000 to 11,000mm3. Very low
WBC indicates severe risk for infection
because the patient does not have sufficient
WBC’s to fight infection. Note, in older
patients, infection may be present without
an increase in WBC count.
2. administer or teach Antimicrobial drugs includes antibacterial,
use of antimicrobial antifungal, antiparasitic and anti viral
agents. All of these agents are either toxic to
the pathogens or retard the pathogen’s
growth. Ideally, the selection of the drug is
based on culture from the infected area; this
is often impossible or impractical and in
these cases; empirical management is
undertaken with broad spectrum drugs.

MEDICATION EXERCISE
>RANITIDINE (ulcin) Soon after surgery, the
150 mg, TID, PO client is encouraged to
walk/ ambulate with
>AMLODIPINE assistance. To speed up the
BESYLATE recovery of the patient,
( vasalat) getting up and moving
5mg,BID ,PO around is highly encourage.
This would also prevent
>METRONIDAZOLE constipation and potentially
500mg,BID, PO dangerous blood clots.
>CEFUROXIME AXETIL Catheter and IV’s will
( zinnat) likely be removed.
500 mg,BID, PO
Start warming up exercise
>PARACETAMOL for neck, shoulder, and feet. body temperature
(acetaminophen)
500mg, PRN, PO, for fever Lie on back with pillow.
Bend the knees, arch back
and push seat against the
floor. Rush back against the
floor and raise the pelvic
area. Contract the
abdominal muscles. Repeat
4-5 times.
In the same position as
above, lift your buttocks up
while pulling in your pelvis
floor. Lower your body and
holding your ribs to keep
HEALTH TEACHING
POST OPERATIVE CARE
TREATMENT
> Abdominal and inguinal
incision
It will heal over the next
few weeks. There would be
mild cramping, light
bleeding, incision pain, and
numbness of skin around
the incision site.
Heavy lifting and strenuous
activity is avoided
Fever
Perform TSB to regulate
Pain and bleeding
Occasional pain and aches
an last for several months
If pain and bleeding
worsens or there are other
concerns, a healthcare
provider should be
consulted.
HYGEINE
Wound dressing should be
removed after 24 hrs and
the scar should keep clean
and dry once it is exposed.
Hand washing to avoid any
complication to occur.
OUT PATIENT DIET
SUPPORT YOUR Soft diet is ordered by the
ABDOMEN physician
Used god posture when you
stand or walk. Hold your Drink up: extra fluids can
abdomen near the incision help replace those lost
during sudden movements during surgery as well as to
prevent constipation.
Use pillows or rolled up
towels for extra support. Out patient….
TAKE IT EASY Full diet- as ordered
Give time to rest. Keep
everything that be needed Increased protein intake if
within reach physician ordered it for fast
recovery of the incision.
TAKE MEDICATION AS
NEEDED
Compliance with
medication is required for
fast recovery
your trunks straight, turn
your knees to one side and
then to other side as far as
possible.

In the same position as in

exercise 3, pull your
stomach in and do cycling
with your legs extending
them at hip and knees
alternately.

Sit well back on an upright

chair. Breathe out holding
your tummy with one hand
and then slowly bend
sideways. Repeat bending
to the other side. Fold your
arms and shoulder level,
slowly twist to look behind
and then twist back. Drop
gently forward from the
waist after 30-60 seconds.
Straightens up slowly.
Fria Joyce G. De Los Santos, BN3-J
NURSING CARE PLAN

NAME: Andres, M. J. C.C.: burns ate left face, left ear, left upper extremities and back
ADDRESS: Ma-ao, Bago City PHYSICIAN: Dr. A. Abayon

ASSESSMENT DIAGNOSIS RATIONALE DESIRED INTERVENTION JUSTIFICATION EVALUATON

OUTCOME

Subjective cues: Impaired skin Precipitating factor After 3 days nurse- Independent:
integrity related to (exposure to open flames or client interaction, the
“Gasakit kag the destruction of the hot objects) client will be able to:
kahapdi sang skin tissues
akon panit nga secondary to partial 1. Prevent
nasunog. thickness burns as Skin in contact with thermal complications while
evidenced by a deep object (open flame) the wounds are still > Assess the affected site > To assess extent of
red and weeping on their healing and determine injury.
Objective cues: appearance of the stage. degree/depth of wounds.
skin. Excessive heat damages
> extensive burns skin tissues > Keep the area clean
on the left deltoid and dry, carefully dress > To assist in the wound’s
area wounds, prevent natural process of healing
> partial Definition: Destruction of epidermal infection and stimulate and to protect the
thickness burn on layer and portions of the circulation to damaged skin with
left ear, left head Impaired skin dermis (Partial thickness surrounding areas dressings.
and left chest integrity – Altered burns)
> skin on affected epidermis and/or > Expose wound to air
areas is deep red dermis. and light if excess > To maintain appropriate
in color and has a moisture is impeding moisture environment for
weeping, wet Source: Microvessels in the area are 2. Maintain optimal healing the wound.
appearance injured nutrition/ physical
> patient’s report Nurse’s Pocket well-being.
of pain on Guide diagnoses, >Determine nutritional
affected site (pain Prioritized status of patient. > To detect potential for
scale of 6 out of intervention and Leakage of large amounts delayed healing or tissue
10) Rationales by of plasma injury exacerbated by
> WBC= 18.3 Doenges,Moorhouse, malnutrition.
thous/mcl Murr > Encourage client and
(NV=5-10 significant others to > To promote tissue
thous/mcl) Causes a blister to form 3. Participate in increase client’s intake of repair.
measures to promote protein rich food
wound healing/
Strength/ Skin in affected area treatment program. > To ascertain
wellness: becomes red, wet and > Provide health teaching understanding of the
painful to client’s significant client’s significant others
>Supportive others regarding the regarding the treatment
family importance of complying plan as well as to gain
Impaired skin integrity to treatment regimen cooperation.
Risk related such as dressing and
factors: 4.Verbalize feelings applying topical
of increased self- medications
> Lack of Source: esteem.
Knowledge
>Poor financial http://nursingcrib.com/burns >To release negative
support feelings toward the
Source: >Encourage client to condition and to prepare
Nurse’s Pocket verbalize feelings and the client in facing
Guide diagnoses, discuss how the comments from her
Prioritized condition affects self- playmates.
intervention and concept.
Rationales by
Doenges,Moorhouse,
Murr
Collaborative: > To remove nonviable,
contaminated, or infected
> Assist in dressing the tissue.
wound, or if
debridement/enzymatic
therapy was indicated.
Source:
Source: Nurse’s Pocket Guide
Nurse’s Pocket Guide diagnoses,
diagnoses, Prioritized intervention
Prioritized intervention and Rationales by
and Rationales by Doenges,Moorhouse,
Doenges,Moorhouse, Murr
Murr