ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE RATIONALE

Objective: Fluid volume deficit After 8 hours of Independent: Goal met:

 Thirst related to the risk of nursing interventions, After 8 hours of
 Weak post operative the patient will 1. change -to protect skin and nursing
appearance bleeding maintain fluid at a dressings frequently monitor losses interventions, the
 Dry skin and functional level patient was able to
lips maintainfluid at a
 Poor skin 2. Measure input -to monitor fluids in the functional level,
turgor and output body
 Pale looking
 Vital signs as
3. Monitor v/s -to assess the patient
follows:
especially pulse and and it serve as
T =37.6
blood pressure baseline data. An
PR=98
increase pulse rate
RR=14
with decrease blood
BP=90/60
pressure may indicate
loss of circulating blood
volume.

4.Note the changes in

mental status and It may indicate
level of consciousness cerebral perfusion
secondary to
hypovolemia,
hypoxemia.

Collaborative:

5.Administer IV fluids
as indicated.

-helps maintain fluids

6. Monitor Hb and in the body
Hct and clotting
factors.
-indicates bleeding,
anemia or other
7. Give medications complications.
as ordered by the
attending physician
-to reduce blood loss
ASSESSMENT DIAGNOSIS RATIONALE DESIRED INTERVENTION JUSTIFICATION EVALUATON
OUTCOME
Goal met:
Subjective cues: Disturbed body Palpable mass and After 2 days Independent: After 2 days client-nurse
“ mahaba yata image related swelling of right nurse-client interaction, the client has able
ang hiwa,ayaw ko to repair of testes. interaction, the 1. Help the patient Patient may perceive changes to cope up with the new
pa makita” as hernia and client will be determine actual that are not present or real changes in his body. He has
claimed by the marks of able to enhance changes. now able to talk and be open
client. incision site as body image and with his life and felt good
evidenced by repair of hernia self-esteem as Expression of feelings can about self as evidenced by
“mahaba yata evidenced by 2. encourage enhance the persons coping nagpapasalamat na din ako
Objective cues: ang hiwa,ayaw ability to look verbalization of strategies. kahit may ganito akong tahi ay
>refusal to talk ko pa makita” touch, talk about positive and negative nabuhay pa din ako, the client
about changes as client marks of incision and care for feelings about the said.
> verbal claimed. site actual altered actual change
expression of body part and
depression and function and Informations are needed bythe
shyness feeling about 3. Teach patient person with disturbed body
> excessive Feeling of how he looks. about normalcy of image to support cognitive
complaint depression and body image appraisal of the changes.
> compensatory shyness disturbance and grief
use of concealing process.
blanket
> Lack of This compensate for the actual
Knowledge Disturbed body 4. teach patient body structures and function.
image adaptive behaviors
Strength/
wellness:

5. Demonstrate
positive caring routine
activities.

Collaborative: To allow the patient interact

with others who have similar
1. refer the patient to problems and needs.
community
resources/support
groups as needs.
 NAME OF DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE REACTION NURSING RESPONSIBILITY
THE DRUG ROUTE ACTION
FREQUEN
CY OF
ADM.

Ranitidine Competitively >active > Contraindicated in-patient CNS: headache, malaise,

> Asses patient for
inhibits action of duodenal and hypersensitive to drug and vertigo
Pharmacolo histamine on the gastric ulcer) those with acute porphyria abdominal pain. Note for
gic Class: H2 at receptor EENT: blurred vision [presence of blood in emesis,
H2 receptor sites of parietal >maintenance > Use cautiously in patients with stool, or gastric aspirate.
antagonist cells, decreasing therapy for hepatic dysfunction. Adjust Hepatic: jaundice
gastric acid duodenal of dosage in-patient with impaired
secretion. gastric ulcer renal function. Others: anaphylaxis, angio >drug may be added to total
edema, burning and itching at parenteral nutrition solutions.
> heart burn injection site.
> instruct patient on proper
use of OT 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 THE DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE REACTION NURSING
DRUG ROUTE ACTION
RESPONSIBILITY
FREQUENCY
OF ADM.
Generic • Relie • Contraindicated with • CNS: Sedation, Assessment
name: f of allergy to tramadol or dizziness or • History:
tramadol mode opioids or acute vertigo, Hypersensi
hydrochlo rate intoxication with headache, tivity to
ride tramadol;
to alcohol, opioids, or confusion,
mode psychotropic drugs. dreaming, pregnancy;
Brand
name: rately • Use cautiously with sweating, acute
Dolcet sever pregnancy, lactation, anxiety, seizures intoxicatio
e seizures, concomitant • CV: n with
Pharmacologic pain use of CNS depressants Hypotension, alcohol,
Class:
or MAOIs, renal or tachycardia, opioids,
Analgesic psychotropi
hepatic impairment. bradycardia
(centrally c drugs or
acting) • Dermatologic:
Sweating, other
pruritus, rash, centrally
pallor, urticaria acting
• GI: Nausea, analgesics;
vomiting, dry lactation;
mouth, seizures;
constipation, concomitan
flatulence t use of
• Other: Potential CNS
for abuse, depressants
anaphylactoid or MAOIs;
reactions renal or
Interactions hepatic
Drug-drug impairment
• Decreased ; past or
effectiveness present
 with history of
carbamazepine opioid
• Increased risk of addiction
tramadol toxicity • Physical:
with MAOIs Skin color,
texture,
lesions;
orientation,
reflexes,
bilateral
grip
strength,
affect; P,
auscultatio
n, BP;
bowel
sounds,
normal
output;
liver and
kidney
function
tests

Interventions
• Control
environme
nt
(temperatur
e, lighting)
if sweating
or CNS
effects
occur.
NAME OF THE DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE REACTION NURSING
DRUG ROUTE ACTION
RESPONSIBILITY
FREQUEN
CY OF
ADM.
Generic name: Blocks ACE Indicated Contraindicated to: o CV: Tachycardia, Assessment
from for: o Contraindicated with angina pectoris, MI, o History:
Captopril converting o Treatmen allergy to captopril, history Raynaud's Allergy to
angiotensin I t of of angiodema. syndrome, CHF, captopril,
Brand name:
to hyperten Use cautiously with impaired hypotension in salt- history of
Capoten
angiotensin sion renal function; CHF; salt or or volume-depleted angioedema,
II, a powerful alone or volume depletion, lactation, patients impaired renal
vasoconstrict in pregnancy. o Dermatologic: function, CHF,
or, leading to combinat Rash, pruritus, salt or volume
decreased ion with pemphigoid-like depletion,
blood thiazide- reaction, scalded pregnancy,
pressure, type mouth sensation, lactation
decreased diuretics exfoliative o Physical: Skin
aldosterone o Treatmen dermatitis, color, lesions,
secretion, a t of CHF photosensitivity, turgor; T; P,
small in alopecia BP, peripheral
increase in patients o GI: Gastric perfusion;
serum unrespon irritation, aphthous mucous
potassium sive to ulcers, peptic membranes,
levels, and conventio ulcers, dysgeusia, bowel sounds,
sodium and nal cholestatic jaundice, liver
fluid loss; therapy; hepatocellular evaluation;
increased used with injury, anorexia, urinalysis,
prostaglandi diuretics constipation renal and liver
n synthesis and o GU: Proteinuria, function tests,
also may be digitalis renal insufficiency, CBC and
involved in o Treatmen renal failure, differential
the t of polyuria, oliguria,
antihyperten diabetic urinary frequency Interventions
sive action. nephropa o Hematologic: o Administer 1
thy Neutropenia, hr before or 2
o Treatmen agranulocytosis, hr after meals.
t of left thrombocytopenia, o Alert surgeon
ventricul hemolytic anemia, and mark
ar pancytopenia patient's chart
dysfuncti Other: Cough, with notice
on after malaise, dry mouth, that captopril
MI lymphadenopathy is being taken;
the
angiotensin II
formation
subsequent to
compensatory
renin release
during surgery
will be
blocked;
hypotension
may be
reversed with
volume
expansion.
o Monitor
patient closely
for fall in BP
secondary to
reduction in
fluid volume
(excessive
perspiration
and
dehydration,
vomiting,
diarrhea);
excessive
hypotension
may occur.
o Reduce
 dosage in
patients with
impaired renal
function.

Teaching
points
o Take drug 1 hr
before or 2 hr
after meals;
do not take
with food. Do
not stop
without
consulting
your health
care provider.
o Be careful of
drop in blood
pressure
(occurs most
often with
diarrhea,
sweating,
vomiting,
dehydration);
if light-
headedness or
dizziness
occurs, consult
your health
care provider.
o Avoid over-
the-counter
medications,
especially
 cough, cold,
allergy
medications
that may
contain
ingredients
that will
interact with
ACE inhibitors.
Consult your
health care
provider.
o These side
effects may
occur: GI
upset, loss of
appetite,
change in
taste
perception
(limited
effects, will
pass); mouth
sores (perform
frequent
mouth care);
rash; fast
heart rate;
dizziness,
light-
headedness
(usually
passes after
the first few
days; change
position
 slowly, and
limit your
activities to
those that do
not require
alertness and
precision).
o Report mouth
sores; sore
throat, fever,
chills; swelling
of the hands,
feet; irregular
heartbeat,
chest pains;
swelling of the
face, eyes,
lips, tongue,
difficulty
breathing.

NAME OF DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE REACTION NURSING

THE DRUG ROUTE ACTION
RESPONSIBILITY
FREQUENCY
OF ADM.
Diclofena
c