Jessa Drug and NCP

DRUG STUDY
NAME OF PATIENT __________________________________________

Age __________ Sex ___________ Civil Status ______________________
Nationality_________________________
Occupation _________________________
Date of Admission _____________________________Chief Complaint / Diagnosis _____________________________________________________________________________________

Brief History
Generic & Brand

Name
Generic Name
Metoclopramide
Trade Name
Reglan,Maxolon
Frequency & Route
5mg TIV
Classification
Antiemetic, GI
stimulant
Action / Uses
Stimulates motility of
upper GI tract
without stimulating
gastric, biliary, or
pancreatic
secretions; appears
to sensitize tissues to
action
of acetylcholine;
relaxes pyloric
sphincter, which,
when combined with
effects on motility,
accelerates gastric
emptying and
intestinal transit; little
effect on gallbladder
or colon motility;
increases
lower esophageal
Contraindications &
Precautions
Precaution
- Previously detected
breast cancer LactationPregnancy- Fluid
overload- Renal
impairment
667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

www.marychilescollge.edu.ph / marychilescollege@gmail.com
Tel. 711 - 4233, 735-5341 to 45
Side Effects
CNS:
Restlessness,
drowsiness, fatigue,
lassitude, insomnia,
extrapyramidal
reactions,
parkinsonism-like
reactions, akathisia,
dystonia, myoclonus,
dizziness, anxiety
CV:
Transient
hypertension
GI:
Nausea, diarrhea
Nursing
Consideration /
Patient Teaching
Before
- Keep
diphenhydramine
injection readily
available in case
extrapyramidal
reactions occur (50
mg IM).
- Have phentolamine
readily available in
case of hypertensive
crisis.
During
- Monitor BP carefully
during IV
administration.
- Monitor for
extrapyramidal
reactions, and
consult physician if
they occur.
- Monitor diabetic
patients.
- Give direct IV
doses slowly over 12minutes.
sphincter pressure;
has sedative
properties; induces
release of prolactin.
After
- Dispose of used
materials properly.
- Educate patient
about side effects.
- Instruct to report
involuntary
movement of the
face, eyes, or limbs,
severe depression,
and severe diarrhea.
- Instruct patient to
take drug exactly as
prescribed.
- Instruct not to use
alcohol, sleep
remedies or
sedatives; serious
sedation could occur.
- Do proper
documentation
Name of Student: Borre, Jessa Anne R.
Rating _________________________________
Year / Section: BSN- IV
C. I. Signature___________________________

Tel. 711 - 4233, 735-5341 to 45
DRUG STUDY
NAME OF PATIENT __________________________________________
Nationality_________________________
Occupation _________________________

Brief History
Generic & Brand

Name
Generic: Ranitidine
Brand: Zantac
Frequency & Route

5mg TIV q6 hrs.
Classification
Action / Uses
-Anti-ulcer
Contraindications &
Precautions
-Pregnancy
-Inhibits the action of

histamine at the H2
receptor site located
primarily in gastric
parietal cells, resulting
in inhibition of gastric
acid secretion
-Lactation (excreted in
breastmilk)
-has some antibacterial

action against H. pylori
-Renal impairments,
Cirrhosis
-Geriatric patients
(more susceptible to
adverse CNS
reactions)
Side Effects
Hypersensitivity,
Cross-sensitivity may
occur; some oral
liquids contain alcohol
and should be avoided
in patients with known
intolerance
Nursing
Consideration /
Patient Teaching
Avoid excessive
alcohol
Assess patient for
epigastric or abdominal
pain and frank or occult
blood in the stool,
emesis, or gastric
aspirate
Nurse should know
that it may cause falsepositive results for
urine protein; test with
sulfosalicylic acid
Inform patient that it
may cause drowsiness
or dizziness

Tel. 711 - 4233, 735-5341 to 45
Inform patient that

increased fluid and
fiber intake may
minimize constipation
Advise patient to report
onset of black, tarry
stools; fever, sore
throat; diarrhea;
dizziness; rash;
confusion; or
hallucinations to health
care professional
promptly
Inform patient that
medication may
temporarily cause
stools and tongue to
appear gray black.
Instruct patients to
monitor for and report
occurrence of druginduced adverse
reaction
Rating _________________________________
C. I Signature___________________________

Tel. 711 - 4233, 735-5341 to 45
DRUG STUDY
NAME OF PATIENT __________________________________________
Nationality_________________________
Occupation _________________________

Brief History
Generic & Brand

Name
Frequency & Route
Generic Name
Cefuroxime (750 mg)
1.5 g TIV once cord is

clamped
Trade Name
Zoltax
Classification
Antibiotic
Action / Uses
Second-hand
cephalosporin that
inhibits cell-wall
synthesis, promoting
osmotic instability;
usually bactericidal.
Contraindications &
Precautions
-
Use cautiously
in pts.
Hypertensive to
penicillin
because of
possibility of
cross-sensitivity
with other
betalactam
antibiotics.
Use with
caution in
breastfeeding
women and in
lactating
women.

Tel. 711 - 4233, 735-5341 to 45
Side Effects
>Body as a whole:
- thrombophlebitis (IV
site)
- pain, burning,
cellulitis (IM site);
superinfections,
positive coombs test.
>GI:
- Diarrhea
- nausea
Antibiotic- associated
colitis
>Skin:
- rash, pruritus,
urticarial
- urogenital
- increase serum
creatinine and BUN,
decrease creatinine
clearance.
Nursing
Consideration /
Patient Teaching
- Determine hx.
Of
hypersensitivity
reactions to
cephalosporin,
penicillin and
hx. Of allergies
particularly to
drugs before
therapy is
initiated.
- Report onset of
loose stools.
- Absorption of
cefuroxime is
enhanced by
food.
- Notify
prescriber
about rashes/
superinfections.
- Do skin test to
know if the pt.

has an allergy
to the
medication.
Rating _________________________________
C. I. Signature___________________________

Tel. 711 - 4233, 735-5341 to 45
DRUG STUDY
NAME OF PATIENT __________________________________________
Nationality_________________________
Occupation _________________________

Brief History
Generic & Brand

Name
Generic: Ketorolac
(30mg)
Brand: Tramadol
Frequency & Route

30mg TIV ANST q
8hrs
Classification
-Anti- pyretic
NSAID
Action / Uses
-Anti- inflammatory
and analgesic activity
inhibits prostaglandins
and leukotriene
synthesis.
Contraindications &
Precautions
Contraindicated with
significant renal
impairment, aspirin,
allergy, recent GI
bleeding or
perforation. Use
cautiously with
impaired hearing;
allergies: hepatic
conditions.

Tel. 711 - 4233, 735-5341 to 45
Side Effects
-
Headache
Dizziness
Somnolence
Insomnia
Fatigue
Tinnitus
Ophthalmologic
effects
Nursing
Consideration /
Patient Teaching
- Be aware that
the pt. may be
at risk for CV
events, GI
bleeding, renal
toxicity, monitor
accordingly.
- Keep
emergency
equipment
readily
available at
time of initial
close, in case
of severe
hypersensitivity
reaction.
- Protect drug
vial from light.
- Do skin test to
know if the pt.
has an allergy
to the
medication.
Rating _________________________________
C. I Signature___________________________

Tel. 711 - 4233, 735-5341 to 45
NURSING CARE PLAN

Name of Patient ________________________________________________
Nationality_________________________
Occupation _________________________
Date of Admission _____________________________Chief Complaint / Diagnosis _________________________________________________________________

Brief History
CUES
S: O:
T: 36.9
- Post op incision
@ right eye
- pupils are
round and
equal; reacts
briskly to light
and
accommodation
; conjunctiva
are pink; sclera
is white in color
Nursing Diagnosis
Risk for infection
related to post- op
incision secondary to
cataract extraction
Scientific
Explanation
Cataract Surgery:
Incision @ the right
eye
Trauma at the Right
eye
Open wound
Risk for infection
Nursing Objective
Long term goal:
- After 8 hrs. of
N.I the pt. will
be able to
prevent
infection.
Short term goal:
After 2-3 hrs. of
nursing intervention
the pt. will be able to:
- Identify the risk
factors that are
present.
- Have
understanding
about the
infection
control.
Nursing Intervention
Independent:
1. Monitor vital
signs.
(temperature)
2. Note risk
factors for
occurrence of
infection in the
post-op
incision.
3. Instruct patient
to wear a
plastic or metal
shield over the
eye with
perforations; a
shield or
glasses should
be worn for

Tel. 711 - 4233, 735-5341 to 45
Scientific
Explanation
Evaluation
-
To obtain baseline
data.
To help the pt. identify

the present risk factors
that may add up to
infection.
-
To protect the eye from

accidental injury.
After 8 hrs. Of
nursing
intervention the
pt. was free
from signs and
symptoms of
infection as
manifested by
absence of
fever.
Goal met
protection
during the day.
4. Make health
teachings
especially in
identification
environmental
risk factors that
could add up
on infection.
Dependent:
1. administer
antibiotic
ointment or
drops;
including
steroids as
ordered.
Name of Student : Borre, Jessa Anne R.
To help the
client modify/
change/ avoid
some of the
environmental
factors present
which can
reduce
incidence of
infection.
To prevent
infection.
Rating _________________________________
________________________________________
Clinical Instructor
Print Name & Signature

Tel. 711 - 4233, 735-5341 to 45
NURSING CARE PLAN

Name of Patient ________________________________________________
Nationality_________________________
Occupation _________________________
Date of Admission _____________________________Chief Complaint / Diagnosis _________________________________________________________________

Brief History
CUES
Nursing Diagnosis
S: Medyo malaki nga

yung hiwa na ginawa
sa tiyan ko,nasa
5inches din kaya baka
matagalan ang
paghilom ng sugat ko.
Impaired skin integrity

related to surgical
incision secondary to
cesarean section
O:
-
T: 37c
Slight elevation
of BP (130/80)
+ redness on
the incision site
+ swelling on
the incision site
5 inches- size
of incision
Dry and intact
surgical
incision site
Scientific
Explanation
Cesarean Section:
Incision at the
abdominal and uterine
cavity
Injury/ trauma on the
skin
Alteration of the skin
Impaired skin integrity
Nursing Objective
Nursing Intervention
Long term goal:

After 8 hrs. Of nursing
intervention the pt. will
be able to have paired
skin integrity.
Independent:
Short term goal:

After 2-3 hrs. of nursing
be able to:
1. Understand
causative
factors, identify
signs of
infection and
report them to
health care
provider
accordingly.
Scientific
Explanation
Evaluation
After 8 hrs. of nursing
be able to have paired
skin integrity as
manifested by:
-
1. Monitor vital
signs.
(Temperature,
pain)
2. Inspect skin on
daily basis and
observe for
changes and
unusualities.
3. Provide and
demonstrate

Tel. 711 - 4233, 735-5341 to 45
To obtain
baseline data.
-
To determine
unusual ties
and report it to
the physician
for prompt
treatment.
-
To prevent
infection of the
Dry and intact

wound
Absence of
redness and
erythema.
Goal met
2. Demonstrate
proper wound
dressing.
proper wound
care.
4. Instruct the pt. to
wash hands
before and after
touching the
wound.
5. Demonstrate and
advise the client
proper deep
breathing
exercise.
Dependent:
1. Administer
antibiotics
(cefuroxime)
as ordered by
the physician.
Name of Student : Borre, Jessa Anne R.
incision site.
-
Maintaining
clean, dry skin
provides a
barrier to
infection.
To maintain the
wound intact.
To prevent
infection and
maintain
integrity of the
skin.
Rating _________________________________
________________________________________
Clinical Instructor
Print Name & Signature

Tel. 711 - 4233, 735-5341 to 45

Jessa Drug and NCP

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Jessa Drug and NCP

Uploaded by

Copyright:

Available Formats

DRUG STUDY

NAME OF PATIENT __________________________________________

Date of Admission _____________________________Chief Complaint / Diagnosis _____________________________________________________________________________________

Generic & Brand

Frequency & Route

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

Name of Student: Borre, Jessa Anne R.

Year / Section: BSN- IV

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

Date of Admission _____________________________Chief Complaint / Diagnosis _____________________________________________________________________________________

Generic & Brand

Frequency & Route

-Inhibits the action of

-has some antibacterial

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

Inform patient that

Year / Section: BSN- IV

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

Date of Admission _____________________________Chief Complaint / Diagnosis _____________________________________________________________________________________

Generic & Brand

Frequency & Route

1.5 g TIV once cord is

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

know if the pt.

Name of Student: Borre, Jessa Anne R.

Year / Section: BSN- IV

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

Date of Admission _____________________________Chief Complaint / Diagnosis _____________________________________________________________________________________

Generic & Brand

Frequency & Route

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

Name of Student: Borre, Jessa Anne R.

Year / Section: BSN- IV

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

NURSING CARE PLAN

Date of Admission _____________________________Chief Complaint / Diagnosis _________________________________________________________________

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

To help the pt. identify

To protect the eye from

Year / Section: BSN- IV

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

NURSING CARE PLAN

Date of Admission _____________________________Chief Complaint / Diagnosis _________________________________________________________________

S: Medyo malaki nga

Impaired skin integrity

Long term goal:

Short term goal:

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

Dry and intact

Name of Student : Borre, Jessa Anne R.

Year / Section: BSN- IV

667 F.T. Dalupan Sr. St., Sampaloc, Manila Philippines

You might also like

Date of Admission _Chief Complaint / Diagnosis _________________________________________________________

Date of Admission _Chief Complaint / Diagnosis _________________________________________________________

Date of Admission _Chief Complaint / Diagnosis _________________________________________________________

Date of Admission _Chief Complaint / Diagnosis _________________________________________________________

Date of Admission _Chief Complaint / Diagnosis _____________________________________

Date of Admission _Chief Complaint / Diagnosis _____________________________________