VII.

MEDICATIONS, IV INFUSIONS, BLOOD TRANSFUSIONS, TREATMENTS GIVEN

Generic/ Dosage/ Nursing

Classification Indication Contraindication Side Effects
Trade Name Frequency Responsibilities
Cefuroxime 300 mg IV q Antiinfective; It is effective for the Hypersensitivity to Body as a Whole: •Determine history
(Kepox) 8h Antibiotic; Second treatment of cephalosporin and Thrombophlebitis of hypersensitivity
Generation penicillinase- related antibiotics; (IV site); reactions to
Cephalosporin producing pregnancy pain, burning, cephalosporins,
Neisseria (category B), cellulitis (IM site); penicillins, and
gonorrhoea lactation. super infections, history of allergies,
(PPNG). Effectively positive Coombs' particularly to drugs,
treats bone and joint test. before therapy is
infections, GI: initiated.
bronchitis, Diarrhea, • Inspect IM and IV
meningitis, nausea, injection sites
gonorrhea, otitis antibiotic- frequently for signs
media, associated colitis. of phlebitis.
pharyngitis/tonsillitis, Skin: • Report onset of
sinusitis, lower Rash, pruritus, loose stools or
respiratory tract urticaria. diarrhea. Although
infections, skin and Urogenital: pseudomembranous
soft tissue Increased serum colitis.
infections, urinary creatinine and • Monitor I&O rates
tract infections, and BUN, decreased and pattern:
is used for surgical creatinine Especially important
prophylaxis, clearance. in severely ill
reducing or patients receiving
eliminating infection high doses. Report
any significant
changes.
Paracetamol 300 mg IV Non-opioid analgesic To relieve mild to Hypersensitivity to Side effects are Assessment & Drug
q4h moderate pain due acetaminophen or rare with Effects
to things such as phenacetin; use paracetamol
headache, muscle with alcohol. when it is taken • Monitor for S&S of:
and joint pain, at the hepatotoxicity, even
backache and recommended with moderate
period pains. It is doses. Skin acetaminophen
also used to bring rashes, blood doses, especially in
 down a high disorders and individuals with poor
temperature. For acute nutrition.
this reason, inflammation of Patient & Family
paracetamol can be the pancreas Education
given to children have occasionally • Do not take other
after vaccinations to occurred in medications (e.g.,
prevent post- people taking the cold preparations)
immunisation drug on a regular containing
pyrexia (high basis for a long acetaminophen
temperature). time. One without medical
Paracetamol is often advantage of advice; overdosing
included in cough, paracetamol over and chronic use can
cold and flu aspirin and cause liver damage
remedies NSAIDs is that it and other toxic
. doesn't irritate the effects.
stomach or • Do not self-
causing it to medicate children
bleed, potential for pain more than 5
Side effects of d without consulting
aspirin and a physician.
NSAIDs • Do not use for
fever persisting
longer than 3 d,
fever over 39.5° C
(103° F), or
recurrent fever.
• Do not give
children more than 5
doses in 24 h unless
prescribed by
physician.
Ranitidine 30 mg Therapeutic: •Treatment and Contraindicated • CNS: • Assess patient for
(Zantac) IV q6h Anti-ulcer agents prevention of in: Confusion, epigastric or
heartburn, acid dizziness, abdominal pain and
Pharmacologic: indigestion, and •Hypersensitivity, drowsiness, frank or occult blood
Histamine H2 sour stomach. Cross-sensitivity hallucinations, in the stool, emesis,
antagonists may occur; some headache or gastric aspirate.
oral liquids • Nurse should know
 that it may cause
contain alcohol • CV: false-positive results
and should be Arrhythmias for urine protein;
avoided in test with
patients with • GI: sulfosalicylic acid.
known Altered taste, • Inform patient that
intolerance. black tongue, it may cause
constipation, dark drowsiness or
Use Cautiously in: stools, diarrhea, dizziness.
drug-induced • Inform patient that
• Renal hepatitis, nausea increased fluid and
impairment fiber intake may
• Geriatric patients • GU: minimize
(more Decreased sperm constipation.
susceptible to count, impotence • Advise patient to
adverse CNS report onset of
reactions) • ENDO: black, tarry stools;
• Pregnancy or Gynecomastia fever, sore throat;
Lactation diarrhea; dizziness;
rash; confusion; or
• HEMAT:
hallucinations to
Agranulocytosis,
health car
Aplastic Anemia,
professional
neutropenia,
promptly.
thrombocytopenia
• Inform patient that
medication may
• LOCAL: temporarily cause
Pain at IM site stools and tongue to
appear gray black.
• MISC:
Hypersensitivity
reactions,
vasculitis
Tranexamic ½ amp q8h Anti-fibrinolytic Prevent excessive 1. In patients with • Nausea • Check for
Acid bleeding acquired defective • Vomit doctor’s order
color vision, since • vision changes • Perform ANST
this prohibits • dizziness prior to
measuring one admission
 endpoint that • Should not be
should be • diarrhea given if positive
followed as a skin test
measure of • Slow IV push
toxicity • Inform the patient
about the
2. In patients with possible side
subarachnoid effect of the drug
hemorrhage. • Advise patient to
Anecdotal report any
experience discomfort on
indicates that the IV insertion
cerebral edema site
and cerebral • Provide safety
infarction may be
caused by
CYKLOKAPRON
in such patients.

3. In patients with
active
intravascular
clotting.
DIAZEPAM Status CENTRAL Drug of choice for Injectable form: Body as a • Monitor for
(dye-az'e-pam) Epilepticus NERVOUS SYSTEM status epilepticus. Shock, coma, Whole: Throat adverse reactions.
Adult: IV/IM AGENT; Management of acute alcohol and chest pain. Most are dose
Apo- 5–10 mg, BENZODIAZEPINE anxiety disorders, intoxication, CNS: related. Physician
Diazepam, repeat if ANTICONVULSANT; for short-term relief depressed vital Drowsiness, will rely on accurate
Diastat, needed at ANXIOLYTIC of anxiety signs, obstetrical fatigue, ataxia, observation and
Diazemuls , E- 10–15 min symptoms, to allay patients, infants confusion, reports of patient
Pam , Meval , intervals up to anxiety and tension <30 d of age. paradoxic rage, response to the
Novodipam , 30 mg, then prior to surgery, Tablet form: dizziness, vertigo, drug to determine
Valium, repeat if cardioversion and Infants <6 mo of amnesia, vivid lowest effective
Valrelease, needed q2– endoscopic age, acute dreams, maintenance dose.
Vivol 4h procedures, as an narrow-angle headache, • Monitor for
Child: IV/IM amnesic, and glaucoma, slurred speech, therapeutic
<5 y, 0.2–0.5 treatment for untreated open- tremor; EEG effectiveness.
mg slowly restless legs. Also angle glaucoma; changes, tardive
q2–5min up used to alleviate during or within 14 dyskinesia. CV: Maximum effect
to 5 mg; >5 y, acute withdrawal d of MAO inhibitor Hypotension, may require 1–2
1 mg slowly symptoms of therapy. Safe use tachycardia, wk; patient
q2–5min up alcoholism, voiding during pregnancy edema, tolerance to
to 10 mg, problems in older (category D) and cardiovascular therapeutic effects
repeat if adults, and lactation is not collapse. Special may develop after 4
needed q2–4 adjunctively for relief established. Senses: Blurred wk of treatment.
h of skeletal muscle vision, diplopia, • Observe
spasm associated nystagmus. GI: necessary
Anxiety, with cerebral palsy, Xerostomia, preventive
Muscle paraplegia, nausea, precautions for
Spasm, athetosis, stiff-man constipation, suicidal tendencies
Convulsions, syndrome, tetanus. hepatic that may be present
Alcohol dysfunction. in anxiety states
Withdrawal Urogenital: accompanied by
Adult: PO 2– Incontinence, depression.
10 mg b.i.d. urinary retention, • Observe patient
to q.i.d. or gynecomastia closely and monitor
15–30 mg/d (prolonged use), vital signs when
sustained menstrual diazepam is given
release IV/IM irregularities, parenterally;
2–10 mg, ovulation failure. hypotension,
repeat if Respiratory: muscular
needed in 3– Hiccups, weakness,
4h coughing, tachycardia, and
Geriatric: PO laryngospasm. respiratory
1–2 mg 1–2 Other: Pain, depression may
times/d (max: venous occur.
10 mg/d) thrombosis, • Lab tests:
Child: PO >6 phlebitis at Periodic CBC and
mo, 1–2.5 mg injection site. liver function tests
b.i.d. or t.i.d. during prolonged
therapy.
 TREATMENT/ NURSING
CLASSIFICATION INDICATION CONTRAINDICATION
INFUSION RESPONSIBILITIES
D5IMB Balanced Hypertonic Solution Slow administration phlebitis, peripheral • Do not administer
Multiple Maintenance essential to prevent edema, cellular unless solution is clear
Solution with 5% overload (100 mL/hr) dehydration and container is
Dextrose -Water intoxication undamaged.
-Severe sodium • Caution must be
depletion exercised in the
administration of
parenteral fluids,
especially those
containing sodium ions to
patients receiving
corticosteroids or
corticotrophin.
D5 0.3% NaCl Hypertonic Solution • Management of severe IMPORTANT • Do not administer
sodium chloride IMPLICATIONS unless solution is clear
depletion when rapid and container is
electrolyte restoration is • Fluid balance, undamaged.
essential serum electrolyte
• Management of severe concentrations
symptoms of (sodium,
hyponatremia including potassium,
seizures, coma, and bicarbonate,
focal neurologic signs chloride,
magnesium), and
acid-base
balance should
be monitored
closely
• Use with caution
if congestive
heart failure, liver
cirrhosis, severe
renal failure,
urinary tract
 obstruction, or in
patients receiving
drugs that can
cause sodium
retention, such as
corticosteroids

VI. LABORATORY AND DIAGNOSTIC EXAMINATION RESULTS

Date Procedure Norms Result Interpretation and Analysis

November 11, Hemoglobin 120 – 150 130 Normal
2010 Hematocrit .40-.50 .41 Normal
RBC 4.2 – 5.4 x 10 4.3 Normal
Elevated; may be due to acute
Neutrophils 0.55 – 0.62 .77
infection
BUN 1.7 – 8.3 4.8 Normal
Decreased; indication of a problem
Creatinine 63 – 97 57
with renal function.
Elevated; Indication of an
ESR 0 – 2 mm/hr 26 mm/hr
inflammation
Urinalysis
a. Color Pale yellow to amber Yellow Normal
b. WBC Negative or rare TMTC; Epithelial-moderate Elevated; may be a sign of infection
c. Specific Grav. 1.015-1.025 1.025 Normal
d. Sugar Negative Negative Normal
e. Reaction (pH) 4.5-8.0 Acidic Normal
HERMANO, Geovanni Rai D.
BSN 207

XI. Nursing Care Plan

Nursing Goal/ Nursing

Analysis Rationale Evaluation
Diagnosis Objectives Intervention
Impaired Physical Scientific Goal: After 2
Mobility related to Implication: weeks of Nursing
Problems and intervention, the
neuromuscular
disabilities related client will have
impairment to CP range from adequate mobility
very mild to very to perform activities
As evidenced by: severe. Their of daily living to
severity is related maximum potential.
S: >”Hindi siya to the severity of
the brain damage. Objectives: INDEPENDENT:
makatulong sa
They may be very 1. After 10 minutes • Carry out and • To prevent The client’s family
mga gawaing subtle, noticeable of nursing teach family to muscle was able to apply
bahay dahil hindi only to medical intervention, the perform stretching contractures. the stretching
siya makatayo o professionals, or client’s family will exercise on exercises to their
makagalaw.” as may be obvious to be able to apply affected limb. child.
verbalized by the the parents and stretching exercises
other caregivers. on affected areas.
mother.
> “Kapag may Immediate cause: 2. After 10 minutes The client/family
• Demonstrate the • To increase
masakit sa kanya, Cerebral palsy is of nursing proper uses of mobility. was able to
parang umuungol caused by an intervention, the assistive device demonstrate the
injury to the brain client/family will be such as wheelchair proper use of
siya, kasi pag
before, during, or able to demonstrate and wrist splints. assistive device.
tinatanong ko, shortly after birth. the use of assistive
sumasagot devices.
naman.” as
verbalized by the Root cause: 3. After 10 minutes • Position the client • To decrease the The client
mother. Failure of the brain of nursing in semi-fowler’s or chance of maintained Semi-
to develop intervention, the semi upright aspiration and fowler’s position
properly client will be able to position. facilitate the and was able to
O: > atrophy (developmental decrease possible mobilization of decrease possible
> Malposition of brain complications. food and fluids complications.
body part, foot malformation) and through
drop Neurological esophagus.
> Atonic muscles damage to the
child's developing 4. After 10 minutes • Encourage to play • To promote joint The client
> Flaccidity,
brain. of nursing exercises that movement and to displays joint
weakness, intervention, the movement.
involve joint promote
spasticity or client will be able to movement and achievement of
sudden display joint promote fine and developmental
involuntary muscle movement. motor skill milestones.
contraction acquisition and
> Muscle strength repetition.
is +1
>Limited range of 5. After 10 minutes DEPENDENT: • To minimize pain The client
motion of nursing • Administering and decrease minimized pain
> Limited ability to intervention, the medications spasticity. and spasticity.
perform fine motor client will be able to intended to
minimize pain and decrease pain and
skills
spasticity. muscle spasticity as
> Persistence of
prescribed.
primitive reflexes
 Nursing Goal/ Nursing
Analysis Rationale Evaluation
Diagnosis Objectives Intervention
Hyperthermia Scientific GOAL: After 4 hours
implication: of nursing
related to illness / interventions, the
PUD • Increased Heat
client will maintain
conservation
core temperature
(Vasoconstriction/
As evidenced by: behaviour within normal range.
OBJECTIVES:
INDEPENDENT:
S: > “Dinala changes). 1. After 10 minutes of • Identify underlying • To provide The client was
naming siya dito • Increased Heat nursing intervention, cause and note for adequate able to recognize
production the chronological knowledge. underlying cause
sa hospital kasi the client’s family will
and importance of
ang taas ng lagnat (involuntary be able to recognize and developmental
underlying cause and treatment, as well
muscular age of the client.
niya.” as importance of as the signs and
contractions) symptoms requiring
verbalized by the treatment, as well as
the signs and further evaluation
mother. Immediate cause: or intervention.
symptoms requiring
> “Mainit siya, Elevated further evaluation or
pabalik-balik ang thermoregulatory intervention.
lagnat niya, set point.
2. After 1 hour of • Render Tepid • To decrease The client was
mamaya bababa, temperature
Root cause: nursing intervention, sponge bath. able to maintain
tapos tataas na Trauma or the client will be able by means
normal
naman mamaya.” illness(cerebral to demonstrate through
temperature.
as verbalized by behaviors to monitor evaporation
palsy) that affects
the mother. hypothalamus. and promote normal and
temperature. • Wrap extremities conduction.
with cotton blankets.
O: >Temp: 38.9°C • To minimize
> warm to touch • Monitor core shivering.
> Flushed skin temperature and
vital signs. • To evaluate
effects and
degrees of
• Monitor and hyperthermi
record all fluid loss a.
such as urine,
vomiting, etc. and • To monitor or
potentiates
note presence/
fluid and
absence of electrolyte
sweating as body loses.
attempts to
increase heat loss
by evaporation,
conduction, and
diffusion.

3. After 1 hour of DEPENDENT:

nursing intervention, • Administer The client was
the client will be able medications such able to minimized
to decrease possible as antipyretics as possible
complications.
ordered. complications.

• Provide • To help in
supplemental lowering the
oxygen. temperature
and to
control
shivering and
seizures.
 • To offset
increased
Oxygen demands
and consumption.