Professional Documents
Culture Documents
ASSESSMENT SUBJECTIVE: Namumutla ako as verbalized by the patient. OBJECTIVE: Pale skin Hemoglobin (74 gm/L as of Sept. 22, 2011) Hematocrit (.234 as of Sept. 22, 2011) Limited range of motion (within the bed) VS:
RR- 24 bpm PR- 92 bpm BP- 80/50 mmHg Temp.- 36.6C
NURSING DIAGNOSIS Ineffective tissue perfusion related to decreased oxygen carrying capacity of blood as evidenced by weakness, pallor, and low hemoglobin
INFERENCE
PLAN After the shift, the patient will: demonstrate adequate in oxygen level (pinkish skin, normal RR) verbalize comfort be free from signs of bleeding
RATIONALE To determine impending problems To promote lung expansion, facilitating adequate oxygen To decrease tissues oxygen demand To avoid excessive use of oxygen To increase fluid in the body Following doctors order To monitor bleeding To avoid hypovolemic shock
EVALUATION After the shift: No bleeding noted Able to promote adequate rest as evidenced by sound sleep
NSAIDS
Hydrogen ions and pepsin
Abdominal Pain
Bleeding
4. Minimize strenuous activities 5. Instruct to increase fluid intake 6. Maintain in soft diet 7. Emphasize avoidance of highly colored foods 8. Monitor episodes of bleeding 9. Keep comfortable
ASSESSMENT SUBJECTIVE: The patient verbalized Medyo nahihilo at namumutla ako. OBJECTIVE: Pale skin Dry mucous membrane Hemoglobin (74 gm/L as of Sept. 22, 2011) Hematocrit (.234 as of Sept. 22, 2011) Post BT of 3 u PRBC For BT of 2 more u PRBC VS:
RR- 24 bpm PR- 92 bpm BP- 80/50 mmHg Temp.- 36.6C
NURSING DIAGNOSIS Fluid volume deficit related to decreased circulating blood as manifested by pallor, hypotension , and low hematocrit.
INFERENCE
PLAN After the shift, the patient will demonstrate adequate hydration as evidenced by moist mucous membrane and normal VS (BP)
RATIONALE To determine impending problems To promote venous return To promote adequate fluid in the body Following doctors order To monitor bleeding To promote adequate energy to the body To avoid hypovolemic shock To determine needs of fluid replacement
EVALUATION Within the shift: The BP increased from 80/50 to 90/70 mmHg No bleeding noted
NSAIDS
Hydrogen ions and pepsin
2. Position in trendelenburgs position 3. Instruct to increase fluid intake 4. Maintain in soft diet 5. Emphasize avoidance of highly colored foods 6. Advise frequent feeding 7. Monitor episodes of bleeding 8. Monitor input and output 9. Keep comfortable
Abdominal Pain
Bleeding
Hypotension
ASSESSMENT SUBJECTIVE: Sumasakit yung tiyan ko, the patient verbalized. OBJECTIVE: Restless With facial grimace With abdominal guarding Pain scale of 6 over 10 Pallor VS:
NURSING DIAGNOSIS Altered comfort related to abdominal pain as evidenced by abdominal guarding and pain scale of 6 over 10.
INFERENCE
PLAN Within the shift, the patient will verbalized decrease of pain and demonstrate ability to sleep and rest appropriately.
NURSING INTERVENTIONS 1. Note reports of pain including location, duration and intensity 2. Position in most comfortable position 3. Maintain in soft diet 4. Emphasize avoidance of highly colored foods 5. Advise small, frequent feeding
RATIONALE To compare previous pain symptoms To promote comfort Following doctors order To monitor bleeding Small meals prevent distention and release of gastrin that can trigger the pain To avoid hypovolemic shock To lessen the pain in GI and for prevention of further pain To promote comfort
EVALUATION Within the shift the patient verbalized decreased of pain as evidenced by pain scale of 2 over 10; able to sleep comfortably; no bleeding noted
NSAIDS
Hydrogen ions and pepsin
Abdominal Pain
6. Monitor episodes of bleeding 7. Identify and limits the food that create discomfort 8. (COLLABORATIVE) administer medications as indicated and prescribed by the doctor (analgesics, antacids, etc.)
CLASSIFICATION
SIDE EFFECTS
OMEPRAZOLE (famazole)
Suppresses gastric secretion by inhibiting hydrogen/ potassium ATPase enzyme system in the gastric parietal cell. Blocks the final step of acid production.
DURATION 3-4hrs
Angina Assess history of Tachycardia hypersensitivity to Bradycardia omeprazole or any of Palpitation its components; Headache Assess for pregnancy, Dizziness lactation Rash Take the drug before Diarrhea meals. Swallow the abdominal capsules whole; do pain not chew, open, or acid crush regurgitatio them. This drug will n need to be taken for nausea up to 8 vomiting wk (short-term) or for constipation a prolonged period (> 5 yr in some cases). back pain Advise patient to report any signs of adverse effect
SPIRONOLACTO NE (Aldactone)
Diuretic/ Antihypertensive
Antagonizes aldosterone in the distal tubules, increasing sodium and water excretion.
headache drowsiness lethargy GI disturbance s inability to achieve or maintain erection irregular menses amenorrhe a ataxia post menopausa l bleeding
Educate patient to avoid hazardous activity such as driving until response to drug is known. Take with meals or milk Avoid excessive ingestion of food high in potassium or use of salt substitutes Diuretic effect may be delayed 2-3 days and maximum hypertensive may be delayed 23weeks Monitor I and O ratios and daily weight, BP, serum electrolytes (K, Na) and renal function BEFORE: Assess fever; note presence of associated signs (diaphoresis, tachycardia, and malaise).
PARACETAMOL (biogesic)
Analgesic
Decreases fever by inhibiting the effects of pyrogen on the hypothalamic heat regulating centers and by a
DURATION 3-4hrs
hypothalamic action leading to sweating and vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have antiinflammatory action because of its minimal effect on peripheral prostaglandin synthesis
DURING: Advise SO to take medication exactly as directed and not to take more than the recommended amount. AFTER: Advise patient to consult health care professional if discomfort or fever is not relieved by routine doses of this drug or if fever is greater than 39.5C (103F) or lasts longer than 3 days.
CIPROFLOXACI N (floxacif)
Antibacterial
Nausea Vomiting Stomach pain Heartburn Diarrhea Feeling an urgent need DURATION to urinate unknown Headache Hives PEAK EFFECT 1-2hrs (PO) immediat e (IV)
Instruct patient not to take ciprofloxacin with dairy products such as milk or yogurt, or with calcium-fortified juice. They could make the medication less effective. Tell patient that
Difficulty bre athing or swallowin g Rapid, irregular, or pounding heartbeat Fainting Fever Joint or muscle pain Unusual bruis ing or bleeding Extremetired ness Lack of energy of appetite Seizures Dizziness Confusion
Ciprofloxacin can cause side effects that may impair his thinking or reactions. Tell patient to be careful if he plans to drive or do anything that requires him to be awake and alert. Instruct patient to take ciprofloxacin with a full glass of water (8 ounces). Inform patient that Ciprofloxacin may cause swelling or tearing of a tendon, especially in the Achilles' tendon of the heel
FUROSEMIDE (piplen)
Diuretic/ Antihypertensive
40 mg tab, PO, OD
Inhibits sodium and chloride reabsorption at the proximal tubules, distal tubules, and
Assess patient for tinnitus, hearing loss, ear pain Monitor for renal, cardiac, neiurologic, GI, pulmonary
ascending loop of Henley, leading to excretion of water together with sodium, chloride and potassium.
CV: orthostatic hypotension, chest pain, ECG changes, circulatory collapse ELECTROLYTES: hypokalemia, hypochloremi c alkalosis, hypoagnese mia, hyperuricemi a ENDO:hypergl ycemia GI: nausea, diarrhea, dry mouth, vomiting, anorexia, pancreatitis GU: polyuria, reanl failure, glycosuria
manifestation of hypokalemia: acidic urine, decreased urine osmolality, nocturia, polyuria and polydipsia Monitor for CNS, GI, cardiovascular, integumentary, neurologic manifestations of hypocalcemia: personality changes, anxiety, disturbances Monitor for manifestations of hyponatremia Monitor electrolytes Precautions: Pregnancy, DM, dehydration, severe renal disease, cirrhosis, ascites