ASSESSMENT

DIAGNOSIS

S:
Ang sakit ng
tiyan ko, as
verbalized by the
patient.

Acute pain r/t

by tissue
distension and
inflammation
amb. guarding
behavior and
facial grimace.

O:
Guarding
behavior
Facial grimace
Irritability
Restlessness
Fatigue
Distracted
behavior
diaphoresis
PR: 88bpm
RR: 24bpm
P: moving
Q: punching pain
R: right upper
quadrant of
abdomen
S: 7/10
T: after eating
and whenever
moving

PLANNING

INTERVENTION

STG:
After 4hrs of

effective nsg.
management,
patient will be
able to verbalize
understanding
and follow

prescribed plan of
care.

I:
Determine and document
presence of patho-physiogical
and psychological causes of
pain.
Assess for referred pain as
appropriate.
Obtain patients assessment of
pain and note changes from
previous reports.
Monitor skin color and VS.

LTG:
After 8hrs of

effective nsg.
management,
patients pain will
be lessened from
7/10 to 3/10.

RATIONALE
To determine underlying causes.

To note for organ dysfunction.

To rule out worsening of condition
or development of
complications.
These are usually altered in
acute pain.
Alcohol or drug abuse affects
bodys tolerance for analgesics.
To promote non-pharmacological
Determine factors in patients
pain management.
lifestyle that can affect
To prevent fatigue.
responses to pain management. To enhance continuous pain
Provide comfort measures,
management even when
ambient environment, and calm
discharged.
activities.
Encourage adequate rest periods. To maintain acceptable level of
Discuss w/ SO on ways in which
pain.
they can assist pt and reduce
precipitating factors that may
cause or increase pain.
D:
Administer analgesics as
indicated.

EVALUATION
STG:
Goal met.
Patient was
able to
verbalize
understanding
and was able to
follow
prescribed plan
of care after
4hrs.S
LTG:
Goal met.
Patients pain
decreased from
7/10 to 3/10
after 8hrs.

ASSESSMENT
S:
Walaakongganaku
main, as verbalized
by the patient.
O:
Loss of weight
Hyperactive bowel
sounds
Loss of appetite
Weakness of
muscles
Decreased
subcutaneous fat
Decreased muscle
mass

DIAGNO
SIS
Imbalanc
ed
nutrition
r/t
inability
to absorb
nutrients
amb. loss
of weight

PLANNING

INTERVENTION

STG:
After 4hrs of
effective nsg.
management,
patient will be
able to verbalize
understanding of
causative factors
and necessary
health care
regimen.

I:
Ascertain understanding of

individual nutritional needs.

Discuss eating habits including

food preferences, intolerances,

or aversions.
Evaluate impact of cultural,

ethnic, or religious desires and

influences.

Assess weight; measure or

calculate body fat and muscle
mass through anthropometric
measurement.
Auscultate bowel sounds. Note
characteristics of stool (color,
amount, frequency, etc)

Note age, body built, strength,

activity, and rest level.

Evaluate daily food intake. Obtain

diary of food intake, patterns
and times of eating.
Prevent and minimize unpleasant
odors and sights.
Promote adequate and timely

fluid intake. Limit fluids 1hr

prior to meal.

Weigh regularly and graph

results.

LTG:
After 3days of
effective nsg.
management,
patient will
demonstrate
progressive
weight gain to
ward goal.

RATIONALE
To determine informational
needs of client/SO.
To appeal to patients
tastes.
To note factors that may
affect food choices.
To establish baseline
parameters
May give further
information about
patients condition.
To help determine
nutritional needs.
To reveal possible cause of
malnutrition and changes
that could be made to
intake.
May have a negative effect
on appetite and eating.
To reduce possibility of
early satiety.
To monitor effectiveness of
efforts.
To educate patient on the
importance of adequate
food intake.

Emphasize importance of wellbalanced, nutritious intake.

Provide information regarding
individual nutritional needs and
ways to meet these needs w/
To further manage
financial constraints.
patients condition.
D:
Administer pharmaceutical
To implement
agents as indicated.
interdisciplinary team
C:
management.

EVALUATIO
N
STG:
Goal met.
Patient was
able to
verbalize
understandin
g about the
health care
regimen
aftere 4hrs
of nsg.
intervention.
LTG:
Goal met.
Patient was
able to
demonstrate
progressive
weight gain
after 3days
of nsg.
Intervention.

 Consult dietician or nutritional

team as indicated.

ASSESSMEN
T
S:
Nanghihinaa
ko as
verbalized by
the patient.

O:
Decresed
urine
output
Decreased
skin turgor
Dry mucous
membranes
Sudden wt.
loss
BP: 100/70
PR: 88bpm

DIAGNOSI
S
Deficient
fluid volume
r/t active
fluid volume
loss amb.
weakness.

PLANNING

INTERVENTION

STG:
I:
After 4hrs of effective Note possible diagnoses
nsg. management,
that may create fluid
patient will be able to
volume deficit.
verbalize
Assess VS, noting low BP,
understanding of
rapid HR, and thready
causative factors and
peripheral pulses.
purpose of individual Note complaints and
therapeutic
physical signs associated
interventions and
w/ dehydration.
medications.
Establish 24-hr fluid
replacement needs and
LTG:
routes to be used.
After 2days of
Keep fluids within patients
effective nsg.
reach and encourage
management, patient
frequent intake, as
will be able to
appropriate.
maintain fluid volume
at a functional level as Maintain accurate I&O and
weigh daily. Monitor urine
evidenced by stable
sp. gravity.
VS.
Discuss factors r/t
occurrence and ways
pt./SO can prevent
dehydration.
D:
Administer IV fluids, as
indicated. Replace blood
products, as ordered.
Administer medications as
ordered.

RATIONALE
To determine underlying
cause.
Changes in Vs are
associated w/ fluid vol.
loss and/or
hypovolemia.
To determine extent of
fluid loss.
Prevents peaks and
valleys in fluid level.
To enhance fluid intake.
To assess changes in
condition.
To educate pt. about the
importance of
maintaining proper
nutrition.
To manage fluid
replacement.
To further manage pt.
condition.

EVALUATION
STG:
Goal met.
Patient was
able to state
understanding
regarding w/
health care
regimen after
4hrs of
effective nsg.
management.
LTG:
Goal partially
met. Patient
was able able
to regain
functional level
of fluid but VS
was not yet
stable after
2days of nsg.
management.

DRUG NAME
Generic Name
TRAMADOL
Brand Name
Ultram

CLASSIFICATION
Analgesics
ROUTE/ DOSE

50mg PO
q12

ACTION
Inhibits reuptake of
serotonin and
norepinephrine in
the CNS

INDICATION
Moderate to
moderately severe
pain.

CONTRAINDICATI
ON

Hypersensitivity
Patients who
are acutely
intoxicated with
alcohol,
centrally acting
analgesics,
opioid
analgesics.

Use catiously in:

-Geriatric patient.
-Renal impairment
-Hepatic
impairment
-Increased
intracranial
pressure or head
trauma
-Acute abdomen
(may preclude
accurate clinical
assessment)
-children <16 yr

SIDE EFFECTS
CNS: seizures,
Dizziness,
Headache
Confusion
Sleep disorder
CV: vasodilation
GI: constipation
Nausea
Abdominal pain
Anorexia
Diarrhea
GU: menopausal
symptoms
Urinary retenion

NURSING
CONSIDERATION
S
1. assess type,
location, and
intensity of pain
before and 2-3hr
(peak) after
administration.
2. assessbp and
respiratory rate
before and
periodically during
administration.
3. assess bowel
function routinely.
Prevention of
constipation should
be instituted with
increase fluid
intake.
4. assess prev.
analgesic
history.tramadol is
not recommended
for patients
dependent on
opioids or who
have prev. received
opioid more than 1
wk. may cause
withdrawal
symptom.
5. monitor patient
for seizures. May
occur within
recommended
dose range.

Generic Name

Prevention of
chemotherapyMETOCLOPRAMIDE induced emesis.
Treatment of post
surgical and
Brand Name
diabetic gastric
stasis. Management
Pasil
of esophageal
reflux. Treatment
and prevention of
nausea and
vomittingwhen
CLASSIFICATION
nasogastric
suctioning is
antiemetics
undesirable.
ROUTE/ DOSE
10mg OD

Blocks dopamine
receptors in
chemoreceptor
trigger zone of the
CNS. Stimulates
motility of the
upper GI tract and
accelerates gastric
emptying. Adjunct
management of
migraine
headaches.

Hypersensitivity
Possible GI
obstruction
History of
seizure
disorders
Parkinsons
disease

CNS: drowsiness,
restlessness,
anxiety,
depression,
irritability
CV: arrhythmias
(bradycardia,
supraventricular
tacycardia),
hypertension,
hypotension
GI: constipation,
diarrhea, dry
mouth, nausea

1. Assess patient
for nausea,
vomiting,
abdominal
distention, and
bowel sounds
before and after
administration
2. Assess patient
for signs of
depression
periodically
throughout
therapy.
3. Instruct patient
to take
metoclopramide
exactly as directed.
4. may cause
drowsiness.
Caution patient to
avoid driving or
other activities
requiring alertness.
5. Advise patient to
avoid concurrent
use of alcohol and
other CNS
depressants while
taking this
medication.

DRUG NAME
Generic Name
RANITIDINE

Brand Name
Zantac

CLASSIFICATION
Antiulcer agents
ROUTE/ DOSE

150 mg OD,
HS

ACTION
Inhibits the action
of histamine at the
H-receptor
site
located primarily in
gastric
parietal
cells, resulting in
inhibition of gastric
and secretion.

INDICATION

CONTRAINDICATI
ON

Short-term

management
of
active
duodenal
ulcers and benign
gastric
ulcers.
Management
of
GERD.
Management
of
hypersecretory
states.

Hypersensitivity
Some
oral
liquids contain
alcohol
and
should
be
avoided
in
patients
with
known
intolerance.

SIDE EFFECTS
CNS:
confusion,
dizziness,
drowsiness,
hallucinations,
headache
CV: arrhythmias
GI: altered taste,
constipation, dark
stools, nausea
GU:
decreased
sperm
count,
impotence
MISC:
hypersensitivity
reactions

NURSING
CONSIDERATION
S
1. Assess patien
for epigastric o
abdominal
pai
and frank or occu
blood in the stoo
emesis or gastri
aspirate.
2. May cause fals
negative results i
skin tests usin
allergenic extracts
Ranitidine
shoul
be
discontinue
24hr before th
test.
3. administer wit
meals
o
immediately
afterward and a
bedtime to prolon
effect.
4. inform patien
that
smokin
interferes with th
action of histamin
antagonists.
5. Inform patien
that
medicatio
may
temporaril
cause stools an
tongue to appea
gray-black.

DRUG NAME
Generic Name

ACTION

Analgesic, antiinflammatory and

KETOROLAC
antipyretic. Inhibits
prostaglandin
Brand Name
synthesis by
inhibition of cycloToradol
oxygenase enzyme.
It also inhibits
leukotriene
synthesis, Help
CLASSIFICATION
stabilize lysosomal
membranes and
NSAIDS
exert antibradykinin activity.
ROUTE/ DOSE

INDICATION

CONTRAINDICATI
ON

Ophthalmic,
Treatment of
allergic
conjunctivitis
and for prophylaxis
and reduction of
inflammation and
associated
symptoms
following ocular
surgery.
Solution for
injection:short
term management
of moderate to
severe acute postoperative pain.

Active peptic ulcer

disease, recent
gastrointestinal GI
bleeding or
perforation,
moderate to severe
renal impairment,
Hypovolemia or
dehydration during
labor or delivery,
lactation,
hypersensitivity to
aspirin or nonsteroidal antiinflammatory
drugs, history of
asthma,
prophylactic
analgesic before
surgery or
operation with high
risk of bleeding or
incomplete
hemostasis.

SIDE EFFECTS

Ophthalmic:tra
nsient stinging
and burning on
instillation,ocul
ar irritation,
allergic
reaction,
superficial
ocular infection.
Gastrointestinal
ulceration
bleeding and
perforation liver
failure.hyperten
sion,
pruritus,
rash ,GI
disturbances,
nausea,
dyspepsia,
diarrhea
,purpura,
headache,
drowsiness,
dizziness,
sweating,
edema,
injection site
pain.

NURSING
CONSIDERATION
S
1. Assess pt.s
condition before
therapy and
regularly thereafter
to monitor the
drugs
effectiveness.
Precaution:
2. Prolonged used
(more than 2 days)
anaphylactic
reaction. 3.
Impaired hepatic
/renal function
,history of liver/
kidney disease 4.
Cardiac
decompensation,
hemostasis ,
hypertension,
coagulation
disorders. 5.
Patients on full anti
coagulant therapy.
Elderly. History of
GIT diseasesss .
Avoid operating
machines.

DRUG NAME
Generic Name
CEFUROXIME

ACTION

INDICATION

Bind to bacterial
cell wall causing cell
death.

Treatment of:
respiratory tract
infections
skin and skin
structures
bone and joint
infections
urinary
tract
and
gynecologic
infections
meningitis

Brand Name
Zinacef

CLASSIFICATION
Anti- infectives
ROUTE/ DOSE
250mg PO
q 12

CONTRAINDICATI
ON

Hypersensitivity
to
cephalosporins

Use cautiously in:

Renal
impairment
Geriatric patient
(concurrent
medications
and
chronic
disease states)
Pregnancy and
lactation (have
been
used
safely)

SIDE EFFECTS
CNS:
seizures
(high doses)
GI:
vomiting
cramps

nausea,
and

DERM:
urticaria

rashes,

HEMAT: bleeding,
hemolytic anemia
MISC:
anaphylaxis,
serum
sickness,
superinfetion.

NURSING
CONSIDERATION
S
1. Assess patient
for infection (vs,
appearance
of
wound,
sputum,
urine, and stool,
wbc) at beginning
and during therapy.
2.
Obtain
specimens
for
culture
and
sensitivity
before
initiating therapy.
First dose may be
given
before
receiving results.
3.
Administer
around the clock.
May
be
administered
on
full
or
empty
stomach.
Administration with
food may minimize
GI irritation.
4.
Cefuroxime
tablets should be
swallowed whole,
not
crushed;
crushed
talets
have
a
strong
bitter taste.
5. advise patient to
report
signs
of
superinfection

DRUG NAME
Generic Name
METRONIDAZOLE

ACTION
Disrupts DNA and
protein synthesis in
susceptible
organisms.

Brand Name

Flagyl

CLASSIFICATION

Anti-infectives,
Anti-ulcer agents
ROUTE/ DOSE

INDICATION

CONTRAINDICATI
ON

Treatment of
the following
anaerobic
infections.
Gynecologic
infections
Skin and skin
structure
Lower
respiratory tract
infections
Perioperative
prophylactic
agent in
colorectal
surgery
Bone and joint
infections

Hypersensitivity
First trimester
of infection

Use cautiously in:

History of
seizures or
neurologic
problems
Severe hepatic
impairment
Pregnancy and
lactation

SIDE EFFECTS
CNS: seizures,
dizziness,
headache
EENT: tearing
GI: abdominal
pain, anorexia,
nausea, vomiting,
diarrhea, dry
mouth and
unpleasant taste
DERM: rashes,
urticaria, mild
dryness
LOCAL: phlebitis
at IV site

NURSING
CONSIDERATION
S
1. Assess patient
for infection (vs,
appearance of
wound, sputum,
urine, and stool,
wbc) at beginning
and during therapy.
2. Obtain
specimens for
culture and
sensitivity before
initiating therapy.
First dose may be
given before
receiving results.
3. Administer
around the clock.
May be
administered on
full or empty
stomach.
Administration with
food may minimize
GI irritation.
4.Monitor
neurologic status
during and after IV
infusions. Inform
physician if
numbness,
weakness, ataxia
or seizures occur.
5. May cause
drowsiness.
Caution patient to
avoid driving or
other activities
requiring alertness.

DRUG NAME

ACTION

INDICATION

CONTRAINDICATI
ON

SIDE
EFFECTS

NURSING
CONSIDERATIONS

Generic Name

reduces elevated
liver enzyme levels
URSODIOL
by facilitating bile
(URSODEOXYCHOLI flow through the
C ACID)
liver and protecting
liver cells. The main
mechanism if
Brand Name
anticholelithic.
Although the exact
Actigall
process of
ursodiol'santicholeli
thic action is not
completely
understood, it is
CLASSIFICATION
thought that the
Gallstone-solubilizing drug is
concentrated in bile
drug
and decreases
biliary cholesterol
ROUTE/ DOSE
by suppressing
hepatic synthesis
and secretion of
cholesterol and by
8-10mg/kg/day PO in inhibiting its
intestinal
2-3 divided doses
absorption. The
reduced cholesterol
saturation permits
the gradual
solubilization of
cholesterol from
gallstones, resulting
in their eventual
dissolution.

Treatment of
Contraindicated
with allergy to
selected
bile salts,
patients with
hepatic
radiolucent,
impairment,
noncalcified
calcified stones,
gallstones in
radiopaque
gallbladders for
stones or
whom elective
radiolucent bile
surgery is
pigment stones,
contraindicated
unremitting
Prevention of
acute
gallstone
cholecystitis,
formation in
cholangitis,
obese patients
biliary
experiencing
obstruction,
rapid weight
gallstone
loss
pancreatitis,
Treatment of
biliary GI fistula
primary biliary
(cholecystectom
cirrhosis
y required),
(tablets only)
pregnancy.
Unlabeled
uses: Cholestasi Use cautiously
with lactation.
s-associated
pruritus,
primary
sclerosing
cholangitis

fever,

chills, body
aches, flu
symptoms;

stomach
pain,

nausea,
diarrhea,
constipatio
n;

dizziness,
tired
feeling;

back pain;

runny or
stuffy nose,
cold
symptoms;
or

headache.

Assess patient
carefully for suitability
of ursodiol therapy.
Alternative therapy
should be reviewed
before using ursodiol.
Give drug in two to
three divided doses.
Do not administer
drug with aluminumbased antacids. If
such drugs are
needed, administer 2
3 hr after ursodiol.
Schedule patients for
periodic oral
cholecystograms or
ultrasonograms to
evaluate drug
effectiveness at 6-mo
intervals until
resolution, then every
3 mo to monitor stone
formation. Stones
recur within 5 yr in
more than 50% of
patients. If gallstones
appear to have
dissolved, continue
treatment for 3 mo
and perform follow-up
ultrasound.