New Ncp Nov 2015

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Name of Student Nurse: CHRISTINA EJERCITO Clinical Instructor: JEANETTE J. ROJO, RN, MAN

Assessment Dianosis Scientific Rationale !lannin Inter"ention Scientific Rationale E"aluation

S: #masuol $uno

%a na in&a'a

si(a) as

"er*ali+ed *( t&e

mot&er

O:

facial frimacedia%&oretic

acute %ain r-t

inflammator(

res%onse of

al"eolar tissues

secondar( to

%neumonia

Tissue inur( or

infection results to

immediate "ascular

res%onse/ transitor(

"asoconstriction

follo'ed

immediatel( *(

"asodilation due to

t&e release of

&istamine,*rad($ini

n and %rostalandin'&ic& in turn leads

to increased

ca%illar(

%ermea*ilit(,

&(%eremia and

cellular e0udation

t&at results to

edema and t&en

%ain caused *(

com%ression of

ner"e endins,

release of %ain

mediators

*rad($inin and

%rostalandins and

e"entuall( loss or

im%aired function.

Reference: Josie

1uiam*ao2

3dan,Masterin

4undamentals of

Nursin 5rdedition,

After a series of

nursin

inter"entions:

Demonstrate relief

of %ain as a*sence of

muscle tension,

a*sence of facial

rimace andrestlessness

%erform a com%re&ensi"e

assessment of %ain to include

location, c&aracteristic, onset,

duration, fre6uenc(,6ualit( and

%reci%itatin factors of %ain.

reduce or eliminate factors t&at

%reci%itate or increase %ain

e0%erience.

Elicit *e&a"iors t&at are

conditioned to %roduce rela0ation,

suc& as dee% *reat&in, music

t&era%(.

Instruct client to re%ort an(

im%ro"ement-e0acer*ation of %ain.

Encourae "er*ali+ation a*out

feelins of %ain.

!ro"ide comfort measures suc& as

re%ositionin

And fi0in t&e *ed s&eets.

%ain is su*ecti"e e0%erience

and must *e descri*ed *( t&e

client in order to %lan

effecti"e treatment.

%ersonal factors can

influence %ain and %ain

tolerance. 4actors t&at ma( *e

%reci%itatin o aumentin

%ain s&ould *e reduced or

eliminated to en&ance t&e

o"erall %ain manaement%roram.

rela0ation tec&ni6ues &el%

reduce s$eletal and muscle

tension '&ic& 'ill reduce t&e

intensit( of t&e %ain.music

t&era%( ser"es as a distracter

from &os%ital noise, t&ere*(

reducin emotional an0iet(

and %ain

3nrelie"ed %ain can create

%ro*lems suc& as aner,

an0iet(, immo*ilit(,

res%irator( %ro*lems and

dela( in &ealin.

onl( t&e client can ude t&e

le"el and distress of %ain,

%ain manaement s&ould *e a

team a%%roac& t&at includes

t&e client.

To %romote comfort and

alle"iate %ain.

Source:

Medical2Surical Nursin, 7

t&

ed. *( 8lac$, Jo(ce M.and

Jane Ho$anson Ha'$s/ %.

995

!atient 'ill &a"e relief of

%ain as a*sence of muscle

tension, a*sence of facial

rimace and restlessness.

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N3RSIN CARE !;AN

Name of t&e !atient: Ca&usa(, Ell(+a Mae Date Admitted:

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S:

)di si(a

na$a$aturo

$a( masuol ura2

ura) "er*ali+ed

*( t&e mot&er

O:

(a'nin

cr(in

'a$es u%

e"er( = &ours

4atiue related

to slee%

de%ri"ation

secondar( to

%neumonia

!rostalandin due to

inflammator( reaction

as a result from t&e

'ound, or

microoranism ma(

result to transmission

of %ain t&ere*( affects

mo*ilit(, mood, restand concentration.

Reference: Josie

1uiam*ao2

3dan,Masterin

4undamentals of

Nursin 5rdedition,

after B &ours of

nursin

inter"entions t&e

%t 'ill *e a*le to:

lessen

discomforts and

o*tain ade6uate

rest.

mani%ulated en"ironment suc&

as cleanin t&e surroundins

and minimi+in noise.

encourae %atient for ade6uate

rest %eriods to o*tain rest and

relie"e fatiue

&a"e %atient in an(

comforta*le %osition as

tolerated

$ee% t&e *ed linens dr( and

'rin$le free to %re"ent

discomforts

instructed to:

2consume foods t&at are ric& in

%rotein, "itamins and calcium

'&ic& can *e a source of ener(

refrain from caffeine, alco&oland ot&er stimulatin su*stances

s%eciall( durin e"enin

2%erform di"ersional acti"ities

suc& as listenin to music to

di"er attentions.

Encourae dee% *reat&in

e0ercises

to %romote comfort

ade6uate rest %eriods

could %re"ent fatiue and

discomfort

Clients

%osition ma( ara"ate

%ain felt. !ositionin

%ro%erl( ma( %romote

comfort and also ensure

ood circulation.

>nutrition is the

fundamental

cellular integrity

and tissue repair

>caffeine has

substances that is

known to disrupt

%atients discomforts 'ill lessen and

'ill o*tain ade6uate rest.

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sleeping patterns

>Diversional

activities will

help the client

focus on other

things rather than

the pain felt

> To facilitate

expansion of

abdomen and to

decrease pain


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N3RSIN CARE !;AN

Name of t&e !atient: Ca&usa(, Ell(+a Mae Date Admitted:

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Name of t&e !atient:;utao, Miuel Date Admitted:

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generic name:

%aracetamol

brand name:

tem%ra

*+,T-:

IFTT

D+#"-:

>7< m

.*-/,-'!:

19&

!1##I.I!

TI+':

Analesicnon2

o%ioid,

Anti%(retic

ntip2retic:

Reduces fe"er *(

actin directl( on

t&e &(%ot&alamic

&eat2reulatin

center to cause

"asodilatation and

s'eatin, '&ic&

&el%s dissi%ate &eat.

nalgesic: Site and

mec&anism of action

unclear.

Tem%orar(

reduction of

fe"er.

Contraindicated 'it&

aller( to

acetamino%&en,

3otentiating:

*ar*iturates,

car*ama+e%ine,

diflunical,

&(dantoins,

isonia+id,

rifa*utin,

rifam%in,

sulfin%(ra+one:increased ris$ of

&e%atoto0icit(

Gido"udine:

increase ris$ of

ranuloc(to%enia.

Inhibiting:

acti"ated

c&arcoal,

c&olest(ramine,

colestipol :

decreased

acetaminino%&en

a*sor%tion.

!'#:Headac&e,

di++iness, let&ar(,

%arest&esia,

"I:&e%atic to0icit(

and failure

",:li"er to0icit(,

ne%&roto0icit(,

4ematologic:*one

marro'de%ression,

42persensitivit2:

ras&, fe"er

naph2la6is %ain,

%&le*itis

3se cautiousl(

'it& im%aired

&e%atic function

and renal failure

>. Do not e0ceed t&e recommended

dosae.

=. Reduce dosae 'it& &e%atic

im%airment.

5. A"oid usin multi%le %re%arations

containin acetamino%&en. Carefull(

c&ec$ all OTC %roducts.

9. Discontinue dru if &(%ersensiti"it(

reactions occur.

@. Assess if %atient &as an(

contraindication to drus


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N3RSIN CARE !;AN

Name of t&e !atient:;utao, Miuel Date Admitted: Cyanosis of nail beds

may represent

vasoconstriction or the

body#s response to

fever"chills$ however

cyanosis of earlobes

mucous membranes and

skin around the mouth

%&warm membranes( is

indicative of systemic

hypoxemia.

>)igh fever %common in

bacterial pneumonia and

influen*a( greatly

increases metabolic

demands and oxygen

consumption and alters

cellular oxygenation.

%atient 'ill dis%la( %atent air'a(

'it& *reat& sounds clearin/ a*sence

of d(s%nea, c(anosis.

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>These measures promote

maximum chest expansion

mobili*e secretions and

improve ventilation.

>+hock and pulmonary

edema are the most common

causes of death in

pneumonia and re,uire

immediate medical

intervention.


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Name of t&e !atient: Faras, Marr( Ann Date Admitted: -=7->? C&ief Com%laint:

Ae: Se0: 4 Ci"il Status: S Address: Diet: DAT ard:4M-S

name of drug specificaction

indications

contraindicatio

n

drug

interaction

adverse

reaction

specific

precaution

nursing responsibilities

generic name:

trane0amic acid

brand name:

Hemostan,

4i*rinon,

C($lo$a%ron,

;(steda, Transamin

classification:

antifi*rinol(tic

route & dosage:

Trane0amic

acid is a

s(nt&etic

deri"ati"e of

t&e amino

acid l(sine. It

e0erts its

antifi*rinol(ti

c effect

t&rou& t&e

re"ersi*le

*loc$ade of

l(sine2

*indin sites

on

%lasminoen

molecules.

Anti2

fi*rinol(tic

dru in&i*its

endometrial

%lasminoen

acti"ator and

t&us %re"ents

fi*rinol(sis

and t&e

*rea$do'n of*lood clots.

T&e

e%ista0is,

&emo%t(sis,

&ematuria, %e%tic

ulcer 'it&

&emorr&ae and

*lood d(scrasias

'it& &emorr&ae

Alleric

reaction to t&e

dru or

&(%ersensiti"it(

!resence of

*lood clots e,

in t&e le, lun,

e(e, *rain,

&a"e a &istor(

of *lood clots,

or are at ris$ for

*lood clot.

DrugDrug: !V: %&le*itis,

t&rom*o%&le*i

tis

"I:

%seudomem*r

anous colitis,

nausea,

anore0ia,

"omitin,

diarr&ea

#$in:

maculo%a%ular

and %ain,

induration,

tem%erature

ele"ation.

!renanc

(.

Trane0amic

acid

crosses t&e

%lacenta.

;actation.

Trane0amic

acid is

distri*uted

into *reast

mil$/

concentrati

ons reac&

a%%ro0imat

>. 3nusual c&ane

in *leedin

%attern s&ould

*e immediatel(

re%orted to t&e

%&(sician.

=. 4or 'omen '&o

are ta$in

Trane0amic

acid to control

&ea"( *leedin,

t&e medication

s&ould onl( *e

ta$en durin t&e

menstrual

%eriod.

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%lasminoen2

%lasmin

en+(me

s(stem is

$no'n to

cause

coaulation

defects

t&rou& l(tic

acti"it( on

fi*rinoen,fi*rin and

ot&er clottin

factors. 8(

in&i*itin t&e

action of

%lasmin

finronol(sin

t&e anti2

fi*rinol(tic

aents reduce

e0cessi"e

*rea$do'n of

fi*rin and

effect%&(sioloical

&emostasis.

el( > of

t&e

maternal

%lasma

concentrati

on.

5. T&e medication

can *e ta$en

'it& or 'it&out

meals.

9. S'allo'

Trane0amic

Acid '&ole

'it& %lent( of

li6uids. Do not

*rea$, crus&, or

c&e' *efore

s'allo'in.

Name of Student Nurse: CHRISTINA EJERCITO Clinical Instructor: CRISTINA MARIE M. MANGANO,RN,RM,MAN

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N3RSIN CARE !;AN

Name of t&e !atient: Reine Ri+o Date Admitted: -=9->? C&ief Com%laint: &(%oastric %ain, c& ills

Ae: >@ Se0: 4 Ci"il S tatus: S Address:8o*on Nort&ern Samar Diet : SD ard:4M-S

name of drug specific

action

indications

contraindication drug

interaction

adverse

reaction

specific

precaution


generic name:

Ranitidine

H(droc&loride

brand name:

Gantac

classification:

antisecretor( &=2

rece%tor

antaonist

route & dosage:

Ranitidine

*loc$s

&istamineH=2rece%tors

in t&e

stomac& and

%re"ents

&istamine2

mediated

astric acid

secretion. It

does not

affect %e%sin

secretion,

%entaastrin2

stimulated

factorsecretion or

serum

astrin..

S&ort2term

treatment of

acti"e

duodenal ulcer

Maintenance

t&era%( for

duodenal ulcer

at reduced

dosae

&(%ersensiti"e

ce%&alos%orin or

%enicillin

DrugDrug:

Ma( increased

ne%&roto0icit('it&

aminol(coside

s

Increased

*leedin effects

'it& oral

anticoaulants

!V: %&le*itis,

t&rom*o%&le*i

tis

"I:

%seudomem*r

anous colitis,

nausea,

anore0ia,

"omitin,

diarr&ea

#$in:

maculo%a%ular

and %ain,

induration,tem%erature

ele"ation.

&(%ersensit

i"e to

%enicillin

8e alert for earl( sins

of &e%atoto0icit( t&ou&

lo' and t&ou&t to *e a

&(%ersensiti"it(

reaction: aundice dar$

urine, %ruritus, (ello'

sclera and s$in, ele"ated

transaminases

es%eciall( A;T and

;DH.

;on2term t&era%( ma(

lead to "itamin

8>=deficienc(.

Note: ;on duration of

action %ro"ides ulcer

%ain relief t&at is

maintained t&rou& t&e

ni&t as 'ell as t&e da(.

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Name of t&e !atient: Date Admitted: -=7->? C&ief Com%laint:

Ae: Se0: M Ci"il Status: M Address: Diet: ;S;4 ard:MM-S


action

indications


interaction

adverse

reaction

specific

precaution


generic name:

Clonidine

brand name:

cata%resclassification:

Anti&(%ertensi

"e

S(m%at&ol(tic

centrall( actin

Central analesic

route & dosage:

Clonidine

&(droc&loride

Cata%res is

an

anti&(%ertensi"e dru

t&at stimulate

s CNS

al%&a=2

adreneric

rece%tors,

in&i*its

s(m%at&etic

cardioacceler

ator and

"asoconstrict

or centers,

and decreases

s(m%at&eticoutflo' from

t&e CNS.

H(%ertension

, used alone or

as %art of

com*ination

t&era%(

Contraindicated 'it&

&(%ersensiti"it(

to clonidine or an(

ad&esi"e la(er

com%onents of

t&e transdermal s(stem.

DrugDrug:

Increased

*leedin effects

'it& oralanticoaulants

!'#:Drowsin

ess, sedation,

dizziness,&ead

ac&e, fatiue

t&at tend to

diminis&

'it&in 9? '$,

dreams,

ni&tmares,

insomnia,

&allucinations,

delirium,

ner"ousness,

restlessness,

an0iet(,

de%ression,

retinal

deeneration

!V: CH4,

ort&ostatic

&(%otension,

%al%itations,

tac&(cardia, *r

3se

cautiousl(

'it& se"ere

coronar(

insufficienc(

, recent

MI, cere*ro"

ascular disea

se/ c&ronic

renal failure/

%renanc(,

lactation.

>. &(%ersensiti"it( to clonidine or

ad&esi"e la(er com%onents of

t&e transdermal s(stem/ se"ere

coronar( insufficienc(, recent

MI, cere*ro"ascular disease/

c&ronic renal failure/ lactation,

%renanc(

=. discontinue a*ru%tl(/

discontinue t&era%( *( reducin

t&e dosae raduall( o"er =9

da(s to a"oid re*ound

&(%ertension, tac&(cardia,

flus&in, nausea, "omitin,

cardiac arr&(t&mias

5.Monitor 8! carefull( '&en

discontinuin clonidine/

&(%ertension usuall( returns 'it&in

9B &r.

9. ma( e0%erience t&ese side effects:Dro'siness, di++iness, li&t2

&eadedness, &eadac&e, 'ea$ness

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ad(cardia, Ra(

nauds %&enom

enon, EC

a*normalities

manifested

as enc$e*ac

& %eriod or

"entricular tri

emin

@. Re%ort urinar( retention, c&anes

in "ision, *lanc&in of finers, ras&.


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N3RSIN CARE !;AN

Name of t&e !atient: Date Admitted: -=7->? C&ief Com%laint:

Ae: Se0: M Ci"il Status: M Address: Diet: ;S;4 ard:MM-S


action

indications


interaction

adverse

reaction

specific

precaution


generic name:

mefenamic acid

brand name:

!onstel

classification:

analesic

NSAID

route & dosage:

In&i*its

s(nt&esis of

%rostalandin

Mefenamic

acid is used for

t&e s&ort2termtreatment of

mild to

moderate %ain

from "arious

conditions.

H(%ersensiti"it( to

dru/I inflammation,or

ulceration.Safet( in

c&ildren K>9 (, durin%renanc( cateor( C,

or lactation is not

esta*lis&ed.

DrugDrug: !'#:Dro'sin

ess, insomnia,

di++iness,

ner"ousness,

confusion,

&eadac&e.

"I:Se"ere

diarr&ea,

ulceration,

and *leedin/

nausea,

"omitin,

a*dominal

cram%s,

flatus,

consti%ation,

&e%atic

to0icit(.

4ematologic:

!roloned

%rot&rom*in

time, se"ere

Histor( of

$idne( or

li"er

disease/*loodd(scrasias/ast

&ma/dia*etes

mellitus/&(%e

rsensiti"it( to

as%irin. ;on

term use

increases ris$

of serious

ad"erse

e"ents.

>. Assess %atients '&o de"elo%

se"ere diarr&ea and "omitin for

de&(dration and electrol(te

im*alance.

=. Discontinue dru %rom%tl( if

diarr&ea, dar$ stools, &ematemesis,

ecc&(moses, e%ista0is, or ras& occur

and do not use aain. Contact

%&(sician.

5. i"e 'it& meals, food, or mil$ to

minimi+e I ad"erse effects.

9. Do not use dru for a %eriod

e0ceedin > '$ manufacturers

'arnin.
http://www.webmd.com/drugs/2/drug-11590/ponstel+oral/detailshttp://www.webmd.com/drugs/2/drug-11590/ponstel+oral/details

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autoimmune

&emol(tic

anemia lon2

term use,

leu$o%enia,

eosino%&ilia,

aranuloc(tos

is,

t&rom*oc(to%

enic %ur%ura,

mealo*lastic

anemia,

%anc(to%enia,

*one marro'

&(%o%lasia.


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S: #masuol a$ ulo

nan $ali%on)

O:

>B=

Documents

New Ncp Nov 2015