Escolar Documentos
Profissional Documentos
Cultura Documentos
Objective: Alteration in comfort; After 45 minutes of nursing 1. Positioned patient – for relaxation Goal met, as
intervention, comfortably on
Grimaced face Pain r/t increased evidenced by
bed.
the patient will be able
RR= 24cpm Intracranial pressure absence
to establish reduction 2. Provided cool & quiet – promotes
PR= 112bpm Secondary to CVA. environment. of facial grimace &
of pain by absence of relaxation
vital signs are normal.
3. Intermittently massaged
grimace face & v/s within
the forehead.
normal range.
– for relaxation
4. Elevated head of the bed.
5. Turned patient at
intervals.
– promote blood circulation
6. Meds given as ordered
– for relaxation
effect
– serves as baseline
data
NURSING CARE PLAN
Objective: Altered tissue After 15mins. of nursing 1. Assessed for s/s of – Provides baseline Goal partially met,
cranial pressure & data.
BP= 140/100mmHG perfusion r/t intervention, the no episode of seizure
effects of cerebral
interruption of blood patient will be able to vasoconstriction. noted, & afebrile.
glucose of brain
– To immediately
implement
5. Meds given as ordered. interventions
before the
occurrence.
– To control blood
pressure.
Objective: Impaired physical After the shift, the 1. Repositioned client – To prevent Goal met, as
every 2 hours pressure ulcer.
Limited ROM Mobility r/t occlusion patient will be able to evidenced by
of major cerebral maintain skin integrity 2. Supported affected – To maintain maintenance of skin
body parts with pillows. position of
Decreased Muscle arteries. by absence of decubitus. function integrity by absence
& reduce risk of
strength of decubitus.
pressure ulcers.
DRUG STUDY
Name of Drug Action Contraindication Adverse Reaction Nursing Considerations Patient Teaching
Generic name: Inhibits cell wall Contraindicated to CV: phlebitis, Before administration ask the Tell the patient to take
Cefuroxime Sodium
synthesis, Patients hypersensitiveThrombophlebitis. patient if he or she is allergic to drugs as prescribed
promoting To other drugs and penicillins or cephalosporins . even after he feels better.
Generic name: Sodium chloride is the Contraindicated to GI: anorexia, nausea, Note for history o Take these tablets only as
abdominal distention
Sodium Chloride principle salt involved in patients with f hypernatremia, fluid prescribed.
Category: stability & electrolyte chloride could be Wash hands before using
Local:
Pregnancy Risk balance detrimental, optalmic preparation.
Chemical cellulitis
category B bacteriostatic is
Tissue necrosis,
contraindicated in Report irritability, confusion,
Ulceration sloughing at
newborns because of tremor, swelling of
site of infiltration,
associated toxicity. extremities, difficulty
pain at a site of
reathing and black tarry
injection.
Use cautiously with stoo.l
or surgical patients.
H2 blocker stomach, inhibiting Use cautiously with CV: tachycardia, bradycardia Decrease doses in
If you are using antacid ,
basal gastric acid impaired renal or hepatic renal and liver failure.
take it exactly
Dosage: secretion and gastric function, pregnancy. GI: constipation, diarrhea,
as prescribed being
500 mg IV q 12⁰acid secretion that is nausea and vomiting, Provide concurrent
stimulated by food, careful of the time of
abdominal pain hepatitis, antacid, therapy to
insulin, histamine, administration.
increased ALT levels. relive pain.
cholinergic agonist,
blood test to
evaluate effects .
Name of drug Actions Contraindications Adverse effect Nursing consideration Patient teaching
Mannitol Acts by increasing Active intracranial GU: dieresis, urinary Signs of metabolic To rise slowly
osmalarity of bleeding, retention, thirst. acidosis: drowsiness. from lying and sitting position
Osmotic Diuretic filtrate which raises severe dehydration, CNS: dizziness, Signs of hypokalemia: The reason for and method of
Dosage:75 cc of fluid in renal renal failure. rebound increase ICP malaise, fatigue,
reabsorption weakness.
hypotension,
hypertension,
tachycardia,
angina-like
chest pains, fever,
chills.
congestion, decrease
intraocular pressure.
Name of drug Action Contraindication Adverse reaction Nursing consideration Patient teaching
Aspirin Blocks pain impulses in
Hypersensitivity to CNS: drowsiness, Give drugs with food orTake extra precautions to
CNS, inhibition of salicylates, tartrazine dizziness, confusion, after meals if GI upset keep drug out of the reach
preparation.
CV: rapid pulse,
pulmonary edema.
Do not use aspirin that
Name of drug Actions Contraindication Adverse effect Nursing consideration Patient teaching
GENERIC NAME: -reduces fever by Contraindicated with CNS: headache Give drug with food if GI Do not exceed
bleeding or bruising,
yellowing
voiding patterns.
Name of drug Actions Contraindication Adverse reaction Nursing consideration Patients teaching
GENERIC NAME: Exact mechanism Contraindicated with GI: anorexia, nausea Monitor urine or Do not discontinue this
medication without
Metformin hydrochloride is not understood; allergy to metformin; and vomiting, serum glucose levels
frequently to consulting your health care
possibly increases CHF, diabetes epigastric discomfort,
peripheral determine provider.
BRAND NAME: complicated by fever heart burn, diarrhea,
utilization of effectiveness of drug
Glumet severe infections, flatulence.
glucose, decreases and dosage. Monitor blood for glucose and
severe trauma,
hepatic glucose ketones as prescribe.
Classification: ketosis, acidosis coma
Production and
Antidiabetic drug
alters intestinal Do not use this drug for
pregnancy.
absorption of
glucose.
Dosage:500 mg 1 tab BID
Avoid using alcohol while taking
this drug.
4. Provided well
ventilated
-heat loss through
environment.
radiation.
5. Administered
medication as
ordered. -to decrease body
temperature
through the use of
pharmacologic
agent.
Name of Drug Action Contraindication Adverse effects Nursing
Considerations
Dosage:
1gm IV q 8⁰