Patient #2: Cerebrovascular Accident Patient

Male, 50 y/o
DIAGNOSIS ANALYSIS GOAL NURSING RATIONALE EVALUATION
INTERVENTIONS
Risk for infection The client will be The client was given
related to skin tissue An infection is an prevented from having – Stress proper – First line of proper wound care and
distraction invasion of body tissue infection and further hand hygiene to defense against prevented from further
by microorganisms and skin damage all SO taking healthcare- skin damage
O: their proliferation there. care of the associated
– The patient Persons at risk for client. infections.
spends his time infection are those
lying on bed. whose natural defense – Administer
– The patient has mechanisms are medications as – Antibiotics
a bedsore on his inadequate to protect prescribe by the prevent
buttocks them from the physician accumulation of
– Patient’s inevitable injuries and microorganisms
wound/sore is exposures that occur at the patient’s
covered with throughout the course wound and
gauze and of living. Open promote fast
hidden under his wounds, traumatic or healing of the
surgical, can be sites – Assist the SO in
diaper. wound.
for infection; soft performing
– Diaper is wet
wound care.
and the urine is tissues (cells, fat, – This would help
leaking out of muscle) and organs the SO to apply
(kidneys, lungs) can – Explain the
the diaper. the wound
also be sites for importance of medicine
infection either after providing properly.
S:
trauma, invasive proper wound
The SO verbalized:
procedures, or by care for the
“ dati naman wala yan – This will
invasion of pathogens patient.
eh, siguro nga marahil increase the
dahil maghapon siyang carried through the knowledge of
bloodstream or – Explain to the
nakahiga kaya ganyan the care
nagsusugat yung likod lymphatic system. SO the providers.
niya.” importance of
“hindi ko din naman turning the
siya lagging maitagilig patient.
kasi nga mabigat siya at
maykahalinhinan din – Turn patient – Enhances the
ako sa pagbabantay sa every two hours knowledge of
kanya dito” the care
“araw araw ko naman providers
nililinisan pero mahirap
kasi nakadiaper din siya
tapos natatakpan ng
diaper yung sigat kaya – This will
kapag napuno yung prevent too
diaper niya inaalala ko much pressure
baka umabot dun sa on the bony
sugat baka prominences at
magkaimpeksiyon.” the back of the
patient and will
M: prevent further
BP 160/100 damage on his
RR 24 bed sore.
PR 75
Temp. 37.8

Drug Name Dosage Classification Indication Contraindication Side Effects Nursing Responsibilities

Paracetamol 1.2 mL antipyretics, Mild pain Hypersensitivity to Hema: hemolytic BEFORE:

q 4 hr PRN nonopioid analgesics Fever acetaminophen or anemia, neutropenia, ~ Advise parents or
od phenacetin; use leukopenia, caregivers to check
with alcohol. pancytopenia. concentrations of liquid
Hepa: jaundice preparations. Errors have
Metabolic: hypoG resulted in serious liver
GI: HEPATIC damage.
FAILURE, ~ Assess fever; note
HEPATOTOXICITY presence of associated
(overdose)GU: renal signs (diaphoresis,
failure (high tachycardia, and
doses/chronic use). malaise).
Derm: rash, urticaria. DURING:
~ Adults should not take
acetaminophen longer
than 10 days and children
not longer than 5 days
unless directed by health
care professional.
 ~ Advise mother or
caregiver 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
39.5°C (103°F) or lasts
longer than 3 days.

Losartan 100 mg/tab OD Angiotensin II – Treatment of – Contraindicated – CNS: Headache, – Administer without
receptor blocker hypertension, with dizziness, regard to meals.
(ARB) alone or in hypersensitivity syncope, – Ensure that patient is
Antihypertensive combination with to losartan, insomnia not pregnant before
other pregnancy (use – CV: Hypotension beginning therapy,
antihypertensive during the – Dermatologic: suggest using barrier
agents second or third Rash, urticaria, birth control while
– Treatment of trimester can pruritus, alopecia, using losartan; fetal
diabetic cause injury or dry skin injury and deaths
neuropathy with even death to – GI: Diarrhea, have been reported.
an elevated serum the fetus), abdominal pain, – Find an alternative
creatinine and lactation. nausea, method of feeding the
proteinuria in – Use cautiously constipation, dry baby if given to a
patients with type with hepatic or mouth nursing mother.
2 (non–insulin- renal – Respiratory: Depression of the
dependent) dysfunction, URI symptoms, renin-angiotensin
diabetes and a hypovolemia. cough, sinus system in infants is
history of disorders potentially very
hypertension – Other: Back dangerous.
pain, fever, gout, – Alert surgeon and
muscle weakness mark patient's chart
with notice that
losartan is being
taken. The blockage
of the renin-
 angiotensin system
following surgery can
produce problems.
Hypotension may be
reversed with volume
expansion.
– Monitor patient
closely in any
situation that may
lead to a decrease in
blood pressure
secondary to
reduction in fluid
volume—excessive
perspiration,
dehydration,
vomiting, diarrhea—
excessive
hypotension can
occur.

Furosemide Loop diuretic IV: Acute Contraindicated – CNS: Dizziness, – Administer with food
pulmonary edema with allergy to vertigo, or milk to prevent GI
furosemide, paresthesias, upset.
sulfonamides; xanthopsia, – Reduce dosage if
allergy to tartrazine weakness, given with other
(in oral solution); headache, antihypertensives;
anuria, severe renal drowsiness, readjust dosage
failure; hepatic fatigue, blurred gradually as BP
coma; vision, tinnitus, responds.
irreversible – Give early in the day
hearing loss so that increased
– CV: Orthostatic urination will not
hypotension, disturb sleep.
volume depletion, – Avoid IV use if oral
cardiac use is at all possible.
arrhythmias, – Do not mix parenteral
thrombophlebitis solution with highly
– Dermatologic: acidic solutions with
Photosensitivity, pH below 3.5.
rash, pruritus, – Do not expose to
 urticaria, light, may discolor
purpura, tablets or solution; do
exfoliative not use discolored
dermatitis, drug or solutions.
erythema – Discard diluted
multiforme solution after 24 hr.
– GI: Nausea, – Refrigerate oral
anorexia, solution.
vomiting, oral – Measure and record
and gastric weight to monitor
irritation, fluid changes.
constipation, – Arrange to monitor
diarrhea, acute serum electrolytes,
pancreatitis, hydration, liver
jaundice function.
– GU: Polyuria, – Arrange for
nocturia, potassium-rich diet or
glycosuria, supplemental
urinary bladder potassium as needed.
spasm
– Hematologic:
Leukopenia,
anemia,
thrombocytopeni
a, fluid and
electrolyte
imbalances
– Other: Muscle
cramps and
muscle spasms

Amlodepine 2.5 mg OD Calcium channel- – Angina pectoris Contraindicated – CNS: Dizziness, – Monitor patient
blocker due to coronary with allergy to light-headedness, carefully (BP, cardiac
Antianginal drug artery spasm amlodipine, headache, rhythm, and output)
Antihypertensive (Prinzmetal's impaired hepatic or asthenia, fatigue, while adjusting drug
variant angina) renal function, sick lethargy to therapeutic dose;
– Chronic stable sinus syndrome, – CV: Peripheral use special caution if
angina, alone or heart block (second edema, patient has CHF.
in combination or third degree) arrhythmias – Monitor BP very
with other agents – Dermatologic: carefully if patient is
– Essential Flushing, rash also on nitrates.
hypertension, – GI: Nausea, – Monitor cardiac
alone or in abdominal rhythm regularly
combination with discomfort during stabilization of
other dosage and
antihypertensives periodically during
long-term therapy.
– Administer drug
without regard to
meals.