Date Lab Test Normal Patients Significance Nursing Care

Value Values
No alteration to the normal Informed patient’s watcher
October 01, Hemoglobin 11 - 16 g/dL 15.5 (Normal) value of the results to provide the patient with
2009 nutritious foods.
The increase number of Advice patient to increase
Hematocrit 37 - 47 % 47.3 (H) hematocrit is due to low food intake rich in vitamin
oxygen level in the blood B12
No alteration to the normal Informed patient’s watcher
WBC 4.5 - 11 10g/L 6.39 (Normal) value of the results to provide the patient with
nutritious foods.
No alteration to the normal Informed patient’s watcher
Platelet 150-450 10g/L 176 (Normal) value of the results to provide the patient with
nutritious foods.
 Generic Dosage Mechanism
Name/ Date Classific And Of Indication Contraindi- Adverse Nursing
Trade Ordered a-tion Frequen Action cation Reaction Responsiblity
Name/ cy
Form of
Medication

Lanoxin Cardiac 0.25mg Digoxin increases Cardiac Failure In patients CNS: Agitation, >Before loading
(Digoxin) October Drug 1 Tab the strength and accompanied by with Dizziness, dose, obtain
01, 2009 OD 6AM vigor of heart atrial hypersensitivi Fatigue, baseline heart rate
Tablet Antiarryth contraction and is fibrillation; ty to the drug Generalized and rhythm, blood
-mic useful in the management of or any of its muscle pressure and
treatment of heart chronic cardiac components weakness, electrolyte levels.
Inotropic failure. It inhibits failure where and in those hallucinations, >Instruct patient
the activity of an systolic with Digoxin headache, and care giver
ezyme that dysfunction or induced malaise, about drug action,
controls ventricular toxicities, paresthesia, dosage regimen,
movement of dilatation is ventricular vertigo pulse taking,
calcium, sodium dominant; fibrillation or CV: reportable signs
and potassium management of ventricular Arrythmias, and follow-up
into heart certain tachycardia heart failure, plans.
muscles. Calcium supraventricu- unless by EENT: Blurred > Instruct patient
controls the force Lar arrythmias, heart failure. vision, myopia, not to substitute 1
of contraction, particularly Used to light flashes, brand of digoxin
inhibiting ATPase chronic atrial patient with photophobia, for another.
increases calcium flatter and MI. GI: Anorexia, > Intruct patient
in heart muscle fibrillation. diarrhea, nausea to eat K reach
and therefore and vomiting food.
increases the
force of heart
 contractions.

Spironolac- Octiober Diuretic 25 mg

tone 01, 2009 ½ Tab Specific Aldactone is Aldactone is GI: Gastric > Monitor vital
(Aldactone) OD 6 AM pharmacologic indicated to contraindicate bleeding, signs as well as
antagonist of patients having d for patients ulceration, intake and output
Tablet aldosterone, hyperaldosteron with anuria, gastritis, > to prevent
acting primarily ism, edema, acute renal diarrhea, serious
through congestive heart insufficiency, cramping, hyperkalemia,
competitive failure, cirrhosis significant nausea & warn patient not
binding of of the liver, impairment of vomiting to eat large
receptors at the nephritic renal GU: impotence amounts of
aldosterone- syndrome, excretory CNS: potassium –
dependent Na-K hypertension, function, or Confusion, containign salt
exchange site in hypokalemia hyperkalemia. ataxia, substitutes
the distal headache, > Tell patient to
convoluted drowsiness, take drug with
renal tubule. It lethargy meals
causes Metabolic:
increased dehydration,hyp
amounts of Na erkalemia,
and water to be hyponatremia,
excreted, while mild acidosis
K is retained. It
acts both as a
diuretic and as
an
antihypertensiv
e drug by this
mechanism.
Cefuroxime Octiober Cephalos- 500 mg Inhibits cell- Treatment of Known Thrombophlebit >Advice the
(Zegen) 01, 2009 porin 1 Tab wall synthesis, bone & joint allergy to is. Pruritus, patient to take
BID 8-8 promoting infections, cephalosporin urticaria, meals before
Capsule osmotic bronchitis (& s. diarrhea, taking the
instability; other lower resp nausea, medication
usually tract infections), pseudomembra >Tell the patient
bactericidal. gonorrhea, nous colitis. to report adverse
Hinders or kills meningitis, Decrease in Hb reaction
susceptible otitis media, & hematocrit, >Advice the
bacteria, peritonitis, transient patient to increase
including many pharyngitis, increase in liver fluid intake
gram-positive sinusitis, skin enzymes,
organisms and infections, elevation in
enteric gram- surgical serum
negative bacilli. infections & creatinine &
UTI. BUN. Possibly
seizure &
angioedema.
Nursing Problem: Shortness of Breath Date Identified: October 2, 2009 Date Evaluated: October 2, 2009

Assessmen Diagnosi Inferenc Planning Interventi Rationale Evaluatio

t s e on n
SUBJECTIVE Impaired Heart failure After 8 hours Independent Goal Unmet
“Naglisud ko ug Gas refers to the of duty Instruct patient Clears airways and Patient was
ginhawa,murag Exchange inability of patient will be ineffective facilitates oxygen not able to
mawad-an gyud related to the heart to able to coughing, delivery. demonstrate
ko ug hangin” decreased maintain demonstrate deep adequate
as verbalized tissue cardiac adequate breathing. ventilation and
by the patient. perfusion output ventilation symptoms of
sufficient to and be free of Encourage respiratory
meet the symptoms of frequent Helps prevent distress are
body’s respiratory position atelectasis and still present.
metabolic distress. changes. pneumonia.
needs or if
Objective: adequate Maintain
-Restlessness cardiac chair/bedrest,
-Chest pain output can with head of Reduces oxygen
- only be bed elevated consumption/demand
Shallow,labored achieved 20–30 s and promotes
breathing with elevated degrees, semi- Maximal lung inflation.
-Orthopnea filling Fowler’s
-Vital Signs pressures. position.
taken as This Support arms
follows: definition with
also includes pillows.
T: 37°C the inability
PR: 84bpm of the heart Collaborative
R: 26cpm to clear Administer Increases alveolar
BP: 130/90 venous supplemental oxygen concentration,
mmHg return, oxygen as which may
resulting in indicated. Correct/reduce tissue
vascular hypoxemia.
congestion
and a Administer Reduces alveolar
secondary medications as congestion, enhancing
drop in indicated: gas exchange.
cardiac Aldactone
output. Heart
failure
commonly
leads to
pulmonary
congestion
and or
peripheral
edema, at
which point it
can be called
a Congestive
Heart
Failure.
Nursing Problem: Chest Pain Date Identified: October 2, 2009 Date Evaluated: October 2, 2009

Assessmen Diagnos Inferenc Plannin Interventi Rationale Evaluation

t is e g on
SUBJECTIVE Decreased Heart failure After 8 Independent Goal Partially
DATA: Cardiac refers to the hours of Auscultate Tachycardia is usually Met
“Sakit akong Output inability of duty patient apical pulse; present (even at rest) Patient was
dughan if related to the heart to will be able assess heart to able to
muginhawa ko altered maintain to display rate, rhythm compensate for participate in
ug kana pod myocardial cardiac vital signs (document decreased ventricular activities that
kong naa ko contractility output within dysrhythmia if contractility. reduce cardiac
buhaton nga and/or sufficient to acceptable telemetry workload but
manginahanglan structural meet the limits, report available). was not able to
ug kusog” as changes body’s decreased display vital
verbalized by metabolic episodes of Monitor BP. In early, moderate, or signs within
the patient. needs or if dyspnea, chronic HF, BP may acceptable
adequate angina. be elevated limits and report
cardiac Participate because of increased decreased
OBJECTIVE output can in activities SVR. In advanced HF, episodes of
DATA: only be that reduce the body may dyspnea,angina
-Chest Pain achieved cardiac no longer be able to .
-Orthopnea with workload. compensate, and
-Tachycardia elevated profound/irreversible
-Restlessness filling hypotension may
-Vital signs pressures. occur.
taken as follows This
T: 37°C definition Encourage rest, Physical rest should
PR: 84bpm also semirecumbent be maintained during
R: 26cpm includes the in bed or chair. acute or
BP: 130/90 inability of Assist refractory HF to
mmHg the heart to with physical improve efficiency of
clear venous care as cardiac contraction
return, indicated. and to decrease
resulting in myocardial oxygen
vascular demand/consumption
congestion and workload.
and a
secondary Provide quiet Psychological rest
drop in environment; helps reduce
cardiac explain emotional stress,
output. medical/nursing which
Heart failure management; can produce
commonly help patient vasoconstriction,
leads to avoid stressful elevating BP and
pulmonary situations; increasing heart
congestion listen/respond rate/work.
and or to expressions
peripheral of
edema, at feelings/fears.
which point
it can be Collaborative Increases available
called a Administer oxygen for myocardial
Congestive supplemental uptake to
Heart oxygen as combat effects of
Failure. indicated. hypoxia/ischemia.
Nursing Problem: Unable to tolerate Date Identified: October 2, 2009 Date Evaluated: October 2, 2009
physical activities
Assessmen Diagnosis Inference Planning Intervention Rationale Evaluation
t
SUBJECTIVE Activity Heart failure After 8 hours Independent Goal Partially
“Kapoyan ko Intolerance refers to the of duty Check vital signs Orthostatic Met
magtindog or related to inability of patient will before and hypotension can Patient was
bisan imbalance the heart to be able to immediately after occur with activity able to
maglakaw between maintain participate in activity, because participate in
lang sa oxygen cardiac desired especially if patient of medication effect desired
palibot,luya supply and output activities; is receiving (vasodilation), fluid activities but
lang gyud demand sufficient to meet own vasodilators, shifts (diuresis), didn’t achieve
kayo ko kadto meet the self-care diuretics, or or compromised an increase in
kausa body’s needs and beta-blockers. cardiac pumping activity
nakuyapan metabolic achieve function. tolerance.
gyud ko” as needs or if measurable
verbalized by adequate increase in Document Compromised
the patient. cardiac activity cardiopulmonary myocardium/inability
output can tolerance, response to activity. to increase stroke
only be evidenced by Note volume during
OBJECTIVE achieved reduced tachycardia, activity may cause
-Fatigue with fatigue and dysrhythmias, an immediate
-Weakness elevated weakness dyspnea, increase
-Restlessness filling diaphoresis, pallor. in heart rate and
-Fainting pressures. oxygen demands,
episodes This thereby aggravating
-Vital signs definition weakness and
taken as also includes fatigue.
follows the inability
T: 37°C of the heart Assess for other Fatigue is a side
PR: 84bpm to clear precipitators/causes effect of some
R: 26cpm venous of fatigue, e.g., medications (e.g.,
BP: 130/90 return, treatments, pain, betablockers,
mmHg resulting in medications. tranquilizers, and
vascular sedatives). Pain and
congestion stressful
and a regimens also
secondary extract energy and
drop in produce fatigue.
cardiac
output. Heart
failure
commonly Evaluate May denote
leads to accelerating activity increasing cardiac
pulmonary intolerance. decompensation
congestion rather
and or than overactivity.
peripheral
edema, at Provide assistance Meets patient’s
which point it with self-care personal care
can be activities as needs without
called a indicated. undue
Congestive Intersperse activity myocardial
Heart periods with rest stress/excessive
Failure. periods. oxygen demand.
Strengthens and
improves cardiac
function under
stress, if
cardiac dysfunction
is not irreversible.
Collaborative
Implement graded
cardiac Gradual increase
rehabilitation/activity in activity avoids
program. excessive
myocardial
workload and
oxygen
consumption.