Ncp Drud Study

DRUG STUDY Name of the patient:Cerilla. Elvie Age: 29 Sex: F Marital Status: M Chief complaints/reason/s for Admission: abdominal pain Medical Diagnosis/Impression: acute cholecystitis Attending Physician: Dr. Cuarte Generic Name

Brand Name

Classifica tion

Ketorola c

Toradol

NSAID

Dosage: 1amp

Frequenc y: TID

Route: IVTT

Action

Indication

Contraindicati on

Religion: RC

Room/Bed: FW

Adverse Effect

Nursing Consideration

Unknown Short term Contraindication o Drowsine . management to ss Produces of hypersensitivity. o Headach anti moderately e inflammat severe acute o Edema ory, pain. o Hyperten analgesic sion and o Nausea antipyreti o GI pain c effects. o Diarrhea o Constipat ion o Flatulenc e o Rashes

o Use cautiously in patient with hepatic or renal impairement. o Correct hypovolemia before treatment with torolac. o Observe for cuagulopathies in those taking coagulants. o IM administration may cause pain at injection site.

Nursing Care Plan Name of the patient: Cerilla, Elvie Age: 29 Sex: F Marital Status: M Religion: RC Chief complaints/reason/s for Admission: abdominal pain Date & Time of Admission: 11/24/08 @ 5pm Accompanied by/informant: mother Medical Diagnosis/Impression: acute cholecystitis Operation performed (if any): Attending Physician: Dr. Cuarte Date/time of Assessments: 11/25/08 @ 12noon Date/time of Evaluation: 11/25/08 @ 3pm

Cues & Evidence Subjective: “init kayo ko maam”, as patient verbalized. Objective: o Temp=37.8 degree Celsius o Pale lips noted. o Flushed skin noted o Skin warm to touch.

Nursing Diagnosis Alteration in body temperature related to infection secondary to acute cholecytitis as evidenced by increase body temperature (37.8 ° Celsius) Scientific Basis: Body temperature elevated above normal range. Reference: NANDA 10th edition.

Objection

Nursing Intervention

As the end of my o Perform TSB. care patient’s temperature will o Promote be within normal surface range 37-37.5 ° cooling. Celsius. o Provide conducive environment. o Encourage to maintain bed rest. Dependent: o Administer antipyretic as doctors order

Rationale

Room/Bed: FW

Evaluation

o To decrease Goal met as evidence by temp temp. o Heat loss by = 37.3 ° Celcuis. radiation & conduction o To rest the patient. o To reduce metabolic demands. o To help reduce to body temperature.

Nursing Care Plan Name of the patient: Rellanos, ConsueloAge: 61 Sex: F Marital Status: M Religion: RC Room/Bed: FW Chief complaints/reason/s for Admission: epistaxis and hypertension Date & Time of Admission: 11-24-08 @ 9:10pm Accompanied by/informant: Daughter Medical Diagnosis/Impression: HPN urgency Operation performed (if any): Attending Physician: DR. Cuarte Date/time of Assessments: 11-25-08 @ 7am Date/time of Evaluation: 11-25-08 @ 3pm Cues & Evidence Subject: “ naghanap akong panan’aw” as verbalized by the patient. Objective: o BP= 150/100mmHg o PR= 112bpm o Weakness noted o Irritable noted.

Nursing Diagnosis

Objection

Nursing Intervention

Risk for injury At the span of o Establish related to blurring of may nursing care rapport. vision secondary to patient’s BP and o Safety hypertension

PR will be measures decrease to its rendered. Scientific Basis: normal range. o Promote At risk of injury a as conducive result of environmental environment condition in o Promote rest interacting with the and sleep individuals adaptive & defensive resources Source: NANDA 10th edition

Rationale

Evaluation

o To gain trust and cooperation o To avoid further injury. o To provide comfort

Goal partially met as evidenced by patient BP decrease from 150/100mmHg to 140/90mmHg and PR decrease from 112bpm to 77bpm

o To conserve energy

Dependent o Administer o To help reduce antihypertensiv BP and PR. e as doctors prescribed

DRUG STUDY Name of the patient: Rellanos, ConsueloAge: 61 Sex: F Marital Status: M Chief complaints/reason/s for Admission: epistaxis and hypertension Medical Diagnosis/Impression: HPN urgency Attending Physician: Dr. Cuarte Generic Name

Brand Name

Classification

Captopril

Capoten

Antihypertensives

Dosage: 50mg

Frequency: q6

Route: sublingual

Action

Indication

Religion: RC

Contraindicat ion

Room/Bed: FW

Adverse Effect

Nursing Considerati on

Decrease Hypertension; Contraindicated o Dizzeness o aldosterone Left in patients with o Headache secretion, ventricular hypersensitive o Fatigue o w/c dysfunction to drug or other o Abdominal reduces after acute ACE inhibitors. pain sodium and myocardial o Nausea water infarction. o Vomiting retention o Persistent and lowers nonproduc blood tive cough o pressure.

Monitor pt’s BP and PR frequently. Instruct pt to take drug 1 hour before meals; food in the GI tract may reduce absorption. Compared with other ACE inhibitors, captopril is the most likely to cause cough.