Patient #2: Cerebrovascular Accident Patient Male, 50 Y/o Diagnosis Risk

Patient #2: Cerebrovascular Accident Patient Male, 50 y/o DIAGNOSIS Risk for infection related to skin tissue distraction

ANALYSIS

An infection is an invasion of body tissue by microorganisms and O: their proliferation there. Persons at risk for – The patient spends his time infection are those whose natural defense lying on bed. – The patient has mechanisms are a bedsore on his inadequate to protect them from the buttocks inevitable injuries and – Patient’s exposures that occur wound/sore is throughout the course covered with of living. Open gauze and hidden under his wounds, traumatic or surgical, can be sites diaper. for infection; soft – Diaper is wet and the urine is tissues (cells, fat, muscle) and organs leaking out of (kidneys, lungs) can the diaper. also be sites for infection either after S: trauma, invasive The SO verbalized: procedures, or by “ dati naman wala yan invasion of pathogens eh, siguro nga marahil dahil maghapon siyang carried through the bloodstream or nakahiga kaya ganyan lymphatic system. nagsusugat yung likod niya.” “hindi ko din naman siya lagging maitagilig kasi nga mabigat siya at maykahalinhinan din ako sa pagbabantay sa

GOAL The client will be prevented from having infection and further skin damage

NURSING INTERVENTIONS –

Stress proper hand hygiene to all SO taking care of the client.

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Administer medications as prescribe by the physician

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Assist the SO in performing wound care.

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Explain the importance of providing proper wound care for the patient.

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Explain to the SO the importance of turning the patient.

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Turn patient every two hours

RATIONALE –

First line of defense against healthcareassociated infections.

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Antibiotics prevent accumulation of microorganisms at the patient’s wound and promote fast healing of the wound.

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This would help the SO to apply the wound medicine properly.

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This will increase the knowledge of the care providers.

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Enhances the knowledge of

EVALUATION The client was given proper wound care and prevented from further skin damage

kanya dito” “araw araw ko naman nililinisan pero mahirap kasi nakadiaper din siya tapos natatakpan ng diaper yung sigat kaya kapag napuno yung diaper niya inaalala ko baka umabot dun sa sugat baka magkaimpeksiyon.”

the care providers

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M: BP 160/100 RR 24 PR 75 Temp. 37.8

This will prevent too much pressure on the bony prominences at the back of the patient and will prevent further damage on his bed sore.

Drug Name

Dosage

Classification

Indication

Contraindication

Side Effects

Nursing Responsibilities

Paracetamol

1.2 mL q 4 hr PRN od

antipyretics, nonopioid analgesics

Mild pain Fever

Hypersensitivity to acetaminophen or phenacetin; use with alcohol.

Hema: hemolytic anemia, neutropenia, leukopenia, pancytopenia. Hepa: jaundice Metabolic: hypoG GI: HEPATIC FAILURE, HEPATOTOXICITY (overdose)GU: renal failure (high doses/chronic use). Derm: rash, urticaria.

BEFORE: ~ Advise parents or caregivers to check concentrations of liquid preparations. Errors have resulted in serious liver damage. ~ Assess fever; note presence of associated signs (diaphoresis, tachycardia, and malaise). 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 receptor blocker (ARB) Antihypertensive

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Treatment of hypertension, alone or in combination with other antihypertensive agents Treatment of diabetic neuropathy with an elevated serum creatinine and proteinuria in patients with type 2 (non–insulindependent) diabetes and a history of hypertension

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Contraindicated with hypersensitivity to losartan, pregnancy (use during the second or third trimester can cause injury or even death to the fetus), lactation. Use cautiously with hepatic or renal dysfunction, hypovolemia.

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CNS: Headache, dizziness, syncope, insomnia CV: Hypotension Dermatologic: Rash, urticaria, pruritus, alopecia, dry skin GI: Diarrhea, abdominal pain, nausea, constipation, dry mouth Respiratory: URI symptoms, cough, sinus disorders Other: Back pain, fever, gout, muscle weakness

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Administer without regard to meals. Ensure that patient is not pregnant before beginning therapy, suggest using barrier birth control while using losartan; fetal injury and deaths have been reported. Find an alternative method of feeding the baby if given to a nursing mother. Depression of the renin-angiotensin system in infants is potentially very dangerous. Alert surgeon and mark patient's chart with notice that losartan is being taken. The blockage of the renin-

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Furosemide

Loop diuretic

IV: Acute pulmonary edema

Contraindicated with allergy to furosemide, sulfonamides; allergy to tartrazine (in oral solution); anuria, severe renal failure; hepatic coma;

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CNS: Dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss CV: Orthostatic hypotension, volume depletion, cardiac arrhythmias, thrombophlebitis Dermatologic: Photosensitivity, rash, pruritus,

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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. Administer with food or milk to prevent GI upset. Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds. Give early in the day so that increased urination will not disturb sleep. Avoid IV use if oral use is at all possible. Do not mix parenteral solution with highly acidic solutions with pH below 3.5. Do not expose to

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Amlodepine

2.5 mg OD

Calcium channelblocker Antianginal drug Antihypertensive

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Angina pectoris due to coronary artery spasm (Prinzmetal's variant angina) Chronic stable angina, alone or in combination with other agents Essential

Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree)

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urticaria, purpura, exfoliative dermatitis, erythema multiforme GI: Nausea, anorexia, vomiting, oral and gastric irritation, constipation, diarrhea, acute pancreatitis, jaundice GU: Polyuria, nocturia, glycosuria, urinary bladder spasm Hematologic: Leukopenia, anemia, thrombocytopeni a, fluid and electrolyte imbalances Other: Muscle cramps and muscle spasms CNS: Dizziness, light-headedness, headache, asthenia, fatigue, lethargy CV: Peripheral edema, arrhythmias Dermatologic: Flushing, rash

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light, may discolor tablets or solution; do not use discolored drug or solutions. Discard diluted solution after 24 hr. Refrigerate oral solution. Measure and record weight to monitor fluid changes. Arrange to monitor serum electrolytes, hydration, liver function. Arrange for potassium-rich diet or supplemental potassium as needed.

Monitor patient carefully (BP, cardiac rhythm, and output) while adjusting drug to therapeutic dose; use special caution if patient has CHF. Monitor BP very carefully if patient is also on nitrates.

hypertension, alone or in combination with other antihypertensives

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GI: Nausea, abdominal discomfort

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Monitor cardiac rhythm regularly during stabilization of dosage and periodically during long-term therapy. Administer drug without regard to meals.