Prez

Generic Name

Brand Name

O x y t o c i n

P i t o c i n

Classifi Mechanism cation of Action O x y t o c i c s

Cause potent and selective stimulation of uterine and mammary gland smooth muscle. (Karch, A., 2007; pp. 1235 – 1237)

Indication

Induction of labor; promotion of uterine contractions postpartum; nasally to stimulate milk “let down” in lactating women.

Contra indication •

•

•

•

Cephalopelvic disproportion previous uterine surgery. Unengaged fetal head, unfavorable fetal position or presentation. Fetal distress without imminent delivery. Placenta previa and cord presentation.

Adverse Effect

•

•

Dosage

Tachycardia, 10 units premature of ventricular oxytocin contractions, hypotension. Nausea and vomiting, coma, seizures, intracranial hemorrhage.

How Supplied 1 ml ampule

Nursing Responsibility ✔

✔

✔

✔

✔

✔

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Assess baseline vital signs, blood pressure, and fetal heart rate. Determine frequency, duration and strength of contractions every 15 mins. Notify the physician if contractions are lasting longer than 1 min; they are occurring more frequently than every 2 min. they stop, or rate. Maintain input and output; be alert for water toxification. Do not confuse with vasopressin (Pitressin), which is an antidiuretic hormone.

Generic Brand Classif Mechanism Name Name ication of Action M a g n e s i u m S u l f a t e

E p s o m S a l t s

A n t i c o n v u l s a n t

Indication

May 1. Treatment of decrease preterm acetylcholin labor. e released 2. Prevention by nerve of seizures impulse but in client with its preeclampsia anticonvuls and ant eclampsia. mechanism is unknown. (Karch, A., 2007; pp.442 – 443)

Contraindication

•

•

Parenteral administration contraindication in patient with heart block or myocardial damage. Contraindicated patient with toxemia during hours preceding delivery.

Adverse Effect Dosage

CNS: depressed reflex. Drowsiness, flaccid paralysis, hypothermia. CV: flushing hypotension, bradycardia, circulatory collapse, depressed cardiac function. EENT: diplopia Metabolic: hypocalcemia. Respiratory: respiratory paralysis Skin: diaphoresis

How Nursing Responsibility Supplied

4 g Injection: deep 50% IM into each buttock

•

•

•

•

•

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Monitor the client closely during the leading dose and when the rate is greater than 2g/h because of side this drug are dose related. Obtain baseline assessment including respiratory neurologic and renal system as well as fetal heart rate and contractions. Auscultate breath sounds, monitor deep tendon reflexes, and assess LOC every hour. Report intake and output less than 25 ml/h to the physician immediately. Know that if excessive magnesium is administered, it can be counteracted by IV calcium.

Generic Name

Brand Name

S c o p o l a m i n e

S c o p o l a m i n e

H y d r o b r o m i d e

H y d r o b r o m i d e Injection

Classif Mechanism Indication ication of Action A n t i c h o l i n e r g i c

Inhibits muscarinic actions of acetylcholine on autonomic effectors innervate by past ganglionic cholinergic neurons. May affect neural pathways originating in inner ear to inhibit nausea and vomiting. (Karch, A., 2007; 596 – 598)

Motion sickness, decreases secretions, obstetric amnesia, relief of urinary problems, adjunctive for ulcer, pupil dilation.

Contraindication

•

•

Contraindicated in patient with glaucoma, obstructive uropathy, obstructive disease of GI tract, asthma, chronic pulmonary disease, myasthenia gravis, paralytic ileus, intestinal atony, unstable CV status in acute hemorrhage, tachycardia from cardiac insufficiency or toxic megacolon. Contraindicated in patient hypersensitivity to belladonna or barbiturates. 43

Adverse Effect Dosage

How Nursing Responsibility Supplied

CNS: 0.4 mg Injection: disorientation, IVTT 0.4 mg, restlessness, and 1ml irritability, dizziness, drowsiness, delirium impaired memory. CV: paradoxical bradycardia, palpitations, tachycardia, flushing. EENT: dilated pupils, blurred vision, increased intraocular pressure. GI: constipation, dry mouth, epigastric distress, nausea, vomiting.

•

•

•

•

•

Raise the side rails as a precaution because some patients become temporarily excited or disoriented and some develop amnesia or become drowsy. Reorient patient as needed. Tolerance may develop when therapy is prolonged. Atropine toxicity may cause dose related adverse reactions. Individual tolerances varies greatly. Warn the patient to avoid activities that require alertness until CNS effects of drug are known. Advise patient to take sips of water, suck on ice chips or sugarless hard candy, or chew sugarless gum if dry mouth occurs.

CUES / EVIDENCE

NURSING DIAGNOSIS / SCIENTIFIC BASIS

GOAL AND OUTCOME CRITERIA

NURSING ACTION

RATIONALE

EVALUATION

Independent Subjective:

Decreased cardiac output “ Taas akong BP” as related to decrease venous return as evidenced by verbalized by the patient. variation of blood pressure. Objective: Scientific Basis: ➢ received patient awake The vascular spasms may side - lying in bed. be caused by increased ➢ hooked with D5LR 1L + cardiac output has injures 10 u of oxytocin infusing the endothelial cells of the well @ 30 gtts/min. @ arteries and the action of left arm. prostaglandins. With PIH, reduced ➢ Edema on the lower this responsiveness to blood extremities. pressure changes appears ➢ with the following vital to be lost. Vasoconcritions signs: oocurs and blood pressure increases dramatically. Temp: 36.7*C (Pilliteri, A.,2003; pp. PP: 85 bpm 404) RR: 21 cpm

After 8 hours of nursing intervention the client will be able to maintain the blood pressure within normal range.

•

Monitor blood pressure every 30 min.

•

Provide calm, restful surroundings, minimize environmental activity or noise.

➢

Specifically: 1. display hemodynamic stability. 2. verbalize knowledge of the disease process, individual risk factor. 3.

participate in activities that reduce cardiac workload.

BP: 140/90 mmHg

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➢

Assessment provides ongoing information about physiologic changes.

The goal was partially met either a short goal was achieved but the long term goal was not of the (Luxner, K., desired outcome partially 2005; pp. 51 was achieved. Help reduced sympathetic stimulation and promotes relaxation. (Gulanik, M., et. al. 2006; pp. 55)

•

Promote bed rest in left lateral recumbent position.

➢

Increased renal and uterine blood flow promoting diuresis and reducing blood pressure.

CUES / EVIDENCE

➢

NURSING DIAGNOSIS / SCIENTIFIC BASIS

GOAL AND OUTCOME CRITERIA

NURSING ACTION

variation of blood pressure as follows: 7:00 pm: 150/100 mmHg

RATIONALE

(Luxner, K., 2005; pp. 50) •

7:30 pm: 150/100 mmHg 8:00 pm: 150/100 mmHg 8:30 pm: 150/100 mmHg 9:00 pm: 140/90 mmHg 9:30 pm: 150/100 mmHg

Maintain activity restriction.

➢

10:00 pm:140/90 mmHg

Reduces physical stress and tension that affect blood pressure. (Gulanik, M., et. al. 2006; pp. 35)

11:00 pm:140/90 mmHg 11:30 pm:140/90 mmHg •

12:00 am:140/90 mmHg 12:30 am:140/90 mmHg

Encourage adequate periods.

➢

rest

1:00 am:130/100 mmHg

To promotes relaxation.

(Doeges M., 2002; pp. 123)

1:30 am:130/100 mmHg •

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Instruct in relaxation techniques such a deep breathing and and guided imagery.

➢

To promotes relaxation and comfort. (Gulanik, M., et. al. 2006; pp. 55)

EVALUATION

CUES / EVIDENCE

NURSING DIAGNOSIS / SCIENTIFIC BASIS

Subjective: “ Labad kayo ang akong ulo ug naiin akong panan-aw” as verbalized by the patient.

Ineffective tissue perfusion: Cerebral related to vasospasm as evidence by severe headache and blurred vision.

Objective: ➢

➢

➢ ➢ ➢ ➢

➢

received patient awake side - lying in bed.

Scientific Basis:

GOAL AND OUTCOME CRITERIA

NURSING ACTION

After 8 hours of Independent nursing intervention the client will be deny any deny • Monitor the vital sign every 30 mins. headache and visual disturbance and . return in the normal state.

Specifically: hooked with D5LR 1L + 10 Arteriolar vasospasm u of oxytocin infusing well and decreased blood 1. report the pain if it is relief. @ 30 gtts/min. @ left arm flow to the retina lead to visual symptoms 2. verbalized the grimaced face such as scotomata method that irritability (blind spots) and provide relief. blurring. The same extremities weakness. 3. follow the non pathologic condition pharmaceutical changes in pupillary leads to cerebral edema regime being reaction and hemorrhages, as provided. Edema on the lower well as to increased central nervous system extremities. irritability, which manifests as headache. Hyperflexia and positive ankle clonus. (Lowdermilk, D.L., et. al., 2004; pp. 843) 35

•

Provide quite and calm environment.

RATIONALE

➢

➢

The goal was partially met either a short Assessment goal was provides ongoing achieved but the information about long term goal physiologic was not of the changes. desired outcome partially (Luxner, K., was achieved. 2005; pp. 51) To minimize external stimuli environment and decrease CNS stimuli. (Luxner, K., 2005; pp. 51)

•

Promote bed rest in left lateral recumbent position.

➢

EVALUATION

To avoid use uterine pressure on vena cava and prevent supine hypotension. (Luxner, K., 2005; pp. 51)

CUES / EVIDENCE

➢

NURSING DIAGNOSIS / SCIENTIFIC BASIS

GOAL AND OUTCOME CRITERIA

with the following vital signs: Temp: 36.7*C

NURSING ACTION

•

Assess for altered level of consciousness.

RATIONALE

➢

PP: 85 bpm RR: 21 cpm

Assess information about neurologic perfusion and irritation. (Luxner, K., 2005; pp. 51)

BP: 140/90 mmHg •

Provide non pharmaceutical measures.

➢

Minimize stimulation and promote relaxation reduce vascular pressure and slow sympathetic response are affected in relieving headache and dizziness. (Doeges M., 2002; pp. 516)

•

36

Maintain safety by providing side rails.

➢

To prevent from injury. (Luxner, K., 2005; pp. 51)

EVALUATION

CUES / EVIDENCE

NURSING DIAGNOSIS / SCIENTIFIC BASIS

Subjective: “ Nanghupong akong tiil” as verbalized by the patient.

Deficient fluid volume related to fluid shift to extravascular space secondary to decrease plasma protein and colloid osmotic presure.

Objective: ➢

➢

received patient awake side - lying in bed. hooked with D5LR 1L + 10 u of oxytocin infusing well @ 30 gtts/min. @ left arm

➢

Edema on the lower extremities.

➢

fair skin tugor

➢

warm

➢

grimaced face

➢

irritability

➢

extremities weakness.

GOAL AND OUTCOME CRITERIA

NURSING ACTION

After 8 hours of Independent nursing intervention the client will be able • Position the patient to exhibit edema. in left lateral recumbent Specifically: position. Maintain 1. Maintain an strict bed rest. intravascular fluid volume as Scientific Basis: evidenced by good Increased tubular skin tugor. reabsorption of sodium retains fluid, 2. Verbalize the edema results. Edema understanding of • Provide dim light is further increased environment. condition and because as more prognosis and its proteins lost, the potential osmotic pressure of complications. the circulating blood the • Maintain falls and fluid diffuses 3. Demonstrate strict behavior to from the circulatory activity. improve or system into the denser maintain the intestitial space to circulation. equalize the pressure. (Pilliteri, A.,2003; pp. 405) 37

RATIONALE

➢

Increased renal and uterine blood flow promoting diuresis and reducing blood pressure and uteroplacental perfusion. (Luxner, K., 2005; pp. 50)

➢

To reduce the external stimuli environment. (Gulanik, M., et. al. pp. 35)

➢

Reduces physical stress and tension that affect blood pressure. (Gulanik, M., et. al. pp. 35)

EVALUATION

The goal was partially met either a short goal was achieved but the long term goal was not of the desired outcome was partially achieved.

CUES / EVIDENCE

➢ ➢

➢

hematocrit level of 49.5% decrease urine output.

NURSING DIAGNOSIS / SCIENTIFIC BASIS

GOAL AND OUTCOME CRITERIA

NURSING ACTION

•

with the following vital signs: Temp: 36.7*C

•

PP: 85 bpm RR: 21 cpm BP: 140/90 mmHg

RATIONALE

Implement dietary fat and cholesterol restrictions and low sodium as indicated.

➢

Monitor the vital signs and record.

➢

Enhances circulation and prevent any complications. (Gulanik, M., et. al. pp. 35) Provide ongoing information about physiologic changes. (Luxner, K., 2005; pp. 51)

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EVALUATION