Assessment

S: masuol kuno
pag nag ginhawa
siya as
verbalized by the
mother

O:
>facial frimace
>diaphoretic

Diagnosis
>acute pain r/t
inflammatory
response of
alveolar tissues
secondary to
pneumonia

Scientific Rationale
Tissue injury or
infection results to
immediate vascular
response; transitory
vasoconstriction
followed
immediately by
vasodilation due to
the release of
histamine,bradykini
n and prostaglandin
which in turn leads
to increased
capillary
permeability,
hyperemia and
cellular exudation
that results to
edema and then
pain caused by
compression of
nerve endings,
release of pain
mediators
bradykinin and
prostaglandins and
eventually loss or
impaired function.

Planning
After a series of
nursing
interventions:
> Demonstrate relief
of pain as absence of
muscle tension,
absence of facial
grimace and
restlessness

Reference: Josie
QuiambaoUdan,Mastering
Fundamentals of
Nursing 3rd edition,

Name of Student Nurse: CHRISTINA EJERCITO

Intervention
>perform a comprehensive
assessment of pain to include
location, characteristic, onset,
duration, frequency,quality and
precipitating factors of pain.

Scientific Rationale
>pain is subjective experience
and must be described by the
client in order to plan
effective treatment.
>personal factors can
influence pain and pain
>reduce or eliminate factors that
tolerance. Factors that may be
precipitate or increase pain
precipitating o augmenting
experience.
pain should be reduced or
eliminated to enhance the
overall pain management
program.
>relaxation techniques help
reduce skeletal and muscle
>Elicit behaviors that are
tension which will reduce the
conditioned to produce relaxation,
intensity of the pain.music
such as deep breathing, music
therapy serves as a distracter
therapy.
from hospital noise, thereby
reducing emotional anxiety
and pain
>Instruct client to report any
>Unrelieved pain can create
improvement/exacerbation of pain.
problems such as anger,
anxiety, immobility,
>Encourage verbalization about
respiratory problems and
feelings of pain.
delay in healing.
>only the client can judge the
level and distress of pain,
pain management should be a
team approach that includes
the client.
>Provide comfort measures such as
> To promote comfort and
repositioning
alleviate pain.
And fixing the bed sheets.
Source:
Medical-Surgical Nursing, 7
th
ed. by Black, Joyce M.and
Jane Hokanson Hawks; p.
443
Clinical Instructor: JEANETTE J. ROJO, RN, MAN

Evaluation
>Patient will have relief of
pain as absence of muscle
tension, absence of facial
grimace and restlessness.

NURSING CARE PLAN

Name of the Patient: Cahusay, Ellyza Mae
Date Admitted: 02/03/16
Chief Complaint: body weakness
Age: 5 y.o
Sex:
f
Civil Status: Single
Address: Washington, Northern Samar
Diet: DAT c SAP

Assessment
S:
>di siya
nakakaturog
kay masuol uraura verbalized
by the mother
O:
>yawning
>crying
>wakes up
every 2 hours

Diagnosis
Fatigue related
to sleep
deprivation
secondary to
pneumonia

Scientific Rationale
> Prostaglandin due to
inflammatory reaction
as a result from the
wound, or
microorganism may
result to transmission
of pain thereby affects
mobility, mood, rest
and concentration.
Reference: Josie
QuiambaoUdan,Mastering
Fundamentals of
Nursing 3rd edition,

Planning
>after 8 hours of
nursing
interventions the
pt will be able to:
>lessen
discomforts and
obtain adequate
rest.

Intervention
>manipulated environment such
as cleaning the surroundings
and minimizing noise.

Scientific Rationale
>to promote comfort

>encourage patient for adequate

rest periods to obtain rest and
relieve fatigue

>adequate rest periods

could prevent fatigue and
discomfort

>have patient in any

comfortable position as
tolerated

> Clients
position may aggravate
pain felt. Positioning
properly may promote
comfort and also ensure
good circulation.

> keep the bed linens dry and

wrinkle free to prevent
discomforts
>instructed to:
-consume foods that are rich in
protein, vitamins and calcium
which can be a source of energy
>refrain from caffeine, alcohol
and other stimulating substances
specially during evening
-perform diversional activities
such as listening to music to
diver attentions.
>Encourage deep breathing
exercises

>nutrition is the
fundamental
cellular integrity
and tissue repair

>caffeine has
substances that is
known to disrupt

Evaluation
>patients discomforts will lessen and
will obtain adequate rest.

sleeping patterns
>Diversional
activities will
help the client
focus on other
things rather than
the pain felt

> To facilitate
expansion of
abdomen and to
decrease pain

Name of Student Nurse: CHRISTINA EJERCITO

Clinical Instructor: JEANETTE J. ROJO, RN, MAN

NURSING CARE PLAN

Assessment
S:
>kakure danay
mag gin hawa
ini siya as
verbalized by
the mother
O:
>productive
cough noted
>difficulty in
breathing

Name of the Patient: Cahusay, Ellyza Mae

Date Admitted: 02/03/16
Chief Complaint: body weakness
Age: 5 y.o
Sex:
f
Civil Status: Single
Address: Washington, Northern Samar
Diet: DAT c SAP
Diagnosis
Scientific
Planning
Intervention
Scientific Rationale
Evaluation
Rationale
>Inflammation of >after 8 hours of
>Assess the rate and depth of
>Tachypnea, shallow respirations,
Ineffective
>Patient will
lung tissues
nursing
respirations and chest
and asymmetric chest movement
releases exudates
interventions the
movement.
are frequently present because of
Airway
display patent airway with breath sounds
which further
pt will be able
discomfort of moving chest wall
Clearance R/T
clearing; absence of dyspnea, cyanosis.
increases
to:
and/or fluid in lung.
production of
>Auscultate lung fields, noting
>Decreased airflow occurs in
increased
>Demonstrate
mucus thereby
areas of decreased or absent
areas with consolidated fluid.
production of
obstruct passage of
airflow and adventitious breath
Bronchial breath sounds can also
improved
air.
sounds:
crackles,
wheezes.
occur
in these consolidated areas.
mucus
ventilation and
Crackles, rhonchi, and wheezes
secondary to
Reference: Josie
are heard on inspiration and/or
oxygenation of
Quiambaoexpiration in response to fluid
inflammation of
tissues by ABGs
Udan,Mastering
accumulation, thick secretions,
Fundamentals of
and airway spams and
alveolar tissues.
within patients
Nursing 3rd
obstruction.
acceptable range
edition,
>Elevate head of bed, change
>Doing so would lower the
position frequently.
diaphragm and promote chest
and absence of
expansion, aeration of lung
segments, mobilization and
symptoms of
expectoration of secretions.
respiratory
>Deep breathing exercises
facilitates maximum expansion of
the lungs and smaller airways.
Coughing is a reflex and a natural
self-cleaning mechanism that
assists the cilia to maintain patent
airways. Splinting reduces chest
discomfort and an upright
position favors deeper and more
>Force fluids to at least 3000
forceful cough effort.
mL/day (unless contraindicated,
>Fluids, especially warm liquids,
as in heart failure). Offer warm,
aid in mobilization and
rather than cold, fluids.
expectoration of secretions.
Name of Student Nurse: CHRISTINA EJERCITO
Clinical Instructor: JEANETTE J. ROJO, RN, MAN
distress.

> Teach and assist patient with

proper deep-breathing exercises.
Demonstrate proper splinting of
chest and effective coughing
while in upright position.

name of drug

specific
action

generic name:

Inhibits cellwall
synthesis, of
bacterial cell
wall causing
cell death.

cefuroxime sodium
brand name:
cefuroxime axetil
classification:
second-generation
cephalosporin
route & dosage:
750mg IVTT q8h

Name of the Patient:Lutao, Miguel Date Admitted: 03/08/16

Chief Complaint: DOB, Fever
Age: 5 y.o
Sex: M Civil Status: S Address: San Roque N. Samar
Diet: DAT c SAP
contraindication
drug
adverse
specific precaution
indications
interaction
reaction
for patients
with infections
of the urinary
and lower
respiratory
tracts,

hypersensitive
cephalosporin or
penicillin

Drug-Drug:
May increased
nephrotoxicity
with
aminoglycoside
s
Increased
bleeding effects
with oral
anticoagulants

CV: phlebitis,
thrombophlebi
tis
GI:
pseudomembr
anous colitis,
nausea,
anorexia,
vomiting,
diarrhea

hypersensitive to penicillin

nursing responsibilities

Before :
>Make sure patient is not
allergic to penicillins or cephalosporins.
>assess if any hypersensitivity
to penicillin
>Observe 10Rs of medication
administration
After:
>Discontinue if hypersensitivity
reaction occurs

Skin:
maculopapular
and pain,
induration,
temperature
elevation.

Name of Student Nurse: CHRISTINA EJERCITO

Clinical Instructor: JEANETTE J. ROJO, RN, MAN

Name of the Patient:Lutao, Miguel Date Admitted: 03/08/16

Chief Complaint: DOB, Fever
Age: 5 y.o
Sex: M Civil Status: S Address: San Roque N. Samar
Diet: DAT c SAP
Name of the
drug

Specific action(s)

Indication

Contraindication(s)

Drug interaction

Adverse reaction

Specific
precaution

generic name:

Antipyretic:
Reduces fever by
acting directly on
the hypothalamic
heat-regulating
center to cause
vasodilatation and
sweating, which
helps dissipate heat.

Temporary
reduction of
fever.

Contraindicated with
allergy to
acetaminophen,

Potentiating:
barbiturates,
carbamazepine,
diflunical,
hydantoins,
isoniazid,
rifabutin,
rifampin,
sulfinpyrazone:
increased risk of
hepatotoxicity
Zidovudine:
increase risk of
granulocytopenia.

CNS:Headache,
dizziness, lethargy,
paresthesia,
GI:hepatic toxicity
and failure
GU:liver toxicity,
nephrotoxicity,
Hematologic:bone
marrow depression,
Hypersensitivity:,
rash, fever
Anaphylaxis, pain,
phlebitis

Use
cautiously
with impaired
hepatic
function and
renal failure

paracetamol
brand name:
tempra
ROUTE:
IVTT
DOSAGE:
400 mg
FREQUENCY
:
Q4h
CLASSIFICA
TION:
Analgesic(nonopioid),
Antipyretic

Analgesic: Site and

mechanism of action
unclear.

1
2

Do not exceed the recommended dosage.

Reduce dosage with hepatic impairment.
3 Avoid using multiple preparations containing
acetaminophen. Carefully check all OTC
products.
4 Discontinue drug if hypersensitivity reactions
occur.
5 Assess if patient has any contraindication to
drugs

Inhibiting:
activated
charcoal,
cholestyramine,
colestipol:
decreased
acetamininophen
absorption.
Name of Student Nurse: CHRISTINA EJERCITO

Name of the
drug

Nursing responsibilities

Clinical Instructor: JEANETTE J. ROJO, RN, MAN

Name of the Patient: Cahusay, Ellyza Mae

Date Admitted: 02/03/16
Chief Complaint: body weakness
Age: 5 y.o
Sex:
f
Civil Status: Single
Address: Washington, Northern Samar
Diet: DAT c SAP
Specific action(s)
Indication
Contraindication(s) Drug interaction
Adverse reaction
Specific
Nursing responsibilities
precaution

generic name:
paracetamol
brand name:
tempra
ROUTE:
IVTT
DOSAGE:
170 mg
FREQUENCY
:
Q4h
CLASSIFICA
TION:
Analgesic(nonopioid),
Antipyretic

Antipyretic:
Reduces fever by
acting directly on
the hypothalamic
heat-regulating
center to cause
vasodilatation and
sweating, which
helps dissipate heat.
Analgesic: Site and
mechanism of action
unclear.

Temporary
reduction of
fever.

Contraindicated with
allergy to
acetaminophen,

Potentiating:
barbiturates,
carbamazepine,
diflunical,
hydantoins,
isoniazid,
rifabutin,
rifampin,
sulfinpyrazone:
increased risk of
hepatotoxicity
Zidovudine:
increase risk of
granulocytopenia.

CNS:Headache,
dizziness, lethargy,
paresthesia,
GI:hepatic toxicity
and failure
GU:liver toxicity,
nephrotoxicity,
Hematologic:bone
marrow
depression,
Hypersensitivity:,
rash, fever
Anaphylaxis, pain,
phlebitis

Use cautiously
with impaired
hepatic function
and renal failure

1.

Do not exceed the recommended

dosage.
2. Reduce dosage with hepatic
impairment.
3. Avoid using multiple preparations
containing acetaminophen. Carefully
check all OTC products.
4. Discontinue drug if hypersensitivity
reactions occur.
5. Assess if patient has any
contraindication to drugs

Inhibiting:
activated
charcoal,
cholestyramine,
colestipol:
decreased
acetamininophen
absorption.
Name of Student Nurse: CHRISTINA EJERCITO

Clinical Instructor: JEANETTE J. ROJO, RN, MAN

Name of the Patient:Lutao, Miguel Date Admitted: 03/08/16

Chief Complaint: DOB, Fever
Age: 5 y.o
Sex: M Civil Status: S Address: San Roque N. Samar
Diet: DAT c SAP
Name of the
drug
generic name:
cetriaxone
brand name:
Rocephin
ROUTE:
IVTT
DOSAGE:
15 mg
FREQUENCY
:
OD
CLASSIFICA
TION:
cephalosporin

Specific action(s)

Ceftriaxone
is a
cephalosporin
antibiotic.
It works by
interfering
with the
formation of
the
bacteria's
cell wall so
that the wall
ruptures,

Indication
Lowers
respiratory
infections
caused by
Streptococcus
pneumonia,
Staphylococc
us aureus,
Haemophilus
influenza, E.
coli,
Enterobactera
erogenes.
Intraabdominal
infections
caused by
E.coli,Klebsi
ellapneumoni
ae

Contraindication(s)

Drug interaction

Adverse reaction

Specific
precaution

Contraindicated with
allergy to
cephalosporins

isoniazid,
rifabutin,
rifampin,

HEMATOLOGIC:
bone marrow
depression

dec. WBC,
platelets, Hct
LOCAL: pain,
inflammation of
IVSite
OTHER:
Super infections,
disulfiram-like
reaction with
alcohol

Use
cautiously
with impaired
hepatic
function and
renal failure

Nursing responsibilities
>perform skin testing prior to giving meds
>Do not mix ceftriaxone with other antimicrobial
drug
DURING:
>Use a separate syringe when giving this drug
>Have Vitamin K available in case
of hypoprothrombinemia occurs AFTER:
>Discontinue if hypersensitivity occurs
>Monitor Blood levels in patients taking this drug

resulting in
the death of
the bacteria.

Name of Student Nurse: CHRISTINA EJERCITO

Clinical Instructor: JEANETTE J. ROJO, RN, MAN

NURSING CARE PLAN

Name of the Patient:Lutao, Miguel Date Admitted: 03/08/16
Chief Complaint: DOB, Fever
Age: 5 y.o
Sex: M Civil Status: S Address: San Roque N. Samar
Diet: DAT c SAP
Assessment
S:
>gin kukure
siya mg
ginhawa as
verbalized by
the mother.
O:
>productive
cough noted
>cough for 2
weeks

Diagnosis
Impaired Gas
Exchange r/t
Alveolarcapillary
membrane
changes
Secondary to
pneumonia.

Scientific Rationale
> Pneumonia is an
infection in one or
both lung. It can be
caused by fungi,
bacteria, or viruses.
Pneumonia causes
inflammation in
your lungs air sacs,
or alveoli. The
alveoli fill with
fluid or pus, in
which there is
ventilationperfusion mismatch.
Reference: Josie
QuiambaoUdan,Mastering
Fundamentals of
Nursing 3rd edition,

Planning
>after 8 hours of nursing
interventions the pt will
be able to:
>Display patent airway
with breath sounds
clearing; absence of
dyspnea, cyanosis.

Intervention
>Assess respiratory rate,
depth, and ease.
>Observe color of skin,
mucous membranes, and
nailbeds, noting presence of
peripheral cyanosis (nail
beds) or central cyanosis
(circumoral)
>Monitor body temperature,
as indicated. Assist with
comfort measures to reduce
fever and chills: addition or
removal of bedcovers,
comfortable room
temperature, tepid or cool
water sponge bath.
>Elevate head and
encourage frequent position
changes, deep breathing,
and effective coughing.
>Observe for deterioration
in condition, noting
hypotension, copious
amounts of bloody sputum,
pallor, cyanosis, change in
LOC, severe dyspnea, and
restlessness.

Scientific Rationale
>Manifestations of
respiratory distress are
dependent on/and
indicative of the degree
of lung involvement and
underlying general health
status.
>Cyanosis of nail beds
may represent
vasoconstriction or the
bodys response to
fever/chills; however,
cyanosis of earlobes,
mucous membranes, and
skin around the mouth
(warm membranes) is
indicative of systemic
hypoxemia.
>High fever (common in
bacterial pneumonia and
influenza) greatly
increases metabolic
demands and oxygen
consumption and alters
cellular oxygenation.

Evaluation
>patient will display patent airway
with breath sounds clearing; absence
of dyspnea, cyanosis.

>These measures promote

maximum chest expansion,
mobilize secretions and
improve ventilation.

Name of Student Nurse: CHRISTINA EJERCITO

>Shock and pulmonary

edema are the most common
causes of death in
pneumonia and require
immediate medical
intervention.
Clinical Instructor: JEANETTE J. ROJO, RN, MAN

name of drug

specific
action

generic name:
tranexamic acid
brand name:
Hemostan,
Fibrinon,
Cyklokapron,
Lysteda, Transamin
classification:
antifibrinolytic
route & dosage:

Tranexamic
acid is a
synthetic
derivative of
the amino
acid lysine. It
exerts its
antifibrinolyti
c effect
through the
reversible
blockade of
lysinebinding sites
on
plasminogen
molecules.
Antifibrinolytic
drug inhibits
endometrial
plasminogen
activator and
thus prevents
fibrinolysis
and the
breakdown of
blood clots.
The

Name of the Patient: Vargas, Marry Ann

Date Admitted: 01/27/16
Chief Complaint:
Age:
Sex: F
Civil Status: S Address:
Diet: DAT
Ward:FMW/S
contraindicatio
drug
adverse
specific
nursing responsibilities
indications
n
interaction
reaction
precaution
epistaxis,
hemoptysis,
hematuria, peptic
ulcer with
hemorrhage and
blood dyscrasias
with hemorrhage

>Allergic
reaction to the
drug or
hypersensitivity
>Presence of
blood clots (eg,
in the leg, lung,
eye, brain),
have a history
of blood clots,
or are at risk for
blood clot.

Drug-Drug:

CV: phlebitis,
thrombophlebi
tis
GI:
pseudomembr
anous colitis,
nausea,
anorexia,
vomiting,
diarrhea
Skin:
maculopapular
and pain,
induration,
temperature
elevation.

1.
>Pregnanc

in bleeding

y.

pattern should

Tranexamic

be immediately

acid

reported to the

crosses the
placenta.>
Lactation.
Tranexamic
acid is
distributed
into breast
milk;
concentrati
ons reach
approximat

Unusual change

physician.
2.

For women who

are taking
Tranexamic
acid to control
heavy bleeding,
the medication
should only be
taken during the
menstrual
period.

plasminogenplasmin
enzyme
system is
known to
cause
coagulation
defects
through lytic
activity on
fibrinogen,
fibrin and
other clotting
factors. By
inhibiting the
action of
plasmin
(finronolysin)
the antifibrinolytic
agents reduce
excessive
breakdown of
fibrin and
effect
physiological
hemostasis.
Name of Student Nurse: CHRISTINA EJERCITO

ely 1% of

3.

The medication

the

can be taken

maternal

with or without

plasma

meals.

concentrati
on.

4.

Swallow
Tranexamic
Acid whole

with plenty of
liquids. Do not
break, crush, or
chew before
swallowing.

Clinical Instructor: CRISTINA MARIE M. MANZANO,RN,RM,MAN

NURSING CARE PLAN

name of drug

specific
action

generic name:
Ranitidine
Hydrochloride
brand name:
Zantac
classification:
antisecretory (h2receptor
antagonist)
route & dosage:

>Ranitidine
blocks
histamine
H2-receptors
in the
stomach and
prevents
histaminemediated
gastric acid
secretion. It
does not
affect pepsin
secretion,
pentagastrinstimulated
factor
secretion or
serum
gastrin..

Name of the Patient: Regine Rizo Date Admitted: 01/24/16

Chief Complaint: hypogastric pain, chills
Age: 15 Sex: F
Civil Status: S Address:Bobon Northern Samar
Diet: SD
Ward:FMW/S
contraindication
drug
adverse
specific
nursing responsibilities
indications
interaction
reaction
precaution

>Short-term
treatment of
active
duodenal ulcer
>Maintenance
therapy for
duodenal ulcer

hypersensitive
cephalosporin or
penicillin

Drug-Drug:
May increased
nephrotoxicity
with
aminoglycoside
s
Increased
bleeding effects
with oral
anticoagulants

CV: phlebitis,
thrombophlebi
tis
GI:
pseudomembr
anous colitis,
nausea,
anorexia,
vomiting,
diarrhea

at reduced
dosage

Skin:
maculopapular
and pain,
induration,
temperature
elevation.

hypersensit
ive to
penicillin

>Be alert for early signs

of hepatotoxicity (though
low and thought to be a
hypersensitivity
reaction): jaundice (dark
urine, pruritus, yellow
sclera and skin), elevated
transaminases
(especially ALT) and
LDH.
>Long-term therapy may
lead to vitamin
B12 deficiency.
>Note: Long duration of
action provides ulcer
pain relief that is
maintained through the
night as well as the day.

Name of Student Nurse: CHRISTINA EJERCITO

Clinical Instructor: CRISTINA MARIE M. MANZANO,RN,RM,MAN

Age:
name of drug

specific
action

generic name:
Clonidine
brand name:
catapres
classification:

>Clonidine
hydrochloride
(Catapres) is
an
antihypertens
ive drug
that stimulate
s CNS
alpha2adrenergic
receptors,
inhibits
sympathetic
cardioacceler
ator and
vasoconstrict
or centers,
and decreases
sympathetic
outflow from
the CNS.

>Antihypertensi
ve
>Sympatholytic (
centrally acting)
Central analgesic
route & dosage:

Name of the Patient:

Sex: M
contraindication

indications
>Contraindicated with
>Hypertension
, used alone or
as part of
combination
therapy

hypersensitivity
to clonidine or any
adhesive layer
components of
the transdermal system.

Civil Status: M
drug
interaction

Date Admitted: 01/27/16

Chief Complaint:
Address:
Diet: LSLF
Ward:MMW/S
adverse
specific
nursing responsibilities
reaction
precaution

Drug-Drug:
Increased
bleeding effects
with oral
anticoagulants

CNS: Drowsin
ess, sedation,
dizziness, head
ache, fatigue
that tend to
diminish
within 46 wk,
dreams,
nightmares,
insomnia,
hallucinations,
delirium,
nervousness,
restlessness,
anxiety,
depression,
retinal

Use

1.

hypersensitivity to clonidine or

cautiously

adhesive layer components of

with severe

the transdermal system; severe

coronary

coronary insufficiency, recent

insufficiency
, recent
MI, cerebrov

MI, cerebrovascular disease;

chronic renal failure; lactation,
pregnancy

ascular disea
se; chronic
renal failure;
pregnancy,
lactation.

2.

discontinue abruptly;

discontinue therapy by reducing

the dosage gradually over 24
days to avoid rebound
hypertension, tachycardia,
flushing, nausea, vomiting,
cardiac arrhythmias

degeneration

3.Monitor BP carefully when

>CV: CHF,

discontinuing clonidine;

orthostatic

hypertension usually returns within

hypotension,

48 hr.

palpitations,

4. may experience these side effects:

tachycardia, br

Drowsiness, dizziness, lightheadedness, headache, weakness

adycardia, Ray

5. Report urinary retention, changes

nauds phenom

in vision, blanching of fingers, rash.

enon, ECG
abnormalities
manifested
as Wenckebac
h period or
ventricular trig
emin

Name of Student Nurse: CHRISTINA EJERCITO

Clinical Instructor: CRISTINA MARIE M. MANZANO,RN,RM,MAN

NURSING CARE PLAN

Age:
name of drug

specific
action

indications

generic name:
mefenamic acid
brand name:
Ponstel
classification:
analgesic
NSAID
route & dosage:

> Inhibits
synthesis of
prostaglandin

>Mefenamic
acid is used for
the short-term
treatment of
mild to
moderate pain
from various
conditions.

Name of the Patient:

Sex: M
contraindication
>Hypersensitivity to
drug;GI inflammation,or
ulceration.Safety in
children <14 y, during
pregnancy (category C),
or lactation is not
established.

Civil Status: M
drug
interaction
Drug-Drug:

Date Admitted: 01/27/16

Address:
adverse
specific
reaction
precaution
CNS:Drowsin
ess, insomnia,
dizziness,
nervousness,
confusion,
headache.
GI:Severe
diarrhea,
ulceration,

>History of
kidney or
liver
disease;blood
dyscrasias;ast
hma;diabetes
mellitus;hype
rsensitivity to
aspirin. Long
term use
increases risk
of serious
adverse
events.

Chief Complaint:
Diet: LSLF
Ward:MMW/S
nursing responsibilities

1. Assess patients who develop

severe diarrhea and vomiting for
dehydration and electrolyte
imbalance.
2. Discontinue drug promptly if
diarrhea, dark stools, hematemesis,
ecchymoses, epistaxis, or rash occur
and do not use again. Contact
physician.

and bleeding;

3. Give with meals, food, or milk to

nausea,

minimize GI adverse effects.

vomiting,

4. Do not use drug for a period

abdominal

exceeding 1 wk (manufacturers

cramps,

warning).

flatus,
constipation,
hepatic
toxicity.
Hematologic:
Prolonged
prothrombin
time, severe

autoimmune
hemolytic
anemia (longterm use),
leukopenia,
eosinophilia,
agranulocytos
is,
thrombocytop
enic purpura,
megaloblastic
anemia,
pancytopenia,
bone marrow
hypoplasia.

Name of Student Nurse: CHRISTINA EJERCITO

Clinical Instructor: CRISTINA MARIE M. MANZANO,RN,RM,MAN

Assessment
S: masuol ak ulo
ngan kalipong
O:
>180/120mmHg
>pain at occipital
region radiating to
the neck in a scale
of 7 out of 10

Diagnosis

Increased cerebral

Planning
After a series of
nursing
interventions:

vascular pressure

> Report

secondary to

pain/discomfort is

hypertension

relieved/controlled.

> acute pain r/t

Scientific Rationale

>Verbalize methods
that provide relief

Intervention
> Note clients attitude toward pain
and use of pain medications,
including any history of substance
abuse.
> Determine specifics of pain
(location, characteristics, intensity
(010 scale), onset and duration).
Note nonverbal cues.
> Encourage and maintain bed rest
during acute phase.
> Provide or recommend
nonpharmacological measures for
relief of headache such as cool
cloth to forehead; back and neck
rubs; quiet, dimly lit room;
relaxation techniques (guided
imagery, distraction); and
diversional activities.
> Eliminate or minimize
vasoconstricting activities that may
aggravate headache (straining at
stool, prolonged coughing, bending
over).
> Assist patient with ambulation as
needed.

Scientific Rationale
> To assess etiology or
precipitating contributory
factors.
> Facilitates diagnosis of
problem and initiation of
appropriate therapy.
Helpful in evaluating
effectiveness of therapy.
> Minimizes stimulation
and promotes relaxation.
> Measures that reduce
cerebral vascular pressure
and that slow or block
sympathetic response are
effective in relieving
headache and associated
complications.
> Activities that increase
vasoconstriction
accentuate the headache in
the presence of increased
cerebral vascular pressure.
> Dizziness and blurred
vision frequently are
associated with vascular
headache. Patient may
also experience episodes
of postural hypotension,
causing weakness when
ambulating.
Source:
Medical-Surgical Nursing
,7
th
ed. by Black, Joyce M.and
Jane Hokanson Hawks; p.
443

Evaluation
>patient will
demonstrate relief of
pain in a scale of 2 from
7

Name of Student Nurse: CHRISTINA EJERCITO

Clinical Instructor: CRISTINA MARIE M. MANZANO,RN,RM,MAN