Generic Brand Classifi Mechanism Indication Contra - Adverse Effect Dosage How Nursing

Name Name cation of Action indication Supplied Responsibility

O P O Cause potent Induction of • Cephalopelvic • Tachycardia, 10 units 1 ml ✔ Assess baseline

x i x and selective labor; disproportion premature of ampule vital signs, blood
y t y stimulation of promotion previous uterine ventricular oxytocin pressure, and fetal
t o t uterine and of uterine surgery. contractions, heart rate.
o c o mammary contractions • Unengaged fetal hypotension. ✔ Determine
c i c gland smooth postpartum; head, • Nausea and frequency, duration
i n i muscle. nasally to unfavorable fetal vomiting, and strength of
n c (Karch, A., stimulate position or coma, contractions every
s 2007; pp. milk “let presentation. seizures, 15 mins.
1235 – 1237) down” in • Fetal distress intracranial ✔ Notify the
lactating without hemorrhage. physician if
women. imminent contractions are
delivery. lasting longer than
• Placenta previa 1 min; they are
and cord occurring more
presentation. 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.
✔
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Generic Brand Classif Mechanism Indication Contraindication Adverse Effect Dosage How Nursing Responsibility
Name Name ication of Action Supplied

M E A May 1. Treatment of • Parenteral CNS: depressed 4 g Injection: • Monitor the client

a p n decrease preterm administration reflex. deep 50% closely during the
g s t acetylcholin labor. contraindication Drowsiness, IM into leading dose and
n o i e released 2. Prevention in patient with flaccid each when the rate is
e m c by nerve of seizures heart block or paralysis, buttock greater than 2g/h
s o impulse but in client with myocardial hypothermia. because of side this
i S n its preeclampsia damage. CV: flushing drug are dose related.
u a v anticonvuls and • Contraindicated hypotension, • Obtain baseline
m l u ant eclampsia. patient with bradycardia, assessment including
t l mechanism toxemia during circulatory respiratory neurologic
S s s is unknown. hours preceding collapse, and renal system as
u a (Karch, A., delivery. depressed well as fetal heart rate
l n 2007; cardiac and contractions.
f t pp.442 – function. • Auscultate breath
a 443) EENT: diplopia sounds, monitor deep
t Metabolic: tendon reflexes, and
e hypocalcemia. assess LOC every
Respiratory: hour.
respiratory • Report intake and
paralysis output less than 25
Skin: ml/h to the physician
diaphoresis immediately.
• Know that if
excessive magnesium
is administered, it can
be counteracted by IV
calcium.

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Generic Brand Classif Mechanism Indication Contraindication Adverse Effect Dosage How Nursing Responsibility
Name Name ication of Action Supplied

S S A Inhibits Motion • Contraindicated in CNS: 0.4 mg Injection: • Raise the side rails as
c c n muscarinic sickness, patient with disorientation, IVTT 0.4 mg, a precaution because
o o t actions of decreases glaucoma, restlessness, and 1ml some patients become
p p i acetylcholine secretions, obstructive irritability, temporarily excited or
o o c on obstetric uropathy, dizziness, disoriented and some
l l h autonomic amnesia, obstructive drowsiness, develop amnesia or
a a o effectors relief of disease of GI delirium become drowsy.
m m l innervate by urinary tract, asthma, impaired Reorient patient as
i i i past problems, chronic memory. needed.
n n n ganglionic adjunctive pulmonary CV: • Tolerance may
e e e cholinergic for ulcer, disease, paradoxical develop when therapy
r neurons. pupil myasthenia gravis, bradycardia, is prolonged.
H H g May affect dilation. paralytic ileus, palpitations, • Atropine toxicity may
y y i neural intestinal atony, tachycardia, cause dose related
d d c pathways unstable CV status flushing. adverse reactions.
r r originating in in acute EENT: dilated Individual tolerances
o o inner ear to hemorrhage, pupils, blurred varies greatly.
b b inhibit tachycardia from vision, • Warn the patient to
r r nausea and cardiac increased avoid activities that
o o vomiting. insufficiency or intraocular require alertness until
m m (Karch, A., toxic megacolon. pressure. CNS effects of drug
i i 2007; 596 – • Contraindicated in GI: are known.
d d 598) patient constipation, • Advise patient to take
e e hypersensitivity to dry mouth, sips of water, suck on
belladonna or epigastric ice chips or sugarless
Injection barbiturates. distress, nausea, hard candy, or chew
vomiting. sugarless gum if dry
mouth occurs.
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 CUES / EVIDENCE NURSING DIAGNOSIS GOAL AND NURSING ACTION RATIONALE EVALUATION
/ SCIENTIFIC BASIS OUTCOME
CRITERIA
Independent
Subjective: Decreased cardiac output After 8 hours of • Monitor blood ➢ Assessment The goal was
“ Taas akong BP” as related to decrease venous nursing intervention pressure every 30 provides partially met
return as evidenced by the client will be able min. ongoing either a short
verbalized by the patient.
variation of blood to maintain the blood information goal was
pressure. pressure within normal about achieved but the
Objective: range. physiologic long term goal
Scientific Basis: changes. was not of the
➢ received patient awake
Specifically:
side - lying in bed. The vascular spasms may (Luxner, K., desired outcome
1. display
2005; pp. 51 was partially
be caused by increased
➢ hooked with D5LR 1L + cardiac output has injures
hemodynamic • Provide calm, achieved.
10 u of oxytocin infusing the endothelial cells of the stability. restful ➢ Help reduced
well @ 30 gtts/min. @ arteries and the action of surroundings, sympathetic
2. verbalize
left arm. minimize stimulation
prostaglandins. With PIH, knowledge of the
environmental and promotes
➢ Edema on the lower this reduced disease process,
activity or noise. relaxation.
extremities. responsiveness to blood individual risk
pressure changes appears factor. (Gulanik, M.,
➢ with the following vital to be lost. Vasoconcritions et. al. 2006;
signs: 3. participate in
oocurs and blood pressure pp. 55)
activities that
Temp: 36.7*C increases dramatically. reduce cardiac • Promote bed rest in ➢ Increased
(Pilliteri, A.,2003; pp. workload. left lateral renal and
PP: 85 bpm
404) recumbent uterine blood
RR: 21 cpm position. flow
BP: 140/90 mmHg promoting
diuresis and
reducing
blood
pressure.
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 CUES / EVIDENCE NURSING DIAGNOSIS GOAL AND NURSING ACTION RATIONALE EVALUATION
/ SCIENTIFIC BASIS OUTCOME
CRITERIA
➢ variation of blood (Luxner, K.,
pressure as follows: 2005; pp. 50)
7:00 pm: 150/100 mmHg ➢ Reduces
• Maintain activity
7:30 pm: 150/100 mmHg physical
restriction.
8:00 pm: 150/100 mmHg stress and
8:30 pm: 150/100 mmHg tension that
9:00 pm: 140/90 mmHg affect blood
9:30 pm: 150/100 mmHg pressure.
10:00 pm:140/90 mmHg (Gulanik, M.,
et. al. 2006;
11:00 pm:140/90 mmHg
pp. 35)
11:30 pm:140/90 mmHg
• Encourage ➢ To promotes
12:00 am:140/90 mmHg adequate rest relaxation.
12:30 am:140/90 mmHg periods. (Doeges M.,
1:00 am:130/100 mmHg 2002; pp. 123)

1:30 am:130/100 mmHg

• Instruct in ➢ To promotes
relaxation relaxation
techniques such a and comfort.
deep breathing and
(Gulanik, M.,
and guided
et. al. 2006;
imagery.
pp. 55)

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 CUES / EVIDENCE NURSING GOAL AND NURSING ACTION RATIONALE EVALUATION
DIAGNOSIS / OUTCOME
SCIENTIFIC BASIS CRITERIA

Subjective: Ineffective tissue After 8 hours of Independent The goal was

“ Labad kayo ang akong ulo perfusion: Cerebral nursing intervention partially met
ug naiin akong panan-aw” as related to vasospasm as the client will be either a short
verbalized by the patient. evidence by severe deny any deny • Monitor the vital ➢ Assessment goal was
headache and blurred headache and visual sign every 30 mins. provides ongoing achieved but the
vision. disturbance and information about long term goal
Objective: .
return in the normal physiologic was not of the
➢ received patient awake side state. changes. desired outcome
- lying in bed. Scientific Basis:
Specifically: (Luxner, K., was partially
➢ hooked with D5LR 1L + 10 Arteriolar vasospasm 2005; pp. 51) achieved.
u of oxytocin infusing well and decreased blood 1. report the pain if
it is relief. Provide quite and ➢ To minimize
@ 30 gtts/min. @ left arm flow to the retina lead •
calm environment. external stimuli
to visual symptoms 2. verbalized the
➢ grimaced face environment and
such as scotomata method that decrease CNS
➢ irritability (blind spots) and provide relief. stimuli.
extremities weakness. blurring. The same
➢ 3. follow the non
pathologic condition (Luxner, K.,
changes in pupillary leads to cerebral edema pharmaceutical
➢ 2005; pp. 51)
reaction regime being
and hemorrhages, as To avoid use
provided. ➢
➢ Edema on the lower well as to increased • Promote bed rest in uterine pressure
extremities. central nervous system left lateral on vena cava and
irritability, which recumbent prevent supine
manifests as headache. position. hypotension.
Hyperflexia and
positive ankle clonus. (Luxner, K.,
2005; pp. 51)
(Lowdermilk, D.L., et.
al., 2004; pp. 843)
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 CUES / EVIDENCE NURSING GOAL AND NURSING ACTION RATIONALE EVALUATION
DIAGNOSIS / OUTCOME
SCIENTIFIC BASIS CRITERIA
➢ with the following vital • Assess for altered ➢ Assess
signs: level of information about
Temp: 36.7*C consciousness. neurologic
perfusion and
PP: 85 bpm
irritation.
RR: 21 cpm
(Luxner, K.,
BP: 140/90 mmHg 2005; pp. 51)
• Provide non ➢ Minimize
pharmaceutical stimulation and
measures. promote
relaxation reduce
vascular pressure
and slow
sympathetic
response are
affected in
relieving
headache and
dizziness.
(Doeges M.,
2002; pp. 516)
• Maintain safety by ➢ To prevent from
providing side injury.
rails. (Luxner, K.,
2005; pp. 51)

36
CUES / EVIDENCE NURSING GOAL AND NURSING ACTION RATIONALE EVALUATION
DIAGNOSIS / OUTCOME
SCIENTIFIC BASIS CRITERIA

Subjective: Deficient fluid volume After 8 hours of Independent The goal was partially
“ Nanghupong akong related to fluid shift tonursing intervention met either a short goal
tiil” as verbalized by extravascular space the client will be able • Position the patient ➢ Increased renal and was achieved but the
the patient. secondary to decrease to exhibit edema. in left lateral uterine blood flow long term goal was
plasma protein and recumbent promoting diuresis
Specifically: not of the desired
colloid osmotic position. Maintain and reducing blood outcome was partially
Objective: presure. 1. Maintain an strict bed rest. pressure and achieved.
intravascular fluid uteroplacental
➢ received patient
Scientific Basis: volume as perfusion.
awake side - lying
Increased tubular evidenced by good
in bed. (Luxner, K., 2005;
reabsorption of skin tugor.
hooked with D5LR pp. 50)
➢ sodium retains fluid, 2. Verbalize the
1L + 10 u of edema results. Edema To reduce the
understanding of • Provide dim light ➢
oxytocin infusing is further increased environment. external stimuli
condition and
well @ 30 gtts/min. because as more environment.
prognosis and its
@ left arm proteins lost, the potential (Gulanik, M., et. al.
➢ Edema on the osmotic pressure of complications. pp. 35)
lower extremities. the circulating blood
falls and fluid diffuses 3. Demonstrate the • Maintain strict ➢ Reduces physical
➢ fair skin tugor from the circulatory behavior to activity. stress and tension
➢ warm system into the denser improve or that affect blood
intestitial space to maintain the pressure.
➢ grimaced face equalize the pressure. circulation. (Gulanik, M., et. al.
➢ irritability (Pilliteri, A.,2003; pp. pp. 35)
405)
➢ extremities
weakness.
37
CUES / EVIDENCE NURSING GOAL AND NURSING ACTION RATIONALE EVALUATION
DIAGNOSIS / OUTCOME
SCIENTIFIC BASIS CRITERIA
➢ hematocrit level of • Implement dietary ➢ Enhances
49.5% fat and cholesterol circulation and
➢ decrease urine restrictions and low prevent any
output. sodium as complications.
indicated.
➢ with the following (Gulanik, M., et. al.
vital signs: pp. 35)
Temp: 36.7*C • Monitor the vital ➢ Provide ongoing
signs and record. information about
PP: 85 bpm
physiologic
RR: 21 cpm changes.
BP: 140/90 mmHg (Luxner, K., 2005;
pp. 51)

38