NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

S- MASAKIT PA.

>PAINSCALE 6 -10

>PERIORBITALHEMATOMA NOTEON LEFT EYE

>POSITIVETENDERNESSNOTED

>GUARDINGBEHAVIOR

>ABLE TOPERFORM ADLWITH MINIMAL

 ASSISTANCE

MODERATEPAIN RELATEDTO ACQUIREDPHYSICALINJURY

 AFTER 5 HOURS OFNURSINGINTERVENTION THEPAIN WILLDECREASE FROMMODERATE TO MILD 

REPOSITIONED COMFORTABLY

BEDSIDE CARE DONE

 APPLIED COLD COMPRESS

ENCOURAGED TO DO DIVERTIONAL ACTIVITIES

EMPHASIZED THE IMPORTANCE OF REST AND SLEEP

EAT FOODS RICH IN CHON, CHO, VIT C, IRON AND CALCIUM

 ADVISED TO

TO EVALUATE AND REASSESS THEEFFECTIVENESS OF INTERVENTIONSGIVEN

INFECTION CAN AGGRAVATE THECONDITION OF THE PATIENT, INFECTIONCONTROL IS A VITAL NURSINGRESPONSIBILTY

TO PREVENT INFECTION,REGURGITATION AND LEAKAGE OF THEILEOSTOMY BAG

TO TRAIN THE DIGESTIVE FUNCTIONESPECIALLY THE PERISTALSIS OF THEPATIENT

TO PREVENT GROSS INDIGESTION OFTHE FOODS SERVED

TO HELP THE PATIENTS DIGESTIVETRACT COPE UP WITH THE SURGICALTRAUMA

NUTRITIONAL SUPPORT TO OPTIMIZETHE AFFECTED ORGANS TO COPE UP

PHYSIOLOGICAL SUPPORT TO OPTIMIZETHE AFFECTED ORGANS TO COPE UP

INFECTION CONTROL

GOAL METPAINSCALE 3-10 

 

 

DOCTORS

ORDER

DRUG

CLASSIFICA

TION

INDICATION CONTRAINDICA

TIONSSIDE EFFECTS NURSING

CONSIDERATION

CIPROFLOXACIN500MG 1 CAPBID

Chemical class:FluoroquinolonederivativeTherapeuticclass: Antibiotic

To treat infectious diarrhea caused bysusceptible organisms (includingCampylobacter jejuni, Citrobacterdiversus, Citrobacter freundii, Enterobactercloacae, Escherichia coli,Haemophilus influenzae, Haemophilusparainfluenzae, Klebsiella pneumoniae,Morganella morganii, Neisseriagonorrhoeae,Proteus mirabilis, Proteus vulgaris,Providencia rettgeri, Providenciastuartii, Pseudomonas aeruginosa,Serratia marcescens, Shigella flexneri,and Shigella sonnei) and gram-positiveorganisms (including Enterococcus faecalis,Staphylococcus aureus,Staphylococcus epidermidis, and

Streptococcus pneumoniae) 

Hypersensitivityto ciprofloxacin,quinolones,or theircomponents 

CNS: Agitation, anxiety, cerebral thrombosis,

confusion, dizziness, headache, insomnia,light-headedness, migraine, nightmares,

 paranoia, peripheral neuropathy,restlessness, seizures, syncope, toxic

 psychosisCV: Angina, atrial flutter, cardiopulmonaryarrest, cardiovascular collapse, hypertension,

MI, orthostatic hypotension, palpitations,

 phlebitis, tachycardia, torsades de pointes, vasculitis, ventricular ectopyEENT: Oral candidiasis

GI: Abdominal pain, constipation, diarrhea,

elevated liver function test results, flatulence,GI bleeding, hepatic failure or necrosis,

hepatitis, indigestion, intestinal perforation,

 jaundice, nausea, pancreatitis, pseudomembranous

colitis, vomitingGU: Crystalluria, hematuria, increased

serum creatinine level, interstitial nephritis,nephrotoxicity, renal calculi, renal failure,

urine retention, vaginal candidiasisHEME: Agranulocytosis, bone marrowdepression, hemolytic anemia,

lymphadenopathy, pancytopenia

MS: Tendinitis, tendon rupture

SKIN: Erythema multiforme, exfoliative

dermatitis, photosensitivity, rash, Stevens-

Johnson syndrome, toxic epidermalnecrolysis,

urticariaRESP: Bronchospasm, pulmonary

embolism, respiratory arrest

Other: Acidosis, anaphylaxis, angioedema,serum sicknesslike reaction

• Urge patient to complete the prescribed course of therapy, even if he feels better

 before it’s finished. • Tell patient not to take drug with dairy 

 products or calcium-fortified juices alone.

• Advise patient to take ciprofloxacin 

2 hours before or 6 hours after a ntacids,

iron supplements, or multivitamins that

contain iron or zinc. Tell him to shake oral

suspension for 15 seconds, not to chew

microcapsules, and not to split, crush, or

chew E.R. tablets.• Encourage patient to drink ple nty of fluids 

during therapy to help prevent crystalluria.

• Urge patient to avoid caffeinated products 

 because caffeine may accumulate in the

 body during ciprofloxacin therapy andcause excessive stimulation.

• Caution patient to avoid excessive exposure 

to sunlight or artificial ultravioletlight because severe sunburn may result.

Tell patient to notify prescriber if sunburn

develops; drug will need to be stopped.

• Urge patient to avoid hazardous activities

until CNS effects of drug are known.

• Advise patient to notify prescriber about 

changes in limb sensation or movement

and about inflammation, pain, or swellingover a joint. Urge patient to rest the affected

limb at the first sign of discomfort.

• Tell patient to stop taking drug and to 

notify prescriber at first sign of rash or

other hypersensitivity reaction.

• Urge patient to report watery, bloody stools to prescriber immediately, even up

to 2 months after drug therapy has ended..

 

 

DOCTORS

ORDER

DRUG

CLASSIFICATION

INDICATION CONTRAINDICA

TIONS

SIDE EFFECTS NURSING

CONSIDERATION

CELECOXIB200MG 1 CAPBID

Anti-inflammatory, antirheumatic 

localizedinflammation 

 Allergic reaction (suchas anaphylaxis orangioedema) to aspirin,other NSAIDs, orsulfonamide derivativesor history ofaspirin-induced nasalpolyps withbronchospasm;hypersensitivity tocelecoxib orits components;treatment ofperioperativepain after coronaryartery bypass graftsurgery 

CNS: Asceptic meningitis, cerebral hemorrhage,

depression, dizziness, fever,

headache, insomnia, ischemic stroke,stroke, suicidal ideation, syncope, transient

ischemic attacks, vertigo

CV: Aortic valve incompetence, chest pain,

congestive heart failure, deep vein thrombosis,

fluid retention, hypertension, MI, palpitations, peripheral edema or gangrene,

sinus bradycardia, tachycardia, thrombosis,

unstable angina, vasculitis, ventricular fibrillation,

ventricular hypertrophy

EENT: Conjunctival hemorrhage, deafness,

labyrinthitis, nasopharyngitis, pharyngitis,

rhinitis, sinusitis, vitreous floaters

ENDO: Hyperglycemia, hypoglycemia

GI: Abdominal pain, diarrhea, elevated liver

function test results, esophageal perforation,flatulence, GI bleeding or ulceration,

hepatic failure, ileus, indigestion, jaundice,

nausea, pancreatitis, perforation of stomach

or intestine, vomiting

GU: Acute renal failure, interstitial nephritis,

ovarian cyst, proteinuria, UTI, urinary

incontinence

HEME: Agranulocytosis, aplastic anemia,

decreased hematocrit and hemoglobin,

leukopenia, pancytopenia, prolonged APTT,

thrombocytopenia

MS: Arthralgia, back pain, elevated serum

CK level, epicondylitis, tendon rupture

RESP: Bronchospasm, cough, dyspnea,

 pneumonia, pulmonary embolism, upperrespiratory tract infection

SKIN: Erythema multiforme, exfoliative

dermatitis, phototoxicity, rash, Stevens-

Johnson syndrome, toxic epidermal necrolysis,

urticaria

Monitor patient closely forthrombotic events, including MIandstroke, because use (especiallylong-termuse) of NSAIDs such ascelecoxib increasesthe risk.WARNING In patient who hasbone marrowsuppression or is receivingantineoplastictherapy, monitor laboratoryresults(including WBC) and assess forinfectionbecause celecoxib’ anti-inflammatory andantipyretic actions may masksigns andsymptoms, such as fever andpain. 

DOCTORS

ORDER

DRUG

CLASSIFICATION

INDICATION CONTRAINDICATIONS SIDE EFFECTS NURSING

CONSIDERATION

 

 

METOCLOPRAMIDE1 AMP IV Q8 FORN/V

Therapeutic class: Antiemetic, upper GIstimulant

chemotherapy-induced vomiting 

Concurrent use ofbutyrophenones, phenothiazines,

or other drugs that may causeextrapyramidal reactions; GI

hemorrhage,mechanical obstruction, or

perforation;hypersensitivity to

metoclopramide or itscomponents;

pheochromocytoma; seizuredisorders 

CNS: Agitation, anxiety,depression, dizziness,

drowsiness,extrapyramidal reactions

(motor restlessness, parkinsonism, tardive

dyskinesia), fatigue,headache, insomnia,

irritability, lassitude,

neuroleptic malignantsyndrome, panic reaction,

restlessnessCV: AV block, fluid

retention, heart failure,hypertension, hypotension,

supraventriculartachycardia

EENT: Dry mouthENDO: Galactorrhea,

gynecomastiaGI: Constipation, diarrhea,

nauseaGU: Menstrual

irregularitiesHEME: Agranulocytosis

SKIN: RashOther: Restless leg

syndrome

• 

•• Advise against activities

that require alertnessfor about 2 hours after eachdose.• Urge patient to avoid alcohol

and CNSdepressants while takingmetoclopramide.They may increase CNSdepression.• Tell patient to immediatelyreport involuntarymovements of face, eyes,tongue, orhands, including lip smacking,chewing,puckering of mouth, frowning,scowling,sticking out tongue, blinking,moving eyes,or shaking arms and legs.• Explain that stoppingmetoclopramidemay cause withdrawalsymptoms thatinclude dizziness,nervousness, andheadache.