care plan and drugs

8/6/2019 Care Plan and Drugs

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MEDICATIONS

DRUG DOSAGE ROUTE FREQUENCY ACTION SIDE-EFFECTSInj. Cefriaxone SB 1 gm IV Q8h 3

rdgeneration

cephalosporin;

Antibacterial

Superinfection,anaphylaxis,

diarrhea, localreactions, blood

dyscrasis, rashes,pruritis.

Inj. Divon

(Diclofenac)

IV NSAID GI disturbances,

headache, dizziness,rash, abnormality

in kidney function,local irritation.

Inj. Rantac 50 mg IV BD H2-receptor

antagonist

Headache,

dizziness,thrombocytopenia,

leucopaenia,confusion,

impotence,somnolence,

vertigo.

Inj. Amikacin 500 mg IV BD Antibacterial Dizziness, ARF,acute tubular

necrosis, electrolyteimbalance, purpura,

nausea, vomiting.


2/8

ASSESSMEST NURSINGDIAGNOSIS

OBJECTIVES INTERVENTIONS RATIONALE IMPLEMENTATION

EVALUATION

SUBJECTIVEDATA

I am feelingsevere pain on

the surgicalsite.

OBJECTIVEDATA

Restless,Irritability.

Acute painrelated to

surgicalincision as

manifested bycomplaints of

pain, facialgrimacing,

irritability,decreased

movement.

The client willexperience

reduced painand become

comfortable.

1.Assess the pain forcharacter, location,

and effectiveness ofrelief measures.

2. Assess the painusing numerical pain

scale.

3. Give acomfortable position

to the patient.

4. Use nonpharmacological

interventions such asdistraction,

relaxation, musicaltherapy etc.

5. Provide heat or

cold application.

6.Administermedications such as

analgesics asprescribed .

To planappropriate

interventions.

Todifferentiate

the type ofpain.

To promoterelaxation.

To reduce the pain by

diverting theattention of

patient frompain.

Cold induce

vasoconstriction, and hot

increasecirculation

To reduce thepain.

Patient has pain onthe surgical wound.

Patient has severepain

Provided acomfortable position

with additionalpillows.

Distract the attentionof the patient by

conversation.

Inj.Divon(Diclofenac) BD

given

Patient says his pain is reduced

and becomecomfortable.


3/8

ASSESSMEST NURSING

DIAGNOSIS

OBJECTIVES INTERVENTIONS RATIONALE IMPLEMENTATIO

N

EVALUATION

SUBJECTIVEDATAI feel weakness

due to nil peroral.

OBJECTIVEDATA

Patient is on

NPO since 3days. Looks soweak.

Alterednutrition lessthan body

requirementrelated to

NPO status asmanifested by

fatigue,

weakness

The client willimprove thenutritional

status.

1. Assess dietaryhabits, recent foodhabits.

2. Administer

prescribed IV fluidssuch as DNS, RL

etc.

3. Check for active

bowel sounds.

4. Before the NG

tube is removed, the patient is started on

oral feedings of clearliquids.(30ml of

fluid). Aspirate thetube after one hour.

5. When fluids are

well tolerated, thetube is removed and

fluids are increasedin frequency with a

slow progression toregular foods

To plan thecare.

To meet the

nutritionalneeds during

postoperative

period.

To assess the

returning of GIfunction. Then

start oralfluids.

To determine

the tolerancelevel. Aspirate

for checkingthe retained

fluid.

To start regular

foods.

He takes mixed diet.

DNS; 5%D; RL and

electrolytes aregiven according to

the order.

Bowel sounds are

heard on 5th

day.Then liquid diet

started.

Oral fluids started

before removal of NG tube. Good

tolerance level.

Rhyles tube

removed on 22nd

.

Nutritionalstatus improved.


4/8

ASSESSMEST NURSING

DIAGNOSIS


N

EVALUATION

OBJECTIVEDATASurgical wound

is present.

Risk forinfectionrelated to

surgicalincision,

inadequatenutrition and

fluid intake ,

invasivecatheter andimmobility.

Patient will notget anyinfection

1.Monitor and reportelevatedtemperature;invasive

lines and catheters,elevated pulse and

respiration etc2.Assess the surgical

wound for redness,

swelling, warm areasurrounding incisionand presence of

purulent drainagefrom the wound.

3.Use strict aseptic

technique in providing wound

care, including handwashing and sterile

dressing techniqueand emptying

drainage devices.4.Administer

antibiotics.Inj.Ceftriaxone, Inj

Amikacin.5..Help patient turn,

cough, and deep breath deeply every

1 to 2 hours whileawake

To determinepossible presence of

infection.

To determine

the infection.

To prevent

woundcontamination.

Prevent

infection.

To prevent

respiratoryinfections.

Vital signs arenormal.

Surgical wound is

clean and healthy.

Amount of drainageis normal.

Sterile techniques

followed.

Inj.Ceftriaxone, Inj

Amikacinadministered.

Not get any

respiratoryinfections.

Patient is notgetting anyinfections.


5/8

ASSESSMEST NURSINGDIAGNOSIS

OBJECTIVES INTERVENTIONS RATIONALE IMPLEMENTATION

EVALUATION

OBJECTIVEDATA

Patientunderwent

vagotomy, amajor

abdominalsurgery.

Risk forinjury: post

operativecomplications

related tobleeding,

distention andatelectasis.

The client willnot suffer from

anycomplications.

1.Assess for anysigns of

complications.

2.Check vital signsevery 30 mintes in

immediatepostoperative

period.

3.Donot repositionthe NG tube or

gastrostomy tubeafter gastric surgery.

4.Assess color,

amount and odor ofthe drainage.

5.Carefully measure

and document intakeand output including

the IV fluids anddrainage.

6.Encourage early

ambulation, deep breathing and

coughing exercise.

To plan thecare

It is the firstsigns for the

complications.

It may be placed directly

over the sutureline.

For assessing

hemorrhage.

For assessing

thecomplications.

To prevent

atelectasis.

Assessed signs ofcomplications.

Vital signs arechecked and

recorded.

NG tube and drain isin proper position.

Yellow green

colored drainage.

Intake and output is

normal.

Early ambulation

started.

Patient has nopostoperative

complications.


6/8

ASSESSMEST NURSING

DIAGNOSIS


N

EVALUATION

SUBJECTIVEDATAI cant able to

sleep in nightdue to pain.

OBJECTIVEDATA

Frequent

yawning andpatientstatement.

Sleep patterndisturbancerelated to

acute pain asmanifested by

yawning andpatient

statement.

Patient will getadequate restand sleep.

1. Ask the patient todescribe the usualsleep environment;

when possible,modify the patients

surroundings.

2. Avoid performing

prolonged or painful procedures withinthe hour before

bedtime.

3. Provideprescribed

analgesics orsedatives.

4. Allow the patient

to follow rituals that promote sleep at

home.

5. Reposition the patient for comfort,

and offersmoothening back

rub.

An unfamiliarenvironmentmay inhibit

sleep.

To prevent

sleepinterference.

Reduce painsensation and

induce sleep.

Help patient to

fall asleep.

Due the bedrest immobility

can increasediscomfort.

Usually he sleepsaround 6 hours.

Painful procedures

are avoided.

Inj. Divon(Diclofenac) given.

Encouraged to

follow rituals.

Repositioned theclient.

Patients sleepimproved.


7/8

ASSESSMEST NURSING

DIAGNOSIS


N

EVALUATION

OBJECTIVEDATA:Patient

repeatedly asksabout

management.

Knowledgedeficitregarding post

operative andhome care as

manifested byrepeated

questions

regardingtherapies.

Patient andfamily acquireadequate

knowledgeregarding

treatments.

1. Assess theknowledge level ofthe patient and

family.

2. Explain dietarymodifications,

including avoidance

of foods that causeepigastric distress.

3. Avoid cigarettessmoking and alcohol

intake.

4. To take allmedications as

prescribed.

5. Explain therelationship between

symptoms andstress. Stress-

reducing activitiesor relaxation

strategies areencouraged.

6.Explain about

follow up care.

To plan theeducationprogramme.

To preventcomplications.

Smoking willdelay healing.

Preventcomplications.

Increasedstress is a risk

factor for PUD

Follow up is

necessary.

Assessed theknowledge of patientand family.

Explained aboutdietary modification.

Explained aboutimportance of

avoidance of badhabits.

Explained aboutmedications.

Explained relaxationtechniques.

Explained follow up.

Patient andfamily acquireadequate

knowledgeregarding

treatments.


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