CHAPTER VII

NURSING CARE PLAN

ASSESSMENT

NURSING

NURSING GOAL

NURSING INTERVENTIONS

RATIONALE

EVALUATION

DIAGNOSIS
Subjective Cue:
Sumasakit ang tiyan ko,
as verbalized.

Alteration in comfort

After 8 hours of nursing

pain related to ductal

interventions, the patient

spasm secondary to

will demonstrate use of

biliary duct

relaxation techniques and

Objective Cues:
With complaints obstruction.

other methods to provide

Assessed general condition

Monitored vital signs.

Performed

comprehensive

Proper interventions
To monitor any changes

>RR= 22 bpm
>Seen patient in semi

from the previous to

fowlers position,

present data. Serve as

comfortably resting.

baseline data.
To assess etiology or

of pain on RLQ of

comfort; patients level of

assessment of pain to include

abdomen
With pain scale of

pain, 9/10, will subside to

location, onset or duration, quality,

4/10.

To assess precipitating

severity and precipitating factors.

Determined
possible
patho-

9/10
With facial

physiological causes of pain

Performed pain assessment each

grimace
With guarding

factors.
To rule out worsening of

behaviour
With teary eyes
Vs taken as

underlying condition.
To provide non-

time pain occurs.

Provided comfort measures such

follows:
T= 37.9
P=84 bpm
R= 26 bpm
BP= 90/60mmHg

as

back

rubbing

breathing exercise.
Provided
calm

environment.
Controlled

temperature.
Maintained on

and
and

contributing factors

pharmacological pain

deep
quiet

environment

management.
To prevent anxiety.

Cool surrounding aids in

decreasing discomfort.
Reduces abdominal
distention, thereby

semi-Fowlers

reduces tension.

position.

To regain strength and

Provided adequate rest and sleep

periods.
Instructed the patient to report

measures may be
instituted.

pain.

prevent fatigue.
So that immediate relief

It will determine if
measures used were not
effective to facilitate

Instruct the patient to evaluate and

report effectiveness of measures
used.

Administered
indicated.

analgesics

as

better interventions.
To immediately alleviate
pain.

ASSESSMENT

Subjective Cue:
Nilalagnat ako, as
verbalized.
Objective Cues:
With warm,

flushed skin
Weak in

appearance
With teary

eyes
Vs taken as
follows:
T= 37.9
P=84 bpm
R= 26 bpm
BP=

NURSING

NURSING

DIAGNOSIS

GOAL

Alteration in

After 8 hours of

body temperature

nursing

increased related

interventions, the

to presence of

patient will have a

pyrogenic
microorganism in
the
thermoregulating
center of the
body.

NURSING INTERVENTIONS

Assessed general condition

Monitored vital signs especially

RATIONALE

temperature.

Monitored

Proper interventions
To monitor any changes
from the previous to

environmental

factors

decreased body

like room temperature and bed linen

temperature.

as indicated.
Provide cooling blanket.

Removed unnecessary clothing that

could only aggravate heat.

Provided tepid sponge bath and
demonstrated S.O. the proper way of

present data.
To regulate external
factors contributing to

fever.
Helpful in decreasing

febrile temperature.
For good body condition

and relaxation.
TSB opens the skin
pores therefore

doing it.

facilitating conduction
and evaporation of heat

90/60mmHg

from a warm surface to a

Applied wet towel on forehead.

Provided adequate rest and sleep

periods.
Administered fluid and electrolyte

replacement.
Encouraged to increase oral fluid

cool surface.
To provide comfort and

easily decrease temp..

To reduce metabolic

demands.
To support circulating
volume, tissue perfusion.

EVALUATION

>Seen comfortably sleeping on bed, with

compress on forehead; latest T= 36.8

intake.
Encouraged to eat fruits high in
Vitamin C such as orange or

dalandan.
Administered
prescribed.

To prevent dehydration.

To boost immune
system.

paracetamol

as

To easily decrease the

febrile temperature.

ASSESSMENT

Subjective Cue:
Palagi akong
nagsusuka, as
verbalized.
Obejctive Cues:
With
episodes of

vomiting
With poor

skin turgor
With dry
skin and

NURSING

NURSING

DIAGNOSIS

GOAL

NURSING INTERVENTIONS

RATIONALE

Fluid loss occurs first in

>Patient was able to exhibit moist mucous

extracellular spaces,

membrane but still has a poor skin turgor.

interventions, the

resulting in poor skin

was able to retain feedings without

episodes of

patient will

turgor and dry mucous

experiencing vomiting.

vomiting

maintain adequate

secondary to

fluid volume as

Risk for fluid

After 8 hours of

volume deficit

nursing

related to

disease
progression.

membrane every shift

Monitored vital signs at least every

Weight patient daily.

membranes
Vs taken as
follows:
T= 37.9
P=84 bpm
R= 26 bpm
BP=
90/60mmHg

membrane.
To monitor any changes
from the previous to

four hours.

evidenced by good
skin turgor and

Assessed skin turgor, mucous

present data.
Changes in weight can

balance intake and

provide info in fluid

output.

balance and the

adequacy of fluid

mucous

EVALUATION

Monitored intake and output of

patients intake and

patient.

Offer the client with iced chips

Encouraged to oral increase fluid

intake.
Encouraged to eat fruits with high

output.
Fluid electrolyte
replacement provides

followed by clear liquids.

volume replacement.
For evaluation of

oral replacement therapy.

To prevent dehydration

caused by vomiting.
For proper hydration.

To prevent further

fluid content such as watermelon

and grapes.
Encouraged to avoid foods that

cause dehydration such as coffee.

Administered anti emetic drug as

prescribed

dehydration
Effective against nausea
and vomiting.

ASSESSMENT

Subjective Cue:
Nagkakaron ako ng
pasa at
pangangati, as
verbalized.
Obejctive Cues:
With

NURSING

NURSING

DIAGNOSIS

GOAL

Risk for bleeding

After 8 hours of

related to

nursing

prolonged

interventions, the

Assessed and monitored vital signs.

Assessed body systems such as skin,

bleeding is
reduced as
evidenced by vital

rashes
With bruise
Vs taken as

signs w/in normal

90/60mmHg

prothrombin time. patients risk for

petechial

follows:
T= 37.9
P=84 bpm
R= 26 bpm
BP=

NURSING INTERVENTIONS

range, absence

significant blood loss

and potential shock.
Fragile tissues and

toothbrush, or mild mouthwash to

altered clotting

clean teeth and gums

mechanisms increase the

Instruct client to avoid forceful

risk of hemorrhage.
These activities can

damage mucous
membrane increasing the

Monitored prothrombin time and

platelet count.

further complaint of pruritus or itching.

accompany bleeding.
Early detection

for presence of blood.

Encouraged use of soft-bristle

straining to have a bowel movement

of bleeding.

Seen patient comfortably lying on bleed, n

of bleeding helps prevent

pressure and

Increased heart rate

membranes, vomitus, stool and urine

blowing, coughing, sneezing and

risk of bleeding.
Bleeding can occur at
PTT > 14 sec. and

Avoided
injections and rectal procedures (suc

platelet <50,000/mm3
Can stimulate bleeding;

To prevent falls or injury.

Plays a key role in

h as enemas and rectal

temperature taking) as necessary.

Maintained safe

environment for patient.

Administered Vitamin K as
prescribed.

CHAPTER VIII
DRUG STUDY

EVALUATION

mucous membranes, gums, nasal

of narrowed pulse
diminished signs

RATIONALE

helping the blood clot.

DRUG NAME

SPECIFIC
ACTION

MECHANISM OF
ACTION

Cefuroxime

Anti-infective
2nd gen
cephalosporin

Inhibits bacterial cell

wall synthesis,
rendering cell wall
osmotically
unstable, leading to
cell death

Metronidazole

Antiprotozoal

It binds to bacterial
and protozoal DNA
to cause loss of
helical structure,
strand breakage,
inhibition of nucleic
acid synthesis and
cell death.

INDICATION

CONTRA
INDICATION

ADVERSE EFFECT

Used as an anti-infective
agent for urinary tract
infections and severe
infections

Hypersensitivity to
cephalosporins and
related antibiotics;
pregnancy (category
B), lactation

Allergic reactions like skin

rash, itching or hives,
swelling of the face, lips or
tongue, dark urine,
difficulty of breathing,
irregular heartbeat or chest
pain, seizures, unusual
bleeding or bruising, white
patches or sores inside the
mouth

Used for the treatment of

serious infection caused by
susceptible anaerobic
bacteria in intra-abdominal
infections, skin infections,
gynecologic infections,
septicemia, and for
preoperative and
postoperative prophylaxis

>Blood dyscrasias.
>Active CNS ds.
>Hypersensitivity to
imidazole.
>Tuberculosis
to
mucous membranes
and certain viral
conditions.
>1st trimester of
pregnancy.
>Lactation
>Children
>Leukopenia
>Peripheral
neuropathy
(long
term therapy)
>Psychiatric
disorders

GI discomfort, anorexia,
nausea, furred tongue, dry
mouth and unpleasant
metallic taste, headache,
less frequently vomiting,
diarrhea, weakness,
dizziness and darkening of
the urine. Watery(tearing)
eyes if applied near to eye
area, transient redness and
mild dryness.

NRSG.
RESPONSIBILITIES

>Determine history of
hypersensitivity reactions
cephalosporins, penicillin
and history of allergies,
particularly to drugs,
>Inspect IM and IV injec
sites frequently for signs
phlebitis.
>Monitor I&O rates and
pattern:
>Monitor for bleeding
>Obtain baseline informa
on patients infection: fev
wound characteristics, W
count(>100,000mm3)and
regularly assess during
treatment.
>Assess for allergic
reactions: rash, urticaria,
pruritus.
>Monitor renal function:
urine output, input-output
ration, polyuria, dysuria,
pyuria, BUN and creatini
>Decreasing output and
increasing BUN, creatinin
may indicate nephrotoxic
>Monitor bowel pattern,
discontinue drug if severe
diarrhea occurs.
>Assess for overgrowth o
infection: peripheral itchi
fever malaise, redness,

swelling, drainage, rash a

change in cough/sputum.

Paracetamol

Analgesic
Muscle relaxant

Relieves pain by
inhibiting
prostaglandin
synthesis at the CNS
but does not have
anti-inflammatory
action because of its
minimal effect on
peripheral
prostaglandin
synthesis.

To relieve mild to moderate

pain due to things such as
headache, muscle and joint
pain, backache and period
pains. It is also used to bring
down a high temperature

Hypersensitivity to Side effects are rare with

acetaminophen
or paracetamol when it is taken
phenacetin; use with at the recommended doses.
alcohol

>Assess patients fever or

pain: type of pain, locatio
intensity, duration,
temperature, diaphoresis
>Assess allergic reactions
rash, urticaria; if this occu
drug may have to
discontinued
>Assess hepatotoxicity; d
urine, clay-colored stools
yellowing of skin and scle
itching, abdominal pain,
fever, diarrhea if patient i
long term therapy.
>Monitor liver and renal
function. AST, ALT biliru
pro-time, BUN, CREA
>Check input and output
ratio; decreasing output m
indicate renal failures.
>Assess for chronic
poisoning: rapid, weak pu
dyspnea: cold, clammy
extremities; report
immediately to prescriber

Vitamin K

Tat-soluble
vitamins
Antifibrinolytic
agents

Synthetic analog of
Vit. K w/c is
essential to hepatic
synthesis of blood
clotting factors
II,VII, IX, X.

Used in the treatment and

prevention of hemorrhage
associated with Vitamin K
deficiency

Hypersensitivity to Flushing, dizziness, rapid

any component of and weak pulse, profuse
the drug
sweating, brief hypotension,
dyspnea, and cyanosis.
Pain, swelling, and
tenderness at the injection
site may occur.

> Assess for patients

condition before therapy
regularly thereafter to
monitor drug effectivenes
>Assess for bleeding:
bruising, hematuria, black
tarry stools and hemateme
>Monitor for possible dru
induced adverse reactions
>Assess patient and famil
knowledge on drug therap
Hypercalcemia may develop >Evaluate for any
contraindications
>Take drug as prescribed
>Warn the patient about
possible side effects and h
to recognize them
>Give with food if GI ups
occurs
>Frequently assess for
hypercalcemia
CNS:Headache, dizziness,
>Report any changes in
fatigue.
urinary elimination such a
GI:Diarrhea, abdominal pain,
pain or discomfort associ
nausea, mild transient increases
with urination, or blood in
in liver function tests.
urine.
Urogenital:Hematuria,
>Report severe diarrhea;
proteinuria.
drug may need to be
Skin:Rash.
discontinued.
>Do not breast feed while
taking this drug.

Keto-analogue

Essential amino
acid

Normalizes metabolic
process, promotes
recycling product
exchange. Reduces
ion concentration of
potassium,
magnesium and
phosphate

>Protein energy
malnutrition
>Prevention and treatment
of conditions caused by
modified or insufficient
protein metabolism in
chronic renal failure

>Allergy and hyper

sensitivity to any
content of this drug
>Hypercalcemia
>Disturbed amino
acid metabolism
>Caution use for
patiet with phenylketonuria

Omeprazole

Proton Pump
Inhibitor

Suppresses gastric acid

secretion relieving
gastrointestinal distress
and promoting ulcer
healing.

>Duodenal and gastric ulcer

>GERD including severe
erosive esophagitis
>Long-term treatment of
pathologic hypersecretory
conditions such as ZollingerEllison syndrome, multiple
endocrine adenomas, and
systemic mastocytosis.

>Long-term use for

gastro
esophageal
reflux
disease,
duodenal ulcers
>Lactation.

Metoclopramide

Anitemetic
GI stimulant

Potent central
dopamine receptor
antagonist. Exact
mechanism of action
not clear but appears to
sensitize GI smooth
muscle to effects of
acetylcholine by direct
action.

>Management of diabetic
gastric stasis
>To prevent nausea and
vomiting associated with
emetogenic cancer
chemotherapy
>To facilitate intubation of
small bowel
>Symptomatic treatment of
GERD.

>Allergy
to
metoclopramide
>GI hemorrhage>Mechanical
obstruction
or
perforation
>Pheochromocytoma
>Epilepsy

CNS: Restlessness, drowsiness,

fatigue, lassitude, insomnia,
extra pyramidal reactions,
parkinsonism -like reactions,
akathisia, dystonia, myoclonus,
dizziness, anxiety
CV: Transient hypertension
GI: Nausea, diarrhea

>Observe 15 rights in dru

administration.
>Assess for allergy to
metoclopramide.
>Assess for other
contraindications.

>Keep diphenhydramine
injection readily available
case extra pyramidal
reactions occur (50 mg IM

Diphenhydramine

>Sedative or
hypnotic
>Antihistamine
>Anti-motion
sickness agent
>Antiparkinsoni
an agent
>Cough
suppressant

Competitively blocks
the effects of histamine
at H1-receptor sites, has
atropine-like,
antipruritic, and
sedative effects.

>Active and prophylactic

treatment of motion sickness
>Nighttime sleep aid
>Parkinsonism (including druginduced parkinsonism and
extrapyramidal reactions)
>Suppression of cough due to
colds or allergy (syrup
formulation)

>cardiac disease or
hypertension
>glaucoma
>gastric or duodenal
ulcers

>CNS: headache, fatigue,

anxiety, tremors, vertigo,
confusion, depression, seizures,
hallucinations
>CV: tachycardia, palpitations,
orthostaic hypotension, heart
failure
>EENT: blurred vision
>GI: dry mouth, nausea,
vomiting, constipation,
flatulence
>GU: urinary hesitancy or
frequency, urine retention
>Hematologic: leukopenia
>Skin: photosensitivity,
dermatitis

>Have phentolamine read

available in case of
hypertensive crisis.
>Caution the client that th
medication may cause
drowsiness, creating
difficulties or hazards or
other activities that requir
alertness.

>Tell the client to take the

medication with food to
decrease GI upset.

>Explain to the client tha

arising quickly form a lyi
or sitting position may ca
orthostatic hypotension.

>Explain to the client tha

use of these drugs in warm
weather may increase the

likelihood of heatstroke.

Mebendazole

Antihelmintic

Irreversibly blocks
glucose uptake by
susceptible
helminthes, depleting
glycogen stores
needed for survival
and reproduction of
helminths, causing
death.

Treatment of Trichuris
trichiura (whipworm),
Enterobius vermicularis
(pinworm), Ascaris
lumbricoides (roundworm),
Ancylostoma duodenale
(common hookworm),
Necator americanus
(American hookworm).

>Allergy to drug
>Pregnancy
(embryotoxic
and
teratogenic
>Avoid
use,
especially during first
trimester)
>Use cautiously with
lactation.

>GI:Transient abdominal
pain, diarrhea.
>BodyWhole: Dizziness,
fever (possibly due to tissue
necrosis in cysts)

>Assess for pregnancy,

lactation and allergy to
mebendazole.

>Assess for temperature,

bowel sounds and output.

>Administer drug with fo

tablets may be chewed,
swallowed whole, or crus
and missed with food.

>Arrange for second cour

of treatment if patient is n
cured 3 weeks after
treatment.

>Arrange for daily laundr

of bed linens, towels, nigh
clothes, and undergarmen
(pinworm)
>Give via side drip

CHAPTER IX
PATHOPHYSIOLOGY

Modifiable Factors:
Alcohol drinker
Increased fat in the
diet

Non modifiable Factors:

Ihaw vendor
Poor sanitation

Warm and tropical

climate
25 years old

Ingestion
of eggs from fecally contaminated foods/drinks
Metronidaz
ole

Excess
cholesterol

Motile larvae pass into the intestines, where they hatch into
larvae
Inability to emulsify all fats

The larvae travel from the liver to the lungs and back to small
intestine for maturation and laying of eggs

Accumulation of undigested fats

Slowed emptying of the

gallbladder

Increased
risk for stone
formation

Diphenhydra
Migration
of ascariasis lumbricoides in common bile duct via
mine +
sphincter of Oddi of jejunum
Mebendazole
Infiltration of ascaris in
biliary tree

Obstructi
on

OBSTRUCTION OF THE CYTIC DUCT/

COMMON BILE DUCT

OBSTRUCTION OF THE
GALLBLADDER

Impaired venous and

Distention of bile duct
lymphatic drainage
proliferation of bacteria

Movement of ascariasis
lumbricoides in and out of
gallbladder

Obstruction of
bile flow

Cefuroxime

Activation and release of

inflammatory mediators found in
all tissues

Friction against
lumen of the cystic
duct

Accumulation of
bilirubin in the
bloodstream

Presence of histamine, kinins,

prostaglandins and leukocytes due to
inflammatory process

Stimulation of
chemoreceptors and
Jaundic
stretch receptors of
e
brain via vagus nerve
afferent
Presence of wave
pain during
Activation of
ascariasis
LIVER:
chemoreceptor

Dilation and increased permeability of

blood vessels (VASODILATION)

Movement of water and

proteins from blood to
Loss of appetite
tissue
Swelling of
gallbladder

Weight loss

Distention of
gallbladder lumen
(Ultrasound Finding)
Increased pressure of tissue
organ
Positive pain on Right Upper
Quadrant of the Abdomen

Alteration in
comfort pain

Migration of
WBC from blood
stream

Ketoanalogue

trigger zone
Dark
High amounts
of
(Vomiting Centerurine
soluble
Vomitin
Medulla
conjugated
g
Oblongata)
bilirubin enter
Risk for
the circulation
fluidare
where they
volume
excreted
within

INTESTINE:
Leukocytosis
and fever

Elevated body
temperature
Paracetamol

Below normal amounts

of bilirubin reach the
intestine for conversion
Imbalanced
nutrition
to urobilinogen
less than body
requirements
Pale stools