contraindication

name of drug
generic name:
cefuroxime
sodium
brand name:
cefuroxime
axetil
classification:
secondgeneration
cephalosporin

specific
action
Inhibits
cell-wall
synthesis,
of bacterial
cell wall
causing
cell death.

indications
for patients
with
infections of
the urinary
and lower
respiratory
tracts,

hypersensitive
cephalosporin or
penicillin

drug
interaction
Drug-Drug:
May
increased
nephrotoxicit
y with
aminoglycosi
des
Increased
bleeding
effects with
oral
anticoagulant
s

adverse
reaction
CV:
phlebitis,
thrombophl
ebitis
GI:
pseudomem
branous
colitis,
nausea,
anorexia,
vomiting,
diarrhea
Skin:
maculopapu
lar and pain,
induration,
temperature
elevation.

specific precaution

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

name of drug
generic name:
Chlorampheni
col
brand name:
Pentamycetin,
Chloromycetin
classification:

specific
action
Chloramph
enicol is
a bacteriost
atic by inhi
biting
protein
synthesis.
It
prevents pr
otein chain
elongation
by
inhibiting
the peptidy
l
transferase
activity of
the
bacterial ri
bosome.

contraindication

drug
interaction

adverse
reaction

specific precaution

hypersensitive
chloramphenicol

Drug: The
metabolism
of chlorprop
amide, dicu
marol, phen
ytoin, tolbut
amide may
be decreased,
prolonging
their
activity. Phe
nobarbital d
ecreases
chloramphen
icol levels.
The response
to ironprepar
ations, folic
acid, and vit
amin
B12 may be
delayed

Hematologi
c: Bone
marrow
depression (
dose-related
and
reversible):
reticulocyto
sis,
leukopenia,
granulocyto
penia,
thrombocyt
openia,
increased
plasma iron,
reduced
Hgb,
hypoplastic
anemia,
hypoprothro
mbinemia.
Non-doserelated and
irreversible

hypersensitive to
penicillin

indications
Chloramphe
nicol has a
broad
spectrum of
activity and
has been
effective in
treating
ocular
infections
caused by a
number of
bacteria
including St
aphylococc
us aureus,
Streptococc
us
pneumoniae
,
and Escheri
chia coli.

nursing responsibilities

A bitter taste may occur 1520 s

after IV injection; it usually
lasts only 23 min.

Report immediately sore throat,

fever, fatigue, petechiae, nose
bleeds, bleeding gums, or other
unusual bleeding or bruising, or
any other suspicious sign of
symptom. Drug therapy should
be discontinued if abnormal
bleeding occurs.

Watch for S&S of

superinfection (see Appendix
F).

Follow dosage and duration of

therapy as prescribed by
physician.

Avoid prolonged or frequent

intermittent use of topical
preparations because systemic
absorption and toxicity can
occur.

Withhold medication and check

pancytopeni
a,
agranulocyt
osis,
aplastic
anemia,
paroxysmal
nocturnal
hemoglobin
uria,
leukemia. C
NS: Neurot
oxicity:
headache,
mental
depression,
confusion,
delirium,
digital
paresthesias
, peripheral
neuritis. Ski
n: Urticaria,
contact
dermatitis,
maculopapu
lar and
vesicular
rashes,

with physician immediately if

signs of hypersensitivity
reaction (see Appendix F),
irritation, superinfection, or
other adverse reactions appear.

Do not breast feed while taking

this drug.

fixed-drug
eruptions. S
pecial
Senses: Vis
ual
disturbances
, optic
neuritis,
optic nerve
atrophy,
contact
conjunctiviti

Name of the
drug

Specific
action(s)

Indication

Contraindicatio
n(s)

Drug
interaction

Adverse
reaction

Specific
precaution

Nursing responsibilities

generic
name:

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

paracetamol
brand
name:
tempra
ROUTE:
IVTT
DOSAGE:
400 mg
Analgesic: Site
FREQUEN
and mechanism
CY:
of action unclear.
Q4h
CLASSIFIC
ATION:
Analgesic(no
n-opioid),
Antipyretic

Temporary
reduction
of fever.

Contraindicated
with allergy to
acetaminophen,

Potentiating: CNS:Headache,
barbiturates,
dizziness,
carbamazepine
lethargy,
, diflunical,
paresthesia,
hydantoins,
GI:hepatic
isoniazid,
toxicity and
rifabutin,
failure
rifampin,
GU:liver
sulfinpyrazone
toxicity,
: increased risk nephrotoxicity,
of
Hematologic:b
hepatotoxicity
one marrow
Zidovudine:
depression,
increase risk of Hypersensitivit
y:,rash, fever
granulocytope
Anaphylaxis,
nia.
pain, phlebitis
Inhibiting:
activated
charcoal,
cholestyramine
, colestipol:
decreased
acetamininoph
en absorption.

Use
cautiously
with
impaired
hepatic
function
and renal
failure

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

Name of the
drug

Specific
action(s)

Indication

generic
name:
ampicillin
brand
name:

Active against
gram-positive
microorganisms
such
as alpha- and be
ta-Hemolytic

Infections
of GU,
respiratory,
and GI
tracts and
skin and

Contraindicatio
n(s)
Hypersensitivity
to penicillin
derivatives;
infectious
mononucleosis

Drug
interaction
Drug: Allopur
inol increases
incidence of
rash.
Effectiveness
of

Adverse
reaction

Specific
precaution

Body as a
Whole: Similar
to those for
penicillin G.
Hypersensitivit

History of
severe
reactions to
cephalospo
rins;
pregnancy

Nursing responsibilities

Determine previous
hypersensitivity reactions to
penicillins, cephalosporins, and
other allergens prior to therapy.

Lab tests: Baseline C&S tests prior

Omnipen-N,
Penbritin
ROUTE:
IVTT
CLASSIFIC
ATION:
antibiotic

streptococci,
soft tissues;
Diplococcus
also
pneumoniae, non gonococcal
-penicillinase
infections,
producing Staph
bacterial
ylococci, and Lis meningitis,
teria. Major
otitis
advantage over
media,
penicillin G is
sinusitis,
enhanced action
and
against most
septicemia
strains
and for
of Enterococci a prophylaxi
nd several grams of
negative strains
bacterial
including Escher endocarditi
ichia coli,
s. Used
Neisseria
parenterall
gonorrhoeae, N.
y only for
meningitidis,
moderately
Haemophilus
severe to
influenzae,
severe
Proteus
infections.
mirabilis,
Salmonella (incl
uding typhosa),
and Shigella. Ina
ctive
against Mycopla
sma, rickettsiae,
fungi, and
viruses.

the AMINOGL
YCOSIDES m
ay be impaired
in patients with
severe endstage renal
disease. Chlor
amphenicol, e
rythromycin,
and tetracycli
nemay reduce
bactericidal
effects of
ampicillin; this
interaction is
primarily
significant
when low
doses of
ampicillin are
used.
Ampicillin
may interfere
with the
contraceptive
action of oral
contraceptives
Estrogens. Fe
male patients

y (pruritus,
urticaria,
eosinophilia,
hemolytic
anemia,
interstitial
nephritis, anaph
ylactoid
reaction);
superinfections.
CNS: Convulsi
ve seizures with
high
doses. GI: Diar
rhea, nausea,
vomiting, pseud
omembranous
colitis. Other:
Severe pain
(following IM);
phlebitis
(following
IV). Skin: Rash

(category
B) or
lactation.

to initiation of therapy; start drug

pending results. Baseline and
periodic assessments of renal,
hepatic, and hematologic
functions, particularly during
prolonged or high-dose therapy.

Note: Sodium content of drug

must be considered in patients on
sodium restriction.

Inspect skin daily and instruct

patient to do the same. The
appearance of a rash should be
carefully evaluated to differentiate
a nonallergenic ampicillin rash
from a hypersensitivity reaction.
Report rash promptly to physician.

Note: Incidence of ampicillin rash

is higher in patients with infectious
mononucleosis or other viral
infections, Salmonella infections,
lymphocytic leukemia, or
hyperuricemia or in patients taking
allopurinol.

should be
advised to
consider
nonhormonal
contraception
while on
antibiotics. Fo
od: Food may
decrease
absorption of
ampicillin, so
it should be
taken 1 h
before or 2 h
after meals.

Name of the
drug

Specific
action(s)

Indication

Contraindicatio
n(s)

Drug
interaction

Adverse
reaction

Specific
precaution

generic
name:
paracetamol
brand
name:
tempra
ROUTE:
IVTT

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

Temporary
reduction
of fever.

Contraindicated
with allergy to
acetaminophen,

Potentiating:
barbiturates,
carbamazepine
, diflunical,
hydantoins,
isoniazid,
rifabutin,
rifampin,

CNS:Headache,
dizziness,
lethargy,
paresthesia,
GI:hepatic
toxicity and
failure
GU:liver

Use
cautiously
with impaired
hepatic
function and
renal failure

Nursing responsibilities

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

Assessment
Diagnosis
Scientific Rationale
Planning
Intervention
Scientific Rationale
Evaluation
S: masuol
>acute pain r/t Tissue injury or After a series of
>perform a comprehensive
>pain is subjective
>Patient will have relief
inflammatory
infection
results
nursing
assessment
of
pain
to
include
experience
and
must
be
of pain as absence of
kuno pag nag
response of
to immediate
interventions:
location, characteristic, onset, described by the client in muscle tension, absence
ginhawa siya
alveolar tissues
vascular
duration, frequency,quality
order to plan effective
of facial grimace and
> Demonstrate
as verbalized
secondary
response;
and precipitating
factors of
treatment. hypersensitivityrestlessness.
helps to
toxicity,
reactions occur.
by the mother which
relief of painsulfinpyrazone
as
pneumonia
transitory
pain.
>personal
factors
can
dissipate heat.
5. Assess if patient has any
CLASSIFIC
: increased risk nephrotoxicity,
absence of
vasoconstriction
influence pain and pain
contraindication to drugs
ATION:
of
Hematologic:b
followed
>reduce
or
eliminate
factors
tolerance.
Factors
that
Analgesic: Site
muscle tension,
Analgesic(no
hepatotoxicity
one or
marrow
immediately by
that precipitate
increase
may be precipitating o
and mechanism
absence
of
facial
n-opioid),
Zidovudine:
depression,
vasodilation
due
pain
experience.
augmenting
pain should
of action unclear.
O:
grimace
and
Antipyretic
increase
risk
of
Hypersensitivit
to the release of
be reduced or eliminated
>facial
y:,rash, fever
histamine,brady
to enhance the overall
granulocytope
restlessness
frimace
Anaphylaxis,
kinin and
pain management
nia.
>diaphoretic
pain, phlebitis
prostaglandin
program.
which in turn
>relaxation techniques
Inhibiting:
leads to
>Elicit behaviors that are
help reduce skeletal and
activated
increased
conditioned to produce
muscle tension which
charcoal,
capillary
relaxation, such as deep
will reduce the intensity
cholestyramine
permeability,
breathing, music therapy.
of the pain.music
hyperemia and
therapy serves as a
, colestipol:
cellular
distracter
from hospital
decreased
exudation that
>Instruct
client
to
report
any
noise,
thereby
reducing
acetamininoph
results to edema
improvement/exacerbation of
emotional anxiety and
en absorption.
and then pain
pain.
pain
caused by
>Unrelieved pain can
compression of
>Encourage verbalization
create problems such as
nerve endings,
about feelings of pain.
anger, anxiety,
release of pain
immobility, respiratory
mediators
problems and delay in
bradykinin and
healing.
prostaglandins
>only the client can
and eventually
judge the level and
loss or impaired
>Provide comfort measures
distress of pain, pain
function.
such as repositioning
management should be a
And fixing the bed sheets.
team approach that
Reference: Josie
includes the client.
Quiambao> To promote comfort
Udan,Mastering
and alleviate pain.
Fundamentals of
Source:
Nursing 3rd
Medical-Surgical Nursi
edition,
ng, 7
th
ed. by Black, Joyce

ASSESSMENT
SUBJECTIVE
>inuuhaw ako
OBJECTIVE:
>dry lips
>poor skin turgor
>cool clammy skin

NURSING
DIAGNOSIS

SCIENTIFIC
RATIONALE
Intestines functions not
>Fluid
only as a passage of
volume deficit chime but also for
related to
digestion, intestine
absorbs water, vitamin B
decrease
and electrolytes.
absorption of
Perforations and
fluid
infection of bowel may
disrupts its normal
secondary to
function causing a
diarrhea and
decrease in absorption
vomiting
and fluid imbalance.
Source: Stump,
Nutritional foundations
and clinical
applications: a nursing
approach,

OBJECTIVES/
PLANNING

NURSING
INTERVENTIONS

After a series of
nursing
interventions the
patient will be
able to:

> Measure and record

I&O (including tubes
and drains). Calculate
urine specific gravity
as appropriate.

> Demonstrate
adequate fluid
balance, as
evidenced by
normal skin
turgor, moist
mucous
membranes, and
individually
appropriate
urinary output.

>Inspect mucous
membranes; assess
skin turgor and
capillary refill.
> Provide voiding
assistance measures as
needed: privacy,
sitting position,
running water in sink,
pouring warm water
over perineum.
> Monitor skin
temperature, palpate
peripheral pulses.

SCIENTIFIC
RATIONALE
>Accurate
documentation helps
identify fluid losses or
replacement needs and
influences choice of
interventions.
>Indicators
of
adequacy
of
peripheral circulation
and cellular hydration.
>Promotes relaxation
of perineal muscles
and may facilitate
voiding efforts.

> Cool or clammy

skin, weak pulses
indicate
decreased
peripheral circulation
and
need
for
additional
fluid
> Monitor laboratory
replacement.
studies: Hb/ Hct,
>
Indicators
of
electrolytes. Compare hydration
and/or
preoperative and
circulating
volume.
postoperative blood
Preoperative anemia
studies.
and/or
low
Hct
combined
with
unreplaced
fluid
losses intraoperatively
will further potentiate
> Give frequent mouth deficit.
care with special
> Dehydration results
attention to protection in drying and painful
of the lips.
cracking of the lips
and mouth.
>Administer IV fluids
and electrolytes.
>The
peritoneum

EVALUATION
>Patient will
have adequate
fluid balance.
> Patient will
demonstrate
adequate fluid
balance, as
evidenced by
normal skin
turgor, moist
mucous
membranes, and
individually
appropriate
urinary output.

ASSESSMENT

NURSING

PLANNING

INTERVENTION

RATIONALE

EVALUATION

DIAGNOSIS
Subjective
mapaso ako anak as
verbalized by the mother.
Objective
Flushed skin
Increased respiratory
rate
Diaphoresis
Warm to touch
VS:
-PR: 72
-RR: 26
-T: 38.6

Hyperthermia
related to
bacterial
infection as
manifested by
flushed skin,
increased
respiratory rate of
26cpm,
diaphoresis,
warm to touch
with a
temperature of
38.6C .

Short term

Independent
1. Monitor vital
signs.
2. Provide tepid
sponge bath. Do
not use alcohol.

After 1 hour of
appropriate
nursing
intervention the
patients
3. Remove excess
temperature will
clothing and
decrease from
covers.
38.6C to 37.5oC.
4. Promote a wellventilated area to
patient.
Long term
After 4 hours or
appropriate
nursing
intervention the
patients vital
signs will return
to normal range
with a
temperature of
36.5-37.5oC,pulse

5. Advise patient to
increase oral fluid
intake.
6. Maintain bed rest.
7. Provide highcalorie diet.

8. Educate and

After 1 hour of nursing

1.Vital signs provide
more accurate
indication of core
temperature.
2.TSB helps in
lowering the body
temperature and
alcohol cools the skin
too rapidly, causing
shivering. Shivering
increases metabolic
rate and body
temperature
3.These decrease
warmth and increase
evaporative cooling.
4.To promote clear
flow of air in the
patients area. One
way of promoting
heat loss.

intervention,
the clients temperature decreased
from 38.6C to 37.7C
as evidenced by decreased
diaphoresis and calm breathing.

After 4 hours of nursing

intervention the patients vital signs
returned to normal range.

rate of 60100bpm and

respiratory rate of
12-20 cycles per
min.

advise support
system (relative)
to do TSB when
patient feels hot.
- Luke warm
water only.
- Make sure that
armpits and
groins were
included in doing
TSB.

5.Additional fluids
help prevent elevated
temperature
associated with
dehydration.
6.Reduce metabolic
demands/ oxygen
consumption
7.To meet increased
metabolic demands.

9. Monitored VS and
8.Teaching the
recheck.
Support system the
right way to do TSB
Dependent
will help in knowing
10. Provide
what to do in case the
antipyretic
patients temperature
medications as
increases
indicated.
9.To know the
effectiveness of
nursing interventions
done and to know the
progress of patients
condition.
10.These drugs
inhibit the
prostaglandin that
serve as mediators of
pain and fever.

ASSESSMENT

NURSING

PLANNING

INTERVENTION

RATIONALE

DIAGNOSIS
Subjective
mapaso ako anak as verbalized by
the mother.
Objective
Flushed skin
Increased respiratory rate
Diaphoresis
Warm to touch
VS:
-T: 38.2

Hyperthermia related to
bacterial infection as
manifested by flushed
skin, , diaphoresis,
warm to touch with a
temperature of 38.2C .

Short term
After 1 hour of
appropriate nursing
intervention the
patients temperature
will decrease from
38.2C to 37.5oC.

Independent
9. Monitor vital signs.
10. Provide tepid sponge
bath. Do not use alcohol.

1.Vital signs provide more

accurate indication of core
temperature.

11. Remove excess clothing

and covers.

2.TSB helps in lowering the

body temperature and alcohol
cools the skin too rapidly,
12. Promote a well-ventilated causing shivering. Shivering
increases metabolic rate and
area to patient.
body temperature
13. Advise patient to increase
Long term
3.These decrease warmth and
oral fluid intake.
increase evaporative cooling.
After 4 hours or
14. Maintain bed rest.
appropriate nursing
4.To promote clear flow of
intervention the
15. Provide high-calorie diet. air in the patients area. One
patients vital signs will
way of promoting heat loss.
return to normal range
with a temperature of
5.Additional fluids help
36.5-37.5oC,pulse rate 16. Educate and advise
support system (relative) prevent elevated temperature
of 60-100bpm and
associated with dehydration.
to do TSB when patient
respiratory rate of 12-20
6.Reduce metabolic
feels hot.
cycles per min.
demands/
oxygen
- Luke warm water only.
consumption
- Make sure that armpits
and groins were included
in doing TSB.

7.To meet increased

metabolic demands.

9. Monitored VS and
recheck.
Dependent
10. Provide antipyretic
medications as indicated.

8.Teaching the Support

system the right way to do
TSB will help in knowing
what to do in case the
patients temperature
increases
9.To know the effectiveness
of nursing interventions done
and to know the progress of
patients condition.
10.These drugs inhibit the
prostaglandin that serve as
mediators of pain and fever.

Assessment
S:
>matamlay
iya lawas, wa
pa katurog
tuhay
verbalized by
the mother
O:
>yawning
>crying
>wakes up
every 2 hours

Diagnosis
Fatigue
related to
sleep
deprivation

Scientific Rationale
,

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

Intervention
Scientific Rationale
>manipulated environment >to promote comfort
such as cleaning the
surroundings and
minimizing noise.
>adequate rest periods
>encourage patient for
could prevent fatigue
adequate rest periods to
and discomfort
obtain rest and relieve
fatigue
> Clients
position may
>have patient in any
aggravate pain felt.
comfortable position as
Positioning properly
tolerated
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

>nutrition is
the fundamental
cellular
integrity and

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

activities such as listening

to music to diver
attentions.
>Encourage deep
breathing exercises

tissue repair

>caffeine has
substances that
is known to
disrupt
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

ASSESSMENT
SUBJECTIVE
masuol la gehap
an iya tiyan. as
verbalized
By the mother
OBJECTIVE

Guarding the
abdominal
incision with
right hand.

facial grimace
noted

NURSING
DIAGNOSIS
Acute pain
related to
LBM

SCIENTIFIC
RATIONALE
Tissue injury or
infection results to
immediate vascular
response; transitory
vasoconstriction
followed immediately
by vasodilation due to
the release of
histamine,bradykinin
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.
Reference: Josie
QuiambaoUdan,Mastering
Fundamentals of
Nursing 3rd edition, p.
156

OBJECTIVES/
PLANNING

NURSING
INTERVENTIONS

After a series of
Assess pain, noting
nursing
location,
interventions the
characteristics,
patient will be able
severity (010
to:
scale). Investigate
and report changes
Verbalize
in pain as
feeling of relief
appropriate.
or reduced
sensation from
pain.
>Keep at rest in semiFowlers position.
Reduce
guarding
behavior
Follow
prescribed
pharmacologica
l regimen

>Encourage early
ambulation.
Provide comfort
measures such as
repositioning
And fixing the bed
sheets.
Monitor patients
vital signs
(BP,HR,RR,Temp)

SCIENTIFIC RATIONALE
> Useful in monitoring effectiveness
of medication, progression of
healing. Changes in characteristics
of pain may indicate developing
abscess or peritonitis, requiring
prompt medical evaluation and
intervention.

>To lessen the pain. Gravity

localizes inflammatory exudate into
lower abdomen or pelvis, relieving
abdominal tension, which is
accentuated by supine position.

>Promotes normalization of organ

function (stimulates peristalsis and
passing
of
flatus,
reducing
abdominal discomfort)
To promote comfort and alleviate
pain.

Are usually altered when there is

pain as the body is trying to fight
and compensate.
To maximize energy available for
healing and meet comfort needs.
Encourage adequate
periods of rest and
sleep.
As pharmacological management
for pain and infection as indicated