NURSING CARE PLAN

Assessment Nursing diagnosis Planning Intervention Rationale Evaluation

S: Impaired gas exchange Short term: Independent: Short term:

O: SPO2 rangers from related to altered oxygen After 5 hours of nursing -monitor skin and mucous -duskiness and central Goal not met
92-96
supply intervention the client: membrane color cyanosis indicate After 5 hours of nursing
-​ Demonstrate advanced hypoxemia intervention the client did
improved -Elevate head of the bed, - oxygen delivery may be not demonstrate improved
ventilation assist patient to assume improved by upright ventilation.
Long term: position to ease work of suctioning Long term:
After 3 days of nursing breathing Goal met
intervention the client - suction when needed -​ Suctioning is After 3 days of nursing
-​ Manifest absence of required when intervention the client
wheezes on cough is ineffective Manifested absence of
auscultation for expectoration of wheezes on auscultation.
secretions
- auscultate breath sounds, -​ Presence of
noting areas of decreased wheezes may
air-flow or presence of indicate
adventitious sound bronchospasm/
- provide quiet retained secretions
environment to allow the -​ External stimuli may
patient to relax prevent relaxation
or inhibit sleep
Collaborative:
-monitor pulse oximetry -​ To identify if hypoxia
is present
-hooked oxygen -​ Use as aid in
treatment
 DRUG STUDY

Drug Mode of action Indication Contraindication Side effects Adverse effect Nursing responsibilities
Generic Name: Inhibits calcium ion -Alone or with other Hypersensitivity; dizziness, fatigue, Arrhythmias, Assessment & Drug
amlodipine influx across cell agents in the Systolic BP <90 mm Hg. headache, insomnia, hypotension, Effects
​ membrane during management of Use Cautiously in: anxiety, nausea, bradycardia, -Monitor BP for
Brand Name: Norvasc cardiac hypertension, angina Severe hepatic vomiting, diarrhea, hypotension, gingival therapeutic
​ depolarization;produc pectoris, and impairment (dose gastric upset, hyperplasia, effectiveness. BP
Classifications: es relaxation of vasospastic reduction constipation, chest dyspepsia, nocturia, reduction is greatest
antihypertensives coronary vascular (Prinzmetal’s) angina. recommended); pain, cough, weight polyuria,urticaria, after peak levels of
Calcium channel smooth muscle, -Angina pectoris due Aortic stenosis; History gain, muscle cramps alopecia, dyspnea, amlodipine are
blockers peripheral vascular to coronary artery of HF; OB, Lactation, pruritus, epistaxis, achieved 6–9 h
Antianginal drug smooth muscle; dilates spasm Pedi: Children 6 yr pulmonary edema, following oral doses.
coronary vascular -Chronic stable (safety not sexual difficulties, -Monitor heart rate;
Category: Pregnancy arteries; increases angina, alone or in established); Geri: flatulence, syncope dose-related
Category C myocardial O2 combination with Dose reduction palpitations (more
​ delivery in patients other agents recommended; qrisk -CNS: dizziness, common in women)
Doctor’s Order: with vasospastic -Essential hypertension, of hypotension light-headedness, may occur.
10mg OD 1 tabl OD angina alone or in Contraindicated with headache, asthenia, Patient & Family
combination with allergy to amlodipine, fatigue, lethargy Education
other hypertensives. impaired hepatic or -CV: peripheral -Report significant
renal function, sick edema, arrhythmias swelling of face or
sinus syndrome, heart -Dermatologic: extremities.
block (second or third flushing, rash -Take care to have
degree​ -GI: nausea, support when standing
), lactation abdominal discomfort & walking due to
possible dose-related
 light-headedness/dizzi
ness.
-Report shortness of
breath, palpitations,
irregular heartbeat,
nausea, or
constipation to
physician
Generic name: Losartan works by Indicated to patients Contraindicated to -Dizziness -Sclera turns yellow Before:
Losartan blocking substances in for treatment of patients with: -Headaches -Irregular heartbeat -check doctor’s order
the body that cause hypertension and -Hyperkalemia -Swelling of face, eyes, -Abdominal pain -Monitored blood
Brand name: blood vessels to Diabetes Mellitus. -Hypotension lips, tongue, throat -Muscle cramps pressure
Cozaar tighten as a result it -Liver Problems -Nausea jaundice
relaxes blood vessels -Mild to moderate -Vomiting During:
Classification: lowering blood kidney impairment -Diarrhea -Regularly assess renal
Angiotensin II pressure and to help -Pain in the abdomen function (BUN)
Receptor Antagonist protect the kidneys * Indicated to the * It is contraindicated *The patient
from damage due to patient with elevated to the patient *The patient experienced After:
Doctor’s order: diabetes. blood pressure as because the patient experienced dizziness abdominal pain. Instructed patients
100 mgtab, 1 tab OD monitored. has hyperkalemia. and headache. immediately report for
swelling of face, eyes,
lips, tongue or throat
and other side effects
experienced by the
patient.
-Monitored blood
pressure and
respiratory rate
-Ensured patient safely
-Educated patient to
avoid salty and fatty
food.
Generic name: Ceftriaxone works by Ceftriaxone is used for contraindicated in Chest pain Black, tarry stools -Notify physician or
Ceftriaxone inhibiting the the treatment of patients with known Shortness of breath Chest pain nursing staff
mucopeptide infections. allergy to the Sore throat immediately if these
Brand name: synthesis in the cephalosporin group Swollen glands *the patient did not reactions occur.
Rocephin bacterial cell *This medication is of antibiotics. sores , ulcers in the experience any of the -
wall.10,11 The indicated to the mouth. following adverse Monitor injection site
Classification: beta-lactam moiety of patient because she is *it is not effects. for pain, swelling, and
cephalosporin ceftriaxone binds to at risk for infections. contraindicated to the *no signs and irritation. Report
antibiotics carboxypeptidases, patient. symptoms prolonged or
endopeptidases, and experienced by the excessive injection site
Doctor’s order transpeptidases in the patient. reactions to the
2g IV OD bacterial cytoplasmic physician.
membrane.

Generic name: A potent loop diuretic Treatment of edema Contraindications to -nausea or vomiting Gastrointestinal System -Assess fluid status.
Furosemide that works to increase associated with furosemide use -diarrhea -Hepatic -Monitor daily weight,
the excretion of Na+ congestive heart include patients with -constipation encephalopathy in intake, and output
Brand name: and water by the failure, cirrhosis of the documented allergies -stomach cramping patients with cirrhosis ratios, amount and
Furoscix, Lasix kidneys by inhibiting liver, and renal to furosemide and -feeling like you or the -Pancreatitis location of edema,
their reabsorption from disease, including the patients with anuria. room is spinning -Jaundice lung sounds, skin
Classification : the proximal and distal nephrotic syndrome, in (vertigo) (intrahepatic turgor, and mucous
Diuretics tubules, as well as the adults and pediatric -dizziness cholestatic jaundice) membranes.
loop of Henle. It works patients. -headache -Increased liver -Notify a health care
Doctor’s order: directly acts on the -blurred vision enzymes professional if thirst, dry
40 mg IV OD cells of the nephron *It is not -itching or rash -Anorexia mouth, lethargy,
and indirectly modifies *Indicated to the contraindicated to the -increased urination -Oral and gastric weakness,
the content of the patient because they patient. irritation hypotension, or
renal filtrate. give this drug after the *the patient -Cramping oliguria occurs.
blood transfusion. experienced -Diarrhea -Monitor BP and pulse
headache -Constipation before and during
administration.
*the patient did not
experience any of the
 following adverse
effects.
Generic Name: inhibits β-oxidation of Trimetazidine is contraindicated to -Dizziness -Rashes -Monitor blood
Trimetazidine fatty acids by blocking indicated for the patients with severe -Headache -Tachycardia pressure and pulse
long-chain symptomatic renal impairment. For -Stomach pain -Flushing rate before and after
Brand Name: 3-ketoacyl-CoA treatment of stable patients with -Diarrhea -arterial hypotension giving themeds
Vestar , thiolase, with the angina pectoris in moderate renal -Indigestion -Assess for
Vastarel effect of enhancing patients inadequately impairment and the -Feeling sick hypersensitivit to
glucose oxidation, controlled or intolerant elderly, -Vomiting trimetazidine,with
Classification: resulting in more to first line therapies. -Itching heart failure and
coronary vasodilator. efficient production of -Hives pregnancy.
Vasodilators open ATP with less oxygen -Feeling of weakness -Administer drug after
blood vessels demand. a patient has eaten
with a full glass of
Doctor’s Order: water.
35mg 1tab BID -Encourage patient to
continue efforts at
smoking cessation.
-Provide safety
measures if lethargy
occurs. -Notify
prescribing

GENERIC NAME: -Inhibits HMG-CoA -Used together with -Hypersensitivity to -Potential for Baseline assessment:
​ Atorvastatin reductase, the a proper diet to atorvastatin. cataracts -Obtain baseline
enzyme that lower cholesterol -Active hepatic -Photosensitivity cholesterol,
BRAND NAME: catalyzes the early and triglyceride disease, -Myalgia triglycerides, LFT.
​ Lipitor step in cholesterol (fats) levels in the breastfeeding, -Rhabdomyolysis.
synthesis. blood. This medicine pregnancy, -Obtain dietary
CLASSIFICATION: may help prevent unexplained history.
​ Antihyperlipid Therapeutic Effect: medical problems elevated LFT results.
Decreases LDL and (eg, chest pain, Intervention/evaluati
emic
DOCTORS ORDER: VLDL, plasma heart attack, or Cautions: on:
1tab OD triglyceride levels; stroke) that are -Anticoagulant -Monitor for
increases HDL caused by fats therapy; history of headache.
concentration. clogging the blood hepatic disease;
vessels substantial alcohol -Assess for rash,
consumption; pruritus, malaise.
patients with prior
stroke/TIA; -Monitor cholesterol,
concomitant use of triglyceride lab
potent CYP3A4 values for
inhibitors; elderly therapeutic
(predisposed to response.
myopathy).
Patient/family
teaching
-Follow special diet
-Do not take other
medications without
consulting physician.
-Do not chew, crush,
dissolve, or divide
tablets.
-Report dark urine,
muscle fatigue,
bone pain.
-Avoid excessive
alcohol intake, large
quantities of
grapefruit products.