NAME OF ORDERED MECHANISM OF CONTRA- SIDE EFFECTS NURSING

DRUG DOSE ACTOIN INDICATION INDICATION &ADVERSE RESPONSIBILITY

REACTONS
Ceftriaxone 1 gm Bactericidal: Perioperative Contraindicated with CNS: head ache,dizziness, > Know the 10 Rights in
IV Inhibits synthesis of Prophylaxis allergy to cephalosporin lethargy,parestesia drug administration
Q 12 hrs Bacterial cell wall, or penicillins or GI: nausea, vomiting, >Perform skin test before
X 4 doses causing cell death penicillins abdominal pain, flatulence, administering to detect if
liver toxicity the patient is allergic to
GU: nephrotoxicity the drug
Hematologic: bone >Assess for patient’s
marrow depression history of liver and renal
Hypersensitivity: ranging depression, lactation and
from rash, fever to pregnancy
anaphylaxis >Have vitamin K
Local: pain, inflammation available in case
at IV site hperprothombinemia
occurs
>Discontinue if
hypersensitivity occurs
>Inform the patient about
the side effects
>Instruct patient to avoid
alcohol while taking the
drug and for 3 days
because severe reactions
often occur

Tramadol 50 mg Binds to mu-opioid Relief of moderate to Contraindicated with CNS: sedation, dizziness > Know the 10 Rights in
IV receptors and inhibits moderately severe pain allergy to tramadol or or vertigo, head ache, drug administration
Q 8 hours the reuptake of opioids or acute confusion, dreaming , >Get patient’s history of
norepinephrine and intoxication with sweating, anxiety and allergy to tramadol or
serotonin; causes alcohol, opioids or seizures opioids
many effects similar psychoactive drug CV: Hypotension, >Inform the patrient
to the tachycardia, bradycardia about the side effects if
opioids,dizziness, sweating or CNS effects
constipation

XI. DRUG STUDY

 NAME OF ORDERED MECHANISM OF CONTRA- SIDE EFFECTS NURSING
DRUG DOSE ACTOIN INDICATION INDICATION &ADVERSE RESPONSIBILITY
REACTONS
Occur
>Limit use in patients
with past/present history
of addiction to or
dependence to opioids

Ketorolac 30 mg Anti-inflammatory Short-term management Contraindicated with CNS: head ache, dizziness, >Know the 10 Rights in
IV and analgesic activity; of pain significant renal insomnia, fatigue, tinnitus drug administration
Q 8 hours inhibits prostaglandins impairment, during labor Dermatology: rash, >Do not mix with
and leukotriene and delivery pruritus, sweating, dry morphine, sulfate,
synthesis mucous membrane mepiridine
GI: nausea, vomiting,
dyspepsia, gastro-intestinal >Instruct patient about
pain, diarrhea, constipation the side effects
GU: dysruia, renal
impairment
Respiratory: dyspnea,
hemoptysis, pharyngitis,
bronchospasm,
Other: peripheral edema,
anaphylactic reaction to
anaphylactic shock
 X. NURSING CARE PLAN

CUES NURSING ANALYSIS GOAL NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
S: “Nsakit pay lang P: Pain, Acute Appendectomy Date: June 23, 2009 Independent >To assess the etiology Date: June 23, ‘09
toy sugat ko.” ↓ Shift: 7-3 >Assess location, characteristic, or precipitating factors Time:2:00 pm
E: t/t disruption of Surgical Incision Time: 8:00 am onset, duration, frequency ,
O: skin, tissue and ↓ quality and severity of pain Goal met AEB:
>with pain scale of muscle integrity Disruption of skin, After 6 hrs of nursing >Note location of surgical Patient reported
4/10 secondary to tissue and muscle intervention the incision >As this can influence that her pain was
>with facial Surgical incision integrity patient will report the amount of post-op lessened from a
grimaces (Appendectomy) ↓ that her pain is lessen >Perform assessment each time experience pain scale of 4/10
>weak appearance Stimulation of sensory from a pain scale of pain occurs, note and investigate >To rule out worsening to 1/10 after 6
>guarding behavior S: AEB: patient’s nerve endings 4/10 to 1/10. changes from previous reports of underlying condition hours of nursing
verbalization of ↓ >Monitor V/S or development of intervention.
V/S: pain with a pain Pain complication
T: 36.6 °C scale of 4/10, facial >Provide quiet environment and >V/S are usually altered
P: 67 bpm grimace, guarding encourage adequate rest period in acute pain
R: 16 cpm behavior and weak Medical Nursing >Encourage use of relaxation >To prevent fatigue
BP: 100/80 mmHg appearance Incredibly Easy, technique and diversional
Pellico, L.H., activities
>To encourage sense of
>Provide additional comfort control and improve
measures such as back rub, coping activities/helps
changing patient’s position, control or alleviate pain
change linen as necessary >To relieve general
discomfort
Dependent
>Administer analgesic as >To maintain acceptable
ordered level of pain

Collaborative
>Instruct patient’s significant >To help control or
others to help patient divert pain alleviate pain
into other things

S:”Medyo agsakit- P: Activity Date: June 23, 2009 Independent

sakit gamin Intolerance Shift: 7-3 >Assess patient’s ability to >To assist in
Toy sugat ko lalo no Time: 8:00 am ambulate or move independently correcting/dealing with Date: June 23, ‘09
aggunay-gunay nak E: r/t limited Appendectomy and safely the situation Time:2:00 pm
adding.” mobility secondary ↓ After 6 hours of
O:
to pain Surgical Incision
↓
nursing intervention
the patient will be ,
>when standing allow legs to
>to prevent hypostatic
hypertension
Goal Met AEB:
Patient was able to
>Facial grimace S: AEB: patient’s Disruption of skin, able to move or dangle first; support him from ambulate without
upon moving verbalization of tissue and muscle ambulate without the side >Gradual increases assistance from
>patient puts her pain upon moving, integrity assistance from > Increase the client’s time out toward mutually others after 6 hours
hand above surgical facial grimace, ↓ others. of bed by 15 minutes each time. established, realistic of nursing
incision when patient puts her Stimulation of sensory Allow him to set a comfortable goals can promote intervention.
moving hand above surgical nerve endings rate of ambulation, and agree on compliance and prevent
>Slowed movement incision when ↓ a distance goal for each shift overexertion
>weak appearance moving, slowed Pain >Lesser pain will allow
>Inability to movement and ↓ >Encourage the client to increase the patient to concentrate
ambulate or walk weak appearance Increase of pain upon activity when pain is at a to walk or ambulate on
without assistance moving minimum or after pain relief her own
from others ↓ measures take effect. > Regular rest periods
V/S: > Plan regular rest periods allow the body to
T: 36.6 °C Limited mobility according to the client’s daily conserve and restore
P: 67 bpm ↓ schedule energy
R: 16 cpm Activity intolerance >Demonstrating
BP: 100/80 mmHg >Assist client in learning or appropriate safety
Medical Nursing trying to walk on her own measures to prevent
Incredibly Easy, injury
Pellico, L.H., >Motivate or encourage
>Teach the patient the patient to move or
importance of ambulating after ambulate on her own
surgery

Collaborative >To enhance patient’s

>Instruct significant others to ability or participate in
assist patient to promote comfort activities
measures to provide relief of
pain

S:”Medyo nagatel P: Impaired Skin Date: June 23, 2009

ading, nagmayat nga Integrity Shift: 7-3 Independent >Redness or swelling
kudkuden.” Time: 8:00 am >Inspect/assess incision site for indicates wound infection
E: r/t disrupted skin redness, swelling or signs of
O: layers secondary to After 6 hrs of nursing evisceration >To assist body’s natural Date: June 23, ‘09
>disrupted skin surgical incision intervention the >Keep the incision site clean and process of infection Time:2:00 pm
layers Surgical Incision patient will avoid dry, carefully change the
>wound area is S: AEB ↓ scratching at the dressing >To promote healing and Goal Met AEB:
warm to touch verbalization of Destruction of skin incision site >Regularly clean the wound prevent infection (-) Scratching on
>(+)slight itchiness on the layers aseptically > Preventing skin the incision site
swelling at the incision site, ↓ > Minimize skin irritation irritation eliminates a after 6 hours of
incision site disrupted skin Broken skin and potential source of nursing
layers, wound area traumatized tissue microorganism entry intervention.
V/S: is warm to touch, ↓ >They aid in skin healing
T: 36.6 °C (+) swelling at the Impaired Skin integrity >Instruct patient to increase
P: 67 bpm incision site intake of foods rich in protein,
R: 16 cpm Medical Nursing minerals and vitamins >Provides for early
BP: 100/80 mmHg Incredibly Easy, >Assess for presence or absence detection of developing
Pellico, L.H., of local wound infection infectious process
> Adequate rest and sleep
>Instruct patient to have helps in faster healing
adequate rest and sleep and recovery

> A wound typically

>Teach and assist the client in
the following:
a.supporting the surgical site
when moving
b.Splinting the area when
coughing, sneezing, or vomiting
Dependent
>Administer antibiotic as
ordered
requires 3 weeks for
strong scar formation.
Stress on the suture line
before this occurs can
cause disruption
>To prevent infection
and promote healing

Collaborative >To promote healing and

>Instruct patient’s significant prevent infection
others the proper way of caring
wound
P: Risk for
Infection Date: June 23, 2009 Independent >To prevent cross- Date: June 23, ‘09
O: Shift: 7-3 >Emphasize good hand washing contamination and to Time:2:00 pm
>presence of wound E: r/t surgical Time: 8:00 am technique for all individuals reduce risk for acquired
(surgical incision) at procedure Surgical Procedure coming in contact with the infection Goal Met AEB:
the right iliac region (Appendectomy) (Appendectomy) After 6 hours of patient >Provides for early
>disruption of skin ↓ nursing intervention >Inspect incision and dressing detection of developing >(-) chills,
layers S: AEB: presence Surgical Incision the occurrence of infectious process >(-) diaphoresis
>(+) slight swelling of surgical wound, ↓ infection will be >Suggestive of presence >(-) report of
at the incision site disruption of skin Destruction of Skin prevented as >Monitor V/S . Note onset of of infection/developing increasing
> wound area is layers, (+) slight Layers evidenced by no fever, chills, diaphoresis, reports sepsis abdominal pain
warm to touch swelling, wound ↓ s/sx of infection will of increasing abdominal pain >To promote healing and >afebrile with a
area is warm to Broken Skin and appear like >Regularly clean the wound prevent infection body temp of
Lab touch traumatized tissue diaphoresis, chills, aseptically >To prevent infection 36.9°C
>WBC is slightly ↓ abdominal pain and >Change wound dressings as after 6 hours of
elevated,12.0 Increased risk for fever. indicated, using aseptic nursing
x10^9/L environmental technique >Identify presence of intervention
exposure to pathogens >Examine wound in terms of healing and provides for
V/S: ↓ appearance, odor and quantity of early detection of wound
T: 36.6 °C Risk for Infection drainage infection
P: 67 bpm >Provides for early
R: 16 cpm Medical Nursing >Observe for localized sign of detection of developing
BP: 100/80 mmHg Incredibly Easy, infection infectious process
Pellico, L.H.,

Dependent >Antibiotics inhibits

>Administer antibiotics as DNA synthesis in
ordered specific anaerobes
causing cell death
>elevated WBC indicates
>Monitor WBC infection

Collaborative >To promote healing and

> Instruct patient’s significant prevent infection
others the proper way of caring
wound

XII. DISCHARGE PLAN

 DIET
 DIET FOODS ALLOWED FOODS TO BE AVOIDED

Without Restriction In Moderation

Regular Diet All Healthy and Nutritious foods N/A N/A
(Any food which will make the body especially green leafy vegetables
healthy, provide growth of tissue, boost
the immune system, and make the
body stronger and healthier)

 TAKE HOME MEDICATIONS

NAME DOSAGE AND TIME FREQUENCY DURATION SIDE EFFECTS WHAT TO DO MEDICATIONS
ACTION AND ADVERSE AND FOODS TO
REACTIONS BE ALLOWED

Tramadol 700 mg, 1 cap 8:00 am TID Until there’s pain CNS: sedation, Discontinue if Alcohol. T ramadol
12:00 noon dizziness or hypersensitivity may impair mental
04:00 pm vertigo, head ache, occurs ability and physical
confusion, coordination.Alcohol
dreaming , may intensify these
sweating, anxiety effects and increase
and seizures the risk of accidental
CV: Hypotension, injury.
tachycardia,
bradycardia

CNS: Headache,
Cefuroxime 500 g 8:00 am TID For 5 days dizziness, lethargy, N/A
Analgesic 12:00 noon paresthesias Discontinue if
>inds to mu- 04:00 pm GI: Nausea, hypersensitivity
opioid receptors vomiting, diarrhea, reaction occurs
 and inhibits the anorexia,
reuptake of abdominal pain,
norepinephrine flatulence,
and serotonin; pseudomembranous
causes many colitis, liver
effects similar to toxicity
the Hematologic:
opioids,dizziness, Bone marrow
constipation depression:
decreased WBC,
decreased platelets,
decreased Hct
GU:
Nephrotoxicity
Hypersensitivity:
Ranging from rash
to fever to
anaphylaxis, serum
sickness reaction
Local: Pain,
abscess at injection
site; phlebitis,
inflammation at IV
site
Other:
Superinfections,
disulfiram-like
reaction with
alcohol

 ACTIVITIES AND REHABILITATION

ALLOWED NOT ALLOWED MODIFIED

>Doing light house hold chores Avoid Repetitive Activities, Including Pillow Talk
Driving
 Most doctors order limited activity following an Keep a pillow handy at all times while you are
appendectomy for at least 3 weeks. This includes no recovering from an appendectomy. Use the pillow to
driving because of medications you may be taking. splint your abdomen when you cough or sneeze.
You must not do any strenuous activities, including Press the pillow firmly against your lower abdomen
anything that requires repetitive motions, including (across your incision area) until your coughing or
such things as pressing the foot pedals while driving sneezing fit passes. This not only helps you comfort-
a vehicle and bending up and down getting pots and wise by minimizing pain from the strain of coughing
pans out of low cabinets in your kitchen. and sneezing, but it also helps prevent popping
stitches. You may also want to press a pillow against
No Heavy Lifting your lower abdomen when you get up and down, at
least for the first couple of days.
While you are recovering from your surgery, you
must not lift anything that weighs over 15 pounds.
Heavy lifting puts too much strain on your lower
abdomen and your abdominal muscles. Strain on
your lower abdomen may rupture the repairs your
surgeon accomplished on the inside while the tissues
and muscles are healing. Heaving lifting may also
pop the stitches in your incision.

 SPECIAL CARE INSTRUCTION

PROCEDURE AND TREATMENT TIME FREQUENCY DURATION

Proper wound Care technique After taking a bath or before sleeping No standard frequency for how often Until the wound have healed and skin
>Using aseptic technique when the dressing should be changed, it is intact
changing the dressing, be especially depends on amount of drainage and
vigilant in performing hand hygiene nature of wound, so it can be as needed
thoroughly before and after changing or daily
the dressing and in adhering to
standard precaution
>Cleanse area around the incision site
>Monitor incision for signs and
symptoms of infection
>Use one gauze square for each wipe,
discarding each square by dumping in
the plastic bag
>Clean around drain, if present,
moving from center outward in a
circular motion, use one gauze square
for each circular motion
>Apply a layer of dry, appropriate
sterile dressing over the wound