ASSESSMENT Subjective: Nahihilo ako as verbalized by the client.

Objective: - Facial Grimace - Weak in appearance - Slowed movement and reaction - Irritable at times - Bed Rest

NURSING DIAGNOSIS Risk for Injury related to neurologic status and post-operative state as manifested by bed rest, malaise, and facial grimace.

PLANNING After 8 hours of nursing interventions the client will be able to demonstrate and identify risk factors and is free from any injury as evidenced by the absence of any wounds, keeping side rails up and verbalization of own safety.

INTERVENTIONS

RATIONALE

EVALUATION After 8 hours of nursing interventions, goal was met, the client was able to demonstrate and identify risk factors and is free from any injury as evidenced by the absence of any wounds, keeping side rails up and verbalization, sige, mag-papaalalay at mag-iingat ako kapag may gagawin o tatayo.

1. Kept and instructed 1. to prevent fall. client to keep side rails up. 2. Demonstrated and 2. to promote safety emphasized to clients when doing something. SOs how to assists client when ambulating or doing a task. 3. Positioned and kept 3. to reduce fatigue. client safe and comfortable at all times. 4. Modified 4. to prevent slippery environment, removed and having an injury. all sharps and slippery objects in her room. 5. Administered 5. to treat underlying medications as conditions. prescribed by the physician. 6. Collaborated and 6. to have safe and referred to physical recommended activity therapist for for her status. individualized interventions.

ASSESSMENT Subjective: Nagsuka ako, wala akong gana kumain as verbalized by the client. Objective: - (+) vomiting - weak in appearance - 25% of food were consumed - post operative status

NURSING DIAGNOSIS Risk for imbalanced nutrition less than body requirements related to loss of appetite as manifested by vomitus, and malaise.

PLANNING After 8 hours of nursing interventions the client will be able to verbalized importance of proper nutrition as evidenced by verbalization of own understanding.

INTERVENTIONS

RATIONALE

EVALUATION After 8 hours of nursing interventions, goal was met, the client was able to verbalized importance of proper nutrition as evidenced by verbalization,

1. Monitored vital signs 1. for baseline data. and recorded. 2. Monitored intake and 2. to know fluid status. output and recorded 3. Instructed client to 3. to prevent restrict fluids before satiety. meals. 4. Encouraged to pick 4. to increase her food, if necessary. appetite. 5. Use flavoring agents, 5. to increase if appropriate. appetite. 6. Demonstrated proper 6. to increase nutrition high in resistance. vitamins and minerals. early

sana hindi na ako magsuka, para makakain her na ako ng tama.

her

body

7. Administered 7. to treat underlying medications, as condition. prescribed. 8. Collaborated and 8. to have individualized referred to nutritionist, and proper diet as necessary. according to her condition.

GENERIC NAME/ BRAND NAME

ROUTE/ DOSAGE

INDICATION

CONTRAINDICATION

ADVERSE REACTION

NURSING IMPLICATION Avoid alcohol while taking this drug and for 3days after because severe reactions often occur. You may experience these side effects: stomach upset, diarrhea.Report severediarrhe a,difficulty breathing,unus ualtiredness or fatigue, pain at injection site. Monitor for and immediately report S&S of angioedema or a severe skin reaction. Lab tests: Urea breath test 46 wks after completion of therapy. Patient & Family Education Contact physician promptly if any of the following occur: Peeling, blistering, or loosening of skin; skin rash, hives, or itching; swelling of the face, tongue, or lips; difficulty breathing or

Cefoxitin (Monowel)

IV 1 gram q8

Prevention of infection

Contraindicated with allergy to cephalosporins or penicillins. Use cautiously with renal failure, lactation, pregnancy

Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence

Pantoprazole (Pantoloc)

IV 40 mg OD

Pathologic gastric hypersecretory conditions

Hypersensitivity. Lactation. Use cautiously in pregnancy and children

Headache, abdominal pain, diarrhea, eructation, flatulence, hyperglycemia

swallowing. Do not breast feed while taking this drug without consulting physician.

Ketorolac (Ketomed)

IV 30 mg q6

Short-term management of pain (up to 5 days)

Contraindicated with significant renal impairment, aspirin allergy, recent GI bleed or perforation Use cautiously with impaired hearing; allergies; hepatic conditions

CNS:headache,dizziness,s omnolence,insomnia,fat igue,dizzinesstinnitus,op hthalmologic effects

Renal impairment, Impaired hearing, allergies, hepatic, Skin color and lesions, orientation, reflexes, peripheral sensation, clotting times, CBC, adventitious sounds. Be aware that patient may be at risk for CV events, GI bleeding, renal toxicity, monitor accordingly. Keep emergency equipment readily available at time of initial dose, in case of severe hypersensitivity reaction . Protect drug vials from lh g. it Administer every 6 hrs to maintain serum levels and control pain.