NCP 1

Asssessmen
Nursing
diagnosis
Plan of
care
Interventi rationale
ons
Objectives
Subjective:
masakit ang ulo
ko verbalize by the
patient
Altered Comfort:
headache
related to
increased
intracranial
pressure
secondary to
fluid
accumulation in
the intracranial
space
Short Term
Objectives
At the end of
8
hour
of
nursing
intervention ,
the
patient
will be able to
Display
relief
of
pain from
4/5
to
2/5.
Appear
relaxed
and able
to
sleep/rest
appropriat
ely.
Independent
1 Determine
specifics of
pain e.g.
location,
characteristics,
intensity (0-5
scale), onset/
duration, note
nonverbal cues.
2.
Encourage/mai
ntain bed rest
during acute
phase.
Subjective :
Restlessness
Diaphoresis
Change in BP,
RR, HR
Facial grimace
3.
Provide/recom
mend non
pharmacologic
measures for
relief of
headache.
4. Monitor vital
signs regularly
5. Provide
comfort
measures such
as touch,
positioning and
back rub.
6. Reposition
patient every 2
to 4 hours
Facilitate
diagnosis of
problem
and
initiation of
appropriate
therapy.
evaluatio
n
Short Term
Objectives
At the of 8 hou
of nursing
intervention,
the patient wil
be able to:
Display
relief
o
Minimizes
pain from
4/5 to 2/5.
stimulation
Appear
/promotes
relaxed and
relaxation
Measures
able to
sleep/rest
that
appropriate
reduce
y.
cerebral
.
vascular
pressure
and that
slow/ block
sympatheti
c response
are
effective in
relieving
headache
and
associated
complicati
ons.
Change
in
vital
signs
indicates
acute
pain and
discomfor
t.
To
promote
non
pharmac
ological
pain
manage
ment
To
promote
comfort,
thus
alleviatin
g
pain
and
promote
circulatio
n.
name of
drug
Mechanism
of action
indications
contraindicatio
ns
Adverse
effect
Nursing
considaratio
n
Generic:
Nalbuphine
Nalbuphine
acts as an
agonist at
specific opioid
receptors in
the CNS to
produce
analgesia,
sedation but
also acts to
cause
hallucinations
and is an
antagonist at
receptors
Relief of
moderate to
severe pain
Hypersensitivity
to nalbuphine,
sulfites;
lactation.
-Use cautiously
with emotionally
unstable clients
or those with a
history of
narcotic abuse;
pregnancy prior
to labor, labor or
delivery,
bronchial
asthma, COPD,
respiratory
depression,
anoxia,
increased
intracranial
pressure, acute
MI when nausea
and vomiting
are present,
CNS:
nervousness,
crying,
depression,
restlessness,
euphoria,
hostility,
confusion,
faintness,
floating,
unusual
dreams,
numbness,
feeling of
heaviness, and
psychotomime
tic effects such
as
hallucinations,
feeling of
unreality and
dysphoria.
-Monitor
respiratory
rate before
and after
giving nubain
because it
causes
respiratory
depression
-Monitor I and
O to
determine if
there is
excessive fluid
loss
-Monitor Bp
before and
after
administering
the
medication to
prevent any
complication
Brand:
Nubain
Cardiovascul
ar:
biliary tract
surgery.
name of
drug
Mechanism
of action
indications
hypertension,
hypotension,
bradycardia,
tachycardia.
contraindicatio
ns
Adverse
effect
Nursing
considaration
Generic
name:
Manitol
Brand name:
Osmirol
Increases
osmotic
pressure of
plasma in
glomerular
filtrate ,
inhibiting
tubular
reabsorotion
of water
andelectrolyte
s.
These actions
enchance
water flow
from various
tissues
ultimately
decrease
intracranial
and
intraocular
pressure
Test dose for

marked oliguria
or suspected
inadequate renal
function , prevent
acute fail during
cardiovascular
and other
sugeries, acute
renal failure , to
reduce
intracranial
pressure and
brain mass ,
reduce
intraocular
pressure , to
promote dieresis
in drug toxicity ,
irrigation during
transurethralresct
ion of prostate
Active
intracranial
bleeding, anuria
secondary to
severe renal
disease ,
progressive
heart failure,
pulmonary
congestion ,
renal damage ,
or renal
dysfunction after
mannitoltherapy
begins
Cns: dizziness ,
headache ,
seizures
CV: chest pain ,
hypotension ,
hypertension ,
tachycardia ,
thromboplebitis
,
Do not give
electrolyte
free manitol
with blood . if
solution
chloride to
each liter of
manitol.
name of
drug
Mechanism
of action
indications
contraindications
Adverse
effect
Generic:
Ketorolac
Inhibits
prostaglandi
n
Synthesis by
decreasing
the activity
of the
enzyme,
cyclooxygen
ase, which
results in
Decreased
formation of
prostaglandi
n
precursors,
chemicals
that cells of
the immune
system
make that
cause the
redness,
fever, and
pain of
inflammatio
n and that
also are
believed to
be
important in
the
production
of noninflammator
y pain
Used for
treating
inflammatio
n and pain
in the
operation
site.
Hypersensitivity
to
ketorolac, aspirin,
other NSAIDs, or
any component
of the
formulation;
patients
who have
developed nasal
polyps,
angioedema, or
bronchospastic
reactions to other
NSAIDs; active or
history of peptic
ulcer
disease;recent or
history of GI
bleeding or
perforation;
patients with
advanced renal
disease or risk of
renal failure.
Prophylaxis
before major
surgery;
suspected or
confirmed
cerebrovascular
bleeding;hemorrh
agic diathesis
Rash
Headaches
Dizziness
Drowsiness
Abdominal
pain
Nausea
Diarrhea
Constipation
Heartburn
Fluid
retention
Brand:
Toradol
Nursing
considaratio
n
-Instruct
client to
avoid
alcohol and
maintain
adequate
hydration
(2-3 L/day of
fluids)
unless
instructed to
restrict fluid
intake.
-Monitor for
signs of pain
relief, such
as an
increased
appetite and
activity
-Instruct
client to
avoid taking
ketorolac
with aspirin
or other
NSAIDs such
as ibuprofen
(Motrin,
Advil),
naproxen
(Aleve,
Naprosyn),
piroxicam
name of
drug
Mechanism
of action
indications
contraindicatio
ns
Adverse
effect
Nursing
considaration
Generic
name:
Diazepam
Exact
mechanisms
of action not
understood
act mainly at
The limbic
system and
reticular
formation.
Management of
anxiety
disorders or for
short term relief
of anxiety.
Contraindicate
d with
hypersensitivity
to
benzodiazepine
s , psychoses ,
acute narrow
angle
gla0cuma ,
shock , coma ,
acute alcoholic
in toxicities.
CNS:
transients ,
mild
drowsiness ,
initially ,
sedation
depression ,
lethargy ,
apathy ,
fatigue , light
head.
Restless and
nasal tension
CV:
bradycardia ,
cv collapse
hyper and
hypotension.
GI:
constipation ,
diarrhea and
vomiting.
Do not
administer
intra
arterially ,
may produce
arteriospasm
, gangrene.
Brand
name:
Apodiazepam
name of
drug
Mechanism
of action
indications
contraindicatio
ns
Adverse
effect
Nursing
considaration
Generic
name:
metronidaz
ole
Brand
name:
flagyl
Inhibits DNA
synthesis in
specific a
anaerobes
causing cell
death :
antiprotozoal
trchomanecei
dal.
Acute infection
with susceptible
anaerobic
bacteria
Contraindicate
d with
hypersensitivit
y to
metronidazole.
Cns:
headache ,
dizziness,
ataxia ,
vertigo and
incoordinatio
n.
GI:
unpleasant
metallic ,
anorexia ,
nausea and
vomiting.
Avoid use
unless
needed.
Metronidazol
e may be
carcinogenic.

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