PLANNING

NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Subjective Cues Acute pain After 2 hours of A. Evaluate pain at Provides information A. Pain levels were After 2 hours of
 Patient experienced the related to nursing intervention, regular intervals about need for or monitored every nursing intervention,
symptoms a couple of disruption of the patient will be able regularly (every 30 effectiveness of 30 minutes. the patient was be able
days ago skin, tissue, and report 3/10 pain minutes noting the interventions. With report 3/10 pain
 The mother of the patient muscle integrity perception as evidenced characteristics and post-surgery, it is not perception as evidenced
reported that the child by: intensity using the 0- possible to by:
also complained of pain  Absence of facial 10 scale). completely eliminate  Absence of facial
in right ear at night mask of pain pain, but analgesics mask of pain
 Patent verbalized  Stable vital signs, can manage it to a  Stable vital signs,
frequent episodes of particularly pulse tolerable level. particularly pulse
tonsilitis rate rate
 Improved focus  Improved focus
Objective Cues  Decreased B. Emphasize Reporting of pain and B. Patient was able  Decreased guarding
 Vital Signs (Pre-op): guarding behaviors patient’s relief can help the to report pain felt behaviors
 Blood pressure:  Appearing relaxed responsibility for health care team and relief of pain.  Appearing relaxed
120/80 mmhg and less tensed reporting pain/ relief understand further and less tensed
 Heart Rate: 90 bpm of pain completely. interventions needed
 Respiratory Rate: 22 to be done.
bpm
  Temp: 38.5 degrees C. Encourage soft Cold food is proven C. Soft and cold food
Celsius food and cold drinks to subside pain were encouraged
 Height: 5’4 such as ice cubes, through numbing the and included in
 Weight: 54 kg low-fat ice creams, area, and soft rather the diet of the
 Febrile popsicles, jell-o and than hard and cruncy patient.
 Dysphagia pudding after full food are also
 Congested and recovery from encouraged to reduce
inflammed eardrums, anesthesia. strain on the injured
especially on the right site.
 Inlammed tonsils
 Patient underwnt D. Encourage the Hydration is D. Patient was able
laboratory tests with the patient to drink important to prevent to drink plenty of
following results: plenty of water. dehydration that may water, amoutning
 white blood cell put the patient at to 1500 mL per
count: 20,500/μL stress and incease day.
(20.5×109/L), pain perception.
 Prothrombin time
(PT): 10-12 seconds
 Partial E. Monitor patient Post tonsillectomy
thromboplastin time tonsils for possible bleeding is
(PTT): 30-45 signs of bleeding. uncommon but is a
 seconds potentially life
 International threatening event that E. No signs of
normalized ratio causes intentse pain bleeding was
(INR): 1:2 ratio on the site of injury. observed.
 Patient underwent
surgery and was brought
to PACU with the F. Promote bed rest. Adequate bed rest can
following orders: prevent further
 Tramadol fatigue and may help
hydrochloride in alleviating pain.
(Ultram) 100 mg IV F. Patient was
every 6 hours PRN G. Provide oral care Salt water gargle is a comliant and
for pain using salt water non-aggressive observed
 Co- amoxiclav 1.2g gargle. antibacterial complete bed rest.
IVTT every 8 hours mouthwash.
for 3 doses G. Oral care was
 Series IVF performed.
 Paracetamol 1 amp
every 4 hrs prn for H. Promote Nonpharmacological
fever nonpharmacological pain management and
 vs every 4 hrs pain management other diversional
such as diversional activities are used to H. Nonpharmacologi
activities. alter psychological cal pain
responses to pain. management was
The distraction offered by the
technique works by nurse and
drawing the observed by the
concentration of the patient.
patient upon non-
painful stimuli to
decrease one’s
awareness and
experience of pain.
Distraction from the
pain lessens the
perception of pain.
Examples include
reading, watching
TV, playing video
games, guided
imagery.
 I. Administer Analgesics either
analgesics work as stimulants of
asprescribed by the opioid receptors to
physician relieve pain or I. Medications were
prevent the synthesis administered.
of prostaglandin
(which is released as
an inflammatory
response and triggers
nociceptors).

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Subjective Cues Risk for injury After 6 hours of nursing A. Assess general status This is to determine A. Data about general After 6 hours of
 Patient experienced the related to interventions, the of the patient including the level of status and orientation nursing interventions,
symptoms a couple of diorientation and patient will remain free patient orientation. orientation of the of the patient were the patient remained
 days ago sensory/perceptu from injury evidenced patient that may put obtained. free from injury
 The mother of the patient al disturbances by: him at higher risk for evidenced by:
reported that the child due to anesthesia  Absent skin injury.  Absent skin
also complained of pain breakdown or breakdown or
in right ear at night injury aside from B. Assess personality Style of personality B. The patient has a injury aside from
 Patent verbalized the site of surgical style that may result in aid to determine the compliant personality the site of surgical
frequent episodes of intervention carelessness. patient’s level of style as assessed. intervention
tonsilitis  No manifestations cooperation.  No manifestations
of pressure ulcers of pressure ulcers
Objective Cues  Remaining free C. Provide medical Signs like medical C. Medical attention  Remaining free
 Vital Signs (Pre-op): from falls attention bracelet to the bracelets are vital for bracelet was provided from falls
 Blood pressure: patient. patients at risk for and worn by the
120/80 mmhg injury because of patient.
 Heart Rate: 90 bpm general anesthesia.
 Respiratory Rate: 22 This will help
bpm healthcare providers
 Temp: 38.5 degrees identify patients who
Celsius they are responsible
 Height: 5’4 for implementing
 Weight: 54 kg actions to promote
 Febrile patient safety.
 Dysphagia
 Congested and D. Thoroughly Familiarzing the D. Patient was
inflammed eardrums, introduce the patient to patient of his introduced to his
especially on the right his surroundings. Place environment will help surroundings.
 Inlammed tonsils the call light within him to avoid
 Patient underwnt reach and teach the accidents. Items that
laboratory tests with the patient on how to call are too far from the
following results: for assistance. patient may cause
 white blood cell hazard.
count: 20,500/μL
(20.5×109/L), E. Ask the mother or This is to provide E. The mother was
 Prothrombin time other relatives to be 24/7 assistance to the adised to stay with
(PT): 10-12 seconds with the patient to patient and to prevent her son at all times.
 Partial prevent him from him from accidentally
thromboplastin time falling during attempts falling or pulling out
(PTT): 30-45 to rise. tubes.
seconds
 International F. Remove all possible Removing this will F. All possible
normalized ratio hazards in the room, save the patient from hazards were
(INR): 1:2 ratio including extreme hot harms due to removed.
 Patient underwent general and cold items or dangerous objects.
 anesthesia equipment.
 Patient underwent
surgery and was brought G. Set the safety bed Bed rails are help G. Safety bed rails
to PACU with the rails. prevent injury from were set.
following orders: falls.
 Tramadol
hydrochloride H. Encourage Positioning reduces H. Patient was
(Ultram) 100 mg IV positioning every 2 the risk for pressure positioned every 2
every 6 hours PRN hours. ulcers in bone hours.
for pain prominent areas of
 Co- amoxiclav 1.2g the body.
IVTT every 8 hours
for 3 doses
 Series IVF
 Paracetamol 1 amp
every 4 hrs prn for
fever
 vs every 4 hrs

Sources:
NANDA International & Herdman, T. H. (2018). NANDA International Nursing diagnoses: Definitions and classification 2018-2020. Wiley-Blackwell.

Vera, M. (2020). 13 Surgery (Perioperative Client) Nursing Care Plans. Nurseslabs. https://nurseslabs.com/13-surgery-perioperative-client-nursing-care-plans/3/

Wayne, G. (2017). Risk For Injury Nursing Care Plan. Nurseslabs. https://nurseslabs.com/risk-for-injury/

DRUG STUDY
A. D5LR 1L @ 30 gtts/min

GENERIC NAME: MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE

NURSING RESPONSIBILITY
lactated ringer's in 5% dextrose Hypertonic solutions are those that have an REACTION
injection effective osmolarity greater than the body fluids.  Itching  Do not administer unless

This pulls the fluid into the vascular by osmosis  Hives solution is clear and container
 resulting in an increase vascular volume. It raises  Swelling of the face is undamaged.
intravascular osmotic pressure and provides fluid,  Puffy eyes  Caution must be exercised in
electrolytes and calories for energy.  Coughing the administration of
BRAND NAME: INDICATION:
 Sneezing parenteral fluids, especially
Lactated Ringer's in 5% Dextrose Lactated Ringer's and 5% Dextrose Injection, USP is
 Sore throat those containing sodium ions
DRUG ILLUSTRATION: indicated as a source of water, electrolytes and calories or
as an alkalinizing agent. to patients receiving
 Difficulty breathing
corticosteroids or
 Fever
corticotrophin.
 Injection site reactions (infection,
 Solution containing acetate
swelling, redness)
should be used with caution as
CLASSIFICATION: CONTRAINDICATION: excess administration may
Intravenous Nutritional Products Solutions containing dextrose may be contraindicated in result in metabolic alkalosis.
DOSAGE/FREQUENCY/ROUTE: patients with known allergy to corn or corn products.
 Solution containing dextrose
Adult: 30 gtts/min, IV should be used with caution in
patients with known
subclinical or overt diabetes
mellitus.
 Discard unused portion.
 In very low birth weight
infants, excessive or rapid
 administration of dextrose
injection may result in
increased serum osmolality
and possible intracerebral
hemorrhage.
 Properly label the IV Fluid
 Observe aseptic technique
when changing IV fluid

B. Tramadol hydrochloride (Ultram) 100 mg IV every 6 hours PRN for pain

GENERIC NAME: MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE

NURSING RESPONSIBILITY
tramadol HCl Tramadol is a centrally acting μ-opioid receptor REACTION
agonist and SNRI (serotonin/norepinephrine  Itching  Advise patient that centrally

reuptake-inhibitor) that is structurally related to  Hives acting analgesics are usually

codeine and morphine. This drug ninds to mu-  Swelling of the face more effective if given before

opioid receptors. Inhibits reuptake of serotonin  Puffy eyes pain becomes severe;

and norepinephrine in the CNS.  Coughing emphasize that adequate pain

BRAND NAME: INDICATION: control will allow better
 Sneezing
Ralivia, Ultram, Ultram ER participation in recovery.
DRUG ILLUSTRATION:  Sore throat
 Tramadol is approved for the management of  Difficulty breathing
moderate to severe pain in adults.  Fever  Emphasize that the risk of
 Injection site reactions (infection, physical addiction (tolerance
swelling, redness) and dependence) is usually
minimal during short-term

CLASSIFICATION: CONTRAINDICATION: treatment of pain. Advise

Therapeutic: analgesics (centrally Patients who have had a hypersensitivity reaction patient that addiction is more

acting) to any opioid. likely during excessive or

Pharmacologic: opioid agonists inappropriate use of centrally

DOSAGE/FREQUENCY/ROUTE: acting analgesics.
Adult: 100 mg IV every 6 hours
 Advise patient to avoid
alcohol and other CNS
depressants because of the
increased risk of sedation and
decreased CNS function.

 Advise patient to increase

fluid intake.

C. Co- amoxiclav 1.2g IVTT every 8 hours for 3 doses

 GENERIC NAME: MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE
NURSING RESPONSIBILITY
co-amoxiclav or Amoxicillin binds to penicillin-binding proteins REACTION
amoxicillin/clavulanic acid within the bacterial cell wall and inhibits  Severe stomach pain,  Instruct patient to notify

bacterial cell wall synthesis. Clavulanic acid is a  Diarrhea which is watery or bloody physician immediately of

β-lactam, structurally related to penicillin, that  Pale or yellowed skin signs of superinfection,

may inactivate certain β-lactamase enzymes.  Dark colored urine including black, furry
BRAND NAME: INDICATIONS: overgrowth on tongue and
 Fever
Augmentin loose or foul-smelling stools.
 Swelling
DRUG ILLUSTRATION: Treatment of otitis media, sinusitis, and  Check the site of IV insertion
 Burning eyes
respiratory infections. for possible inflammation
 Skin pain followed by a red or
after administration of the
purple rash that spreads (on the face
drug.
or upper body) with blisters and
 Instruct patient and
peeling
family/caregivers to report
 Nausea
CLASSIFICATION: CONTRAINDICATION: other troublesome side effects
 Diarrhea
Therapeutic: anti-infectives, antiulcer Contraindicated in patients with a history of such as severe or prolonged
agents serious hypersensitivity reactions (e.g., skin problems (rash, itching)
Pharmacologic: aminopenicillins anaphylaxis or Stevens-Johnson syndrome) to or GI problems (nausea,
DOSAGE/FREQUENCY/ROUTE: amoxicillin, clavulanate or to other beta lactam vomiting, diarrhea).
Adult: 1.2g IVTT every 8 hours for 3 antibacterial drugs (e.g., penicillins and
doses cephalosporins).

Contraindicated in patients with a previous

history of cholestatic jaundice/hepatic
dysfunction associated withc co-amoxiclav.

D. Paracetamol 1 amp every 4 hrs prn for fever

GENERIC NAME: MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE

NURSING RESPONSIBILITY
Paracetamol Paracetamol exhibits analgesic action by REACTION
peripheral blockage of pain impulse generation. It  Nausea  Instruct patient and

produces antipyresis by inhibiting the  Vomiting family/caregivers about the

hypothalamic heat-regulating centre. Its weak  Constipation. signs of liver toxicity and

anti-inflammatory activity is related to inhibition  Headache renal failure. Signs include

of prostaglandin synthesis in the CNS.  Difficulty sleeping severe nausea and vomiting,
BRAND NAME: INDICATIONS: yellow skin or eyes, fever,
 Erythema
Naprex, Amadol sore throat, malaise, weakness,
DRUG ILLUSTRATION:  Flushing
Treatment of fever and mild to moderate pain. facial edema, lethargy, and
 Pruritus.
  Pain and burning sensation at IV unusual bleeding or bruising.
site  Encourage early recognition
 Thrombocytopenia and notification of the
 Liver failure physician about these signs.
 Instruct patient and
CLASSIFICATION: CONTRAINDICATION:
family/caregivers to report
Therapeutic: antipyretics, nonopioid Hypersensitivity to the drug. Severe hepatic
severe or prolonged skin
analgesics impairment or active liver disease (IV).
DOSAGE/FREQUENCY/ROUTE: reactions such as rash, itching,

Adult: 1 amp every 4 hrs pm and hives.

 Assess pain to document
whether this drug is successful
in helping manage the
patient's pain and decreasing
impairments.
 Monitor signs of leukopenia
and neutropenia (fever, sore
throat, signs of infection) or
unusual weakness, fatigue,
and excessive bleeding that
might be due to anemia or
 other blood dyscrasias. Report
these signs to the physician.

References:

Ciccone, C. D. (2016). Acetaminophen. In Davis’s Drug Guide for Rehabilitation Professionals. Opgehaal van fadavispt.mhmedical.com/content.aspx?aid=1134158387

Ciccone, C. D. (2016). Amoxicillin. In Davis’s Drug Guide for Rehabilitation Professionals. Opgehaal van fadavispt.mhmedical.com/content.aspx?aid=1134159723

Ciccone, C. D. (2016). Tramadol. In Davis’s Drug Guide for Rehabilitation Professionals. Opgehaal van fadavispt.mhmedical.com/content.aspx?aid=1134187043

DrugBank. (2021). Tramadol. https://go.drugbank.com/drugs/DB00193

RxList. (2020). AUGMENTIN. https://www.rxlist.com/augmentin-drug.htm#description.