A. MEDICAL MANAGEMENT a. IVT, Blood transfusion, Nebulization, Total parenteral nutrition, NGT, Oxygen therapy etc.

Generic/Brand Name

Date Ordered / Date Discontinue

Route of Administration / Dosage / Frequency

General Description

Indication

Clients Response

Nursing Considerations

D5LR

June 22, 2013 Ordered June 27, 2013 Discontinue

TIV D5LR 1L

D5LR is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply in a single dose container for IV administration.

Indicate for parental replacement for extracellular losses of fluid and electrolytes, as required by the clinical condition of the patient.

Patient respond to treatment without any allergic reaction.

Before: -Check for doctors order for IV insertion, its drop factor and amount ordered During: -Make sure that the cannula is in place. -Assess the site for bleeding and swelling. Make sure that IV infusion is in correct regulation. -Secure the tube, make sure that it is not dislodging After: Document date and time given and date discontinued.

B. DRUG STUDY
Generic / Brand Name/ Classification Date Ordered/ Given / Discontinued Route of Administration / Dosage / Frequency Mechanism of Action Clients Response

Nursing Responsibility

Cefuroxime Anti-bacterial agent

June 22,2013 Ordered June 22,2013 Given June 25,2013 Discontinued

TIV 750 mg Q8

Inhibits cell-wall synthesis, promoting osmotic instability. Usually bactericidal.

Client respond to treatment without any allergic reaction.

Ask patient hes had any reaction to previous cephalosporins or penicillin theraphy Advice that drug might indicate possible side effects. Assess for allergic reactions, if reactions occur stop the medication. Document the medication, dosage, date and time of administration, route and signature. Assess pain, note type, location and intensity prior and following administration. Instruct patient on how or when to ask for and take pain medication. Instruct the patient that this drug may cause drowsiness or dizziness. Assess for allergy, discontinue if allergy occurs. Advice patient to consult if rash, itching, edema, block stools, persistent headache, influenza-like syndromes (chills, fever, muscle aches, pain) occurs Document the medication, dosage, date and time of administration, route and signature. No anti inflammatory should be given. This includes aspirin and the like.

Ketorolac Nonsteroidal Antiinflammatory agents

June 23,2013

TIV 30mg Q6

Inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Also has antipyretic and antiinflammatory properties

The client did not encounter any allergic reaction to the drug

Competitively inhibits

Ranitidine Anti-ulcer agents

June 23,2013

TIV Q8

the action of Histamine(H2) at receptor sites of the parietal cells, decreasing gastric acid secretion

No allergies or complications noted

Antacids should be taken one hour before or one hour after ranitidine, as this inhibits the effectiveness. Can be taken without regard to meals. Absorption not affected by food. Assess for allergy, discontinue if allergy occurs. Document the medication, dosage, date and time of administration, route and signature. Assess type, location, and intensity of pain before and after administration. Educate the patient about the possible side effects of the drug. Advise the patient that this might cause dizziness or drowsiness. Encourage patient to turn, cough and locate deeply every 2 hours. Document the medication, dosage, date and time of administration, route and signature.

Binds to operate receptors in the CNS causing inhibition of ascending pain pathway, altering the perception and response to pain. Also inhibits receptake of norephinephrin and serotonin, which also modifies the ascending pain pathway. It relieves the pain of the patient.

Tramadol June 23,2013 TIV D5W 500cc

Omeprazole

June 22, 2013

TIV 400mg OD

It has been characterized as a gastric-pump inhibitor, in that it blocks the final step of acid production. This effect is doserelated and leads to inhibition of both basal and stimulated acid secretion irrespective of the stimulus.

Educate the patient about the possible side effects of the drug Instruct the patient that he/she might experience dizziness and headache Instruct the patient to increased fluid intake because it might cause constipation or diarrhea Document the medication, dosage, date and time of administration, route and signature.