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ASSESSMENT NURSING
DIAGNOSIS
PLANNING IMPLEMENTATIONS RATIONALE EVALUATIONS
Objective cue: ๏ Fatigue ๏ Frequent yawning ๏ Seen napping during the day ๏ Drooping eyes Disturbed sleep pattern related to environmental stimuli as manifested by objective cues. Within the rotation of rendering effective nursing interventions the patient will be able to maintain 8 hours of sleep during the night
INDEPENDENT:
๏ Established rapport ๏ Instructed not to nap during the daytime ๏ Provide bedtime care ๏ Instructed to drink warm milk before going to bed ๏ Encourage to avoid too much fluid intake before bedtime ๏ Maintained therapeutic communication DEPENDENT: ๏ Administered medication as ordered ๏ Monitored vital signs and recorded Health Teachings: ๏ Encourage appropriate indoor light setting during day and night ๏ Advised the importance of follow up check-up ๏ To gain trust ๏ It can disrupt sleeping pattern ๏ To promote physical comfort ๏ It facilitates sleep ๏ It may lead to nocturnal episode ๏ For effective communication of the client ๏ For fast recovery ๏ To serve as baseline data ๏ Helps in promotion of normal sleep-wake patterns ๏ For continuity of care Within the rotation of rendering effective nursing implementations the patient was able to maintain 8 hours of sleep during the night
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE IMPLEMENTATIONS
Objective cue:
- Poor eye to eye contact - Answered questions inappropriately - With flight of ideas - Memory deficit, altered attention span, and decreased ability to grasp ideas. Disturb thought processes related to degenerative process as manifested by objective cues - Within the rotation of rendering nursing interventions the patient will be able to maintain usual reality orientation.
INDEPENDENT:
- Established rapport - Maintained therapeutic communication - Reorient to names, places, date and time - Approached in a slow, calm manner - Presented reality concisely and briefly and do not challenge illogical thinking. - Reduced provocative stimuli, negative criticism, arguments and confrontations. DEPENDENT: - Administered medication as ordered. - Monitored vital signs HEALTH TEACHINGS: - Encouraged participation in resocialization activities and groups when available - To gain trust - For effective communication to the client - To prevent further deterioration and maximize level of function - To create therapeutic milieu - To develop coping strategies - To avoid triggering fight/flight responses. - For fast recovery - To serve as a baseline data - To create therapeutic milieu and assist client to develop coping strategies. - within the rotation of rendering effective nursing implementations the patient was able to maintain usual reality.
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE IMPLEMENTATIONS
Objective cue:
- Poor Hygiene - Inability to dress self - Inability to bath and groom self Self-care deficit related to bipolar affective disorder as manifested by objective cues Within the rotation rendering effective nursing interventions the patient will be able to participate in self- care activities
INDEPENDENT:
๏ Provided necessary adaptive equipment ๏ Refer specialized needs to occupational therapy ๏ Allow patient significant others to adequate time for self-care activities DEPENDENT: ๏ Monitored and recorded vital signs HEALTH TEACHING: ๏ Advised patient significant others to do good grooming and proper hygiene to the patient. ๏ Instructed to wash hands before and after doing activities ๏ Promotes independence and may enhance safety ๏ Self-image improves when they can perform personal care independently ๏ Enhances coordination and continuity of care ๏ To serve as a baseline data ๏ To promote comfort and relaxation ๏ To eradicate the growth of microorganisms Within the rotation of rendering effective nursing implementations the patient was able to participate in self-care activities GOAL MET
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION OBJECTIVE CUE: Changes in relationship pattern in family satisfaction Risk for interrupted family process related to changes in interaction with community as manifested by the objective cues Within 1hr of rendering nursing interaction the client will not express his feelings freely and appropriately INDEPENDENT:
- Established rapport
- Ensure 24hr watcher
- Encouraged of verbalization of feelings
- Stayed with the client
- Advised the client to maintain hygiene and grooming HEALTH TEACHING - Encouraged patient to eat food - Educated the patient
- To gain patientโs trust
- To ensure safety
- To identify appropriate intervention
- To comfort the client
- For wellness
- To boost immune system
- To have knowledge After 1hr of rendering nursing implementation the client will express his feelings freely and appropriately
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION OBJECTIVE CUES
- restlessness -changes in behavior and performance -interrupted night time sleep Risk for violence related to psychotic symptomatology as manifested by the objective cues After 1hr of nursing patient interaction the patient would be relieved of his anxiety regarding his self- harm INDEPENDENT ๏ Frequently assess clientโs behavior for signs of increased agitation of hyperactivity ๏ Decreased environmental stimuli by providing a calming environment or assigning a private room ๏ Maintain a consistent approach, employ consistent expectations, and provide a structured environment ๏ Early detection and intervention of escalating mania will prevent the possibility of harm to self and to others and decreased the need for seclusion ๏ Help decreased escalation of anxiety and manic symptoms ๏ Clear and consistent limits and expectations minimize potential for clientโs manipulation of staff After 1hr of nursing patient interaction the patient was able to be relieved of his anxiety After series of nurse patient interaction the patient was able to cope properly
NAME OF DRUG PHARMACOLOGICAL
DOSSAGE
MECHANISM
OF ACTION
INDICATION/
CONTRAINDICATION
SIDE EFFECTS/
ADVERSE
EFFECTS
SPECIAL
PRECAUTIONS
NURSING
RESPONSIBILITIES
Generic name: Diphenhydramine hydrochloride Brand Name: Benadrex Classification: Anti-Histamine Pharmacologic: H1 receptor Generation: First-generation Antihistamiine Dosage: 50 mg Route: IM Frequency: PRN Timing: NOW Competes with histamine for H 1 -receptor sites. Prevents, but doesnโt reverse, histamine- mediated responses, particularly those of the bronchial tubes, GI tract, uterus, and blood vessels. Structurally related to local anesthetics, drugs provide local anesthesia and suppresses cough reflex. Indication: Symptomatic relief to allergic conditions including urticaria and angioedema, rhinitis and conjunctivitis and in pruritic skin disorders. Contraindications: ๏ Contraindicated in patients hypersensitive to drug; newborns; premature neonates; breast-feeding women; patients with angle- closure glaucoma, stenosing peptic ulcer, symptomatic prostatic hyperplasia, bladder neck obstruction, or pyloroduodenal obstruction; and those having acute asthmatic attack. ๏ Avoid use for patient taking MAO inhibitors. ๏ Use with caution in patients with prostatic hyperplasia, asthma, COPD, increased intraocular pressure, hyperthyroidism, CV CNS: drowsiness, confusion, insomnia, headache, vertigo, sedation, sleepiness, dizziness, incoordination, fatigue, restlessness, tremor, nervousness, seizures. CV: palpitations, hypotension, tachycardia. EENT: diplopia, blurred vision, nasal congestion, tinnitus. GI: nausea, vomiting, diarrhea, dry mouth, constipation, epigastric distress, anorexia. GU: dysuria, urine retention, urinary frequency. HEMATOLOGIC: hemolytic anemia, thrombocytopenia, agranulocytosis. RESPIRATORY: thickening of bronchial secretions. SKIN: urticaria, photosensitivity, rash. OTHER: anaphylactic shock. ๏ Do not use topical prep containing anti- histamines for acute vesicular and exudative dermatoses due to an increase risk of allergic reactions and inducing sensitization. May affect ability to drive or operate machinery. Pregnancy ๏ Consider 16Rโs in administering medication. ๏ Monitor vital signs. ๏ Stop administering drug 4 days before diagnostic skin testing. ๏ Alternate injection sites to prevent irritation. Give I.M injection deep into large muscle. ๏ Dizziness, excessive sedation, syncope, toxicity, paradoxical stimulation and hypertension are more likely to occur in the elderly. ๏ Warn patient not to take this drug with any other products containing diphenhydramine (including topical therapy) because of increased adverse
disease, and hypertension. ๏ Children younger than age 12 should use drug only as directed by prescriber. reactions. ๏ Instruct patient to take drug 30 minutes before travel to prevent motion sickness. ๏ instruct the patient to avoid alcohol and hazardous activities that requires alertness. ๏ warn patient of possible photosensitivity reaction. ๏ Perform moments of 5 before and after the procedure.
OTHER :
gynecomastia SIDE EFFECTS
- dizziness, lightheadedness, drowsiness, difficulty urinating, sleep disturbances, headache, and anxiety may occur.
NAME OF DRUG PHARMACOLOGICAL DOSAGE MECHANISM OF ACTION INDICATION/ CONTRAINDICATION ADVERSE EFFECTS/SIDE EFFECTS SPECIAL PRECAUTION NURSING RESPONSIBILITIES GENERIC NAME: Olanzapine BRAND NAME: Zyprexia CLASSIFICATION: Antipsychotic Dopaminergic PRAHRMACOLOGICAL CLASSIFICATION: Atypical Antipsychotic DOSAGE: 10mg ROUTE: Oral FREQUENCY: Once a day TIMING: 6am Unknown; may immediate antipsychotic activity by both dopamine and serotonin type 2 (5- hydroxytryptami n [HT]2) Antagonism: also may antagonize muscarinic receptors, histaminic (HT) and alpha adrenergic receptors. INDICATION Acute and maintenance treatment of schizophrenia and other psychoses where positive symptoms are prominent CONTRAINDICATION Known hypersensitivity to the drug ADVERSE EFFECTS: CNC: neuroleptic malignant syndrome CV: peripheral edema, tachycardia GI: abdominal pain RESPI: pharyngitis SIDE EFFECTS: Nervousness, vomiting, headache, constipation Use cautiously in elderly or debilitated patients or with CV or cerebrovascula r disease, dehydration, seizure disorder. ๏ท Observe 16 Rโs ๏ท Monitor for elevations of temperature ๏ท Monitor for many possible drug inter action before beginning therapy ๏ท Do not dispense more than 1 week supply at a time.
diseases as its histone deacetylase (HDAC) inhibition property.
