lOMoARcPSD|5734770
Nursing care plan
Fundamentals of Nursing Practice (San Diego State
University)
,
, lOMoARcPSD|5734770
N206 Medications
S: Patient is a 72 y/o male. Patient is here for suspected diagnosis of rhabdomyolysis. He is a full code with NKA.
B: Patient has history of hypertension and osteoarthritis, and no past pertinent surgical history. Patient lives alone and was found on the floor by his daughter.
A: (for assessment) – define what the med does, state why the patient needs the med.
R: (for recommendation)- state if you would give or hold med. If you choose to hold the med, state why and that you would alert the patient care provider.
Generic Name: Dosage: 650 mg A: Acetaminophen is metabolized by the liver (Nursing Central, 2014). It reduces production of
Ac-etaminophen Safe dose: total dose prostaglandins in the brain, which elevates a person’s pain threshold. It also reduces fever through action
NTE 3g / 24 hr on the heat-regulating center of the brain. Patient’s vitals revealed a febrile state and patient reported pain
Trade Name: Frequency: every 6 and severe cramps in lower back and legs
Tylenol hours prn
Route: PO R: I would recommend giving this medication. Patient’s very high fever, 40.1 degrees Celcius, needs to be
Therapeutic Class: Anal- Time: prn (last dose 4 decreased. The patient is also experiencing severe discomfort in lower back and legs with movement, and
gesics hours ago) this medication would relieve that discomfort. I would check the patients fever and BP q 4 hours and once
the fever is controlled, hold medication so HR is not decreased unnecessarily as pt vitals revealed a low sys-
Pharmacologic Class: tolic (80).
An-tipyretics
Rationale for use: pain
Expected therapeutic effect:
relieve pain
Action:
Inhibits synthesis of
prostaglandins that may
serve as mediators of pain
and fever, primarily in the
CNS. (Nursing Central, 2014)
Generic Name: Promethazine Dosage: 12.5 mg A: Promethazine woks as an antihistamine, having an inhibitory effect on the chemoreceptor trigger zone in
Safe dose: the medulla, resulting in antiemetic properties, and also produces CNS depression by decreasing stimulation
Trade Name: Frequency: q 6 hours of the CNS reticular system (Nursing Central, 2014). Patient reports nausea and vomiting, and this medica-
Phenergan prn tion is effective in controlling the feeling of nausea, and thus controls vomiting.
Route: IV
Therapeutic Class: Time: prn, last dose 4 R: If the patient reports feelings of nausea and vomiting, then this medication should be given. This pt
Tricyclic hours ago should not vomit due to current dehydration and electrolyte imbalance. I would check patient’s symptoms at
least q 4 hours, should be evaluated for effectiveness within 30 mins of administration. Also check IV inser-
Nursing care plan
Fundamentals of Nursing Practice (San Diego State
University)
,
, lOMoARcPSD|5734770
N206 Medications
S: Patient is a 72 y/o male. Patient is here for suspected diagnosis of rhabdomyolysis. He is a full code with NKA.
B: Patient has history of hypertension and osteoarthritis, and no past pertinent surgical history. Patient lives alone and was found on the floor by his daughter.
A: (for assessment) – define what the med does, state why the patient needs the med.
R: (for recommendation)- state if you would give or hold med. If you choose to hold the med, state why and that you would alert the patient care provider.
Generic Name: Dosage: 650 mg A: Acetaminophen is metabolized by the liver (Nursing Central, 2014). It reduces production of
Ac-etaminophen Safe dose: total dose prostaglandins in the brain, which elevates a person’s pain threshold. It also reduces fever through action
NTE 3g / 24 hr on the heat-regulating center of the brain. Patient’s vitals revealed a febrile state and patient reported pain
Trade Name: Frequency: every 6 and severe cramps in lower back and legs
Tylenol hours prn
Route: PO R: I would recommend giving this medication. Patient’s very high fever, 40.1 degrees Celcius, needs to be
Therapeutic Class: Anal- Time: prn (last dose 4 decreased. The patient is also experiencing severe discomfort in lower back and legs with movement, and
gesics hours ago) this medication would relieve that discomfort. I would check the patients fever and BP q 4 hours and once
the fever is controlled, hold medication so HR is not decreased unnecessarily as pt vitals revealed a low sys-
Pharmacologic Class: tolic (80).
An-tipyretics
Rationale for use: pain
Expected therapeutic effect:
relieve pain
Action:
Inhibits synthesis of
prostaglandins that may
serve as mediators of pain
and fever, primarily in the
CNS. (Nursing Central, 2014)
Generic Name: Promethazine Dosage: 12.5 mg A: Promethazine woks as an antihistamine, having an inhibitory effect on the chemoreceptor trigger zone in
Safe dose: the medulla, resulting in antiemetic properties, and also produces CNS depression by decreasing stimulation
Trade Name: Frequency: q 6 hours of the CNS reticular system (Nursing Central, 2014). Patient reports nausea and vomiting, and this medica-
Phenergan prn tion is effective in controlling the feeling of nausea, and thus controls vomiting.
Route: IV
Therapeutic Class: Time: prn, last dose 4 R: If the patient reports feelings of nausea and vomiting, then this medication should be given. This pt
Tricyclic hours ago should not vomit due to current dehydration and electrolyte imbalance. I would check patient’s symptoms at
least q 4 hours, should be evaluated for effectiveness within 30 mins of administration. Also check IV inser-
