Asssessment
Objectives Subjective: masakit ang ulo ko verbalize by the patient
Nursing diagnosis
Plan of care
Short Term Objectives At the end of 8 hour 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 appropriately.
Interventions rationale
Independent 1 Determine specifics of pain e.g. location, characteristics, intensity (0-5 scale), onset/ duration, note nonverbal cues. 2. Encourage/maintain bed rest during acute phase. 3. Provide/recommend non pharmacologic measures for relief of headache. Facilitate diagnosis of problem and initiation of appropriate therapy.
evaluation
Short Term Objectives At the end of 1 hour 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 appropriately. .
Altered Comfort: headache related to increased intracranial pressure secondary to fluid accumulation in Restlessness Diaphoresis the intracranial Change in BP, RR, space HR Facial grimace
4. Monitor vital signs regularly 5. Provide comfort measures such as touch, positioning and back rub. 6. Reposition patient every 2 to 4 hours
Minimizes stimulation/pro motes relaxation Measures that reduce cerebral vascular pressure and that slow/ block sympathetic response are effective in relieving headache and associated complications. Change in vital signs indicates acute pain and discomfort. To promote non pharmacologic al pain management To promote comfort, thus alleviating pain and promote circulation.
name of drug
Generic: Nalbuphine Brand: Nubain
Mechanism of action
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 µ receptors
indications
Relief of moderate to severe pain
contraindications
-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, biliary tract surgery.
Adverse effect
CNS: nervousness, crying, depression, restlessness, euphoria, hostility, confusion, faintness, floating, unusual dreams, numbness, feeling of heaviness, and psychotomimetic effects such as hallucinations, feeling of unreality and dysphoria. Cardiovascular: hypertension, hypotension, bradycardia, tachycardia. Gastrointestinal: cramps, dyspepsia, bitter
Nursing considaration
-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
name of drug
Mechanism of action
Increases osmotic pressure of plasma in glomerular filtrate , inhibiting tubular reabsorotion of water andelectrolytes . These actions enchance water flow from various tissues ultimately decrease intracranial and intraocular pressure
indications
contraindications
Adverse effect
Nursing considaration
Generic name: Manitol Brand name: Osmirol
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 transurethralresction of prostate
Active intracranial bleeding, anuria secondary to severe renal disease , progressive heart failure, pulmonary congestion , renal damage , or renal dysfunction after mannitoltherapy begins
Ceftin is a βbacterial infections, Generic: lactam type such as: Cefuroxime antibiotic. More bronchitis specifically, it is gonorrhea Brand: a Lyme disease Cidokez second infections of generation the ears, cephalosporin. throat, Cephalosporins sinuses, work the same urinary tract, way as and skin penicillins: they interfere with the peptidoglycan synthesis of the bacterial wall by inhibiting the final transpeptidation needed for the cross-links.
,oCNS: Headache,
allergy to cephalosporin antibiotics
oDetermine history dizziness, lethargy, of paresthesias hypersensitivity reactions oGI: Nausea, to cephalosporins, vomiting, penicillins, and diarrhea, anorexia, history of abdominal pain, allergies, flatulence, particularly to pseudomembranous drugs, before colitis, liver toxicity therapy is oHematologic: Bone initiated. marrow depression: oInspect IM and IV decreased WBC, injection decreased platelets, sites frequently for decreased Hct signs of phlebitis. oGU: Nephrotoxicity oReport onset of oHypersensitivity: loose Ranging from rash stools or diarrhea. to Although fever to anaphylaxis, pseudomembranous serum sickness colitis. reaction oMonitor I&O rates oOther: and Superinfections, pattern: Especially disulfiram-like important in reaction severely ill with alcohol patients receiving high doses. Report any significant changes
name of drug Generic: Ketorolac Brand: Toradol
Mechanism of action Inhibits prostaglandin Synthesis by decreasing the activity of the enzyme, cyclooxygenase, which results in Decreased formation of prostaglandin precursors, chemicals that cells of the immune system make that cause the redness, fever, and pain of inflammation and that also are believed to be important in the production of noninflammatory pain
indications Used for treating inflammation and pain in the operation site.
contraindications 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;hemorrhagic diathesis
Nursing considaration -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