DRUG PROFILE

S.N. Generic Name Trade Name Dose Route Frequency

1. Pantoprazole Pantocid 40mg Intravenous BD
2. Ketorolac Ketolac 30mg/ml Intravenous TDS
3. Clavam Clavam 1.2gm Intravenous TDS
4. Tramadol Tramadol 50mg Intravenous SOS
5. Ondensteron Ondem 4mg Intravenous SOS
Name of Drug Dose Route Mechanism of Indication Side Effects Contraindication Nursing
action Consideration
-Generic 40mg in Intravenous, It is a specific -Peptic Ulcer -Diarrhoea -Hypersensitivity -Give tablet
Name: Vial Oral inhibitors of proton And duodenal -Headache without regard to
Pantoprazole In my In my patient pump that Ulcer -Dizziness meal, tablet should
-Trade Name: patient in suppresses final -Gastro esophageal -Pruritis not be crush, chew
Pantocid, injection intravenous step in gastric acid, Reflux Disease -Skin rash or split
Panzel pantopra form production by -Hyperacidity No any side -Refrigerate vial,
-Functional zole forming covalent -Reflux esophagitis effects protect from light.
Class: Proton 40mg is bond to two sites of -Zollinger Ellison present in -Explains
Pump given the H/K+ ATPase Syndrome my patient importance of
Inhibitos enzyme system at -NSAID induced due to this taking drug exactly
the secretory ulcer medicine as prescribed.
surface of the -
gastric parietal cell
present which is
responsible for
section of proton
(H+). This prevents
H+ to HCl. Thus
gastric acid is
reduced.
 Name of Drug Dose Route Mechanism of Indication Side Effects Contraindication Nursing
action Consideration
-Generic Name: -30mg Intravenous The primary -Mild to -GIT: Nausea, -Peptic Ulcer -Advise patient to
Ketorolactrimeth IV/IM and oral mechanism of moderate pain: vomiting, -Asthma and take NSAID after
amine -10mg administration action responsible joint pain, dyspepsia, GI atopic tendencies meal
-Trade TDS/ In my patient for anti- toothache, irritation, peptic -Renal -Check for signs of
Name:Ketolac QID intravenous inflammatory, musculoskelet ulceration insufficiency bleeding,
-Functional orally form antipyretic and al pain, back -CNS: headache -Hypovolemia especially with
Class:NSAID In my analgesic effects is pain, -Respiratory: -Dehydration aspirin
drugs patient the inhibition of neuralgia, dyspnea, asthma, -Patients are
30mg prostaglandin post-operative pulmonary suggested to take a
-Chemical Class TDS synthesis by pain. edema lot of water with
Non-Selective competitive -Inflammation, NSAID
COX-2 blocking of the osteoarthritis, -Find the time to
inhibitors(1st enzyme rheumatoid talk to patients
generation cyclooxygenase. arthritis, about pain and
NSAID) spondylitis. their illness
generally so as to
ease a lot of
distress associated
with the pain.

Name of Dose Route Mechanism of Indicatio Side Effects Contraindication Nursing Consideration
 Drug action n
-Generic -1.2 gm TDS Intrave It inhibits the -Intra -GIT - hypersensitivity, - inform patient to tell if
Name: In my patient; 1.2 nous synthesis of abdomina nausea,voiting, hepatic any rashes developed.
Clavum gm IV TDS. and bacterial cell wall l diarrhea dysfunction -obtain specimen foe
orally by binding to one infection. -Skin dermatitis, sensitivity test before
In my or more of the - -Blood hemolytic starting the dose.
patient penicillin binding Respirato anemia, Give IV injection with
intrave protein which in ry tract thrombocytopenia, dilution with sterile
nous turn inhibits the infection. neutropenia water for injection.-
infusio final -Surgical -Liver: Elevation in -Inject the drug slowly
n was transpeptidation prophyla AST,ALT over 10-15 min.
given step of xis -Miscellaneous: -Give pre information to
but peptidoglycon -Urinary Convulsion,vaginal patient that medication
later synthesis in tract candidiasis. can cause pain at
on inj bacterial cell infections injection site.
PCM walls, thus inhibit .
change cell wall bio
d to synthesis.
Tablet
PCM

Name of Dose Route Mechanism of Indication Side effect Contraindication Nursing Consideration
drug action
Tramadol Above 20 years Intave Inhibits Pain Body: Malaise. Acute -Assess for level of pain
nous cyclooxygenase Cardiovascular: Va intoxication with relief and administer
50 or 100mg 4-6
ConZip, Orally (COX)-2; does sodilation. alcohol, dose as needed only.
hourly by the Ii/v or
Rybix, not affect COX-1 Central Nervous hypnotics, -Monitor vital signs
I/M route.
Ryzolt, (at therapeutic System: Anxiety, analgesics, and assess for
Ultram, For post-operative concentrations), Confusion, opioids, or orthostatic hypotension
Ultram ER, pain 100mg. During thereby Coordination psychotropic or signs of CNS
Zydol the 60 minutes decreasing disturbance, medicinal depression.
Classificati following the initial formation of Euphoria, Miosis, products. -Discontinue drug and
ons: bolus, further doses prostaglandin Nervousness, notify physician if S&S
patients who are
ANALGES of 50mg may be synthesis Gastrointestinal: of hypersensitivity
receiving
IC; NARC given every 10-20 Abdominal pain, occur.
monoamine
OTIC (OPI minutes, up to a total Anorexia, -Assess bowel and
oxidase (MAO)
ATE dose of 250mg Flatulence. bladder function; report
inhibitors or who
AGONIST) including the initial Musculoskeletal: H urinary frequency or
have taken them
bolus. total daily ypertonia retention.
within the last 14
dose of 400mg. -Use seizure precautions
days.
Prototype: Skin: Rash. for patients who have a
Children
Morphine Special - in patients with history of seizures.
sulfate Tramadol Senses: Visual epilepsy not -Monitor ambulation
hydrochloride 50 disturbance. adequately and take appropriate
mg/ml solution for Urogenital: Menop controlled by safety precautions.
injection. ausal symptoms, treatment. -Dosage reduction is
Urinary frequency, recommended for
-Hypersensitivity
Urinary retention patients with renal
insufficiency and
hepatic impairment.

-Store at 15°–30° C
(59°–86° F).

Name of Dose Route Mechanism Indication Side effect Contradictions Nursing considerations
drug of action
It is a Intavenous Nausea Abdominal  Instruct the patient to take drug 30 min
Generic dopamine , Blocks the and Cramps Hypersensitivity prior to meal
name antagonist in Orally action of Diarrhea Prolactin  Don’t mix with other injection , give
ondanstero serotonin. vomiting
the CTZ and Nausea releasing deep IM
n Functional pituitary
GI tract. It Rash  Assess for possible contraindications or
also is an α2- dyspepsia Itching tumour cautions history of allergy to antiemetic
Class Treatment
and β2- Hives, and (prolactinoma) to avoid potential hypersensitivity
serotonin of
5-HT3 rece adrenergic hyperprolacti Use in children reactions; impaired renal or hepatic
antagonist in cytotoxic nemia (the under 2 years function
ptor
antagonists the stomach. drugs and symptoms of of age  Assess the patient’s neurological status,
. radiation which may including level of orientation, affect, and
include reflexes,
breast  Examine the abdomen, including the
enlargement, liver, and auscultate bowel sounds
galactorrhea,  Assess complaints of nausea and evaluate
breast emesis; note color, amount, and
pain/tenderne frequency of vomiting episodes
ss,  Instruct the client to avoid over-the-
gynecomasti counter preparations.
a,  Instruct the client not to consume alcohol
hypogonadis while taking antiemetics.
m, and Advise pregnant women to avoid
menstrual antiemetics during the first trimester
irregularities)
. Administration
Oral
Taken with a glass of water
Intravenous
Slowly over 5 to 15 minutes
Nursing Care Plan
SN. Assessment Nursing Nursing Plan of Action Implementation Rational Evaluation
Diagnosis Goal
2. Subjective Deficient Patient -To assess the vital -Vital sign were It helps in finding Goals was
data: patient fluid volume will be sign. assessed changes in vital sign partially
visitors said, related to able to routinely. due to blood loss. met as
“he felt low fluid improve patient was
weakness all intake as fluid able to
over my body” evidenced by volume -To observe the improve
yellow balance. patients individual Observed patient -To do intervention as fluid
Objective data: colored physiological response. soon as possibel balance as
patient seemed urine. response to bleeding evidence by
weak such as fatigue, good fluid
weakness. I/O gives an accurate intake.
vital signs: information of the
-To monitor and client’s fluid status.
PR:80/min record I/O charting Monitored I/O
T:97.6 ˚F strictly. charting strictly.
R:20/min
BP: 120/80
mm of Hg
S.N Assessment Nursing Diagnosis Nursing Goals Planning Intervention Rational Evaluat
ion
1. Objective data: -Altered bowel Patient will -To check on usual -Usual pattern -It provides My
-stool not passed. elimination; constipation maintain passage pattern of elimination, of bowel baseline data for goal
- less fluid intake related to decrease fluid of soft, formed frequency, and elimination, further was
-Bowel sound intake as evidenced by stool at consistency of stool, frequency was intervention fully
hypoactive irregular bowel pattern. frequency intake and output. checked. met as
-Lack of activity perceived as -To promote and patient
normal by encourage habitual efecatio
patient within bowel habit. -Patient was -It help to n next
2days of encouraged to stimulate day of
interventions go to toilet defecation interve
and try to ntion
-To encourage to take defecate at and
fluid to 2000- usual time i.e. patient
3000ml/day. 6am in the -It helps to keep verbaliz
-To encourage patient morning. fecal mass soft ed
to take high fibre diet -Patient was passage
encouraged to -It adds bulk to the of
take 2-3litre of stool and makes stool..
-To encourage patient fluid. defecation easier.
physical activity and -High fibre -It promotes
exercise. diet was peristalsis and
encouraged strengthen
such as lentils, abdominal muscle.
peas, broccoli
-Patient was
taught
abdominal
exercises.
S.N Assessment Nursing Diagnosis Nursing Goals Planning Intervention Rational Evaluat
ion
3. Subjective Data: Deficient Knowledge Patient visitor -To identify the -Patient and -It helps to provide My
Patient visitors related to lack of will be able to leraner and assess his brother baseline data for goals
said that patient exposure to disease explain disease motivation and was motivated further was
visitors have no condition as evidenced state, recognize willingness of patient and were intervention. fully
idea about by request for need for to learn, willing to met as
different treatment information, confusion. medications and misconceptions learn about patient
modalities. understand regarding disease disease visitor
Objective data: treatment within condition and condition. was
First exposure of 20minutes. treatment -It helps to able to
disease in family -To provide physical concentrate and explain
history. comfort to patient and -Patient was focus more his
-Frequent family member and kept in Semi- completely in what disease
questioning grant calm and Fowler’s is being discussed. state,
peaceful position and recogni
environmental her family ze need
without interruption. member. for
-To give information -Increasing medicat
regarding disease understanding ion and
condition, causes, risk alleviates fear of underst
factors, management, -Accurate unknown so it and
prognosis, and information helps to alleviate about
treatment in was provided fear and broaden their
understandable way. about disease knowledge. treatme
-To encourage condition nt.
question and explain
them -It helps to two
way
communication

-Encouraged
 to ask
question.
S.N Assessment Nursing Diagnosis Nursing Goals Planning Intervention Rational Evaluat
ion
4. Subjective data: Alteration in sleep Patient sleeping -Create quiet -Turning of -To Provide My
Patient seems pattern related pattern will be environment bright light peaceful goal
restless at night hospitalization as improved. -Maintain room -Closed the environment at was
time according to evidenced by tired face temperature door and try to sleep time. fully
patient visitors. -Provide comfort maintained -To provide warm met as
measures ventilation. to elevate sleeping the
-Advised the pattern patient
patient to - It helps to express
sleep patient provide comfort. good
in desirable -It helps to sleep sleep
Position. security habit.
-Controlled crowded -Provide good -It helps to express
visitors in the ward. security in the his problems and
ward. feel secure
-Provide family -Allow the
support. visitors to stay
with her.
 Daily Progress Report
Date 2077-09-25 2077-09-26 2077-09-27
Date of Admission(DOA: 2nd Day of Admission 3rd Day of Admission 4th Day of admission
2077-09-23) 2nd Postoperative day 3rd Postoperative day 4th postoperative day
General condition Satisfactory, well alert, Patient complain of pain Patient condition seems satisfactory.
oriented to time place and incision site
person
Weight 52kg 52kg 52kg
Blood Pressure 110/80 mm of HG 120/80 mm of HG 100/80 mm of HG
Temperature 97F 96.8F 98F
Pulse 88b/m 80b/m 72b/m
Respiration 22b/m 20b/m 22b/m
SPO2 96% 98% 97%
Glasgow Comma Scale E4V5M6 E4V5M6 E4V5M6
Intake/ Output 2500ml in 24hours 2000ml in 24hours 1800ml in 24 hours
Drain 600ml in 24hrs 400ml in 24 hrs 300ml in 24 hrs
Diet Normal diet Normal diet Normal diet
Medication Intravenous fluid RL III pint in Drip off Drip off
24hrs
Medication added or stopped No any medication added Injection pantop changed to Injection PCM changed to tab PCM
tab pantop OD 500mg PO TDS
Nursing care Monitor intake output History taking and physical -Encourage patient for ambulation
Assist doctors during dressing examination done -Encourage for fluid intake
Encourage patients for -Strictly monitor intake and output
ambulation
Patient complainof abdominal
distension so as prescribed
doctor enema stat given
Health Teaching Informal health teaching given Informal teaching was given in Informal teaching was given in diet
 on disease condition, causes, deep breathing and coughing exercise and sleep pattern
sign and symptoms and exercise and its benefits
treatment
Special Instruction Observed any leakage from Provide enema stat Injection medication changed to tab
drain site medicine