Care Plan Sample

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PLAN OF CARE
PRIMARY DRUG: CEFAZOLIN SODIUM
Patient ID #:
Catheter Type:
Overall Goal: Eradication of infection
Anticipated Outcome:
Actual Outcome:
Patient Name:
Nursing Agency:
PROBLEM/
IDENTIFIED NEED
Hypersensitivity reactions:
anaphylaxis, urticaria, rash
INCREMENTAL GOAL(S)
Minimize hypersensitivity
reactions
Thrombophlebitis
Minimize thrombophlebitis
Eosinophilia, leukopenia,
thrombocytopenia
GI complaints: nausea,
vomiting, diarrhea,
pseudomembranous colitis
Elevated liver enzymes
Minimize adverse hematological
effects
Minimize adverse gastrointestinal
effects
Renal toxicity
Positive Coomb’s Test
Seizures
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Pharmacy:
ACTION/INTERVENTION
- Get patient’s allergy history prior to
administration
- Nurse will instruct patient to report rash or
any trouble with breathing
- Maintain analphylactic kit at bedside
Ensure proper dilution and use of in-line
filter; instruct patient to report pain at
injection site
Monitor CBC with differential
INCREMENTAL OUTCOME
Instruct patient/caregiver to report any signs
of nausea, diarrhea, or abdominal pain
Pharmacist will monitor patient’s liver
enzymes
Prevent adverse renal effects
Pharmacist will monitor BUN and serum
creatinine
Avoid misinterpretation of positive Note that false-positive Coomb’s Test have
Coomb’s Test
been reported
Avoid CNS toxicity
High dose therapy will be used with caution,
especially in patients with renal dysfunction
Minimize adverse hepatic effects
Medication Therapy Protocol  Copyright 2006  Care Partners Consulting Pharmacists, LLC.  All Rights Reserved
6208/090906
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