Wendy Brandhorst
02-14-05
Name: Wendy Brandhorst’s patient (rm 6A Rehab)
Current Medical/Surgical Diagnosis: Encephalopathy, head trauma
Age: 83 Code Status: Full LEO
Admitted Date: 02/01/05
Discharge Date: 02/11/05 Date of Care: 02/11/05
PERSON
Psychosocial
Ms. X is an 83 year old retired antiques dealer. She is 5 ft tall and 124 lb and admitted to NAMC on
February 01, 2005 for encephalopathy and head trauma related to a fall she sustained at home during
the night. She has an edema on the superior portion if her head from the latest fall. She is oriented X3
during the day, but gets confused and sometimes has hallucinations and gets combative at night
(possibility of Sundowners Syndrome). Her code status is a full Leo. She is scheduled to go home at
1100 this am. Her son came to pick her up at 1100 and went home with a walker and bedside
commode (They actually forgot the commode, but the son is to be called later in the day. She has been
instructed to follow up with her doctor in 4 weeks. She also has prescriptions for PT, OT, and home
health (Accumed).
Past medical/surgical procedures include: tonsillectomy, hysterectomy, laminectomy, hallucinations,
cholecystectomy, depression, angina, HTN, pneumonia, anorexia, Sjogren’s Syndrome, chronic pain
in all joints, bilateral cataracts, mental disturbance.
She recently moved in with her son in Round Rock. He assists her with her basic needs and her
daughter also helps occasionally. She is able to get around he house with only little difficulty and
minimal assistance with ADLs.
P need medications: Zoloft 50mg PO daily
Elimination
Ms. X has daytime urinary incontinence due to urgency and difficulty in ambulation. Urine is clear
and yellow in color. She uses a bedside commode when urgency is strong. Otherwise she uses the
restroom for elimination needs. She occasionally has constipation, however, has regular BMs (once a
day of normal consistency and color) when taking Dulcolax PO and Maalox Suspension. She has also
used Dulcolax suppository during stay in hospital.
E need medications:
Miralax 17gm PO daily, Dulcolax 5mg PO daily prn/ 10mg RC daily prn; Colace 100mg PO BID prn;
Imodium 2mg PO QID prn; Maalox Suspension 15mL PO Q2H prn;
Rest, Regulatory, Reproduction
Generalized pain in joints treated with pain medication as needed. Pain is moderate to severe in the left
shoulder which has only been slightly relieved during stay. She is taking Restoril to promote sleep
therefore reduce hallucination and confusion episodes at night.
R need medication: Tylenol 650mg PO and RC Q4H prn; Darvocet 1-2tab PO Q4-Q6H prn; Restoril
15mg PO HS prn; Ultracet 1 UDTab PO QID prn, Benadryl 25mg PO HS;
Hydrochlorothiazide 6.25mg PO daily; Levaquin 500mg PO Qam; Levoxine 0.075mg PO
daily; Robitussin-DM 10mL PO Q4H prn; Phenergan 25mg PO/IM/RC Q4H prn
Safety
ALLERGIES: Sulfa drugs, Tetanus, Iodine contrast, Shellfish, crab, shrimp
CODE STATUS: Full LEO
Ms. X is a high risk for fall. She has a history of several falls at home, usually at night. In addition,
during the night she has confusion and hallucinations. She has encephalopathy which either causes or
adds to these symptoms. Ms. X has limited vision due to macular degeneration. She can decipher the
presence of objects as big as a fist within a foot of her face, but needs direction with smaller objects,
therefore adding to the fall risk particularly while in the hospital which is an unfamiliar environment.
Her gait is often steady and slow, but her balance can be easily challenged. There is an increased
problem when moving from a standing to sitting position. Many medications she is taking may cause
drowsiness.
Ms. X complained of irritation on both heels and pads were placed on her heels and feet propped on a
pillow to prevent pressure ulcers. The skin was intact with only slight erythema on the right heel at
time of discharge, but she stated she has no irritation.
Oxygenation
Latest vitals: R 14; HR 70 and regular; T 98.3; B/P 150/68; O 99%RA.
She has a history of atrial fibrillation, but there are no direct concerns at this time.
O need meds: Norvasc 5mg PO BID; Bayer Children’s Aspirin 81mg PO daily; Tenex 1mg PO HS;
Lidoderm 1 each TP daily; Micro-K 10mEq PO BID
Nutrition:
Ms. X has eaten well while in the hospital – 90%-100% of meals. Skin is pink, moist, with good
turgor. Hair is normal.
N need meds: Theragran tabs 1UDTab PO daily; Protonix 40mg PO daily at 0630
MEDICAL DIAGNOSIS —
Mosby’s Dictionary p. 595
Online sources:
 http://www.merck.com/mmhe/index/ind_en.html
 St Davids intranet site
Encephalopathy is defined as any abnormal condition of the structure or the function of the brain
tissues, especially chronic, destructive, or degenerative conditions. The cause of encephalopathy
frequently remains undetermined, but there are related conditions including: alcohol withdrawal,
meningitis, encephalitis, brain tumors, non-convulsive seizures, central venous thrombophlebitis,
bacterial endocarditis, fat embolism, basilar artery thrombosis, traumatic brain injury, and right
hemisphere stroke can present with an acute confusional state. In order to determine the cause of
patient’s condition physicians will look at the patient’s history, physical examination, or review of
medications for clues to etiology.
I do not know the cause of encephalopathy in Ms. X ( I am not sure the doctors know either), however,
from the types I have read about, traumatic encephalopathy (seen below as Dementia pugilistica, or
chronic progressive traumatic encephalopathy) seems to most resemble Ms. X’s symptoms and
conditions. I will use this version for the purpose of this document. See below for a list and short
description of other types of encephalopathy.
chronic kidney failure… may ensue from the buildup of metabolic waste products in the blood
… severe high blood pressure causes the brain to swell requiring emergency treatment
… can result from high level of lead in the blood
(hepatic)… is a disorder in which brain function deteriorates because toxic substances
normally removed by the liver build up in the blood
therapy…exposing the brain to radiation can cause acute encephalopathy with fluid
accumulation in the brain
… very rare degenerative diseases of the brain thought to be caused by a protein that
converts to an abnormal form called a prion.
Traumatic… dementia pugilistica (chronic progressive traumatic encephalopathy) may develop in
people who have repeated head injuries…. They often develop symptoms similar to those of
Parkinson's disease, and some of them also develop normal-pressure hydrocephalus
… neurological disorder of acute onset caused by a thiamine deficiency and often
associated with chronic alcoholism.
Symptoms/Clinical Manifestations:
The symptoms of liver encephalopathy are those of decreased brain function, especially impaired
consciousness. In the earliest stages, subtle changes appear in logical thinking, personality, and
behavior. The person's mood may change, and judgment may be impaired. Normal sleep patterns may
be disturbed. The person's breath may have a musty sweet odor. When the person stretches out the
arms, the hands cannot be held steady and the person displays a crude flapping motion of the hands
(asterixis). As the disorder progresses, the person usually becomes drowsy and confused, and
movements and speech become sluggish. Disorientation is common. A person with encephalopathy
may be agitated and excited, but this is uncommon. Seizures are also uncommon. Eventually, the
person may lose consciousness and lapse into a coma.
Risk Factors: Fetus exposed to alcohol; chronic alcoholism, repetitive head trauma, infection of prion,
high exposure to lead, kidney failure, liver failure
Diagnostic Studies: An electroencephalogram (EEG) may help in diagnosing early encephalopathy.
Even in mild cases, an EEG shows abnormal brain waves. Blood tests usually show abnormally high
levels of ammonia.
Note: In an older person, liver encephalopathy may be more difficult to recognize in its early stages,
because its initial symptoms (such as disturbed sleep patterns and mild confusion) may be attributed to
dementia or are erroneously labeled as delirium.
POSSIBLE NURSING DIAGNOSES
Risk for fall r/t dizziness and confusion s/t neurological changes; voiding urgency and altered vision
s/t macular degeneration
Chronic Pain AEB patient report
Impaired Physical Mobility r/t pain and impaired vision
Disturbed Sleep Pattern r/t mental disturbances AEB waking at night and hallucinations
Acute Confusion AEB lack of orientation and hallucinations when awakening at night s/t
encephalopathy
Risk for Ineffective Family Coping: Caregiver Role Strain r/t recent caregiver role changes s/t falls
Risk for Impaired Skin Integrity r/t decreased mobility AEB irritability and erythema of heels
Urge Urinary Incontinence AEB patient report
NURSING CARE PLAN
Nursing
Diagnosis &
Support Data
Goal/Outcome &
Outcome Attainment
Risk for injury: falls 1) Patient will be free of
Nursing
Interventions
1a) Change position
Scientific
Rationale
1a) Orthostatic
Evaluation
1a) Each time
r/t dizziness and
confusion s/t
neurological
changes; voiding
urgency and altered
vision s/t macular
degeneration
injury during hospitalization.
Outcome Attainment
The goal was successfully
attained during the patient’s
hospital stay.
Support Data
 Hx of falls
 Altered mental
state at night
resulting in
hallucinations and
confusion
 Macular
Degeneration
 Limited and
slow mobility.
Acute Confusion
AEB lack of
orientation and
hallucinations when
awakening at night
s/t encephalopathy
1) Patient will have reduced
number of episodes of
confusion.
2) Patient and Family will
verbalize ways to maximize
safety during nighttime
slowly to prevent
orthostatic
hypotension.
1b) Explain
importance of using
call light to ask for
assistance before
getting up; keep
bedside rails up.
1c) Assist/instruct
patient with use of
mobility aids.
1d) Stand slightly
behind patient with
hands on patient’s
arms when patient is
ambulating.
1e) Keep area clear of
clutter
1f) Administer sleep
aids as prescribed
1g) Describe
placement of items in
room and relay any
changes to
environment
1e)Use bedside
commode for urinary
urgency
hypotension may
occur as result of
venous pooling, or as
a side effect of
medication admin.
1b) Bed side rails
help remind patient
to call for help, and
prevent accidental
falls from the bed.
1c) Identifies
potential risks in the
environment and
heightens awareness
of risks so caregivers
are more alert to
dangers.
1d) If patient is
knowledgeable and
confident in the
usage of a mobility
aid, there will be less
risk for fall.
1e) If patient begins
to fall, caregiver is
able to move behind,
slip hands under
arms, and assist
patient to a chair or
slowly slide patient
to floor.
1f) Keeping
walkway clear
reduces risk of fall
1g) Sleep aids help
reduce waking at
night, therefore
reducing the number
of confusion
episodes.
1e) Knowledge of
objects in room
decreases chance of
running into them
unexpectedly.
1f) Bedside
commode reduces
distance to travel
during urgency.
patient was helped
into chair or to
bedside commode,
her feet were
dangled at bedside
and she was asked
if dizzy.
1b) Patient had no
difficulty using her
call button, and
understood the
importance of
asking for
assistance to get out
of bed.
1c) Patient
demonstrated
proper use of
walker and used
this to ambulate
from bedside.
1d) I assisted
patient when
ambulating to
restroom, although I
only used her right
arm for support
because her left
shoulder hurt from
a previous fall.
1e) Items in room
were kept in an
organized fashion
and explained to
patient.
1g) Sleep aids were
used and helpful in
reducing nighttime
episodes.
1h) Bedside
commode was used
at night (as per
report from night
nurse).
1a) Dispense
medications as
directed.
1b) Minimize sensory
impairment.
2a) Teach: use of
1a) Sleep aids help
reduce waking at
night, therefore
reducing the number
of confusion
episodes.
1a) sleep aids were
used with moderate
success
1b) patient had
access to glasses
and stated needs
episodes
Support Data
See nursing
diagnoses
walker and bedpan.
Maintain consistency
and stability in
environment to
Outcome Attainment
I cannot say for sure that both minimize confusion
of these outcomes were met. and onset of
My discussion with the patient hallucinations. Keep
areas free of clutter.
and family as they left was
minimal. I do know the patient
understands and demonstrates
use of walker and bedside
commode. As far as I can tell
she is med compliant. The son
is attentive to needs.
1b) Lack of sight can regarding sight.
cause or add to the
2) patient
state of confusion.
demonstrates use of
walker and bedpan
1c) patient and
family teaching is
important to manage
and prevent illness
and increases
likelihood of
compliance.
MEDICATION INFORMATION
Name: Norvasc, Amlodipine besylate
Dosage: 5mg PO BID
Classification: calcium channel blocker
Action: calcium ion channel blocker that inhibits the influx of calcium ions into vascular smooth
muscle and cardiac muscle thus decreasing myocardial contractility and oxygen demand; peripheral
arterial vasodilator that acts directly on vascular smooth muscle to cause a reduction in peripheral
vascular resistance and reduction in blood pressure.
Indication: antihypertensive, anti angina
Side Effects: headache, fatique, somnolence, edema, dizziness, flushing, palpitations, nausea,
abdominal pain, dyspepsia
Nursing Considerations: get baseline B/P and pain rating before beginning therapy and monitor
throughout treatment. Extreme COPD pt may experience increase in severity and frequency of angina.
Give SL Nitroglycerine prn for acute angina.
Name: Bayer Children’s Aspirin, aspirin
Dosage: 81mg PO Daily
Classification: nonopioid analgesic, antipyretic, anti-inflammatory, antiplatelet
Action: analgesic and anti-inflammatory: block prostaglandin synthesis; fever: act on heat-regulating
center to cause peripheral vasodilation, therefore promote sweating; impede clotting: blocking
prostaglandin synthesis prevents formation of platelet-aggragating substances
Indication: relieve pain, reduce fever, reduce risk of transient ischemic attacks and MI (impede
clotting)
Side Effects: tinnitus, hearing loss, GI bleeding, NVD, dyspepsia, hepatitis, thrombocytopenia, rash,
bruising, angiodema, Reye’s syndrome
Nursing Considerations: give with food, milk, antacid or large glass of water; to maximize absorption
give PR after a bowel movement or HS; hold dose and notify dr. if GI bleeding occurs; stop aspirin 57 days before surgery.
Name: Benadryl, diphenhydramine HCL
Dosage: 25mg PO HS
Classification: antihistamine, antiemetic, antivertigo agent, antitussive, sedative-hypnotic,
antidyskinetic
Action: competes with histamine for H1receptor sites on effector cells. prevents histamine’s effects on
Indication: rhinitis, allergy symptoms, motion sickness, Parkinson’s Disease, sedation, nighttime
sleep aid, nonproductive cough.
Side Effects: drowsiness, confusion, insomnia, headache, sedation, incoordination, restlessness,
tremors, nervousness, seizures, hypotension, tachycardia, diplopia, blurred vision, nasal congestion,
tinnitus, NVD, dry mouth, epigastric distress, dysuria, urine retention, urine frequency
Nursing Considerations: may reduce H/H, platelet and granulocyte counts; do not give via IV faster
than 25mg/min; risk for injury r/t drug-induced adverse CNS reactions; give with food or milk to
reduce GI distress; alternate injection sites to prevent irritation and give IM injections in a deep large
muscle.
Name: Tenex, guanfacine HCL
Dosage: 1mg PO HS
Classification: centrally acting sympatholytic
Action: unknown; may inhibit central vasomotor center decreasing sympathetic outflow to heart,
kidneys, and peripheral vasculature.
Indication: antihypertensive
Side Effects: drowsiness, fatigue, dizziness, headache, insomnia, bradycardia, orthostatic hypotension,
rebound HTN, constipation, nausea, diarrhea, dry mouth, dermatitis, puritis
Nursing Considerations: give daily doses HS to minimize daytime drowsiness, risk for constipation,
pt. teaching: not to stop med abruptly to prevent rebound HTN, avoid activities requiring alertness
until side effects are known
Name: hydrochlorothiazide
Dosage: 6.25mg PO Daily
Classification: diuretic, antihypertensive
Action: promotes water and sodium excretion and lowers BP
Indication: reduce edema, reduce HTN
Side Effects: dehydration, orthostatic hypotension, anorexia, pancreatitis, nausea, nocturia, polyuria,
renal impairment, aplastic anemia, agranulocytosis, leucopenia, thrombocytopenia, hepatic
encephalopathy, hypokalemia, hyperglycemia, fluid and electrolyte imbalance incl. metabolic acidosis,
photosynsitivity, gout
Nursing Considerations: give drug in morning to prevent nocturia; give with food if GI upset occurs,
monitor: BP, I/O, weight, electrolyte levels, creatinine, BUN, uric acid levels
Name: Levaquin, levofloxacin
Dosage: 500mg PO Qam
Classification: broad-spectrum antibacterial
Action: bactericidal
Indication: acute maxillary sinusitis, acute bacterial exacerbation of chronic bronchitis, communityacquired pneumonia, mild to moderate skin infections, UTIs, mild to moderate acute pyelonephritis,
traveler’s diarrhea, uncomplicated cervical, urethral or rectal gonorrhea, urogenital chlamydial
infections, acute PID
Side Effects: seizures, headache, insomnia, dizziness, encephalopathy, paresthesia, pain, chest pain,
palpitations, vasodilation, abnormal ECG, NVD, constipation, abdominal pain , dyspepsia,
psuedomembranous colitis, lymphocytopenia, hypoglycemia, back pain, Steven-Johnsons Syndrome
Nursing Considerations: may lower glucose, H/H, WBC and lymphocyte levels – monitor levels; PO
and IV dosages are same, give IV by infusion only over 60min, do not mix with other drugs; risk for
fluid volume defecit -give PO meds with plenty of fluid, treat hypersensitivity with epinephrine,
oxygen, IV fluid, antihistamines, corticosteroids, and airway mgmt; if excessive CNS stimulation
occurs stop meds, notify dr, and take seizure precautions.
Name: Synthroid, levothyroxine sodium
Dosage: 0.075mg PO Daily
Classification: thyroid hormone replacement
Action: raises thyroid levels in body
Indication: congenital hypothyroidism, myxedema coma, hypothyroidism, thyroid hormone
replacement
Side Effects: fever, headache, tremor, nervousness, insomnia, palpitations, tachycardia, cardiac arrest,
nausea, diarrhea, appetite change, menstrual irregularities, weight loss, leg cramps, diaphoresis
Nursing Considerations: monitor for coronary insufficiency in pt with CAD; IV – don’t mix with
other meds, infuse over 1-2min, monitor BP and HR; dosage requirements are bout 25% lower in pts
over 60YO, start pt on lowest possible dose, may need to reduce anticoagulant if applicable, teach –
take at same time each day to maintain levels, take in morning to prevent insomnia, call dr if
palpitations, sweating, nervousness, SOB, unusual bruising/bleeding, do not change brands if achieve
stable response
Name: Lidoderm, lidocaine
Dosage: 1 each TP daily
Classification: ventricular antiarrhythmic
Action: abolish ventricular arrhythmias – decreases depolarization, automaticity, and excitability on
ventricles during diastole
Indication: Ventricular arrhythmias from MI, cardiac manipulation or digoxin toxicicty
Side Effects: seizure, light-headedness, confusion, tremor, somnolence, restlessness, hypotension,
bradycardia, new or worsening arrythmias, cardiac arrest, respiratory arrest, status asthmaticus,
diaphoresis
Nursing Considerations: pt must be on cardiac monitor when infusing via IV; monitor: BP, ECG
(widening QRS or PR interval), electrolytes, BUN and creatinine levels; monitor pt for toxicity:
seizures, somnolence, confusion, paresthesia; give IM injections on deltoid only;
Name: Theragran, therapeutic multivitamin
Dosage: 1 UDTab Daily
Classification:
Action:
Indication:
Side Effects:
Nursing Considerations: teach: do not take more than indicated dosage.
Name: Protonix, pantoprazole sodium
Dosage: 40mg PO Daily at 0630
Classification: proton pump inhibitor
Action: suppresses gastric acid secretion
Indication: GERD, short-term and long-term treatment of pathologicl hypersectretion conditions r/t
Zollinger-Ellison Syndrome
Side Effects: headache, insomnia, asthenia, migraine, anxiety, dizziness, CP, pharyngitis, rhinitis,
sinusitis, abdominal pain, constipation, dyspepsia, gastroenteritis, NVD, hyperglycemia,
hyperlipidemia, back and neck pain, hypertonia, bronchitis, dyspnea, upper RTI, rash
Nursing Considerations: risk for aspiration r/t GI disorder; pt teach: take at same time every day, do
not need to take with regard to meals, do not crush or break pill; report if abdominal pain, or signs of
bleeding
Name: Miralex, polyethylene glycol 3350
Dosage: 17g PO Daily
Classification: laxative and bowel evacuant
Action: cleanses bowel by acting as an osmotic agent
Indication: bowel preparation before GI exam; management of acute iron overload
Side Effects: nausea, vomiting, bloating, cramps
Nursing Considerations: use tap water to reconstitute, do not use cold water, do not add flavoring or
other ingredients, risk of diffecient fluid volume if GI probs.
Name: Micro-K, potassium chloride
Dosage: 10mEq PO BID
Classification: mineral
Action: replace and maintain potassium lvl
Indication: prevent and treatment of hypokalemia, acute MI
Side Effects: arrythmias, heart block, cardiac arrest, ECG changes(prolonged PR, widened QRS, ST
depression, tall/tented t waves), paresthesia, weakness or heaviness of limbs, listlessness, mental
confusion, NVD, ulcerations, oliguria, respiratory paralysis
Nursing Considerations: make sure powders are completely dissolved before giving, give with or just
after meals with full glass of water or juice to decrease GI irritation; preparations are not
interchangeable; don’t postop until urine flow is established.
Name: Zoloft, sertraline HCL
Dosage: 50mg PO Daily
Classification: antidepressant – serotonin reuptake inhibitor
Action: relieves depression – may be linked to inhibited neural uptake of serotonin in CNS
Indication: depression, PTSD, social anxiety disorder, premenstrual dysphoric disorder, premature
ejaculation
Side Effects: headache, tremor, nervousness, dizziness, insomnia, para/hyp/hyperesthesia, fatigue,
twitching, confusion, dry mouth, NVD, thirst, constipation, male sexual dysfunction, increased appetite
Nursing Considerations: give once daily either morning or evening, with or without food; don’t give
within 14 day of MAO inhibitor therapy; mix oral concentrate with water, ginger-ale or lemon-lime
soda only; advise pt not to do activities requiring alert CNS functioning until effects are known.
Name: Tylenol, acetaminophen
Dosage: 650mg PO, 650mg RC, q4h prn
Classification: nonopioid analgesic, antipyretic
Action: relieves pain: probably by preventing or reducing prostaglandin synthesis; reduce fever:
probably by acting on the hypothalamic heat-regulating center
Indication: mild pain or fever; osteoarthritis
Side Effects: neutropenia, leucopenia, pancytopenia, thrombocytopenia, hemolytic anemia, liver
damage, jaundice, hypoglycemia, rash
Nursing Considerations: calculate dosage based on level of drug when giving oral preparations
because drops and elixir hve different concentrations; teach: drug is for short-term use only, high dose
or long-term use may cause liver damage, do not take with alcohol, use med for temp >103.1 F or for
fever > 3 days.
Name: Dulcolax, bisacodyl
Dosage: 5mg PO, 10mg RC Daily prn
Classification: stimulant laxative
Action: relieve constipation – increase peristalsis probably by irritating smooth muscle of intestine
and promoting fluid accumulation in colon and sm. Intestine.
Indication: chronic constipation; prep for childbirth, surgery or rectal/bowel exam
Side Effects: tetany; NVD; burning sensation in rectum, abdominal cramping; laxative dependence;
alkalosis; hypokalemia; fluid and electrolyte imbalance, muscle weakness
Nursing Considerations: check frequency and characteristics of stool to determine effectiveness;
auscultate for bowel sounds at least once per shift; don’t give within 1 hour of milk or antacids; insert
suppository as high as possible, but not within stool
Name: Colace, docusate sodium
Dosage: 100mg PO BID prn
Classification: emollient laxative
Action: softens stool by reducing surface tension of interfacing liquid contents of bowel. This
promotes incorporation of additional liquid into stool.
Indication: stool softener
Side Effects: throat irritation; bitter taste; diarrhea, mild abdominal cramping, laxative dependence
with long-term use
Nursing Considerations: give liquid in milk, juice or infant formula to mask the taste; store drug away
from light at 59-86oF; stop drug if abdominal cramping occurs
Name: Robitussin-DM Syrup, guaifenesin/d-methorphan
Dosage: 10ml PO q4h prn
Classification: expectorant
Action: thins respiratory secretions for easier removal
Indication: expectorant
Side Effects: drowsiness, stomach pain, NVD, skin rash
Nursing Considerations: assess for fluid volume deficit if GI reactions occur; teach: take with full
glass of water, notify dr if cough lasts longer than 1 week
Name: Imodium, loperamide HCL
Dosage: 2mg PO qid prn
Classification: antidiarrheal
Action: relieves diarrhea by inhibiting peristalsis activity, prolonging transit in bowel
Indication: acute and chronic diarrhea, including Traveler’s diarrhea
Side Effects: drowsiness, fatigue dizziness, dry mouth, abdominal pain/distention/discomfort,
constipation, nausea, vomiting
Nursing Considerations: check dosage carefully because oral liquids have different concentrations;
teach: see medical treatment if diarrhea lasts more than 48 hours, do not exceed recommended dose,
notify dr and stop taking drug if abdominal distension occurs
Name: Maalox Suspension, magnesium hydroxide/aluminum hydroxide
Dosage: 15ml PO q2h prn
Classification: laxative
Action: reduces total acid load in GI tract, elevates gastric pH to reduce pepsin activity, strengthens
gastric mucosal barrier, and increases esophageal sphincter tone
Indication: constipation, evacuate bowel before surgery, acid indigestion, GERD, PUD, heartburn
Side Effects: abdominal cramping, nausea, diarrhea, laxative dependence with long-term use, fluid and
electrolyte imbalances
Nursing Considerations: monitor electrolytes during long-term use, especially magnesium, time drug
so that it does not interfere with activities/sleep, chill before serving to help palatability, shake
suspension well and give with large amount of water. Teach; use of fiber in diet; drug for short-term
use only
Name: Phenergan, promethazine HCL
Dosage: 25mg IM, 25mg RC, 25mg PO q4h prn
Classification: antiemetic, antivertigo, antihistamine, sedative
Action: competes with histamine for H1-receptor sites on effector cells.
Indication: motion sickness, nausea, vomiting, rhinitis, allergy symptoms, sedation, routine preop or
postop sedation, or adjunct to analgesics
Side Effects: sedation, confusion, restlessness, tremors, drowsiness, hypotension, ECG changes,
transient myopia, nasal congestion, anorexia, nausea, vomiting, diarrhea, dry mouth, urine retention,
leucopenia, agranulocytosis, thrombocytopenia, photosensitivity, venous thrombosis at injection site
Nursing Considerations: give with food or milk to reduce GI distress, risk for injury due to sedating
effect, contains sulfite, don’t give SC, stop drug 48hours before and 24hours after a myelogram; teach:
avoid alcohol, take 30-60min before travel, gum, candy, ice chips may relieve dry mouth, avoid
sunlight
Name: Darvocet, propoxyphene napsylate/aspirin
Dosage: 1-2tab PO q4-q6h prn
Classification: centrally acting analgesic
Action: bind with opioid receptors in CNS, altering perception and emotional response to pain
(unknown mechanism)
Indication: mild to moderate pain
Side Effects: dizziness, sedation, nausea, vomiting, constipation, abdominal pain, skin rashes,
lightheadedness, headache, weakness, euphoria, dysphoria, hallucinations, and minor visual
disturbances, respiratory depression, euphoria
Nursing Considerations: give with food to minimize GI distress, monitor fluid balance if GI distress
occurs, pain relief is considered equal to aspirin, tolerance and physical dependence have been
observed, note: 65mg propoxyphene HCL = 100mg propoxyphene napsylate, teach: do not take more
than recommended dosage due to risk of CNS depression, avoid driving while on med, take care in
ambulating, avoid alcohol
Name: Restoril, temazepam
Dosage: 15mg PO HS prn
Classification: sedative-hypnotic
Action: may act on limbic system, thalamus and hypothalamus to produce hypnotic effect therefore
promote sleep
Indication: short-term treatment of insomnia
Side Effects: drowsiness, confusion, dizziness, lethargy, disturbed coordination, daytime sedation,
nightmares, vertigo, euphoria, weakness, blurred vision, nausea, diarrhea, dry mouth, physical or
psychological dependence
Nursing Considerations: make sure patient swallows pill before leaving bedside, supervise walking;
teach: avoid activities requiring mental alertness or physical coordination
Name: Ultracet Tablet, tramadol hcl/acetaminophen
Dosage: 1 UDTab PO qid prn
Classification: centrally acting synthetic opioid analgesic
Action: relieves pain by unknown action, possible action is by binding to opioid receptors and
inhibiting reuptake of norepinephrine and serotonin
Indication: moderate to moderately severe acute pain
Side Effects: asthenia, fatigue, hot flushes, dizziness, headache, tremors, abdominal pain, constipation,
diarrhea, dyspepsia, flatulence, dry mouth, nausea, vomiting, anorexia, anxiety, confusion, euphoria,
insomnia, nervousness, somnolence, pruritus, rash, increased sweating.
Nursing Considerations: closely monitor patient at risk for seizures, monitor for drug dependence,
give before onset of pain for best results, hold dose and notify dr if respiratory rate < 12, constipation
is very common, teach: take only as prescribed, refrain from activities until CNS effects are known,
take care when ambulating, check with dr before taking OTCs.