Formilleza, Patricia

Juripae, Shayna
BSN-F
February 17, 2022

Minda 29 years old. Came to ER for nausea and vomiting, positive HCG results. Vitalsigns T=37, BP= 110/80; RR=23 breaths /minute. Her last
menstrual flow was last month and its about 100 days that she missed her menstrual cycle. Pregnancy test displays positive. Ultrasound revealed
dense growth but no fetal growth in the uterus. Medical diagnosis: HD Mole (Throphoblastic disease

Drug Mechanism of Side Effects Indication Contraindication Nursing

Action Responsibilities

Generic Name: Methotrexate  Black, tarry Indicated to • Contraindicated in 8Check and verify with
Methotrexate causes cells to stools. patients with patients hypersensitive to the doctor's order and
release a molecule blood in the Trophoblastic drug and in those with Kardex.
Brand Name: that blocks urine or tumors psoriasis or RA who also Always observe client’s
Trexall chemicals that stools. have alcoholism, alcoholic 10 rights to drug
promote  bloody liver, chronic liver administration:
Classification: inflammation, vomit. disease,  Right patient
Antineoplastics according to the  increased immunodeficiency  Right
Arthritis heartbeat. syndromes, or blood medication
Route: Foundation.  itching, dyscrasias.  Right dosage
Oral, IM rash,  Right route
reddening • Contraindicated in  Right time
Dosage: of the skin. breastfeeding women  Right
15 to 30 mg PO  sores in the documentation
or IM daily for mouth or • Contraindicated during  Right client
5 days lips. pregnancy. Don't use it in education
 stomach women of child bearing  Right to refuse
Frequency: pain. potential unless benefits  Right
PO or IM daily  swelling of outweigh risks. assessment
for 5 days the eyelids,  Right
face, lips, evaluation.
hands, feet,
or lower and fluid intake and
legs. output daily.

Encourage fluid intake

of 2 to 3 L daily.

Monitor uric acid

level.

Advise female latient

to stop breastfeeding
during therapy.

Monitor for side effects

and adverse effects

Record the drug

administered.
 Drug Mechanism of Side Effects Indication Contraindication Nursing
Action Responsibilities

Generic Name: Cross-links CV: Cardiotoxicity Cyclophosphamide • Contraindicated in Check and verify with
Cyclophosphamide strands of with very high is indicated for the patients the doctor's order and
cellular DNA doses and with treatment of: hypersensitive to Kardex.
Brand Name: and interferes doxorubicin malignant drug and in those
Procytox with RNA GI: nausea and lymphomas with severe bone Always observe client’s
transcription, vomiting, anorexia, marrow suppression 10 rights to drug
Classification: causing an stomatitis or urinary outflow administration:
Antineoplastics imbalance of GU: hemorrhagic obstruction.  Right patient
growth that cystitis, impaired • Drug may cause  Right
Route: leads to cell fertility fetal harm if used medication
Oral death. Hematologic: during pregnancy  Right dosage
Dosage: leukopenia, .  Right route
25 mg, 50 mg thrombocytopenia, • Drug appears in  Right time
anemia human milk. Patient
 Right
Hepatic: should discontinue
Frequency: documentation
hepatotoxicity breastfeeding or
PO  Right client
Others: Secondary discontinue taking
malignant disease, drug, taking into
education
 Right to refuse
anaphylaxis, account importance
hypersensitivity of drug to the  Right
reactions mother. assessment
 Right
• Amenorrhea, evaluation.
transient or
permanent, develops Adequately hydrate
in a proportion of patient before and after
women treated with dose to decrease the risk
drug. The risk of for cystitis.
premature
menopause increases Monitor CBC and renal
 with age. function tests and LFT
results

Monitor uric acid level

Advise female patient
to stop breastfeeding
during therapy because
of risk of toxicity to
infant.

Monitor for side effects

and adverse effects

Record the drug

administered.

NURSING CARE PLAN

CUES NURSIN GOALS NURSING RATIONAL IMPLEMENT EVALUA

G AND INTERVENT E ATION TION
DIAGN DESIRE IONS
OSIS D
OUTCO
ME

Subject Nausea After 24 Assess nausea A thorough Characteristics After 24

ive and hours of characteristics assessment such as history, hours of
Cues: vomiting nursing . and duration, nursing
“Nasus related to interventi evaluation of frequency, interventio
uka po abnormal ons, the nausea can severity, ns, the
ako” as growth patient help medications patient has
verbali in uterine will determine and measures recovered
zed by tissue recover interventions used to from
the from to lessen or alleviate the nausea and
patient nausea ease the problem for vomiting
and Avoid fatigue problem. nausea have from
Objecti vomiting and sudden been abnormal
ve from movements. Sudden documented. growth in
Cues: abnormal movements uterus.
growth in and fatigue Bedrest in a
Vital uterus. worsen Semi-Fowler’s
Signs: nausea and position has
T=37 can induce been promoted
BP= Provide an vomiting. and encouraged
110/80 emesis basin patient to
RR=23 within easy reduce
breaths reach of the Nausea and excessive and
/minute
patient. vomiting are sudden
closely movements..
related. Keep
emesis basin Emesis basin
out of sight has been placed
but within the within patient’s
patient’s reach in case of
reach if vomiting
Allow the nausea has a episodes.
patient to use psychogenic
non component.
pharmacologi
cal nausea These
control methods have
techniques helped
such as patients Permitted
relaxation, alleviate the patient to use
guided condition but calming guided
imagery, needs to be imagery and
music used before it music therapy.
therapy, occurs. Taught patient
distraction, or breathing
deep exercises.
breathing
exercises.

Give This
frequent, approach will
small help maintain Foods such as
amounts of nutritional dry crackers,
foods that status. For bland, simple
appeal to the some foods like
patient. patients, an broth, rice,
empty bananas, or
stomach gelatin have
exacerbates been provided.
nausea.
Provide an Stomach
opportunity acids and bile Assisted patient
for oral care from vomit in oral care
after each damage teeth, through
episode. gums, and brushing teeth
throat after episodes
Apply a cool,
damp cloth to Placing a Applied cold
the client’s cool compress for 10
forehead, compress can minutes every
neck, and help reduce patient’s
wrists. the feeling of episodes
being hot
because it
counteracts
the
hypothalamu
s' efforts to
raise body
temperature,
thus easing
Tell patient to the feeling of Nauseous odors
avoid foods nausea. have been
and smells avoided.
that trigger
nausea. Strong and
noxious
Position the odors can Encouraged and
patient contribute to positioned
upright while nausea. patient to sit
eating and for upright while
eating.
1 to 2 hours Reduces
post-meal. nausea and
vomiting.

Collaborative:

Administer
antineoplastic
s as ordered.
 Explained the
purpose of the
Antineoplasti medication and
cs such as administered it.
Cyclophosph Monitored the
amide and effects of
Methotrexate medication
inhibits after taking.
abnormal
growth in
womb that
causes
nausea and
vomiting.