Module 3: Labor and Delivery and Neonatal Drugs PDF

University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING...

University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM Learning Module in NCM 106 PHARMACOLOGY Prepared by: John Ian L. Lamasan, M.A.N., R.N. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM NCM 106: PHARMACOLOGY MODULE 3 DRUGS AFFECTING IN THE BODY SYSTEM Module Overview This module is designed for nursing students to have a comprehensive introduction to the concepts, principles of Pharmacology and to Integrate knowledge of physical, social, natural and health sciences and humanities in nursing pharmacology Module Outcomes At the end of the module the learner should be able to: 1. Provide appropriate health education related to drug therapy. 2. Evaluate compliance and response of client to the medications prescribed. 3. Use available clinical evidence that can ensure safe medication administration. 4. Document client’s condition/response/ outcomes related to drug therapy. 5. Manage resources (human, physical, financial, time) efficiently and effectively in safe drug administration. Use appropriate communication/ interpersonal techniques/strategies to ensure a working relationship with the client and/or support system in medication administration. Ensure intra-agency, inter-agency, multidisciplinary and sectoral collaboration in medication administration. Assume personal responsibility to keep abreast with current trends in nursing pharmacology Exemplify love for country in the service of the Filipinos. Discuss various technological advances in ensuring safe medication administration Manifest professionalism and excellence in planning for safe medication practice. Module Content: a. Reproductive System b. Pregnancy and Pre-term labor drugs c. Labor and Delivery and Neonatal drugs d. Postpartum and Newborn drugs e. Women’s Reproductive Health and Menopause f. Men’s Reproductive Health and Reproductive Disorders g. Infertility and Sexually Transmitted Infections A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM LABOR AND DELIVERY AND NEONATAL DRUGS DRUGS FOR PAIN CONTROL DURING LABOR During the first stage of labor, uterine contractions produce progressive cervical effacement and dilation. As the first stage of labor progresses, uterine contractions become stronger, longer, and more frequent, and discomfort increases. Pain and discomfort in labor are caused by uterine contraction, cervical dilation and effacement, hypoxia of the contracting myometrium, and perineal pressure from the presenting part. Pain perception is influenced by physiologic, psychological, social, and cultural factors, in particular, the woman’s past experience with pain, anticipation of pain, fear and anxiety, knowledge deficit of the labor and delivery process, and involvement of support persons. Nonpharmacologic Measures  Ambulation  Supportive positioning of the gravid uterus and promotion of uterine perfusion  Touch and massage  Hygiene and comfort measures  Support persons  Breathing and relaxation techniques  Transcutaneous electrical nerve stimulation  Hypnosis  Acupuncture  Hydrotherapy (warm-water baths or showers) ANALGESIA/SEDATION Systemic medications used during labor include sedativetranquilizers, narcotics agonists, and mixed narcotic agonist-antagonists; these may be administered orally (sedative-hypnotic drugs), intravenously (IV), or intramuscularly (IM). SEDATIVE-TRANQUILIZERS  Most commonly given for false labor, latent labor, or with ruptured membranes without true labor  Minimize maternal anxiety and fear  Promote rest and relaxation and decrease fear and anxiety, but they do not provide pain relief.  The sedative drugs most commonly used are barbiturates or hypnotics— generally secobarbital sodium (Seconal) and pentobarbital sodium (Nembutal)  Other drugs, such as phenothiazine derivatives and hydroxyzine, can be given alone during early labor or in combination with narcotic agonists when the patient is in active labor.  Potentiate the analgesic action of the opioids and minimize emesis. NARCOTIC AGONISTS  Given for active labor  Administered parenterally or via regional blocks. When administered with neuraxial anesthesia, a lower dose of anesthetic is required for effective pain relief, thereby minimizing side effects.  These drugs interfere with pain impulses at the subcortical level of the brain.  To effect pain relief, opioids interact with mu and kappa receptors.  For example, morphine sulfate activates both mu and kappa receptors. OPIOIDS WITH MIXED NARCOTIC AGONISTANTAGONIST EFFECTS  Exert their effects at more than one site—often an agonist at one site and an antagonist at another.  Two most commonly used narcotic-agonistantagonist drugs are butorphanol tartrate and nalbuphine.  With dose-ceiling effect A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM PRENATAL THERAPY FOR SURFACTANT DEVELOPMENT Generic Name Route and Uses Side Effects and Pregnancy (Brand Name) Dosage Special Consideration Category SEDATIVE- HYPNOTICS pentobarbital IV Short-acting barbiturate. No effects on uterine (Nembutal) 100-200 mg Sedative. tone or contractility; To decrease anxiety during rapidly crosses placenta; latent phase of labor. can cause decreased variability in FHR because of decreased CNS control over heart rate. May have prolonged depressant effects on neonate. May increase CNS depression with alcohol, narcotics, antihistamines, tranquilizers, and monoamine oxidase inhibitors (MAOIs). Avoid valerian, St. John’s wort, kava kava, gotu kola. NARCOTIC AGONIST fentanyl citrate IM/IV Muscle rigidity may occur C (Sublimaze) 50-100 mcg with too-rapid IV administration. Inject over 3-5 min. Watch for respiratory depression in neonates of mothers who receive this drug in labor. May see withdrawal symptoms in neonate if mother was regular opioid user during pregnancy. Be alert to risk of overdose in patients using CNS depressants, phenothiazines, ethanol, and tricyclic antidepressants. Herbal interactions include increased CNS depression with use of St John’s wort, kava kava, and gotu kola. Contraindicated in patients with severe asthma. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM morphine IM/IV Binds to CNS opiate Used for relief of C sulfate 5-10 mg receptors and inhibits moderate to severe pain, (D, if (Duramorph) IV ascending pain pathways. for preoperative prolonged 2-5 mg q4h medication, and as use or supplement to high at- anesthesia. term dose) Cautious use with MAOIs and meperidine. Use of selective serotonin reuptake inhibitors (SSRIs) or meperidine may precipitate serotonin syndrome. Use with caution in patients with biliary tract disease and seizure disorders. May cause drowsiness and respiratory depression, sedation, euphoria, hallucinations, headache, and palpitations. Do not give if respirations 24 hours Documented fetal intolerance of uterine contractions Chorioamnionitis Prematurity Postdates (>42 weeks’ gestation) Placenta previa or suspected abruptio placentae Intrauterine growth retardation Severe gestational hypertension Positive contraction stress test Multiparity (six or more) Maternal diabetes mellitus (classes B- Multifetal gestation F) History of uterine trauma Maternal renal disease Previous major surgery in the area of the cervix or uterus Isoimmunization Prior classical uterine incision Intrauterine fetal death Active genital herpes infection Umbilical cord prolapse Excessive amniotic fluid causing overdistended uterus Approaches of Labor Induction 1. Mechanical Methods 2. Prostaglandins MECHANICAL METHODS One mechanical method involves insertion of a 36F indwelling catheter through an undilated cervix and internal os with subsequent inflation of the 30-mL balloon. The indwelling catheter bulb provides a mechanical stimulation similar to “stripping of the membranes.” When the catheter “falls out,” the patient is started on IV oxytocin. A second mechanical method is insertion of an extraamniotic saline infusion with a balloon catheter into the space between the internal cervical os and the placental membrane to induce labor. A third mechanical method is membrane “stripping.” With membrane stripping, there is release of prostaglandin F2 from the decidua or prostaglandin E2 from the cervix. Watch a video clip here: https://www.youtube.com/watch?v=QbyZguiHJLk PROSTAGLANDINS Labor induction uses administration of dinoprostone, the naturally occurring form of prostaglandin E2 (PGE2). It is thought that intracervically or intravaginally administered PGE2 acts to create cervical effacement and softening through a combination of contraction-inducing and cervical- ripening properties, possibly secondary to an increased submucosal water content and collagen degradation resulting from collagenase secretion in response to PGE2. One approach uses prefilled syringes of commercially prepared dinoprostone cervical gel 0.5 mg (Prepidil gel), which is introduced just inside the cervical os. A second approach is the placement in the posterior vaginal fornix of a vaginal insert dinoprostone (Cervidil) containing 10 mg of controlled-release dinoprostone at 0.3 mg/h. Watch a video clip here: https://www.youtube.com/watch?v=ofb9qMvh1d8 A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM DRUGS THAT ENHANCE UTERINE MUSCLE CONTRACTILITY Generic Name Route and Dosage Uses Side Effects and Pregnancy (Brand Name) Special Consideration Category DINOPROSTONE FOR CERVICAL RIPENING dinoprostone Intracervical: Naturally Patients may have C cervical gel Contains 0.5 mg of occurring form of reactive (Prepidil gel) dinoprostone in 2.5 prostaglandin E2 nonstress test before first mL of gel for (PGE2). Used to dose. Monitor uterine intracervical use. ripen unfavorable activity and FHR; suggest Repeat in 6-12 h if cervix at or near 20-min FHR strip before negative cervical or term in pregnant doses. Must be at room uterine response. women needing temperature before Maximum 24- h labor induction. administration and dose is 1.5 mg, administered by sterile supplied in 3 doses. technique. Must not be Before beginning placed above level of oxytocin (Pitocin, cervical os. Patient is to Oxytocin) after the remain recumbent 15-30 Prepidil min following administration, administration of gel and there should be a 2 h after insert. May 6- to 12-h delay augment other oxytocic agents; therefore no concomitant use; sequential use 6-12 h after gel is recommended. Insert may be inserted with minimal amount of water-soluble lubricant. Wear sterile gloves when administering. dinoprostone Vaginal: Contains Remove insert, and have (Cervidil vaginal 10 mg of oxygen or beta- inserts) dinoprostone in a adrenergic drugs to treat timed-release uterine hyperstimulation. insert, releasing 0.3 Use insert at room mg/h. Insert is left temperature. Wear in place for 12 h. sterile gloves to decrease Oxytocin (Pitocin) risk of absorption as may be started 30- inserted high into vagina, 60 min after posterior fornix. removal of insert. Assess cervical dilation In contrast to gel, and effacement at time insert may be of insertion. After removed with FHR administration, patient decelerations or remains in lying position uterine for 30 min to 2 h. hyperstimulation. Monitor FHR and uterine Ripening stimulation. Have unfavorable cervix: medication available for frequent Intravaginal: gastrointestinal side 10 mg over 12 h; effects of abdominal remove 12 h after cramping, diarrhea, insertion or at nausea, and vomiting. onset of active A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM labor UTEROTONIC DRUGS oxytocin IV: To induce or Maternal effects with X (Pitocin) 10 units (1 amp) augment labor undiluted IV use only: diluted in 1000 mL contractions; to hypertension, lactated Ringer’s treat uterine dysrhythmias, solution to 10 atony; to tachysystole, and uterine milliunits/mL stimulate milk hyperstimulation. letdown Tachysystole is 6 or more (intranasal spray) uterine contractions in a 20-min window. Mechanism of (Hyperstimulation is Action: defined as uterine Promotes uterine contractions lasting at contractions by least 2 min or 5 or more increasing contractions in a 10-min intracellular window.) concentrations of Seizures, water calcium in uterine intoxication if given in myometrial tissue, electrolyte-free solution thereby increasing or at a rate greater than the activity of the 20 milliunits/min. (Water calcium- intoxication is manifested dependent by nausea, vomiting, phosphorylating hypotension, tachycardia, enzyme myosin and cardiac arrhythmias.) light-chain kinase. The nasal spray Life-threatening: Patient: works by forcing Intracranial hemorrhage, milk into larger cardiac dysrhythmias, ducts and sinuses. asphyxia; fetus: jaundice, This occurs hypoxia because oxytocin promotes milk Contraindicated in ejection by vaginal delivery, proven causing cephalopelvic contraction of the disproportion, fetal smooth-muscle intolerance of labor, fibers surrounding hypersensitivity, the breast alveoli anticipated nonvaginal and lactiferous delivery, ducts. pregnancy (intranasal spray) methylergonovine PO: Prevention and Not routinely C maleate 0.2-0.4 mg, q6-12h; treatment of administered IV because (Methergine) max: 1 wk postpartum of possible sudden hemorrhage, hypertensive and IM: subinvolution, and cerebrovascular 0.2 mg after postabortion accidents; limit use in delivery of anterior hemorrhage. patients with shoulder Exhibits similar hypertension (especially (if full obstetric smooth-muscle IV). supervision), after action to delivery of ergotamine, but Adverse reactions: placenta, or primarily affects transient hypertension, postpartum; repeat smooth muscle, diaphoresis, palpitations, q2-4h; oral doses producing dizziness, headache, may follow sustained nausea, vomiting, A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM parenteral contractions and tinnitus, transient chest shortening third pain, dyspnea IV: stage of labor. Same as for IM; but Contraindicated with slowly over 1 min maternal sepsis, labor with careful induction, threatened monitoring of BP spontaneous (IV route for acute abortion; do not use with emergencies only vasodepressors, other [e.g., bleeding]) ergot alkaloids, or vasoconstrictors. Appears in breast milk, but interference with breastfeeding is less than with ergonovine. OXYTOCIN In addition to labor induction, IV oxytocin can also be used for labor augmentation. It facilitates smooth-muscle contraction in the uterus of a patient already in labor but experiencing inadequate uterine contractility (tightening and shortening of uterine muscles). The patient with uterine inertia (uterine inactivity or hypotonic contractions) may be more responsive to oxytocin than the patient who has not begun labor; therefore a lower starting dose will be needed. ERGOT ALKALOIDS The ergot alkaloids (one of a large group of alkaloids derived from a fungus) act by direct smooth-muscle-cell receptor stimulation. These drugs are not used during labor, because they can cause sustained uterine contractions (tetanic contractions), which would result in fetal hypoxia and possibly rupture of the uterus. The uterus becomes more sensitive to these drugs too. After delivery, however, sustained contractions are effective in the prevention or control of postpartum hemorrhage and the promotion of uterine involution. The most commonly used ergot derivative is methylergonovine maleate (Methergine). Methylergonovine maleate can be given by mouth but is most frequently administered by the IM route.IV administration is not recommended and is given only in emergency situations. SURFACTANT THERAPY IN PRETERM BIRTH SYNTHETIC SURFACTANT One approach to respiratory difficulties in the preterm infant is surfactant replacement therapy. This is used to prevent the development of respiratory distress syndrome (RDS) (respiratory disease of the newborn with absence, deficiency, or alteration in surfactant production). Surfactant (a lipoprotein in the alveoli that reduces surface tension of pulmonary fluids and keeps alveoli open during expiration) replacement therapy is also used to decrease the severity of RDS after diagnosis. Supplementing the amount of endogenous surfactant available to maintain distention of the alveolar sacs is the focus of this therapy. DRUGS THAT ENHANCE UTERINE MUSCLE CONTRACTILITY Generic Name Route and Dosage Uses Side Effects and Pregnancy (Brand Name) Special Consideration Category beractant 4 mL/kg per dose Monitor infant’s arterial or (Survanta) ET (divide into 4 transcutaneous intratracheal quarter doses and measurement of systemic suspension give each quarter oxygen or carbon dioxide. dose with infant in Drug should appear off- different position) white to light brown. Swirl in one of two vial gently; DO NOT modes: SHAKE. Some foaming is A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM normal. Store at 36° to 46° Prophylaxis: 1 dose F (2°-8°C); warm 20 min at within 15 min of room temperature or in birth ifpossible; hand for at least 8 min. repeat in 6h if Do not artificially warm. respiratory distress For prevention dose, begin continues; preparation before maximum 4 doses infant’s birth. in 48 h (6 h apart). Do not warm or return drug to refrigerator more Rescue: 4 mL/kg than once. Adverse intratracheally (also reactions: transient divide into 4 bradycardia, oxygen quarter doses and desaturation (associated give each with dosing procedure); ET quarter dose with tube reflux; ET blockage; different infant pallor; vasoconstriction; positioning). hypotension; hypocarbia; hypercarbia; and apnea. Give dose as soon All reactions resolve with as RDS is symptomatic diagnosed, treatment. preferably within 8 h of birth. Repeat in 6 h, giving a maximum of 4 doses in 48 h calfactant 3 mL/kg of birth Give preferably within 30 (Infasurf) weight as soon as min after birth. Give possible after birth. through an ET tube. Give as 2 doses of Draw dose with 20-gauge 1.5 mL/kg each needle; avoid foaming. every Gently agitate for 12 h for total of 3 dispersion of drug. Does doses not have to be warmed before administration. Refrigerate at 36°-46° F (2°-8° C). Adverse reactions: bradycardia, airway obstruction, apnea, hypoventilation, cyanosis, ET tube reflux, ET blockage A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM Activity 2.1 – Reflective Thinking Instructions: 1. Watch a video clip here https://www.youtube.com/watch?v=n2MeMy6_R9Q 2. On the box provided, write briefly your reaction on the video presented. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM Activity 2.2. – Watch, Think and Create Instructions: 1. Watch and analyze the clip here https://www.youtube.com/watch?v=A5-0s3EEtQw 2. Using the format provided below, make a nursing care plan on the medication used during the induction of labor. ASESSMENT PLANNING NURSING INTERVENTIONS EVALUATION A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM Reflective thinking Name of student:________________________________ Year & section:_____________________ Date:__________________ CRITERIA POINTS SCORE 4 3 2 1 Clear Shows superior Shows adequate Shows some Shows little explanation of knowledge of knowledge of the understanding of understanding of key issue/case the issues, key issues, key the issues, key the issues, key problems problems, problems, problems, Appropriate Issue were Issue were Issue were not Inadequate analysis, clearly identified partially identified analysis of the evaluation, identified issue synthesis of the issue/case Interpretation Demonstrate Demonstrate less Lacks critical No critical and critical thinking critical thinking thinking skills thinking skills skills about the skills about the about the topic about the topic application topic and the topic and the student’s own student’s own impressions and impressions and interpretations interpretations of the case of the case Summary Well organized, Well organized, Well organized, Weakly paragraph demonstrates but but organized logical demonstrates demonstrates sequencing and illogical illogical sentence sequencing or sequencing and structure sentence sentence structure structure Grammar and Punctuations There is 1 error There are 2 or 3 There are 4 or spelling and in Punctuations errors in more errors in capitalizations and/or Punctuations Punctuations are correct capitalizations and/or and/or capitalizations capitalizations TOTAL /20 pts A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM CRITERIA 4 3 2 1 WEIGHT Identifies Identifies Identifies Problems CORRECT CORRECT CORRECT identified is nursing nursing nursing not found in problems problems problems the NANDA basing on basing on basing on or no NANDA; NANDA; NANDA; problems Follows the follows the Follows the identified at ___x1=____ PES format for PES format PES format for all; Nursing the diagnostic for the the diagnostic Diagnosis label; list diagnostic label; some appropriate label; some cues are not cues to support cues are not significant or the problem; significant did not supply uses nursing uses medical significant terminology; terminology supporting both elements for the details at all; does not say etiology; both uses medical the same thing; elements does terminology in cause and not say the any elements effect correctly same thing; does not sat stated. cause and OR say the effect clearly same thing. stated Student Some Most objective All objective demonstrates objective is is not specific, is NOT full knowledge; not specific, measurable specific, Objective is measurable (uses verbs measurable specific, (uses verb found in the (uses verbs ___x.5=___ measurable found in the taxonomy of found in the Objectives (uses verbs taxonomy of objectives), taxonomy of found in the objectives), attainable, objectives), taxonomy of attainable realistic, time- attainable, objectives), realistic, and bound; most realistic, and attainable, time-bound; related to the time-bound; realistic, and some not concept. all not related time-bound; all related to the to the are related to concept. concept. the concept. A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan  University of San Agustin General Luna St., Iloilo City 5000, Philippines www.usa.edu.ph COLLEGE OF HEALTH AND ALLIED MEDICAL PROFESSIONS-NURSING PROGRAM All Most Some No interventions interventions Interventions interventions ___x2=___ are addressed are addressed are addressed are addressed to eliminate or to eliminate or to eliminate or to eliminate alleviate the alleviate the alleviate the or alleviate etiology of the etiology of the etiology of the the etiology Interventions nursing nursing nursing of the nursing problem and is problem and problem and is problem; OR in congruence is in in congruent student has with the congruent with the no nursing Goal/objective; with the Goal/ Goal/objective; interventions/ all are objective; some are strategies most are appropriate to planned at all. appropriate to appropriate to the client’s the client’s the client’s understanding, understanding understanding and resources; and resources; and resources; not specific and specific and specific and not laid out in laid out in laid out in detail; some are detail; realistic detail; realistic realistic Able to evaluate Able to Able to evaluate Failed to correctly in evaluate in accordance evaluate. accordance with correctly in with only some the outcome accordance of the outcome criteria/objective with the criteria/ Evaluation and able to give outcome objective and is correct criteria/ unable to give justification to objective and justification. ___x.5= the evaluation by but is unable to ___ listing, give correct appropriate justification to significant cues. evaluation by listing appropriate significant cues. (20 points) Total -- A Legacy of Excellent Education in Virtus et Scientia Email: [email protected] | Tel. No.: (033) 337-4841 to 44 | Fax No.: (033) 337-4403 jilamasan