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Table of Contents
I. Introduction
A. Background of the study
B. Rationale for Choosing the Case
C. Significance of the Study
D. Scope and Limitation
II. Clinical Summary
A. General Data
B. Chief Complaint
C. Nursing History
a. History of Present Illness
b. Past Medical History
c. Familial History
d. Social History
D. Physical Assessment
F. Laboratory and Diagnostic Exams
G. Impression/Diagnosis
III. Clinical Discussion of Disease
A. Anatomy and Physiology
B. Pathophysiology
C. Drug Studies
IV. Nursing Process
A. Problem List
B. Nursing Care Plan
C. Long Term Objective
D. Discharge Planning
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INTRODUCTION
A. Background of the Study
This is a case of a 30 y/o, G1P0 who came in due to left back pain. Present
complaint started 1 day PTA when Px experienced left back pain radiating to the
lumbosacral area and difficulty of breathing usually after coughing. Persistent coughing
and back pain, Px was advised and was admitted in our institution.
B. Rationale for Choosing the Case
The case was studied for the following reasons:
1. to know the anatomy and physiology of the lungs
2. to know the pathophysiology of pulmonary edema
3. to know the appropriate nursing intervention in handling Px with pulmonary
edema
4. to know the appropriate medical management in caring for patient with
pulmonary edema
C. Significance of the Study
This study will be able to help students, specially nursing students to know
everything about pulmonary edema, thus being able to render proper nursing care and
intervention to patients with pulmonary edema. This, if implemented, will make it easier
for patients to restore their health. This study may also help student nurses to be more
effective nurses.
D. Scope and Limitation
This study only engage in the following topics:
1. anatomy and physiology of the lungs
2. pulmonary edema
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CLINICAL SUMMARY
A. General Data
Name: Rosario S. Banaag
Address: B11 116 PH2 Kawal, Dagat-dagatan, Caloocan City
Date of Birth: 12/18/1976
Age: 29 y/o
Sex: Female
Civil Status: Single
Nationality: Filipino
B. Chief Complaint
Difficulty of breathing
C. Nursing History
a. History of Present Illness
Admitting a case of a 30 y/o, G1P0 who came in due to left back pain.
Present complaint started 1 day PTA when Px experienced left back pain radiating to the
lumbosacral area and difficulty of breathing usually after coughing. Nebulization with
Salbutamol was done affording temporary relief. Persistence prompted consult at
Puericulture where she was advised to consult at a tertiary hospital. 16 hours PTA,
persistence of left back pain associated with DOB prompted consult at Jose Reyes
Memorial Medical Foundation where CBC, UA, UTS and x-ray was requested. She was
advised admission however went on HAMA. Persistence forced consult at our institution
and was subsequently admitted.
b. Past Medical History
(+) suicide attempt – 1990, drug intoxication with anti-TB, confined at
JRMMC
(+) allergy to food – chicken
(-) allergies to drugs
(+) HPN, Dx: Oct. 2006, on Aldomet 250 mg TID, HBP: 160/100
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HBP: 160/100 UBP: 120/90
(+) asthma, Dx 1 week ago at Puericulture, on Ventolin 2 mg tablet q 60
no DM, no PTB
c. Familial History
(+) HPN, both parents (+) asthma - father
(+) DM – mother (+) heart problem – mother
(-) cancer
d. Social History
♣ HS graduate
♣ presently unemployed
♣ living – in for 1 year to 30 y/o computer engineer, Palestinian, whom
she met 2 years ago at Dubai
♣ non-smoker, non-alcoholic beverage drinker
♣ menarche – 14 y/o with regular monthly interval lasting 3-4 days
consuming 2-3 pads/day
D. Physical Assessment
Date of Assessment: 11-22-06
Vital Signs: Temp.: 36.60C RR: 28 bpm
PR: 120 beats/min BP: 150/100
General Survey: Px is conscious, coherent, tachycardia, tachypnea
Parts to be Assessed Technique Used Deviation from Normal
skin palpation, inspection None
head inspection, palpation None
eyes inspection None
ears/nose inspection None
mouth/throat inspection None
neck inspection None
chest/lungs auscultation (+) crackles, R midlung
field
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heart auscultation tachycardia
abdomen inspection None
extremities inspection (+) edema on both LE
E. Patterns of Functioning
♣ Activity/Rest
Ability to engage to necessary activities of life, but is having difficulty
having adequate sleep.
♣ Circulation
Inability to transport oxygen necessary to meet cellular needs.
♣ Elimination
Ability to excrete waste products.
♣ Food / Fluid
Ability to maintain intake and utilize nutrients and liquids to meet
physiologic needs.
♣ Hygiene
Ability to perform daily hygienic activities.
♣ Neurosensory
Impaired perception, integration, and respond to internal and external
cues.
♣ Pain / Discomfort
Inability to control internal / external environment to maintain comfort.
♣ Respiration
Inability to provide and use oxygen to meet physiologic needs.
♣ Safety
Ability to provide a safe growth-promoting environment.
♣ Sexuality
Ability to meet requirements and characteristics of female role.
♣ Social Interaction
Ability to establish and maintain relationship among others.
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F. Laboratory and Diagnostic Examination
Date: 11-21-06
Components Results Normal Values Interpretation
Neutrophils 69.0% 55%
Lypnhocytes 24.7% 34%
Monocytes 4.8% 1.0%
Eosinophils 1.5% 3.0%
Platelet 522 x 109 L 150-450 x 109 L
Components Results Normal Values
pO2 85 mmHg 80-100 mmHg mild hypoxemia
pCO2 21.00 mmHg 35-45 mmHg respiratory alkalosis
HCO3 12.70 mmol/L 22-26 mmol/L metabolic acidosis
results: mild hypoxemia with respiratory alkalosis and metabolic acidosis
Date: 11-22-06
Components Results Normal Values Interpretation
total protein 58.0 g/L 60-70 g/L
globumin 22.5 g/L 23-35 g/L
PTT 35.0 secs 60-70 secs
PT 81.4% 100%
Date: 11-24-06
Components Results Normal Values Interpretation
hemoglobin 1.519 mmol/L 1.86-2.58 mmol/L
erythrocytes 0.33 mmol/L 0.38-0.47 mmol/L
Date: 11-23-06
Radiological Report
There is a prominence of the pulmonary vascularity.
Heart appear markedly enlarged.
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There is haziness in both mod & lower lungfields.
Interstitial infiltrates are likewise noted bilaterally.
Both hemidiaphragms & sulci are obscured.
G. Impression
Cardiomegaly with pulmonary edema
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CLINICAL DISCUSSION OF DISEASE
A. Anatomy and Physiology
The lungs are paired cone-shaped organs in the thoracic cavity. They are
separated from each other by the heart and other structures in the mediastinum which
separates the thoracic cavity into two anatomically distinct chambers. As a result, should
trauma cause one lung to collapse, the other may remain expanded. Our lungs are located
within our chest cavity inside the rib cage. They are made of spongy, elastic tissue that
stretches and constricts as you breathe. The airways that bring air into the lungs (the
trachea and bronchi) are made of smooth muscle and cartilage, allowing the airways to
constrict and expand. The lungs and airways bring in fresh, oxygen-enriched air and get
rid of waste carbon dioxide made by your cells. They also help in regulating the
concentration of hydrogen ion (pH) in our blood.
Two layers of serous membrane, collectively called the pleural
membrane, enclose and protect each lung. The superficial layer lines the wall of the
thoracic cavity and is called the parietal pleura; the deep layer, the visceral pleura,
covers the lungs themselves. Between the visceral and parietal pleurae is a small space,
the pleural cavity, which contains a small amount of lubricating fluid secreted by the
membranes. This fluid reduces friction between the membranes, allowing them to slide
easily over one another during breathing. Pleural fluid also causes the two membranes to
adhere to one another, a phenomenon called surface tension. Separate pleural cavities
surround the left and right lungs. Inflammation of the pleural membrane, called pleurisy
or pleuritis, may in its early stages cause pain due to friction between the parietal and
visceral layers of the pleura. If the inflammation persists, excess fluid accumulates in the
pleural space known as pleural effusion.
The lungs extend from the diaphragm to just slightly superior to the
clavicles and lie against the ribs anteriorly and posteriorly. The broad inferior portion of
the lung, the base, is concave and fits over the convex area of the diaphragm. The narrow
superior portion of the lung is the apex. The surface of the lung lying against the ribs, the
costal surface, matches the rounded curvature of the ribs. The mediastinal (medial)
surface of each lung contains a region, the hilus, through which bronchi, pulmonary
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blood vessels, lymphatic vessels, nerves enter and exit. These structures are held together
by the pleura and connective tissue and constitute the root of the lung. Medially, the left
lung also contains a concavity, the cardiac notch, in which the heart lies. Due to the
space occupied by the heart, the left lung is about 10% smaller than the right lung.
Although the right lung is thicker and broader, it is also somewhat shorter than the left
lung because the diaphragm is higher on the right side, accommodating the liver that lies
inferior to it.
The lungs almost fill the thorax. The apex of the lungs lies superior to the
medial third of the clavicle and is the only area that can be palpated. The anterior, lateral,
and posterior surfaces of the lungs lie against the ribs. The base of the lungs extends from
the sixth costal cartilage arteriorly to the spinous process of the tenth thoracic vertebra
posteriorly. The pleura extends about 5 cm below the base from the sixth costal cartilage
anteriorly to the twelfth rib posteriorly. Thus, the lungs do not completely fill the pleural
cavity in this area. Removal of excessive fluid in the pleural cavity can be accomplished
without injuring lung tissue by inserting the needle posteriorly through the seventh
intercostal space, a procedure termed thoracentesis.
Lobes, Fissures, and Lobules
One or two fissure divide each lung into lobes. Both lungs have an
oblique fissure, which extends inferiorly or anteriorly; the right lung also has a
horizontal fissure. The oblique fissure in the left lung separates the superior lobe from
the inferior lobe. In the right lung, the superior part of the oblique fissure separates the
superior lobe from the inferior lobe, whereas the inferior part of the oblique fissure
separates the inferior lobe from the middle lobe. The horizontal fissure of the right lung
subdivides the superior lobe, thus forming a middle lobe.
Each lobe receives its own secondary bronchus. Thus, the right primary
bronchus gives rise to three secondary bronchi called the superior, middle, and inferior
(lobar) secondary bronchi, whereas the left primary bronchus gives rise to superior and
inferior (lobar) secondary bronchi. Within the substance of the lung, the secondary
bronchi give rise to the tertiary (segmental) bronchi, which are constant in both origin
and distribution – there are ten tertiary bronchi in each lung. The segment of the lung
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tissue that each tertiary that each tertiary bronchus supplies is called a
bronchopulmonary segment. Bronchial and pulmonary disorders that are localized in a
bronchopulmonary segment may be surgically removed without seriously disrupting the
surrounding lung tissue.
Each bronchopulmonary segment of the lungs has many small
compartments called lobules, each of which is wrapped in elastic connective tissue and
contains a lymphatic vessel, an arteriole, a venule, and a branch froma terminal
bronchiole. Terminal bronchioles subdivide into microscopic branches called respiratory
broncdhioles. As the respiratory bronchioles penetrate more deeply into lungs, the
epithelial lining changes from simple cuboidal to simple squamous. Respiratory
bronchioles, in turn, subdivide into several alveolar ducts. The respiratory passages from
the trachea to the alveolar ducts contain about 25 orders of branching; that is, branching –
from the trachea into primary bronchi (first order braching) into secondary bronchi
(second order branching) and so on down to the alveolar ducts – occurs about 25 times.
Alveoli
Around the circumference of the alveolar ducts are numerous alveoli and
alveolar sacs. An alveolus is a cup-shaped outpouching lined by simple squamous
epithelium and supported by a thin elastic basement membrane; an alveolar sac consists
of two or more alveoli that share a common opening. The walls of the alveoli consist of
two types of alveolar epithelial cells. Type I alveolar cells, the predominant cells, are
simple squamous epithelial cells that form a nearly continuous lining of the alveolar wall.
Type II alveolar cells, also called septal cells, are fewer in number and are found
between type I alveolar cells. The thin type I alveolar cells are the main sites of gas
exchange. Type II alveolar cells, which are rounded or cuboidal epithelial cells whose
free surface between the cells and the air moist. Included in the alveolar fluid is
surfactant, a complex mixture of phospholipids and lipoproteins. Surfactant lowers the
surface tension of alveolar fluid, which reduces the tendency of alveoli to collapse.
Associated with the alveolar walls are alveolar macrophages (dust cells), wandering
phagocytes that remove fine dust particles and other debris in the alveolar spaces. Also
present are fibroblasts that produce reticular and elastic fibers. Underlying the type I
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alveolar cells is an elastic basement membrane. On the outer surface of the alveoli, the
lobule’s arteriole and venule disperse into a network of blood capillaries that consist of a
single layer of endothelial cells and basement membrane.
The exchange of O2 and CO2 between the air spaces in the lungs and the
blood takes place by diffusion across the alveolar and capillary walls, which together
form the respiratory membrane. Extending from the alveolar air space to blood plasma,
the respiratory membrane consists of four layers:
1. a layer of type I and type II alveolar cells and associated alveolar macrophages
that constitutes the alveolar wall
2. an epithelial basement membrane underlying the alveolar wall
3. a capillary basement membrane that is often fused to the epithelial basement
membrane
4. the endothelial cells of the capillary
Despite having several layers, the respiratory membrane is very thin –
only 0.5 µm thick, about one-sixteenth the diameter of a red blood cell. This thinnes
allows rapid diffusion of gases. Moreover, it has been estimated that the lungs contain
300 million alveoli, providing an immense surface area of 70 m2 – about the size of a
handball court – for the exchange of gases.
Blood Supply to the Lungs
The lungs receive blood via sets of arteries; pulmonary arteries and
bronchial arteries. Deoxygenated blood passes through the pulmonary trunk, which
divides into a left pulmonary artery that enters the left lung and a right pulmonary arter
that enters the right lung. Return of the oxygenated blood to the heart occurs by way of
the four pulmonary veins, which drain into the left atrium. A unique feature of pulmonary
blood vessels is their constriction in response to localized hypoxia (low O2 level). In all
other body tissues, hypoxia causes dilation of blood vessels, which serves to increase
blood flow to a tissue that is not receiving adequate O2. In the lungs, however,
vasoconstriction in response to hypoxia diverts pulmonary blood from poorly ventilated
areas to well-ventilated regions of the lungs. This phenomenon is known as ventilation-
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perfusion coupling because the perfusion (blood flow) to each area of the lungs matches
the extent of ventilation (airflow) to alveoli in that area.
Bronchial arteries, which branch from the aorta, deliver oxygenated blood
to the lungs. This blood mainly perfuses the walls of the bronchi and bronchioles.
Connection exist between branches of the bronchial arteries and branches of the
pulmonary arteries, however, and most blood returns to the heart via pulmonary veins.
Some blood, however, drains into bronchial veins, branches of the azygos system, and
returns to the heart via the superior vena cava.
Breathing Pattern
When we inhale, the diaphragm and intercostal muscles (those are the
muscles between your ribs) contract and expand the chest cavity. This expansion lowers
the pressure in the chest cavity below the outside air pressure. Air then flows in through
the airways (from high pressure to low pressure) and inflates the lungs. When you exhale,
the diaphragm and intercostal muscles relax and the chest cavity gets smaller. The
decrease in volume of the cavity increases the pressure in the chest cavity above the
outside air pressure. Air from the lungs (high pressure) then flows out of the airways to
the outside air (low pressure). The cycle then repeats with each breath.
As we breathe air in through our nose or mouth, it goes past the epiglottis
and into the trachea. It continues down the trachea through your vocal cords in the
larynx until it reaches the bronchi. From the bronchi, air passes into each lung. The air
then follows narrower and narrower bronchioles until it reaches the alveoli.
Within each air sac, the oxygen concentration is high, so oxygen passes or
diffuses across the alveolar membrane into the pulmonary capillary. At the beginning
of the pulmonary capillary, the hemoglobin in the red blood cells has carbon dioxide
bound to it and very little oxygen. The oxygen binds to hemoglobin and the carbon
dioxide is released. Carbon dioxide is also released from sodium bicarbonate dissolved in
the blood of the pulmonary capillary. The concentration of carbon dioxide is high in the
pulmonary capillary, so carbon dioxide leaves the blood and passes across the alveolar
membrane into the air sac. This exchange of gases occurs rapidly (fractions of a second).
The carbon dioxide then leaves the alveolus when you exhale and the oxygen-enriched
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blood returns to the heart. Thus, the purpose of breathing is to keep the oxygen
concentration high and the carbon dioxide concentration low in the alveoli so this gas
exchange can occur!
B. Pathophysiology of Pulmonary Edema
Pulmonary edema is excess water in the lung. The normal lung contains
very little water. It is kept dry by lymphatic drainage & a balance among capillary
hydrostatic pressure, capillary oncotic pressure, & capillary permeability. In addition,
surfactant lining the alveoli repels water, helping fluid from entering the alveoli.
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Modifiable Non-modifiable
lifestyle – crowded environment genetics – (+) HPN
- overdoing of activities - (+) asthma
history – intoxication of anti-TB - (+) heart problem
respiratory and cardiac distress
disrupted lung architecture
increased permeability
increased force of LV contraction
increased LV O2 demand
LV hypoxia
decreased forc of LV contraction
increased LV preload
pulmonary edema
flooded alveoli increased pulmonary vascular
resistance
compliance (stiff lungs)
RV failure
hypoxemia
increased RV preload
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if treated if not treated
oxygenation, suctioning, fibrosis
medical treatment
development of complications
healing
involvement of all system
recovery
compromiseimmune system
shock
death
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C. Drug Study
Classification Action Available
Form
Indication Contraindication Adverse
Effects
Nursing
Consideration
drugs for fluid
and electrolyte
balance
potassium-
sparing diuretic;
antagonizes
aldosterone in
the distal
tubules,
increasing Na
and H2O
excretion
tablets – 25 mg
- 50 mg
- 100 mg
> edema
> hypertension
> diuretic-induced
hyperaldosteronism
>heart failure as
adjunt to ACE
inhibitors or loop
diuretics
>hypersensitivity
to the drug
> Px with anuria,
acute or
progressive renal
insufficiency,
hyperkalemia
> give drug with
meal to enhance
absorption
> protect drug
from light
> monitor
electrolyte level,
I & O, & BP
> inform the
laboratory that
the Px is taking
the drug because
it may interfere
with tests that
measure digoxin
level
> maximum
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antihypertensive
respone may be
delayed for up to
2 weeks
> watch for
hyperchloremic
metabolic
acidosis
> instruct Px to
take drug in
morning to
prevent need to
urinate at night
> warn Px to
avoid excessive
ingestion of
potassium-rich
foods to avoid
hyperkalemia
> caution Px to
avoid
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performing
hazardous
activities if
adverse CNS
rxns occur
DIAZEPAM
Antenex, Apo-Diazepam, Diastat, Diazemuls, Diazepam Intensol, Ducene, Novo-Dipam, DMS-Diazepam, Valium, Vinol
Page 19
Classification Action Available Form Indication Contraindication Adverse Effects Nursing
Considerations
anxiolytics
CNS drugs
unknown capsule – 15 mg
injection – 5
mg/ml
oral sol. –
5mg/5ml
- 5mg/ml
rectal gel –
2.5 mg
- 5 mg
- 10 mg
- 15 mg
- 20 mg
tablets – 2 mg
- 5 mg
- 10 mg
> anxiety
> pre-op
ssedation
> cardioversion
> Px
hypersensitive to
drug or soy
protein
> Px experiencing
shock, coma, or
acute alcohol
intoxication
> in pregnant
women, specially
first trimester
> children
younger than age
6 mos.
> CNS –
drowsiness,
dysarthria,
slurred speech,
tremor, transient
amnesia, fatigue,
ataxia, headache,
insomnia,
paradoxical
anxiety,
hallucinations,
minor changes in
EEG patterns
> CV –
hypotension, CV
collapse,
bradycardia
EENT – diplopia,
blurred vision,
> use diastat
rectal gel to treat
no more than 5
episodes per
month & no
more than one
episode every 5
days
> dilute oral
concentrate sol.
just before
giving
> monitor
periodic hepatic,
renal, &
hematopoeitic
fxn studies in Px
receiving
repeated or
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nystagmus
GI – nausea,
constipation,
diarrhea with
rectal form
GU –
incontinence,
urine retention
HEPATIC –
jaundice
RESP. –
respiratory
depression, apnea
SKIN – rash
OTHER – altered
llibido, physical
or psychological
dependence, pain,
phlebitis at
injection site
prolonged
therapy
> warn Px to
avoid activities
that require
alertness & good
coordination
> tell Px to avoid
alcohol while
taking drug
> notify Px that
smoking may
decrease drug’s
effectiveness
> warn Px not to
abruptly stop
drug because
withdrawal
symptoms may
occur
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> warn woman
to avoid use
during
pregnancy
AMIKACIN SULFATE
Amikin
Classification Action Available Form Indication Contraindication Adverse Effect Nursing
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Considerations
aminoglycoside inhibits protein
synthesis by
binding directly
to the 30S
ribosomal
subunit;
bactericidal
injection –
50 mg/ml
- 250 mg/ml
- 5 mg/ml in
NSS
> serious
infections caused
by sensitive
strains of
Pseudomonas
aeuroginosa, E.
coli, Proteus,
Klebsiella, or
Staphylococcus
> uncomplicated
UTI caused by
organism not
susceptible to
less toxic drugs
>mycobacterium
avium complex
> Px
hypersensitive to
drug
> CNS –
neuromuscular
blockade
> EENT –
ototoxicity
> GU –
azotemia,
nephrotoxicity,
possible increase
in urinary
excretion of
casts
>MUSCULO
- SKELETAL
- arthralgia
> RESP. – apnea
> obtain
specimen for
C&S before
giving first dose
> evaluate Px’s
hearing before &
during therapy if
he will be
receiving drug
longer than 2
weeks
> weight Px &
review renal fxn
studies before
first dose
> correct
dehydration
before therapy
> monitor renal
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fxn
> watch for s/s
of superinfection
> if no response
occurs after 3-5
days, stop
therapy & obtain
new specimens
for C&S
> instruct Px to
promptly report
adverse rxn
> encourage Px
to maintain
adequate fluid
intake
CAPTOPRIL
Acenorm, Capoten, Enzace, Novo-Captopril
Classification Action Available Indication Contraindication Adverse Effects Nursing
Page 24
Form
Considerations
antihypertensive
cardiovascular
system drug
inhibits ACE,
preventing
conversion of
angiotensin I to
angiotensin II, a
potent
vasoconstrictor;
less angiotensin
II decrease
peripheral
arterial
resistance,
decrease
aldosterone
secretion, which
reduces Na &
H2O
tablets –
12.5mg
- 25 mg
- 50 mg
- 100 mg
> hypertension
> left
ventricular
dysfunction
> Px
hypersensitive to
the drug
> CNS – dizziness,
fainting, headache,
malaise, fatigue,
fever
> CV –
tachycardia,
hypotension,
angina pectoris
> GI – abdominal
pain, anorexia,
constipation,
diarrhea, dry
mouth, dysgeusia,
nausea, vomiting
>HEMATOLOGIC
– leucopenia,
agranulocytosis,
pancytopenia,
anemia,
> monitor Px’s
BP & PR
frequently
> assess Px for
signs of
angioedema
> monitor WBC
& differential
counts in Px with
impaired renal
fxn or collagen
vascular dse
before starting
Tx, q 2 weeks for
the first 3 mos of
therapy, &
periodically
thereafter
> instruct Px to
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thrombocytopenia
>METABOLIC –
hyperkalemia
> RESP. –
dyspnea; dry,
persistent,
nonreproductive
cough
> SKIN – rash,
maculopapular
rash, pruritus,
alopecia
> OTHER –
angioedema
take drug 1 hour
ac taking
> inform Px that
light-headedness
is possible
> tell Px to use
caution in hot
H2O & during
exercise
> advise Px to
notify prescriber
if pregnancy
occurs
> urge Px to
promptly report
swelling of the
face, lips, or
mouth, or
difficulty
breathing
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CEPHALEXIN
(hydrochloride) Keftab
(monohydrate) Apu-Cephalex, Biocef, Keflex, Novo-Lexin, Nu-Cephalex
Classification Action Available Form Indication Contraindication Adverse Effects Nursing
Page 27
Considerations
cephalosporins
anti-infective
first generation
cephalosporin
that inhibits
cell-wall
synthesis,
promoting
osmotic
instability;
usually
bactericidal
(hydrochloride)
tablets – 500mg
(monohydrate)
capsules-250mg
- 500 mg
oral susp. –
125mg/5ml
- 250 mg/5ml
tablets – 250mg
- 500mg
- 1 g
> respiratory
tract, GIT, skin,
soft tissue,
bone, & joint
infections &
otitis media
caused by E.
coli
> in Px
hypersensitive to
the drug
> CNS – dizziness,
headache, fatigue,
agitation,
confusion,
hallucinations
> GI –
pseudomembrane-
ous colitis, nausea,
anorexia, vomiting,
diarrhea, gastritis,
glossitis,
dyspepsia,
abdominal pain,
anal pruritus,
tenesmus, oral
candidiasis
> GU – genital
pruritus,
candidiasis,
> ask Px about
post rxns to
cephalosporins
or penicillin
therapy before
giving first dose
> ontain
specimen for
C&S before
giving first dose
> monitor Px for
superinfection if
therapy is
prolonged
> treat group A
beta-hemolytic
streptococcus
infections for a
minimum of 10
Page 28
vaginitis,
interstitial nephritis
>HEMATOLOGIC
- netropenia,
eosinophilia,
anemia,
thrombocytopenia
>MUSCULO –
SKELETAL –
arthritis, asthralgia,
joint pain
> SKIN –
maculopapular &
erythematus rashes,
irticaria
> OTHER –
hypersensitivity
rxns, serum
sickness,
anaphylaxis
days
> tell Px to take
drug exactly as
prescribed even
after feeling
better
> instruct Px to
take drug with
foodor milk
> tell Px to
notify prescriber
if rash or s/s of
superinfection
develop
Page 29
FERROUS FUMARATE
Femiron, feostat, hemocyte, ircon, nephrofer, novofumas, palafer, palafer pediatric drops, vitron – C
Classification Action Available Form Indication Contraindication Adverse Effects Nursing
Considerations
hematinics provides drops – 45mg / > iron deficiency > Px with primary > GI – nausea, > between meal
Page 30
elemental iron,
an essential
component in
the formation of
hemoglobin
0.6 ml
oral susp. –
100 mg/5 ml
tablets – 63mg
- 200 mg
- 324 mg
- 325 mg
- 350 mg
tablets – 100mg
> as a
supplement
during
pregnancy
hemochromatosis
or hemosiderus,
hemolytic
anemia, peptic
ulcer dse,
regional enteritis,
or ulcerative
colitis
> Px receiving
repeated blood
transfusion
epigastric pains
vomiting,
constipation,
diarrhea, black
stools, anorexia,
> OTHER –
temporarily
stained teeth
from suspension
& drops
doses are
preferable
> check for
constipation
> tell Px to take
tablets with juice
or water but not
with milk or
antacids
> tell Px to take
suspension with
straw & place
drops at back of
throat
> caution Px not
to crush talets
> advice Px not
to substitute 1
iron salt for
another
Page 31
MEFENAMIC ACID
Ponstan, Ponstel
Classification Action Available
Form
Indication Contraindication Adverse Effects Nursing
Considerations
Nonsteroidal
anti-
inhibits
prostaglandin’s
capsule -250mg > short term
relief of mild to
> ulceration
> chronic
> CNS –
headache,
> tell Px to take
drug with milk
Page 32
inflammatory
analgesic
synthesis;
possesses anti-
inflammatory,
antipyretic, &
analgesic effects
- 500 mg moderate pain inflammation of
the GIT
> pregnancy
> children under
14 y/o
> hypersensitivity
to the drug
dizziness,
somnolence,
insomnia, fatigue,
tinnitus,
ophthalmologic
effects
> GI – nausea,
dyspepsia, GI
pain, diarrhea,
vomiting,
constipation,
flatulence
> RESP. –
dyspnea,
hemoptysis,
pharyngitis,
brocnhospasm,
rhinitis
>
HEMATOLOGIC
- bleeding,
or food to
decrease Gi
upset
> arrange for
periodic
opthalmogic
examination for
long term
therapy
> tell Px to take
only the
prescribed
dosage
> inform Px that
drowsiness or
dizziness can
occur
> instruct Px to
d/c drug &
consult
prescriber if
Page 33
platelet inhibition
with higher doses,
neutropenia,
eosinophilia,
leukopenia,
pancytopenia,
thrombocytopenia,
agranulocytis,
granulocytopenia,
aplastic anemia,
decreased Hcb or
Hct, bone marrow
depression,
menorrhagia
> GU – dysuria,
renal impairment
> SKIN –rash,
pruritus, sweating,
dry mucous
membrane,
stomatitis
adverse rxn
occur
Page 34
> OTHER –
peripheral edema,
enaphylactoid
rxns to fatal
anaphylactic
shock
DIGOXIN
Digitex, Digoxin, Lanoxicaps, Lanoxin
Classification Action Available Form Indication Contraindication Adverse Effects Nursing
Considerations
Inotropics
Cardiovascular
system drugs
Inhibits sodium
– potassium –
activated
capsule –
0.05 mg
> heart failure
> tachycardia
> Px with
hypersensitivity
> CNS – fatigue,
generalized
muscle
> before giving
loading dose,
obtain baseline
Page 35
adenosine
triphosphate,
promoting
movement of
calcium from
extracellular to
intracellular
cytoplasm and
strengthening
myocardial
contraction
- 0.1 mg
- 0.2 mg
elixir –
0.05 mg/ml
injection –
0.05mg/ml
- 0.1 mg/ml
- 0.25 mg/ml
tablets –
0.125 mg
- 0.25mg
to the drug
> Px with digitalis
induced toxicity,
ventricular
fibrillation, or
ventricular
tachycardia
unless caused by
heart failure
weakness,
agitation,
hallucinations,
headache,
malaise,
dizziness,
vertigo, stupor,
paresthesia
> CV –
arrythmias
> EENT –
yellow-green
halos around
visual images,
bulrred vision,
light flashes,
photophobia,
diplopia
> GI – anorexia,
nausea,
vomiting,
data and ask Px
about use of
cardiac
glycosides
within the
previous 2-3
weeks
> loading dose is
usually divided
over the first 24
hours with
approximately
half the loading
dose given in the
first dose
> before giving
drug, take
apical-radial
pulse for a
minute
Page 36
diarrhea > monitor
potassium level
carefully
METOPROLOL TARTRATE
Apo-Metoprolol, Apo-Metoprolol Type L, Betaloc, Betaloc Durules, Lopresor SR, Lopresor, Minax, Novo-Metoprolol, Nu-Metop
Classification Action Available Form Indication Contraindication Adverse Effects Nursing
Considerations
antihypertensive decreases
cardiac output,
injection – > hypertension > Px
hypersensitive to
> CNS – fatigue,
dizziness,
> always check
Page 37
cardiovascular
system drug
peripheral
resistance, and
cardiac oxygen
consumption
1 mg/ml in 5-
ml ampules
tablets – 50mg
- 100 mg
- 200 mg
the drug
> Px with sinus
bradycardia,
greater than 1st
degree heart
block,
cardiogenic
shock, or overt
cardiac failure
depression
> CV –
bradycardia,
hypotension,
heart failure, AV
block
> GI – nausea,
vomiting
> RESP. –
dyspnea
> SKIN – rash
Px’s apical pulse
> monitor
glucose level
closely
> Monitor BP
frequently
> store drug at
room
temperature
> tell Px to take
it with meals
> caution Px to
avoid driving if
taking the drug
> tell Px to alert
prescriber if
shortness of
breatn occurs
Page 39
NALBUPHINE HYDROCHLORIDE
Nubain
Classification Action Available Form Indication Contraindication Adverse Effects Nursing
Considerations
opiod analgesics
central nervous
system drug
binds with
opiate receptors
in the CNS,
injection-
10 mg/ml
> moderate to
severe pain
> Px
hypersensitive to
> CNS –
headache,
sedation,
> reassess Px
level of pain at
least 15 & 30
Page 40
altering
perception of
and emotional
response to pain
- 20 mg/ml the drug dizziness,
vertigo,
nervousness,
depression,
restlessness,
crying,l
euphoria,
hostility,
confusion,
unusual dreams,
hallucinations,
speech
disturbance,
delusions
> CV –
hypertension,
hypotension,
tachycardia,
bradycardia
> EENT –
blurred vision,
mins. after
parenteral
administration
> monitor
circulatory &
respiratory status
> caution Px
about getting out
of bed or
walking
Page 41
dry mouth
> GI – cramps,
dyspepsia, bitter
taste, nausea,
vomiting,
constipation
> GU – urinary
urgency
> RESP. –
respiratory
depression,
dyspnea, asthma,
pulmonary
edema
> SKIN –
pruritus,
burning,
urticaria,
clamminess,
diaphoresis
Page 42
Problem Nursing
Diagnosis
Scientific
Rationale
Objective Nursing
Intervention
Rationale Evaluation
difficulty of
breathing
Subjective Cues:
“medyo
nahihirapan nga
akong huminga,
lalo na pag
Ineffective
breathing pattern
r/t lung
compliance as a
result of
accumulation of
fluid in the
disrupted lung
architecture
compliance
hypoxemia
At the end of the
nursing shift, the
Px will be able to
experience
adequate
respiratory fxn.
INDEPENDENT
> place Px in a
semi to high
fowler position if
not
contraindicated
> this position
allow increased
diaphragmatic
excursion &
maximum lung
expansion,
At the end of the
nursing shift, the
Px was able to
experience
adequate
respiratory fxn.
as evidencedof
Page 43
nauubo ako”, as
verbalized by the
client
Objective Cues:
> (+) crackles
>rapid, shallow,
irregular
respiration
> use of
accessory
muscles when
coughing
> abnormal
blood gases
> abnormal chest
x-ray result
pulmonary
interstitium difficulty
breathing
> instruct &
assist Px to
change position,
deep breathe, &
cough or “huff”
every 1-2 hours
which promotes
optimal alveolar
ventilation
> frequent
repositioning
helps loosen
secretions &
promotes a more
effective cough.
It also promotes
maximum lung
expansion &
stimulates
surfactant
production.
Coughing or
huffing
mobilizes
secretions &
facilitates
removal of these
the ff.:
> normal rate,
rhythm & depth
of respiration
> improved
breath sounds
> (-) crackles
> blood gases
within normal
ranges
> Px verbalizes
relief from
difficulty of
breathing
Page 44
> implement
measures to
reduce pain –
splint incision
with pillow
during coughing
& deep breathing
DEPENDENT
> implement
measures to
facilitate
secretions from
the respiratory
tract
> a Px with pain
often guards
respiratory
efforts – pain
reduction
enables the client
to breathe more
deeply which
enhances
alveolar
veltilation &
O2/CO2
exchange
> excessive
secretions and
inability to clear
secretions from
the respiratory
Page 45
removal of
pulmonary
secretions –
suction – as
orderes
> maintain O2
therapy as
ordered
> administer
meds that may
be ordered to
improve Px’s
respiratory status
tract lead to
stasis of
secretions
> supplemental
O2 increases the
concentration of
oxygen in the
alveoli, which
increases the
diffusion of O2
across the
alveolar –
capillary
membrane
> medication
therapy is an
integral part of
treating many
respiratory
condition
Page 47
Problem Nursing
Diagnosis
Scientific
Rationale
Objective Nursing
Interventions
Rationale Evaluation
Page 48
fear
Subjective Cues:
“natatakot nga
ako eh. kasi sabi
ng doctor may
high blood daw
ako. eh lagi pa
kong nahihilo.
kaya
pakiramdam ko
tuloy parang ang
sama-sma ng
pakiramdam ko.
Hindi pa ko
makatulog ng
maayos
kakaisip”, as
verbalized by the
client
Objective Cues:
> disturbed sleep
pattern
Fear r/t
persistent
headache
pre-eclampsia
altered BP
dizziness
disturbed sleep
pattern
feeling of
anxiety
fear
At the end of the
nursing shift, the
Px will be able to
experience a
reduction of fear
INDEPENDENT
> encourage
verbalization of
feelings &
concerns
> assure Px that
staff members
are nearby;
respond to call
signal as soon as
possible
> reinforce
physician’s
explanations &
clarify
> verbalization
of feelings &
concerns helps
client identify
factors that are
causing anxiety
> close contact
& a prompt
response to
requests provide
a sense of
security &
facilitates the
development of
trust, thus
reducing the
client’s anxiety
> factual
information & an
awareness of
what to expect
At the end of the
nursing shift, the
Px will be able to
experience a
reduction of fear
as evidenced by
the ff:
> verbalization
of decreased fear
& understanding
of the medical
procedures
Page 49
Problem Nursing
Diagnosis
Scientific
Rationale
Objective Nursing
Interventions
Rationale Evaluation
Page 50
potential
complications of
heart failure
Subjective Cues:
“Hindi kaya
matuloy to sa
puso, kasi meron
kaming sakit sa
puso”, as
verbalized by the
Px
Objective Cues:
> Hx of heart dse
> hypertension’
> development
of crackles
> chest x-ray
showing
pulmonary
edema
potential
complications of
heart failure r/t
acute pulmonary
edema d/t
accumulation of
fluid in the lungs
Hx of
hypertension,
heart dse.
pulmonary
edema
further lung &
heart distress
complications of
heart failure
At the end of the
whole nursing
shift, the Px will
be able to have
mild to moderate
prognosis from
pulmonary
edema to prevent
complications
INDEPENDENT
> implement
measures to
improve cardiac
output
> place Px in a
high fowler
position
DEPENDENT
> maintain O2
therapy
> administer
meds - diuretics
> in order to
reduce
pulmonary
vascular
congetion
> to improve
lung expansion
> to improve O2
intake
> to reduce fluid
accumulation in
the lungs
At the end of the
whole nursing
shift, the Px was
able to have mild
to moderate
prognosis from
pulmonary
edema as
evidenced by the
ff.”
>(-) crackles
> normal result
of x-ray
- blood gas result
within normal
range
Page 51
> worsening
blood gases