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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
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Page 1: Case Study

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

Page 2: Case Study

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

Page 3: Case Study

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

Page 4: Case Study

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

Page 5: Case Study

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.

Page 6: Case Study

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.

Page 7: Case Study

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

Page 8: Case Study

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

Page 9: Case Study

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

Page 10: Case Study

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

Page 11: Case Study

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-

Page 12: Case Study

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

Page 13: Case Study

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.

Page 14: Case Study

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

Page 15: Case Study

if treated if not treated

oxygenation, suctioning, fibrosis

medical treatment

development of complications

healing

involvement of all system

recovery

compromiseimmune system

shock

death

Page 16: Case Study

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

Page 17: Case Study

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

Page 18: Case Study

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: Case Study

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

Page 20: Case Study

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

Page 21: Case Study

> warn woman

to avoid use

during

pregnancy

AMIKACIN SULFATE

Amikin

Classification Action Available Form Indication Contraindication Adverse Effect Nursing

Page 22: Case Study

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

Page 23: Case Study

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: Case Study

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

Page 25: Case Study

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

Page 26: Case Study

CEPHALEXIN

(hydrochloride) Keftab

(monohydrate) Apu-Cephalex, Biocef, Keflex, Novo-Lexin, Nu-Cephalex

Classification Action Available Form Indication Contraindication Adverse Effects Nursing

Page 27: Case Study

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: Case Study

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: Case Study

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: Case Study

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: Case Study

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: Case Study

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: Case Study

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: Case Study

> 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: Case Study

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: Case Study

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: Case Study

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 38: Case Study
Page 39: Case Study

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: Case Study

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: Case Study

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: Case Study

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: Case Study

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: Case Study

> 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: Case Study

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 46: Case Study
Page 47: Case Study

Problem Nursing

Diagnosis

Scientific

Rationale

Objective Nursing

Interventions

Rationale Evaluation

Page 48: Case Study

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: Case Study

Problem Nursing

Diagnosis

Scientific

Rationale

Objective Nursing

Interventions

Rationale Evaluation

Page 50: Case Study

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: Case Study

> worsening

blood gases

Page 52: Case Study