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Presented by:Carandang, Genesis M.
Gomez, Myla D.Paje, Laura Megan A.
San Pedro, Hana Cyril V.
DMMC INSTITUTE OF HEALTH SCIENCESTANAUAN CITY, BATANGASCOLLEGE OF NURSING
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Brief description of the disease:Diabetes mellitus is a chronic metabolic
disorder brought about by increased bloodsugar (hyperglycemia) due to inadequate
utilization of blood sugar. Inability of thebody to utilize blood sugar may be due toinherited and/or acquired deficiency in theproduction of insulin by the pancreas, or by
the ineffectiveness of the insulin produced orinsensitivity of insulin receptor to insulin thusuptake of sugar even with presence of insulinis inadequate.
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The symptoms of diabetes may bepronounced, subdued, or even absent such as
the excessive secretion of urine (polyuria),thirst (polydipsia), weight loss and tiredness.
Prolonged uncontrolled or erratic elevated
blood sugar can cause microvascularcomplications in the kidneys (diabeticnephropathy), nerves (diabetic neuropathy),blood vessels (thrombus formation), vision
(diabetic retinopathy), immune systemweakening, sexual function weakening, andothers.
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Diabetic nephropathy is the most commoncause of death and disability in diabetes. It is
also known as Kimmelstiel-Wilson syndrome,
or nodular diabetic glomerulosclerosis and
intercapillary glomerulonephritis. Around half
of end-stage renal disease is probably due
to diabetic nephropathy.
Heart failure is the inability of theheart to pump enough blood to meet the
metabolic demands of the body, is the end
result of many conditions.
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Frequently, it is a long-term effect ofcoronary heart disease and myocardial
infarction when left ventricular damage isextensive enough to impair cardiac output.As a result, cardiac output falls, leading todecreased tissue perfusion. The body initially
adjusts to reduced cardiac output byactivating inherent compensatorymechanisms to restore tissue perfusion.These normal mechanisms may result in
vascular congestion- and hence, thecommonly used term congestive heartfailure.
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Epidemiology:
Recently compiled data show thatapproximately 150 million people havediabetes mellitus worldwide, and that this
number may well double by the year 2025.Extrapolated prevalence figures show thatthere are more than 5 million Filipinos withdiabetes today. Central obesity, which means
big and bigger tummies, predisposes todeveloping type 2 diabetes.
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The prevalence of diabetes mellitus in heartfailure populations is close to 20% compared
with 4 to 6% in control populations.Epidemiological studies have demonstratedan increased risk of heart failure in diabetics;moreover, in diabetic populations, poor
glycemic control has been associated with anincreased risk of heart failure. Variousmechanisms may link diabetes mellitus toheart failure: firstly, associated co-
morbidities such as hypertension may play arole; secondly, diabetes accelerates thedevelopment of coronary atherosclerosis;
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thirdly, experimental and clinical studiessupport the existence of a specific diabetic
cardiomyopathy related to microangiopathy,metabolic factors or myocardial fibrosis.Subgroup analyses of randomized trialsdemonstrate that diabetes is also animportant prognostic factor in heart failure.In addition, it has been suggested that thedeleterious impact of diabetes may be
especially marked in patients with ischemiccardiomyopathy.
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Name: Client MAD
Gender: Female
Age: 77 years old
Address: Ramonita, Darasa, TanauanCity
Civil Status: Widow
Birthday: August 02, 1934 Birthplace: Badiangan, Iloilo
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Nakaupo lang siya nung 1 am
kasi nahihirapan siyang huminga.
Uminom na siya ng gamot pero walapa din epekto, kaya dinala na naminsiya dito sa ospital. Akala ng nanay ko
hindi na siya makakaabot ng ospitalkasi hirap na talaga siyang huminga. as verbalized by the patientsdaughter.
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3 hours PTA, patient suddenlyexperienced chest pain described asheaviness, substernal in location
accompanied by difficulty ofbreathing. She self-medicate with 1tab Isordil sublingual 2 doses but
afforded no relief of chest pain due topersistence of difficulty of breathing,prompted consult, then admitted.
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Last June 2011,the patient wasadmitted in Iloilo due to Pneumoniawith (+) HPN, and HBP of 140/80.
VI. FAMILY HISTORY: Diabetes Mellitus
Hypertension
Asthma
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Patient received in Semi- Fowlers position
Conscious and Awake
Dried lips
Teary eyes
Supple skin Non-edematous
Capillary refill of > 3 seconds
Insulin injection site at right arm SQ Distended chest
Crackles on left lower lobe
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Dyspnea
Afebrile
Blood pressure of 140/100 mmHg BMI
Height- 148 cm
Estimated body weight- 50 kg
With Foley catheter
Anuria
Restlessness
Worried Appetite changes
Sedentary lifestyle
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Health Management / Health Perception Aware of her present illness
Follows therapy & medical regimen.
Nutritional Metabolic Has appetite but conscious eating
Allowed for clear liquid but sip of water only.
Normal skin turgor
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Elimination No problem on Bowel Elimination
With Foley catheter because patient has UTI
Activity / Exercise Bedridden / received patient in lying
position. Difficulty sleeping because of chest pain
Nahihirapan akong huminga kapagnakahiga, as verbalized by the patient.
Physician ordered semi-fowlers
Led a sedentary lifestyle.
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Sleep Rest Always awake; reports difficulty of sleeping
because of chest pain. Cognitive / Perception No sensory deficit
Oriented to time, place, & person
Responsive but fatigue
Responds appropriately to verbal &physical stimuli.
Memory intact Report chest pain.
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Role / Relationship Patient is a widow. Lives in her 5th daughter house.
2nd son died of DM 3 years ago.
Husband was amputated then died 4years ago.
Other children lives in Iloilo.
Has good relationship with family
member. Plain housewife.
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Self- perception / Self Concept
Expresses concern and worry over her sonsand daughter on why did they leave theirwork for her.
Well groomed
Coping / Stress Anxious about her sickness Cries during interview
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Value / Belief
Catholic Middle class
Sexuality/ Relationship Widow
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Pancreas Elongated
Tapered organ located across the back of theabdomen.
Head which is the right side of the organ isthe widest part of the organ that lies in thecurve of the duodenum.
The tapered left side extends slightly upwardis called the tail of the pancreas and endsnear the spleen.
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The pancreas is made up of two types ofglands:
1.Exocrine
- The exocrine gland secretes digestiveenzymes. These enzymes are secreted into anetwork of ducts that join the main
pancreatic duct, which runs the length of thepancreas.
2. Endocrine
- The endocrine gland, which consists of the
islets of Langerhans, secretes hormones intothe bloodstream.
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The main function of pancreas are:
a. to aid digestion and
b. produce hormones that control bloodglucose levels
Blood glucose the fuel that provides thebody's cells with energy.
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Are tiny nest of cells that scatteredthroughout the pancreas.
Beta cells that produce and store thehormone insulin until needed.
Alpha cells, which make and store glucagon,a hormone that counteracts the effects ofinsulin.
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Figure 1.1- Regulation of blood glucose levels by a negativefeedback mechanism involving pancreatic hormones.
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The pancreas has digestive and hormonalfunctions:
The enzymes secreted by the exocrine glandin the pancreas help break downcarbohydrates, fats, proteins, and acids in theduodenum.
The hormones secreted by theendocrine gland in the pancreas are insulinand glucagon and somatostatin .
Insulin and glucagon - which regulate the
level of glucose in the blood. Somatostatin - prevents the release of the
other two hormones
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KIDNEYS Essential regulatory organ that maintain the
volume and composition of body fluid by Filtration
Reabsorption
Secretion
Retroperitoneal organ
situated on the posterior wall of the abdomenon each side of the vertebral column, atabout the level of the 12th rib.
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Figure 1.2- The Urinary System
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On sectioning: kidney has a pale outer
region- the cortex
a darker inner region-the medulla( divided into8-18 conical regions
the renal pyramids.
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Is the structural and functional unit ofkidney.
Each nephron is made up of:
The Glomerulus- the filtering unit;
125ml/min of filtrate is formed by thekidneys as blood is filtered through thissieve-like structure. This filtration isuncontrolled.
The Proximal Convoluted tubule-controlled absorption of glucose, sodium,and other solutes goes on in this region.
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The Loop of Henle - This region isresponsible for concentration and dilutionof urine by utilising a counter-currentmultiplying mechanism.
The Distal Convoluted Tubule - Thisregion is responsible, along with thecollecting duct that it joins, for absorbing
water back into the body
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Figure 1.3 Structure of the Nephron
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A closed system of the heart and bloodvessels
The heart pumps blood
Blood vessels allow blood to circulate to allparts of the body
The function of the cardiovascular
system is to deliver oxygen andnutrients and to remove carbon dioxideand other waste products
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Location
Thorax between the lungs
Pointed apex directed toward left hip
About the size of your fist
Less than 1 lb.
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Figure 1.4 Location of the heart within thethorax.
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Pericardium a double serousmembrane
Visceral pericardium -next to heart
Parietal pericardium - outside layer
Serous fluid fills the space betweenthe layers of pericardium
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Three layers
EpicardiumOutside layer
This layer is the parietal pericardium
Connective tissue layerMyocardium
Middle layer
Mostly cardiac muscleEndocardium
Inner layer
Endothelium
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Right and left side act as separatepumps
Four chambers
Atria
Receiving chambers Right atrium
Left atrium
VentriclesDischarging chambers
Right ventricle
Left ventricle
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Allow blood to flow in only one direction
Four valves
Atrioventricular valves between atria andventricles
Bicuspid valve (left)
Tricuspid valve (right)
Semilunar valves between ventricle and
artery
Pulmonary semilunar valve
Aortic semilunar valve
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Valves open as blood is pumped through
Held in place by chordae tendineae (heartstrings)
Close to prevent backflow
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CHEMISTRY September 10, 2011 September 11, 2011 September 12, 2011Creatinine CI Normal 0.51-
0.95
SI Normal45.08-83.98
H 1.58 mg/dlH 143.90 mg/dl
-
-
H 2.09 mg/dlH 184.76 mmol/L
Potassium CI Normal 3.50-
4.5
SI Normal 3.50-
4.5
3.70 mmol/L
3.70 mmol/L
4.50 mmol/L
4.50 mmol/L
-
-
CKMB CI Normal 7.25
SI Normal 7.25
H 45.45 U/LH 45.45 U/L
4.50 mmol/L
4.50 mmol/L
-
-
BUN CI Normal 8-23
SI Normal
1.34- 3.84
H 27.61 mg/dlH 139.23 mmol/L
-
-
-
-
Sodium CI Normal 135-
148
SI Normal
135- 148
143.90 mmol/L
143.90 mmol/L
-
-
-
-
Ionized Calcuim CI Normal1.12- 1.32
1.28 mmol/L - -
FBS CI Normal 74-109
SI Normal 4.11- 6.05
H 125.78 mg/dlH 6.98 mg/dl
-
-
-
-
Uric Acid CI Normal 2.4-5.7
SI Normal
142.80- 309.15
H 5.81 mg/dlH 345.87 mg/dl
-
-
-
-
SGOT CI Normal 0.00-32SI Normal 0.00-32
H 47.53 U/LH 47.53 U/L -- --
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Increase levels in the blood suggest diseaseor conditions that effect kidney function suchas damage to or swelling of blood vessels inthe kidney. Bacterial infection of the kidney,
death of cells in the kidneys small tubules.
LABORATORY INTERPRETATION:
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SEROLOGY September 10, 2011 September 11, 2011 September 12, 2011
Myoglobin Normal 0.0-
107 ng/dl
H 176 ng/ml - -BNP Normal 0.00-100
pg/ml
H 122.0 pg/ml - -D-dimer Normal 0.0- 400
mg/ml
H 790 ng/ml - -BLOOD TYPE A+
ANALYTE September 10, 2011 September 11, 2011 September 12, 2011Hct Normal 0.37-0.47 L 0.28 vol% L 0.35 vol% L 0.36vol%Hgb Normal 120-150 g/L L 90 g/L L 113vol% L 118vol%RBC count Normal 4-6x10
12/L
L 2.9x10 12/L L 3.6x10 12/L L 3.8x10 12/LWBC count Normal 5-10x10 9/L
6 x10 9/L L 4.9x10 9/L 5.3x10 9/LPlatelet count Normal
150000-300000
171000/cumm 136000/cumm L 130000/cummLymphocytes Normal
0.200-0.5000
0.343% 0.215% L 0.158%Eosinophils Normal
0.000- 0.010
0.060% H 0.064% H 0.079%
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Hgb low- oxygen in blood may result toshortness of breath. In order to compensatethe deficiency of oxygen in the blood, thebody tries to enhance the output of the heart.Due this, symptoms like palpitations, chest
pain and aggravation of heart problems canbe observed of heart failure. In casehemoglobin become extremely low it cancause enlargement of the heart and also showthe sign of heart failure. Physically thesymptoms of low hemoglobin that can bevisible are pale skin, nail bed and gums.
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Hct (low) refered to as being anemic some ofthe common reason is the kidney failure.
RBC(low) means that the patient has anemiaacute or chronic blood loss, malnutrition,chronic inflammation or a nutritionaldeficiencies including iron, copper, VitaminB12 or B6.
WBC (low) decrease in number becomedefendless against damage by bacteria,viruses, parasites and tumor cells.
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Lymphocytes (low) decreases immunityagainst fighting tumor and viruses, anddecreases the activation of B lymphocytes andT lymphocytes production.
Eosinophils (High) its function is to destroyallergens and inflammatory chemicals andrelease enzymes that disable parasite.
Platelet (low) decrease in number result toimbalance homeostatic mechanism in which itplays a role in during bleeding, vascularspasms platelet plug formation and blood
clotting (coagulation).
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URINALYSIS: Macroscopic Chemical Microscopic-cell Color Light yellow albumin(-) Pus cells 30-35/HPF Transparency Slightly turbid Sugar (-) RBC 0-1/HPF
Reaction 6.5
Specific gravity 1.010
Crystal Epithelium Amorphous Orates: many Squamous Moderate
Bacteria Moderate
ABG Analysis pH 7.449 HCO3 24.5 F1O2 5LPM via nasal canula
pCO2 35.0 BE 0 O2 Sat 95% PO2 66
Normal Values pH- 7.449 HCO3- 21-26 mEq/L shunt 3-10%
pCO2 35-45mmhg BE +2 VO/VT 0.2-0.4
PO2 80-100mmHg O2Sat 95-100%
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GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATION
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pantoprazole Panto IV(CAN),
Pantoloc
(CAN),
Protonix,
Protonix IV
PRESCRIBED:4 mg IV once aday
HANDBOOK:40mg PO dailymaintenancehealing oferosiveesophagitis for8wk or less. The8-wk coursemay be repeatedif healing has
not occurred;give continuallyforhypersecretorydisorders; 40mg/day IV for7-10 days. Upto 240 mg/day
or IV has beenused for severehypersecretorysyndromes.
ORAL: Short-term(8 wk orless) and long-term tx of GERD
Maintenancehealing oferosiveesophagitis
Long-term txof pathologicalhypersecretoryconditions
IV: Short-term
(7-10 days) tx ofGERD in patientsunable tocontinue oraltheraphy
IV: Tx ofpathologicalhypersecretory
conditionsassociated withZollinger-Ellisonsyndrome andother neoplasticconditions
Unabeled use:Tx of duodenal
ulcer.
CNS: Headache,
dizziness,
asthnenia,
vertigo,
insomnia,apathy, anxiety,
paresthesias,
dream
abnormalities
DERMATOLOGIC:
Rash,
inflammation,urticaria,
pruritus,
alopecia, dry skin
GI: Diarrhea,
abdominal pain,
nausea,
vomiting,constipation, dry
mouth, tongue
atrophy
RESPIRATORY:
URI sx, cough,
epistaxis,
pneumonia.
ASSESSMENTHISTORY:
Hypersensitivity
to any proton
pump inhibitoror any drug
components,
pregnancy,
lactation
PHYSICAL: Skin
lesions; T;
reflexes, affect;urinary output,
abdominal
examination;
respiratory
auscultation
INTERVENTIONS-Administeronce or twice a
day. Caution
patient to
swallow tablets
whole; not to
cut, chew, or
crush.
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATION
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OTHER:Cancer inpreclinicalstudies, backpain, fever,
vitamin B12deficiency
WARNING POINTS-Take the drugonce or twice a
day. Swallow the
tablets wholedonot chew, cut, or
crush them.
- Arrange to have
regular medical
follow-up care
while you are
using this drug.-Maintain all of
the usual
activities and
restrictions that
apply to your
condition. If this
becomes difficult,consult your
health care
provider.
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATION
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carvedilol Apo-Carvedilo
(CAN), Coreg,
Coreg CR, PMS-
Carvedilol (CAN),
ratio-Carvedilol
(CAN)
PRESCRIBED:6.25 mg/tab; 1tab BID
HANDBOOK:- Hypertension:6.25 mg PO bid;maintain for 7-14days, thenincrease to 12.5mg PO bid ifneeded tocontrol BP. Donot exceed 50mg/day.- Heart failure:Monitor pt. veryclosely,individualizedose based onpt. response.Initial dose,
3.125 mg PObid for 2 wk,may then beincreased to6.25 bid. Do notincrease dosesat intervals
- Hypertension,
alone or with
other oral drugs,
especially
diuretics.
- Tx of mild tosevere heart
failure of
ischemic or
cardiomyopathic
origin with
digitalis,
diuretics, ACEinhibitors
- Left ventricular
dysfunction
(LVD) after MI
- Unabled uses:
Angina (25-50
mg bid)
- CNS:
Dizziness,vertigo,tinnitus, fatigue,emotional
depression,paresthesias,
sleep
disturbances.
-CV:
bradycardia,orthostatic
hypertension,heart failure,
cardiac
arrhythmias,
pulmonary
edema,
hypotension
- GI: Gastricpain,
flatulence,
constipation,
diarrhea,
hepatic failure
INTERVENTIONS:Warning :Do notdiscontinue drugabruptly afterchronic therapy,(hypersensitivityto cathecolaminesmay havedeveloped,causingexacerbation ofangina, MI, andventriculararrhythmias) ;taper druggradually over 2wk withmonitoring.- Give with foodto decreaseorthostatic
hypotension andadverse effects.-Monitor fororthostatichypotension andprovide safetyprecautions.- Monitor diabetic
pt. closely;
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATION
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shorter than2wk. Maximumdose, 25 mg PObid in pts.weighing lessthan 85 kg or50 mg PO bid inpts. weighingmore than 85kg.- LVD followingMI; 6.25 mg PObid; increaseafter 3-10 days
to target doseof 25 mg bid.For conversionfrom tablets toCR capsules,follow theseinstructions. Fordosage of 6.25
mg daily. (3.125mg bid ), give10 mg CRcapsules oncedaily. For 50 mg(25 mg bid),give 80 mg CRcapsules once
daily.
- RESPIRATORY:Rhinitis,
pharyngis,
dyspnea
- OTHER:
Fatigue, backpain, infections
drug may maskhypoglycemia orworsenhyperglycemia.-Take drug withmeals- Do not stoptaking drugunless instructedto do so by ahealth careprovider.- Avoid use ofover-the-counter
medications.- If you arediabetic, promptlyreport changes inglucose level.- Report difficultybreathing,swelling of
extremities,changes in colorof stool or urine,very slow heartrate, continueddizziness.
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATIONO l IV Ed
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Furosemide Apo-Furosemide(CAN),FurosemideSpecial (CAN),Lasix
PRESCRIBED:20 mg IV/ every12hrs.
HANDBOOK:Hypertension;
40 mg bid PO. Ifneeded,additionalantihypertensives may be added.
- Oral, IV: Edema
associated with
heart failure,
cirrhosis, renal
disease
- IV: Acutepulmonary
edema
- Oral:
Hypertension
- CNS:Dizziness,vertigo,parasthesias,xanthopsia,weakness,
headache,drowsiness,fatigue,blurredvision,tinnitus,irreversible,hearing loss
- CV:Orthostatichypotension,volume,depletion,cardiacarrhythmias,thromboplebi
tis
Dermatologic:Photosensitivity, rash,pruritus,urticaria,purpura,
exfoliativedermatitis,
INTERVENTIONS
- Reduce dosage ifgiven with otheranti-hypertensives;re-adjust dosage
gradually as BPresponds.- Give early in theday so thatincreased urinationwill not disturbsleep.- Avoid IV use if
oral use is at allpossible.Warning: Do notmix parenteralsolution withhighly acidicsolutions with pHbelow 3.5.
- Do not expose tolight, which maydiscolor tablets orsolution; do notuse discoloreddrug or solutions.
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATION
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erythemamultiforme-GI: Nausea,anorexia,vomiting, oraland gastricirritation,constipation,diarrhea, acutepancreatitis,
jaundice-GU: Polyuria,nocturia,glycosuria,aurinary bladderspasm-HEMATOLOGIC: Leukopenia,anemia,thrombocytopenia, fluid and
electrolyteimbalances,hyperglycemia,hyperuricemia
- Other: Musclecramps andmuscle spasms
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATION
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clopidogrelbisulfate
Plavix PRESCRIBED:75 mg 1tab ODp.c
HANDBOOK:Adults- Recent MI,CVA, orestablishedperipheralarterial disease:75 mg PO daily.
- Acutecoronarysyndrome:300mg PO loadingdose then 75mg/day PO withaspirin, given ata dose from 75-325 mg oncedaily.
- Tx of pts. at
brisk for
ischemic
eventsrecent
MI, recent
ischemic CVA,peripheral artery
disease
- Tx of pts. with
acute coronary
syndrome
- Unabled use:
As loading dosewith aspirin to
prevent adverse
cardiac events in
coronary
implantation.
- CNS:Headache,dizziness,weakness,
syncope,flushing
- CV:Hypertension,edema
- Dermatologic:Rash, pruritus
- other:Increasedbleeding risk
-Assess for anyallergy toclopidogrel,pregnancy, lactation,bleeding
disorders,recentsurgery, hepaticimpairment,peptic ulcer.- Providecomfortmeasures &arrange foranalgesics ifheadacheoccurs.- Monitor pt. forincreasesbleeding; limitinvasiveprocedures.- Take daily asprescribed. Maybe taken withmeals.- Report rash,chest pain,fainting, severeheadache,abnormal
bleeding or
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATION
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azithromycin Zithromax, Zmax PRESCRIBED:500 mg tab
HANDBOOK:ADULTS- Mild tomoderatebacterialexacerbations.
500 mg POsingle dose bon
first day,followed by 250mg PO daily ondays 2-5 for atotal dose of 1.5g or 500mg/day PO for3days.
Unlabeled uses:
-Uncomplicated
gonococcal
infections
caused by N.
gonorrhoeae,
gonococcal
pharyngitis
caused by N.
gonorrhoeae,
chlamydial
infectionscaused by C.
trachomatis.
- CNS:
Dizziness,
headache,
vertigo,
somnolence,
fatigue
- other:
Superinfections,
photosensitivity,
vaginitis
- Culture site ofinfection beforetherapy.-Administer onan empty
stomach 1 hr.before or 2-3 hr.after meals. Foodaffects theabsorption ofthis drug.- Prepare Zmaxby adding 60 ml
water to bottle,shake well.- Take the full
courseprescribed. Donot take withantacids. Tabletsand oralsuspension canbe taken with orwithout food.- Prepare Zmaxby adding 60 mlof water (1/4cup_ water tyobottle, shakewell, drink all atonce.
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATION
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atrovastatin
calcium
Lipitor PRESCRIBED:40 mg/ tab OD
p.c or pm
HANDBOOK:ADULTS:- Initially, 10-20mg PO oncedaily withoutregard meals; ifmore than 45%reduction in LDLis needed, may
start within 40mg daily; formaintenance,10-80mg POdaily. May becombined withbile acid-bindingresin. Check
lipid levels every2-4 wk; adjustdose as needed.
Hypercholesterolemia: Adjunctto diet to reduceelevated totalcholesterol, LDL
cholesterol,ApolipoproteinB, andtriglyceridelevels.
Type III familialhyperlipoproteinemia: To treatpatients withprimarydisbetalipoproteinemia who donot respondadequately todiet.
Elevated serumtriglycerides: Asan adjunct todiet for thetreatment ofpatients withelevated serumtriglyceride
levels.
GI disturbaces.Headache,myalgia,asthenia,insomnia;
angioneuroticedema. Musclecramps,myositis,myopathy,cholestatic
jaundice;peripheralneuropathy;pruritus.
-Documentindications fortherapy, onsetand duration ofillness, other
medicationstaken.
-Monitorcholesterol,triglycerides andliver functiontests beforetherapy andreassessregularly. LDLand VLDLshould bewatched closely;if increased,drug should bediscontinued.
-Assessnutrition anddietary habits:Weight, exercisehabits, lifestyleand completenutritional
analysis.
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Homozygousfamilialhypercholesterolemia: To reducetotal cholesterol
and LDLcholesterol inpatients withhomozygousfamilialhypercholesterolemia as anadjunct to otherlipid-loweringtreatments or ifsuch treatmentsare unavailable.
-Assess formuscle pain,tenderness,obtain CPK ifthese occur,
drug may needto bediscontinued.-Monitor bowelpattern daily;diarrhea may bea problem.-Administertotal daily doseat any time ofday.-Store in coolenvironment inairtight, light-resistantcontainer.-Inform patientthat complianceis needed forpositive resultsto occur.-Teach patientthat risk factorsshould bedecreased:high-
fat diet,
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digoxin Lanoxin PRESCRIBED:0.25g/tab tab
HANDBOOK:Rapid oral
loading: 750-1500mcg givenby mouth as asingle dose.Slow oralloading: 250-750mcg dailyfor 1 week.
Chronic cardiacfailure withatrialfibrillation,ventricular
dilatation,supraventricular arrhythmias.
Anorexia.Gastrointestinal disturbances.CNS effects.Atrial
tachycardia.Gynecomastia.
Obtain patientshistory ofunderlyingcondition beforetherapy.
Assess anddocument apicalpulse for 1 fullminute beforegiving drug.Monitor ECGcontinuouslyduring parenteralloading doses andfor patients withsuspectedtoxicity. Providehemodynamicmonitoring forpatients withheart failure oradministeringmultiple cardiacdrugs.Monitor cardiacstatus,electrolytes andrenal function.Assess possibledrug-induced
adverse reaction.
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Assess druglevel.Assess patientsand familys
knowledge ofdrug therapy.Do not give atthe same timeas antacids orother drugs thatdecreaseabsorption.Oraladministrationroute: give oraladministrationwith or withoutfood; may crushtablets.Give potassiumsupplements ifordered forpotassium levels
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ISDN Isoket PRESCRIBED:5mg/tab; 1 tabTID
HANDBOOK:40mg OD or 20mg twice a daytaken aftermeals.
tx for severecongestive heartfailure CHF) incombinationwith cardiac
glycosides,diuretics,angiotensin-corvertingenzyme (ACE)inhibitors,arterialvasodilators.
CNS: headache,apprehension,restlessness,weakness, vertigo,dizziness,
faintness.
CV: Tachycardia,retrosternaldiscomfort,palpitations,hypotensionangina, reboundhypertension,atrial fibrillation
GU: Dysuria,urinaryfrequency
Other:thrombocytopenia
-Assess forpain: duration,time started,activity beingperformed,
character,intensity.-Monitor BP,pulse atbaseline andduringtreatment.-Hold SL tabletunder tongueuntil dissolved;do not takeanything oraladministrationwhen SL tabletis in place.-Give 1 hourbefore or 2hours aftermeals with 8 ozof water.- Sustainedrelease tabletshould not bechewed, brokenor crushed;
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-Instruct patientto swallowsustainedrelease tabletwhole, do not
chew;sublingualtablet should bedissolved undertongue, do notswallow;chewable tabletshould bechewedthoroughly; donot skip ordouble doses;- Warn patientto avoid alcoholand OTCmedicationsunless approvedby physician.-Instruct patientthat drug maybe taken beforestressfulactivity.- Warn patientto avoid driving
if dizziness
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATION( C d G l f
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carnitine (L-carnitine)
Carnicor PRESCRIBED:Oral solution1gm/bottle 1bottle 2x daily
HANDBOOK:1-3 g.
Acute andchronicmyocardialischemia,angina pectoris,cardiac failure,arrhythmia, MI.
Gastrointestinaldisturbances:nausea,vomiting,diarrhea, andabdominalcramps.
-Monitor forprevious hx ofpt. andhypersensitivityto the drugs.- Monitorperiodic bloodchemistries,V/S, plasmacarnitineconcentrations.- Monitoroverall clinicalcondition.- Assesstolerance andtherapeuticresponse of pt.to drugs.- Give alone ordissolve indrinks or liquidfoods.- Space dosesevenly every 3to 4 hrs.- Given by oraladministration,up to 200mgper kg BW daily,
in 2-4 divide
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- Inform pt. thatdose should bereduced if withcarnitinedeficiencysecondary tohemodialysis.- Advice pt. toadd dairy andred eat in diet tohave a greatsource ofcarnitine, butconsult aphysician ordietician beforedoing so.
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATIONi l t Ald t 25 Adj ti CNS Di i Obt i t h
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spironolactone Aldactone PRESCRIBED: 25mg/tab; 1tabOD
HANDBOOK:Essential HPN=50-100 mg/PO.May becombined withdiuretics.
Adjunctivetherapy inedemaassociated withHF, nephriticsyndrome whenother therapiesare inadequateorinappropriate.
CNS: Dizziness,headache,drowsiness,fatigue, ataxia,confusionGU: irregularmenses,amenorrhea,postmenopausalbleeding
-Obtain pt. hx,including drughx and anyknownhypersensitivity- Assess fluidvolume status:input outputratios andrecord,distended redveins crackles inlung, quality,and specificgravity of urine,skin turgor,adequacy ofpulses, moistmucousmembranesshould bereported.
- monitorelectrolytes:potassium,sodium,calcium,magnesium;also includeBUN, ABGs, uric
acid CBC, blood
GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATIONit li ti J i U d U Obt i ti t
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sitagliptin Januvia PRESCRIBED:50mg / tab; 1tab ODHANDBOOK:Administer withor withoutmeals. Adult>18 yrs, 100mg once daily.
Used as anadjunct to dietand exercise forthemanagement oftype 2 diabetesmellitus. It isalso used incombinationwithmetforminoethiazolidione asa adjunct to dietand exercise inpatient withtype 2 diabetesmellitus whohave notachieved aadequateglycemic controlwith metformin
or PPAR(Peroximeproliferator-activatedreceptor)agonistsmonotherapy.
Upperrespiratory tractinfection,headache andnasophryngitis.Peripheraledema, pain,osteoarthritisanorexia,dizziness,hypoglycemia.
-Obtain patienthistory andhypersensitivityto other drugs.-Monitor C&Sand report forsignificant GIdistress-Monitor bloodglucose andHbA1c-Monitor bloodlevels of digoxinwith concurrenttherapy.-Assess renalfunction prior toinitiayion oftherapy andperiodicallythereafter.-Note that
dosageadjustment isrecommendedfor moderate tosevere renalimpairment.Educate patientregarding type 2
diabetes and its
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONExcess fluid
INDEPENDENT:Place patient in To facilitate
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OBJECTIVE:-decreasedHgb/Hct
-Bloodpressurechanges
-oliguria
Excess fluidvolume
related tocompromised
regulatorymechanism
asmanifestedby decreasein Hb/Hct
andhypertension.
Short term goal:After 8 hours of
nursinginterventions,the patient willhave stabilizedfluid volume asevidenced by
balanced I&O ,vital signs
within normalclients normal
limits.
Long term goal:After discharge,the patient willdemonstratebehaviors tomonitor fluid
status andreduce
recurrence offluid excess.
Place patient insemi-fowlersposition, asappropriate.
Promote earlyambulation.
Provide quietenvironment,
limiting externalstimuli.
Discuss importanceof fluid restrictions
and hiddensources of intake
(such as foods highin water content).
Suggestinterventions, such
as frequent oralcare, chewing
gum/hard candy,
and use of lip balm.
To facilitatemovement of
diaphragm, thusimprovingrespiratory
effort.Ambulation can
help inpreventingstasis and
reducing therisk of tissue
injury.To provide restand relaxationto the patient.
In order for thepatient to have
knowledgeregarding
preventivemeasures.
To reducediscomfort of
fluidrestrictions.
Short term goal:After 8 hours of
nursinginterventions,
the patient hadstabilized fluid
volume asevidenced bybalanced I&O,
vital signswithin normalclients normal
limits.
Long term goal:After discharge,the patient willdemonstratebehaviors tomonitor fluid
status andreduce
recurrence offluid excess.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
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Stress need formobility and/ or
position changes.
COLLABORATIVE:Restrict sodium and
fluid intake, asindicated.
Consult dietitian, asneeded.
To preventstasis and
reduce risk oftissue injury.
An intake ofsodium andfluids can
further causefluid volume
excess.
To know theright diet for the
patient.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONActivity
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Subjective:-reports
difficulty inbreathing
-RR: 24 cpm- BP: 140/100
Activityintolerancerelated toimbalancebetweenoxygen
supply anddemand asmanifestedby dyspneaand bloodpressurechangesduring
activities.
Short term goal:After 8 hours of
nursinginterventions,the patient will
identify negativefactors affecting
activitytolerance andeliminate orreduce theireffects when
possible.
Long term goal:After 3 days of
renderingnursing care,
the patient willachieve
measurableincrease in
activitytolerance asevidenced by
reduced fatigueand weaknessand vital signswithin normallimits during
activity.
INDEPENDENT:Check V/S before and
immediately afteractivity.
Assess for otherprecipitations or
causes of fatigue toinclude this in the plan
of care.
Adjust activities.
Plan care with restperiods between
activities.
Provide positiveatmosphere while
acknowledgingdifficulty of the
situation for thepatient.
Assist with activities.
Promote comfort
measures.
To assess forintolerance.
To preventoverexertion.
To reducefatigue.
Helps tominimize
frustration andrechannel
energy.
To protectclient from
injury.
To enhance
patientsartici ation.
Short termgoal:Outcome met:
patientidentifiednegativefactors
affectingactivity
tolerance andeliminated orreduced their
effects.
Long termgoal:Outcome met:
patientachieved
measurableincrease in
activity
tolerance asevidenced by
reduced fatigueand weaknessand vital signswithin normallimits during
activity.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONReview expectations To establish
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Review expectationsof patient and SOs.
Give patientinformation that
provides evidenceof daily/weekly
progress.
To establishindividual goals.
To sustainmotivation
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONImpaired
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OBJECTIVE:(+) Foleycatheter
(+) UTI
Urine output of40 ml,yellowish incolor
Impairedurinary
eliminationrelated to
urinary tractinfection asmanifestedby urinaryretention.
Short term goal:At the end ofthe shift, theclient will be
able to care ofurinary catheterand establish
adequateoutput.
Long term goal:After 3 days of
nursingintervention, the
patient willdemonstratebehaviors/
techniques toprevent urinary
infection.
INDEPENDENT:Assess patency ofurinary catheter.
Use asepsis andhand hygiene in
providing care andmanipulating theurinary system.
Provide informationabout adequacy of
urine output,condition and
patency of Foleycatheter. Maintainacidic environmentof the bladder by
the use of agents,such as vitamin Cwhen appropriate.
Demonstrate properpositioning of
catheter drainagetubing and bag.
To check if theurinary catheteris still in place
and isfunctioning well.
Prevents orreduces the risk
ofcontaminationof the Foley
catheter.
To discouragebacterialgrowth.
To facilitatedrainage and
prevent reflux.
Short term goal:At the end ofthe shift, the
patient was ableto care of
urinary catheteras manifested
by limitingmovement andhas established
adequateurinary outputof 150-200 ml.
Long term goal:After 3 days of
nursinginterventions,
the patientdemonstrated
behaviors/techniques to prevent
urinaryinfection.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
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Emphasize theimportance of
keeping area cleanand dry.
Instruct in properapplication and care
of appliance forurinary diversion.
To reduce therisk of infection
and/or skinbreakdown.
To promoteodor control.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONI i d
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OBJECTIVE:Abnormal ABG
HypoxiaCapillary refill
> 3 secondsRestlessnessRR: 29 cpm
Impaired gasexchangerelated to
alteredoxygen-
carryingcapacity ofblood as
manifestedby hypoxia,tachypnea,
slow,capillary refill
andrestlessness.
Short term goal:After 8 hours of
nursinginterventions,the patient will
demonstrateimproved
ventilation andadequate
oxygenation oftissues by ABGswithin clientsnormal limits.
Long term goal:After discharge,the patient will
be able toparticipate in
treatmentregimen.
INDEPENDENT:Monitor vital signs.
Assess energy level
and activitytolerance.
Elevate head of bed.Position clientappropriately.
Encourage adequate
rest and limitactivities withinclient tolerance.Promote calm,
restful environment.
Providepsychological
support, active-listenquestions/concern.
Encourage frequentposition changes
and deep-breathingand coughing
exercises.
To monitor forchanges.
To evaluate
degree ofcompromise.
To maximizeeffort.
Helps limit
oxygen needsand
consumption.
To reduceanxiety.
Promotesoptimal chestexpansion and
drainage of
secretions.
Short term goal:At the end ofthe shift, thepatient will
demonstrated
improvedventilation and
adequateoxygenation asevidenced byABGs within
normal limits.
Long term goal:After discharge,
the patientparticipated in
treatmentregimen as
evidenced bythe patient
doing deep-breathingexercises.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONEmphasize the Helps in
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Emphasize theimportance of
nutrition.
COLLABORATIVE:Provide
supplementaloxygen at lowest
concentrationindicated by
laboratory resultsand clients
symptoms orsituation.
Discuss oxygentherapy and safety
measures, asindicated.
Helps inimproving
stamina andreducing the
work of
breathing.
To correct/improveexisting
deficiencies.
To promotewellness.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONRisk for falls
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OBJECTIVE:-77 years old-Hypoxia-Anemia-Post-prandial
blood sugarchanges
Risk for fallsrelated to ageof 77.
Short term goal:After 8 hours of
nursinginterventions,the patient will
verbalizeunderstandingfor factors thatcontribute to
possibly of falls.
Long term goal:After discharge,the patient willdemonstrated
behaviours andlifestyle changes
to reduce riskfactors andprotect self
from injury/.
INDEPENDENT:Teach client to
minimize or reducethe orthostatic
hypotension effect.
Observe individualsgeneral health
status.
Note factorsassociated with age,
gender, anddevelopmental level.
Evaluateuse/misuse/failureto use assistive aids
when indicated.
To reduce riskfor fall.
Noticing factorsthat might
affect safety,such as chronicor debilitatingconditions, use
of multiplemedications,
recent trauma,can evaluate
source/degreeof risk.
Elderly are atgreatest risk
because of lackof ability to
self- protect.
Client has highrisk for falls due
to use ofunfamiliar
device.
Short term goal:After 8 hours of
nursinginterventions,the patient has
verbalizedunderstandingfor factors thatcontribute forpossibility offalls such asorthostatic
hypotension.
Long term goal:After discharge,
the patientdemonstrated
behaviours andlifestyle changes
to reduce riskfactors and
protected selffrom injury asmanifested by
the use ofassistive aidsand asking for
personalcompanions.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATIONEvaluate clients Affects ability to
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Evaluate client scognitive status.
COLLABORATIVE:Assist in treatment
and provideinformation
regarding clientsdisease/ condition.
Review medicationregimen and how it
affects client.
Affects ability toperceive ownlimitations or
recognizedanger.
May result inincreased risk of
falls.
Use of certainmedications can
contribute toweakness,confusion,
balance and gaitdisturbances.
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9/10/11 Client MAD, 77/F, Married, Filipino fromIloilo, admitted for the first time.Chief complaint: Difficulty of breathingHistory of Present Illness: 3 hours PTA, patientsuddenly experienced chest pain described asheaviness, substernal in location accompaniedby difficulty of breathing. She self-medicatewith 1 tab Isordil sublingual 2 doses but
afforded no relief of chest pain due topersistence of difficulty of breathing, promptedconsult, then admitted.
Past Medical History: June, 2011- admitted in
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Iloilo due to Pneumonia
(+) HPN? HBP: 140/80
Family History:Hypertension: parents
Diabetes Mellitus and Asthma- Father
Personal and Social:- patient is non-smoker and non-alcoholic
- no allergies to food and medications.
ROS:(+) easy fatigability,(-) anorexia, wt. loss(+) blur of vision, (-) dizziness,
(-) tinnitus, (-) syncope, (-) DND,
(-)orthopnea
Physical Examination:
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- conscious, awake
- BP: 110/70
- slightly pale, palpebral conjunction, TPC,no NAD(no active disease)
- supple neck, no NVE, (+) crackles LLL
- nonreactive bowel sound, non-tenderAssessment:Acute Coronary Syndrome
DM Type IIHPN Stage 2
UTI
9/10/11- S:-No chest pain x 6
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p
-No difficulty of breathing-No headache
O:-BP 130/90 HR:76 RR:29-awake and conscious
-no retractions,(+) crackles lower
lungA: - Congestive Heart Failure- Acute Coronary Syndrome
- DM Type II- UTI
-Hypertension CardiovascularDisease
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http://www.medicinenet.com 8:46 pm
http://medicalcenter.osu.edu 8:58pm http://www.healthcommunities.com 9:00pm
http://www.britannica.com 9:13pm
http://emedicine.medscape.com 9:19pm http://www.britannica.com 9:25pm
http://www.checkdiabetes.org 10:31pm
http://www.google.com.ph 10:47pm
http://www.healthcarendiet.com 10:50pm http://blog.saravanakidneystonecare.com
10:56pm (Sept. 16,2011)
http://www.medicinenet.com/http://medicalcenter.osu.edu/http://www.healthcommunities.com/http://www.britannica.com/http://emedicine.medscape.com/http://www.britannica.com/http://www.checkdiabetes.org/http://www.google.com.ph/http://www.healthcarendiet.com/http://blog.saravanakidneystonecare.com/http://blog.saravanakidneystonecare.com/http://www.healthcarendiet.com/http://www.google.com.ph/http://www.checkdiabetes.org/http://www.britannica.com/http://emedicine.medscape.com/http://www.britannica.com/http://www.healthcommunities.com/http://medicalcenter.osu.edu/http://www.medicinenet.com/8/4/2019 Grand Case 2011 Final!
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http://nursingdepartment.blogspot.com
11:28 pm www.nih.gov 5:12pm
www.medicine.net.com 5:14pm
www.wikianswer.com 5:19pm
www.livestrong.com 5:33pm
www.chfpatients.com 5:34pm
www.labtestonline.com 5:39pm
www.mayoclinic.com 5:59pm www.medweb.bham.ac.uk 6:01pm
www.wisegeek.com 6:30pm
September 18,2011
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Lemone, Priscilla. Medical-Surgical Nursing.Critical Thinking in client care. 3rd ed.
Smeltzer,Suzanne C.,Brunner and Suddarthstextbook of Medical-Surgical Nursing tenth
edition, vol.I Lippincott Williams and Wilkins, Critical Care
Nursing made Incredibly easy!
Marieb Elaine N., Essentials of HumanAnatomy and Physiology
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Karch Amy M., 2011 Lippincotts NursingDrug Guide
PPDs Nursing Drug Guide 2ng Edition
PPD The Filipino Doctors Drug Guide 10
Edition 2010/2011 Doenges Marilynn E., Nurses Pocket Guide10
Edition
Doenges, Marilynn E., Nurses Pocket Guide11 Edition
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Doenges Marilynn E., Nurses Pocket Guide 12Edition
Mosbys Nursing PDQ
Palma Gregory N., G & A Notes