NCP Background, Demographic Data, Dordon's Functional Health, Drug Study SAint Louis University

I. Patient’s Profile:

Full name: ?Patient’s Nick name: ?Sex: FEMALECivil Status: SINGLEAge 25 YEARS OLDBirth date: NOVEMBER 12, 1984Birth place: DAMARTIS, LA UNIONAddress NATIONAL HIGHWAY DAMARTIS, LA

UNIONOccupation: UNEMPLOYEDWeight: 115 POUNDSHeight 4 FEET; 11 INCHESPayee: MOTHER AND FATHERReligion: ROMAN CATHOLICNationality: FILIPINOCultural Affinity: ILOCANOLanguages spoken: TAGALOG, ENGLISH, ILOCANOLanguage Understood: TAGALOG, ENGLISH, ILOCANODate admitted: ?Time admitted: 4:35 pmChief Complaint: FEVER AND COUGHWard: ?Latest Hospitalization/admission: JANUARY 2010

II. Health History

A. Chief Complaint:

Upon ?’s admission on February 22, 2010 at 4:35 pm in Saint Louis Hospital of Sacred Heart, her chief complaints were fever and cough. The patient had pale conjunctiva and mucosa upon her arrival in the institution.

B. History of Present Illness:

?’s condition started one week prior to admission when she had productive cough with yellowish color phlegm. She also experienced difficulty of breathing particularly every night. There was no medication taken by the patient during the incident.

Three days prior to admission, the patient had fever with chills. She was able to reach temperature of 38 degrees Celsius. Because of this, she had taken paracetamol 500 mg and salbutamol expectorant syrup which offered slight relief of her condition. 1 day prior to hospitalization, she still had fever. She continued taking her medications. However the condition persisted therefore she sought for consultation and was admitted to Saint Louis University Hospital of Sacred Heart.

C. History of Past Illness:

In year 2000, the patient was diagnosed with hemolytic anemia. Because of this, she maintained folic acid therapy. She was taking the drug once a day. She was hospitalized for about ten times already.1 year ago, the patient had undergone blood transfusion. The patient easily gets tired whenever she was performing any activity.

Nursing care plan Submitted by: MEDINA, PATRICK LUIS1

According to the patient and her sister, her immunizations are adequate and appropriate with the Expanded Program on Immunization and correct age as the bases. She already received DPT1, DPT2, DPT3, OPV1, OPV2, OPV3, Hepa B1, Hepa B2, Hepa B3, and Anti Measles1, from a Health center without any physiologic adverse reaction to him.

1st dose 2nd dose 3rd dose Place Reaction

BCG Given; can’t remember

Health center none

DPT Given; can’t remember

Given; can’t remember


Health center none

OPV Given; can’t remember



Health Center none

Hepa B Given; can’t remember



Health Center none

Anti Measles Given; can’t remember

Health Center none

D. Family Health History and social/ environment history:

? is the second child of the Oropilla family. Her mother has gravid para score of G2P2 (2-0-0-2-0). Her mother and father are the decision makers of the family hence they were a combination type of family. Her parents are the breadwinners. The patient lives in a concrete type of house with family. They had no other companion in their non-congested house. Their house consisted of two rooms and located on a non-congested area. Their toilet is not a flush type. They don’t have any pet and there garbages are collected weekly. There primary source of drinking water came from refilling station while their domestic water came from water district.

The patient is non alcoholic and non smoker.

The patient noted no history of asthma, hypertension, diabetes mellitus, heart disease, cancer or other heredo-familial disease.

*Course of Confinement:

?’s condition started a week PTA when she had experienced productive cough with yellowish color phlegm and difficulty of breathing every night. 3 PTA, the patient had fever with chills hence she had taken paracetamol 500 mg and salbutamol expectorant syrup which provided slight relief of her condition. The patient’s condition persisted therefore she sought for consultation and was admitted to SLU-HSH last February 22, 2010 at 4:35 pm. Upon admission, she appears weak and had slender body built, neat appearance, dry skin, calm emotional status, alert mental status, and fully awake level of consciousness. The nurses hooked IVF of PNSS started as an infusion. The health workers monitored her vital signs, assessed her capillary refill and level of consciousness, regulated IVF at 16 hours and performed TSB. The nurses’ initial diagnosis to the patient was risk for infection.

Throughout her confinement, she had undergone various diagnostic test like 4 CBC, 1 Urinalysis, 1 Ultrasound, 1 X-ray, 1 Creatinine Test, 1 BUN test, 1 SGOT and


SGPt test, B1, B2 test, 1 alkPO4 test and 1 parasitology. The medications given to the patient were salbutamol neb now, ketorolac 30g IV now, ↑ acetylceistine 200 mg 1 sachet TID, cefuroxime 750 mg IV q 8°, Paracetamol 1 amp IV q 4° PRN for headache and fever, omeprazole 20 mg 1 tab OD, flic acid 5 mg 1 cap OD, azithromycin 500 mg 1 tab OD, ketonoine, cefuroxime 500 mg 1 tab PRN, prednisone 20 g 1 tab OD, hydrocortisone 100 mg IV now then q 12° and dulcolax. 10 bottles of PNSS, 2 bottles of D5W and 2 packed RBCs were infused. The nursing diagnoses identified were risk for infection, impaired peripheral tissue perfusion, ineffective peripheral tissue perfusion, disturbed sleeping pattern, and acute pain. Some of the nursing interventions done were monitoring of the vital signs, assessment of the general status, assessment of sleep pattern, provision of rest periods, administration of the prescribed medications, positioning the patient in semi fowler’s position, provision of comfort, encouragement of verbalization of feelings and discomfort, emphasis on the importance of adequate rest, teaching proper hand washing and teaching of DBE and CE. Last March 1, 2010, the patient had a may go home order with final diagnosis of hemolytic anemia s/p blood transfusion, polysinusitis, pneumonia in immunocompromised host and related disorder.

III. Gordon’s Health Pattern:

1. Health perception and management

The patient had a chief complaint of cough and fever upon admission to the hospital. Latest diagnostics of the patient revealed that Neutrophil is 44.2 (low) and lymphocyte was 46.3 (high). This indicates that the patient is prone to infection. She is alert, responsive, coherent and oriented to time, place and person. According to her, she is willing to do proper hand washing in order to prevent infection. She go to check-up only if sign of disease is felt. She visits the dentist at least twice a year. The patient understood the therapeutic regimens and diagnosis of the physician. This was confirmed by her S.O. who said “Alam naman niya yung sakit niya e kaya nga siya nandito”. Thorough health history was not given by her during the data gathering hence confirmation and validation were done to her S.O. She had very limited and der response to the questions asked to her. The patient complied on the therapeutic regimens and medications although there were times wherein she was not taking her medications on time. She doesn’t want to be disturbed when she was sleeping. However there was no other difficulty in therapeutic regimen noted. She was capable of relating the progression of illness in detail. According to the patient, she had completed her immunization and it was complete and adequate based on Expanded Program on Immunization of DOH. This was validated by her SO. According to the patient when she was home, she always washed her hands before eating and took a bath daily. During observation, the patient did not wash her hands prior to eating. During her confinement, she did facial wash daily. The patient wanted to improve her condition thus she seeked for health workers. The patient did not noted any family history of disease. She was a non alcohol drinker and non-smoker. Last February 28, 2010, she appears week however on March 1, 2010, the condition improved since she was capable of mobilizing herself by her own without assistance. She had participated and undergone various diagnostics such as CBC, Urinalysis, Ultrasound, X-ray, Creatinine Test, BUN test, SGOT and SGPT test, B1, B2 test, alkPO4 test and parasitology. He had undergone blood transfusion twice during her confinement. According to the patient, this was her 10th hospitalization.>Vital Signs (March 1, 2010)PR: 70 beats/minutesTemperature (Axilla) 36.5 degree CelsiusBP: 110/70 mmHg, R, lyingRR: 21 cycles/minute

2. Nutrition and metabolism


The patient presently weighs 115 kilograms with height of 4 ‘ 11 “ according to the patient. The patient has ectomorph body type. According to the patient, she had lost weight however she can no longer recall the amount of body weight loss. The patient’s temperature (axilla) is 36.5 degrees Celsius. No nausea and vomiting noted during her confinement. Usually, her breakfast, lunch and dinner are composed of rice and viand. The viand that she prefers is vegetables. His usual snacks include bread, biscuit or sandwich. The last meal she had taken is adobo and rice. She prefers vegetable and fruits. She eats less meat because according to her S.O. “Baka sawa nay an sa meat kasi nagtitinda kami ng karne”. She drinks soft drinks but not alcohol. The patient took about adequate amount of water daily about 10 glasses of water. She doesn’t drinks liquor. The patient doesn’t smoke. Her previous weakness, fever, coughs and difficulty of breathing affects her nutrition. During those times, she had less appetite in eating. She was taking iron for her dietary supplement. She complies with her medications. She has good skin turgor however she has pale conjunctiva and mucous membrane. No evidence of edema noted. His capillary refill takes about 2 seconds. She has complete sets of yellow teeth. No scale nor dandruff noted on patient’s head. She has pale conjunctiva and mucous membrane. Hematoma was seen on the right arm of the patient. No tenderness noted on her abdomen upon palpation.

3. Elimination

No episodes of vomiting noted. The patient had no frequency in urine. Usually, every 1 hour she urinates 200 cc of urine with a usual color of white or yellow. She urinates depends upon her intake. Last urine voided is white. She is able to control urine. The last stool of patient noted is color brown and watery. There is no difficulty in passing stool. The patient is in the IV therapy: D5W 1 L x 16 hours.

I&0 last March 1, 2010 (7:00-3:00 shift)INPUT OUTPUT

Oral Infusion Total Urine Total1050 500 1550 1000 1000

Urine: 5 times Stool: 1 time (watery)

4. Activity and exercise pattern

The patient does not work. She usually performed the household chores such as cleaning the house. Her hobby is watching television. She is frequently in sleep. According to her S.O, this serves as her relaxation activity. She is not member of any type of organization. According to the patient, she easily experiences fatigue, and weakness. She is a non-smoker and non-alcoholic. The patient is cooperative in performing deep breathing exercises and coughing exercises. She can mobilize on her own and doesn’t need assistance in performing activities of daily living.

RR=21 CPM PR=70BPM

5. Cognition and perception

Eye (Vision):The patient is not using eye glasses. According to her, she has no difficulty in

seeing. She has symmetry eyebrows. No dryness and scaling of the eyebrows noted. No tenderness palpated on the eyebrows. No tearing observed. She has pale conjunctiva.

Ears (Hearing):


The patient has light brown ears proportionate to the head and face. No lumps or lesions observed. No discharges noted. The patient responded immediately during the interview. She is not irritable.

Nose (Olfactory): The patient has symmetrical nose. No deformities and lesions noted. No

discharges or flaring from nose seen. The patient has no difficulty in breathing. Productive cough is observed to occur at few times.

Mouth:The patient has symmetrical closure in the mouth. She has color light pale lips.

She incomplete sets of light yellow teeth. No lesions noted in the lips.

The patient is oriented to time, place and person. She can speak and understand Tagalog, English and Ilocano.

6. Sleep and rest

Last February 15, 2010, the patient slept from 9:00 pm up to 7 am. According to the patient, she infrequently experienced insomnia. The patient frequently experiences interruptions in sleeping that’s why she has incomplete sleep at night. She was easily got disturbed while on sleep. The patient usually takes naps every morning and afternoon. She also spent time watching television as a form of his rest. She is frequently in sleep. She is cooperative in performing deep breathing exercises and coughing exercises.

7. Self-perception and self-concept

The patient is coherent, alert and responsive. Sometimes she has eye to eye contact during interview. She has no foul smell. She walks normally, stands and sits straightly. Her dress is appropriate to situation and climate. She was cooperative during interventions like vital signs taking and interview although sometimes she gives short responses on questions asked to her. She responded in some of our questions during the interview. She was not irritable during data gathering. She has a soft voice and looks shy.

8. Roles and relationships

The patient lives with her family in a concrete, non congested house with two rooms. The patient is sometimes sociable to her neighbors however sometimes she likes to be alone. According to her, she has good relationship with the neighborhoods. She is also closed to his family at the same time. She is unemployed. She is a non-smoker and non-alcoholic person. She usually spent time to hang out with her friends.

9. Sexuality and reproduction

The patient is single and she doesn’t have boy friend yet. She doesn’t experience difficulty in urinating and passing stool. She has regular menstrual cycle and doesn’t experience any abnormalities like dysmenorrhea.

10. Coping and stress management

When problem comes, the patient together with her family immediately does an action to find solution. To cope when stress, she sleeps and watches TV to relax herself. The patient doesn’t drink beer or smoke. The support system comes from her mother and father who works as meat vendors. She participates and complies to the prescribed


medicines and other treatment given to her like blood transfusion and IV therapy. She is cooperative in performing DBE and CE.

11. Values and beliefs

The patient is part of the Roman Catholic religion. She never consulted any herbal doctor, “maghihilot” or “albularyo” yet. The patient has no belief that could affect the provision of health care delivery system. She said that she follows the Filipino culture in living just like using “po” and “opo”.

***Diagnostics:

1. CBC (March 01, 2010)

WBC 7.45 10 e9 / L 5-1044.2 %N 45-7046.3 %L 20-407.86 %M 0-120.839 %E 0-8

RBC 5.19 (4.50 – 6)HGB 131 g/L (110-150)HCT .377 L (.37-.47)MCV 72.7 fL (76-96)MCH 25.2 pg (27-32)McHc 346 g/L (320-360)

Implication:

White blood cell (WBC) count is a count of the actual number of white blood cells per volume of blood. Both increases and decreases can be significant. Neutrophils function is for phagocytosis thus low neutophils indicates susceptibility to bacterial infection. There is high lymphocytes which may indicate presence of infection because of its increase response against infectious attack.. When the general defense systems of the body have been penetrated by dangerous invading microorganisms, lymphocytes help provide a specific response to attack the invading organisms. NURSING CONSIDERATION: limit visitors because they are susceptible to infection, hand washing because it is the most effective way of eradicating microbes, do not swallow the sputum to prevent infection

2. VARIOUS TEST February 22, 2010

TEST VALUE REF RANGEALK P: 99.0 35-129CREA G .6 .6-1.3ASAT 58.3 0-38ALAT 197 0-41UREA 3.0 2.5-6D Bili .19 0-.30TBIL-G 1.19 .1-1.20


Implication:

High ALAT and ASAT may indicate damage to patient’s red Blood cell. This happens because the patient was diagnosed with hemolytic anemia. The enzymes are release due to massive RBC destruction.

3. URINALYSIS

Fevruary 9, 2010Physical examination Chemical examination Other examination

Color: lightyellow Albumin: Negative Pregnancy test: - - -Reaction: Acidic Sugar: Negative Method: - - -Appearance: turbid Acetone: - - - Others: - - -Specific gravity: 1.005 Others : - - - Bacteria: fewPus cells: 0-3/hpf Crystals: Negative Amorphous Urates:

NegativeMucus threads: occasioanl Casts: Negative Yeast cells: negEpithelial cell: few RBC-0-1/hpf

Implication:It is important to get the urinalysis in order to determine the presence of blood in

urine. The patient has 0-1 hpf in urine which might indicate that RBC escape through urine in the course of brisk hemolysis (Uthman,2004)

4. PARASITOLOGY

FEB. 24, 2010Color: BlackConsistency: Formed

Method Ova / parasite Cyst

Direct fecal smear neg negRBC- negativePus cells - negative

Parasites could be one of the causative factors of CAP hence its presence on the body of the patient is determined to determine of the parasites already multiply.

The patient’s stool is color black. She is suspected of anemia. This is one way to trace whether the patient is excreting blood through stool in order to do immediate correction and management.

5. UTZ and X-RAY

2/11/10>Steaky densities are seen in both lower lung zones>Cardiac shadow is enlarged>Intact diaphragm>A convexity to left of upper thoracic segment is noted have Cobb’s angle of 30 degrees>Soft tissue shadows


Impression: Bibasal Pneumonia.

Implication:These findings give impression of pneumonia. The patient was diagnosed with

CAP with the aid of this diagnostic test.

++Drug Analysis

A. omeprazole 20 mg 1 tab OD

Generic name: omeprazole

Brand name: Losec

Drug classes Antisecretory agent Proton pump inhibitor

Therapeutic actions Gastric acid-pump inhibitor: Suppresses gastric acid secretion by specific

inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.

Indications Long-term therapy: Treatment of pathologic hypersecretory conditions

Contraindications and cautions Contraindicated with hypersensitivity to omeprazole or its components. Use cautiously with pregnancy, lactation.

Adverse effects CNS: Headache, dizziness, asthenia, 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 symptoms, cough, epistaxis Other: Cancer in preclinical studies, back pain, fever

InteractionsDrug-drug

WARNING: Increased serum levels and potential increase in toxicity of benzodiazepines, phenytoin, warfarin; if these combinations are used, monitor patient very closely

Decreased absorption with sucralfate; give these drugs at least 30 min apartNursing considerationsAssessment

History: Hypersensitivity to omeprazole or any of its components; pregnancy, lactation

Physical: Skin lesions; T; reflexes, affect; urinary output, abdominal examination; respiratory auscultation

Interventions before meals. Caution patient to swallow capsules whole—not to open, chew, or

crush them. If using oral suspension, empty packet into a small cup containing 2 tbsp of water. Stir and have patient drink immediately; fill cup with water and have patient drink this water. Do not use any other diluent.

WARNING: Arrange for further evaluation of patient after 8 wk of therapy for gastroreflux disorders; not intended for maintenance therapy. Symptomatic


improvement does not rule out gastric cancer, which did occur in preclinical studies.

Administer antacids, if needed.Teaching points

Take the drug before meals. Swallow the capsules whole; do not chew, open, or crush them. If using the oral suspension, empty packet into a small cup containing 2 tablespoons of water. Stir and drink immediately; fill cup with water and drink this water. Do not use any other liquid or food to dissolve the packet. This drug will need to be taken for up to 8 weeks (short-term therapy) or for a prolonged period (> 5 years in some cases).

Have regular medical follow-up visits. You may experience these side effects: Dizziness (avoid driving or performing

hazardous tasks); headache (request medications); nausea, vomiting, diarrhea (maintain proper nutrition); symptoms of upper respiratory tract infection, cough (do not self-medicate; consult with your health care provider if uncomfortable).

Report severe headache, worsening of symptoms, fever, chills.

B. Folic acid 5 g 1 cap OD

Generic name: folic acid (folate)

Brand name: Folvite

Drug class Folic acid Vitamin supplement

Therapeutic actions Required for nucleoprotein synthesis and maintenence of normal erythropoiesis.

Indications Treatment of anemias due to sprue, nutritional deficiency,

Contraindications and cautions Contraindicated with allergy to folic acid preparations;

pernicious, aplastic, normocytic anemias. Use cautiously during lactation.

Adverse effects Hypersensitivity: Allergic reactions Local: Pain and discomfort at injection site


Decrease in serum phenytoin and increase in seizure activity with folic acid preparations

Decreased absorption with sulfasalazine, aminosalicyclic acidNursing considerations Assessment

History: Allergy to folic acid preparations; pernicious, aplastic, normocytic anemias; lactation

Physical: Skin lesions, color; R, adventitious sounds; CBC, Hgb, Hct, serum folate levels, serum vitamin B12 levels, Schilling test

Interventions Administer orally if at all possible. With severe GI malabsorption or very severe

disease, give IM, IV, or subcutaneously. Test using Schilling test and serum vitamin B12 levels to rule out pernicious

anemia. Therapy may mask signs of pernicious anemia while the neurologic deterioration continues.

WARNING: Use caution when giving the parenteral preparations to premature infants. These preparations contain benzyl alcohol and may produce a fatal gasping syndrome in premature infants.


WARNING: Monitor patient for hypersensitivity reactions, especially if drug previously taken. Keep supportive equipment and emergency drugs readily available in case of serious allergic response.

Teaching points When the cause of megaloblastic anemia is treated or passes (infancy, pregnancy),

there may be no need for folic acid because it normally exists in sufficient quantities in the diet.

Report rash, difficulty breathing, pain or discomfort at injection site.

C. Fluimucil 300 mg 1 sachet TID

Brand name: Fluimucil

Generic name: Acetylcysteine

Indication: CAP

Drug Classification: Mucolytic agent

Mechanism of Action: Exerts mucolytic action through its free sulfhydryl group which opens up the

disulfide bonds in the mucoproteins thus lowering mucous viscosity. The exact mechanism of action in acetaminophen toxicity is unknown. It is thought to act by providing substrate for conjugation with the toxic metabolite.

Adverse Effects: Hypersensitivity reactions have been reported in patients receiving acetylcysteine,

including bronchospasm, angioedema, rashes and pruritus, may occur. Other adverse effects reported include nausea and vomiting, fever, syncope, sweating, arthralgia, blurred vision, disturbances of liver function.

Contraindication: MAO inhibitor therapy within 14 days initiating therapy; severe hypertension;

severe. Coronary artery disease, hypersensitivity to pseudoedephrine, acrivastine or any component; renal impairment.

Nursing Responsibilities: Monitor effectiveness of therapy and advent of adverse/allergic effects. Instruct

patient in appropriate use and adverse effects to report.A. Salbutamol 1 neb q 8 hours

Generic name: Albuterol sulfate

Brand name: Salbutamol

Classification: Bronchodilators

Action: Relaxes bronchial, uterine, and vascular smooth muscle by stimulating beta2

receptors Binds to beta2-adrenergic receptors in airway smooth muscle, leading to

activation of adenylcyclase and increased levels of cyclic-3', 5'-adenosine monophosphate (cAMP). Increases in cAMP activate kinases, which inhibit the phosphorylation of myosin and decrease intracellular calcium. Decreased intracellular calcium relaxes smooth muscle airways.

Relaxation of airway smooth muscle with subsequent bronchodilationIndication:

Used as a bronchodilator in the management of CAPContraindication:


Use cautiously in patients w/ CV disorders, hyperthyroidism, or diabetes mellitus and in those who are unusually responsive to adrenergics.

Adverse effect: CNS: nervousness, restlessness, tremor, headache, insomnia. CV: chest pain palpitations, angina, arrhythmias, hypertension. GI: nausea, vomiting. Endo: hyperglycemia. F and E: hypokalemia. Neuro: tremor

NURSING CONSIDERATION:BEFORE:

Assess lung sounds, pulse, and blood pressure before administration and during peak of medication. Note amount, color, and character of sputum produced.

Monitor pulmonary function tests before initiating therapy and periodically throughout course to determine effectiveness of medication.

DURING: Observe for paradoxical bronchospasm (wheezing). If condition occurs, withhold

medication and notify physician or other health care professional immediately. Instruct mother to take missed dose as soon as remembered, spacing remaining

doses at regular intervals. Do not double doses or increase the dose or frequency of doses.

AFTER: Inform the mother not to smoke near the child and to avoid respiratory irritants. Advise the mother to rinse the child’s mouth with water after each inhalation dose

to minimize dry mouth.

D. Paracetamol 1 amp IV q 4 hours PRN for headache and fever

PARACETAMOL 500 mg 1 tab q 6 hours PRN (>37.8)

Generic Name: paracetamol

Brand Name: Aceta

Drug classes: Antipyretic/Analgesic (nonopioid)

Therapeutic actions Reduces fever by acting directly on the hypothalamic heat-regulating center to

cause vasodilation and sweating, which helps dissipate heat. Analgesic: Site and mechanism of action unclear.

Indications Fever

Contraindications and cautions Contraindicated with allergy to acetaminophen. Use cautiously with impaired hepatic function, chronic alcoholism,

pregnancy, lactation.Adverse effects

CNS: Headache CV: Chest pain, dyspnea, myocardial damage when doses of 5–8 g/day are

ingested daily for several weeks or when doses of 4 g/day are ingested for 1 yr

GI: Hepatic toxicity and failure, jaundice GU: Acute kidney failure, renal tubular necrosis Hematologic: Methemoglobinemia—cyanosis; hemolytic anemia—

hematuria, anuria; neutropenia, leukopenia, pancytopenia, thrombocytopenia, hypoglycemia


Hypersensitivity: Rash, feverDrug-drug Interactions

Increased toxicity with long-term, excessive ethanol ingestion Increased hypoprothrombinemic effect of oral anticoagulants Increased risk of hepatotoxicity and possible decreased therapeutic effects

with barbiturates, carbamazepine, hydantoins, rifampin, sulfinpyrazone Possible delayed or decreased effectiveness with anticholinergics Possible reduced absorption of acetaminophen with activated charcoal Possible decreased effectiveness of zidovudine

Nursing considerationsAssessment

History: Allergy to acetaminophen, impaired hepatic function, chronic alcoholism, pregnancy, lactation

Physical: Skin color, lesions; T; liver evaluation; CBC, LFTs, renal function tests

Interventions Do not exceed the recommended dosage. Consult physician if needed for children < 3 yr; if needed for longer than

10 days; if continued fever, severe or recurrent pain occurs (possible serious illness).

Avoid using multiple preparations containing acetaminophen. Carefully check all OTC products.

Give drug with food if GI upset occurs. Discontinue drug if hypersensitivity reactions occur. Treatment of overdose: Monitor serum levels regularly, N-acetylcysteine

should be available as a specific antidote; basic life support measures may be necessary.

Teaching points Do not exceed recommended dose; do not take for longer than 10 days. Take the drug only for complaints indicated; it is not an anti-inflammatory

agent. Avoid the use of other over-the-counter preparations. They may contain

acetaminophen, and serious overdosage can occur. If you need an over-the-counter preparation, consult your health care provider.

Report rash, unusual bleeding or bruising, yellowing of skin or eyes, changes in voiding patterns

F. DulcolaxGeneric name:

BisacodylBrand name:

DulcolaxMIMS Class :

Laxatives, PurgativesMechanism of Action:

Bisacodyl acts mainly in the large intestine by increasng its motility to effect bowel evacuation.

Stimulates peristalsis by directly irritating the smooth muscle of the intestine, possibly the colonic intramural plexus; alters water and electrolyte secretion producing net intestinal fluid accumulation and laxation

Stimulant laxatives encourage bowel movements by acting on the intestinal wall. They increase the muscle contractions that move along the stool mass. Stimulant laxatives are a popular type of laxative for self-treatment. However, they also are more likely to cause side effects. One of the stimulant laxatives, dehydrocholic acid, may also be used for treating certain conditions of the biliary tract

Indication: empty the bowels before surgery and examinations such as X-ray


Contraindications: Acute surgical abdomen or intestinal obstruction, severe dehydration, faecal

impaction, chronic use. Ileus, intestinal obstruction, acute surgical abdominal conditions like appendicitis,

acute inflammatory bowel diseases, intestinal rectal, or stomach bleeding, and in severe dehydration. Hypersensitivity to the drug.

Special Precautions: Swallow the tab whole. Pregnancy; inflammatory bowel disease.

Side effect: stomach cramps upset stomach diarrhea stomach and intestinal irritation faintness irritation or burning in the rectum (from suppositories)

Nursing Considerations: Take Dulcolax by mouth with or without food. Take Dulcolax with a full glass of water (8 oz/240 mL). Swallow Dulcolax whole. Do not break, crush, or chew before swallowing. Do not take Dulcolax within 1 hour after taking an antacid or milk. Use Dulcolax with caution in the ELDERLY; they may be more sensitive to its

effects. Dulcolax should not be used in CHILDREN younger than 6 years old; safety and

effectiveness in these children have not been confirmed.Patient Teaching:

If you miss a dose of Dulcolax and are taking it regularly, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once.

Do not use for longer than 1 week without checking with your doctor. Using Dulcolax for a long time may result in loss of normal bowel function.

Do not take additional laxatives or stool softeners with Dulcolax unless directed by your doctor.

Rectal bleeding or failure to have a bowel movement within 12 hours after use of a laxative may be a sign of a serious condition. Stop use and contact your doctor.

If you notice a sudden change in bowel habits that lasts for 2 weeks or more, do not continue using Dulcolax . Instead, check with your doctor.

PREGNANCY and BREAST-FEEDING: If you become pregnant, contact your doctor. You will need to discuss the benefits and risks of using Dulcolax while pregnant. It is not known if Dulcolax is found in breast milk. If you are or will be breast-feeding take Dulcolax , check with your doctor. Discuss any possible risks to your baby.

F. Ketorolac 30 g IV now

GENERIC NAME: Ketorolac

BRAND NAME: Toradol

CLASSIFICATION: Nonsteroidal anti-inflammatory agents, nonopioid analagesics

MECHANISM OF ACTION: Inhibits prostaglandin synthesis, producing peripherally mediated

analgesia Also has antipyretic and anti-inflammatory properties. Therapeutic effect:Decreased pain


INDICATION: Short term management of pain (not to exceed 5 days total for all routes

combined)CONTRAINDICATIONS:

Hypersensitivity Cross-sensitivity with other NSAIDs may exist¨Pre- or perioperative use Known alcohol intoleranceUse cautiously in:

1) History of GI bleeding2) Renal impair-ment (dosage reduction may be required)3) Cardiovascular diseaseSIDE EFFECTS/ ADVERSE EFFECTS:- CNS:1) drowsiness2) abnormal thinking3) dizziness4) euphoria5) headache-- RESP:1) asthma2) dyspnea- CV:1) edema2) pallor3) vasodilation- GI:1) GI Bleeding2) abnormal taste3) diarrhea4) dry mouth5) dyspepsia6) GI pain7) nausea- GU:1) oliguria2) renal toxicity3) urinary frequencyNURSING IMPLICATIONS/RESPONSIBILITIES:

Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria.

Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration.

Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy.

Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional.

Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur.

Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.

G. Cefuroxime 500 mg 1 tab now GENERIC NAME:

CefuroximeBRAND NAME:


CeftinCLASSIFICATION

AntibacterialMechanism of Action:

Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.

Contraindications: Hypersensitivity to cefuroxime, any component of the formulation, or other

cephalosporins Patients with known allergy to penicillins or cephalosphorins

iNDICATION : in treating infections of Upper and Lower respiratory tract

ADVERSE REACTIONS : Anaphylaxis, pseudomembranous colitis, nausea and vomiting, transient

elevation of liver enzymes.Adverse ReactionsGI

Nausea; vomiting; diarrhea; anorexia; abdominal pain or cramps; flatulence; colitis, including pseudomembranous colitis.

Genitourinary Pyuria; renal dysfunction; dysuria; reversible interstitial nephritis; hematuria;

toxic nephropathy.Hematologic

Eosinophilia; neutropenia; lymphocytosis; leukocytosis; thrombocytopenia; decreased platelet function; anemia; aplastic anemia; hemorrhage.

Hepatic Hepatic dysfunction; abnormal LFT results.

Miscellaneous Hypersensitivity, including Stevens-Johnson syndrome, erythema multiforme,

toxic epidermal necrolysis; candidal overgrowth; serum sickness–like reactions (eg, skin rashes, polyarthritis, arthralgia, fever); phlebitis, thrombophlebitis, and pain at injection site.

H. Hyrdrocortisone 100 mg IV now q 12 hours Generic Name

HydrocortisoneTrade Name

Cortef, Solu-Cortef, Hydrocortone, Cortenema Pharmacologic Class

Adrenal cortical steroid Corticosteroid Glucocorticoid

MOA: Enters target cells and binds to cytoplasmic receptor; initiates many complex reactions that are responsible for its anti-inflammatory, immunosuppressive (glucocorticoid), and salt-retaining (mineralocorticoid) actions. Some actions may be undesirable, depending on drug use.Indication

-Replacement therapy in adrenal cortical insufficiencyo Hematologic disorders

Side effects: Vertigo, headache, paresthesias, insomnia, seizures, psychosis

Nursing consideration:


Before- Assess for contraindications.- Assess body weight, skin color, V/S, urinalysis, serum electrolytes, X-rays, CBC. - Arrange for increased dosage when patient is subject to unusual stress.- Do not give live vaccines with immunosuppressive doses of hydrocortisone.- Observe the 15 rights of drug administration.During- Give daily before 9am to mimic normal peak diurnal corticosteroid levels.- Space multiple doses evenly throughout the day.- Use minimal doses for minimal duration to minimize adverse effects.- Do not give IM injections if patient has thrombocytopenic purpura. - Taper doses when discontinuing high-dose or long-term therapy.After- Monitor client for at least 30 minutes.- Educate client on the side effects of the medication and what to expect.- Instruct client to report pain at injection site.- Instruct client to take drug exactly as prescribed.- Dispose of used materials properly.- Document that drug has been given.

I. Azithromysin 500 mg 1 tab OD

Generic name: azithromycin

Brand name: Zithromax

Drug class Macrolide antibiotic

Therapeutic actions Bacteriostatic or bactericidal in susceptible bacteria.

Indications CAP

Contraindications and cautions Contraindicated with hypersensitivity to azithromycin, erythromycin, or any

macrolide antibiotic. Use cautiously with gonorrhea or syphilis, pseudomembranous colitis, hepatic or

renal impairment, lactation.Adverse effects

CNS: Dizziness, headache, vertigo, somnolence, fatigue GI: Diarrhea, abdominal pain, nausea, dyspepsia, flatulence, vomiting, melena,

pseudomembranous colitis Other: Superinfections, angioedema, rash, photosensitivity, vaginitis


Decreased serum levels and effectiveness of azithromycin with aluminum and magnesium-containing antacids

Possible increased effects of theophylline Possible increased anticoagulant effects of warfarin

Drug-food Food greatly decreases the absorption of azithromycin


History: Hypersensitivity to azithromycin, erythromycin, or any macrolide antibiotic; gonorrhea or syphilis, pseudomembranous colitis, hepatic or renal impairment, lactation


Physical: Site of infection; skin color, lesions; orientation, GI output, bowel sounds, liver evaluation; culture and sensitivity tests of infection, urinalysis, liver and renal function tests

Interventions Culture site of infection before therapy. Administer on an empty stomach 1 hr before or 2–3 hr after meals. Food affects

the absorption of this drug. Counsel patients being treated for STDs about appropriate precautions and

additional therapy.

Teaching points Take this drug on an empty stomach 1 hr before or 2–3 hr after meals; it should

never be taken with food. Take the full course prescribed. Do not take with antacids.

These side effects may occur: Stomach cramping, discomfort, diarrhea; fatigue, headache (medication may help); additional infections in the mouth or vagina (consult with health care provider for treatment).

Report severe or watery diarrhea, severe nausea or vomiting, rash or itching, mouth sores, vaginal sores.

J. Prednisone 1omg a tab OD

Generic name: prednisone

Brand name: Winpred

Drug classes Corticosteroid (intermediate acting) Glucocorticoid Hormone

Therapeutic actions Enters target cells and binds to intracellular corticosteroid receptors, thereby

initiating many complex reactions that are responsible for its anti-inflammatory and immunosuppressive effects.

Indications CAP (inflammation

Adverse effects CNS: Vertigo, headache, paresthesias, insomnia, seizures, psychosis,

cataracts, increased IOP, glaucoma (long-term therapy); euphoria, depression

CV: Hypotension, shock, hypertension and CHF secondary to fluid retention, thromboembolism, thrombophlebitis, fat embolism, cardiac arrhythmias

Electrolyte imbalance: Na+ and fluid retention, hypokalemia, hypocalcemia

Endocrine: Amenorrhea, irregular menses, growth retardation, decreased carbohydrate tolerance, diabetes mellitus, cushingoid state (long-term effect), increased blood sugar, increased serum cholesterol, decreased T3 and T4 levels, HPA suppression with systemic therapy longer than 5 days

GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention, nausea, vomiting, increased appetite, weight gain (long-term therapy)

Hypersensitivity: Hypersensitivity or anaphylactoid reactions Musculoskeletal: Muscle weakness, steroid myopathy, loss of muscle

mass, osteoporosis, spontaneous fractures (long-term therapy)


Other: Immunosuppression, aggravation or masking of infections; impaired wound healing; thin, fragile skin; petechiae, ecchymoses, purpura, striae; subcutaneous fat atrophy


Increased therapeutic and toxic effects with troleandomycin, ketoconazole

Increased therapeutic and toxic effects of estrogens, including hormonal contraceptives

Risk of severe deterioration of muscle strength in myasthenia gravis patients who also are receiving ambenonium, edrophonium, neostigmine, pyridostigmine

Decreased steroid blood levels with barbiturates, phenytoin, rifampin Decreased effectiveness of salicylates


History: Infections; renal or liver disease, hypothyroidism, ulcerative colitis with impending perforation, diverticulitis, active or latent peptic ulcer, inflammatory bowel disease, CHF, hypertension, thromboembolic disorders, osteoporosis, seizure disorders, diabetes mellitus; hepatic disease; lactation

Physical: Weight, T, reflexes and grip strength, affect and orientation, P, BP, peripheral perfusion, prominence of superficial veins, R, adventitious sounds, serum electrolytes, blood glucose

Interventions Administer once-a-day doses before 9 AM to mimic normal peak corticosteroid

blood levels. Increase dosage when patient is subject to stress. WARNING: Taper doses when discontinuing high-dose or long-term therapy to

avoid adrenal insufficiency. Do not give live virus vaccines with immunosuppressive doses of corticosteroids.

Teaching points Do not stop taking the drug without consulting your health care provider. Avoid exposure to infections. Report unusual weight gain, swelling of the extremities, muscle weakness, black

or tarry stools, fever, prolonged sore throat, colds or other infections, worsening of the disorder for which the drug is being taken.

X. List of Prioritized Diagnosis and Rationale:

PRIORITIZATION: ACTUAL OR POTENTIAL1. Ineffective airway clearance r/t presence of

secretion secondary to CAPACTUAL

2. Risk for infection r/t loss of secondary defense secondary to CAP

ACTUAL

3.5. Impaired gas exchange r/t airway constriction secondary to CAP

POTENTIAL

3.5. Impaired gas exchange r/t occluded airway secondary to CAP

POTENTIAL

5. fluid volume deficit r/t decreased hemoglobin POTENTIAL6.5. Acute pain r/t inflammatory process secondary

to polysinusitisPOTENTIAL

6.5. Acute pain r/t inflammatory process secondary POTENTIAL


to CAP

RATIONALE

Prioritization is done to be able to identify the different health problems of the patient needs to be addressed first and given much focus. It is also the process of establishing a preferential sequence for addressing nursing diagnoses and intervention. In prioritizing the different nursing problems, theories are considered as rationale of the prioritization.

NURSING DIAGNOSIS RATIONALE OF PRIORITIZATION

1. Ineffective airway clearance r/t presence of secretion secondary to CAP

Ineffective airway clearance is an actual problem that must be addressed first. According to the Maslow’s Hierarchy of need, oxygen is part of the physiologic need. According to OFFTERAS, oxygen must be addressed first. According to Kalish Expanded Theory of Hierarchy, oxygen must be prioritized first because its part of the survival need.

2. Risk for infection r/t loss of secondary defense secondary to CAP

This is an actual problem and presently existing. The patient could be of risk of infection due to low Neutrophils count. Preventive interventions are still applicable in order to prevent the presence of infection.

Impaired gas exchange is an actual problem that must be addressed next. Balancing the oxygen supply of the patient is managed through oxygenation which is readily available in the institution hence it’s prioritized second because the previous nursing diagnosis requires more nursing interventions. Based on Maslow’s Hierarchy of need, oxygen is part of the physiologic need. According to OFFTERAS, oxygen must be addressed first. According to Kalish Gas exchange disorders are highly prioritized because they are life threatening.

3.5. Impaired gas exchange r/t airway constriction secondary to CAP

This is a potential problem and presently not existing however such may occur particularly if there will be complication of CAP.Based on Maslow’s Hierarchy of need, oxygen is part of the physiologic need. According to OFFTERAS, oxygen must be addressed first. According to Kalish Gas exchange disorders are


highly prioritized because they are life threatening.

3.5. Impaired gas exchange r/t occluded airway secondary to CAP

This is a potential problem. It is not presently existing however it may happen if airway occlusion will occur.According to Maslow’s Hierarchy of need, oxygen is part of the physiologic need. Based on OFFTERAS, oxygen must be addressed first. According to Kalish Gas exchange disorders are highly prioritized because they are life threatening.

5. fluid volume deficit r/t decreased hemoglobin

This is a potential problem because the patient has hemolytic anemia. Fluid related problem is prioritized next to oxygen problem in relation to OFFTERAS. Fluid is one of the physiologic needs according to Maslow.

6.5. Acute pain r/t inflammatory process secondary to polysinusitis

This is a potential problem since this problem doesn’t exist however it may occur based on pathophysiologic occurrence. According to Maslow if the physiologic needs are into met, it can result to pain.

6.5. Acute pain r/t inflammatory process secondary to CAP

This is a potential problem since this problem doesn’t exist however it may occur based on pathophysiologic occurrence. According to Maslow if the physiologic needs are into met, it can result to pain.


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