Davao Doctors College

8/8/2019 Davao Doctors College

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DAVAO DOCTORS COLLEGE

Gen. Malvar St., Davao City

DRUG STUDY

Name: Binancilan, Maryfiel Mosquera Date of Admission: Sept. 8, 2010

Age: 52 Sex: Female Civil Status: Married Room/Bed no:559 Attending Physician: Dr. Crisostomo Serrano, Sr.

GENERIC NAME

BRANDNAME

CLASSIFICATION

MECHANISM OF

ACTION

INDICATION

CONTRAINDICATION

ADVERSEREACTION

DOSAGE NURSINGRESPONSIBILIT

Y

Phenylpro

panolamin

e HCl +

Paracetam

ol

Nasathera cap Nasal

Decongestant,

Antipyretic,

analgesic

It constricts

(shrinks) blood

vessels (veins

and arteries),

which reduces

swelling of

mucousmembranes in

areas such asthe nose and

sinuses. It

thins mucous,

increases

lubrication of

the respiratory

tract (lungs,

nose and

throat), and

increases theremoval of

mucous.

Nasal

congestion

due to

common

colds, rhinitis

& sinusitis.

Patients w/

coronary

thrombosis,

HTN,

hyperthyroidism,

close-angle

glaucoma. Itshould not be

usedconcomitantly w/

or w/in 2 wk of

MAOI therapy.

Cardiac diseases,

angina of effort,

diabetes & in

patients receiving

digitalis &

antidepressants &w/ prostate

enlargement.

Pregnancy.

Giddiness,

nausea, vomiting,

sweating, thirst,

tachycardia,

precordial pain,

palpitations,

difficulty inmicturition,

muscularweakness &

tremors, anxiety,

restlessness &

insomnia,

paranoid

psychosis,

delusions &

hallucinations.

phenylpro

panolamin

e 25 mg.

paracetam

ol 250 mg,

Give 1

cap tid

Encouraged

patient to

increase oral

fluid intake

Instruct

patient to

avoid operating

machine or

driving since it

can cause

dizziness

Do not take

phenylpropanolami

ne if you have taken

a monoamine

oxidase inhibitor

(MAOI)

Monitor BP

before givingPhenylpropanolami

ne

Name: Davalos, Meriam Dorres M. Section: C Group: 26


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DRUG STUDY

Name: Binancilan, Maryfiel Mosquera Date of Admission: Sept. 8, 2010

Age: 52 Sex: Female Civil Status: Married Room/Bed no:559 Attending Physician: Dr. Crisostomo Serrano, Sr.

GENERIC NAME

BRANDNAME

CLASSIFICATION

MECHANISM OF

ACTION

INDICATION

CONTRAINDICATION

ADVERSEREACTION

DOSAGE NURSINGRESPONSIBILIT

YCefuroxime

AxetilZinnat Anti-infective:

second-generation

cephalosporin

It inhibits

bacterial cell

wall synthesis,

rendering cell

wall

osmotically

unstable;

Eradication of

gram-negative

bacilli and

gram-positive

organisms;

treatment of

serious lower

respiratory

tract, urinarytract, skin, and

gonococcal

infections,

septicemia,

and

meningitis.

Hypersensitivity

to cephalosporins

or penicillins

Carnitine

deficiency

Use cautiously

in: renal or hepatic

impairment pregnant or

breastfeeding

patients

children.

CNS: headache,

hyperactivity,

hypertonia, seizures GI:

nausea, vomiting,

diarrhea, abdominal

pain, dyspepsia,

pseudomembranous

colitis

GU: hematuria, vaginal

candidiasis, renaldysfunction, acute renal

failure

Hematologic:

hemolytic anemia,

aplastic anemia,

hemorrhage

Hepatic: hepatic

dysfunction

Metabolic:

hyperglycemia

Skin: toxic epidermal

necrolysis, erythema

multiforme, Stevens-

Johnson syndrome

Other: allergic reaction,

superinfection,anaphyla

xis

500mg 1

tab tid

Advise patient to

immediately report

rash or bleeding

tendency.

Instruct patient to

take drug with food

every 8 hours asprescribed.

Teach patient howto recognize signs

and symptoms of

superinfection.

Instruct him to

report right away.

Advise patient to

report CNS

changes.

As appropriate,

review all othersignificant and life-

threatening adverse

reactions and

interactions,

especially those

related to the drugs,

tests, and foods

mentioned above.



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NURSING CARE PLAN

Patients Name: Binancilan, Maryfiel Mosquera Age: 52 Sex: Female Room/bed no: 559 Date of Admission: Sept. 8,2010

Civil Status: Married Religion: Catholic Attending Physician: Dr. Crisostomo Serrano, Sr. Diagnosis: CAP- LR, Maxillary Sinusitis

PROBLEM SCIENTIFICBASIS

GOALSOBJECTIVE

CRTERIA

NURSINGINTERVENTION

RATIONALE EVALUATION

S : Kagalkal kayo

akong ubo ba as

verbalized by the

patient

Cough results from

irritation of the

mucous membrane

anywhere in the

respiratory tract.

Persistent andfrequent cough can be

exhausting and can

cause pain. A coughthat worsens when

patient is supine

suggests postnasal

drip (sinusitis).

Sputum production is

the reaction of the

lungs to any

constantly recurring

irritant.

Reference: Smeltzer,

et.al. Brunner and

Suddarths Textbook

of Medical- Surgical

Nursing. 11thEdition.

2008. Lippincott

Williams & Wilkins

Within the 8 hour

span of care, the

patient will be able to:


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COMPREHENSIVE ASSESSMENT

A. PERSONAL DATA

Name: Binancilan, Maryfiel M. Age: 52 Sex: Female Civil Status: Married Religion: Catholic

Address: Blk.6 Lot8 Ph.2 Roseville Subd., Lanang, Dvo. Cty Occupation: Retired EmployeeChief Complain: Shortness of breath, backpain Attending Physician: Dr. Crisostomo Serrano Sr.

Date of Admission: Sept. 8, 2010 Impression to Diagnosis: CAP- LR, Maxillary Sinusitis

B. FAMILY BACKGROUND

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_________________________________________________________________________

C. EFFECTS/EXPECTATIONS OF ILLNESS TO FAMILY AND SELF

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_________________________________________________________________________________________________________

D. HISTORY OF PAST ILLNESS

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_________________________________________________________________________

E. HISTORY OF PRESENT ILLNESS

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_________________________________________________________________________


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FUNCTIONAL PATTERNONGOING ASSESSMENT

GUIDELINES PATIENT DAY 1 DAY 2 DAY 3

I. Mental Status

a. state of mental consciousness Alert, conscious, coherent N/A

b. orientation Oriented to place, time,situation, place

c. intellectual capacity Able to understand, canoperate simple math, with

good intact memory

d. vocabulary level Speaks fluently in hispreferred dialect, without

sluggishness

e. attention span Able to participate in long-term conversation

f. ability to understand Able to understand well

II. Status of Special Senses

a. auditory perception Able to hear well to verbalstimuli

b. visual perception Able to see clearly withoutvisual aids, no blurring in

vision

c. speech perception Able to speak fluently enoughto be understood

d. tactile perception Able to respond and feel totouch or pain stimulus

e. olfactory perception Able to distinguish variousodor

III. Motor Ability

a. current mobility No limitation in mobility, canambulate well

b. posture With normal gait, erectposture

c. range of motion Able to do active and passivejoint motion without pain and

difficulty


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d. muscle and nerve status Nerves and motor action arecoordinated and symmetrical

e. loss of extremities Complete upper and lowerextremities

IV. Body Temperature

a. ranges Normal temp. from 36-37.50C

V. Respiratory Status

a. character Regular inspiratory andexpiratory, with clear breath

sound, no retraction

b. use of respiratory aids Can breathe without difficulty,without use of resp aids

c. interference in respiration No interference in respiration

d. abnormal respiratory opening No abnormal opening

VI. Circulatory Status

a. character of arterial pulseWith strong, bounding pulse,regular in rhythm, with pr of

60-100bpm

b. apical-radial pulse With equal pulse, symmetricalapical-radial pulse

c. intravenous fluids No intravenous hooked to pt

VII. Nutritional Status

a. condition of buccal cavity With pink and moist buccalmembrane, no ulceration

noted

b. digestion of food With regular digestive action,with good appetite

c. weight Wt is appropriate for hisheight

VIII. Elimination Status

a. bowel Able to defecate daily withoutstraining, with yellow-brown

feces

b. bladder Voiding freely without pain,urinate approx. 240cc/8hr of

clear-yellow urine

c. abnormalities No abnormalities ineliminating feces and urine


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IX. Female Reproductive Status

a. age of menarche Menarche starts at10-15y.o.

b. pattern of menses Regular monthly cycle of 28days average, duration of 3-5days, consume 3-4 pads

c. pregnancy Nulligravid state

d. vaginal discharge With clear, vaginal disharges,not foul odor

X. State of Skin and Appendages

a. skin Smooth, warm to touch, withgood skin turgor, without

lesions and abrasions

b. hair Evenly-distributed hair, shiny,without any infestation, and

dandruff

c. nails Clean, trimmed nails, withpink nailbed, normal

curvature, with CRT


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XIII. Nursing Diagnosis

1. Ineffective Airway Clearance r/t retained thick copious bronchial secretion

2.

3.

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