Grand Case 2011 Final!

8/4/2019 Grand Case 2011 Final!

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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-

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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.



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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.



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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;



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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.



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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



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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



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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.



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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

GENERIC NAME BRAND NAME DOSAGE/FREQUENCY INDICATION ADVERSEREACTION NURSINGCONSIDERATIONI f h


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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.


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.


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.


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.


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.



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.



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.


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/


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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
http://nursingdepartment.blogspot.com/http://www.nih.gov/http://www.nih.gov/http://www.medicine.net.com/http://www.wikianswer.com/http://www.livestrong.com/http://www.chfpatients.com/http://www.labtestonline.com/http://www.mayoclinic.com/http://www.medweb.bham.ac.uk/http://www.wisegeek.com/http://www.wisegeek.com/http://www.medweb.bham.ac.uk/http://www.mayoclinic.com/http://www.labtestonline.com/http://www.chfpatients.com/http://www.livestrong.com/http://www.wikianswer.com/http://www.medicine.net.com/http://www.nih.gov/http://www.nih.gov/http://nursingdepartment.blogspot.com/


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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

Grand Case 2011 Final!

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Transcript of Grand Case 2011 Final!