Beruflich Dokumente
Kultur Dokumente
COLLEGE OF NURSING
BAGUIO CITY
NCP
(CASE STUDY)
SUBMITTED BY:
FERRER, Tristan
GALINATO, Michael
RABARA, Romuel
ALMEROL, Bernalyn
BLANCO, Catherine
BOADO, Andrienne
DAMASCO TY, Mikaella
LAGUINDAY, Michelle
MEJIA, Camille
PARAS, Mary Margarette
SARMIENTO, Ellaine Joyce
URAYENZA, Aira Joyce
SUBMITTED TO:
Ma’am Shiela Adversalo
I. Demographic Data
2 weeks prior to admission, patient has difficulty of breathing with associated cough and chest pains. No head ache, no fever and no nausea and vomiting.
No medical consultations were done.
1 week prior to admission, after lifting a heavy object, client felt right flank pain described as shooting in character. No fever, head ache or nausea and
vomiting noted. The patient sought consult to his private physician and was given Arcoxia and Myonal affording slight relief. The patient’s right flank pain persisted
in the next few days even having Arcoxia and Myonal. The patient had DOB when sleeping and lying flat on bed.
He was relieved when he was doing right lateral decubitus position. Patient’s flank pain persisted despite the medications and when the pain was already
severe, the patient was brought to the institution for further management and evaluation; hence, admission.
Patient has no known allergies to food and drugs. No major operations were done and no trauma noted. Immunizations were unrecalled.
The patient has been diagnosed with CVD, RMCA on 2006 and his last admission was July 2009 due to removal of boil. The patient was a known
hypertensive and diabetic. Maintenance drugs include Norises, Lifezar, Aspilet, Metformin and Plavix with good compliance.
IV. Family History
The patient claims to have a history of heredofamilial diseases such as DM and HPN and denied any history of CAD, asthma, cancer, CVD, goiter and
kidney diseases.
V. A. Course of Confinement
This is the case of Jesus Tan, a 59 yr old male, married, Filipino, Roman Catholic, born in Cebu City on September 18, 1950, currently residing at 214
Naguilian Road Baguio City. He was admitted for the 2nd time in this institution on August 25, 2009, with a chief complaint of right flank pain. He was given an
IVF of Plain NSS upon admission.
VI. B. Diagnostics
MCV 76.0-96.0
MCH 331 g/L 320-360
Platelet: adequate
Comments: Normocytic, normochromic
RBCs
MCHC 27.0-32.0
28.2 pg
Interpretation:
This test is used to aid in diagnosing anemia and other blood disorders and certain cancers of the blood; to monitor blood loss and infection; to monitor a patient's
response to cancer therapy, such as chemotherapy and radiation. It is also used to diagnose and/or monitor bleeding and clotting disorders through platelet count and
to evaluate bleeding and clotting disorders and to monitor anticoagulation (anti-clotting) therapies through prothrombin time.This test was done to determine the
existence of an infection and to determine if blood components are within normal levels. An increase in the WBCs in indicative of infection whereas a decrease in
the HGB or HCT indicates the possibility that the blood may not be able to adequately supply body’s demands for oxygen. All findings in the examination are
within the normal range.
X-Ray Report
Chest
There is homogeneous opacity seen in the right lung field. Observing the right hemidiaphragm and costophrenic angle.
The tracheal air column and mediastinal structures are directed to the right.
Cardiac shadow cannot be evaluated. Atherosclerotic aortic knob. Intact left hemidiaphragm and costrophrenic angle.
• Massive pleural effusion, right
• Atherosclerotic aortic knob
Thoracic and Lumbar
Osteophytic lippings are seen in the articulatory margins of the thoracic and lumbar spine
No evident fracture or listhesis
Line of gravity is physiologic
Intact pedicle and disc spaces
Lumbarized S1 vertebral body
Atherosclerotic abdominal aorta
• Degenerative disease of the thoracic and lumbar spine
• Lumbarized S1
Interpretation:
X-rays are especially useful in the detection of pathology of the skeletal system, but are also useful for detecting some disease processes in soft tissue.Client has
been given an impression diagnosis of massive pleural effusion. In order to confirm the diagnosis, a chest x-ray has been performed. Results convey that there is
massive pleural effusion at the right lung pleura and reveals atherosclerosis of the abdominal aorta which means that there are increased cholesterol deposits at the
wall of the abdominal aorta which may obstruct blood flow.
X-Ray Report
Follow up chest study since August 25, 2009 reveals minimal clearing of the previously seen right sided pleural effusion.
The left lung field is still unremarkable
The tracheal air column and mediastinal structure now appear midline
Cardiac shadow still could not be evaluated properly
A CTT tube is seen in the right peripheral hemithorax
No interval change noted
Interpretation:
X-rays are especially useful in the detection of pathology of the skeletal system, but are also useful for detecting some disease processes in soft tissue.After the
insertion of a CTT to drain pleural fluid, x-ray reveals minimal clearing of the right pleural effusion which means that there is minimal decrease in the pleural
volume found at the right lung.. This x-ray has been done as a follow up to the previous x-ray in order to determine the progress of the condition and to check the
placement of the CTT at the same time.
X-Ray Report
August 27, 2009
Follow up study since 08-26-09 shows further clearing of the previously seen right sided pleural effusion.
The lung is still unremarkable
No internal changes noted
Interpretation:
X-rays are especially useful in the detection of pathology of the skeletal system, but are also useful for detecting some disease processes in soft tissue.This x-ray is
done as a follow up of the recent x-ray. This is to determine whether the pleural fluid has been reduced. The result reveals further clearing of the right pleural
effusion which means that the CTT is effective in draining pleural secretions.
Hematology
August 25, 2009
Interpretation:
A complete blood cell count is a measurement of size, number, and maturity of the different blood cells in a specific volume of blood. A complete blood cell count
can be used to determine many abnormalities with either the production or destruction of blood cells. Variations from the normal number, size, or maturity of the
blood cells can be used to indicate an infection or disease process. Often with an infection, the number of white blood cells will be elevated. The use of this test is
To aid in diagnosing anemia and other blood disorders and certain cancers of the blood; to monitor blood loss and infection; to monitor a patient's response to cancer
therapy, such as chemotherapy and radiation. Since the patient is a diabetic and needs to undergo an invasive procedure, his clotting and bleeding time should be
known in order to determine whether the procedure can be pursued. It is also important to determine the patient’s blood type and Rh factor to prepare for Blood
transfusion if in case bleeding persists and is uncontrolled during the procedure.
Physical Description
Volume: 22 mL
Apperance: turbid
Color: red
Microscopic Description
Smears
- Few atypical cells with medium-sized to large oval nuclei, occasionally with prominent nucleoli, scanty to moderate amount of cytoplasm seen singly
in small clusters
- Few lymphocytes and occasional macrophages
- Few mesothelial cells
- Some erythrocytes
Interpretation:
The test is performed to determine the cause of fluid accumulation in the pleural space (pleural effusion), or when cancer is suspected. In an abnormal test,
malignant (cancerous) cells are present and may indicate a cancerous tumor. This test most often detects breast cancer, lung cancer, and lymphoma. Pleural fluid
from the CTT drain has to be examines in order to determine whether there is a presence of infection at the pleural area. The result reveals the presence of atypical
cells with few lymphocytes and occasional macrophages indicating the presence of an infectious process; with the body’s defenses trying to combat infection by the
release of phagocytic cells.
Plasma Examination
September 2, 2009
Interpretation:
The prothrombin time is the time it takes plasma to clot after addition of tissue factor (obtained from animals). This measures the quality of the extrinsic pathway (as
well as the common pathway) of coagulation. The prothrombin time is the time it takes plasma to clot after addition of tissue factor (obtained from animals). This
measures the quality of the extrinsic pathway (as well as the common pathway) of coagulation. This test has been performed to determine effectiveness of client’s
clotting capacity. Prothrombin is converted to thrombin during clotting. The prothrombin value is quite high indicating that the patient has good clotting capacity.
Creatinine G
September 4, 2009
1.2 mg/dL
Normal Value: 0.6-1.3 mg/dL
Interpretation:
Creatinine tests measure the level of the waste product creatinine in your blood and urine. These tests tell how well your kidneys are working. The substance
creatine is formed when food is changed into energy through a process called metabolism. Creatine is broken down into another substance called creatinine, which
is taken out of your blood by the kidneys and then passed out of your body in urine. Creatinine is made at a steady rate and is not affected by diet or by normal
physical activities. If your kidneys are damaged and cannot work normally, the amount of creatinine in your urine goes down while its level in your blood goes up.
Normal levels of creatinine in the blood are approximately 0.6 to 1.2 milligrams (mg) per deciliter (dl) in adult males and 0.5 to 1.1 milligrams per deciliter in adult
females. The most common causes of longstanding kidney disease in adults are high blood pressure and diabetes mellitus. The cretainine level of the patient is 1.2
mg/dL which revealed that kidneys are not damaged or deficient and did not lead to sudden rise in the blood levels.
11:30 AM – 137
Interpretation:
CBG consisting in measuring the glucose (sugar) content in the blood is done on a regular basis in diabetes patients to determine their glucose level (Normal = 90 -
120). It consists in making a pinprick with a sterile throwaway lancet in a fingertop, collecting a blooddrop (capillary blood) on a chemical strip, which is introduced
in a glucosemeter. The result appears in a LED.The purpose is to find out if the dosis of medecine which the patient is taking is correct and if his diet is right or if
corrections should be made. It is done in general from one to various times a week.
Indication: HPN
Mechanism of Action: Blocks the strong BP raising effect of angiotensin II by competing with angiotensin II for tissue binding sites and prevent angiotensin II
from combining with its receptors in the body tissues. It blocks the Angiotensin II AT1 receptors and decreases arterial BP by decreasing vasoconstriction and
systemic vascular resistance.
Side Effects: Facial edema, Fever, angina pectoris, 2nd degree AV block, arrhythmia, diarrhea, dry mouth, anemia, gout, muscle cramps, arthritis, anxiety disorder,
migraine, nervousness
Interactions: Co-administration of losartan and cimetidine led to an increase of about 18% in AUC of losartan but did not affect the pharmacokinetics of its active
metabolite. Losartan and phenobarbital, when used concomitantly led to a reduction of about 20% in the AUC of losartan and that of its active metabolite. Losartan
did not affect the pharmacokinetics and pharmacodynamics of warfarin, oral or IV digoxin, and ketoconazole.
Nursing Considerations: Check BP before each dose. Observe for interactions when administering other drugs that may decrease the drug’s effect such as
adrenergics. Instruct to report if any adverse effects are experienced. Instruct to take drug regularly
Indications: NIDDS Type 2, inadequately controlled by proper dietary management and exercise especially in obese diabetic patients, patients no longer
responding to sulphonylureas, either alone or in combination with other drugs
Mechanism of Action: Inhibits alpha-glucosidase enzymes (sucrose, maltase, amylase) in the GI tract and thereby delay digestion of complex carbohydrates into
glucose and other simple sugars. As a result, glucose absorption is delayed and there is small increase in blood glucose levels following a meal. It is metabolized in
the GI by digestive enzymes and intestinal bacteria. Some of the metabolites are absorbed systemically and excreted in the urine; plasma concentrations are
increased in the presence of renal impairment.
Contraindications: Cardiac failure, ketoacidosis, chronic liver disease, recent MI, acute or chronic alcoholism, conditions likely to predispose to lactic acidosis
Side Effects: Diarrhea, lactic acidosis, anorexia, abdominal pain, nausea and metallic taste
Interactions: Reduction in metformin HCl dosage may be required in patients receiving metformin HCl and cimetidine concomitantly to reduce the risk of lactic
acidosis.
Nursing Considerations: Assess changes in blood sugar levels (400 mg/100ml is dangerous). Ideally administer at the beginning of a meal so the drug will be
present at the GIT with food and be able to block the digestion of CHOs. Instruct to report any side effects
Indications: rheumatoid arthritis, psoriatic arthritis, osteoarthritis, ankylosing spondylitis, chronic low back pain, acute pain, gout
Mechanism of Action: Inhibits isoform 2 of cyclo-oxigenase enzyme (COX-2). This reduces the generation of prostaglandins (PGs) from arachidonic acid. Among
the different functions exerted by PGs, their role in the inflammation cascade should be highlighted. COX-2 selective inhibitor (aka "COXIB") showed less marked
activity on type 1 cycloxigenase compared to traditional non-steroidal anti-inflammatory drugs (NSAID). This reduced activity is the cause of reduced
gastrointestinal toxicity, as demonstrated in several large clinical trials performed with different COXIB
Contraindications: Hypersensivity, acute peptic ulceration, or active GI bleeding, bronchospasm, acute rhinitis, nasal polyps, angioneurotic oedema, urticaria
Side Effects: Immune system disorders, nervous system disorders, cardiac disorders, respiratory and thoracic mediastinal disorders
Nursing Responsibilities: Administer with full glass of fluid during or after meals to decrease gastric irritation. Observe for decrease in the severity of pain.
Instruct client to report any untoward effects
Indications: Spastic paralysis in conditions such as cerebrovascular disease, spastic spinal paralysis, cervical spondylosis, postoperative sequelae (including from
cerebrospinal tumour), sequelae to trauma (e.g. spinal trauma or head injury), amyotrophic lateral sclerosis, cerebral palsy, spinocerebellar degeneration, spinal
vascular diseases and other encephalomyelopathies, improvement of muscular hypertonic symptoms in conditions such as cervical syndrome, periarthritis of the
shoulder, and lumbago
Mechanism of Action: Eperisone acts by relaxing both skeletal muscles and vascular smooth muscles, and demonstrates a variety of effects such as reduction of
myotonia, improvement of circulation, and suppression of the pain reflex. The drug inhibits the vicious cycle of myotonia by decreasing pain, ischaemia, and
hypertonia in skeletal muscles, thus alleviating stiffness and spasticity, and facilitating muscle
Nursing Considerations: Caution the patient on the possible side effects of the drug. Monitor for signs of psychological hypofunction during treatment. Administer
the drug after meals to decrease gastric irritation
Indications: Treatment of constipation, particularly when associated with prolonged bed rest, evacuation of the bowel prior to radiologic studies or surgery
Mode of Action: Stimulates peristalsis, alters fluid and electrolyte transport producing fluid accumulation in the colon.
Contraindication: Hypersensitivity, abdominal pain, obstruction, nausea or vomiting, especially when associated with fever or other signs of an acute abdomen
Interactions: Antacids may remove enteric coating of tablets. May decrease the absorption of other orally administered drugs because of increased motility and
decreased transit time.
Nursing Implication: Assess patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. Assess color, consistency, and
amount of stool produced.
Generic Name: Paracetamol
Mode of Action: Paracetamol exhibits analgesic action by peripheral blockage of pain impulse generation. It produces antipyresis by inhibiting the hypothalamic
heat-regulating centre. Its weak anti-inflammatory activity is related to inhibition of prostaglandin synthesis in the CNS.
Side Effects: Nausea, allergic reactions, skin rashes, acute renal tubular necrosis.
Interactions: Reduced absorption of cholestyramine within 1 hr of admin. Accelerated absorption with metoclopramide. Decreased effect with barbiturates,
carbamazepine, hydantoins, rifampicin and sulfinpyrazone. Paracetamol may increase effect of warfarin.
Nursing Implications: Assess patient for signs and symptoms of infection. Assess patients pain characteristics.
Contraindications: Hypersensitivity to cephalosporins, penicillins & local anesth eg lidocaine (in IM use
Side Effects: Shock, hypersensitivity reactions, hematologic, renal & hepatic disturbances. Digestive & resp effects. Vit deficiencies & alteration in bacterial flora.
Nursing Implications: Assess patient for infection. Obtain specimen for culture and sensitivity. Monitor intake and output and daily weight to assess hydration
status and renal function
Brand Name:
Indications: Short term treatment for anxiety, insomia, sleepwalking, seizures, muscle spasms,
Mode of Action: Diazepam is a long-acting benzodiazepine with anticonvulsant, anxiolytic, sedative, muscle relaxant and amnestic properties. It increases neuronal
membrane permeability to chloride ions by binding to stereospecific benzodiazepine receptors on the postsynaptic GABA neuron within the CNS and enhancing the
GABA inhibitory effects resulting in hyperpolarisation and stabilisation.
Contraindications: Hypersensitivity; preexisting CNS depression or coma, respiratory depression; acute pulmonary insufficiency or sleep apnoea; severe hepatic
impairment; acute narrow angle glaucoma; children < 6 mth; pregnancy and lactation.
Side Effects: Psychological and physical dependence with withdrawal syndrome; fatigue, drowsiness, sedation, ataxia, vertigo, confusion, depression, GI
disturbances, changes in salivation, amnesia, jaundice, paradoxical excitation, elevated liver enzyme values; muscle weakness, visual disturbances, headache,
slurring of speech and dysarthria; mental changes; incontinence, constipation; hypotension, tachycardia; changes in libido; pain and thrombophloebitis at Inj site
(IV).
Interactions: Increased clearance of diazepam when used with phenytoin, carbamazepine and phenobarbital. Reversible deterioration of parkinsonism may occur
when given together with levodopa. Combination with lithium may produce hypothermia.
Nursing Implications: Assess patients general status. Caution the patient on the possible side effects of the drug. Monitor for signs of psychological hypofunction
during treatment.
Indications: Adjunct to diet and exercise to lower blood glucose in patients with type 2 diabetes mellitus as monotherapy and in combination with metformin or
insulin when diet and exercise plus the single agent do not result in adequate glycemic control.
Mode of Action: Oral hypoglycemic agent. Glimepiride is a sulfonylurea antidiabetic agent. It lowers blood glucose primarily by stimulating the release of insulin
from functioning pancreatic β-cells. Glimepiride also provides overall glycemic control by increasing sensitivity of peripheral tissues to insulin.
Contraindications: Known hypersensitivity to glimepiride. Diabetic ketoacidosis with or without coma. Treat this condition with insulin.
Interactions: Nonsteroidal anti-inflammatory drugs (NSAIDs), sulfonamides and highly protein-bound drugs eg, salicylates, chloramphenicol, coumarins,
probenecid, monoamine oxidase inhibitors and β-blockers can potentiate the hypoglycemic action of glimepiride and sulfonylureas. Thiazides and other diuretics,
corticosteroids, phenothiazines, thyroid products, estrogen, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics and isoniazid tend to produce
hyperglycemia and may lead to loss of glycemic control. Closely observe the patient on glimepiride for loss of glycemic control when these drugs are co-
administered. Co-administration of aspirin (1 g 3 times a day) and glimepiride leads to a 34% decrease in the mean AUC and 4% decrease in the mean Cmax of
glimepiride. However, there is no evidence of clinically significant adverse interactions with uncontrolled concurrent administration of aspirin and other salicylates.
Concomitant administration of propranolol (40 mg 3 times a day) and glimepiride significantly increases Cmax, AUC and t½ of glimepiride by 23%, 22% and 15%,
respectively. Potential interactions between oral miconazole and oral hypoglycemic agents have been reported. Potential interactions of glimepiride with other drugs
metabolized by cytochrome P-450 2C9 also include phenytoin, diclofenac, ibuprofen, naproxen and mefenamic acid.
Nursing Implications: Assess patient for signs and symptoms of hypoglycemia. Assess patient for any change in blood glucose.
Mode of Action: Ketorolac inhibits prostaglandin synthesis by decreasing the activity of the cyclooxygenase enzyme.
Contraindications: Hypersensitivity to aspirin or other NSAIDs, asthma. Hypovolaemia or dehydration. Do not give postoperatively to patients with high risk of
haemorrhage. History of peptic ulcer or coagulation disorders. Nasal polyps, angioedema, bronchospasm. Labour. Moderate to severe renal impairment. GI
bleeding, cerebrovascular bleeding. As prophylactic analgesic before surgery. Pregnancy, lactation.
Side Effects: GI ulcer, bleeding and perforation, drowsiness, rash, bronchospasm, hypotension, psychosis, dry mouth, fever, bradycardia, chest pain, dizziness,
headache, sweating, oedema, pallor, liver function changes. Transient stinging and local irritation (ophthalmic).
Interactions: May reduce effects of antihypertensives (e.g. ACE inhibitors or angiotensin II receptor antagonists). Increased risk of renal toxicity with ACE
inhibitors, diuretics. Increased adverse effects with aspirin or other NSAIDs. Hallucinations may occur when used with fluoxetine, thiothixene, alprazolam.
Nursing Implications: Assess patient’s pain, signs of dizziness, nervousness and GI disturbances. Medicine should be taken after meals.
Mode of Action: Nalbuphine is a phenanthrene derivative opioid analgesic with mixed opioid agonist and antagonist activity. It inhibits the ascending pain
pathways, altering the perception of and response to pain by binding to opiate receptors in the CNS. It also produces generalised CNS depression.
Contraindications: May impair ability to drive or operate machinery. Emotionally unstable patients or patients with history of opiate abuse; closely monitor these
patients during long-term therapy. Impaired respiration due to other drugs, uraemia, bronchial asthma, severe infection, cyanosis, respiratory obstruction. MI
patients who exhibit nausea and vomiting and in those about to undergo biliary tract surgery. Head injury, intracranial lesions or pre-existing increased intracranial
pressure. Renal or hepatic impairment. Elderly and debilitated patients. Pregnancy and lactation.
Side Effects: Sedation, dizziness, vertigo, miosis, headache; nausea, vomiting, dry mouth; itching, burning, urticaria. Respiratory depression, dyspnoea, asthma;
speech difficulty, urinary urgency, blurred vision, flushing, warmth; clamminess.
Interactions: Additive CNS depressant effects may occur with other CNS depressants e.g. alcohol, anaesthetics, anxiolytics, hypnotics, TCAs and antipsychotics
Nursing Implications: Assess pain characteristics. Assess for signs of dizziness, headache, nausea and vomiting.
Indications: For the relief of the signs and symptoms of osteoarthritis and rheumatoid arthritis in adults. Management of acute pain in adults especially in
postoperative pain. Reduce the number of adenomatous colorectal polyps in familial adenomatous polyposis (FAP), as an adjunct to usual care (eg, endoscopic
surveillance surgery). Treatment of dysmenorrhea.
Mode of Action: Celecoxib is a nonsteroidal anti-inflammatory drug (NSAID) that exhibits anti-inflammatory, analgesic and antipyretic activities. The mechanism
of action of celecoxib is believed to be due to inhibition of prostaglandin synthesis, primarily via inhibition of cyclooxygenase-2 (COX-2), and at therapeutic
concentrations in humans, celecoxib does not inhibit the cyclooxygenase-1 (COX-1) isoenzyme.
Contraindications: Patients with known hypersensitivity to celecoxib and those who have demonstrated allergic-type reactions to sulfonamide. Patients who have
experienced asthma, urticaria, or allergic-type reactions after taking acetyl salicylic acid (ASA) or other NSAIDs including other COX-2 specific inhibitors. Severe,
rarely fatal, anaphylactic-like reactions to NSAIDs have been reported in such patients. Patients with renal impairment associated with creatinine clearance of <30
mL/min. Patients with severe hepatic impairment (Child-Pugh Class C), heart failure and inflammatory bowel disease. Patients who have previously had a
myocardial infarction (MI) or stroke and in the peri-operative period undergoing cardiac or major vascular surgery.
Interactions: Celecoxib metabolism is predominantly mediated via cytochrome P-450 2C9 in the liver . Co-administration of celecoxib with drugs that are known
to inhibit 2C9 should be done with caution. Patients who are known or suspected to be P-450 2C9 poor metabolizers based on a previous history should be
administered celecoxib with caution as they may have abnormally high plasma levels due to reduced metabolic clearance.
Nursing Implications: Assess patient’s pain, signs of dizziness, nervousness and GI disturbances. Medicine should be taken after meals.
Generic Name: Pregabalin
Mode of Action: Alpha2-delta ligand modulator (Anti-neuropathic pain/Anticonvulsant/Antiepileptics). In vitro studies show that pregabalin binds to an auxiliary
subunit (α2-δ protein) of voltage-gated calcium channels in the central nervous system, potently displacing [3H]-gabapentin. Two lines of evidence indicate that
binding pregabalin to the α2-δ site is required for analgesic and anticonvulsant activity in animal models: (1) Studies with the inactive R-enantiomer and other
structural derivatives of pregabalin and (2) Studies of pregabalin in mutant mice with defective drug binding to the α2-δ protein. In addition, pregabalin reduces the
release of several neurotransmitters, including glutamate, noradrenaline and substance P. The significance of these effects for the clinical pharmacology of
pregabalin is not known.
Side Effects: Increased appetite, Dizziness, somnolence, vertigo, Blurred vision, diplopia, Dry mouth, constipation, vomiting, flatulence
Interactions: Since pregabalin is predominantly excreted unchanged in the urine, undergoes negligible metabolism in humans (<2% of a dose recovered in urine as
metabolites), does not inhibit drug metabolism in vitro, and is not bound to plasma proteins, pregabalin is unlikely to produce, or be subject to, pharmacokinetic
interactions.
Accordingly in in vivo studies no clinically relevant pharmacokinetic interactions were observed between pregabalin and phenytoin, carbamazepine, valproic acid,
lamotrigine, gabapentin, lorazepam, oxycodone or ethanol. In addition, population pharmacokinetic analysis indicated that the commonly used drug classes, oral
antidiabetics, diuretics and insulin, and the commonly used antiepileptic drugs, phenytoin, carbamazepine, valproic acid, lamotrigine, phenobarbital, tiagabine and
topiramate, had no clinically significant effect on pregabalin clearance. Similarly, these analysis indicated that pregabalin had no clinically significant effect on
Nursing Implications: Assess patients general status. Caution the patient on the possible side effects of the drug. Monitor for signs of psychological hypofunction
during treatment.
Generic Name: Clopidogrel
Indications: Prevention of atherothrombotic events in: Patients suffering from myocardial infarction (from a few days until <35 days), ischemic stroke (from 7 days
until <6 months) or established peripheral arterial disease. Patients suffering from acute coronary Non-ST segment elevation acute coronary syndrome (unstable
angina or non-Q-wave myocardial infarction) including patients undergoing a stent placement following percutaneous coronary intervention, in combination with
ASA; ST segment elevation acute myocardial infarction, in combination with ASA in medically treated patients eligible for thrombolytic therapy. (See
Pharmacology under Actions.)
Mode of Action: Platelet aggregation inhibitors excluding heparin. ATC Code: BO1AC/04. Pharmacodynamics: Clopidogrel selectively inhibits the binding of
adenosine diphosphate (ADP) to its platelet receptor, and the subsequent ADP-mediated activation of the GPIIb/IIIa complex, thereby inhibiting platelet
aggregation. Biotransformation of clopidogrel is necessary to produce inhibition of platelet aggregation. Clopidogrel also inhibits platelet aggregation induced by
other agonists by blocking the amplification of platelet activation by released ADP. Clopidogrel acts by irreversibly modifying the platelet ADP receptor.
Consequently, platelets exposed to clopidogrel are affected for the remainder of their lifespan and recovery of normal platelet function occurs at a rate consistent
with platelet turnover
Contraindications: Hypersensitivity to clopidogrel or any component of Plavix. Severe liver impairment. Active pathological bleeding eg, peptic ulcer or
intracranial hemorrhage.
Interactions: Warfarin: The concomitant administration of clopidogrel with warfarin is not recommended since it may increase the intensity of bleedings.
Glycoprotein IIb/IIIa Inhibitors: Clopidogrel should be used with caution in patients who may be at risk of increased bleeding from trauma, surgery or other
pathological conditions that receive concomitant glycoprotein IIb/IIIa inhibitors
Nursing Implications: Assess for signs of GI bleeding. Assess for abdominal distention. Assess vital signs especially the cardiac rate.
V. Physical Examination
a. Health-Perception-Health-Management Pattern
Whenever the patient or anyone in the family gets sick, home management is done initially. In the case of fever, self-medication of Paracetamol is done to
decrease body temperature. Whenever the patient experiences sore throat, gargling with bactidol, orahex or warm water with salt is done.
If in case the condition is not relieved by home management, the patient seeks for medical assistance. The patient doesn’t take in antibiotics or any other
drug that has not been prescribed by the physician; except for Paracetamol.
The patient has regular goes for regular monthly check ups to his private doctor for the management of his DM. He complies strictly with his therapeutic
regimen and takes all drugs prescribed by the doctor.
At present, he is at risk of infection related to traumatized tissue secondary to the CTT insertion and the VATS he underwent on September 4.
Patient is awake, conscious and oriented to time, place and persons. There are no tremors, nystagmus or ataxia observed.
Patient’s pupillary size and reaction to light are normal on both eyes. Hearing is slightly impaired on his left ear but he does not use a hearing aid. There are
no discharges from the ears. There is no nasal congestion and the patient has a patent airway. His taste sensation is normal but tongue movement is slightly altered
due to the mild stroke he experienced in 2006. There are no masses on his neck and no palpable lymph nodes. Chest expansion is symmetrical with no adventitious
lung sounds but with decreased breath sounds on the right lung.
He has a cardiac rate of 80 bpm and has been diagnosed to have adynamic pericardium. There is no tenderness noted on his abdominal area. He has no
edematous extremities and skeletal deformities and has good capillary refill of 2 seconds. He does not feel any numbness or tingling sensation at present.
He has a positive perception of his health and believes that his condition will go back to normal after hospitalization.
b. Nutritional-Metabolic Pattern
Patient eats a balanced diet. His preference is fish with a few vegetables and avoids meat. He loves condiments especially bagoong but has avoided such
since he has suffered mild stroke in 2006. At home, common dishes include ginataang kalabasa, labong and pinakbet. His average water intake at home ranges
from 6-8 glasses a day. He drinks milk, coffee and coke zero occasionally.
At the hospital, the patient has an input of approximately 420 cc during the 7-3 shift.
Since patient has experienced flank pain 1 week prior to admission, eating pattern has been affected because of the pain he feels when assuming a sitting
position during meals. He has refrained from taking in rice and viand and preferred eating bread with ham and egg; that he can eat even on a supine position.
At the hospital, he was given a diabetic diet with low cholesterol and low saturated fat. He has no known allergies to food and drugs and was able to return to
his usual eating pattern at the hospital. He was initially on NPO before the VATS has been performed but was informed that he can resume his usual and regular diet
after the surgery as long as tolerated.
c. Elimination Pattern
Patient has normal bowel sounds with no abdominal tenderness. He has undergone hemorrhoidectomy in 2004 and does not experience any difficulty in
voiding and defecating at home or at the hospital. He voids approximately 6 times per day with yellow to dark yellow urine. His usual bowel movement is once a
day with semi-solid to hard stools of usually brown color. He did not pass stools during the 7-3 shift and urinated 1 during the shift. He has a CTT tube placed on
the right chest draining a dark red discharge. His total output is approximately 455 cc with 315 cc from bladder and 140 cc from the pleural fluid.
d. Activity-Exercise Pattern
His usual activities at home include reading the newspaper, watching TV and sweeping the backyard occasionally. He does not perform gross mechanical
activities at home and was placed on CBR without BRPs since admission in this institution. He does not climb the stairs going to the second floor of their house but
believes that he can do so. He does not perform any physical exercise at home and has a sedentary lifestyle in general.
He has been a smoker since 15 years old consuming 5 packs per day. He also used to be a chronic alcohol beverage drinker but has stopped smoking and
drinking 9 years ago.
Since he has felt right flank pain a week before admission, he has preferred lateral decubitus postion and has experienced difficulty in changing bed position
and standing on his own. His condition persisted even during the first days of his stay at the hospital.
He has experienced DOB with associated cough and chest pains 2 weeks PTA but has normal diaphragmatic breathing at present. He has an RR of 20 cycles
per minute a day before the surgery and 16 cycles per minute when he was brought back to the surgical ward after the VATS.
He has limited ROM with stooping noted when walking. He is able to perform ADLs without assistance and no longer experiences any difficulty in changing
bed positions and is able to tolerate standing, sitting and supine positions.
He is also able to perform DBE on his own to relieve pain and facilitate breathing.
e. Sleep-Rest Pattern
Patient sleeps approximately 6-8 hours at night and takes a nap for about 2 hours in the afternoon. He is able to go back to sleep immediately whenever he
wakes up to void at night. He did not experience any sleeping problems before he complained for flank pain.
At the hospital, he experienced sleep disturbances due to the pain he feels secondary to the insertion of the CTT. Since he was given Arcoxia, he has
resumed his usual sleep pattern.
Some of his relaxation techniques at home include watching TV and reading newspapers.
f. Cognitive-Perceptual Pattern
He is oriented to time, place and persons. He is alert but irritable at times due to the pain that he feels at the site of the CTT insertion. The pain was rated as
5/10, characterized as pricking and non-radiating. It is felt whenever he wakes up in the morning and whenever he changes bed positions. Pain has however been
relieved when Arcoxia has been administered.
He is coherent and knowledgeable about his condition and is able to comprehend and understand the treatment and invasive diagnostic procedures that he
needs to undergo.
After the surgery, patient rated post-operative pain as 7/10, characterized as pricking, radiating to the entire right chest up to the right hypochondriac region,
exacerbated when changing bed positions and performing gross movements. Facial grimacing and guarding behaviors have been observed. No diaphoresis has been
observed. Patient has narrowed focus accompanied with reduced interaction with people and is not conversant. Verbal messages are very minimal.
There are no signs of confusion, disorientation or disturbed thought processes.
g. Self-Perception-Self-Concept Pattern
Patient is a retired military officer and projects a good self image. He is however, irritable at times. He feels a sense of superiority over the others including
his wife and HWs. He voice becomes louder whenever he insists on a point which he believes is right.
He denies any anxiety in relation to the upcoming invasive procedures to be done to him. He does not experience any body image disturbance or sense of
powerlessness even after his stroke.
h. Role-Relationship Pattern
Patient is irritable at times and his interaction with others including his wife and HW is affected. Because of the sense of superiority that he feels for himself,
his wife is very submissive to his opinions and ideals. Despite this, his marital relationship with his wife is still intact. He manifests obstinacy towards health care
providers as manifested by his attempts to remove the oxygen mask placed on him after the VAST.
Their family is intact. His 3 children, James 30 y/o, Angelo 29 y/o and Augusto 27 y/o, are currently living with them; and their youngest, Teresa 17 y/o
stays in Manila for her College education.
He denies any impact of the change of his health condition to his role and relationship pattern. The wife verbalized that he has no social activities and does
not go to church. His verbal communication is affected by his altered speech pattern caused by his stroke. Despite this, he is still able to communicate his feelings
and concerns in a manner that can be understood by others.
i. Sexuality-Reproductive
He has no history of prostate problems but does not undergo regular prostate exams. He has no history of penile bleeding or any other sexual problems or
STDs of any kind.
The patient has 4 children and has intact marital status with his wife, Elizabeth Tan. He has no alterations in terms of desired sex role and there are no
conflicts with regards to his sexual orientation and variant preferences. There are no concerns, conflicts and problems with regards to the patient’s sexuality. He is
masculine in appearance, grooming and action.
j. Coping-Stress-Tolerance Pattern
Patient copes well to his condition primarily due to the effectiveness of his support systems and his positive outlook and viewpoint of his present condition.
He is not anxious about the invasive procedures to be done to him.
Whenever their family is faced with problems requiring major decisions, he acts as the head of the family and the primary decision maker.
He is brave and outgoing. He does not experience any fear, anxiety, hopelessness, powerlessness, sadness or depression is relation to this hospitalization.
k. Value-Belief Pattern
The patient is a Roman Catholic but does not go to church. He believes in the existence of supernatural beings but does not believe that these can affect his
health. He does not believe is usog, barang, kulam etc. He does not consider going to an albularyo as a substitute for medical assistance. He believes that the health
team is the only reliable source of treatment. He believes that all diseases are results of pathogenic invasion or part of the degenerative/aging process that everyone
undergoes in life.
He does not believe that being a smoker since he was 15 years old has any relation to his current respiratory problems.
o Impaired Gas Exchange r/t accumulation of fluids at the pleural cavity secondary to pleural effusion
-This is an overt problem and is of primary importance in accordance to the concept of ABC( Airway, Breathing, Circulation). In the case of our
patient, he experienced DOB 2 weeks PTA. One week PTA, he felt flank pain which is associated to accumulation of fluids in the pleural cavity therefore
interefering lung expansion resulting in decreased oxygen inhalation. If the patient's airway is blocked, breathing will not be possible, and oxygen cannot
reach the lungs and be transported around the body in the blood, which will result in hypoxia and cardiac arrest
o Impaired tissue integrity r/t tissue trauma secondary to VATS and CTT insertion
- This is an overt problem and is of tertiary importance since the break in the skin caused by the procedures done to the patient may result to complications
such as infection.
o Risk for imbalanced fluid volume r/t accumulation of secretions secondary to pleural effusion
- The client’s problem with regards to the accumulation of fluid has already been addressed by the insertion of the CTT. This problem is of least importance
since it may only take place if management has not been effective in reducing/draining accumulated fluid. This however is least likely to take place since the
client has significant volumes of CTT drains.
NCP PROPER
P > Impaired gas exchange related to accumulation of fluids at the pleural cavity secondary to pleural effusion
S > ”Nahihirapan akong huminga lalo na kapag nakahiga ako ng diretso. Dapat nakatagilid ako parati.” as verbalized by the patient.
“May ubo pa rin siya pero wala naming plema” as verbalized by the wife
Difficulty in breathing
Irritable at times
With intact and patent CTT draining dark-red discharges to a one-way bottle
Restlessness noted
Goal: After 3 days of nursing interventions, the patient will have an adequate oxygenation and absence of respiratory distress
STO: After a day of nursing interventions, the patient will be able to:
a. Verbalizes information about smoking correctly, risks of continuing, benefits of quitting, techniques to optimize cessation efforts
Edx:
Explain the need to To decrease oxygen Goal not met if no
restrict and pace consumption improvement or
activities willingness occurred.
Teach the patient To facilitate adequate air His condition will stay
appropriate breathing exchange and secretion the same. He will do
techniques clearance pursed lip and
diaphragmatic breathing
Limit visitors as Reduces likelihood of incorrectly or will
indicated exposure to other infectious totally not adopt the
pathogens exercise taught. He will
not participate from any
nursing intervention
Educate regarding Smoking causes permanent done.
hazards of smoking damage to the lung and
diminishes the lungs’
protective mechanisms
O:
pain rated as 7/10 (1 as the lowest and 10 as the highest), characterized as pricking, radiating to the entire right chest up to the right hypochondriac region
pain is exacerbated when changing bed positions and performing gross movements
no diaphoresis noted
elevated BP of 160/80 mmHg and normal T=35.8 degrees Celsius, PR=80 bpm and RR=16 cycles per minute
facial grimacing noted
guarding behavior observed
no teeth clenching noted
narrowed focus accompanied with reduced interaction with people
not conversant
LTO: After 3 days of nursing interventions, the client will report a significant decrease (2 pts or more) in the severity of pain.
Incision during the CTT insertion creates a break in the skin tissue of the chest wall. This tissue trauma is sensed by the neurons which transmits pain
signals passing through the spinal cord to the brain. Injury activates two kinds of nociceptors namely the A-delta fibers and the C-fibers. The A-delta fibers are
responsible for immediate yet short-lived pain perceived as pricking at the site of injury. On the other hand, the C-fibers are activated after the A-delta fibers which
transmits a vague, throbbing and persistent pain. This is the pain that is continuously perceived by the patient. Neurons transmit the impulses to the brain and the
brain in response, generates a feedback to the site of injury. The feedback consists of reflexive involuntary muscle contractions perceived as pain. Other feedbacks
may also manifest in the form of increased temperature and diaphoresis.
*Dx > Monitor v/s and note for * Increase in temperature may
changes indicate progress of infection. Goal fully met if the client
Monitoring vital signs and reports a significant decrease in
noting for changes serves as the severity of pain. He is able
baseline data for evaluating to report a noticeable decrease
effectiveness of interventions. in the severity of pain. He will
Any abnormal changes implies take all the drugs prescribed by
abnormality and problem.
When client perceives pain, this the physician. He is able to
may serve as a sympathetic perform DBE correctly without
stimulus that may increase the assistance. He obtains adequate
body’s vital functions such as rest and sleep. If the client rates
an increase in PR and RR. the pain as 5 or less
*Ed
>Encourage divertional *Helps the patient divert his
activities attention thus reduce tension Goal not met if no decrease
and relaxation promotion in the severity of pain is
reported. If the client
refuses to take all the
> Encourage verbalization * Verbalization of feelings will drugs prescribed by the
physician. If the client
of feelings about pain help validates the objective
refuses to perform DBE
data gathered and to know the with/without the nurse’s
proper intervention to address assistance. If the client is
the problem not able to rest at all. If the
client still rates the pain as
7 out of 10
> Encourage the client to take * Rest allows the body time to
adequate rest period heal itself and prevent the
increase in the severity of the
condition