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Pamantasan ng Lungsod Pasig COLLEGE OF NURSING

Case Study on

Obstructive Jaundice secondary to Cholelithiasis

Submitted By Princess Celmea S. Aspuria Group A BSN III-Nightingale

Submitted To Mr. David Allan Alcantara, RN

August 2011

Chapter I

INTRODUCTION
Obstructive jaundice is caused by a blockage of the bile ducts, which prevents the bile from flowing out of the liver. Obstructive jaundice can also occur if the bile ducts are missing or have been destroyed. As a result, bile cannot pass out of the liver, and bilirubin is forced back into the blood. The manifesting features and clinical signs and symptoms of obstructive jaundice are: yellow discoloration of the skin and the mucous membranes; stools are pasty and whitish; urine becomes dark yellow-brown; nausea; vomiting; pruritus or itching of the skin; fever; pain in the abdomen; loss of appetite; fatigue; confusion; headache. Obstructive jaundice frequently requires a surgical cure. If the original passageways cannot be restored, surgeons have several ways to create alternate routes. A popular technique is to sew an open piece of intestine over a bare patch of liver. Tiny bile ducts in that part of the liver will begin to discharge their bile into the intestine, and pressure from the obstructed ducts elsewhere will find release in that direction. As the flow increases, the ducts grow to accommodate it. Soon all the bile is redirected through the open pathways. Approximately 10 to 15 percent of the people with gallstones have them in the common bile duct. More elderly people have gallstones in the common bile duct, for it is estimated that 25 percent of them have stones in this duct. Most gallstones are formed within the gallbladder, but many leave the gallbladder and migrate to the common bile duct. From there, the stones may continue on to the small intestines or stay in the common bile duct and obstruct the bile flow

Chapter II

PURPOSE AND OBJECTIVE OF THE STUDY


General Objective This study focuses on obstructive jaundice, the causative factors of obstructive jaundice and its diseases process, as well as the different medical and nursing management for obstructive jaundice. Specific Objectives Identify factors that caused obstructive jaundice Discuss the disease process of obstructive jaundice and the roots of the signs and symptoms of the disease Discuss briefly the patients health history and identify what caused the disease Discuss the anatomy and physiology of the gallbladder and liver, as well as related organs to the disease Discuss the medical and surgical management for obstructive jaundice Provide a theoretical framework for the study Provide a nursing care plan for the prioritized patient problem/diagnosis

Chapter III

SIGNIFICANCE OF THE STUDY


To the client and family or significant others This study will inform the client as well as his family about his current condition, the causes of his disease and how they could manage his condition. To the health care providers and the nursing practice and nursing education This study will help expound case studies on obstructive jaundice secondary to Cholelithiasis. To the future researchers This study would serve as a reference on the case study of obstructive jaundice secondary to Cholelithiasis.

Chapter IV

PATIENTS PROFILE
Biographic Data
Name: Patient X Address: Pinagbuhatan, Pasig City Age: 45 years old Gender: Male Marital Status: Single Occupation: City Government Employee, BCEO Religious Orientation: Roman Catholic Health Care Financing and Usual Source of Medical Care: Philhealth Chief Complaint: Abdominal pain accompanied by cough, after a day, the abdominal pain started radiating towards the back. The patient went to the emergency room and was given antacids by Dr. Uclaray. After 3 days the started having dyspnea, he went back to the emergency room and was then admitted to the Male Surgery Ward

Nursing Health History


A. History of Present Illness Symptoms started one (1) year ago Problem occurred when patient started to drink alcohol often (about at least thrice a week) Patient sought consultation at the hospitals emergency room Doctor gave pain relievers and buscopan

The problem made a huge impact on the patients life. He has to stop from work.

A. Past History Patient had a history of measles during childhood Patient had completed childhood immunizations from the local health center No known allergies No past accidents or injuries Chronic health condition: anemic A. Family History of Illness No family member had an illness similar to the patient Patients mother is also anemic Siblings, and patients father are hypertensive Pain Assessment Patient experienced pain/discomfort for 1 year Patient rated pain with a scale of 10/10 Pain was described as stabbing, radiating from abdominal area towards the back Pain is felt with ascending intensity Patient could not identify what alleviates or aggravates the pain Patient managed pain by seeking help to the emergency room

Gordons Functional Health Pattern


A. Health Perception and Health Management Pattern Patient had been living having vices Patient seldom had coughs and colds in the past Patient takes vitamins to keep self healthy Substance abuse of tobacco and alcohol: Started at age 25 and consumes 2 packs of cigarettes a day and takes alcohol for about once to thrice a week Patient finds difficulty in following what doctors/nurses suggest in the past Patient perceives that alcoholic drinks and eating much fatty foods caused the disease B. Nutrition and Metabolic Pattern Patient eats five (5) times a day, usually rice

Patient drinks water of approximately two (2) liters per day Patient had a weight loss from 85 kilos to 61 kilos upon admission No change in appetite noted Patient is prescribed with soft diet

C. Elimination Pattern Patients bowel was described as yellowish then turned to gray, with acid-like bubbles; patient defecates every day Urine was described as amber-colored to reddish with a frequency of six (6) times a day, usually at night Excessive perspiration noted D. Activity-Exercise Pattern Patient stated sufficient energy for completing required activities prior admission Patient considers his work as his daily exercise E. Sleep-Rest Pattern Patient sleeps at approximately 6 hours per night Patient experiences dyspnea when sleeping Sleep is intermittent and the client feels tired after waking up Patient take naps during noon time Patient relaxes himself by watching TV, having a conversation with others, smoking, and drinking alcohol F. Cognitive Perceptual Pattern Patient had no previous eye checkups; Patient states he is farsighted Patient verbalizes observation of memory loss Patient had no difficulty on learning G. Self-Perception and Self-Concept Pattern Patients states that he feels good about himself and someone who will start a new lifestyle upon discharge Patient observes weight loss Waiting makes the patient angry Anxiety and depression, caused by the presence of Jackson Pratt and T-Tube to be placed for six weeks H. Role-Relationship Pattern Patient lives with mother, significant other, children, and helper Family is having financial problems

Patient and significant other are both working for the family The family talks things over in handling problems Mother is the patients support system in times of stress The clients illness have caused depression to the family Patient belongs to social groups and has close friends Things go well with the patient at work, however, income is not sufficient for needs Patient is in good terms with his neighbors Neighborhood and community services are available in meeting the clients needs

I. Sexuality-Reproductive Pattern No known changes or problems in sexual relations since illness started Significant other uses contraceptives J. Coping-Stress Tolerance Pattern When the patient is tense, he sometimes drinks alcohol to help him sleep Major stressors are when the patient is handling students at work Mother is most helpful in talking things over No known big changes for the past two years, just the current illness of the patient K. Value-Belief Pattern Religion is important in the patients life Praying helps the patient when difficulties arise Being in the hospital does not interfere with the patients religious practices

Physical Assessment
A. Vital Signs and Anthropometric Measurements Temperature: 36C axilla Pulse Rate: 84 beats per minute regular Respiratory Rate: 20 cycles per minute regular BP: 140/100mmHg lying

B. General Survey Patient is conscious and coherent. Oriented with no signs of distress. Patients body development is mesomorphic, well developed and looks according to age. Patient is well nourished. In a calm emotional state

C. Skin Skin shows jaundice, smooth texture with good skin turgor. Skin is cool to touch and wet/clammy. Presence of T-tube and JP drain are present in the right upper quadrant part of the abdomen D. Head Normocephalic configuration. Fontanelles closed. Fine and evenly distributed hair. Clean scalp E. Eyes Eyelids symmetrical. Pale conjunctiva. Icteric sclera. Smooth cornea and lens. Equal pupil size. Fixed reaction to light on both eyes. Uniform constriction and uniform convergence. Patient is farsighted F. Ears Normoset ears. Symmetrical gross hearing G. Nose Symmetrical nasolabial fold. Midline septum. Pale mucosa and negative discharge. Symmetrical gross smelling. Non-tender sinuses H. Mouth Negative deviation on lips. Tongue midline with white spots present. Patient is using dentures. Pale gums and mucosa. Negative lesions. Speech is intact I. Pharynx Uvula midline. Pinkish mucosa. Tonsils not inflamed J. Neck Midline trachea. Nonpalpable cervical lymph nodes and thyroids. Normal ROM K. Chest and Lungs Eupneic breathing. Patient is barrel chested with APL ratio of 1:1. Chest expansion and tactile fremitus symmetrical. L. Heart Point of maximal impulse found at 5th intercostals space, left midclavicular line. Faint heart sounds

M. Breast and Axilla Symmetrical. Non-tender N. Abdomen Presence of T-tube and Jackson-Pratt drainage at right upper quadrant. Sunken umbilicus. Globular configuration. Normoactive bowel sounds (14 per minute). Negative bruit O. Genito-Urinary System Refused P. Back and Extremities Regular peripheral pulses. Pale nail beds. Full ROM of joints. Equal size and normal tone of muscles. Spine midline. Negative costovertebral angle tenderness

Chapter V

ANATOMY AND PHYSIOLOGY


The hepatobiliary system refers to the liver, gall bladder and bile ducts organs that are involved with the production, storage, transport and release of bile, a secretion that prepared fats for further digestion.

Liver The liver is the largest glandular organ of the body. It weighs about 3 lb (1.36 kg). It is reddish brown in color and is divided into four lobes of unequal size and shape. The liver lies on the right side of the abdominal cavity beneath the diaphragm. Blood is carried to the liver via two large vessels called the hepatic artery and the portal vein. The hepatic artery carries oxygen-rich blood from the aorta (a major vessel in the heart). The portal vein carries blood containing digested food from the small intestine. These blood vessels subdivide in the liver repeatedly, terminating in very small capillaries. Each capillary leads to a lobule. Liver tissue is composed of thousands of lobules, and each lobule is made up of hepatic cells, the basic metabolic cells of the liver. Gallbladder The gallbladder is a small pear-shaped organ that stores and concentrates bile. The gallbladder is connected to the liver by the hepatic duct. It is approximately 3 to 4 inches (7.6 to 10.2 cm) long and about 1 inch (2.5 cm) wide.

The function of the gallbladder is to store bile and concentrate. Bile is a digestive liquid continually secreted by the liver. The bile emulsifies fats and neutralizes acids in partly digested food. A muscular valve in the common bile duct opens, and the bile flows from the gallbladder into the cystic duct, along the common bile duct, and into the duodenum (part of the small intestine). Bile Ducts The common bile duct (ductus choledochus) is a tube-like anatomic structure in the human gastrointestinal tract. It is formed by the union of the common hepatic duct and the cystic duct (from the gall bladder). It is later joined by the pancreatic duct to form the ampulla of Vater. There, the two ducts are surrounded by the muscular sphincter of Oddi. When the sphincter of Oddi is closed, newly synthesized bile from the liver is forced into storage in the gall bladder. When open, the stored and concentrated bile exits into the duodenum. This conduction of bile is the main function of the common bile duct. The hormone cholecystokinin, when stimulated by a fatty meal, promotes bile secretion by increased production of hepatic bile, contraction of the gall bladder, and relaxation of the Sphincter of Oddi. Several problems can arise within the common bile duct. If clogged by a gallstone, a condition called choledocholithiasis can result. In this clogged state, the duct is especially vulnerable to an infection called ascending cholangitis. Very rare deformities of the common bile duct are cystic dilations (4 cm), choledochoceles (cystic dilation of the ampulla of Vater (38 cm)), and biliary atresia. Bile Production Bile is produced by hepatocytes, draining through the many bile ducts that penetrate the liver. During this process, the epithelial cells add a watery solution that is rich in bicarbonates that dilutes and increases alkalinity of the solution. Bile then flows into the common hepatic duct, which joins with the cystic duct from the gallbladder to form the common bile duct. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. If the sphincter of Oddi is closed, bile is prevented from draining into the intestine and instead flows into the gallbladder, where it is stored and concentrated to up to five times its original potency between meals. This concentration occurs through the absorption of water and small electrolytes, while retaining all the original organic molecules. Cholesterol is also released with the bile, dissolved in the acids and fats found in the concentrated solution. When food is released by the stomach into the duodenum in

the form of chyme, the duodenum releases cholecystokinin, which causes the gallbladder to release the concentrated bile to complete digestion. The human liver can produce close to one liter of bile per day (depending on body size). About 95% of the salts secreted in bile are reabsorbed in the terminal ileum and re-used. Blood from the ileum flows directly to the hepatic portal vein and returns to the liver where the hepatocytes reabsorb the salts and return them to the bile ducts to be re-used, sometimes two to three times with each meal. Pancreas The pancreas lies beneath the stomach and is connected to the small intestine at the duodenum. The pancreas contains enzyme producing cells that secrete two hormones. The two hormones are insulin and glucagon. Insulin and glucagon are secreted directly into the bloodstream, and together, they regulate the level of glucose in the blood. The pancreas produces the body's most important enzymes. The enzymes are designed to digest foods and break down starches. The pancreas also helps neutralize chyme and helps break down proteins, fats and starch. Chyme is a thick semi fluid mass of partly digested food that is passed from the stomach to the duodenum. If the pancreas is not working properly to neutralize chyme and break down proteins, fats and starch, starvation may occur.

Chapter VI

PATHOPHYSIOLOGY

Chapter VII

LABORATORIES AND DIAGNOSTIC TEST

Chest X-Ray (Radiography) The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging. The chest x-ray is performed to evaluate the lungs, heart and chest wall. A chest x-ray is typically the first imaging test used to help diagnose symptoms such as: shortness of breath; a bad or persistent cough; chest pain or injury; fever.

X-RAY RESULTS Chest: Chest PA/AP (Adult) Both lung fields are clear Heart and great vessels are normal size and configuration Other chest structures are unremarkable IMPRESSION: NORMAL CHEST ABDOMEN: Examination show no abnormal finding in the visceral and retroperitoneal soft tissues and bony thorax No abnormal mass nor calcification seen Intestinal gas pattern are within normal No other significant finding IMPRESSION: NORMAL ABDOMEN

Ultrasound Ultrasound uses high-frequency sound waves to look at organs and structures inside the body. Health care professionals use them to view the heart, blood vessels, kidneys, liver and other organs. During pregnancy, doctors use ultrasound tests to examine the fetus. Unlike x-rays, ultrasound does not involve exposure to radiation.

ULTRASOUND RESULTS Ultrasound Proc: HBT/Pancreas The liver is normal in size with increase parenchymal echogenicity. No discrete mass or abnormal calcification. The portal vein and its tributaries are unremarkable The gallbladder is normal in size and echo. A strong echo with distal acoustic shadowing is noted with the gallbladder. It measured 1.34 x 1.14 x 0.89 cm. The wall is of normal thickness. The common bile duct and biliary passages are of normal character with anechoic lumen. The pancreas is of normal size and echo. No discrete mass or calcification is noted. Peripancreatic are unremarkable. IMPRESSION: FATTY LIVER, CHOLECYCTOLITHIASIS, NORMAL PANCREAS Hemoglobin and Hematocrit Hematocrit and hemoglobin measurements are blood tests. They are part of a complete blood count, or CBC. SECTION OF HEMATOLOGY August 10, 2010 Result 131.0 0.42 Normal Value 135.00-180.00 g/L 0.40 0.54 g/L

Hemoglobin: Hematocrit

SECTION OF HEMATOLOGY August 13, 2010 Result 98.0 0.30 Normal Value 135.00-180.00 g/L 0.40 0.54 g/L

Hemoglobin: Hematocrit

Blood Typing SECTION OF HEMATOLOGY ABO Typing: O Rh Typing: Positive

Urea, Sodium, Potassium, AST, ALT, ALK AST (Serum Glutamic-Oxalocetic Transaminase - SGOT) - found primarily in the liver, heart, kidney, pancreas, and muscles. Seen in tissue damage, especially heart and liver. ALT (Serum Glutamic-Pyruvic Transaminase - SGPT) - Decreased SGPT in combination with increased cholesterol levels is seen in cases of a congested liver. We also see increased levels in mononucleosis, alcoholism, liver damage, kidney infection, chemical pollutants or myocardial infarction ALKALINE PHOSPHATASE - Used extensively as a tumor marker it is also present in bone injury, pregnancy, or skeletal growth (elevated readings. Low levels are sometimes found in hypoadrenia, protein deficiency, malnutrition and a number of vitamin deficiencies

Urea Sodium Potassium AST ALT ALK

LO LO LO HI HI HI

Chapter VIII

THEORETICAL FRAMEWORK
Dorothea Orems Self Care Deficit Theory is most applicable for the patient which is on his post operative state due to obstructive jaundice. The patient is unable to move independently due to the presence of t-tube and Jackson-Pratt drainage attached to his abdomen. The self care deficit theory proposed by Orem is a combination of three theories, i.e. theory of self care, theory of self care deficit and the theory of nursing systems. In the theory of self care, she explains self care as the activities carried out by the individual to maintain their own health. The self care agency is the acquired ability to perform the self care and this will be affected by the basic conditioning factors such as age, gender, health care system, family system etc. Therapeutic self-care demand is the totality of the self care measures required. The self care is carried out to fulfill the self-care requisites. There are mainly 3 types of self care requisites such as universal, developmental and health deviation self care requisites. Whenever there is an inadequacy of any of these self care requisite, the person will be in need of self care or will have a deficit in self care. The deficit is identified by the nurse through the thorough assessment of the patient. Once the need is identified, the nurse has to select required nursing systems to provide care: wholly compensatory, partly compensatory or supportive and educative system. The care will be provided according to the degree of deficit the patient is presenting with. Once the care is provided, the nursing activities and the use of the nursing systems are to be evaluated to get an idea about whether the mutually planned goals are met or not. Thus the theory could be successfully applied into the nursing practice.

Chapter IX

MEDICAL-SURGICAL MANAGEMENT
Surgery
Open Cholecystectomy This operation has been employed for over 100 years and is a safe and effective method for treating symptomatic gallstones, ones that are causing significant symptoms. At surgery, direct visualization and palpation of the gallbladder, bile duct, cystic duct, and blood vessels allow safe and accurate dissection and removal of the gallbladder. Intra-operative cholangiographyhas been variably used as an adjunct to this operation. The rate of common bile duct exploration for choledocholithiasis (gallstones in the bile duct) varies from 3% in series of patients having elective operations to 21% in series that include all patients. Major complications of open cholecystectomy are infrequent and include common duct injury, bleeding, biloma, and infections. Open cholecystectomy is the standard against which other treatments must be compared and remains a safe surgical alternative. T-Tube Insertion During liver-transplant surgery, the surgeon may find it necessary to place a small tube, called a T-tube, into the bile duct. The T-tube allows bile to drain out of the patient's body into a small pouch, known as a bile bag. The amount of bile, which varies in color from deep gold to dark green, can then be measured. If a Ttube is put in place, it may remain attached to a bile bag for a week or possibly longer. When the bile bag is removed the T-tube will be tied or capped. It will remain in place for several months so that it can be used for special testing. The T-tube is attached to the skin with a stitch. The dressing around the tube should be changed at least once daily, and more often if it becomes moist. The transplant nurse will show the patient how to change the dressing without pulling out the T-tube. Other drains may be in the patient's abdomen during the postoperative period. A common name for these drains is Jackson-Pratt (JP). They are used to drain fluid from around the liver. Generally, these drains are removed before the patient goes home.

Drug Study
Drug Classificat ion/ Indication
Antacids, Antireflux Agents & Antiulcerant s/

Dose, Route & Frequen cy


50mg OD while on NPO then discontinu e once on DAT

Mechanism of Action

Contrain dication

Side Effects/ Adverse Effects


Diarrhea, nausea, fatigue, constipation, vomiting, flatulence, acid regurgitation, taste perversion, arthralgia, myalgia, urticaria, dry mouth, dizziness, headache, paraesthesia, abdominal pain, skin rashes, weakness, back pain, upper respiratory infection, cough. Potentially

Drug Interaction

Nursing Responsibilit ies


Give meals before

Omeprazole

Omeprazole suppresses gastric acid secretion by specific inhibition of the enzyme system hydrogen/potassium adenosine triphosphatase (H+/K+ ATPase) present on the secretory surface of the gastric parietal cell. Onset: Antisecretor y: approx 1 hr; peak effect:0.5-3.5 hr. Duration: 72 hr. Absorption: Rapid but variable (oral); dose-dependent. Bioavailability: Oral: approx 30-40%. Distribution: Protei n-binding: 95%. Metabolism: Exten sively hepatic; converted to

Omeprazol e is contraindic ated in patients hypersensi tive to it. Omeprazol e should be used when the benefits outweigh the risks in patients with hepatic disease or a history of hepatic disease, as the drugs half life may be prolonged and dosage

Decreases absorption of itraconazole, ketocon azole, dasatinib, oral iron salts. Decreases levels of nelfinavir. Increases levels of benzodiazepines (e.g. diazepam, midazol am, triazolam), HMGCoA reductase inhibitor, CYP2C19 substrates (e.g. citalopram, diazepam, methsuximide, phenytoi n, propranolol, and sertraline), and CYP2C9 substrates (e.g. bosentan, dapsone, fluoxetine, glimepiride, glipizide, losartan, montelukast, nateglinide, paclitaxel, phenytoin, warfarin, and zafirlukast). Decreased levels/effects with CYP2C19 inducers (e.g. aminoglutethimide, carb

Do not crush or chew tablets, swallow whole Evaluate for therapeutic response like relief of Gastrointestinal symptoms Question if Gastrointestinal discomfort, nausea, and diarrhea occurs.

hydroxyomeprazole and omeprazole sulfone. Excretion: Via urine (77%) and bile. Elimination half-life: 0.5-3 hr.

adjustment may be necessary.

Fatal: Anaph ylaxis.

amazepine, phenytoin, and rifampin). Decreases excretion of methotrexate. Enhances the adverse/toxic effect of cilostazol. May alter the concentrations/effects of clozapine. Avoid concurrent use with clopidogrel.

Drug

Classifica tion/ Indicatio n


Levofloxaci n ; Belongs to the class of fluoroquinol ones. / Used in the systemic treatment of infections.

Dose, Route & Freque ncy


750mg TIV OD

Mechanism of Action

Contrai ndicatio n
Hypersens itivity to levofloxac in or other quinolone s. Child <18 yr.

Side Effects/ Adverse Effects


Oral/IV: Nausea, diarrhoea, constipation, headache, insomnia, inj site reactions (IV). Ophthalmic: Transient decrease in vision, ocular burning, ocular

Drug Interaction

Nursing Responsibilities

Levofloxaci n

Levofloxacin exerts antibacterial action by inhibiting bacterial topoisomerase IV and DNA gyrase, the enzymes required for DNA replication, transcription repair and recombination. It has in vitro activity against a

Increased concentration of ciclosporin or tacrolimus. Reduced absorption with didanosine, ferro us sulfate or dietary supplements containing zinc, calcium, magnesium or iron. May increase plasma levels of theophylline.

(1) first make sure the patient does not have an allergy to it before you give it, (2) run it slowly enough so it won't sting/burn going in, and (3) make sure you flush it after you give it to be sure the patient received all the medication and

wide range of gram-negative and gram-positive microorganisms. Absorption: Rapid and complete absorption from the GIT (oral); peak plasma concentrations within 1-2 hr. Distribution: Wide ly distributed in bronchial mucosa, lungs; CSF (relatively poor). Protein-binding: 3040%. Metabolism: Limit ed. Excretion: Mainly via urine (largely as unchanged drug); 6-8 hr (elimination half-life).

pain or discomfort, foreign body sensation, headache, fever, pharyngitis, photophobia. Potentially Fatal: Anaphyl axis.

Increased risk of tendon rupture with corticosteroids. Reduced absorption with sucralfate and antacids containing magnesium and aluminium; administer at least 2 hr before or 2 hr after antacids. Increased half-life and decreased clearance of procainamide. Altered glucose levels with antidiabetic agents (e.g. insulin, glyburide). Potentially Fatal: Increased risks of ventricular arrhythmias with QT prolonging drugs e.g. class IA (quinidine, procainamide) or class III (amiodarone, sotalol) antiarrhythmics, fluox etine, imipramine. Increased risk of CNS stimulation and seizures with NSAIDs. Increased prothrombin time with warfarin.

that it all went through the IV into the vein.

Drug

Classificat ion/ Indication


Antiamoebics / Antiamoebics

Dose, Route & Frequency


500mg TIV q8h

Mechanism of Action

Contraindica tion

Side Effects/ Adverse Effects


Nausea, headache, anorexia. Occasionall y, vomiting, diarrhea, epigastric cramping, constipation , mild leukopenia.

Drug Interaction

Nursing Responsibilities

Metronidazol e

Metronidazole is bactericidal against susceptible bacteria. Its exact mechanism of action is not completely understood, but it is taken up by anaerobic organisms where it is reduced to an unidentified polar compound. It is believed that this compound is responsible for the drugs antimicrobial activity by disrupting DNA and nucleic acid synthesis in the bacteria.

History of blood dyscrasia. 1st trimester of pregnancy in patients w/ trichomoniasis.

Alcohol, disulfira m, oral anticoagulants.

Should be taken on an empty stomach (Take at least 1 hr before meals.).

Drug

Classifica tion/ Indicatio n

Dose, Route & Freque ncy

Mechanism of Action

Contraindica tion

Side Effects/ Adverse Effects

Drug Interactio n

Nursing Responsibilities

Tramadol

Analgesics (Opioid) / Management of moderate to severe pain.

50mg TIV q6h, prn

Tramadol is metabolized by Nand O-demethylation and glucuronidation or sulfation in the liver. The metabolite Odesmethyltramadol is pharmacologically active. Tramadol is widely distributed, crosses the placenta and appears in small amounts in breast milk. The elimination t following oral administration is about 6 hrs. Paracetamol is readily absorbed from GIT with peak plasma concentrations occurring about 10-60 min after oral administration. Paracetamol is distributed into most body tissues. It crosses the placenta and is present in the breast milk. Plasma protein-binding is negligible at usual therapeutic concentrations but increases with increasing concentration. The elimination tfollowing oral administration is about 1-3 hrs.

Hypersensitivity to codeine or opioids. Acute intoxication w/ alcohol, hypnotics, narcotics, centrally-acting analgesics, opioids or psychotropic drugs. Opioiddependent patients, chronic alcoholism. Lactation.

Dizziness, nausea, somnolence. Asthenia, fatigue, hot flushes, headache, tremor, abdominal pain, constipation. diarrhea, dyspepsia, flatulence, dry mouth, vomiting, anorexia, anxiety, confusion, euphoria, insomnia, nervousness, pruritus, rash, increased sweating.

Carbamazepi ne, quinidine, CYD2D6 inhibitors (eg fluoxetin e, paroxetine , amitriptyline) , MAOIs, SSRIs, digoxin, warfarin; other CNS depressants, tricyclic antidepressa nts; other paracetamolcontaining products. Alc ohol.

May be taken with or without food Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration. Assess BP & RR before and periodically during administration. Respiratory depression has not occurred with recommended doses. Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids and bulk and with laxatives to minimize constipating effects.

Drug

Classific ation/ Indicatio n

Dose, Route & Frequen cy

Mechanism of Action

Contraindi cation

Side Effects/ Adverse Effects

Drug Interaction

Nursing Responsibilities

Paracetamol

Analgesics (Non-Opioid) & Antipyretics

300mg 1amp TIV as needed for fever

The exact mechanism of action of acetaminophen is not known. Acetaminophen relieves pain by elevating the pain threshold, that is, by requiring a greater amount of pain to develop before a person feels it. It reduces fever through its action on the heat-regulating center of the brain. Specifically, it tells the center to lower the body's temperature when the temperature is elevated.

Should be taken with food (Take immediately after meals.).

GI, renal, hepatic, CNS, otic & ocular, dermatologic effects. Fluid retention, increased BP, hypotension, CVA & palpitations.

Anticoagulant & thrombolytic agents. Aspirin, salicylate, phenylbutazone, indomethacin & other NSAIDs. ACE inhibitors, furos emide & thiazides. Alcoh ol.

Should be taken with food (Take immediately after meals.). Do not exceed recommended dose; do not take for longer than 10 days. Take the drug only for complaints indicated; it is not an antiinflammatory agent.

Drug

Classific ation/ Indicatio n

Dose, Route & Freque ncy

Mechanism of Action

Contrai ndicati on

Side Effects/ Adverse Effects

Drug Interactio n

Nursing Responsibilities

Vitamin K

fat-soluble vitamins; antifibrinolytic agents

1amp q8h

TIV

Vitamin k, indicated in the treatment of coagulation disorders which are due to faulty formation of factors II, VII, IX and X when caused by vitamin K deficiency or interference with vitamin K activity.

Hypersen sitivity to any componen t of this medicatio n.

Deaths have occurred following i.v. administration of phytonadione. Transient flushing sensations and peculiar sensations of taste have been observed following phytonadione injection as well as rare instances of dizziness, rapid and weak pulse, profuse sweating, brief hypotension, dyspnea, and cyanosis. Bronchospasm, shock, cardiac and/or respiratory arrest may also occur. Pain, swelling, and tenderness at the injection site may occur. The possibility of allergic sensitivity (i.e., rash, urticaria), including an anaphylactoid reaction, should be kept in mind. Large doses of vitamin K or its analogues may further depress liver function in patients with severe hepatic disease and thereby further decrease the concentration of prothrombin.

Phylloquinone (K1) or menaquinone (K2) are capable of blocking the blood thinning action of anticoagulants like warfarin, which work by interfering with the action of vitamin K. They also reverse the tendency of these drugs to cause arterial calcification in the long term.

1.Instruct patient to take this drug as ordered 2.Cooking does not destroy substantial amounts of vitamin K 3. Caution patient to avoid IM injection and activities leading to injury. 4. Advise patient to report any symptoms of unusual bleeding or bruising. 5. Patients receiving vitamin K therapy should not take OTC Medications without advice of Health Care professionals. 6. Advise patient to carry identification at all times describing disease process.

Drug

Classificat ion/ Indication

Dose, Route & Frequency

Mechanism of Action

Contraindication

Side Effects/ Adverse Effects

Drug Interaction

Nursing Responsibilities

Ketorolac

Nonsteroi 30mg dal Anti- q8h, Inflammat doses

TIV Ketorolac is Hypersensitivity GI 6 a to aspirin & other bleeding nonsteroidal NSAIDs. History of ,

Anticoagula Should be taken nts eg low- with food (Take dose hepari immediately

ory Drugs (NSAIDs) / Shortterm managem ent of moderate to severe post-op p ain

antiinflammator y drug (NSAID) that is chemically related to indomethaci n and tolmetin.

asthma, nasal polyps, bronchospasm or angioedema, peptic ulceration or GI bleeding. Moderate or severe renal impairment. Patients w/ hypovolemia or dehydration, coagulation or hemorrhagic disorders, confirmed or suspected cerebrovascular bleeding. Pregnancy & lactation. Childn <2 yr.

perforati on & peptic ulceratio n. Anaphyl axis, rash, broncho spasm, laryngea l edema & hypoten sion

n, NSAIDs, asp irin, oxypentifyll ine, proben ecid.

after meals.).

Chapter X

NURSING CARE PLAN

Chapter XI

DISCHARGE PLANNING

Medication T-tube to be remained intact for 6 weeks upon discharge Exercise/Economy ROM exercises to promote blood circulation Treatment/Therapy Wound dressing change every 24-72 hours Outpatient Consultation Consultation at the OPD department every week upon discharge and t-tube drain check-up Diet Restrict patient from fatty foods and drinking alcoholic beverages Spirituality and Sexuality Maintain religious practices upon discharge