Pamanta&an n' Lun'&!$ n' Mari.

ina
C!ll ' !f Nur&in'
Mari3ina Cit

A CASE STUDY OF PATIENT P At AMANG RODRIGUEZ MEMORIAL MEMORIAL HOSPITAL

In Partial Fulfillm nt !f t" A#a$ mi# R %uir m nt& In R lat $ L arnin' E() ri n# * Pr & nt $ t! t" C!ll ' !f Nur&in' Summ r +,--

Submitted to: MAAM VICTORIA BEDONIA, RN, MAN Clinical Instructor Submitted b : BIEN, !"EENIE #ANE M$ CABRERA, ANDREA MARIE M$ CAN%AS, MAR& RANIA N$ CERE'O, ARNE% B$ D"E(AS, C)ER&%% ROSE T$ EB"EN, MI%A*ROS T$ +ERRAER, MARICAR C$ +%ORES, RIC)E%%E S$ *RA&DA, C)ARINA B$ MACA%INO, E"*INE D*$ MASAN*CA&, #ONE% D$ MONTENE*RO, MAR, ANTON& -$ BSN ./0 1Old Curriculum2

APRIL +,* +,--

GOALS T4e 5oal 6or conductin5 t4is case stud is 6or t4e com7letion o6 t4e re8uirements in Related %earnin5 E97erience in NCM:;<$ T4is is also 6or t4e students to en4ance 3no=led5e and to a77l t4e a77ro7riate nursin5 mana5ement 6or clients =it4 Acute *lumerulone74ritis accuratel and e66icientl $ T4is stud also aims to de>elo7 t4e s3ills t4at are a77lied 6or t4e care o6 7atient =it4 t4is condition$ SPECIFIC GOALS/ ,NO?%ED*E - Students s4ould be able to describe t4e di66erence o6 =it4 Acute *lumerulone74ritis 6rom ot4er diseases t4at 4as t4e same si5n and s m7toms$ S,I%%S Students s4ould demonstrate s7eci6ic s3ills includin5: o )istor ta3in5 - Students s4ould be able to obtain, document and 7resent an a5e/ a77ro7riate medical 4istor t4at di66erentiates amon5 etiolo5 o6 disease$ o -4 sical E9am S3ills - Students s4ould be able to 7er6orm a 74 sical e9am to establis4 t4e dia5nosis and se>erit o6 disease$ o Communication S3ills - Students s4ould be able to e97lain s7eci6ic treatment 7lans 6or t4e indi>idual 7atient@s situation, counsel and educate 7atients about t4e disease$ ATTIT"DE - Eac4 student s4ould be able to: a$ %earn 4o= to establis4ed nurse/7atient interaction b s4o=in5 courtes and res7ect to client$ b$ %earn 4o= to coo7erate and establis4ed camaraderie =it4 ot4er 5rou7 members$ O01ECTI2ES/ - To discuss brie6l t4e causati>e 6actors t4at ma 4a>e 7reci7itated t4e onset o6 t4e condition - To be able to relate si5ns and s m7toms mani6ested b t4e 7atient - To be 6amiliariAe =it4 =4at 3ind o6 )ealt4 care s4ould be 5i>en to 7atient - To be a=are o6 =4at 3ind o6 7recaution s4ould considered

INTRODUCTION/ T4e =ord 7re>alence o6 -rimar *lomerulone74ritis usuall means t4e estimated 7o7ulation o6 7eo7le =4o are mana5in5 -rimar *lomerulone74ritis at an 5i>en time 1i$e$ 7eo7le =it4 -rimar *lomerulone74ritis2$ T4e term @incidence@ o6 -rimar *lomerulone74ritis means t4e annual dia5nosis rate, or t4e number o6 ne= cases o6 -rimar *lomerulone74ritis dia5nosed eac4 ear 1i$e$ 5ettin5 -rimar *lomerulone74ritis2$ )ence, t4ese t=o statistics t 7es can di66er: a s4ort disease li3e 6lu can 4a>e 4i54 annual incidence but lo= 7re>alence, but a li6e/lon5 disease li3e diabetes 4as a lo= annual incidence but 4i54 7re>alence$ )ere in t4e -4ili77ines t4e 7re>alence is :B,0CD ear <;;E$ DISEASE PROCESS/ D finiti!n *lomerulone74ritis 15loe/mer/u/lo/nu4/+R&/tis2 is in6lammation o6 t4e tin 6ilters in our 3idne s 15lomeruli2$ *lomeruli remo>e e9cess 6luid, electrol tes and =aste 6rom our bloodstream and 7ass t4em into our urine$ Also called 5lomerular disease, 5lomerulone74ritis can be acute F a sudden attac3 o6 in6lammation F or c4ronic F comin5 on 5raduall $ In most cases, t4e stimulus o6 t4e reaction is 5rou7 A stre7tococcal in6ection =4ic4 ordinaril 7recedes t4e onset o6 5lomerolone74ritis b </. =ee3s$ I6 5lomerulone74ritis occurs on its o=n, it@s 3no=n as 7rimar 5lomerulone74ritis$ I6 anot4er disease, suc4 as lu7us or diabetes, is t4e cause, it@s called secondar 5lomerulone74ritis$ I6 se>ere or 7rolon5ed, t4e in6lammation associated =it4 5lomerulone74ritis can dama5e our 3idne s$ Treatment de7ends on t4e t 7e o6 5lomerulone74ritis ou 4a>e$ S3m)t!m& Si5ns and s m7toms o6 5lomerulone74ritis ma de7end on =4et4er ou 4a>e t4e acute or c4ronic 6orm, and t4e cause$ &our 6irst indication t4at somet4in5 is =ron5 ma come 6rom s m7toms or 6rom t4e results o6 a routine urinal sis$ Si5ns and s m7toms ma include: -in3 or cola/colored urine 6rom red blood cells in our urine 14ematuria2

+oam urine due to e9cess 7rotein 17roteinuria2 )i54 blood 7ressure 14 7ertension2 +luid retention 1edema2 =it4 s=ellin5 e>ident in our 6ace, 4ands, 6eet and abdomen In se>ere 6orm it ma mani6est 4eadac4e, malaise, 6lan3 7ain and oli5uria +ati5ue 6rom anemia or 3idne 6ailure Elderl 7atient ma 4a>e circulator o>erload, d s7nea, en5or5ed nec3 >eins, cardiome5al and 7ulmonar edema

Cau& & A >ariet o6 conditions can cause 5lomerulone74ritis, ran5in5 6rom in6ections t4at a66ect our 3idne s to diseases t4at a66ect our =4ole bod , includin5 our 3idne s$ Sometimes t4e cause is un3no=n$ )ere are some e9am7les o6 conditions t4at can lead to in6lammation o6 t4e 3idne s@ 5lomeruli$

Inf #ti!n P!&t4&tr )t!#!##al 'l!m rul!n )"riti&4 *lomerulone74ritis ma de>elo7 a =ee3 or t=o a6ter reco>er 6rom a stre7 t4roat in6ection or, rarel , a s3in in6ection 1im7eti5o2$ An o>er7roduction o6 antibodies stimulated b t4e in6ection ma e>entuall settle in t4e 5lomeruli, causin5 in6lammation$ S m7toms usuall include s=ellin5, reduced urine out7ut and blood in t4e urine$ C4ildren are more li3el to de>elo7 7ost/stre7tococcal 5lomerulone74ritis t4an are adults, and t4e @re also more li3el to reco>er 8uic3l $ T &t& an$ $ia'n!&i& S7eci6ic si5ns and s m7toms ma su55est 5lomerulone74ritis, but t4e condition o6ten comes to li54t =4en a routine urinal sis is abnormal$ Tests to assess our 3idne 6unction and ma3e a dia5nosis o6 5lomerulone74ritis include: Urin t &t5 A urinal sis ma s4o= red blood cells and red cell casts in our urine, an indicator o6 7ossible dama5e to t4e 5lomeruli$ "rinal sis results ma also s4o= =4ite blood cells, a common indicator o6 in6ection or in6lammation, and increased 7rotein, =4ic4 ma indicate ne74ron dama5e$ Ot4er indicators, suc4 as increased blood le>els o6 creatinine or urea, are red 6la5s$ 0l!!$ t &t&5 T4ese can 7ro>ide in6ormation about 3idne dama5e and im7airment o6 t4e 5lomeruli b measurin5 le>els o6 =aste 7roducts, suc4 as creatinine and blood urea nitro5en$ Ima'in' t &t&5 I6 our doctor detects e>idence o6 dama5e, 4e or s4e ma recommend dia5nostic studies t4at allo= >isualiAation o6 our 3idne s, suc4 as a 3idne G/ra , an ultrasound e9amination or a com7uteriAed tomo5ra74 1CT2 scan$

6i$n 3 7i!)&35 T4is 7rocedure in>ol>es usin5 a s7ecial needle to e9tract small 7ieces o6 3idne tissue 6or microsco7ic e9amination to 4el7 determine t4e cause o6 t4e in6lammation$ A 3idne bio7s is almost al=a s necessar to con6irm a dia5nosis o6 5lomerulone74ritis$ Tr atm nt f!r "i'" 7l!!$ )r &&ur ,ee7in5 our blood 7ressure under control is 3e to 7rotectin5 our 3idne s$ To control our 4i54 blood 7ressure and slo= t4e decline in 3idne 6unction, our doctor ma 7rescribe one o6 se>eral medications, includin5: Diuretics An5iotensin/con>ertin5 enA me 1ACE2 in4ibitors An5iotensin II rece7tor a5onists -enicillin Corticosteroids T" ra)i & f!r a&&!#iat $ .i$n 3 failur +or acute 5lomerulone74ritis and acute 3idne 6ailure, dial sis can 4el7 remo>e e9cess 6luid and control 4i54 blood 7ressure$ T4e onl lon5/term t4era7ies 6or end/sta5e 3idne 6ailure are 3idne dial sis and 3idne trans7lantation$ ?4en a trans7lant isn@t 7ossible, o6ten because o6 7oor 5eneral 4ealt4, dial sis becomes t4e onl o7tion$

Lif &t3l an$ "!m r m $i & Restrictin5 salt inta3e to 7re>ent or minimiAe 6luid retention, s=ellin5 and 4 7ertension Cuttin5 bac3 on 7rotein and 7otassium consum7tion to slo= t4e buildu7 o6 =astes in our blood Maintainin5 a 4ealt4 =ei54t Controllin5 our blood su5ar le>el i6 ou 4a>e diabetes Pr 8 nti!n T4ere@s no =a to 7re>ent most 6orms o6 5lomerulone74ritis$ )o=e>er, 4ere are some ste7s t4at ma be bene6icial: See3 7rom7t treatment o6 a stre7 in6ection causin5 a sore t4roat or im7eti5o$ To 7re>ent in6ections t4at can lead to some 6orms o6 5lomerulone74ritis, suc4 as )IV and 4e7atitis, 6ollo= sa6e/se9 5uidelines and a>oid intra>enous dru5 use$ Control our blood 7ressure, =4ic4 lessens t4e li3eli4ood o6 dama5e to our 3idne s 6rom 4 7ertension$

Control our blood su5ar to 4el7 7re>ent diabetic ne74ro7at4 $

Nur&in' mana' m nt Re>ie= 6luid and diet restriction$ Measure and record inta3e and out7ut$ Instruct 7atient to sc4edule 6ollo= u7 e>aluation o6 blood 7ressure, urinal sis 6or 7rotein, and B"N and creatinine studies to determine i6 disease 4as =orsened$ Instruct 7atient to noti6 74 sician i6 in6ection or s m7toms o6 renal 6ailure occur: 6ati5ue, nausea, >omitin5, diminis4in5 urinar out7ut Re6er to 4ome care nurse as indicated 6or assessment and detection o6 earl s m7toms and 6ollo= u7 e>aluation

PATIENTS PROFILE A$ -atient Data -atient - is t4e oun5er o6 t=o c4ildrenH 4es I ears old and an incomin5 *rade . t4is #une$ Born 4ere in Mari3ina Cit , 4e is li>in5 =it4 4is relati>es in %amuan, Mari3ina Cit , alon5 =it4 4is brot4er, Mar3 B ears old, =4o is an incomin5 5rade 0 student t4is #une at Malanda Elementar Sc4ool$ A Roman Cat4olic b reli5ion and 5oes to c4urc4 e>er Sunda =it4 4is Aunt$ -atient - stands :<I cm and =ei54t <I$D 35 and 4is BMI result o6 :C$0 s4o=s t4at 4e is under =ei54t$

B$ )istor o6 -resent Illness +e= =ee3s 7rior to admission, 4e e97erienced stre7tococcal t4roat in6ection and =as brou54t to a clinic nearb t4eir residence and 4e =as 5i>en some medication to treat t4e disease$ +e= da s 7rior to admission, 7atient =as e97eriencin5 s=ellin5 o6 6ace and t4e returned to t4e same clinic but =4en t4e doctor ins7ect t4e client 4e ad>ise 7atient to be admitted to t4e c4osen 4os7ital$ C$ )istor o6 -ast illness Accordin5 to 7atient -s aunt, 4e doesnt 4a>e an serious illness and 4e Just commonl e97erienced cou54 and 6lu$ T4is =as 4is 6irst admission to t4e 4os7ital$ D$ Social )istor -atient - usuall s7ends 4is time 7la in5 =it4 4is cousins outside t4e 4ouse durin5 >acation and li3e ot4er normal 3ids, 4e 5oes to sc4ool on sc4ool da s$ )e usuall eats 6ried c4ic3en, e55 and 6ried 6is4 durin5 4is meal i6 t4ere is no 6ried c4ic3enH 4e usuall re8uests a 6ried dis4$ )e also li3es street 6oods 1e$5 3=e3/3=e3, 6is4balls2 durin5 4is merienda time$

LA0ORATORY RESULTS Urinal3&i& Macroso7ic E9amination Normal Value Color %i54t Stra= to Dar3 &ello=

Result Amber

Inter7retation Dru5s and 6ood can c4an5e color o6 t4e urine

Trans7arenc

Clear

Turbid

Due to increased RBC =4ic4 indicates bacterial in6ection

C4emical Stri7 E9amination Reaction S7eci6ic *ra>it Su5ar -rotein

Normal Value Acidic :$;;D/:$;.; Ne5ati>e ;

Result Acidic :$;<D Ne5ati>e -ositi>e 1K.2

Inter7retation Normal Normal Normal Related to 3idne d s6unction due to A*N

Microsco7ic E9amination -us Cells RBC E7it4elial Cell H mat!l!'3 E9amination +BS Eosino74il 0l!!$ C" mi&tr3 E9amination Sodium

Normal Value ;/< 476 :/< 7er l76 +e=

Result </0 Too numerous to count Rare

Inter7retation Indicates in6ection Indicates in6ection

Normal Value .$I/D$I mmolL% I;/:.. umolL%

Result .$I. DD$I

Inter7retation Normal Result o6 in6ection

Normal Value :.D/:0D mmolL%

Result :0C$I mmolL%

-otasium

.$D/D$. mmolL%

0$DC mmolL%

Inter7retation Indicates 4 7o3alemia related to 3idne d s6unction Normal

G!r$!n& -- Fun#ti!nal H alt" Patt rn& +unctional )ealt4 Be6ore -attern )os7italiAation

Durin5 )os7italiAation

Anal sis

)ealt4 -erce7tionL )ealt4 Mana5ement

Accordin5 to 7atient 4e =as4es 4is 4ands be6ore eatin5 4is meals and 4e ta3e a bat4 on 4is o=n dail $

Nutritional/ Metabolic

-atient told us t4at b eatin5 4is meals =e =ill become 4ealt4 and stron5 and 4e eats all 3inds o6 6ood$

Elimination

Accordin5 to 4is mot4er be6ore 4os7italiAation 7atient 6orced 4imsel6 to urinate$

Durin5 4os7italiAation t4e student nurses 7oint out t4at 4and =as4in5 s4ould be done in 7ro7er =a and instructed 4is mot4er t4at s4e must assist 4er son in ta3in5 4is bat4$ Durin5 7atients sta in t4e 4os7ital, t4e student nurses e97lained to 4im t4e im7ortance o6 5ood nutrition and it is not onl about eatin5 an 6ood, 4e must c4oose 6ood =4ic4 is 5ood 6or 4is 4ealt4$ Durin5 4os7italiAation 4e 4as a co3e/color/ li3e urine =4en 6urosemide =as administered and 4e =as closed monitor o6 in7ut and out7ut, and 6luid restriction b CD;ccL da Durin5 4os7italiAation our 7atient remained in bed and 4as no acti>ities or e9ercise$ Durin5 4os7italiAation t4e 7atients co5niti>e/ 7erce7tual remained t4e same$

Due to 7ro7er 4ealt4 teac4in5 in 7ro7er 4 5iene durin5 t4e 7atients sta in 4os7ital t4e 7atient is more a=are in ad>anta5e and im7ortance o6 5ood and 7ro7er 4 5iene Durin5 4os7italiAation our 7atient 5ets 7ro7er nutrition

Acti>it /E9ercise

Co5niti>e/ -erce7tual

Our 7atient =as >er acti>e 7la in5 =it4 4is 7la mates outside o6 4is 4ouse and it ser>es as 4is dail routine T4e 7atient in6ormed us t4at s4e is in 5ood condition$

)is 4os7italiAation ease 4is 4ard time I urinatin5 =it4 t4e use o6 diuretic as a 6orm o6 treatment 6or t4e disease, but due to it 7atient ma de>elo7 6luid and electrol te imbalance t4us monitorin5 o6 4is in7ut and out7ut is done Because o6 4er con6inement t4e 7atient =as unable to 7la and cannot do an acti>ities$ Bein5 con6ined did not c4an5e t4e 7atients co5niti>e/ 7erce7tion$

Slee7/Rest

Sel6/-erce7tionL Sel6 Conce7t Role/relations4i7

Be6ore 4os7italiAation t4e 7atient slee7s 6or more t4an I4ours dail =4ic4 includes 4is a6ternoon na7 6rom :7m/.7m, 4e usuall slee7s :;7m in t4e e>enin5 and Cam in t4e mornin5 Not a77licable Be6ore 4os7italiAation our 7atient =as t4e oun5est c4ild in t4e 6amil 4e is >er acti>e and 4e is t4e one =4o is ta3en care b 4is 6amil Not a77licable Be6ore con6inement t4e 7atient co7es =it4 4is boredom b 7la in5 outside 4is 4ouse all da and =atc4in5 t>$ Accordin5 to 4im 4is da =as not com7lete =it4out 7la in5$ T4e 7atient is cat4olic and 4e 5oes to c4urc4 =it4 4is 6amil $ Accordin5 to =4at 4is mot4er told 4im Stron5 6ait4 to *od 4el7s t4e 7atient s7irituall to

Durin5 4os7italiAation t4e 7atient 4as a 4ard time in slee7in5 because t4e ot4er 7atients noise bot4ers 4im$

Durin5 con6inement t4e 7atient 4as more time to slee7 =4en s4e =as at 4ome$

Not a77licable Durin5 4os7italiAation s4e =as unable to do 4is usual acti>it $ )e is still bein5 cared b 4is mot4er$ Not a77licable Durin5 4os7italiAation t4e 7atient 6ound con6inement leads 4im to boredom, 4e cant 7lat nor =atc4 t>$ )e =ants to 5o 4ome and return to 4is usual acti>it Durin5 con6inement 7atient cant 5o to c4urc4 but 4e still belie>es t4at -a7a #esus =ill cure 4im

Not a77licable E>en 4is con6inement didnt c4an5e 4is role as a oun5est son but 4is usual acti>it as a c4ild =as restricted due to 4is condition$ Not a77licable Boredom is anot4er 6orm o6 stressor, due to 4is con6inement 7atient =as unable to do 4is usual acti>it =4ic4 leads to boredom Due to con6inement t4e 7atient cant 5o to c4urc4 but it doesnt a66ect 4is stron5 =ill to *od$

Se9ualit / Re7roducti>e Co7in5 L Stress/ Tolerance

Value/Belie6

alle>iate t4e condition =it4 *od@s =ill PHYSICAL ASSESSMENT 2ital &i'n& Tem7erature: .B$B Res7irator Rate: <0 Assessment S6IN / Color Ins7ection MTe9ture Ins7ection and -al7ation MTur5or Ins7ectionL -al7ation MTem7erature -al7ate M%esion Ins7ection L 7al7ation /)air M!ualit Ins7ection MDistribution Ins7ection MTe9ture Ins7ectionL -al7ation /Nails MColor o6 nail bed Ins7ection MBlanc4 Test Ins7ectionL -al7ation HEAD MS4a7e and SiAe Ins7ection EYES /E e condition Ins7ection /4air distribution o6 Ins7ection t4e e ebro=s /E elid and las4es Ins7ection /Blin3 res7onse Ins7ection /E eballs Ins7ection / ConJucti>a Ins7ection / -u7ils Ins7ection /Sclera Ins7ection EARS MColor Ins7ection MAuricle Ins7ectionL -al7ation

-ulse Rate: :;D b7m B-: :.;L:;;mm45 +indin5s Anal sis +lus4ed Smoot4 *ood ?arm to touc4 scar rLt s3in o7eration +ine E8uall distributed smoot4 Due to 6e>er Normal Normal Due to 6e>er Due to 7ast o7eration Normal Normal Normal

S4ort and clean

normal

Smoot4 contour Normal >ision E>enl distributed -u66 e elid Blin3 S mmetric -ale -ERR%A ?4ite S mmetrical Sli54tl 7ale

Normal Normal Normal

Normal Normal Normal Normal

M-inna ME9ternal cannal M)earin5 Acti>it NOSE /E9ternal /Se7tum /Mucosa /-atenc / Nasal ca>ities MOUTH / %i7s 1color2 / Oral mucosa /Ton5ue /Teet4 /*ums NEC6 /Nec3 muscle / % m74 nodes /Trac4ea /t4 roid 5land CHEST /S4a7e /%un5 e97ansion /Breat4in5 7attern MBreat4 sounds MDe6ormities A0DOMEN / Abdomen

Ins7ectionL -al7ation Ins7ectionL -al7ation Ins7ection Ins7ection Ins7ection Ins7ection Ins7ection Ins7ection Ins7ection Ins7ection Ins7ection Ins7ection Ins7ection

Recoil =4en 6olded Some cerumen Normal S mmetrical midline 7ale Bot4 7atent moist -ale 7allor -in3, centrall located com7lete -ale no sores

Normal

Normal Normal Normal Normal Normal

Normal Normal Normal

Ins7ectionL -al7ation Ins7ectionL -al7ation Auscultation Ins7ectionL -al7ation Ins7ection Ins7ection Ins7ection Auscultation Ins7ection

S mmetrical Not 7al7able Midline Not 7al7able

Normal Normal Normal Normal

Bronc4o>esicular As mmetric

Normal Normal

Ins7ectionL -al7ation /s3in inte5rit Ins7ectionL -al7ation /contour and Ins7ectionL s mmetr -al7ation /-al7ation -al7ation /Bladder -al7ation /%i>er -al7ation UPPER AND LO9ER E:TREMITIES

No lesion Rounded Muscle 5uardin5 Not 7al7able Not 7al7able

Normal

Normal Normal

/Motor stren5t4 /Muscle tone /De6ormit /-eri74eral 7ulse /% m74 nodes /7resence o6 >aricosities /le5s )andsL 6in5ers Arms *enitals

Ins7ection Ins7ectionL -al7ation Ins7ectionL -al7ation Ins7ection Ins7ection Ins7ection Ins7ection Ins7ection

None S mmetrical -al7able None

Normal Normal

Normal Normal Normal Normal -atient re6used

-atient re6used

Pri!riti;ati!n Nur&in' Pr!7l m& Ris3 6or in6ection

Pri!rit3 Dtt

Rati!nal T4is is a least 7riorit 7roblem, since it is onl a ris3, but since t4e 7atient 4as decreased immune res7onse t4is 7roblem must be 7re>ented$ Electrol tes 7la a >ital role in maintainin5 bod 7rocesses$ Too muc4 o6 too little o6 t4e minerals t4at ma3e u7 t4e electrol tes can cause serious 7roblems$ A moderate ur5enc but >er im7ortant$ -ediatric 7atient and 4is 6amil need 4ealt4 education to 7romote sel6/a=areness necessar to 7atient inde7endent 4ealt4care$

Nutritional Imbalanced less t4an bod re8uirements related to

t4

,no=led5e de6icit .RD

Ris3 6or 6luid and electrol te imbalance

<nd

Nutrition ma3es a di66erence in t4e rate and 8ualit o6 7atients reco>er , =4ic4 7re7ares to 6unction at a 4i54er le>el in treatment / co5niti>el , mentall , and sociall $ Due to inabilit to eliminate 6luid t4ere is a 6luid retention and It mi54t lead to ot4er 7roblems li3e 7ulmonar edema$

E9cess 6luid >olume

:st

A&& &&m nt S/N la5in5 ma si7on an5 ana3 3o, 7ero =al na si an5 iban5 sa3it, ta7os lumobo na lan5$ *a5alin5 7a ba si aO Namamana ba itoO /serial 8uestions b 7atients an9ious mot4er$

Dia'n!&i& ,no=led5e de6icit c4aracteriAe d b serial 8uestions and a77earance o6 con6usion b 7atient and 6amil

Plannin' A6ter :D/.; minutes o6 nursin5 inter>entions, 7atientL relati>e understands t4e needs and condition o6 7atient care, and >erbaliAes relie6 o6 con6usion

Int r8 nti!n In$ ) n$ nt/ Assess 7atient and 6amil s 3no=led5e o6 t4e disease and its mana5ement Encoura5e 6amil to as3 8uestions and >erbaliAe concerns -lan t4e 4ealt4 teac4in5 in a =a not to o>er=4elm t4e 7atient and 4is relati>es Discuss si5ns and s m7toms e97erienced b t4e 7atient 4imsel6 Teac4 t4e 7atient and t4e relati>es earl detection o6 =arnin5 si5ns -ro>ide in6ormation about t4e course o6 t4e disease and its treatment

Rati!nal

E8aluati!n A6ter .; minutes o6 4ealt4 teac4in5 and nursin5 inter>entions 7atient and relati>e >erbaliAes understandin5 o6 7atients needs and careH mani6ests =ill6ul coo7eration and relie6 o6 con6usion

To 7re7are t4e 7atient and 4is 6amil 6or and e66icient 4ealt4 teac4in5 To 7rioritiAe 7atients concerns e$5$ clari6 in5 4is an9ious 8uestions

O: / / / /

+or t4e 6amil to learn and 4el7 eac4 ot4er in t4eir mana5ement o6 t4e condition +or 7rom7t and e66ecti>e 7atient care +or t4e 7atient and 6amil to a77reciate 6ollo= u7 care, essential 6or 7atients reco>er

Tem7: .B$B C -R: :;D b7m RR: <0 B-: :.;L:;; mm)5 / -u66 e elids / Dr and 7allor s3in / Tea/colored urine

A&& &&m nt E97lain t4at A*N is not communicable nor 4ereditar but 7rolon5ed colds or cou54 s4ould 4a>e been treated 7rom7tl

T4at sim7le illness can seriousl e9acerbate

Su7< #ti8 / 6a"it )! 'an3an an' .!n$i&3!n n' ana. .! na)a.a )la3ful )!" ni3a &a 7a"a3 "in$i .! &3a &ina&a=a3 a& >8 r7ali; $ 73 t" m!t" r O7< #ti8 &/ ?0P -@,A-,, t! B,AC,mm"' ?' n rali; $ $ ma ?!l$ &#ar !n

.n

D&ur' r3E

A&& &&m nt SubJecti>e: PA3ala 3o tumataba lan5 si a, 7ero an5 bilis at iba na un5 itsura / As >erbaliAed b t4e 7atients mot4er ObJecti>es: Q-atient =ei54t <B35s 6rom

Dia'n!&i& +luid >olume e9cess c4aracteri Aed b 7u66 e elid decrease 6acial s=ellin5

)lannin' A6ter :/< da s o6 nursin5 inter>enti on t4e 7atient =ill mani6est decrease or absence o6 edema, =L >ital si5ns controlle d =Lin limit

int r8 nti!n Qmonitor R record VS Qmonitor R record IRO and c4aracter o6 urine as =ell as 6re8uenc Q=ei54t 7atient dail R abdominal 5irt4 Qrestrict 6luid inta3e to CD;ml as 7rescribed Q7ro>ide no added salt

rati!nal Qes7ecial B- 6or 4 7ertensi>e condition Qto obser>e 3idne 6unction, diuretic admin$ And electrol tes balance Qto monitor status o6 edema Qto control bod 6luid >olume Qto 7re>ent 6luid retention

8aluati!n A6ter : to < da s o6 nursin5 inter>ention t4e 7atient 4as mani6ested o6 decreased or absence o6 edema =it4 >ital si5ns controlled =Lin limit

<035s in . =ee3s$ QB-::.;L:; Q*enerali Aed Edema notabl 7u66 e elid decrease 6acial s=ellin5

diet Q7ro>ide ade8uate s3ill care 7ro74 la9is Qadminister diuretics K monitor lab results QAdminister anti4 7erten si>e Qteac4 7atientLrelati >e to identi6 si5ns o6 renal 6ailure, cardiac condition K 4 7ertensi>e com7lication Qinstruct 7atient to re7ort si5ns o6 blood urine, 4eadac4e, or edema at sites, e$5$ 5enitals K sternum =4en l in5, an3le =4en sittin5

Qto

7re>ent trauma to to edematus c4ec3 electrol tes imbalance

Qto

Qto

7re>ent Bcom7lication Qto c4ec3 74 sician 6or earl treatment

A&& &&m nt SubJecti>e: ,a4it 7o 5an an an5 3ondis on n5 ana3 3o na7a3a 7la 6ul 7o4 ni a sa ba4a 4indi 3o s a sinasa=a as P>erbaliAed b t4e

Dia'n!&i& )i54 ris3 6or inJur 6all relati>e to ort4ostatic B- c4an5e or 7ossible seiAuresS

Plannin' A6ter .; mins o6 nursn5 inter>entionH7atie nt Mot4er 1care5i>er2>erbali Aed sel6/care measures to reducesLa>oid inJur 6rom 6alls or seiAures

Int r8 nti!n Qassess 7atient 6or 7artici7atin5 6ocus suc4 as acti>it R discom6ort Qcontinue monitorin5 >Ls IRO R 7atients conscious Q3ee7 7atient rested on bed or limit acti>it Qarise =L ambulation

Rati!nal Qto attend to non>erbal si5ns o6 7atient Qto antici7ate need 6or 74 sician 7rom7t attention Qto lessen ris3 o6 6all i6 diAAiness Qstress tri55er 7air K com6ort Qaids in lun5 e97ansion K

E8aluati!n A6ter .;minutes o6 4ealt4 teac4in5$ Nursin5 inter>entio n 7atient K mot4er understand 7ossible ris3 K ta3en intiati>e to 7ractice sel6 measure to inJur 6or

mot4er ObJecti>es: QB- :.;L:;; to I;LD;mm4 5 Q5eneraliAed edema Qold scar on 3nee 1sur5er 2

QminimiAe noise or en>ironment stimuli Qencoura5e rela9ation suc4 as dee7 breat4in5 e9ercise Q3ee7 lo= salt lo= 6at diet, 6luid restriction to CD;ml Qele>ate 4ead o6 bed .; de5ree Qinstruct 7atient and relati>e su77ort to assistL remind 7atient to c4an5e 7osition slo=l e$5$ sit be6ore standin5 u7 6rom a l in5 7osition$

5ood e>aluation Qto maintainL control bod 6luid 7artici7atin5 increase blod 7ressure Qto minimiAe c4an5es in 7osition t4at tri55er li54t4eadedn ess Qto allo= t4e bod to ada7t to redistribution o6 blood

6alls

DRUG STUDY G n ri# Nam

A8aila7l f!rm& A#ti!n

P"arma#!.in t i#& Oral Onset / <; min -ea3 / .; min SR Onset / <; min -ea3 / <$DTE 4r M ta7!li&m/

Dru'4La74 F!!$ Int ra#ti!n Dru'4$ru' Cimetidine, ranitidine: Ma decrease ni6edi7ine metabolism$ Ma need to adJust dosa5e$

A$8 r& ff #t CNS: diAAiness, li54t/ 4eadedness, somnolence, 4eadac4e, =ea3ness, s nco7e, ner>ousness$ CV: 7eri74eral edema,

Nur&in' Int ra#ti!n Don@t 5i>e immediate/ release 6orm =it4in : =ee3 o6 acute MI or in acute coronar s ndrome$ Alert: Des7ite t4e 7re>iousl

ni6edi7ine

Ca7sules: :; m5, <; m5 Tablets 1e9tended/ release2: .; m5, E; m5, B; m5

"n3no=n$ T4ou54t to in4ibit calcium ion in6lu9 across cardiac and smoot4/muscle cells, decreasin5 contractilit and o9 5en

demand$ Also ma dilate coronar arteries and arterioles$

)e7aticH T:L<: <T D 4r Di&tri7uti!n/ Crosses 7lacentaH enters breast mil3 E(#r ti!n/ +eces, urine

Di5o9in: Ma cause ele>ated di5o9in le>el$ Monitor di5o9in le>el$ +entan l: Ma cause se>ere 4 7otension$ Monitor blood 7ressure$ -4en toin: Ma reduce 74en toin metabolism$ Monitor 74en toin le>el$ -ro7ranolol, ot4er beta bloc3ers: Ma cause 4 7otension and 4eart 6ailure$ "se to5et4er cautiousl $ Dru'4" r7 Don5 8uai:

4 7otension, 7al7itations, 4eart 6ailure, MI, 6lus4in5$ EENT: nasal con5estion$ *I: nausea, diarr4ea, consti7ation, abdominal discom6ort$ Musculos3elet al: muscle cram7s$ Res7irator : d s7nea, 7ulmonar edema, cou54$ S3in: ras4, 7ruritus$

=ides7read S$%$ use o6 ni6edi7ine ca7sules 1or t4e Ubite and s=allo=U met4od2, a>oid t4is route o6 administration$ E9cessi>e 4 7otension, MI, and deat4 ma result$ Monitor blood 7ressure re5ularl , es7eciall in 7atients =4o ta3e beta bloc3ers or anti4 7ertensi> es$ ?atc4 6or s m7toms o6 4eart 6ailure$ Alt4ou54 rebound e66ect 4asn@t been obser>ed =4en dru5 is sto77ed, reduce dosa5e slo=l under

0ran$ Nam

D!&a' 2a&!&)a&ti# an'ina DPrin;m talF& !r 8ariant an'inaE* #la&&i# #"r!ni# &ta7l an'ina ) #t!ri& Adults: Initiall , :; m5 1s4ort/ actin5 ca7sules2 -$O$ t$i$d$ "sual e66ecti>e dosa5e ran5e is :; to <; m5 t$i$d$ Some 7atients ma re8uire u7 to .; m5 8$i$d$ Ma9imum dail dose is :I; m5$ AdJust dosa5e o>er C to :0 da s to e>aluate

In$i#ati!n Vasos7astic an5ina 1-rinAmetal@s or >ariant an5ina2, classic c4ronic stable an5ina 7ectoris ) 7ertension

Ma increase anti4 7erten si>e e66ect$ Discoura5e use to5et4er$ *in35o: Ma increase e66ects o6 ni6edi7ine$ Discoura5e use to5et4er$ *insen5: Ma increase ni6edi7ine le>elsH 7ossible to9icit $ Discoura5e use to5et4er$ Melatonin: Ma inter6ere =it4 anti4 7erten si>e e66ect$ Discoura5e use to5et4er$ Dru'4f!!$

7rescriber@s su7er>ision$ Alert: Don@t con6use ni6edi7ine =it4 nimodi7ine or nicardi7ine$ T a#"in' P!int& I6 7atient is 3e7t on nitrate t4era7 =4ile ni6edi7ine dosa5e is bein5 adJusted, ur5e continued com7liance$ -atient ma ta3e S$%$ nitro5l cerin, as needed, 6or acute c4est 7ain$ Tell 7atient t4at c4est 7ain ma =orsen brie6l =4en be5innin5 dru5 or =4en dosa5e is increased$

res7onse$ Or, .; to E; m5 1e9tended/ release tablets, e9ce7t Adalat CC2 -$O$ once dail $ Ma9imum dail dose is :<; m5$ AdJust dosa5e o>er C to :0 da s to e>aluate res7onse$ H3) rt n&i!n Adults: .; or E; m5 -$O$ 1e9tended/ release2 once dail $ AdJusted o>er C to :0 da s$ Doses lar5er t4an B; m5 1Adalat CC2 and :<; m5 1-rocardia G%2 aren@t recommended$ Cla&&ifi#ati!n Pr )arati!n not indicated Calcium C!ntrain$i#ati! n Contraindicated in 7atients

*ra7e6ruit Juice: Ma increase bioa>ailabilit o6 ni6edi7ine$ Discoura5e use to5et4er$ E66ects on lab test results Dru'4la7 Ma increase A%T, AST, al3aline 74os74atase , and %D) le>els$

Instruct 7atient to s=allo= e9tended/ release tablets =it4out brea3in5, crus4in5, or c4e=in5 t4em$ Ad>ise 7atient to a>oid ta3in5 dru5 =it4 5ra7e6ruit Juice$ Reassure 7atient ta3in5 t4e e9tended/ release 6orm t4at a =a9/ matri9 U54ostU 6rom t4e tablet ma be 7assed in t4e stools$ Dru5 is com7letel absorbed be6ore t4is occurs$ Tell 7atient to 7rotect ca7sules 6rom direct li54t and moisture and to store at room tem7erature$

c4annel/ bloc3er Antian5inal Anti4 7er/ tensi>e

4 7ersensiti>e to dru5$ "se cautiousl in 7atients =it4 4eart 6ailure or 4 7otension and in elderl 7atients$ "se e9tended/ release tablets cautiousl in 7atients =it4 se>ere *I narro=in5$

G n ri# Nam

A8aila7l f!rm& A#ti!n

P"arma#!.in ti#& Route

Dru'4La74 F!!$ Int ra#ti!n

A$8 r& ff #t CNS: >erti5o, 4eadac4e, diAAiness, 7arest4esia, =ea3ness, restlessness, 6e>er$ CV: ort4ostatic

Nur&in' Int r8 nti!n To 7re>ent nocturia, 5i>e -$O$ and I$M$ 7re7arations in t4e mornin5$ *i>e second dose in earl a6ternoon$

6urosemide

InJection: :; m5Lml Oral solution: :; m5Lml, 0; m5LD ml Tablets: <; m5, 0; m5, I; m5, D;; m5

A 7otent loo7 diuretic t4at in4ibits sodium and c4loride reabsor7tion at t4e 7ro9imal and distal tubules and t4e

Dru'4$ru' Amino5l cosid Oral e antibiotics, Onset / E; min cis7latin: Ma -ea3 / E;T:<; increase min ototo9icit $ Duration / ETI "se to5et4er 4r cautiousl $

ascendin5 loo7 o6 )enle$ IV, IM Onset / D min -ea3 /.; min Duration / < 4r M ta7!li&m/ )e7aticH T:L<: .;TE; min Di&tri7uti!n/ Crosses 7lacentaH enters breast mil3 E(#r ti!n/ +eces, urine

Am74otericin B, corticosteroids , corticotro7in, metolaAone: Ma increase ris3 o6 4 7o3alemia$ Monitor 7otassium le>el closel $ Antidiabetics: Ma decrease 4 7o5l cemic e66ects$ Monitor 5lucose le>el$ Anti4 7ertensi >es: Ma increase ris3 o6 4 7otension$ "se to5et4er cautiousl $ Cardiac 5l cosides, neuromuscula r bloc3ers: Ma increase to9icit o6 t4ese dru5s 6rom 6urosemide/

4 7otension, t4rombo74lebiti s =it4 I$V$ administration$ EENT: transient dea6ness, blurred or ello=ed >ision$ *I: abdominal discom6ort and 7ain, diarr4ea, anore9ia, nausea, >omitin5, consti7ation, 7ancreatitis$ *": nocturia, 7ol uria, 6re8uent urination, oli5uria$ )ematolo5ic: a5ranuloc tosi s, leu3o7enia, t4romboc to7e nia, aAotemia, anemia, a7lastic anemia$ )e7atic: 4e7atic

Alert: Monitor =ei54t, blood 7ressure, and 7ulse rate routinel =it4 lon5/term use and durin5 ra7id diuresis$ +urosemide can lead to 7ro6ound =ater and electrol te de7letion$ I6 oli5uria or aAotemia de>elo7s or increases, dru5 ma need to be sto77ed$ Monitor 6luid inta3e and out7ut and electrol te, B"N, and carbon dio9ide le>els 6re8uentl $ ?atc4 6or si5ns o6 4 7o3alemia, suc4 as muscle =ea3ness and cram7s$

induced 4 7o3alemia$ Monitor 7otassium le>el$ C4lorot4iaAide , c4lort4alidone , 4 droc4lorot4i aAide, inda7amide, metolaAone: Ma cause e9cessi>e diuretic res7onse, causin5 serious electrol te abnormalities or de4 dration$ AdJust doses care6ull , and monitor 7atient closel 6or si5ns and s m7toms o6 e9cessi>e diuretic res7onse$ Et4acr nic

d s6unction$ Metabolic: >olume de7letion and de4 dration, as m7tomatic 4 7eruricemia, im7aired 5lucose tolerance, 4 7o3alemia, 4 7oc4loremic al3alosis, 4 7er5l cemia, and 6luid and electrol te imbalances, includin5 dilutional 4 7onatremia, 4 7ocalcemia, and 4 7oma5nese mia$ Musculos3elet al: muscle s7asm$ S3in: dermatitis, 7ur7ura, 74otosensiti>it reactions, transient 7ain

Consult 7rescriber and dietitian about a 4i54/ 7otassium diet$ +oods ric4 in 7otassium include citrus 6ruits, tomatoes, bananas, dates, and a7ricots$ Monitor 5lucose le>el in diabetic 7atients$ +urosemide ma not be =ell absorbed orall in 7atient =it4 se>ere 4eart 6ailure$ Dru5 ma need to be 5i>en I$V$ e>en i6 7atient is ta3in5 ot4er oral dru5s$ Monitor uric acid le>el, es7eciall in 7atients =it4 a 4istor o6 5out$

0ran$ Nam

D!&a'

In$i#ati!n

acid: Ma at I$M$ inJection increase ris3 site$ o6 ototo9icit $ Ot4er: 5out$ A>oid usin5 to5et4er$ %it4ium: Ma decrease lit4ium e9cretion, resultin5 in lit4ium to9icit $ Monitor lit4ium le>el$ NSAIDs: Ma in4ibit diuretic res7onse$ "se to5et4er cautiousl $ -4en toin: Ma decrease diuretic e66ects o6 6urosemide$ "se to5et4er cautiousl $ -ro7anolol: Ma increase 7ro7ranolol le>el$ Monitor 7atient closel $ Salic lates: Ma cause

Monitor elderl 7atients, =4o are es7eciall susce7tible to e9cessi>e diuresis, because circulator colla7se and t4romboemboli c com7lications are 7ossible$ Store tablets in li54t/resistant container to 7re>ent discoloration 1doesn@t a66ect 7otenc 2$ Re6ri5erate oral 6urosemide solution to ensure dru5 stabilit $ Alert: Don@t con6use 6urosemide =it4 torsemide or %asi9 =it4 %ono9$$ T a#"in' P!int&

%asi9

Acute 7ulmonar edema Adults: 0; m5 I$V$ inJected slo=l o>er : to < minutesH t4en I; m5 I$V$ in E; to B; minutes i6 needed$ Edema Adults: <; to I; m5 -$O$ dail in t4e mornin5, second dose in E to I 4oursH care6ull adJusted u7 to E;; m5 dail i6 needed$ Or, <; to 0; m5 I$V$ or I$M$, increased b <; m5 8 < 4ours until desired e66ect ac4ie>ed$ In6ants and c4ildren: < m5L35 -$O$ dail , increased b : to < m5L35 in E to I 4ours i6

salic late to9icit $ "se to5et4er cautiousl $ Sucral6ate: Ma reduce diuretic and anti4 7ertensi >e e66ect$ Se7arate doses b < 4ours$ Dru'4" r7 Aloe: Ma increase dru5 e66ects$ Discoura5e use to5et4er$ Dandelion: Ma inter6ere =it4 diuretic acti>it $ Discoura5e use to5et4er$ *insen5: Ma decrease loo7 diuretic e66ect$ Discoura5e use to5et4er$ %icorice: Ma cause une97ected ra7id

Ad>ise 7atient to ta3e dru5 =it4 6ood to 7re>ent *I u7set, and to ta3e dru5 in mornin5 to 7re>ent need to urinate at ni54t$ I6 7atient needs second dose, tell 4im to ta3e it in earl a6ternoon, E to I 4ours a6ter mornin5 dose$ In6orm 7atient o6 7ossible need 6or 7otassium or ma5nesium su77lements$ Instruct 7atient to stand slo=l to 7re>ent diAAiness and to limit alco4ol inta3e and strenuous e9ercise in 4ot =eat4er to

neededH care6ull adJusted u7 to E m5L35 dail i6 needed$ ) 7ertension Adults: 0; m5 -$O$ b$i$d$ Dosa5e adJusted based on res7onse$ Ma be used as adJunct to ot4er anti4 7ertensi>e s i6 needed$

7otassium loss$ Discoura5e use to5et4er$ Dru5/li6est le Sun e97osure: Ma increase ris3 6or 74otosensiti>it reactions$ Ad>ise 7atient to a>oid e9cessi>e sunli54t e97osure$ Eff #t& !n la7 t &t r &ult& Ma increase 5lucose, c4olesterol, and uric acid le>els$ Ma decrease 7otassium, sodium, calcium, ma5nesium, and 4emo5lobin le>els$ Ma decrease

Cla&&ifi#ati!n %oo7 diuretic

Pr )arati!n +or direct inJection, 5i>e o>er : to < minutes$ +or in6usion, dilute =it4 DD?, normal saline solution, or lactated Rin5er@s solution, and in6use no more

C!ntrain$i#ati! n Contraindicated in 7atients 4 7ersensiti>e to dru5 and in t4ose =it4 anuria$ "se cautiousl in 7atients =it4 4e7atic cirr4osis and in t4ose aller5ic to

a>oid =orsenin5 diAAiness u7on standin5 8uic3l $ Ad>ise 7atient to immediatel re7ort rin5in5 in ears, se>ere abdominal 7ain, or sore t4roat and 6e>erH t4ese s m7toms ma indicate 6urosemide to9icit $ Alert: Discoura5e 7atient ta3in5 6urosemide at 4ome 6rom storin5 di66erent t 7es o6 dru5s in t4e same container, increasin5 t4e ris3 o6 dru5 errors$ T4e most 7o7ular stren5t4s o6 6urosemide and di5o9in are

t4an 0 m5Lminute to a>oid ototo9icit $ "se 7re7ared in6usion solution =it4in <0 4ours$ Don@t use discolored 1 ello=2 inJectable 7re7aration$

sul6onamides$ "se 6urosemide durin5 7re5nanc onl i6 7otential bene6its to mot4er clearl out=ei54 ris3s to 6etus$

5ranuloc te, ?BC, and 7latelet counts$

=4ite tablets about e8ual in siAe$ Tell 7atient to c4ec3 =it4 7rescriber or 74armacist be6ore ta3in5 OTC dru5s$ Teac4 7atient to a>oid direct sunli54t and to use 7rotecti>e clot4in5 and a sunbloc3 because o6 ris3 o6 74otosensiti>it reactions$ A$8 r& ff #t CNS: diAAiness, li54t/ 4eadedness, somnolence, 4eadac4e, =ea3ness, s nco7e, ner>ousness$ Nur&in' Int ra#ti!n Don@t 5i>e immediate/ release 6orm =it4in : =ee3 o6 acute MI or in acute coronar s ndrome$

G n ri# Nam

A8aila7l f!rm& A#ti!n

P"arma#!.in t i#& Oral Onset / <; min -ea3 / .; min SR Onset / <; min -ea3 / <$DTE 4r

Dru'4La74 F!!$ Int ra#ti!n Dru'4$ru' Cimetidine, ranitidine: Ma decrease ni6edi7ine metabolism$ Ma need to

ni6edi7ine

Ca7sules: :; m5, <; m5 Tablets 1e9tended/ release2: .; m5, E; m5, B; m5

"n3no=n$ T4ou54t to in4ibit calcium ion in6lu9 across cardiac and smoot4/muscle cells, decreasin5

contractilit and o9 5en demand$ Also ma dilate coronar arteries and arterioles$

M ta7!li&m/ )e7aticH T:L<: <T D 4r Di&tri7uti!n/ Crosses 7lacentaH enters breast mil3 E(#r ti!n/ +eces, urine

adJust dosa5e$ Di5o9in: Ma cause ele>ated di5o9in le>el$ Monitor di5o9in le>el$ +entan l: Ma cause se>ere 4 7otension$ Monitor blood 7ressure$ -4en toin: Ma reduce 74en toin metabolism$ Monitor 74en toin le>el$ -ro7ranolol, ot4er beta bloc3ers: Ma cause 4 7otension and 4eart 6ailure$ "se to5et4er cautiousl $

CV: 7eri74eral edema, 4 7otension, 7al7itations, 4eart 6ailure, MI, 6lus4in5$ EENT: nasal con5estion$ *I: nausea, diarr4ea, consti7ation, abdominal discom6ort$ Musculos3elet al: muscle cram7s$ Res7irator : d s7nea, 7ulmonar edema, cou54$ S3in: ras4, 7ruritus$

Alert: Des7ite t4e 7re>iousl =ides7read S$%$ use o6 ni6edi7ine ca7sules 1or t4e Ubite and s=allo=U met4od2, a>oid t4is route o6 administration$ E9cessi>e 4 7otension, MI, and deat4 ma result$ Monitor blood 7ressure re5ularl , es7eciall in 7atients =4o ta3e beta bloc3ers or anti4 7ertensi> es$ ?atc4 6or s m7toms o6 4eart 6ailure$ Alt4ou54 rebound e66ect 4asn@t been obser>ed =4en dru5 is sto77ed,

0ran$ Nam

D!&a' 2a&!&)a&ti# an'ina DPrin;m talF& !r 8ariant an'inaE* #la&&i# #"r!ni# &ta7l an'ina ) #t!ri& Adults: Initiall , :; m5 1s4ort/ actin5 ca7sules2 -$O$ t$i$d$ "sual e66ecti>e dosa5e ran5e is :; to <; m5 t$i$d$ Some 7atients ma re8uire u7 to .; m5 8$i$d$ Ma9imum dail dose is :I; m5$ AdJust dosa5e

In$i#ati!n Vasos7astic an5ina 1-rinAmetal@s or >ariant an5ina2, classic c4ronic stable an5ina 7ectoris ) 7ertension

Dru'4" r7 Don5 8uai: Ma increase anti4 7erten si>e e66ect$ Discoura5e use to5et4er$ *in35o: Ma increase e66ects o6 ni6edi7ine$ Discoura5e use to5et4er$ *insen5: Ma increase ni6edi7ine le>elsH 7ossible to9icit $ Discoura5e use to5et4er$ Melatonin: Ma inter6ere =it4 anti4 7erten si>e e66ect$ Discoura5e use

reduce dosa5e slo=l under 7rescriber@s su7er>ision$ Alert: Don@t con6use ni6edi7ine =it4 nimodi7ine or nicardi7ine$ T a#"in' P!int& I6 7atient is 3e7t on nitrate t4era7 =4ile ni6edi7ine dosa5e is bein5 adJusted, ur5e continued com7liance$ -atient ma ta3e S$%$ nitro5l cerin, as needed, 6or acute c4est 7ain$ Tell 7atient t4at c4est 7ain ma =orsen brie6l =4en be5innin5 dru5 or =4en

o>er C to :0 da s to e>aluate res7onse$ Or, .; to E; m5 1e9tended/ release tablets, e9ce7t Adalat CC2 -$O$ once dail $ Ma9imum dail dose is :<; m5$ AdJust dosa5e o>er C to :0 da s to e>aluate res7onse$ H3) rt n&i!n Adults: .; or E; m5 -$O$ 1e9tended/ release2 once dail $ AdJusted o>er C to :0 da s$ Doses lar5er t4an B; m5 1Adalat CC2 and :<; m5 1-rocardia G%2 aren@t recommended$ Cla&&ifi#ati!n Pr )arati!n C!ntrain$i#ati! n

to5et4er$ Dru'4f!!$ *ra7e6ruit Juice: Ma increase bioa>ailabilit o6 ni6edi7ine$ Discoura5e use to5et4er$ E66ects on lab test results Dru'4la7 Ma increase A%T, AST, al3aline 74os74atase , and %D) le>els$

dosa5e is increased$ Instruct 7atient to s=allo= e9tended/ release tablets =it4out brea3in5, crus4in5, or c4e=in5 t4em$ Ad>ise 7atient to a>oid ta3in5 dru5 =it4 5ra7e6ruit Juice$ Reassure 7atient ta3in5 t4e e9tended/ release 6orm t4at a =a9/ matri9 U54ostU 6rom t4e tablet ma be 7assed in t4e stools$ Dru5 is com7letel absorbed be6ore t4is occurs$ Tell 7atient to 7rotect ca7sules 6rom direct li54t and

not indicated Calcium c4annel/ bloc3er Antian5inal Anti4 7er/ tensi>e

Contraindicated in 7atients 4 7ersensiti>e to dru5$ "se cautiousl in 7atients =it4 4eart 6ailure or 4 7otension and in elderl 7atients$ "se e9tended/ release tablets cautiousl in 7atients =it4 se>ere *I narro=in5$

moisture and to store at room tem7erature$

G n ri# Nam

A8aila7l f!rm& A#ti!n

P"arma#!.in t i#&

Dru'4La74 F!!$ Int ra#ti!n Dru5/dru5

A$8 r& ff #t CNS/ Verti5o, 4eadac4e, 7arest4esias, insomnia, seiAures, 7s c4osis C2/) 7otensio n, s4oc3, 4 7ertension and C)+ secondar to 6luid retention, t4romboemboli sm, t4rombo74lebiti s, 6at embolism, cardiac arr4 t4mias secondar to electrol te disturbances D rmat!l!'i#/ T4in, 6ra5ile s3inH 7etec4iaeH ecc4 mosesH 7ur7uraH striaeH

Nur&in' Int ra#ti!n 9ARNING/ *i>e dail be6ore B AM to mimic normal 7ea3 diurnal corticosteroid le>els and minimiAe )-A su77ression$ S7ace multi7le doses e>enl t4rou54out t4e da $ Do not 5i>e IM inJections i6 7atient 4as t4romboc to7e nic 7ur7ura$ Rotate sites o6 IM re7ositor inJections to a>oid local atro74 $ "se minimal doses 6or minimal

4 drocortisone sodium succinate

TabletsFD, :;, <; m5H oral sus7ensionF:; m5LD m%, <D, D; m5Lm%H inJectionF<D, D; m5Lm%, :;;, <D;, D;;, :,;;; m5L>ialH to7ical lotionF ;$<DV, ;$DV, :V, <V, <$DVH to7ical li8uidF :VH to7ical oilF :VH to7ical solutionF:VH to7ical s7ra F :VH creamF ;$<V, ;$DV, :V, <$DVH ointment F;$DV, :V, <$DVH to7ical 5el F:V, <V

Enters tar5et cells and binds to c to7lasmic rece7torsH initiates man com7le9 reactions t4at are res7onsible 6or its anti/ in6lammator , immunosu77res si>e 15lucocorticoid2, and salt/ retainin5 1mineralocorticoi d2 actions$ Some actions ma be undesirable, de7endin5 on dru5 use$

Oral Onset /:/<4ours Increased -ea3 T :/<4ours steroid blood le>els =it4 IM 4ormonal Onset / ra7id contrace7ti> -ea3 T 0/I4rs es,troleando m cin,3etoc I2 onaAole, Onset/ estro5en immediate -ea3/ "n3o=n Decreased steroid blood PR le>els =it4 Onset/slo= 74en toin, -ea3/ ./D da s 74enobarbit al, ri6am7in, c4olest rami M ta7!li&m/ ne )e7aticH T:L<: I;T:<; min Decreased serum le>el Di&tri7uti!n/ o6 salic lates Crosses 7lacentaH enters Decreased breast mil3 e66ecti>enes s o6 E(#r ti!n/ antic4olinest "rine erases

1ambenoniu m, edro74oniu m, neosti5mine, 7 ridosti5mi ne2, 3etoconaAol e, estro5en

subcutaneous 6at atro74 EENT/ Cataracts, 5laucoma 1lon5/term t4era7 2, increased IO-

duration to minimiAe ad>erse e66ects$ Ta7er doses =4en discontinuin5 4i54/dose or lon5/term t4era7 $ Arran5e 6or increased dosa5e =4en 7atient is subJect to unusual stress$ Ensure t4at ade8uate amount o6 Ca<K is ta3en i6 7rolon5ed administration o6 steroids$ "se alternate/ da maintenance t4era7 =it4 s4ort/actin5

Dru5/lab test En$!#rin / Amenorr4ea, +alse/ irre5ular ne5ati>e menses, nitroblue/ 5ro=t4 tetraAolium retardation, test 6or decreased bacterial carbo4 drate in6ection tolerance and 1=it4 diabetes s stemic mellitus, absor7tion2 cus4in5oid state 1lon5/ Su77ression term t4era7 2, )-A o6 s3in test su77ression reactions s stemic =it4 t4era7 lon5er Ma t4an D da s decrease serum GI/ -e7tic or 7otassium eso74a5eal le>els, T.,

and T0 le>els ulcer, 7ancreatitis, abdominal distention, nausea, >omitin5, increased a77etite and =ei54t 5ain 1lon5/term t4era7 2 H mat!l!'i#/ NaK and 6luid retention, 4 7o3alemia, 4 7ocalcemia, increased blood su5ar, increased serum c4olesterol, decreased serum T. and T0 le>els

corticosteroids =4ene>er 7ossible$ 9ARNING/ Do not 5i>e li>e >irus >accines =it4 immunosu77re ssi>e doses o6 4 drocortisone$ -ro>ide antacids bet=een meals to 4el7 a>oid 7e7tic ulcer$ To7ical dermatolo5ic administration

"se caution =it4 occlusi>e dressin5sH ti54t or 7lastic H3) r& n&iti8i dia7ers o>er t3/ a66ected area Ana74 lactoid can increase or s stemic 4 7ersensiti>it absor7tion$ reactions

0ran$ Nam Solu/Corte6

D!&a' AD"%TS Indi>idualiAe dosa5e, based on se>erit and res7onse$ *i>e dail dose be6ore B AM to minimiAe adrenal su77ression$ I6 lon5/term t4era7 is needed, alternate/da t4era7 s4ould be considered$ A6ter lon5/term t4era7 , =it4dra= dru5

In$i#ati!n Re7lacement t4era7 in adrenal cortical insu66icienc Aller5ic statesF se>ere or inca7acitatin5 aller5ic conditions ) 7ercalcemia associated =it4 cancer S4ort/term in6lammator and aller5ic disorders, suc4

Mu&#ul!&. l tal/ Muscle =ea3ness, steroid m o7at4 and loss o6 muscle mass, osteo7orosis, s7ontaneous 6ractures 1lon5/ term t4era7 2 Ot" r/ Immunosu77re ssion, a55ra>ation or mas3in5 o6 in6ections, im7aired =ound 4ealin5

A>oid 7rolon5ed use, es7eciall near e es, in 5enital and rectal areas, on 6ace, and in s3in creases$ T a#"in' P!int& Ta3e t4is dru5 e9actl as 7rescribed$ Do not sto7 ta3in5 t4is dru5 =it4out noti6 in5 our 4ealt4 care 7ro>iderH slo=l ta7er dosa5e to a>oid 7roblems$ Dosa5e reductions ma create adrenal insu66icienc $ Re7ort an 6ati5ue, muscle and Joint 7ains,

slo=l to a>oid adrenal insu66icienc $ +or maintenance t4era7 , reduce initial dose in small increments at inter>als until lo=est clinicall satis6actor dose is reac4ed$ IM, IV 14 drocortisone sodium succinate2 :;;TD;; m5 initiall and 8 <T :; 4r, based on condition and res7onse$ Acute adrenal insu66icienc 14 drocortisone sodium 74os74ate2: :;; m5 IV 6ollo=ed b

as r4eumatoid art4ritis, colla5en diseases 1S%E2, dermatolo5ic diseases 17em74i5us2, status ast4maticus, and autoimmune disorders )ematolo5ic disordersF t4romboc to7en ic 7ur7ura, er t4roblasto7e nia Tric4inosis =it4 neurolo5ic or m ocardial in>ol>ement "lcerati>e colitis, acute e9acerbations o6 MS, and 7alliation in some leu3emias

anore9ia, nausea, >omitin5, diarr4ea, =ei54t loss, =ea3ness, diAAiness, or lo= blood su5ar 1i6 ou monitor blood su5ar2$ Ta3e =it4 meals or snac3s i6 *I u7set occurs$ Ta3e sin5le dail or alternate/da doses be6ore B AMH mar3 calendar or use ot4er measures as reminder o6 treatment da s$ Do not o>eruse Joint a6ter intra/ articular inJections, e>en

:;; m5 8 I 4r in IV 6luids$ -EDIATRIC -ATIENTS Indi>idualiAe dosa5e based on se>erit and res7onse rat4er t4an on 6ormulae t4at correct adult doses 6or a5e or =ei54t$ Care6ull obser>e 5ro=t4 and de>elo7ment in in6ants and c4ildren on 7rolon5ed t4era7 $ Oral 14 drocortisone and c 7ionate2 <;T<0; m5Lda in sin5le or di>ided doses$ AD"%TS AND

and l m74omas Intra/articular or so6t/tissue administration: Art4ritis, 7soriatic 7la8ues Retention enema: +or ulcerati>e colitis, 7roctitis Dermatolo5ic 7re7arations: To relie>e in6lammator and 7ruritic mani6estations o6 dermatoses t4at are steroid res7onsi>e Anorectal cream, su77ositories: To relie>e discom6ort o6 4emorr4oids and 7erianal

i6 7ain is 5one$ +re8uent 6ollo=/u7 >isits to our 4ealt4 care 7ro>ider are needed to monitor dru5 res7onse and adJust dosa5e$ ?ear a medical alert ID 1lon5/term t4era7 2 so t4at an emer5enc medical 7ersonnel =ill 3no= t4at ou are ta3in5 t4is dru5$ &ou ma e97erience t4ese side e66ects: Increase in a77etite, =ei54t 5ain 1some o6 5ain ma be 6luid

-EDIATRIC -ATIENTS IV, IM or subcutaneous 14 drocortisone and 4 drocortisone sodium 74os74ate2 <;T<0; m5Lda usuall in di>ided doses 8 :< 4r$ IM, IV 14 drocortisone sodium succinate2 Reduce dose, based on condition and res7onse, but 5i>e no less t4an <D m5Lda $ Retention enema 14 drocortisone2

itc4in5 or irritation

retentionH monitor inta3e2H 4eartburn, indi5estion 1eat 6re8uent small mealsH use o6 antacids ma 4el72H increased susce7tibilit to in6ection 1a>oid cro=ds durin5 7ea3 cold or 6lu seasons, and a>oid an one =it4 a 3no=n in6ection2H 7oor =ound 4ealin5 1i6 inJured or =ounded, consult 4ealt4 care 7ro>ider2H muscle =ea3ness, 6ati5ue 16re8uent rest 7eriods ma 4el72$ Re7ort unusual =ei54t 5ain, s=ellin5 o6

: :;; m5 ni54tl 6or <: da s$ Intrarectal 6oam 14 drocortisone acetate2 : a77licator dail or bid 6or < =3 and e>er second da t4erea6ter$ Intra/articular, intralesional 14 drocortisone acetate2 DT<D m5, de7endin5 on Joint or so6t/ tissue inJection site$ To7ical dermatolo5ic 7re7arations A77l s7arin5l to a66ected area bidT8id$ Pr )arati!n

lo=er e9tremities, muscle =ea3ness, blac3 or tarr stools, >omitin5 o6 blood, e7i5astric burnin5, 7u66in5 o6 6ace, menstrual irre5ularities, 6e>er, 7rolon5ed sore t4roat, cold or ot4er in6ection, =orsenin5 o6 s m7toms$

Cla&&ifi#ati!n

C!ntrain$i#ati!

n S stemic administration Corticosteroid, s4ort actin5 *lucocorticoid Adrenal cortical steroid )ormone Contraindicated =it4 6un5al in6ections, amebiasis, 4e7atitis B, >accinia, or >aricella, and antibiotic/ resistant in6ections$ "se cautiousl =it4 3idne disease 1ris3 to edema2H li>er disease, cirr4osis, 4 7ot4 roidismH ulcerati>e colitis =it4 im7endin5 7er6orationH di>erticulitisH recent *I sur5er H acti>e or latent 7e7tic ulcerH in6lammator bo=el disease 1ris3s

e9acerbations or bo=el 7er6oration2H 4 7ertension, C)+H t4romboemboliti c tendencies, t4rombo74lebitis , osteo7orosis, seiAure disorders, metastatic carcinoma, diabetes mellitusH TBH lactation$ Retention enemas, intrarectal 6oam Contraindicated =it4 s stemic 6un5al in6ections, recent intestinal sur5er , e9tensi>e 6istulas$ "se cautiousl

=it4 7re5nanc $ To7ical dermatolo5ic administration Contraindicated =it4 6un5al, tubercular, 4er7es sim7le9 s3in in6ectionsH >accinia, >aricellaH ear a77lication =4en eardrum is 7er6orated$ "se cautiousl =it4 7re5nanc , lactation$

Di&#"ar' $ Plannin' M 4 Strict com7liance to medication re5imen/Antibiotics 6or C da s MAm7icillin Rati!nal / to 7re>ent secondar in6ection E T H ,ee7 t4e 5enital area clean Rati!nal / it 4el7s reduce t4e c4ance o6 introducin5 bacteria 6rom t4e rectal area to t4e uret4ra$ - Instruct 7atient to do 4and =as4in5 be6ore and a6ter urination and do not dela urination =4en it is necessar $ O Encoura5e t4e 7atient to >isit t4e 74 sician 6or condition monitorin5$ Em74asiAe t4e im7ortance o6 6ollo= u7 e9aminations is necessar to detect c4ronic renal 6ailure Encoura5e t4e 7atient to 4a>e a lo= c4olesterol and lo= sodium diet includes Encoura5e t4e 7atient to continue 7ra in5 and see3 5uidance 6rom *od Discuss t4e >i5orous su77orti>e care includes bed rest, 6luid and dietar sodium restrictions and correction o6 electrol tes imbalances Encoura5e 7atient to 4a>e a clean and sa6e en>ironment 6or 6aster reco>er $ Clean and sa6e en>ironment 7romotes com6ort and rela9ation 6or 6aster reco>er o6 t4e 7atient$ Encoura5e t4e 7atient to be calm and maintain a com6ort 7osition$ Educate t4e 7atients care ta3er t4e im7ortance o6 7ro7er medication administration and timin5$

D S -