CP Acute Renal Failure Chap7

CHAPTER VII MEDICAL AND NURSING MANAGEMENT
This chapter presents the laboratory tests of the patient and the interpretation of the results. It also includes the laboratory results, discharge planning, drug studies, health teachings, prognosis, problem list, Gordons functional health patterns, prioritization of nursing diagnoses and nursing care plans.
IDEAL MEDICAL AND NURSING MANAGEMENT a. Medical Management Laboratory and Diagnostics Examinations:
o
Serum creatinine An increase in the amount of creatinine in the blood (serum creatinine) is usually the first sign of acute renal failure. Repeated tests of serum creatinine can help monitor the progress of renal failure and can help determine whether treatment has been successful.
Blood urea nitrogen (BUN)
BUN measures the amount of nitrogen in your blood that comes from the waste product urea. If your kidneys are not
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able to remove urea from the blood normally, your BUN level increases.
o
Blood electrolyte tests, such as calcium, phosphate (phosphorus), potassium, and sodium. Potassium testing is used to detect concentrations that are too high or too low. While calcium test aids in the diagnosis of neuromuscular, skeletal, and endocrine disorders; arrhythmias; blood-clotting deficiencies; and acid-base imbalance.
Complete blood count (CBC)
A CBC provides important information about the red blood cells, white blood cells, and platelets. It can be used to check for diseases or infections that could be causing renal failure.
Erythrocyte sedimentation rate (ESR, or sed rate) or antinuclear antibodies (ANA) test
These may be used to screen for infection, autoimmune disease, and other disorders, if your medical history and symptoms suggest that one of these conditions might be present.
Urinalysis
Examines a sample of your urine. The results can provide information about urine sediment, which is useful for evaluating kidney damage (intrinsic acute renal failure).
It also looks for:
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o Urine eosinophils
A type of white blood cell. The presence of eosinophils in the urine may be a sign that an allergic reaction is damaging the kidneys. Often the allergic reaction is caused by a medicine.
Fractional excretion of sodium (FeNa)
It measures how well the kidneys can process sodium (Na), based on the levels of sodium and creatinine in both the urine and the blood. This test can help distinguish pre renal acute renal failure, where there has been no damage to the kidney itself, from intrinsic acute renal failure, caused by damage to the kidneys.
24-hour urine collection
Urine output is measured over a 24-hour period. You may have a small tube (catheter) inserted into your bladder to collect all of the urine you produce. Reduced urine output may or may not occur with acute renal failure, depending on the cause. Careful measurement of urine output over time can also help monitor fluid balance in a person who has renal failure.
Retrograde pyelography
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During this test, the doctor inserts a thin, lighted tube (cystoscope) into your urethra. A catheter is then put through the cystoscope and into a ureter. Dye is injected through the catheter and X-rays are taken.
o Renal Ultrasonography Estimates renal size and rules out treatable obstructive uropathy.
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Magnetic resonance imaging (MRI) For this type of MRI, the abdomen is positioned inside a strong magnetic field. The MRI can detect changes in the structure of the kidneys and urinary tract.
Kidneys scan (renal scintigraphy) A kidney scan may also help evaluate whether blood flow to the kidney is normal or whether a blockage is present.
o The doctors may recommend/ do: Evaluation of acute renal failure with a medical history and physical exam. Check all the medicines that have been taken and ask about any other illnesses.
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Surgical relief of obstruction. Correction of underlying fluid excess or deficits. Correction and control of biochemical imbalances such as in:
HYPERKALEMIA give glucose and insulin to shift potassium into cells; cation exchange resin orally or by enema to promote rectal excretion of potassium.
ACIDOSIS give sodium bicarbonate; be prepared for mechanical ventilation.
Restoration and maintenance of blood pressure through IV fluids and vasopressors. Maintenance of adequate nutrition Low protein diet with supplemental amino acids and vitamins. Administration of a low protein diet to delay inevitable renal replacement therapy or to lengthen the interval between sessions is physiologically unsound. Initiation of hemodialysis, peritoneal dialysis or continuous renal replacement therapy for patients with progressive azotemia and other life threatening complications. Dialysis as needed to control hyperkalemia, pulmonary edema, metabolic acidosis, and uremic symptoms
Adjustment of drug regimen.
b.
Nursing Management
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Assessment
During the Oliguric anuric phase: Assess urine volume less than 400 mL per 24 hours; increase in serum creatinine, urea, uric acid, organic acids, potassium and magnesium; lasts 3 to 5 days if infants and children, 10 to 14 days in adolescents and adults.
During the Diuretic phase: Assess when it begins with urine output exceeds 500 mL per 24 hours and ends when BUN and creatinine levels stop rising; length is variable.
Recovery Phase: asymptomatic; lasts several months to 1 year. In Pre renal disease: Decrease tissue turgor, dryness of mucous membranes, weight loss, flat neck veins, hypotension and tachycardia.
In Intra renal disease: presentation usually varies; usually have edema, may have fever, skin rash.
Assess for nausea, vomiting, diarrhea and lethargy.
Diagnosis Disturbed thought processes Excess fluid volume Imbalanced Nutrition: Less than body Requirements Risk for infection
Planning The goals are to attain optimal level of nutrition, maintenance of F&E balance, maintenance of optimal tissue healing and avoidance of complications.
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Nursing Interventions MONITORING Monitor 24- hour urine volumes to follow clinical course of the disease. Monitor BUN, creatinine and electrolytes. Monitor signs and symptoms of hypovolemia or hypervolemia because regulating capacity of kidneys is in adequate.
Monitor urine specific gravity; measure and record intake and output, including urine gastric suction, stools, wound drainage, perspiration. Specific gravity fixed at 1.010 indicates kidneys inability to concentrate urine.
Monitor electrocardiogram for dysrhythmias and changes associated with electrolyte imbalance, and report signs and symptoms of hyperkalemia.
Monitor ABG levels as necessary to evaluate acid- base balance.
Weigh the patient daily to provide an index of fluid balance. Measure blood pressure at various times during the day with patients in supine, sitting and standing positions.
Monitor for signs of infection. Watch and report mental status changes, including lassitude, lethargy and fatigue progressing to irritability, disorientation, twitching and seizures.
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SUPPORTIVE CARE
Adjust fluid intake to avoid volume overload and dehydration. a. Fluid restriction is not usually initiated until renal function is quite low. b. Give only enough fluids to replace losses during oliguric anuric phase. c. Fluid allowance should be distributed throughout the day. d. Restrict sodium and water intake if there is evidence of extracellular excess.
Watch for cardiac dysrhythmias and heart failure from hyperkalemia, electrolyte imbalance or fluid overload. Have resuscitation equipment available in case of cardiac arrest.
Treat hyperkalemia as ordered: administer sodium bicarbonate or glucose and insulin to drive potassium cells.
Watch for signs of urinary tract infection and remove bladder catheter as soon as possible.
Work with the dietician to regulate protein intake according to the type of renal impairment. Protein and potassium are usually restricted.
Institute seizure precautions, provide padded side rails and have airway and suction equipment at the bedside.
Encourage and assist the patient to turn and move because drowsiness and lethargy may reduce activity.
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HEALTH TEACHINGS Explain that the patient may experience residual defects in kidney function for long time for acute illness. Encourage the patient to report for routine urinalysis and follow up examinations. Advise patient to avoid any medication unless specifically prescribed. Recommend resuming activity gradually because muscle weakness will be present from excessive catabolism. Evaluation Expected Patient Outcomes
Consumes a healthy and balance diet. Maintains fluid balance. Feels less anxious. Acquires information about diagnosis, surgical procedure and self care after discharge.
Express feelings and concerns about self. Recovers without complications.
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ACTUAL MEDICAL AND NURSING MANAGEMENT
COMPLETE BLOOD COUNT 01/15/11 A complete blood count is a common blood test, providing information on the general health status and is a tool for checking disorders such as anemia, infection and thrombocytopenia. Complete blood count provides detailed information about three types of cells: red blood cells, white blood cells and platelets. PURPOSES: To assess overall health. To diagnose a medical condition. To monitor medical treatment. To monitor medical condition.
PREPARATION: If blood sample is tested only for CBC, a person can eat and drink normally before the test.
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If a person is having other/additional test at the same time, she may need to fast for a certain amount of time before the test. PROCEDURE: A member of health care team specifically a Medical technologist takes a sample of blood. A needle is inserted into the nein in the arm. The blood sample is brought/ sent to the laboratory for analysis.
NURSING RESPONSIBILITIES: Explain to the patient the purpose of the test. Tell the patient that a blood sample will be taken and that she may feel slight discomfort from the tourniquet and needle puncture. Use gloves when obtaining and handling all specimens. Transport specimen to the laboratory as soon as possible.
Diagnostic/laboratory
Date 01/15/11
Result
Normal values
Interpretation
WBC
19.17
5-10 x 10 g/L
Monocytes
0.05
0.030.06 %
Increase indicates infection (urinary tract infection) Still within the normal range.
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Eosinophil
0.01
0.020.04 %
Basophils Neutrophils Hemoglobin
0.00 0.82 173.4
0.000.01 % 0.550.65 % 120140 SI g/L 0.400.50 x 10 ^ 12/ L
Hematocrit
0.52
RBC
6.0
4.5-5.0 u^3 82-92 u ^3 32- 36 g/dl 27-31 pg
MCV MCHC
86 38.5
MCH
33.2
Platelet
337
150350 x
Slight decrease, no significance but low value may indicate allergies and endocrine disorders Within normal range Increase indicates infection. Increase may occur due to dehydration. Increase may be due to dehydration/ several episodes of vomiting. Increase may be due to dehydration. Within normal range Increase may indicate anemia. Increase may indicate anemia (pernicious). Within normal
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10^ g/L
range
FECALYSIS 01/15/11 Fecalysis is also known as stool analysis. It refers to a series of laboratory tests done on fecal samples to analyze the condition of a persons digestive tract in general. Among other things, a fecalysis is performed to check for the presence of any reducing substances such as white blood cells (WBCs), sugars, or bile and signs of poor absorption as well as screen for colon cancer. Fecalysis is the basic examination of the stool which includes the inspection of the consistency, color and testing for occult blood. It is inexpensive and noninvasive that can be performed at home as well as at the doctors office. PREPARATION: If he is taking any medications, these must be screened as some can affect test results. A patient is usually discouraged as well from taking aspirin, alcohol, vitamin C, ibuprofen and certain types of food if his fecal sample will be checked for any sign of blood. Recent travel and X-Ray tests can also affect the results of fecalysis.
PROCEDURE:
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The patient must urinate first to prevent any urine from mixing with his feces later on.
He must also wear gloves when its time to handle stool and transfer it to a safer container. Solid and liquid fecal samples are both acceptable as long as they do not have urine or other foreign substances like soap, water, and toilet paper mixed in them.
If the patient is suffering from diarrhea, placing a plastic wrap and securing it under the toilet seat could facilitate the collection process.
Collected samples must be brought to the doctors office or laboratory as soon as possible. Delays could compromise the quality of the sample. Volume or amount is also important so the patient must be sure he has collected an adequate amount of stool.
Diagnostic/ laboratory Consistency
Date 01/15/11
Result
Normal values
Interpretation
Watery
Color
Yellow
Soft and bulky, small and dry, dependi ng on the diet. Brown
May indicate metabolic problems
RBC
0-1/ HPF
None
Change in color depends on the kind of food taken. May indicate GI bleeding
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Pus cells Remarks: intestinal ova and parasites seen.
0-2/HPF
None
May indicate infection
CLINICAL CHEMISTRY SECTION 01/15/11 This test is used to measure serum levels of calcium, the most abundant mineral in the body. More than 98% of the body's calcium is found in bones and teeth, but relative concentrations in those structures may vary as the body maintains calcium balance. The body excretes calcium daily, regular ingestion of calcium in food (at least 1 g/day) is necessary for normal calcium balance. It is used to detect concentrations that are too high or too low. Purpose To aid diagnosis of neuromuscular, skeletal, and endocrine disorders; arrhythmias; blood-clotting deficiencies; and acid-base imbalance. Patient preparation
Explain to the patient that this test is used to determine blood calcium levels.
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Tell him that the test requires a blood sample. Explain who will perform the venipuncture and when.
Explain that he may experience slight discomfort from the needle puncture and the tourniquet but that collecting the sample usually take less than 3 minutes.
Inform him that he needn't restrict food or fluids before the test.
Procedure and posttest care
Perform a venipuncture (without a tourniquet if possible), and collect the sample in a 7-ml red-top or red marble-top tube.
If a hematoma develops at the venipuncture site, apply warm soaks.
Diagnostic/ laboratory Potassium
Date 01/15/11
Result
Normal values
Interpretation
4.3 mmol/ L 3.05 mmol/L
3.5- 5.1 mmol/ L 2.102.54 mmol/L
Calcium
Still within normal range. Increase may be due to episodes of vomiting. Still
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Sodium
144
137-145
mmol/L Creatinine 2.2 mg/dl
mmol/L 0.8- 1.5
within normal range. Increase may be due t dehydrati on and may indicate impaired kidney function.
URINALYSIS 01/16/11 Urinalysis is a test that evaluates a sample of your urine. It is used to detect and assess a wide range of disorders, including urinary tract infection, kidney disorders and diabetes. Urinalysis involves examining the appearance, concentration and content of urine. A laboratory technician will examine the urines appearance. Urinalysis is also called the Dipstick test.
PURPOSE: To assess your overall health. To diagnose a medical condition. To monitor a medical condition.
PREPARATION:
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If urine is tested only for urinalysis, a person can eat and drink normally before the test.
If a person is having other/additional test at the same time, she may need to fast for a certain amount of time before the test.
PROCEDURE: A laboratory technician will examine the urines appearance. Urine can be collected at home or at the doctors office. A container will be given for the urine sample. Ideally urine should be collected in the morning because at that time urine is concentrated and abnormal results may be obvious. The urine sample should be collected using a clean- catch method at least 15 mL. Deliver the sample to the laboratory, if you cant deliver it within 30 minutes; refrigerate the sample unless youve been instructed. The urine sample is then tested by placing a dipstick in the urine.
NURSING RESPONSIBILITIES: Explain how to collect a clean catch specimen of at least 15 mL. Explain that there is no food or fluids restriction. Obtain a first voided morning specimen if possible. Medications may be restricted for it may affect laboratory results.
Diagnostic/ Laboratory
Date
Result
Normal values
Interpretation
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01/16/11 Color Yellow Straw yellow, amber Clear Normal
Transparency
Hazy
Reaction Specific gravity Sugar Albumin
5.0 1.020 Negative Positive (3+)
4.5-8 1.0021.030 Negative Negative
Signifies high level of sediment may be present in case of urinary tract infection and an indicator of kidney disorder. Still within normal range. Still within normal range Normal Large amounts of protein may indicate kidney problem. Normal It may indicate any kidney problems. Pus cells in the urine may
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Crystals Amorphous urates
None Few
None None
Pus cell
0-2/ HPF
Negative
Erythrocytes
1015/HPF
Negative
indicate infection. Indicates kidney disorder, blood disorder or bladder cancer.
CLINICAL CHEMISTRY SECTION 01/17/11 This test is used to measure serum levels of calcium, the most abundant mineral in the body. More than 98% of the body's calcium is found in bones and teeth, but relative concentrations in those structures may vary as the body maintains calcium balance. The body excretes calcium daily, regular ingestion of calcium in food (at least 1 g/day) is necessary for normal calcium balance. Purpose To aid diagnosis of neuromuscular, skeletal, and endocrine disorders; arrhythmias; blood-clotting deficiencies; and acid-base imbalance. Patient preparation
Explain to the patient that this test is used to determine blood calcium levels.
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Tell him that the test requires a blood sample. Explain who will perform the venipuncture and when.
If a hematoma develops at the venipuncture site, apply warm soaks. Date 01/17/11 Result Normal values Interpretation
2.8 mmol/ L
3.5- 5.1 mmol/ L
Calcium
1.37 mmol/L
2.102.54 mmol/L 137-145 mmol/L
Sodium
130 mmol/L
Decrease may be due to dehydrati on and vomiting. Decrease may indicate low cardiac status. Decrease may be caused by excessive fluid loss caused by
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vomiting and diarrhea.
CLINICAL CHEMISTRY SECTION POTASSIUM TEST 01/19/11
Potassium testing is frequently ordered along with other electrolytes, a part of routine physical. It is used to detect concentrations that are too high or too low. Potassium is a mineral vital to skeletal, cardiac and smooth muscle activity. It is involved in maintaining acid- base balance and as well as contributes to the intracellular enzyme reactions.
Purpose: To aid in the diagnosis of skeletal and cardiac disorders as well as acid- base imbalance.
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Patient preparation

Explain to the patient that this test is used to determine blood potassium levels. Tell him that the test requires a blood sample. Explain who will perform the venipuncture and when.
If a hematoma develops at the venipuncture site, apply warm soaks. Date 01/19/11 Result Normal values Interpretation
4.1 mmol/ L
3.5- 5.1 mmol/ L
Still within normal range.
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ARTERIAL BLOOD GAS ANALYSIS 01/19/11 Arterial blood gas (ABG) analysis is used to measure the partial pressures of oxygen (PaO2), carbon dioxide (pacO2), the pH of an arterial sample, Oxygen content (O2CT), oxygen saturation (SaO2) and bicarbonate (RCO3 -) values. A blood sample for ABG analysis may be drawn by percutaneous arterial puncture or from an arterial line.
Purpose

To evaluate gas exchange in the lungs. To assess integrity of the ventilatory control system. To determine the acid-base level of the blood. To monitor respiratory therapy.
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Patient preparation
Explain to the patient that this test is used to evaluate how well the lungs are delivering oxygen to blood and eliminating carbon dioxide.
Tell him that the test requires a blood sample. Explain who will perform the arterial puncture and when and which site - radial, brachial, or femoral artery has been selected for the puncture.
Inform him that he needn't restrict food or fluids. Instruct the patient to breathe normally during the test, and warn him that he may experience a brief cramping or throbbing pain at the puncture site.

Perform an arterial puncture. After applying pressure to the puncture site for 3 to 5 minutes, tape a gauze pad firmly over it. (If the puncture site is on the arm, don't tape the entire circumference; this may restrict circulation.)
If the patient is receiving anticoagulants or has a coagulopathy, hold the puncture site longer than 5 minutes if necessary.
Monitor vital signs, and observe for signs of circulatory impairment, such as swelling, discoloration, pain, numbness, and tingling in the bandaged arm or leg.
Watch for bleeding from the puncture site. Date 01/19/11 Result Normal values Interpretation
Diagnostic/ laboratory pH
7.190
7.357.45
Decrease may
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PCO2
13.9
35-45 mmHg
PO2 HCO3
82 5.3
80-105 mmHg 22-26 mmol/L
indicate acidity of blood. Decrease may result from the decrease pH or acidity of the blood. It serves as a respirator compone nt of acidbase determin ation. Normal Decrease may result from the decrease pH or acidity and may indicate metabolic acidosis. It serves as a metabolic compone nt of acid base balance. Decrease may be due to acidosis or decrease pH.
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BE
-23
-2 to +3 mmol/L
SO2
93
95-98%
Slight decrease, no significan ce but low may indicate inadequat e perfusion.
CHEST P.A 01/19/2011 The chest x-ray is the most commonly performed diagnostic x-ray examination. 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. PURPOSE: Chest X-ray can show: The condition of the lungs. Heart related lung problems.
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The size and outline of the heart. Blood vessels. Calcium deposits. To help diagnose or monitor treatment for conditions
PREPARATION: You may be asked to remove some or all of your clothes and to wear a gown during the exam. You may also be asked to remove jewelry, dentures, eye glasses and any metal objects or clothing that might interfere with the x-ray images.
Women should inform the physician that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation.
PROCEDURE: A radiologist is the one who perform the procedure and analyzes the result. During the procedure, the body is positioned between the X-ray camera and the X-ray digital recorder. The person will be asked to move into different positions or angles. During the front view, the person stands against the plate that contains the X- ray film or digital recorder. You hold arms up or to the sides and roll shoulders forward, and then take a deep breath.
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During the side views, you turn and place one shoulder on the plate and raise your hands over the head, and then take a deep breath again.
RADOLOGIC FINDINGS RESULT: Patch of heavy densities are seen in the right lower lung field. These are questionable opacities in the right apex. Left lung is clear, heart is clear. Heart is not enlarged, sulci are intact. Trachea is at the midline. Bony thoracic cage is intact. Rest of the included structures is unremarkable. IMPRESSION: Pneumonia Suggest Apico- lordotic view for further evaluation of the right apex. CLINICAL CHEMISTRY SECTION CREATININE TEST 01/23/11 The creatinine test measures urine levels of creatinine, the chief metabolite of creatine. Produced in amounts proportional to total body muscle mass, creatinine is removed from the plasma primarily by glomerular filtration and is excreted in the urine. Because the body doesn't recycle it, creatinine has a relatively high, constant clearance rate, making it an efficient indicator of renal function. A standard method for determining urine creatinine levels is based on Jaffe's reaction; in which creatinine treated with an alkaline picrate solution yields a bright orange-red complex.
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Purpose
To help assess glomerular filtration. To check the accuracy of 24-hour urine collection based on the relatively constant levels of creatinine excretion.
Patient preparation

Explain to the patient that this test helps evaluate kidney function. Inform him that he needn't restrict fluids but shouldn't eat an excessive amount of meat before the test.
Advise him that he should avoid strenuous physical exercise during the collection period.
Tell him the test usually requires urine collection over a 24-hour period and teach him the proper collection technique.
Collect the patient's urine over a 24hour period. Use a specimen bottle that contains a preservative to prevent the degradation of creatinine.
Resume administration of medications withheld during the test. Tell the patient he may resume normal diet and activity.
Diagnostic/ laboratory
Date
Result
Normal values
Interpretation
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01/23/11 Creatinine 1.5 mg/dl 0.71.5mg Still within the normal range.
DOCTORS ORDER
Date and Time
Doctors Order
Rationale
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11/15/ 11
Please admit under the service of Dr. Espinosa- Baas. Please secure consent.
For management of present condition.

Done
for legal purposes and to ensure clients knowledge, understanding of his condition and cooperation to the management of his condition. and monitor patients condition and progress. Vital signs are usually altered when there is uneasiness or discomfort felt.
TPR q4.
To assess, compare
Start IVF PLR1L to run fast drip 500 cc then regulate at 40 gtts/ min.
Helps
IVF to follow PNSS1 L to run at 30 gtts/ min
to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body.PLR is an isotonic solution in which is usually used for when there is dehydration and hypovolemia. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PNSS s an isotonic solution
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used when there is hyponatremia and shock. Laboratory Tests: Complete Count. Blood
A complete blood
count is a common blood test, providing information on the general health status and is a tool for checking disorders such as anemia, infection and thrombocytopenia. Complete blood count provides detailed information about three types of cells: red blood cells, white blood cells and platelets.
Urine Analysis
Urinalysis is a test that evaluates a sample of your urine. It is used to detect and assess a wide range of disorders, including urinary tract infection, kidney disorders and diabetes. Urinalysis involves examining the appearance, concentration and content of urine. Potassium testing is frequently ordered along with other electrolytes, a part of routine physical.
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Serum Potassium
It is used to detect concentrations that are too high or too low. Potassium is a mineral vital to skeletal, cardiac and smooth muscle activity.
Sodium
Sodium
testing is frequently ordered along with other electrolytes, a part of routine physical. It is used to detect concentrations that are too high or too low. Sodium is a mineral vital to renal reabsorption and excretion as well as for transmitting impulses and contracting muscles.
Calcium.
Serum Creatinine.
Done to measure the serum level of calcium as well as to aid in the diagnosis of neuromuscular, skeletal, and endocrine disorders; arrhythmias; bloodclotting deficiencies; and acid-base imbalance. The creatinine test measures urine levels of creatinine, the chief metabolite of creatinine. It also helps in assessing the glomerular filtration capacity
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of the kidney. Medications: Plasil 1 amp IVTT now then q8 run for continuity.
Prior
Risek 40 mg IVTT O.D
Metronidazole 500 mg TID P.O.
11/15/11 11 AM (+) seizure seconds. for
Refer labs to A.P. Fast drip 300 cc IVF now.
Serum electrolytes to lab now and refer to Dr. Espinosa, once in. Start dopamine drip
to admission patient experienced episodes of nausea and vomiting. The drug was given to relieve or prevent vomiting. Patient was diagnosed to have metabolic acidosis, wherein the body produces too much acid. The drug was given to treat hyperacidity and decrease/prevent gastric secretion. The patient also was diagnosed to have amoebiasis. This drug was given to treat amoebiasis. Done for further evaluation of the laboratory result. Intravenous fluids must be properly regulated as ordered by the doctor. This is to ensure balance of the intake and output as well as to prevent possible complications. Done for further examinations and evaluation of results. Based on the
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with Dopamine 200 mg + D5 W 200cc to run at 10 gtts, then titrate until systolic BP = 100 mmHg.
12 PM BP: palpatory 60 mmHg.
Titrate dopamine drip
Run present IVF at 500 cc fast drip then regulate IVF at 140 cc/ hr.
Regulate IVF D5 NSS 1 L at 140 cc/ hr.
3:15 PM (+) dyspnea BP: 50/ 20 mmHg.
Increase dopamine drip to 20 gtts/min.
assessment, patients blood pressure is palpatory only to 60 mmHg that is why the drug was given to improve perfusion to vital organs and to correct hypotension. Titrate is done by increasing the drop rate until the desired BP is achieved. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Intravenous fluids must be properly regulated as ordered by the doctor. This is to ensure balance of the intake and output as well as to prevent possible complications. D5 NSS is usually used when there is dehydration, shock and circulatory insufficiency. Given to improve perfusion to vital organs and to correct hypotension. Increasing the drip
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Fast drip 200cc from present IVF.
4:30 PM Tachypneic, Acidotic breathing, sunken eyeballs, 4x LBM since this AM.
NaHCO3 25 meq + 25 cc IVF Slow IVTT.
6:35 PM (-) urine output
Insert foley catheter and attach to urobag.
Intake and output q shift and record.
7:40 PM BM- once, (-) urine output Fast drip 500 cc PLR
IVF: PLR gtts/min
L x 30
rate was done to improve perfusion and also to improve blood pressure of the patient. Intravenous fluids must be properly regulated as ordered by the doctor. Patient was diagnosed to have metabolic acidosis that is why the drug was given to treat metabolic acidosis and reduce gastric secretion it should be given slowly to prevent irritation. Done to facilitate urine elimination as well as to monitor the urine output of the patient. Done to monitor and check the balance between the total amount taken and released/ excreted. Intravenous fluids must be properly regulated as ordered by the doctor. PLR is usually used when there is dehydration and hypovolemia. Helps to expand intravascular volume; corrects
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Fast drip 500 cc now x 30 mins.
IVF to follow: PLR x 8.
Refer if still without urine output after 1 hour.
7:50 PM (+) back pain, (-) urine output Give tramadol 50 mg IVTT now.
PLR 1L, fast drip another 500 cc x 2 cycles 30 minutes apart.
an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PLR is usually used when there is dehydration and hypovolemia. Intravenous fluids must be properly regulated as ordered by the doctor. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PLR is usually used when there is dehydration and hypovolemia. Done to monitor and evaluate clients condition and for the doctor to attend the said problem. Patient experienced pain due to increase gastric secretion that is why the drug was given to relieve pain felt. Intravenous fluids must be properly regulated as ordered by the doctor. PLR is
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9 PM BM- twice, watery
Give Loperamide cap TID.
9:50 PM
IVF to follow: PLR x 8- 3 bottles.
Fast drip 500 cc now x 2 cycles 30 minutes apart. IVF to follow: Right D5 NM 1L x 8- 2 bottles.
Fast drip PNSS 500 cc now x 2 cycles 30 minutes apart.
usually used when there is dehydration and hypovolemia. Patient was diagnosed to have gastrointestinal infection, Acute Gastroenteritis and Amoebiasis in which one of its manifestations is loose bowel movement. The drug was given to treat diarrhea. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PLR is usually used when there is dehydration and hypovolemia. Intravenous fluids must be properly regulated as ordered by the doctor. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Intravenous fluids must be properly regulated as
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1/16/11 6:20 AM BP: palpatory 50 mmHg, (+) BM
Fast drip PLR 500 cc now. Run present IVF PLR 1 L x 8.
Start tazobactam (vigocid) 2.25 g q shift, ANST.
Loperamide capsules TID.
To follow D5 NSS at 120 cc/ hr.
ordered by the doctor. PNSS is usually used when there is hyponatremia and shock. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PLR is usually used when there is dehydration and hypovolemia. The patient was diagnosed to have Pneumonia that s why the drug was given to treat Pneumonia and combat infection. Patient was diagnosed to have gastrointestinal infection, Acute Gastroenteritis and Amoebiasis in which one of its manifestations is loose bowel movement. The drug was given to treat diarrhea. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the
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1:30 PM BP: 70/40 mmHg
Refer to DR. Dequina. Start Dobutamine 250mg /500 mL run at 5gtts/min.
Decrease dopamine drip at 10 gtts/min.
Continue vigocid, loperamide and metronidazole.
Refer. D5 LR 1 L at 160 cc/ hour Left arm.
body. D5 NSS is usually used when there is dehydration, shock and circulatory insufficiency. Done for further evaluation and management. Based on the assessment, patients blood pressure is palpatory only to 80 mmHg; the drug was given to improve cardiac output. Dopamine is indicated to improve perfusion of vital organs, the dosage was slowed down or reduced since the perfusion and blood pressure is improving. Vigocid is indicated to treat metabolic acidosis; loperamide is indicated to treat diarrhea and metronidazole is indicated to treat amoebiasis. It is done for continuity of the progress of treating underlying conditions. Done for further valuation and management. Helps to expand intravascular
127
Ketorolac 30 mg q shift IV PRN for pain.
3:30 PM
ABG stat.
Serum Creatinine
volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Patient experienced pain due to the increase gastric secretion that is why the drug was given to relieve pain felt. To measure the partial pressures of oxygen (PaO2), carbon dioxide (pacO2), the pH of an arterial sample, Oxygen content (O2CT), oxygen saturation (SaO2) and bicarbonate (RCO3 -) values. The creatinine test measures urine levels of creatinine, the chief metabolite of creatine. It also helps in assessing the glomerular filtration capacity of the kidney. Potassium testing is frequently ordered along with other electrolytes, a part of routine physical. It is used to detect concentrations that are too high or too low. Potassium is a mineral vital to
128
Potassium
skeletal, cardiac and smooth muscle activity. Calcium Done to measure the serum level of calcium as well as to aid in the diagnosis of neuromuscular, skeletal, and endocrine disorders; arrhythmias; blood-clotting deficiencies; and acid-base imbalance. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Based on the assessment, patients blood pressure is palpatory only to 70/40 mmHg, the drug was given to improve cardiac output. Ordered because of the possible injury or fall due to hypotension and some CNS side effects of the drugs. Helps to expand intravascular volume; corrects
129
Change D5 NM 1L to PNSS 1 L at 100 gtts/ min.
Start Dobutamine 250 mg on D5 W 250 cc at 30 gtts/ min. now.
Complete bed rest.
IVF: I. Right C.C near, fainting, PLR 1 L x 70 gtts/ BP: palpatory 80 min. mmHg, (-) urine To follow: 4:30 PM
output.
PLR
1 L at 60 gtts/min. PLR 1 L at 50 gtts/ min.
Remaining Dopamine, Please add furosemide 20 mg run this at 10 gtts /min.
To follow: Dopamine 200mg in D5 W 250 cc premixed + furosemide 20 mg at 10 gtts/min.
Dobutamine drip at 30 gtts/min.
To follow:
an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PLR is usually used when there is dehydration and hypovolemia. Based on the assessment, patients latest blood pressure is palpatory that is why the drug was given to improve perfusion to vital organs and to correct hypotension. Furosemide is added to treat edema. Based on the assessment, patients latest blood pressure is palpatory that is why the drug was given to improve perfusion to vital organs and to correct hypotension. Furosemide is added to treat edema. Based on the assessment, patients blood pressure is palpatory, the drug was given to improve cardiac output.
130
Dobutamine 250 mg
in D 5 W 750 cc at 30 gtts/ min.
Based
II. Left Present PNSS at 160 gtts/ min. To follow: PNSS 1 L at 150 gtts/min. then NSS 1 at 120 gtts/min.
Medications: Ercefuryl TID.
cap
P.O.
Ciprobay XR 500 mg 1 tab P>O now then OD after lunch start tonight.
on the assessment, patients blood pressure is palpatory, the drug was given to improve cardiac output. D5 W is usually used when there is fluid loss. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PNSS s an isotonic solution used when there is hyponatremia and shock. Patient was diagnosed to have gastrointestinal infection, Acute Gastroenteritis and Amoebiasis in which one of its manifestations is loose bowel movement. The drug was given to treat diarrhea. Patient was diagnosed with different infections such as Pnuemonia, urinary tract infection and septic shock. This drug was given to treat or combat infection.
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Continue O2. Citicholine 500 mg IV q 8.
Done
Advised ICU admission, will wait for their decision. For close please. watch
Family was advised to boil drinking water.
Please patency foley catheter.
of
Wife was taught on aspiration precaution.
to improve breathing pattern. Based on assessment, patients blood pressure is very low and he was diagnosed of having prolonged hypotension. This drug was given to improve perfusion of vital organs and to correct hypotension. Patient is in severe condition which requires close monitoring and evaluation. Patients condition is already severe which requires close monitoring in order to attend immediately problems. The cause of amoebiasis of the client is due to the water taken from the river that is why it should be boiled to ensure safe and clean water. Done to ensure that the catheter is still functioning and also to determine urine output accurately. Done in order for the significant others to attend needs and problems of
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Add 10 mg of furosemide on present Dopamine drip then on the Dopamine drip to follow add 40 mg furosemide instead of 20 mg. Fast drip 200 cc of PNSS
12 MN BP: 70/40 mmHg, BM: 3x- 1000 cc.
their patient as well as to be involved in the management of the clients condition. Based on assessment patient has edema due to 3rd space fluid shfting. It was given to treat edema as well as to improve perfusion to vital organs. Intravenous fluids must be properly regulated as ordered by the doctor. PNSS is usually used when there is hyponatremia and shock.
Helps
IV to follow on the Left, PNSS 1 L at 100 gtts/min x 3 bottles.
1/17/11 1:15 AM Repeat serum creatinine at 6 PM.
to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PNSS is usually used when there is hyponatremia and shock. Patient was diagnosed to have acute renal failure. This is done to assess glomerular filtration status this may help in
133
5:45 AM
Give sodium bicarbonate 1 amp very slow IV push stat for 15 minutes.
Repeat dose after 10 minutes. Put side drip at left arm D5 W 200 cc + 2 ampules of Na HCO3 to run at 20 gtts/min.
Fast drip at Left arm IV 200 cc.
IVF to follow: Right arm, PLR 1 L x 40 gtts/ min.
determining kidney function. Patient was diagnosed to have metabolic acidosis that is why the drug was given to treat metabolic acidosis and reduce gastric secretion it should be given slowly to prevent irritation. To continue the progress of treating metabolic acidosis. Patient was diagnosed to have metabolic acidosis that is why the drug was given to treat metabolic acidosis and reduce gastric secretion. D5 W is usually used when there is fluid loss. Intravenous fluids must be properly regulated as ordered by the doctor. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PLR is usually used when there is dehydration and hypovolemia.
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Left arm, PNSS 1 L x 120 gtts/min. x 2 bottles.
Helps
7AM Creatinine 5.8 mg/dl, (-) urine output for more than 48 .
Suggest referral to Dr. Torre because of increasing creatinine. Please carry out order of Dr. Dequina.
11:45 AM With urine output, active, HR: 100bpm
Repeat serum creatinine in AM.
IVF Right: Decrease dobutamine to 16 gtts/min. then consume to of BP is > 90 systolic.
to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PNSS is usually used when there is hyponatremia and shock. Done for further examinations and evaluation of results. To update the nurse and the client about his condition, for continuity of care. Patient was diagnosed to have acute renal failure which requires close monitoring of creatinine, an indicator of kidney function. Done to assess glomerular filtration status this may help in determining kidney function. Based on the assessment, patients blood pressure is already stable that is why the drug dosage was reduced. This was given to improve cardiac
135
Decrease Dopamine-
furosemide drip to 6 gtts/min.
Mainline IVF to follow: D5 NM 1 L x 6
D5 NSS 1 L x 6
D5 NM 1 L x 7
12:20 PM
Left:
NaHCO3 drip at 20
gtts/ min.
output. Dopamine is indicated to improve perfusion of vital organs, the dosage was slowed down or reduced since the perfusion and blood pressure is improving. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. D5 NSS is usually used when there is dehydration, shock and circulatory insufficiency. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Patient was diagnosed to have metabolic acidosis
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Mainline PNSS 1 L at
60 gtts/min. Then PNSS 1 L at 60 gtts/min.
Urine C&S please.
Citicholine IV up to tomorrow AM only.
Please continue to monitor VS q 1-2
that is why the drug was given to treat metabolic acidosis and reduce gastric secretion. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PNSS is usually used when there is hyponatremia and shock. Done to determine presence of microorganism in the urine as well its type. Based on assessment, patients blood pressure is very low and he was diagnosed of having prolonged hypotension. This drug was given to improve perfusion of vital organs and to correct hypotension. It was to be consumed since the patients blood pressure had already come back. Vital signs should be monitored frequently because
137
and I&O q 4 and refer accordingly.
11:30 PM UO: 250 cc, BP: 120/90 mmHg
Moderate fast drip the remaining 250 cc on PNSS then IVF to follow, PNSS 1 L at 100 gtts/min. x 4 bottles.
11:55 PM K: 2.8, C: 1.37, Na: 130. Calvit/ Caltrate Plus 1 tab P.O now then 1 tab 3x a day.
Please incorporate 40 meqs KCl + present IVF of D5 NSS and run at 30 gtts/ min.
client is hypotensive and certain medications are given. I & O should also be monitored to ensure the balance between the total amount taken and released/ excreted. Intravenous fluids must be properly regulated as ordered by the doctor. PNSS is usually used when there is hyponatremia and shock. Patient was diagnosed to have metabolic acid and low serum calcium level. This drug was given to treat hyperacidity as well as to supplement calcium. Patient was diagnosed also to have hypokalemia, low serum potassium level that is why KCl was given to supplement potassium in our body. D5 NSS helps to expand intravascular volume; corrects an underlying imbalance in fluids
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Start side drip D5 W 500 cc + 2 ampules Calcium carbonate at 20 gtts/min.
1/18/11 10:15 AM IVF: Right: Feeling better Mainline: Present: D5 now, regular NSS with KCl at 30 rhythm, (-) rales, gtts/min. soft abdomen.
and electrolytes, and compensates the loss in the body. Patient was diagnosed to have metabolic acid and low serum calcium level. This drug was given to treat hyperacidity as well as to supplement calcium. D5 W is usually used when there is fluid loss. Patient was diagnosed also to have hypokalemia, low serum potassium level that is why KCl was given to supplement potassium in our body. D5 NSS helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body.
Patient
To follow: D5 NM 1 L + 20 meq KCl at 26 gtts/ min.
was diagnosed also to have hypokalemia, low serum potassium level that is why KCl was given to supplement potassium in our body. D5 NSS
139
D5 NM 1 L + 16 meq
at 20 gtts/min.
DopamineFurosemide consume.
drip
to
Calcium carbonate drip to consume.
Left:
Mainline: Present: PNSS decrease to 50 gtts/min.
helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Dopamine is used to improve perfusion of vital organs and correct hypotension while Furosemide is used to treat edema. These drugs were about to consume, since the patients vital signs was already stable. Patient was diagnosed to have metabolic acid and low serum calcium level. This drug was given to treat hyperacidity as well as to supplement calcium. Intravenous fluids must be properly regulated as ordered by the doctor. PNSS is an
140
To follow: PNSS 1 gtts/min. PNSS 1 gtts/min.
L L
at at
40 30
NaHCO3
drip
to
consume.
Please check every hour that each IVF is flowing accordingly. VS q 4.
Discontinue IV omeprazole shift to omeprazole 20 mg 1 tab P.O BID.
isotonic solution used when there is hyponatremia and shock. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. PNSS is an isotonic solution used when there is hyponatremia and shock. Patient was diagnosed to have metabolic acidosis that is why the drug was given to treat metabolic acidosis and reduce gastric secretion. Intravenous fluids must be properly regulated as ordered by the doctor. Vital signs should be monitored frequently because client is hypotensive. Patient was diagnosed to have metabolic acidosis. This drug was given to decrease gastric secretion. Done so that shock will not be experienced by the patient that may
141
Allow to sit.
1/19/11 9:15 AM BP: 160/90 mmHg, (+) rales both lungs, (+) congestion
Regulate IVF at right
arm to KVO.
Close IVF at left arm.
Furosemide
40 mg very slow IVTT now.
Monitor VS every 15 minutes until stable.
Refer for unusualities. 11:50 AM Impact of dyspnea, no after formula 1.5 L.

Transfer IV line from
right arm to left arm and regulate to 15 gtts/min.
cause sudden decrease of blood pressure. Intravenous fluids must be properly regulated as ordered by the doctor. This may be done to discontinue IVF or drug administration requires it. Based on the assessment done, patient has edema due to 3rd space fluid shifting. This drug was given to treat edema. It should be given slowly to avoid irritation. Vital signs should be monitored frequently because client is hypotensive and it is usually altered when there is discomfort and abnormalities felt. For further management and to attend the problem immediately. Intravenous fluids must be properly regulated as ordered by the doctor. It is done may be because the site at the right arm is not already patent or good as
142
Repeat serum creatinine- 1/221/11
Repeat
serum potassium today.
well as to prevent IV complications. To assess glomerular filtration status this may help in determining kidney function. It is used to detect concentrations that are too high or too low. Potassium is a mineral vital to skeletal, cardiac and smooth muscle activity. This is to prevent drug-drug interactions as well as promote proper absorption of drugs. Patient was diagnosed to have metabolic acidosis. This drug was given to decrease gastric secretion. The drug dosage is reduced may be because there is already less gastric secretion. Patient was diagnosed to have Pneumonia and was suspected to have PTB, minimal. To help diagnose or monitor treatment for conditions, as well as to assess lung condition.
To
Give P.O. meds. At least 1 hour apart.
Decrease omeprazole OD hours of sleep.
1:40 PM S/o: alert, lack BM Request for: Chest X- Ray, sitting. was 10 PM last night, labored and fast breathing, BP: 130/90 mmHg, HR: 80bpm, (-) rales, UO: 2,250
measure
the
143
cc (time- 7 AM to 1:40 PM). ABG this afternoon.
partial pressures of oxygen (PaO2), carbon dioxide (pacO2), the pH of an arterial sample, Oxygen content (O2CT), oxygen saturation (SaO2) and bicarbonate (RCO3 -) values.
Patient
O2 PRN.
Please relay serum K+
ASAP by sun call to me or Dr. Torre. Discontinue Ercefuryl Discontinue Loperamide. Discontinue Kitnos.
was diagnosed to have Pneumonia, which may cause difficulty of breathing that is why O2 was given to support breathing and improve breathing pattern. For further evaluation and management. Underlying conditions treated using these medications maybe are already cured.
Patient
2 PM
Suggest: Consume present stock of IV metronidazole then shift to flagyl 500 mg 1 tab P.O TID after meals.
Carry out all to follow D5 NM 1 L at 10- 12
was diagnosed to have amoebiasis. This drug was given to treat the said condition and to combat infection. Done to update the nurse and client about his condition and the new orders made. This is also to ensure continuity of care.
144
gtts/min.
Patient
6:15 PM ABG relayed; pH:7.190 PCO2:13.9 PO2:82 HCO3: 5.3 BE: (-23) SO2:93 TCO2:6
result
Hook to O2 with 2-3 L/min via nasal cannula.
Give NaHCO3 1 amp slow IV push for 15 minutes.
1/20/11 11 AM Still acidotic breathing but less than yesterday, alert, coversant, last B was last night formed.
At the same time, hook to side drip, D5 W 500 cc + 2 ampules NaHCO3 to run at 20 gtts/ min. Please result. relay CXR
NaHCO3 10 gms. 2 tablets TID P.O start today.
NaHCO3
drip
to
was diagnosed to have Pneumonia, which may cause difficulty of breathing that is why O2 was given to support breathing and improve breathing pattern. Patient was diagnosed to have metabolic acidosis that is why the drug was given to treat metabolic acidosis and reduce gastric secretion. It should be given slowly to prevent irritation. To increase effectivity of the drug as well as the progress of treating metabolic acidosis. For further evaluation and management. Patient was diagnosed to have metabolic acidosis that is why the drug was given to treat metabolic acidosis and reduce gastric secretion. Patient was diagnosed to have metabolic acidosis that is why the drug was given to treat metabolic
145
consume.
11:10 AM CXR noted. Zinnat 500 mg 1 tab P.O BID after breakfast and dinner.
Flagyl x 3 days now.
4:25 PM Formed stool, urine output: 4.3 L
Suggest decreasing Zinnat 500 mg 1 tab OD P.O.
5:00 PM Please carry suggestions of Torre. out Dr.
1/21/11 3:15 PM Will that PTB once, creatinine is back to normal, (-) Sx now, BP: 120/80 mmHg, HR: 78 bpm Suggest to remove catheter tomorrow 8 AM.
acidosis and reduce gastric secretion. Patient was diagnosed to have infections such as pneumonia, urinary tract infection, acute gastroenteritis and GIT infections that is why the drug was given to treat infection and it. Patient was diagnosed to have amoebiasis. This drug was given to treat the said condition and to combat infection. The drug is indicated to treat infections. The drug dosage is reduced may be because signs of infection are diminishing. Done to update the nurse and client about his condition and the new orders made. This is also to ensure continuity of care. Patients present condition already permits him to void on his own or void in the comfort room. It is should be done since the patient has been attached with catheter for a couple of days,
146
Continue bladder training once foley catheter is removed tomorrow, please refer urine retention. IVF to follow, D5 NM 1 L x 24.
4:00 PM Creatinine: 2.1 mg/dl, Patient seen.
Please carry suggestions of Dequina.
out Dr.
1/22/11 12:20 PM Repeat serum creatinine on 1/ 23/ 11- AM.
this is to stimulate urination. Helps to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Done to update the nurse and client about his condition and the new orders made. This is also to ensure continuity of care. Patient was diagnosed to have acute renal failure which requires a close monitoring of creatinine, one indicator of kidney function. To assess glomerular filtration status this may help in determining kidney function.
Helps
IVF:
Present D5 NM
to run at 6-8 gtts/min.
to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. Patient was diagnosed to have metabolic acidosis that is why the drug was given to
147
Side drip: D5
W 500 cc + 2 ampules of NaHCO3 at 20 gtts/min. 9:15 PM Adequate urine output, latest creatinine: .5 mg/dl, conversant, (-) LBM.
Decrease calvit 1 tab OD.
treat metabolic acidosis and reduce gastric secretion. D5 W is usually used when there is fluid loss. Patient was diagnosed to have metabolic acidosis, which causes increase gastric secretion. The drug was given to reduce gastric secretion. The dosage should be reduced maybe because the serum calcium level is already normal as well as there is already less gastric secretion.
Helps
Thank you for referring IVF: D5 NM 1 L x 8.
1/23/11 5:35 PM Able to sit, (-) for Sx, good appetite, +2 edema, BP:
Continue medications. Lasix 40 mg 1 tab tab P.O
to expand intravascular volume; corrects an underlying imbalance in fluids and electrolytes, and compensates the loss in the body. To continue the progress of improving condition. Based on the assessment done, patient has edema due to 3rd space fluid shifting. This drug was given to treat edema.
148
130/80 mmHg, HR: 80 bpm
now and tab P.O tomorrow 7 AM. For possible discharge tomorrow if fine with APs.
1/24/11 10:40 AM (-) Sx, ambulatory although not strong and stable yet, BP: 120/70 mmHg, HR: 78 bpm.
MGH anytime.
Home medications: Ciprobay XR 500 mg # 6 only 1 tab P.O OD after lunch.
Other physicians should be consulted to ensure agreement about the full recovery and stability of the patients condition. Ordered MGH by the doctor may indicate patients full recovery from the past condition and no complications had occurred. This may indicate that the client is already stable. Patient was diagnosed with different infections such as Pnuemonia, urinary tract infection and septic shock. This drug was given to treat or combat infection.
Patient
Calvit #30 1 tab P.O OD after breakfast.
was diagnosed to have low serum calcium level as well as metabolic acidosis, which causes increase gastric secretion. The drug was given to reduce gastric secretion and to supplement calcium. Patient was diagnosed to have
149
NaHCO3
10 gms. #20 only 2 tabs P.O TID.
Zinnat to consume present stock.
Omeprazole #6 1 tab P.O OD 7AM.
Lasix 40 mg #1 only tab P.O OD 7AM.
metabolic acidosis that is why the drug was given to treat metabolic acidosis and reduce gastric secretion. Patient was diagnosed to have infections such as pneumonia, urinary tract infection, acute gastroenteritis and GIT infections that is why the drug was given to treat infection and it. Patient was diagnosed to have metabolic acidosis that is why the drug was given to treat metabolic acidosis and reduce gastric secretion. Based on the assessment done, patient has edema due to 3rd space fluid shifting. This drug was given to treat edema. For further evaluation. Through these, the patient could again have amoebiasis and possibly acquire infection, To remove dirt and microorganism in our hands and prevent having
150
Check up with Dr. Baas and Espinosa. Advised: Be careful with water and foods.
Proper hand washing
Monitoring of serum creatinine
infection. Patient was diagnosed to have acute renal failure which requires a close monitoring of creatinine an indicator of kidney function. Done to assess glomerular filtration status this may help in determining kidney function.
151
PHARMACOLOGIC MANAGEMENT
January 15, 2011
Loperamide Metoclopramide (Plasil)
1 cap TID 1 amp IVTT RN for vomiting q 8 1 cap P.O. TID
January 16, 2011
Nifuroxazide (Ercefuryl) Etofamide (Kitnos) Citicholine Piperacillin tazobactam (Vigocid)
500 mg 1 tab P.O BID 500 mg IV q8 2.25 gm IVTT ANST (-) q8 2 tablets P.O TID
January 17, 2011
Potassium Chloride (Kalium)
January 19, 2011
Metronidazole (Flagyl) Ketorolac Ciprofloxacin (Ciprobay XR) NaHCO3 Cefuroxime (Zinnat) axetil
500 mg 1 tab P.O. BID
January 23, 2011
30 mg IVTT PRN for pain q 8 500 mg 1 tab P.O. OD
2 tablets P.O. TID 500 mg 1 tab P.O. OD
Calcium carbonate (Calvit) Omeprazole (Risek) Furosemide (Lasix)
1 tab P.O. OD 20 mg 1 tab P.O. HS 40 mg 1 tab
152
Brand name: ZINNAT Generic name: cefuroxime axetil Classification: Anti-infectives- 2ND Genaration Cephalosporins Indications:
Lower respiratory infections. Infections of the urinary. Uncomplicated UTIs.
Contraindications: Patients hypersensitive to drug or other cephalosorins. Patients hypersensitive to penicillin because of possibility of cross sensitivity with other beta- lactam antibiotics. Drug interaction: Aminoglycosides, Loop diuretics, Probenecid Actual Dosage: 500 mg 1 tab P.O OD
153
Mechanism of action: Second generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability; usually bactericidal. Adverse reactions:

CV: phlebitis and thrombophlebitis. GI-:pseudomembranous colitis, anorexia, diarrhea, nausea and vomiting. HEMATOLOGIC: transient neutropenia, eosinophilia, hemolytic anemia, and thrombocytopenia.
SKIN: maculopapular and erythematous rashes, urticaria, pain, induration, strile abscesses, temperature elevation, tissue sloughing at I. M injection site.
OTHER: hypersensitivity reactions, serum sickness and anaphylaxis.
Nursing responsibilities: ASSESSMENT:
Assess for allergy to cephalosporin. If allergic to one type, the patient should not receive any other type of cephalosporin.
Assess vital signs which include the elevated temperature. Assess urine output which includes the decrease urine output. Report abnormal findings.
Assess for the laboratory result specifically the white blood cell count.
154
Assess for the degree or severity of infection by observing signs of infection and laboratory results.
DIAGNOSIS:
Ineffective Protection r/t invasion of microorganisms as manifested by increased white blood cell count- 19.17 x 10^g/L.
PLANNING:
Clients infection will be controlled and later eliminated.
IMPLEMENTATION: Verify the Doctors order. Perform skin testing. Observe the 12 rights in medication. Observe for signs of hypersensitivity. Monitor vital signs, urine output and laboratory results. Report for any abnormalities. Explain to the patient that the drug may have a bitter taste. Instruct the patient to take the drug as prescribed. Observe and notify physician about loose stools and diarrhea.
Nursing Considerations:
155
If patient is unable to swallow tablets, the drug may be crushed or dissolved in small amounts of apple, orange or grape juice.
To enhance absorption, drug can be given with food.
Health Teachings:
Instruct client to take the complete course of medication when when symptoms of infection have ceased.
Instruct patient in proper hygiene. Instruct patient to report any side effects from use of oral cephalosporin drug which may include anorexia, nausea and vomiting, headache, itching and rash,
Advise the patient to take medication with food if gastric irritation occurs.
EVALUATION:
Evaluate the effectiveness of the cephalosporin by determining if the infection has ceased and no side effects.
Rationale: Patient was diagnosed to have different infections such as Pneumonia, urinary tract infections, acute gastroenteritis and GIT infection. This drug was given to treat and combat infection.
156
Brand name: FLAGYL Generic name: metronidazole Classification: Antiamoebics / Other Antibiotics/ Antiprotozoal Agent Indications:
Amoebiasis anaerobic infection
Contraindications: In patients hypersensitive to drug or other nitroimidazole derivatives.
157
Use cautiously in patients with history of blood dyscrasias, CNS disorder or visual field changes.
Patients who take hepatotoxic drugs or hepatic disease and alcoholism.
Drug interaction: Cimetidine, Lithium, oral anticoagulants and Phenobarbital. Actual Dosage: 500 mg 1 tab P.O after meals x 3 days TID Mechanism of action: Direct acting trichomonacide and amebicide that works inside and outside the intestines. Its thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis, causing cell death. Adverse reactions: CNS: fever, vertigo, headace, ataxia, dizziness, syncope, incoordination, confusion, irritability, depression, weakness, insomnia, seizures and peripheral neuropathy.
CV: flattened T wave, edema, flushing, thrombophlebitis. EENT: rhinitis, pharyngitis and sinusitis. GI-: abdominal cramping or pain, stomatitis, epigastric distress, nausea and vomiting, anorexia, diarrhea, constipation, dry mouth and metallic taste.
GU: darkened urin, polyuria, dysuria, cystitis, dyspareunia, dryness of vagina and vulva, vaginitis and genital pruritus.
158
HEMATOLOGIC: transient leucopenia, neutropenia. MUSCULOSKELETAL: fleeting joint pains. SKIN: Skin rash. OTHERS: overgrowth of non- susceptible organisms, especially Candida.

Assess vital signs for future comparison. Assess characteristics of stool which includes the color, consistency and odor. Assess for the frequency, duration and interval of defecation. Assess/ obtain history of allergy. Assess for urine output.
DIAGNOSIS:
Ineffective Protection r/t invasion of microorganisms as manifested by increased white blood cell count-19.17 x 10 ^g/L
PLANNING: Clients infection will be resolved or infection will be prevented.
IMPLEMENTATION:
159
Check and verify the Doctors order. Observe the 12 rights in medication. Observe for signs of hypersensitivity. Monitor vital signs. Compare with baseline findings. Give drug with meals to minimize GI irritation. Explain to patient that he may experience a metallic taste and have dark or red brown urine.
Monitor the clients urinary output. Observe for side effects and adverse reactions such as nausea, vomiting and headache.
Instruct the client to take the drug as prescribed. Record number and characteristics of stools.
Nursing Considerations: Observe patient for edema, because Flagyl may cause sodium retention.
Health Teachings:
Advice to avoid alcohol intake and drugs with alcohol content at least 3 days after the treatment.
Instruct patient in proper hygiene. Instruct to take drug with food to minimize gastric irritation. Instruct to report immediately any neurologic symptoms such as seizures and peripheral neuropathy.
160
Instruct to report/ notify prescriber for unusual responses.
EVALUATION: Evaluate the effectiveness of the drug by noting absence of the infection.
Rationale: patient was diagnosed to have amoebiasis manifested by loose bowel movement. The drug was given to treat amoebiasis.
Brand name: CIPROBAY XR Generic name: ciprofloxacin Classification: Fluoroquinolones Indications:

Infections of the respiratory tract. Urinary tract infection.

161
Septicemia, infections in patients w/ reduced host defenses.
Contraindications: In patients hypersensitive to fluoroquinolones. Use cautiously in patients with CNS disorders, such as seizure disorders. Drug may cause CNS stimulation. Drug interaction: Increased serum theophylline; NSAIDs; cyclosporine; warfarin. Potentiate effect of glibenclamide. Probenecid increases
ciprofloxacin serum conc. Al- & Mg-containing antacids. Actual Dosage: 500 mg 1 tab P.O OD
Mechanism of action: Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase thus having bactericidal effect. Adverse reactions:
CNS: headache, restlessness, tremor, dizziness, fatigue, drowsiness, insomnia, depression, paresthesia. lightheadedness, confusion, hallucinations, seizures and
CV: thrombophlebitis, edema and chest pain. GI: nauseas, diarrhea, vomiting, abdominal pain or discomfort, oral candidiasis, pseudomembranous colitis, dyspepsia, flatulence and constipation.
GU: crystalluria, interstitial nephritis.

162
HEMATOLOGIC: eosinophilia, leucopenia, neutropenia and thrombocytopenia. MUSCULOSKELETAL: arthralgia, joint or back pain, joint inflammation, joint stiffness, tendon rupture, aching and neck pain.
SKIN: rash, photosensitivity, exfoliative dermatitis, burning, pruritus and erythema.
OTHER: hypersensitivity reactions
Nursing responsibilities: ASSESSMENT: Assess vital signs and compare results with future vital signs. Assess for allergy to fluoroquinolones. If allergic, the patient should not receive it.
Assess vital signs which include the elevated temperature. Assess urine output which includes the decrease urine output. Report abnormal findings.
Assess for the laboratory result specifically the white blood cell count. Assess for the degree or severity of infection by observing signs of infection and laboratory results.
Assess the urine output; fluid intake should be at least 2 L/ day.
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DIAGNOSIS:
Ineffective Protection r/t invasion of microorganisms as manifested by increased white blood cell count-19.17 x 10 ^g/L.
PLANNING: Clients infection will be controlled and later eliminated.
IMPLEMENTATION:
Check and verify the Doctors order. Observe the 12 rights in medication. Monitor for signs of hypersensitivity. Perform skin test, to assess allergy. Monitor vital signs. Monitor patients intake and output. Observe patient for signs of crystalluria. Observe for signs of infection such as elevated temperature. Instruct patient to drink plenty of fluids to reduce risk of urine crystals. Report for any abnormalities. Instruct the patient to take the drug as prescribed.
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Be aware of drug interactions, wait up to 6 hours before giving another drug to avoid decreasing drugs effects.
Food does not affect absorption but may delay peak drug levels.
Health Teachings:
Instruct patient to avoid using quinolones and orange juice with calcium for this can reduce gastric absorption of the drug.
Warn patient to avoid hazardous tasks that require alertness, until effects of drug are known.
Instruct patient to avoid caffeine while taking drug because of potential for increased caffeine effects.
Instruct to notify prescriber if unusual responses may occur. Instruct patient to minimize sunlight contact for this can cause photosensitivity.
Rationale: Patient was diagnosed to have different infections such as Pneumonia, urinary tract infections, acute gastroenteritis and GIT infection. This drug was given to treat and combat infection.
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Brand Name: Generic name: ketorolac tromethamine Classification: Nonsteroidal Antiinflammatory Drug Indications: Short term management of moderate to severe acute post-operative pain.
Contraindications: Contraindicated in patients hypersensitive to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation. Use cautiously in patients who are elderly or have hepatic or renal impairment or cardiac decompensation. Actual Dosage: 30 mg IVTT PRN for pain q 8 Adverse Reactions:

CNS: drowsiness, sedation, dizziness and headache. CV: edema, hypertension, palpitations and arrhythmias. GI: nausea, dyspepsia, GI pain, diarrhea, peptic ulceration, vomiting, constipation and stomatitis.
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HEMATOLOGIC: decreased platelet adhesion, purpura and prolonged bleeding time.
SKIN: pruritus, rash and diaphoresis
Nursing Responsibilities: ASSESSMENT: Assess the clients history of allergy to NSAIDs. Assess the client or gastrointestinal upset and peripheral edema. Assess patients pain before and I hour after treatment: type, location, intensity, and ROM. Assess for nonverbal cues which may help determining the degree and severity of pain felt.
Assess for signs of bleeding.
DIAGNOSIS:
Acute pain r/t increased gastric secretion secondary to metabolic acidosis as manifested by autonomic response increased white blood cell count of 19.17 x 10 ^ g/L.
PLANNING:
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Clients pain felt will then be relieved and inflammation will then subside.
IMPLEMENTATION:
Check and verify the Doctors order. Observe the 12 rights in drug administration. Observe for signs of hypersensitivity. Monitor vital signs. Check for peripheral edema especially in the morning. Administer NSAIDs at mealtime or with food to prevent GI upset. Watch and report if the client has gastrointestinal discomfort. Observe for bleeding ad black stools. Bleeding time can be prolonged. Monitor for possible adverse reactions. Instruct patient to take medications as prescribed.
Nursing Considerations: NSAIDs may mask the signs and symptoms of infection because of its antipyretic and antiinflammatory actions.
Health Teaching:
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Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine or stool; coffee ground vomit and black tarry stool
Instruct patient to report side effects of NSAIDs such as nausea and vomiting, peripheral edema, GI upset, petechiae and dizziness.
Instruct the client to take NSAIDs with meals or food to reduce GI upset. Teach patient some pain management such as deep breathing exercises. Teach patient some diversional activities such as listening to music and reading newspapers to divert attention to pain felt.
EVALUATION: Evaluate the effectiveness of the drug therapy, such as a decrease in pain is achieved. Rationale: Patient was diagnosed to have metabolic acidosis, in which there is increase gastric secretion thus causing irritation. The drug was given to relieve pain.
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Brand name: RISEK Generic name: omeprazole Classification: Anti- ulcer Drugs- Proton Pump Inhibitor Indications: Hyperacidity
Contraindications: Patient hypersensitive to drug and its components. Use cautiously in patients with respiratory alkalosis and hypokalemia.
Drug interaction: Increased serum theophylline; NSAIDs; cyclosporine; warfarin. Potentiate effect of glibenclamide. Probenecid increases
ciprofloxacin serum conc. Al- & Mg-containing antacids. Actual Dosage: 20 mg 1 tab P.O HS
Mechanism of action: Inhibits activity of acid pump and binds to hydrogen- potassium adenosine triphosphate at secretory surface of gastric parietal cells to block formation of gastric acid.
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Adverse reactions:

CNS: headache, dizziness and asthenia. GI: diarrhea, abdominal pain, nausea and vomiting, constipation, flatulence. Musculoskeletal :back pain Respiratory: cough, upper respiratory tract infection Skin: rash
Assess gastrointestinal complaints. Assess the patients pain including the type, duration, severity, frequency and location.
Assess fluid and electrolyte imbalance, including intake and output. Assess for the gastric pH.
DIAGNOSIS: Acute pain r/t increased gastric secretion secondary to metabolic acidosis as manifested by autonomic response increased white blood cell count of 19.17 x 10 ^ g/L. PLANNING:
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Client will no longer experience abdominal pain after the drug therapy.
IMPLEMENTATION: Check and verify Doctors order. Observe the 12 rights of Drug Administration. Administer drug 30 minutes before meals. Instruct to take the drug on an empty stomach at least 1 hour before meals. Monitor vital signs. Monitor the patients intake and output. Monitor pain, including its frequency, duration, interval, characteristics and severity. Caution patient to avoid hazardous activities, if he gets dizzy. Watch and report for unusual response.
Nursing Considerations: Omeprazole increases its own bioavailability with repeated doses. Drug is labile in gastric acid; less drug is lost to hydrolysis because drug increases gastric pH. Health Teachings:
Instruct patient to swallow tablets or capsules whole and not to open, crush or chew.
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Instruct patient to take drug 30 minutes before meals. Teach patient some pain management such as deep breathing exercises due to its side effect.
Instruct patient to increase fluid intake. Teach deep breathing exercises, to decrease pan felt. Teach some diversional activities such as listening to music to divert attention.
EVALUATION: Determine the effectiveness of the drug therapy and the presence of any side effects. The client should be free of pain. Rationale: Patient was diagnosed to have metabolic acidosis, in which there is increase gastric secretion thus causing irritation. The drug was given to treat metabolic acidosis and to reduce gastric secretion.
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Brand name: CALVIT Generic name: calcium carbonate Classification: Electrolytes and replacement solutions/ Anti-Ulcer Drug Indications: Hyperacidity Hypocalcemic emergency Dietary supplement
Contraindications: Cancer patients with bone metastases, ventricular fibrillation, hypercalcemia, or renal calculi.
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Drug interaction: Atenolol, tetracyclines, cardiac glycosides, calcium channel blocker.
Actual Dosage: 1 tab P.O OD Mechanism of action: Replaces calcium and maintains calcium level. Adverse reactions:

CNS: tingling sensations, sense of oppression or heat waves, syncope. CV: vasodilation, mild drop of blood pressure, vasodilation, bradycardia, arrhythmias and cardiac arrest.
GI: irritation, constipation, abdominal pain, thirst, hemorrhage, chalky taste, nausea and vomiting.
GU: polyuria, rna calculi. Metabolic: Hypercalcemia SKN: local reactions including burn, necrosis, tissue sloughing, cellulitis, soft tissue calcification irritation and pain.
Nursing responsibilities: ASSESSMENT: Assess the patients pain, incuding the type, duration, severity and frequency. Assess the patients renal function.
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Assess for fluid and electrolyte imbalances, especially calcium levels. Assess for the drug history or any drug-drug interactions. Assess laboratory results such as the serum calcium level.
DIAGNOSIS: Acute pain r/t increased gastric secretion secondary to metabolic acidosis as manifested by autonomic response increased white blood cell count of 19.17 x 10 ^ g/L.
PLANNING: Client will be free of abdominal pain after the drug management.
IMPLEMENTATION: Check and verify the Doctors order. Observe 12 rights during drug administration. Monitor for hypersensitivity reactions. Use all calcium products with extreme caution in digitalized patients and patients with renal and cardiac disease. Monitor pain, including its frequency, duration, interval, characteristics and severity.
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To avoid constipation and bloating and to improve absorption, give calcium carbonate in divided doses.
Check for signs and symptoms of severe hypercalcemia such as confusion, delirium and coma. Signs and symptoms of mild hypercalcemia are nausea and vomiting.
Report for abnormalities.
Nursing Considerations: Use calcium carbonate with extreme caution in digitalized patient and patient with renal and cardiac diseases. Health Teachings:
Tell patient to take oral calcium 1 to 1 hours after meals if GI upset occurs. Tell patient to take oral calcium with a full glass of water. Advise patient not to take calcium carbonate indiscriminately or to switch antacids without prescribers advice.
Tell patient who takes chewable tablets to chew thoroughly before swallowing and to follow with a glass of water.
Instruct patient to take drug as prescribed.
EVALUATION:
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Determine the effectiveness of the anti- ulcer treatment and the presence of side effects. The client should be free of pain.
Rationale: Patient was diagnosed with metabolic acidosis, wherein there is increase gastric secretion. The drug was given to treat hyperacidity and supplement calcium.
Brand name: Generic name: sodium bicarbonate Classification: Acidifiers and Alkalinizers Indications:
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Metabolic acidosis Antacid
Contraindications:
Patients with metabolic or respiratory alkalosis and in those with hypocalcemia in which alkalosis may produce tetany.
Use caution in patients with renal insufficiency, heart failure and edematous. Patients losing chloride because of vomiting.
Drug interaction: Anorexiants, flecainide and tetracyclines. 2 tablets P.O TID
Actual Dosage:
Mechanism of action: Restores buffering capacity of the body and neutralizes excess acid. Adverse reactions: CNS: tetany CV: edema GI: gastric distention, belching and flatulence
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METABOLIC: hypokalemia, hypernatremia, metabolic alkalosis, hyperosmolarity.
Assess the patients pain, including the type, duration, severity and frequency. Assess the patients renal function. Assess for fluid and electrolyte imbalances, especially sodium levels. Assess for the drug history or any drug-drug interactions. Assess laboratory results such as HCO3 and serum sodium levels.
DIAGNOSIS: Acute pain r/t increased gastric secretion secondary to metabolic acidosis as manifested by autonomic response increased white blood cell count of 19.17 x 10 ^ g/L. PLANNING: Patient will be free of abdominal pain after the drug management.
IMPLEMENTATION: Check and verify Doctors order. Observe the12 rights of drug administration. Observe for signs of hypersensitivity.
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Inform prescriber about the laboratory results. Monitor pain, including its frequency, duration, interval, characteristics and severity.
Encourage the patient to drink 2 oz of water after antacid to ensure that the drug reaches the stomach.
Administer antacid 1 to 3 hours after meals and at bedtime. Instruct to take drug as prescribed. Instruct the patient with the use of relaxation techniques.
Nursing Considerations: Tell patient not to take drug with milk because doing so may cause high levels of calcium in the blood, abnormally high alkalinity in tissues and fluids or kidney stones. Health Teachings:
Advise the client to avoid foods and liquids that can cause gastric secretion. Explain to the client that stools may become speckled and white. Instruct the client to report pain, coughing or vomiting of blood. Teach patient some diversional activities such as listening to music and reading newpapers to divert attention to pain felt.
Teach deep breathing exercises to reduce pain felt.
EVALUATION: Determine the effectiveness of the anti- ulcer treatment and the presence of side effects. The client should be free of pain.
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Rationale: Patient was diagnosed with metabolic acidosis, wherein there is increase gastric secretion. The drug was given to treat hyperacidity.
Brand name: LASIX Generic name: furosemide

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Classification: Diuretics Indications: Edema
Contraindications: Hypersensitive to drug and in those with anuria.
Drug interaction: Aminoglycoside, antibiotics, cardiac glycoside, NSAIDs, Phenytoin. 40 mg 1 tab
Actual Dosage:
Mechanism of action: A potent loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle.
Adverse reactions:
CNS: headache, dizziness, weakness, vertigo, paresthesia, restlessness and fever.
CV: orthostatic hypotension and thrombophlebitis. EENT: blurred or yellowed vision, transient deafness.
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GI: abdominal discomfort and pain, diarrhea, constipation, nausea and vomiting. GU: frequent urination, nocturia, polyuria, oliguria and frequent urination. HEMATOLOGIC: azotemia, anemia, thrombocytopenia and leukopenia. METABOLIC: volume depletion and dehydration, impaired glucose tolerance, hypokalemia, hyperglycemia and hypocalcemia.
MUSCULOSKELETAL: muscle spasm SKIN: dermatitis, photosensitivity.
Assess patients vital signs. Assess patients weight. Assess patients intake and output. Note whether hypertensive to sulfonamides is. Assess for history of allergic reaction
DIAGNOSIS:
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Excess Fluid volume r/t compromised regulatory mechanism as manifested by edema.
PLANNING: Patients edema will be decreased.
IMPLEMENTATION:
Check and verify the Doctors order. Observe the 12 rights in drug administration. Observe for hypersensitivity. To prevent nocturia, give P.O preparations in the morning. Give second doses in early afternoon.
Monitor weight, blood pressure and pulse rate routinely with long term use. Weigh patient daily. If oligura develops, drug may need to be stopped. Monitor fluid intake and output. Watch for signs of hypokalemia, such as muscle weakness and cramps. Refrigerate oral furosemide solution to ensure drug stability.
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Store tablets in light- resistant container to prevent discoloration.
Health Teachings:

Advise patient to take drug with food to prevent GI upset. Advise to take drug in morning to prevent need to urinate at night. Inform patient of possible need for potassium or magnesium supplements.
Instruct patient to stand slowly to prevent dizziness and to limit strenuous exercise.
Advise patient to inform immediately ringing of ears, severe abdominal pain, sore throat and fever.
Instruct to take drug as prescribed.
EVALUATION: Evaluate the effectiveness of drug action; decreased fluid retention or fluid overload; check for side effects and increase in urine output. Rationale: Patient was diagnosed to have acute renal failure, thus there is compromised regulatory mechanism causing 3rd space fluid shifting. The drug was given to treat edema.
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Generic Name: metoclopramide Brand Name: PLASIL Classification: Antiemetic, GI stimulant Dosage: 1 ampule IVTT prn for vomiting q8o Indications:
Disturbances of GI motility Nausea and vomiting Metabolic diseases
Contraindications:

Patients hypersensitive to drug and in those with seizure disorders. GI hemorrhage Mechanical obstruction or perforation.
Mechanism of Action: Stimulates motility of upper GI tract without stimulating gastric, biliary, or pancreatic secretions; appears to sensitize tissues to action of acetylcholine; relaxes pyloric sphincter, which, when combined with effects on motility, accelerates gastric emptying and intestinal transit; little effect on gallbladder or colon motility; increases lower esophageal sphincter pressure; has sedative properties; induces release of prolactin.
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Adverse Reactions:
CNS: restlessness, drowsiness, fatigue, insomnia, dizziness, anxiety, lassitude, fever, depression, confusion, hallucinations, headache, dizziness and extra pyramidal symptoms.
CV: transient hypertension, hypotnsion, suraventricular tachycardia and bradycardia.
GI: Nausea, diarrhea and bowel disorders. GU: urinary frequency and incontinence. HEMATOLOGIC: neutropenia and agranulocytosis. SKIN: rash and urticaria.
Nursing Responsibilities: ASSESSMENT:

Assess for history of allergy to metoclopramide. Assess episodes of vomiting including the frequency, interval and duration. Assess for characteristics of the vomitus including the color, consistency and odor.
Assess for GI hemorrhage, mechanical obstruction or perforation, depression. Assess physical aspect such as the orientation, reflexes, affect, bowel sounds, and normal output.
DIAGNOSIS: Fluid Volume Deficit r/t active fluid loss as manifested by vomiting and loose bowel movement.
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PLANNING:
The underlying cause of vomiting is determined and corrected.
IMPLEMENTATION:
Check and verify the Doctors order. Observe the 12 rights in drug administration. Observe for hypersensitivity. Monitor vital signs. Monitor patients intake and output. Monitor the episodes of vomiting. Monitor and check characteristics of the vomitus including the color, consistency
and odor.
Monitor bowel sounds. Explain to patient that slight discomfort may be felt at the IV site. Observe and monitor for signs of dehydration.
Patients intake and output must be strictly monitored, to determine for signs of dehydration.
Health teaching:

Tell patient to avoid activities that require alertness for 2 hours after doses. Urge patient to report persistent or serious adverse reactions promptly.
EVALUATION: Evaluate the effectiveness of antiemetic by noting the absence of vomiting.
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Rationale: It is used to treat nausea and vomiting.
Generic Name: loperamide Brand Name: Classification: Antidiarrheal Dosage: 1 cap TID Indications:
Diarrhea
Mechanism of Action: Inhibits peristaltic activity, prolonging transit of intestinal contents. Adverse Reactions: CNS: drowsiness, fatigue, dizziness, GI: dry mouth, abdominal pain, distention, or discomfort, constipation, nausea, vomiting. Skin: rash, hypersensitivity reactions Contraindications: Contraindicated in patients hypersensitive to drug and in those who must avoid constipation.
Contraindicated in patients with bloody diarrhea or diarrhea with fever greater than 101o F (38o C).
Use cautiously in patients with hepatic disease.
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Assess interval and frequency of bowel movements. Assess for the characteristics of stool including its color, consistency and odor. Assess bowel sounds. Assess for vital signs. Assess for the fluid and electrolyte losses. Assess for laboratory results such as the serum potassium and sodium level.
DIAGNOSIS: Fluid Volume Deficit r/t active fluid loss as manifested by vomiting and loose bowel movement PLANNING:

Clients bowel movement will no longer be diarrhea, Patients body fluid will be restored.
IMPLMENTATION: Check and verify the Doctors order. Observe the 12 rights in drug administration. Observe for hypersensitivity. Monitor fluid and electrolyte balance. Monitor patients vital signs. Monitor and observe for characteristics of stools.
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Warn patient to avoid activities that require mental alertness until CNS effects of drug are known.
Notify physician if diarrhea does not stop in a few days or if abdominal pain, distension, or fever develops.
Record number and consistency of stools.
Nursing considerations:
If clinical symptoms dont improve within 48 hour, stop therapy, notify prescriber and consider other alternatives.
Health teaching:
Instruct patient not to engage in potentially hazardous activities until response to drug is known.
Instruct patient to report for nausea, abdominal pain or abdominal discomfort. Teach patient measures to relieve dry mouth; rinse mouth frequently with water, ice chips and sugarless gum.
Instruct patient to take drug as prescribed. Instruct to notify prescriber if unusual responses may occur.
EVALUATION:
Evaluate the effectiveness of the drug; diarrhea has stopped. Continue to monitor vital signs.
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Rationale: It is used to lessen or treat diarrhea resulting from gastroenteritis and amoebiasis.
Generic Name: piperacillin sodium and tazobactam Brand Name: VIGOCID Classification: Anti-infectives Indications: Moderate to severe pneumonia. Moderate to severe infections from piperacillin- resistant strains of microorganisms. Contraindications: Contraindicated to patients hypersensitive to drug or other penicillin. Use cautiously in patients with bleeding tendencies, uremia, hypokalemia and allergic to other drugs. Dosage: 2.25 gm IVTT ANST (-) q8o Mechanism of Action: Inhibits cell wall synthesis during bacterial multiplication.
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Indications: Moderate to severe infections from piperacillin-resistant, piperacillintazobactam producing strains of microorganism in appendicitis and peritonitis caused by E. coli. Adverse Reactions:

CNS: fever, headache, insomnia, agitation, dizziness, anxiety and seizures. CV: hypertension, tachycardia, chest pain and edema. EENT: rhinitis. GI: diarrhea, nausea, vomiting, constipation, dyspepsia, stool changes, abdominal pain.
GU: interstitial nephritis. HEMATOLOGIC: thrombocytopenia. anemia, eosinophilia, neutropenia, leukopenia and
RESPIRATORY: dyspnea. SKIN: rash and pruritus. OTHERS: pain, anaphylaxis, inflammation, phlebitis and hypersensitivity reactions.
Nursing Responsibilities: ASSESSMENT: Assess for allergy to penicillins. If allergic to one type, the patient should not receive any other type of penicillins.
Assess vital signs which include the elevated temperature. Assess patients vital signs, especially respiratory rate.
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Assess urine output which includes the decrease urine output. Report abnormal findings.
Assess for the laboratory result specifically the white blood cell count. Assess for the degree or severity of infection by observing signs of infection and laboratory results.
DIAGNOSIS:
Ineffective Protection r/t invasion of microorganisms as manifested by increased white blood cell count-19.17 x 10 ^g/L.
PLANNING:
Patients infection will be controlled and later eliminated.
IMPLEMENTATION:

Check and verify the Doctors order. Observe for the 12 rights of drug administration. Watch for signs and symptoms of hypersensitivity. Monitor vital signs especially the temperature. Monitor patients intake and output. Monitor respiratory rate and observe for difficulty in breathing. Check and Auscultate for lung sounds. Monitor for signs of infection such as the elevated temperature and chills. Administer drug for 30 minutes.
Administer drug very slowly for 30 minutes to avoid irritation.

195
Health teaching:
Tell patient to take entire quantity of drug exactly as prescribed, even if he feels better.
Inform patient to notify prescriber if rash, fever, or chills develop. Advise patient to report discomfort at IV injection site. Explain to patient that slight discomfort at IV injection site can be felt.
EVALUATION:
Evaluate the effectiveness of antibacterial agent by determining whether the infection has ceased and whether side effects had occurred.
Rationale: Patient was diagnosed to have pneumonia. This drug is used to treat infection caused gram-positive and gram-negative.
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Generic Name: potassium chloride Brand Name: KALIUM DURULE Classification: Electrolytes and minerals Dosage: 2 tabs P.O TID Mechanism of Action: Supplemental potassium in the form of high potassium food or potassium chloride may be able to restore normal potassium levels. It replaces potassium and maintains potassium level. Indications:

For hypokalemia Indicated when potassium is depleted by severe vomiting, and prolonged dieresis
Contraindications:
In patients with severe renal impairment with oligura, anuria or azotemia. Use cautiously in patients with cardiac disease or renal impairment.
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Adverse Reactions:
CNS: paresthesia of limbs, listlessness, confusion, weakness or heaviness of limbs and flaccid paralysis.
CV: arrhythmias, heart block, cardiac arrest, hypotension, postinfusion phlebitis. GI: nausea and vomiting, abdominal pain, and vomiting METABOLIC: hyperkalemia RESPIRATORY: respiratory paralysis
Nursing Responsibilities: ASSESSMENT: Assess for signs and symptoms of hypokalemia which include nausea and vomiting, abdominal distention and soft, flabby muscles. Assess laboratory result such as serum potassium level. Assess for fluid and electrolyte imbalances. Assess for patients intake and output. Assess patients vital signs.
DIAGNOSIS: Imbalanced Nutrition: Less than Body Requirements r/t active fluid loss as manifested by serum potassium level of 2.8 mmol/ L. PLANNING:
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Patients serum potassium level will be within normal range.
IMPLEMENTATION: Check and verify the Doctors order. Observe the 12 rights of drug administration. Observe for hypersensitivity. Monitor patients vital signs. Monitor patients intake and output. Monitor electrolytes level by checking the laboratory results. Monitor renal function by checking the laboratory results specifically the creatinine and potassium level. Administer while patient is sitting up or standing (never in recumbent position) to prevent drug- induced esophagus. Nursing Considerations: Dont crush sustained release potassium products. Enteric coated tablets may increase risk of GI bleeding. Health Teachings:
Tell patient to take with or after meals with full glass of water or fruit juice to lessen GI distress.
Teach patient signs and symptoms of hyperkalemia. Tell patient to notify prescriber if signs of hyperkalemia may occur.
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Warn patient not to use salt substitutes concurrently, except with prescribers permission.
Instruct to take drug as prescribed.
EVALUATION:
Evaluate the patients serum potassium level. Report to the physician if the level remains abnormal.
Rationale: Patient was diagnosed to have hypokalemia. The drug was given to provide a direct replacement of potassium in the body.
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Generic Name: citicoline Brand Name: Classification: Peripheral Vasodilators and Cerebral Activators Dosage: 500 mg IV q8o Indications:

Intracranial traumatism. Cerebral insufficiency.
Mechanism of Action: Citicoline is an interneuronal communication enhancer. It increases the neurotransmission levels because it favors the synthesis and production speed of dopamine in the striatum, acting then as a dopaminergic agonist thru the inhibition of tyrosine- hydroxylase. Adverse Reactions:

CNS: dizziness, wariness, paresthesia and fatigue. SKIN: rash, pruritus and urticaria. ALLERGIC REACTION: itching, swelling in the face and hands, bradycardia, headache and nausea and vomiting.
Contraindications: Parasympathetichypertonia
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Assess patients vital signs. Assess patients neurologic and mental status. Assess for history of allergic reaction to drug.
DIAGNOSIS:
Ineffective renal tissue perfusion r/t hypovolemia and diminished blood flow to the kidney as manifested by prolonged low blood pressure and decreased urine output.
PLANNING:
Clients blood pressure will increase or improve.
IMPLEMENTATION:
Verify doctors order Observe the 12 rights in drug administration. Observe for signs of hypersensitivity. Perform skin test to assess allergy. Monitor vital signs. Take Citicholine as prescribed Monitor patients neurologic status. Note for adverse reactions Instruct to take drug as prescribed.
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Before administering the drug, vital signs must be first taken and must be accurate.
Health Teachings:
Instruct to take medications on time. Small frequent meals, frequent mouth care may reduce nausea and vomiting. Advice patient to observe good oral hygiene. Instruct patient to avoid strenuous activities. Instruct patient to report or notify the physician for undesirable responses.
EVALUATION:
Evaluate the effectiveness of drug by determining the whether the blood pressure increased or improved.
Rationale: Patient was diagnosed to have prolonged hypotension. The drug was given to improve perfusion of vital organs as well as the blood pressure.
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Generic Name: Nifuroxazide Brand Name: Ercefuryl Classification: Antidiarrheal Dosage: 1 cap p.o BID Mechanism of Action: Indications: As a supplement to rehydration, treatment of acute diarrhea presumed to be of bacterial origin in the absence of suspected invasive phenomena (impaired general condition, fever, and sign of toxicity or infection). Adverse Reactions: Allergic reactions, skin rash, urticaria, Quincke's edema or anaphylactic shock. Contraindications:
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Patients with hypersensitivity to nitrofuran derivatives or to any of the ingredients of Ercefuryl.
Ercefuryl capsules is contraindicated in children <6 years due to the risk of choking.

Assess interval and frequency of bowel movements. Assess for the characteristics of stool including its color, consistency and odor. Assess bowel sounds. Assess for vital signs. Assess for the fluid and electrolyte losses. Assess for laboratory results such as the serum potassium and sodium level.
DIAGNOSIS:
Diarrhea r/t ingestion of contaminants as manifested by urgency to defecate, and loose watery stools.
PLANNING:
Client will be able to regain normal bowel movement.
IMPLEMENTATION: Check and verify the Doctors order. Observe the 12 rights in drug administration. Observe for hypersensitivity. Monitor patients vital signs. Monitor for patients intake and output.
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Weigh patient daily. Monitor for the interval and frequency of bowel movements. Monitor for the characteristics of stool including its color, consistency and odor. Check for the bowel sounds. Monitor fluid and electrolyte balance by checking the laboratory results. Record number and consistency of stools.
If clinical symptoms dont improve within 48 hour, stop therapy, notify prescriber and consider other alternatives.
Health teaching:
Instruct patient to notify physician if diarrhea does not stop in a few days or if abdominal pain, distension, or fever develops.
Teach patient not to engage in other potentially hazardous activities until response to drug is known.
Teach some measures to relieve dry mouth; rinse mouth frequently with water, ice chips and sugarless gums.
Instruct patient to take drug as prescribed.
EVALUATION:
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Rationale: It is used to treat diarrhea resulting from amoebiasis and acute gastroenteritis.
Generic Name: Etofamide Brand Name: Kitnos Classification: Antiamoebics Dosage: 500 mg 1 tab p.o BID Mechanism of Action: Etofamide is a luminal amoebicide acting principally on the bowel lumen with actions and uses similar to diloxanide furoate. Indications: Acute & chronic intestinal amoebiasis. Adverse Reactions: Flatulence, vomiting, urticaria, pruritis. Contraindications: Etofamide is contraindicated to patients with known hypersensitivity to and any of this group. Nursing Responsibilities: ASSESSMENT: Assess vital signs for future comparison.
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Assess characteristics of stool which includes the color, consistency and odor. Assess for the frequency, duration and interval of defecation. Assess/ obtain history of allergy. Assess for urine output.
DIAGNOSIS:
Ineffective Protection r/t invasion of microorganisms as manifested by increased white blood cell count-19.17 x 10 ^g/L
PLANNING: Clients infection will be resolved or infection will be prevented.
IMPLEMENTATION:
Check and verify the Doctors order. Observe the 12 rights in medication. Observe for signs of hypersensitivity. Monitor the patients intake and output. Monitor the laboratory results and compare with baseline findings. Monitor vital signs. Compare with baseline findings. Give with meals to minimize GI irritation.
208
Record number and characteristics of stools. Monitor for the characteristics of stool which includes the color, consistency and odor.
Monitor for the frequency, duration and interval of defecation Observe for side effects and adverse reactions such as nausea, vomiting and headache.
Nursing Considerations: Patients intake and output especially the frequency and interval of defecation must be monitored strictly to monitor signs of dehydration. Health Teachings: Instruct patient in proper hygiene. Instruct to report immediately any neurologic symptoms such as seizures and peripheral neuropathy. Instruct the client to take the drug as prescribed. Instruct to report/ notify prescriber for unusual responses. Instruct to take drug with food to minimize gastric irritation.
Rationale: patient was diagnosed to have amoebiasis manifested by loose bowel movement. The drug was given to treat amoebiasis.
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Prognosis
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Poor (1)
Fair (2)
Good (3)
Justification Before seeking for medical assistance, Mr. C is already experiencing vomiting and loose bowel movement for 4 days. This period of time caused his blood pressure to be very low and caused him to experience generalized weakness. He was not diagnosed immediately since he does not have regular check-ups. However, symptoms started to occur after eating kinilaw, which was 4 days before the admission, and by which according to the physician, was added by the habit of drinking water from the river without boiling. It is poor even though his family practices healthy lifestyle by eating fruits and vegetables fresh from their backyard. Also, even if he does not have any vices, like smoking and drinking alcoholic beverages, their health practices, contributed a lot to what had happened to him. Examples are by not boiling the water gotten from nearby river before using it for drinking, not washing hands before eating, and by not cleaning feet and body after work, and by eating raw fish which might not be properly prepared. When he was in the hospital, all he wanted was for the treatment of vomiting and loose bowel movement. After being diagnosed with his condition, he shows willingness in cooperating with medical advices and nursing procedures since he also wanted to recover fast and go back to his usual activities like farming. He is also complying with the medications prescribed for him. Since kidney function is reduced in older age, the older a person is, the greater the risk. Mr. C has a fair score being 67 years old. In his age, he is able to cooperate and manage during the treatment of his condition. They are surrounded with farm lots and plants on their house. They enjoy fresh air. His wife is very particular in the cleanliness of their house. Though presence of a nearby river is beneficial for them, it caused them unhealthy practice by not boiling the water from it before drinking. He is well loved and supported by his 211 husband and 3 children even before his admission up to the duration of his hospitalization. He also has a close relationship among them.
Duration of Illness
Onset
Precipitating Factors
Willingness to Compliance of Treatment
Age
Environment
Family Support
Scoring:
The patients score is 2.14 which is a fair prognosis. The patient wasnt able to seek immediately for medical assistance after experiencing vomiting and loose bowel movement. Because of some unhealthy practices, he was hospitalized. But then, his attitude helped him as he was being treated. He cooperates well and follows medical advices. He is not hard headed and he complies with all the medicines with the help of his familys care and support.
Discharge Planning
General Condition of client upon discharge Good 3- 2.7 Fair 2.5- 1.6 Poor 1- 1.5
During student nurse-patient interaction upon discharge, Mr. C was wearing a comfortable pair of orange shirt and brown shorts and a pair of flat slip-ons while lying in the bed. He was oriented enough to follow instructions and answers questions asked by the student nurse. METHOD
212
Medications Encouraged patient to comply all prescribed medications and take maintenance medications religiously.
Instructed the patient to take the following home medication as ordered by the physician: Ciprobay XR 500 mg 1 tab P.O OD after lunch. Calvit 1 tab P.O OD after breakfast.
NaHCO3 10 gms 2 tabs P.O TID.
Zinnat to consume present stock. Omeprazole 1 tab P.O OD 7AM. Lasix 40 mg tab P.O OD 7AM.
Environment/Exercise Instructed patient to avoid strenuous activities.
Treatment

Encouraged patient to have frequent check up. Advised monitoring of serum creatinine.
Hygiene
213
Instructed patient to take a bath every day. Emphasize the importance of proper hygiene.
Proper hand washing.
Out-patient
Advice to visit or have a follow up check-up with Dr. Baas- Espinosa on January 28, 2011.
Diet Be careful with water and foods.
214

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CHAPTER VII MEDICAL AND NURSING MANAGEMENT

Blood urea nitrogen (BUN)

Complete blood count (CBC)

It also looks for:

Fractional excretion of sodium (FeNa)

24-hour urine collection

ACIDOSIS give sodium bicarbonate; be prepared for mechanical ventilation.

Assess for nausea, vomiting, diarrhea and lethargy.

Monitor ABG levels as necessary to evaluate acid- base balance.

Express feelings and concerns about self. Recovers without complications.

ACTUAL MEDICAL AND NURSING MANAGEMENT

Basophils Neutrophils Hemoglobin

0.00 0.82 173.4

0.000.01 % 0.550.65 % 120140 SI g/L 0.400.50 x 10 ^ 12/ L

4.5-5.0 u^3 82-92 u ^3 32- 36 g/dl 27-31 pg

Diagnostic/ laboratory Consistency

May indicate metabolic problems

Pus cells Remarks: intestinal ova and parasites seen.

May indicate infection

Procedure and posttest care

If a hematoma develops at the venipuncture site, apply warm soaks.

Diagnostic/ laboratory Potassium

4.3 mmol/ L 3.05 mmol/L

3.5- 5.1 mmol/ L 2.102.54 mmol/L

mmol/L Creatinine 2.2 mg/dl

mmol/L 0.8- 1.5

01/16/11 Color Yellow Straw yellow, amber Clear Normal

Reaction Specific gravity Sugar Albumin

5.0 1.020 Negative Positive (3+)

4.5-8 1.0021.030 Negative Negative

Crystals Amorphous urates

indicate infection. Indicates kidney disorder, blood disorder or bladder cancer.

Procedure and posttest care

Diagnostic/ laboratory Potassium

3.5- 5.1 mmol/ L

2.102.54 mmol/L 137-145 mmol/L

vomiting and diarrhea.

CLINICAL CHEMISTRY SECTION POTASSIUM TEST 01/19/11

Procedure and posttest care

Diagnostic/ laboratory Potassium

3.5- 5.1 mmol/ L

Still within normal range.

Procedure and posttest care

80-105 mmHg 22-26 mmol/L

Slight decrease, no significan ce but low may indicate inadequat e perfusion.

Procedure and posttest care

Date and Time

For management of present condition.

IVF to follow PNSS1 L to run at 30 gtts/ min

Risek 40 mg IVTT O.D

Metronidazole 500 mg TID P.O.

11/15/11 11 AM (+) seizure seconds. for

Refer labs to A.P. Fast drip 300 cc IVF now.

12 PM BP: palpatory 60 mmHg.

Titrate dopamine drip

Regulate IVF D5 NSS 1 L at 140 cc/ hr.

3:15 PM (+) dyspnea BP: 50/ 20 mmHg.

Increase dopamine drip to 20 gtts/min.

Fast drip 200cc from present IVF.

NaHCO3 25 meq + 25 cc IVF Slow IVTT.

6:35 PM (-) urine output

Insert foley catheter and attach to urobag.