Você está na página 1de 89

1

XAVIER UNIVERSITY
ATENEO DE CAGAYAN

A CASE STUDY ON A 34 YEAR OLD MALE PATIENT


DIAGNOSED WITH ACUTE RESPIRATORY FAILURE
SECONDARY TO SEPSIS SECONDARY TO ACUTE
NECROTIZING PANCREATITIS AND DIABETES
MELLITUS TYPE II SECONDARY TO ACUTE
NECROTIZING PANCREATITIS

Submitted to:
Ms. Geraldine Lacar, RN
Mr. George Gordon Lim, RN
Mrs. Leonora Sumaylo, RN
Fourth year Clinical Instructor

Submitted by:
Absin, Mary Grace
Abuzo, Ana Kris
Ardiente, Robbie Jay
Coraler, TC May
Cue, Marc Anthony
Dial, Mia Joy
Guzman, Van Ryan
Ilagan, Leah Elizabeth
Lawan, Gail
Manus, Gretta Carmel
Murillo, Joaquin II
Pasoquin, Joyce Dane
Taal, Mary Anneriza
Vega, Angela Paula
Yap, Lionel Bryan

BSN 4NC and NG


Group AA2

September 22, 2007


2

TABLE OF CONTENTS

I. Introduction……………………………………………………………3
General objective…………………………………………………5
Specific objectives………………………………………………..5
Scope and limitations……………………………………………..6
II. Assessment
Patient demographic data…………………………………………7
Assessment tool…………………………………………………..8
Laboratory results………………………………………………..15
III. Anatomy and physiology……………………………………………16
IV. Pathophysiology
Narrative form……………………………………………………22
Schematic Diagram………………………………………………24

V. Medical management
General management…………………………………………….25
Drug study……………………………………………………….30
VI. Nursing management ………………………………………………61
VII. Discharge planning………………………………………………..72
VIII. Prognosis…………………………………………………………76
IX. Conclusion…………………………………………………………77
X. Recommendation……………………………………………………78
XI. Bibliography……………………………………………………….79
XII. Appendix………………………………………………………….81
3

INTRODUCTION

This is a case of patient RP, 34 years ols, male, admitted on august 10, 2007, with the
presenting diagnosis of Acute Respiratory Failure secondary to sepsis secondary to acute
necrotizing pancreatitis; Diabetes Mellitus type II secondary to acute necrotizing pancreatitis.
Under the care of the XUSN4 of block NC and NG during the I.C.U. rotation in Maria Reyna
Hospital.
Acute pancreatitis is defined as an acute inflammatory process of the pancreas with
variable involvement of other regional tissues or remote organ systems. In acute pancreatitis,
protease trypsinogen enzyme, produced by the exocrine pancreas, converts into active trypsin;
the enzyme most responsible for auto-digestion of the pancreas, causes primarily the pain and
complications of pancreatitis.
Acute pancreatitis is classified further into mild and severe forms. Mild acute pancreatitis
is associated with minimal organ dysfunction and uneventful recovery. Severe acute pancreatitis
is associated with pancreatic necrosis and may lead to organ failure or local complications.
The International Symposium on Acute Pancreatitis in 1992 defined pancreatic necrosis
as the presence of one or more diffuse or focal areas of nonviable pancreatic parenchyma, which
is often associated with peripancreatic fat necrosis. By definition, pancreatic necrosis represents
a severe form of acute pancreatitis.
Type 2 diabetes mellitus, previously known as adult-onset diabetes, maturity-onset
diabetes, or non-insulin-dependent diabetes mellitus (NIDDM)—is due to a combination of
defective insulin secretion and insulin resistance or reduced insulin sensitivity (defective
responsiveness of tissues to insulin), which almost certainly involves the insulin receptor in cell
membranes. In short, Type 2 diabetes occurs when your pancreas does not make enough insulin
or is unable to use the insulin effectively. When the body does not make enough insulin or has
trouble using insulin, the cells do not absorb enough sugar from the blood - leading to high blood
sugar levels and diabetes.
This disease condition occurred from pancreatic insulin producing beta cell damage. Beta
cells (beta-cells, β-cells) are a type of cell in the pancreas in areas called the islets of Langerhans.
They make up 65-80% of the cells in the islets. These cells are responsible in making and
releasing insulin, a hormone that controls the level of glucose in the blood.
4

Respiratory failure is a syndrome in which the respiratory system fails in one or both of
its gas exchange functions: oxygenation and carbon dioxide elimination. In practice, respiratory
failure is defined as a PaO2 value of less than 60 mm Hg while breathing air, or a PaCO 2 of more
than 50 mm Hg. Furthermore, acute respiratory failure is characterized by life-threatening
derangements in arterial blood gases and acid-base status.
Acute renal failure (ARF) is the rapid breakdown of renal (kidney) function that occurs
when high levels of uremic toxins (waste products of the body's metabolism) accumulate in the
blood. This disease condition occurs when the kidneys are unable to excrete the daily load of
toxins in the urine.
The above mentioned disease conditions is a brief overview of the presenting diagnosis
of the patient. Thorough discussion of the presenting diagnosis shall be reflected in Anatomy &
Physiology and in Pathophysiology.
5

General objective

At the end of one hour of case presentation, we will be able to improve our knowledge in various

concepts related to our patient’s condition, and skills in careful assessment and rendering of

nursing interventions involved in the management of our client’s case; and develop positive

attitudes by cooperation and sense of teamwork as we accomplish our case study using concepts

that we have acquired from our NCM 104 classes and previous related subjects in the BSN and

AHSE curriculum.

Specific objectives

1. Perform a thorough assessment and careful gathering of data that are clinically significant

and will be utilized as reliable cues for our care plans.

2. Further completion of data that will supplement our assessment, such as laboratory

results, doctor’s orders and monitoring sheets.

3. Trace and familiarize the pathophysiology of our patient’s disease process.

4. Design individualized nursing care plans based on nursing diagnoses that are suitable and

feasible to carry out.

5. Carry out nursing interventions that are effective, reality based, time-bounded, achievable

and beneficial for our client.

6. Come up with a medical management, a prognosis, and a discharge plan that are suitable

and individually designed as well as clinically and scientifically based.

7. Develop a sense of teamwork in coming up with the case study by division of labor and

merging of ideas to establish data consistency.


6

SCOPE AND LIMITATION

The study focuses on the assessment, anatomy, and pathophysiology and its diagram,

medical management-both ideal and actual, nursing care plans, ideal discharge plan, prognosis,

recommendation and conclusion revolving around the diagnosis of the patient which is Acute

Respiratory Failure secondary to sepsis secondary to acute necrotizing pancreatitis; Diabetes

Mellitus type II secondary to acute necrotizing pancreatitis. Noted complications in the

Respiratory System and Urinary System were also taken into consideration to better understand

the said disease condition.

This study is limited only to the available records found on the patient’s chart and the

information being provided for by the family members present at the patient’s room during the

time of assessment. Other factors that will also be considered as limitations to this study would

include the short-duration of time given for ICU rotation.


7

Patient demographic profile

Name of patient: RP

Age: 34 years old

Sex: Male

Address: B-37 L-20 Grand Europa Lumbia Cagayan de Oro City

Civil status: Single

Height: 5’11”

Weight: 72.7 kgs

Language spoken: Visayan, Filipino

Religion: Roman Catholic

Nationality: Filipino

Occupation: unemployed

Income: None

Chief complaint: change in sensorium

Admission diagnosis: Acute Respiratory Failure secondary to sepsis secondary to

acute necrotizing pancreatitis; Diabetes Mellitus type II

secondary to acute necrotizing pancreatitis

Date of confinement: August 10, 2007

Name of attending physician: Dr. Valmores, Dr. A. Sison, and Dra. Solas
8

College of Nursing
Xavier University
Ateneo de Cagayan

LEVEL IV
NURSING HISTORY & ASSESSMENT RECORD

NAME OF PATIENT: RP CHIEF COMPLAINT: Change in Sensorium


AGE: 34 DIAGNOSES: Acute respiratory failure
secondary to sepsis and
acute necrotizing pancreatitis;
Diabetes Mellitus type 2
secondary to acute necro-
tizing pancreatitis;hypoalbuminemia
acute necrotizing pancreatitis;
Hospital acquired pneumonia;
Pulmonary edema; Acute renal
Failure sec. acute necrotizing
pancreatitis; hypokalemia sec. to
insulin drip.
DATE: TIME: ( / ) AM NAME OF ATTENDING
8/10/07 10:00 ( ) PM PHYSICIAN:
Dr.Valmores, Dr. Sison,
Dra.Solas

ADMITTED BY: ADMITTED FROM:


( ) Ambulatory ( ) Wheelchair ( ) Home
( / ) Stretcher ( / ) ER
Temperature:37.7 Pulse:119bpm Respiration: Blood Height:5’11” Weight:72.7kgs
36.3 86bpm MV Pressure:
18cpm 100/70
mmhg
Language/Dialeect spoken: Visayan dialect
(/) Oriented to unit ( ) Not Oriented Reason: ( ) Confused ( ) Comatose
( ) Critical ( ) Language Barrier
Religion: Roman Catholic Status: Single
INFORMANT: ( ) Patient ( ) Others (specify)
Friend and younger sister
CHIEF COMPLAINT/REASON FOR HOSPITALIZATION:
1 day PTA, Pt. was noted to be sleeping most of the time without food/fluid intake. On
the day of admission, the patient becomes so hypotensive with a blood pressure of 60/40mmhg,
thus prompted for admission in Maria Reyna Hospital.
Duration/Onset of problem: 1 day PTA (Aug. 9,2007)
Treated for symptoms before: (/) No
9

ALLERGIES:
(/) None known ( ) Yes (Specify Allergen)
RP’s younger sister verbalized, “ Wala mana sya’y allergies sa pagkaon og tambal.”

MAJOR ILLNESS, OPERATIONS, AND HOSPITALIZATIONS


Medical History: ( ) Heart disease ( ) Renal disease
( ) Hyperrtension ( ) Cancer
( ) Stroke (/) Substance Abuse:
Alcohol and cigarette
( ) Lung Disease ( ) Others
Comments: RP’s younger sister verbalized that,” kusog kayo gyud na sya manigarilyo,
Makahurot na syag mga isa ka pack taga adlaw.” She then added, “ grabe kayo japon na sya
gainom.”

Family History: ( ) Heart disease ( ) Renal disease


( ) Hypertension ( ) Cancer
( ) Stroke ( ) Substance abuse
( ) Lung disease ( ) Others: Diabetes Mellitus
Comments: RP’s younger sister verbalized that, “karon lang gyud mi nakabalo na diabetic man
diay akong papa,”

SURGICAL HISTORY/HOSPITALIZATIONS ( INCLUDE DATES): As written on the


RP’s chart, he undergone craniotomy last March 2005, due to gunshot wound.

NUTRITION/METABOLIC PATTERN
Meal pattern: Usually, RP eats three times a day. However, on our first assessment, RP is on
NPO status. He is getting nutrition through TPN.On our second assessment, RP is fed per NGT 6
times a day.

Appetite: ( ) Good ( ) Fair ( ) Poor ( /) NA


Changes in eating habits: ( ) No ( ) Yes ( / ) NA
Appetite changes: ( ) No ( / ) Yes Time period: 1 day PTA, RP was observed to be
sleeping without food/ fluid intake.
Weight loss/gain: (+) weight loss; from
78kgs to 72.7kgs in one week Special diet: On our first assessment, RP is
on TPN_Kabiven(1400 kcal). On our 2nd
assessment, RP is on NGT feeding of 1800
kcal/day in 1000 cc water in 6 divided
doses + 6 egg whites/day.
Comments: RP’s younger sister verbalized that, “ grabe gyud ang iyang pagniwang,tambok mani
sya sauna.” Imbalanced nutrition: Less than body requirements; weakness was also noted,and
pale conjunctiva and mucous membranes.

TEETH (/ ) Own
Comments: Yellowish white in color. RP’s younger sister verbalized that,”kumpleto pa man na
iyang ngipon, wala pud na sya gagamit og bisag unsa para ngipon.”
10

ELIMINATION PATTERN
BLADDER ( / ) Catheter
Comments: RP is on urinary catheter draining well to a yellow colored urine. RP’s latest intake
was 740 cc and his latest output was 860 cc. Polyuria was noted.
BOWEL ( / ) Diaper
Comments: RP’s younger sister verbalized that, “ makalibang na sya mga kausa sa usa ka adlaw,
ako may ga ilis sa iyang diaper.” His stool is yellowish brown in color, soft, and in moderate
amount.

SLEEP OR REST PATTERN


( ) No difficulty ( ./ ) Yes (describe) According to the patient’s sister RP has
difficulty in sleeping. He could not sleep continuously and seems to be awake most of the time
during the day. “Sige ra og mata-mata, sugod buntag padulong hapon”.

Use of sleeping aids ( /) No ( ) Yes

Comments/Nursing Problem Identified : As observed patient RP seems to be disturbed easily,


whenever people would come across or visit him, he would open his eyes.

ACTIVITY/EXERCISE
Activities of Daily Living (I= Independent, A=With Assistance, D=Dependent)
Eating: (D) Bathing: (D) Dressing: (D)
Grooming: (D) Toileting: (D) Ambulating: (D)

ACTIVITY LEVEL ( ) Active ( / ) Sedentary

Comments/Nursing Problem Identified: RP is currently on complete bed rest and is dependent in


all activities of his daily living. He is taken cared by his “yaya” and his siblings. According to his
sister the patient does not have work and he usually stays at home and helps with the household
chores.

BEHAVIOR PATTERN
BEHAVIOR ( ) relaxed ( ) mildly anxious
(/ ) moderately anxious ( ) very anxious

Psychiatric History: Upon assessment patient is moderately anxious and irritable. According to
his sister RP had episodes of psychosis after he under went craniectomy because of a gunshot.
“Paghuman atong napusilan siya, naa na dayon times na makalina iyang storya, mura siyag
bata.” Og “naa gyud usahay mutukar na siya saputon lang kalit og di kaila.” As verbalized by
his sister.

SUBSTANCE ABUSE
Tobacco ( ) no ( / ) yes Cigarette/Cigar/Pipe 1 pack /day/wk
Drugs ( / ) no ( ) yes Type:____________
Alcohol ( ) no ( / ) yes Amount: 3 long neck/week
11

Comments/Nursing Problem Identified: As verbalized by his “yaya” the patient is a smoker


he can consume 1 pack of cigarette a day. RP is a chronic drinker,makahurot na sya og mga tulo
ka long neck sa isa ka semana”, “balay ra man na siya, gatambay2x lang, inom og manigarilyo
pud dayon” as verbalized by significant other.

SEXUALITY/REPRODUCTIVE PATTERN
Comments/Nursing Problem Identified: As observed and verbalized by the significant other
patient has scrotal inflammation with minimal white discharges.

PHYSICAL ASSESSMENT

NEUROLOGICAL ASSESSMENT

On the first assessment, patient was conscious and able to respond by nodding. He

manifested weak lower extremities and because of this, pillows are placed under the legs to

prevent any further discomfort. He was oriented to the place but not the time. His speech and

swallowing is compromised because of the presence of a mechanical ventilation. Pupils were

4mm in size with the Right pupil sluggish and Left pupil briskly reactive to light

accommodation.

Upon second assessment, RP had no mechanical ventilation attached to him however

patient still had difficulty in vocalization with episodes of irritability and disorientation because

he could not identify some of his relatives. Both pupils briskly reactive to light accommodation

and 3mm in size. Weakness still noted in extremities.

RESPIRATORY ASSESSMENT

On the first assessment, patient RP was hooked on mechanical ventilator but is not fully

dependent on it; the mode was set only to assist and control. Crackles noted on both lungs , there

was deep labored breathing accompanied by the use of accessory muscles.


12

On the second assessment, crackles still present and RP is coughing ineffectively due to

post-extubation and white secretions noted in RP’s oral cavity. Lips and mucous membranes are

pale but respirations are normal.

CARDIOVASCULAR ASSESSMENT

RP has a heart rate of 119bpm and was noted with sinus tachycardia.

PERIPHERAL-VASCULAR ASSESSMENT

Partial range of motion noted in the lower extremities. Weak and thready pulse was noted

especially in the lower extremities.

GENITOURINARY ASSESSMENT

RP was on a Foley Bag Catheter with urine clear and color yellow. Based on lab results,

presence of ketones was noted (40mg/dL). There was scrotal inflammation with minimal whitish

discharges.

Upon second assessment, there was an increase in urine output noted (O=870cc,

I=740cc). RP still on catheter and on diaper. Blister formation noted at the scrotal and sacral

area.

MUSKULOSKELETAL ASSESSMENT

There was full range of motion in RP’s upper extremities but with the lower, only partial.

Weakness was noted on the lower extremities.

SKIN ASSESSMENT

Oral mucosa was noted to be dry and lips were scaly and dry. Skin is intact except on the

right arm due to the presence of CVP catheter and on the three toes of his right leg due to

presence of blisters with sizes ranging from 6mm-8mm in diameter.


13

On the second assessment, blisters were still evident on the R toes but with additional

blister formation on the Right heel, scrotal and sacral area. Skin is dry.

CURRENT MEDICATIONS

Bactidol oral care TID

1 neb duavent + ½ neb azmavent q6h

Pantoprazole (ulcepraz) 40 mg IVT OD

Citicholine 500mg IVT slow q12h

Furosemide to run in 2-3 hours q12h

Ciprofloxacin 200mg IV drip q12h

Hydrocortisone 100mg vial IVTT q8h

Imipenem and Cilastatin (Tienam) 500mg IVTT q12h

Cefepime 1g IVTT slow q12h

Tranexamic acid (Hemostan) 500mg/amp q8h

Ianzoprazole (Prevacid) 30 mg 1 tab OD/NGT

Glargine Insulin (Lantus) 30 “u” SQ before 8am

Ranitidine 50 mg IV q12h

Dopamine 2gm with D5NSS 300cc

Sodium Bicarbonate 50mg IVTT 4 vials with D5W at 10gtts/min

Tazobactam (Tazocin)4.5 IVTT now then 2.75 mg q12h

Insulin Aspart (Novorapid) 10 “u” SQ before each feeding

Potassium Chloride,60 mg IVTT

-patient RP has no knowledge on the medications prescribed in his treatment regimen.

ROLE RELATIONSHIP PATTERN AND DISCHARGE PLAN


14

RP is fully dependent on the mother who resides in Germany due to the fact that he has

no work and has been unemployed for quite some time. He lives in Gran Europa with his 5

siblings and their families. They will also be the ones assisting RP when at home. Patient seems

to anticipate in returning home however, no order was made yet for any discharge due to further

evaluation and treatment. Patient RP is not in need of a social welfare service because the mother

who works abroad is able to compensate for the medical services.


15

LAB0RATORY RESULTS REFERENCE INTERPRETATION

EXAMINATION VALUES
ARTERIAL BLOOD GAS
> PaCO2 43.3 35 – 45 Normal
> HCO3 14.2 22 – 26 Low Metabolic Acidosis
> pH 7.2 7.35 – 7.45 Acidic
> PaO2 82.3 % 95% – 100% Low

CBC
> WBC 19.6 x 10^3/ uL 5 – 10 X10^3/uL High
> Platelet 80 x 10^6/ mm3 140 – 440 Low

x10^6/mm3

URINALYSIS
> BUN 58 mg/dL 8 – 20 mg/dL High
> Creatinine 3.2 mg/dL .8 – 1.5 mg/dL High
> Ketones 40 mg/dL Ketonuria
> Albumin Fraction 1.9 g/dL 3.5 – 5 g/dL Hypoalbuminemia

BLOOD CHEMISTRY
> Potassium 3.0 mmol/L 3.5 – 5.1 mmol/L Hypokalemia
HGT (Latest result) 151 mg/dL 60 – 110 mg/dL High
ANATOMY AND PHYSIOLOGY
The Pancreas
The pancreas is an endocrine and exocrine organ located retroperitoneally in the upper
abdomen overlying the spine. It is a glandular organ that secretes digestive enzymes and
hormones. In humans, the pancreas is a yellowish organ about 7 in. (17.8 cm) long and 1.5 in.
(3.8 cm) wide. It lies beneath the stomach and is connected to the small intestine at the
duodenum. The pancreas is supplied by the gastroduodenal arteries and by branches of the
splenic artery. The splenic vein and artery run superiorly and posteriorly; the mesenteric vein
lies in the angle between the head and body of the gland. At this point the superior mesenteric
vein and splenic vein join to form the portal vein.
16

Most of
the

Figure 1. Relationships and blood supply of pancreas.


pancreatic tissue consists of grapelike clusters of cells that produce a clear fluid (pancreatic
juice) that flows into the duodenum through a common duct along with bile from the liver.
Pancreatic juice contains three digestive enzymes: tryptase, amylase, and lipase that, along with
intestinal enzymes, complete the digestion of proteins, carbohydrates, and fats, respectively.
Scattered among the enzyme-producing cells of the pancreas are small groups of endocrine
cells, called the islets of Langerhans, that secrete two hormones, insulin and glucagon. The
pancreatic islets contain several types of cells: alpha-2 cells, which produce the hormone
glucagon; beta cells, which manufacture the hormone insulin; and alpha-1 cells, which produce
the regulatory agent somatostatin. These hormones are secreted directly into the bloodstream,
and together, they regulate the level of glucose in the blood. Insulin lowers the blood sugar level
and increases the amount of glycogen (stored carbohydrate) in the liver; glucagon has the
opposite action. Failure of the insulin-secreting cells to function properly results in diabetes,
which can occur in two major forms, the division being between juvenile onset and onset in
maturity.

The exocrine portion of the pancreas accounts for about 80% of the total glandular
volume. It consists of at least two functional units: acinar cells, which secrete primarily digestive
17

enzymes; and centroacinar or ductal cells, which secrete fluids and electrolytes. Pancreatic
secretion is regulated by several peptides that are released from the gastrointestinal tract. Some
of these peptides, such as secretin and cholecystokinin (CCK), stimulate pancreatic secretions,
whereas somatostatin and pancreatic polypeptide inhibit their release. The pancreas secretes
about 20 digestive enzymes and cofactors. Some enzymes are activated in the duodenum by
enterokinases and calcium. These enzymes account for most of the intraluminal digestion of
dietary proteins, triglycerides and carbohydrates. They are also important in the cleavage of
certain vitamins (such as A and B12) from carrier molecules, thereby allowing them to be
absorbed efficiently. Because pancreatic enzymes are secreted in great excess, maldigestion and
serious nutritional deficiencies occur only when over 90% of the gland has been destroyed.

The Cardiovascular System

The heart is the pump responsible for maintaining adequate circulation of oxygenated
blood around the vascular network of the body. It is a four-chamber pump, with the right side
receiving deoxygenated blood from the body at low pressure and pumping it to the lungs (the
pulmonary circulation) and the left side receiving oxygenated blood from the lungs and pumping
it at high pressure around the body (the systemic circulation).

The myocardium (cardiac muscle) is a specialized form of muscle, consisting of


individual cells joined by electrical connections. The contraction of each cell is produced by a
rise in intracellular calcium concentration leading to spontaneous depolarization, and as each cell
is electrically connected to its neighbor, contraction of one cell leads to a wave of depolarization
and contraction across the myocardium.

This depolarization and contraction of the heart is controlled by a specialized group of


cells localized in the sino-atrial node in the right atrium- the pacemaker cells.

1. These cells generate a rhythmical depolarization, which then spreads out over the atria to
the atrio-ventricular node.
2. The atria then contract, pushing blood into the ventricles.
3. The electrical conduction passes via the Atrio-ventricular node to the bundle of His,
which divides into right and left branches and then spreads out from the base of the
18

ventricles across the myocardium.


4. This leads to a 'bottom-up' contraction of the ventricles, forcing blood up and out into the
pulmonary artery (right) and aorta (left).

5. The atria then re-fill as the myocardium relaxes.

The 'squeeze' is called systole and normally lasts for about 250ms. The relaxation period,
when the atria and ventricles re-fill, is called diastole; the time given for diastole depends on the
heart rate.

The Respiratory System

The respiratory system is situated in the thorax, and is


responsible for gaseous exchange
between the circulatory system and
the outside world. Air is taken in
via the upper airways (the nasal
cavity, pharynx and larynx)
through the lower airways
(trachea, primary bronchi and
bronchial tree) and into the small
bronchioles and alveoli within the
lung tissue.
The lungs are divided into lobes;
The left lung is composed of the upper lobe, the lower lobe and the
19

lingula (a small remnant next to the apex of the heart), the right
lung is composed of the upper, the middle and the lower lobes.

Mechanics of Breathing

To take a breath in, the external intercostal muscles contract, moving the ribcage up and
out. The diaphragm moves down at the same time, creating negative pressure within the thorax.
The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as
well. This creates negative pressure within the lungs, and so air rushes in through the upper and
lower airways.

Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if
they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is
air in the pleural space (pneumothorax).

Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form very narrow terminal
bronchioles, which terminate in the alveoli. There are many millions of alveoli in each lung, and
these are the areas responsible for gaseous exchange, presenting a massive surface area for
exchange to occur over.

Each alveolus is very closely associated with a network of capillaries containing


deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin,
allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves
into the alveolus as the concentration is much lower in the alveolus than in the blood, and O 2
moves out of the alveolus as the continuous flow of blood through the capillaries prevents
saturation of the blood with O2 and allows maximal transfer across the membrane.

Control of Respiration

0ur respiratory rate changes. When active, for example, respiratory rate goes up; when
less active, or sleeping, the rate goes down. Also, even though the respiratory muscles are
voluntary, we can't consciously control them when we are sleeping.
20

The rhythmicity center of the medulla:

 controls automatic breathing


 consists of interacting neurons that fire either during inspiration (I neurons) or expiration
(E neurons)
o I neurons - stimulate neurons that innervate respiratory muscles (to bring about
inspiration)
o E neurons - inhibit I neurons (to 'shut down' the I neurons & bring about
expiration)

Apneustic center (located in the pons) - stimulate I neurons (to promote inspiration) Pneumotaxic
center (also located in the pons) - inhibits apneustic center & inhibits inspiration
 Factors involved in increasing respiratory rate:
 Chemoreceptors - located in aorta & carotid arteries (peripheral chemoreceptors) & in the
medulla (central chemoreceptors)
 Chemoreceptors (stimulated more by increased CO2 levels than by decreased O2 levels)
> stimulate Rhythmicity Area > Result = increased rate of respiration
21

NARRATIVE PATHOPHYSIOLOGY

Acute necrotizing pancreatitis is the acute inflammation and necrosis of pancreas

parenchyma and focal enzymic necrosis of pancreatic fat and vessels. It is known to be

precipitated by chronic alcoholism. Other factors such as obesity and sedentary lifestyle are also

known to contribute to the development of the condition. It is common in people 30-40 years of

age and in those who take drugs such as Thiazide diuretics and steroids for drug therapy.

Given these factors, there will be partial obstruction of the sphincter of Oddi which leads

to obstruction to the outflow of pancreatic enzymes and leakage of these enzymes to pancreatic

tissues. Along with premature activation of these enzymes, autodigestion occurs, leading to acute

necrotizing pancreatitis.
22

Pancreatic enzymes may also leak into the blood stream and circulate into the lungs and

kidneys, prompting the release of proinflammatory mediators. These pancreatic enzymes and

mediators such as kinins increase vascular permeability and dilate blood vessels, further leading

to loss of plasma volume and increased permeability to protein. Increased permeability to protein

can lead to loss of albumin causing hypoalbuminemia. Loss of albumin stimulates lipoprotein

synthesis by the liver leading to hyperlipidemia.

Increase in vascular permeability also causes loss of plasma volume which leads to

decrease in blood volume and decreased renal blood flow resulting to ischemia. Toxic oxygen-

free radicals are generated, promoting swelling, injury and necrosis of nephrons. Acute tubular

necrosis occurs leading to decrease in filtration pressure and decrease in GFR resulting to acute

renal failure.

On the other hand, pancreatic enzymes circulating in the blood goes to the lungs causing

injury to the capillary endothelium further leading into disruption of surfactant production by the

alveoli and increased capillary permeability. Increase in capillary permeability causes movement

of fluid and plasma protein from capillary to interstitial space (alveolar septum) and alveoli.

Decrease in blood volume (hypovolemia) and pleural effusion then occurs. Pleural effusion

results to pulmonary edema which impairs gas exchange. Blood oxygen level is then decreased

(hypoxemia), resulting to acute respiratory failure.

Another result of acute necrotizing pancreatitis is damage to the alpha and beta cells of

the islet of Langerhans. There is decrease in insulin production and increase in glucagon

production. Decrease in serum insulin level can cause significant increase in blood glucose level,

a condition known as diabetes mellitus type 2. In DM II there is increase in osmolarity and

chronic elevation in blood glucose level. The increase in osmolarity will then lead to increased
23

capillary permeability leading to increased urine output and decreased body fluids. This will

trigger the thirst mechanism of the body resulting to polydipsia. Chronic elevations in glucose

level, on the other hand, will cause glycoprotein deposits in the cell wall leading to three possible

conditions namely: diabetic neuropathy, diabetic nephropathy and impaired immune function.

Thus, increasing the client’s susceptibility to infection.

Production of excess glucagon results to production of glucose from protein and fat stores

(gluconeogenesis). There is wasting of lean body mass and serum ketones (byproduct of

gluconeogenesis) that promote ketosis.


24
25

MEDICAL MANAGEMENT

The medical management of patient RP’s condition focused on alleviating of the

symptoms and treating its underlying causes. The following is a table presenting the ideal

management of the patient’s condition as well as the actual management given to the patient

during his hospital stay.

IDEAL MANAGEMENT ACTUAL MANAGEMENT

MANAGEMENT FOR ACUTE


NECROTIZING PANCREATITIS:

1. Restoration of circulating blood volume - Venoclysis of PNSS 1 L, moderate fast


with IV crystalloid or colloid solutions drip then regulated at 40 drops per
or blood products minute, followed by Lactated Ringer’s
solution and regulated according to
patient’s requirement at left arm
- Venoclysis of Lactated Ringer’s
solution @ right arm
2. Invasive monitoring in severe - CVP insertion at patient’s bedside,
pancreatitis reading was 9 cm H2O
3. Maintenance of adequate oxygenation - Endotracheal intubation of the patient
reduced by pain, anxiety, acidosis, - Mechanical ventilation
abdominal pressure, or pleural - O2 inhalation of 5 L/min following
effusions; and adequate respiratory care endotracheal extubation
because of the risk for elevation of the - Chest X-ray PA
diaphragm, pulmonary infiltrates and - Monitoring of the patient’s Arterial
effusion, and atelectasis. Blood Gas

4. Pain control to alleviate pain and - No pain management given


anxiety, which increases pancreatic
secretions
5. Rest of the GI Tract
a. Withhold oral feedings to decrease - Patient was NPO temporarily
pancreatic secretions
b. Nasogastric intubation and suction - Intubation of the patient with a French
to relieve gastric stasis and 16, opened to drain
distention - Administration of Bactidol (Hexetidine)
TID for oral care
6. Maintenance of alkaline gastric pH - Administration of Ranitidine 50 mg
with H2 antagonists and antacids to IVTT q12h
26

suppress acid drive of pancreatic - Administration of Ianzoprazole


secretions and to prevent stress ulcer (Prevacid) 30 mg 1 tab OD / NGT
complications of illness. - Administration of Pantoprazole
(Ulcepraz) 40 mg IVTT OD
7. Nutrition provided with parenteral - Nasogastric feeding with Osteurized
feedings, as needed Formula, 60 cc
8. Pharmacotherapy
a. Electrolyte replacement as needed - Administration of Potasssium Chloride
and Sodium bicarbonate to reverse 60 mg IVTT to treat hypokalemia
metabolic acidosis - Administration of NaHCO3 50 mEq in
3 vials IVTT
- Administration of NaHCO3 drip: 4 vials
with 250 cc D5W at 10 drops/ minute

b. Regular insulin to treat - Insulin Aspart (Novorapid) 10 “u” SQ


hyperglycemia before each feeding
- Insulin Glargine (Lantus) 30 “u” SQ
before 8 am feeding
c. Antibiotic therapy for sepsis - Administration of Ciprofloxacin
(Ciprobay), 200 mg IV drip q12h
MANAGEMENT FOR ACUTE
RESPIRATORY FAILURE
1. Oxygen therapy to correct hypoxemia - Endotracheal intubation of the patient
- Mechanical ventilation
- O2 inhalation of 5L/min following
endotracheal extubation

2. Mobilization of secretions - Suctioning of the Oral Cavity and


Endotracheal tube PRN
3. Bronchodilators to reduce - Administration of Duavent 1 nebule
bronchospasm plus ½ nebule Asmavent q6h
4. Corticosteroids to reduce inflammation - Administration Hydrocortisone 100 mg
vial IVTT q8h
MANAGEMENT FOR DIABETES
MELLITUS TYPE 2
1. Diet
a. Dietary control with caloric - Full diabetic diet at 1800 kcal/g in 3
restriction of carbohydrates and meals and 2 snacks, with the following
saturated fats to maintain ideal body specifications:
weight a. CHO 60 %
b. CHON 20 %
c. Fat 20 %
2. Exercise
 Regularly scheduled exercise to
promote the utilization of
carbohydrates, assist with weight
27

control, enhance the action of


insulin, and improve cardiovascular
fitness
3. Medication
a. Oral antidiabetic agents if glucose - No oral antidiabetic agent was
control is not achieved with diet administered
and exercise only
b. Insulin therapy when unresponsive - Administration of the following
to diet, exercise and oral Insulins:
antidiabetic therapy a. Insulin Glargine (Lantus) 30 “u” SQ
before 8 am feeding
b. Insulin Aspart (Novorapid) 10 “u”
SQ before each feeding
4. Monitoring of control blood glucose - Hemoglucose tests TID, pre-breakfast,
pre-lunch and pre-dinner
MANAGEMENT FOR HOSPITAL
ACQUIRED PNEUMONIA

1. Antimicrobial therapy upon laboratory - Administration of Ciprofloxacin, 200


identification of causative organism and mg IV drip q12h
sensitivity to specific antimicrobials - Administration of Cefepime 1g ICTT
OD
- Administration of Imipinem +
Cilastatin (Tienam) 500 mg IVTT q12h
- Administration of Piperacillin-
Tazobactam (Tazocin)4.5 IVTT noe
then 2.75 mg q12h
2. Oxygen therapy if patient has
inadequate gas exchange - Endotracheal intubation of the patient
- Mechanical ventilation
- O2 inhalation of 5L/min following
3. Pulse oximetry and Arterial Blood Gas endotracheal extubation
Analysis to determine the need for - Patient was constantly hooked to a
oxygen and to evaluate the therapy pulse oximeter
- Arterial Blood Gas Analysis was
conducted
MANAGEMENT FOR PULMONARY
EDEMA
1. Treatment of underlying disorder - Management of acute necrotizing
pancreatitis
2. Oxygen therapy to correct hypoxemia - Endotracheal intubation of the patient
- Mechanical ventilation
- O2 inhalation of 5L/min following
endotracheal extubation
3. Administration of morphine to reduce - No pain management
anxiety and control pain
28

MANAGEMENT FOR ACUTE RENAL


FAILURE
1. Maintenance of fluid balance. Be alert - Intake and Output monitoring and
for and correct underlying fluid recording every shift
excesses or deficits - Measurement of central venous
pressure, 9 cm H2O
2. Restore maintain blood pressure - Administration of Dopamine 2 grams
WITH 300 cc D5NSS
- Correction of hypotension through the
administration of:
a. 1.5 L Lactated Ringer’s solution at
moderate fast drip then regulating
@ 60 drops per minute
b. Administration of 1 L Normal
Saline Solution at 40 drops per
minute on the left arm after
administered IVF was consumed
c. Administration of 1 L Lactated
Ringer’s Solution at 50 drops per
minute as follow-up to administered
intravenous fluid
3. Maintain nutrition. - Total Parenteral Nutrition after
temporary NPO then
- Nasogastric feeding with Osteurized
Formula, 60 cc
4. Hemodialysis, peritoneal dialysis or - No dialysis or renal replacement was
continued renal replacement indicated for the patient
5. Diuretic agents to control fluid volume - Administration of Furosemide (to run
for 2 hours) BID
MANAGEMENT OF HYPOKALEMIA
1. Restoration of potassium levels - Incorporation of 40 mEq Potassium
a.administration of 40 to 80 mEq/ Day Chloride to patient’s intravenous fluid
of potassium STAT
- Administration of Potassium
Chloride,60 mg IVTT
MANAGEMENT OF HYPOALBUMINEMIA
1. Correction of low albumin levels - Administration of Albuminar 25% 50
cc stat
- Addition of 6 egg whites to daily food
intake
29

DRUG STUDY

Generic Name: ALBUMIN 25 % Brand Name: ALBUMINAR 25


Classification: BLOOD DERIVATIVE Dosage/ Administration/ Route: 50 cc STAT

INDICATION THERAPEUT MECHANISM CONTRA- PHARMACO SIDE ADVERSE NURSING


S IC EFFECTS OF ACTION INDICATIONS - KINETICS/ EFFECTS EFFECTS RESPONSIBILITIE
AND PHARMACO S
CAUTIONS DYNAMICS
Treatment of Restoration of Provides  Contraindicate  Directly Headach Vascular  Watch for
hypoalbumine albumin to intravascular d in enters the e Overload hemorrhage or
mia normal levels oncotic measure hypersensitivit circulation Nausea Hypotension shock. Rapid
in a 5:1 ratio, y to the drug following IV Vomiting Tachycardia increase in blood
shifting fluid and in those infusion. Urticaria Altered pressure may cause
from interstitial with severe Rash respiration bleeding from sites
spaces to the anemia, or Back Dyspnea that aren’t apparent
circulation and cardiac failure. pain Pulmonary at lower pressures.
slightly edeme  Monitor vital
increasing the signs carefully.
Chills
plasma protein  Watch for signs of
level. vascular overload
(heart failure or
pulmonary edema).
 Monitor fluid
intake and output,
protein, electrolyte
and hemoglobin
levels, and
hematocrit during
the therapy.

Generic Name: HEXETIDINE Brand Name: BACTIDOL


30

Classification: ANTIBACTERIAL Dosage/ Administration/ Route: oral care TID

INDICATIO THERAPEUTIC MECHA- CONTRA- PHARMACO SIDE ADVERSE NURSING


NS EFFECTS NISM INDICATIONS AND - KINETICS/ EFFECTS EFFECTS RESPONSIBILITIE
OF CAUTIONS PHARMACO S
ACTION DYNAMICS
For general Bacterial cell Kills  Contraindicated if  Directly Warm Aspiration  Elevate head of
oral hygiene death microorga the patient has enters the feeling in the bed to prevent
nisms in known circulation the mouth aspiration.
the oral hypersensitivity to following IV Altered  Ensure aspiration
mucosa the drug or its infusion. sense of precaution
that are components taste measures.
susceptibl  Use full strength
e to the of the drug.
drug;  Use padded
improves tongue depressor
integrity and soak it in
of mouth Bactidol when
tissue and administering to an
protects intubated client.
tooth
surfaces
against
formation
of decay
acids.

Generic Name: CEFEPIME Brand Name: (no brand name given)


31

Classification: ANTIBACTERIAL; CEPHALOSPORIN Dosage/ Administration/ Route: 1 gram IVTT OD

INDICATION THERAPEUT MECHANISM CONTRA- PHARMACO SIDE ADVERSE NURSING


S IC EFFECTS OF ACTION INDICATIONS - KINETICS/ EFFECTS EFFECTS RESPONSIBILITIE
AND PHARMACO S
CAUTIONS DYNAMICS
Treatment of Bacterial cell Inhibits bacterial  Contraindicate  Absorption: Anorexia Unusual  Check culture and
hospital- death cell wall d in Well Nausea bleeding sensitivity of
acquired synthesis, hypersensitivit absorbed. Vomiting Difficulty sputum results to
pneumonia promote osmotic y to the drug,  Distribution: Headach breathing ensure that this is
instability and cephalosporins Widely e Hives the drug of choice
destroy bacteria. ,or beta- dirtributed. Dizziness Sore mouth or for the patient.
lactam Enter the Itching throat  Monitor renal
antibiotics. CSF only Rash function before and
 Cautious use when the during the therapy.
in patients meninges are  Ensure that the
hypersensitive inflamed. patient receives the
to penicillin Cross the full course of the
because of placenta and therapy.
possibility of enter  Monitor patient
cross- breastmilk in for signs of
sensitivity with low superinfections and
other beta- concentration adverse reactions to
lactam s. the drug.
antibiotics.  Excretions:  Monitor IV site. If
80 % renally phlebitis occurs,
excreted. change site.
 Half-Life: 0.7
to 1.2 hours.

Generic Name: CIPROFLOXACIN Brand Name: CIPROBAY


32

Classification: FLUOROQUINOLONE Dosage/ Administration/ Route: 200 mg IV drip q12h

INDICATION THERAPEUT MECHANISM CONTRA- PHARMACO SIDE ADVERSE NURSING


S IC EFFECTS OF ACTION INDICATIONS - KINETICS/ EFFECTS EFFECTS RESPONSIBILITIE
AND PHARMACO S
CAUTIONS -
DYNAMICS
Treatment of Bacterial cell Inhibits bacterial  Contraindicate  Absorption: Nausea utricaria  Check culture and
hospital- death DNA synthesis, d in Well Vomiting oral candidiasis sensitivity of
acquired mainly blocking hypersensitivit absorbed. Diarrhea crystalluira sputum results to
pneumonia; DNA gyrase; y to the drug  Distribution: Abdomin hematuria ensure that this is
sepsis bactericidal. or other Widely al cramps seizures the drug of choice
secondary to fluoroquinolon distributed. Flatulenc for the patient.
acute e; severe renal Enter the e  Monitor renal
necrotizing disease; CSF only Headach function before and
pancreatitis pregnancy; when the e during the therapy.
breastfeeding. meninges are Dizziness  Ensure that the
 Cautious use inflamed. Fatigue patient receives the
in patients Cross the full course of the
Restlessn
with CNS placenta and therapy.
ess
disorders, such enter breast  Monitor patient
Insomnia
as severe milk in low for signs of
cerebral concentration Rash
superinfections and
arteriosclerosis s. Flushing
adverse reactions to
or seizure  Excretions: Tinnitus the drug.
disorders and 50 % photosen  Monitor IV site. If
in those at risk unchanged in sitivity phlebitis occurs,
for seizures. urine. change site.
Drugs may
cause CNS
stimulation.

Generic name: CITICHOLINE Brand name: (no brand name given)


33

Classification: CNS STIMULANT Dosage/ Administration/ Route: 500 MG IVTT slow q12h

INDICATI THERAPEU MECHANI CONTRA- PHARMACO SIDE ADVERSE NURSING


ON TIC SM OF INDICATI - KINETICS/ EFFECTS EFFECTS RESPONSIBILIT
EFFECTS ACTION ONS AND PHARMACO IES
PRECAUTI -DYNAMICS
ONS
Pancreatitis Stimulates the Act as a Contraindic Absorption:  Nervousness  Hypertension  Arrange to
Reticular cortical and ated in the rapidly  Insomnia  Arrhythmias dispense the least
Activating RAS presence of absorbed  Dizziness  Angina amount of drug
System stimulant, known  Headache  Difficulty with possible to
possibly by allergy to Distribution:  Blurred vision accommodation minimize the risk
increasing the drug; Unknown.  Anorexia of overdosage
the release marked and drug abuse.
 Nausea
of anxiety, Metabolism &  Monitor wight,
 Weight loss
catecholami agitation, or Excretion: CBC, and ECG
nes from the tension and Metabolized to ensure early
presynaptic severe by the liver detection of
neurons, fatigue or and excreted adverse effects
leading to an glaucoma; in urine. and proper
increase in cardiac interventions.
stimulation disease; Half-life: 2-15  Provide safety
of the pregnancy hours. measures such as
postsynaptic and; side rails and
neurons lactation. assistance with
ambulation if
Use CNS effects
cautiously occur to prevent
in patients patient injury.
with a
history of
drug
34

dependence
, including
alcoholism
and; with
hypertensio
n.

Generic Name: DOPAMINE Brand name: (no brand name given)


35

Classification:ADRENERGICS Dosage/Administration/Route: 2 g in 300 cc D5NSS

Indications Therapeuti Mechanis Contraindications Pharmacokinetics/ Side Adverse Nursing


c Effects m of Pharmacodynamics Effects Reaction Responsibilities
Action

> Adjunct Increased Tanawa sa >Tachyarrhythmi Absorption: >Headach > Mydriasis > Monitor blood
to standard cardiac ang as Administered IV e >Hypotensi pressure, heart rate,
measure s to output, dosage >Pheochromocyt only, resulting in > Dyspnea on pulse pressure, ECG,
improve increased please oma complete >Palpitati > Angina pulmonary capillary
Blood blood >Hypersensitivit bioavailability ons weigh pressure
pressure, pressure y to bisulfites > Nausea (PCWP), cardiac
cardiac and Distribution: > output, CVP.
output, and improved Widely distributed Vomiting
urine blood but does not cross > Monitor urine
output. flow. the blood brain output frequently
barrier throughout
administration.
Metabolism and Report decreases in
Excretion: urine output
Metabolized in the promptly.
liver, kidneys, and
plasma. > If
hypotensionoccurs,
administration rate
should be increased.
If hypotension
continues more potent
vasoconstrictors
(nor-epinephrine may
be administered.

> Explain to the


36

patient the rationale


for instituting this
medication and the
nee for frequent
monitoring.

> Advise the patient


to inform the nurse
immediately if chest
pain; dyspnea;
numbness, tingling, or
burning of extremities
occur.

> Instruct patient to


inform nurse
immediately of pain
or discomfort at the
site of administration.

Generic Name: FUROSEMIDE Brand Name: LASIX


Classification: LOOP DIURETIC Dosage/ Administration/ Route: (to run for 2 hours) BID
37

INDICATION THERAPEUT MECHANISM CONTRA- PHARMACO SIDE ADVERSE NURSING


S IC EFFECTS OF ACTION INDICATIONS - KINETICS/ EFFECTS EFFECTS RESPONSIBILITIE
AND PHARMACO S
CAUTIONS DYNAMICS
Acute Renal Treatment of Inhibition of  Contraindicate  Absorption: Nausea Severe  Monitor urinary
Faiulre fluid retention sodium and d in presence Rapidly Diarrhea dehydration output to determine
or fluid water of severe bsorbed. Electroly Marked body or fluid gain
overload reabsorption electrolyte  Distribution: te hypertension or loss. Urinary
from the Loop of imbalances; 95 % is imbalanc output should be at
henle and distal hypovolemia; widely e least 25 mL/ hour or
and renal anuria; distributed; Vertigo 600 mL per 24
tubules; hypersensitivit crosses the Crampin hours.
potassium, y to placenta g  Check the client’s
magnesium, and sulfonamides  Metabolism Rash weight to determine
calcium may be and in hepatic and fluid loss or gain. A
Headach
excreted. coma. Excretions: loss of 2.2 to 2.5
e
excreted in Weaknes pounds is
urine, some s equivalent to a fluid
in feces. loss of 1 liter.
ECG
 Onset: 5 changes  Monitor vital
minutes. signs. Be alert for
Blurred
 Peak: 20-30 marked decrease in
vision
minutes blood pressure.
Photosen
 Duration: 2  Administer IV
sitivity
hours. furosemide slowly;
hearing loss may
occur if rapidly
injected.
 Observe for signs
and symptoms of
hypokalemia (<3.5
mEq/ L), such as
muscle weakness,
38

abdominal
distention,leg
cramps, and/or
cardiac
dysrhythmies.
 Check serum
potassium levels.

Generic name: HYDROCORTISONE Brand name: (no brand name given)


Classification: CORTICOSTEROID Dosage/ Administration/ Route: 1000 mg IVTT q8h
39

INDICATI THERAPEUT MECHANIS CONTRA- PHARMACO SIDE ADVERSE NURSING


ON IC M OF INDICATIO - KINETICS/ EFFECTS EFFECTS RESPONSIBILITI
EFFECTS ACTION NS AND PHARMACO ES
PRECAUTI -DYNAMICS
ONS
Treatment Suppression Blocks the Contraindicat Absorption:  Headache  Depression  Administer in the
of of action of ed in active Well  Restlessne  Euphoria morning to
inflammator inflammation arachidonic untreated absorbed. ss  Increased coincide with the
y reaction and acid, which infection;  Anorexia intracranial body’s normal
modification leads to a lactation; and Distribution:  Nausea pressure secretion of
of the normal decrease in known Widely  Vomiting  Increased cortisol.
immune the formation alcohol, distributed,  Acne intraocular  Taper doses
response of bisulfate, or crosses the pressure when
 Decreased
prostaglandi tartrazine placenta, and  Cataracts discontinuing
wound
ns and hypersensitiv probably  Hypertension from high doses
healing
leukotrienes. ity or enters breast or from long
 Ecchymos  Peptic ulcer
Without intolerance. milk. term therapy to
es  Adrenal
these give the adrenal
chemicals, Cautious use Metabolism  Hirsutism suppression
glands a chance
the normal in children; and  Petechiae  Hyperglycemia
to recover and
inflammator stress; Excretion:  Fragility  Fluid retention
produce
y reaction is pregnancy Metabolized  Weight  Hypokalemia adrenocorticoids
blocked. and in mostly by the gain/ loss  Hypokalemic  Arrange for
Hydrocortiso chronic liver.  Muscle alkalosis increased dosage
ne also treatment. pain  Thromboemboli when patient is
impairs the Half-life: 1.5-  Increased sm under stress to
ability of 2 hours susceptibil  Thrombophlebit supply increased
phagocytes (plasma), 8- ity to is demands for
to leave the 12 hours infection  Muscle wasting corticosteroids
bloodstream (tissue),  Osteoporosis associated with
and move to adrenal  Aseptic necrosis stress reaction.
injured suppression of joints  Do not give live
40

tissues. It lasts 1.25-1.5  Cushingoid virus vaccines


also blocks days. appearance when the patient
the ability of is
lymphocytes immunosppuress
to act in the ed because there
immune is an increased
system, risk of infection.
including a  Protectthe patient
blocking in from
the unnecessary
production of exposure to
antibodies. infection and
invasive
procedure
because the
steroids suppress
the immune
system and the
patient is at
increased risk for
infection.

Generic name: IANSOPRAZOLE Brand name: PREVACID


Classification: PROTON-PUMP INHIBITOR; ANTI-ULCER AGENT Dosage/ Administration/ Route: 30 mg 1 tab OD/
NGT
41

INDICATIO THERAPEUTI MECHANIS CONTRA- PHARMAC SIDE ADVERSE NURSING


N C M OF INDICATION O- EFFECTS EFFECTS RESPONSIBILITI
EFFECTS ACTION S AND KINETICS/ ES
PRECAUTIO PHARMAC
NS O-
DYNAMICS
Prevention Diminished Binds to an Contraindicate Absorption:  Headache  No  Assess patient
of Stress accumulation enzyme in d in 80 %  Diarrhea known routinely for
Ulcer of acid in the the presence hypersensitivit absorbed  Abdominal adverse epigastric or
complication gastric lumen, of acidic y to the drug. after oral pain effects abdominal pain
of Acute with lessened gastric pH, administratio  Nausea and for blood in
Necrotizing acid reflux. preventing Use cautiously n.  Rash stool, emesis, or
Pancreatitis the final in geriatric  Dizziness gastric aspirate.
transport of patients; severe Distribution:  Administer
hydrogen hepatic Unknown. medication before
ions into the impairment; meals.
gastric pregnancy; Metabolism  Crush the
lumen. lactation or; & Excretion: medication before
children below Extensively administering via
1 year old. metabolized the NG tube.
by the liver  Flush the tube
to inactive after medication
compounds. administration.
Converted
intra-
cellularly to
at least two
other anti-
secretory
compounds.

Half-life:
42

Less than 2
hours.

Generic name: IMIPENEM/CILASTATIN Brand name: (no brand name given)


Classification: CARBAPENEMS; ANTI-INFECTIVES Dosage/ Administration/ Route: 500 mg IVTT q12h
43

INDICATIO THERAPEUTI MECHANIS CONTRA- PHARMACO SIDE ADVERSE NURSING


N C M OF INDICATION - KINETICS/ EFFECTS EFFECTS RESPONSIBILITI
EFFECTS ACTION S AND PHARMACO ES
PRECAUTIO -DYNAMICS
NS
Treatment of Bactericidal Imipenem Contraindicate Absorption:  Dizziness  Seizures  Assess patient for
sepsis action against binds to the d in IV absorption  Somnolen  Hypotension infection at the
secondary to susceptible bacterial cell hypersensitivit results in ce  Pseudo- beginning of and
Acute bacteria. wall, y to the drug. complete  Diarrhea membranous throughout the
Necrotizing resulting in bioavailabiliti  Nausea colitis therapy.
Pancreatitis cell death. Use cautiously es.  Vomiting  Eosinophilia  Obtain a history
and Combination in patients with  Rash  Anaphylaxis before initiating
treatment of with previous Distribution:  Superinfecti therapy to
 Pruritus
Hospital cilastatin history of Widely on determine
 Sweating
Acquired prevents hypersensitivit distributed. previous use of
Pneumonia renal y; seizure Crosses the  Urticaria
and reactions to
inactivation disorders; placenta and  Phlebitis
penicllins.
of imipenem, geriatric enters breast at IV site
 Obtain specimen
resulting in patients; renal milk.  Fever
for culture and
high urinary impairment; sensitivity before
concentration pregnancy; Metabolism initiating therapy.
s. lactation. and Excretion:  Observe patient
70 % is for signs and
excreted symptoms of
unchanged by anaphylaxis. If
the kidneys. present,
discontinue the
Half- drug and notify
life:prolonged the physician.
in renal  Infuse slowly
impairment, because rapid
infusion may
44

result in nausea,
vomiting, unusual
tiredness or
weakness,
dizziness or
sweating.

Generic name: INSULIN ASPART Brand name: NOVORAPID


Classification: PANCREATIC; ANTIDIABETIC Dosage/ Administration/ Route: 10 “u” SQ before each
feeding

INDICATIO THERAPEU MECHANI CONTRA- PHARMACO SIDE ADVERSE NURSING


45

N TIC SM OF INDICATI - KINETICS/ EFFECTS EFFECTS RESPONSIBILIT


EFFECTS ACTION ONS AND PHARMACO IES
PRECAUTI -DYNAMICS
ONS
Prevention Control of Lowers Contraindic Absorption:  Urticaria  Hypoglycemia  Assess patient
of blood glucose blood ated in Rapidly  Itching  Rebound for signs and
Hyperglyce glucose by hypersensiti absorbed from  Redness hyperglycemia symptoms of
mia after increasing vity to the subcutaneous  Swelling  Lipodystrophy hypoglycemia
each meal its transport drug. administration  Lipohypertrophy and
into cells sites.  anaphylaxis hyperglycemia
and Cautiously periodically
promoting use in Distribution: throughout the
the patients Widely therapy.
conversion with distributed.  Monitor body
of glucose infection; in weight
to glycogen. pregnancy Metabolism periodically.
It also and; stress. and  Monitor blood
promotes Excretion: glucose every
the Metabolized ---- throughout
conversion by the liver, therapy, more
of amino spleen, kidney frequently in
acids to and muscle. times of stress.
proteins in  If hypoglycemia,
muscles; Half-life: 5-6 which is a
stimulates minutes but is manifestation of
triglyceride prolonged in overdose, occurs,
formation patients with administer oral
and; inhibits diabetes. glucose. Severe
the release Biologic half- hypoglycemia is
of free fatty life is 1-1.5 a life threatening
acids. hours. emergency and
its treatment
includes IV
46

glucose,
glucagon or
epinephrine.
 Because
medication errors
involving insulin
have resulted in
serious patient
harm and death,
clarify all
ambiguous
orders.

Generic Name: INSULIN GLARGINE Brand Name: LANTUS


Classification: ANTIDIABETIC Dosage/ Administration/ Route: 30 “U” SQ before 8 am
feeding

INDICATION THERAPEUT MECHANISM CONTRA- PHARMACO SIDE ADVERSE NURSING


47

S IC EFFECTS OF ACTION INDICATIONS - KINETICS/ EFFECTS EFFECTS RESPONSIBILITIE


AND PHARMACO S
CAUTIONS DYNAMICS
Management Control of Lowers glucose  Contraindicate  Absorption: Urticaria Hypoglycemia  Desired glucose
of Diabetes blood glucose level by d in Rapidly Itching Rebound levels as well as the
Mellitus type 2 stimulating hypersensitivit absorbed fro Redness hyperglycemia doses and timing of
peripheral y to glargine, SQ Swelling Lipodystrophy antidiabetic
glucose uptake, preservatives, administratio Allergic Lipohypertroph medication must be
especially by or additives. n site reactions y determined
skeletal, muscle,  Cautious use  Distribution: Anaphylaxis individually.
and fat and by during stress, Widely  Glucose
inhibiting hepatic pregnancy and dirtributed. monitoring is
glucose infection.  Metabolism recommended for
production. and all patients.
Excretions:  The rate of
Metabolized absorption, onset
by the liver, and duration may
spleen, be affected by
kidney and exercise and other
muscle. variables, such as
 Half-Life: 5- illness and
6 minutes. emotional stress.
 Hypoglycemia is
the most common
adverse effect of
insulin. Early
symptoms may be
different or less
pronounced in
patients with long
duration of
diabetes, diabetic
nerve disease or
48

intensified diabetes
control. Monitor
glucose level
closely in these
patients because
severe
hypoglycemia may
result before the
patient may develop
symptoms.

Generic name: MUPIROCIN Brand name: BACTROBAN


Classification: LOCAL ANTI-INFECTIVE Dosage/ Administration/ Route:

INDICATI THERAPEUTI MECHANI CONTRA- PHARMACO- SIDE ADVERS NURSING


ON C SM OF INDICATIONS KINETICS/ EFFECTS E RESPONSIBILI
49

EFFECTS ACTION AND PHARMACO- EFFECTS TIES


PRECAUTION DYNAMICS
S
Skin Bacterial Unknown. Contraindicat Absorption:  Headache  taste  Take note that
Lesion death Thought to ed in Penetrates  Burning perversi drug is not for
inhibit hypersensitivit outer layers  Pruritus on ophthalmic or
bacterial y to the drug. of skin;  Stinging  abdome internal use.
protein and systemic  Rash n pain  Do not use in
RNA Use absorption  Pain  ulcerativ prolonged time
synthesis cautiously in minimal e because it may
 erythema
patients with stomatiti cause of
through
burns or large s nonsusceptible
intact skin
open wounds bacteria and
and in those fungi. Notify
with impaired Metabolism:
the doctor if
renal function Skin: 3% to
the condition
because monic acid doesn’t
serious renal improve o gets
toxicity may Half-life orse in 3 to 5
occur. elimination: days.
17-36  Observe
minutes patient for local
adverse effects
Excretion: of the
Urine medication.
50

Generic name: PANTOPRAZOLE Brand name: ULCEPRAZ


Classification: GASTRIC ACID PUMP INHIBITOR; ANTI-ULCER AGENT Dosage/ Administration/ Route: 40 mg IVTT OD

INDICATIO THERAPEUTI MECHANIS CONTRA- PHARMAC SIDE ADVERSE NURSING


51

N C M OF INDICATION O- EFFECTS EFFECTS RESPONSIBILITI


EFFECTS ACTION S AND KINETICS/ ES
PRECAUTIO PHARMAC
NS O-
DYNAMICS
Prevention Diminished Binds to an Contraindicate Absorption:  Headache  Hyperglycem  Assess patient
of Stress accumulation enzyme in d in patients well  Diarrhea ia routinely for
Ulcer of acid in the the presence with absorbed  Abdomin epigastric or
complication gastric lumen, of acidic hypersensitivit al pain abdominal pain
of Acute with lessened gastric pH, y to the drug. Distribution:  Eructatio and for frank or
Necrotizing acid reflux. preventing Unknown. n occult blood in
Pancreatitis the final Use cautiously  Flatulenc stool, emesis, or
transport of in pregnancy or Metabolism e gastric aspirate.
hydrogen lactation. & Excretion:  Administer over
ions into the Mostly 25 minutes at a
gastric metabolized rate of 3 mg/min.
lumen. by the liver  Patients receiving
via CYP IV pantoprazole
System; should be
inactive converted to PO as
metabolites soon as possible.
are excreted  Administer
in urine through filter to
(71%) and remove
feces (18 %). precipitates that
may form when
Half-life: 1 solution is mixed.
hour.
52

Generic Name: PIPERACILLIN- TAZOBACTAM Brand Name: TAZOCIN


INDICATION THERAPEUT MECHANISM CONTRA- PHARMACO SIDE ADVERSE NURSING
S IC EFFECTS OF ACTION INDICATIONS - KINETICS/ EFFECTS EFFECTS RESPONSIBILITIE
AND PHARMACO S
CAUTIONS -
DYNAMICS
Treatment of Bacterial cell Binds to  Contraindicate  Absorption: Rashes Seizures  Check culture and
hospital- death bacterial cell d in Well Urticaria Arrhythmias sensitivity of
53

acquired wall membrane, hypersensitivit absorbed. Diarrhea Congestive sputum results to


pneumonia causing cell y to penicillins  Distribution: Nausea Heart Failure ensure that this is
death. Spectrum or Widely Phlebitis Nephritis the drug of choice
is extended tazobactams. dirtributed. at IV site Fluid and for the patient.
compared with  Cautious use Enter the Electrolyte  Monitor renal
penicillins. in renal CSF only imbalances function before and
impairment, when the Bleeding, during the therapy.
sodium meninges are increased  Ensure that the
restriction, inflamed. bleeding time patient receives the
pregnancy and Cross the Metabolic full course of the
lactation. placenta and Alkalosis therapy.
enter Anaphylaxis  Monitor patient
breastmilk in Superinfections for signs of
low superinfections and
Drug-induced
concentration adverse reactions to
nephritis
s. the drug.
Pseudomembra
 Excretions:  Monitor IV site. If
nous colitis
80 % renally phlebitis occurs,
excreted. change site.
 Half-Life: 0.7
to 1.2 hours.
Classification: ANTI-INFECTIVES; EXTENDED SPECTRUM PENICILLINS Dosage/ Administration/ Route: 4.5 g IVTT
now then 2.75 g IVTT q 12 h

Generic Name: POTASSIUM CHLORIDE Brand name: (no brand name given)
Classification: MINERAL AND ELECTROLYTE REPLACEMENTS/SUPPLEMENTS Dosage/ Route: 60 mg IVTT

Indications Therapeutic Mechanism of Contraindicatio Pharmacokinetic Side Adverse Nursing


Effects Action ns s/ Effects Reaction Responsibiliti
Pharmacodynam es
ics
54

>Treatment/prevent >Replaceme > Maintain >Hyperkalemia Absorption: >Abdomin >Confusion > Assess for
ion of potassium nt acid-base > Severe renal Well absorbed al pain >Restlessne signs and
depletion balance, impairment following oral > Diarrhea ss symptoms of
>Prevention isotonicity and > Untreated administration > Nausea > Weakness hypokalemia
of electrophysiolo Addison’s >Vomiting >Arrhythmi and
deficiency gic balance of disease Distribution: as hyperkalemia
the cell > Severe tissue Enters > ECG Monitor
trauma extracellular changes pulse, blood
> Activator as >Hyperkalemic fluid; then >Ulecration pressure, and
many familial actively > Stenotic ECG changes
enzymatic periodic transported into lesions periodically
reactions; paralysis cells. > Irritation during IV
essential to > Potassium at Ivsite therapy.
transmission of acetate Metabolism and > Paralysis
nerve impulses; injection Excretion: >Paresthesi > Monitor
contraction of contains Excreted by the a serum
cardiac, aluminum, kidneys potassium
skeletal, and which may before and
smooth muscle, become toxic Half-life: periodically
gastric with prolonged Unknown. during
secretion; renal use to high risk therapy
function; tissue groups (renal
synthesis; and impairment, > Symptoms
carbohydrate premature of toxicity are
metabolism. neonates) those of
hyperkalemia

> If
hypokalemia
is seconfary
to diuretic
therapy,
consideration
55

should be
given to
decreasing
the dose of
diuretic,
unless there
is a history of
significant
arrhythmias
or concurrent
digitalis
glycoside
therapy.

Generic Name: RANITIDINE Brand name: (no brand name given)


Classification: _ANTIULCER AGENTS/HISTAMINE H2 ANTAGONISTS Dosage/Administration/Route: 50 mg IV q 12 h

Indications Therapeutic Mechanis Contraindicat Pharmacokinetics/ Side Adverse Nursing


Effects m of ions Pharmacodynamics Effects Reaction Responsibilities
Action
56

>Maintenan
ce of > Healing Inhibits > Absorption: 50% >Confusi >Arrhythmias > Assess patient for
alkaline and the action Hyprsensitivi absorbed after PO on >Gynecomasti epigastric or
gastric pH prevention of of ty and IM >Dizzine a abdominal pain and
ulcers histamine > Cross administration ss >Agranulocyt frank or occult blood
at the H2 hypersensitiv >Drowsi osis in the stool, emesis, or
> Decreased receptor ity may occur Distribution: All ness > Aplastic gastric aspirate.
symptoms of site > Some oral agents enter breast >Halluci anemia
gastroephage located liquids milk and nations > Anemia > Instruct patient to
al reflux primarily contain cerebrospinal fluid >Headac >Neutropenia take medication as
in the alcohol and he >Thrombocyt directed for the full
> Decreased gastric should be Metabolism and > Nausea openia course of therapy, even
secretion of parietal avoided in Excretion: >Impoten >Hypersensiti if felling better. Take
gastric acid cells, patients with metabolized by the ce vity reactions missed doses as soon
resulting known liver, mostly on > Vaculitis as remembered but not
in intolerance. first pass, 30% if almost time for next
inhibition excreted unchanged dose. Do not double
of gastric by the kidneys after dose.
acid PO administration.
secretion > Advise patients
taking OTC
preparations as to take
the maximum dose
continuously for more
than two weeks
without consulting
health care
professional. Notify
health care provider if
difficulty swallowing
occurs if abdominal
pain persists.
57

> Inform patient that


smoking interferes
with the action of
histamine antagonsists.
Encourage the patient
to quit smoking or at
least not to smoke after
last dose of the day.

> Advise patient to


avoid alcohol,
products containing
aspirin or NSAIDS,
and foods that may
cause an increase in GI
irritation

> Inform patient that


increased fluid and
fiber intake and
exercise may minimize
constipation.

Generic Name: SALBUTAMOL + IPRATROPIUM Brand Name: DUAVENT


Classification: BRONCHODILATOR Dosage/ Administration/ Route: 1 neb + ½
neb Asmavent q 6 h
INDICATION THERAP MECHANISM CONTRA- PHARMACO SIDE ADVERSE NURSING
S EUTIC OF ACTION INDICATIONS - KINETICS/ EFFECTS EFFECTS RESPONSIBILITIE
EFFECT AND CAUTIONS PHARMACO S
S DYNAMICS
58

Treatment of Bronchod Salbutamol  Contraindicated in  Peak: 2 hours Headache Tremor  Monitor the
hypoxemia ilation binds to beta2- hypersensitivity to  Metabolism Insomnia Hypokalemia patient’s response
caused by adrenergic drug and in and Dizziness Bronchospasm to the drug therapy
hospital receptors in patients peanut/ Distribution: Dry and Bronchitis to determine the
acquired airway smooth soy allergy. widely irritated Hypersensitivi effectiveness of the
pneumonia muscle, leading  Cautious use in distributed nose and ty reactions dosage and to adjust
to activation of cardiac disease, and throat Tachycardia the dosage as
adenyl cyclase hypertension, metabolized Nasal Palpitation needed.
and increased hyperthyroidism, by the liver. congestion Muscle  Provide comfort
level of cAMP diabetes, Enters the Nausea measures including
cramps
 Ipratropium glaucoma, breastmilk. Vomiting rest periods, a quiet
Nervousness
inhibits geriatric patients,  Excretion: Cough environment,
Hypertension
cholinergic pregnancy, excreted in dietary control of
Dyspnea CNS
receptors in lactation, children the urine. caffeine and
Wheezing Stimulation
bronchial below 2 y.o., headache therapy as
smooth muscles, patients with Altered needed, to help the
resulting in bladder neck taste patient cope with
decreased obstruction, Increased the drug therapy.
concentrations prostate appetite  Watch out for side
of cGMP, hypertrophy and Malaise and adverse effects
causing during urinary of the drugs.
bronchodilation retention.

Generic Name: SODIUM BICARBONATE Brand name: (no brand name given)
Classification: ALKANIZING AGENTS Dosage/Administration/Route: 4 vials in 250 cc
D5NSS

Indications Therapeutic Mechanism Contraindicatio Pharmacokinetics/ Side Adverse Nursing


Effects of Action ns Pharmacodynami Effects Reaction Responsibilitie
cs s
59

>Manageme >Alkalinizatio > Acts as an > Metabolic or Absorption: >Flatulenc > Tetany > IV: Assess
nt of n alkalinizing respiratory Following oral e > Metabolic fluid balance
metabolic agent by alkalosis administration, > Gastric alkalosis
acidosis >Neutralizatio releasing > Hypocalcemia excess distention >hypernatremi > Report
n of gastric bicarbonate > Excessive bicarbonate is > Sodium a symptoms of
acid. ions. chloride loss absorbed and and water >hypocalcemi fluid overload
> As an antidote results in retention a
> Following following metabolic > Irritation >hypokalemia > Assess
oral ingestion of alkalosis and at IV site patient for
administratio strong mineral alkaline urine. signs of
n, releases acids acidosis,
bicarbonate, > Patients on Distribution: alkalosis,
which is sodium Widely paresthesia,
capable of restricted diets distributed into tetany, altered
neutralizing (oral use as an extracellular fluid. brerathing
gastric acid. antacid only) pattern,
> Renal failure Metabolism and hypernatremia,
(oral use as an Excretion: or
antacid only) Sodium and hypokalemia
> Severe bicarbonate are throughout the
abdominal pain excreted by the therapy.
of unknown kidneys
cause, as >Avoid
especially if Half-life: extravasation,
associated with Unknown. as tissue
fever (oral use irritation or
as an antacid cellulites may
only) occur. If
infiltration
occurs, confer
with physician
or other health
60

care
professional
regarding
warm
compresses
and infiltration
of site with
lidocaine or
hyaluronidase.

> Antacid:
Assess patient
for epigastric
or abdominal
pain and frank
or occult blood
in the stool,
emesis, or
gastric
aspirate.

Generic name: TRANEXAMIC ACID Brand name: HEMOSTAN


Classification: ANTI-FIBRINOLYTI Dosage/ Administration/ Route: 500 mg amp IVTT
q8h

INDICATI THERAPEUT MECHANIS CONTRA- PHARMACO- SIDE ADVERSE NURSING


ON IC M OF INDICATION KINETICS/ EFFECTS EFFECTS RESPONSIBILITI
EFFECTS ACTION S AND PHARMACO- ES
61

PRECAUTIO DYNAMICS
NS
Prophylaxis Hemostasis Stop the Contraindicate Peak: 1 to 3  Dizziness  Fertility  Monitor clinical
for bleeding natural d in patients hours  Tinnitus problems response and
tendencies / plasminogen with  Headache  Elevated clotting factor
hemorrhage clot- pronounced Onset: Rapid  Weakness serum levels regularly,
dissolving thrombotic  Nausea creatine in order to
mechanism tendency w/o Duration:  Cramps phosphokin arrange to adjust
by blocking simultaneous Duration of ase (CPK) dosage, as
 Diarrhea
its activation use of infusion needed.
 Hypotensio
or by anticoagulant  Offer support and
n
directly and in patients safety measures
inhibiting with defective  Malaise
to prevent patient
plasmin. color vision. injury.
Use cautiously  Monitor the
in renal patient for any
insufficiency signs of
and in massive thrombosis, in
bleeding o the order to arrange
upper urinary to use comfort
tract. and support
measures, as
needed.

NURSING MANAGEMENT

Assessment Nursing diagnosis Objective Intervention Rationale Evaluation


Subjective: 1) Ineffective Short term: Independent: After 30 minutes,
“Maglisud man Airway Clearance At the end of 30 > position the head midline with >open/maintain airway patency the patient was
syag ginhawa related to retained minutes, the patient flexion appropriate for client’s able to express
62

tungod sa mga secretions and will be able to: condition non- verbally by
plemas nya, unya impaired gag -demonstrate and association of
dili pa gyud nya reflex secondary maintain airway > elevate the head of the bed and > gravity decreases pressure on things like pillow
maluwa” as to presence of patency change position every 2 hrs the diaphragm and enhancing as smooth feeling/
verbalized by mechanical -demonstrate non- drainage of ventilation to relieved and
patient’s ventilator verbalize different lung segments comfort. Also
significant other. understanding of secretions were
causes and it’s >do suctioning of secretions using > helps in evacuation of improving
management suction machine secretions gradually
throughout
Long term: > reinforce techniques that would > for the client to understand improving with
Objective: At the end of 8 hrs, help client express his and express what he had wanted suctioning and
> attempts to the patient will be understanding on the information to verbalize or say since the expectorates/suctio
expectorate but able to: being given like: patient cant express verbally, ned secretions into
can’t do it - maintain clear association of words into action yellow to green
>crackles present airway and a. associate actions or things on or things may be a great help to colored at minimal
on both lungs demonstrate which the patient would like/ both the nurse and the patient. amount,. The
upon auscultation techniques that aids wanted to express patient was as well
>deep and in b.encourage by nodding, raising compliant to
labored breathing expectorant/suctioni eyebrows and raising thumb for procedures and
>use of accessory ng through approval and turning head side-to- interventions given
muscles secretion machine side for disapproval .

Assessment Diagnosis Objectives Intervention Rationale Evaluation


Subjective: 2)Ineffective Short term: Independent: -The patient was
“O, galisud breathing At the end of 30 -position patient with -for optimal breathing able to manifest
man na siya pattern minutes of nursing proper body alignment. pattern improved
ug ginhawa.” related to intervention, pt. will -monitor vital signs -for comparative baseline respiratory pattern,
As verbalized decreased be able to: including O2 saturation. data with an O2
by SO energy and -manifest improved -auscultate chest regularly -to note presence of saturation of 98%
63

weakness. respiratory pattern secretions or character of and no signs of


Objective: -patient’s SO will breath sounds. cyanosis or
-on verbalize awareness -elevate head of bed as -to promote physiological hypoxia.
mechanical of causative factors appropriate ease of maximal
ventilation and lifestyle inspiration.
-HR = 119 changes(i.e.cessation -suction airway as needed -to clear secretions
bpm of smoking) -reposition patient every 2 -to mobilize secretions and
-presence of hours or regularly prevent pressure ulcers.
mimimal Long term: -provide reassurance and -air hunger can produce an
pleural At the end of 8 allay anxiety by staying extremely anxious state.
effusion hours of nursing with patient during acute
based on x- intervention, patient episodes of respiratory
ray report will be able to have: distress.
-use of -normal O2 -maintain calm attitude -to limit level of anxiety
accessory saturation(97-100%) when dealing with patient.
muscles -no signs of cyanosis -encourage adequate rest -to limit fatigue
-deep and and other symptoms periods.
labored of hypoxia. -encourage patient/SO to -to provide optimal
breathing -normal ABG values develop plan for smoking recovery of condition.
-weak lower cessation
extremities Dependent:
-speech and Administer bronchodilator -this relaxes bronchial
swallowing is such as Salbutamol muscles which allows the
compromised. (duavent 1 neb + ½ neb patient to breathe
asmavent q 6 hrs.) as comfortably.
ordered by doctor -for optimal oxygenation

Administer O2 (5 L/min) - for effective oxygenation


of the body
64

Assessment Nursing diagnosis Objective Intervention Rationale Evaluation

Subjective: 3)Deficient Fluid Short term: Independent: We were not


“ Oo.Sige na syag Volume Related At the end of 1 hour > Monitor vital signs, especially > Tachycardia and hypotension anymore able to
ihi-ihi” to hyperglycemic- of nursing noting respiratory status changes are classic symptoms of evaluate the
induced osmotic interventions, the or alterations in BP. hypoglycemia. Respiratory patient’s intake
Objective: diuresis. patient’s significant changes may occur as the lungs and output since
> dry lips, mucous others/patient will attempt to remove acids by the patient was
membranes be able to identify creating a compensatory transferred to the
65

> weak and signs and symptoms respiratory alkalosis. private room
thready pulse of hyperglycemia during/ within our
>imcreased urine > monitor Intake and Output >Facilitates accurate measurement shift.
output Long term: every 4 hours. and effectiveness of volume
>> intake less At the end of 4 replacement and maintenance of
than output ( I- hours of nursing adequate circulation fluid volume.
740cc, O-860cc) interventions, the
patient will be able
to have vital signs > Assess patient’s mental status > Mental status changes occur
within normal range and observe for significant with exceedingly high or low
and have equal changes glucose levels, electrolyte
balance between imbalances and acidotic states.
intake and output.
>Instruct patient/family > Provides information and
members regarding signs and promotes more timely
symptoms of hyperglycemia. identification of complications.

Dependent:
> Administer Insulin glargine > Increases glucose transport
(Lantus) 30 “u” SQ before 8 across muscle and fat cell
am(long acting) feeding as membranes to reduce glucose
ordered. And insulin aspart 10 levels.
“u” SQ before each feeding
(short acting) as ordered.

Assessment NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


DIAGNOSIS

SUBJECTIVE: 4)Imbalanced Short term: Independent: At the end of 30


Nutrition: Less At the end of 30  Provid3e - Provides nutrition mins. of nursing
SO verbalized
66

“Nagniwang gyud Than Body mins. of nursing high nutrient and helps restore interventions, the
na siya sukad Requirements interventions, the liquids as bowel function. patient/SOs was
nahospital.” related to insulin patient/SOs will be soon as able to verbalized
deficiency able to determine patient is avoidance of diet
OBJECIVES: proper diet for the able to rich in fats, sodium ,
 Fatigue patient, diet low in tolerate oral such as dried fish,
 Weakness fats, sodium and intake with bagoong, fatty
 Increased carbohydrates. progression meats, mayonnaise.
glucose to solid
level; Hgt: Long term: foods. At the end of 8 hrs.
151 mg/dL At the end of 8 hrs.  Instruct - Complex of nursing
(NV: 60 – of nursing patient/SOs carbohydrates interventions, the
100 mg/dL) interventions, the in dietary decrease the amount patient was able to
 (+) Weight patient will be able management of insulin needs, have intake of
loss: from to have intake of , with ideal reduce serum appropriate amounts
78kgs to appropriate amounts amount of cholesterol and help and types of calories
72.7kgs in and types of calories 60% CHO, to satiate patient. and have glucose
one week and have glucose 20% fats, Food should be levels within
 Presence of levels within and 20% scheduled for peak acceptable range, as
appetite acceptable range. CHON to be effects of insulin as evidenced by Hgt of
changes divided in well as patient 90mg/dL.
 Dry mucous designated preference.
membrane no. of meals - Diet high in fats,
and snacks Na and CHO
 Scaly, dry
daily. increases blood
lips
sugar level.

 Encourage
patient to
avoid diet
rich in fats
and sodium
and reduce - Increases glucose
67

intake of transport across


carbohydrate muscle and fat cell
s. membranes to
reduce glucose
Dependent: level.
 Administer
Lantus 30 - Assist in
“u” SQ facilitating
before 8am adjustmens to diet
feeding as for patient’s special
ordered. needs and facilitates
dev’t of workable
Collaborative: meal plans.
 Consult with
a dietician.

Assessment NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION


DIAGNOSIS

Subjective: 5)Impaired Skin Short term: Independent: At the end of 30


none Integrity related to At the end of 30  Remove wet - prevents mins. of nsg.
presence of blisters mins. of nsg. diapers and wet aggrevating the interventions,
Objective: on right heel, right interventions, linens promply. condition. patient will be free
 Blisters on 3rd and 4th toes, patient will be free  Clean blisters - To promote of itching, as
right heel, sacral area and of itching, as regularly using healing. evidenced by
68

right 3rd and scrotal area evidenced by normal saline absence of


4th toes, secondary to absence of sol’n or restlessness.
sacral area physical restlessness. antiseptic.
and scrotal immobilization for  Instruct patient - To prevent At the end of 8 hrs.
area long hours Long term: not to touch/ further damage of nursing
 Redness on At the end of 8 hrs. rub affected to skin integrity. interventions, the
affected of nursing areas. patient
parts interventions, the demonstrated
 Restlessness patient will display Dependent: improvements in his
improvement in  Apply - To promte blisters as evidenced
blisters as Bactroban healing using by decreased
evidenced by ointment BID pharmacologic redness and absence
decreased redness as ordered. approach. of pus and swelling.
and absence of pus
and swelling which
are signs of
infections.
69

Assessment Diagnosis Objectives Intervention Rationale Evaluation


Subjective: 6)Sleep Short term: Independent: After 8 hours of
pattern At the end of 2 -provide comfortable -this is to give comfort nursing
“Gamata- disturbance hours, the patient position during sleep and and also avoid pressure intervention, patient
mata mana related to will be able : provide: ulcer to develop. was able to
sya permi,dili discomfort -at least try to sleep -well groomed and -to make the patient feel gradually
straight iyang secondary to undisturbed for two straightened mattresses comfortable improving from 1-2
tulog” as attachment of hours straight and bed covers and -this is to let the patient hours of sleeping.
verbalized by tubings and especially in the pillow. feel fresh and at ease It’s a good sign and
the presence of evening. -change patient’s gown while lying on back; back indication that
informant. blisters. -demonstrate and into new one rubbing allows procedures should
understand tolerable -do evening care/morning circulation of blood then be taking cared of
Objective: tecniques that would care, especially the back promoting comfort seriously especially
-frequent be suitable for rubbing. when client sleep
yawning sleeping. -minimize use of lights if -so as not patient be hygiene is
-appears not necessary; maintain disturbed during on and abnormal, this may
weak Long term: quite environment off lights. exacerbate other
-with At the end of 8 -positioning during sleep -this may contribute to symptoms, which
gestures of hours, client will be in which he could hindrances during client may
sleepiness able to : properly breathe,check sleeping. experience. is
like the eyes -sustain 2-3 hours of mechanical abnormal, this may
wanted to undisturbed sleep ventilation,airway and exacerbate other
close since client others. symptoms, which
-RR= 31 maximum of -maintain environment -to promote relaxation client may
cpm, dyspnea sleeping time is 30 conducive to sleep/rest. experience.
-moderately minutes to 1 hour. -organize nursing care -to promote minimal
anxious interruption in sleep or
-blisters rest
noted at -limit fluids before -to reduce need for
sacral area bedtime voiding during night
70

Dependent:
Administer sedatives as -this is to make patient
ordered by the doctor. sleep comfortable.
71

Assessment Diagnosis Objectives Intervention Rationale Evaluation


Subjective: 7)Mild Short term: Independent: After 30 mins of
“sige ra na anxiety At the end of 30 1. Monitor physical 1. To measure the nursing
siya og mata related to minutes of nursing responses of the extent on which the interventions pt. SD
mata sa alteration of intervention, the patient. patient can follow demonstrated
gabi-i” as health status patient will be able instructions. healthy ways in
verbalized secondary to to: 2. Establish a 2. To build rapport dealing and
by patient’s present  verbalize therapeutic with the patient and expressing anxiety
sister. medical awareness relationship allay fear and i.e (diversional
condition. of feelings between the patient apprehension. activities and
Objective: of anxiety and the student comfort masures)
-restlessness  identify 2 nurse by conveying
-insomnia healthy empathy and
-patient was ways in unconditional
restrained. dealing and positive regard.
expressing 3. Be available to the 3. To gain trust from
anxiety such patient for listening the patient and for
as and talking. the patient to be
diversional open in expressing
activities what he feels.
and comfort 4. Encourage patient 4. For the nurse to
measures. to verbalize what he know and
feels and needs. immediate
Long term: interventions will
At the end of 2 days be given. It is also
of nursing help release and
interventions, the lessen anxiety.
patient will be able 5. Encourage patient 5. Promote patient’s
to report and to express feelings self-esteem.
demonstrate through actions.
decrease anxiety as
evidenced by
absence of 6. Provide accurate 6. Helps client to
72

restlessness and information about identify what is


appearing relaxed. his condition. reality based.

7. Provide comfort 7. It’s a non-


measures and pharmacologic
diversional approach in dealing
activities such as with anxiety.
providing a calm
and quiet
environment, soft
music and back
rubbing.
8. Include patient’s 8. It would help client
significant others in to identify what is
the health reality based
teachings. .
9. Provide health 9. To provide
teaching about continuity of care.
behaviors that is
indicative for mild
anxiety such as
restless, irritable,
wakeful, reports of
insomnia and etc.
Dependent:
1. Provide anxiolytic or 1. To reduce if not
anti anxiety drugs as totally eliminate
ordered. anxiety.
73

DISCHARGE PLAN

Medications Exercises Treatment Health teachings Out- patient Diet Spirituality


follow-up
> strict > teach patient >compliance to >strict compliance >pt. SD and >diet should >pt should
compliance to exercises that medication with to medication SO should be include: always be
medications only be at supervision, or especially back on -low: sugar, encourage and
tolerable rate remind the SO to administration and specified time fat, emphasized to
> maintenance like: always be maintenance of written in their carbohydrate the fact that, all
dose should be - passive ROM reminded for insulin therapy discharge slip should be lifted
known of upper and client’s recovery -20%CHON, to God alone,
lower >avoidance of food > pt. should be 20% HCHO, that even
> side effects extremities >proper timing and that contains: accompanied 60% CHO medication may
and drug especially duration during -caffeinated by significant not be effective
interactions of procedure like the drinks and food others for -high fiber, it if Faith is not
medication >proper medication at like: coffee, cola, explanation, inhibits being practiced
indicated for positioning prescribed time, and chocolates and results, and glucose by the Lord.
DM during sleep or dosage, route and the likes findings, and absorption in
when awake, so other rights in even stand as a the intestines >reinforce that
as to allow administration of >limit if not avoid support for the illness
airway and medication and stop smoking client -also give Ca experienced was
breathing and alcohol emotionally supplements, not brought
properly >buying/complying consumption, it to manage about by other
of necessary may exacerbates >also indicate hypocalcemia factors, or a
>deep breathing equipments should the condition the date, and Vit. D for curse from God,
at tolerable pace be followed as physician’s absorption of he should be
prescribed >encourage food name in the Calcium reminded that
>encourage also rich in protein, for pts. Card so as God alone can
verbalization of >social interactions collagen synthesis not to be be the most
feelings; if able also by significant and healing of confused on source of
to others plays an tissues- like: fish, when to come healing in all
write provide important role in eggs, meat and back and aspect of human
pen and paper, it the recovery of the other dairy products where to have person
74

is exercises on client (if not check- up


the digitals as contraindicated and
well, and even if prescribe by the
her cognition physician.)
and mental
ability. >encourage SO to
participate in the
course of treatment
by being the means
of the therapy since
SD is dependent on
his ADL,
medication and
other instructions
should be
emphasize
75

PROGNOSIS

Early evaluation and risk stratification for patients with acute pancreatitis are

important to differentiate patients with mild versus severe disease because patients with

severe disease often need intensive care treatment. Several scoring systems can predict

the severity of pancreatitis, and recent work has attempted to compare their relative

predictive values.

In most cases, acute pancreatitis goes away on its own after a couple of days with

no complications and no further problems. About 10% of patients develop complications,

such as a pseudocyst or abscess in the pancreas,that may require monitoring or additional

treatment.

Pancreatitis caused by heavy drinking is likely to come back if drinking

continues. Over time, permanent damage may be done to the pancreas, and a chronic

form of the disease may develop

Patients usually recover fully from acute pancreatitis and do not experience

recurrence if the cause is removed. Alcohol consumption should be eliminated even if it

is not the determined as the cause of the disease. Smoking, which stresses the body's

defenses against inflammation, should be stopped. If gallstones were the cause, then

removal of the gallbladder is required to prevent further attacks. For those patients in

whom a cause is not readily identified, there should be consideration of other diagnostic

testing such as endoscopic ultrasound.


76

CONCLUSION

Nursing care and management of the client with type 2 diabetes mellitus is both

complex and challenging. Especially that the disease is already severe and with

complications present. Compliance to the medication regimen could be a burden to the

family considering that it needs be strict and lifelong. Having a thorough understanding

of the pathophysiologic changes, knowing what to expect clinically and becoming

familiar with the standards of care, patient education in reference to the nature of the

disease, as well as educating the client’s significant others is essential for the better

understanding of the client’s condition. Hence, patient education in conjunction with the

nursing care could be a great factor in achieving positive outcomes. As student nurses, we

are responsible for developing an individualized plan of care that reflects the client’s

medications, diet and physical activity during the development and progression of

different phases of recovery. Not only would the health teachings be directed to the

patient himself but to the significant others as well.

The group would have had a complete and productive evaluation of patient RP’s

condition and his progress if we were able to conduct a home visit however, due to the

wrong information provided, i.e. address given by SO and as stated in the chart, the group

wasn’t able to do so. Some members of the group went to the specified location (Grand

Europa) but upon arrival to the area, the address particularly the block/street and lot was

not present or in existence. The group also tried calling up the patient or his SO through

the phone information but there were no record of the names of our patient and SO

(sister).
77

Recommendation

The proponents of this case analysis recommend that further study will be made

on the different diagnosis of the patient. In order for the health care providers including

nurses and student nurses will be equipped with knowledge, skills and attitude in

rendering care for patients having this type of diseases. Further study about these diseases

will help the family who have relative’s having this type of multiple disease, will have

better understanding about this condition, In order that they could better take care of their

family member.

This study is also recommended for nursing students who will conduct case

presentation that they will be able to have a flow on the proponents needed for a case

presentation. They will be equipped with knowledge, skills and attitude in conducting a

case presentation especially in making a thorough assessment of their patient.

It is also of high consideration that further evaluation be done to determine the

progress and compliance of the patient to the out-patient treatment regimen like being

able to conduct a home visit. Aside from this, the sources of data for this case

presentation is only limited to the assessments, laboratory results, patient’s chart and

personal interview with the patient, as well as on his significant others thus, other sources

of data, such as personal interview with the patient’s attending physician must also be

done for more information regarding the patient’s condition. Progression of the patient’s

recovery must also be monitored and documented regularly to determine the necessary

changes and improvement of patient’s care. Nevertheless, this case presentation is

recommended to be used as a reference for future studies about type 2 diabetes mellitus.
78

BIBLIOGRAPHY:

- “Respiratory Failure”. http://www.emedicine.com/med/topic2011.htm. Sat


Sharma, MD, FRCPC, FACP, FCCP, DABSM. June 29, 2006
- “Acute Renal Failure”. http://www.nephrologychannel.com/arf/. Stanley J.
Swierzewski III, M.D. September 7, 2007
- “Excerpt from Pancreatitis, Acute”.
http://www.emedicine.com/radio/byname/pancreatitis-acute.htm. Glenda
Romero, MD. 2006
- “Acute Necrotinizing Pancreatitis”.
http://usagiedu.com/articles/html/necr/necr.pdf. Todd H. Baron, M.D, et al.
May 6, 1999
- “Acute Pancreatitis”. http://en.wikipedia.org/wiki/Acute_pancreatitis.
Wikipedia. September 15, 2007
- “Diabetes Mellitus”. http://en.wikipedia.org/wiki/Diabetes_mellitus.
Wikipedia. September 18, 2007
- “Beta Cell”. http://en.wikipedia.org/wiki/Beta_cell. Wikipedia. September 5,
2007
- “Type 2 (Non-Insulin-Dependent) Diabetes Mellitus”.
http://www.med.umich.edu/1libr/guides/noninsul.htm. Martha Funnell, MS,
RN, CDE. April 2004
- Black, J & Hawks, J. Medical-Surgical Nursing: Clinical Management for

Positive Outcomes. 7th Ed.Vol 2.

- Doenges, M., Moorhouse, M., Geissler-Murr A. Nurses Pocket Guide: Diagnosis,

Interventions and Rationales. 9th ed. Davis Co. Copyright 2005

- Karch A. Focus on Nursing Pharmacology. 2nd ed. Lippincott Williams and

Wilkins. Copyright 2005.

- Smeltzer, S. Bare, B. Brunner and Suddarth’s textbook of Medical-Surgical

Nursing. 10th Ed. Vol.1. Lippincott and Williams. Copyright 2004.


79

- Nettina, Sandra M. RN, MSN, CS, ANP. The Lippincott Manual of Nursing

Practice. 7th Ed. Vol. 1. Lippincott and Williams. 1996.

- Porth, Carol Mattson.2002. Pathophysiology: Concepts of Altered heath states. 6th

edition. USA. Lippincott Williams and Wilkins

- Bullock, Barbara L. and Henze.2000. Focus on Pathophysiology. Philippines.

Lippincott Williams and Wilkins

- Huether, Sue E. and Kathryn I.McCance Understanding Pathophysiology. 3rd

edition.USA. Mosby Inc.

- Springhouse Nurse’s Drug Guide 2005. 6th ed. Lippincott Williams and Wilkins.

- http://www.infoplease.com/ce6/sci/A0812296.html

- The Columbia Electronic Encyclopedia, 6th ed. Copyright © 2007, Columbia

University Press.

- http://www.infoplease.com/ce6/sci/A0830631.html

- http://www.infoplease.com/ce6/sci/A0817329.html

- http://www.le.ac.uk/pathology/teach/va/anatomy/case2/frmst2.html

- http://www.niehs.nih.gov/oc/factsheets/ozone/ithurts.htm

- http://people.eku.edu/ritchisong/RITCHISO/301notes6.htm
80

Appendix

Nurses Notes

Date Notes

8-19-07
> received on bed awake conscious and coherent to
both verbal and tactile stimuli ; with pupils @ 5mm
sluggish, reactive light accommodation; normal
power on both upper and lower extremities; GCS q 4
score 15
> hooked to cardiac monitor on sinus rhythm (-)
arrythmias
Ineffective > initial v/s taken and recorded BP: 110/70 mmHg;
Airway O2 sat: 98%, HR: 88bpm
clearance
> with ET @ 22 cm Lip level to vent: TV: 400ml,
RR: 10cpm, F1O2 35% PS 10 cm H2O on SIMV
mode with minimal yellowish sticky oral secretions
with MOD yellow ETA. Secretions suctioned q hour
and PRN turned to sides q 2 – able to turn with NEB
q 6h; oral care BID
> with NGT for of 166 cc q 4 – tolerated FED with
NGT
aspiration precaution and due PO Meds; intake
Standard
measured and recorded; standard followed

FBC > with FBC to urobag draining well to moderate


Standard yellowish colored urine - cloudy; output measured
and recorded; standard followed
> with blister @ R heal toes and scrotum area; and
Impaired
sacral area - apply bactoban
Skin
> with Hgt monitoring q 4 7:30 am – Hgt result
Integrity
relayed to Dr. Lolong = Coverage Lantus 20 units
and Novorapid given q before feeding
81

> RR decrease to 10 pressure support 10 for 1 hr –


tolerated
8:00am
> RR decrease to 8 pressure support decrease 8 for 1
9:00am hr – tolerated
> patient hooked to T-piece @ 5 L/min saturating
11:00am
well t o100%
> for possible extubation if weaning tolerated and
labs within normal limit
> extubation hold
> endorsed to pm shift

8-19-07 > received awake on bed; with GCS score of 25/15,


6:00am with spontaneous eye opening, obeys command and
oriented to place, time and person; with 4 mm size
on both pupils and sluggishly reactive to light and
accommodation; upper and lower extremities are in
normal power
> initial v/s taken and recorded with BP: 90/60, HR:
99bpm; T: 36
> on bladder training 4 hours clamped; 30 minutes –
released; tolerated
> Hgt result 3:30 pm was 151 mg/dl relayed to Dr.
Austria with orders to coverage of insulin
> result was 76 mg/dl relayed to Dr. Austria to hold
7:30pm covergage
> for possible transport tomorrow
> seen and examined by Dr. Sison with orders
8:10pm
carried out
> encourage oral feeding as ordered
> ICU care rendered; needs attended
> endorsed
> received awake on bed; responsive to all forms of
stimuli
82

8-20-07 (PM) > initial v/s taken and recorded with BP: 130/90
mmHg. HR: 87 bpm, RR: 12 cpm, and T: 35.6
> hooked to cardiac monitor on sinus rhythm (-)
PACs, (-) PVCs

> with FBC attached to urobag draining yellow


colored urine; outputmeasured and recorded
FBC
> FBC standard followed
Standard
> with ongoing venoclysis at both arms
> no infiltration observed

IVF
> with blister @ R heel, toes, sacral and scrotum
Standard
area
Impaired > applied bactroban once on affected area
Skin > with Hgt monitoring q4h and relayed result to IM
Integrity ROD
> given aspart 10 u SQ pre-feeding
DM
> DM standard followed
Standard
> CXR film – for official recording
> decrease BUN and pressure support to 8 at 6am
Gen. Notes today
> for possible extubation @ 8 am today
> kept watched for any unusualities
> needs anticipated
> endorsed

> kept HR and BP monitored


> provided calm and quiet environment to promote
83

8- 21-07 (AM) rest


> with O2 inhalation @ 2 LPM via nasal prong
> turned to sides @ intervals
> placed on MHBR
> O2 sat monitoring, saturating well @ 97-99%
> with NGT for OF 166 cc q4 and due PO meds
given
NGT
> may have sips of H2O/ clear soup
Standard
> encourage oral feeding
> (-) NGT drainage
> standard followed
> with FBC attached to urobag, draining yellow
colored urine
FBC > output monitored and recorded
Standard > FBC standard followed
> with Hgt monitoring q4h, relayed result to IMROD
and with insulin coverage
> given dose of Xlosarapid 8 u SQ as ordered
DM
> DM standard followed
Standard
> with blister @ R heel, toes, sacral and scrotal area
> applied bactroban over affected area
Impaired
> with ongoing venoclysis @ R arm (CVP line) –
Skin
infusing well
Integrity
IVF > due IVTT meds given
Standard > no infiltration observed
> IVF standard followed

> on bladder training


> 4 clamped and 30 minutes released
84

Gen. Notes > kept watched for any unusualities


> needs anticipated
> endorsed

> received awake on bed, conscious and coherent


> hooked to cardiac monitor on sinus rhythm; no
8-21-07 (AM)
arrhythmias noted
> placed on MHBR
> turned to sides @ intervals; back tapping rendered
Ineffective
> on O2 sat monitoring saturating well 98-100%
Breathing
> with due nebulization given
Pattern
> seen and examined by Dr. Solas with orders to off
O2; remove NGT – done and carried out
9:30am
> voids per diaper/urinal
> output measured and recorded
> on DM diet – consumed share with fair appetite
with strict aspiration precaution
> with Hgt monitoring pre-feeding
> results relayed to ROD with orders carried out
> for CXR – PA tomorrow am – requested
> needs attended
> Nursing care done
> endorsed
85

Doctor’s Notes

Date ordered Doctor’s Order


8-19-07 > BUN and PS at 8am and 6pm tomorrow (8-20-07) for 2 hours
6:55am > for possible extubation at 8am tomorrow
K=4.1

12:05pm > revise insulin administration as follows


 30 units glorgine insulin (Lantus) SQ
before 8am feeding
 10 units insulin aspart (NOVORAPID) SQ
before each feeding

 > problem: hypohaluis


12:35pm > HRd extubation
> side drip: to D5W 500cc in q shift follow 90 cc D5W + 10 mg KCl
to MN in 1 hour x 5 cycles
> Repeat K after 5th of KCl drip.
> look back to mechanical vent. At 5L/min

8:25am
> for extubation – done
> suction excretion ET and Oral
> O2 inhalation at 5 L/ min via nasal canula
> possible trans-out tomorrow
9:00am
> start bladder training

11:00am
> may have sips of water/clear soup
> decrease O2 to 2 L/ min
>D/ IC IVF at left arm
86

> NNO
12:00nn

7:00pm > IVF TF with PLR 1 L at 10 gtts/min


> hold 7pm dosage of Novorapid
> decrease Dovos qid to * lib SQ before each feeding
8:10pm > repeat CBC; CREA, K tomorrow
> encourage oral feeding

8-21-07
> include serum albumin on blood reaction
5:15 am
> remove FBC and refer if with out output for 4 hours
>D/C Prevoid once stock is consumed
> inform surg. Resident re = CVP line
> IVF TF with PLR @ 10 gtts/min
> CXR PA in Lab
> Resume NGT
9:30am
> Off O2
> incorporate 60mg KCl in present IVF
> shift ciprofloxacin IV to P.O 5mg BID
> D/C albumin
> may transfer to referred room of choice
> start diabetic diet at 1800 Kcal/ of single mg and more of
polysaccharide fat; CH 60%, CHO 30%, fat 20%

8-21-07
Trans-out Orders

> may transfer to room of choice under D5S volume 1 L/ O2


9:30am
> regulated plain LR 1 L + 60 Meg KCl at 10 gtts/ml
> meds: cifloxacin 500g + eb bid – D7# Do
cefeprine1 gm IVTT q OD – D7 to complete 10 days
Lantus 30 units SQ before 8 hr feeding
Novo rapid 8 units SQ before lunch and dinner and
87

breakfast
> Duavent + net q6hrs nebulization
> TPR; v/s q4hrs
> Hgt TID pre-breakfast, pre-lunch and pre-dinner – record in
separate sheet
> full diabetic diet at 1800 Kcal/ gw/ no more of single mgs and
more of polysaccharide fat with the ff: specifications:
HO 60% in 3 meals and 2 snacks
CHON 20%
Fat 20%
> strict aspiration precaution
> I and O qshift
> inform surgery resident
> effective accordingly
> inform APS
> for pt CXR PA in am
88

Progress Notes

8-15-07

A case of 34 Y.O M/ single. Admitted due to sensorial changes on his 5th


Hospital day with P.W.I

1. Acute Respiratory Failure Type II secondary to Sepsis secondary to Acute


Necrotizing Pancreatitis/ Hypotension secondary to Acute Necrotizing
Pancreatitis.

A. Acute Renal Failure


B. Hypoalbuminuria secondary
C. Thrombocytopenia secondary to Pulmonary Edema secondary
to B secondary to A
2. Diabetes Milletus type II; newly diagnosed
3. Hospital Acquired Pneumonia
4. S/P craniotomy

8-17-07

Impression:
Acute Necrotizing Pancreatitis – resolving
Acute Respiratory Failure – resolving
Acute Renal Failure – resolving
Pulmonary Edema secondary to Hypoalbuminemia secondary to
Acute Illness

S/P Craniotomy secondary to Gun shot wound – 2005


MODS resolved 8/16
89

Problem 1 Acute Respiratory Failure – resolving


Pulmonary Edema secondary to Hypoalbuminemia secondary to
Acute Illness

S = Px has no subjective data


O = 100/60
Good coughing reflex
Awake; oriented
+ rates mid to basal area
A = with persistence of the Pulmonary Edema on P5
Symbolized by possibility of fatigue

P = increase serum albumin to 3.0 to 3.8 with albuminar infusion

Problem 2 Diabetes Mellitus type II newly diagnosed


S = none
O = Hgt is for 45 g/dL – 34.29 g/dL
A = with NGT feeding, control of blood sugar level
P = adjust insulin drip accordingly

Você também pode gostar