Case Presentation Final

OSPA FARMERS MEDICAL CENTER
Nursing Service
June 2013
A Case Presentation on Mr. A, Male, 53 years old diagnosed with Cardiopulmonary Arrest secondary to Septic Shock secondary to Pneumonia- High risk with
Multi organ Failure, Colonic Adenocarcinoma, Hypertensive Cardiovascular Disease, Chronic Lung Disease, S/P Explore Laparotomy and Right
Hemicolectomy
Submitted by:
Arvin Joseph Aunzo
Malony Docena
Ma. Rowena Grace Ferrer
Jygar Garciano
Crizaldy Metran
Jasmin Monreal
Nikki Sia
I.
SYNOPSIS AND BACKGROUND OF SUBJECT MATTER
CANCER
Cancer is a class of diseases characterized by out-of-control cell growth. There are over 100 different types of cancer, and each is
classified by the type of cell that is initially affected. Cancer harms the body when damaged cells divide uncontrollably to form lumps or
masses of tissue.
COLONIC ADENOCARCINOMA
Colon adenocarcinoma is the most common type of gastrointestinal cancer. This type of cancer begins in the cells of glandular structures
in the inner layer of the colon and spreads first into the wall of the colon and potentially into the lymphatic system and other organs.
Risk factors:
Family history of adenomatous polyposis or Gardners syndrome

both marked by the growth of multiple colon and rectal polyps
Individuals aged 50 years old and above
Diet high in fat and low in fiber
Personal history of previous cancer or inflammatory bowel disease.
Examinations:
Digital Rectal Exam
Blood tests
Colonoscopy
Flexible sigmoidoscopy
Double-contrast barium enema
Manifestations:
May be asymptomatic for up to five years
Rectal bleeding
Fatigue
Shortness of breath
Angina
Changes in bowel habits
Abdominal discomfort
Anemia
Bowel obstruction
The pathologist notes the size of the tumor, how close the cancer is to the edge of the removed tissue, and whether or not the tumor invaded blood or
lymphatic vessels. These factors determine the likelihood of the cancer remaining in or returning to the affected area. In some situations, a primary care
physician or specialist may order imaging tests including a chest x-ray or CT scan to see if the tumor has spread to the lungs, lymph nodes, liver,or
ovaries.With all necessary tests completed, the pathologist determines the cancers stage. Stage 1 colon adenocarcinomas are small and confined to the
colon, and stage 4 tumors have spread beyond areas near the colon. Stages between 2 and 3 describe conditions in between these two extremes.
Stages of the tumor:
TX. Primary tumour cannot be assessed
T0. No evidence of primary tumour
Tis. Carcinoma in situ
T1, T2, T3, T4. Increasing size and/or local extent of the primary tumor
Stages of spread to lymphatic system:
NX: Doctors cannot determine if cancer extends to nearby lymph nodes.
N0: Cancer has not extended to nearby lymph nodes.
N1: Cancer has extended to nearby lymph nodes.
Metastasis:
MX: Doctors cannot determine if metastasis has taken place.
M0: Metastasis has not taken place.
M1: Metastasis has taken place.
Stage Groupings
Stage I: T1 N0 M0
Stage IIA: T2 N0 M0 or T3 N0 M0
Stage IIB: T1 N1 M0 or T2 N1 M0
Stage III: T3 N1 M0 or T4 any N M0
Stage IV: any T any N M1
Survival rates (5-yr relative survival rate)
Stage 0: 75%
Stage 1: 60%
Stage IIA: 40%
Stage IIB: 20%
Stage III: 15%
Stage IVA: 15%
Stage IVB: <5%
Management:
Surgical Management
A radical bowel resectionalso known as a partial colectomy or hemicolectomyis the type of surgery performed on most patients.
Chemotherapy
This treatment delivers drugs throughout the body, slows the cancers progression and reduces pain. Chemotherapy can be used before and
after surgery and can be combined with immunotherapy or radiation therapy.
Radiation therapy
This is where pinpointed high-energy beamscan be used to shrink tumors or to destroy cancer cells that remain after surgery. This treatment
is also used to relieve the symptoms of advanced colon cancer.
HYPERTENSIVE CARDIOVASCULAR DISEASE

Hypertensive cardiovascular disease also known as hypertensive heart disease occurs due to the complication of hypertension or high blood pressure. In
this condition the workload of the heart is increased manifold and with time this causes the heart muscles to thicken. The heart continues pumping blood
against this increased pressure and over a period of time the left ventricle of the heart enlarges and this in turn causes the blood pumped by heart to
reduce. It is the enlargement of the heart, heart failure and coronary artery disease that results from high blood pressure.
Causes:
High or elevated blood pressure
Manifestations:
Arrhythmias
Shortness of breath
Weakness and fatigue
Swelling in the lower extremities
Greater frequency of urination at night
Chest pain
Sweating and dizziness
Nausea
Examinations:
Electrocardiogram
Chest X-ray
CT scan of the chest
Coronary angiogram
Echocardiogram
Treatment and Management:

Drug therapy
Beta blockers, angiotensin converting enzyme inhibitors (ACE), calcium channel blockers, diuretics etc depending upon particulars of each
individual case
Regular and close monitoring of blood pressure
Changes in lifestyle and diet patterns
Complications:
When left untreated hypertensive cardiovascular disease can cause angina, heart attack, stroke, heart failure, arrhythmias and sudden death.
CHRONIC LUNG DISEASE
Also known as Chronic Obstructive Pulmonary Disease (COPD) or Chronic Obstructive Airway Disease
used to refer to chronic respiratory diseases such as chronic bronchitis and emphysema.
It is a progressive disease that causes difficulty in breathing. The term "progressive" here
means that the disease worsens over time. Under these conditions, the airways become
narrowed and limited flow of air to and from the lungs cause a shortness of breath.
(COAD), is a term
Causes:
Smoking
Air pollution
Manifestations:
Cough usually productive and is intermittent
Dyspnea on exertion
Diagnosis:
Pulmonary (Lung) Function Testing

This is the most important tool used to confirm chronic lung disease. It can detect the
disease in the early stages when the patient may not show any symptoms. One of the
tests requires a patient to breathe into a spirometer machine. The readings from the
spirometer will then confirm the presence of chronic lung disease and assess its severity.
This test is also useful in monitoring the patient's progress over time and to review the
effectiveness of
treatment.
Chest X-ray
A chest X-ray is useful to rule out other conditions which may seem like chronic lung disease. It is also useful in detecting the complications of
chronic lung disease. However, just a chest X-ray alone cannot confirm the diagnosis of chronic lung disease.
ABG measurements
This is done to assess baseline oxygenation and gas exchange.
Treatment and Management:

Cessation of smoking
Drug
therapy
Bronchodilators
Inhaled and oral steroids
Combination inhalers
Phophodiesterase-4 inhibitors A new type of medication approved for people with severe COPD is roflumilast (Daliresp), a phosphodiesterase-4 inhibitor. This drug
decreases airway inflammation and relaxes the airways. Common side effects include diarrhea and weight loss.
Antibiotics
Lung therapies
Oxygen therapy
Pulmonary rehabilitation program
Surgical management
Lung volume reduction therapy In this surgery, your surgeon removes small wedges of damaged lung tissue. This creates extra space in your chest cavity so that the
remaining lung tissue and the diaphragm work more efficiently. In some people, this surgery can improve quality of life and prolong survival.
Lung transplant
EXPLORATORY LAPAROTOMY
Explore laparotomy is a method of abdominal exploration: using a surgical incision that opens the abdomen wall to gain access to the abdominal cavity.
Purpose:
It may be recommended to a patient who has abdominal pain of unknown origin. In addition, bleeding into the abdominal cavity is considered a
medical emergency such as in ectopic pregnancies. It is used to determine the source of pain and perform repairs if needed. Exploratory laparotomy
may be used to examine the abdominal and pelvic organs (such as the ovaries, fallopian tubes, bladder, and rectum) for evidence of endometriosis.
Any growths found may then be removed.
Complications:
Bleeding
Infection
Failure to find the cause of the problem; more surgery or other treatments may be needed
Poor healing of the incision

Damage, injury, or problems with the bowels
Risks of anaesthesia
What to expect before the procedure:
What
Your doctor will do pre-operative evaluation in the clinic 1 week before the procedure (if not an emergency case).
You may need to undergo some routine tests before your operation e.g heart trace (ECG), x-ray and blood tests for cardio-pulmonary clearance.
You will be admitted a day before the scheduled procedure.
Consents must be secured
Nothing by mouth for 8 hours prior to the time of the procedure
If ordered by the physician, cleaning or fleet enema will be given for further bowel preparation.
Insertion of Intravenous Line
Diagnostic exams as ordered by the physician like Complete blood count, blood typing, urinalysis and ultrasound.
Pre-operative medicines and antibiotics will be administered.
Instructions regarding change of gown, removal of jewellery, dentures, contact lenses, hair accessories, nail polish and make up will be given.
An hour before the scheduled operation, you will be wheeled down to the delivery room.
Abdominoperineal prep (shaving) will be done.
to expect during the procedure:
Prior to the time of operation, you will be wheeled in to the operating room where a surgical nurse will do the necessary preparations such as
placement of cardiac leads, hooking to the cardiac monitor, oxygen administration thru nasal cannula, and placement of leggings.
Your surgeon will probably meet you in the operating room where an anaesthesiologist will be ready.
Prior to the procedure, for verification that the right patient and right procedure will be done, Signing in will be called, wherein you will be asked to
state in your full name, date of birth, name of your surgeon and anaesthesiologist, as well as the procedure to be done.
After the introduction of anaesthesia, a curtain will be raised over your mid-section and your arms will be outstretched in order for the
anaesthesiologist and nurse to have access to your I.V.
A Foley catheter will be inserted. This is not a painful procedure, and if you have an anaesthesia in you won't feel it at all. Then the surgical nurse will
clean the incision site with betadine.
Once an adequate level of anaesthesia has been reached, the initial cut into the skin will be made. The surgeon will then explore the abdominal
cavity for disease.
Alternatively, samples of various tissues and/or fluids will be removed for further analysis and will be sent to the laboratory for microscopic
examination.
The surgeon will then close the incision.
What to expect after the procedure
After the operation, you will be wheeled into recovery where you will be observed for two hours as the anaesthetic wears off.
You will be hooked to the cardiac monitor to check your vital signs, and you will also be hooked to the oxygen.
Post-operative medicines will be given to you. Depending upon the nature of your surgery and your doctor's assessment of your pain, you probably
will be given a pain drip to address the pain.
The foley catheter will remain until further orders.
After the recovery period, you will be transferred to your room if there are no complications.
Turning from side to side is advised. An abdominal binder is applied to support your cut.
Eat nothing per mouth or take only sips of water or clear liquids or as ordered by your physician on the first day of operation or until flatus passed
out.
At home:
During the first two weeks, avoid tiring activities such as lifting heavy objects.
Slowly increase your activities. Begin with light chores, short walks, and some driving. Depending on your job, you may be able to return to work.
To promote healing, eat a diet rich in fruits and vegetables.
Try to avoid constipation by:
o
Eating high-fiber foods
o
Drinking plenty of water
o
Using stool softeners if needed
Take proper care of the incision site. This will help to prevent an infection.
Follow your doctor's instructions
When to call your doctor

After you leave the hospital, contact your doctor if any of the following occurs:
Fever or chills
Redness, swelling, increasing pain, excessive bleeding, or any discharge from the incision site
Increasing pain or pain that does not go away
Your abdomen becomes swollen or hard to the touch
Diarrhea or constipation that lasts more than 3 days
Bright red or dark black stools
Dizziness or fainting
Nausea and vomiting
Cough, shortness of breath, or chest pain
Pain or difficulty with urination
Swelling, redness, or pain in your leg
RIGHT HEMICOLECTOMY
This is an operation to remove the right side of the colon. It may be performed for patients with
a colon cancer, or for certain non-cancerous conditions such as Crohns disease. In most cases
operation can be performed via a laparoscopic (keyhole) surgical technique.
During the operation the right side of the colon and the last part of the small intestine are
removed. This involves taking away the blood vessels and lymph nodes to that part of the bowel.
surgeon then re-makes the join (anastomosis) between the small intestine and the remaining part of the
The surgeon may use either sutures or special staples to make this join.
the
The
colon.
This type of surgery does not require the formation of a stoma i.e. ileostomy or colostomy.
If there are any special circumstances that mean that a stoma may be required the surgeon will discuss these issues beforehand. The operation time may
vary for this type of surgery but is usually around 2 hours. The piece of bowel that is removed is sent to the pathology department where the pathologist
carefully examines it. The results are usually available within two weeks of the operation.
Risks:
There are risks associated with any abdominal operation. Pre-operative assessments of heart and lung conditions are made, as well as any coexisting
medical conditions.
Bleeding although rare
Wound infections
Anastomotic leak the join that is made in the bowel leaks
Ileus Sometimes the bowel may take longer than normal to start working
Obstruction
What to expect after the operation:
After the operation patients will have an intravenous drip, which is normally in place for 24 hours, or until, a normal fluid intake is resumed.
A catheter (tube inserted to drain the bladder) is normally kept in place for 24hours.
Occasionally an abdominal drain is used (small tube passing through the abdominal wall). This is normally removed after a few days.
An epidural is often used in keyhole and open surgery to provide pain relief after the operation and is usually continued at least until the next day.
The anaesthetist will be able to discuss this with you before the operation.
Patients are allowed to eat and drink as soon as they feel able after the operation (usually the same day).
Patients are encouraged to mobilise as soon as possible after the operation.
Hospital stay is usually 2-5 days for keyhole surgery and 5-7 days for open surgery although this may vary.
Following discharge from hospital, patients are encouraged to keep mobile. They should avoid heavy lifting or increased physical activities for about 6
weeks. Patients can normally resume driving after about 2 weeks but this may vary particularly if the operation is done as an open procedure.
A follow up consultation is usually arranged after about two weeks. Patients can always be seen sooner if there are problems.
PNEUMONIA
Pneumonia or Pneumonitis, a more general term, is an inflammation of one or both lungs caused by a bacteria, viruses or fungi. It is often caused by inhaled pneumococci of the species
Streptococcus pneumonia. When a person has pneumonia, the alveoli and bronchioles of the lungs swell, fill with pus or fibrous exudates and the oxygen in the body is incapable of reaching the
blood. Pneumonia is named for the way in which a person gets the infection. The two common forms of pneumonia are Hospital-acquired Pneumonia (HAP) and Community-acquired Pneumonia
(CAP).
In Hospital-acquired Pneumonia, a person starts to experience the symptoms of pneumonia more than 48 hours after the admission to the hospital especially those patients on mechanical
ventilator. It is more serious than Community-acquired pneumonia since the patient already has an underlying illness.
Community-acquired Pneumonia occurs outside the hospital or other healthcare settings. The most common symptom of pneumonia is a cough that produces sputum. A person that has
CAP can also experience chest pain, chills, fever, and shortness of breath. Common microorganisms responsible for CAP include pathogens Streptococcal pneumoniae, Haemophilus influenza,
Legionella, and Pseudomonas aeruginosa.
Signs and Symptoms:
The symptoms of pneumonia are quite variable, depending on the age of the person infected and the cause of pneumonia.
fever
chills
cough
unusually rapid breathing
chest pain
vomiting
loss of appetite
In severe cases, the person may manifest bluish or gray color of lips and fingernails. If pneumonia is in the lower part of the lungs, there may be no breathing problems but the client may
have fever, abdominal pain or vomiting. When pneumonia is caused by bacteria, an infected child usually becomes sick quickly and experiences the unexpected onset of high fever and labored
breathing. When pneumonia is caused by viruses, symptoms tend to appear more gradually and are often less severe than in bacterial pneumonia. Wheezing may be more common in viral
pneumonia.
Etiology:
Many different microorganisms can cause community-acquired pneumonia. These include different kinds of bacteria, viruses, and, fungi.
Bacteria are the most common case of pneumonia. Bacterial pneumonia can occur on its own or develop after the client had a cold or flu. This type of pneumonia often affects one lobe or
area of a lung. Streptococcus pneumoniae is the most common of all bacteria. Other types of bacterial pneumonia include:
Legionella pneumophila - which is sometimes called Legionnaires disease that causes serious outbreaks related to exposure to cooling tower, de
corative fountains, and whirlpool spas
Mycoplasma pneumonia - which is acquired in crowded places such as in schools, prison cells and squatters area
Haemophilus influenza - wherein incidence greatest in alcoholics and elderly.
Viruses are the most common cause of pneumonia in children younger than 5 years old. These viruses include respiratory syncytial virus (RSV), adenoviruses, influenza viruses,
metapneumovirus, and parainfluenza viruses. With pneumonia, the inflammatory process reaches the alveolar area which results to edema and exudation. Symptoms of viral pneumonia are
difficult to distinguish from those of bacterial pneumonia.
Fungi include Coccidioidomycosis, Histoplasmosis, and Cryptococcus and these three types are often found in soil. Serious fungal infections are most common in people who have weak
immune systems as a result of long-term use of medicines to suppress their immune systems.
Diagnostic Tests:
Crackles are heard in the chest area with the use of a stethoscope. Other abnormal breathing sounds may also be heard through the stethoscope or when performing percussion -tapping
on the chest wall. Doctors may order a chest x-ray if pneumonia is suspected and they usually make the diagnosis of pneumonia after a physical examination. The following tests are usually used
for diagnosis:
CBC to check white blood cell count
Arterial blood gases to see if enough oxygen is getting into the blood from the lungs
CT scan of the chest to examine the structures inside the chest and to look for bleeding or fluid collections in the lungs or other areas
Gram's stain and culture of your sputum to determine the microorganism causing the disease
Pleural fluid culture to check if there is fluid in the space surrounding the lungs
Prognosis:
With treatment, most patients will improve within 2 weeks especially if the duration of the administration of drugs is followed properly. Elderly or debilitated patients may need longer treatment.
Those who may be more likely to have complicated pneumonia include:
Older adults or very young children since their immune system is weak or immature
People whose immune system does not work well
People with other serious medical problems such as diabetes or cirrhosis of the liver
Treatment:
In most cases, pneumonia can be treated with oral antibiotics or via intravenous.. The type of antibiotic used depends on the type of pneumonia. Patients may be hospitalized for treatment
if they have pneumonia caused by pertussis or other bacterial pneumonia that causes high fevers and respiratory distress. They may also be hospitalized if supplemental oxygen is needed, they
have lung infections that may have spread into the bloodstream, they have chronic illnesses that affect the immune system, they are vomiting so much that they cannot take medicine by mouth,
and if they have recurrent episodes of pneumonia.
Patients with mild pneumonia who are otherwise healthy are sometimes treated with oral macrolide antibiotics:
Azithromycin
Clarithromycin
Erythromycin
Patients with other serious illnesses, such as heart disease, chronic obstructive pulmonary disease, or emphysema, kidney disease, or diabetes are often given one of the following:
Fluoroquinolone (levofloxacin (Levaquin), sparfloxacin (Zagam), gemifloxacin (Factive), or moxifloxacin (Avelox)
High-dose amoxicillin or amoxicillin-clavulanate, plus a macrolide antibiotic (azithromycin, clarithromycin, or erythromycin)
Cephalosporin antibiotics (for example, cefuroxime or cefpodoxime) with a macrolide (azithromycin, clarithromycin, or erythromycin)
If the cause is a virus, typical antibiotics will not be effective. Sometimes, however, doctors may use antiviral medication.
Nursing Management:
1) Removing secretions is important since these may interfere with the gas exchange in the body and may delay the recovery of the client.
i) Encourage patient to drink 2 to 3 liters of water per day to liquefy and loosens secretion for easy removal.
i) Teach the patient deep breathing exercises with the use of an incentive spirometer to promote lung expansion and may also induce cough.
ii) Encourages the patient to perform effective and direct cough which includes correct positioning and proper use of an incentive spirometer.
iii) Monitor patient for cough and sputum production.
2) In patients with pneumonia, the respiratory rate is increased because of the increased overload inflicted by labored breathing and fever.
i) Encourage patient, with the help of the SO, to increase the fluid intake.
3) Most patients who experience shortness of breath and fatigue have a decreased appetite and will only prefer to take fluids.
i) Give the patient fluids with electrolytes for this may help provide fluids, electrolytes and calories.
4) Providing health teachings to the patient and family to encourage them to participate for the fast recovery of the patient.
i) The patient and family should be given enough information about the causes, management of symptoms, prevention, and treatment of pneumonia.
ii) Supply information about the factors that can lead to the development of the disease and to remind the patient to avoid these harmful factors especially those that can affect the bodys
immune system.
iii) Explain to the patient and family the importance of the management strategies that have been planned and implemented.
iv) Explanations should be given simple, clear and in language that the patient can understand. If possible, written materials which serve as reminders are preferred to be given to the
patient.
SEPTIC SHOCK
Septic shock is a serious medical condition which is caused by decreased blood flow in the body, which leads to multiple organ failure as the body is slowly starved of the important
components in blood. The mortality rate for septic shock is generally around 50%, although some hospitals have a much better mortality rate. This condition most commonly occurs in the
young, the elderly, and people with compromised immune systems
Risk factors:
Extremes of age ( < 10 y and >70 y)

Primary diseases (eg, liver cirrhosis, alcoholism, diabetes mellitus, cardiopulmonary diseases, solid malignancy, hematologic malignancy)
Immunosuppression (eg, neutropenia, immunosuppressive therapy, corticosteroid therapy, IV drug abuse , complement deficiencies)
Major surgery, trauma, burns
Invasive procedures (eg, catheters, intravascular devices, prosthetic devices, hemodialysis and peritoneal dialysis catheters, endotracheal tubes)
Previous antibiotic treatment
Prolonged hospitalization
Other factors, such as childbirth, abortion, and malnutrition
Prognosis:
The mortality rate of severe sepsis and septic shock is frequently quoted as anywhere from 20% to 50%. In some studies, the mortality rate specifically caused by the septic episode itself is
specified and is 14.3-20%. Mortality varies depending on the degree of illness.
The following clinical characteristics are related to the severity of sepsis:
An abnormal host response to infection

Site and type of infection
Timing and type of antimicrobial therapy
Offending organism
Development of shock
Any underlying disease
Patients long-term health condition
Location of the patient at the time of septic shock
CARDIOPULMONARY ARREST
Cardiac arrest is a condition in which the heart has stopped beating or is not beating efficiently enough to sustain life. Cardiac arrest, also called sudden cardiac arrest, is rapidly fatal within
minutes if not immediately treated with CPR, defibrillation, and advanced life support measures.
Causes:
certain serious cardiac arrhythmias

ventricular fibrillation, an ineffective, disorganized attempt of the ventricles to beat
extreme slowing of the heartbeat (bradycardia)
obstruction of electrical impulses in the heart (heart block)
cardiac asystole (a stoppage of any activity in the heart)
can also be caused by drowning, electrocution, respiratory arrest, choking, trauma
by certain conditions that cause electrical abnormalities in the heart, such as long QT syndrome and Wolff-Parkinson-White syndrome.
Risk Factors:
This can happen in any age group or population, but people most at risk include:
those who have a history of coronary artery disease

and/or a history of a previous heart attack.
cardiovascular disease, congenital heart defects, electrolyte imbalance, smoking, diabetes, obesity, and recreational drug use, such as cocaine and methamphetamine.
Symptoms:
loss of consciousness
Loss of pulses.
Death can occur within minutes if CPR and defibrillation are not initiated immediately and advanced life support measures are not started rapidly thereafter.
II.
BIOGRAPHICAL DATA
Gordons Functional Health Pattern

Demographic Data
Name: MR. A
Nationality: Filipino
Age/Sex: 53yrs old/male
Educational Level: College Graduate
Address: Brgy. San Isidro, Ormoc City
Civil Status: Married
Birthdate: December 27,1959
Religion: Roman Catholic
Birthplace: Ormoc City
Occupation: Government Employee
Source of Data
A. Primary
-- Patient
B. Secondary
--MS. AA, 20y/o, daughter
C. Tertiary
--Patients Chart
Reasons for seeking health care
*Chief Complaints: Decreased bowel movement with fever, cough and coryza
Admitted at OSPA-FMC, Mr. A, a 53y/o male patient from Brgy. San Isidro, Ormoc City, on February 24,2013 at 2:15pm.
Past Health History
The patient didnt have problems at birth or any congenital diseases. He never suffered any serious illness or has undergone any surgical operation.
No significant accidents or injuries happened. He has no known allergies to food or drugs. He doesnt smoke or even drink any alcoholic beverages.
Family History
The patient has 4 children, three of them are girls, and 1 is a boy, all are living in good health. Among his siblings, he is the youngest. His older
brother died having diagnosed with Pneumonia.
Before Hospitalization
During Hospitalization
Health Perception and Health Management

The patient rated himself with a rate scale of 6 in which 1 is the lowest and 10 is the highest. He claimed that health is really valuable to him as a father.
Eating the right kind of food, exercising, and managing stress are his ways to keep himself healthy.
He defined healthy as a state wherein an individual who is able to do his ADLs. he also stated that his current condition maybe due to his eating
habits (admitted that he likes eating salty and fatty foods).
Nutritional and Metabolic Pattern
Before Hospitalization:
***24-Hour Diet Recall
Breakfast (7:00am)
1 cup of rice
1pc egg
3pcs hotdog
1 glass of water
Lunch (12:00nn)
2 cups of rice
2 pcs fish
1 cup of vegetable soup
500ml of soft drink
Snack (4:00pm)
2 pcs banana cue
1 glass of soft drink
Dinner (7:30pm)
2 cups of rice
2 sticks of pork barbeque
2 glasses of water
The patient was under NPO (nothing per orem).
The patient has a good appetite and sometimes takes multivitamins.

He verbalized that he doesnt have any problem on chewing or swallowing.
He admitted that he sometimes experiences abdominal pain.
Bladder Elimination Pattern
Clients typical voiding pattern averages from 4-5 times per day with a
The patient was catheterized. Because he was under NPO, his urine output
yellowish colored urine amounting to about 1000-1500ml. The patient
was lesser. Approximately about 500-800ml per day.
claimed that his output balances his approximate daily fluid intake. He
didnt notice any abnormalities or problem regarding his urination. No
complains of incontinence or hesitancy. The patient doesnt use any
diuretics.
Bowel Elimination Pattern
A month before the patients colonic mass was found out and being Since the time of his admission up to the time he was transferred to ICU, the
diagnosed of having a colon cancer, he claimed that he usually defecates 4- patient wasnt able to defecate.
5 times weekly. On the month of January, the patient started to feel
abdominal pain, and noticed of having difficulty in defecating and started
taking laxatives.
Sleep-Rest Pattern
He has an average of 8-10 hours of sleep per day. Usually sleeps at around His hospital stay altered his usual sleeping pattern. He already had difficulty
9 or 10 oclock in the evening, and rises at 6:00 am. His weekend sleep in falling asleep because he admitted that he was already anxious of what
pattern doesnt differ from his weekdays. He never had any difficulty in was happening to him and he was now more concerned of his health. He
claimed of having nighttime awakenings, about 3-4 times.
sleeping or in falling asleep. However, he has his rituals in taking a bath
before retiring to make himself more comfortable and this helps promote
sleep.
Activity and Exercise Pattern
Clients usual day starts at 6 in the morning. Upon waking up, he helps
Client was confined to bed with no toilet privileges.
prepare their breakfast. Sometimes, he gets to stroll at their neighborhood.
His daily routine at home serves as his exercise.
Self-Perception and Self-Concept Pattern
The client perceived himself as a normal person contented in his role as a father and a partner. He speaks in moderate tone and maintains a good eye
contact which signifies self-confidence. He considers his family as his strength. In relation to this, he does his very best to be a good father and a husband
to make his family strong despite any circumstances or problems that come.
Roles and Relationship Pattern
Being a father, his major responsibility is to take care of his children and He claimed that his confinement affected his role as a father because he can
provide them their needs. He claimed to have a good relationship with his no longer attend to the needs of his family.
neighbors and participate in any social groups or neighborhood activities.
He and his wife belong to a religious group, Couples for Christ. He is
contented with his role as a father and a husband.
Coping and Stress Tolerance Pattern
According to the patient, getting sick is very stressful. His hospital stay greatly affects his family since he can no longer attend to the needs of his family
and activities at home will be restricted. He also considers financial matter as a stressor. Talking to his family, praying to God, and trying to solve the
problem, and sometimes seeking help from others are his ways to relieve tension and deal with the stress.
Sexuality- Reproductive Pattern
The patient was circumcised when he was 8 years old. He claimed that he had his first sexual contact at the age of 20. He uses condom as his method of
contraception. He has no problem regarding his sexual activity or satisfaction.
Value and Belief Pattern
According to the patient, the most important source of his strength is his family and God. He and his wife are members of the Couples for Christ religious
affiliation.
III.
PHYSICAL EXAMINATION
Patients Progress
APPEARANCE: received per wheelchair, awake, conscious, responsive, coherent, afebrile with the following vital signs: BP= 130/70 mmhg, PR= 80 bpm. RR= 22 cpm, T=
37.7C/axilla
On February 24, 2013 at 2:19pm, patient was admitted to OSPA-FMC under the service of Dr. N.Aviles for complaints of changes in bowel habits noted 1 month prior to
admission, along with cough and fever still 1 month prior to admission. Patient was advised for possible OR hence this admission. AP instructed health personnel of the
following: TPR q 4H, Full low salt diet. Laboratory tests done: CBC, platelet count, blood typing, Creatinine, RBS, Na+, K+, U/A MSCC, Stool exam, ECG 12-leads, CXR-PA
view, with labs taken as outpatient to be attached. AP also ordered for co management with Dr. R. Tomaro for pre-op meds and surgery schedule, Dr. Arevalo for CP
clearance after 2D-Echo. Medications prescribed were Irbesartan (Aprovel) 150mg/tab 1 tab OD (8am),
Levocetirizine + Montelukast (Zykast) 10/5mg 1 tab OD q HS (9pm)
Assessment Day
Date performed: February 26, 2013
11pm> examined sitting on bed, awake, conscious, responsive, coherent, afebrile with IVF bottle 4 D5LR 1L @ 30 gtts/min infusing well @ Right arm,
with the following V/S: BP= 130/70 mmHg, HR= 80 bpm, RR= 22 cpm, T= 37.7 0C
GENERAL MEASUREMENTS:
Height: 150.5cm or 59 inches
Weight: 93 kg
Ideal Body Weight ( IBW) = 45kg
IBW kg= (height cm 100) X10%
BMI= 40.9
BMI= weight kg / height m2
BODY MASS INDEX BASED ON ASIA-PACIFIC OBESITY GUIDELINES
Underweight < 18.5
Healthy
18.6 - 22.9
Overweight > 23.0
At risk
23 24.9
Obese I
25 29.9
Obese II
> 30
(Source: PPDs Compendium of Philippine Medicine 8th Ed. Pasig City Philippines: MEDICOMM PACIFIC INC., 2006. p.192)
SKIN AND NAILS:

Warm, smooth, no rashes noted, good turgor mobility, light brown complexion, no lesions, no scars, no cyanosis, no jaundice, no nail clubbing, CRT< 2
seconds, pinkish nail beds
HEAD:
Symmetric, round, hard, smooth without lesions or lumps noted, no swelling, tenderness, or crepitation noted with movement on temporomandibular
joints, mouth fully opens and closes, symmetrical facial features, hair is unevenly distributed, receding hairline, straight and black hair, no flaking or lice
infestation in the hair.
EYES:
Eyeballs are symmetrical, pinkish palpebral conjunctivae, no discharges, thick and evenly distributed eyebrows, equally distributed eyelashes, no scaling,
no swelling of lacrimal apparatus, no lesions or any foreign bodies in the palpebral conjunctiva, no unusual discharges, lens is clear; round, uniform, dark
brown colored iris, (+) PERRLA(constrict upon illumination, converge, the other pupil constricts as the opposite pupil is illuminated), (+) cardinal gaze,
reduced peripheral vision, eyeballs are symmetrical , (+) CORNEAL REFLEX (the reflection or the light strike at the same point within the eyes; patient as
able to read nurses ID at 2 ft. distance (Nikki Sia)
EARS AND HEARING:
Ears are equal in size bilaterally, the auricles have the same color with facial skin, pinna in line with outer canthus of the eyes and no tenderness noted
upon palpation. Small amount of cerumen present. No lesions and swellings noted. No difficulty in hearing normal spoken words at about 2 feet distance,
no tenderness upon palpation

NOSE AND SINUSES:
Nose is located in the midline of the face, nasal septum at the midline, clear frontal and maxillary sinuses on transillumination, no abnormal discharges
MOUTH AND THROAT:
Pinkish and moist lips, symmetrical contour. Patient is able to purse lips without difficulty. Pinkish oral mucosa noted. Tongue is pink in color, moist, slightly rough,
no lesions, moves freely, no tenderness, uvula is positioned at midline, tonsils not inflamed, (+) gag reflex.
NECK:
ROM is full and controlled, trachea is at midline, no engorged vesicles noted, non-palpable lymph nodes.
THORAX AND LUNGS:
no lesions, no warts, skin color is the same as the rest of the body, equal chest expansion, scapulae symmetric and non-protruding; sternum is at midline;
ribs slope downward with symmetric intercostal space; retractions and bulging not noted; no tenderness, pain, nor unusual sensations reported;
temperature equal bilaterally; harsh breath sounds noted, (+)rhonchi
HEART:
S1 distinct, S2 distinct, regular rhythm, no murmurs, normal rate = 80 bpm
PERIPHERAL VASCULATURE:
CRT < 2 seconds, no arm edema noted, with IVF bottle 4 D5LR @ 30 gtts/min infusing well @ Right arm
Peripheral Pulses Rate (L & R) Strength
Carotid
83
+3
Brachial
80
+2
Radial
80
+2
P tibialis
80
+2
Strength Grading
0 absent
+1 weak
+2 normal
+3 full, firm
+4 bounding
BREAST AND AXILLA:
(-) Gynecomastia , non-palpable axillary lymph nodes, areola brown in color,
ABDOMEN:
Abdomen is globular without lumps or bulges. Normoactive bowel sounds (12-15 clicks/minute) on all quadrants. Generally tympanic, umbilicus at
midline, Dull abdominal pain noted but patient claimed it as tolerable.
BACK:
No scars, no lesions, no masses and no tenderness noted.
EXTREMITIES:
no scars or lesions, same color with the rest of the body, (+) ROM no limitations of movements, strong peripheral pulses, CRT< 2 secs, pinkish nailbeds ,
no lesions
MUSCULOSKELETAL:
Able to maintain flexion against resistance without pain, coordinated movements, good muscle tone, no joint swelling
MUSCLE STRENGTH:
5/5
5/5
5/5
5/5
SCALES FOR GRADING MUSCLE STRENGTH:
5 ACTIVE MOTION AGAINST FULL RESISTANCE
4 ACTIVE MOTION AGAINST SOME RESISTANCE
3 ACTIVE MOTION AGAINST GRAVITY
2 PASSIVE ROM
1 SLIGHT FLICKER OF CONTRACTION
0 NO MUSCULAR CONTRACTION
GENITALIA:
Grossly male and claims of having no lesions and discharges upon assessment.
Neurologic Assessment
NEUROLOGIC ASSESSMENT:
MENTAL STATUS:
Awake, alert, oriented to place(able to recognize that he is in the hospital, person around him(able to identify his wife as his S.O) and time(able to say
that its already night time), clothes appropriate for weather, good eye contact, speaks spontaneously, follows directions accurately, able to recall his
birthday- (remote memory), able to state the date of today- February 26, 2013 (current memory).
MOTOR-CEREBRAL FUNCTION:
(+) rapid alternating movements, (+) finger-thumb test, (+) finger-nose test, (+) button-unbutton shirt and open-close zipper, able to rapidly turn palm up
and down, tandem and Romberg test were not assessed since the patient was lying in bed.
SENSORY:
(+) STEREOGNOSIS: able to identify ballpen with eyes closed
(+) GRAPHESTHESIA: able to identify number 7 when drawn on palm with eyes closed
(+) KINESTHESIA: able to identify the direction wherein the nurse lifted the patients hands with eyes closed.
(+)TEMPERATURE SENSATION: correctly identifies between hot and cold temperature over various body parts
CRANIAL NERVE TESTING:

I Olfactory (Sensory): able to smell oranges provided by SO
II Optic (Sensory): was able to read nurses name printed on ID at 2 ft distanceIII Oculomotor (Motor): equal eye movement, (+)PERRLA, full peripheral
vision, (+)cardinal gaze
IV Trochlear (Motor): (+) PERRLA, (+)cardinal gaze
V Trigeminal (Sensory And Motor): strong muscle of mastication, (+) blink reflex, can open and close mouth
VI Abducens (Motor): (+) cardinal gaze
VII Facial (Sensory): able to feel light touch on face, able to taste oranges
(Motor): able to close eyes, smile, frown, raise eyebrows, wrinkle forehead, able to clench jaw from side to side
VIII Acoustic or Vestibulocochlear (Sensory): able to hear whisper words at 5 inches distance, can hear watch ticking at 2 inch distance,
IX Glossopharyngeal (Sensory): (+) gag reflex, able to taste oranges, (Motor): able to swallow
X Vagus (Sensory): (+) gag reflex, (motor): able to swallow
XI Spinal accessory (Motor): able to shrug shoulders against resistance, able to turn head from side to side
XII Hypoglossal (Motor): tongue located @ midline, able to move tongue from side to side & can stick out
Deep Tendon Reflexes:
LEFT: (+2) biceps reflex, (+2) triceps reflex, (+2) brachioradialis reflex, (+2)
RIGHT: (+2) biceps reflex, (+2) triceps reflex, (+2) brachioradialis reflex, (+2)
SCALE FOR GRADING REFLEX RESPONSES:
0 No Reflex Response
+1 Minimal Activity
+2 Normal Response
+3 More Active than Normal
+4 Maximal Activity (Hyperactive)
Post-op Assessment
Post-op Assessment
Date
Performed:
February 28, 2013
11pm> examined lying
on
bed,
awake,
conscious, responsive,
coherent, afebrile,with
NGT open to drain,
with 02 inhalation at
3LPM via nasal cannula,
Date
Performed:
March 1, 2013
6pm> examined lying
on
bed,
awake,
conscious,
coherent,
responsive, with NGT
open to drain, with
Oxygen inhalation at
6LPM via nasal cannula,
ICU Assessment Day

1
Date
Performed:
March 2, 2013
11pm> examined lying
on
bed,
awake,
conscious, responsive,
coherent, afebrile, with
NGT open to drain, with
Oxygen inhalation via
face mask at 10LPM,
ICU Assessment
ICU Assessment
ICU Assessment
Date
Performed:
March 4, 2013
12am> examined lying
on
bed,
asleep,
afebrile, on high back
rest, with NGT open to
drain, with Oxygen
inhalation via nasal
cannula at 5LPM, with
Date
Performed:
March 7, 2013
4pm> examined lying
on bed, unconscious,
febrile with skin warm
to touch, with NGT open
to
drain
,
with
Endotracheal
tube
attached to mechanical
Date
Performed:
March 8, 2013
4pm> examined lying
on bed, unconscious,
and unresponsive to
painful stimuli, febrile
with skin warm to
touch, with NGT open to
drain
,
with
with IVF bottle 3 D5LR

1L + Biomix + D50W
50cc
@
20cc/hr
infusing well @ Right
arm, with Piggyback1
Celemin Plus at 20cc/hr.
With Kabiven drip 1000
cal/1400cc at 80 cc/hr
infusing well at
Left
arm via infusion mat,
with FBC-UB draining
tea colored urine, with
the following V/S: BP=
110/60 mmHg, HR= 82
bpm, RR= 24cpm, T=
36.90C
with Isoket drip (Isoket

10mg/amp) in 90cc
D5W at 10cc/hr via
infusion mat infusing
well @Right arm, #2
Kabiven
1000
cal/1400cc
@80cc/hr
via
infusion
pump
infusing
well
@Left
arm,
with
FBC-UB
draining tea colored
urine,
with
the
following
V/S:
BP=180/100
mmHg,
HR=
143
bpm,
RR=36cpm, O2 Sat @
91%, T= 39.50C
NOSE AND SINUSES:

With Oxygen inhalation
at 3LPM via nasal
cannula, RR at 24cpm
NOSE AND SINUSES:

at 6LPM via nasal
cannula, RR at 36cpm
PERIPHERAL
VASCULATURE: CRT <
2 seconds, no arm
edema noted
THORAX AND LUNGS:

harsh breath sounds
still noted, (+)rhonchi,
wheezes on both lung
fields upon auscultation
THORAX AND LUNGS:

harsh breath sounds
still noted, (+)rhonchi
ABDOMEN:
Globular abdomen, with
abdominal
binder,
ABDOMEN:
Globular abdomen, with
abdominal
binder,
abdominal pain at the
right side aggravated
by
movement
and
relieved by lying down
with Isoket drip at

10cc/hr infusing well @
Right arm, Kabiven drip
at 50cc/hour @Left arm
via infusion mat, with
FBC-UB draining teacolored urine, with the
following
V/S:
BP=
100/70 mmHg, HR= 94
bpm, RR= 20 cpm, T=
35.90C, SpO2= 100%
Isoket drip at 8cc/hr

infusing well @ Right
arm, Kabiven drip at
70cc/hour @Left arm
via infusion mat, with
FBC-UB draining teacolored urine, with the
following
V/S:
BP=
130/90 mmHg, HR= 90
bpm, RR= 19 cpm, T=
36.00C, SpO2= 100%
SKIN
AND
NAILS:
Poor skin turgor noted,
pale nail beds noted
SKIN AND NAILS:

Poor skin turgor noted,
pale nail beds noted
NOSE AND SINUSES:

at 10LPM via facemask,
shortness of breath
noted
HEAD:
noted
THORAX AND LUNGS:

harsh breath sounds
ABDOMEN:
Globular
abdomen,
hypoactive
bowel
sounds,
percussed
abdominal
dullness,
with
post-op
site,
abdominal
pain
aggravated
by
headache
NOSE AND SINUSES:

at 5LPM via nasal
cannula
THORAX
AND
LUNGS:
harsh breath sounds
fields
upon
auscultation
ABDOMEN:
Globular
abdomen,
hypoactive
bowel
sounds,
percussed
ventilator
with
the
following
settings:
TV=500ml, FiO2=60%
BUR= 14cpm,
with
ongoing #2 D5NSS 1L
@ 10gtts/min infusing
well @ Right arm, #5
Kabiven
1000cal/1400cc
at
40cc/hour at Left arm,
#1 D5W 242cc + 8cc
Levophed@15cc/hour
@Left foot with FBC-UB
without urine output,
with the following V/S:
BP= 80/60 mmHg, HR=
118 bpm, RR= 25 cpm,
T=
39.80C,
SpO2=
100%
EYES: Pale palpebral
conjunctivae, pupils size
3, sluggish reaction to
light
SKIN AND NAILS: Poor
skin turgor noted, pale
nail beds noted, CRT 3
secs
THORAX AND LUNGS:
harsh breath sounds
Endotracheal
tube
attached to mechanical
ventilator
with
the
following
settings:
TV=500ml, FiO2=100%
BUR= 12cpm,
with
ongoing #4 D5NSS 1L
@ 10gtts/min infusing
well,
PB: #4 Levophed 2
amps
+242cc
D5W
@30cc/hr via infusion
mat
#1 Dopamine 400/250
@20cc/hr via infusion
mat,
#1 D5W 250cc +
Dobine
2
amps
@10cc/hour
With
Kabiven
drip
1000cal/1400cc
at
20cc/hr, with FBC-UB
without
any
urine
output noted, with the
following
V/S:
BP=
60/40 mmHg, HR= 132
bpm, RR= 16 cpm, T=
40.70C/axilla,
SpO2=
NO reading, GCS=3
(E1M1V1)
EYES: Pale palpebral
conjunctivae,
pupils
nonreactive to light and
accomodation
abdominal pain at the

right side aggravated
by
movement
and
relieved by lying down
with a pain scale of
8/10, (with 10 as the
highest
and
1
as
lowest), with an incision
from operation covered
with gauze, intact and
dry.

highest
and
1
as
dry.
MUSCLE STRENGTH:
4/5 4/5
3/5 3/5
MUSCLE STRENGTH:
4/5 4/5
3/5 3/5
movement and relieved

by immobility and DBE
highest
and
1
as
dry.
EXTREMITIES: CRT< 2
secs, no lesions,
MUSCLE STRENGTH:
4/5
4/5
3/5
3/5
abdominal
dullness,
with
post-op
site,
abdominal
pain
aggravated
by
movement
and
relieved by immobility
and DBE with a pain
scale of 3/10, (with 10
as the highest and 1 as
lowest),
with
an
incision from operation
covered with gauze,
intact and dry.
EXTREMITIES:
CRT<
3secs, no lesions, non
pitting edema on all
extremities
MUSCLE STRENGTH:
1/5
1/5
0/5
0/5
MUSCLE STRENGTH:
4/5
4/5
3/5
3/5
PERIPHERAL
VASCULATURE:
Weak pulses noted
SKIN AND NAILS: Poor
skin turgor noted, pale
nail beds noted, CRT 3
secs
THORAX AND LUNGS:
harsh breath sounds
wheezes on both long
EXTREMITIES:
CRT3
secs, no lesions, non
pitting edema on all
extremities
MUSCLE STRENGTH:
0/5
0/5
0/5
0/5
IV.
PERTINENT LABORATORY TESTS/ DIAGNOSTIC EXAMINATION RESULTS
I. COMPLETE BLOOD COUNT

Purpose: The CBC provides valuable information about the blood and to some extent the bone marrow, which is the blood-forming tissue. The CBC is also used as a
preoperative test to ensure both adequate oxygen carrying capacity and hemostasis. Also this is used to identify persons who may have an infection, to diagnose anemia,
to identify acute and chronic illness, bleeding tendencies, and white blood cell disorders such as leukemia, to monitor treatment for anemia and other blood diseases, and
to determine the effects of chemotherapy and radiation therapy on blood cell production.
DIFFERENTIAL COUNT
Purpose: gives relative percentage of each type of white blood cell and also helps reveal abnormal white blood cell populations (eg, blasts, immature granulocytes, or
circulating lymphoma cells in the peripheral blood).
COMPLETE
PERPETUAL SUCCOUR HOSPITAL - OPD
Date:
February
16,
Physician: Dr. Hans Potot
Test Name
Result
White Blood Cell
8.39
Neutrophils
59
Lymphocytes
24
Monocytes
11
Eosinophils
5
Basophils
1
Hemoglobin
11.0
Hematocrit
33.0
Red blood cell
4.7
Mean
Corpuscular
66.1
Volume
Mean Corpuscular Hgb
18.9
Mean Corpuscular Hgb
29
Conc.
Red Cell Distribution
23.0
Width
Platelet Count
403
Mean Platelet Volume
3.97
BLOOD
COUNT
2013
07:44
AM
Units
x 10^9/L
%
%
%
%
%
g/dL
%
10^12/L
fL
Reference Range
4.10 10.9
47.0 80.0
13.0 40.0
2.00 11.0
0.00 5.00
0.00 2.00
13.5 17.5
41.0 53.0
4.50 5.90
80.0 100.0
pg
g/L
26.0 34.0
31.0 36.0
11.6 14.8
x 10^9/L
fL
140.0 440.0
0.00 100.0
Implication:
HCT If the HCT level is lower than normal, this may indicate presence of anemia. Anemia causes fatigue and weakness which are the symptoms manifested by
the patient. Anemia has many causes, including low levels of certain vitamins or iron, blood loss, or an underlying condition.
MCH, MCHC, RDW and MCV MCV and MCH blood test results should always be studied together for proper prognosis. Increase or decrease in both MCV and
MCH levels are used to determine vitamin B6 or mineral (copper or iron) deficiencies and/or excess B12 and folic acid. With MCHC blood test (also known as an MCH
test), it is conducted to test a person for anemia. If there is a low count of MCHC, it indicates anemia. A specific type of Anemia, Iron Deficiency Anemia, presents a
high RDW and low MCV which is evident on the patients results.
TAKEN @ OSPA - FMC
NORMAL
VALUES/
UNIT
TESTS
2/24
2/25
2/26
COMPLET
E BLOOD
COUNT
5.010.0x10^
9/L male
5.010.0x10
female
4.66.2x10^1
2/L male
4.25.4x10^1
2/L female
12.017.0g/dL
male
11.015.0g/dL
female
40.054.0%
male
37.047.0%
female
80.0-96.0
fl
27.0-31.0
pg
32.0-36.0
g/dL
2/28
2/28
3/3
8:18A
8:26A
8:08A
3/4
3/5
3/6
3/7
3/7
WBC
11.2
9.8
8.9
17.2
17.6
10.2
11.7
13.7
16.2
14.5
14.3
RBC
4.33
4.30
4.59
4.63
4.89
4.17
5.14
5.48
4.60
4.88
HGB
10.6
9.7
11.0
10.8
11.8
9.3
11.5
13.6
14.5
11.6
11.4
HCT
32.0
30.0
33.0
33.7
36.0
30
38
40.8
43.5
35.0
35.0
MCV
69.5
69.7
71.0
72.8
72.8
73.4
74.9
74.5
72.5
70.4
MHC
19.9
22.0
20.7
23.1
21.9
21.8
22.4
22.3
22.0
22.3
MCHC
28.6
32.0
29.1
31.7
30.1
29.7
29.9
29.9
30.3
31.5
11.0-16.0
%
150450x10^9
/L
RDW
25.81
25.71
26.51
25.91
25.91
25.71
25.61
26.31
27.11
PLT
563
572
546
485
488
289
255
340
308
303
354
DIFFERE
NTIAL
COUNT
Neutrophil
64.9
68.2
67.2
86.2
88.7
87.4
84.2
78.7
88.5
88.0
85.4
20.1
14.5
16.9
5.9
4.1
5.3
6.8
14.9
4.6
6.3
8.5
07%
Lymphocyt
es
Monocyte
11.8
13.0
11.7
7.7
6.0
7.1
7.5
6.2
6.7
5.4
5.9
16%
Eosinophil
2.9
4.1
3.8
0.1
1.1
0.2
1.3
0.1
0.1
0.0
0.1
02%
Basophil
0.3
0.2
0.4
0.1
0.1
0.0
0.2
0.1
0.1
0.1
0.1
50 70%
20 40 %
27.41
Implication:
RBC, HGB and HCT - The results of red blood cell count, hemoglobin and hematocrit are related because they each measure aspects of your red blood cells. If the
measures in these three areas are lower than normal, this may indicate presence of anemia. Anemia causes fatigue and weakness which are the symptoms
manifested by the patient. Anemia has many causes, including low levels of certain vitamins or iron, blood loss, or an underlying condition. Looking at another
perspective with regards to the patient experiencing septic shock, hemoglobin concentration dictates oxygen-carrying capacity in blood, which is crucial in shock to
maintain adequate tissue perfusion. The goal is to maintain a hematocrit level greater than 30% and a hemoglobin concentration higher than 10 g/dL. As with the
patient, he has not sustained a HCT level greater than 30% and haemoglobin concentration higher than 10g/dL especially on dates 2/25 and 3/3. These results can
be considered one of the factors that predispose the patient to experience septic shock.
MCH, MCHC, RDW and MCV MCV and MCH blood test results should always be studied together for proper prognosis. Increase or decrease in both MCV and
MCH levels are used to determine vitamin B6 or mineral (copper or iron) deficiencies and/or excess B12 and folic acid. With MCHC blood test (also known as an MCH
test), it is conducted to test a person for anemia. If there is a low count of MCHC, it indicates anemia. A specific type of Anemia, Iron Deficiency Anemia, presents a
high RDW and low MCV which is evident on the patients results.
PLT - Platelets, an acute-phase reactant, usually increase at the onset of any serious stress and are typically elevated in the setting of inflammation.
WBC, NEU - WBCs are crucial to body defense against disease. In this case, the increase in WBC is caused by the increase in of its type, the neutrophils.
Neutrophils increase in number in the presence of an inflammation.
LYM and MONO - Lymphocytes are divided into T cells and B cells; T cells are involved in immune reactions; B cells are involved in antibody production.
Monocytes are similar to neutrophils, but they are produced very quickly and live longer. Low lymphocyte and monocyte levels may indicate severe infection,
inherited bone marrow disease, autoimmune disease, poor nutrition, non-functioning bone marrow, chemotherapy, or excessively high levels of some medications.
II. TROPONIN TEST

Purpose: measures the levels of certain proteins called troponin T and troponin I in the blood. These proteins are released when the heart muscle has been
damaged, such as a heart attack. The more damage there is to the heart, the greater the amount of troponin T and I there will be in the blood. T he most common reason to
perform this test is to determine if chest pain is due to a heart attack. Your doctor will order this test if you have chest pain and signs of a heart attack. The test is usually
repeated two more times over the next 12 to 16 hours.
NORMAL VALUES
SI UNITS
CONVENTIONAL
Ug
0.0 0.01 ug/l
TEST
March 1,
2013
March 2,
2013
Troponin I
<0.01
(negative)
<0.01
(negative)
Implication: The results taken are within the normal range
III. URINALYSIS
Purpose: Urinalysis are usually used to as a general health screening test to detect renal and metabolic diseases, diagnosis of diseases or disorders of the kidneys or
urinary tract monitoring of patients with diabetes. In addition, quantitative urinalysis tests may be performed to help diagnose many specific disorders, such as endocrine
diseases, bladder cancer, osteoporosis, and porphyries(a group of disorders caused by chemical imbalance.
January 22, 2013 @ 8:23:58 AM

Microscopic Examination
Color
Transparency
Yellow
Slightly turbid
Chemical Examination
pH
Specific gravity
Leukocytes
Blood
Sugar
Nitrite
Protein
Urobilinogen
Ketone
Bilirubin
5.0
1.025
Negative
Negative
Negative
Negative
1+
Negative
Negative
Negative
Pus cells
Red cells
Epithelial cells
Bacteria
Cast
Microscopic / Urine Flowcytometry

International System
Conventional
Results
Reference Range
Results
Reference Range
11.6
0-11/uL
2.1
0-2/HPF
9.2
0-11/uL
1.7
0-2/HPF
9.4
0-11/uL
1.7
0-2/HPF
1.9
0-111/uL
0.3
0-20/HPF
0.1
0-1/uL
0.3
0-3/LPF
Implication:
Slightly turbid - Normal urine can be clear or cloudy. Substances that cause cloudiness but that are not considered unhealthy include mucus, sperm and prostatic
fluid, cells from the skin, normal urine crystals, and contaminants such as body lotions and powders. Other substances that can make urine cloudy, like red blood
cells, white blood cells, or bacteria, indicate a condition that requires attention. Urine color and clarity can be a sign of what substances may be present in urine.
However, confirmation of suspected substances is obtained during the chemical and microscopic examinations.
Protein 1+ - Normally protein is not present in urine. It is common in renal disease because damage to glomeruli or tubules allows protein to enter urine.
Pus cells 11.6/uL - The presence of pus cells in the urine is medically termed as Pyuria and is a common symptom in a number of medical conditions. Probably the
most common occurrence of pyuria can be attributed to the existence of a urinary tract infection.
MACROSCOPIC
Color
Transparency
pH
Specific gravity
Protein
Glucose
Blood
Nitrite
Bilirubin
Urobilinogen
Ketone
Leukocyte
MICROSCOPIC
Red cells
Pus cells
Epithelial cells
Amorphous urates
Bacteria
Mucus threads
February 24, 2013
February 28, 2013
Light yellow
Clear
5.0
1.015
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Dark yellow
Slightly turbid
6.5
1.015
2+
Negative
1+
Negative
Negative
Negative
1+
Trace
0.2/HPF
0.1/HPF
0.1/HPF
41.3/uL
16.6/uL
4.6/uL
0.1/HPF
0.8/uL
Crystals
Casts
0.0/HPF
0.9/uL
Implication:
Leukocytes in urine - Leukocytes are white blood cells (WBC) that work with the immune system to defend against infectious disease. Damage to the kidneys,
ureters, urethra or bladder can cause leukocytes to appear. The body expels excess leukocytes when they have become damaged or killed fighting off an infection,
causing them to be expelled in the urine. A small number of leukocytes will always be found in the urine as old cells are passed from the system. If a high number of
leukocytes are found in the urine, this is a sign that there may be an infection in the urinary system. A consistent high level of leukocytes in the urine can also
negatively affect the bladder or kidneys.
Blood and increase amount of Red cells in urine - Blood in urine can come from any condition that results in infection, inflammation, or injury to the urinary
system. Typically, microscopic hematuria indicates damage to the upper urinary tract (kidneys), while visible blood indicates damage to the lower tract (ureters,
bladder, or urethra).
Presence of Ketones in urine - In nondiabetic persons, ketonuria may occur during acute illness or severe stress. Approximately 15% of hospitalized patients
may have ketonuria, even though they do not have diabetes. In a diabetic patient, ketone bodies in the urine suggest that the patient is not adequately controlled
and that adjustments of medication, diet, or both should be made promptly. In the nondiabetic patient, ketonuria reflects a reduced carbohydrate metabolism and
an increased fat metabolism.
Pus cells 16.6/uL - The presence of pus cells in the urine is medically termed as Pyuria and is a common symptom in a number of medical conditions. Probably the
March 4, 2013 @ 9:27:42PM

Microscopic Examination
Color
Transparency
Dark yellow
Slightly turbid
Chemical Examination
pH
Specific gravity
Leukocytes
Blood
Sugar
Nitrite
Protein
5.5
1.020
Trace
2+
Negative
Negative
1+
Urobilinogen
Ketone
Bilirubin
Pus cells
Red cells
Epithelial cells
Bacteria
Cast
Negative
1+
Negative
Microscopic / Urine Flowcytometry

International System
Conventional
Results
Reference Range
Results
Reference Range
29.7
0-11/uL
5.3
0-2/HPF
119.8
0-11/uL
21.6
0-2/HPF
19.6
0-11/uL
3.5
0-2/HPF
2.8
0-111/uL
0.5
0-20/HPF
0.1
0-1/uL
0.3
0-3/LPF
Implication:
Leukocytes in urine - Leukocytes are white blood cells (WBC) that work with the immune system to defend against infectious disease. Damage to the kidneys,
ureters, urethra or bladder can cause leukocytes to appear. The body expels excess leukocytes when they have become damaged or killed fighting off an infection,
causing them to be expelled in the urine. A small number of leukocytes will always be found in the urine as old cells are passed from the system. If a high number of
leukocytes are found in the urine, this is a sign that there may be an infection in the urinary system. A consistent high level of leukocytes in the urine can also
negatively affect the bladder or kidneys.
Blood and Red cells 119.8/uL in urine - Blood in urine can come from any condition that results in infection, inflammation, or injury to the urinary system.
Typically, microscopic hematuria indicates damage to the upper urinary tract (kidneys), while visible blood indicates damage to the lower tract (ureters, bladder, or
urethra).
Presence of Ketones in urine - In nondiabetic persons, ketonuria may occur during acute illness or severe stress. Approximately 15% of hospitalized patients
may have ketonuria, even though they do not have diabetes. In a diabetic patient, ketone bodies in the urine suggest that the patient is not adequately controlled
and that adjustments of medication, diet, or both should be made promptly. In the nondiabetic patient, ketonuria reflects a reduced carbohydrate metabolism and
an increased fat metabolism.
Pus cells 29.7/uL- The presence of pus cells in the urine is medically termed as Pyuria and is a common symptom in a number of medical conditions. Probably the
Epithelial cells in urine 19.6/uL - Transitional epithelial cells line the urethra and bladder. In a person with an active inflammation, more cells may be shed as a
result of irritation. Likewise, injuries can cause an increase in transitional epithelial cells. Paired with findings like blood in the urine and bacteria, they can be a sign
of an infection.
IV. STOOL EXAMINATION

Purpose: Stool specimen collection is the process of obtaining a sample of a patient's feces for diagnostic purposes. This procedure is used to test for infectious organisms,
mucus, fat, parasites, or blood in the stool.
February 25, 2013

MACROSCOPIC
Color
Consistency
Mucus
Blood
Adult Parasite
Black
Mushy
MICROSCOPIC
Red blood cells

Pus cells
Ova of Parasites
Amoebic Troph
Starch granules
Fat globules
Vegetable cells
Occult blood
0-2/HPF
0-1/HPF
None seen
Some
-
is
(GI)
first
like
juices as it passes through the intestines.
Implication: Black stool usually means that the blood

coming from the upper part of the gastrointestinal
tract. This includes the esophagus, stomach, and the
part of the small intestine. Blood will typically look
tar after it has been exposed to the body's digestive
V. BLOOD CHEMISTRY
Purpose: A test to assess a wide range of conditions and the function of organs. Often, blood tests check electrolytes, the minerals that help keep the body's fluid levels in
balance, and are necessary to help the muscles, heart, and other organs work properly. To assess kidney function and blood sugar, blood tests measure other substances.
SI UNITS
NORMAL VALUES
CONVENTIONAL
TESTS
mmol/L
Men 53-97/ Women

44-80
Creatinine
u/l
Men 80-306/ Women

64-306
Alkaline
Phosphate
Up to 220
Amylase
2/24
103.89
2/28
3/1
90.22
3/2
3/3
3/4
124.95
104.39
3/5
3/6
345.10
232.0
325.6
3/7
mmol/L
mmol/L
%
u/l
135 -155
3.6 -5.5
4.5 6.3
0.0 -248
Sodium
Potassium
HBA1c
LDH
Lipase
145.2
3.7
3.96
148.3
3.94
3.67
4??
6.02
Trop I (-)
55.24
Implication:
Creatinine levels The kidneys maintain the blood creatinine in a normal range. Creatinine has been found to be a fairly reliable indicator of kidney function.
Elevated creatinine level signifies impaired kidney function or kidney disease. As the kidneys become impaired for any reason, the creatinine level in the blood will
rise due to poor clearance of creatinine by the kidneys. Abnormally high levels of creatinine thus warn of possible malfunction or failure of the kidneys.
Amylase 325.6 Amylase testing is performed to diagnose a number of diseases that elevate amylase levels. Pancreatitis, for example, is the most common
reason for a high amylase level. When the pancreas is inflamed, amylase escapes from the pancreas into the blood. Within six to 48 hours after the pain begins,
amylase levels in the blood start to rise. Levels will stay high for several days before gradually returning to normal. There are other causes of increased amylase. An
ulcer that erodes tissue from the stomach and goes into the pancreas will cause amylase to spill into the blood. Amylase is also found in the liver, fallopian tubes,
and small intestine; inflammation of these tissues also increases levels. Gall bladder disease, tumors of the lung or ovaries, alcohol poisoning, ruptured aortic
aneurysm, and intestinal strangulation or perforation can also cause unusually high amylase levels.
Potassium 6.02 Potassium levels can be affected by how the kidneys are working, the blood pH, the amount of potassium you eat, the hormone levels in your
body, severe vomiting, and taking certain medicines, including potassium supplements. Certain cancer treatments that destroy cancer cells can also make
potassium levels high. A potassium level that is too high or too low can be serious. Abnormal potassium levels may cause symptoms such as muscle cramps or
weakness, nausea, diarrhea, frequent urination, dehydration, low blood pressure, confusion, irritability, paralysis, and changes in heart rhythm.
VI. ARTERIAL BLOOD GAS ANALYSIS

Purpose: An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery. This test is used to check how
well your lungs are able to move oxygen into the blood and remove carbon dioxide from the blood. As blood passes through your lungs, oxygen moves into the blood while
carbon dioxide moves out of the blood into the lungs. An ABG test uses blood drawn from an artery, where the oxygen and carbon dioxide levels can be measured before
they enter body tissues.
ARTERIAL BLOOD GAS (EG7+)
TEST
TCO2
REFERENCE
RANGE/
UNIT
2/24
3/1
3/2
3/4
3/6
3/7
3/7
3/8
23 27
mmoL/l
24
28
27
30
23
26
26
24
pH
pCO2
pO2
HCO3
BEecf
sO2
Sodium
Potassiu
m
iCa++
Hct
Hgb
REMAR
KS
Implication:
March
March
March
March
7.35 7.45
35 45
mmHg
80 105
mmHg
22 26
mmoL/l
(-2) (+3)
mmoL/l
95 98 %
135 155
mmoL/l
3.6 5.5
7.413
7.457
7.452
7.437
7.427
7.24
7.33
7.464
35.9
38.2
37.6
42.9
33.1
56.8
46.6
32.6
79
119
65
76
77
77
177
62
22.9
27
26.3
28.9
21.8
24.3
24.7
23.4
-2
-3
-3
-1
96
99
93
95
96
92
94
93
137
138
144
144
142
143
146
3.5
4.1
3.7
4.7
6.1
5.8
1.07
1.1
1.14
1.08
1.06
1.08
35
11.9
36
12.2
35
11.9
43
14.6
23
9.8
32
10.9
O2 @
8LPM
O2 @
6LPM
O2 @
5LPM
O2 @
8LPM
33
11.2
O2 @
8LPM
via
NC
FIO2
@
100%
FIO2
@
60%
1.12 1.32
mmoL/l
40 54 %
12 17 g/dL
Room
air
1, 2, and 4 Uncompensated Metabolic Alkalosis with Mild Hypoxemia

6 Fully Compensated Respiratory Acidosis with Mild Hypoxemia
7 Uncompensated Respiratory Acidosis with Mild Hypoxemia
8 Uncompensated Respiratory Alkalosis with Mild Hypoxemia
March 8, 2013 @ 01:55AM

FIO2 = 60%
TEST
TCO2
RESULT
24
NORMAL VALUE
23 27
UNITS
mmoL/l
pH
pCO2
pO2
HCO3
BEecf
sO2
Sodium
Potassium
iCa++
Hct
Hgb
7.464
32.6
62
23.4
0
93
146
6
1
32
10.9
7.35 7.45
35 45
80 105
22 26
(-2) (+3)
95 98
135 155
3.6 5.5
1.12 1.32
40 54
12 17
mmHg
mmHg
mmoL/l
mmoL/l
%
mmoL/l
mmoL/l
mmoL/l
%
g/dL
Implication: Uncompensated Respiratory Alkalosis with Mild Hypoxemia
March 8, 2013 @ 09:58AM

FIO2 = 100%
TEST
TCO2
pH
pCO2
pO2
HCO3
BEecf
sO2
Sodium
Potassium
iCa++
Hct
Hgb
RESULT
20
7.372
33
158
19.2
-6
99
145
5.2
1.03
31
10.5
Implication: Fully Compensated Metabolic Acidosis with Mild Hypoxemia
NORMAL VALUE
23 27
7.35 7.45
35 45
80 105
22 26
(-2) (+3)
95 98
135 155
3.6 5.5
1.12 1.32
40 54
12 17
UNITS
mmoL/l
mmHg
mmHg
mmoL/l
mmoL/l
%
mmoL/l
mmoL/l
mmoL/l
%
g/dL
VII. COLONOSCOPY
Purpose: is a procedure used to see inside the colon and rectum. Colonoscopy can detect inflamed tissue, ulcers, and abnormal growths. The procedure is used to look for
early signs of colorectal cancer and can help doctors diagnose unexplained changes in bowel habits, abdominal pain, bleeding from the anus, and weight loss. Colonoscopy
has two purposes:
1) Screening colonoscopy
- is performed on patients without symptoms or problems, in order to detect polyps in the lining of the large intestine. Colon cancer arises from polyps, and
screening colonoscopy aims to remove the polyps and thereby prevent colon cancer.
2) Diagnostic colonoscopy
- is performed on patients who are having symptoms or problems, such as rectal bleeding, altered bowel habits, unexplained anemia, or pain.
During colonoscopy biopsies (small tissue samples) can be taken to aid in diagnosis. Polyps are also removed (polypectomy) by passing a loop of wire over the polyp
and cauterizing it off with electric current. All polyps and tissue samples are sent to a pathology laboratory for microscopic examination.
February 28, 2013

Physician: Dr. Potot
Procedure: Colonoscopy
Instrument: CFQ 180
Pre-Op Impressions: Colonic mass
FINDINGS:
Scope was inserted up to the cecum and
colon was noted to be very redundant
(+) Friable, modular, fungating mass at the
hepatic flexure and distal ascending colon
(+) small polyps at transverse and sigmoid
colon
FRIABLE, MODULAR,
FUNGATING MASS
POLYPS
Post-Op Diagnosis:
1. Colonic CA, hepatic flexure, and ascending colon
2. Colonic polyps, transverse, and sigmoid
Remarks: For Surgery
SURGICAL PATHOLOGY ANALYSIS

February 18, 2013
Physician: Dr. Potot
Source of Specimen: Polyp, transverse
Clinical Impression: Adenomatous Polyp
History: (+) Polyp, (+) Constipation, (+) Abdominal pain
Gross:
The specimen, labelled polyp, transverse, consists of small irregular fragments of soft, whitish-tan tissue measuring in the aggregate 8 x 6 x 1 which are
totally processed.
Microscopic:
Microscopic examination of four step sections of the totally embedded specimen in a single slide, shows five (5) small pieces of colon mucosa. Two (2) of
these are lined by columnar epithelium and composed of tubular glands surrounded by edematous stroma. The stroma shows a mild lymphoid infiltrate. The other
three (3) pieces show an increase in the number of glands with piled-up epithelium demonstrating loss of polarity. No evidence of malignancy is however seen.
Diagnosis:
Tissue from transverse colon:
HYPERPLASTIC POLYP
VIII. CHEST X-RAY AP (Anteroposterior) VIEW
Purpose: provides a two-dimensional image of the bodys internal structures. When aimed at the chest, the x-ray image displays the lungs, the heart, the rib cage, the
sternum, the diaphragm, and the spine. An important purpose of the chest x-ray is to examine the lungs. One of the first steps in evaluating a patient with symptoms such
as shortness of breath, cough, or wheezing is to take a radiograph of the chest. This provides information about how well the lungs inflate, whether there is any abnormal
material present within the lungs, and if fluid has collected around the lungs. Information from the study can support making diagnoses such as pneumonia, asthma, and
chronic obstructive pulmonary disease (COPD).The chest x-ray can also evaluate the heart. Often patients with symptoms such as sudden chest pain, palpitations,
shortness of breath with activity, and an inability to lie flat due to shortness of breath undergo this imaging test. Radiologists can examine the borders of the heart to see if
any of the heart chambers are enlarged. They can also evaluate whether the overall size of the heart is increased, which can signify the presence of a number of heart
diseases.
February 24, 2013

Radiologic Findings:
Previous studies reviewed and comparison made
The lungs are clear. The trachea is centered on the midline. Calcific densities outline the aortic arch. The cardiac shadow is not enlarged. Pulmonary vasculature and
mediastinal structures are within normal limits. Hemidiaphragms and costophrenic sulci are intact bilaterally. Marginal osteophytes seen along the lateral margin of the
thoracic and imaged lumbar vertebrae. The soft tissue and visualized osseous structures are unremarkable
Impression:
No acute cardiopulmonary findings
Atherosclerosis of the thoracic aorta
Degenerative changes in the thoraco-lumbar vertebrae
February 28, 2013
Patchy densities both lower lungs
The thoracic aorta is tortuous
The pulmonary vessels are within normal limits
The cardiac shadow is normal in size and shape
The trachea is at midline
The superior mediastinum is not widened
Both hemidiaphragms are sharp and distinct
Presence of osteophytes noted along the right lateral margin of the thoracic spine
Comparative study of the previous radiograph taken 02/24/13 shows new infiltrates in both lower lung
Impression:
Bibasal pneumonia
March 2, 2013
Follow-up study of the previous radiograph taken 02/28/13 shows increase of opacities in the left lower lung blunting the left hemidiaphragm
The trachea is at the midline
Both hemidiaphragm are sharp and distinct
The osseous thoracic cage showed no significant abnormality
Impression:
Bibasal pneumonia with minimal amount of left pleural effusion
March 4, 2013
Follow-up AP view of the chest done on 03/04/13 as compared to 03/02/13 shows interval decreased in the previously mentioned haziness at both lower lobes. The trachea
is centered on the midline. Calcific densities outline the aortic arch. The cardiac shadow is not enlarged. Pulmonary vasculature and mediastinal structures are within
normal limits. Hemidiaphragms and costophrenic sulci are intact bilaterally. Marginal osteophytes seen along the lateral margin of the thoracic and imaged lumbar
vertebrae. The soft tissue and visualized osseous structures are unremarkable.
Impression:
Interval decreased/ improvement of the previously mentioned haziness/ pulmonary infiltrates at both lower lobes.
Degenerative changes in the thoraco-lumbar vertebra
March 5, 2013
Note the study is taken in expiratory phase

Follow-up AP view of the chest done on 03/05/13 as compared to 03/04/13 agina shows hazy densities at both lower lobes. The trachea is centered on the midline. Calcific
densities outline the aortic arch. The cardiac shadow is not enlarged. Pulmonary vasculature and mediastinal structures are within normal limits. Marginal osteophytes seen
along the lateral margin of the thoracic and imaged lumbar vertebrae. Rest of the findings remain essentially unchanged.
Impression:
Hazy densities at both lower lobes maintained
Degenerative changes in the thoraco-lumbar vertebra
March 7, 2013
CHEST AP (PORTABLE)
Patchy opacities both lower lungs
No signs of pulmonary congestion
The thoracic aorta is tortuous
ETT in place
The trachea is at the midline
Both hemidiaphragms are sharp and distinct
The osseous thoracic cage showed no significant abnormality
Comparative study of the previous radiograph taken 03/04/13 shows increase of opacities in both lower lungs
Impression:
Progression of the pneumonia both lower lungs
ETT in place
IX. ABDOMINAL FLAT PLATE
Purpose: is an imaging test to look at organs and structures in the belly area. Organs include the spleen, stomach, and intestines.
March 6, 2013
Gas distended large bowel loops from ascending to transverse and descending colon.
There is air in the rectal ampulla
Presence of osteophytes noted along the lateral margin of the lumbar spine.
No calcification noted.
Impression:
Localized ileus.
Degenerative oseoarthrosis of the lumbar spine.
X. ULTRASOUND OF THE UPPER ABDOMEN

Purpose: An abdominal ultrasound uses reflected sound waves to produce a picture of the organs and other structures in the upper abdomen. An abdominal ultrasound can
evaluate the abdominal aorta, liver, gallbladder, spleen, pancreas, and kidneys.
March 5, 2013
SONOGRAPHIC REPORT
Findings:
There is presence of ascites.
The gallbladder wall is diffusely thickened measuring 6.8mm in thickness. No evidence of lithiasis nor intraluminal mass lesion. The common duct is not dilated. The
intrahepatic ducts are unremarkable. The liver is not enlarged and exhibits fine homogeneous echotexture with smooth outer contours.
No focal lesions seen.
The spleen and imaged portion of the pancreas and spleen appear unremarkable with homogeneous echotexture and smooth outer contours. No gross parenchyma mass
lesion noted.
Impression:
Ascites
Diffuse gallbladder wall thickening
Unremarkable liver, spleen, and imaged portion of the pancreas sonographically.
XI. ULTRASOUND OF THE RIGHT HEMITHORAX

Purpose: lung ultrasound (LUS) may represent a useful tool for the evaluation of many pulmonary conditions in cardiovascular disease. The main application of LUS for the
cardiologist is the assessment of B-lines. B-lines are reverberation artifacts, originating from water-thickened pulmonary interlobular septa. Multiple B-lines are present in
pulmonary congestion, and may help in the detection, semiquantification and monitoring of extravascular lung water, in the differential diagnosis of dyspnea, and in the
prognostic stratification of chronic heart failure and acute coronary syndromes.
March 5, 2013
SONOGRAPHIC REPORT
Findings:
Scan of the right hemithorax shows non-turbid pleural fluid with an estimated volume 98mL.
Impression:
Minimal right pleural effusion, as described.
XII. ECG-12 Leads
Purpose: a noninvasive routine examination of the electrical activity of the heart that is used to reflect underlying heart conditions
February 24, 2013
Sinus tachycardia, Left atrial abnormality, non-specific ST-T wave changes
March 1, 2013
Sinus tachycardia, rate-related ST-T wave changes. When compared to previous tracing (02/24/13), the rate is now faster.
March 5, 2013
Sinus rhythm, non-specific ST-T wave changes
SUMMARY OF INTERPRETATION
2D ECHO STUDY
Purpose: An echocardiogram is a graphic outline of the hearts movement. During an echocardiogram test, an ultrasound that comes from a hand-held wand placed on
your chest is used to provide pictures of the hearts valves and chambers and help the sonographer evaluate the pumping action of the heart. Two- dimensional (2-D) Echo
and is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right
ventricle. Echo is often combined with Doppler ultrasound and color Doppler to evaluate blood flow across the hearts valves.
Findings:
Eccentric left ventricular hypertrophy (left ventricular ass index of 140.26gm/m2 and relative wall thickness of 0.42) with adequate wall motion and contractility.
Normal left atrial geometry with left atrial volume index of 13.37cc/m2.
Normal dimensions of the right atrium, right ventricle, main pulmonary artery and aortic root.
Thickened mitral valve leaflets without restriction of motion
Structurally normal tricuspid valve and pulmonic valve
No evidence of intracardiac thrombus or pericardial effusion
DOPPLER STUDY
Purpose: A Doppler ultrasound test uses reflected sound waves to see how blood flows through a blood vessel. It helps doctors evaluate blood flow through major arteries
and veins, such as those of the arms, legs, and neck. It can show blocked or reduced blood flow through narrowing in the major arteries of the neck that could cause
a stroke. It also can reveal blood clots in leg veins (deep vein thrombosis, or DVT) that could break loose and block blood flow to the lungs (pulmonary embolism). See
pictures of a stroke and an embolus . During pregnancy, Doppler ultrasound may be used to look at blood flow in an unborn baby (fetus) to check the health of the fetus.
Findings:
Prolonged isovolumic relaxation time indicative of impaired left ventricular relaxation
Mild pulmonary hypertension with pulmonary artery pressure of 50mmHg by pulmonary acceleration time
CONCLUSION:
Eccentric left ventricular hypertrophy with adequate contractility and systolic function but with Doppler evidence of grade 1 diastolic dysfunction
V.
DRUG ADMINISTRATION OVERVIEW

doses, dose changes, dates changes, missed doses, medication errors, duration of therapies, frequency of administration of PRN meds, etc.
PO
Medications
Irbesartan
(Aprovel)
Levocetirizin
e+
Montelukast
(Zykast)
Lactulose
(Movelax)
Frequen
cy
Dosage
2/24
2/25
2/26
2/27
OD
150mg/ta
b 1 tab
3:20
PM
8
AM
8
AM
NPO
@ OR
OD QHS
1 tab
9 PM
9 PM
9 PM
NOW
30cc
6:45PM
NOW
then
Paracetamol
500mg/ta
b
1 tab
Captopril
PRN for SBP
150mmgH
8AM
TODAY
then
10PM
TONIGHT
PRN
Q6H
22.5 cc
8AM
20.5cc
10PM
25mg/ tab
1 tab - SL
3/1
3/2
3/3
3/4
10AM
(for
headac
he)
10:30A
M (for
headac
he)
8PM
(for
fever)
PRN Q4H
Phosphosod
a
2/28
8AM
3/5
3/6
3/7
HOLD 3/5
3/8
Metronidazo
le (Patryl)
1PM
Ciprofloxaci
n (Ciprobay)
1PM
Sildenafil
(Neo-Up)
Amlodipine
(Amvasc)
NOW
then
OD 6AM
Ivbradine
(Coralan)
ISMN
(ElantanLon
g)
NOW
then OD
6AM
NOW
then
OD 6AM
500mg/ta
b
2 tabs
500mg/ta
b
1 tab
50mg/tab
1 tab
Metronidazo
le (Dazomet)
TID
NAcetylcystei
n (Fluimucil)
dissolve in
glass
water
OD HS
600mg/ta
b
1 tab
PRN Q6H
50mg/tab
1 tab
PARENTERAL
Cefuroxime
(Ambixime)
HOLD 3/5
10:30
AM
HOLD 3/5
200mg/ca
p
1 cap
45mg/cap
1 cap
500mg/ta
b
1 tab
BID
100mmHg
10AM
3PM
50mg/cap
1 cap
Omeprazole
(Omepran)
for SBP
HOLD 3/5
5mg/tab
1 tab
BID
10:30
AM
11AM
10mg/tab
1 tab
Celecoxib
(Celebrex)
Catapres SL
1PM
2PM
11PM
HOLD 3/5
7PM
DEFERED 3/5
7PM
DEFERED 3/5
4PM
HOLD 3/5
4AM
NOW
Frequenc
y
Q8H
7PM
110/60
mmHg
100/6
0
mmH
g
70/40
mmH
g
60/40
mmH
g
3/5
3/6
3/7
3/8
5AM
Dosage
2/24
2/25
2/26
2/27
2/28
3/1
750mg
IVTT
6:45PM
2AM
10AM
6PM
2AM
10AM
6PM
2AM
@OR
3PM
5AM
2PM
9PM
D/C
3/2
3/3
3/4
9PM
Metronidazo
le (Zol)
Tranexamic
Acid (Fibrex)
Vitamin K
(Pytogen)
6AM
2PM
10PM
6AM
@OR
6AM
1PM
9PM
6AM
2PM
9PM
2AM
10AM
6PM
2AM
@OR
2PM
10PM
6AM
2PM
10PM
6AM
2PM
10PM
2PM
2AM
2PM
2AM
Q8H
Q8H
500mg
IVTT
9AM
6PM
NOW
10mg
IVTT
9AM
Q12H
1 ampIVTT
@ 6PM
Omeprazole
(Zefxon)
6AM
on BT
10PM
500mg
IV drip
then OD
6PM
9:15PM
5AM
1PM
9PM
6AM
10AM
Tramadol
40mg
IVTT
Pipeacillin +
Tazobactam
(Vigocid)
AFTER
FAST DRIP
40mg
very slow
IVTT in
10mins
6PM
6PM
6PM
6AM
2PM
10PM
REVISED 3/3
50mg
slow IVTT
12PM
12PM
12PM
12PM
12:21P
M@ OR
7:50
PM
10PM
2PM
10PM
6AM
2PM
10PM
6AM
1PM
9PM
5AM
1PM
9PM
5AM
1PM
9PM
5AM
1PM
NOW
4AM
NOW
EXTRA
DOSE
Q6H
1 amp
IVTT
NOW
30mg/am
p
amp
IVTT
NOW
11:05
AM
4PM
10PM
4AM
10AM
4PM
10PM
4AM
10AM
4PM
10PM
4AM
10AM
4PM
10PM
4AM
HOLD 3/3
11:35A
M
8PM
4.5g IVTT
then Q8H
6AM
2PM
10PM
x 8 DOSES
11:30
AM
1 amp
Ketorolac
(Ketomed)
6AM
2PM
10PM
6PM
NOW
Q8H
5AM
2PM
10PM
6AM
2PM
x 4 DOSES
OD
Furosemide
6AM
2PM
10PM
5AM,
10PM
6AM
2PM
10PM
5AM
1PM
9PM
5AM
1PM
10PM
6AM
1PM
D/C
12PM
NOW
Furosemide
NOW
20mg
slow IVTTT
over
5mins
40mg
slow IVTT
IN 10mins
NOW
Paracetamol
for fever T
38 C
0
then
Q6H PRN
8PM
5PM
2:10P
M
5:05A
M
6PM
300mg
IV
5PM
3AM
2PM
6PM
10:30A
6PM
11AM
6PM
6AM
12PM
6PM
12PM
6PM
Q6H-RTC
Digoxin
(Lanoxin)
Levofloxacin
(Floxel)
NOW
0.25mg
IVTT
NOW
0.125mg
IVTT
NOW
then OD
12AM
6AM
500mg
IV drip
5PM
6PM
8PM
2:10P
M 4PM
5AM
2:20P
M
10:05P
M
9AM
7:40P
M
3:40A
M
8PM
8PM
8PM
8PM
9AM
9AM
8PM
8PM
11:35
AM
6:30
AM
9AM
3AM
10AM
RX
3AM
10cc
1 amp
very slow
IVTT over
20mins
Calcium
gluconate
NOW
Hydrocortiso
ne
(Solucortef)
NOW
100mg
IVTT
NOW
5mg slow
IVTT
Nalbuphine
(Nalphine)
Q6H
amp
7PM
2AM
3:10P
M
9PM
3:15A
M
3AM
9AM
3PM
9PM
NOW
EXTRA
DOSE
NOW
2:30A
M
9AM
12:15
AM
HOLD
3/7
Metoclopra
mide (Plasil)
x 6 DOSES
Hyoscine NButylbromid
e
(Buscopan)
Cefixime
(Cepiram)
Q6H
NOW
11:35
AM
6PM
10mg
amp
2AM
12:45P
M6PM
12AM
6AM
12PM
6PM
12AM
6AM
12PM
6PM
20mg
ampule
HOLD 3/5
NOW
1 gm
6AM
6PM
6AM
6PM
6AM
6PM
9AM
7:45
AM
8:20
PM
1:30
AM
8:45
PM
NaHCO3 1
vial very
slow IVTT
over 5mins
NOW
50cc IV
bolus
Diazepam
NOW
1 amp
7:25
AM
D50W
NOW
1 vial IV
bolus
8PM
Humulin R
NOW
5 u SQ
8:30
PM
D50W +
Humulin R 3
u IV bolus
simultaneou
sly
Q4H
X 4doses
TREATMENT
Salbutamol
(Ventolin)
Frequenc
y
1HR PREOP
Q6H
12AM
6AM
12PM
6PM
3:20A
M
6:15A
M
Q6H
then
Q12H
HOLD 3/5
12AM
4AM
8AM
12AM
Dosage
2/24
2/25
1 nebule
neb +
2cc PNSS
Q6hrs
2/26
7AM
10PM
4AM
10AM
4PM
10PM
4AM
12PM
@OR
2/27
2/28
3/1
3/2
3/3
3/5
3/6
3/7
3/8
nebule
Salbutamol
(Asmalin)
12AM
6AM
12PM
REVISED 3/1
12AM
6AM
12PM
6PM
nebule
+ 2cc
PNSS
NOW
nebule
+ 2cc
PNSS
2PM
NOW
1 respule
2AM
2:15A
M
NOW
VI.
12AM
6AM
12PM
6PM
Q6H
NOW
Deep
Breathing
Exercise
6PM
6PM
12AM
6AM
12PM
6PM
EXTRA
DOSE
neb
EXTRA
DOSE
1 neb
10x/day
WAKING
HRS ONLY,
QH
12AM
6AM
12PM
6PM
12AM
6AM
12PM
6PM
12AM
6AM
12PM
6PM
12AM
6AM
12PM
6PM
12AM
6AM
12PM
6PM
8:50A
M
8:30
PM
(3-11)
ASLEE
P, (311)
ASLEE
P (7-3)
(3-11)
(11-7)
(7-3)
(3-11)
(11-7)
(7-3)
ANATOMY AND PHYSIOLOGY

A. The Gastrointestinal System
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the
pharynx, oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by
secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important
functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break food down into nutrients, which can be absorbed into the body to provide energy. In the case
of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms
of nausea, vomiting, diarrhea, malabsorption, constipation or obstruction. Gastrointestinal problems are very common and most people will have
experienced some of the above symptoms several times throughout their lives.
Basic structure
The gastrointestinal tract is a muscular tube lined by a special layer of cells, called epithelium. The contents of the
tube are considered external to the body and are in continuity with the outside world at the mouth and the anus.
Although each section of the tract has specialised functions, the entire tract has a similar basic structure with regional
variations.
The wall is divided into four layers:
Mucosa
The innermost layer of the digestive tract has specialised epithelial cells supported by an underlying connective tissue
layer called the lamina propria. The lamina propria contains blood vessels, nerves, lymphoid tissue and glands that
support the mucosa. Depending on its function, the epithelium may be simple (a single layer) or stratified (multiple
layers).
Areas such as the mouth and oesophagus are covered by a stratified squamous (flat) epithelium so they can survive the wear and tear of passing food.
Simple columnar (tall) or glandular epithelium lines the stomach and intestines to aid secretion and absorption. The inner lining is constantly shed and
replaced, making it one of the most rapidly dividing areas of the body! Beneath the lamina propria is the muscularis mucosa. This comprises layers of
smooth muscle which can contract to change the shape of the lumen.
Submucosa
The submucosa surrounds the muscularis mucosa and consists of fat, fibrous connective tissue and larger vessels and nerves. At its outer margin there is a
specialized nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and
submucosa.
Muscularis externa
This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibres separated by the
myenteric plexus or Auerbach plexus. Neural innervations control the contraction of these muscles and hence the
mechanical breakdown and peristalsis of the food within the lumen.
Serosa/mesentery
The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium.
Individual components of the gastrointestinal system

Oral cavity
The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified squamous oral mucosa with keratin covering those areas subject to
significant abrasion, such as the tongue, hard palate and roof of the mouth.
Salivary glands
Three pairs of salivary glands communicate with the oral cavity. Each is a complex gland with numerous acini lined by secretory epithelium. The acini
secrete their contents into specialised ducts. Each gland is divided into smaller segments called lobes. Salivation occurs in response to the taste, smell or
even appearance of food. This occurs due to nerve signals that tell the salivary glands to secrete saliva to prepare and moisten the mouth. Each pair of
salivary glands secretes saliva with slightly different compositions.
Parotids
The parotid glands are large, irregular shaped glands located under the skin on the side of the face. They secrete 25% of saliva. They are situated below
the zygomatic arch (cheekbone) and cover part of the mandible (lower jaw bone
Submandibular
The submandibular glands secrete 70% of the saliva in the mouth. They are found in the floor of the mouth, in a groove along the inner surface of the
mandible. These glands produce a more viscid (thick) secretion, rich in mucin and with a smaller amount of protein. Mucin is a glycoprotein that acts as a
lubricant.
Sublingual
The sublinguals are the smallest salivary glands, covered by a thin layer of tissue at the floor of the mouth. They produce approximately 5% of the saliva
and their secretions are very sticky due to the large concentration of mucin. The main functions are to provide buffers and lubrication.
Oesophagus
The oesophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. It extends from the pharynx to the stomach after passing
through an opening in the diaphragm. The wall of the oesophagus is made up of inner circular and outer longitudinal layers of muscle that are supplied by
the oesophageal nerve plexus. This nerve plexus surrounds the lower portion of the oesophagus. The oesophagus functions primarily as a transport
medium between compartments.
Stomach
The stomach is a J shaped expanded bag, located just left of the midline between the oesophagus and small intestine. It is divided into four main regions
and has two borders called the greater and lesser curvatures. The first section is the cardia which surrounds the cardial orifice where the oesophagus
enters the stomach. The fundus is the superior, dilated portion of the stomach that has contact with the left dome of the diaphragm. The body is the largest
section between the fundus and the curved portion of the J.
This is where most gastric glands are located and where most mixing of the food occurs. Finally the pylorus is the curved base of the stomach. Gastric
contents are expelled into the proximal duodenum via the pyloric sphincter. The inner surface of the stomach is contracted into numerous longitudinal folds
called rugae. These allow the stomach to stretch and expand when food enters. The stomach can hold up to 1.5 litres of material.
The functions of the stomach include:
The short-term storage of ingested food.
Mechanical breakdown of food by churning and mixing motions.
Chemical digestion of proteins by acids and enzymes.
Stomach acid kills bugs and germs.
Some absorption of substances such as alcohol.
Small intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the
stomach to the ileo-caecal valve separating the ileum from the caecum. The small intestine is compressed into numerous folds and occupies a large
proportion of the abdominal cavity.
The duodenum is the proximal C-shaped section that curves around the head of the pancreas. The duodenum serves a mixing function as it combines
digestive secretions from the pancreas and liver with the contents expelled from the stomach. The start of the jejunum is marked by a sharp bend, the
duodenojejunal flexure. It is in the jejunum where the majority of digestion and absorption occurs. The final portion, the ileum, is the longest segment and
empties into the caecum at the ileocaecal junction.
The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by
enzymes from the pancreas and bile salts from the liver and gallbladder. These secretions enter the duodenum at the Ampulla of Vater. After further
digestion, food constituents such as proteins, fats, and carbohydrates are broken down to small building blocks and absorbed into the body's blood stream.
The lining of the small intestine is made up of numerous permanent folds called plicae circulares. Each plica has numerous villi (folds of mucosa) and each
villus is covered by epithelium with projecting microvilli (brush border). This increases the surface area for absorption by a factor of several hundred. The
mucosa of the small intestine contains several specialised cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous
to protect the intestinal lining from digestive actions.
Large intestine
The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, caecum, ascending, transverse,
descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm.
The caecum is the expanded pouch that receives material from the ileum and starts to compress food products into faecal material. Food then travels along
the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before it passes through the anorectal canal to the anus. Thick bands of
muscle, known as sphincters, control the passage of faeces.
The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal surface is
flat with several deep intestinal glands. Numerous goblet cells line the glands that secrete
mucous to lubricate faecal matter as it solidifies. The functions of the large intestine can be
summarised as:
1.
The accumulation of unabsorbed material to form faeces.
2.
Some digestion by bacteria. The bacteria are responsible for the formation of intestinal
gas.
3.
Reabsorption of water, salts, sugar and vitamins.

Liver
The liver is a large, reddish-brown organ situated in the right upper quadrant of the abdomen.
It is surrounded by a strong capsule and divided into four lobes namely the right, left, caudate
and quadrate lobes. The liver has several important functions. It acts as a mechanical filter by
filtering blood that travels from the intestinal system. It detoxifies several metabolites
including the breakdown of bilirubin and oestrogen. In addition, the liver has synthetic
functions, producing albumin and blood clotting factors. However, its main roles in digestion
are in the production of bile and metabolism of nutrients. All nutrients absorbed by the intestines pass through the liver and are processed before traveling
to the rest of the body. The bile produced by cells of the liver, enters the intestines at the duodenum. Here, bile salts break down lipids into smaller
particles so there is a greater surface area for digestive enzymes to act.
Gall bladder
The gallbladder is a hollow, pear shaped organ that sits in a depression on the posterior surface of the liver's right lobe. It consists of a fundus, body and
neck. It empties via the cystic duct into the biliary duct system. The main functions of the gall bladder are storage and concentration of bile. Bile is a thick
fluid that contains enzymes to help dissolve fat in the intestines. Bile is produced by the liver but stored in the gallbladder until it is needed. Bile is released
from the gall bladder by contraction of its muscular walls in response to hormone signals from the duodenum in the presence of food.
Pancreas
Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its head communicates with the duodenum and its tail extends to the
spleen. The organ is approximately 15cm in length with a long, slender body connecting the head and tail segments. The pancreas has both exocrine and
endocrine functions. Endocrine refers to production of hormones which occurs in the Islets of Langerhans. The Islets produce insulin, glucagon and other
substances and these are the areas damaged in diabetes mellitus. The exocrine (secretrory) portion makes up 80-85% of the pancreas and is the area
relevant to the gastrointestinal tract.
The Cardiovascular System

The cardiovascular system can be thought of as the transport system of the body.
This system has three main components: the heart, the blood vessel and the blood itself.
The heart is the system's pump and the blood vessels are like the delivery routes. Blood can be thought of as a fluid which contains the oxygen and
nutrients the body needs and carries the wastes which need to be removed. The following information describes the structure and function of the heart and
the cardiovascular system as a whole.
Function and Location of the Heart
The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies
left of the middle of the chest.
Structure of the Heart

The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm
across the broadest point and about 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but
allows it to move as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle.
Chambers of the Heart
The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and
a bottom chamber. The two top chambers are known as the left and right atria (singular: atrium). The atria receive blood from different sources. The left
atrium receives blood from the lungs and the right atrium receives blood from the rest of the body. The bottom two chambers are known as the left and
right ventricles. The ventricles pump blood out to different parts of the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out
blood to the rest of the body. The ventricles have much thicker walls than the atria which allows them to perform more work by pumping out blood to the
whole body.
Blood Vessels
Blood Vessel are tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries are blood vessels which carry
blood from the heart to the body. There are also microscopic blood vessels which connect arteries and veins together called capillaries. There are a few
main blood vessels which connect to different chambers of the heart. The aorta is the largest artery in our body. The left ventricle pumps blood into the
aorta which then carries it to the rest of the body through smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It
splits into pulmonary arteries which take the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our
body drain into the inferior vena cava (IVC) or the superior vena cava (SVC). These two large veins then take the blood from the rest of the body into the
right atrium.
Valves
Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates which prevent blood from flowing
in the wrong direction. They are found in a number of places. Valves between the atria and ventricles are known as the right and left atrioventricular valves,
otherwise known as the tricuspid and mitral valves respectively. Valves between the ventricles and the great arteries are known as thesemilunar valves.
The aortic valve is found at the base of the aorta, while the pulmonary valve is found the base of the pulmonary trunk. There are also many valves found in
veins throughout the body. However, there are no valves found in any of the other arteries besides the aorta and pulmonary trunk.
What is the Cardiovascular System?
The cardiovascular system refers to the heart, blood vessels and the blood. Blood contains oxygen and other nutrients which your body needs to survive.
The body takes these essential nutrients from the blood. At the same time, the body dumps waste products like carbon dioxide, back into the blood, so they
can be removed. The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive. Veins
deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as
the body has unloaded it back into the blood). All the veins drain into the superior and inferior vena cava which then drain into the right atrium. The right
atrium pumps blood into the right ventricle. Then the right ventricle pumps blood to the pulmonary trunk, through the pulmonary arteries and into the
lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen
which the body can use. From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this
oxygen-rich blood out into the aorta which then distributes it to the rest of the body through other arteries. The main arteries which branch off the aorta
and take blood to specific parts of the body are:
Carotid arteries, which take blood to the neck and head
Coronary arteries, which provide blood supply to the heart itself
Hepatic artery, which takes blood to the liver with branches going to the stomach
Mesenteric artery, which takes blood to the intestines
Renal arteries, which takes blood to the kidneys
Femoral arteries, which take blood to the legs

The body is then able to use the oxygen in the blood to carry out its normal functions. This blood will again return back to the heart through the veins and
the cycle continues.
What is the Cardiac Cycle?

The cardiac cycle is the sequence of events that occurs in one complete beat of
the heart.
The pumping phase of the cycle, also known as systole, occurs when heart muscle
contracts.
The filling phase, which is known as diastole, occurs when heart muscle relaxes. At
the beginning of the cardiac cycle, both atria and ventricles are in diastole. During
this time, all the chambers of the heart are relaxed and receive blood. The
atrioventricular valves are open. Atrial systole follows this phase. During atrial
systole, the left and right atria contract at the same time and push blood into the left
and right ventricles, respectively. The next phase is ventricular systole. During
ventricular systole, the left and right ventricles contract at the same time and pump
blood into the aorta and pulmonary trunk, respectively. In ventricular systole, the atria are relaxed and receive blood. The atrioventricular valves close
immediately after ventricular systole begins to stop blood going back into the atria. However, the semilunar valves are open during this phase to allow the
blood to flow into the aorta and pulmonary trunk. Following this phase, the ventricles relax that is ventricular diastole occurs. The semilunar valves close
to stop the blood from flowing back into the ventricles from the aorta and pulmonary trunk. The atria and ventricles once again are in diastole together and
the cycle begins again.
Components of the Heartbeat
The adult heart beats around 70 to 80 times a minute at rest. When you listen to your heart with a stethoscope you can hear your heart beat. The sound is
usually described as "lubb-dupp". The "lubb" also known as the first heart sound, is caused by the closure of the atrioventricular valves. The "dupp" sound
is due to the closure of the semilunar valves when the ventricles relax (at the beginning of ventricular diastole). Abnormal heart sounds are known
as murmurs. Murmurs may indicate a problem with the heart valves, but many types of murmur are no cause for concern.
The Electrocardiogram
The heart has an inbuilt rhythm of contraction and relaxation. A small group of heart muscle cells called the pacemaker help achieve this. The pacemaker
generates an electrical impulse which spreads over the atria, making them contract. This impulse then spreads to the ventricles, causing them to contract.
The electrical changes that spread through the heart can be detected at the surface of the body by an instrument called the electrocardiograph. Electrodes
are placed in a number of positions over the chest and the electrical changes are recorded on moving graph paper as an electrocardiogram (ECG).
Effects of Aging on the Heart in Men and Women
As a part of the normal aging process a number of changes occur to the cardiovascular system.
Our heart rate slows down because the time between heartbeats increases as we age. This is one of the main reasons why the heart is unable to
pump out more blood during exercise when we become old.
The amount of blood the heart pumps each minute can change as we age. It decreases slightly in older women. However, it does not change in
healthy older men who have no heart disease. The reason for the difference between the sexes is not fully understood.
As we age, our blood pressure falls much more on standing from the sitting position compared to when we are younger. This phenomenon is known
as postural hypotension. This explains why elderly people are more likely to feel dizzy or to fall when they stand up quickly from a resting position.
Respiratory System
The respiratory system consists of all the organs involved in breathing. These include the
nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important
brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of
is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes
is funnelled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the
carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the
system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get
product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain.
The Upper Airway and Trachea
When you breathe in, air enters your body through your nose or mouth. From there, it travels down
your throat through the larynx (or voicebox) and into the trachea (or windpipe) before entering your
these structures act to funnel fresh air down from the outside world into your body. The upper
airway is important because it must always stay open for you to be able to breathe. It also helps to
moisten and warm the air before it reaches your lungs.
things: it
carbon dioxide, which
through which the air
bloodstream
and
respiratory
rid of the waste
lungs. All
The Lungs
The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body,
which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left
lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the
left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller
portions, called 'bronchopulmonary segments'.
These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment
receives its own blood supply and air supply.
Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and
branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the
important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel
called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very
close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through
the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream.
Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In
this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.
Blood Supply
The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come
directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can
be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins
into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs.
The Work of Breathing

The Pleurae
The lungs are covered by smooth membranes that we call pleurae. The pleurae have two layers, a 'visceral' layer which sticks closely to the outside surface
of your lungs, and a 'parietal' layer which lines the inside of your chest wall (ribcage). The pleurae are important because they help you breathe in and out
smoothly, without any friction. They also make sure that when your ribcage expands on breathing in, your lungs expand as well to fill the extra space.
The Diaphragm and Intercostal Muscles
When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The diaphragm, a large, sheet-like muscle which stretches across
your chest under the ribcage, does much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in, the diaphragm
contracts and flattens out, expanding the space in your chest and drawing air into your lungs. Other muscles, including the muscles between your ribs
(the intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not normally require your muscles to work. This is
because your lungs are very elastic, and when your muscles relax at the end of inspiration your lungs simply recoil back into their resting position, pushing
the air out as they go.
VII. PATHOPHYSIOLOGY OF THE DISEASE
VIII. PRIORITIZED LIST of NURSING PROBLEMS

1.
2.
3.
4.
5.
6.
7.
8.
9.
Acute pain
Ineffective Airway Clearance
Impaired Gas Exchange
Altered Body Defenses
Impaired Skin Integrity
Altered bowel movement: Constipation Impaction
Fatigue
Partial Self-Care Deficit
Readiness for Enhanced Learning
IX.
NURSING CARE PLAN

NURSING DIAGNOSIS
Date Identified: February 27, 2013

1. Acute pain related to disruption of tissue
secondary to S/P Explore Laparotomy and Right
Hemicolectomy as manifested by verbal report of
sharp gnawing pain with a pain scale of 8/10 with
10 as the highest and 1 as the least painful
aggravated by movement and touch and relieved by
rest; guarding behaviour; facial grimacing and
verbalization of Musakit siya inig lihok ug kung
mahikapan nako ang dapit sa tahi.
SB: Most individuals experience some pain after
surgical procedure. Many factors (motivational,
affective, cognitive and emotional) influence the
pain experience. The degree and severity of
postoperative pain and the individuals tolerance of
pain depend on the incision site, the nature of the
surgical procedure, the extent of surgical trauma,
the type of anesthetic agent and how the agent was
administered. (Source: Smeltzer, Bare, Hinkle and
Cheever.2008. brunner and Suddarths Textbook of
Medical- Surgical Nursing. 11th edition.Volume 1.
Lippincott Williams and Wilkins )
OUTCOMES
Within 8 hours
of
nursing
interventions,
the
individual
will be able to:
verbalize
decrease
in pain
experienc
ed, using
pain
scale,
from 8/10
(with 1 as
the least
painful
and 10 as
the most
painful) to
at least
3/10
verbalize
reduced
occurrenc
e of pain
do deep
breathing
exercises
and
INTERVENTION
S
1. Noted
location of
surgical
site
2. Assessed
for referred
pain.
3. Assessed
characteris
tic of pain
as reported
by
individual
4. Observed
nonverbal
cues/ pain
behaviours
5. Reposition
ed
individual
in bed
6. Utilized
soft and
RATIONALE
R: can influence the
amount of
postoperative pain
experienced.
R: to help determine
possibility of
underlying
condition.
R: pain is a
subjective
experience and
cannot be felt by
others.
R: observations
may/ may not be
congruent with
verbal reports or
maybe only
indicator present
when client is
unable to
verbalize.
R: to promote
nonpharmalogical
pain
management.
R: to reduce tension
and distract
attention
EVALUATION
February 28, 2013
Within 8 hours of nurse-individual
interaction, the individual was able
to:
verbalize alleviation of pain
from a pain scale of 8/10 to
6/10 with 10 as the most
painful and 1 as the least
painful
do deep breathing exercises
and splinting under
supervision
have adequate rest
verbalize Mayo jud nga
maminaw na lang ko ug
music ug magsturya sa ako
pamilya aron di ko
makahunahuna sa sakit.
March 1, 2013
Within 8 hours of nurse-individual
to:
verbalize alleviation of pain
from a pain scale 6/10 to
4/10 with 10 as the most
painful and 1 as the least
painful
splinting
with or
without
the
supervisio
n of
nurses
have
adequate
rest
verbalize
effectiven
ess of
relaxation
technique
s
mellow
music in
promoting
relaxation
7. Provided
time to
have
adequate
rest
8. Taught how
to perform
deep
breathing
exercises
9. Taught how
to perform
splinting
and
emphasize
d its
importance
10.Asked to
demonstrat
e DBE and
splinting
11.Kept
environme
nt calm,
quiet, and
conducive
to rest and
relaxation
12.Promoted
R: to reduce fatigue
and conserve
enough energy for
performing ADLs
R: to reduce tension
and promote
relaxation
R:
to
prevent
dehiscence
and
evisceration
R:
to
evaluate
effectiveness
of
health teachings
R: to promote
nonpharmalogical
pain management
R: to distract
individuals
attention from
pain
R: to give the
individual a mind
setting on a
definite goal of
reducing pain
through
cooperating with
student nurses
interventions
R: to evaluate
do deep breathing exercises

and splinting with less
supervision
have adequate rest
verbalize Mawala-wala jud
ang sakit gamay basta mag
deep breathing ko
socializatio
n with
others as a
form of
diversional
activity
13.Planned
with the
individual
regarding
setting
goals on an
attainable
pain scale
reduction
14.Monitored
changes in
characteris
tic,
frequency,
and pain
scale of
pain as
reported
by
individual
15.Administer
ed
Tramadol
(Narcotic
Analgesic:
alters
perception
and
effectiveness of
interventions and
improving plan of
care
R: to relieve or
prevent
postoperative pain
from occurring or
worsening.
response
to pain by
binding to
mu-opiate
receptors
in the CNS)
and
Ketorolac
(NSAID:
nonselective
inhibitors
of COX) as
ordered
2. Ineffective airway clearance related to
retained secretions in the respiratory tract, infection
and inflammation in the lung parenchyma
secondary to
pneumonia as manifested by
presence of harsh breath sounds such as rhonchi on
both lung fields upon auscultation, productive cough
with yellowish to whitish viscous sputum, increased
respiratory rate of 27cpm (6 pm), (+) nasal flaring,
dyspnea during continuous movement and relieved
by rest, and elevated CBC results (Feb 28, 2013) of
WBC= 217.6 k/uL (Normal value: 5.0-10.0-10.9
k/uL), NEU= 88.7% (Normal Value: 50-70%).
SB: The most common symptom of pneumonia is a
cough that produces sputum. Other common
symptoms include chest pain, chills, fever, and
shortness of breath. These symptoms may vary,
Within 8 hours
of nursing
interventions,
the patient will
be able to:
have no
more
adventitio
us breath
sounds
upon
auscultati
on
have a
respirator
y rate
that is
within
normal
1. Continuous
ly
monitored
respiratory
rate, depth
and
adventitiou
s
breath
sounds.
2. Elevated
head
of
bed
or
positioned
to
Semifowlers,
and
encourage
d SO to
R: To know if there is
any presence of
respiratory distress
and other
complications, and to
ascertain status and
note progress.
R: To take advantage
of gravity decreasing
pressure
on
the
diaphragm
and
enhancing drainage
of
ventilation
to
different lung fields.
February 28, 2013

After
4
hours
of
nursing
interventions, client still has harsh
breath sounds such as rhonchi on
both lung fields upon auscultation,
productive cough with whitish to
greenish
sputum,
increased
respiratory rate of 24cpm (10 pm),
(+) nasal flaring, dyspnea during
continuous movement and relieved
by rest.
March 1, 2013
R: To promote lung
expansion,
proper
breathing
pattern
After
8
hours
of
nursing
intervention, client still has harsh
breath sounds such as rhonchi on
however, depending on how extensive the disease

is and which organism is causing it.
Symptoms vary even more in infants and older
people. Fever may not occur. Chest pain may not
occur, or people may not be able to communicate
that they have chest pain. Sometimes the only
symptom is rapid breathing or a sudden refusal to
eat. An older person may suddenly become
confused. Laboratory tests like a complete blood
count may show a high white blood cell count,
indicating the presence of an infection or
inflammation.
(Source:Medical-Surgical Nursing 5th edition
Ignatavicius and Workman, pp. 633-639)
by
range
(1220cpm)
display
absence
of cough
with no
more
secretions
, not
experienc
e dyspnea
during
continuou
s
movemen
t, (-) nasal
flaring
Have a
laboratory
result that
is within
the
normal
range.
change
clients
position
every
hours.
and
encourage
expectoration.
2
3. Taught and
encourage
d
client,
with SOs
assistance,
deep
breathing
exercises
and huffing
cough
exercise to
maximize
effort.
4. Demonstra
ted
and
taught to
SO
to
perform
chest
tapping on
client.
5. Kept
environme
nt
clean
and
R:
To
promote
expectoration/remov
al of secretions.
R: To prevent the
worsening of clients
symptoms.
R:
To
identify
infectious
process
and promote timely
interventions.
R: To prevent spread
and multiplication of
harmful
microorganisms.
R: To prevent fatigue
and
hasten
the
recovery process.
R: Oxygen therapy
increases the supply
of
oxygen
to
both lung fields upon auscultation,

productive cough with whitish to
greenish
sputum,
increased
respiratory rate of 22cpm (6 pm), (-)
nasal
flaring,
dyspnea
during
continuous movement and relieved
by rest.
allergen
free.
6. Continuous
ly
observed
for signs of
infection
like
fever
associated
with
dyspnea,
change in
sputum
color,
amount or
character.
7. Emphasize
d to SO the
importance
of
performing
proper
hygienic
measures
like
handwashi
ng,
especially
before and
after
coming in
contact
with client.
8. Promoted
adequate
periods of
the lungs and

thereby
increasing
the availability of
oxygen to the body
tissues,
especially
when the client is
suffering
from hypoxia and/or
hypoxemia.
R:
A
beta-2
adrenergic
agonist
that
promotes
dilation
of
the
bronchial
smooth
muscles
and
increasing the flow of
air in the bronchial
tubes,
I:
asthma,
bronchospasm, A/E:
tachycardia,
palpitations,
dry
mouth,
chest
tightness,
C/I:
hypersensitivity
to
drug)
rest
and
sleep.
9. Administer
ed
O2
inhalation
at 3L/min
via
nasal
cannula as
needed.
10.Administer
ed
Salbutamol
(Ventolin) 1
nebule
+
2cc PNSS
every
6
hours
3. Impaired gas exchange related to inability to
move secretions and ventilation perfusion
imbalance secondary to BIBASAL? pneumonia as
manifested by nasal flaring, productive cough with
yellowish to whitish viscous sputum and ineffective
Desired
Outcome:
Within the whole
course
of
1.
Continuously
auscultated
breath sounds
and assessed
coughing and moderate hypoxemia, with abnormal

ABG results: (attach results)
SB: Inflamed and fluid-filled alveolar sacs cannot
exchange oxygen and carbon dioxide effectively.
Alveolar exudate tends to consolidate, so it is
increasingly difficult to expectorate. Bacterial
pneumonia may be associated with significant
ventilation-perfusion mismatch as the infection
grows.
(Medical-Surgical Nursing, Black-Hawks vol. 2, p.
1842)
nursing
interventions,
the patient will
be
able
to
maintain
optimal
gas
exchange
as
evidenced
by
normal arterial
blood
gases
(ABGs), no signs
of
respiratory
distress will be
noted
like
tachycardia,
tachypnea,
cyanosis
and
dyspnea, and px
will be able to
demonstrate
breathing
exercises
that
were taught by
nurses.
breathing
pattern.
R: to ascertain
status and
note progress.
2.
Continuously
assessed skin
for coolness,
pallor,
cyanosis,
diaphoresis,
delayed
capillary refill.
R: changes
reflect
diminished
circulation and
hypoxia.
3. Positioned
to moderate
high back rest.
R: for optimal
diaphragm
excursion.
4. Provided
chest
physiotherapy
, such as
chest tapping
and deep
breathing
exercises.
R: to aid in
loosening the
secretions for
easier
expectoration
and promote
full lung
expansion.
5. Encouraged
fluid intake as
tolerated.
R: to help
moisten and
loosen
secretions.
6. Assisted in
frequently
changing
positions
every 2 hours
as needed.
R: To facilitate
secretion
movement
and drainage.
7. Encouraged
to have
adequate rest
and limit
activities as
tolerated.
R: to prevents
over fatigue
and reduces
oxygen
consumption
and demands.
8. Promoted a
calm and

4. Altered Body Defenses related to abnormal
blood profile secondary to infection as manifested
by CBC results as of 02/28/13 reveals increased
Within 8 hours
of nursing
interventions,
restful
environment.
R: to promote
relaxation and
conservation
of energy.
9. Encouraged
SO to assist
px in doing
deep
breathing and
coughing
techniques.
R: to facilitate
adequate air
exchange and
secretion
clearance.
10.
Encouraged or
assisted with
ambulation as
indicated.
R: to promote
lung
expansion,
facilitates
secretion
clearance, and
stimulates
deep
breathing.
1. Assessed
skin
integrity
for
R: Note risk factors

for occurrence
of infection.
March 1, 2013
Within 8 hours of nursing
interventions, the client was able
WBC count=17.2 k/uL (N.V.=4.10-10.9k/uL) and

Neutrophil count=86.2 (N.V.=50-70%), incision sites
for right hemicolectomy.
SB:
The skin provides a barrier to the outside
world and the dangers of infection, environmental
hazards and chemicals, and temperature. A break or
damage to this barrier can allow pathogens get
inside the body system and thus cause infection.
(Source:
http://www.medicinenet.com/stitches/article.htm)
A higher than normal number of WBC may
not directly cause symptoms, but the high number
of cells can be indication of a disease such as an
infection.
(Source: The Merck Manual of Medical Information
second home edition page 887)
the client will be

able to:
be free
from s/s
of sepsis
such as
fever and
chills
demonstr
ate no
signs of
superinfe
ction
such as
diarrhea,
black
furry
tongue
Verbalize
understa
nding
about the
importan
ce of
proper
hand
washing.
2.
3.
4.
5.
6.
7.
occurrence
of
infection.
Noted s/s
of sepsis
such as
fever,
chills, (+)
blood
cultures.
Hand
washing
done
before and
after
patient
contact.
Monitored
and limit
exposure
to visitors
Discussed
necessity
of taking
antibiotics
in full
course.
Stressed
proper
hand
washing to
client and
SO.
Monitored
for signs of
superinfect
to:
R: Sepsis can be a
complication of
infection.
R: Prevent transfer
of
microorganisms.
R: To lessen
exposure to
microorganisms
R: Premature
discontinuation
of treatment
may result to
return of
infection.
R: To prevent
transfer of
microorganisms.
R: Superinfection
may result from
prolonged
antibiotic
therapy.
R: To maintain a
therapeutic
environment
and to promote
clients comfort
R: To assist bodys
natural process
of repair for
be free from s/s of sepsis

such as fever and chills
no signs of superinfection
noted such as diarrhea, black
furry tongue, mouth sores
Understood the importance
of handwashing through
verbalizations of importante
kaayo na ang maghugas ug
kamot, dili lang kay ako, apil
pud ang ako pamilya aron
maglikay ta sa infection.
March 2, 2013
to:
demonstrate no signs of
sepsis, fever as well as
superinfection
March 3, 2013
to:
be free from s/s of sepsis
such as fever and chills
maintain his wound dressing
clean and dry
ion such as
diarrhea,
black furry
tongue,
vaginal
itching
8. Kept bed
linens
clean and
dry.
early wound
healing
9. Advised to
keep
wounds
area clean
and dry
and
provided
dressing of
wounds.
5. Impaired skin integrity related to disrupted
integument secondary to surgery as manifested by
presence of incision about 7 inches in length at
midline area of abdomen.
SB: Incised wounds are made by a clean cut with a
sterile, sharp instrument, such as those made by
the surgeon in every surgical procedure. Clean
wounds are usually closed by sutures after all
bleeding vessels have been ligated carefully.
Ongoing assessment of the surgical site involves
inspection for approximation of wound edges,
integrity of suture staples, redness, discoloration,
warmth, swelling, unusual tenderness or drainage.
Within 8 hours
of
nursing
interventions,
the
individual
will be able to:
verbalize
understan
ding on
ways to
prevent
infection
show no
signs of
infection
1. Noted skin
color,
texture
and turgor
2. Checked
incision
sites for
signs of
infection
3. Kept the
incision
area clean
R: to provide
baseline assessment
and for future
comparisons.
R: for early referral
whenever there are
significant findings
R: to assists bodys
natural process of
repair.
R: to reduce
bacterial colonization
February 28, 2013

Within
8
hours
of
nursing
interventions, the individual was
able to:
verbalize Importante jud
ang hygiene aron di mainfect ang samad
show no signs of infection
such as swelling, and
presence of secretions but
mild redness was noted
show no signs of
complications especially
dehiscence or evisceration
(Source:
brunner
Surgical
Williams
Smeltzer, Bare, Hinkle and Cheever.2008.

and Suddarths Textbook of MedicalNursing. 11th edition.Volume 1. Lippincott
and Wilkins )
such as
redness,
swelling,
and
presence
of
secretions
show no
signs of
complicati
ons
especially
dehiscenc
e or
eviscerati
on and
bleeding
on
incision
sites
exhibit a
fast
healing
process of
the
wound
and dry
4. Promoted
proper
hygiene
5. Maintained
adequate
hydration
6. Monitored
skin on
daily basis,
describing
lesions, its
characteris
tics and
possible
changes.
7. Emphasize
d
importance
of proper
handwashi
ng by
health
team,
individual
and S.Os of
family
8. Emphasize
d to avoid
touching
incision
site
9. Instructed
R: Promotes
circulation and
reduces risks
associated with
immobility.
R: to monitor
progress of healing
and effectiveness of
care
R: a first line defense
against health care
associated
infections.
R: frequent touching
poses a big risk for
infection
R: to avoid potential
complications of
dehiscence or
evisceration and
bleeding on incision
sites
R: to control feelings
of helplessness and
deal with situation
and bleeding on incision sites

show very minimal signs of
wound healing
March 1, 2013
Within
8
hours
of
nursing
able to:
show no signs of infection
such as swelling, and
presence of secretions but
mild redness was still noted
show no signs of
complications especially
dehiscence or evisceration
and bleeding on incision sites
show very minimal signs of
wound healing at the borders
of the wounds
to move
slowly and
avoid
strenuous
activities
10.Instructed
client
about
stress
reduction
such as
DBE and
rest.
6. Altered bowel movement: Constipation
Impaction related to obstructive colonic polyps at
transverse and sigmoid colon.
Subjective:
tulo na kaadlaw wala ko kalibang as verbalized by
the patient
Objective:
>hypoactive bowel sounds
>Percussed abdominal dullness
>straining when defecating
SB:
Partial
obstruction produces constipation, nausea,
abdominal distention, and
abdominal pain. Partial obstruction occasionally
paradoxically produces
intermittent diarrhea as stool moves beyond the
obstruction
(http://www.med.upenn.edu/gastro/documents/Med
After 8 hours of
nursing
interventions,
patient will
establish or
return to normal
patterns of
bowel
functioning.
To provide
measures so as
for client to
defecate
everyday
Nursing Orders:
Specifically,
patient will be
able to:
1. Defecate
once a day.
1.Determined the
pattern of
defecation for
clients and train
clients to do so.
2.have
consistency of
soft stool
INDEPENDENT:
2.Set the time is

right for clients
such as
Actual Evaluation:
Goal not met, no presence of bowel
movement
on
the
following
24hours.
ClinNAcolonicpolyps.pdf).
3. eliminate
feces without
the need for
excessive
straining
defecation after
meals.
3. Provided
coverage of
nutritional fiber
according to the
indication.
4. Give fluids if
not
contraindicated
2-3 liters per day.
COLLABORATIVE:
5. Provided
laxatives or
enemas as
indicated
Date identified: March 3, 2013

7. Fatigue related to decreased oxygen carrying
capacity of the blood secondary to disease process
as manifested by consistently low RBC with the
current result of 4.17 M/uL, low haemoglobin result
of 9.3g/dL; verbalizations of being tired even after
sleeping: Kapoy gihapon bisag nakatulog nako
pero naningkamot sad ko nga mabawi ang akong
kusog , appears to have lack of energy to perform
simple activities and individual looks drowsy most of
the time.
SB:
Low red blood cell count (anemia) leads to fatigue
and weakness.
Within 8 hours
of
nursing
interventions,
the
individual
will be able to:
rest well
for an
adequate
period of
time
verbalize
decreased
fatigue in
performin
1. Assessed
for
possible
causes of
fatigue
such as
emotional
stress,
depression
and
physical
R: Identifying the
related factors of
fatigue can aid in
determining possible
causes and
establishing plan of
care.
R: Both increased
physical exertion can
Date identified: March 3, 2013

4. Fatigue related to decreased
oxygen carrying capacity of the
blood secondary to disease process
as manifested by consistently low
RBC with the current result of 4.17
M/uL, low haemoglobin result of
9.3g/dL; verbalizations of being
tired even after sleeping: Kapoy
gihapon bisag nakatulog nako pero
naningkamot sad ko nga mabawi
ang akong kusog , appears to have
lack of energy to perform simple
activities and individual
looks
drowsy most of the time.
(Source:
http://www.healthcentral.com/ency/408/000554.htm
l)
When your body is in the state of a low red blood
cell count, it causes low oxygen level symptoms of
fatigue, dizziness, weakness, chest pain, racing
heart rate, and shortness of breath.
(Source: http://www.healthblurbs.com/blood-countscauses-for-low-high-red-and-white-blood-cell-count/)
Fatigue occurs in 14% to 96% of people with cancer,

especially those receiving treatment for their
cancer. Fatigue is complex, and has biological,
psychological, and behavioral causes. Fatigue is
difficult to describe and people with cancer may
express it in different ways. Fatigue can become a
very important issue in the life of a person with
cancer. It may affect how the person feels about
him- or herself, his or her daily activities, family
care, and relationships with others.
(Source:http://www.cancer.gov/cancertopics)
g ADLs
demonstr
ate
increase
in
physical
activity
such as
sitting,
standing,
ambulatin
g, and
self-care
appear
more
awake
and nondrowsy
illness.
2. Assessed
the
individuals
usual level
of physical
activity.
3. Observed
for pain
before
activity.
4. Provided a
calm, quiet
environme
nt to
minimize
stimuli
5. Provided
an
environme
nt
conducive
to relieve
fatigue
such as
proper
contribute to fatigue
and to serve as
baseline data for
future evaluation of
interventions.
R: Pain restricts the
client from achieving
maximal activity
level and is often
exacerbated by
movement.
R: Bright lighting,
noise, visitors and
frequent distraction
can inhibit
relaxation, interrupt
rest or sleep and
contribute to fatigue.
R: To promote rest.
R: Provides relief of
fatigue.
R: To enhance
ability to
SB:
Low red blood cell count (anemia)
leads to fatigue and weakness.
(Source:
http://www.healthcentral.com/ency/
408/000554.html)
When your body is in the state of a
low red blood cell count, it causes
low oxygen level symptoms of
fatigue, dizziness, weakness, chest
pain, racing heart rate, and
shortness of breath.
(Source:
http://www.healthblurbs.com/bloodcounts-causes-for-low-high-red-andwhite-blood-cell-count/)
Fatigue occurs in 14% to 96% of

people with cancer, especially those
receiving treatment for their cancer.
Fatigue is complex, and has
biological,
psychological,
and
behavioral
causes.
Fatigue
is
difficult to describe and people with
cancer may express it in different
ways. Fatigue can become a very
important issue in the life of a
person with cancer. It may affect
how the person feels about him- or
ventilation.
6. Positioned
individual
comfortabl
y in bed.
7. Afforded
rest and
sleep.
8. Promoted
comfort
measures
such as
providing
therapeutic
touch, and
provided
for relief of
pain such
as back
rubs.
9.
Encourage
d to
develop
habits to
promote
effective
rest/sleep
participate in
activities
R: Exercise can
reduce fatigue
and help the
individual build
endurance for
physical activity.
R: Promoting
relaxation before
sleep and
providing for
several hours of
uninterrupted
sleep can
contribute to
energy
restoration.
R: A plan that
balances periods
of activity with
periods of rest can
help the individual
complete desired
activities without
adding to levels of
fatigue.
R: To let the
individual feel
secure when
herself, his or her daily activities,

family care, and relationships with
others.
(Source:http://www.cancer.gov/canc
ertopics)
patterns.
10.Assisted
the
individual
to develop
a schedule
for daily
activity
and rest.
11.Encourage
d S.O to
stay at
individuals
bed side at
all times.
12.Asked to
verbalize
ways on
how to
manage
fatigue.
13.Observed
physical
signs of
fatigue
(restlessne
ss and
hand
sleeping.
R: Making definite
plans increases
the likelihood that
the client will cope
more effectively in
similar situation.
R: To note
congruency
between
subjective and
objective data
obtained.
R: When concerns
are stated at loud,
problems can be
discussed reducing
possibility of stress, a
contributing factor to
fatigue
R: Clients
eagerness to help
own self aids in
his faster
recovery.
tremors).
14.Encourage
d to share
impact of
illness on
lifestyle
and
compared
it to
previous/n
ormal
activity
level.
15.Participate
d in the
treatment
of
condition
by taking
enough
rest and
conserving
energy
while in
the
hospital.
8. Partial Self-care deficit related to weakness
and fatigue as manifested by need of assistance in
performing ADLS such as bathing, dressing and
toileting with the verbalization of Manginahanglan
gihapon ko ug tabang para maligo ug mag-ilis. Dili
Within 8 hours
of
nursing
interventions,
the
individual
will be able to:
1. Assessed
individuals
tolerance
level to
specific
R: to have a baseline
data on which ADL
the individual needs
to be assisted fully or
partially and which
March 1, 2013
Within
8
hours
of
nursing
able to:
verbalize discover the
man ko makaligo diri kay higda ra man ko, trapo

trapo lang sa mi.
SB: Factors such as regression, pain, anxiety,
fatigue, weakness, cognitive impairment, or
depression may alter clients ability to perform selfcare, resulting to self-care deficit. (Shives, Louise
Rebraca. Psychiatric Mental Health Nursing 7 th
Edition. p 158)
discover
the
barriers in
performin
g self-care
activities
and apply
technique
s to
overcome
these
barriers
rest well
for an
adequate
period of
time
verbalize
decreased
fatigue
and
weakness
in
performin
g ADLs
demonstr
ate
increasing
independ
ence in
performin
g ADLs
such as
changing
clothing,
sponge
ADLs
2. Inspected
skin
regularly.
3. Allowed
sufficient
time for
client to
accomplish
tasks to
fullest
extent of
ability.
4. Stressed
necessity
of allowing
for
frequent
rest
periods
following
activities.
5. Monitored
increase in
independe
nt ADL
performanc
does not need

assistance at all
R: Scaling of skin
due to dryness
may indicate
poor self-care
and signal need
for closer
monitoring. Signs
of inflammation
may also be
noted.
R: Shows health
providers
support and
willingness to
attend to clients
needs.
R: Preventing
increase in level
of fatigue.
R: to evaluate
effectivity of care
and health
teachings and
planning with
individual
R: to build a
trusting
relationship and
barriers in performing selfcare activities such as limited

mobility, weakness, and
fatigue
plan for techniques to
overcome identified barriers
Understand the need of rest
periods to regain energy as
manifested by his
verbalization Aww, sa akong
kundisyon ron, mas gi
kinahanglan jud ang
pagpahuway kay para di
kaayo ko dali kapuyon.
verbalize kapoy gihapon ako
paminaw bisan nakapahuway
na ko.
Perform ADLs such as
changing clothing, grooming,
oral care, but still with full
assistance of SO
March 2, 2013
Within
8
hours
of
nursing
able to:
apply techniques such as
energy conservation, rest,
and exercise to overcome
identified self-care barriers
have adequate rest
verbalize Kapoy gihapon ako
paminaw pero arang-arang
na kay makalihok-lihok na ko
gamay
bathing,
grooming,
oral care,
and
voiding
and
defecatin
g
e
6. Established
rapport
with
individual
7. Assisted
individual
in
identifying
the
different
barriers in
self-care
8. Assessed
for the
individuals
view in
achieving
his ADLS
and how
his present
condition
affects it.
9. Planned
with
individual
on what
techniques
to decrease
individuals
anxiety in asking
for assistance
R: identifying
problems with
the individual
gives them the
sense of
participating in
their plan of care
R: Individual
individuals view
may vary and it
serves as basis
for primary
interventions by
healthcare
providers.
R: Enhances
commitment to
plan, optimizing
outcomes.
R: Enhances
coordination and
continuity of
care.
R. Eases
frustration over
lost
independence.
Perform ADLs such as

changing clothing, oral care
but still with assistance of
nurses and SO
to use to
overcome
identified
barriers.
10.Communic
ated plan
of care to
other
caregivers
11.Supervised
but allow
as much
autonomy
as
possible.
Date Identified: March 1, 2013
9. Readiness for enhanced learning related to
interest in acquiring new information regarding
current condition
Cues:
willingness to know how feeding goes
Kabiven drip
having a positive attitude with regards to
condition
SB: Individual interest has been viewed as a
relatively long-lasting predisposition to reengage
with particular objects and events. Increased
knowledge, value, and positive affect have been
connected with individual interest. Situational
interest refers to a psychological state elicited by
environmental stimuli. The state is characterized by
focused attention and an immediate affective
Within 1 hour of
nurse-individual
interaction, the
individual will be
able to:
identify
and ask
questions
regarding
his
condition
Identify
and ask
questions
about the
equipme
nts
around
1. Determine
d
motivation
for learning
2. Provided
adequate
information
regarding
feeding.
3. Encourage
d to
verbalize
any
clarificatio
ns needed.
R: Provides insight
useful in
developing
goals and
identifying
information
needs
R: to aid client
know better of
his condition.
R: to aid in clients
gaining of
information.
R: to correct
misconceptions
Within 1 hour of nurse-individual

to:
ask and was clarified about
the information of the
Kabiven drip and how
parenteral nutrition is
recommended when oral or
enteral nutrition is
insufficient, impossible or
contraindicated
understand why the infusion
mat is needed for infusing
Kabiven
reaction. The affective component is generally

positive, although it may also include some
negative emotions.
(Source: Alexander, Patricia A.; Jetton, T. L.; and
Kulikowich, Jonna M. 1995. "Interrelationship of
Knowledge, Interest, and Recall: Assessing a Model
of Domain Learning." Journal of Educational
Psychology 87:559 - 575.)
X.
him
(Infusion
mat and
Kabiven
drip)
4. Encourage
d client to
verbalize
any
misunderst
andings or
misconcept
ions heard.
immediately
and intervened
with the correct
way
DISCHARGE PLAN
MEDICATIONS
Instructed to take the medications as to the right route, dosage, amount and timing
Advised SO to monitor patients intake of medication, especially those for maintenance.
Instructed to keep taking drugs within full course treatment.
Instructed not to stop drugs abruptly or double dose without consulting the physician.
Encouraged not to self-medicate.
Instructed patient and SO to check the expiry date of drugs.
ACTIVITIES of DAILY LIVING
Advised patient to avoid stressing oneself and avoid doing strenuous activities such as carrying heavy objects.
Stressed importance of adequate rest and sleep.
Encouraged to do regular exercise such as walking and jogging at least 3 times a week.
Instructed to ask assistance in performing Activities of Daily Living especially those activities that the patient might have difficulty performing with.
Encouraged to have relaxation activities such as listening to music, reading, and deep breathing exercise.
TREATMENT
Stressed importance of hand washing and encouraged patient to make it a habit.
Advised to do proper personal hygiene (e.g. skin care and oral care).
Encouraged family to be active and give their full support on the patients disease management.
Advised patient to report to the nearest health facility if there are unusual signs and symptoms manifested.
Encouraged to have regular check-up with his attending physician.
HEALTH TEACHING
Environment
Encouraged to maintain a safe home free from any hazards such as sharp objects, chemicals and matches.
Encouraged to provide adequate lightning on stairs and bathrooms to avoid injury or any accidents.
Encouraged to maintain cleanliness of the house and surroundings, minimizing allergens such as dust and pollens.
Advised patient to keep the floor dry all the times and free from obstacles to avoid accidents.
Advised patient to maintain a good personal relationship with relatives and friends and to communicate as openly as possible as a mean of stress
relief.
Instructed patient and significant others to keep patients environment clean, neat/in order and well-ventilated.
Coping and Spirituality
Encouraged to develop personal relationship with God and talk to Him daily.
Encouraged patient to strengthen his faith in the Lord despite his present condition.
Advised patient to pray regularly and to go to Church every Sunday with the family.
Encouraged family to express their love and support.
Encouraged family to extend their patience whenever they are taking care of the patient, which can be demanding at times.
Encouraged patient and significant others to maintain a loving and harmonious relationship.
DIET
Instructed patient to read labels and be cautious of his food intake which may contraindicate the maintenance medications and so as to control blood
glucose levels.
Encouraged patient to continue low salt diet such as fresh fruits, vegetables, lean meat, poultry and unprocessed grains
Avoid high salt and high fat, cholesterol diet such as dairy products, grains, cereals, junk foods, condiments and other processed foods.
Advised patient not to eat too much sweet food such as pastries, soda and candies.
Encouraged patient to take a well-balanced diet of carbohydrates, protein and fiber like wheat, rice, bread, fish, red meat, fruits.
Encouraged to eat foods rich in iron such as organ meat and cereals.
FINAL DIAGNOSIS
1. Cardiopulmonary Arrest secondary to Septic Shock secondary to Pneumonia-High Risk with Multi-organ Failure
(Cardiac/Pulmonary/Renal/Gastrointestinal)
2. Colonic Adenocarcinoma
3. Hypertensive Cardiovascular Disease
4. Chronic Lung Disease
5. S/P Explore Lap/ Right Hemicolectomy
Appendix A
Sources and References:
http://www.cap.org/apps/docs/reference/myBiopsy/ColonAdenocarcinoma.pdf
http://www.chas.sg/chronicdisease
http://www.birminghambowelclinic.co.uk/treatments-right-hemicolectomy/
http://www.rightdiagnosis.com/c/cardiac_arrest/
Smeltzer, S., Bare, B.(2004) Brunner & Suddarths Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott
Williams & Wilkins
National Cancer Institute (2009) .Colon and Rectal Cancer. Retrieved May 9, 2010 from
http://www.cancer.gov/cancertopics/types/colon-and-rectal
Group 1 would like to thank our Almighty Father for his blessings and divine guidance throughout the course of preparation and presentation of this case.
We would also like to express our gratitude to the patient, Mr. A and his family for trusting us, for their patience and accommodation throughout the whole
course of hospitalization and even during the making of this case presentation. Also, to Mr. Nestor Ibanez for giving us this opportunity to grow as nurses
and helping us continue our education and learning beyond the classroom and school settings. To OSPA-FMC for giving us the chance to be part of the
nursing service family and for bringing us to where we are now, better and skilled professionals.
Appendix B
DRUG STUDY
DRUG
CLASSIFICA
TION
Irbesartan
(Aprovel)
Angiotensin II
Antagonist
MECHANISM OF ACTION
INDICATION
CONTRAIN
DICATION
ADVERSE EFFECTS
NURSING RESPONSIBILITIES
PO Medications
Irbesartan is a potent, orallyactive, selective angiotensin II
receptor (type AT1) antagonist.
It is expected to block all actions
Treatment of essential
hypertension.
Treatment of renal
disease on patients
>Hypersensitivity to
irbesartan or any
component of
Aprovel.
Hyperkalemia
Headache
Dizziness
Orthostatic
1.Monitor vital signs especially the

patients blood pressure before drug
administration (for baseline data) and
after drug administration.
of angiotensin II mediated by the

AT1 receptor, regardless of the
source or route of synthesis of
angiotensin II. The selective
antagonism of the angiotensin II
(AT1)
receptors
results
in
increases in plasma renin levels
and angiotensin II levels and a
decrease in plasma aldosterone
concentration. Irbesartan lowers
blood pressure with minimal
change in heart rate.
Montelukast inhibitsbronchocons
triction
due
toantigenchallenge.Montelukast
is
aselectiveleukotrienereceptorant
agonist
of
thecysteinylleukotrieneCysLT
1receptor.Thecysteinylleukotrien
es(LTC4, LTD4,LTE
4)
are
products
of arachidonicacidmetabolism
that are
releasedfrom
variouscells, includingmast cells
andeosinophils.They
bind
tocysteinylleukotrienereceptors(
CysLT) found inthe humanairway
with hypertension and ty

pe 2 diabetes mellitus as
part of an
antihypertensive drug
regimen.
>Pregnancy and
Lactation: As a
precautionary
measure, irbesartan
should preferably
not be used during
the 1st trimester of
pregnancy.
Aprovel is
contraindicated
during lactation.
hypertension
2. Close monitoring of serum

potassium levelsto see if patient
experiences hyperkalemia
3. Instructed patient not to abruptly
stand or get out of bed as the drug
make cause dizziness.
Used in the systemic

treatment of obstructive
airway diseases.
>Severe renal or
hepatic impairment.
>Pregnancy &
lactation.
- Asthenia
- fatigue
- fever
- abdominal pain
- dyspepsia
- infectious
gastroenteritis
- dizziness
- headache
- nasal congestion
- cough
1.Instructed patient to avoid activities

requiring mental alertness like driving
as its side effect includes dizziness.
2. Monitor vital signs
3. Auscultate lung to assess presence
of adventitious breath sounds
Treatment of chronic &

habitual constipation
prevention & treatment
of portal systemic
encephalopathy (PSE)
including stages of
hepatic pre-coma & coma
For patients
w/ hemorrhoidsafter
colon/anal surgery or
other conditions where a
soft stool is beneficial.
Headache
toothache
fever associated with
>Galactosemia or
disaccharide
deficiency
> intestinal
obstruction
>galactose&/or
lactose-free diet.
- Abdominal cramping
- Abdominal
distension
- Belching
- Flatulence
- Excessive bowel
activity
- Nausea
- Vomiting
- Hypokalemia
- Hypernatremia
1.May be taken with or without food.

May be taken w/ meals to reduce GI
discomfort. Dilute w/ water, milk, or
fruit juice to improve taste.
2. Note characteristic, color,
consistency and amount of stool.
3. Asses abdominal status of patient
> Lactating mothers

> Liver damage
- Adverse effects at
therapeutic doses are
rare.

patients temperature
2. Instructed to perform Tepid Sponge
Levocetirizin
e+
Montelukast
(Zykast)
Antihistamines
&Antiallergics
Lactulose
(Movelax)
Laxative,
Osmotic
Constipation:
hyperosmotic
agent, increase stool water
contents, soften stool
Hepatic
encephalopathy:
breakdown
of
lactulose
to
organic acids (lactic, formic, &
acetic acids) by colonic bacteria
acidifies colonic contents which
subsequently inhibit diffusion of
ammonia back to blood
Paracetamol
Analgesics
(Non-Opioid) &
Antipyretics
Paracetamol
produces
antipyresis through action on
the
hypothalamic
heat-
Phosphosoda
Laxative,
Osmotic
Captopril
PRN for SBP
ACE inhibitors
150mmgH
regulating center and analgesia

by
elevation of
the
pain
threshold.
Fleet phospho soda works by
dehydrating the intestines in
order to clear the bowels and
produce a bowel movement. In
some cases, it can create
electrolyte imbalance and cause
calcium to build up in the
kidneys. The calcium collects to
form kidney stones and cause
phosphate nephropathy, renal
damage and, in some cases,
total kidney failure.
colds
menstrual and muscle
pain
Bowel preparation for
Colonoscopy
ACE
inhibitor,
competitive
inhibitor
of
angiotensin
converting enzyme
Captopril
prevents
the
conversion of angiotensin I to
angiotensin
II
(a
potent
vasoconstrictor)
through
inhibition of ACE by competing
with
physiologic
substrate
(angiotensin I) for active site of
ACE; inhibition of ACE initially
results in decreased plasma
angiotensin II concentrations &
consequently, blood pressure
may be reduced in part through
decreased
vasoconstriction,
increases renin activity, and
decreases aldosterone secretion;
Also increases renal blood flow.
Management of
HPN, heart
failure following MI &
diabetic nephropathy.
Bath
3. Afforded time to rest
> Kidney damage
- Possible QT interval
prolongation due to
electrolyte
imbalance
- Aspiration
- Bloating
- Colonic mucosal
ulceration
- Nausea
- Electrolyte
imbalance:
hyperphosphatemia,
hypocalcemia,
hypernatremia,
hypokalemia
- Metabolic acidosis,
dehydration
1.Should be taken on an empty

stomach. Take on an empty stomach 1
hr before or 2 hr after meals. Dilute
recommended dose w/ glass of
water, drink & follow w/ 1 full glass of
water.
2. Asses abdominal status
3. Note characteristic, color,
consistency and amount of stool.
>History of
angioedema
associated w/
previous ACE
inhibitor therapy
>hereditary/idiopath
ic
angioneuroticedema
>Pregnancy &
lactation.
- Hyperkalemia
- Hypersensitivity
reactions
- Skin rash
- Hypotension
- Pruritus
- Cough
- Chest pain
- Palpitations
- Proteinuria
- Tachycardia
- Cardiac arrest
- Orthostatic
Hypotension
- Dizziness
- Ataxia
- Confusion
- Depression
- Somnolence
- Angioedema
- Photosensitivity
- Neutropenia
- ARF if renal artery
1.Take the drug on empty stomach

patients blood pressure before and
after drug administration
make cause dizziness and orthostatic
HPN.
Metronidazol
e (Patryl,
Dazomet)
Antiamoebics
Inhibits nucleic acid synthesis by

disrupting
DNA;
amebicidal,
bactericidal, trichomonacidal
Treatment of the
following infections
caused by susceptible
microorganisms: Urogenit
al trichomoniasis, both
symptomatic and
asymptomatic;
amoebiasis; giardiasis;
vaginal infections
including bacterial
vaginosis; treatment of
medical and surgical
infections due to
susceptible anaerobic
pathogens.
> Patients with prior

hypersensitivity to
metronidazole or
nitroimidazole
derivatives.
>Use in
pregnancy: Metroni
dazole crosses the
placenta and enters
the fetal circulation
rapidly. Use of
metronidazole in the
1st-trimester of
pregnancy is
contraindicated. Its
potential benefits to
the mother should
be weighed against
the possible risks to
the fetus.
Ciprofloxacin
(Ciprobay)
Fluoroquinolon
es
Inhibits relaxation of DNA;

inhibits
DNA-gyrase
in
susceptible organisms; promotes
breakage of double-stranded
DNA
Infections of the resp

tract, middle ear, sinuses,
eyes, kidneys & urinary
tract, genital organs,
abdomen, skin & soft
tissues, bones &
joints; septicemia,
infections in patients w/
reduced host defense&
for selective intestinal
decontamination in
immunosuppressed
>Hypersensiti-vity to
ciprofloxacin or
other quinolones.
>Pregnancy &
lactation.
stenosis
- Renal impairment
- Impotence
- Appetite loss
- Candidiasis
- Diarrhea
- Dizziness
- Headache
- Nausea
- Vomiting
- Ataxia
- Dark urine
- Disulfiram-type
reaction with
ethanol
- Furry tongue
- Hypersensitivity
- Leukopenia
- Metallic taste
- Neuropathy
- Pancreatitis
- Seizures
- Thrombophlebitis
- Xerostomia
- Encephalopathy
- Aseptic meningitis
- Optic neuropathy
- Stevens-Johnson
syndrome
- Toxic epidermal
necrolysis
- Nausea, diarrhea,
vomiting, dyspepsia,
abdominal pain,
flatulence, anorexia,
dizziness, headache,
tiredness, agitation,
trembling. Very rarely,
insomnia, peripheral
paralgesia, sweating,
unsteady gait,
convulsions, increase in
intracranial pressure,
1. Culture and sensitivity studies

should be taken before taking the
drug.
2.Instruct patient to take the
medication with food as to avoid GI
irritation
3. Instruct patient to take the full
course of medication regimen as to
prevent resistance to the drug
4. Encourage to perform hand washing
frequently

drug.
2. Instruct patient to take the
irritation
3. Instructed not to take the
medication w/ antacids, Fe or dairy
products.
patients.
Sildenafil
(Neo-up)
Amlodipine
(Amvasc)
Drugs for
Erectile
Dysfunction
Calcium
Channel
Blocker
Sildenafil inhibits the cGMPspecific phosphodiesterase type

5 (PDE5) which is responsible for
degradation of cGMP in the
corpus
cavernosum
located
around the penis. Penile erection
during sexual stimulation is
caused by increased penile
blood flow resulting from the
relaxation of penile arteries and
corpus
cavernosal
smooth
muscle.
This
response
is
mediated by the release of nitric
oxide (NO) from nerve terminals
and endothelial cells, which
stimulates the synthesis of cGMP
in smooth muscle cells. Cyclic
GMP causes smooth muscle
relaxation and increased blood
flow
into
the
corpus
cavernosum. The inhibition of
phosphodiesterase
type
5
(PDE5) by sildenafil enhances
erectile function by increasing
the amount of cGMP.
Inhibits transmembrane influx of
extracellular calcium ions across
membranes of myocardial cells
and vascular smooth muscle
cells without changing serum
calcium
concentrations;
this
inhibits cardiac and vascular
smooth
muscle
contraction,
thereby dilating main coronary
For the treatment of

erectile dysfunction and
to relieve symptoms of
pulmonary arterial
hypertension (PAH).
>Patients taking
organic nitratecontaining food and
drugs.
> hepatic or severe
renal impairment
Treatment
of hypertension Prophyl
axis of angina.
amlodipine or any
dihydropyridine
calcium antagonist;
advanced aortic
stenosis because the
drug can worsen the
abnormal valve
pressure gradient
anxiety states,
nightmares, confusion,
depression,
hallucinations, impaired
taste & smell, visual
disturbances, tinnitus,
transitory impairment
of hearing, esp at high
frequencies, skin
reactions
- headache, flushing
and dyspepsia
- visual disturbances,
dizziness and nasal
congestion
- diarrhea, muscle pain,
skin rashes and urinary
or respiratory tract
infection
> priapism

frequently

2. Monitor vital signs especially the
make cause dizziness and orthostatic
HPN.
Edema
Headache
Fatigue
Palpitations
Dizziness
Nausea
Flushing
Abdominal pain
Somnolence
1.Monitor vital signs

2. Instructed to avoid high-fat diet as
this slows the effect of the drug as well
as to avoid drinking grapefruit juice if
using this drug.
3. Instruct patient to report difficult or
painful urination, rash, dizziness,
palpitations.
and systemic arteries
Ivbradine
(Coralan)
Anti-Anginal
Drugs
Ivabradine is a pure heart ratelowering

agent,
acting
by
selective and specific inhibition
of
the
cardiac
pacemaker Ifcurrent
that
controls
the
spontaneous
diastolic depolarization in the
sinus node and regulates heart
rate.
Treatment of Coronary
Artery Disease:
Symptomatic treatment
of chronic stable angina
pectoris in coronary
artery disease patients
with normal sinus rhythm.
Indicated in patients
unable to tolerate or with
a contraindication to the
use of -blockers or in
combination with blockers in patients
inadequately controlled
with an optimal -blocker
dose and whose heart
rate is >60 bpm.
Treatment of Chronic
Heart Failure
associated with this

condition; pregnant
women, women of
childbearing
potential or
breastfeeding
mothers; severe
liver failure; known
history of shock.
ivabradine or to any
excipients of
Coralan; resting
heart rate of <60
bpm prior to
treatment;
cardiogenic shock;
acute myocardial
infarction; severe
hypotension (<90/50
mmHg); severe
hepatic insufficiency;
sick sinus syndrome;
sino-atrial block;
pacemakerdependent; unstable
angina; AV-block of
3rd degree.
ISMN
(Elantan
Long)
Anti-Anginal
Drugs
Isosorbide-5-mononitrate causes
a relaxation of vascular smooth
muscle,
thereby
inducing
vasodilatation.
Both peripheral arteries and
veins are relaxed by isosorbide5-mononitrate. The latter effect
Long-term treatment
of coronary artery
disease
long-term treatment
and prevention of angina
pectoris (including post
myocardial infarction).
>Known
hypersensitivity to
the isosorbide-5mononitrate, to
other nitrates or
nitrites, or to any of
the excipients of
- Eye Disorders: Blurred

vision.
- Cardiovascular
Disorders: Bradycardia,
hypotension
Palpitations, Sinus
arrhythmia, unstable
angina, aggravated
angina pectoris, atrial
fibrillation, myocardial
ischemia, myocardial
infarction and
ventricular tachycardia.
- Gastrointestinal
Disorders: Nausea,
constipation and
diarrhea.
- General Disorders:
Headache
- Investigations:
Hyperuricemia,
eosinophilia, elevated
creatinine in blood.
- Skin and
subcutaneous tissue
disorders: rash,
Erythema, pruritus,
urticaria.
- Dizziness
- Headache
- Restlessness
- Hypotension
- Flushing
- Tachycardia
- Orthostatic

patients heart rate before and after
drug administration
2. Asses patient for any unusualities
such as palpiations
3. Instructed to avoid performing
strenuous activities such as lifting
heavy objects and encouraged to take
time to rest in between activities

patients heart rate before and after
drug administration
2. Asses patient for any unusualities
such as palpiations
3. Instructed to avoid performing
strenuous activities such as lifting
Celecoxib
(Celebrex)
NSAIDs
promotes venous pooling of

blood and decreases venous
return to the heart, thereby
reducing
ventricular
enddiastolic pressure and volume
(preload). The action on arterial
and at higher dosages arteriolar
vessels, reduce the systemic
vascular resistance (afterload).
This in turn reduces the cardiac
work.
Long-term treatment
of congestive heart
failure in combination
with digitalis and/or
diuretics.
Inhibits cyclooxygenase-2 (COX2); does not affect COX-1
Treatment of signs and

symptoms
of osteoarthritis and rheu
matoid arthritis.
Management and
treatment of postsurgical
Elantan.
>Acute myocardial
infarction with low
filling pressure, low
cardiac filling
pressures,
aortic/mitral valve
stenosis
> hypertrophic
obstructive
cardiomyopathy
(HOCM)
>constrictive
pericarditis
>cardiac tamponade
> acute circulatory
failure (shock,
vascular collapse)
> very low blood
pressure
>diseases
associated with a
raised intracranial
pressure eg,
following a head
trauma and
including cerebral
haemorrhage
>marked anemia
>closed angle
glaucoma;
hypovolemia
>during nitrate
therapy,
phosphodiesterase
inhibitors (eg,
sildenafil) must not
be used
>Patients with
known
hypersensitivity to
celecoxib and those
who have
demonstrated
hypotension
- Palpitations
- Syncope
- Methemoglobinemia
- Nausea
- Vomiting
heavy objects and encouraged to take

time to rest in between activities
- Headache
- Hypertension
- Fever
- Dyspepsia
- Upper respiratory
tract infection
1.Asses pain, noting the characteristic

of the pain, onset, location, severity,
pattern, and aggravating factors.
2. Note patients pain scale.
3. Monitor vital signs
4. Encourage diversional activities
Omeprazole
(Omepran)
Proton Pump
Inhibitors
Omeprazole is a potent inhibitor

of gastric acid secretion. It
reduces gastric acid secretion by
inhibiting the parietal cell H+-K+ATPase (proton pump) in gastric
parietal cells. This enzyme is
responsible for electroneural
exchange of H+ and K+ ions
during
the
formation
of
hydrochloric acid (HCl).
and dental pain and

acute
flarepain of osteoarthritis
Treatment of acute
pain, including primary
dysmenorrhea.
Relief of signs and
symptoms of ankylosing
spondylitis.
Regression and
reduction in the number
of adenomatous
colorectal polyps which
may lead to the
development of colorectal
cancer in patients with
familial adenomatous
polyposis (FAP), as an
adjunct to usual care (eg,
endoscopic surveillance,
surgery).
For acute and
chronic low back pain.
allergic-type
reactions to
sulfonamides.
>Celebrex should
not be given to
patients who have
experienced asthma,
urticaria or allergictype reactions after
taking aspirin or
other NSAIDs.
- Arthralgia
- Cough
- Vomiting
- Diarrhea
- Gastroesophageal
reflux
- Sinusitis
- Abdominal pain
- Nausea
- Back pain
- Insomnia
- Pharyngitis
- Flatulence
- Rash
- Dizziness
- Peripheral edema
- Erythema multiforme
- Exfoliative dermatitis
- Stevens-Johnson
Syndrome
- Toxic epidermal
necrolysis
- Anemia
- Hepatitis
- Jaundice
- Increase in serum
AST (SGOT)
concentrations
such as watching television, talking to

family and friends.
Benign gastric ulcer

duodenal ulcer
gastroesophageal reflux
disease (GERD)
Acid aspiration
prophylaxis.
omeprazole
- Dermatologic: Skin
rash, urticaria, pruritus.
- Gastrointestinal:
Constipation, diarrhea,
flatulence, nausea,
vomiting, acid
regurgitation,
abdominal pain.
- Others: Asthenia,
headache,
photosensitivity,
dizziness,
lightheadedness,
arthritic and myalgic
symptoms, paresthesia.
1. Assess GI system: bowel sounds,

abdomen for pain and
swelling, appetite loss.
2. Report any changes in urinary
elimination such as pain or discomfort
associated with urination, or blood in
urine.
3. Monitor urinalysis for hematuria and
proteinuria. Periodic liver function tests
with prolonged use.
4. Take medication before meals
NAcetylcystein
(Fluimucil)
dissolve in
glass water
Catapres SL
for SBP
100mmHg
Cough & Cold

Preparation
Mucolytic activity through its

sulfhydryl group, which opens
up disulfide bonds in the
mucoproteins
and
lowers
mucous viscosity of pulmonary
secretions
Alpha II
Agonists,
Central Acting
Central
sympatholytic
via
stimulation of central alpha
receptors; results in reduced
sympathetic outflow, causing
decreased PVR, HR, BP, and
renal
vascular
resistance;
produces
presynaptic
and
postjunctional
alpha-2
adrenoreceptor analgesia by
preventing
pain
signal
transmission to brain
2nd Generation
Cephalosphori
n
Binds
to
penicillin
binding
proteins
and
inhibits
final
transpeptidation
step
of
peptidoglycan
synthesis,
resulting in cell wall death.
Condition of patient, severity of
infection, and susceptibility of
microorganism determine proper
dose
and
route
of
administration.
Resists
degradation by beta-lactamase
Acute & chronic resp

tract infections w/
abundant mucus
secretions due to
acute bronchitis,
chronic bronchitis & its
exacerbations, pulmonary
emphysema& bronchiect
asis.
Hypertension
>Asthmatic
patients>Patients w/
history of peptic
ulceration
>foods containing
phenylketonurics
- urticaria,
bronchospasm, nausea,
vomiting
- Rhinitis, stomatitis
1.Auscultate lung fileds for

adventitious sounds
2. Note any unusualities such as
nausea and vomiting
3. Encourage to perform deep
breathing exercises
>Diseases affecting
rhythmic & AV
conduction system
of the heart; renal
failure.
- Skin reactions; patch

- Dry mouth
- Somnolence
- Headache
- Fatigue
- Drowsiness
- Dizziness
- Hypotension, epidural
- Postural hypotension,
epidural
- Anxiety
- Constipation
- Sedation
- Nausea/vomiting, PO
- Malaise
- Orthostatic
hypotension
- Anorexia, PO
- Abnormal LFTs
- Rash
- Weight gain, PO

- Diarrhea
- Decreased Hgb/Hct
- Eosinophilia
- Nausea/vomiting
- Vaginitis
- Transient rise in
hepatic transaminases
- Thrombophlebitis
- Transient neutropenia
& leukopenia
- Increase in BUN
&creatinine

drug.
2. Performed skin testing before the
drug is to be administered to the
patient
irritation
PARENTERAL
Cefuroxime
(Ambixime)
Pharyngitis/Tonsillitis
Acute Bacterial
Maxillary Sinusitis
Acute Bacterial
Exacerbations of Chronic
Bronchitis
Secondary Bacterial
Infections of Acute
Bronchitis
Uncomplicated
Pneumonia
Uncomplicated Skin &
>History of
hypersensitivity to
cefuroxime or other
cephalosporinseg,
cephalexin.
Skin Structure Infections

Uncomplicated Urinary
Tract Infections
Uncomplicated
Gonorrhea
Disseminated
Gonorrhea
Early Lyme Disease
Renal Impairment
Other Indications &
Uses
B. burgdorferi, E. coli, H.
influenzae, Klebsiella
spp., M. catarrhalis, N.
gonorrhoeae, P. mirabilis,
S. pneumoniae, S.
pyogenes
Metronidazol
e (Zol)
Antiamoebics
Inhibits nucleic acid synthesis by

disrupting DNA; amebicidal,
bactericidal, trichomonacidal
Tranexamic
Acid (Fibrex)
Haemostatics
Tranexamic acid is a synthetic

derivative of the amino acid
lysine.
It
exerts
its
antifibrinolytic effect through the
reversible blockade of lysinebinding sites on plasminogen
molecules. Anti-fibrinolytic drug
Treatment of infections
caused by susceptible
anaerobic
microorganismsPerioper
eative prophylaxis to
reduce the incidence of
postoperative bacterial
infections in patients at
high risk for such
infections
Treatment of intestinal
and extraintestinal or
invasive amoebiasis inclu
ding amoebic liver
abscess
Treatment of pelvic
inflammatory disease
(PID) in combination with
fluoroquinolones.
Tranexamic acid is used
for the prompt and
effective control
of hemorrhage in various
surgical and clinical area.
>1st trimester of
pregnancy w/
trichomoniasis. >
Lactation
>Not advisable to
use for prolonged
periods in patients
predisposed to
thrombosis. >Not
recommended for
prophylaxis during
- Rash

frequently
- GI upset
- burning sensation in
the tongue
- metallic taste
- overgrowth of
Candida
- rash
- urticarial
- Headache
- dizziness
- somnolence
- incoordination
- depression
- Drug fever
- darkened urine
- mild leukopenia
- Peripheral neuropathy
- myalgia&paresthesia
after high doses.
- GI disorders: nausea,
vomiting, anorexia
- headache
- impaired renal
insufficiency
- hypotension when IV
injection is too rapid.

drug.
patient
irritation
frequently
1.IVTT form: Inject the medication

slowly to prevent persistence of
hypotension.
2. Note bleeding pattern and report
unusual changes.
3. Ensure patients safety. Avoid sharp
objects and prevent patient from fall.
inhibits
endometrial
plasminogen activator and thus
prevents fibrinolysis and the
breakdown of blood clots. The
plasminogen-plasmin
enzyme
system is known to cause
coagulation defects through lytic
activity on fibrinogen, fibrin and
other
clotting
factors.
By
inhibiting the action of plasmin
(finronolysin) the anti-fibrinolytic
agents
reduce
excessive
breakdown of fibrin and effect
physiological hemostasis.
Vitamin K
(Pytogen)
Hemostatic,
Vitamin, Fat
soluble
Omeprazole
(Zefxon)
Proton Pump
Inhibitors
Omeprazole is a potent inhibitor

of gastric acid secretion. It
reduces gastric acid secretion by
inhibiting the parietal cell H+-K+ATPase (proton pump) in gastric
parietal cells. This enzyme is
responsible for electroneural
exchange of H+ and K+ ions
during the formation of
hydrochloric acid (HCl).
pregnancy & before

delivery.
>Current
administration of
factor
IXcomplexconcentrat
es or anti-inhibitor
coagulant
concentrates
For Reversal of
Warfarin Effects
Coagulation disorders
due to decreased
formation of phytondependent factors II, VII,
IX, and X, anticoagulant
induced
hypoprothrombinemia,
prophylaxis & treatment
of hemorrhagic disease of
newborns
Reversal of warfarin
anticoagulant effects
(CAUTION: INR decrease
may take 24-48 hr; too
much phytonadione can
cause warfarin resistance
for up to one week)
-lactating women
-people with
metabolic condituin
called Glocuse-6phosphate
dehydrogenase
deficiency
-people who take
warfarin
- Flushing
- Taste alterations
- Dyspnea
- Hypotension
- Anaphylaxis with rapid
IV (has resulted in
death)
- Hyperbilirubinemia
(premature neonates)
-monitor patient constantly. Severe

reactions, including fatalities, have
occurred during and immediately after
IV injections.
Benign gastric ulcer

duodenal ulcer
gastroesophageal reflux
disease (GERD)
Acid aspiration
prophylaxis.
omeprazole
- Dermatologic: Skin
rash, urticaria, pruritus.
- Gastrointestinal:
Constipation, diarrhea,
flatulence, nausea,
vomiting, acid
regurgitation,
abdominal pain.
- Others: Asthenia,
headache,
1. Assess GI system: bowel sounds,

abdomen for pain and
swelling, appetite loss.
2. Report any changes in urinary
elimination such as pain or discomfort
associated with urination, or blood in
urine.
3. Monitor urinalysis for hematuria and
proteinuria. Periodic liver function tests
with prolonged use.
Furosemide
Tramadol
Loop diuretics
Loop
diuretic;
inhibits
reabsorption of Na+ and Cl- at
proximal and distal renal tubules
and loop of Henle. By interfering
with
the
chloride
binding
cotransport system, it cuases an
increase in water, calcium,
magnesium,
sodium,
and
chloride.
Edema
Indicated for edema
associated with
congestive heart failure,
liver cirrhosis, and renal
disease, including
nephrotic syndrome
Refractory CHF may
require larger doses
Pulmonary edema
Hypertension
Acute Pulmonary
Edema/Hypertensive
Crisis/Increased ICP
Hyperkalemia
Hypermagnesemia
Renal Impairment
Hepatic Impairment
Other Indications &
Uses
Use when fluid-retention
refractory to thiazides, or
impaired renal function
-patients with anuria

-hypersensitivity to
furosemide
Opioid
Analgesics
Nonopioid
derived
synthetic
opioid,
centrally
acting
analgesic, but may act at least
partially by binding to opioid
receptors
Moderate-Severe
Pain
Immediate-release
Orally Disintegrating
Renal Impairment
Hepatic Impairment
HIV-Associated
Neuropathy
tramadol or any
other component of
this product or
opiods.
-lactation
-pregnancy
photosensitivity,
dizziness,
lightheadedness,
arthritic and myalgic
symptoms, paresthesia.
- Hyperuricemia
- Hypokalemia
- Hypomagnesemia
- Hypocalcemia
- Glucose intolerance
- Glycosuria
- Urinary frequency
- Anorexia
- Diarrhea
- Nausea
- Dizziness
- Headache
- Restlessness
- Weakness
- Hypotension
- Vertigo
- Hearing impairment
- Tinnitus
- Muscle cramps
- Anaphylaxis
- Rash
- Urticaria
- Photosensitivity
- Increased patent
ductusarteriosus during
neonatal period
- Anemia
- Fever
- Oral irritation
- Perspiration
4. Take medication before meals
-assess type, location, and intensity of

pain before and 2-3hr peak after
administration.
-assess BP and RR before and
periodically during administration.
-assess previous analgesic history.
Dizziness
Vertigo
Constipation
Nausea
Headache
Somnolence
Vomiting
Pruritus
Overdose Management
May use normal saline for volume
replacement
May use dopamine or norepinephrine
to treat hypotension
If dysrhythmia due to decreased K+ or
Mg+ suspected replace aggressively
Discontinue treatment if no symptoms
after 6hr
Postherpetic
Neuralgia
- Agitation
- Anxiety
- Emotional lability
- Euphoria
- Hallucinations
- Nervousness
- Spasticity
- Asthenia
- Dyspepsia
- Sweating
- Diarrhea
- Dry mouth
- Hypertonia
- Malaise
- Menopausal
symptoms
- Rash
- Urinary retention
- Urinary frequency
- Vasodilation
- Visual disturbance
- Abnormal gait
- Amnesia
- Cognitive dysfunction
- Depression
- Difficulty in
concentration
- Dysphoria
- Dysuria
- Fatigue
- Hallucinations
- Menstrual disorder
- Motor system
weakness
- Orthostatic
hypotension
- Paresthesia
- Seizures
- Suicidal tendencies
- Syncope
- Tremor
- Tachycardia
- Abnormal ECG
- Angioedema
Ketorolac
(Ketomed)
NSAIDs
Inhibits
synthesis
of
prostaglandins in body tissues
by
inhibiting
at
least
2
cyclooxygenase
isoenzymes,
cyclooxygenase-1 (COX-1) and
-2 (COX-2)
May inhibit chemotaxis, may
alter
lymphocyte
activity,
decrease
proinflammatory
cytokine activity, and may
inhibit neutrophil aggregation.
These effects may contribute to
its anti-inflammatory activity
Moderately Severe
Acute Pain
Renal Impairment
Hepatic Impairment
-hypersensitivity
-cross-sensitivity
with other NSAIDs
-history of gi
bleeding
-renal impairement
-cardiovascular ds.
Bronchospasm
Flushing
Hypertension
Hypotension
Myocardial ischemia
Palpitation
Urticaria
Withdrawal syndrome
- Dyspepsia
- Headache
- GI pain
- Nausea
- Somnolence
- Constipation
- Diarrhea
- Dizziness
- Drowsiness
- Edema
- Hypertension
- Increased BUN
- Increased serum Cr
- Pallor
- Purpura
- Pruritus
- Vasodilation
- Abnormal thinking
- Anaphylaxis
- Blurred vision
- Bronchospasm
- Cholestatic jaundice
- Depression
- Difficulty in
concentration
- Dysgeusia
- Euphoria
- Hemolytic-uremic
syndrome
- Hepatitis
- Hyperkalemia
- Hyponatremia
- Hypotension
- Increased LFTs
- Insomnia
-patients who have asthma, aspirininduced allergy, and nasal polyps are
at increased risk for developing
hypersensitivity reactions. Assess for
rhinitis, asthma and urticaria.
-assess pain
Advise patient to consult if rash,
itching, visual disturbances, tinnitus,
weight gain, edema, black stools,
persistent headache.
- Laryngeal/lingual
edema
- Liver failure
- Melena
- Nervousness
- Oliguria
- Pallor
- Peptic ulcer
- Rash
- Rectal bleeding
- Stomatitis
- Urinary frequency
- Urinary retention
- Vasodilation
Piperacillin +
Tazobactam
(Vigocid)
Paracetamol
for fever T
380C
Antiinfective;
Beta-lactam
antibiotic;
antipsuedomonal
penicillin
Analgesics
(non- opoid)
Antipyretics
It is similar to that of other

penicillins interfere with
bacterial cell wall synthesis
promotes loss of membrane
integrity and leads to death of
the organism.
Inhibits the synthesis of

prostaglandins that may serve
as mediators of pain and fever,
primarily in the CNS
Treatment of moderate to
severe appendicitis,
uncomplicated and
complicated skin and skin
structure infections,
nosocomial or
community-acquired
pneumonia cased
piperacillin- resistant,
piperacillin/tazobactam
susceptible, beta
lactamase producing
bacteria.
History of allergic
reactions to
penicillins,
cephlosporins, betalactamase inhibitors.
Mild pain
Fever
Hypersensitivity to
paracetamol or
intolerance to the
medication.
CNS: headache,
insomnia,fever
GI: diarrhea, nausea,
constipation, vomiting,
pseudomembranous
colitis
SKIN: hypersensitivity
reactions, rash, pruritus
Hema: haemolytic
anemia, neutropenia,
leukopenia,
pancytopenia
Hepa: jaundice
GI: hepatic failure,
hepatotoxity(overdose)
GU: renal failure (high
doses/ chronic use)
DERM: rash, urticaria

drug.
patient
irritation
frequently
-advise patients to check
concentrations of liquid preparations.
-assess fever, note presence of
associated sighns (tachycardia and
malaise.)
Digoxin
(Lanoxin)
Antidysrhythm
ic, Inotropic
agent
In
heart
failure,
increases
contractility
by
inhibiting
sodium/potassium ATPase pump
in
myocardial
cells,
which
subsequently promotes calcium
influx
via
sodium-calcium
exchange pump
In supraventricular arrhythmias,
suppresses AV node conduction,
which
increases
refractory
period
and
decreases
conduction velocity,
causing
positive
inotropic
effect,
decreased ventricular rate, and
enhanced vagal tone
Heart Failure, Atrial

Fibrillation
-Digitalis toxicity,
ventricular
tachycardia/fibrillatio
n, obstructive
cardiomyopathy.
-Arrhythmias due to
accessory pathways
- Dizziness
- Mental disturbances
- Diarrhea
- Headache
- Nausea
- Vomiting
- Maculopapular rash
- Anorexia
- Cardiac dysrhythmia
- Arrhythmia in children
(consider a toxicity)
- Visual disturbance
(blurred or yellow
vision)
- Heart block
- Asystole
- Tachycardia
Monitor apical pulse for 1minute before

administering; hold dose if pulse <60
in adult or <90 in infant; retake pulse
in 1 hr. If adult remains <60 or infant
<90, hold drug and notify prescriber.
Note any change from baseline rythm
or rate
Levofloxacin
(Floxel)
Fluoroquinolon
e
Inhibits DNA gyrase activity

L stereoisomer of the D/L parent
compound ofloxacin, the Disomer form is inactive
Good
monotherapy
with
extended
coverage
against
Pseudomonas species, as well as
excellent
activity
against
pneumococcus
Community Acquired
Pneumonia
Nosocomial
Pneumonia
Acute Bacterial
Sinusitis
Acute Bacterial
Exacerbation of
Chronic Bronchitis
Inhalational Anthrax,
Post-Exposure
Complicated
Skin/Skin Structure
Infections
Uncomplicated
Skin/Skin Structure
Infections
Chronic Bacterial
Prostatitis
Complicated
UTI/Acute
Pyelonephritis
Uncomplicated UTI
Plague
Indication: Treatment of
Yersinia pestis(plague);
-sensitivity reaction
and allergic reaction
to medication.
- Taste disturbance
- Nausea
- Headache
- Diarrhea
- Insomnia
- Pharyngitis
- Constipation
- Dizziness
- Dyspepsia
- Vomiting
- Rash
- Pruritus
- Chest pain
- Edema
- Fatigue
- Moniliasis
- Injection site reaction
- Pain
- Vaginitis
- Cardiac disorders:
Cardiac arrest,
palpitation, ventricular
tachycardia and
arrhythmia
- Nervous system
disorders: Tremor,
Administration
Administer without regard to food
Recommended that the oral solution
be taken 1hr before or 2hr after eating
drug.
patient
irritation
frequently
also indicated for

prophylaxis (following
exposure)
Pseudomonas
aeruginosaPulmonar
y Infection
Treatment of pulmonary
infections due to
Pseudomonas aeruginosa
and other bacteria in
patients with cystic
fibrosis patients
Renal Impairment
Administration
Administer without regard
to food
Recommended that the
oral solution be taken 1hr
before or 2hr after eating
Other Indications &
Uses
Aeromonashydrophila,
Campylobacter jejuni,
Citrobacterdiversus,
Citrobacterfreundii,
Chlamydia pneumoniae,
Enterococcus faecalis,
Enterobacter cloacae, E.
coli, H. influenzae, H.
parainfluenzae,
Klebsiellapneumoniae,
Legionella pneumophila,
Morganellamorganii, M.
catarrhalis, Proteus
mirabilis, Providenciaspp,
Pseudomonas
aeruginosa, Serratiaspp,
Staphylococcus aureus,
Streptococcus
pneumoniae, S.
pyogenes,
Ureaplasmaurealyticum
First Line: Campylobacter
jejuni, Citrobacterfreundii,
convulsions,
paresthesia, vertigo,
hypertonia,
hyperkinesias,
abnormal gait,
somnolence, syncope
- Metabolic disorders :
hypoglycemia,
hyperglycemia,
hyperkalemia
- Blood/lymphatic
system disorders:
anemia,
thrombocytopenia,
granulocytopenia
- Musculoskeletal
/connective tissue
disorders : arthralgia,
tendonitis, myalgia,
skeletal pain
- GI disorders: gastritis,
stomatitis, pancreatitis,
esophagitis,
gastroenteritis,
glossitis,
pseudomembranous/C.
difficile colitis
Hepatobiliary disorders:
abnormal hepatic
function, incr hepatic
enzymes, incr alkaline
phosphatase
- Psychiatric disorders:
Anxiety, agitation,
confusion, depression,
hallucinations,
nightmares, sleep
disorder, anorexia,
abnormal dreaming
- Immune
hypersensitivity
reaction
- Acute renal failure
- Urticaria
Enterobacterspp (others,
egAeromonashydrophila,
Legionella pneumophila,
Morganellamorganii not
unanimous)
- Phlebitis
- Epistaxis
- Musculoskeletal and
connective tissue
disorders: Tendon
rupture, muscle injury,
rhabdomyolysis
- Skin and
subcutaneous tissue
disorders: StevenJohnson Syndrome,
toxic epidermal
necrolysis, erythema
multiforme,
photosensitivity/photot
oxicity
- Blood and lymphatic
system disorders:
pancytopenia, aplastic
anemia, leukopenia,
hemolyticanemia,
eosinophilia
- Hepatobiliary
disorders: Hepatic
failure, hepatitis,
jaundice
- Psychiatric disorders:
Psychosis, paranoia,
suicidal ideation,
isolated reports of
suicide attempts
- Nervous system
disorders: exacerbation
of myasthenia gravis,
anosmia, ageusia,
parosmia, dysgeusia,
peripheral neuropathy,
abnormal EEG,
dysphonia, isolated
reports of
encephalopathy
- Hypersensitivity
reactions
- Cardiac disorders:
Prolonged QT interval;
torsades de pointes
- Visual disturbances
- Ear disorders:
hypoacusis, tinnitus
- Interstitial nephritis
- Multi-organ failure
- Pyrexia
- Vasodilatation
Calcium
gluconate
Fluid and
Electrolytic
and water
balance agent;
replacement
solution.
Bone
mineral
component;
cofoactor
in
enzymatic
reactions,
essential
for
neurotransmission,
muscle
contraction, and many signal
transduction pathways
Hydrocortiso
ne
(Solucortef)
Corticosteroid
s
Controls
or
prevents
inflammation by controling the
rate
of
protein
synthesis,
suppressing migration of PMNs &
fibroblasts, & reversing capillary
permeability
Hypocalcemia
Treatment of conditions
arising from calcium
deficiency (eg,
hypocalcemictetany,
hypoparathyroidism)
Cardiac Arrest
Management of cardiac
arrest only in presence of
hyperkalemia,
hypocalcemia, or
hypermagnesemia
(routine use for cardiac
arrest not recommended,
because it yields no
improvement in survival)
Hydrofluoric Acid
Burn
Calcium
Channel Blocker
Overdose
Hyperkalemia
Hypermagnesemia
Anti-inflammatory &
Immunosuppressive
Status Asthmaticus
Adrenal Insufficiency
Other Indications &
Uses
Corticosteroid responsive
dermatoses,
inflammatory conditions,
hypercalcemia of
malignancy, shock
-Ventricular
fibrillation,
metastatic bone ds,
injection into
myocardium,
administration to SC
or IM routes; renal
calculi;
hypercalcemia.
-- Bradycardia
- Hypotension
- Headache
- Constipation
- Diarrhea
- Flatulence
- Nausea
- Vomiting
- Hypomagnesemia
- Hypophosphatemia
- Extravasation necrosis
-assess for cutaneous burning

sensations and peripheral vasodilation
with moderate fall in BP, during direct
IV injection.
-monitor ECG during IV administration
to detect evidence of hypercalcemia;
decreaced QT interval associated with
inverted T wave.
-observe IV site closely. Extravasation
may result in tissue irritation and
necrosis.
-monitor for hypocalcemia and
hypercalcemia.
-systemic fungal
infections and
known
hypersensitivity to
the drug or any
component of
formulation.
- Insomnia
- Indigestion
- Increased appetite
- Hirsutism
- Arthragia
- Cataract
- Epistaxis
- DM
- Adrenal suppression
- Psychosis
- Vertigo
-Give daily before 9 am to mimic

normal peak diurnal corticosteroid
levels and minimize hypothalamicpituitary- adrenal suppression.
-space multiple dose evenly
throughout the day.
- do not give IM injections if patient has
thrombocytopenic purpura.
-provide antacids between meals to
help avoid peptic ulcer.
- Pseudotumorcerebri
(on withdrawal)
- Acne
- Osteoporosis
- Myopathy
- Delayed wound
healing
Nalbuphine
(Nalphine)
Metoclopram
ide (Plasil)
Opioid
Analgesic
Narcotic agonist-analgesic of
kappa opiate receptors and
partial antagonist of mu opiate
receptors; inhibits ascending
pain pathways, which causes
alteration in response to pain;
produces analgesia, respiratory
depression, and sedation
Analgesia
Anesthesia
Supplement
Renal Impairment
Hepatic Impairment
Other Indications &
Uses
General/local anesthesia
adjunct, pain, pain/labor
nalbuphine,
sulphites
-lactation
- Sedation
- Clamminess
- N/V
- Dizziness
- Xerostomia
- Headace
- Vertigo
- Miosis
- Hypertension
- Hypotension
- Bradycardia
- Pulmonary edema
- Tachycardia
- Itching
- Burning
- Urticaria
- Respiratory
depression
- Dyspnea
- Asthma
-assess type, location, and intensity of

pain before and 2-3hr peak after
administration.
-assess BP and RR before and
periodically during administration.
-assess previous analgesic history.
Antiemetic,
Prokinetic
Agent
Blocks dopamine receptors in

chemoreceptor trigger zone of
CNS and sensitizes tissues to
acetylcholine; increases upper
GI motility but not secretions;
increases
lower
esophageal
sphincter tone
ChemotherapyInduced Nausea &

Vomiting
Diabetic
Gastroparesis
Small Bowel
Intubation/Radiologic
Examination of Upper
GI Tract
Gastroesophageal
Reflux Disease
Postoperative
Nausea & Vomiting
-sensitivity to
metoclopramide
-intolerance to
metoclopramice
-history of seizure
d/o
- Extrapyramidal
symptoms
- Fatigue
- Restlessness
- Sedation
- Diarrhea
- Nausea
- Galactorrhea
- Gynecomastia
- Impotence
- Menstrual disorders
- Neuroleptic malignant
syndrome
- Hematologic
abnormalities
-assess patient for nausea, vomiting

and abdominal distention and bowel
sounds before and after
administration.
-advise patient to avoid concurrent use
of alcohol and other CNS depressant
while taking this medication.
Hyoscine NButylbromide
(Buscopan)
Antispasmodic
;
Anticholinergic
Cefixime
(Cepiram)
3rd Generation
Cephalosphori
n
Hyoscine-n-butybromide (HNBB)
acts by interfering with the
transmission of nerve impulses
by acetylcholine in the
parasympathetic nervous
system.
Buscopan exerts a spasmolytic
action on the smooth muscle of
the gastrointestinal,biliary and
urinary tracts. As a quaternary
ammonium derivative, hyoscineN-butylbromide does not enter
the central nervous system.
Therefore, anticholinergic side
effects at the central nervous
system do not occur. Peripheral
anticholinergic effects result
from a ganglion-blocking action
within the visceral wall as well
as from anti-mascarinic activity.
Third-generation
oral
cephalosporin
with
broad
activity against gram-negative
bacteria. By binding to one or
more of the penicillin-binding
proteins, it arrests bacterial cell
wall synthesis and inhibits
bacterial growth.
Relief of spasm of the

genitor-urinary tract or
gastrointestinal tract
and for the symptomatic
relief of irritable bowel
syndrome.
-should not be
administered to pt.
With myasthenia
gravis, megacolon
and narrow angle
glaucoma.
-should not be given
to pt with a known
hypersensitivity to
the medication.
-dizziness
-increased ICP
-disorientation
-restlessness
-irritability
-drowsiness
-confusion
-hallucination
-hypotension
-tachycardia
-palpitations
-flushing
-dry mouth
-constipation
-nausea
-urinary retention
-dyspnea
-depressed respiration
- Drug compatibility should be

monitored closely in pt requiring
adjuctive therapy.
-avoid driving and operating
machinery after parenteral
administration.
-avoid strict heat.
-re orient pt as needed.
Acute Bronchitis &

Acute Exacerbations of
Chronic Bronchitis
Pharyngitis
&Tonsillitis
Uncomplicated
Gonorrhea
STD Prevention
Uncomplicated
Urinary Tract
Infections
Renal Impairment
Other Indications &
Uses
E. coli, H. influenzae, N.
gonorrhoeae, P. mirabilis,
S. pneumoniae, S.
pyogenes,
Enterobacteriaceae,
Salmonella spp,
Serratiaspp, Shigellaspp
Hypersensitivity to
cephalosporin.
- Diarrhea
- Abdominal pain
- Dyspepsia
- Flatulence
- Nausea
- Rash
- Urticaria
- Pruritus
- Erythema multiforme
- Stevens-Johnson
syndrome
- Serum sickness-like
reaction
- Thrombocytopenia
- Leukopenia
- Eosinophilia
- Prolonged PT
- Fever
- Vomiting
- Headache
- Dizziness
- Pseudomembranous
colitis

drug.
patient
irritation
frequently
- Vaginitis
- Candidiasis
- Transaminase
elevations
- Increased BUN
- Increased creatinine
NaHCO3 1
vial very
slow IVTT
over 5mins
Diazepam
D50W
Antiulcer
agents
Alkalinizing
agent
Sodium Bicarbonate acts an

alkalinizing agent by releasing
bicarbonate ions. Following oral
administration of this
medication, it releases
bicarbonate which is capable of
neutralizing gastric acid.
Chronic metabolic
acidosis.
Dyspepsia
Severe metabolic acidosis
-metabolic or
respiratory alkalosis;
hypernatremia
-severe pulmonary
edema
-hypocalcemia
-hypochlorhydria
-Mood changes
-tiredness
-SOB
-muscle weakness
-irregular heartbeat
-muscle hypertonicity
-twitching
-tetany
-hypernatremia
-stomach cramps
Antiepileptic
Anxiolytic
Benzodiazepin
e
Modulates postsynaptic effects

of
GABA-A
transmission,
resulting in an increase in
presynaptic inhibition. Appears
to act on part of the limbic
system, as well as on the
thalamus and hypothalamus, to
induce a calming effect
Anxiety
Alcohol Withdrawal
Endoscopy
Preoperative
Sedation
Muscle Spasm
Seizure Disorder
Status Epilepticus
benzodiazepines;
psychoses, acute
narrow-angle
glaucoma, shock,
coma, acute
alcoholic
intoxification,
pregnancy, inguinal
hernia, cardiac
defects,
microcephaly,
pyloric stenosis.
- Ataxia
- Euphoria
- Incoordination
- Somnolence
- Rash
- Diarrhea
- Hypotension
- Fatigue
- Muscle weakness
- Respiratory
depression
- Neutropenia
- Local effects: Pain,
swelling,
thrombophlebitis,
carpal tunnel
syndrome, tissue
necrosis
- Phlebitis if too rapid IV
push
Caloric agent
-Rapidly increases blood glucose

levels
-Transient osmotic diuretic
-Documented
hypoglycaemia
-Seizures of unknown
etiology
-Cerebral/meningeal
No significant
contraindications in
the emergency
setting.
-Pain, phlebitis at
injection site
-Hyperglycemia and
glycosuria
-fluid overload
- Asses pt. Fluid balance throughout

the therapy. Assessment includes
intake and output, daily wt., edema
and lungsounds.
- Symptoms of fluid overload should be
reported such as hypertension, edema,
difficulty in breathing or dyspnea, rales
or crackles and frothy sputum.
-assess signs of acidosis
-iv sites should be observed closely
-monitor fluid and electrolyte balance.
-do not mix with other solutions; do not
mix in plastic bags or tubing.
-inject slowlt into large vein; 1ml/min
frequency of blood glucose monitoring

is determined by the type of insulin
regimen and health status of pt.
-monitor for hyperglycemia
-check BP, I&O ratio and blood glucose
Humulin R
Hormone and
synthetic
substitute
Short acting, clear, colorless

solution of exogenous
unmodified insulin extracted
from beta cells in pork pancreas
or synthesized by recombinant
DNA technology(human).
Enhances transmembrane
passage of glucose across cell
membranes of most body cells
and by unknown mechanism
may itself enter the cell to
activate selected intermediary
metabolic processes. Promotes
conversion of glucose to
glycogen.
Bronchodilator
(therapeutic)
Adrenergics
(pharmacologi
c)
It relieves nasal congestion and

reversible bronchospasm by
relaxing the smooth muscles of
the bronchioles. The relief from
nasal congestion and
bronchospasm is made possible
by the following mechanism that
takes place when Salbutamol is
administered.
First, it binds to the
beta2-adrenergic
receptors in the airway
of the smooth muscle
which then leads to the
activation of the adenyl
cyclise and increased
levels of cyclic- 35adenosine
monophosphate(cAMP).
When cAMP increases,
kinases are activated.
edema r/t eclampsia

Treatment of diabetic
ketoacidosis
-insulin dependent
diabetis mellitus
Hypersensitivity to
insulin and animal
protein.
-aphasia
-pernality changes
-maniacal behaviour
-lipoatrophy and
lipohypertrophy of
injection sites
-localized allergic
reactions at injection
site.
-generalized urticaria or
bullae
-lymphadenopathy
every hour during treatment

-frequency of blood glucose monitoring
is determined by the type of insulin
regimen and health status of pt.
-monitor for hypoglycaemia
-check BP, I&O ratio and blood glucose
every hour during treatment
D50W +
Humulin R 3
u IV bolus
simultaneous
ly
TREATMENT
Salbutamol
(Ventolin)
-To control and prevent

reversible airway
obstruction caused by
asthma or COPD
-Quick relief for
bronchospasm
-For the prevention of
exercise-induced
bronchospsm
-Long-term control agent
for patients with chronic
or persistent
bronchospasm.
adrenergic amines
fluorocarbons
>nervousness
>restlessness
>tremor
>headache
>insomnia
>chestpain
>palpitations
>angina
>arrhythmias
>hypertension
>nausea and vomiting
>hyperglycemia
>hypokalemia
1. Assess lung sounds, PR and BP

before drug administration and during
peak of medication.
2. Observe fore paradoxical spasm and
withhold medication and notify
phycisian if condition occurs.
3. Allow at least 1 minute between
inhalation of aerosol medication.
4. Advise pt to rinse mouth with water
after each inhalation to minimuze dry
mouth.
5. inform pt that this may cause an
unusual or bad taste
Salbutamol
(Asmalin)
Bronchodilator
(therapeutic)
Adrenergics
(pharmacologi
c)
Kinases inhibit the

phosphorlation of
myosin and decrease
intracellular calcium.
Decreaced in
intracellular calcium will
result to the relaxation
airways.
It relieves nasal congestion and
reversible bronchospasm by
relaxing the smooth muscles of
the bronchioles. The relief from
nasal congestion and
bronchospasm is made possible
by the following mechanism that
takes place when Salbutamol is
administered.
First, it binds to the
beta2-adrenergic
receptors in the airway
which then leads to the
activation of the adenyl
cyclise and increased
levels of cyclic- 35adenosine
monophosphate(cAMP).
When cAMP increases,
kinases are activated.
Kinases inhibit the
phosphorlation of
myosin and decrease
intracellular calcium.
Decreaced in
intracellular calcium will
result to the relaxation
airways.
-To control and prevent

reversible airway
obstruction caused by
asthma or COPD
-Quick relief for
bronchospasm
-For the prevention of
exercise-induced
bronchospsm
-Long-term control agent
for patients with chronic
or persistent
bronchospasm.
adrenergic amines
fluorocarbons
>nervousness
>restlessness
>tremor
>headache
>insomnia
>chestpain
>palpitations
>angina
>arrhythmias
>hypertension
>nausea and vomiting
>hyperglycemia
>hypokalemia
1. Assess lung sounds, PR and BP

before drug administration and during
peak of medication.
2. Observe fore paradoxical spasm and
withhold medication and notify
phycisian if condition occurs.
3. Allow at least 1 minute between
inhalation of aerosol medication.
4. Advise pt to rinse mouth with water
after each inhalation to minimuze dry
mouth.
5. inform pt that this may cause an
unusual or bad taste

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OSPA FARMERS MEDICAL CENTER

SYNOPSIS AND BACKGROUND OF SUBJECT MATTER

Family history of adenomatous polyposis or Gardners syndrome

HYPERTENSIVE CARDIOVASCULAR DISEASE

Treatment and Management:

CHRONIC LUNG DISEASE

Pulmonary (Lung) Function Testing

Treatment and Management:

Poor healing of the incision

What to expect before the procedure:

The surgeon will then close the incision.

What to expect after the procedure

When to call your doctor

Bleeding although rare

Anastomotic leak the join that is made in the bowel leaks

What to expect after the operation:

Signs and Symptoms:

CBC to check white blood cell count

Extremes of age ( < 10 y and >70 y)

An abnormal host response to infection

certain serious cardiac arrhythmias

those who have a history of coronary artery disease

Gordons Functional Health Pattern

Health Perception and Health Management

The patient was under NPO (nothing per orem).

The patient has a good appetite and sometimes takes multivitamins.

SKIN AND NAILS:

no tenderness upon palpation

CRANIAL NERVE TESTING:

ICU Assessment Day

with IVF bottle 3 D5LR

with Isoket drip (Isoket

NOSE AND SINUSES:

NOSE AND SINUSES:

THORAX AND LUNGS:

THORAX AND LUNGS:

with Isoket drip at

Isoket drip at 8cc/hr

SKIN AND NAILS:

NOSE AND SINUSES:

THORAX AND LUNGS:

NOSE AND SINUSES:

abdominal pain at the

with a pain scale of

movement and relieved

PERTINENT LABORATORY TESTS/ DIAGNOSTIC EXAMINATION RESULTS

I. COMPLETE BLOOD COUNT

II. TROPONIN TEST

0.0 0.01 ug/l

Implication: The results taken are within the normal range

January 22, 2013 @ 8:23:58 AM

Microscopic / Urine Flowcytometry

February 24, 2013

February 28, 2013

March 4, 2013 @ 9:27:42PM

Microscopic / Urine Flowcytometry

IV. STOOL EXAMINATION

February 25, 2013

Red blood cells

Implication: Black stool usually means that the blood

Men 53-97/ Women

Men 80-306/ Women

VI. ARTERIAL BLOOD GAS ANALYSIS

ARTERIAL BLOOD GAS (EG7+)