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I.

INTRODUCTION

Skull is the skeleton of the head of a vertebrate forming a bony or cartilaginous case that encloses and protects the brain and chief sense organs and supports the jaws (http://www.merriam-webster.com/dictionary/skull). Skull is divided into frontal, parietal, temporal and occipital bone. The frontal bone forms the forehead and the anterior part of the top of the skull. Parietal means wall, and the two large parietal bones form the posterior top and much of the side walls of the skull. Each temporal bone on the side of the skull contains an external auditory meatus (ear canal), a middle ear cavity, and an inner ear labyrinth. The occipital bone forms the lower, posterior part of the brain case.

Inside the skull is the brain that is vital to our existence. It controls our voluntary movements, and it regulates involuntary activities such as breathing and heartbeat. It dictates the behaviors that allow us to survive and makes us who we are. The brain is the control center of the body and mind, governing everything from movement, sensation and speech, to thought, emotion and memory. . Because the brain is divided into regions the Frontal Lobes, Parietal Lobes, Temporal Lobes, and Occipital Lobes. The frontal lobes are the motor areas that generate the impulses for voluntary movement. The largest portions are for movement of the hands and face, those areas with many muscles capable of very fine or precise movements. The parietal lobes receive impulses from receptors in the skin and feel and interpret the cutaneous sensations. the temporal lobes receive impulses from receptors in the nasal cavities for the sense of smell. the occipital lobes. These areas see. The visual association areas interpret what is seen, and enable the thinking cerebrum to use the information (Essentials of Anatomy and Physiology fifth edition). Skull fractures may occur with head injuries. Although the skull is tough, resilient, and provides excellent protection for the brain, a severe impact or blow can result in fracture of the skull. It may be accompanied by injury to the brain. The brain can be affected directly by damage to the nervous system tissue and bleeding. The brain can also be affected indirectly by blood clots that form under the skull and then compress

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the underlying brain tissue (subdural or epidural hematoma). A depressed skull fracture is a break in a cranial bone (or "crushed" portion of skull) with depression of the bone in toward the brain. (http://www.nlm.nih.gov/medlineplus/ency/article/000060.htm).

Surgical management for skull injury is craniotomy. Craniotomy opening into the cranium with removal of a bone flap and opening the dura to remove a lesion, repair a damage area, drain blood or relieve increase intracranial pressure. (Lewis, Sharon et. Al. Medical Surgical Nursing.). In the Philippines 56% of people with an Acquired brain injury Traumatic Brain Injury were more likely to be living in a capital city compared with 46% in the rest of the state. 82% with an acquired brain injury or traumatic brain injury related stated that their situation was caused by motor vehicle, workplace, medical error, contact sport accident or injury. 84% with an acquired or traumatic brain injury suffered neuro trauma along with neuro psychological disabling conditions such as short term memory problems. (http://www.cdc.gov/TraumaticBrainInjury) Patient Chera Mae Ebol Jolo, 18-year old female, has a diagnosis of Gunshot wound left frontal, point of entry, no point of exit; open depressed skull fracture left frontal secondary epidural hematoma left frontotemporoparietal. The group chose him to be the subject for case analysis because the diagnosis captured the groups interest for study for them to be able to extend their understanding about brain injury. This case analysis presents the diagnosis, the diagnostic tests done and interpretation of results, and actual and possible management and treatment. This case study contributes to nursing education through provision of information regarding brain injury (Epidural hematoma due to gunshot wound). Through awareness, nurses and even student nurses will be faster and more accurate with rendering health teachings and providing nursing interventions to improve nursing practice. Moreover, nursing research will extend in identifying other possible causes of the disease or injury, other risk factors, new more accurate and convenient diagnostic tests and treatment.

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II.

PHYSICAL ASSESSMENT

Pre-Operative Assessment General Survey

Patient received on a stretcher in supine position. She was conscious, restless, and irritable. She was respiratory distress. She had an IVF of PLR 1L @ KVO rate infusing well at left metarcarpal vein. Patient is with foley catheter attached to urobag at 250cc level. HEAD: Patient with normocephalic head. Wound found at frontal area and presence of blood and with pre op dressing. Hair is about 15 inches in length and evenly distributed.

Post-operative assessment I. General Survey

Upon assessment patient was lying on bed awake and on supine position and moderate high back rest, with watcher at bedside. She had an intravenous mainline of PNSS 1L 80cc/hr infusing well at left metacarpal vein. Swelling at her both eyes noted and shes not able to open her left eye. Coordinated body movement was noted. Her body built is endomorphic with a height of 5 feet and 2 inches. Body is symmetrical proportional and has no deformities noted except for the bruises and pain felt by the patient at her chest area. Shes with post op dressing at frontal area; supported with stodeinet. According to her father the patient can already sit by supporting her and also can talk in a low tone of voice. II. Vital signs Temperature Blood pressure Cardiac rate Respiratory rate Pulse rate Vital Signs Result 37.3 C 120-80 72 20 75 Normal Values 36.5-37.5 C 110/70-130/90 80-90 bpm 12-20 cpm 80-90 bpm Indication Normal Normal Normal Normal Normal

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III.

Skin and Nails Upon inspection, her skin is brown in color and is uniform all throughout the body. Skin is uniform in color except in folds like axilla and groins. The skin was warm to touch and has a dry texture. It has a good skin turgor. Presence of bruises in the chest area noted. Nail beds are pale in color and convex in shape. Nails on fingers and toes have a smooth texture. Capillary refill time is 3 seconds.

IV.

Head and Skull

Her skull is normocephalic and symmetrical in shape. Surgical incision was found at left frontal area with post op dressing supported with stodeinet. Her hair was shaved head because of the surgical incision. Facial features is symmetrical, so as the facial movements. She can move her head from left to right.

V.

Eyes Patients eye was swollen. Her eyebrows were black in color, thick in distribution, and were evenly distributed. Her eyebrows and eyelids were symmetrical with each other. Her eyelashes were not that long and turned slightly outward.

VI.

Ears

The color of the auricles was congruent with the color of the facial skin. It has a normal shape, symmetric in size, and lies above the line of the outer canthus. No areas of tenderness noted. Also, her ears were firm and pinna recoils after it is folded. There were no discharges, inflammation and tenderness noted on both ears.

VII.

Nose and Sinuses


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Our patients external nose was symmetric and straight and uniform in color. No flaring or discharges were noted. Upon palpation of the external nose, no tenderness, lesions, masses were noted. Air moves freely as the client breathes through the nares. The nasal cavities were inspected with the use of the penlight. The floor of the nose and the integrity and position of the nasal septum were examined. The mucosa was pink, clear, no observed lesions. In addition, the nasal septum was intact and in midline. Upon palpation of the maxillary and frontal sinuses, no tenderness was noted.

VIII.

Mouth

Lips are moist, pale in color with symmetrical contour. Ulcerations, lesions, edema and other unusualities not noted. Gums are also pink in color without lesions and swelling. She has a total of 20 numbers of teeth. Teeth are yellowish in color. The tongue is on a central position, pinkish in color, moist, no palpable nodules or lesions, able to move freely and with a tongue base prominent with veins. Upon inspection, the hard & soft palate is smooth and pinkish. Uvula was also located on the mid line. Gag reflex is present. Bad mouth odor was also noted. IX. Neck

The neck muscles were equal in size and head centered. The movements were coordinated. The patients neck is weak and had difficulty in hyperextending it. There were no swelling and inflammation noted upon observation and palpation. Thyroid gland and Lymph nodes are not palpable. The trachea is situated in the midline and no tenderness was present.

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X.

Chest and Lungs

On lateral and posterior view, her chest is symmetrical. The spine is straight and vertically aligned with right and left shoulders. There were no deviations noted on the spine. The temperature is within normal range and tenderness in chest is noted. Her skin is intact. She had a full and symmetric lung expansion. Her breathing pattern is also regular. Breath sounds are also normal upon auscultation. Difficulty in breathing was not noted. During palpation the patient complained pain on her chest area.

XI.

Heart Upon auscultation of the heart, the point of maximum impulse was heard at the left mid clavicular at the 5th intercostal spaces. Heart rate is 72 beats per minute with no murmur and other irregularities noted.

XII.

Breast and Axillae Breast is symmetrical with skin of uniform color. Discharges, masses, lesions and other abnormalities were not present. Axillae is free from rashes, infections, masses and other unusualities not noted.

XIII.

Abdomen Abdomen was free from bulges, masses, edema, tenderness and other abnormalities noted. Audible sounds with 10 sounds per minute. Bladder is not distended.

XIV.

Genitourinary Shes wearing an adult diaper. Were not able to assess the genitourinary. She verbalized that theres no difficulty in urinating.
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XV.

Extremeties Peripheral pulses are symmetrical and regular. Her shoulders and arms were symmetrical and no signs of abnormalities. The palms are smooth in texture with complete set of ten (10) fingers. Its texture was smooth and no abnormalities noted. The nail beds of the fingernails were pale and have a capillary refill of 3 seconds. . It has a complete set of ten (10) toes and with clean and well-trimmed toe nails.

XIV.

Neurological System

Language

She was able to respond verbally with low tone of voice. She responds to verbal command like raising her right hand.

Orientation

She was not oriented to time, place and names of family members present at the bedside.

Memory

She was able to remember her name, birthday, and address but she cannot remember what time and date she had an accident.

Attention span

She

was

attentive

and

responsive

during

assessment. Level consciousness of The pupillary size is 3mm in diameter and is briskly reactive to light accommodation. Both hands have moderate handgrip response. Muscle weakness is evident. She has a GCS of 15 and RLS of 1.

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GLASCOW COMA SCALE

Faculty Eye Opening Verbal Response

Responsive Spontaneous Makes incomprehensible sounds

Score 4 5

Motor Response

Obeys verbal command Total:

6 15

CRANIAL NERVES

CRANIAL NERVE Olfactory

HOW IT WAS ASSESSED

RESULT

Patient is asked to sniff and Able to identify the smell of identify aromatic substances alcohol. such as alcohol.

Optic

Patient was asked to look Only the right pupil reacted straight forward and using a when exposed to light

penlight, we assessed for because she cannot open accommodation. the left eye

Patient was asked to read Patient was able to read the content of our ward the content of our ward notebook to check for visual notebook.

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acuity. Oculomotor Pupils are examined for size She cannot open her left and shape. Pupillary reflex eye because hematoma

is tested with penlight and was present. But her right ability to follow direction or eye was able to do all the moving objects. Trochlear ocular movements.

Asked the patient to follow Only the right eye was the pen with the eyes only assessed and she was being moved; without able to move eye laterally

moving the head. Trigeminal Ophthalmic Maxillary Mandibular Motor: Chewing and jaw She opening and clenching Sensory: Conveying sensory data from eyes (cornea), nose, mouth, scalp, teeth, and was able every jaw to eat meal. strength.

porridge Moderate

She was able to feel the pen that we touch on her face. She was able to see clearly and was able to identify alcohol. the scent of

jaw,forehead, facial skin

Abducens

Asked the patient to gaze Able

to

move

eyes

the pen while it was being laterally. moved laterally. Facial Patient was asked to close She was able to perform all eyes, frown, smile, clench the facial expressions. teeth and raise eyebrows. Vestibulocochlear Assess patients ability to Able to answer whispers hear spoken words. Tick- questions 4 inches away watch test was done and from ears. She was able to
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assessed for balance

hear ticking of the watch on both ears. We were not able to assess her balance because she has still not enough strength to stand.

Glossopharyngeal

Gag and swallowing reflexes Able to move her tongue are checked by using and her gag reflex was present.

padded tongue depressor. Vagus

Asked patient to drink a No hoarseness of voice glass of water. noted and able to swallow small amounts of water. She can now communicate with other people but in a low tone of voice.

Accessory

Ask patient to rotate head Able to rotate her head but and shrug shoulders against when resistance. shrugging her

shoulders she feels pain and was not able to do it

Hypoglossal

Patient is asked to stick out She was able to protrude tongue and move from side tongue to side. and move it

laterally without deviation. She was able to eat

porridge.

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BIOGRAPHICAL DATA A. PATIENTS DATA NAME: Chera Mae Jolo AGE: 18 SEX: Female

ADDRESS: Aurora Extension, Digos City BIRTHDAY: RELIGION: Christian (Roman Catholic) NATIONALITY: Filipino EMPLOMENT STATUS: Employed PLACE OF OCCUPATION: MONTHLY INCOME: MOTHERS NAME: Rosegin Jolo FATHERS NAME: Bernabi Jolo OCCUPATION: BIRTHPLACE: CIVIL STATUS: Single

ECONOMIC STATUS FATHERS OCCUPATION: Feed meal Company,Digos City MONTHLY INCOME: 9,000 PHP MOTHERS OCCUPATION: Housewife

EDUACTIONAL ATTAINMENT ELEMENTARY: Magsaysay Elementary School,Digos City HIGH SCHOOL: Digos City National High School (3rd year)

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B. CLINICAL DATA HOSPITAL: San Pedro Hospital DATE OF ADMISSION: 06/30/11 TIME:1:00 am CHIEF COMPLAINT: Gunshot Wound MANNER OF ADMISSION: Ambulance WARD: San Lorenzo ATTENDING PHYSICIAN: FINAL DIAGNOSIS: Gunshot wound left frontal, point of entry, no point of exit; open depressed skull fracture left frontal secondary epidural hematoma left ROOM #: CASE TYPE: Private

frontotemporoparietal.

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FAMILY HISTORY (GENOGRAM) MATERNAL


Luzminda Ebol 73 Alejandro Ebol 60 Pasj Jolo,

PATERNAL
Eladio Tunacao,

Roman 50

Robino 26

Rojel 37 Rsegin 42 Rosa 43

Arnold 54

Jocelyn 48

Locefe 49

Rosalina 50

Rodulfo 56

Bernabi 52

Eladio 58

Chera Mae, 18

LEGEND: Hypertension Complicated Kidney Disease Deceased

Ellen 20

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Narrative Genogram The genogram shows the three generations of the Jolo family from their grandparents, uncles and aunts up to the siblings of our patient, CM. As observed in the tracing of the genogram, some of the familys illnesses are alike with each other and are therefore hereditary. As we can see the maternal side is free from hereditary diseases. Robino died at 26 due to his job as a soldier. While the paternal side has complicated kidney disease and hypertension nonetheless most of the family members do not show signs and symptoms of these diseases, Rodulfo died because of kidney disease at 56. Past Health History Chera Mae Jolo our client didnt experience measles during her childhood years the common illnesses that she experienced during her childhood are flu, cough and colds. Her father verbalized that they used herbal medicine in managing illnesses before going to a physician. Also in the past 4 years, she was hospitalized due to typhoid fever. The immunization of our client was incomplete, she only received BCG, 1 Hepa B, 1 OPV and 1 DPT. In her way of living, she doesnt have any vices. She only drinks occasionally and she doesnt smoke. However, her father mentioned that she is fond of eating in fast food carenderias. She has no food allergies. Present Health history Chera Mae Jolo .has been shot in the internet cafe at the frontal area of her head that cause her brain injury. She was admitted at San pedro hospital June 30, 2011, 4:15 am due to Gun Shoot wound. The diagnosis of the patient was Gunshot wound left frontal, point of entry, no point of exit; open depressed skull fracture left frontal secondary epidural hematoma left frontotemporoparietal. The procedure that was done to our client was Debridment of frontal area and craniotomy that last for two to three hours. After two days the client was able to sit on her bed without the support of the nurse and she was able to talk in low voice tone. She was also oriented to the place and she can identify the name of her father.

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III.

MANAGEMENT

A. Medical Surgical Management

A1. Drugstudy

Preoperative medication Generic Name: ketorolac tromethamine Brand Name: Toradol, Acular Classification: Nonsteroidal anti-inflammatory drug; nonopioid analgesic; antipyretic Mechanism of Action: Inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Also has antipyretic and anti-inflammatory properties. Therapeutic effects: Decreased pain. Route PO IV IM Onset 30-60 min; unknown immediate 10 min Peak 30-60 min; 2-3 hr 1-3 min; 1-2 hr 30- 60 min; 1-2 hr Duration 6-8 hr; 4-6 hr /+ 6-8 hr; 6 hr /+ 6-8 hr; 6 hr /+

Indications: Short- term management or pain (not to exceed 5 days total for all routes combined).

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Contraindications: Hypersensitivity; cross-sensitivity with other NSAIDs may exist; OB: Labor, delivery or lactation; Pre- or perioperative use; Known alcohol intolerance (injection only); Perioperative pain from coronary artery bypass graft (CABG) surgery. Use cautiously in: Cardiovascular disease or risk factors for cardiovascular disease (may risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke, especially with prolonged use); History of GI bleeding; Renal impairment (dosage reduction may be required); Geri: appears on Beers list. Geriatric patients have increased risk of GI bleeding; OB, Pedi: Pregnancy and children (use not recommended during 2nd half of pregnancy). Dosage: IV (Adults < 65 yr): Single dose 60 mg. Multiple dosing 30 mg q 6 hr (not to exceed 120 mg/day) Actual Dose: 30 gram,q8 IVTT Drug Interaction: Drug-Drug. ACE inhibitors: May cause renal impairment, particularly in volumedepleted patients. Avoid using together in volume-depleted patients. Anticoagulants, salicylates: May increase salicylate or anticoagulant levels in the blood. Use together with extreme caution and monitor patient closely. Antihypertensives, diuretics: May decrease effectiveness. Monitor patient closely. Lithium: May increase lithium level. Monitor patient closely. Methotrexate: May decrease methotrexate clearance and increase toxicity. Avoid using together.

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Drug-herb. Dong quai, feverfew, garlic, ginger, horse chestnut, red clover: May cause bleeding. Discourage use together. White willow: Herb and drug contain similar components. Discourage use together. Side effects/ adverse reactions: CNS: drowsiness, sedation, dizziness, headache. CV: edema, hypertension, palpitations, arrhythmias. GI: nausea, dyspepsia, GI pain, diarrhea, peptic ulceration, vomiting, constipation, flatulence, stomatitis. Hematologic: decreased platelet adhesion, purpura, prolonged bleeding time. Skin: pruritusm rash, diaphoresis. Other: pain at injection site. Nursing Responsibilities: 1. Document indications for therapy, onset, location, pain intensity/ level, and characteristics of symptoms. 2. Note any previous experience with NSAIDs and the results. 3. Assess for any asthma, aspirin-induced allergy, or nasal polyps. 4. Determine any liver or renal dysfunction; assess hydration. 5. Drug may cause drowsiness and dizziness; tell patient to avoid activities that require mental alertness until drug effects realized. 6. Tell patient to avoid alcohol, ASA, and all OTC agents without approval. 7. Report any unusual bruising/ bleeding, weight gain, swelling of feet/ ankles, increased joint pain, change in urine patterns or lack of response. 8. NSAIDs may mask signs and symptoms of infection because of their antipyretic and anti- inflammatory actions. 9. Serious GI toxicity, including peptic ulcer and bleeding, can occur in patient taking NSAIDs, despite lack of symptoms. 10. Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine, or stool; coffee- ground vomit; and black, tarry stool. Tell him to notify prescriber immediately if any of these occurs.

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Generic Name: ranitidine hydrochloride Brand Name: Zantac Classification: Gastrointestinal agent; Histamine H2 receptor blocking drug; antiulcer agents Mechanism of Action: Inhibits the action of histamine at the H2- receptor site located primarily in gastric parietal cells, resulting in inhibition of gastric acid secretion. Therapeutic effects: Healing and prevention of ulcers. Decreased symptoms of gastroesophageal reflux. Decreased secretion of gastric acid. Route IV Onset unknown Peak 15 min Duration 8-12 hr

Indications: Short- term treatment of active duodenal ulcer; maintenance therapy for duodenal ulcer patient after healing acute ulcer; treatment of gastroesophageal reflux disease; short-term treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions (e.g. Zollinger- Ellison syndrome, systemic mastocytosis, and postoperative hypersecretion); heartburn. Contraindications: Patients hypersensitivity to drug and those with acute porphyria. Use cautiously on patients with hepatic dysfunction. Adjust dosage in patients with impaired renal function.

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Dosage: Duodenal Ulcer, Gastric Ulcer, Gastroesophageal Reflux IV 50 mg q 6- q 8; 150-300 mg/ 24 hr by continuous infusion Pathologic Hypersecretory Conditions IV 50 mg q 6- q 8 h Actual Dose: 50mg q 8 IVTT

Drug Interaction: Drug-Drug. Antacids: May interfere with ranitidine absorption. Stagger doses, if possible. Diazepam: May decrease absorption of diazepam. Monitor patient closely. Glipizide: May increase hypoglycemic effect. Adjust glipizide dosage as directed. Procainamide: May decrease renal clearance of procainamide, Monitor patient closely for toxicity. Warfarin: May interfere with warfarin clearance. Monitor patient closely. Side effects/ adverse reactions: CNS: vertigo, malaise, headache. EENT: blurred vision. Hepatic: jaundice. Other: burning and itching at injection site, anaphylaxis, angioedema. Nursing Responsibilities: 1. Document indications for therapy, onset/ characteristics of symptoms, other agents used and anticipated treatment period.

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2. Assess stomach/ abdominal pain, noting characteristics, frequency of occurrence and things that alter it. Note for blood in emesis, stool, or gastric aspirate. 3. Obtain CBC; assess for infections, renal or liver disease. 4. May cause drowsiness or dizziness. Caution patient to avoid activities requiring alertness until response to the drug is known. 5. Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase GI irritation. 6. Inform patient that increased fluid and fiber intake and exercise may minimize constipation. 7. Advise patient to report any evidence of yellow discoloration of skin or eyes, or diarrhea. 8. Tell patient to report any confusion/ disorientation, unusual bruising or bleeding, black tarry stools, or rash immediately. 9. Advise patient to report onset of fever, sore throat to health care professional promptly. 10. Report as scheduled to determine extent of healing and expected length of therapy.

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Generic Name: phytomenadione, phytonadione Brand Name: AquaMEPHYTON Classification: Vitamins; Antidote Mechanism of Action: An antihemorrhagic factor that promotes hepatic formation of active coagulation factors. Route PO IM, Sq IV Onset 6-12 hr 1-2 hr 1-2 hr Peak unknown 3-6 hr 3-6 hr Duration unknown 12-14 hr 12 hr

Indications: Prevention and treatment of hypoprothrombinemia, which may be associated with: Excessive doses of oral anticoagulants, Salicylates, Certain anti infective agents, Nutritional deficiencies, Prolonged total parenteral nutrition. Prevention of hemorrhagic disease of the newborn. Management of coagulation disorders when caused by vitamin K deficiency, or interference with vitamin K activity. Contraindications: Hypersensitivity; Hypersensitivity or intolerance of benzyl alcohol (injection only).

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Dosage: Anticoagulant Overdose Adult: IV Emergency only: 10-15 mg at a rate of 1 mg/min, may be repeated in 4 h if bleeding continues. Actual Dose: 10mg IV Drug Interaction: Drug-Drug. Large doses will counteract the effect of warfarin. Large doses of salicylates or broad-spectrum anti infectives may increase vitamin K requirement. Bile acids sequestrants, mineral oil, and sucralfate may decrease vitamin K absorption from GI tract. Side effects/ adverse reactions: GI: gastric upset, unusual taste. Derm: flushing, rash, urticaria. Hemat: hemolytic anemia. Local: erythema, pain at injection site, swelling. Misc: allergic reactions, hyperbilirubinemia (large doses in very premature infants), kernicterus.

Nursing Responsibilities: 1. Monitor patient constantly. Severe reactions, including fatalities, have occurred during and immediately after IV injection. 2. Lab test: baseline and frequent PT/INR. 3. Frequency, dose, and therapy duration are guided by PT/INR clinical response. 4. Monitor therapeutic effectiveness which is indicated by shortened PT, INR, bleeding, and clotting times, as well as decreased hemorrhagic tendencies.

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5. Be aware that patients on large doses develop temporary resistance to coumarin-type anticoagulants. If oral anticoagulant is reinstituted, larger than former doses may be needed. Some patients may require change to heparin. 6. Instruct patient to maintain consistency in diet and avoids significant increases in daily intake of vitamin k-rich foods when drug regimen is stabilized. Know sources rich in vitamin k: asparagus, broccoli, cabbage, lettuce, turnip greens, pork or beef liver, green tea, spinach, watercress, and tomatoes.

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Generic Name: Hypertonic Lactate Solution

Brand Name: Totilac

Classification: Intravenous & other sterile solutions

Mechanism of Action: TOTILAC contains strong ions which are fully dissociative into anions (lactate and chloride) and cations (sodium, potassium, calcium) when dissolved in water. Sodium, a principal cation of extracellular fluid and its high concentration provides hypertonicity that is beneficial in fluid resuscitation as it improves hemodynamic with small volume. Lactate, a physiological metabolite and acts as energetic substrate, which is actively oxidized by every mitochondrion-containing cell, i.e. the vast majority of cells in the body, especially in highly active organs such as brain, kidney, heart and muscles. Its oxidation results in energy release similar to that of glucose (4 Kcal/g of lactate). Following a hypoxic period, lactate is a preferred or even an obligatory energy substrate over glucose because lactate acts as a ready to use substrate since its oxidation does not require investment of ATP, unlike glucose, and its usage prevent the reactive oxygen species (ROS) production. Beside oxidation, lactate can be converted into glucose via gluconeogenic pathway, which occurs mainly in liver but also in kidney. Calcium, it plays role in cardiac contractility. Potassium, it prevents hypokalemia, which might be caused by sodium lactate infusion.

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TOTILAC solution is neutral (pH=7.0) and when lactate is metabolized, it doesnt cause acidosis effect. Indications: Resuscitation fluid in intra- & postcardiac surgery. Small volume fluid therapy for rapid restoration of intravascular volume (hemorrhagic shock, dengue shock, burnt patient, etc.); prevention of hypovolemia and maintaining stable hemodynamic status (perioperative condition); as an alternative in the treatment of metabolic acidosis, electrolyte disorder (hyponatremia); treatment for tissue/ peripheral edema; reduction of intracranial pressure in traumatic brain injury; source of alternative energy substrate during cell restoration post-ischemia. Contraindications: States of hypovolemia & hyponatremia (plasma Na >155 mmol/L) & severe renal failure. Dosage: Intraop: 1st loading: 3 mL/kg body wt w/in 15 min IV after fast fluid replacement administration at the beginning of surgery. Intraoperative:

First loading of 3ml/kg BW in 15 minutes intravenously at the beginning of surgery.

Maintenance of 1.5 ml/kg BW/ hour during the surgery Second loading of 1.5 ml/kg BW in 15 minutes intravenously after protamine administration.

Post-operative: Maximum dose 10cc/kg BW in 12 hours intravenously.


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When the maximum dose of hypertonic sodium lactate solution is reached, it is permitted to infuse 6% hydroxyethyl starch (HES) in case of necessity of maintaining fluid therapy.

Maintenance: 1.5 mL/kg body wt/hr during surgery. 2nd loading: 1.5 mL/kg body wt w/in 15 min IV when hemodynamics are stable after protamin administration. On-pump CBP: 2nd loading given after CPB is off & approx 15 min after protamin administration. Post-op: IV w/ infusion rate 1.5 mL/kg body wt. Max: 10 mL/kg body wt w/in 12 hr. Acutal Dose: 250cc @ 125cc/hour Drug Interaction: Precipitation w/ inorganic phosphate, hydrogen carbonate or oxalate. Side effects/ adverse reactions: Febrile response, infection at site of inj, venous thrombosis or phlebitis extending from site of inj, extravasation & hypervolemia.

Nursing Responsibilities: 1. Monitor patient VS and status of patient throughout the administration. 2. Monitor therapeutic effectiveness of solution. 3. Monitor input and output and electrolytes. 4. Watch for any unusualities. 5. Observe for signs and symptoms of hypovolemia & hyponatremia. 6. Report any unusualities.

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INTRAOPERATIVE DRUGS Generic Name: fentanyl citrate Brand Name: Sublimaze Classification: Central nervous system agent; opioid analgesic; narcotic (opiate) agonist Mechanism of Action: Binds with opiate receptors in the CNS, altering the response to and perception of pain. Produces CNS depression. Synthetic, potent narcotic analgesic with pharmacologic actions qualitatively similar to those of morphine and meperidine, but action is more prompt and less prolonged. Principal actions: analgesia and sedation. Drug-induced alterations in respiratory rate and alveolar ventilation may persist beyond the analgesic effect. Emetic effect is less than with either morphine or meperidine. Route I.V. I.M. Transdermal Transmucosal Indications: Analgesic supplement to general anesthesia; usually with other agents (ultrashort acting barbiturates; neuromuscular blocking agents and inhalation anesthetics) to produce balanced anesthesia. Induction/ maintenance of anesthesia (with oxygen or oxygen/ nitrous oxide and a neuromuscular blocking agents). Neuroleptanalgesia/ Onset 1-2 min 7-15 min 12-24 hr 5-15 min Peak 3-5 min 20-30 min 1-3 days 20-30 min Duration 30-60 min 1-2 hr Variable Unknown

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neuroleptanesthesia (with or without nitrous oxide). Supplement to regional/ local anesthesia. Preoperative and postoperative analgesia. Contraindications: Patients who have received MAO INHIBITORS within14 d; myasthenia gravis; labor and delivery, lactation. Safety during pregnancy (category C) or in children <12 y is not established. Hypersensitivity; Cross-sensitivity among agents may occur; Known intolerance. Use cautiously in: Geriatric, debilitated, or critically ill patients; Diabetes; Severe renal, pulmonary or hepatic disease; CNS tumors; Increased intracranial pressure; Head trauma; Adrenal insufficiency; Undiagnosed abdominal pain; Hypothyroidism;

Alcoholism; Cardiac disease (arrhythmias); Pregnancy and lactation. Dosage: Preoperative Use IM, IV (Adults and Children >12yr): 50-100 mcg 30-60 min before surgery. Adjunct to General Anesthesia IM, IV (Adults and Children >12 yr): Low dose- minor surgery 2 mcg/ kg. Moderate dose- major surgery 2-20 mcg/ kg. High dose- major surgery 20-50 mcg/ kg. Adjunct to Regional Anesthesia IM, IV (Adults and Children >12 yr): 50-100 mcg. Postoperative Use (Recovery Room) IM, IV (Adults and Children >12 yr): 50-100 mcg; may repeat after 1-2 hr. General Anesthesia IV (Adults and Children >12 yr): 5-100 mcg/ kg (up to 150 mcg/ kg).
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Sedation /Analgesia IV (Adults and Children >12 yr): 0.5-1 mcg/ kg/ dose, may repeat after 30-60 min. Acutal Dose: 50 mg Drug Interactions: Drug- Drug. Amiodarone: May cause hypotension, bradycardia, and decreased cardiac output. Monitor patient closely. CNS depressants, general anesthetics, hypnotics, MAO inhibitors, other opioid analgesics, sedatives, tricyclic antidepressants: May cause additive effects. Use together cautiously. Reduce dosages of these drugs and reduce fentanyl dose by to 1/3. CYP3A4 inducers (carbamazepine, phenytoin, rifampin): May decrease

analgesic effects. Monitor patient for adequate pain relief. Diazepam: May cause CV depression when given with high doses of fentanyl. Monitor patient closely. Droperidol: May cause hypotension and decrease pulmonary arterial pressure. Use together cautiously. Potent CYP3A4 inhibitors (clarithromycin, erythromycin, itraconazole,

ketoconazole, nefazodone, nelfinavir, ritonavir, troleandomycin): May cause increased analgesia, CNS depression, and hypotensive effects. Monitor patients respiratory status and vital signs. Drug- lifestyle. Alcohol use: May cause additive effects. Discourage use together. Side effects/ adverse reactions: CNS: confusion, paradoxical excitation/ delirium, postoperative depression, postoperative drowsiness. EENT: blurred/ double vision. Resp: Apnea, Laryngospasm, allergic bronchospasm, respiratory depression. CV: arrhythmias, bradycardia,
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circulatory depression, hypotension. GI: biliary spasm, nausea/ vomiting. Derm: facial itching. MS: Skeletal and thoracic muscle rigidity (with rapid IV infusion).

Nursing Responsibilities: 1. Document indications for therapy, anticipated time frame, and any previous use. Have opioid antagonist (naloxone) available to reverse drug effect as needed. 2. Discuss the use of anesthetic agents and the sensations to expect with the patient before surgery. 3. Explain pain assessment scale to patient. 4. Monitor VS; assess for skeletal and thoracic muscle rigidity and weakness, Respiratory depression may persist. 5. Monitor circulatory and respiratory status and urinary function carefully. Drug may cause respiratory depression, hypotension, urine retention, nausea, vomiting, ileus, or altered level of consciousness, no matter how it is given. 6. Note any neurovascular or pulmonary disease. Instruct in coughing and deep breathing exercises before therapy to ensure compliance. 7. Caution patient to change positions slowly to minimize orthostatic hypotension. Geri. Geriatric patients may be a greater risk for orthostatic hypotension and, consequently, falls. 8. Teach patient to take precautions until drug effects have completely resolved. 9. Medication causes dizziness and drowsiness. Advise patient to call for assistance during ambulation and transfer and to avoid driving or other activities requiring alertness for 24 hrs after administration during outpatient surgery. 10. Instruct patient to avoid alcohol or other CNS depressants for 24 hr after administration for outpatient surgery.

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Generic Name: atracurium besylate Brand Name: Tracrium Classification: Autonomic Nervous System Agent; Skeletal Muscle Relaxant, Nondepolarizing; Neuromuscular Blocker Mechanism of Action: A nondepolarizing drug that keeps acetylcholine from binding to receptors on motor end plate, thus blocking neuromuscular transmission. Route I.V. Onset 2 min Peak 3-5 min Duration 35- 70 min

Indications: Adjunct to general anesthesia to facilitate endotracheal intubation and relax skeletal muscles during surgery or mechanical ventilation. Contraindications: Contraindicated in patients hypersensitive to drug. Use cautiously in elderly or debilitated patients and in those with CV disease; severe electrolyte disorder; bronchogenic carcinoma; hepatic, renal, or pulmonary impairment; neuromuscular disease; or myasthenia gravis. Dosage: Adult/Child: IV 2 yr, 0.4- 0.5 mg/kg initial dose , then 0.08- 0.1 mg/ kg 20-45 min after the first dose if necessary, reduce doses if used with general anesthetics. Acutal Dose: 55mg,20mg,10mg

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Drug Interaction: Drug- Drug. Amikacin, gentamicin, neomycin, streptomycin, tobramycin: May increase the effects of nondepolarizing muscle relaxant including prolonged respiratory depression. Use together cautiously. May reduce nondepolarizing muscle relaxant dose. Carbamazepine, phenytoin, theophylline: May reverse, or cause resistance to. Neuromusckular blockade. May need to increase atracurium dose. Clindamycin, general anesthetics ( enflurane, halothane, isoflurane), kanamycin, polymyxin antibiotics (colistin, polymyxin B sulfate), procainamide, quinidine, quinine, thiazide and loop diuretics, trimethaphan, verapamil: May enhance neuromuscular blockade, increasing skeletal muscle relaxation and prolonging effect of atracurium. Use together cautiously during and after surgery. Corticosteroids: May cause prolonged weakness. Monitor patient closely. Edrophonium, neostigmine, pyridostigmine: May inhibit drug and reverse neuromuscular block. Monitor patient closely. Lithium, magnesium salts, opioid analgesics: May enhance neuromuscular blockade, increasing skeletal muscle relaxation and possibly causing respiratory paralysis. Reduce atracurium dose. Succinylcholine: May cause quicker onset or atracurium; may increase depth of neuromuscular blockade. Monitor patient. Side effects/ adverse reactions: CV: flushing, bradycardia, hypotension, tachycardia. Respiratory: prolonged, doserelated apnea, wheezing, increased bronchial secretions,

dyspnea,bronchospasm, laryngospasm. Skin: skin flushing, erythema, prutitus, urticaria, rash. Other: anaphylaxis.

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Nursing Responsibilities: 1. Document indications for therapy, expected duration, and other agents/ therapies trialed. 2. Use a peripheral nerve stimulator to assess neuromuscular response and recovery intraoperatively. 3. Obtain baseline ECG, VS, and lab studies and monitor. May cause vagal stimulation resulting in bradycardia, hypotension, and arrhythmias. IV atropine may be used to treat bradycardia. 4. Drug should only be used on a short-term basis and in a continuously monitored environment. Drug blocks the effect of acetylcholine at the myoneural junction thus preventing neuromuscular transmission. 5. Client may be fully conscious and aware of surroundings and conversations. Drug does not affect pain threshold or anxiety; administer analgesics/ antianxiety agents regularly. Reassure that once drug wears off they may resume talking/ moving. 6. During drug administration, client may be able to see and hear things in the immediate environment but will be unable to move or talk. This will resolve once the medication is discontinued. Monitor breathing machine and protect eyes with patches or drops. May also need to medicate for anxiety or pain. 7. Give analgesics for pain. Patient may have pain but not be able to express it. 8. Once spontaneous recovery starts, reverse atracuriuminduced

neuromuscular blockade with an anticholinesterase (such as neostigmine or edrophonium), usually given with an anticholinergic such as atropine. Complete reversal of neuromuscular blockade is usually achieved within 8-10 mins after using and anticholinesterase. 9. Monitor respirations and vital signs closely until patient has fully recovered from neuromuscular blockade, as indicated by tests of muscle strength (hand grip, head lift, and ability to cough).
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10. A nerve stimulator and train-of-four monitoring are recommended to confirm antagonism of neuromuscular blockade and recovery of muscle strength. make sure spontaneous recovery is evident before attempting reversal with neostigmine. 11. Prior to use of succinylcholine doesnt prolong duration of action, but quickens onset and may deepen neuromuscular blockade.

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Generic Name: thiopental sodium Brand Name: Pentothal Classification: Central Nervous System agent; General anesthetic; sedative- hypnotic; barbiturate Mechanism of Action: Ultra short- acting barbiturate; induces brief general anesthesia without analgesia by depression of CNS. Loss of consciousness is rapid. Reduction in cardiac output and peripheral vasodilation frequently accompany anesthesia. Rapid redistribution of agent out of brain reduces anesthesia level and increases reflex airway hyperactivity to mechanical stimulation. Muscle relaxation is slight, and reflexes are poorly controlled. Route IV Onset 30-60 sec Duration 1030 min Half-life 12 min

Indications: To induce hypnosis and anesthesia prior to or as supplement to other anesthetic agents or as sole agent for brief (15-min) operative procedures. Also used as an anticonvulsant and sedative- hypnotic and for narcoanalysis and narcosynthesis in psychiatric disorders. Contraindications: Hypersensitivity to barbiturates; history of paradoxic excitation, absence of suitable veins for IV administration; status asthmaticus; acute intermittent or other hepatic porphyrias. Safety during pregnancy ( category C), lactation, or children is not established.

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Dosage: Induction Adult: IV Test Dose 25-75 mg, then 50-75 mg at 20-40 s intervals, and additional 50 mg may be given as needed. Convulsions Adult: IV 75-125 mg Narcoanalysis Adult: IV 100 mg/ min until confusion occurs Acutal Dose: 100+40mg

Drug Interaction: CNS depressants potentiate CNS and respiratory depression. Phenothiazines increase risk of hypotension. Probenecid may prolong may prolong anesthesia. Herbal: Kava- kava, valerian may potentiate sedation. Side effects/ adverse reactions: (1%) CNS: headache, retrograde amnesia, emergence delirium, prolonged somnolence and recovery. CV. Myocardial depression, arrthmias, circulatory

derpression. GI: nausea, vomiting, regurgitation of gastric contents, rectal irritation, cramping, rectal bleeding, diarrhea. Respiratory: respiratory depression with apnea; hiccups, sneezing, coughing, bronchospasm, laryngospasm. Body as a whole: Hypersensitivity reactions, anaphylaxis (rare), hypothermia, thrombosis and sloughing (with extravasation); salivation, shivering, skeletal muscle hyperactivity.

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Nursing Responsibilities: 1. Monitor vital signs q3- 5 min before, during, and after anesthetic administration until recovery and into postoperative period, if necessary. 2. Report increases in pulse rate or drop in blood pressure. Hypovolemia, cranial trauma, or premedication with opioids increases potential for apnea and symptoms of myocardial depression ( decreased cardiac output and arterial pressure). 3. Shivering, excitement, muscle twitching may develop during recovery period if patient is in pain. 4. Onset of drug effect is rapid, with loss of consciousness withing 30- 60 s.

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Generic Name: succinylcholine chloride (suxamethonium chloride) Brand Name: Anectine, Quelicin, Sucostrin Classification: Autonomic nervous system agent; Depolarizing skeletal muscle relaxant; Neuromuscular blocking drug Mechanism of Action: Binds with a high affinity to cholinergic receptors, prolonging depolarization of the motor end plate and ultimately producing muscle paralysis. Synthetic ultrashort- acting depolarizing neuromuscular blocking agent with high affinity for acetycholine (Ach) receptor sites. Route I.V. I.M. Onset 30-60 sec 2-3 min Peak 1-2 min Unknown Duration 4-10 min 10-30 min

Indications: To produce skeletal muscle relaxation as adjunct to anesthesia; to facilitate intubation and endoscopy, to increase pulmonary compliance in assisted or controlled respiration, and to reduce intensity of muscle contractions in pharmacologically induced or electroshock convulsions. Contraindications: Hypersensitivity to succinylcholine; family history of malignant hyperthermia. Safety in pregnancy (category C) is not established. Cautious use: During delivery by cesarean section; lactation, kidney, liver, pulmonary, metabolic, or cardiovascular disorders; dehydration, electrolyte imbalance, patients taking digitalis, severe burns or trauma, fractures, spinal cord injuries, degenerative or dystrophic neuromuscular diseases, low plasma pseudocholinesterase levels ( recessive genetic trait, but often associated with severe anemia, dehydration,
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marked changes in body temperature, exposure to neurotoxic insecticides, certain drugs); collagen diseases, porphyria, intraocular surgery, glaucoma. Dosage: Surgical and Anesthetic Procedures Adult: IV 0.3-1.1 mg/kg administered over 10-30 s, may give additional doses PRN IM 2.5-4 mg/kg up to 150 mg Prolonged Muscle Relaxation Adult: IV 0.5-10 mg/min by continuous infusion Acutal Dose: 60mg Drug Interaction: Drug-Drug. Aminoglycosides, anticholinesterase, such as echothiophate,

edrophonium, neostigmine, physostigmine, pyridostigmine, general anesthestics, such as enflurane, halothane, isoflurane, glucocorticoids, hormonal contraceptives, polymyxin antibiotics, such as colistin, polymyxin B sulfate: May enhance neuromuscular blockade; increasing skeletal muscle relaxation and potentiating effect. Use together cautiously during and after surgery. Cardiac glycosides: May cause arrhythmias. Use together cautiously. Cyclophosphamide , lithium, MAO inhibitors: May enhance neuromuscular blockade and prolong apnea. Use together cautiously. Opioid analgesics: May enhance neuromuscular blockade, increasing skeletal muscle relaxation and possibly causing respiratory paralysis. Use together cautiously. Parenteral magnesium sulfate: May enhance neuromuscular blockade, may increase skeletal muscle relaxation, and may cause respiratory paralysis. Use together cautiously, preferably at reduced doses.

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Drug- herb. Melatonin: May potentiate blocking properties of drug. Ask patient about herbal remedy use, and recommend caution.

Side effects/ adverse reactions: CV: bradycardia, tachycardia, hypertension, hypotension, arrhythmias, flushing, cardiac arrest. EENT: increased intraocular pressure. GI: excessive salivation. Metabolic: hyperkalemia. Musculoskeletal: muscle fasciculation, postoperative muscle pain, jaw rigidity. Respiratory: prolonged respiratory depression, apnea,

bronchoconstriction. Skin: rash. Other: malignant hyperthermia, allergic or idiosyncratic hypersensitivity reactions, anaphylaxis, rhabdomyolysis with acute renal failure. Nursing Responsibilities: 1. List agents currently prescribed to ensure that none interact unfavorably. Note if the client is taking digitalis products or quinidine. These clients are sensitive to the release of intracellular potassium. 2. Obtain baseline ECG, electrolytes, liver and renal function studies. Those with low plasma pseudocholinesterase levels are sensitive to the effects of succinylcholine and require lower doses. 3. Document any evidence/ history of MS, malignant hyperthermia, CPK myopathy, acute glaucoma, or eye injury; drug generally contraindicated. 4. Monitor baseline electrolyte determinations and vital signs. Check respiration every 5-10 mins during infusion. 5. Monitor respirations closely until tests of muscle strength (hand grip, head lift, and ability to cough) indicate full recovery from neuromuscular blockade. 6. Medicate for pain and anxiety as drug does not affect and client is unable to speak. Reassure that they will regain function once therapy is completed.

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7. Keep airway clear. Have emergency respiratory support equipment (endotracheal equipment, ventilator, oxygen, atropine, and epinephrine) immediately available. 8. Patient may experience postprocedural muscle stiffness and pain (caused by initial fasciculations following injections) for as long as 24-30hr. Reassure patient that postoperative stiffness is normal and will soon subside. 9. Be aware that hoarseness of sore throat are common even when pharyngeal airway has not been used. 10. Report residual muscle weakness to physician.

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Generic Name: ampicillin sodium and sulbactam sodium Brand Name: Unasyn Classification: Antiinfective; Antibiotic; Aminopenicillin Mechanism of Action Inhibits cell-wall synthesis during bacterial multiplication. Route I.V. I.M. Onset Immediate unknown Peak 15 min unknown Duration Unknown unknown

Indications: Treatment of infections due to susceptible organisms in skin and skin structures (e.g. Klebsiella pneumonia, Staphylococcus aureus) and intraabdominal infections (e.g. Escherichia coli) and for gynecologic infections (e.g. Bacteroides sp. Including B. fragilis). Also used for infections caused by ampicillin- susceptible organisms.

Contraindications: Hypersensitivity to penicillins; mononucleosis. Cautious use : Hypersensitivity to cephalosporins; pregnancy (cat B) or lactation. Dosage: Systemic infections Adult/Child: IV/IM 40 kg, 1.5 (1 g ampicillin, 0.5 g sulbactam) to 3 g (2 g ampicillin, 1 g sulbactam) q 6 h (max: 4 g sulbactam/d) Acutal Dose: 750mg

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Drug Interaction: Drug-Drug. Allopurinol: May increase risk of rash. Monitor patient for rash. Hormonal contraceptives: May decrease hormonal contraceptive effectiveness, leading to unintended pregnancy. Strongly advise use of additional form of contraception during penicillin therapy. Oral anticoagulants: May increase risk of bleeding. Monitor PT and INR. Probenecid: May increase ampicillin level. Probenecid may be used for this purpose. Side effects/ adverse reactions: CV: thrombophlebitis, vein irritation. GI: nausea, vomiting, diarrhea, glossitis, stomatitis, gastritis, black hairy tongue, enterocolitis, pseudomembranous colitis. Hematologic: anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leucopenia, agranulocytosis. Skin: pain at injection site. Other: hypersensitivity reactions, anaphylaxis, overgrowth of nonsusceptible organisms. Nursing Responsibilities: 1. Before giving drug, ask patient about allergic reactions to penicillin although a negative history of penicillin allergy is no guarantee against future allergic reaction. Also, obtain specimen for culture and sensitivity tests. Therapy may begin pending results. 2. Dosage is expressed as total drug. Each 1.5-g vial contains 1 g ampicillin sodium and 0.5 g sulbactam sodium. 3. In patients with impaired renal function, decrease dosage. 4. Monitor liver function test results during therapy, especially in patients with impaired liver function. 5. Monitor patient carefully during the first 30 min after initiation of IV therapy for signs of hypersensitivity and anaphylactoid reaction. Serious anaphylactoid
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reactions

require

immediate

use

of

emergency

drugs

and

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management. 6. Ensure adequately hydrated. Assess for diarrhea and sign and symptoms of superinfection. 7. If large doses are given or if therapy is prolonged, bacterial or fungal superinfection may occur, especially in elderly, debilitated, or

immunosuppressed patients. 8. Tell patient to report rash, fever, or chills. A rash is the most common allergic reaction. 9. Advise patient to report discomfort at I.V. insertion site. 10. Warn patients that I.M. injection may cause pain at injection site.

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Generic Name: parecoxib Na Brand Name: Dynastat Classification: Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) Mechanism of Action: COX-2 selective inhibitor. Pharmacotherapeutic Group: Coxib. Parecoxib is a prodrug of valdecoxib. The mechanism of action of valdecoxib is by inhibition of cyclooxygenase-2 (COX-2)-mediated prostaglandin synthesis.

Cyclooxygenase is responsible for generation of prostaglandins. Two isoforms, COX-1 and COX-2, have been identified. COX-2 is the isoform of the enzyme that has been shown to be induced by pro-inflammatory stimuli and has been postulated to be primarily responsible for the synthesis of prostanoid mediators of pain, inflammation and fever. At therapeutic doses, valdecoxib is a COX-2 selective inhibitor of both peripheral and central prostaglandins and does not inhibit COX-1, thereby sparing COX-1dependent physiological processes in tissues, particularly the stomach, intestine and platelets. COX-2 is also thought to be involved in ovulation, implantation and closure of the ductus arteriosus and CNS functions (fever induction, pain perception and cognitive function). Indications: Management of acute pain. It may be used preoperatively to prevent or reduce postoperative pain and can reduce opioid requirements when they are used concomitantly.

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Contraindications: Hypersensitivity to parecoxib or to any other ingredient of Dynastat. Patients who have demonstrated allergic-type reactions to sulfonamides, acetylsalicylic acid (aspirin) or nonsteroidal anti-inflammatory drugs (NSAIDS) including other cyclooxygenase-2 (COX-2) specific inhibitors; asthma and urticaria. Dosage: Management of Acute Pain: Recommended Single or Initial Dose: 40 mg IV/IM followed by 20 or 40 mg every 6-12 hrs, as required, up to a maximum daily dosage of 80 mg. Prevention or Reduction of Postoperative Pain: Recommended Dose: 40 mg administered IV/IM (but preferably IV) 30-45 min prior to surgical incision. Continued medication with parecoxib postoperatively may be needed for adequate analgesic effect. Drug Interaction: Fluconazole and Ketoconazole: Co-administration of fluconazole, a CYP2C9 inhibitor and ketoconazole, a CYP3A4 inhibitor, enhanced the AUC of valdecoxib by 62% and 38%, respectively. When parecoxib is co-administered with fluconazole, the lowest recommended dose of parecoxib should be used. No dosage adjustment is necessary when parecoxib is co-administered with ketoconazole. (See Dosage & Administration.) ACE Inhibitors: Inhibition of prostaglandins may diminish the antihypertensive effect of ACE inhibitors. This interaction should be given consideration in patients receiving parecoxib concomitantly with ACE inhibitors.

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Diuretics: Clinical studies have shown that NSAIDs, in some patients, can reduce the natriuretic effect of furosemide and thiazides by inhibition of renal prostaglandin synthesis. Lithium: Valdecoxib produced significant decreases in lithium serum clearance (25%) and renal clearance (30%) resulting in a 34% higher serum AUC compared to lithium alone. Lithium serum concentrations should be monitored closely when initiating or changing parecoxib therapy in patients receiving lithium.

Side effects/ adverse reactions Autonomic Nervous System: Hypotension. Body as a Whole: Back pain. Central and Peripheral Nervous System: Dizziness. GI System: Alveolar osteitis (dry socket), constipation and flatulence. Platelet, Bleeding and Clotting: Ecchymosis. Psychiatric: Agitation and insomnia. Skin and Appendages: Increased sweating and pruritus. Events Occurring 0.5% and <1%: Application Site: Injection site pain. Autonomic Nervous System: Dry mouth. Body as a Whole: Asthenia and peripheral edema. Hearing and Vestibular: Earache.

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Heart Rate and Rhythm: Bradycardia. Metabolic and Nutritional: Hyperglycemia. Musculoskeletal System: Arthralgia. Respiratory System: Pharyngitis. Skin and Appendages: Rash and skin postoperative complications. Urinary System: Oliguria. Nursing Responsibilities 1. Document indications for therapy, onset, location, pain intensity/ level, and characteristics of symptoms. 2. Note any previous experience with NSAIDs and the results. 3. Assess for any asthma, aspirin-induced allergy, or nasal polyps. 4. Determine any liver or renal dysfunction; assess hydration. 5. Drug may cause drowsiness and dizziness; tell patient to avoid activities that require mental alertness until drug effects realized. 6. Tell patient to avoid alcohol, ASA, and all OTC agents without approval. 7. Report any unusual bruising/ bleeding, weight gain, swelling of feet/ ankles, increased joint pain, change in urine patterns or lack of response. 8. NSAIDs may mask signs and symptoms of infection because of their antipyretic and anti- inflammatory actions. 9. Serious GI toxicity, including peptic ulcer and bleeding, can occur in patient taking NSAIDs, despite lack of symptoms. 10. Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine, or stool; coffee- ground vomit; and black, tarry stool. Tell him to notify prescriber immediately if any of these occurs.

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Generic Name: lidocaine hydrochloride Brand Name: Dilocaine, Xylocaine Classification: Cardiovascular agent; Antiarrythmic Class 1B; Central Nervous System agent; Local Anesthetic (Amide type) Mechanism of Action: A Class 1B antiarrythmic that decreases the depolarization, automaticity, and excitability in the ventricles during the diastolic phase by direct action on the tissues, especially the Purkinje network. Route I.V. I.M. Onset Immediate 5-15 min Peak Immediate 10 min Duration 10-20 min 2 hr

Indications: Rapid control of ventricular arrhythmias occurring during acute MI, cardiac surgery, and cardiac catheterization and those caused by digitalis intoxication. Also as surface and infiltration anesthesia and for nerve block, including caudal and spinal block anesthesia and to relieve local discomfort of skin and mucous membranes. Patch for relief of pain associated with post-herpetic neuralgia. Contraindications: Contraindicated in: Hypersensitivity; cross-sensitivity may occur; Third- degree heart block. Use cautiously in: Liver disease, CHF, patients weighing <50 kg, and geriatric patients (reduce bolus and/or maintenance dose); Respiratory depression; Shock; Heart block; Pregnancy or lactation. Dosage: Ventricular Arrythmias

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Adult: IV 50-100 mg bolus at a rate of 20-50 mg/ min, may repeat in 5 min, then start infusion of 20-50 mcg/kg/min (1-4 mg/min) immediately after first bolus IM/SC 200300 mg IM, may repeat once after 60-90 min Child: IV 0.5-1 mg/kg bolus dose, then 10-50 mcg/kg/min infusion Anesthetic uses Adult: Infiltration 0.5%- 1% solution. Nerve block 1%-2% solution. Epidural 1%2% solution. Caudal 1%-1.5% solution. Spinal 5% with glucose . Saddle block 1.5% with dextrose Topical 2.5%-5% jelly, ointment, cream, or solution. Drug Interaction: Drug-Drug. Atenolol, metoprolol, nadolol, pindolol, propranolol: May reduce hepatic metabolism of lidocaine, increasing the risk of toxicity. Give bolus doses of lidocaine at a slower rate and monitor lidocaine leved closely. Cimetidine: May decrease clearance of lidocaine increasing risk of toxicity. Consider using a different H2 receptor antagonist if possible. Monitor lidocaine level closely. Mexiletine, tocainide: May increase pharmacologic effects. Avoid using together. Phenytoin, procainamide, propranolol, quinidine: May increase cardiac depressant effects. Monitor patient closely. Succinylcholine: May prolong neuromuscular blockade. Monitor patient closely. Drug-herb: Pareira: May increase the effects of neuromuscular blockade. Discourage use together. Drug-lifestyle: Smoking: May increase metabolism of lidocaine. Monitor patient closely.

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Side effects/ adverse reactions: CNS: Confusion, light-headedness, restlessness, stupor, tremor, lethargy, somnolence, anxiety, hallucinations, nervousness, paresthesia, muscle twitching, seizures. CV: hypotension, bradycardia, new or worsened arrhythmias, cardiac arrest. EENT: tinnitus, blurred or double vision. GI: vomiting. Respiratory: respiratory depression and arrest. Skin: soreness at injection site. Other: anaphylaxis, sensation of cold. Nursing Responsibilities: 1. Note indications for therapy and any hypersensitivity to amide-type local anesthetics. 2. Those with hepatic or renal disease or who weigh less than 45.5 kg will need to be watched closely for adverse side effects; adjust dosage as directed. 3. Document CNS status; report sudden changes in mental status, dizziness, visual disturbances, twitching, and tremors. These symptoms may precede convulsions. Review pulmonary findings; assess for respiratory depression. 4. Monitor liver and renal function studies, electrolytes, VS, and ECG; assess for hypotension and cardiac collapse. 5. View monitor strips for myocardial depression, variations of rhythm, or aggravation of arrhythmia during infusion. 6. IM use may increase creatine phophokinase levels. Use of enzyme determination without isoenzyme separation, as a diagnostic test for acute MI, may be compromised. 7. Drug is used to eradicate ventricular arrhythmias. It is generally administered IV in a continuously monitored environment. 8. Report any evidences of dizziness or altered mentation; may be a sign of toxicity and progress to seizures and coma. 9. Smoking is not permitted during drug therapy. Refer to smoking cessation for alternative therapy. 10. Tell patient to report adverse reactions promptly because toxicity can occur.

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Generic Name: propofol Brand Name: Diprivan Classification: Cental Nervous System Agent, General Anesthesia; Sedative-Hypnotic Mechanism of Action: Sedative-hypnotic used in the induction and maintenance of anesthesia or sedation. Produces amnesia. Route IV Onset < 40 sec Peak Unknown Duration 3-5 min

Indications: Induction or maintenance of anesthesia as part of a anesthesia technique; conscious sedation in mechanically ventilated patients. Contraindications: Hypersensitivity to propofol, soybean oil, egg lecithin, or glycerol; Labor and delivery. Use cautiously in: Patients with severe cardiac or respiratory disorders or history of epilepsy or seizures. Dosage: Induction of Anesthesia Adult: IV 2-2.5 mg/kg q 10 s until induction onset Geriatric: IV 1-1.5 mg/kg q 10 s until induction onset Maintenance of Anesthesia Adult: IV 100-200 mcg/kg/min
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Geriatric: IV 50-100 mcg/kg/min Conscious Sedation Adult: IV 5 mcg/kg/min for at least min, may increase by 5-10 mcg/kg/min q 5-10 min until desired level of sedation is achieved (may need maintenance rate of 5-50 mcg/kg/min) Drug Interaction: Drug-Drug. Additive CNS and respiratory depression with alcohol,

antihistamines, opioid analgesics, and sedative/ hypnotics (dosage reduction may be required). Theophylline may antagonize the CNS effects of propofol. Propofol may increase the serum concentrations of alfentanil. Cardiorespiratory instabilitiy can occur when used with acetazolamide. Serious bradycardia can occur with concurrent use of fentanyl in children. Increased risk of hypertriglyceridemia with intravenous fat emulsion Side effects/ adverse reactions: CNS: dizziness, headache. Resp: Apnea, cough. CV: bradycardia, hypotension, hypertension. GI: abdominal cramping, hiccups, nausea, vomiting. Derm: flushing. Local: burning, pain, stinging, coldness, numbness, tingling at IV site. MS: involuntary muscle movements, perioperative myoclonia. GU: discoloration of urine (green). Misc: fever. Nursing Responsibilities: 1. Assess respiratory status, pulse, and blood pressure continuously throughout propofol therapy. Frequently causes apnea lasting 60 sec. Maintain patient airway and adequate ventilation. Propofol should be used only by individuals experienced in endotracheal intubation, and equipment for this procedure should be readily available. 2. Assess level of sedation and level of consciousness throughout and following administration.

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3. When using for ICU sedation, wake-up and assessment of CNS function should be done daily throughout maintenance to determine minimum dose required for sedation. 4. Maintain a light level of sedation during these assessments; do not discontinue. Abrupt discontinuation may cause rapid awakening with anxiety, agitation, and resistance to mechanical ventilation. 5. If overdose occur, monitor pulse, respiration, and blood pressure

continuously. 6. Maintain patent airway and assist ventilation as needed. If hypotension occurs, treatment includes IV fluids, repositioning, and vasopressors. 7. Inform patient that this medication will decrease mental recall of the procedure. 8. May cause drowsiness or dizziness. Advise patient to request assistance prior to ambulation and transfer and to avoid driving or other activities requiring alertness for 24 hr following administration. 9. Advise patient to avoid alcohol or other CNS depressants without advice of a health care professional for 24 hr following administration. 10. Advise patient that performance of activities requiring mental alertness may be impaired for some time after drug use.

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Generic Name: clonidine hydrochloride Brand Name: Catapres, Catapres-TTS Classification: Cardiovascular Agent; Central-Acting Antihypertensive; Analgesic Mechanism of Action: Stimulates alpha-adrenergic receptors in the CNS; which results in decreased sympathetic outflow inhibiting cardioacceleration and vasoconstriction centers. Prevents pain signal transmission to the CNS by stimulating alpha-adrenergic receptors in the spinal cord. Therapeutic Effects: decreased blood pressure. Decreased pain. Route PO Transdermal Epidural Onset 30-60 min 2-3 days unknown Peak 2-4 hr unknown 30-60 min Duration 8-12 hr 7 days unknown
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Indications: Step 2 drug in stepped- care approach to treatment of hypertension, either alone or with diuretic or other antihypertensive agents. Epidural administration as adjunct therapy for severe pain. PO, Transdermal: Management of mild to moderate hypertension. Epidural: Management of cancer pain unresponsive to opioids alone. Contraindications: Contraindicated in patients hypersensitive to the drug. Transdermal form is contraindicated in patients hypersensitive to any component of the adhesive layer of transdermal system. Epidural form is contraindicated in patients receiving anticoagulant therapy, in those with bleeding diathesis, in those with an injection site, and in those who are hemodynamically unstable or have severe CV disease. Use cautiously in patients with severe coronary insufficiency, recent MI, cerebrovascular disease, chronic renal failure, or impaired liver function. Dosage: Severe Pain Adult: Epidural. Start infusion at 30 mcg/ h and titrate to response. Use rates >40 mcg/h with caution Hypertension Adult: PO 0.1 mg b.i.d. or t.i.d., may increase by 0.1- 0.2 mg/d until desired response is achieved (max 2.4 mg/d) Transdermal 0.1 mg patch once q7d, may increase by 0.1 mg q 1-2 wk Drug Interaction:
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Drug-Drug. Additive sedation with CNS depressants, including alcohol, antihistamines, opioid analgesics, and sedative/ hypnotics. Additive hypotension with other antihypertensives and nitrates. Additive bradycardia with myocardial depressants, including beta blockers. MAO inhibitors, amphetamines, beta blockers, prazosin, or tricyclic antidepressants may decrease antihypertensive effect. Withdrawal

phenomenon may be increased by discontinuation of beta blockers. Epidural clonidine prolongs the effects of epidurally administered local anesthetics. May decrease effectiveness of levodopa. Increase risk of adverse cardiovascular reactions with verpamil. Side effects/ adverse reactions: CNS: drowsiness, dizziness, fatigue, sedation, weakness, malaise, agitation, depression. CV: orthostatic hypotension, bradycardia, severe rebound hypertension. GI: constipation, dry mouth, nausea, vomiting, anorexia. GU: urine retention, impotence. Metabolic: weight gain. Skin: pruritus, dermatitis with transdermal patch, rash. Other: loss of libido. Nursing Responsibilities: 1. Monitor intake and output ratios and daily weight, and assess for edema daily, especially at beginning of therapy. 2. Monitor blood pressure and pulse frequently during initial dosage adjustment and periodically throughout therapy. Report significant changes. 3. Pain: assess location, character, and intensity of pain prior to, frequently during first few days, and routinely throughout administration. 4. Monitor for fever as potential sign of catheter infection. 5. Opioid Withdrawal: Monitor patient for signs and symptoms of opioid withdrawal (tachycardia, fever, runny nose, diarrhea, sweating, nausea, vomiting, irritability, stomach cramps, shivering, unusually large pupils, weakness, difficulty sleeping, and goose-flesh). 6. Lab test considerations: May cause transient increase in blood glucose levels. May cause decreased urinary catecholamine and vanillylmandelic acid (VMA)
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concentrations; these may increase on abrupt withdrawal. May cause weakly positive Coombs test result. 7. Observe patient for tolerance to drugs therapeutic effects, which may require increased dosage. 8. When drug is given epidurally, carefully monitor infusion pump and inspect catheter tubing for obstruction or dislodgement. 9. Caution patient that drug may cause drowsiness but that this adverse effect usually diminishes over 4-6 weeks. 10. Inform patient that dizziness upon standing can be minimized by rising slowly from a sitting or lying position and avoiding sudden position changes.

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Postoperative Drugs Generic Name: mannitol Brand Name: Osmitrol, Resectisol Classification: Electrolytic and Water Balance Agent; Osmotic Diuretic Mechanism of Action: Increases osmotic pressure of glomerular filtrate, inhibiting tubular reabsorption of water and electrolytes; drug elevates plasma osmolality, increasing water flow into extracellular fluid. Route IV Onset 30-60 min Peak 1 hr Duration 6- 8 hr

Indications: Adjunct in the treatment of: Acute oliguric renal failure, Edema, increased intracranial or intraocular pressure, Toxic overdose. GU irrigant: During tranaurethral procedures (2.5-5% solution). Contraindications: Contraindicated in patients hypersensitive to drug. Contraindicated in patients with anuria, severe pulmonary congestion, frank pulmonary edema, severe heart failure, severe dehydration, metabolic edema, progressive renal disease of dysfunction, or active intracranial bleeding ( except during craniotomy).

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Dosage: IV infusion Adult 50-100 g. Children 0.25-2 g/kg body wt. Reduction of intracranial or intraocular pressure 0.25-2 g/kg body wt over 3-60 min. Renal failure 200 mg/kg body wt over 3-5 min. Drug Interaction: Drug-Drug. Lithium: May increase urinary excretion of lithium. Monitor lithium level closely. Hypokalemia increases the risk of digoxin toxicity. Side effects/ adverse reactions: CNS: seizures, dizziness, headache, fever. CV: edema, thrombophlebitis, hypotensioin, hypertension, heart failure, tachycardia, angina-like chest pain, vascular overload. EENT: blurred vision, rhinitis. GI: thirst, dry mouth, nausea, vomiting, diarrhea. GU: urine retention. Metabolic: dehydration. Skin: local pain, urticaria. Other: chills. Nursing Responsibilities: 1. Monitor vital signs, including central venous pressure and fluid intake and output hourly. 2. Report increasing oliguria. 3. Check weight, renal function, fluid balance, and serum and urine sodium and potassium levels daily. 4. In comatose or incontinent patient, use urinary catheter because therapy is based on strict evaluation of fluid intake and output. If patient has urinary
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catheter, use an hourly urometer collection bag to evaluate output accurately and easily. 5. Drug can be used to measure glomerular filtration rate. 6. To relieve thirst, give frequent mouth care or fluids. 7. Drug is commonly used in chemotherapy regimens to enhance dieresis of renally toxic drugs. 8. Dont give electrolyte-free solutions with blood. If blood is given

simultaneously, add at least 20 mEq of sodium chloride to each liter of drug solution to avoid pseudoagglutination. 9. Tell patient that he may feel thirsty or have dry mouth, and emphasize importance of drinking only the amount of fluids orederd. 10. Instruct patient to promptly report adverse reactions and discomfort at I.V site.

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Generic Name: lansoprazole Brand Name: Prevacid Classification: Proton pump inhibitor; Antisecretory; Antiulcer agents Mechanism of Action: Inhibits action of proton pump and binds to hydrogen-potassium adenosine triphosphatase, located at secretory surface of gastric parietal cells, to block secretion of gastric acid. Route PO Onset rapid Peak 1.7 hr Duration More than 24 hr

Indications: Treatment of peptic ulcer disease & other conditions where inhibition of gastric acid secretion may be beneficial. Contraindications: Hypersensitivity pregnancy (cat C). Dosage:
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to lansoprazole, lactation. Severe hepatic impairment,

Benign gastric ulcer 30 mg daily in the morning for 8 wk. Duodenal ulcer 30 mg daily in the morning for 4 wk. Prevention of relapse of duodenal ulcer Maintenance: 15 mg daily. NSAID-associated duodenal & gastric ulcer 15-30 mg once daily for 4 wk. Peptic ulcer disease w/ H pylori Triple therapy: Lansoprazole 30 mg + clarithromycin 500 mg + amoxicillin 1 g bid for 1 wk OR Lansoprazole 30 mg + clarithromycin 500 mg + metronidazole 400 mg bid for 1 wk OR Lansoprazole 30 mg + clarithromycin 1 g + metronidazole 400 mg bid for 1 wk. Zollinger-Ellison syndrome & other hypersecretory conditions Initially 60 mg once daily. Daily doses of 120 mg should be given in 2 divided doses. GERD 30 mg daily in the morning for 4 wk. Maintenance: 15-30 mg daily. Acid-related dyspepsia 15-30 mg daily in the morning for 2-4 wk. Drug Interaction:

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Drug: May decrease theophylline levels. Sucralfate decreases lansoprazole bioavailability. May interfere with absorption of ketoconazole, digoxin, ampicillin, or iron salts. Food: food reduces peak lansoprazole levels by 50%

Side effects/ adverse reactions: CNS: fatigue, dizziness, headache. GI: nausea, diarrhea, constipation, anorexia, increased appetite, thirst elevated serum transaminases (AST, ALT). Skin: rash. Nursing Responsibilities: 1. Document indications for therapy, onset, duration, characteristics. Triggers of symptoms, and any other agents trialed. 2. Monitor CBC, electrolytes, triglycerides, renal and LFTs; reduce dose with severe liver disease. 3. Assess patient routinely for epigastric or abdominal pain and for frank or occult blood in stool, emesis, or gastric aspirate. 4. For best effect, instruct patient to take drug no more than 30 minutes before eating. 5. Instruct patient to take medications as directed for the full course of therapy, even if feeling better. 6. Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation. 7. May occasionally cause dizziness. Caution patient to avoid activities requiring alertness until response to medication is known. 8. Advise patient to report onset of black tarry stools; diarrhea; or abdominal pain to health care professional promptly.

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Generic Name: furosemide Brand Name: Lasix Classification: Electrolytic and water balance agent; Loop diuretic Mechanism of Action: A potent loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle. Route PO IM IV Onset 30-60 min 10-30 min 5 min Peak 1-2 hr unknown 30 min Duration 6-8 hr 4-8 hr 2 hr

Indications: Edema due to heart failure, hepatic impairment or renal disease. Hypertension. Contraindications: History of hypersensitivity to furosemide or sulfonamides; increasing oliguria, anuria, fluid and electrolyte depletion states; hepatic coma; pregnancy (cat C), lactation.
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Cautious use: infants, older adults; hepatic cirrhosis, nephritic syndrome; cardiogenic shock associated with acute MI; history of SLE; history of gout; patients receiving digitalis glycosides or potassium depleting steroids. Dosage: Adult 20-50 mg IM/IV. If response is inadequate after 1-2 hr, increase dose to 80 mg by slow IV. May be given as 1-2 doses daily or intermittently. Children 0.5-1.5 mg/kg/day, max of 20 mg/day. Infant 1 mg/kg/day.

Administration rate should not exceed 4 mg/min.

Drug Interaction: Enhanced ototoxic effects if combined w/ aminoglycosides & cisplatin. Enhanced effects of oral anticoagulants, lithium & propranolol. Increased risk for digitalis-induced arrhythmia. Decreased response if given w/ NSAIDs & probenecid. Side effects/ adverse reactions: Fluid & electrolyte imbalance eg hyponatremia & ECF depletion, hypochloremic alkalosis, hypokalemia. Ototoxicity manifested as tinnitus, deafness & vertigo. Hypersensitivity reactions eg skin rashes, drug fever, interstitial nephritis & photosensitivity. Hyperuricemia, hyperglycemia & dyslipidemia. Nursing Responsibilities: 1. Document indications for therapy and any other agents trialed. 2. Monitor BP, weight, edema, breath sounds, I&O, and electrolytes. 3. Observe for signs and symptoms of hypokalemia. 4. Instruct patient to take medicine in the morning on an empty stomach to enhance interruption of sleep at night. May take with food or milk if GI upset.

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5. Instruct patient to time administration to participate in social activities and to minimize need to interrupt sleep and to void frequently. 6. Tell patient to immediately report any muscle weakness/ cramps, dizziness, ringing in the ears, sore throat, fever, severe abdominal pain, numbness, or tingling. 7. Drug may cause BP to drop. Tell patient to change positions from lying to standing slowly. 8. Tell patient to avoid alcohol and not to exercise heavily in hot weather. 9. Instruct patient to use sunscreens and protective clothing when exposed to sun to minimize the effects of drug- induced photosensitivity. 10. Advise patient to report onset of adverse reactions to health care professional promptly.

Generic Name: sultamicillin tosylate Brand Name: Unasyn (oral) Classification: Antiinfective; Antibiotic; Aminopenicillin Mechanism of Action: Unasyn Oral: Following oral administration in humans, sultamicillin is hydrolyzed during absorption to provide sulbactam and ampicillin in 1:1 molar ratio in the systemic circulation. The bioavailability of an oral dose is 80% of an equal IV dose of sulbactam and ampicillin. Administration following food does not affect the systemic bioavailability of sultamicillin. Peak serum levels of ampicillin following sultamicillin are approximately twice those of an equal dose of oral ampicillin. Elimination half-lives are approximately 0.75 and 1 hr for sulbactam and ampicillin respectively in healthy volunteers, with 5075% of each agent being excreted in the urine unchanged. Elimination half-lives are increased in the elderly and in patients with renal dysfunction. Probenecid decreases the renal tubular secretion of both ampicillin and sulbactam. Concurrent use of

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probenecid with sultamicillin results in increased and prolonged blood levels of ampicillin and sulbactam. Indications: Infections caused by susceptible microorganisms. Typical indications are upper and lower respiratory tract bacterial infections pneumonias; including sinusitis, otitis urinary tract infections

media, epiglottitis and tonsillitis; and pyelonephritis;

intra-abdominal

infections

including peritonitis, cholecystitis,

endometritis and pelvic cellulitis; bacterial septicemia; skin, soft tissue, bone and joint infections and gonococcal infections.

Contraindications: Individuals with a history of an allergic reaction to any of the penicillins. Dosage: Tab: Adults and the Elderly: Recommended Dose: 375-750 mg twice daily.

Drug Interaction: Allopurinol: The concurrent administration of allopurinol and ampicillin

substantially increases the incidence of rashes in patients receiving both drugs as compared with patients receiving ampicillin alone. There are no data concerning concurrent administration of sultamicillin and allopurinol. Aminoglycosides: Mixing ampicillin with aminoglycosides in vitro has resulted in substantial mutual inactivation; if these groups of antibacterials are to be administered concurrently, they should be administered at separate sites at least 1 hr apart.

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Anticoagulants: Parenteral penicillins can produce alterations in platelet aggregation and coagulation tests. These effects may be additive with anticoagulants. Bacteriostatic Drugs (Chloramphenicol, Erythromycin, Sulfonamides and

Tetracyclines): Bacteriostatic drugs may interfere with the bactericidal effect of penicillins; it is best to avoid concurrent therapy. Estrogen-Containing Oral Contraceptives: There have been case reports of reduced oral contraceptive effectiveness in women taking ampicillin, resulting in unplanned pregnancy. Although the association is weak, patients should be given the option to use an alternate or additional method of contraception while taking ampicillin. Methotrexate: Concurrent use with penicillins has resulted in decreased clearance of methotrexate and in methotrexate toxicity. Patients should be closely monitored. Leucovorin dosages may need to be increased and administered for longer periods of time. Probenecid: Probenecid decreases renal tubular secretion of ampicillin and sulbactam when used concurrently; this effect results in increased and prolonged serum concentrations, prolonged elimination half-life and increased risk of toxicity. Side effects/ adverse reactions: Body as a Whole: Anaphylactoid reaction and anaphylactic shock. Central and Peripheral Nervous: Rare reports of convulsions. Gastrointestinal: The most frequently observed side effect was diarrhea/loose stool. Nausea, vomiting, epigastric distress and abdominal cramps have been observed. As with other ampicillin-class antibiotics, enterocolitis and pseudomembranous colitis rarely may occur. Hematopoietic and Lymphatic: Anemia, hemolytic anemia, thrombocytopenia, eosinophilia and leukopenia have been reported during therapy with sulbactam
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sodium/ampicillin sodium. These reactions are reversible on discontinuation of therapy and are believed to be sensitivity reactions. Liver/Biliary: Transient elevations of ALT (SGPT) and AST (SGOT)

transaminases, bilirubinemia, abnormal hepatic function and jaundice. Skin/Skin Structures: Common: Rash, itching and other skin reactions were infrequently observed. Rare reports of Stevens-Johnson syndrome, epidermal necrolysis and erythema multiforme were infrequently observed. Urinary: Rare reports of interstitial nephritis. Others: Drowsiness/sedation, fatigue/malaise and headache have been rarely

Nursing Responsibilities: 1. Before giving drug, ask patient about allergic reactions to penicillin although a negative history of penicillin allergy is no guarantee against future allergic reaction. Also, obtain specimen for culture and sensitivity tests. Therapy may begin pending results. 2. In patients with impaired renal function, decrease dosage. 3. Monitor liver function test results during therapy, especially in patients with impaired liver function. 4. Ensure adequately hydrated. Assess for diarrhea and sign and symptoms of superinfection. 5. Tell patient to report rash, fever, or chills. A rash is the most common allergic reaction.

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Generic Name: ampicillin sodium and sulbactam sodium Brand Name: Unasyn Classification: Antiinfective; Antibiotic; Aminopenicillin Mechanism of Action Inhibits cell-wall synthesis during bacterial multiplication. Route I.V. I.M. Onset Immediate unknown Peak 15 min unknown Duration Unknown unknown

Indications: Treatment of infections due to susceptible organisms in skin and skin structures (e.g. Klebsiella pneumonia, Staphylococcus aureus) and intraabdominal infections (e.g. Escherichia coli) and for gynecologic infections (e.g. Bacteroides sp. Including B. fragilis). Also used for infections caused by ampicillin- susceptible organisms.

Contraindications: Hypersensitivity to penicillins; mononucleosis. Cautious use : Hypersensitivity to cephalosporins; pregnancy (cat B) or lactation. Dosage: Systemic infections Adult/Child: IV/IM 40 kg, 1.5 (1 g ampicillin, 0.5 g sulbactam) to 3 g (2 g ampicillin, 1 g sulbactam) q 6 h (max: 4 g sulbactam/d) Acutal Dose: 750mg

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Drug Interaction: Drug-Drug. Allopurinol: May increase risk of rash. Monitor patient for rash. Hormonal contraceptives: May decrease hormonal contraceptive effectiveness, leading to unintended pregnancy. Strongly advise use of additional form of contraception during penicillin therapy. Oral anticoagulants: May increase risk of bleeding. Monitor PT and INR. Probenecid: May increase ampicillin level. Probenecid may be used for this purpose. Side effects/ adverse reactions: CV: thrombophlebitis, vein irritation. GI: nausea, vomiting, diarrhea, glossitis, stomatitis, gastritis, black hairy tongue, enterocolitis, pseudomembranous colitis. Hematologic: anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leucopenia, agranulocytosis. Skin: pain at injection site. Other: hypersensitivity reactions, anaphylaxis, overgrowth of nonsusceptible organisms. Nursing Responsibilities: 1. Before giving drug, ask patient about allergic reactions to penicillin although a negative history of penicillin allergy is no guarantee against future allergic reaction. Also, obtain specimen for culture and sensitivity tests. Therapy may begin pending results. 2. Dosage is expressed as total drug. Each 1.5-g vial contains 1 g ampicillin sodium and 0.5 g sulbactam sodium. 3. In patients with impaired renal function, decrease dosage. 4. Monitor liver function test results during therapy, especially in patients with impaired liver function. 5. Monitor patient carefully during the first 30 min after initiation of IV therapy for signs of hypersensitivity and anaphylactoid reaction. Serious anaphylactoid
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reactions

require

immediate

use

of

emergency

drugs

and

airway

management. 6. Ensure adequately hydrated. Assess for diarrhea and sign and symptoms of superinfection. 7. If large doses are given or if therapy is prolonged, bacterial or fungal superinfection may occur, especially in elderly, debilitated, or

immunosuppressed patients. 8. Tell patient to report rash, fever, or chills. A rash is the most common allergic reaction. 9. Advise patient to report discomfort at I.V. insertion site. 10. Warn patients that I.M. injection may cause pain at injection site.

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A2. Surgical Technique Position Rationa le Supine position and moderate high back rest To facilitat e comfort able surgical access to the operativ e site, reduces bleedin g (mostly by avoidin g venous congest ion), prevent s pressur e damag e to skin, -For superficial closure of Large curve line skin incision crossing the left frontal area
Is a circular incision, it is convenien t and comfortabl e. It provides sufficient exposure of the operation field. It provides adequate surgical access, good healing of skin flaps and a good cosmetic result.

Incision

Rationale

Suture s Vicryl 3.0

Rationale

Instruments

is

an

A. Cutting Instruments

absorbable, synthetic, It is indicated for tissue approximati on and soft

a. Metzenbaum (1) b. Mayo Scissors (1) c. Suture Scissors(1) d. Knife (1)

ligation. The suture holds its tensile

strength for approximat ely three to four weeks in and tissue, is

B. Grasping Instruments a. Adson with teeth(1) b. Adson without teeth(1) c. Tissue forceps with teeth(1) d. Tissue forceps without teeth(1) e. Allis(3) f. Curve

completely absorbed by hydrolysis within days. 70

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nerves, joints and muscle s, minimiz es adverse cardiac and respirat ory proble ms, and provide s good access for the anesthe tist. The head was position ed in a 20 degree angle this is for better visualiz Prolen e 3.0

skin mucosa.

mosquito clamps(16) g. Fine curves(12)

-nonabsorbable polypropyle ne suture. It is indicated for skin closure and other injuries to the fascia. Its advantages include high tensile strength, minimal tissue reactivity, and slipperiness (allowing easy removal from tissues).

h. Straight clamps (6) i. Needle holder (2) j. Towel clips (4)

C. Retracting (NONE)

D. Ancillary a. Medium Sponge (10) b. Operating Sponge (10) c. Cottonoids (10) d. Needles Atraumatic- 2 Non-atraumatic-12 e. Cotary cord

BRAIN SET

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ation of the frontal part of the head of which the gunshot wound was located.

Patient Chera Mae Jolo, was received in the OR department on June 30, 7am. At 7:47am, general endotracheal anesthesia was inducted by Dr. L. Encarnacion. Skin preparation was done by the nurse on duty aseptically at 7:48am. Foley catheter was inserted by Dr. Enanoria and was attached to a uro bag. The patient was placed in a supine position. This facilitates a more convenient surgical access as well as reducing the bleeding, preventing pressure damage to skin nerves, joints and muscles, minimizes adverse cardiac and respiratory problems, and provides good access for the anesthetist. The head was also positioned in a 20 degree angle for better visualization of the left frontal part of the head of where the gunshot wound was located. At 8:45am, procedure was started by Dr. Lagapa. The type of technique in used in incision was large curvelive incision crossing the left frontal area. It is a circular shaped incision and pretty much convenient for the physician during the operation. It exposes the site of operation and provides adequate surgical access, good healing of skin flaps and a good cosmetic result. One of the sutures used in the operation was Vicryl. It is an absorbable and synthetic and is indicated for the approximation and ligation of the soft tissues. It also
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helps in the closure of the skin mucosa. The tensile strength of the suture holds for approximately three to four weeks in tissue and is completely absorbed by hydrolysis within 70 days. Another suture used was Prolene. It is a non-absorbable polypropylene suture indicated for skin closure and other injuries to the fascia. It has a high tensile strength, minimal tissue reactivity, and slipperiness allowing easy removal from tissues.

The instruments used for the cutting knife, metzenbaum, mayo scissors, and suture scissors were used. While tissue forceps with teeth, tissue forceps without teeth, adsons with teeth, adsons without teeth, curved mosquito clamps, fine curve clamps, straight clamps, allis, and needle holder were used in grasping. There were no retracting instruments that were used. For the ancillary instruments, were the medium sponge, operating sponge, cottonoids, and needles (Atraumatic and Non-atraumatic needles). For the other instrument is the brain set.

USES OF SURGICAL INSTRUMENTS

GRASPING Towel Clips to attach towels, spring clips with middle crossover and spring at end. Inward curving, sharp pointed tips. Used to fix drapes to tissue with minimal trauma Needle Holder to hold and guide suture needles securely for suturing

Fine Curves Allis to clamp or handle hard tissues to clamp and restrict arteries or tissue, to control the flow of blood

Tissue Forceps with teeth to grasp and handle hard tissues

Tissue Forceps without teeth


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to grasp and handle soft tissues

Adsons with teeth to grasp or handle hard tissues and other material Adsons without teeth to grasp or handle soft tissues and other material

Curved Mosquito Clamps to hold delicate tissue or compress a bleeding vessel

Straight clamp - an instrument with serrated jaws and locking handles, used for gripping, holding, joining, supporting, or compressing an organ, vessel, or tissue. In surgery, clamps generally are used for hemostasis and clamping tissue

CUTTING Knife to cut tissues

Metzenbaum scissors - Lightly built curved scissors with blunt-pointed, narrow blades Mayo scissors -heavy-duty surgical scissors with narrowed but blunt pointed blades, which may be straight or curved

Suture scissors -use for cutting sutures

ANCILLARY ACCESSORY Cotary Cord for incision and coagulation

Medium sponge

Operating sponge
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Cottonoids Needles (Atraumatic and Non-atraumatic)

OTHERS

Brain set

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IV. RELATED NURSING THEORY FLORENCE NIGHTINGALES ENVIRONMENTAL THEORY Assumpations Of Nightingale's Theory Natural laws Mankind can achieve perfection Nursing is a calling Nursing is an art and a science Nursing is achieved through environmental alteration Nursing requires a specific educational base Nursing is distinct and separate from medicine Nightingales canons: major concepts

Nightingales Canons: Major Concepts Ventilation and warming Light, noise


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Cleanliness of rooms/walls Health of houses Bed and bedding Personal cleanliness Variety Chattering hopes and advices Taking food. what food? Petty management/observation

Nursing Paradigms

Nightingales documents contain her philosophical assumptions and beliefs regarding all elements found in the metaparadigm of nursing. These can be formed into a conceptual model that has great utility in the practice setting and offers a framework for research conceptualization. (selanders lc, 2010)

Nursing Nursing is different from medicine and the goal of nursing is to place the patient in the best possible condition for nature to act. Nursing is the "activities that promote health (as outlined in canons) which occur in any caregiving situation. They can be done by anyone." Person

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People are multidimensional, composed of biological, psychological, social and spiritual components. Health Health is not only to be well, but to be able to use well every power we have.Disease is considered as dys-ease or the absence of comfort. Environment "Poor or difficult environments led to poor health and disease". "Environment could be altered to improve conditions so that the natural laws would allow healing to occur."

BETTY NEUMANS SYSTEM MODEL IN NURSING PRACTICE Metaparadigm in Nursing Betty Neumans theory incorporated the concept of a whole person and an open system approach. The concept is aimed towards the development of a person in a state of wellness having the capacity to function optimally. The main role of the nurse in her theory is to help a person to adapt with environmental stimuli causing illnesses back to a state of wellness. Nursing Neuman believes that nursing requires a holistic approach, an approach that considers all factors affecting a clients health. The model sets a structure that depicts the part and subparts of a client as a complete system. This concept provides the nurse to consider that a clients physical, physiological, mental, social, cultural, developmental, and spiritual well-being is dynamic. Therefore, a nurse must be able to adjust to meet the individual and unique needs of every client.
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Person Neuman regarded the concept of a person as an individual, family, community, or the the society. She sees a person as an open system that works together with other parts of its body as it interact with the environment. An open system is characterized presence of an exchange of information and reaction with other factors surrounding a person. Health Neuman considers health as dynamic in nature. A persons health depends upon which state of the health continuum they are in line with, the person maybe in line with the state of wellness or illness. The state of wellness exist when all the part or system of person works harmoniously. Disharmonious system reflects illness as a result of unmet needs of a person. The state of health varies according to the degree of reaction a person has to environmental forces. If a person successfully copes with the environmental influences and is able to maintain adequate level of health, the person can preserve the integrity of all the parts of the system. Environment The environment can be an internal, external and created force that interacts with a persons state of life. It can alter or improve the systems in which a person exist. These forces are what Neuman termed as the stressors. Stressors are tensions that produce alterations in the normal flow of the environment.

System Model in Nursing Practice Client Variables The client variables can be one or combination of the following: physiological, sociocultural, developmental, spiritual. These variables function to achieve stability in relation to the environmental stressors experienced by the client.

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Lines of Resistance Act when the normal line of defense is invaded by too much stressor, producing alteration in the clients health. It acts to facilitate coping to overcome the stressors that are present within the individual. Normal Line of Defense To achieve the stability of the system, and the normal line of defense must act in coordination with the normal wellness state. It must reflect the actual range of responses that is normally acted by clients in response to any stressors. It is the baseline in determining the level of wellness of client within the continuum of health.

Flexible Line of Defense Serves as a boundary for the normal line of defense to adjust to situations that threaten the imbalance within the clients stability. It expanded the range of normal defense from becoming invaded by the stressors, thus increasing its protection. Stressors Stressors are forces that produce tensions alterations or potential problems causing instability within the clients system. The importance of identifying the stressors helps nurses to appropriately use actions to address and help solve the produced problem. Reaction Ractions are the outcomes of produced results of certain stressor and actions of the lines resistance of a client that it can be positive or negative depending on the degree of reaction the client produces to adjust and adapt with the situation. Neuman
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specified these reactions as negentropy or entropy. Negentropy is set towards stability or wellness, while egentropy is set towards disorganization of the system producing illness.

Prevention Is used to attain balance within the contiunuum of health these are actions that generate good results or are aimed towards hindering negative outcomes Three Levels of Prevention Primary- prevention that focuses on foreseeing the result of an act or situation and preventing its unnecessary effects as possible. Secondary- focuses on helping alleviate the actual existing effects of an action that altered the balance of health of a person. Tertiary- focuses on actual treatments or adjustments to facilitate the strengthening of person after being exposed to a certain disease or illnesses.

Reconstitution Reconstitution is the adjustment state from the degree of reaction. It is a state of going back to the actual state of health before the illness occurred.

Relevance We have chosen the theories of Nightingale and Neuman because it is the most relevant and most applicable in the case of our client.

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The environmental theory highlighted the benefit of good environments in preventing illness. The nurses role include the management of the environment in a number of ways to improve patients recovery. Just like in the case of our patient, as nurses we need to make sure that we provide comfort to the patient; protection from emotional distress and the conservation of energy while allowing the patient to participate on self-care activities. The System Model theory is much related to our client as for this theory can be used to help our client in different areas. Its applicability is congruent with the social, physical, physiological, psychological, spiritual aspects of a person which is very holistic. The case of our client is very tragic for her and also for her family. We chose this theory because it gives us the idea on how to have an accurate assessment, planning, implementation and evaluation of the planned care for the clients. For short we are doing a holistic approach to our client, especially shes facing a complicated health problem. We can also use this theory in organizing a framework to plan care at primary, secondary, and tertiary levels of prevention of health care. V. Nursing Management

Preoperative: Preoperative care is defined as "Care given during the period prior to undergoing surgery when psychological and physical preparations are made according to the special needs of the individual patient. This period spans the time between the client's already made the decision for surgical procedures up to the time the patient is receive by the operating room department." The preoperative care is the preparation and management being rendered to the patient prior to the surgery. This includes both the physical and psychological preparation for the client. Preoperative health teaching meets the patient's need for information regarding the things that patient may experience in the surgical procedure and those necessary interventions patient can do in order to compensate to the demand of the operation.

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Interventions Ideal

Interventions Actual the health Allowing started to questions

Rationale client to ask the

1. Allow the client time to ask Before questions about procedures Professionals and surgery.

regarding

explain the surgical procedure procedure she is about to to the significant others of the undergo may help in

patient, they will be given the alleviating the anxiety being time to ask about there experience by the client, since

concerns in relation to the surgical operation is consider procedures to be discussed. to be one of the biggest events in one's own life. 2. Explain all procedures to Dr. Lagapa, the attending Proper explanation of all the the client and give reasons for physician them. explain procedure, of the the patient procedures to be render to surgical the client facilitates client's

Frontoparietal participation for the success

Craniotomy to the significant of the different procedures, others prior to the approval of thus this may give client as the consent before the well as client's significant

significant others will make its others of the importance of decision about the certain those procedures. matters. 3. Determine the client's level As the activity goes on, Dr. Client's understanding about of understanding of operative Lagapa procedure to answers those the procedures is first best from the client's

ascertain inquiries of the watcher or achieve

whether signature on permit significant others. represents informed consent.

attending physician, sufficient knowledge and information

can help client to relieve feeling of anxiety thus

producing stress. 4. Allow and encourage the client to ventilate feelings There are certain fears that client may experience as the client decided to submit thy
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about diagnosis and surgery.

selves for surgery, allowing client to share her feelings enables provider the to health gave care

specific

support which can greatly help in order to prepare client for the procedures. 5. Tell the client what to expect Room, in the Operating and/or This certain interventions

enables to help the growth of client's participation throughout and the

recovery,

intensive care units, including use of anticipated

cooperation

surgical procedures.

equipments. 6. Inform the client if the plan is to return him or her to other than the present room. We cannot stop instances that client's condition may alter before, during and after most the

especially

procedures made, since there will be a cessation that the client may experience since her body will start to

compensate to the demands of operations, proper

information to the client and her significant others provide a certain information about what thus the patient is

experiencing. 7. Encourage so nutritional that any Correct nutritional status of the client, will serve as a significant factors for the

assessment

nutrient deficiencies can be

Page | 93

corrected.

success

of

the

surgical

procedures, thus a set of test must be done to the patient, in order to correct existing problem and free client from the manifestations of other forms of complications. 8. Provide spiritual counselor if desired by the client or family. Different individuals have

there own spiritual view with the different matters they will be undergo, providing spiritual counselor under clients wants may help in building client's confidence and faith in facing certain procedures.

9. Consider needs of the family surgery. when discussing

Client's

significant

others

have their rights to know what the client will be experiencing, this will help to formulate trust and cooperation to the health professionals most especially to the surgical team.

10.

Teach

the

client

the

Teaching client about different techniques to be done after the surgery gives client the knowledge of the different interventions she can perform after surgery, preoperative

activities that will be instituted after surgery related to

ventilatory functions like: a. Diaphragmatic breathing; b. Controlled couging; c. Deep breathing d. Incentive spirometry e. Splinting; and

interventions like this serve as important factor since client is interested of the ways they
Page | 94

f. Turning.

can do to recover faster, because if you this before the procedure client is very much irritable in due to pain that they are experiencing.

11. Teach the client physical exercises that will be used to promote surgery. a. Leg exercises including dorsiflexion; b. Ambulation routines; c. Isometric exercises; 12. Inform the client to expect some discomfort after surgery and teach the importance of requesting pain. medication for circulation after

This will enhance client's easy recovery since proper blood flow or circulation to the body especially to the affected

area, facilitates faster healing of such.

Since there are certain part of the body which trauma, can proper

experience

explanation to the possibility of client's experiencing of pain is very much important, in relation to this patient can perform those techniques that can alleviate pain due to different incision that may cause trauma to a certain body part.

13. Make certain that history, Different laboratory test done Different test results provide a physical examination results, unto like the CT scan, specific use especially before

recent laboratory tests, and Complete blood Count, Rh the time that the patient is chest x-ray report are entered Compatibility test and the like about to be submitted for the on the chart. are being attached to the start of the procedure, since
Page | 95

client's

chart of

before decision submitted

the those

test

may

give

formulation client being

of significant information about for the limitation of the drugs to be administer client, and to do necessary interventions in

surgical procedures.

order to prevent underlying harm to the patient. 14. Minimize all members of the medical team, especially the anesthetist, of the client's allergies problems and and other health prominently Overcrowded place creates more tension to the patient, in relation to this it also place a high risk instance that the sterile unsterile field due may to become minimal

mark the chart.

space or areas for mobility in the environment. 15. Minimize the risk of Our clients hair was shaved As a health care provider we by prior to surgery. protect patient from infection since patient is at risk of skin acquiring such especially

postoperative

infection

proper skin preparation: a. Cleanse the

thoroughly with antimicrobial preparation as ordered; b. Shampoo hair when head,

during the surgical procedure. Interventions must be

correctly be established in order to free patient from any form of infection.

procedure

involves

neck, or upper chest area; and c. Shave skin if ordered. 16. Carry out ordered

One of our basic interventions is to follow0up and perform preoperative preparation

preoperative preparation: a. Enemas; b. Douches; and c. Irrigations.

before the client is to be sent to the operating room,

Page | 96

preparation serve as stepping zone for the success of the operation to be made unto the client. Proper preparations also

enhance client's readiness to submit herself for operation. 17. Remove nail polish from Client's nail polish was being In order to assess client's fingers and toes. removed as part of the nurse condition especially the blood preparation of the client for circulation all over the client's operation. body that is best assess on fingernails and toe nails. Nails polish can also serve as a source of microorganisms which place client's at risk of acquiring infection. 18. Administer prescribed There are some instances that patient is very much anxious, thus resulting them of not submitting themselves to sleep, rest is very much in need in order for the client to have strength surpass the operations she is about to experience. administration coupled with However, must the be

sleeping medications: a. Sedative-Hypnotics; b. Antianxiety agents.

doctor's

prescription because sleeping medication different effectiveness have length this there of ensures

Page | 97

client's safety and prevent any forms of delay to the scheduled procedures. 19. Inform the client not to Her attending physician, Dr. Placing client's nothing by take anything by mouth after Lagapa ordered her to be on mouth is one of the major midnight the night before the NPO temporarily. surgery, remove fluid, and place bedside. obvious signs at requirements follow, patient must certain surgical

this

interventions is use to prevent accidental puncturing of any organs of the body wherein those processed foods and water goes. It also help to prevent succeeding

complications to the client such as infection. 20. Provide care for the client on the day of surgery: a. In the morning, check the Client's vital signs is being Vital signs serve as your client's vital signs and assess check before the client is baseline of results in order to overall physical status: record being sent to the operating monitor client's status and and report any deviations to room. physician. results: BP: 120/80 mmHg TEMP.: 35.3 C PR: 98 bpm RR: 28 cpm Client's vital signs condition. Getting the client's vitals signs before the

procedure help in identifying those areas where result are either increase or decrease, in order for the health

professionals to perform a certain intervention in order to correct any problem


Page | 98

in

relation with the client's vital signs. b. Check the client's medical Client's medical chart is being Different test results provide a chart to ensure that pertinent checked before the client is specific use especially before test results are present. received to the operating the time that the patient is

room. The checking is done about to be submitted for the by the nurse on duty. start of the procedure, since those test may give a

significant information about the limitation of the drugs to be administer client, and to do necessary interventions in

order to prevent underlying harm to the patient. c. Complete the preoperative Preoperative checklist. complete necessary checklist and is Early completion facilitates of the

different checklist

proper

information

is time management, in order to

being check and completed meet the scheduled time to as the patient is receive by start as well as the time to the Operating room staff. end the operation since the longer the operations goes the more you place client's life in danger or at great risk. d. Provide hygiene and assist The health professional in Proper client into hospital gown. Emergency Room change her operation clothing in to hospital gown during the hygiene prior to

prevents actual

delay surgical

and her hair was shaved prior procedure, it also prevents to client's submission to the instances that patient appears operating room. to be unpleasant to surgical team. This act also prevent patient from forming
Page | 99

any

forms of complications in due to infections. Hospital gown is being worn depending on the hospital policy and this prevents client from being exposed. Preparation also facilitates to perform the procedure

according to its scheduled time. e. Have the client void. Emptying the bladder prevent it from any accidental forms of punctures procedure thus make the since

prolong

surgical team should also give importance to the area being damage. Accidental

puncturing also place client at risk for acquiring infection. f. Remove prosthetics such as Client does not wear any In order to prevent aspiration dentures and wigs. dentures and wigs as the since patient is being

client is being receive in the anesthetize and either place operating room. in its unconscious state

depending on the type of anesthesia being given unto her.

g. Arrange for insertion of any tubes as ordered. G1.Nasogastric tube; and G2.Indwelling urinary

Especially to client's whose bladder is full, in order to prevent any variations that serve as a hindrance for the
Page | 100

catheter.

success

of

the

surgery

insertion of catheter is given in order to prevent any forms of accident. Preparing client for those tube insertion may facilitate in proper time

management. h. Arrange for insertion of Patient is with an Intravenous Preparing client for those tube Intravenous line as ordered. of D5LR 1L at infusing well at 60 cc/hr., insertion the right intravenous in and insertion proper even may time

metacarpal vein and PLR 1L facilitate

at KVO rate infusing well at management. This also help left metacarpal vein; regulated in maintaining clients level of and it is flowing. hydration since they are also at risk of experiencing

dehydration since client are being place in NPO. i. Store any client valuables according to hospital policy. In order to ensure that client's valuables are being secured into the place wherein you are in great confident that those valuables won't be lost since this play an important role to client's life and also the nurse or the institution will be place into question once those

valuables are lost. j. Make sure identification The patient has ID band in This ensures that the correct band is on client's wrist. her wrist and its confirmed patient is to be brought to the that she is really the patient. operating room.
Page | 101

k.

Administer

prescribed An antibiotic as ordered is There to

are

preoperative

preoperative medications as being administered ordered; 1. Antianxiety agents; 2. Sedatives; 3. Narcotics analgesics; and 4. Anticholinergics. client such as

the medications which are being

Ampicillin- prescribed by the doctor, this facilitates client's status and health condition all throughout the procedure, since patient feels many things prior to surgery like anxiety which can greatly affects her as vital a

Sulbactam.

signs,which

serve

significant factors to monitor client's throughout. l. Put side rails up after Side rails of the stretcher In order to facilitate client's administering medications. where the patient lies are up. safety. Thus preventing any accidental falls causing harm to our patient. m. Transfer the client to a Patient is being transferred A call from the operating room stretcher room when operating from the hospital bed to a serve as a time for the health the stretcher as the operating professionals called the to transport condition all

calls;

fasten

stretcher strap in place before room transporting.

ER client to operating room for

Department where the patient she is about to be prepared stays. inside the operating room itself. This prevent boredom and increase anxiety to

patient while waiting for the time of operation being in the operating room. n. Consider the emotional needs of both the client and family on the day of surgery. Patient at this time are at the height grade, of there emotional emotional

providing

Page | 102

support

and

catering

the

needs of the patient may reduce client's anxiety and thus keep thy self ready for the surgery. 21. Provide care for the client in the operative suite. a. Take client to a holding Client is first being place on Placing client to the holding area outside of the operating the area of the operating area keeps the client safe room. room near the Student's since there are health

dressing room being attended professionals which can look by ER nurses and OR nurses after her. on duty. b. Insert an intravenous Especially to client's whose bladder is full, in order to prevent any variations that serve as a hindrance for the success of the surgery

catheter (if not already in place); usually done by the nurse or anesthetist.

insertion of catheter is given in order to prevent any forms of accident. Preparing client for those tube insertion may facilitate in proper time

management.

c.

Transfer

client

to

the

A call from the operating room serve as a time for the health professionals to transport

operating room by stretcher; a laminar airflow room is often use for orthopedic surgery.

client to operating room for she is about to be prepared inside the operating room
Page | 103

itself. This prevent boredom and increase anxiety to

patient while waiting for the time of operation being in the operating room. d. Complete checklist. The checklist is already Early completion facilitates of the

signed before the patient is checklist

proper

being sent to the operating time management, in order to room which facilitates proper meet the scheduled time to time management. start as well as the time to end the operation since the longer the operations goes the more you place client's life in danger or at great risk.

e. Apply monitoring device as needed.

Application of the monitoring device will serve as important gadget in order to monitor client's condition and status especially operations during and after the the

procedures since this is the critical part of the Surgery. f. Allay client's surgical anxiety; clients Alleviating client's anxiety

ambulatory

facilitates client's cooperation throughout the procedure

remain aware during most of their stay in the operating room because are local frequently

especially during the events wherein client only receive local anesthesia wherein

anesthetics used.

client is awake while the operation is being performed.


Page | 104

g. Anesthesia is introduced by Anesthesia was being given Monitor

client

once

the anesthetist to produce to the client when the surgeon anesthesia is being rendered four stages of anesthesia: Stage drowsy 1: Client and decided to start the in order to facilitates client's safety patient since at this time there

becomes procedure. loses

loses

consciousness. Stage 2: Stage of Excitement; muscles are tense, breathing maybe irregular. Stage 3. Depression of vital signs and reflexes; operation begins during this phase. Stage 4: Complete

consciousness of those thing within the operating room

most especially those who receive spinal, epidural, and combined spinal and epidural anesthesia.

Respiratory depression. h. Anesthetist inserts an This contributes of to the the being

endotracheal tube or airway after the administration of an intravenous anesthetic.

effectiveness anesthesia

administered, thus the client can achieve its designated effects.

i. Position client for surgery.

Client is place in a supine Different procedures requires position in a moderate high different forms of positioning back rest. which certainly facilitate easy access to the concerned area thus is being tried to be fixed and to be return to its normal functioning.

j.

Operating role

room of

nurse client the

Different specific

roles

have

their

assumes advocate

responsibilities

during

especially in assisting and catering the needs of the


Page | 105

intraoperative phase:

1. The scrub nurse hands the surgeon sterile instruments and sponges, and supplies; and counts

whole surgical team, proper identification of

responsibilities facilitates for the complete success of the operations that the patient is to be submitted.

instruments; of used

disposes

instruments; 2. The circulating nurse

positions the client on the table, drapes the client, and assist the surgeon and scrub nurse to don sterile attire.

Intraoperative The term "intraoperative" refers to the time during surgery. Intraoperative care is patient care during an operation and ancillary to that operation. Activities such as monitoring the patient's vital signs, blood oxygenation levels, fluid therapy, medication transfusion, anesthesia, radiography, and retrieving samples for laboratory tests, are examples of intraoperative care. Intraoperative care is provided by nurses, anesthesiologists, nurse anesthetists, surgical technicians, surgeons, and residents, all working as a team. Intraoperative care is patient care during an operation and ancillary to that operation. Intraoperative care includes the activities performed by the health care team during surgery that ensure the patient's safety and comfort, implement the surgical procedure, monitor and maintain vital functions, and document care given. The intraoperative time period can vary greatly from less than one hour to 12 hours or more, depending on the complexity of the surgery being performed.
Page | 106

Ideal

Actual

Rationale This serve as a key stone in

1. The time the patient is An immediate assessment being receive by

the was being done by the health order to confirm that client the capability the of

Operating room department, professional in order to check has perform a thorough client's present condition.

undergoing

operation,

assessment with regards to the client's those significant condition which factors

since surgical operations also place a life threatening

especially provides

scenario to the patient for no one can predict of what

which permits approval of the procedure

certain events might happen during the operations.

2.

Take

time chart

to

review At this time the ER nurse

Paying special attention on

patient's

before reads the client's chart before the client's chart provides the assurance that it is the correct patient, and it also facilitates to have sufficient knowledge about the client.

receiving a certain patient the OR nurse will accept the coming from a certain client in the operating room department.

department.

3. The patient must clearly The Nurse on Duty checked Patient

must

be

clearly

identified before receiving the the ID bond of the patient to identified in order to ensure patient in the Operating Room clarify if she is really the that the patient who is being for scheduled operation in a patient. certain areas in the body . sent to the operating room is the right patient to whom those surgical procedures are designed.

4. Establish rapport to the client upon receiving the

Building rapport serve as a stepping stone in order for the


Page | 107

client in the operating room department.

foundation cooperation

of

trust

and the

between

health care team and the patient. 5. Emotional support at this very moment comes from the health professionals inside Different individual being

submitted for operation feels mix emotions however the fear reign within each others heart thus providing emotional support is very important.

the operating room, thus it is one of our responsibility to provide emotional support to the patient. 6. Provide a sufficient time to interact with the client

Interaction helps to alleviate anxiety and fear that the client is experiencing.

especially about their own feelings for the operation

since the scheduled time is fast approaching. 7. Ask client about the The Circulating nurse Knowing items where client hypersensitivity

necessary things or foods administers skin testing to the experience wherein client is allergic at, patient. such as seafood, eggs and the like.

reaction is very much in need for there are some

medications that need to be administered during the to the extent client of

operations. And also proper identification of such prevents any underlying problems.

Page | 108

9. Since the patient is for surgical operation the health professionals should ask the patient if he or she has maintenance drugs and what are those drugs.

Some patient do take drugs in due health to there preexisting like

condition

hypertension, disorders

Respiratory having such

conditions serve as an alarm for the surgical team that they should pay special attention to the occurrence of such.

10. Ask patient whether he or she has hypertension, asthma and other forms of health condition.

Some patient do take drugs in due health to there preexisting like such

condition having

hypertension,

conditions serve as an alarm for the surgical team that they should pay special attention to the occurrence of such. 11. Position the patient The patient was being place The patient must be protected from injuries that may occur due to malpositioning of the extremities. Proper positioning also facilitates easy access to the site which is the subject for the operations.

properly according to the type in supine position in a of operation that the patient moderate high back rest for will undergo. the Craniotomy and debridement.

12.

Provide

necessary

In order to identify client's status, as well as client's


Page | 109

activities in order to assess

the client's physical, mental, psychological, and nutritional status, before the induction of different forms of medications unto the patient. 13. Assess also the client's level of fear through sparing sometime to communicate to the patient.

ability

to

surpass

the

procedures, thus preventing any forms of delay during the operation.

Client's fear rises once the patient is within the vicinity of the operating room, thus

providing communication may help alleviate such fears.

14. Record client's vital signs Client's vital signs is being

To monitor the oxygen

specifically patient's cardiac recorded and being written on cardiac activity, oxygen rate, blood pressure, and the board as well as it was being recorded in the chart saturation and blood pressure of the patient during the

client's Oxygen Saturation.

both the Anesthesiologist and operation. To check for proper the circulating nurse. body circulation during the procedure. 15. If there will be an instance Oxygen is being administered Doctor's order is required for that the client requires oxygen to the client. administration, administer they are the one who has a sufficient knowledge whether to perform as specific

such however it must be coupled with doctor's order.

intervention to the patient. One reason is due to the effect of anesthesia. The

patient is risk to impaired gas exchange infections immobility,


Page | 110

and

pulmonary of

because

immunosuppression, decreased restriction. 16. Observe proper sterile or Those within the sterile field This prevent any underlying aseptic preparing techniques those in really observe aseptic or harm to patient, especially the LOC and fluid

necessary sterile

technique from the chance of putting them at risk

instruments which are to be time the nurse open the pack to have infection. use for the surgical until to be use for the surgical Following aseptic technique and until the maintain the sterility of the field, making a successful operation. 17. Arrange those The Scrub nurse, arrange the Proper arrangement facilitates ease as well as proper time management thus preventing any forms of delay.

operations that the client will operation undergo.

procedure is done.

equipments properly it can be instruments both in the mayo arrange according to its order table and back up table in an of use and position wherein organize manner. And in the one who handle the accordance to its importance

instruments feels comfortable of use. at.

18.

In

preparing

for

the Since the type of Anesthesia

Since the outside area may

induction of the anesthesia used is General Endotracheal contain microorganisms, if left the nurse should perform the Anesthesia. No need to application of antiseptic disinfect the site. unclean once the needle is being inserted to the client there are some

disinfectant on the site before inserting anesthesia. the needle for

microorganisms that goes in as the needle enters the body thus preventing infection.

19.

The

induction

of In our patient, the type of

Anesthesia plays a vital role in a certain surgical

appropriate anesthesia for the anesthesia being used is

Page | 111

procedure is done by the General anesthesia via anesthesiologist. We should Intravenous. maintain or provide a quite environment during induction.

procedure. There are different forms of anesthesia that can be administer to the client depending on the extent of operation. Providing a quite environment, lessen the

tension that the client feel and it also allows client to relax and have its rest.

20. There are instances that Foley Catheter was being the doctor will order insertion inserted to the patient by the of catheter to the patient, the Circulating Nurse following procedure aseptically much and be must done the aseptic techniques. be

Insertion usually

of done

Catheter if

is

patient's

bladder seems to be full. In order to irrigate urine and preventing any form of action that can cause the field to be unsterile.

position or place properly to prevent accidental removal of the tube. 21. Perform skin preparation The Circulating Nurse does on the surgical site, where the the skin preparation at the operation will be done. surgical site before the surgical procedure starts.

Skin preparation is usually done to patient with a visible hair growth in the site of incision, thus cleaning of such prevent any harm to the patient.

22. Different individuals inside Scrub nurse 1 and 2 perform

Proper

hand

scrubbing of

the operating room plays an hand scrubbing right after the removes important role. One the major opening of the big pack was member of the surgical team done.

accumulation

microorganisms to a certain part of the body.


Page | 112

is the Scrub nurse, the scrub must perform hand scrubbing in order for him or her to gain access to manipulate the

sterile field. 22. Maintaining the field free All throughout the procedure from any form of all the surgical team put This prevent any underlying harm to patient, especially the

microorganisms all throughout special concern or attention in chance of putting them at risk the surgical the operation maintaining the sterility of the to have infection. principles of field. Following aseptic technique maintain the sterility of the field, making a successful operation. To monitor the oxygen oxygen

following sterility,

and

proper

movement around the sterile field. 23. Monitor the client's vital The anesthesiologist, signs (CR, BP, and SPO2) all Circulating nurse monitor throughout the procedure and client vital signs and record it report any unusualities from in the patient chart for the results of patient's vital documentation. signs.

cardiac

activity,

saturation and blood pressure of the patient during the

operation. To check for proper body circulation during the procedure.

24. As the surgeon gain the The Scrub nurse wipes the usage of a certain surgical instruments with a wet instruments, the excess blood medium sponge after the or debris that is present in the doctor use that certain

Providing time in cleaning the instruments after being used by the Doctor, prevents any unwanted stains to the sterile which dirt can

said used instruments must instruments and return it to its field, be clean or have been wipe proper place. off.

sometimes be place to other instruments and this acts

conditioned the instruments ready to use again.


Page | 113

25.

The

counting

of

the Initial counting is done after

To prevent a certain form of injury because of a certain instrument inside the being client's retained body.

sponges, needles

instruments,and the preparation of the mayo must be done table by the scrub nurse and

repetitively in an organize circulating nurse. Then the manner following the first, second, and third

Counting ensures that the instruments present in the field are complete.

sequence of counting and counting was done. report it to the surgical team in a well modulated voice and it must be correct. 26. Document all the All necessary documentation

Proper documentation acts as a legal basis of the different procedures being rendered to the patient. Recording in a systematic manner provide easy access in order to

necessary information in a of the different procedures systematic manner, including was being done by the the time as well as all the circulating nurse. event that happen inside the operating room.

browse a certain scenario at that very moment. 27. Since the operation is The surgical team provides an Since patient's level of

already finished it is part of underlying care to the patient consciousness at this very our responsibilities to take after the surgery. good care to our client. moment is not yet under its normal degree, rendering

proper care prevent patient from experiencing any form of harm.

28.

After

the

surgical The nurse on duty, OR tech.

We cannot stop a certain

procedure change the client's and the student nurses joined instance that client gowns gown, linens into a clean one, there hands in changing may get dirt changing those the transfer
Page | 114

then application of mattress is client's gown and other linens. prevents

of

also allowed.

They also suction the mouth of the patient after the surgery.

microorganisms and it use to project client in a pleasant manner. This initiates a close

29. Transport client going to The Patient is being

the PACU or recovery room transported to the ICU instead monitoring in relation to the per stretcher make sure that in the PACU by an OR tech. the side rails are being raised. With side rails place up. client's condition as well as client's status after

undergoing different surgical procedures. 30. Do the after care of the The after care of the different To instruments use, as well as instruments use was being cleaning the area where the accomplished by the student operation took place. nurses on duty including the remove the transferred

microorganisms

during the operation, and to make sure that they are ready use for the next

student who handle the case. to

procedures. 31. Inform the client's The client and her relatives that For instance of surgical

significant

others

the were informed immediately by procedures, it is not only the patient who experience

operation is finish, coupled the attending physician tell with about necessary client's information about the surgical procedure present being done informing them

anxiety and fear but also client's significant others thus immediate communication to the client's significant others alleviate fears and the feeling of anxiety they are

condition and the place where that the operation is already the client is to be submitted finished. immediately after the surgical procedures.

experiencing.

Page | 115

POSTOPERATIVE Postoperative Phase begins with the admission of the patient to the PACU and ends with a follow-up evaluation in the clinical setting or at Home. The scope of the nursing care covers a wide range of activities during this period. In immediate postoperative phase, the focus includes maintaining the patients airway, monitoring vital signs, assessing the effects of the anesthetic agents, assessing the patient for complications and providing comfort and pain relief. There are three phases of postoperative period: the Immediate postoperative which begins the first 4 hrs. after the surgery; the Intermediate postoperative which begins 4 hrs. after the surgery to first 24 hrs; Extended postoperative which begins first day up to 4th day after the surgery.

Page | 116

Ideal

Actual

Rationale Vital signs are measured to monitor hemodynamic,

1. Assess neurologic status After the surgical procedure, and vital signs frequently and the ICU nurse monitors the compare with baseline values. VS of the client q15 and they also monitor the NVS of the patient. BP: 130/90 mmHg RR: 20cpm CR:28bpm Temp: 36.6C Sp02: 97 The NVS result: In the ICU- 4/12 In the San Lorenzo Ward-1/15 2. Assess orientation

cardiac and ventilatory status. Moderate temperature

elevation can be expected after intracranial surgery

because of the reaction to blood at the operative site or in the subarachnoid space. Decrease in LOC may be a sign of increase ICP.

and The nurse asks to move her Due

to

the

effect

of

ability to move extremities.

extremities; she was able to anesthesia, the muscles are respond to it. The patient is relaxed; ability to move her responsive but she is not extremities indicates that the oriented to place. effect of anesthesia is slowly disappearing.

3. Assess using the Aldrete score to the patient. There are 5 areas of assessment: The muscle activity, Circulation, level and 02

This scoring system used to determine general the condition patients and

readiness for transfer from the PACU. assessed The at patient is

repiration, Conscious saturation.

regular

intervals(15-30 mins.). Patient with a score lower than 7 must remain in the PACU until her condition improves or they are transferred to an intensive
Page | 117

care area, depending on their postoperative scores. 4. Insert for signs and Breaking in aseptic technique may lead to sepsis and it is life threatening to the patient. Aseptic technique is used in handling dressings, drainage systems, 5. Perform safety precautions The patients up side rails Safety intravenous and baseline

symptoms of infection; the incision site is monitored for redness, tenderness, bulging, separation and foul odor.

arterial lines. precautions is

such as raising the siderails, remains restrain,etc.

and

there

is important for the patients because anesthesia she and post

always a watcher to check to safety her because she is restless. undergone

one complications of

intracranial surgery is seizure. 6. Reinforce need to begin The nurse instructs the deep-breathing exercises. 7. Administer oxygen. Our client hooked in the oxygen; O2 cannula @ 23L/min. per nasal cannula. and leg patient to do deep-breathing. This deep breathing is

essential for faster recovery from anesthesia. Our client undergone General anesthesia; experienced patients has

prolonged

anesthesia, with all muscle relaxed. The patient is risk for impaired gas exchange and pulmonary infections because of immobility,

immunosuppression, decrease restriction. 8. Assess IV site for patency Patient is with an IVF of Fluid and electrolytes
Page | 118

LOC

and

fluid

and infusions for correct rate PNSS and solution.

1L

120cc/hr. imbalances of

may the

occur patients

infusing well at left metacarpal because vein.

underlying condition and its management or as

complication of surgery. Our patient is NPO for how many hrs.and she is risk for fluid and electrolytes imbalance

like dehydration and the likes. 9. Elevate head of bed to 30 Upon assessment, the head degrees. of the bed elevate to 30 degrees. The head of the bed is raised to decrease pressure and to promote normal drainage.

Elevate head of bed to reduce ICP and facilitate respirations. 10. Maintain head and neck in The head and neck of the To prevent further injury in the neutral alignment. patient maintained in neutral surgical site. Extreme head alignment by not hyperextend rotation is avoided because or limiting her head this raises ICP.

movement. 11. Change position slowly. The client can change So as not to cause any injury. the patient help to

position slowly by turning her additional body side to side. Repositioning every 2

hrs.will

mobilize

pulmonary

secretions and stasis. 12. Monitor intake and output Our client monitors her intake Intake frequently. and output q shift. Intake: 590cc Output: 800cc and Output are

measured as a guide to fluid and electrolyte replacement. Also to avoid fluid

overhydration. 13. Monitor pulse oximetry. Our client hooked in pulse It is an effective tool to
Page | 119

oximetry. Sp02: 97%

monitor for subtle or sudden changes in oxygen saturation. It is used in all settings where oxygen saturation monitoring is needed such as ambulatory surgical settings.

14. Suction airway as needed. The ICU nurse suctioned the When an Endotracheal tube is mouth to remove secretions in after the surgery. place; it to is usually the

necessary

suction

patients secretions because of the decreased

effectiveness of the coughing mechanism. suctioning bronchospasm Unnecessary can and initiate cause the

mechanical trauma to tracheal mucosa.

15. Administer steroids as ordered. 16. Observe for signs and symptoms hematoma, of one subdural of the

Steroids

is

prescribed

to

reduce brain swelling. Subdural hematoma is

caused by head trauma and the manifestation usually

possible side effects of the surgery.

appears 48 hrs.-2 weeks after the injury. Our client had head trauma due to Gun shot

wound so there is possibility that she might experience this kind of disease. 17. Assess degree and A certain amount of bloody drainage in a wound drainage
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character of drainage.

system or on the dressing is expected, but excessive

amounts should be reported to the surgeon. If the drainage continuous, the surgeon will change the dressing. 18. Reinforce dressing as needed. It should be dry and intact. This will prevent the

occurrence of infection. This dressing provides a proper environment for wound

healing, to absorb drainage, to splint or immobilize the wound and the likes.

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VI.

NURSING CARE PLAN

Preoperative Nursing Diagnosis Objective of Care Nursing Interventions 1. Applying pressure on Fluid Volume deficit related to severe blood loss secondary to gunshot wound Within 6 hours of nursing care and management, our patient will be to improve fluid volume as evidenced by: Rationale: There is a fluid deficit because of the injury to the head of our patient, there is severe blood loss that had occurred to our patient. a. Absence signs of fluid loss such as capillary refill time within normal range (23 seconds), good skin turgor, and pinkish mucosa. the wound area. Rationale: To prevent further bleeding thus decreasing fluid loss. 2. Check Vital signs Rationale: To have baseline data, for early detection. 3. Administer intravenous fluids as ordered by the physician. Rationale: b. Have vital signs in normal range T- 36.5-37.5 RR- 18-20 CR- 70-90 PR- 70-90 BP This is for the

replacement of the loss of body electrolytes that was lost. 4. Assess for the signs of dehydration like tachycardia,
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c. Reduce fluid loss through applying techniques such as pressure on the site.

hypotension, and poor skin turgor. Rationale: This is one sign of fluid imbalance in our body. Therefore, there is a need for replacement for the betterment of the patient.

5. Monitor the intake and output of the patient. Rationale: This will serve as a data for the comparison if there are any changes in the patients condition.

6. Have a laboratory test as ordered by the physician. Rationale: To detect decrease in the different components of blood this may cause bleeding. 7. Maintain an indwelling catheter. Rationale: This provides accurate
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assessment of urine output.

Intraoperative Nursing Diagnosis Risk for injury related to decrease level of consciousness Objective of Care Within 3 hours of nursing care in the operating room , our patient will be free from injury as evidenced by: Rationale: In the condition of our patient, she was unconscious, with that, she doesnt know of what she was doing and was not able a. safety precautions such as proper positioning, restraining properly and raising side rails; b. free from bruises
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Nursing Intervention 1. Position the client properly. Rationale: Improper positioning can lead to further injury especially to client with decrease level of consciousness

to think of what would be the consequences of her actions.

and scratches c. improve level of consciousness

2. Restrain the extremities of the patient. Rationale: To avoid unusual movements thus facilitating the surgical process

3. Do not leave the patient unattended. Rationale: To keep the patients safety 4. Stabilize both transport cart and operating room bed when transferring client to and from operating room table.

5. Provide body and limb support for client during transfers, using adequate numbers of personnel Rationale: to prevent client fall or compromise of any body system, and/or to prevent
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injury to personnel 6. Instruct patient to avoid rubbing and scratching or provide gloves if necessary Rationale: Rubbing and scratching can cause further injury and delay healing.

7. Dress the surgical site properly Rationale: Teaching increases the patients ability to manage therapy independently.

Postoperative Nursing Diagnosis Disturbed thought process related to head trauma secondary to gunshot wound Objective of Care Within 8 hours of nursing care and management, our patient will be able to regain her normal thought process as evidenced by: Rationale: Due to the gunshot and operation that our patient had, it is expected that a.) Identify person, place, and time; b.) cognitively retrieve and Nursing Intervention 1. Assess the degree of disorientation to the time, place, person, and situation regularly and frequently. Rationale: This will determine the amount of reorientation and
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there would be cognitive alterations and decreased level of consciousness

report previously stored information. c.) Normal RLS/GCS (1/15)

intervention the patient will need to evaluate reality accurately. 2. Orient the patient to surroundings and reality as needed: Use the patients name when speaking to him or her. Speak slowly and clearly. Present information in a mattered-of-fact manner. Rationale: This decreases the chances of misinterpretations. Refer to the time of day, date, and recent events in your interactions with the patient. Rationale: These serve to ground the here and now, and provide cues that maintain orientation.

Encourage the
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patient to have familiar personal belongings in his or her environment. Rationale: These decrease the sense of alienation that the patient may feel in a strange environment. Familiar personal possessions increase the patients comfort level.

Be matter of fact and respectful when correcting the patients misperceptions of reality.

Rationale: A non-judgmental approach is used to enhance selfesteem and maintain orientation. Use the words you and I instead of we. Rationale: This increases orientation and encourages the patient to maintain his or her sense
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of separateness and personal boundary.

3. Avoid discussing the patients condition with her presence. Rationale: This hinders the patient to feel that the people around her, pity her because of her condition. 4. Exercise the patients knowledge by means of asking her of where she is at present time. Rationale: This exercises the cognitive ability of the patient so she will be oriented of the time, place and of what her situation is.

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VII.

REFERENCES

Barbara and Kizior, Robert. Saunders. Nursing Drug Handbook. Elsevier Saunders. 11830, Westline Industrial Road, St. Louis, MO. 63149. 2005 Black and Hawks, Jane Hokanson. Medical-Surgical Nursing: Clinical Management for Positive Outcomes.7th Edition.Elevier Saunders. 11830 Westline Industrial Drive, St. Louis, Missouri 63146. 63146. 2005. Bullock, Barbara L. and Henze, Reet L.Focus on Pathophysiology. Lippincott. Philadelphia. 2000. Burke, Lemon, et. al.Medical Surgical Nursing Care. 2nd edition. Mohn-Brown Pearson. Prentice Hall.USA 2005 Dewit, Susan C. Medical Surgical Nursing: Concepts and Practice. Samdas Elsevier. 11830, Westline Drive, St. Louis, Missouri 63146. 2009. Lewis, Sharon, et.al. Medical Surgical Nursing.7th Edition Mosby Elsvier.11830 Westline Industrial Drive, St.Louis, Missouri 63146. 2007. Marieb, Elaine N.Essentials of Human Anatomy & Physiology.9th Edition.Pearson. Education South Asia Pte. Ltd. 23-25 First Lok Yang Road, Jurong, Singapore. 629733. 2008. MIMS. CMP Medica United Business Media. 8747 Paseo de Roxas, Makati City 1226. Philippines. 2007 Nursing 2008 Drug Handbook. Lipincott Williams and Wilkins. 323 Norris Town Road., Suite 200, Ambler, PA. 19002-2748. 2008. Porth, Carol Mattson. Pathophysiology: Concepts of Altered Health States Lippincott William and Wilkins. 530 Walnut Street,Philadelphia. 2005.
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Shier,

David.et.al. Human Anatomy and Physiology. 10th Edition.McGraw-Hill Companies, Inc.1211 Avenue of the Americas, New York,NY. 2004.

. Smeltzer, Suzanne C.et.al.Textbook of Medical Surgical Nursing. 11th edition. Lippincott Williams. and Wilkins. 2008.

Tortora, Gerard J. and Derrickson, Bryan. Priniciples of Anatomy and Physiology.11th Edition.John Wiley & Sons, Inc.111 River Street, Hoboken, NJ. 07030. 2006

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