In partial fulfilment of the Requirements in NCM 101

COMPREHENSIVE NURSING PROCESS

Pulmonary Tuberculosis
Catt II Pneumothorax

PREPARED BY:

3D
CHAPTER 1 ASSESSMENT

A. Nursing Health History

1. Personal Data

Name: Mr. R.T.

Age: 41 years old
Gender: Male
Address: Paranaque City
Date of Birth: October 16, 1969
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Married
Occupation: Fisher man

2. Chief Complain

Difficulty of breathing.

3. History of present illness

The client was diagnosed of Pulmonary Tuberculosis last 2005. His

medication before was Rifampicin and Streptomycin. The client stopped
his medications 2 years ago because he had a sputum examination last
2008 which claimed that he was negative for Pulmonary Tuberculosis.
Two hours prior to confinement, the client had Difficulty of breathing
accompanied by productive cough with a characteristic of whitish sputum
then persistent fever. After further assessment and laboratory results, the
client was diagnosed of Pulmonary Tuberculosis: Category III.

4. Past medical history

The client had childhood illness of cough and colds, sneezing and runny
nose, tonsillitis, pneumonia and asthma. He also had measles and mumps
when he was 5 years old. The immunization of the patient is complete.
The patient has no allergies on food or medications. He was been
hospitalized before because of Pulmonary Tuberculosis last 2005 and this
is the second time that the client was confined.

He experienced accident on the ocean which he encountered high tidal

waves like a tsunami because of a typhoon coming while he was fishing
 5. Family health history

LEGEND:

client Tuberculosis dead

Boy diabetes daughter/son

girl hypertension married/parents

6. Social history

Mr. RT is finished secondary level of education which is 3 rd year high school

Malabon City. His past father worked as a fisherman while his past mother is
a housewife. He worked before as a fisherman on Manila bay at Navotas City.
He wasn’t seen his wife and only child 7 years ago because thay lack money
for transportation form tarlac to manila. And his perception with their
environment and neighborhood, he is satisfied about it but about the
accessibility of health care and nutritional resources he stated that; “Lahat na
ngayon may bayad, bihira ng libre.”
Review of System:

PERSON’s Gordon Approach

P-sychological

I. Self Perception-Self Concept Pattern

Mr. R.T described his self by stating that; “Masyado na akong

nangangayayat, dati hindi ganito katawan ko.” It represent that the client is
really concious about his body image. As he verbalized his feeling toward
his self; “Parang pabigat na ako sa kapatid ko.” He also emphasized about
his body image is that; “Lumalaki tong tiyan ko tapos lagi pang may
nakalagay na plastic bag dito sa tiyan ko.” (Pertaining to the CTT at the
right part of client’s abdomen.) Mr. R.T had changes felt toward his
body since he was hospitalized, he stated; “Gusto kong gumaling at para
makakain ako ng maayos. Kasi ngayon hindi ko na makain yung mga dati
kong nakakain.” The things or persons that caused him anger, and anxiety
was his pass life experiences being carefree about his health, se said that;
“Wala naman masyado, pero nagsi-sisi lang ako at di ko iningatan ang
sarili ko, pati tuloy ang pamilya ko nawalay na sa’kin.”

II. Role Relationship Pattern

Mr. R.T was not well supported by himself instead he was sustained by
the daughter of his elder sister. And according to him he stated; “Nakikitira
lang ako sa kapatid ko.” For family function, he is not good at it and for
their adequacy of income it was insufficient for him and his family
especially his wife and daughter. According to Mr. R.T he verbalized;
“Wala na, hindi na ako makapagtrabaho. Kulang ang pera, pero
pinagkakasya naman kahit papano kaso malaki din gastos ko dito kaya
yung asawa ko’t anak di maka dalaw kapos sila sa pera pampasahe.” As
for their stuctural characteristics he said; “Hindi na ako makatulong.” And
his perception with their environment and neighborhood, he is satisfied
about it but about the accessibility of health care and nutritional resources
he stated to me that; “Lahat na ngayon may bayad, bihira ng libre.”

III. Sexuality and Reproductive Pattern

Mr. R.T. verbalized his situation with his wife and daughter; “Dalawa dapat
anak namin kaso nakunan ang asawa ko sa panganay namin, kaya
sumamba kami para mabiyayaan ulit ng isa pang anak. Napagbigyan
naman kami kaso simula ng nagkasakit na ako naiwan ko na sila at yung
anak ko, anim na taon palang ng nagkahiwalay kami. Hindi na din ako
nadadalaw dahil walang pampasahe, sa Tarlac pa kasi yun.”

IV. Cognitive Perceptual

Mr. R.T. doesn’t have any hearing difficulties and he stated it by; “Malakas
ang pandinig ko.” But he is present of visual problems and he doen’t take
any medication or eyeglass for it. He is unable to read newspaper, he just
deals with its pictures and large fonts. About the changes on his memory
he verbalized; “Hindi naman ako masyadong makakalimutin” as supported
by assessment on his mental status in orienting through time, place, and
person. For Mr. R.T. pain discomfort he stated it; “Sumasakit tong tiyan
 ko lalo na pag madami akong nakakain, kaya hindi na lang ako kumakain
ng madami.”

V. Coping Stress Tolerance Pattern

The client felt being anxious most of the time especially when he is
encountering abdominal pain, and being uncomfortable when coughing
because it is one of contributing factor why does Mr. R.T. felt the pain on
his abdomen. As for his coping strategies, being a ward patient he just
stayed on bed lying and had slowed movement to minimize the pain.
Person that most helpful in talking things over for him is his elder sister.
He and his sister is left among their 5 other siblings so they just helped
each other & be able to continue living.

VI. Value Belief Pattern

Mr. R.T. stated about his frustration in life; “Nahihirapan na ako kasi hindi
na ako makaranas ng ginhawa.” According to him, the person that held
important for him was his wife and daughter, and the one who influenced
his life was his family but for him, he can’t ignore his friends/co-fishermen
for passing in their vices. Mr. R.T. was Born Again and he is really in to
God, he depended on Him in a way of giving him another child, and as I
observed Mr. R.T is wearing a rosary on his neck. He is also thankful to
God because even he is very ill he knows that God is always beside him
and guiding him.

E-limination

According to the client when he is not yet hospitalized he defecate 1x per day
and sometimes it is watery. But when he is in San Lazaro he didn’t defecate 1 week ago
so his doctor prescribed him Lactulose for being constipated. While his urine elimination
when he is still able to do ADL, he urinate 5x per day and sometimes it is yellow
(concentrated). But since he was hospitalized he urinate 1-2x per day but it was still
concentrated and sometimes felt pain about it. Mr. R.T was not really excessive in
perspiration and does not have any bad odor.

R-est and Activity

I. Activity Exercise Pattern

The client was a fisherman so as for his type and level of activities he
verbalized it; “Nangingisda ako at ako ang bumubuhay sa pamilya ko, eh
ngayong nagkasakit na ako wala na akong nagagawa kundi umupo at
humiga.” Mr. R.T. has a passed leisure activity when he is still fishing, he
is excessive is drinking alcohol with his friends, which is for their past time.
For his functional level of ADL: in feeding most of the time he eats 3-4 x
per day that composed of tuyo, daing, bangus, rice, noodles, maling,
vegetables, an sinigang, for breakfast are bread and egg with coffee.
According to him, he eats a lot and his body image was really big not look
like what he had during this assessment (thin appearance). He took a
bath 1x per day, but now he didn’t even have a chanced to do it alone. He
does cook to his family and they are really fund of having fish because for
him they had it for free.
 II. Sleep Rest Pattern

Mr. R.T verbalized; “Madalas dati lagi akong alas-dos ng umaga (2am)
gumigising para lumaot na at mangisda. Pero kapag wala namang ginagawa
minsan alas-otso ng gabi (8pm) tulog na ako, ang gising ko na din nun alas-
otso ng umaga (8am), medyo mahaba ang tulog ko pag ganun.” But as of
now the client mention for being disturbed in sleeping pattern because of pain
felt through his abdomen. As stated; “Ngayon hirap akong matulog dahil nai-
istorbo ako sa sakit na nararamdaman ko sa tiyan.”

S-afe Environment

The client does not have any allergy to food, or medications and other. His skin
integrity on right hand was presented of IV insertion, and at the right part of his
abdomen there’s CTT attachment. The client doesn’t really have any changes in body
temperature.

O-xygenation

The client’s tolerance with daily activities when he is not yet hospitalized was
really in good health, but soon he is hospitalized he is feeling of difficulty of breathing.
He stated it; “Dati okay naman, ngayon parang kinakapos ako sa pag hinga at parang
may bumabara kapag umuubo ako.” He does not have any changes on the color of his
skin, but his capillary refill was more than 3 seconds. The client is on Oxygen
Therapy via Nasal Canula @ 2-3Lpm.

N-utrition

Mr. R.T.’s daily food intake when he was not yet hospitalized is very healthy (i.e.,
vegetables, fish- daing, bangus, tuyo, rice, sinigang, maling, noodles, bread.) except for
his vices (i.e., Alcohol, & smoking). According to him; “Malakas akong kumain, kaso
ngayon kahit pilitin kong kumain parang napipigilan ako kasi sumasakit naman tong
tiyan ko, kaya ito nangangayayat na ako.”

B. Physical Assessment

 General Appearance

Mr. R.T has a small frame body built and with the height of 5’[Link] vital
signs are as follows: Blood pressure of 90/60 mmHg, Pulse rate of 75
bpm, RR= 18 cpm, and temperature of 36.5C. Patient has staggering gait
he is inappropriately dressed and has body odor.

 Mental Status

He is conscious and cooperative. He knows the people around him , the

time and the place .He uses simple words in answering question.

 Skin

His skin is tan in color. The temperature of the skin is warm and the
moisture is dry. It has a rough texture and has an elastic and mobile skin
turgor . (Skin Tatoo is present.)

 Nails
 Nails are smooth and are shaped convex 160. Capillary Refill is exceed 3
seconds. Nail bed color is pink.

 Head and Face

Mr. R.T skull is proportionate to his body size. Scalp is not tender and
does not have lesions. Hair is black in color, his face and facial movement
is symmetrical.

 Eyes

The eyes of the patient are straight normal and her eyebrows are thin. His
eyelids and eyelashes manifest an effective closure and blink response is
frequent and bilateral. Mr. R.T eyeballs are also symmetric and firm. His
bulbar conjunctivas are clear and her palpebral conjunctivas are pink. Her
sclera is also white. The size of his pupil is equal and both eyes have a
brisk reaction to light and accommodation. In visual acuity, the patient has
difficulty in recognizing objects even if it is 12-14 inches away from him.

 Ears

The patient’s auricles are brown and symmetric to each other. Both are
elastic and not tender and it recoils when folded. There are no lesions and
inflammations observed. There is presence of some cerumen in external
canal. When tested his hearing acuity, the patient responds to normal and
whispered voice.

 Nose

Mr. R.T external nose is tan in color and septum is in midline. Mucosa is
pink, both nose are patent and there are no discharges noted. His nasal
cavity is moist and his sinuses are not tender.

 Mouth

Patient’s lips are symmetrical and pink. His mucosa is also pink and
tongue is in the midline, with a pink color and rough texture. Her teeth are
incomplete and his gums are also pink. There are no mouth sores
observed.

 Pharynx

Uvula is in midline position. Mucosa is pink. Tonsils and posterior pharynx

are not inflamed. Gag reflex is present.

 Neck

Neck muscles are equal in size. Lymph nodes are palpable, thyroid gland
are non palpable. Trachea is in midline.

 Chest and Lungs

 The shape of the lungs is AP to lateral ratio 1:2 which is normal. The lung
expansion of the anterior and posterior lungs is asymmetrical. The
fremitus is also symmetrical and there are vibrations felt when he talks.
The breathing pattern is regular and the breath sound is the sound is
crackles. His heart rate is 75 beats/min and the rhythm is regular. The
pulmonic, aortic, tricuspid and apical sites of pulses have regular rhythm
of beating.

 Abdomen

Mr. R.T abdomen is tan in color, there lesion present due to CTT attached
in right part of the lungs .His Abdomen is flat. Palpation is Tender .Bladder
is distended.

 Genitalia

This body part was not assessed

C. Diagnostic Procedures

 Hematology

Is concerned with the study of blood, the blood-forming organs, and blood
diseases.

 Nursing Responsibilities

1. Inform the client to the procedure to be done. Inform the doctor

about any medications the clients are taking (Drugs that may
increase WBC counts include: Allopurinol , Aspirin , Chloroform,
Corticosteroids , Epinephrine, Heparin, Quinine ,Triamterene. Drugs
that may lower your WBC count include: Antibiotics ,
Anticonvulsants , Antihistamines, Antithyroid drugs , Arsenicals,
Barbiturates , Chemotherapy drugs , Diuretics, Sulfonamides )

2. Certain drugs may interfere with test results.

3. Look for the site, it is usually in the inside elbow. Clean the inside
elbow with antiseptic.

4. Cover the site to avoid bleeding and infection.

5. Collaborate with the laboratory for the test results.

Name of Clinical Interpretation

Date Values
Procedure: Normal Values
Ordered: Obtained
Hematology

Decreased
Hemoglobin 140.00-170.00
138.00gu/L Anemia, recent
gu/L hemorrhage, fluid
retention.

RBC 4.00gu/L
4.00-5.40gu/L NORMAL

WBC Increased
4.50-11.00 gu/L 14.00gu/L
Infection, tissue necrosis

Platelet 200.00-400.00 Decreased

184.00gu/L
gu/L Immune disorder

Hematocrit Decreased
0.40-0.50 gu/L 0.39gu/L
anemia

D. ANATOMY AND PHYSIOLOGY

 UPPER RESPIRATORY TRACT

Respiration is defined in two ways. In

common usage, respiration refers to
the act of breathing, or inhaling and
exhaling. Biologically speaking,
respiration strictly means the uptake of
oxygen by an organism, its use in the
tissues, and the release of carbon
dioxide. By either definition, respiration
has two main functions: to supply the
cells of the body with the oxygen
needed for metabolism and to remove
carbon dioxide formed as a waste
product from metabolism. This lesson
describes the components of the upper
respiratory tract.

The upper respiratory tract conducts air from outside the body to the lower respiratory
tract and helps protect the body from irritating substances. The upper respiratory tract
consists of the following structures:

The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the upper
trachea. The esophagus leads to the digestive tract.

One of the features of both the upper and lower respiratory tracts is the mucociliary
apparatus that protects the airways from irritating substances, and is composed of the
ciliated cells and mucus-producing glands in the nasal epithelium. The glands produce a
layer of mucus that traps unwanted particles as they are inhaled. These are swept
toward the posterior pharynx, from where they are swallowed, spat out, sneezed, or
blown out.

Air passes through each of the structures of the upper respiratory tract on its way to the
lower respiratory tract. When a person at rest inhales, air enters via the nose and
mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a
tube like structure that connects the back of the nasal cavity and mouth to the larynx, a
passageway for air, and the esophagus, a passageway for food. The pharynx serves as
a common hallway for the respiratory and digestive tracts, allowing both air and food to
pass through before entering the appropriate passageways.

The pharynx contains a specialized flap-like structure called the epiglottis that lowers
over the larynx to prevent the inhalation of food and liquid into the lower respiratory
tract.

The larynx, or voice box, is a unique structure that contains the vocal cords, which are
essential for human speech. Small and triangular in shape, the larynx extends from the
epiglottis to the trachea. The larynx helps control movement of the epiglottis. In addition,
the larynx has specialized muscular folds that close it off and also prevent food, foreign
objects, and secretions such as saliva from entering the lower respiratory tract.

LOWER RESPIRATORY TRACT

The lower respiratory tract begins with the trachea, which is just below the larynx. The
trachea, or windpipe, is a hollow, flexible, but sturdy air tube that contains C-shaped
cartilage in its walls. The inner portion of the trachea is called the lumen.

The first branching point of the respiratory tree occurs at the lower end of the trachea,
which divides into two larger airways of the lower respiratory tract called the right
bronchus and left bronchus. The wall of each bronchus contains substantial amounts of
cartilage that help keep the airway open. Each bronchus enters a lung at a site called
the hilum. The bronchi branch sequentially into secondary bronchi and tertiary bronchi.

The tertiary bronchi branch into the bronchioles. The bronchioles branch several times
until they arrive at the terminal bronchioles, each of which subsequently branches into
two or more respiratory bronchioles.

The respiratory bronchiole leads into alveolar ducts and alveoli. The alveoli are bubble-
like, elastic, thin-walled structures that are responsible for the lungs’ most vital function:
the exchange of oxygen and carbon dioxide.

Each structure of the lower respiratory tract, beginning with the trachea, divides into
smaller branches. This branching pattern occurs multiple times, creating multiple
branches. In this way, the lower respiratory tract resembles an “upside-down” tree that
begins with one trachea “trunk” and ends with more than 250 million alveoli “leaves”.
Because of this resemblance, the lower respiratory tract is often referred to as the
respiratory tree.

In descending order, these generations of branches include:

 Trachea
 Right Bronchus and Left Bronchus
 Secondary Bronchi
 Tertiary Bronchi
 Bronchioles
 Terminal Bronchioles
 Respiratory Bronchioles
 Alveoli

THE LUNGS

The thoracic cage, or ribs, and the

diaphragm bound the thoracic cavity.
There are two lungs that occupy a
significant portion of this cavity.

The diaphragm is a broad, dome-shaped

muscle that separates the thoracic and
abdominal cavities and generates most of
the work of breathing. The inter-costal
muscles, located between the ribs, also
aid in respiration. The internal
intercostals muscles lie close to the lungs
and are covered by the external
intercostals muscles.

The lungs are cone-shaped organs that

are soft, spongy and normally pink. The lungs cannot expand or contract on their own,
but their softness allows them to change shape in response to breathing. The lungs rely
on expansion and contraction of the thoracic cavity to actually generate inhalation and
exhalation. This process requires contraction of the diaphragm.

To facilitate the movements associated with respiration, each lung is enclosed by the
pleura, a membrane consisting of two layers, the parietal pleura and the visceral pleura.

The parietal pleura comprise the outer layer and are attached to the chest wall. The
visceral pleura are directly attached to the outer surface of each lung. The two pleural
layers are separated by a normally tiny space called the pleural cavity. A thin film of
serous or watery fluid called pleural fluid lines and lubricates the pleural cavity. This fluid
prevents friction and holds the pleural surfaces together during inhalation and
exhalation.
E. Pathophysiology of Pulonary Tuberculosis
MODIFIABLE NON MODIFIABLE

 Alcoholism  With pre existing

 Occupation medical condition
which is
Malnourishment

Mycobacterium Tubercle
Bacilli

Dried Droplet Nuclei

 Dyspnea
 Productive cough
Inflammation in Alveoli
 Fever
 Weakness

Lymph nodes filter drainage

Primary Tubercle

Necrosis

Cessation  Weight loss

 Calcified Liquefaction
 Increases RR
 Dyspnea
 Productive
“GHON TUBERCLE” Cavity
cough
(primary)  Chest and
back pain

TUBERCULOSIS

AFB> Acid Fast Bacili Nursing Management:

 Encourage Increase
PPD> Purified Protein
Fluid Intake
Derivatives
 Instruct about
Hygiene measures,
including mouth and
Drug Chemotherapy nose when coughing
and sneezing.
Rifampicin
 Provide patient with
Izoniazid
adequate rest period
Pyridoxine
 Promote adequate
Ethambutol
nutrition
Streptomycin
 Monitor Drug
Comliance.
Chapter 2 Planning

A. List of prioritized Diagnoses

Rank Nursing Diagnosis Rationale

Acute pain related to
irritation of nerve endings
1 within pleural space by
foreign object (chest
tube)
Ineffective breathing
pattern related to
2
decreased lung
expansion
Impaired gas exchange
related to alveolar-
2
capillary membrane
changes (tuberculosis )
CUES NURSING SCIENTIFIC GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS EXPLANATION OBJECTIVES INTERVENTION
Independent:
Subjective: Acute pain related Lung collapse Short term Goal: Short term Goal:
to irritation of nerve ↓ After 3 hour of Change dressing To minimize After 3 hour of
“Sumasakit tong endings within Accumulation of air nursing every shift irritation/ infection nursing
tiyan ko lalo na pag pleural space by in the pleural intervention the intervention the
madami akong foreign object space client will: Divert attention To distract client was:
nakakain” as (chest tube) ↓ thru reading attention and
verbalized by the ↓ lung expansion Pain scale will magazines, reduce pain Pain scale will
client. ↓ decrease from 5/10 listening to radio, decrease from 5/10
Insertion of CTT to 3/10. to 3/10.
Objective: ↓ Encourage deep To reduce tension
Pain scale= 5/10 Presence of (-) Facial grimace breathing exercise (-) Facial grimace
CTT on the right foreign object in (-) guarding (-) guarding
abdomen pleural space behaviour Provide massage To divert attention behaviour
(+) facial grimace ↓ (-) restlessness (-) restlessness
(+) guarding Irritation of nerve Dependent:
behavior endings Administer To treat pain
(+) restlessness ↓ Long term goal: medication as Long term goal:
(+) he just stayed Pain After 24 hour of ordered by the After 24 hour of
on bed lying and nursing physician. nursing
had slowed intervention the intervention the
movement to client will: client was:
minimize the pain
Pain Scale= 1/10 Pain Scale= 1/10
(-) infection at the (-) infection at the
site of CTT site of CTT
CUES NURSING SCIENTIFIC GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS EXPLANATION OBJECTIVES INTERVENTION

Subjective: Ineffective Lung collapse Short term goal: Monitor v/s To note for
breathing pattern ↓ After one hour of especially changes and Short term goal:
“Dati okay naman, related to Accumulation of air the nursing the RR improvements After one hour of
ngayon parang decreased lung in pleural space intervention the the nursing
kinakapos ako sa expansion ↓ client will: Auscultate lungs To evaluate the intervention the
pag hinga at Decrease lung every 4-6 hours rate, quality, and client was:
parang may expansion RR will decrease depth of patient’s
bumabara kapag ↓ from 23 to 16- respirations RR will decrease
umuubo ako” as Insertion of CTT 20cpm Assess patency of from 18cpm
verbalized by the ↓ drainage from To validate proper
client. Ineffective Long term goal: chest tubes functioning Long term goal:
breathing pattern After 8 hours of After 8 hours of
duty the client will: Encourage deep duty the client was:
Objective: (-) dyspnea breathing exercise To increase lung (+)decrease
RR= 23cpm (+) regular expansion dyspnea
(+) crackles breathing pattern Position client in (+) regular
(+) dyspnea (-) restlessness HBR To increase breathing pattern
(+) restlessness compliance with (-) restlessness
(+) O2 therapy respiration
(+) diminished
breath sounds Dependent:
(+) hyperresonant Administer low flow To treat hypoxemia
percussion oxygen (1-2L/min)
via nasal cannula
CUES NURSING SCIENTIFIC GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS EXPLANATION OBJECTIVES INTERVENTION
Short term goal:
Subjective: Impaired gas Presence of Short term goal: Independent: After 1 hour of the
exchange related mycobacterium After 1 hour of the Note respiratory To evaluate degree nursing
“Dati okay naman, to alveolar-capillary tuberculosis in the nursing rate, depth of compromised intervention the
ngayon parang membrane lungs intervention the client was:
kinakapos ako sa changes ↓ client will: Auscultate breath To evaluate degree
pag hinga at (tuberculosis ) Inhibits lung sounds of compromised Verbalized
parang may function Verbalize causative factors
bumabara kapag ↓ causative factors Elevate head of To maintain airway and appropriate
umuubo ako” as Alveolar capillary and appropriate bed/ position client interventions
verbalized by the membrane interventions appropriately
client. changes Participate in the
↓ Participate in the Encourage To promote optimal regimen of
Objective: Impaired gas regimen of frequent position chest expansion treatment
CTT on the right exchange treatment changes and deep and drainage
abdomen ↓ breathing/ secretions Long term Goal:
(+) restlessness Restlessness Long term Goal: coughing exercise After 6 hours of the
RR= 23bpm Tachypnea After 6 hours of the nursing
nursing Reinforce need of To promote intervention the
intervention the adequate rest wellness client will:
client will:
Review risk factors RR is 18.
RR will range from For prevention and
23 to 16 to 20cpm. Dependent: management (-)restlessness
Administer
(-)restlessness medications

Administer o2
therapy
CHAPTERR 3 IMPLEMENTATION

A. Medical management

1. Drug study

Classification/ Dose, Route and Mechanisms of Nursing

Drug Contraindications Side effects
Indication Frequency action Responsibilities
Metronidazole Anti-infectives PO 7.5 mg/kg q6hr (not • Disrupts DNA and hypersensitivity CNS: seizures, dizziness, Administer with food or
Anti-protozoals to exceed 4g/day) protein synthesis in headache milk to minimize GI
susceptible organisms • GI: abdominal pain, irritation. Tablets may be
• Bactericidal, or anorexia, nausea, crushed for patients with
amebicidal action diarrhea, dry mouth, difficulty swallowing.
furry tongue, glossitis, • Instruct patient to take
unpleasant taste, medication exactly as
vomiting directed evenly spaced
• Hematologic: times between dose, even
leukopenia if feeling better. Do not
• Skin: rashes, urticaria skip doses or double up
on missed doses. If a
dose is missed, take as
soon as remembered if
not almost time for next
dose.
•May cause dizziness or
light-headedness.
Caution patient or other
activities requiring
alertness until response
to medication is known.
• Inform patient that
medication may cause an
unpleasant metallic taste.
• Inform patient that
medication may cause
urine to turn dark.
• Advise patient to
consult health care
 professional if no
improvement in a few
days or if signs and
symptoms of
superinfection (black
furry overgrowth on
tongue; loose or foul-
smelling stools.

Classification/ Dose, Route Mechanisms of Nursing

Drug Contraindications Side effects
Indication and Frequency action Responsibilities
Tranexamic Antifibrinolytic acid Oral, 25 mg per Tranexamic acid Carcinogenicity/Tumorigenicity Signs of potential » Importance of not
Acid kg of body weight competitively side effects, using more or less
antihemorrhagic every six to eight inhibits activation of Mutagenicity especially blurred medication than the
hours, beginning plasminogen , vision or other amount prescribed
one day before the thereby reducing Pregnancy/Reproduction changes in vision,
dental procedure. conversion of hypotension, and » Proper dosing
However, plasminogen to thrombosis or Missed dose: Taking
intravenous plasmin thromboembolism. as soon as possible,
administration of the (fibrinolysin), an then returning to
medication enzyme that regular dosing
immediately prior to degrades fibrin schedule; not
surgery may be clots, fibrinogen, doubling doses
preferred. When and other plasma
tranexamic acid is proteins, including » Proper storage
used, a single factor the procoagulant
VIII infusion of 40 factors V and
International Units VIII Tranexamic
per kg of body acid also directly
weight, inhibits plasmin
activity, but higher
doses are required
than are needed to
reduce plasmin
formation .In vitro ,
the antifibrinolytic
potency of
tranexamic acid is
approximately 5 to
10 times that of
aminocaproic acid 
 Classification/ Dose, Route and Mechanisms of Contraindication Nursing
Drug Side effects
Indication Frequency action s Responsibilities
Ketorolac Nonsteroidal anti- 30mg/amp1 amp IM - Inhibits - Hypersensitivity  CNS: Patients who have
inflammatory agents, prostaglandin - Cross-sensitivity 1) drowsiness asthma, aspirin-
nonopioid analagesics synthesis, producing with other NSAIDs 2) abnormal thinking induced allergy, and
peripherally mediated may exist¨Pre- or 3) dizziness nasal polyps are at
analgesia perioperative use 4) euphoria increased risk for
- Also has antipyretic - Known alcohol 5) headache- developing
and anti-inflammatory intoleranceUse - RESP: hypersensitivity
properties. cautiously in: 1) asthma reactions. Assess for
- Therapeutic 1) History of GI 2) dyspnea rhinitis, asthma, and
effect:Decreased pain bleeding - CV: urticaria.
2) Renal impair-ment 1) edema - Assess pain (note
(dosage reduction may 2) pallor type, location, and
be required) 3) vasodilation intensity) prior to and
3) Cardiovascular - GI: 1-2 hr following
disease 1) GI Bleeding administration.
2) abnormal taste - Ketorolac therapy
3) diarrhea should always be
4) dry mouth given initially by the
5) dyspepsia IM or IV route. Oral
6) GI pain therapy should be used
7) nausea only as a continuation
- GU: of parenteral therapy.
1) oliguria - Caution patient to
2) renal toxicity avoid concurrent use
3) urinary frequency of alcohol, aspirin,
NSAIDs,
acetaminophen, or
other OTC
medications without
consulting health care
professional.
 Classification/ Dose, Route and Mechanisms of Contraindication Nursing
Drug Side effects
Indication Frequency action s Responsibilities
Ferrous sulfate Iron Preparation tab Elevates the serum • Hypersensitivity  • Dizziness • Advise patient to
iron concentration • Severe hypotension. •N&V take medicine as
which then helps to • Nasal Congestion prescribed.
form High or trapped • Dyspnea • Caution patient to
in the • Hypotension make position changes
reticuloendothelial • CHF slowly to minimize
 cells for storage and • MI orhtostatic
eventual conversion to • Muscle cramps hypotension.
a usable form of iron. • Flushing • Instruct patient to
avoid concurrent use
of alcohol or OTC
medicine without
consulting the
physician.
• Advise patient to
consult physician if
irregular heartbeat,
dyspnea, swelling of
hands and feet and
hypotension occurs.
• Inform patient that
angina attacks may
occur 30 min. after
administration due
reflex tachycardia.

Classification/ Dose, Route and Mechanisms of Nursing

Drug Contraindications Side effects
Indication Frequency action Responsibilities
Generic: 20mg 1 cap OD Omeprazole is in a Omeprazole is While veterinary
class of drugs contraindicated in use is quite limited,
omeprazole, For the treatment called proton pump patients the drug appears
omeprazole/sodiu of acid-reflux inhibitors (PPI) that hypersensitive to to be quite well
m bicarbonate disorders (GERD), block the it. Omeprazole tolerated in both
peptic ulcer production of acid should be used dogs and cats at
Brand: disease, H. pylori by the stomach. when the benefits effective dosages.
Prilosec, Zegerid eradication, and Other drugs in the outweigh the risks Potentially, GI
prevention of class include in patients with distress (anorexia,
gastroinetestinal lansoprazole hepatic disease or colic, nausea,
bleeds with NSAID (Prevacid), a history of hepaticvomiting,
use. rabeprazole disease, as the flatulence,
(Aciphex), drug’s half life maydiarrhea) could
pantoprazole be prolonged and occur as well as
(Protonix), and dosage adjustment hematologic
esomeprazole may be necessary. abnormalities (rare
(Nexium). Proton in humans),
pump inhibitors are Omeprazole’s urinary tract
used for the safety during infections,
treatment of pregnancy has not proteinuria, or
conditions such as been established, CNS disturbances.
ulcers, but a study done in Chronic very high
gastroesophageal rats at doses of up doses in rats
reflux disease to 345 times those caused
(GERD) and the recommended did enterochromaffin-
Zollinger-Ellison not demonstrate like cell
syndrome, which any teratogenic ef hyperplasia and
are all caused by fects. Increased gastric carcinoid
stomach acid. embryo-lethality tumors; effects
Omeprazole, like has been noted in occurred in dose
other proton-pump lab animals at very related manner.
inhibitors, blocks high dosages. It is The clinical
the enzyme in the unknown whether significance of
wall of the omeprazole is these findings for
stomach that excreted in milk. long term low-dose
produces acid. By clinical usage is
blocking the not known.
 However, at the
current time in
humans, dosing for
enzyme, the
longer than 8
production of acid
weeks is rarely
is decreased, and
recommended
this allows the
unless the benefits
stomach and
of therapy
esophagus to heal.
outweigh the
potential risks.

Classification/ Dose, Route and Mechanisms of Nursing

Drug Contraindications Side effects
Indication Frequency action Responsibilities
Generic: 1 amp PRN Reduced • Anti-pyretic • •Hematologic: • Use liquid form
Paracetamol absorption of Contraindicated in hemolytic anemia, for children and
• Symptomatic cholestyramine patients neutropenia, patients who have
Brand: relief of pain difficulty
Generic Name: swallowing.
•
• Paracetamol • In children, don’t
exceed five doses
Brand Name: in 24 hours.
• Biogesic • Advise patient
that drug is only for
Dosage: short term use and
within 1 hr of hypersensitive to
drug. to consult the
• Adults and admin.
physician if giving
children 500- Accelerated
• Use cautiously in to children for
1000 mg orally absorption with leucopenia,
patients with long longer than 5 days
e metoclopramide. pancytopenia.
term alcohol use or adults for
Decreased effect
because longer than 10
with barbiturates, • Hepatic:
therapeutic days.
carbamazepine, Jaundice
doses cause
hydantoins, • Advise patient or
hepatotoxicity in • Metabolic:
rifampicin and caregiver that
these Hypoglycemia
sulfinpyrazone. many over the
patients.
Paracetamol may counter products
increase effect of contain
warfarin • acetaminophen; be
aware
of this when
calculating total
daily
dose.

• Warn patient that

high doses or
u
 Classification/ Dose, Route and Mechanisms of Nursing
Drug Contraindications Side effects
Indication Frequency action Responsibilities
Generic: Administration of Anuria Dizziness,
furosemide Furosemide is a furosemide with Hypersensitivity lightheadedness,
potent diuretic aminoglycoside States of severe or fainting spells
(water pill) that is antibiotics (for electrolyte Signs of
 used to eliminate example, depletion dehydration or low
Brand: water and salt from gentamicin) or electrolytes, such
the body. In the [ethacrynic acid as:
kidneys, salt (Edecrin) - another
(composed of diuretic] may Dry mouth
sodium and cause hearing Thirst
chloride), water, damage. Weakness
and other small Furosemide Lethargy
molecules competes with Drowsiness
normally are aspirin for Restlessness
filtered out of the elimination in the Muscle pain or
blood and into the urine by the muscle cramps
tubules of the kidneys. Low blood
kidney. The filtered Concomitant use pressure
fluid ultimately of furosemide and (hypotension)
becomes urine. aspirin may, Decreased
Most of the therefore, lead to urination
sodium, chloride high blood levels A rapid heart rate
and water that is of aspirin and (tachycardia) or
filtered out of the aspirin toxicity. irregular heart
blood is Furosemide also rhythm
reabsorbed into may reduce (arrhythmia)
the blood before excretion of lithium Nausea or
the filtered fluid (Eskalith, Lithobid) vomiting
becomes urine and by the kidneys,
is eliminated from causing increased
the body. blood levels of
Furosemide works lithium and
by blocking the possible side
absorption of effects from
sodium, chloride, lithium. Sucralfate
and water from the (Carafate) reduces
filtered fluid in the the action of
kidney tubules, furosemide by
causing a profound binding furosemide
increase in the in the intestine and
output of urine preventing its
(diuresis). The absorption into the
onset of action body. Ingestion of
after oral furosemide and
administration is sucralfate should
within one hour, be separated by
and the diuresis two hours.
lasts about 6-8
hours. The onset
of action after
injection is five
minutes and the
duration of diuresis
is two hours. The
diuretic effect of
furosemide can
cause depletion of
sodium, chloride,
body water and
other minerals.
Therefore, careful
medical
supervision is
necessary during
treatment. The
FDA approved
furosemide in July
1982.
 Classification/ Dose, Route and Mechanisms of Nursing
Drug Contraindications Side effects
Indication Frequency action Responsibilities
GENERIC NAME: Spironolactone Acute renal
spironolactone can lower blood inuficiency, anuria
BRAND NAME: sodium levels hyperkalemia,
Aldactone while raising blood pregnancy
potassium levels.
Excessively high
blood potassium
levels can lead to
potentially life-
threatening
abnormalities in
the rhythm of the
heart. Therefore,
spironolactone
usually is not
administered with
other agents that
can raise blood
potassium levels,
such as potassium
supplements,
angiotensin
converting enzyme
(ACE) inhibitors
[for example,
enalapril
(Vasotec)],
indomethacin
(Indocin), or other
potassium-sparing
diuretics.
Spironolactone
can cause
elevation of blood
digoxin (Lanoxin)
to toxic levels,
requiring
adjustment of the
digoxin dosage.
 2. Treatment

IVF, CCT

3. Diet

Liquid diet
The patient is in liquid diet. Losing weight with minimal effort
sounds like a win-win situation. With ads promising that you
can drink your way to a slimmer figure and detoxify your
body to boot, liquid diets sound too good to be true -- and
often, they are.

Liquid diets control calorie intake by restricting what you eat

to mostly or all liquids. How they work varies from product to
product. Some liquid diets are fluid only -- juices or shakes
that replace all of your meals, three or four times a day.
These programs are either do-it-yourself options sold over
the counter, or medically supervised plans available only
through doctors' offices or hospitals.

Other types of liquid diets replace just one or two meals

(usually breakfast and lunch) with drinks, but let you eat a
healthy, balanced dinner. These diets may also include
snack bars for in-between meals.

4. Activity and Exercise

ROM Exercise

5. Surgical management(if any)

None

B. Nursing Management

 Encourage Increase Fluid Intake

 Instruct about Hygiene measures, including mouth and nose when
coughing and sneezing.
 Provide patient with adequate rest period
 Promote adequate nutrition
 Monitor Drug Compliance.

C. Client’s Daily Progress Chart

Diagnosti
Day c Diet Activity Medication Treatment Surgery
Procedure
Admission Hematology DAT None Spironolactone IIVF None
furosemide
Paracetamol
omeprazole,
Ferrous sulfate
Ketorolac
 Tranexamic
Acid
Metronidazole
Day 5 Liquid None Spironolactone IVF Aand None
Diet furosemide CCT
Paracetamol
omeprazole,
Ferrous sulfate
Ketorolac
Tranexamic
Acid
Metronidazole

CHAPTER 4 EVALUATION

A. Narrative

B. Discharge Planning Instruction

M
 Rifampicin
 Isoniazid
 Pyrazinamide
 Ethambutol
 Streptomycin

E
 ROM Exercise

T
 None

H
 Instruct about Hygiene measures, including mouth and nose when
coughing and sneezing.
 Don’t forget to drink the medicine to avoid multiple drug resistant

O
 After 1week after discharge

D
 DAT