Saint Louis University

College of Nursing
Baguio City

A CASE STUDY FOR

PATIENT X

Submitted to:
Mrs. Rachel Alfonso, R.N.

Submitted by:
ANDAYA, Sonia
BERNABE, Juvy Anne
BORJA, Peter Paul John
CASPE, Amory
DEMICAIS, Sheena Mae
GARCIA, Ma. Lourdes
MAGTUBA, Karen Joy
NOVELA, Catherine
PARTOSAN, Ceryll Keisha
PUGONG, Kriseth
SOTERO, Marvin
SUNGA, Myrhine
 Demographic Data

Patient “X”

Age: 25 years old

Sex: Male

Status: Single

Birthday: January 30, 1983

Birthplace: Nueva Vizcaya

Address: #22 Lower Brookside, Baguio City

Occupation: Supervisor at People support Company

Date admitted: January 27, 2009

Time admitted: 4:20pm

Chief Complaint: Fever

Final Diagnosis: T/C typhoid fever

Last hospitalization: December 26, 2008

Attending Physician: Dra. Urmaza- Alarte

Bp: 120-130/ 70-90

 History of Present Illness

5 months prior to admission, the client experienced fever and flu. He sought for consultation to
this institution and was admitted with the diagnosis of acute tonsilopharyngitis. Diagnostics done are CBC,
U/A, S/E, and chest X-ray. 2 months prior to the admission, the patient have been experiencing on & off
fever. The patient took in Biogesic and Bioflu without consulting any medical assistance. 1 month prior to
the latest admission , the patient was admitted in SLU on December 26, 2008 for 5 hospital days due to
fever, nausea and dyspnea. Patient was discharged as a case of herpes simplex type 1 T/C typhoid fever;
Acid related disorder. 5 days prior to latest admission, patient had an intermittent fever. Patient’s
temperature reached 40 degrees celcius with associated anorexia, body weakness and headache. No other
associated sign and symptoms. He took in 3 biogesic 500mg tablet every 4 hours that relieved the
condition. However, 2 days prior to admission patient had another episode of fever with associated
appearance of rashes, non petechial on the upper extremities and volar area with the same sign and
symptoms with development of joint pain. No associated nose bleeding, abdominal pain, dysuria, LBM,
colds and cough. No medecine taken for rashes. Paracetamol was continued. Rashes noted to disappear
after 1 day. Persistence of fever without relief by paracetamol prompted consult, hence admitted.

Past Medical History

According to the patient and our institution records, the patient has previous records of
hospitalization of illness. In addition to, this was the patient’s third time to be admitted in this institution.
The first admission, August 14, 2008-August 17, 2008 was due to acute tonsilopharyngitis; Second
admission, December 26, 2008- December 31, 2008 was due to herpes simplex type 1 T/C typhoid fever;
Acid related disorder; Third admission, January 7, 2009- January 11, 2009 was due to typhoid fever.
Fortunately, patient’s blood pressure was within normal range during his admission to our
institution. No allergies on food and drugs were also noted.

Socio-Cultural Background
The patient has a good relationship with the family members. He is the eldest among the three
siblings in their family. He works as a supervisor at People Support Call Center. The patient considers
himself as the breadwinner of the family. The environment where the family lives is clean as stated by the
patient. The family does not have beliefs and practices affecting health care.
Patient’s religious affiliation is Roman Catholic and his ethnic background is Ilocano. The patient is
smoking for 3 pack years beginning when he was first year in college until now. He is an occasional alcohol
beverage drinker.

Heredofamilial History
 The patient’s family has no family history of hypertension, DM, Bronchial Asthma, Cardio vascular diseases
and Cancer. All family members are healthy and functioning well as verbalized by the patient.
His present condition was due to unhealthy lifestyle and work related factors.

Laboratory Results

UTZ of whole Abdomen

- Pancreas
- Liver
- Spleen
 NORMAL

GB: An enlarged Disclosing a small, non adherent feces measuring approximately 2m, the GB
measure 3m.

I: Small Wall Coherent Cholestone

LS: Polyp

Dr. Urmaza
Dr. Grailo

ULTRASOUND of The whole abdomen:

January 08, 2009

Liver:
Normal liver echopattern, contour and size.
No evident focal lesion. The Intrahepatic bile radicles, partial and systemic vessels are not dilated.

Gallbladder:
The Gall bladder is unenlarged discllosing a small wall adherent focus measuring approximately
2mm. The gall bladder wall measure 3mm. The CBD is not dilated measuring 4mm.

Pancreas:
The pancreatic head body, tail measures 7 x 7 x 9 mm respectively.
The pancreatic duct is not dilated. Normal echotexture with no evident focal lesion.

Kidneys:
The right kidney measures 101 x 41 x 36 mm while the left kidney measures 94 x 42 x 60 mm with a
cortical thickness of 77mm and 15 mm respectively. Normal echopattern, contour and renal sinus. No
Caliectasia or focal lesions. No peripheral pathology noted.

Spleen:
Measures 94 x 34 mm disclosing normal lesions. 4 parenchymal echopattern. No focal lesions.
Splenic vessels are normal in caliber.
 Para
COMPONENT: Normal Ranges:
aortic:
WBC 10.3 10eg/L 5.00-10.00
No
 46.7 % N 45.0- 70.0 % N
evident
 41.5 % L 20.0 – 40.00 % L
 11.0 % M 0.00- 12.00 % M
 0.098 % E 0.00 – 8.00 % E
 0.757 % B 0.00- 2.00 % B

RBC 6.13 e 12/L 4.50-6.00

HGB 173 g/L 110- 150
HCT .517 L/L 0.37- 0.47
MCV 84.4 f/L 76.0-96.0
MCH 28.2 PG 27.0-32.0
MCHC 334 g/L 320- 360
Platelet: ADEQUATE
Comment: Normocytic, Normochromic
lymphadenopathies noted in the para aortic area.

Small wall adherent cholesterol stoneversus polyp.

Sonographically normal liver, pancreas,kidneys, spleen and para aortic.

X-RAY:
January 07, 2009

Chest PA:
The lung feilds are clear with normal lung roots. The heart, mediatinum and diaphragm appear
physiologic normal soft tissue and osseous structure seen in the chest wall and shoulder girdle.

Impression: Normal cardio-pulmonary findings

Complete Blood Count

  Hematology / CBC are series of tests of the peripheral blood that provide a tremendous amount of
information about the hematologic system and many other organ systems. They are inexpensively, easily,
and rapidly performed as a screening test.

 Test results shows that the client has high RBC, HGB, HCT and WBC (lymphocytes). Increase in RBC and
HGB indicates that the patient is compensating for the need for oxygen consumption since the patient
experienced dyspnea. Increase in WBC (lymphocytes) indicates a need to fight an infection since the client
has typhoid fever and HIV. And lastly, hematocrit increases as RBC increases.

Miscellaneous

Source of specimen:
Whole blood/ semen

Exam desired:
Serologic test for typhoid

Method:
SD bioline

IgG------- negative
IgM------- negative

 Interpretation: IgM is the antibody that immature B Cells synthesize and insert into their plasma
membranes. It is the predominant class of antibody produced after initial contact with bacteria
and/virus while IgG is the predominant antibody of the secondary antibody response. Since the
patient has negative result of IgM, and IgG, this means that he did not yet produced antibodies for
typhoid fever.

Dec. 26, 2008 D/C Admitted

4:50 8:10 pm
12/31

Herpes type I t/C typhoid Acid related D/O

Urinalysis
Date: January 08, 2009

Physical examination other examination Chemical examination

Color yellow bacteria occasional albumin negative

Reaction alkaline amorphous phosphates
occasional sugar negative
Appearance turbid yeast cell negative

Sp gr 1.005
Microscopic examination
Pus cells 0-2/HPF crystals negative
RBC 0-1/HPF casts negative
Mucus threads occasional
Epithelial cells occasional

* Urinalysis is an analysis of the volume and the physical, chemical, and microscopic properties of urine. Patient’s
urinalysis reveals normal findings.
 13 AREAS OF ASSESSMENT

I. PSYCHOLOGICAL STATUS

The patient, Mr. X, a 25 year old male, presently residing at Baguio City in an apartment with her aunt. He is a
supervisor at People Support Baguio. He is Roman Catholic without any particular belief or practice affecting health
care. He is the eldest child and considers himself as the breadwinner of their family. His recreational activities include
reading magazines and going out with friends. He is currently in a relationship with another male individual and they
have been together for 2months. With his income, he is able to provide for his basic needs like food, clothing, housing,
and drugs for maintenance of good health. The patient is usually healthy and strong and can perform ADLs with ease
before having such illness.

II. MENTAL AND EMOTIONAL STATUS

The patient is a BS accountancy graduate thus he is a well educated person and is able to understand the course
and procedure of confinement. He also has a wide range of English and Tagalog vocabulary and understands Ilocano,
thus communication is effective. He has a full level of consciousness but often times observed to have signs of
depression. He is able to response to verbal stimuli. Furthermore, he is able to response to noise and light as evidence
by his preference of keeping the room as dim as possible. He is also able to respond to touch and painful stimuli and
spontaneous activity. He is oriented to time place and persons around him. He is able to read and write and has the
ability to comprehend and follow directions. He has also a great perception and understanding of health problems and
compliant to the goals of medical and nursing therapy given to him. Being a Roman Catholic, there were no noted
beliefs and attitudes about the disease.
He has an appropriate affect. He is open and approachable to friends but is aloof to medical personnel. He is
able to see and hear things that others see or hear. Normally he is very confident and has a high self- esteem but ever
since the diagnosis of his disease he had a sudden change in his affect as verbalized by his significant others. The
patient mentioned of not taking any substances that can alter emotional response.

III. ENVIRONMENTAL STATUS

The patient is able to walk and eat by himself. He is presently occupying a private room in our institution. All
equipments in the room are in place within the patient’s reach and kept in safety. There were no restraining and
supportive devices used by the patient. The room was properly ventilated and has proper lightning. Upon inspection,
there were no noted lesions or wounds within the patient’s skin. The staff nurse advised to use double gloves when
extracting blood and obtaining secretions. The patient is equipped with rubbing alcohol and soap in the room. He uses
rubbing alcohol especially before eating.

IV. SENSORY STATUS

EYES: The eyelids of the patient are proportionate with his skin. Eyes are normally symmetrical with the face and in
level with each other. Eyelashes and eyebrows are equally distributed. No tenderness noted on his eyelids. Palpebral
conjunctiva is pinkish in color. Sclera is reddish upon inspection. There were no corrective devices used by the
patient. There were no known deficits noted

EARS: Ears of the client are proportionate with the head and face. The two pinna are bilaterally symmetrical and in
level with the lateral canthus of the eyes. Moreover, during palpation, no lumps or lesions are noted.
His ear canals are clean for there are absence of discharges and cerumen noted.

NOSE: The client’s nose has the same color with the face. It is also proportionate with the head and face. There are no
lesions or deviations noted.
Upon inspection and palpation, no occlusions or tenderness noted. His nasal cavity is pinkish in color. There is
an absence of inflammations, swellings, exudates or abnormal discharges.

TONGUE: The patient is able to discriminate sweet sour, salt and bitter but it was noted that he does not have a good
appetite that lead weakness on patient’s body.

TACTILE: The patient is able to discriminate sharp and dull, light and firm touch. In addition to, he is also able to
perceive heat, cold and pain in proportion to stimulus. He can discriminate common objects by touch such as pillows
and coins and denies any aberrant sensations.

SPEECH FORMULATIONS AND PERCEPTIONS: The lips of the patient are symmetrical. It is pinkish in color and
noted of dryness with no presence of lumps or ulcers.
The patient is not using dentures.
The tonsils are pinkish and the size is graded +1, which is an indication of normal tonsils.
When the client was asked to show his tongue, we noted that he has a whitish, located midline, moist and
symmetrical tongue.
Upon palpation of the tongue, it shows no lumps, which are a good indication of absence of oral cancer.
The mouth of the patient is not deviated.

V. MOTOR STATUS
The patient can perform activities of daily without any assistance. Upper and lower extremities of the client are
symmetrical. There were no muscle wasting, deformities and abnormal innervations noted. There is no palpated and
observed edema or lesions.
The patient has generalized body weakness. Both his upper and lower arms cannot exert enough and equal
strength to resist the force applied.
Symmetrical sensation is noted on both extremities. He can easily distinguish pain and light sensation on both
extremities.

VI. NUTRITIONAL STATUS

Client has a regular eating habit that is three times a day. Patient usually eats in a fast food chain prior to
hospitalization. Patient does not eat that much because of loss of appetite. Prior to hospitalization, the patient’s usual
food contents comprised mostly of vegetables and fruits. The patient is not selective when it comes to food. There are
no religious dietary restrictions and no symbol meaning of foods. He has a slender body built; nail base is firm; He
does not have any dentures that can interfere with eating. Furthermore, the patient does not experience difficulty in
swallowing. Nausea and vomiting has not been reported by patient. Height and weight were not obtained during data
collection. No presence of nasogastric tube.

VII. ELIMINATION STATUS

BOWEL: Normal pattern of elimination of the client is once a day. During the shift, the patient was able to defecate
once. Client’s stool is characterized as soft and brown. He does not feel nauseated and does not have any episodes of
flatulence. He is not taking any medications related to bowel elimination.

URINE: Within the day of admission, the patient urinates about 2 times. He does have difficulty when urinating. No
pain was also noted.

VIII. FLUID AND ELECTROLYTES

The patient takes in fluid via oral and parenteral route. He consumes water about 2000 cc a day. Urination
and is his main output. Dehydration is not visible through the test of skin turgor. Mouth has no visible
lesions, mucous membranes are not dry. IVF received by the patient includes PLRS 1L x 8 hours.

IX. CIRCULATORY STATUS

During the shift, patient’s pulse rate is 80 beats per minute, characterized as strong quality and of regular
rhythm. This was taken in lying position. Blood pressure of the patient is 120/90 mm Hg taken on the left arm
while lying. The patient’s capillary refill is within 1-2 seconds.

X. RESPIRATORY STATUS

Client has no obstruction in airway. The respiratory rate of the client is 20 times per minute, not too
shallow not too deep and can breath easily without compromising function of accessory muscles. skin is
brownish in color; nail beds are pinkish to white; lips is from brownish to pinkish; no clubbing of nails; has
no altered level of consciousness and is alert and answer to queries if there is a need to; has no supportive
devices; client shows standard breathing patterns.
He verbalized that he smokes and consumes half pack of cigarettes per day.
Client’s thorax is light brown, symmetrical and oval. There is absence of lumps, masses or bulges and
observed pulsation within the thorax. .
His inspiratory and expiratory phases are equal also.
      

XI. TEMPERATURE
 Upon assessment, patient’s skin is warm to touch with a temperature of 38 degree Celsius obtain
through a tympanic thermo scan. There is presence of mild perspiration. Patient was observed fully covers self
with linen up to chest level

XII. INTEGUMENTARY STATUS

Patient’s skin is generally light fair in color and has good skin turgor; nail base is firm when palpated
and curved but angle is still 160 degrees; soft, thick, black and evenly distributed hair with no parasite
infestation; has a moderately moist skin. Skin is smooth no excessive sweating or oiliness. There is an absence of
lesions.

XIII. COMFORT AND REST

Client states usual sleeping hours is up to 6 hours prior to admission but was increased to 10 hours
when admitted. He verbalized that it is because he wants to rest most of the time and does not want to talk
much with the medical personnel. Skin is light fair in color; nail beds are pinkish to white in color; lips are
pinkish and dry and are symmetrical; client easily gets tired. The patient also complained of easy fatigability,
weakness and cold intolerance.
 Nursing Diagnosis

Reference: Human Response Patterns (Unitary Person) and Maslow’s Hierarchy of Needs
List of Problems Category
Actual Potential Overt Covert
Hyperthermia related to
infectious process

Ineffective protection related to

impaired first line of defense

Imbalanced nutrition: less than

body requirements related to
loss of appetite
Constipation related to
insufficient physical activities

Nausea related to underlying

disease process

Activity intolerance related to

generalized body weakness

Impaired skin integrity related to

hyperthermia

Anxiety related to underlying

disease condition

Impaired verbal communication

related to physiological
condition
Impaired social interaction
related to physiological factor

Deficient diversional activity

related to prolonged
hospitalization
Risk for falls related to
generalized body weakness

Risk-prone health behavior

related to inadequate
comprehension of smoking

LIST OF PRIORITIZED PROBLEMS:

1. Hyperthermia related to infectious process

2. Ineffective protection related to impaired first line of defense
3. Imbalanced nutrition: less than body requirements related to loss of appetite
4. Constipation related to insufficient physical activities
 5. Nausea related to underlying disease process
6. Activity intolerance related to generalized body weakness
7. Impaired skin integrity related to hyperthermia
8. Anxiety related to underlying disease condition
9. Impaired verbal communication related to physiological condition
10. Impaired social interaction related to physiological factor
11. Deficient diversional activity related to prolonged hospitalization
12. Risk for falls related to generalized body weakness
13. Risk-prone health behavior related to inadequate comprehension of smoking

Justification
Nursing diagnosis’ Basis: Maslow’s Hierarchy of Needs and Human Response Patterns (Unitary
Person)

Hyperthermia related to infectious process

Maintenance of a body temperature within a narrow range is necessary for normal functioning of
the body. Straying too far out of the normal range of body temperatures can have very serious
physiological consequences. In case of our patient, since he is undergoing infectious process, thermostatic
control centers of his hypothalamus is producing fever. The high body temperature associated with
infectious fever is thought to enhance the body’s immune responses, eliminating the pathogens. But if this
elevated temperature persists, the body loses a large amount of fluid because of heat-loss mechanisms and
can further weaken the infected patient. Other complications that can occur are the following: tachycardia,
headache, confusion, convulsions or loss of consciousness and brain damage that can be detrimental. This
is the most highly prioritized problem because during the times that we handled our patient, he is
experiencing a persistent high grade temperature that even reached up to 40 degrees Celsius. After several
medical and nursing interventions, sometimes his elevated temperature still persisted.

Ineffective protection related to impaired first and third line of

defense
Individuals normally have defenses that protect the body from infection. The internal environment of the
human body is protected by a continuous mechanical barrier formed by the cutaneous membrane (skin) and mucous
membranes, often called the first line. Since the client have been experiencing an on & off high grade fever, his skin
integrity is also being altered. The client experienced hot flushes, non-petechial rashes on upper extremities and
volar area. Specific immunity, part of the body’s third line of defense, is orchestrated by two different classes of a
type of white blood cell called the lymphocyte. It helps in fighting foreign bodies and is involve in infectious process.
Client’s WBC specifically his lymphocytes are elevated based on his CBC. Once these systems are altered, potential
.Decrease in the ability to guard self from internal or external threats such as illness or injury can lead to more
serious complications.
Pathophysiology of Abdominal Aortic Aneurysm
 List of Drugs

1. Generic Name: Dibencozide

Brand Name: Heracline 1 tab

Indication: Poor appetite in infants children and adults. Adjuvant to treatment of tuberculosis and other
chronic ailments, Convalescence from acute infection or surgery. Faulty nutrition in older people,
Premature babies, Low birth weight. Retarded growth

Mechanism of Action: Dibencozide increases the protein efficiency coefficient ie, the percentage of bound
nitrogen for protein build-up in the body compared to ingested nitrogen with food intake. The initial sign of
effectiveness is manifested by a marked increase in appetite. Thus, dibencozide facilitates optimum
utilization of dietary protein intake, contributes to the formation and repair of body tissues and stimulates
appetite.

Classification: Appetite Enhancer

Nursing Consideration:
 It was given with meals or mixed in meals and can take before meals.
 Can’t take with milk

2. Generic Name: Paracetamol

Brand name: Tempra Forte

Indication: Fever, headache, muscular aches & pain, toothache, colds, earache, fever due to tonsillectomy,
inoculations & vaccinations.

Mechanism of action: Its mode of action was known to be different to other pain relievers, but although it
produces pain relief throughout the body the exact mechanism was not clear.

The production of prostaglandins is part of the body's inflammatory response to injury, and inhibition of
prostaglandin production around the body by blocking the cyclooxygenase enzymes known as COX-1 and
COX-2 has long been known to be the mechanism of action of aspirin and other non-steroidal anti-
inflammatory drugs (NSAIDs) such as ibuprofen. However, their action in blocking COX-1 is known to be
responsible for also causing the unwanted gastrointestinal side effects associated with these drugs.

Paracetamol has no significant action on COX-1 and COX-2, which left its mode of action a mystery but did
explain its lack of anti-inflammatory action and also, more importantly, its freedom from gastrointestinal
side effects typical of NSAIDs.

Early work (1) had suggested that the fever reducing action of paracetamol was due to activity in the brain
while its lack of any clinically useful anti-inflammatory action was consistent with a lack of prostaglandin
inhibition peripherally in the body.

Now, recent research (2) has shown the presence of a new, previously unknown cyclooxygenase enzyme
COX-3, found in the brain and spinal cord, which is selectively inhibited by paracetamol, and is distinct from
the two already known cyclooxygenase enzymes COX-1 and COX-2. It is now believed that this selective
inhibition of the enzyme COX-3 in the brain and spinal cord explains the effectiveness of paracetamol in
relieving pain and reducing fever without having unwanted gastrointestinal side effects.

Classification: Analgesics (Non-Opioid) & Antipyretics

Adverse Drug Reaction: Thrombocytopenia, leucopenia, pancytopenia, neutropenia & agranulocytosis.

Nursing Consideration:

 use cautiously in patient with impaired renal & hepatic function.

3. Moriamin Forte

Contents: 5-oxyanthranilic acid 0.2 mg, Ca pantothenate 5 mg, folic acid 0.2 mg, l- isoleucine 5.9 mg, l-
acetyltryptophan 5 mg, l- leucine 18.3 mg, l- lysine HCl 25 mg, l- methionine 18.4 mg, nicotinamide 20 mg, l-
phenylalanine 5 mg, l- threonine 4.2 mg, l- valine 6.7 mg, vit A 2,000 iu, vit B 1 5 mg, vit B12 1 mcg, vit B2 3
mg, vit B6 2.5 mg, vit C 20 mg, vit D 200 iu, vit E 1 mg

Indication: Malnutrition, protein & vit deficiencies, anemia, convalescence, restoration & maintenance of
body resistance, pregnancy & lactation, adjuvant in the therapy of peptic ulcer & TB.

Adverse Drug Reaction: Hypervitaminosis (large dose)

Classification: Vitamins &/or Minerals

Nursing Consideration: May be taken with or without food (May be taken w/ meals for better absorption or
if GI discomfort occurs.)
Patient Teaching: May color urine yellow.

4. Generic Name: Metoclopramide

Brand Name: Plasil

Indication: Disturbances of GI motility including GERD & diabetic gastroparesis. Nausea & vomiting of
central & peripheral origin associated w/ surgery, metabolic diseases, infectious diseases, migraine
headache or drugs including cancer chemotherapy. Facilitate small bowel intubation & radiological
procedures of GIT.

Contraindication: GI hemorrhage, mechanical obstruction or perforation, pheochromocytoma, epileptics.

Mechanism of action: Pharmacology: Metoclopramide, a dopamine antagonist, stimulates motility of the

upper gastrointestinal tract without stimulating gastric, biliary or pancreatic secretions. Its mode of action
is unclear. It seems to sensitize tissues to the action of acetylcholine. The effect of metoclopramide on
motility is not dependent on intact vagal innervation but it can be abolished by anticholinergic drugs.
Metoclopramide increases the tone and amplitude of gastric (especially antral) contractions, relaxes the
pyloric sphincter and the duodenum and jejunum, resulting in accelerated gastric emptying and intestinal
transit. It increases the resting tone of the lower esophageal sphincter.

Pharmacokinetics: Peak plasma levels are reached 30-60 min following an oral dose. Excretion is primarily
in the urine. The plasma half-life is about 3 hrs. Metoclopramide undergoes minimal hepatic metabolism,
except for simple conjugation. Its safe use has been described in patients with advanced liver disease
whose renal function was normal.

Classification: Antiemetics / GIT Regulators, Antiflatulents & Anti-inflammatories

Adverse Drug Reaction: The most frequent adverse reactions to metoclopramide are restlessness,
drowsiness, fatigue and lassitude which occur in approximately 10% of patients. Less frequently,
extrapyramidal symptoms, insomnia, headache, dizziness, nausea, galactorrhea, gynecomastia, rash
including urticaria, or bowel disturbances may occur.

Nursing Consideration:
 Should be taken on an empty stomach (Take 10 mins before meals.)
  Advise patient to avoid alcohol and other CNS depressants that enhance sedating properties of this
drug.

5. Generic Name: Ciprofloxacin

Brand Name: Cipro

Classification:
Functional class: Urinary Anti Infective Broad Sprectrum
Chemical Class: Fluoroquinolone

Action: interferes with conversion of intermediate DNA fragments into high molecular weight DNA in
bacteria; DNA gyrase inhibitor.

Indication: adult urinary tract infection ( including complicated);chronic bacterial prostatitis; acute sinusitis;
lower respiratory, skin, bone, joint infection; infectious diarrhea, exposure to inhalation anthrax,
conjunctivitis, corneal ulcers (ophthalmic)

Contraindication: hypersensitivity to quinolones

Nursing Consideration:
 Assist the patient to previuous sensitivity reaction
 Assess patient for s/s of infection including characteristics of wounds, sputum, urine, stool, WBC
>10,000³mm, fever; obtain baseline information before during treatment
 Obtain C&s before beginning drug therapy to identify if correct treatment has been initiated
 Assess for anaphylaxis; rash, urticaria, dyspnea, pruritus, chills, fever, joint pain; may occur a few
days after therapy begins; epinephrine resuscitation equipment should be available for anaphylactic
reaction
 Identify urine output; if decreasing, notify prescriber( may indicate nephrototoxicity); also check for
increase BUN, creatinine

Patient Education:
 teach patient to report sore throat, bruising, bleeding, joint pain; may indicate blood dyscrasias
 advise patient to notify prescriber of diarrhea with blood or pus
 advise patient to rinse mouth frequently, use sugarless candy or gum or dry mouth

6. Generic name: Bisacodyl

Brand name: Dulcolax

Classification: laxative, stimulants; diphenyl methane

Action: acts directly on the intestine by increasing the motor activity; thought to irritate the colonic
intramural plexus; increases water in the colon

Indication: short term treatment of constipation, bowel or rectal preparation for surgery, examination

Contraindication: hypersensitivity, rectal fissures, abdominal pain, nausea, vomiting, appendicitis, acute
surgical abdomen, ulcerated hemorrhoids, acute hepatitis, fecal impaction, intestinal or biliary tract
obstraction

Nursing Responsibility:
  Monitor blood, urine electrolytes if used often by patient; check input and output ratio to identify
fluid loss.
 Asses cramping, rectal bleeding, nausea, vomiting; if these symptoms occur, drug should be
discontinued; identify caused of constipation; identify whether fluid, bulk, or exercise missing from
lifestyle

Patient Teaching:
 Discuss with the patient adequate fluid and bulk consuption is necessary.
 Advise patient that normal blood movements do not always occur daily.
 Teach patient not to use in presence of abdominal pain, nausea, vomiting; tell patient to notify
prescriber if constipation unrelief or if symptoms of electrolyte imbalance occur: muscle cramps,
pain, weakness, excessive thirst.
 Assessment Explanation of the Goals and Objectives Interventions Rationale Evaluation
problem
Date of assessment: Hyperthermia describes Goal: Dx:
January 28, 2009 an increase in normal Client will maintain >Monitor the vital signs especially >Serves as a comparative Goal is fully met if:
body temperature that is normal body the temperature of the client baseline data
S: >“Giniginaw ako”, 36.4-37.5ºC to levels that temperature a. The body temperature of the client
verbalized by the patient are above abnormal. >Monitor environmental >Room temperature/number is lowered from 38.1 oC to 37.5 oC
Hyperthermia is usually LTO: temperature of blankets should be altered
O:>flushed skin caused by the erroneous After 3 days of to maintain near-normal b. The client removes excess clothing
>skin is warm to touch setting of the nursing intervention, body temperature when he feels warm
> teary-eyed thermoregulation center, the client will be able to
>received patient pale, which is actually the return to normal body >To open the pores and c. The client drinks at least eight
conscious and responsive to hypothalamus by the high temperature. Tx: promote heat loss via glasses per day
verbal stimuli level of pyrogens. >Perform Tepid Sponge bath, evaporation Note: Use of ice
>seen patient in bed most of These pyrogens refer to After series of nursing avoid use of alcohol water/alcohol may cause d. The significant others will perform
the time any substance which intervention, the chills, actually elevating TSB to help lower the temperature of
>with IVF regulated at 32 would induce a patient will verbalize temperature. In addition, the client.
gtt/min, infusing well at left temperature rise and sense of satisfaction alcohol is very drying to skin.
arm usually carried by the with rest and comfort Goal is partially met if:
VITAL SIGNS: blood into the brain. >To promote heat loss
T = 38oC via the tympanic, STO: through sweating a. the temperature decreased from
PR = 80 bpm REFERENCE: After the nursing 38.1oC to 37.7oC
RR = 20 cpm Fundamentals of Nursing interventions, the client >Provide source of ventilation >To promote heat loss
BP= 120/90 mmHg 7th Edition by Barbara will be able to: by opening the windows through urination b. skin is warm to touch
Kozier et. Al, page 489-
HEMATOLOGY TEST: 490. a. lower the >Offered 1 glass of water or fresh due to the following factors:
temperature from 38.1 fruit juice per hour as tolerated >To promote heat loss trough a. client resistant to have TSB
o
RBC: 6.13 e 12/L C to 37.7 oC convection to provide b. client resistant to increase fluid
NV: 4.5 - 5.5x 106 /ml >Remove unnecessary linens or comfort intake
INTERPRETATION: Elevated b. discuss the blankets c. significant others does not perform
importance of his >Paracetamol is an TSB to the client
Hematocrit: 43% medications in relation antipyretic which helps
NV: (%) 41 – 50 to his health >Administered paracetamol as per regulate the body Goal is not met if:
INTERPRETATION: Normal doctor’s order temperature
a. the temperature did not change
Hemoglobin: 14.5 g/dL >To encourage significant
NV: (g/dl) 13.5 - 16.5 Ed: others to perform TSB b. client shows signs and symptoms
INTERPRETATION: Normal >Demonstrate proper TSB to independently of fever
 significant others.
WBC: 13,500 cells/ml due to the following factors:
NV: (cells/ml) 4,500 - 10,000 a. insufficient ventilation
INTERPRETATION: High >To promote evaporation of b. improper medication
heat from the client’s body to
Phosphate: 2.0 mg/dL provide comfort to the client. Recommendations:
NV: 2.5 - 4.5 mg/dL >Encourage significant others to a. Do an extensive health teaching
INTERPRETATION: Low perform TSB to the patient. and explanation of the benefits of
>To understand the benefits TSB to the significant others.
Sodium: 130 mEq/L of increasing fluid intake to
NV:135 - 147 mEq/L attain normal body b. Do an extensive health teaching on
INTERPRETATION: Low temperature the importance of increased fluid
>Discuss the importance of intake
A:>Hyperthermia related to increasing fluid intake. >To provide comfort; to
infectious process prevent exhaustion

>To provide comfort to the

>Encourage rest and sleep. client

Reference:
Nursing Care Plans 6th Edition
>Discuss the importance of by Marilynn E. Doenges, et al.
removing unnecessary linens.
 Assessment Explanation of the problem Goals and Objectives Interventions Rationale Evaluation
Date of Assessment: Ineffective protection is the Goal: The patient will Dx: Objective is fully met if the
September 20, 2008 decrease in the ability to manifest effective >Note underlying disease >Jaundice is a yellow color patient will manifest
guard self from internal or protection by manifesting pathology involved in the skin, the mucous effective first line of
Px: Potential Sepsis external threats such as effective first line of defense membranes, or the eyes. protection by:
illness or injury. The body’s The yellow pigment is from
S: “Ok naman na siya, first line of defense is the Specific Objectives: bilirubin, a byproduct of old a. manifesting recovery from
tinatapos na lang niya ang skin/integument. The red blood cells. jaundice
antibiotic therapy niya”, integument covers the body After series of nursing
verbalized by the mother and protects the deeper intervention, the patient will >Note skin color, texture >The normal skin color b. moist soft skin with good
tissues from injury, from regain effective protection and turgor should be pinkish to slight skin turgor
O: >with dry skin noted drying and from invasion by without occurrence of any brown except for areas with
>skin is warm to touch foreign organisms; it type of skin diseases excessive melanin c. normal lab results
>with loud cry noted contains the peripheral secretions like groin and
>with flushed skin noted endings of many of the After series of nursing areola. Abnormal skin d. no subsequent infection
>received patient pale with sensory nerves; it plays an intervention, the patient will discoloration like yellow occurs
thin body built important part in the maintain intact first line of discoloration of the skin
>with good skin turgor regulation of the body defense without signs of indicates jaundice and it e. good sucking
noted temperature, and has also jaundice should be treated . Dryness
>on ongoing intensive limited excretory and of the skin can cause lesions
phototherapy absorbing powers. The skin and cracks which can lead to
>on antibiotic therapy serves a protection: an subsequent infection. Poor
>with slight jaundice noted anatomical barrier from skin turgor indicates
over the neck area and pathogens and damage dehydration and weakness
lower extremities between the internal and as well.
external environment in
VITAL SIGNS (5:00 pm): bodily defense; Langerhans >Monitor vital signs q 40 >Vital signs not only serve as
T = 36.6 0C via the axilla, cells in the skin are part of a baseline data but also
PR = 110 bpm the adaptive immune indicate further
RR = 88 cpm system.; sensation: contains complications. In jaundice,
a variety of nerve endings because of destruction of
HEMATOLOGY TEST that react to heat and cold, RBC which can lead to
Date: September 20, 2008 touch, pressure, vibration, bleeding, there will be
and tissue injury; see increase in RR, PR but
Erythrocytes: 0.63 somatosensory system and decrease in temperature
Normal Value: 0.37-0.47 haptics; heat regulation: the and BP
INTERPRETATION: High skin contains a blood supply
far greater than its >Review lab values >Lab values indicate
Hgb: 231.65 requirements which allows functioning of the body as a
Normal Value: 110-150 g/L precise control of energy whole. If their is increase
INTERPRETATION: High loss by radiation, convection erythrocytes, it indicates
and conduction. Dilated that there is bleeding/
Leukocytes: 20.4 blood vessels increase destruction of the RBC
Normal Value:5-10 x 109/L perfusion and heat loss causing the bone marrow to
INTERPRETATION: High while constricted vessels produce more RBC. Increase
greatly reduce cutaneous leukocytes and lymphocytes
Lymphocytes: 0.54 blood flow and conserve signal infection and
Normal Value: 0.20-0.40 heat. Erector pili muscles hemoglobin is increase
INTERPRETATION: High are significant in animals; when there is increase in
and control of evaporation: Tx: RBC production.
the skin provides a relatively
A: Ineffective protection dry and impermeable >Provide maximum
related to impaired first line barrier to fluid loss. Loss of exposure to phototherapy > The patient has potential
of defense this function contributes to in developing skin diseases
the massive fluid loss in and infection in the body in
burns. which medications alone
does not treat those
infections. During
phototherapy the patient
REFERENCE: skin or the entire body is
Fundamentals of Nursing 7th exposed to blue light. This
Edition by Barbara Kozier et. blue light is high in radiation
Al. and heat causing growth of
bacteria and bacterial death.
Furthermore, the
phototherapy gives heat to
the newborn so that
hypothermia may happen.
This gives the new born a
time to gradually adapt from
the warm environment of
the uterus to the external
environment.
>Administer gentamycin as
ordered > It works by inhibiting to
NR: the bacterial ribosomal
-Give the medicine after a subunit. It inhibits the
negative skin test translocation of the
-Give the medicine for the peptidyl-tRNA from the A-
entire length of time site to the P-site and causing
prescribed by doctor misreading of mRNA. If this
because of possible happens, bacteria are
resistance of bacteria unable to synthesize
-It should be given in IV proteins vital to its growth;
pump because of pain to the thus bacterial cell death
veins occurs. Ribosomes function
-Monitor for adverse in protein synthesis through
reactions of the drug translation.

>Administer Penicillin G
potassium as ordered
NR: > Penicillin G Potassium kills
-Give the medicine after a bacteria by interfering with
negative skin test the ability to synthesize cell
-Give the medicine for the wall. It inhibits the
entire length of time formation of peptidoglycan
prescribed by doctor crosslinks in the cell wall.
because of possible Peptidoglycan is a polymer
resistance of bacteria consisting of sugar and
-It should be given in IV amino acids that forms the
pump because of pain to the plasma membrane of
veins bacteria. Penicillin G
-Monitor for adverse Potassium inhibits
reactions of the drug production of bacterial cell
wall by binding to bacterial
enzyme-binding proteins or
transpeptidases.
Transpeptidases are
enzymes that cross-links the
peptidoglycan chains to
form rigid cell wall. If this is
inhibited, it weakens the cell
wall of the bacteria, causing
>Maintain sterile technique bacterial cell death.
when assessing the patient
>When the skin is dry, there
is weakening of the skin by
increasing the possibility of
 cracking the skin thus
exposing it externally.
Aseptic techniques in
performing intervention
>Evaluate adverse reaction reduce subsequent
of drugs infection.

Gentamycin and PenG

should be given after a
negative skin test because
the patient may be allergic
to such medicines.
Ed: Furthermore, these drugs
has side effects to skin such
>Encouraged breast-feeding as rashes and pruritus

>Breast-milk has
electrolytes and
nourishments that can give
the infant energy.
Furthermore, It has
>Encourage change of antibodies which helps the
position from side to side body fight against antigen

>The first line of defense is

regained by protecting the
skin from further damage

Reference:
Nursing Care Plans 6th
Edition by Marilynn E.
Doenges, et al.