PAMANTASAN NG LUNGSOD NG MAYNILAINTRAMUROS, MANILA

COLLEGE OF NURSING

Case Presentati

onSubmitted to:

Prof. Maricel Chua R.N.

Submitted by:Arnaiz, Danica Rose A.

Baltazar, Clarisse Ann C.Baraquia, Maria Maxine Victoria G.

Bautista, Nicole M.Bernat, Adina S.

Borja, Aerianne Joyce S.Calaycay, Jamaica Ann T.

Introduction

Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both. Normally a certain amount of glucose circulates in the blood. The major sources of this glucose are absorption of ingested food in the gastrointestinal tract and formation of glucose by the liver from food substances. Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production and storage of glucose. In a diabetic state, cells may stop responding to insulin or the pancreas may stop producing insulin entirely. This leads to hyperglycemia. Diabetes is also a multisystem disorder which affects the wound healing process. Physiological changes in tissues and cells may delay healing and complications of diabetes also have an impact.

There are two types of diabetes mellitus, type I and type II respectively. Type I diabetes is said to be the juvenile diabetes, having its onset at any age below 30 years and is insulin-dependent. These type I diabetics has little or no endogenous insulin, making them need insulin to preserve life. On the other hand, type II diabetes is said to be the adult-onset diabetes, occurring usually over 30 years of age. Type II diabetics are non-insulin-dependent.

Latest data says that at the rate diabetes cases are increasing in the country, there will be some 6.16 million diabetic Filipinos by 2030, health experts warned the other day. According to Dr. Joey Miranda, secretary of the American Association of Clinical Endocrinology-Philippines, there were 3.4 million diabetes cases in the country in 2010, representing a prevalence rate of 7.7 percent. Citing data from the World Health Organization and International Diabetes Foundation, he said that by 2030, the prevalence rate is projected to rise to 8.9 percent or 6.16 million cases. These figures represent an increase of 15.6 percent and 84.2 percent in prevalence rate and the number of cases, respectively.

Causes of this disease is still a mystery yet some genetic and environmental factors put people to risk like lifestyle and familial history of diseases.

Objectives

GENERAL OBJECTIVES:

After 4 days of exposure to Ospital Ng Sampaloc, Medicine Ward Area, the student nurses are expected to be able to apply the theoretical skills learned on lectures, have a systematic and well organized manner of collecting and analyzing data, able to provide optimum or quality care to the patient, and be able to discuss the disease and its processes.

SPECIFIC OBJECTIVES:Specifically, the student nurses should be able to: Establish rapport with the patient to be able to gather important information about his past and present conditions.

To be able to use the nursing process as framework to care for the patient Conduct a thorough physical assessment as a apart of baseline data gathering Know the anatomy and physiology of the affected body part with regards to patient’s condition

Trace the pathophysiology of the disease condition Know the laboratory and diagnostic procedures done including the normal and abnormal findings and values for comparison

Determine and interpret the medical management employed Identify appropriate nursing management for the patient’s condition Identify and study the drugs prescribed to the patient which affect the patient’s current situation

Construct a nursing care plan and health teachings strategies that is appropriate for the patient’s problem

Formulate a prognosis based on all the gathered information

Comprehensive Health History

Date of interview: November 22, 2007

Name of Informant: Virginia Fernandez

Relationship with the patient: Grandmother

BIOGRAPHICAL DATAPatient: Patient X

Sex: Male

Age: 44 years old

Date of Birth: August 21, 1969

Address: Sta. Mesa, Manila

Civil status: Married

Nationality: Filipino

Religion: Roman Catholic

Date of Admission: June 27, 2013

Hospital Number: 534007

MEDICAL DIAGNOSISDiabetes Mellitus II t/c Chronic Kidney Disease

CHIEF COMPLAINTClient complained of non-healing wound on right calcaneus.

HISTORY OF PRESENT ILLNESS This is a case of a male patient who had experienced swelling on his right foot and

applied hot compress to alleviate the pain. Days after, blisters appeared resulting to

a wound. The scab was removed and caused continuous bleeding.

PAST MEDICAL HISTORY Upon interview, patient stated that he never had any illnesses, allergies to any

foods or medications, but had a previous hospitalization prior to his hospitalization.

In the year 2011 he was admitted at Ospital ng Maynila Medical Center and was

confined for four days due to continuous bleeding of extracted tooth. Past

medications were not recalled.

FAMILY HISTORY OF ILLNESS The informant stated that the patient’s parents have a known history of familial

diseases such as hypertension and diabetes mellitus.

LIFESTYLE Upon conduction of assessment, the patient stated that he doesn’t smoke and use

substances but drinks alcohol almost every day. In addition, whenever the patient

has free time, he often plays basketball with his co-workers.

PSYCHOSOCIAL HISTORYPrimary Language: Tagalog

Mood: Sociable; responds to any of the questions asked by the group in a pleasant

way.

Family Relations: The patient has a good relationship with his parents.

MEDICATIONS:1. Cloxacillin, 500 mg/cap, q8h x 7 days

2. Linagliptin, 5 mg/tab, OD

3. Losartan, 50 mg/tab, OD

4. Clonidine, 75 mcg/tab 5. Diphenhydramine, IV prior to BT

Review of Systems

General: patient in supine positionConscious and coherent with IVF

PNSS x 8 hours hooked at right arm, infusing well.

Vital signs as follows: Temp: 37.1°C PR: 80 bpm RR: 18 cpm BP: 140/90

Skin: (–) pallor(–) jaundice

(–) pruritus(+) rashes (scaly)(–) masses(+) wound

Head: (–) headache(–) head injury(–) tenderness(–) lesions

Eyes: (+) icteric sclera(–) edema(+) glasses

(–) inflammation(–) excessive tearing(–) dry eyes(–) nodules

Ears: (–) tinnitus(–) pain(–) discharge

Nose: (–) allergies(–) sinus problem(–) polyps(–) sneezing(–) epistaxis

Throat: (+) dental caries

(–) bleeding gums(–) mouth sores(–) ulcerations(–) difficulty swallowing

Respiratory: (–) diaghprammatic

excursion(–) chest pain

(–) dyspnea(–) cough(–) hemoptysis

Cardiovascular: (–) chest pain(–) SOB(–) pulsations(–) edema

Gastrointestinal: (–) abdominal pain(RLQ)(–) anorexia

(–) ascites(–) anorexia

(–) diarrhea(–) hematochezia(–) hemorrhoids

Endocrine: (–) fatigue(+) polydipsia(+) polyphagia

Musculoskeletal: (+) edema(right foot)

(–) stiffness(–) joint swelling

(+) arthritis

Physical Assessment

General Appearance:The patient is a male adult, 44 years of age. Upon assessment, the patient was

conscious, coherent, and responsive. He was also seen lying on bed with IVF PNSS x 8

hours regulated at 30-31 gtts/min hooked at right arm, infusing well. The patient has no

problem in ambulation.

V/S taken: time: 12noonTemperature: 37.1

Heart Rate: 80 bpm

Respiratory Rate: 18 cpm

Blood Pressure: 140/90mmHg

Skin:Upon inspection, the patient’s skin has brown complexion. The skin when

palpated felt warm and dry. There were some scars and rashes on his upper

extremities. Patient has a gangrenous wound on right calcaneus, about 1 inch in size,

wherein the area within 10 cm from the wound is swelling.

HEENT:The patient’s skull is rounded, normocephalic, no nodules, symmetrical, and no

tenderness. The patient’s scalp is free of lesions and no infestations were present in the

hair. The pupils are equal and are both reactive to light. The eyeballs are centered with

icteric sclerae. The client’s conjunctivas are shiny, smooth, and pink in color. No

vascularizations were found and visual acuity is within normal limit. Patient can read 12

font size letters within 2 feet and six ocular movements, which assess the motor

function of the eyes, are intact. Ears are not low set and both sides are symmetrical.

Hearing acuity is normal and the patient can hear the tick of the watch when placed

close to the ear. Nose is symmetrical and no lesions or unusual discharges were

present. Both nostrils were assessed and no excessive flarings were found. The outer

lips are dark in color, symmetrical, dry, and with a pinkish upper palate and buccal

mucosa. No oral lesions were found and gag reflex was also elicited. Moreover, dental

caries were also present. Lastly, the neck is centered and thyroid gland is not enlarged.

Respiratory System:Upon inspection, the chest is symmetrical in shape and the breathing pattern of

the patient was quiet and respirations are effortless. The thorax moves easily without

difficulty upon registration. No spinal deformities noted. No adventitious breath sounds

were heard upon auscultation of lung fields.

Cardiovascular System:The Point of Maximal Impulse (PMI) is located at the patient’s 5 th left ICS mid-

clavicular line. No chest pain was noted and heart sounds are all normal but with a

slight increase from normal. Pulses in the extremities are in the same rate as with the

other pulses.

Gastrointestinal System:The patient is currently on diabetic diet and defecates regularly. There is no any

abnormality in the abdominal skin wall. Upon palpation, there is neither tenderness nor

masses felt. Normal abdominal sounds are being heard, thus giving normal abdominal

findings.

Genitourinary System:Assessment on the client’s genitalia was not performed to respect client privacy.

Musculoskeletal System:

The client does not show any limitation in movement upon inspection. He can move

freely, extends and rotates his extremities without any discomfort, and he stands and

walks without support.

Neurologic System:The patient can comprehend spoken language and has proper orientation of

things around him. Memory status is intact and the patient was also able to discriminate

sharp and dull sensations however, the patient has a feeling of numbness within the

area where his wound is located.

Cranial Nerve Assessment:CRANIAL NERVE ASSESSMENT

Olfactory (I) No problem with the patient’s sense of smell was elicited since he can identify which foods are being presented to him without looking at it.

Optic (II) The patient can read from 12 to 14-inch distance. The patient can see objects in the periphery when looking straight ahead.

Oculomotor (III) The patient has bilateral and symmetrical extra ocular movements. The pupils constrict when looking at near objects and dilate when looking at far objects. Pupils converge when near object is moved to the nose.

Trochlear (IV) The patient has bilateral and symmetrical extra ocular movements.

Trigeminal (V) The patient is able to elicit blink reflex, can feel light sensation from the wisp of cotton.

Abducens (VI) The patient has bilateral and symmetric lateral eye movements.Facial (VII) The patient is able to smile, can raise the eyebrows

symmetrically, is able to frown, puff cheeks and close eyes tightly bilaterally. Patient is able to identify various tastes on the tip of the tongue.

Vestibulocochlear (VIII)

The patient can hear spoken words and able to identify the ticking of the watch.

Glossopharyngeal (IX)

The patient can identify tastes on the posterior tongue. The patient can move his tongue from side to side and up and down.

Vagus (X) The patient can identify tastes on the posterior tongue. The patient can move his tongue from side to side and up and down. He also has audible speech and has no hoarseness noted.

Accessory (XI) The patient is able to shrug his shoulders even when force is applied and can turn head to side against resistance.

Hypoglossal (XII) The patient can protrude his tongue at midline and can move it from side to side.

Therefore, client’s assessment of the cranial nerves is intact and fully functional.

Diagnostic Tests Complete Blood Count (CBC) Common Blood test. CBC is the calculation of

the cellular blood. These calculations are generally determined by special machines that analyze the different components of blood in less than a minute. CBC measures the concentration of the White Blood Cells (WBC), Red Blood Cells (RBC), and platelets. It is performed by obtaining a few millilitres of blood sample from the patient using a syringe.

Date Test Normal Values Result InterpretationJune 24, 2013 Hematology

report:

WBC count> segmenters> lymphocyte

RBC>HgB>Hct>Platelet count

4.860 – 70 %30 – 40 %

M 14-16 g/dlM 0.40-0.57130 – 140 x 10

5.08020

6.80.20182

Date Test Normal Values Result InterpretationJune 29, 2013 Hematology

report:

WBC count> segmenters> lymphocyte

RBC>HgB

>Hct

>Platelet count

4.860 – 70 %30 – 40 %

M: 14 – 16g/dlM: 0.40 – 0.57%130 – 140 x 10

10.79010

7.8

0.23

Blood Chemistry Tests Blood chemistry tests are often ordered prior to surgery or a procedure to examine the general health of a patient. This blood test, commonly referred to as a Chem 7 because it looks at 7 different substances found in the blood, is routinely performed after surgery as well.

Blood Chemistry Components

Blood Urea Nitrogen (BUN)

BUN is a measure of kidney function. A high level may indicate that the kidneys are functioning less than normal.

Carbon Dioxide (CO2)

This test measures the amount of carbon dioxide in the blood. Most carbon dioxide is present in the form of bicarbonate, which is regulated by the lungs and kidneys. The test result is an indication of how well the kidneys, and sometimes the lungs, are managing the bicarbonate level in the blood.

Creatinine

Creatinine is produced by the body during the process of normal muscle breakdown. High levels may indicate kidney impairment, low blood pressure, high blood pressure or another condition. Some medications can also cause a higher than normal level of blood creatinine. Low levels may be caused by late stage muscular dystrophy, myasthenia gravis and over hydration.

Glucose

This test shows the level of glucose in the blood. High levels of glucose can indicate the presence of diabetes or another endocrine disorder. Keep in mind that some medications and the timing of the test in relation to meals can radically alter the results. Do not assume that your results indicate a problem until you have consulted with your physician.

Serum Chloride (Cl)

This test shows the level of chloride in the blood. Chloride binds with electrolytes including potassium and sodium in the blood and plays a role in maintaining the proper pH of the blood. Chloride levels can vary widely if the patient is dehydrated or overly hydrated, if the kidneys are not functioning properly. Heart failure and endocrine problems can also contribute to abnormal chloride results.

Serum Potassium (K)

This test shows the level of potassium in the blood. Potassium plays an important role in muscle contractions and cell function. Both high and low levels of potassium can cause problems with the rhythm of the heart so it is important to monitor the level of potassium after surgery. Patients who are taking diuretics regularly may require regular blood tests to monitor potassium levels, as some diuretics cause the kidneys to excrete too much potassium.

Serum Sodium (Na)

This portion of the test shows the amount of sodium present in the blood. The kidneys work to excrete any excess sodium that is ingested in food and beverages. Sodium levels fluctuate with dehydration or over-hydration, the food and beverages consumed, diarrhea, endocrine disorders, water retention (various causes), trauma and bleeding.

FBS (Fasting Blood Sugar) Test The fasting blood sugar test is also used to test the effectiveness of different medication or dietary changes on people already diagnosed as diabetic.

HbA1c HbA1c is a lab test that shows the average level of blood sugar (glucose) over the previous 3 months. It shows how well you are controlling your diabetes. 

SGPT The term SGPT stands for Serum Glutamic Pyruvate Transaminase. This is an enzyme that is found in the cells of the liver. It is also commonly known as Alanine Transaminase, abbreviated as ALT. In a normally healthy individual, the level of SGPT is measurable in the blood. When there is acute liver damage, the level of SGPT tends to rise dramatically. It should be noted that the level of SPGT may be elevated in an individual who has recently performed physical

exercise. An elevation in the level of ALT is not a confirmation of a diagnosis of liver damage. It is used in conjunction with other types of liver test to confirm whether the patient has indeed suffered from liver damage.

SGOT The SGOT test measures the amount of a substance called glutamic-oxaloacetic transaminase (GOT) in your blood. It is an enzyme found in the liver, muscles (including the heart), and red blood cells. It is released into the blood when cells that contain it are damaged. Other names for this enzyme are aspartate aminotranskinase, aspartate transaminase, and AST. The SGOT level is measured to check the function of your liver, kidneys, heart, pancreas, muscles, and red blood cells. It is also measured to check on medical treatments that may affect the liver.

Date Tests Normal Values Results InterpretationJune 24, 2013 HbA1c

BUN

Crea

Na

K

4.0 – 6.0%1.7 – 8.3 mmol/L35.3 – 123.7 umol/L135 – 145 mmol/L3.5 – 5.5 mmol/L

4.310.7

133.4

132.8

2.96June 27, 2013 FBS

BUN

Crea

Uric Acid

SGOT

SGPT

4.11 – 5.87 mmol/L1.7 – 8.1 mmol/LM: 59 – 104 umol/LM: 202.3 – 416.5 umol/LM up to 40 U/LM up to 41 U/L

5.12

7.76

165.5

452.5

59.8

17.5July 1, 2013 BUN

Crea

2.49 – 6.42 umol/LM: 59 – 104 umol/L

8.05

193.

Urinalysis A urinalysis (UA), also known as routine and microscopy (R&M), is an array of tests performed on urine, and one of the most common methods of medical diagnosis. The word is a portmanteau of the words urine and analysis. The target parameters that can be measured or quantified in urinalysis include many substances and cells, as well as other properties, such as specific gravity.

A part of a urinalysis can be performed by using urine test strips, in which the test results can be read as color changes. Another method is light microscopy of urine samples.

Color: YellowTransparency: Sl. TurbidpH: 5.0Specific Gravity: 1.005Protein: +4Glucose: (-)

Anatomy and Physiology

PancreasThe pancreas, a retroperitoneal gland that is about 12-15 cm long and 2.5 cm thick, lies posterior to the greater curvature of the stomach. The pancreas consists of a head, a body, and a tail and is usually connected to the duodenum by two ducts. The head is the expanded portion of the organ near the curve of the duodenu; superior to and to the left of the head are the central body and the tapering tail. Pancreatic juices are secreted by exocrine cells into small ducts that ultimately unite to form two longer ducts, the pancreatic duct and the accessory duct. These in turn convey the secretions into the small intestine. The

pancreatic duct (duct of Wirsung) is the larger of the two ducts. In most people, the pancreatic duct joins the common bile duct from the liver and gallbladder and enters the duodenum as a dilated common duct called the hepatopancreatic ampulla (ampulla of Vater). The ampulla opens on an elevation of the duodenal mucosa known as the major duodenal papilla, which lies about 10 cm inferior to the pyloric sphincter of the stomach. The passage of pancreatic juice and bile through the hepatopancreatic ampulla into the small

intestine is regulated by a mass of smooth muscle known as the sphincter of the hepatopancreatic ampulla (sphincter of Oddi). The other major duct of the pancreas, the accessory duct (duct of Santorini), leads from the pancreas and empties into the duodenum about 2.5 cm superior to the hepatopancreatic ampulla.The pancreas is made up of small clusters of glandular epithelial cells. About 99% of the clusters, called acini, constitute the exocrine portion of the organ. The cells within acini secrete a mixture of fluid and digestive enzyme called pancreatic islet (islet of Langerhans), form the endocrine portion of the pancreas. These cells secrete the hormones glucagon, insulin, somatostatin, and pancreatic polypeptide. Each day pancreas produces 1200-1500 ml of pancreatic juice, a clear, colorless liquid consisting mostly of water, some salts, sodium bicarbonate and the several enzymes. The sodium bicarbonate gives pancreatic juice a slightly alkaline pH (7.1-8.2) that buffers acidic gastric juice in chime, stops the action of pepsin from the stomach, and creates the proper pH for the action of digestive enzymes in the small intestine. The enzymes in pancreatic juice include a starch-digesting enzyme called pancreatic amylase; several protein-digesting enzyme called trypsin, chymotrypsin, carboxypeptidase, and elastase; the principal triglyceride-digesting enzyme n adult called pancreatic lipase; nucleic acid-digesting called ribonuclease and deoxyribonuclease. The protein-digesting enzymes of the pancreas are produced in an inactive form just as pepsin is produced in the stomach as pepsinogen. Because they are inactive, the

enzymes do not digest cells of the pancreas itself. Trypsin is secreted in an inactive form called trypsinogen. Pancreatic acinar cells also secrete a protein called trypsin inhibitor that combines with any trypsin formed accidentally in the pancreas or in pancreatic juice and blocks its enzymatic activity. When trypsinogen reaches the lumen of the small intestine, it encounters an activating brush-border enzyme called enterokinase which splits off part of the trypsinogen molecule to from trypsin. In turn, trypsin acts on the inactive precursor (called chymotrypsinogen, procarboxypeptidase, & proelastase) to produce chymotrypsin, carboxypeptidase, elastase, respectively.

Medical-Surgical Management

MEDICAL-SURGICAL MANAGEMENT

Management should be aimed at alleviating symptoms and minimizing the risk of long-term complications. A diagnosis of Diabetes Mellitus doesn’t indicate an operation unless a part of the body is greatly affected. The medication given to manage the

disease was Linagliptin 5mg/tab once a day. It is an antidiabetic medicine which increases the production of insulin to control the blood sugar level. To manage a non healing wound brought about by Diabetes Mellitus, Cloxacilline, an antibiotic, 500 mg/capsule was given every 8 hours for 7 days, and changes of wound dressing were also done to prevent further infection. CBG monitoring or Capillary Blood Glucose monitoring was also performed in order to keep track of the level of concentration of glucose in the blood. To manage Hypertension, antihypertensive drugs were administered. Losartan 50mg/tab was given once a day and Clonidine 75mcg/tab. Anemia, secondary to Chronic Kidney disease, was managed through a Blood Transfusion. Diphenhydramine was given prior to Blood Transfusion to lessen allergic reactions that may be brought about by the transfusion.

NURSING MANAGEMENT

INTERVENTIONSThe nurse administered medications on the right time and monitored the patient

for effects and side effects. The nurse performed Capillary Blood Glucose monitoring. The nurse changes the dressing of the non healing wound to prevent further infection. Education

The patient was taught daily self-care skills to prevent acute fluctuations in blood glucose and to incorporate into their lifestyle many preventive behaviors for avoidance of long-term diabetic complications. Patient was educated about nutrition, medication effects and side effects, exercise, disease progression, prevention strategies, and CBG monitoring techniques.

ACTION INDICATION CONTRAINDICATION ADVERSE REACTIONS

NURSING CONSIDERATIONS

PATIENT TEACHING

ClonidineCatapres-TTS

Clonidine HydrochlorideCatapres, Duracion

Pharmacologic Class:Centrally acting alpha agonist

Pregnancy risk category: C

Unknown. Thought to stimulate alpha2

receptors and inhibit the central vasomotor centers, decreasing sympathetic outflow to the heart, kidneys, and peripheral vasculature, and lowering peripheral vascular resistance, blood pressure and heart rate.

Route:1. P.O2. Transderma

l3. Epidural

Onset:1. 30-60 mins.2. 2-3 days3. Unknown

Peak:1. 2-4 hrs.2. 2-3 days3. 30-60 mins.

Duration:1. 12-24 hrs.2. 7-8 days3. Unknown

Half Life:6-20 hrs.

Management of all grades of hypertension.

- hypersensitivity to drug- Transdermal form is contraindicated in Px hypersensitive to any component of the adhesive layer of transdermal system.- Epidural form is contraindicated in Px receiving anticoagulant therapy, in those with bleeding diathesis, in those with an injection site infection, and in those that are hemodynamically unstable or have severe CV disease.- Use cautiously in patients with severe coronary insufficiency, conduction disturbances, recent MI, cerebrovascular disease, chronic renal failure or impaired liver function.

CNS: drowsiness, dizziness, sedation, weakness, fatigue, malaise, agitation, depression.CV:bradycardia, severe rebound hypertension, orthostatic hypotension.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.

- Drug may be given to lower BP rapidly in some hypertensive emergencies.- Monitor BP and PR frequently.- Observe Px for tolerance to drug’s therapeutic effects, which may require increased dosage.- Don’t confuse clonidine with quinidine or clomiphene; or Catapres with Cetapred or Combipres.

- Advise Px that stopping drug abruptly may cause severe rebound high BP. Tell him that dosage must be reduced gradually over 2 to 4 days as instructed by prescriber.- Tell Px to take the last dose immediately before bedtime.- Reassure Px that the transdermal patch usually remains attached despite showering and other routine daily activities.- Caution Px that drug may cause drowsiness but that this adverse effect usually diminishes over 4 to 6 weeks.- Inform Px that dizziness upon standing can be minimized by rising slowly from a sitting or lying position and avoiding sudden position changes.

ACTION INDICATION CONTRAINDICATION ADVERSE REACTIONS NURSING CONSIDERATIONS

PATIENT TEACHING

Losartan PotassiumCozaar

Inhibits vasoconstrictive and aldosterone-secreting action of

- Hypertension- Nephropathy in Type 2 diabetic patients

- hypersensitivity to drug- Breastfeeding isn’t recommended during losartan therapy.

Patients with hypertension or left ventricular hypertrophyCNS: dizziness, asthenia, fatigue, headache, insomnia.

- Drug can be used alone, or with other antihypertensive.- Monitor Px BP

- Tell Px to avoid salt substitutes; these products may contain

Pharmaco-logic Class:Angiotensin II receptor antagonist

Pregnancy risk category: C; D in 2nd and 3rd trimesters

angiotensin II by blocking angiotensin II receptor on the surface of vascular smooth muscle and other tissue cells.

Route:P.O

Onset:Unknown

Peak:1 hr.

Duration:Unknown

Half Life:2 hrs.

- To reduce risk of stroke in patients with hypertension and left ventricular hypertrophy

- Use cautiously in Px with impaired renal or hepatic function.- Drugs that act directly on the renin-angiotensin system can cause fetal and neonatal morbidity and death when given to women in the second or third trimester of pregnancy. These problems haven’t been detected when exposure was limited to the first trimester. If pregnancy is suspected, notify prescriber because drug should be stopped.

CV:edema, chest pain.EENT: nasal congestion, sinusitis, pharyngitis, sinus disorder.GI:abd. pain, nausea, dyspepsia.Musculoskeletal: muscle cramps, myalgia, back or leg pain.Respiratory: Cough, upper respiratory infection.Other: angioedemaPatients with nephropathyCNS: asthenia, fatigue, fever, hypesthesia.CV: chest pain, hypotension, orthostatic hypotension.EENT: sinusitis, cataract.GI: diarrhea, dyspepsia, gastritis.GU: UTI.Hematologic: anemia.Metabolic: hyperkalemia, hypoglycaemia, weight gain.Musculoskeletal:back pain, leg or knee pain, muscle weakness.Respiratory:Cough bronchitis.Skin:cellulitis.Other:flu-like syndrome, diabetic vascular disease, angioedema, infection, trauma, diabetic neuropathy.

closely to evaluate effectiveness of therapy.- Monitor Px who also takes diuretics for symptomatic hypotension.- Regularly assess the Px’srenal function.- Px with severe heart failure whose renal function depends on the angiotensin-aldosterone system may develop acute renal failure during therapy. Closely monitor the Px, especially during the first few weeks of therapy.- Don’t confuse Cozaar with Zocor.

potassium, which can cause high potassium level in Px taking losartan.- Inform woman of childbearing age about consequences of 2nd and 3rd trimester exposure to drug. Prescriber should be notified immediately if pregnancy is suspected.- Advise Px to immediately report swelling of face, eyes, lips, or tongue, or any breathing difficulty.

ACTION INDICATION CONTRAINDICATION ADVERSE REACTIONS

NURSING CONSIDERATIONS

PATIENT TEACHING

Diphenhydramine HydrochlorideBenadryl

Pharmacologic Class:Ethanolamine derivative

Pregnancy risk category: B

Competes with histamine for H1 receptor sites. Prevents, but doesn’t reverse, histamine-mediated responses, particularly those of the bronchial tubes, GI tract, uterus, and blood vessels. Structurally

- Rhinitis, allergy symptoms, motion sickness, Parkinson’s Disease- Sedation- Night-time sleep aid- Non-productive cough (syrup only)

- hypersensitivity to drug; newborns; premature neonates; breastfeeding women; Px with angle closure glaucoma, stenosing peptic ulcer, symptomatic prostatic hyperplasia, bladder neck obstruction, or pyloroduodenal obstruction; and those having an acute asthma attack.- Avoid use in Px taking

CNS: drowsiness, sedation, sleepiness, dizziness, incoordination, seizure, confusion, insomnia, headache, vertigo, fatigue, restlessness, tremor, nervousness.CV: palpitations, hypotension, tachycardia.EENT: diplopia, blurred vision, nasal congestion, tinnitus.

- Stop drugs 4 days before diagnostic skin testing.- Alternate injection sites to prevent irritation. Give IM injection deep into large muscle.- Dizziness, excessive sedation, syncope, toxicity, paradoxical stimulation, and hypotension are more likely to occur in the

- Warn Px not to take this drug with any other products that contain diphenhydramine because of increased adverse reactions.- Instruct Px to take drug 30 mins. Before travel to prevent motion sickness.- Tell Px to take drug with food or milk to reduce GI distress.- Warn Px to avoid alcohol and hazardous activities that require alertness until CNS

related to local anesthetics, drug provides local anesthesia and suppresses cough reflex.

MAO inhibitors.- Use with caution in Px with prostatic hyperplasia, asthma, COPD, increased intraocular pressure, hyperthyroidism, CV disease, and hypertension.- Children younger than age 12 should use drug only as prescribed.

GI: dry mouth, nausea, epigastric distress, vomiting, diarrhea, constipation, anorexia.GU: dysuria, urine retention, urinary frequency.Hematologic: thrombocytopenia, agranulocytosis, hemolyticanemia.Respiratory:thickening of bronchial secretions.Skin:urticaria, photosensitivity, rash.Other: anaphylactic shock.

elderly.- Don’t confuse diphenhydramine with dimenhydrinate; don’t confuse Benadryl with Bentyl or Benazepril.

effects of drug are known.- Tell Px that coffee or tea may reduce drowsiness. Urge caution if palpitations develop.- Inform Px that sugarless gum, hard candy or ice chips may relieve dry mouth.- Tell Px to notify prescriber if tolerance develops because a different antihistamine may need to be prescribed.- Advise use of sunblock for photosensitivity reactions.

ACTION INDICATION CONTRAINDICATION ADVERSE REACTIONS

NURSING CONSIDERATIONS

PATIENT TEACHING

LinagliptinTradjenta

Pharmacologic Class:Dipeptidyl Peptidase IV Inhibitor

Pregnancy risk category: B

DPP-4 degrades the incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP). Thus, linagliptin increases the concentrations of active incretin hormones, stimulating the release of insulin in a glucose-dependent manner and decreasing the levels of glucagon in the circulation.Route:P.O

Indicated as an adjunct to diet and exercise to improve glycemic controlin adults with type 2 diabetes mellitus.

- Hypersensitivity-Type 1 diabetes mellitus-Diabetic ketoacidosis

-Nasopharyngitis (4.3%)-Hyperlipidemia (2.8%;with pioglitazone)-Cough (2.4%; with metformin and sulfonylurea)-Hypertriglyceride mia (2.4%; with sulfonylurea)-Weight gain (2.3%;with pioglitazone)-Hypoglycemia7.6%-over all incidence22.9% incidence compared with placebo plus metformin and a sulfonylurea

- Before taking linagliptin, assess if the client have allergy in medication.-Before using this medication, tell your doctor or pharmacist your medical history, especially of: disease of the pancreas(pancreatitis).-You may experience blurred vision, dizziness, or drowsiness due to extremely low or high blood sugar levels. Do not drive, use machinery, or do any activity that requires alertness or clear vision until you are sure you can perform such activities

-Informing patients of the potential risks and benefits of linagliptin and of alternative therapies.-Informing patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and HbA1C testing, recognition and management of hypoglycemia and hyperglycemia, and assessment of complications of diabetes mellitus.-Seeking medical advice promptly during periods of stress (e.g., fever, trauma, infection, surgery) as medication requirements may change.-Informing patients that response to all antidiabetic therapies should be monitored by periodic measurements of blood

Onset:15-30 mins.Peak:1.5 hrs.

Duration:12-24 hrs.Half Life:12 hours

glucose and HbA1C, with a goal of decreasing these levels toward the normal range.-Informing clinicians if any unusual symptom develops or if any existing symptom persists or worsens.-Informing their clinicians if they are or plan to become pregnant or plan to breast-feed.-Informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs and dietary or herbal supplements, as well as any concomitant illnesses.

ACTION INDICATION CONTRAINDICATION ADVERSE REACTIONS

NURSING CONSIDERATIONS

PATIENT TEACHING

CloxacillinAvastoph

Pharmacologic Class:Anti-infective, Antibiotic

Pregnancy risk category: B

Interferes with cell wall replication of susceptible organisms, the cell wall, rendered osmotically unstable, swell, bursts from osmotic pressure; resists the penicillinase action that inactivates penicillins.

Treatment of infections caused by pneumococci,Group A beta-hemolytic streptococci, and penicillin G sensitive staphylococci.Prophylaxis:

- History of hypersensitivity to penicillins and cephallosporins. Sever pneumonia, emphysema, bacteremia, pericarditis ,meningitis and purulent and septic arthritis during the acute the stage. Sub-

EENT:occasionally,laryngeal edema,Skin:urticaria, skin rashes, exfoliative dermatitis, rashGI:GI disturbances, nausea, vomiting, epigastric distress,

- Perform skin testing before giving the medication.-Administer drug slowly to the IV line-Explain to the patient that antibiotic therapy lasts for 7 days will take the drug without any miss.

- Take medication around the clock, do not miss a dose, and continue taking the medication until it is finished.-Report to physician the onset of hypersensitivity reaction (see Appendix F) and super infections.-Check with physician if GI adverse effects (nausea,

Route:IntravenousOnset:Few DaysPeak:1 hrDuration:6 hrsHalf Life:0.65 hr

Staphylococcal infection during major cardiovascular and orthopedic surgery

conjunctival infections diarrhea and flatulence, antibiotic-associated pseudomembranouscolitisGU:Interstitial nephritis and vasculitisHematologic:eosinophilia, agranulocytosis, anemia, thrombocytopenia,transient rise in transminases and alkaline phophataseOther:Hypersensitivity reactions, serum sickness-like reactions, fever

-Make sure that the patient takes the drug at the same time of the day. And also to prevent them being drug resistant.-Provide rest and comfort.-Assess for any signs of hypersensitivity reaction such as purpura, rash, urticaria, exfoliative dermatitis, itching

vomiting, diarrhea) appear.-Do not breast feed while taking this drug.

Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Subjective:

“Hindi gumagaling yung sugat ko, dugo ng dugo” As verbalized by the patient.

Objective: Dry wound

dressing VS taken as

follows:T-PR- 80bpmRR- 18cpmBP- 140/90mmHg

Risk for Infection related to inadequate primary

defense

After 8 hours of nursing interventions, the patient will be able to identify the risk factors and the occurrence of infection will be reduce or control to a manageable level and maintain skin intact.

Independent:1. Observation for signs of

infection and inflammation such as fever, redness, pus in the wound, purulent sputum, urine color cloudy and foggy.

2. Maintain aseptic technique with any procedures. Provide wound care, as appropriate.

3. Emphasize the importance of hand washing technique.

4. Compare and note any changes in the wound.

5. Inspect dressing and wound; note characteristics of drainage

Dependent:1. Obtain for culture and

sensitivity test , as indicated.

2. Administer anti-biotics, as indicated.

After 8 hours of nursing interventions, the patient was able to identify interventions to prevent or reduce the risk of infection. The goal was met.

Nursing Care PlanASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Subjective: “Lagi akong

umiinom ng alak kapag wala akong ginagawa at mahilig din ako sa matatamis na pagkain” as verbalize by the patient

Objective: Lack of

information source

VS taken as follows:T-PR- 80bpmRR- 18cpmBP-140/90mmHg

 Knowledge deficit related to lack of

desire to seek information and

information resource

After 3 hours of nursing intervention the patient will be able to verbalize understanding of the condition/ disease process and treatment.

Independent:1. Assess the level of

knowledge of the client and family about the disease process.

2. 2. Select teaching strategies that will enhance teaching/learning effectiveness, such as discussion, demonstration, and visual materials. Provide all the equipment needed for the patient to learn.

3. Provide information about the condition of the client. The disease process and sign & symptoms of the condition.

4. Discuss lifestyle changes that may be needed to prevent complications in the future, and or control the disease process.

5. Discuss the choice of therapy or treatment.

Goal met. After 3 hours of Nurse-patient interaction, the patient is able to understand his condition and treatment.

Encourage clients to explore options or obtain alternative.

6. Provide information to families about the progress of patient in an appropriate manner.

7. Instruct the patient about the signs and symptoms to report on health care givers, in a proper way.

8. Reinforce the importance of adhering to treatment regimen and keeping follow up appointments.

Assessment Diagnosis Planning Intervention EvaluationSubjective:

“Lagi akong umiinom ng alak kapag wala akong ginagawa at mahilig din ako sa matatamis na pagkain” as verbalize by the patient

Objective:

Temperature: 37.1

Heart Rate: 80 bpm

Respiratory Rate: 18

cpm

Blood Pressure:

140/90mmHg

Risk for Imbalanced nutrition less than body requirements related to reduction of carbohydrate metabolism due to insulin deficiency

After 8 hour of nursing intervention the patients can ingest calories or nutrients right

1.) Measure weight as indicate

2.) Determine the diet program

3.) Taking of physical assessment (bowel sounds, abdominal pain, abdominal bloating N & V)

4.) Involve the family in meal planning

5.) Observation of signs of hypoglycemia

6.) Conduct a health teaching with the patient that will help in identifying the following food that he need to intake

7.) Determine the food that might contribute in the severity in the occurrence of the disease

8.) Document the intervention that was made and assessment that was seen. It can help for future

After 8 hour of nurse and patient interaction he patient was clearly given an instruction on ehat to ingest , the goal was met

reference for the patients’s health status

Assessment Diagnosis Planning Goal Intervention Rationale EvaluationSubjective cues:“hindi gumagaling yung sugat ko sa paa”

Objective:The skin around the wound are also necrotizing`

Temperature: 37.1

Heart Rate: 80

bpm

Respiratory Rate:

18 cpm

Blood Pressure:

140/90mmHg

Impaired skin integrity related to non-healing wound secondary to DM

After 8 hours of nursing intervention the patient’s risk for impaired skin integrity will be lessen through some various techniques that will be done and some health teaching that will be conducted

After the procedure the patient is expected to have a:

1.) Have a good and healthy skin condition

2.) Be able to cope with ADL and will function normally

3.) Be knowledgeable on how to treat or prevent alteration in the skin

Assess the site of affected area

Discuss pain control if needed

Site the importance of adequate nutrition

Teach the following or appropriate position for pressure relief

Make a ROM

To identify the severity of the wound

To help patient cope towards proper pain management

It can help thepatient in choosing the food he needed to eat in order to have a good process of wound healing

To minimize further skin trauma

Proper

Goal partially met. After 8 hours of nurse and patient interaction the some of the goal was done and was able to help in repairing the skin. Some are not fully meet because it requires continuous intervention and cannot finish in just a 8 hour duty. Health teaching was properly done.

schedule

Give information in signs of infection

Demonstrate wound cleaning

Encourage verbalization of feelings

Identify things or sources that might affect the severity of the wound

Document any changes or abnormality or progress in the site of affected area

skin management

To teach the client on how to handle himself independently

To recognize or to give a cue in signs and symptoms

To prevent further damage

This may serve as a history or reference of the patient

Assessment Diagnosis Planning Intervention EvaluationSubjective: “ hindi naman masakit ang sugat ko eh, di na din nakakaramdam yung parting banda ditto”

Objective: Upon palpation

the patient did not sense any pain in the site of the wound, thus feeling numb.

The patient has an IV cotraotion in the right hand

Risk for injury related to numbness in the right foot and an IV contraption

After 8 hours of nursing intervention, the patient is expected to identify , classify and prevent the possible things that might cause further injury in the site of necrotizing wound and IV contraption

1.) Assess the ADL of the patient and identify the activities that might contribute in acquiring injury

2.) Conduct health teaching on how to properly take care of the body by preventing the risk of injury

3.) Assess the sign of displacement in IV contraption

4.) Provide health teaching for the patient

5.) Document the findings and intervention was done for future references

After 8 hours of nurse nd patient interaction the following intervention was done properly , therefore the goal was met