Tetanus Case Study

St. Anthony College of Roxas City San Roque Extension, Roxas City 5800 Capiz, Philippines

Bachelor of Science in Nursing 4C- 2011

TETANUS Submitted by:

Xy-Za Roy Marie D. Albaña Glorie Anne D. Anisco Khris John V. Balbuena Charmaine Cheryl Iris V. Bellosillo Joanna Keith D. Batuigas April Rose D. Benitez Karen Kay D. Bulan Shiehon A. Ferraris Marie Ann B. Magbanua Free Van Roy Paclibar

Submitted to:

Ms. Wila C. Valles, RN Clinical Instructor INTRODUCTION 1

TETANUS

Comes from the Greek word “tetanus” meaning taut and “teiteim” which means to stretch. It is also called lockjaw. It is a serious infectious disease of the nervous system in which toxin causes severe muscle spasm. It is a medical condition characterized by a prolonged contraction of skeletal muscle fibers. It is caused by a bacterium Clostridium tetani . Infection generally occurs throug through h wound wound contam contamina inatio tion n and often often involv involves es a cut or deep deep punctu punctured red wound. Tetanus is often associated with rust, but this concept is somewhat misl mislea eadi ding ng.. The The C.Te C.Teta tani ni is an Anae Anaero robi bic c bact bacter eria ia whic which h surv surviv ives es in an environment that lacks oxygen, thus with or without rust a person may have a tetanus once C. Tetani enters the wound. Contaminated wounds are the site where tetanus bacteria multiply. Deep wounds or those with distallized tissue are particularly prone to tetanus infection. The tetanus toxin affects the site of interaction between the nerve and the muscle that it stimulates, this region is called the neuromuscu neuromuscular lar junction. junction. The tetanus tetanus toxin toxin amplifies amplifies the chemical chemical signals from the nerve to the muscles to tighten up in a continuous contraction or spasm. This results in either localized or generalized muscle spasm. The incubation period ranges from 3 to 21 days, usually about 8 days. In general the further the injury site is from the central nervous system, the longer the incubation period. The shorter the incubation period, the higher the chance of death. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, three different forms of tetanus have been described. Local tetanus is an uncommon form of the disease, in which patients have persistent contraction of muscles in the same anatomic area as the injury. These contractions may persist for many weeks weeks before before gradua gradually lly subsid subsiding. ing. Loc Local al tetanu tetanus s may preced precede e the the onset onset of generalized tetanus but is generally milder. Only about 1% of cases are fatal. Tetanus can be prevented by vaccination with tetanus toxoid. A booster is needed every 10 years after primary immunization. In the Philippines the incidence rate of tetanus is 12 out of 86, 241,627.

Objectives 2

General objectives: This This case case stud study y is desi design gned ed for for the the stud studen entt nurs nurses es to beco become me practiced, well-informed and mannered in delivering holistic care for patients diagnosed with Tetanus.

Specific Objectives: Skills •

To demonstrate the vision/mission of the school which is service

oriented, research motivated, technology enable and Vincentian inspired. •

Imply appropriate medical nursing management for Tetanus.

Knowledge •

Discuss the anatomy and physiology of the Nervous system.

•

Define Tetanus. Learn about major etiologic its causes, identify its

clinical manifestations and risk factors. •

Be familiar with the pathophysiology of Tetanus.

•

Be acquainted with the different drugs, its actions, and perform

obligatory nursing responses for each. Plan for a suitable nursing care

•

Attitude •

Establish a nurse-patient interaction through exchanging of

thoughts and information •

Institute bond between the student nurse and the patient.

ANATOMY AND PHYSIOLOGY 3

Nervous System

The nervous system is an organ system containing a network of specialized cells cells called called neurons that that coordin coordinate ate the actions actions and transm transmit it signals signals betwee between n different parts of its body. The nervous system consists of two parts, central and peripheral. The central nervous system contains the brain, brain, and spinal cord. cord. The peripheral nervous system consists of sensory neurons, clusters of neurons called ganglia, ganglia, and nerves connecting them to each other and to the central nervous syst system em.. Thes These e regi region ons s are are all all inte interc rcon onne nect cted ed by mean means s of comp comple lex x neur neural al pathways. pathways. The enteric enteric nervous nervous system, system, a subsys subsystem tem of the periph periphera erall nervous nervous system, system, has the capacity, capacity, even when severed from the rest of the nervous nervous system through its primary connection by the vagus nerve, nerve, to function independently in controlling the gastrointestinal system.

The Central Nervous System is the body’s body’s information information headquarters, headquarters, ultimately ultimately regulating nearly all body functions. The CNS includes: The Brain Brain – Proces Processes ses incomin incoming g inform informati ation on from from within within the body, body, and outside the body by way of the sensory nerves of sight, touch, smell, sound, and taste. Commands Commands are then sent back throughout the body. The brain also stores and process processes es langua language, ge, communi communicat cation, ion, emotion emotions, s, though thoughts, ts, dreams dreams,, and memories. In other words, the brain is where all thinking and decision-making takes place. •

The Spinal Cord – Is the main pathway for information connecting the brain and peripheral peripheral nervous system. It extends extends from the brain about 18 inches down •

4

the bony spinal column, which serves as its protection. protection. The spinal cord is a tube made up of nerve fibers. fibers. Electrical impulses travel through the nerves and allow the brain to communicate with the rest of the body.

The Peripheral Nervous System is responsible for the remainder of the body. It includes cranial nerves (nerves emerging from the brain), spinal nerves (nerves emerging from the spinal cord) and all the major sense organs. The PNS includes: The Somat Somatic ic Nervou Nervous s System System (SNS) (SNS) – Resp Respons onsib ible le for for all all musc muscula ularr activities that we consider voluntary or that are within our conscious control.

•

The Autonomic Nervous System (ANS) – Responsible for all activities that occur automatically and involuntarily, such as breathing, muscle contractions within the digestive system, and heartbeat. The components of the ANS work together to create a balanced response to outside stimuli 1. The ANS includes:

•

o

The Sympathetic System – Stimulates cell and organ function. The

sympathetic system is activated by a perceived danger or threat, very strong emotions emotions such as fear, fear, anger anger or excitem excitement ent,, by intense intense exercise, exercise, or when when under large amounts of stress. Basically, anything the body perceives as an emergency will trigger a protective response. Once initiated, it speeds up heart rate, increases the activity of the sweat and adrenal glands, slows down the digestive system and sends blood to the skin and muscles; all of which prepare the body for a “fight or flight” response. The Parasympathetic System – Inhibits cell and organ function. The para parasy symp mpat athet hetic ic syst system em slow slows s down down heart heart rate, rate, resum resumes es dige digest stion ion,, and and increa increases ses relaxa relaxatio tion n throug throughout hout the body. body. This “rest “rest and digest” digest” respon response se counteracts the “fight or flight” response and helps the body recuperate after a cris crisis is is ov over er.. A pers person on's 's norma normall rest restin ing g hear heartt rate rate is dete determ rmin ined ed by the the parasympathetic system. If blood pressure is too high or blood carbon dioxide levels are too low, this system slows the heart down and lowers its output. o

NEUROMUSCULAR SYSTEM The combination of the nervous system and the muscles, working together to perm permit it movem movement ent,, is know known n as the the neur neurom omusc uscul ular ar syst system. em. Neur Neurom omusc uscul ular ar disorders include motor neuron diseases, neuropathies and muscular dystrophies. The brain cont contro rols ls the the move moveme ments nts of skel skelet etal al (volu (volunta ntary ry)) muscl muscles es via via specialised nerves. Neurons send signals to other cells as electrochemical waves travelling along thin thin fibres fibres called called axons, axons, which which cause cause chemica chemicals ls called called neurotransmitters to be released at junctions called synapses. synapses. A cell that receives a synaptic synaptic signal may be excited excited,, inhibit inhibited, ed, or otherw otherwise ise modulat modulated. ed. Sensor Sensory y neurons neurons are are activa activated ted by phys physic ical al stim stimul ulii impi impingi nging ng on them, them, and and send send sign signal als s that that info inform rm the the cent centra rall nervous nervous system system of the state of the body body and the externa externall environ environment ment.. Mot Motor or neurons, situated either in the central nervous system or in peripheral ganglia, connect the nervous system to muscles or other effector organs. Central neurons, which in vertebrates greatly outnumber the other types, make all of their input and 5

outpu outputt conne connect ction ions s with with other other neur neurons ons.. The The inter interac acti tions ons of all all these these type types s of neurons form neural circuits that generate an organism's perception of the world and determine its behavior. Along with neurons, the nervous system contains other specialized specialized cells called glial cells (or simply simply glia), glia), which which provid provide e structu structural ral and metabolic support.

If you want to move part of your body, a message is sent to particular neurons (nerve (nerve cells), cells), called upper motor neurons. Upper motor neurons neurons have long tails (axons (axons)) that go into and thro throug ugh h the the brai brain, n, and and into into the the spin spinal al cord cord,, wher where e they they connect connect with with lower lower motor motor neuron neurons. s. At the spinal spinal cord, the lower motor neurons in the spinal cord send their axons via nerv nerves es in the the arms arms and and legs legs dire direct ctly ly to the the musc muscle le they they control.

A typical muscle is serviced by anywhere between 50 and 200 (or more) lower motor neurons. Each lower motor neuron is subdivided into many tiny branches. The tip of each branch is called a presynaptic terminal. This connection between the tip tip of the the nerve nerve and and the musc muscle le is also also call called ed the the neur neurom omusc uscul ular ar junc juncti tion. on. The electri electrical cal signal signal from the brain brain trav travels els down down the nerves nerves and prompt prompts s the release of the chemical acetylcholine from the presynaptic terminals. This chemical is picked up by special sensors (receptors) in the muscle tissue. If enough receptors are stimulated by acetylcholine, your muscles will contract.

-Vital InformationName: Mr. F.B. 6

Age: 78 Sex: Male Address: Dulangan Pilar, Capiz Civil Status: Married Religion: Roman Catholic Occupation: Fishpond operator Date and Time Admitted: June 5, 2010; 11:50 am Ward: SCL 328 Chief Complaint: Difficulty of swallowing Final Diagnosis: Tetanus Stage 3;Aspiration Pneumonia, HPN Stage I Attending Physician: Dr. R. H

CLINICAL ASSESSMENT

Nursing History One week before admission, patient experience a massive toothache and was relief by pain relievers. He did not bother to ask for consultation because he believes that it will subsides in due time. 4 days after acquiring the dental problem, problem, he complained complained of difficulty difficulty in swallowing swallowing foods. The patient and family disregard to seek consultation not until they thought that Mr. FB was having a mild stroke. He was very weak and was unable to open his mouth. He can no longer eat foods, and his family are scared for his health thus they prompted for admission in June 7, 2010.

Past Health Problem Mr. Mr. F.B. F.B. has has no hist histor ory y of past past ho hosp spit ital aliz izat atio ion. n. So Some meti time mes s he A.B. experienced mild fever, coughs, and cold but manageable and treated treated with Pulmon F.B. over ov er the the count counter er drug drugs s like like para parace ceta tamo moll and and solm solmux ux.. He has has no know known n ary allergies to food, drugs and animals. infectio Old age n Family History His father died because of old age and his mother died of pulmonary infection. On the other hand, his elder sister is known to be hypertensive and the second sibling has goiter.

FAMILY GENOGRAM

C.B. 85 HPN

L.B. 80 Goiter

F.B. Tetanus

7

M

Legends

Female

Male

Patient

Death

Patterns of Functioning Pattern

Home

Hospitalization 8

Breathing Pattern

No respiratory problems. Has Resp Respir irat ator ory y rate rates s beca became me never ever com complai plaine ned d of any any rapid, rapid, shallow shallow breath breaths s are breathing difficulty. noted. Difficulty of breathing is always claimed.

Circulation

Claimed to never been had a BP check-up before hospitalization.

The average BP is 140/100 mmHg during hospital stay.

Sleeping Pattern

Usually sleeps at 9 pm and wakes up at 5 am. 8-10 hour slee sleep p dura durati tion on.. Uses Uses two pillow and comforter

Sleeps at 10 pm and wakes up at 6 am. Uses one pillow and blanket. Disturbed sleep is usually complained whenever whenever excessive excessive stimuli stimuli is observed.

Drinking Pattern

Usually drinks 8-10 glasses of water a day.

Eating Pattern

Eats three times a day. He eats ats more ore car carbohy bohydr dra ate, te, vege vegeta tabl bles es and and adeq adequa uate te protein. Mr. F.B isn’t fond of using eating utensils since he is stay stayin ing g on his his pond pond,, he eats using his bare hands.

Elimination Patterns

Defecates once daily in Defec efeca ates tes for adequ dequat ate e amou amount nt,, gold golden en times a week. brown in color.

a. Bowel b. Urin rinatio ation n

Personal hygiene

With NGT, cannot tolerate to drink water because of lock jaw. He was been on parenteral feed feedin ing g and and has has NGT NGT upon upon admis dmissi sion on.. An OTF OTF 1600 600 calo calori ries es is divi divid ded into into 6 equal feedings everyday.

abou aboutt

2-3 2-3

Urinates normally With urinary incontinence, a approximately 3-5x a day in week after h is first an adequate amount. admi admiss ssion ion,, he on only ly pass passes es 40 cc cc of urine. urine. He was was then inserted inserted with foley catheter catheter attached to urobag with an adequate amount, yellowish in color. His daily job as a pond operator requires a dirty and heavy heavy tasks. tasks. Takes Takes a bath bath daily but isn’t fond of brushing his teeth.

Morning care done with oral care of bactedol. ol. Using cotton and tongue depressor.

9

Recreational and Exercise

His walks from house to the fish pond which took almost 30 mins. is what they cons consid ider ered ed to be his his dail daily y exerci exercise. se. He drinks drinks alcohol alcohol and play ”tong”tong-its its”” with with his friends.

No recr recrea eati tiona onall acti activi viti ties. es. Cannot tolerate to stand or sit. sit. Pas Passiv sive e ROM exerci exercises ses done.

Brief Social, Cultural and Religious Background

a. Educat Education ional al Back Backgro ground und F.B. finishes his elementary education in Dulangan Elementary School and his secondary education reaches up to 3 rd year in Dulangan National High School. He never had the chance to study in college because of financial constraints. b. Oc Occu cupa pati tion on He is a fulltime fishpond operator, who manages their own family’s fishpond. He spends most of his time on his pond which was 20 mins. away from their residence. c. Reli Religi giou ous s Pra Pract ctic ice e Mr. Mr. F.B F.B is a Roma Roman n Cath Cathol olic ic.. He does does no nott atte attend nd Sund Sunday ay mass mass regularly since he is usually at his fishpond, but his family claims that he always pray. d. Econ Econom omic ic Sta Statu tus s Mr. Mr. F.B F.B belo belong ngs s to a midd middle le clas class s group group,, he has has no fix fix econo economi mic c income for they only had a quarterly harvest. But they claim that it was enough to support the whole family. His two daughters are also working abroad which also helps them financially.

Clinical Inspection 1. Vita Vitall sig signs ns T=38.2oC

CR= 104 bpm

BP= BP= 140/100 mmHg

RR= 30 bpm

2. Height = 6’1 3. Weight= 88 kg

PHYSICAL ASSESSMENT 10

General Appearance

Mr. F.B., 76 year-old male, with poor posture and gait. He is lying on bed on a semi- fowlers position. He is lethargic and irritable. He cannot respond to questions well and is not well oriented. Mainline IVF: PNSS 1L is atta attache ched d at the the left left basi basili lic c vein vein runni running ng at 20 cc/hr cc/hr.. Urina Urinary ry cath cathet eter er is well well atta attach ched ed in the the ureth urethra ra with with urob urobag ag in plac place. e. O2 at 4 LPM via nasal cannula is in place. No edema noted.

Skin

Skin is brown in complexion, warm, and dry with poor skin turgor. turgor. No pallor and edema.

Hair

Has Has a shor shortt blac black k hair hair mixe mixed d with with gray gray on ones es,, well well distributed. No presence of flakes, lice or lesions noted.

Nails

Head

Face Eyes

Nails are short and clean. Are pink in color and slightly curved with smooth and rounded edges. No clubbing of fingers noted. Head is normocephalic, no palpable nodules or masses noted. lesions are not noted. Face is wrinkled due to old age. age . (+) Facial grimace and locking of jaw noted. Anicter Anicteric ic sclera sclerae e with with pupils pupils round round and black in colo colorr which constricts from 4mm-2mm. Has brisk reaction to light. No cataract noted. Slightly pale conjunctiva noted.

Ears

Top of pinna is aligned with the outer corners of both eyes; size is normal and equal; similar in color to face; (-) discharges discharges and swelling, swelling, with poor acuity to whisper voice.. Cerumen not noted. voice

Nose

With presence of cilia. Has no discharges nor sinusitis. Nasal cannula attached to both nostrils at 4LPM. NGT is attached (L).

Mouth

Neck Breast Upper Extremities Chest Respiratory System

Cardiovascular

Lips are dry with cracking and slightly pale oral mucosa was noted. With no inflammation of tonsils. Has poor dention, with bleeding gum and halitosis. Distention of jugular vein noted. Breast are firm. No mass palpated. Both arms are weak. Can perform passive movements only. Respiratory rate of 24-34 breaths/min, shallow breaths in uniform rhythm. Occasional cough noted with whitish sputum. With supplemental O2 @ 4LPM. Well tolerated with O 2 saturation ranging from 97-99%. Crackles is usually heard. Apical pulse at the left midclavicular line averaging at 86 11

System Gastrointestinal System Genito-urinary System

bpm. Skip beats not noted upon auscultation. Abdominal pain noted. With several attempts of bowel movements.

Musculoskeletal System

Restles Restless s at few times. times. Have Have been on seizure seizure attack attacks. s. Movements are weak weak.. Cannot tolerate standing. standing. Able to sit on wheelchair. With weak handgrip.

Urina Urinary ry cath cathet eter er (Fre (Frenc nch h 14) 14) inta intact ct on ureth urethra ra and and attached to urobag. Passes yellow colored urine in minimal amounts.

GENERAL APPRAISAL Speech

Speaks in native language. He presently can not talk due to illness.

Language

Can speak only Hiligaynon when he was still able to talk.

Hearing

Has poor acuity to whispered voice.

Mental status

He is lethargic and irritable.

Emotional Status

Unable to express emotions.

LABORATORY RESULTS

June 05, 2010 12

Protein Metabolites and Electrolytes Test

Results

Normal Values

Creatinine

HI 161.8 umol/L

71.0 – 133.0 umol/L

Sodium

LO 134.5 mmol/L

137.0 – 145.0 mmol/L

Significance of Abnormal Result May be due to dehydration. Hyponatremia may result from inadequate sodium intake or excessive sodium loss due to profuse sweating.

June 06, 2010 Lipids and lipoproteins Test

Results

Cholesterol

HI 5.21 mmol/L

Direct HDLC

LO 0.86 mmol/L

Normal Values 0.00 – 5.20 mmol/L 1.00 – 1.60 mmol/L

Significance of Abnormal Result Indicates Hypercholesterolemia leading to Hypertension

June 16, 2010 Hematology Test

Results

Hematocrit

LO 0.31 vol. (fr)

Hemoglobin

LO 103 g/L

Normal Values 0.42 – 0.52

130.0

Significance of Abnormal Result Low Hct suggest anemia, or hemodilution A decreased value of hemoglobin can be caused by low red blood cell count, by a lack of hemoglobin in the erythrocytes, which also indicates fluid retention.

Red Blood Cell Count

LO 3.61 x 10^12/L

4.2 – 5.4 x 10^12/L

Indicates fluid overload.

White Blood Cell Count

HI 11.9 x 10^9/L

4 – 10 x 10^9/L

Segmenters

HI 0.86

0.50 – 0.65

Eosinophils

0.01

0.01 – 0.04

Lymphocytes

LO 0.07

0.25 – 0.30

Monocytes

HI 0.06

0.02 – 0.05

Platelet

380 x 10^9/L

An elevated WBC count indicates infection due to traumatized tissue. An elevated value (neutrophilia) occurs in response to bacterial infection. Normal A decreased value occurs with impaired lymphatic drainage. An elevated value occurs in response to infection. Normal

140 – 400 x

13

10^9/L June 16, 2010 Urinalysis Test

Results

Color

Pale straw

Transparency Reaction Sp. Gravity Protein

Hazy pH 6.0 1.020 trace

Glucose Amorph. U/P RBC / hpf WBC / hpf Epithelial Cells Bacteria Yeast cells

negative few HI 11 – 20 / hpf 2 -7 / hpf Occassional Moderate many

Normal Values Straw to dark yellow clear 4.5 – 8.0 1.003 – 1.030 negative

negative 0 – 3 / hpf 0 – 5 / hpf None None None

Significance of Abnormal Result Normal

Protein in the urine (proteinuria) may indicate hypertension. Normal Indicates bleeding Normal

June 8,2010 TPSA(mini-VIDAS) VIDAS TPSA is intended for use with a VIDAS (VITEK ImmunoDiagnostic Assay System) instrument as an automated enzyme-linked fluorescent immunoassay (ELFA) for the quantitative measurement of total prostate specific antigen in human serum. The VIDAS TPSA assay is indicated as an aid in the management of patients with prostate cancer and as an aid in the detection of prostate cancer in conjunction with digital rectal examination (DRE) in men age 50 years or older. Prostate biopsy is required for diagnosis of prostate cancer.

Test

TPSA

Results

Normal Values

7.31mg/ml

normal: 03.72mg/ml

Significance of Abnormal Result Increased result shows prostatic impairment

14

June 7,2010 CT SCAN Cranial Plaw

Test

Impression

Neurocranium

Plain axial tomography section of the head shows no definite focal parendrymal lesions or any abnormal hyperdense collection. The midline structures are undisplaced with the interhemispheric fissure centered on the midline. The cerebrum shows slightly widened cortical sulcation. The cerebral ventricles are prominent. There are no signs of increased intracranial pressure. The posterior fossa, brainstem and sellar region appear normal. The petromastoids, bony calvanium and included orbits or paranasal sinuses are unremarkable. INTERPRETATION: Cerebral Atrophic Changes.

15

June 17,2010 CHEST X-RAY

Impression Bilateral pneumonia with progression in the left. Left pleural effusion. Bronchiectasis right lung base. Atheromatous and tortuous aorta. Dextroscoliosis, thoracic spine.

16

MEDICATIONS

NAME OF DRUG and DOSE

Omeprazole 20mg 1 tab BID

Brand Name: Prosec

ACTION

MECHANISM OF ACTION

INDICATION

Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.

GERD, frequent heartburn.

SIDE EFFECTS

1. Headache Headache 2. Nausea Nausea 3. Vomiting Vomiting

CONTRAINDICATIONS

NURSING RESPONSIBILITIES

Hypersensitivity Hypersensitivity to omeprazole and its components.

1.Administer 1.Administer drug before before meal is serve. 2. Monitor for any urinary

4. Diarrhea Diarrhea

elimination such as pain

5. Constipation

or discomfort associated

6. Abdominal Pain

with urination.

7. Flatulen Flatulence ce

3. If

8. Dry mouth mouth

Antisecretory Antisecretory drug

seve severe re

diar diarrh rhea ea

obser bserv ved, ed,

drug drug

need

to

is

may may be

discontinued.

Proton Pump Inhibitor

17


Moxifloxacin 400mg 1tab OD

Brand Name: Avelox

ACTION

MECHANISM OF ACTION

Bactericidal; interferes with DNA replication, repair, transcription, and recombination recombination in susceptible gramnegative and grampositive bacteria, preventing cell reproduction and leading to cell death.

INDICATION

Treatment of Infection caused by anaerobic bacteria.

SIDE EFFECTS

1. Head Headac ache he 2. Insomnia Insomnia 3. Nausea Nausea 4. Diarrhea Diarrhea

CONTRAINDICATIONS

Contraindicated with allergy to fluoroquinolones, prolonged QT interval, hypokalemia.


1.Cont 1.Contin inue ue

ther therap apy y

as

indicated indicated for conditio condition n being treated.

2. Administer oral drug 4 hr before or at least 8 hr

afte afterr

other other

anta antaci cids ds

or

anion-co anion-contain ntaining ing

drugs.

Antibiotic Fluoroquinolone

3. Do not chan change ge dosag dosage e when switching from IV to oral dose.

18


MECHANISM OF ACTION

INDICATION

Solfenacin

Counteracts smooth muscle spasm of the urinary tract by relaxing the detrusor

Treatment of overactive bladder with symptoms of

5mg 1tab

SIDE E EF FFECTS

1. Dry Dry mout mouth h 2. Constipation 3. Urinary retention

CONTRAINDICATIONS

Contraindicated with allergy to drug or any component of the drug, severe hepatic


1. Provide frequent small meals if GI upset occurs. 2. Establish bowel


Moxifloxacin 400mg 1tab OD

Brand Name: Avelox

ACTION

MECHANISM OF ACTION

INDICATION

Bactericidal; interferes with DNA replication, repair, transcription, and recombination recombination in susceptible gramnegative and grampositive bacteria, preventing cell reproduction and leading to cell death.

Treatment of Infection caused by anaerobic bacteria.

SIDE EFFECTS

1. Head Headac ache he 2. Insomnia Insomnia 3. Nausea Nausea 4. Diarrhea Diarrhea

CONTRAINDICATIONS

Contraindicated with allergy to fluoroquinolones, prolonged QT interval, hypokalemia.


1.Cont 1.Contin inue ue

ther therap apy y

as

indicated indicated for conditio condition n being treated.

2. Administer oral drug 4 hr before or at least 8 hr

afte afterr

other other

anta antaci cids ds

or

anion-co anion-contain ntaining ing

drugs.

Antibiotic Fluoroquinolone

3. Do not chan change ge dosag dosage e when switching from IV to oral dose.

18


MECHANISM OF ACTION

INDICATION

Solfenacin

Counteracts smooth muscle spasm of the urinary tract by relaxing the detrusor and other smooth muscle through the action at the muscarinic parasympathetic receptors.

Treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency.

5mg 1tab

Brand Name: VESIcare

SIDE E EF FFECTS


CONTRAINDICATIONS

Contraindicated with allergy to drug or any component of the drug, severe hepatic impairment, urine retention, gastric retention, uncontrolled uncontrolled narrow-angle glaucoma.


1. Provide frequent small meals if GI upset occurs. 2. Establish bowel program if constipation is a problem. 3. Establish precautions precautions

ACTION

if CNS effects occur. 4. Measure post-void post-void

Muscarinic receptor

residual urine

entagonist

volume if patient

Urinary antispasmodic

has difficulty in voiding.

19


MECHANISM OF ACTION

INDICATION

SIDE EF EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES 1. Administer once a day,

Tamsulosin 250 mg

Blocks the smooth muscle alpha1adrenergic receptors in the prostate,

Adjunct in managing urethral stones.

1. Somn Somnol olen ence ce 2. Insomnia Insomnia 3. Orthostatic

Hypersensitivity Hypersensitivity to tamsulosin, prostate cancer, pregnancy.

30 minutes after the same meal each day.

2. Monitor patient carefully


MECHANISM OF ACTION

INDICATION

Solfenacin

Counteracts smooth muscle spasm of the urinary tract by relaxing the detrusor and other smooth muscle through the action at the muscarinic parasympathetic receptors.

Treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and urinary frequency.

5mg 1tab

Brand Name: VESIcare

SIDE E EF FFECTS


CONTRAINDICATIONS

Contraindicated with allergy to drug or any component of the drug, severe hepatic impairment, urine retention, gastric retention, uncontrolled uncontrolled narrow-angle glaucoma.


1. Provide frequent small meals if GI upset occurs. 2. Establish bowel program if constipation is a problem. 3. Establish precautions precautions

ACTION

if CNS effects occur. 4. Measure post-void post-void

Muscarinic receptor

residual urine

entagonist

volume if patient

Urinary antispasmodic

has difficulty in voiding.

19


MECHANISM OF ACTION

INDICATION

SIDE EF EFFECTS

CONTRAINDICATIONS


Tamsulosin 250 mg BID

Brand Name: Harnal

ACTION

Blocks the smooth muscle alpha1adrenergic receptors in the prostate, prostatic capsule, prostatic urethra, bladder neck, leading to relaxation, of the bladder, and prostate, and improving the flow of urine in cases of BPH.




30 minutes after the same meal each day.


hypotension 4. Abnormal Abnormal

for orthostatic

ejaculation

hypotension; hypotension; dizziness,

5. Decrea Decreased sed libid libido o

and syncope is high with the first dose. Establish safety precautions as appropriate.

Alpha adrenergic blocker (peripheral acting)

20


MECHANISM OF ACTION

INDICATION

Lactulose

The drug passes unchanged into colon where bacteria break it down to organic

Treatment of constipation.

20cc until BM occurs q8hours

SIDE EF E FFECTS

1. Tran Transi sien entt flatulence 2. Distenti Distention on

CONTRAINDICATIONS


Contraindicated with allergy to lactulose, lowgalactose diet.

1. Do not administer other other laxa laxati tive ve lactulose.

whil while e

usin using g


MECHANISM OF ACTION

INDICATION

SIDE EF EFFECTS

CONTRAINDICATIONS


Tamsulosin 250 mg BID

Brand Name: Harnal

ACTION

Blocks the smooth muscle alpha1adrenergic receptors in the prostate, prostatic capsule, prostatic urethra, bladder neck, leading to relaxation, of the bladder, and prostate, and improving the flow of urine in cases of BPH.



30 minutes after the


same meal each day.

hypotension


4. Abnormal Abnormal

for orthostatic

ejaculation

hypotension; hypotension; dizziness,

5. Decrea Decreased sed libid libido o

and syncope is high with the first dose. Establish safety precautions as appropriate.

Alpha adrenergic blocker (peripheral acting)

20


MECHANISM OF ACTION

INDICATION

Lactulose

The drug passes unchanged into colon where bacteria break it down to organic acids that increase the osmotic pressure in the colon and slightly acidify the colonic contents, resulting in an increase in stool water content, stool softening, and laxative action. This also results in migration of blood ammonia into the colon contents with subsequent trapping and expulsion of the feces.


MECHANISM OF ACTION

INDICATION


Brand Name: Lactulose

ACTION

Ammonia reaction drug Laxative


SIDE EF E FFECTS


CONTRAINDICATIONS



1. Do not administer other other laxa laxati tive ve

whil while e

usin using g

lactulose.

3. Intestinal cramps 4. Belching Belching

2. Monitor serum serum ammonia


levels.

6. Nausea Nausea 3. Carefully monitor blood glucose glucose levels levels in diabetic diabetic patients.

SIDE EF EFFECTS

CONTRAINDICATIONS


21

1. Do not administer to Tetanus Immune Globulin 250/amp 4amps deep IM (stat)

Supplies passive immunity to those individuals who have low or no immunity to the toxin produced by the tetanus organism, Clostridium

Is indicated for prophylaxis against tetanus following injury in patients whose immunization is

1. Tend Tender erne ness ss 2. Muscle Muscle stif stiffne fness ss at injection site

patients patients with history of Contraindicated to patients with a history of

3. Urti Urtica cari ria a

prior systemic allergic

4. Angi Angioe oedem dema a

reactions following the

5. F

administration of human

allergy globulin

to

gamma or

anti

immunoglobulin

A

antibodies.


MECHANISM OF ACTION

INDICATION

Lactulose

The drug passes unchanged into colon where bacteria break it down to organic acids that increase the osmotic pressure in the colon and slightly acidify the colonic contents, resulting in an increase in stool water content, stool softening, and laxative action. This also results in migration of blood ammonia into the colon contents with subsequent trapping and expulsion of the feces.


MECHANISM OF ACTION

INDICATION


Brand Name: Lactulose

ACTION

Ammonia reaction drug Laxative


SIDE EF E FFECTS


CONTRAINDICATIONS



1. Do not administer other other laxa laxati tive ve

whil while e

usin using g

lactulose.

3. Intestinal cramps 4. Belching Belching

2. Monitor serum serum ammonia


levels.

6. Nausea Nausea 3. Carefully monitor blood glucose glucose levels levels in diabetic diabetic patients.

SIDE EF EFFECTS

CONTRAINDICATIONS


21


Brand Name: Tetanus immune globulin

ACTION

Immune globulin

Supplies passive immunity to those individuals who have low or no immunity to the toxin produced by the tetanus organism, Clostridium tetani. The antibodies act to neutralize the free form of the powerful exotoxin produced by this bacterium

Is indicated for prophylaxis against tetanus following injury in patients whose immunization is incomplete or uncertain. It is also indicated, although evidence of effectiveness is limited, in the regimen of treatment of active cases of tetanus.

1. Tend Tender erne ness ss 2. Muscle Muscle stif stiffne fness ss at injection site

patients patients with history of Contraindicated to patients with a history of

3. Urti Urtica cari ria a




allergy

to

gamma

globulin

or

anti

immunoglobulin

A

antibodies.

5. Fever ever


6. Chi Chills lls

immunoglobulin

2. Admin Administ ister er 2 weeks weeks

7. Chest Chest tigh tightne tness ss

preparations, and

before or 3 months after

8. Precip Precipito itous us fall fall

severe

in BP

thrombocytopenia thrombocytopenia or any coagulation disorder that would contraindicate intramuscular injections.

immune

globulin

administr administratio ation n

because because

antibodies

in

th e

globulin preparation may interfere

with

the

immune response to the vaccination. 3. Do not mix globul globulin in with

any

other

medications. 4. Monitor patient’s vital signs continuo continuously usly and observe

for

any

symp sympto toms ms

duri during ng

IM 22

administration. 5.

Pro Provide vide

measures patient comf comfor ortt

comfor mfortt or

to

teach provid e

meas measur ures es

to

help patient to cope with


Brand Name: Tetanus immune globulin

ACTION

Supplies passive immunity to those individuals who have low or no immunity to the toxin produced by the tetanus organism, Clostridium tetani. The antibodies act to neutralize the free form of the powerful exotoxin produced by this bacterium

Immune globulin

1. Tend Tender erne ness ss

Is indicated for prophylaxis against tetanus following injury in patients whose immunization is incomplete or uncertain. It is also indicated, although evidence of effectiveness is limited, in the regimen of treatment of active cases of tetanus.

patients patients with history of

2. Muscle Muscle stif stiffne fness ss

Contraindicated to

allergy

patients with a history of

at injection site 3. Urti Urtica cari ria a




to

gamma

globulin

or

anti

immunoglobulin

A

antibodies.

5. Fever ever


6. Chi Chills lls

immunoglobulin

2. Admin Administ ister er 2 weeks weeks

7. Chest Chest tigh tightne tness ss

preparations, and

before or 3 months after

8. Precip Precipito itous us fall fall

severe

in BP

thrombocytopenia thrombocytopenia or any coagulation disorder

immune

globulin

administr administratio ation n

because because

antibodies

in

th e

globulin preparation may

that would

interfere

contraindicate intramuscular injections.

with

the

immune response to the vaccination. 3. Do not mix globul globulin in with

any

other

medications. 4. Monitor patient’s vital signs continuo continuously usly and observe

for

any

symp sympto toms ms

duri during ng

IM 22

administration. 5.

Pro Provide vide


comfor mfortt or

to

teach provid e

meas measur ures es

to

help patient to cope with the discomforts discomforts of drug therapy.


MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING RESPONSIBILITIES 23

Tramadol 50mg IV q8 PRN for severe pain

Brand Name:

Treats moderate to

1.

Nausea

2.

Vomiting

3.

Sweating

of neuralgia of neuralgia,,

4.

Constipation

including trigeminal

5.

Drowsiness

moderately severe pain and most types

Treatment of acute to chronic pain.

Acute intoxication with alcohol hypnotics, analgesics or psychotropic, narcotic withdrawal treatment.

1. Do Do not take more medicatio medication n as a single single dose or take more dos doses per per day day than han prescribed by the doctor.

administration. 5.

Pro Provide vide


comfor mfortt or

to

teach provid e

meas measur ures es

to

help patient to cope with the discomforts discomforts of drug therapy.


MECHANISM OF ACTION

INDICATION

SIDE EFFECTS


CONTRAINDICATIONS

23


Brand Name: Tramal

Treats moderate to

1.

Nausea

2.

Vomiting

3.

Sweating


4.

Constipation


5.

Drowsiness



neuralgia.. neuralgia

6. Resp Respir irat ator ory y depression

ACTION



Store this medicine medicine at 2. Store room room temp temper erat atur ure, e, away away from from heat heat and and light.

Analgesic u-opiod 3. Do not stop stop tak taking Tramadol without talkin talking g to the doctor doctor

receptor antagonist


MECHANISM OF ACTION

INDICATION

SIDE EF EFFECTS

CONTRAINDICATIONS


24

Pen G 4 mullion q6 ANST via soluset (8-2)

Inhibits enzymes responsible for cell wall synthesis of susceptible organisms. This

Penicillin G is reserved for severe infections.

1. Naus ausea 2. Vomi Vomiti ting ng 3. Diar Diarrh rhea ea 4. Abdomi Abdominal nal pain pain 5. Coli Coliti tis s

Patients with known allergies to penicillin and hypersensitivity hypersensitivity to cephalosporins

1. Have Have a antibi antibioti otic c skin skin test test done done before before giving giving dose dose to ensure ensure hypersensitivity reactions. 2.

Give Give by IM rou route te


Brand Name: Tramal

Treats moderate to

1.

Nausea

2.

Vomiting

3.

Sweating


4.

Constipation


5.

Drowsiness



neuralgia.. neuralgia


6. Resp Respir irat ator ory y depression


Store this medicine medicine at 2. Store room room temp temper erat atur ure, e, away away from from heat heat and and light.

ACTION

Analgesic u-opiod 3. Do not stop stop tak taking Tramadol without talkin talking g to the doctor doctor

receptor antagonist


MECHANISM OF ACTION

INDICATION

SIDE EF EFFECTS

CONTRAINDICATIONS


24


Inhibits enzymes responsible for cell wall synthesis of


creates an

6. Anor Anorex exia ia

osmotically

7. Hypersensitivity

9.

that swells and


3. Continue therapy for at leas leastt 2 days days afte afterr infection h as disappeare disappeared, d, usually usually 710 days.

Urticaria,, Urticaria Superinfection

bursts from osmotic pressure.

MECHANISM OF ACTION

1. Have Have a antibi antibioti otic c skin skin test test done done before before giving giving dose dose to ensure ensure hypersensitivity reactions. 2. Give Give by IM rou route te only.

8. Neurotoxicity

unstable cell wall

Antibiotic

3. Diar Diarrh rhea ea

5. Coli Coliti tis s

organisms. This

ACTION

2. Vomi Vomiti ting ng


4. Abdomi Abdominal nal pain pain

susceptible Brand Name: Pen G

1. Naus ausea

4. Use the smallest dose possible for IM injection to avoid pain and discomfort.

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS


Metronidazole, 500mg , IV q8 hrs.

Brand Name: Flagyl

Bactericidal: inhibits DNA synthesis in specific anaerobes, causing cell death.

Treatment of bacterial infection (a drug of choice for Tetanus)

1. Head Headac ache he 2. Dizzin Dizzines ess s 3. Atax Ataxia ia 4. Vert Vertig igo o

Contraindicated Contraindicated with hypersensitivity to metronidazole; use cautiously with CNS disease, hepatic disease, candidiasis,

1.

Avoi Avoid d use use unle unless ss

needed. Metronidazole may be carcinogenic. 2. Redu Reduce ce dosa dosage ge in in


Inhibits enzymes responsible for cell wall synthesis of


creates an

6. Anor Anorex exia ia

osmotically

7. Hypersensitivity

9.

that swells and


3. Continue therapy for at leas leastt 2 days days afte afterr infection h as disappeare disappeared, d, usually usually 710 days.

Urticaria,, Urticaria Superinfection

bursts from osmotic pressure.

MECHANISM OF ACTION

1. Have Have a antibi antibioti otic c skin skin test test done done before before giving giving dose dose to ensure ensure hypersensitivity reactions. 2. Give Give by IM rou route te only.

8. Neurotoxicity

unstable cell wall

Antibiotic

3. Diar Diarrh rhea ea

5. Coli Coliti tis s

organisms. This

ACTION

2. Vomi Vomiti ting ng


4. Abdomi Abdominal nal pain pain

susceptible Brand Name: Pen G

1. Naus ausea

4. Use the smallest dose possible for IM injection to avoid pain and discomfort.

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS




Brand Name: Flagyl


1. Head Headac ache he 2. Dizzin Dizzines ess s 3. Atax Ataxia ia 4. Vert Vertig igo o 5. Inso Insomn mnia ia

ACTION

Contraindicated Contraindicated with hypersensitivity to metronidazole; use cautiously with CNS disease, hepatic disease, candidiasis, blood dyscrasias.

1.

Avoi Avoid d use use unle unless ss

needed. Metronidazole may be carcinogenic. 2. Redu Reduce ce dosa dosage ge in in hepatic disease.

6. Fati Fatigu gue e 7. Incont Incontine inence nce

Antiprotozoal

8. GI upse upsett


MECHANISM OF ACTION

INDICATION

SIDE EF EFFECTS

CONTRAINDICATIONS


26

Telmisartan 40mg/12.5, I tab OD

Brand Name: Micardis

Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland.

Treatment of hypertension, alone or in combination with other hypertensives.

1. Dizz Dizzin ines ess s 2. Head Headac ache he 3 . n au aus ea ea 4. vomi vomiti ting ng

Contraindicated with hypersensitivity to telmisartan.

1. Moni Monito torr hear heartt rate rate below below normal normal level level before giving drug.

Use cautiously with hepatic or biliary impairment, hypovolemia.

2. Check effectiv effectivity ity of the drug. Closely monitor BP and heart



Brand Name: Flagyl


1. Head Headac ache he 2. Dizzin Dizzines ess s 3. Atax Ataxia ia 4. Vert Vertig igo o 5. Inso Insomn mnia ia

ACTION

Contraindicated Contraindicated with hypersensitivity to metronidazole; use cautiously with CNS disease, hepatic disease, candidiasis, blood dyscrasias.

1. Avoi Avoid d use use unle unless ss needed. Metronidazole may be carcinogenic. 2. Redu Reduce ce dosa dosage ge in in hepatic disease.

6. Fati Fatigu gue e 7. Incont Incontine inence nce

Antiprotozoal

8. GI upse upsett


MECHANISM OF ACTION

INDICATION

SIDE EF EFFECTS

CONTRAINDICATIONS


26





MECHANISM OF ACTION

INDICATION





2. Check effectiv effectivity ity of the drug. Closely monitor BP and heart rate.

5. diar diarrh rhea ea

ACTION

Angiotensin II receptor antagonist Antihypertensive


SIDE EFFECTS

CONTRAINDICATIONS


27

Diazepam 5mg IV q8

*Muscle relaxant: Acts mainly at the Adjunct for relief limbic system and of reflex skeletal reticular formation; muscle spasm mat act in spinal cord due to local to produce skeletal pathology or muscle relaxation; secondary to potentiates the

1. Drow Drowsi sine ness ss 2. Dizz Dizzin ines ess s 3 . G I up se se t 4. brad bradyc ycha hard rdia ia

Contraindicated with hypersensitivity hypersensitivity to benzodiazepines; psychoses, acute narrowangle glaucoma, shock, coma, acute alcoholic intoxication.

1. Moni Monito torr hear heartt rate rate before giving drug. 2. Closely Closely monitor monitor BP.





MECHANISM OF ACTION

INDICATION





2. Check effectiv effectivity ity of the drug. Closely monitor BP and heart rate.

5. diar diarrh rhea ea

ACTION

Angiotensin II receptor antagonist Antihypertensive


SIDE EFFECTS

CONTRAINDICATIONS


27

Diazepam 5mg IV q8

ACTION

Antiepileptic; Anxiolytic

*Muscle relaxant: Acts mainly at the Adjunct for relief limbic system and of reflex skeletal reticular formation; muscle spasm mat act in spinal cord due to local to produce skeletal pathology or muscle relaxation; secondary to potentiates the trauma; effects of GABA, an spasticity caused inhibitory by upper neurotransmitter. motoneuron disorders

Skeletal muscle relaxant (centrally acting)



INDICATION


Use cautiously with elderly or debilitated patients; impaired liver or renal function; and in patients with history of substance abuse.

*Parenteral: Treatment of tetanus

MECHANISM OF ACTION


SIDE EFFECTS

CONTRAINDICATIONS


28

Acetylcysteine 600g/1 tab in 50 diluent OD

Brand Name:

Mucolytic activity: Splits links in the mucoproteins contained in respiratory mucus secretions,

Mucolytic adjuvant therapy for abnormal, viscid, or inspissated mucus secretions in acute and chronic

1. Incr Increa ease se productivity of cough 2. Naus Nause ea 3. GI ups upset et..

Contraindicated with hypersensitivity hypersensitivity to acetylcysteine; acetylcysteine; use caution and discontinue immediately if bronchospasm occurs.

1. Ensure Ensure proper proper dilution of tablet. 2. Monito Monitorr heart heart rate rate before giving the drug.

Diazepam 5mg IV q8

ACTION

Antiepileptic; Anxiolytic

*Muscle relaxant: Acts mainly at the Adjunct for relief limbic system and of reflex skeletal reticular formation; muscle spasm mat act in spinal cord due to local to produce skeletal pathology or muscle relaxation; secondary to potentiates the trauma; effects of GABA, an spasticity caused inhibitory by upper neurotransmitter. motoneuron disorders

Skeletal muscle relaxant (centrally acting)



INDICATION


Use cautiously with elderly or debilitated patients; impaired liver or renal function; and in patients with history of substance abuse.

*Parenteral: Treatment of tetanus

MECHANISM OF ACTION


SIDE EFFECTS

CONTRAINDICATIONS


28


Brand Name: Fluimucil

Mucolytic activity: Splits links in the mucoproteins contained in respiratory mucus secretions, decreasing the viscosity of the mucus.

Mucolytic adjuvant therapy for abnormal, viscid, or inspissated mucus secretions in acute and chronic bronchopulmonary disease.



1. Ensure Ensure proper proper dilution of tablet. 2. Monito Monitorr heart heart rate rate before giving the drug. 3. Monito Monitorr urin urine e output.

ACTION

Mucolytic


MECHANISM OF ACTION

INDICATION

SIDE E EF FFECTS

CONTRAINDICATIONS


Bisacodyl Suppository 1 stick per rectum

The drug passes unchanged into the colon where bacteria breaks it down to organic acid that increase the osmotic pressure in the colon

Short term relief of constipation

1. Swea Sweati ting ng 2. Flus Flushi hing ng 3. muscle muscle cramps cramps 4. exce excess ssiv ive e thirst

Contraindicated in cases of allergy to these drugs; acute abdominal pain.

1. Do not give drug within 1 hour of any other drugs. 2. Rep o orrt flus flushi hing ng,, cramps

sweating, muscle scle and


Brand Name: Fluimucil

Mucolytic activity: Splits links in the mucoproteins contained in respiratory mucus secretions, decreasing the viscosity of the mucus.

Mucolytic adjuvant therapy for abnormal, viscid, or inspissated mucus secretions in acute and chronic bronchopulmonary disease.



1. Ensure Ensure proper proper dilution of tablet. 2. Monito Monitorr heart heart rate rate before giving the drug. 3. Monito Monitorr urin urine e output.

ACTION

Mucolytic


MECHANISM OF ACTION

INDICATION

SIDE E EF FFECTS

CONTRAINDICATIONS



Brand Name: Dulcolax

ACTION

Laxative


The drug passes unchanged into the colon where bacteria breaks it down to organic acid that increase the osmotic pressure in the colon and slightly acidify the colonic contents, resulting in an increase in stool water content, stool softening, laxative action.


MECHANISM OF ACTION

INDICATION

1. Swea Sweati ting ng 2. Flus Flushi hing ng 3. muscle muscle cramps cramps


1. Do not give drug within 1 hour of any other drugs.

CONTRAINDICATIONS


4. exce excess ssiv ive e thirst

SIDE E EF FFECTS

2. Rep o orrt sweating, flus flushi hing ng,, muscle scle cramps and excessive thirst.

30

Paracetamol 500mg 1tab q4 PRN

Reduces fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating which helps disspates heat

Relief of mild to moderately severe pain and treatment for fever

1. Naus ausea 2. GI upse upsett 3. Dizz Dizzin ines ess s

Contraindicated to patients hypersensitive hypersensitive to Paracetamol

1. Give Give drug drug with with food food if GI upset occurs. 2. Disc Discon onti tinu nue e drug drug hypersensitivity reactions occur.

if


Brand Name: Dulcolax

ACTION

Laxative


The drug passes unchanged into the colon where bacteria breaks it down to organic acid that increase the osmotic pressure in the colon and slightly acidify the colonic contents, resulting in an increase in stool water content, stool softening, laxative action.


MECHANISM OF ACTION

INDICATION

1. Swea Sweati ting ng 2. Flus Flushi hing ng 3. muscle muscle cramps cramps


1. Do not give drug within 1 hour of any other drugs.

CONTRAINDICATIONS


4. exce excess ssiv ive e thirst

SIDE E EF FFECTS

2. Rep o orrt sweating, flus flushi hing ng,, muscle scle cramps and excessive thirst.

30


Reduces fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating which helps disspates heat. heat .


MECHANISM OF ACTION

INDICATION

1. Naus ausea 2. GI upse upsett


3. Dizz Dizzin ines ess s

1. Give Give drug drug with with food food if GI upset occurs. 2. Disc Discon onti tinu nue e drug drug hypersensitivity reactions occur. 3. Check for temperature.

ACTION

if

body

Antipyretic


SIDE E EF FFECTS

CONTRAINDICATIONS


31

Furosemide 5mg IV now

ACTION

Inhibits reabsorption of the sodium and chloride from the proximal and distal tubules oral ascending limb of the loop of Henle

Treatment for fluid retention.

1. Dizz Dizzin ines ess s 2. Vert Vertig igo o 3. Weak Weakne ness ss 4. Head Headac ache he

Allergy to drug, Anuria, Severe Renal Failure

1. Monitor Blood pressure pressure for sudden sudden Hypotension 2. Moni Monito torr the the and Output.

Inta Intake ke


Reduces fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating which helps disspates heat. heat .


MECHANISM OF ACTION

INDICATION

1. Naus ausea 2. GI upse upsett



1. Give Give drug drug with with food food if GI upset occurs. 2. Disc Discon onti tinu nue e drug drug hypersensitivity reactions occur. 3. Check for temperature.

ACTION

if

body

Antipyretic


SIDE E EF FFECTS

CONTRAINDICATIONS


31


ACTION

Inhibits reabsorption of the sodium and chloride from the proximal and distal tubules oral ascending limb of the loop of Henle leading to Sodium – rich dieresis.




2. Vert Vertig igo o 3. Weak Weakne ness ss


4. Head Headac ache he

Inta Intake ke

5. Drow Drowsi sine ness ss 6. Fati Fatigu gue e

Loop Diuretic

7. Orth Orthos osta tati tic c Hypotension 8. Card Cardia iac c Arrhytmias


MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS


Digoxin 0.251 tab OD (7am)

ACTION

Increase intra cellular calcium and allows more calcium to enter myocardial cell during depolarization via sodium – potassium pump

Indicated for arrhythmias, abnormal heart contractility.

1. Arrhyt Arrhythmi hmias as 2. Head Headac ache he 3. Weak Weakne ness ss 4. Drow Drowsi sine ness ss

Allergy to Digitalis preparation. Ventricular Tachycardia, Ventricular Fibrilation, Heart Block, Sick Sinus Syndrome, Acute MI

3. Moni Monito torr hear heartt rate rate below below normal normal level level before giving drug. 4. Chec Check k effe effect ctiv ivit ity y of the the drug drug.. Clos Closel ely y monitor BP and heart


ACTION

Inhibits reabsorption of the sodium and chloride from the proximal and distal tubules oral ascending limb of the loop of Henle leading to Sodium – rich dieresis.




2. Vert Vertig igo o 3. Weak Weakne ness ss


4. Head Headac ache he

Inta Intake ke

5. Drow Drowsi sine ness ss 6. Fati Fatigu gue e

Loop Diuretic

7. Orth Orthos osta tati tic c Hypotension 8. Card Cardia iac c Arrhytmias


MECHANISM OF ACTION

INDICATION

SIDE EFFECTS

CONTRAINDICATIONS



ACTION

Increase intra cellular calcium and allows more calcium to enter myocardial cell during depolarization via sodium – potassium pump mechanism.




3. Moni Monito torr hear heartt rate rate below below normal normal level level before giving drug. 4. Chec Check k effe effect ctiv ivit ity y of the the drug drug.. Clos Closel ely y monitor BP and heart rate.

Cardiac Glycoside

33

TEXTBOOK DISCUSSION PATHOPHYSIOLOGY


ACTION

Increase intra cellular calcium and allows more calcium to enter myocardial cell during depolarization via sodium – potassium pump mechanism.




3. Moni Monito torr hear heartt rate rate below below normal normal level level before giving drug. 4. Chec Check k effe effect ctiv ivit ity y of the the drug drug.. Clos Closel ely y monitor BP and heart rate.

Cardiac Glycoside

33

TEXTBOOK DISCUSSION PATHOPHYSIOLOGY TETANUS

Teta Tetanu nus s is an acut acute, e, ofte often n fata fatall dise diseas ase e caused by an exotoxin produced in a wound

disinfectants,

and

by Clostridium tetani. Clostridium tetani is a gram gram-p -pos osit itiv ive, e, none no nenca ncaps psula ulate ted, d, moti motile, le, obliga obligativ tively ely anaero anaerobic bic bacill bacillus. us. It exists exists in vegetative and sporulated forms. Spores are highly resistant to disinfections by chemical or heat, but vegetative vegetative forms are susceptible to the bacter bactericid icidal al effect effect of heat, heat, chemica chemicall a number of antibiotics.

Clostridium tetani is a noninvasive organism. It is found in soil and in the intesti intestine ne and feces of horses horses,, sheep, sheep, cattle cattle,, dogs, dogs, cats, cats, rats, rats, guinea guinea pigs pigs and chic chicke ken. n. Manur nure-tr e-trea eatted soil soil may may cont contai ain n larg large e numb number ers s of spor spores es too. too.

Tetanus occurs after spores or vegetative bacteria gain access to tissues and produce toxin locally. The usual mode of entry is trough a puncture wound or laceration. Tetanus may also follow elective surgery, burn wounds, otitis media, dental infection, abortion and pregnancy. Neonatal tetanus usually follows infection

TEXTBOOK DISCUSSION PATHOPHYSIOLOGY TETANUS

Teta Tetanu nus s is an acut acute, e, ofte often n fata fatall dise diseas ase e caused by an exotoxin produced in a wound

disinfectants,

and

by Clostridium tetani. Clostridium tetani is a gram gram-p -pos osit itiv ive, e, none no nenca ncaps psula ulate ted, d, moti motile, le, obliga obligativ tively ely anaero anaerobic bic bacill bacillus. us. It exists exists in vegetative and sporulated forms. Spores are highly resistant to disinfections by chemical or heat, but vegetative vegetative forms are susceptible to the bacter bactericid icidal al effect effect of heat, heat, chemica chemicall a number of antibiotics.

Clostridium tetani is a noninvasive organism. It is found in soil and in the intesti intestine ne and feces of horses horses,, sheep, sheep, cattle cattle,, dogs, dogs, cats, cats, rats, rats, guinea guinea pigs pigs and chic chicke ken. n. Manur nure-tr e-trea eatted soil soil may may cont contai ain n larg large e numb number ers s of spor spores es too. too.

Tetanus occurs after spores or vegetative bacteria gain access to tissues and produce toxin locally. The usual mode of entry is trough a puncture wound or laceration. Tetanus may also follow elective surgery, burn wounds, otitis media, dental infection, abortion and pregnancy. Neonatal tetanus usually follows infection of th e umbilical stump.

In the prese esence of anaero erobic con ond ditions, ns, the spores ores germ erminat nate. Toxins,includi Toxins,including ng tetanolysin tetanolysin (which (which potentiates potentiates infection) infection) and tetanospasm tetanospasmin in (a potent potent neurotox neurotoxin) in) are are produc produced. ed. Tetano Tetanospa spasmi smin, n, often often referr referred ed to as tetanu tetanus s toxin, toxin, causes causes clinica clinicall tetanus tetanus.. The toxin toxin produ produced ced is dissem disseminat inated ed throug through h the bloodstream and lymphatic system. However, it does not enter the central nervous system through this route, as it cannot cross the blood brain barrier except at the fourth ventricle. The toxin is exclusively taken up by the neuromuscular junction, where it migrates retrograde transynaptically at the rate 75-250mm/day, a process which which takes takes 3-14 3-14 days, days, protect protected ed from from neutral neutralizi izing ng antito antitoxin, xin, predom predomina inantly ntly to inhibitory synapses to prevent the release of acetylcholine.

The toxin acts after the incubation period (3-14) days) at several sites within the central central nervou nervous s system system,, includi including ng periph periphera erall motor motor end plates, plates, spinal spinal cord, cord, brain brain and sympat sympathet hetic ic nervou nervous s system system.. The typica typicall clinica clinicall manife manifesta statio tions ns of tetanus are caused when tetanus toxin interferes with release release of neurotrasmi neurotrasmitters, tters, blocking inhibitor impulses. 34

Blockade of spinal inhibition is produced when the toxin acts at the synapse of interneurons interneurons of inhibitory inhibitory pathways and motor neurons. General muscle rigidity rigidity arises from uninhibited afferent stimuli entering the central nervous system from the periphery. The effect of the toxin on the brain is controversial; direct inoculation can cause seizures. One of the many complications from tetanus is respiratory failure secondary to spas spasms ms,, obst obstru ruct ctio ion n by secr secret etio ions ns,, exha exhaus usti tion on and and pulm pulmon onar ary y aspi aspira rati tion on.. Cardiovascular complications thought to be due to hyperactivity of the sympathetic nervous system include tachycardia, with heart rates over 180 beats per minute, sever severe e vaso vasocon const stri rict ction ion and and hype hypert rten ensi sion. on. Auto Autonom nomic ic dysf dysfunc uncti tion on is seen seen as increased basal sympathetic activity and episodes of sympathetic over activity.

Tetanus Symptoms

In generalized tetanus, the initial complaints may include any of the following: Irrita Irritabil bility ity,, muscle muscle cramps cramps,, sore sore muscle muscles, s, weakne weakness, ss, or diffic difficult ulty y swallowing are commonly seen. Facial Facial muscles muscles are are often often affect affected ed first. first. Trismus or loc lockj kjaw aw is most most • common. This condition results from spasms of the jaw muscles that are responsible for chewing. A sardonicsmile -medically termed risussardonicus -- is a characteristic feature that results from facial muscle spasms. Musc Muscle le spas spasms ms are are prog progres ressi sive ve and and may may incl includ ude e a char charac acte teri rist stic ic • arching of the back known as opisthotonus. Muscle spasms may be intense enough to cause bones to break and joints to dislocate. Seve Se vere re case cases s can can invol involve ve spas spasms ms of the the vocal vocal cord cords s or musc muscle les s • involved in breathing. If this happens, death is likely, unless medical help (mechanical ventilation with a respirator) is readily available. •

35

Signs and textbook

symptoms

in

the

Signs and symptoms manifested by the patient

Irritability/ Restlessness



muscle cramps



Weakness



difficulty swallowing



Lockjaw



Stiffness



Reflex spasms



↑Blood pressure



↑temperature



Irregular heart beat Sweating



Seizure



Complications of Tetanus In cases of severe tetanus infection, a number of possible complications can develop Fractures The repeated muscle spasms and convulsions that are caused by a tetanus infection may lead to fractures in the vertebrae (bones in the back), as well as in other bones. Bone fractures can sometimes result in a condition called myositis ossificans circumscripta, which is where bone begins to form in the soft tissues, often around a joint. 36

Aspiration pneumonia If you have a tetanus infection, muscle rigidity (stiffness) can make coughing and swallowing difficult. This can cause aspiration pneumonia to develop. Aspi As pira rati tion on pneum pneumoni onia a occur occurs s as a resu result lt of inhal inhalin ing g the secr secret etion ions, s, or conte content nts, s, of the the stom stomac ach, h, whic which h can can lead lead to a lower lower respi respira rato tory ry trac tractt infection. Laryngospasm Laryngospasm is where the larynx (voicebox) goes into a brief, temporary spasm that usually lasts for between 30-60 seconds. Laryngospasm prevents oxygen from reaching your lungs, making breathing difficult. Tetanic seizures Tetanic seizures are convulsions (fits) that are similar to epileptic fits. They can occur in severe cases of tetanus where the infection has spread to the brain. Someone with a severe tetanus infection may experience severe and frequent tetanic seizures. Pulmonary embolism A pulmonary embolism is a serious and potentially life-threatening condition. It is caused by a blockage in a blood vessel in the lungs that can affect brea breath thin ing g and and circ circula ulati tion. on. It is ther theref efor ore e vita vitall that that trea treatm tment ent is given given immediately immediately in the form of anti-clotting anti-clotting medication medication and, if required, oxygen therapy.

Acute renal failure The severe muscle spasms that are associated with a tetanus infection can cause a condition that is known as rhabdomyolysis. Rhabdomyolysis is where the skeletal muscles are rapidly destroyed, destroyed, resulting in myoglobin myoglobin (a muscle protein) leaking into the urine. This can lead to acute (severe) renal failure (kidney failure).

Preventing tetanus Immunisation is the best way to prevent a tetanus infection from occurring. The complete course of the tetanus vaccination consists of five doses. The vaccine enables your body to create antibodies against the tetanus toxin (tetanospasmin), providing protection from the illness should you be exposed to the Clostridium tetani bacterium in the future.

37

Lifestyle Dental infection

Age Sex

Clostridium tetani enters body through a wound

Pathophysiology Anaerobic conditions allow germination of spores andTETANUS production of toxins

[Patient centered ] via blood and Toxins are produced and disseminated lymphatics

Tetanospasmin enters the nervous system peripherally at the myeoneural junction and is transported transported centripetally into into neurons of CNS

Interfers with neurotransmitter release to block inhibitors

Leads to unopposed muscle contraction and spasm

Lockjaw Stiffness Neck rigidity Dysphagia Restlessness

↑BP ↑temperature sweating SEIZURE causing opisthotonos

Reflex spasms

38 Aspiration Pneumonia Hypertension

39

CONCEPT MAP

2 Ineffective airway clearance r/t retained and excessive secretions

1

Acute pain r/t muscle rigidity 2o unopposed muscle contraction

Ineffective breathing pattern r/t impaired lung muscle contraction

4

Cc: Difficulty of swallowing

Impaired physical mobility r/t neuromuscular impairment

8

3

Dx: Tetanus

Impaired swallowing r/t pharyngeal muscle spasm

stage 3 7

Disturbed sleep pattern r/t excessive environmental stimuli

5 6

Urinary incontinence r/t bladder outlet obstruction

Altered thermoregulation: Hyperthermia r/t tissue trauma 2o presence of C. of C. tetani 40

NURSING CARE PLAN

41

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Subjective “Gatiskog “Gatiskog naman siya kung makibot o masilawan” masilawan” as verbalized. Objectives: • •

RR= 30bpm BP= 140/100 mmHg

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Independent:


After nursing interventions, interventions, will demonstrate a reduction in pain behaviors such as absence of facial grimace and guarding.

1. Handled client’ s gently doin doing g activity.

2. Minimize

the To promote body safety and while allows nurs nursin ing g experience less pain during care activity.

To promote rest

Lydia Hall’s Care, Core, Cure

Florence

Goal was met. (-) guarding behavior

NURSING CARE PLAN

41

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Subjective “Gatiskog “Gatiskog naman siya kung makibot o masilawan” masilawan” as verbalized. Objectives: • • • • • • • • •

RR= 30bpm BP= 140/100 mmHg (+) Facial grimace (+) Guarding (+) diaphoresis (+) lockjaw (+)muscle spasm (+)periodontal infection (+)hyperextension of head

INTERVENTION

NURSING THEORY

RATIONALE

EVALUATION

Independent:





2. Minimize move moveme ment nt dimmed provided.

To promote rest and and and avoid light excitation of neurons leading to muscle contractions.

3. Mainta Maintaine ined d side side rail up.

Deped Dep edent ent : 1. Administered Tramadol 50 mg IV as ordered 2. Diaz Diazep epam am 5mg 5mg intravenously given as ordered.

3. Metronidazole,

To ensure safety when seizure and muscle rigidity occurs.

Treats moderate to moderately severe pain It is a muscle relaxant. That helps reduce muscle contractions causing pain. Trea Treatm tmen entt bacterial


Goal was met. (-) guarding behavior

Florence Nightingale’s Environment Theory


Ernestine Weidenbach’s Prescriptive Theory Ernestine Weidenbach’s Prescriptive Theory

of Ernestine

42

NURSING DIAGNOSIS

ASSESSMENT

PLANNING

Subjective


Objectives: • • • • • • • •

NURSING THEORY

RATIONALE

EVALUATION

Independent:

“Gatiskog “Gatiskog naman siya kung makibot o masilawan” masilawan” as verbalized.

•

INTERVENTION

RR= 30bpm BP= 140/100 mmHg (+) Facial grimace (+) Guarding (+) diaphoresis (+) lockjaw (+)muscle spasm (+)periodontal infection (+)hyperextension of head




2. Minimize move moveme ment nt dimmed provided.

To promote rest and and and avoid light excitation of neurons leading to muscle contractions.

3. Mainta Maintaine ined d side side rail up.

Deped Dep edent ent : 1. Administered Tramadol 50 mg IV as ordered 2. Diaz Diazep epam am 5mg 5mg intravenously given as ordered.

3. Metronidazole,

To ensure safety when seizure and muscle rigidity occurs.

Treats moderate to moderately severe pain It is a muscle relaxant. That helps reduce muscle contractions causing pain. Trea Treatm tmen entt bacterial

Goal was met.


(-) guarding behavior



Ernestine Weidenbach’s Prescriptive Theory Ernestine Weidenbach’s Prescriptive Theory

42

of Ernestine

43

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Objectives: •

RR=30 bpm

RATIONALE

NURSING THEORY

EVALUATION

Independent:

Sub ject ive: “Ginabudlayan “Ginabudlayan siya mag ginhawa” as verbalized by the folks.

INTERVENTION

Ineffective airway clearance r/t retained and excessive secretions

To maintain a patent airway be able to demonstrate effective coughing and clear breath sounds.

1. Suct Suctio ione ned d secr secret etiions needed.

To maintain as patent airway and prevent aspiration.

2. Elev Elevat ated ed head head of To the bed/ change change advantage gravity posi positi tion on ever every y decreasing

take of

Virginia Henderson’s Basic Care Component Florence Nightingale’s Environment

Goal was partially met. RR decreased to 24 bpm but still with crackles.

43

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Objectives: •

RR=30 bpm

•

AR=120bpm

•

(+) crackles

•

(+)productive cough

•

(+)restlessness

•

(+) drooling

•

(+) impaired swallowing

•

X-ray results shows Bilateral pneumonia and bronchiectasis

RATIONALE

NURSING THEORY

EVALUATION

Independent:


INTERVENTION





take 2. Elev Elevat ated ed head head of To a d v a n t a g e of the bed/ change change gravity posi positi tion on ever every y decreasing 2hours pressu pressure re on the diap diaphr hrag agm m and and enhancing drainage. 3. Kept

the

environment allergen free like dust.

4. Encour Encourage aged d deep deep brea breath thin ing g

and and

Prec Precip ipit itat ator ors s of allergic type respiratory reactions that can trig trigge gerr onse onsett of acute episodes. episodes . To promote oxygenation and maximize effort.

coughing exercise. 5. Position midline flexion.

Dep edent ede nt :

To open or maintain main tain open with airway.

head

Virginia Henderson’s Basic Care Component Florence Nightingale’s

Goal was partially met. RR decreased to 24 bpm but still with crackles.

Environment Theory


Virginia Henderson’s Basic Care Component


44

ASSESSMENT

NURSING DIAGNOSIS

PLANNING


Objectives: •

AR=120bpm

•

(+) crackles

•

(+)productive cough

•

(+)restlessness

•

(+) drooling

•


•


RR=30 bpm

•

RATIONALE

NURSING THEORY

EVALUATION

Virginia Henderson’s

Goal was partially met.

Independent:


INTERVENTION



Basic Care Component

take 2. Elev Elevat ated ed head head of To a d v a n t a g e of the bed/ change change gravity posi positi tion on ever every y decreasing 2hours pressu pressure re on the diap diaphr hrag agm m and and enhancing drainage. 3. Kept

the

Prec Precip ipit itat ator ors s of allergic type respiratory reactions that can trig trigge gerr onse onsett of acute episodes. episodes .

environment allergen free like dust.


Environment Theory


To promote oxygenation and maximize effort.

4. Encour Encourage aged d deep deep brea breath thin ing g

Florence Nightingale’s

and and


coughing exercise. 5. Position midline flexion.

RR decreased to 24 bpm but still with crackles.

To open or maintain main tain open with airway.

head


44

Dep edent ede nt :

45

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Sub ject ive: “Ginabudlayan “Ginabudlayan siya mag ginhawa” as ginhawa” as verbalized by the folks.

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION



Independent:

Ineffective breathing pattern r/t impaired lung muscle

To demonstate ability to breathe comfortably as evidienced by normal respiratory rate of 16-20

1. Suct Suctio ione ned d secr secret etio ions ns needed.

To maintain patent as airway and prevent aspiration.

2. Elevate head of

El

atio atio

of

head head

RR lowered down to 24

45

ASSESSMENT

NURSING DIAGNOSIS

PLANNING


Objectives: •

RR=30 bpm

•

AR=120bpm

•

(+) Labored breathing

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION



Independent:


To demonstate ability to breathe comfortably as evidienced by normal respiratory rate of 16-20 bpm.



2. Elevate head of bed/ placed on high back rest.

Elev Elevat atio ion n of head head may decrease dyspneic dyspneic episodes. episodes. An upright upright position position facilitates lung expansion.

•

(+)restlessness

•

(+) drooling

•


•

(+) nasal flaring

3. Assisted in It can be a helpful taking control of technique in maximizing breathing respiratory function

•


Dependent: 1. Admini Administe stered red oxygen at 4Lpm as ordered.

Oxygen therapy helps decreased dyspnea.

Collaborative: 2. Comb Combiv iven entt nebulization done by pulmoaide.

Acts as bronchodilator to promote effective airway passage .

RR lowered down to 24 bpm. Florence Nightingale’s Environment Theory Dorothea Orem’s Self-care Deficit

Ernestine Weidenbach’s Prescriptive Theory


46

ASSESSMENT

NURSING DIAGNOSIS

PLANNING


Objectives: •

RR=30 bpm

•

AR=120bpm

•

(+) Labored breathing

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION



Independent:


To demonstate ability to breathe comfortably as evidienced by normal respiratory rate of 16-20 bpm.



2. Elevate head of bed/ placed on high back rest.

Elev Elevat atio ion n of head head may decrease dyspneic dyspneic episodes. episodes. An upright upright position position facilitates lung expansion.

•

(+)restlessness

•

(+) drooling

•


•

(+) nasal flaring

3. Assisted in It can be a helpful taking control of technique in maximizing breathing respiratory function

•


Dependent: 1. Admini Administe stered red oxygen at 4Lpm as ordered.

Oxygen therapy helps decreased dyspnea.

Collaborative: 2. Comb Combiv iven entt nebulization done by pulmoaide.

Acts as bronchodilator to promote effective airway passage .

RR lowered down to 24 bpm. Florence Nightingale’s Environment Theory Dorothea Orem’s Self-care Deficit



46

47

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Sub ject ive: “ Nabudlayan siya magtulon ” as ” as verbalized by the folks.

Objectives: •

(+)lockjaw (+)restlessness

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION



Depende epe ndent: nt:

Impaired swallowing related to pharyngeal muscle spasm

After nursing intervention patient will demonstrate effective swallowing without muscle straining.

1. Nasoga Nasogastr stric ic tube tube inserted by ROD

To provide parenteral feeding in adequate amount.

Able to open his mouth. Ind ependen epen dent: t: 2. Provid Provided ed meals meals in in a quiet

The client c an achi achiev eve e a more more


47

ASSESSMENT

NURSING DIAGNOSIS

PLANNING



Sub ject ive: “ Nabudlayan siya magtulon ” as ” as verbalized by the folks.

Objectives: •

(+)lockjaw

•

(+)restlessness

•

(+) drooling (+) impaired swallowing (+)hyperextesion (+)hyperextesion of head (+)gum bleeding

• • •

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION



Depende epe ndent: nt: 1. Nasoga Nasogastr stric ic tube tube inserted by ROD


Able to open his mouth. Ind ependen epen dent: t: 2. Provid Provided ed meals meals in in a quiet environment away from excessive stimuli.

The client c an achi achiev eve e a more more effectiv effective e swallow swallow by foc focusi using on chewing and moving foods/fluids to the back of the mouth where the swallowi swallowing ng reflex reflex is triggered.

3. Have Have suctio suction n equipment available during feeding.

For aspiration precaution.

4. Kept Kept wit with h an upright position for 15mins to an hour after meal.

This position uses gravity to aid in the flow of foods/fluids through the esophagus.

5. Instructed family how to monitor and detect aspiration after eating.

For the family to be aware for any situation so that we can avoid aspiration even when nurses are not in their room




Lydia Hall’s Care, Core, Cure 48

ASSESSMENT

NURSING DIAGNOSIS

PLANNING



Sub ject ive:

Objectives: (+)lockjaw

•

(+)restlessness

•

(+) drooling (+) impaired swallowing (+)hyperextesion (+)hyperextesion of head (+)gum bleeding

• • •

RATIONALE

NURSING THEORY

EVALUATION



Depende epe ndent: nt:

“ Nabudlayan siya magtulon ” as ” as verbalized by the folks.

•

INTERVENTION

1. Nasoga Nasogastr stric ic tube tube inserted by ROD


Able to open his mouth. Ind ependen epen dent: t: 2. Provid Provided ed meals meals in in a quiet environment away from excessive stimuli.

The client c an achi achiev eve e a more more effectiv effective e swallow swallow by foc focusi using on chewing and moving foods/fluids to the back of the mouth where the swallowi swallowing ng reflex reflex is triggered.

3. Have Have suctio suction n equipment available during feeding.

For aspiration precaution.

4. Kept Kept wit with h an upright position for 15mins to an hour after meal.

This position uses gravity to aid in the flow of foods/fluids through the esophagus.

5. Instructed family how to monitor and detect aspiration after eating.

For the family to be aware for any situation so that we can avoid aspiration even when nurses are not in their room




Lydia Hall’s Care, Core, Cure 48

49

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Altered thermoregulation: Hyperthermia r/t tissue trauma 2 o presence of

To lower down body temperature to 37.5oC after 2 hours of nursing interventions.

Sub ject ive: “Gina “Gina lagnat siya” as verbalized by the folks.

Objectives: •

T=38.2oC

•

(+) body

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION


Goal was met.

Independent:

C. tetani

1. Tepi Tepid d spong sponge e bath done.

It lower down body temperature.

2. Roo Room’s m’s temperature cooled down.

A consistent temperatu temperature re limits limits environmental effects on thermoregulation


Body temp. is 37.3oC. (-) Shivering

49

ASSESSMENT

NURSING DIAGNOSIS

PLANNING


Objectives: •

T=38.2oC

•

(+) body weakness

•

(+)flushed and warm skin

•

(+) sweating

•

(+) shivering

•

(+) periodontal trauma

•

WBC=11.9 x 10^9/L

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION


Goal was met.

Independent:







C. tetani

3. Prov Provid ided ed thick-wool blanket to prevent further chills.

4. Dimmed the light and provided a peaceful environment for rest. Minimized stimulus. Depede Dep edent nt : 4. Parace Paracetam tamol ol 500 500 mg, 1 tab given orally as ordered. 5. Admini Administe stered red Metronidazole 500 mg intrav intraveno enousl usl as

This will help maintain a normal body temperature and prevents shivering.

Promotes rest and relaxation , and prevents from disturbances.

Antipyretic that treats fever, by lowering down body temp. An antibiotic used to treat infection caused by anaerobic C. tetani.



Environment Theory Florence Nightingale’s Environment Theory




50

NURSING DIAGNOSIS

ASSESSMENT

PLANNING

INTERVENTION


Objectives: •

T=38.2oC

•

(+) body weakness

•

(+)flushed and warm skin

•

(+) sweating

•

(+) shivering

•

(+) periodontal trauma

•

WBC=11.9 x 10^9/L

RATIONALE

NURSING THEORY

EVALUATION


Goal was met.

Independent:







C. tetani

3. Prov Provid ided ed thick-wool blanket to prevent further chills.

This will help maintain a normal body temperature and prevents shivering.

Promotes rest and relaxation , and prevents from disturbances.

4. Dimmed the light and provided a peaceful environment for rest. Minimized stimulus.

Antipyretic that treats fever, by lowering down body temp.

Depede Dep edent nt : 4. Parace Paracetam tamol ol 500 500 mg, 1 tab given orally as ordered.

An antibiotic used to treat infection caused by anaerobic C. tetani.

5. Admini Administe stered red Metronidazole 500 mg intrav intraveno enousl usl as



Environment Theory Florence Nightingale’s Environment Theory




50

51

ASSESSMENT

NURSING DIAGNOSIS

PLANNING


After nursing interventions, will void urine volume of at least 30 cc every hour.

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Dependent epen dent:: Objectives: •

Urine volume/fluid output= 40 cc within 8 hours .

•

(+) body weakness

•

(+) muscle rigidity

•

Creatinine= HI 161.8 umol/L

1. Foley Foley Cathet Catheter er inserted as ordered.

2. Administered Tamsulosin 20cc intravenously as prescribed.

To promote adequate urine elimination.

Helps to manage urethral stones and improves the flow of urine

Virginia Henderson’s Basic Component Ernestine Weidenbach’s Prescriptive Theory

Goal was met. Urine output=300 cc after 8 hours

51

ASSESSMENT

NURSING DIAGNOSIS

PLANNING



INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION



•

(+) body weakness

•

(+) muscle rigidity

•


•

TPSA=7.31mg/ml



3. Solfenacin 5mg 1tab given via NGT as ordered.


Virginia Henderson’s Basic Component



Smoothen urethral muscle and relieved symptoms of urge urinary incontinence incontinence



Independent: 1. Impl Implem emen entt measures to ensure the patency (e.g. keep tubing free of kinks, keep collection bag below bladder level) 2. Encourage fluid intake in small amount frequently.

3. Prov Provid ide e an an environment that

Maintaining patency of the indwelling catheter prevents urinary incontinence incontinence

Drinking a large amount of fluid at one time results in rapid filling of the bladder which increases pressure in the bladder and the subsequent risk of incontinence Environmental factors may contribute to

Florence Nightingale’s Environmental Theory


52 Florence Nightingale’s

ASSESSMENT

NURSING DIAGNOSIS

PLANNING



INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION



•

(+) body weakness

•

(+) muscle rigidity

•


•

TPSA=7.31mg/ml



3. Solfenacin 5mg 1tab given via NGT as ordered.





Smoothen urethral muscle and relieved symptoms of urge urinary incontinence incontinence



Independent: 1. Impl Implem emen entt measures to ensure the patency (e.g. keep tubing free of kinks, keep collection bag below bladder level) 2. Encourage fluid intake in small amount frequently.

3. Prov Provid ide e an an environment that

Maintaining patency of the indwelling catheter prevents urinary incontinence incontinence

Drinking a large amount of fluid at one time results in rapid filling of the bladder which increases pressure in the bladder and the subsequent risk of incontinence Environmental factors may contribute to



52 Florence Nightingale’s

53

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

Sub ject ive: “Madali “Madali siya makibot sa

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATION

Florence

Goal was

Independent:

Disturbed sleep

After nursing interventions,

1. Keep Keep enviro environme nment nt quiet for sleeping,

Provides more

53

ASSESSMENT

NURSING DIAGNOSIS

PLANNING


After nursing interventions, will able to have undisturbed sleep with long intervals.

Sub ject ive:

Objectives: (+) too much visitors

•

(+) disturbed sleep

•

(+) Weakness

•

(+) Lethargic

•

(+) Irritable

•

(+) hyperextension of head (+) body stiffness

•

RATIONALE

NURSING THEORY

EVALUATION

Independent:

“Madali “Madali siya makibot sa gasulod, ga tiskog naman siya, hindi siya katulog ” as ” as verbalized by the folks.

•

INTERVENTION

1. Keep Keep enviro environme nment nt quiet for sleeping, eliminate noise.

Provides more relaxing and comfortable environment for sleeping.

2. Perfor Perform m nursin nursing g procedures all at the same time if possible before patient to go to sleep.

Reduces disturbances in sleeping.

3. Adjust Adjusted ed lighti lighting ng by dimming the lights.

Light may alter or disturb patient’s sleep.


Goal was met. Slept at long intervals undisturbed.



Dependent: 1. Administered Diazepam 50mg intravenously

Acts as muscle relaxant and an anxiolytic.


54

Discharge Planning Mr. Mr. F.B’ F.B’s s fami family ly deci decide ded d to go ho home me even even thou though gh he was was no nott in good good NURSING

PLANNI

NURSING

EVALUATI

ASSESSMENT

NURSING DIAGNOSIS

PLANNING


After nursing interventions, will able to have undisturbed sleep with long intervals.

Sub ject ive:

RATIONALE

NURSING THEORY

EVALUATION

Independent:

“Madali “Madali siya makibot sa gasulod, ga tiskog naman siya, hindi siya katulog ” as ” as verbalized by the folks. Objectives: •

(+) too much visitors

•

(+) disturbed sleep

•

(+) Weakness

•

(+) Lethargic

•

(+) Irritable

•

(+) hyperextension of head (+) body stiffness

•

INTERVENTION

1. Keep Keep enviro environme nment nt quiet for sleeping, eliminate noise.

Provides more relaxing and comfortable environment for sleeping.

2. Perfor Perform m nursin nursing g procedures all at the same time if possible before patient to go to sleep.

Reduces disturbances in sleeping.

3. Adjust Adjusted ed lighti lighting ng by dimming the lights.

Light may alter or disturb patient’s sleep.


Goal was met. Slept at long intervals undisturbed.



Dependent: 1. Administered Diazepam 50mg intravenously

Acts as muscle relaxant and an anxiolytic.


54

Discharge Planning Mr. Mr. F.B’ F.B’s s fami family ly deci decide ded d to go ho home me even even thou though gh he was was no nott in good good ASSESSMENT

NURSING DIAGNOSIS

PLANNI NG

Sub Su bjecti je ctive ve:: “Di “Di na siya kahulag mayad indi parehas sadto ” as ” as verbalized by the folks. Objectives: •

(+) body weakness

•

(+)Reluctan ce to attempt movement. (+)Limited range of motion. Decreased muscle strength.

•

•

INTERVENTION

RATIONALE

NURSING THEORY

EVALUATI ON

Indep In depen ende dent nt : After 16 Impaired hours (2 physical days 6-2 mobility shift) of nursing r/t interventio neuromusc ns, the patient will ular or impairment maintain increase . strength

1 . E v a l u at e or continuously monitor degree of pain. 2. Maintain bed rest or chair rest when Indicated. Schedule activities providing frequen frequentt rest rest periods ods and uninterrupted night time sleep.

and function of affected or compensat ory body part.

Assist with active or passive range of motion. 3.

Virginia Goal Level Level of activi activity ty Henderson’ or exercise was not s depends on met. Basic progression progression and Componen resolution (+) body t weakness Systemic rest during cute Florence attacks and Nightingale’ important s throughout all Environmen phases of tal Theory disease to reduce fatigue and improve strength Hildegard Peplau’s Maintains or Interperso improves joint nal Theory function, muscle of Nursing strength, and general stamina. Florence Nightingale’ Maximizes joint s function, maintains Environmen

Discharge Planning Mr. Mr. F.B’ F.B’s s fami family ly deci decide ded d to go ho home me even even thou though gh he was was no nott in good good ASSESSMENT

NURSING DIAGNOSIS

PLANNI NG

Sub Su bjecti je ctive ve::

Objectives: •

(+) body weakness

•

(+)Reluctan ce to attempt movement. (+)Limited range of motion. Decreased muscle strength.

•

RATIONALE

NURSING THEORY

EVALUATI ON

Indep In depen ende dent nt :

“Di “Di na siya kahulag mayad indi parehas sadto ” as ” as verbalized by the folks.

•

INTERVENTION

After 16 Impaired hours (2 physical days 6-2 mobility shift) of nursing r/t interventio neuromusc ns, the patient will ular or impairment maintain increase . strength

1 . E v a l u at e or continuously monitor degree of pain. 2. Maintain bed rest or chair rest when Indicated. Schedule activities providing frequen frequentt rest rest periods ods and uninterrupted night time sleep.

and function of affected or compensat ory body part.

Assist with active or passive range of motion. 3.

4. Encourage patient to maintain upright and erect posture when sitting, standing, or walking.

Virginia Goal Level Level of activi activity ty Henderson’ or exercise was not s depends on met. Basic progression progression and Componen resolution (+) body t weakness Systemic rest during cute Florence attacks and Nightingale’ important s throughout all Environmen phases of tal Theory disease to reduce fatigue and improve strength Hildegard Peplau’s Maintains or Interperso improves joint nal Theory function, muscle of Nursing strength, and general stamina. Florence Nightingale’ Maximizes joint s function, maintains Environmen mobility that tal Theory can precipitate acute attack.

condit condition, ion, and they they have have signed signed a DAMADAMA- Dischar Discharged ged Against Against Medica Medicall Advice. Advice. Nevertheless the following discharge planning was formulated: MEDICATIONS The following medications must be comply: • • • • • • •

-Metronidazole 500mg 1 tab q8 (10am – 6pm – 2am) -Acetylcysteine (Fluimucil)) 600g / 1 tab in 50cc OD -Telmisartan (Micardis) 40mg 1 tab OD -Tramadol 50mg 1 tab q4 PRN for sever pain -Omeparazol (Prosec) 20mg / 1 tab BID -Digoxin 0.25g 1 tab OD (7am) -Moxiflacin (Avelox) 400mg 1 tab OD 55

EXERCISE AND ACTIVITY • • • •

-Advise folks to assist the patient in doing passive range of motion -Instructed folks to avoid stressful activities for patient -Let the folks provide healthy hygiene to the patient -Encourage to seek psychological support and social group therapy

TREATMENT Nebulization treatment must be resume upon discharge and continuous Oxygen therapy is needed by Mr. F.B HOME TEACHINGS •

•

•

-Educate the folks about what is Tetanus and on how to take the prescribed medication of the patient -Advice the folks to let the patient sleep in long intervals and avoid to much stressor to the patient -Teach the folks on what are the possible side effects and effects of the medication to the patient

OUT PATIENT FOLLOW-UP Mr. F.B’s condit condition ion requir requires es thorou thorough gh medica medicall attenti attention, on, he shall shall have have a recommended return visit at the hospital. He was encouraged to comply patient follow-up. DIET Mr. F.B was discharged with NGT attached for his h is parenteral feeding. An OTF 1600 cal shall be divided into 6 equal feedings SPIRITUALITY Advise Advise folks folks to seek spiritual spiritual help help from from priest priests, s, nuns any religious religious organization member they know in the society for spiritual counseling

BIBLIOGRAPHY

•

Smeltzer, S., Bare, B., Hinkle, J. & Cheever, K. (2008). Brunner &

Suddar Suddarth’ th’s s Textbo Textbook ok of Medica Medical-S l-Surg urgica icall Nursing Nursing,, 11th Ed. Lippincott Williams & Wilkins. •

Seeley, R., Stephens, T. & Tate, P. (2007). Essentials of Anatomy &

Physiology, 6th Ed . McGraw-Hill. •

Bickle Bic kley, y, L. (2007) (2007).. Bates’ Bates’ Poc Pocket ket Guide Guide to Physic Physical al Assessm Assessment ent &

History Taking, 5 th Ed . Lippincott Williams & Wilkins

56

•

Karch, A. (2009). (2009). 2009 Lippincott’s Lippincott’s Nursing Nursing Drug Guide. Guide . Lippincott Lippincott

Williams & Wilkins. •

Octaviano, E. & Balita, C. (2008). Theoretical Foundations of Nursing:

The Philippine Perspective. Ultimate Learning Series •

www.wikipedia.org

•

www.doh.gov.ph

•

www.eMedicine.com

57

Tetanus Case Study

Recommend Documents