Republic of the Philippines

Naval State University

College of Arts and Sciences
NURSING AND HEALTH SCIENCES DEPARTMENT
Naval, Biliran

DRUG THERAPEUTIC RECORD

NAME: Duba, Erlinda SEX: Female AGE: 70 years old WARD: Medical DATE: 08 13 17 SHIFT: 7:00am 3:00pm
DIAGNOSIS: CAP MR, BAIAE CHIEF COMPLAINTS: Fever, cough and difficulty of breathing PHYSICIAN: Dr. Sabornido
DRUG CLASSIFICATION INDICATIONS SIDE EFFECTS/ ADVERSE NURSING RESPONSIBILITIES
EFFECTS
- Anti histamine - Relief of symptoms - asthenia /fatigue - Check physicians order.
associated w/seasonal & - fever
BRAND NAME perennial allergic - abdominal pains - Observe the rights in
rhinitis. - trauma giving medication.
Montelukast - infectious
GENERIC NAME gastroenteritis - Report any untoward/
- dental pain symptoms of allergic
- dizziness reaction.
1 tablet
DOSE MECHANISM OF ACTION CONTRAINDICATIONS - headache
Montelukast inhibits broncho Hypersensitivity to one of its - cough
constriction due to antigen component. Severe renal or - nasal congestion
Once a day
challenge. Montelukast is a hepatic impairment. - influenza
FREQUENCY
selective leukotriene receptor - rash
antagonist of the cysteinyl - Somnolence
leukotriene CysLT receptor. The - dry mouth
TIME cysteinyl leukotrienes are - hypersensitivity
products of arachidonic acid - convulsion
Oral metabolism that are released - visual disturbances
ROUTE from various cells, including - palpitation
mast cells and eosinophils.
 Republic of the Philippines
Naval State University
College of Arts and Sciences
NURSING AND HEALTH SCIENCES DEPARTMENT
Naval, Biliran

DRUG THERAPEUTIC RECORD

NAME: Duba, Erlinda SEX: Female AGE: 70 years old WARD: Medical DATE: 08 13 17 SHIFT: 7:00am 3:00pm
DIAGNOSIS: CAP MR, BAIAE CHIEF COMPLAINTS: Fever, cough and difficulty of breathing PHYSICIAN: Dr. Sabornido
DRUG CLASSIFICATION INDICATIONS SIDE EFFECTS/ ADVERSE NURSING RESPONSIBILITIES
EFFECTS
- Anti infective penicillin - Treatment of symptoms - Dry mouth - Obtain patient history
associated with allergic - Headache increase drug history
BRAND NAME conditions (including - Fatigue and any unknown
ocular symptoms) - Rhinitis allergies
Levocetirizine - abdominal pain
- migraine - Monitor pulse, BP,
GENERIC NAME
respiration

1 tablet - Observe dizziness and

DOSE MECHANISM OF ACTION CONTRAINDICATIONS excessive sedation
Long-acting non-sedating Patient with severe renal
Once a day antihistamine that selectively impairment, patient with rare
FREQUENCY inhibits peripheral HI receptor. problems of galactose
intolerance.

TIME

Oral
ROUTE
 Republic of the Philippines
Naval State University
College of Arts and Sciences
NURSING AND HEALTH SCIENCES DEPARTMENT
Naval, Biliran

DRUG THERAPEUTIC RECORD

NAME: Duba, Erlinda SEX: Female AGE: 70 years old WARD: Medical DATE: 08 13 17 SHIFT: 7:00am 3:00pm
DIAGNOSIS: CAP MR, BAIAE CHIEF COMPLAINTS: Fever, cough and difficulty of breathing PHYSICIAN: Dr. Sabornido
DRUG CLASSIFICATION INDICATIONS SIDE EFFECTS/ ADVERSE NURSING RESPONSIBILITIES
EFFECTS
Pharmacologic Class - Replacement therapy in CNS: Vertigo, headache, BEFOR
- Adrenal cortical steroid adrenal cortical in sufficiency paresthesias, insomnia, - Assess
BRAND NAME - Corticosteroid - Allergic statessevere seizures, psychosis for contraindication
- Glucocorticoid or incapacitating allergic CV: Hypotension, shock, HPN - Assess body weight,
Therapeutic Class conditions and heart failure secondary to skin color, V/S,
Hydrocortisone
- Hormone - Hematologic disorders fluid retention, thrombo urinalysis, serum
GENERIC NAME embolism, thrombophlebitis,
- Ulcerative colitis electrolytes, X-rays,
fat embolism, cardiac CBC.
100 mg arrhythmias - Arrange for increased
DOSE MECHANISM OF ACTION CONTRAINDICATIONS Derm: Thin, fragile skin, dosage when patient
Enters target cells and binds to Concentrations petechiae, ecchymoses, is subject to unusual
Every 6 hours cytoplasmic receptor; initiates - Allergy to any component of purpura, striae, subcutaneous stress.
FREQUENCY many complex reactions that the drug Fungal infections fat atrophy - Do not give live
are responsible for its anti- - Amebiasis EENT: Cataracts, glaucoma, vaccines with
inflammatory, - Hepatitis B increased IOP immunosuppressive
immunosuppressive - Vaccine or varicella Endocrine: doses of hydrocortiso
TIME (glucocorticoid), and salt- Amenorrhea, irregular mens,
- Antibiotic ne.
retaining (mineralocorticoid) growth retardation, decreased - Observe the 15 rights
IVTT - resistant infections
actions. Some actions maybe carbohydrate tolerance and of drug
- Immunosuppression
ROUTE undesirable, depending on drug DM, cushingoid state, HPA. administration.
use.
DURING
- Give daily before
9am to mimic normal
peak
diurnal corticosteroid
Levels
- Space multiple doses
evenly throughout
the day.
- Use minimal doses
for minimal duration
to minimize adverse
effects.
- Do not give IM
injections if patient
has
thrombocytopenic
purpura
- Taper doses when
discontinuing high-
dose or long-term
therapy.
AFTER
- Monitor client for at
least 30minutes
- Educate client on the
side effects of the
medication and what
to expect.
- Instruct client to
report pain at
injection site.
- Instruct client to take
drug exactly as
prescribed.
- Dispose of used
materials properly
- Document that drug
has been given
 Republic of the Philippines
Naval State University
College of Arts and Sciences
NURSING AND HEALTH SCIENCES DEPARTMENT
Naval, Biliran

DRUG THERAPEUTIC RECORD

NAME: Duba, Erlinda SEX: Female AGE: 70 years old WARD: Medical DATE: 08 13 17 SHIFT: 7:00am 3:00pm
DIAGNOSIS: CAP MR, BAIAE CHIEF COMPLAINTS: Fever, cough and difficulty of breathing PHYSICIAN: Dr. Sabornido
DRUG CLASSIFICATION INDICATIONS SIDE EFFECTS/ ADVERSE NURSING RESPONSIBILITIES
EFFECTS
- Anti bacterial Lower respiratory tract GI: - Ensure that the patient
infections, otitis media, sinusitis, - Diarrhea has adequate fluid
BRAND NAME skin & soft tissue infections, UTI, - Nausea and vomiting intake during any
pre& post-surgical procedures, Hematology: diarrhea attack.
bone & joint, infections, dental - Anemia - Ice chips and crackers to
Co amoxiclav
infections. - Neutropenia prevent nausea and
GENERIC NAME
Allergic reactions vomiting
- Itching - The drug must be taken
1.2 gms in equal doses around
- Rashes
DOSE MECHANISM OF ACTION CONTRAINDICATIONS the clock to maintain
- Wheezing
Co-amoxiclav is an antibacterial History of penicillin level in the blood.
- Hepatitis
Every 8 hours combination consisting hypersensitivity. Super - This could indicate
of amoxicillin (as sodium) and infections involving - cholestatic
FREQUENCY - jaundice allergy to drug and it
the beta-lactamase inhibitor, Pseudomonas or candida. should be reported.
clavulanic acid (as potassium Pregnancy & lactation. - Dose with caution and
clavulanate). Amoxicillin is the 4- monitor hepatic
TIME hydroxy analogue of ampicillin. function at regular
Amoxicillin hinders the cell wall interval
IVTT synthesis of sensitive bacteria.
ROUTE