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Submitted to: Ms. Pamela Montecarlo Garlet, RN
Submitted by: Jesse James Edjec BN3N
Date DECEMBER 1, 2009
II. TABLE ON CONTENTS
I. Introduction --------------------------------------------------------------------II. Objectives ---------------------------------------------------------------------III. Anatomy and Physiology --------------------------------------------------IV. Definition of Terms ---------------------------------------------------------V. Baseline Data -----------------------------------------------------------------VI. Nursing History (Gordon’s Functional Health Pattern) ----------------VII. Health History --------------------------------------------------------------VIII. Assessment -----------------------------------------------------------------IX. Laboratory and Radiology -------------------------------------------------X. Pathophysiology --------------------------------------------------------------XI. Nursing Care Plan -----------------------------------------------------------XII. Drug Study ------------------------------------------------------------------XIII. Health Teaching -----------------------------------------------------------XIV. Bibliography ----------------------------------------------------------------
Patient R.C. is a 17 year-old boy who was admitted at the CLMMRH last November 24, 2009 due to severe pain at her right lower quadrant, the patient was diagnosed with acute appendicitis. The patient underwent emergency appendectomy few hours prior to admission when he had sudden onset of epigastric pain, that later localized to the right lower quadrant. Appendicitis is the inflammation of the vermiform appendix and was first described as a pathologic condition by Reginald Fitz in 1886; it is caused by an obstruction attributed to infection, stricture, fecal mass, foreign body or tumor. Appendicitis can affect either gender at any age, but is most common in male ages 10-30. Appendicitis is the most common disease requiring surgery and one of the most commonly misdiagnosed diseases. Appendectomy, removal of the appendix, is the standard treatment for acute appendicitis, it is important to immediately remove the appendix after the diagnosis to prevent the occurrence of the life-threatening complication of appendix. The most frequent complication of appendicitis is perforation. Perforation of the appendix can lead to a periappendiceal abscess (a collection of infected pus) or diffuse peritonitis (infection of the entire lining of the abdomen and the pelvis). The major reason for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours after the onset of symptoms is at least 15%. Therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay. I have never experienced appendicitis my whole life, and thus I am grabbing this opportunity to uncover certain answers and find solutions or interventions in handling this kind of disease. This discussion is very important to me because acute appendicitis is one of the most common surgical emergencies seen in the Philippines. Over 250,000 appendectomies are performed annually.
II. NURSING OBJECTIVE
• To widen and enhance the student nurse’s knowledge and skills through additional research about the nature of the disease, its signs and symptoms, its pathophysiology, its diagnosis and treatment. • Gather as much information and knowledge about appendicitis which is one of the most common surgical emergencies in the country. • To formulate the appropriate nursing intervention and plan of care to prevent further complications as well as to promote wellness
• To obtain necessary information regarding the patient and her condition • To assess the patient’s overall health status • To identify patient’s health care needs through analysis of all the data gathered • To assist the patient throughout rehabilitation, recovery and discharge • To impart necessary health teachings to the patient • To perform appropriate nursing care in conjunction with the condition of the patient
III. ANATOMY AND PHYSIOLOGY
The Appendix is a closed-ended, narrow tube up to several inches in length that attaches to the cecum , the first part of the colon, like a worm. The anatomical name for the appendix is vermiform appendix which means worm-like appendage. It's pencil-thin and normally about 4 inches (7 cm) long. The appendix is usually located in the right iliac region, just below the ileocecal valve (designated McBurney's point) and can be found at the midpoint of a straight line drawn from the umbilicus to the right anterior iliac crest. The inner lining of the appendix produces a small amount of mucus that flows through the open center of the appendix and into the cecum. The wall of the appendix contains lymphatic tissue that is part of the immune system for making antibodies. During the first few years of life, the appendix functions as a part of the immune system, it helps make immunoglobulin. But after this time period, the appendix stops functioning. However, immunoglobulins are made in many parts of the body; thus, removing the appendix does not seem to result in problems with the immune system. Like the rest of the colon, the wall of the appendix also contains a layer of muscle, but the muscle is poorly developed. The large intestine is the second to last part of the digestive system—the final stage of the alimentary canal is the anus —in vertebrate animals. Its function is to absorb water from the remaining indigestible food matter, and then to pass useless waste material from the body. This article is primarily about the human gut, though the information about its processes are directly applicable to most mammals. The large intestine consists of the cecum and colon. It starts in the right iliac region of the pelvis, just at or below the right waist, where it is joined to the bottom end of the small intestine. From here it continues up the abdomen, then across the width of the abdominal cavity, and then it turns down, continuing to its endpoint at the anus. The large intestine is about 1.5 metres (4.9 ft) long, which is about one-fifth of the whole length of the intestinal canal. The cecum or caecum (from the Latin caecus meaning blind) is a pouch, connecting the ileum with the ascending colon of the large intestine. It is separated from the ileum by the ileocecal valve (ICV) or Bauhin's valve, and is considered to be the beginning of the large intestine. It is also separated from the colon by the cecocolic junction.
IV. DEFINITION OF TERMS
ABDOMEN - the part of the body of a vertebrate that contains the stomach, intestines, and other organs APPENDIX - anatomy small outgrowth from large intestine: a blind-ended tube leading from the first part of the large intestine (cecum), near its junction with the small intestine. In humans it is small, occurs in the lower right-hand part of the abdomen, and contains cells of the immune system APPENDICITIS - Acute inflammation of the vermiform (wormlike) appendix, a blind tube projecting from the cecum APPENDECTOMY - operation to remove appendix: a surgical operation to remove the appendix ALIMENTARY CANAL - the principal part of the digestive system. It begins at the mouth and extends to the anus ANUS - the opening at the lower end of the alimentary canal through which feces are released CECUM - the pouch in which the large intestine begins, which is open at one end COLON – the large intestine EPIGASTRIUM - the upper middle part of the abdomen ILEOCECAL VALVE - a membranous structure between the cecum and the small intestine that regulates the passage of food material from the small intestine to the large intestine and also prevents the passage of toxic waste products from the large intestine back into the small intestine IMMUNOGLOBULIN - glycoprotein with a high molecular weight that acts like an antibody and is produced by white blood cells during an immune response
INFECTION - injurious contamination of the body or part of the body by pathogenic agents, such as fungi, bacteria, protozoa, rickettsiae, or viruses, or by the toxins that these agents may produce LARGE INTESTINE - last section of the intestinal tract: the end section of the alimentary canal reaching from ileum to anus, and consisting of the cecum, colon, and rectum. Its function is to extract water and form feces MCBURNEY'S POINT - and can be found at the midpoint of a straight line drawn from the umbilicus to the right anterior iliac crest OBSTRUCTION - block or hindrance: somebody or something that causes or forms a blockage or hindrance PATHOLOGIC - extreme: uncontrolled or unreasonable PERFORATION - making holes or having them: the act of making a hole or holes in something or the state of being perforated PERITONITIS - inflammation of abdomen lining: inflammation of the membrane that lines the abdomen (peritoneum) PERIUMBILICAL AREA – within the umbilicus ROVSIGN SIGN - exist when the lower left abdomen is palpated by the doctor, but causes pain in the right PSOAS SIGN - If the hip is moved and stretched, this can cause pain to be felt at the spot where the appendix lies STRICTURE - a severe criticism or strongly critical remark TUMOR - an abnormal uncontrolled growth or mass of body cells, which may be malignant or benign and has no physiological function
V. BASELINE DATA
Name: R. C. Address: Talisay city Age: 17 No. of Dependents: Birthdate: September 19, 1992 Birthplace: Kabangkalan City Gender: Male Civil Status: Single Religion: Roman Catholic Educational level: College level Nationality: Filipino Occupation: none Date of admission: November 24, 2009 Attending Physician: Dr. Taroja Chief complaint: Abdominal Pain Date of surgery: November 24, 2009
VI. NURSING HISTORY (Gordon’s Functional health pattern)
1. HEALTH MAINTENANCE – PERCEPTION PATTERN > The client consults his doctor whenever he experiences some changes regarding his health; this includes stomach pain, high fever, and any other health problems. He never believed in “hilots” or any natural remedies. He takes medicines such as biogesic for fever, solmux for occasional cough and some antibiotics. He also takes clusivol and enervon once a day as his daily supplement.
2. NUTRITION – METABOLIC PATTERN > Patient eats 3 times a day and drinks water at same time. Has good appetite and has no significant dietary restrictions. He said that he is heavier before than the present. He likes to eat different kinds of foods, especially chicken adobo. He doesn’t like his food dry, it always comes with a soup.
3. ELIMINATION PATTERN > Patient approximately voids 5 times a day and defecates everyday. This is his elimination pattern before his hospitalization. Under normal conditions, client has normal elimination pattern, but due to his operation, his elimination pattern is also altered.
4. ACTIVITY AND EXERCISE PATTERN > Client does his own self exercise, he jogging and crutches during weekends
5. SLEEP AND REST PATTERN > Client has no problem when it comes to rest or sleep periods. He sleeps 8 hours a day, from 9pm till 7 in the morning, he sometimes takes a nap in the afternoon.
6. COGNITIVE PERCEPTION > Patient has complete level of visual, auditory, olfactory and gustatory functioning and can speak or pronounce words clearly.
7. SELF-PERCEPTION SELF-CONCEPT PATTERN > Client is on appropriate age, he has high level of self-esteem. And very confident in facing different kinds of personalities.
8. ROLE RELATIONSHIP PATTERN > Client is the second child from the five children. He has his own responsibilities in doing chores inside the house, and responsible for the safety of his younger sisters and brothers.
9. SEXUALITY RELATIONSHIP PATTERN > Client has no experienced of having a companion of his opposite sex. And is not experiencing any problems with regards to his reproductive organs and sexual response.
10. COPING-STRESS PATTERN > When the client experience some difficulties and problems he shares it to his friends and ask them for opinions and solutions. He plays computer as his problem management.
11. VALUES AND BELIEF PATTERN > Client has no beliefs in other religions. He is a roman catholic and he doesn’t believe in any other Gods. He has its own values in life that has been taught by their churh.
VI. HEALTH HISTORY
1. History of Present Illness Patient was in usual state of good health until November 24, 2009, after having his dinner he experienced a severe pain at his abdomen which started at the area around his periumbilical area shifted to right lower quadrant region. He was immediately rushed to the hospital and was admitted at CLMMRH at 9:55 PM, He was diagnosed with acute appendicitis. He underwent an emergency appendectomy a few hours prior to admission, November 23, 2009. Her operation begun at 12:08 AM and ended at 12:40 AM, her surgeon was Dr. Taroja According to the patient, He had been experiencing mild pain at her abdominal region since he was 14 years old, He even consulted it to the doctor but they did not pay much attention to it thinking that it was just a manifestation of his kidney problem and that it was nothing serious. The patient’s vital signs during the shift were as follow: Temperature: 36.2 °C Pulse Rate: 86 bpm Respiratory Rate: 20 cpm Blood Pressure: 120/80 mmHg 2. Past Health History a. Childhood illness > The client has only experienced stomach pain and minor health problems such as occasional cough, colds, and mild fever. b. Past Hospitalization > Patient has no previous hospitalization, no history of Hypertension, Diabetes, Cancer, no known allergies. c. Serious/ chronic illness > The client has no experience of any serious or chronic illness. He only experienced stomach pain and minor health problems such as occasional cough, colds, and mild fever. d. Previous Surgery > No previous history of surgical operation. 3. Family/ Social History No known family history of Hypertension, diabetes, pulmonary tuberculosis, cancer, allergies and other hereditofamilial diseases.
Systems Review Cephalo Caudal a. General appearance > Neat Appearance with dark complexion and short curly hair > Wearing T-shirt with matching long pants b. Vital signs > Blood Pressure: 120/80 mmHg > Temperature: 36.2°C > Pulse Rate: 86 bpm > Respiratory Rate: 20 cpm c. Integumentary > Warm to touch; Afebrile, T: 36.2°C > With good skin turgor d. Cardiovascular > With IVF #1 PLR 1L x 100cc/hr, infusing well at right cephalic vein > Blood pressure of 120/80 mmHg, Pulse rate of 80 bpm > With good capillary refill at less than 2 seconds e. Respiratory > Breathes spontaneously to room air at 34 cpm > With symmetrical rise and fall of chest upon respiration f. Abdomen > Flat abdomen with thumblike protrusion of his right lower quadrant g. Gastrointestinal Tract > On NPO as ordered > Has not defecated upon assessment > Able to pass out flatus upon assessment > With normoactive bowel sounds at 13 cpm h. Gastrourinary Tract > Able to void freely to a light yellow colored urine i. EENT > Pupils Equally Round and Reactive to Light Accommodation > With pinkish conjunctiva j. Musculoskeletal > Moderately active, moving freely; ambulatory
IX. LABORATORY AND RADIOLOGY HEMATOLOGY REPORT Test requested: CBC, Platelet (November 24, 2009) Laboratory/ Results Normal values Diagnostic Test Hemoglobin 163 g/L 130-180 Hematocrit 0.49 % 0.40-0.54 RBC Count 5.4 x 4.5-6.2 COAGULATION PROFILE Platelet Count 290 x10 150-450 WBC Count DIFFERENTIAL COUNT Neutrophil Segmented Lymphocytes Eosinophil TOTAL 19.4 x109/L 4.5-10.0 55-65 50-60 25-35 1-3
Interpretations normal normal Normal normal increased
81 18 01 100
% % % %
increased decreased normal
URINALYSIS REPORT (November 24, 2009) COLOR CHARACTER ALBUMIN REACTION SPECIFIC GRAVITY PUS CELL SQUAMOUS BACTERIA NORMAL Light or pale Yellow Clear (-) 4.6-8 1.010-1.025 0 (-) (-) ACTUAL Light Yellow Slightly turbid (-) 6.5 pH 1.010 2-4 (+) (+) Implication Normal Abnormal Normal Normal Normal Abnormal Abnormal Abnormal Nursing Responsibility > increase fluid intake
> increase fluid intake >Administer antibiotic as ordered > increase fluid intake >Administer antibiotic as ordered > increase fluid intake > increase intake of Vitamin C >Administer antibiotic as
IDEAL LABORATORY STUDIES:
1. WHITE BLOOD CELL COUNT The white blood cell count in the blood usually becomes elevated with infection. In early appendicitis, before infection sets in, it can be normal, but most often there is at least a mild elevation even early. Unfortunately, appendicitis is not the only condition that causes elevated white blood cell counts. Almost any infection or inflammation can cause this count to be abnormally high. Therefore, an elevated white blood cell count alone cannot be used as a sign of appendicitis.
2. ABDOMINAL X-RAY An abdominal x-ray may detect the fecalith (the hardened and calcified, peasized piece of stool that blocks the appendiceal opening) that may be the cause of appendicitis. This is especially true in children.
3. ULTRASOUND An ultrasound is a painless procedure that uses sound waves to identify organs within the body. Ultrasound can identify an enlarged appendix or an abscess. Nevertheless, during appendicitis, the appendix can be seen in only 50% of patients. Therefore, not seeing the appendix during an ultrasound does not exclude appendicitis. Ultrasound also is helpful in women because it can exclude the presence of conditions involving the ovaries, fallopian tubes and uterus that can mimic appendicitis.
4. LAPAROSCOPY Laparoscopy is a surgical procedure in which a small fiber optic tube with a camera is inserted into the abdomen through a small puncture made on the abdominal wall. Laparoscopy allows a direct view of the appendix as well as other abdominal and pelvic organs. If appendicitis is found, the inflamed appendix can be removed with the laparascope. The disadvantage of laparoscopy compared to ultrasound and CT is that it requires a general anesthetic.
X. PATHOPHYSIOLOGY Obstruction of the appendix (by fecalith, lymph node, tumour, foreign objects)
Increase intraluminal pressure
Distention of the Appendix
→ causes pain
Decrease venous drainage
Blood flow and oxygen restriction to the appendix
Bacterial Invasion of the Blood wall
Necrosis of the appendix
Acute pain on RLQ The pathophysiology of appendicitis is the constellation of processes that leads to the development of acute appendicitis from a normal appendix. The main thrust of events leading to the development of acute appendicitis lies in the appendix developing a compromised blood supply due to obstruction of its lumen and becoming very vulnerable to invasion by bacteria found in the gut normally. Obstruction of the appendix lumen by fecalith, enlarged lymph node, worms, tumor, or indeed foreign objects, brings about a raised intra-luminal pressure, which causes the wall of the appendix to become distended. Normal mucus secretions continue within the lumen of the appendix, thus causing further build up of intra-luminal pressures. This in turn leads to the occlusion of the lymphatic channels, then the venous return, and finally the arterial supply becomes undermined. Reduced blood supply to the wall of the appendix means that the appendix gets little or no nutrition and oxygen. It also means a little or no supply of white blood cells and other natural fighters of infection found in the blood being made available to the appendix. The wall of the appendix will thus start to break up and rot. Normal bacteria found in the gut gets all the inducement needed to multiply and attack the decaying appendix within 36 hours from the point of luminal obstruction, worsening the process of appendicitis. This leads to necrosis and perforation of the appendix. Pus formation occurs when nearby white blood cells are recruited to fight the bacterial invasion. A combination of dead white blood cells, bacteria, and dead tissue makes up pus. The content of the appendix (fecalith, pus and mucus secretions) are then released into the general abdominal cavity, bringing causing peritonitis.
So, in acute appendicitis, bacterial colonization follows only when the process have commenced. These events occur so rapidly, that the complete pathophysiology of appendicitis takes about one to three days. This is why delay can be deadly. Pain in appendicitis is thus caused, initially by the distension of the wall of the appendix, and later when the grossly inflamed appendix rubs on the overlying inner wall of the abdomen (parietal peritoneum) and then with the spillage of the content of the appendix into the general abdominal cavity (peritonitis). Fever is brought about by the release of toxic materials (endogenous pyrogens) following the necrosis of appendicael wall, and later by pus formation. Loss of appetite and nausea follows slowing and irritation of the bowel by the inflammatory process. Early symptoms of appendicitis are those symptoms that most people with this condition may recognize and complain of. They include lower right sided abdominal pain of gradual onset, feeling sick (or nausea), and loss of appetite. Any one with these three symptoms can be assumed to have appendicitis until proven otherwise.
Abdominal pain This pain typically starts from around the belly button (peri-umbilical region), or the upper central abdomen (epigastrium) and then move downwards and to the lower right abdomen (right iliac fossa). When the pain occurs in this pattern, it is the most dependable of all symptoms of appendicitis, as over 8 out 10 (80%) cases that present this way is definitely due to the appendix. In some other individuals, the pain starts right way from the right iliac fossa. Depending on where the tip of the appendix is, the pain could even be on the right flank (retrocaecal appendix). If the appendix is quite long, and in the pelvic cavity, it could as well cause lower left abdominal pain, with frequent passage of urine if the inflamed appendix irritates the bladder. When the appendix is severely inflamed, the pain can be localized to a spot on the outer one third of a line drawn between the belly button and front of the tip of the waist bone called the McBurney’s point. The Mc Burney’s point is also often the point of maximum tenderness when the abdomen is examined. The pain is even worse when the hand is suddenly removed from that spot because of the appendix rubbing on the covering of the abdomen (Rebound tenderness). There is also a sign referred to as the Rovsign sign. This is said to exist when the lower left abdomen is palpated by the doctor, but causes pain in the right. If the appendix is the pelvic type, examining the back passage (rectal examination) would cause some pain too. If the hip is moved and stretched, this can also cause pain to be felt at the spot where the appendix lies. This is referred to as the psoas sign.
XI. Nursing Care Plan >
PRE-OPERATIVE NURSING CARE PLAN
Assessment Diagnosis > Anxiety related to impending surgery as evidenced by restlessness Definition: Disturbed behavior is due to apprehension of the outcome of the surgery and imagined threat to one’s health. Anxiety A state of apprehension, uncertainty, and fear resulting from the anticipation of a realistic or fantasized threatening event or situation, often impairing physical and psychological functioning. Rationale Expected Outcome
After days of nursing interventions, the client will be able to:
Independent: 1.Perform a comprehensive assessment of pain
> poor eye contact >Extraneous movement (rocking movements) >Restlessness
Appendicitis ↓ Admission ↓ Appendectomy ↓ Anxiety
Verbalize awareness of feelings of anxiety.
- to include location, characteristics, duration frequency, severity (0 to 10 or face scale) and precipitating/ aggravating factors. - This can point to
After 8 hour of nursing interventions: 1- Goal met:
2. Observe the
the client has able to manage pain and smile And able to verbalize awareness of feelings of anxiety.
“Nakulbaan ko sa operasyon na matabo” as verbalized by the patient.
Risk: poor eating habits & change in usual foods pattern Strength: good family support and optimistic in life
clients behavior. Note any unusual activities.
3. Encourage adequate rest periods
the clients level of anxiety.
2- Goal met: the client has able to defecate during my shift 3.- Goal met: the client has able to play with his younger brother and cheery smile noted
2. Defecate - to prevent fatigue
3. Continue usual daily activities.
Collaborative: 1. Administer anti- Helps to manage
anxiety drugs/sedatives, as ordered. 2. Review medications regimen and possible interactions, especially with OTC drugs/alcohol, and so forth. Discuss appropriate drug substitutions,
the pt. experiencing anxiety.
- Helps minimize
side effects of drugs that may aggravate the condition.
changes in dosage or time of dose.
1 Risk (NCP) > POST-OPERATIVE Assessment
NURSING CARE PLAN
Rationale Expected Outcome Nursing Intervention Justification Evaluation
Actual Objective: >Facial Grimace >Guarding behavior >Cannot ambulate >Pain score of 6 >Incision site in the abdomen (7 inches) is erythematous. Subjective:
>Acute pain related to tissue injury secondary to surgical intervention as evidenced by report of 6 pain scale. Definition: Pain is characterized by its intensity, location and duration Acute Pain is common to the client who undergone surgery procedure because there is a break in the skin Source: NANDA
Appendicitis ↓ Admission ↓ Appendectomy ↓ Post appendectomy ↓ Presence of surgical incision ↓ Acute pain
After days of nursing interventions, the client will be able to:
Independent: 1.Perform a comprehensive assessment of pain
“Nagasaki tang akun tinay-an”. verbalized by the patient.
Risk: poor eating habits & change in usual foods pattern Strength: good family support and optimistic in life
1. Verbalize reduction of pain from 6 to 4. and will be able to ambulate
2. The Client will be able to demonstrate nonpharmacologi cal technique for relaxation.
Encourage use of relaxation techniques
2. 3. Provide comfort
- to include location, characteristics, duration frequency, severity (0 to 10 or face scale) and precipitating/ aggravating factors. - To distract attention
After 8 hour of nursing interventions:
and reduce tension
1- Goal met:
the client has able to manage pain and smile
4. Encourage adequate rest periods Collaborative: 1. Administer
promote no pharmacological pain management
- to prevent fatigue 2- Goal met: Client has able to maintain pain level and have not aggravated.. and breathing exercise noted
analgesics, as indicated
2. Review medications regimen and possible interactions, especially with OTC drugs/alcohol, and so forth. Discuss appropriate drug substitutions, changes in dosage or time of dose.
maintain “acceptable” level of pain
- Helps minimize side
effects of drugs that may aggravate the condition.
XII. DRUG STUDY Name of Drug Dosage Frequency Route
30mg, IVTT q8
Mechanism of action
1. Ketorolac tromethamine (Toradol) CLASSIFICATION: CNS drugs / NSAID’s
Possesses antiinflammatory, analgesics and antipyretic effects
> Management of severe, acute pain in adults that requires analgesia and the opiate level, usually in a postoperative setting
> Hypersensitivity to the drug or allergic symptoms to aspirin or other NSAID’s. > Active peptic ulcer , recent GI bleeding or perforation, history of peptic ulcer or GI bleeding. > Advanced renal impairment
CNS: drowsiness, sedation, dizziness, headache CV: edema, hypertension, palpitations, arrhythmias GI: nausea, dyspepsia, GI pain, diarrhea, peptic ulceration, vomiting, constipation, flatulence, stomatitis Hematologic: decreased platelet adhesion, pupura, prolonged bleeding time Skin: pruritus, rash, diaphoresis Other: pain at injection site CNS: vertigo, malaise, headache. EENT: blurred vision Hepatic: jaundice Other: burning and itching at injection site, anaphylaxis, angioedema
> Use as part of a regular analgesic schedule rather than on as needed basis.> Give oral form with meals > If pain returns within 3-5 hours, the next dose can be increased by up to 50 % > Do not mix IV/IM ketorolac in a small volume with morphine sulfate, meperinide HCL, promethazine HCL, or hydroxyzine HCL, will precipitate from solution.
2. Ranitidine CLASSIFICATION: GIT drugs / Antiulcer drugs
50mg, IVTT q8
Inhibits histamine at H2 receptor site in the gastric parietal cells, which inhibits gastric acid secretion.
> Used in the management of various gastrointestinal disorders such as dyspepsia gastrointestinal reflux disease [GERD], peptic ulcer and zolungerellisou syndrome. Prophylaxis of GI hemorrhage from the stress ulceration and in patients at risk of developing acid aspiration during general anesthesia prophylaxis of mendelson syndrome.
> Hypersensitivity to drug or its components > Alcohol intolerance (with some oral products) > History of acute porphyria.
> Assess patient for abdominal pain. Note presence of blood in emesis, stool, or gastric aspirate > Ranitidine may be added to total parenteral nutrition solution > Evaluate results of laboratory tests, therapeutic effectiveness and adverse reactions (bradycardia, PVC’s, tachycardia, CNS changes, rash, gynecomasticia, GI disturbance and hepatic failure.) > Assess knowledge and teach patient appropriate use, possible side effects or appropriate interventions and adverse symptoms to report.
Name of Drug
Dosage Frequency Route
500mg, 1 tab TID
Mechanism of action
1. Cefuroxime CLASSIFICATION: Anti-invectives/ Cephalosporins
Second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
> Perioperative prevention
> Contraindicated in patients hypersensitivity to drug or other cephalosporins. >Use cautiously in patients hypersensitive to penicillin because of possibility of crosssensitivity with other beta-lactam antibiotics.
CV: phlebitis, thrombophlebitis GI: pseudomembranous colitis, nausea and vomiting, anorexia, diarrhea Hematologic: transient neutropenia, eosinophilia, hemolytic anemia, thrombocytopenia. Skin: maculopapular and erythematous rashes, urticaria, pain, induration, sterile abscesses, temperature elevation. Other: hypersensitivity reactions, serum sickness, anaphylaxis. CNS: dizziness, headache, insomnia, fatigue CV: arrhythmias, palpitations, tachycardia, heart failure, hypertension GI: abdominal pain, diarrhea, dyspepsia, flatulence
> Before administration, ask patient if he is allergic to penicillin or cephalosporins. > Obtain specimen for culture and sensitivity tests before giving first dose. > For I.M. administration, inject deep into a large muscle, such as the gluteus maximus or the lateral aspect of the thigh > Absorption of cefuroxime is enhanced by food.
2. Meloxicam CLASSIFICATION: NSAID, CNS drug
15mg, 1 tab OD prn for pain
Unknown, may inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic and antipyretic effects
> Relief from pain
> Contraindicated in patients hypersensitivity to drug.
> Rehydrate dehydrated patients before starting drug > Watch for signs and symptoms of overt poor overall health >NSAIDs can cause fluid retention: closely monitor patients who have hypertension, edema, or heart failure. > ascorbic acid aren’t interchangeable; verify preparation before use. > Make sure powders are completely dissolved before giving. >Enteric-coated tablets aren’t recommended because of increased risk of GI bleeding and small-bowel ulcerations.
3. Ascorbic acid CLASSIFICATION: Vitamin C
250mg 1 tab BID
Vitamin C is essential in the synthesis of collagen, a connective tissue protein of the body
> vitamin C deficiency > Post operative incisions
> Contraindicated in patients hypersensitivity to ascorbic acid >Large doses of vitamin C should be given with care to patients with hyperoxaluria.
CNS: paresthesia of limbs, listlessness, confusion, flaccid paralysis. CV: arrhythmias, heart block, hypotension ECG changes. GI: nausea, vomiting, diarrhea Metabolic: hyperkalemia Respiratory: respiratory paralysis.
XIII. HEALTH TEACHING
Ketorolac tromethamine (Toradol) 30mg IVTT q8
` for acute pain
Personal hygiene pertains to hygiene practices performed by an individual to care for one’s bodily health and well being through cleanliness. Conditions and practices that serve to promote or preserve health. Personal hygiene practices include: seeing a doctor, seeing a dentist, regular washing (bathing or showering) of the body, regular hand washing, brushing and flossing of the teeth, and healthy eating. >self-help bath/Bed bath >Tepid sponge bath >Brushing and flossing the teeth - to remove dental plaque >providing special oral care -to maintain intactness of health of lips, tongue and mucus membranes of the mouth. -to prevent oral infections
> Continue prescription drugs if symptoms comes back >Compliance to follow up check ups > Continue ROM and leg exercises - to avoid further complications to health > Adequate fluids - for hydration > Prevention/Promoti on of diseases must be implemented > Rest for comfort > Careful handling of items in the environment, to minimize viral contamination.
> LEG EXERCISES - to promote blood circulation. Moderate exercise in the morning within the patient’s limit and with rest. Inform client that the normal activity can be resumed after 3-4 weeks.
` Ranitidine 50mg, IVTT
q8 For inhibiting gastric acid secretion. `Teach the patient & folks about the indications of the drugs and let them know the effect & adverse effects of the medications. Client must understand the importance of drugs to their body and why they must acquire it. Remind them to question and not to administer medication that have been, improperly stored, look discolored, or do not look like their usual medication. Advise the patient to always read the label before taking a drug, to take it exactly as prescribed, and never to share prescription drugs. Encourage them to ask further questions about their drugs. After discussion make sure the client understands and ask to repeat if verification is needed.
> Ketorolac - Management of severe, acute pain in adults that requires analgesia and the opiate level, usually in a postoperative setting. > Ranitidine - inhibits gastric acid secretion. Used in the management of various gastrointestinal disorders such as dyspepsia and patients at risk of developing acid aspiration during general anesthesia prophylaxis of mendelson syndrome. Laboratory test >Regular monitoring of CBC (platelets) - To prevent lowering of platelets that may cause spontaneous bruising & bleeding > Urinalysis - serves as indication for infection.
Practice of ingesting food in a regulated fashion to achieve or maintain a controlled weight. In most cases the goal is weight loss in those who are overweight or obese, but some athletes aspire to gain weight (usually in the form of muscle) and diets can also be used to maintain a stable body weight. > Balanced diet - Eat fresh fruits and vegetables for essential nutrients and minerals - strengthen immunity > Avoid junk and street foods - to avoid GIT infections - to prevent complications such as amoeba and hepatitis. > Regular bowel elimination
>ROM -for circulation improvement. Exercises may not be important, but it can minimize the chance of acquiring and spreading of diseases.
1. Brunner and Suddarth's Textbook of Medical-Surgical Nursing i. by Suzanne C. Smeltzer and Brenda G. Brade 2. Fundamentals of Nursing by Kozier 3. Nurses’s Drug Handbook by George R. Spratto and Adrienne L. Woods
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