Don Mariano Marcos Memorial State University

South La Union Campus

COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES
Agoo, La Union
Tel. 072.682.0663/ichams.dmmmsu-sluc.com
Embracing World Class Standards NURSING DEPARTMENT Care to learn, Learn to care

Name: JOSELYN M. LACHICA Program and Course: BSN IV

CASE 1 – CLIENT IN MECHANICAL VENTILATION

TASK 1: Using the ABC, Identify the life threatening injuries of the patient. Why?
 Airway – patent airway with no signs of current obstruction
 Breathing – tachypneic and regular with increased effort displayed by accessory muscle
use
 Circulation – tachycardia and mild hypotension. 1+ distal pulses bilaterally and skin is
warm and dry

TASK 2: With the given data on the scenario, furnish the Kardex in the chart.

KARDEX
Name of Patient: ____Patient A____________ Age: 42 Sex: Male C.S.:_____
Address: ______________________________ Religion: _______ Service: ______ Ward: ______
Date Admitted: October 10, 2020 @11:30PM Admitting Diagnosis: _________________________
Admitted by: __________________________ Allergies: _____________________
Surgical Intervention: _____________________________ Date Discharged: _______________

Date Nursing Needs Date Nursing Intervention

Resolved
Identified

Date Diagnostic Procedure Date Treatment/Management/Diet

10/12/20 Head CT Scan 10/10/20 Admitted Medical ICU

Neurologic Monitoring taken
on 02 support of non-rebreathing
mask at 10 lpm
10/11/20 NGT & IFC draining
Referred to Anesthesia

Date Intravenous/Blood Transfusions Date Special Endorsement

Consumed

10/10/20 IVF of PNSS 1 l x 8 hours

10/11/20 IVF of PNSS 1L + 40 meqs KCL to run for Patient is placed flat on bed and
8 hours at 800 cc level tube vent is placed at 10 cm level
draining to yellowish fluid of 10 cc.
Maintain in NPO
 IVF to follow: PNSS 1 L + 40 meqs
Kcl x 8 hours then IVF of PNSS 1L +
20 meqs kcl x 8 hours then PNSS 1L
x 8 hours rate.
Watched out for decreased in
sensorium, increasing restlessness,
signs and symptoms of IICP, sign
and symptoms of bleeding,
difficulty of breathing and
decreasing urinary output.

Date Medication Ordered Date Operation Schedule if Any

Totilac 100 ml every 6 hours 10/11/20 Intubated and on general

anesthesia during operation.
Ceftriaxone 1-gram iv q8h, 3:00-4:00 Operation started
10/10/2020
am
Tranexamic acid 500 mg iv q8h
One dose of vit k/amp given
10/11/2020 Paracetamol 600 mg iv every 4 hours for
3 days
Fentanyl 2 mg iv every 2 hours
TASK 3: Make a drug study on the medications given to the patient.

DRUG STUDY
DRUG NAME
(GENERIC NAME,
DRUG MECHANISM OF SIDE EFFECTS AND NURSING
BRAND NAME, CONTRAINDICATIONS
CLASSIFICATION ACTION ADVERSE REACTIONS RESPONSIBILITIES
DOSE, ROUTE,
DOSAGE)
Ceftriaxone Third-Generation Chemical Effect: CNS: dizziness, fever, Contraindicated in  Assess patient’s
Cephalosporin Inhibits cell-wall headache patients hypersensitive infection before therapy
Generic name: synthesis, promoting GI: diarrhea, dysgeusia, to drug or other and regularly thereafter.
Ceftriaxone Antibiotic osmotic instability; nausea, cephalosporins.  Before giving first dose,
usually bactericidal. pseudomembranous obtain specimen for
Brand name: colitis, vomiting culture and sensitivity
Rocephin Therapeutic Effect: GU: genital pruritis and tests. Begin therapy
Hinders or kills candidiasis pending test results.
Dose: 1g susceptible bacteria. Hematologic:  Before giving first dose,
eosinophilia, leukopenia, ask patient about
Route: IV thrombocytosis previous reactions to
Skin: pain, induration, and cephalosporins or
Dosage: q8 tenderness at injection penicillin. Be alert for
site; phlebitis; rash adverse reactions and
Other: hypesensitivity drug interactions.
reactions (serum sickness,  If adverse GI reactions
anaphylaxis) occur, monitor patient’s
hydration.
 Assess patient’s and
family’s knowledge of
drug therapy.
 DRUG NAME
(GENERIC NAME,
DRUG MECHANISM OF SIDE EFFECTS AND NURSING
BRAND NAME, CONTRAINDICATIONS
CLASSIFICATION ACTION ADVERSE REACTIONS RESPONSIBILITIES
DOSE, ROUTE,
DOSAGE)
Fentanyl Opioid Chemical Effect: CNS: anxiety, asthenia, Contraindicated in  Assess patient’s
May bind with opiate clouded sensorium, patients intolerant of underlying condition
Generic name: Analgesic receptors in CNS, confusion, depression, drug. Transdermal before starting therapy.
Fentanyl altering both dizziness, euphoria, fentanyl is  Evaluate degree of pain
Anesthetic perception of and hallucinations, headache, contraindicated in relief provided by each
Brand name: emotional response nervousness, sedation, patients hypersensitive dose.
Sublimaze to pain. somnolence to adhesives; patients  Periodically monitor
CV: arrhythmias, who need postoperative postoperative vital signs
Dose: 2mg Therapeutic Effect: bradycardia, chest pain, pain management; and bladder function.
Relieves pain. hypertension, hypotension patients who have Because drug
Route: IV EENT: dry mouth acute, mild, or decreases both rate and
GI: abdominal pain, intermittent pain that depth of respirations,
Dosage: q2 constipation, ileus, can be managed with monitoring or arterial
nausea, vomiting nonopioid drugs; and oxygen saturation may
GU: urine retention patients who aren’t help assess respiratory
Respiratory: apnea, opioid tolerant. Don’t depression.
dyspnea, hypoventilation, use in patients with  Be alert for adverse
respiratory depression increased intracranial reactions and drug
Skin: diaphoresis, pruritus pressure, impaired interactions.
Other: physical consciousness, or  Assess patient’s and
dependence, reaction at coma. family’s knowledge of
application site (edema, drug therapy.
erythema, papules)

DRUG NAME DRUG MECHANISM OF SIDE EFFECTS AND CONTRAINDICATIONS NURSING

 (GENERIC NAME,
BRAND NAME,
CLASSIFICATION ACTION ADVERSE REACTIONS RESPONSIBILITIES
DOSE, ROUTE,
DOSAGE)
Paracetamol Para-aminophenol Chemical Effect: Hematologic: hemolytic Contraindicated in  Assess patient’s pain or
Derivative Blocks pain anemia, neutropenia, patients hypersensitive temperature before and
Generic name: impulses, probably leukopenia, pancytopenia, to the drug. during therapy.
Paracetamol Nonopioid Analgesic by inhibiting thrombocytopenia  Assess patient’s drug
prostaglandin or pain Hepatic: jaundice, severe history, and calculate
Brand name: Antipyretic receptor sensitizers. liver damage total daily dosage
Abenol, Elixir, Tylenol May relieve fever by Metabolic: hypoglycaemia accordingly. Many OTC
acting in Skin: rash, urticaria products and
Dose: 600mg hypothalamic heat- combination prescription
regulating center. pain products contain
Route: IV acetaminophen.
Therapeutic Effect:  Be alert for adverse
Dosage: q4 for Relieves pain and reactions and drug
3days reduces fever. interactions.
 Assess patient’s and
family’s knowledge of
drug therapy.

DRUG NAME DRUG MECHANISM OF SIDE EFFECTS AND CONTRAINDICATIONS NURSING

(GENERIC NAME, CLASSIFICATION ACTION ADVERSE REACTIONS RESPONSIBILITIES
 BRAND NAME,
DOSE, ROUTE,
DOSAGE)
Potassium Chloride Potassium Chemical Effect: CNS: mental confusion, Contraindicated in  Assess patient’s
Supplement Aids in transmitting flaccid paralysis, patients with untreated condition before therapy
Generic name: nerve impulses, paresthesia of limbs, Addison disease, and regularly thereafter
Potassium Chloride Mineral contracting cardiac weakness or heaviness of adrenocortical to monitor drug
and skeletal muscle, limbs, listlessness insufficiency, acute effectiveness.
Brand name: Cena- and maintaining CV: ECG changes, dehydration, heat  During therapy, monitor
K, KDur, Slow-K intracellular tonicity, hypotension, arrhythmias, cramps, hyperkalemia, ECG, renal function,
cellular metabolism, heart block, cardiac arrest hyperkalemic form of fluid intake and output,
Dose: 40 meqs acid-base balance, GI: nausea, vomiting, familial periodic and potassium,
and normal renal diarrhea, abdominal pain, paralysis, other creatinine, and BUN
Route: IV function. flatulence, GI ulceration conditions linked to levels.
GU: oliguria extensive tissue  Be alert for adverse
Dosage: To run for 8 Therapeutic Effect: Respiratory: respiratory breakdown, or severe reactions and drug
hours at 800 cc level Replaces and paralysis renal impairment with interactions.
maintains potassium Skin: cold skin, gray oliguria, anuria, or  Assess patient’s and
level. pallor, phlebitis azotemia. family’s knowledge of
Other: irritation at I.V. site drug therapy.

DRUG NAME DRUG MECHANISM OF SIDE EFFECTS AND CONTRAINDICATIONS NURSING

(GENERIC NAME, CLASSIFICATION ACTION ADVERSE REACTIONS RESPONSIBILITIES
BRAND NAME,
 DOSE, ROUTE,
DOSAGE)
Totilac Intravenous & Other Precipitation may Like other IV, reactions Hypersensitivity to  Assess patient’s pain
Sterile Solutions occur with the which may occur because thiamin HCl. Hepatic before starting therapy
Generic name: addition of of the solution or the coma or at risk of and regularly thereafter
Hypertonic Lactate anorganic technique of hepatic coma; severe to monitor drug’s
Solution phosphate, hydrogen administration include renal failure or effectiveness.
carbonate or oxalate. febrile response, infection azothemia; CHF; severe  Be alert for adverse
Brand name: Totilac at the site of injection, acidosis; abnormal reactions and drug
venous thrombosis or electrolyte metabolism; interactions.
Dose: 100ml phlebitis extending from reduced urine output  Assess patient’s and
the site of injection, due to obstructive family’s knowledge of
Route: IV extravasation and uropathy; abnormal drug therapy.
hypervolemia. If an amino acid metabolism.
Dosage: q6 adverse
reaction does occur,
discontinue the
administration, evaluate
the patient, institute
appropriate
therapeutic
countermeasure and save
the remainder of the fluid
for examination if deemed
necessary.

DRUG NAME DRUG MECHANISM OF SIDE EFFECTS AND CONTRAINDICATIONS NURSING RESPONSIBILITIES
(GENERIC NAME, CLASSIFICATION ACTION ADVERSE REACTIONS
BRAND NAME,
 DOSE, ROUTE,
DOSAGE)
Tranexamic Antifibrinolytic Tranexamic acid The more common side Contraindicated in  Monitor blood pressure,
competitively inhibits effects of tranexamic acid patients with pulse, and respiratory
Generic name: Antihemophilic activation of include nausea, diarrhea, hypersensitivity to status as indicated by
Tranexamic Acid plasminogen (via stomach pain or tranexamic acid or any severity of bleeding.
Hemostatic Agent binding to the kringle discomfort, vomiting, of the ingredients.  Monitor for overt
Brand name: domain), thereby chills, fever, severe, bleeding every 15–30
Lysteda Lysine Analog reducing conversion headache (throbbing), min.
of plasminogen to back or joint pain, muscle  Monitor neurologic
Dose: 500mg plasmin (fibrinolysin), pain, muscle stiffness, status (pupils, level of
an enzyme that difficulty moving, runny or consciousness, motor
Route: IV degrades fibrin clots, stuffy nose. activity) in patients with
fibrinogen, and other subarachnoid
Dosage: q8 plasma proteins, hemorrhage.
including the  Assess for
procoagulant factors thromboembolic
V and VIII. complications.(especially
Tranexamic acid in patients with history).
also directly inhibits Notify physician of
plasmin activity, but positive Homans’ sign,
higher doses are leg pain hemorrhage,
required than are edema, hemoptysis,
needed to reduce dyspnea, or chest pain.
plasmin formation.  Monitor platelet count
and clotting factors prior
to and periodically
throughout therapy in
patients with systemic
fibrinolysis.

DRUG NAME DRUG MECHANISM OF SIDE EFFECTS AND CONTRAINDICATIONS NURSING

(GENERIC NAME, CLASSIFICATION ACTION ADVERSE REACTIONS RESPONSIBILITIES
BRAND NAME,
 DOSE, ROUTE,
DOSAGE)
Vitamin K Synthetic Analogue of Chemical Effect: An CNS: dizziness, Contraindicated in  Assess patient’s
Vitamin k antihemorrhagic seizurelike movement patients with condition before starting
Generic name: factor that promotes CV: cardiac irregularities, hypersensitivity to the therapy and regularly
Phytonadione Blood Coagulation hepatic formation of flushing, rapid and weak drug or any of its thereafter to monitor
Modifier active prothrombin. pulse, transient component. drug’s effectiveness.
Brand name: hypotension after I.V.  Monitor PT to determine
Mephyton Therapeutic Effect: administration. dosage effectiveness.
Controls abnormal Skin: diaphoresis,  Failure to respond to
Dose: 1amp bleeding. erythema vitamin K may indicate
Other: anaphylaxis and coagulation defects.
Route: IV anaphylactoid reactions;  Be alert for adverse
cramplike pain; pain, reactions and drug
Dosage: One dose swelling, and hematoma at interactions.
injection site  If adverse GI reactions
occur, monitor patient’s
hydration.
 Assess patient’s and
family’s knowledge of
drug theraphy.