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: DIANNE D. VILLANNUEVA Program and Course: BSN IV

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

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

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

DRUG NAME DRUG CLASSIFICATION MECHANISM OF SIDE EFFECTS AND ADVERSE CONTRAINDICATIONS NURSING RESPONSIBILITIES
(GENERIC NAME, ACTION REACTIONS
 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 of thiamin HCl. Hepatic coma before starting therapy
Generic name: addition of the solution or the technique or at risk of hepatic coma; and regularly thereafter to
Hypertonic Lactate anorganic phosphate, of severe renal failure or monitor drug’s
Solution hydrogen carbonate or administration include azothemia; CHF; severe effectiveness.
oxalate. febrile response, infection at acidosis; abnormal  Be alert for adverse
Brand name: Totilac the site of injection, venous electrolyte metabolism; reactions and drug
thrombosis or phlebitis reduced urine output due interactions.
Dose: 100ml extending from the site of to obstructive uropathy;  Assess patient’s and
injection, extravasation and abnormal amino acid family’s knowledge of
Route: IV hypervolemia. If an adverse metabolism. drug therapy.
reaction does occur,
Dosage: q6 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 CLASSIFICATION MECHANISM OF SIDE EFFECTS AND ADVERSE CONTRAINDICATIONS NURSING RESPONSIBILITIES
(GENERIC NAME, ACTION 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 discomfort, tranexamic acid or any of severity of bleeding.
Hemostatic Agent binding to the kringle vomiting, chills, fever, the ingredients.  Monitor for overt bleeding
Brand name: Lysteda domain), thereby severe, headache every 15–30 min.
Lysine Analog reducing conversion of (throbbing), back or joint  Monitor neurologic status
Dose: 500mg plasminogen to pain, muscle pain, muscle (pupils, level of
plasmin (fibrinolysin), stiffness, difficulty moving, consciousness, motor
Route: IV an enzyme that runny or stuffy nose. activity) in patients with
degrades fibrin clots, subarachnoid
Dosage: q8 fibrinogen, and other hemorrhage.
plasma proteins,  Assess for
including the thromboembolic
procoagulant factors V complications.(especially
and VIII. Tranexamic in patients with history).
acid also directly Notify physician of
inhibits plasmin positive Homans’ sign, leg
activity, but higher pain hemorrhage, edema,
doses are required hemoptysis, dyspnea, or
than are needed to chest pain.
reduce plasmin  Monitor platelet count
formation. and clotting factors prior
to and periodically
throughout therapy in
patients with systemic
fibrinolysis.

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