I.

PATIENT’S INFORMATION
Background:
Name: Patient X
Age: 6-year-old.
Gender: Female
Marital (Civil) Status: S
Nationality:
Religion:
Address and phone Number:
Birthdate:
Birthplace:
Weight: 23.89 kg/m2 [the 98th percentile for age]

SIGN AND SYMPTOMS

Signs:
BMI: 23.89 kg/m2 [the 98th percentile for age]
Enlarged tonsils: (2-3+)
Symptoms:
-The patient is experiencing fatigue and excessive daytime sleepiness (EDS).
-Having trouble performing ADL.
-Rapid increase of weight despite the help of a dietrician.

Chief Complaints:
-According to the statement the patient has fallen asleep at school nearly every day for
the past 1-2 months and falls into a deep sleep unless she is kept active.
-At home, she is taking more naps during the day, falling asleep in the car, and struggling
with schoolwork.

II. HISTORY OF PRESENT / PAST ILLNESS

History of past Illness:

- A 6-year-old girl with a long-standing history of severe asthma and eczema.
- The patient’s asthma remained stable for a year but then progressed to the extent that the
dosage of inhaled fluticasone was increased to 220 µg twice daily.
- Montelukast (5 mg daily) and nasal fluticasone (50 µg) were added to her regimen. In
addition, diphenhydramine (25 mg) was prescribed to be used as needed for excessive
itchiness, eczema flares, and allergic asthma flares. The patient remained well and was
followed up in the clinic approximately every 3 months
- After 6 months, significant weight gain and an increasing body mass index (BMI) were
recorded
- From the age of 7-8 years, the patient demonstrated a modest weight loss from the
changes in her diet. However, symptoms of fatigue, excessive daytime sleepiness (EDS),
 and inattention in school developed over a 1- to 2-month period, and her weight started to
increase rapidly despite the dietary intervention.
History of Present illness:
- The patient has fallen asleep at school nearly every day for the past 1-2 months and falls
into a deep sleep unless she is kept active.
- On physical examination, the patient has mild to moderate obesity (BMI of 23.89 kg/m2
[the 98th percentile for age]) and enlarged tonsils (2-3+). Had difficulty with focusing
and staying awake in the clinic.
Family History:
The patient's family history is notable for obesity, obstructive sleep apnea (OSA) that requires
continuous positive airway pressure (CPAP) in her father, and narcolepsy in an uncle and a
grandfather.

III. DIAGNOSIS
Narcolepsy

IV. ANATOMY AND PHYSIOLOGY

The nervous system is an organ system that coordinates voluntary and involuntary actions
and responses by transmitting signals between different parts of our bodies.
Neurons
Central to the functioning of the nervous system is an extensive network of specialized
cells called neurons. Neurons feature many thin projecting fibers called axons, which penetrate
deep into tissues. They are able to communicate with other cells by chemical or electrical means
at synapses. Neuronal function is supported by neuroglia, specialized cells which provide
nutrition, mechanical support, and protection.
Divisions of the Nervous System
In most animals, including humans, the nervous system consists of two parts: central and
peripheral. The central nervous system (CNS) is composed of the brain, spinal cord, and
cerebellum. The peripheral nervous system (PNS) consists of sensory neurons, motor neurons,
and neurons that communicate either between subdivisions of the PNS or connect the PNS to the
CNS
 The nervous system has three broad functions: sensory input, information processing, and
motor output. In the PNS, sensory receptor neurons respond to physical stimuli in our
environment, like touch or temperature, and send signals that inform the CNS of the state of the
body and the external environment. This sensory information is then processed by the CNS,
predominantly by the brain.
After information is processed, motor neurons return signals to the muscles and glands of
the PNS, which responds with motor output. Central neurons, which in humans greatly
outnumber the sensory and motor neurons, make all of their input and output connections with
other neurons. The connections of these neurons form neural circuits that are responsible for our
perceptions of the world and determine our behavior. Along with neurons, the nervous system
relies on the function of other specialized cells called glial cells, or glia, that provide structural
and metabolic support to the nervous system.
Central Nervous System
The CNS includes the brain and spinal cord along with various centers that integrate all
the sensory and motor information in the body. These centers can be broadly subdivided into
lower centers, including the spinal cord and brain stem, that carry out essential body and organ-
control functions and higher centers within the brain that control more sophisticated information
processing, including our thoughts and perceptions. Further subdivisions of the brain will be
discussed in a later section.
Peripheral Nervous System
The PNS is a vast network of nerves consisting of bundles of axons that link the body to
the brain and the spinal cord. Sensory nerves of the PNS contain sensory receptors that detect
changes in the internal and external environment. This information is sent to the CNS via
afferent sensory nerves. Following information processing in the CNS, signals are relayed back
to the PNS by way of efferent peripheral nerves.

The hypothalamus is a deep brain region just in front of the brainstem. It regulates
arousal, sleep, hunger, body temperature, and other fundamental behaviors. Hypocretins are only
produced by a small cluster of neurons in the hypothalamus, a brain region located roughly
behind the eyes and between the ears. Of the billions of neurons in the brain, only about
100,000–200,000 produce hypocretins. Hypocretins are released from these neurons during
wakefulness and bind to specific hypocretin receptors on target neurons, which increases the
activity of these neurons.
V. PATHOPHYSIOLOGY
Narcolepsy is a chronic neurologic sleep disorder characterized by abnormal sleep
tendencies, including excessive daytime sleepiness, disturbed nocturnal sleep, and manifestations
related to rapid eye movements (REM) sleep such as cataplexy (muscle weakness triggered by
emotions), sleep paralysis, and hypnopompic or hypnagogic hallucinations. Narcolepsy is
clinically categorized as occurring with cataplexy or without cataplexy.
Narcolepsy with cataplexy is genetically associated with the human leukocyte antigen,
suggesting the involvement of the immune system. A small portion of cases of narcolepsy
without cataplexy is also HLA positive. The most likely cause for narcolepsy has been identified
as a loss of hypothalamic neurons that contain the peptide orexin, which is also called
hypocretin.
Research has started to reveal details about the underlying biology of narcolepsy, but
more is known about NT1 than NT2. Even with growing knowledge, the exact causes and risk
factors for each condition are not fully understood.

Narcolepsy Type 1

NT1 is associated with the symptom of cataplexy, which is the sudden loss of muscle
tone. NT1 was formerly known as “narcolepsy with cataplexy.” Not all patients who are
diagnosed with NT1 experience episodes of cataplexy. NT1 can also be diagnosed when a person
has low levels of hypocretin-1, a chemical in the body that helps control wakefulness. Even
when not present at diagnosis, cataplexy eventually occurs  in a significant number of people
with low levels of hypocretin.
Narcolepsy type 1 is thought to be due to the permanent loss of hypocretin neurons.
Patients with narcolepsy type 1 have low or undetectable levels of cerebrospinal fluid (CSF)
hypocretin.
Based on animal models, loss of hypocretin neurons is thought to lead to inconsistent signaling
of wake-promoting neurons responsible for maintaining wakefulness and muscle tone and inhibit
NREM and REM-sleep promoting neurons (eg, dopaminergic, noradrenergic, serotonergic
neurons).
 Wake-promoting neurons fail to activate cortical and subcortical arousal regions and fail
to inhibit sleep-promoting neurons (ie, GABAergic neurons), resulting in excessive
daytime sleepiness.
 Certain wake-promoting neurons that also suppress REM signaling fail to inhibit REM-
promoting neurons, resulting in cataplexy and other abnormal manifestations of REM
sleep such as hypnagogic/hypnopompic hallucinations and sleep paralysis.2,3
 Disruption of mutually inhibitory sleep-wake circuits may also lead to unwanted
transitions from sleep to wakefulness and to associated sleep disruption.
Even though researchers know more than ever about NT1, most individual cases still occur with
no clear, direct cause. People with a family history of NT1 have about a 1-2% chance of
developing the condition. This is a small risk overall but a significant increase in risk relative to
people without a family history.

Narcolepsy Type 2

NT2 was formerly known as “narcolepsy without cataplexy.” People with NT2 have
many similar symptoms as people with NT1, but they do not have cataplexy or low levels of
hypocretin-1. If a person with NT2 later develops cataplexy or low hypocretin-1 levels, their
diagnosis can be reclassified as NT1. This change in diagnosis is estimated to occur in about
10% of cases.
Narcolepsy type 2 is likely a heterogeneous disorder. In patients with narcolepsy type 2,
cataplexy is not present, and CSF hypocretin-1 levels are usually normal or unknown. One
quarter to one third of patients diagnosed with narcolepsy type 2 may actually have hypocretin
deficiency, which would classify them as narcolepsy type 1, if levels were known, and about 8%
may have intermediate levels of CSF hypocretin. These patients are more likely to develop
cataplexy over time than those with normal hypocretin levels. The exact cause of narcolepsy type
2 is unknown.

VI. MEDICAL MANAGEMENT (Ideal | Actual)

DOCTOR’S ORDER
Ideal:
 Stimulants. Drugs that stimulate the central nervous system are the primary
treatment to help people with narcolepsy stay awake during the day. Doctors often
try modafinil (Provigil) or armodafinil (Nuvigil) first for narcolepsy.
 Sunosi (solriamfetol) and pitolisant (Wakix) are newer stimulants used for
narcolepsy, headache and anxiety. Pitolisant may also be helpful for cataplexy.
 Some people need treatment with methylphenidate (Aptensio XR, Concerta,
Ritalin, others) or various amphetamines. These medications are very effective
but can be addictive. They may cause side effects such as nervousness and heart
palpitations.
 Selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine
reuptake inhibitors (SNRIs). Doctors often prescribe these medications, which
suppress REM sleep, to help alleviate the symptoms of cataplexy, hypnagogic
hallucinations and sleep paralysis. They include fluoxetine (Prozac, Sarafem) and
venlafaxine (Effexor XR).
 Tricyclic antidepressants. These older antidepressants, such as protriptyline
(Vivactil), imipramine (Tofranil) and clomipramine (Anafranil), are effective for
cataplexy
 Sodium oxybate (Xyrem). This medication is highly effective for cataplexy.
Sodium oxybate helps to improve nighttime sleep, which is often poor in
narcolepsy. 
Actual:
 The patient was presented to a pediatric pulmonary and sleep medicine clinic.
Patient has a long-standing history of asthma and eczema and was prescribed with
an inhaled corticosteroid (fluticasone, 88 µg, inhaled twice daily), albuterol
sulfate (180 µg, inhaled as needed), and ipratropium bromide (34 µg, inhaled as
needed). Her asthma remained stable for a year but then progressed to the extent
that the dosage of inhaled fluticasone was increased to 220 µg twice daily.
 For eczema, aggressive regimen of hydrating bleach baths, moisturizing lotions,
nonsedating antihistamines, and PRN use of topical hydrocortisone or
triamcinolone, pimecrolimus, and mupirocin.
 Montelukast (5 mg daily) and nasal fluticasone (50 µg) were added to her
regimen. In addition, diphenhydramine (25 mg) was prescribed to be used as
needed for excessive itchiness, eczema flares, and allergic asthma flares.
 The patient had a significant weight gain and a sudden increase of BMI and was
referred to a dietician for weight loss consultant.
 The patient was referred to a pediatric otolaryngologist for consideration of
nocturnal polysomnography (NPSG) or an adenotonsillectomy to help clarify
matters.
MEDICAL MANAGEMENT
Ideal:
 Doctors and clinicians perform considerable research and clinical trials in the
areas of narcolepsy and other sleep disorders, including causes, diagnosis and
treatment options.
 Doctor will also provide proper medication to relieve symptoms and
complications.
 Physician may perform a detailed medical and sleep history, physical
examination, medication history and sleep studies .
 Sleep history. Physicians will ask you for a detailed sleep history. A part of the
history involves filling out the Epworth Sleepiness Scale, which uses a series of
short questions to gauge your degree of sleepiness.
 Sleep records. Physicians may be asked to keep a detailed diary of your sleep
pattern for a week or two, so your doctor can compare how your sleep pattern and
alertness are related.
Actual:
 Medication was prescribed to the client by a physician to relieve sign and
symptoms.
 Patient was referred to different health care worker (dietician, pediatrician,
pediatric otolaryngologist) to maximize treatment.
 The nurse assessed the client’s usual sleep habits and recent sleep quality as part
of the initial nursing assessment.
 Physical assessment has been conducted
LABORATORIES
Ideal:
 Diagnosis of narcolepsy are the polysomnogram (PSG) and the multiple sleep
latency test (MSLT). These tests are usually performed in a sleep disorders center.
 Polysomnography. This test measures a variety of signals during sleep using
electrodes placed on your scalp. 
 Multiple sleep latency test. This examination measures how long it takes you to
fall asleep during the day. 
Actual:
The NPSG demonstrates the following:
 A respiratory disturbance index and an apnea-hypopnea index (AHI) of 6.2 per
hour
 Sleep latency of 0.5 minutes and rapid eye movement (REM) latency of 0.5
minutes
 A sleep efficiency of 87.5%
 18.2% of total sleep time in stage N1, 36.4% in N2, 29.9% in N3, and 15.5% in
REM sleep
 An arousal index of 18.6
 A periodic leg movement index of 6.3
 Multiple periods of wakefulness scattered throughout the night and six REM
periods
VIII. MEDICAL SURGERY
The patient was referred to a pediatric otolaryngologist for consideration of an
adenotonsillectomy.

VIII. NURSING MANAGEMENT (Ideal | Actual)

Dependent
Ideal:
 Doctors and clinicians have performed considerable research and clinical trials in
the areas of narcolepsy and other sleep disorders, including causes, diagnosis and
treatment options. Doctors will also provide proper medication to relieve
symptoms and complications.
 Physicians may recommend the patient to other health care professionals to
maximize treatment.
Actual:
 The nurse will administer medication that prescribed by the doctor.
 The physician transferred the patient to other health care professional to treat
other complications.
Independent
Ideal:
 Assess client’s usual sleep habits and recent sleep quality as part of the initial
nursing assessment. Take note of sleep latency, frequency and duration of naps,
Ease of falling asleep in places other than the usual bedroom.
 Assess patients’ perception of cause of sleep difficulty and possible relief
measures to facilitate treatment take note of frequency of snoring, apparent pauses
in breathing, and kicking movements.
 Improve patient lifestyle and daily activity by creating daily activity schedule.
Encourage daily exercise.
 Evaluate effects of medications and adverse effect that can disrupt sleeping
pattern
 Encourage patient to bath in the morning to increase productivity.
 Educate patients, parents, teachers, and other care providers concerning the
symptoms, prognosis, and safety precautions.
Actual:
 The nurse assessed the patient by noting background information, such as
patient’s past and present illness history, family history, chief complaint, and
noting signs of symptoms.
 Document past and present prescribed medication.
 Conduct physical assessment and current health status.
Collaborative
Ideal:
  Doctors trained in sleep medicine, as well as doctors trained in brain and nervous
system conditions (neurology), mental health conditions (psychiatry), lung and
breathing conditions (pulmonary medicine), children's health (pediatrics), and
other areas, work together to determine the most appropriate treatment to help
manage the illness.
Actual:
 The patient met with a dietician to help manage sudden weight gain
 Patient was referred to a pediatric otolaryngologist for consideration of nocturnal
polysomnography (NPSG) or an adenotonsillectomy.
 An otolaryngologist assessed the patient and mentioned that she has not tolerated
nasal fluticasone well, that she is a chronic mouth breather, and that her tonsils are
enlarged (3+). As a result, an NPSG is ordered to help clarify matters.

XI. REHABILITATION
Children with narcolepsy should be monitored by both the primary pediatrician and the
pediatric neurologist. Regular follow-up is necessary for monitoring drug effectiveness, response
to treatment, and potential side effects; it should be done at least annually and, if the patient is on
a stimulant, preferably every 6 months. A sleep medicine specialist, if available, also should see
the patient regularly. Patients should contact narcolepsy support groups.

 Educate patients, parents, teachers, and other care providers concerning the
symptoms, prognosis, and safety precautions.
 Improve patient lifestyle and daily activity by creating daily activity schedule.
Encourage daily exercise
 Advice patient to maintain a regular sleep/wake schedule and follow strict health
diet plan as advice by a dietician.
 Encourage patient to document and keep a sleeping journal to see progress.
 Discuss to the patient about safety precaution and the risk of being a narcoleptic
patient.
 Discuss the proper order / intake of medication recommended by the physician.
Also inform the patient about the possible side effect and adverse effect.
GENERIC BRAND CONTRAINDICATI ADVERSE SPECIAL NURSING
DOSAGE FREQUENCY INDICATIONS SIDE EFFECTS
NAMES NAMES ONS EFFECTS PRECAUTIONS CONSIDERATIONS
Fluticasone Flonase, 88 µg BID Fluticasone is used Hypersensitivity to the Along with its -Dysphonia -It is very important -Ward the patient to use
Flovent to relieve seasonal medication. Many needed effects, a that your doctor check cautiously with
and year-round formulations contain milk medicine may -Oropharyngeal your progress at untreated infections and
allergic and non- proteins or lactose, and cause some regular visits to make suppressed immune
allergic those with known unwanted effects. -Cough sure this medicine is function
nasal symptoms, allergies to these Although not all of Pneumonia working properly and
such as stuffy/runny substances should not use these side effects to check for unwanted
nose, itching, and this medication. may occur, if they effects. -Medication may cause
sneezing. It can also do occur, they may - Respiratory tract
headache, insomnia,
help relieve allergy Fluticasone is need medical -If your symptoms do bronchospasm, nasal
Infection
eye symptoms such contraindicated as a attention. not improve within a congestion, adrenal
as itchy, watery primary treatment of Check with your few days or if they suppression
-Nasopharyngitis
eyes. This acute bronchospasm. doctor immediately become worse, check
medication belongs if any of the with your doctor.
-Oropharyngeal -Monitor patient’s
to a class of drugs following side candidiasis - Check with your respiratory status
known as Oral inhalation: Primary effects occur: doctor immediately if
corticosteroids. treatment of status -Hoarseness of voice blurred vision, -May lead to decreased
asthmaticus or other acute -More common difficulty in reading, bone density
asthma episodes requiring -Bloody nose -Throat irritation or any other change in
intensive measures. -cough vision occurs during
-fever -Instruct patients using
or after treatment. corticosteroids and
Nasal: Treatment of -headache Your doctor may want
asthma, current or recent -muscle aches bronchodilators that
your eyes be checked
nasal septal ulcers, -pain or tenderness by an
they need to use
surgery, injury or trauma around the eyes and ophthalmologist. bronchodilators first.
that is not fully healed. -cheekbones
-sore throat - This medicine may -instruct patient to stop
Topical: Untreated -stuffy or runny cause holes or ulcers smoking
cutaneous infections, nose in the cartilage of the
rosacea, acne vulgaris, -tightness of the nose and delay wound
perioral dermatitis, chest healing. Make sure
perianal and genital -troubled breathing your doctor knows if
pruritus, pruritus without -unusual tiredness you have had nose
inflammation; dermatoses or weakness surgery, a nose injury,
including dermatitis and or an infection in your
nappy rash in infants less nose in the last few
than 3 months. months before using
this medicine.
-Using too much of
this medicine or using
it for a long time may
increase your risk of
having adrenal gland
problems.
-This medicine may
decrease bone mineral
density when used for
a long time. A low
bone mineral density
can cause weak bones
or osteoporosis.
-This medicine may
slow down a child's
growth. If you think
your child is not
growing properly
while using this
medicine,
- Do not take other
medicines unless they
have been discussed
with your doctor. This
includes prescription or
nonprescription (over-
the-counter [OTC])
medicines and herbal or
vitamin supplements.
 GENERIC BRAND CONTRAINDICATIO SIDE ADVERSE SPECIAL NURSING
NAMES
DOSAGE FREQUENCY INDICATIONS
NAMES NS EFFECTS EFFECTS PRECAUTIONS CONSIDERATIONS
Albuterol Proventil 180 µg PRN -Relief and Contraindicated with -chest pain, fast or CNS: Advise the pt to -Use minimal doses for
Sulfate HFA prevention of -hypersensitivity to pounding -Apprehension practice the ff: minimal periods; drug
bronchospasm in albuterol; heartbeats; -Anxiety tolerance can occur with
Ventolin patients with -tachyarrhythmias, -fear -To Consult your prolonged use.
-upset stomach, -CNS stimulation
HFA reversible tachycardia caused by physician and
vomiting; -hyperkinesia -Maintain a beta-
obstructive airway digitalis intoxication; -Insomnia
pharmacist if you
adrenergic blocker
Proair disease -general anesthesia with -tremor are allergic to
-painful urination; (cardioselective beta-
HFA halogenated -Drowsiness albuterol and any blocker, such as atenolol,
-Inhalation: hydrocarbons or -irritability other medications should be used with
-dizziness;
Treatment of acute cyclopropane. -weakness respiratory distress) on
attacks of -Use cautiously with -feeling shaky or
-Do not stop taking standby in case cardiac
bronchospasm diabetes nervous; CV: the anti- arrhythmias occur.
hyperthyroidism -Cardia arrythmias inflammatory
-Prevention of psychoneurotic -Tachycardia medicine, even if -Prepare solution for
-headache, back
exercise-induced individuals; labor and -palpitations your asthma seems inhalation by diluting 0.5
pain, body aches;
-Anginal pain mL 0.5% solution with
bronchospasm delivery (oral use has or better, unless your
delayed second stage of doctor tells you to 2.5 mL normal saline;
Dermatologic: deliver over 5–15 min by
-Unlabeled use: labor; parenteral use of -cough, sore -Sweating nebulization.
Adjunct in treating beta2-adrenergic throat, sinus pain, -pallor -Tell your patient
serious agonists can accelerate runny or stuffy -Flushing that the medication
nose. -Do not exceed
hyperkalemia in fetal heart beat and inhalation recommended dosage;
dialysis patients; cause hypoglycemia and GI: sometimes causes administer pressurized
seems to lower hypokalemia -Nausea wheezing and inhalation drug forms
potassium pulmonary edema in the -Vomiting difficulty breathing during second half of
concentrations mother and -Heartburn inspiration, because the
when inhaled by hypoglycemia in the airways are open wider
Respiratory: and the aerosol
patients on neonate)
-Breathing distribution is more
hemodialysis lactation; the elderly complication
(more sensitive to CNS -Pulmonary edema
effects). -Coughing extensive.
-Bronchospasm
-Paradoxical Airway
 GENERIC BRAND CONTRAINDICATIO SIDE ADVERSE SPECIAL NURSING
DOSAGE FREQUENCY INDICATIONS
NAMES NAMES NS EFFECTS EFFECTS PRECAUTIONS CONSIDERATIONS
Ipratropium Atrovent, 34 µg PRN Ipratropium is -Hypersensitivity to soy -dry mouth -Bronchitis May cause -Protect solution for
Bromide Atrovent used to control lecithin or related food paradoxical inhalation from light.
HFA and prevent products. S-cough, -respiratory tract bronchospasm.
symptoms infections. Caution when used -Use nebulizer
(wheezing and -Contraindicated with -headache in patients who are mouthpiece instead of
shortness of hypersensitivity to -Chest pain sensitive to face mask to avoid
breath) caused by atropine or its -nausea, sympathomimetic blurred vision or
derivatives, soy bean or -arrhythmia agents.
ongoing lung aggravation of narrow-
peanut allergies -dizziness
disease (chronic angle glaucoma.
(aerosol). -oedema Not for treatment
obstructive -difficulty of acute episodes of
pulmonary -Use cautiously with breathing. -hypertension, bronchospasm. -Can mix albuterol in
disease-COPD whi narrow-angle glaucoma, nebulizer for up to 1 hr.
ch prostatic hypertrophy, -hypokalaemia Caution when used Ensure adequate
includes bronchitis  bladder neck in patients with CV hydration, control
and emphysema). obstruction, pregnancy, -palpitation disease as β- environmental
It works by lactation agonists may temperature to prevent
relaxing the -tachycardia increase BP, heart hyperpyrexia.
muscles around rate and risk
the airways so -Headache of arrhythmias. -Have the patient void
that they open up before taking
and you can -dizziness Monitor blood medication to avoid
breathe more glucose in diabetics. urinary retention
easily. -fatigue
Monitor
-insomnia serum potassium
levels especially in
-tremor patients who are on
concurrent
-nervousness. treatment with
xanthine
 derivatives, steroids
or diuretics.

Caution when used

in patients with
narrow angle
glaucoma,
hyperthyroidism, pr
ostatic hyperplasia,
bladder neck
obstruction, seizure
disorders, renal or
hepatic impairment.

Safety and efficacy

have not been
established in
children <12 yr.

Increased risk of GI
motility disturbance
in patients with
cystic fibrosis.
Pregnancy and
lactation

GENERIC BRAND CONTRAINDICATIO SIDE ADVERSE SPECIAL NURSING

DOSAGE FREQUENCY INDICATIONS
NAMES NAMES NS EFFECTS EFFECTS PRECAUTIONS CONSIDERATIONS
Montelukast Singulair 5 mg OD Antagonizes the Contraindicated if there Body aches or CNS: -Montelukast may -Use cautiously in:
effects of is a hypersensitivity. pain fatigue, headache, cause some people
leukotrienes, weakness, to be agitated, -Acute attacks of
which mediate the Difficulty in disoriented, asthma
following: Airway breathing EENT: irritable, or display
edema, Smooth otitis (children), other abnormal -Hepatic impairment
muscle Dryness or sinusitis (children), behaviors. It may (may need lower doses)
constriction soreness of the Resp: cough, also cause some
Altered cellular throat rhinorrhea, people to have -Reduction of
activity; Result is suicidal thoughts corticosteroid therapy
decreased Loss of voice GI: and tendencies or to (may increase the risk
inflammatory abdominal pain, become more of eosinophilic
process. Indicated Pain or diarrhea (children), depressed. conditions).
for prevention and tenderness dyspepsia, nausea
chronic treatment around the eyes (children), increased -Report any unusual -Drugs which induce
of asthma. and cheekbone liver enzymes, thoughts or the CYP450 enzyme
Indicated for behaviors that system (phenobarbital
prevention and Pain, redness, or Derm: trouble you or your and rifampin) may
chronic treatment swelling in the Rash, child, especially if decrease the effects of
of asthma. ear they are new or get Montelukast
Misc: worse quickly.
EOSINOPHILIC Make sure the
stomach pain
CONDITIONS doctor knows if you
(INCLUDING or your child have
Stuffy or runny
CHURG-STRAUSS trouble sleeping, get
nose
SYNDROME), fever upset easily, or start
to act reckless. Also
tell the doctor if you
or your child have
sudden or strong
feelings, such as
feeling nervous,
angry, restless,
 violent, or scared.
-Do not take other
medicines unless
they have been
discussed with your
doctor. This
includes
prescription or
nonprescription
(over-the-counter
[OTC]) medicines
and herbal or
vitamin
supplements.

GENERIC BRAND CONTRAINDICATIO SIDE ADVERSE SPECIAL NURSING

DOSAGE FREQUENCY INDICATIONS
NAMES NAMES NS EFFECTS EFFECTS PRECAUTIONS CONSIDERATIONS
Diphenhydra Benadryl 25mg PRN Competitively -Hypersensitivity; Acute : FREQUENT: -CNS: drowsiness, Tell your doctor and - if patient is having
mine blocks effects of attacks of asthma; Drowsiness, dizziness, headache. pharmacist if you acute allergic reaction,
histamine at Lactation; Known dizziness are allergic to obtain history of
peripheral H1 alcohol intolerance -EENT: blurred diphenhydramine, recently ingested foods,
receptor sites. (some liquid products). muscle vision, tinnutus. any other drugs, environmental
medications, or any exposure, emotional
Reason taking: -Use Cautiously in: weakness, -CV: hypotension, of the ingredients in stress.
Treatment of Severe liver disease; palpitations. diphenhydramine
allergic reactions, Angle closure hypotension preparations. -Monitor B/P, rate,
parkinsonism; glaucoma; Seizure -GI: anorexia, dry depth, rhythm, type of
prevention/treatme disorders; Prostatic urinary mouth, constipation, respiration; quality, rate
nt of nausea, hyperplasia; Peptic nausea. of pulse. Assess lung
vomiting, vertigo ulcer. retention sounds for rhonchi,
due to motion -GU: dysuria, wheezing, rales.
sickness; thickening of frequency, urinary
antitussive; short- bronchial retention. Tolerance to
term management secretions antihistaminic effect
of insomnia. -Derm: generally does not
Topical form used dry mouth, photosensitivity. occur; tolerance to
for relief of nose ,throat sedative effect may
pruritus, insect -Resp: chest occur.
bites, skin lips; in elderly: tightness, thickened
irritations sedation, bronchial secretions, Avoid tasks that require
dizziness, wheezing. alertness, motor skills
hypotension. until response to drug is
-Local: pain at IM established.
site.
Dry mouth, drowsiness,
dizziness may be an
expected response of
drug. Avoid alcohol.
 GENERIC BRAND DOSAG CONTRAINDICATIO SIDE ADVERSE SPECIAL NURSING
E
FREQUENCY INDICATIONS
NAMES NAMES NS EFFECTS EFFECTS PRECAUTIONS CONSIDERATIONS
Hydrocortiso Hydrocort, PRN Treatment of - Allergy to any Depression CNS: -Before starting -Establish baseline and
ne Alphosyl, primary of component of the drug Flushing Vertigo, headache, Hydrocortisone continuing data on BP,
Aquacort, Secondary adrenal Sweating paresthesia’s, treatment, make weight, fluid and
Cortef, cortex - Fungal infections Headache insomnia, seizures, sure you tell your electrolyte balance, and
Cortenema, insufficiency - Amebiasis Mood changes psychosis doctor blood glucose.
SoluCortef rheumatic - Hepatitis B hypertension about any other  
disorders, collagen - Vaccinia or varicella circulatory CV: medications you are -Lab tests: Periodic
disease, - Antibiotic collapse Hypotension, shock,  taking serum electrolytes
dermatologic -resistant infections HPN and heart failure blood glucose, Hct and
disease, and - Immune suppression secondary to fluid -Do not take aspirin, Hgb, platelet count,and
ophthalmic retention, thrombo ibuprofen or WBC with differential.
inflammatory embolism, naproxen or  
process. thrombophlebitis, fat products containing -Monitor for adverse
embolism, cardiac these unless your effects. Older adults and
arrhythmias doctor specifically patients with low
Replacement permits this. serum albumin are
therapy in adrenal Dermatologic: especially susceptible to
cortical Thin, fragile skin, -Do not receive any adverse effects.
insufficiency petechiae, kind of  
- Allergic states – ecchymoses, purpura, immunization or -Be alert to signs of
severe or in striae, subcutaneous vaccination without hypocalcemia.
capacitating fat atrophy your doctor's  
allergic conditions approval while -Ophthalmoscopic
- Hematologic EENT: taking examinations are
disorders Cataracts, glaucoma, Hydrocortisone. recommended every 2–
- Ulcerative colitis increased IOP 3 mo, especially if
Endocrine: -If you have been on patient is receiving
Amenorrhea, Hydrocortisone pills ophthalmic steroid
irregular men’s, daily, for a long therapy.
growth retardation, period of time,  
 decreased serious side effects -Monitor for persistent
carbohydrate may occur if you backache or chest pain;
tolerance and DM, discontinue compression and
cushingoid state, Hydrocortisone spontaneous fractures of
HPA abruptly. Do not long bones and
suppression stop taking vertebrae present
systemic Hydrocortisone hazards.
,hyperglycemia unless directed by  
your healthcare -Monitor for and report
GI: provider. changes in mood and
Peptic or esophageal behavior, emotional
ulcer, pancreatitis, -Do not change the instability, or
abdominal distention, dose of psychomotor activity,
nausea, vomiting, Hydrocortisone on especially with long
increased appetite your own. term therapy.
and weight gain.  
-Inform your health -Be alert to possibility
Hematologic: care professional if of masked infection and
Na and fluid you are pregnant or delayed healing (anti-
retention, may be pregnant inflammatory and
hypocalcemia, prior to starting this immunosuppressive
increased blood treatment. actions).
sugar, Increased Pregnancy category  
serum cholesterol, Note: Dose adjustment
decreased T3 -For both men and may be required if
and T4 levels women: Do not patient is subjected to
conceive a child severe stress(serious
(get pregnant) while infection, surgery, or
taking injury).
Hydrocortisone.

GENERIC BRAND CONTRAINDICATIO SIDE ADVERSE SPECIAL NURSING

DOSAGE FREQUENCY INDICATIONS
NAMES NAMES NS EFFECTS EFFECTS PRECAUTIONS CONSIDERATIONS
Triamcinolo Cinolar, 34 µg PRN -Triamcinolone Contraindicated with -burning itching CNS: Vertigo, Use cautiously with - Administer once-a-day
ne Kenalog, topical is used to infections, especially irritation headache, paresthesiapregnancy doses before 9 AM to
Triderm treat the itching, tuberculosis, fungal s, insomnia, seizures,
(teratogenic in mimic normal peak
redness, dryness, infections, -stinging redness psychosis, cataracts,preclinical studies); corticosteroid
crusting, scaling, amebiasis, vaccinia and or drying of the increased IOP, kidney or liver blood levels.
inflammation, and varicella, and antibiotic- skin glaucoma. disease,
discomfort of resistant infections; hypothyroidism, -Increase dosage when
various skin lactation. -acne CV: Hypotension, ulcerative colitis patient is subject to
conditions, shock, hypertension with impending stress.
including psoriasis -change in skin and CHF secondary perforation,
(a skin disease in color. to fluid retention, diverticulitis, active -Taper doses when
which red, scaly thromboembolism, or latent peptic discontinuing high-dose
patches form on -unwanted hair thrombophlebitis, fat ulcer, inflammatory or long-term therapy.
some areas of the growth. embolism, cardiac bowel disease, CHF,
body and eczema arrhythmias hypertension, -Do not give live virus
(a skin disease that -tiny red bumps thromboembolic vaccines with
causes the skin to or rash around Electrolyte disorders, immunosuppressive
be dry and itchy the mouth. imbalance: Na+ and osteoporosis, doses of corticosteroids.
and to sometimes fluid seizure disorders,
develop red, scaly -small white or retention, hypokalemi diabetes -Taper systemic steroids
rashes). red bumps on the a, hypocalcemia mellitus. carefully during transfer
skin. to inhalational steroids;
- It is also used as Endocrine: Amenorrh deaths
a dental paste to ea, irregular menses, caused by adrenal
relieve the growth retardation, insufficiency have
discomfort of decreased occurred.
mouth sores. carbohydrate
tolerance, diabetes -Use caution when
mellitus, cushingoid occlusive dressings,
state (long-term tight diapers, and so
effect), forth cover affected
increased blood area; these can increase
sugar, increased systemic absorption
 serum cholesterol, when using topical
decreased T3 and preparations.
T4 levels,
hypothalamic- -Avoid prolonged use of
pituitary-adrenal topical preparations
(HPA) suppression near the eyes, in genital
with systemic therapy and rectal
longer areas, and in skin
than 5 days creases.
-Do not stop taking the
drug without consulting
your health care
provider.

-Avoid exposure to
infections.

-Report unusual weight

gain, swelling of the
extremities, muscle
weakness, black or tarry
stools, fever, prolonged
sore throat, colds or
other infections,
worsening of your
disorder.

GENERIC BRAND CONTRAINDICATIO SIDE ADVERSE SPECIAL NURSING

DOSAGE FREQUENCY INDICATIONS
NAMES NAMES NS EFFECTS EFFECTS PRECAUTIONS CONSIDERATIONS
Pimecrolimu Elidel PRN -Indicated as Contraindicated in -mild burning or Skin: Mild burning or -Before - Assess for and report
s second-line individuals with a warm feeling of warm feeling of using pimecrolimus, persistent skin irritation
therapy for the history of treated skin, treated skin; tell your doctor that develops following
short-term and hypersensitivity to swollen hair follicles; or pharmacist if you application of the cream
non-continuous pimecrolimus or any of -headache, acne or warts; are allergic to it or if and lasts for more than
chronic treatment the components of the burning, stinging, you have any 1 wk.
of mild to cream. -cold symptoms tingling, or soreness other allergies. This
moderate atopic (stuffy nose, of treated skin product may contain Inform the patient to:
dermatitis in non- sneezing), (especially during the inactive ingredients,
immunocompromi first few days of which can cause -Minimize exposure of
sed adults and -swollen hair treatment); allergic reactions or treated area to natural or
children 2 years of follicles, other problems. artificial sunlight.
age and older, who CNS: Headache;
have failed to -acne or warts, -Talk to your -Stop topical
respond RS: Cold symptoms pharmacist for more application once signs
adequately to other -burning, such as stuffy nose, details. of dermatitis have
topical stinging, sneezing; Before using disappeared. Resume
prescription tingling, or this medication, tell application at the first
treatments, or soreness of GI: Upset stomach; your doctor or sign of recurrence.
when those treated skin, Musculo: muscle pharmacist your
treatments are not pain; or feeling more medical history, -Wash hand thoroughly
advisable. -upset stomach, sensitive to hot or especially of: after application if
muscle pain, and cold temperatures current hands are not the
feeling more infections, immune treatment sites.
sensitive to hot system problems. Report any significant
or cold skin irritation that
temperatures -This medication results from application
may make you more of the cream.
sensitive to the sun.
Limit your time in
the sun. Avoid
tanning booths and
sunlamps.
 -Use sunscreen and
wear protective
clothing when
outdoors. Tell your
doctor right away if
you get sunburned
or
have skin blisters/re
dness.

-This medication
should be used only
when clearly needed
during pregnancy.
Discuss the risks
and benefits with
your doctor.

GENERIC BRAND CONTRAINDICATIO SIDE ADVERSE SPECIAL NURSING

DOSAGE FREQUENCY INDICATIONS
NAMES NAMES NS EFFECTS EFFECTS PRECAUTIONS CONSIDERATIONS
Mupirocin Bactroba PRN Bactroban Cream Contraindicated in: -Blistering, -Bactroban Cream Avoid contact w/ Instruct patient on the
n, Topical treatment Hypersensitivity to any Cutaneous eyes. Discontinue correct application of
Bactroba of secondarily ingredient in Mupirocin -crusting, hypersensitivity use if sensitization mupirocin.
n Nasal, infected traumatic Ointment reactions. reaction or severe
and lesions eg,small -irritation,  -Bactroban Ointment local irritation occur -Advise patient to apply
Centany lacerations, Burning (localized to & medication exactly as
sutured wounds or -itching, area of application). prolonged/significan directed for the full
abrasions. t diarrhea occurs. course of therapy. If a
Bactroban -reddening of the Overgrowth of non- dose is missed, apply as
Ointment Topical skin. susceptible soon as possible unless
treatment organisms in almost time for next
of primary skin -canker sores. prolonged use. Not dose.
infections eg, suitable for ophth or
impetigo, -cracked, dry, intranasal use. -Avoid contact with
folliculitis, scaly skin. Bactroban Cream eyes. Patient should
furunculosis & Pregnancy. consult health care
ecthyma. -pain Bactroban Ointment professional if
Secondary Do not use at the symptoms have not
infectionseg, -swelling site of central improved in 3-5 days.
infected eczema, venous cannulation
infected traumatic -tenderness, nor in conjunction
lesions including w/ cannula.
abrasions, insect -warmth on the Moderate to severe
bites, minor skin. renal impairment.
wounds & burns. sores, Lactation.
Bacterial
contamination -ulcers,
prophylaxis.
- white spots on
the lips or tongue
or inside the
mouth.
 ASSESSMENT
NURSING BACKGROUND
DATE SUBJECTIV PLANNING INTERVENTION RATIONALE EVALUATION
OBJECTIVE DIAGNOSIS KNOWLEDGE
E
March 15, 2021 The NPSG “The Fatigue related to Fatigue is a subjective After 8 hours of Ascertain the Using an -Patient verbalized
demonstrates symptoms of poor physical complaint with both nursing intervention, patient belief about appropriate feelings of increased
the following: fatigue, condition and acute and chronic the patient will: what is causing quantitative energy and improved
excessive nonrestorative conditions. It is the his/her fatigue.: scoring scale, 1 wellbeing.
- A respiratory daytime sleep pattern. self-recognized state in severity, changes in to 10 for
disturbance sleepiness which an individual -Verbalize increased severity over time, example, can aid -Patient demonstrates
index and an (EDS), and experiences an energy and aggregating factors the patient to a more positive and
apnea- inattention in overwhelming improved wellbeing. or alleviating factors formulate the happier attitude
hypopnea school sustained sense of and the frequency. amount of than before the
index (AHI) of developed exhaustion and -Be more active fatigue interventions were
6.2 per hour over a 1- to 2- decreased capacity for experienced.  It applied
month period, physical and mental -Be able to know the is important to  
- Sleep latency and her weight work that is not cause of fatigue. conclude if the -Patient is able to
of 0.5 minutes started to relieved by rest. patient’s level of identify factors that
and rapid eye increase However, it is fatigue is aggravate and relieved
movement rapidly despite important to know that constant or if it her fatigue.
(REM) latency the dietary fatigue is not the same varies over time.
of 0.5 minutes intervention.” as tiredness. Tiredness Assess the patient’s Fatigue can -Patient is able to
is temporary. Fatigue ability to perform restrict the record aggravating
-A sleep is associated with a ADLs, instrumental patient’s ability factors that led
efficiency of “daytime variety of physical and activities of daily to participate in to determining
87.5% sleepiness psychological living (IADLs), and self-care and do relieving factors
seemed to be conditions. An demands of daily his or her role
-18.2% of total progressive, overwhelming, living (DDLs). responsibilities
sleep time in and she would sustained sense of in the family and
stage N1, fall asleep exhaustion and society, such as
36.4% in N2, suddenly even decreased capacity for working outside
29.9% in N3, when she physical and mental the home.
and 15.5% in wanted to be work at the usual level.
REM sleep awake.”
-An arousal
index of 18.6
-A periodic
leg movement
index of 6.3.

-Multiple
 INTERVENTION
Determine presence of sleep disturbances
Observe physiological reaction to activities such as any alterations in BP, respiratory
rate, or heart rate
Evaluate need for individual assistance.
Assess the patient’s nutritional ingestion for adequate energy sources and metabolic
demands.
Assess the patient’s typical level of exercise and physical movement.
Assess the patient’s sleep patterns for quality, quantity, time taken to fall asleep and
feeling upon awakening and observe alteration in thought processes or behaviors.
Assess the patient’s routine recommendation and over-the-counter drugs.
Aid the patient with developing a schedule for daily activity and rest. Emphasize the
importance of frequent rest periods.
Encourage verbalization of feelings about the impact of fatigue.
Aid the patient develop habits to promote effective rest/sleep patterns.
RATIONALE
Fatigue can be a consequence of sleep deprivation. 
Tolerance varies significantly, depending on the phase of the disease progression,
nutrition condition, fluid balance, and quantity or sort of opportunistic diseases that
patient has been subjected to.
Established realistic activities with the patient and encourage forward movement. 
Fatigue may be a symptom of protein-calorie malnutrition, vitamin deficiencies, or iron
deficiencies.
Increased physical exertion and inadequate levels of exercise can add to fatigue.
Changes in the patient’s sleep pattern may be a contributing factor in the development
of fatigue. Numerous factors can exacerbate fatigue, together with sleep deprivation,
emotional distress, side effects of drugs, and progressing CNS disease.
Fatigue may be a medication side effect or an indication of a drug interaction. The
nurse must perform particular notice to the patient’s utilization of beta-blockers,
calcium channel blockers, tranquilizers, alcohol, muscle relaxants, and sedatives.
A plan that balances periods of activity with periods of rest can aid the patient
complete preferred activities without contributing to levels of fatigue
Acknowledgement that living with fatigue is both physically and emotionally
challenging helps in coping.
Promoting relaxation before sleep and providing for several hours of uninterrupted
sleep can contribute to energy restoration.