DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.

COLLEGE OF NURSING
2nd Semester, S.Y. 2020-2021

TIZON, ROYCE VINCENT E. 2-C 27 SEPTEMBER 2021

GROUP H

Patient’s profile
Demographic data

Name: Gabrintina, M. Birthplace: Pasig City

Hospital No.: 314623 Address: San Roque, Liloan, Southern Leyte
Date of admission: September 8, 2021 Civil Status: Single
Time of admission: 6:07 AM No. of Children: 4
Sex: Female No. of Siblings: 9
Age: 46 Occupation: Housemaid
Nationality: Filipino Significant other: Gabrintina, F.
Birthdate: May 20, 1975

History of Present Illness

8 months prior to admission, client noted new onset of dyspnea associated with gradual
increase in abdominal girth. She was admitted at a hospital in Riyadh, Saudi. As claimed by the
significant other, paracentesis was done. Workup was also done which showed unremarkable results
as claimed but patient has no copy of the said results. Client then went home to the Philippines.
During the interim, client still noted a gradual increase in abdominal girth. 4 months prior to
admission, client went to a hospital at Southern Leyte with a chief complaint of an increasing
abdominal girth. Paracentesis was done and client was referred to Eastern Visayas Regional Medical
Center at Tacloban City. Client was only advised biopsy of omental area and was discharged. She was
also seen by OB and was cleared. 3 weeks prior to admission, client’s abdominal girth was still
increasing and this time with associated dyspnea. Client went again to EVRMC for consultation.
Workup was done and it revealed a massive pleural effusion. Pigtail catheter was done and client was
sent home. 2 days prior to admission, client noted no drain from the pigtail catheter. Hours before
prior to admission, client had dyspnea even at rest, hence this consult.

Past Health history

Client underwent cholecystectomy during the 1990’s. Client is also hypertensive with good
compliance to Amlodipine which she takes for maintenance. Other than the mentioned hospitalization
and procedures, client did not have any other medical history. Client does not have any allergies that
she knows of and does not quite remember vaccinations taken.

Obstetric history
Client had 4 pregnancies and 4 completed pregnancies past the viable age of gestation. All
four of her children were born term and none were pre-term. Client did not have any abortion. All 4
children are alive and well.

Gynecologic history
Client had her menarche at the age of 12. Client also stated that her menstruation is regular
and that it occurs every month. Client said that on the onset of her current illness, her menstruation
has become irregular and that it rarely occurs every 3 months or so. Client noted light pain on her
lower abdomen every time she gets her period. An estimated 5 sanitary napkins are used in a day of
menstruation according to the client.

Family history
According to client, her family did not have any health issues. Her siblings, parents, significant
other, as well as her children according to her were healthy. None of the family members had a history
of drug and alcohol use as well.

Psychosocial history
Client is a 46-years old woman that lives in San Roque, Liloan, Southern Leyte. Born on May
20, 1975, Ms. Gabrintina is a recently returned OFW from Riyadh, Saudi. Client does not have an
exercise routine because of her current illness. According to her, she’s too weak to exercise. Client
does not participate in any sports. She also doesn’t drink or smoke. Client eats about 3 meals a day
and also intake snacks in between meals. Approximately 1 cup of rice is consumed by the client.
Client’s diet includes meats, fish, rice, fruits, and vegetables. Client stated that her hobby is cleaning
and that she was fond of it because of her work as well.

Gordon’s Typology of Functional Health Patterns

Health Perception and Health Management
According to client, the general health of the family is in good condition. Aside from her, her
significant other as well as their children does not have any diseases or illnesses. In order to stay
healthy, client stated that she and her family eats good food such as vegetables and fruits. She does
not smoke nor drink alcohol. Clients said that she does not have regular check-up with her health care
provider and mentioned that she only goes when she feels discomfort or pain.

Nutrition and Metabolism

The family’s typical daily food intake according to the client is approximately 3 times a day.
She also considers everyone in the family as a healthy eater. Approximately around 1 liter of liquid is
consumed by each family member each day. Client does not see anyone in the family as underweight
or overweight. There are also no unexplained weight gain or loss.

Elimination
Client does not have any difficulty in defecation and urination. She stated that she defecates
around twice a day and urinates about 4-6 times a day depending on how much liquid she intakes.

Activity and Exercise

The main source for the client’s activity is cleaning. Other than that, client does not exercise
or participate in any recreational sports.

Cognition and Perception

Client does not have trouble speaking in front of many people. She also does not have a hard
time learning new things. She stated that she is a fast learner and that she can quickly do a thing when
she puts her mind into it.
Sleep and Rest
Client stated that during this time of her illness, she has trouble sleeping at night. Client tries
to sleep around 8 pm but then wakes up again after 2 hours or so. She does not have any trouble
waking up and client usually wakes up at around 4 am. Client does not have any nightmare and usually
sleeps when she has time.

Self-Perception and Self-Concept

Client stated that when around a lot of people, she does not feel shy. Although she dislikes it
when there are a lot of people. According to client, she doesn’t recall any times when she doubted
herself. She also keeps her head up high to not feel that she is losing hope.

Roles and Relationships

The most important persons in the client’s life are her family. She is mostly close with her
eldest daughter and this is the person she could always talk to whenever she feels sad. There weren’t
times in her life that she felt alone because her family is always there for her. Even when the client
was working abroad, she made sure that she contacts her family every day.

Sexuality and Reproduction

Client had her menarche at the age of 12. Her period was regular and occurs every month until
she got sick. According to her, upon the onset of her illness, she started having irregular periods that
would rarely occur around once every 3 months. Her lower abdomen is lightly painful everytime she
haves her menstruation. Around 5 sanitary napkins are used when she has her period.

Coping and Stress Tolerance

When the client has a problem, she usually talks to her eldest daughter first. She said that her
daughter is always available when she wants to talk to her. Even though they are apart, client says
that she always video calls. To lessen her stress, the client always tries to clean. She says that by
doing this, she can lessen the stress she feels. She hasn’t received any counseling and does not take
any medication for stress.
Values and Belief
According to client, although religion is important, it is not the top priority in her life. She said
that it is not based on religion on who’s going to be saved or not. The client always prays before going
to sleep, waking up, before and after eating, before going out, and when she goes home. She reads the
bible at home and stated that she believes in Jesus Christ. Client stated that she believes in Him for
He is the creator.
 Laboratory Tests
EXAMINATION RESULTS UNIT NORMAL VALUES SIGNIFICANCE

Low RBC counts, hemoglobin and hematocrit

Hemoglobin 97 g/L 120-150 levels can be caused by other things too, such as
a lot of bleeding or malnutrition. Kidney disease,
liver disease (cirrhosis), cancer, and medications
Hematocrit 0.32 L/L 0.37 – 0.47 used to treat cancer can also cause low levels.

RBC 3.90 x10^12/L 4.2 – 0.47

This indicates that infection is happening in the
WBC 26.42 x10^9/L 4.8 – 10.8 body that causes an increase in WBC’s

Neutrophils 0.96 0.43 – 0.65 High

Lymphocytes 0.02 0.20 – 0.45 Low

Monocytes 0.02 0.05 – 0.12 Low

Eosinophils 0.00 0.01 – 0.03 Low

Indicates RBCs are smaller than normal

(microcytic); caused by iron deficiency anemia
MCH 25 pg 27 - 31

May be low when MCV is low; decreased MCHC

values (hypochromia) are seen in conditions such
MCHC 307 g/L 320 - 360 as iron deficiency anemia and thalassemia.
 Decreased albumin levels are more frequently
associated with chronic conditions affecting the
liver like cirrhosis. Although albumin is produced
in the liver, abnormally low albumin levels can
Albumin 32 g/L 64 - 83 also be tied to kidney conditions, malnutrition,
inflammation, infection, thyroid disease, and
gastrointestinal problems.
A low A/G ratio has been associated with a
number of illnesses, and this may be tied to
inflammation. A/G ratio can be decreased with
A/G ratio 0.82 1.6 – 2.4 short-term problems that cause inflammation,
such as tissue trauma or infection, as well as
chronic inflammatory conditions and nutritional
problems.

Gram Stain Results

Specimen Cell Result Interpretation
Pleural Fluid Pus Cells ++ This indicates that the pleural fluid obtain from the client contains pus
cells. This is a sign of infection.

Drug order Mechanism of Action
Losartan potassium Inhibits vasoconstrictive •
and aldosterone secreting •
Therapeutic Class: action of angiotensin II
Antihypertensive by blocking angiotensin
II receptor on the surface •
Pharmacologic Class:
ARBs of vascular smooth
Drug Study
Indication Contraindication Side effects/Adverse effects Nursing Consideration
HTN • Contraindicated in patients • Frequent (8%): Upper • Drug can be used alone or
Nephropathy in hypertensive to drug respiratory tract infection. with other antihypertensives
patients with type • Use cautiously in patients • Occasional (4%–2%): • Monitor patient’s BP closely
2 diabetes with impaired renal or Dizziness, diarrhea, cough. to evaluate effectiveness of
To reduce risk of hepatic function Rare (1% or less): Insomnia, therapy. When used alone,
stroke in patients dyspepsia, heartburn, back/leg drug has less of an effect on
with HTN and pain, muscle cramps, myalgia,
 muscle and other tissue left ventricular nasal congestion, sinusitis, BP in black patients than in
DOSAGE: cells. hypertrophy depression. patients of other races.

50 mg • Overdosage may manifest as • Monitor patients who are

hypotension and tachycardia. also taking diuretics for
Bradycardia occurs less often. symptomatic hypotension
Institute supportive measures • Regularly assess patient’s
renal function (via creatinine
and BUN levels)
• Patients with sever HF
whose renal function
depends on the angiotensin-
aldosterone system may
develop acute renal failure
during therapy. Closely
monitor patient’s BP, renal
function, and potassium
levels, especially during first
few weeks of therapy and
after dosage adjustments
Spinorolactone Interferes with sodium • Edema Hypersensitivity to • Frequent: Hyperkalemia (in • Baseline assessment: Weigh
reabsorption by • Hypertension spironolactone. Acute renal pts with renal insufficiency, pt; initiate strict I&O.
competitively inhibiting • Hypokalemia insufficiency, significant those taking potassium Evaluate hydration status by
Therapeutic Class:
Diuretics action of aldosterone in impairment of renal excretory supplements), dehydration, assessing mucous
• Primary
distal tubule, promoting function, anuria, hyperkalemia, hyponatremia, lethargy. membranes, skin turgor.
Aldosteronism
Pharmacologic Class:
sodium and water Addison’s disease, concomitant • Occasional: Nausea, vomiting, Obtain baseline serum
• HF
excretion, increasing use with eplerenone. Cautions: anorexia, abdominal cramps, electrolytes, renal/hepatic
Potassium-sparing potassium retention. Dehydration, hyponatremia, diarrhea, headache, ataxia, function, urinalysis. Assess
diuretics-aldosterone Therapeutic Effect: concurrent use of supplemental drowsiness, confusion, fever. for edema; note location,
receptor antagonists
Produces diuresis, lowers potassium, elderly pts, mild renal • Male: Gynecomastia, extent. Check baseline vital
B/P. impairment, declining renal impotence, decreased libido. signs, note pulse
DOSAGE: function, ACE inhibitors or Female: Menstrual rate/regularity.

50 mg
angiotensin receptor blockers. irregularities (amenorrhea, • Intervention/evaluation:
postmenopausal bleeding), Monitor serum electrolyte
breast tenderness. values, esp. for increased
• Rare: Rash, urticaria, potassium, BUN, creatinine.
hirsutism. Monitor B/P. Monitor for
• Severe hyperkalemia may hyponatremia: mental
produce arrhythmias, confusion, thirst,
bradycardia, EKG changes cold/clammy skin,
(tented T waves, widening drowsiness, dry mouth.
QRS complex, ST segment Monitor for hyperkalemia:
depression). May proceed to colic, diarrhea, muscle
cardiac standstill, ventricular twitching followed by
fibrillation. Cirrhosis pts at risk weakness/paralysis,
for hepatic decompensation if arrhythmias. Obtain daily
dehydration, hyponatremia weight. Note changes in
occurs. Pts with primary edema, skin turgor.
aldosteronism may experience • Patient/family teaching
rapid weight loss, severe •Expect increase in volume,
fatigue during high-dose frequency of urination.
therapy. • Therapeutic effect takes several
days to begin and can last for
 several days when drug is
discontinued. This may not
apply if pt is on a potassium-
losing drug concomitantly (diet,
use of supplements should be
established by physician).
• Report irregular or slow pulse,
symptoms of electrolyte
imbalance
• Avoid foods high in potassium,
such as whole grains (cereals),
legumes, meat, bananas,
apricots, orange juice, potatoes
(white, sweet), raisins.
• Avoid alcohol.
•Avoid tasks that require
alertness, motor skills until
response to drug is established
(may cause drowsiness).
Tramadol Binds to mu-opioid • Moderate to Hypersensitivity to traMADol, • Frequent (25%–15%): • Baseline assessment Assess
receptors, inhibits Moderately opioids. (Additional) Immediate- Dizziness, vertigo, nausea, onset, type, location,
Therapeutic Class: reuptake of Severe Pain Release, Extended-Release: constipation, headache, duration of pain. Assess drug
Analgesic norepinephrine, Acute alcohol intoxication, drowsiness. history, esp.
serotonin, inhibiting concurrent use of centrally acting • Occasional (10%–5%): carBAMazepine, analgesics,
Pharmacologic Class:
Synthetic centrally ascending and descending analgesics, hypnotics, opioids, Vomiting, pruritus, CNS CNS depressants, MAOIs.
active analgesics pain pathways. psychotropic drugs, stimulation (e.g., nervousness, Review past medical history,
 Therapeutic Effect: hypersensitivity to opioids. anxiety, agitation, tremor, esp. epilepsy, seizures.
DOSAGE: Reduces pain. (Additional) ConZip: euphoria, mood swings, Assess renal function, LFT.
Severe/acute bronchial asthma, hallucinations), asthenia, • Intervention/evaluation
50 mg
hypercapnia, significant diaphoresis, dyspepsia, dry Monitor pulse, B/P,
respiratory depression. Caution: mouth, diarrhea. renal/hepatic function.
CNS depression, anoxia, • Rare (less than 5%): Malaise, Assist with ambulation if
advanced hepatic cirrhosis, vasodilation, anorexia, dizziness, vertigo occurs.
respiratory depression, elevated flatulence, rash, blurred vision, Dry crackers, cola may
ICP, history of seizures or risk urinary retention/frequency, relieve nausea. Palpate
for seizures, hepatic/renal menopausal symptoms. bladder for urinary retention.
impairment, treatment of acute • Seizures reported in pts Monitor daily pattern of
abdominal conditions, opioid receiving traMADol within bowel activity, stool
dependent pts, head injury, recommended dosage range. consistency. Sips of water
myxedema, hypothyroidism, May have prolonged duration may relieve dry mouth.
hypoadrenalism, pregnancy. of action, cumulative effect in Assess for clinical
Avoid use in pts who are suicidal pts with hepatic/renal improvement, record onset
or addiction prone, emotionally impairment, serotonin of relief of pain.
disturbed, depressed, heavy syndrome (agitation, • Patient/family teaching
alcohol users, hallucinations, tachycardia, • May cause dependence.
elderly pts, debilitated pts. hyperreflexia). May cause • Avoid alcohol, OTC
suicidal ideation and behavior. medications (analgesics,
sedatives).
• May cause drowsiness,
dizziness, blurred vision.
 • Avoid tasks requiring alertness,
motor skills until response to
drug is established.
• Report severe constipation,
difficulty breathing, excessive
sedation, seizures, muscle
weakness, tremors, chest pain,
palpitations.
Ceftrioxone Binds to bacterial cell • Uncomplicated • History of • Frequent: Discomfort with IM • Baseline assessment Obtain
Therapeutic Class: membranes, inhibits cell gonococcal hypersensitivity/anaphylactic administration, oral CBC, renal function tests.
Antibiotics wall synthesis. vulvovaginitis reaction to cefTRIAXone, candidiasis (thrush), mild Question for history of
Therapeutic Effect: • UTI; lower cephalosporins. diarrhea, mild abdominal allergies, particularly
Pharmacologic Class:
Third-generation Bactericidal. respiratory tract, Hyperbilirubinemic cramping, vaginal candidiasis. cephalosporins, penicillins.
cephalosporine gynecologic, neonates, esp. premature Occasional: Nausea, serum • Intervention/evaluation
bone or joint, infants, should not be treated sickness–like reaction (fever, Assess oral cavity for white
DOSAGE: intra-abdominal, with cefTRIAXone (can joint pain; usually occurs after patches on mucous
skin, or skin- displace bilirubin from its second course of therapy and membranes, tongue (thrush).
2g binding to serum albumin, resolves after drug is
structure Monitor daily pattern of
infection; causing bilirubin discontinued). bowel activity, stool
septicemia encephalopathy). Do not • Rare: Allergic reaction (rash, consistency. Mild GI effects
• Meningitis administer with calcium pruritus, urticaria), may be tolerable (increasing
• Perioperative containing IV solutions, thrombophlebitis (pain, severity may indicate onset
prophylaxis including continuous redness, swelling at injection of antibiotic-associated
calcium-containing infusion site). colitis). Monitor I&O, renal
• Acute bacterial
such as parenteral nutrition • Antibiotic-associated colitis, function tests for
otitis media
(in neonates) due to the risk other superinfections nephrotoxicity, CBC. Be
 • Acute otitis of precipitation of (abdominal cramps, severe alert for superinfection:
media cefTRIAXone-calcium salt. watery diarrhea, fever) may fever, vomiting, diarrhea,
• Cautions: Hepatic result from altered bacterial anal/genital pruritus, oral
impairment, history of GI balance in GI tract. mucosal changes (ulceration,
disease (esp. ulcerative colitis, Nephrotoxicity may occur, pain, erythema).
antibiotic-associated colitis). esp. in pts with preexisting • Patient/family teaching
History of penicillin allergy. renal disease. Pts with history • Discomfort may occur with
of penicillin allergy are at IM injection.
increased risk for developing a • Doses should be evenly
severe hypersensitivity spaced.
reaction (severe pruritus, • Continue antibiotic therapy
angioedema, bronchospasm, for full length of treatment
anaphylaxis).
Clindamycin Inhibits protein synthesis • Bacterial • Hypersensitivity to • Frequent: Systemic: • Baseline assessment: Obtain
of bacterial cell wall by Vaginosis
binding to bacterial • clindamycin. Abdominal pain, nausea, baseline WBC. Question pt
Acne Vulgaris
Therapeutic Class: ribosomal receptor sites. • Cautions: Severe hepatic vomiting, diarrhea. for history of allergies.
Antibiotics Topically, decreases fatty
acid concentration on dysfunction; history of GI • Topical: Dry, scaly skin. Avoid, if possible,
skin. Therapeutic Effect: disease (especially colitis). Vaginal: Vaginitis, pruritus. concurrent use of
Pharmacologic Class: Bacteriostatic or
Lincomycin derivatives bacteriocidal. • Occasional: Systemic: neuromuscular blocking
Phlebitis; pain, induration at agents.

DOSAGE: IM injection site; allergic • Intervention/evaluation

reaction, urticaria, pruritus. Monitor daily pattern of
300 mg • Topical: Contact dermatitis, bowel activity, stool
abdominal pain, mild diarrhea, consistency. Report diarrhea
burning, stinging. Vaginal: promptly due to potential for
serious colitis (even with
 Headache, dizziness, nausea, topical or vaginal
vomiting, abdominal pain. administration). Assess skin
• Rare: Vaginal: Hypersensitivity for rash (dryness, irritation)
reaction. with topical application.
With all routes of
administration, be alert for
superinfection: fever,
vomiting, diarrhea,
anal/genital pruritus, oral
mucosal changes (ulceration,
pain, erythema).
• Patient/family teaching
• Continue therapy for full length
of treatment.
• Doses should be evenly spaced.
• Take oral doses with at least 8
oz water.
• Use caution when applying
topical clindamycin concurrently
with peeling or abrasive acne
agents, soaps, alcohol-containing
cosmetics to avoid cumulative
effect.
• Do not apply topical
preparations near eyes, abraded
areas.
 • Report severe persistent
diarrhea, cramps, bloody stool.
• Vaginal: In event of accidental
contact with eyes, rinse with
large amounts of cool tap water.
• Do not engage in sexual
intercourse during treatment.
• Wear sanitary pad to protect
clothes against stains. Tampons
should not be used.
Azithromycin Binds to ribosomal • Mild to • Hypersensitivity to • Occasional: Systemic: Nausea, • Baseline assessment:
receptor sites of Moderate azithromycin or other vomiting, diarrhea, abdominal Question for history of
Therapeutic Class: susceptible organisms, Respiratory macrolide antibiotics. pain. hepatitis, allergies to
Antibiotics inhibiting RNA Tract, Skin, Soft History of cholestatic • Ophthalmic: Eye irritation. azithromycin,
dependent protein Tissue Infections jaundice/hepatic impairment • Rare: Systemic: Headache, erythromycins. Assess for
Pharmacologic Class:
Macrolides synthesis. Therapeutic • MAC Prevention associated with prior dizziness, allergic reaction. infection (WBC count,
Effect: Bacteriostatic or • MAC Treatment azithromycin therapy. • appearance of wound,
Antibiotic-associated colitis,
bactericidal, depending Cautions: Hepatic/renal evidence of fever).
DOSAGE: • Otitis Media other superinfections may
on drug dosage.
• Pharyngitis,
impairment, myasthenia result from altered bacterial • Intervention/evaluation:
500 mg gravis, hepatocellular and/or balance in GI tract. Acute Check for GI discomfort,
Tonsillitis
cholestatic hepatitis (with or interstitial nephritis, nausea, vomiting. Monitor
• Pneumonia,
without jaundice), hepatic hepatotoxicity occur rarely. daily pattern of bowel
Community-
necrosis. May prolong QT activity and stool
Acquired
interval. consistency. Monitor LFT,
• Bacterial
CBC. Assess for
Conjunctivitis
hepatotoxicity: malaise,
 fever, abdominal pain, GI
disturbances. Be alert for
superinfection: fever,
vomiting, diarrhea,
anal/genital pruritus, oral
mucosal changes (ulceration,
pain, erythema).
• Patient/family teaching
• Continue therapy for full length
of treatment.
•Avoid concurrent
administration of aluminum- or
magnesium-containing antacids.
• Bacterial conjunctivitis: Do not
wear contact lenses.