Cebu Institute of Technology

University
N. Bacalso Ave., Cebu City Philippines

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

INDIVIDUAL REQUIREMENTS
HISTORY, REVIEW OF SYSTEMS, AND DRUG STUDY
PSH- WARD 4 (ONCO WARD)

IN PARTIAL FULFILLMENT OF THE COURSE RLE 402

SUBMITTED BY:
ENCARGUEZ, DARA SOPHIA
BSN 4-N1

SUBMITTED TO:
AUDA F. RUSSEL, RN, MN, DSN
FACULTY

MAY 16, 2022

 CEBU INSTITUTE OF TECHNOLOGY
UNIVERSITY

COLLEGE OF NURSING

HEALTH ASSESSMENT TOOL

Name of Student: Dara Sophia N. Encarguez Level: IV Section: N1 Rating:

Nursing Health History

A. Biographic Data
Initials of Client/Patient: C.R.O.
Residence: Rizal Avenue Brgy. Dos, Katipunan, Zamboanga Del Norte
Contact Number : 09352350945 Nationality: Filipino
Religion : Roman Catholic Birth of Date: May 21, 1930
Age: 91 years old Sex: Female Civil Status: Widow
Educational Attainment: Bachelor’s Degree
Occupation: Retired Teacher

Name of Hospital: Perpetual Succour Hospital Ward & Room No.: 4B-427
Date of Admission: May 06, 2022 Attending Physician: Dr. Edgar Gebusion Molleno
Impression / Admitting Diagnosis: 1. Obstructive jaundice secondary to chronic calculous cholecystitis and
cholelithiasis 2. Hypertensive cardiovascular disease – not in failure

Source of Information:
( / ) Patient
( / ) Others, (Initials of SO): A.L.O.

Relationship to patient: Grandson

B.Admitting Complaint/s
Jaundice

Vital Signs: Temperature: 36.5°C PR: 79 bpm RR: 20 cpm

BP: 140/70 mmHg Pain Score: N/A

C. History of Present Illness

Two months prior to admission, patient noted onset of jaundice, icteric sclerae with abdominal discomfort
more prominently at the epigastric area. No associated nausea and vomiting. No fever and chills noted. Ultrasound
was done which showed gall stones. No surgery done but was given liver supplements instead.
In the interim, jaundice progressed and patient noted acholic stools. Patient noted occasional chills. Still no
consult was done. No medications taken.
Persistence of symptoms prompted second ultrasound which showed intrahepatic and extrahepatic biliary
duct ectasia secondary to obstruction by distal CBD stone, hydrops of gallbladder with chole cystolithiasis. This
prompted the patient to seek admission.
Review of Systems

REVIEW OF SYSTEMS
Check any that apply
Are you having problems with EARS, Are you having any
Do you have any of these conditions?
NOSE or THROAT? HEART-RELATED ISSUES?
Unable to transfer Cold/Flu Heart attack
Unable to walk without assistance Loose teeth of wear dentures Heart murmur
Unable to lie flat Earaches Pacemaker
Use supplemental oxygen Hearing loss Palpitations/fluttering
Headaches Ringing in the ears High Blood Pressure
Fatigue Sinus problems Rapid Heart Rate
Weakness Nasal congestion Irregular heart rhythm
Insomnia Sore throat Chest pain or pressure
Weight gain/loss Hoarseness Shortness of breath
Pregnant/possibly pregnant Vertigo Swelling hands, feet, ankles
Night sweats Recurrent nosebleeds
Nursing a child Difficulty swallowing

Are you having any Are you having Are you having any
RESPIRATORY PROBLEMS? INTESTINAL PROBLEMS? GENITAL/URINARY PROBLEMS?
Coughing blood Blood in stools Prostate problems
Chronic cough Stomach pain Frequent urination
Shortness of breath Black, tarry stools Blood in urine
Asthma Constipation Pain with urination
Bronchitis Decreased appetite Urinary discharge
Emphysema Diarrhea Genital sores
Pneumonia Food intolerance Abnormal menstruation
Tuberculosis Heartburn
Jaundice
Nausea
Vomiting

Are you having any Are you having Are you having any
SKIN PROBLEMS? ENDOCRINE PROBLEMS? NEUROLOGIC PROBLEMS?
Skin rash Enlarged glands in the neck Dementia
Abnormal lesions Bulging eyes Involuntary movements
Hives Heat or cold intolerance Balance problems
Sores Increased thirst Vertigo
Increased urination Fainting
Memory problems
Numbness of extremities
Seizures
Tingling
Tremors

Are you having any Are you having Are you having any
MENTAL HEALTH PROBLEMS? MUSCULOSKELETAL PROBLEMS? HEMATOLOGIC PROBLEMS?
Depression Joint pain/stiffness/redness Enlarged lymph nodes
Nervousness Back pain Tender lymph nodes
Tension/Irritability Muscle pain Easy bleeding or bruising
Excessively elevated mood Muscle wasting Blood transfusion
Hallucinations Easily broken bones

Patient's Name: C.R.O.

 DOSAGE/FREQ/ MECHANISM OF ACTION NURSING RESPONSIBILITIES
NAME OF INDICATIONS/
CLASSIFICATION SIDE EFFECTS ADVERSE EFFECTS
DRUG CONTRAINDICATIONS
ROUTE/SUPPLIED (Before, During, After)

GENERIC ORAL: Stimulant laxative Bisacodyl is deacetylated to INDICATIONS: GASTROINTESTINAL SIGNIFICANT: BEFORE:
NAME: TABLET: the active bis-(p-  Used on a short- DISORDERS:  Fluid and 1. Checked and validated the doctor’s order
5 to 15 mg orally once a hydroxyphenyl)-pyridyl-2- term basis to treat  Abdominal electrolyte and/or medication order prior to the
Bisacodyl day as needed methane (BHPM) by an constipation cramps imbalance e.g. administration of the medication.
intestinal deacetylase. BHPM  Used to empty the and/or pain metabolic 2. Observed the Ten Rights of medication
Duration of therapy: can stimulate bowels before  Diarrhea acidosis or administration.
Up to 1 week parasympathetic nerves in the surgery and certain  Nausea alkalosis, 3. Ensured proper preparation of drugs and
BRAND NAME: colon directly to increase medical hypocalcaemia, took note of the drugs’ mechanism of action
RECTAL: motility and secretions. procedures NERVOUS SYSTEM hypokalaemia and side effects.
Dulcolax 4. Obtained a history on allergies or any
SUPPOSITORY: DISORDERS: (prolonged use)
10 mg (1 suppository) Bisacodyl stimulates CONTRAINDICATION:  Faintness other drugs, foods or substances that the
rectally once a day as adenylate cyclase, increasing  Hypersensitivity  Syncope GASTROINTESTINAL patient may be allergic to.
needed cyclic AMP, leading to active  Obstruction or DISORDERS:
transport of chloride and severe impaction LOCAL:  Abdominal pain DURING:
Duration of therapy: bicarbonate out of cells.  Symptoms of  Bloody diarrhea 1. Identified patient and validated patient’s
 Local rectal
Up to 1 week Sodium ions, potassium ions, appendicitis or  Nausea identity by checking the bed number and
irritation
and water passively leave the acute surgical  Abdominal arm band.
 Rectal
cell; while sodium and abdomen cramps 2. Explained what the medication is for as
burning
chloride ions are unable to be  Vomiting  Haematochezia well as its possible side and adverse effects
reabsorbed. to the body.
 Rectal bleeding METABOLIC  Vomiting
 Abdominal 3. Took patient’s vital signs.
Water is also be transported
DISORDER:
discomfort 4. Prepared the medication and ensured
from the luminal side of cells  Dehydration
 Anorectal whether the medication is within its expiry
into the vasculature by date and is still intact.
IMMUNULOGIC discomfort
aquaporin 3. Bisacodyl 5. Informed the patient of the route of the
DISORDER:  Rectal burning
decreases expression of administration.
 Slight (suppository)
aquaporin 3, preventing water SUPPOSITORY ADMINISTRATION
from moving into the indisposition  Colitis
 Washed hands and donned
vasculature, which may plastic apron and gloves
contribute to increased water METABOLISM AND  Positioned the patient lying on the
in the colon. NUTRITION left side with her or his knees
DISORDERS: drawn up to the abdomen. This
Bisacodyl directly stimulates  Dehydration eases the passage of the
parasympathetic nerves in the suppository into the rectum
colon, stimulating contraction NERVOUS SYSTEM (Dougherty and Lister, 2004).
of longitudinal smooth muscle DISORDERS: Gravity and the anatomical
but not circular smooth  Dizziness structure of the sigmoid colon
muscle. also indicate that inserting the
suppository with the patient in this
Reference: position will aid retention.

DRUGBANK Online. (n.d.).
Bisacodyl. Retrieved from:
https://go.drugbank.com/drug
s/DB09020
ORAL ADMINISTRATION
 Positioned a plastic-backed
absorbent sheet underneath the
patient.
 Assessed the area and performed
a digital rectal examination.
 Broke the suppository seal.
 Lubricated the end of the
suppository with lubricating gel.
 Gently separated the buttocks,
identifying the anus.
 Slowly inserted the lubricated
suppository into the rectum.
 Attended to perianal hygiene.
 Asked the patient to retain the
suppository as suggested in the
manufacturer’s recommendations.
 Provided a bedpan, commode or
nurse call system as indicated.
 Disposed of any waste.
 Removed apron and washed
hands.
 Gave the medication in the
evening or before breakfast
because of action time required.
 Gave enteric coated tablets whole
to avoid gastric irritation.
Instructed the patient not to cut or
crush. Patient should not chew
tablets.
 Gave the medication with a full
glass (240 mL) of water or other
liquid.

AFTER:
1. Recorded and documented the
administration of medication.
2. Evaluated periodically patient's need for
continued use of drug; bisacodyl usually
produces 1 or 2 soft formed stools daily.
3. Monitored patients receiving concomitant
anticoagulants. Indiscriminate use of
laxatives results in decreased absorption of
vitamin K.
 4. Added high-fiber foods slowly to regular
diet to avoid gas and diarrhea. Adequate
fluid intake includes at least 6–8
glasses/day.
5. Informed patient not to take the
medication within 1 hour of antacids or milk.
These substances may cause premature
dissolution of enteric coating; early release
of drug in stomach may result in gastric
irritation and loss of cathartic action.
6. Instructed patient not to breast feed while
taking this drug without consulting her
physician.

DOSAGE/FREQ/ MECHANISM OF ACTION NURSING RESPONSIBILITIES

NAME OF INDICATIONS/
CLASSIFICATION SIDE EFFECTS ADVERSE EFFECTS
DRUG CONTRAINDICATIONS
ROUTE/SUPPLIED (Before, During, After)
GENERIC PATIENT’S DOSE: Angiotensin II Micardis (telmisartan) is a INDICATIONS: AUTONOMIC BLOOD AND BEFORE:
NAME: 40 mg receptor antagonists nonpeptide angiotensin II  Used for the NERVOUS SYSTEM LYMPHATIC SYSTEM 1. Checked and validated the doctor’s order
receptor (type AT1 10 ) treatment of DISORDERS: DISORDERS: and/or medication order prior to the
Telmisartan FREQUENCY: antagonist. Angiotensin II is hypertension, to  Impotence  Eosinophilia administration of the medication.
Once a day (OD) formed from angiotensin I in a lower blood  Increased 2. Observed the Ten Rights of medication
reaction catalyzed by pressure. sweating CARDIAC DISORDERS: administration.
ROUTE: angiotensin- converting  Flushing  Atrial fibrillation 3. Ensured proper preparation of drugs and
BRAND NAME: enzyme (ACE, kininase II). took note of the drugs’ mechanism of action
Oral (PO) CONTRAINDICATIONS:  Congestive
Angiotensin II is the principal  In patients who are CARDIOVASCULAR heart failure and side effects.
Micardis pressor agent of the renin- 4. Obtained a history on allergies or any
SUPPLIED: hypersensitive to DISORDERS:  Myocardial
Tablet angiotensin system, with any component of  Palpitation infarction other drugs, foods or substances that the
effects that include micardis  Angina  Tachycardia patient may be allergic to.
vasoconstriction, stimulation  In patients with pectoris  Bradycardia
of synthesis and release of anuria. DURING:
 Abnormal
aldosterone, cardiac  For co- 1. Identified patient and validated identity by
ECG EAR AND LABYRINTH
stimulation, and renal administration with checking the bed number and arm band.
 Hypertension DISORDERS:
reabsorption of sodium. aliskiren in patients 2. Explained what the medication is for as
Telmisartan blocks the  Peripheral  Vertigo
with diabetes. edema well as its possible side and adverse effects
vasoconstrictor and to the body.
aldosterone-secreting effects GENERAL DISORDERS
CENTRAL NERVOUS 3. Took patient’s vital signs.
of angiotensin II by selectively AND ADMINISTRATION
SYSTEM DISORDERS: 4. Prepared the medication.
blocking the binding of SITE CONDITIONS:
5. Informed patient about the route of
angiotensin II to the AT 1  Insomnia  Asthenia
administration.
receptor in many tissues,  Somnolence  Edema 6. Made sure that the patient is aware that
such as vascular smooth  Migraine he/she must not exceed the recommended
muscle and the adrenal gland.  Paresthesia IMMUNE SYSTEM dosage amount.
Its action is therefore  Involuntary DISORDERS: 7. Gave the whole tablet with a glass of
independent of the pathways muscle  Anaphylactic water; instructed patient to swallow it whole
for angiotensin II synthesis. contractions reaction and not to chew for doing so can release all
There is also an AT 2 receptor  Hypoesthesia of the drug at once, increasing the risk of
found in many tissues, but AT INFECTIONS AND side effects.
2 is not known to be GASTROINTESTINAL INFESTATIONS: 8. Ensured that the patient has swallowed
associated with DISORDERS:  Urinary tract and taken the medication.
cardiovascular homeostasis.  Flatulence infection
Telmisartan has much greater  Constipation AFTER:
affinity (>3,000 fold) for the AT  Gastritis METABOLISM AND 1. Recorded and documented the
1 receptor than for the AT 2 NUTRITION administration of medication.
 Dry mouth
receptor. Blockade of the DISORDERS: 2. Monitored BP carefully after initial dose;
 Hemorrhoids
renin-angiotensin system with  Hypoglycemia and periodically thereafter. Monitored more
ACE inhibitors, which inhibit  Gastroesopha
geal reflux (in diabetic frequently with preexisting biliary
the biosynthesis of patients) obstructive disorders or hepatic
angiotensin II from  Toothache
insufficiency.
angiotensin I, is widely used 3. Monitored concomitant digoxin levels
HEPATO-BILIARY NERVOUS SYSTEM
in the treatment of throughout therapy.
DISORDERS:
hypertension. ACE inhibitors DISORDERS:  Syncope
also inhibit the degradation of  Elevations of  Headache
bradykinin, a reaction also liver enzymes
catalyzed by ACE. Because or serum RENAL AND URINARY
telmisartan does not inhibit bilirubin DISORDERS:
ACE (kininase II), it does not  Renal failure
affect the response to METABOLIC  Renal
bradykinin. Whether this DISORDERS: impairment
difference has clinical  Gout including acute
relevance is not yet known.  Hypercholest renal failure
Telmisartan does not bind to erolemia
or block other hormone  Diabetes REPRODUCTIVE
receptors or ion channels mellitus SYSTEM AND BREAST
known to be important in
DISORDERS:
cardiovascular regulation.
MUSCULOSKELETAL  Erectile
Blockade of the angiotensin II
DISORDERS: dysfunction
receptor inhibits the negative
 Arthritis
regulatory feedback of
angiotensin II on renin  Arthralgia SKIN AND
secretion, but the resulting  Leg cramps SUBCUTANEOUS
increased plasma renin  Myalgia TISSUE DISORDERS:
activity and angiotensin II  Drug eruption
circulating levels do not PSYCHIATRIC (toxic skin
overcome the effect of DISORDERS: eruption mostly
telmisartan on blood pressure.  Anxiety reported as
 Depression toxicoderma,
Reference:  Nervousness rash, and
urticaria),
RESPIRATORY angioedema
Micardis (telmisartan). (n.d.).
DISORDERS: (with fatal
Www.centerwatch.com.
outcome)
Retrieved May 16, 2022, from  Asthma
https://www.centerwatch.com/  Rhinitis
directories/1067-fda- VASCULAR DISORDER:
 Dyspnea
approved-drugs/listing/3832-  Orthostatic
 Epistaxis
micardis- hypotension
telmisartan#:~:text=Mechanis VASCULAR
m%20of DISORDERS:
%20Action&text=Telmisartan  Cerebrovascu
%20blocks%20the lar disorder
%20vasoconstrictor%20and
SPECIAL SENSES
DISORDERS:
 Abnormal
 vision,
 Conjunctivitis
 Tinnitus
 Earache

REFERENCES:

1. DRUGBANK Online. (n.d.). Bisacodyl. Retrieved from: https://go.drugbank.com/drugs/DB09020

2. Drugs.com. (2020). Bisacodyl Side Effects. Retrieved from: https://www.drugs.com/sfx/bisacodyl-side-effects.html
3. Drugs.com. (2021). Bisacodyl Dosage. Retrieved from: https://www.drugs.com/dosage/bisacodyl.html
4. Higgins, D. (2007). Bowel care Part 6 – Administration of a suppository. Nursing Times; 103: 47:, 26-27.
5. Micardis (telmisartan). (n.d.). Www.centerwatch.com. Retrieved May 16, 2022, from https://www.centerwatch.com/directories/1067-fda-approved-drugs/listing/3832-micardis-telmisartan#:~:text=Mechanism
%20of%20Action&text=Telmisartan%20blocks%20the%20vasoconstrictor%20and
6. Micardis. (2020, August 11). RxList; RxList. https://www.rxlist.com/micardis-drug.htm#interactions
7. MIMS. (n.d.). Bisacodyl. Retrieved from: https://www.mims.com/philippines/drug/info/bisacodyl?mtype=generic