Western Mindanao State University

College of Nursing
Zamboanga City

Alternative Learning System

Related Learning Experience
EMERGENCY ROOM

Instructions:
Answer the provided questions comprehensively following the subsequent format.
Use the Times Roman Font Style
Utilize at least three (3) or more references
References should be 2015 and latest
Output should be submitted as posted in the Google Class Assignment in PDF Format
Use the templates as guides in accomplishing your output
You will be graded according to the Rubric given

https://www.123rf.com/photo_57911846_a-motion-blurred-photograph-of-a-senior-female-patient-on-stretcher-
or-gurney-being-pushed-at-speed-.html
SCENARIO: A Case of Medical Emergency in Diabetes Insipidus (Hypernatremia)
A 52 year old female was brought to the emergency room presenting with seizure. Seizure event lasted for less
than 60 seconds. Nurse Jose noted copious amount of secretions in the patient's mouth, patient looking slightly
pale, restless and lethargic with GCS of 11. The sister reports that the patient has been drinking large volume of
water for the past 2 days and complains of being dizzy when standing. Vitals as follows:

Vital Signs
Blood pressure (BP) : 85/60 mmHg
Heart rate (HR) : 130 beats/min
Respiratory rate (RR) : 33 breaths/min
Temperature : 36.50 C
Sp02 : 91%
Height : 154 cm
Weight : 58kg
GCS : 11

The doctor ordered the following medications:

Medications:
Phenytoin, loading dose, 10mg/kg, IV, over 30 minutes, STAT
Chlorothiazide, 500mg, IV, STAT
Dextrose 5% Water solution, 500ml, IV, over 1 hour

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History:
Weakness for the last 3 days. Complains of dizziness when standing and having severe thirst.

Lifestyle factors:

The patient habitually self-medicate. She claimed to have “UTI” due to pain in the abdominal area and took the
spare ofloxacin tabs she had from her previous consultation prescription.

Laboratory results:
Examinations Patient’s Result Normal Value Indication
URINE OSMOLALITY 300 mOsm/Kg
SERUM SODIUM 150 mmol/L

Procedure:
MRI SCAN : Shows brain shrinkage

Source: https://n.neurology.org/content/67/5/880

Case Study Questions:

Initial blood gas was ordered for the patient. Result shows the following:

BLOOD GAS
Parameters Result
Blood pH 7.5
pC02 35
p02 67
HC03 35
02 sat 88

Analyze the blood gas result. DETERMINE THE ACID-BASE ISSUE.

Discuss briefly the CAUSE of the acid-base issue in relation to the case scenario.

Your Tasks:

Determine the need for the required laboratory and diagnostic examinations.
Give the indications for the abnormal result/values
Illustrate the organ involved and label accordingly.
Discuss the normal function of the organ involved.
Explain the pathophysiology based on the diagnosis.
Create the pathologic pathway of the pathogenesis (the development of the disease and the chain of events
leading to the illness) contributing to the patient’s illness condition.
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Synthesize the life-threatening pathway as a consequence of the patient’s refusal / non-compliance with
treatment
Answer case study questions.
Formulate 2 Nursing Care Plan of according to the case scenario. And this should be based on the NANDA
approved Nursing Diagnosis.
Give 2 nursing problems (2 NCPs)
PRIORITIZE the problems and cite your reference/s
Develop a Drug Study based on your patient’s medications.

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EXAMPLE:

Pathogenesis of Appendicitis

Fecaliths / Appendicoliths Intraluminal Scarring Tumors Pathogens Other Disease

Obstruction of the Appendiceal Lumen

Bacterial Overgrowth

Inflammation

Subjective Cues: Objective Cues:

1. Periumbilical Pain 1. Localized tenderness
2. Anorexia, Nausea & Vomiting 2. Rebound tenderness
3. Persistent, Continuous Pain in the RLQ 3. Muscle guarding
localized at McBurney’s point 4. Flexed right leg
5. Low grade fever

Resolved through Surgery (Appendectomy)

Life-Threatening Pathway (Patient’s refusal / non-compliance with treatment)

 Signs & Symptoms of Over 48 hours

 Without Intervention

PERFORATION

Leak of Content into the Omentum and Surrounding Tissues

COMPLICATIONS

Small bowel obstruction Abscess Formation Peritonitis

Escalating diffuse abdominal pain with rapid development

of toxicity as evidenced by:
1. Dehydration
2. Signs of sepsis
 Oliguria
 Hypotension
 Acidosis
 High-grade fever

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3. Drug Study
GENERIC NAME: Phenytoin
BRAND NAME: Dilantin
DRUG ILLUSTRATION:
CLASSIFICATION:
Pharmacotherapeutic: Hydantoin
Clinical: Anticonvulsant
DOSAGE/FREQUENCY/ROUTE:
Status Epilepticus
IV: ADULTS, ELDERLY,
ADOLESCENTS: Loading dose: 20
mg/kg at maximum rate of 50 mg/min.
May repeat in 10 min after loading
dose with dose of 5–10 mg/kg.
INFANTS, CHILDREN: Loading
dose: 20 mg/kg at maximum rate of 1
MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE
NURSING RESPONSIBILITY
Stabilizes neuronal membranes in motor REACTION
cortex. Decreases influx of sodium Side Effects: BASELINE ASSESSMENT
during generation of nerve impulses.  Drowsiness
 Lethargy
Therapeutic Effect: Decreases seizure  Confusion
activity.  Slurred speech
INDICATION:  Irritability
 Management of generalized tonic-  Gingival hyperplasia
clonic seizures  Hypersensitivity
 Complex partial seizures reaction
 Status epilepticus  Constipation
 Prevention of seizures from head  Dizziness
trauma/neurosurgery  Nausea
 Prevention of early post-traumatic
seizures following traumatic brain Adverse Reaction: INTERVENTION/EVALUATION
injury.  Withdrawal may
precipitate status
CONTRAINDICATION: epilepticus
 Hypersensitivity to Phenytoin or  Blood dyscrasias
hydantoins  Osteomalacia
 Concurrent use of delavirdine  Toxic phenytoin blood
 History of acute phenytoin therapy concentration
 Second and third degree AV blocks  Ataxia
 Sinoatrial blocks  Nystagmus
 Sinus bradycardia
 Diplopia
 Adams-Stokes Syndrome
 Suicidal thoughts
 Severe cutaneous
reaction
 DRESS
 Anticonvulsant: Review history of
seizure disorder (intensity,
frequency, duration, LOC).
 Initiate seizure precautions.
 LFT, CBC should be performed
before beginning therapy and
periodically during therapy.
 Repeat CBC 2 wks following
 initiation of therapy and 2 wks
following administration of
maintenance dose.
 Observe frequently for recurrence of
 seizure activity.
 Monitor ECG for cardiac
arrhythmia.
 Assess for clinical improvement
(decrease in intensity/frequency of
seizures).
 Monitor for signs/symptoms of
depression, suicidal tendencies,
unusual behavior.
 Monitor CBC with differential, renal
function, LFT, B/P (with IV use).
 Assist with ambulation if
drowsiness, lethargy occurs.
 Monitor for suicidal ideation or
behaviors.
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mg/kg/min. May give additional dose
of 5–10 mg/kg after loading dose.
Seizure Control (Maintenance)
Note: Loading dose not used in pts
with history of renal/hepatic disease.
PO: ADULTS, ELDERLY: Loading
Dose: 1 g divided into 3 doses given
at 2-hr intervals. Maintenance (begins
24hrs after loading dose): Initially 100
mg 3 times/day; adjust at no less than
7–10-day intervals. Usual dose: 100
mg 3–4 times/day up to 200 mg 3
times/day (may consider 300 mg once
daily in pts established on 100 mg 3
times/day). CHILDREN: Initially, 5
mg/ kg/day in 2–3 divided doses.
Adjust dose at 7- to 10-day intervals.
Maintenance: 4–8 mg/kg/day.
Maximum: 300 mg/day.
 Monitor for therapeutic serum level
(10–20 mcg/mL).
 Therapeutic serum level: 10–20
mcg/mL; toxic serum level: greater
than 20mcg/mL. Free unbound
levels: Therapeutic: 1–2 mcg/mL;
toxic: more than 2 mcg/mL.
PATIENT/FAMILY TEACHING
 Pain may occur with IV injection.
 To prevent gingival hyperplasia
(bleeding, tenderness, swelling of
gums), maintain good oral hygiene,
gum massage, regular dental visits.
 Serum levels should be performed
every mo for 1 yr after maintenance
dose is established and q3mos
thereafter.
 Report sore throat, fever, glandular
swelling, skin reaction (hematologic
toxicity).
 Drowsiness usually diminishes with
continued therapy.
 Avoid tasks that require alertness,
motor skills until response to drug is
established.
 Do not abruptly withdraw
medication after long-term use (may
precipitate seizures).
 Strict maintenance of drug therapy is
essential for seizure control,
arrhythmias
 Avoid alcohol
 Report changes in behavior, thoughts
of suicide
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 Reference/s:
Kizior, R. J., & Hodgson, K. J. (2019).pg 932-935. Saunders nursing drug handbook 2020.
GENERIC NAME: Chlorothiazide
BRAND NAME: Mircrozide
DRUG ILLUSTRATION:
CLASSIFICATION:
Pharmacotherapeutic: Sulfonamide
derivative. Thiazide diuretic.
Clinical: Antichypertensive
DOSAGE/FREQUENCY/ROUTE:
Hypertension
PO: ADULTS: Initially, 12.5–25 mg
once daily. May increase up to 50
MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE
NURSING RESPONSIBILITY
Inhibits sodium reabsorption in distal REACTION
renal tubules, causing excretion of sodium, Side Effects: BASELINE ASSESSMENT
potassium, hydrogen ions, water.  Increased urinary
frequency
Therapeutic Effect: Promotes diuresis;  Potassium depletion
reduces B/P.  Orthostatic hypotension
INDICATION:  Headache
 Treatment of mild to moderate  GI disturbances
hypertension  Photosensitivity
 Edema in HF
 Hepatic cirrhosis Adverse Reaction:
 Renal dysfunction  Water loss/dehydration
 Treatment of calcium  Acute hypotensive
nephrolithiasis episodes
 Hyperglycemia INTERVENTION/EVALUATION
 Pancreatitis
 Pulmonary edema
 Blood dyscrasias
 Allergic pneumonitis
 Lethargy
CONTRAINDICATION:  Coma
 Hypersensitivity to Phenytoin or
chlorothiazude
 Anuria
 History of hypersensitivity to
sulfonamides or thiazide diuretics
 Check vital signs, esp. B/P for
hypotension, before administration.
Assess baseline electrolytes, esp. for
hypokalemia.
 Evaluate skin turgor, mucous
membranes for hydration status.
Evaluate for peripheral edema.
 Assess muscle strength, mental
status.
 Note skin temperature, moisture.
 Obtain baseline weight.
 Monitor I&O.
 Continue to monitor B/P, vital signs,
electrolytes, I&O, daily weight. Note
extent of diuresis.
 Watch for changes from initial
assessment (hypokalemia may result
in weakness, tremor, muscle cramps,
nausea, vomiting, altered mental
status, tachycardia; hyponatremia
may result in confusion, thirst,
cold/clammy skin) esp. alert for
potassium depletion in pts taking
digoxin (cardiac arrhythmias).
 Potassium supplements are
frequently ordered.
 Check for constipation (may occur
with exercise diuresis).
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 mg/day in 1–2 divided doses.
ELDERLY: Initially, 12.5 mg once
daily. Titrate in 12.5 mg increments PATIENT/FAMILY TEACHING
up to 50 mg/day in 1–2 divided doses.  Expect increased frequency
(diminishes with continued use),
Usual Pediatric Dosage volume of urination.
(Edema/HTN)  To reduce hypotensive effect, go
PO: CHILDREN 2–12 YRS: 1–2 from lying to standing slowly.
mg/kg/day. Maximum: 100 mg/day.  Eat foods high in potassium, such as
CHILDREN 6 MOS–2 YRS: 1–2 whole grains (cereals), legumes,
mg/kg/day in 1–2 divided doses. meat, bananas, apricots, orange
Maximum: 37.5 mg/day. CHILDREN juice, potatoes (white, sweet),
YOUNGER THAN 6 MOS: 1–3 raisins.
mg/kg/day in 2 divided doses.  Protect skin from sun, ultraviolet
Maximum: 37.5 mg/day. light (photosensitivity may occur).

Dosage in Renal Impairment

Creatinine clearance less than 30
mL/min: Generally not effective.
Avoid use with creatinine clearance
less than 10 mL/min.
Reference/s:
Kizior, R. J., & Hodgson, K. J. (2019).pg 568-570. Saunders nursing drug handbook 2020.

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GENERIC NAME: Ciprofloxacin
BRAND NAME: Pycip
DRUG ILLUSTRATION:
CLASSIFICATION:
Pharmacotherapeutic:
Fluoroquinolone.
Clinical: Antibiotic
DOSAGE/FREQUENCY/ROUTE:
Usual Dosage Range
PO: ADULTS, ELDERLY: 250–750
mg q12h. CHILDREN: (Mild to
moderate infections): 10 mg/kg twice
MECHANISM OF ACTION: SIDE EFFECTS/ADVERSE
NURSING RESPONSIBILITY
Inhibits enzyme, DNA gyrase, in susceptible REACTION
bacteria, interfering with bacterial cell Side Effects: BASELINE ASSESSMENT
replication.  Nausea  Question for history of
 Diarrhea hypersensitivity to ciprofloxacin,
Therapeutic Effect: Bactericidal.  Dyspepsia quinolones; myasthenia gravis,
INDICATION:  Vomiting renal/hepatic impairment.
 Treatment of susceptible infection due  Constipation
to E. Coli, K. pneumonia, E cloacae,  Flatulence INTERVENTION/EVALUATION
P. mirabilis, P. vulgaris, P.  Confusion  Obtain urinalysis for microscopic
aeruginosaH. influenzae, M. analysis for crystalluria prior to and
 Crystalluria
catarrhalis, S. pneumoniae, S. aureus during treatment. Evaluate food
 Burning and crusting of
(methicillin susceptible), S. tolerance.
eye
epidermidis, S. pyogenes, C. jejuni,  Monitor daily pattern of bowel
 Altered taste
Shigella spp., S. typhi activity, stool consistency.
 Sensation of foreign
 Encourage hydration (reduces risk of
body in eye
crystalluria).
 Eyelid redness
 Monitor for dizziness, headache,
 Itching
visual changes, tremors.
 Assess for chest, joint pain.
Adverse Reaction:
 Ophthalmic: Observe therapeutic
 Superinfection
response.
 Nephropathy
 Cardiopulmonary arrest
PATIENT/FAMILY TEACHING
CONTRAINDICATION:  Cerebral thrombosis  Do not skip doses; take full course of
 Hypersensitivity ciprofloxacin and  Hypersensitivity therapy.
other qionolones. reaction
 Maintain adequate hydration to
 Concurrent use of tizanidine  Photosensitivity prevent crystalluria.
 Muscle weakness  Do not take antacids within 2 hrs of
 Toxic epidermal ciprofloxacin(reduces/destroys
necrolysis effectiveness).
 Stevens-Johnson
 Shake suspension well before using;
Syndrome do not chew microcapsules in
 Hepatotoxicity
suspension.
 Tendonitis  Sugarless gum, hard candy may
 Tendon rupture relieve bad taste.
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 daily. Maximum: 500 mg/dose.  Avoid caffeine.
(Severe infections): 15–20 mg/kg  Report tendon pain or swelling.
twice daily. Maximum: 750 mg/dose.  Avoid exposure to sunlight/artificial
IV: ADULTS, ELDERLY: 200–400 light (may cause photosensitivity
mg q12h. CHILDREN: 10 mg/kg q8– reaction).
12h. Maximum: 400 mg/dose.  Report persistent diarrhea..

Usual Ophthalmic Dosage

ADULTS, ELDERLY, CHILDREN:
(Solution): 1–2 drops q2h while
awakefor 2 days, then 1–2 drops q4h
whileawake for 5 days. (Ointment):
Apply 3 times/day for 2 days, then 2
times/day for 5 days

Usual Otic Dosage

ADULTS, ELDERLY, CHILDREN:
Otic solution 0.2%. Instill 0.25 mL
(0.5 mg) 2 times/day for 7 days.

Reference/s:
Kizior, R. J., & Hodgson, K. J. (2019).pg 253-255. Saunders nursing drug handbook 2020.

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