COURSE IN THE WARD July 06, 2007  Patient was admitted at 3:00 pm, conscious and coherent, not in CP distress, with pink conjunctiva, icteric sclerae, flabby abdomen, soft and non tender, no edema with a chief complaint of epigastric pain with a pain scale of 9/10 upon admission- intensity, location and characteristics of pain was assessed.  Intravenous fluid (D5NR 1 liter to run for 10 hours) started.  Patient was scheduled for Endoscopic Retrograde Cholangio Pancreatography (ERCP) on July 07, 2007 at 3:00pm and Cholecystectomy at 5:00pm.  Consent for the ERCP and Cholecystectomy was secured and the patient was advised to be on NPO after midnight. July 07, 2007  Clotting time test done  Patient was started on NPO after midnight and IVF of D5NR 1 liter was regulated to 120ml/Hr.  Cefuxitine 1 Gram/IV every 8 hrs (ANST) was started.  ERCP was done at 3 pm and ended at 4:30 pm, patient was maintained at NPO.  At 10:10 pm the patient was transferred to the operating room for Cholecystectomy with I.O.C. The operation was started by11:50 pm.  O2 inhalation via nasal cannula was ordered at 3LPM. July 08,2007  IOC was done before closing the surgical incision  Specimen (gallbladder) was sent to surgical pathology for histopath  After the operation the patient was transferred to the Recovery Room and Vital signs every 15 minutes was ordered for 2 hours and 30 minutes thereafter until Vital signs are stable.  At 4am the patient was still in the recovery room with epidural catheter.  With IVF D5NR 1 liter, with foley catheter and urine bag.  Suctioning PRN was ordered.  IVF to follow is D5NR 1 liter to run for 8 hours, I and O monitoring every shift was ordered.  Post op Medications were: monowel 1gram IV every 8 hrs, pantoloc 40 mg IV once a day, epidural morphine sulfate 0.027 10cc every 12 hours RTC x 3 doses. First Dose of Morphine Sulfate was given at 4am.  At 6:30 am patient is fully awake, not in cardio pulmonary distress, no nausea, vomiting, able to move all extremities, BP- 130/90 SPO2- 99% at room air, Aldrete score- 10, and VAS is 1/10.  Patient was given 1 ampule of plasil at 7:10 am due to complaints of nausea,  General Liquids Diet was started and Deep breathing Exercise was instructed.  Pantoloc IV was shifted to Prevacid FDT 30mg/tab once before breakfast.  Epidural morphine sulfate 0.027% 10cc given as second dose at 3pm. 20

 Patient complained of nausea and was given 1 ampule 10mg of plasil IV. July 09,2007  Epidural Morphine sulfate 0.027% 10cc given as third dose (3/3) Epidural catheter removed at 6am, (+) dizziness when try to sit.  Liver Profile Test was done  Doses of morphine sulfate and NSAID’s completed.  Hepatitis Profile was ordered in the morning of July 10, 2007. July 10, 2007  IVF was discontinued at 12NN.  Hepatitis profile was done  Full low fat Diet was ordered.  Discharge orders was ordered at 12:25 pm,  Clinical follow up was scheduled after a week.  Home meds ordered was prevacid 30 mg/ tab 1 tab OD prebreakfast x 1 wk, Cefuroxime500 mg 1tablet (1 tab every 12 hours for 5 days), Arcoxia 90 mg 1 tablet (only if there is pain). July 11, 2007  For repeat SGPT, bilirubin, alkaline phosphatase after 1 week.  Patient was instructed by the clinical pharmacist about home medications  Patient was seen and instructed by the dietician about her diet  Discharged at 12:15 pm with stable vital signs


MEDICATIONS BRAND NAME/ GENERIC NAME/ CLASSIFICATION Generic name: LANSOPRAZOLE Brand name: PREVACID Drug Classification: Gastric acid -pump inhibitor DOSAGE 30 mg PO once a day taken before eating ACTION/ INDICATION


Binds to an enzyme in their the presence of acidic gastric pH, preventing the final transport of hydrogen ions into gastric lumen. Treatment of pathologic hypersecretory conditions

 

Generic name: MONOWEL Brand name: CEFOXITIN Na Drug Classification: Anti- infective

1 GM IV Q 8°

Binds to bacterial cell wall membrane , causing cell death Treatment of the following infections due to susceptible organisms .(skin and skin structure infctions

Assess patient routinely for epigastric or abdominal pain or occult blood in stool or gastric aspirate. Administer drug before meals Inform client that drug may occasionally cause drowsiness therefore the patient should ambulate with assistance Assess patient for infection (vital signs) Before initiating therapy, obtain a history to determine previous use of and reactions to penicillin. Monitor IV site during administration for signs of inflammation, its patency and signs of inflammation Initiate measures that would potentiate action of the drug like


proper handwashing before and after handling the patient Generic name: KETOPROFEN Brand name: ORUDIS Drug Classification: Nonsteroidal antiinflammatory agent, Non-opoid analgesics 100 mg IV Q8° - ANST RTC x 3 Doses + 100mL PNSS

Inhibits prostaglandin synthesis. Management of mild to moderate pain

Assess patients who have asthma ,aspirin -induced allergy. Assess pain (type, location,& intensity) prior to & 1 hr following administration. Use cautiously in patients with history of peptic ulcer disease, renal dysfunction, fluid retention Advise patient to call the attention of the nurse if any untoward signs and symptoms noted. Inform the client that the drug may cause drowsiness

Generic name: PLASIL Brand name: METOCLOPROMIDE


Drug Classification: Antiemetic Generic name: CEFUROXIME Brand name: ZEGEN Drug classification: Anti- infective 500 mg PO Q12°

Blocks dopamine receptors in chemoreceptor trigger zone of the CNS Nausea and vomiting of central and peripheral origin associated with surgery. Surgical prophylaxs

Observe patient for signs/symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing)


Generic name: 0.02% : Freq: MORPHINE RTC Q12° x 3 Brand name: dosesMORPHINE SULFATE Strength 10 mL Drug Classification: Opoid Analgesic (agonist)

Binds to opiate receptors in the CNS.Alters the perception of and response to painful stimuli, while producing generalized CNS depression. Management of severe pain

Assess for any change in vital signs. Monitor for any signs of toxicity and overdose such as respiratory depression and coma Assess bowel function routinely. Prevention of constipation should be instituted with increased intake of fluids. Monitor patient routinely for bloody or black tarry stools; blurred vision or vision changes; change in the amount of urine produced; signs of serious allergic reaction (shortness of breath, wheezing, trouble breathing; hives, swelling of the lips, tongue or throat); signs of heart attack (chest pain, pressure, or tightness; shortness of breath; sweating; nausea and vomiting)

Generic name: LUMIRACOXIG Brand name: PREXIGE Drug Classification: COX-2 selective inhibitor non-steroidal anti-inflammatory drug

400 mg PO once a day x 3 days

NSAIDs work by reducing a substance in the body that leads to inflammation and pain. Lumiracoxib is used to treat osteoarthritis of the knee. It works by relieving pain and reducing swelling and inflammation


Generic name: Pantoprazole Brand name: Pantoloc Drug Classification: Anti Ulcer Drug

40 mg IV OD • Inhibits proton pump activity by binding to hydrogen – potassium adenosine triphosphatase, located at secretory surface of gastric parietal cells, to suppress gastric acid secretion • Report any untoward signs and symptoms


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