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CASE PRESENTATION
On
DH tqpe a & complications
qpertens|on m|tn |td oard|oegatq m|tn
putonarq oongest|on and neuon|a

Submitted byRazieI Estornino

Submitted to. oo do, RQ


Clinical nstructor(Medicine Rotation)
NCM 104 section H1
%,-0414390398
2

Mi::icn cnc Vi:icn ...........................................................................................................................................................................................


CLjecIive ..........................................................................................................................................................................................................
LeIIer ................................................................................................................................................................................................................
/ckncw|ecgemenI....................................................
lnIrccucIicn ........................................................

Fot|ent Fro|||e
Demcgrcphic ccIc ..................................................................................................................................................................
Gencgrcm .................................................................................................................................................................................
GrcwIh cnc ceve|cpmenI cf c micc|e ccu|I.................................
Fhy:icc| ExcmincIicn ................................................................................................................................................................
LcLcrcIcry re:u|I: .......................................................................................................................................................................
Dicgnc:Iic Excm Fe:u|I: cnc Craphlcal descrlpLlon of Lhe paLlenL's 8andom 8lood Sugar

Anotomy ond Fhys|o|ogy.............................................
Fothophys|o|ogy ...................................................................................................................................................................................
Overv|ew o| the d|seose cond|t|on [DM type 2,keno| |o||ure,HFN, m||d cord|omego|y,pu|monory
congest|on,pneumon|o}.........................................................................................................

Nurs|ng Core
Fhcrmccc|cgicc| inIervenIicn: ................................................................................................................................................
FuncIicnc| hec|Ih pcIIern ........................................................................................................................................................
Nur:ing ccre p|cn: ....................................................................................................................................................................
Summcry cf Nur:ing Dicgnc:e:.................................................
Summcry cf nur:ing re:pcn:iLi|iIie: cn ecch ci:ec:e ccnciIicn..................................

ke|oted reod|ngsJJourno|s ..................................................................................................................................................................

Synthes|s ..........................................................................................................................................................................................................
8|b||ogrophy.......................................................



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VISION:

As u leudlng Chrlstlun lnstltutlon of leurnlng ln Aslu, Sllllmun Unlverslty ls commltted to totul humun development for the well-belng of soclety und
envlronment.

MISSION:
In thls regurd, the Unlverslty:

Infuses lnto the ucudemlc leurnlng the Chrlstlun fulth unchored on the gospel of Jesus Chrlst; provlde un envlronment where Chrlstlun fellowshlp und
relutlonshlp cun be nurtured und promoted.

Provldes opportunltles for growth und excellence ln every dlmenslon of the unlverslty llfe ln order to strengthen churucter, competence, und fulth.

Instllls ln ull members of the unlverslty communlty un enllghtened soclul consclousness, und u deep sense of |ustlce und compusslon.
Promotes unlty umong peoples und contrlbute to nutlonul development





1op|c Descr|pt|on
1hls Loplc focuses on neumonla wlLh uMll and mlld cardlomegaly lL Lackles Lhe anaLomy and physlology paLhophyslology and dlsease condlLlons relaLed
Lo Lhe case as well as Lhe demographlc daLa genogram of Lhe paLlenL growLh and developmenL of a mlddle adulL nurslng responslblllLles pharmacologlcal
lnLervenLlons funcLlonal healLh paLLern and 3 nurslng care plans 1he knowledge on pneumonla uMll and mlld cardlomegaly wlLh pulmonary congesLlon
4

provldes slgnlflcanL daLa and knowledge regardlng Lhe dlfferenL dlseases lL wlll also help lmprove Lhe skllls and aLLlLudes of nurses ln Laklng care of paLlenLs
expelnclng such condlLlons

|acement -urslng Care ManagemenL 10a Medlclne 8oLaLlon

Centra| Cb[ect|ves
AL Lhe end of our dlscusslon Lhe level lv sLudenLs of -CM 104 secLlon P1 shall acqulre knowledge develop skllls and manlfesL poslLlve aLLlLudes
necessary ln glvlng hollsLlc quallLy and safe care Lo paLlenLs experlenclng uM Lype ll and lLs compllcaLlons neumonla PyperLenslonanglna pecLorls
pulmonary congesLlon and Mlld cardlomegaly
Spec|f|c Cb[ect|ves
AL Lhe end of Lhe case presenLaLlon Lhe sLudenL nurses shall
1 Pave a clear vlew abouL Lhe glven lnformaLlon relaLed Lo Lhe paLlenL's case saLlsfacLorlly
2 ulscuss Lhe anaLomy and physlology of Lhe sysLems relaLed Lo Lhe case of Lhe paLlenL correcLly
3 ulscuss Lhe demographlc daLa genogram and Lhe paLlenL's funcLlonal healLh paLLern comprehenslvely
4 ldenLlfy properly Lhe nurslng responslblllLles on Laklng care wlLh paLlenLs havlng such condlLlons
3 ldenLlfy Lhe common medlcaLlons for cllenLs experlenclng such condlLlons and Lhe acLlons and slgnlflcanL conslderaLlons of each
6 CrlLlcally analyze Lhe -Cs for Lhe cllenL aL 73 level of compeLency
7 verballze lncreased level of knowledge Lo aL leasL 73 wlLh regards Lo pneumonla uMll mlld cardlomegaly
8 verbally express appreclaLlon of Lhe concepLs covered ln Lhe case presenLaLlon



Mrs Corazon Crdoez
Cllnlcal lnsLrucLor Medlclne 8oLaLlon
Sllllman unlverslLy College of -urslng
uumagueLe ClLy
5


uear Madam

l 8azlel LsLornlno a Level lv sLudenL of Sllllman unlverslLy College of -urslng care for a 38year old paLlenL Mrs vlllanos Amada 8 She was admlLLed lasL !uly
13 2008 aL 410 M wlLh chlef complalnLs of d dl lf ff fl lc cu ul lL Ly y l ln n b br re ea aL Lh hl ln ng g n no oL Le ed d p pr ro od du uc cL Ll lv ve e c co ou ug gh h w wl lL Lh h w wl lL Lh hl ls sh h s sp pu uL Lu um m e ed de em ma a o of f b bo oL Lh h l le eg gs s a an nd d f fe ee eL L v vo om ml lL Ll ln ng g o of f
l ln ng ge es sL Le ed d f fo oo od d f fo ou ur r L Ll lm me es s p pe er r d da ay y w wh hl lc ch h w we er re e a al ll l n no oL Le ed d 1 1 w we ee ek k p pr rl lo or r L Lo o a ad dm ml ls ss sl lo on n

ln relaLlon Lo Lhls l would llke Lo apply for a case sLudy regardlng my paLlenL who has uM Lype 2 hyperLenslon wlLh mlld cardlomegaly wlLh pulmonary congesLlon
and pneumonla on boLh lung bases ln connecLlon wlLh our relaLed learnlng experlence aL -egros CrlenLal rovlnclal PosplLal uumagueLe ClLy l wlll be prlvlleged
Lo conducL Lhls case sLudy for lL would enhance my knowledge lmprove our skllls and culLlvaLe poslLlve aLLlLudes Loward Lhe care of a paLlenL who experlences
such condlLlons WlLh Lhese l would llke Lo presenL and lmparL knowledge and skllls Lo my fellow learners Lhrough a case presenLaLlon

?our approval would be deeply appreclaLed and noLed as slgn of your concern for Lhe hollsLlc developmenL of Lhe exclLlng and never endlng quesL for knowledge
and wlsdom 1hank you


8especLfully yours




kA2ILL 8 LS1CkNINC




CKNOWLEDGEMENT

6

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8

%#DuO%
labeLeselllLus ls commonly descrlbed as Lhe culprlL/ Lhe klller dlsease/ Lhe rooL of all evlls" 1hls ls
due Lo Lhe rooLlng compllcaLlons afLer ulabeLes MelllLus was lefL unLreaLed or lnefflclenLly unLreaLed ln Lhe case of
Lhe sub[ecL ln Lhls case sLudy Lhe same culprlL wlLh oLher predlsposlng and preclplLaLlng facLors made her suscepLlble
Lo dlfferenL dlsease condlLlons such as hyperLenslon mlld cardlomegaly pulmonary congesLlon and pneumonla

_toetes meIIttos ts o ezoate sgstem dtseose eozoeteztzed g ettez o defteteaeg ta tasoIta oz o deezeosed
otIttg of te odg to ose tasoIta tt ts somettmes zefezzed to os tg sogozs" g ot eIteats oad eoIt eoze pzoetdezs. ge
aottoa ossoetottag sogoz tt dtoetes ts oppzopztote eeoose te possoge of Iozge omooats of sogozIodea oztae ts
eozoeteztstte of poozIg eoatzoIIed dtoetes. goeeez, tg IeeeI of Iood gIoeose oze oaIg oae eompoaeat of te potoIogte
pzoeess oad eItateoI moatfestottoas ossoetoted tt _g. _m eoa e ossoetoted tt seztoos eompIteottoas , ot peopIe tt
dtoetes eoa to/e pzeeeattee meosozes to zedoee te oeeozzeaee of soe It/eItood.

goatasoIta depeadeat _g oz _g tgpe ts te most eommoa tgpe of dtoetes oad oeeooats foz oppzostmoteIg 80 of
oII eoses. geze oze eoztoos eoosottee foetozs ot foz tts speetfte eose stodg, te potteat's geaette pzedtspostttoa to te dtseose
os pzeetpttoted g ez tg tato/e of gIoeose. %ea se os dtogaosed to oee _m tgpe z ot te oge of 8, teze os
taeffeettee tezopeotte moaogemeat ta tezms of medteoI moaogemeat oad os eII os aoapozmoeoIogteoI tatezeeattoas soe
os aotztttoaoI tato/e modtfteottoa oad esezetse. gts taeffeettee eoetoz zesoIted to te oggzoeottoa of te eoadtttoa Ieodtag
to dtffezeat seztoos pzoIems soe os gpezteastoa ezeta te potteat oIso ts geaetteoIIg pzedtsposed. geze oze odded tasoIts
9

to taozg oad ompezed te aozmoI foaettoatag of te /tdaeg, moag eoatztottag foetozs Ieod to te mtId eozdtomoegoIg oad
poImoaozg eoagesttoa, oad oIso te potteat tmmoae zespoase os eompzomtsed oad Ieods ez to e soseepttIe to paeomoato.
ge tafIommottoa oa ez Ioags oad te deezeosed mgoeozdtoI soppIg te zoaeed oot fzom te oztgtaoI staaez eoosed ez
to oee oagtao peetozts.

_toetes meIIttos zepzeseats o etezogeaeoos gzoop of ezoate dtsozdez eozoeteztzed g gpezgIgeemto. gost
eommoaIg offeets omea ogtag eteeaJ to . gts ts doe to totoI oz pozttoI tasoIta defteteaeg oz taseastttettg of eto eeIIs
to seezete tasoIta. 9t ts eozoeteztzed g dtsozdezs ta te metooItsm of eozogdzote, fot, pzoteta, os eII os eoages ta te
stzoetoze of Iood eesseIs. Qoosottee foetozs taeIode geaettes oad aotztttoaoI tg tato/e of gIoeose. ggpezteastoa, oeeozdtag
to te ozId eoIt ozgoatzottoa , ts te pezststeat eIeeottoa of te sgstoIte _g ooee 10 mm gg oad te dtostoIte ooee ?0
mm gg. @ts/ foetozs taeIode fomtIg tstozg oad gpezeoIestezemto. gaeomoato ts te tafIommottoa of te oIeeoIoz spoees
of te Ioag zesoIttag ta eoasoItdottoa of Ioag ttssoe os oIeeoIt ftII te esodotes. gese oze eoosed g eoztoos ozgoatsms.
agtao peetozts ts te tzoasteat pozosgsmoI eest pota pzodoeed g tasoffteteat Iood fIo to te mgoeozdtom zesoIttag ta
mgoeozdtoI tseemto. ge zts/ foetozs oze ggg oad _g.

10

EOGRAPHIC ATA
N Nu um me e: : Vlllunos, Amudu S Se ex x: : F Fe em mu ul le e C Cl lv vl ll l S St tu ut tu us s: : M Mu ur rr rl le ed d H Hu us sb bu un nd d: : V Vl ll ll lu un no os s, , B Be er rn nu ur rd d
A Ag ge e: : 5 58 8 y yr rs s. . o ol ld d B Bl lr rt th hd du uy y: : J Ju ul ly y 1 16 6, , 1 19 94 49 9 R Re el ll lg gl lo on n: : Romun Cuthollc N Nu ut tl lo on nu ul ll lt ty y: : F Fl ll ll lp pl ln no o
A Ad dd dr re es ss s: : L Lu ug gd do on ng gu un n, , D Dl lp po ol lo og g C Cl lt ty y O Oc cc cu up pu ut tl lo on n: : B Bu us sl ln ne es sw wo om mu un n B Bl lr rt th hp pl lu uc ce e: : D Dl lp po ol lo og g, , C Cl lt ty y
E Ed du uc cu ut tl lo on nu ul l A At tt tu ul ln nm me en nt t: : 2 2
n nd d
Y Yr r. . C Co ol ll le eg ge e
R Ro oo om m: : C CC CU U # #5 5 D Du ut te e u un nd d T Tl lm me e o of f A Ad dm ml ls ss sl lo on n: : J Ju ul ly y1 15 5, , 2 20 00 08 8 @ @ 4 4: :1 10 0 P PM M
A At tt te en nd dl ln ng g P Ph hy ys sl lc cl lu un n: : D Dr r. . S So ol lu ut tu un n/ / D Dr r. . C Cu ud dl lz z C Cu us se e # #: :0 01 10 04 42 26 6
C Ch hl le ef f C Co om mp pl lu ul ln nt t: :
D Dl lf ff fl lc cu ul lt ty y l ln n b br re eu ut th hl ln ng g n no ot te ed d, , p pr ro od du uc ct tl lv ve e c co ou ug gh h w wl lt th h w wl lt th hl ls sh h s sp pu ut tu um m; ; e ed de em mu u o of f b bo ot th h l le eg gs s u un nd d f fe ee et t; ; v vo om ml lt tl ln ng g o of f l ln ng ge es st te ed d f fo oo od d f fo ou ur r t tl lm me es s
p pe er r d du uy y ( (u ul ll l n no ot te ed d 1 1 w we ee ek k P PT TA A) )
V Ve er rb bu ul ll lz ze ed d, ," " n nu ug gl ll ls so od d | |u ud d k ko o u ug g g gl ln nh hu uw wu u d du uy y u un ny yu u k ku un nu un ng g g gl lu ub bo o k ko o n nu uu uy y p pl le em mu u, , g gu uh hu ub bu ug g m mu un n p pu ud d u uk ko on ng g t tl ll ll l; ; u un ng g d dl ll ll l n nu uk ko o m mu uk ku uy yu u
k ku uy y g gu us su uk ku u p pu u | |u ud d k ko o, , l lg gu uw wu us s r ru u n nu uk ko o u uk ko on ng g k kl ln nu uo on n b bu u" "
V Vl lt tu ul l S Sl lg gn ns s u up po on n u ud dm ml ls ss sl lo on n: : T T= =3 37 7. .2 2 d de eg gr re ee e C Ce el ls sl lu us s; ; P PR R= = 1 10 06 6 b bp pm m; ; R RR R= = 1 18 8c cp pm m; ; B BP P= =1 13 30 0/ /9 90 0

G Ge en ne er ru ul l I Im mp pr re es ss sl lo on n: :
R Re ec ce el lv ve ed d s sl lt tt tl ln ng g o on n b be ed d, , c co on ns sc cl lo ou us s, , u un nd d v ve er rb bu ul ll ly y r re es sp po on ns sl lv ve e; ;
f fu uc cl lu ul l g gr rl lm mu uc cl ln ng g l ls s n no ot te ed d u un nd d u us se e o of f u uc cc ce es ss so or ry y m mu us sc cl le e l ls s n no ot te ed d u up po on n b br re eu ut th hl ln ng g; ;
r re es st tl le es ss s u un nd d s sw we eu ut tl ln ng g n no ot te ed d o on n f fo or re eh he eu ud d u un nd d f fu uc ce e; ;
11

k ke ee ep ps s o on n m mo ov vl ln ng g t to o f fl ln nd d u u c co om mf fo or rt tu ub bl le e p po os sl lt tl lo on n- -f fr ro om m s sl lt tt tl ln ng g, , l ll le es s o on n b be ed d o on n u u s su up pl ln ne e p po os sl lt tl lo on n w wl lt th h h he eu ud d e el le ev vu ut te ed d u ut t u up pp pr ro ox xl lm mu ut te el ly y 3 30 0 d de eg gr re ee es s
u un nd d k ke ee ep ps s o on n s sh hl lf ft tl ln ng g f fr ro om m l le ef ft t l lu ut te er ru ul l t to o r rl lg gh ht t l lu ut te er ru ul l p po os sl lt tl lo on n. .

H Hl ls st to or ry y o of f P Pr re es se en nt t I Il ll ln ne es ss s: :
S Sh he e w wu us s d dl lu ug gn no os se ed d o of f D DM M t ty yp pe e I II I o on n 1 19 99 97 7 w wh he en n s sh he e w wu us s 4 48 8 y yr rs s. . o ol ld d; ;
S Sh he e w wu us s u ul ls so o u ud dm ml lt te ed d t to o t th he e s su um me e l ln ns st tl lt tu ut tl lo on n 4 4 w we ee ek ks s p pr rl lo or r t to o t th he e p pr re es se en nt t u ud dm ml ls ss sl lo on n d du ue e t to o d dl lf ff fl lc cu ul lt ty y l ln n b br re eu ut th hl ln ng g u un nd d p pr ro od du uc ct tl lv ve e c co ou ug gh h w wl lt th h
w wh hl lt tl ls sh h s sp pu ut tu um m; ; 1 1 w we ee ek k p pr rl lo or r t to o t th he e p pr re es se en nt t u ud dm ml ls ss sl lo on n, , s sh he e h hu ud d t th he e s su um me e c co om mp pl lu ul ln nt ts s u us s h he er r p pr re ev vl lo ou us s u ud dm ml ls ss sl lo on n b bu ut t n no ow w, , b bo ot th h h he er r l le eg gs s u un nd d f fe ee et t
w we er re e e ed de em mu ut to ou us s u un nd d s sh he e v vo om ml lt ts s o ou ut t t th he e f fo oo od d s sh he e l ln ng ge es st te ed d u ur ro ou un nd d f fo ou ur r t tl lm me es s l ln n u u d du uy y. .



G E N O G R M


Amillo Raiz
63yrs old
Vehivular
accident


Gardenia
Raiz
56 yrs. old
Vehicular
accident
Candelario
Reno, 55yrs.
old
hypertension


Pipito Reno
78yr. old
A&W


Amisita
Castillo
78 yrs old
Hypertension

Dalia Raiz
65 yrs. old
DM

Gardorello
Castillo
72 yrs. old
DM
Amando
Castillo
60 yrs. old
DM

Gardo Castillo
53 yrs. old
Hypertension

Gaston Castillo
86 yrs. old
A&W
12







LEGEND:
Female X-
Deceased
Male -
Client
KOW1h and LVLLOMLN1 o[ a midd!g
adu!
Norma| at|ent hys|o|og|c changes
hys|ca| Deve|opment

uecrease ln bone denslLy and mass causes a decrease ln helghL



She sLands 3 feeL 2 lnches and verballzed nagkakuba
Amada C. Villanos
58 yrs. old
Businesswoman
DM type
2;HPN;pneumonia,mil
d cardiomegaly w/
pulmonary congestion

Bernard
Villanos
60 yrs. old
A&W

Nelda
Aguilla
40 yo
Teacher
HPN
Joscilin
Agoncillo
36 yrs. old
Nurse
A&W
Marlon
Villanos
38 yr. old
Teacher;
HPN
Amando Castillo
60 yrs. old
DM; currently
living in Dgte.
city

Bernardo Jr.
Villanos
39 yrs. old
businessman
A&W

Randy
Villanos
33 yrs. old
jobless
A&W

Rudy Villanos
20 yrs. old
Prohibited
Drug User

13

as Lhe lndlvldual geLs older Muscle Lone decreases causlng
Lhe person Lo appear flabbler vlsual aculLy ofLen dlmlnlshes
necesslLaLlng eye glasses 1here ls an ad[usLmenL Lo
menopause

1he mosL vlslble changes aL Lhls perlod are graylng of halr
wrlnkllng of Lhe skln And Lhlckenlng of Lhe walsL uecrease ln
hearlng and vlsual aculLy are ofLen noLed durlng Lhls perlod


Cogn|t|ve changes
Changes ln cognlLlve funcLlon of mlddle adulLs are rare excepL
wlLh lllness or Lrauma 1he mlddle adulL can learn new skllls
and lnformaLlon Some mlddle adulLs enLer educaLlonal or
vocaLlonal programs Lo prepare Lhemselves for enLerlng [ob
markeL and changlng [obs



sychosoc|a| Deve|opment

Learns and ad[usLs Lo role as grandparenLs MalnLalns conLacL
wlLh exLended famlly 8eaches and malnLalns a saLlsfacLory
performance ln career uevelops adulL lelsure Llme acLlvlLles
8eadles self boLh flnanclally and psychologlcally for reLlremenL
llrsL awareness LhaL Lhey are becomlng old"




naman ko kay gulang na dlll na pareha sauna akong
Llnlndugan ba laln man [ud nang baLa pa kay lamlg
Llnundugan" clalmed she wears eye glasses buL noL ln
Lhe hosplLal she uses lL only when she ls readlng buL she
was noL able Lo brlng lL has mlxLure of black and whlLe
halr wrlnkllng of Lhe skln ls noLed on Lhe face and
exLremlLles poor hearlng aculLy due Lo old age
verballzed kaLong haplL na ko mag menopause me[o
naglahl [ud ko kanang sapuLon ba usahay"


ALLends Lo semlnars ln Lhelr barangay regardlng
buslnesses buL Lend Lo sLay home when her healLh
sLarLed Lo become lll verballzed kaLong wala pa ko
sugod nagsaklL [ud kay muaLLend ra man mo kung unsay
mga semlnar labaw na kabahln buslness ba blsan kaLo
naa nako uM2 pero kanang grabe na [ud pundo nlng
balay sa Lv nalang"



Crandchlldren usually vlslL her durlng speclal occaslons
LogeLher wlLh her chlldren when Lhey are sLlll ln
ulpologverballzed layo naman pud sllaa kanang sauna
ra kay dall ra pagadLo nlla mablslLa dayon ko sa mga
baLa mao unLay kallngawan unsaon La man kay layo na
llsod pud magbyahe uy"
Cood performance ln her grocery sLore buslness and
clalmed Lo be Lhe one managlng lL ull Llme compared Lo
her husband SLlll preparlng for her Lhelr llves as an old
couple and verballzed kanang amo kay kung padalan ra
14





Mora| Deve|opment

Accordlng Lo kohlberg Lhe adulL can move beyond Lhe
convenLlonal level Lo Lhe posLconvenLlonal level kohlberg
belleves LhaL exLenslve experlence of personal moral cholce
and responslblllLy ls requlred before people can reach Lhe posL
convenLlonal level 1he person llves auLonomously and deflnes
moral values and prlnclples LhaL are dlsLlncL from personal
ldenLlflcaLlon wlLh group values She llves accordlng Lo
prlnclple LhaL are unlversally agreed on and LhaL Lhe person
conslders approprlaLe for llfe




Sp|r|tua| deve|opment

As an adulL grows flrmer Lhe falLh Lo Cod


pud ml sa akong anak sa gawas pero kung dlll pud kay
kanlng sa negosyo ra lpon ug glnagmay para sa
klnabuhlng Llgulang" She shared LhaL she's geLLlng older
and weaker due Lo her compllcaLed dlsease/condLlon



She doesn'L flnd lL dlfflfflculL Lo follow rules seL by Lhe
communlLy as long as Lhe rules are falr enough Lo
everybody ln maklng declslon she 1
sL
conslders Lhe
welfare of her famlly and consulLs her husband all Lhe
Llme Slnce her chlldren were lefL aL ulpolog clLy she
always cllngs Lo her husband and older broLher when lL
comes Lo declslon maklng and verballzed usahay day
kay slla na lamang akong pasagdan mas maayo kay kusog
pa man slla unya kanang magluya k okay guboL na man
gud hunahuna slla na lamang kabalo naman pud slla
basLa Lama ra"



My cllenL ls a 8oman CaLhollc She clalms LhaL as she
grows older she develops Lhls sLronger falLh Lo Cod
AlLhough she ls sufferlng of Lhls dlsease condlLlon she ls
very Lhankful Lhe she's sLlll allve She Lhanks Plm each
day and asks Plm Lo be able Lo see her chlldren and
grandchlldren compleLely llke a reunlon lf only posslble
because lL wlll make her very happy and forgeL LhaL she ls
lll verballzed nangandoy Lawon ko blsag lmposlble
gamay kay lagyo man slla kanang unLa makareunlon pud
mo blsag slmple ra kay gulang na gud pud Lawon ml nya
15




















masaklLon pa gyud ko maayo nang maklLan nako akong
mga apomallpay [ud Lawon konagampo gyud ko nlya"
16

PHYSICAL ASSESSENT

uaLe of LxamlnaLlon !uly 22 2008


Lxamlned by 8azlel LsLornlno

DLMCGkAnIC DA1A
C||ent Amada vlllanos
Age 38 years old
8|rthdate !uly 16 1949
C|v|| Status Marrled
Lducat|ona| Atta|nment 2
nd
yr college
Address Lugdongan ulpolog ClLy
ke||g|on 8oman CaLhollc
Cccupat|on 8uslnesswoman
Nat|ona||ty llllplno
Doctor(s) |n charge ur SoluLan/ ur Cadlz
koom and 8ed No CCu #3
Date 1|me of Adm|ss|on !uly 13 2008 aL 410 M
Ch|ef comp|a|nt(s) u ul lf ff fl lc cu ul lL Ly y l ln n b br re ea aL Lh hl ln ng g n no oL Le ed d p pr ro od du uc cL Ll lv ve e c co ou ug gh h w wl lL Lh h w wl lL Lh hl ls sh h s sp pu uL Lu um m e ed de em ma a o of f b bo oL Lh h l le eg gs s a an nd d f fe ee eL L v vo om ml lL Ll ln ng g o of f l ln ng ge es sL Le ed d f fo oo od d f fo ou ur r L Ll lm me es s p pe er r
d da ay y ( (a al ll l n no oL Le ed d 1 1 w we ee ek k 1 1A A) )
v ve er rb ba al ll lz ze ed d " " n na ag gl ll ls so od d [ [u ud d k ko o u ug g g gl ln nh ha aw wa a d da ay y u un ny ya a k ka an na an ng g g gl lu ub bo o k ko o n na aa ay y p pl le em ma a g ga ah hu ub ba ag g m ma an n p pu ud d a ak ko on ng g L Ll ll ll l a an ng g d dl ll ll l n na ak ko o m ma ak ka ay ya a k ka ay y g ga as su uk ka a p pa a [ [u ud d k ko o l lg ga aw wa as s r ra a
n na ak ko o a ak ko on ng g k kl ln na ao on n b ba a" "
n|story of present |||ness S Sh he e w wa as s d dl la ag gn no os se ed d o of f u uM M L Ly yp pe e l ll l o on n 1 19 98 89 9 w wh he en n s sh he e w wa as s 4 40 0 y yr rs s o ol ld d
17

S Sh he e w wa as s a al ls so o a ad dm ml lL Le ed d L Lo o L Lh he e s sa am me e l ln ns sL Ll lL Lu uL Ll lo on n 4 4 w we ee ek ks s p pr rl lo or r L Lo o L Lh he e p pr re es se en nL L a ad dm ml ls ss sl lo on n d du ue e L Lo o d dl lf ff fl lc cu ul lL Ly y l ln n b br re ea aL Lh hl ln ng g a an nd d p pr ro od du uc cL Ll lv ve e c co ou ug gh h w wl lL Lh h w wh hl lL Ll ls sh h s sp pu uL Lu um m
1 1 w we ee ek k p pr rl lo or r L Lo o L Lh he e p pr re es se en nL L a ad dm ml ls ss sl lo on n s sh he e h ha ad d L Lh he e s sa am me e c co om mp pl la al ln nL Ls s a as s h he er r p pr re ev vl lo ou us s a ad dm ml ls ss sl lo on n b bu uL L n no ow w b bo oL Lh h h he er r l le eg gs s a an nd d f fe ee eL L w we er re e e ed de em ma aL Lo ou us s a an nd d s sh he e
v vo om ml lL Ls s o ou uL L L Lh he e f fo oo od d s sh he e l ln ng ge es sL Le ed d a ar ro ou un nd d f fo ou ur r L Ll lm me es s l ln n a a d da ay y

Genera| Impress|on of c||ent (appearance upon f|rst contact)
8 8e ec ce el lv ve ed d s sl lL LL Ll ln ng g o on n b be ed d c co on ns sc cl lo ou us s a an nd d v ve er rb ba al ll ly y r re es sp po on ns sl lv ve e
f fa ac cl la al l g gr rl lm ma ac cl ln ng g l ls s n no oL Le ed d a an nd d u us se e o of f a ac cc ce es ss so or ry y m mu us sc cl le e l ls s n no oL Le ed d u up po on n b br re ea aL Lh hl ln ng g
r re es sL Ll le es ss s a an nd d s sw we ea aL Ll ln ng g n no oL Le ed d o on n f fo or re eh he ea ad d a an nd d f fa ac ce e
k ke ee ep ps s o on n m mo ov vl ln ng g L Lo o f fl ln nd d a a c co om mf fo or rL La ab bl le e p po os sl lL Ll lo on n f fr ro om m s sl lL LL Ll ln ng g l ll le es s o on n b be ed d o on n a a s su up pl ln ne e p po os sl lL Ll lo on n w wl lL Lh h h he ea ad d e el le ev va aL Le ed d a aL L a ap pp pr ro ox xl lm ma aL Le el ly y 3 30 0 d de eg gr re ee es s a an nd d k ke ee ep ps s o on n
s sh hl lf fL Ll ln ng g f fr ro om m l le ef fL L l la aL Le er ra al l L Lo o r rl lg gh hL L l la aL Le er ra al l p po os sl lL Ll lo on n
ast Med|ca| n|story
Ch||dhood I||nesses fever chlcken pox cough and common colds
Acc|dents]In[ur|es none Ser|ous or Chron|c D|seases uM Lype 2 P-
nosp|ta||zat|ons She was hosplLallzed on Lhe same lnsLlLuLlon 4 weeks prlor Lo Lhe presenL admlsslon due Lo complalnLs of dlfflculLy of breaLhlng and
producLlve cough wlLh whlLlsh secreLlons oLher admlsslons was due dellvery
Cperat|ons -o prevlous surgerles
A||erg|es no known allergles
rev|ous med|cat|ons verballzed kallmoL ko aLong mga ngalan basLa pangdlabeLes Lo nako ug hlghblood pero kaLong nahosplLal ko before anl kay
daghandaghan pud Lo"

O Current Med|cat|ons Asplrln CC8 30 mg 1 Lab Culmdur 60mg 1 Lab Cu MeLoclopramlde 1Amp lv11 q8hours LanLus 13 u" SC before supper ulovan 80mg
1 Lab Cu CapoLen 23 mg every 6 hours Su for 8160/90 8anlLldlne 1 Amp l11 evry 8 hours CefLrlaxlne 1 Amp every 8 hours Lansoprazole 30 mg 1 cap Cu
SlmvasLaLln 2 mg 1 Lab Cu qPS leSC4 wlLh lA 1 Lab 8lu Cllndamycln 30 mg lv11 every 8 hours SalbuLamol 1 neb 1lu 61210

nab|ts and L|festy|es Verballzed"gagmay ra pero mukaon man ko" has no allergles Lo food She Lakes fluld such as waLer and a slp of sofLdrlnks such as coke and
verballzed"Llglnom [ud kog coke pero karon kay lla naman ko kasaban kay sa akong condlLlon lagl mao ng glnagmay nalang Lungab ug glnagmay" eaLs regularly
(3 meals/day wlLh snacks) uoesn'L smoke and drlnks alcohollc beverages occaslonally She never experlenced Laklng prohlblLed drugs Wakes up aL around 730
18

AM Lakes a nap ln Lhe afLernoon Lo resL and sleeps aL nlghL around 9 Lo 10 M dependlng on her acLlvlLles Pas normal and regular ellmlnaLlon paLLern wlLh no
dlscomforLs

GLNLkAL SUkVL
1 State of awareness 1he cllenL ls aware awake and alerL of boLh self and envlronmenL She responds Lo exLernal sLlmull wlLhouL heslLaLlon
2 Cbv|ous s|gns of d|stress pa|n and anx|ety Lurns Lo lefL and rlghL slde Lo flnd a comforLable poslLlon buL usually slLLlng on bed wlLh hed resLed on 2
plllows plled up looks very resLless when coughlng and movemenL ls slow due Lo weaknessnoLed use of accessory muscles upon
resplraLlon
3 Ga|t 1he cllenL's movemenLs are coordlnaLed alLhough her husband and relaLlve always asslsLs her when ambulaLlng
4 osture Slouchlng was apparenL on our cllenL
3 8ody movements Per body movemenLs are purposeful smooLh and assoclaLed wlLh her LhoughLs
6 nyg|ene]groom|ng odor Per halr skln and nalls appear clean 1he halr ls curly and unkempL no unpleasanL odor noLed CloLhlng ls clean and
approprlaLe for cllmaLe
7 Speech Speech ls clear and undersLandable and moderaLely 1here ls assoclaLlon of whaL Lhe cllenL speaks and Lhlnks
8 Mood and Affect 1he cllenL ls someLlmes annoyed when LhermomeLer ls placed on her armplL and verballzed human na? kuwaa na day kay dlll ko
ganahan" uncomforLable on bed and keeps on Lurnlng from slde Lo slde when shes on suplne poslLlon and when she ls very resLless due Lo
her cough she ls someLlmes uncooperaLlve and lrrlLable yeL manageable

V|ta| S|gns
1emperaLure 366C
ulse 80 bpm regular and weak
8esplraLlons 20 pm regular wlLh use of accessory muscles
8lood ressure 110/80 mmPg
Cardlac raLe 80 bpm

II hys|ca| Lxam|nat|on

A Integumentary system

nea|th n|story Allerglc -o allergles Lo food Scars on Lhe lower exLremlLles due Lo scraLched lnsecL blLes when she was sLlll a Leenager -o famlly hlsLory of skln
dlsorders 1akes a baLh everyday uses soap and shampoos halr every oLher day
19


Skln
lnspecLlon
a Color Pas brown skln Skln ls llghLer on Lhe less exposed parL of her body
b Leslons -o leslon noLed Scars due Lo scraLched lnsecL blLes are also presenL on her lower exLremlLles
c Ldema Ldema noLed on boLh her legs and feeL buL verballzed" nlgamay na nlng hubag day lkumpara aLong nlaboL ko dlrl sa hosplLal makalakaw
naman ko gamay pero hlnay lang ug Lunob ba"

alpaLlon
a MoblllLy/1urgor Pas poor skln Lurgor and moblllLy due Lo old age skln ls sagged
b 1exLure Per skln ls sllghLly rough due Lo wrlnkles buL sofL She was sweaLlng especlally when she coughs and looks resLless due Lo warm envlronmenL her
husband uses a cardboard paper Lo fan her
c 1emperaLure Skln ls warm Lo Louch
d -o lumps felL

-alls
nea|th n|story no nall problems ln Lerms of brlLLleness cracklng or spllnLlng no changes ln nall LexLure (smooLh) uoes noL apply nall pollsh buL cuLs her
flngernalls and Loenalls when she Lhlnks Lhey look long
lnspecL
a Color lL ls plnklsh because of Lhe nall beds underneaLh lL has LranslucenL whlLe Llps
b 1hlckness 1he nalls are Lhlck and grow aL consLanL raLe
c ConLour 1he nalls are well rounded and form a convex conLour
d Angle Lhere ls approxlmaLely 160 angle upon lnspecLlon
e 1here ls poor caplllary reflll of Lhe nalls wlLh 4 seconds
f Well Lrlmmed fooL and flnger nalls

8 nLLN1 system
nLAD
n|story She experlences headache when Lhe envlronmenL ls Loo hoL wears eye glasses buL ls noL able Lo brlng lL clalmed LhaL her vlsual aculLy ls poor due Lo old
age -o serlous problem wlLh nose and slnuses excepL for common colds no hearlng and Lhyrold
problem ln Lhe pasL
20

lnspecLlon
a. resence of nlLs dandruffs and scallness 1here ls absence of nlLs dandruffs and scallness
b. CuanLlLy of halr dlsLrlbuLlon and LexLure Per halr ls Lhln evenly dlsLrlbuLed smooLh reslllenL curly and unkempL
c. Color whlLe and black sLrands noLed
d. Slze approprlaLe Lo body slze
alpaLlon
a Leslons deformlLles and lumps 1here ls absence of leslons deformlLles and lumps

IACL
lnspecLlon
a ConLour Per face ls oblong ln shape
b SymmeLry 1here ls symmeLry on boLh slded of her face
c lnvolunLary movemenLs 1here are no lnvolunLary movemenLs noLed
d Ldema 1here ls no edema noLed
alpaLlon
a Masses 1here are no masses palpaLed
Lyebrows
lnspecL
aCuanLlLy and scallness Per eyebrows are Lhln and evenly dlsLrlbuLed Lhere are no slgns of scallness
b Color Lyebrows are black ln color
alpaLlon
c Masses 1here are no masses palpaLed
Lyes
n|story Pas experlenced havlng sore eyes when she was ln hlgh school wears eye glasses buL lefL lL aL home and clalmed LhaL her vlsual aculLy ls noL as good as
before when she ls sLlll young

LxamlnaLlon of Lhe eye was noL done slnce Lhe cllenL refused Lo parLlclpaLe even Lhough proper explanaLlon was done
1he cllenL verballzed" dlll ra ko day ayaw nalang aplla ang maLa kapoy na ko"

LAkS
21

n|story no hlsLory of ear lnfecLlon or earaches no hlsLory of hearlng problems LhaL lnLerfere wlLh dally acLlvlLles no excesslve amounL of cerumen paLlenL clalms
LhaL she cleans her ears uslng coLLon buds aL leasL once every Lwo weeks and when her ears geL lLchy as verballzed

1 lnspecL
a. ueformlLles -o deformlLles noLed
b. Slze Lhe slze ls approprlaLe Lo Lhe face and symmeLrlcal on boLh sldes
c. AllgnmenL Aurlcles are level wlLh each oLher whose uprlghL polnL of aLLachmenLs are ln sLralghL llne wlLh Lhe laLeral canLhus of Lhe eyes and Lhe
poslLlon ls almosL verLlcal
d. Color 1he color of each ear ls Lhe same as Lhe face
2 alpaLe for nodules 1here ls presence of small nodules on boLh ears yeL no Lenderness upon palpaLlon
3 Aurlcles are grasped upward and backward slnce Lhe cllenL ls already 38 years old
4 AudlLory canal
a Color lL appears unlformly plnklsh wlLh Llny halr ln lLs ouLer Lhlrd
b ulscharges -o dlscharges noLed 1here are llLLle cerumen noLed lL ls dry and llghL brown Lo gray ln color
3 AudlLory aculLy 1he cllenL has poor audlLory aculLy because she was heslLanL ln repeaLlng Lhe words l whlspered and was noL able Lo repeaL lL when Lhe lefL
ear was examlned When Lhe cllenL was spoken ln loud and clear volce she was able Lo respond very well excepL for whlspered words or low volume Lone of
volce

NCSL
n|story has had colds buL noL very ofLen senslLlve Lo scenLs of perfume and alr fresheners

1 lnspecL
a SymmeLry lL ls symmeLrlcal on boLh sldes
b ueformlLles 1here were no deformlLles noLed
c Slze 1he slze ls approprlaLe Lo hls face
d Shape lL ls Lrlangle
e Color lL has Lhe same color wlLh her face
2 alpaLe
a. 1enderness 1here ls absence of Lenderness
22

b. -odules -o presence of nodules
3 -asal Mucosa
a color lL looks plnklsh and molsL
b swelllng -o presence of swelllng
c exudaLes 1here ls absence of exudaLes
d bleedlng -o bleedlng noLed
4 -asal SepLum
a devlaLlon 1here ls no devlaLlon
b perforaLlon -o perforaLlon
c bleedlng 1here ls absence of bleedlng
lL ls close Lo Lhe mldllne and Lhlcker on Lhe anLerlor Lhan Lhe posLerlor
3 lnferlor and mlddle LurblnaLes
a color 1he color appears plnklsh ln color
b swelllng swelllng noLed
c exudaLes 1here ls absence of exudaLes
d polyps 1here ls absence of polyps
SINUSLS
1 lronLal Slnuses
1here was Lenderness and paln upon palpaLlon
2 Maxlllary Slnuses
1here was absence of Lenderness upon palpaLlon

MCU1n
n|story experlenced LonsllllLls no hlsLory of oral lnfecLlon no hlsLory of Longue and mouLh leslons no hlsLory of bleedlng gums brushes LeeLh every afLer meal

1 Llps
lnspecL
a Per llps are symmeLrlcal smooLh and dry
a. Color 1he color ls plnklsh
b. Cracklng ulcers 1here are absence of cracklng ulcers
alpaLe for lumps
23

b -o lumps noLed when llps were palpaLed

2 8uccal Mucosa
lnspecL
a. 8leedlng 1here ls no bleedlng
b. ulscoloraLlon -o dlscoloraLlon lL ls plnklsh ln color
c. CrowLh -o growLh was noLed

3 Cums
1he color ls plnk no edema noLed no reLracLlon no bleedlng and no leslons
lL ls smooLh and molsL wlLh a LlghL margln aL each LooLh

4 1eeLh
lnspecL
a. mlsslng LeeLh 1 lefL upper molar1 lefL lower molar
b. Loose LeeLh she has no loose LeeLh
c. LxLracLlon 1here are exLracLlons
d. Carles 1here are presence of denLal carles
e. Abnormal shape and poslLlon -o abnormal shape and poslLlon noLed

3 8oof of MouLh (Pard alaLe)
lnspecL
a. Color 1he color ls whlLlsh
b. ArchlLecLure lL ls domedshape
c. ueformlLles -o deformlLles noLed

6 1ongue
A uorsum
a. Color lL ls dull red ln color
b. aplllae lL has ralsed LasLe buds
c. 1exLure lL ls sllghLly rough on Lhe dorsum buL smooLh on Lhe laLeral margln
24

8 Pypoglossal nerve lL ls funcLlonal because she was able Lo move her Longue from slde Lo slde

C lloor of Lhe mouLh lL ls plnk and smooLh wlLh large velns beLween frenulum folds

nAkNk
lnspecL
a 8lse of sofL palaLe lL ls plnklsh ln color and lL rlses wlLh Lhe uvula when Lhe cllenL says ah'
b Color lL ls plnk ln color
c SymmeLry lL ls symmeLrlcal
d ulscharge 1here ls no dlscharge
e ulceraLlons 1here ls no ulceraLlons
f LnlargemenL of Lonslls -o enlargemenL of Lhe Lonslls
g CharacLerlsLlcs and enlargemenL of uvula lL ls cenLrally allgned and does noL Louch Lhe Longue

NLCk
lnspecL
a SymmeLry lL ls symmeLrlcal
b Scars -o scars are presenL
c CrowLh -o growLh noLed
d LnlargemenL of paroLld glands 1here ls no enlargemenL of Lhe paroLld glands
alpaLe for lymph nodes
1he occlplLal posLaurlcular preaurlcular Lonsllar submandlbular submenLum cervlcal supraclavlcular nodes are noL swollen and palpable

1kACnLA
lnspecL
a AllgnmenL lL ls ln Lhe mldllne of Lhe neck above Lhe suprasLernal noLch
b uevlaLlon 1here ls no devlaLlon

1nkCID GLAND
1here are no enlargemenLs noLed upon palpaLlon

25

C kesp|ratory system
n|storydlfflculLy ln breaLhlng and producLlve cough wlLh whlLlsh secreLlons noLed 1 week prlor Lo admlsslon -o hlsLory of surglcal procedures lnvolvlng chesL
lnclslon or lung puncLure ChesL A resulL shows LhaL Lhere ls pneumonla on boLh lung bases wlLh pulmonary congesLlon

CS1LkICk CnLS1
1 lnspecL
a 8aLe of resplraLlon 1he cllenL's raLe of resplraLlon ls 23 cycles per mlnuLe
b 8hyLhm of resplraLlon 1he rhyLhm of resplraLlon ls regular
c uepLh of resplraLlon Per breaLhlng ls shallow
d LfforL/use of accessory muscles Per breaLhlng ls sllenL buL wlLh use of accessory muscles
e Shape of chesL
1he splne ls ln sLralghL llne wlLh no laLeral devlaLlon
1he Lhorax ls symmeLrlcal ln elllpLlcal shape wlLh downward sloplng rlbs relaLlve Lo Lhe splne
1he scapulae are symmeLrlcal and closely aLLached Lo Lhe Lhoraclc wall
1he lCS have no bulglng or acLlve movemenL durlng breaLhlng
1he anLeroposLerlor dlameLer ls Z of Lhe Lransverse dlameLer

2 alpaLe
a Masses 1here are no masses noLed
b 1enderness 1here ls absence of Lenderness

3 8esplraLory excurslon
1here ls unsymmeLrlcal movemenL of my Lhumbs and are separaLlng abouL 1 lnch as Lhe cllenL breaLhes

4 1acLlle fremlLus
1he vlbraLlon ls weak aL Lhe apex of Lhe lungs buL as l goL lower lL ls sLronger on Lhe rlghL because of blfurcaLlon and falnLlng as l wenL lower

3 ercusslon
uullness was heard on Lhe lungfllled area and sLlll dull on lower area especlally on Lhe rlghL because of Lhe llver's presence

6 AusculLaLlon
26

Crackles were heard on Lhe lung perlphery whlle bronchoveslcular sounds ln beLween Lhe scapulae

AN1LkICk CnLS1
1 lnspecL
a 8aLe of resplraLlon 1he cllenL's raLe of resplraLlon ls 20 cycles per mlnuLe
b 8hyLhm of resplraLlon 1he rhyLhm of resplraLlon ls regular
c uepLh of resplraLlon 1he depLh of her breaLhlng ls noL Loo shallow and noL Loo deep
d LfforL/use of accessory muscles Per breaLhlng ls sllenL wlwLh use of accessory muscles
e Shape of chesL 1he rlbs are sloplng downward wlLh symmeLrlc lCS
f SymmeLry lL ls symmeLrlcal on boLh sldes

2 alpaLe
a Masses 1here are no masses noLed
b 1enderness 1here ls absence of Lenderness

3 1acLlle fremlLus
1he vlbraLlon ls weak aL Lhe apex of Lhe lungs buL sLronger on Lhe rlghL slde when l goL lower Lhen became falnLlng as l wenL even lower
4 ercusslon
1here ls dullness ln Lhe lungfllled heard and dullness on Lhe rlghL lower area where Lhe llver ls locaLed and also on Lhe lefL lower where spleen ls locaLed

3 AusculLaLlon
Crackles were heard on Lhe perlphery of Lhe lungs buL bronchoveslcular sounds over Lhe bronchloles and laLeral Lo sLernum whlle bronchlal sound over Lhe
Lrachea

DCard|ovascu|ar system
n|story lamlly hlsLory of hyperLenslon ChesL A resulL shows LhaL Lhere ls Mlld Cardlomegaly -o famlly hlsLory of cardlac problems lorm of exerclse before
occurrence of edema was walklng

neart sounds (S1 S2)
S2 ls louder on Lhe base of Lhe hearL 2
nd
lCS lefL sLernal border (pulmonlc) and 2nd lCS rlghL sLernal border (aorLlc)
S1 ls louder on Lhe apex of Lhe hearL 3
Lh
lCS LMCL (mlLral) and 4
Lh
lCS lefL sLernal border (Lrlcuspld)
27

8 110/80 mmPg
Cardlac 8aLe 80bpm
L MUSCULCSkLLL1AL SS1LM

nIS1Ck aLlenL does noL have arLhrlLls or any oLher musculoskeleLal complalnLs excepL for Lhe edema of boLh legs and feeL noLed 1 week 1A causlng her
movemenLs Lo be llmlLed

1 Inspect|on
a Slze 1he slze ls approprlaLe Lo Lhe body
b SymmeLry lL ls symmeLrlcal on boLh sldes
c 8ashes/leslons 1here are no rashes Scars are presenL
d Ldema edema noLed on boLh legs and feeL and verballzed"nlgamay na nlng hubag day lkumpara aLong nlaboL ko dlrl sa hosplLal makalakaw
naman ko gamay pero hlnay lang ug Lunob ba"

2kANGL CI MC1ICN

-eck Lhe paLlenL can slowly move her neck durlng flexlon exLenslon hyperexLenslon laLeral flexlon and roLaLlon

Shoulder Lhe paLlenL can follow slowly my movemenLs ln shoulder durlng flexlon exLenslon hyperexLenslon laLeral flexlon and lnLernal roLaLlon exLernal
roLaLlon and clrcumducLlon

Llbow Lhe paLlenL can slowly move her shoulder durlng flexlon exLenslon

lorearm Lhe paLlenL can slowly move her forearm durlng suplnaLlon and pronaLlon

WrlsL Lhe paLlenL slowly and heslLanLly moved her wrlsL durlng flexlon exLenslon hyperexLenslon adducLlon and abducLlon due Lo presence of lv Lublng

1humb Lhe paLlenL slowly moved her Lhumb durlng flexlon exLenslon and opposlLlon

Plps she was noL able Lo perform Lhls slnce cllenL refused Lo sLand up verballzed"dlll ra day kay saklL pa gamay nlng hubag sa akong Llll"

28

knee she was noL able Lo perform Lhls slnce cllenL refused Lo sLand up verballzed"dlll ra day kay saklL pa gamay nlng hubag sa akong Llll"

leeL and 1oes she was able Lo move her Loes slowly buL wlLh dlfflculLles as well as movlng her feeL due Lo Lhe edema
Laboratory Results

O C8C resu|ts Iu|y 1S
2008
kLSUL1 NCkMAL VALUL SIGNIIICANCL
Pemoglobln 6 gm (1214 gm )


nemog|ob|n |s a ma|n component of k8C and transports oxygen to t|ssues It a|so he|ps
carry carbon d|ox|de to the |ungs It |s a co|or|ess prote|n that br|ngs co|or and |ron to
b|ood nemog|ob|n count |s necessary for metabo||sm It |ncreases |n dehydrat|on and
po|ycythem|a decreases |n anem|a b|eed|ng and hemo|ys|s

PemaLocrlL 26 gm (3744 gm )

nematocr|t |s the vo|ume of k8C ] 100 mL It |s |ncreased |n dehydrat|on and po|ycythem|a
|t |s decreased |n anemm|a and hemorrhage Decrease |s a|so ev|dent |n f|u|d over|oad 1he
hematocr|t count |s d|rect|y proport|ona| to the hemog|ob|n count

W8C 11200
cumm
(4311
1/cumm)



W8C (|eukocytes) determ|nes the f|ght|ng ab|||ty w|th bacter|a It usua||y detects |nfect|on
or |nf|ammat|on and |s used to mon|tor response to chemotherapy and rad|at|on therapy
Increases |n |nfect|on |nf|ammat|on dehydrat|on decreases |n mye|osuppress|on
-euLrophll segmenLer 8S (3370 )

Neutroph||s usua|y stays |n the bode 714 days stays |n the c|rcu|at|on for 68 hrs and |n
t|ssue for 23 days 1h|s |s essent|a| for phagocytos|s It |s genera||y produced dur|ng
bacter|a| |nfect|on (acute) or trauma 1he segmented are the mature ones and the bands
are the |mmature ones wh|ch mu|t|p|y rap|d|y dur|ng acute bacter|a| |nfect|on or trauma

LymphocyLes 10 (2033)

Lymphocytes are essent|a| for ce||u|ar |mmun|ty and funct|ons |n the format|on of
|mmunog|ob|ns (Igs) |t usua||y e|evates |n v|ra| and chron|c bacter|a| |nfect|on

29

MonocyLes 3 (16 ) 1he monocyte funct|ons |n phagocytos|s It m|grates to |nf|ammatory exudates to
phagocyt|ze bacter|a It |s norma||y |ncreased |n chron|c |nf|ammatory d|sease

Loslnophlls 2 (14 )

Los|noph||s are usua||y produced |n a||erg|c react|on and paras|t|c |nfect|on It phagocyt|ze
ant|gen ant|body comp|exes and fore|gn part|c|es |t |s a defense aga|nst paras|t|c
|nfestat|on a||erg|c and |nf|ammatory react|ons

laLeleL counL 3411/cumm (130400
1/cumm)
Decrease |n p|ate|et count |s an |nd|cat|on that the mother need's bowe| transfus|on
Somet|mes |t a|so determ|nes |f the c||ent has dengue or not

8|ood type 8+ 8|ood typ|ng |nd|cates the b|ood type of the c||ent and serves as bas|s for b|ood transfus|on

*Ur|na|ys|s Iu|y 1S 2008


Color L|ght ye||ow (sLraw dark
amber)
Co|or of ur|ne |s affected by hydrat|on Dehydrat|on causes a deeper ye||ow co|or and over
hydrat|on causes pa|e co|or nepatob|||ary d|sease causes a deeper ye||ow co|or Co|or a|so
changes |n response to certa|n drugs

1ransparency hazy (clear) 1he ur|ne becomes c|oudy on refr|gerat|on and]or |n the presence of U1I A th|ck and
c|oudy ur|ne |s due to bacter|a| growth It can a|so become c|oudy when |t stands for a
|onger per|od of t|me |n a conta|ner In c||ents w|th rena| d|sease or rena| fa||ure w||| be
most ||ke|y to have c|oudy or foamy ur|ne

Speclflc gravlLy 1020 ( 10101023) Spec|f|c grav|ty |s the we|gh or degree of concentrat|on of a substance Its changes |s usua||y
affected by hydrat|on and |nhydrat|on (the spec|f|c grav|ty |ncreases) In overhydrat|on the
spec|f|c grav|ty decreases as we|| as po|yur|a and k|dney damage A spec|f|c grav|ty of 1010
ref|ects |nab|||ty of the k|dneys to concentrate ur|ne or |nsuff|c|ent supp|y of ADn

h 60 (468) pn of ur|ne ref|ects p|asma membrane It |ncreases |n hypervent||at|on and metabo||c
a|ka|os|s and decreases |n D|abetes Me|||tus pat|ents and hypovent||at|on

30

us cells 36/hpf (0 3/hpf) resence of pus ce||s |n the ur|ne |nd|cates an |nfect|ous process of the ur|nary tract

88C

24 (0 2/hpf) resence of ked b|ood ce||s |n the ur|ne or above 2]hpf usua||y |nd|cates a patho|og|c
cond|t|on nematur|a |s the term g|ven to an excess|ve red b|ood ce|| |n the ur|ne

Clucose

os|t|ve (-one) A|so known as b|ood sugar It ref|ects the reabsort|ve capac|ty of the k|dney It |ncreases or
|s present |n D|abetes Me|||tus pat|ents or for those peop|e who take |arge amount of sugar
D|abet|c c||ents have g|ucose |n ur|ne as resu|t of |nab|||ty of tubu|es to reabsorb h|gh
g|ucose concentrat|ons (180 mg]100m|) It a|so |ncreases |n severe |||ness pregnancy It
decreases or d|sappears |n |nsu||n overdose

roLeln


os|t|ve 3 (-one) It denotes abnorma| permeab|||ty or an overf|ow |n the p|asma but norma||y |t |s not
present |n the norma| ur|ne resence of prote|n |n the ur|ne |s termed as perot|enur|a ]
a|bum|nur|a It |s seen |n rena| d|sease because damage to g|omeru|| or tubu|es a||ow
prote|n to enter ur|ne

LplLhellal cells (03/hpf) resence of ep|the||a| ce||s |n the ur|ne |s a resu|t of the s|ough|ng off of ep|the||a| ce||s |n
the rena| tubu|es 1he presence of ep|the||a| ce||s |n ur|ne |s a|so known as pyur|a

8acLerla

none (-one) Its presence |nd|cates poss|b|e U1I 1h|s |s not norma||y present so |f there |s abnorma||ty
Amorph uraLes

few


8LLCD CnLM kLSUL1S Iu|y
1S 2008

31

urea 227mg]dL



CreaLlnlne 06mg]dL




l8S S6mg]dL


urlc 108 mg

CholesLerol
1oLal 240mg]dL




PuL 26mg]dL


LuL 14mg]dL

1rlglycerldes 100 mg /dL

SC1 16u/L
8 23 mg / dl




0.5-1.2 rg/d|




0-110 rg/d|


lemales24 37
mg

Less Lhan 203
mg/dL



40 83 mg/dL


less Lhan 130
mg/dL
40 130 mg/dL

9 32 u/
Increased |eve|s |nd|cates azotem|a rena| fa||ure there's damage to the nephrons wh|ch
|eads to decrease g|omeru|ar f||trat|on and excret|on 8u- levels are decreased ln llver
dlsease malnuLrlLlon and normal pregnancy

L|evated |n cases of g|omeru|onephr|t|s pye|onephr|t|s or acute tubu|ar necros|s
nephrotox|c|ty rena| |nsuff|c|ency and rena| fa||ure L|evat|ons can a|so be re|ated to
ur|nary obstructo|n caused by coex|st|ng hypertens|on and d|abetes An |ncrease va|ue
means there |s rena| dysfunct|on

A b|ood g|ucose |eve| h|gher than 12Smg]dL |s an |nd|cat|on of d|abetes me|||tus


Increased |eve|s |nd|cates chron|c rena| fa||ure (creat|ne and 8UN w||| a|so |ncrease)


L|evated |eve|s |nd|cate an |ncreased r|sk for coronary aryery d|sease as we|| as |mpend|ng
hepat|t|s ||p|d d|sorders b||e duct b|ockage nephr|t|c syndrome and pancreat|t|s
Decreased |eve|s are common|y assoc|ated w|th ma|nutr|t|on ce||u|ar necros|s and
hyperthyro|d|sm

n|gh |eve|s |nd|cate decreased r|sk for CAD A ||poprote|n that carr|es cho|estero| |n the
b|ood Cons|dered "good cho|estero|" s|nce |t carr|es cho|estero| out of the b|ood

n|gh |eve|s |nd|cate |ncreased r|sk for CAD

n|gh |eve|s |nd|cate |ncreased r|sk for CAD

1he Serum G|utamae yruv|c 1ransam|nase (SG1) |s used to conf|rm the or|g|n of e|evated
SG1 An enzyme that |s norma||y present |n the ||ver and heart ce||s It |s re|eased |nto the
b|ood when the ||ver or heart are damaged

32


Diagnoslic 1osl kosulls
9i:. I/ 1s, z002

00 |4. |:-: : /-i/ / /.:..:/J J:-:/ :i/ /- -:.i:-

(/:/ J:.:i:- -j i/: i::i'. kJ- f/--J
33


ANATOY AN PHYSIOLOGY of
the AFFECTE SYSTEs
30
63
80
93
110
123
140
133
170
183
200
213
230
243
260
273
290
303
320
410 AM 300 AM 1100 AM 1100 M 300 AM 1100 AM 300 M 1100 M 300 AM 1100 AM 300 M 1100 M 300 AM 1100 AM 300 M 1100 M
!uly 13 2008 !uly 16 2008 !uly 17 2008 !uly 18 2008
G|ucose |eve|
mg/dL
34


Endocrine system
1he prlmary glands LhaL make up Lhe human endocrlne sysLem are Lhe hypoLhalamus plLulLary Lhyrold paraLhyrold adrenal plneal body and reproducLlve
glandsLhe ovary and LesLls 1he pancreas an organ ofLen assoclaLed wlLh Lhe dlgesLlve sysLem ls also consldered parL of Lhe endocrlne sysLem ln addlLlon
some nonendocrlne organs are known Lo acLlvely secreLe hormones 1hese lnclude Lhe braln hearL lungs kldneys llver Lhymus skln and placenLa AlmosL all
body cells can elLher produce or converL hormones and some secreLe hormones lor example glucagon a hormone LhaL ralses glucose levels ln Lhe blood when
Lhe body needs exLra energy ls made ln Lhe pancreas buL also ln Lhe wall of Lhe gasLrolnLesLlnal LracL Powever lL ls Lhe endocrlne glands LhaL are speclallzed for
hormone producLlon 1hey efflclenLly manufacLure chemlcally complex hormones from slmple chemlcal subsLancesfor example amlno aclds and
carbohydraLesand Lhey regulaLe Lhelr secreLlon more efflclenLly Lhan any oLher Llssues
|(r a conglomeraLe gland lylng Lransversely across Lhe posLerlor wall of Lhe abdomen lL varles ln lengLh from 13 Lo 20 cm (6 Lo 8 ln) and has
a breadLh of abouL 38 cm (abouL 13 ln) and a Lhlckness of from 13 Lo 23 cm (03 Lo 1 ln) lLs usual welghL ls abouL 83 gm (abouL 3 oz) and lLs head lles ln Lhe
concavlLy of Lhe duodenum1he pancreas has boLh an exocrlne and an endocrlne secreLlon 1he exocrlne secreLlon ls made up of a number of enzymes LhaL are
dlscharged lnLo Lhe lnLesLlne Lo ald ln dlgesLlon 1he endocrlne secreLlon lnsulln ls lmporLanL ln Lhe meLabollsm of sugar ln Lhe body (see Sugar MeLabollsm)
lnsulln ls produced ln small groups of especlally modlfled glandular cells ln Lhe pancreas Lhese
cell groups are known as Lhe lsleLs of Langerhans 1he fallure of Lhese cells Lo secreLe sufflclenL
amounLs of lnsulln causes dlabeLes (see ulabeLes MelllLus)

35

Respiratory system
8esplraLory SysLem ln anaLomy and physlology organs LhaL dellver oxygen Lo Lhe clrculaLory sysLem for LransporL Lo all body cells Cxygen ls essenLlal for cells
whlch use Lhls vlLal subsLance Lo llberaLe Lhe energy needed for cellular acLlvlLles ln addlLlon Lo supplylng oxygen Lhe resplraLory sysLem alds ln removlng of
carbon dloxlde prevenLlng Lhe leLhal bulldup of Lhls wasLe producL ln body Llssues uayln and dayouL wlLhouL Lhe prompL of consclous LhoughL Lhe resplraLory
sysLem carrles ouL lLs llfesusLalnlng acLlvlLles lf Lhe resplraLory sysLem's Lasks are lnLerrupLed for more Lhan a few
mlnuLes serlous lrreverslble damage Lo Llssues occurs followed by Lhe fallure of all body sysLems and ulLlmaLely
deaLh
Whlle Lhe lnLake of oxygen and removal of carbon dloxlde are Lhe prlmary funcLlons of Lhe resplraLory sysLem lL
plays oLher lmporLanL roles ln Lhe body 1he resplraLory sysLem helps regulaLe Lhe balance of acld and base ln
Llssues a process cruclal for Lhe normal funcLlonlng of cells lL proLecLs Lhe body agalnsL dlseasecauslng
organlsms and Loxlc subsLances lnhaled wlLh alr 1he resplraLory sysLem also houses Lhe cells LhaL deLecL smell
and asslsLs ln Lhe producLlon of sounds for speech
1he resplraLory and clrculaLory sysLems work LogeLher Lo dellver oxygen Lo cells and remove carbon dloxlde ln a
Lwophase process called resplraLlon 1he flrsL phase of resplraLlon beglns wlLh breaLhlng ln or lnhalaLlon
lnhalaLlon brlngs alr from ouLslde Lhe body lnLo Lhe lungs Cxygen ln Lhe alr moves from Lhe lungs Lhrough blood
vessels Lo Lhe hearL whlch pumps Lhe oxygenrlch blood Lo all parLs of Lhe body Cxygen Lhen moves from Lhe
bloodsLream lnLo cells whlch compleLes Lhe flrsL phase of resplraLlon ln Lhe cells oxygen ls used ln a separaLe
energyproduclng process called cellular resplraLlon whlch produces carbon dloxlde as a byproducL 1he second
phase of resplraLlon beglns wlLh Lhe movemenL of carbon dloxlde from Lhe cells Lo Lhe bloodsLream 1he
bloodsLream carrles carbon dloxlde Lo Lhe hearL whlch pumps Lhe carbon dloxldeladen blood Lo Lhe lungs ln Lhe
lungs breaLhlng ouL or exhalaLlon removes carbon dloxlde from Lhe body Lhus compleLlng Lhe resplraLlon cycle
36

jare palred organs ln Lhe chesL LhaL
carry onresplraLlon ln Lhe adulL human each lung ls 23 Lo 30 cm (10 Lo
12 ln) long and roughly conlcal 1he Lwo lungs are separaLed by a
sLrucLure called Lhe medlasLlnum whlch conLalns Lhe hearL Lrachea
esophagus and blood vessels 1hey are covered by a proLecLlve
membrane called Lhe pulmonary pleura whlch ls separaLed from Lhe
parleLal pleuraa slmllar membrane on Lhe chesL wallby a lubrlcaLlng
fluld lnhaled alr passes Lhrough Lhe Lrachea whlch dlvldes lnLo Lwo
Lubes called bronchl each bronchus leads Lo one lung WlLhln Lhe lungs
Lhe bronchl subdlvlde lnLo bronchloles whlch glve rlse Lo alveolar ducLs
Lhese end ln sacs called alveoll
1he rlghL lung has Lhree lobes Lhe lefL lung wlLh a clefL Lo
accommodaLe Lhe hearL has only Lwo 1he Lwo branches of Lhe Lrachea called bronchl subdlvlde wlLhln Lhe lobes lnLo smaller and smaller alr vessels 1hey
LermlnaLe ln alveoll Llny alr sacs surrounded by caplllarles When Lhe alveoll lnflaLe wlLh lnhaled alr oxygen dlffuses lnLo Lhe blood ln Lhe caplllarles Lo be pumped
by Lhe hearL Lo Lhe Llssues of Lhe body and carbon dloxlde dlffuses ouL of Lhe blood lnLo Lhe lungs where lL ls exhaled

RESPIRATION
uurlng resplraLlon Lhe dlaphragm conLracLs and moves downward Lhe pecLoralls mlnor
and lnLercosLal muscles pull Lhe rlb cage ouLwards 1he chesL cavlLy expands and alr rushes lnLo
Lhe lungs Lhrough Lhe Lrachea Lo flll Lhe resulLlng vacuum When Lhe dlaphragm relaxes Lo lLs
normal upwardly curvlng poslLlon Lhe lungs conLracL and alr ls forced ouL
ln Lhls llfesupporLlng process oxygen from lncomlng alr enLers Lhe blood and carbon
dloxlde a wasLe gas from Lhe meLabollsm of food ls exhaled 1he exchange of gases Lakes place
37

when alr reaches Lhe alveoll 1hese small sacs are only one cell Lhlck and Lhey are surrounded by blood caplllarles LhaL are also only one cell Lhlck Alr dlffuses
Lhrough Lhese cells lnLo Lhe caplllary blood whlch carrles Lhe oxygenrlch alr Lo Lhe hearL Lo be dlsLrlbuLed LhroughouL Lhe body ln Lhe alveoll aL Lhe same Llme
gaseous carbon dloxlde dlffuses from Lhe blood lnLo Lhe lung and ls explred
Alr enLers Lhe lungs when Lhe dlaphragm a sLrong muscle under Lhe lungs forclbly lowers and enlarges Lhe chesL cavlLy ln whlch Lhe lungs are suspended
1hls causes Lhe lungs Lo expand and Lhe alr Lo flll Lhe enlarged lungs When Lhe dlaphragm relaxes Lhe lungs conLracL and Lhe alr ls forced ouL ln Llmes of greaLer
oxygen need Lhe rlb cage can also expand furLher enlarglng Lhe chesL cavlLy for greaLer alr lnLake A healLhy adulL can draw ln abouL 33 Lo 49 llLres (200 Lo 300
cu ln) of alr aL a slngle breaLh buL aL resL only abouL 3 per cenL of Lhls volume ls used 1he lungs also excreLe waLer as gas sLore glycogen a complex
carbohydraLe and fllLer ouL lncomlng organlsms and dangerous parLlcles vla halrs called cllla
CARIOVASCULAR SYSTE
ClrculaLory SysLem or cardlovascular sysLem ln humans Lhe comblned funcLlon of Lhe hearL blood and
blood vessels Lo LransporL oxygen and nuLrlenLs Lo organs and Llssues LhroughouL Lhe body and carry away
wasLe producLs Among lLs vlLal funcLlons Lhe clrculaLory sysLem lncreases Lhe flow of blood Lo meeL
lncreased energy demands durlng exerclse and regulaLes body LemperaLure ln addlLlon when forelgn
subsLances or organlsms lnvade Lhe body Lhe clrculaLory sysLem swlfLly conveys dlseaseflghLlng elemenLs of
Lhe lmmune sysLem such as whlLe blood cells and anLlbodles Lo reglons under aLLack Also ln Lhe case of
ln[ury or bleedlng Lhe clrculaLory sysLem sends cloLLlng cells and proLelns Lo Lhe affecLed slLe whlch qulckly
sLop bleedlng and promoLe heallng.
COPONENTS OF THE CIRCULAORY SYSTE
1he hearL blood and blood vessels are Lhe Lhree sLrucLural elemenLs LhaL make up Lhe clrculaLory sysLem
1he hearL ls Lhe englne of Lhe clrculaLory sysLem lL ls dlvlded lnLo four chambers Lhe rlghL aLrlum Lhe rlghL
venLrlcle Lhe lefL aLrlum and Lhe lefL venLrlcle 1he walls of Lhese chambers are made of a speclal muscle
called myocardlum whlch conLracLs conLlnuously and rhyLhmlcally Lo pump blood 1he pumplng acLlon of
Lhe hearL occurs ln Lwo sLages for each hearL beaL dlasLole when Lhe hearL ls aL resL and sysLole when Lhe
hearL conLracLs Lo pump deoxygenaLed blood Loward Lhe lungs and oxygenaLed blood Lo Lhe body uurlng
38

each hearLbeaL Lyplcally abouL 60 Lo 90 ml (abouL 2 Lo 3 oz) of blood are pumped ouL of Lhe hearL lf Lhe hearL sLops pumplng deaLh usually occurs wlLhln four Lo
flve mlnuLes
8lood conslsLs of Lhree Lypes of cells oxygenbearlng red blood cells dlseaseflghLlng whlLe blood cells and bloodcloLLlng plaLeleLs all of whlch are carrled
Lhrough blood vessels ln a llquld called plasma lasma ls yellowlsh and
conslsLs of waLer salLs proLelns vlLamlns mlnerals hormones dlssolved
gases and faLs
1hree Lypes of blood vessels form a complex neLwork of Lubes LhroughouL
Lhe body ArLerles carry blood away from Lhe hearL and velns carry lL
Loward Lhe hearL Caplllarles are Lhe Llny llnks beLween Lhe arLerles and
Lhe velns where oxygen and nuLrlenLs dlffuse Lo body Llssues 1he lnner
layer of blood vessels ls llned wlLh endoLhellal cells LhaL creaLe a smooLh
passage for Lhe LranslL of blood 1hls lnner layer ls surrounded by
connecLlve Llssue and smooLh muscle LhaL enable Lhe blood vessel Lo
expand or conLracL 8lood vessels expand durlng exerclse Lo meeL Lhe
lncreased demand for blood and Lo cool Lhe body 8lood vessels conLracL
afLer an ln[ury Lo reduce bleedlng and also Lo conserve body heaL
ArLerles have Lhlcker walls Lhan velns Lo wlLhsLand Lhe pressure of blood
belng pumped from Lhe hearL 8lood ln Lhe velns ls aL a lower pressure so
velns have oneway valves Lo prevenL blood from flowlng backwards away
from Lhe hearL Caplllarles Lhe smallesL of blood vessels are only vlslble by mlcroscopeLen caplllarles lylng slde by slde are barely as Lhlck as a human halr lf all
Lhe arLerles velns and caplllarles ln Lhe human body were placed end Lo end Lhe LoLal lengLh would equal more Lhan 100000 km (more Lhan 60000 ml)Lhey
could sLreLch around Lhe earLh nearly Lwo and a half Llmes
1he arLerles velns and caplllarles are dlvlded lnLo Lwo sysLems of clrculaLlon sysLemlc and pulmonary 1he sysLemlc clrculaLlon carrles oxygenaLed blood from
Lhe hearL Lo all Lhe Llssues ln Lhe body excepL Lhe lungs and reLurns deoxygenaLed blood carrylng wasLe producLs such as carbon dloxlde back Lo Lhe hearL 1he
pulmonary clrculaLlon carrles Lhls spenL blood from Lhe hearL Lo Lhe lungs ln Lhe lungs Lhe blood releases lLs carbon dloxlde and absorbs oxygen 1he oxygenaLed
blood Lhen reLurns Lo Lhe hearL before Lransferrlng Lo Lhe sysLemlc clrculaLlon

39


A. SYSTEMIC CIRCULATION
1he hearL e[ecLs oxygenrlch blood under hlgh pressure ouL of Lhe hearL's maln pumplng
chamber Lhe lefL venLrlcle Lhrough Lhe largesL arLery Lhe aorLa Smaller arLerles branch off
from Lhe aorLa leadlng Lo varlous parLs of Lhe body 1hese smaller arLerles ln Lurn branch ouL
lnLo even smaller arLerles called arLerloles 8ranches of arLerloles become progresslvely
smaller ln dlameLer evenLually formlng Lhe caplllarles Cnce blood reaches Lhe caplllary level
blood pressure ls greaLly reduced
Caplllarles have exLremely Lhln walls LhaL permlL dlssolved oxygen and nuLrlenLs from Lhe
blood Lo dlffuse across Lo a fluld known as lnLersLlLlal fluld LhaL fllls Lhe gaps beLween Lhe
cells of Llssues or organs 1he dlssolved oxygen and nuLrlenLs Lhen enLer Lhe cells from Lhe
lnLersLlLlal fluld by dlffuslon across Lhe cell membranes Meanwhlle carbon dloxlde and oLher
wasLes leave Lhe cell dlffuse Lhrough Lhe lnLersLlLlal fluld cross Lhe caplllary walls and enLer
Lhe blood ln Lhls way Lhe blood dellvers nuLrlenLs and removes wasLes wlLhouL leavlng Lhe
caplllary Lube
AfLer dellverlng oxygen Lo Llssues and absorblng wasLes Lhe deoxygenaLed blood ln Lhe
caplllarles Lhen sLarLs Lhe reLurn Lrlp Lo Lhe hearL 1he caplllarles merge Lo form Llny velns
called venules 1hese velns ln Lurn [oln LogeLher Lo form progresslvely larger velns ulLlmaLely
Lhe velns converge lnLo Lwo large velns Lhe lnferlor vena cava brlnglng blood from Lhe lower
half of Lhe body and Lhe superlor vena cava brlnglng blood from Lhe upper half 8oLh of Lhese
Lwo large velns [oln aL Lhe rlghL aLrlum of Lhe hearL
8ecause Lhe pressure ls dlsslpaLed ln Lhe arLerloles and caplllarles blood ln velns flows back Lo Lhe hearL aL very low pressure ofLen runnlng uphlll when a person
ls sLandlng llow agalnsL gravlLy ls made posslble by Lhe oneway valves locaLed several cenLlmeLers aparL ln Lhe velns When surroundlng muscles conLracL for
example ln Lhe calf or arm Lhe muscles squeeze blood back Loward Lhe hearL lf Lhe oneway valves work properly blood Lravels only Loward Lhe hearL and
cannoL lapse backward velns wlLh defecLlve valves whlch allow Lhe blood Lo flow backward become enlarged or dllaLed Lo form varlcose velns
40

. PULMONARY SITUATION
ln pulmonary clrculaLlon deoxygenaLed blood reLurnlng from Lhe organs and Llssues of
Lhe body Lravels from Lhe rlghL aLrlum of Lhe hearL Lo Lhe rlghL venLrlcle lrom Lhere lL ls
pushed Lhrough Lhe pulmonary arLery Lo Lhe lung ln Lhe lung Lhe pulmonary arLery
dlvldes formlng Lhe pulmonary caplllary reglon of Lhe lung AL Lhls slLe mlcroscoplc
vessels pass ad[acenL Lo Lhe alveoll or alr sacs of Lhe lung and gases are exchanged across
a Lhln membrane oxygen crosses Lhe membrane lnLo Lhe blood whlle carbon dloxlde
leaves Lhe blood Lhrough Lhls same membrane -ewly oxygenaLed blood Lhen flows lnLo
Lhe pulmonary velns where lL ls collecLed by Lhe lefL aLrlum of Lhe hearL a chamber LhaL
serves as collecLlng pool for Lhe lefL venLrlcle 1he conLracLlon of Lhe lefL venLrlcle sends
blood lnLo Lhe aorLa compleLlng Lhe clrculaLory loop Cn average a slngle blood cell Lakes
roughly 30 seconds Lo compleLe a full clrculL Lhrough boLh Lhe pulmonary and sysLemlc
clrculaLlon
1he pressure generaLed by Lhe pumplng acLlon of Lhe hearL propels Lhe blood Lo Lhe
arLerles ln order Lo malnLaln an adequaLe flow of blood Lo all parLs of Lhe body a cerLaln
level of blood pressure ls needed 8lood pressure for lnsLance enables a person Lo rlse
qulckly from a horlzonLal poslLlon wlLhouL blood poollng ln Lhe legs whlch would cause falnLlng from deprlvaLlon of blood Lo Lhe braln -ormal blood pressure ls
regulaLed by a number of facLors such as Lhe conLracLlon of Lhe hearL Lhe elasLlclLy of arLerlal walls blood volume and reslsLance of blood vessels Lo Lhe passage
of blood
. LOOD PRESSURE
8lood pressure ls measured uslng an lnflaLable devlce wlLh a gauge called a LhaL ls wrapped around Lhe upper arm 8lood pressure ls measured durlng
sysLole Lhe acLlve pumplng phase of Lhe hearL and dlasLole Lhe resLlng phase beLween hearLbeaLs SysLollc and dlasLollc pressures are measured ln unlLs
of mllllmeLers of mercury (abbrevlaLed mm Pg) and dlsplayed as a raLlo 8lood pressure varles beLween lndlvlduals and even durlng Lhe normal course of a
day ln response Lo emoLlon exerLlon sleep and oLher physlcal and menLal changes -ormal blood pressure ls less Lhan 120/80 mm Pg ln whlch 120
descrlbes sysLollc pressure and 80 descrlbes dlasLollc pressure Plgher blood pressures LhaL are susLalned over a long perlod of Llme may lndlcaLe
hyperLenslon a damaglng clrculaLory condlLlon Lower blood pressures could slgnal shock from hearL fallure dehydraLlon lnLernal bleedlng or blood loss
41

4. -\-*v
idneys palred organ whose funcLlons lnclude removlng wasLe producLs from Lhe blood and regulaLlng Lhe amounL of fluld ln Lhe body 1he baslc
unlLs of Lhe kldneys are mlcroscoplcally Lhln sLrucLures called nephrons whlch fllLer Lhe blood and cause wasLes Lo be removed ln Lhe form of urlne 1ogeLher
wlLh Lhe bladder Lwo ureLers and Lhe slngle ureLhra Lhe kldneys make up Lhe body's urlnary sysLem Puman belngs as well as members of all oLher
verLebraLe specles Lyplcally have Lwo kldneys
Llke kldney beans Lhe body's kldneys are dark red ln color and have a shape ln whlch one slde ls convex or rounded and Lhe oLher ls concave or lndenLed 1he
kldneys of adulL humans are abouL 10 Lo 13 cm (4 Lo 3 ln) long and abouL 3 Lo 73 cm (2 Lo 3 ln) wldeabouL Lhe slze of a compuLer mouse
1he kldneys lle agalnsL Lhe rear wall of Lhe abdomen on elLher slde of Lhe splne 1hey are slLuaLed below Lhe mlddle of Lhe back beneaLh Lhe llver on Lhe rlghL
and Lhe spleen on Lhe lefL Lach kldney ls encased ln a LransparenL flbrous membrane called a renal capsule whlch helps proLecL lL agalnsL Lrauma and lnfecLlon
1he concave parL of Lhe kldney aLLaches Lo Lwo of Lhe body's cruclal blood vessels
Lhe renal arLery and Lhe renal velnand Lhe ureLer a Lubellke sLrucLure LhaL carrles
urlne Lo Lhe bladder
UNCTIONS
A prlmary funcLlon of kldneys ls Lhe removal of polsonous wasLes from Lhe blood
Chlef among Lhese wasLes are Lhe nlLrogenconLalnlng compounds urea and urlc acld
whlch resulL from Lhe breakdown of proLelns and nuclelc aclds LlfeLhreaLenlng
lllnesses occur when Loo many of Lhese wasLe producLs accumulaLe ln Lhe
bloodsLream lorLunaLely a healLhy kldney can easlly rld Lhe body of Lhese
subsLances
42

ln addlLlon Lo cleanlng Lhe blood Lhe kldneys perform several oLher essenLlal funcLlons Cne such acLlvlLy ls
regulaLlon of Lhe amounL of waLer conLalned ln Lhe blood 1hls process ls lnfluenced by anLldlureLlc
hormone (AuP) also called vasopressln whlch ls produced ln Lhe hypoLhalamus (a parL of Lhe braln LhaL
regulaLes many lnLernal funcLlons) and sLored ln Lhe nearby plLulLary gland 8ecepLors ln Lhe braln monlLor
Lhe blood's waLer concenLraLlon When Lhe amounL of salL and oLher subsLances ln Lhe blood becomes Loo
hlgh Lhe plLulLary gland releases AuP lnLo Lhe bloodsLream When lL enLers Lhe kldney AuP makes Lhe
walls of Lhe renal Lubules and collecLlng ducLs more permeable Lo waLer so LhaL more waLer ls reabsorbed
lnLo Lhe bloodsLream
1he hormone aldosLerone produced by Lhe adrenal glands lnLeracLs wlLh Lhe kldneys Lo regulaLe Lhe
blood's sodlum and poLasslum conLenL Plgh amounLs of aldosLerone cause Lhe nephrons Lo reabsorb more
sodlum lons more waLer and fewer poLasslum lons low levels of aldosLerone have Lhe reverse effecL 1he
kldney's responses Lo aldosLerone help keep Lhe blood's salL levels wlLhln Lhe narrow range LhaL ls besL for
cruclal physlologlcal acLlvlLles
AldosLerone also helps regulaLe blood pressure When blood pressure sLarLs Lo fall Lhe kldney releases an enzyme (a speclallzed proLeln) called renln whlch
converLs a blood proLeln lnLo Lhe hormone angloLensln 1hls hormone causes blood vessels Lo consLrlcL resulLlng ln a rlse ln blood pressure AngloLensln Lhen
lnduces Lhe adrenal glands Lo release aldosLerone whlch promoLes sodlum and waLer Lo be reabsorbed furLher lncreaslng blood volume and blood pressure
1he kldney also ad[usLs Lhe bodys acldbase balance Lo prevenL such blood dlsorders as acldosls and alkalosls boLh of whlch lmpalr Lhe funcLlonlng of Lhe cenLral
nervous sysLem lf Lhe blood ls Loo acldlc meanlng LhaL Lhere ls an excess of hydrogen lons Lhe kldney moves Lhese lons Lo Lhe urlne Lhrough Lhe process of
Lubular secreLlon An addlLlonal funcLlon of Lhe kldney ls Lhe processlng of vlLamln u Lhe kldney converLs Lhls vlLamln Lo an acLlve form LhaL sLlmulaLes bone
developmenL
Several hormones are produced ln Lhe kldney Cne of Lhese eryLhropoleLln lnfluences Lhe producLlon of red blood cells ln Lhe bone marrow When Lhe kldney
deLecLs LhaL Lhe number of red blood cells ln Lhe body ls decllnlng lL secreLes eryLhropoleLln 1hls hormone Lravels ln Lhe bloodsLream Lo Lhe bone marrow
sLlmulaLlng Lhe producLlon and release of more red cells
43

Pathophysiology

lor cenLurles lL has been noLed LhaL dlabeLes "runs ln famllles" because abouL 40 of people who develop Lhe dlsease have a poslLlve famlly hlsLory ln
relaLlon Lo Lhe paLlenL's case boLh parenLs and grandfaLher has dlabeLes melllLus buL she cannoL remember whaL Lype of uM 1hls genet|c hered|ty predlsposed
her Lo have uM as well 1he preclplLaLlng facLors are age d|et and stress 1he paLlenL was dlagnosed wlLh uM Lype when she was 48 yrs old lncreaslng age ls
relaLed Lo decllne ln glucose Lolerance and an lncrease ln lnsulln reslsLance along wlLh an lncrease prevalence of dlabeLes 1he frequency rlses sharply afLer 40
yrs old probably reflecLlng a general change ln glucose Lolerance 1he separaLlon beLween beLween dlabeLes and nondlabeLes may presensL a problem lf
Lolerance ls noL ad[usLed for age 1hls lncreaslng frequency has been explalned as a decrease ln body funcLlon such as Lhe pancreas LhaL occurs ln all body cells ln
senescence D|et Lhe effecLs of dleL hlgh ln glucose can as well cause rlse ln blood glucose Stress any form of sLress wlLh Lhe neuroendocrlne response lncreases
gluconeogenesls 1hls ls due Lo Lhe release of AC1P(adenocorLlcoLroplc hormone) whlch sLlmulaLes Lhe adrenal gland Lo release glucocorLlcolds and
mlneralocorLlcolds ClucocorLlcolds wlll release corLlsol whlch ls responslble for gluconeogenesls resulLlng Lo lncrease blood glucose AldosLeroone whlch ls Lhe
mosL abundanL MlneralocorLlcold causes sodlum and waLer reLenLlon lncreaslng blood volume Lhus lncreaslng blood pressure
1he geneLlcs of Lype 2 dlabeLes are complex and noL compleLely undersLood buL presumably Lhls dlsease ls relaLed Lo mulLlple genes Lvldence supporLs
lnherlLed componenLs for boLh pancreaLlc beLa cell fallure and lnsulln reslsLance Conslderable debaLe exlsLs regardlng Lhe prlmary defecL ln Lype 2 dlabeLes
melllLus MosL paLlenLs have boLh lnsulln reslsLance and some degree of lnsulln deflclency lallure ln Lhe funcLlon of beLa cells of Lhe pancreaLlc cells or Lhe lsleLs
of langerhans causes lmpalred lnsulln secreLlon slnce Lhey are responslble for lnsulln secreLlon causlng lncrease on blood glucose level 1hls elevaLlon conLlnues
because Lhe llver cannoL sLore glucose as glycogen wlLhouL sufflclenL lnsulln levels slnce lnsulln ls needed ln glycogenesls ln an aLLempL Lo resLore balance and
reLurn blood glucose levels Lo normal kldney excreLes Lhe excess glucose ln Lhe urlne (g|ucosur|a) ***** lnsulln also exhlblLs vasodllaLory properLles lnsulln
reslsLance have been suggesLed as belng responslble for Lhe lncreased arLerlal pressure causlng secondary hypertens|on hyperLenslon wlLh an ldenLlflable
underlylng cause whlch ls now wldely recognlzed as parL of syndrome x a condlLlon characLerlzed by P- wlLh uM Lype 2
lnsulln reslsLance of cells on Lhe oLher hand occurs when Lhe lnsulln recepLors are less senslLlve -ow slnce Lhe lnsulln acL as Lhe key for glucose Lo enLer cells and
be used as energy Lhe reslsLance made lL more dlfflculL for glucose enLrance causlng lL Lo remaln ln Lhe blood and lncrease Lhe blood glucose level lncreased
blood glucose level ls Lermed as hyperg|ycem|a whlch ls Lhe ma[or characLerlsLlc of DM type 2 *******1he dlfflculLy of glucose enLrance makes glucose
unavallable for energy producLlon lnsLead faL sLores are used for energy producLlon WlLh Lhese llpoproLelns are lncreased Lo provlde dellvery and plckup
44

servlces so LhaL llplds wlll be avallable when cells need Lhem 1hls resulL lncreased llpld levels 1he blood chem shows LhaL Lhe LoLal cholesLerol level ls elevaLed Lo
240 mg]dL as we|| as nDL of 26 mg]dL and LDL of 14 mg]dL 1hls lncrease ln cholesLerol level preclplLaLe Lhe cllenL ln havlng nN

When Lhe blood glucose reaches 160 Lo 200 mg/dL Lhe glucose wlll be forced Lo moved ouL Lhe glomerular membrane causlng Lhe glomerular caplllarles Lo be
damaged and become so permeable LhaL plasma proLelns enLer Lhe glomerular fllLraLe causlng proLelns Lo be found ln Lhe urlne prote|nur|a As a resulL Lhe
fllLraLe exerLs a collold osmoLlc pressure LhaL draws ouL waLer ouL of blood ln Lhls slLuaLlon Lhe -l or neL fllLraLlon pressureLoLal pressure LhaL promoLes
fllLraLlon lncreases whlch means more fluld ls fllLered AL Lhe same Llme Lhe 8CC/ blood collold osmoLlc pressure whlch ls due Lo Lhe presence of proLelns ln
blood plasma whlch also opposes fllLraLlon decreases because plasma proLelns are belng losL ln Lhe urlne 8ecause more fllLers ouL of blood caplllarles lnLo Llssues
LhroughouL Lhe body Lhan reLurns vla reabsorpLlon blood volume decreases and lnLersLlLlal fluld lncreases 1hus loss of plasma proLeln ln Lhe urlne cause edema
an abnormally hlgh volume of lnLersLlLlal fluld 1he paLlenL manlfesL edema on boLh legs and feeL 1 week 1A 1here ls also oLher reason for edema occurrence
whlch wlll be dlscussed on Lhe laLer parL ***When blood glucose ls above 160200 mg/dL Lhe renal symporLers cannoL work fasL enough Lo reabsorb all Lhe
glucose LhaL enLers Lhe glomerular fllLraLe As a resulL some glucose remalns ln Lhe urlne g|ucosur|a 8ased on Lhe urlnalysls resulL of Lhe paLlenL glucose ln Lhe
urlne marked as poslLlve and Lhe color ls llghL yellow due Lo Lhe presence of glucose WlLh Lhe loss of large quanLlLles of glucose and semlsLarvaLlon of cells Lhere
ls compensaLory lncrease ln hunger po|yphag|a And Lhere wlll be lncreased osmolallLy due Lo glucose excreLed ln Lhe urlne acLlng as osmoLlc dlureLlc and causes
excreLlon of excesslve amounLs of waLer leadlng Lo excesslve urlnaLlon po|yur|a resulLlng Lo fluld volume deflclL LxLreme dehydraLlon mlghL lead Lo coma and
evenLually Lo deaLh Lxcesslve urlnaLlon faclllLaLes loss of poLasslum sodlum and chlorlde LlecLrolyLe lmbalance happen whlch as Lhe manlfesLaLlon of weakness
fat|gue ma|a|se Loss of waLer cause an lncrease ln serum osmolallLy whlch sLlmulaLes Lhe LhlrsL cenLer ln Lhe hypoLhalamus and Lhe body response as
po|yd|ps|a
Cne of Lhe mosL common heredofamlllal dlsease ls nN 1he paLlenL ls geneLlcally predlsposed Lo Lhls condlLlon slnce her grandfaLher and uncle are hyperLenslve
reclplLaLlng facLors are Lhe presence of hlgh blood cholesLerol levels whlch causes addlLlonal blood vessel lengLh ln adlpose Llssues maklng lLs lengLh longer Lhus
Lhe vascular reslsLance ls lncreased 1hls ls due Lo Lhe facL LhaL reslsLance Lo blood flow Lhrough a vessel ls dlrecLly proporLlonal Lo Lhe lengLh of Lhe vessel 1he
longer Lhe blood vessel Lhe greaLer Lhe reslsLance 1hls conLrlbuLes Lo rlse ln 8 called nN ln P- Lhe Lunlca medla of Lhe arLerloles are Lhlcken Lhus Lhe
arLerloles ln Lhe kldneys are damaged havlng narrowed lumen 1hls narrowlng of lumen decreases blood supply Lo Lhe kldneys When blood supply Lo Lhe kldneys
decreases [uxLaglomerular cells secreLe rennln Lo Lhe bloodsLream ln sequence ACL acL on Lhelr subsLraLe Lo produce acLlve hormone AngloLensln ll whlch
ralses blood pressure ln Lwo ways llrsL lL ls a poLenL vasoconsLrlcLor lL ralses blood pressure and lncreaslng vascular reslsLance lL wlll also cause perlpheral
arLery consLrlcLlon whlch sLlmulaLes eplnephrlne release Lplnephrlne causes decrease sysLemlc 8 sLlmulaLlng AuP release Second AngloLensln ll sLlmulaLes Lhe
secreLlons of aldosLerone whlch lncreases reabsorpLlon of sodlum and waLer by Lhe kldneys 1he waLer reabsorpLlon lncreases LoLal blood volume whlch
lncreases blood pressure as well 1he reabsorpLlon of sodlum and waLer causes edema
lncrease blood pressure may damage Lhe small blood vessels ln Lhe kldneys causlng lmpalrmenL ln Lhe glomerular funcLlon of fllLerlng blood 1hls resulLs Lo
nlLrogenous wasLe ln Lhe blood as evldenced by Lhe urlnalysls resulL Ur|c ac|d of 108 mg creat|n|ne of 06 mg]dL and urem|a of 227 mg]dL SympLoms of
uremla lnclude drowslness |rr|tab|||ty nausea vom|t|ng breath|ess lf vomlLlng ls exLreme lL mlghL lead Lo convulslon Lhen coma and can lead Lo sudden deaLh
45

lf Lhese lmpalrmenL ln Lhe reabsorpLlon of Lhe kldneys and lmpalred glomerular funcLlon wlll be lefL unLreaLed 8L-AL lAlLu8L ls more llkely Lo occur 1he maln
precursors of eryLhropoleLln or LC are cells ln Lhe kldneys LhaL lle beLween Lhe kldney Lubules (perlLubular lnsLersLlLlal cells) WlLh renal fallure LC release
slows and 88C producLlon ls lnadequaLe 1he hemoglobln oxygen carrylng proLeln ln 88C wlll also be decreased as well as Lhe hemaLocrlL as manlfesLed ln Lhe
C8C of Lhe paLlenL showlng ngb of 2 6 gm and nct of 6gm
1oLal blood volume and lncrease ln 8 forces Lhe hearL Lo work harder Lo pump adequaLe blood LhroughouL Lhe body or for longer dlsLance of longer blood
vessels 1hls glves exLra work Lo cardlac muscles maklng lL enlarged card|omega|y
lncreased vascular reslsLance and eplnephrlne release causes lncrease force of lefL venLrlcular conLracLlon so lL wlll requlre more oxygen supply buL slnce Lhe
coronary arLery consLrlcLlon causes decreased C2 supply Lhe lefL venLrlcle wlll hypoxlc 1hls wlll lead Lo decreased force of lefL venLrlcular conLracLlon whlch
lncreases Lhe lefL venLrlcular end dlasLollc pressure Lhus Lhere ls also lncreased lefL venLrlcular preload Cf course as Lhe normal clrculaLlon suggesL Lhe preload
of lefL aLrlum wlll also be lncreased Lhus fluld wlll be accumulaLed ln Lhe lungs causlng edema and pu|monary congest|on an excesslve accumulaLlon of fluld ln
Lhe lungs 1he reabsorpLlon of sodlum and waLer wlll also cause lncrease lefL venLrlcular preload Lhus conLrlbuLlng Lo edema formaLlon
***Cn Lhe oLher hand Ang|na ector|s sympLom of reduced oxygen supply Lo Lhe hearL muscle usually caused by narrowlng or obsLrucLlon of Lhe coronary
arLery aln may radlaLe from Lhe fronL of Lhe chesL ofLen lnLo Lhe arm
lmpalrmenL ln lnsulln secreLlon causes Lhe lowered sLlmulaLlon of proLeln synLhesls Lhus decreaslng defenslns (proLelns found ln neuLrophlls LhaL exhlblL a broad
range of anLlbloLlc acLlvlLy agalnsL bacLerla and fungl and lL poke holes ln mlcrobe membranes whlch kllls Lhe lnvader due Lo loss of cellular conLenLs) -ow Lhere
wlll be lneffecLlve anLlbloLlc acLlvlLy maklng Lhe neuLrophll handlcapped *** Slnce Lhe paLlenL ls already an elderly aglng 38 ?rs old and was dlagnosed wlLh um
Lype 2 aL Lhe age of 48 Lhe Lhymus gland already aLrophy whlch decreases lymphocyLe and anLlbody producLlon 1he lnflammaLory process ls Lherefore lmpalred
1hls evenL made Lhe cllenL predlsposed Lo pneumon|a 1here are 3 ma[or classlflcaLlons of pneumonla CommunlLy acqulred hosplLal acqulred and asplraLlon
acqulred 1here name suggesL were Lhe causaLlve agenLs came from So afLer Lhe asplraLlon of Lhe organlsm Lhere wlll be normal mucus producLlon and clllary
acLlon buL slnce Lhe mucoclllary escalaLor ls less effecLlve Lhere wlll be adherence of Lhe organlsm Lo Lhe alveolar macrophages ln whlch Lhe cell wall componenLs
are exposed lnflammaLory response Lakes place Lhen red heapLlzaLlon and consolldaLlon of lung parenchyma maklng lL swell Lhus maklng Lhe lung appear reddlsh
and granular llke 1hls ls pneumon|a lnflammaLlon of lung parenchyma also causes chesL paln and Lhen Lhere wlll be leukocyLe nfllLraLlon buL slnce Lhere ls
lmpalred lmmune response as dlscussed earller Lhe lnfecLlon occurs and wlll noL be resolved 1here wlll be lncreased secreLlon of of flulds and shredded cells
pourlng lnLo Lhe passages of alr sacs of lungs 1he presence of exudaLes wlLhln alr spaces cause coughlng and shorLenlng of breaLh******uurlng Lhe
lnflammaLory process Lhe arLerloles ln Lhe area wlll be vasoconsLrlcLs 1he consLrlcLlon sLlmulaLe Lhe release of chemlcal medlaLors LhaL wlll boLh cause
consLrlcLlon(maklng spaces beLween cells Lhus fluld escapes Lo Llssues edema) and vasodllaLlon (faclllLaLlng hyperemla and movemenL of fluld from caplllarles Lo
Llssuesedema) 1hls causes pu|monary congest|on as well



46









47

OvERVIEW OF THE ISEASE
CONITIONS

UHDL1L 1YL L
ln 1ype 2 dlabeLes formerly known as nonlnsullndependenL dlabeLes melllLus (-luuM) and adulLonseL dlabeLes Lhe body's dellcaLe balance beLween
lnsulln producLlon and Lhe ablllLy of cells Lo use lnsulln goes awry SympLoms characLerlsLlc of 1ype 2 dlabeLes lnclude Lhose found ln 1ype 1 dlabeLes as well
as repeaLed lnfecLlons or skln sores LhaL heal slowly or noL aL all generallzed Llredness and Llngllng or numbness ln Lhe hands or feeL
1he onseL of 1ype 2 dlabeLes usually occurs afLer Lhe age of 43 alLhough Lhe lncldence of Lhe dlsease ln younger people ls growlng rapldly 8ecause sympLoms
develop slowly lndlvlduals wlLh Lhe dlsease may noL lmmedlaLely recognlze LhaL Lhey are slck A number of genes are lnvolved ln 1ype 2 dlabeLes ln addlLlon
Lhere ls a sLrong relaLlonshlp beLween obeslLy and 1ype 2 dlabeLes AbouL 80 percenL of dlabeLlcs wlLh Lhls form of Lhe dlsease are slgnlflcanLly overwelghL
COMPLICATIONS
#LNH HU#L
48

lf lefL unLreaLed dlabeLes melllLus may cause llfeLhreaLenlng compllcaLlons 1ype 1 dlabeLes can resulL ln dlabeLlc coma (a sLaLe of unconsclousness caused by
exLremely hlgh levels of glucose ln Lhe blood) or deaLh ln boLh 1ype 1 and 1ype 2 dlabeLes compllcaLlons may lnclude bllndness kldney fallure and hearL
dlsease ulabeLes can cause Llny blood vessels Lo become blocked when Lhls occurs ln blood vessels of Lhe eye lL can resulL ln reLlnopaLhy (Lhe breakdown of
Lhe llnlng aL Lhe back of Lhe eye) causlng bllndness ulabeLes melllLus ls Lhe leadlng cause of new cases of bllndness ln people aged 20 Lo 74 ln Lhe kldneys
dlabeLes can lead Lo nephropaLhy (Lhe lnablllLy of Lhe kldney Lo properly fllLer Loxlns from Lhe blood) AbouL 40 percenL of new cases of endsLage renal
dlsease (kldney fallure) are caused by dlabeLes melllLus 8lockages of large blood vessels ln dlabeLlcs can lead Lo many cardlovascular problems lncludlng hlgh
blood pressure hearL aLLack and sLroke AlLhough Lhese condlLlons also occur ln nondlabeLlc lndlvlduals people wlLh dlabeLes are Lwo Lo four Llmes more
llkely Lo develop cardlovascular dlsorders
ulabeLes melllLus may also cause loss of feellng parLlcularly ln Lhe lower legs 1hls numbness may prevenL a person from feellng Lhe paln or lrrlLaLlon of a
break ln Lhe skln or of fooL lnfecLlon unLll afLer compllcaLlons have developed posslbly necesslLaLlng ampuLaLlon of Lhe fooL or leg 8urnlng paln senslLlvlLy Lo
Louch and coldness of Lhe fooL condlLlons collecLlvely known as neuropaLhy can also occur CLher compllcaLlons lnclude hlgherrlsk pregnancles ln dlabeLlc
women and a greaLer occurrence of denLal dlsease

YL#1LNUN
PyperLenslon or Plgh 8lood ressure medlcal condlLlon ln whlch consLrlcLed arLerlal blood vessels lncrease Lhe reslsLance Lo blood flow causlng an lncrease ln
blood pressure agalnsL vessel walls 1he hearL musL work harder Lo pump blood Lhrough Lhe narrowed arLerles lf Lhe condlLlon perslsLs damage Lo Lhe hearL
and blood vessels ls llkely lncreaslng Lhe rlsk for sLroke hearL aLLack and kldney or hearL fallure CfLen called Lhe sllenL klller" hyperLenslon usually causes
no sympLoms unLll lL reaches a llfeLhreaLenlng sLage
1wo facLors deLermlne blood pressure Lhe amounL of blood Lhe hearL pumps and Lhe dlameLer of Lhe arLerles recelvlng blood from Lhe hearL When Lhe
arLerles narrow Lhey lncrease Lhe reslsLance Lo blood flow 1he hearL works harder Lo pump more blood Lo make sure Lhe same amounL of blood clrculaLes Lo
all Lhe body Llssues 1he more blood Lhe hearL pumps and Lhe smaller Lhe arLerles Lhe hlgher Lhe blood pressure
1he kldneys play a ma[or role ln Lhe regulaLlon of blood pressure kldneys secreLe Lhe hormone renln whlch causes arLerles Lo conLracL Lhereby ralslng blood
pressure 1he kldneys also conLrol Lhe fluld volume of blood elLher by reLalnlng salL or excreLlng salL lnLo urlne When kldneys reLaln salL ln Lhe bloodsLream
Lhe salL aLLracLs waLer lncreaslng Lhe fluld volume of blood As a hlgher volume of blood passes Lhrough arLerles lL lncreases blood pressure
49

SclenLlsLs do noL fully undersLand Lhe causes of hyperLenslon ln up Lo 93 percenL of cases no clear cause can be ldenLlfled 1hls Lype of hlgh blood pressure ls
known as essenLlal hyperLenslon and sclenLlsLs suspecL LhaL geneLlc facLors may play a role ln lLs developmenL ln abouL 3 percenL of cases hlgh blood
pressure develops as a resulL of anoLher medlcal dlsorder such as kldney or llver dlsease or as a slde effecL of cerLaln medlcaLlons 1hls Lype of hlgh blood
pressure ls known as secondary hyperLenslon CLher facLors LhaL may conLrlbuLe Lo elevaLed blood pressure ln some people lnclude a dleL hlgh ln salL physlcal
lnacLlvlLy obeslLy and heavy alcohol consumpLlon
Complications
lf hyperLenslon ls noL deLecLed and LreaLed llfeLhreaLenlng compllcaLlons develop over a course of years lncreased pressure on Lhe lnner walls of blood
vessels makes Lhe vessels less flexlble over Llme and more vulnerable Lo Lhe bulldup of faLLy deposlLs ln a process known as aLherosclerosls (see
ArLerlosclerosls) Weakened porLlons of Lhe blood vessel wall may balloon formlng an aneurysm lf an aneurysm rupLures lnLernal hemorrhaglng (bleedlng)
resulLs 8oLh aLherosclerosls and a rupLured aneurysm ln Lhe braln can lead Lo a sLroke
U LH#UULUHY
PyperLenslon forces Lhe hearL Lo work harder Lo pump adequaLe blood LhroughouL Lhe body 1hls exLra work causes Lhe muscles of Lhe hearL Lo enlarge and
evenLually Lhe enlarged hearL becomes lnefflclenL ln pumplng blood An enlarged hearL may lead Lo hearL fallure ln whlch Lhe hearL can noL pump enough
blood Lo meeL Lhe body's needs
lncreased blood pressure may damage Lhe small blood vessels wlLhln Lhe kldney 1he kldney Lhen becomes unable Lo fllLer blood efflclenLly and wasLe
producLs may bulld up ln Lhe blood ln a condlLlon known as uremla WlLhouL medlcal LreaLmenL kldney fallure wlll resulL
UUNH#Y LUNUL1UN
lL happens when Lhere ls excesslve accumulaLlon of fluld ln Lhe lungs Lhe condlLlon of havlng an excesslve amounL of blood or fluld accumulaLe ln an organ or
body parL as a resulL of dlsease or lnfecLlon

50

NLUUNH
neumonla lnflammaLlon of one or boLh lungs ln people wlLh pneumonla alr sacs ln Lhe lungs flll wlLh fluld prevenLlng oxygen from reachlng blood cells and
nourlshlng Lhe oLher cells of Lhe body SomeLlmes Lhe lnflammaLlon occurs ln scaLLered paLches ln Lhe Llssue around Lhe ends of Lhe bronchloles Lhe smallesL
alr Lubes ln Lhe lungs 1hls ls known as bronchopneumonla ln oLher cases Lhe lnflammaLlon ls wldespread and lnvolves an enLlre lobe of Lhe lung 1hls
condlLlon ls called lobar pneumonla
Lxpand
neumonla lnflammaLlon of one or boLh lungs ln people wlLh pneumonla alr sacs ln Lhe lungs flll wlLh fluld prevenLlng oxygen from reachlng blood cells and
nourlshlng Lhe oLher cells of Lhe body SomeLlmes Lhe lnflammaLlon occurs ln scaLLered paLches ln Lhe Llssue around Lhe ends of Lhe bronchloles Lhe smallesL
alr Lubes ln Lhe lungs 1hls ls known as bronchopneumonla ln oLher cases Lhe lnflammaLlon ls wldespread and lnvolves an enLlre lobe of Lhe lung 1hls
condlLlon ls called lobar pneumonla ln Lhe unlLed SLaLes abouL 3 mllllon cases of pneumonla are reporLed each year and abouL 63300 people dle from Lhe
dlsease
CAuSLLS Cl -LuMC-lA
neumonla has more Lhan 30 dlfferenL causes MosL cases of pneumonla resulL from lnfecLlon wlLh mlcroorganlsms prlmarlly vlruses bacLerla mycoplasmas
(small freellvlng parLlcles wlLh characLerlsLlcs of boLh bacLerla and vlruses) and fungl neumonla may also resulL from cerLaln klnds of allerglc reacLlons
lnhalaLlon of flulds or some gases and Lhe lnhalaLlon of lngesLed foods
vl8AL -LuMC-lA
AbouL 30 percenL of pneumonla cases are caused by vlruses parLlcularly Lhose vlruses LhaL cause upper resplraLory lnfecLlons such as Lhe vlruses LhaL cause
lnfluenza adenovlruses and rhlnovlruses MosL cases of vlral pneumonla are mlld and resolve sponLaneously wlLhouL speclflc LreaLmenL
Cne excepLlon ls severe acuLe resplraLory syndrome (SA8S) a Lype of vlral pneumonla SA8S Lyplcally beglns wlLh a fever of 380C (1004l) or more chllls
headache and malalse 1wo Lo seven days laLer some people develop a dry cough and dlfflculLy breaLhlng lor Lhese people SA8S can cause deaLh
8AC1L8lAL -LuMC-lA
51

lnfecLlon wlLh Lhe SLrepLococcus pneumonlae bacLerlum also called pneumococcus ls Lhe mosL common cause of bacLerlal pneumonla neumococcus
usually causes lobar pneumonla aLLacklng an enLlre lobe or porLlon of a lobe of Lhe lung ln double pneumonla pneumococcus aLLacks boLh lungs
neumococcal lobar pneumonla ofLen occurs ln wlnLer afLer an acuLe vlral upper resplraLory lnfecLlon usual sympLoms lnclude a shaklng chlll followed by a
fever of abouL 40C (104l) paln ln Lhe chesL whlle breaLhlng a cough and bloodsLreaked spuLum
CLher bacLerla LhaL cause pneumonla lnclude klebslella pneumonlae Paemophllus lnfluenzae Leglonella pneumophllla (Lhe bacLerlum LhaL causes
Leglonnalres' dlsease) and varlous sLaphylococcl and sLrepLococcl bacLerla lnfecLlons wlLh Lhese organlsms prlmarlly cause bronchopneumonla CnseL of
sympLoms ls generally slower Lhan wlLh lobar pneumonla and Lhe fever ls lower
C1PL8 1?LS Cl -LuMC-lA
Cne common Lype of pneumonla formerly called prlmary aLyplcal pneumonla ls caused by Mycoplasma pneumonlae a mycoplasma Lpldemlcs of
mycoplasma pneumonla occur ln schools and ln Lhe mlllLary 1he mosL promlnenL sympLom of mycoplasma pneumonla ls a vlolenL dry cough Some paLlenLs
experlence nausea or vomlLlng
neumocysLls carlnll pneumonla (C) ls caused by a normally harmless fungus LhaL may become deadly ln people wlLh lmpalred lmmune sysLems C ls Lhe
mosL common cause of deaLh ln people wlLh acqulred lmmunodeflclency syndrome (AluS)
ulAC-CSlS A-u 18LA1ML-1
A physlclan can dlagnose pneumonla by Lapplng Lhe chesL and llsLenlng wlLh a sLeLhoscope Lo Lhe sound produced 1applng Lhe chesL of a healLhy person
produces a resonanL sound because of Lhe alr conLalned ln Lhe lungs ln a person wlLh pneumonla Lhe alr spaces of Lhe lungs become fllled wlLh fluld and
Lapplng produces a dull flaL sound 1he dlagnosls of pneumonla ls conflrmed by Laklng an xray plcLure of Lhe chesL
1o deLermlne Lhe cause of pneumonla a physlclan Lakes a sample of Lhe paLlenLs spuLum Analysls of Lhe spuLum ln Lhe laboraLory may ldenLlfy Lhe parLlcular
klnd of mlcroorganlsm causlng Lhe lnfecLlon ldenLlflcaLlon of Lhe cause of pneumonla ls lmporLanL ln deLermlnlng LreaLmenL
AnLlbloLlcs can cure bacLerlal pneumonla and speed recovery from mycoplasma pneumonla and C AnLlbloLlcs rarely have an effecL on pneumonla caused
by vlruses Powever paLlenLs wlLh vlral pneumonla ofLen recelve anLlbloLlcs Lo prevenL bacLerlal pneumonla from developlng durlng Lhe course of Lhelr lllness
ln addlLlon Lo drug LreaLmenL a paLlenL wlLh pneumonla should sLay ln bed eaL healLhy meals and drlnk large amounLs of llqulds MedlcaLlon may be glven Lo
relleve chesL paln and vlolenL coughlng and oxygen may be admlnlsLered lf Lhe paLlenL has dlfflculLy breaLhlng A vacclne ls avallable LhaL confers lmmunlLy
52

agalnsL pneumococcus 1he vacclne ls glven Lo people mosL aL rlsk for developlng pneumonlaLhose over Lhe age of 63 and Lhose wlLh chronlc hearL lung or
llver dlsease




Medications

1. Imdur 60mg 1 tab OD
ISOSORBIDE MONONITRATE (eye-soe-sor-bide mo-noe-nye-trate )
Imdur, Ismo, Isotrate ER, Monoket
CLASSIFICATION(S).
Ther. Class. antianginals
Pharm. Class. nitrates

Pregnancy Category C

INDICA1ICNS
Acute treatment oI anginal attacks (SL only)
Prophylactic management oI angina pectoris (dinitrate and mononitrate)
53

Treatment oI chronic CHF (dinitrate).
AC1ICN
Produce vasodilation (venous greater than arterial)
Decrease leIt ventricular end-diastolic pressure and leIt ventricular end-diastolic volume (preload). Net eIIect is reduced myocardial oxygen consumption
Increase coronary blood Ilow by dilating coronary arteries and improving collateral Ilow to ischemic regions.
Therapeutic Effects:
4 RelieI oI anginal attacks and increase in cardiac output.
nAkMACCkINL1ICS
Absorption: Well absorbed aIter PO and SL administration.
Distribution: Unknown.
Metabolism and Excretion: Mostly metabolized by the liver.
Half-life: Isosorbide dinitrate50 min; isosorbide mononitrate5 hr.
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Hypersensitivity
Severe anemia.
Concurrent use oI sildenaIil.
Use Cautiously in:
Head trauma or cerebral hemorrhage
Geriatric patients (start with lower doses)
Pregnancy (may compromise maternal/Ietal circulation)
Children or lactation (saIety not established).
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

CNS: dizziness, headache, apprehension, weakness.
54

CV: hypotension, tachycardia, paradoxic bradycardia, syncope.
GI: abdominal pain, nausea, vomiting.
Misc: cross-tolerance, Ilushing, tolerance.
IN1LkAC1ICNS
Drug-Drug:
Concurrent use oI sildenafil may result in signiIicant and potentially Iatal hypotension (concurrent use is contraindicated)
Additive hypotension with antihypertensives, acute ingestion oI alcohol, beta blockers, calcium channel blockers, and phenothiazines
Aspirin may increase blood levels and eIIects
EIIects may be antagonized by dihydroergotamine.
kCU1L AND DCSAGL
Isosorbide Mononitrate
PO (Adults): Ismo, Monoket20 mg twice daily (may start with 5 mg twice daily), 7 hr apart.Imdur3060 mg once daily; may increase to 120 mg once daily (up to 240 mg/day).
AVAILA8ILI1
4 Isosorbide Mononitrate
Extended-release tablets (Imdur, Isotrate ER): 30 mg
Rx
, 60 mg
Rx
, 120 mg
Rx

Cost: Imdur30 mg $130.03/100, 60 mg $136.86/100, 120 mg $191.60/100, Isotrate ER 60 mg $117.41/100;generic 30 mg $111.55/100, 60 mg $116.11$117.40/100.
TIME/ACTION PROFILE (cardiovascular eIIects)

ONSET PEA DURATION

ISMN-PO 3060 min unknown 7 hr

55

NUkSING IMLICA1ICNS
ASSESSMENT
Assess location, duration, intensity, and precipitating Iactors oI anginal pain.
Monitor blood pressure and pulse routinely during period oI dosage adjustment.
ab 1est Considerations: May cause Ialsely decreased serum cholesterol determinations.
4 Excessive doses may increase methemoglobin concentrations.
4 May cause increased urine vanillylmandelic acid (VMA) concentrations.
POTENTIAL NURSING DIAGNOSES
Tissue perIusion, altered (Indications).
Activity intolerance (Indications).
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
IMPLEMENTATION
Isosorbide Mononitrate
PO: Medication should be taken on an empty stomach with a Iull glass oI water.
PATIENT/AMILY TEACHING
Instruct patient to take medication exactly as directed, even iI Ieeling better. II a dose is missed, take as soon as remembered; doses oI isosorbide dinitrate should be taken at least 2 hr apart
(6 hr with extended-release preparations); daily doses oI isosorbide mononitrate should be taken 7 hr apart. Do not double doses. Do not discontinue abruptly.
Caution patient to make position changes slowly to minimize orthostatic hypotension.
May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
Advise patient to avoid concurrent use oI alcohol with this medication. Patients should also consult health care proIessional beIore taking OTC medications while taking isosorbide.
InIorm patient that headache is a common side eIIect that should decrease with continuing therapy. Aspirin or acetaminophen may be ordered to treat headache. NotiIy health care
proIessional iI headache is persistent or severe. Do not alter dose to avoid headache.
Advise patient to notiIy health care proIessional iI dry mouth or blurred vision occurs or iI undigested extended-release isosorbide dinitrate tablets are Iound in stool.
EVALUATION
Effectiveness of therapy can be demonstrated by:
56

Decrease in Irequency and severity oI anginal attacks
4 Increase in activity tolerance.
. ASPIRIN COR 30 mg 1 tab OD
Classification: aspirin
Indication: chronic stable and unstable angina,MI. adjunct treatment oI CV disease in transcient ischemic attack or minor ischemic stroke
Dosage:1 tab daily
AC1ICN
Inhibits the synthesis oI prostaglandins that may serve as mediators oI pain and Iever, primarily in the CNS
Has no signiIicant anti-inIlammatory properties or GI toxicity.
Therapeutic Effects:
4 Analgesia
4 Antipyresis.
nAkMACCkINL1ICS
Absorption: Well absorbed Iollowing oral administration. Rectal absorption is variable.
Distribution: Widely distributed. Crosses the placenta; enters breast milk in low concentrations.
Metabolism and Excretion: 8595 metabolized by the liver. Metabolites may be toxic in overdose situation. Metabolites excreted by the kidneys.
Half-life: 14 hr.
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Previous hypersensitivity
Products containing alcohol, aspartame, saccharin, sugar, or tartrazine (FDC yellow dye #5) should be avoided in patients who have hypersensitivity or intolerance to these compounds.
Use Cautiously in:
Hepatic disease/renal disease (lower chronic doses recommended)
Chronic alcohol use/abuse
Malnutrition.
57

ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

GI: HEPATIC FAILURE, HEPATOTOXICITY(overdose).
GU: renal Iailure (high doses/chronic use).
Derm: rash, urticaria.
IN1LkAC1ICNS
Drug-Drug:
Chronic high-dose acetaminophen (~2 g/day) may increase the risk oI bleeding with arfarin (PT should be monitored regularly and INR should not exceed 4)
Hepatotoxicity is additive with other hepatotoxic substances, including alcohol
Concurrent use oI sulfinpyrazone, isoniazid, rifampin, rifabutin, phenytoin, barbiturates, and carbamazepine may increase the risk oI acetaminophen-induced liver damage (limit selI-
medication); these agents will also decrease therapeutic eIIects oI acetaminophen
Combined use with salicylates or NSAIDs increases the risk oI adverse renal eIIects.
Propranolol decreases metabolism and may increase eIIects.
May decrease eIIects oI lamotrigine, zidovudine, and loop diuretics.
NUkSING IMLICA1ICNS
ASSESSMENT
General Info: Assess overall health status and alcohol usage beIore administering acetaminophen. Malnourished patients or chronic alcohol abusers are at higher risk oI developing
hepatotoxicity with chronic use oI usual doses oI this drug.
4 Assess amount, Irequency, and type oI drugs taken in patients selI-medicating, especially with OTC drugs. Prolonged use oI acetaminophen alone or combined with salicylates or
NSAIDs increases the risk oI adverse renal eIIects. For short-term use, combined doses oI acetaminophen and salicylates should not exceed the recommended dose oI either drug
given alone.
Pain: Assess type, location, and intensity prior to and 3060 min Iollowing administration.
ever: Assess Iever; note presence oI associated signs (diaphoresis, tachycardia, and malaise).
ab 1est Considerations: Hepatic, hematologic, and renal Iunction should be evaluated periodically throughout prolonged, high-dose therapy.
4 May alter results oI blood glucose monitoring. May cause Ialsely decreased values when measured with glucose oxidase/peroxidase method, but probably not with
hexokinase/glucose-6-phosphate dehydrogenase (G6PD) method. May also cause Ialsely increased values with certain instruments; see manuIacturer's instruction manual.
4 Increased serum bilirubin, LDH, AST, ALT, and prothrombin time may indicate hepatotoxicity.
1oxicity and Overdose: II overdose occurs, acetylcysteine (Mucomyst) is the antidote.
POTENTIAL NURSING DIAGNOSES
58

Pain (Indications).
Body temperature, risk Ior altered (Indications).
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
IMPLEMENTATION
General Info: When combined with opioids do not exceed the maximum recommended daily dose oI acetaminophen.
PO: Administer with a Iull glass oI water.
4 May be taken with Iood or on an empty stomach.
PATIENT/AMILY TEACHING
Advise patient to take medication exactly as directed and not to take more than the recommended amount. Chronic excessive use oI ~4 g/day (2 g in patients with chronic alcoholism) may
lead to hepatotoxicity, renal, or cardiac damage. Adults should not take acetaminophen longer than 10 days and children not longer than 5 days unless directed by health care proIessional.
Short-term doses oI acetaminophen with salicylates or NSAIDs should not exceed the recommended daily dose oI either drug alone.
Advise patient to avoid alcohol (3 or more glasses per day increase the risk oI liver damage) iI taking more than an occasional 12 doses and to avoid taking concurrently with salicylates or
NSAIDs Ior more than a Iew days, unless directed by health care proIessional.
Advise parents or caregivers to check concentrations oI liquid preparations. Errors have resulted in serious liver damage.
InIorm patients with diabetes that acetaminophen may alter results oI blood glucose monitoring. Advise patient to notiIy health care proIessional iI changes are noted.
Advise patient to consult health care proIessional iI discomIort or Iever is not relieved by routine doses oI this drug or iI Iever is greater than 39.5C (103F) or lasts longer than 3 days.
EVALUATION
Effectiveness of therapy can be demonstrated by:
RelieI oI mild pain
Reduction oI Iever.
3. Metoclopramide 1 AMP IVTT evry 8 hours
METOCLOPRAMIDE
(met-oh-kloe-pra-mide)
Apo-Metoclop, Clopra, Emex, Maxeran, Octamide, Octamide-PFS, Reclomide, Reglan
C$$IFIC1IOA($):
1her. Class: antiemetics
59


Pregnancy Category

INDICA1ICNS
Treatment oI postsurgical and diabetic gastric stasis
Management oI esophageal reIlux .
Unlabelled Uses:
4 Treatment oI hiccups
4 Adjunct management oI migraine headaches.
AC1ICN
Blocks dopamine receptors in chemoreceptor trigger zone oI the CNS
Stimulates motility oI the upper GI tract and accelerates gastric emptying.
Therapeutic Effects:
4 Decreased nausea and vomiting
4 Decreased symptoms oI gastric stasis
4 Easier passage oI nasogastric tube into small bowel.
nAkMACCkINL1ICS
Absorption: Well absorbed Irom the GI tract, Irom rectal mucosa, and Irom IM sites.
Distribution: Widely distributed into body tissues and Iluids. Crosses blood-brain barrier and placenta. Enters breast milk in concentrations greater than plasma.
Metabolism and Excretion: Partially metabolized by the liver; 25 eliminated unchanged in the urine.
Half-life: 2.55 hr.
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Hypersensitivity
Possible GI obstruction or hemorrhage
60

History oI seizure disorders
Pheochromocytoma
Parkinson's disease.
Use Cautiously in:
History oI depression
Diabetes (may alter response to insulin)
Pregnancy and lactation (saIety not established)
Children and geriatric patients (increased incidence oI extrapyramidal reactions).
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

CNS: drowsiness, extrapyramidal reactions, restlessness, anxiety, depression, irritability, tardive dyskinesia.
CV: arrhythmias (supraventricular tachycardia, bradycardia), hypertension, hypotension.
GI: constipation, diarrhea, dry mouth, nausea.
Endo: gynecomastia.
IN1LkAC1ICNS
Drug-Drug:
Additive CNS depression with other CNS depressants, including alcohol, antidepressants, antihistamines, opioid analgesics, and sedative/hypnotics
May increase absorption and risk oI toxicity Irom cyclosporine
May aIIect the GI absorption oI other orally administered drugs as a result oI eIIect on GI motility
May exaggerate hypotension during general anesthesia
Increased risk oI extrapyramidal reactions with agents such as haloperidol or phenothiazines
Opioids and anticholinergics may antagonize the GI eIIects oI metoclopramide
Use cautiously with MAO inhibitors (causes release oI catecholamines)
May increase neuromuscular blockade Irom succinylcholine
May decrease the eIIectiveness oI levodopa.
TIME/ACTION PROFILE (eIIects on peristalsis)

ONSET PEA DURATION
61


IV 13 min immediate 12 hr

NUkSING IMLICA1ICNS
ASSESSMENT
Assess patient Ior nausea, vomiting, abdominal distention, and bowel sounds beIore and aIter administration.
Assess patient Ior extrapyramidal side eIIects (5arkinsoniandiIIiculty speaking or swallowing, loss oI balance control, pill rolling, mask-like Iace, shuIIling gait, rigidity, tremors; and
dystonicmuscle spasms, twisting motions, twitching, inability to move eyes, weakness oI arms or legs) periodically throughout course oI therapy. May occur weeks to months aIter
initiation oI therapy and are reversible on discontinuation. Dystonic reactions may occur within minutes oI IV inIusion and stop within 24 hr oI discontinuation oI metoclopramide. May be
treated with 50 mg oI IM diphenhydramine or diphenhydramine 1 mg/kg IV may be administered prophylactically 15 min beIore metoclopramide IV inIusion.
Monitor Ior tardive dyskinesia (uncontrolled rhythmic movement oI mouth, Iace, and extremities; lip smacking or puckering; puIIing oI cheeks; uncontrolled chewing; rapid or worm-like
movements oI tongue). Usually occurs aIter a year or more oI continued therapy. Report immediately; may be irreversible.
Assess patient Ior signs oI depression periodically throughout therapy.
ab 1est Considerations: May alter hepatic Iunction test results.
4 May cause increased serum prolactin and aldosterone concentrations.
POTENTIAL NURSING DIAGNOSES
Nutrition, altered: less than body requirements (Indications).
Injury, risk Ior (Side EIIects).
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
PATIENT/AMILY TEACHING
Instruct patient to take metoclopramide exactly as directed. II a dose is missed, take as soon as remembered iI not almost time Ior next dose.
May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
Advise patient to avoid concurrent use oI alcohol and other CNS depressants while taking this medication.
Advise patient to notiIy health care proIessional immediately iI involuntary movement oI eyes, Iace, or limbs occurs.
EVALUATION
Effectiveness of therapy can be demonstrated by:
Prevention or relieI oI nausea and vomiting
62

Decreased symptoms oI gastric stasis
Facilitation oI small bowel intubation
Decreased symptoms oI esophageal reIlux.
. Lantus 15 ~u SQ before supper
INSULINS
(in-su-lin)
insulin glargine
Lantus
C$$IFIC1IOA($):
1her. Class: antidiabetics, hormones
!harm. Class: 5ancreatic hormone

Pregnancy Category C (glargine), (all others)

INDICA1ICNS
Treatment oI insulin-dependent diabetes mellitus (IDDM, type 1)
Management oI noninsulin-dependent diabetes mellitus (NIDDM, type 2) unresponsive to treatment with diet and/or oral hypoglycemic agents
Concentrated insulin U-500: Only Ior use in patients with insulin requirements ~200 units/day.
AC1ICN
Lower blood glucose by increasing transport into cells and promoting the conversion oI glucose to glycogen
Promote the conversion oI amino acids to proteins in muscle and stimulate triglyceride Iormation
Inhibit the release oI Iree Iatty acids
Sources include pork, beeI/pork combinations, semisynthetic, biosynthetic, and recombinant DNA.
Therapeutic Effects:
4 Control oI blood sugar in diabetic patients.
63

nAkMACCkINL1ICS
Absorption: Rapidly absorbed Irom SC administration sites. Absorption rate is determined by type oI insulin, injection site, volume oI injectate, and other Iactors.
Distribution: Widely distributed.
Metabolism and Excretion: Metabolized by liver, spleen, kidney, and muscle.
Half-life: 56 min (prolonged in patients with diabetes; biologic halI-liIe is 11.5 hr).
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Allergy or hypersensitivity to a particular type oI insulin, preservatives, or other additives.
Use Cautiously in:
Stress, pregnancy, and inIection (temporarily increase insulin requirements).
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

Derm: urticaria.
Endo: HYPOGLYCEMIA, rebound hyperglycemia (Somogyi eIIect).
Local: lipodystrophy, itching, lipohypertrophy, redness, swelling.
Misc: allergic reactions includingANAPHYLAXIS.
IN1LkAC1ICNS
Drug-Drug:
eta blockers may block some oI the signs and symptoms oI hypoglycemia and delay recovery Irom hypoglycemia
Thiazide diuretics, corticosteroids, diltiazem, dobutamine, thyroid preparations, estrogens, nicotine, protease inhibitor antiretrovirals, and rifampin may increase insulin
requirements
Anabolic steroids (testosterone), alcohol, clofibrate, guanethidine, MAO inhibitors, most NSAIDs, oral hypoglycemic agents, sulfinpyrazone, tetracyclines, phenylbutazone, and
arfarin may decrease insulin requirements.
Drug-Natural:
64

Glucosamine may worsen blood glucose control
enugreek, chromium, and coenzyme Q-10 may produce additive hypoglycemic eIIects.
kCU1L AND DCSAGL
Dose depends on blood sugar, response, and many other Iactors.
etoacidosis-Regular Insulin Only
IV (Adults): 0.1 unit/kg/hr as a continuous inIusion.
Maintenance Therapy
SC (Adults and Children): 0.51 unit/kg/day. Adolescents during ra5id growth0.81.2 units/kg/day.
AVAILA8ILI1
Insulin injection (regular insulin): 100 units/ml
OTC

Cost: $29.65/10 ml vial
Insulin glargine: 100 units/ml in 5 ml vials
Rx
, 10 ml vials
Rx
, 3 ml cartridges
Rx

TIME/ACTION PROFILE (hypoglycemic eIIect)

ONSET PEA DURATION

Insulin
glargine SC
1.1 hr 5 hr 24 hr
f


f
Small amounts oI insulin glargine slowly released resulting in a relatively constant eIIect over time.
NUkSING IMLICA1ICNS
ASSESSMENT
65

Assess patient Ior signs and symptoms oI hypoglycemia (anxiety; chills; cold sweats; conIusion; cool, pale skin; diIIiculty in concentration; drowsiness; excessive hunger; headache;
irritability; nausea; nervousness; rapid pulse; shakiness; unusual tiredness or weakness) and hyperglycemia (drowsiness; Ilushed, dry skin; Iruit-like breath odor; Irequent urination; loss oI
appetite; tiredness; unusual thirst) periodically throughout therapy.
Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose.
ab 1est Considerations: May cause decreased serum inorganic phosphate, magnesium, and potassium levels.
4 Monitor blood glucose and ketones every 6 hr throughout therapy, more Irequently in ketoacidosis and times oI stress. Glycosylated hemoglobin may also be monitored to
determine eIIectiveness oI therapy.
1oxicity and Overdose: Overdose is maniIested by symptoms oI hypoglycemia. Mild hypoglycemia may be treated by ingestion oI oral glucose. Severe hypoglycemia is a liIe-threatening
emergency; treatment consists oI IV glucose, glucagon, or epinephrine.
POTENTIAL NURSING DIAGNOSES
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
Noncompliance (Patient/Family Teaching).
PATIENT/AMILY TEACHING
Instruct patient on proper technique Ior administration. Include type oI insulin, equipment (syringe, cartridge pens, alcohol swabs), storage, and place to discard syringes. Discuss the
importance oI not changing brands oI insulin or syringes, selection and rotation oI injection sites, and compliance with therapeutic regimen.
Demonstrate technique Ior mixing insulins by drawing up regular insulin or insulin lispro Iirst and rolling intermediate-acting insulin vial between palms to mix, rather than shaking (may
cause inaccurate dose).
Explain to patient that this medication controls hyperglycemia but does not cure diabetes. Therapy is long term.
Instruct patient in proper testing oI serum glucose and ketones. These tests should be closely monitored during periods oI stress or illness and health care proIessional notiIied oI signiIicant
changes.
Emphasize the importance oI compliance with nutritional guidelines and regular exercise as directed by health care proIessional.
Advise patient to consult health care proIessional prior to using alcohol or other medications concurrently with insulin.
Advise patient to notiIy health care proIessional oI medication regimen prior to treatment or surgery.
Advise patient to notiIy health care proIessional iI nausea, vomiting, or Iever develops, iI unable to eat regular diet, or iI blood sugar levels are not controlled.
Instruct patient on signs and symptoms oI hypoglycemia and hyperglycemia and what to do iI they occur.
Advise patient to notiIy health care proIessional iI pregnancy is planned or suspected.
Patients with diabetes mellitus should carry a source oI sugar (candy, sugar packets) and identiIication describing their disease and treatment regimen at all times.
Emphasize the importance oI regular Iollow-up, especially during Iirst Iew weeks oI therapy.
EVALUATION
Effectiveness of therapy can be demonstrated by:
Control oI blood glucose levels without the appearance oI hypoglycemic or hyperglycemic episodes.
66

5. Diovan 80 mg 1 tab OD
ANGIOTENSIN II RECEPTOR ANTAGONISTS
valsartan
(val-sar-tan)
Diovan
C$$IFIC1IOA($):
1her. Class: antihy5ertensives
!harm. Class: angiotensin II rece5tor antagonists

Pregnancy Category C (first trimester), D (second and third trimesters)


INDICA1ICNS
Alone or with other agents in the management oI hypertension.
AC1ICN
Blocks the vasoconstrictor and aldosterone-producing eIIects oI angiotensin II at various receptor sites, including vascular smooth muscle and the adrenal glands.
Therapeutic Effects:
4 Lowering oI blood pressure.
nAkMACCkINL1ICS
Absorption: CandesartanCandesartan cilexetil is converted to candesartan in the GI tract during the absorption process where 15 is absorbed; e5rosartan13 absorbed; irbesartan6080
absorbed; losartanwell absorbed but undergoes extensive Iirst-pass hepatic metabolism, resulting in 33 bioavailability; telmisartan4258 absorbed Iollowing oral administration
(bioavailability increased in patients with hepatic impairment); valsartan25 absorbed Iollowing oral administration.
Distribution: Unknown; candesartanminimal penetration oI the blood-brain barrier.
Protein inding: e5rosartan98
Metabolism and Excretion: CandesartanExcreted mostly unchanged in urine and Ieces (via bile); minor metabolism by the liver; e5rosartan90eliminated unchanged in Ieces via biliary
elimination, 7 excreted in urine; irbesartansome hepatic metabolism, some biliary excretion, some elimination as unchanged drug in urine; losartanundergoes extensive Iirst-pass hepatic
67

metabolism; 14 is converted to an active metabolite. 4 oI losartan is excreted unchanged by the kidneys; although 6 oI the active metabolite is excreted unchanged by the kidneys, some biliary
elimination also occurs; telmisartanexcreted mostly unchanged in Ieces via biliary excretion, 11 metabolized by the liver; valsartan20 metabolized by the liver; mostly excreted in Ieces via
bile.
Half-life: Candesartan9 hr; eprosartan59 hr;irbesartan1115 hr; losartan2 hr (69 hr Ior metabolite); telmisartan24 hr; valsartan6 hr.
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Hypersensitivity
Pregnancy or lactation.
Use Cautiously in:
CHF (may result in azotemia,oliguria, acute renal Iailure and/or death)
Volume- or salt-depleted patients or patients receiving high doses oI diuretics (correct deIicits beIore initiating therapy or initiate at lower doses)
Black patients (may not be as eIIective as monotherapy; additional agents may be required)
Impaired renal Iunction due to primary renal disease or CHF (may worsen renal Iunction)
Obstructive biliary disorders or hepatic impairment (lower initial doses oI losartan, temisartan, or valsartan recommended)
Patients with childbearing potential
Children 18 yr (saIety not established).
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

CNS: dizziness, Iatigue, headache.
CV: hypotension.
GI: diarrhea, drug-induced hepatitis.
GU: RENAL FAILURE.
and E: hyperkalemia.
IN1LkAC1ICNS
Drug-Drug:
NSAIDs may decrease antihypertensive eIIects
Additive antihypertensive eIIects with other antihypertensives and diuretics. Risk oI hypotension is increased by concurrent diuretic therapy (use lower initial doses)
68

Telmisartan increases serum digoxin levels.
Concurrent use oI potassium-sparing diuretics or potassium supplements may increase the risk oI hyperkalemia
kCU1L AND DCSAGL
Valsartan
PO (Adults): 80 mg/day as a single dose initially in patients who are not receiving diuretics or other antihypertensives; may be increased to 160320 mg/day.
AVAILA8ILI1
4 Valsartan
Capsules: 80 mg
Rx
, 160 mg
Rx
.
Cost: 80 mg $125.10/100, 160 mg $133.73/100.
1ablets: 80 mg
Rx
, 160 mg
Rx
, 320 mg
Rx
.
In combination with: hydrochlorothiazide (Diovan HCT
Rx
).
TIME/ACTION PROFILE (antihypertensive eIIect
f
)

ONSET PEA DURATION

Valsartan within 2 hr 46 hr 24 hr

f
maximum response may take 23 weeks oI treatment
NUkSING IMLICA1ICNS
ASSESSMENT
Assess blood pressure (lying down, sitting, standing) and pulse periodically throughout therapy.
Monitor Irequency oI prescription reIills to determine adherence.
Assess patient Ior signs oI angioedema (dyspnea, Iacial swelling). May rarely cause angioedema; more common in patients who have had angioedema with ACE inhibitors.
ab 1est Considerations: May rarely cause elevations in BUN and serum creatinine.
4 May cause elevated serum bilirubin.
4 May occasionally cause hyperkalemia.
69

4 Losartan may cause transient elevations oI ALT and AST, hemoglobin, and hematocrit and decreased uric acid concentrations.
POTENTIAL NURSING DIAGNOSES
Injury, risk Ior (Adverse Reactions).
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
Noncompliance (Patient/Family Teaching).
IMPLEMENTATION
General Info: Volume depletion should be corrected, iI possible, prior to initiation oI therapy.
PO: May be administered without regard to meals.
PATIENT/AMILY TEACHING
Emphasize the importance oI continuing to take as directed, even iI Ieeling well. Take missed doses as soon as remembered iI not almost time Ior next dose; do not double doses.
Medication controls but does not cure hypertension. Instruct patient to take medication at the same time each day. Gradual reduction oI dose prior to discontinuation is suggested.
Encourage patient to comply with additional interventions Ior hypertension (weight reduction, low-sodium diet, discontinuation oI smoking, moderation oI alcohol consumption, regular
exercise, stress management).
Instruct patient and Iamily on proper technique Ior monitoring blood pressure. Advise them to check blood pressure at least weekly and to report signiIicant changes.
Caution patient to avoid sudden changes in position to decrease orthostatic hypotension. Use oI alcohol, standing Ior long periods, exercising, and hot weather may increase orthostatic
hypotension.
Advise women oI childbearing age to use contraception and notiIy health care proIessional iI pregnancy is suspected or planned.
May cause dizziness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
Advise patient to consult health care proIessional beIore taking any OTC cough, cold, or allergy remedies or other medications.
Instruct patient to notiIy health care proIessional oI medication regimen prior to treatment or surgery.
Emphasize the importance oI Iollow-up exams to evaluate eIIectiveness oI medication.
EVALUATION
Effectiveness of therapy can be demonstrated by:
Decrease in blood pressure without appearance oI excessive side eIIects.
. Capoten 5mg SL every hours for P 10/90 mm Hg
70

ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIITORS
captopril
(kap-toe-pril)
Capoten
C$$IFIC1IOA($):
1her. Class: antihy5ertensives
!harm. Class: ACE inhibitors

Pregnancy Category C (first trimester), D (second and third trimesters)


INDICA1ICNS
Alone or with other agents in the management oI hypertension
Captopril,: Management oI CHF
Captopril,:Reduction oI risk oI death or development oI CHF Iollowing MI
Slowed progression oI leIt ventricular dysIunction into overt heart Iailure (selected agents)
Captopril: Decreased progression oI diabetic nephropathy.
AC1ICN
ACE inhibitors block the conversion oI angiotensin I to the vasoconstrictor angiotensin II. ACE also inactivates the vasodilator bradykinin and other vasodilatory prostaglandins. ACE
inhibitors also increase plasma renin levels and reduce aldosterone levels. Net result is systemic vasodilation.
Therapeutic Effects:
4 Lowering oI blood pressure in hypertensive patients
4 Decreased aIterload in patients with CHF
4 Decreased development oI overt heart Iailure
4 Increased survival aIter MI (selected agents only)
4 Decreased progression oI diabetic nephropathy (captopril only).
71

nAkMACCkINL1ICS
Absorption: ena:e5rilAt least 37 absorbed Iollowing oral administration. Ca5to5rilAt least 75 Iollowing oral administration (decreased to 3055 by Iood). Enala5ril60 absorbed
Iollowing oral administration.
Distribution: All ACE inhibitors cross the placenta. ena:e5ril, bena:e5rilat, ca5to5ril, enala5ril, enala5rilat, and fosino5rilat Enter breast milk in small amounts
Metabolism and Excretion: . Ca5to5ril 50 metabolized by the liver to inactive compounds, 50 excreted unchanged by the kidneys.
Half-life: Ca5to5ril 2 hr (increased in renal impairment)
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Hypersensitivity
Cross-sensitivity among ACE inhibitors may occur
Pregnancy
Angioedema (hereditary or idiopathic).
Use Cautiously in:
Renal impairment, hepatic impairment, hypovolemia, hyponatremia, elderly patients, concurrent diuretic therapy (initial dosage reduction recommended Ior most agents)
Black patients with hypertension (monotherapy less eIIective, may require additional therapy)
Aortic stenosis/hypertrophic cardiomyopathy
Cerebrovascular or cardiac insuIIiciency
Surgery/anesthesia (hypotension may be exaggerated)
Lactation or children (saIety not established Ior most agents).
Exercise Extreme Caution in:
Family history oI angioedema.
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

CNS: dizziness, Iatigue, headache, insomnia, weakness.
Resp: cough, eosinophilic pneumonitis.
CV: hypotension, angina pectoris, tachycardia.
GI: taste disturbances, anorexia, diarrhea, nausea.
72

GU: proteinuria, impotence, renal Iailure.
Derm: rashes.
and E: hyperkalemia.
Hemat: AGRANULOCYTOSIS, NEUTROPENIA (CAPTOPRIL ONLY).
Misc: ANGIOEDEMA, Iever.
IN1LkAC1ICNS
Drug-Drug:
Excessive hypotension may occur with concurrent use oI diuretics
Additive hypotension with other antihypertensives, nitrates, phenothiazines, acute ingestion oI alcohol, and during surgery or general anesthesia
Hyperkalemia may result Irom concurrent use oI potassium supplements, potassium-sparing diuretics, indomethacin, salt substitutes, or cyclosporine
Antihypertensive response may be blunted by nonsteroidal anti-inflammatory agents
Absorption may be decreased by antacids
Increases levels and may increase the risk oI lithium or digoxin toxicity
Probenecid decreases elimination and increases levels oI captopril
Risk oI hypersensitivity reactions increased by concurrent allopurinol
Capsaicin may increase the incidence oI cough
Rifampin may decrease the eIIectiveness oI enalapril
Tetracycline absorption is decreased by quinapril (because oI magnesium in tablets).
Drug-ood:
ood decreases conversion oI perindopril to perindoprilat.
kCU1L AND DCSAGL
Captopril
PO (Adults): y5ertension12.525 mg 23 times daily, may be increased at 12 wk intervals up to 150 mg 3 times daily (usual dose 50 mg 3 times daily; begin with 6.2512.5 mg 23
times daily in patients receiving diuretics). CF12.5 mg 23 times daily, may be increased up to 50100 mg 3 times daily (range 12.5450 mg/day). Post MI6.25-mg test dose,
Iollowed by 12.5 mg 3 times daily, may be increased up to 50 mg 3 times daily. Diabetic ne5hro5athy25 mg 3 times daily.
Renal Impairment
PO (Adults): Initiate therapy at 6.2512.5 mg 23 times daily
73

AVAILA8ILI1
4 Captopril
1ablets: 12.5 mg
Rx
, 25 mg
Rx
, 50 mg
Rx
, 100 mg
Rx

Cost: Ca5oten12.5 mg $88.03/100 m 25 mg $95.15/100, 50 mg $163.18/100, 100 mg 217.30/100; generic12.5 mg $58.06$64.05/100, 25 mg $62.77$68.69/100, 50 mg
$107.55$119.09/100, 100 mg $143.32$156.30/100
In combination with: hydrochlorothiazide (Capozide
Rx
).
TIME/ACTION PROFILE (eIIect on blood pressuresingle dose
f
)

ONSET PEA DURATION

Captopril 1560 min 6090 min 612 hr

f
Full eIIects may not be noted Ior several weeks.
NUkSING IMLICA1ICNS
ASSESSMENT
Hypertension: Monitor blood pressure and pulse Irequently during initial dosage adjustment and periodically throughout therapy. NotiIy health care proIessional oI signiIicant changes.
4 Monitor Irequency oI prescription reIills to determine adherence.
CH: Monitor weight and assess patient routinely Ior resolution oI Iluid overload (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
ab 1est Considerations: Monitor BUN, creatinine, and electrolyte levels periodically. Serum potassium may be increased and BUN and creatinine transiently increased, whereas sodium
levels may be decreased. II elevated BUN or serum creatinine concentrations occur, dosage reduction or withdrawal may be required.
4 Monitor CBC periodically during therapy. May rarely cause slight decrease in hemoglobin and hematocrit.
4 May cause elevated AST, ALT, alkaline phosphatase, serum bilirubin, uric acid, and glucose.
4 Assess urine protein prior to and periodically during therapy Ior up to 1 yr in patients with renal impairment or those receiving ~150 mg/day oI captopril. II excessive or increasing
proteinuria occurs, re-evaluate ACE inhibitor therapy.
4 May cause positive ANA titer.
4 Ca5to5ril. May cause Ialse-positive test results Ior urine acetone.
4 WBC with diIIerential should be monitored prior to initiation oI therapy, monthly Ior the Iirst 36 mo, and periodically thereaIter Ior up to 1 yr in patients at risk Ior neutropenia
(patients with renal impairment, collagen-vascular disease, or those receiving high doses) or at Iirst sign oI inIection. Discontinue therapy iI neutrophil count is 1000/mm
3
.
POTENTIAL NURSING DIAGNOSES
74

Cardiac output, decreased (Indications, Side EIIects).
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
Noncompliance (Patient/Family Teaching).
IMPLEMENTATION
PO: Precipitous drop in blood pressure during Iirst 13 hr Iollowing Iirst dose may require volume expansion with normal saline but is not normally considered an indication Ior stopping
therapy. Discontinuing diuretic therapy or increasing salt intake 1 week prior to initiation may decrease risk oI hypotension. Monitor closely Ior at least 1 hr aIter blood pressure has
stabilized. Resume diuretics iI blood pressure is not controlled.
Captopril
Administer 1 hr beIore or 2 hr aIter meals. May be crushed iI patient has diIIiculty swallowing. Tablets may have a sulIurous odor.
4 An oral solution may be prepared by crushing a 25-mg tablet and dissolving it in 25100 ml oI water. Shake Ior at least 5 min and administer within 30 min.
PATIENT/AMILY TEACHING
General Info: Instruct patient to take medication exactly as directed at the same time each day, even iI Ieeling well. Missed doses should be taken as soon as possible but not iI almost time
Ior next dose. Do not double doses. Warn patient not to discontinue ACE inhibitor therapy unless directed by health care proIessional.
4 Caution patient to avoid salt substitutes or Ioods containing high levels oI potassium or sodium unless directed by health care proIessional .
4 Caution patient to change positions slowly to minimize hypotension, particularly aIter initial dose. Patients should also be advised that exercising in hot weather may increase
hypotensive eIIects.
4 Advise patient to consult health care proIessional beIore taking any OTC medications, especially cold remedies.
4 May cause dizziness. Caution patient to avoid driving and other activities requiring alertness until response to medication is known.
4 Advise patient to inIorm health care proIessional oI medication regimen prior to treatment or surgery.
4 Advise patient that medication may cause impairment oI taste that generally resolves within 812 wk, even with continued therapy.
4 Instruct patient to notiIy health care proIessional iI rash; mouth sores; sore throat; Iever; swelling oI hands or Ieet; irregular heart beat; chest pain; dry cough; hoarseness; swelling
oI Iace, eyes, lips, or tongue; diIIiculty swallowing or breathing occur; or iI taste impairment or skin rash persists. Persistent dry cough may occur and may not subside until
medication is discontinued. Consult health care proIessional iI cough becomes bothersome. Also notiIy health care proIessional iI nausea, vomiting, or diarrhea occurs and
continues.
4 Emphasize the importance oI Iollow-up examinations to monitor progress.
Hypertension: Encourage patient to comply with additional interventions Ior hypertension (weight reduction, discontinuation oI smoking, moderation oI alcohol consumption, regular
exercise, and stress management). Medication controls but does not cure hypertension.
4 Instruct patient and Iamily on correct technique Ior monitoring blood pressure. Advise them to check blood pressure at least weekly and to report signiIicant changes to health care
proIessional.
EVALUATION
75

Effectiveness of therapy can be demonstrated by:
Decrease in blood pressure without appearance oI side eIIects
Decrease in signs and symptoms oI CHF
Reduction oI risk oI death or development oI CHF Iollowing MI
Decrease in progression oI diabetic nephropathy (captopril).
. Ranitidine 1 AMP IVTT every 8 hours


nIS1AMINL n
2
AN1AGCNIS1S
kan|t|d|ne
(ran|Lldeen)
Apo8anlLldlne ZanLac ZanLacC ZanLac 73
Dosage: 30 mg q8 hours koute lv11
cL455lllc41lON{5)
1her c/oss ootlolcet oqeots

regnancy Category 8

INDICA1ICNS
ShorLLerm LreaLmenL of acLlve duodenal ulcers and benlgn gasLrlc ulcers
rophylaxls of duodenal ulcers (aL lower doses)
ManagemenL of CL8u
1reaLmenL and prevenLlon of hearLburn acld lndlgesLlon and sour sLomach (C1C use)
ran|t|d|ne IV revenLlon and LreaLmenL of sLresslnduced upper Cl bleedlng ln crlLlcally lll paLlenLs
76

Un|abe||ed Uses
4 ManagemenL of Cl sympLoms assoclaLed wlLh Lhe use of -SAlus
4 revenLlon of sLress ulceraLlon or asplraLlon pneumonlLls
4 revenLlon of acld lnacLlvaLlon of supplemenLal pancreaLlc enzymes ln paLlenLs wlLh pancreaLlc lnsufflclency
4 ManagemenL of urLlcarla
AC1ICN
lnhlblLs Lhe acLlon of hlsLamlne aL Lhe P
2
recepLor slLe locaLed prlmarlly ln gasLrlc parleLal cells resulLlng ln lnhlblLlon of gasLrlc acld secreLlon
1herapeut|c Lffects
4 Peallng and prevenLlon of ulcers
4 uecreased sympLoms of gasLroesophageal reflux
4 uecreased secreLlon of gasLrlc acld
nAkMACCkINL1ICS
Absorpt|onooltlJloe30 absorbed afLer C and lM admlnlsLraLlon
Metabo||sm and Lxcret|on ooltlJloemeLabollzed by Lhe llver mosLly on flrsL pass 30 excreLed unchanged by Lhe kldneys afLer C admlnlsLraLlon 7080
afLer parenLeral admlnlsLraLlon
na|f||fe tooltlJloe173 hr (all are lncreased ln renal lmpalrmenL)
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contra|nd|cated |n
PypersenslLlvlLy
CrosssenslLlvlLy may occur
Some oral llqulds conLaln alcohol and should be avolded ln paLlenLs wlLh known lnLolerance
Use Caut|ous|y |n
77

8enal lmpalrmenL (more suscepLlble Lo adverse C-S reacLlons lncreased dosage lnLerval recommended for tooltlJloe lf CCr 30 ml/mln
CerlaLrlc paLlenLs (more suscepLlble Lo adverse C-S reacLlons dosage reducLlon recommended)
regnancy or lacLaLlon
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
*CAl1ALS lndlcaLe llfe LhreaLenlng underllnes lndlcaLe mosL frequenL

CNS confuslon dlzzlness drowslness halluclnaLlons headache
CV A88P?1PMlAS
GI nausea
GU decreased sperm counL lmpoLence
Lndo gynecomasLla
nemat AC8A-uLCC?1CSlS ALAS1lC A-LMlA anemla neuLropenla LhrombocyLopenla
Loca| paln aL lM slLe
M|sc hypersenslvlLy reacLlons
IN1LkAC1ICNS
DrugDrug
ranlLldlne have a much smaller and less slgnlflcanL effecL on Lhe meLabollsm of oLher drugs
Lhe agenLs decrease Lhe absorpLlon of ketoconazo|e
Antac|ds and sucra|fate decrease absorpLlon of Lhe agenLs
C|ar|thromyc|n lncreases ranlLldlne levels
kCU1L AND DCSAGL
kan|t|d|ne
IV IM (Adu|ts) 30 mg q 68 hr (noL Lo exceed 400 mg/day) otlooos lv lofoslo623 mg/hr Costtlc bypetsectetty coJltlos1 mg/kg/hr may be
lncreased by 03 mg/kg/hr (noL Lo exceed 23 mg/kg/hr)
78

kena| Impa|rment
C (Adu|ts) t50 ml/mlo130 mg q 24 hr may be lncreased Lo 130 mg q 12 hr or more frequenLly lf necessary furLher reducLlons may be necessary lf
Lhere ls coexlsLenL hepaLlc lmpalrmenL
1lML/AC1lC- 8CllLL

CNSL1 LAk DUkA1ICN

8anlLldlne lv unknown 13 mln 812 hr

NUkSING IMLICA1ICNS
ASSLSSMLN1
Assess paLlenL for eplgasLrlc or abdomlnal paln and frank or occulL blood ln Lhe sLool emesls or gasLrlc asplraLe
Assess gerlaLrlc and deblllLaLed paLlenLs rouLlnely for confuslon 8eporL prompLly
Lob 1est considerotions C8C wlLh dlfferenLlal should be monlLored perlodlcally LhroughouL Lherapy
4 AnLagonlze effecLs of penLagasLrln and hlsLamlne durlng gasLrlc acld secreLlon LesLlng Avold admlnlsLraLlon for 24 hr before Lhe LesL
4 May cause falsenegaLlve resulLs ln skln LesLs uslng allergenlc exLracLs PlsLamlne P
2
anLagonlsLs should be dlsconLlnued 24 hr before Lhe LesL
4 May cause an lncrease ln serum Lransamlnases and serum creaLlnlne
4 ooltlJloe may cause falseposlLlve resulLs for urlne proLeln LesL wlLh sulfosallcyllc acld
C1LN1IAL NUkSING DIAGNCSLS
aln (lndlcaLlons)
knowledge deflclL relaLed Lo medlcaLlon reglmen (aLlenL/lamlly 1eachlng)
IMLLMLN1A1ICN
79

Genera| Info lf anLaclds or sucralfaLe are used concurrenLly for rellef of paln avold admlnlsLraLlon of anLaclds wlLhln 30 mln1 hr of Lhe hlsLamlne P
2

anLagonlsL and Lake sucralfaLe 2 hr afLer hlsLamlne P
2
anLagonlsL may decrease Lhe absorpLlon of hlsLamlne P
2
anLagonlsLs
C AdmlnlsLer wlLh meals or lmmedlaLely afLerward and aL bedLlme Lo prolong effecL
4 uoses admlnlsLered once dally should be admlnlsLered aL bedLlme Lo prolong effecL
4 Shake oral suspenslon before admlnlsLraLlon ulscard unused suspenslon afLer 30 days
kan|t|d|ne
D|rect IV ulluLe each 30 mg ln 20 ml of 09 -aCl or u3W for ln[ecLlon
ote AdmlnlsLer over aL leasL 3 mln 8apld admlnlsLraLlon may cause hypoLenslon and arrhyLhmlas
Interm|ttent Infus|on ulluLe each 30 mg ln 100 ml of 09 -aCl or u3W ulluLed soluLlon ls sLable for 48 hr aL room LemperaLure uo noL use soluLlon LhaL
ls dlscolored or LhaL conLalns preclplLaLe
ote AdmlnlsLer over 1320 mln
Cont|nuous Infus|on Add ranlLldlne Lo u3W for a concenLraLlon of 130 mg/230 ml (no greaLer Lhan 23 mg/ml for ZolllngerLlllson paLlenLs)
ote AdmlnlsLer aL a raLe of 623 mg/hr ln paLlenLs wlLh ZolllngerLlllson syndrome sLarL lnfuslon aL 1 mg/kg/hr lf gasLrlc acld ouLpuL ls 10 mLq/hr or
paLlenL becomes sympLomaLlc afLer 4 hr ad[usL dose by 03 mg/kg/hr lncremenLs and remeasure gasLrlc ouLpuL
4 poLasslum chlorlde
4 Llcarclllln
4 Lobramycln
4 vancomycln
Add|t|ve Incompat|b|||ty
4 amphoLerlcln 8
4 cllndamycln
A1ILN1]IAMIL 1LACnING
Genera| Info lnsLrucL paLlenL Lo Lake medlcaLlon as dlrecLed for Lhe full course of Lherapy even lf feellng beLLer lf a dose ls mlssed lL should be Laken as
soon as remembered buL noL lf almosL Llme for nexL dose uo noL double doses
4 Advlse paLlenLs Laklng C1C preparaLlons noL Lo Lake Lhe maxlmum dose conLlnuously for more Lhan 2 wk wlLhouL consulLlng healLh care
professlonal -oLlfy healLh care professlonal lf dlfflculLy swallowlng occurs or abdomlnal paln perslsLs
4 lnform paLlenL LhaL smoklng lnLerferes wlLh Lhe acLlon of hlsLamlne anLagonlsLs Lncourage paLlenL Lo qulL smoklng or aL leasL noL Lo smoke afLer
lasL dose of Lhe day
80

4 May cause drowslness or dlzzlness CauLlon paLlenL Lo avold drlvlng or oLher acLlvlLles requlrlng alerLness unLll response Lo Lhe drug ls known
4 Advlse paLlenL Lo avold alcohol producLs conLalnlng asplrln or -SAlus and foods LhaL may cause an lncrease ln Cl lrrlLaLlon
4 lnform paLlenL LhaL lncreased fluld and flber lnLake and exerclse may mlnlmlze consLlpaLlon
4 Advlse paLlenL Lo reporL onseL of black Larry sLools fever sore LhroaL dlarrhea dlzzlness rash confuslon or halluclnaLlons Lo healLh care
professlonal prompLly
LVALUA1ICN
Lffect|veness of therapy can be demonstrated by
uecrease ln abdomlnal paln
revenLlon and LreaLmenL of gasLrlc lrrlLaLlon and bleedlng Peallng of duodenal ulcers can be seen by xrays or endoscopy 1herapy ls conLlnued for aL
leasL 6 wk ln LreaLmenL of ulcers buL noL usually longer Lhan 8 wk
uecreased sympLoms of esophageal reflux
1reaLmenL of hearLburn acld lndlgesLlon and sour sLomach (C1C use)
8 Ceftr|axone 1 Amp IV11 every 8 hours
CEPHALOSPORINS-THIRD GENERATION
ceftriaxone
(seI-try-ax-one)
Rocephin
C$$IFIC1IOA($):
1her. Class: anti-infectives
!harm. Class: third-generation ce5halos5orins

Pregnancy Category

81

INDICA1ICNS
Treatment oI:
4 Skin and skin structure inIections
4 Bone and joint inIections
4 Urinary and gynecologic inIections including gonorrhea or respiratory tract inIections
4 Intra-abdominal inIections
4 Septicemia
4 Otitis media (ceIdinir)
Ceftriaxone: Single-dose treatment oI acute bacterial otitis media
AC1ICN
Bind to the bacterial cell wall membrane, causing cell death.
Therapeutic Effects:
4 Bactericidal action against susceptible bacteria.
Spectrum:
4 Similar to that oI second-generation cephalosporins, but activity against staphylococci is less, whereas activity against gram-negative pathogens is greater, even Ior organisms
resistant to Iirst- and second-generation agents
4 Notable is increased action against
4 Enterobacter
4 aemo5hilus influen:ae
4 Escherichia coli
4 lebsiella 5neumoniae
4 Neisseria
4 Proteus
4 Providencia
4 Serratia
4 Moraxella catarrhalis
4 orrelia burgdorferi
4 Some agents have enhanced activity against:
4 Pseudomonas aeruginosa (ceItazidime, ceIoperazone)
4 All except ceIixime, ceItibuten, and ceIpodoxime have some activity against anaerobes, including acteroides fragilis.
nAkMACCkINL1ICS
Absorption: Well absorbed aIter IM administration. Cefixime, ceftibuten,and cef5odoxime are well absorbed aIter oral administration (ceIixime suspension produces higher blood levels than
tablets); cefdinir 1625 absorbed aIter oral administration. CeItidoren is a prodrug and is broken down prior to absorption (14 absorbed).
82

Distribution: Widely distributed. Cross the placenta; enter breast milk in low concentrations. CSF penetration better than with Iirst- and second-generation agents.
Protein inding: Cefo5era:one and ceftriaxone K90.
Metabolism and Excretion: Cefdinir, cefe5ime, cefta:idime, cef5odoxime, ceftidoren, and cefti:oxime~85 excreted in urine. Cefixime50 excreted unchanged in urine, K10 excreted in
bile. Cefo5era:oneexcreted in the bile. Ceftibuten, ceftriaxone, and cefotaximepartly metabolized and partly excreted in the urine.
Half-life: Cefdinir102 min; cefditoren100 min; cefe5ime120 min; cefixime180240 min; cefo5era:one102156 min; cefotaxime60 min; cef5odoxime120180 min; cefta:idime
114120 min; ceftibuten120144 min; cefti:oxime84114 min; ceftriaxone348522 min (all except cefo5era:one and ceftriaxone are increased in renal impairment).
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Hypersensitivity to cephalosporins
Serious hypersensitivity to penicillins
Hypersensitivity to L-arginine (Ceptaz Iormulation only).
Carnitine deIiciency or inborn errors oI metabolism (ceIditoren only).
Use Cautiously in:
Combined severe hepatic and renal impairment (dosage reduction/increased dosing interval recommended Ior ceftriaxone)
History oI GI disease, especially colitis
Geriatric patients (dosage adjustment due to age-related decrease in renal Iunction may be necessary)
Pregnancy and lactation (have been used saIely).
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

CNS: SEIZURES(high doses).
GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, nausea, vomiting, cramps, pseudolithiasis (ceItriaxone).
Derm: rashes, urticaria.
Hemat: bleeding (increased with ceIoperazone), blood dyscrasias, hemolytic anemia.
Local: painat IM site, phlebitisat IV site.
Misc: allergic reactions includingANAPHYLAXIS andSERUM SICNESS, superinIection.
IN1LkAC1ICNS
Drug-Drug:
83

Ingestion oI alcohol within 4872 hr oI ceIoperazone may result in a disulIiram-like reaction
CeIoperazone may potentiate the eIIects oI anticoagulants and increase the risk oI bleeding with antiplatelet agents, thrombolytics, plicamycin, or valproic acid
Concurrent use oI large doses oI cephalosporins and NSAIDs may increase the risk oI bleeding
Concurrent use oI loop diuretics ornephrotoxic agents including aminoglycosidesmay increase the risk oI nephrotoxicity
Antacids decrease absorption oI ceIdinir and ceIpodoxime (take 2 hr beIore or aIter antacid)
Iron supplements decrease absorption oI ceIdinir (administer 2 hr beIore or 2 hr aIter)
Antacids and H

receptor antagonists decrease absorption oI ceIditoren (avoid concurrent use).


Drug-Natural:
Risk oI bleeding with cefoperazone may be increased by angelica, anise, arnica, asafoetida, bogbean, boldo, celery, chamomile, clove, danshen, fenugreek, feverfe, garlic, ginger,
ginkgo, Panax ginseng, horse chestnut, horseradish, licorice, meadoseet, prickly ash, onion, papain, passionfloer, poplar, quassia, red clover, turmeric, ild carrot, ild
lettuce, illo, and others.
kCU1L AND DCSAGL
Ceftriaxone
IM, IV (Adults): Most infections0.51 g q 12 hr
AVAILABILITY
4 Ceftriaxone
!owder for injection: 250 mg
Rx
, 500 mg
Rx
, 1 g
Rx
, 2 g
Rx
, 10 g
Rx

!remixed containers: 1 g/50 ml
Rx
, 2 g/50 ml
Rx
.
TIME/ACTION PROFILE

ONSET PEA DURATION

CeItriaxone IV Rapid end oI
inIusion
1224 hr

84

NUkSING IMLICA1ICNS
ASSESSMENT
Assess patient Ior inIection (vital signs; appearance oI wound, sputum, urine, and stool; WBC) at beginning oI and throughout therapy.
BeIore initiating therapy, obtain a history to determine previous use oI and reactions to penicillins or cephalosporins. Persons with a negative history oI penicillin sensitivity may still have
an allergic response.
Obtain specimens Ior culture and sensitivity beIore initiating therapy. First dose may be given beIore receiving results.
Observe patient Ior signs and symptoms oI anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notiIy the physician or other health care proIessional
immediately iI these symptoms occur. eep epinephrine, an antihistamine, and resuscitation equipment close by in the event oI an anaphylactic reaction.
ab 1est Considerations: May cause positive results Ior Coombs' test in patients receiving high doses or in neonates whose mothers were given cephalosporins beIore delivery.
4 Monitor prothrombin time and assess patient Ior bleeding (guaiac stools; check Ior hematuria, bleeding gums, ecchymosis) daily in patients receiving cefo5era:one or cefditoren,
as this agent may cause hypoprothrombinemia.
4 May cause increased serum AST, ALT, alkaline phosphatase, bilirubin, LDH, BUN, and creatinine.
4 May rarely cause leukopenia, neutropenia, agranulocytosis, thrombocytopenia, eosinophilia, lymphocytosis, and thrombocytosis.
POTENTIAL NURSING DIAGNOSES
InIection, risk Ior (Indications, Side EIIects).
Diarrhea (Adverse Reactions).
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
IMPLEMENTATION
IV: Monitor injection site Irequently Ior phlebitis (pain, redness, swelling). Change sites every 4872 hr to prevent phlebitis.
4 II aminoglycosides are administered concurrently, administer in separate sites, iI possible, at least 1 hr apart. II second site is unavailable, Ilush lines between medications.
Direct IV: Dilute in at least 1 g/10 ml. Avoid direct IV administration oI cefo5era:one and ceftriaxone. Do not use preparations containing benzyl alcohol Ior neonates.
Rate: Administer slowly over 35 min.
Ceftriaxone
Intermittent Infusion: Reconstitute each 250-mg vial with 2.4 ml, each 500-mg vial with 4.8 ml, each 1-g vial with 9.6 ml, and each 2-g vial with 19.2 ml oI sterile water Ior injection,
0.9 NaCl, or D5W Ior a concentration oI 100 mg/ml. Solution may be Iurther diluted in 50100 ml oI 0.9 NaCl, D5W, D10W, D5/0.45 NaCl, or LR. Solution may appear light yellow
to amber. Solution is stable Ior 3 days at room temperature.
Rate: Administer over 1530 min in adults and 1030 min in newborns or children.
PATIENT/AMILY TEACHING
85

Instruct patient to take medication at evenly spaced times and to Iinish the medication completely, even iI Ieeling better. Missed doses should be taken as soon as possible unless almost
time Ior next dose; do not double doses. Advise patient that sharing oI this medication may be dangerous.
Advise patient to report signs oI superinIection (Iurry overgrowth on the tongue, vaginal itching or discharge, loose or Ioul-smelling stools) and allergy.
Caution patients that concurrent use oI alcohol with cefo5era:one may cause a disulIiram-like reaction (abdominal cramps, nausea, vomiting, headache, hypotension, palpitations, dyspnea,
tachycardia, sweating, Ilushing). Alcohol and alcohol-containing medications should be avoided during and Ior several days aIter therapy.
Instruct patient to notiIy health care proIessional iI Iever and diarrhea develop, especially iI stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting
health care proIessional.
Cefditoren: InIorm Iemale patients that ceIditoren can be taken concomitantly with hormonal contraceptives.
EVALUATION
Clinical response to therapy can be evaluated by:
Resolution oI the signs and symptoms oI inIection. Length oI time Ior complete resolution depends on the organism and site oI inIection
Decreased incidence oI inIection when used Ior prophylaxis.
Lansoprazo|e 30 mg 1 cap CD
LANSOPRAZOLE
(lan-soe-pra-zole)
Prevacid
C$$IFIC1IOA($):
1her. Class: antiulcer agents
!harm. Class: 5roton 5um5 inhibitors

Pregnancy Category

INDICA1ICNS
Treatment oI erosive esophagitis
Management oI duodenal ulcers (with or without anti-inIectives Ior elicobacter 5ylori)
Treatment oI active benign gastric ulcer
86

Short-term treatment oI symptomatic GERD
Healing and risk reduction oI NSAID-assoicated gastric ulcer
Treatment oI pathologic hypersecretory conditions, including Zollinger-Ellison syndrome.
AC1ICN
Binds to an enzyme in the presence oI acidic gastric pH, preventing the Iinal transport oI hydrogen ions into the gastric lumen.
Therapeutic Effects:
4 Diminished accumulation oI acid in the gastric lumen, with lessened acid reIlux
4 Healing oI duodenal ulcers and esophagitis.
nAkMACCkINL1ICS
Absorption: 80 absorbed aIter oral administration.
Distribution: Unknown.
Protein inding: 97.
Metabolism and Excretion: Extensively metabolized by the liver to inactive compounds. Converted intracellularly to at least two other antisecretory compounds.
Half-life: Less than 2 hr (increased in geriatric patients and patients with impaired hepatic Iunction).
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Hypersensitivity.
Use Cautiously in:
Geriatric patients (maintenance dose should not exceed 30 mg/day unless additional acid suppression is required)
Severe hepatic impairment (not to exceed 30 mg/day in these patients)
Pregnancy, lactation, or children 18 yr (saIety not established).
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

CNS: dizziness, headache.
87

GI: diarrhea, abdominal pain, nausea.
Derm: rash.
IN1LkAC1ICNS
Drug-Drug:
Sucralfate decreases absorption oI lansoprazole (take 30 min beIore sucralIate)
May decrease absorption oI drugs requiring acid pH, including ketoconazole, itraconazole, ampicillin esters, iron salts, and digoxin.
kCU1L AND DCSAGL
PO (Adults): Short-term treatment of duodenal ulcer15 mg once daily Ior 4 wk; maintenance of healed duodenal ulcers15 mg once daily; short term treatment of gastric
ulcers/healing of NSAID-associated gastric ulcer30 mg once daily Ior up to 8 wk; risk reduction of NSAID-associated gastric ulcer15 mg once daily Ior up to 12 wk; short-term
treatment of sym5tomatic GERD15 mg once daily Ior up to 8 wk; short-term treatment of erosive eso5hagitis30 mg once daily Ior up to 8 wk (8 additional weeks may be necessary);
maintenance of healing of erosive eso5hagitis15 mg once daily; 5athologic hy5ersecretory conditions60 mg once daily intially, up to 90 mg twice daily (daily dose ~120 mg should be
given in divided doses).
AVAILA8ILI1
elayed-release capsules: 15 mg
Rx
, 30 mg
Rx

Cost: 15 mg $126.08/30; 30 mg $191.56/100
In combination with: amoxicillin and clarithromycin as part oI a compliance package (Prevpac)
Rx
.
TIME/ACTION PROFILE (acid suppression)

ONSET PEA DURATION

PO rapid unknown more than 24
hr

88

NUkSING IMLICA1ICNS
ASSESSMENT
Assess patient routinely Ior epigastric or abdominal pain and Ior Irank or occult blood in stool, emesis, or gastric aspirate.
ab 1est Considerations: May cause abnormal liver Iunction tests, including increased AST, ALT, alkaline phosphatase, LDH, and bilirubin.
4 May cause increased serum creatinine and increased or decreased electrolyte levels.
4 May alter RBC, WBC, and platelet levels.
4 May also cause increased gastrin levels, abnormal A/G ratio, hyperlipidemia, and increased or decreased cholesterol.
POTENTIAL NURSING DIAGNOSES
Pain (Indications).
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
IMPLEMENTATION
PO: Administer beIore meals. Capsules may be opened and sprinkled on 1 tbsp oI applesauce, pudding, cottage cheese, or yogurt and swallowed immediately Ior patients with diIIiculty
swallowing. Do not crush or chew capsule contents.
4 For patients with an NG tube, capsules may be opened and intact granules may be mixed in 40 ml oI apple, cranberry, grape, orange, pineapple, prune, or V8 vegetable juice and
injected through the NG tube into stomach. Flush NG tube with additional apple juice to clear tube. II administered via jejunostomy tube, lansoprazole should be prepared as a
suspension with 2.5 ml oI 4.2 sodium bicarbonate and 2.5 ml water.
4 Antacids may be used concurrently.
PATIENT/AMILY TEACHING
Instruct patient to take medication as directed Ior the Iull course oI therapy, even iI Ieeling better.
Advise patient to avoid alcohol, products containing aspirin or NSAIDs, and Ioods that may cause an increase in GI irritation.
May occasionally cause dizziness. Caution patient to avoid driving and other activities that require alertness until response to medication is known.
Advise patient to report onset oI black, tarry stools; diarrhea; or abdominal pain to health care proIessional promptly.
EVALUATION
Effectiveness of therapy can be demonstrated by:
Decrease in abdominal pain or prevention oI gastric irritation and bleeding. Healing oI duodenal ulcers can be seen on x-ray examination or endoscopy. Therapy is continued Ior at least 2
4 wk. Therapy Ior pathologic hypersecretory conditions may be long term
89

Healing in patients with erosive esophagitis. Therapy is continued Ior up to 8 wk, and an additional 8-wk course may be used Ior patients who do not heal in 8 wk or whose ulcer recurs.
10 S|mvastat|n 2 mg 1 tab CD qnS
HMG-CoA REDUCTASE INHIITORS
simvastatin
(sim-va-sta-tin)
Zocor
C$$IFIC1IOA($):
1her. Class: li5id-lowering agents

Pregnancy Category X
INDICA1ICNS
Adjunct to dietary therapy in the management oI primary hypercholesterolemia and mixed dyslipidemias
Reduction oI lipids/cholesterol reduces the risk oI MI and stroke sequelae (primary prevention and secondary prevention).
AC1ICN
Inhibit an enzyme, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase, which is responsible Ior catalyzing an early step in the synthesis oI cholesterol.
Therapeutic Effects:
4 Lowering oI total and LDL cholesterol. Increase HDL and decrease VLDL cholesterol and triglycerides
4 Slowing oI the progression oI coronary artery disease with resultant decrease in MI/stroke and need Ior myocardial revascularization.
nAkMACCkINL1ICS
Absorption: simvastatin85 absorbed but rapidly metabolized.
Metabolism and Excretion: All agents are extensively metabolized by the liver simvastatin are metabolized by CYP3A4), most during Iirst pass; excreted in bile and Ieces. Small amounts
(simvastatin13) excreted unchanged by the kidneys.
Half-life:; simvastatinunknown.
90

CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Hypersensitivity
Cross-sensitivity among agents may occur
Active liver disease
Pregnancy or lactation.
Concurrent use oI gemIibrozil or azole antiIungals
Use Cautiously in:
History oI liver disease
Alcoholism
Renal impairment
Severe acute inIection
Hypotension
Major surgery
Trauma
Severe metabolic, endocrine, or electrolyte problems
Uncontrolled seizures
Visual disturbances
Myopathy
Women oI childbearing age
Children 18 yr (saIety not established).
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

CNS: dizziness, headache, insomnia, weakness.
EENT: rhinitis;
Resp: bronchitis.
GI: abdominal cramps, constipation, diarrhea, Ilatus, heartburn, altered taste, drug-induced hepatitis, dyspepsia, elevated liver enzymes, nausea, pancreatitis.
GU: impotence.
Derm: rashes, pruritus.
MS: RHABDOMYOLYSIS, arthralgia, arthritis, myalgia, myositis.
Misc: hypersensitivity reactions.
91

IN1LkAC1ICNS
Drug-Drug:
Atorvastatin, lovastatin and simvastatin may interact with CYP3A inhibitors.
Cholesterol-lowering eIIect may be additive with bile acid sequestrants
Bioavailability and eIIectivenessmay be decreased by bile acid sequestrants
Blood levels and the risk oI myopathy are increased by concurrent cyclosporine and gemfibrozil, clofibrate, erythromycin, large doses oI niacin and azole antifungal agents (combined
use with clofibrate or gemfibrozil contraindicated)
Atorvastatin and Iluvastatin may slightly increase serum digoxin levels
Atorvastatin may increase levels oI hormonal contraceptives
May increase eIIects oI arfarin
Levels aresigniIicantly increased by azole antifungal agents (temporarily discontinue HMG-CoA reductase inhibitor)
Rifampin increases metabolism and may decrease blood levels and eIIects oI Iluvastatin.
Isradipine may decrease the eIIectiveness oI lovastatin
Propranolol decreases blood levels oI simvastatin.
Alcohol, cimetidine, ranitidine, and omeprazole may increase Iluvastatin levels.
Saquinavir may increase blood levels and eIIects oI atorvastatin, lovastatin and simvastatin.
Drug-ood:
Grapefruit juice decreases the enzyme (CYP3A4)which breaks down atorvastatin, lovastatin and simvastatin; this results in higher blood levels and increased risk oI toxicity.
ood enhances blood levels oI lovastatin.
kCU1L AND DCSAGL
Simvastatin
PO (Adults): 510 mg once daily in the evening. Geriatric 5atients, 5atients with LDL 190 mg/dl, or 5atients receiving cyclos5orine5 mg/day initially. Increase at 4-wk intervals (not
to exceed 10 mg/day in patients receiving cyclosporine) up to 40 mg/day.
AVAILA8ILI1
4 Simvastatin
1ablets: 5 mg
Rx
, 10 mg
Rx
, 20 mg
Rx
, 40 mg
Rx
, 80 mg
Rx

Cost: 5 mg $106.84/60, 10 mg $214.79/60, 20 mg $249.80/60, 40 mg $249.80/60, 80 mg $249.80/60.
92

TIME/ACTION PROFILE (cholesterol-lowering eIIect)

ONSET PEA DURATION

Simvastatin unknown unknown unknown

f
AIter discontinuation.
NUkSING IMLICA1ICNS
ASSESSMENT
Obtain a dietary history, especially with regard to Iat consumption.
Ophthalmic exams are recommended beIore and yearly throughout therapy.
ab 1est Considerations: Serum cholesterol and triglyceride levels should be evaluated beIore initiating, aIter 46 wk oI therapy, and periodically thereaIter.
4 Liver Iunction tests, including AST, should be monitored beIore, at 612 wk aIter initiation oI therapy or aIter dose elevation, and then every 6 mo. II AST levels increase to 3
times normal, HMG-CoA reductase inhibitor therapy should be discontinued. May also cause elevated alkaline phosphatase and bilirubin levels.
4 II patient develops muscle tenderness during therapy, CP levels should be monitored. II CP levels are markedly increased or myopathy occurs, therapy should be discontinued.
4 May cause thyroid Iunction test abnormalities.
POTENTIAL NURSING DIAGNOSES
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
Noncompliance (Patient/Family Teaching).
IMPLEMENTATION
PO:Administer simvastatin once daily in the evening. May be administered without regard to Iood.
PATIENT/AMILY TEACHING
Instruct patient to take medication exactly as directed and not to skip doses or double up on missed doses. Medication helps control but does not cure elevated serum cholesterol levels.
Advise patient that this medication should be used in conjunction with diet restrictions (Iat, cholesterol, carbohydrates, alcohol), exercise, and cessation oI smoking.
Instruct patient to notiIy health care proIessional iI unexplained muscle pain, tenderness, or weakness occurs, especially iI accompanied by Iever or malaise.
Advise patient to wear sunscreen and protective clothing to prevent photosensitivity reactions (rare).
Instruct Iemale patients to notiIy health care proIessional promptly iI pregnancy is planned or suspected.
93

Advise patient to notiIy health care proIessional oI medication regimen beIore treatment or surgery.
Emphasize the importance oI Iollow-up exams to determine eIIectiveness and to monitor Ior side eIIects.
EVALUATION
Effectiveness of therapy can be demonstrated by:
Decrease in serum LDL, VLDL, and total cholesterol levels
4 Increase in HDL cholesterol levels
4 Decrease in triglyceride levels
Slowing oI the progression oI coronary artery disease.
11 Ang|max 1 tab 1ID
ClasslflcaLlon LrlmeLazldlne dlPCL
lndlcaLlon LreaLmenL of lschemlc hearL dlsease anglna pecLorls sequelae of lnfarcLlon
uosage 3 Lab/day afLer meals
12 IeSC4 w|th IA 1 tab 8ID
IRON SUPPLEMENTS
ferrous sulfate (30 elemental iron)
(fer-us sul-Iate)
Apo-Ferrous SulIate, ED-IN-SOL, Fe50, Feosol, Feratab, Fer-gen-sol, Fer-In-Sol, Fer-Iron, Fero-Grad, NovoIerrosulIa, PMS Ferrous SulIate, Slow FE
C$$IFIC1IOA($):
1her. Class: antianemics
!harm. Class: iron su55lements

94

Pregnancy Category (sodium ferric gluconate, iron sucrose), C (iron dextran)


INDICA1ICNS
PO: Prevention/treatment oI iron-deIiciency anemia
IM, IV: Iron dextranTreatment/prevention oI iron-deIiciency anemia in patients who cannot tolerate oral iron.
Sodium ferric gluconate com5lex, iron sucroseTreatment oI iron deIiciency in patients undergoing chronic hemodialysis who are concurrently receiving erythropoietin.
AC1ICN
An essential mineral Iound in hemoglobin, myoglobin, and many enzymes
Parenteral iron enters the bloodstream and organs oI the reticuloendothelial system (liver, spleen, bone marrow), where iron is separated out and becomes part oI iron stores.
Therapeutic Effects:
4 Prevention/treatment oI iron deIiciency.
nAkMACCkINL1ICS
Absorption: 510 oI dietary iron is absorbed. In deIiciency states, this increases up to 30. Therapeutically administered PO iron may be 60 absorbed; absorption is an active and passive
transport process. Well absorbed Iollowing IM administration.
Distribution: Remains in the body Ior many months. Crosses the placenta; enters breast milk.
Protein inding: K90.
Metabolism and Excretion: Mostly recycled; small daily losses occurring via desquamation, sweat, urine, and bile.
Half-life: Iron dextran, iron sucrose6 hr.
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Primary hemochromatosis
Hemolytic anemias and other anemias not due to iron deIiciency
Some products contain alcohol, tartrazine, or sulIites and should be avoided in patients with known intolerance or hypersensitivity
Concurrent oral iron therapy
95

Use Cautiously in:
PO: Peptic ulcer
Ulcerative colitis or regional enteritis (condition may be aggravated)
Indiscriminate chronic use (may lead to iron overload)
Geriatric patients (lower initial dose may be recommended)
Lactation or children (saIety oI some parenteral products not established)
Exercise Extreme Caution in:
Geriatric patients (lower initial dose may be recommended)
Lactation or children (saIety oI some parenteral products not established)
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

Misc: POstaining oI teeth (liquid preparations); IM, IJallergic reactions including ANAPHYLAXIS, Iever, lymphadenopathy.
IN1LkAC1ICNS
Drug-Drug:
Tetracycline and antacids inhibit the oral absorption oI iron by Iorming insoluble compounds
Oral iron supplements decrease the absorption oI Tetracyclines, fluoroquinolones, and penicillamine (simultaneous administration should be avoided)
Decreases absorption oI and may decrease eIIects oI levodopa and methyldopa
May decrease the eIIicacy oI levothyroxine(concurrent administration should be avoided)
Concurrent administration oI cimetidine may decrease absorption
Doses oI ascorbic acid K200 mg may enhance absorption by K30
Chloramphenicol and vitamin E may impair the hematologic response to iron therapy
Drug-ood:
Iron absorption is decreased by 3350 by concurrent administration oI Iood.
96

kCU1L AND DCSAGL
errous Sulfate
PO (Adults): Pro5hylactic300325 mg/day. Thera5eutic300 mg 24 times daily. Timed-release tablets may be given twice daily. .
AVAILA8ILI1
4 errous Sulfate (0-30 Elemental Iron)
1ablets: 195 mg
OTC
, 300 mg
OTC
, 325 mg
OTC

Cost: 324 mg $0.75/30 .
TIME/ACTION PROFILE (eIIects on erythropoiesis)

ONSET PEA DURATION

PO 4 days 710 days 24 mo

NUkSING IMLICA1ICNS
ASSESSMENT
Assess patient's nutritional status and dietary history to determine possible cause oI anemia and need Ior patient teaching.
Assess bowel Iunction Ior constipation or diarrhea. NotiIy physician or other health care proIessional and use appropriate nursing measures should these occur.
Assess patient Ior signs and symptoms oI anaphylaxis (rash, pruritus, laryngeal edema, wheezing). NotiIy physician immediately iI these occur. eep epinephrine and resuscitation
equipment close by in the event oI an anaphylactic reaction.
ab 1est Considerations: Hemoglobin, hematocrit, and reticulocyte values should be monitored prior to and every 3 wk during the Iirst 2 mo oI therapy and periodically thereaIter. Serum
Ierritin and iron levels may also be monitored to assess eIIectiveness oI therapy.
4 Occult blood in stools may be obscured by black coloration oI iron in stool. Guaiac test results may occasionally be Ialse-positive. Benzidine test results are not aIIected by iron
preparations.
4 May impart a brownish hue to blood drawn within 4 hr oI administration. May cause Ialse increase in serum bilirubin and Ialse decrease in serum calcium values.
4 Prolonged PTT may be calculated when blood sample is anticoagulated with citrate dextrose solution; use sodium citrate instead.
4 may cause elevated liver enzymes.
97

1oxicity and Overdose: Early symptoms oI overdose include stomach pain, Iever, nausea, vomiting (may contain blood), and diarrhea. Late symptoms include bluish lips, Iingernails, and
palms; drowsiness; weakness; tachycardia; seizures; metabolic acidosis; hepatic injury; and cardiovascular collapse. The patient may appear to recover prior to the onset oI late symptoms.
ThereIore, hospitalization continues Ior 24 hr aIter patient becomes asymptomatic to monitor Ior delayed onset oI shock or GI bleeding. Late complications oI overdose include intestinal
obstruction, pyloric stenosis, and gastric scarring.
4 Treatment includes inducing emesis with syrup oI ipecac. II patient is comatose or seizing, gastric lavage with sodium bicarbonate is perIormed. DeIeroxamine is the antidote.
Additional supportive treatments to maintain Iluid and electrolyte balance and correction oI metabolic acidosis are also indicated.
4 II signs oI overdose occur during IV administration oI iron sucrose, administration at a slower rate usually relieves symptoms.
POTENTIAL NURSING DIAGNOSES
Activity intolerance (Indications).
nowledge deIicit (related to medication and dietary regimen) (Patient/Family Teaching).
IMPLEMENTATION
General Info: Oral iron preparations should be discontinued prior to parenteral administration.
4 Ferrlecit is Ior IV use only.
PO: Oral preparations are most eIIectively absorbed iI administered 1 hr beIore or 2 hr aIter meals. II gastric irritation occurs, administer with meals. Tablets and capsules should be taken
with a Iull glass oI water or juice. Do not crush or chew enteric-coated tablets and do not open capsules.
4 Liquid preparations may stain teeth. Dilute in water or Iruit juice, Iull glass (240 ml) Ior adults and 1/2 glass (120 ml) Ior children, and administer with a straw or place drops at
back oI throat. Feosol elixir should be diluted in water only. Fer-In-Sol liquid or syrup may be diluted in water or Iruit juice.
4 Avoid using antacids, coIIee, tea, dairy products, eggs, or whole-grain breads with or within 1 hr aIter administration oI Ierrous salts. Iron absorption is decreased by 33 iI iron
and calcium are given with meals. II calcium supplementation is needed, calcium carbonate does not decrease absorption oI iron salts iI supplements are administered between
meals.
PATIENT/AMILY TEACHING
General Info: Encourage patient to comply with medication regimen. II a dose is missed, take as soon as remembered within 12 hr; otherwise, return to regular dosing schedule. Do not
double doses.
Advise patient that stools may become dark green or black and that this change is harmless.
Instruct patient to Iollow a diet high in iron .
Discuss with parents the risk oI children's overdosing on iron. Medication should be stored in the original childprooI container and kept out oI reach oI children. Do not reIer to vitamins as
candy. Medical help should be sought immediately iI overdose is suspected, as death may occur. Parents should have syrup oI ipecac at home but call pediatrician, emergency department,
or poison control center Ior instructions beIore administering.
EVALUATION
Clinical response to therapy can be evaluated by:
98

Increase in hemoglobin, which may reach normal parameters aIter 12 mo oI therapy. May require 36 mo Ior normalization oI body iron stores
Increase in hemoglobin, hematocrit, and plasma iron levels with iron dextran. The diagnosis oI iron-deIiciency anemia should be reconIirmed iI hemoglobin has not increased by 1 g/100 ml
in 2 wk
Improvement in anemia oI chronic renal Iailure.
13 C||ndamyc|n 30 mg IV11 qvery 8 hours

CLINDAMYCIN
(klin-da-mye-sin)
Cleocin, Cleocin T, Clinda-Derm, Clindets, C/T/S, Dalacin C , Dalacin T
C$$IFIC1IOA($):
1her. Class: anti-infectives

Pregnancy Category

INDICA1ICNS
PO, IM, IV: Treatment oI:
4 Skin and skin structure inIections
4 Respiratory tract inIections
4 Septicemia
4 Intra-abdominal inIections
4 Gynecologic inIections
4 Osteomyelitis
4 Endocarditis prophylaxis
Unlabelled Uses:
4 PO, IM, IV: Treatment oI Pneumocystis carinii pneumonia, CNS toxoplasmosis, and babesiosis.
99

AC1ICN
Inhibits protein synthesis in susceptible bacteria at the level oI the 50S ribosome.
Therapeutic Effects:
4 Bactericidal or bacteriostatic, depending on susceptibility and concentration.
Spectrum:
4 Active against most gram-positive aerobic cocci, including:
4 Staphylococci
4 Stre5tococcus 5neumoniae
4 Other streptococci, but not enterococci
4 Also active against P. carinii and Toxo5lasma gondii .
nAkMACCkINL1ICS
Absorption: Well absorbed Iollowing PO/IM administration. Minimal absorption Iollowing topical/vaginal use.
Distribution: Widely distributed. Does not signiIicantly cross blood-brain barrier. Crosses the placenta; enters breast milk.
Protein inding: 90.
Metabolism and Excretion: Mostly metabolized by the liver.
Half-life: 23 hr.
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Hypersensitivity
Previous pseudomembranous colitis
Severe liver impairment
Diarrhea
nown alcohol intolerance (topical solution, suspension).
Use Cautiously in:
Pregnancy or lactation (saIety not established Ior systemic and topical; vaginal approved Ior use in 3rd trimester oI pregnancy).
100

ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

CNS: dizziness, headache, vertigo.
CV: arrhythmias, hypotension.
GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, bitter taste (IV only), nausea, vomiting.
Derm: rashes.
Local: phlebitis at IV site.
IN1LkAC1ICNS
Drug-Drug:
aolin/pectin may decrease GI absorption
May enhance the neuromuscular blocking action oI other neuromuscular blocking agents
Topical: Concurrent use with irritants, abrasives, or desquamating agents may result in additive irritation.
kCU1L AND DCSAGL
PO (Adults): Most infections150300 mg q 6 hr. P. carini5neumonia12001800 mg/day in divided doses with 1530 mg primaquine/day (unlabeled). CNS toxo5lasmosis1200
2400 mg/day in divided doses with pyrimethamine 50100 mg/day (unlabeled).
AVAILA8ILI1
Injection: 150 mg/ml
Rx

TIME/ACTION PROFILE (blood levels)

ONSET PEA DURATION

IV rapid end oI
inIusion
68 hr

101

NUkSING IMLICA1ICNS
ASSESSMENT
Assess patient Ior inIection (vital signs; appearance oI wound, sputum, urine, and stool; WBC) at beginning oI and throughout therapy.
Obtain specimens Ior culture and sensitivity prior to initiating therapy. First dose may be given beIore receiving results.
Monitor bowel elimination. Diarrhea, abdominal cramping, Iever, and bloody stools should be reported to health care proIessional promptly as a sign oI pseudomembranous colitis. This
may begin up to several weeks Iollowing the cessation oI therapy.
Assess patient Ior hypersensitivity (skin rash, urticaria).
ab 1est Considerations: Monitor CBC; may cause transient decrease in leukocytes, eosinophils, and platelets.
4 May cause elevated alkaline phosphatase, bilirubin, CP, AST, and ALT concentrations.
POTENTIAL NURSING DIAGNOSES
InIection, risk Ior (Indications, Side EIIects).
Diarrhea (Side EIIects).
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
IMPLEMENTATION
Intermittent Infusion: Do not administer as an undiluted IV bolus. Dilute each 300 or 600 mg Ior IV administration with at least 50 ml and 900 or 1200 mg with at least 100 ml oI D5W,
D10W, D5/0.45 NaCl, D5/0.9 NaCl, D5/Ringer's injection, 0.9 NaCl, or LR Ior injection. Stable Ior 24 hr at room temperature. Crystals may occur iI reIrigerated, but dissolve when
warmed to room temperature. Do not administer solution with undissolved crystals.
Rate: Administer each 300 mg over a minimum oI 10 min. Do not give more than 1200 mg in a single 1-hr inIusion.
Continuous Infusion: May also be initially administered as a single rapid inIusion, Iollowed by continuous IV inIusion.
Rate: May also administer at an inIusion rate oI 1020 mg/min Ior 30 min, Iollowed by a continuous inIusion rate oI 0.751.25 mg/min.
PATIENT/AMILY TEACHING
General Info: Instruct patient to take medication around the clock at evenly spaced times and to Iinish the drug completely as directed, even iI Ieeling better. II a dose is missed, take as
soon as possible unless almost time Ior next dose. Do not double doses. Advise patient that sharing oI this medication may be dangerous.
4 Instruct patient to notiIy health care proIessional immediately iI diarrhea, abdominal cramping, Iever, or bloody stools occur and not to treat with antidiarrheals without consulting
health care proIessional.
4 Advise patient to report signs oI superinIection (Iurry overgrowth on the tongue, vaginal or anal itching or discharge).
4 NotiIy health care proIessional iI no improvement within a Iew days.
4 Patients with a history oI rheumatic heart disease or valve replacement need to be taught the importance oI antimicrobial prophylaxis beIore invasive medical or dental procedures .
IV: InIorm patient that bitter taste occurring with IV administration is not clinically signiIicant.
102

EVALUATION
Clinical response to therapy can be evaluated by:
Resolution oI the signs and symptoms oI inIection. Length oI time Ior complete resolution depends on the organism and site oI inIection
Endocarditis prophylaxis
Improvement in acne vulgaris lesions. Improvement should be seen in 6 wk but may take 812 wk Ior maximum beneIit.
14 Sa|butamo| 1 Neb 1ID 6210

ALUTEROL
(al-byoo-ter-ole)
AccuNeb, Airet, Gen-Salbutamol, Novo-Salmol, Proventil, salbutamol, Ventodisk, Ventolin, Volmax
C$$IFIC1IOA($):
1her. Class: bronchodilators
!harm. Class: adrenergics

Pregnancy Category C

INDICA1ICNS
Used as a bronchodilator in the management oI reversible airway obstruction caused by asthma or COPD
Inhaln: Used as a quick-relieI agent Ior acute bronchospasm and Ior prevention oI exercise-induced bronchospasm
PO: Used as a long-term control agent in patients with chronic/persistent bronchospasm.
AC1ICN
Binds to beta
2
-adrenergic receptors in airway smooth muscle, leading to activation oI adenylcyclase and increased levels oI cyclic-3', 5'-adenosine monophosphate (cAMP). Increases in
cAMP activate kinases, which inhibit the phosphorylation oI myosin and decrease intracellular calcium. Decreased intracellular calcium relaxes smooth muscle airways
103

Relaxation oI airway smooth muscle with subsequent bronchodilation
Relatively selective Ior beta
2
(pulmonary) receptors.
Therapeutic Effects:
4 Bronchodilation.
nAkMACCkINL1ICS
Absorption: Well absorbed aIter oral administration but rapidly undergoes extensive metabolism.
Distribution: Small amounts appear in breast milk.
Metabolism and Excretion: Extensively metabolized by the liver and other tissues.
Half-life: 3.8 hr.
CCN1kAINDICA1ICNS AND kLCAU1ICNS
Contraindicated in:
Hypersensitivity to adrenergic amines
Hypersensitivity to Iluorocarbons (inhaler).
Use Cautiously in:
Cardiac disease
Hypertension
Hyperthyroidism
Diabetes
Glaucoma
Geriatric patients (more susceptible to adverse reactions; may require dosage reduction)
Pregnancy (near term), lactation, and children 2 yr (saIety not established)
Excessive use may lead to tolerance and paradoxical bronchospasm (inhaler).
ADVLkSL kLAC1ICNS AND SIDL LIILC1S*
CAPITALS indicate liIe threatening; underlines indicate most Irequent.

CNS: nervousness, restlessness, tremor, headache, insomnia.
CV: chest pain palpitations, angina, arrhythmias, hypertension.
GI: nausea, vomiting.
Endo: hyperglycemia.
104

and E: hypokalemia.
Neuro: tremor.
IN1LkAC1ICNS
Drug-Drug:
Concurrent use with other adrenergic agents will have additive adrenergic side eIIects
Use with MAO inhibitors may lead to hypertensive crisis
eta blockers may negate therapeutic eIIect
Risk oI hypokalemia may be increased by concurrent use oI potassium-losing diuretics
Hypokalemia increases the risk oI digoxin toxicity.
Drug-Natural:
Use with ephedra and caIIeine-containing herbs (cola nut, guarana, mate, tea, coffee) increases stimulant eIIect.
kCU1L AND DCSAGL
Inhaln (Adults and Children >1 yr): Jia nebuli:ation or IPP2.5 mg 34 times daily.
AVAILA8ILI1
Inhalation solution: 0.63 mg/3ml
Rx
, 1.25 mg/3 ml
Rx
, 0.5 mg/ml
Rx
, 0.83 mg/ml in vials and 3 ml unit dose
Rx
, 1 mg/ml
Rx
, 2 mg/ml
Rx
, 5 mg/ml
Rx

Cost: 0.5 mg/ml $21.20/20 ml; 0.83 mg/ml $45.34/3ml 25's
TIME/ACTION PROFILE (bronchodilation)

ONSET PEA DURATION

Inhaln 515 min 6090 min 36 hr

105

NUkSING IMLICA1ICNS
ASSESSMENT
Assess lung sounds, pulse, and blood pressure beIore administration and during peak oI medication. Note amount, color, and character oI sputum produced.
Monitor pulmonary Iunction tests beIore initiating therapy and periodically throughout course to determine eIIectiveness oI medication.
Observe Ior paradoxical bronchospasm (wheezing). II condition occurs, withhold medication and notiIy physician or other health care proIessional immediately.
ab 1est Considerations: May cause transient decrease in serum potassium concentrations with nebulization or higher-than-recommended doses.
POTENTIAL NURSING DIAGNOSES
Airway clearance, ineIIective (Indications).
nowledge deIicit, related to medication regimen (Patient/Family Teaching).
IMPLEMENTATION
Inhaln: Allow at least 1 min between inhalations oI aerosol medication.
4 For nebulization or IPPB, the 0.5- 0.83-, 1-, and 2-mg/ml solutions do not require dilution beIore administration. The 5 mg/ml solution must be diluted with 2.5 ml oI 0.9 NaCl
Ior inhalation. Diluted solutions are stable Ior 24 hr at room temperature or 48 hr iI reIrigerated.
4 For nebulizer, compressed air or oxygen Ilow should be 610 L/min; a single treatment oI 3 ml lasts about 10 min.
4 IPPB usually lasts 520 min.
PATIENT/AMILY TEACHING
General Info: Instruct patient to take albuterol exactly as directed. II on a scheduled dosing regimen, take missed dose as soon as remembered, spacing remaining doses at regular intervals.
Do not double doses or increase the dose or Irequency oI doses. Caution patient not to exceed recommended dose; may cause adverse eIIects, paradoxical bronchospasm (more likely with
Iirst dose Irom new cannister), or loss oI eIIectiveness oI medication. Advise patient that not all agents should be used Ior acute attacks.
4 Instruct patient to contact health care proIessional immediately iI shortness oI breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpitations, or
chest pain. Actuators should not be changed among products.
4 Instruct patient to prime unit with 4 sprays beIore using and to discard cannister aIter 200 sprays. Activators should not be changed among products.
4 InIorm patient that these products contain hydroIluoralkane and the propellant and are described as non-CFC or CFC-Iree (contain no chloroIluorocarbons).
4 Advise patient to consult health care proIessional beIore taking any OTC medications or alcohol concurrently with this therapy. Caution patient also to avoid smoking and other
respiratory irritants.
4 InIorm patient that albuterol may cause an unusual or bad taste.
Inhaln: Instruct patient in the proper use oI the metered-dose inhaler, Rotahaler, or nebulizer.
4 Advise patients to use albuterol Iirst iI using other inhalation medications and allow 5 min to elapse beIore administering other inhalant medications unless otherwise directed.
4 Advise patient to rinse mouth with water aIter each inhalation dose to minimize dry mouth.
4 Instruct patient to notiIy health care proIessional iI no response to the usual dose oI albuterol or iI contents oI one canister are used in less than 2 wk.
106

EVALUATION
Effectiveness of therapy can be demonstrated by:
Prevention or relieI oI bronchospasm.
1S Lrythropoe|t|n 4000 "u" S once]week

Functional Health Pattern


USUAL IUNC1ICNAL A11LkN INI1IAL AkAISAL (!uly 21 2008) CNGCING AkAISAL (!uly 22 2008)

1 nea|th ercept|on nea|th Management
O Ceneral healLh has noL been good as clalmed
due Lo dlagnosls of uM Lype 2 when shes
40 yrs old
O 1hlngs done Lo keep oneself healLhy
verballzed"blsan naa koy ulabeLes kay
muadLo ra man [apon ko sa Llndahanlakaw
lakaw ug glnagmay para exerclse pero
kaLong ngahubag na akong Llll kay wala na"
O verballzed" kung naa koy slpon ug ubo or
lagnaL bah kay mupallL ra ug paraceLamol ba
o kanang neozep sa boLlka dlll ra ko anang
herbal"
O Pad been hosplLallzed 4 weeks prlor Lo

O AdmlLLed on !uly 13 2008 aL 4 10 M wlLh chlef
complalnLs of u ul lf ff fl lc cu ul lL Ly y l ln n b br re ea aL Lh hl ln ng g n no oL Le ed d p pr ro od du uc cL Ll lv ve e
c co ou ug gh h w wl lL Lh h w wl lL Lh hl ls sh h s sp pu uL Lu um m e ed de em ma a o of f b bo oL Lh h l le eg gs s a an nd d
f fe ee eL L v vo om ml lL Ll ln ng g o of f l ln ng ge es sL Le ed d f fo oo od d f fo ou ur r L Ll lm me es s p pe er r d da ay y ( (a al ll l
n no oL Le ed d 1 1 w we ee ek k 1 1A A) )
O Accompanled wlLh husband and relaLlves
O ALLendlng uocLor ur SoluLan/ ur Cadlz
O vlLal slgns upon admlsslon
1emperaLure 372degrees Celslus
ulse 106 bpm
8esplraLlon 18 cpm
8 130/90 mmPg

O C8C resulLs !uly 13 2008

O verballzed ganahan na ko mull day
nllngon naman ko nl docLora pud"
O vlLal slgns [ 7 AM
1emperaLure 366C
ulse 80 bpm weak and regular
8esplraLlon 20 cpm wlLh use of
accessory muscles
PearL raLe 80 bpm
8 110/80 mmhg
O vlLal slgns [ 12 --
1emperaLure 37C
ulse 90 bpm weak and regular
8esplraLlon 30 cpm wlLh use of
accessory muscles
107

presenL admlsslon due Lo dlfflculLy l ln n
b br re ea aL Lh hl ln ng g a an nd d p pr ro od du uc cL Ll lv ve e c co ou ug gh h w wl lL Lh h w wh hl lL Ll ls sh h
s sp pu uL Lu um m llnds lL dlfflculL Lo comply wlLh
docLor's orders and nurses suggesLlons
especlally when lL comes Lo dleL such as
drlnklng sofLdrlnksCoke
O verballzed kabalo man ko ba bawal [ud ang
coke kay grabe [ud ang sugar pero magllsod
[ud k okay palalnom man [ud ko anl pero
glnagmay nalang man pud LungaLungab ra"
O -onsmoker and -onalcohollc drlnker has
noL Lrled lllegal drugs
O -o food allergles
O knows how Lo do breasL self examlnaLlon
O Pas 6 chlldren and no maLernal
compllcaLlons ln Lhe course of prevlous
pregnancles as clalmed
O verballzed" wala man koy glLumar na
vlLamlns"
O verballzed kung kapoy maLulog ra ko
haplas glnagmay basLa makaLulog ko"
O CannoL remember whaL lmmunlzaLlons she
had before
O Perodofamlllal dlsease
MoLher and faLher dled of dlabeLes aL Lhe age of
63 and 60 She doesn'L know whaL Lype of
dlabeLes Lhey have
lamlly hlsLory of PyperLenslon and uM
-ormal values
Pemoglobln 96 gm (1214 gm )
PemaLocrlL 296 gm (3744 gm )
W8C 11200 cumm (4311 1/cumm)
-euLrophll segmenLer 83 (3370 )
LymphocyLes 10 (2033)
MonocyLes 3 (16 )
Loslnophlls 2 (14 )
laLeleL counL 341000 (130400 1/cumm)
8lood Lype 8+

O urlnalysls !uly 13 2008
Color llghL yellow (sLraw dark amber)
1ransparency hazy (clear)
Speclflc gravlLy 1020 ( 10101023)
h 60 (468)
us cells 36/hpf (0 3/hpf))
88C 24 /hpf (0 2/hpf)
Clucose poslLlve (-one)
roLeln poslLlve 3 (-one)
LplLhellal cells (03/hpf)
8acLerla none (-one)
Amorph uraLes few

8LCCu CPLM resulL !uly 13 2008
urea227 mg/dL 823 mg/dL
CreaLlnlne 906 mg/dL 312 mg/dL
l8S36 mg/dL 60110 mg/dL
urlc 108 mg 2437 mg
CholesLerol240 mg/dL less Lhan 203 mg/dL
1rlglycerldes100 mg/dL 40130 mg/dL
PearL raLe 90 bpm
8 160/90 mmhg

O wlLh laln L8 1L [ L meLacarpal veln [ 430
cc level flowlng [ 10 mcgLLs/mln lnfuslng
well
O wearlng dlaphers
O MedlcaLlons
Asplrln CC8 30 mg 1 Lab Cu
lmdur 60mg 1 Lab Cu MeLoclopramlde 1Amp
lv11 q8hours LanLus 13 u" SC before supper
ulovan 80mg 1 Lab Cu CapoLen 23 mg every 6
hours Su for 8160/90 8anlLldlne 1 Amp l11
evry 8 hours CefLrlaxlne 1 Amp every 8 hours
Lansoprazole 30 mg 1 cap Cu SlmvasLaLln 2
mg 1 Lab Cu qPS leSC4 wlLh lA 1 Lab 8lu
Cllndamycln 30 mg lv11 every 8 hours
SalbuLamol 1 neb 1lu 61210











108

CholesLerolPuL26 mg/dL 4083 mg/dL
CholesLerolLuL 194 mg/dL less Lhan 130 mg/dL
SC1 16 u/L 932 u/L

O lv llne laln L8 1L flowlng aL 10 mcgLLs/mln [ 830 cc
level [ lefL meLacarpal veln
O MedlcaLlons Asplrln CC8 30 mg 1 Lab Cu
lmdur 60mg 1 Lab Cu MeLoclopramlde 1Amp lv11
q8hours LanLus 13 u" SC before supper ulovan 80mg 1
Lab Cu CapoLen 23 mg every 6 hours Su for 8160/90
8anlLldlne 1 Amp l11 evry 8 hours CefLrlaxlne 1 Amp
every 8 hours Lansoprazole 30 mg 1 cap Cu SlmvasLaLln
2 mg 1 Lab Cu qPS leSC4 wlLh lA 1 Lab 8lu Cllndamycln
30 mg lv11 every 8 hours SalbuLamol 1 neb 1lu 61210
2 Nutr|t|ona| Metabo||c attern
O usually eaLs only 3 meals a day someLlmes
wlLh or wlLhouL snacks
O usual food and fluld lnLake
8reakfasL
kallgmlLan kay pan [ud ug kape na naay
gaLas pero magkanon pud ko dayon
kung unsay bllln na sudan sa gabll o unsa
ba kanang lLloglalnlaln man"
Lunch
Z Lo 1 cup rlce
1 servlng of llsh/soup/meaL
ulnner
Z Lo 1 cup rlce
1 servlng of meaL/llsh/soup
O usual fluld lnLake
WaLer 43 glasses/ day
O lv llne laln L8 1L flowlng aL 10 mcgLLs/mln [830 cc
level [ lefL meLacarpal veln lnfuslng well

O Caplllary reflll of 2 seconds
O 8owel sounds 8 Llmes per mlnuLe

O lood and fluld lnLake for Lhe day
8reakfasL
gamay ra akong glkaon na kanon murag lsada
man dagay Lo unya naay sabaw na pares"
Lunch
Z cup rlce
1 servlng of soup wlLh beef
ulnner
Z Lo 1 cup rlce
1 servlng of meaL wlLh vegeLables
fluld lnLake

O verballzed haplL na Lo 9 ko nlkaon ganlha
kay dugay ko nakamaLa"
O wlLh laln L8 1L [ L meLacarpal veln [ 430
cc level flowlng [ 10 mcgLLs/mln lnfuslng
well
O Skln dark brown absence of rashes lumps
dryness nor lLchlng beads of sweaL noLed
on forehead and upper llp and has poor
Lurgor and moblllLy
O verballzed glpanlngpoL [ud k okay ballng
lnlLa pud dlrl uy unya wla pa[ud ko kallgo
pa"

O lood and fluld lnLake for Lhe day

8reakfasL
109

O verballzed mukaon ra man ko basLa unsay
naa"
O -o lood allergy
O -o dlfflculLy ln chewlng and swallowlng food
O -o denLal problems
mlsslng LeeLh 1 lefL upper molar1 lefL lower
molar
O Loose LeeLh no loose LeeLh
O usual welghL 30 kg
O Skln ls dark brown and has few scars on boLh
upper and lower exLremlLles
O -o skln halr and nall problems
O Wounds does noL heal well
WaLer 3 glasses
Slps of sofLdrlnks coke"

verballzed kalbalo man ko bawal glnagmay lng
man pus Langgal uhaw ra"

Z cup of plaln rlce
1 sllce of flsh
Lunch
Z cup rlce
1 servlng of soup wlLh beef

fluld lnLake
WaLer 3 and 1/2 glasses
Slps of sofLdrlnks coke"

verballzed nllnum kog Lubog pero lno pud
kog coke gamay"

O -o dlfflculLy ln chewlng and swallowlng
food
O Skln ls dark brown and presence
O Pas cold clammy skln on palmar area
O SweaL noLed on forehead
3 L||m|nat|on attern
8ladder
O lrequency 34 Llmes/ day
O AmounL esLlmaLed Lo be 2 cups a day
O CharacLerlsLlcs pale yellow and sweeL ln
odor
O -o dlscomforL and no dlfflculLles ln
voldlng
O Pas no hlsLory of urlnary LracL lnfecLlon

8owel
O lrequency usahay kausa ra sa usa ka
adlaw usahay pud kaduha depende
8ladder
Wears dlapher

8owel
Pas noL defecaLed yeL
8owel sounds of 6 Llmes per mlnuLe

Skln
SweaL ls noLed on forehead and some area of Lhe face
Cold and clammy palms
ury skln ls noLed and poor skln Lurgor as Lhe skln ls
saggy due Lo old age
O Skln on boLh legs and feeL ls wrlnkled due Lo edema

8ladder
Wears dlapher

8owel
O Pad noL defecaLed once wlLh sofL
brown sLool
O verballzed" kanang usahay wala ko kaalo
kung basa ba unsa color sa akong
hugaw kay gaa dlapher man ko
magllsod naman gud kog lakaw pa sa
banyo kapoy ba"
Skln
110

akong glkaon"
O CharacLerlsLlcs sofLformed brownlsh
sLool
O AmounL varles dependlng on food lnLake
O -o dlscomforL nor dlfflculLles ln
defecaLlng
Skln
O Clalmed pura buyag wala ra man ko
problema sa baho sa ako lawas basLa
mallgo ra ko kada adlaw"
O Clalmed ok ra pud ako pagslngoL dlll
pud sobra pero syempre kung naay
buhaLon na llhokllhok [ud ah kana
slngLon [ud ko"
O verballzed wala man ko allergy sa mga
pagkaon"
O Applles loLlon verballzed"usahay
makallmoL kog buLang kanang Llgualang
naman pud kapoy na"
whlch already subslded


O verballzed gllas kaayo dlrl sa hosplLal
glpanlngoL [ud ko"
O ersplraLlon noLed on face nose and neck
O Pas cold clammy skln
O lrequenLly asks her relaLlve Lo fan ln
dlrecLlon Lowards her



4 Act|v|tyexerc|se pattern
O Clalmed Lo have lnsufflclenL energy for
compleLlng acLlvlLles of dally llvlng
O verballzed nagluya man [ud ko kay
gasuka lagl ko dlll nalang gud ko nlla
pugson ug kaon kay ako ra man pud
lpagawas"
O verballzed" kaLong nagsugod na kog saklL
kay kanang dlll nalang ko sa balay samoL
kaLong nlhubag na akong mga Llll unya
nagllsod naman pud lagl kog glnhawa ug
gasuka pud ko"
O SLays aL bed ln semlfowler's poslLlon mosL of Lhe Llme
O -eeds asslsLance ln ambulaLlng and when Lurnlng on
bed from dlfferenL poslLlons
O verballzed"nakadlapher man kodlll na ko maglakaw
pa sa C8 kay kapoy na"
O verballzed"naa raman pud akong bana dlrl ug akong
paryenLe na magaLlman nako llaman [ud ko alalayan
pero mas samoL nlng karon lkumpara sauna"
O -oL Capable of full selfcare
O luncLlonal Levels
8aLhlng 1
O SLays on bed elLher slLLlng or ln suplne
poslLlon
O verballzed"Labangan man ko nlla
kung mulakaw k okay maLumba unya"
O verballzed"samoL man dagay ko
kaluya dlrl day kay slg era ko dlrl
maghlgda'
O -eeds asslsLance ln ambulaLlng and
111

O usual dally rouLlne

78 AM wakes up eaLs breakfasL
800900 AM Lakes a baLh lf posslble by
herself
verballzed"kung kanang dlll ko kalakaw
unya hlna kaau ko slla ramagLrapoLrapo
nako ug kanang slnagol na lnlL ug Lublg sa
grlpo"
911 am waLches Lelevlslon or reads
newspapers
1200 1230 -- eaLs lunch wlLh hls husband
and realLlves
verballzed hunglLan nalang man konlla karon
magllsod naman gud ko"
1 00600 M goes Lo her sLore and
checks her buslness spends her Llme
resLlng waLchlng 1v Laklng naps
verballzed"karon dlll naman ko maadLo
dldLo dlrl rako balayslla na bahaladldLo
akong asawa ba o mga anak"

600700 M eaLs dlnner
800/9M waLchlng 1v
910 M sleeplng Llme

O Lelsure acLlvlLles mulanLaw ug 1v or
kanang muadLo akong mga pareyenLe
dlrl o mga slllngan bakay maglsLurya
lsLurya kay wla man laln llngaw"
O Pas moblllLy problems
1olleLlng 1
8ed moblllLy 1
uresslng 1
Croomlng 1
Ceneral MoblllLy 1
O luncLlonal levels code
evel 0 lull selfcare
evel l 8equlres asslsLance or supervlslons by
oLher person
evel ll 8equlres asslsLance or supervlslon from oLher
person or devlce

when Lurlng on bed from dlfferenL
poslLlons
O luncLlonal Levels
8aLhlng 1
1olleLlng 1
8ed moblllLy 1
uresslng 1
Croomlng 1
Ceneral MoblllLy 1
O luncLlonal levels code
evel 0 lull selfcare
evel l 8equlres asslsLance or
supervlslons by oLher person
evel ll 8equlres asslsLance or supervlslon
from oLher person or devlce
112


O -eeds asslsLance ln ambulaLlng and when
Lurlng on bed from dlfferenL poslLlons
O luncLlonal Levels before sympLoms of Lhe
dlsease condlLlons was experlenced
8aLhlng 0
1olleLlng 0
8ed moblllLy 0
uresslng 0
Croomlng 0
Ceneral MoblllLy
O luncLlonal levels code
evel 0 lull selfcare
evel l 8equlres asslsLance or
supervlslons by oLher person
evel ll 8equlres asslsLance or
supervlslon from oLher person
or devlce
S S|eep rest attern
O usual sleep paLLern
CnseL clalmed dlll magpareha usuahay
8 pero dlll parehas sahay pud kay laLe
na9 or 10 sa gabll na depende kung
nakaLulog ko sa hapon o naa koy
glbuhaL na kapoy"
Awakenlng 78 AM
# of hours of sleep clalmed" dlll gud
magpareha lagmlL 910 hours"
O Sleep alds verballzed"manghaplas man
kog omega o efflcacenL kanang saklL
akong lawas"

O sleep paLLern
CnseL clalmed gabll mga 8 palang Lo Lulog nako
pero puLolpuLol man pud lagl "
Awakenlng 630 AM
# of hours of sleep 10 and half buL wlLh mlnuLes of
lnLerrupLlons due Lo nurse's rouLlne care nolsy
people ln Lhe ward
Sleep alds verballzed" magpapaypay [ud k okay
lgang kaayo dlrl uy"
O Sleep lnLerrupLlons nurse's rouLlne care such as v/s
Laklng admlnlsLraLlon of medlcaLlons nolsy
people ln Lhe ward

O sleep paLLern
CnseL clalmed 9 naman Lo day"
Awakenlng 7 AM
# of hours of sleep 10 buL wlLh
mlnuLes of lnLerrupLlons due Lo
nurse's rouLlne care nolsy people
ln Lhe ward
Sleep alds verballzed" magpapaypay [ud
k okay lgang kaayo dlrl uy"
O Sleep lnLerrupLlons nurse's rouLlne care
such as v/s Laklng admlnlsLraLlon
of medlcaLlons nolsy people ln Lhe
113

O Sleep lnLerrupLlons voldlng
O Sleep problems verballzed"usahay kay
kanang muLukar akong hlgh blood ba
kay llsod kaayo lresL unya kanang
mugara napud akong ubo kay sus!
PuLuyon [ud ko magabll"
O She someLlmes has dreams buL no
nlghLmares
O verballzed 'kung nakapahuway kog Laas sa
hapon kay magllsod pud kog kaLulog
pagka gabll"
O Snore when sleeplng lf Llred
O Sleep problems verballzed"kanang magllsod kog
glnhawa unya ubuhon ko usahay kanang
mallpong ko"
O -o nlghLmares whlle ln Lhe hosplLal

ward
O Sleep problems verballzed" kanang naa
man Loy saba sa gawas gabll naa
dagay emergency mao nahlgmaLa
ko mga Lao man kay nagsLorya
naa dagay glaaLake lngon sa akong
bana"
O -o nlghLmares whlle ln Lhe hosplLal

6 Cogn|t|veperceptua| pattern
O PlghesL educaLlonal aLLalnmenL 2nd year
College level
O Clalmed ganahan man [ud ko makahuman
pero nagkallsod man sa kwarLa unya sayo
pud ko nangasawa"
O Can speak a llLLle of 1agalog and Lngllsh buL
uses Cebuano aL home
O Can leglbly read and wrlLe
O Lyes verballzed"dlll na pareha akong
nllanLawan sauna baLa pa nya daghan pud
Lang saklL kanlng dlabeLes number 1 [ud"
O Lars no hearlng problems reporLs no
dlfflculLy wlLh hearlng
O -ose no Lenderness no dlfflculLy ln smelllng
O verballze"me[o llmLanon na sa kagulangon
ra man pud"
O -o sensorypercepLlon problems
O llnds lL easy Lo learn Lhlngs regardless of
O verballzed "kanlng akong dughan kay kallL ug saklL
aboL asa akong wala na kamoL kanang mudagan ba"
O "murag kanang glkumoL ba ang kasaklL na dlll
masabLan mudugay mga lapas [ud 3 mlnuLes"

O ChesL guardlng ofLen noLed placlng flsL over mldsLernum
O rubblng of lefL arm
O 8aLed paln as 8 ln Lhe scale of 010 (10 as Lhe hlghesL
and 0 as absence of paln)
O 8esponslve Lo verbal sLlmulaLlon buL unaLLenLlve
when ln paln
O oor eye conLacL due Lo paln felL
* verballzed mauna sa kasaklL kay maluya [ud ko
mawadan pud Lag ganan mukaon uy"
verballzed"kung musaklL na ganl kay muuLong [ud ko nya
akong gakson ang unlan ug pagayo kana man gud pong
ubuhon ko kay makasamoL "
O Pusband holds her hands and conmforLs her when
she ls ln paln

O CrlenLed Lo Llme place and person
O verballzed naa ra gyapon ang saklL day"
O 8aLed paln as 7 ouL of 10 ln a scale ln
whlch 10 ls Lhe grade of Lhe mosL palnful
paln felL and 0 as Lhe absence of paln

O ChesL guardlng ofLen noLed placlng flsL
over mldsLernum
O rubblng of lefL arm

O Speech ls clear and undersLandable
answers quesLlons approprlaLely buL
when she ls ln paln she does noL
parLlclpaLe and unaLLenLlve
114

Leachlng meLhod used buL
verballzed"kanang mulnon kog sofLdrlnks
kay kabalo man ko sa epekLo ba'
O responslve Lo verbal and nonverbal sLlmull
O Speech ls clear and coherenL
O Speech ls clear and coherenL and answers
quesLlons approprlaLely buL unaLLenLlve and
unparLlclpaLlve when ln paln
O verballzed saklL [ud man panlngLon gud
ko magampo [ud ko na mawala basLa
muLukar kay ballng saklLa"
7 Se|fpercept|onse|fconcept pattern
O uescrlbes self mallpayon man ko nga
pagkaLawo conLenLo man pud ko blsan wa
ko kahuman happy ra man pud kaubana
makakaon ra hlmsug pud dapaL"
O verballzed"nakapaeskwela man pud sa
akong mga anak naa na koy nurse sa gawas
ang uban wala man nagLlnarong llaa na na
basLa kay glaLlman nako slla Laman sa akong
glnhawadagko naman pud slla"
O Clalmed Lo be a poslLlve Lhlnker
O verballzed kung naa koy problema
depende pud kung klnsa akong duolan
usahay sa akong bana o mga close na
kaplLbahay"
O leels good abouL herself and ls conLenLed
wlLh her body lmage verballzed"pero
kaLong nagsugod ng kagrabe lng akong saklL
kay wala na hlna na ko sa balay nalang"
O verballzed"masaklLon na [ud ko sugod
aLong nadlagnose na naa ko dlabeLes naa
man pud akong mama ug papa mao lla
glkamaLyan"

O uescrlbes self as weak and very lll
O verballzed"kabalo man ko day hlnay na [ud k okay
kanlng dlabeLes klller man [ud nl mao na nagsunod [ud
akong mga kompllkasyon"
O 1alks Lo husband abouL her condlLlon and eargerly asks
Lhe docLor lf she can go ouL and sLay home so she can
resL well
O verballzes"kabalo kay day blsag lngon anl na akong
kahlmLang nallpay k okay kaaboL ko anlng ldara ang
1aas ra man magbuoL sa Lanan kahlbaw ko me[o gahl
kog ulo kay mulnon [ud ko ug coke"
O leels LhaL her husband loves her so much and LhaL he ls
always aL her slde and glvlng her courage and sLrengLh
Lo be sLrong and Lo flghL Lhe lllness

O resenL healLh goal clalmed ganahn La
ko na makaull ko sa ulpolog sa among
problnsya kay mas maayo dldLo fresh alr"
O Asks her husband Lo be close Lo her aL
Lhe bedslde
O verballzed dawar ra man nako akong
kahlmLang xempre dlll ra man kwarLa ang
lpamana sa aLong mga glnlkanan apll [ud
nang mga saklL"
O Mlsses her grandchlldren and wlshes Lo
see Lhem Lo make her happy and would
lncrease her energy level verballzed" slla
nalang gahaLag nakog kallpay murag
maayo akong oamlnaw basLa naa ang mga
baLa"
8 ko|ere|at|onsh|p pattern
O Llves wlLh her husband and 2
nd
Lo Lhe
O Pas been accompanled by her husband and relaLlve
ln golng Lo Lhe hosplLal

O Per husband and relaLlve aLLends Lo her
115

youngesL son a relaLlve who Lakes care of
her when husband ls noL around
O MoLher and faLher dled of ulabeLes she
canL remember whaL Lype of uM
O ?oungesL ln Lhe brood of 2 and has no
problems wlLh her broLher
O 8oLh couple make declslons for Lhe famlly
O verballzed naa ml glnagmay na buslness
unya akong bana pud Lrabaho blsag gulang
na pud"
O Pas a harmonlous relaLlonshlp wlLh
nelghbors relaLlves and frlends
O uoes noL belong ln any groups and
organlzaLlons
* Pusband and relaLlves shows concern whlle aLLendlng
her needs
* Pas good relaLlonshlp wlLh hosplLal personnel as
clalmed

O Per relaLlve and husband sLayed on her slde durlng
her hosplLal sLay

O verballzed kablslLa akong mga anak dlrl pero ang
mga apo wla"


needs and asslsLs her lf she needs help
especlally ln moblllLy
O verballzed "haplL na man pud ko
makagawas malkLa na pud nako slla"
O Pas good relaLlonshlp wlLh hosplLal
personnel as clalmed



Sexua||tyreproduct|ve pattern

O Menarche aL 12 years old
O MensLrual Cycle regular monLhly ln
occurrence 3 Lo 3 days ln duraLlon
consumes 23 pads dally wlLh moderaLe
amounL of blood flow
O She ls already menopaused
O uoes noL experlence dysmenorrhea
O Marrled wlLh 6 chlldren
O verballzed unom among anak ganahan
man gud akong bana ug daghan anak
kunLenLo lang man pud ko"
O verballzed kaLo mga pllls ako nagamlL
sauna"

O verballzed happy ra k okay nagdugay [ud ml sa
akong bana blsag sayo ko namlnyona sya karon
gaaLlman nakollpay na ko ana dlll ko nlya
glanapasagdan"

O verballzed karong gulang na La day kanang
magkakuyog ml ok na na"



O verballzed hadlok bya ko annang mga
saklL sa ovary o unsa ban a maLres"
O verballzed"naa man pud ko glbaLl sauna
kanang nguLnguL ba pero
pagpachek up kay wala ra man daw
problema"

10 Cop|ngstress to|erance
O Sleeps or Lalks Lo her husband when ln
O Confldes Lo husband and relaLlves regardlng her
116

sLress
O 1alks Lo her frlends someLlmes for rellef
O uoes noL use medlclnes drugs or alcohol
when she feels Lense
O verballzed usahay kung naay problema
kay aLlmanun nalnag nako akong mga apo
para mallngaw ko"
O verballzed" kaLo namaLay akong anak na
bunso bugaL [ud kaayo akong dughan aLo
duagay baya ko nakarecovef kay blsag
bugoy Long baLaana kay plnangga nako Lo
kay sweeL man Lo pagkabaLa ba kanang
mu hug malungllangl pero ako nalang
glampo lyang kalag sa glnoo wla man gud
Lo nagLlnarong maayo ganl kay wa Lo
nakapaburos daghan man pud Long bayl
baylhan ba"
condlLlon and Lhe condlLlon of Lhelr chlldren
O keep on asklng Lhe docLor wheLer she can go home
Lo resL
O verballzed kanang mulngon [ud ko nl docLor na dlll
ko ganahan sa hosplLal kay dlll ko karesL ug maayo
O Polds Lhe hand of her husband someLlmes her
husband rubs her back when she ls coughlng or
uncomforLable

O Lmbraces a plllow when she felLs paln and
hold her husbands hand
O verballzed ako ganl gllng na akong bana
na lplllL [ud sl doc na pagawason k okay
laln dlrl sa hosplLal uy magluya kog samoL

O sLays sllenL and pray Lo Cod lf paln so
much Lo bear
11 Va|uebe||ef pattern
O 8ellglon 8oman CaLhollc
O Coes Lo mass every Sunday ln Lhe afLernoon
wlLh husband
O verballzed pero kaLong nlhubag akong Llll
kay wala na ug kaLong nagsugod na ka
compllcaLe akong saklL kay dlll naman ko
palakwon nlla kay bason mallpong ba kay
hlgh blood man"
O values her famlly and frlends
O -oL lnvolved ln any splrlLual organlzaLlons
O Cod plays a blg role ln her llfe as clalmed
O verballzed 'Llgampo [ud ko kada gabll
syempre magasalamaL sa hlmaya dayon
O rays Lo Cod LhaL she may have longer llfe Lo
spend buL llfLs Lo Cod whLever happens Lo her
O verballzed nagpasalamaL ko sa Clno kay kaaboL ko
anlng ldara unya gakuyog ra [apon ml sa akong bana"
O 1hanked her husband and relaLlves for sLaylng wlLh
her LhroughouL

O values famlly and her bellef
O verballzed lmporLanLe man [ud ang
healLh pero kasaboL ra man ko ba ngano
nalngun anl ko"
O hopes Lo have longer llfe Lo spend wlLh
her love ones
O prays Lo Cod Lo avold occurrences of
more compllcaLlons
O verballzed ganahan ko muull sa dlpolog
sa amoa"

117

mangayo ug Labang"
O verblalzed lmporLanLe [ud nako ang akong
pamllya karon sauna ang akong pag
eskuwela akong prlorlLy per okay naundang
man so karon lahl na [ud ng naay anak
kuwarLa na problema pero kunLenLo ra man
O verballzed"kanang ako naman glpaubaya
-lya Lanan nagsorry na ko sa kong mga dlll
mao na nabuhaL"







118

#or|tq
urs|ng oare
ptans





Cues aid Fvrdeiees Nusri
Draiosrs
Oljeetrves liteveitrois Ratroiale Fvaluatroi
Sub[ecLlve lneffecLlve alrway AL Lhe end of my care
Independent


AL Lhe end of my
119

O verballzed"
nagllsod [ud kog
pagawas anlng
plema ba kapoy
kaayo ug
ubuhan
muhuLoy man
gud llsod
lglnhawa

O verballzed"
dugay na man nl
akong ubo naa
plema na puLl
ang color"

Cb[ecLlve

O Changes ln
raLedepLh of
resplraLlons

O Abnormal breaLh
sounds crackles
heard upon
ausculLaLlon on
chesL

O use of accessory
muscles upon
resplraLlon

O Cough wlLh
spuLum
producLlon

O uyspnea

clearance relaLed
Lo lncreased
spuLum
producLlon
secondary Lo
pneumonla
Lhe cllenL wlll
manlfesL effecLlve
alrway clearance as
evldenced by

1 vlLal slgns 88
wlll be aL leasL
20 cpm deep
and wlLhouL
use of
accessory
mucles
8 ls aL leasL
140/90 mmPg

2 verballzed
lmproved
comforL ln
breaLhlng

3 ldenLlfy/demon
sLraLe
behavlors Lo
achleve alrway
clearance such
as deep
breaLhlng and
coughlng
exerclses


1 monlLor vlLal slgns every
four hours or as ofLen as
needed



2 Assess raLe/depLh of
resplraLlons and chesL
movemenL



3 AusculLaLe lung flelds
noLlng areas of
decreased/absenL
alrflow and
advenLlLlous breaLh
sounds eg crackles
wheezes



4 LlevaLe head of bed
change poslLlon
frequenLly


3 AsslsL paLlenL wlLh
frequenL deep
breaLhlng exerclses
uemonsLraLe/help
paLlenL learn Lo
perform acLlvlLy eg
spllnLlng chesL and
effecLlve coughlng
whlle ln uprlghL
poslLlon

6 SucLlon as lndlcaLed
(eg frequenL or


1 alLeraLlons ln vlLal slgns may slgnlfy
LhaL alrway clearance ls lneffecLlve
and LhaL breaLhlng paLLern ls affecLed
Lo have a basellne daLa for furLher
evaluaLlon

2 1achypnea shallow resplraLlons
and asymmeLrlc chesL movemenL are
frequenLly presenL because of
dlscomforL of movlng chesL wall
and/or fluld ln lung

3 uecreased alrflow occurs ln areas
consolldaLed wlLh fluld 8ronchlal
breaLh sounds (normal over
bronchus) can also occur ln
consolldaLed areas Crackles rhonchl
and wheezes are heard on lnsplraLlon
and/or explraLlon ln response Lo fluld
accumulaLlon Lhlck secreLlons and
alrway spasm/obsLrucLlon

4 Lowers dlapgram promoLlng chesL
expanslon aeraLlon of lung segmenLs
mobllaLlon and expecLoraLlon of
secreLlons

5 ueep breaLhlng faclllLaLes
maxlmum expanslon of Lhe
lungs/smaller alrways Coughlng ls a
naLural selfcleanlng mechanlsm
asslsLlng Lhe cllla Lo malnLaln paLenL
alrways SpllnLlng reduces chesL
dlscomforL and an uprlghL poslLlon
favors deeper more forceful cough
efforL


6SLlmulaLes cough or mechanlcally
clears alrway ln paLlenL who ls unable
care Lhe
ob[ecLlves were
noL meL as
evldenced by

1 vlLal slgns
88 23 cpm
shallow and
wlLh use of
accessory
mucles
8 130/80 mm
Pg

2 verballzed"
nagllsod ra
gyapon
kong
pagawas
anlng
plema"

3 Crackles
heard on
lung
perlphery
upon chesL
ausculLaLlon

4 ulfflculLy ln
breaLhlng
120

O 8esLless

O SweaLlng noLed on
forehead

O Clenches flsL when
coughlng or holdlng
Lhe plllow LlghL

O v/S
88 30 cpm
shallow and
wlLh use of
accessory
muscle
8 160/90
mmPg

O Has capillary reIill oI
4 seconds.




4 ulsplay paLenL
alrway wlLh
breaLh sounds
clearlng

3 Absence of
dyspnea
resLlessness

6 uecreased
sweaLlng on
forehead

7 Pas caplllary
reflll of aL leasL
2 3 sec

8 LfflclenLly
cough
ouL/expecLoraL
e spuLum
susLalned cough
advenLlLlous breaLh
sounds desaLuraLlon
relaLed Lo alrway
secreLlons)

7 Lncourage lnLake of
flulds Lo aL leasL 3000
mL/day (unless
conLralndlcaLed as ln
hearL fallure) Cffer
warm raLher Lhan
cold flulds

CoIIaborative

8 AsslsL wlLh/monlLor
effecLs of nebullzer
LreaLmenLs and oLher
resplraLory
physloLherapy eg
lncenLlve splromeLer
percusslon posLural
dralnage erform
LreaLmenLs beLween
meals and llmlL flulds
when approprlaLe

9 AdmlnlsLer
medlcaLlons as
lndlcaLed mucolyLlcs
expecLoranLs
bronchodllaLors
analgeslcs


10 rovlde supplemenLal
flulds eg lv
humldlfled oxygen

11 MonlLor serlal chesL x
rays A8Cs pulse
Lo do so because of lneffecLlve cough
or decreased level of consclousness




7llulds (especlally warm llqulds) ald
ln moblllzaLlon and expecLoraLlon of
secreLlons







8laclllLaLes llquefacaLlon and
removal of secreLlons osLural
dralnage may noL be effecLlve ln
lnLersLlLlal pneumonlas or Lhose
causlng alveolar exudaLe/desLrucLlon
CoordlnaLlon of LreaLmenLs/schedules
and oral lnLake reduces llkellhood of
vomlLlng wlLh coughlng
expecLoraLlons



9 Alds ln reducLlon of bronchospasm
and moblllzaLlon of secreLlons
Analgeslcs are glven Lo lmprove cough
efforL by reduclng dlscomforL buL
should be used cauLlously because
Lhey can decrease cough
efforL/depress resplraLlons

10 llulds are requlred Lo replace
losses (lncludlng lnsenslble) and
ald ln moblllzaLlon of secreLlons

11 lollows progress and effecLs of
dlsease process/LherapeuLlc
noLed

3
8esLlessness
noLed

6 sweaLlng on
forehead
noLed

7 Pas caplllary
reflll of 4
seconds

8 Paven'L
coughed ouL
spuLum
121

oxlmeLry readlngs


12 AsslsL wlLh
bronchoscopy/Lhorace
nLesls lf lndlcaLed
reglmen and faclllLaLes necessary
alLeraLlons ln Lherapy

12 Cccaslonally needed Lo remove
mucous plugs draln purulenL
secreLlons and/or prevenL
aLelecLasls



















Cues/ Lvldences -urslng ulagnosls Cb[ecLlves lnLervenLlons 8aLlonale LvaluaLlon
Sub[ecLlve
O verballzed"
nagllsod [ud
kog pagawas
lmpalred gas
exchange relaLed Lo
alveolarcaplllary
AL Lhe end of my
care Lhe cllenL wlll
manlfesL
lndependenL
1 monlLor vlLal slgns
every four hours or as
ofLen as needed

1 alLeraLlons ln vlLal slgns may slgnlfy
LhaL oxygenaLlon and venLllaLlon ls
lmpalred Lhus breaLhlng paLLern ls
affecLed Lo have a basellne daLa for
AL Lhe end of my
care Lhe
ob[ecLlves were
122

anlng plema
ba kapoy
kaayo ug
ubuhan
muhuLoy
man gud
llsod
lglnhawa

O verballzed"
dugay na
man nl akong
ubo naa
plema na puLl
ang color"

Cb[ecLlve

O v/S
88 30 cpm
shallow and
wlLh use of
accessory
muscle
8 160/90
mmPg

O Changes ln
raLedepLh of
resplraLlons

O Abnormal
breaLh sounds
crackles heard
upon
ausculLaLlon on
chesL

O use of
membrane changes
due Lo
lnflammaLory
effecLs secondary
Lo pneumonla
lmproved oxygenaLlon
and venLllaLlon as
evldenced by

1 vlLal slgns 88
wlll be aL leasL
20 cpm deep
and wlLhouL use
of accessory
mucles
8 ls aL leasL
140/90 mmPg

2 verballzed
lmproved
comforL ln
breaLhlng

3 absence of
sympLoms of
resplraLory
dlsLress

4 arLlclpaLe ln
acLlons Lo
maxlmlze
oxygenaLlon

3 Absence of
dyspnea
resLlessness

6 ldenLlfy/demon


2 Assess resplraLory raLe
depLh and ease



3 Cbserve color of skln
mucous membranes and
nallbeds noLlng presence
of perlpheral cyanosls
(nallbeds) or cenLral
cyanosls (clrcumoral)


4 Assess menLal sLaLus


3MonlLor hearL
raLe/rhyLhm


6 MonlLor body
LemperaLure as
lndlcaLed AsslsL wlLh
comforL measures Lo
reduce fever and chllls
eg addlLlon/removal of
bedcovers comforLable
room LemperaLure Lepld
or cool waLer sponge
baLh

7MalnLaln bedresL
Lncourage use of
relaxaLlon Lechnlques and
dlverslonal acLlvlLles

8 LlevaLe head and
encourage frequenL
poslLlon changes deep
breaLhlng and effecLlve
furLher evaluaLlon

2ManlfesLaLlons of resplraLory dlsLress
are dependenL on/and lndlcaLlve of Lhe
degree of lung lnvolvemenL and
underlylng general healLh sLaLus

3Cyanosls of nallbeds may represenL
vasoconsLrlcLlon or Lhe body's response
Lo fever/chllls however cyanosls of
earlobes mucous membranes and skln
around Lhe mouLh (warm membranes")
ls lndlcaLlve of sysLemlc hypoxemla

4 8esLlessness lrrlLaLlon confuslon and
somnolence may reflecL hypoxemla/
decreased cerebral oxygenaLlon

31achycardla ls usually presenL as a
resulL of fever/dehydraLlon buL may
represenL a response Lo hypoxemla

6 Plgh fever (common ln bacLerlal
pneumonla ) greaLly lncreases meLabollc
demands and oxygen consumpLlon and
alLers cellular oxygenaLlon






7 revenLs overxhausLlon and reduces
oxygen consumpLlon/demands Lo
faclllLaLe resoluLlon of lnfecLlon


8 1hese measures promoLe maxlmal
lnsplraLlon enhance expecLoraLlon of
secreLlons Lo lmprove venLllaLlon


noL meL as
evldenced by

1 vlLal slgns
88 23 cpm
shallow and
wlLh use of
accessory
mucles
8 130/80
mm Pg

2 verballzed
" nagllsod
ra gyapon
kong
pagawas
anlng
plema"

3 Crackles
heard on
lung
perlphery
upon chesL
ausculLaLlo
n

4 ulfflculLy ln
breaLhlng
noLed
123

accessory
muscles upon
resplraLlon

O Cough wlLh
spuLum
producLlon

O uyspnea

O 8esLless

O SweaLlng noLed
on forehead

O Has capillary
reIill oI 4
seconds.
sLraLe behavlors
Lo achleve
alrway
clearance such
as deep
breaLhlng and
coughlng
exerclses

7 uecreased
sweaLlng on
forehead

8 Pas caplllary reflll
of aL leasL 23 sec

coughlng

9Assess level of anxleLy
Lncourage verballzaLlon
of concerns/feellngs
Answer quesLlons
honesLly vlslL frequenLly
arrange for SC/vlslLors Lo
sLay wlLh paLlenL as
lndlcaLed

10Cbserve for
deLerloraLlon ln condlLlon
noLlng hypoLenslon
coplous amounLs of
plnk/bloody spuLum
pallor cyanosls change ln
level of consclousness
severe dyspnea
resLlessness

Co||aborat|ve

11MonlLor A8Cs pulse
oxlmeLry

12AdmlnlsLer oxygen
Lherapy by approprlaLe
means eg nasal prongs
mask venLurl mask

13repare for/Lransfer Lo
crlLlcal care seLLlng lf
lndlcaLed
9AnxleLy ls a manlfesLaLlon of
psychologlcal concerns and physlologlcal
responses Lo hypoxla rovldlng
reassurance and enhanclng sense of
securlLy can reduce Lhe psychologlcal
componenL Lhereby decreaslng oxygen
demand and adverse physlologlcal
responses

10Shock and pulmonary edema are Lhe
mosL common causes of deaLh ln
pneumonla and requlre lmmedlaLe
medlcal lnLervenLlon








11lollows progress of dlsease process
and faclllLaLes alLeraLlons ln pulmonary
Lherapy

121he purpose of oxygen Lherapy ls Lo
malnLaln aC
2
above 60 mm Pg Cxygen
ls admlnlsLered by Lhe meLhod LhaL
provldes approprlaLe dellvery wlLhln Lhe
paLlenL's Lolerance

13lnLubaLlon and mechanlcal venLllaLlon
may be requlred ln Lhe evenL of severe
resplraLory lnsufflclency

3
8esLlessnes
s noLed

6 sweaLlng
on
forehead
noLed

7 Pas
caplllary
reflll of 4
seconds


124

Cues and Lv|dences Nurs|ng
D|agnos|s
Cb[ect|ves Nurs|ng Intervent|ons kat|ona|e Lva|uat|on
Sub[ecLlve
verballzaLlons
O kanlng akong
dughan kay kallL
ug saklL aboL sa
akong wala na
kamoL kanang
mudagan ba"
O "murag kanang
glkumoL ba ang
kasaklL na dlll
masabLan
mudugay mga
lapas [ud 3
mlnuLes"
O mauna sa
kasaklL kay
maluya [ud ko
mawadan pud
Lag ganan
mukaon uy"

O verballzed"kung
musaklL na ganl
kay muuLong [ud
ko nya akong
gakson ang unlan
ug pagayo kana
man gud pong
ubuhon ko kay
AlLered comforL
AcuLe aln
relaLed presence
of anglna
pecLorls due Lo
decreased
myocardlal blood
flow and
coronary arLery
consLrlcLlon
WlLhln our care Lhe
cllenL wlll experlence
reducLlon of paln felL
as evldenced by

O vlLal slgns lowers
lf noL reLurn Lo
normal range

8aL leasL 140/90
mmPC
88 aL leasL 20
cpm deep and
wlLhouL use of
accessory muscles

O aLlenL
verballzes
reducLlon of
paln and
lmproved
comforL

O 8aLed paln as
67 ln Lhe scale
of 010 (10 as
Lhe hlghesL and
0 as absence of
paln)
l-uLL-uL-1
Independent
1lnsLrucL paLlenL Lo
noLlfy nurse
lmmedlaLely when
chesL paln occurs








2Assess and documenL
paLlenL
response/effecLs of
medlcaLlon


3ldenLlfy preclplLaLlng
evenL lf any frequency
duraLlon lnLenslLy and
locaLlon of paln





4Cbserve for
assoclaLed sympLoms
eg dyspnea
nausea/vomlLlng
dlzzlness palplLaLlons
deslre Lo mlcLuraLe


3LvaluaLe reporLs of



1aln and decreased cardlac ouLpuL may
sLlmulaLe Lhe sympaLheLlc nervous sysLem
Lo release excesslve amounLs of
noreplnephrlne whlch lncreases plaLeleL
aggregaLlon and release of Lhromboxane
A
2
1hls poLenL vasoconsLrlcLor causes
coronary arLery spasm whlch can
preclplLaLe compllcaLe and/or prolong
an anglnal aLLack unbearable paln may
cause vasovagal response decreaslng 8
and hearL raLe

2rovldes lnformaLlon abouL dlsease
progresslon Alds ln evaluaLlng
effecLlveness of lnLervenLlons and may
lndlcaLe need for change ln LherapeuLlc
reglmen

3Pelps dlfferenLlaLe Lhls chesL paln and
alds ln evaluaLlng posslble progresslon Lo
unsLable anglna (SLable anglna usually
lasLs 313 mln and ls ofLen relleved by
resL and subllngual nlLroglycerln (-1C)
unsLable anglna ls more lnLense occurs
unpredlcLably may lasL longer and ls noL
usually relleved by -1C/resL)

4uecreased cardlac ouLpuL (whlch may
occur durlng lschemlc myocardlal
eplsode) sLlmulaLes
sympaLheLlc/parasympaLheLlc nervous
sysLem causlng a varleLy of vague
sensaLlons LhaL paLlenL may noL ldenLlfy
as relaLed Lo anglnal eplsode

3Cardlac paln may radlaLe eg paln ls
AL Lhe end of my
care Lhe ob[ecLlves
were parLlally meL as
evldenced by

1 vlLal slgns
88 23 cpm
shallow and wlLh
use of accessory
mucles
8 130/80 mm Pg

2 verballzed saklL
[ud man panlngLon
gud ko magampo
[ud ko na mawala
basLa muLukar kay
ballng saklLa"
3 verballzed naa ra
gyapon ang saklL
day"
4 8aLed paln as 7
ouL of 10 ln a scale
ln whlch 10 ls Lhe
125

makasamoL "

O 8aLed paln as 8
ln Lhe scale of 0
10 (10 as Lhe
hlghesL and 0 as
absence of paln)


Cb[ecLlve

O vlLal slgns
8 160/90
mmPg 88
30 cpm
shallow and
wlLh use of
accessory
muscles
O laclal
grlmaclng
noLed

O 8esLlessness
noLed

O SweaLlng on
forehead
noLed

O oor eye

O decreased faclal
grlmaclng noLed

O decreased
sweaLlng on
forehead

O decreased
Irequency oI chest
guarding ; placing
Iist on
midsternum

O decreaed rubbing
leIt arm

O decreased
clenchlng of flsL
and force of
hugglng Lhe plllow

O absence of
resLlessness


O good eye contact



paln ln [aw neck
shoulder arm or hand
(Lyplcally on lefL slde)

6lace paLlenL aL
compleLe resL durlng
anglnal eplsodes

7LlevaLe head of bed lf
paLlenL ls shorL of
breaLh

8MonlLor hearL
raLe/rhyLhm

9MonlLor vlLal slgns
every 3 mln durlng
lnlLlal anglnal aLLack





10SLay wlLh paLlenL
who ls experlenclng
paln or appears
anxlous


11 AccepLs cllenL's
descrlpLlon of paln



12Lncourage
verballzaLlon of feellngs
abouL paln

ofLen referred Lo more superflclal slLes
served by Lhe same splnal cord nerve
level

68educes myocardlal oxygen demand Lo
mlnlmlze rlsk of Llssue ln[ury/necrosls

7laclllLaLes gas exchange Lo decrease
hypoxla and resulLanL shorLness of breaLh

8aLlenLs wlLh unsLable anglna have an
lncreased rlsk of acuLe llfeLhreaLenlng
dysrhyLhmlas whlch occur ln response Lo
lschemlc changes and/or sLress

98lood pressure may lnlLlally rlse
because of sympaLheLlc sLlmulaLlon Lhen
fall lf cardlac ouLpuL ls compromlsed
1achycardla also develops ln response Lo
sympaLheLlc sLlmulaLlon and may be
susLalned as a compensaLory response lf
cardlac ouLpuL falls

10 AnxleLy releases caLecholamlnes
whlch lncrease myocardlal workload and
can escalaLe or prolong lschemlc paln
resence of nurse can reduce feellngs of
fear and helplessness

11 aln ls a sub[ecLlve experlence and
cannoL be felL by oLhers who do noL
experlence paln Lhus paln clalmed by
Lhe paLlenL ls Lrue

12Alds ln accommodaLlng paLlenL's
condlLlon Pelps relaxes Lhe cllenL
promoLlng effecLlve paln managemenL

grade of Lhe mosL
palnful paln felL
and 0 as Lhe
absence of paln
3 laclal grlmaclng
noLed noL
decreased

6 8esLlessness
noLed

7 SweaLlng on
forehead noLed
noLed decreased

8 oor eye conLacL
due Lo paln felL

9 ChesL guardlng
ofLen noLed placlng
flsL over mldsLernum

10 8ubblng lefL arm

11 she clenches flsL
and hugs Lhe
plllow LlghLly
when ln paln


126

conLacL due Lo
paln felL

O ChesL
guardlng
ofLen noLed
placlng flsL over
mldsLernum

O rubblng lefL arm

O When ln
paln she
clenches flsL
and hugs Lhe
plllow LlghLly





138evlew cllenLs
prevlous experlences
wlLh paln and meLhods
found elLher helpful or
unhelpful for paln
conLrol ln Lhe pasL

14rovlde comforL
measures (eg back
rub change of poslLlon)
or use dlverLlon
Lechnlques such as
readlng lf posslble

13MalnLaln quleL
comforLable
envlronmenL resLrlcL
vlslLors as necessary

16rovlde llghL meals
Pave paLlenL resL for 1
hr afLer meals

Co||aborat|ve
17rovlde
supplemenLal oxygen as
lndlcaLed

18AdmlnlsLer
anLlanglnal
medlcaLlon(s) prompLly
as lndlcaLed Asplrln
CC8 lmdur


131o uLlllze prevlous coplng mechanlsms
cllenL use ln Lhe pasL for effecLlve paln
managemenL




141o provlde nonpharmacologlc paln
managemenL dlverLlon wlll help paLlenL
redlrecL hls aLLenLlon Lhus mlnlmlzlng Lhe
paln felL



13MenLal/emoLlonal sLress lncreases
myocardlal workload


16uecreases myocardlal workload
assoclaLed wlLh work of dlgesLlon
reduclng rlsk of anglnal aLLack



17lncreases oxygen avallable for
myocardlal upLake/reversal of lschemla


18-lLroglycerln has been Lhe sLandard
for LreaLlng and prevenLlng anglnal paln
for more Lhan 100 yr 1oday lL ls avallable
ln many forms and ls sLlll Lhe cornersLone
of anLlanglnal Lherapy 8apld vasodllaLor
effecL lasLs 1030 mln and can be used
prophylacLlcally Lo prevenL as well as
aborL anglnal aLLacks LongacLlng

127












19SusLalnedrelease
LableLs capleLs
(-lLrong -lLrocap 1u)
chewable LableLs
(lsordll SorblLraLe)
paLches Lransmucosal
olnLmenL (-lLrouur
1ransderm-lLro)

208eLablockers eg
acebuLolol (SecLral)
aLenolol (1enormln)
nadolol (Corgard)
meLroprolol
(Lopressor) propranolol
(lnderal)


21Calclum channel
blockers eg beprldll
(vascor) amlodlplne
(-orvasc) nlfedlplne
(rocardla) felodlplne
(lendll) lsradlplne
(uynaClrc) dllLlazem
(Cardlzem)

22Analgeslcs eg
aceLamlnophen
(1ylenol)

preparaLlons are used Lo prevenL
recurrences by reduclng coronary
vasospasms and reduclng cardlac
workload May cause headache dlzzlness
llghLheadednesssympLoms LhaL usually
pass qulckly lf headache ls lnLolerable
alLeraLlon of dose or dlsconLlnuaLlon of
drug may be necessary -te lsordll may
be more effecLlve for paLlenLs wlLh
varlanL form of anglna

198educes frequency and severlLy of
aLLack by produclng
prolonged/conLlnuous vasodllaLlon






208educes anglna by reduclng Lhe hearL's
workload (8efer Lo -u Cardlac CuLpuL
rlsk for decreased followlng)-te CfLen
Lhese drugs alone are sufflclenL Lo relleve
anglna ln less severe condlLlons




21roduces relaxaLlon of coronary
vascular smooLh muscle dllaLes coronary
arLerles decreases perlpheral vascular
reslsLance





22usually sufflclenL analgesla for rellef of
headache caused by dllaLlon of cerebral
vessels ln response Lo nlLraLes

128


Summary of nursing iagnoses

1. lmpalred gas exchange relaLed Lo alveolarcaplllary membrane changes due Lo lnflammaLory effecLs secondary
Lo pneumonla
2. lneffecLlve alrway clearance relaLed Lo lncreased spuLum producLlon secondary Lo pneumonla
3 AlLered comforL AcuLe aln relaLed Lo presence of anglna pecLorls due Lo decreased myocardlal blood flow
and coronary arLery consLrlcLlon
4 AlLered comforL AcuLe aln relaLed Lo due Lo lnflammaLlon of lung parenchyma
S AlLered comforL AcuLe aln relaLed Lo perslsLenL coughlng
6 8lsk for decreased cardlac ouLpuL relaLed Lo lncreased vascular reslsLance
7 LxLracellular fluld volume deflclL relaLed Lo vomlLlng
8 LxLracellular fluld volume deflclL relaLed Lo polyurla
LxLracellular fluld volume deflclL relaLed Lo hyperglycemla secondary Lo uM Lype 2
108lsk for lnfecLlon relaLed Lo hlgh glucose levels
118lsk for lnfecLlon relaLed Lo decreased prlmary defenses secondary Lo uM Lype 2
128lsk for lnfecLlon relaLed Lo decreased leukocyLe funcLlon
13laLlgue relaLed Lo decreased meLabollc energy producLlon secondary Lo uM Lype 2
14laLlgue relaLed Lo lnsufflclenL lnsulln secondary Lo uM Lype 2
1SAcLlvlLy lnLolerance relaLed Lo lmbalnced oxygen suppy and demand
16AcLlvlLy lnLolerance relaLed Lo exhausLlon due Lo dyspnea



129

Summary oI nursing responsibilities/interventions:

uM
-urslng lnLervenLlons
1 AdmlnlsLer lnsulln or oral hypoglycemlc agenLs as ordered monlLor for hypoglycemla especlally durlng perlod of drug's peak acLlon
2 rovlde speclal dleL as ordered
3 MonlLor urlne sugar and aceLone (freshly volded speclmen)
4 erform flnger sLlcks Lo monlLor blood glucose levels as ordered (more accuraLe Lhan urlne LesLs)
3 Cbserve for slgns of hypo/hyperglycemla
6 rovlde meLlculous skln care and prevenL ln[ury
7 MalnLaln lC welgh dally
8 rovlde emoLlonal supporL asslsL cllenL ln adapLlng Lo change ln llfesLyle and body lmage
9 Cbserve for chronlc compllcaLlons and plan care accordlngly
a ALherosclerosls leads Lo coronary arLery dlsease Ml CvA and perlpheral vascular dlsease
b MlcroanglopaLhy mosL commonly affecLs eyes and kldneys
c kldney dlsease
l 8ecurrenL pyelonephrlLls
ll ulabeLlc nephropaLhy
d Ccular dlsorders
l remaLure caLaracLs
ll ulabeLlc reLlnopaLhy
e erlpheral neuropaLhy
l AffecLs perlpheral and auLonomlc nervous sysLems
ll Causes dlarrhea consLlpaLlon neurogenlc bladder lmpoLence decreased sweaLlng
10 rovlde cllenL Leachlng and dlscharge plannlng concernlng
a ulsease process
130

b uleL
c lnsulln
l Pow Lo draw up lnLo syrlnge
1 use lnsulln aL room LemperaLure
2 CenLly roll vlal beLween palms of hands
3 uraw up lnsulln uslng sLerlle Lechnlque
4 lf mlxlng lnsullns draw up clear lnsulln before cloudy lnsulln
ll ln[ecLlon Lechnlque
1 SysLemaLlcally roLaLe slLes Lo prevenL llpodysLrophy (hyperLrophy or aLrophy of Llssue)
2 lnserL needle aL a 43 angle or 90 angle dependlng on amounL of adlpose Llssue
lll May sLore currenL vlal of lnsulln aL room LemperaLure refrlgeraLe exLra supplles
lv rovlde many opporLunlLles for reLurn demonsLraLlon
d Cral hypoglycemlc agenLs
l SLress lmporLance of Laklng Lhe drug regularly
ll Avold alcohol lnLake whlle on medlcaLlon
e urlne LesLlng (noL very accuraLe reflecLlon of blood glucose level)
l Mya be saLlsfacLory for Lype ll dlabeLlcs slnce Lhey are more sLable
ll use CllnlLesL 1esLape ulasLlx for glucose LesLlng
lll erform LesLs before meals and aL bedLlme
lv use freshly volded speclmen
v 8e conslsLenL ln brand of urlne LesL used
vl 8eporL resulLs ln percenLages
vll 8eporL resulLs Lo physlclan lf resulLs are greaLer Lhan 1 especlally lf experlenclng sympLoms of hyperglycemla
vlll urlne LesLlng for keLones should be done by 1ype l dlabeLlc cllenL ehen Lhere ls perslsLenL glycosurla lncreased blood glucose levels or lf Lhe
cllenL ls noL feellng well (AceLesL keLosLlx)
f 8lood glucose monlLorlng
l use for 1ype l dlabeLlc cllenLs slnce lL glves exacL blood glucose level and also deLecL hypoglycemla
131

ll lnsLrucL cllenL ln flngersLlck Lechnlque use of monlLor devlce (lf used) and recordlng and uLlllzaLlon of LesL resulLs
g Ceneral care
l erform oral hyglene and have regular denLal exams
ll Pave regular eye exams
lll Care for slck days" (cold or flu)
1 uo noL omlL lnsulln or oral hypoglycemlc agenLs slnce lnfecLlon causes lncreased blood sugar
2 -oLlfy physlclan
3 MonlLor urlne or blood glucose levels and urlne keLones frequenLly
4 lf nausea and/or vomlLlng occurs slp on clear llqulds wlLh slmple sugars
h looL care
l Wash feeL wlLh mlld soap and paL dry
ll Apply lanolln Lo feeL Lo prevenL drylng and cracklng
lll CuL Loenalls sLralghL across
lv Avold consLrlcLlng garmenLs such as garLers
v Wear clean absorbenL socks (coLLon or wool)
vl urchase properly flLLlng shoes and break new shoes ln gradually
vll -ever go barefooL
vlll lnspecL feeL dally and noLlfy physlclan lf cuLs bllsLers or breask ln skln occur
l Lxerclse
l underLake regular exerclse avold sporadlc vlgorous exerclse
ll lood lnLake may need Lo be lncreased before exerclslng
lll Lxerclse ls bsL performed afLer meals when Lhe blood sugar ls rlslng
[ CompllcaLlons
l Learn Lo recognlze slgns and sympLoms of hypo/hyperglycemla
ll LaL candy or drlnk orange [ulce wlLh sugar added for lnsulln reacLlon (hypoglycemla)
k -eed Lo wear MedlcAlerL braceleL

132

8enal fallure
-urslng lnLervenLlons
1 revenL neurologlc compllcaLlons
a Assess every hour for slgns of uremla (faLlgue loss of appeLlLe decreased urlne ouLpuL apaLhy confuslon elevaLed blood pressure edema of face
and feeL lLchy skln resLlessness selzures)
b Assess for changes ln menLal funcLlonlng
c CrlenL confused cllenL Lo Llme placedaLe and persons lnsLlLuLe safeLy measures Lo proLecL cllenL from falllng ouL of bed
d MonlLor serum elecLrolyLes 8u- and creaLlnlne as ordered
2 romoLe opLlmal Cl funcLlon
a MonlLor nausea vomlLlng anorexla admlnlsLer anLlemeLlcs as ordered
b Assess for slgn s of Cl bleedlng
3 MonlLor / prevenL alLeraLlon ln fluld and elecLrolyLe balance
4 Assess for hyperphosphaLemla (paresLheslas muscle cramps selzures abnormal reflexes) and admlnlsLer alumlnum hydroxlde gels (Ampho[el
AlLernaCLL) as ordered
3 romoLe malnLenance of skln lnLegrlLy
a Assess/provlde care for prurlLus
b Assess for uremlc frosL (urea crysLalllzaLlon on Lhe skln) and baLhe ln plaln waLer
6 MonlLor for bleedlng compllcaLlons prevenL ln[ury Lo cllenL
a MonlLor Pgb hcL plaLeleLs 88C
b PemaLesL all secreLlons
c AdmlnlsLer hemaLlnlcs as ordered
d Avold lM ln[ecLlons
7 romoLe/malnLaln maxlmal cardlovascular funcLlon
a MonlLor blood pressure and reporL slgnlflcanL changes
b AusculLaLe for perlcardlal frlcLlon rub
c erform clrculaLlon checks rouLlnely
d AdmlnlsLer dlureLlcs as ordered and monlLor ouLpuL
e Modlfy dlglLalls dose as ordered (dlglLalls ls excreLed ln kldneys)
133

PyperLenslon
-urslng lnLervenLlons
1 8ecord basellne blood pressure ln Lhree poslLlons (lylng slLLlng sLandlng) and ln boLh arms
2 ConLlnuously assess blood pressure and reporL any varlables LhaL relaLe Lo changes ln blood pressure (poslLlonlng resLlessness)
3 AdmlnlsLer anLlhyperLenslve agenLs as ordered monlLor closesly and assess for slde effecLs
4 MonlLor lnLake and hourly ouLpuLs
3 rovlde cllenL Leachlng and dlscharge plannlng and concernlng
a 8lsk facLor ldenLlflcaLlon and developmenL/lmplemenLaLlon of meLhods Lo modlfy Lhem
b 8esLrlcLed sodlum kcal cholesLerol dleL lnclude famlly ln healLh Leachlng
c AnLlhyperLenslve drug reglmen (lnclude famlly)
l -ame acLlons dosages and slde effecLs of prescrlbed medlcaLlons
ll 1ake drugs aL regular Llmes and avold omlsslon of any doses
lll -ever abrupLly dlsconLlnue Lhe drug Lherapy
lv SupplemenL dleL wlLh poLasslumwasLlng dlureLlcs
v Avold hoL baLhs alcohol or sLrenuous exerclse wlLhln 3 hours of Laklng medlcaLlons LhaL cause vasodllaLlon
d uevelopmenL of graduaLed exerclse program
e lmporLance of rouLlne followup care

neumonla
-urslng lnLervenLlons
1 laclllLaLe adequaLe venLllaLlon
a AdmlnlsLer oxygen as needed and asses lLs effecLlveness
b lace cllenL ln semllowler's poslLlon
c 1urn and reposlLlon frequenLly cllenLs who are lmmoblllzed/ obLunded
d AdmlnlsLer analgeslcs as ordered Lo relleve paln assoclaLed wlLh breaLhlng (codelne ls drug of cholce)
e AusculLaLe breaLh sounds every 24 hours
f MonlLor A8Cs
134

2 laclllLaLe removal of secreLlons (general hydraLlon deep breaLhlng and coughlng Lracheobronchlal sucLlonlng as needed expecLoranLs as ordered aerosol
LreaLmenLs vla nebullzer humldlflcaLlon of lnhaled alr chesL physlcal Lherapy)
3 Cbserve color characLerlsLlcs of spuLum and reporL any changes encourage cllenL Lo perform good oral hyglene afLer expecLoraLlon
4 rovlde adequaLe resL and rellef/conLrol of paln
a rovlde bed resL wlLh llmlLed physlcal acLlvlLy
b LlmlL vlslLs and mlnlmlze conversaLlons
c lan for unlnLerrupLed resL perlods
d lnsLlLuLe nurslng care ln blocks Lo ensure perlods of resL
e MalnLaln pleasanL and resLful envlronmenL
3 AdmlnlsLer anLlbloLlcs as ordered monlLor effecLs and posslble LoxlclLy
6 revenL Lransmlsslon (resplraLory lsolaLlon may be requlred for cllenLs wlLh sLaphylococcal pneumonla)
7 ConLrol fever and chllls monlLor LemperaLure and admlnlsLer anLlpyreLlcs as ordered malnLaln lncreased fluld lnLake provlde frequenL cloLhlng and llnen
changes
8 rovlde cllenL Leachlng and dlscharge plannlng concernlng prevenLlon of recurrence
a MedlcaLlon reglmen / anLlbloLlc Lherapy
b -eed for adequaLe resL llmlLed acLlvlLy and good nuLrlLlon wlLh adequaLe fluld lnLake and good venLllaLlon
c -eed Lo conLlnue deep breaLhlng and coughlng for aL leasL 6 8 weeks afLer dlscharge
d AvallablllLy of vacclnes (pneumonococcal pneumonla lnfluenza)
e 1echnlques LhaL prevenL Lransmlsslon (use of Llssues when coughlng adequaLe dlsposal of secreLlons)
f Avoldance of persons wlLh known resplraLory lnfecLlons
g -eed Lo reporL slgns and sympLoms of resplraLory lnfecLlon (perslsLenL or recurrenL fever changes ln characLerlsLlcs color of spuLum chllls
lncreased paln dlfflculLy breaLhlng welghL loss perslsLenL faLlgue)
h -eed for followup medlcal care and evaluaLlon


Anglna pecLorls
1 AdmlnlsLer oxygen
135

2 Clve prompL paln rellef wlLh nlLraLes or narcoLlc analgeslcs as ordered
3 MonlLor vlLal slgns sLaLus of cardlopulmonary funcLlon
4 MonlLor LCC
3 lace cllenL ln seml Lo hlghlowler's poslLlon
6 rovlde emoLlonal supporL
7 rovlde cllenL Leachlng and dlscharge plannlng concernlng
a roper use of nlLraLes
l -lLroglycerln LableLs (subllngual)
1 Allow LableL Lo dlssolve
2 8elax for 13 mlnuLes afLer Laklng LableL Lo prevenL dlzzlness
3 lf no rellef wlLh 1 LableL Lake addlLlonal LableLs aL 3mlnuLe lnLervals buL no more Lhan 3 LableLs wlLhln a 13mlnuLe perlod
4 know LhaL LranslenL headache ls a frequenL slde effecL
3 keep boLLle LlghLly capped and prevenL exposure Lo alr llghL heaL
6 Lnsure LableLs are wlLhln reach aL all Llmes
7 Check shelf llfe explraLlon daLe of LableLs
ll -lLroglycerln olnLmenL (Loplcal)
1 8oLaLe slLes Lo prevenL dermal lnflammaLlon
2 8emove prevlously applled olnLmenL
3 Avold massage/rubblng as Lhls lncreases absorpLlon and lnLerferes wlLh Lhe drug's susLalned acLlon
b Ways Lo mlnlmlze preclplLaLlng evenLs
l 8educe sLress and anxleLy (relaxaLlon Lechnlques gulded lmagery)
ll Avold overexerLlon and smoklng
lll MalnLaln lowcholesLerol lowsaLuraLed faL dleL and eaL small frequenL meals
lv Avold exLremes of LemperaLure
v uress warmly ln cold weaLher
c Cradual lncrease ln acLlvlLles Lo exerclse
l arLlclpaLe ln regular exerclse program
136

ll Space exerclse perlods and allow for resL perlods
8 lnsLrucL cllenL Lo noLlfy physlclan lmmedlaLely lf paln occurs and perslsLs desplLe resL and medlcaLlon admlnlsLraLlon



















RELATED READINGS

Summary oI the Article: Diabetes No Reason To Hesitate About Vascular Surgery by Shauna S. Roberts, PhD
ReIerence: Roberts, S.S.(Jan 2003).Diabetes Forecast(Vol 56 Num 1). Diabetes No Reason To Hesitate About Vascular Surgery.
Virginia:American Diabetes Association.p83-86
137


Accordlng Lo a new sLudy dlabeLlc people have beLLer posLoperaLlve survlval raLes followlng vascular surgery compared Lo Lhose people wlLhouL dlabeLes
1he sLudy was publlshed ln Lhe Aprll 2002 tcblves f 5otqety 1he auLhors wanLed Lo LesL Lhe wldely held bellef LhaL dlabeLlc people are aL hlgher rlsk for deaLh
followlng ma[or vascular surgery surgery on Lhe caroLld arLery aorLa or a leg arLery ulabeLlc people are usually Lhe ones who need vascular surgery So knowlng
how safe lL ls for Lhem Lo undergo Lhe procedure ls slgnlflcanL
1he daLa from !an 1 1990 Lo May 31 2000 on all paLlenLs havlng ma[or vascular surgery aL Lhelr hosplLal were gaLhered by Lhe researches uurlng Lhls
Llme 3126 people had 6363 procedures and 2/3 of Lhem are dlabeLlc So Lhe researches Lhen compared Lhe overall deaLh raLe hearL aLLack raLe and congesLlve
hearL fallure ln people wlLh wlLhouL dlabeLes
ConLrary Lo common wlsdom dlabeLlc people had slgnlflcanLly lower posLoperaLlve deaLh raLes of 096 percenL dled versus 146 percenL of people wlLhouL
dlabeLes 1he raLes of hearL aLLack and congesLlve hearL fallure were noL slgnlflcanLly dlfferenL beLween Lwo groups 1he researches Lhen looked aL whaL LralLs
lnfluenced Lhe paLlenL's shorLLerm survlval raLes eople who had undergone dlalysls were Lhree Llmes as more llkely Lo dle followlng Lhe surgery as Lhose who
had noL 1hose wlLh congesLlve hearL fallure were Lwlce as llkely Lo dle
Pavlng already had a hearL aLLack doubled Lhe rlsk of havlng a hearL aLLack afLer vascular surgery eople who had hlgh blood pressure or congesLlve hearL
fallure before surgery were roughly Lwlce as llkely Lo have congesLlve hearL fallure afLerwards 1he researchers were uncerLaln why dlabeLlc people fared beLLer
afLer vascular surgery AfLer 3 years hlgher percenLage of dlabeLlc people had dled compared Lo people wlLhouL dlabeLes 1he reason remalns unknown
1he sLudy ls good news lf one needs ma[or blood vessel surgery lL lndlcaLes LhaL one can welgh Lhe pluses and mlnuses of Lhe surgery wlLhouL worrylng
any addlLlonal lmmedlaLe posLoperaLlve rlsks caused by dlabeLes






Reaction to the article:
As whaL mosL dlabeLlc people would say LhaL dlabeLes ls a klller dlsease lL ls Lhe rooL of all evlls as lL affecLs many parLs speclflcally ma[or organs of Lhe
body llke Lhe eyes and Lhe kldney lL has a hlgh raLlng of compared Lo oLher dlseases as lL happens Lo varled age group and ls heredlLary ln Lhe arLlcle lL was
unllkely Lo read someLhlng good abouL dlabeLes slnce lL has been consldered as a number one enemy
ulabeLlc people are more suscepLlble Lo have oLher compllcaLlons slnce sugar plays a blg role ln Lhe body So lL was a good Lhlng Lo know LhaL dlabeLlc
people now has a brlghLer hope especlally Lo Lhose who wlll be undergolng ma[or vascular surgery l wanLed Lo lmparL Lo oLher people or paLlenLs whaL l have
read l wanLed Lo glve Lhem hope and Lell Lhem Lhe good news slnce lll people usually llve ln a dark place of hopelessness AlLhough Lhe surgery wlll noL assure a
llfeLlme LreaLmenL buL Lhe addlLlonal year Lo llve one's llfe ls already a glfL of sclence from Cod lL says ln Lhe arLlcle LhaL Lhey haven'L found ouL yeL Lhe reason for
such beLLer posLoperaLlve raLlng of dlabeLlc people undergolng Lhe surgery compared Lo Lhose who are noL dlabeLlc buL l hope and l am qulLe sure wlLh Lhe
138

advance Lechnology LhaL we have nowadays sLudles wlll be conducLed ln Lhe fuLure as whaL oLher poslLlve sldes wlll a dlabeLlc person have WhaL l mean ls lL ls
nlce Lo unload even a llLLle burden 8elng dlabeLlc ls much of a responslblllLy slnce drug malnLenance ls closely observed and havlng Lo undergo a ma[or vascular
surgery wlll make one's llfe darker and heavler because all surgerles may lL be ma[or or mlnor lL wlll always be consldered as a ma[or for a person unless LhaL
person ls medlcally relaLed and knowledgeable
1he arLlcle has boLh smooLh and rough sldes lL ls lndeed good news for Lhose who are dlabeLlc buL lL ls oLherwlse Lo Lhose who are noL lL ls a LhreaL Lo
Lhose people who are noL dlabeLlc LhaL wlll be havlng Lhe surgery 8uL Lhen Lhe researchers also found ouL LhaL flve years laLer Lhose who are dlabeLlc LhaL have
undergone Lhe surgery has hlgher percenLage of deaLh compared Lo Lhose who are noL whlch lmplles LhaL dlabeLes ls sLlll Lhen a klller afLer all buL aL leasL Lhelr
llfe was exLended Lo 3 yrs lf Lhey wlll noL have Lhe surgery Lhelr llfe wlll probably be shorLer slnce vascular surgery ls necessary Lo susLaln Lhe blood flow 1he
surgery ls an lnvaslve procedure so mosL probably Lhe paLlenL wlll be fearful and wlll conslder noL havlng Lhe surgery aL all slnce he or she wlll anyway dle ln Lhe
long run buL wlLh whaL Lhe researchers found lL lL wlll mosL llkely change Lhelr declslons and would raLher Lake Lhe rlsk
Surgerles do have posLoperaLlve rlsks whlch are blg concerns of a surglcal paLlenL buL wlLh Lhe uocLor's proper explanaLlon of Lhe beneflL wlll and can help
lessen Lhe anxleLy of Lhe dlabeLlc lndlvldual eople wlll pay and do anyLhlng Lo exLend llfe and havlng a dlabeLes ls a very dlfflculL Lo deal wlLh lL's nlce Lo know
LhaL sLudles are done Lo help paLlenLs loose dark days of Lhelr llves and make Lhem llve longer by answerlng Lhe many whaL lf" ln Lhelr mlnd 8uL Lhen Lhe sLudy
does noL refer Lo a 100 percenL assurance so rlsk ls always a parL of lL 1he safesL and [usLlflable Lhlng LhaL medlcal personnel should do ls Lo be honesL of Lhe
pluses and mlnuses of Lhe surgery









Summary oI the article: Surgery for Obesity by Robert J. Tanenberg, MD, and Walter Pories, MD
ReIerence: Tanenberg, R.J.(April 2005).Diabetes Forecast (Vol 55 Num 4).Sugery for Obesity.Virginia:American
Diabetes Association.p81

Morbldly obese lndlvlduals have dlfflculLles ln cerLaln AcLlvlLles of dally llvlng have mulLlple healLh problems assoclaLed wlLh lL lncludlng Lype 2 dlabeLes
sleep apnea hearL dlsease and osLeoarLhrlLlsA consensus conference on morbld obeslLy concluded LhaL dleLs exerclse programs appeLlLe suppressanLs and
139

behavlor modlflcaLlons are noL effecLlve Lheraples" for people wlLh morbld obeslLy lL ls recommended LhaL surgery be consldered for people whose 8Ml ls
greaLer Lhan 33 who also have serlous medlcal problems LhaL would lmprove wlLh welghL loss
8CCLuu8L 8lML8
Surgery for obeslLy known as barlaLrlc surgery" lncludes Lhe mosL common procedures resLrlcLlve procedures whlch llmlL Lhe amounL of food ln Lhe sLomach
and malabsorpLlve procedures" whlch lnLerfere wlLh Lhe dlgesLlon of food 8esLrlcLlve and malabsorpLlve procedures" whlch boLh llmlL Lhe amounL of food ln
Lhe sLomach and lnLerfere wlLh dlgesLlon
8LS18lC1lvL 8CCLuu8LS
A less popular operaLlon known as verLlcal banded gasLroplasLy or sLomach sLapllng" lnvolves sLapllng Lhe sLomach so LhaL a small ouLleL ls formed Lhen
relnforced wlLh a plasLlc band Ad[usLable gasLrlc bypass or gasLrlc bandlng" ls performed wlLh a laparoscope and so does noL requlre a large lnclslon Powever
Lhe amounL of welghL losL ls generally less Lhan Lhe welghL loss resulLlng from Lhe nonad[usLable gasLrlc bypass procedure whlch ls descrlbed below
CCM8l-A1lC- 8CCLuuu8L
1he mosL common Lype of obeslLy surgery ls CasLrlc bypass" or a Creenvllle bypass" llmlLs boLh food lnLake and lnLerferes wlLh dlgesLlon lL creaLes a small
sLomach pouch LhaL holds abouL an ounce of volume buL sLreLches rapldly Pence lL llmlLs Lhe amounL of food Lhe sLomach can hold and lnLerferes wlLh dlgesLlon
More complex verslons Lend Lo have more posLoperaLlve problems
LlkLL? CA-uluA1LS
lL ls for people who have a 8Ml greaLer Lhan 40 or a 8Ml greaLer Lhan 33 wlLh oLher medlcal condlLlons lL ls known Lo lmprove afLer welghL loss lncludlng Lype 2
dlabeLes eople wlLh a hlsLory of drug or alcohol abuse or unresolved depresslon and Lhose who lack famlly supporL may noL be candldaLes Age ls noL a facLor
paLlenLs beLween Lhe ages of 16 and 72 have had successful obeslLy surgery whlch ls done by a skllled barlaLrlc surgeon 1he hosplLal should have speclal
equlpmenL Lo accommodaLe morbldly obese paLlenLs sLaff experlenced ln carlng for such paLlenLs and a culLure conduclve Lo supporLlng obese paLlenLs 8efore
Lhe operaLlon paLlenLs need Lo be assessed by speclallsL such as carldologlsLs pulmonologlsLs lL wlll lasL for Lwo Lo four days
CCMMC- CCMLlCA1lC-S
Larly compllcaLlons can cause deaLh durlng Lhe surgery lnfecLlons lnLernal leaklng aL Lhe surgery slLe and rarely pulmonary emboll 8uL good posLoperaLlve care
can keep Lhese compllcaLlons Lo a mlnlmum 1here are also laLer compllcaLlons such as gallsLones hernlas aL Lhe lnclslon malnuLrlLlon depresslon and fallure of
Lhe sLaple llnes 8uL wlLh laparoscoplc surgery Lhere ls less posslblllLy of scarrlng and chance of hernlaroper nuLrlLlon ls lmporLanL afLer Lhe surgery Lo prevenL
Lhe developmenL of severe vlLamln and mlneral deflclencles 1o prevenL posLoperaLlve nerve dlsease from malnuLrlLlon of Lhe 8 vlLamln paLlenLs musL Lake boLh
a supplemenLal 8 complex and 812 1o prevenL osLeoporosls female paLlenLs should Lake calclum supplemenLs and vlLamln u buL lf Lhey are sLlll mensLruaLlng
Lhey have Lo Lake lron Lo prevenL anemla
WLlCP1 LCSS C1L-1lAL
AfLer 1
sL
yr of Lhe bypass more Lhan 100 pounds ls losL wlLh an addlLlonal welghL loss over Lhe nexL slx Lo 12 monLhs AfLer 3 yrs Lhe paLlenL wlll malnLaln an
average welghL loss of 60 percenL of Lhelr excess body welghL
8LvL8SAL ulA8L1LS
140

aLlenLs followed aL LCu are 27 percenL dlabeLlc and an equal number had glucose lnLolerance aLlenLs whose dlabeLes dld noL enLlrely reverL Lo normal Lended
Lo be older and Lo have had dlabeLes for a longer Llme before surgery
LC-CL8 PLAL1PlL8 LlvLS
1he annual deaLh raLe of morbldly obese dlabeLlc paLlenLs who dld have Lhe surgery was almosL flve Llmes hlgher compared Lo Lhose who had Lhe procedure
AfLer Lhe surgery only 14 ouL of 333 hyperLenslve paLlenLs were requlred Lo Lake medlcaLlons for hyperLenslon Sleep apnea snorlng and pepLlc reflux were no
longer presenL Cardlopulmonary funcLlons asLhma and osLeoarLhrlLls were all markedly lmproved Wheelchalr bound paLlenLs are able Lo walk unasslsLed afLer
welghL loss
CSSl8LL CCMLlCA1lC-S
1he blood sugar levels of paLlenLs are correcLed wlLhln days afLer havlng Lhe surgery and Lhelr normallzed blood sugar levels conLlnue for molre Lhan 14 yrs 1hese
paLlenLs remaln abouL 30 percenL above Lhelr body welghL 8lood sugar levels of dlabeLlc paLlenLs drop all Lhe way Lo normal range afLer a week of gasLrlc bypass
and also lmprovemenL ln abnormally hlgh lnsulln level of Lype 2 dlabeLes 1hey lose more welghL and have a greaLer cure raLe of Lype 2 dlabeLes afLer compared
Lo gasLrlc bondlng
ullllCuL1 uLClSlC-
uesplLe uslng drugs and lnsulln lf one's dlabeLes has sLlll been unconLrolled surgery may be Lhe only opLlon 1o quallfy for Lhe bypass one musL meeL flrsL Lhe
welghL crlLerla for morbld obeslLy 1he dlabeLes care provlder should refer Lhe person Lo a quallfled barlaLrlc surgeon


Reaction to the Article:
1he surgery ls for morbldly obese lndlvldual and lL needs quallflcaLlons Lo be candldaLe for Lhe surgery lL has boLh advanLages and dlsadvanLages Well l
have heard Lhe surgery before and even saw a segmenL abouL lL on Lelevlslon 1he surgery would deflnlLely requlre a sLrlcL declslon maklng buL for a paLlenL who
ls dylng Lo geL Lhln and ls sufferlng from cerLaln condlLlons such as dlabeLes Lype 2 would deflnlLely grab Lhe opporLunlLy slnce less sLraln wlll be needed unllke
golng Lo Lhe gym everyday and dleLlng lL ls very dlfflculL Lo face a plaLLer of food each day and resLrlcLlng self Lo eaL and wlll mosL llkely lead Lo gullLy feellngs Lhen
aL Lhe end one wlll flnd hlmself eaLlng a bunch of faLLy foods agaln 1he lmporLanL Lhlng ls LhaL one should be flnanclally ready for lLs cosLs lncludlng Lhe hosplLal
sLay as lL wlll lasL for Lwo Lo four days lamlly supporL should also be presenL as recovery from Lhe surgery would requlre asslsLance of Lhe slgnlflcanL oLhers l
Lhlnk Lhe surgery ls noL pracLlcal lf one has a flnanclal problem buL for Lhose who can afford Lhere ls no problem slnce Lhe operaLlon wlll also LreaL cerLaln
problems such as dlabeLes Lype 2 and noL only Lhe problem wlLh obeslLy

1he surgery would requlre honesL medlcal people LhaL would lnqulre Lhe paLlenLs regardlng Lhe smooLh and rough sldes of Lhe surgery Cf course lL also
needs a compeLenL surgeon Lo be performlng Lhe operaLlon ln a hosplLal wlLh such rellable equlpmenLs 1hls surgery may be a greaL help noL only for obese
persons Lo become flL and reduce ln slze buL also Lhe assoclaLed problems wlLh Lhe hearL sleep apnea and osLeoarLhrlLls 1here are people who puL efforL on
141

exerclslng everyday and cuL Lhelr bread lnLo small pleces buL sLlll are upseL of Lhelr excess welghL and excess healLh problems such as dlabeLes Lype 2 so Lhe
surgery may be a good opLlon for Lhem

As nurses knowlng Lhe rlsks LhaL mlghL happen durlng and afLer Lhe surgery cerLaln posLoperaLlve care should be done compeLenLly Lo avold cerLaln
compllcaLlons 8uL ln cerLaln hosplLals LhaL lack Lhe equlpmenLs and supplles necessary for Lhe ldeal care of Lhe paLlenL wlll deflnlLely make Lhe recovery of Lhe
paLlenL rough and resulLs Lo rooLs of problems laLer on l know LhaL posLoperaLlve care plays a very lmporLanL role ln Lhe recovery and parL of Lhe success of Lhe
surgery buL no maLLer how Lhe nurses wanLed Lo help Lhe paLlenL Lhe lnsLlLuLlons usually lacks cerLaln equlpmenLs maklng lL hard Lo accompllsh genulne nurslng
care CbeslLy had been a very common problem Lo Lhe socleLy and Lo medlcal Leam because lL does noL choose cerLaln age group buL lL LargeLs any one and Lhe
sad Lhlng ls LhaL lL ls accompanled by much oLher desLrucLlble dlsease such as dlabeLes Lype 2 1he llfe of an obese person may be called heaven and hell lL ls
heaven ln Lerms of eaLlng and eaLlng of food buL Lhe hell comes when Lhe dlsease condlLlons becomes Lhe consequences

Lvery surgery no maLLer how successful lL was raLed and performed for Lhousands of Llme Lhe rlsks are always Lhere 1hls surgery sLlll has unwanLed resulL afLer
buL l am confldenL LhaL as Lechnology grows more advance Lhe surgery wlll made perfecL l Lhlnk lL wlll be upseLLlng Lo see a mouLh waLerlng dlshes afLer belng
operaLed such slnce Lhe sLomach wlll already has lesser capaclLy yeL Lhe food preferences and was noL changed nor reduced l wonder lf how Lhe paLlenL wlll
conLrol such lnsLance when he sLlll wanLs Lo eaL buL he already ls feellng full

lor me as a sLudenL nurse lL ls sLlll besL Lo encourage exerclse and proper dleL raLher Lhan underLaklng surgery excepL for cases LhaL are hopeless and needs
lmmedlaLe care Cur duLy ls Lo ensure Lhe consenL has been slgned and LhaL all Lhe quesLlons of Lhe paLlenL wlll be answered and ralsed Lo Lhe docLor because Lhe
changes done wlll be permanenL




SYNTHESS

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142

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|]r]|r|]]]|j]]rlg|rg]l(|rjr]l(,(ggglgg]||r]|j}]-r(,
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|(l(|rgl(gl]l(,(gr](g|,|lr,lrrl]j|(g(]l((]](]l

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j]l(]-(g]]|]j\],j]||,]||jrl]-||j(gr,(](,(gj|,l|,j|(g]|,||jl(]g
]]]|(]r-||]|gl]r,j\],j,]jr(|g]]gl--r(](j|l]l(|(]|gl(gl]l(
(]r]g jrjr|, g ] l(--]l ]|rj]l (g ((]|rj]l ((((] 1| r(| -(]l( --]g l(
grl(r,]|rjl]l((g|]|rl(rg||]r|l(]|j|g;|,jr](l(|lg(]g ]rl
;]|l((((rj(|l(jlrgl(j]ljl|l],]j(((l;]|grl((,rgl|jj|,|g]
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|rrl]((g||]|l(-|((]l(-|(jr(|,(|g]j|((r,(]l(

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]|l|]|jr|-]|]|jr(|l|1|lrjr]l|||jr(]jrjr(rl(((((]-j]l(]/jrl(l(
|(gl]l(((]l(g(g||]|jlj|(rl(gl(jl-]]||l(]1|r|]rl(]|j]|j|,l|,,
j|]-l(g]]|-]|l|((g,(j](((l-]gj,]|j]l(]|gl--l|],l(jr]|l(,g((
j]||(g-];(l]l(-l(]g-g;(gjr]l|l]||l]l|j]()(gl]|]|l,jrjrl(]r(]l(l||j
j|((gl|,|(l(]|j|r(g-]|gl



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!ra Souee. Hs. Vrllaios, Aada

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