A Case Study Presented to the Faculty of The Ateneo de Davao University College of Nursing

A Case Study on

Cholecystitis with Gallstones, Diabetes Mellitus Type 2

Submitted by: Kristi Ann Cabonita Marie Allexis Campaner Francis Thomie Caranay Rico Janrev Castaeda Rashed Eduard Ceniza Joanna Paula Concepcion

Submitted to: Loreto Deonaleth Estor, RN, MN

July 2010

TABLE OF CONTENTS

Acknowledgement.3 Introduction4 Objectives..6 Patients Data.8 Genogram Health History.9 Developmental Data...12 Physical Assessment...17 Complete Diagnosis21 Anatomy and Physiology22 Etiology27 Symptomatology..32 Pathophysiology...35 Doctors Order..49 Diagnostic Examination...58 Drug Study74 Nursing Theories92 Nursing Care Plans.95 Discharge Planning.107 Prognosis.110 Conclusion..113 Recommendation.114 Bibliography.117

ACKNOWLEDGMENT

In accomplishing great things, we must not only think, but believe in the power of our cognition; not only aim but make our visions tangible; and at the end of the day, not only smile at the thought of accomplishment, but look back to where the strength to achieve such success came from. The proponents would like to extend their warmest gratitude to all the people who helped make the success of this undertaking a reality. First and foremost, to our parents, for giving us support and encouragement every day, for making us feel loved and cared for. To our Clinical Instructor, Mrs. Loreto Deonaleth Estor, RN, MN, for her invaluable time and effort rendered to us; for her guidance all throughout the our ward exposure. For being a friend and companion in the area. And lastly, to the Almighty Father, for His unceasing love and blessings; for giving us enough power and fortitude to face all the hardships in the making of this work. To Him be all glory and praise!

INTRODUCTION

The gallbladder is a small pear-shaped organ which aids in the digestive process. Its function is to store and concentrate bile - a digestive liquid continually secreted by the liver. The bile in turn emulsifies fats and neutralizes acids in partly digested food. Despite its importance in the digestion of fat, many people are unaware of their gallbladder. Fortunately enough, the gallbladder is an organ that people can live without. Perhaps, this fact contributes to the laxity of the majority. The gallbladder tends to be taken for granted ignored of the proper care and conditioning. Lifestyle together with heredity, sex, race and age are just some factors that leave a room for gallbladder complications to occur. This study is about cholelithiasis. Problems with the way bile is made and excreted (emptied) from the gallbladder may cause cholelithiasis. Bile is a balanced mixture of water, cholesterol (fat), bile salts and bilirubin (yellow pigment). Stones may be made from different bile materials. Cholesterol stones are formed when the bile has too much cholesterol and not enough bile salts. It is thought that liver and blood diseases, such as hepatitis and anemia, may cause pigment stones. Gallstones may also be formed when bile does not empty from the gallbladder as fast as it should. In an Italian study, 20% of women had stones, and 14% of men had stones. In a

Danish study, gallstone prevalence in persons aged 30 years was 1.8% for men and 4.8% for women; gallstone prevalence in persons aged 60 years was 12.9% for men and 22.4% for women. (http://emedicine.medscape.com/article/774352-overview). In the Philippines, there were 131 males (18%) and 609 (82%) females, with a female ratio male 4.6:1. Benign lesions

comprised 99% (mean age 36), mostly chronic cholelithiasis (97%) and acute cholelithiasis which constituted 15 cases only (2%), malignant lesions comprised only 7 cases for example 1% of all lesions (mean age 65)

(http://www.thedoctorsdoctor.com/diseases/gallbladder_chronic_cholelithiasis.htm#epidemiolog y). The significance of studying this case is to enhance or broaden our knowledge as well as the patients who are suffering this disease and also to those people who are in high risk of having this disease for us to share our knowledge for the primary prevention and simple interventions of the disease. Thus they are in a pursuit for knowledge to be able to impart it to others. Furthermore, this case is quite interesting since it does not always affect only females and elderly. It can affect everyone. It can be alarming since many people are confused and unaware of the symptoms presented. As teen-agers living in a fast-phased world and governed by schedules, they too are predisposed to lifestyle modification especially diet and food preferences which can contribute to the disease. With this study, the student nurses hope to apply their learning in taking care not only of their patients but also of themselves.

OBJECTIVES

After 3 days of data gathering, research and analysis, the student nurse shall have devised objectives that will guide them for the proper understanding and fair interpretation of the case of their chosen patient.

GENERAL OBJECTIVES Cognitive The student nurses first main goal is to gain knowledge through the completion of the case study and to impart this learning to the patient, and to those directly and indirectly involved with the completion of this case. Specific Objectives under Cognitive aspect Within the 3 days span of duty, the student nurses will be able to: Gather significant data from the patients chart which includes the doctors order, laboratory exams and etc. to have complete information about the patients current condition. Research on the anatomy and physiology of the clients affected system. Research on the possible causes and also the symptoms the patient experienced that may suggest the current condition of the patient. Research and understand the disease process of the patients illness. Determine and interpret the medical management employed including laboratory and diagnostic procedures.

Identify and study the drugs prescribed to the patient which affects the patients current situation.

Psychomotor In this aspect, the student nurses goal is to apply all what they have learned during the process of completing this case study to improve nursing care that will meet the patients need for the improvement of his general welfare.

Specific Objectives under Psychomotor aspect Within the 3 days span of duty, the student nurses will be able to: Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need Formulate nursing care plans and apply them to satisfy the patients needs and give appropriate nursing interventions. Make a discharge plan for the patient using M.E.T.H.O.D and validate the patients prognosis according to categories.

Affective With the knowledge gained and through the application of this knowledge, another goal is that the student nurses will be able to empathize with the current situation of the patient and to gain some values like the value of patience and calmness which is important for a them to have in order to become better nurses in the future.

Specific Objectives under Affective aspect Within the 3 days span of duty, the student nurses will be able to: Establish rapport and therapeutic communication in order to gain information about the patient which includes the medical and family health history, expectations of his condition, gather significant data from the patients chart and to his family and etc.; and for the betterment of nursing care. Assume the role of being the patients advocate.

Patients Data Name: Tommy Age/sex: 59y.o/M Address: 396 KM 5 Sampaguita St. Buhangin, Davao City Birth date: 08/14/1950 Birthplace: Davao Oriental Father: Francis Mother: Marie Date of Admission: 06-30-2010 Admitting physician: Dr. Analisa Moscoso Chief Complaint: Right upper quadrant abdominal pain History of Past illness: Childhood- no previous admission or operation Adult- hypertensive, diabetic Injuries- none Personal history: smoker, no food allergies , alcoholic,

History of present illness: Patient is a known hypertensive and diabetic. 4 days PTA the patient had an onset of abdominal pain located more on the epigastric area with lower back pain. He consulted a physician and was again diagnosed with UTI and was given Ofloxacin. One day prior to admission still with abdominal pain but patient verbalized it was more on the right upper quadrant area, with fever. He was advised to have an abdominal ultrasound.

FAMILY BACKGROUND AND HEALTH HISTORY Family Background The patients parents, Francis who died with an ulcer and hypertension and Marie have 8 children. The patient is the second child among the children which is comprised by four boys and four girls. The family used to live in Manay however in the year 1970 the couple decided to transfer to Davao City for good together with their children. Our patient named Tommy was already 20 years old then. In the year 1972 he met his wife Tessa whom he married in the year 1977. Until now they still live in Davao City particularly at Buhangin. Their marriage gave them 4 children with two boys and two girls. Their eldest child is already a graduate of a business course but is jobless right now while the second child is presently working as a manager in a private company. The third child works as a clinical instructor at the University of Immaculate Conception. Lastly their youngest child is still a trainee at the Bureau of Fire and Protection. The couple have their own small business which serves as their source of income. The couple usually earns at around 30,000-40,000 a month with nata de coco production business here in Davao and a coconut plantation in Manay. The family belongs to the middle class. Since the family earns a decent amount of cash, they have their own private vehicle as means of their transportation, their monthly electricity bill will range from 3,000-5,000 pesos, their water bill is within 600-1000 pesos, their food would range at 10,000 pesos a month, and they have their own helper. Lifestyle and diet Tommy wakes up at around 4:00-5:00 a.m. he then goes jogging and sometimes biking which has been his daily routine until he got sick. Their usual meals include fish, meat and vegetables. They also love eating fruits for desert like Durian. He also used to play

basketball regularly but stopped during his 40s. He claims that he used to smoke 2 packs of cigarette a day and also stated that he used to drink a bottle or two of beer with his friends every week. Past Health and Medical History The patient claimed that he didnt have a single immunization during his childhood. He has been a hypertensive for four years, they have known this when he went for a check up in the year 2006,he was then prescribed by the physician with a maintenance medication; Pritor 4 mg 1 tablet OD. He has also been a diabetic for three years now with a medication of Lamiperide 3 mg OD. He has no food allergies. Present Health and Medical History Patient is a known hypertensive and diabetic. 4 days PTA the patient had an onset of abdominal pain located more on the epigastric area with lower back pain. He consulted a physician and was again diagnosed with UTI and was given Ofloxacin. One day prior to admission still with abdominal pain but patient verbalized it was more on the right upper quadrant area, with fever. He was advised to have an abdominal ultrasound. Effects / Expectation of Illness With that experience, Tommy was able to realize how important it is to have prompt treatment to an illness. He stated the importance of a healthy balanced diet together with the destructive effects of smoking and drinking. Because of his experience he learned to be cautious. He and his family expect him to get well as soon as possible after the treatment and management done to him.

DEVELOPMENTAL DATA

Erikson's Stages of Psychosocial Development Erikson's eight stages reflect both positive and negative aspects of the critical life periods. Erikson envisions life as a sequence of levels of achievement. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial, or unsuccessful. Erikson believes that the greater the task achievement, the healthier the personality of the person; failure to achieve a task influences the person's ability to achieve the next task. These developmental tasks can be viewed as a series of crises, and successful resolution of these crises is supportive to the person's ego. Failure to resolve the crises is damaging to the ego.

Stage

Description

Result

Justification

Middle Adulthood

According to Erik Erikson, the ACHIEVED developmental task in middle adult

Tommy is able to display behaviors that are acceptable for his age that could say that he achieved generativity. He is able to expand his interests at this time with his familys support and has assumed the responsibilities of middle aged person.He mostly spends his time with

(25 to 65 years is concerned for the next years old) generation as well as involvement family, friends, and

GENERATI with VITY

vs. community. Generativity is the of the establishing next and

STAGNATI concern ON guiding

generation.

Socially-valued disciplines are

work expressions

and of

his family together. Even though his children are all grown up and busy with their own life, they still make time for each other and share to each other their experiences. Their family is very open to each other. Each family member is able to express his/her feelings and opinions. Tommy is a very responsible father to his children and a father to his wife. As a father, he has molded his children into a better person they are today, good and responsible person. As a middle-aged adult, he is in to various activities in the society in order to maintain a good societal functioning like participating in the development of their own community.

generativity. Simply having or wanting children does not in and of itself achieve generativity. During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativitya sense of

productivity and accomplishmentresults. In contrast, a person who is self-centered and unable or

unwilling to help society move forward develops a feeling of stagnation- dissatisfaction with the relative lack of productivity.

Kohlberg's Stages of Moral Development This theory specifically addresses moral development in children and adults. The morality of an individuals decision was not Kohlbergs concern; rather, he focused on the reasons an individual makes a decision. Stage Description Result Justification

PostConventional Stage (Social contract orientation)

People

who

exhibit

At this stage of Kohlberg's Moral Development theory, the client

postconventional morality view ACHIEVED rules as useful but changeable mechanismsideally rules can maintain the general social order and protect human rights. Rules are not absolute dictates that must be obeyed without question. Contemporary

begins to account for the differing values, opinions and beliefs of other people. The patient views rules of law are important for maintaining a society, but members of the society should agree upon these standards. The family members are able to express their feelings and thoughts. They are very open to each other. The patient sees to it that the decision of the family should be based on everybodys opinion. They

theorists often speculate that many people may never reach this level of abstract moral reasoning. The world is viewed as holding

different opinions, rights and values. Such perspectives

discuss in the family if there are any problems. Tommy sees to it that everybody should be equal.

should be mutually respected as unique to each person or

community. Laws are regarded as social contracts rather than rigid edicts. Those that do not promote the general welfare should be changed when

necessary to meet the greatest good for the greatest number of people. This is achieved

through majority decision, and inevitable Democratic ostensibly reasoning. compromise. government based on is this

Freud's Model of psychosexual development According to Freuds theory of psychosexual development, the personality develops in five overlapping stages from birth to adulthood. The libido changes its location of emphasis within the body from one stage to another. Therefore, a particular area has special significance to a client at a particular stage. If the individual does not achieve a satisfactory progression at each stage, the personality becomes fixated at that stage. Stage Description Result Justification

Genital (13 years Energy is directed and older) toward attaining a full sexual maturity and function and development of skills needed to cope with the environment. This stage involves a reactivation of the pre-genital impulses. These impulses are usually displaced, and the individual passes to the genital stage of

ACHIEVED

Tommy is happily married with Tessa and is still together and loving each other. The couple have four children. Although they are not very active nowadays in terms of their sexual drives, yet they still manage to show their love through a very mature way, in loving and caring each other as well as to their children. According to Tommy, he did not experience any sexual problem. He has his family and other loved ones who guide and help him

maturity. An inability to resolve conflicts can result in sexual problems, such as frigidity, impotence, and the inability to have a satisfactory sexual relationship.

through the problems in life.

Physical Assessment

General Survey Physical assessment was taken on July 6, 2010 at 11:00am, Six days 10 hours and 45 minutes after time of admission, 3 daysafter surgery. Received Sitting on bed, conscious, alert and responsive with an on-going IVF bottle number D5LR + moriamin 2ampule at 170cc level infusing well at a rate of 42-43 gtt/min to left metacarpal vein. Upon entering in the room of a 59 year old male with spectacles who is watching television with a height of 59 with a weight of 181 pounds and is wearing a dark blue colored t-shirt and short pants. Appears clean and neat with hair combed. No noted foul body odor. Was relaxed, fully rested with no hesitancy in changing body position. With good range of facial expressions varying with mood. No noted pallor or other noticeable signs of illness. Is cooperative and able to follow requests with promptness and is in a sociable mood and willing to interact. Speech is understandable, moderate pace. Voice is fully audible, speaks at moderate volume and has clear voice tone. Speaks clearly with coherent organization of thought, speaks in logical sequence, makes sense and has good sense of reality with minimal vagueness and is able to further respond to and clarify inquiries. Vital Signs are: Blood Pressure: 130/100 Respiratory Rate: 18 Pulse Rate: 82 Temperature: 36.1

Neurological System Has no noted difficulty in speaking: Is fully oriented upon interview and is able to state the current location, time of the day, day of the week, duration of hospital stay, duration of illness and the names of the family members. With regards to memory, is able to recall various events of the day including time seen by the physician and visits my family members and is also able to recall and reiterate information given early in the interview. However has problems recalling some health details such as the grade of eyeglasses. Has good attention span with maintained eye contact. Fully conscious with spontaneous eye opening. Good motor function upon verbal request and is able to converse normally with good grammar, sentence structure and showed ability to speak bilingually.

Skin Upon inspection, skin color varies from light to deep brown. Skin is generally uniform except in areas exposed to the sun including face and upper extremities which is of a darker tone. Skin is generally uniform except the areas exposed to the sun. areas of lighter pigmentation include the palms, lips and nail beds. No edema noted. Moderate amount of facial wrinkles noted most abundant on outer canthus of the eye, under the eye and around the mouth. Minimal amount of dark spots and moles noted in left and right side of face particularly below the eye, neck and chest. With noted patch of dry skin approximately 3 inches in length on right inner foot proximal to talus bone and also on right elbow. Upon palpation, skin was neither excessively dry nor excessively moist. Skin felt generally warm on areas under the cover of clothing but cool on the

arms. With a Temperature of 36.1. Skin springs back to previous state upon light pinching of the left forearm indicating good skin turgor.

Head Upon inspection, the skull is normocephalic and symmetric, with frontal, parietal, and occipital prominences and has smooth skull contour. Palpation of the skull reveals absence of nodules and masses has symmetric facial features. Facial movements are symmetrical and is particularly evident when showing emotions such as smiling. Head is full of hair, generally black in color but with moderate amount of gray strands, and short, not reaching ear level in langth. Hair is parted through the left side and does not cover the face. Has thin hair strands and dry hair. No presence of infection or infestation was noted. Eyes Wears spectacles however, were removed during the time of assessment. Eyebrows are full of hair, equally distributed and generally black in color. Eyebrows were symmetrically aligned with equal movement. Eye lashes were equally distributed and curled slightly outward. The skin of the eyelids were intact, no discharges and no discoloration. Lids close symmetrically however with noted infrequent blinking with a rate of 8 blinks per minute; bilateral blinking. Upon inspection, sclera is generally white though with some noted redness near outer canthus of both eyes. No noted visible sclera above corneas. Palpebral conjunctiva appeared smooth and pink. Lacrimal gland, lacrimal sac and nasal lacrimal duct had no noted edema or tearing. Has brown colored iris. Pupils are black in color, equal in size of about 2mm. Noted bouth pupil having a distinct cloudiness upon inspection with a penlight. Both pupils constrict when

illuminated however, noted right pupil is more briskly reactive to light. Both eyes coordinated and move in unison. Has noted visual difficulty when not wearing spectacles. Unable to read print writing held with a distance of approximately 14 inches from front of face. With spectacles, is able to read but still with noted difficulty as evidenced by squinting. Noted small temporal peripheral field of vision on the both; unable to see object coming from right periphery until an estimated 70 degrees from central field of vision. Ears During inspection, the color of auricles is same as the facial skin and is symmetrical. Auricles are aligned with the outer canthus of the eye. Upon palpation, found to be firm and not tender; no noted pain. Pinnea recoils after it is folded. Noted dry cerumen upon inspection with a penlight but no noted excessive discharge or blood. Upon assessment of hearing, normal voice tones are audible. No noted difficulty in hearing. Nose Upon inspection, nose is wide, symmetric and straight. Upon palpation, no noted tenderness or lesions. Able to breath freely through nares. Noted olfactory difficulties. Upon inspection with a penlight, mucosa is pink and full of hair; no noted swelling, redness, growth or lesions. Nasal septum is intact and in the midline between the nasal chambers. Mouth Upon inspection outer lips are dark pink in color; appeared soft, moist and smooth; with symmetrical contour and has ability to purse lips. Noted slight dryness and roughness. Inner, lips are pinkish red and uniform in color; is moist, soft and smooth. Has no teeth on his upper gums.

Gums are pink, moist with presence some noted dark patches. No noted retraction of gums. Tongue is in central position of the mouth, light pink in color; moist; slightly rough with noted thin whitish coating in some areas. Papillae are raised. Able to move side to side. Smooth tongue base with prominent veins. No noted lesions or dryness. Hard palate is light pink and irregular in texture. Uvula is positioned in midline of palate. Neck During inspection, neck muscles are equal in size and head is centered. Coordinated head movement. Has noted dry wound dressing on posterior portion of neck. Head has full range of motion except when attempting to hyper extend. Shows hesitancy when attempting to hyperextend and unable to hyperextend head to full 60 degrees. Upon palpation, no noted enlarged lymph nodes. Trachea is in central placement in the midline of the neck. Thyroid gland not visible upon inspection. Chest and lungs Has symmetrical anterior chest expansion with a respiratory rate of 18 breaths per minute. Spine is vertically aligned. No noted productive coughing. Upon auscultation, no noted adventitious breath sounds. Breathing pattern rhythmic and with minimal effort during respirations. Right and left shoulders are of the same height. Anterior chest wall is intact, no noted tenderness or masses. Posterior chest has full and symmetric respiratory excursion. Upon palpation of the posterior chest there is bilateral symmetry of vocal fremitus although faint vibrations. Upon percussion of the posterior chest, sounds resonate; no noted dullness or flatness over lung tissue. Upon auscultation of the upper chest using a stethoscope, no noted adventitious breath sounds.

Heart Upon auscultation, the two heart sounds are audible, the systole and diastole. Upon palpation of the carotid artery, pulse volumes are symmetric, with full pulsations and good thrusting quality. Thrusting quality remains the same when client breathes, turns head, and changes from sitting to from semi-fowlers position. Radial pulse is also symmetric in volume along with full pulsations and good thrusting quality. Noted increased pulse rate of 82 beats per minute. Jugular veins not visible upon inspection. Abdomen Abdomen round, flabby and is uniform, medium brown in color with unblemished skin. Noted wound dressing on upper right quadrant of abdomen. With noted abdominal pain upon sudden movement. Abdomen has rounded, symmetrical countour. No noted enlargement of liver or spleen. Has symmetrical movements upon respiration. Upon auscultation, bowel sounds are audible, with irregular gurgling noises at a rate of two per minute. Upon palpation, no noted tenderness; relaxed abdomen with soft texture. Genito-Urinary No noted change in urinary pattern. Urine is light yellow-colored. No noted pain while urinating. No observed hematuria. Back and Extremities Upon inspection upper extremities and lower extremities are grossly proportional to body shape. Nails of upper extremities are trimmed and cleaned with capillary refill of less than 2 seconds. Toenails are trimmed and cleaned. No noted deformities or edema. Upon palpation,

muscles are firm. No noted tremors. Upper body muscles are at 100% of normal strength on each side of the body and able to fully move against gravity and resistance. Joints in upper extremities have good range of motion. Joints move smoothly with no noted deformities, swelling, pain, tenderness or crepitation. Spinal column vertically aligned. Noted difficulty ambulating without assistance. Unable to stand unassisted. Suggested functional level classification of 3. Spinal column is straight with no noted protrusions or deformities.

DEFINITION OF COMPLETE DIAGNOSIS

CHOLELITHIASIS The presence of gallstones in the gallbladder. The condition affects about 20% of the population above 40 years of age and is more prevalent in women and in persons with cirrhosis of the liver. Many patients complain of unlocalized abdominal discomfort, eructation, and intolerance to certain foods. Others have no symptoms. In patients with severe attacks of biliary pain associated with cholelithiasis, cholecystectomy is recommended to prevent such complications as cholecystitis, cholangitis, and pancreatitis. Also called chololithiasis. See also biliary calculus, cholecystitis. Mosbys Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition Also known as gallstones, these hard masses are formed in the gallbladder or passages, and can cause severe upper right abdominal pain radiating to the right shoulder, as a result of blocked bile flow. Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. The presence of stones or calculi (gallstones) in the gallbladder results from changes in bile components. Gallstones are made of cholesterol, calcium bilirubinate, or a mixture of cholesterol and bilirubin pigment. They arise during periods of sluggishness in the gallbladder resulting from pregnancy, use of oral contraceptives, diabetes mellitus, Crohns disease, cirrhosis of the liver, pancreatitis, obesity, and rapid weight loss.

Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified CHOLECYSTITIS Cholecystitis, an acute or chronic inflammation of the gallbladder, is usually associated with a gallstone impacted in the cystic duct; the inflammation develops behind the obstruction. Cholecystitis accounts for 10% to 25% of all patients requiring gallbladder surgery. Mosbys Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition Inflammation of the gallbladder, a complication of gallstones which are formed by cholesterol and pigment (bilirubin) in bile. (Bile is produced in the liver and stored in the gallbladder). Cholecystitis is frequently associated with infection in the gallbladder. Risk factors for cholesterol gallstones include age, obesity, female gender, multiple pregnancies, birth control pills, and heredity. The most common symptom is pain in the upper abdomen. Smeltzer, Suzzane C. and Brenda G. Bare. Medical Surgical Nursing. Volme 2. 10th Edition. Lippincott Williams & Wilkins: Philadelphia. Copyright 2004.

Cholecystitis is inflammation of the gallbladder, a small organ near the liver that plays a part in digesting food. Normally, fluid called bile passes out of the gallbladder on its way to the small intestine. If the flow of bile is blocked, it builds up inside the gallbladder, causing swelling, pain, and possible infection. McCance, Kathryn L. and Huether, Sue E., Pathophysiology 2nd Edition

DIABETES MELLITUS

Diabetes mellitus is a group of metabolic diseases in which defects in insulin secretion or action result in high blood sugar level.

Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both (The American Diabetes Association, 1997). Type II DM is formerly known as Non-insulin Dependent Diabetes Mellitus. Type 2 diabetes usually occurs at any age but most cases occur after age 30. More than 80% of the clients are overweight and do always experience classic symptoms. Kowalski, M.T., Rosdahl, C.B.;Basic Nursing

Diabetes mellitus occurs when beta cells are unable to produce insulin (Type I DM) or produce an insufficient amount of insulin (Type II DM). As a result, glucose does not enter cells but remains in the blood.

Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified

ANATOMY AND PHYSIOLOGY

HEPATOBILLARY TREE LIVER A. Location and size of the liver- largest gland in the body, weighs approximately 1.5 kg; lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium.

B. Liver lobes and lobules- two lobes separated by the falciform ligament 1. Left lobe- forms about one sixth of the liver 2. Right lobe- forms about five sixths of the liver; divides into right lobe proper, caudate lobe, and quadrate lobe 3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein extends through the center of each lobule

C. Bile ducts 1. Small bile ducts form right and left hepatic ducts 2. Right and left hepatic ducts immediately join to form one hepatic duct 3. Hepatic duct merges with cystic duct to form the common bile duct, which opens into the duodenum

D. Functions of the liver 1. Glucose Metabolism -after a meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose. -glucose can be synthesized by the liver through the process gluconeogenesis 2. Ammonia Conversion -use of amino acids from protein for gluconeogenesis result in the formation of ammonia as a byproduct. Liver converts ammonia to urea 3. Protein Metabolism -Liver synthesizes almost all of the plasma protein including albumin, alpha and beta globulins, blood clotting factors plasma lipoproteins 4. Fat Metabolism -Fatty acid can be broken down for the production of energy and production of ketone bodies 5. Vitamin and Iron Storage

-stores vitamin A, D, E, K 6. Drug Metabolism 7. Bile Formation -bile is formed by the hepatocytes -composed of water, electrolytes such as sodium, potassium, calcium, chloride, bicarbonate, lecithin, fatty acids, cholesterol, bile salts -collected and stored in the gallbladder and emptied in the intestine when needed for digestion a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny spheres called micelles b. Sodium bicarbonate increases pH for optimum enzyme function c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are wastes products excreted by the liver and eventually eliminated in the feces

GALLBLADDER The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the body is to harbor bile and aid in the digestive process.

Anatomy The cystic duct connects the gall bladder to the common hepatic duct to form the common bile duct. The common bile romero duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla. The fundus of the gallbladder is the part farthest from the duct, located by the lower border of the liver. It is at the same level as the transpyloric plane.

Microscopic anatomy The different layers of the gallbladder are as follows: The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses, which are pouches inside the lining. Under the epithelium there is a layer of connective tissue (lamina propria). Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum. There is essentially no submucosa separating the connective tissue from serosa and adventitia.

Size and Location of the Gallbladder

The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It lies on theundersurface of the livers right lobe and is attached there by areolar connective tissue.

Structure of the Gallbladder Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach.

Function of the Gallbladder The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and mucosa, results when obstruction of bile flow into the duodenum occurs. Bile is thereby denied its normal exit from the body in the feces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing fat enters

the digestive tract, stimulating the secretion of cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum. BILIRUBIN PRODUCTION AND ELIMINATION

Bilirubin is the substance that gives bile its color. It is formed from senescent red blood cells. In the process of degradation, the hemoglobin from the red blood cell is broken down from biliverdin, which is rapidly converted to free bilirubin thru biliverdin reductase. Free bilirubin, which is not soluble in plasma, is transported in the blood attached to plasma albumin. Even when it is bound to albumin, this bilirubin is still called free bilirubin. As it passes through the liver, free bilirubin is released from its albumin carrier molecule and moved into the hepatocytes. Inside the hepatocytes, free bilirubin is converted to conjugated bilrubin thru glucoronyl transferase, making it soluble to bile. Conjugated bilirubin is secreted as a constituents of bile, and in this form, it passes through the bile ducts into the small intestine. In the intestine, approximately one half of the bilirubin is converted into a highly soluble substance called urobilinogen by the intestinal flora. Urobilinogen is either absorbed into the portal circulation or excreted in the feces. Most of the urobilinogen that is absorbed is returned to the liver to be reexcreted into the bile. A small amount of urobilinogen, approximately 5% is absorbed into the general circulation and then excreted by the kidneys. Usually, only a small amount of bilirubin is found in the blood; the normal level of total serum bilirubin is 0.1 to 1.2 mg/dL. Laboratory measurements of bilirubin usually measure the free and the conjugated bilirubin as well as the total bilirubin. These are reported as the direct (conjugated) bilirubin and the indirect (unconjugated or free) bilirubin.

Anatomy and Physiology of the Pancreas

The

pancreas

consists of two major types

of secretory tissues. This reflects its dual function as an exocrine gland that secretes digestive juice and as an endocrine gland that releases hormones. The exocrine function of the pancreas is localized in the acinar cells that synthesize and secrete digestive juices. The endocrine function of the pancreas is localized in the islet cells (islets of Langerhans), which synthesize and secrete hormones including insulin and glucagon. The exocrine pancreas is composed of closely packed acini draining into a series of branched ducts. The acini are composed of several wedge-shaped serous cells surrounding a central lumen. These are typical polarized secretory cells with a spherical nucleus and a basophilic cytoplasm. Eosinophilic secretory vesicles rich in digestive enzymes (zymogen granules) may be seen toward the apex of each acinar cell. The base of each pyramidal acinar

cell lies on the basement membrane which surrounds each acinus. Beneath this basement membrane is a rich capillary network. Interspersed among the exocrine acinar glands are lightly staining, spherical clusters of cells without ducts, acini, or obvious zymogen granules: the endocrine islets of Langerhans. At least 4 different kinds of cells in these clusters, specialized to produce different hormones. Alpha cells stain deep pink by H+E and produce glucagon, which stimulates glycogenolysis and lipolysis in other tissues to raise blood glucose levels. Beta cells stain stain light pink and produce insulin, which has many effects, such as promoting other tissues (particularly liver muscle and adipose tissue) to take up and metabolize glucose, lowering blood sugar levels. Dysfunction or destruction of the beta cells is one of the many causes of diabetes. Excess blood sugar (hyperglycemia) causes excretion of abnormally large volumes of urine rich in glucose. The kinds of islet cells are less numerous and difficult to pick out without special staining techniques. They produce several other hormones. These interspersed endocrine cells are arranged as cords separated by a network of fenestrated capillaries. Both the endocrine cells and the blood vessels are innervated by autonomic nerves.

ETIOLOGY AND SYMPTOMATOLOGY

A. ETIOLOGY

Predisposing Present/ Absent Factors Age Present According to the Framingham Study, which examined the risk factors for cholelithiasis in a 10year follow-up study of 30to 59-year-old subjects, the risk of cholelithiasis within 10 years was highest among the 55- to 62-yearold age group, and most of the patients were diagnosed with cholelithiasis in their fifties and sixties. Although The patient is aged 59 years old. Rationale Justification

the incidence of cholelithiasis in female patients of all age groups is more than double that of male patients, the difference between the incidence in men and women tends to shrink with increasing age Family History Present First-degree (parents, children) relatives The patient reports of siblings, of and having family

individuals members who were

with gallstones are 1 diagnosed with times more likely to have cholelithiasis and gallstones than if they did cholecystitis. not have a first-degree with gallstones. comes that are

relative Further from genetic

support twin studies factors

important in determining who gets gallstones.

Sex

Absent

Women are more likely to develop gallstones than men, with a ratio of 2:1.

The patient is male.

Race

Absent

Epidemiologic studies have The patient is of shown variations in the prevalence of gallstones in different ethnic populations, with particularly high rates in Native Americans. Asian Heritage.

Precipitating Present/ Absent Factors Obesity Absent Cholelithiasis is one of the main diseases associated with obesity. The Framingham study also confirms that cholelithiasis The patients BMI is within the normal range. Rationale Justification

patients tend to be more obese than noncholelithiasis patients. However, there is a report that this tendency is much more prominent in female than in male patients Diabetes Mellitus Present Diabetes Mellitus accounts for the swelling most of the time in acalculous cholecystitis. This is due to the AIDS Absent Enlarged liver and/or abnormal liver functions are observed in two/thirds of AIDS patients, some of whom have biliary tract disease. Ninety percent of the patients complain of upper abdominal pain and have enlarged intra- and extrahepatic bile ducts on The patient does not have AIDS. The patient has Diabetes Mellitus.

abdominal ultrasonography. Abnormal findings on abdominal ultrasonography and computed tomography are seen in 81% and 78% of patients, respectively. Acalculous cholecystitis in AIDS patients is characterized by: (1) younger age than in nonAIDS patients, (2) problems with oral ingestion (3), right upper abdominal pain, (4) a marked increase in alkaline phosphatase and a mild increase in serum bilirubin level, and (5) association with cytomegalovirus and cryptosporidium

infections. According to a review of abdominal surgery for AIDS patients, acute cholecystitis is the most frequent reason for performing open surgery in AIDS patients.

Drugs

Absent

According to the review by The patient has not Michielsen et al., regarding the association between drugs and acute cholecystitis, 90%95% of acute cholecystitis cases are caused by cholelithiasis, and drugs promoting the formation of stones are indirectly associated with a risk of acute cholecystitis. been taking any drugs in a long span of time, specially those mentioned to contribute to stone formation.

It is reported that women taking oral conceptives have a higher risk of having gallbladder disease, but there also is a report which denies the association between the disease and these drugs (level 2a).54 Among various drugs used for the treatment of hyperlipidemia, only fibrate is shown to be associated with gallstone diseases (level 2b).55 One report suggests that thiazides induce acute cholecystitis (level 3b),56 and another report denies this association (level 3b).57 The administration of a large dose of ceftriaxone, a third-

generation cephalosporin antimicrobial, in infants, precipitates calcium salt in bile and forms a sludge in 25%45% of them, but these effects disappear when the medication is discontinued (level 4).53 It is reported that the longterm administration of octreotide causes cholestasis, and that administration for a year causes cholelithiasis in 50% of patients (level 4).53 Hepatic artery infusion will cause chemical cholecystitis (level 4).53 Erythromycin and ampicillin are reported to be a cause of hypersensitive cholecystitis (level 4).53

According to a metaanalysis of the risk of disease induced by hormone replacement therapy, the relative risks (RRs) of cholecystitis were 1.8 (95% confidence interval [CI], 1.62.0) and 2.5 (95% CI, 2.02.9) at less than 5 years of treatment and at 5 and more years, respectively (level 1a).58

Ascaris

Absent

The complications of ascariasis include hepatic, biliary, and pancreatic diseases. Complications in the biliary tract include: (1) cholelithiasis with the ascarid as a nidus for stone formation, (2) acalculous

The patient has not been affected by any scaris infection.

cholecystitis (3), acute cholangitis (4), acute pancreatitis, and (5) hepatic abscess. Biliary tract disease is caused by the obstruction of the hepatic and biliary tracts by the entry of ascarids from the duodenum through the papilla. Ascarids entering the biliary tract usually return to the duodenum in a week, but if they stay over 10 days there, they will die and form a nidus for stone formation. Ascarid-associated biliary diseases occur more frequently in women (male/female ratio, 1 : 3) and less frequently in infants. The risk of biliary

complications is higher in pregnant than in nonpregnant women. In epidemic regions such as China and Southeast Asia, ascariasis is a frequent cause of cholelithiasis.

Crohns Disease

Absent

Individuals with Crohn's disease of the terminal ileum are more likely to develop gallstones. Gallstones form because patients with Crohn's disease lack enough bile acids to solubilize the cholesterol in bile. Normally, bile acids that enter the small intestine from the liver and gallbladder are absorbed back into the body in the

The patient doesnt have Crohns disease.

terminal ileum and are secreted again by the liver into bile. In other words, the bile acids recycle. In Crohn's disease, the terminal ileum is diseased. Bile acids are not absorbed normally, the body becomes depleted of bile acids, and less bile acids are secreted in bile. There are not enough bile acids to keep cholesterol dissolved in bile, and gallstones form High Levels of Blood Triglycerides Gallstones occur more frequently in individuals with elevated blood triglyceride levels.

Drastic dieting /

Absent

Rapid weight loss by whatever means, very low

The patient did not fast nor attempted to lose

Fasting

calorie diets or obesity surgery, causes cholesterol gallstones in up to 50% of individuals. Many of the gallstones will disappear after the weight is lost, but many do not. Moreover, until they are gone, they may cause problems. Fasting renders the gallbladder less active, thus making the bile more concentrated.

weight by drastic measures.

Parity

Absent

Pregnancy increases the risk for cholesterol gallstones because during pregnancy, bile contains more cholesterol, and the gallbladder does not

The patient is male

contract normally. The risk of cholelithiasis in women begins to increase when adolescence begins and it declines when the menopause begins. It is also said that the use of oral conceptives is correlated with a risk of gallbladder disease. It is considered, therefore, that levels of estrogen and progesterone are involved in the formation of gallstones. Cholecystitis is the second most common cause of acute abdomen, following appendicitis, in pregnant women, and occurs in one of 1600 to 10 000 pregnant women. Cholelithiasis is the most frequent cause of

cholecystitis in pregnancy and accounts for 90% or more of all causes of cholecystitis Routine ultrasonography found cholelithiasis in 3.5% of pregnant women but it is unknown whether pregnancy increases the risk of cholecystitis. The frequency of cholecystectomy in pregnant women is lower than that in non-pregnant women. This is not because of the lower incidence of cholecystectomy in pregnant women, but because physicians tend to refrain from performing any operation during pregnancy. Though there

are few reports of patients undergoing cholecystectomy during pregnancy, there is no evidence that laparoscopic surgery increases the maternal or fetal risks.

B. SYMPTOMATOLOGY Symptoms Biliary Colic Present/Absent Present Rationale Justification

Biliary colic is a very The patient reported to have specific type of pain, experienced this symptom. occurring primary as or the only

symptom in 80% of people with gallstones who develop

symptoms.

Biliary

colic occurs when the extrahepatic cystic, common ductsor

hepatic

bile-are

suddenly blocked by a gallstone. progressing obstruction, as from a tumor, does not cause biliary colic.) Behind the obstruction, fluid accumulates and (Slowly-

distends the ducts and gallbladder. In the

case of hepatic or common bile this duct is

obstruction, due to

continued

secretion of bile by the liver. In the case of cystic duct

obstruction, the wall

of

the

gallbladder

secretes fluid into the gallbladder. It is the distention of the ducts or gallbladder that

causes biliary colic.

Dyspepsia (with abdominal bloating and discomfort)

Present

Due to the backing up of bile, there is a limited ability to dissolve fatty substances taken by meals, thus causing dyspepsia.

The patient reported to have experienced this symptom

Flatulence

Absent

Patients usually have symptoms of acute cholecystitis in the initial stage. (3) emphysematous cholecystitis, in which air appears in the gallbladder wall due

The patientdid not manifest this symptom.

to infection with gasforming anaerobes, including Clostridium perfringens Fever Present Fever is a sign of infection and inflammation resulting from the infection of microorganisms. Increased WBC Present A high white blood cell count suggests inflammation, an abscess, gangrene, or a perforated gallbladder. The gallbladder wall has white blood cells present, with areas of necrosis and suppuration. In this stage, the active repair The laboratory results of the patient shows an elevation of the patients WBCs The patient reported to have had experienced this symptom.

process of inflammation is evident.

Right Upper Quadrant Pain

Present

Symptoms occur with gallstones when the gallbladder contracts, often after a meal, resulting in occlusion of the cystic duct with a stone that produces symptoms, typically

The patient reported to have had experienced this symptom

pain. This pain may even radiate to the back behind the right scapula and the right shoulder.

Jaundice

Absent

Jaundice condition in

is

a which

The patient did not manifest this symptom.

bilirubin accumulates in the body. Bilirubin

is brownish-black but yellow when it is not too concentrated. A build-up of bilirubin in the body turns the skin and whites of the eye yellow. Jaundice occurs when there is prolonged obstruction of the bile ducts. The obstruction may be due to gallstones, but it also may be due to many other causes of obstruction, for

example, tumors of the bile ducts or

surrounding Jaundice, generally by

tissues. itself, not

does

cause problems.

Dark Urine

Absent

If people pass dark urine and lightcolored stools, the common bile duct is probably blocked by a stone, causing a backup of bile in the liver.

The patient did not manifest this symptom

Clay colored stools

Absent

If people pass dark urine and lightcolored stools, the common bile duct is probably blocked by a stone, causing a backup of bile in the liver.

The patient did not manifest this symptom

Murphys Sign

Present

Murphy's sign guarding in right upper quadrant on deep inspiration

The patient manifested this symptom.

DOCTORS ORDER

DATE 6/30/10 12:00 PM

ORDER

RATIONALE

REMARKS

Please admit patient under For close monitoring of the patient and Admitted the service of Dr. proper management of his condition

Moscoso. Low salt and low fat, Low salt, low fat diet is designed to Patient informed diabetic diet, small limit the total amount of fat, salt and cholesterol in the diet to reduce serum lipid levels and avoid excessive sodium retention to prevent ascites and

frequent feedings.

generalized edema. Monitor Vital Signs q4 Vital signs are important for baseline Taken hours and record. assessment and to monitor patients recorded. condition which evaluates the whole treatment course, especially the and

medications he received that could be a contributing factor in the variation results of the vital signs Laboratory tests: Complete Blood Ccount CBC with PC determines the quantity Done with Platelet of each quantity of blood cell in a given

specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. This is done to know any condition of the client that may affect his medical management. Urinalysis Urinalysis is performed to screen for Done urinary tract disorders, kidney

disorders, urinary neoplasm and other medical conditions that produce

changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition. This test is also used to monitor the effects of certain procedures done to patient and to check if genito-urinary is in normal state or not. Fasting Blood Sugar A method for learning how much Done glucose (sugar) there is in a blood sample taken after an overnight fast. The fasting blood glucose test is commonly used in the detection

of diabetes mellitus.

Serum Glutamic Pyruvic SGPT is an enzyme that is normally Done Transaminase present in liver and heart cells. SGPT is released into blood when the liver or heart is damaged. The blood SGPT levels are thus elevated with liver damage (for example, from viral

hepatitis) or with an insult to the heart (for example, from a heart attack). Serum Creatinine The test is done to evaluate kidney Done function. Creatinine is removed from the body entirely by the kidneys. If kidney function is abnormal, creatinine levels will increase in the blood because less creatinine is released through your urine. S. Uric acid Test is used to learn whether the body Done might be breaking down cells too quickly or not getting rid of uric acid quickly enough. Lipid profile The lipid profile is a group of tests that Done are often ordered together to determine risk of coronary heart disease. They are tests that have been shown to be good

indicators of whether someone is likely to have a heart attack or stroke caused by blockage of blood vessels or hardening of the arteries

(atherosclerois). ECG The electrocardiogram (ECG or EKG) Done but not

is a diagnostic tool that measures and attached to chart records the electrical activity of the heart in exquisite detail. Interpretation of these details allows diagnosis of a wide range of heart conditions. CXR (PA) A chest radiograph, commonly called Done a chest x-ray (CXR), is a projection radiograph of the chest used to

diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are among the most common films taken, being diagnostic of many conditions. Start PNSS (please venoclysis 1L with Intravenous lines provide easy access Started

@100cc/hr for drug administration intravenously incorporate (IVTT). Plain normal saline solution is isotonic to body fluid and is commonly

moriamin s2 2 amps)

used for rehydration. Moriamin s2 is an aminoacid supply for the conditions such as malnutrition, pre- and post-operations. Medications: Paracetamol 500mg tab, 1 tab Paracetamol is used to reduce Given q4h PRN or fever fever reduction. is used to treat Given caused by

Clindamycin 300 mg IVTT Clindamycin q12h (ANST) serious

infections

susceptible strains of anaerobes streptococci, staphylococci,

pnemococci , reserve use for penicillin a llergic patients or when penicillin is inapprorpriate HNBB Bromide (hyoscine or N-Butyl HNBB is an antipasmodic drug. It Given Hyoscine treats conditions associated w/

ButylBromide) 1 amp now visceral spasms. then q8h Lactulose 30 ml OD at bed Lactulose is a laxative used to treat Given time I&O q shift constipation. Intake and output helps gauge Done fluid balance in the body of the patient. This would also check if

patients elimination pattern is normal or impaired. Watch out for any unusualities To closely monitor patient and Watched out prevent any complications. Refer accordingly This may create a collaborative Referred treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client. Additional meds: (after breakfast) Telmisartan (Pritor plus) 40mg An / 12.5 mg 1 tab OD angiotensin this II drug receptor Given is an

antagonist,

antihypertensive drug to treatment for hypertension, alone or in combination antihypertensive. Glimiperide 3 mg 1 tab OD Glimiperide is an antidiabetic Given with other

drug. It adjunct to diet to lower glucose level in patients with type 2 (non-insulin dependent) diabetes mellitus 9:00 pm Nalbuphine amp IVTT now An Opoid agonist antagonist Given

analgesic. It relieves moderate to

severe

pain.

Preoperative

analgesia, as a supplement to surgical anesthesia. 07/01/10 2:00 am IVF to follow with PNSS 1L Intravenous lines provide easy Hooked with 2 amp moriamin s2 to run access for drug administration at 100 cc/hr intravenously (IVTT). Plain

normal saline solution is isotonic to body fluid and is commonly used for rehydration. Moriamin s2 is an aminoacid supply for the conditions such as malnutrition, operations. 9:00 am Follow up all lab results and This is done since the laboratory Followed up and attach to chart results are needed in the medical attached to chart management condition. Increase IVF ro 120 cc/hr To increase intake of the patient Regulated through intravenous; to maintain hydration. Essentiale forte 1 tab TID Essentiale forte is an cholagogues, Given cholelitholytics & hepatic of the patients preand post-

protector drug. This is given to the

patient since the ultrasound shoes tht the patient has gall stones. Start levofloxacin 500 mg OD A ANST IVTT flouroquinolone antibiotic; Started

bactericidal interferes with DNA inhibiting DNA gyrase repication is susceptible gram negative and gram positive bacteria prevent cell reproduction.

3:55 pm

Glucovance 500 mg /5 1 tab An antidibetic drug that stimulates Given BID insulin release from functioning beta cells in th pancreas; may improve binding between insulin and insulin receprtors or increase the numbers of insulin receptor : more potent in effect than first generation sulfonylurea.

7/2/10 7:50 am

For surgical clearance please Surgical clearance allows patient Dr. inform Dr. Sanchez For repeat CBC to be prepared for the procedure. informed

Sanchez

To determine the effect of drugs Taken given and to evaluate progress of the patient.

For CBG now

Capillary blood glucose testing is Taken used for the care of people with

diabetes as a monitoring tool giving a guide to blood glucose levels. Soft diet Soft diet is a diet soft in texture, Patient informed low in residue, easily digested and well tolerated; easy to chew and swallow providing essential

nutrients in the form of liquids and semisolid foods. This is also to prevent gastric irritation and

stomach upset. 11:00 am HGT = 11.4 For CBG q6h (5-11-5-11) To closely monitor patients blood Done glucose. 11:17 am Humulin R 8 u IVTT now An antidiabetic drug given to Given patient to reduce blood glucose. Schedule for OR 2 pm today To perform surgery to patient that Consent secured. secure consent would remove the stones seen in Scheduled his gall bladder through the OR for

ultrasound done. Informed consent is the permission obtained from the patient/guardian to perform a specific test or procedure. This

also evaluates whether the patient has understood the surgeon and his or her condition. To secure the consent of the client is important for legal purposes. 12:45 pm For CP clearance c/o M Cardiopulmonary clearance CP not cleared

Durban

required before surgery to ensure that the patient doesnt have any cardiopulmonary problems which could interfere and complicate the surgery.

For Trop I now

Troponin

tests

are

primarily Done

ordered for people who have chest pain to see if they have had a heart attack or other damage to their heart. 1:00 pm Pre-schedule OR 4 pm if with To perform surgery to patient that Not scheduled cp clearance would remove the stones seen in his gall bladder through the

ultrasound done. Informed consent is the permission obtained from the patient/guardian to perform a specific test or procedure. This

also evaluates whether the patient has understood the surgeon and his or her condition. To secure the consent of the client is important for legal purposes. Cardiopulmonary clearance

required before surgery to ensure that the patient doesnt have any cardiopulmonary problems which could interfere and complicate the surgery. 2:15 pm May hold OR temporarily Operation was hold due to failure Hold to obtain CP clearance. Possible tomorrow clearance Discontinue clindamycin and Antibiotics are discontinued and Discontinued levofloxacin shifted to another antibiotics rescheduling Done to reschedule the patient for Done. pending cardiac operation. cleared CP

Start ampicillin sulbactam An antibiotic that treats mild to Started 1.5 gms q 8h IVTT ANST Update Dr. Sanchez moderate infections. This creates a collaborative Dr. Sanchez

treatment among the client and the updated health care providers; thus it also

makes a good coordination on the treatment of the client. IVF: PNSS to run at 120cc/h Plain normal saline solution is Hooked isotonic to body fluid and is commonly used for rehydration. Please give Glucovance pc and Glucovance is a combination of Given Glimiperide ac two types of pills. One pill helps your body make more insulin. The other pill lowers the amount of glucose made by your liver and helps your insulin work the way it should. Glimiperide is an

antidiabetic drug. It adjunct to diet to lower glucose level in patients with type 2 (non-insulin

dependent) diabetes mellitus. 5:00 pm Shift present IVF to D5W to 5% Dextrose in Water is a type of Shifted KVO rate isotonic fluid on initial

administration, but when glucose is metabolized, it produces free water.This water may expand both the ICF & ECF fluid volume, thus, acts as a hypotonic solution.

10:30 pm

Discontinue Glimiperide

To prevent hypoglycemia

Discontinued

Sitagliptin + metformin 1 tab Is an antidiabetic drug. It is an Given OD pc after lunch adjunct to diet improve and exercise to control in

glycemic

patients with type 2 diabetes mellitus, antibiotics. Please give glucovance after Glucovance is a combination of Given breakfast and after supper two types of pills. One pill helps your body make more insulin. The other pill lowers the amount of glucose made by your liver and helps your insulin work the way it should. For CPK-MB tom am CPK-MB test is a cardiac marker Done used to assist diagnoses of an acute myocardial infarction. 7/3/10 5:50 am Give humulin R 5u IVTT Humulin R is an antidiabetic drug Given now then repeat CBG 2 hrs given to patient to reduce blood post prandial glucose. CBG is done to evaluate the effect of insulin to the patient after eating a meal. 11:30 Relay CPK-MB asap pls. In order to know the result of the Relayed with other oral

test. Please give humulin R 6u An antidiabetic drug given to Given now patient to reduce blood glucose.

Please schedule OR this 2 pm, Scheduling patient to OR allows Scheduled Dr. Sanchez aware patient undergone operation.

Secure consent, please inform Informed consent is the permission Consent secured. OR obtained from the patient/guardian OR aware to perform a specific test or procedure. This also evaluates whether the patient has understood the surgeon and his or her

condition. To secure the consent of the client is important for legal purposes. 1:30 pm Give Metoclopramide (Plasil) Metoclopramide increases muscle Given 1 amp now IVTT contractions in the upper digestive tract. This speeds up the rate at which the stomach empties into the intestines. Give ranitidine 50 mg 1 amp Ranitidine is an antisecretory (h2- Given IVTT now receptor antagonist), antiulcer

drug. Since the patient will be on NPO status, it is important to give

ranitidine to prevent ulcer. 5:00 pm NPO temporarily NPO is ordered to prepare the Patient informed gastrointestinal surgery. The tract prior to and

stomach

esophagus relaxes when anesthesia is administered which makes it possible for food to move up into your mouth from where a patient may aspirate it down to their trachea into their lungs. Such aspirate is usually very acidic (pH around 1-3) and can cause severe damage to the lungs requiring artificial ventilation. VS q 15 mins until stable Monitoring the vital signs in this Monitired close timed-manner will verify if recorded the patient is experiencing post operative complications, has and

weaned out from anesthesia, and is already stable. IVF at 150 cc/hr Increasing IVF rate to 150 cc/hour Regulated is important to prevent patient from dehydration since patient is

still on NPO. IVF to follow D5NSS 150 5% Dextrose in normal saline cc/hr solution is a hypertonic solution. Hypertonic solutions have tonicity or solute concentration in ECF greater than that of the ICF. Therefore, it pulls fluids out of the ICF and the cell shrinks. (ST-) Tazocin 2.25 grams q 8 hours Piperacillin (Tazocin) is a beta- Given IVTT ANST next dose 2 am lactam antibiotic and is mainly bactericidal. Tramadol 300 mg + pNSS 500 Tramadol is a narcotic-like pain Given cc @ 25 micro drops reliever. Tramadol is used to treat moderate to severe pain. Tramadol extended-release is used to treat moderate to severe chronic pain when treatment is needed around the clock. Given to patient post-op for pain. Ketorolac 15 mg q 6 hours This medication is a nonsteroidal Given IVTT anti-inflammatory drug that

relieves pain and reduces swelling. It is for short-term use only (no

more than 5 days). O2 3-4 LPM This is to relieve hypoxia, Indicated

headache, nausea, as well as to restore the ability of the cells of the body to carry on normal metabolic function. Refer accordingly This creates a collaborative referred

treatment among the client and the health care providers; thus it also makes a good coordination on the treatment of the client. 7:35 pm BP 150/100 aware + pain at the surgical site 8/10 comfortable/ assesment 140/100 Continue BP monitoring q 15 Monitoring the vital signs in this Monitored mins until stable then q 2hrs close timed-manner will verify if recorded the patient is experiencing post operative complications, has and

weaned out from anesthesia, and is already stable. Refer for persistent increase bp To closely monitor patient for Referred or any unusualities unusualities interventions immediately. and will be proper given

8:40 pm

May increase tramadol drop to Tramadol may be increased of Noted 100cc/hr patient complains of pain.

7/4/10

13.2 mmol May give 5 u RI IVTT now An antidiabetic drug given to Given patient to reduce blood glucose.

5:10 am

Shift D5NSS 1 L to PNSS 1 L IVF was shifted from hypertonic Shifted at same rate (150 cc/hr) to isotonic to maintain balance within body. Plain normal saline solution is isotonic to body fluid and is commonly used for

rehydration. Give humulin R 4 units IVTT An antidiabetic drug given to Given now 8:00 am Decrease CBG to q 12 hours patient to reduce blood glucose. To continue monitoring blood Carried out glucose. Change dressing of wound Maintaining wound cleanliness is Changed (drain site) very important to prevent any infection that can be caused by enter of microorganisms through the incision site. IVTT tramadol 300 mg in 500 Tramadol is a narcotic-like pain Given cc PNSS to run in 24 hours reliever. Tramadol is used to treat moderate to severe pain. Tramadol

extended-release is used to treat moderate to severe chronic pain when treatment is needed around the clock. Given to patient post-op for pain. 9:00 am IVF to follow PNSS 1L 150 Plain normal saline solution is Noted cc/hr isotonic to body fluid and is commonly used for rehydration. 7/5/10 5:20 am Shift IVF to D5NSS KSS) 1L 5% Dextrose in normal saline Shifted and solution is a hypertonic solution.

(previously

incorporate moriamin sr 2 Hypertonic solutions have tonicity amps @ 120 cc/hr or solute concentration in ECF greater than that of the ICF. Therefore, it pulls fluids out of the ICF and the cell shrinks. Moriamin s2 is an aminoacid supply for the conditions such as malnutrition, operations. 7:00 am IVF to follow D5NSS + 2 5% Dextrose in normal saline Noted amps moriamin to run @ solution is a hypertonic solution. 120cc/hr Hypertonic solutions have tonicity or solute concentration in ECF preand post-

greater than that of the ICF. Therefore, it pulls fluids out of the ICF and the cell shrinks. Moriamin s2 is an aminoacid supply for the conditions such as malnutrition, pre- and post-operations. For serum Na and K deter this This is done to measure the Done am concentration of electrolytes which are needed for both the diagnosis and management of renal, water other

endocrine, balance,

acid-base, and many

conditions. Their importance lies in part with the serious

consequences that follow from the relatively small changes that

diseases or abnormal conditions may cause. This is done for diagnosing dietary deficiencies, excess loss of nutrients due to urination, vomiting, and diarrhea, or abnormal shifts in the location of an electrolyte within the body.

Insert 2 Dulcolax suppository Bisacodyl is a stimulant laxative. Done adult now It acts directly on the bowels, stimulating the bowel muscles to cause a bowel movement. Constipation, pre operative use, short term relief of constipation, to prevent training, to remove

ingested poisons from th lower GI tract. 9:45 am BP = 140/90 Increase tramadol drip to 120 The intensity of pain felt by the Done cc/hr 11:10 am 3:00 pm patient increased. Done

Revise tramadol drip rate to 30 Intensity of pain has decreased. micro gtts/min

IVF to follow D5NSS 1 L + 2 Moriamin s2 is an aminoacid Noted amps moriamin @ 120cc/hr supply for the conditions such as preand post-

t/f: PNSS 500 cc + 300 mg malnutrition, tramadol to run @ 120 cc/hr

operations. It is incorporated to D5NSS electrolyte. Tramadol is a narcotic-like pain reliever. Tramadol is used to treat moderate to severe pain. Given to since D5NSS has

patient post-op for pain. 4:00 pm d/c tramadol drip Patient can already tolerate pain. Tramadol dip

start celebrex 200 mg BID to Celebrex is a nonsteroidal Anti- discontinued; start 6 pm tonight inflammatory Drugs (NSAIDs) celebrex started

(+BM x1 +flatus x4) bp=150/100 May remove metformin sitaglaptin + Sitaglaptin + metformin may be Noted removed if blood glucose will be on normal range. May remove Telmisartan Telmisartan may be removed if BP Noted of the patient will be on normal range. 7:30 pm May have general liquids in A general liquid diet consists of Patient noted small amount clear liquids, such as water, broth and plain gelatin that are easily digested and leave no undigested residue in your intestinal tract. Your doctor may prescribe a clear liquid diet after NPO order. May give Telmisartan (Pritor An plus) 40 mg/12.5 mg tab, 1 tab angiotensin this II drug receptor Given is an

(Pritor plus)

antagonist,

antihypertensive drug to treatment for hypertension, alone or in

combination antihypertensive. May have soft diet in am

with

other

Diet was shifted to soft diet Patient informed because patient was already with flatues. Soft diet is a diet soft in texture, low in residue, easily digested and well tolerated; easy to chew and swallow providing

essential nutrients in the form of liquids and semisolid foods. To follow: D5NSS 1 L + 2 5% Dextrose in normal saline Followed up amps moriamon @ 120 cc/hr solution is a hypertonic solution. Hypertonic solutions have tonicity or solute concentration in ECF greater than that of the ICF. Therefore, it pulls fluids out of the ICF and the cell shrinks. Moriamin s2 is an aminoacid supply for the conditions such as malnutrition, pre- and post-operations. 7/6/10 8 am C/D Ivf and Ivf meds Patient can already tolerate P.O Consumed medications. IVF can be discontinued and

discontinued since IVF is used as

an access for IVTT meds. Saltamicillin 750 mmg 1 tab q Sultamicillin is an antibiotic that is Given 8hrs indicated for perioperative post operative

rophylaxis and prophylaxis. Soft low fat diet

Soft low fat diet is a diet soft in Patient informed texture, low in residue, easily digested and well tolerated but low in fat content to reduce serum lipid contents; swallow easy to chew and

providing

essential

nutrients in the form of liquids and semisolid foods. Drain mobilized Dressing done To drain discharges in the wound. Done

Maintaining wound cleanliness is Done very important to prevent any infection that can be caused by enter of microorganisms through the incision site.

Revised celecoxib to 400 mg 1 A Nonsteroidal Anti-inflammatory Revised tab OD Drugs (NSAIDs) that is intended to relieve pain while minimizing the gastrointestinal adverse effects.

8:25 am

Dressing of wound (check Maintaining wound cleanliness is Done area) very important to prevent any infection that can be caused by enter of microorganisms through the incision site.

7/7/10

Okay for discharge if so Patient can already go home if he Patient informed desired Dressing and drain off wishes to do so. Maintaining wound cleanliness is Done very important to prevent any infection that can be caused by enter of microorganisms through the incision site. Unasyn 750 mg 1 tab q 8hr Unasyn (Ampicillin + Sulbactam) Given #15 is an antibiotic that treats mild to moderate infections. Celecoxib 800 mg 1 cap O.D. A Nonsteroidal Anti-inflammatory Given # 10 Drugs (NSAIDs) that is intended to relieve pain while minimizing the gastrointestinal adverse effects.

9:20 am

May go home

Doctor

ordered

patient

may Carried out

already go home Home med: Sitagliptin + metformin Is an antidiabetic drug. It is an Patient informed

(Janumet) 500 mg1 tab OD adjunct to diet after lunch x 1 month improve

and exercise to control in

glycemic

patients with type 2 diabetes mellitus, antibiotics. Telmisartan (Pritor plus) 1 tab An OD after breakfast x 1month angiotensin this II drug receptor Patient informed is an with other oral

antagonist,

antihypertensive drug to treatment for hypertension, alone or in combination antihypertensive. For ultrasound of liver, fbs To re-assess the liver and blood Patient informed after 1 month sugar after the discharge. To determine if there are stones left in the gallbladder. with other

Generic Name

Moriamin Forte Brand Name Classification Ordered Dose Mode of Action Indications malnutrition, protein and vitamin deficiencies, anemia, convalescence, restoration and maintenance of body resistance, pregnancy and lactation, adjuvant in the therapy of peptic ulcer and TB. Calcium pantothenic multivitamins and minerals

Contraindications

contraindicated for patients with malabsorption syndrome

Drug Interactions Side Effects and Adverse Reactions hypervitaminosis (large doses)

Nursing Responsibilities

Assess patient for signs of vitamin deficiency before and periodically throughout

Paracetamol

Generic Name

acetaminophen paracetamol

Brand Name Classification Ordered Dose Mode of Action

Tylenol, Tempra Non-narcotic analgesic, Antipyretic 500 mg 1 tab q 4 hours, PRN Produces analgesia by unknown mechanism, but it is centrally acting in the CNS by increasing the pain threshold by inhibiting cyclooxygenase. Reduces fever by direct action on hypothalamus heat-regulating center with consequent peripheral vasodilation, sweating, and

dissipation of heat. Unlike aspirin, has little effect on platelet aggregation, does not affect bleeding time, and produces no gastric bleeding. Indications Fever reduction. Temporary relief of mild to moderate pain. Generally as substitute for aspirin when the latter is not tolerated or is contraindicated Contraindications Hypersensitivity to acetaminophen or phenacetin; use with alcohol. Drug Interactions Cholestyramine may decrease acetaminophen absorption. With chronic coadministration, barbiturates,

carbamazepine, phenytoin, and rifampin may increase potential for chronic hepatotoxicity. Chronic, excessive ingestion of alcohol will increase risk of hepatotoxicity.

Side Effects and Adverse Reactions

Body as a Whole: Negligible with recommended dosage; rash. Acute poisoning: Anorexia, nausea, vomiting, dizziness, lethargy, diaphoresis, chills, epigastric or abdominal pain, diarrhea; onset of hepatotoxicity elevation of serum transaminases (ALT, AST) and bilirubin; hypoglycemia, hepatic coma, acute renal failure (rare). Chronic ingestion: Neutropenia, pancytopenia, leukopenia, thrombocytopenic purpura, hepatotoxicity in alcoholics, renal damage.

Nursing Responsibilities

Assessment & Drug Effects 1) Monitor for S&S of: hepatotoxicity, even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have ingested alcohol over prolonged periods; poisoning, usually from accidental ingestion or suicide attempts; potential abuse from psychological dependence (withdrawal has been associated with restless and excited responses). 2) Administer tablets or caplets whole or crushed and give with fluid of patient's choice. 3) Chewable tablets should be thoroughly chewed and wetted before they are swallowed.

4) Do not coadminister with a high carbohydrate meal; absorption rate may be significantly retarded. 5) Store in light-resistant containers at room temperature, preferably between 1530 C (59 86 F).

Patient & Family Education 6) Do not take other medications (e.g., cold preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects. 7) Do not self-medicate adults for pain more than 10 d (5 d in children) without consulting a physician. 8) Do not use this medication without medical direction for: fever persisting longer than 3 d, fever over 39.5 C (103 F), or recurrent fever. 9) Do not give children more than 5 doses in 24 h unless prescribed by physician.

Generic Name

Clindamycin

Brand Name Classification Ordered Dose Mode of Action

Dalacin Lincosamide Antibiotic

Inhibits protein synthesis in susceptible bacteria causing cell death.

Indications

Serious infections caused by susceptible strains of anaerobes streptococci, staphylococci, pnemococci ,

reserve use for penicillin a llergic patients or when penicillin is inapprorpriate Contraindications Drug Interactions Contraindicated in patient with allergy of clindamycin Increased neuromuscular blockade with neuromuscular blocking agent

Decreased GI absorption with kaolin,aluminum salts Side Effects and Adverse Reactions Sideeffects CV:Hypotension GI : severe colitis , vomiting,nausea ,a diarrhea, Hematological: Neutropenia, leucopenia, agranulocytosis Local: sterile Abcess, Thrombophlebitis ADVERSE Effects: Cardiac arrest Pseuomembranous colitis Nursing Responsibilities 1. Site infection or acne, skin color , lesions. 2. Administer drug with full glass of water 3. Do not give IM injections of more than 600mg inject deep into large muscle to avoid complication 4. Do not use for minor bacterial or viral infection 5. Administer with food 6. Take full oral prescribed drug . 7. Report severe or watery diarrhea, abdominal pain and any lesions

Generic Name

Hyoscine Butylbromide Brand Name Classification Ordered Dose Mode of Action Relaxes the GI and GU tractsOne type of antispasmodic is used for smooth muscle contraction, especially in tubular organs of the gastrointestinal tract. The effect is to prevent spasms of the stomach, intestine or urinary bladder. Both dicyclomine and hyoscyamine are antispasmodic due to their anticholinergic action. Both of these drugs have general side effects and can worsen gastroesophageal reflux disease.[3] Indications Conditions associated w/ visceral spasms. Buscin antipasmodic

Contraindications

Prostatic enlargement; paralytic ileus or pyloric stenosis & ulcerative colitis; myasthenia gravis. Angle-closure

glaucoma or narrow angle between the iris & cornea. Drug Interactions Atropine, amantadine, phenothiazine antipsychotic,

tricyclic antidepressants & some antihistamines. Alcohol Side Effects and Adverse Reactions Dry mouth; difficulty in swallowing & talking, thirst. Reduced bronchial secretions, dilatation of pupil w/ loss of accomodation & photophobia, flushing, dry skin, transient bradycardia followed by tachycardia w/ palpitations & arrhythmias & difficulty in micturition; constipation Nursing Responsibilities
1. 2.

Ensure aqequate hydration Provide environmental control to prevent hyperprexia

3. 4. 5.

Avoid hot environments Avoid alcohol serious sedation can occur Take as prescribed 30-60 minutes before meals

Generic Name

Lactulose Brand Name Classification Laxative, ammonia redcuing agent Ordered Dose Mode of Action The drug passes unchanged in colon where bacteria break it down to organic acids that increase the osmotic pressure in the colon slightly acidify colonic content, resulting in an increase stool water content, stool softening and laxative action Indications Treatment of constipation lactulose

Contraindications

Allergy to lactulose

Drug Interactions Side Effects and Adverse Reactions GI: transient flatulence, distention. Intestinal cramps, belching, diarrhea , nausea, Other: acid-base imbalance Nursing Responsibilities
1. 2.

Do not freeze Give laxative with water or fruit juice, milk to increase palatability

3.

Do not administer any laxative while using lactulose

4. 5.

Monitor serum ammonia levels Carefully monitor blood glucose in diabetic clients

6. 7.

Do not use continuously for I week Bowel movements will increase 2-4 times a day

Generic Name

Telmisartan Brand Name Classification Micardis Angiotensin II receptor antagonist antihypertensive Ordered Dose Mode of Action 12.5mg itab OD Selectively blocks the binding angiotensin II specific tissue receptors found in the vascular smooth muscle and adrenal gland ; this action blocks the vasoconstriction effect of the rennin angiotensin system, as well as the release of aldosterone , leading to decrease BP Indications Treatment for hypertension,alone or in combination with other antihypertensive Contraindications Contraindicated with hypertensitivity ti telmisartan ,

pregnancy(during the second and third trimester can cause death to fetus

Drug Interactions Side Effects and Adverse Reactions

Increased serum levels if combined with digoxin CNS: lightheadedness , headache ,dizziness, muscle weakness CV: hypotension Derma : rash , dermatitis , pruritus GI: constipation Flatulence, vomiting, Dry mouth GU: decrease renal function Respiratory: Asthma, dyspnea, epistaxis, Cough Other : back pain Gout

Nursing Responsibilities

1. Alert the surgeon if hypotension occurs 2. The blockage of RENIN-angiotensin sytem following surgery can produce problems. Hypotension may be reversed with volume expansion 3. If BP does not reached desired levels, diuretics or other hypertensice may be added to termisatan (monitor BP of client Carefully) 4 Take drug without regards to meals

5 . Do not stop taking this drug without consulting your doctor. 6. report fever,chills,dizziness

Generic Name

Glimiperide Brand Name Classification Ordered Dose Mode of Action Amaryl Antidiabetic drug,Sulfonylurea 3mg 1tab OD A sulfonylurea that probably stimulates insulin release from pancreatic beta cells, reduces glucose output by the liver, and increase peripheral sensitivity to insulin Indications Adjunct to diet to lower glucose level in patients with type 2 (non-insulin dependent) diabetes mellitus Contraindications Contraindicated in patients hypersensitive to drugs and in those with diabetic ketoacidosis Contraindicated in pregnant or breastfeeding women and as sole therapy in type 1 diabetes.

Drug Interactions Drug-drug : amantadine anabolic steroids ,antibiotic

,clorampenicol, clofibrate, MAO inhibitors,probenecid ,salicylates ,sulfonamides, Oral anticoagulants May increase hypoglemic activity Corticosteroids,glucagon,phenytoin,rifampin,thiazide antidiuretic; may decrease hypoglemic response

Side Effects and Adverse Reactions

Dizziness , drowsiness, headache , nausea, constipation, diarrhea ,leucopenia, hemolytic anemia, hypoglycemia,skin rash, pruritus, photosensitivity

Nursing Responsibilities

1) Give immediate release tablets about 30 mins. Before meals. 2) Some patients may attain effective control on a once daily regimen , whereas others respond better

with divided dosing 3) Patient may switch from immediate release dose to extended release tablets at the nearest equivalent total daily dose. 4) Glipizide is a second generation sulfonylurea. The frequency of adverse reaction appears lower than 2nd generation. 5) During periods of increased stress, patient may need insulin therapy. Monitor patient closely for hyperglycemic in these situations. 6) Tell the patient to carry candy and other simple sugars to treat mild low glucose episodes. 7) Instruct patient not to change drug dosage without prescribers consent and to report abnormal blood and urine glucose test result. 8) Tell the patient nit to take other drugs without checking with prescriber.

Generic Name

Nalbuphine Hydrochloride Brand Name Classification Ordered Dose Mode of Action Nalbuphine acts as an agonist at specific opoid receptors in the CNC to produce analgesia and sedation but also acts to cause hallucinations and is an antagonist at mu receptors Indications Relief of moderate to severe pain Preoperative analgesia, as a supplement to surgical anaesthesia and for obstetric analgesia during labor and Nubain Opoid agonist antagonist analgesic

delivery

Contraindications

Hypersensitivity ti nalbuphine

Drug Interactions

Potnetiation of effects with barbiturates anesthetic or other CNS Depressant

Side Effects and Adverse Reactions

CNS: Sedation, clamsiness, sweating , headache , nervousness, restleness, rying confusion, dizziness, vertigo , flushing , feeling of warmth , blurred vision, feeling of floating CV: hypotension hypertension, bradycardia , tachycardia Dermatoligic: pruritus, burning , urticaria GI; Nausea vomiting, dry mouth Respiratory: respiratory depression , dyspnea , Asthma

Nursing Responsibilities

1. Provide safety measures 2. Check for orientation ,reflexes, vision pulse, urine output. 3. Use cautiously to patient with history of addiction to Nubain 4. Taper dosage when discontinuing after prolonged used to avoid prolonge

withdrawal symptoms 5. Keep opoid antagonist and facilities for assisted or controlled respiration in caseof respiratory depresiion 6. Reassure patient about addiction liability

Generic Name

Essentiale Forte Brand Name Classification Ordered Dose Mode of Action Essentiale/Forte regulates membrane permeability and improves the exchange of substances between the intraand extracellular space. It activates metabolic function and supports the energy balance of the liver. It restores enzyme functions and promotes detoxification of the liver. Neutral Essentiale Forte Cholagogues, Cholelitholytics & Hepatic Protectors

fats and cholesterol are transformed into transportable forms and led to their physiological oxidation. Liver cell regeneration is stimulated and the bile is stabilized. Indications Acute and Chronic Hepatitis: Dystrophy and cirrhosis of the liver, biliary stasis and hepatic coma. Liver Damaged by Toxins: Fatty liver (eg, in diabetes, tuberculosis and chronic rheumatism), prophylaxis of recurrent gallstones, radiation damage, nephrotic syndrome and gestoses Contraindications Drug Interactions Side Effects and Adverse Reactions Nursing Responsibilities Should be taken with food

Generic Name

Levofloxacin

Brand Name Classification Ordered Dose Mode of Action

Levaquin FLuroquinolone antibiotic 500mg itab Bactericidal interferes with DNA inhibiting DNA gyrase rep;ication is susceptible gram negative and gram positive bacteria prevent cell reproduction

Indications

UTIs, lower respiratory tract infections, skin and skin structure infections, bone and joint infections, GI infection or infectious diarrhea, chronic bacterial prostatitis,

nosocomial pneumonia, acute sinusitis. Post-exposure prophylaxis for anthrax. Contraindications Known hypersensitivity to levofloxacin viral or other tendon

fluoroquinolones,

syphilis,

infection;

inflammation or tendon pain; pregnant women (category C). Drug Interactions Increased risk of CNS effects with ethanol, barbiturates, antihistamine and other sedative drugs. Side Effects and Adverse Reactions GI: Nausea, vomiting, diarrhea, cramps, gas,

pseudomembranous colitis. Metabolic: Transient increases in liver transaminases, alkaline phosphatase, lactic

dehydrogenase, and eosinophilia count. Musculoskeletal:

Tendon rupture, cartilage erosion. CNS: Headache, vertigo, malaise, peripheral neuropathy, seizures (especially with rapid IV infusion). Skin: Rash, phlebitis, pain, burning, pruritus, and erythema at infusion site. Special Senses: Local burning and discomfort, crystalline precipitate on superficial portion of cornea, lid margin crusting, scales, foreign body sensation, itching, and conjunctival

hyperemia. Nursing Responsibilities Assessment & Drug Effects 1) Report tendon inflammation or pain. Drug should be discontinued. 2) Lab tests: Culture and sensitivity tests should be done prior to initial dose. Treatment may be implemented pending results. 3) Monitor urine pH; it should be less than 6.8, especially in the older adult and patients receiving high dosages of ciprofloxacin, to reduce the risk of crystalluria. 4) Monitor I&O ratio and patterns: Patients should be well hydrated; assess for S&S of crystalluria. 5) Monitor plasma theophylline concentrations, since drug may interfere with half-life.

6) Administration with theophylline derivatives or caffeine can cause CNS stimulation. 7) Assess for S&S of GI irritation (e.g., nausea, diarrhea, vomiting, abdominal discomfort) in clients receiving high dosages and in older adults. 8) Monitor PT and INR in patients receiving coumarin therapy. 9) Assess for S&S of superinfections

Patient & Family Education 10) Immediately report tendon inflammation or pain. Drug should be discontinued. 11) Fluid intake of 23 L/d is advised, if not contraindicated. 12) Report sudden, unexplained joint pain. 13) Restrict caffeine due to the following effects (e.g., nervousness, insomnia, anxiety, tachycardia). 14) Report possible toxicity. If taking theophylline derivatives, there is potential for adverse effects. 15) Report nausea, diarrhea, vomiting, and abdominal pain or discomfort. 16) Use caution with hazardous activities until reaction

to drug is known. Drug may cause light-headedness

Generic Name

glyburide and metformin Brand Name Glucovance

Classification Ordered Dose Mode of Action

Antidiabetic drug , sulfonylurea

Stimulates insulin release from functioning beta cells in th pancreas; may improve binding between insulin and insulin receprtors or increase the numbers of insulin receptor : more potent in effect than first generation sulfonylurea

Indications

Adjucnt to lower blood glucose level with type 2 diabetes mellitus

Contraindications

Diabetic ketoacidosis,sole therapy of type 1 DM , serious heapatic impairement, uremia, Coma

Drug Interactions

Drugs that can raise blood sugar include: isoniazid; diuretics (water pills);

y y

y y y y y y

steroids (prednisone and others); phenothiazines (Compazine and others); thyroid medicine (Synthroid and others); birth control pills and other hormones; seizure medicines (Dilantin and others); and diet pills or medicines to treat asthma, colds or allergies.

Drugs that can lower blood sugar include: nonsteroidal anti-inflammatory drugs (NSAIDs); aspirin or other salicylates (including PeptoBismol);
y y y y

y y

sulfa drugs (Bactrim and others); a monoamine oxidase inhibitor (MAOI); beta-blockers (Tenormin and others); or probenecid (Benemid). ciprofloxacin (Cipro); furosemide (Lasix); nifedipine (Adalat, Procardia); cimetidine (Tagamet) or ranitidine (Zantac); amiloride (Midamor) or triamterene (Dyrenium); digoxin (Lanoxin);

y y y y y y

y y y y

morphine (MS Contin, Kadian, Oramorph); procainamide (Procan, Pronestyl, Procanbid); quinidine (Cardioquin, Quinidex, Quinaglute); trimethoprim (Proloprim, Primsol, Bactrim, Cotrim, Septra); or

vancomycin (Vancocin, Lyphocin).

Side Effects and Adverse Reactions

y y

feeling short of breath, even with mild exertion; or swelling or rapid weight gain.

Other less serious side effects may be more likely to occur, such as: sneezing, runny nose, cough or other signs of a cold;
y y y

headache; dizziness; or mild nausea, vomiting, diarrhea, stomach pain.

Nursing Responsibilities

1. give drug before meal 2. avoid alcohol while using this drug 3. monitor urine , blood glucose and ketones continue treatment regimen

4. Do not use Glucovance if you have congestive heart failure or kidney disease, or if you are in a state of diabetic ketoacidosis (call your doctor for treatment with insulin). 5. Before taking Glucovance, tell your doctor if you have heart disease, liver disease, or a history of heart attack or stroke. 6. Know the signs of low blood sugar (hypoglycemia) and how to recognize them, including hunger, headache, confusion, irritability, drowsiness, weakness, dizziness, tremors, sweating, fast heartbeat, seizure (convulsions), fainting, or coma (severe hypoglycemia can be fatal). Always keep a source of sugar available in case you have symptoms of low blood sugar. 7. Check for blood sugar before and after the therapy 8. Glucovance is only part of a complete program of treatment that also includes diet, exercise, and weight control. It is important to use this medicine regularly to get the most benefit

Generic Name

Ampicillin+ Sulbactam

Brand Name

Ampimax vial

Classification Ordered Dose Mode of Action

Antibiotic 1.5 IVTT q8 Ampicillin exerts bactericidal action on both gram-positive and gram-negative organisms. Its spectrum includes gram-positive organisms e.g. S pneumoniae and other

Streptococci, L monocytogenes and gram-negative bacteria e.g. M catarrhalis, N gonorrhoea, N meningitidis, E coli, P mirabilis, Salmonella, Shigella, and H influenzae. Ampicillin exerts its action by inhibiting the synthesis of bacterial cell

wall. Sulbactam inhibits -lactamases and extends the spectrum of ampicillin to include -lactamase producing pathogens.

Indications

Mild to moderate infections (i.e.; skin, intra-abdominal and gynecological infections)

Contraindications Drug Interactions

Allergy to penicillins, infectious mononucleosis Several case reports describe methotrexate toxicity in patients following coadministration of methotrexate and penicillins. Penicillins may reduce the renal clearance of methotrexate resulting in elevated methotrexate methotrexate serum toxicity concentrations (e.g. renal and failure,

myelosuppression,

mucositis,

dermatologic

abnormalities). If the combination is unavoidable, close monitoring of methotrexate drug levels and for signs of methotrexate toxicity is necessary.

Side Effects and Adverse

Side Effects: Mild diarrhea; pain, swelling, or redness at

Reactions

injection site. Adverse Effects: Pain at Inj site, thrombophlebitis, diarrhoea, itching, nausea, vomiting, flatulence, candidiasis, fatigue, malaise, headache, chest pain, glossitis, abdominal distention, dysuria, urinary retention, oedema, erythema, epistaxis, mucosal bleeding. Fatal anaphylaxis.

Nursing Responsibilities

Nursing Responsibilities: 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Infuse slowly as a bolus over no less than 15 seconds. 4. Tell patient that she may experience side effects brought upon by the drug. 5. Instruct to report intolerable side effects for prompt intervention. 6. Instruct to report if she experiences adverse effects.

Generic Name

Sitagliptin+metformin Brand Name Classification Januvia Therapeutic Class: Antidiabetic Pharmacologic Class: Dipeptidyl Peptidase IV Inhibitor

Ordered Dose Mode of Action Slows the inactivation of the incretin hormones , increasing these hormone levels and prolonging their activity. The incretin hormones stimulates insulin release in response to a meal and help to regulate glucose homeostasis throughtout the day. This increases and prolongs insulin release and reduces hepatic glucose production to achive glycemic control. Indications Adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus, with other oral antibiotics Contraindications Drug Interactions With hypersensitivity to sitagliptin Risk of hypoglycemia when combined with other drugs or herbal medicines known to cause hypoglycemia ; monitor patient closely to adjust dosage as needed. Side Effects and Adverse Reactions CNS: headache Respiratort:nasopharyngitis, URIs Other: hypoglycemia Nursing Responsibilities 1. Monitor blood glucose levels before during and after the therapy 2. Ensure patient to continue diet and exercise

program for management of type 2 diabetes 3. Ensure the patient to continue with appropriate use of other drugs to manage type 2 DM 4. This drug should be take n once a day with or without food 5. Arrange periodi c monitoring of your FBS 6. Watch out for signs of hypoglycemia hunger, headache, confusion, irritability; o drowsiness, weakness, dizziness, tremors; o sweating, fast heartbeat; o seizure (convulsions); or o fainting, coma (severe hypoglycemia can be fatal).

7. Report signs of infection, uncontrolled bld glucose , severe headache and stress.

Generic Name

Metoclopramide

Brand Name

Octamide PFS, Reglan

Classification

GI stimulant, antiemetic, dopaminergic blocker

Ordered Dose Mode of Action

1amp now IVTT Stimulates the muscles of the gastrointestinal tract including the muscles of the lower esophageal sphincter, stomach, and small intestine by interacting with receptors for acetylcholine and dopamine on gastrointestinal muscles and nerves; decreases the reflux of stomach acid by strengthening the muscle of the lower esophageal sphincter; stimulates the muscles of the stomach and thereby hastens emptying of solid and liquid meals from the stomach and into the intestines; interacts with the dopamine receptors in the brain and can be effective in treating nausea.

Indications

Stimulation of gastric emptying prior to surgery

Contraindications

Hypersensitivity to metoclopramide, GI hemorrhage, mechanical obstruction or perforation;

pheochromocytoma (may cause hypertensive crisis);

epilepsy Side Effects: drowsiness, restlessness, fatigue, anxiety, insomnia, depression, sedation, nausea, diarrhea, urinary frequency

Drug Interactions

Decreased absorption of Cefprozil, cimetidine, digoxin from the stomach Increased oral bioavailability or absorption of acetaminophen, tetracycline Decreased effect on gastric emptying with cyclosporine, ethanol, levodopa,

anticholinergic, opioid analgesics, levodopa Increased risk of serious adverse effects due to excess release of neurotransmitters with MAOIs for example, isocarboxazid (Marplan), phenelzine (Nardil), tranylcypromine (Parnate), selegiline (Eldepryl), and procarbazine (Matulane)

Side Effects and Adverse Reactions

parkinsons-like

reactions,

involuntary

muscle

movements,

facial grimacing,

dystonic reactions

resembling tetanus, transient hypertension, tardive dyskinesia, myoclonus

Nursing Responsibilities

Nursing Responsibilities: 1. Assess patient for contraindication. 2. Assess for baseline data. 3. Give direct IV dose slowly (over 1 to 2 minutes). 4. Monitor BP carefully during IV administration. 5. Monitor for extrapyramidal reactions, and consult physician if they occur. 6. Keep diphenhydramine injection readily available in case of extrapyramidal reactions. 7. Have phentolamine readily available in case of hypertensive crisis (most likely to occur with

undiagnosed pheochromocytoma). 8. Tell patient that she may experience side effects brought upon by the drug. 9. Instruct patient to report involuntary movement of the face, eyes or limbs, severe depression, severe

diarrhea. 10.Provide a safe environment if restlessness,

involuntary muscle movement occur.

Generic Name

ranitidine hydrochloride Brand Name Classification Ordered Dose Mode of Action Zantac Antisecretory (h2-receptor antagonist); Antiulcer 50 mg q 8 hours, IVTT Potent anti-ulcer drug that competitively and reversibly inhibits histamine action at H2-receptor sites on parietal cells, thus blocking gastric acid secretion. Indirectly reduces pepsin secretion but appears to have minimal effect on fasting and postprandial serum gastrin concentrations or secretion of gastric intrinsic factor or mucus. Indications Short-term treatment of active duodenal ulcer; maintenance therapy for duodenal ulcer patient after healing of acute ulcer; treatment of gastroesophageal reflux disease; shortterm treatment of active, benign gastric ulcer; treatment of pathologic GI hypersecretory conditions (e.g., ZollingerEllison syndrome, systemic mastocytosis, and

postoperative hypersecretion); heartburn

Contraindications

Hypersensitivity to ranitidine; acute porphyria; OTC administration in children <12 y.

Drug Interactions

May reduce absorption of cefpodoxime, cefuroxime, delavirdine, ketoconazole, itraconazole.

Side Effects and Adverse Reactions

CNS:

Headache,

malaise,

dizziness,

somnolence,

insomnia, vertigo, mental confusion, agitation, depression, hallucinations in older adults. CV: Bradycardia (with rapid IV push). GI: Constipation, nausea, abdominal pain, diarrhea. Skin: Rash. Hematologic: Reversible decrease in WBC count, thrombocytopenia. Body as a Whole: Hypersensitivity reactions, anaphylaxis (rare).

Nursing Responsibilities

Assessment & Drug Effects 1) Potential toxicity results from decreased clearance (elimination) and therefore prolonged action; greatest in the older adult patients or those with hepatic or renal dysfunction. 2) Lab tests: Periodic liver functions. Monitor creatinine clearance if renal dysfunction is present or suspected. When clearance is <50 mL/min, manufacturer recommends reduction of the dose to 150 mg once q24h with cautious and gradual reduction of the interval to q12h or less, if

necessary. 3) Be alert for early signs of hepatotoxicity (though low and thought to be a hypersensitivity reaction): jaundice (dark urine, pruritus, yellow sclera and skin), elevated transaminases (especially ALT) and LDH. 4) Long-term therapy may lead to vitamin B12 deficiency.

Patient & Family Education 5) Note: Long duration of action provides ulcer pain relief that is maintained through the night as well as the day. 6) Be aware that even if symptomatic relief is provided by ranitidine, this should not be interpreted as absence of gastric malignancy. Follow-up examinations will be scheduled after therapy is discontinued. 7) Adhere to scheduled periodic laboratory checkups during ranitidine treatment. 8) Do not supplement therapy with OTC remedies for gastric distress or pain without physician's advice (e.g., Mylanta II reduces ranitidine absorption).

9) Do not smoke; research shows smoking decreases ranitidine efficacy and adversely affects ulcer healing.

Generic Name

Piperacillin Sodium Brand Name Classification Ordered Dose Mode of Action Tazocin Antibiotic, Betalactam 2.25gm q8 Piperacillin is a beta-lactam antibiotic and is mainly bactericidal. It inhibits the final stage of bacterial cell wall synthesis by preferentially binding to specific

penicillin-binding proteins (PBPs) located inside the bacterial cell wall. This interferes with bacterial cell wall synthesis promotes loss of membrane integrity and leads to death of the organism. Indications Lower respiratory tract, Intraabdominal, and bone and joint infections; septicemia, urinary tract infections. Also used prophylactically as empiric antiinfective therapy in granulocytopenic patients. Contraindications Hypersensitivity to penicillins. Use cautiously to patient with tendencies of bleeding. Drug Interactions Anticoagulants: may increase risk of bleeding Probenecid: decrease elimination of piperacillin Side Effects and Adverse Reactions Coughing, superinfections, inflammation, systemic Injection abscess, anaphylaxis, site reactions fever, (pain,

phlebitis),

eosinophilia,

leukopenia, hypernatremia, bleeding, rash. Nursing Responsibilities Assessment & Drug effect 1. Obtain history of hypersensitivity to penicillins, cephalosporins, administration 2. Obtain specimen for culture and sensitivity tests or other drugs prior to

vefore giving first dose. 3. Watch out for any sign of superinfection in patient with prolonged therapy 4. Monitor patients sodium intake 5. Monitor parameters. 6. Withhold drug and report to physician if signs of an allergic reaction develop (e.g., itching, rash, hives). 7. Report significant, unexplained diarrhea. 8. Do not mix with other drugs hematologic and coagulation

Patient & Family Education

9. Tell patient or significant others to report adverse reaction promptly 10. Advise patient or significant others to alert nurse if discomfort occurs at I.V. site

Generic Name

tramadol hydrocholoride/paracetamol Brand Name Classification Ordered Dose Mode of Action Dolcet Narcotic analgesic 50 mg, 1 tab PRN Centrally acting opiate receptor agonist that inhibits the uptake of norepinephrine and serotonin, suggesting both opioid and nonopioid mechanisms of pain relief. May produce opioid-like effects, but causes less respiratory depression than morphine. Indications Management of moderate to moderately severe pain.

Contraindications

Hypersensitivity to tramadol or other opioid analgesics; patients on MAO inhibitors; patients acutely

intoxicated with alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic drugs; substance abuse; patients on obstetric preoperative medication; abrupt discontinuation; alcohol intoxication; pregnancy (category C); lactation; children <16 y. Drug Interactions Carbamazepine significantly decreases tramadol

levels (may need up to twice usual dose). Tramadol

may increase adverse effects of mao inhibitors. tricyclic antidepressants, cyclobenzaprine,

phenothiazines, selective serotonin-reuptake inhibitors (ssris), mao inhibitors may enhance seizure risk with tramadol. May increase CNS adverse effects when used with other cns depressants. Herbal: St. John's wort may increase sedation. Side Effects and Adverse Reactions CNS: Drowsiness, dizziness, vertigo, fatigue, euphoria,

headache,

somnolence,

restlessness,

confusion, anxiety, coordination disturbance, sleep disturbances, seizures. CV: Palpitations, vasodilation. GI: Nausea, constipation, vomiting, xerostomia, dyspepsia, diarrhea, abdominal pain, anorexia,

flatulence. Body as a Whole: Sweating, anaphylactic reaction (even with first dose), withdrawal syndrome (anxiety, sweating, nausea, tremors, diarrhea,

piloerection, panic attacks, paresthesia, hallucinations) with abrupt discontinuation. Skin: Rash. Special Senses: Visual disturbances. Urogenital: Urinary retention/frequency, menopausal symptoms. Nursing Responsibilities 1) Assess for level of pain relief and administer prn dose as needed but not to exceed the

recommended total daily dose. 2) Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression. 3) Discontinue drug and notify physician if S&S of hypersensitivity occur. 4) Assess bowel and bladder function; report urinary frequency or retention. 5) Use seizure precautions for patients who have a history of seizures or who are concurrently using drugs that lower the seizure threshold. 6) Monitor ambulation and take appropriate safety precautions. 7) Exercise caution with potentially hazardous activities until response to drug is known. 8) Understand potential adverse effects and report problems with bowel and bladder function, CNS impairment, and any other bothersome adverse effects to physician.

Generic Name

Ketorolac

Brand Name Classification NSAID

Toradol

Ordered Dose Mode of Action Ketorolac tromethamine is a nonsteroidal anti-

inflammatory drug (NSAID) that exhibits analgesic

activity in animal models. The mechanism of action of ketorolac, like that of other NSAIDs, is not completely understood but may be related to prostaglandin synthetase inhibition. The biological activity of ketorolac tromethamine is associated with the S-form. Ketorolac tromethamine possesses no sedative or anxiolytic properties. Indications TORADOLORAL (ketorolac tromethamine), a

nonsteroidal anti-inflammatory drug (NSAID), is indicated for the short-term (up to 5 days in adults), management of moderately severe acute pain that requires analgesia at the opioid level and only as continuation treatment following IV or IM dosing of ketorolac tromethamine, if necessary. The total combined duration of use of TORADOLORAL and ketorolac tromethamine should not exceed 5 days. Contraindications GASTROINTESTINAL RISK CARDIOVASCULAR RISK RENAL RISK

Drug Interactions

Aspirin

When TORADOL is administered with aspirin, its protein binding is reduced, although the clearance of free TORADOL is not altered. The clinical significance of this interaction is not known; however, as with other NSAIDs, concomitant administration of ketorolac tromethamine and aspirin is not generally

recommended because of the potential of increased adverse effects. Diuretics Clinical studies, as well as postmarketing observations, have shown that TORADOL can reduce the natriuretic effect of furosemide and thiazides in some patients. This response has been attributed to inhibition of renal prostaglandin synthesis. During concomitant therapy with NSAIDs, the patient should be observed closely for signs of renal failure. ACE Inhibitors/Angiotension II Receptor

Antagonists Concomitant use of ACE inhibitors and/or angiotension II receptor antagonists may increase the risk of renal impairment, particularly in volume-depleted patients.

Reports suggest that NSAIDs may diminish the antihypertensive effect of ACE inhibitors and/or angiotension II receptor antagonists. This interaction should be given consideration in patients taking NSAIDs concomitantly with ACE inhibitors and/or angiotension II receptor antagonists. Side Effects and Adverse Reactions Body as a Whole: fever, infections, sepsis Cardiovascular: congestive heart failure,

palpitation, pallor, tachycardia, syncope Dermatologic: urticaria Gastrointestinal: eructation, gastritis, anorexia, dry mouth, thirst, hepatitis, alopecia, photosensitivity,

esophagitis, glossitis,

excessive

hematemesis,

increased appetite, jaundice, melena, rectal bleeding Hemic and Lymphatic: epistaxis, ecchymosis, leukopenia,

eosinophilia, thrombocytopenia

Metabolic and Nutritional: weight change

Nervous System: abnormal dreams, abnormal thinking, depression, symptoms, anxiety, asthenia, confusion,

euphoria, hallucinations,

extrapyramidal hyperkinesis,

inability to concentrate, insomnia, nervousness, paresthesia, somnolence, stupor, tremors,

vertigo, malaise Reproductive, female: infertility Respiratory: asthma, cough, dyspnea,

pulmonary edema, rhinitis Special Senses: abnormal taste, abnormal vision, blurred vision, hearing loss Urogenital: increased cystitis, urinary dysuria, frequency, hematuria, interstitial

nephritis, oliguria/polyuria, proteinuria, renal failure, urinary retention

Nursing Responsibilities 1. Oral formulation should not be given as an initial dose

2. Use minimum effective dose for the individual patient 3. Do not shorten dosing interval of 4 to 6 hours 4. Total duration of treatment in adult patients: the combined duration of use of IV or IM dosing of ketorolac tromethamine and

TORADOLORAL is not to exceed 5 days. 5. TORADOL is a potent NSAID and may cause serious side effects such as gastrointestinal bleeding or kidney failure, which may result in hospitalization and even fatal outcome. 6. TORADOL, like other NSAIDs, can cause GI discomfort and rarely, serious GI side effects, such as ulcers and bleeding, which may result in hospitalization and even death. 7. TORADOL, like other NSAIDs, may cause serious CV side effects, such as MI or stroke, which may result in hospitalization and even death. 8. Patients should promptly report signs or symptoms of unexplained weight gain or edema to their physicians. 9. Patients should be informed of the signs of an

anaphylactoid

reaction

(eg,

difficulty

breathing, swelling of the face or throat). If these occur, patients should be instructed to seek immediate emergency help.

Generic Name

Bisacodyl Brand Name Classification Ordered Dose Mode of Action Relieving occasional constipation and irregularity. It may also be used for other conditions as determined by your doctor. Bisacodyl is a stimulant laxative. It acts directly on the bowels, stimulating the bowel muscles to cause a bowel Dulcolax Laxative

movement.

Indications

Constipation, pre operative use ,short term relief of constipation, to prevent training, to remove ingested poisons from th lower GI tract

Contraindications

y y

you are allergic to any ingredient in Bisacodyl you have severe stomach pain; appendicitis; severe constipation; stomach, intestinal, or rectal bleeding; or intestinal blockage

y y

you cannot swallow without chewing you are having abdominal surgery

Drug Interactions Side Effects and Adverse Reactions Seek medical attention right away if any of these SEVERE side effects occur: Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue). Cramps; faintness; stomach discomfort.

Nursing Responsibilities

1. 2.

Take Bisacodyl by mouth with or without food. Take Bisacodyl with a full glass of water (8 oz/240 mL).

3.

Drinking extra fluids while you are taking Bisacodyl is recommended. Check with your doctor for instructions.

4.

Swallow Bisacodyl whole. Do not break, crush, or chew before swallowing.

5.

Do not take Bisacodyl within 1 hour after taking an antacid or milk.

6.

If you miss a dose of Bisacodyl and are taking it regularly, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once.

7.

Do not use for longer than 1 week without checking with your doctor. Using Bisacodyl for a long time may result in loss of normal bowel function.

8.

Do not take additional laxatives or stool softeners with Bisacodyl unless directed by your doctor.

9.

Rectal bleeding or failure to have a bowel movement within 12 hours after use of a laxative may be a sign of a serious condition. Stop use and

contact your doctor.

10. If you develop nausea, vomiting, or stomach pain,

stop using Bisacodyl and check with your doctor.

11. If you notice a sudden change in bowel habits that

lasts for 2 weeks or more, do not continue using Bisacodyl. Instead, check with your doctor.
12. Use Bisacodyl with caution in the ELDERLY; they

may be more sensitive to its effects.

13. Bisacodyl should not be used in CHILDREN

younger than 6 years old; safety and effectiveness in these children have not been confirmed.

Generic Name

Celecoxib

Brand Name

Celebrex

Classification

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Ordered Dose

Mode of Action

The mechanism of action of Celebrex is believed to be due to the inhibition of prostaglandin synthesis, primarily via inhibition of cyclooxygenase-2 (COX-2), and at therapeutic concentrations in humans, Celebrex does not inhibit the cyclooxygenase-1 (COX-1) isoenzyme.

Indications

It is intended to relieve pain while minimizing the gastrointestinal adverse effects usually seen with conventional NSAIDs. In practice, its primary indication is in patients who need regular and long term pain relief: there is probably no advantage to using celecoxib for short term or acute pain relief over conventional

NSAIDs.

Contraindications

Patients with known hypersensitivity to celecoxib and those who have demonstrated allergic-type reactions to

sulfonamides. Celebrex should not be given to patients who have experienced asthma, urticaria or allergic-type reactions after taking aspirin or other NSAIDs. Severe, rarely fatal, anaphylactic-like reactions to NSAIDs have been reported in such patients (see Warnings and Precautions). Celebrex is contraindicated for the treatment of perioperative pain in the setting of coronary artery bypass graft (CABG) surgery

Drug Interactions

Fluconazole & other CYP2C9 inhibitors. Warfarin & other anticoagulant. Non aspirin NSAID. ACE inhibitor, angiotensin II antagonist, diuretics, lithium.

Side Effects and Adverse

C Anaphylactic reactions, renal toxicity. Hallucination,

Reactions

ageusia, anosmia, aseptic menlugitis, vasculitis, GI hemorrhage. Hepatitis, liver failure, interstitial nephritis. photosensitivity reaction, multiforme, epidermal exfoliative dermatitis, erythema toxic

Stevens-Johnson necrolysis &

syndrome,

menstrual

disorder.

Cerebral hemorrhage, fulminant hepatitis, liver necrosis, hyponatremia, conjunctivitis. cough; fever; skin rash; sneezing; sore throat; swelling of face, fingers, feet, and/or lower legs; Back pain; dizziness; gas;

headache; heartburn ; inability to sleep; nausea ; pain or burning in throat; stomach pain; stuffy or runny nose

Nursing Responsibilities

1. Inform the patient regarding that doses can be given without regard to timing of meals. 2. Patients should be informed of the signs and symptoms of an anaphylactoid reaction (e.g., difficulty breathing, swelling of the face or throat). Patients should be instructed to seek

immediate emergency assistance if they develop any of these signs and symptoms 3. Check with your doctor as soon as possible if any of the following side effects occur: Bloody or black tarry stools; burning feeling in chest or stomach; chills; congestion in chest;

cough; diarrhea; fatigue; fever; loss of appetite; muscle aches and pains; breath; nausea; shortness of tenderness in

stomach pain (severe);

stomach area; unusual weight gain; vomiting of blood or material that looks like coffee grounds; weakness 4. Assess for contraindication. 5. Assess for baseline data. 6. Tell patient that she may experience side effects that are brought about by the drug. 7. Instruct her to report intolerable side effects so management can be done.

Generic Name

sultamicillin

Brand Name

Sulmicil

Classification Ordered Dose Mode of Action

Antibiotic

Sultamicillin inhibits microorganisms and it

-lactamases in penicillin-resistant

acts against sensitive organisms during the stage of active multiplication by inhibiting biosynthesis of cell wall mucopeptide Indications Perioperative prophylaxis; Post operative prophylaxis

Contraindications

Hypersensitivity.

Drug Interactions

: Concurrent use increases risk of bleeding with warfarin and methotrexate toxicity; decreases efficacy of

oestrgen-containing oral contraceptives. Excretion of ampicillin is reduced when used with probencid.

Side Effects and Adverse Reactions

Side Effects: Diarrhoea, nausea, vomiting, rashes, pruritus, dizziness

Adverse Effects: Diarrhoea, nausea, vomiting, rashes, pruritus, blood dyscrasias, superinfections, dizziness, dyspnoea. Anaphylaxis.

Nursing Responsibilities

Nursing Responsibilities: 1.Assess for contraindication. 2. Assess for baseline data. 3. Tell patient that she may experience side effects that are brought about by the drug. 4. Instruct her to report intolerable side effects so management can be done. 5. Instruct her to eat frequent small meals 6. Instruct patient to avoid alcohol because severe reactions could occur. 7.Tell patient to report any adverse effects that she may experience.

Generic Name

Regular Insulin Brand Name Classification Ordered Dose Mode of Action Humulin R, Novolin R, Actrapid, Antidiabetic Drug 6 U, 10 U subcutaneous Increases Glucose transport across muscle and fat cells membranes to reduce glucose level . Promotes conversion of glucose to its storage from , glycogen : triggers amino acid uptake and conversion to protein in muscle cells and inhibits protein degradation; stimulates triglyceride

formation and inhibits release of free fatty acids from adipose tissue ; stimulates lipoprotein lipase activity ; which converts circulating lipoproteins to fatty acid.

Indications

Moderate to severe diabetic ketoacidosis or hperosmolar hyperglycemia

y y y y Contraindications Drug Interactions

Mild diabetic ketoacidosis Newly diagnosed diabetes mellitus Control of hyperglycemia hyperkalemia

Contraindicated during episodes of hypoglycemia

Several drugs augment the action of insulin and may lower blood glucose to a dangerous level (hypoglycemia). To prevent hypoglycemia when these drugs are used, the dose of insulin may need to be reduced. Such drugs include alcohol, MAO inhibitors like phenelzine (Nardil), betablockers like propranolol (Inderal), salicylates like aspirin (Bayer) or salsalate (Disalcid), and anabolic steroids like methyltestosterone (Android). There are other drugs that augment the blood glucoselowering effect of insulin, but they are less likely to interact with insulin or have less of an effect. Such drugs include tetracycline antibiotics like doxycycline (Vibramycin), guanethidine (Ismelin), oral hypoglycemic drugs like glyburide (Diabeta), sulfa antibiotics like sulfadiazine, and

ACE inhibitors like captopril (Capoten). There also are drugs that decrease the effect of insulin. Interactions are less likely and/or less serious. These drugs include diltiazem (Cardizem), niacin, corticosteroids like prednisone, estrogens, oral contraceptives, thyroid hormones like levothyroxine (Synthroid), isoniazid, epinephrine, thiazide diuretics like hydrochlorothiazide, and furosemide (Lasix).

Side Effects and Adverse Reactions

Insulin may cause minor and usually temporary side effects such as rash, irritation or redness at the injection site. To help prevent hypoglycemia, eat meals on a regular schedule. Too much insulin can cause low blood sugar (hypoglycemia). The symptoms include cold sweat, shaking, rapid heart rate, weakness, headache and fainting

Nursing Responsibilities

1) monitor patient closely for symptoms of hypoglycemia 2) use only syringes calibrated for the particular concentration of insulin given 3) press but dont rub the injection site after administration 4) Rotate injections sites to avoid overuse of

one area.Diabetic patients may achieve better control if injection site is rotated within the same anatomic region 5) Dont use insulin that changes color or becomes clumped or granular in appearance 6) Check expiration date on vial before using contents 7) Make sure patient knows that drug relieves symptoms but dont cure disease 8) Monitor patient for hyperglycemia

NURSING THEORIES

Faye Glenn Abdellahs 21 Nursing Problems Faye Glenn Abdellah emphasized that nursing should always be patient-focused. What she meant by patient-focused is that nurses should be able to identify the detectable conditions ailing the patient and provide a nursing intervention in order to better the condition of the patient. She professed that a nurse must first identify a problem of the patient and through the use of critical thinking, subsequently solve the problem.

Abdellahs Metaparadigm Although she did not clearly provide a definition for each major concept, abdellah did refer to individuals and/or families as recipients of care. Her description of health is the total health needs of a person and a healthy state of mind and body. She includes society in the planning for optimum health on local, state and international levels but emphasizes that nursing service is primarily for the individual. Nursing for Abdellah is a comprehenseive service that is based on an art and science and aims to help people, sick or well, cope with their health needs.

In order to aid nurses in identification and solving, Abdellah formulated a typology called the 21 nursing problems. These problems were based on the physical, social and emotional needs of the patient, the types of interpersonal relationshops between the nurse and the patient and the common elements of patient care.

Abdellahs Typology of the 21 Nursing Problems are as follows: 1.To promote good hygiene and physical comfort 2. To promote optimal activity, exercise, rest, and sleep 3. To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection 4. To maintain good body mechanics and prevent and correct deformities 5. To facilitate the maintenance of a supply of oxygen to all body cells 6. To facilitate the maintenance of nutrition of all body cells 7. To facilitate the maintenance of elimination 8. To facilitate the maintenance of fluid and electrolyte balance 9. To recognize the physiologic responses of the body to disease conditions 10. To facilitate the maintenance of regulatory mechanisms and functions 11. To facilitate the maintenance of sensory function 12. To identify and accept positive and negative expressions, feelings, and reactions 13. To identify and accept the interrelatedness of emotions and organic illness 14. To facilitate the maintenance of effective verbal and nonverbal communication 15. To promote the development of productive interpersonal relationships 16. To facilitate progress toward achievement of personal spiritual goals 17. To create and maintain a therapeutic environment 18. To facilitate awareness of self as an individual with varying physical, emotional, and developmental needs 19. To accept the optimum possible goals in light of physical and emotional limitations

20. To use community resources as an aid in resolving problems arising from illness 21. To understand the role of social problems as influencing factors in the cause of illness

Summary Abdellahs 21 nursing problems are especially useful in the case of our patient since our patient has several of these nursing problems. Our verbalized that although he does try to get some exercise he is no longer able to do it as often as he used to. He no longer plays sports or jogs and the morning and has reduced his biking regimen to only less than three times per week at a distance significantly lesser than what he had done before. Taking into consideration the patients age and physical limitations, we addressed this problem by suggesting exercise in the form of long, moderately paced walks after his legs regain full strength to provide a good cardiovascular workout without straining the body too much. The patient at the time of the interview had difficulty ambulating as well as poor eyesight thus would be prone to accidents and injury. We provided intervention to counter this problem through assisting the patient when ambulating, removed objects that were lying on the floor that could cause the patient to slip as well as raising the bed rails when sleeping. As a post-operative patient, the threat of infection will be ever-present until the wound can completely heal. Thus we provided strict monitoring of the wound dressing and any signs of a possible infection that manifests in the client. Since the client had a cholecystectomy, it would mean that the nutritional balance to his cells as well as the maintenance of elimination may be affected due to the decrease of the bodys ability to emulsify fat hence we advised the client to minimize his intake of fatty foods in order to facilitate better digestion and absorption of nutrients.

Some of Abdellahs 21 nursing problems were already present in the patient upon receiving him and we forsee that several more may present as time goes by considering his condition, thus proper intervention by the nurse must be conducted in order to adequately facilitate good health. Abdellahs theory is an indispensible part of the nursing practice since it provides a road map as to how we can provide precise, patient focused care.

Imogene Kings Goal Attainment Theory In the heart of Imogene Kings theory is the belief that the patient and the nurse can work together to define and reach a mutually agreed upon goal. King suggests that human beings have three fundamental needs. These are the need for the health information, the need for care with an emphasis on the prevention of illness, and the need for care when human beings are unable to help themselves. This theory suggests that the focus of nursing is the care of the human being, which King believes is an open system that is constantly interacting with their environment. The nurse can act as environmental stimuli through interaction and together with the patient, can perceive, judge and act together and ultimately put together a set of goals and a plan to which subsequent action will be taken.

Kings Metaparadigm King defines health as dynamic life experiences of a human being, which implies continuous adjustment to stressors in the internal and external environment through optimum use of ones resources to achieve maximum potential for daily living. Enviornment is defined as a

function of balance between internal and external interactions. Nursing according to orem, is a process of action, reaction and interaction whereby nurse and client share information about their perceptions in the nursing situation .

Summary In our patients case we made extensive use of Imogene Kings goal attainment theory, especially when it came to post-operative care and interventions and also in the management of his diabetes. We made use of this theory most especially in the assessment phase of the nursing process since it is only the client alone that is able to identify the subjective cues. We worked with the client and established with him to watch out for signs of infection. This is an application of Kings theory in that we as student nurses gave the information to the signs of infection and agreed with the client to mutually monitor his wound with a similar goal of early detection. We also worked with the client for diet modification with a goal of increasing his protein and vitamin c intake to facilitate faster wound healing. Another objective set with the client is to improve his exercise habits with gradual increase in difficulty to allow a stable return of his ambulating abilities and overall cardiovascular health. The application of Kings theory is however, most evident and detailed in our discharge plan since upon discussing it with the client, we set a goal to achieve all of the specified instruction in the discharge plan and to return to the physician for a follow-up assessment Kings theory is unique and invaluable to a student nurse in that it teaches both the nurse and the patient that the nursing process isnt just about the nurses efforts and interventions but

the collaboration of both parties to achieve a single, realistic goal for the betterment of the patient.

Myra Levines Conservation Model Levines conservation model is a nursing theory that focuses on the promotion of adaption and the maintenance of the perceived wholeness of the individual. This is done through the use of the four principles of conservation. Levine defines adaptation as the life process by which, over time, people maintain their wholeness or integrity as they respond to environmental challenges (George, Julia B. RN Nursing Theories, The base for Professional Nursing Practice Fourth Edition). There are two types of environment that an individual can adapt to namely the internal environment and the external environment. The internal environment is a combination of the physiological and pathophysiological aspect of an individual that is persistently under the influence and challenged by the external environment. The external environment are the factors that are not within a persons direct biological process but rather influence it. There are three components of the external environment. These are the perceptual environment, the operational environment and the conceptual environment. The perceptual environment refers to the part of the environment in which a person responds to with their sensory organs such as light, temperature, sound, taste and smell. The operational environment is the portion of the environment that interacts with living tissue even if the organism does not have any way of sensing its presence. There include radiation,

microorganisms and pollutants. The conceptual environment is the more humanistic part of the external environment which includes language, culture, ideas, symbols. When adaptation occurs the product is conservation. Conservation is a universal concept, a natural law, that deals with defense of wholeness and system integrity. Conservation defends the wholeness of living systems by ensuring their ability to confront change appropriately and retain the unique identity (George, Julia B. RN Nursing Theories, The base for Professional Nursing Practice Fourth Edition.) Conservation has four basic principles to which it adheres to and can therefore be achieved. These are: 1. The conservation of energy of the individual. This refers to the balancing of energy input and output to avoid excessive fatigue and facilitate recovery. This can be achieved through rest and the limitation of strenuous activities as well as the maintenance of proper nutrition. 2. The conservation of the structural integrity of the individual This focuses on the healing process since Levine believed that healing the defense of wholeness. This refers to the maintenance and restoration of the body to prevent physical breakdown and promote healing. 3. The conservation of the personal integrity of the individual. Refers to the sense of self of the individual. This can be preserved by recognizing the individual as one who strives for recognition, respect, self awareness, selfhood and self determination.

4.

The conservation of the social integrity of the individual. This refers to the conservation of an individuals place within a society as not to become

isolated due to his/her condition. A nurses role in the four principles of conservation is to assist he person with the process of retaining wholeness through the lease expense of effort. As such we must assist the client in conserving all integrity.

Summary This theory is important since our patient is a post-operative patient also with diabetes mellitus both of which would have an undeniable affect on his physical well being especially with regards to the energy and structural integrity of the individual. It is important to maintain the energy since these diseases will make him especially susceptible to physical stress which could lead to worsening of the conditions. The structural integrity is also at risk since the condition may eventually lead to the physical breakdown of the patient if not maintained. Being in this condition also leaves the risk of the patient developing poor self-concept since his body is currently in a weakened state and thus has to rely extensively on other people. This may lead to the patient viewing himself as a burden. As nurses, we can use the conservation model to help him maintain his personal integrity by introducing methods to which he can take care of herself and showing him the respect he deserves. Social integrity also needs to be persevered because as of the moment, the patient is still recovering and is not able to fully return to his normal roles in society. The duration of the recovery time may vary on how well the wound is healing a time which he may develop a sense of isolation. We can use Levines theory to suggest to the family

to support the patient through these tough times and, if needed, educate them on the condition to avoid alteration of views.

DISCHARGE PLAN MEDICATIONS:  Instruct the patient to comply with the medications ordered by the physician.  Home medication, must be strictly followed for fast recovery. Encourage to take food supplements such as vitamin and minerals to boost up patients immunity.  Explain why the medication is given and the importance of taking it up.

EXERCISE:  The patient should be encouraged to resume his activities of daily living at home to promote independence and for timely recovery.  Regular exercise should also be encouraged to promote good blood circulation in the body.

TREATMENT:  The patient should be encouraged to cooperate with the treatment and procedure ordered by the physician for his timely recovery.

 Instruct patient to take Janumet 500 mg one tablet once a day for one month  Instruct patient to take pritor plus once a day after breakfast for one month.

HEALTH-TEACHINGS:  The patient should be instructed to have sleep early at night and rest during the day.  The patient should avoid places where environmental sanitation is poor .  Encourage patient to comply with the medications.  Instruct client in techniques to protect the integrity of skin, care or dressing. OUT-PATIENT  Any odd signs such as fever, wound infection, recurrence of fever, etc. must be immediately reported to the physician.  Instruct the patient to come back after a week or so for a follow-up check up.

DIET  A well- balanced diet is necessary for good wound healing and recovery. Instruct the patient to eat foods that are from the four basic food groups: dairy products, meat, vegetables and fruits.  Encourage the patient to increase fluid intake.  Encourage patient to avoid fatty and salty foods. Discourage patient from vices such as smoking and drinking

PROGNOSIS

GOOD FAIR POOR Onset of the illness

JUSTIFICATION The onset of cholelithiasis takes time. It takes time for the stone to form. Moreover, unlike diseases that has sudden onset like heartatack, the onset of cholecystitis is not sudden therefore it can still be treated while it is still at early stage.

Duration of illness

Cholecystitis is a slow progressing disease. There is still time to treat the patient with medicines and treatments like surgery. The patient also do something regarding his illness while it is still early and did not disregard it.

Precipitating factors

The precipitating factor present in the patient is diabetes mellitus. Diabetes mellitus is a metabolic diseases that is characterized by high blood sugar (glucose) levels, that result from defects in insulin secretion, or action, or both. This disease is lifetime disease. However there are a lot of ways a person can do to prevent any complications. One of which is constant monitoring of blood glucose. The patient is also very compliant with his maintenance drug for diabetes which is Glimiperide. Therefore, this factor can be modified but with strict compliance to it.

Willingness to take medications and treatment

The patient has maintenance medications which are Pritor plus and glimiperide. The patient complies with the medications strictly. Moreover, the patient is very willing to take the medications prescribed to him by the doctor. He is also willing

to undergone treatment and surgery that would be good for his health. Age The age of the patient is 59. He is already in the middle age. He is in the age bracket that were susceptible to illnesses. Unlike young adults who have strong immune system and recover fast, middle aged adults recover slowly and their immune systems are deteriorating. However, he is physically fit and he maintains healthy body. Environmental factors The clients home as reported is conducive for rest and sleep. The patient lives in a therapeutic environment. There are smaller chances of pollution and noise. It can be said that the environment as well was generally peaceful and calm is very favorable for rest and promotes better health. Moreover, the hospital is also clean and conducive for healing. Family Support The family has been very supportive throughout. His sons and daughters were supportive. His two daughters who are nurses are taking good care of him. His two sons were supporting him especially

watching over him while he is in the hospital. Computation:  Poor: (0*1)/7  Fair: (2*2)/7 = 0/7 = 4/7 = 15/7 2.71

 Good: (5*3)/7 Total: Total 3 3 1 General Prognosis: 1-1.6 = POOR

1.7-2.3 = FAIR 2.4-3.0 = GOOD

Rationale for a Good Prognosis

As shown by the calculated prognosis in relation to the different factors involved, the patient has a good chance of survival. The factors presented in relation to prognosis shows that patient can cope up after being discharged. The precipitating factor present in the patient is diabetes mellitus. Diabetes mellitus is a metabolic disease that is characterized by high blood sugar (glucose) levels that result from defects in insulin secretion, or action, or both. This disease is lifetime disease. However there are a lot of ways a person can do to prevent any complications. One of which is constant monitoring of blood glucose. The patient is also very

compliant with his maintenance drug for diabetes which is Glimiperide. Therefore, this factor can be modified but with strict compliance to it. Moreover, The age of the patient is 59. He is already in the middle age. He is in the age bracket that was susceptible to illnesses. Unlike young adults who have strong immune system and recover fast, middle aged adults recover slowly and their immune systems are deteriorating. However, he is physically fit and he maintains healthy body. However, on the other hand, the onset of cholelithiasis takes time. It takes time for the stone to form. Moreover, unlike diseases that has sudden onset like heart attack, the onset of cholecystitis is not sudden therefore it can still be treated while it is still at early stage. Cholecystitis is a slow progressing disease. There is still time to treat the patient with medicines and treatments like surgery. The patient also does something regarding his illness while it is still early and did not disregard it. The patient has maintenance medications which are Pritor plus and glimiperide. The patient complies with the medications strictly. Moreover, the patient is very willing to take the medications prescribed to him by the doctor. He is also willing to undergone treatment and surgery that would be good for his health. The clients home as reported is conducive for rest and sleep. The patient lives in a therapeutic environment. There are smaller chances of pollution and noise. It can be said that the environment as well was generally peaceful and calm is very favorable for rest and promotes better health. Moreover, the hospital is also clean and conducive for healing. The family has been very supportive throughout. His sons and daughters were supportive. His two daughters who are nurses are taking good care of him. His two sons were supporting him especially watching over him while he is in the hospital.

RECOMMENDATION With this case presentation, as a group weve acquired a lot of knowledge and experiences that could really help us to become an efficient and competent nurse in the near future. Weve also seen our strengths and realized the weakness and flaws we have as a group. With this, we have formulated recommendations for the betterment of the majority, for the patient and his family, for the institution, for the school and lastly, for the group. For the patient, we recommend that he should comply with the doctors order and eat nutritious food more often. He should religiously comply with the home medicatios and checkups instructed to him. Furthermore the family should be there to support their loved one in times of ups and downs. Each member of the family should not neglect their health. They should promote a good diet and healthy lifestyle for the betterment of the patient. They should not hesitate to seek medical help whenever needed. Instead they should practice seeing a medical professional before an illness worsens. The medical institution should continue their optimal medical service to all patients. Their quality service should be maintained for the better of all patients. For our group, the commendable group work and cooperation should be continued throughout, improve on the things where we committed mishaps. And for Ateneo De Davao Universitys College of Nursing, we recommend that everyone in the faculty and staff continue to mold student nurses to be the best future registered nurses that they can be.