Ê
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Diabetes Mellitus has been for centuries, although it has not been fully
understood and the disease takes its name from the Greek for ³passing
through´ because of one of its main symptoms ± excessive urine production.
During the 15 th century the word mellitus was from the Latin word for ³honey´
when it was noted that many patients with diabetes had high levels of sugar in
their blood and urine. One third of this cases are undiagnosed, and the rest of
the cases, patient have self -denial that¶s why they are left untreated and
cause death for its complications.

Diabetes is a disease in which your blood glucose, or sugar, levels are too
high. Glucose comes from the foods you eat. Insulin is a hormone that helps
the glucose gets into your cells to give them energy. With Type 1 diabetes,
your body does not make insulin. With Type 2 diabetes, the more common
type, your body does not make or use insulin well. Without enough insulin, the
glucose stays in your blood.

Over time, having too much glucose in your blood can cause serious
problems. It can damage your eyes, kidneys, and nerves. Diabetes can also
cause heart disease, stroke and even the need to remove a limb. Pregnant
women can also get diabetes, called gestational diabetes.

Symptoms of Type 2 diabetes may include fatigue, thirst, weight loss,

blurred vision and frequent urination. Some people have no symptoms. A
blood test can show if you have diabetes. Exercise, weight control and
sticking to your meal plan can help control your diabete s. You should also
monitor your glucose level and take medicine if prescribed.

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ÊÊ

  

 


 


A case of Patient Dee, 61 years-old, female, and married. She is

a Roman Catholic who lives at Purok-5 Lunao Gingoog City and
currently she was retired government worker at palace. She was born
on March 07, 1945. She weighs 48 kls and 5¶2´ in height and a medium
built. She is a mother of five of children and her husband is a barangay
councilor in Lunao Gingoog City. In which income is enou gh for the
family needs and that completion of medications can be sustained.




   

Last February 11, 2010 10:00am. Patient Dee came to Gingoog

District Hospital she complaints ³magpa-putol ko sa akong tiil´ as
verbalized by the patient. Upon admission vital signs were taken and
recorded as T 36.6 P-68bpm R-21cpm BP-140/90. Admitting diagnosis
is diabetic. Prior to admission Patient Dee was burnt by a plastic and
since then the wound does not heal. Procedure done was IVF of PNSS
1L during admission. Last February 12, 2010 was undergone BKA at
left foot, blood transfusion was infuse at left arm after operation. CBC,
FBS, RBS, Cr, CXRY, U/A, S/E were also done during days of
admission.

Upon assessment Patient Dee was lying on bed, responsive and

no presence of body and breathe odor. Patient is in good grooming.
During assessment she is cooperative and listened attentively.

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 She was hospitalized a year ago due to stroke at Gingoog
District Hospital. She is at risk of hypertension and diabetes at her
mother side. Thus, she is known as diabetic for 15 years.

   






!"#"!$$%

Subjective:

Patient Dee usual diet was oatmeal and fresh milk.almost 500-
800 mg/dl she could intake that foods contain carbohydrate, fats and protein.
Thus, she¶s not allowed to eat sweet foods and soft drinks.She eats 3x a day
usually she eat ½ cup of oatmeal and fresh milk during breakfast. For lunch
she eat ½ cup oatmeal and the same with the dinner ½ cup oatmeal and her
last meal intake was lunch. Patient Dee experienced loss of appetite also
nausea and vomiting. Her usual weight is 55 kg and it changed to 48kg.

Objective:

Patient Dee current weight is 48 kg. Skin turgor was slow/poor

and skin color is pale. Skin temperature is warm when touched. Condition of
her teeth is good as well as the appearance of her tongue. Oral mucous
membrane is moist. With ongoing IVF of PNSS 1L infused at right arm.

! 

!"!"!$$%

Subjective:

Patient Dee is on diabetic diet. She prefers to eat oatmeal in

every meal. She is currently taking vitamin C and Vitamin B complex. Foods
eaten per meal at home were strictly no sugar. She ate three times a day and
is prohibited foods rich in sugar.

·
 Objective:

Skin turgor found to be poor, dry and warmth to touch. Condition

of the gum is good, tongue is in good condition and oral mucous membranes
are moist.

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Subjective:

Patient Dee has a normal bowel pattern, she defecate once a

day. Character of stool is well formed and brown in color. She usually void
more or less 5 times. Character of urine is pale yellow in color and clear.

Objective:

Abdomen is soft when palpation performed. With the presence

of FBC attached to urine bag. Urine was pale yellow in color and clear.

! 


Subjective:

She defecates once a day usually in the morning, which indicate

elimination pattern is normal. The character of stool is soft and well
formed. She voids five times a day. Character of urine is pale yellow.

Objective:
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 Abdomen is soft. Bowel sounds is located at left lower quadrant
and is normoactive. She¶s on diaper.

  







Subjective:

Patient Dee was noted with non productive cough.

Objective:

Patient Dee respiratory rate is 23 cpm. Breath sound is clear.

! 


Subjective:

Same in the 1 st assessment still she was noted with non

productive cough.

Objective:

Respiratory rate is 27 cpm. Respiratory depth is at 2 seconds

then expired. Non labored breathing is noted .

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Subjective:


 Patient Dee has a history of hypertension.

Objective:

Radial pulse is normal. Breath sound is clear. Has warm to touch temp
in the extremities and pale color. Distribution of hair is fair. General color is
pale. Lips is dry and nail beds is good. Has an ongoing IVF of PNSS infused
@ R arm regulated to KVO.

! 



Subjective:

She has history of hypertension. Upon assessment pain is noted at her

amputated leg.

Objective:

Blood Pressure is taken at the right arm with patient in sitting position:
BP is 120/80mmHg and pulse rate of 84bpm .

 & ''  '




Subjective:

Patient Dee was a former government employee. Her usual activities

are just watching TV and sometimes sweeping the floor. She consumed 8
hours of sleep and nap is 3 hours. She is dependent in terms of toileting. She
prepared to have her personal care @ 6 a m. With assistance required. She
completed the immunization.

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Objective:

Muscle tone is weak. Appears pallor and skin temperature is warm

when touched.

!


Subjective:

Her activities in daily living she is dependent in terms of mobility,

hygiene, feeding, dressing or grooming and toileting. She preferred to take a
bath in the morning. Patient Dee has a sedentary lifestyle; she just spend her
leisure time by sitting and watching T.V. She sleeps 7 -8 hours a day. Patient
Dee has no food and drug allergy, she also claimed that she is fully
immunized.

Objective:

Generally patient Dee¶s appearance is good, she has a goon hygiene

and no body odor note. Patient Dee is awake an responsive upon
assessment. She responds appropriately. Patient¶s body temperature is 36.7
Celsius skin is dry and wrinkled when touch .

£  


 


 




Subjective:

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 Patient Dee claim of headache at occipital area but the pain is
bareable. She experience numbness in the lower extremities.

Objective:

Patient Dee is oriented to time, place, person an d situation. She

appears drowsy.

! 


Subjective:

Patient Dee complained tingling at her amputated leg.

Objective:

Patient Dee is cooperative and responsive upon assessment .

  


 




Subjective:

³sakit ang pinutlan nako nga tiil´, as verbalized by the patient.

Objective:

Patient seen guarding her amputated leg with facial grimace. Pain
scale of 8 out of (1 -10).



! 
(

Subjective:

Patient Dee verbalizes pain at her amputated leg.

Objective:

Patient is responsive and without excessive changes in position, she is

calm, friendly and eager to participate in the interview. Blood pressure is
normal at range of 120/80mmHg and pulse rate is 84bpm.

) ' &

 


Subjective:

Patient Dee is not sexually active. Her age of menarche is when

she was 13 years old and she consumed 3 pads a day. Her la st menstruation
period was 16 years ago at her 45 years of age.

Objective:
She never had gone to any breast examination.


! 


Subjective:
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 Patient Dee is sexually inactive. Her age of menarche is 13 years old
with the length of cycle of 24 days, duration of period is 4 -5 days. Her last
menstrual period was 16 years ago at her 45 years of age.

Objective:

She never had gone to any breast examination.


*
££ 

 




Subjective:

According to patient Dee fatigue is the most stress factors of her life.
She handles this problem through relaxing.

Objective:

Patient Dee appears calm and has normal physiologic response.

! 


Subjective:
Patient Dee is a mother, living in a simple life and peace together with
her husband and five children. She¶s really stress in her amputated leg and
the only way she can handle it is to rest.

Objective:
Upon assessment patient D ee is calm with clear speech, have a good
verbal and non-verbal communication and family interaction.

å

 

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 Patient Dee is a Roman Catholic. She¶s part of the Couples for Christ
and has strong faith with God. She go to church every Sunday together with
her family. Patient Dee believes in spiritual and religious practices such as
quack doctors and helots

ÊÊÊ
&
+,

Person¶s growth and developmental is highly individualized; however,

its sequence of growth and development is predictable. Stages of growth
usually correspond to certain developmental changes (Kozier & Erbs. Vol.1 8 th
edition).

According to Havighurst¶s Developmental Task, Patient Dee belongs to

later maturity in which characteristics are as follows: (1) adjusting to
decreasing physical strength and health, (2) adjusting to retirement and
reduce income, (3) meeting social or civil obligations, (4) establishing
satisfactory physical living arrangement. From the above mentioned of theory,
patient Dee belongs/or is applicable to this theory. Since she underwent BKA,
she was really adjusting to her present condition.

John Piaget¶s Phases of cognitive theory (15 years and above) refers
to the ways in which people learn to think, reason and use language for
reasoning. This involves one¶s intellectual capacity and ability to process
information. Patient Dee belongs to the last phases and stages which is the
formal operational phase in which she uses rational thinking and reasoning is
deductive and futuristic.

According to Freud¶s five stages of development, Patient Dee is in the

stage of Genital (Age from puberty and after) in which energy is directed
toward full sexual maturity and function and development of skills needed to

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cope with the environment. With regards to these characteristics, our client is
no longer active or applicable on this theory because of her below the knee
amputation which lead s her to be stable and stagnant.

Kohlberg¶s theory is the stage of moral development in which patient

Dee belongs to the third level -the post conventional stage (middle -age or
older adult). She belongs to the Universal Ethical Principle Orientation in
which decisions and behaviors on internalize rules, on conscience rather than
social laws.

Erik Erickson¶s theory, patient Dee belongs to the Adulthood years (25 -
65 years old) with the central task of Generativity vs. Stagnation. At this
stage/level, the person is creative, productive, and shows concern for others.
However, because of her present condition, patient Dee is no longer
applicable to this theory. She showed lack of interests and commitment.

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 Êå
 


Last February 11, 2010.Patient Dee was admitted and seen by

the ROD and given orders for laboratories examination for further
evaluations such as CBC, with Platelet Count, U/A, S/E, FBS, Lipid
Profile, and Creatinine and Chest X-ray.

Laboratory results of Patient Dee reported as follows: CBC is for

evaluation of general health status. A CBC test usually includes White
Blood Cells (WBC or leukocytes count) which protect the body against
infection and it helps attack and destroys the bacteria, virus or other
organisms causing, it in case of infection. WBC defferential includes:
lymphocytes, neutrophils, monocytes, segmenters and platelets. WBC
result is 30,100/mm3 (normal value = 5,000 ± 15,000/mm3) this
indicates increased in value, indicating presence of infec tion. Epithelial
cells are normal. Bacteria is plenty, it indicate that person is risk for
infection.
Red Blood Cell (RBC) count is blood cells which carry oxygen
from the lungs to the rest of the body. RBC result is 4 -6 (normal
findings= 0-3 with a high power field 1 or 2 with a low power field).

Hematocrit (Hct) is a test which measures the amount of space

(volume). Hematocrit result is 34.3 ml/dl (normal value male = 42 ± 54%
female = 37 ± 47% ml/dl) it is with in normal range, which indicate
absence of anemia.

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 A hemoglobin test is a blood test which is used to determine how much
hemoglobin a patient has in his or her body. This test is usually performed as
part of a complete blood count, Hemoglobin result is 1.5 g/dl (normal value
female = 12-16 g/dl) it indicates that Hemoglobin is with in normal
range, indicating good iron status.
Lymphocytes = 9% (normal value = 15-40%), Segmenters result
91% (normal value = 45-70%) which indicates immunodeficiency from
immunosuppressive therapy, or poor lymphatic circulation.

A platelet count is a test to measure how many platelets you have in

your blood. Platelets help the blood clot. They are smaller than red or white
blood cells Platelet result is 224,000mm3 (normal range=150,000 -
400,000 mm3), it is a normal finding.

RBS or Random blood sugar test taken from a non-fasting subject.

RBS result is 225 mg/dl (normal values=65-110mg/dl), this result
indicates patient is prone to infection. Sugar is positive (normal findings
negative) indicates increased levels with hyperglycemia may indicate
diabetes mellitus.

Fasting Blood Sugar (FBS) is a carbohydrate metabolism test

which measure plasma, a blood glucose level after a fast. Fasting
stimulate the release of hormone glucagon, which in turn raises plasma
glucose level. In people without diabetes, the body will produce and
process insulin to counter act the rise in glucose level. In people with
diabetes this does not happen, and the tested glucose level will remain
high. FBS result is 117 mg/dl (normal values=65 -110mg/dl) this result is
increased level with hyperglycemia may indicate dia betes mellitus.

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 Lipid profile is a group of test that are often ordered together to
determine risk of coronary heart disease this include: Total Cholesterol,
high density lipoprotein cholesterol ± (often called good cholesterol), low
density lipoprotein cholesterol ± (often called bad cholesterol).
Cholesterol is 127mg/dl (normal values=150-200mg/dl), it interpret
terminal states of debilitating disease.

Urinalysis is used as a screening and diagnostic tool because it

can help detect substance or cellular material into urine associated with
different metabolic and kidney disorders. It is ordered widely and
routinely to detect any abnormalities that require follow up . It is also
used to detect urinary tract infections (UTI) and other disorder of the
urinary system. Result and characteristic of urine were the color is
yellow (normal findings=pale straw colored) indicates as normal. Clarity
of urine is cloudy (normal fi ndings= clear to slightly hazy) , after ingestion
of food, phosphates may proceed to cloudiness in normal urine. Specific
gravity result is 1.020 (normal findings= 1.003 -1.035) it signify as
normal.

Albumin is normal finding cast coarine gramular cost: i s 24 LPF

(normal findings= absent/scant), lead poisoning or nephrosclerosis.
p\pus cell is 18.25 indicates presence of dead bacteria and fragments of
dead tissue. Ph result is 6.0 (normal finding= 4.5 -8.0).

Stool exam is a test done in a stool (feces) sample to help

diagnose certain condition affecting the digestive tract. The condition
can include infection (such as from parasites, virus, or bacteria) or poor
nutrient absorption.

Chest X-ray is a projection radiograph of the chest used to

diagnose condition affecting the chest, its content and nearby

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structures. Chest radiograph are among the most common field taken,
being diagnostic of many condition. Chest X-ray result were in normal.

  


  

   


Treat diabetes mellitus by lowering glucose levels in the blood. With
the exceptions of insulin, exenatide, and pramlintide, all are administered
orally and are thus also called oral hypoglycemic agents or oral
antihyperglycemic agents. There are different classes of anti-diabetic drugs,
and their selection depends on the nature of the diabetes, age and situation of
the person, as well as other factors.

 




Medicines that reduce or relieve headaches, sore muscles, arthritis or
any number of other aches and pains. There are many different pain
medicines, and each one has advantages and risks. Some types of pain
respond better to certain medicines than others. E ach person may also have
a slightly different response to a pain reliever.

   


Are powerful medicines that fight bacterial infections. Used properly,
antibiotics can save lives. They either kill bacteria or keep them from
reproducing.

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 Are classes of drugs that are used to treat hypertension (high blood
pressure)

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Are foods, compounds, or drugs taken to induce bowel movements or
to loosen the stool, most often taken to treat constipation. Certain stimulant,
lubricant, and saline laxatives are used to evacuate the colon for rectal and
bowel examinations, and may be supplemented by enemas in that
circumstance.

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Are substances that your body needs to grow and develop normally.
Each vitamin has specific jobs. If you have low levels of certain vitamins, you
may develop a deficiency disease. Some vitamins may help prevent medical
problems. Vitamin A prevents night blindness.

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-Gastrointestinal
GENERI Treatment Allergy to metformin; upset -Endocrine: Decreases 

C: of subjects CHF; diabetes -Diarrhea Hypoglycemia, hepatic
-Cramps lactic acidosis
with non- complicated by glucose -History: Allergy to
-Nausea -GI: 0norexia,
Glucoph insulin- fever, severe nausea, vomiting,
production metformin; diabetes
-Vomiting
age dependent infections, severe epigastric and intestinal complicated by fever,
-
diabetes Increased flatule discomfort,heartbu glucose severe infections,
mellitus (ty trauma, major nce rn, diarrhea absorption;
pe II surgery, ketosis, -Hypersensitivity: increases severe trauma, major
BRAND: diabetes) acidosis, coma (use Allergic skin insulin surgery, ketosis,
insulin); reactions, eczema, sensitivity acidosis, coma; type 1 or
metformi pruritus, erythema, juvenile diabetes,
n urticaria
hydrochl serious hepatic or renal
oride Type 1 or juvenile impairment, uremia,
thyroid or endocrine
diabetes, serious impairment,
hepatic impairment,
serious renal glycosuria,
impairment, uremia, hyperglycemia
Classific thyroid or associated with primary
ation: renal disease, CHF
endocrine
Anti- impairment, -ҏPhysical: Skin color,
diabetic glycosuria, lesions; T, orientation,
hyperglycemia reflexes, peripheral
associated with sensation; R,
primary renal
adventitious sounds;

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 disease; labor and liver evaluation, bowel
delivery--if sounds; urinalysis, BUN,
Dosage: metformin is used serum
BID PO during pregnancy,
discontinue drug creatinine, liver function
tests, blood glucose,
at least 1 mo before CBC
delivery; lactation,
safety not Ê& 

established.
-Monitor urine or serum
glucose levels frequently
to determine
effectiveness of drug

and dosage.

-ҏArrange for transfer to

insulin therapy during
periods of high stress
(infections,

surgery, trauma).

-Use IV glucose if
severe hypoglycemia
occurs as a result of
overdose.

+ 
 

-ҏDo not discontinue this

Ô

 medication without
consulting your health
care provider.

-ҏMonitor urine or blood

for glucose and ketones
as prescribed.

-ҏDo not use this drug

during pregnancy.

-Avoid the use of alcohol

while on this drug.

-ҏReport fever, sore

throat, unusual bleeding
or bruising, rash, dark
urine, light-colored

stools, hypo- or
hyperglycemic reactions.

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(
Moderate to Should not be £ &( Nausea, Binds to mu- -Assess type,
moderately administered to Vasodilation. dizziness, opioid receptors. location, and
TRAMADOL severe pain patients who drowsiness, intensity of pain
£
&
Inhibits reuptake before and 2-3 hr
have previously tiredness,
'( Anxiety, of serotonin and (peak) after
demonstrated fatigue, administration.
Confusion, norepinephrine in
hypersensitivity sweating,
Coordination the CNS.
(
to tramadol, any disturbance, vomiting, dry -Assess BP & RR
other component Euphoria, Miosis, mouth and before and
Ultram of this product or Nervousness, postural periodically during
opioids, including Sleep disorder. hypotension. administration.
acute intoxication
with any of the .  ( -Assess bowel
£   (
following: alcohol, Abdominal pain, function routinely.
hypnotics, Anorexia, Prevention of
Analgesics narcotics, Flatulence. constipation
centrally acting should be
analgesics, ,( instituted with
Hypertonia. increased intake
opioids or
of fluids and bulk
(
psychotropic and with laxatives
, ( Rash.
drugs to minimize
1tab now then constipating
TID prn for effects.
severe pain
-Prolonged use
may lead to
physical and
psychological
dependence and

ÔÔ
 tolerance,
although these
may be milder
than with opioids.

-Monitor patient
for seizures. May
occur within
recommended
dose range.

-Encourage
patient to cough
and breathe
deeply every 2 hr
to prevent
atelactasis and
pneumonia.

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Acute infection Contraindicated £(
£(
vertigo, Inhibits DNA 0



with susceptible with Deadache, incoordination, synthesis in
metronidazole anaerobic hypersensitivity dizziness, insomnia, specific - '(
CNS or
bacteria to metronidazole; ataxia seizures, (obligate) hepatic disease;
pregnancy (do anaerobes, candidiasis
not use for ҏ.Ê(
peripheral causing cell (moniliasis); blood
(
 npleasant neuropathy, death; dyscrasias;
trichomoniasis in metallic taste, fatigue antiprotozoal-
Flagyl first trimester anorexia, trichomonacidal, pregnancy;
nausea, .Ê(
GI upset, amebicidal: lactation
vomiting, Biochemical
diarrhea cramps mechanism of
' (

£    : action is not Reflexes, affect;
.-(
.-(
Dysuria, known. skin lesions, color
Antibiotic darkening of incontinence, (with topical
the urine ҏJ(
application);
Antibacterial Thrombophlebitis
J(
(IV abdominal exam,
Amebicide redness, liver palpation;
burning, urinalysis, CBC,
Antiprotozoa dryness, and liver function tests
skin irritation
Ê

  

(
-Avoid use unless

necessary.
500mg q6 Metronidazole is
carcinogenic in

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 some rodents.

-Administer oral
doses with food.

-Apply topically
(¬etroGel,
¬etroCream) after
cleansing the
area. Advise
patient that
cosmetics may be
used over the area
after application.

-Reduce dosage
in hepatic disease.

½

   

-Take full course

of drug therapy;
take the drug with
food if GI upset
occurs.

-Do not drink

alcohol
(beverages or
preparations
containing alcohol,

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 cough

syrups); severe
reactions may
occur.

-Your urine may

appear dark; this
is expected.

-Refrain from
sexual intercourse
unless partner
wears a condom
during treatment
for trichomoniasis.

-Apply the topical

preparation by
cleansing the area
and then rubbing a
thin film into the
affected area.
Avoid contact with
the eyes.
Cosmetics may be
applied to the area
after application.

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Suscepti Known nausea - The bactericidal 0



ble hypersensitivity dizziness, fainting, action of Avelox
diarrhea
Moxifloxacin strains of to any fast or pounding results from the -  '(
Allergy
sinusitis, component of dizziness heartbeat; interference with to fluoroquinolones;
bronchitis moxifloxacin or topoisomerase II prolonged QTc interval, hyp
, other -sudden pain or and IV. okalemia, hepatic
(
pneumon quinolones or swelling near your dysfunction; seizures;
ia, skin any of the joints (especially Topoisomerases lactation, pregnancy
0velox structure excipients in your arm or are essential
infections ankle); enzymes which -
' (
Skin color,
Pregnancy and control DNA lesions; T; orientation,
lactation -diarrhea that is topology and reflexes, affect; R,
£   (
watery or bloody; assist in DNA adventitious sounds; P, BP;
Children and replication, repair, mucous membranes, bowel
antibiotic growing -confusion, and transcription. sounds; liver function tests,
adolescents hallucinations, dep ECG, CBC
ression, unusual
thoughts or Ê

  
behavior;
- Arrange for culture and
seizure (convulsio sensitivity tests before
ns); beginning therapy.

-pale or yellowed -Continue therapy as

skin, dark colored indicated for condition being
urine, fever, treated.
weakness;
-Administer oral drug 4 hr
-urinating less before or at least 8 hr after

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 than usual or not antacids or other anion-
at all; containing drugs.

-easy bruising -Do not change dosage

or bleeding; when switching from IV to
oral dose.
-numbness,
tingling, or -¦Ê.( Discontinue
unusual pain drug at any sign of
anywhere in your hypersensitivity (rash,
body; photophobia) or with severe
diarrhea.
-fever, sore throat,
and headache wit -¦Ê.(
Discontinue
h a severe drug and monitor ECG if
blistering, peeling, palpitations or dizziness
and red skinrash; occurs.
or
-Monitor clinical response; if
-the first sign of no improvement is seen or a
any skin rash, no relapse occurs, repeat
matter how mild. culture and sensitivity tests.

½

   

-Take oral drug once a day

for the period prescribed. If
antacids are being taken,
take drug 4 hr before or at
least 8 hr after the antacid.

-You may experience these

Ô
 side effects: Nausea,
vomiting, abdominal pain
(eat frequent small meals);
diarrhea or constipation
(consult nurse or physician);
drowsiness, blurring of
vision, dizziness (observe
caution if driving or using
dangerous equipment);
sensitivity to the sun (avoid
exposure, use a sunscreen).

-Report rash, visual

changes, severe GI
problems, weakness,
tremors, palpitations,
sensitivity to light.

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.GGÊ£(
-Infections Hypersensitivity -diarrhea £: dizziness, Reversibly -Assess for

caused by to clindamycin or (mild) headache, vertigo binds to 50S infection (vital
Clindamycin susceptible lincomycin ribosomal signs;
HCL anaerobic or -nausea and CV: arrythmias, subunits appearance of
gm + aerobic vomiting hypotension preventing wound, sputum,
bacteria: Upper peptide bond urine, and stool;
& -stomach pain .Ê( formation thus
(
pseudomembranous inhibiting -WBC) at
lower colitis, diarrhea, bacterial beginning and
Dalacin C respiratory bitter taste (IV only), protein throughout
tract, skin & nausea, vomiting synthesis; therapy.

soft tissue, bacteriostatic
bone & joint, ( rashes or bactericidal -Obtain
£    : gynecological, depending on specimens for
Antibiotics intraabdominal J( phlebitis at drug culture and
(anti-infective Infections, IV site concentration, sensitivity prior
septicemia & infection site, to initiating
endocarditis, and organism. therapy.
dental
infections. - Monitor bowel
When used elimination.
concurrently w/
an -Assess patient
aminoglycoside for
antibiotic eg hypersensitivity
gentamicin, (skin rash,
tobramycin, it

·

is effective in urticaria).
preventing
peritonitis or
intra-
abdominal -Monitor CBC
abscess after
bowel
perforation &
bacterial
contamination
secondary to
trauma.

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Generic prevention Transient mild Diarrhea, GI disturban ces. The possible anti - G6PD deficiency.
Name: and Contraindicated soreness may occur May cause atherogenic Haemochromatosi
treatment in those persons at the site acidification of the urine; activity of vitamin s; hyperoxaluria.
Vitamin C of scurvy of intramuscular or su precipitation of urate, cysti C may be
who have shown Diabetics; patients
bcutaneous injection. ne or oxalate stones, explained in a few
hypersensitivity Too- ordrugs in the urinary tra ct. ways. Oxidation of prone to recurrent
Brand
Name: to any rapid intravenous adm low-density renal calculi.
component of inistration of the lipoprotein (LDL)
solution may cause is thought to be a Neonates;
Potencei this preparation. temporary faintness key early step in pregnancy
Classifica or dizziness. atherogenesis. (Ingestion of large
Vitamin C protects
tion: doses has resulted
against LDL
peroxidation by in scurvy in
Vitamins
scavenging neonates);
peroxyl radicals in
Dosage the aqueous lactation.
phase. Vitamin C
500mg may enhance
1tab OD endothelial
function by
promoting the
synthesis of nitric
oxide (also known
as NO and EDRF
for endothelium -
derived relaxing
factor) or by
preventing its

·Ô
 inactivation by
scavenging
superoxide
radicals.
Superoxide reacts
with nitric oxide to
form peroxynitrite.
High
concentrations of
vitamin C are
required to
prevent the
interaction of
superoxide with
nitric oxide,
extracellularly.
Although such
high plasma
concentrations are
feasible if vitamin
C is given
parenterall y, they
are likely not to
occur with oral
administration of
vitamin C.

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Vitamin B Vitamin B -Numbness of Although the Vitamins belonging to Because of in

complex is complex fingers with preparation is group B possess a vitro
Vitamin B indicated in should not tingling feeling very well biology activity in low incompatibility
following be used in tolerated, in rare concentrations and the preparation

diseases, hypersensi -Loss of muscle cases in exert a regulating effect should not be
manifesting with tivity to any coordination predisposed on the cell function. used
£   a vitamine B of the patients itching, They participate in simultaneously
 (
deficiency: vitamins, -Mood swings urticaria, and number of enzyme (in the same
neuritis; alcohol, containing Quincke¶s systems and in such a syringe) with
Vitamins toxic, and post in the -Depression edema may manner in the following
infectious preparation appear. regulation of preparations:
polyneuritis; , as well as carbohydrate, protein Benzilpenicillin
diabetic in patients and lipid metabolism. and oxacyllin
(
polineuropathy; with 2-nd After the conforming to (the antibiotic
neuralgia; or 3-rd pyrophosphate Vitamin precipitates and
sciatica; central degree B1 participates in the is inactivated),
spastic arterial carbohydrate, and macrolides
conditions; hypertensi protein metabolism, as (insoluble
myasthenia; on. well as in synthesis of sedimentation
paresthesia; nucleic acids as a co- is formed);
atherosclerosis; enzyme. It influences Chloramphenic
Wernicke¶s the neural impulse ol
encephalopathy; conduction in the (precipitation);
vegetative synapse. Vitamin B2 Vitamin B12
neurosis; improves the (cobalt ions
dermatitis; carbohydrate and lipid destruct vitamin

·ÿ
neurodermatitis; metabolism, and is B2); Vitamin C
psoriasis; lupus related to aminoacid (inactivates
erythematodes; metabolism. It vitamin B6).
furunculosis; participates in iron and The preparation
stomatitis; porphyrin exchange, in could be used
cheilitis; glositis; hemoglobin synthesis in pregnant and
colitis; hepatitis; and in the tissue nursing women.
chronic alcohol respiration. Vitamin B6
abuse; asthenia; is a part of following
anemia; enzymes:
intoxications. decarboxylase and
transaminase. It
participates in
histamine, free fatty
acid, and aminoacid
metabolism. The
vitamin plays a role in
the normal functioning
of the central and
peripheral nervous
system, skin, and
gastrointestinal tract.
Nicotinic acid and its
amide are included in
co-dehydrases,
participating in the
hydrogen transport and
in oxygenation-
restoration processes,
necessary for the tissue
respiration.

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-Treatment of Allergy to £å(
Blood Urea Blocks ACE 

Captopril
hypertension captopril; Tachycardia, Increased, from converting
impaired renal angina Blood angiotensin I to " '(
Allergy
-Treatment of function; CHF; pectoris, CHF, Potassium angiotensin II, a to captopril,
diabetic salt/volume hypotension in Increased, powerful impaired renal
(
nephropathy depletion, salt/volume Nodal Rhythm, vasoconstrictor, function, CHF,
lactation, depleted Blood Creatine leading to salt/volume
Capoten pregnancy. patients Increased, decreased depletion,
Syncope, blood pressure, pregnancy,
Dermatologic: Bradycardia, decreased lactation
Rash, pruritus Blood aldosterone -
' ( Skin
£   (
Pressure secretion, a color, lesions,
GI: Gastric Decreased, small increase turgor; T; P, BP,
Antihypertensive irritation, Asthenia, in serum peripheral
aphthous Blood Glucose potassium perfusion;
ulcers, peptic Increased levels, and mucous
ulcers, sodium and fluid membranes,
(
dysgeusia loss; increased bowel sounds
prostaglandin
25mg SL prn for GU: synthesis also Ê& 

BP Proteinuria may be involved
160/100mmHg in the -Administer 1 hr
antihypertensive before or 2 hr
action. after meals.

-Alert surgeon
and mark
patient's chart

·u
 with notice that
captopril is being
taken; the
angiotensin II
formation
subsequent to
compensatory
renin release
during surgery
will be blocked.

-Monitor patient
closely for fall in
BP secondary to
reduction in fluid
volume
(excessive
perspiration and
dehydration,
vomiting,
diarrhea);
excessive
hypotension may
occur

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. "Lactulose For Contraindicated -Flatulence and GI: abdominal Relieves -Assess patient¶s
constipation in patients on intestinal cramps & constipation, condition before
 "Cephulac low-GA lactose cramps distention, decreases blood starting therapy and
diet belching ammonia regularly thereafter

-Excessive diarrhea, concentration to monitor drug
dosage can lead flatulence, effectiveness. If
£    - to diarrhea with nausea, vomiting patient has hepatic
Laxative potential encephalopathy,
complications assess mental
such as: condition

( 20 cc 6 loss of -monitor patient¶s

now fluids, electrolyte levels
6 hypokale during long-term
mia use.
6 hypernatr
emia. -In a patient with
hepatic disease,
-Nausea monitor ammonia
level.
- Vomiting
-Assess patient and
family¶s knowledge
of drug therapy.

-Constipation
related to
underlying

·
 condition.

-Don¶t confuse
lactulose with
lactose.

-Replace fluid loss.

-To minimize sweet

taste, dilute with
water or fruit juice
or give with food.

-If enema isn¶t

retained for at least
30 minutes, repeat
dose.

-Patient¶s
constipation is
relieved.

-Patient and family

state understanding
of drug therapy.

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(
Angina pectoris Allergy to £(
Atrial Fibrillation, Inhibits the Assessment
due to coronary amlodipine, Dizziness, light-
Blood Potassium movement of
Amlodipine artery spasm impaired hepatic headedness, Increased, Bundle calcium ions · '( Allergy
besylate (Prinzmetal's or renal function, headache, Branch Block across the to amlodipine,
variant angina) sick sinus asthenia, Right, Continuous membranes of impaired hepatic
syndrome, heart fatigue, Haemodiafiltration, cardiac and or renal function,
· Chronic block (second or lethargy Bundle Branch arterial muscle sick sinus
(
stable angina, third degree), Block Left, cells; inhibits syndrome, heart
alone or in lactation. · £å(
Convulsion, Loss transmembrane block, lactation,
norvas combination with Peripheral of Consciousness, calcium flow,
other agents · Use edema, Atrioventricular which results in ·
' (
Skin
cautiously with arrhythmias Block, the depression lesions, color,
· Essential CHF, pregnancy Bradycardia, of impulse edema; P, BP,
£   (
hypertension, · (
Cardiac Arrest, formation in baseline ECG,
alone or in Flushing, rash Blood Creatinine specialized peripheral
antihypertensive combination with Increased, Shock cardiac perfusion,liver
other ·.Ê(
Nausea, pacemaker evaluation, GI
antihypertensives abdominal cells. normal output;
discomfort liver and renal
(
function tests,

urinalysis
10mg 1tab OD
@ 7am Ê& 

· Monitor BP very
carefully if
patient is also on

ÿ

 nitrates.

·Administer drug
without regard to
meals.

Teaching points

- Take with
meals if upset
stomach occurs.

·You may
experience these
side effects:
Nausea,
vomiting (eat
frequent small
meals);
headache

- Report irregular
heartbeat,
shortness of
breath, swelling
of the hands or
feet, pronounced
dizziness,
constipation.

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Infections of Hypersensitivity Nausea; Diarrhea,indigesti Combination -Obtains patient¶s

URT, to penicillins, vomiting; on, nausea, ofamoxicillin, a history of allergy
Co-amoxiclav possible cross diarrhoea; vomiting, ȕ-lactamase
LRT, GUT, sensitivity with shortness candidiasis, rash. antibiotic; with -assess patient
skin and other b-lactams. of breath, Rarely, clavulanic acid, for sings and
History of wheezing, pseudomembran a ȕ- lactamase symptoms of
(
Soft tissue, penicillinassociat rash, ous, colitis, inhibitor; results infection wound
bone and ed cholestatic itching, hepatitis, in antibiotic with characteristics,
Amoxicillinclavul jaundice/ hives. cholestatic an increased sputum, urine
anate Joint, septic Hepatic Also: jaundice, spectrum of stool, fever
abortion, dysfunction. cholestatic crystalluria, toxic action and andWBC count
jaundice epidermal restored efficacy
Peripheral (liver necrolysis, against ȕ- -assess for
£   (
sepsis, problems); reversible lactamase allergic
erythema leucopenia, producing
Anticoagulants Intra- multiforme; thrombocytopeni amoxicillinresist -reactions during
abdominal toxic a, hemolytic ant Bacteria.
epidermal anaemia, CNS -treatment rash,
Sepsis, necrolysis disturbances uritcaria,
 :1.2 g septicaemia, (affecting
IVTT q8 ANST the -pruritus, chills,
Peritonitis epidermis fever, joint pains.
&postsurgical of the
skin); -Monitor for signs
Infections, exfoliative of nephrotoxocity:
dermatitis urine casts,
Prophylaxis and rarely oliguria,

ÿÔ
against prolonged proteinuria,
bleeding increased BUN,
Infections time, and creatinine
associated headache,
dizziness, -Assess bowel
With major convulsion patterns; bloody
surgical s diarrhea,
cramping,
Procedure possible
(for IV pseudomembrano
us colitis
Presentation)
-Monitor for
bleeding:
ecchymosis,
bleeding gums,
hematuria, and
stool guaiac daily
if on longterm
therapy.

-Assess for
overgrowth of
infection: perineal
itching, fever,
malaise, redness,
pain, swelling,
and drainage,
rash.

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G.N ± Monotheraphy Contraindication Headache CNS: headache Decreases -Obtain history of

Pioglitazone adjunct to diet in patient who are insulin patient¶s
and exercise to hypertensive to -Sinus CV: edema, resistance in underlying
improve the drug or any of heart failure the periphery condition before
glycemic its components. -Infections and in liver, starting therapy
B.N ± Actos control in Also EENT: resulting in and regularly
patients with contraindicated in -Upper pharyngitis, decreased thereafter to
type 2 diabetes patient with type respiratory sinusitis glucose monitor drug¶s
mellitus, or 1 diabetes infections. output by the effectiveness.
Classification ± combination mellitus on DKA, Hematologic: liver. Lowers
thiazolidinedione, therapy with a patient with - Muscle pain anemia glucose -Assess patient
antidiabetic sulfonylurea, evidence of level. for excessive fluid
metformin or active liver Metabolic: volume. Monitor
insulin when disease, patient aggravated patient with heart
diet, exercise, with ALT level - Tooth diabetes failure for
Dosage - 30mg and the single more than 2 ½ problems mellitus, increased edema.
Po Od drug. times the limit of hypoglycemia
normal, and with -Measure liver
patients who combination enzymes at start
experienced -Sore throat therapy, weight of therapy, every
jaundice while gain. 2 months for the
taking first year of
triglitazone. Musculoskeletal: therapy, and
-Swelling or myalgia periodically
water weight thereafter. Obtain
gain (edema) Respiratory: liver function test
upper results in patients

ÿÿ
 respiratory tract who develop
infection evidence of liver
dysfunction, such
Other: tooth as nausea,
disorder vomiting,
abdominal pain,
fatigue, anorexia,
or diarrhea.

-Monitor
hemoglobin level
and hematocrit,
especially during
the first 4 to 12
weeks of therapy.

-Monitor glucose
level regularly,
especially during
situations of
increased stress,
such as infection,
fever, surgery
and trauma.

-Check
glycosylated
hemoglobin level
periodically to
evaluate
therapeutic

ÿ
 response to drug.

-Risk for injury

related to drug-
induce
hyperglycemia

-Deficient
knowledge
related to drug
therapy

-Monitor patient
for signs and
symptoms of
heart failure. If
signs and
symptoms occur,
reconsider
thiazolidinedione
therapy. Drug
shouldn¶t be used
in patients with
severe heart
failure or those
who have limited
mobility or are
confined to bed.

-Watch for
hypoglycemia in
patients taking

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 pioglitazone with
insulin or a
sulfonylurea.

-Patient¶s glucose
level is normal
with drug therapy.

-A patient doesn¶t
experience
hypoglycemia.

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. 
" Perioperati -Contraindicated in -dark urine CNS: seizures, First -before giving
Cefazolin ve patient who are headache, confusion generation drug, ask
sodium prevention hypertensive to -easy cephalosp patient if she
in drug or other bruising/bleeding orin that is allergic to
 
" contaminat cephalosporins. inhibits cell penicillin or
Ancef ed surgery - CV: phlebitis, wall cephalosporin
-use cautiously in fast/pounding/irreg thrombophlebitis with IV synthesis, s.

breast-feeding ular heartbeat injection promoting
women and in osmotic -obtain
£   patient with a -seizures instability. specimen for
  - anti- history of colitis or culture and
infective renal insufficiency. -unusual weakness GI: diarrhea, sensitivity test
pseudomembranous before giving

-yellowing colitis, nausea, anorexia, first dose
eyes/skin vomiting, glossitis,
 ± dyspepsia, abdominal -if creatinine
1 gm IV q -mental/mood cramps, anal pruritus, oral clearance
8h ANST changes (such as candidiasis. falls below
(-) confusion) 55ml/min,
adjust
-serious allergic dosage.
reaction GU: genital
-if large
6 rash pruritus, candidiasis, doses are
6 itching/swell vaginitis given,
ing therapy is
(especially prolonged or

ÿ
 of the patient is at
face/tongue/ high risk,
throat) Hematologic: monitor
6 severe neutropenia, leukopenia, patient for
dizziness thrombocytopenia, signs and
6 trouble eosinophilia symptoms of
breathing super
infection.

Skin:maculopapular&eryt
hematous rashes,
urticarial, pruritus, pain

Other: anaphylaxis,
hypersensitivity reactions,
serum sickness, drug
fever.

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. 
* Mild -contraindicated in -Constipation Hematologic: To relieve -alert: many

Paracetamol pain or patient who are -Diarrhea hemolytic anemia, pain and OTC and
fever hypersensitivity to -Dizziness leukopenia, reduce fever. prescription
 
* Tylenol drugs -Drowsiness neutropenia, products contain
-Excitability pancytopenia acetaminophen;
-Headache
£   
-use cautiously in be aware of this
- loss of appetite
Analgesia and patients with long -Nausea;nervousness
Hepatic: jaundice when calculating
antipyretic term alcohol use or anxiety total daily doses.
because -Ttrouble sleeping Metabolic:

* 500 therapeutic doses -Upset stomach hypoglycemia -use liquid form
mg 1tab q 4h cause -Vomiting for children and
for fever. hepatotoxicity in -Weakness Skin: rash, patient who
these patients. urticarial have difficulty
swallowing.

-in children,
don¶t exceed five
doses in 24
hours.





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. 
This medication Subarachnoid Diarrhea; Nausea, This acts -Assess baseline BP

(
is used for hemorrhage, giddiness; vomiting, against and pulse before
short-term acquired defective nausea; diarrhea breakdown of starting IV, patient
Tranexamic control of color vision. vomiting. might clots (by frequently for
Acid bleeding in Severe allergic occur. If inhibiting or
hemophiliacs, reactions (rash; these stopping -hypotension during
including dental hives; difficulty persist or plasminogen IV infusion which may
extraction breathing; worsen, activation and indicate the infusion

(
procedures. tightness in the notify your fibrinolysis), is to fast.
chest; swelling doctor and so it is
Cyklokapron of the mouth, promptly. useful in -Slow the IV and
face, lips, or Very stopping repot to the
tongue); calf unlikely but severe blood physician.
pain, swelling, report loss as it
£   (
or tenderness; promptly: increases clot -Observe patient for
changes in vision formation. signs and symptoms
Fibrinolytic vision changes, of thrombosis, such
Inhibitor (disturbance of dizziness. as leg pain,
color, respiratory distress, o
sharpness, or chest pain and report.
field of vision);
(
chest pain; -Anticipate reduced
decreased dosage in patients
500mg IVTT urination; one- with impaired renal
q8 hours sided function.
weakness;
pain, swelling,

c
 or redness at
the injection
site; severe - Stress the
headache; importance of
shortness of opthalmological
breath; speech examinations at
problems. regular interval during
therapy.

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. 
Humulin R -contraindicated in -Redness, itching, or GG+( blurred Increases -Regular insulin

( (U-500) is patient¶s with swelling at the site of the vision glucose is for patients
Insulin especially history of systemic injection. transport with circulatory
useful for allergic reaction to .Ê( dry mouth across collapse,
the pork when -signs of low blood muscle and diebetic
treatment porcine-derive glucose:  ( fat cell ketoacidosis,
of diabetic products are use hypoglycemia membranes hypercalemia.
patients or hypersensitivity ? anxiety to reduce

with of any component ? blurred  Ê( rashes, glucose -check expiration
(
marked prepration vision urticaria, Pruritus, level. Helps date on vial
insulin ? confusion swelling, redness, convert before using
Humulin R resistance -contraindicated ? difficulty stinging, warm at glucose to contents.
during episodes of concentrati injection site. glycogen;
hypoglycemia. ng triggers -monitor patient
? difficulty  '( amino acid for
£   -inhaled form is speaking increase cough, uptake and hyperglycemia
: ant contraindicated in ? dizziness respiratory tract conversion to (rebound, or
diabetic patient¶s who ? drowsiness infection, protein and somogyi effect)
agent
smoke, quit ? fast dyspnea, reduce muscle cells;
smoking within the heartbeat pulmonary stimulates -for a patient
past 6 months, ? headache function. triglyceride using inhaled
have poorly ? hunger formation insulin, obtain
 : controlled lung ? nausea 0( and inhibits baseline and
disease or allergic ? nervousne lypoatrophy, release of periodic
5 ³u´ to any of its ss analphylaxis. free fatty pulmonary
? numbness acids from function test.

·
ingredients. or tingling adipose Carefully monitor
of the lips, tissue; and glucose levels
fingers, or stimulates when switching
tongue lipoprotein, to subcutaneous
? sweating lipase to inhaled
? tiredness activity, insulin.
? trembling which
? weakness converts -make sure
circulating patient knows
lipoproteins that drug
to fatty acids. relieves
symptoms but
doesn¶t cure
disease.

-instruct patient
about the
disease and
importance of
following
therapeutic
regimen,
adhering specific
diet, losing
weight, getting
exercise,
following
personal hygiene
program and
avoiding
infection.

ÿ
 -emphasize
importance of
timing injection
with eating and
of not skipping
meals.

-advise patient
not to change
order in which
insulins are
mixed or model
or brand of
insulin, syringe
and/or needle.




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2nd-line therapy Renal disease or Upper respiratory

when diet, dysfunction, CHF, Frequency not infection, Stimulates Should be taken
Norsulin exercise & initial acute or chronic defined. diarrhea, insulin release with meals. Dietary
treatment w/ a metabolic acidosis Central nervous dizziness, nausea from the modification based

sulfonylurea or including diabetic system: & vomiting, pancreatic beta on ADA
metformin HCl do ketoacidosis w/ or Headache, headache, cells; reduces recommendations is

(
not result in w/o coma. Hepatic nervousness, musculoskeletal glucose output a part of therapy.
adequate disease. dizziness pain, abdominal from the liver; Decreases blood
glycemic control Dermatologic: pain. lowers plasma glucose


in patients w/ Rash, erythema, glucose concentration.
type 2 DM. pruritus, urticaria. concentrations. Hypoglycemia may
£   (
Antidiabetis Agent Sulfonylureas Gliclazide has occur. Must be able
have also been also been to recognize
associated with shown to symptoms of
rare decrease hypoglycemia
( 500mg 1 photosensitivity platelet (palpitations,
tab bid.s and porphyria aggregation at sweaty palms, light
cutanea tarda therapeutic headedness).
Endocrine & doses.
metabolic:
 
G 
Hypoglycemia This medication is
(dose dependent), used to control
hyponatremia diabetes; it is not a
(rare) cure. Other
Gastrointestinal: components of
Nausea, vomiting, treatment plan are
diarrhea, important: follow
epigastric fullness, prescribed diet,
gastritis medication, and

u
Hematologic: exercise regimen.
Agranulocytosis, Take exactly as
leukopenia, directed; with
thrombocytopenia, meal(s) at the same
anemia time each day. Do
Hepatic: Jaundice, not change dose or
LDH increased, discontinue without
transaminases consulting
increased prescriber. Avoid
Miscellaneous: alcohol while taking
Disulfiram this medication;
reaction (very low could cause severe
potential) reaction. Inform
prescriber of all
other prescription or
OTC medications
you are taking; do
not introduce new
medication without
consulting
prescriber. Do not
take other
medication within 2
hours of this
medication unless
advised by
prescriber. If you
experience
hypoglycemic
reaction, contact
prescriber
immediately.

Ñ
 Maintain regular
dietary intake and
exercise routine and
always carry quick
source of sugar with
you. You may be
more sensitive to
sunlight (use
sunscreen, wear
protective clothing
and eyewear, and
avoid direct
sunlight). You may
experience side
effects during first
weeks of therapy
(headache,
nausea); consult
prescriber if these
persist. Report
severe or persistent
side effects,
extended vomiting
or flu-like
symptoms, skin
rash, easy bruising
or bleeding, or
change in color of
urine or stool.
















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Treatment of Contraindicated in ; Cough
Inhibits - Hypertension should

hypertension. patients who are angiotensin be managed according
; Hypotension

Enalapril
treatment of hypersensitive to this liver converting to appropriate
symptomatic product and in ; Dizziness dysfunction enzyme, guidelines.
congestive patients with a and skin interfering w/
heart failure, history ; Fatigue yellowing conversion of - Treatment with van
(
of angioedema relate ; Hyperkalemi (jaundice) angiotensin I ACE inhibitor can be
d to previous a to started in the
treatment with angiotensin II community in the
Vasotec ; Nausea
an angiotensin majority of people with
converting ; Vomiting heart failure.
enzyme inhibitor and
in patients with ; Elevated - In patients taking
£   (
hereditary BUN, Cr diuretics, close
oridiopathic angioede supervision is needed
ACE inhibitors ; Musculoskel
ma when commencing
etal pain
treatment
; URI
symptoms - The initial dose of
(
ACE has a risk of 1 st
dose hypotension,

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20mg 1tab therefore Pt. should be
@7pm PO advised to sit or lie
down for 2-4 hours
after this.
- Evaluate therapeutic
response.

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0 00½
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'

The pancreas gland lies at the back of the abdominal cavity, weighs
approximately 80 -100 gm and is approximately 20 cm long. It is divided into five
parts. The head and uncinate process nestle within the curve of the duodenum, to
the right of the spine. The neck of the pancreas lies in front of the superior
mesenteric artery and vein, the gut vessels which supply the whole of the small
bowel and these vessels are important factors in consideration of operability of
pancreatic tumours. The body of the pancreas is triangular in cross -section and
extends to the left side of the abdomen from the neck of the pancreas and leads into
the tail of the gland. The tail of the pancreas lies over the left kidney and nestles in
the hilum of the spleen. The pancreatic duct collects pancreatic juice made in the
gland and runs from the tail of pancreas up to the head of the gland where it joins the
second part of the duodenum. There are many variations in the blood supply to the
pancreas

' '

The function of the pancreas is to make digestive enzymes which digest food
materials in the small intestines. In addition the pancreas also makes insulin which
controls the blood glucose levels.

The adult pancreas produces 10 -20g of pancreatic enzymes in an active

form. The canard or gland cells of the pancreas carry out this work and pancreatic
juice is activated when it enters the duodenum by the enzyme enterokinase.
Secretion of enzymes by pancreatic gland cells is stimulated by the hormone
cholecystokinin which is released from the wall of the duodenum. In addition the
hormone secretin, results in the pancreas making bicarbonate rich fluid and it has
been estimated that pancreatic ductal cells can each secrete their own volume of
fluid in two to three minutes.

uc
In addition the pancreas contains Islet of Langerhans the cells of which have four
types of hormone secreting cells: A-cells secrete glucagon, B-cells secrete insulin,
D-cells secrete somatostatin and PP-cells secrete pancreatic polypeptide. A failure
of B-cells results in the condition of diabetes.

Pancreatic juice is a colourless thin fluid which is either gin -clear or slightly
opalescent. It contains large amounts of enzymes and all their precursors
(zymogens). The enzymes have different c ategories of activity. Proteolytic enzymes
such as trypsin, chymotrypsin and elastase cleave peptide bonds and digest
proteins. Carboxypeptidases are also proteolytic enzymes which digest proteins.
On arrival of inactive pancreatic juice in the duodenum , enterokinase which is
produced by the brush border of the duodenum, converts trypsinogen to trypsin and
releases trypsinogen activation peptide, TAP. Active trypsin activates all the other
proteolytic enzymes which then digest protein foods that are wit hin the duodenum.
The pancreas also produces lipase which is activated in the duodenum and helps
digest fat. Pancreatic amylase is responsible for digesting starch and other
carbohydrates. The digestive power of activated pancreatic juice is phenomenal a nd
should activated pancreatic juice make its way outside the gut, auto -digestion of the
body's organs and structures can occur. It is for this reason that the complications of
pancreatic surgery are so feared.

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Non-Modifiable Modifiable
Sedentary
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-Family History
Diet
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defect Defect

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Amputation

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Pathophysiology

Signs & symptoms

Treatment

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Independent
Subjective: Ineffective airway Long-term: After a series of
clearance related to 1. Encourage deep breathing 1. To mobilize if there is nursing
-³sige ko ubo´, decrease energy as At the end of 5 hours and coughing exercise. secretions intervention, the
as verbalized by evidence by dry cough. duty the patient will client verbalizes
2. Encourage to drink more 2. To liquefy if there is
the patient verbalized fluids. secretions understanding of
understanding of cause cause and
Objective: 3. Instruct to keep 3. To maintain adequate,
and therapeutic environment allergen free. patent airway therapeutic
management regimen. management
-non-productive 5. Teach the patient to 3. To open airway in at -rest
cough position head midline with or compromised individual. regimen and
flexion appropriate for
maintained airway
age/condition.
patency a little.
Dependent
Goals partially met
1. Give tramadol 50 mg 1. To improve cough
1 amp IVTT q 8h when pain is
inhibiting effort .

2. Monitor/document
serial chest x-ray 2. To assess
changes, note
complication.

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Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis

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Subjective: Acute pain Short term goal: Independent: After the series of
related to nursing intervention
³sakit ang naputlan injuring agents At the end of 12 1. Encourage patient to -to assist client to the patient was able
nako nga tiil´ as physical as hours duty the verbalized feelings explore methods for followed prescribed
verbalized by the evidence by patient will about the pain. alleviation/control of pharmacological
client. below knee demonstrate use of pain regimen and treated
amputation and relaxation skills and use of relaxation
Objective: diversional activities
facial grimace. 2. Encourage adequate skills and diversional
as indicated for activities a little.
-Below knee rest periods. -to prevent fatigue
individual situation.
amputation and to promote

Long term goal wellness.

-facial grimace
3. Encourage right brain -enhancing sense of
At the end of two
-reduced interaction stimulation with well-being and to
days duty the patient
with people and activities such as assist client to deal
will follow the
environment music. with pain.
prescribed
4. Teach patient on how
-pain scale of 7 (0 - pharmacological
to heal by developing -to promote wellness
10) management.
sense of internal
control, by being
responsible for own
treatment, and by

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 obtaining information.
5. Discuss impact of pain
on -to promote wellness \

lifestyle/independence
and ways to maximize
level of functioning.

Dependent:

1. Administer analgesic -to maintain

as indicated to maximal ³acceptable´ level of
dosage as needed . pain.
2. Refer for counseling.
-presence of acute
pain affects all
relationships and
3. Provide for individual
promotes wellness
physical therapy

-to promote wellness,

promote active, not
passive role.

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Subjective: Impaired physical Short term goal: Independen t: After the series of
mobility related to nursing
³Di kaayo ko paka loss of limb as At the end of 4 hours 1. Encourage to use -to promote wellness intervention client
lihok-lihok tungod sa evidence by limited duty the patient will of adjunctive verbalized in
akong tiil na gi -putol´ ability to perform verbalize devices (walker) understanding of
as verbalized by the skills. understanding of 2. Encourage situation/risk
-promote well-being and
patient. situation / risk factor adequate intake factors and
maximize energy
and individual of fluids/nutritious maintained or
Objective: function production
treatment regimen foods. increased
and safety 3. Instruct in use of -to promote optimal level strength and
-limited range of
measures. side rails, of function and prevent function of
motion: limited ability
overhead complications and for affected body
to perform skills. Long term goal: trapeze, and position changes. part.
-slowed movement roller pad.
At the end of 2 days
duty the patient will
-gait changes
maintained or -to promote optimal level
(decreased walking
increased strengths 4. Teach client for of functions.
speed)
and functions of regular skin care

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-below knee affected and/or to include
amputation compensatory body pressure area
part. management.
5. Instruct patient
-to reduce fatigue
schedule
activities with
adequate rest
periods during
the day.

Dependent:

1. Consult with
-to develop individual
physical/occupati
exercise/mobility
onal therapist as
program and identify
indicated.
appropriate adjunctive
devices.

2. Administer -to permit maximal

medications and effort/involvement in
vit.C prior to activity and to promote
activity as wellness.
needed.

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Objective: Potential risk for Short term goal: Independent: After the series of
infection related to nursing intervention
-wound on wound on amputated. At the end of 12 1. Maintain -Minimizes patient¶s wound is
amputated hours duty the patient aseptic opportunity for free from purulent
leg wound will be free of technique introduction of drainage but probably
purulent drainage when bacteria. patient¶s wound will
-afebrile changing not be free from signs
Long term goal: dressings/cari and symptoms for
ng for wound. infection due to her
At the end of 2 weeks -An early detection of
2. Inspect unstable blood sugar
duty client¶s wound developing infection
dressing and level.
will be free from signs provides opportunity
wound, note
and symptoms of for timely intervention
characteristic Goals partially met.
infection. and prevention of
of drainage.
more serious
complication.

1.) Monitor vital -Temperature

signs. elevated may reflect

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 developing sepsis.

Dependent:

1. Obtain -identifies presence

wound/draina of infection/specific
ge culture as organism.
appropriate.
2. Administer -wide spectrum

antibiotic and antibiotic may be

vitamins as used prophylacticaly,

indicated. or antibiotic may be

geared toward
specific identified
organism. Vit.C
promotes and repair
damage skin tissue
those providing early
wound healing.

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Objective: Actual Short term Independent:

impaired goal: 1. Elevate grafted are if -reduces swelling; limits After the
-dry and skin At the end of possible/appropriate risk of graft separation. series of
wrinkled skin integrity 12 hours nursing
related to duty client 2. Maintain desired position -movement of tissues intervention
-poor skin mechanical will verbalize and immobility of area when under graft can dislodge it, client
turgor factors feelings of indicated. interfering with optimal verbalized
(surgery- increased healing. feelings of
-amputated leg BKA) self-esteem increased
and ability to self-
manage 3. Evaluate color of grafted -evaluates effectiveness of esteem/ability
situation. and donor sites, note circulation and identifies to manage
presence/absence of developing complications. situation

healing.

Goals are
met
Dependent: -to assist with developing
plan of care for
1. Consult with wound/ stoma problematic or potentially
specialist, as indicated. serious wounds.

2. Refer to dietitian or certified -to enhance healing;

diabetes educator, as reduce risk of recurrence
appropriate of diabetic ulcers.

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Before patient Dee was discharge d from the hospital, she was
given home instructions that are essential in the cure of her disease. Take
home medications such as Avelox (400mg one tablet, once daily for two
weeks), Dalocin (300mg, one capsule three times daily for two weeks), and
vitamin C (500mg one tablet per orem once daily) to help patient in her fast
recovery. She was also instructed on the following: Drug action, dosage, side
effect, and the importance of continuing medications. Patient Dee was taught
and significant others about the completion of the treatment to gain
cooperation in the treatment regimen. Compliance of the medications as
ordered for the effectiveness of the treatment. Daily wound dressing aseptically
to avoid wound infection. Avoid eating salty foods and fatty foods, and also
food rich in sugar to maintain diet and to decrease sugar level a nd instructed
her to increase fluid intake to avoid dehydration. Compliance to medication
regimen from present illness for fast recovery. Follow -up check up to the
hospital with the physician for reevaluation. Proper intake of prescribe food like
vitamin C for collagen synthesis. Encourage the patient to pray always and ask
to God for guidance and for fast recovery to illness. Encourage patient to read
Bible for spiritual guidance.

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Diabetes Mellitus is a chronic disease which is difficult to cure. Management
concentrates on keeping blood sugar levels as close as normal as possible without
presenting undue patient danger.
Patient education, understanding and participation is vital signs that
complication of diabetes are far less common and less sever in people who have
well/managed blood sugar levels. Wider health problems may accelerate the
deleterious effects of diabetes. These include smoking, elevated cho lesterol levels,
obesity, high blood pressure and lack of regular exercise. according to one study,
common with high blood pressure (hypertension) we¶re three times more likely to
develop type 2 diabetes as compared with women with optimal blood pressure a fter
adjusting for various factors such as age, ethnicity, smoking, alcohol intake, body
mass index (BMI), exercise, family history of diabetes. (Harvard medical school,
U.S.A).
Treatments goals for older patient with diabetes vary with the individual, an d
take into a count health status, as will as life expectancy, level of dependence and
willingness to adhere to a treatment regimen.
Diabetic patent are often advice to receive regular consultation from a
physician (at least every 3 -6 months).

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Now a day the cost medicine is getting higher, so we must refrain from getting
sick.
As for this case our nursing interventions shows that the effect of the care due
to compliance of medicines since the family can provide the necessary expenses.
Patient Dee can afford to see a private doctor for a thorough examination.

Having diagnosis of DM type 2 is stressful in the part of the patient itse lf as

well as to the family members. As a rule, there should be a support from the family
which provides comfort to the patient, the fact to our client is that she does not have
a feeling of depression because she was able to accept that have these kind of
disease and that her family are supported enough.

Diet and lifestyle should be strictly observed or change for further

complication and for recovery our nursing intervention would fail those modifiable
risk factors are not controlled.

We hope that though this case study, we are all being able to realize our
individual concerns and limitations. We, as students want to learn a lot of things in
this field. Through our studies and lectures we learn how to relate theory into
practice which is essential for us to be good nurses in the future and a globally
competent.

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2Ê


-Doenges, Marilyn E., et, al. Nurses¶ Pocket Guide, Edition 11, Pages 77 -84,
409-413, 624-627, 457-461, 498-503.

-Scribd.com

-Skarch, Amy M. 2009 Lippincott¶s Nursing 2008 drug handbook, Edition

pages 21-23, 416-417, 215, 145.

-Nursing Care Plan, Guidelines for planning patient care, edition 2. F.A. Davis
Company, Philadelphia. pages 645 -657.

-Medical-Surgical Nursing: concepts and clinical application 2 nd edition 2009.

Josie quiambao-Udan, RN, MAN.

-Mastering Fundamentals of Nursing: concepts and clinical application 3 rd

edition 2009, Josie Quiambao -Udan, RN, MAN.



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; Urine color is yellow

; Specific gravity result is 1.020
; Albumin is normal finding cast coarine gramular cost: is 24 LPF
; Pus cell is 18.25




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; Character of stool is well formed and yellow in color



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; RBC result is 4-6
; Epithelial cells are normal.
; Bacteria are plenty.
; Ph result is 6.0
; WBC
; RBS result is 225 mg/
; Fasting Blood Sugar (FBS) is 117 mg/dl.
; Cholesterol is 127mg/dl (normal values=150 -200mg/dl),
; Hemoglobin is with in normal range
; Lymphocytes = 9%
; Segmenters = 91%
; Platelet=224,000mm3

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2/11/10
8pm
Ú Pls. admit
Ú Secure consent
Ú IVF PNSS 1L @KVO rate
Ú IVF TF PNSS 1L @ SR
Ú Labs:
1. CBC with PCt,BT,
2. U/A
3. S/E
4. FBS AM,LIPID PROF.
5. Creatinine
Ú Meds:
1. Norsulin 500mg per 5, 1 tab BID hold pending labs
2. Cefazolin 1amp IV q8h(-)
3. Metronidazole 500 mg 1 tab q6h
4. PCM 500mg 1 tab q4h for fever
Ú I&O q shift
Ú Refer to surgery department for future evaluation and
management(tomorrow AM)
Ú Refer as needed
Ú To await for her orders
Ú Diabetic diet

2/11/10
Ú Chest x-ray, PA
Ú RBS now/HGT
Ú Metronidazole 500 mg IV q 6h
Ú Tramadol 50 units IVTT q 8h
Ú NPO
Ú Hold PO meds
Ú Menodione 1 amp IM now

2/12/10
Ú Pls. secure PRBC or FWB 2 units of patients¶ blood type

2:55 pm
Ú For proper screening and cross matching for OR use

8:40 pm
Ú Monitor US q 15 mins until stable and fully awake.
Ú O2 inhalation 2-3 Lpm until fully awake
Ú DAT with full diabetic diet until fully awake
Ú Measure I&O q 4h

Ô
 Ú Please get KBS now and refer result
Ú Follow IVF plain NSS 1L @ 30 gtts/min
Ú Meds
? Tranexamic acid 500 g IVTT q8h for 4 days
? Metronidazole 500 g IVTT q 6h
? Tramadol 50g IVTT q 8h ± please inject 20 mg slowly
? Cefazolin 1 gm IVTT q 8h
Ú Please refer accordingly

9:20pm
Ú Transfer unit available FWN at ward after proper x -matching the
terminated when consumed

11 pm
Ú Give humulin r 5 ³u´ SQ now then referred RBS after 4h if still more
than 150 give another 5 ³u´

11:05pm
Ú Refer for RBS > 150 to ROD

2/13/10
2:30pm
Ú Hold humulin r
Ú Start glucaohage tan OD
Ú Refer to med dept. for co-management
Ú Daily dressing

4:30pm
Ú IVFTF plain NSS 2L @ SR

160/100
Ú Captopril 25 mg 1tab SL now
Ú Amlodipine 10 mg 1 tab OD
Ú Refer to Dr. Valdehueza on reading

2/14/10
Ú IVF to follow PNSS 1L @ SR
Ú Captopril 25 mg 1tab SL now

2/15/10
Ú Thank you for referral
Ú Pls. repeat CBC today
Ú Increase glucaphage to glucaphage XR BID PO
Ú For RBS today
Ú Pls. start bladder training; clamp for 2 hrs then release for 30 mins.
Ú Captopril 25 mg 1tab BP > 160/100
Ú D/C cefazolin once consumed
Ú Increase IVF rate to 60 cc/hr

·
 Ú Continue co.amoxiclan 1.29 ms IVTT q 8h ANST
Ú Start ploglitazone 30 mg 1tab OD PO
Ú For RBS on Wednesday, pls relay
Ú Captopril 25 mg 1 tab for BP > 160/100
Ú Start enalapril 10 mg 1tab @PRN OD PO
Ú Pls. follow-up antibiotics, inform ROD if patient cannot comply
Ú IVFTF of PNSS 1tab on SR

NO BM x 3 days
Ú Lactulose 30 cc
Ú IVFTF with PNSS 1L @ SR
Ú May use coramoxiclan 625 mg, 1tab q8h PO

2/18/10
Ú Oral meds
? Avelox 400 mg 1 tab OD x 2 weeks
? Dalacin C 300 1cap TID x 10days
? Vit. C 500, PO OD x 15 days
Ú Drip object ± drain
Ú Set dressing daily
Ú May be discharge after 3 days
Ú TCB after 1 week

7:00pm
Ú Remove FBC

2/19/10
Ú IVFTF with PNSS 1L @SR
Ú Continue meds.
Ú For possible D/C on Monday

2/20/10
Ú Vit. B complex 1 tab OD

2/21/10
9:35am
Ú For discharge tomorrow; dressing before discharge
Ú Meds
? Avelox 400g 1tab OD x 2 weeks
? Dalacin C 300 mg 1 cap TID x 10 days
? Vit. C 500 mg 1 tab OD x 15 days
? TCB after 1 week and follow-up (Thursday)
Ú Daily wet dressing

ÿ



2/11/10
3-11
Ú Newly admitted to a 61 y.o female married client came in done to
infected wound @ left foot
Ú V/S taken and recorded
Ú Seen and examined by ROD with orders carried out
Ú Venoclysis started with PNSS 1L @ KVO rate
Ú Diabetic diet
Ú Initial meds given
Ú For CBC, PC crenitinine ± instructed
Ú For FBS and lipid profile NPO @ 8pm instructed
Ú For U/A and S/E instructed
Ú On I&O monitoring q shift
Ú For referral to surgery dept for further evaluation and management
tomorrow morning
Ú Endorsed to ward per wheel chair

3-11
Ú Received patient per wheel chair from ER with ongoing IVF
Ú V/S taken and recorded
Ú Due meds given
Ú Kept rested
Ú Keep watched for unusualities
Ú Needs attended
Ú Endorsed

11-7
Ú Received asleep with KSS PNSS 1L @ 60cc/hr
Ú V/S taken and recorded
Ú Due meds given
Ú Still for labs
Ú For referral to surgery dept in Am
Ú Watched for any unusualities
Ú I&O recorded

2/12/10
Ú Received on bed with PNSS @ 800 cc level
Ú Conscious during rounds
Ú V/S taken and recorded
Ú Schedule for BkA
Ú Consent sign
Ú With pre op checklist
Ú Endorsed to OR with 500 IVF going on


2/12/10
5pm
Ú Received patient stretcher, with IVF on of PNSS 1L
Ú Patient reassured, advised
Ú D5 LR 1L followed up to consumed IVF

5:30
Ú WB type 0 500cc, compatible with serial # 743336 hook up as blood
transfusion @ Left arm

5:50
Ú Spinal anesthesia induced by Vilma Simbulan
Ú Skin prep done
Ú Draped aseptically

9pm
Ú Received from OR with IVF R arm PNSS 1L @ 300 cc level. L arm
compatible blood ± ³O´ with serial # 743336 consumed.
Ú IVFTF @ PNSS @ 30 gtts/min
Ú V/S monitored and recorded
Ú Full diabetic diet when fully awake
Ú For RBS now; sequential
Ú Meds given
Ú Keep watched for any unusualities

11-7
Ú Received awake on bed with ongoing IVF R PNSS 1L @ 850 cc
level regulated @ 30 gtts/min ± infusing well and L arm with
compatible blood (FWB) ³O´ with serial # 7433345
Ú Above FWB consumed and terminated with compatible blood (FW)
³O´ with serial # 743345
Ú V/S taken and recorded
Ú Still for RBS ± requested
Ú Kept watched for any unusualities
Ú Needs attended
Ú Endorsed

3-11
Ú Received on bed with PNSS 1L @ 450 cc level
Ú V/S checked and recorded
Ú Due meds given
Ú For referral to medicine department
Ú Kept watched for any unusualities

11-7
Ú Received awake on bed with PNSS 1L @ 250 cc level
Ú V/S taken and recorded

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Ú Due meds given
Ú Still for referral to Dr. Valduhueza
Ú Watched for any unusualities

2/14/10
7-3
Ú Awake on bed with PNSS 1l @ 900 cc level flowing
Ú Still wake looking
Ú Still for FBS lipid U/A, S/E reminds
Ú V/S check and recorded
Ú Available meds given
Ú On bed resting

3-11
Ú Received on bed with PNSS 1L @ 200cc level
Ú IVFTF PNSS 1L @ SR
Ú V/S taken and recorded
Ú Due avail meds given
Ú Still for referral to Dr. Valduhueza
Ú For FBS, lipid NPO instructed
Ú Still for labs
Ú Keep watched for unusualities

11-7
Ú Received asleep on bed with PNSS 1L 700cc level
Ú V/S taken and recorded
Ú Due avail meds given
Ú Still for U/A, S/E reminded
Ú NPO for FBS, lipid prof instructed
Ú For referral to Dr. Valduhueza ± endorsed
Ú Daily dressing ± done
Ú Watch for unusualities

2/15/10
7-3
Ú Received on bed with PNSS 1L 700 cc level.
Ú V/S taken and recorded
Ú With post

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