Benguet State University

COLLEGE OF NURSING
La Trinidad, Benguet

A Case Study on

Colonic Carcinoma
Presented to the
Faculty of the College of Nursing,
Benguet State University

In Partial Fulfillment of the Requirements in

Related Learning Experience 105

Submitted by:
Group 8
Audray Kyle Saydoven
Noreen Paligpig
Kathleen Mae Panagan
Graile Pinas
Aaron Rafael Perkins
Shiki Charelle Reforba
Warren Jae Sandoval
Ma. Lorena Gabrielle Sanqui
Corazon Sepulchre
Marsha Sepulchre
Jo-anne Bray Siadto
Marinel Tabarejos
Bherly Frank Tamid-ay

Submitted to:
Jon Erik Saluta, RN

January 2011
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I. Patient’s Information
Name: Felipe Dacnas Alunday Sr.
Address: Allaguia, Pinukpok, Kalinga
Birthdate: June 11, 1947
Age: 63 years old
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: January 3, 2011
Time of Admission: 4.05 pm
Admitting Physician: : Mathew B. Bawayan
Attending Physician: Ponadon, Besarino, Douglas
Admitting Diagnosis: Colonic Carcinoma S/P Anterior Resection (July 23, 2011)
S/P Third Cycle Chemotherapy
Principal Diagnosis: Colonic Carcinoma S/P Anterior Resection (July 23, 2011) S/P
Fourth Cycle Chemotherapy
II. Clinical History
Chief Complaint: For fourth chemotherapy
Review of systems:
(+) Body Weakness, (-) Nausea and vomiting, (+) Anorexia, (-) Abdominal pain, (-)
Constipation, (-) Diarrhea, (-)Diziness, (-) HA
History of Present Illness:
Present condition started when the patient was diagnosed with colon
cancer last July 2010. Patient underwent colonic resection on July 2010 and was
advised to undergo chemotherapy. Previous chemotherapies were done in
BGHMC institution. There was associated nausea and vomiting. Patient was
scheduled for his fourth chemotherapy hence admitted.
Past medical History:
(-) Other Hospitalization
(+) HPN – 2010
(-) Accidents or trauma in the past
(-) Allergies
Family History:
(+) Hypertension, (-)DM, (-) BA, (-) CAD, (-) PTB
Social and Environmental History
Smoker, Non – alcoholic beverage drinker
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III. Anatomy and Physiology

COLON
The colon is the last part of the digestive system in most vertebrates; it
extracts water and salt from solid wastes before they are eliminated from the
body, and is the site in which flora-aided (largely bacteria) fermentation of
unabsorbed material occurs. Unlike the small intestine, the colon does not play a
major role in absorption of foods and nutrients. However, the colon does absorb
water, potassium and some fat soluble vitamins.
In mammals, the colon consists of four sections: the ascending colon, the
transverse colon, the descending colon, and the sigmoid colon (the proximal
colon usually refers to the ascending colon and transverse colon). The colon,
cecum, and rectum make up the large intestine.
The location of the parts of the colon are either in the abdominal cavity
or behind it in the retroperitoneum. The colon in those areas is fixed in location.
Arterial supply to the colon comes from branches of the superior
mesenteric artery (SMA) and inferior mesenteric artery (IMA). Flow between
these two systems communicates via a "marginal artery" that runs parallel to the
colon for its entire length. Historically, it has been believed that the arc of Riolan,
or the meandering mesenteric artery (of Moskowitz), is a variable vessel
connecting the proximal SMA to the proximal IMA that can be extremely
important if either vessel is occluded. However, recent studies conducted with
improved imaging technology have questioned the actual existence of this
vessel, with some experts calling for the abolition of the terms from future
medical literature.
Venous drainage usually mirrors colonic arterial supply, with the inferior
mesenteric vein draining into the splenic vein, and the superior mesenteric vein
joining the splenic vein to form the hepatic portal vein that then enters the liver.
Lymphatic drainage from the entire colon and proximal two-thirds of the
rectum is to the paraaortic lymph nodes that then drain into the cisterna chyli.
The lymph from the remaining rectum and anus can either follow the same
route, or drain to the internal iliac and superficial inguinal nodes. The pectinate
line only roughly marks this transition.

Ascending colon
The ascending colon, on the right side of the abdomen, is about 25 cm
long in humans. It is the part of the colon from the cecum to the hepatic flexure
(the turn of the colon by the liver). It is secondarily retroperitoneal in most
humans. In ruminant grazing animals, the cecum empties into the spiral colon.
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Anteriorly it is related to the coils of small intestine, the right edge of the
greater omentum, and the anterior abdominal wall. Posteriorly, it is related to
the iliacus, the iliolumbar ligament, the quadratus lumborum, the transverse
abdominis, the diaphragm at the tip of the last rib; the lateral cutaneous,
ilioinguinal, and iliohypogastric nerves; the iliac branches of the iliolumbar
vessels, the fourth lumbar artery, and the right kidney. The ascending colon is
supplied by parasympathetic fibers of the vagus nerve (CN X).
Arterial supply of the ascending colon comes from the ileocolic artery and
right colic artery, both branches of the SMA. While the ileocolic artery is almost
always present, the right colic may be absent in 5–15% of individuals.

Transverse colon
The transverse colon is the part of the colon from the hepatic flexure to
the splenic flexure (the turn of the colon by the spleen). The transverse colon
hangs off the stomach, attached to it by a wide band of tissue called the greater
omentum. On the posterior side, the transverse colon is connected to the
posterior abdominal wall by a mesentery known as the transverse mesocolon.
The transverse colon is encased in peritoneum, and is therefore mobile
(unlike the parts of the colon immediately before and after it). Cancers form
more frequently further along the large intestine as the contents become more
solid (water is removed) in order to form feces.
The proximal two-thirds of the transverse colon is perfused by the middle
colic artery, a branch of SMA, while the latter third is supplied by branches of the
IMA. The "watershed" area between these two blood supplies, which represents
the embryologic division between the midgut and hindgut, is an area sensitive to
ischemia.

Descending colon
The descending colon is the part of the colon from the splenic flexure to
the beginning of the sigmoid colon. The function of the descending colon in the
digestive system is to store food that will be emptied into the rectum. It is
retroperitoneal in two-thirds of humans. In the other third, it has a (usually
short) mesentery. The arterial supply comes via the left colic artery.

Sigmoid colon
The sigmoid colon is the part of the large intestine after the descending
colon and before the rectum. The name sigmoid means S-shaped (see sigmoid).
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The walls of the sigmoid colon are muscular, and contract to increase the
pressure inside the colon, causing the stool to move into the rectum.
The sigmoid colon is supplied with blood from several branches (usually
between 2 and 6) of the sigmoid arteries, a branch of the IMA. The IMA
terminates as the superior rectal artery. Sigmoidoscopy is a common diagnostic
technique used to examine the sigmoid colon.

Redundant colon
One variation on the normal anatomy of the colon occurs when extra
loops form, resulting in a longer than normal organ. This condition, referred to as
redundant colon, typically has no direct major health consequences, though
rarely volvulus occurs resulting in obstruction and requiring immediate medical
attention.[4] A significant indirect health consequence is that use of a standard
adult colonoscope is difficult and in some cases impossible when a redundant
colon is present, though specialized variants on the instrument (including the
pediatric variant) are useful in overcoming this problem.

Standing gradient osmosis

Water absorption at the colon typically proceeds against a transmucosal
osmotic pressure gradient. The standing gradient osmosis is a term used to
describe the reabsorption of water against the osmotic gradient in the intestines.
This hypertonic fluid creates an osmotic pressure that drives water into the
lateral intercellular spaces by osmosis via tight junctions and adjacent cells,
which then in turn moves across the basement membrane and into the
capillaries.

Functions of the Colon

There are differences in the large intestine between different organisms,
the large intestine is mainly responsible for storing waste, reclaiming water,
maintaining the water balance, absorbing some vitamins, such as vitamin K, and
providing a location for flora-aided fermentation.Vitamin K is essential as a
coagulation factor.
By the time the chyme has reached this tube, most nutrients and 90% of
the water have been absorbed by the body. At this point some electrolytes like
sodium, magnesium, and chloride are left as well as indigestible parts of ingested
food (e.g., a large part of ingested amylose, protein which has been shielded
from digestion heretofore, and dietary fiber, which is largely indigestible
carbohydrate in either soluble or insoluble form). As the chyme moves through
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the large intestine, most of the remaining water is removed, while the chyme is
mixed with mucus and bacteria (known as gut flora), and becomes feces. The
ascending colon receives fecal material as a liquid. The muscles of the colon then
move the watery waste material forward and slowly absorb all the excess water.
The stools get to become semi solid as they move along into the descending
colon. The bacteria break down some of the fiber for their own nourishment and
create acetate, propionate, and butyrate as waste products, which in turn are
used by the cell lining of the colon for nourishment. No protein is made
available. In humans, perhaps 10% of the undigested carbohydrate thus
becomes available; in other animals, including other apes and primates, who
have proportionally larger colons, more is made available, thus permitting a
higher portion of plant material in the diet. This is an example of a symbiotic
relationship and provides about one hundred calories a day to the body. The
large intestine produces no digestive enzymes -— chemical digestion is
completed in the small intestine before the chyme reaches the large intestine.
The pH in the colon varies between 5.5 and 7 (slightly acidic to neutral).
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IV. Colonic Carcinoma / Colon Carcinoma / Colon Cancer

Definition:
It is a disease in which malignant (cancer) cells form in the tissues of the
colon.
The colon is part of the body's digestive system. The digestive system
removes and processes nutrients (vitamins, minerals, carbohydrates, fats,
proteins, and water) from foods and helps pass waste material out of the body.
The digestive system is made up of the esophagus, stomach, and the small and
large intestines. The first 6 feet of the large intestine are called the large bowel
or colon. The last 6 inches are the rectum and the anal canal. The anal canal ends
at the anus (the opening of the large intestine to the outside of the body).

Risk Factors:
Age and health history can affect the risk of developing colon carcinoma .
Risk factors include the following:
 Age 50 or older.
 A family history of carcinoma of the colon or rectum.
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 A personal history of carcinoma of the colon, rectum, ovary,

endometrium, or breast.
 A history of polyps in the colon.

Signs and Symptoms:

 A change in bowel habits.
 Blood (either bright red or very dark) in the stool.
 Diarrhea, constipation, or feeling that the bowel does not empty completely.
 Stools that are narrower than usual.
 Frequent gas pains, bloating, fullness, or cramps.
 Weight loss for no known reason.
 Feeling very tired.
 Vomiting.
A specimen removed from a patient with colonic carcinoma

V. Pathophysiology of Colonic Carcinoma

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General: Age: above 50 y.o Physical Inactivity

Diet Alcohol Intake Ulcerative Colitis

Colon Polyps Genetics

Gender: More common
in males

Cells that line the colon are very active, constantly

dividing and creating buds known as polyps. Most
polyps are small, benign growths that usually stop
growing.

But a tiny percentage of these polyps keep growing, sometimes for 10 years or more. Various genetic mutations can transform
them into cancerous tumors. The most commonly mutated gene in all colorectal cancer is the APC gene, which produces the APC
protein. The APC protein is the "brake" on the β-cateninprotein. Without APC, β-catenin translocates (moves) into the nucleus, binds
to DNA, and activates the expression of more proteins. (If APC is not mutated in colorectal cancer, then β-catenin itself is.)

As these tumors grow larger, they gather more

mutations and begin to burrow deeper into the muscle
wall that lines the colon.

Once the cancer invades the blood and lymph systems,

Patient Based:
malignant cells can break off and spread to other organs.
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The patient is a 63 year old male, suffering from colon cancer (Colonic carcinoma). He
was diagnosed last July 2010 after having a check-up. As stated by his daughter, the patient has
high fiber but low protein intake. Also, he has suffered from peptic ulcer. He is a smoker but not
alcoholic. Moreover, based from the tests done to the patient, polyps were present in his
intestines.

History of ulcer

63 year old Male

Smoker

Formation of Polyps
(intramucosal epithelial
lesion)

Cancers grow.

Cancers invade the muscularis

mucosa, lymphatic structures,
and vascular structures and
involve regional lymph nodes,
adjacent structures, and
distant sites.

Colonic Carcinoma

VI. Diagnostics Procedures or Tests for Colonic Carcinoma

The following tests and procedures may be used:
 Physical exam and history: An exam of the body to check general signs of
health, including checking for signs of disease, such as lumps or anything else
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that seems unusual. A history of the patient's health habits and past illnesses
and treatments will also be taken.
 Fecal occult blood test: A test to check stool (solid waste) for blood that can
only be seen with a microscope. Small samples of stool are placed on special
cards and returned to the doctor or laboratory for testing. 
 Digital rectal exam: An exam of the rectum. The doctor or nurse inserts a
lubricated, gloved finger into the rectum to feel for lumps or anything else
that seems unusual.
 Barium enema: A series of x-rays of the lower gastrointestinal tract. A liquid
that contains barium (a silver-white metallic compound) is put into the
rectum. The barium coats the lower gastrointestinal tract and x-rays are
taken. This procedure is also called a lower GI series.

Barium enema procedure. The patient lies on an x-ray table. Barium liquid is put into the
rectum and flows through the colon. X-rays are taken to look for abnormal areas.

Sigmoidoscopy: A procedure to look inside the rectum and sigmoid (lower) colon for
polyps, abnormal areas, or cancer. A sigmoidoscope is inserted through the rectum
into the sigmoid colon. A sigmoidoscope is a thin, tube-like instrument with a light
and a lens for viewing. It may also have a tool to remove polyps or tissue samples,
which are checked under a microscope for signs of cancer.

Sigmoidoscopy. A thin, lighted tube is inserted through the anus and rectum
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and into the lower part of the colon to look for abnormal areas.

Colonoscopy: A procedure to look inside the rectum and colon for polyps, abnormal
areas, or cancer. A colonoscope is inserted through the rectum into the colon. A
colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may
also have a tool to remove polyps or tissue samples, which are checked under a
microscope for signs of cancer.

Colonoscopy. A thin, lighted tube is inserted through the anus and rectum and into the colon to
look for abnormal areas.

 Biopsy: The removal of cells or tissues so they can be viewed under a

microscope by a pathologist to check for signs of cancer.
 Virtual colonoscopy: A procedure that uses a series of x-rays called
computed tomography to make a series of pictures of the colon. A computer
puts the pictures together to create detailed images that may show polyps
and anything else that seems unusual on the inside surface of the colon. This
test is also called colonography or CT colonography.

VII. Laboratory Finding

Ultrasonogaphy:
Left hemidiaphragm is opacified. Heart is enlarged. Right hilar fullness. Bones are
unremarkable. Well defined opacity measuring 3 X 2.5 cm at the right pleural base
margin.
Impression: Pleural base mass to consider metastasis. Pleural Effusion left. Right
hilar fullness.

VIII. Surgical and Medical Treatment

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Surgery
Surgery is the most common treatment for all stages of colon cancer. The
cancer is removed using one of the following types of surgery:
• Local excision: If the cancer is found at a very early stage, the doctor may
remove it without cutting through the abdominal wall. Instead, the doctor may
put a tube through the rectum into the colon and cut the cancer out. This is
called a local excision. If the cancer is found in a polyp (a small bulging piece of
tissue), the operation is called a polypectomy.
• Resection: If the cancer is larger, the doctor will perform a partial
colectomy (removing the cancer and a small amount of healthy tissue around it).
The doctor may then perform an anastomosis (sewing the healthy parts of the
colon together). The doctor will also usually remove lymph nodes near the colon
and examine them under a microscope to see whether they contain cancer.

Colon cancer surgery with anastomosis. Part of the colon containing the cancer
and nearby healthy tissue are removed, and then the cut ends of the colon are
joined.
• Resection and colostomy: If the doctor is not able to sew the 2 ends of
the colon back together, a stoma(an opening) is made on the outside of the body
for waste to pass through. This procedure is called a colostomy. A bag is placed
around the stoma to collect the waste. Sometimes the colostomy is needed only
until the lower colon has healed, and then it can be reversed. If the doctor needs
to remove the entire lower colon, however, the colostomy may be permanent.
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Colon cancer surgery with colostomy. Part of the colon containing the cancer and
nearby healthy tissue is removed, a stoma is created, and a colostomy bag is
attached to the stoma.
• Radiofrequency ablation: The use of a special probe with tiny electrodes
that kill cancer cells. Sometimes the probe is inserted directly through the skin
and only local anesthesia is needed. In other cases, the probe is inserted through
an incision in the abdomen. This is done in the hospital with general anesthesia.
• Microwave ablation destroys liver tumors using heat generated by
microwave energy.
• Cryosurgery: A treatment that uses an instrument to freeze and destroy
abnormal tissue, such as carcinoma in situ. This type of treatment is also called
cryotherapy.
• Even if the doctor removes all the cancer that can be seen at the time of
the operation, some patients may be given chemotherapy or radiation therapy
after surgery to kill any cancer cells that are left. Treatment given after the
surgery, to increase the chances of a cure, is called adjuvant therapy.

Adjuvant Therapy
Even if all the cancer that can be seen at the time of the operation is
removed, some patients may be given radiation therapy or chemotherapy after
surgery to kill any cancer cells that are left. Treatment given after surgery to
increase the chances of a cure is called adjuvant therapy.

Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of
cancer cells, either by killing the cells or by stopping them from dividing. When
chemotherapy is taken by mouth or injected into a vein or muscle, the drugs
enter the bloodstream and can reach cancer cells throughout the body (systemic
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chemotherapy). When chemotherapy is placed directly into the spinal column,

an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer
cells in those areas (regional chemotherapy).
Chemoembolization of the hepatic artery may be used to treat cancer that
has spread to the liver. This involves blocking the hepatic artery (the main artery
that supplies blood to the liver) and injecting anticancer drugs between the
blockage and the liver. The liver's arteries then deliver the drugs throughout the
liver. Only a small amount of the drug reaches other parts of the body. The
blockage may be temporary or permanent, depending on what is used to block
the artery. The liver continues to receive some blood from the hepatic portal
vein, which carries blood from the stomach and intestine.
The way the chemotherapy is given depends on the type and stage of the
cancer being treated.

Radiation Therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other
types of radiation to kill cancer cells or keep them from growing. There are two
types of radiation therapy. External radiation therapy uses a machine outside the
body to send radiation toward the cancer. Internal radiation therapy uses a
radioactive substance sealed in needles, seeds, wires, or catheters that are
placed directly into or near the cancer. The way the radiation therapy is given
depends on the type and stage of the cancer being treated.

IX. Nursing Considerations

NURSING GOAL
1) Support the patient in managing, pain, nutrition, dehydration, fatigue etc.
2) Improve quality of life by promoting rehabilitation for survivals of cancer.
3) Maintain the dignity.
POSSIBLE DIAGNOSIS
1) ANXIETY
 Assess level of anxiety
 Establish therapeutic relationship
 Encourage to express feelings (develop rapport)
 Improve specific information
 Provide Safe environment
 Crisis Intervention (expect for the worse)
2) DISTURBED BODY IMAGE
 Discuss the meaning of the loss and change
 Observe and evaluate the interaction with the relatives.
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 Allow denial but do not participate in the denial. ( do not argue, or do

not favor)
 Assist the client ( significant others to cope with the changes in
appearance)
 Teach way to reduce the alopecia enhance the appearance until the
hair grows back.
 Teach the client to participate to the care of afflicted body area.
3) ANTICIPATORY GRIEVING
 Use therapeutic communication skills with provide an open
environment for the client or significant others to discuss their
feelings realistically.
 Answer question about illness and prognosis honesty but always
encourage hope.
 Encourage the dying client to make funeral, burial plans ahead of
time, be sure that the will is in order.
 Encourage client to continue taking past in activity he enjoys including
maintaining employment as long as possible.
4) RISK FOR INFECTION
 Monitor Vital signs
 Monitor WBC
 Teach to avoid crowded places and practice personal hygiene.
 Protect skin and mucous membrane from injury.
 Encourage increase protein, vitamins, and vitamin C.
5) RISK FOR INJURY
 Assess for sign and symptoms of obstruction.
 Teach to differentiate minors to serious problem.
 Monitor laboratory results.
6) ENHANCED NUTRITION LESS THAN BODY REQUIREMENTS
 Assess current eating pattern.
 Teach the principles of good nutrition.
 Manage problem that interfere feeding
 cold drinks
 soft blend, soft liquid
 Teach to supplement meals with nutritional supplements
 Teach to make food diary.
 Parenteral Nutrition.

7) IMPAIRED SKIN TISSUE INTEGRITY
 Oral, pharyngeal, esophageal, mucous membrane.
 Signs and Symptoms
 Ulcers – tongue, mucous membrane in mouth, throat
 Lesides – ulcerations
 Fungal Infections
 Red swollen gums
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 Xerostomia – excessive dryness – mucous membrane

 Carefully assessment , evaluate the tissue impairment
 Teach measured to prevent infection.

X. Drug Study
a. Ranitidine hydrochloride
Brand Name: Zantac
Indications:

1. Short-term treatment of active duodenal ulcer. Most patients heal within

4 weeks. Studies available to date have not assessed the safety of
ranitidine in uncomplicated duodenal ulcer for periods of more than 8
weeks.
2. Maintenance therapy for duodenal ulcer patients at reduced dosage after
healing of acute ulcers. No placebo-controlled comparative studies have
been carried out for periods of longer than 1 year.
3. The treatment of pathological hypersecretory conditions (e.g., Zollinger-
Ellison syndrome and systemic mastocytosis).
4. Short-term treatment of active, benign gastric ulcer. Most patients heal
within 6 weeks and the usefulness of further treatment has not been
demonstrated. Studies available to date have not assessed the safety of
ranitidine in uncomplicated, benign gastric ulcer for periods of more than
6 weeks.
5. Maintenance therapy for gastric ulcer patients at reduced dosage after
healing of acute ulcers. Placebo-controlled studies have been carried out
for 1 year.
6. Treatment of GERD. Symptomatic relief commonly occurs within 24 hours
after starting therapy with ZANTAC 150 mg twice daily.
7. Treatment of endoscopically diagnosed erosive esophagitis. Symptomatic
relief of heartburn commonly occurs within 24 hours of therapy initiation
with ZANTAC 150 mg 4 times daily.
8. Maintenance of healing of erosive esophagitis. Placebo-controlled trials
have been carried out for 48 weeks.

Side Effects
Central Nervous System
Rarely, malaise, dizziness, somnolence, insomnia, and vertigo. Rare cases
of reversible mental confusion, agitation, depression, and hallucinations have
been reported, predominantly in severely ill elderly patients. Rare cases of
reversible blurred vision suggestive of a change in accommodation have been
reported. Rare reports of reversible involuntary motor disturbances have been
received.
Cardiovascular
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As with other H2-blockers, rare reports of arrhythmias such as

tachycardia, bradycardia, atrioventricular block, and premature ventricular
beats.
Gastrointestinal
Constipation, diarrhea, nausea/vomiting, abdominal discomfort/pain, and
rare reports of pancreatitis.
Hepatic
There have been occasional reports of hepatocellular, cholestatic, or
mixed hepatitis, with or without jaundice. In such circumstances, ranitidine
should be immediately discontinued. These events are usually reversible, but in
rare circumstances death has occurred. Rare cases of hepatic failure have also
been reported. In normal volunteers, SGPT values were increased to at least
twice the pretreatment levels in 6 of 12 subjects receiving 100 mg intravenously
4 times daily for 7 days, and in 4 of 24 subjects receiving 50 mg intravenously 4
times daily for 5 days.
Musculoskeletal
Rare reports of arthralgias and myalgias.
Hematologic
Blood count changes (leukopenia, granulocytopenia, and
thrombocytopenia) have occurred in a few patients. These were usually
reversible. Rare cases of agranulocytosis, pancytopenia, sometimes with marrow
hypoplasia, and aplastic anemia and exceedingly rare cases of acquired immune
hemolytic anemia have been reported.
Endocrine
Controlled studies in animals and man have shown no stimulation of any
pituitary hormone by ZANTAC and no antiandrogenic activity, and cimetidine-
induced gynecomastia and impotence in hypersecretory patients have resolved
when ZANTAC has been substituted. However, occasional cases of impotence
and loss of libido have been reported in male patients receiving ZANTAC, but the
incidence did not differ from that in the general population. Rare cases of breast
symptoms and conditions, including galactorrhea and gynecomastia, have been
reported in both males and females.
Integumentary
Rash, including rare cases of erythema multiforme. Rare cases of alopecia
and vasculitis.
Respiratory
A large epidemiological study suggested an increased risk of developing
pneumonia in current users of histamine-2-receptor antagonists (H 2RAs)
compared to patients who had stopped H2RA treatment, with an observed
adjusted relative risk of 1.63 (95% CI, 1.072.48). However, a causal relationship
between use of H2RAs and pneumonia has not been established.
Other
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Rare cases of hypersensitivity reactions (e.g., bronchospasm, fever, rash,

eosinophilia), anaphylaxis, angioneurotic edema, acute interstitial nephritis, and
small increases in serum creatinine.

NURSING IMPLICATIONS/RESPONSIBILITIES
 Assess patient for epigastric or abdominal pain and frank or occult blood in the
stool, emesis, or gastric aspirate.
 Nurse should know that it may cause false-positive results for urine protein; test
with sulfosalicylic acid.
 Inform patient that it may cause drowsiness or dizziness.
 Inform patient that increased fluid and fiber intake may minimize constipation.
 Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea;
dizziness; rash; confusion; or hallucinations to health car professional promptly.
 Inform patient that medication may temporarily cause stools and tongue to
appear gray black.
b. dexamethasone
Brand Name: Decadron
Indications:
Allergic States
Control of severe or incapacitating allergic conditions intractable to adequate
trials of conventional treatment in asthma, atopic dermatitis, contact dermatitis, drug
hypersensitivity reactions, perennial or seasonal allergic rhinitis, and serum sickness.
Dermatologic Diseases
Bullous dermatitis herpetiformis, exfoliative erythroderma, mycosis fungoides,
pemphigus, and severe erythema multiforme (Stevens-Johnson syndrome).
Endocrine Disorders
Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is
the drug of choice; may be used in conjunction with synthetic miner-alocorticoid
analogs where applicable;in infancy mineralocorticoid supplementation is of particular
importance), congenital adrenal hyperplasia, hypercal-cemia associated with cancer,
and nonsuppurative thyroiditis.

Gastrointestinal Diseases
To tide the patient over a critical period of the disease in regional enteritis and
ulcerative colitis.

Hematologic Disorders
Acquired (autoimmune) hemolytic anemia, congenital (erythroid) hypoplastic
anemia (Diamond-Blackfan anemia), idiopathic thrombocytopenic purpura in adults,
pure red cell aplasia, and selected cases of secondary thrombocytopenia.
Miscellaneous
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Diagnostic testing of adrenocortical hyperfunction, trichinosis with neurologic or

myocardial involvement, tuberculous meningitis with subarachnoid block or impending
block when used with appropriate antituberculous chemotherapy.

Neoplastic Diseases
For the palliative management of leukemias and lymphomas.

Nervous System
Acute exacerbations of multiple sclerosis, cerebral edema associated with
primary or metastatic brain tumor, craniotomy, or head injury.
Ophthalmic Diseases
Sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory
conditions unresponsive to topical corticosteroids.
Renal Diseases
To induce a diuresis or remission of proteinuria in idiopathic nephrotic
syndrome or that due to lupus erythematosus.
Respiratory Diseases
Berylliosis, fulminating or disseminated pulmonary tuberculosis when used
concurrently with appropriate antituberculous chemotherapy, idiopathic eosinophilic
pneumonias, symptomatic sarcoidosis.
Rheumatic Disorders
As adjunctive therapy for short-term administration (to tide the patient over an
acute episode or exacerbation) in acute gouty arthritis, acute rheumatic carditis,
ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, including juvenile
rheumatoid arthritis (selected cases may require low-dose maintenance therapy). For
the treatment of dermatomyositis, polymyositis, and systemic lupus erythematosus.

Side Effects
Allergic Reactions
Anaphylactoid reaction, anaphylaxis, angioedema.
Cardiovascular
Bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement,
circulatory collapse, congestive heart failure, fat embolism, hypertension, hyper-trophic
cardiomyopathy in premature infants, myocardial rupture following recent myocardial
infarction (see WARNINGS: Cardio-Renal), edema, pulmonary edema, syncope,
tachycardia, thromboembolism, thrombophlebitis, vasculitis.
Dermatologic

Acne, allergic dermatitis, dry scaly skin, ecchymoses and petechiae, erythema,
impaired wound healing, increased sweating, rash, striae, suppression of reactions to
skin tests, thin fragile skin, thinning scalp hair, urticaria.
Endocrine
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Decreased carbohydrate and glucose tolerance, development of cushingoid

state, hyperglycemia, glycosuria, hirsutism, hypertrichosis, increased requirements for
insulin or oral hypoglycemic agents in diabetes, manifestations of latent diabetes
mellitus, menstrual irregularities, secondary adrenocor-tical and pituitary
unresponsiveness (particularly in times of stress, as in trauma, surgery, or illness),
suppression of growth in pediatric patients.
Fluid and Electrolyte Disturbances
Congestive heart failure in susceptible patients, fluid retention, hypokalemic
alkalosis, potassium loss, sodium retention.
Gastrointestinal
Abdominal distention, elevation in serum liver enzyme levels (usually reversible
upon discontinuation), hepatomegaly, increased appetite, nausea, pan-creatitis, peptic
ulcer with possible perforation and hemorrhage, perforation of the small and large
intestine (particularly in patients with inflammatory bowel disease), ulcerative
esophagitis.
Metabolic
Negative nitrogen balance due to protein catabolism.
Musculoskeletal
Aseptic necrosis of femoral and humeral heads, loss of muscle mass, muscle
weakness, osteoporosis, pathologic fracture of long bones, steroid myopathy, tendon
rupture, vertebral compression fractures.
Neurological/Psychiatric
Convulsions, depression, emotional instability, euphoria, headache, increased
intracranial pressure with papilledema (pseudotumor cerebri) usually following
discontinuation of treatment, insomnia, mood swings, neuritis, neuropathy, paresthesia,
personality changes, psychic disorders, vertigo.
Ophthalmic
Exophthalmos, glaucoma, increased intraocular pressure, posterior subcapsular
cataracts.
Other
Abnormal fat deposits, decreased resistance to infection, hiccups, increased or
decreased motility and number of spermatozoa, malaise, moon face, weight gain.

Nursing considerations:
Assessment:
(1) history for systemic administration – renal/hepatic disease,
hypothyroidism,ulcerative colitis.
(2) fistory for ophthalmic preparations – vaccinia, varicella, ocular TB.
(3)Physical for systemic admin. – blood glucose, serum electrolytes, R,
adventitious sounds. (4)physical for topical dermatologic preparations: affected
area for infections, skin injury.
Interventions:
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 Don’t give drug to nursing mothers since drug is secreted in the breast
milk forsystemic admin.
 Don’t use intranasal product with untreated local nasal infections,
epistaxis,nasal trauma.
 Use caution when occlusive dressings, tight diapers over covered areas;
these canincrease systemic absorption for topical dermatologic prep.
Teaching points:
 Avoid exposure to infection. Administer decongestant nose drops first if
nasal passages are blocked. Avoid contact with eyes. Report worsening
of condition
c. cefuroxime
Brand Name: Cefuroxime
Indications:
1. Lower Respiratory Tract Infections, including pneumonia, caused by Streptococcus
pneumoniae, Haemophilus influenzae (including ampicillin-resistant strains), Klebsiella
spp., Staphylococcus aureus (penicillinase- and non-penicillinase-producing strains),
Streptococcus pyogenes, and Escherichia coli.
2. Urinary Tract Infections caused by Escherichia coli and Klebsiella spp.
3. Skin and Skin-Structure Infections caused by Staphylococcus aureus (penicillinase-
and non-penicillinase-producing strains), Streptococcus pyogenes, Escherichia coli,
Klebsiella spp., and Enterobacter spp.
4. Septicemia caused by Staphylococcus aureus (penicillinase- and non-penicillinase-
producing strains), Streptococcus pneumoniae, Escherichia coli, Haemophilus influenzae
(including ampicillin-resistant strains), and Klebsiella spp.
5. Meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae
(including ampicillin-resistant strains), Neisseria meningitidis, and Staphylococcus
aureus (penicillinase- and non-penicillinase-producing strains).
6. Gonorrhea: Uncomplicated and disseminated gonococcal infections due to Neisseria
gonorrhoeae (penicillinase- and non-penicillinase-producing strains) in both males and
females.
7. Bone and Joint Infections caused by Staphylococcus aureus (penicillinase- and non-
penicillinase producing strains).

Side Effects:
Local Reactions:
Thrombophlebitis has occurred with IV administration in 1 in 60 patients.

Gastrointestinal:
Gastrointestinal symptoms occurred in 1 in 150 patients and included diarrhea
(1 in 220 patients) and nausea (1 in 440 patients). The onset of pseudomembranous
colitis may occur during or after antibacterial treatment
Hypersensitivity Reactions:
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Hypersensitivity reactions have been reported in fewer than 1% of the patients

treated with cefuroxime and include rash (1 in 125). Pruritus, urticaria, and positive
Coombs' test each occurred in fewer than 1 in 250 patients, and, as with other
cephalosporins, rare cases of anaphylaxis, drug fever, erythema multiforme, interstitial
nephritis, toxic epidermal necrolysis, and Stevens-Johnson syndrome have occurred.
Blood:
A decrease in hemoglobin and hematocrit has been observed in 1 in 10 patients
and transient eosinophilia in 1 in 14 patients. Less common reactions seen were
transient neutropenia (fewer than 1 in 100 patients) and leukopenia (1 in 750 patients).
A similar pattern and incidence were seen with other cephalosporins used in controlled
studies. As with other cephalosporins, there have been rare reports of
thrombocytopenia.
Hepatic:
Transient rise in SGOT and SGPT (1 in 25 patients), alkaline phosphatase (1 in 50
patients), LDH (1 in 75 patients), and bilirubin (1 in 500 patients) levels has been noted.
Kidney:
Elevations in serum creatinine and/or blood urea nitrogen and a decreased
creatinine clearance have been observed, but their relationship to cefuroxime is
unknown.
Postmarketing Experience with Cefuroxime: In addition to the adverse events
reported during clinical trials, the following events have been observed during clinical
practice in patients treated with cefuroxime and were reported spontaneously. Data are
generally insufficient to allow an estimate of incidence or to establish causation.
Neurologic: Seizure.
Non-site specific:
Angioedema.
Cephalosporin-class Adverse Reactions: In addition to the adverse reactions
listed above that have been observed in patients treated with cefuroxime, the following
adverse reactions and altered laboratory tests have been reported for cephalosporin-
class antibiotics:
Adverse Reactions:
Vomiting, abdominal pain, colitis, vaginitis including vaginal candidiasis, toxic
nephropathy, hepatic dysfunction including cholestasis, aplastic anemia, hemolytic
anemia, and hemorrhage.
Several cephalosporins, including cefuroxime, have been implicated in triggering
seizures, particularly in patients with renal impairment when the dosage was not
reduced.If seizures associated with drug therapy should occur, the drug should be
discontinued. Anticonvulsant therapy can be given if clinically indicated.

Nursing Considerations
Body as a Whole:
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 Determine history of hypersensitivity reactions to cephalosporins, penicillins,

and history of allergies, particularly to drugs, before therapy is initiated.
 Inspect IM and IV injection sites frequently for signs of phlebitis.
 Report onset of loose stools or diarrhea.
 Monitor I&O rates and pattern: Especially important in severely ill patients
receiving high doses. Report any significant changes.

d. ambroxol
Classification: Mucolytic
Adverse effect
Occasional gastrointestinal side effects may occur but these are almost
invariably mild.
Indication
Adjuvant therapy in patients with abnormal, viscid, or inspissated mucous
secretions in acute and chronic bronchopulmonary diseases, and in pulmonary
complications of cystic fibrosis and surgery, tracheostomy, and atelectasis. Also used in
diagnostic bronchial studies and as an antidote for acute acetaminophen poisoning.
Assessment & Drug Effects
 Monitor for S&S of aspiration of excess secretions, and for
 Bronchospasm (unpredictable); withhold drug and notify physician immediately
if either occur.
 Lab tests: Monitor ABGs, pulmonary functions and pulse oximetry as indicated.
 Have suction apparatus immediately available. Increased volume of respiratory
tract fluid may be liberated; suction or endotracheal aspiration may be
necessary to establish
 and maintain an open airway.
Patient & Family Education
 Report difficulty with clearing the airway or any other respiratory distress.