PAMANTASAN NG LUNGSOD NG MAYNILA

INTRAMUROS, MANILA


COLLEGE OF NURSING







Submitted to:
Prof. Maricel Chua R.N.


Submitted by:
Arnaiz, Danica Rose A.
Baltazar, Clarisse Ann C.
Baraquia, Maria Maxine Victoria G.
Bautista, Nicole M.
Bernat, Adina S.
Borja, Aerianne Joyce S.
Calaycay, Jamaica Ann T.



Introduction

Diabetes mellitus is a group of metabolic diseases characterized by
elevated levels of glucose in the blood (hyperglycemia) resulting from defects in
insulin secretion, insulin action, or both. Normally a certain amount of glucose
circulates in the blood. The major sources of this glucose are absorption of ingested
food in the gastrointestinal tract and formation of glucose by the liver from food
substances. Insulin, a hormone produced by the pancreas, controls the level of
glucose in the blood by regulating the production and storage of glucose. In a
diabetic state, cells may stop responding to insulin or the pancreas may stop
producing insulin entirely. This leads to hyperglycemia. Diabetes is also a
multisystem disorder which affects the wound healing process. Physiological
changes in tissues and cells may delay healing and complications of diabetes also
have an impact.

There are two types of diabetes mellitus, type I and type II respectively.
Type I diabetes is said to be the juvenile diabetes, having its onset at any age
below 30 years and is insulin-dependent. These type I diabetics has little or no
endogenous insulin, making them need insulin to preserve life. On the other hand,
type II diabetes is said to be the adult-onset diabetes, occurring usually over 30
years of age. Type II diabetics are non-insulin-dependent.
Latest data says that at the rate diabetes cases are increasing in the
country, there will be some 6.16 million diabetic Filipinos by 2030, health experts
warned the other day. According to Dr. Joey Miranda, secretary of the American
Association of Clinical Endocrinology-Philippines, there were 3.4 million diabetes
cases in the country in 2010, representing a prevalence rate of 7.7 percent. Citing
data from the World Health Organization and International Diabetes Foundation, he
said that by 2030, the prevalence rate is projected to rise to 8.9 percent or 6.16
million cases. These figures represent an increase of 15.6 percent and 84.2 percent
in prevalence rate and the number of cases, respectively.
Causes of this disease is still a mystery yet some genetic and
environmental factors put people to risk like lifestyle and familial history of diseases.





Objectives
GENERAL OBJECTIVES:
After 4 days of exposure to Ospital Ng Sampaloc, Medicine Ward Area, the student
nurses are expected to be able to apply the theoretical skills learned on lectures,
have a systematic and well organized manner of collecting and analyzing data, able
to provide optimum or quality care to the patient, and be able to discuss the disease
and its processes.

SPECIFIC OBJECTIVES:
Specifically, the student nurses should be able to:
Establish rapport with the patient to be able to gather important information about
his past and present conditions.
To be able to use the nursing process as framework to care for the patient
Conduct a thorough physical assessment as a apart of baseline data gathering
Know the anatomy and physiology of the affected body part with regards to
patients condition
Trace the pathophysiology of the disease condition
Know the laboratory and diagnostic procedures done including the normal and
abnormal findings and values for comparison
Determine and interpret the medical management employed
Identify appropriate nursing management for the patients condition
Identify and study the drugs prescribed to the patient which affect the
patients current situation
Construct a nursing care plan and health teachings strategies that is
appropriate for the patients problem
Formulate a prognosis based on all the gathered information















Comprehensive Health History

Date of interview: November 22, 2007
Name of Informant: Virginia Fernandez
Relationship with the patient: Grandmother


BIOGRAPHICAL DATA
Patient: Patient X
Sex: Male
Age: 44 years old
Date of Birth: August 21, 1969
Address: Sta. Mesa, Manila
Civil status: Married
Nationality: Filipino
Religion: Roman Catholic
Date of Admission: June 27, 2013
Hospital Number: 534007

MEDICAL DIAGNOSIS
Diabetes Mellitus II t/c Chronic Kidney Disease


CHIEF COMPLAINT
Client complained of non-healing wound on right calcaneus.

HISTORY OF PRESENT ILLNESS
This is a case of a male patient who had experienced swelling on his right foot and
applied hot compress to alleviate the pain. Days after, blisters appeared resulting to
a wound. The scab was removed and caused continuous bleeding.



PAST MEDICAL HISTORY
Upon interview, patient stated that he never had any illnesses, allergies to any
foods or medications, but had a previous hospitalization prior to his hospitalization.
In the year 2011 he was admitted at Ospital ng Maynila Medical Center and was
confined for four days due to continuous bleeding of extracted tooth. Past
medications were not recalled.

FAMILY HISTORY OF ILLNESS
The informant stated that the patients parents have a known history of familial
diseases such as hypertension and diabetes mellitus.


LIFESTYLE
Upon conduction of assessment, the patient stated that he doesnt smoke and use
substances but drinks alcohol almost every day. In addition, whenever the patient
has free time, he often plays basketball with his co-workers.


PSYCHOSOCIAL HISTORY
Primary Language: Tagalog
Mood: Sociable; responds to any of the questions asked by the group in a pleasant
way.
Family Relations: The patient has a good relationship with his parents.

MEDICATIONS:
1. Cloxacillin, 500 mg/cap, q8h x 7 days
2. Linagliptin, 5 mg/tab, OD
3. Losartan, 50 mg/tab, OD
4. Clonidine, 75 mcg/tab
5. Diphenhydramine, IV prior to BT

Review of Systems
General: patient in supine position
Conscious and coherent with IVF
PNSS x 8 hours hooked at right arm,
infusing well.

Vital signs as follows:
Temp: 37.1C
PR: 80 bpm
RR: 18 cpm
BP: 140/90

Skin: () pallor
() jaundice
() pruritus
(+) rashes (scaly)
() masses
(+) wound

Head: () headache
() head injury
() tenderness
() lesions

Eyes: (+) icteric sclera
() edema
(+) glasses
() inflammation
() excessive tearing
() dry eyes
() nodules

Ears: () tinnitus
() pain
() discharge

Nose: () allergies
() sinus problem
() polyps
() sneezing
() epistaxis

Throat: (+) dental caries
() bleeding gums
() mouth sores
() ulcerations
() difficulty swallowing

Respiratory: ()
diaghprammatic
excursion
() chest pain
() dyspnea
() cough
() hemoptysis

Cardiovascular: () chest pain
() SOB
() pulsations
() edema

Gastrointestinal: () abdominal
pain(RLQ)
() anorexia
() ascites
() anorexia
() diarrhea
() hematochezia
() hemorrhoids

Endocrine: () fatigue
(+) polydipsia
(+) polyphagia

Musculoskeletal: (+)
edema(right foot)
() stiffness
() joint swelling
(+) arthritis






Physical Assessment

General Appearance:
The patient is a male adult, 44 years of age. Upon assessment, the patient was conscious,
coherent, and responsive. He was also seen lying on bed with IVF PNSS x 8 hours regulated at 30-
31 gtts/min hooked at right arm, infusing well. The patient has no problem in ambulation.

V/S taken: time: 12noon
Temperature: 37.1
Heart Rate: 80 bpm
Respiratory Rate: 18 cpm
Blood Pressure: 140/90mmHg

Skin:
Upon inspection, the patients skin has brown complexion. The skin when palpated felt warm
and dry. There were some scars and rashes on his upper extremities. Patient has a gangrenous
wound on right calcaneus, about 1 inch in size, wherein the area within 10 cm from the wound is
swelling.

HEENT:
The patients skull is rounded, normocephalic, no nodules, symmetrical, and no tenderness.
The patients scalp is free of lesions and no infestations were present in the hair. The pupils are equal
and are both reactive to light. The eyeballs are centered with icteric sclerae. The clients conjunctivas
are shiny, smooth, and pink in color. No vascularizations were found and visual acuity is within
normal limit. Patient can read 12 font size letters within 2 feet and six ocular movements, which
assess the motor function of the eyes, are intact. Ears are not low set and both sides are
symmetrical. Hearing acuity is normal and the patient can hear the tick of the watch when placed
close to the ear. Nose is symmetrical and no lesions or unusual discharges were present. Both
nostrils were assessed and no excessive flarings were found. The outer lips are dark in color,
symmetrical, dry, and with a pinkish upper palate and buccal mucosa. No oral lesions were found and
gag reflex was also elicited. Moreover, dental caries were also present. Lastly, the neck is centered
and thyroid gland is not enlarged.



Respiratory System:
Upon inspection, the chest is symmetrical in shape and the breathing pattern of the patient
was quiet and respirations are effortless. The thorax moves easily without difficulty upon registration.
No spinal deformities noted. No adventitious breath sounds were heard upon auscultation of lung
fields.

Cardiovascular System:
The Point of Maximal Impulse (PMI) is located at the patients 5
th
left ICS mid-clavicular line.
No chest pain was noted and heart sounds are all normal but with a slight increase from normal.
Pulses in the extremities are in the same rate as with the other pulses.

Gastrointestinal System:
The patient is currently on diabetic diet and defecates regularly. There is no any abnormality in
the abdominal skin wall. Upon palpation, there is neither tenderness nor masses felt. Normal
abdominal sounds are being heard, thus giving normal abdominal findings.



Genitourinary System:
Assessment on the clients genitalia was not performed to respect client privacy.

Musculoskeletal System:
The client does not show any limitation in movement upon inspection. He can move freely,
extends and rotates his extremities without any discomfort, and he stands and walks without
support.
Neurologic System:
The patient can comprehend spoken language and has proper orientation of things around
him. Memory status is intact and the patient was also able to discriminate sharp and dull sensations
however, the patient has a feeling of numbness within the area where his wound is located.







Cranial Nerve Assessment:
CRANIAL NERVE ASSESSMENT
Olfactory (I) No problem with the patients sense of smell was elicited since
he can identify which foods are being presented to him without
looking at it.
Optic (II) The patient can read from 12 to 14-inch distance. The patient
can see objects in the periphery when looking straight ahead.
Oculomotor (III) The patient has bilateral and symmetrical extra ocular
movements. The pupils constrict when looking at near objects
and dilate when looking at far objects. Pupils converge when
near object is moved to the nose.
Trochlear (IV) The patient has bilateral and symmetrical extra ocular
movements.
Trigeminal (V) The patient is able to elicit blink reflex, can feel light sensation
from the wisp of cotton.
Abducens (VI) The patient has bilateral and symmetric lateral eye movements.
Facial (VII) The patient is able to smile, can raise the eyebrows
symmetrically, is able to frown, puff cheeks and close eyes
tightly bilaterally. Patient is able to identify various tastes on the
tip of the tongue.
Vestibulocochlear
(VIII)
The patient can hear spoken words and able to identify the
ticking of the watch.
Glossopharyngeal
(IX)
The patient can identify tastes on the posterior tongue. The
patient can move his tongue from side to side and up and down.
Vagus (X) The patient can identify tastes on the posterior tongue. The
patient can move his tongue from side to side and up and down.
He also has audible speech and has no hoarseness noted.
Accessory (XI) The patient is able to shrug his shoulders even when force is
applied and can turn head to side against resistance.
Hypoglossal (XII) The patient can protrude his tongue at midline and can move it
from side to side.

Therefore, clients assessment of the cranial nerves is intact and fully functional.










Diagnostic Tests
Complete Blood Count (CBC) Common Blood test. CBC is the calculation of the cellular
blood. These calculations are generally determined by special machines that analyze the
different components of blood in less than a minute. CBC measures the concentration of the
White Blood Cells (WBC), Red Blood Cells (RBC), and platelets. It is performed by obtaining a
few millilitres of blood sample from the patient using a syringe.
Date Test Normal Values Result Interpretation
June 24, 2013 Hematology
report:

WBC count
> segmenters
> lymphocyte

RBC
>HgB
>Hct
>Platelet count




4.8
60 70 %
30 40 %


M 14-16 g/dl
M 0.40-0.57
130 140 x 10



5.0
80
20


6.8
0.20
182





Date Test Normal Values Result Interpretation
June 29, 2013 Hematology
report:

WBC count
> segmenters
> lymphocyte

RBC
>HgB

>Hct

>Platelet count




4.8
60 70 %
30 40 %


M: 14 16g/dl
M: 0.40
0.57%
130 140 x 10



10.7
90
10


7.8

0.23







Blood Chemistry Tests Blood chemistry tests are often ordered prior to surgery or a
procedure to examine the general health of a patient. This blood test, commonly referred to as
a Chem 7 because it looks at 7 different substances found in the blood, is routinely performed
after surgery as well.
Blood Chemistry Components
Blood Urea Nitrogen (BUN)
BUN is a measure of kidney function. A high level may indicate that the kidneys are functioning less
than normal.
Carbon Dioxide (CO2)
This test measures the amount of carbon dioxide in the blood. Most carbon dioxide is present in the
form of bicarbonate, which is regulated by the lungs and kidneys. The test result is an indication of
how well the kidneys, and sometimes the lungs, are managing the bicarbonate level in the blood.
Creatinine
Creatinine is produced by the body during the process of normal muscle breakdown. High levels may
indicate kidney impairment, low blood pressure, high blood pressure or another condition. Some
medications can also cause a higher than normal level of blood creatinine. Low levels may be caused
by late stage muscular dystrophy, myasthenia gravis and over hydration.
Glucose
This test shows the level of glucose in the blood. High levels of glucose can indicate the presence of
diabetes or another endocrine disorder. Keep in mind that some medications and the timing of the
test in relation to meals can radically alter the results. Do not assume that your results indicate a
problem until you have consulted with your physician.
Serum Chloride (Cl)
This test shows the level of chloride in the blood. Chloride binds with electrolytes including potassium
and sodium in the blood and plays a role in maintaining the proper pH of the blood. Chloride levels
can vary widely if the patient is dehydrated or overly hydrated, if the kidneys are not functioning
properly. Heart failure and endocrine problems can also contribute to abnormal chloride results.
Serum Potassium (K)
This test shows the level of potassium in the blood. Potassium plays an important role in muscle
contractions and cell function. Both high and low levels of potassium can cause problems with the
rhythm of the heart so it is important to monitor the level of potassium after surgery. Patients who are
taking diuretics regularly may require regular blood tests to monitor potassium levels, as some
diuretics cause the kidneys to excrete too much potassium.
Serum Sodium (Na)
This portion of the test shows the amount of sodium present in the blood. The kidneys work to excrete
any excess sodium that is ingested in food and beverages. Sodium levels fluctuate with dehydration
or over-hydration, the food and beverages consumed, diarrhea, endocrine disorders, water retention
(various causes), trauma and bleeding.
FBS (Fasting Blood Sugar) Test The fasting blood sugar test is also used to test the
effectiveness of different medication or dietary changes on people already diagnosed as
diabetic.
HbA1c HbA1c is a lab test that shows the average level of blood sugar (glucose) over the
previous 3 months. It shows how well you are controlling your diabetes.

SGPT The term SGPT stands for Serum Glutamic Pyruvate Transaminase. This is an enzyme
that is found in the cells of the liver. It is also commonly known as Alanine Transaminase,
abbreviated as ALT. In a normally healthy individual, the level of SGPT is measurable in the
blood. When there is acute liver damage, the level of SGPT tends to rise dramatically. It should
be noted that the level of SPGT may be elevated in an individual who has recently performed
physical exercise. An elevation in the level of ALT is not a confirmation of a diagnosis of liver
damage. It is used in conjunction with other types of liver test to confirm whether the patient
has indeed suffered from liver damage.

SGOT The SGOT test measures the amount of a substance called glutamic-oxaloacetic
transaminase (GOT) in your blood. It is an enzyme found in the liver, muscles (including the
heart), and red blood cells. It is released into the blood when cells that contain it are damaged.
Other names for this enzyme are aspartate aminotranskinase, aspartate transaminase, and
AST. The SGOT level is measured to check the function of your liver, kidneys, heart,
pancreas, muscles, and red blood cells. It is also measured to check on medical treatments
that may affect the liver.

Date Tests Normal Values Results Interpretation
June 24, 2013

HbA1c
BUN

Crea

Na

K
4.0 6.0%
1.7 8.3
mmol/L
35.3 123.7
umol/L
135 145
mmol/L
3.5 5.5
mmol/L
4.3
10.7

133.4

132.8

2.96

June 27, 2013 FBS

BUN

Crea

Uric Acid

SGOT

SGPT
4.11 5.87
mmol/L
1.7 8.1
mmol/L
M: 59 104
umol/L
M: 202.3
416.5 umol/L
M up to 40 U/L
M up to 41 U/L
5.12

7.76

165.5

452.5

59.8

17.5

July 1, 2013 BUN

Crea
2.49 6.42
umol/L
M: 59 104
umol/L
8.05

193.


Urinalysis A urinalysis (UA), also known as routine and microscopy (R&M), is an array of tests
performed on urine, and one of the most common methods of medical diagnosis
.
The word is a
portmanteau of the words urine and analysis. The target parameters that can be measured or
quantified in urinalysis include many substances and cells, as well as other properties, such as
specific gravity. A part of a urinalysis can be performed by using urine test strips, in which the
test results can be read as color changes. Another method is light microscopy of urine
samples.
Color: Yellow
Transparency: Sl. Turbid
pH: 5.0
Specific Gravity: 1.005
Protein: +4
Glucose: (-)








Anatomy and Physiology

Pancreas
The pancreas, a retroperitoneal gland that is about 12-
15 cm long and 2.5 cm thick, lies posterior to the
greater curvature of the stomach. The pancreas
consists of a head, a body, and a tail and is usually
connected to the duodenum by two ducts. The head is
the expanded portion of the organ near the curve of the
duodenu; superior to and to the left of the head are the
central body and the tapering tail.
Pancreatic juices are secreted by exocrine cells into
small ducts that ultimately unite to form two longer ducts, the pancreatic duct and the
accessory duct. These in turn convey the secretions into the small intestine. The
pancreatic duct (duct of Wirsung) is the larger of
the two ducts. In most people, the pancreatic duct
joins the common bile duct from the liver and
gallbladder and enters the duodenum as a dilated
common duct called the hepatopancreatic
ampulla (ampulla of Vater). The ampulla opens
on an elevation of the duodenal mucosa known as
the major duodenal papilla, which lies about 10
cm inferior to the pyloric sphincter of the stomach.
The passage of pancreatic juice and bile through
the hepatopancreatic ampulla into the small
intestine is regulated by a mass of smooth muscle known as the sphincter of the
hepatopancreatic ampulla (sphincter of Oddi). The other major duct of the pancreas,
the accessory duct (duct of Santorini), leads from the pancreas and empties into the
duodenum about 2.5 cm superior to the hepatopancreatic ampulla.
The pancreas is made up of small clusters of glandular epithelial cells. About 99% of the
clusters, called acini, constitute the exocrine portion of the organ. The cells within acini
secrete a mixture of fluid and digestive enzyme called pancreatic islet (islet of
Langerhans), form the endocrine portion of the pancreas. These cells secrete the
hormones glucagon, insulin, somatostatin, and pancreatic polypeptide.
Each day pancreas produces 1200-1500 ml of pancreatic juice, a clear, colorless liquid
consisting mostly of water, some salts, sodium bicarbonate and the several enzymes.
The sodium bicarbonate gives pancreatic juice a slightly alkaline pH (7.1-8.2) that
buffers acidic gastric juice in chime, stops the action of pepsin from the stomach, and
creates the proper pH for the action of digestive enzymes in the small intestine. The
enzymes in pancreatic juice include a starch-digesting enzyme called pancreatic
amylase; several protein-digesting enzyme called trypsin, chymotrypsin,
carboxypeptidase, and elastase; the principal triglyceride-digesting enzyme n adult
called pancreatic lipase; nucleic acid-digesting called ribonuclease and
deoxyribonuclease.
The protein-digesting enzymes of the pancreas are produced in an inactive form just as
pepsin is produced in the stomach as pepsinogen. Because they are inactive, the
enzymes do not digest cells of the pancreas itself. Trypsin is secreted in an inactive
form called trypsinogen. Pancreatic acinar cells also secrete a protein called trypsin
inhibitor that combines with any trypsin formed accidentally in the pancreas or in
pancreatic juice and blocks its enzymatic activity. When trypsinogen reaches the lumen
of the small intestine, it encounters an activating brush-border enzyme called
enterokinase which splits off part of the trypsinogen molecule to from trypsin. In turn,
trypsin acts on the inactive precursor (called chymotrypsinogen,
procarboxypeptidase, & proelastase) to produce chymotrypsin, carboxypeptidase,
elastase, respectively.






























Medical-Surgical Management

MEDICAL-SURGICAL MANAGEMENT

Management should be aimed at alleviating symptoms and minimizing the risk of
long-term complications. A diagnosis of Diabetes Mellitus doesnt indicate an operation
unless a part of the body is greatly affected. The medication given to manage the
disease was Linagliptin 5mg/tab once a day. It is an antidiabetic medicine which
increases the production of insulin to control the blood sugar level. To manage a non
healing wound brought about by Diabetes Mellitus, Cloxacilline, an antibiotic, 500
mg/capsule was given every 8 hours for 7 days, and changes of wound dressing were
also done to prevent further infection. CBG monitoring or Capillary Blood Glucose
monitoring was also performed in order to keep track of the level of concentration of
glucose in the blood. To manage Hypertension, antihypertensive drugs were
administered. Losartan 50mg/tab was given once a day and Clonidine 75mcg/tab.
Anemia, secondary to Chronic Kidney disease, was managed through a Blood
Transfusion. Diphenhydramine was given prior to Blood Transfusion to lessen allergic
reactions that may be brought about by the transfusion.


NURSING MANAGEMENT

INTERVENTIONS
The nurse administered medications on the right time and monitored the patient
for effects and side effects. The nurse performed Capillary Blood Glucose monitoring.
The nurse changes the dressing of the non healing wound to prevent further infection.
Education
The patient was taught daily self-care skills to prevent acute fluctuations in
blood glucose and to incorporate into their lifestyle many preventive behaviors for
avoidance of long-term diabetic complications. Patient was educated about nutrition,
medication effects and side effects, exercise, disease progression, prevention
strategies, and CBG monitoring techniques.














































ACTION INDICATION CONTRAINDICATI
ON
ADVERSE
REACTIONS
NURSING
CONSIDERATIO
NS
PATIENT TEACHING
Clonidine
Catapres-TTS

Clonidine
Hydrochloride
Catapres,
Duracion

Pharmacologic
Class:
Centrally acting
alpha agonist

Pregnancy risk
category: C
Unknown. Thought
to stimulate alpha
2
receptors and
inhibit the central
vasomotor centers,
decreasing
sympathetic
outflow to the
heart, kidneys, and
peripheral
vasculature, and
lowering peripheral
vascular
resistance, blood
pressure and heart
rate.

Route:
1. P.O
2. Transderma
l
3. Epidural
Onset:
1. 30-60 mins.
2. 2-3 days
3. Unknown
Peak:
1. 2-4 hrs.
2. 2-3 days
3. 30-60 mins.
Duration:
1. 12-24 hrs.
2. 7-8 days
3. Unknown
Management
of all grades of
hypertension.
- hypersensitivity to
drug
- Transdermal form
is contraindicated in
Px hypersensitive to
any component of
the adhesive layer
of transdermal
system.
- Epidural form is
contraindicated in
Px receiving
anticoagulant
therapy, in those
with bleeding
diathesis, in those
with an injection site
infection, and in
those that are
hemodynamically
unstable or have
severe CV disease.
- Use cautiously in
patients with severe
coronary
insufficiency,
conduction
disturbances, recent
MI, cerebrovascular
disease, chronic
renal failure or
impaired liver
function.
CNS: drowsiness,
dizziness,
sedation,
weakness, fatigue,
malaise, agitation,
depression.
CV:bradycardia,
severe rebound
hypertension,
orthostatic
hypotension.
GI: constipation,
dry mouth,
nausea, vomiting,
anorexia.
GU: urine
retention,
impotence.
Metabolic: weight
gain.
Skin: pruritus,
dermatitis with
transdermal patch,
rash.
Other: loss of
libido.
- Drug may be
given to lower BP
rapidly in some
hypertensive
emergencies.
- Monitor BP and
PR frequently.
- Observe Px for
tolerance to
drugs therapeutic
effects, which
may require
increased
dosage.
- Dont confuse
clonidine with
quinidine or
clomiphene; or
Catapres with
Cetapred or
Combipres.
- Advise Px that
stopping drug abruptly
may cause severe
rebound high BP. Tell
him that dosage must
be reduced gradually
over 2 to 4 days as
instructed by
prescriber.
- Tell Px to take the
last dose immediately
before bedtime.
- Reassure Px that the
transdermal patch
usually remains
attached despite
showering and other
routine daily activities.
- Caution Px that drug
may cause
drowsiness but that
this adverse effect
usually diminishes
over 4 to 6 weeks.
- Inform Px that
dizziness upon
standing can be
minimized by rising
slowly from a sitting or
lying position and
avoiding sudden
position changes.

ACTION INDICATION CONTRAINDICATI
ON
ADVERSE REACTIONS NURSING
CONSIDERATIO
NS
PATIENT
TEACHING
Losartan
Potassium
Cozaar

Pharmaco-
logic Class:
Angiotensin II
receptor
antagonist

Pregnancy
risk
category: C;
D in 2
nd
and
3
rd
trimesters
Inhibits
vasoconstrictive
and
aldosterone-
secreting action
of angiotensin II
by blocking
angiotensin II
receptor on the
surface of
vascular smooth
muscle and
other tissue
cells.

Route:
P.O

Onset:
Unknown

Peak:
1 hr.

Duration:
Unknown

Half Life:
2 hrs.
- Hypertension
- Nephropathy
in Type 2
diabetic
patients
- To reduce
risk of stroke in
patients with
hypertension
and left
ventricular
hypertrophy
- hypersensitivity to
drug
- Breastfeeding isnt
recommended
during losartan
therapy.
- Use cautiously in
Px with impaired
renal or hepatic
function.
- Drugs that act
directly on the renin-
angiotensin system
can cause fetal and
neonatal morbidity
and death when
given to women in
the second or third
trimester of
pregnancy. These
problems havent
been detected when
exposure was
limited to the first
trimester. If
pregnancy is
suspected, notify
prescriber because
drug should be
stopped.
Patients with hypertension or left
ventricular hypertrophy
CNS: dizziness, asthenia,
fatigue, headache, insomnia.
CV:edema, chest pain.
EENT: nasal congestion,
sinusitis, pharyngitis, sinus
disorder.
GI:abd. pain, nausea,
dyspepsia.
Musculoskeletal: muscle
cramps, myalgia, back or leg
pain.
Respiratory: Cough, upper
respiratory infection.
Other: angioedema
Patients with nephropathy
CNS: asthenia, fatigue, fever,
hypesthesia.
CV: chest pain, hypotension,
orthostatic hypotension.
EENT: sinusitis, cataract.
GI: diarrhea, dyspepsia,
gastritis.
GU: UTI.
Hematologic: anemia.
Metabolic: hyperkalemia,
hypoglycaemia, weight gain.
Musculoskeletal:back pain, leg
or knee pain, muscle weakness.
Respiratory:Cough bronchitis.
- Drug can be
used alone, or
with other
antihypertensive.
- Monitor Px BP
closely to
evaluate
effectiveness of
therapy.
- Monitor Px who
also takes
diuretics for
symptomatic
hypotension.
- Regularly
assess the
Pxsrenal
function.
- Px with severe
heart failure
whose renal
function depends
on the
angiotensin-
aldosterone
system may
develop acute
renal failure
during therapy.
Closely monitor
the Px, especially
- Tell Px to
avoid salt
substitutes;
these products
may contain
potassium,
which can
cause high
potassium
level in Px
taking losartan.
- Inform
woman of
childbearing
age about
consequences
of 2
nd
and 3
rd

trimester
exposure to
drug.
Prescriber
should be
notified
immediately if
pregnancy is
suspected.
- Advise Px to
immediately
report swelling
of face, eyes,
lips, or tongue,
Half Life:
6-20 hrs.
Skin:cellulitis.
Other:flu-like syndrome,
diabetic vascular disease,
angioedema, infection, trauma,
diabetic neuropathy.


during the first
few weeks of
therapy.
- Dont confuse
Cozaar with
Zocor.
or any
breathing
difficulty.
ACTION INDICATION CONTRAINDICATIO
N
ADVERSE
REACTIONS
NURSING
CONSIDERATION
S
PATIENT TEACHING
Diphenhydra
mine
Hydrochloride
Benadryl

Pharmacologi
c Class:
Ethanolamine
derivative

Pregnancy
risk category:
B
Competes
with histamine
for H
1
receptor
sites.
Prevents, but
doesnt
reverse,
histamine-
mediated
responses,
particularly
those of the
bronchial
tubes, GI tract,
uterus, and
blood vessels.
Structurally
related to local
anesthetics,
drug provides
local
anesthesia
and
suppresses
cough reflex.
- Rhinitis,
allergy
symptoms,
motion
sickness,
Parkinsons
Disease
- Sedation
- Night-time
sleep aid
- Non-
productive
cough (syrup
only)
- hypersensitivity to
drug; newborns;
premature neonates;
breastfeeding
women; Px with angle
closure glaucoma,
stenosing peptic
ulcer, symptomatic
prostatic hyperplasia,
bladder neck
obstruction, or
pyloroduodenal
obstruction; and
those having an
acute asthma attack.
- Avoid use in Px
taking MAO
inhibitors.
- Use with caution in
Px with prostatic
hyperplasia, asthma,
COPD, increased
intraocular pressure,
hyperthyroidism, CV
disease, and
hypertension.
- Children younger
CNS: drowsiness,
sedation,
sleepiness,
dizziness,
incoordination,
seizure, confusion,
insomnia,
headache, vertigo,
fatigue,
restlessness,
tremor,
nervousness.
CV: palpitations,
hypotension,
tachycardia.
EENT: diplopia,
blurred vision, nasal
congestion, tinnitus.
GI: dry mouth,
nausea, epigastric
distress, vomiting,
diarrhea,
constipation,
anorexia.
GU: dysuria, urine
retention, urinary
frequency.
- Stop drugs 4
days before
diagnostic skin
testing.
- Alternate
injection sites to
prevent irritation.
Give IM injection
deep into large
muscle.
- Dizziness,
excessive
sedation, syncope,
toxicity,
paradoxical
stimulation, and
hypotension are
more likely to
occur in the
elderly.
- Dont confuse
diphenhydramine
with
dimenhydrinate;
dont confuse
Benadryl with
Bentyl or
- Warn Px not to take
this drug with any other
products that contain
diphenhydramine
because of increased
adverse reactions.
- Instruct Px to take drug
30 mins. Before travel to
prevent motion
sickness.
- Tell Px to take drug
with food or milk to
reduce GI distress.
- Warn Px to avoid
alcohol and hazardous
activities that require
alertness until CNS
effects of drug are
known.
- Tell Px that coffee or
tea may reduce
drowsiness. Urge
caution if palpitations
develop.
- Inform Px that
sugarless gum, hard
candy or ice chips may
than age 12 should
use drug only as
prescribed.
Hematologic:
thrombocytopenia,
agranulocytosis,
hemolyticanemia.
Respiratory:thicken
ing of bronchial
secretions.
Skin:urticaria,
photosensitivity,
rash.
Other: anaphylactic
shock.
Benazepril. relieve dry mouth.
- Tell Px to notify
prescriber if tolerance
develops because a
different antihistamine
may need to be
prescribed.
- Advise use of sunblock
for photosensitivity
reactions.

ACTION INDICATION CONTRAINDICATIO
N
ADVERSE
REACTIONS
NURSING
CONSIDERATION
S
PATIENT TEACHING
Linagliptin
Tradjenta

Pharmacologi
c Class:
Dipeptidyl
Peptidase IV
Inhibitor

Pregnancy
risk category:
B
DPP-4
degrades the
incretin
hormones
glucagon-like
peptide-1
(GLP-1) and
glucose-
dependent
insulinotropic
polypeptide
(GIP). Thus,
linagliptin
increases the
concentrations
of active
incretin
hormones,
stimulating the
release of
insulin in a
glucose-
Indicated as
an adjunct to
diet and
exercise to
improve
glycemic
controlin adults
with type 2
diabetes
mellitus.
- Hypersensitivity
-Type 1 diabetes
mellitus
-Diabetic ketoacidosis
-Nasopharyngitis
(4.3%)
-Hyperlipidemia
(2.8%;with
pioglitazone)
-Cough (2.4%; with
metformin and
sulfonylurea)
-Hypertriglyceride
mia (2.4%; with
sulfonylurea)
-Weight gain
(2.3%;with
pioglitazone)
-Hypoglycemia
7.6%
-over all incidence
22.9% incidence
compared with
placebo plus
metformin and a
sulfonylurea
- Before taking
linagliptin, assess
if the client have
allergy in
medication.
-Before using this
medication, tell
your doctor or
pharmacist your
medical history,
especially of:
disease of the
pancreas(pancreat
itis).
-You may
experience blurred
vision, dizziness,
or drowsiness due
to extremely low or
high blood sugar
levels. Do not
drive, use
-Informing patients of
the potential risks and
benefits of linagliptin
and of alternative
therapies.
-Informing patients
about the importance of
adherence to dietary
instructions, regular
physical activity,
periodic blood glucose
monitoring and HbA1C
testing, recognition and
management of
hypoglycemia and
hyperglycemia, and
assessment of
complications of
diabetes mellitus.
-Seeking medical advice
promptly during periods
of stress (e.g., fever,
dependent
manner and
decreasing the
levels of
glucagon in
the circulation.
Route:
P.O
Onset:
15-30 mins.
Peak:
1.5 hrs.

Duration:
12-24 hrs.
Half Life:
12 hours



machinery, or do
any activity that
requires alertness
or clear vision until
you are sure you
can perform such
activities
trauma, infection,
surgery) as medication
requirements may
change.
-Informing patients that
response to all
antidiabetic therapies
should be monitored by
periodic measurements
of blood glucose and
HbA1C, with a goal of
decreasing these levels
toward the normal
range.
-Informing clinicians if
any unusual symptom
develops or if any
existing symptom
persists or worsens.
-Informing their
clinicians if they are or
plan to become
pregnant or plan to
breast-feed.
-Informing clinicians of
existing or contemplated
concomitant therapy,
including prescription
and OTC drugs and
dietary or herbal
supplements, as well as
any concomitant
illnesses.











ACTION INDICATION CONTRAINDICATI
ON
ADVERSE
REACTIONS
NURSING
CONSIDERATIO
NS
PATIENT TEACHING
Cloxacillin
Avastoph

Pharmacologic
Class:
Anti-infective,
Antibiotic

Pregnancy risk
category: B
Interferes with cell
wall replication of
susceptible
organisms, the cell
wall, rendered
osmotically
unstable, swell,
bursts from
osmotic pressure;
resists the
penicillinase action
that inactivates
penicillins.
Route:
Intravenous
Onset:
Few Days
Peak:
1 hr
Duration:
6 hrs
Half Life:
0.65 hr
Treatment of
infections
caused by
pneumococci,
Group A beta-
hemolytic
streptococci,
and penicillin
G sensitive
staphylococci.
Prophylaxis:
Staphylococcal
infection
during major
cardiovascular
and orthopedic
surgery
- History of
hypersensitivity to
penicillins and
cephallosporins.
Sever pneumonia,
emphysema,
bacteremia,
pericarditis
,meningitis and
purulent and septic
arthritis during the
acute the stage.
Sub-conjunctival
infections
EENT:
occasionally,laryng
eal edema,
Skin:
urticaria, skin
rashes, exfoliative
dermatitis, rash
GI:
GI disturbances,
nausea, vomiting,
epigastric distress,
diarrhea and
flatulence,
antibiotic-
associated
pseudomembrano
uscolitis
GU:
Interstitial nephritis
and vasculitis
Hematologic:
eosinophilia,
agranulocytosis,
anemia,
thrombocytopenia,t
ransient rise in
transminases and
- Perform skin
testing before
giving the
medication.
-Administer drug
slowly to the IV
line
-Explain to the
patient that
antibiotic therapy
lasts for 7 days
will take the drug
without any miss.
-Make sure that
the patient takes
the drug at the
same time of the
day. And also to
prevent them
being drug
resistant.
-Provide rest and
comfort.
-Assess for any
signs of
hypersensitivity
reaction such as
- Take medication
around the clock, do
not miss a dose, and
continue taking the
medication until it is
finished.
-Report to physician
the onset of
hypersensitivity
reaction (see
Appendix F) and
super infections.
-Check with physician
if GI adverse effects
(nausea, vomiting,
diarrhea) appear.
-Do not breast feed
while taking this drug.
alkaline
phophatase
Other:
Hypersensitivity
reactions, serum
sickness-like
reactions, fever
purpura, rash,
urticaria,
exfoliative
dermatitis, itching





Nursing Care Plan




































ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Subjective:

Hindi
gumagaling yung
sugat ko, dugo
ng dugo As
verbalized by the
patient.

Objective:
Dry wound
dressing
VS taken as
follows:
T-
PR- 80bpm
RR- 18cpm
BP-
140/90mmHg


Risk for Infection
related to inadequate
primary defense






















After 8 hours of nursing
interventions, the
patient will be able to
identify the risk factors
and the occurrence of
infection will be reduce
or control to a
manageable level and
maintain skin intact.




Independent:
1. Observation for signs of
infection and inflammation
such as fever, redness,
pus in the wound, purulent
sputum, urine color cloudy
and foggy.

2. Maintain aseptic
technique with any
procedures. Provide
wound care, as
appropriate.

3. Emphasize the importance of
hand washing technique.

4. Compare and note any
changes in the wound.

5. Inspect dressing and
wound; note
characteristics of drainage

Dependent:
1. Obtain for culture and
sensitivity test , as
indicated.

2. Administer anti-biotics, as
indicated.


After 8 hours of nursing
interventions, the patient
was able to identify
interventions to prevent or
reduce the risk of
infection. The goal was
met.

Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

Subjective:
Lagi akong
umiinom ng
alak kapag
wala akong
ginagawa at
mahilig din ako
sa matatamis
na pagkain as
verbalize by the
patient

Objective:
Lack of
information
source

VS taken as
follows:
T-
PR- 80bpm
RR- 18cpm
BP-
140/90mmHg

Knowledge deficit
related to lack of
desire to seek
information and
information resource

























After 3 hours of
nursing intervention
the patient will be able
to verbalize
understanding of the
condition/ disease
process and
treatment.

Independent:
1. Assess the level of
knowledge of the
client and family
about the disease
process.

2. 2. Select teaching
strategies that will
enhance
teaching/learning
effectiveness, such
as discussion,
demonstration, and
visual materials.
Provide all the
equipment needed
for the patient to
learn.

3. Provide information
about the condition
of the client. The
disease process and
sign & symptoms of
the condition.

4. Discuss lifestyle
changes that may be
needed to prevent
complications in the
future, and or control
the disease process.


Goal met. After 3
hours of Nurse-
patient interaction,
the patient is able to
understand his
condition and
treatment.
5. Discuss the choice
of therapy or
treatment.
Encourage clients to
explore options or
obtain alternative.

6. Provide information
to families about the
progress of patient
in an appropriate
manner.

7. Instruct the patient
about the signs and
symptoms to report
on health care
givers, in a proper
way.

8. Reinforce the
importance of
adhering to
treatment regimen
and keeping follow up
appointments.
















Assessment Diagnosis Planning Intervention Evaluation
Subjective:
Lagi
akong
umiinom ng
alak kapag
wala akong
ginagawa
at mahilig
din ako sa
matatamis
na
pagkain as
verbalize
by the
patient

Objective:

Temperature:
37.1
Heart Rate: 80
bpm
Respiratory Rate:
18 cpm
Blood Pressure:
140/90mmHg

Risk for
Imbalanced
nutrition less than
body
requirements
related to
reduction of
carbohydrate
metabolism due
to insulin
deficiency
After 8 hour of
nursing intervention
the patients can
ingest calories or
nutrients right
1.) Measure weight
as indicate
2.) Determine the
diet program
3.) Taking of physical
assessment
(bowel sounds,
abdominal pain,
abdominal
bloating N & V)
4.) Involve the family
in meal planning
5.) Observation of
signs of
hypoglycemia
6.) Conduct a health
teaching with the
patient that will
help in identifying
the following food
that he need to
intake
7.) Determine the
food that might
contribute in the
severity in the
occurrence of the
disease
8.) Document the
intervention that
was made and
After 8 hour of nurse and
patient interaction he
patient was clearly given
an instruction on ehat to
ingest , the goal was met
assessment that
was seen. It can
help for future
reference for the
patientss health
status


Assessment Diagnosis Planning Goal Intervention Rationale Evaluation
Subjective
cues:
hindi
gumagaling
yung sugat ko
sa paa


Objective:
The skin
around the
wound are also
necrotizing`


Temperature:
37.1
Heart Rate: 80
bpm
Respiratory
Rate: 18 cpm
Blood
Pressure:
140/90mmHg
Impaired skin
integrity related
to non-healing
wound
secondary to
DM
After 8 hours of
nursing
intervention the
patients risk
for impaired
skin integrity
will be lessen
through some
various
techniques that
will be done
and some
health teaching
that will be
conducted
After the
procedure the
patient is
expected to have
a:
1.) Have a
good and
healthy
skin
condition
2.) Be able to
cope with
ADL and
will function
normally
3.) Be
knowledge
able on
how to
treat or
prevent
alteration in
the skin
Assess the site
of affected area




Discuss pain
control if
needed






Site the
importance of
adequate
nutrition







Teach the
following or
To identify
the
severity of
the wound
To help
patient
cope
towards
proper
pain
managem
ent
It can help
thepatient
in
choosing
the food
he needed
to eat in
order to
have a
good
process of
wound
healing
To
minimize
further
Goal partially
met. After 8
hours of nurse
and patient
interaction the
some of the
goal was done
and was able
to help in
repairing the
skin. Some are
not fully meet
because it
requires
continuous
intervention
and cannot
finish in just a 8
hour duty.
Health
teaching was
properly done.
appropriate
position for
pressure relief
Make a ROM
schedule


Give
information in
signs of
infection
Demonstrate
wound cleaning





Encourage
verbalization of
feelings



Identify things
or sources that
might affect the
severity of the
wound
Document any
changes or
abnormality or
progress in the
site of affected
area
skin
trauma
Proper
skin
managem
ent



To teach
the client
on how to
handle
himself
independe
ntly
To
recognize
or to give
a cue in
signs and
symptoms
To
prevent
further
damage

This may
serve as a
history or
reference
of the
patient








Assessment Diagnosis Planning Intervention Evaluation
Subjective:
hindi naman masakit
ang sugat ko eh, di na
din nakakaramdam
yung parting banda
ditto

Objective:
Upon palpation
the patient did
not sense any
pain in the site
of the wound,
thus feeling
numb.
The patient has
an IV cotraotion
in the right
hand
Risk for injury related
to numbness in the
right foot and an IV
contraption
After 8 hours of
nursing intervention,
the patient is expected
to identify , classify
and prevent the
possible things that
might cause further
injury in the site of
necrotizing wound and
IV contraption
1.) Assess the
ADL of the
patient and
identify the
activities that
might
contribute in
acquiring injury
2.) Conduct health
teaching on
how to properly
take care of the
body by
preventing the
risk of injury
3.) Assess the sign
of displacement
in IV
contraption
4.) Provide health
teaching for
the patient
5.) Document the
findings and
intervention
was done for
future
references
After 8 hours of nurse nd
patient interaction the
following intervention was
done properly , therefore the
goal was met