Chapter IV

MEDICAL MANAGEMENT

1.

Diagnostic Test

DATE

TYPE OF
TEST

RESULT

UNITS

REFERENCE
INTERVAL

97

g/dL

12.5 17

Hematocrit

0.33

36.0 50.0

RBC

3.99

x10E3/uL

4.10 5.60

WBC

13.46

x10E3/uL

4.0 10.5

Neutrophil

84

40 74

Lymphocyte

11

14 46

Monocyte

4 13

07

December Complete Hemoglobin

7, 2014
Blood Count

Basophil 1.000

PLATELET

304

x10E3/uL

140 415

MCH

24.3

pg

27.0 34.0

MCHC

29.6

g/dL

32.0 36.0

MCV

82.2

fL

80 98

2.

Medical Management

DRUG STUDY

D5LR

Generic Name:

dextrose monohydrate, sodium chloride,

sodium lactate, potassium chloride,
calcium chloride

Classification:

hypertonic, nonpyrogenic, parenteral

fluid, electrolyte, nutrient replenisher

Ordered Dose:

D5LR 1L @ 120 cc/hr(30gtts/min)

Suggested Dose:

1000 mL @ 30 gtts/min

Mode of Action:

Hypertonic solutions are those that have an effective

osmolarity greater than the body fluids. It increases
the solute concentration of the plasma, allowing water
out of the cell and into the extracellular compartment
to restore osmotic equilibrium.

Side Effects:

Diarrhea (less severe), Nausea & vomiting (less

severe), inflammation of the vein (less severe),
stomach cramps (less severe), tingling of hands and
feet (severe)

Adverse Effects:

Hypersensitivity, chest pain, chest discomfort,

bronchospasm, dyspnea, nausea, pyrexia,
Hyperkalemia, Hypervolemia, excessive dose may

lead to fluid and sodium overload which is a risk for

edema
Nursing
Responsibilities:
1

Check the solution if it is clear and undamaged before administration

Caution must be exercised in administration of parenteral fluids, especially

those containing sodium ions to patients receiving corticosteroids or
corticotrophin

Solution containing acetate should be used with caution as excess

administration may result in metabolic alkalosis

Discard unused portion

Properly label IV fluid

Observe aseptic technique when changing the IV fluid

MAGNESIUM SULFATE

Generic Name:

magnesium sulfate

Brand name:

Epsom Salt

Classification:

mineral, electrolyte

Ordered Dose:

MgSO4 drip: D5Water 50cc

+ 5 g MgSO4@ 25gtts/min

Suggested Dose:

Seizure Prevention in
Preeclampsia/Eclampsia:

Initial: IM: 4 to 5 g of a 50% solution every 4

hours as necessary. IV: 4 g of a 10% to 20%
solution, not exceeding 1.5 mL/min of a 10%
solution. Maintenance: IV Infusion: 1 to 2
g/hour. Maximum dose should not exceed 30
to 40 g/day.

Mode of Action:

It is naturally occurring mineral that is important for

many systems in the body especially the muscles and
nerves. It increases water in the intestines. It can also
be used as a laxative to relieve occasional
constipation.

Side Effects:

CNS: drowsiness, flaccid paralysis, hypothermia

CV:

depressed cardiac function

EENT: diplopia
Metabolic: hypocalcemia
Skin: diaphoresis

Adverse Effects:

CNS: depressed reflexes

CV: flushing, hypotension, bradycardia, circulatory
collapse
Respiratory: respiratory paralysis

Drug Interaction:

Nursing
Responsibilities:

Drug to drug: Anesthetics, CNS depressants: May

cause additive CNS depression. Use together
cautiously. Cardiac glycosides: May worsen
arrhythmias. Use together cautiously. Neuromuscular
blockers: May cause increased neuromuscular
blockade. Use together cautiously.

Watch for respiratory depression and signs and symptoms of heart block

Monitor fluid intake and output. Make sure urine output is 100 ml or more
in a 4-hour period before each dose.

Effective anticonvulsant level ranges from 2.5 to 7.5 mEq/L

DEXAMETHASONE

Generic Name:

dexamethasone

Brand Name:

Baycadron,
Dexamethasone
Intensol

Classification:

cortecosteroid

Ordered Dose:

6 mg 1 tab q 12
hours x 4 doses

Mode of Action:

Dexamethasone is a corticosteroid that prevents the

release of substances in the body that cause
inflammation. It decreases inflammation, mainly by
stabilizing leukocyte lysosomal membranes;
suppresses immune response; stimulates bone
marrow; and influences protein, fat, and carbohydrate
metabolism.

Side Effects:

CNS: psychotic behavior, vertigo, headache,

paresthesia, depression

CV:

hypertension, edema, thrombophlebitis

EENT: cataracts, glaucoma

Adverse Effects:

Drug Interaction:

GI:

GI irritation, increased appetite, nausea,

vomiting

GU:

increased urine glucose and calcium levels

CNS: euphoria, insomnia, pseudotumor cerebri,

seizures
CV:

heart failure, arrhythmias, thromboembolism

GI:

peptic ulceration, pancreatic

Aminoglutethimide: May cause loss of

dexamethasone-induced adrenal suppression.
Antidiabetes, including insulin: May decrease
response. May need dosage adjustment. Aspirin,
indomethacin, other NSAIDs: May increase risk of GI
distress and bleeding. Barbiturates, carbamazepine,
phenytoin, rifampacin: May decrease corticosteroid
effect. Increase corticostreroid dosage. Cardiac
glycosides: May increase risk of arrhythmia resulting
from hypokalemia. May need dosage adjustment.
Cyclosporine: May increase toxicity. Monitor patient
closely. Ephedrine: May cause decreased half-life and
increased clearance of dexamethasone. Monitor
patient. Oral anticoagulants: May alter dosage
requirements. Monitor PT closely. Potassiumdepleting drugs such as thiazide diuretics: May
enhance potassium-wasting effects of
dexamethasone. Monitor potassium level. Salicylates:
May decrease salicylate level. Skin-test antigens:
May decrease response. Postpone skin testing until
therapy is completed. Taxoids, vaccines: May
decrease anti-body response and may increase risk
of neurologic complications.

Nursing
Responsibilities:
10

Determine whether patient is sensitive to other corticosteroids

11

Most adverse reactions to corticosteroids are dose- or duration-dependent

12

For better results and less toxicity, give once-daily dose in morning

13

Give oral dose with food when possible. Patient may need drugs to
prevent GI irritation

14

Monitor patients weight, blood, pressure, and electrolyte levels

15

Inspect patients skin for petechiae

16

Monitor patient for cushingoid effects, including moon face, buffalo hump,
central obesity, thinning hair, hypertension, and increased susceptibility to
infection

TERBUTALINE
Generic Name:

terbutaline

Brand Name:

Brethine

Classification:

beta2 agonist

Ordered Dose:

Terbutaline cap SQ now

Suggested Dose:

0.25 mg every 6 hours

(subcutaneous)

Mode of Action:

Side Effects:

It is a bronchodilator. It works
by relaxing muscles in the
airways to improve breathing.

CNS: weakness
CV:

tachycardia, flushing

GI:

heartburn

Metabolic: hypokalemia
Respiratory: dyspnea
Skin: diaphoresis

Adverse Effects:

CNS: nervousness, tremor, drowsiness, dizziness,

headache, weakness
CV:

palpitations, arrhythmias

GI:

nausea and vomiting

Respiratory: paradoxical bronchospasm with prolonged use

Drug Interaction:

Cardia glycosides, cyclopropane, halogenated inhaled

anesthetics, levodopa: May increase risk of arrhythmias.
CNS stimulants: May increase CNS stimulation. MAO
inhibitors: when given with sympathomimetics, may cause
severe hypertension. Propanol: May block bronchidilating
effects of terbutaline.

Nursing
Responsibilities:
17

Give subcutaneous injections in the side of the deltoid

18

Protect the drug from light. Dont use if discolored

19

Drug may reduce the sensitivity of spirometry for the diagnosis of

bronchospasm

FERROUS SULFATE

Generic Name:

ferrous sulfate

Brand Name:

Feosol

Classification:

hematinic

Ordered Dose:

FeSO4 1 tab B.I.D

Suggested Dose:

15-30 mg elemental
iron P.O. daily
during last two
semesters

Mode of Action:

Provides elemental iron, an essential component in the

formation of hemoglobin

Side Effects:

GI:

epigastric pain, vomiting, diarrhea, anorexia

Other: temporarily stained teeth from liquid forms

Adverse Effects:

GI:

Drug Interaction:

Antacids, cholestyramine, resin, cimetidine: May decrease

iron absorption. Chloramphenicol: May delay response to
iron therapy. Levodopa, methyldopa: May decrease
absorption and effort of levodopa and methyldopa. Vitamin
C: May increase iron absorption. Use together for
therapeutic effect.

Nursing

nausea, constipation, black stools

Responsibilities:
20

Between meal doses are preferable. Drug can be given with some foods,
although absorption may be decreased.

21

Oral iron may turn stools black. Although this unabsorbed iron is harmless.

22

Monitor hemoglobin level, hematocrit, and reticulocyte count during

therapy

ISOXSUPRINE

Suggested Dose:

Generic Name:

isoxsuprine

Brand Name:

Vasodilan

Classification:

vasodilator

Ordered Dose:

Isoxsuprine
10 mg 1 tab
T.I.D x 5
days (PO)

10 to 20 milligrams (mg) three or four times a day.

Mode of Action:

It relaxes veins and arteries, which makes them wider and

allows blood to pass through them more easily.

Side Effects:

Nausea or vomiting (more common for injection)

Adverse Effects:

CNS: Dizziness.
CV:
Low blood pressure, palpitations, fast heart rate, lung
swelling and flushing.
GI:
Nausea, vomiting and abdominal distress.
Others: Rash and allergic reactions such as hives, difficulty
breathing, tightness in the chest.

Drug Interaction:

Although certain medicines should not be used together at

all, in other cases two different medicines may be used
together even if an interaction might occur. In these cases,
your doctor may want to change the dose, or other
precautions may be necessary. Tell your healthcare
professional if you are taking any other prescription or
nonprescription (over-the-counter [OTC]) medicine.

Nursing
Responsibilities:
23

Monitor for therapeutic effectiveness: Response to treatment of peripheral

vascular disorders may take several weeks. Evaluate clinical
manifestations of arterial insufficiency.

24

Monitor BP and pulse; may cause hypotension and tachycardia. Supervise

ambulation.

25

Observe both mother and baby for hypotension and irregular and rapid
heartbeat if isoxsuprine is used to delay premature labor. Hypocalcemia,
hypoglycemia, and ileus have been observed in babies born of mothers
taking isoxsuprine.

26

Notify physician of adverse reactions (skin rash, palpitation, flushing)

promptly; symptoms are usually effectively controlled by dosage reduction
or discontinuation of drug.

27

Prevent orthostatic hypotension by making position changes slowly and in

stages, particularly from lying down to sitting upright and avoid standing
still.

UTROGESTAN

Generic Name:

utrogestan

Ordered Dose:

utrogestan 200 mg cap T.I.D per vagina

Suggested Dose:

200 mg thrice a day

Mode of Action:

Synthetic long-acting glucocorticoid that depresses

formation, release, and activity of endogenous mediators of
inflammation, including prostaglandins, kinins, histamine,
liposomal enzymes, and complement expression. It also
modifies the body's immune response. It replaces hormones.
UTROGESTAN 100mg capsules have all the properties of

endogenous progesterone with induction of a full secretory

endometrium and in particular gestagenic, antioestrogenic,
slightly antiandrogenic and antialdosterone effects.
Side Effects:

Local itching, burning, or discharge

Adverse Effects:

Cardiac arrest, hypertension, diarrhea, nausea & vomiting

Drug Interaction:

Aminoglutethimide: May decrease dexamethasone

induced adrenal suppression.
Amphotericin B: Cardiac enlargement and CHF have
been reported.
Anticholinesterases: May antagonize
anticholinesterase effects in myasthenia gravis.
Anticoagulants, oral: May alter anticoagulant dose
requirements.
Antidiabetic agents: Dexamethasone may increase
blood glucose levels, necessitating antidiabetic agent
dosage adjustments.
Aprepitant: Dexamethasone plasma levels may be
elevated and the half-life prolonged, increasing the
pharmacologic effects and adverse reactions.
Cholestyramine, epinephrine: Dexamethasone
plasma levels may be reduced, decreasing the
efficacy.
Cyclosporine: Activity of cyclosporine and
dexamethasone may be increased. In addition,
convulsions have been reported.
CYP3A4 substrates (eg, erythromycin, indinavir):
Plasma levels may be reduced by dexamethasone,
decreasing efficacy.
Digoxin: Because of possible dexamethasoneinduced hypokalemia, the risk of arrhythmias may be
increased.
Hepatic enzyme inducers (eg, barbiturates,
carbamazepine, phenytoin, rifampacin):
Dexamethasone plasma levels may be reduced,
decreasing the efficacy. In addition, seizure control
with phenytoin may be altered.
Hepatic enzyme inhibitors (eg, azole antifungal
agents [eg, ketoconazole], estrogens including oral
contraceptives, macrolide antibiotics [eg,
erythromycin]): Dexamethasone plasma levels may
be elevated, increasing the pharmacologic effects and

adverse reactions. In addition, ketoconazole can

inhibit adrenal corticosteroid synthesis, causing
adrenal insufficiency during dexamethasone
withdrawal.
NSAIDs, salicylates: Risk of GI adverse reactions
may be increased. In addition, salicylate levels and
efficacy may be reduced.
Potassium-depleting agents (e.g., amphotericin B,
loop and thiazide diuretics): Risk of hypokalemia may
be increased.
Thalidomide: Use with caution; TEN has been
reported with concurrent use of dexamethasone.
Nursing
Responsibilities:
28

Monitor vital signs of patient

29

Remind patient that this drug is not taken orally but per vagina

30

Observe side effects and adverse effects

31

Encourage patient to report any symptoms of the side effects or allergic

reactions

NIFEDIPINE

Generic Name:

nifedipine

Classification:

calcium
channel
blocker

Ordered Dose:

10 mg 1 tab
every 6
hours

Mode of Action:

inhibit calcium ion influx across cardiac and smooth muscle

cells, decreasing contractility and oxygen demand. Also may
dilate coronary arteries

Side Effects:

CNS: somnolence, synecope, nervousness hypotension,

palpitations
EENT: nasal congestion
GI: diarrhea, constipation, abdominal discomfort
Respiratory: dyspnea, pulmonary edema, cough
Skin: rash, pruritus

Adverse Effects:

CNS: dizziness, light-headed, headache, weakness

CV:

Drug Interaction:

flushing, peripheral edema, heart failure, MI

antiretroviral: May decrease nifedipine metabolism. Monitor

blood pressure closely. Azole antifungals: May increase the
effects of nifedipine. Fentanyl: May cause severe
hypotension. Rifamycin: May decrease nifedipine levels.

Nursing
Responsibilities:
32

Dont use capsules S.L. to rapidly reduce severe high blood pressure
because the result may be fatal.

33

Monitor blood pressure regularly

34

Watch symptoms for heart failure

3.

Surgical Management

The patients only surgery was a caesarean section. She has

a gravida of 3, parity of 2 and has no abortion. In the year 2009 was
her first pregnancy which she gave birth to a baby boy via
caesarean section. 2 years after (2011), she gave birth to a baby
girl, again via caesarean section.
The previous Caesarean sections were all classical. So, on
her present pregnancy ( third pregnancy ), the physician decided to
have a Classical Caesarean section, especially that she was
diagnosed with placenta previa totalis. The patients life would be at
risk of she will deliver NSVD.