ST.

PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

Nursing History

I.

General Data
a. Personal Data
i. Initial name of the patient: VN
ii. Address: SIaton Negros Oriental
iii. Phone number: 09268483091
iv. Age: 25
v. Birthdate: May 20,1991
vi. Place of birth: Las Pinas, Manila
vii. Sex: Male
viii. Citizenship: Filipino
ix. Marital Status: Single
x. Occupation: Bartender
xi. Religion: Roman catholic
xii. Date of Admission: October 7, 2016 at 4 am
xiii. Health care financing: Philhealth
xiv. Physician: Dr. Lagorra
b. Source of information:
i. Client (60%)
ii. Relative (40%) Girlfriend

c. Chief of Complaint
Pagmata nako, grabe kayo ang pagka lipong nako. Naka suka ko ato dayun wala
nakoy mabati sa akoang paa. Mura kog na paralyze atong mga orasaas verbalized by
the patient

II.

History of present illness

a. Precipitating/Palliative factor
i. Patient was at his boarding house, sleeping when he suddenly
woke up and then felt his body weaken. He cannot feel his legs and
what seems to be paralyze. He turned on his side and then started
vomiting. It only lasted a few minutes when he was rushed to the
hospital
b. Description
i. Generalized weakness
c. Quality
i. Cannot feel anything
d. Region
i. Lower right and left extremeties
e. Aggraviating factors
i. Activity
f. Relieving factors
i. Rest
g. Associated symptoms

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

h.
i.
j.
k.

III.

IV.

i. Malaise
ii. Nausea and vomiting
Severity/Quantity of symptoms
i. Severe pain
Timing
i. Sudden
Duration of signs and symptoms
i. Minutes (20)
Frequency of signs and symptoms
i. Years (3 years ago)

A. Summary of Present Illness

a. Patient was experiencing a fast bowel movement earlier that
day. And when he fell asleep after his work, he woke up at the
feeling of severe nausea. He started vomiting and realized that
he couldnt move his feet anymore. Patient describe the signs
and symptoms as really disturbing, as it caused him generalized
weakness. He had the same case 3 years ago because he has
a history of a decrease in number of potassium. He indicated
that the aggravating factors of his condition is the severity of the
activity and he is relieved by it through resting, He rated the
severity of the signs and symptoms as 7 which is severe pain.
The timing was sudden and lasted for about 20 minutes.
Past History
a. Childhood illnesses
i. Chicken pox
b. Hospitalization
i. Patient was hospitalized on 2013 due to the same case he is
experiencing now
ii. He didnt undergone any surgeries
c. Immunization
i. Patient is fully immunized
d. Laboratory examination
i. Potassium (2)
e. Current medication (before admission)
i. Calium
ii. Vitamin (Enervon)
f. Allergies
i. Patient does not have any allergies on food, medication and animal

Family History
a. Diabetes Mellitus Grandfather
b. Hypertension- Father

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

Interpretation:
There is no connection with the case of his grandfather and father to the
patient. The patient does not have any of the following diseases.

V.

Psychosocial Profile History

a. Nutritional Patterns:
i. Meal pattern is irregular due to his work. He eats midnight snacks
and lunch. He works from 1pm-2am
b. Sleep/Rest pattern
i. Sleep (Hours of Sleep): 9 hours
ii. No medication used to aid sleep
iii. No Sleeping disorders

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

c. Personal Habits
i. Patient smokes occasionally especially when he is stressed
ii. Patient drinks liquor because he works in a bar so he needs to
taste his made alcoholic beverages- 3 times a week

Nursing History taken by:

Sydelle Thelma P. Gravador
SN-SPUD

Drug Study

Generic name: Pantoprazole

Brand name: Pantoloc
Action- Used to treat certain stomach and esophagus problems (such as acid reflux). It
works by decreasing the amount of acid your stomach makes. This medication relieves
symptoms such as heartburn, difficulty swallowing, and persistent cough. It helps heal

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

acid damage to the stomach and esophagus, helps prevent ulcers, and may help
prevent cancer of the esophagus.
Classification- Proton pump inhibitor
Indication- Duodenal and gastric ulcer, moderate and severe reflux esophagitis.
Eradication of H. pylori in patient with peptic ulcers, pathological hyper secretory
conditions. Symptomatic improvement and healing of mild reflux esophagitis. Prevention
of gastro-duodenal ulcers induced by NSAID in patients at risk with a need for
continuous NSAID treatment
Side Effects- Headache or diarrhea may occur. If any of these effects persist or worsen,
tell your doctor or pharmacist promptly.
Adverse effects- Symptoms of a low magnesium blood level (such as unusually
fast/slow/irregular heartbeat, persistent muscle spasms, seizures).
Contraindication- known hypersensitivity to any of the constituents of Pantoloc or of the
combination partners. Mild gastrointestinal complaints eg, nervous dyspepsia. Pantoloc
must not be used in combination treatment for eradication of H. pylori in patients with
moderate to severe hepatic or renal dysfunction
Nursing consideration- Assess underlying condition before therapy and after to monitor
drug effectiveness. Assess GI symptoms: epigastric/abdominal pain, bleeding and
anorexia. Monitor for possible drug induced adverse reaction

Generic name: Trimetazidine

Brand name: Vastarel
Classification: anti-angina
Indication: acute angina attacks- prevent situation that may cause anginal attack
Contraindication: lactation
Action: Selective inhibition of an enzymeof fatty acid
-oxidation: the long-chain 3-ketoacyl CoA thiolase (3-KAT).This inhibition results
in: Reduction in fatty acid oxidation; Stimulation of glucose oxidation. The coupling of
glycolysis with glucose oxidation is improved and ATP production is further increased,
while cell acidosis andCa2+ overload are limited. The increase in total glucose
utilization has been evidenced by studies using 18FDG positron emission tomography
(PET)

Adverse effects: Nausea andVomiting,headache,edema

Nursing considerations:
1. Check for doctors order

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

2. Monitor blood pressure and pulse rate before and after giving the meds.
3. Notify prescribing signs of heart failure such as swelling of hands and feet or SOB.
4. Advise patient of the side effects of the drug

Generic name: Cefuroxime

Brand name: Zinacef
Classification:2nd generation cephalosporin
Action: Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Indication: treatment of serious infections of the lower respiratory tracts
Adverse reaction: Pseudomembranous colitis, hypersensitivity, reactions, serum
sickness, anaphylaxis
Side Effects:-Diarrhea, nausea, vomiting, rash, pain, temperature elevation, tissue
sloughing at IM injection site
Contraindications: Hypersensitivityto cefuroxime, any component or other cephalosporin
Nursing consideration: Assess for previous history of reactions to other cephalosporin or
penicillin

Generic name: Platexan

Brand name: Clopidogrel
Classification: Platelet aggregation inhibitor
Indication: Prevention of atherosclerotic events in peripheral arterial disease or within 35
days of myocardial infarction or within 6 months of ischemic stroke or in acute coronary
syndrome without ST-segment elevation.

Action: Clopidogrel is used to prevent heart attacks and strokes in persons with heart
disease, recent stroke, or blood circulation disease. It is also used with aspirin to treat
new/worsening chest pain (new heart attack, unstable angina) and to keep blood
vessels open and prevent blood clots after certain procedures (such as cardiac stent).It
works by blocking certain blood cells called platelets and prevents them from forming
harmful blood clots. This "anti-platelet" effect helps keep blood flowing smoothly in your
body.

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

Adverse Reactions: The incidence of adverse effects, particularly dyscrasias, is lower

with clopidogrel, although fatalities have been reported. Other adverse effects, reported
rarely include serum sickness, interstitial pneumonitis, erythema multiforme, StevensJohnson syndrome, lichen planus and myalgia.
Consideration should be given to stopping clopidogrel 5-7 days before elective surgery.

Generic Name: Gliclazide

Brand Name: Diamicron
Drug Classification: Oral Anti-Diabetic agent
Indication: Diamicron MR is used in the treatment of type II(non-insulin
dependent)diabetes that cannot be controlled with diet and exercise
Action: Gliclazide is a blood glucose-lowering agent. Non-insulin dependent
diabetes(NIDDM) is due to a decreased sensitivity of the body cells to insulin, but the
pancreas still has the ability to produce insulin. Gliclazide stimulates the islet cells of the
pancreas to secrete insulin, and also increases their sensitivity to their normal stimulus,
glucose. These effects restore the(first-phase) insulin secretion that has become
diminished in NIDDM patients. Gliclazide also has effects outside the pancreas, where it
improves insulin-stimulated usage of glucose.
Contraindication: This medication must not be used in the following cases:
-if you are allergic to gliclazide
-if you have diabetes requiring treatment with insulin,
-in case of diabetes complicated by ketosis and acidosis, diabetic precoma
-if you suffer from severe liver or kidney disease.
-in case of porphyria: accumulation of pigments (porphyria) in the body
-if you are presently taking a treatment with miconazole
-if you are breast-feedingt

Side effects: Disturbances of the gut such as diarrhoea, constipation, indigestion,

nausea, vomiting or abdominal pain. Temporary visual disturbances.
Nursing consideration: Patients who are NPO may need to have their dose held to avoid
hypoglycemia

Generic name: Metoprolol

Brand name: Lopressor
Classification: Beta-adrenergic blocking agents
Action: Unkown. A selective beta blocker that selectively blocks beta1 receptors;
decreases cardiac output, peripheral resistance, and cardiac oxygen consumption; and
depresses rennin secretion

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

Indication: Hypertension Acute MI Angina Pectoris

Contraindication: Hypersensitive to drug. Pt. with sinus bradycardia, cardiogenic shock
and heart failure
Side effects:
CV: hypotension
GI: nausea and vomiting
Respi:dyspnea
Skin:rash
Adverse effects: CV: Bradycardia Heart failure
Nursing responsibilities:
1. Always check patients apical pulse
2. Monitor BP
3. Store drug at room temperature.
4.Inform patient about the side effects and adverse effects of the medication.
5.Advise patient to take it with meals.
6.Tell patient to report if he/she feels shortness of breath.
7. Tell patient that metoprolol is not advisable to breastfeeding mothers.
8.Advise not to withdrawn drug abruptly

Generic Name: Aspirin

Brand name: Apo-ASA (CAN)

Classification:
Antipyretic
Analgesic (nonopioid)
Anti-inflammatory
Antirheumatic
Antiplatelet
Salicylate
NSAID
Action: Analgesic and antirheumatic effects are attributable to aspirins ability to inhibit
the synthesis of prostaglandins, important mediators of inflammation. Antipyretic effects
are not fully understood, but aspirin probably acts in the thermoregulatory center of the

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

hypothalamus to block effects of endogenous pyrogen by inhibiting synthesis of the

prostaglandin intermediary. Inhibition of platelet aggregation is attributable to the
inhibition of platelet synthesis of thromboxane A2, a potent vasoconstrictor and inducer
of platelet aggregation. This effect occurs at low doses and lasts for the life of the
platelet (8 days). Higher doses inhibit the synthesis of prostacyclin, a potent vasodilator
and inhibitor of platelet aggregation.
Indications

Mild to moderate pain

Fever
Inflammatory conditionsrheumatic fever, rheumatoid arthritis, osteoarthritis
Reduction of risk of recurrent TIAs or stroke in males with history of TIA due to fibrin
platelet emboli
Reduction of risk of death or nonfatal MI in patients with history of infarction or unstable
angina pectoris
MI prophylaxis
Unlabeled use: Prophylaxis against cataract formation with long-term use

Adverse effects

Acute aspirin toxicity: Respiratory alkalosis, hyperpnea, tachypnea, hemorrhage,

excitement, confusion, asterixis, pulmonary edema, seizures, tetany, metabolic acidosis,
fever, coma, CV collapse, renal and respiratory failure (dose related, 2025 g in adults,
4 g in children)
Aspirin intolerance: Exacerbation of bronchospasm, rhinitis (with nasal polyps, asthma,
rhinitis)
GI: Nausea, dyspepsia, heartburn, epigastric discomfort, anorexia, hepatotoxicity
Hematologic: Occult blood loss, hemostatic defects
Hypersensitivity: Anaphylactoid reactions to anaphylactic shock
Salicylism: Dizziness, tinnitus, difficulty hearing, nausea, vomiting, diarrhea, mental
confusion, lassitude (dose related)
Contraindications

Contraindicated with allergy to salicylates or NSAIDs (more common with nasal polyps,
asthma, chronic urticaria); allergy to tartrazine (cross-sensitivity to aspirin is common);
hemophilia, bleeding ulcers, hemorrhagic states, blood coagulation defects,
hypoprothrombinemia, vitamin K deficiency (increased risk of bleeding)

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

Use cautiously with impaired renal function; chickenpox, influenza (risk of Reyes
syndrome in children and teenagers); children with fever accompanied by dehydration;
surgery scheduled within 1 wk; pregnancy (maternal anemia, antepartal and postpartal
hemorrhage, prolonged gestation, and prolonged labor have been reported; readily
crosses the placenta; possibly teratogenic; maternal ingestion of aspirin during late
pregnancy has been associated with the following adverse fetal effects: low birth weight,
increased intracranial hemorrhage, stillbirths, neonatal death); lactation.
Nursing considerations

Assessment

History: Allergy to salicylates or NSAIDs; allergy to tartrazine; hemophilia, bleeding

ulcers, hemorrhagic states, blood coagulation defects, hypoprothrombinemia, vitamin K
deficiency; impaired hepatic function; impaired renal function; chickenpox, influenza;
children with fever accompanied by dehydration; surgery scheduled within 1 wk;
pregnancy; lactation
Physical: Skin color, lesions; T; eighth cranial nerve function, orientation, reflexes, affect;
P, BP, perfusion; R, adventitious sounds; liver evaluation, bowel sounds; CBC, clotting
times, urinalysis, stool guaiac, LFTs, renal function tests
Interventions

BLACK BOX WARNING: Do not use in children and teenagers to treat chickenpox or flu
symptoms without review for Reyes syndrome, a rare but fatal disorder.
Give drug with food or after meals if GI upset occurs.
Give drug with full glass of water to reduce risk of tablet or capsule lodging in the
esophagus.
Do not crush, and ensure that patient does not chew SR preparations.
Do not use aspirin that has a strong vinegar-like odor.
WARNING: Institute emergency procedures if overdose occurs: Gastric lavage,
induction of emesis, activated charcoal, supportive therapy.

ST. PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2015-2016
NCM103

Assignment
In
NCM103
(RLE)

Submitted by: Sydelle Thelma P. Gravador

Submitted to: Mrs. Gerah Mae Valle RN, MAN