A care for client with client with adverse drug reaction

secondary to Anti-TB medication.

In partial fulfillment of Related Learning Experience (R.L.E)

Submitted By:
Portugal, Marc
Prodigalidad, Jhonelle
Quiambao, Bianca
Rambaud, David
Redoble, Arlie
Reyel, Arby
Reyes, Jennelyn
Roderos, Mitch Angela
Rojero, Catherine Mae

BSN 4C GROUP II S.Y 2011-2012

SCOPE AND LIMITATION

For the two weeks of rotation of BSN 4C Group 2 in Ospital ng Makati, the group was
able to handle the case of a client with adverse drug reaction secondary to Anti-TB medication.
However during that time, the duties and responsibilities ought to be done by the student nurses
had serves as a hindrance to give way for an intensive nursing patient interaction. Aside from the
time constraints, the patient is scheduled for discharge during that time. But we were fortunate
enough to gather data that has provided us knowledge and to support our case study which is to
be presented on this day. The group would like to apologize beforehand for the limited amount of
information. Yet rest assured that the case presented reflects our utmost learning extracted from
the information available.
INTRODUCTION
We BSN group 2 find this case as an interesting one because it is our first time to
encounter this kind of case and it leaves some questions on our mind that let us come to a
decision to choose this case for our case study.
Isoniazid has rarely caused very serious (possibly fatal) liver disease. The risk of liver
disease is increased in people who are 35 years and older, who use alcohol or illegal injection
drugs, or who currently have long-term liver problems. Tell your doctor immediately if you
develop

symptoms

of

liver

disease,

including

persistent

nausea/vomiting,

severe

stomach/abdominal pain, unusual weakness/tiredness, dark urine, yellowing eyes/skin.

Hepatic effect
Hepatitis has been reported in less than 5% of patients receiving isoniazid alone. Jaundice
is usually preceded by a prodromal illness with fatigue, nausea, malaise, abdominal pain, and
anorexia. Asymptomatic increases in liver function tests may occur. Isoniazid should be
discontinued if hepatotoxicity occurs, usually defined as SGOT greater than four times normal
The mechanism of hepatic injury is unknown but may be related to the acetyl metabolite
of isoniazid. Patients exhibiting hepatotoxicity are more likely to be fast acetylators of isoniazid.
Eight cases of severe hepatitis resulting in death or transplantation have been evaluated by the
Department of Health of New York. Duration of isoniazid use before onset of hepatitis ranged
from 21 to 142 days, and seven patients continued use of isoniazid at least 10 days after onset of
2

symptoms. Massive hepatic necrosis was a common finding and cholestasis was present in two
of five cases.
The risk is age related with a greater occurrence reported in patients who are 35 years or
older. The risk of hepatitis is also increased in patients who consume alcohol daily, in women,
and in minorities. In a study of 2651 women beginning isoniazid preventive therapy during
pregnancy or postpartum, 5 cases of isoniazid-induced hepatitis were identified, including two
fatalities. In another review of deaths due to isoniazid, eight of 21 women between 15 and 44
years old were within one year postpartum. In general, death due to isoniazid hepatotoxicity
occurs more frequently in women than men.
Fulminate hepatitis, characterized by jaundice, disorders of consciousness and elevated
serum transaminases up to 80 times the upper limit of normal, has occasionally occurred in
patients receiving isoniazid with rifampin. Rifampin, by virtue of its enzyme-inducing activity,
likely increases the reactive metabolite of isoniazid thought to be responsible for the
hepatotoxicity associated with isoniazid.
Monthly monitoring and interviewing of patients should take place. Patients should be
fully informed regarding the risk of hepatotoxicity associated with isoniazid, educated about the
signs and symptoms of liver damage, and instructed to contact their physician immediately if
they develop signs or symptoms.

DEMOGRAPHIC DATA
Clients name : Patient B.R
Gender: Male
Age, Birth date and Birth place: 25years old, April 5,1986 at Makati
Marital Status: Single
Nationality: Filipino
Religion: Islam
Address: 4565 Jerry St. Pio Del Pillar Makati City
Educational Background: College Graduate
Occupation: Financial and Corporate Relations
Usual Source of Medical Care: Ospital ng Makati

A. SOURCE AND RELIABLITY OF INFORMATION

Patients Chart
Patients Mother
Patient Himself
B. REASON FOR SEEKING CARE
Naninilaw ang buong katawan
pababalik balik na lagnatAs verbalized by the patient
C. HISTORY OF PRESENT ILLNESS
23 days Prior to admission From the patients interview, Patient B.R has undergone
physical examination as requirement for his new job, when the company physician
detected a bullae from his CT Chest Scan.thus, the patient was prescribed to take in
Isoniazid with Vitamin B complex
2 weeks Prior to admission Patient B.R complaints of experiencing easy fatigability,
anorexia and generalized weakness
4 days Prior to admission Patient B.Radditionally developed fever,jaundice and
hemoptysis. Hence persistence of symptoms has lead the patient for subsequent
admission
Upon Admission - Patients vital signs was taken and recorded of blood pressure of
120/80, PR: 86, RR: 21, Temp: 36.6 c with a general survery of jaundce and ecteric
scelera. The patient was hooked with D5LR 1 L x 125cc/hr at left metacarpal vein with
4

laboratory tests rendered such as HbsAg, LFT, ECG, CBC, Na, K, BUN, ultrasound and
Chest X-Ray are taken likewise.
D. PAST MEDICAL HISTORY
Pediatric/Childhood/ Adult Illness: Patient has has a history of drug reaction secondary to
anti-tubercular drugs especifically Isoniazid when he was 1 years old. at that time,
patient had jaundice, hepatomegaly and purpura examination for work, a granuloma was
noted on CAT.
Injuries or accidents: The client recieved multiple injuries due to stampede (10 y/0)
Serious/ Chronic Illnesses: PTB primary complex (1 y/o)
Hospitalizations: Patient was hospitalized due to Viral Infection last 2007
Operations: No known operations
Obstetric history: Not applicable
Immunizations: The client verbalized of having complete immunization of DPT, OPV,
BCG and Measles vaccine.
Allergies: The client stated to have food allergies in Eggplant, Egg and Shrimp
Medications prior to confinement: The client recieved 23 days of Isoniazid Medication
with unrecalled dosage but of an approximate of less than 25 mg
Last Examination Date: October 31,2011

E. FAMILY HISTORY

Mother

Father

(+) HPN

(+) HPN

(+) DM

(+) DM

?? Age

?? Age

?? Age

?? Age

25 y/o

LEGEND

Male

Female

Client

Heredo-Family Illness
Maternal

The Mother side of Patients B.R is known to be hypertensive and with Diabetes Mellitus.
The client recalled no other inherited illness besides the one indicated above.
FatherThe Father side of Patients B.R is known to be hypertensive and with Diabetes Mellitus.
The client recalled no other inherited illness besides the one indicated above.
F. SOCIO-ECONOMIC
The client consists of a nuclear family and lives together with his parents and
siblings. The client states that he contributes for the family financial expenses. Financial
Resources are adequate enough to provide for them for the expenses of their everyday
living that is by means of his father and with and the help of his siblings who were
working likewise though the occupation was not identified. Prior to admission, the client
was hired to be a Financial and Corporate Relations at the company with an average
income of 18,000 php per month.
G. DEVELOPMENTAL HISTORY

Erik Erickson
Psychosocial Theory

Age

IntimacyVs. Isolation

19 30
y/o

Task
Young
need

Patients Description
adults The client is presently single for 6

to

intimate,

form months and

does not comit in

loving intimate

relationships.

relationships with moreover,there was an observed

other

people. conflict

between

the

family

Success leads to members as suported by the

strong

patients verbaliztion that they are

relationships,

presently facing a a problem

while
results
loneliness
isolation.

failure between their family. The client is

in at risk for loneliness and Isolation
and if inadequate support that may
affectt

his

development

problems are left unresolved.

H. REVIEW OF SYSTEMS
1. Regional Examinations

if

(Nov. 24, 2011, 10:30 am)

Vital Signs:
Temp : 36.1c RR: 14cpm PR: 64cpm BP: 110/70mmHg
General Assessment:
Patient was conscious and coherent; lying on bed and both feet secured. Skin is clean
and smooth but it was yellow in color, also has a good or normal skin turgor. Nails are
long but not dirty and with normal capillary refill. Patient has an abdominal pain in
right lower quadrant when eating with heplock inserted at left metacarpal vein.

Date of
Assessment

System

November 24,
2011

Integumentary

Normal Findings

Actual Findings

Smooth and good skin

I:
turgor, no lesions or any

discoloration, no
clubbing, no breaks
&abnormal curvature.

Yellowish complexion, no lesion,

no swelling and edema.
Normal looking
Visible veins on both arms
Has a temperature of 36.2c.

In nails:

Long and clean nails and round

nails.
Nailbed yellowish in color

P:
Warm, soft, smooth, and has a good
skin turgor.
In nails:
Hard, immobile, and smooth.

November 24,
2011

Hair and Head

No lesion, no
tenderness, no pain on
palpation, no masses, no
lumps, no nodules or
depression, symmetrical

I:
-His hair color is black, hair is evenly
distributed,
-Has thick hair.
-No presence of parasite and dandruff.
-In scalp: Symmetrical and round and
no lesion.
P:
7

-Hair texture is smooth and soft.

-In head the texture is smooth and
firm.
November 24,
2011

Eyes

Eyelid intact, no
redness, swelling,
discharge or lesions.
Eyeballs are moist &
glossy, conjunctiva
numerous small blood
vessels. Sclera white.
Good eye contact.

I:
-Lid margins moist and light pink,
lashes short, evenly spaced and curled
outward.
-Bulbar conjunctiva is clear with tiny
vessels visible, palpebral conjunctiva
is light pink with no discharge and the
color of the sclera is yellowish.
- In PERRLA:
*Cornea is transparent and the shape
of the iris and pupil is round and
equal.
*The left and right eye has a good
reaction to light (constrict and dilate)
-In extra ocular movements:
*Both eyes coordinated well in all
directions.

November 24,
2011

Ears

Ears are symmetrical

with 10 degrees angle.
Color is same in facial
with no tenderness or
any nodule and without
any presence of
discharge.

I:
-Equal size and similar appearance.
-No lesions, color yellow same with
his complexion.
P:
-Warm, smooth, no nodules and no
tenderness in auricle and tragus.

November 24,
2011

Mouth and
Throat

32 adult teeth are

present with moist and
pink mucous membrane
without any lesions or
swelling.

I & P:
-Lips and surrounding tissue relatively
symmetrical.No lesions, swelling and
drooping.
-Lip is light pink; moist, smooth and
with no lesions.
-Buccal mucosa is light pink, moist
and without lesions.-Gums are light
pink, and moist.
-In tongue:
*Moist, some papillae present,
symmetrical appearance, midline
fissures present and the color is pink
and color white at the center and no
lesions as well as the sides of the
8

tongue.
*Hard palate: slightly pink. *Soft
palate: pink, -Has 32 teeth and
yellowish in color.
November 24,
2011

Neck

No tenderness on
palpation, no pain,
symmetrically align, no
enlarged lymph nodes,
no tracheal lateral
deviation.

I:
-Neck is symmetric with head
centered and without bulging masses.
P:
-Smooth skin, firm, and none tender
and none enlarged nodules.

November 24,
2011

Breast and
Axillae

No palpable nodules and I:

lesions. Breast is firm
-Nipples have no discharges and not
and round.
cracked.

November 24,
2011

Respiratory

Intercostals spaces are

even and relaxed; chest
symmetry is equal, no
pain or tenderness, and
no abnormal breath
sound.

I:
-The color of his chest is similar to his
complexion.
-Intercostals spaces are even and
relaxed.
-Chest symmetry is equal
-Thorax: is straight.
-The RR of the patient is 14cpm.
P: No pain or tenderness.
A: Lung is clear to auscultation on
inspiration and expiration.

November 24,
2011

Cardiovascular

No fatigue on simple
activities, no
arrhythmias and heart
murmurs. PR=60100bpm.

PR : 64 bpm
BP: 110/70 mmHg
I:-Neck veins are not distended.
P:
-No vibrations or palpitation in aortic,
pulmonic, or tricuspid area.
A:-No murmur sound heard.

November 24,
2011

Abdominal

No pain, No palpable
masses and tenderness,
Flat and round.

I:
-Flat abdomen
P:
-Upon palpation patient experienced
mild pain right lower quadrant.

November
24,2011

Musculoskeletal

Have good range of

-Does not need assistance to stand and
motion and no limitation toes point straight ahead. Able to
of movements.
shrug shoulders against resistance.
9

November 24,
2011

Neurologic

Have no tremors
paralysis. Oriented, no
history of seizures,
mental dysfunction or
hallucinations.

-No presence of tremors, oriented, no

history of seizures, mental dysfunction
or hallucinations.

November
24,2011

Lympathic

Has no bleeding
tendencies, normal
lymph nodes.

No swollen lymph nodes.

2. Laboratory Studies/Diagnostics
Laboratory (Date)
10/31/11

Result

Interpretation/Significance

M - 14-18 g/dl
F 12 -16 g/dl

15.5

Normal

Hematocrit

M 0.40 0.54
F 0.37 0.37

0.47

Normal

White Blod Cells

4.0 11.0

7.6

Normal

Red Blood Cells

M 5.0 -6.4

4.8

Below Normal

Hemoglobin

Normal Value

Indicates anemia, bone marrow

failure, erythropoietin deficiency,
hemolysis or transfusion reaction
hemorrhage.
DIFFERENTIAL COUNT
Segmenters

0.5 0.7

0.62

Above Normal

Lymphocytes

0.2 0.4

0.31

Above Normal
Increased in presence of
infection

Monocytes

0.02 0.05

0.07

Above Normal
Seen in chronic inflammation,
stress
response,hyperadrenocorticism ,
and immune-mediated disease

Platelet

150- 300

145

Normal

Laboratory (Date)
11/04/11

Normal Value

Result

Interpretation/Significance

M - 14-18 g/dl
F 12 -16 g/dl
M 0.40 0.54
F 0.37 0.37

15.4

Normal

Hemoglobin
Hematocrit

0.43

Normal

White Blod Cells

4.0 11.0

6.9

Normal

Red Blood Cells

M 5.0 -6.4

4.5

Below Normal
Indicates anemia, bone marrow
failure, erythropoietin deficiency,
hemolysis or transfusion reaction
10

hemorrhage.

DIFFERENTIAL COUNT
Segmenters

0.5 0.7

0.67

Above Normal

Lymphocytes

0.2 0.4

0.26

Above Normal
Increased in presence of
infection

Monocytes

0.02 0.05

0.07

Above Normal
Seen in chronic inflammation,
stress
response,hyperadrenocorticism ,
and immune-mediated disease

Platelet

150- 300

155

Normal

10/31/11
Clinical
Chemistry
Section
AST (SGOT)
ALT (SGPT)
Alkaline

S.I
Result
3603
3933
190

Unit

u/L
u/L
u/L

Range

15-37
30-65
50-165

Conversion
Result
3603
3933
190

Unit

u/L
u/L
u/L

Result

15-37
30-55
50-165

Interpretation

Above Normal
Above Normal
Above Normal

Phosphtase

Sodium

133

u/L

136-145

133

meq/L 136-145

Above normal
indicates
response of
cholestatic
liver disease
Below Normal

Potassium

u/L

3.5-5.1

meq/L 3.5-5.1

Normal

S.I
Result

Unit

Range

11/19/11
Clinical
Chemistry
Section

Conversion
Result

Unit

Result

AST (SGOT)

104

u/L

15-37

104

u/L

15-37

ALT (SGPT)

268

u/L

30-65

268

u/L

30-55

Interpretation

Above Norma
Serum AST
and ALT
increased in
liver damage,
Above Normal

11/13/11
Clinical

S.I

Unit

Range

Conversion

Unit

Result

Interpretation
11

Chemistry
Section
Total Protein

Albumin

Globulin

Result
104

268

31

/C Ratio

Result
g/L

g/L

64-82

34-50

6.20

g/dL

3.10

g/L

30-32

3.10

1.1-1.6

1.00

g/dL

g/dL

6.4-8.1

Above Normal

3.4-5.0

May indicate
Chronic infection
(including
tuberculosis), Liver
dysfunction,
Dehydration,
Alcoholism
Above Normal

3-3.2

May indicate
Dehydration, Poor
protein utilization
Normal

1.1-1.5

Normal

11/07/11
Clinical Chemistry Section
Billirubin
Total
Direct
Indirect
11/1/11
Clinical

S.I

Chemistry

Result

Section
BUN
Creatinine

3.3
54

Results
0-20-52 umol/L
433.50
0-8.55 umol/L
201.70
0-11.97 umol/L
231.80
Unit

Range

Conversion

Interpretation
Above Normal

Unit

Result

Interpretation

mg/dL
mg/dL

7.0-18.0
0.60-

Normal
Normal

Result
mmol/L 2.5-6.4
umol/L 53-115

9.24
0.61

1.30
11/01/11
Blood Coagulation Tests
Prothrombin Time
% Activity
INR
PTT

Range
10.4 14.0 sec
73 -127 %
0.88 1.21 sec
30.4 41.2 sec

Results
27.7 sec
27.6 %
2.78 sec
75 sec

Interpretation
Above Normal
Normal
Above Normal
Above Normal

Range
10.4 14.0 sec
73 -127 %
0.88 1.21 sec
30.4 41.2 sec

Results

Interpretation
Above Normal
Normal
Above Normal
Above Normal

11/07/11
Blood Coagulation Tests
Prothrombin Time
% Activity
INR
PTT

29 sec
26 %
2.93 sec
93.2 sec

12

10/31/11
URINALYSIS
DATE:
LAB NO.
PATIENTS NAME:
ROOM
AGE:
SEX: MALE
PHYSICAL
Color

Dark Yellow

Transparency

Slightly Hazy

pH

CHMICAL

6.0

Protein

+3

Sugar

NEGATIVE

Specific Gravity 1.030

MICROSCOPIC
CRYSTALS
Amorphous Urates

FEW

CELLS
White Blood cells

7 10 hpf

Red blood cells

3 5 hpf

Epithelial cells

MODERATE

OTHERS
Bactaeria & Mucus Threads: OCCASIONAL

13

3. Other Assessment Tools

Procedure
11/22/11

Indication
The acid-fast stain is an
especially important test

Acid Fast Stain

Specimen

for the

Results
Microscopic
Examination :

Negative

genus Mycobacterium, to
rule out pulmonary
tuberculosis.

Nursing intervention
Pre
Advise patient to drink a lot of fluids
the night before the test. It makes the
test more accurate if it's done first
thing in the morning.
Advised patient not to take antibiotics
and some sulfonamides because it
may interfere with test results,
causing the results to be falsely
negative.
Prior to breakfast, the patient will be
asked to provide a 5-10 mL
specimen of sputum delivered into a
sterile cup with a screw top lid.
Intra

11/18/11

Acid Fast
Stain Specimen

Microscopic
Examination:

Negative

Asked patient to cough deeply and

spit
the substance that comes up from the
lungs (sputum) into a container.
Patient may be asked to inhale a mist
of salty steam in order to cough
more deeply and produce sputum.

Post

Place it in a sterile container, label

appripiately and immdiately forward
in the laboratory.

14

Procedure

Indication

11/19/11

Results
(+) Small

Nursing intervention
Pre

CT scanning or
Bullae, both
sometimes called CAT
apices minimal
CT Chest Scan

Remove all Metal objects including

jewelry, eyeglasses, dentures and
hairpins. Patient may also be asked
to remove hearing aids and
removable dental work.

Instruct not to eat or drink anything

for several hours beforehand,
especially if a contrast material will
be used in exam.

scanning is a noninvasive
fibrosis left
medical test that helps
upper lung
physicians diagnose and
normal
treat medical conditions.
parenchyma
CT scanning combines
special x-ray equipment
with sophisticated
computers to produce

(-) opacities or
densities
Intra

A chest ct scan takes about 30

mins., which includes preparation
time

Patient mat lie on a narrow table

that moves through the hole

While inside the scanner, an x-ray

tube moves around your body. You
will wear soft buzzing, clicking or
whirring noises as the scanner takes
pictures

The technician will ask you to lie

still and hold your breath for short
periods. these measures help make
the picture as clear as possible the
scan itself

multiple images or
pictures of the inside of
the body. These crosssectional images of the
area being studied can
then be examined on a
computer monitor, printed
or transferred to a CD.

Post

CT exams are generally painless,

fast and easy.

After a CT exam, you can return to

your normal activities.

15

Procedure

Indication

Results

Nursing intervention

16

11/1/2011

An

Gall bladder not

Pre

Abdominal

abdominal ultrasound

visualized likely

Ultrasound

uses reflected sound

contracted. Suggest

waves to produce a

follow-up scan after 3

picture of the organs

days.

and other structures in

the upper abdomen.
Sometimes a
specialized ultrasound
is ordered for a
detailed evaluation of

Instruct patient on NPO prior to

procedure
For a study of the liver, gallbladder,
spleen, and pancreas, you may be
asked to eat a fat-free meal on the
evening before the test
Explain that the procdure is noninvasize and painless
Instruct patient to wear
comfortable, loose-fitting clothing
Instruct to remove all clothing and

jewelry in the area to be examined.

Intra

a specific organ

Assist patient in proper positioning

Instruct that There will be little
discomfort. The conducting gel may
feel slightly cold and wet.

Post

Assist patient in cleaning the gel

and Aftercare of materials

17

Procedure
10/31/11

Indication
HBsAG stands for

Results

HbsAg
(qualitative)

hepatitis B surface

Non-Reactive

Nursing intervention
Pre Interventions

Explain the procedure to the

patient.

Specimens submitted for testing

are handled according to the HRL
SOP entitled "Sample Handling"

No special instructions such as

fasting or special diets are
required. Diurnal variation is not a
major consideration.

Specimens may be serum,

recalcified plasma, or plasma.
Serum specimens may be
collected using regular red-top or
serum-separator Vacutainers.

antigen. It
indicates current
Hepatitis B
infection.

Intra Interventions

Required sample volume is 10 L

for the assay; 1.0 mL will permit
repeat analyses as well as other
testing.

Post Interventions

18

Procedure
10/31/11

Indication
Electrocardiogram

Electrocardiogram

(ECG) provides 12

Results
A.V Block I

Specimens should be stored in

plastic vials and sealed tightly to
prevent desiccation of the sample.

Serum or plasma samples are

collected aseptically to minimize
hemolysis and bacterial
contamination.

Samples are stored in labeled 2

mL Nalgene cryovials or
equivalent.

Nursing intervention
Pre

limbs and chest wall.

Explain the procedure to the

patient.
Instruct patient to wear
comfortable, loose-fitting clothing
Instruct to remove all Metal
objects including jewelry,
eyeglasses, dentures and hairpins.
Patient may also be asked to
remove hearing aids and
removable dental work.
In some instances, men may
require the shaving of a small
amount of chest hair to obtain
optimal contact between the leads
and the skin

ECG is crucial for

Intra

establishing many

vector views of the

Cannot rule out

hearts electrical

lateral

activity as reflected by

infarction

electrical potential
differences between
positive and negative
electrodes placed in the

cardiac diagnoses,
especially arrhythmias
and myocardial

EKG leads are attached to the

body while the patient lies flat on
a bed or table. Leads are attached
to each extremity (four total) and
to six pre-defined positions on the
front of the chest. A small amount
19

ischemia.

of gel is applied to the skin, which

allows the electrical impulses of
the heart to be more easily
transmitted to the EKG leads.
Instruct that the test takes about
five minutes and is painless.

I. FUNCTIONAL ASSESSMENT
HEALTH PERCEPTION-HEALTH MANAGEMENT
Prior to admission, the patient tells his stressful schedule he had from his previous work.
The patient works everyday in midnight shift of from 12:00 am 9:00 am or up to 3:00 am
12:00 noon, in which has affected his health in general. Furthermore, the patient does not
consume multivitamins but does not experienced colds in the past 3 months as far as he could
remember.
The client is aware of the etiology of his illness and positively adheres to medical
advices. The client feels well unlike his first admission. That sobrang dilaw ko verbalized
by the patient as he exclaims his disbelief from the extent of his disease process. The client
claims that he acquired his disease during his infant years being exposed to PTB and learned
to exhibit an adverse reaction to Isoniazid back then. Presently, the Patient does not find any
difficulty on the advices given by doctors and nurses to him,he believes that by cooperating
and adhering on the medications would continually make her better and soon to be
discharged. The client adheres to therapeutic regimen of taking Essential Forte 1 tab T.I.D
and Silymarin Capsule T.I.D

SELF-ESTEEM, SELF CONCEPT/SELF PERCEPTION PATTERN

Before the patient was admitted, he sees himself being able to do things according to
the manner he wants it. He does not mind his health not until the manifestation of discomfort
brought from his disease. Presently, the client verbalized difficulty of being sick; he stated
that he will find it hard to adjust from it. The client admitted that his self-perception in his
body has changed, as he needs to be more conscious in taking care of himself such as
20

refraining from stressful situations, refraining from alcoholic beverages and smoking. The
client honestly verbalized a change of perception about self. That because of his condition,
job opportunities are lessened because of its permanent effects. Despite of it, though
Matatagalan nga lang ang pagkakawala ng paninilaw ko as verbalized by the client but He
affirms a positive prognosis to his health, the patient stated that he is looking forward to be at
home, and to make up the responsibilities that he had missed due to his absence.

ACTIVITY/EXERCISE PATTERN
Prior to confinement, the client describes his previous activities as stressful. the client
takes his OJT as being recently hired from that certain company. The client usually works
midnight around 12:00 am 9:00 am or 3:00am 12:00 pm . The client remarks his previous
activities as a form of exercise. His favorite sports are basketball and

. But he prefers to

stay at home and rest during his free time.

Presently, the patient is confined in the primary holding unit. The client assumes full
self care on himself. The client is on bed rest and does minimal activities. He states that he
would play games in his cell phone or listen to music to let the time pass. The client is noted
to be sleeping most of the time.
Feeding

Grooming

Bathing

Gen. Mobility

Toiling

House
maintenance

Bed mobility

Dressing

Legends:
Level 0 Self Care
Level I Use of equipments
Level II Assistance from another person
Level III Requires assistance from another person or device
Level IV Dependent and does not participate
SLEEP/REST PATTERN
The client has 9 hours of sleep and sleeps around 10 oclock in the evening and wakes up
around 8oclock in the morning. The client states that he feels full rested upon waking up. The
client has no difficulty of sleeping except from some external factors such as the noise of other

21

patients that he shares the ward with. The client does not use any sleeping pills but prefers to
play music in his radio to induce sleep. The client frequently naps in the morning.
NUTRITIONAL-METABOLIC PATTERN
The client eats three times a day with low salt and low fat diet, the client prefers to eat in
small frequent meals to prevent the pricking pain in his right upper quadrant and for the reason to
minimize the workload of his liver to digest nutrients. The client has poor appetite and
experienced weight loss of 3kg, from 58 kg to 55kg. There client is has food allergy in Eggplant,
Egg and Shrimp. The client drinks 7-8 glasses of water.
ELIMINATION PATTERN
The client states that he defecates once a day usually in the morning in soft brown stool
without difficulty and use of laxatives. The client urinates 4x day or more varying in his fluid
intake; he verbalizes no difficulty in voiding.
SEXUALITY/REPRODUCTIVE
The client is presently single for 6 months and is sexually inactive. He was circumcised
by the age of 11.
INTERPERSONALRELATIONSHIPS/RESOURCES

The client is the youngest son among his 3 siblings. The client verbalized that there has been
a problem faced by the family from the previous months, the presently affects the interpersonal
relationships between his siblings and parents. In terms of decision making, the client assumes
full responsibility of himself in terms of his personal issues. But when in terms to health and
other concerns affecting the family, the client considers the opinions of his family as well.
COPING & STRESS MANAGEMENT/ TOLERANCE PATTERN
The client states that whenever he feels frustrated, he would initially avoid the stressful
situation to deliberately think before making out judgments. He stated that he perceive problems
positively and would joke about it to help him relieve stress. .
VALUES/ BELIEFS
The client is an Islam since birth. However, he states that he does barely attend their
church and practice due to preoccupation to other things.

22

As of the present time, the client stated that his condition will eventually pass and he will
recover quickly.He stated that he will abstain from drinking alcoholic beverages, smoking, and
from over abusing his body.
J, PERSONAL/SOCIAL HISTORY
Habits: The client has the habit of smoking to past time, improve concentration or to help him
relive from experiencing anxiety and stress.
Vices: The client started drinking at the age of 13 of Beer as his alcoholic preference. The client
started smoking 4 packs of green Malboro cigarettes at age 13
Lifestyle: The client was known to live in a stressful lifestyle.
Clients usual daily life: The clients typical day is working as financial and corporate relations
in midnight then goes straight home for rest and preparation his next shift. the client would
watch DVDs or rest during his day offs.
Rank/Order in the family: the Client is ranked as the youngest son to his 3 siblings.
Travel: The clients known travel is from his home and to his work. The client has no previous
local and intonation travel for the past 6 months.

J. ENVIRONMENTAL HISTORY
The client lives together with his parents and siblings. The client describes his residency as a
compound where his extended relatives family lives. The client described their house as
bungalow type which is well ventilated and and adequate to live for household members of five.
The client stated that their home is adequately supplied by water, electricity and near from
establishments such as market, church and school. Environmental problems that were identified
are the presence of by standers who frequently drinks alcoholic beverages, and a semi talyer that
brings polluted air.
K. PEDIATRIC HISTORY
Maternal and Birth history
23

Birth date: April 5, 1986

Hospital: Not assessed

Birth Weight: Unrecalled

Type of Delivery: Normal Spontaneous Delivery
Condition after Birth: The client is born stable in condition

Mother:
Complications of Delivery: No known complications
Anesthesia during Labor: No known usage of anesthesia
Exposure to Teratogenic agents during pregnancy: No known exposure to teratogenic
agents

I.

PATHOPHYSIOLOGY
Adverse Drug Reaction 2 to anti-TB medications

PREDISPOSING
II.
FACTORS

Age

PRECIPITATING
FACTORS

Immunity

History of TB Prim0ary
Complex (1 y.o)
History of
hepatomegaly,purpura and
granuloma

Lifestyle
Smoking
Alcoholic
Stress

23 days of Medicating Isoniazid

AV BLOCK I
HEPATOXICITY

Elevated Liver
Function Tests

Impaired Liver Function

Impaired ability to
emulsify fat

Impaired water
regulation

Impaired Bilirubin
excretion 24

Insufficient
coagulating factors

Right Upper
Quadrant Pain

Imbalance in water
and sodium

Delayed Blood
Clotting

Hyponatremia

Elevated bilirubin
levels

Jaundice

Adverse Reaction 2 to Anti-TB medication

25

III.

CONCEPT MAPPING
1. Impaired liver function related to
hepatotoxic medication as evidenced
adverse reaction of Isoniazid

Adverse Reaction 2 to Anti-TB medication

Patient B.R; 25 y/o Male.
4. Disturbed body image
related to increased production
of Bilirubin as evidenced by
jaundice

Temp.: 36.1c RR: 14cpm PR: 64cpm BP: 110/70mmHg

23 days of taking isoniazid medications
Jaundice
Enteric sclera
Weight Loss from 58 to 55 kg
BMI of 18.5 (undewrweight)
Elevated Liver function tests, Bilirubin
CT Chest Scan result:
UZ result: Liver is likely contracted
Complaints of right upper quadrant pain after eating (P/S of 6/10)
Facial Grimace
Verbalization of negative perception to self

2. Acute pain related to

inflammation and swelling of
the liver as evidenced by pain
in right upper quadrant

3. Imbalance Nutrition: Less than

body requirements related to
inability to digest adequate
nutrients

26

IV.

PROBLEM LIST
Actual

Problem

Problem

Remarks

Number
Impaired liver function related

The client exhibited an abnormally elevated

to hepatotoxic medication as

Liver Funtion tests, indicating an impaired

evidenced adverse reaction of

liver funtion.

2
Isoniazid
Patient has complaints of right upper quadrant
pain after eating or belching. The problem is
3

Acute pain related to

suspected to persist to impairment of the liver.
inflammation and swelling of
the liver as evidenced by pain in There is a decrease in weight due to feeding
right upper quadrant

modifications caused by his present liver

impairment. Thus, the client is unable to

Imbalance Nutrition: Less than

nourish his body in desireable range (BMI of

body requirements related to

18. 5) Weight loss is clearly evident due to the

inability to digest adequate

fall of his weight from to 58 kg to 55kg

nutrients
Impairement in the liver has caused difficulty
excretion of metabolic waste such as
bilirubin, such excessive amount of bilirubin
manifested from the clients yellowish
discoloration of skin, sclera and nail beds.

27

Disturbed body image related to

increased production of
Bilirubin as evidenced by
jaundice

28

V.

NURSING CARE PLAN

Cues/Needs

Nursing
Diagnosis
Impaired liver
function
related to
hepatotoxic
medication as
evidenced
adverse
reaction of
Isoniazid

Subjective:
kahit ng bata pa ako,
naninilaw ako sa pag
umiinom ako ng
Isoniazid as
verbalized by the
patient

Objective:
With history of of
taking isoniazid
for23 days
medications
Jaundice
Enteric sclera
Elevated Liver
function tests,
AST =3603 u/L
ALT = 3933 u?L
Bilirubin: 433.50
umol/L
UZ result: Liver is
likely contracted

Planning

Implementation

Rationale

After 2 weeks Review results by obtaining

of nursing
previous Liver Function
intervention,
Tests such as SGPT, SGOT,
there will be a
Creatinine, Alkaline
decrease
Phosphtase
manifestation of
liver failure as Emphasize the importance of
abstaining any forms of
evidenced by an
alchoholic beverages
improvement in
liver function
results from

Encouraged client to avoid

previous
eating deep fried foods,
examinations.
chicken skin, chicharon
which are high in fats

Administered hepato
protectors and
multivitamins as orderesd
a.) Silymarin
b.) Essential Forte
c.) Mutivitamns
Emphasized the need for
follow-up check-ups and
ahering to monitoring of
Liver function tests such as

Indicates presence of hepatotoxic

medication and need for medical
treatment.

To reduce incidence of cirrhosis or

severity f liver damage/failre

To prevent aggravation of disease.

Liver is responsible for fat
emulsification

Evaluation
After 2 weeks of
nursing
intervention,
Liver function
test taken last
October 31.2011
decreased as of
result taken last
November
19,2011
AST = 104 (n:
15-37)
ALT =268 (n:3065)

To promote pharmacologic
treatment of disease

To monitor and determine

effecitiveness of therapeutic
regimen

29

SGPT, SGOT, Creatinine,

Alkaline Phosphtase

Cues/Needs
Subjective:
Sumasakit ang
tsyan ko sa tuwing
nakain ako as
verbalized by the
patient

Objective:
Pain Scale of 6/10
With complaints of
pain after meal
or during
Facial grimace

Nursing
Diagnosis
Acute pain
related to
inflammation
and swelling
of the liver
as evidenced
by pain in
right upper
quadrant

Planning

Implementation

\.

Rationale

By the end of Monitored Vital signs q 30 until the Baseline data is important to help
8 hours of
patient
stable
especially Determine patients current health
nursing
respiratory rate and blood status and evaluate efficacy of
intervention,
nursing interventions rendered
pressure
the
Patient will Assess the patients pain by using The clients report of pain is the
verbalize a
the 10 point pain rating scale q4 single most reliable indicator of
decrease in
hrs or PRN during the 2-10pm pain.
pain scale
shift.
from 6/10 to
0/10
Pain is a subjective experience and
Performed comprehensive
must be described by the client in
assessment to pain include
order to plan effective treatment
location \, characteristic, onset,
duration, frequency,
quality, intensity or

Evaluation
By the end of
8 hours of
nursing
intervention,
the
Patient will
verbalized a
decrease in
pain scale from
6/10 to 0/10

severity

Provided nonpharmacologic pain

relief methods, such as breathing
exercises, music therapy,
distraction and progressive
relaxation before, after, and if
possible during painful activities.

Relaxation techniques decrease

oxygen consumption, respiratory
rate, heart rate, and muscle tension,
which interrupt the cycle of pain
anxietymuscle tension.

30

 Kept side rails up and bed in low

position.

Administered Pain medications as

ordered such as Tramadol

Cues/Needs
Subjective:
Ang lake pa ng
katawan ko dati
kumpara sa
ngayon. ang lake
talaga ng
pinangayat ko
as verbalized by
the patient
Objective:
Weight Loss
from 58 to 55
kg
BMI of 18.5
(undewrweight
)
Complaints of

Nursing
Diagnosis
Imbalance
Nutrition:
Less than
body
requirement
s related to
inability to
digest
adequate
nutrients as
evidenced
by BMI of
18.5

Planning

To reduce likelihood of falls and to

promote a safe environment.

To promote pharmacologic
measures in relieving pain

Implementation

After 4 hours of Assessed the present weight of the

nursing
client by the use of weighing scale
intervention, the
Determined the clients attitude

patient will
towards eating.
verbalize
understanding on
the importance
of proper diet
Educated the client regarding
the importance of eating
healthy foods in terms
of benefits to his body such
as green leafy
vegetablesfoods, citrus
fruits such as dalandan,
orange, calamansi juice,
bayabas to increase the

bodysimmunity

Rationale
Provides baselinedata about the
client.
Psychological factors towards
eating may affect one persons
appetite and also to know the
clients eating habits.
Education provides ample
information that the client may
not be aware 8of, hence leading
to the kind of eating habits and
diet he is following.

Evaluation
After 4 hours
of nursing
intervention,
the patient
verbalized
understanding
on the
importance
of proper diet

Caffeinated beverages may

decrease the appetite and will
make the client feel full easily
31

right upper
quadrant pain
after eating

Cues/Needs

Nursing
Diagnosis
Subjective:
Disturbed body
Ang panget
image related to
kong tignan,
increased
para na akong
production of
spongebob as
Bilirubin as
verbalized by the evidenced by
patient
jaundice

Instructed the client to avoid

caffeineated beverages like To minimize occurances of right
upper quadrant pain by
coffee, tea, softdrinks and
reducing the workload of the
energy drinks.
liver
Encourged the client to eat in small
To prevent aggravation of
frequent feeding
disease. Liver is responsible for
Instructed the patient to
fat emulsification and water
sodium-regulation
avoid foods rich in fats
found in deep fried foods,
chicken skin, chicharon and To assist as needed and to
offer support and
foods rich in salt such as
encouragement.
Canned goods and procesed
meats
Seasoned foods
Dried fish
Stayed with client during
meals.
Planning
Implementation
At the end of Observed emotional
changes.
8 hours of
nursing
intervention Assess mental and physical influence of
the client will
present condition on the clients
verbalize
emotional state
understandin
Established therapeutic nurse-client
g of body
relationship
changes.

Rationale
May indicate acceptance
or non-acceptance of
situation.
To determine factors
influencing emotional
state

Evaluation
After 8 hours of
nursing
intervention the
client
verbalized
understanding
of body
changes.

Objective:
32

Regognized behaviours indicative of

over concern with body and its process

Verbalization
of negative
perception to
self
With
jaundice and
enteric sclera

Encourage verbalization of concerns of

disease process, future expectations.
Invovle patient in planning care and
scheduling activities
Assessed clients current level of
adaptation and progress.
Assist with grooming needs as necessary.

Conveys an attitude of
caring and to develop a
sense of trust
Serves as objective cues to
determine extent of

Provides opportunity to
identify fears/mis-concept
and deal with them
directly.
Enhances of feeling of
competency/self worth.
Encourages independence
and participation in
therapy
To determine coping
abilities and skills

Cues/Needs
Subjective:
Matatagalan pa bago
bumalik ang kulay ko as
verbalized by the patient
Objective:

Nursing
Diagnosis
Risk for
situational low
self-esteem
related to
disturbed body
image as

Planning
After 2 weeks
of nursing
intervention,
the patient will
acknowledge
factors that

Implementation

Determined

individual factors that

would contirbute in
diminishing selfesteem

Maintaining appearance
enhances self-image.
Rationale
Evaluation
Adverse reaction of
medicating Isoniazid
has caused yellowish
discoloration of skin

After 2 weels of nursing

intervention, the patient
verbalized
acknowledgement of
factors that contributes to
feelings of low self-esteem
33

With Jaundice, Enteric

Sclera and Yellowish
Nail beds

evidenced by
Jaundice

lead to
possibility of
feelings of low
self-esteem

Determined client
awareness of own
responsibility for
dealing with
situation, personal
growth and so forth

To detemine
awareness of
situation to detemine
the individuals
coping skills

Assessedfore
presence of negative
attitudes or self-talk

Contributes to view
of situation as
hopeless/ difficult

Observed non-verbal
languanges

Incongruencies
between verbal and
non-verbal
communication
requires clarification

Assesed family
To determine
dynamics and support
adequate spport
of client
system of the patient
Provide information
about disease process, To help the patient
prognosis, and
alleviate the emotional
treatment needs.
disturbances that hes
Enhance self-concept,
feeling and for the
acceptance of situation
patients faster
recovery and will do
no further harm.

34

MEDICAL-SURGICAL MANAGEMENT
i.
DRUG NAME

Pharmacotherapeutics

Among the pharmacodynamic

Acute, subacute &

SIDE
EFFECTS
Abdominal pain,

properties were reported

chronic

nausea, diarrhea

in hypersensitivity or all

hepatoprotective effects found in

hepatitis; toxic

and allergic

ergy to any ingredients

numerous experimental models into

metabolic liver

reaction(skin

of the preparation.

Essential Forte

acute liver damage eg, induced by

diseases, intoxications

rash)

Classification:

ethanol, alcyl alcohol, carbon

(eg from

tetrachloride, paracetamol and

drugs); infection, fatty

galactosamine. Moreover, in

degeneration of the liver

Dosage:

chronic models (ethanol,

due to

1 tab

thioacetamide, organic solvents),

alcohol, hypernutrition,

the inhibition of steatosis and

DM,

fibrosis was also seen. As active

kwashiorkor, pregnancy;

principle has been suggested

cholestasis; pre- & post-

accelerated membrane regeneration

op care,

and stabilisation, inhibited lipid

esp in liver/gallbladder

peroxidation and inhibited collagen

surgery

Brand Name:

Brand Name:

Hepatic Protectors

MECHANISM OF ACTION

INDICATION

NURSING IMPLICATION
Do not use Essentiale

synthesis.
35

DRUG NAME
Generic Name:

Contains fat soluble vitamins (A, D

Treatment and

SIDE
EFFECTS
GU: Urine

Theravim

and E) and most water-soluble

prevention of vitamin

Discoloration

nutrition deficiency prior to

vitamins (B-Complex vitamins B1,

deficiencies.

MISC: Allergic

and throughout therapy.

B2, B3, B5, B6, B12, Vit. C, biotin

Dietary supplement for

reactions to

Instruct to notify side effects

and folic acid). These vitamins are a the treatment and

preservatives,

of medication to physician.

diverse group of compounds

prevention of vitamin

additives or

Encourage to comply on

necessary for normal growth and

deficiencies. These

colorants.

medication.

development. Many act as

vitamins are necessary

coenzymes or catalysts in numerous

for normal growth and

Contraindicated

Vitamins and

metabolic processes. Liquid

development. Many act

in ypersensitivity recommendations. Explain

Supplements

products do not contain folic acid.

as coenzymes or

to preservatives,

that the best source of

catalysts in numerous

colorants, or

vitamins is a well balanced

metabolic processes

additives,

diet with foods from the 4

including

basic food groups.

Brand Name:
Multivitamin
Classification:

Dosage:
1 tab

MECHANISM OF ACTION

INDICATION

NURSING IMPLICATION
Assess patient for signs of

Encourage patient to comply

with physicians

tartrazine,
saccharin, and
aspartame

36

DRUG NAME
Brand Name:
Silymarin
Brand Name:
Liveraide
Dosage:
1 tab

MECHANISM OF ACTION

INDICATION

SIDE
EFFECTS
Liver Cell Growth-Silymarin from -Liver Diseases, acute, Common:
milk thistle appears to promote the chronic hepatitis
Diarrhea caused
growth of some types of cells in the - Protect liver from by mild laxative
liver. Milk thistle is not used to prevent toxins, heavy metals, effect, uterine
and menstrual
Hepatitis C Virus from causing liver
alcohol, poisons
stimulation.
disease. Rather, milk thistle is used
- Cholagogue
with the hope that it would minimize
the damage to the liver that HCV can - Fatty degeneration of Case report: One
report of a
the liver
cause.
patient who
Antihepatotoxic
Activity-Studies - Jaundice
experienced
suggest that silymarin from milk thistle - Psoriasis
intermittent
can block various types of toxins from Uterine
tonic,
episodes of
entering and injuring liver cells.
menstrual difficulties
sweating,
Antioxidation-Milk thistle Silymarin - Spleen, kidney, gall
nausea,
may be an effective "antioxidant," bladder tonic
vomiting,
which means milk thistle may help - Varicose veins
diarrhea,
fight a destructive chemical process in
abdominal pain,
the body known as "oxidation." In
weakness and
oxidation,
harmful
substances
collapse that
produced in the body (called free
resolved after
radicals) can damage cells. Some
discontinuation
studies suggest that milk thistle
of supplement.

NURSING IMPLICATION

Know the 10 rights in giving

medication

Observe proper position in

taking medication to prevent
aspiration
Encourage patient drink
plenty of water to enhance
absorption
Encourage patient to comply
to
the
physicians
recommendation concerning
about the drug.

silymarin can prevent these substances

from damaging liver cells.
Inflammation
Inhibition-Milk
thistle's Silymarin is thought to prevent
inflammation (swelling) of the liver;
this may be described as displaying
anti-inflammatory properties.

37

DISCHARGE HEALTH TEACHING

Content
M-medication
Multivitamins
Silymarine
Liveraid.

To adhere in prescribed
therepautic regimen for health
maintainance and resistance.

Strategy
Instruct patient to take the prescribed
medications

as

ordered

by

the

physician.
Instruct patient to avoid taking OTC
drugs unless given with medical
advice

E-exercise

To promote a healthy
lifestyle, maximizing the

minutes of

level of health and increase

perfrom

the bodys immunity.

activities as a means of exercise

Attending the follow up

T-treatment

Encourage patient to include atleast 30

check up.

walking or jogging or

tolerated

and

preferred

Encourage patient to attend follow up

check up of Liver Function Tests to
determine

the

progression

or

aggravation of disease

Health teaching about the

disease, exercise and diet.

Instruct the patient toavoid all forms

of vices that could affect his health
status especially such habits that are

Instruct that they need to have

hepatotoxic
cigarettes

liver
and

like
drinking

smoking
alcohol
38

H-health teaching

a health check up.

beverages.
Emphasize the importance of adhering

O-OPD

Maintain and ensure adequate

to medications and attending follow-

intake for noursihment,

up check up.

If any signs of symptoms are

Instruct patient to eat in small frequent

present go to the nearest

feeding to reduce work load of liver

Instruct patient to avoid consumption

hospital for check up.

of salty and fatty foods. .
Advise patient to refer to health care
professional if jaundice, right upper
pain and other discomforts persists.

D-diet

S-signs and symptoms

VI.

ONGOING APPRAISAL
Patient B.R, a 25 year old male, has been admitted to Ospital ng Makati last October 31,

2011 with the chief complaint of jaundice and on and off fever. Upon assessment, it was
observed that the patient is conscious, with generalized jaundice and with enteric sclera.
Thus, was diagnosed to have a drug-induced hepatitis. The client is admitted in Emergency
Room and inserted of D5LR 1 L x 125cc/hr at left metacarpal vein with laboratory tests
39

rendered such as HbsAg taken on October 31, 2011 and resulted as non-reactive, but
observed to have elevated AST of 3603 u/L (n= 15-37), ALT of 3933 u/L (n=30-65), Alkaline
Phosphatase of 190u/L (n=50-165 u/L). ECG taken on same date reveals to have AV block I,
CBC, Na, K, BUN, ultrasound and Chest X-Ray are taken likewise.
Blood coagulation test done at November 1, 2011 with an increase of Prothrombin time
of 27.7 sec (n=10.4-14 sec), INR (2.78 n= 0.88-1.21), PTT of 75 sec (n =30.4-41.2 sec). The
client is ordered for low salt and low fat diet. Abdominal ultrasound reveals liver to be likely
contracted, suggests follow-up scan after 3 days.
. By November 2, 2011, Blood Coagulation tests were repeated and ordered for TPAG.
The client is prescribed with Vitamin K 1 amp Q8 x 3 doses; regulate IVF for 1 L x 100cc/hr
and for repeat of ultrasound. From the subsequent weeks upon admission the The client
complaints of body malaise, fever and loose of appetite
By November 5, latest ultrasound reveals same result like before. By November 15, 2011,
patient claims to have pricking right upper quadrant pain and was given Tramadol 500 mg
tab. by November 16, 2011 the client was ordered for chest x-ray Postero-Anterior View
Lateral, and chest CT scan and Repeat AFB
Presently, the client is for discharge with latest liver function test taken last November 19,
2011. The client appears jaundice, with enteric sclera and yellosih nail beds with vital signs
of Temp.: 36.1c RR: 14cpm PR: 64cpm BP: 110/70mmHg.

40

41