A CASE STUDY PRESENTATION ON

HIRSCHSPRUNG DISEASE
`

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

Andig, Hussam
Cailing, Genilou
Canono, Ena Katherine
De Guia, Cher Kelly
Dimas, Norainah
Geographia, Kristyne Daphnie
Macabangun, Jamal
Macmod, Ommayah
Nacasabog, Nichole Julienne
Panalondong, Farhana
Tactaquin, Hiedralyn Gwen

OCTOBER 2019
 TABLE OF CONTENTS

PAGES
I. TITLE PAGE i
II. TABLE OF CONTENTS ii
III. LIST OF TABLES iii
IV. LIST OF FIGURES iv
V. OBJECTIVES 1
General Objectives
Specific Objectives
VI. DEFINITION OF TERMS 2
VII. INTRODUCTION OF THE CASE 3
VIII. NURSING HEALTH HISTORY 5
Vital Information 5
History of Present Health Concern 4
Past Health History 4
IX. DISCHARGE PLAN 29
X. REFERENCES 30
XI. APPENDICES 31
Diagnostic Test
XII. CONCEPT MAP

ii
 LIST OF TABLES
TABLE PAGE
1. Physical Examination and Review of Systems of Superman 8
2. Gordon’s Functional Health Pattern Assessment 9
3. Developmental Level 10
4. Normal Anatomy and Physiology 11
Nursing Care Plans
5. Acute Pain 13
6. Imbalanced Nutrition: Less Than Body Requirements 18
7. Constipation 20
8. Risk for Compromised Family Coping 22
9. Drug Study 23

iii
 LIST OF FIGURES
FIGURE PAGE
1. Genogram Showing the Family History of Superman 7

iv
 1

OBJECTIVES
General Objective:

At the end of one and a half - hour case presentation, the participants will be able to

demonstrate knowledge regarding the general health and disease process of the patient with

Hirschsprung’s disease and its management.

Specific Objectives:

At the end of one and a half-hour case presentation, the participants will be able to:

1. Accurately present a thorough general assessment of the client which includes physical

assessment and family history taking;

2. Understand the pathophysiology and etiology of the case being presented;

3. Create a concept map for the said disease;

4. Efficiently provide appropriate and proper nursing diagnosis in line with the client’s

medical condition, skillfully formulate nursing care plans for the problems identified and;

5. Construct a discharge plan.

 2

DEFINITION OF TERMS

Constipation. Infrequent bowel movements or difficult passage of stools that persists for several
weeks or longer. Constipation is generally described as having fewer than three bowel movements
a week.
Down syndrome. Also known as trisomy 21. A genetic disorder caused by the presence of all or
part of a third copy of chromosome 21. It is usually associated with physical growth delays, mild
to moderate intellectual disability, and characteristic facial features.
Enterocolitis. An inflammation of the digestive tract, involving enteritis of the small intestine and
colitis of the colon. It may be caused by various infections, with bacteria, viruses, fungi, parasites,
or other causes.
Hirschsprung disease (HSCR). A birth defect. This disorder is characterized by the absence of
particular nerve cells (ganglions) in a segment of the bowel in an infant. The absence of ganglion
cells causes the muscles in the bowels to lose their ability to move stool through the intestine
(peristalsis).
Neonates. A newborn baby, specifically a baby in the first 4 weeks after birth. After a month, a
baby is no longer considered a neonate.
Peristalsis. A series of wave-like muscle contractions that moves food to different processing stations in
the digestive tract.

Pneumonia. An infection that inflames the air sacs in one or both lungs. The air sacs may fill with
fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty
breathing.
Soave procedure. A way to avoid the risks of injury to pelvic structures inherent in the
Swenson procedure. The Soave procedureconsists of removing the mucosa and submucosa of the
rectum and placing the pull-through bowel within a “cuff” of aganglionic muscle.
Streptococcus pneumoniae (pneumococcus). Gram-positive bacterium that is responsible for the
majority of community-acquired pneumonia. It is a commensal organism in the human respiratory
tract, meaning that it benefits from the human body, without harming it.
 3

INTRODUCTION

The gastrointestinal (GI) system is so long and so diverse, a multitude of possible disorders

can occur along the tract, including both congenital disorders and acquired illnesses. The GI

system is responsible for taking in processing nutrients for all parts of the body, any problem with

the system can quickly affect other body systems, and if not adequately treated, can affect overall

health, growth, and development.

According to Pillitteri (2014), Hirschsprung disease, or aganglionic megacolon, is an

absence of ganglionic innervation to the muscle of a section of the bowel, in most instances, the

lower portion of the sigmoid colon just above the anus. The absence of nerve cells means there are

no peristaltic waves in this section to move fecal material through the segment of the intestine.

This result in chronic constipation or ribbonlike stools (stools passing through such a small, narrow

segment look like ribbons). The incidence of aganglionic disease is higher in the siblings of a child

with the disorder than other children. It also occurs more often in males than in females. It is caused

by an abnormal gene on chromosome 10. The incidence is approximately in 1 to 5,000 births.

As mentioned by Wong’s, Hirschsprung disease is a congenital anomaly that results in

mechanical obstruction from inadequate motility of part of the intestine. It accounts for about one

fourth of all cases of neonatal intestinal obstruction. The incidence is in 1 to 1,500 live births. It is

four times more common in males than in females and follows a familial pattern in a small number

of cases. Hirschsprung disease is associated with other anomalies such as Down syndrome. It may

be an acute, life-threatening condition or a chronic disease.

Clinical manifestations vary according to the age when symptoms are recognized, the

length of the affected bowel, and the occurrence of complications such as enterocolitis. In the

newborn period, abdominal distention, vomiting, constipation, and failure to pass meconium

within the first 48 hours of life are likely to occur. Neonates may also have signs of acute intestinal

obstruction, including abdominal distention that is relieved by rectal simulation or enemas.

The majority of children with Hirschsprung disease require surgery rather than medical

therapy with frequent enemas. Once the child is stabilized with fluid and electrolyte replacement,

if needed, surgery is performed, with a high rate of success.

 4

In the Philippines, Hirschsprung’s Disease ranks 9th over the top 10 cases causing

morbidity to Filipino children and the mortality rate can reach up to 50%. The treatment is still

surgery, such as Soave procedure. The Soave procedure consists of removing the mucosa and

submucosa of the rectum and placing the pull-through bowel within a “cuff” of aganglionic

muscle.

The purpose of this study is to further understand the interesting and rare disease that any

newborn could ever have. This study will be useful in the future, as we encounter different kinds

of diseases especially the rare ones.

 5

NURSING HEALTH HISTORY

VITAL INFORMATION

Code name: Superman

Age: 4 months old

Gender: Male

Civil status: Child

Date of birth: May 18, 2019

Place of birth: St. Mary Maternity, Iligan City

Race: Asian

Cultural or Ethnic Background/Group: Maranao

Religion: Islam

Usual health care provider/s: Dr. Nadal

Date of admission: September 29, 2019

Date of discharge: October 03, 2019

Source/s of history: 70% parents/guardians, 30% chart

Reason/s for seeking health care: Abdominal distention

Primary attending physician: Dr. Nadal

Consultants/Specialists: Dr. Sta Maria, Dr. Rasul

Initial Impression/Diagnosis: Gastrointestinal obstruction probably secondary to Hirschsprung

Disease

Final Diagnosis: Hirschsprung Disease

 6

HISTORY OF PRESENT HEALTH CONCERN

3 days PTA, onset of change in bowel habits, noted with yellowish, formed stools. This

was associated with abdominal distention and was not associated with decrease in appetite. One

day PTA, symptoms persisted now associated with intermittent fever, undocumented, no

medications given, no consult done, this was also associated with decrease in appetite. Hours PTA

patient was given Restime one dose. Persistence prompted admission.

PAST HEALTH HISTORY

Immunizations: (/) BCG

(/) Hepa

(/) DPT

(/) Pneumococcal

Allergies: None

Recent concern: Constipation (2019)

 7

Figure 1. GENOGRAM SHOWING THE FAMILY HISTORY OF SUPERMAN

65 64 63 60

40 38 30 28 35 33 31 27 25 21

8 7 6 5 3 2 4 m/o

Diabetes
Male
LEGEND: Hirschsprung Disease
Female Patient
 8

Table 1
PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS OF SUPERMAN

AREAS ASSESSED OBJECTIVE FINDINGS PROBLEM IDENTIFIED

INTUGEMENTARY  Warm to touch FLUID VOLUME EXCESS
SYSTEM  Sclerema
HEENT HEAD IMPAIRED ORAL AND
 Normocephalic NASAL MUCOUS
 No lesions MEMBRANE
EYES
 Anicleric sclera
 Pink conjunctiva
EARS
 No deformities
 No discharges
NOSE
 Septum midline
NECK
 Supples
 No lymphadenopathy
THROAT
 No tonsillar
enlargement
MOUTH
 Dry lips
RESPIRATORY SYSTEM  No retractions
 Clear breath sounds
CARDIOVASCULAR  Regular rate and
SYSTEM rhythm
 No murmurs
GASTROINTESTINAL  Abdominal distention ACUTE PAIN
SYSTEM  Constipation
 Change in BM CONSTIPATION
 Hypoactive bowel
sounds ALTERED BOWEL
 Soft to touch ELIMINATION

IMBALANCED
NUTRITION: LESS THAN
BODY REQUIREMENTS
NEUROMUSCULAR  Good peripheral
SYSTEM pulses
 Motor 5/5
 Normal bulk
 Normal tone
 No seizures
 9

Table 2
GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT
Health Pattern Before Hospitalization During Hospitalization

1. Health Perception and Health Improved condition still in

Improved health condition
Management Pattern close monitoring

2. Nutrition and Metabolism Breastfed for 3 months

NPO
Pattern Complementary food - cerelac

3 days PTA : yellowish formed

stool Defecated once (small,
3. Elimination Pattern
1 day PTA: Experienced yellowish, watery)
constipation

4. Activity and Exercise Pattern Rolls over the bed Lying on bed

5. Cognition and Perception

N/A N/A
Pattern

6. Sleep and Rest Pattern 3 days PTA : restless Improved sleeping pattern

7. Self-Perception and Self-

N/A N/A
Concept Pattern

8. Roles and Relationship

Bonds with parents and siblings Less interaction
Pattern

9. Sexuality and Reproduction

N/A N/A
Pattern

10. Coping and Stress Tolerance

N/A N/A
Pattern

11. Values and Belief Pattern N/A N/A

 10

Table 3
DEVELOPMENTAL LEVEL

REGARDS 2 mos

SOCIAL SMILE 2 mos

GOOD HEAD 2 mos

CONTROL
ROLLS OVER 3 mos

SITS ALONE --

CRAWLS --

FIRST TEETH --

STANDS ALONE --

WALKS ALONE --

FIRST WORD --

RUNS --

BLADDER TRAINING --

BOWEL TRAINING --

COUNT 1 TO 10 --

KNOWS FULL NAME --

 11

Table 4
NORMAL ANATOMY AND PHYSIOLOGY OF THE DIGESTIVE SYSTEM
ORAL CAVITY Mostly known as Mouth, is the first part of the
digestive tract. It is bounded by the lips and
tongue.
PHARYNX Mostly known as Throat, which connects the
mouth with the esophagus, consists of three
parts: The nasopharynx, the oropharynx, and
the laryngopharynx. Normally, only the
oropharynx and laryngopharynx transmit food.
SALIVARY GLANDS There are three major parts of salivary glands:
The parotid, submandibular, ad sublingual
glands. Salivary glands produce saliva, which
is a mixture of serous and mucous fluid.
ESOPHAGUS A muscular tube, lined with moist stratified
squamous epithelium, which extends from the
pharynx to the stomach. About 25 cm long and
lies anterior to the vertebrae and posterior to
the trachea within the mediastinum.
STOMACH An enlarged segment of the digestive tract in
the left superior part of the abdomen. The
opening from the esophagus into the stomach
is called the gastroesophageal opening. The
region of the stomach around the
gastroesophageal opening is called the cardiac
region because it is near the heart. The most
superior part of the stomach is the body, which
turns to the right, forming a greater curvature
on the left and a lesser curvature on the right.
The opening from the stomach into the small
intestine is thy pyloric opening, which is
surrounded by a relatively thick ring of smooth
muscle called pyloric sphincter. The region of
the stomach near the pyloric opening is the
pyloric region. The submucosa and mucosa of
the stomach are thrown into large folds called
rugae.
PANCREAS Located retroperitoneal, posterior to the
stomach in the inferior part of the left upper
quadrant. It has a head near the midline of the
body and a tail that extends to the left, where it
touches the spleen.
SMALL INTESTINE About 6 meters long and consists of three
parts: The duodenum, jejunum, and the ileum.
The duodenum, is about 25 cm long, the
jejunum, is about 2.5 m long and makes up
two-fifths of the total length of the small
intestine. The ileum, is about 3.5 m long and
makes up three-fifths of the small intestine.
LARGE INTESTINE Consists of the cecum, colon, rectum, and anal
canal. Cecum, the proximal end of the large
intestine where it joins with the small intestine
at the ileocecal junction. Colon, about 1.5-1.8
cm long and consists of four parts, the
ascending colon, transverse colon, descending
 12

colon, and sigmoid colon; ascending colon,

extends superiorly from the cecum to the right
colic flexure, near the liver, where it turns to
the left, transverse colon, extends from the
right colic flexure to the left flexure near the
spleen where the colon turns inferiorly,
descending colon, extends from the left colic
flexure to the pelvis where it becomes the
sigmoid colon.
LIVER Weighs about 1.36 kg and is located in the
right upper quadrant of the abdomen, tucked
against the inferior surface of the diaphragm.
GALLBLADDER A small sac on the inferior surface of the liver
that stores ad concentrates bile.
APPENDIX A sac that extends inferiorly about 6 cm past
the ileocecal junction and attached to the
cecum is a tube about 9 cm long called
appendix.
ANUS External digestive tract opening.
 13

Acute Pain

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE

Subjective: Acute pain SHORT TERM

“May nararamdamang sakit OUTCOME:
ang anak ko.” as verbalized
by the mother.
Within 2hour of nursing
Objective: interventions, the SO of the
Irritability patient will verbalize
Pain scale using EVENDOL understanding the cause of
and CHIPS the pain.
LONG TERM
OUTCOME:
Within 2days of nursing
interventions, the SO will
notice that the patient is in
comfort feeling.
 Foresee the need for pain relief. 
 One’s perception of time may
 Acknowledge reports of pain
immediately.
Preventing the pain is one thing
that a patient experiencing it can
consider. Early intervention may
decrease the total amount of
analgesic required.
become distorted during painful
experiences. Pain can be
aggravated with anxiety and fear
especially when pain is delayed. An
immediate response to reports of
pain may decrease anxiety in the
patient. Demonstrated concern for
the patient’s welfare and comfort
fosters the development of trusting
relationship.

 Patients may experience an

exaggeration in pain or a decreased
ability to tolerate painful stimuli if
environmental, intrapersonal, or
 Get rid of additional stressors or intrapsychic factors are further
sources of discomfort whenever stressing them.
possible.
 One’s experiences of pain may
become exaggerated as a result of
exhaustion. Pain may result in

 Provide rest periods to promote
relief, sleep, and relaxation.
 Determine the appropriate pain
relief method.
Pharmacological methods include
the following:
 Nonopioids (acetaminophen), a
nonselective NSAID, or a
selective NSAID (e.g.,
cyclooxygenase [COX]-2
inhibitor)
 Opioid analgesics
14
fatigue, which may result in
exaggerated pain. A peaceful and
quiet environment may facilitate
rest.
 Patients with acute pain should be
given a nonopioid analgesic
around-the-clock unless
contraindicated.
 NSAIDs work in peripheral tissues.
Some block the synthesis of
prostaglandins, which stimulate
nociceptors. They are effective in
managing mild to moderate pain.
 Opioids may be administered
orally, intravenously, systemically
by PCA systems, or epidurally
(either by bolus or continuous
infusion). Intramuscular injections
are not reliably absorbed. Opioids
are indicated for severe pain,
especially in the hospice or home
setting.
 Local anesthetics block pain
transmission and are used for pain
in specific areas of nerve
distribution.

 Local anesthetic agents
 The aid of an imagined event or a
Nonpharmacological methods
include the following:
Cognitive-behavioral strategies as
follows:
 Imagery
 Distraction techniques
 Relaxation exercises,
biofeedback, breathing
exercises, music therapy
Cutaneous stimulation as follows:
 Massage of the affected area
when suitable
15
mental picture involves use of the
five senses to divert oneself from
painful stimuli. Increasing one’s
concentration, these techniques
help an individual decrease the pain
experience. Breathing
modifications and nerve
stimulations are some of the
methods. The aim of these
techniques is to lessen the stress,
tension, subsequently decreasing
the pain.
 A massage traps pain
transmission, increases endorphin
levels, and minimizes tissue
edema. This method requires
another person to perform the
massage.
 TENS demands the application of
two or four skin electrodes. Pain
modulation happens through a
mild electrical current. The
patient is able to control the

 Transcutaneous electrical nerve
stimulation (TENS) units
 Hot or cold compress
 Provide analgesics as ordered,
evaluating the effectiveness and
inspecting for any signs and
symptoms of adverse effects.
 Report to the physician when
interventions are unsuccessful
and ineffective.
16
intensity and frequency of the
electrical stimulation.
 Heat decreases pain through
improved blood blow to the area
and through reduction of pain
reflexes. Cold lessens pain,
inflammation, and muscle
spasticity by decreasing the
release of pain-inducing
chemicals and regulating the
conduction of pain impulses.
 Effectiveness of pain medications
must be evaluated individually
because it is absorbed and
metabolized differently by
patients. Analgesics may cause
mild to severe side effects.
 Patients who demand pain
medications at more frequent
intervals than prescribed may
actually require higher doses or
more potent analgesics.
 Patient may give up trying to cope
with pain when he or she
perceives pain as everlasting and
unresolvable.
 17

 Unexpected IV incompatibilities
 Remind the patient that pain is may occur.
limited and that there are other
approaches to minimizing pain.
 Improper use of an epidural
If the patient is on PCA:
catheter can result to neurological
 Restrict the use of an IV line for injury or infection.
PCA only; ask a pharmacist
before combining other drugs
with opioids being infused.

If the patient is receiving epidural

analgesia:
 Label all tubing (e.g., epidural
catheter, IV tubing to epidural
catheter) clearly to prevent the  This prevents inadvertent
accidental administration of analgesic overdosing.
unseemly fluids or drugs into
the epidural space.
 These drugs reverse the opioid
For the patient with PCA or
epidural analgesia: effect in case of respiratory
depression.
 Place a “No additional
analgesia” warning over the
bed.

 Keep Narcan or other opioid-

reversing agents readily
available.
 18

Imbalanced nutrition: less than body requirements

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective: Imbalanced nutrition, SHORT TERM GOAL: Independent: SHORT TERM
“Hindi na nakakain ang less than body OUTCOME ACHIEVED:
anak ko.” as verbalized requirements, related Within several hours of  Assessed patient’s  To establish baseline
by the mother. to inability to procure nursing interventions, the weight on admission. parameter of weight. After several hours of
adequate amount of patient will be able to nursing interventions, the
Objective: food secondary to demonstrate increased  Weight patient daily on  To document the weight patient was able to
 Altered bowel loss of appetite. appetite. regular intervals. gain/loss of the patient. demonstrate increased
sounds. appetite.
 Reports of LONG TERM GOAL:  Noted age, body build,  This helps in determining
abdominal pain strength, activity and rest the nutritional needs of the
or cramping. Within 2days of nursing level. patient. LONG TERM
 V/S taken as interventions, the patient OUTCOME ACHIEVED:
follows: will be able to develop  Evaluated total daily  To reveal possible changes
T – 36.5 normal weight and height food intake. that could be made in After 2days of nursing
P - 130 appropriate for his age. patient’s intake. interventions, the patient
R - 30 was able gain weight and
height appropriate for his
 Monitor Intake and  To observe the balance
age.
Output. between the ingested and
eliminated foods and fluids
of the infant.

 Used foods appropriate  To encourage food intake

for his age that can and to enhance food
stimulate appetite. satisfaction.

 Promoted high fluid  To reduce possibility of

intake. early satiety.
 19

 Present pleasant  To enhance enthusiasm

environment during during eating.
eating.

 Encouraged small  This will promote weight

frequent meals that is gain and nitrogen balance.
high in calories and
protein.

 Promoted breast feeding.  This provide nutrients that

is needed by the infant.
 20

Constipation

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective: Constipation related SHORT TERM Independent: SHORT TERM
“Hindi na makadumi to reduced bowel GOAL: OUTCOME ACHIEVED:
ang anak ko.” as function  Evaluated usual dietary  Because disruption in usual
verbalized by the habits and liquid intake. schedule can cause further
mother. Within several hours constipation. After several hours of
of nursing nursing interventions, the
Objective: interventions, the  Noted activity level  Sedentary lifestyle may affect patient was able to have a
 Hard, formed patient will be able to pattern. elimination pattern. daily bowel movement by
stool, ribbon- have a daily bowel enema.
like stool movement by enema.  Palpated abdomen  To note presence of
 Anorexia abdominal distention.
 Distended
abdomen LONG TERM  Noted usual elimination  To determine usual pattern of LONG TERM
 Hypoactive GOAL: habits. elimination and to assess OUTCOME ACHIEVED:
bowel sounds current pattern of elimination.
 Abdominal
Within 2days of  Noted color, amount of After 2days of nursing
dullness  Provide baseline for
 Frequent but nursing intervention, stool during enema/ in intervention, the patient was
comparison, promotes
nonproductive the patient will be able colostomy. able to regain normal
recognition of changes.
desire to to regain normal pattern of bowel
pattern of bowel  Auscultated abdomen for functioning.
defecate.  Bowel sounds are caused by
functioning.
 V/S taken as presence of bowel peristaltic movements of
follows: Sounds every shift. small intestine and are not
T – 36.5 normally altered in
P - 130 constipation.
R - 30
 Encouraged high fiber  Fiber passes through the
diet. intestine essentially
 21

unchanged. When it reaches

the colon, it forms a gel
which ads bulk to the stool
and makes defecation easier.

 Promoted high fluid intake  To promote passage of soft

(1-2L/day). stool.

Dependent:

 Administer enemas daily

 This is done before the
as ordered.
surgery to achieve bowel
movements.
 Administer laxatives as
 To promote peristaltic
ordered.
movements.
 22

Risk for compromised family coping

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
Subjective: Risk for SHORT TERM Independent: Independent LONG TERM
“Hindi ko alam kung compromised GOAL:  Identified underlying  To know the causative and OUTCOME ACHIEVED:
paano naming family coping situations that may contributing factors.
malalampasan ang related to Within several hours of contribute to the inability to
pasanin ng anak ko.” as chronic illness nursing interventions, provide assistance. After 2days of nursing
verbalized by the mother. in child the parents will be able intervention, the patient
to identify resources  Listened to the parents’  To be able to identify cues shall manifest no signs of
within themselves to remarks, comments and that can help the patient to respiratory distress.
deal with the situation. expression of concern. reactivate skills to deal with
Objective: situation.
 attempts assistive
behaviors with less LONG TERM GOAL:  Encourage family members  To assist the family in SHORT TERM
than satisfactory to express feelings openly developing interventions to OUTCOME ACHIEVED:
result. and clearly. deal with the situation.
Within 2days of nursing
 Parents display interventions, the  Discussed underlying  To help them understand and After 1hours of nursing
protective behavior parents will be able to reasons for behaviors with accept patient’s behavior. intervention, the client was
towards their child. cope with the level of family. able to verbalized
stress present from their understanding of the
 Parents withdraws child’s condition.  Involve the family in  This enhances the interventions given to
from the patient. planning care as often as commitment to plan. improve his/her condition.
possible.
 Parents display
sudden outburst of  Promote assistance of  To identify ways in
emotions and family in providing patient demonstrating support while
inferences with care, as appropriate. maintaining independence.
necessary nursing
and medical
interventions.
 23

DRUG STUDY
DRUG DRUG MECHANISM OF DOSAGE/ROUTE/REQUENCY SIDE EFFECTS NURSING
CLASSIFICATION ACTION CONSIDERATIONS
1. Metronidazole Amebicide, Disrupts DNA, Anaerobic Infections FREQUENT - Question for history
Antibacterial, inhibiting nucleic acid IV: children/infants: 30mg/kg/day Systemic: anorexia, of hypersensitivity to
Antibiotic, synthesis. Therapeutic in 3 divided doses. Maximum: nausea, dry mouth, metronidazole, other
Antiprotonoal effect: produces 1,500mg/day metallic taste. nitro imidazole
bactericidal, Vaginal: symptomatic derivatives.
antiprotozoal, cervicitis/vaginitis, - Monitor daily pattern
amebicidal, abdominal cramps, of bowel activity,
trichomonacidal uterine pain. stool consistency.
effects. Produces anti- OCCASIONAL - Monitor I&O, assess
inflammatory, Systemic: diarrhea, for urinary problems.
immunosuppressive constipation, Be alert to
effects when applied vomiting, dizziness, neurologic
topically. erythematous rash, symptoms
urticarial, reddish- (dizziness,
brown urine. paresthesia of
extremities).
- Assess for rash,
urticaria.
- Educate the family:
Urine may be red-
brown or dark.
- Avoid alcohol,
alcohol-containing
preparations (cough
syrups, elixirs) for at
least 48 hrs after last
dose.
2. Paracetamol Analgesic, non- Appears to inhibit Children 12 yrs. And younger: 10- Rare- hypersensitivity - Assess for clinical
narcotic analgesic, prostaglandin 15 mg/kg/dose q4-6h. reaction improvement and
antipyretic synthesis in the CNS relief of pain, fever.
 24

and, to a lesser extent, Adverse/toxic

block pain impulses reaction: anorexia,
through peripheral nausea, diaphoresis,
action. Acts centrally fatigue within 12-24
on hypothalamic heat- hrs.
regulating center,
producing peripheral
vasodilation (heat
loss, skin erythema,
diaphoresis).
Therapeutic effect:
results in antipyresis.
Produces analgesic
effect.
3. Piperacillin Antibiotic Inhibit cell wall Children 2-8 mos: 80mg Frequent - Question for history
synthesis by binding piperacillin component/kg/dose Diarrhea, headache, of allergies, esp. to
to bacterial cell q8h. constipation, nausea, penicillin,
membranes. insomnia, rash. cephalosporins.
Therapeutic effect; Occasional - Monitor daily pattern
bactericidal. Vomiting, dyspepsia, of bowel activity,
pruritus, fever, stool consistency;
agitation, candidiasis, mild GI effects, may
dizziness, abdominal be, tolerable, but
pain, edema, anxiety, increasing severity
dyspnea, rhinitis. may indicate onset
of antibiotic-
associated colitis.
- Monitor I&O,
urinalysis.
- Monitor serum
electrolytes, esp.
potassium, and renal
function tests.
 25

4. Ranitidine Gastric acid secretion Inhibit histamine Po: 2mg/kg/day in divided doses Occasional (2%): - Obtain history of
inhibitor, Histamine-2 action at histamine 2 q12h. diarrhea. epigastric/abdominal
(H2) antagonist receptors of gastric IV: initially, 1.5mg/kg/dose, then Rare (1%): pain.
parietal cells. 1.5-2 mg/kg/doses q12h. constipation, - Monitor serum ALT,
Therapeutic Effect: IV infusion: loading dose: 1.5 headache (may be AST levels, BUN,
inhibits gastric acid mg/kg, then 1-2 mg/kg/day (0.04- severe). creatinine.
secretion. Reduces 0.08 mg/kg/hr). - Assess mental status
gastric volume, in elderly.
hydrogen ion - Smoking decreases
concentration of effectiveness of
gastric juice. medication.
- Transient
burning/pruritus may
occur with IV
administration.
- Report headache.
- Avoid alcohol,
aspirin.
5. Calcium Antacid, electrolyte. Essential element of Pedia: Parenteral: pain, rash, - Assess BP, EKG and
gluconate the body; helps 200-500 mg/day IV (2-5mL of redness, burning of cardiac rhythm, renal
maintain the 10% solution); for infants, no injection site, function, serum
functional integrity of more than 200mg IV (2mL of 10% flushing, nausea, magnesium,
the nervous system; solution) given in divided doses vomiting, phosphate,
helps maintain cardiac diaphoresis, potassium.
function, blood hypotension. Milk - Monitor signs of
coagulation; is an alkali syndrome. hypercalcemia.
enzymes cofactor and - Do not take within 1-
affects the secretory 2 hours of other oral
activity of endocrine medications, fiber
and exocrine glands; containing foods.
neutralizes or reduces - Avoid excessive use
gastric acidity. of alcohol, tobacco,
caffeine.
 26

WARNING:
- Have pt. remain
recumbent for a
short time after IV
injection.
- Adm. Into
ventricular cavity
during cardiac
resuscitation, not
into myocardium.
- Warm calcium
gluconate if
crystallization has
occurred.
- Monitor cardiac
response closely
during parenteral
treatment with
calcium.
6. Digoxin Cardiac glycoside. HF: inhibits PO 1-23 months: 35-60 mcg/kg Dizziness, headache, - Assess apical pulse.
Antiarrhythmic sodium/potassium IV: 30-50 mcg/kg diarrhea, rash, visual If pulse is 60 or
cardiotonic. ATPase pump in disturbances. less/min., withhold
myocardial cells. the drug, contact
Promotes calcium physician. Blood
influx. Increases samples are best
contractility. taken 6-8 hrs after
dose or just before
next dose.
- Monitor pulse for
bradycardia, EKG
for arrhythmias for
1-2 hrs after adm.
(excessive slowing
 27

of pulse may be first

clinical sign of
toxicity.)
- Assess for GI
disturbances,
neurologic
abnormalities q2-4h
during loading dose.
Follow guidelines to
take apical pulse and
report pulse 60 or
less/min.
- Do not increase or
skip dose.
- Do not take OTC
medications without
consulting physician.
- Report decreased
appetite,
nausea/vomiting,
diarrhea, visual
changes.
7. Amikacin Aminoglycoside, Inhibit protein in IV. IM adults, elderly, children, Frequent: phlebitis, - Dehydration must be
antibiotic susceptible bacteria infants: 5-7.5 mg/kg/dose q8h. thrombosis. treated prior to
by binding to 30S Neonates: 15 mg/kg/dose q12-48h Occasional: rash, aminoglycoside
ribosomal unit. (based on wgt) fever, urticarial, therapy. Establish
Therapeutic Effect: pruritus. baseline hearing
interferes with protein Rare: neuromuscular acuity before
synthesis of blockade (difficulty beginning therapy.
susceptible breathing, - Monitor I&O ,
microorganisms. drowsiness, urinalysis.
weakness).
 28

- Monitor results of
serum peak/trough
levels.
- Be alert to ototoxic,
neurotoxic,
nephrotoxic
symptoms.
- Check IM injection
site for pain,
induration.
- Evaluate IV site for
phlebitis.
- Assess for skin rash,
diarrhea,
superinfection,
changes of oral
mucosa.
- Continue antibiotic
for full length of
treatment.
 29

DISCHARGE PLAN

A. PROCESS THE CONSENT FORMS

 Admission Waiver Agreement
 Emergency Room pre-admission checklist
 Intensive Care Unit Compliance Form
 Checklist for pre-op preparation
 Authorization for medical/ surgical treatment
 Operative Record for:
i. Sepsis secondary to enterocolitis, PCAP- HR; Right I5 cutdown

B. SECURE LEGAL CONSENT FORMS

 Refusal form: Refusal for intubation
 Life support Refusal Form: 1:00PM
i. Emergency medications: Epinephrine
ii. Endotracheal intubation
 30

REFERENCES
Doenges, Moorhouse, &Murr (2006). Nurse’s pocket guide: diagnoses, prioritized interventions
and rationales. 10th edition. Philadelphia. PHL: F.A. Davis company
Fischbach, F. & Dunning III, M. (2015). A manual of laboratory and diagnostic tests. 9th edition.
Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins.
Hockenberry, M. & Wilson, D. (2015). Wong’s nursing care of infants and children. 10th edition.
United States of America: Elsevier
Hodgson, B., & Kizior, R. (2016). Saunders NURSING DRUG handbook 2016. United States of
America: Elsevier
Karch, J. (2012). 2012 LIPPINCOTT’S Nursing Drug Guide. Philadelphia: Wolters Kluwer,
Lippinccot Williams & Wilkins
Leeuwen, A. & Bladh, M. (2015). Davis’s comprehensive handbook of laboratory and diagnostic
tests with nursing implications. 6th edition. Philadelphia. PHL: F.A. Davis company
LeMone, P. & Burke, K. (2014). Medical-Surgical nursing critical thinking in client care. 5th
edition. Singapore: Pearson Education.
VanPutte, et al., (2016) Seeley's essentials of anatomy & physiology, 9th edition: McGraw Hill
Education
 31

APPENDICES
DIAGNOSTIC TESTS
DIAGNOSTIC TEST/ RESULT NORMAL VALUES INTERPRETATION SIGNIFICANCE NURSING RESPONSIBILITIES
DATE
Abdominal X-ray 1. Explain the purpose and
09/29/2019 Not Normal abdominal procedure of the test to SO.
indicated structures Normal diet is allowed unless
contraindicated.
2. Assure SO that the procedure in
itself is not painful.
3. Remove belts, zippers, jewelry,
and other ornamentation from the
abdominal area.
4. Interpret test outcomes and
monitor for intra-abdominal
disease.
Calcium
09/30/2019 2.34 2.2-2.7 mmol/L Normal Normal calcium levels with 1. Explain purpose and procedure.
overall normal results in Encourage relaxation.
other tests indicate no 2. Positively identify the patient
problems with calcium and label the appropriate
metabolism specimen container with the
10/01/ 2019 2.00 Decreased May be due to malabsorption corresponding patient
or pancreatic dysfunction, demographics, initials of the
acute pancreatitis, alkalosis, person collecting the specimen,
vitamin d deficiency or date, and time of collection.
malnutrition. 3. Teach the patient and family the
importance of adequate dietary
calcium intake to maintain
health.
 32

Hemoglucotest
09/30/2019 218 70-110 mg% Increased Hyperglycemia 1. Instruct SO about to restrict
child with food for 8 hours.
19 Decreased Hypoglycemia Water is permitted.
2. Do not fast longer than 8 hours.
207 Increased Hyperglycemia Prevents starvation.
3. Note the last time the patient ate
in the record and on the
ABG laboratory requisition.

October 01, 2019

O2 saturation 99 % 95-98 % Increased

pH 7.220 7.35-7.45 Increased Indicates excess of base; may 1. Inform the SO that this test can
indicate hyperthermia or assist in assessing blood oxygen
hyperventilation. balance and oxygenation level.
2. Obtain any history of bleeding
PO2 179 mmHg 80-105 mmHg Increased Hyperoxygenation; may be disorders.
due to High FiO2, 3. Inform SO that specimen
Hyperventilation. collection and post procedure
care of the puncture site usually
PCO2 31.4 mmHg 35-46 mmHg Decreased May indicate hyperthermia take 10 to 15 min.
or hyperventilation. 4. Inform SO that a report of the
results will be made available to
Base excess -15 mmol/L -2-+3 mmol/L Decreased To bring pH to (near) the requesting HCP, who will
normal. later explain the results.
5. Reinforce information given by
HCO3 12.8 22-26 mmol/L Decreased May indicate diarrhea, lactic the patient’s HCP regarding
mmol/L acidosis, renal failure, further testing, treatment, or
drainage of referral to another HCP.
pancreatic juice.
 33

total CO2 14 mmol/L 23-27 mmol/L Decreased

CBC

RBC 4.81 4-6x10 12/L Normal High RBC may indicate

September 30, 2019 4.31 absolute or relative
October 01, 2019 polycythemia. 1. Explain to the patient the RBC
count evaluates the number of
A low RBC may indicate blood cells and detects possible
anemia, fluid overload, or
blood disorders.
hemorrhage beyond 24
hours. 2. Fill collection tube completely.
Hematocrit
3. Explain test procedure. Explain
September 30, 2019 0.38 0.40-0.54 Below Normal Low HCT suggests anemia,
that slight discomfort may be felt
October 01, 2019 0.34 hemodilution or massive
blood loss. when the skin is punctured.
4. Encourage to avoid stress if
High HCT indicates possible because altered
polycythemia or physiologic status influences and
hemoconcentration caused
changes normal hematologic
by blood loss and
values.
dehydration.
Hemoglobin 5. Fatty meals may alter some test
September 30, 2019 122.0 130-160g/l Below Normal Low HGB level may indicate results as a result of lipidemia.
October 01, 2019 108.0 anemia, recent hemorrhage
or fluid retention causing 6. Apply manual pressure and
hemodilution. dressings over puncture site on
removal of dinner.
High HGB level suggests
hemoconcentration from 7. Monitor the puncture site for
polycythemia or dehydration oozing or hematoma formation.
 34

WBC 59.60 8. Instruct to resume normal

09/30/2019 40.81 5-10x10g/L Decreased Increased count commonly activities and diet.
10/01/2019 signals infection such as an
abscess, meningitis,
appendicitis, leukemia and
tissue necrosis, myocardial
infarction or gangrene.

Decreased count indicates

bone marrow depression
from viral infections from
Segmenters toxic reactions.
9/30/19 0.26 0.05-0.10 Increased
10/01/19 0.24

Monocytes
9/30/19 0.10 0.03-0.07 Below Normal Increase count indicates
10/01/19 0.09 carcinoma monocytic
leukemia or lymphoma,
collagen vascular disease
such as systemic lupus
erythematous and
rheumatoid arthritis
infections, sub-acute
bacterial endocarditis,
tuberculosis, hepatitis and
malaria.
Eosinophils
9/30/19 0 0.01-0.03 Normal Increased count is often
10/01/19 0 linked to allergic diseases
and parasites.
 35

Decreased count occurs in

condition such as aids,
aplastic anemia, and bone
marrow suppression.
Basophils
9/30/19 0 0-0.1 Normal Basophilic leukocytosis is
10/01/19 0 linked to myeloproliferative
disease (myelofibrosis;
agnogenic myeloid
metaplasia and
polycythemia.)
A rapid decrease in basophils
in linked to anaphylactic
reaction

Platelet Count
9/30/19 619 140-450 x 10 Normal This test evaluates changes
1. Explain test purposes and blood
10/01/19 434 in the body potassium levels
and diagnoses acid –base and drawing procedure.
Potassium water imbalances. 2. Do not have patient open and
9/30/19 6.06 3.5-5.3 mmol/L Increased close fist while drawing blood.
10/01/19 3.97 3. Monitor changes in body
potassium and intervene as
appropriate.
Sodium
9/30/19 132.3 135-148 mmol/L Normal Sodium levels are used to 1. Explain test purposes and
10/01/19 138.5 determined electrolytes, acid
procedure
– base balance, water
balance, water intoxication, 2. Interprets test outcomes and
and dehydration monitor for fluid and sodium
imbalances
36