A Case Of Electrical Burn
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MEDICAL MANAGEMENT Doctor’s order Admitting orders 3/12/09 2:35 pm EB 110% TBSA SPT-DPT inv R hand and L leg Open Fracture Fx L forearm
Rationale
Pls admit patient to burn unit under the service of Dr. H. Santos(Charity)
the patient had major burn injury thus, he needed to be properly monitored and taken care of in the burn unit
Secure consent for admission and management
to document that the patient has granted permission for admission and management
NPO
to prevent aspiration of vomitus because Nausea and vomiting typically occur due to paralytic ileus resulting from the stress of injury
Start Venoclysis c PNSS 1L>180 cc/hr. for CBC c BT Na,K
BUN, Crea -U/A
to replace lost fluids and electrolytes to prevent irreversible shock -To determine blood volume and blood type - to determine serum Na levels( hyponatremia is usually present)Serum Na levels vary in response to fluid resuscitation to assess renal function to check on the hydration status to assess renal function to check for any abnormalities in the urine that can aid in diagnosing certain diseases
-ECG-done outside to evaluate cardiac function.
X-ray L forearm AP,L done outside X-ray R hand and forearm X-ray L ankle include foot -Start Cefazolin 2 g IV LD ANST (-) then 1 g q8h
Omeprazole 40 mg/ vial 1 vial OD per IV
Tramadol 100 mg/amp 1 amp q8h for pain Refer to Ortho for evaluation and management
Electrical current immediately contracts muscle and cardiac dysrhythmias and spinal injuries often result from the muscular contraction to determine the type of fracture
an anti infective used to prevent the develepmont of infection and as a surgical prophylaxis a proton pump inhibitor that blocks final step of gastric acid secretion to prevent patient from developing stress ulcer brought about by the injury indicated for moderate to severe acute pain for evaluation and management of the patient
please insert IFC
to monitor urine output
pls. monitor VS q2h
to determine irregularities from the patient’s normal VS Check on the stability of the Patient
Monitor UO q 1h to assess renal function and hydration status inform plastic surgeon once admitted Refer 9: 40 pm to OR Anesthesia post-op order
for further management
to PACU
for easy access to experienced medical team members, monitoring and support, special equipment and medications
O2 inhalation via FM @ 6Lpm For adequate oxygenation Monitor VS q 15 min until stable
to determine irregularities from the patient’s VS Check on the stability of the Patient
Diet-DAT once fully awake regulate IVF PNSS q 30 gtts/min IVF TF D5LR 1Lx12 Meds: Nalbuphine 10 mg amp TIV q 4h x 6 doses Ketorolac 30 mg TIV q 6h x 4 doses Continue Cefazolin 1g TIV q8h
For nutritional needs. Patient can eat his food preference as tolerated for correct infusion rate to prevent phlebitis and infiltration for fluid replacement Indicated for Post-op somatic & visceral pain Possesses anti-inflammatory, analgesic, and anti pyretic effects
Moderate high back rest To prevent infection Encourage DBE to prevent aspiration
Keep warm and comfortable
to clear secretions, help expel residual anesthetic agents, mobilize secretions and prevent alveolar collapse to promote relaxation and comfort
Refer 6:15 pm-Give Paracetamol 1 amp now IV
as an immediate relief for fever and pain
3/14/09 Pls give Paracetamol 200 mg IV PRN basis( T of >38.0)
symptomatic relief of fever and pain
IVTF PNSS 1L x8h x3 cycles for fluid and electrolyte balance Refer 3/15/09 IVTF D5LR 1L x8h x 3 cycles
for fluid and electrolyte balance
refer 3/16/09 will refer to senior on duty Maintain IVF/ IV meds
Daily wound care
for close monitoring of patient’s condition For the maintenance of therapeutic effects of IVF and medications
DAT
To prevent proliferation infection-causing microorganisms in the wound
for transfer of service to Ortho. Please inform
for nutritional needs. Patient can eat his food preference as tolerated
Refer
of
For better management
3/17/09 Decrease VS monitoring to q 4h IVF D5LR 1L @ 30 gtts/min To determine irregularities in VS Patient referral ortho to Sr. we’ll co-manage the patient for “E” debridement,irrigation L forearm
for correct infusion rate to prevent phlebitis and infiltration for better management
secure consent for procedure
to remove tissue contaminated by bacteria and foreign bodies and to remove devitalized tissues
for OR on call Refer
to document that the patient has granted permission for admission and management for preparation of an operating procedure
March 18, 2009 IVFTF D5LR TL for 8 hrs x 3 cycles
Maintain on NPO
I&O monitoring q 4
For fluid replacement To prepare patient for the surgical procedure To monitor fluid status
Refer March 20, 2009 For blood replacement Please transfuse 2U PRBC properly typed and cross matched Still for BT
To evaluate BT outcome
Repeat H&H p BT Refer Addendum: Start O2 @3 lmp
For adequate oxygenation
TSB c/o relatives
To decrease body temp via evaporation
Continue monitoring q 4hours To determine irregularities in VS ORTHO For COD today For transfusion of 2U PRBC properly typed
To prevent proliferation of infection causing microorganism in the wound For blood replacement To avoid blood agglutination
March 22, 2009 COD done
To prevent proliferation of infection causing microorganism in the wound
Cont. IVF/ IV meds Daily wound care
For the maintenance of therapeutic effects of IVF and medications To prevent proliferation of infection causing microorganism in the wound
Repeat H&H Transfer pt. to ortho penthouse
To evaluate BT outcome For better management
March 23, 2009 Transfer pt. to ortho ward under the service of DR. Geromilla
For better management
9:30am Pls. facilitate BT 4U PRBC once available
For blood replacement
Start FeSO4 1 tab TID
For Iron supplementation
For COD today Refer accdgly.
To prevent proliferation of infection causing microorganism in the wound
March 24, 2009 9:30 High protein diet Green leafy veg. to diet
For tissue repair For Iron supplementation
Cont. IV meds
For the maintenance of therapeutic effects of medications
IVF to FF: PNSS 1L x KVO
For fluid replacement and hydration status
Facilitate BT pls.
For blood replacement
Wound care pls.
To prevent proliferation of infection causing microorganism in the wound
Refer to rehab for bedside conditioning
To prepare the patient for ambulation
March 25, 2009 Pls. facilitate transfusion of 1U of PRBC BT precautions pls. Paracetamol 300 mg IV RTC for T > 38°C Refer
To increase O2 carrying capacity in symptomatic anemia To prevent Anaphylactic shock symptomatic relief of fever and pain
March 26, 2009 7:00 am For COD today For H&H d/c IFC: WOF bladder distention Continue IVF/IV meds IVF to FF: PNSS 1L x KVO
To prevent proliferation of infection causing microorganism in the wound To evaluate BT outcome To assess urinary retention For the maintenance of therapeutic effects of IVF and medications For fluid replacement and hydration status
March 27, 2009 H&H noted
To evaluate BT outcome
For transfusion of 2U PRBC properly typed & cross matched
For blood replacement
Cont. IVF/IV meds
For the maintenance of therapeutic effects of IVF and medications
IVF to FF: PNSS 1L x KVO
For fluid replacement and hydration status
For COD tom.
To prevent proliferation of infection causing microorganism in the wound
Refer March 29, 2009 6:30 am For COD tomorrow
to prevent infection and to keep the wound from moisture that is a good medium for bacterial proliferation
Cont IVF/ IV meds for the maintenance of
Encourage wheelchair IVF to ff: PNSS 1L x KVO Still for referral for total body casting Refer March 30, 2009 9:05 Still for BT of 2 “U” PRBC properly typed and crossmatched
therapeutic effects of IVF and medications for ambulation without overexertion of the patient’s energy for fluid replacement and hydration status to prevent further injuries and damage
to replace lost blood products
IVF: PNSS 1L x KVO Cont. oral meds Refer April 01, 2009 Still for transfusion of 1 “U” PRBC properly typed and crossmatched Cont IVF/ IV meds
for fluid replacement and hydration status for the maintenance of therapeutic effects of oral medications
to replace lost blood products; to prevent blood reaction
IVF: PNSS 1L x KVO
for the maintenance of therapeutic effects of IVF and medications
For COD today
for fluid replacement and hydration status
2 pm For COD today For referral for total body casting April 07, 2009
to prevent proliferation of infection-causing bacteria in the wound to prevent proliferation of infection-causing bacteria in the wound
NPO p pm to prevent further injuries and damage Start D5LR 1L x 8 on NPO Meds Nalbuphine IV 500 mg April 08, 2009 Maintain on NPO For CBC today Refer
April 09, 2009 Still for BT IVF to ff: PNSS 1L x KVO
to prevent aspiration once the patient is called for surgical procedure for fluid replacement and nutritional needs of the patient while on NPO Relief of moderate to severe pain. to prevent aspiration once the is called for surgical procedure to determine blood abnormalities in its components, and volume
Start Fe SO4 1 tab PO For H&H Cont. wound care
to replace lost blood products
Refer
for fluid replacement and hydration status
April 10, 2009 9:20 am Still for CBG Cont IVF/ IV meds For COD today
for iron supplementation to evaluate BT outcome to prevent wound contamination and infection
Refer accordingly April 11,2009
to determine blood glucose levels
Cont. FeSO4 1 tab IVF to ff: PNSS 1L x KVO Cont. wound care Refer April 12, 2009 Facilitate transfusion of 1 “U” PRBC properly typed and crossmatched Facilitate CBC c APC Refer April 14, 2009
for the maintenance of therapeutic effects of IVF and medications to prevent proliferation of infection-causing bacteria in the wound
for iron supplementation for fluid replacement and hydration to prevent wound contamination and infection
NPO p mn to replace lost blood products Start D5LR 1L x 8 once on NPO Cont. meds
to determine blood abnormalities in its components, and volume
Refer April 15, 2009 Maintain on NPO For emergency debridement
Fixator & ex H x L For COD today Refer
to prevent aspiration once the patient is called for surgical procedure for fluid replacement and nutritional needs of the patient while on NPO for the maintenance of therapeutic effects of oral medications
9:30 pm DAT then NPO p mn
to prevent aspiration once the patient is called for surgical procedure
IVF to ff: PNSS 1L x KVO
to remove tissue contaminated c bacteria and foreign bodies and to remove devitalized tissues
Refer April 16, 2009 For CBC c APC total Maintain in NPO
attached to bone fragments to stabilize them to prevent proliferation of infection-causing bacteria in the wound to prevent aspiration once the patient is called for surgical procedure for fluid replacement and hydration status
to determine blood abnormalities in its components, and volume to prevent aspiration once the patient is called for surgical procedure
PATIENT’S PROFILE BIOGRAPHICAL DATA: Name: M.D.M. Age: 25 yrs old Sex: Male Civil status: Single Address: Towerville 2, Hector block 38 lot 6 , San Jose del Monte, Bulacan Religion: Roman Catholic Nationality: Filipino ADMISSION DATA: Admission date: March 12, 2009 Admission time: 3:00 pm Attending physician: Dr. Tamayo Admitting diagnosis: Electrical Burn Chief complaint: difficulty of flexing due to pain HISTORY OF PAST AND PRESENT ILLNESS History of present illness •
Few hours prior to admission patient fell while tapping on an electric post thus sustaining injury
Past Medical History •
No known past medical illnesses
Family History •
No known hereditary diseases
Personal history • High school graduate • Unemployed
•
No allergies to foods
PHYSICAL ASSESSMENT Admission(March 12,2009) VITAL SIGNS PR=75 bpm RR=21 cpm TEMP=37.3 °C PHYSICAL ASSESSMENT Skin
Skin color – deep brown Skin turgor – slowly goes back to its previous state Skin warm to touch Visible skin lesions
Hair Evenly distributed hair Thick hair No infestations Nails
Fingernail plate shape- convex curvature Texture- smooth Bed- highly vascular and pink Tissues- intact epidermis Capillary refill test- return to its normal color
Skull and Face Rounded Smooth skull contour Absence of nodules
Symmetric facial movements
Eyes
Eyebrows evenly distributed and symmetrically aligned Eyelashes equally distributed Eyelids- skin intact, no discharge, no discoloration Pupils- black in color, equal in size. Round
Ears Auricles- color same as facial skin Symmetrical, aligned with outer canthus Nose Symmetric and straight No discharge No tender or lesions Mouth Outer: soft, moist, smooth Inner: pink color, moist, smooth Thorax and Lungs
Symmetric Spine is aligned Skin intact No lesions Full and symmetric chest expansion
Abdomen No lesions flat Extremities No edema Skin lesions Right forearm amputated
With external fixator on left arm With elastic bandage of the left lower leg due to2nd degree burn LABORATORY TEST RESULTS
HEMATOLOGY HEMATOLOGY Components
Result Normal Values
Interpretation
WBC
16.3 4.5 – 11X103/cu mm
Increase in value may indicate that the patient has an acute bacterial infection or infectious disease, or he is in inflammatory state
Hemoglobin
14.9 M: 14.0 – 17.0 gm/dL F: 12.0 – 14.0 gm/dL NB: 18.7 – 20.1 gm/dL
Normal Decreased level would suggest anemia, acute blood loss, and severe hemorrhage while elevated value may indicate dehydration and polycythemia vera
Hematocrit
43.3%
M: 40 – 50% F: 38 – 48% NB: 49 – 58%
Normal Values decreases in anemia and increases in dehydration and polycythemia
DIFFERENTIAL COUNT Neutrophil
76%
45 – 65%
Increase in value may be due to presence of acute bacterial infection, inflammation, stress or drug reaction
Lymphocyte s
18%
25 – 40%
Decreased level may suggest that the patient has an aplastic anemia, leukemia, immunodeficiency
Monocytes
3%
2 – 6% Normal Values increases in viral infection, parasitic disease, collagen and hemolytic disorder Values decreases when patient is taking corticosteroid, or suffers in RA and HIV infection
Eosinophil
3%
2 – 4% Normal Values increases during allergic reaction, parasitic infestation and eosinophilic leukemia, and decreases
in patient with endocrine disorders, and during stress Platelet
204
Mean Corpuscular Volume (MCV)
90.2
Mean Corpuscular Hemoglobin (MCH)
31.0
Mean 34.4% Corpuscular Hemoglobin Concentrati on (MCHC)
Red Blood Cell Distribution Width (RDW)
13.0
150 – Normal 450,00 Thrombocytopenia is associated with anemias. 0/mm3 Thrombocytosis (elevated platelet count) occurs in polycythemia vera. 80 – 100 µm3
Normal Decreased level is associated with microcytic anemia like iron deficiency anemia Values increases in macrocytic anemias like aplastic, hemolytic and pernicious
27 – 31 Normal pg It is decreased in hypochromic anemias, and increased in hyperchromic anemias. 32 – 36%
Normal It is diminished (hypochromic) in microcytic anemias, and normal (normochromic) in macrocytic anemias (due to larger cell size, though the hemoglobin amount or MCH is high, the concentration remains normal). MCHC is elevated in hereditary spherocytosis.
11.6 - Normal 14.6 % Vitamin B12 deficiency produces a macrocytic (large cell) anemia with a normal RDW. However, iron deficiency anemia initially presents with a varied size distribution of red blood cells, and as such shows an increased RDW. And in the case of a mixed iron and B12 deficiency we will have a mix of both large cells and small cells hence the RDW will usually be elevated.
CHEMISTRY Test
Result
Sodium
137.5
Potassium
4.21
Normal Values
Interpretation
135 – 148 Normal mEq/L Value increases in increased intake, either orally or parentally of sodium Decrease in value is associated with burns, Addison’s disease, sodium-losing nephropathy, vomiting, diarrhea, fistulas, tube drainage, ascites, renal insufficiency with acidosis 3.50 – 5.30 mEq/L
Normal Blood levels of potassium may be higher than normal when patient is suffering from diabetic ketosis, renal failure, and Addison’s disease. Value decreases when patient is taking Thiazide diuretics and steroid therapy, or also may suggest cushing’s syndrome, cirrhosis with ascites, hyperaldosteronism, malignant hypertension, poor dietary habits, chronic diarrhea, diaphoresis, renal tubular necrosis, malabsorption syndrome, vomiting
March 12, 2009 CHEMISTRY Test
Result
Normal Values
Creatinine
100
53115,000 mmol/L
Resul t Conv ersio n 1.13
Unit
Normal Values
Interpretation
m g/d L
0.5 – 1.3
Normal Values increases in skeletal muscle necrosis/atrophy, starvation, hyperthyroidism, kidney disease,
March 20, 2009 HEMATOLOGY Componen Result Normal Values ts
Interpretation
Hemoglobi n
6.0
M: 13 – 18 gm/dL F: 12 – 16 gm/dL
Decrease level suggest anemia and may also be associated with blood loss (traumatic injury, surgery, bleeding), nutritional deficiency, bone marrow problems, immunosuppression
Hematocri t
17.6 %
M: 42 – 52% F: 35 – 47%
A low hematocrit is referred to as being anemic. Some of the more common reasons are loss of blood (traumatic injury, surgery, bleeding colon cancer), nutritional deficiency (iron, vitamin B12, folate), bone marrow problems (replacement of bone marrow by cancer, suppression by chemotherapy drugs, kidney failure), and abnormal hematocrit (sickle cell anemia).
March 26, 2009 HEMATOLOGY Componen Result Normal Values ts
Interpretation
Hemoglobi n
8.5
M: 13 – 18 gm/dL F: 12 – 16 gm/dL
Decreased level would suggest anemia, acute blood loss, and hemodilution
Hematocri t
24.9 %
M: 42 – 52% F: 35 – 47%
Values decreases in anemia
March 31, 2009 CROSSMATCHING RESULT Blood Typing
Result
Interpretation
ABO
“O”
Individuals with type O blood can receive blood from donors of only type O, so as to prevent hemolytic transfusion reaction.
RH
(+)
Individual who inherited the D antigen. This is to prevent Rh incompatibility reaction. Blood Component
PRBC
Extraction Date: March 28, 2009 Expiration Date: April 1, 2009
To increase oxygen carrying capacity in symptomatic anemia patients
April 7, 2009 CROSSMATCHING RESULT Blood Typing
Result
Interpretation
ABO
“O”
Individuals with type O blood can receive blood from donors of only type O, so as to prevent hemolytic transfusion reaction.
RH
(+)
Individual who inherited the D antigen. This is to prevent Rh incompatibility reaction. Blood Component
PRBC
Extraction Date: April 5, 2009 Expiration Date: May 10, 2009
To increase oxygen carrying capacity in symptomatic anemia patients
Generic Name: cefazolin sodium Brand Name: Ancef, Kefzol Classification: First generation cephalosporin (anti-infective)
MECHANISM OF ACTION
DOSAGE/ FREQUEN CY Interferes with Cefazolin 1 bacterial cell gm TIV q wall synthesis, 8h causing cell to rupture and die.
INDICATION Treatment variety of infections due to susceptible organism: Respiratory tract, GIT, GUT, OTIC, bone, skin soft tissues, post-op infection, bacteremia, septicemia, endocaditis, surgical prophylaxis
ADVERSE REACTION
CONTRAINDICATI ON
Drug induce fever, Hypersensitivity to GI side effects, cephalosporins skin rashes, eosinophilia, allergic nephritis, anaphylactic reaction, hematological changes, headache, dizziness, malaise, shock, cytopenia, thrombocytopenia , alteration of bacterial flora.
NURSING CONSIDERATIO N Monitor CBC, Prothrombin time, Kidney and liver function test result Watch for signs and symptoms of superinfection and other serious adverse reaction Tell patient to report reduce urinary output, persistent diarrhea, bruising and bleeding Instruct the patient to take the drug exactly as prescribed and to complete full course of drug therapy even when he feels better. As appropriate review all other significant life threatening reactions and interactions especially those related to the drugs, test and behaviors
Generic Name: omeprazole Brand Name: Omepron Classification: Proton Pump inhibitor
Generic Name: Nalbuphine HCl Brand Name: Nubain [amp] MECHANISM OF DOSAGE/ INDICATIO ADVERSE CONTRAINDICATI ACTION FREQUEN REACTION ON MECHANISM DOSAGE/ INDICATIONN CY OF ACTION FREQUEN ADVERSE CONTRAINDICATI Binds to opiate receptors Nalbuphine Relief of REACTION Sedation. ON Patients who are CY in the CNS, causing IV moderate Infrequentl Hypersensitivity hypersensitive to to Thought to be Omeprazol10 mg Duodenal ulcer, Headache, inhibition of ascending push q 4 to severe y nalbuphine HCl or a gastric e 40 mg/ gastric ulcer, rarely rash, drug or its pain pathways, altering hours x6 pain. Pre- pruritis, sweating, components. any component, pump reflux the perception of vial and doses op GI upsets, including sulfites; inhibitor in pain;1 vial OD esophagitis, dizziness, response to analgesia,parasthesia, vertigo, pregnancy that it blocks per IV associated produces generalized as a dizziness; (prolonged use or the step duodenal gastric somnolence, CNS final depression supplemen dry mouth; high dosages at of acid ulcers, insomnia,ver t to production by gastroduodenal tigo,headache, term) allergic inhibiting the erosion, balanced diarrhea, anesthesia, reactions. H+/K+ ATPHelicobacter constipation, surgical flatulence, ase system of pylori- associated anesthesia, the secretory peptic ulcer increased for obstet surface of the disease, liver ric the enzyme,mal gastric dyspepsia(in parietal cell. relief of analgesia aise,hyperse symptomsduring in nsitivity labor & patient with reaction epigastricrelief of pain pain/discomfort following with or without MI. Post-op heartburn),Zollin ger-Ellisonsomatic & syndromevisceral pain.
NURSING CONSIDERATION NURSING CONSIDERATION Abrupt discontinuation after sustained Consider dosageuse (generally days) adjustment >10 in those mayhepatic cause withdrawal with failure symptoms. Mixed agonist-antagonist: Avoid activities that Incidence of require mental psychomimetic effect is alertness until drug lower than with effects’ realized; may pentazocine; may cause dizziness precipitate withdrawal in narcotic-dependent For short term use patients. only, drug inhibits total gastric secretion. Side effects of prolonged therapy and suppression of acid secretion alter bacterial colonization and lead to hypochlorhydria which may cause an increased risk for gastric tumors
Classification: Anaesthetics - Local & General, Analgesics (Opioid)
Generic Name: Ketorolac tromethamine Brand Name: Apo-Ketorolac Classification: Non-steroidal anti-inflammatory drug
MECHANISM OF ACTION
DOSAGE/ FREQUEN CY Possesses Ketorolac anti30 mg q 6 inflammatory, hours x 4 analgesic, doses and anti pyretic effects
INDICATION
ADVERSE REACTION
CONTRAINDICATI ON
As a single or multiple dose regimen on a regular or as needed schedule for the management of moderate to severe pain that requires analgesia at the opioid level
Systemic use: Headache, dizziness, drowsiness, diarrhea, nausea, dyspepsia/indigestio n, epigastric pain, edema
Hypersensitivity to the drug or allergic symptoms; Active peptic ulcer disease; those at risk for renal failure
NURSING CONSIDERATIO N 1. Use as a part of a regular analgesic rather than on an as needed basis 2. Do not mix IV/IM in a small volume(i.e, a syringe) with morphine sulfate, meperidine, HCL, promethazine HCL, or hydroxyzine HCL; will precipitate from solution
Generic Name: tramadol hydrochloride Brand Name: Ultram Classification: Non-steroidal anti-inflammatory drug
MECHANISM OF ACTION Inhibits re uptake of serotonin and norepinephrin e in the CNS
DOSAGE/ FREQUENC Y Tramado l 100 mg/amp 1 amp q8h for pain
INDICATION
ADVERSE REACTION
CONTRAINDICATI ON
For moderate to severe acute or chronic pain e.g. cancer or post op pain
Seizures, hypersensitivity reactions, respiratory depression; CV, CNS, musculoskeletal and urogenital disorder, nausea, vomiting, abdominal distention,anorexia, dependence,
Acute intoxication with alcohol, analgesics, hypnotics or psycho tropics, patients receiving MAOI’s , severe respiratory depression, cerebral pathology
NURSING CONSIDERATIO N assess patient’s response to drug 30 mins. after dministration Monitor respiratory status, withhold drug and contact prescriber if respiration becomes shallow or slower than 12 cpm Inform patient that drug can cause physical and psychological dependence.
Generic Name: Paracetamol Brand Name: Aeknil Classification: Analgesics (Non-Opioid) & Antipyretics
MECHANISM OF ACTION Paracetamol is
DOSAGE/ FREQUENC Y Paracetamo l 300 mg Iv prn for temp. >380C
INDICATION
ADVERSE REACTION
Pyrexia of
Skin
unknown origin
eruption,
and for
hematologic
symptomatic
al toxicity
relief of fever
e.g.,
and pain
thrombocyto
associated with
penia and
common
leucopenia,
peak plasma
childhood
methemoglo
levels are
disorders,
binaem-ia
attained in 10
tonsillitis, upper which can
min to 1 hr and
respiratory
result in
the half-life is
tract infections,
cyanosis,
75 min to 3 hrs.
post-
and on long-
Distribution of
immunization
term use,
paracetamol to
reactions, after
renal
most body
tonsillectomy
damage can
tissues and
and other
result.
fluids is both
conditions
rapid and
where patient is
uniform.
unable to take
Approximately
oral
85% of a dose
medications but
of paracetamol
where
is excreted in
paracetamol
the urine within
can be
24 hrs after
administered
administration.
with advantage.
rapidly and almost completely absorbed from the GIT. Following oral administration,
Paracetamo l 1 amp IV prn basis for temp >37.80C
For prevention
CONTRAINDICATIO N Nephropathy.
NURSING CONSIDERATION 1. Never take more than 2 tablets (of 500mg each day) at any one time and no more than 4 times in 1 day. 2. Paracetamol may be taken with or without food. 3. If you need pain relief fast, take it on an empty stomach as food may slow down the absorption of paracetamol. 4. Do not double a dose under any circumstances. 5. Do not take paracetamol of you have liver or kidney problem. 6. Do not take this medicine with other products that contain paracetamol. 7. Avoid alcohol
Generic Name: ferrous sulfate Brand Name: Apo ferrous sulfate Classification: Anti Anemic Iron
MECHANISM OF ACTION Iron is absorbed from the duodenum and upper jejunum by anactive mechanism through the mucosal cells where it combines with the protein transferring and is stored in the body as hemosiderin or aggregated ferritin w/c is found in the reticuloendothelia l cells of the liver, spleenand bone marrow
DOSAGE/ FREQUEN CY Ferrous sulfate 1 tab OD
INDICATION Prophylaxis and treatment of iron deficiency and iron deficiency anemia; dietary supplement for iron
ADVERSE REACTION
CONTRAINDICATI ON
GI irritation and blackening of stool, constipation, nausea and anorexia, diarrhea
Hemosiderosis, hemochromatosis, peptic ulcer, regional enteritis, ulcerative colitis. Hemolytic anemia, pyridoxine responsive anemia, liver cirrhosis
NURSING CONSIDERATI ON Eggs, milk, coffee or tea consumed with a meal or 1 hour after may significantly inhibit the absorption of dietary iron Ingestion of calcium and iron supplements with food can decrease absorption by 1/3 Note any GI bleeding, tarry stools or bright blood in stool or vomitus Note any complaints of fatigue, pallor. Poor skin turgor or change in mental status Take with meals
Date: 4/17/09 Subjective: > “ Masakit tong mga sugat ko” as verbalized by the patient.” Pain scale of 8 out of 10. Objective: > V.A.S. >guarding behaviors >restless >narrowed focus Date: 4/17/09 Subjective: “Nadamay lang naman ako eh, tapos ganito na nangyari”, as verbalized by the patient.
Objective: > amputated R arm > Negative feelings about body/self, >fear of rejection >Focus on past appearance, abilities;
Date:4/17/09 Subjective: “Eto nga eh putol na yung kamay ko, tas ung kabila sunog din.”as verbalized by the patient. Objective: >absence of viable tissue on L arm > c multiple lesions on extremities and trunk > presence of fluid exudates on injured areas
PDAGDAG NLNG N2 SA P.A OR SA S & S HYPOTENSIVE UNG PATIENT THROUGHOUT OUR SHIFT
Rationale
Pls admit patient to burn unit under the service of Dr. H. Santos(Charity)
the patient had major burn injury thus, he needed to be properly monitored and taken care of in the burn unit
Secure consent for admission and management
to document that the patient has granted permission for admission and management
NPO
to prevent aspiration of vomitus because Nausea and vomiting typically occur due to paralytic ileus resulting from the stress of injury
Start Venoclysis c PNSS 1L>180 cc/hr. for CBC c BT Na,K
BUN, Crea -U/A
to replace lost fluids and electrolytes to prevent irreversible shock -To determine blood volume and blood type - to determine serum Na levels( hyponatremia is usually present)Serum Na levels vary in response to fluid resuscitation to assess renal function to check on the hydration status to assess renal function to check for any abnormalities in the urine that can aid in diagnosing certain diseases
-ECG-done outside to evaluate cardiac function.
X-ray L forearm AP,L done outside X-ray R hand and forearm X-ray L ankle include foot -Start Cefazolin 2 g IV LD ANST (-) then 1 g q8h
Omeprazole 40 mg/ vial 1 vial OD per IV
Tramadol 100 mg/amp 1 amp q8h for pain Refer to Ortho for evaluation and management
Electrical current immediately contracts muscle and cardiac dysrhythmias and spinal injuries often result from the muscular contraction to determine the type of fracture
an anti infective used to prevent the develepmont of infection and as a surgical prophylaxis a proton pump inhibitor that blocks final step of gastric acid secretion to prevent patient from developing stress ulcer brought about by the injury indicated for moderate to severe acute pain for evaluation and management of the patient
please insert IFC
to monitor urine output
pls. monitor VS q2h
to determine irregularities from the patient’s normal VS Check on the stability of the Patient
Monitor UO q 1h to assess renal function and hydration status inform plastic surgeon once admitted Refer 9: 40 pm to OR Anesthesia post-op order
for further management
to PACU
for easy access to experienced medical team members, monitoring and support, special equipment and medications
O2 inhalation via FM @ 6Lpm For adequate oxygenation Monitor VS q 15 min until stable
to determine irregularities from the patient’s VS Check on the stability of the Patient
Diet-DAT once fully awake regulate IVF PNSS q 30 gtts/min IVF TF D5LR 1Lx12 Meds: Nalbuphine 10 mg amp TIV q 4h x 6 doses Ketorolac 30 mg TIV q 6h x 4 doses Continue Cefazolin 1g TIV q8h
For nutritional needs. Patient can eat his food preference as tolerated for correct infusion rate to prevent phlebitis and infiltration for fluid replacement Indicated for Post-op somatic & visceral pain Possesses anti-inflammatory, analgesic, and anti pyretic effects
Moderate high back rest To prevent infection Encourage DBE to prevent aspiration
Keep warm and comfortable
to clear secretions, help expel residual anesthetic agents, mobilize secretions and prevent alveolar collapse to promote relaxation and comfort
Refer 6:15 pm-Give Paracetamol 1 amp now IV
as an immediate relief for fever and pain
3/14/09 Pls give Paracetamol 200 mg IV PRN basis( T of >38.0)
symptomatic relief of fever and pain
IVTF PNSS 1L x8h x3 cycles for fluid and electrolyte balance Refer 3/15/09 IVTF D5LR 1L x8h x 3 cycles
for fluid and electrolyte balance
refer 3/16/09 will refer to senior on duty Maintain IVF/ IV meds
Daily wound care
for close monitoring of patient’s condition For the maintenance of therapeutic effects of IVF and medications
DAT
To prevent proliferation infection-causing microorganisms in the wound
for transfer of service to Ortho. Please inform
for nutritional needs. Patient can eat his food preference as tolerated
Refer
of
For better management
3/17/09 Decrease VS monitoring to q 4h IVF D5LR 1L @ 30 gtts/min To determine irregularities in VS Patient referral ortho to Sr. we’ll co-manage the patient for “E” debridement,irrigation L forearm
for correct infusion rate to prevent phlebitis and infiltration for better management
secure consent for procedure
to remove tissue contaminated by bacteria and foreign bodies and to remove devitalized tissues
for OR on call Refer
to document that the patient has granted permission for admission and management for preparation of an operating procedure
March 18, 2009 IVFTF D5LR TL for 8 hrs x 3 cycles
Maintain on NPO
I&O monitoring q 4
For fluid replacement To prepare patient for the surgical procedure To monitor fluid status
Refer March 20, 2009 For blood replacement Please transfuse 2U PRBC properly typed and cross matched Still for BT
To evaluate BT outcome
Repeat H&H p BT Refer Addendum: Start O2 @3 lmp
For adequate oxygenation
TSB c/o relatives
To decrease body temp via evaporation
Continue monitoring q 4hours To determine irregularities in VS ORTHO For COD today For transfusion of 2U PRBC properly typed
To prevent proliferation of infection causing microorganism in the wound For blood replacement To avoid blood agglutination
March 22, 2009 COD done
To prevent proliferation of infection causing microorganism in the wound
Cont. IVF/ IV meds Daily wound care
For the maintenance of therapeutic effects of IVF and medications To prevent proliferation of infection causing microorganism in the wound
Repeat H&H Transfer pt. to ortho penthouse
To evaluate BT outcome For better management
March 23, 2009 Transfer pt. to ortho ward under the service of DR. Geromilla
For better management
9:30am Pls. facilitate BT 4U PRBC once available
For blood replacement
Start FeSO4 1 tab TID
For Iron supplementation
For COD today Refer accdgly.
To prevent proliferation of infection causing microorganism in the wound
March 24, 2009 9:30 High protein diet Green leafy veg. to diet
For tissue repair For Iron supplementation
Cont. IV meds
For the maintenance of therapeutic effects of medications
IVF to FF: PNSS 1L x KVO
For fluid replacement and hydration status
Facilitate BT pls.
For blood replacement
Wound care pls.
To prevent proliferation of infection causing microorganism in the wound
Refer to rehab for bedside conditioning
To prepare the patient for ambulation
March 25, 2009 Pls. facilitate transfusion of 1U of PRBC BT precautions pls. Paracetamol 300 mg IV RTC for T > 38°C Refer
To increase O2 carrying capacity in symptomatic anemia To prevent Anaphylactic shock symptomatic relief of fever and pain
March 26, 2009 7:00 am For COD today For H&H d/c IFC: WOF bladder distention Continue IVF/IV meds IVF to FF: PNSS 1L x KVO
To prevent proliferation of infection causing microorganism in the wound To evaluate BT outcome To assess urinary retention For the maintenance of therapeutic effects of IVF and medications For fluid replacement and hydration status
March 27, 2009 H&H noted
To evaluate BT outcome
For transfusion of 2U PRBC properly typed & cross matched
For blood replacement
Cont. IVF/IV meds
For the maintenance of therapeutic effects of IVF and medications
IVF to FF: PNSS 1L x KVO
For fluid replacement and hydration status
For COD tom.
To prevent proliferation of infection causing microorganism in the wound
Refer March 29, 2009 6:30 am For COD tomorrow
to prevent infection and to keep the wound from moisture that is a good medium for bacterial proliferation
Cont IVF/ IV meds for the maintenance of
Encourage wheelchair IVF to ff: PNSS 1L x KVO Still for referral for total body casting Refer March 30, 2009 9:05 Still for BT of 2 “U” PRBC properly typed and crossmatched
therapeutic effects of IVF and medications for ambulation without overexertion of the patient’s energy for fluid replacement and hydration status to prevent further injuries and damage
to replace lost blood products
IVF: PNSS 1L x KVO Cont. oral meds Refer April 01, 2009 Still for transfusion of 1 “U” PRBC properly typed and crossmatched Cont IVF/ IV meds
for fluid replacement and hydration status for the maintenance of therapeutic effects of oral medications
to replace lost blood products; to prevent blood reaction
IVF: PNSS 1L x KVO
for the maintenance of therapeutic effects of IVF and medications
For COD today
for fluid replacement and hydration status
2 pm For COD today For referral for total body casting April 07, 2009
to prevent proliferation of infection-causing bacteria in the wound to prevent proliferation of infection-causing bacteria in the wound
NPO p pm to prevent further injuries and damage Start D5LR 1L x 8 on NPO Meds Nalbuphine IV 500 mg April 08, 2009 Maintain on NPO For CBC today Refer
April 09, 2009 Still for BT IVF to ff: PNSS 1L x KVO
to prevent aspiration once the patient is called for surgical procedure for fluid replacement and nutritional needs of the patient while on NPO Relief of moderate to severe pain. to prevent aspiration once the is called for surgical procedure to determine blood abnormalities in its components, and volume
Start Fe SO4 1 tab PO For H&H Cont. wound care
to replace lost blood products
Refer
for fluid replacement and hydration status
April 10, 2009 9:20 am Still for CBG Cont IVF/ IV meds For COD today
for iron supplementation to evaluate BT outcome to prevent wound contamination and infection
Refer accordingly April 11,2009
to determine blood glucose levels
Cont. FeSO4 1 tab IVF to ff: PNSS 1L x KVO Cont. wound care Refer April 12, 2009 Facilitate transfusion of 1 “U” PRBC properly typed and crossmatched Facilitate CBC c APC Refer April 14, 2009
for the maintenance of therapeutic effects of IVF and medications to prevent proliferation of infection-causing bacteria in the wound
for iron supplementation for fluid replacement and hydration to prevent wound contamination and infection
NPO p mn to replace lost blood products Start D5LR 1L x 8 once on NPO Cont. meds
to determine blood abnormalities in its components, and volume
Refer April 15, 2009 Maintain on NPO For emergency debridement
Fixator & ex H x L For COD today Refer
to prevent aspiration once the patient is called for surgical procedure for fluid replacement and nutritional needs of the patient while on NPO for the maintenance of therapeutic effects of oral medications
9:30 pm DAT then NPO p mn
to prevent aspiration once the patient is called for surgical procedure
IVF to ff: PNSS 1L x KVO
to remove tissue contaminated c bacteria and foreign bodies and to remove devitalized tissues
Refer April 16, 2009 For CBC c APC total Maintain in NPO
attached to bone fragments to stabilize them to prevent proliferation of infection-causing bacteria in the wound to prevent aspiration once the patient is called for surgical procedure for fluid replacement and hydration status
to determine blood abnormalities in its components, and volume to prevent aspiration once the patient is called for surgical procedure
PATIENT’S PROFILE BIOGRAPHICAL DATA: Name: M.D.M. Age: 25 yrs old Sex: Male Civil status: Single Address: Towerville 2, Hector block 38 lot 6 , San Jose del Monte, Bulacan Religion: Roman Catholic Nationality: Filipino ADMISSION DATA: Admission date: March 12, 2009 Admission time: 3:00 pm Attending physician: Dr. Tamayo Admitting diagnosis: Electrical Burn Chief complaint: difficulty of flexing due to pain HISTORY OF PAST AND PRESENT ILLNESS History of present illness •
Few hours prior to admission patient fell while tapping on an electric post thus sustaining injury
Past Medical History •
No known past medical illnesses
Family History •
No known hereditary diseases
Personal history • High school graduate • Unemployed
•
No allergies to foods
PHYSICAL ASSESSMENT Admission(March 12,2009) VITAL SIGNS PR=75 bpm RR=21 cpm TEMP=37.3 °C PHYSICAL ASSESSMENT Skin
Skin color – deep brown Skin turgor – slowly goes back to its previous state Skin warm to touch Visible skin lesions
Hair Evenly distributed hair Thick hair No infestations Nails
Fingernail plate shape- convex curvature Texture- smooth Bed- highly vascular and pink Tissues- intact epidermis Capillary refill test- return to its normal color
Skull and Face Rounded Smooth skull contour Absence of nodules
Symmetric facial movements
Eyes
Eyebrows evenly distributed and symmetrically aligned Eyelashes equally distributed Eyelids- skin intact, no discharge, no discoloration Pupils- black in color, equal in size. Round
Ears Auricles- color same as facial skin Symmetrical, aligned with outer canthus Nose Symmetric and straight No discharge No tender or lesions Mouth Outer: soft, moist, smooth Inner: pink color, moist, smooth Thorax and Lungs
Symmetric Spine is aligned Skin intact No lesions Full and symmetric chest expansion
Abdomen No lesions flat Extremities No edema Skin lesions Right forearm amputated
With external fixator on left arm With elastic bandage of the left lower leg due to2nd degree burn LABORATORY TEST RESULTS
HEMATOLOGY HEMATOLOGY Components
Result Normal Values
Interpretation
WBC
16.3 4.5 – 11X103/cu mm
Increase in value may indicate that the patient has an acute bacterial infection or infectious disease, or he is in inflammatory state
Hemoglobin
14.9 M: 14.0 – 17.0 gm/dL F: 12.0 – 14.0 gm/dL NB: 18.7 – 20.1 gm/dL
Normal Decreased level would suggest anemia, acute blood loss, and severe hemorrhage while elevated value may indicate dehydration and polycythemia vera
Hematocrit
43.3%
M: 40 – 50% F: 38 – 48% NB: 49 – 58%
Normal Values decreases in anemia and increases in dehydration and polycythemia
DIFFERENTIAL COUNT Neutrophil
76%
45 – 65%
Increase in value may be due to presence of acute bacterial infection, inflammation, stress or drug reaction
Lymphocyte s
18%
25 – 40%
Decreased level may suggest that the patient has an aplastic anemia, leukemia, immunodeficiency
Monocytes
3%
2 – 6% Normal Values increases in viral infection, parasitic disease, collagen and hemolytic disorder Values decreases when patient is taking corticosteroid, or suffers in RA and HIV infection
Eosinophil
3%
2 – 4% Normal Values increases during allergic reaction, parasitic infestation and eosinophilic leukemia, and decreases
in patient with endocrine disorders, and during stress Platelet
204
Mean Corpuscular Volume (MCV)
90.2
Mean Corpuscular Hemoglobin (MCH)
31.0
Mean 34.4% Corpuscular Hemoglobin Concentrati on (MCHC)
Red Blood Cell Distribution Width (RDW)
13.0
150 – Normal 450,00 Thrombocytopenia is associated with anemias. 0/mm3 Thrombocytosis (elevated platelet count) occurs in polycythemia vera. 80 – 100 µm3
Normal Decreased level is associated with microcytic anemia like iron deficiency anemia Values increases in macrocytic anemias like aplastic, hemolytic and pernicious
27 – 31 Normal pg It is decreased in hypochromic anemias, and increased in hyperchromic anemias. 32 – 36%
Normal It is diminished (hypochromic) in microcytic anemias, and normal (normochromic) in macrocytic anemias (due to larger cell size, though the hemoglobin amount or MCH is high, the concentration remains normal). MCHC is elevated in hereditary spherocytosis.
11.6 - Normal 14.6 % Vitamin B12 deficiency produces a macrocytic (large cell) anemia with a normal RDW. However, iron deficiency anemia initially presents with a varied size distribution of red blood cells, and as such shows an increased RDW. And in the case of a mixed iron and B12 deficiency we will have a mix of both large cells and small cells hence the RDW will usually be elevated.
CHEMISTRY Test
Result
Sodium
137.5
Potassium
4.21
Normal Values
Interpretation
135 – 148 Normal mEq/L Value increases in increased intake, either orally or parentally of sodium Decrease in value is associated with burns, Addison’s disease, sodium-losing nephropathy, vomiting, diarrhea, fistulas, tube drainage, ascites, renal insufficiency with acidosis 3.50 – 5.30 mEq/L
Normal Blood levels of potassium may be higher than normal when patient is suffering from diabetic ketosis, renal failure, and Addison’s disease. Value decreases when patient is taking Thiazide diuretics and steroid therapy, or also may suggest cushing’s syndrome, cirrhosis with ascites, hyperaldosteronism, malignant hypertension, poor dietary habits, chronic diarrhea, diaphoresis, renal tubular necrosis, malabsorption syndrome, vomiting
March 12, 2009 CHEMISTRY Test
Result
Normal Values
Creatinine
100
53115,000 mmol/L
Resul t Conv ersio n 1.13
Unit
Normal Values
Interpretation
m g/d L
0.5 – 1.3
Normal Values increases in skeletal muscle necrosis/atrophy, starvation, hyperthyroidism, kidney disease,
March 20, 2009 HEMATOLOGY Componen Result Normal Values ts
Interpretation
Hemoglobi n
6.0
M: 13 – 18 gm/dL F: 12 – 16 gm/dL
Decrease level suggest anemia and may also be associated with blood loss (traumatic injury, surgery, bleeding), nutritional deficiency, bone marrow problems, immunosuppression
Hematocri t
17.6 %
M: 42 – 52% F: 35 – 47%
A low hematocrit is referred to as being anemic. Some of the more common reasons are loss of blood (traumatic injury, surgery, bleeding colon cancer), nutritional deficiency (iron, vitamin B12, folate), bone marrow problems (replacement of bone marrow by cancer, suppression by chemotherapy drugs, kidney failure), and abnormal hematocrit (sickle cell anemia).
March 26, 2009 HEMATOLOGY Componen Result Normal Values ts
Interpretation
Hemoglobi n
8.5
M: 13 – 18 gm/dL F: 12 – 16 gm/dL
Decreased level would suggest anemia, acute blood loss, and hemodilution
Hematocri t
24.9 %
M: 42 – 52% F: 35 – 47%
Values decreases in anemia
March 31, 2009 CROSSMATCHING RESULT Blood Typing
Result
Interpretation
ABO
“O”
Individuals with type O blood can receive blood from donors of only type O, so as to prevent hemolytic transfusion reaction.
RH
(+)
Individual who inherited the D antigen. This is to prevent Rh incompatibility reaction. Blood Component
PRBC
Extraction Date: March 28, 2009 Expiration Date: April 1, 2009
To increase oxygen carrying capacity in symptomatic anemia patients
April 7, 2009 CROSSMATCHING RESULT Blood Typing
Result
Interpretation
ABO
“O”
Individuals with type O blood can receive blood from donors of only type O, so as to prevent hemolytic transfusion reaction.
RH
(+)
Individual who inherited the D antigen. This is to prevent Rh incompatibility reaction. Blood Component
PRBC
Extraction Date: April 5, 2009 Expiration Date: May 10, 2009
To increase oxygen carrying capacity in symptomatic anemia patients
Generic Name: cefazolin sodium Brand Name: Ancef, Kefzol Classification: First generation cephalosporin (anti-infective)
MECHANISM OF ACTION
DOSAGE/ FREQUEN CY Interferes with Cefazolin 1 bacterial cell gm TIV q wall synthesis, 8h causing cell to rupture and die.
INDICATION Treatment variety of infections due to susceptible organism: Respiratory tract, GIT, GUT, OTIC, bone, skin soft tissues, post-op infection, bacteremia, septicemia, endocaditis, surgical prophylaxis
ADVERSE REACTION
CONTRAINDICATI ON
Drug induce fever, Hypersensitivity to GI side effects, cephalosporins skin rashes, eosinophilia, allergic nephritis, anaphylactic reaction, hematological changes, headache, dizziness, malaise, shock, cytopenia, thrombocytopenia , alteration of bacterial flora.
NURSING CONSIDERATIO N Monitor CBC, Prothrombin time, Kidney and liver function test result Watch for signs and symptoms of superinfection and other serious adverse reaction Tell patient to report reduce urinary output, persistent diarrhea, bruising and bleeding Instruct the patient to take the drug exactly as prescribed and to complete full course of drug therapy even when he feels better. As appropriate review all other significant life threatening reactions and interactions especially those related to the drugs, test and behaviors
Generic Name: omeprazole Brand Name: Omepron Classification: Proton Pump inhibitor
Generic Name: Nalbuphine HCl Brand Name: Nubain [amp] MECHANISM OF DOSAGE/ INDICATIO ADVERSE CONTRAINDICATI ACTION FREQUEN REACTION ON MECHANISM DOSAGE/ INDICATIONN CY OF ACTION FREQUEN ADVERSE CONTRAINDICATI Binds to opiate receptors Nalbuphine Relief of REACTION Sedation. ON Patients who are CY in the CNS, causing IV moderate Infrequentl Hypersensitivity hypersensitive to to Thought to be Omeprazol10 mg Duodenal ulcer, Headache, inhibition of ascending push q 4 to severe y nalbuphine HCl or a gastric e 40 mg/ gastric ulcer, rarely rash, drug or its pain pathways, altering hours x6 pain. Pre- pruritis, sweating, components. any component, pump reflux the perception of vial and doses op GI upsets, including sulfites; inhibitor in pain;1 vial OD esophagitis, dizziness, response to analgesia,parasthesia, vertigo, pregnancy that it blocks per IV associated produces generalized as a dizziness; (prolonged use or the step duodenal gastric somnolence, CNS final depression supplemen dry mouth; high dosages at of acid ulcers, insomnia,ver t to production by gastroduodenal tigo,headache, term) allergic inhibiting the erosion, balanced diarrhea, anesthesia, reactions. H+/K+ ATPHelicobacter constipation, surgical flatulence, ase system of pylori- associated anesthesia, the secretory peptic ulcer increased for obstet surface of the disease, liver ric the enzyme,mal gastric dyspepsia(in parietal cell. relief of analgesia aise,hyperse symptomsduring in nsitivity labor & patient with reaction epigastricrelief of pain pain/discomfort following with or without MI. Post-op heartburn),Zollin ger-Ellisonsomatic & syndromevisceral pain.
NURSING CONSIDERATION NURSING CONSIDERATION Abrupt discontinuation after sustained Consider dosageuse (generally days) adjustment >10 in those mayhepatic cause withdrawal with failure symptoms. Mixed agonist-antagonist: Avoid activities that Incidence of require mental psychomimetic effect is alertness until drug lower than with effects’ realized; may pentazocine; may cause dizziness precipitate withdrawal in narcotic-dependent For short term use patients. only, drug inhibits total gastric secretion. Side effects of prolonged therapy and suppression of acid secretion alter bacterial colonization and lead to hypochlorhydria which may cause an increased risk for gastric tumors
Classification: Anaesthetics - Local & General, Analgesics (Opioid)
Generic Name: Ketorolac tromethamine Brand Name: Apo-Ketorolac Classification: Non-steroidal anti-inflammatory drug
MECHANISM OF ACTION
DOSAGE/ FREQUEN CY Possesses Ketorolac anti30 mg q 6 inflammatory, hours x 4 analgesic, doses and anti pyretic effects
INDICATION
ADVERSE REACTION
CONTRAINDICATI ON
As a single or multiple dose regimen on a regular or as needed schedule for the management of moderate to severe pain that requires analgesia at the opioid level
Systemic use: Headache, dizziness, drowsiness, diarrhea, nausea, dyspepsia/indigestio n, epigastric pain, edema
Hypersensitivity to the drug or allergic symptoms; Active peptic ulcer disease; those at risk for renal failure
NURSING CONSIDERATIO N 1. Use as a part of a regular analgesic rather than on an as needed basis 2. Do not mix IV/IM in a small volume(i.e, a syringe) with morphine sulfate, meperidine, HCL, promethazine HCL, or hydroxyzine HCL; will precipitate from solution
Generic Name: tramadol hydrochloride Brand Name: Ultram Classification: Non-steroidal anti-inflammatory drug
MECHANISM OF ACTION Inhibits re uptake of serotonin and norepinephrin e in the CNS
DOSAGE/ FREQUENC Y Tramado l 100 mg/amp 1 amp q8h for pain
INDICATION
ADVERSE REACTION
CONTRAINDICATI ON
For moderate to severe acute or chronic pain e.g. cancer or post op pain
Seizures, hypersensitivity reactions, respiratory depression; CV, CNS, musculoskeletal and urogenital disorder, nausea, vomiting, abdominal distention,anorexia, dependence,
Acute intoxication with alcohol, analgesics, hypnotics or psycho tropics, patients receiving MAOI’s , severe respiratory depression, cerebral pathology
NURSING CONSIDERATIO N assess patient’s response to drug 30 mins. after dministration Monitor respiratory status, withhold drug and contact prescriber if respiration becomes shallow or slower than 12 cpm Inform patient that drug can cause physical and psychological dependence.
Generic Name: Paracetamol Brand Name: Aeknil Classification: Analgesics (Non-Opioid) & Antipyretics
MECHANISM OF ACTION Paracetamol is
DOSAGE/ FREQUENC Y Paracetamo l 300 mg Iv prn for temp. >380C
INDICATION
ADVERSE REACTION
Pyrexia of
Skin
unknown origin
eruption,
and for
hematologic
symptomatic
al toxicity
relief of fever
e.g.,
and pain
thrombocyto
associated with
penia and
common
leucopenia,
peak plasma
childhood
methemoglo
levels are
disorders,
binaem-ia
attained in 10
tonsillitis, upper which can
min to 1 hr and
respiratory
result in
the half-life is
tract infections,
cyanosis,
75 min to 3 hrs.
post-
and on long-
Distribution of
immunization
term use,
paracetamol to
reactions, after
renal
most body
tonsillectomy
damage can
tissues and
and other
result.
fluids is both
conditions
rapid and
where patient is
uniform.
unable to take
Approximately
oral
85% of a dose
medications but
of paracetamol
where
is excreted in
paracetamol
the urine within
can be
24 hrs after
administered
administration.
with advantage.
rapidly and almost completely absorbed from the GIT. Following oral administration,
Paracetamo l 1 amp IV prn basis for temp >37.80C
For prevention
CONTRAINDICATIO N Nephropathy.
NURSING CONSIDERATION 1. Never take more than 2 tablets (of 500mg each day) at any one time and no more than 4 times in 1 day. 2. Paracetamol may be taken with or without food. 3. If you need pain relief fast, take it on an empty stomach as food may slow down the absorption of paracetamol. 4. Do not double a dose under any circumstances. 5. Do not take paracetamol of you have liver or kidney problem. 6. Do not take this medicine with other products that contain paracetamol. 7. Avoid alcohol
Generic Name: ferrous sulfate Brand Name: Apo ferrous sulfate Classification: Anti Anemic Iron
MECHANISM OF ACTION Iron is absorbed from the duodenum and upper jejunum by anactive mechanism through the mucosal cells where it combines with the protein transferring and is stored in the body as hemosiderin or aggregated ferritin w/c is found in the reticuloendothelia l cells of the liver, spleenand bone marrow
DOSAGE/ FREQUEN CY Ferrous sulfate 1 tab OD
INDICATION Prophylaxis and treatment of iron deficiency and iron deficiency anemia; dietary supplement for iron
ADVERSE REACTION
CONTRAINDICATI ON
GI irritation and blackening of stool, constipation, nausea and anorexia, diarrhea
Hemosiderosis, hemochromatosis, peptic ulcer, regional enteritis, ulcerative colitis. Hemolytic anemia, pyridoxine responsive anemia, liver cirrhosis
NURSING CONSIDERATI ON Eggs, milk, coffee or tea consumed with a meal or 1 hour after may significantly inhibit the absorption of dietary iron Ingestion of calcium and iron supplements with food can decrease absorption by 1/3 Note any GI bleeding, tarry stools or bright blood in stool or vomitus Note any complaints of fatigue, pallor. Poor skin turgor or change in mental status Take with meals
Date: 4/17/09 Subjective: > “ Masakit tong mga sugat ko” as verbalized by the patient.” Pain scale of 8 out of 10. Objective: > V.A.S. >guarding behaviors >restless >narrowed focus Date: 4/17/09 Subjective: “Nadamay lang naman ako eh, tapos ganito na nangyari”, as verbalized by the patient.
Objective: > amputated R arm > Negative feelings about body/self, >fear of rejection >Focus on past appearance, abilities;
Date:4/17/09 Subjective: “Eto nga eh putol na yung kamay ko, tas ung kabila sunog din.”as verbalized by the patient. Objective: >absence of viable tissue on L arm > c multiple lesions on extremities and trunk > presence of fluid exudates on injured areas
PDAGDAG NLNG N2 SA P.A OR SA S & S HYPOTENSIVE UNG PATIENT THROUGHOUT OUR SHIFT
