Ptb - Ncm 101 Grand Case

Intr oductio n The rising incidence of tuberculosis has economic repercussions not only for the patient’s family but also for the country. Eighty percent of people afflicted with tuberculosis are in the most economically productive years of their lives, and the disease sends many self-sustaining families into poverty. The rise in the incidence of tuberculosis has been due to the low priority accorded to anti-tuberculosis activities by many countries. The unavailability of anti-TB drugs, insufficient laboratory networking, poor health infrastructures, including a lack of trained health personnel, have also contributed to the rise in the incidence of the diseases. According to the World Health Organization, the Philippines ranks sixth in the world for the number of cases of tuberculosis and has the highest number of cases per head in Southeast Asia. Almost two thirds of Filipinos have tuberculosis, and up to five million people are infected yearly in our country.

Tuberculosis At A Glance Tuberculosis (TB) is an infection, primarily in the lungs caused by bacteria called Mycobacterium tuberculosis. It is spread usually from person to person by breathing infected air during close contact. TB can remain in an inactive (dormant) state for years without causing symptoms or spreading to other people. When the immune system of a patient with dormant TB is weakened, the TB can become active (reactivate) and cause infection in the lungs or other parts of the body. The risk factors for acquiring TB include close-contact situations, alcohol and IV drug abuse, and certain diseases (for example, diabetes, cancer, and HIV) and occupations (for example, health-care workers). The most common symptoms of TB are fatigue, fever, weight loss, coughing and night sweats. The diagnosis of TB involves skin tests, chest x-rays, sputum analysis (smear and culture), and PCR tests to detect the genetic material of the causative bacteria. Inactive tuberculosis maybe treated with an antibiotic to prevent the TB infection from becoming active. Active TB is treated, usually successfully with combination of one or more of several drugs. Drug-resistant TB is a serious, as yet unsolved, public health problem, especially in Southeast Asia, the countries of the former Soviet Union, Africa, and in prison populations. Poor patient compliance, lack of detection of resistant strains, and unavailable therapy are the key reasons for the development of drug-resistant TB. The occurrence of HIV has been responsible for an increased frequency of tuberculosis. Control of HIV in the future, however, should substantially decrease the frequency of TB.

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History * 1882 * “Consumption” * 1940s * mid 80s-90s * March 24, 1997 * (1963)- May 2007

 Global Impact of Tuberculosis One third of the world’s population is infected with the TB bacillus. There are 8 million new cases of TB each year and 3 million people die of the disease (170,000 cases are children). TB is the leading cause of death in HIV-infected persons.

PAT IE NT’ S PROF IL E           

Name: LML Address: PLC Poblacion, Muntinlupa City Date of Birth: October 27, 1959 Age: 49 years old Sex: Female Civil Status: Married Nationality: Filipino Religion: Roman Catholic Occupation: Housewife Admission Date/Time: August 25, 2008 - 2:00 pm Attending Physician:Dr. E.S.

ADMI TTI NG HI ST ORY: This is a case of a 49 year old, female, diabetictype 2, non-hypertensive patient who was admitted at Alabang Medical Clinic last August 25, 2008 around 2:00 pm, with complains of difficulty of breathing and body weakness. Two months prior to admission, the patient experienced progressive body weakness, decreased appetite, with productive coughing, and pleuritic chest. The husband was prompted to bring her to the hospital for further evaluation, since the patient was known to have DMII, lost to follow up for the entire 8 months and had stopped taking her medications.

Ph ysic al Asse ssm ent: >GS: conscious, coherent >Skin: pale >HEENT: pinkish palpebral conjunctivae, palpable lymph nodes >C/L: symmetrical chest expansion, harsh crackles breath sound heard on upper lobe of left lung >Heart: Normal Rate Regular Rhythm, (-) murmurs >Abdomen: Unremarkable >GUT/Genitalia: Unremarkable >IE: Unremarkable >Extremities: Unremarkable

Admitting Impression: Diabetes Mellitus 2, poorly controlled r/o Pneumonia t/c Pulmonary Tuberculosis

Final Diagnosis: Pulmonary Tuberculosis, Category 2, stage3

Past Medical History: >4x hospitalization- gave birth (normal delivery) >4x hospitalization- due to illnesses (DM, PTB) >initiates self-medication on simple illnesses such as colds, cough, and fever(paracetamol, alaxan, tuseran forte). Family History: FATHER MOTHER DIABETES (-) (+) HYPERTENSION (-) (-) ASTHMA (-) (+) The patient had family history of diabetes, as well as respiratory disease such as asthma. According to the patient, she had no childhood immunizations particularly BCG vaccine, which made her susceptible to acquire respiratory diseases such as Tuberculosis. Social History: The patient resides in a congested environment, unemployed since the birth of her first child and lives a sedentary lifestyle.

Ana tom y a nd Phy si ol og y

URT

LRT

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Is a membraneous tube that consists of dense regular connective and smooth muscle reinforced with 15-20 "C"-shaped pieces of cartilage. Cartilages form the anterior and lateral sides.  Protect the trachea and maintain an open passageway for air. Posterior wall contains no cartilage and consists of a ligamentous membrane and smooth muscle which can alter the diameter of the trachea. Esophagus lies immediately posterior to the cartilage-free posterior wall of the trachea. · Trachea is lined with pseudostratified ciliated columnar epithelium that contains numerous goblet cells.

 Bronchi  Trachea divides into the right and left primary bronchi.  Right bronchus is shorter and wider and is more vertical than the left bronchus.  Primary bronchi extend from the mediastinum to the lungs.  The lining of the bronchi is the same as the trachea and the bronchi are supported by "C"-shaped cartilage rings.

How Does Lungs protect themselves: ◙ First, the nose acts as a filter when breathing in, preventing large particles of pollutants from entering the lungs. ◙ If an irritant does enter the lung, it will get stuck in a thin layer of mucus (also called sputum or phlegm) that lines the inside of the breathing tubes. ◙ Mucus is "swept up" toward the mouth by little hairs called cilia that line the breathing tubes. ◙ The last of the common methods used by the lungs to protect themselves can also create problems. The airways in the lungs are surrounded by bands of muscle. When the lungs are irritated, these muscle bands can tighten, making the breathing tube narrower as the lungs try to keep the irritant out. The rapid tightening of these muscles is called bronchospasm

◙ Cough and sneeze reflex:

Irritant touches the surface of the glottis, Trachea or bronchus. ↓ Sensory signals are transmitted to the medulla. ↓ Motor signals are transmitted Back to the respiratory system. ↓ Respiratory muscles contract very rapidly Generating high pressures in the lungs while The vocal cords remain tightly closed. ↓ Vocal cords open suddenly, allowing pressurized air in the lungs to flow out in a blast

Muscles involved in respiration Quiet

Forced (in addition to muscles involved in quite respiration)

Inspiration

Diaphragm (contraction) Intercostal muscles (to prevent inward bellowing) Scalene muscles

Sternocleidomastoid muscle Pectoralis muscles Serratus anterior muscle Erector spinae Quadratus lumborum

Expiration

Elastic recoil of the lungs Abdominal muscles Intercostal muscles (to Latissimus dorsi prevent outward bellowing) Diaphragm (relaxation)

Laboratory Re sults

WBC

RESULT

NORMAL VALUES

He matolo gy 0 8-2 5 15.1 x 10 9/L

5-10 x 10 9/L

3.0 x 10 12/L

M 4.5-5.5 F 4.0-5.0

NEUTROPHIL SEG

0.88

0.55-0.70

LYMPHOCYTE

0.12

0.20-0.35

RBC

DIFFERENTIAL COUNT

EOSINOPHIL

0-0.01

MONOCYTE

0.03-0.05

PLATELET COUNT

603.00

142-424,000 UL

HGB

86 g/l

M 130-160 F 120-140

HCT

0.26

M 0.42-0.50 F 0.37-0.47

OTHERS

Hgt 144 mg/dl

WBC

RESULT

NORMAL VALUES

He matolo gy 0 8-2 6 9.6

5-10 x 10 9/L

3.85

M 4.5-5.5 F 4.0-5.0

NEUTROPHIL SEG

0.83

0.55-0.70

LYMPHOCYTE

0.13

0.20-0.35

RBC

DIFFERENTIAL COUNT

EOSINOPHIL

0-0.01

MONOCYTE

0.04

0.03-0.05

PLATELET COUNT

Adequate

142-424,000 UL

HGB

110 g/l

M 130-160 F 120-140

HCT

0.33

M 0.42-0.50 F 0.37-0.47

Blo od Ch em 0 8-2 6 RESULTS

UNITS

NORMAL VALUES

90

Mg/dl

70-105

HOL

101

Mg/dl

140-310

G

107

Mg/dl

35-160

RIC

425.14

Umol/l

155.00-428.00

UN

4.98

Mmol/l

2.90-8.20

LT

7

IU/L

10-40

ST

14

IU/L

10-42

DLD

13.63

Mg/dl

29.00-71.54

DL

66.0

Mg/dl

66.0-178.0

LDL

21.40

Mg/dl

0.00-40.00

LU

ABG 08-27 RESUL T

NORMAL VALUES

pH

7.46

7.35 – 7.45

PAO2

73.4

95 – 100 mmHg

PACO2

31.7

35 – 45 mmHg

HCO3

22

22 – 26 mEq/L

TCO2

23

25 - 30 mmol/l

BE

-1.8

-2 to +2 mmol/l

O2 SAT

95.60%

96% - 98%

X-r ay Chest x-ray The left lung is hyper aerated. Both lobes have multiple, thin-walled, lucent structures with no bronchovascular structures. Thick pleura covers the lung from apex to base, including the sinuses. The right upper lobe has soft densities. The rest of the right lung fields are clear. The heart size cannot be assesses. The left hemidiaphragm is indisctinct. A long horizontal fluid interface is projected on it. The right hemidiaphragm is normal. The thoracic cage is normal. Impression: Extensive PTB with destroyed left lung. Empyema in the legt hemithorax is suspected. Suggest doing a left lateral decubitus film.

Sp utu m te st 08-2 8 AFB Stain Day 3 Greater than 25 polymorphonuclear cells Less than 25 epithelial cells Positive for acid fast bacilli: 3+ More than 10 AFB/OIF in at least 20 visual fields Day 2 Greater than 25 polymorphonuclear cells Less than 25 epithelial cells Positive for acid fast bacilli: 3+ More than 10 AFB/OIF in at least 20 visual fields Day 1 Greater than 25 polymorphonuclear cells Less than 25 epithelial cells Positive for acid fast bacilli: 3+ More than 10 AFB/OIF in at least 20 visual fields

He moglobin A1 C

A1C CONCENTRATION

RESUL T

NORMAL VALUES

5.7%

3.82%-6.52%

Ult raso und 0 8-25 Chest ultrasound Real time scanning of the left lung shows fluid with estimate volume of 157cc. Impression: Pleural effusion, left.

Blo od c hem 0 8-2 6

POTASSIU M

RESUL T

NORMAL VALUES

4.05

3.5-5.3 mmol/L

Blo od c hem 0 8-2 5

RESULT S

UNITS

NORMAL VALUES

NA

130.3

Mmol/l

135.0-145.0

K

2.54

Mmol/l

3.60-5.00

CREA

96.82

Umol/l

53.00-115.00

Cr oss-ma tching report 08-2 5 Patients ABO Type “O” RH+ Donor’s ABO Type “O” RH+

RESULT

NORMAL RESULTS

PHYSICAL

Ur in alysi s 0 8-2 5 COLOR

Yellow

Straw - Dark yellow

TRANSPARENCY

Hazy

Clear - Hazy

pH

6.0

4.5-7.8

SPECIFIC GRAVITY

1.020

1.003-1.029

EPITHELIST CELLS

Moderate

small amounts

PUS CELLS

35-40/hpf

RBC

0-3/hpf

male: 0-3/hpf female: 0-5/hpf

BACTERIA

Few

Negative

OTHERS

Ketones (-)

Negative

SUGAR

Negative

Negative

ALBUMIN

trace

MICROSCOPIC

CHEMICAL

Tr oponin t est Troponin – 1

negative

Med ical Man age me nt

August 25, 2008 Hgt: 214mg/dl

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Admit to room of choice under Dr. Jarcia Secure consent TPR every shift Diabetic diet Complete Blood Count Accurate Platelet Count Hemoglucotest Electrocardiogram Chest x ray Urinalysis with urine ketones Stat serum sodium, potassium Creatinine Fasting Blood Sugar Glycosylated hemoglobin Blood Urea Nitrogen Uric acid Lipid profile Alanine Aminotransferase (ALT), Aspartate Aminotransferase (AST)

 IVF: Plain NSS 1 L to run for 8 hours  Plain NSS 1 L to run for 12 hours  Humulin R 5 units subcutaneous  Vital sign every 1 hour and record  Refer accordingly  Esomeprazole (Nexium) ampule 40 mg once a day IV  Erdosteine (Ectrin) 300 mg tablet twice a day by mouth  Cefuroxime 750 mg every 8 hours IV After negative skin test  1 Nebule Salbutamol every 4 hours

August 25, 2008 4:55 pm

 Prepare and transfuse 2 units Packed Red Blood Cell properly typed and cross matched to run 5 hours each with 2 hours interval  Benadryl 1 ampule prior to each blood transfusion  Oxygen at 4 liters/minute as needed for dyspnea

August 25

 Refer to Dr. Jennie Estrada for comanagement  Incorporate 40 mEq Potassium Chloride to the present IVF  Kalium Durule 1 tablet twice a day  hemoglucotest every 6 hours and record  Transderm patch 5 mg anterior chest wall once a day

7:35 pm

 Incorporate 40 mEq Potassium Chloride to the next IVF  Plain NSS 1 L x KVO once on blood transfusion. Please insert another line

8:20 pm

 Paracetamol tablet 500 mg tablet every 4 hours as needed for temperature ≥ 37.6 C

August 26, 2008 9:15 am

 Please do chest ultrasound with marking

1:30 pm

 IVF to follow: Plain NSS 1 L + 40 mEq Potassium Chloride x 10 hours

August 26

 Repeat Complete Blood Count 6 hours post blood transfusion

August 26

 For hemoglucotest twice a day pre meals

8:00 pm

 IVF to follow Plain NSS 1L + 40 mEq Potassium Chloride x 10 hours

August 27, 2008 3:48 am Attending physician informed IVF to follow x KVO

 No need for now  Discontinue on the left (IVF)

8:45 am

 IVF to follow 1L Plain NSS 1L x KVO

August 27

 Please maintain oxygen at 5 liters/minute

August 27

 Please maintain oxygen at 5 liters/minute

5:20 pm

 Decrease nebulization to every 6 hours

August 27

 Glimepiride 1 mg 1 tablet pre breakfast  Transfer service to Dr. Jennie Estrada

August 28, 2008 12:30 pm

 Culture and sensitivity and sputum acid fast bacilli smear results  Ferrous Sulfate (United Home) 325 mg 1 tablet twice a day

5:30 pm Informed of Hgt: 54 mg/dl Asked if for repeat Hgt afterwards

 Please advise her to eat on schedule. Increase Hgt monitoring to three times a day

8:30 pm Informed of blood pressure: 90/60 Asked if Nitroglycerin patch should be continued

 Hold Nitroglycerin patch for now

August 29, 2008 5:00 am Attending physician’s informed regarding 61 mg/dl and resident on duty informed

 Let the patient eat then re-check after 1 hour

6:30 am Attending physician regarding the latest Hgt result 71 mg/dl

9:30 am

 To follow: Plain NSS 1 L x KVO

10:45 am

 Hemoglucotest:35  Please give D50-50 IV now  Repeat hemoglucotest after 1 hour

11:00 am Attending physician informed hemoglucotest:35 and that D50-50 IV is ongoing

 Hold antibiotic medications  Give D50-50 IV PRN for hemoglucotest <80mg/dl

12:00 pm  Hemoglucotest :53 mg/dl (premeals)  Referred to resident on duty

 Let patient eat her lunch first

August 29, 2008

 To consume tablets if Kalium durule then discontinue  Hold Glimeperide  IVF to follow D5NSS 1 L to run for 12 hours  Start Myrin P Forte 3 tablets OD(before breakfast)  Please incorporate Benutrex-C 1 ampule to present IVF for 3 cycles

5:30 pm  Hemoglucotest : 54mg/dl  Asked if D50-50 is to be given.

 Please advise patient to eat. Repeat hemoglucotest afterwards. If still low may give due D5050 1 vial

 Attending physician informed of hemoglucotest: 58mg/dl  Patient was asked to eat

 Ok. Thanks

11:30 pm  Resident on duty informed regarding patient complaints  Avail stocks 16mg

 Give SERC 8mg/tab  Ok give 16mg/tab

 Do ECG, then do August 30, 2008 hemoglucotest,if the 2:20 am result is 80 mg/dl  Resident on duty give D50-50 informed about patient’s condition, cold and clammy BP90/60mm/Hg

 Hemoglucotest: 38 mg/dl

 Give D50-50 again

9:00 am

 Repeat Hemoglucotest

11:00 am

 Refer to Endocrinologist  Follow up blood c/s

 Please elevate left 12:30 pm leg with 2 pillows  Resident on duty and  FD 800 cc then attending physician informed of BP increase hour to 6 80/50. hours Endocrinologist not available

2:20 pm  Resident on duty informed of patient Hemoglucotest: 76 mg/dl as of 7 am

 To follow: D5NSS to run for 6 hoursLet the patient eat her lunch May not repeat hemoglucotest

9:30 pm

 Please follow blood c/s result

9:50 pm

 Problem: BM 8 times since am, small amount  For stool examination  Kindly update attending physician

11:15 pm

 IVF to follow: D5NSS 1L + Benutrex-C 1 ampule to run for 6 hours

August 31,2008 1:30 am

 Facilitate fecalysis

7:00 am

 IVF to follow: D5NSS 1L + Benutrex-C 1ampule to run for 6 hours

3:40 pm  Attending Physician informed of 4 times BM

 Please do fecalysis now  Start Erceflora 1 vial TID

6:35 pm

 TF: D5NSS 1 L + 1 ampule Benutrex-C to run for 6 hours for 2 cycles.

11:00 pm

 TF blood c/s formal report  To consume tablets of Kalium durule then discontinue  Facilitate fecalysis  Start Streptomycin 1.5 mg (ANST) IM 3 times a week (M-WR)

September 1, 2008 2:13 pm

 To consume stocks of Tazocin then to Unasyn 750 mg/tablet; 1 tablet BID

 To consume stocks of Tazocin then to Unasyn 750 mg/tablet; 1 tablet BID

 Let the relative look on other drugstores  IVF TF: D5NSS + 1 ampule Benutrex-c to run for 8 hours in 2 cycles

9:15 pm

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To consume IVF then discontinue May go home for request tomorrow am Therapeutics: Unasyn 750 mg in 2 daysLevox 500 mg OD in 8 days Myrin P Forte 3 tablets OD in 5-7 days Streptomycin 1.5 mg IM 3 times a week (M-W-R) (ANST) To consume tablets of other medications and discontinue.OPD to follow on September 18, 2008, Thursday, 10:00 am

11:00 pm

 Thanks. Discontinue HGT monitoring

Drug S tudy

Ethambutol

Generic Name -Ethambutol

Brand Name -Myrin P Forte

Classification -Anti-TB Agents

Dosage -3 tab OD in 5 to 7 days before breakfast.

Mechanism of Action -Ethambutol interferes with RNA synthesis, causing suppression of Mycobacteria multiplication. It also has bacteriostatic action against M tuberculosis by acting on rapidly growing pathogens in cavity walls and is also effective in slowgrowing pathogens.

Indication

Contraindication

Side effects

-Initial phase treatment & retreatment of all forms of TB in category I & II patients caused by susceptible strains of mycobacteria.

-Alcoholism, optic neuritis, impaired hepatic function, severe renal insufficiency, hyperuricemia, gouty arthritis, jaundice, retrobulbar neuritis. Pregnancy & lactation.

-Disorders of the blood & lymphatic system, immune system, metabolism & nutrition, CNS, eye, GI, hepatobiliary, skin & SC tissues, musculoskeletal, connective tissue & bone, renal/urinary, reproductive system & breast. Fever, malaise, flu-like syndrome, dryness of mouth.

Nursing Consideration -Perform visual acuity and color descrimination test before and during the therapy. -Assess liver and renal function before and during the therapy. -Assess patient mental status often: affect mood, behavior change. watch out for confusion and hallucination -Assess patient for visual disturbance that may indicate optic neurisyis

Streptomycin

Generic Name -Streptomycin

Brand Name -Streptomycin

Classification Aminoglycosides

Dosage -1.5G ANST(-) IM 3TYMS 2 WEEK (M-W-F0

Mechanism of Action -Inhibits protein synthesis in bacterial cell by building direct to 30S ribosomal subunits, causing inaccurate peptide sequence to form In protein chain, resulting in bacterial death.

Indication

Contraindication

Side effects

-Part of combination therapy of active tuberculosis; use in combination with other agent for treating of streptococcus or enterococcal endocarditic, mycobacterial infection, plague, tularemia, and brucellosis

-Pregnancy; hypersensitivity

-Abnormal skin sensation around the face; vertigo; fever -Severe allergic reactions (rash; hives; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); decreased urination; dizziness; headache; hearing loss; hives; lightheadedness; loss of balance; muscle weakness; nausea; numbness or tingling; ringing or roaring in the ears; skin rash or itching; vaginal irritation or discharge; vomiting

Nursing Consideration -Assess patient with previous sensitivity reaction. -Assess patient with signs and symptoms of infection including characteristic of sputum, urine, stool, WBC>10,000/mm3 -Obtain baseline information before and during treatment -Identify urine output, If decrease, notify physician. -Assess over growth of infection: perineal itching, fever redness, pain swelling, drainage, rash, diarrhea, chain in cough sputum. -Monitor input and output, report sudden change

Levofloxacin

Generic Name -Levofloxacin

Brand Name -Levaquin -Quixin

Classification - Antibiotic -Fluoroquinolone

Dosage -500 mg OD in 8 days.

Mechanism of Action -The levorotatory isomer of ofloxacin which inhibits DNA topoisomerase, more commonly referred to as the DNA gyrase. DNA gyrase is necessary for bacterial DNA replication and some aspects of transcription, repair, recombination and transposition. Inhibition of DNA gyrase in susceptible microorganisms results in the inhibition of ATPdependent negative supercoiling of DNA, inhibition of ATPindependent relaxation of supercoiled DNA and promotion of doublestranded DNA breakage resulting in bacterial cell death.

Indication

Contraindication

- Treatment of adults -Hypersensitivity to ≥18 yr w/ mild, quinolones. IV moderate & severe Epilepsy, history of infections caused by tendon disorders susceptible strains of related to microorganisms in fluoroquinolone the following therapy. Childn, conditions: pregnancy & Community-acquired pneumonia lactation. , acute bacterial exacerbation of chronic bronchitis, acute maxillary sinusitis, complicated & uncomplicated skin & skin structure infections, acute pyelonephritis, complicated & uncomplicated UTI, nosocomial pneumonia, chronic bacterial prostatitis.

Side effects - Diarrhea, abdominal discomfort, nausea, anorexia, abdominal pain, vomiting, stomatitis & heartburn; insomnia, headache & dizziness; rash, pruritus & eczema; muscle & joint pain; bone marrow depression. Increased liver enzymes. Pain, reddening at the inj site, phlebitis.

Nursing Consideration - Store in a dry place at temperatures not more than 30°C. - Should be used with caution in patients with a known or suspected CNS disorder that may predispose to seizures or lower seizure threshold -Take the oral solution 1 hr before or 2 hrs after eating. -Avoid multivitamins with zinc, iron products, sucralfate, and Mg- or Alcontaining antacids 4 hr before and after dose.

Ampicillin

Generic Name -Ampicillin Salbactam

Brand Name -Unasyn -Ampicillin Sodium

Classification -Antibiotic -Penicillin

Dosage -750 mg 1 tab BID for 11 days

Mechanism of Action -synthetic, broad spectrum antibiotic suitable for gramnegative bacteria. Acid resistant, destroyed by penicillinase.

Indication

Contraindication

Side effects

-respiratory tract infections due to nonpenicillinaseproducing Haemophilus influenzae -GI infections -GU infections -use of the injection only for bacterial meningitis -use of the injection for septicemia and endocarditis

- Hypersensitivity; infectious mononucleosis.

-hypersensitivity -nausea -vomiting -gastritis -stomatitis

Nursing Consideration -Take 1 hr before or 2 hr after meals; food may interfere with absorption -Take for prescribed number of days -Ampicillin chewable tablets should not be swallowed whole -May decrease effectiveness of oral contraceptives -Do not save for future use or share with family members/friends who have similar symptoms

Cefuroxime

Generic Name -Cefuroxime

Brand Name -Romicef

Classification Cephalosporins

Dosage -750mg IV q 8 ANST (-)

Mechanism of Action -Cefuroxime binds to one or more of the penicillin-binding proteins (PBPs) which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell wall, thus inhibiting biosynthesis and arresting cell wall assembly resulting in bacterial cell death.

Indication

Contraindication

Side effects

-Treatment of infections caused by Staphylococcus, Strepcoccus, pneumococci, meningococci & other susceptible microorganisms.

-Hypersensitivity to cephalosporins.

-Diarrhea; -nausea & vomiting -abdominal pain

Nursing Consideration -Give Cefuroxime at same time each day. -Do not give if the patient have diarrhea, a stomach or intestinal infection, or a blood clotting problem -Assess for severe allergic reaction. -Check the patency of IV line before administration.

Piperacillin + Na Tazobactam

Generic Name - Piperacillin + Na Tazobactam

Brand Name -Tazocin

Classification -Penicillins

Dosage - 750 mg per tablet, 1 tablet BID

Mechanism of Action -The combination has activity against many Gram-positive and Gram-negative pathogens and anaerobes, including Pseudomonas aeruginosa. -Triggering of the pneumococcal autolytic enzyme by inhibitors of cell wall synthesis.

Indication

Contraindication

Side effects

- Treatment of infections in the lower resp tract eg severe community-aquired pneumonia & healthcare pneumonia; uncomplicated & complicated skin & skin structure infections; intraabdominal infections w/ peritonitis eg complicated appendicitis; complicated & uncomplicated UTI; gynecologic infection eg postpartum endometritis or pelvic inflammatory disease; bacterial infection in neutropenic patients

-Hypersensitivity to penicillins, cephalosporins & βlactam inhibitors.

-Upset stomach, vomiting, unpleasant or abnormal taste, diarrhea, gas, headache, constipation, insomnia, rash, itching skin, swelling, shortness of breath, unusual bruising or bleeding.

Nursing Consideration - May prolong bleeding time when used with anticoagulants - Assess hematopoietic function periodically. - Perform periodic electrolyte determinations in patients with low K reserves. - Increased risk of fever and rash in patients with cystic fibrosis. Increased risk of bleeding manifestations. Prolonged treatment may increase risk of superinfections.

Erdosteine

Generic Name -Erdosteine

Brand Name -Ectrin

Classification -Mucolytics

Dosage -300mg 1 cap. 1 cap BID PO

Mechanism of Action -Peak plasma levels are reached after 3060 min. Ectrin has subsequent complete metabolism in similar metabolites.

Indication

Contraindication

Side effects

-Acute bronchitis, chronic bronchitis & its exacerbations. Resp disorders characterised by abnormal bronchial secretions & impaired mucus transport

-Hepatic cirrhosis & cystathioninesynthetase enzyme deficiency. Phenylketonuria (susp only).

-No gastrointestinal nor systemic side effects due to Ectrin have been observed..

Nursing Consideration -Monitor the effect of the drugs. -Watch out for the adverse reaction. -monitor RR

USW c Salbutamol

Generic Name -Salbutamol

Brand Name -Aero Vent

Classification -Antiasthmatic -COPD Preparation

Dosage -1 nebule Salbutamol every 4 hrs

Mechanism of Action -Bronchodilator. -Salbutamol is a βadrenergic stimulant which has a highly selective action on the receptors in bronchial muscle and in therapeutic doses, it has little or no action on the cardiac receptors.

Indication

Contraindication

Side effects

-Indicated in the treatment of acute severe asthma & in routine management of chronic bronchospasm unresponsive to conventional therapy.

-Patients with a history of hypersensitivity to any of the components of AeroVent.

-A small increase in heart rate may occur in patients who inhale a large dosage of salbutamol. This is not usually accompanied by any changes in the electrocardiogram. Other side effects which occur with very high doses of salbutamol by inhalation are peripheral vasodilatation and the fine tremor of skeletal muscle.

Nursing Consideration -Salbutamol 2.5-mg nebules should be used with care in patients known to have received large doses of other sympathomimetic drugs. It should be administered cautiously to patients suffering from thyrotoxicosis. -Great care is also needed in patients with cardiovascular disease -An increased risk of arrhythmias may also occur if sympathomimetic agents are given -the potential for paradoxical bronchospasm should be kept in mind

Nitroglycerin

Generic Name -Nitroglycerin

Brand Name -Nitro 5TT

Classification -Anti-Anginal Drugs

Dosage -Transderm patch 5 mg anterior chest wall once a day

Mechanism of Action -Glyceryl trinitrate dilates the peripheral blood vessels thus reducing the workload of the heart. Deponit NT 5/10 is designed to release a constant amount of glyceryl trinitrate onto the skin and then by transdermal absorption directly into the systemic circulation. The oncedaily application will ensure that the patient receives sufficient glyceryl trinitrate for prophylaxis against attacks for 24 hrs.

Indication

Contraindication

Side effects

-Prophylaxis of angina pectoris. Long-term treatment of CHD. Treatment of chronic heart failure in combination w/ digitalis &/or diuretics.

-Acute circulatory failure (shock), severe hypotension, acute myocardial infarction.

-Headaches may develop initially but usually, these will disappear after a few days. There is also the possibility of reflex tachycardia, postural hypotension, nausea and dizziness. Allergic skin reactions may occur in sensitive patients.

Nursing Consideration -Assess for chest pain before administration of drugs. -Monitor V/S -Should not be used during the first 3 months of pregnancy unless advised by the physician. -It increases the antihypertensive properties of vasodilators, calcium antagonists, antihypertensives, tricyclic antidepressants and alcohol. -Not suitable for acute anginal attacks

Humulin R

Generic Name -Humulin R

Brand Name -Eli Lilly

Classification -Insulin Preparations

Dosage -Humulin R, 5 units SQ.

Mechanism of Action Neutral human insulin of recombinant DNA origin. A short-acting preparation that may be administered by SC or IV injection. Onset of action occurs at approximately 30 min, with a duration of about 5 hrs and peak activity at 1-3 hrs.

Indication

Contraindication

Side effects

-Treatment of diabetes mellitus for the control of hyperglycemia.

Hypoglycemia.

Sweating, dizziness, palpitation, tremor, hunger, restlessness, tingling in the hands, feet, lips or tongue, lightheadedness, inability to concentrate, headache, drowsiness, sleep disturbances, anxiety, blurred vision, slurred speech, depressive mood, irritability, abnormal behavior, unsteady movement and personality changes. -Hypoglycemia

Nursing Consideration -If the insulin substance (the cloudy material) settles at the bottom of the bottle, the bottle must be carefully rotated before the injection. -Should not be used if it is cloudy, unusually viscous, precipitated or even slightly colored. -Always examine the appearance of the insulin before administering a dose. -Do not use if the insulin substance (the white material) remains visibly separated from the liquid after mixing. -Hold if there is signs of hypoglycemia

Glimepiride

Generic Name -Glimepiride

Brand Name -Acotril tab

Classification -Oral anti diabetic agent

Dosage -1mg/tab 1tab prebreakfast

Mechanism of Action -Blood glucose lowering through stimulation of insulin release from the pancreas and insulin sensitivity at receptor site; reduction of basal hepatic glucose secretion; ineffective if patients lacks functioning beta-cell

Indication

Contraindication

Side effects

-Type 2 DM when hyperglycemia cannot be adequately controlled by diet & exercise alone. -Combination therapy w/ metformin & insulin when the use of either of these agents alone is inadequate to control hyperglycemia.

-Hypersensitivity to sulfonylureas. Impaired renal function. Insulindependent (type 1) DM. Ketoacidosis (w/ or w/o coma). Severe infection, trauma. Pregnancy & lactation.

-Hypoglycemia chest pain or irregular heartbeat; confusion; dark urine; fainting;

Nursing Consideration -Assess for allergies prior to start of the therapy -Assess for potential inter action with other prescription, OTC medication or herbal products the patient may be take -Monitor CBC, glcosylated Hgb (baseline every 3 months) while ongoing treatment check liver test function periodically. AST,LDH and renal studies -Hold if there are signs of hypoglycemia.

Esomeprazole Generic Name -Esomeprazole

Brand Name -Nexium iv

Classification -Antacid -Antireflux agents -Antiulcerants

Dosage -IV vial 40 mg OD

Mechanism of Action -Inhibits the H+K+ATPase pump (proton pump) in gastric parietal cells effectively blocking the final step in acid production, thereby reducing gastric acidity.

Indication

Contraindication

Side effects

-Treatment of gastroesphageal reflux disease (GERD) as an alternative to oral therapy in patients when oral therapy is not appropriate. -Hyperacidity

-Hypertensive -Metabolic Alkalosis

-Headache, abdominal pain, constipation, diarrhea, flatulence, nausea & vomiting.

Nursing Consideration -Assess patients condition before and during the therapy. -Assess hepatic function because drug is extensibly metabolized in the liver. -Report for adverse reaction.

Bacillus clausii

Generic Name -Bacillus clausii

Brand Name -Erceflora

Classification -Antidiarrheals

Dosage -1 vial TID

Mechanism of Action -a preparation consisting of suspension of Bacillus clausii spores, normal inhabitants of the intestine, with no pathogenic powers. Administered orally, Bacillus clausii spores, due to their high-resistance to both chemical and physical agents, cross the barrier of the gastric juices reaching unharmed the intestinal tract where they are transformed into metabolically active vegetative cells.

Indication

Contraindication

Side effects

-Treatment of acute diarrhea w/ duration of ≤14 days due to infections, drugs or poisons or for chronic or persistent diarrhea w/ duration of >14 days.

-None

-No side effects have been reported, up to the present time, with the use of the drug.

Nursing Consideration -Should be administered in the interval between 1 dose of antibiotic and the next. -Does not interfere with the ability to drive or use machinery. -No contraindications regarding the use of Erceflora during pregnancy and lactation.

Serc

Generic Name -Serc

Brand Name -Solvey Pharma

Classification -Antivertigo Drugs

Dosage - 8 mg 1-2 tab. To be taken tid.

Mechanism of Action -Exerts a relaxant action on the precapillary sphincters of the microcirculation of the inner ear, and thereby increases the blood supply to the stria vascularis of the labyrinth. Investigations into the acute, subacute and chronic effects of betahistine in animals have demonstrated the low toxicity and safety of the drug.

Indication

Contraindication

Side effects

-Meniere's disease, Meniere -like syndrome characterized by attacks of vertigo, tinnitus & sensorineural deafness, peripheral vertigo.

-Hypersensitivity to betahistine diHCl or to any of the excipients of Serc.

-Mild gastric complaints have been reported. They can often be eliminated by reducing the dosage. Also, skin rashes have been reported.

Nursing Consideration - Patients with phaeochromocytoma or bronchial asthma should be treated with extra care. - It is recommended to use Serc with caution in patients with a history of peptic ulcer. - There is insufficient data on the use of this drug during pregnancy to evaluate possible harmful effects.

Paracetamol

Generic Name -Paracetamol

Brand Name -Tempra

Classification -Analgesics (NonOpioid) & Antipyretics

Dosage - PRN 500mg/tab every 4 hrs for T≥37.6

Mechanism of Action -Decrease fever by inhibiting the effect of pyrogens on the hypothalamic heat regulating center and by hypothalamic action leading to sweating and vasodilation. -Relieving of pain by inhibiting prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its minimal effect on the peripheral prostaglandin synthesis.

Indication

Contraindication

Side effects

-Fever -headache -muscle pain

-Hypersensitive

-Hypothermia dark urine or pale stools; unusual fatigue; yellowing of the skin or eyes.

-toothache -colds

Nursing Consideration -Assess patients fever of pain, location, intensity, duration, temperature,

Ferrous Sulfate

Generic Name -Ferrous Sulfate

Brand Name -Ferrous Sulfate ( United Homes)

Classification -Vitamins and minerals (pre and post natal)/ antianemic

Dosage -325mg/tab 1 tab BID

Mechanism of Action -Provides/replace elemental iron, an essential component in formation of hemoglobin in red blood cell development

Indication

Contraindication

Side effects

-Iron deficiency

-Hypersensitivity

-Constipation; darkened or green stools; diarrhea; nausea; stomach upset.Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); black, tarry stools; blood or streaks of blood in the stool; fever; vomiting with continuing sharp stomach pain

Nursing Consideration -Obtain baseline assessment of iron deficiency before starting the therapy. -Monitor for adverse reaction. -Assess bowel elimination; increase water, bulk and activity constipation occurs. -Assess patients and family knowledge of drug therapy. -Evaluate hemoglobin; hematocrit and reticulocyte count during therapy. -Assess diet and nutrition amount of iron diet. -Identify cause of iron loss or anemia

Kalium Durule

Generic Name -Kalium Durule

Brand Name -AstrZeneca

Classification Electrolytes

Dosage -1 tab TID

Mechanism of Action - Potassium is needed to maintain good health. Although a balanced diet usually supplies all the potassium a person needs, potassium supplements may be needed by patients who do not have enough potassium in their regular diet or have lost too much potassium because of illness or treatment with certain medicines.

Indication

Contraindication

Side effects

Hypokalemia. Prophylaxis during treatment w/ diuretics.

-Renal insufficiency, -hyperkalemia -untreated Addison's disease -constriction of the esophagus &/or obstructive changes in the alimentary tract.

-

Nursing Consideration - This medicine must be diluted in at least one-half glass (4 ounces) of cold water or juice to reduce its possible stomachirritating or laxative effect. - f on a salt (sodium)restricted diet, check with the doctor before using tomato juice to dilute medicine. Tomato juice has a high salt content. - Swallow the tablets whole with a full (8ounce) glass of water. Do not chew or suck on the tablet. -Assess for signs of hyperkalemia. -Monitor PR

Nu r si ng Man a ge men t

Promoting Oxygenation / ineffective airway clearance Intervention •Assess respiratory status. Note depth, rate, and character of breathing. •Assess cough ( productive, weak, or hard )

Rationale

►symptoms may be masked by chronic respiratory conditions ►it becomes frequent and productive, maybe accompanied with chest pain

•Assess nature of secretions: color, amount, consistency

►hemoptysis maybe present in advanced cases

•Auscultate lungs for presence of normal and abnormal lung sounds

►Bronchial breath sounds and crackles maybe present ►low- grade fever occurs

•Monitor vital signs •Monitor oxygen saturation through arterial blood gas/ pulse oximetry

►decreased oxygen saturation and increased PaCo2 are signs of hypoxia and respiratory compromise

•Position the client on fowler’s/ orthopneic

►to allow for maximum chest expansion

•Encouraging or providing frequent changes in position every 2 hours

►to keep the lungs open and clear of secretions

•Encouraging ambulation

►help shift respiratory secretions in the airway

•Deep breathing and coughing exercises

►allows for the removal of secretions from the airway

•Hydration

►maintains the moisture of the respiratory mucous membrane used to treat respiratory problems ►for reducing excessive mucus and provide patent airway

•Provide respiratory medications including bronchodilators, expectorants etc. as doctor’s ordered •Oxygen therapy •Suctioning

►to maintain the patient’s oxygen ►mechanical aspiration of the airways involving the used of catheter inserted through nose, mouth of tracheal tube

Infection Intervention

•Induce sputum with heated aerosol if needed to expedite diagnosis and start early treatment •Monitor sputum cultures

rationale

►precautions to prevent airborne transmission are important during and after procedures that stimulate coughing ►indicated until the patient responds to the medication

•Have patient cover mouth when coughing or sneezing

►this decreases airborne contaminants

•Teach patient hand washing techniques to use after handling sputum

►friction and running water effectively remove microorganisms from hands

•Provide a high- protein, high- calorie, increased- fluid diet

►This maintains optimal nutritional status

•Refer patient contacts to be assessed for possible infection and for chemoprophylactic treatment

►this prevents spread or development of infection

•Administer medications as ordered. •Report all confirmed TB cases to the health department

►anti- TB drugs treatment should be promptly initiated for patients with TB disease. ►coordination of follow-up care and contact investigation to facilitate propylaxis for patient contacts.

Nutrition, Altered , Less than Body requirements intervention •Document patient’s nutritional status on admission, noting skin turgor, current weight and degree of weight loss, integrity of oral mucosa, ability/ inability to swallow, presence of bowel tones, history of nausea/ vomiting or diarrhea •Ascertain patient’s usual dietary pattern, likes/ dislikes •Monitor intake/ output and weight periodically •Encourage and provide for frequent rest periods. •Investigate anorexia, nausea and vomiting and note possible correlation to medication •Provide oral care before and after respiratory treatment •Encourage small frequent meals with foods high in protein and carbohydrates •Encourage SO to bring foods from home and share meals with patient

rationale ►useful in defining degree/ extent of problem and appropriate choice of interventions

►helpful in identifying specific needs. ►Useful in measuring effectiveness of nutritional and fluid support ►Helps to conserve energy ►May affect dietary choices and identify areas for problem solving, to enhance intake ►For oral hygiene ►Maximize nutrient intake ►Creates a normal social environment

Nu r si ng Ca r e Pla n

Nursing Care Plan Name: L. L. Age/Sex: 49/F Medical Diagnosis: Pulmonary Tuberculosis Stage III Category II Nursing Diagnosis: Ineffective airway clearance related to accumulation of excessive mucus secretions on tracheobronchial as evidence by difficulty of Short term goal: At the end of intervention, the patient will expel secretions easily to promote airway clearance. Long term goal: The patient will maintain patent airway with decrease presence of secretions after hospitalization. Cues S ► “nahihirapan akong huminga” as verbalized by the patient. O ► RR=38cpm ► (+)productive cough ► with greenish phlegm ► weak in appearance ► (+) crackles on upper left lung

Problem Difficulty in breathing

Scientific Reason The airway parts of the respiratory system which air flows, was blocked to get from the external environment to the alveoli by the excessive mucus secreted by the goblet cells. Ref. Medical-Surgical Book

Ref. Medical- Surgical book

Interventions ► Assessed patients knowledge about her condition. ► Monitored for vital signs ► Positioned head midline with flexion. ► Elevated head of bed/change position every two hours. ► Encouraged deep breathing and coughing exercises. ► Increase oral fluid intake to at least 2000 ml/day. ► Discourage use of oil based products around nose. ► Monitor vital signs and observed for signs of respiratory distress. ► Provided with information about the necessity of expectorating secretions. ► Given bronchodilators as ordered by doctor.

Rationale ► Patient education will vary on disease as well as the patient’s cognitive level. ► To gather baseline data and noted changes. ► To maintain open airway at rest. ► To take advantage of gravity decreasing pressure on diaphragm. ► To maximize effort in mobilization of secretions. ► To promote systematic hydration and to help liquefy secretions, ► To prevent aspiration into lungs. ► To assess changes and noting complications. ► For the patient to be aware of the importance of expectorating secretions. ► For mobilization of secretions.

Evaluation Goal met. The patient was able to expelled secretion easily.

Nursing Care Plan Name: L. L. Age/Sex: 49/F Medical Diagnosis: Pulmonary Tuberculosis Stage III Category II Nursing Diagnosis: Social isolation related to disease process as evidenced by accommodation on an isolation room. Short term goal: At the end of my intervention, the patient will be able to verbalize understanding about the purpose of isolation process. Long term goal: After hospitalization, the patient will express increase sense of self-worth even undergoing isolation process. Cues S► “Mga pamilya ko na lang ang dumadalaw sa’kin” as verbalized by the patient. O► hostile behavior ►moody ►irritable ►withdrawn eye contact during conversation.

Problem loss of self- esteem

Scientific Reason

Interventions

Rationale

Tuberculosis is very contagious, spread by airborne droplet nuclei that are produce when an infected person coughs or sneezes .Clients with this condition must be treated carefully, some of them were isolated to prevent the transmission of microorganisms. As a result, the patient’s enduring personality characteristics were decreased. Ref. Medical-Surgical Book

►Identified blocks to social contacts.

►To prevent contributing factors to problem ►To be able to deeply understand patient’s thoughts and condition. ►Promotes trust and establish rapport.

►Listened to comments of client regarding sense of isolation. ►Established therapeutic nurseclient relationship. ►Explained the nature of disease and mode of transmission. ►Encouraged open visitation when possible and/or telephone contact. ►Provided positive reinforcement when patient’s makes move towards others. ►Provided with clean and comfortable environment.

►To provide client’s awareness. ►To maintain involvement with others. ►Encouraged client’s continuation of efforts and to enhance selfesteem. ►To provide comfort measures for the patient.

Evaluation Goal met. The patient verbalized understanding about the purpose of isolation process.

Nursing Care Plan Name: L.L. Age/Sex: 49/F Medical Diagnosis: Pulmonary Tuberculosis Stage III Category II Nursing Diagnosis: Risk for activity intolerance related to generalize weakness as evidenced by verbal report of fatigue. Short term goal:` At the end of my intervention, the patient will be able to walk on short distances with assistance as tolerated by the patient. Long term goal: After hospitalization, the patient will be able to perform self care activities with minimal assistance. Cues S► “Nanghihina ako“ as verbalized by the patient. O► RR=38cpm ► weak in appearance ► refuse to perform daily activities. ►functional level 4 – dyspnea and fatigue at rest

Problem body weakness

Scientific Reason

Interventions

Tuberculosis maybe extra- pulmonary and affect organs / tissues other than the lungs. This process causes reduction in muscle strength and its function, which leads to generalized weakness and impairs the ability to maintain activity. Ref: medical- surgical book

► Determined the patient’s perception of causes of fatigue. ► Assessed the patient’s level of mobility. ► Assessed nutritional status. ► Assessed emotional response to change in physical status.

► Establish guidelines and goal of activity with the patient. ► Encouraged adequate rest periods. ► Encouraged physical activity consistent with the patient’s energy resources.

Rationale ► Assessments guide treatment. ►To define what the patients is capable of, which is necessary before setting realistic goals. ►Adequate energy reserves are required for activity. ►Depression resulting from the inability to perform required activities can further aggravate activity intolerance. ►Motivation is enhance if the patient participates in goal setting. ►Provides time for energy conservation and recovery. ►This promotes a sense of autonomy while being realistic about capabilities.

Evaluation Goal met The patient walked on a short distance with assistance.

► Encouraged active range of motion exercises. ► Provide emotional support will increasing activity. ► Encouraged patients to choose activities that gradually build endurance. ►Teach the patient to recognize signs of physical over activity. ► Involve the patient in goal setting and care planning.

►Exercise maintains muscle strength and joint range of motion. ►Patient may be fearful of overexertion and potential damage to the heart. ►Physically inactive patients need to improve functional capacity through repetitive exercises over a longer period of time. ►Promotes awareness of when to reduce activity. ►Setting small, attainable goals can increase self confidence and selfesteem.

Th e end