1. The document discusses tetanus, an infectious disease caused by the Clostridium tetani bacterium. It enters the body through a wound and releases a toxin that causes painful muscle spasms.
2. It describes the three forms of tetanus - localized, generalized, and neonatal tetanus. The incubation period ranges from 3 to 21 days. Vaccination can prevent tetanus through tetanus toxoid booster shots every 10 years.
3. The objectives of the case study are for nursing students to learn how to provide holistic care for tetanus patients through demonstrating appropriate medical management, discussing anatomy/physiology of the nervous system, and establishing nurse-patient
1. The document discusses tetanus, an infectious disease caused by the Clostridium tetani bacterium. It enters the body through a wound and releases a toxin that causes painful muscle spasms.
2. It describes the three forms of tetanus - localized, generalized, and neonatal tetanus. The incubation period ranges from 3 to 21 days. Vaccination can prevent tetanus through tetanus toxoid booster shots every 10 years.
3. The objectives of the case study are for nursing students to learn how to provide holistic care for tetanus patients through demonstrating appropriate medical management, discussing anatomy/physiology of the nervous system, and establishing nurse-patient
1. The document discusses tetanus, an infectious disease caused by the Clostridium tetani bacterium. It enters the body through a wound and releases a toxin that causes painful muscle spasms.
2. It describes the three forms of tetanus - localized, generalized, and neonatal tetanus. The incubation period ranges from 3 to 21 days. Vaccination can prevent tetanus through tetanus toxoid booster shots every 10 years.
3. The objectives of the case study are for nursing students to learn how to provide holistic care for tetanus patients through demonstrating appropriate medical management, discussing anatomy/physiology of the nervous system, and establishing nurse-patient
San Roque Extension, Roxas City 5800 Capiz, Philippines Bachelo of Science in !using 4C- 2011 "E"A!#S Su$%itte& $y' Xy-Za Roy Marie D. Albaa Glorie Anne D. Anisco Khris John V. Balbuena Charmaine Cheryl Iris V. Bellosillo Joanna Keih D. Baui!as A"ril Rose D. Benie# Karen Kay D. Bulan $hiehon A. %erraris Marie Ann B. Ma!banua %ree Van Roy &aclibar Su$%itte& to' Ms. 'ila C. Valles( R) Clinical Instructor INTRODUCTION ( TETANUS Comes from the Greek word tetanus meaning taut and teiteim which means to stretch. It is also called lockaw. It is a serious infectious disease of the ner!ous s"stem in which to#in causes se!ere muscle s$asm. It is a medical condition characteri%ed &" a $rolonged contraction of skeletal muscle fi&ers. It is caused &" a &acterium Clostridium tetani. Infection generall" occurs through wound contamination and often in!ol!es a cut or dee$ $unctured wound. Tetanus is often associated with rust' &ut this conce$t is somewhat misleading. The C.Tetani is an Anaero&ic &acteria which sur!i!es in an en!ironment that lacks o#"gen' thus with or without rust a $erson ma" ha!e a tetanus once C. Tetani enters the wound. Contaminated wounds are the site where tetanus &acteria multi$l". (ee$ wounds or those with distalli%ed tissue are $articularl" $rone to tetanus infection. The tetanus to#in affects the site of interaction &etween the ner!e and the muscle that it stimulates' this region is called the neuromuscular unction. The tetanus to#in am$lifies the chemical signals from the ner!e to the muscles to tighten u$ in a continuous contraction or s$asm. This results in either locali%ed or generali%ed muscle s$asm. The incu&ation $eriod ranges from ) to *+ da"s' usuall" a&out , da"s. In general the further the inur" site is from the central ner!ous s"stem' the longer the incu&ation $eriod. The shorter the incu&ation $eriod' the higher the chance of death. In neonatal tetanus' s"m$toms usuall" a$$ear from - to +- da"s after &irth' a!eraging a&out . da"s. /n the &asis of clinical findings' three different forms of tetanus ha!e &een descri&ed. 0ocal tetanus is an uncommon form of the disease' in which $atients ha!e $ersistent contraction of muscles in the same anatomic area as the inur". These contractions ma" $ersist for man" weeks &efore graduall" su&siding. 0ocal tetanus ma" $recede the onset of generali%ed tetanus &ut is generall" milder. /nl" a&out +1 of cases are fatal. Tetanus can &e $re!ented &" !accination with tetanus to#oid. A &ooster is needed e!er" +2 "ears after $rimar" immuni%ation. In the 3hili$$ines the incidence rate of tetanus is +* out of ,4' *-+'4*.. Objectives ) General objectives: This case stud" is designed for the student nurses to &ecome $racticed' well5informed and mannered in deli!ering holistic care for $atients diagnosed with Tetanus. Specific Objectives: Skills To demonstrate the !ision6mission of the school which is ser!ice oriented' research moti!ated' technolog" ena&le and 7incentian ins$ired. Im$l" a$$ro$riate medical nursing management for Tetanus. Knowlede (iscuss the anatom" and $h"siolog" of the Ner!ous s"stem. (efine Tetanus. 0earn a&out maor etiologic its causes' identif" its clinical manifestations and risk factors. 8e familiar with the $atho$h"siolog" of Tetanus. 8e ac9uainted with the different drugs' its actions' and $erform o&ligator" nursing res$onses for each. 3lan for a suita&le nursing care !ttit"de Esta&lish a nurse5$atient interaction through e#changing of thoughts and information Institute &ond &etween the student nurse and the $atient. !N!TO#$ !ND %&$SIO'OG$ * Nervo"s S(ste) The nervo"s s(ste) is an organ s"stem containing a network of s$eciali%ed cells called neurons that coordinate the actions and transmit signals &etween different $arts of its &od". The ner!ous s"stem consists of two $arts' central and $eri$heral. The central ner!ous s"stem contains the &rain' and s$inal cord. The $eri$heral ner!ous s"stem consists of sensor" neurons' clusters of neurons called ganglia' and ner!es connecting them to each other and to the central ner!ous s"stem. These regions are all interconnected &" means of com$le# neural $athwa"s. The enteric ner!ous s"stem' a su&s"stem of the $eri$heral ner!ous s"stem' has the ca$acit"' e!en when se!ered from the rest of the ner!ous s"stem through its $rimar" connection &" the !agus ner!e' to function inde$endentl" in controlling the gastrointestinal s"stem. The Central Nervo"s S(ste) is the &od":s information head9uarters' ultimatel" regulating nearl" all &od" functions. The CNS includes; T*e +rain < 3rocesses incoming information from within the &od"' and outside the &od" &" wa" of the sensor" ner!es of sight' touch' smell' sound' and taste. Commands are then sent &ack throughout the &od". The &rain also stores and $rocesses language' communication' emotions' thoughts' dreams' and memories. In other words' the &rain is where all thinking and decision5making takes $lace. T*e Spinal Cord < Is the main $athwa" for information connecting the &rain and $eri$heral ner!ous s"stem. It e#tends from the &rain a&out +, inches down + the &on" s$inal column' which ser!es as its $rotection. The s$inal cord is a tu&e made u$ of ner!e fi&ers. Electrical im$ulses tra!el through the ner!es and allow the &rain to communicate with the rest of the &od". The %erip*eral Nervo"s S(ste) is res$onsi&le for the remainder of the &od". It includes cranial ner!es =ner!es emerging from the &rain>' s$inal ner!es =ner!es emerging from the s$inal cord> and all the maor sense organs. The 3NS includes; T*e So)atic Nervo"s S(ste) ,SNS- < ?es$onsi&le for all muscular acti!ities that we consider !oluntar" or that are within our conscious control. T*e !"tono)ic Nervo"s S(ste) ,!NS- < ?es$onsi&le for all acti!ities that occur automaticall" and in!oluntaril"' such as &reathing' muscle contractions within the digesti!e s"stem' and heart&eat. The com$onents of the ANS work together to create a &alanced res$onse to outside stimuli + . The ANS includes; o T*e S()pat*etic S(ste) < Stimulates cell and organ function. The s"m$athetic s"stem is acti!ated &" a $ercei!ed danger or threat' !er" strong emotions such as fear' anger or e#citement' &" intense e#ercise' or when under large amounts of stress. 8asicall"' an"thing the &od" $ercei!es as an emergenc" will trigger a $rotecti!e res$onse. /nce initiated' it s$eeds u$ heart rate' increases the acti!it" of the sweat and adrenal glands' slows down the digesti!e s"stem and sends &lood to the skin and muscles@ all of which $re$are the &od" for a fight or flight res$onse. o T*e %aras()pat*etic S(ste) < Inhi&its cell and organ function. The $aras"m$athetic s"stem slows down heart rate' resumes digestion' and increases rela#ation throughout the &od". This rest and digest res$onse counteracts the fight or flight res$onse and hel$s the &od" recu$erate after a crisis is o!er. A $ersonAs normal resting heart rate is determined &" the $aras"m$athetic s"stem. If &lood $ressure is too high or &lood car&on dio#ide le!els are too low' this s"stem slows the heart down and lowers its out$ut. NEU?/BUSCU0A? SCSTEB The com&ination of the ner!ous s"stem and the muscles' working together to $ermit mo!ement' is known as the neuromuscular s"stem. Neuromuscular disorders include motor neuron diseases' neuro$athies and muscular d"stro$hies. The brain controls the mo!ements of skeletal =!oluntar"> muscles !ia s$ecialised ner!es. Neurons send signals to other cells as electrochemical wa!es tra!elling along thin fi&res called a#ons' which cause chemicals called neurotransmitters to &e released at unctions called s"na$ses. A cell that recei!es a s"na$tic signal ma" &e e#cited' inhi&ited' or otherwise modulated. Sensor" neurons are acti!ated &" $h"sical stimuli im$inging on them' and send signals that inform the central ner!ous s"stem of the state of the &od" and the e#ternal en!ironment. Botor neurons' situated either in the central ner!ous s"stem or in $eri$heral ganglia' connect the ner!ous s"stem to muscles or other effector organs. Central neurons' which in !erte&rates greatl" outnum&er the other t"$es' make all of their in$ut and 5 out$ut connections with other neurons. The interactions of all these t"$es of neurons form neural circuits that generate an organismAs $erce$tion of the world and determine its &eha!ior. Along with neurons' the ner!ous s"stem contains other s$eciali%ed cells called glial cells =or sim$l" glia>' which $ro!ide structural and meta&olic su$$ort. If "ou want to mo!e $art of "our &od"' a message is sent to $articular neurons =nerve cells>' called u$$er motor neurons. U$$er motor neurons ha!e long tails =axons> that go into and through the &rain' and into the s$inal cord' where the" connect with lower motor neurons. At the s$inal cord' the lower motor neurons in the s$inal cord send their a#ons !ia ner!es in the arms and legs directl" to the muscle the" control. A t"$ical muscle is ser!iced &" an"where &etween D2 and *22 =or more> lower motor neurons. Each lower motor neuron is su&di!ided into man" tin" &ranches. The ti$ of each &ranch is called a $res"na$tic terminal. This connection &etween the ti$ of the ner!e and the muscle is also called the neuromuscular unction. The electrical signal from the &rain tra!els down the ner!es and $rom$ts the release of the chemical acet"lcholine from the $res"na$tic terminals. This chemical is $icked u$ &" s$ecial sensors =rece$tors> in the muscle tissue. If enough rece$tors are stimulated &" acet"lcholine' "our muscles will contract. ./ital Infor)ation. Na)e: Br. E.8. , !e: ., Se0: Bale !ddress: (ulangan 3ilar' Ca$i% Civil Stat"s: Barried Reliion: ?oman Catholic Occ"pation: Eish$ond o$erator Date and Ti)e !d)itted: Fune D' *2+2@ ++;D2 am 1ard: SC0 )*, C*ief Co)plaint: (ifficult" of swallowing 2inal Dianosis: Tetanus Stage )@As$iration 3neumonia' G3N Stage I !ttendin %*(sician: (r. ?. G C'INIC!' !SS3SS#3NT N"rsin &istor( /ne week &efore admission' $atient e#$erience a massi!e toothache and was relief &" $ain relie!ers. Ge did not &other to ask for consultation &ecause he &elie!es that it will su&sides in due time. - da"s after ac9uiring the dental $ro&lem' he com$lained of difficult" in swallowing foods. The $atient and famil" disregard to seek consultation not until the" thought that Br. E8 was ha!ing a mild stroke. Ge was !er" weak and was una&le to o$en his mouth. Ge can no longer eat foods' and his famil" are scared for his health thus the" $rom$ted for admission in Fune .' *2+2. %ast &ealt* %roble) Br. E.8. has no histor" of $ast hos$itali%ation. Sometimes he e#$erienced mild fe!er' coughs' and cold &ut managea&le and treated with o!er the counter drugs like $aracetamol and solmu#. Ge has no known allergies to food' drugs and animals. 2a)il( &istor( Gis father died &ecause of old age and his mother died of $ulmonar" infection. /n the other hand' his elder sister is known to &e h"$ertensi!e and the second si&ling has goiter. 2!#I'$ G3NOGR!# - %.B. .l& age A.B. Pul%on ay infectio n C.B. 85 /P! *.B. 80 0oite %.B. +eanus B 'eends
2e)ale #ale %atient Deat* %atterns of 2"nctionin %attern &o)e &ospitali4ation 8 +reat*in %attern No res$irator" $ro&lems. Gas ne!er com$lained of an" &reathing difficult". ?es$irator" rates &ecame ra$id' shallow &reaths are noted. (ifficult" of &reathing is alwa"s claimed. Circ"lation Claimed to ne!er &een had a 83 check5u$ &efore hos$itali%ation. The a!erage 83 is +-26+22 mmGg during hos$ital sta". Sleepin %attern Usuall" slee$s at H $m and wakes u$ at D am. ,5+2 hour slee$ duration. Uses two $illow and comforter Slee$s at +2 $m and wakes u$ at 4 am. Uses one $illow and &lanket. (istur&ed slee$ is usuall" com$lained whene!er e#cessi!e stimuli is o&ser!ed. Drinkin %attern Usuall" drinks ,5+2 glasses of water a da". Iith NGT' cannot tolerate to drink water &ecause of lock aw. 3atin %attern Eats three times a da". Ge eats more car&oh"drate' !egeta&les and ade9uate $rotein. Br. E.8 isn:t fond of using eating utensils since he is sta"ing on his $ond' he eats using his &are hands. Ge was &een on $arenteral feeding and has NGT u$on admission. An /TE +422 calories is di!ided into 4 e9ual feedings e!er"da". 3li)ination %atterns a5 +owel (efecates once dail" in ade9uate amount' golden &rown in color. (efecates for a&out *5) times a week. b5 Urination Urinates normall" a$$ro#imatel" )5D# a da" in an ade9uate amount. Iith urinar" incontinence' a week after his first admission' he onl" $asses -2 cc of urine. Ge was then inserted with fole" catheter attached to uro&ag with an ade9uate amount' "ellowish in color. %ersonal *(iene Gis dail" o& as a $ond o$erator re9uires a dirt" and hea!" tasks. Takes a &ath dail" &ut isn:t fond of &rushing his teeth. Borning care done with oral care of &actedol. Using cotton and tongue de$ressor. 1 Recreational and 30ercise Gis walks from house to the fish $ond which took almost )2 mins. is what the" considered to &e his dail" e#ercise. Ge drinks alcohol and $la" tong5its with his friends. No recreational acti!ities. Cannot tolerate to stand or sit. 3assi!e ?/B e#ercises done. +rief Social6 C"lt"ral and Reliio"s +ackro"nd a5 3d"cational +ackro"nd E.8. finishes his elementar" education in (ulangan Elementar" School and his secondar" education reaches u$ to ) rd "ear in (ulangan National Gigh School. Ge ne!er had the chance to stud" in college &ecause of financial constraints. b5 Occ"pation Ge is a fulltime fish$ond o$erator' who manages their own famil":s fish$ond. Ge s$ends most of his time on his $ond which was *2 mins. awa" from their residence. c5 Reliio"s %ractice Br. E.8 is a ?oman Catholic. Ge does not attend Sunda" mass regularl" since he is usuall" at his fish$ond' &ut his famil" claims that he alwa"s $ra". d5 3cono)ic Stat"s Br. E.8 &elongs to a middle class grou$' he has no fi# economic income for the" onl" had a 9uarterl" har!est. 8ut the" claim that it was enough to su$$ort the whole famil". Gis two daughters are also working a&road which also hel$s them financiall". Clinical Inspection 75 /ital sins TJ),.* o C CR8 +2- &$m +%J +-26+22 mmGg RR8 )2 &$m ). &ei*t 8 4:+ *. 1ei*t8 ,, kg %&$SIC!' !SS3SS#3NT (0 General !ppearance Br. E.8.' .4 "ear5old male' with $oor $osture and gait. Ge is l"ing on &ed on a semi5 fowlers $osition. Ge is lethargic and irrita&le. Ge cannot res$ond to 9uestions well and is not well oriented. Bainline I7E; 3NSS +0 is attached at the left &asilic !ein running at *2 cc6hr. Urinar" catheter is well attached in the urethra with uro&ag in $lace. /* at - 03B !ia nasal cannula is in $lace. No edema noted. Skin &air Nails Skin is &rown in com$le#ion' warm' and dr" with $oor skin turgor. No $allor and edema. Gas a short &lack hair mi#ed with gra" ones' well distri&uted. No $resence of flakes' lice or lesions noted. Nails are short and clean. Are $ink in color and slightl" cur!ed with smooth and rounded edges. No clu&&ing of fingers noted. &ead 2ace Gead is normoce$halic' no $al$a&le nodules or masses noted. lesions are not noted. Eace is wrinkled due to old age. =K> Eacial grimace and locking of aw noted. 3(es 3ars Nose #o"t* Anicteric sclerae with $u$ils round and &lack in color which constricts from -mm5*mm. Gas &risk reaction to light. No cataract noted. Slightl" $ale conuncti!a noted. To$ of $inna is aligned with the outer corners of &oth e"es@ si%e is normal and e9ual@ similar in color to face@ =5> discharges and swelling' with $oor acuit" to whis$er !oice. Cerumen not noted. Iith $resence of cilia. Gas no discharges nor sinusitis. Nasal cannula attached to &oth nostrils at -03B. NGT is attached =0>. 0i$s are dr" with cracking and slightl" $ale oral mucosa was noted. Iith no inflammation of tonsils. Gas $oor dention' with &leeding gum and halitosis. Neck +reast Upper 30tre)ities (istention of ugular !ein noted. 8reast are firm. No mass $al$ated. 8oth arms are weak. Can $erform $assi!e mo!ements onl". C*est ?es$irator" rate of *-5)- &reaths6min' shallow &reaths in uniform rh"thm. Respirator( S(ste) /ccasional cough noted with whitish s$utum. Iith su$$lemental /* L -03B. Iell tolerated with /* saturation ranging from H.5HH1. Crackles is usuall" heard. Cardiovasc"lar A$ical $ulse at the left midcla!icular line a!eraging at ,4 (( S(ste) &$m. Ski$ &eats not noted u$on auscultation. Gastrointestinal S(ste) A&dominal $ain noted. Iith se!eral attem$ts of &owel mo!ements. Genito."rinar( S(ste) Urinar" catheter =Erench +-> intact on urethra and attached to uro&ag. 3asses "ellow colored urine in minimal amounts. #"sc"loskeletal S(ste) ?estless at few times. Ga!e &een on sei%ure attacks. Bo!ements are weak. Cannot tolerate standing. A&le to sit on wheelchair. Iith weak handgri$. G3N3R!' !%%R!IS!' '!+OR!TOR$ R3SU'TS Fune 2D' *2+2 () Speec* S$eaks in nati!e language. Ge $resentl" can not talk due to illness. 'an"ae Can s$eak onl" Giliga"non when he was still a&le to talk. &earin Gas $oor acuit" to whis$ered !oice. #ental stat"s Ge is lethargic and irrita&le. 3)otional Stat"s Una&le to e#$ress emotions. %rotein #etabolites and 3lectrol(tes Test Res"lts Nor)al /al"es Sinificance of !bnor)al Res"lt Creatinine GI +4+., umol60 .+.2 < +)).2 umol60 Ba" &e due to deh"dration. Sodium 0/ +)-.D mmol60 +)..2 < +-D.2 mmol60 G"$onatremia ma" result from inade9uate sodium intake or e#cessi!e sodium loss due to $rofuse sweating. Fune 24' *2+2 'ipids and lipoproteins Test Res"lts Nor)al /al"es Sinificance of !bnor)al Res"lt Cholesterol GI D.*+ mmol60 2.22 < D.*2 mmol60 Indicates G"$ercholesterolemia leading to G"$ertension (irect G(0C 0/ 2.,4 mmol60 +.22 < +.42 mmol60 Fune +4' *2+2 &e)atolo( Test Res"lts Nor)al /al"es Sinificance of !bnor)al Res"lt Gematocrit 0/ 2.)+ !ol. =fr> 2.-* < 2.D* 0ow Gct suggest anemia' or hemodilution Gemoglo&in 0/ +2) g60 +)2.2 A decreased !alue of hemoglo&in can &e caused &" low red &lood cell count' &" a lack of hemoglo&in in the er"throc"tes' which also indicates fluid retention. ?ed 8lood Cell Count 0/ ).4+ # +2M+*60 -.* < D.- # +2M+*60 Indicates fluid o!erload. Ihite 8lood Cell Count GI ++.H # +2MH60 - < +2 # +2MH60 An ele!ated I8C count indicates infection due to traumati%ed tissue. Segmenters GI 2.,4 2.D2 < 2.4D An ele!ated !alue =neutro$hilia> occurs in res$onse to &acterial infection. Eosino$hils 2.2+ 2.2+ < 2.2- Normal 0"m$hoc"tes 0/ 2.2. 2.*D < 2.)2 A decreased !alue occurs with im$aired l"m$hatic drainage. Bonoc"tes GI 2.24 2.2* < 2.2D An ele!ated !alue occurs in res$onse to infection. 3latelet ),2 # +2MH60 +-2 < -22 # Normal (* +2MH60 Fune +4' *2+2 Urinal(sis Test Res"lts Nor)al /al"es Sinificance of !bnor)al Res"lt Color 3ale straw Straw to dark "ellow Normal Trans$arenc" Ga%" clear ?eaction $G 4.2 -.D < ,.2 S$. Gra!it" +.2*2 +.22) < +.2)2 3rotein trace negati!e 3rotein in the urine =$roteinuria> ma" indicate h"$ertension. Glucose negati!e negati!e Normal Amor$h. U63 few ?8C 6 h$f GI ++ < *2 6 h$f 2 < ) 6 h$f Indicates &leeding I8C 6 h$f * 5. 6 h$f 2 < D 6 h$f Normal E$ithelial Cells /ccassional None 8acteria Boderate None Ceast cells man" None Fune ,'*2+2 T%S!,)ini./ID!S- 7I(AS T3SA is intended for use with a 7I(AS =7ITEN Immuno(iagnostic Assa" S"stem> instrument as an automated en%"me5linked fluorescent immunoassa" =E0EA> for the 9uantitati!e measurement of total $rostate s$ecific antigen in human serum. The 7I(AS T3SA assa" is indicated as an aid in the management of $atients with $rostate cancer and as an aid in the detection of $rostate cancer in conunction with digital rectal e#amination =(?E> in men age D2 "ears or older. 3rostate &io$s" is re9uired for diagnosis of $rostate cancer. (+ Test Res"lts Nor)al /al"es Sinificance of !bnor)al Res"lt T3SA 95:7);)l normal; 25 )..*mg6ml Increased result shows $rostatic im$airment Fune .'*2+2 CT SC!N Cranial %law (5 Test I)pression Ne"rocrani") 3lain a#ial tomogra$h" section of the head shows no definite focal $arendr"mal lesions or an" a&normal h"$erdense collection. The midline structures are undis$laced with the interhemis$heric fissure centered on the midline. The cere&rum shows slightl" widened cortical sulcation. The cere&ral !entricles are $rominent. There are no signs of increased intracranial $ressure. The $osterior fossa' &rainstem and sellar region a$$ear normal. The $etromastoids' &on" cal!anium and included or&its or $aranasal sinuses are unremarka&le. INT3R%R3T!TION: Cere&ral Atro$hic Changes. Fune +.'*2+2 C&3ST <.R!$ I)pression 8ilateral $neumonia with $rogression in the left. 0eft $leural effusion. 8ronchiectasis right lung &ase. Atheromatous and tortuous aorta. (e#troscoliosis' thoracic s$ine. (, #3DIC!TIONS N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S O)epra4ole *2mg + ta& 8I( +rand Na)e: 3rosec Su$$resses gastric acid secretion &" s$ecific inhi&ition of the h"drogen5 $otassium AT3ase en%"me s"stem at the secretor" surface of the gastric $arietal cells@ &locks the final ste$ of acid $roduction. GE?(' fre9uent heart&urn. +. Geadache *. Nausea ). 7omiting -. (iarrhea D. Consti$ation 4. A&dominal 3ain .. Elatulence ,. (r" mouth G"$ersensiti!it" to ome$ra%ole and its com$onents. +.Administer drug &efore meal is ser!e. ). Bonitor for an" urinar" elimination such as $ain or discomfort associated with urination. *. If se!ere diarrhea is o&ser!ed' drug ma" need to &e discontinued. !CTION Antisecretor" drug 3roton 3um$ Inhi&itor (- N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S #o0iflo0acin -22mg +ta& /( +rand Na)e: A!elo# 8actericidal@ interferes with (NA re$lication' re$air' transcri$tion' and recom&ination in susce$ti&le gram5 negati!e and gram5 $ositi!e &acteria' $re!enting cell re$roduction and leading to cell death. Treatment of Infection caused &" anaero&ic &acteria. +. Geadache *. Insomnia ). Nausea -. (iarrhea Contraindicated with allerg" to fluoro9uinolones' $rolonged OT inter!al' h"$okalemia. +. Continue thera$" as indicated for condition &eing treated. *. Administer oral drug - hr &efore or at least , hr after antacids or other anion5containing drugs. ). (o not change dosage when switching from I7 to oral dose. !CTION Anti&iotic Eluoro9uinolone (8 N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S Solfenacin Dmg +ta& +rand Na)e: 7ESIcare Counteracts smooth muscle s$asm of the urinar" tract &" rela#ing the detrusor and other smooth muscle through the action at the muscarinic $aras"m$athetic rece$tors. Treatment of o!eracti!e &ladder with s"m$toms of urge urinar" incontinence' urgenc"' and urinar" fre9uenc". +. (r" mouth *. Consti$ation ). Urinar" retention Contraindicated with allerg" to drug or an" com$onent of the drug' se!ere he$atic im$airment' urine retention' gastric retention' uncontrolled narrow5angle glaucoma. +. 3ro!ide fre9uent small meals if GI u$set occurs. *. Esta&lish &owel $rogram if consti$ation is a $ro&lem. ). Esta&lish $recautions if CNS effects occur. -. Beasure $ost5!oid residual urine !olume if $atient has difficult" in !oiding. !CTION Buscarinic rece$tor entagonist Urinar" antis$asmodic (1 N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S Ta)s"losin *D2 mg 8I( +rand Na)e: Garnal 8locks the smooth muscle al$ha+5 adrenergic rece$tors in the $rostate' $rostatic ca$sule' $rostatic urethra' &ladder neck' leading to rela#ation' of the &ladder' and $rostate' and im$ro!ing the flow of urine in cases of 83G. Adunct in managing urethral stones. +. Somnolence *. Insomnia ). /rthostatic h"$otension -. A&normal eaculation D. (ecreased li&ido G"$ersensiti!it" to tamsulosin' $rostate cancer' $regnanc". +. Administer once a da"' )2 minutes after the same meal each da". *. Bonitor $atient carefull" for orthostatic h"$otension@ di%%iness' and s"nco$e is high with the first dose. Esta&lish safet" $recautions as a$$ro$riate. !CTION Al$ha adrenergic &locker =$eri$heral acting> )0 N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S 'act"lose *2cc until 8B occurs 9,hours +rand Na)e: 0actulose The drug $asses unchanged into colon where &acteria &reak it down to organic acids that increase the osmotic $ressure in the colon and slightl" acidif" the colonic contents' resulting in an increase in stool water content' stool softening' and la#ati!e action. This also results in migration of &lood ammonia into the colon contents with su&se9uent tra$$ing and e#$ulsion of the feces. Treatment of consti$ation. +. Transient flatulence *. (istention ). Intestinal cram$s -. 8elching D. (iarrhea 4. Nausea Contraindicated with allerg" to lactulose' low5 galactose diet. +. (o not administer other la#ati!e while using lactulose. *. Bonitor serum ammonia le!els. ). Carefull" monitor &lood glucose le!els in dia&etic $atients. !CTION
Ammonia reaction drug 0a#ati!e N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S )( Tetan"s I))"ne Glob"lin *D26am$ -am$s dee$ IB =stat> +rand Na)e: Tetanus immune glo&ulin Su$$lies $assi!e immunit" to those indi!iduals who ha!e low or no immunit" to the to#in $roduced &" the tetanus organism' Clostridium tetani. The anti&odies act to neutrali%e the free form of the $owerful e#oto#in $roduced &" this &acterium Is indicated for $ro$h"la#is against tetanus following inur" in $atients whose immuni%ation is incom$lete or uncertain. It is also indicated' although e!idence of effecti!eness is limited' in the regimen of treatment of acti!e cases of tetanus. +. Tenderness *. Buscle stiffness at inection site ). Urticaria -. Angioedema D. Ee!er 4. Chills .. Chest tightness ,. 3reci$itous fall in 83 Contraindicated to $atients with a histor" of $rior s"stemic allergic reactions following the administration of human immunoglo&ulin $re$arations' and se!ere throm&oc"to$enia or an" coagulation disorder that would contraindicate intramuscular inections. +. (o not administer to $atients with histor" of allerg" to gamma glo&ulin or anti immunoglo&ulin A anti&odies. *. Administer * weeks &efore or ) months after immune glo&ulin administration &ecause anti&odies in the glo&ulin $re$aration ma" interfere with the immune res$onse to the !accination. ). (o not mi# glo&ulin with an" other medications. -. Bonitor $atient:s !ital signs continuousl" and o&ser!e for an" s"m$toms during IB !CTION Immune glo&ulin )) administration. D. 3ro!ide comfort measures or teach $atient to $ro!ide comfort measures to hel$ $atient to co$e with the discomforts of drug thera$". N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S )* Tra)adol D2mg I7 9, 3?N for se!ere $ain +rand Na)e: Tramal Treats moderate to moderatel" se!ere $ain and most t"$es of neuralgia' including trigeminal neuralgia. Treatment of acute to chronic $ain. +. Nausea *. 7omiting ). Sweating -. Consti$ation D. (rowsiness 4. ?es$irator" de$ression Acute into#ication with alcohol h"$notics' analgesics or $s"chotro$ic' narcotic withdrawal treatment. +. (o not take more medication as a single dose or take more doses $er da" than $rescri&ed &" the doctor. ). Store this medicine at room tem$erature' awa" from heat and light. *. (o not sto$ taking Tramadol without talking to the doctor !CTION Analgesic u5o$iod rece$tor antagonist N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S )+ %en G - mullion 94 ANST !ia soluset =,5*> +rand Na)e: 3en G Inhi&its en%"mes res$onsi&le for cell wall s"nthesis of susce$ti&le organisms. This creates an osmoticall" unsta&le cell wall that swells and &ursts from osmotic $ressure. 3enicillin G is reser!ed for se!ere infections. +. Nausea *. 7omiting ). (iarrhea -. A&dominal $ain D. Colitis 4. Anore#ia -. G"$ersensiti!it" 8. Neuroto#icit" 1. Urticaria' Su$erinfection 3atients with known allergies to $enicillin and h"$ersensiti!it" to ce$halos$orins +. Ga!e a anti&iotic skin test done &efore gi!ing dose to ensure h"$ersensiti!it" reactions. *. Gi!e &" IB route onl". ). Continue thera$" for at least * da"s after infection has disa$$eared' usuall" .5 +2 da"s. -. Use the smallest dose $ossi&le for IB inection to a!oid $ain and discomfort. !CTION Anti&iotic N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S )5 #etronida4ole6 D22mg ' I7 9, hrs. +rand Na)e: Elag"l 8actericidal; inhi&its (NA s"nthesis in s$ecific anaero&es' causing cell death. Treatment of &acterial infection =a drug of choice for Tetanus> +. Geadache *. (i%%iness ). Ata#ia -. 7ertigo D. Insomnia 4. Eatigue .. Incontinence ,. GI u$set
Contraindicated with h"$ersensiti!it" to metronida%ole@ use cautiousl" with CNS disease' he$atic disease' candidiasis' &lood d"scrasias. +. A!oid use unless needed. Betronida%ole ma" &e carcinogenic. *. ?educe dosage in he$atic disease. !CTION Anti$roto%oal N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S ), Tel)isartan -2mg6+*.D' I ta& /( +rand Na)e: Bicardis Selecti!el" &locks the &inding of angiotensin II to s$ecific tissue rece$tors found in the !ascular smooth muscle and adrenal gland. Treatment of h"$ertension' alone or in com&ination with other h"$ertensi!es. +. (i%%iness *. Geadache ). nausea -. !omiting D. diarrhea Contraindicated with h"$ersensiti!it" to telmisartan. Use cautiousl" with he$atic or &iliar" im$airment' h"$o!olemia. +. Bonitor heart rate &elow normal le!el &efore gi!ing drug. *. Check effecti!it" of the drug. Closel" monitor 83 and heart rate. !CTION Angiotensin II rece$tor antagonist Antih"$ertensi!e N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S )- Dia4epa) Dmg I7 9, Acts mainl" at the lim&ic s"stem and reticular formation@ mat act in s$inal cord to $roduce skeletal muscle rela#ation@ $otentiates the effects of GA8A' an inhi&itor" neurotransmitter. PBuscle rela#ant; Adunct for relief of refle# skeletal muscle s$asm due to local $atholog" or secondar" to trauma@ s$asticit" caused &" u$$er motoneuron disorders P3arenteral; Treatment of tetanus +. (rowsiness *. (i%%iness ). GI u$set -. &rad"chardia
Contraindicated with h"$ersensiti!it" to &en%odia%e$ines@ $s"choses' acute narrow5 angle glaucoma' shock' coma' acute alcoholic into#ication. Use cautiousl" with elderl" or de&ilitated $atients@ im$aired li!er or renal function@ and in $atients with histor" of su&stance a&use. +. Bonitor heart rate &efore gi!ing drug. *. Closel" monitor 83. !CTION Antie$ile$tic@ An#iol"tic Skeletal muscle rela#ant =centrall" acting> N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S )8 !cet(lc(steine 422g6+ ta& in D2 diluent /( +rand Na)e: Eluimucil Bucol"tic acti!it"; S$lits links in the muco$roteins contained in res$irator" mucus secretions' decreasing the !iscosit" of the mucus. Bucol"tic adu!ant thera$" for a&normal' !iscid' or ins$issated mucus secretions in acute and chronic &roncho$ulmonar" disease. +. Increase $roducti!it" of cough *. Nausea ). GI u$set. Contraindicated with h"$ersensiti!it" to acet"lc"steine@ use caution and discontinue immediatel" if &ronchos$asm occurs. +. Ensure $ro$er dilution of ta&let. *. Bonitor heart rate &efore gi!ing the drug. ). Bonitor urine out$ut. !CTION Bucol"tic N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S )1 +isacod(l Su$$ositor" + stick $er rectum +rand Na)e: (ulcola# The drug $asses unchanged into the colon where &acteria &reaks it down to organic acid that increase the osmotic $ressure in the colon and slightl" acidif" the colonic contents' resulting in an increase in stool water content' stool softening' la#ati!e action. Short term relief of consti$ation +. Sweating *. Elushing ). muscle cram$s -. e#cessi!e thirst Contraindicated in cases of allerg" to these drugs@ acute a&dominal $ain. +. (o not gi!e drug within + hour of an" other drugs. *. ?e$ort sweating' flushing' muscle cram$s and e#cessi!e thirst. !CTION 0a#ati!e N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S *0 %araceta)ol D22mg +ta& 9- 3?N ?educes fe!er &" acting directl" on the h"$othalamic heat5 regulating center to cause !asodilation and sweating which hel$s diss$ates heat. ?elief of mild to moderatel" se!ere $ain and treatment for fe!er +. Nausea *. GI u$set ). (i%%iness Contraindicated to $atients h"$ersensiti!e to 3aracetamol +. Gi!e drug with food if GI u$set occurs. *. (iscontinue drug if h"$ersensiti!it" reactions occur. ). Check for &od" tem$erature. !CTION Anti$"retic N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S *( 2"rose)ide Dmg I7 now Inhi&its rea&sor$tion of the sodium and chloride from the $ro#imal and distal tu&ules oral ascending lim& of the loo$ of Genle leading to Sodium < rich dieresis. Treatment for fluid retention. +. (i%%iness *. 7ertigo ). Ieakness -. Geadache D. (rowsiness 4. Eatigue .. /rthostatic G"$otension ,. Cardiac Arrh"tmias Allerg" to drug' Anuria' Se!ere ?enal Eailure +. Bonitor 8lood $ressure for sudden G"$otension *. Bonitor the Intake and /ut$ut. !CTION 0oo$ (iuretic N!#3 O2 DRUG and DOS3 #3C&!NIS# O2 !CTION INDIC!TION SID3 3223CTS CONTR!INDIC!TIONS NURSING R3S%ONSI+I'ITI3S *) Dio0in 2.*D+ ta& /( =.am> Increase intra cellular calcium and allows more calcium to enter m"ocardial cell during de$olari%ation !ia sodium < $otassium $um$ mechanism. Indicated for arrh"thmias' a&normal heart contractilit". +. Arrh"thmias *. Geadache ). Ieakness -. (rowsiness Allerg" to (igitalis $re$aration. 7entricular Tach"cardia' 7entricular Ei&rilation' Geart 8lock' Sick Sinus S"ndrome' Acute BI ). Bonitor heart rate &elow normal le!el &efore gi!ing drug. -. Check effecti!it" of the drug. Closel" monitor 83 and heart rate. !CTION Cardiac Gl"coside ** T3<T+OOK DISCUSSION %!T&O%&$SIO'OG$ T3T!NUS Tetanus is an acute' often fatal disease caused &" an e#oto#in $roduced in a wound &" Clostridium tetani. Clostridium tetani is a gram5$ositi!e' nonenca$sulated' motile' o&ligati!el" anaero&ic &acillus. It e#ists in !egetati!e and s$orulated forms. S$ores are highl" resistant to disinfections &" chemical or heat' &ut !egetati!e forms are susce$ti&le to the &actericidal effect of heat' chemical disinfectants' and a num&er of anti&iotics. Clostridium tetani is a nonin!asi!e organism. It is found in soil and in the intestine and feces of horses' shee$' cattle' dogs' cats' rats' guinea $igs and chicken. Banure5treated soil ma" contain large num&ers of s$ores too. Tetanus occurs after s$ores or !egetati!e &acteria gain access to tissues and $roduce to#in locall". The usual mode of entr" is trough a $uncture wound or laceration. Tetanus ma" also follow electi!e surger"' &urn wounds' otitis media' dental infection' a&ortion and $regnanc". Neonatal tetanus usuall" follows infection of the um&ilical stum$. In the $resence of anaero&ic conditions' the s$ores germinate. To#ins'including tetanol"sin =which $otentiates infection> and tetanos$asmin =a $otent neuroto#in> are $roduced. Tetanos$asmin' often referred to as tetanus to#in' causes clinical tetanus. The to#in $roduced is disseminated through the &loodstream and l"m$hatic s"stem. Gowe!er' it does not enter the central ner!ous s"stem through this route' as it cannot cross the &lood &rain &arrier e#ce$t at the fourth !entricle. The to#in is e#clusi!el" taken u$ &" the neuromuscular unction' where it migrates retrograde trans"na$ticall" at the rate .D5*D2mm6da"' a $rocess which takes )5+- da"s' $rotected from neutrali%ing antito#in' $redominantl" to inhi&itor" s"na$ses to $re!ent the release of acet"lcholine. The to#in acts after the incu&ation $eriod =)5+-> da"s> at se!eral sites within the central ner!ous s"stem' including $eri$heral motor end $lates' s$inal cord' &rain and s"m$athetic ner!ous s"stem. The t"$ical clinical manifestations of tetanus are caused when tetanus to#in interferes with release of neurotrasmitters' &locking inhi&itor im$ulses. *+ 8lockade of s$inal inhi&ition is $roduced when the to#in acts at the s"na$se of interneurons of inhi&itor" $athwa"s and motor neurons. General muscle rigidit" arises from uninhi&ited afferent stimuli entering the central ner!ous s"stem from the $eri$her". The effect of the to#in on the &rain is contro!ersial@ direct inoculation can cause sei%ures. /ne of the man" com$lications from tetanus is res$irator" failure secondar" to s$asms' o&struction &" secretions' e#haustion and $ulmonar" as$iration. Cardio!ascular com$lications thought to &e due to h"$eracti!it" of the s"m$athetic ner!ous s"stem include tach"cardia' with heart rates o!er +,2 &eats $er minute' se!ere !asoconstriction and h"$ertension. Autonomic d"sfunction is seen as increased &asal s"m$athetic acti!it" and e$isodes of s"m$athetic o!er acti!it". Tetan"s S()pto)s In generali%ed tetanus' the initial com$laints ma" include an" of the following; Irrita&ilit"' muscle cram$s' sore muscles' weakness' or difficult" swallowing are commonl" seen. Eacial muscles are often affected first. Trismus or lockaw is most common. This condition results from s$asms of the aw muscles that are res$onsi&le for chewing. A sardonicsmile 55 medicall" termed risussardonicus 55 is a characteristic feature that results from facial muscle s$asms. Buscle s$asms are $rogressi!e and ma" include a characteristic arching of the &ack known as o$isthotonus. Buscle s$asms ma" &e intense enough to cause &ones to &reak and oints to dislocate. Se!ere cases can in!ol!e s$asms of the !ocal cords or muscles in!ol!ed in &reathing. If this ha$$ens' death is likel"' unless medical hel$ =mechanical !entilation with a res$irator> is readil" a!aila&le. *5 Co)plications of Tetan"s In cases of se!ere tetanus infection' a num&er of $ossi&le com$lications can de!elo$ 2ract"res The re$eated muscle s$asms and con!ulsions that are caused &" a tetanus infection ma" lead to fractures in the !erte&rae =&ones in the &ack>' as well as in other &ones. 8one fractures can sometimes result in a condition called m"ositis ossificans circumscri$ta' which is where &one &egins to form in the soft tissues' often around a oint. *, Sins and s()pto)s in t*e te0tbook Sins and s()pto)s )anifested b( t*e patient Irrita&ilit"6 ?estlessness muscle cram$s Ieakness difficult" swallowing 0ockaw Stiffness ?efle# s$asms 8lood $ressure tem$erature Irregular heart &eat Sweating Sei%ure !spiration pne")onia If "ou ha!e a tetanus infection' muscle rigidit" =stiffness> can make coughing and swallowing difficult. This can cause as$iration $neumonia to de!elo$. As$iration $neumonia occurs as a result of inhaling the secretions' or contents' of the stomach' which can lead to a lower res$irator" tract infection. 'ar(nospas) 0ar"ngos$asm is where the lar"n# =!oice&o#> goes into a &rief' tem$orar" s$asm that usuall" lasts for &etween )2542 seconds. 0ar"ngos$asm $re!ents o#"gen from reaching "our lungs' making &reathing difficult. Tetanic sei4"res Tetanic sei%ures are con!ulsions =fits> that are similar to e$ile$tic fits. The" can occur in se!ere cases of tetanus where the infection has s$read to the &rain. Someone with a se!ere tetanus infection ma" e#$erience se!ere and fre9uent tetanic sei%ures. %"l)onar( e)bolis) A $ulmonar" em&olism is a serious and $otentiall" life5threatening condition. It is caused &" a &lockage in a &lood !essel in the lungs that can affect &reathing and circulation. It is therefore !ital that treatment is gi!en immediatel" in the form of anti5clotting medication and' if re9uired' o#"gen thera$". !c"te renal fail"re The se!ere muscle s$asms that are associated with a tetanus infection can cause a condition that is known as rha&dom"ol"sis. ?ha&dom"ol"sis is where the skeletal muscles are ra$idl" destro"ed' resulting in m"oglo&in =a muscle $rotein> leaking into the urine. This can lead to acute =se!ere> renal failure =kidne" failure>. %reventin tetan"s Immunisation is the &est wa" to $re!ent a tetanus infection from occurring. The com$lete course of the tetanus !accination consists of fi!e doses. The !accine ena&les "our &od" to create anti&odies against the tetanus to#in =tetanos$asmin>' $ro!iding $rotection from the illness should "ou &e e#$osed to the Clostridium tetani &acterium in the future. *- %at*op*(siolo(
QPatient centeredR *8 +,+A)-$ Clostridium tetani entes $o&y though a 2oun& Anaeo$ic con&itions allo2 ge%ination of spoes an& po&uction of toxins "oxins ae po&uce& an& &isse%inate& 3ia $loo& an& ly%phatics Tetanospasmin entes the ne3ous syste% peipheally at the %yeoneual 4unction an& is tanspote& centipetally into neuons of C!S 5ntefes 2ith neuotans%itte elease to $loc6 inhi$itos 7ea&s to unoppose& %uscle contaction an& spas% 7oc64a2 8BP Stiffness 8te%peatue !ec6 igi&ity s2eating 9ysphagia SE5:#RE causing Restlessness opisthotonos Reflex spas%s Age Sex 7ifestyle 9ental infection
pesence of C. tetani 1 5%paie& s2allo2ing ;t phayngeal %uscle spas% 2 Acute pain ;t %uscle igi&ity ) o unoppose& %uscle contaction 1 5neffecti3e $eathing patten ;t i%paie& lung %uscle contaction 3 5neffecti3e ai2ay cleaance ;t etaine& an& excessi3e secetions 4 Cc' 9ifficulty of s2allo2ing 9x' +eanus sa!e 3 NURSING C!R3 %'!N +( +) !SS3SS#3NT NURSING DI!GNOSIS %'!NNING INT3R/3NTION R!TION!'3 NURSING T&3OR$ 3/!'U!TION Subjective Gatiskog naman siya kung makibot o masilawan as !er&ali%ed. Objectives: ??J )2&$m 83J +-26+22 mmGg =K> Eacial grimace =K> Guarding =K> dia$horesis =K> lockaw =K>muscle s$asm =K>$eriodontal infection =K>h"$ere#tension of head Acute $ain r6t muscle rigidit" * o uno$$osed muscle contraction After nursing inter!entions' will demonstrate a reduction in $ain &eha!iors such as a&sence of facial grimace and guarding. Independent: (. Gandled the client:s &od" gentl" while doing nursing acti!it". ). Binimi%e mo!ement and dimmed light $ro!ided. ). Baintained side rail u$. Depedent : (. Administered Tramadol D2 mg I7 as ordered *. (ia%e$am Dmg intra!enousl" gi!en as ordered. *. Betronida%ole' D22mg ' gi!en To $romote safet" and allows e#$erience less $ain during care acti!it". To $romote rest and a!oid e#citation of neurons leading to muscle contractions. To ensure safet" when sei%ure and muscle rigidit" occurs. Treats moderate to moderatel" se!ere $ain It is a muscle rela#ant. That hel$s reduce muscle contractions causing $ain. Treatment of &acterial infection caused 0"dia Gall:s Care Core Cure Elorence Nightingale:s !nvironment "#eory Elorence Nightingale:s !nvironment "#eory Ernestine Ieiden&ach:s Prescriptive "#eory Ernestine Ieiden&ach:s Prescriptive "#eory Ernestine Ieiden&ach:s Goal was )et5 =5> guarding &eha!ior +* ++ !SS3SS#3NT NURSING DI!GNOSIS %'!NNING INT3R/3NTION R!TION!'3 NURSING T&3OR$ 3/!'U!TION Sub jective: Ginabudlayan siya mag gin#awa$ as !er&ali%ed &" the folks. Objectives: ??J)2 &$m A?J+*2&$m =K> crackles =K>$roducti!e cough =K>restlessness =K> drooling =K> im$aired swallowing S5ra" results shows 8ilateral $neumonia and &ronchiectasis Ineffecti!e airwa" clearance r6t retained and e#cessi!e secretions To maintain a $atent airwa" &e a&le to demonstrate effecti!e coughing and clear &reath sounds. Independent: +. Suctioned secretions as needed. *. Ele!ated head of the &ed6 change $osition e!er" *hours ). Ne$t the en!ironment allergen free like dust. -. Encouraged dee$ &reathing and coughing e#ercise. D. 3osition head midline with fle#ion. Depedent : +. Administered To maintain $atent airwa" and $re!ent as$iration. To take ad!antage of gra!it" decreasing $ressure on the dia$hragm and enhancing drainage. 3reci$itators of allergic t"$e res$irator" reactions that can trigger onset of acute e$isodes. To $romote o#"genation and ma#imi%e effort. "o open o %aintain open ai2ay. Is a mucol"tic 7irginia Genderson:s %asic Care Component Elorence Nightingale:s !nvironment "#eory Elorence Nightingale:s !nvironment "#eory 7irginia Genderson:s %asic Care Component Elorence Nightingale:s !nvironment "#eory Ernestine Goal was partiall( )et5 ?? decreased to *- &$m &ut still with crackles. +5 +, !SS3SS#3NT NURSING DI!GNOSIS %'!NNING INT3R/3NTION R!TION!'3 NURSING T&3OR$ 3/!'U!TION Sub jective: Ginabudlayan siya mag gin#awa$ as !er&ali%ed &" the folks. Objectives: ??J)2 &$m A?J+*2&$m =K> 0a&ored &reathing =K>restlessness =K> drooling =K> im$aired swallowing =K> nasal flaring S5ra" results shows 8ilateral $neumonia and &ronchiectasis Ineffecti!e &reathing $attern r6t im$aired lung muscle contraction To demonstate a&ilit" to &reathe comforta&l" as e!idienced &" normal res$irator" rate of +45*2 &$m. Independent: +. Suctioned secretions as needed. ). Ele!ate head of &ed6 $laced on high &ack rest. ). Assisted in taking control of &reathing Dependent: +. Administered o#"gen at -0$m as ordered. Collaborative: *. Com&i!ent ne&uli%ation done &" $ulmo5 aide. To maintain $atent airwa" and $re!ent as$iration. Ele!ation of head ma" decrease d"s$neic e$isodes. An u$right $osition facilitates lung e#$ansion. It can &e a hel$ful techni9ue in ma#imi%ing res$irator" function /#"gen thera$" hel$s decreased d"s$nea. Acts as &ronchodilator to $romote effecti!e airwa" $assage & 0"dia Gall:s Care Core Cure Elorence Nightingale:s !nvironment "#eory (orothea /rem:s Sel'(care De'icit Ernestine Ieiden&ach:s Prescriptive "#eory Ernestine Ieiden&ach:s Prescriptive "#eory Goal was partiall( )et5 ?? lowered down to *- &$m. +- +8 !SS3SS#3NT NURSING DI!GNOSIS %'!NNING INT3R/3NTION R!TION!'3 NURSING T&3OR$ 3/!'U!TION Sub jective: )abudlayan siya magtulon $ as !er&ali%ed &" the folks. Objectives: =K>lockaw =K>restlessness =K> drooling =K> im$aired swallowing =K>h"$ere#tesion of head =K>gum &leeding Im$aired swallowing related to $har"ngeal muscle s$asm After nursing inter!ention $atient will demonstrate effecti!e swallowing without muscle straining. D ependent: +. Nasogastric tu&e inserted &" ?/( Ind ependent: *. 3ro!ided meals in a 9uiet en!ironment awa" from e#cessi!e stimuli. ). Ga!e suction e9ui$ment a!aila&le during feeding. -. Ne$t with an u$right $osition for +Dmins to an hour after meal. 5. Instructed famil" how to monitor and detect as$iration after eating. To $ro!ide $arenteral feeding in ade9uate amount. The client can achie!e a more effecti!e swallow &" focusing on chewing and mo!ing foods6fluids to the &ack of the mouth where the swallowing refle# is triggered. Eor as$iration $recaution. This $osition uses gra!it" to aid in the flow of foods6fluids through the eso$hagus. Eor the famil" to &e aware for an" situation so that we can a!oid as$iration e!en when nurses are not in their room 0"dia Gall:s Care Core Cure Elorence Nightingale:s !nvironment "#eory 7irginia Genderson:s %asic Care Component Elorence Nightingale:s !nvironment "#eory 0"dia Gall:s Care Core Cure Goal was partiall( )et5 A&le to o$en his mouth. +1 50 !SS3SS#3NT NURSING DI!GNOSIS %'!NNING INT3R/3NTION R!TION!'3 NURSING T&3OR$ 3/!'U!TION Sub jective: Gina lagnat siya$ as !er&ali%ed &" the folks. Objectives: TJ),.* o C =K> &od" weakness =K>flushed and warm skin =K> sweating =K> shi!ering =K> $eriodontal trauma I8CJ++.H # +2MH60 Altered thermoregulation; G"$erthermia r6t tissue trauma * o $resence of C& tetani To lower down &od" tem$erature to )..D o C after * hours of nursing inter!entions. Independent: +. Te$id s$onge &ath done. *. ?oom:s tem$erature cooled down. ). 3ro!ided thick5wool &lanket to $re!ent further chills. +. (immed the light and $ro!ided a $eaceful en!ironment for rest. Binimi%ed stimulus. Depedent : -. 3aracetamol D22 mg' + ta& gi!en orall" as ordered. D. Administered Betronida%ole D22 mg intra!enousl" as It lower down &od" tem$erature. A consistent tem$erature limits en!ironmental effects on thermoregulation This will hel$ maintain a normal &od" tem$erature and $re!ents shi!ering. 3romotes rest and rela#ation ' and $re!ents from distur&ances. Anti$"retic that treats fe!er' &" lowering down &od" tem$. An anti&iotic used to treat infection caused &" anaero&ic C& tetani& 0"dia Gall:s Care Core Cure Elorence Nightingale:s !nvironment "#eory Elorence Nightingale:s !nvironment "#eory Elorence Nightingale:s !nvironment "#eory Ernestine Ieiden&ach:s Prescriptive "#eory Ernestine Ieiden&ach:s Prescriptive "#eory Goal was )et5 8od" tem$. is )..) o C. =5> Shi!ering 5( 5) !SS3SS#3NT NURSING DI!GNOSIS %'!NNING INT3R/3NTION R!TION!'3 NURSING T&3OR$ 3/!'U!TION Objectives: Urine !olume6fluid out$utJ -2 cc within , hours. =K> &od" weakness =K> muscle rigidit" CreatinineJ GI +4+., umol60 T3SAJ..)+mg6ml Urinar" incontinence r6t &ladder outlet o&struction After nursing interventions, will void urine volume of at least 30 cc every hour. D ependent: +. Eole" Catheter inserted as ordered. ). Administered Tamsulosin *2cc intra!enousl" as $rescri&ed. *. Solfenacin Dmg +ta& gi!en !ia NGT as ordered. Independent: +. Im$lement measures to ensure the $atenc" =e.g. kee$ tu&ing free of kinks' kee$ collection &ag &elow &ladder le!el> ). Encourage fluid intake in small amount fre9uentl". ). 3ro!ide an en!ironment that encourages To $romote ade9uate urine elimination. Gel$s to manage urethral stones and im$ro!es the flow of urine Smoothen urethral muscle and relie!ed s"m$toms of urge urinar" incontinence Baintaining $atenc" of the indwelling catheter $re!ents urinar" incontinence (rinking a large amount of fluid at one time results in ra$id filling of the &ladder which increases $ressure in the &ladder and the su&se9uent risk of incontinence En!ironmental factors ma" contri&ute to functional 7irginia Genderson:s %asic Component Ernestine Ieiden&ach:s Prescriptive "#eory Ernestine Ieiden&ach:s Prescriptive "#eory Florence Nightingales Environmental Theory 0"dia Gall:s Care Core Cure Florence Nightingales Environmental Goal was )et5 Urine out$utJ)22 cc after , hours 5* 5+ !SS3SS#3NT NURSING DI!GNOSIS %'!NNING INT3R/3NTION R!TION!'3 NURSING T&3OR$ 3/!'U!TION Sub jective: *adali siya makibot sa gasulod ga tiskog naman siya #indi siya katulog $ as !er&ali%ed &" the folks. Objectives: =K> too much !isitors =K> distur&ed slee$ =K> Ieakness =K> 0ethargic =K> Irrita&le =K> h"$ere#tension of head =K> &od" stiffness (istur&ed slee$ $attern r6t e#cessi!e en!ironmental stimuli After nursing inter!entions' will a&le to ha!e undistur&ed slee$ with long inter!als. Independent: +. Nee$ en!ironment 9uiet for slee$ing' eliminate noise. *. 3erform nursing $rocedures all at the same time if $ossi&le &efore $atient to go to slee$. ). Adusted lighting &" dimming the lights. Dependent: (. Administered (ia%e$am D2mg intra!enousl" 3ro!ides more rela#ing and comforta&le en!ironment for slee$ing. ?educes distur&ances in slee$ing. 0ight ma" alter or distur& $atient:s slee$. Acts as muscle rela#ant and an an#iol"tic. Florence Nightingales Environmental Theory 7irginia Genderson:s %asic Component Florence Nightingales Environmental Theory Ernestine Ieiden&ach:s Prescriptive "#eory Goal was )et5 Sle$t at long inter!als undistur&ed. Disc*are %lannin Br. E.8:s famil" decided to go home e!en though he was not in good condition' and the" ha!e signed a (ABA5 (ischarged Against Bedical Ad!ice. Ne!ertheless the following discharge $lanning was formulated; #3DIC!TIONS The following medications must &e com$l"; 5Betronida%ole D22mg + ta& 9, =+2am < 4$m < *am> 5Acet"lc"steine =Eluimucil>> 422g 6 + ta& in D2cc /( 5Telmisartan =Bicardis> -2mg + ta& /( 5Tramadol D2mg + ta& 9- 3?N for se!er $ain 5/me$ara%ol =3rosec> *2mg 6 + ta& 8I( 5(igo#in 2.*Dg + ta& /( =.am> 5Bo#iflacin =A!elo#> -22mg + ta& /( 55 !SS3SS#3NT NURSING DI!GNOSIS %'!NNI NG INT3R/3NTION R!TION!'3 NURSING T&3OR$ 3/!'U!TI ON Sub jective: Di na siya ka#ulag mayad indi pare#as sadto $ as !er&ali%ed &" the folks. Objectives: =K> &od" weakness =K>?eluctan ce to attem$t mo!ement. =K>0imited range of motion. (ecreased muscle strength. Im$aired $h"sical mo&ilit" r6t neuromusc ular im$airment . After 16 hours ! days 6"! shift# of nursing interventio ns, the $atient will maintain or increase strength and function of affected or com$ensat ory %ody $art. Independent : +. E!aluate or continuousl" monitor degree of $ain. *. Baintain &ed rest or chair rest when Indicated. Schedule acti!ities $ro!iding fre9uent rest $eriods and uninterru$ted night time slee$. 3. Assist with active or $assive range of motion. -. Encourage $atient to maintain u$right and erect $osture when sitting' standing' or walking. 0e!el of acti!it" or e#ercise de$ends on $rogression and resolution S"stemic rest during cute attacks and im$ortant throughout all $hases of disease to reduce fatigue and im$ro!e strength &aintains or im$roves 'oint function, muscle strength, and general stamina. Ba#imi%es oint function' maintains mo&ilit" that can $reci$itate acute attack. 7irginia Genderson: s %asic Componen t Florence Nightingale s Environmen tal Theory Gildegard 3e$lau:s Interperso nal "#eory o' )ursing Florence Nightingale s Environmen tal Theory Goal was not )et5 =K> &od" weakness
3<3RCIS3 !ND !CTI/IT$ 5Ad!ise folks to assist the $atient in doing $assi!e range of motion 5Instructed folks to a!oid stressful acti!ities for $atient 50et the folks $ro!ide health" h"giene to the $atient 5Encourage to seek $s"chological su$$ort and social grou$ thera$" TR3!T#3NT Ne&uli%ation treatment must &e resume u$on discharge and continuous /#"gen thera$" is needed &" Br. E.8 &O#3 T3!C&INGS .Educate the folks a&out what is Tetanus and on how to take the $rescri&ed medication of the $atient 5Ad!ice the folks to let the $atient slee$ in long inter!als and a!oid to much stressor to the $atient 5Teach the folks on what are the $ossi&le side effects and effects of the medication to the $atient OUT %!TI3NT 2O''O1.U% Br. E.8:s condition re9uires thorough medical attention' he shall ha!e a recommended return !isit at the hos$ital. Ge was encouraged to com$l" $atient follow5u$. DI3T Br. E.8 was discharged with NGT attached for his $arenteral feeding. An /TE +422 cal shall &e di!ided into 4 e9ual feedings S%IRITU!'IT$ Ad!ise folks to seek s$iritual hel$ from $riests' nuns an" religious organi%ation mem&er the" know in the societ" for s$iritual counseling +I+'IOGR!%&$ Smelt%er' S.' 8are' 8.' Ginkle' F. T Chee!er' N. =*22,>. %runner + Suddart#,s "extbook o' *edical(Surgical )ursing -- t# !d& 0i$$incott Iilliams T Iilkins. Seele"' ?.' Ste$hens' T. T Tate' 3. =*22.>. !ssentials o' .natomy + P#ysiology / t# !d. BcGraw5Gill. 8ickle"' 0. =*22.>. %ates, Pocket Guide to P#ysical .ssessment + 0istory "aking 1 t# !d. 0i$$incott Iilliams T Iilkins 5, Narch' A. =*22H>. 2334 5ippincott,s )ursing Drug Guide. 0i$$incott Iilliams T Iilkins. /cta!iano' E. T 8alita' C. =*22,>. "#eoretical 6oundations o' )ursing: "#e P#ilippine Perspective& Ultimate 0earning Series www.wiki$edia.org www.doh.go!.$h www.eBedicine.com 5-