Mini Case Study

HEALTH HISTORY
5 days prior to admission, patient experienced episodes of fever and anuria. For those 5
days, the first three days was where the patient experienced episodes of fever and for the next 2
days, anuria was manifested by the patient.
HEALTH ASSESSMENT
NEUROLOGICAL:
Sensorium: drowsy/lethargic
Speech: Slurred
Motor: paraplegia
Can follow simple commands
GLASGOW COMA SCALE:

1900H: Eye opening (3, to speech), Motor response (6, obeys commands), Verbal response (5,
oriented) Total: 14
2000H:Eye opening (3, to speech), Motor Response (6, obeys commands) Verbal response (5,
oriented)
Total: 14
PUPILS:
1900H Right: Size (2 mm) Reaction (+)
Left: Size (2mm) Reaction (+)
2000H Right: Size (2 mm) Reaction (+)
Left: Size (2mm) Reaction (+)
MOTOR ACTIVITY:
1900H Arms: flexion
Legs: Weakness
2000H Arms: flexion
Legs: Weakness
RESPIRATORY:
Oxygenation: with oxygen inhalation at 1 lpm via nasal cannula
Breathing: with spontaneous and non-labored
Breath sounds: fine rales
CARDIOVASCULAR:
No chestpain
Swelling/ edema on extremities: upper extremities
Peripheral pulses: palpable, on all sites
Cardiac rhythm: sinus bradycardia
GASTRO-INTESTINAL:
No vomiting and nausea
Abdomen: round
Nutrition: NGT NPO except medication
Bowel Movement the whole shift: 0
Tube/drainage: NGT connected to the bedside
GENITO-URINARY
Bladder: non-distended
Tube/drainage: foley catheter (16)
Dark yellow urine
With episodes of anuria
INTEGUMENTARY:
Skin condition: warm
With rashes, bruises, laceration on the upper extremities (left arm)
With pressure ulcer at lower extremities (right leg)
Skin color: jaundiced
PSYCHOSOCIAL:
Mood Behavior: restless
Activities: CBR without bathroom privilege
May dangle legs
May sit up on bed
May use bedside commode
OTHER NURSING CARE RENDERED:

Turning every 2000H
DRUG STUDY
Generic and Brand Name of Drug:
Meropenem (Meromax)
Drug Classification:
Beta-lactam antibiotic
Drug Action/s: penetrates cell wall of most gram positive and gram negative bacteria to reach
penicillin-binding protein targets
Dose, frequency and route of administration (doctor’s order):
500 mg 1 IV, Q12H
Indication/s (reason/s) for administering the medication to the patient:
To treat skin and abdominal infections caused by bacteria
Contraindications: Hypersensitivity to drug, its components and other beta lactams.
Most common side-effects of the Most common adverse effects of the

medication medication
 Nausea  easy bruising/bleeding

 Vomiting  hearing changes (such as decreased
 Diarrhea hearing, ringing in the ears)
 Constipation  mental/mood changes (such as
 Headache/soreness confusion)
 numb/tingling skin
 swelling ankles/feet
 unusual weight gain
 unusual tiredness.
Nursing Responsibilities to be considered when administering the medication.
1. Monitor for CNS irritability and seizures.

2. In prolonged therapy, evaluate hematopoietic, renal and hepatic function.
3. Collect specimens for culture and sensitivity testing as needed.
Patient Health Teachings in relation to the medication
1. Advise patient to report such adversereactions as CNS irritability, diarrhea,rash,

shortness of breath, or pain atinfusion site.
2. As appropriate, review all other significant and life-threatening adversereactions and
interactions, especiallythose related to the drugs.
Amiodarone (Anoion)
Drug Classification: antiarrhythmics (class III)
Drug Action/s: Prolongs action potential and refractory period. Inhibits adrenergic
stimulation. Slows the sinus rate, increases pulse rate and decreases peripheral vascular
resistance (vasodilation).

200 mg NGT BID
Treatment for life-threatening ventricular arrythmias
Contraindications:
Sinus bradycardia, sino-atrial heart block.

 Nausea  Adult respiratory distress syndrome

 Vomiting  Pulmonary Fibrosis
 Fatigue  Pulmonary Toxicity
 Anorexia  Heart Failure
 Constipation  Worsening of arrhythmias
1. Monitor EKG continuously during IV infusion and initiation of PO therapy.

2. Monitor for pulmonary toxicity.
3. Monitor liver and thyroid functions throughout long-term therapy.
1. Advise patient that photosensitivity reactions may occur. Protective clothing and sun-
block are recommended during and for 4 months after therapy.
2. Inform patients that blueish discoloration of the face, neck, and arms is a possible side
effects. This is usually reversible and will fade over several mo. Notify health care
professional if this occurs.
Pantoprazole (Pantropaz)
Drug Classification: Proton-pump inhibitor
Drug Action/s: Binds to an enzyme in the presence of gastric pH, preventing the final
transport of hydrogen ions into the gastric lumen.
40 mg IV Q12H
Used to treat damage from gastroesophageal disease (GERD)
Contraindications:
Contraindicated in patients with a history of hypersensitivity to the drug itself, components of
the formulation, and/or other benzimidazole PPIs, including omeprazole, lansoprazole,
raberprazole, esomeprazole or dexlansoprazole.

 Headache  Acute nephritis

 Abdominal pain  Flatulence
 Diarrhea  Headache
 Joint pain  Insomnia
 Dizziness  Skin rash
1. Assess GI symptoms: epigastric or abdominal pain, bleeding and anorexia.

2. Monitor for possible drug induced adverse reaction.
3. Monitor for and immediately report S&S of angioedema or a severe skin reaction.
1. Inform patient that pantoprazole may increase the risk of bone fractures.
2. Instruct patient to notify healthcare professional of all medications, vitamins, or herbal
products being taken and consult healthcare professional before taking any new
medications.
PATHOPHYSIOLOGY
Student Name: Dazlynne S. Cartujano CI: Mrs. Vanessa Langcay
RLE Group: 1
Community/Area: Manila Doctors Hospital (Intensive Care Unit)
LEARNING FEEDBACK DIARY

For the first day of Clinical Duty at Manila Doctors Hospital, I was filled with mixed
emotions. I was excited because I have an opportunity to learn and apply what I have learned in
class at a new environment and at the same time, I was also nervous since it was our first time
inside the Intensive Care Unit. As we entered the unit, I witnessed many complicated health
cases that are being treated and monitored carefully to each of the patients’ lives. I saw how hope
and faith is essential inside the Intensive Care Unit. That despite the patients’ critical condition,
our goal as nurses is to give them hope and help them I their healing process. I have witnessed
how my patient improved from not being able to respond to responding to anyone who gets near
his bedside. I also have witnessed how my patient was more than willing to let me and the other
nurses help him with his condition.
As I continue the shift, I also had an opportunity to learn new things and facts inside the
Intensive Care Unit, be it small or big information. All in all, my new learnings and experiences
inside the Intensive Care Unit was an addition in to move forward to the path in being a
Paulinian Nurse I ought to be in the future.

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HEALTH HISTORY

GLASGOW COMA SCALE:

OTHER NURSING CARE RENDERED:

Generic and Brand Name of Drug:

Dose, frequency and route of administration (doctor’s order):

500 mg 1 IV, Q12H

Indication/s (reason/s) for administering the medication to the patient:

To treat skin and abdominal infections caused by bacteria

Contraindications: Hypersensitivity to drug, its components and other beta lactams.

Most common side-effects of the Most common adverse effects of the

 Nausea  easy bruising/bleeding

Nursing Responsibilities to be considered when administering the medication.

1. Monitor for CNS irritability and seizures.

Patient Health Teachings in relation to the medication

1. Advise patient to report such adversereactions as CNS irritability, diarrhea,rash,

Drug Classification: antiarrhythmics (class III)

Dose, frequency and route of administration (doctor’s order):

Indication/s (reason/s) for administering the medication to the patient:

Treatment for life-threatening ventricular arrythmias

Sinus bradycardia, sino-atrial heart block.

Most common side-effects of the Most common adverse effects of the

 Nausea  Adult respiratory distress syndrome

Nursing Responsibilities to be considered when administering the medication.

1. Monitor EKG continuously during IV infusion and initiation of PO therapy.

Patient Health Teachings in relation to the medication

Drug Classification: Proton-pump inhibitor

Dose, frequency and route of administration (doctor’s order):

Indication/s (reason/s) for administering the medication to the patient:

Used to treat damage from gastroesophageal disease (GERD)

Most common side-effects of the Most common adverse effects of the

 Headache  Acute nephritis

Nursing Responsibilities to be considered when administering the medication.

1. Assess GI symptoms: epigastric or abdominal pain, bleeding and anorexia.

Patient Health Teachings in relation to the medication

LEARNING FEEDBACK DIARY

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