Baseline Data:

Name of Patient: RLH Diagnosis: Community Acquired Pneumonia HR

Age/Sex: 57, Male Physician’s Name: Dr. Joselito Maestral
Chief complaints: Difficulty of breathing

Medications Exercise Treatment Hygiene Outpatient Referral Diet

Laboratories
*Diazepam Passive Range of Motion *Bed bath *Inform significant others *Oral tube feeding
-the nurse or another person *Urinalysis to report signs of pain, and - every 4 hours with 60%
C- moves each of the client’s -is a physical, chemical and - To promote cleanliness, fever because it signifies carbohydrates content, 20%
Anxiolytic, Skeletal muscle joints through heir microscopic analysis of the to provide comfort and infection to CTT insertion fat and 20% protein with an
relaxant, anticonvulsant, complete range of urine. relaxation, to improve the site. additional of 5 egg whites
sedative-hypnotic. movement, maximally client’s self-image, to - to prevent aspiration
Indicated for muscle spasm stretching all muscle groups *Triglycerides condition the skin, to *Follow up Consultation
within each plane over each -are blood lipids formed by stimulate peripheral to monitor the changes of *Foods high in calories
H- joint esteriphication of glyceride circulation of the client. the patient’s condition.
Relieves anxiety, muscle and three fatty acids are - to meet the daily
spasm, and seizures, Active-Assistive Range of carried by the serum *Oral care *Instruct the client to nutritional needs of the
promotes calmness and Motion lipoproteins. comply with home client
sleep -carried out with client and - to maintain the intactness medications and
the nurse participating. The *LDL cholesterol and health of the oral maintenance drugs in
Assessment parameter of client is encouraged to -to monitor lipid counts to mucosa, to prevent oral order to promote and hasten
effectiveness. carry out as much of each client with hyperlipidemia. infections, to clean and recovery.
(-) muscle spasm movement as possible, moisten the membranes of
within the limitations of *HDL cholesterol the mouth and lips *Encourage client to
E- strength and immobility - To monitor lipid counts to perform regular exercises
2.5mg IVTT now client with hyperlipidemia. Suctioning of secretion and maintain a healthy
*Temporomandibular Joint - is a method of removing lifestyle
C- -open mouth *cholesterol excessive secretions from
• Be alert for adverse -close mouth - Indicator of the airway

47
 reaction atherosclerosis or coronary - to remove secretions
• Avoid hazardous *Shoulder artery disease To provide patent airway
activities when using -abduction
drug -adduction (anterior &
• Tell patient to avoid using posterior) *Routine fluid analysis
alcohol when under drug -horizontal flexion and - Indicates the amount and
therapy extension characteristic of pleural
• Tell patient to take drug -internal & external rotation fluid
exactly as prescribed and
not to stop abruptly
• Warn patient of physical *Elbow *AFB staining
and psychological -rotation for supination and - Test done to detect
dependence pronation Presence of TB

K- *Wrist *Gram stain

• Obtain patients -flexion, extension & - Test done to detect the
underlying condition hyperextension presence of PTB and
before starting the -circumduction pneumonia
therapy, and reassess -radial flexion & ulnar
regularly thereafter flexion *ABG
-are usually ordered to
• Periodically monitor
*Hands and Fingers assess disturbances of acid-
hepatic, renal and
- flexion, extension & base balance caused by a
hematopoietic function
hyperextension respiratory disorder and
• Look for adverse reaction -abduction & adduction metabolic disorder.
and drug interaction
• Don’t mix injectable from *Foot *RBS
with other drug because -internal & external rotation -Test done to level of sugar
diazepam is incompatible in the blood
with drugs *Ankle
• Possibility of abuse and -plantar flexion & *BUN
addiction exist. Don’t

47
 withdraw drug abruptly dorsiflexion -Is an effective test
after long-term use. -eversion & inversion primarily for determining
Withdrawal symptoms renal function.
may occur.
Coughing Deep Breathing *Prothrombin time
Exercise -measures the clotting
- Facilitate
ability of factors I,II,V,VII
*Lactulose expectoration of
and X.
secretion from the *Hepatitis B Surface
C- respiratory tract Antigen
Laxatives. Indicated for - Facilitate maximum -done to determine the
constipation lung expansion presence of heap b virus in
the blood in either an active
H- Splinting of the Affected or carrier state.
Relieves constipation, Site
decreases blood ammonia - Relieves the client *Hepatitis C Virus Test
concentration. from pain -is formerly a non A, non B
hepatitis. Transmitted
Assessment parameter of Changing Positions parenterally.
effectiveness. Frequently
Patient’s constipation is - Prevent from *Complete blood count
relieved pressure ulcers (CBC), also known as full
- Promote proper blood count (FBC) or full
E- body circulation blood exam (FBE) or blood
Lactulose 30cc IVTT Q4 panel

-is a test panel requested by

C- a doctor or other medical
• Be alert for adverse professional that gives
reaction information about the cells
• Don’t confuse lactulose in a patient's blood.

47
 with lactose
• Diarrhea indicate
overdose
• To minimize sweet taste,
dilute in water or fruit
juice or give with food
• Tell patient about adverse
reaction and to tell
prescriber if more than 3
soft stools are passed.
• Store drug at room
temperature 30°C
K-
• Contraindicated in patient
on low-galactose diet
• Use cautiously in patient
with DM because drug
contain lactose, galactose,
and other sugars.
• Assess patient’s condition
before starting therapy
and regularly thereafter to
monitor drug
effectiveness.
• Monitor patient’s
electrolyte in long term
use
• Be alert for adverse
reactions
Abnormally high or low
counts may indicate the
presence of many forms of
disease, and hence blood
counts are amongst the
most commonly performed
blood tests in medicine, as
they can provide an
overview of a patient's
general health status.
*Serum Creatinine
-is used along with a BUN
(blood urea nitrogen) test to
assess kidney function.
Both are frequently ordered
as part of a basic or
comprehensive metabolic
panel (BMP or CMP),
groups of tests that are
performed to evaluate the
function of the body’s
major organs.
*Serum Potassium
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• Don’t confuse lactulose
with lactose.
• Replace fluid loss
• Diarrhea may indicate
overdose
• Store drug at room
temperature 30°C
Azithromycin
C-
Antibiotic
> acute exacerbation of
COPD cause by. S.
pneumonia
>AP cause by S.
pneumonia
H – Client is free from
infection
E- 500 mg, IVTT, OD
C – Tell client to be alert of
adverse reactions
K–
• Assess if patient is
hypersensitivity to drug
• Be alert for any adverse
-is ordered to check the
potassium level of the
client. To detect presence
of hypo or hyperKalemia.
To monitor potassium
levels during health
problems
Treatment
*Oxygen therapy
-is the administration of
oxygen at a concentration
of pressure greater than that
found in the environmental
atmosphere. It is
particularly useful in
treatment of hypoxemic
state and results in adequate
transport of oxygen by
blood.
*Nasogastric intubation
-is a medical process
involving the insertion of a
plastic tube (nasogastric
tube, NG tube) through the
nose, past the throat, and
down into the stomach.
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 reaction -the main use of a
• Assess patient’s nasogastric tube is for
infection before starting feeding and for
therapy administering drugs and
• Before giving first dose, other oral agents.
obtain specimen for
culture and sensitivity *Intravenous therapy or
tests IV therapy
• Instruct patient to take
drugs exactly as -is the giving of liquid
prescribed substances directly into a
• Tell patient to report vein.
adverse reaction -It’s purpose is to supply
• Don’t give with antacids fluid when client are unable
to take in an aequate
• Tell patient that drug can
volume of fluid by mouth.
be taken with or without
To provide glucose, the
foods
main fuel for metabolism.
Tell patient to avoid
To provide salts needed to
prolonge exposure to sun.
maintain electrolyte
balance
Furosemide
PNSS
C – Diuretics
PLR
• Actue pulmonary edema
• Edema Endotracheal Intubation
• Heart and chronic renal - Insertion of a hollow
impairment curved polyvinylchloride
• Hypertension tube through either the nose
Hypercalemia or the mouth into the
trachea accomplished by
H–

47
(-) crackels means of a bladed
(-) edema instrument/ laryngoscope

E- 60 mg, IVTT, now Mechanical Venilator

-machine that keeps air
C – Tell Patient to be alert moving in and out of the
of averse rection lungs of a patient that can’t
breth unaided
K–
• Assess patient’s Medications:
underlying condition 1. Ertapenem
before starting therapy. 2. Omeprazole
Monitor wt., peripheral 3. Azithromycin
edema, breath sounds, 4. Albuminate
BP, fluid I&O, and 5. Hydrocortisone
electrolyte, glucose 6. Furosemide
BUN, and carbon dioxide 7. Nitroglycerine
levels 8. Diazepam
• Be alert for advers 9. Atropine Sulfate
reaction and drug 10. Lactulose
interaction 11. Aminoleban
• If oliguria or azotemia 12. Combivent
develops or increases
notify prescriber
• Instruct pt. to report
ringing in ears, severe
abd. Pain, or sore throat
and fever because they
may indicate toxicity
• Tell patient to check with
the prescriber before

47
 taking OTC drugs or
gerbil remedies
• Evaluate if patient is free
form edema.

Atropine Sulfate
C- Anticholinergics
• GIT disorder
• GU disorder
• Respiratory disorder

H-
Effectiveness
Patient is relive form
bradycardia

Decrease in secretions

E-
0.5 mg, IVTT, STAT

C–
Tell patient of Adverse
reactions

K–
• `Monitor VS. tachycardia
is a side effect that occurs
with large doses of
anticholinergics such as
atropine sulfate

47
• Assess urine output.
Urinary retention may
occur
• Check bowel sounds.
absence of bowel sounds
may indicate paralytic
ileus resulting from a
decrease GI motility.
• Raise side rails for client
who are confused and
debilitated. Atropine
sulfate could cause CNS
stimulation (Excitement
or confusion)

Aminoleban

C – Amino Acids

H–
Faster wound healing
Relieve from hepatic
encephalopathy

E - 1 satchet, BID

C- Tell patient of Adverse

drug reaction

K–
• Contraindicated to

47
 patient with severe renal
impairment and
abnormal amino acid
metabolism
• Use cautiously in patient
with severe acidosis,
CHF

Ertrapenem

C- Antibiotic
• Community acquired
pneumonia caused by
Steptococcus
Pneumoniae
• Complicated UTI

H – Patient is free from

infection

E - 1g, IVTT, OD

C-
Tell patient of Advrse drug
reaction
Tell patient to take drug as
prescribed

K–

• Check for previous

47
 penicillin, cephalosporin,
or other betalactam
hypersensitivity
• Monitor renal, hepatic,
and hematopoetic
function, during
prolonged therapy
• Inform patient of potential
adverse reactions and
urge him to notify
prescriber immediately
if they occur
• If allergic reaction occurs
stop drug immediately
and give immediate
treatment with airway
management,
epinephrine, o2 and IV
streroids
• Overdose may cause
Nausea, diarrhea, and
dizziness. If an overdose
occurs stop drugs and
treat supportively until
drug has been eliminated
from the body

Omeprazole

C- Antacid
• Pathologic

47
 hypersecretory
conditions
• Duodenal ulcer
• Heartburn
• Posterior laryngitis

H–
Patient is free from gastric
discomfort

E - 40 mg, IVTT, OD

C- Tell patient of adverse

drug reactions

Teach patient to take only

drug as prescribed

K-

• Assess patients conditions

before starting therapy
and regularly thereafter
to monitor drug’s
effectiveness
• If GI reaction occurs
monitor patients,
hydration
• Explain importance of
taking drugs exactly as
prescribed

47
• Advise patient that OTC
isn’t intended for
immediate relieve of
heartburn
• Lower doses aren’t
needed for patients with
renal and hepatic
impairment
• Warn patient not to chew,
crush tablets or capsules
Albumine

C- Plasma Volume
Expanders
• Hypovelemic shock
• hypotrotenemia
• hyperbilurubinemia

H-
(-) Hyponatremia
(-) Hypovolemia
(-) Hyperbilirubinemia

E – 1 vial, IVTT, q12

C – Tell patient to be aware

of adverse drug reactions

K–
• monitor fluid intake and
output, protein,

47
 electrolyte, hgb, hct
levels
• Monitor patients blood
pressure often during
therapy
• If hypotension occurs
slow and stop infusion
• Tell patient report chills,
fever, dyspnea, nausea
and rash immediately

Hydrocortisone

C – glucocorticoids
• Treatment of primary
or secondary adrenal
cortex insufficiency,
rheumatic disorders,
collagen disease,
allergic states,
respiratory disease,
allergic and
inflammatory
ophthalmic
processes.Constipation

H–
(-) Inflammation
(-) Respiratory Distress
Relieve from
Hypoglycemia

47
E - 200 mg, IVTT, STAT

C – Tell patient to be alert

of adverse drug reaction
Tell Patient not to abruptly
stop taking drug without
prescribers consent

• K - Monitor patient’s
weight, BP, and
electrolyte levels
• Monitor patient for
stress, fever, trauma,
surgery may increase
adrenal insufficiency
• Be alert for adverse
reactions and drug
interactions
• Notify prescriber about
adverse reactions
• Instruct patient to carry
or wear medical
identification that
identifies need for
supplemental systemic
glucocorticoid for strss
• Warn patient about easy
bruising
Tell patient not to abruptly
stop taking the drug

47
without prescriber’s
consent

Nitroglycerin

C – Vasodilator
Angina Pectoris

H – (-) Chest Pain

E - 5 mg, transdermal,
STAT

C - Tell patient to be alert

of adverse drug reaction

K–
• Assess the patient’s
condition before starting
drug therapy and to
monitor drug
effectiveness
• Tell patient that abruptly
stopping the drug causes
coronary vasospasm
• Instruct patient to use
caution when wearing
transdermal patch near
microwave oven leaking
radiation may heat
metallic backing of patch

47
 and cause burns
• If drug is ineffective
immediately notify
prescriber and keep
patient at rest
• Tell patient how to use
prescribe form of drug
• Apply transdermal forms
to any non hairy areas
except lower parts of
arms and legs to promote
maximum

Salbutamol

C – Bronchodilator
• Broncho spasm

H–
(-) wheezing
(-) dyspnea

E- ½ nebule, steam
inhalation, q4

C – Tell patient to be alert

of adverse drug reactions

K–
• contraindicated to
patient hypersensitive

47
 to drug
• use cautiously in patient
CV disorders,
hyperthyroidism, DM
• obtain baseline data of
patient respiratory status
and assess patient often
during therapy
• If more than 1 dose is
ordered wait at least two
minutes between
nebulized doses. If
corticosteroid inhaler is
used, first have patient
use bronchodilator wait
5 minutes, and then
have patient use
corticosteroid inhaler.
This permits
bronchodilator to open
air passages for
maximum effectiveness.

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