Download pptx - Diabetic Ketoacidosis

Presented By:

MARIE JUNE BARGO BEBING BSN,RN

IRISH KRISTIAN REYES TAMBANGAN BSN,RN

DIABETIC KETOACIDOSIS

(DKA)

This presentation aims to study the case of a particular patient in ICU that concerns the topic DKA (Diabetic Ketoacidosis). The aspects looked into were the overview of the disease mentioned above, personal data of patient and all the important matters that concerns nursing care, nursing management and nursing tasks. The observations and all the data that will be mentioned in this study will be treated confidential and for educational purpose only. In this regard, the research done in this course of study will be treated with high ethical consideration.

Scope and limitations

Diabetic ketoacidosis is a acute, major, life threatening complication of Diabetes that mainly occurs in patient with Type 1 diabetes, but it is not uncommon in some patients with Type 2 DM. This condition is a complex disordered metabolic state characterized by hyperglycemia, ketoacidosis and ketonuria.

Overview of the disease

GRAPH

ACIDOSIS

KETOSISHYPERGLYCE

MIA

DKA

The most common scenarios for DKA are underlying or concomitant infection (40%), missed insulin treatment (25%) and newly diagnosed, previously unknown diabetis (15%). Other associated causes make up roughly 20% in the various scenarios.

ETIOLOGY

61 y.o. Male, born on January 1, 1954, Syrian by nationality, married, stands 173 cm tall and weighs 91 kilograms. Known case of Type I Diabetes Mellitus, He has no known allergies.

PERSONAL DATA

Mr. X had Type I Diabetes Mellitus for about 10 years, as he could remember. He was only taking oral medication for his DM. He is also hypertensive.

He has no impairment or disabilities and He has not undergone any surgical procedures in the past.

PAST HEALTH HISTORY

Mr. X presented to the emergency department with severe constipation for about 5 days. Prior to the day of presentation to the Emergency Room, Mr. X claimed that he visited four doctors and they gave him four different prescriptions and all failed to help him to relieve his constipation. He didn’t remember any of the medication names. With a known DM and HPN, Mr. X was worried that this caused him severe constipation.

HISTORY OF PRESENT ILLNESS

EATING PATTERN

PATTERNS OF FUNCTIONING

Before illness During illness Analysis

-Eats 4-5 times a day with two heavy meals.

-Three days prior to

admission, ate less than 3 times a day.

-On liquid diet/diabetic

low salt diet as per Doctor’s order, eats

without assistance.

-Mr.X lost his appetite a little

bit due to no bowel

movement. Never the less,

he was seen eating well on a liquid diet with full compliance and improved

day by day.

DRINKING PATTERN


-Drinks 3-5 bottles of

500ml mineral water/day

-Drinks tea and can tolerate at

least 4-6 cups/day

-approximately two 500 ml

bottled water /day

-Mr.X feels thirsty most of

the day because of the weather as he claimed but

clinically may be connected to his DM. Drank less water on admission because he

claimed he was not feeling

thirsty most of the time.

ELIMINATION PATTERNVOIDING

Before illness During illness analysis

8-10 times/day

Color:yellow amber

Characteristics:Clear

Amount:1000-1500ml/

day

On Foley catheter

Output:1500-2500ml

Urine output increased since

some furosemide was given as part of

his moderate regimen.

BOWEL


Usually after breakfast

Amount:Moderate

Characteristics:formed, soft,

brownish

On colostomy drainage

Characteristics:coffee

brown,soft to liquid form

Mr. X undergone surgery to relieve his

severe constipation.

PHYSICALLEVEL OF COMPETENCIES


Did Activities of Daily Living

independently.

Slightly dependent on his wife or domestic helper especially upon wearing his

slippers or washing prior to

prayer time.

Moves freely on bed but needs assistance on going up and

down the bed or in sitting.

Mr.X felt slightly

uncomfortable of his condition

prior to admission.

He has the difficulty to

bend down and move.

HYGIENE


Takes a bath everyday.

Needs assistance from

the nurse especially upon

change of gown.

Mr.X said he wasstill

uncomfortable with his

colostomy, his movements are limited but he is well aware that maybe without

the colostomy nor the IV lines, he could do this tasks alone.

SLEEPING PATTERN


Sleeps 6-9 hours/day

Sleeps whenever he

wants, anytime he wants.

Sometimes, he claimed that he is not aware of

the time.

Mr.X’s sleeping pattern was

only changed because he is not used to

people coming in and out of

his room.

PATHOPHYSIOLOGY OF DIABETIC KETOACIDOSIS

INFECTION STRESS

EXCESS SECRETION OF GLYCOGEN AND OTHER COUNTER REGULATORY

HORMONES

ACIDOSIS

DEHYDRATION

VOMITING

GLYCOGENENOLYSIS AND

GLUCONEOGENESIS

POTASSIUM LOSS

OSMOTIC DIURESIS

HYPERGLYCEMIA

DECREASE GLUCOSE UPTAKE

INADEQUATE INSULIN

MISSED INSULIN DOSE

NEW-ONSET DIABETES

KETOSIS

KETOGENESIS

INCREASED LIPOLYSIS OF ADIPOSE TISSUE

PATIENT’S BODY : Average built

VITAL SIGNS: GCS 15/15BP 102/68MMHGPR 93BPMTEMP 36.4 RR 24BPM

RESPIRATORY:-breathing with normal pattern-02 sat : 98%

CARDIOVASCULAR:-no chest pain noted-pulse rate on normal range-cardica rhythm on monitor, normal and stable-capillary refill normal

PHYSICAL ASSESSMENT

GASTROINTESTINAL-with colostomy on left lower quadrant of

abdomen slightly distended.GENITOURINARY

-FC 14 size-urine color: slightly hazy

MUSCULOSKELETAL-with spontaneous but cautious movements-upper and lower extremities in full range of

motion.INTEGUMENTARY

-with slightly pale complexion, warm skin-with good skin turgor-no edema noted-with light skin peeling and redness at left lower back

ONGOING APPRAISAL08-05-2015-received patient on side lying position, with et tube in place connected to mechanical ventilator on vcv mode; fio2 40%, tv 500, rt 12, peep 6, i:e 1:2, pmax 35-with arterial line at right radial artery-iv cannula g20 at right cephalic vein, g16 at right brachial vein, with ongoing nss at 100 ml/hr-with remifentanyl at 0.04mcg/kg/hr, midazolam 2mg/hr-with colostomy left lower quadrant of abdomen with brownish colored output-surgical wound on abdomen with clean and dry dressing-gcs 9/15 (e3m5v1)-with full rom, pale looking, pupils 3mm bilateral brisk reactive to light, +bowel sounds, clear breath sounds, with symmetrical chest rise.-attached to cardiac monitor-on DKA protocol

09-05-2015-received patient on right side lying position, awake, with et tube in place connected to mechanical ventilator on pcv mode; fio2 40%, pinsp 14, rtae 10, peep 6, i:e 1:2, pmax 35-with arterial line at right radial artery-with NGT connected to free drain with greenish output-with foley catheter connected to urometer draining to a yellowish colored urine-iv cannula g20 at right cephalic vein, g20 at right metacarpal vein, g16 at right brachial vein, with ongoing D10 nss at 150 ml/hr-with remifentanyl at 0.04mcg/kg/hr, midazolam 2mg/hr, labetalol 0.2mg/min, insulin infusion @0.05units/kg-with colostomy left lower quadrant of abdomenwith brownish colored output-surgical wound on abdomen with clean and dry dressing-gcs 9/15 (e3m5v1)-with full rom, pale looking, pupils 3mm bilateral brisk reactive to light, +bowel sounds, clear breath sounds, with symmetrical chest rise.-attached to cardiac monitor-on DKA protocol

10-05-2015-received patient on right lateral position, with head elevated at 30 degrees.-GCS 15/15 (E4V5M6)-with ivf of D10nss+40 meqs kcl@150ml/hr via infusion pump-with NGT fr.14 in place, on open draining with greenish output-with colostomy @ left lower quadrant of abdomen, abdomen slightly distended.-iv cannula g20 at right cephalic vein, g20 at right metacarpal vein, g16 at right brachial

vein-with redness and skin peeling on the left side of the trunk-still on DKA protocol

11-05-2015-received patient on right lateral position-GCS 15/15-breathing spontaneously with O2 3LMP via nasal cannula-iv cannula g20 on left and right hand-nitroglycerine@10mcg/min-attached to cardiac monitor, febrile-with foley catheter in place with adequate output-with colostomy @ left lower quadrant of abdomen-with redness and skin peeling on the left side of the trunk

12-05-2015-received patient on right side lying position-conscious and coherent, GCS 15/15- with nasal cannula@3LMP, saturating well@97%-connected to cardiac monitor: BP 134/65mmhg, RR 15bmp, HR 86bmp, Temp. 36.8-with IV cannula g20 @ right hand connected to Nitroglycerine infusion-with arterial line @ left radial artery-on foley catheter f14 with urine output 30-40ml/hr-noted blister @ left lower back and burn-like wound- with colostomy @ left lower quadrant of abdomen

Urea 6.1 mmol/L N: 2.78-8.07mmol/L

Creatinine 76 umol/L N: 62-106umol/L

Potassium 4.7mmol/L N:3.5-5.1mmol/L

Sodium 139mmol/L N:136-145mmol/L

WBC 6.95K/UL N:4-11K/UL

Neutrophils 4.58K/UL N:2-6.9K/UL

Hgb 9.5g/dl N:13-17.4g/dl

Hematocrit 32.9% N:39-52%

LABORATORY RESULTS06-05-2015

08-05-2015

Urea 8.1mmol/L N: 2.78-8.07mmol/L

Creatinine 89umol/L N: 62-106umol/L

Sodium 134mmol/L N:136-145mmol/L

Potassium - N:3.5-5.1mmol/L

Chloride 102mmol/L N:98-107mmol/L

Bicarbonate 18mmol/L N:22-29mmol/L

Magnesium 0.69mmol/L N:0.7-1.05mmol/L

Phosphorus 1.62mmol/L N:0.87-1.45mmol/L

WBC 10.33K/UL N:4-11K/UL

Hgb 8.0g/dl N:13-17.4g/dl

Hematocrit 27.7% N:39-52%

Beta-OH 3.7 -

Ca (serum) 2.0 2.15-2.55mmol/L

Continuation…

Urea 9.5 - - - - - - N: 2.78-8.07mmol/L

Creatinine 109 - - - - - - N: 62-106umol/L

Sodium 135 137 137 137 139 138 140 N:136-145mmol/L

Potassium 5.31 5.35 4.70 4.37 4.72 4.39 4.30 N:3.5-5.1mmol/L

Chloride 104 106 106 109 110 110 112 N:98-107mmol/L

HCO3 18 17 18 19 - 19 19 N:22-29mmol/L

Phosphorus

- 1.57 1.33 0.79 0.88 0.71 0.61 N:0.87-1.45mmol/L

magnesium

- - - - - 0.69 - N:0.7-1.05mmol/L

09-05-2015

HCO3 19 7 19 18 N:22-29mmol/L

Sodium 144 143 138 143 N:136-145mmol/L

Potassium 4.51 4.73 4.60 4.66 N:3.5-5.1mmol/L

Chloride 114 113 110 113 N:98-107mmol/L

Phosphorus 0.77 0.68 0.64 0.64 N:0.87-1.45mmol/L

Lactate 1.01 N:0.5-2.2 mmol/L

10-05-2015Beta-OH 0.1 - - - - -

Bicarbonate 19 17 19 17 18 N:22-29mmol/L

Sodium 144 143 143 142 142 N:136-145mmol/L

Potassium 4.49 4.44 4.35 4.57 4.56 N:3.5-5.1mmol/L

Chloride 114 114 116 112 110 N:98-107mmol/L

Phosphorus 0.65 - 0.65 0.68 0.78 N:0.87-1.45mmol/L

Magnesium - - - - 0.77 N:0.7-1.05mmol/L

Urea 3.3 - - - - N: 2.78-8.07mmol/L

Creatinine 63 - - - - N: 62-106umol/L

Hgb 0.77g/dl N:13-17.4g/dl

11-05-2015 12-05-2015Beta-OH 0.8 9.25 -Hgb 9.2 9.25 N:13-17.4g/dl

Urea 3.1 5.2 N: 2.78-8.07mmol/L

Creatinine 62 69 N: 62-106umol/L

Sodium 138 141 N:136-145mmol/L

Potassium 4.21 4.35 N:3.5-5.1mmol/L

Chloride 1.08 106 N:98-107mmol/L

Bicarbonate 19 18 N:22-29mmol/L

Magnesium 0.72 0.70 N:0.7-1.05mmol/L

Phosphorus 0.99 1.00 N:0.87-1.45mmol/L

Upon admission to ICU (08-05-2015)0300

NPOD5% NS 120ml/hrMedications

Perfalgan 1g IV QIDPethidine 75mg IM TIDFlagyl 500mg IV TIDPantoprazole 40mg IV OD

CBC q6hKFT, Betahydroxy Butaric AcidMedium dose Insulin Sliding Scale1L NSS given bolus

Then 100ml/hrLower limb doppler done

(applied pneumatic stockings)Medications

Calcium gluconate 2g IV STATInsulin 10iu in 200ml D10%Sodium Bicarbonate 50ml IV STAT1L NSS given bolusRemifentanyl infusion 0.02-0.2meg/kg/min

0344 Medications Midazolam 2-10mg/hr

Lasix 40mg IV STAT

MEDICAL MANAGEMENT

1505 KFT, LFT, Ca, hgb STATABGAlbumin 5% 500ml IV STATNS 1000ml IV STATDKA PROTOCOL1 unit PRBC transfused (PT,PTT,INR) NormalMedications

Lantus 20iu @ bed time/day(Medium Dose Regular Insulin Sliding Scale on

hold)Hibor 3500iu SC/dayTazocin 4.5g q6h IV

1900 2 Units PRBC transfusedMedications

Labetalol 40mg IV infusion STAT given

09-05-2015Medications

Mgso4 5g+200ml NS over 2hr STATPotassium phosphate 20mmol+200ml NS over 3hrs STATSeptic screening doneExforge 160/5mg PO ODSedation on HOLDMechanical Ventilator on CPAP-PS

Then ABG was checked after 30 minutes1300 Extubated then put to 6LPM via Face Mask

Ventolin 2.5 mg – nebulization givenABG repeated

10-05-20151635 Medication

Potassium phosphate 20mmol+200ml NSS over 3 hours STATIncentive spirometer done

1843 NGT removedLiquid diet startedChest / abdominal X-rayMedications

Nitroglycerin infusion 2 to 100 mcg/minPethidine 50mg IV STAT

Maintained Systolic BP around 140ABG Repeated

DKA PROTOCOL STOPPEDAfter 1 hour Electrolytes repeated with Beta Butiric Acid


Potassium phosphate 20mmol+200ml NSS 3 hours STAT

Morphine 5mg IV STAT and q8h PRNPerfalgan 1G IV QIDLabetalol 200mg ORAL TIDMebo cream TID


Nitroglycerin discontinuedLasix 40mg IV STATMorphine 5mg IV STATTRANSFERED TO SURGICAL WARD

DRUG STUDY

Brand name PerfalganDrug classification Analgesic, AntipyreticMechanism of action mechanism of action is associated with

inhibition of prostaglandin synthesis, the predominant influence on the thermoregulation center in the hypothalamus that enhances heat transfer.

Indication short term mild to moderate pain and/or fever.Contraindication : -hypersensitivity to paracetamol -chronic active alcoholism -marked disturbances of liver function and / or kidney disease -anemia -pregnancyAdverse effect -vomiting, fever, rash, neutropoenia(rarely),

leucopoenia(rarely), thrombocytopenia(rarely). Hepatotoxic effects: methemoglobinemia, renal and liver dysfunction, hypochromic anemia for long term use.

PARACETAMOL IV

Nursing responsibilitiesAssessment

-Monitor for s&s of: hepatotoxicity, even with moderate acetaminophen doses, poisoning, usually from accidental ingestion or suicide attempts; potential abuse from psychological dependence (withdrawal has been associated with restless and excited responses).

Patient & family education -Do not take other medications (e.g., cold

preparations) containing acetaminophen without medical advice; overdosing and chronic use can cause liver damage and other toxic effects.

-Do not self-medicate adults for pain more than 10 days without consulting a physician.

-Do not use this medication without medical direction for: fever persisting longer than 3 d, fever over 39.5° c (103° f), or recurrent fever.

Brand name Fleet enemaDrug classification Lubricant, LaxativeMechanism of action Works by slowing the absorption of water from the bowel,

which softens the stool. Relieving occasional constipation or fecal impaction (severe constipation). It may also be used to cleanse and remove residue from the bowel in certain situations (eg, after using a barium enema).

IndicationOccasional constipation or bowel cleansing before rectal exam.

ContraindicationMegacolon. Bowel obstruction. Imperforate anus. Chf.

Adverse effectRectal seepage, anal irritation, pruritus ani, rectal reflex impairment, infection/impaired healing of anorectal lesions.

MINERAL OIL

Nursing responsibilities-Check the doctor’s order.

-Provide privacy. To prevent feeling of embarrassment.

-Promote relaxation. To relax anal sphincter and facilitate insertion of rectal tube.

-Position the client: Adult – left lateral position.

-Sizes of rectal tube to be used is: Adult – fr. 22-32

-If abdominal cramps occur during introduction of solution, temporarily stop the flow of solution by clamping the tube until peristalsis relaxes.

-After introduction of the solution, press buttocks together to inhibit the urge to defecate.

-Do perianal care.

-Make relevant documentation.

Brand name HumuLIN R, NovoLIN R, ReliOn/HumuLIN R

Drug classification HormoneMechanism of action

It works by lowering levels of glucose (sugar) in the blood. Regular insulin is a short-acting form of insulin.

IndicationDiabetes.

ContraindicationDuring episodes of hypoglycemia

Adverse effectHypoglycemia, hypokalemia, local or systemic allergy, edema.

REGULAR INSULIN

-Use only needles designed for insulin delivery to give your insulin injection.-Different insulin pens may require different pen needles. Make sure that you have the correct needle for your device. -Do not carry an insulin pen with a needle attached to it. -Use a different site for each injection; about 1 inch away from previous injection sites.

Nursing responsibilities

Brand name A-hydrocort®, Solu-cortef Drug classification CorticosteroidMechanism of action

Glucocorticoids bind to the cytosolic glucocorticoid receptor(GR), a type nuclear receptor that is activated by ligand binding. After a hormone binds to the corresponding receptor, the newly formed complex translocates itself into the cell nucleus, where it binds to glucocorticoid response elements(GRE) in the promoterregion of the target genes resulting in the regulation of gene expression This process is commonly referred to as transcriptional activation, or transactivation

HYDROCORTISONE

IndicationPrescribed for severe allergies, arthritis, asthma, multiple sclerosis and skin conditions. It is also used to treat certain types of cancer.

ContraindicationContraindicated in patients with systemic fungal infection, who are taking mifepristone and hypersensitivity to drug.

Adverse effect

headache,nausea,vomiting,dizziness,insomnia,restlessness,unusual moods,increased sweating, skin easy bruising,tiny purple skin spots,irregular or absent menstrual periods.

Assessment & drug effects-Establish baseline and continuing data on bp, weight, fluid

and electrolyte balance, and blood glucose.- Be alert to signs of hypocalcemia.-Monitor for persistent backache or chest pain.-Monitor for and report changes in mood and behavior,

emotional instability, or psychomotor activity, especially with long-term therapy.

-Be alert to possibility of masked infection and delayed healing (antiinflammatory and immunosuppressive actions).

Patient & family education-Expect a slight weight gain with improved appetite. -Do not ignore dyspepsia with hyperacidity. Report symptoms

to physician and do not self-medicate to find relief.-Do not use aspirin or other otc drugs unless prescribed

specifically by the physician.-Do not abruptly discontinue drug; doses are gradually

reduced to prevent withdrawal symptoms.

Nursing Responsibilities

Brand name FlagylDrug classification AntibioticMechanism of action

Metronidazole is an antibiotic effective against anaerobic bacteria and certain parasites. Anaerobic bacteria are single-celled, living organisms that thrive in environments in which there is little oxygen (anaerobic environments). Anaerobic bacteria can cause disease in the abdomen (bacterial peritonitis), liver (liver abscess), and pelvis (abscess of the ovaries and the fallopian tubes).

Indication- Symtopmatic intestinal and extraintestinal amebiasis as well as infections with trichomonas vaginalis and giardia lamblia. -Anaerobic infections (e.g. Cerebral abscesses, intra-abdominal abscesses, gynecological infections of the pelvic organs, soft tissue infections, osteomyelitis)

Contraindication Patients with a prior history of hypersensitivity to metronidazole or other nitroimidazole derivatives.

Adverse effectDizziness, headache, diarrhea, nausea, stomach pain, loss of appetite, constipation, changes in taste, and dry mouth.

METRONIDAZOLE

-Discontinue therapy immediately if symptoms of cns toxicity develop.

-Monitor especially for seizures and peripheral neuropathy (e.g., numbness and paresthesia of extremities).

-Monitor for s&s of sodium retention, especially in patients on corticosteroid therapy or with a history of chf.


Brand name AproxinDrug classification Nonsteroidal anti-inflammatory drug

(nsaid)Mechanism of action

Reducing hormones that cause inflammation and pain in the body.

Indication Used to treat pain or inflammationContraindication

So-called aspirin intolerance. Active peptic ulcer. Advanced renal failure.

Adverse effectUpset stomach, mild heartburn or stomach pain, diarrhea, constipation, bloating, dizziness, headache, nervousness, skin itching or rash;blurred vision; or ringing in your ears.

NAPROXEN

-Take detailed drug history prior to initiation of therapy.- Observe for signs of allergic response in those with aspirin or other nsaid sensitivity.-Schedule baseline and periodic auditory and ophthalmic examinations in patients receiving prolonged or high dose therapy.-Monitor therapeutic effectiveness.


Brand name Protonix IVDrug classification Proton Pump InhibitorMechanism Of Action

Suppresses the final step in gastric acid production by covalently binding enzyme at the secretory surface of the gastric parietal cell.

IndicationPatients with erosive esophagitis (damage to the esophagus from stomach acid), and other conditions involving excess stomach acid such as zollinger-ellison syndrome.

ContraindicationPatients with known hypersensitivity to any component of the formulation or any substituted benzimidazole

Adverse effectFever, cold symptoms such as stuffy nose, sneezing, sore throat;stomach pain, gas, nausea, vomiting;mild diarrhea; or joint pain.

PANTOPRAZOLE

-Monitor for and immediately report s&s of angioedema or a severe skin reaction.

Patient & family education

-Contact physician promptly if any of the following occur: peeling, blistering, or loosening of skin; skin rash, hives, or itching; swelling of the face, tongue, or lips; difficulty breathing or swallowing.


Brand name Kalcinate, cal-g, cal-gluDrug classification Mineral Supplement, ElectrolytesMechanism of action

Calcium is necessary for many normal functions of your body, especially bone formation and maintenance . Calcium can also bind to other minerals (such as phosphate) and aid in their removal from the body.

Indication-hypocalcemic tetany, hypocalcemia related to hypoparathyrodism-hypocalcemia-osteomalacia-magnesium sulfate overdosage

ContraindicationVentricular fibrillation, heart disease, long-term kidney problems, kidney stone, kidney disease, high amount of calcium in urine, high amount of calcium in the blood

Adverse effectNausea or vomiting, decreased appetite, constipation, dry mouth, increased thirst and increased urination.

CALCIUM GLUCONATE

Assessment & drug effects

-Monitor ecg and bp and observe patient closely during administration.

-Advise ambulatory patient to remain in bed for 15–30 min or more depending on response following injection.


-Symptoms of mild hypercalcemia, such as loss of appetite, nausea, vomiting, or constipation may occur. If hypercalcemia becomes severe, call health care provider if feeling confused or extremely excited.

-Do not use other calcium supplements or eat foods high in calcium, like milk, cheese, yogurt, eggs, meats, and some cereals, during therapy.

-


Brand name Generic only. No brands available.Drug classification ElectrolyteMechanism of action

It works by neutralizing excess acid in the blood. It may also replace bicarbonate when there are excess losses from the body.

IndicationTreating metabolic acidosis (a condition in which there is too much acid in the body) and certain drug intoxications, and replacing bicarbonate lost due to severe diarrhea.

Contraindication-allergic to any ingredient in sodium bicarbonate-alkalosis (too little acid in the body) or low blood levels of calcium or chloride-vomiting patient

Adverse effectirritability; muscle spasms or twitching; pain, redness, or swelling at the injection site

SODIUM BICARBONATE

-Assess the client’s fluid balance throughout the therapy. -Symptoms of fluid overload should be reported such as hypertension, edema, difficulty breathing or dyspnea, rales or crackles and frothy sputum.-Sigs of acidosis should be assessed such as disorientation, headache, weakness, dyspnea and hyperventilation.-Assess for alkalosis by monitoring the client for confusion, irritability, paresthesia, tetany and altered breathing pattern.

-Iv sites should be observed closely. Extravasation should be avoided as tissue irritation or cellulitis may occur when taking sodium bicarbonate.-If infiltration occurs, the physician should be notified immediately.


Brand name ultivaDrug classification narcotic pain relieverMechanism of action

it works by dulling the pain perception center in the brain.Indication

Preventing and treating pain during and after procedures and surgery.

Contraindication -Allergic to any ingredient in remifentanyl or to similar medicines.Adverse effect Changes in vision; chills; dizziness; drowsiness; fever; headache;

itching; nausea; shivering; sweating; vomiting.Nursing responsibility

-Monitor vital signs during postoperative period-observe for and immediately report any s&s of respiratory distress or respiratory depression, or skeletal and thoracic muscle rigidity and weakness.-Monitor for adequate postoperative analgesia.

REMIFENTANYL

Brand name generic only. No brands available.Drug classification benzodiazepineMechanism of action

- It works in the central nervous system (brain) to cause sleepiness, muscle relaxation, and short-term memory loss, and to reduce anxiety.

IndicationReducing anxiety or producing drowsiness or anesthesia before certain medical procedures or surgery. It may also be given continuously to maintain sedation or anesthesia in certain patients

Contraindication-Patients allergic to any ingredient in midazolam.-Patients with acute narrow-angle glaucoma -Severe mental problems (eg, psychosis)-Severe liver disease-Patients with alcohol intoxication with abnormal vital signs.

Adverse effectBlurred vision; changes in blood pressure, breathing, and heartbeats; coughing; dizziness; drowsiness; dry mouth; headache; hiccups; nausea; pain during injection; pain, redness, or tenderness at the injection site; short-term memory loss; slurred speech; vomiting.

MIDAZOLAM

Assessment & drug effects-Inspect insertion site for redness, pain, swelling, and other

signs of extravasation during iv infusion.-Monitor for hypotension, especially if the patient is

premedicated with a narcotic agonist analgesic.-Monitor vital signs for entire recovery period. -Be aware that overdose symptoms include somnolence,

confusion, sedation, diminished reflexes, coma, and untoward effects on vital signs.

Patient & family education-Do not drive or engage in potentially hazardous activities

until response to drug is known. You may feel drowsy, weak, or tired for 1–2 d after drug has been given.

-Review written instructions to assure future understanding and compliance. Patient teaching during amnestic period may not be remembered. Even if dose is small and depth of amnesia is unclear, relearn information.


Brand name LasixDrug classification Loop diuretic (water pill)Mechanism of action

Prevents your body from absorbing too much salt, allowing the salt to instead be passed in your urine.

Indication-Treats fluid retention (edema) in people with congestive heart failure, liver disease, or a kidney disorder .-This medication is also used to treat high blood pressure (hypertension).

ContraindicationPronounced hyponatremia or hypovolemia and anuria.

Adverse effectRinging in your ears, hearing loss itching, loss of appetite, dark urine, clay-colored stools, jaundice,nausea and vomiting, weight loss, body aches, numbness, swelling, rapid weight gain.

FUROSEMIDE

Assessment & drug effects-Observe patients receiving parenteral drug carefully; closely

monitor bp and vital signs. -Observe older adults closely during period of brisk diuresis.

Sudden alteration in fluid and electrolyte balance may precipitate significant adverse reactions.

-Monitor for s&s of hypokalemia Patient & family education

-Consult physician regarding allowable salt and fluid intake.-Ingest potassium-rich foods daily (e.g., bananas, oranges,

peaches, dried dates) to reduce or prevent potassium depletion.

-Make position changes slowly because high doses of antihypertensive drugs taken concurrently may produce episodes of dizziness or imbalance.

-Avoid replacing fluid losses with large amounts of water.-Avoid prolonged exposure to direct sun.


Brand name albuminar-25; albuminar-5; albutein 25%; albutein 5%; buminate 25%; buminate 5%; plasbumin-25; plasbumin-5.

Drug classification long acting agent for plasma volume expansion, antihyperbilirubinemic

Mechanism of action An important regulator of the volume of circulating blood. It accounts for 70 to 80% of the colloid oncotic pressure of plasma.

IndicationShock burns pancreatitis and peritonitis

ContraindicationPatients with cardiac failure, pulmonary edema or severe anemia because of the risk of acute circulatory overload

Adverse effectChills, fever, tachycardia, hypotension, urticaria, skin rash and nausea

ALBUMIN 5%

Asessment & drug effects-Monitor bp, pulse and respiration, and iv albumin flow

rate. Adjust flow rate as needed to avoid too rapid a rise in bp..

-Observe closely for s&s of circulatory overload and pulmonary edema.

-Monitor i&o ratio and pattern. Report changes in urinary output. Increase in colloidal osmotic pressure usually causes diuresis, which may persist 3–20 h.

-Withhold fluids completely during succeeding 8 h, when albumin is given to patients with cerebral edema.

Patient & family education-Report chills, nausea, headache, or back pain to

physician immediately..


Brand name Lantus Opticlik Cartridge, Lantus Solostar PenDrug classification Hormone Mechanism of action

It works by lowering levels of glucose (sugar) in the blood. Lantus is a long-acting form of insulin that is slightly different from other forms of insulin that are not man-made.

IndicationTreatment of adult and pediatric patients with type 1 diabetes mellitus or adult patients with type 2 diabetes mellitus who require basal (long-acting) insulin for the control of hyperglycemia.

ContraindicationPatients with hypersensitivity to lantus or one of its excipients.

Adverse effectItching skin rash over the entire body, wheezing, trouble breathing, fast heart rate, sweating, or feeling like you might pass out.

LANTUS


-Monitor for s&s of hypoglycemia especially after changes in insulin dose or type.

-Monitor blood glucose level.

-Withhold drug and notify physician if patient is hypokalemic.


-Do not inject into areas with redness, swelling, itching, or dimpling.

-Ingest some form of sugar (e.g., orange juice, dissolved table sugar, honey) if symptoms of hypoglycemia develop; and seek medical assistance.

-Check blood sugar as prescribed.

-Notify the physician of any of the following: fever, infection, trauma, diarrhea, nausea, or vomiting. Dosage adjustment may be needed.

-Do not take any other medication unless approved by physician.

NURSING RESPONSIBILITIES

Brand name HiborDrug classification Anticoagulant agentMechanism of action

Help to prevent blood from clotting in the blood vesselsIndication

-after general abdominal surgery in patients with a moderate risk of venous thromboembolism. -thromboembolic disease in nonsurgical patients-clotting in the extracorporeal circuit during haemodialysis -after a major orthopaedic surgery in patients with high risk venous thromboembolism.

Contraindication -in patients who have allergic reaction after being given any medicine

containing bemiparin sodium or heparin -patients suffering from any condition which results in tendency to bleed excessively. -in case of bacterial endocarditis. - in patients with active major bleeding - in patients having an injury to or are about to have an operation in the brain, spine, eyes and/or ears.

BEMIPARINE SODIUM

Adverse effect-Bleeding: this may occur during the treatment of anticoagulant ,thrombocytopenia: in rare cases, there may be a decrease in the number of platelets. Patients may develop bruises (violet marks) at injection sites, local reactions: rarely, mild skin allergic reactions (skin rash, itching) may occur.

Assessment & Drug Effects

-Check patients history of allergic reaction after being given any medicine containing bemiparin sodium

-Monitor platelet count closely. Withhold drug and notify physician if platelet count less than 100,000/mm3.

-Monitor closely patients with renal insufficiency and older adults who are at higher risk for thrombocytopenia.

Patient & Family Education-Report to physician promptly signs of unexplained bleeding such

as: pink, red, or dark brown urine; red or dark brown vomitus; bleeding gums or bloody sputum; dark, tarry stools.

-Do not take any OTC drugs without first consulting physician.

Nursing Responsibilities

Brand name TazocinDrug classification Antibacterial agentMechanism of action

it works by blocking the bacteria's cell wall growth, which kills the bacteria.

IndicationTreating moderate to severe infections caused by certain bacteria.

Contraindication-You are allergic to any ingredient in piperacillin/tazobactam-You have a history of allergic reaction to any penicillin (eg, amoxicillin)

Adverse effect-Constipation; diarrhea; headache; indigestion; nausea; pain, swelling, or redness at the injection site; trouble sleeping; vomiting.

PIPERACILLIN/TAZOBACTAM

Assessment & drug effects-Obtain history of hypersensitivity to penicillins, -Monitor patient carefully during the first 30 min after initiation of the infusion for signs of hypersensitivity.

Patient & family education-Report rash, itching, or other signs of hypersensitivity immediately.-Report loose stools or diarrhea as these may indicate pseudomembranous colitis.


Brand name trandateDrug classification adrenergic receptor blocker.Mechanism of action

It works by blocking both alpha and beta receptors in the body, which lowers blood pressure.

Indication Used to treat hypertension (high blood pressure).

Contraindication-You are allergic to any ingredient in labetalol-You have second- or third-degree (complete) heart block, moderate to severe first-degree heart block after a heart attack, heart failure or shock caused by serious heart problems-You have asthma, obstructive airway disease, or other breathing disorders-You have severe slow heartbeat or severe low blood pressure

Adverse effectDizziness; indigestion; lightheadedness; nausea; pain, swelling, or redness at the injection site; stuffy nose; temporary tingling of the scalp; unusual tiredness.

LABETALOL

Assessment & drug effects-Monitor bp and pulse during dosage adjustment period. -Monitor diabetic patients closely; drug may mask usual cardiovascular response to acute hypoglycemia (e.g., tachycardia).-Maintain patient in supine position for at least 3 h after iv administration.

Patient & family education-Make all position changes slowly and in stages, particularly from lying to upright position. Older adult patients are especially sensitive to hypotensive effects.-Do not drive or engage in other potentially hazardous activities until response to drug is known.


Brand name exforgeDrug classification calcium channel blockerMechanism of action

It works by relaxing the muscles of your heart and blood vessels.

IndicationUsed to treat high blood pressure

Contraindication-Hypersensitivity to the active substances’- Severe renal impairment- Second and third trimesters of pregnancy.- Severe hypotension.- Shock (including cardiogenic shock).

Adverse effectHives; difficulty breathing; swelling of your face, lips, tongue, or throat.

AMLODIPINE/VALSARTAN

-Monitor bp for therapeutic effectiveness. -Monitor for s&s of dose-related peripheral or facial edema-Monitor bp with postural changes.- Report postural hypotension. Monitor more frequently when additional antihypertensives or diuretics are added.


Brand name Neutra-phos-kDrug classification urinary acidifierMechanism of action

It works by increasing the amount of acid in the urine, which lowers the ph of the urine. This may reduce the growth of some bacteria in the urine and help dissolve calcium kidney stones.

Indication kidney stones.

Contraindication-You are allergic to any ingredient in potassium phosphate powder for solution-You have severe adrenal insufficiency (addison disease), infected kidney stones, struvite stones, severe kidney damage, or high levels of phosphates or potassium in the blood-You are taking a potassium-sparing diuretic (eg, triamterene)

Adverse effectAbdominal pain; diarrhea; nausea; vomiting.

POTASSIUM PHOSPHATE


-Monitor i&o ratio and pattern in patients receiving the parenteral drug. If oliguria occurs, stop infusion promptly and notify physician.

-Monitor patients receiving parenteral potassium closely with cardiac monitor. Irregular heartbeat is usually the earliest clinical indication of hyperkalemia.

-Be alert for potassium intoxication (hyperkalemia) may result from any therapeutic dosage, and the patient may be asymptomatic..


-Learn about sources of potassium with special reference to foods and otc drugs.

-Do not use any salt substitute unless it is specifically ordered by the physician. These contain a substantial amount of potassium and electrolytes other than sodium.

-Notify physician of persistent vomiting because losses of potassium can occur


Brand name generic only. No brands available.Drug classification mineral. Mechanism of action

It works by replacing magnesium in patients who have low magnesium levels in the body due to illness or treatment with certain medicines

Indication-Treating low magnesium levels .-It is also used in pregnant women to control seizures due to certain complications of pregnancy

ContraindicationYou are allergic to any ingredient in magnesium sulfateYou have a severe irregular heartbeat

Adverse effectdizziness; flushing; irregular heartbeat; muscle paralysis or weakness; severe drowsiness; sweating.

MAGNESIUM SULFATE

Assessment & drug effects-Observe constantly when given iv. Check bp and pulse q10–15 min or more often if indicated.-Early indicators of magnesium toxicity (hypermagnesemia) include cathartic effect, profound thirst, feeling of warmth, sedation, confusion, depressed deep tendon reflexes, and muscle weakness.-Monitor respiratory rate closely. Report immediately if rate falls below 12.-Check urinary output, especially in patients with impaired kidney function. Therapy is generally not continued if urinary output is less than 100 ml during the 4 h preceding each dose.-Have calcium gluconate readily available in case of magnesium sulfate toxicity.

Patient & family education-Recommended daily allowances of magnesium are obtained in a normal diet. Rich sources are whole-grain cereals, legumes, nuts, meats, seafood, milk, most green leafy vegetables, and bananas.


Drug classification bronchodilatorMechanism of action

Relaxes muscles in the airways and increases air flow to the lungsIndication

Treating or preventing breathing problems in patients who have asthma or certain other airway diseases.

ContraindicationPatients with a history of hypersensitivity to albuterol or any other components.

Adverse effectRare cases of hypersensitivity reactions, including urticaria, angioedema and rash

Nursing responsibilities-Assess lung sounds, pr and bp before drug administration and during peak of medication.-Advise the patient to rinse mouth with water after each inhalation to minimize dry mouth.

VENTOLIN INHALATION

Brand name generic only. No brands available.Drug classification nitrateMechanism of action

It works by relaxing (widening) blood vessels. Chest pain occurs when the heart needs more oxygen than it can get. Relaxing blood vessels allows blood to flow more easily. This reduces the heart's workload and the amount of oxygen needed by the heart.

IndicationTreating high blood pressure during surgery, controlling congestive heart failure associated with heart attack, treating chest pain in certain patients, and lowering blood pressure during surgery.

Contraindication-You are allergic to any ingredient in nitroglycerin-You have had a stroke or other bleeding in the brain, swelling of the sac surrounding the heart, or interference of blood returning to the heart-You are taking avanafil, riocituat, sildenafil, tadalafil, or vardenafil

Adverse effectDizziness or light-headedness; headache; irritation at the injection site.

NITROGLYCERIN

Assessment & drug effects-Administer iv nitroglycerin with extreme caution to patients with hypotension or hypovolemia since the iv drug may precipitate a severe hypotensive state.-Assess for headaches. Approximately 50% of all patients experience mild to severe headaches following nitroglycerin. -Assess for and report blurred vision or dry mouth.-Be alert for overdose symptoms: hypotension, tachycardia; warm, flushed skin becoming cold and cyanotic; headache, palpitations, confusion, nausea, vomiting, moderate fever, and paralysis. Tissue hypoxia leads to coma, convulsions, cardiovascular collapse. Death can occur from asphyxia.

Patient & family education-Keep record for physician of number of angina attacks, amount of medication required for relief of each attack, and possible precipitating factors.-Report blurred vision or dry mouth. -Change position slowly and avoid prolonged standing. Dizziness, light-headedness, and syncope (due to postural hypotension) occur most frequently in older adults.


Brand name demerolDrug classification synthetic opioid analgesicMechanism of action

Like morphine, pethidine exerts its analgesic effects by acting as an agonist at the μ-opioid receptor

IndicationModerate to severe pain including pain before, during and after an operation.

Contraindication-History of hypersensitivity to pethidine.-Coma- It also contra-indicated in conditions associated with raised intracranial pressure and in head injury.-Acute respiratory depression and when there is risk of paralytic ileus or obstructive airways disease.

Adverse effectRash, itching/swelling (especially of the face/tongue throat), dizziness, trouble breathing.

PETHIDINE

Assessment & drug effects-Give narcotic analgesics in the smallest effective dose and for the least period of time compatible with patient's needs.-Assess patient's need for prn medication. Record time of onset, duration, and quality of pain.-Monitor vital signs closely. Heart rate may increase markedly, and hypotension may occur. -Schedule deep breathing, coughing (unless contraindicated), and changes in position at intervals to help to overcome respiratory depressant effects.-Chart patient's response to drug and evaluate continued need.

Patient & family education-Do not take other CNS depressants.


Drug classification narcotic.Mechanism of action

Morphine binds to opioid receptors, molecular signalling activates the receptors to mediate certain actions.

IndicationTreat moderate to severe pain

ContraindicationSevere asthma or breathing problems, a blockage in your stomach or intestines, or a bowel obstruction called paralytic ileus.

Adverse effectHives; difficult breathing; swelling of your face, lips, tongue, or throat.

MORPHINE

Assessment & drug effects-Obtain baseline respiratory rate, depth, and rhythm and size of pupils before administering the drug. -Observe patient closely to be certain pain relief is achieved. -Monitor for respiratory depression; it can be severe for as long as 24 h after epidural or intrathecal administration.

-Assess vital signs at regular intervals. Morphine-induced respiratory depression may occur even with small doses, and it increases progressively with higher doses.-Encourage changes in position, deep breathing, and coughing (unless contraindicated) at regularly scheduled intervals. -Monitor i&o ratio and pattern. Report oliguria or urinary retention.

Patient & family education-Do not use of any otc drug unless approved by physician.-Use caution or avoid tasks requiring alertness (e.g., driving a car) until response to drug is known since morphine may cause drowsiness, dizziness, or blurred vision.

NURSING RESPONSIBILITIES

Brand name mebo cream/ moist exposed burn ointment Drug classification tissue healing agent, anti-inflammatoryMechanism of action

Inducing an anti·inflammatory effect reducing thereby edema and erythema. Creating an atmosphere unfavorabie for bacterial and fungal colonization, isolating and protecting exposed and injured nerve endings producing thereby an analgesic effect.

Indication-To clear away heat and toxic material, to relieve the pain and to promote regeneration. Treating -burns, scalds, chemical burn caused by various reasons.

ContraindicationFor patient hypersensitive to sesame oil.

Adverse effectNo adverse reaction has been reported.

Nursing responsibility-Wound care-Closely monitor the distal blood circulation on the affected limbs:- Closely monitor the changes of patients’ condition-Maintenance of the patent airway: for the patients with burns on the head or neck areas, especially for those with severe burns around the nasal and oral areas

NATURAL HERBS

NURSING CARE PLANNursing Diagnosis Assessment Intervention Rationale Evaluation

Acute pain related to surgical procedure. (Hemicolectomy with colostomy)

Objective:-facial grimace but does not verbalize pain unless asked

INDEPENDENTassess charateristics of pain

assessment of pain is the first step in pain management and allows for treatment planning.

patient reports pain control to a level of less than 3 on rating scale of 0-10

Vital signs:-BP 140/90mmhg-TEMP 37.6-HR 78-RR 23

assess signs associated with pain

acute pain may cause elevated BP, HR and TEMP. The patient’s skin may also be pale and cool.

patient uses pain relief strategies

Subjective:-“pain is sometimes tingling” as verbalized by the patient

assess the patient’s expectation for pain relief

some patient expect only decreased pain other patient expects complete elimination of pain

-pain scale 6 -onset is sudden, then disappears -intermittent duration

teach patient to do deep breathing exercise and do some diversional activities like watching tv and praying etc.

relaxes patient’s nerve thereby decreases anxiety and relieves pain

DEPENDENTdetermine if a patient controlled analgesia device is needed

PCA is an IV infusion of morphine which is controlled by the patient. The patient is able to manage her pain relief within limits.

Nursing Diagnosis

Assessment Intervention Rationale Evaluation

Impaired physical mobility related to pain and discomfort

Objective:-colostomy in place-ROM full range but finds it difficult to sit down and turn to sides

Independentassess the patient’s ability to perform activities of daily living

restricted movement reduces the patient’s ability to perform ADL

performs physical activities independently

subjective:”sometimes it is difficult to go down the bed” as verbalized by the patient

assess the safety of the patient’s environment

wires,linens,slippers used on transferring from bed to chair must not cause any harm to the patient

encourage early ambulation if not contraindicated. Advance activity from dangling legs, sitting in chair, to ambulation

early mobility promotes independence and prevents debilitation

Dependenta.administer analgesic medication

analgesic reduce pain that impedes movement

Nursing Diagnosis

Assessment Intervention Rationale Evaluation

Risk for impaired skin integrity related to pain and discomfort resulting to prolonged bedrest

Objective:Skin redness with blister at the left lower back

Independenta.assess skin turgor, temperature, moisture and integrity especially at the bony prominence

a.skin assessment provides a basis for interventions. Healthy skin should have good turgors, be warm and dry, free from bruises, excoriation and rashes

No further peeling of the skin affected, other parts of the body will remain intact as evidenced by an absence of redness over bony prominence

b.assess the patient’s ability to shift weight while sitting, turn over in bed

b.immobility is the most significant risk factor for skin breakdown

c.assess nutritional status including weight and serum albumin

c.an albumin level of <2.5mg/dl indicates protein depletion and high risk for skin breakdown

d.encourage the patient to turn from side to side frequently

d.to release the pressure inserted on particular side of the body

Mr. X must follow a low salt diet. He is also encouraged to reduce the intake of high carbohydrate food. He is encouraged to ambulate well at home, monitor his random blood sugar religiously and adhere with his medication regimen. Change of colostomy bag will be demonstrated and an immediate relative must give a return demonstration (for cases when patient decided to do the colostomy care at home).Medicines:Mebo ointment TID/PRNTrandate 200mg PO TIDExforge 160 5mg/160mg PO ODLantus 20iu SC at bed timeOPD follow-up check up after one week post discharge.

DISCHARGE PLAN

Mr. X is a 61 y.o patient, a known case of Diabetes Mellitus. He came to the emergency department with a chief complaint of severe constipation. After laboratory investigations and diagnostic procedures, he was sent to operating room to undergo Hemicolectomy with ileostomy formation.

He was transferred to ICU for close monitoring. He was intubated from OR and was extubated two days after. A day before extubation He had an episode of Diabetic Ketoacidosis. Hospital protocol for DKA was followed. Two days after, his laboratory results improved and so the doctor ordered to stop the DKA Protocol.

Before Mr.X was transferred to ward, he had a GCS of 15/15. He was well aware of his whereabouts and was very cooperative with the healthcare team.

GENERAL EVALUATION