Chapter IV

MEDICAL MANAGEMENT

1. Diagnostic Test

DATE TYPE OF TEST

RESULT UNITS REFERENCE INTERVAL

December 7, 2014

Complete Blood Count

Hemoglobin

Hematocrit

RBC

WBC

Neutrophil

Lymphocyte

Monocyte

Basophil

PLATELET

97

0.33

3.99

13.46

84

11

4

1.000

304

g/dL

%

x10E3/uL

x10E3/uL

%

%

%

%

x10E3/uL

12.5 – 17

36.0 – 50.0

4.10 – 5.60

4.0 – 10.5

40 – 74

14 – 46

4 – 13

0 – 7

140 – 415

MCH

MCHC

MCV

24.3

29.6

82.2

pg

g/dL

fL

27.0 – 34.0

32.0 – 36.0

80 – 98

2. Medical Management

DRUG STUDY

D5LR

Generic Name: dextrose monohydrate, sodium chloride, sodium lactate, potassium chloride, calcium chloride

Classification: hypertonic, nonpyrogenic, parenteral fluid, electrolyte, nutrient replenisher

Ordered Dose: D5LR 1L @ 120 cc/hr(30gtts/min)

Suggested Dose: 1000 mL @ 30 gtts/min

Mode of Action: Hypertonic solutions are those that have an effective osmolarity greater than the body fluids. It increases the solute concentration of the plasma, allowing water out of the cell and into the extracellular compartment to restore osmotic equilibrium.

Side Effects: Diarrhea (less severe), Nausea & vomiting (less severe), inflammation of the vein (less severe), stomach cramps (less severe), tingling of hands and feet (severe)

Adverse Effects: Hypersensitivity, chest pain, chest discomfort, bronchospasm, dyspnea, nausea, pyrexia, Hyperkalemia, Hypervolemia, excessive dose may lead to fluid and sodium overload which is a risk for edema

Nursing

Responsibilities:

1. Check the solution if it is clear and undamaged before administration

2. Caution must be exercised in administration of parenteral fluids, especially those containing sodium ions to patients receiving corticosteroids or corticotrophin

3. Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis

4. Discard unused portion

5. Properly label IV fluid

6. Observe aseptic technique when changing the IV fluid

MAGNESIUM SULFATE

Generic Name: magnesium sulfate

Brand name: Epsom Salt

Classification: mineral, electrolyte

Ordered Dose: MgSO4 drip: D5Water 50cc + 5 g MgSO4@ 25gtts/min

Suggested Dose: Seizure Prevention in Preeclampsia/Eclampsia:

Initial: IM: 4 to 5 g of a 50% solution every 4 hours as necessary. IV: 4 g of a 10% to 20% solution, not exceeding 1.5 mL/min of a 10% solution. Maintenance: IV Infusion: 1 to 2 g/hour. Maximum dose should not exceed 30 to 40 g/day.

Mode of Action: It is naturally occurring mineral that is important for many systems in the body especially the muscles and nerves. It increases water in the intestines. It can also be used as a laxative to relieve occasional constipation.

Side Effects: CNS: drowsiness, flaccid paralysis, hypothermia

CV: depressed cardiac function

EENT: diplopia

Metabolic: hypocalcemia

Skin: diaphoresis

Adverse Effects: CNS: depressed reflexes

CV: flushing, hypotension, bradycardia, circulatory collapse

Respiratory: respiratory paralysis

Drug Interaction: Drug to drug: Anesthetics, CNS depressants: May cause additive CNS depression. Use together cautiously. Cardiac glycosides: May worsen arrhythmias. Use together cautiously. Neuromuscular blockers: May cause increased neuromuscular blockade. Use together cautiously.

Nursing

Responsibilities:

7. Watch for respiratory depression and signs and symptoms of heart block

8. Monitor fluid intake and output. Make sure urine output is 100 ml or more in a 4-hour period before each dose.

9. Effective anticonvulsant level ranges from 2.5 to 7.5 mEq/L

DEXAMETHASONE

Generic Name: dexamethasone

Brand Name: Baycadron, Dexamethasone Intensol

Classification: cortecosteroid

Ordered Dose: 6 mg 1 tab q 12 hours x 4 doses

Mode of Action: Dexamethasone is a corticosteroid that prevents the release of substances in the body that cause inflammation. It decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism.

Side Effects: CNS: psychotic behavior, vertigo, headache, paresthesia, depression

CV: hypertension, edema, thrombophlebitis

EENT:cataracts, glaucoma

GI: GI irritation, increased appetite, nausea, vomiting

GU: increased urine glucose and calcium levels

Adverse Effects: CNS: euphoria, insomnia, pseudotumor cerebri, seizures

CV: heart failure, arrhythmias, thromboembolism

GI: peptic ulceration, pancreatic

Drug Interaction: Aminoglutethimide: May cause loss of dexamethasone-induced adrenal suppression. Antidiabetes, including insulin: May decrease response. May need dosage adjustment. Aspirin, indomethacin, other NSAIDs: May increase risk of GI distress and bleeding. Barbiturates, carbamazepine, phenytoin, rifampacin: May decrease corticosteroid effect. Increase corticostreroid dosage. Cardiac glycosides: May increase risk of arrhythmia resulting from hypokalemia. May need dosage adjustment. Cyclosporine: May increase toxicity. Monitor patient closely. Ephedrine: May cause decreased half-life and increased clearance of dexamethasone. Monitor patient. Oral anticoagulants: May alter dosage requirements. Monitor PT closely. Potassium-depleting drugs such as thiazide diuretics: May enhance potassium-wasting effects of dexamethasone. Monitor potassium level. Salicylates: May decrease salicylate level. Skin-test antigens: May decrease response. Postpone skin testing until therapy is completed. Taxoids, vaccines: May decrease anti-body response and may increase risk of neurologic complications.

Nursing

Responsibilities:

10. Determine whether patient is sensitive to other corticosteroids

11. Most adverse reactions to corticosteroids are dose- or duration-dependent

12. For better results and less toxicity, give once-daily dose in morning

13. Give oral dose with food when possible. Patient may need drugs to prevent GI irritation

14. Monitor patient’s weight, blood, pressure, and electrolyte levels

15. Inspect patient’s skin for petechiae

16. Monitor patient for cushingoid effects, including moon face, buffalo hump, central obesity, thinning hair, hypertension, and increased susceptibility to infection

TERBUTALINE

Generic Name: terbutaline

Brand Name: Brethine

Classification: beta2 agonist

Ordered Dose: Terbutaline ½ cap SQ now

Suggested Dose: 0.25 mg every 6 hours (subcutaneous)

Mode of Action: It is a bronchodilator. It works by relaxing muscles in the airways to improve breathing.

Side Effects: CNS: weakness

CV: tachycardia, flushing

GI: heartburn

Metabolic: hypokalemia

Respiratory: dyspnea

Skin: diaphoresis

Adverse Effects: CNS: nervousness, tremor, drowsiness, dizziness, headache, weakness

CV: palpitations, arrhythmias

GI: nausea and vomiting

Respiratory: paradoxical bronchospasm with prolonged use

Drug Interaction: Cardia glycosides, cyclopropane, halogenated inhaled anesthetics, levodopa: May increase risk of arrhythmias. CNS stimulants: May increase CNS stimulation. MAO inhibitors: when given with sympathomimetics, may cause severe hypertension. Propanol: May block bronchidilating effects of terbutaline.

Nursing

Responsibilities:

17. Give subcutaneous injections in the side of the deltoid

18. Protect the drug from light. Don’t use if discolored

19. Drug may reduce the sensitivity of spirometry for the diagnosis of bronchospasm

FERROUS SULFATE

Generic Name: ferrous sulfate

Brand Name: Feosol

Classification: hematinic

Ordered Dose: FeSO4 1 tab B.I.D

Suggested Dose: 15-30 mg elemental iron P.O. daily during last two semesters

Mode of Action: Provides elemental iron, an essential component in the formation of hemoglobin

Side Effects: GI: epigastric pain, vomiting, diarrhea, anorexia

Other: temporarily stained teeth from liquid forms

Adverse Effects: GI: nausea, constipation, black stools

Drug Interaction: Antacids, cholestyramine, resin, cimetidine: May decrease iron absorption. Chloramphenicol: May delay response to iron therapy. Levodopa, methyldopa: May decrease absorption and effort of levodopa and methyldopa. Vitamin C: May increase iron absorption. Use together for therapeutic effect.

Nursing

Responsibilities:

20. Between meal doses are preferable. Drug can be given with some foods, although absorption may be decreased.

21. Oral iron may turn stools black. Although this unabsorbed iron is harmless.

22. Monitor hemoglobin level, hematocrit, and reticulocyte count during therapy

ISOXSUPRINE

Generic Name: isoxsuprine

Brand Name: Vasodilan

Classification: vasodilator

Ordered Dose: Isoxsuprine 10 mg 1 tab T.I.D x 5 days (PO)

Suggested Dose: 10 to 20 milligrams (mg) three or four times a day.

Mode of Action: It relaxes veins and arteries, which makes them wider and allows blood to pass through them more easily.

Side Effects: Nausea or vomiting (more common for injection)

Adverse Effects: CNS: Dizziness. CV: Low blood pressure, palpitations, fast heart rate, lung swelling and flushing. GI: Nausea, vomiting and abdominal distress. Others: Rash and allergic reactions such as hives, difficulty breathing, tightness in the chest.

Drug Interaction: Although certain medicines should not be used together at all, in other cases two different medicines may be used together even if an interaction might occur. In these cases, your doctor may want to change the dose, or other precautions may be necessary. Tell your healthcare professional if you are taking any other prescription or nonprescription (over-the-counter [OTC]) medicine.

Nursing

Responsibilities:

23. Monitor for therapeutic effectiveness: Response to treatment of peripheral vascular disorders may take several weeks. Evaluate clinical manifestations of arterial insufficiency.

24. Monitor BP and pulse; may cause hypotension and tachycardia. Supervise ambulation.

25. Observe both mother and baby for hypotension and irregular and rapid heartbeat if isoxsuprine is used to delay premature labor. Hypocalcemia, hypoglycemia, and ileus have been observed in babies born of mothers taking isoxsuprine.

26. Notify physician of adverse reactions (skin rash, palpitation, flushing) promptly; symptoms are usually effectively controlled by dosage reduction or discontinuation of drug.

27. Prevent orthostatic hypotension by making position changes slowly and in stages, particularly from lying down to sitting upright and avoid standing still.

UTROGESTAN

Generic Name: utrogestan

Ordered Dose: utrogestan 200 mg cap T.I.D per vagina

Suggested Dose: 200 mg thrice a day

Mode of Action: Synthetic long-acting glucocorticoid that depresses formation, release, and activity of endogenous mediators of inflammation, including prostaglandins, kinins, histamine, liposomal enzymes, and complement expression. It also modifies the body's immune response. It replaces hormones. UTROGESTAN 100mg capsules have all the properties of endogenous progesterone with induction of a full secretory endometrium and in particular gestagenic, antioestrogenic, slightly antiandrogenic and antialdosterone effects.

Side Effects: Local itching, burning, or discharge

Adverse Effects: Cardiac arrest, hypertension, diarrhea, nausea & vomiting

Drug Interaction: Aminoglutethimide: May decrease dexamethasone induced adrenal suppression.

Amphotericin B: Cardiac enlargement and CHF have been reported.

Anticholinesterases: May antagonize anticholinesterase effects in myasthenia gravis.

Anticoagulants, oral: May alter anticoagulant dose requirements.

Antidiabetic agents: Dexamethasone may increase blood glucose levels, necessitating antidiabetic agent dosage adjustments.Aprepitant: Dexamethasone plasma levels may be elevated and the half-life prolonged, increasing the pharmacologic effects and adverse reactions.Cholestyramine, epinephrine: Dexamethasone plasma levels may be reduced, decreasing the efficacy.Cyclosporine: Activity of cyclosporine and dexamethasone may be increased. In addition, convulsions have been reported.CYP3A4 substrates (eg, erythromycin, indinavir): Plasma levels may be reduced by dexamethasone, decreasing efficacy.Digoxin: Because of possible dexamethasone-induced hypokalemia, the risk of arrhythmias may be increased.Hepatic enzyme inducers (eg, barbiturates, carbamazepine, phenytoin, rifampacin): Dexamethasone plasma levels may be reduced, decreasing the efficacy. In addition, seizure control with phenytoin may be altered.Hepatic enzyme inhibitors (eg, azole antifungal agents [eg, ketoconazole], estrogens including oral contraceptives, macrolide antibiotics [eg, erythromycin]): Dexamethasone plasma levels may be elevated, increasing the pharmacologic effects and adverse reactions. In addition, ketoconazole can inhibit adrenal corticosteroid synthesis, causing adrenal insufficiency during dexamethasone withdrawal.NSAIDs, salicylates: Risk of GI adverse reactions may be increased. In addition, salicylate levels and efficacy may be reduced.Potassium-depleting agents (e.g., amphotericin B, loop and thiazide diuretics): Risk of hypokalemia may be increased.Thalidomide: Use with caution; TEN has been reported with concurrent use of dexamethasone.

Nursing

Responsibilities:

28. Monitor vital signs of patient

29. Remind patient that this drug is not taken orally but per vagina

30. Observe side effects and adverse effects

31. Encourage patient to report any symptoms of the side effects or allergic reactions

NIFEDIPINE

Generic Name: nifedipine

Classification: calcium channel blocker

Ordered Dose: 10 mg 1 tab every 6 hours

Mode of Action: inhibit calcium ion influx across cardiac and smooth muscle cells, decreasing contractility and oxygen demand. Also may dilate coronary arteries

Side Effects: CNS: somnolence, synecope, nervousness hypotension, palpitations

EENT:nasal congestion

GI: diarrhea, constipation, abdominal discomfort

Respiratory: dyspnea, pulmonary edema, cough

Skin: rash, pruritus

Adverse Effects: CNS: dizziness, light-headed, headache, weakness

CV: flushing, peripheral edema, heart failure, MI

Drug Interaction: antiretroviral: May decrease nifedipine metabolism. Monitor blood pressure closely. Azole antifungals: May increase the effects of nifedipine. Fentanyl: May cause severe hypotension. Rifamycin: May decrease nifedipine levels.

Nursing

Responsibilities:

32. Don’t use capsules S.L. to rapidly reduce severe high blood pressure because the result may be fatal.

33. Monitor blood pressure regularly

34. Watch symptoms for heart failure

35. Surgical Management

The patient’s only surgery was a caesarean section. She has a gravida of 3, parity of 2 and has no abortion. In the year 2009 was her first pregnancy which she gave birth to a baby boy via caesarean section. 2 years after (2011), she gave birth to a baby girl, again via caesarean section.

The previous Caesarean sections were all classical. So, on her present pregnancy ( third pregnancy ), the physician decided to have a Classical Caesarean section, especially that she was diagnosed with placenta previa totalis. The patient’s life would be at risk of she will deliver NSVD.