San Lorenzo Ruiz College of Ormoc

College of Nursing

Ormoc City

Name of Patient: Serenio, Olympio Lota Hospital No.: 39096- 2011

Diagnosis: Post-gliotic seizure secondary to CVA Room No.: MM8

Diabetes Mellitus, type 2 Physician: Dr. Honey Alcantara/

Essential Hypertension, stage I Dr. Dennis Daniel Roa

Hypokalemia

PHYSIOLOGIC BODY PARTS

INSPECTION PALPATION PERCUSSION AUSCULTATION

Head and Neck

Head Normocephalic and symmetrical

Normal skull which looks smooth, no masses non-tender, and depressions, no pain felt

Hair White and gray, no scars noted, lighter skin color than complexion

Flat shaft, brittle, moist from perspiration/ oily, thin

Scalp Lighter in color than skin complexion, moist from perspiration, no scars, free from dandruff

Without masses, no pain felt, no lumps

Forehead No wounds/ scars, color is even which is light brown, lentigens (brown age spots) slightly noted

No pain felt, without lesions and depressions, no masses, no pain felt, , temporal pulse= 61 bpm synchronized on both sides with normal strength, warm to touch

Face Oval, , symmetrical facial features, dry skin, poor skin turgor, facial grimace and facial wrinkles noted

No masses, no pain felt, no swelling

Eyes In line with each other/ symmetrical, non-protruding

Eyebrows Bilateral, grayish and white in color, evenly distributed, symmetrically aligned, parallel

No masses, no lumps, no nodules

PHYSIOLOGIC BODY PARTS

INSPECTION PALPATION PERCUSSION AUSCULTATION

Eyelashes Evenly distributed, slightly curved outward, black, blink reflex= 15 times per minute

Active blink reflex, thin

Eyelids UPPER LIDS: Involuntary

Symmetrical, Intact, able to open and close, pale pink in color, dry, drooping eyelids

LOWER LIDS:Symmetrical, intact, able to open and close, pale pink in color, dry

when blinking

Involuntary when blinking

Sclera white, absence of lesions, small veins are visible

Conjunctivae Not inflamed; pale pink in color, moist

Cornea Transparent and glossy, teary looking, clear

Iris Equal in size of both eyes and brownish in color, appears flat with a regular shape

Pupil Black, Equally round, reactive to light and accommodation

Muscle Function Both eyes are well coordinated, it moves smoothly and symmetrically

and follows the 6 fields of gaze.

Muscle Balance Constricting during light reflex and simultaneously during consensual light reflex

Visual Acuity 20/20 (Normal Vision); Upon admission,, patient experienced blurring of vision and gradually returns to normal

Peripheral Vision Able to see the stimulus at about 90 degrees temporally, 50 degrees superiorly, 70 degrees inferiorly, and 60 degrees nasally

Nose Found in the midline of the face with no lesions and no presence of discharges

No masses, no lumps, no pain felt

Frontal Sinus Evidence of swelling around the eyes and nose, gray during transillumination

Slightly tender upon palpation

Dull sound

Maxillary Sinus Evidence of swelling around the eyes and nose, grayish color during transillumination

Slightly tender Dull sound

Mouth

Lips Pallor, pale pink in color, cracked and dry

Non-tender, no pain felt, soft, no lumps

Gums Pale pink in color, no bleeding, smooth

No pain felt

Teeth Yellowish, 27 teeth, 2 extracted, and dentures for molars noted, presence of dental plaques also noted

Tongue Pink in color and is in the midline of the mouth. It moves freely and the dorsal and ventral surface is moist.

Frenulum Attached to the tongue, pink in color

Sublingual Pink in color, absence of lesions, blood vessels visible

Hard Palate Slightly whitish Hard

in color and dome-shaped with ridges, no lesions, dry

Soft Palate Light pink in color, concave, no lesions, moist

Soft

Uvula Hanging in the midline of soft palate, pink in color, slightly dry

Tonsils

Speech

Pink, moist, not inflamed

Slightly slurred

No pain felt

EARS Bilaterally equal, without swelling, light brown in color consistent with the patient’s facial skin, no discharges, laterally aligned with the outer canthus of the eye, symmetrical, and pendulous

Firm, absence of lumps, no pain felt

Auditory Acuity Able to perceived the words and sounds equally in both ears

Neck Able to move the head in full range of motion without complaints or

Smooth, absence of lesions, no pain felt, carotid pulse= 61 bpm synchronized and strong pulse

discomforts, able to move neck with full ROM: flexion= 45°, hyperextension= 60°, lateral abduction= 40°, rotation=10°

Lymph Nodes Not inflamed No pain felt during palpation

Trachea Appears in midline

Placed centrally in midline, spaces are equal on both sides, not deviated

Thyroid Gland Moves up when swallowing, no visible masses

No enlargement, masses and tenderness

Thorax

Chest Anterior Lighter in color, equal rise and fall, breathing route is 18 cycles per minute, moist with perspiration

Equal chest expansion, full symmetric excursion, warm skin, axillary temperature= 37.8°C

Resonance on lung area, flat on ribs

Clear sounds on both lobes of the lungs

Lungs Respiratory rate= 18 cycles per minute, bilateral symmetry

Resonant sound on intercostals spaces, flat on ribs

Clear sounds on both lobes of the lungs

Heart Nonpalpable, heartbeats=61 bpm

Dull Sound Apical pulse= 61 bpm

Chest Posterior Spine vertically align, symmetrical

Warm to touch, no pain felt, full and symmetric expansion

Resonant sound heard

Clear sounds on both lobes of the lungs

Abdomen Color is the same with the body, flat, umbilicus in the midline and non-protruding

No pain felt no lumps, absence of masses, and lesions

Tympanic sound over the stomach, dullness over the liver and spleen

High pitched sound/ gurgles: 8 times/minute

Liver No pain felt, lightly palpable

Dull sound

Spleen Non palpable Dull soundKidney Non palpable, no

painDull sound

Extremities

Upper Even in color, hairy, slight age spots noted, numbness and difficulty moving left hand, with ongoing IVF #4 of PNSS 1L @ 20 gtts/min at the level of 150 cc infusing well @ right hand; unable to perform gross and fine motor skills at left hand

No pain felt, capillary refill less than 3 seconds, brachial and radial/ulnar pulse palpable, T= 37.8 degrees CelsiusPR= 61 bpm

BP= 120/80 mmhg

Muscle tone

Muscle strength

Color is even, poor skin turgor, wrinkles, and unable to resist the force exerted on his left hand and was able to resist force

no pain felt, no lumps, non-tender, warm and moist from perspiration.Patient has weak resistance to force exerted to him

Reflexes

exerted on the right hand

Biceps= flexion of the forearmTriceps= extension of the elbowBrachioradialis= supination and flexion of forearm

Lower Equal in size, brown in complexion, even skin tone, hairy legs

No pain felt, popliteal/dorsalis pedis and tibal pulse palpable

Muscle Strength Weak resistance to force exerted on him

Muscle tone

Reflexes

Color is even, unable to move left leg, symmetrical, age spots and wrinkles noted

No pain felt, non-tender, no lumps, warm to touch

Patellar= extension of the kneeAchilles= planter flexion of the feetPlantar= toes curved/plantar flexion of the toes

Gait Patient is confined to bed (non-ambulatory) due to left-sided weakness. Gait

was not assessed.

Balance Patient is confined to bed (n0n-ambulatory) due to left-sided weakness. Balance was not assessed.

Coordination Patient is confined to bed. Coordination was not assessed.

San Lorenzo Ruiz College of Ormoc

College of Nursing

Ormoc City

Name of Patient: Serenio, Olympio Lota Hospital No.: 39096- 2011

Diagnosis: Post-gliotic seizure secondary to CVA Room No.: MM8

Diabetes Mellitus, type 2 Physician: Dr. Honey Alcantara/

Essential Hypertension, stage I Dr. Dennis Daniel Roa

Hypokalemia

DRUG THERAPEUTIC RECORD

Drug/ Dose/ Frequency/

Route

Classification/ Mechanism of

Cction

Indications/ Contraindica-

tions/Side Effects

Principles of Care

Treatment Evaluation

Metformin

HCl

Dose:

500mg

Route:

Oral

Frequency:

BID

Classification:

Antidiabetic

Mechanism of

Action:

Exact

mechanism is

not understood

which possibly

Indications:

-Adjunct to diet to

lower blood

glucose with type 2

DM

-As part of

combination

therapy with

insulin wherein

1. Do not

discontinue

this

medication

without

consulting

healthcare

provider.

2.

Monitor

urine or

serum

glucose

levels

frequently to

determine

effectiveness

of drug and

Medications

taken at

ordered dose,

date and time.

Desired

effects

obtained.

Timing:

10 am

10 pm

increases

peripheral

utilization of

glucose,

decreases.

either drug alone

cannot control

glucose levels in

patients with type 2

DM

Contraindications:

-Hypersensitivity to

the drug, CHF;

diabetes

complicated by

fever, severe

infections, major

surgery

Side Effects:

Gastrointestinal:

Nausea, vomiting,

anorexia,

heartburn, diarrhea

and flatulence

Hypersensitivity:

-allergic skin

Monitor

blood

glucose and

ketone as

prescribed.

Swallow

extended-

release

tablets

whole; do

not crush or

chew.

Do not use

this drug

during

pregnancy.

Avoid

using

alcohol

while

dosage.

Arrange for

transfer to

insulin

therapy

during

periods of

high stress.

Use IV

glucose if

severe

hypoglycemi

a occurs as a

result of

overdose.

Increased

risk of

hypoglycemi

a occurs as a

result of

reactions, eczema,

pruritus, erythema,

urticaria

taking the

drug.

Report your

fever, sore

throat,

unusual

rash or

bruising,

dark-urine,

light-

colored

stools,

hypo- or

hyperglyce

mic

reactions.

overdose.

.

Amlodipine

desylate

(Norvasc)

Dose:

Classification:

Calcium-

Channel

Blocker

Indications:

-Hpertension

Contraindications:

-Hypersensitivity

-Monitor

patient

carefully.

-Monitor

-Caution

patient to

continue

taking drug,

even when

Medications

taken at

ordered dose,

date and time.

Desired

500 mg

Route:

Oral

Frequency:

TID

Timing:

6 am

2 pm

10 pm

Mechanism of

Action:

Inhibits

calcium ion

influx across

cardiac and

smooth muscle

cells, thus

decreasing

myocardial

contractility

and oxygen

demand; also

dilated

coronary

arteries and

arterioles.

-used cautiously to

patients receiving

other peripheral

vasodilators

Side effects:

CNS:

-headache, fatigue,

dizziness, light-

headedness,

paresthesia

CV:

-edema, flushing,

palpitations

Gastrointestinal:

-nausea, abdominal

pain

Genitourinary:

-sexual difficulties

Musculoskeletal:

-muscle pain

blood

pressure

frequently

during

initiation of

therapy.

-Notify

prescriber

if signs of

heart failure

occur, such

as swelling

of hands

and feet or

shortness of

breathing.

-Alert:

Don’t

confuse

with

Amiloride.

feeling

better.

-Tell the

patient SL

Nitroglycrei

n may be

taken as

needed when

angina

symptoms

are acute. IF

patient

continues

nitrate

therapy

during

adjustment

of

amlodipine

dosage, urge

continued

compliance.

effects

obtained.

Citicoline

Dose:

500 mg

Route:

Oral

Frequency:

TID

Timing:

6 am

2 pm

10 pm

Classification:

-Neurotonics

-Nootropics

Mechanism of

Action:

Increases

blood flow and

oxygen

consumption in

the brain. It is

also involved

in the synthesis

of lecithin.

Increases the

neurotransmiss

ion levels

because it

favors the

synthesis and

production

Indications:

-Parkinson’s

disease

-Head acute

cerebral injury

-Cerebrovascular

disease

Contraindications:

-Parasympathetic

hypertonia

Side Effects:

-diarrhea

-hypertension/

hypotension

-blurred vision

-chest pain

-tachycardia

-restlessness

-body temperature

-May be

taken

without

food. With

or without

meals.

-Should not

be taken in

the late

afternoon

because it

can cause

difficulty in

sleeping.

-Should be

started

within 24

hours of a

stroke.

Administer

this

medication

without

regard to

meals.

-Observe

closely or

monitor

patient’s

neurologic

status.

-Report

physician for

unusualities

such as

rashes and

chest

tightness

Medications

taken at

ordered dose,

date and time.

Desired

effects

obtained.

speed of

dopaminergic

antagonist

through the

inhibition of

tyrosine

hydroxylase.

elevation -Monitor

neurostatus

while

taking the

drug.

-Contact

physician

immediatel

y if allergic

reaction

such as

hives,

rashes and

chest

tightness

occurs.

occurs.

-Slowly

injexct over

3- 5 minutes

into a vein

or into a Y-

port.

Phenytoin

(Dilantin)

Dose:

100 mg

Classification:

Anticonvulsant

/ Antiepileptic

Mechanism of

Indications:

-to control tonic-

clonic (grandmal)

and complex partial

(temporal lobe)

-

REquireme

nts usually

increase

during

-Tell the

patient to

notify

prescriber if

skin rash

Medications

taken at

ordered dose,

date and time.

Desired

Route:

Oral

Frequency:

TID

Timing:

6 am

2 pm

10 pm

Action:

Unknown. A

hydantoin

derivative that

probably

stabilizes

neuronal

membranes

and limits

seizure activity

by either

increasing

influx of

sodium ions

across cell

membranes in

the motor

cortex during

nerve impulses

generation.

seizures

-for patient

requiring a loading

dose

-to prevent and

treat seizures

during

neurosurgery

-status epilepticus

Contraindications:

-Hypersensitivity to

the drug

-Sinus bradycardia,

SA block, 2nd- and

3rd- degree AV

block, or Adam-

Stokes syndrome

-Used cautiously to

those with hepatic

dysfunction,

hypotension

-Elderly

pregnancy.

-Use only

clear

solution for

injection.

-Don’t give

IM unless

dosage

adjustments

are made.

-Divided

doses given

with or

after meals

may

decrease

adverse GI

reactions.

-Stop drug

develops.

-Advise

patient to

avoid

driving and

other

potentially

hazardous

activities

that require

mental

alertness

until drug’s

CNS effects

are known.

-Advise

patient not to

change

brands or

dosage

forms once

effects

obtained.

Side Effects:

CNS:

-ataxia, slurred

speech, dizziness,

mental confusion,

twitching,

nervousness,

headache

CV:

-periateritis, nodosa

EENT:

-nystagmus,

diplopia, blurred

vision

Metabolic:

-osteomalacia

Hepatic:

-toxic hepatitis

if rash

appears.

-Don’t stop

drug

suddenly

because this

may worsen

seizures.

-Monitor

drug level

in blood.

-Monitor

CBC and

calcium

level every

6 months

and

periodically

onitor

hepatic

he’s

stabilized on

therapy.

-Tell patient

not to use

capsules that

are

discolored.

-Advise

patient to

control

alcohol.

-Warn

patient and

parents not

to stop drugs

abruptly.

-Stress the

importance

function.

.

of good oral

hygiene and

regular

dental

examination.

Glimepiride

Dose:

3 mg

Route:

Oral

Frequency:

OD

Timing:

8 am

Classification:

-Medium to

long-acting

sulfonylurea

Antidiabetic

drug

Mechanism of

Action:

Unknown.

Lowers

glucose level

possibly by

stimulating

Indications:

-Adjunct to diet

and exercise to

lower- blood

glucose level in

patients with tpe 2

DM whose

hyperglycemia

can’t be managed

by diet and exercise

alone

-Adjunct to diet

and exercise in

conjunction with

-May be

used

together

with insulin

for patients

who lose

glucose

control

after first

responding

to therapy.

-Monitor

fasting

-Tell patient

to take the

drug first

meal of the

day.

-Make sure

patient

understands

that the

therapy

relieves

symptoms

but does not

Medications

taken at

ordered dose,

date and time.

Desired

effects

obtained.

release of

insulin from

functioning

pancreatic beta

cells and may

lead to

increased

sensitivity of

peripheral

tissues to

insulin.

insulin or

metformin therapy

in patients with

type 2 DM whose

hyperglycemia

cannot be managed

by glimepiride-

alone maximum

dosage.

Contraindications:

-hypersensitivity to

the drug

-Pregnant or

elderly clients

-breastfeeding

patients

-debilitated or

malnourished

patients

Side Effects:

CNS:

glucose

level

periodically

to

determine

therapeutic

response.

-Use of oral

hypoglyce

mics may

carry higher

risk of CV

mortality

than use of

diet alone

or diet and

insulin

therapy.

-When

changing

patient

cure the

disease.

-Stress the

importance

of adhering

to diet,

weight

reduction

exercise and

personal

hygiene

programs.

-Advise

patient to

wear/ carry

identificatio

n at all

times.

-Advise

woman to

-dizziness,

asthenia,, headache

EENT:

-changes in

accommodation,

Gastrointestinal:

-nausea

Hematologic:

-leukopenia,

hemolytic anemia

Skin:

-pruritus, erythema,

urticaria,

photosensitivity

reactions

Hepatic:

-cholestatic

jaundice

from other

sulfonylure

ases to

glimepiride,

transition

period is

not needed.

consult

prescriber

before

planning

pregnancy.

Dexamethas

one

Dose:

Classification:

Corticosteroid

Mechanism of

Indications:

-crebral edema

-inflammatory

conditions

-Determine

whether the

patient is

sensitive to

-Tell patient

not to stop

drug

abruptly or

Medications

taken at

ordered dose,

date and time.

4 mg tab

1 tab

Route:

Oral

Frequency:

BID

Timing:

8 am

6 pm

Action:

Not clearly

defined.

Decreases

inflammation,

mainly by

stabilizing

leukocyte

lysomal

membranes;

suppresses

immune

response;

stimulates

bone marrow;

& influences

protein,

fat ,and

carbohydrate

metabolism.

-shock

-adrenocortical

insufficiency

Contraindications:

-Hypersensitivity to

the drug

-recent MI

-patients with GI

ulcer, renal disease,

hypertension,

osteoporosis, DM,

hypothyroidism,

cirrhosis,

diverticulitis,

seizures, heart

failure

Side Effects:

CNS:

-euphoria,

insomnia, vertigo,

headache,

other

corticostero

ids.

-For better

results and

less

toxicity,

give once-

daily dose

in the

morning.

-Give oral

dose with

food when

possible.

-Give IM

injection

deeply into

gluteal

muscle.

without

prescriber’s

consent.

-Instruct

patient to

take drug

with food or

milk.

-Teach

patient the

signs and

symptoms of

early adrenal

insufficiency

, fatigue,

muscle

weakness,

joint pain,

fever,

anorexia,

nausea,

Desired

effects

obtained.

paresthesia,

seizures

CV:

-heart failure,

hypertension,

edema, arrthymias,

thrombophlebitis,

thromboembolism

EENT:

-cataracts,

glaucoma

Route

injection

sites to

prevent

muscle

atrophy.

-Always

adjust to

lowest

effective

dose.

-Watch for

depression

pr

psychotic

episodes

especially

in high-

dose

therapy.

shortness of

breath,

dizziness,

and fainting.

-Warn

patient about

easy

bruising.

-Advise

patient to

avoid

exposure in

infections

(such as

measles and

chicken pox)

and to notify

the

prescriber if

such

exposure

-Diabetic

patient may

need

increased

insulin;

monitor

glucose

levels.

occurs.