Nursing Care Plan Essay

This essay has a total of 11864 words and 76 pages.

Nursing Care Plan

Course: NUR 1210L


Dates of Care: 12, 13, 19 & 20 Sept 96

Date Submitted: 11/15/96

Student Names: Anthony Bernardi, SN/SPJC


STUDENT Anthony Bernardi
DATE November 15, 1996

Client’s Clinical Picture (5)
(Initial Cephacaudal assessment)

Textbook Description of Diagnosis (5)

Summary of Client’s Progress (5)

Completion of Holistic NCP Tool (30)


GOALS (10)







Cover Page 1
Grading Point Scale 2
Table of Contents 3
Summary Page 4
Client’s Clinical Picture (Cephacaudal Assessment) 5
Medical Diagnosis 6
Textbook Description of Disease 6-12
Treatments and Procedures 13
Summary of Caregiver Progress Notes 14
Diagnostic Values Out Of Normal Range Clinical Implications 16
Radiology 17
Medications 18-52
Holistic Nursing Care Plan Form 53-62
List of Nursing Diagnosis 65
Five Nursing Diagnoses 66-70
References 71

Please see attached Cephacaudal Assessment (Pages 5)

MEDICAL DIAGNOSIS: Current diagnosis:Necrotizing pneumonia,
cachexia secondary to malnutrition / infection, hypothroidism, NIDDM, empyema RUI,
Aspergilloma, RUI, and depression. HX: HTN, atrial fibrillation, COPD, asthma

See attached Disease Process Description (pages 6-12-)

See attached Caregiver Progress Notes (page 14-15)

Mr. GB is a 78 year old white male admitted to Bay Pines VAMC on 6/18/96. for “
atypical chest pain and hemoptysis”. V/S BP 114/51, P 84, R 24, T 97.4. He seems
alert and oriented x 3 and cheerful. Bowel sounds present x 4. Pt. has a red area on
his coccyx. Silvadene treatments have been started. Pt. Has a fungal lung infection with
a pleural suction drainage tube inserted in his chest . Pt is extremely thin with poor
skin turgor with a diagnosis of cachexia ( wasting) secondary to malnutrition and
infection. Patient is no known allergies to drugs but is allergic to aerosol sprays
disinfectants and dust.. Advanced directives on chart. Code status DNR. Primary
physician Dr. R, Thoracic surgeon Dr. L. Psychology Dr.W. There is PT, OT Dietary and
Infectious Disease consults when necessary. He lives with his wife who he has been
married to for 56 years. His son and his daughter come to visit him. He does not smoke.
He wears dentures but did not bring them. He dose not use a hearing aid but he does have
a hearing deficit.

Pt. is able to do all his ADL’s with limited assistance. He wants to get better and
leave the HSP. Pt. Stated’ 90 days is to long to be here”. Pt. States that
he is concerned about caring for his tube site when he goes home and does not feel that
his wife can do this for him.

Diet: Pureed Hi protein, low fat, anti-dumping with Calorie count (all meals) and drink
supplements between meals. TPN @ 79cc/hr 12hr around the clock through PICC line

MEDICAL DIAGNOSIS: Empyema, Hemoptysis, Necrotizing pneumonia, Aspergillosis (Aspergillus
fumigatus) cachexia secondary to malnutrition/infection, hypothyroidism, Diabetes Type II
melitius , and depression.

HEMOPTYSIS: Expectoration of blood arising from the oral cavity, larynx, trachea, bronchi
or lungs (Tabor’s, 17th ed. 1989 p.879)

CACHEXIA SECONDARY TO MALNUTRITION/INFECTION : The state of ill health, malnutrition, and
wasting It may occur in any chronic diseases, certain malignancies and advanced pulmonary
tuberculosis. (Tabor’s, 17th ed. 1989 p.287)

NECROTIZING PNEUMONIA: Aspiration pneumonia. Aspiration pneumonia is frequently called
necrotizing pneumonia because of the pathologic changes in the lungs. It usually follows
aspiration of material in the mouth into the trachea and subsequently the lungs. The
aspirated material. Either food, water, or vomitus, is the triggering mechanism for the
pathology of this type of pneumonia. If the aspirated material is an inert substance (e.g.
barium or nonacid stomach contents), the initial manifestation is usually caused by
obstruction of airways. When the aspirated materials contain gastric acid, there is
chemical injury to the lung parenchyma with infection as a secondary event usually 48 to
72 hours later. The infecting organism is usually one of the normal oropharyngeal flora.
The clinical manifestations proceed as those of a classic pneunococcal or streptococcal
pneumonia. Fungi may also be a cause of pneumonia. These infections are not transmitted
from person to person, and the patient does not have to be placed in isolation. The
clinical manifestations are similar to those of bacterial pneumonia. Skin and serology
tests are available to assist in identifying the infecting organism. However,
identification of the organism In a sputum specimen or in other body fluids is the best
diagnostic indicator. (Lewis, S.M. & Collier, p. 643-644)

ASPERGILLOSIS INFECTIONS : There are several forms of Aspergillosis infections. All are
caused by one or more of the many different Aspergillus fungus species; only a few of
these organisms are capable of producing disease in humans. These species are spread
through the air and can be found almost any place in the world. Because these spores are
inhaled, they usually affect the lungs or other airway passages such as the bronchial
tubes, nose and sinuses. The fungi can be invasive, affecting any tissue, mucous membrane
or vital organ of the body.

Allergic Bronchopulmonary Aspergillosis (ABPA) is an immune disorder that occurs in people
with asthma or chronic obstructive pulmonary disease (COPD) infected with Aspergillosis
fungi. It causes an excess of certain white blood cells (eosinophils), an infiltration of
the lungs, and impaction of the bronchial tubes with eosinophils and Aspergillus
organisms. Symptoms of this disease may consist of fever, shortness of breath (dyspnea),
chest pain, wheezing, a cough with sputum (with or without blood) or a generalized
feeling of ill-health (malaise). This form of Aspergillosis is not usually invasive, but
it can lead to a chronic dilation of the bronchial tubes (bronchiectasis).

Pulmonary Mycetoma, also known as Aspergilloma or "fungus ball", is a form of
Aspergillosis that often occurs as a result of the Aspergillus fungus growing together
(colonization) in a cavity of the lungs. These cavities are usually caused by other
pulmonary diseases such as tuberculosis, sarcoidosis, histoplasmosis or coccioidomycosis.
The fungus ball can be seen on x-rays. This form of Aspergillosis is characterized by a
chronic cough, weight loss, a generalized feeling of ill-health (malaise) and the
spitting up of blood (hemoptysis).

Fulminative or Invasive Aspergillosis is another form of this disorder that can cause
distribution of the Aspergillus fungus to other parts of the body. This disease can
progress from a localized infection to a widespread erosion and ulceration of the
bronchial system and an inflammation of the vascular system (vasculitis). Vasculitis is a
narrowing of the inside of a blood vessel that can obstruct the flow of blood to the
tissues. This lack of blood can cause damage to the tissues (necrosis), and a possible
formation of blood clots (thrombosis). Invasive Aspergillosis is usually first confined
to the lungs but it can spread through the blood to other organs especially the liver,
brain, kidneys, skin, gastrointestinal tract and other sites. This can be a very serious
disease which can have a slow or rapid course. It is seen in those whose immune system
has been weakened by other illnesses, especially people with cancer (e.g., Leukemia,
Hodgkin's Disease), kidney transplant patients or those undergoing certain drug

Occasionally, Aspergillosis can cause Infective Endocarditis which is an infection of the
inner lining of the heart muscle (endocardium). A type of infective endocarditis,
prosthetic valvular endocarditis (PVE), may develop in patients who have previously had
artificial (prosthetic) heart valve replacement. This infection may occur as a result of
contamination of the operating room area by the Aspergillus spores. Drug addicts are also
more susceptible to this form of Aspergillosis.

Mycetoma, also known as Madura Foot, is a chronic infection produced by Aspergillosis as
well as several other fungi. It is a progressive fungal disease that is characterized by
lesions of the foot, face, trunk, hand or leg. These lesions can cause swelling,
hardening, pus formation, sinus drainage and abscesses that can lead to bone destruction
and deformities. It is more commonly seen in tropical climates.

Aspergillosis is a group of infectious diseases that are caused by the inhalation of the
Aspergillus fungus. The spores that cause these infections can be found in decaying
vegetable matter, grains, grass, leaves, soil, wet paint, air conditioning systems, on
refrigerator walls and in construction and fireproofing materials. It is not known why
most people resist infection from this common fungus, and why others are more susceptible
to infection. A weakened immune system, or an abnormal immune response to the fungus, may
cause the fungus to proliferate and become a threat to one's health.

Aspergillosis is a rare disorder that affects males and females in equal numbers. It is
seen more often in those people who have chronic respiratory problems or whose immune
system has been weakened by other serious illnesses or drug therapy.

DEPRESSION: Depression is the most common functional disorder. Signs of depression include
sadness, low energy, diminished memory and concentration, sleeping disturbances, appetite
disturbance, with withdrawal, irritability, alcohol abuse, expressed feelings of
helplessness and hopelessness, apathy, impaired attention span, and expression of suicidal
wishes. Depression is often treatable and reversible through use of antidepressant
medications and counseling. (Brunner/ Suddarth, 1988)

HYPERTENSION: Hypertension can be defined arbitrarily as persistent levels of blood
pressure in which the systolic pressure is above 140 mm Hg and the diastolic pressure is
above 90 mm Hg. In the elderly population, hypertension is defined as systolic pressure
above 160 mm Hg and diastolic pressure above 90 mm Hg. Hypertension is a major cause of
heart failure, stroke, and kidney failure. It is called the “silent killer”
because the person who has it is often symptom free. Gerontological Considerations:
Changes in the peripheral vascular system are responsible for the changes in blood
pressure that occur with age. As the age related process of atherosclerosis evolves, the
ability of the vessels to distend and recoil is reduced. Consequently, the aorta and large
arteries are less able to accommodate the ejected stroke volume, and a decrease in cardiac
output and increase in peripheral resistance result. Systolic blood pressure increases as
a result of the increased peripheral resistance, and pulse pressure widens subsequent to
the diastolic fall that accompanies reduced distensibility of the aorta. The risk factors
for high blood pressure that are present in the population in general continue into old
age. These are approximately the same for elderly men and women. (Brunner/ Suddarth, 1988)

CHRONIC OBSTRUCTIVE PULMONARY DISEASE : Chronic obstructive pulmonary disease (COPD) is
the most common cause of death and disability due to lung disease in the United States.
COPD is a broad classification that includes a group of conditions associated with chronic
obstruction of air flow entering or leaving the lungs. Airway obstruction is diffuse
airway narrowing, causing increased resistance to air bronchiectasis, emphysema, and
asthma. Basically, the person with COPD has (1) excessive secretion of mucus within the
airways not due to specific causes (bronchitis or bronchiectasis), (2) an increase in the
size of the air spaces distal to the terminal bronchioles with loss of alveolar walls and
elastic recoil of the lungs (emphysema), and (3) narrowing of the bronchial airways that
varies in severity (asthma). As a result there is a subsequent derangement of airway
dynamics for example, loss of elasticity and obstruction of air flow. There is often an
overlap of these conditions. (Brunner/ Suddarth, 1988 )

ASTHMA : Asthma is an intermittent, reversible, obstructive airway disease characterized
by increased responsiveness of the trachea and bronchi to various stimuli. This results in
narrowing of the airways, causing dyspnea This narrowing of the airway changes in degree,
either spontaneously or because of therapy. Asthma differs from other obstructive lung
diseases in that it is a reversible process, and patients may exhibit no symptoms for a
prolonged period of time. Asthma is a reversible diffuse airway obstruction. The
obstruction is caused by one or more of three developments: (1) contraction of muscles
surrounding the bronchi, which narrows the airway (2) swelling of membranes that line the
bronchi and (3) filling of the bronchi with thick mucus. In addition, there is bronchial
muscle enlargement, mucous gland enlargement, thick, tenacious sputum, and hyperinflation
or air trapping in the alveoli but most of what is known involves the immunologic system
and the autonomic nervous system. (Brunner/ Suddarth, 1988

ATRIAL FIBRILLATION: Atrial fibrillation (disorganized and uncoordinated twitching of
atrial musculature) is usually associated with atherosclerotic heart disease, rheumatic
heart disease, CHF, thyrotoxicosis, or pulmonale, or congenital heart disease. Atrial
fibrillation is characterized by the following- lowing: Rate: An atrial rate of 350 to
600 beats per minute ventricular response usually 120 to 200 beats per minute. P waves: No
discernible P waves: irregular undulation, termed fibrillary or “f” waves, is
seen; PR interval cannot be measured. QRS complex: Usually normal. Conduction: Usually
normal through the ventricles. Characterized by an irregular ventricular response, because
the AV node is incapable of responding to the rapid atrial rate. Impulses that are
transmitted cause the ventricles to respond irregularly. Rhythm: Irregular and usually
rapid, unless controlled. Irregularity of rhythm is due to concealed conduction within the
AV node. A rapid ventricular response reduces the time for ventricular filling and hence
the stroke volume. The atrial kick, which is 25 to 30% of the cardiac output, is also
lost. Congestive heart failure frequently follows. There is usually a pulse deficit, the
numerical difference between apical and radial pulse rates. Treatment is directed toward
eliminating the cause, decreasing the atrial irritability, and decreasing the rate of the
ventricular response. In patients with chronic atrial fibrillation, anticoagulant therapy
may be used to prevent thromboemboli from forming in the atria. Drugs of choice to treat
atrial fibrillation are similar to those used in the treatment of paroxysmal atrial
tachycardia, digitalis preparation is used to slow the heart rate, and an antidysrhythmic
such as quinidine is used to correct the dysrhythmia. (Brunner, & Suddarth 1988).

TYPE II DIABETES MELLITUS: In diabetes, insulin is not secreted in proportion to blood
glucose levels because of several possible factors: deficiency in the production of
insulin by the beta cells, insensitivity of the insulin secretory mechanism of the beta
cells, delayed or insufficient release of insulin, or excessive inactivation by chemical
inhibitors or “binders” in the circulation. In some non-insulin dependent
persons with diabetes, however, insulin secretion is increased, resulting in higher ,
circulating insulin levels. Although excess insulin is present, it is not utilized because
of an inadequate number of insulin receptors present on cells. This mechanism has been

observed in obese patients. With weight loss, the number of insulin receptors on the
cells increases, thereby allowing glucose to enter the cell. This may result in return of
a normal glucose tolerance. (Burner/ Suddarth, 1988 )

HYPOTHYROIDISM : Hypothyroidism is a condition in which there is a slow progression of
thyroid hypofunction, followed by symptoms indicating thyroid failure. More than 95% of
patients with hypothyroidism have primary dysfunction of the thyroid gland itself. When
the thyroid dysfunction is due to failure of the pituitary gland, it is known as secondary
hypothyroidism; when failure of the hypothalamus is the underlying cause, the term
tertiary hypothyroidism is used. When thyroid deficiency is present at birth, the
condition is known as cretinism. In such instances, the mother may also suffer from
thyroid deficiency. (Brunner/ Suddarth, 1988)

Patients activity orders are as tolerated with wheel chair transport. Pt needs partial
assist with ADLs. He is continent of B & B with assistance

Needs to be turned in bed Q 2 hr, elevate heels in bed . Pt has a special mattress.
Encourage I.S. Q 1 hr w/a. IV flush q shift peripheral line. PICC line flush.
Chest tube to water seal to 20cm, with cont. suction 55-60 wall green. DO NOT DISCONTINUE SUCTION.
Chest tube dressing change no deviations from present form.
Accurate I&O’s . VS. Q shift and prn. with lung sounds assessment. Skin assessment
q 2 hr with wound assessment at the same time(abrasion on the back ) and finger
ulceration. FSGs q 6 hr with Sliding scale coverage. Weight every week on Monday.

All times are approximate
07:30 Received report on G.B. from night shift.
08:00 Spoke with G.B. before breakfast was delivered. Vital signs taken and noted.
Insured patency of chest drainage tubes and amount of fluid from last shift. Noted time
and initialed on collecting container.

09:00 09:00 medications given and noted
09:30 Assisted G.B. with ADL’s. Pt stated that he wasn’t very hungry. Pt. Ate
only 25% of solid food. Noted intake of 250ml. Urine output after breakfast 225ml. Pt.
Performed own bed bath and oral care. Lotion applied to Pt. Pt. Helped into bedside
commode. Curtains drawn for privacy.

10:30 Dressing change on tube insertion site as ordered. Skin assessment done and lung
sounds checked. Check position of G.B. He had re-positioned himself for comfort

10:45 X-Ray of G.B. performed in room. G.B. dressed and assisted into wheel chair.
11:00 Reported pt status to Team Leader.
11:00 Documented morning activities in appropriate charts, i.e. Nsg Notes, treatment book and V/S charts.
11:15 Returned to room to interview G.B. . Pt was cheerful but stated that he was feeling
tired and wanted to be helped back into bed.

11:45 Noted I & O
12:00 G. B. In bed resting comfortably. Reported pt status to team leader and report off floor to post-conference.


BUN 32H 10-26 A. Increased BUN levels (azotemia) 1. The most common cause of increased
BUN level is inadequate excretion due to kidney disease or urinary obstruction,
frequently- : occurring in cases of prostate enlargement. (A) An increased BUN of 50 to
150 mg / 100 ml indicates serious impairment of renal function. (Fishbach p. 312)

Creatinine .5H 0.7-1.4 A disorder of kidney function reduces excretion of creatinine,
resulting in increased levels of blood creatinine. The test is used to diagnose impaired
renal function. It is a more specific and sensitive indicator of kidney disease than BUN,
although in chronic renal disease, BUN correlates more accurately with symptoms of uremia
than does the blood creatinine.( (Fishbach p. 312)

WBC 10.4H 5-10 A. Leukocytosis (white blood cell count above l0000 / gl) 1. Leukocytosis
is usually due to an increase of only one type of White cell and is given the name of the
type of cell that shows white cell and is given the name of the type of cell that shows
the main increase. .In increase in circulating leukocytes is rarely due to a proportional
increase in leukocytes of all types. When it occurs it is usually to hemoconcentration.
Leukocytosis occurs in acute infections in which the degree of increase of white cells
depends on, 1. The severity of the infection, 2. The patient’s resistance, 3. The
patient’s age.(Fishbach p. 25.)

RBC 2.96L 4.2-5.6 Decreased RBC Values . Anemia, a condition in which there is a
reduction in the number of circulating RBCs, in the amount of hemoglobin, and/or in the
volume of packed cell(hematocrit).(Fishbach p. 41)

HGB 10.L 13.1-17.2 Anemia
HCT 29.3L 39-50 decreased hematocrit values are an indicator of anemia. In hematocrit of
30 or less means the patient is moderately to severely anemic.

ALBUMIN 3.1l 3.9-5 decreased albumin levels severe hypoalbuminemia is often associated
with edema and decreased transport function such as hypocalcemia. Decreased albumin levels
are caused by many different conditions i.e. Nephrosis (Fishbach p. 363)

LY# 1.2L 1.8-2.6 Anemia
MCH 34H 26-34 An increase of the MCH is associated with macrocytic anemia.
MCV 99.2H 87 -103 Note VA values differ from Fishbach. F the MCV is greater than 103 mm3,
the red cell 5 are macrocy tic.

PLT 433H 150-350 Abnormally increased numbers of platelets (thrombocythemial
thrombocytosis) occur in iron-deficiency and posthemorrhagic anemia acute infections and
many other diseases. In 50% of those patients who exhibit an unexpected increase in plate-
lets, a malignancy will be found. This malignancy is usually disseminated, advanced, or

MPV 6.3L 8 -10L This test is done in the investigation of various hematologic disorders
such as thrombocytopenic purpura, and study of alcoholics under treatment.

Na 135 135-148 Hyponatremia usually reflects a relative excess of body water rather than a low total body sodium.
K 4.6 2.7-4.5 Hyperphosphatemia (increased phosphorus levels) The most common causes of
elevated blood phosphate levels are in association with kidney dysfunction and uremia.
This is because phosphate is so closely regulated by the kidneys. Renal insufficiency and
severe nephritis (accompanied by elevated- : BUN and creatine)

Albumin 3.1 3.8-5.0 albumin is a protein that is formed in the liver and that helps to
maintain normal distribution of water in the body (colloidal osmotic pressure). It also
helps in the transport of blood constituents such as ions, pigments, bilirubin, hormones,
fatty acids, enzymes, and certain drugs. Decreased albumin levelsDecreased albumin levels
are caused by many different conditions- inadequate iron intake, Severe liver diseases
Malabsorption, Starvation, excessive administration of IV glucose in water

F/Y empyema status no change since 9/3/96. F/U - bilateral sever pulmonary emphysema &
interstitial fibrosis. CBC shows high levels of WBC’s and bends indicative of
ongoing infection. Chemistry shows elevated liver enzymes. UA and C&S are negative. Blood
cultures are also negative. Sputum C&S and Gram Stain show WBC* 25, Eph.*10 and presence
of Alpha streptococcus & neisseria.

LABS AND X-RAYS: CXR done on 9/3 shows normal heart size, no change in the status of
pulmonary fibrosis, emphysema but there is new fluid in R major fissure. Echo done 7/22
reveals L ventricular systolic dysfunction and ejection fraction of 31%. ECG done 7/29
shows Arterial Fibrillation. CT-scan of chest is ordered.

Albuterol, Proventil, Proventil Repetabs, Salbutamol, Ventolin, Ventolin Rotacaps, Volmax
Func. class.: Adrenergic b2 agonist
Action: Causes bronchodilation by action on b2 (pulmonary) receptors by increasing levels
of cAMP, which relaxes smooth muscle; produces bronchodilation, CNS, cardiac stimulation,
as well as increased diuresis and gastric acid secretion; longer acting than isoproterenol

Uses: Prevention of exercise-induced asthma, bronchospasm, production of premature labor
Dosage and routes:
To prevent exercise-induced asthma
• Adult: INH 2 puffs 15 min before exercising, NEB/LPPB 5 mg tid-qid
• Adult: INH 1-2 puffs q4-6h PO 2-4 mg tid-qid, not to exceed 8 mg
Prevention of premature labor
Available forms: Aerosol 90 mg/actuation; tabs 2, 4 mg; syr 2 mg/5 ml, cont rel 4, 8 mg
Side effects/adverse reactions:
CNS: Tremors, anxiety, insomnia, headache, dizziness, stimulation, restlessness, hallucinations, flushing, irritability
EENT: Dry nose, irritation of nose and throat
CV: Palpitations, tachycardia, hypertension, angina, hypotension, dysrhythmias
GI: Heartburn, nausea, vomiting
MS: Muscle cramps
Contraindications: Hypersensitivity to sympathomimetics, tachydysrhythmias, severe cardiac disease
Precautions: Lactation, pregnancy , cardiac disorders, hyperthyroidism, diabetes
mellitus, hypertension, prostatic hypertrophy, narrow-angle glaucoma, seizures,
exercise-induced bronchospasm (aerosol) in children *12 years

Well absorbed PO, extensively metabolized in the liver, excreted in urine, crosses
placenta, breast milk, blood-brain barrier

PO: Onset hr, peak 2 hr, duration 4-6 hr, half-life 2 hr
PO-ER: Onset hour; peak 2-3 hr; duration 12 hr
INH: Onset 5-15 min, peak 1-1 hr, duration 4-6 hr, half-life 4 hr
• Increased action of aerosol bronchodilators
• Increased action of albuterol: tricyclic antidepressants, MAOIs, other adrenergics
• May inhibit action of albuterol: other b-blockers

• Respiratory function: vital capacity, forced expiratory volume, ABGs, lung sounds,
heart rate and rhythm (baseline)

• That patient has not received theophylline therapy before giving dose
• Client’s ability to self-medicate
• For evidence of allergic reactions
• After shaking, exhale, place mouthpiece in mouth, inhale slowly, hold breath, remove, exhale slowly
• Gum, sips of water for dry mouth
• PO with meals to decrease gastric irritation
• Syrup to children (no alcohol, sugar)
• Storage in light-resistant container, do not expose to temperatures over 86 F (30 C)
• Therapeutic response: absence of dyspnea, wheezing after 1 hr, improved airway exchange, improved ABGs
Teach patient/family:
• Not to use OTC medications; extra stimulation may occur
• Use of inhaler; review package insert with patient
• To avoid getting aerosol in eyes; blurring may result
• To wash inhaler in warm water qd and dry
• To avoid smoking, smoke-filled rooms, persons with respiratory infections
• That paradoxical bronchospasm may occur and to stop drug immediately
• To limit caffeine products such as chocolate, coffee, tea, and colas
Treatment of overdose: Administer a b2-adrenergic blocker

Creon Capsules,
Func. class.: Digestant
Chem. class.: Pancreatic enzyme-bovine/porcine
Action: Pancreatic enzyme needed for proper pancreatic functioning
Uses: Exocrine pancreatic secretion insufficiency, cystic fibrosis (digestive aid),
steatorrhea, pancreatic enzyme deficiency

Dosage and routes:
• Adult and child: PO 1-3 caps/tabs ac or with meals, or 1 caps/tab with snack or 1-2 pdr pkt ac
Available forms: Tab 8000, 11,000, 30,000 U; caps 8000, 30,000 U; enteric coated caps
4000, 5000, 20,000, 25,000 U; powd 16,800 U

Side effects/adverse reactions:
GI: Anorexia, nausea, vomiting, diarrhea
GU: Hyperuricuria, hyperuricemia
Contraindications: Allergy to pork, chronic pancreatic disease
Precautions: Pregnancy
• Decreased absorption: cimetidine, antacids, oral iron
• I&O ratio; watch for increasing urinary output
• Fecal fat, nitrogen, pro-time during treatment
• For polyuria, polydipsia, polyphagia (may indicate diabetes mellitus)
• After antacid or cimetidine; decreased pH inactivates drug
• Powder mixed in prepared fruit for infants, children
• Whole, not crushed or chewed (enteric coated)
• Low-fat diet to decrease GI symptoms
• Powder mixed with pureed fruit; take tabs with or before food
• Storage in tight container at room temperature

Digoxin, Lanoxicaps, Lanoxin
Func. class.: Antidysrhythmic, cardiac glycoside
Chem. class.: Digitalis preparation
Action: Inhibits the sodium-potassium ATPase, which makes more calcium available for
contractile proteins, resulting in increased cardiac output

Uses: CHF, atrial fibrillation, atrial flutter, atrial tachycardia, rapid digitalization in these disorders
Dosage and routes:
• Adult: IV 0.5 mg given over *5 min, then PO 0.125-0.5 mg qd in divided doses q4-6hr as needed
• Elderly: PO 0.125 mg qd maintenance
• Child *2 yr: PO 0.02-0.04 mg/kg divided q8h over 24 hr; maintenance 0.006-0.012
mg/kg qd in divided doses q12hr; IV loading dose 0.015-0.035 mg/kg over *5 min

• Child 1 mo-2 yr: IV 0.03-0.05 mg/kg in divided doses over *5 min q48h; change to
PO as soon as possible; PO 0.035-0.060 mg/kg divided in 3 doses over 24 hr; maintenance
0.01-0.02 mg/kg in divided doses q12h

• Neonates: IV loading dose 0.02-0.03 mg/kg over *5 min in divided doses q4-8h;
change to PO as soon as possible; PO loading dose 0.035 mg/kg divided q8h over 24h;
maintenance 0.01 mg/kg in divided doses q12hr

• Premature infants: IV 0.015-0.025 mg/kg divided in 3 doses over 24 hr, given over
*5 min; maintenance 0.003-0.009 mg/kg in divided doses q12h

Available forms: Caps 50, 100, 200 mg; elix 50 mg/ml; tabs 125, 250, 500 mg; inj 100, 250 mg/ml
Side effects/adverse reactions:
CNS: Headache, drowsiness, apathy, confusion, disorientation, fatigue, depression, hallucinations
CV: Dysrhythmias, hypotension, bradycardia, AV block
EENT: Blurred vision, yellow-green halos, photophobia, diplopia
GI: Nausea, vomiting, anorexia, abdominal pain, diarrhea
Contraindications: Hypersensitivity to digitalis, ventricular fibrillation, ventricular
tachycardia, carotid sinus syndrome, 2nd or 3rd degree heart block

Precautions: Renal disease, acute MI, AV block, severe respiratory disease,
hypothyroidism, elderly, pregnancy , sinus nodal disease, lactation, hypokalemia

PO: Onset -2 hr, peak 6-8 hrs, duration 3-4 days
IV: Onset 5-30 min, peak 1-5 hr, duration variable, half-life 1.5 days excreted in urine
• Hypokalemia: diuretics, amphotericin B, carbenicillin, ticarcillin, corticosteroids, piperacillin
• Decreased digoxin level: thyroid agents
• Increased blood levels: propantheline bromide, spironolactone quinidine,
verapamil, aminoglycosides PO, amiodarone, anticholinergics, quinine

• Increased bradycardia: b-adrenergic blockers, antidysrythmics
• Toxicity: adrenergics, amphotericin, corticosteroids, diuretics, glucose, insulin,
reserpine, succinylcholine, quinidine, thioamines

• Incompatible with acids, alkalies, Ca salts
Lab test interferences:
Increase: CPK
• Apical pulse for 1 min before giving drug; if pulse *60 in adult or *90 in an
infant, take again in 1 hr; if *60 in adult, call physician; note rate, rhythm, character

• Electrolytes: K, Na, Cl, Mg, Ca; renal function studies: BUN, creatinine; blood
studies: ALT, AST, bilirubin, Hct, Hgb before initiating treatment and periodically

• I&O ratio, daily weights; monitor turgor, lung sounds, edema
• Monitor drug levels (therapeutic level 0.5-2 ng/ml)
• Cardiac status: apical pulse, character, rate, rhythm
• PO with or without food; may crush tabs
• K supplements if ordered for K levels *3, or foods high in K: bananas, orange juice
• IV undiluted or 1 ml of drug/4 ml sterile H2O, D5, or NS; give over *5 min through
Y-tube or 3-way stopcock; during digitalization close monitoring is necessary

• Storage protected from light
Therapeutic response: decreased weight, edema, pulse, respiration, rales; increased urine
output; serum digoxin level (0.5-2 ng/ml)

Teach patient/family:
• Not to stop drug abruptly; teach all aspects of drug, to take exactly as ordered
• To avoid OTC medications, since many adverse drug interactions may occur; do not take antacid at same time
• To notify physician of any loss of appetite, lower stomach pain, diarrhea,
weakness, drowsiness, headache, blurred or yellow vision, rash, depression, toxicity

• Toxic symptoms of this drug and when to notify physician
• To maintain a sodium-restricted diet as ordered
• To report shortness of breath, difficulty breathing, weight gain, edema, persistent cough
Treatment of overdose: Discontinue drug; administer K; monitor ECG, administer an
adrenergic blocking agent, digoxin immune FAB

Func. class.: Antihypertensive
Chem. class.: Angiotension-converting enzyme (ACE) inhibitor
Action: Selectively suppresses renin-angiotensin-aldosterone system; inhibits ACE;
prevents conversion of angiotensin I to angiotensin II; results in dilation of arterial,
venous vessels

Uses: Hypertension, alone or in combination with thiazide diuretics
Dosage and routes:
• Adult: PO 10 mg qd initially, then 20-40 mg/day divided bid or qd
Available forms: Tabs 10, 20 mg
Side effects/adverse reactions:
CV: Hypotension, chest pain, palpitations, angina, orthostatic hypotension
GU: Proteinuria, Increased BUN, creatinine, decreased libido
HEMA: Decreased Hct, Hgb, eosinophilia, leukopenia, neutropenia
INTEG: Angioedema, rash, flushing, sweating, photosensitivity, pruritus
RESP: Cough, sinusitis, dyspnea, bronchospasm
META: Hyperkalemia
GI: Nausea, constipation, vomiting, diarrhea
CNS: Insomnia, paresthesia, headache, dizziness, fatigue, memory disturbance, tremor, mood change
MS: Arthralgia, myalgia
Contraindications: Hypersensitivity to ACE inhibitors, pregnancy (D), lactation, children
Precautions: Impaired liver function, hypovolemia, blood dyscrasias, CHF, COPD, asthma, elderly
PO: Peak 3 hr; serum protein binding 97%; half-life 12 hr; metabolized by liver (metabolites excreted in urine, feces)
• Increased hypotension: diuretics, other antihypertensives, ganglionic blockers, adrenergic blockers
• Increased toxicity: vasodilators, hydralazine, prazosin, K-sparing diuretics, sympathomimetics
• Decreased absorption: antacids
• Decreased antihypertensive effect: indomethacin
• Increased serum levels of: digoxin, lithium
• Increased hypersensitivity: allopurinol
Lab test interferences:
False positive: Urine acetone
• Blood studies: neutrophils, decreased platelets
• B/P, orthostatic hypotension, syncope
• Renal studies: protein, BUN, creatinine; watch for increased levels that may indicate nephrotic syndrome
• Baselines in renal, liver function tests before therapy begins
• K levels, although hyperkalemia rarely occurs
• Dipstick of urine for protein qd in first morning specimen; if protein is
increased, a 24-hr urinary protein should be collected

• Edema in feet, legs daily
• Allergic reactions: rash, fever, pruritus, urticaria; drug should be discontinued if antihistamines fail to help
• Renal symptoms: polyuria, oliguria, frequency, dysuria
• IV infusion of 0.9% NaCl (as ordered) to expand fluid volume if severe hypotension occurs
• Storage in tight container at 86 F (30 C) or less
• Supine or Trendelenburg position for severe hypotension
• Therapeutic response: decrease in B/P
Teach patient/family:
• Not to discontinue drug abruptly
• Not to use OTC products (cough, cold, allergy) unless directed by physician; do
not use salt substitutes containing potassium without consulting physician

• Importance of complying with dosage schedule, even if feeling better
• To rise slowly to sitting or standing position to minimize orthostatic hypotension
• To notify physician of mouth sores, sore throat, fever, swelling of hands or feet,
irregular heart beat, chest pain

• To report excessive perspiration, dehydration, vomiting, diarrhea; may lead to fall in B/P
• That drug may cause dizziness, fainting, light-headedness during 1st few days of therapy
• That drug may cause skin rash or impaired perspiration
• How to take B/P; normal readings for age group Treatment of overdose: 0.9% NaCl IV INF, hemodialysis

Flucinolone, Fluocinolone Acetonide, Fluonid, Flurosyn, Synalar, Synalar-HP, Synemol,
Fluocinonide, Lidemol, Lidex, Lidex-E, Vasoderm, Vasoderm E

Func. class.: Topical corticosteroid
Chem. class.: Synthetic fluorinated agent, group II potency
Action: Possesses antipruritic, antiinflammatory actions
Uses: Psoriasis, eczema, contact dermatitis, pruritus
Dosage and routes:
• Adult and child: Apply to affected area tid-qid
Available forms: Oint 0.05%; cream 0.05%; sol 0.05%; gel 0.05%
Side effects/adverse reactions:
INTEG: Burning, dryness, itching, irritation, acne, folliculitis, hypertrichosis, perioral
dermatitis, hypopigmentation, atrophy, striae, miliaria, allergic contact dermatitis,
secondary infection

Contraindications: Hypersensitivity to corticosteroids, fungal infections
Precautions: Pregnancy (C), lactation, viral infections, bacterial infections
• Temperature: if fever develops, drug should be discontinued
• Only to affected areas; do not get in eyes
• Medication, then cover with occlusive dressing (only if prescribed), seal to
normal skin, change q12h; use occlusive dressings with extreme caution

• Only to dermatoses; do not use on weeping, denuded, or infected area
• Cleansing before application of drug
• Treatment for a few days after area has cleared
• Storage at room temperature
• Therapeutic response: absence of severe itching, patches on skin, flaking
Teach patient/family:
• To avoid sunlight on affected area; burns may occur
Beef NPH Iletin II, Humulin N, Iletin NPH, Insulatard NPH, NPH Iletin I, Pork NPH Iletin
II, Novolin N, NPH Insulin, NPH Purified Pork

Func. class.: Antidiabetic
Chem. class.: Exogenous unmodified insulin
Action: Decreases blood sugar; indirectly increases blood pyruvate, lactate; decreases phosphate, potassium
Uses: Ketoacidosis, type I (IDDM), type II (NIDDM) diabetes mellitus, hyperkalemia
Dosage and routes:
• Adult: SC dosage individualized by blood, urine glucose, usual dose 7-26 U; may increase by 2-10 U/day if needed
Available forms: SC 100 U/ml
Side effects/adverse reactions:
CNS: Headache, lethargy, tremors, weakness, fatigue, delirium, sweating
CV: Tachycardia, palpitations
EENT: Blurred vision, dry mouth
GI: Hunger, nausea
META: Hypoglycemia
INTEG: Flushing, rash, urticaria, warmth, lipodystrophy, lipohypertrophy
SYST: Anaphylaxis
Contraindications: Hypersensitivity to protamine
Precautions: Pregnancy (B)
• Increased hypoglycemia: salicylate, alcohol, b-blockers, anabolic steroids,
fenfluramine, phenylbutazone, sulfinpyrazone, guanethidine, oral hypoglycemics, MAOIs,

• Decreased hypoglycemia: thiazides, thyroid hormones, oral contraceptives,
corticosteroids, estrogens, dobutamine, epinephrine

SC: Onset 1-2 hr, peak 4-12 hr, duration 18-24 hr
Metabolized by liver, muscle, kidneys; excreted in urine
Lab test interferences:
Increase: VMA
Decrease: K, Ca
Interference: Liver function studies, thyroid function studies
• Fasting blood glucose, 2 hr PP (80-150 mg/dl normal fasting level) (70-130 mg/dl-normal 2 hr level)
• Urine ketones during illness; insulin requirements may increase during stress, illness
• Hypoglycemic reaction that can occur during peak time
• After warming to room temperature by rotating in palms to prevent injecting cold insulin
• Increased doses if tolerance occurs
• Human insulin to those allergic to beef or pork
• Storage at room temperature for *1 mo, keep away from heat and sunlight,
refrigerate all other supply, do not use if discolored; do not freeze

• Rotation of injection sites within one area: abdomen, upper back, thighs, upper
arm, buttocks; keep record of sites

• Therapeutic response: decrease in polyuria, polydipsia, polyphagia, clear
sensorium, absence of dizziness, stable gait

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