I.

PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA
PATIENTS NAME: Mr. AD
ADDRESS: Tarlac City, Tarlac
AGE: 43 years old
SEX: Male
BIRTH DATE: November 15, 1969
RANK IN THE FAMILY: 2nd in the family
NATIONALITY: Filipino
CIVIL STATUS: Married
DATE OF ADMISSION: July 17, 2013
ORDER OF ADMISSION:
DIAGNOSIS:
ATTENDING PHYSICIAN: Dr. De Leon
CHIEF COMPLAINT: Difficulty of breathing, Body weakness and pain on the left chest area.
B. HISTORY OF PRESENT ILLNESS
4 days prior to admission, the patient had suffered from motorcycle accident, fell into a ditch sustaining injuries on the chest and left
lung. Patient was brought to E.R after he had experienced difficulty of breathing and thereby admitted.
C. PAST HEALTH HISTORY/STATUS
Childhood Illnesses: The patient already experienced having chickenpox and measles.
Immunization: The patient cant remember when he had received his dose of BCG and Hepa B.
Major Illnesses: None
Current medications: Patient was prescribed

D. FAMILY ASSESSMENT

NAME

RELATION

AGE

SEX

OCCUPATION

EDUCATIONAL ATTAINMENT

LD

Wife

42

Female

Housewife

High School graduate

MD

Son

26

Male

Service Crew

College Undergraduate

ED

Daughter

20

Female

NONE

College Graduate

E. SYSTEM REVIEW
1. HEALTH PERCEPTION
Clients perception of health: Dapat kumain kanang masusustansyang pagkain para maging malakas ka at healthy
Clients perception about Illness: Kagaya ngayon mahina ako diko na kayang gawin ang ginagawa ko dati
2. NUTRITIONAL-METABOLIC PATTERN
Food: The patient usually drinks coffee and eats bread at breakfast and usually had a combination of meat, vegetables and rice for
lunch and dinner; he drinks coffee two times a day.
Water: He usually drinks 8 10 glasses of water every day.
Beverages: He drinks alcoholic beverages 2-3 times a week.
3. ELIMINATION PATTERN
During hospitalization, he defecates every day, brown in color and foul in odor. With indwelling folley catheter connected to urine
bag, the urine color is pale yellow and has aromatic odor.

4. ACTIVITY-EXERCISE PATTERN
DURING HOSPITALIZATION
III Feeding

III Dressing

III Grooming

III Bathing
III Bed mobility

III Toileting
IV Home maintenance

IV Cooking

Legend
0 full care
I
requires use of equipment
II requires assistance or supervision from others
III requires assistance or supervision from another, and equipment and a device
IV dependent; doesnt participates

5. COGNITIVE-PERCEPTUAL PATTERN
Mr. AD can see objects clearly with the aid of his eyeglasses. He can taste food as its taste. He can hear well since he answers
our questions upon interview.
6. SLEEP-REST PATTERN
He usually sleeps 7:00 PM. Patient stated some sleeping alterations because at times he felt in pain in breathing. He is not using
any sleeping aids. Client also complains of difficulty in breathing and pain in breathing.
7. SELF PERCEPTION PATTERN
During hospitalization, the clients perception about himself is, Mahina ako, malaki ang pinagbago ko .Regardless of his
situation, Mr .A.D was disappointed of what happen because they spend a lot of money for his treatment. As stated by Mr. A.D
his weakness and strength is his family. The patient stated that Dapat bumalik na ang dati kong lakas dahil kailangan kong
magtrabaho para sa pamilya ko.

8. ROLE RELATIONSHIP PATTERN

According to the Mr. A.D, because he is the head of the family, he is the one who provides the needs of his family and sometimes
gives some to his mother.
9. SEXUALITY REPRODUCTIVE PATTERN

Client stated that he engages in sexual activity with his wife. In connection with their sexuality-productive pattern they both established
good relationship. Mr. A.D and his wife dont have any reproductive problems. He did not experience any sexual abuse likewise.
10. COPING-STRESS TOLERANCE PATTERN
He states that stress and problems in life as sakit sa ulo, Mr. A.D manages his problem together with his wife.
11. VALUE BELIEF PATTERN
Mr. AD is a Roman Catholic Christian valuing the word of Christ and believes he is there.
F.HEREDO-FAMILIAL ILLNESS

G.

PATERNAL

MATERNAL

No Known Illness

No Known Illnes

DEVELOPMENTAL HISTORY

THEORIST

AGE

SEX

PATIENTS DESCRIPTION

Erick Erickson

Middle Adulthood: 65 to death

Male

Ego Development Outcome: Generativity vs. S

or Stagnation
Basic Strengths: Production and Care

Now work is most crucial. Erikson observed that m

when we tend to be occupied with creative and me
and with issues surrounding our family. Also, midd
when we can expect to "be in charge," the role we
envied.

Piaget

Sigmund Freud

II.

Formal operational
(11 years and up)

Male

Puberty to Death

Male

The patient Can solve hypothetical problems

reasoning, understands causality and can dea
present and future.

The Genital Stage

Erogenous Zone: Maturing Sexual In
During the final stage of psychosexual developme
develops a strong sexual interest in the opposite s
begins during puberty but last throughout the rest
Where in earlier stages the focus was solely on in
interest in the welfare of others grows during this s
stages have been completed successfully, the ind
now be well-balanced, warm and caring. The goal
to establish a balance between the various life are

PHYSICAL ASSESSMENT
A. General Survey
1. Overall appearance and grooming: Upon assessment Mr.LMQ is conversant and conscious; he also appears weak.

2.
3.
4.
5.

Symptoms of distress: Mr. AD has symptoms of distress.

Posture and gait: On his condition, he cant stand and move independently.
Affect and mood: Upon our interview, Mr. AD is showing unhappy mood and is irritable.
Vital signs of the day of physical examination
Temperature: 36.5C
Respiratory rate: 28 breaths per minute
Pulse rate: 95 bpm
Blood pressure: 110/80 mmHg
6. Height and weight:
Height: 5 feet 1 inches
BMI: 22.86 = Normal
Weight: 121 lbs
B. Regional Exam IPPA technique was utilized
1. Hair, head and face: Hair: Upon inspection Mr.ADs hair are evenly distributed. Its texture is dull, rough and thick. There is no
presence of infection.
Head and face: The clients head is rounded, smooth skull contour, and normocephalic. His face is symmetric in facial movement
and there is no presence of any nodules or masses upon inspection and palpation.
2. Eyes: Upon inspection of the clients eyes, its eyebrows and eyelashes are symmetrically aligned and hair is evenly
distributed. The palpebral conjunctivae are pale in color. The pupils are equally round and reactive to light and accommodation.
3. Nose: Upon assessment Mr. AD nose is symmetric and straight, no discharge, no tenderness, no lesions, nasal septum intact
and in midline. Client is receiving oxygen inhalation via nasal cannula. The client complains difficulty in breathing.
4. Ears: Both ears are same in color with the facial skin, symmetrical, auricle aligned with the outer canthus of the eyes 10 from
vertical, not tender, pinna recoils after it is folded.
5. Mouth and throat: The clients mucous membrane is pink in color, slightly dry, smooth in texture, complete teeth and client can
swallow.
6. Neck and Lymph nodes: The clients neck muscles are equal in size, no visible nodules nor masses upon palpation.
7. Skin: Mr. has tan skin complexion and has good skin turgor.
8. Nails: Well cut and clean nail tips, and has normal blanch test with good capillary refill and pale.
9. Thorax and lungs: Clients respiration is 28 bpm; abnormal breaths with paradoxical breathing
10. Cardiovascular: With PR of 95 bpm, regular heartbeat and no swishing sounds heard. Blood pressure is 110/80 mmHg.
11. Breast and axilla: Breasts skin even with the chest wall. No nodules noted on axilla upon palpation
13. Extremities: Left and right upper extremities are equal in size and length; no deformities noted
14. Genitals: Not assessed
15. Rectum and anus: Not assessed
III.

PERSONAL/SOCIAL HISTORY
a Habits/Vices: Client doesnt smoke.
b Caffeine: The patient drinks coffee trice a day.
c Smoking The patient doesnt smoke
d Alcohol The patient drinks alcohol.

e
f
g
h
i
j

Tea The patient doesnt drink tea.

Drugs The patient doesnt take prohibited drugs
Social Affiliation - none
Rank in the family 2nd in the family
Travel (within 6 mos.) Has not traveled 6 months before hospitalization
Educational Attainment High School graduate

IV.

ENVIRONMENTAL HISTORY
Client resides in a semi-concrete house. His family lives with them. They had a congested neighborhood.

V.

LABORATORY RESULTS
1. ULTRASOUND
Date: 01/31/2013
Examination

IMPRESSION

Whole Abdomen Ultrasound

-

Abdominal sonography reveals the liver, homogenous, with normal

in abdominal size and echogenecity with no mass or cyst noted.
The gallbladder is demonstrated with no calculus seen,
Gallbladder is not dilated, and pancreas and abdominal aorta are
obscured bowel gas. The spleen is not enlarged with none evident
laceration noted. The kidneys are with normal size and
echogenecity with no solid mass or cyst or calculus or
hydronephrosis seen. No free fluid seen in the amount of pleural
effusion is seen in the left. There is solid tissue noted in the left
lung. No urinary bladder mass or calculus seen. The prostate
measures 30%2.1x2.2 cm with an estimated weight of 7.8 g.

Normal size homogenous liver with no mass or cyst noted no

calculus seen in the gallbladder.
The common duct and the intrahepatic duct are not dilated.
No renal solid mass or cyst or calculus or hydronephrosis is
seen
Small amount of left pleural effusion
Solid tissue in the lung, contusion changes
No free fluid seen in the abdomen and pelvis at the time of
exam.
No urinary bladder mass or calculus seen
Prostate is not enlarged.

2. BLOOD COUNT
Date: 01/30/2013
COMPONENT AND QUANTITY
WBC
Lymphocytes

RESULT
13.0
1.7

NORMAL VALUE
(4.0-10.0)10^3/ul
(1.0-5.0) 10^3/ul

Monocytes

0.9

(0.1-1.0) 10^3/ul

Granulocytes

10.5

(2.0-8.0) 10^3/ul

RBC
HGB
HTC

5.62
15
47.7

(4.00-6.20) 10^6/ul
(12.0-18.0)9/dl
37.0-55.0%

SIGNIFICANCE
Increased: Possible infection
Increased: Indicative of possible
infection
Increased: Inflammatory
Response
Increased: Indicative of possible
infection
Normal
Normal
Normal

3. ARTERIAL BLOOD GAS

COMPONENTS
pH
pCo2

RESULTS
7.393
48.8 mmHg

NORMAL VALUES
(7.35-7.45)
(35-45mmHg)

Po2
HCO3

80.8mmHg
29.1 meq/dl

(80-100 mmHg)
(22-26 meq/dl)

Oxygen saturation

93%

95-100%

SIGNIFICANCE
Normal
Increased: Indicates
Underventilation
Normal
Increased: Indicative of Metabolic
Acidosis
Decreased: Indicative of
hypoxemia

VIII. PATHOPHYSIOLOGY OF FLAIL CHEST

PREDISPOSING
FACTORS:
1. Diet
2. Trauma (Motorcycle
accident)

PRECIPITATING FACTORS:
1. Age
2. Gender

Diet: Decreased Calcium

and minerals needed for
healthy bones in the diet

Decreased bone density

(Fragile and weak bone) and
higher affinity to sustain
fracture

Force or direct blow exerted

against rib cage stronger
than structurally withstand

Men are tend to have

higher and heavier
workload

Potential injury to the lung

parenchyma by direct
penetration

VI. INTRODUCTION

Injury and fracture to the

rib cage

In upper rib, potential injury to

the pleural or intra-abdominal
viscera

Hematoma formation at
fracture site. Tissue
inflammation resulting in
pain.

Interfere with normal costovertebral and

diaphragmatic muscle excursion,
potentially causing ventilatory
insufficiency

A flail chest is a life-threatening medical condition that occurs when a segment of the rib cage breaks under extreme
stress and becomes detached from the rest of the chest wall. It occurs when multiple adjacent ribs are broken in
multiple places, separating a segment, so a part of the chest wall moves independently. The flail segment moves in
the opposite direction as the rest of the chest wall: because of the ambient pressure in comparison to the pressure
inside the lungs, it goes in while the rest of the chest is moving out, and vice versa. This so-called "paradoxical
motion" can increase the work and pain involved in breathing. Flail chest is invariably accompanied by pulmonary
contusion, a bruise of the lung tissue that can interfere with blood oxygenation. The constant motion of the ribs in the
flail segment at the site of the fracture is extremely painful, and, untreated, the sharp broken edges of the ribs are
likely to eventually puncture the pleural sac and lung, possibly causing a pneumothorax. Typical paradoxical motion is
associated with stiff lungs, which requires extra work for normal breathing, and increased lung resistance, which
makes air flow difficult.

VII. ANATOMY AND PHYSIOLOGY OF THE AFFECTED BODY PART

PHYSIOLOGY OF THE LUNGS

LUNGS
- The lung is the essential respiration organ. The right lung is divided into 3 lobes (upper, middle and lower) whereas the left has only 2
(upper and lower).
BRONCHIAL TREE
- When people inhale, air moves down the trachea or windpipe. The trachea splits into two pipes called the right and left main stem
bronchus. Each bronchus provides an air passageway to a lung. Each bronchus continues to divide into many bronchi, or small pipes,
which further divide throughout the lungs into millions of tiny branches called bronchioles. This system of bronchi and bronchioles is
referred to as the bronchial tree. The bronchial tubes are lined with very small hair-like structures called cilia. Cilia use a constant
wave-like motion to carry mucus up the airway to the throat where it is either swallowed or coughed out.
ALVEOLI
- At the end of each bronchiole are small sacs called alveoli. Alveoli are responsible for exchanging oxygen and carbon dioxide.
This process helps remove foreign substances and germs from the respiratory system to reduce the risk of infection.

LOBES
- The right lung is divided into three sections called lobes. This tissue contains the bronchioles, alveoli, and capillaries necessary for
oxygenation of the blood. The left lung has only two lobes because of its anatomical position (next to the heart) in the chest cavity.
PLEURA
- The lungs are surrounded by a membrane called the pleura. This membrane wraps around each lung and helps to separate them from
the wall of the chest cavity. A very small amount of fluid is present between the pleural linings. It acts as a lubricant during lung
inflation and deflation, easing inspiration and expiration.
RIB CAGE
- Also known as the thoracic cage, is a bony and cartilaginous structure which surrounds the thoracic cavity and supports the pectoral
girdle, forming a core portion of the human skeleton. A typical human rib cage consists of 24 ribs, the sternum (with Xiphoid process),
costal cartilages, and the 12 thoracic vertebrae. It, along with the skin and associated fascia and muscles, makes up the thoracic wall
and provides attachments for the muscles of the neck, thorax, upper abdomen, and back.
DIAPHRAGM
- The diaphragm is the muscle responsible for inflating and expanding the lungs. When your inhale, the diaphragm muscle contracts
and presses the bottom parts of the left and right lung, causing the lungs to inflate. When you exhale, the diaphragm relaxes

ASSESSMENT

Subjective:
Hirap akong
makahinga
Objective:

Restlessness
Abnormal
ABGs result
Nasal Flaring
Irritability
Weakness
Use of
accessory
muscles in
breathing

NURSING
DIAGNOSIS

SCIENTIFIC
BACKGROUND

PLANNING

Impaired gas
exchange related
to alveolar
capillary
membrane injury

Flail Chest is
invariably
accompanied by
pulmonary
contusion, a bruise
of the lung tissue
that can interfere
with blood
oxygenation.

Patient will
demonstrate
improved
adequate tissue
oxygenation
after 30
minutes of
rendering
nursing
interventions.

NURSING
INTERVENTION

Monitor vital signs

Monitor pulse
oximetry

Note effectiveness of
cough mechanism

Elevate head of bed

Vital Signs:
BP: 110/80 mmHg
PR: 110 bpm
RR: 28 bpm
TEMP.: 36.8oC
OXYGEN
SATURATION: 93%

Assist client in
position changes
and breathing
exercises

Encourage adequate
rest and limit
activities to within
client tolerance

RATIONALE

- Indicative of
respiratory
distress and used
as a baseline data
-To determine
oxygenation and
levels of carbon
dioxide retention
-To evaluate
degree of
compromise
-To improve
breathing when
pain is inhibiting
effort and promote
lung expansion
-To increase
normal breathing,
to allow the chest
wall to reposition
itself back to
normal conditions.
-To help limit
oxygen needs or
consumption

EVALUATION

GOAL MET
After 30 minutes of
rendering nursing
interventions the
patient had
demonstrated
adequate tissue
oxygenation and
improved ventilation.
Vitals Signs:
BP: 110/80 mmHg
PR: 98bpm
RR: 23 bpm
TEMP.: 36.5oC
OXYGEN
SATURATION: 98%

Provide
psychological
support

DEPENDENT:
Administer
supplemental
oxygen as ordered

-To reduce anxiety

for maximum
cooperation in
interventions

-To offset
increased oxygen
demands and
consumptions

ASSESSMENT

Subjective:
Nahihirapan akong
gumalaw gaya ng
dati
Objective:
Slowed
movement

Needs support
in moving

Experience
difficulty in doing
certain actions
because of pain

NURSING
DIAGNOSIS
Activity
intolerance
related to
multiple rib
fracture

SCIENTIFIC
BACKGROUND

PLANNING

NURSING
INTERVENTION

RATIONALE

It is a state in which
a person has
insufficient physical
or psychological
energy to endure or
perform desired
physical activities
this could be
related to any pain
or discomfort that a
patient feels. Rib
fracture may
induce pain and
may hinder in
performing an
activity.

After 2 hours of
nursing
interventions
the patient will
be able to
tolerate simple
activities.

Identify the
activities the
patient can
perform which are
very essential to
refrain patient
from doing
nonessential
actions

-To assess
activities that he
can perform when
in pain

Assist with
activities of daily
living.

-To reduce energy

expenditure but
avoid doing things
for patient when
he can still
perform to
increase patients
selfesteem

Encourage to
perform deep
breathing exercise.

-To help reduce

the pain by
relaxation of
muscles

Encourage
adequate rest
periods
especially
before ambulation
and meals

-To reduce
cardiac workload

EVALUATION

GOAL MET
After 2hours
rendering of
nursing intervention
the patient can
tolerate simple
activities.

ASSESSMENT
Subjective:
Sobrang sakit ng
dibdib ko

NURSING
DIAGNOSIS

SCIENTIFIC
BACKGROUND

PLANNING

Acute pain
related to 6th9th segmented
rib fracture

The constant
motion of the ribs in
the flail segment at
the site of the
fracture is
extremely painful.

The patient will

establish relief
of pain and
decrease in
pain scale of
8/10 to 2/10
after 1 hour of
rendering
nursing
interventions.

NURSING
INTERVENTION

RATIONALE

GOAL MET
INDEPENDENT:
Monitor vital signs

-To establish
baseline data and
this is usually altered
in acute pain.

Determine clients
acceptable level of pain or
pain control goals.

-Pain perception
varies with individual
and situation.

Assess fro referred pain

as possible

-To help determine

the underlying
condition or organ
dysfunction

Instruct use of relaxation

technique such as: focus
breathing.

-To distract attention

and reduce tension.

Vital Signs:

Assist in repositioning

BP: 110/80
mmHg
PR: 110 bpm
RR: 28 bpm
TEMP.: 36.8oC

-Repositioning
may decrease
pain

Assist client to learn

proper breathing
techniques

Pain Scale: 8/10

Objective:

Weak in
appearance
Restlessness
Guarding
behavior
Facial grimace
noted
Irritability
Use of
accessory
muscle in
breathing

EVALUATION

Observe for non verbal

cues and pain behaviors

-To assist in muscle

and generalized
relaxation
-Observation may
not be congruent

After 1hour of
nursing
intervention
patient had
established
relieved of pain
and had a pain
scale of 2/10

with the verbal report

Encourage adequate rest

periods

-To prevent
fatigue and
oxygen
consumption

Provide and discuss with

individual exercise
program if tolerated

-To promote active

rather than passive
role and enhances
sense of control

DEPENDENT:
Administer analgesics as
ordered.

- reduces the
oxidized form of
the COX
enzyme,
preventing it
from forming
proinflammatory
chemicals. This
leads to a
reduced amount
of prostaglandin
E2 in the CNS,
thus lowering
the
hypothalamic
set-point in the
thermoregulator
y centre

X. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY

1. Acute Pain Related to respiratory muscle injury due to ineffective breathing.
2. Impaired gas exchange related to alveolar capillary membrane changes.
3. Activity intolerance related to multiple rib fracture.

XII.

ONGOING APPRAISAL:
August 30, 2013
7:00 -7:00 pm
Mr. LMQ is lying on bed, conscious and conversant; he is slightly weak in appearance. He has ongoing Intravenous fluid of 5%
Dextrose on Water Solution in 10-15 drops per minute at 500 cc level. Vital signs taken: BP: 160/90 mmHg, Temp.: 37. 0 C, RR:
20 bpm, RR: 78 bpm. Physical assessment and history taking was done.

XIII.

DISCHARGE PLAN:
Medications: Instruct patient to continue taking the prescribe drugs .
Exercise: Instructed the patient to avoid extraneous work.
Treatment: Instruct patient to continue medications. And avoid crowded places most especially places have high level of
irritants.
Clinic Follow up: Instruct patient to have their follow up check up after one week and follow the scheduled given.
Diet: The diet should be high caloric. Always drink a lot of water. Also eat fruits and vegetables. Eat vitamin c rich food to
strengthen immune systems.
Danger Signs: Instruct patient to seek medical attention if problem occurs.

SUBMITTED BY:
GROUP 2
CASTILLO, JANNINE KAY
CASTISIMO, MARK CHRISTIAN
CRUZ, MARIONNE CARLEN
CUARESMA, WENDY PRECIOSA
CUSION, EMIL JOHN

DOCTOR, LAI MAE

DOMINGO, LADY LYN
ELEGADO, PRINCESS
GANDIA, JARIYA
GODOY, ERLINE BELLE

Generic Name: Ketorolac

Brand Name: Ketomed
Drug Classification: NSAIDs
Indication: Short-term management of pain.
Mechanism of
Action

Adverse Effect

Anti
inflammatory
and analgesic
activity; inhibits
prostaglandin
and leukotriene
synthesis.

Contraindication

CV: MI
GI: GI Bleeding, Perforation
GU: Nephrotoxicity
Dysuria, Hematuria, Oliguria
HEMA: Blood Dyscrasias

Renal impairment
Aspirin allergy
Concurrent use of
NSAIDs.
Active peptic ulcer
disease.

Side Effects

Nursing Consideration

Instruct the patient that avoids

Dizziness,
Drowsiness,Nausea
Vomiting, Diarrhea

driving and other activities.

Increase fluid intake, Administer Anti
emetic if Vomiting Anti diarrheal if
Diarrhoea occurs
Instruct the patient to report chest
pain
Check for the Stool of the patient if
theres presence of melena
Check for Renal Studies: BUN,
Creatine, Protein
Check for urine output, Check for
Urinalysis if theres a presence
blood in the urine
Check for the result of CBC for
blood dyscrasias
Check the Chart/History of the
patient of Peptic Ulcer disease,
if the patient has PUD, Dont
administer
Discontinue if allergy persists
Notify the Physician

Generic Name: Morphine So4

Brand Name: Morphitec
Drug Classification: Opiods
Indication: To relieve acute or chronic moderate to severe pain
Mechanism of
Action

Adverse Effect

Binds with and

activates opiod
receptors in
brain and spinal
cord to produce
analgesia and
euphoria.

Contraindication

Acute alcoholism
Withdrawal syndrome

Side Effects

Blurred vision
Bradycardia
Hypotension
Anemia

CV: Ortho Hypotension

GI: Abdominal cramps, Nausea, Vomiting

Dry Mouth

Nursing Consideration

Instruct the patient limit

ambulation
Monitor cardiac rate
Instruct the patient to rise to bed
slowly and dangle feet before
standing up
Monitor Complete blood count
result
Instruct the patient to frequently
sip water
Instruct the patient to rise to bed
slowly and dangle feet before
standing up
Monitor borborygmy sounds
Discontinue if allergy persists
Notify the Physician

GENERIC NAME: nalbuphine

BRAND NAME:Nubain
CLASSIFICATION: Analgesic
DOSAGE: 5mg intravenously as needed for severe pain
INDICATION: Relief of moderate to severe pain

MECHANISM OF ACTION
Binds with opiate
receptors in the CNS:
ascending pain pathways
in limbic system,
thalamus, midbrain,
hypothalamus, altering
perception of and
emotional response to
pain.

CONTRAINDICATION
History of
hypersensitivity to
nalbuphine, opiate
agonists;
pregnancy
( category C )

SIDE EFFECT
CV:

Tachycardia

GI:

SKIN:

Nausea
Vomiting
Sweaty
Clammy skin

NURSING CONSIDERATION
Obtain drug history
Monitor vital signs after parenteral route
Monitor allergic reactions: rash, pruritus, and
urticaria.
Monitor ambulatory patients; nalbuphine may
produce drowsiness.
Watch for respiratory depression.
Avoid abrupt termination of nalbuphine following
prolonged use, which may result in symptoms
similar to narcotic; abdominal cramps, nasal
congestion, restlessness, anxiety.

Generic name: Cefuroxime

Brand Name: Mefoxin
Drug classification: Cephalosporins
Indication: Gram- Negative Bacilli

MECHANISM
OF ACTION

ADVERSE REACTION

CONTRAINDICATION

Bind to

Contraindicated in

bacterial cell

patients who have shown

wall

hypersensitivity to

membrane,

cefoxitin and the

causing cell

cephalosporin group of

death

antibiotics.

GI: Pseudomembranous colitis

GU: Nephrotoxicity, Renal Failure

SIDE EFFECTS

Dizziness
Headache
Nausea

NURSING CONSIDERATION
Instruct the patient that avoid driving
Instruct The patient that the drug will cause
headache
Instruct the patient that avoid driving
And other activities.
Increase fluid intake, Administer Anti Emetic for

Diarrhea, Vomiting

vomiting and Anti diarrheals for Diarrhea

Monitor if theres increase borborygmy sounds
Monitor patient for signs and symptoms of

Cramps

Pseudomembranous colitis
Monitor Urine Output, Assess for Renal Studies:
Protein, BUN, Creatinine results
Check for the Complete Blood Count Results of the
patient

HEMA: Leukopenia,
Thrombocytopenia, Agranulocytosis,
Neutropenia, Lymphocytosis,
Eosinophilia
INTEG: Steven-Johnsons Syndrome

Monitor patient for signs and symptoms of SJS.