DIABETES SEPTIC CARBUNCLE,

WITH SUPPURATION

INTRODUCTION

 

Description of the Disease/Disorder

Diabetes mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action or both. Normally, a certain amount of glucose circulates in the blood. The major sources of this glucose are absorption of ingested food in GT and formation of glucose by the liver from food substances. Insulin controls the levels of glucose in the blood by regulating the production and storage of glucose. In DM, the cells may stop responding to insulin or the pancreas may stop producing insulin entirely leading to hyperglycemia.

Carbuncle is an infection larger than a boil and with several openings for discharge of pus. It is an infection of the subcutaneous tissues involving the hair follicles and an abscess larger than a boil, usually with one or more openings draining pus onto the skin. It is usually caused by bacterial infection, most commonly Staphylococcus aureus. The infection is contagious and may spread to other areas of the body or other people. Often, the direct cause of a carbuncle cannot be determined. Things that make carbuncle infections more likely include friction from clothing or shaving, generally poor hygiene and weakening of immunity. For example, persons with diabetes and immune system diseases are more likely to develop staphylococcal infections.

 

Signs and Symptoms of Diabetes septic carbuncle • Polyuria•Polydipsia•Polyphagia•Dry skin•Skin lesions or wounds that are slow to heal•Recurrent infection•presence of several skin boils•infected mass is filled with fluid, pus, and dead tissue•carbuncle may be the size of a pea or as large as a golf ball•It may be red and irritated, and might hurt when touched•It may also grow very fast and have a white or yellow center•Sometimes, other symptoms may occur, such as fatigue, fever and a general discomfort or sick feeling•Itching may occur before the carbuncle develops

• Prevalence of the Disease/Disorder (Philippines) • The prevalence of diagnosed diabetes increased in all age groups. People between 65 and 74 years old had the

highest prevalence, followed by people of 75 years of age or older, people 45 to 64 years of age, and people younger than 45 years of age. In 2002, the prevalence of diagnosed diabetes among people 65 to 74 years of age (16.8%) was almost 14 times that of the people younger than 45 years of age (1.2%). However, many people with diabetes were undiagnosed.

• Men are more prone than women to get carbuncles, as those who are elderly, malnourished, obese, or use of corticosteroids. Carbuncles are also more likely to occur under conditions of poor hygiene, friction by clothing, or moist skin (maceration). Although the exact incidence of carbuncles is unknown, they are not common.

• Patient Case Introduction • Patient X, 58 years old who lived in P-5, Baybay Tinagsa Kolambugan Lanao del Norte was admitted on Feb. 22, 2011at

3:06pm in MUMC with a chief complaint of diabetes septic necrotizing mass in the left upper quadrant of her abdomen and with a pain scale of 7/10, 10 as the highest. She was diagnosed by Dr. I. Pala of diabetes septic carbuncle, upper abdomen with suppuration.

• Upon assessment, her vital signs were temp. 360C, PR: 106 bpm, RR: 25cpm, BP: 140/80 mmHg, Wt: 48 kg, she was ambulatory and also has nonproductive cough that occurs a day PTA

PRESENT ILLNESS REACTIONS TO AND EXPECTATIONS ABOUT HOSPITALIZATION

Patient X was admitted on Feb. 22, 2011 @3:06pm in MUMC with a chief complaint of diabetes septic necrotizing mass in the left upper quadrant of her abdomen.

She manifests guarding behavior with a pain scale of 7/10, 10 is the highest.

Upon admission, she was ambulatory with the v/s of: Temp:360C PR: 106 bpm RR: 25cpm BP: 140/80 mmHg Wt: 48 kg

“ hasol kayo ning magkadiabetes kay daghan kayo ang akong mga bantayonon”, as verbalized by the patient.

“hasol pod kayo kung magsakit ning akong hubag sa tiyan kay makahunong ko sa akong gtrabaho”, as verbalized by the patient.

”Dili na ko mkapanilhig ug laba kay sakit akong hubag” as verbalized by the patient.

“Patient is widowed and verbalized, “la naman ko bana pero sa akong mga anak ug apo ko naglihok, pero kay maospital mn ko dili na nako sila mabantayan”.

“kapoy kayo magmentenar sa ako tambal ug mahal pa jd paliton”, as verbalized by the patient.

The patient was worried about her hospitalization due to financial constraints.

PREVIOUS ILLNESS REACTIONS ABOUT TREATMENT AND DIAGNOSTIC PROCEDURES

Patient X was admitted the year 2003and was diagnosed with DM.

Patient undergone several Laboratory tests and was diagnosed with Diabetes Mellitus.

“nagpaospital ko kay para maayo akong gibati” as verbalized by patient.

“ngano diay ni mihubag ug duro ako samad? Maulian ra kaha ning akong hubag?”’ as verbalized by the patient Patient claims that she feels uncomfortable whenever her

body is exposed during examinations and treatments.

Nursing HistoryNormal Patterns of Functioning

(Before Admission)

Clinical Inspection Observation on First day of Duty

On-going Appraisal Observation on 2nd day of Duty

Other Sources Laboratory Exam Result

PATTERNS OF FUNCTIONINGRESPIRATION

Patient X stated that she did not experience feeling out of breath.

“sauna magubo ko pero wala plema” as verbalized by patient.

Patient does not use tobacco and is not practicing breathing exercise.

Has nonproductive cough occurred a day PTA

Nonproductive cough noted

Use of accessory muscle noted

RR as of 8 am: 25cpm RR as of 12 nn: 26cpm SOB Crackles noted upon

auscultation

Dyspnea noted Nonproductive cough RR as of 8 am: 23cpm RR as of 12 nn: 24cpm Crackles noted upon

auscultation

CXR result reveals : Streak densities

L-upper lobe Cardiac shadow is w/in

normal size and configuration

Tracheal shadow is in midline

Bone and other chest structures are unremarkable

Impression: PTB minimal most

probably inactive in L-upper lobe

CIRCULATION Patient pointed that her

lower extremities feels colder time to time while her back feels warmer sometimes.

Patient claimed that she does not feel her heart pound nor skip beats.

Wound noted at LUQ with purplish discoloration with pus

Pale skin noted BP as of 8am: 140/80

mmHg BP as of 12nn: 150/90

mmHg PR as of 8am: 106bpm PR as of 12nn: 102bpm Temp: 36.8 C Capillary refill test more

than 3sec.

Wound noted at LUQ with purplish discoloration with pus

BP as of 8am: 130/80 mmHg

BP as of 12nn: 150/80 mmHg

PR as of 8am: 104 bpm PR as of 12nn: 98bpm Temp: 36.8 C Capillary refill test more

than 3 sec.

Random blood sugar is above 500mg/dL

WBC: 1.2x103/mm3

RBC: 4.5x106/uL Hgb: 14.0g/dL Hct: 45% Platelet: 350,000/mm3

FOOD AND FLUID INTAKE Patient eats 3meals/day

with 2in between snacks. Meal usually contains large amount of rice and either fish, vegetable, or meat.

Patient is fond of eating sweets and fatty foods PTA.

Drinks 4-7 glasses of water a day

Seasonings include magic sarap, salt, vetsin, and etc.

On Diabetic diet Served and consumed

diet Weighs 52kg and stands

5’3” tall. Body build is skinny and appears pale.

Drink aprrox. 6 cup of water from 7am-3pm

Had eaten ½ cup rice, ½ cup tinolang isda,

On Diabetic diet Served and consumed diet Drink aprrox. 5 cup of

water from 7am-3pm Had eaten ½ cup rice, ½

cup tinolang isda, 5 cups of water.

ELIMINATION Patient voids 3-6 times a

day usually during bed time.

Frequency of bowel movement is every other day without timing.

Experienced difficulty in eliminating bowel.

Had not defecated from 7am-3pm

Had voided 4 times from 7am-3pm shift with estimated 900ml in amount with light yellow in color

Not defecated but Had voided 3 times from 7am-3pm shift with estimated 1200ml in amount with cloudy white urine

Creatinine is 1.01 mg/dL BUN is 12mg/dLU/A

Appearance: CloudyColor: AmberOdor: AromaticpH: 7.5Glucose: +2WBC: 2RBC: <2

REST AND SLEEP Patient usually sleeps 6-7

hours a day. Goes to bed at 10pm and wakes up around 4-5 am.

Patient watches TV before going to bed.

Experienced difficulty sleeping when wound is in pain.

Not able to take proper sleep since hospitalization due to environmental factors.

Patient is lying on bed and appears drowsy and yawning

Had slept 8hours last night from 10pm-6am.

Had utilized 2 pillows. One is under her head and the other is in between her thigh.

She had her 1hr nap at 1-2pm

EXERCISE Owns a sari2x store which she

manages alone. Fond of watching TV and eating when

nothing to do.

Can perform active ROM Patient is ambulatory with assistance

from bed to comfort room about 20 steps.

Movement is slow and steps are small.

PAIN/DISCOMFORT Patient claimed that she experienced

pain from headache years before. Reports discomfort from the wound at her abdomen 2 weeks before admission.

Resorts to medicine to relieve pain. Medicines include Cephalexin and Mefenamic acid.

Patient described the pain as 7 on a 0-10 scale

Guarding behavior noted Patient often covers the area of the

wound. Pain scale reduce at 4/10 after 2hrs of

pharmacologic mngt.

Complaint of pain at the carbuncle on her L-upper abdomen with a pain scale of 5/10.

Still manifest guarding behavior around wound.

REGULATORY MECHANISM “normal man nang hilantanon ta” as

verbalized by the patient. Patient claim that she had not

experienced seizures but sometimes felt dizzy.

Patient had her menopause at the age of 45.

RR as of 8am: 25cpm RR as of 12nn: 26cpm BP as of 8am: 140/80 mmHg BP as of 12nn: 150/90 mmHg PR as of 8am: 106bpm PR as of 12nn: 102bpm Temp: 36.8 C Skin appears pale Diaphoretic Dry mucous membrane noted with

cracked lips

RR as of 8am: 23cpm RR as of 12nn: 24cpm BP: 130/80 mmHg BP as of 12nn: 150/80 mmHg PR as of 8am: 104bpm PR as of 12nn: 98bpm Temp: 37 C Skin appears pale

PERSONAL HYGIENE Patient claimed that she usually takes a

bath every other day at 9am. Patient brush her teeth sometimes. All of her teeth are artificial. Had an ingrown before at her right big

toe. Usually waits for skin problems to be

gone by itself.

Skin appears pale Hair appears white and grayish Nails and mouth appears pale Dry mucous membrane noted with

cracked lips Dentures are removed

Skin appears pale Had already a well trimmed nails Had a wound dress newly

changed-7:30am Without dentures

COMMUNICATION AND SPECIAL SENSES Patient claims that she’s having difficulty seeing,

speaking, and hearing. Used eyeglasses to read and see distant objects.

Dentures are removed. Leans forward to hear voices and

has difficulty seeing. Uses glasses to see clearly. Communicates well when she is

able to hear properly. Answers heard questions properly. Words are not so clear due to

absence of teeth dentures.

Had difficulty hearing especially when talked in a moderate tone.

Uses glasses to see clearly. Words are not so clear due

to absence of teeth dentures.

COPING WITH STRESS Patient talks to family and relatives to release stress. Usually asks for advice from her son. Patient said that she usually cries when upset and

then talks to her son about it.

Patient answers our questions appropriately

Patient is in good mood as evidenced by positive social interaction with others Patien t appears lethargic.

Patient answers our questions appropriately

She positively interact with other people

RELIGIOUS LIFE Patient is member of UCCP and go to church every

Sunday. Past member of CWL Reads the bible when she had time

No religious medals worn No pictures or objects related to

religion noted Has an interruption in her

religious life during hospitalization

No religious medals worn No pictures or objects

related to religion noted

SOCIAL/OCCUPATIONAL LIFE “sa tindahan ra ko cge pundo” as verbalized by

client. Mother of 1 son and grandmother of 2 kids. Stays with son, daughter-in-law, and 2

grandchildren “gatuo ko na dli mayo manudlay basta gadaot or

gasakit” as verbalized by the patient.

Patient would entertain visitors Patient continuously update his son,

who is at work, through text

Patient positively interacts to other patients in the room, SO, and health care providers.

RECREATION/DIVERSION Goes to vacation when there is time and

money Went to wedding at Cagayan de Oro

city Watches TV as preparation to sleep

Often chats with SO and other patient

Tends to have some naps when there’s nothing more to do.

Often chats with SO and other patient

HEALTH SUPERVISION “wala na nako namaintenar akong tambal

sukad atong 2005 kay namatay akong bana ug wala nako kwarta”, as verbalized by the patient.

Does not strictly monitor her blood glucose level at home

Does not take her Humulin R religiously due to cost of the drug

Follows prescribed pharmacologic regimen

Follows what the physician had instructed her like maintaining proper hygiene and diet.

Lab Test/Exam Normal Values Results DateInterpretation/

Significance

Random Blood Sugar < 200 mg/dL Above 500 mg/dL/02-22-11

Hyperglycemia, Diabetes

CBC

WBC 5,000-10,000/mm3 12 x103/mm302-22-11 Leukocytosis, acute

infection

RBC 4.2-5.4 x 106/uL 4.5x106/uL02-22-11

Within Normal Limit

Hgb 12.0-16.0 14.0g/dL02-22-11

Within Normal Limit

Hct 37-47% 45%02-22-11

Within Normal Limit

Platelet 150,000-400,000/mm3 350,000/mm302-22-11

Within Normal Limit

U/A

Creatinine 0.5-1.5 mg/dL1.01 mg/dL

02-22-11

02-22-11Within Normal Limit

BUN 10-20mg/dL12mg/dL

02-22

02-22-11Within Normal Limit

DIAGNOSTIC TEST

Endocrine system (Pancreas) Integumentary system

  Figure 1. Illustration of the Organ System ___Endocrine System: Pancreas___

And Integumentary system

ANATOMY AND PHYSIOLOGY

  

Physiology of the Organ System

In physiology, the endocrine system is a system of glands, each of which secretes a type of hormone into the bloodstream to regulate the body. The endocrine system is an information signal system like the nervous system. Hormones are substances (chemical mediators) released from endocrine tissue into the bloodstream that attach to target tissue and allow communication among cells. Hormones regulate many functions of an organism, including mood, growth and development, tissue function, and metabolism. The field of study that deals with disorders of endocrine glands is endocrinology, a branch of internal medicine.

The endocrine system is made up of a series of glands that produce chemicals called hormones. A number of glands that signal each other in sequence is usually referred to as an axis, for example, the hypothalamic-pituitary-adrenal axis. Typical endocrine glands are the pituitary, thyroid, and adrenal glands. Features of endocrine glands are, in general, their ductless nature, their vascularity, and usually the presence of intracellular vacuoles or granules storing their hormones. In contrast, exocrine glands, such as salivary glands, sweat glands, and glands within the gastrointestinal tract, tend to be much less vascular and have ducts or a hollow lumen.

 

This study primariyly focus on the physiology of the pancreas which includes the following:•Produces Insulin (Primarily) by β Islet cells which is responsible in the Intake of glucose, glycogenesis and glycolysis in liver and muscle from blood and intake of lipids and synthesis of triglycerides in adipocytes Other anabolic effects.• •Secretes Glucagon (Also Primarily) by α Islet cells which is responsible in glycogenolysis and gluconeogenesis in liver for the increase of blood glucose level• •Secretes Somatostatin δ Islet cells that Inhibit release of insulin[4] and of glucagon. It is responsible also for the suppression of the exocrine secretory action of pancreas.• •Secretes Pancreatic polypeptide by PP cells which Self regulate the pancreas secretion activities and effect the hepatic glycogen levels.

The integumentary system (From Latin integumentum, from integere 'to cover'; from in- + tegere 'to cover'[1]) is the organ system that protects the body from damage, comprising the skin and its appendages[2][3] (including hair, scales, feathers, and nails). The integumentary system has a variety of functions; it may serve

to waterproof, cushion, and protect the deeper tissues, excrete wastes, and regulate temperature, and is the attachment site for sensory receptors to detect pain, sensation, pressure, and temperature. In humans the integumentary system also provides vitamin D synthesis.

The integumentary system has multiple roles in homeostasis. All body systems work in an interconnected manner to maintain the internal conditions essential to the function of the body. The skin has an important job of protecting the body and acts as the body’s first line of defense against infection, temperature change,and other challenges to homeostasis.

Functions include:•Protect the body’s internal living tissues and organs•Protect against invasion by infectious organisms•Protect the body from dehydration•Protect the body against abrupt changes in temperature, maintain homeostasis•Help excrete waste materials through perspiration•Act as a receptor for touch, pressure, pain, heat, and cold (see Somatosensory system)•Protect the body against sunburns•Generate vitamin D through exposure to ultraviolet light•Store water, fat, glucose, and vitamin D

Predisposing Factor

Age (58 y/o)

Hereditary (both of her parents had diabetes)

Precipitating Factor

-Sedentary lifestyle (lack of excersise)

Diet (high fat, fond of eating sweet food)

Decreased production of insulin by pancreas

Decreased insulin secretion

Decreased utilization of glucose by cell

Blood viscosity

Slower blood circulationPolyuria

Increased risk for infection

Delayed wound healing

Staphylococcal Infection

Furuncle

Failure to wall off a furuncle

Invasion of neighboring tissue

Carbuncle

Decreased sensitivity of cell to insulin

Decreased peripheral glucose uptake (into cell)

HyperglycemiaOsmotic Diuresis

Cellular starvation

Polyphagia

Increase BP

Cellular DHN

Polydipsia

Increased risk for wound infection

PATHOPHYSIOLOGY (Diagram – Client based) 

Diabetic neuropathies

Nephropathy

Peripheral neuropathies

Foot and Leg Problems

Diabetes Furuncles complicate to carbuncle

Long-Term Complications

Macrovascular Complication

CADCerebro-vascular diseasePeripheral vascular disease

Microvascular Complication

·Decreased utilization of glucose by muscle, fat and liver

·Increased production of glucose by liver

Hyperglycemia

Blurred vision Polyuria

Lack of insulin

Dehydration

Polydipsia

Increased breakdown of fat

Increased fatty acids

Increased ketone bodiesAcetone breath

Poor appetite

NauseaAcidosisNausea

Vomiting

Abdominal painIncreasingly rapid respiration

Diabetic retinopathy

PATHOPHYSIOLOGY (Diagram – Book based) 

TOP 10 PRIORITY NURSING DIAGNOSIS 1. Acute pain related to an abscess of subcutaneous tissue

involving hair follicles.2. Ineffective tissue perfusion related to blood hyperviscosity.3. Impaired skin integrity related to presence of wound.4. Anxiety related to change in health status.5. Risk for fluid volume deficit related to polyuria.6. Risk for injury related to biochemical disturbance7. Self-care deficit (Bathing) related to decreased motivation8. Impaired dentition related to ineffective oral hygiene9. Deficient knowledge about diabetes self-care skills related

to inaccurate/ incomplete information presented10. Disturbed sleep pattern related to environmental factors.

Nursing Care Plan

Student’s Name: __________________ Area of Assignment: Special Area, MUMC Date: __________________________ 1.Nursing Diagnosis No__1_: _Acute pain related to subcutaneous tissue involving hair follicles.(PE format)

Cues/Evidences Outcome Criteria Nursing Intervention Rationale Evaluation

Subjective: “hasol pod kayo kung magsakit ning akong hubag sa tiyan kay makahunong ko sa akong gtrabaho”, as verbalized by the patient.

Objective:

> pain scale of 7/10,

10 is the highest

> manifest guarding

behavior especially

in her left upper

abdomen

> grimace

> autonomic

responses: PR: 106 bpm RR: 22cpm BP: 140/90 mmHg

diaphoresis

At the end of 2 hours

nursing intervention, the

patient will:

report pain is

relieved

verbalize method

that provide relief

demonstrate use of

relaxation skills

and diversional

activities as

indicated for

individual situation

Independent:

Perform comprehensive

assessment of pain to include

location, severity (0to10 or

faces scale), and precipitating

or aggravating factors.

Perform pain assessment each

time pain occurs.

Teach and encourage patient

relaxation techniques and

diversional activities like

DBE, TV/radio, socialization

with others

Dependent:

Administer centrally-acting

analgesic,Tramadol (Ultram)

50 mg cap 1 TID po as orders

by the physician.

Collaborative:

(optional depending on the

problem)

To assess

etiology/precipitating

contributory factors.

To evaluate patient’s

response to pain.

To assist patient to

explore methods for

alleviation/control of

pain. To maintain

acceptable level of pain.

After 2 hours nursing

intervention, the patient

had:

Reported decrease of

pain scale from 7 to

4/10, 10 is the

highest.- goal met

Verbalized methods

that provide pain

relief like listening to

radio.-goal met

Demonstrated DBE

to alleviate pain.-

partially met

Nursing Care Plan

Student’s Name: __________________ Area of Assignment: Special Area, MUMC Date: __________________________ 1.Nursing Diagnosis No__2_: _Ineffective tissue perfusion (Peripheral) related to blood hyperviscosity (PE format)

Cues/Evidences Outcome Criteria Nursing Intervention Rationale Evaluation

Subjective:

Objective:

SOB noted

Capillary refill

test >3sec. RR as of 8 am:

25cpm RR as of 12 nn:

26cpm Cold, clammy

skin noted

At the end of 8hrs

nursing intervention, the

patient will:

Verbalize

understanding of

condition to

therapeutic

regimen

Demonstrate

behavior/ lifestyle

changes to imorive

circulation (dietary

program, exercise)

Independent:

note presence of conditions

that can affect multiple

systems (DM)

investigate reports of pain out

of proportion to degree of

injury

assess lower extremities

noting skin texture, presence

of edema, and non-healing

wound.

Measure capillary refill

Encourage ambulation

Elevate legs

Dependent:

Collaborative:

(optional depending on the

problem)

To assess

contributing factor

Note degree of

impairment

To note degree of

involvement

To note degree of

impairment

Enhances venous

return

To maximize tissue

perfusion

After 8hrs nursing

intervention, the patient

had:

Verbalized

understanding of

condition to

therapeutic regimen-

partially met

Demonstrated

behavior/ lifestyle

changes to improve

circulation (dietary

program, exercise)-

partially met

Nursing Care Plan

Student’s Name: __________________ Area of Assignment: Special Area, MUMC Date: __________________________ 1.Nursing Diagnosis No__3_: __ Impaired skin integrity related to lesions and inflammatory response____________( (PE format)

Cues/Evidences Outcome Criteria Nursing Intervention Rationale Evaluation

Subjective:

Objective:

Presence of

carbuncle with

pus in left

upper abdomen

Disruption of

skin surface

(epidermis)

Disruption of

skin layer

(dermis)

At the end of 8hrs

nursing intervention, the

patient will:

Demonstrate

proper wound care

Identify ways to

prevent infection

Independent:

Identify underlying

condition/pathology involved

(diabetes mellitus)

Note odors emitted from the

skin/ area of injury.

Inspect skin in daily basis,

describing lesions and changes

observed.

Keep the area clean/dry,

carefully dress wounds

Teach and Encourage patient

to maintain proper hygiene

and wound care

Dependent:

Administer

antibiotic,Cefuroxime (Ceftin)

750 mg IVTT q80 ANST, as

ordered.

Collaborative:

(optional depending on the

problem)

To assess

causative/contributin

g factors

To assess extent of

injury

To determine impact

of condition

To assist body’s

natural process of

repair.

To prevent further

complication

To promote wound

healing and prevent

further infection.

After 8hrs nursing

intervention, the patient

had:

Demonstrated proper

wound care- goal met

Identify ways to

prevent infection –

goal met

Date Order (Medications) Rationale/Significance/ Nursing Responsibility

2/22/11 Cefuroxime 750 mg IVTT q80 ANST Used to treat skin and skin structure infections.

Tramadol 50 mg cap 1 TID po Relieves pain associated to painful carbuncle.

Humulin R 10 “U” SQ now Used as antidiabetic that lower blood glucose by stimulating glucose uptake in

skeletal muscle and fat, inhibiting hepatic glucose production.

Start Amikacin (Cinmik) 250 mg q80 IVTT ANST Used as anti-infective to treat bacterial infection commonly caused by S. aureus.

Metronidazole (Flagyl) 500 mg tab TID po Treatment of the following anaerobic infections: Intra-abdominal infections (may

be used with a cephalosporin)

Start PNSS 1L @30m gtts/min Used as route to IVTT medications.

TPR q40 To monitor pt’s v/s

Diabetic diet To manage diabetes mellitus

CXR PA view To view patient respiratory organs for possible lung consolidation

ECG 12 leads To monitor cardiac electrical activity

Please sched for debridement & drainage tomorrow pm To surgically intervene carbuncle

2/23/11 Humulin R 10 “U” SQ now Used as antidiabetics that lower blood glucose by stimulating glucose uptake in

skeletal muscle and fat, inhibiting hepatic glucose production.

Captopril 25 g 1 tab q80 po for

BP > 140/90 mmHg

Used to manage hypertension.

PNSS 1L @30m gtts/min Used as route to IVTT medications.

2/24/11 Humulin R 10 “U” SQ now Used as antidiabetics that lower blood glucose by stimulating glucose uptake in

skeletal muscle and fat, inhibiting hepatic glucose production.

PNSS 1L @30m gtts/min Used as route to IVTT medications.

DOCTOR’S ORDER

Generic NameBrand Name

Dosage

ClassificationPharmaco-dynamics

Pharmaco-kinetics

IndicationContra-

indication

Adverse Effects/ Side

EffectsNursing Responsibilities

Cefuroxime (Ceftin) 750 mg IVTT q80 ANST

Second-generation cephalosporin

Probenecid- decrease excretion and increases blood levels. If alcohol is ingested within 48-72 hours of cefotetan, a disulfram-like reaction may occur. Cefotetan- may increase effects of anticoagulants and icrease risk of bleeding with antiplatelet agents, thrombolytic agents, NSAIDs or valproic acid.Risk of bleeding with cefotetan may be increased with garlic, ginger, ginkgo.

Absorption: well-absorbed following oral administration. Distribution: widely distributed. Penetration to CSF is poor, but adequate for cefuroxime to treat meningitis. Crosses placenta and enter breast milk in lower concentration.Metabolism & excretion: excreted primarily unchanged by the kidneys.

Tx. of : Resp.

tract infection

Skin and skin structure infections

Bone and joint infection

UTI and gynecologic infections

Meningitis

Otitis media

Hyper-sensitivity to cephalosporinsSerious hypersensitivity to penicillins.

CNS: seizures (high doses)GI: pseudomembranous colitis, diarrhea, jaundice, n/v,cramps.Derm: rashes, urticariaHemat: bleeding, blood dyscrasias, hemolytic anemiaLocal: pain at IM site, phlebitis at IV site.Misc: allergic reactions including anaphylaxis and serum sickness, superinfection

Assess for infection (v/s, appearance of wound, sputum, urine and stool, WBC) at beginning and during therapy.

Before initiating a therapy, obtain hx to determine previous use of and reactions to penicillin or cephalosporin.

Obtain specimen for C&S before initiating therapy.

Observe pt. for s/sx of anaphylaxis (rash, pruritus, laryngeal edema, wheezing)

Assess for renal dysfunction and adjust dose accordingly.

DRUG STUDY

Generic NameBrand Name

Dosage

Classification

Pharmaco-dynamics

Pharmaco-kinetics

IndicationContra-

indication

Adverse Effects/ Side

EffectsNursing Responsibilities

Tramadol (Ultram) 50 mg cap 1 TID po

Analgesics (centrally-acting)

Increase risk of CNS depression when used concurrently with other CNS depressants including alcohol, antihistamines, sedatives, opioid analgesics, anesthetic or psychotropic agents.Increase risk of seizures with high doses of penicillin, cephalosporin, phenothiazines, or antidepressants.

Absorption: 75% absorbed after oral administration.Distribution: crosses placenta; enters breast milkMetabolism & excretion: mostly metabolized by the liver; one metabolite has analgesic activity; 30% is excreted unchanged in urine.

Moderate to moderately severe pain

Hypersensitivity.Cross-sensitivity with opioids may occur. Patients who are acutely intoxicated with alcohol, sedatives, centrally-acting analgesics, opioid analgesics or psychotropic agents.Patients who are physically dependent on opiod analgesics (may precipitate withdrawal).Not recommended for use during pregnancy and lactation.

CNS: seizures, dizziness, headache, somnolence, anxiety, CNS stimulation, confusion, euphoria, malaise, nervousness, sleep disorder, weakness.EENT: visual disturbancesCV: vasodilationGI: constipation, nausea, abd.pain, anorexia, diarrhea, dyspepsia, dry mouth, flatulence, vomiting.Derm: pruritus, sweatingNeuro: hypertoniaMisc: physical & psychological dependence, tolerance

Assess type, location, and intensity of pain before & 2-3hr(peak) after administration.

Assess BP and RR before and periodically during administration. Respiratory depression has not occurred with recommended doses.

Assess bowel function routinely. Prevention of constipation should be instituted with increase intake of fluids and bulk with laxatives to minimize constipation effect.

Monitor patient for seizures. May occur with recommended dose range.

Overdose may cause respiratory depression and seizures. Naloxone (Narcan) may reverse some but not all of the sx of overdose.

DRUG STUDY

Generic Name

Brand NameDosage

ClassificationPharmaco-dynamics

Pharma-cokinetics

IndicationContra-

indication

Adverse Effects/ Side

EffectsNursing Responsibilities

Regular insulin (Humulin R) 10 “U” SQ now

Antidiabetics, hormones

Glucose lowering effects may be decrease by corticosteroids, danazol, diazoxide, diuretics, sympathomimetic agents, estrogens, progestins.Blood glucose lowering effect and risk of hypoglycemia may be increase by oral antidiabetic agents, ACE inhibitors, MAO inhibitors, propoxyphene, sulfonamides. Beta blockers and reserpine may block some signs of and delay recovery from hypoglycemia.

Absorption: rapidly absorb from subcutaneous administration site.Distribution:Widely distributedMetabolism & excretion:Metabolized by liver, spleen, kidneys, and muscle.

Tx. of DM, can be used to treat DKA

HypoglycemiaAllergy or hypersensitivity to a particular type of insulin, preservatives or other additives.Use cautiously in: Stress Pregnancy

Infection

Derm: urticariaEndo: hypoglycemia, rebound hyperglycemia (Somogyi effect)Local: lipodystrophy, Itching, Rednes, SwellingMisc: allergic reactions including anaphylaxis

Assess patient for signs and symptoms of hypoglycemia (anxiety, restlessness, mood changes, tingling in excessive huger, headache, irritability, nausea, nervousness, rapid pulse, shakiness) and hyperglycemia (confusion, drowsiness, flushed dry skin, fruit-like breath odor, rapid deep breathing frequent urination, loss of appetite, unusual thirst)

Monitor body wt. periodically during therapy.

Overdose is manifested by hypoglycemia. Mild hypoglycemia nay be treated by ingestion of oral glucose. Severe hypoglycemia as a life-threatening emergency; tx consists of IV glucagon.

DRUG STUDY

Generic Name

Brand NameDosage

Classifica-tion

Pharmaco-dynamics

Pharmaco-kinetics

IndicationContra-

indication

Adverse Effects/ Side

EffectsNursing Responsibilities

Amikacin (Cinmik) 250 mg q80 IVTT ANST

AntiinfectivesAminoglyco-sides

Inactivated by penicillin and cephalosporin when co administered to patients with renal insufficiency. Possible respiratory paralysis after inhalation anesthetics or neuromuscular blocking agents. Increased incidence of ototoxicity with loop diuretics. Increased incidence f nephrotoxicity with other nephrotoxic agents.

Absorption: well-absorbed after IM administration. IV administration results in complete bioavailability. Some absorption follow administration by other routes.Distribution:Widely distributed throughout extracellular fluid; crosses placenta; small amt. enter in breast milk. Poor penetration into CSF.Metabolism & excretion: excretion is >90% renal

Tx of serious gramnegative bacillary infection and infections caused by staphylococci, when penicillin or other less toxic drugs are contraindicated.

Hypersensitivity. Most parenteral products contain bisulfites and should be avoided in patient with known intolerance. Products containing benzyl alcohol should be avoided in neonates. Cross-sensitivity among aminoglycosides may occur.

EENT: ototoxicity (cochlear and vestibular)GU: nephrotoxcityF&E: hypo- magnesemiaMS: muscle paralysis (high parenteral doses)Misc: hypersensitivity reactions.

Assess for infection (v/s, appearance of wound, sputum, urine and stool, WBC) at beginning and during therapy.

Obtain specimen for C&S before initiating therapy.

Evaluate CN VIII by audiometry before and throughout therapy.

Monitor I&O and daily wt. to assess hydration and renal function.

Assess pt for superinfection(ever, URTI, vaginal itchiness/ discharge, increasing malaise, diarrhea). Report to physician or other health care professional.

Monitor neurologic status. Before administering oral medication, assess pt’s ability to swallow.

DRUG STUDY

Generic NameBrand Name

Dosage

Classifica-tion

Pharmaco-dynamics

Pharmacokinetics IndicationContra-

indication

Adverse Effects/ Side

EffectsNursing Responsibilities

Metronidazole (Flagyl) 500 mg tab TID po

Anti-infectivesAntiprotozoalsAntiulcer agents

Cimetidine may decrease the metabolism of metronidazole. Phenobarbital and rifampin increases metabolism and may decrease effectiveness. Metronidazole increases the effects of pheytoin, lithium, and warfarin.Disulfiram-like reaction may occur with alcohol ingestion. May cause acute psychosis and confusion with disulfiram. Increased risk of leucopenia with fluorouracil or azarthioprine.

Absorption: 80% absorbed after oral administration. Minimal absorption after topical or vaginal application.Distribution: Widely into most tissues fluids, including CSF. Crosses the placenta and enters fetal circulation rapidly; enters breast milk in concentrations equal to plasma levels.Metabolism & Excretion: Partially metabolized by the liver (30-60%), partially excreted unchanged in the urine, 6-15% eliminated in the feces.

Tx of the following anaerobic infections: intra-abdominal infections (maybe used with a cephalosporin), Gynecologic infections, skin and skin structure infections, lower respiratory tract infections, bone and joint infections, CNS infections, septicemia, endocarditis

Hypersensitivity.Hypersensitivity to parabens (topical only). Patients receiving corticosteroids or predisposed to edema

CNS: seizures, dizziness, headacheEENT: tearing (topical only)GI: abdominal nausea, diarrhea, dry mouth, furry tongue, vomitingDerm: rashes, urticaria, mild dryness, skin irritation, transient rednessHemat: leucopeniaLocal: phlebitis at IV siteNeuro: peripheral neurpathy

Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.

Obtain specimen for C&S before initiating therapy. First dose may be given before receiving results.

Monitor neurologic status during and after IV infusions. Inform physician if numbness, paresthesia, weakness, ataxia, or seizure occur.

Monitor intake and output and daily weight, especially for patients on sodium restriction. Each 500mg of Flagyl IV for dilution contains 5 mEq of sodium; each 500mg of Flagyl RTU contains14 mEq of sodium.

DRUG STUDY

Generic NameBrand Name

DosageClassification Pharmacodynamics Pharmacokinetics Indication Contraindication Adverse Effects/

Side Effects Nursing Responsibilities

Captopril 25 g 1

tab q80 po for BP > 140/90 mmHg

Antihypertensives

Excessive hypotension may occur with concurrent use of diuretics, other antihypertensive, nitrates, phenothiazines, acute ingestion of alcohol and during surgery or general anesthesia. Hyperkalemia may result from concurrent use of potassium supplements, potassium-sparing diuretics, indomethacin, salt substitutes, or cyclosporine.

Absorption: At least 75% following oral administration (decreased to 30-55% by food)Distribution: All ACE inhibitors cross the placenta.Metabolism & Excretion: metabolized by the liver to inactive compounds, 50% excreted unchanged by the kidneys

Reduction of risk of death or development of CHF following MI. Slowed progression of left ventricular dysfunction into overt heart failure.

Decreased progression of diabetic nephropathy

HypersensitivityCross-sensitivity among ACE inhibitors may occur

CNS: dizziness, fatigue, headache, insomnia, weaknessResp: cough, eosinophilic, pneumonitisCV: hypotension, angina pectoris, tachycardiaGI: taste disturbances, anorexia, diarrhea, hepatoxicity (rare), nauseaGU: proteinuria, impotence, renal failureDerm: rashesHemat: agranulocytosis, neutropenia

Monitor blood pressure and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes

Monitor frequency of prescription refills to determine adherence

Assess urine protein prior to and periodically during therapy for up to 1 year in patients with renal impairment or those receiving > 150 mg/day of captopril. If excessive or increase proteinuria occurs, re-evaluate ACE inhibitor therapy.

Monitor weight and assess patient routinely for resolution of fluid overflow

DRUG STUDY