I.

INTRODUCTION

A. Brief Description

Stevens - Johnson syndrome (SJS), also called erythema multiforme major is a lifethreatening condition affecting the skin in which cell death causes the epidermis to separate
from the dermis. SJS is a skin and mucous membrane disease characterized by an eruption of
macules, papules, nodules, vesicles, and/or bullae with characteristic "bull's-eye" lesions usually
occurring on the dorsal aspect of the hands and forearms. The syndrome is thought to be a
hypersensitivity complex affecting the skin and the mucous membranes that can also affect the
eyes. Although the majority of cases are idiopathic, the main class of known causes is
medications, followed by infections and (rarely) cancers.
Stevens-Johnson syndrome is a limited form of toxic epidermal necrolysis by destruction
and detachment of the skin epithelium and mucous membranes involving less than 10% of the
body surface area. SJS can be triggered by a drug allergy, more rarely, by infections or bone
marrow transplantation. In 25 to 30% of cases, the cause is unclear. Patients should be
admitted to an intensive care or burns unit as soon as the diagnosis is suspected.
Reepithelialization is rapid (2-3 weeks).
SJS may have full-thickness epidermal necrosis, but with lesser detachment of the
cutaneous surface; and mucous membrane involvement. Maculopapular exanthema and
hypersensitive skin syndrome are other spectrum of cutaneous drug reactions. Maculopapular
exanthema is characterized by cutaneous fine pink macules and papules, lesions which usually
fade within 12 weeks following cessation of drug treatment.

It is a fatal allergic reaction to drugs and microorganisms. SJS can be caused by infections,
usually following viral infections such as herpes simplex virus, influenza, mumps, cat-scratch
fever, histoplasmosis, Epstein-Barr virus
Drugs precipitate over 50% of SJS cases and up to 95% of TEN cases. Sulfa drugs
(eg,

co-trimoxazole, sulfasalazine ),

(eg, phenytoin , carbamazepine ,phenobarbital , valproate ),

antiepileptics
antibiotics

(eg,

aminopenicillins, quinolones, cephalosporins), and miscellaneous individual drugs

(eg, piroxicam , allopurinol , chlormezanone) are most often implicated. Cases that
are not due to drugs are attributed to infection (mostly with Mycoplasma
pneumoniae), vaccination, and graft-vs-host disease. Rarely, a cause cannot be
identified.
Signs:
A. Distinctive Target or Iris skin lesion
1. Starts as erythematous Macule that becomes raised
2. Distribution: Symmetrical involvement
a. Onset on distal extremities (often dorsal hands)
b. Progress proximally (often extensor surfaces)
c. Oral Mucosal involvement may be present
3. Develops concentrically into target lesion by day 2
a. Center: Dusky erythema or Vesicle
b. Middle: Pale edematous ring
c. Outer: Dark band of erythema
4. Progresses
a. Central necrosis
b. Some lesions may coalesce into annular Plaques
5. Healing
a. Scarring
b. Postinflammatory Hyperpigmentation
B. Alternative presentations
1. Non-transient Urticarial Plaques

2. Vesicles or bullae form in prior Macule or wheal

Symptoms:
A. Rash develops after prodrome
B. Mild prodrome for 7-10 days may be present
1. Malaise
2. Fever
3. Headache
4. Rhinorrhea
5. Cough

B. Statistics
International / Local
Stevens-Johnson Syndrome is listed as a "rare disease" by the Office of Rare Diseases
(ORD) of the National Institutes of Health (NIH). This means that Stevens-Johnson Syndrome,
or a subtype of Stevens-Johnson Syndrome, affects less than 200,000 people in the US
population.
SJS is a rare condition, with a reported incidence of around 2.6 per million people per
year. In the United States, there are about 300 new diagnoses per year.

II.

OBJECTIVES

A. General Objectives
At the end of the clinical exposure, I should be able to attain and enhance my
knowledge, skills and attitude to provide nursing care to our patient with Stevens - Johnson
syndrome.
B. Specific Objectives
During the exposure, I should be able to:
Cognitive:
Discover how the patient acquired the disease through the nursing health history,
physical examinations, and some other some other factors that may contribute in relation
to Stevens - Johnson syndrome and be able to assess, organize and validate those data
efficiently.
Understand Steven Johnson Syndrome, its causes and pathophysiology.
Design a plan of care for patient with Stevens - Johnson syndrome (SJS).
To be able to formulate those data into nursing diagnoses that may aid in the patients
current health condition.
To be able to set priorities and goal outcomes in collaboration with the patient.
Skills:
Conduct physical assessment and organize data efficiently.
Perform nursing procedures effectively and correctly to attain his optimum level of
wellness.
Attitude:
To be able to establish rapport with the patient and folks.
To be able to develop respect and trust.

III.

ANATOMY AND PHYSIOLOGY OF THE DISEASE

THE SKIN

The skin is the largest organ in the human body. For the average adult human, the skin
has a surface area of between 1.5-2.0 square meters (16.1-21.5 sq ft.), most of it is between 2
3 mm (0.10 inch) thick. The average square inch (6.5 cm) of skin holds 650 sweat glands, 20
blood vessels, 60,000 melanocytes, and more than a thousand nerve endings.
The skin is the outer covering of the body. In humans, it is the largest organ of the
integumentary system made up of multiple layers of mesodermal tissue, and guards the
underlying muscles, bones, ligaments and internal organs. Skin of a different nature exists
in amphibians, reptiles, birds. Human skin is not unlike that of most other mammals except that
it is not protected by a pelt and appears hairless though in fact nearly all human skin is covered
with hair follicles. The adjective cutaneous literally means "of the skin" (from Latin cutis, skin).
Because it interfaces with the environment, skin plays a key role in protecting (the body)
against pathogens

and

excessive

water

loss.

Its

other

functions

are

insulation, temperature regulation, sensation, synthesis of vitamin D, and the protection

of vitamin B folates. Severely damaged skin will try to heal by forming scar tissue. This is often
discolored and depigmented.
In humans, skin pigmentation varies among populations, and skin type can range
fromdry to oily. Such skin variety provides a rich and diverse habit for bacteria which number
roughly a 1000 species from 19 phyla.
Skin has mesodermal cells, pigmentation, or melanin, provided by melanocytes, which
absorb some of the potentially dangerous ultraviolet radiation (UV) in sunlight. It also
contains DNA-repair enzymes that help reverse UV damage, and people who lack the genes for
these enzymes suffer high rates of skin cancer. One form predominantly produced by UV
light, malignant melanoma, is particularly invasive, causing it to spread quickly, and can often be
deadly. Human skin pigmentation varies among populations in a striking manner. This has led to
the classification of people(s) on the basis of skin color.

Skin layers

Skin is composed of three primary layers:

the epidermis, which provides waterproofing and serves as a barrier to infection;

the dermis, which serves as a location for the appendages of skin; and

the hypodermis (subcutaneous adipose layer).

1. Epidermis
Epidermis, "epi" coming from the Greek meaning "over" or "upon", is the outermost
layer of the skin. It forms the waterproof, protective wrap over the body's surface and is made
up of stratified squamous epithelium with an underlying basal lamina.
The epidermis contains no blood vessels, and cells in the deepest layers are nourished
by diffusion from blood capillaries extending to the upper layers of the dermis. The main type of
cells which make up the epidermis are Merkel cells, keratinocytes, with melanocytes and
Langerhans

cells also

present.

The

epidermis

can

be

further

subdivided

into

the

following strata (beginning with the outermost layer): corneum, lucidum (only in palms of hands
and bottoms of feet), granulosum, spinosum, basale. Cells are formed through mitosis at the
basale layer. The daughter cells move up the strata changing shape and composition as they
die due to isolation from their blood source. The cytoplasm is released and the protein keratin is
inserted. They eventually reach the corneum and slough off (desquamation). This process is
called keratinization and takes place within about 27 days. This keratinized layer of skin is
responsible for keeping water in the body and keeping other harmful chemicals
and pathogens out, making skin a natural barrier to infection.
Components
The epidermis contains no blood vessels, and is nourished by diffusion from the dermis.
The

main

type

of

cells

which

make

up

the

epidermis

are keratinocytes, melanocytes, Langerhans cells and Merkels cells. The epidermis helps the
skin to regulate body temperature.
Sublayers
Epidermis is divided into the following 5 sublayers or strata:

Stratum corneum

Stratum lucidum

Stratum granulosum

Stratum spinosum

Stratum germinativum (also called "stratum basale")

2. Dermis
The dermis is the layer of skin beneath the epidermis that consists of connective tissue and
cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a
basement membrane. It also harbors many Mechanoreceptor/nerve endings that provide the
sense of touch and heat. It contains the hair follicles, sweat glands, sebaceous glands, apocrine

glands,lymphatic vessels and blood vessels. The blood vessels in the dermis provide
nourishment and waste removal from its own cells as well as from the Stratum basale of the
epidermis.
The dermis is structurally divided into two areas: a superficial area adjacent to the
epidermis, called the papillary region, and a deep thicker area known as the reticular region.

Papillary region

The papillary region is composed of loose areolar connective tissue. It is named for its
fingerlike projections called papillae that extend toward the epidermis. The papillae provide the
dermis with a "bumpy" surface that interdigitates with the epidermis, strengthening the
connection between the two layers of skin.
In the palms, fingers, soles, and toes, the influence of the papillae projecting into the
epidermis forms contours in the skin's surface. These are called friction ridges, because they
help the hand or foot to grasp by increasing friction. Friction ridges occur in patterns that are
genetically and epigenetically determined and are therefore unique to the individual, making it
possible to use fingerprints or footprints as a means of identification.

Reticular region

The reticular region lies deep in the papillary region and is usually much thicker. It is
composed of dense irregular connective tissue, and receives its name from the dense
concentration

of collagenous, elastic,

and reticular fibers

that

weave

throughout

it.

These protein fibers give the dermis its properties of strength, extensibility, and elasticity.
Also located within the reticular region are the roots of the hair, sebaceous glands, sweat
glands, receptors, nails, and blood vessels.
Tattoo ink is held in the dermis. Stretch marks from pregnancy are also located in the dermis.

3. Hypodermis

The hypodermis is not part of the skin, and lies below the dermis. Its purpose is to attach the
skin to underlying bone and muscle as well as supplying it with blood vessels and nerves. It
consists

of

loose

connective

tissue

and

elastin.

The

main

cell

types

are fibroblasts, macrophagesand adipocytes (the hypodermis contains 50% of body fat). Fat
serves as padding and insulation for the body.
Microorganisms like Staphylococcus epidermidis colonize the skin surface. The density of
skin flora depends on region of the skin. The disinfected skin surface gets recolonized from
bacteria residing in the deeper areas of the hair follicle, gut and urogenital openings.

Skin performs the following functions:

1. Protection - an anatomical barrier from pathogens and damage between the internal
and external environment in bodily defense; Langerhans cells in the skin are part of
the adaptive immune system.
2. Sensation - contains a variety of nerve endings that react to heat and cold, touch,
pressure, vibration, and tissue injury.
3. Heat regulation - the skin contains a blood supply far greater than its requirements
which allows precise control of energy loss by radiation, convection and conduction.
Dilated blood vessels increase perfusion and heatloss, while constricted vessels greatly
reduce cutaneous blood flow and conserve heat.

4. Control of evaporation - the skin provides a relatively dry and semi-impermeable

barrier to fluid loss. Loss of this function contributes to the massive fluid loss in burns.
5. Aesthetics and communication - others see our skin and can assess our mood,
physical state and attractiveness.
6. Storage and synthesis: acts as a storage center for lipids and water, as well as a means
of synthesis of vitamin D by action of UV on certain parts of the skin.
7. Excretion - sweat contains urea, however its concentration is 1/130th that of urine,
hence excretion by sweating is at most a secondary function to temperature regulation.
8. Absorption - Oxygen, nitrogen and carbon dioxide can diffuse into the epidermis in
small amounts, some animals using their skin for their sole respiration organ (contrary to
popular belief, however, humans do not absorb oxygen through the skin). In addition,
medicine can be administered through the skin, by ointments or by means of
adhesive patch, such as the nicotine patch or iontophoresis. The skin is an important
site of transport in many other organisms.
9. Water resistance - The skin acts as a water resistant barrier so essential nutrients aren't
washed out of the body.

IV.

VITAL INFORMATION
Name (initials): R.A
Age: 65 years old
Sex: Female
Address: Panay, Capiz
Civil Status: Married
Religion: Roman Catholic
Occupation: -------Date and Time admitted: November 11, 2009 at 3:50 pm

Ward: Intensive Care Unit (ICU) Cubicle F

Chief Complaint: Unresponsiveness
Admitting Diagnosis: T/C Anaphylactic Shock, T/C Stevens - Johnson syndrome,
S/P CVA, T/C Restroke
Attending Physician/s: Dr. J.B

V.

CLINICAL ASSESSMENT
A. Nursing History
2 days prior to admission, Mrs R.A was noted to have appearance of maculopapular

rashes on the trunk progressing to whole body, and was noted to have oral sores. She is
febrile and Mrs. R.A was noted to be unresponsive.
B. Past Health Problem / Status
Past Illnesses: Mr. R.A is a 65 year old Female positive from Cerebrovascular disease,
Renal disease, Hypertension, and Cardiovascular disease diagnosed last October 2009 and
she is having her maintenance.
C. Family History of Illness
Both of her parents have hypertension, diabetes mellitus type -2 and a history of,
Cardiovascular disease. Some of her siblings have it too.

FAMILY GENOGRAM

DM -2,
HPN

M.A

P.A

83

92

R.A

M.A

G.A

L.A

65

63

60

59

T/C Anaphylactic
Shock, T/C Stevens Johnson syndrome,
S/P CVA, T/C Restroke

DM -2,
HPN

Dm -2,
HPN, CVA

N.A
56

A.A

F.L

B.A

53

50

41

HPN

LEUKEMIA

P.A
69

N.A

F.A

C.Z

J.L

R..L

H.B

J.L

41

39

37

32

29

26

24

HPN

MOTOR RIDE
ACCIDENT

Legend:
Deceased male
Deceased female
Indicates patient

Living male
Living female

VI.

BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND

A. Educational Background
Mr. R.A is an elementary graduate.
B. Occupational Background
She is being supported by her children.
C. Religious Background
She is a Roman Catholic and attends mass on Sundays and prays the rosary at
night together with her family.
D. Economic Status
They belong to a middle class type of family and most of her children have works
already.

VII.

CLINICAL INSPECTION
A. Vital Signs

Temperature
Pulse Rate
Respiration
Blood

Upon Admission
39C
96 bpm
18 bpm

Pressure
Cardiac Rate

60 / 90mmHg
100 bpm

B. Height, Weight, BMI no data

C. Physical Assessment

During Care
36.3C
58 - 112 bpm
16 - 24 bpm
60/80 - 170/100 mmHg
60 - 115 bpm

General
Mrs. R.A is unresponsive and restless. (+)
erythematous,

(+)

maculopapular

rashes.

Skin, Hair, Nails

Dry and scaly skin, uniform in color, (+) hematoma
in right arm. Hair is black with visible white hair, no
lice and dandruff and dry scalp. Fingernails are
dirty and untrimmed.

Head, Face, Lymphatics

No head injuries, round in shape and oily face.

HEENT
Color of the eyes is dark brown, anicteric sclera
with pale conjunctiva. His right & left ear canal are
not

clean,

(-)

discharges,

brown

in

color,

symmetrical in shape. Hearing is good with no pain

and infections. Have frequent colds. No discharges
or secretions and nosebleeds. Lips are dry and
choppy, (+) oral sores. NGT and O2 at 3L/min via
Nasal Cannula noted.
Neck and Upper extremities
No lumps or swollen glands. Arms are not able to
move freely. GCS of 5 11.

Chest, Breast and Axilla

Normal respiration upon admission with RR of 18
bpm and abnormal during care 16- 24 bpm.

Respiratory System (Chest and Lungs)

Thorax is symmetric. RR is above normal. (+)
dyspnea, (+) slightly tachycardic .CXR results:
Dextroscoliosis,

Thoracic

spine, Atheromatous

aorta

Cardiovascular System
Blood pressure upon admission is 60 / 80, during
my care is 60 / 90 170 / 100. (+) dyspnea, (+)
slightly tachycardic, Cardiac rate is above normal
with AR of 70 115 bpm and respiration of 16 - 24
bpm.

Gastrointestinal System
Feeding is through NGT with Diben at 250 cc every
4 hours.

Genito Urinary System

Foley catheter noted. Sometimes her urine output
is low but sometimes its normal. 700 1500 cc /
shift.

Musculoskeletal System
(+) weakness, (+) limitation of motion or activity, (+)
grossly, (+) maculopapular rashes, Legs are not
able to move freely. GCS of 5 11 (+)
erythematous.

D. General Appraisal
Speech: Mrs. R.A is unresponsive.
Language: Mrs. R.A is unresponsive, she cannot respond to any verbal command.
Hearing: Mrs. R.As hearing is quite good but she cannot response.
Mental Status: Mrs. R.A is not coherent, she cannot communicate.

Emotional status: Mrs. R.A sometimes cries.

VIII.

LABORATORY AND DIAGNOSTIC DATA

A. Hematology
Hematology or hematology is the branch of biology (physiology), pathology, clinical

laboratory, internal medicine, and pediatrics that is concerned with the study of blood, the blood
of forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis,
treatment, prognosis, and prevention of blood diseases.
Test

Result

Normal

Significance

Values
Date: 11/12/09
WBC count
RBC count

15.6x10^9/L
4.90x10^12/L

4.5-11.0
4.2-5.4

Infection
The result is Within Normal

Hemoglobin

140g/L

120-160

Range.
The result is Within Normal

Hematocrit

0.40 vol.fr

0.37-0.47

Range.
The result is Within Normal

Bands
Segmenters
Eosinophils
Basophils

0.01
0.98 %
4
0.0%

Range.
50 65%
0-3
0-1

Lymphocytes

0.01%

20-45

Monocytes

5%

0-8

Allergic reactions
The result is Within Normal
Range.
It signifies severe
debilitating illnesses.
The result is Within Normal
Limits.

B. Blood Chemistry
The serum chemistry profile is one of the most important initial tests that are commonly
performed on sick or aging patient. A blood sample is collected from the patient. The blood is then
separated into a cell layer and serum layer by spinning the sample at high speeds in a machine
called centrifuge. The serum layer is drawn off and a variety of compounds are then measured.
These measurements aid the veterinarian in assessing the function of various organs and body
systems.
Test
Date: 11/12 /09

Result

Normal Values

Significance

Glucose

11.52

4.10 5.90

Hyperglycemia

Sodium

mmol/L
125.3

137.0 145.0

Renal insufficiency,

Creatinine

mmol/L
210.9

71.0 133.0

uremia
Impaired renal function,

Cholesterol

ummol/L
2.44

Direct HDLC
LDL

mmol/L
.58 mmol/L
1.20

0.00 5.20

shock
The result is Within Normal

1.00 1.60
1.71 4.60

Range.
Indicates risks in CAD
The result is Within Normal

VLDL

mmol/L
1.65

0.00 1.03

Range.
Elevation indicates

Potassium

mmol/L
4.72

3.5 5.10

Triglycerides

ummol/L
1.42 mmol /

Urea

L
26.66

increase risk in CAD

The result is Within Normal

0.00 1.69

Range.
The result is Within Normal

2.50 6.10

Range.
Impaired renal function

mmol /L

C. ABG Analysis
It is also called arterial blood gas (ABG) analysis, is a test which measures the amounts
of oxygen and carbon dioxide in the blood, as well as the acidity (pH) of the blood. It indicates
how well the lungs and kidneys are interacting to maintain normal blood pH (acid-base balance).
It evaluates how effectively the lungs are delivering oxygen to the blood and how efficiently they
are eliminating carbon dioxide from it.
Test
Date: 11/11/09
pH

Result

Normal Values

Significance

7.39

7.35 7.45

The result is Within Normal

Limits.

pO2
HCO3
PaCO2

296.1 mmHg
19.2 mmol/L
32.2 mmol/L

80 100 mmHg
22 26 mmol/L
35 - 45mmol/L

Acidosis
Alkalosis

ABE
SBE
SBC
O2 saturation

-4.2 mmol/L
-48 mmol/L
21 mmol/L
99.8%

TCO2

45.2 mmol/L

-2 - +2

97 100%

The result is Within Normal

Limits.

D. Urinalysis

A urinalysis is a test performed on a patient's urine sample to diagnose

conditions and diseases such as urinary tract infection, kidney infection, kidney stones,
inflammation of the kidneys, or screen for progression of conditions such as diabetes
and high blood pressure.
Test
Date: 11/11/09
(Macroscopic)
Color
Transparency

Result

Normal Range

Dark Straw

Straw, Amber,

Cloudy

Transparent
Clear

Significance

Abnormal
indicates

pH

5.0

4.5 8.0

results.
infection

It
like

pyuria or bacteuria
The result is Within Normal
Limits.

Specific Gravity

1.030

1.010- 1.030

The result is Within Normal

Glucose

Negative

Negative

Limits.
The result is Within Normal
Limits.

(Microscopic)
Amorph. U/P
RBC/hpf
WBC/hpf
Epith. Cells
Mucus thread

many
0-1
02
many
moderate

Infection

Infection
Infection

E. HbAIc Determination
The use of hemoglobin A1c (HbAIc) is for monitoring the degree of control of glucose
metabolism in diabetic patients.
Test
Date: 11/12/09
HbAIc
F. CXR AP(Mobile)

Result

Normal Values

-7.9 %

-4.2 6.2%

Significance

DM

Test
Date: 11/12/09
CXR (anterior)

Findings

Impression

The lung fields are clear,

Dextroscoliosis,

The cardiac shadow is not enlarged,

Curvilinear calcific opacity is noted in

Thoracic spine
Atheromatous aorta

the aortic arch,

There is a lateral curvature of the
thoracic spine with convexity to the
Right,
The CP angles, diaphragm, and soft
tissue structures are unremarkable.
G. Troponin I Determination
Test
Date: 11/11/09
Trop. I

Result
< 0.01 ug/L

Hypersensitivity - caused by many drugs, viral infections, and malignancies.

IX.

PATHOPHYSIOLOGY

Formation of reactive metabolites that bind to and alter cell proteins.

Precipitating factors:
Predisposing Factors:
Age: 65 y.o

Lifestyle: Smoking, Eating

fatty foods.

Family History:
Certain disease:
hypertension, diabetes
Cardiovascular disease
mellitus typea-2,
Triggering
T-cellmediated cytotoxic reaction to drug antigens in keratinocytes.
diagnosed last October 2009,
Cardiovascular disease
Hypertension, Renal
disease, Cerebrovascular

Immune complexes formed by auto antibodies and autoantigens combining.

Inflammatory response in tissues.

STEVENS-JOHNSON SYNDROME

X.

MEDICAL MANAGEMENT
A. Drug Study

XI.
XII.

Name
of the

XIII.
XIV.

XV.
Ge

XVI.

XVII.

XIX.

Ac

XVIII. Mech

XX.

XXI.
Indi

XXII.

XXIII.
Side

Drug

neri

tio

anism

cati

Effec

with

of

ons

ts

Dosag

Na

e
XXVII.

XXVIII.

Hi
za

XXIX.
XXX. 30mg

me
XXXI.

XXIV. Contraind

XXVI. Nursing

ications

Responsibilities

Actio
n
XXXIV.

XXXIX.

XXXV. An

sop

tis

c acid

roz

ecr

ole

eto

pump

ry

inhibit

XXXIII.

dru

tab

g
XXXVI.
XXXVII.

XL.

XLI.

XXXII. Lan

,1
BID

XXV.

Gastri

or.
Suppr
esses
gastric

Proton

acid

pu

secreti

mp

on by

inh

specifi

ibit

or

inhibiti

XLII.

Sho
rt
ter
m
trea
tme
nt
(up
to 8
wee
ks)
of
gas
tric
ulce
r.

XLIII. Hea
ling

XLVIII.

LX.

XLIX. Dizzi

LXI.

ness
L.
LI.

LXIII. 1. Administer before

cated with

meals.
LXIV.

Head

itivity to

LXV.

ache

lansoproz

swallow the capsule

ole or any

whole, not

Naus

of its

chew,open or crush.

ea

compartm

LXVI.

ents.

LXVII. 3. For NGT, place

LIV.
LV.

Contraindi
hypersens

LII.
LIII.

LXII.

Vomit

15 or 30 mg tablet

ing

and draw 4 10 ml

LVI.
LVII.
LVIII.

2. Let the patient

of water, shake
Diarr

gently for quick

hea

dispersal.
LXVIII.

XXXVIII.

on of
the
hydrog
en
potass
ium
ATPas
e
enzym
e
syste
m at
the
secret
ory
surfac
e of
the
gastric
parieta
l cells;
blocks
the
final

of
NS
AID
rela
ted
gas
tric
ulce
r.
XLIV. Mai
nte
nan
ce
ther
apy
for
hea
ling
of
ero
sive
eso
pha
gitis
,
duo
den
al
ulce

LIX.

LXIX. 4. Report severe

headache,
worsening of
symptoms, fever,
and chills.
LXX.
LXXI. 5. Arrange to have a
regular medical
follow up care
while taking this
drug.

step of
acid
produc
tion.

rs.
XLV.
XLVI.
XLVII.

LXXII.

LXXVII.

LXXIII. Ecost

LXXVIII.

LXXIX.

LXXXIII.

LXXX. An

LXXXIV.

LXXXV.
Inh

LXXXVI.

XCI.
A

XCII.

XCIX.
Naus
ea

C.

CI.
Contraindi

CII.

imv

tih

ibits

dju

LXXIV.

ast

yp

HMG-

nct

XCIII.

allergy to

CIII.

LXXV. 20 mg,

atin

erli

CoA

to

XCIV. Head

simvastati

CIV.

1 tab

pid

reduct

diet

LXXVI. BID

em

ase,

in

ic

the

the

LXXXI.

enzym

trea

e and

CV.

LXXXII.

e that

tme

joint

CVI.

HMG-CoA

cataly

nt

aches

changes in vision,

red

zes

of

and

unusual bleeding or

uct

the

elev

pains

bruising, dark urine

as

first

ate

XCVII.

or light-colored

step in

XCVIII. Sensi

stool, fever, muscle

inh

the

tota

tivity

ibit

choles

to

CVII.

or

terol

chol

lights.

CVIII.

synthe

est

ache

cated with

1. Take drug in the

evening.
2. Explain to patient

n, fungal

not to drink

XCV.

byproduct

grapefruit juice while

XCVI. Muscl

s.

using this drug.

3. Report GI upset,

pain or soreness.

CIX.

sis

erol

CX.

pathw

and

CXI.

ay,

LDL

CXII.

resulti

chol

CXIII.

ng in a

est

CXIV.

decrea

erol

CXV.

se in

with

CXVI.

serum

pri

choles

mar

terol,

serum

hyp

LDLs,

erc

and

hols

either

tero

an

lemi

increa

a.

se or

LXXXVII.

no

LXXXVIII. T

chang

e in

red

serum

uce

HDLs.

the
risk
of

CV
A.
LXXXIX.
XC.

Tre
atm
ent
for
pati
ent
with
isol
ate
d
trig
ylce
ride

CXVII.

CXXI.

CXXIII.

CXXIX.

s.
CXXXI.

CXXX. Enters

CXXXII.

CXLVI.

CXLVIII.

CXLI. Weig

CXLVII.

CXVIII. Apo

CXXII. Pre

CXXIV.Co

Predni

dni

rtic

target

hort

ht

indicated

sone

son

ost

cells

tem

loss

with

CL.

ero

and

ma

CXLII.

infections

CLI.

id

binds

nag

CXLIII. Muscl

especially

day before 9 am

CXXV.

to

em

TB, fungal

mimic normal peak

CXXVI.

intrace

ent

weak

infections,

corticosteroid blood

CXIX.
CXX. 1 tab,
BID

CXL.

Contra

CXLIX. 1. Take drug with

meals.
2. Administer once a

Glucocorti

llular

of

coi

cortico

vari

CXLIV.

, vaccinia

CLII.

steroid

ous

CXLV. Fever

and

CLIII. 3. Increase dosage

CXXVII.

recept

infla

varicella

when patient is

ors,

mm

and

subject to stress.

CXXVIII.

initiati

ator

antibiotic

CLIV.

Hormone

ng

resistant

CLV.

many

and

infections,

signs and side

compl

alle

lactation.

effects.

ex

rgic

reactio

diso

ns that

rder

are

s.

respon

CXXXIII.

sible

CXXXIV.

for its

ller

anti-

gic

inflam

rea

matory

ctio

and

ns.

immun

CXXXV.

osuppr

CXXXVI.

essive

CXXXVII.

effects

CXXXVIII.

ness

amebiasis

levels.

4. Report unusual

.
CLVI.
CLVII. Neuro

CLX.

CLXII.

CLXI.

CLXIII. Nu

cetam

CLXVI.
ero

CLVIII.

ton

CLIX. 1 tab,

ics

TID

CXXXIX.
CLXXI.

CLXVII.

ncre
ase
s

CLXXII.

CLXXXII.

CXCIII.

CLXXXIII. Di

CXCIV.Contraindi

zzine

cated with

meals. (Before

ss

hypersens

meals)

VA
CLXXIII.
CLXXIV.

CXCIX.
CC.

CLXXXIV.

itivity to

CCI.

CLXXXV. Di

drug and

CCII.

1. Take drug with

CLXIV.

bloo

equ

CLXV. No

ela

arrhe

history of

report for any

otr

flow

e of

renal

allergy reaction that

opi

and

Stro

CLXXXVI.

disease.

may occur.

cs

O2

ke

CLXXXVII. N

con
sum
ptio
n in
the
brai
n. It
is

CLXXV.
CLXXVI.

ause
C

lved
in
the

ne

CLXXXVIII.

ce <20

nic

CLXXXIX.

mL/min

Vert

CXC. Vomit

).

igo
CLXXVII.

ing
CXCI.
CXCII. Head

CLXXVIII.

CLXXIX.

bios

CLXXX.

ynth

CLXXXI.

ache

CCIII.
CCIV. 3. Take drug with a
glass of water.

clearan

hro

also
invo

CXCV. (creatini

CXCVI.
CXCVII.
CXCVIII.

2. Observe and

CCV.
CCVI.
CCVII.
CCVIII.

esis
of
lecit
hin.

CLXVIII.
CLXIX.
CCIX.

CCXIV.

CCXVI.

CCX. Aspile

CCXV. As

t Ec

piri

CCXI.

CCXXV.

CCXXIX.

CCXXIV. Or

CCXXVI. S

CCXXX.

CCXXXVII.
H

CCXXXIX.
CCXL. 1. Observe and

CCXVII.

al

tok

eada

CCXXXVIII.

report if the patient

Anticoagul

antico

che

Contraindicated

experiences allergy

CCXII. 80 mg,
1 tab

CLXX.
CCXXIII.

ant
CCXVIII.

CCXIII.OD

agulan

CCXXVII.

CCXXXI.

with

reaction.

CCXXVIII. T

CCXXXII. N

asthma,

CCXLI.
CCXLII.

interfe

ran

ause

rhinitis,

CCXIX.

re with

scie

history of

Antiplatele

the

nt

CCXXXIII.

active

CCXLIII.

hepati

isch

CCXXXIV. V

peptic

CCXLIV.

CCXX.

emi

omitin

ulcer

whole, do not chew,

CCXXI.

synthe

disease

crush or bite the tab.

Fibrinolyti

sis of

atta

CCXXXV.

and

the

ck.

CCXXXVI. F

hypersens

c
CCXXII.

vitami
nK
depen
ds

ever

itivity to
aspilet.

2. Give the drug

with meals.
3. Swallow

clottin
g
factor
resulti
ng in
their
eventu
al
depleti
on and
prolon
gation
of
clottin
CCXLV.
CCXLVI.

Ple

ndil

CCL.

CCLII.

g time.
CCLVII.

CCLIX.

CCLXI.

CCLI. Fel

CCLIII. Ca

CCLVIII.

CCLX. Ess

CCLXII.

Inh

CCLXIX.
N

CCLXX.

CCLXXI.
Contra

CCLXXII. 1. Take this drug

odi

lci

ibits

enti

ause

indicated

with meals. If upset

pin

um

the

al

with

stomach occurs;

ch

move

hyp

CCLXIII.

allergy to

swallow tablet

mg, 1

an

ment

erte

CCLXIV.

felodipine

whole, do not cut,

tab

nel

of

nsio

eada

or other

crush, or chew.

calciu

n,

che

calcium

CCLXXIII.

blo

m ions

alo

CCLXV.

channel-

CCLXXIV. 2. Do not drink

ck

across

ne

CCLXVI.

CCXLVII.
CCXLVIII. 10

CCXLIX. OD

blockers,

grapefruitwhile

er

the

or

omitin

sick sinus

CCLIV.

memb

in

syndrome,

CCLXXV.

CCLV. An

ranes

co

CCLXVII.

heart

CCLXXVI. 3. Report for

tih

of

mbi

CCLXVIII.

block

irregular heart beat,

yp

cardia

nati

(second

shortness of breath,

ert

c and

on

degree)

swelling of the

en

vascul

with

hands or feet,

siv

ar

oth

pronounced

smoot

er

dizziness,

anti

constipation.

muscl

hyp

erte

cells;

nsiv

greter

es.

CCLVI.

selecti
vely
for
vascul
ar
smoot
h
muscl
e as
compa

using this drug.

red to
cardia
c
muscl
e;
leads
to
arterial
and
corona
ry
artery
vasodi
lation
and
decrea
sed
periph
eral
vascul
ar
resista
nce.

CCLXXVII.
CCLXXVIII.

NURSING MANAGEMENT

A. Concept Map of Nursing Problems

CCLXXIX. ASSES
SMENT

CCLXXX. N

CCLXXXI. PLA

URSI

NNING

CCLXXXII.NURSIN
G

RATIONA

NG

INTERVEN

DIAG

TION/S

ation perfusion imbalance specifically altered blood flow.

CCLXXXIII.

les, (+) Pallor, (+) Decreased, (+) Tachycardia, RR- 24 bpm, AR 70 - 115 bpm, BP - 60/80 - 170/100 mmHg, O2 Sat. 97

NOSI

CCLXXXVI.
CCLXXXVII.

S
CCCI.
CCCII. Impair

CCCIII.
CCCIV.

After

CCCV.
CCCVI.

CCCXLVIII.
Indepen

bjective/s:
ed
4 hours
dent:
CCCXLIX.
1.
Position
CCCL. 1.
(+) Restlessness
gas
of
CCCVII. MRS.
CCLXXXVIII.
Lowe
excha
nursing
(+) DOB
RA in semi
diaph
CCLXXXIX.
nge r/
interventi
fowlers
(+) Crackles
m
t
on, MRS.
CCXC.
position and
prom
(+) Pallor
Ventila
RA will
change
g che
CCXCI.
tion
have
position
(+) Decreased
5. Impaired
skin integrity r/t bed sores at the right buttock.
expa
perfusi
decrease
CCXCII.
Objective/s:
every 2
and
(+) bed(+)
sore
atrelated
the Right
buttock (coccyx
rashes all over the body, (+) Dry and nscaly
Tachycardia
ltered thermoregulation
to invasion
of pathogens
onarea), (+) Maculopapular
in
hours
Objective/s:
CCXCIII.
decre
imbala
difficulty
CCCVIII.
CC:
Unresponsiveness
Temp.
37.924
C,bpm
Skin warm to
RRCCCIX.
press
Dx: t/c Stevens-Johnson
Syndrtome
Touch, Weak in
CCXCIV.
nce
of
2.
Provide
back
Appearance, WBC 15.6x10^9/L (N.V - 4.5-11.0),
on th
AR 70 - 115
specifi
breathing
Lymphocytes 0.01% (N.V - 20-45)
CCCX.
tapping
bpm
abdo
cally
AEB
to MRS. RA.
CCXCV.
CCCLI.
CCCXI.
BP - 60/80 altered
decrease
CCCLII. 3
CCCXII.
170/100 mmHg
blood
RR.
This
CCCXIII.
CCXCVI.
CCCXIV.
O2 Sat. 97
flow.
allow
CCCXV.
100%
mobi
CCCXVI.
CCXCVII.
3.
Suction
as
O2 via nasal
on an
CCCXVII. Indicate
cannula at
expe
3L/min.
d.
ral perfusion
r/t decreased
arterial flow
AEB decreased
pulses, in
pale
/ lungs
cool feet, thick brittle nails.
3. Infection
r/t
invasion
of
bacterial
microorganism
the
ation
CCXCVIII.
CCCXVIII.
CCCXIX.
ess, (+) Pallor, (+) Cold clammy skin,Objective/s:
(+) dry and chopped lips, (+) pale / cool feet, RR 24 bpm, BP - 60/80 - 170/100secre
mm
Pulse Oximeter
CCCXX.
s.
CCCXXI.
attached.
Based on the Laboratory results:
CCCLIII.
CCCXXII.
CCXCIX.
CCCLIV.
ol/L (1.00 1.60)CCC.
Eosinophils 4.0% (0-3%),
4. Note rate,
CCCLV.
WBC 15.6x10^9/L (4.5 11.0 X 10 ^ 9/L), (+) whitish
0.00 1.03)
CCCLVI.
rhythm and
productive cough, (+), Temperature. 37.9C

1 4.60)

6.2%)

0 X 10 ^ 9/L)

3. Clears airw

depth of

from

respiration.
CCCXXIII.
CCCXXIV.
CCCXXV.
CCCXXVI.
CCCXXVII.
ependent:

secretions
CCCLVII.
D

CCCLVIII.
CCCLIX.

1. Administer O2
CCCXXVIII. therapy
3 L/min
CCCXXIX.
CCCXXX.
CCCXXXI.
2. Nebulization
CCCXXXII. 1L/m
with combivent
CCCXXXIII.
CCCXXXIV.
CCCXXXV.
CCCXXXVI.
CCCXXXVII.
CCCXXXVIII.
CCCXXXIX.
CCCXL.
Collabo
rative:
1. Monitor Pulse
oximeter for
oxygenation.
CCCXLI.
CCCXLII.
CCCXLIII.
CCCXLIV.
CCCXLV.
CCCXLVI.
CCCXLVII.

CCCLX.
4. The

respiration
become

shallow, an

the patient
begin to

hypoventil

CCCLXI.
CCCLXII.
CCCLXIII. 1

reliev
o2

defic
CCCLXIV.
CCCLXV.
CCCLXVI.
CCCLXVII.2

loose
and

lique

secre
s.
CCCLXVIII.

2. Monitor arterial
blood gases
and note
changes.

CCCLXIX.
CCCLXX.
CCCLXXI.
CCCLXXII.
CCCLXXIII.

1. This tool
useful to
detect
changes
oxygena
Oxygen
saturatio
should b
maintain
at 90% o
greater.
CCCLXXIV.
CCCLXXV.

2. PaCO2 a
PaO2 ma
fluctuate
These ar
the signs
respirato
failure.

CDVII.
CDVIII. ASSESSME

CDIX. NURSIN

NT

CDX. PLANN

CDXI.

ING

DIAGN

NURSI

CDXII.

NG

RATIONA

CDXIII.NURSI

LE

NG

INTERVENTION

CDXIV.EVALU
ATION

THEO

OSIS

RY
AND
THEO
RIST

CDXV.

CDXXVI.

CDXXVIII.

CDXVI. Objective/S:

CDXXVII. Alte

CDXXIX. Afte

Temp. 37.9 C

red

CDXVII.

thermor

hours

Skin warm to

egulatio

of

CDXVIII.

Touch

CDXIX.

Weak in

CDXX.

Appeara

nce

(N.V - 4.5-11.0)

Lymphocytes L
CDXXII.
.01% (N.V - 20-

ndent:

CDLXXIII.

CDLI.

CDLXII.

CDLXXIV. Goa

1. May help reduce

1. Provide tepid
sponge bath.

CDLXIII.

Bet

l met.

fever and provide

ty Neuman (Help

CDLXXV.

comfort.

the clients system

CDLXXVI. Tem

CDLII.

attain, maintain

perature

CDXXXIII.

related

interven

CDXXXIV.

CDLIII.

and regain system

is

to

tion, the

CDXXXV.

CDLIV.

stability.)

decreas

invasion

patient

CDXXXVI.

CDLV.

CDXXXVII.

2. Room

ns

15.6x10^9/L

Indepe

CDLXI.

nursing

pathoge

WBC result

CDXXXII.

CDL.

of

CDXXI.

r2

CDXXXI.

temper

2. Provide a cool

CDLXIV.
CDLXV.

ed from
Bet

temperature/

ty Neuman (On

to
36.3C

ature

and calm

number of

the whole person

will

environment.

blankets should

and reaction to
stress.)

decreas

CDXXXVIII.

be altered to

e from

CDXXXIX.

maintain near

CDLXVI.

37.9 C

CDXL.

normal body

CDLXVII.

CDLVI. temperatur

CDLXVIII.

to 36.3

CDXLI.

37.9C

45)

C within

CDXLII.

CDXXIII.

the

CDXLIII.

CDXXIV.

shift.

CDXXV.

e.

3. Monitor

CDXXX.

CDLXIX.

CDLVII.

CDLXX.

Bet

3. Temperature

ty Neuman (Help

patients

elevation may

the clients system

temperature

occur because of

attain, maintain

every hour.

various factors

and regain system

such as presence

stability.)

CDXLIV.
CDXLV.
CDXLVI.

of infection.
Depen

CDLVIII.

dent:

1. To help reduce

1. Administer

CDLXXI.
CDLXXII. Dor
othy

fever by acting

Johns

directly on the

ons

aracetamol

heat regulating

theory

300 mg IV. (by

system

of

NOD)

CDLIX.

Human

CDXLVII.

CDXLVIII.
CDXLIX.

CDLX.

Behavi
oral
System
(Medici
ne
focus:
Cure)

CDLXXVII.
CDLXXVIII.
CDLXXIX.

CDLXXX.
CDLXXXI.
CDLXXXII.
CDLXXXIII.
CDLXXXIV.
CDLXXXV.
CDLXXXVI.
CDLXXXVII.
CDLXXXVIII.
CDLXXXIX. ASSES
SMENT

CDXC. NURSING
DIAGNOS
IS

CDXCI. PLANNIN
G

CDXCII.

INTER

VENTION/
S

CDXCIII.

RATIO
NALE

CDXCIV.

NUR
SING

THEORI
ST/S

CDXCV.

EVAL
UATION

CDXCVI.

DXVI.

DXXII.

DXXVI.

CDXCVII. Objecti

DXVII. Infection

DXXIII. To

DXXVII.

ve/s:

r/t

CDXCVIII. Based

invasion

on the

of

1. Note for

severity

DXXVIII.

Infections

DLXVI.
physic

must

DCVIII.Goal

DLXXXVII. Erne

Partially

stine

Met.

be treated to stop

Weiden

DCIX.
DCX. After 8

al evidence of

the immune

back

results:

microorg

infection

infection

response .

(Nurse

hours of

Eosinophils

anism in

with the

DXXIX.

DLXVII.

meets

nursing

the lungs

hospital

DXXX.

DLXVIII.

through

interventi

DXVIII.

stay AEB

DXXXI.

DLXIX.

identific

on MRS.

DXIX.

by

DXXXII.

ation of

R.A was

DXX.

decrease

2. Implement

needs)

able to

DXXI.

DXXXIII.

appro

people in contact

L (4.5

temperat

priate measures to

with the patient is

11.0 X 10 ^

ure and

protect the patient

the primary method

9/L)

expelled

from potential

to reduce the risk of

othea

s and her

mucus

infection sources.

infection.

Orems

temperat

theory

ure

of

decrease

increase in cardiac

Nursing

d to

and blood

output reflected by

Concept

pressure.

tachycardia and

DCXII.

normal or

(Identifie

DCXIII.

WBC

DI.

15.6x10^9/

DII.
(+) whitish

DIII. productive
cough

DXXIV.

DIV.

DXXV.

(+) Temperature.

DV. 37.9C
DVI.

the

1.

DLXXXVI.

of

D.

endent:

DLXV.

DCVII.

bacterial

(0-3%)

Indep

DLXXXV.

Laboratory

CDXCIX. 4.0%

prevent

DLXIV.

2. Hand washing
DLXX.

secretion

DXXXIV.

DLXXI.

s.

DXXXV.

3. There is an

3. Monitor heart rate

DXXXVI.
DXXXVII.

by all

DLXXII. elevate

DLXXXVIII.

cough out
mucus

DLXXXIX. Dor

s what

secretion

DCXI. 36.3 C.

DVII.

DXXXVIII.

d BP.

Nursing

DVIII.

DXXXIX.

DLXXIII.

Care is

DIX.
DX.

4. Monitor
temperature.

4. This provides
DLXXIV.

inform

needed)
DXC.

DXI.

DXL.

ation about the

DXCI.

DXII.

DXLI.

patients response

DXCII. Ernesti

DXIII.

DXLII.

to invading

ne

DXIV.

DXLIII.

organisms.

Weiden

DXV.

DXLIV.

Temperature may

back

DXLV.

be higher 38C or

(Nurse

DXLVI.

lower than 36C

meets

DXLVII.

DLXXV.

through

5. Instruct the folks to

5. To prevent the

identific

wear smack gown

patient from

ation of

when entering the

harmful

needs)

cubicle.

microorganism

DXCIII.

DXLVIII.

from the outside.

DXCIV.Ernesti

DXLIX.

DLXXVI.

6. Observe sterile
technique.

DLXXVII.
6. To prevent of

ne
Weiden
back

DL.

infection and

(Nurse

DLI.

complications

meets

DLII.

DLXXVIII.

through

DLIII.

DLXXIX.

identific

DLIV. Depende

DLXXX.

ation of

nt:

1. Analgesics &

needs)

DLV.

1.

Antipyretic, for

DXCV.

Administer

moderate pain and

DXCVI.

Paracetamol

fever.

DXCVII.

300 mg IV (by

DLXXXI.

DXCVIII.

NOD).

DLXXXII.

DXCIX.

DLVI.

DLXXXIII.

y Neuman (Help

Bett

DLVII.

DLXXXIV. 2. For

the clients system

DLVIII.

the allergic

attain, maintain and

reaction.

regain

2. Administer
Pred 20 1 tab.

system

stability.)

DLIX.

DC.

DLX.

DCI.

DLXI.

DCII.

Betty

DLXII.

Neuman (Help the

DLXIII.

clients

system

attain, maintain and

regain

system

stability.)
DCIII.
DCIV. Dorothy
Johnso
ns

theory
of
Human
Behavio
ral
System
(Medicin
e focus:
Cure)
DCV.
DCVI. Dorothy
Johnso
ns
theory
of
Human
Behavio
ral
System
(Medicin
e focus:
Cure
DCXIV.
DCXV.
DCXVI.

DCXVII.
DCXVIII.
DCXIX.
DCXX. ASSESSM
ENT

DCXXI.

DCXXII.

URSI

PLA

DCXXIII.

NURSI

NNING

DCXXIV. RATIONA

NG

DCXXV.

LE

NUR

DCXXVI. EVA

SING

LUATIO
N

NG

INTERVEN

THEORI

DIAG

TION/S

ST/S

NOSI
S
DCXXVII.

DCXLVII.

DCXLIX.

DCXXVIII. Objecti

DCXLVIII. In

DCL.

ve/s:

(+) Paleness
DCXXIX.
(+) Weakness
DCXXX.
(+) Pallor
DCXXXI.
(+) Cold clammy
skin.
DCXXXII.
(+) dry and
chopped lips
DCXXXIII.
(+) pale / cool
feet
DCXXXIV.
RR 24 bpm
DCXXXV.
BP - 60/80 -

effect

hours of

ive

nursing

perip

interven

heral

tion,

perfu

MRS.

sion

RA will

DCLXXVIII.
DCLXXIX.
DCLII. Independe
DCLXXX.
nt:
DCLXXXI.
1. Minimize interruption
DCLIII.
of blood flow, reduces
1. Elevate feet
venous pooling.
using pillow or
DCLXXXII.
elevate the leg
DCLXXXIII.
part of the bed.

r/t

maintain

DCLIV.

decre

adequat

DCLV.

ased

e level

DCLVI.

arteri

of

DCLVII.

hydratio

2. Note for

al

After 8

DCLI.

flow

n to

dehydration.

AEB

maximiz

Monitor intake

decre

and output.

DCLXXXIV.
2. Glycosuria may result
in dehydration with
consequent reduction
of circulating volume
and further impairment
of peripheral
circulation.

DCXCVIII.

DCCXV.

DCXCIX.

DCCXVI. Goal

DCC.

partially

DCCI. Virginia

met.

Henders

DCCXVII.

ons

DCCXVIII. After

theory of

8 hours

14 Basic

of

Needs

nursing

(Doing

intervent

the for

ion.

the

MRS.

patient

RA was

what

able to

they

maintain

cannot

adequat

170/100 mmHg
DCXXXVI.

P 58 bmp
DCXXXVII.
Blood Glucose
11.52 mmol/L
(4.10 5.90)
DCXXXVIII.
DCXXXIX.
DCXL.
Direct HDLC - .
58 mmol/L (1.00
1.60)
DCXLI.
VLDL - 1.65
mmol/L (0.00
1.03)
DCXLII.
LDL - 1.20
mmol/L (1.71
4.60)
DCXLIII.
HbAIc - -7.9 %
(-4.2 6.2%)
DCXLIV.

Intake 1056cc
DCXLV.

Output 745 cc

ased

perfusio

DCLVIII.

pulse

n, AEB

DCLIX.

s,

balance

DCLX.

3. OTF 200 cc of

pale /

DCLXXXV.
3.Antidiabetic diet.
DCLXXXVI.

cool

intake /

Diben given

DCLXXXVII.

feet,

output,

through patent

DCLXXXVIII.

thick

moist

NGT.

brittle

skin /

DCLXI.

nails.

mucous

DCLXII.

membra

DCLXIII.

ne.

DCLXXXIX.

Indepe

ndent:
1. Administer
Simvastatin
DCLXIV.

DCXCVI.

DCLXV.
DCLXVI.
DCLXVII.
DCLXVIII.

1. Antihyperlipidemic
DCXC.
DCXCI.
DCXCII.
DCXCIII.
DCXCIV.
DCXCV.

Collabo

rative:
DCLXIX.
1. Monitor Blood

DCXCVII.
1. To know the
changes in the
previous result.

do for

e level of

themselv

hydratio

es)

n AEB

DCCII.

Pulse

DCCIII.

Erne
stine

90 bpm,
DCCXIX. Intak

Weiden

back

1145cc

(Nurse

and

meets

Output

through

of

identifica

1100cc.

tion of
needs)
DCCIV.
DCCV. Ernestin
e
Weiden
back
(Nurse
meets

Chemistry Profile.

through

DCLXX.

identifica

DCLXXI.

tion of

DCCXX.

DCXLVI.

DCLXXII.

needs)

DCLXXIII.

DCCVI.

DCLXXIV.

DCCVII.

DCLXXV.
DCLXXVI.
DCLXXVII.

Doro

thy
Johnso
ns
theory of
Human
Behavior
al
System
(Medicin
e focus:
Cure)
DCCVIII.
DCCIX.

Lydi

a Halls
theory of
Compon
ents of
Nursing /
Caring
(Core
and

Cure
-shared
with
other
health
care
provider
s)
DCCX.
DCCXI.
DCCXII.
DCCXIII.
DCCXIV.
DCCXXI.
DCCXXII.
DCCXXIII.

DCCXXV.

DCCXXIV. ASS

DCCXXVI. DIA

ESSMEN

GNOSIS

DCCXXVII.

DCCXXIX. NURS
ING

DCCXXVIII.

DCCXXX.
DCCXXXI. RATIONA

INTERVE

PLANNING

DCCXXXII.

DCCXXXIII.

NURSING

LE

THEOR

NTION

Y AND

DCCXXXIV.
EVALUATION

THEORI
ST
DCCXXXV.
DCCXXXVI.
Objective/s:

DCCXLVII.

DCCXLIX.

DCCXLVIII.

DCCL. To

Impaired skin
integrity

display

DCCLI.
DCCLII.

Indep

endent:

timely 1. Protect skin from

DCCLXXIV.

DCCC.

DCCCXIV.

DCCLXXV.

DCCCI.

DCCCXV. Goal

DCCLXXVI.

1,

The poor peripheral

DCCCII.

Erne

stine

Partially
met.

r/t bed

healing

trauma and

circulation of PAD

Weiden

DCCCXVI.

at the Right

sores at

of bed

prolonged pressure.

places the patient at

back

DCCCXVII.

buttock

the right

sores

DCCLIII.

high risk for injury.

(Nurse

After 8 hours of

(coccyx area).

buttock.

without

DCCLIV.

DCCLXXVII.

meets

Nursing

complica

DCCLV.

DCCLXXVIII.

through

interventi

tions

DCCLVI.

2. To prevent

identific

on,

infections.

ation of

affected

needs)

area is

(+) bed sore

DCCXXXVII.

(+)

within 2. Keep the infected

Maculopapular

the

area dry always.

DCCLXXIX.

rashes all over

hospital

DCCLVII.

DCCLXXX.

the body.

stay.

DCCLVIII.

DCCLXXXI.

DCCCIV.

DCCLIX.

DCCLXXXII.

y Neuman (Help

and

3. Scratching can

the clients system

cleaned.

DCCXXXVIII.

3. Note for

Bett

ed dry

scratching skin

DCCLXXXIII. cause

attain, maintain and

Bed

scaly skin.

and of keeping

lesions and open sores.

regain

sores is

(+) Scratching
of the skin.
DCCXL.

maintain

(+) Dry and

DCCXXXIX.

DCCCIII.

(+) Dirty nails,

finger nails short

DCCLXXXIV.

system

stability.)

still

and clean.

DCCLXXXV.

DCCCV.

DCCLX.

DCCLXXXVI.

DCCCVI. Erne

DCCLXI.

DCCLXXXVII.

4. Put mittens on

4.Mittens prevent

stine
Weiden

hands if

excessive

back

necessary.

scratching.

(Nurse

untrimmed.

DCCLXII.

DCCLXXXVIII.

meets

DCCXLI.

DCCLXIII.

DCCLXXXIX.

through

DCCLXIV.

DCCXC.

identific

DCCXLII.

noted.

DCCXLIII.

5. Note the patients

DCCXLIV.

ability to move.

greater risk for

DCCLXV.

skin breakdown.

DCCXLV.
DCCXLVI.

5.Immobility is

ation of
needs)
DCCCVII.

DCCLXVI.

DCCXCI.

DCCCVIII.

Bett

DCCLXVII.

DCCXCII.

y Neuman (Help

DCCLXVIII.

DCCXCIII.

the clients system

DCCXCIV.

attain, maintain and

6. Position patient

6.To avoid pressure

regain

on the non

on affected area

infected area.

causing for the

DCCCIX.

DCCLXIX.

severity.

DCCCX.

system

stability.)
Erne

DCCLXX.

DCCXCV.

stine

DCCLXXI.

DCCXCVI.

Weiden

DCCLXXII.

DCCXCVII.

back

DCCLXXIII.

DCCXCVIII.

(Nurse

DCCXCIX.

meets
through
identific
ation of
needs)
DCCCXI.
DCCCXII.

Bett

y Neuman (Help
the clients system

attain, maintain and

regain

system

stability.)
DCCCXIII.
DCCCXVIII.
DCCCXIX.
DCCCXX.
DCCCXXI.
DCCCXXII.
DCCCXXIII.
DCCCXXIV.
DCCCXXV.
DCCCXXVI.

DCCCXXVII.
DCCCXXVIII.

DISCHARGE PLANNING

DCCCXXIX.
DCCCXXX.
DCCCXXXI.

M edications

Medications prescribed by the physician should be taken properly, to help

the patient lessen unusual condition. (MRS. RA is still admitted in the hospital)
DCCCXXXII.
DCCCXXXIII.

E xercise and Activity

DCCCXXXIV. Encourage folks to help MRS. RA to have an active range of motion

exercises thrice daily to maintain her muscle strength.
DCCCXXXV. Get plenty of rest. Adequate rest is important to maintain progress toward
full recovery and to avoid relapse.
DCCCXXXVI.
DCCCXXXVII.

T reatment

DCCCXXXVIII.
Give supportive treatment. Proper diet and oxygen to increase
oxygen in the blood when needed.
DCCCXXXIX.Treatment is one of the main factors in restoration of health and curing of
the failure in the body system. Treatments are given to the patient for a specific time until
treatment is not more needed by the patient.
DCCCXL.
DCCCXLI. H ome Teaching/s
DCCCXLII.
Encourage the folks to wash patients hands. The hands come in daily
contact with germs that can cause infections. These germs enter ones body when he touch
his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk.
DCCCXLIII. Tell folks to avoid exposing the patient to an environment with too
much pollution (e.g. smoke). Smoking damages ones lungs natural defenses against
respiratory infections.
DCCCXLIV.

O ut patient follow up

DCCCXLV.
Keep all of follow-up appointments, even though the patient feels better.
Its important to have the doctor monitor his progress.
DCCCXLVI.
DCCCXLVII.

D iet

DCCCXLVIII. Drink lots of fluids, especially water. Liquids will keep patient from
becoming dehydrated and help loosen mucus in the lungs.

DCCCXLIX.

Advice the patient not to eat foods that is high in cholesterol such as the

fatty portion of the pork that may increase the level of her blood pressure but to eat more green
and leafy vegetables.
DCCCL.
DCCCLI.

S pirituality and Sexuality

DCCCLII. In order to improve her spiritual aspects, he may attend holy masses or listen to
gospel readings and pray the holy rosary or she may seek for divine providence to
the Lord. Assist the patient that may include spiritual resources to help her deal with
it.
DCCCLIII.
DCCCLIV.
DCCCLV.
DCCCLVI.
DCCCLVII.
DCCCLVIII.
DCCCLIX.
DCCCLX.
DCCCLXI.
DCCCLXII.
DCCCLXIII.
DCCCLXIV.
DCCCLXV.
DCCCLXVI.
DCCCLXVII.
DCCCLXVIII.
DCCCLXIX.
DCCCLXX.
DCCCLXXI.
DCCCLXXII.
DCCCLXXIII.
DCCCLXXIV.
DCCCLXXV.
DCCCLXXVI.
DCCCLXXVII.
DCCCLXXVIII.
DCCCLXXIX.
DCCCLXXX.
DCCCLXXXI.
DCCCLXXXII.
DCCCLXXXIII.
DCCCLXXXIV.

DCCCLXXXV.
DCCCLXXXVI.
DCCCLXXXVII.
DCCCLXXXVIII.
DCCCLXXXIX.

XIV.BIBLIOGRAPHY / REFERENCES

DCCCXC.
Nursing Care Plan Diagnosis and Interventions 8th Ed
DCCCXCI.
By: Gulanick and Myers
Nursing Diagnosis Handbook A Guide for Planning Care 7th Ed.
DCCCXCII.
By: Betty J. Ackley and Gail b. Ladwig
Drug Information Handbook for Nursing 2nd Ed.
DCCCXCIII.
By: Lilley, Harrington and Snyder
MIMS 2008 - 2009 Ed.
Professional Guide to Pathophysiology 2nd Ed.
DCCCXCIV.
By: Kozier and Erbs

DCCCXCV.
DCCCXCVI.
DCCCXCVII.
DCCCXCVIII.
DCCCXCIX.
CM.
CMI.
CMII.
CMIII.
CMIV.
CMV.
CMVI.
CMVII.
CMVIII.
CMIX.
CMX.
CMXI.
CMXII.
CMXIII.
CMXIV.
CMXV.
CMXVI.
CMXVII.
CMXVIII.
CMXIX.
CMXX.

CMXXI.
CMXXII.
CMXXIII.
CMXXIV.
CMXXV.
CMXXVI.
CMXXVII.
CMXXVIII.
CMXXIX.
CMXXX.
CMXXXI.
CMXXXII.
CMXXXIII.
CMXXXIV.
CMXXXV.
CMXXXVI.
CMXXXVII.
CMXXXVIII.
CMXXXIX.
CMXL.
CMXLI.
CMXLII.
CMXLIII.
CMXLIV.
CMXLV.
CMXLVI.
CMXLVII.
CMXLVIII.
CMXLIX.
CML.
CMLI.
CMLII.
CMLIII.
CMLIV.
CMLV.
CMLVI.

CMLVII.
CMLVIII.
CMLIX.
CMLX.
CMLXI.
CMLXII.
CMLXIII.
CMLXIV.
CMLXV.
CMLXVI.
CMLXVII.
CMLXVIII.
CMLXIX.
CMLXX.
CMLXXI.
CMLXXII.
CMLXXIII.
CMLXXIV.