Republic Of the Philippines

WESTERN MINDANAO STATE UNIVERSITY

COLLEGE OF NURSING
ZAMBOANGA CITY

Related Learning Experience

ROTATION 5 OUTPUT
ZCMC Medical Ward
(Ward 5)
Patient’s Profile, Study of Illness Condition, Pathophysiology,
Nursing Care Plan, and Drug Studies

Submitted by:
Alih, Fatima Shadeena
Amilhusin, Al-khafiz
Angeles, Joana Catlyne U.
Angkaya, Fharhata A.
Asmadun, Ylaiza Maye

Submitted To:
Sitti Rashida M. Muharram, RN, MAN
Clinical Instructor
PATIENT’S PROFILE

Patient’s name: Marites Mendoza Gender: Female

Age: 28 years old Civil status: Married
Occupation: Vendor
Address: Tala Boalan, Zamboanga city

Chief complaint: Right arm pain (Urgent)

Subjective cues:
Patient verbalized “Dwele gayodt mio braso si tan labada iyo aste nuay ya
iyo man kaya el dolensya”
Significant other verbalized “Hinde man she ele ta abla kanamun kay chene
ele kosa ta sinti asta nuay ya gad tele pwede agwanta el dolor” and
“Ta dwele disuyu mano pati mahina gayodt disuyu kwerpo hinde ele tanto ta
pwede mobe kay ta tormenta ase subi suyu braso porkawsa na dolensya.”
Objective cues:
➢ Pain scale:7/10
➢ Tenderness noted
➢ Erythema (Redness)
➢ Edematous (Swelling) of right arm and lower extremities
➢ Presence of skin trauma and wound
➢ Skin is warm
History: Diabetes and Hypertension (Maternal)
Admitting Diagnosis: CELLULITIS RIGHT ARM DKA MILD NEWLY DIAGNOSED DM
TYPE 2; ESSENTIAL HPN; COVID SUSPECT
Vital signs taken:
Temperature:36.6 PR: 80 bpm
BP: 130/80 mmHg O2sat: 97%
RR: 18 bpm

Medications:
• Clindamycin 600 mg • Omeprazole 40mg
• Paracetamol • Levetiracetam 500 mg
• Insulin 6cc/hour • PNSS 30 gtts/min
• Diazepam 5mg • 0.9 NaCl 1L

LABORATORY RESULTS
Complete Blood Count
Red blood cell L 3.5 Normal: 4.0-5.5
Hemoglobin L 100 Normal: 120-160
Hematocrit L 0.29 Normal: 0.36-0.46
White blood cell H 10.5 Normal: 5.0-10.0

Differential Count

Neutrophils H 77 Normal: 40-70

Lymphocyte L 15 Normal: 20-45

Clinical Chemistry Result

Creatinine H 169.30 Normal: 46-92

Sodium L 135.00 Normal: 137-145
Albumin L 27.70 Normal: 35-50
Ferritin H 289.00 Normal: 11.1-264
 GORDON’S FUNCTIONAL HEALTH PATTERN

1.) Health perception/ Health management pattern

➢ As verbalized by the patients significant other, their opinion about health is that she
said “Makamiedo gane ma’am nue maskin ta kwida tu imbonamenta dituyu kwerpo
pati ta kome tu mga masustansya si na lahi deostedes el sakit tormento man iwas
kunele.”
➢ Patient Mendoza does not drink alcoholic beverages and does not smoke.
➢ No allergies in medicines and food
➢ Patient does not do exercise according to the significant other she often feels tired and
only likes to seat most of the time (Sedentary Lifestyle).
➢ Patient does not go for a regular checkup because she doesn’t want to bother her family
and does not utilize the health center in their barangay.

2.) Nutrition-metabolic pattern

➢ Patient drinks soft drinks occasionally, she only drinks soft drinks whenever there is a
celebration or event.
➢ The patient eats 3 times a day. Her favorite food is grilled fish and vegetable salad.
The patient’s significant others also stated that her father has a small garden with lots
of vegetables and fruits.
➢ Her usual food includes rice, meat, vegetable, and fruits.
➢ She drinks 6-8 glasses of water a day.
➢ Upon assessment, the patient has poor skin integrity and with presence of edema due
to cellulitis secondary to DKA.

3.) Elimination pattern

➢ The patient’s urine color is cloudy yellow. The patient’s significant other verbalized
that she experiences difficulty of urinating and painful urination and has a small
amount of urine.
➢ Patient has no problem with defecation, patient does not use laxative.

4.) Activity exercise pattern

➢ Patient is a vegetable vendor, but she does not do gardening she only cleans the house
as a form of exercise.
➢ Patient has sedentary lifestyle.

5.) Sleep-rest pattern

➢ As verbalized by the patient’s significant others “Hinde daw ele ta pwede durmi
 imbonamenta kay dwele suyu braso si man bangga bangga lang, poreso kunswenyo
ele pirmi.”
➢ The patient does not use any medication to aid in sleeping.
➢ The patient’s significant other stated that she suffers from stress due to the pain in her
right arm.

6.) Cognitive-perceptual pattern

➢ The patient’s vision is normal, she does not have any auditory problem, as well as
touch and sense of smell.
➢ The patient does not have trouble in sentence making.

7.) Self-perception and self-concept pattern

➢ The patient significant others verbalized that the patient feels depressed because of
what is happening to her but with the help, love, and support of her family she is to
fight back whatever she is experiencing right now.

8.) Role-relationship pattern

➢ The patient is a mother of 3 children, the eldest is an OFW and the others are still
studying. Her relationship with her husband is good as well their children.
➢ The patient verbalized that she would keep on fighting no matter what because her
family needs her.

9.) Sexuality-reproduction pattern:

➢ The patient has no problem in reproduction.

10.) Coping-stress tolerance pattern

➢ Patient’s significant other verbalized that her coping mechanism is to spend time with
her loved ones.

11.) Value-belief pattern

➢ The patient’s religion is roman catholic.

➢ She always goes to church together with her husband.
 STUDY OF ILLNESS CONDITION (SIC)

ASSESSMENT ANATOMY PHYSIOLOGY PATHOPHYSIOLO ANALYSIS

GY
Signs and Symptoms manifested Illustrate and label the system Normal function of the organ Concept Mapping of the Correlate the patient’s sign and symptoms
by the patient: and organ involved involved disease condition to the disease condition

Subjective cues: System involved: The patient’s disease condition, ccellulitiss,

Integumentary System INTEGUMENTARY SYSTEM is a common bacterial skin infection that
The patient’s significant other
verbalized the following: The integumentary system is causes redness, swelling, and pain in the
made up of your skin, nails, infected area of the skin. The signs and
• “Ta dwele disuyu mano pati
hair and the glands and nerves symptoms associated with the disease are
mahina gayot disuyu kwerpo
red area of skin that tends to expand,
hinde ele tanto ta pwede on your skin. It acts as a swelling, tenderness, pain, warmth, fever,
mobe kay ta tormenta ase physical barrier — protecting red spots, blisters, and skin dimpling. The
subi suyu braso porkawsa na your body from bacteria, majority of the above-mentioned cues
dolensya.” infection, injury, and sunlight. where manifested by the patient. First, the
It also helps regulate your patient experiences pain in the right arm. A
Objective cues: body temperature and allows pain scale score of 7/10 was verbalized by
Upon arrival: the patient. The disease is often known as a
you to feel skin sensations like
• Presence of edema were painful skin infection that makes it
hot and cold. challenging for the patient to close their
noted at the lower
hands and walk. The disease can cause
extremities and right arm. • Normal function of the extensive tissue and nerve damage that
• Facial grimacing was Organs involved: organs involved results to the pain manifested by the
noted. Skin patient. Next, the tenderness experienced
• Patient is restless. SKIN by the patient resulted from the
• Upon palpation and The skin is the body’s largest inflammation of the affected skin.
assessment of the patient’s According to Center for Disease Control
organ, made of water, protein,
and Prevention (2022), cellulitis appears as
skin: erythema, tenderness, fats and minerals. Your skin a red, swollen, and painful area of skin that
and presence of wounds protects your body from germs is warm and tender to the touch. When the
and trauma are noted. and regulates body bacteria entered a break in the skin and
• Skin is warm to touch. temperature. Nerves in the spread, infection occurred which resulted
 skin help you feel sensations to the redness of skin (erythema), swelling
Vital signs were taken: like hot and cold. Your skin, of right arm and extremities, and warmth
• Temperature: 36.6 along with your hair, nails, oil skin manifested by the patient. The
presence of the spreading erythematous
degrees Celsius glands and sweat glands, is
inflammation of the deep dermis and
Normal: 36.6-37.2 part of the integumentary subcutaneous tissue rules out further the
degrees Celsius system. patient disease condition. Overall, the signs
Indication: Within normal and symptoms manifested by the patient
range. contributes to the totality of the disease
• Pulse rate: 80 beats per condition which is cellulitis.
minute
Discuss the indication for the lab exam
Normal: 80-120 beats per
minute The patient’s RBC result is 3.5 million
Indication: Within normal cells/mcL which is deviated and lower
limits. from the normal range of 4.0-5.5 million
• Respiratory rate: 18 cells/mcL. It indicates anemia or iron
breaths per minute deficiency. The patient’s hemoglobin is
100 g/L which is also deviated and lower
Normal: 12-18 breaths per
from the normal range of 120-160 g/L. It
minute indicates anemia or low oxygen in the
Indication: Within normal body. Then, the Hematocrit result is 0.29%
range which is deviated and lower compared to
• Blood pressure:130/80 the normal range of 0.36%-0.46%. It
mmHg indicates that a patient has a few red blood
cell. The patient’s WBC result is 10.5
Normal: 90-110/55-
cells/mcL which is deviated and higher
80mmHg from the normal range of 5.0-10.0
Indication: Elevated cells/mcL. It indicates infection.
blood pressure Furthermore, the patient creatinine level is
• Oxygen saturation:97% 169.30 umol/L which is deviated and
in room air higher than the normal range of 46-92
umol/L. This indicates kidney problem.
Lastly, the patient albumin result is 27.70
g/L which is deviated or lower from the
 Normal: 97-99% normal range of 35-50 g/L. It indicates liver
Indication: Within normal and kidney problem.
range
• Weight: 280 kg (617 lbs)
Explain the significance of the abnormal
Normal: 169-202 lbs results
Indication: Patient is
overweight. Overall, it is important to take note of all
the results of laboratory examinations,
LAB RESULTS: especially the abnormal or positive results
• RBC: 3.5 million because these results could help in finding
cells/mcL the specific condition of the patient. Most
Normal: 4.0–5.5 million patients whose results are outside the
reference range or the normal value will
cells/mcL
most likely undergo another series of
Indication: Low RBC laboratory examinations to help find out the
• Hgb: 100 g/L specific condition and to determine the
Normal: 120–160 g/L treatment and intervention that will be
Indication: Low Hgb given to the specific patient.
• Hct: 0.29%
Normal: 0.36-0.46%
Indication: Low Hct
• WBC: 10.5 cells/mcL
Normal: 5.0–10.0
cells/mcL
Indication: High WBC
(Infection)
• Platelet count: 229/mcL
Normal: 150– 350/mcL
Indication: Within normal
range.
• Creatinine: 169.30
umol/L
Normal: 46-92 umol/L
Indication: High (kidney
problem)
• Albumin: 27.70g/L
Normal: 35-50 g/L
Indication: Low
(liver/kidney problem)

Cite Reference/s Cite Reference/s Cite Reference/s Cite Reference/s

Farinde, A. (2020). Lab https://microbenotes.com/inte Cleveland (2021). Function of National Health Services (2021). Cellulitis.
values, Normal Adult. gumentary-system/ Integumentary system. https://www.nhs.uk/conditions/cellulitis/.
Retrieved September 21, 2023, Retrieved September 21,2023,
https://my.clevelandclinic.org from: Penn Medicine (2023). Cellulitis.
from:
/health/articles/10978-skin https://my.clevelandclinic.org/ https://www.pennmedicine.org/for-
https://emedicine.medscape.co health/body/22827- patients-and-visitors/patient-
m/article/2172316-overview integumentary- information/conditions-treated-a-to-
system#:~:text=It's%20made z/cellulitis#:~:text=Staphylococcus%20an
%20up%20of%20your,sensati d%20streptococcus%20bacteria%20are,ca
ons%20like%20hot%20and% n%20cause%20a%20skin%20infection..
20cold.
 PATHOPHYSIOLOGY/ PATHOGENESIS

RISK FACTOR: ETIOLOGICAL CAUSE:

The following risk factors may It is caused by bacteria that enter
allow bacteria to get through the and infect the tissue through
skin: breaks in the skin.
Injuries that cause a break in the skin. ⚫ Causative agent of the diseases:
Chronic skin conditions Staphylococcus and streptococcus
Chickenpox and shingles bacteria
Injection drug use
Infection with Group A
Streptococcus

Immune response resulting in

the formation of antibodies
SIGNS AND SYMPTOMS:
against Group A Streptococcus

Antibodies formed exhibit cross

Right arm pain (Pain scale: 7/10) reactivity with host tissues
(Joints, arms)

. Tenderness noted
Antibodies act on the normal
tissue and cause damage
Treatment:
Redness of skin (Erythema)
Clindamycin 600 mg/ IV/ q6

Treatment:
Swelling of right arm and lower extremities
Paracetamol 500 mg/ PO/ q4

Treatment:
Presence of skin trauma and wound
Insulin 6cc/ IV/ q1

Skin is warm Other medications:

Diazepam 5 mg
Omeprazole 40 mg
CELLULITIS Levetiracetam 500 mg
References:
Center for Disease Control and Prevention (2022). Cellulitis: All You Need to Know. https://www.
cdc.gov/groupastrep/diseases-public/Cellulitis.html#:~:text=The%20following%20are%20
risk%20factors,Chickenpox%20and%20shingles.
 LIFE THREATENING PATHWAY OF CELLULITIS

Phatogens (Staphylococcus aureus, Streptococcus pyogenes, Staphylococcus

epidermidis) that makes up the normal flora form a protective layer.

Cut, break, trauma in the skin results to infection.

Bacterial proliferation in the subcutaneous tissue

Disruption to the normal subcutaneous micro-circulation

Local ischemia, nerve infraction, thrombosis of small vessels, and tissue necrosis

Spread in the body into the bloodstream leading to amputation, shock, and sepsis.

DEATH

References:
• Johns Hopkins University (2023). Cellulitis https://www.hopkinsmedicine.or/
health/conditions- and-diseases/cellulitis.
• Holland, K. (2020). What are the side effects of Cellulitis, and How can I
Prevent Them? https://www.healthline.com/health/cellulitis-
complications#summary.
 NURSING CARE PLAN (NCP)

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Subjective cues: At the end of 8 Independent: After 8 hours of
The patient Impaired hours of nursing ⚫ Check distal • Pulses are an indicative ⚫ Checked distal pulses nursing
verbalized, Tissue intervention, the pulses regularly. property of sufficient regularly. intervention, the
“Dwele gayodt Perfusion patient will be able perfusion to the specific patient will be able
related to to: body part. Absence or to:
mio braso si tan
interrupted • The patient will weakness of pulses may be • The patient was
labada iyo aste
sustain a sign of impaired able to sustain
nuay ya iyo man blood flow to
adequate perfusion. adequate
kaya el dolensya” organs and peripheral peripheral
tissues perfusion, as ⚫ Assess the skin • ⚫ Assessed the skin perfusion, as
Pale color or bluish
Significant other secondary to evidenced by color, discoloration, or spotty color, temperature, evidenced by
verbalized, cellulitis as strong pulses, temperature, and skin may be an indication and sensation of all strong pulses,
“Hinde man she evidenced by skin is warm to sensation of all of the presence of extremities skin is warm to
ele ta abla pain, reduced touch, with a extremities. blockage in the skin. touch, with a
kunamun kay sensation in normal normal
chene ele kosa ta extremities, capillary refill, • Hair loss and brittle nails ⚫ Assessed for signs of capillary refill,
sinti asta nuay ya prolonged and wounds are ⚫ Assess for signs of are because of reduced decreased tissue and wounds are
healed. decreased tissue blood flow to the hair perfusion. During the healed.
gad tele pwede wound
perfusion. For follicles and nails. assessment,
agwanta el healing, skin peripheral arterial peripheral pulses are
Extremities are cool due to
dolor” is warm to disease (PAD), weak. There is the
reduced perfusion in the
touch, and shiny skin, hair presence of edema,
arteries, secondary to
Objective cues: weak loss, thick nails, plaque build-up skin is warm to touch,
peripheral pallor, cool to (Ischemia). Weak or normal pulses, dull
⚫ Tenderness pulses touch the skin, absent pulses are a result and continuous pain,
noted decrease or of decreased blood supply. superficial ulcers
⚫ Erythema absence of pulses, At rest, there is less with uneven edges.
(Redness) sharp-rest pain oxygen demand by the
⚫ Edematous with intermittent muscles, resulting in
claudication, decreased blood supply to
(Swelling) of necrosis in these areas. This will lead
right arm and ulcers. For to sharp, intermittent pain
lower Venous while resting. Arterial
extremities insufficiency, wound ulcers are pale and
brown sometimes are necrotic
⚫ Presence of discoloration of because of the small
skin trauma the skin from the amount of blood supply to
and wound ankles up to the the wound. Arterial
⚫ Skin is warm calves, there is the wound ulcers are pale and
to touch presence of sometimes are necrotic
edema, skin is because of the small
warm to touch, amount of blood supply to
normal pulses, the wound. With the
History: Diabetes dull and increase of venous blood
and Hypertension continuous pain, pressure, there is a pooling
(Maternal) superficial ulcers of blood that causes
with uneven valvular damage in the
Admitting edges. veins. This causes fluid to
Diagnosis: back up and leak out into
CELLULITIS surrounding tissues
RIGHT ARM resulting in edema. Dull
and continuous pain is
DKA MILD
because of venous
NEWLY hypertension, ulceration.
DIAGNOSED
DM TYPE 2; ⚫ Take note of the • Normal capillary refill ⚫ Took note of the
ESSENTIAL capillary refill time should not exceed 3 capillary refill time.
HPN; COVID time. seconds for nail beds. Pale
SUSPECT nail beds are an indication
of poor perfusion.

Vital signs are • Stable blood pressure and ⚫ Monitored vital signs
taken as follows: ⚫ Monitor vital mean arterial pressure of at closely. Vital signs
signs closely. least 65 is advisable to are taken as follows:
Temperature:36.6
ensure an adequate BP: 130/80 mmHg
PR: 80 bpm O2sat: 97%
BP: 130/80mmHg perfusion of organs and
tissues. Oxygen saturation
O2sat: 97%
should be at a satisfactory
RR: 18 bpm level to guarantee an
adequate oxygen supply.
Lab values:
Hemoglobin: ⚫ Check • Low oxygen saturation ⚫ Checked hemoglobin
100 (L) hemoglobin level and affinity for level regularly. Based
Normal: 120-160 regularly. hemoglobin, the oxygen on the lab results, the
utilization will be reduced, hemoglobin level of
the patient is 100
Creatinine: resulting in less amount of which indicates a low
169.30 (H) oxygen circulating in the hemoglobin level.
Normal: 46-92 body.

⚫ Keep track of the • Reduced urine output may ⚫ Was able to track the
patient’s fluid be a sign of decreased patient’s fluid
balance. Monitor perfusion of the kidneys. If balance. Monitored
the patient’s this happens, other vital patient’s amount of
amount of intake organs like the brain will intake and output,
and output, color be affected as well. In this color of the urine, and
of the urine, and situation, Impaired its clarity. Based on
its clarity. cerebral perfusion might the lab results, the
Checking of renal take place. Lab values creatinine level of the
function tests is such as BUN and patient is 169.30
advisable. creatinine are helpful to which indicates a
identify if there are any high creatinine level.
changes in renal function.

⚫ Monitor the • ECG changes such as ST ⚫ Monitored the

patient’s cardiac depression, ST elevation, patient’s cardiac
rhythm. T wave inversion, new rhythm. The patient’s
onset of left bundle branch ECG shows a normal
block all indicate Ischemia result.
or may be cardiac events
that block myocardial
tissue perfusion.

Cite Reference/s

Doenges, M.E Moorhouse, M. F, & Murr, A.C (2019) Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationale (15th Edition)
 NURSING CARE PLAN (NCP)

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
Subjective cues: Acute At the end of 8 Independent At the end of 8
The patient Pain related to hours of nursing hours of nursing
verbalized, impaired skin intervention and • Position the patient • To be more comfortable. • Positioned the client intervention and
“Dwele gayodt integrity health teaching, the in a comfortable in a comfortable health teaching, the
secondary to patient will be able position. position. patient was able to:
mio braso si tan
cellulitis as to:
labada iyo aste
evidenced by • Encourage • To divert attention on • Encouraged
nuay ya iyo man Pain scale: ambulation or even pain and increases ambulation or even • Demonstrates
kaya el dolensya” 7/10, • Demonstrate minimal movement circulation. minimal movement of the use of
erythema, and the use of of unaffected part. unaffected part. appropriate
Significant other edema on the appropriate diversional
verbalized, right arm and diversional • Provide rest, sleep, • To provide comfort. • Provided rest, sleep, activities and
“Hinde man she lower
activities and and relaxation. and relaxation. relaxation
ele ta abla extremities
relaxation skills.
kunamun kay skills. • Instruct family • To provide rest and • Instructed the family
chene ele kosa ta member to eliminate comfort. member to eliminate
any positive stressor any positive stressor • Verbalized
sinti asta nuay ya
or discomfort. or discomfort. understanding
gad tele pwede of risk factors
agwanta el
dolor” • Instruct and • Help to promote • Instructed and and
demonstrate of how circulation, relaxation of demonstrated of how demonstrate
to do a deep muscles. to do a deep breathing interventions
Objective cues: breathing exercise. exercise. that prevent
Pain scale:7/10 impaired skin
⚫ Tenderness • Handle extremity • To avoid inflicting pain • Handled extremity integrity
noted with great care and on the extremity with great care and
⚫ Erythema gentleness gentleness • The patient
(Redness) reported pain
⚫ Edematous scale of 3/10
(Swelling) of • Educate the client • Adequate hydration and • Educated the client
right arm and about adequate nutrition assistance help about adequate
lower nutrition and sustain skin turgor, nutrition and
extremities hydration. moisture, and hydration.
suppleness, which give
elasticity to prevent skin
 damage due to pressure.
Vital signs are Patients with a restricted
taken as follows: amount of fluid intake
Temperature:36.6 secondary to a cardiac
PR: 80 bpm reserve are limited.
BP: 130/80
• Verbalize • Keep the skin clean • To reduce the risk of skin • Instructed the family
mmHg and dry. damage, the affected area and the patient to
understanding
O2sat: 97% of risk factors must be kept clean and aways keep the skin
RR: 18 bpm and dry. Provide daily skin clean and dry.
demonstrate hygiene to patients who
History: Diabetes interventions are bed bound and
and Hypertension that prevent incontinence care as
(Maternal) necessary.
impaired skin
integrity
Admitting • Use pillows to • Often cellulitis is • Used pillows to
Diagnosis: elevate the affected accompanied by elevate the affected
CELLULITIS area. swelling, which can area.
cause pain. Elevation of
RIGHT ARM
the area may help with
DKA MILD reducing edema and
NEWLY pain.
DIAGNOSED
DM TYPE 2; • Instruct the client to • Rubbing and scratching • Instructed the client to
ESSENTIAL avoid rubbing and can cause further injury avoid rubbing and
HPN; COVID scratching. Provide and delay healing. scratching. Provide
SUSPECT gloves or clip the Rubbing the skin gloves or clip the
nails if necessary. vigorously or repetitively nails if necessary.
Lab values: can cause abrasions. It
Hemoglobin: 100 may lead to skin
breakdown, making the
(L)
skin more susceptible to
Normal: 120-160 infection.
Creatinine: • Encourage a low- • Educate patients that • Encouraged a low-
169.30 (H) sodium diet. large amounts of sodium sodium diet.
Normal: 46-92 cause the body to retain
water in an attempt to
dilute it which causes
fluid overload. Instruct
 on ways to lower sodium
intake.
Dependent
• The patient will • Administer pain • Pain control helps the • Administered pain
report medication as patient get adequate rest, medication as
satisfactory ordered. a state that is much ordered.
pain control at a needed for healing.
pain score of 3
or less on a pain
scale of 1 to 10.

Cite Reference/s

• Swearingen, P. R.N. (2016). All-in-One Nursing Care Planning Resource Medical-Surgical, Pediatric, Maternity, and Psychiatric (4 ed.).
• Curran, A. (2022). Cellulitis Nursing Diagnosis and Nursing Care Plans. NurseStudy.Net. Nursing Education Site. https://nursestudy.net/cellulitis-nursing-
diagnosis/
• Caruso, S., Lukey, A. (2023). Acute Pain Nursing Diagnosis & Care Plans. Nurse Together. https://www.nursetogether.com/acute-pain-nursing-diagnosis-care-
plan/
• Wagner, M. (2022). Edema Nursing Diagnosis & Care Plan. Nurse Together. https://www.nursetogether.com/edema-nursing-diagnosis-care-plan/
 DRUG STUDY
GENERIC NAME MECHANISM OF ACTION SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
REACTION • Observe 14 rights in
Clindamycin acts by inhibiting bacterial protein administering
synthesis at the level of the 50S ribosome. As a result, it CNS: Headache
Climdamycin • Assess patients and regularly
exerts a prolonged postantibiotic effect. It may decrease
throughout therapy
toxin production and increase microbial opsonization CV: Thrombophlebitis
• Before giving first dose, obtain
and phagocytosis even at subinhibitory concentrations.
specimen for culture and
BRAND NAME INDICATION EENT: pharyngitis sensitivity test, begin therapy
Treatment for staphylococci, streptococci, pending results
Cleocin Phosphate,
pneumococci, Bacteroides, fusibacterium, clostridium
GI: abdominal pain, Anorexia, bloody • Monitor renal, hepatic, and
Cleocin T, Clindagel, or tarry stools, constipation, diarrhea, hematopoetic functions during
perfringens, and other sensitive aerobic and anaerobic dysphagia, esophagitis, flatulence,
ClindaMax, Clindesse, Clindets, prolonged therapy.
organisms. nausea, psuedomembranuscolitis,
Dalacin C Phosphate,Dalacin T,
Endocarditis prophylaxis for dental procedures in • Be alert for adverse reactions and
Evoclin Zindaclin. unpleasant or bitter taste, vomiting. drug interactions
patients allergic to penicillin
- acne vulgaris • If adverse GI reactions occurs,
GU: UTI monitor patient’s hydration
- bacterial vaginosis
- pneumocystis jiroveci (carinii) pneumonia • Teach patient how to store oral
HEMATOLOGIC: Eosinophilia,
- toxoplasmosis (cerebral or ocular) solution.
thrombocytopenia, transient
immunocompromised patients • Tell patient to take entire amount
leukopenia
DRUG ILLUSTRATION CONTRAINDICATION prescribed even after he feels
better
SKIN: maculopapular rash, urticaria
Contraindicated in patients hypersensitive to drug or • Warn patient that I.M. injection
lincomycin-use cautiously in patients with renal or OTHER: anaphylaxis, erythema, pain may be painful
hepatic disease, asthma, history of GI disease, or (I.V. use), induration, pain; sterile • Instruct patient to report diarrhea
significant allergies. abscess and to avoid self-threatening
psudomembranuscolitis
• Tell patient receiving drug I.V. to
report discomfort at infusion site.
CLASSIFICATION
Antibiotic; Anti-infectives

DOSAGE/FREQUENCY
/ROUTE

Adult: PO 150-450mg q6h

IM/IV 300MG Q6-8h
 DRUG STUDY
GENERIC NAME MECHANISM OF ACTION SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
REACTION • Observe 14 rights in administering medication
• Suppresses the spread of seizure activity
• Monitor for adverse reactions. Most are dose
through the motor cortex of the brain Throat and chest pain. related. Physician will rely on accurate
Diazepam (cerebral cortex) CNS: Drowsiness, fatigue, ataxia, observation and reports of patient response to the
• Effective in treating tremors and anxiety confusion, paradoxic rage, drug to determine lowest effective maintenance
• Diminishes recall of patient cardioversion dizziness, vertigo, amnesia, vivid dose.
BRAND NAME INDICATION dreams, headache, slurred speech, • Monitor for therapeutic effectiveness. Maximum
tremor; EEG changes, tardive effect may require 1–2 wk; patient tolerance to
• Short-term management of anxiety dyskinesia. therapeutic effects may develop after 4 wk of
• Insomnia associated with anxiety treatment.
Valium • Sleepwalking CV: Hypotension, tachycardia, • Observe necessary preventive precautions for
• Night terrors edema, cardiovascular collapse. suicidal tendencies that may be present in anxiety
• Premedication before anesthesia Special Senses: Blurred vision, states accompanied by depression.
• Adjunct in the management of seizures diplopia, nystagmus. • Observe patient closely and monitor vital signs
• Muscle spasms when diazepam is given parenterally;
• Acute symptoms of alcohol withdrawal GI: Xerostomia, nausea, hypotension, muscular weakness, tachycardia,
• Premedication constipation, hepatic dysfunction. and respiratory depression may occur.
DRUG ILLUSTRATION CONTRAINDICATION • Lab tests: Periodic CBC and liver function tests
Urogenital: Incontinence, urinary during prolonged therapy.
Injectable form: Shock, coma, acute alcohol retention, gynecomastia • Supervise ambulation. Adverse reactions such as
intoxication, depressed vital signs, obstetrical (prolonged use), menstrual drowsiness and ataxia are more likely to occur in
patients, infants <30 d of age. Tablet form: irregularities, ovulation failure. older adults and debilitated or those receiving
Infants <6 mo of age, acute narrow-angle larger doses. Dosage adjustment may be
glaucoma, untreated open-angle glaucoma; Respiratory: Hiccups, coughing, necessary.
during or within 14 d of MAO inhibitor therapy. laryngospasm. • Monitor I&O ratio, including urinary and bowel
Safe use during pregnancy (category D) and elimination.
Other: Pain, venous thrombosis,
CLASSIFICATION
lactation is not established.
phlebitis at injection site. • Note: Smoking increases metabolism of
diazepam; lowering clinical effectiveness. Heavy
Central Nervous System smokers may need a higher dose than the
Agent; Benzodiazepine nonsmoker.
Anticonvulsant; Anxiolytic • Note: Psychic and physical dependence may occur
DOSAGE/FREQUENCY in patients on long-term high dosage therapy, in
/ROUTE those with histories of alcohol or drug addiction,
or in those who self-medicate.
3mg slow IV push, repeated
or as needed for seizure
episode
 DRUG STUDY
GENERIC NAME MECHANISM OF ACTION SIDE EFFECTS/ADVERSE NURSING RESPONSIBILITY
REACTION • Watch out for signs of
Normal saline is a sterile, nonpyrogenic solution for
Normal Saline hypervolemia not administer
fluid and electrolyte replenishment.
• Increased serum osmolality unless a solution is clear and
BRAND NAME INDICATION • Hypernatremia container is undamaged.
• Hypokalemia • Never stop hypertonic solutions
Used because it has little to no effect on the tissues and • Altered thermoregulation. abruptly
Plain NSS
Makes the person feel hydrated preventing • Pulmonary edema • Don't give concentrated solutions
hypovolemia
• Cardiovascular overload IM or subcutaneously
DRUG ILLUSTRATION CONTRAINDICATION • Check vital signs frequently.
• Report adverse reactions
Heart failure
• Monitor fluid intake and output
-Pulmonary edema
and weight carefully, Watch
-Renal impairment
carefully
Sodium retention

CLASSIFICATION
Mineral and electrolyte replacement
DOSAGE/FREQUENCY
/ROUTE
IV Fluid 1L 30ml/hr

REFERENCES
• CLIMDAMYCIN Drug Study: Clindamycin: Uses, interactions, mechanism of action | DrugBank Online. (n.d.). DrugBank. https://go.drugbank.com/drugs/
DB01190
• DIAZEPAM Drug Study: Prentice Hall Nurse’s drug guide. (n.d.). http://www.robholland.com/Nursing/Drug_Guide/?fbclid=IwAR3pBlFDICXyLvRNq_uScXvdx
kYcDv4__J7BKg-QygcmvzxXVVaBmOyiQF4
• PLAIN NORMAL SALINE Drug Study: Normal Saline - 0.9% NACL Pharmacology & Usage Details | Medicine India. (n.d.). https://www.
medicineindia.org/pharmacology-for-generic/42/normal-saline-09-nacl#:~:text=This%20solution%20of%20sodium%20chloride%20in%20sterile%20water,not
%20leak%20out%20into%20the%20extra%20vascular%20spaces.