Adverse isonizid


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Adverse isonizid

  1. 1. A care for client with client with adverse drug reaction secondary to Anti-TB medication. In partial fulfillment of Related Learning Experience (R.L.E) Submitted By: Portugal, Marc Prodigalidad, Jhonelle Quiambao, Bianca Rambaud, David Redoble, Arlie Reyel, Arby Reyes, Jennelyn Roderos, Mitch Angela Rojero, Catherine Mae BSN 4C GROUP II S.Y 2011-2012 1
  2. 2. SCOPE AND LIMITATION For the two weeks of rotation of BSN 4C Group 2 in Ospital ng Makati, the group wasable to handle the case of a client with adverse drug reaction secondary to Anti-TB medication.However during that time, the duties and responsibilities ought to be done by the student nurseshad serves as a hindrance to give way for an intensive nursing patient interaction. Aside from thetime constraints, the patient is scheduled for discharge during that time. But we were fortunateenough to gather data that has provided us knowledge and to support our case study which is tobe presented on this day. The group would like to apologize beforehand for the limited amountof information. Yet rest assured that the case presented reflects our utmost learning extractedfrom the information available. INTRODUCTION We BSN group 2 find this case as an interesting one because it is our first time toencounter this kind of case and it leaves some questions on our mind that let us come to adecision to choose this case for our case study. Isoniazid has rarely caused very serious (possibly fatal) liver disease. The risk of liverdisease is increased in people who are 35 years and older, who use alcohol or illegal injectiondrugs, or who currently have long-term liver problems. Tell your doctor immediately if youdevelop symptoms of liver disease, including persistent nausea/vomiting, severestomach/abdominal pain, unusual weakness/tiredness, dark urine, yellowing eyes/skin.Hepatic effect Hepatitis has been reported in less than 5% of patients receiving isoniazid alone. Jaundiceis usually preceded by a prodromal illness with fatigue, nausea, malaise, abdominal pain, andanorexia. Asymptomatic increases in liver function tests may occur. Isoniazid should bediscontinued if hepatotoxicity occurs, usually defined as SGOT greater than four times normal The mechanism of hepatic injury is unknown but may be related to the acetyl metaboliteof isoniazid. Patients exhibiting hepatotoxicity are more likely to be fast acetylators of isoniazid.Eight cases of severe hepatitis resulting in death or transplantation have been evaluated by theDepartment of Health of New York. Duration of isoniazid use before onset of hepatitis rangedfrom 21 to 142 days, and seven patients continued use of isoniazid at least 10 days after onset of 2
  3. 3. symptoms. Massive hepatic necrosis was a common finding and cholestasis was present in twoof five cases. The risk is age related with a greater occurrence reported in patients who are 35 years orolder. The risk of hepatitis is also increased in patients who consume alcohol daily, in women,and in minorities. In a study of 2651 women beginning isoniazid preventive therapy duringpregnancy or postpartum, 5 cases of isoniazid-induced hepatitis were identified, including twofatalities. In another review of deaths due to isoniazid, eight of 21 women between 15 and 44years old were within one year postpartum. In general, death due to isoniazid hepatotoxicityoccurs more frequently in women than men. Fulminate hepatitis, characterized by jaundice, disorders of consciousness and elevatedserum transaminases up to 80 times the upper limit of normal, has occasionally occurred inpatients receiving isoniazid with rifampin. Rifampin, by virtue of its enzyme-inducing activity,likely increases the reactive metabolite of isoniazid thought to be responsible for thehepatotoxicity associated with isoniazid. Monthly monitoring and interviewing of patients should take place. Patients should befully informed regarding the risk of hepatotoxicity associated with isoniazid, educated about thesigns and symptoms of liver damage, and instructed to contact their physician immediately ifthey develop signs or symptoms. 3
  4. 4. DEMOGRAPHIC DATA Client’s name : Patient B.R Gender: Male Age, Birth date and Birth place: 25years old, April 5,1986 at Makati Marital Status: Single Nationality: Filipino Religion: Islam Address: 4565 Jerry St. Pio Del Pillar Makati City Educational Background: College Graduate Occupation: Financial and Corporate Relations Usual Source of Medical Care: Ospital ng Makati A. SOURCE AND RELIABLITY OF INFORMATION  Patient’s Chart  Patient’s Mother  Patient Himself B. REASON FOR SEEKING CARE “Naninilaw ang buong katawan” “pababalik balik na lagnat”As verbalized by the patient C. HISTORY OF PRESENT ILLNESS 23 days Prior to admission From the patient’s interview, Patient B.R has undergone physical examination as requirement for his new job, when the company physician detected a bullae from his CT Chest Scan.thus, the patient was prescribed to take in Isoniazid with Vitamin B complex 4
  5. 5. 2 weeks Prior to admission – Patient B.R complaints of experiencing easy fatigability, anorexia and generalized weakness 4 days Prior to admission – Patient B.Radditionally developed fever,jaundice and hemoptysis. Hence persistence of symptoms has lead the patient for subsequent admission Upon Admission - Patient’s vital signs was taken and recorded of blood pressure of 120/80, PR: 86, RR: 21, Temp: 36.6 c with a general survery of jaundce and ecteric scelera. The patient was hooked with D5LR 1 L x 125cc/hr at left metacarpal vein with laboratory tests rendered such as HbsAg, LFT, ECG, CBC, Na, K, BUN, ultrasound and Chest X-Ray are taken likewise.D. PAST MEDICAL HISTORY Pediatric/Childhood/ Adult Illness: Patient has has a history of drug reaction secondary to anti-tubercular drugs especifically Isoniazid when he was 1 years old. at that time, patient had jaundice, hepatomegaly and purpura examination for work, a granuloma was noted on CAT. Injuries or accidents: The client recieved multiple injuries due to stampede (10 y/0) Serious/ Chronic Illnesses: PTB primary complex (1 y/o) Hospitalizations: Patient was hospitalized due to Viral Infection last 2007 Operations: No known operations Obstetric history: Not applicable Immunizations: The client verbalized of having complete immunization of DPT, OPV, BCG and Measles vaccine. Allergies: The client stated to have food allergies in Eggplant, Egg and Shrimp Medications prior to confinement: The client recieved 23 days of Isoniazid Medication with unrecalled dosage but of an approximate of less than 25 mg Last Examination Date: October 31,2011 5
  6. 6. E. FAMILY HISTORY Father Mother (+) HPN (+) HPN (+) DM (+) DM ( ?? Age ?? Age ?? Age ?? Age 25 y/o LEGEND Male Female Client Heredo-Family Illness Maternal – The Mother side of Patient’s B.R is known to be hypertensive and with Diabetes Mellitus. The client recalled no other inherited illness besides the one indicated above. Father- The Father side of Patient’s B.R is known to be hypertensive and with Diabetes Mellitus. The client recalled no other inherited illness besides the one indicated above.F. SOCIO-ECONOMIC The client consists of a nuclear family and lives together with his parents and siblings. The client states that he contributes for the family financial expenses. Financial Resources are adequate enough to provide for them for the expenses of their everyday living that is by means of his father and with and the help of his siblings who were working likewise though the occupation was not identified. Prior to admission, the client was hired to be a Financial and Corporate Relations at the company with an average income of 18,000 php per month. 6
  7. 7. G. DEVELOPMENTAL HISTORY Erik Erickson Psychosocial Theory Age Task Patient’s Description IntimacyVs. Isolation 19 – 30 Young adults The client is presently single for 6 y/o need to form months and does not comit in intimate, loving intimate relationships. relationships with moreover,there was an observed other people. conflict between the family Success leads to members as suported by the strong patient’s verbaliztion that they are relationships, presently facing a a problem while failure between their family. The client is results in at risk for loneliness and Isolation loneliness and if inadequate support that may isolation. affectt his development if problems are left unresolved.H. REVIEW OF SYSTEMS 1. Regional Examinations (Nov. 24, 2011, 10:30 am) Vital Signs: Temp : 36.1°c RR: 14cpm PR: 64cpm BP: 110/70mmHg General Assessment:  Patient was conscious and coherent; lying on bed and both feet secured. Skin is clean and smooth but it was yellow in color, also has a good or normal skin turgor. Nails are long but not dirty and with normal capillary refill. Patient has an abdominal pain in right lower quadrant when eating with heplock inserted at left metacarpal vein. 7
  8. 8. Date of System Normal Findings Actual Findings AssessmentNovember 24, Integumentary Smooth and good skin I: 2011 turgor, no lesions or any discoloration, no  Yellowish complexion, no lesion, clubbing, no breaks no swelling and edema. &abnormal curvature.  Normal looking  Visible veins on both arms  Has a temperature of 36.2°c. In nails:  Long and clean nails and round nails.  Nailbed yellowish in color P:  Warm, soft, smooth, and has a good skin turgor. In nails:  Hard, immobile, and smooth.November 24, Hair and Head No lesion, no I: 2011 tenderness, no pain on palpation, no masses, no -His hair color is black, hair is evenly lumps, no nodules or distributed, depression, symmetrical -Has thick hair. -No presence of parasite and dandruff. -In scalp: Symmetrical and round and no lesion. P: -Hair texture is smooth and soft. -In head the texture is smooth and firm.November 24, Eyes Eyelid intact, no I: 2011 redness, swelling, discharge or lesions. -Lid margins moist and light pink, Eyeballs are moist & lashes short, evenly spaced and curled glossy, conjunctiva outward. numerous small blood vessels. Sclera white. -Bulbar conjunctiva is clear with tiny Good eye contact. vessels visible, palpebral conjunctiva is light pink with no discharge and the color of the sclera is yellowish. - In PERRLA: *Cornea is transparent and the shape of the iris and pupil is round and equal. *The left and right eye has a good reaction to light (constrict and dilate) 8
  9. 9. -In extra ocular movements: *Both eyes coordinated well in all directions.November 24, Ears Ears are symmetrical I: 2011 with 10 degrees angle. Color is same in facial -Equal size and similar appearance. with no tenderness or any nodule and without -No lesions, color yellow same with any presence of his complexion. discharge. P: -Warm, smooth, no nodules and no tenderness in auricle and tragus.November 24, Mouth and 32 adult teeth are I & P: 2011 Throat present with moist and pink mucous membrane -Lips and surrounding tissue relatively without any lesions or symmetrical.No lesions, swelling and swelling. drooping. -Lip is light pink; moist, smooth and with no lesions. -Buccal mucosa is light pink, moist and without lesions.-Gums are light pink, and moist. -In tongue: *Moist, some papillae present, symmetrical appearance, midline fissures present and the color is pink and color white at the center and no lesions as well as the sides of the tongue. *Hard palate: slightly pink. *Soft palate: pink, -Has 32 teeth and yellowish in color.November 24, Neck No tenderness on I: 2011 palpation, no pain, symmetrically align, no -Neck is symmetric with head enlarged lymph nodes, centered and without bulging masses. no tracheal lateral deviation. P: -Smooth skin, firm, and none tender and none enlarged nodules.November 24, Breast and No palpable nodules and I: 2011 Axillae lesions. Breast is firm -Nipples have no discharges and not and round. cracked.November 24, Respiratory Intercostals spaces are I: 2011 even and relaxed; chest symmetry is equal, no -The color of his chest is similar to his pain or tenderness, and complexion. no abnormal breath sound. -Intercostals spaces are even and 9
  10. 10. relaxed. -Chest symmetry is equal -Thorax: is straight. -The RR of the patient is 14cpm. P: No pain or tenderness. A: Lung is clear to auscultation on inspiration and expiration.November 24, Cardiovascular No fatigue on simple PR : 64 bpm 2011 activities, no arrhythmias and heart BP: 110/70 mmHg murmurs. PR=60- 100bpm. I:-Neck veins are not distended. P: -No vibrations or palpitation in aortic, pulmonic, or tricuspid area. A:-No murmur sound heard.November 24, Abdominal No pain, No palpable I: 2011 masses and tenderness, Flat and round. -Flat abdomen P: -Upon palpation patient experienced mild pain right lower quadrant. November Musculoskeletal Have good range of -Does not need assistance to stand and 24,2011 motion and no limitation toes point straight ahead. Able to of movements. shrug shoulders against resistance.November 24, Neurologic Have no tremors -No presence of tremors, oriented, no 2011 paralysis. Oriented, no history of seizures, mental dysfunction history of seizures, or hallucinations. mental dysfunction or hallucinations. November Lympathic Has no bleeding No swollen lymph nodes. 24,2011 tendencies, normal lymph nodes. 2. Laboratory Studies/Diagnostics Laboratory (Date) Normal Value Result Interpretation/Significance10/31/11 M - 14-18 g/dl 15.5 NormalHemoglobin F – 12 -16 g/dlHematocrit M – 0.40 – 0.54 0.47 Normal F – 0.37 – 0.37White Blod Cells 4.0 – 11.0 7.6 Normal 10
  11. 11. Red Blood Cells M – 5.0 -6.4 4.8 Below Normal Indicates anemia, bone marrow failure, erythropoietin deficiency, hemolysis or transfusion reaction hemorrhage. DIFFERENTIAL COUNTSegmenters 0.5 – 0.7 0.62 Above NormalLymphocytes 0.2 – 0.4 0.31 Above Normal Increased in presence of infectionMonocytes 0.02 – 0.05 0.07 Above Normal Seen in chronic inflammation, stress response,hyperadrenocorticism , and immune-mediated diseasePlatelet 150- 300 145 Normal Laboratory (Date) Normal Value Result Interpretation/Significance11/04/11 M - 14-18 g/dl 15.4 NormalHemoglobin F – 12 -16 g/dlHematocrit M – 0.40 – 0.54 0.43 Normal F – 0.37 – 0.37White Blod Cells 4.0 – 11.0 6.9 NormalRed Blood Cells M – 5.0 -6.4 4.5 Below Normal Indicates anemia, bone marrow failure, erythropoietin deficiency, hemolysis or transfusion reaction hemorrhage. DIFFERENTIAL COUNTSegmenters 0.5 – 0.7 0.67 Above NormalLymphocytes 0.2 – 0.4 0.26 Above Normal Increased in presence of infectionMonocytes 0.02 – 0.05 0.07 Above Normal Seen in chronic inflammation, stress response,hyperadrenocorticism , and immune-mediated diseasePlatelet 150- 300 155 Normal 11
  12. 12. 10/31/11 Clinical S.I Unit Range Conversion Unit Result Interpretation Chemistry Result Result SectionAST (SGOT) 3603 u/L 15-37 3603 u/L 15-37 Above NormalALT (SGPT) 3933 u/L 30-65 3933 u/L 30-55 Above NormalAlkaline 190 u/L 50-165 190 u/L 50-165 Above NormalPhosphtase Above normal indicates response of cholestatic liver diseaseSodium 133 u/L 136-145 133 meq/L 136-145 Below NormalPotassium 4 u/L 3.5-5.1 4 meq/L 3.5-5.1 Normal 11/19/11 Clinical S.I Unit Range Conversion Unit Result Interpretation Chemistry Result Result Section Above Norma AST (SGOT) 104 u/L 15-37 104 u/L 15-37 Serum AST and ALT increased in liver damage, ALT (SGPT) 268 u/L 30-65 268 u/L 30-55 Above Normal 11/13/11 Clinical S.I Unit Range Conversion Unit Result Interpretation Chemistry Result Result SectionTotal Protein 104 g/L 64-82 6.20 g/dL 6.4-8.1 Above Normal May indicate Chronic infection (including tuberculosis), Liver dysfunction, Dehydration, AlcoholismAlbumin 268 g/L 34-50 3.10 g/dL 3.4-5.0 Above Normal May indicate Dehydration, Poor 12
  13. 13. protein utilizationGlobulin 31 g/L 30-32 3.10 g/dL 3-3.2 Normal /C Ratio - 1.1-1.6 1.00 1.1-1.5 Normal 11/07/11Clinical Chemistry SectionBillirubin Results Interpretation Total 0-20-52 umol/L 433.50 Above Normal Direct 0-8.55 umol/L 201.70 Indirect 0-11.97 umol/L 231.80 11/1/11Clinical S.I Unit Range Conversion Unit Result InterpretationChemistry Result ResultSectionBUN 3.3 mmol/L 2.5-6.4 9.24 mg/dL 7.0-18.0 NormalCreatinine 54 umol/L 53-115 0.61 mg/dL 0.60- Normal 1.30 11/01/11 Blood Coagulation Tests Range Results Interpretation Prothrombin Time 10.4 – 14.0 sec 27.7 sec Above Normal % Activity 73 -127 % 27.6 % Normal INR 0.88 – 1.21 sec 2.78 sec Above Normal PTT 30.4 – 41.2 sec 75 sec Above Normal 11/07/11 Blood Coagulation Tests Range Results Interpretation Prothrombin Time 10.4 – 14.0 sec 29 sec Above Normal % Activity 73 -127 % 26 % Normal INR 0.88 – 1.21 sec 2.93 sec Above Normal PTT 30.4 – 41.2 sec 93.2 sec Above Normal 13
  14. 14. 10/31/11 URINALYSIS DATE: LAB NO. PATIENT’S NAME: ROOM AGE: SEX: MALE PHYSICAL CHMICAL Color Dark Yellow Protein +3 Transparency Slightly Hazy pH 6.0 Sugar NEGATIVE Specific Gravity 1.030 MICROSCOPIC CRYSTALS Amorphous Urates FEW CELLS White Blood cells 7 – 10 hpf Red blood cells 3 – 5 hpf Epithelial cells MODERATE OTHERS Bactaeria & Mucus Threads: OCCASIONAL 14
  15. 15. 3. Other Assessment Tools Procedure Indication Results Nursing intervention11/22/11 The acid-fast stain is an Microscopic Pre Examination : especially important test Advise patient to drink a lot of fluids the night before the test. It makes theAcid Fast Stain for the test more accurate if its done firstSpecimen Negative thing in the morning. genus Mycobacterium, to Advised patient not to take rule out pulmonary antibiotics and some sulfonamides because it may interfere with test tuberculosis. results, causing the results to be falsely negative. Prior to breakfast, the patient will be asked to provide a 5-10 mL specimen of sputum delivered into a sterile cup with a screw top lid.11/18/11 Intra Asked patient to cough deeply and spitAcid Fast the substance that comes up from the lungs (sputum) into a container.Stain Specimen Microscopic Examination: Patient may be asked to inhale a mist of salty steam in order to cough Negative more deeply and produce sputum. Post Place it in a sterile container, label appripiately and immdiately forward in the laboratory. 15
  16. 16. Procedure Indication Results Nursing intervention11/19/11 CT scanning or (+) Small Pre sometimes called CAT Bullae, both Remove all Metal objects including scanning is a noninvasive apices minimal jewelry, eyeglasses, dentures andCT Chest Scan hairpins. Patient may also be asked medical test that helps fibrosis left to remove hearing aids and removable dental work. physicians diagnose and upper lung Instruct not to eat or drink anything treat medical conditions. normal for several hours beforehand, especially if a contrast material will parenchyma be used in exam. CT scanning combines (-) opacities or Intra special x-ray equipment A chest ct scan takes about 30 with sophisticated densities mins., which includes preparation time computers to produce Patient mat lie on a narrow table that moves through the hole multiple images or While inside the scanner, an x-ray pictures of the inside of tube moves around your body. You will wear soft buzzing, clicking or the body. These cross- whirring noises as the scanner takes pictures sectional images of the The technician will ask you to lie still and hold your breath for short area being studied can periods. these measures help make then be examined on a the picture as clear as possible the scan itself computer monitor, printed Post or transferred to a CD. CT exams are generally painless, fast and easy. After a CT exam, you can return to your normal activities. 16
  17. 17. Procedure Indication Results Nursing intervention11/1/2011 An Gall bladder not PreAbdominal abdominal ultrasound visualized likely Instruct patient on NPO prior to procedureUltrasound uses reflected sound contracted. Suggest For a study of the liver, gallbladder, spleen, and pancreas, you may be waves to produce a follow-up scan after 3 asked to eat a fat-free meal on the evening before the test picture of the organs days. Explain that the procdure is non- invasize and painless and other structures in Instruct patient to wear comfortable, loose-fitting clothing the upper abdomen. Instruct to remove all clothing and jewelry in the area to be examined. Sometimes a Intra specialized ultrasound Assist patient in proper positioning Instruct that There will be little is ordered for a discomfort. The conducting gel may feel slightly cold and wet. detailed evaluation of a specific organ Post Assist patient in cleaning the gel and Aftercare of materials 17
  18. 18. Procedure Indication Results Nursing intervention10/31/11 HBsAG stands for Pre InterventionsHbsAg hepatitis B surface Non-Reactive Explain the procedure to the(qualitative) patient. antigen. It Specimens submitted for testing indicates current are handled according to the HRL SOP entitled "Sample Handling" Hepatitis B No special instructions such as infection. fasting or special diets are required. Diurnal variation is not a major consideration. Specimens may be serum, recalcified plasma, or plasma. Serum specimens may be collected using regular red-top or serum-separator Vacutainers. Intra Interventions Required sample volume is 10 μL for the assay; 1.0 mL will permit repeat analyses as well as other testing. Post Interventions Specimens should be stored in plastic vials and sealed tightly to prevent desiccation of the sample. Serum or plasma samples are collected aseptically to minimize hemolysis and bacterial contamination. Samples are stored in labeled 2 mL Nalgene cryovials or equivalent. 18
  19. 19. Procedure Indication Results Nursing intervention10/31/11 Electrocardiogram A.V Block I PreElectrocardiogram (ECG) provides 12 Explain the procedure to the patient. vector views of the Cannot rule out Instruct patient to wear comfortable, loose-fitting clothing heart’s electrical lateral Instruct to remove all Metal objects including jewelry, activity as reflected by infarction eyeglasses, dentures and hairpins. Patient may also be asked to electrical potential remove hearing aids and removable dental work. differences between In some instances, men may require the shaving of a small positive and negative amount of chest hair to obtain optimal contact between the leads electrodes placed in the and the skin limbs and chest wall. Intra ECG is crucial for EKG leads are attached to the body while the patient lies flat on establishing many a bed or table. Leads are attached to each extremity (four total) and cardiac diagnoses, to six pre-defined positions on the front of the chest. A small amount especially arrhythmias of gel is applied to the skin, which allows the electrical impulses of and myocardial the heart to be more easily transmitted to the EKG leads. ischemia. Instruct that the test takes about five minutes and is painless. I. FUNCTIONAL ASSESSMENT HEALTH PERCEPTION-HEALTH MANAGEMENT Prior to admission, the patient tells his stressful schedule he had from his previous work. The patient works everyday in midnight shift of from 12:00 am – 9:00 am or up to 3:00 am – 12:00 noon, in which has affected his health in general. Furthermore, the patient does not consume multivitamins but does not experienced colds in the past 3 months as far as he could remember. The client is aware of the etiology of his illness and positively adheres to medical advices. The client feels well unlike his first admission. That “sobrang dilaw ko” verbalized by the patient as he exclaims his disbelief from the extent of his disease process. The client 19
  20. 20. claims that he acquired his disease during his infant years being exposed to PTB and learnedto exhibit an adverse reaction to Isoniazid back then. Presently, the Patient does not find anydifficulty on the advices given by doctors and nurses to him,he believes that by cooperatingand adhering on the medications would continually make her better and soon to bedischarged. The client adheres to therapeutic regimen of taking Essential Forte 1 tab T.I.Dand Silymarin Capsule T.I.DSELF-ESTEEM, SELF CONCEPT/SELF PERCEPTION PATTERN Before the patient was admitted, he sees himself being able to do things according tothe manner he wants it. He does not mind his health not until the manifestation of discomfortbrought from his disease. Presently, the client verbalized difficulty of being sick; he statedthat he will find it hard to adjust from it. The client admitted that his self-perception in hisbody has changed, as he needs to be more conscious in taking care of himself such asrefraining from stressful situations, refraining from alcoholic beverages and smoking. Theclient honestly verbalized a change of perception about self. That because of his condition,job opportunities are lessened because of it’s permanent effects. Despite of it, though“Matatagalan nga lang ang pagkakawala ng paninilaw ko” as verbalized by the client but Heaffirms a positive prognosis to his health, the patient stated that he is looking forward to be athome, and to make up the responsibilities that he had missed due to his absence.ACTIVITY/EXERCISE PATTERN Prior to confinement, the client describes his previous activities as stressful. the clienttakes his OJT as being recently hired from that certain company. The client usually worksmidnight around 12:00 am – 9:00 am or 3:00am – 12:00 pm . The client remarks his previousactivities as a form of exercise. His favorite sports are basketball and . But he prefers tostay at home and rest during his free time. Presently, the patient is confined in the primary holding unit. The client assumes fullself care on himself. The client is on bed rest and does minimal activities. He states that hewould play games in his cell phone or listen to music to let the time pass. The client is notedto be sleeping most of the time. 20
  21. 21. Feeding 0 Grooming 0 Bathing 0 Gen. Mobility 0 Toiling 0 House 0 maintenance Bed mobility 0 Dressing 0 Legends: Level 0 – Self Care Level I – Use of equipments Level II– Assistance from another person Level III –Requires assistance from another person or device Level IV – Dependent and does not participateSLEEP/REST PATTERN The client has 9 hours of sleep and sleeps around 10 o’clock in the evening and wakes uparound 8’oclock in the morning. The client states that he feels full rested upon waking up. Theclient has no difficulty of sleeping except from some external factors such as the noise of otherpatients that he shares the ward with. The client does not use any sleeping pills but prefers toplay music in his radio to induce sleep. The client frequently naps in the morning.NUTRITIONAL-METABOLIC PATTERN The client eats three times a day with low salt and low fat diet, the client prefers to eat insmall frequent meals to prevent the pricking pain in his right upper quadrant and for the reason tominimize the workload of his liver to digest nutrients. The client has poor appetite andexperienced weight loss of 3kg, from 58 kg to 55kg. There client is has food allergy in Eggplant,Egg and Shrimp. The client drinks 7-8 glasses of water.ELIMINATION PATTERN The client states that he defecates once a day usually in the morning in soft brown stoolwithout difficulty and use of laxatives. The client urinates 4x day or more varying in his fluidintake; he verbalizes no difficulty in voiding.SEXUALITY/REPRODUCTIVE The client is presently single for 6 months and is sexually inactive. He was circumcisedby the age of 11.INTERPERSONALRELATIONSHIPS/RESOURCES The client is the youngest son among his 3 siblings. The client verbalized that there has beena problem faced by the family from the previous months, the presently affects the interpersonal 21
  22. 22. relationships between his siblings and parents. In terms of decision making, the client assumesfull responsibility of himself in terms of his personal issues. But when in terms to health andother concerns affecting the family, the client considers the opinions of his family as well.COPING & STRESS MANAGEMENT/ TOLERANCE PATTERN The client states that whenever he feels frustrated, he would initially avoid the stressfulsituation to deliberately think before making out judgments. He stated that he perceive problemspositively and would joke about it to help him relieve stress. .VALUES/ BELIEFS The client is an Islam since birth. However, he states that he does barely attend theirchurch and practice due to preoccupation to other things. As of the present time, the client stated that his condition will eventually pass and he willrecover quickly.He stated that he will abstain from drinking alcoholic beverages, smoking, andfrom over abusing his body.J, PERSONAL/SOCIAL HISTORYHabits: The client has the habit of smoking to past time, improve concentration or to help himrelive from experiencing anxiety and stress.Vices: The client started drinking at the age of 13 of Beer as his alcoholic preference. The clientstarted smoking 4 packs of green Malboro cigarettes at age 13Lifestyle: The client was known to live in a stressful lifestyle.Client’s usual daily life: The client’s typical day is working as financial and corporate relationsin midnight then goes straight home for rest and preparation his next shift. the client wouldwatch DVD’s or rest during his day offs.Rank/Order in the family: the Client is ranked as the youngest son to his 3 siblings.Travel: The client’s known travel is from his home and to his work. The client has no previouslocal and intonation travel for the past 6 months. 22
  23. 23. J. ENVIRONMENTAL HISTORY The client lives together with his parents and siblings. The client describes his residency as acompound where his extended relative’s family lives. The client described their house asbungalow type which is well ventilated and and adequate to live for household members of five.The client stated that their home is adequately supplied by water, electricity and near fromestablishments such as market, church and school. Environmental problems that were identifiedare the presence of by standers who frequently drinks alcoholic beverages, and a semi talyer thatbrings polluted air.K. PEDIATRIC HISTORY Maternal and Birth history Birth date: April 5, 1986 Hospital: Not assessed Birth Weight: Unrecalled Type of Delivery: Normal Spontaneous Delivery Condition after Birth: The client is born stable in condition Mother: Complications of Delivery: No known complications Anesthesia during Labor: No known usage of anesthesia Exposure to Teratogenic agents during pregnancy: No known exposure to teratogenic agents 23
  24. 24. I. PATHOPHYSIOLOGY Adverse Drug Reaction 2 to anti-TB medications PREDISPOSING PRECIPITATING II. FACTORS FACTORS Age Immunity History of TB Prim0ary Lifestyle Complex (1 y.o) History of hepatomegaly,purpura and Smoking granuloma Alcoholic Stress 23 days of Medicating Isoniazid AV BLOCK I HEPATOXICITY Elevated Liver Function Tests Impaired Liver FunctionImpaired ability to Impaired water Insufficient Impaired Bilirubin emulsify fat regulation coagulating factors excretion Right Upper Imbalance in water Delayed Blood Elevated bilirubin Quadrant Pain and sodium Clotting levels Hyponatremia Jaundice Adverse Reaction 2 to Anti-TB medication 24
  25. 25. III. CONCEPT MAPPING 1. Impaired liver function related to hepatotoxic medication as evidenced adverse reaction of Isoniazid Adverse Reaction 2 to Anti-TB medication Patient B.R; 25 y/o Male.4. Disturbed body image Temp.: 36.1°c RR: 14cpm PR: 64cpm BP: 110/70mmHg 2. Acute pain related to  23 days of taking isoniazid medicationsrelated to increased  Jaundice inflammation and swelling ofproduction of Bilirubin as  Enteric sclera the liver as evidenced byevidenced by jaundice  Weight Loss from 58 to 55 kg pain in right upper quadrant  BMI of 18.5 (undewrweight)  Elevated Liver function tests, Bilirubin  CT Chest Scan result:  UZ result: Liver is likely contracted  Complaints of right upper quadrant pain after eating (P/S of 6/10)  Facial Grimace  Verbalization of negative perception to self 3. Imbalance Nutrition: Less than body requirements related to inability to digest adequate 25 nutrients
  26. 26. IV. PROBLEM LIST Actual Problem Problem Remarks Number Impaired liver function related The client exhibited an abnormally elevated 1 to hepatotoxic medication as Liver Funtion tests, indicating an impaired evidenced adverse reaction of liver funtion. Isoniazid 2 Acute pain related to Patient has complaints of right upper quadrant inflammation and swelling of pain after eating or belching. The problem is the liver as evidenced by pain in suspected to persist to impairment of the liver. right upper quadrant 3 Imbalance Nutrition: Less than There is a decrease in weight due to feeding body requirements related to modifications caused by his present liver inability to digest adequate impairment. Thus, the client is unable to nutrients nourish his body in desireable range (BMI of 18. 5) Weight loss is clearly evident due to the fall of his weight from to 58 kg to 55kg 26
  27. 27. 4 Disturbed body image related to Impairement in the liver has caused difficulty increased production of excretion of metabolic waste such as Bilirubin as evidenced by bilirubin, such excessive amount of bilirubin jaundice manifested from the client’s yellowish discoloration of skin, sclera and nail beds. 27
  28. 28. V. NURSING CARE PLAN Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Impaired liver After 2 weeks Review results by obtaining Indicates presence of hepatotoxic After 2 weeks of“ kahit ng bata pa ako, function of nursing previous Liver Function medication and need for medical nursingnaninilaw ako sa pag related to intervention, Tests such as SGPT, treatment. intervention,umiinom ako ng hepatotoxic there will be a SGOT, Creatinine, Alkaline Liver functionIsoniazid” as medication as decrease Phosphtase test taken lastverbalized by the evidenced manifestation of October 31.2011patient adverse liver failure as Emphasize the importance To reduce incidence of cirrhosis decreased as of reaction of evidenced by an of abstaining any forms of or severity f liver damage/failre result taken last Isoniazid improvement in alchoholic beverages NovemberObjective: liver function 19,2011 With history of of results from taking isoniazid previous Encouraged client to avoid To prevent aggravation of AST = 104 (n: for23 days examinations. eating deep fried foods, disease. Liver is responsible for 15-37) medications chicken skin, chicharon fat emulsification ALT =268 (n:30- Jaundice which are high in fats 65) Enteric sclera Elevated Liver function tests, Administered hepato To promote pharmacologic AST =3603 u/L protectors and treatment of disease ALT = 3933 u?L multivitamins as orderesd Bilirubin: 433.50 a.) Silymarin umol/L b.) Essential Forte UZ result: Liver is c.) Mutivitamns likely contracted Emphasized the need for To monitor and determine follow-up check-ups and effecitiveness of therapeutic ahering to monitoring of regimen Liver function tests such as SGPT, SGOT, Creatinine, Alkaline Phosphtase . 28
  29. 29. Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Acute pain By the end of  Monitored Vital signs q 30 until Baseline data is important to help By the end of“ Sumasakit ang related to 8 hours of the patient stable especially Determine patient’s current health 8 hours oftsyan ko sa tuwing inflammation nursing respiratory rate and blood status and evaluate efficacy of nursingnakain ako” as and swelling intervention, pressure nursing interventions rendered intervention,verbalized by the of the liver as the thepatient evidenced by Patient will  Assess the patient’s pain by using The client’s report of pain is the Patient will pain in right verbalize a the 10 point pain rating scale q4 single most reliable indicator of verbalized a upper decrease in hrs or PRN during the 2-10pm pain. decrease inObjective: quadrant pain scale shift. pain scale from from 6/10 to 6/10 to 0/10 Pain Scale of 0/10  Performed comprehensive Pain is a subjective experience and 6/10 assessment to pain include must be described by the client in With complaints location , characteristic, onset, order to plan effective treatment of pain after duration, frequency, meal or during quality, intensity or severity Facial grimace  Provided nonpharmacologic pain Relaxation techniques decrease relief methods, such as breathing oxygen consumption, respiratory exercises, music therapy, rate, heart rate, and muscle tension, distraction and progressive which interrupt the cycle of pain– relaxation before, after, and if anxiety–muscle tension. possible during painful activities.  Kept side rails up and bed in low position. To reduce likelihood of falls and to promote a safe environment.  Administered Pain medications as ordered such as Tramadol To promote pharmacologic measures in relieving pain 29
  30. 30. Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Imbalance After 4 hours of Assessed the present weight of the Provides baselinedata about the After 4 hours“Ang lake pa ng Nutrition: nursing client by the use of weighing scale client. of nursingkatawan ko dati Less than intervention, the intervention,kumpara sa body patient will Determined the client’s attitude Psychological factors towards the patientngayon. ang lake requirements verbalize towards eating. eating may affect one person’s verbalizedtalaga ng related to understanding on appetite and also to know the understandingpinangayat ko” inability to the importance client’s eating habits. on theas verbalized by digest of proper diet importancethe patient adequate Educated the client regarding the Education provides ample of proper diet nutrients as importance of eating healthy foods information that the client mayObjective: evidenced in terms of benefits to his body not be aware 8of, hence leading by BMI of such as green leafy to the kind of eating habits and Weight Loss 18.5 vegetablesfoods, citrus fruits such diet he is following. from 58 to 55 as dalandan, orange, calamansi kg juice, bayabas to increase the BMI of 18.5 body’simmunity (undewrweight ) Instructed the client to avoid Caffeinated beverages may Complaints of caffeineated beverages like coffee, decrease the appetite and will right upper tea, softdrinks and energy drinks. make the client feel full easily quadrant pain after eating Encourged the client to eat in small To minimize occurances of frequent feeding right upper quadrant pain by reducing the workload of the Instructed the patient to avoid foods liver rich in fats found in deep fried foods, chicken skin, chicharon and To prevent aggravation of foods rich in salt such as disease. Liver is responsible for Canned goods and procesed meats fat emulsification and water Seasoned foods sodium-regulation Dried fish To assist as needed and to offer Stayed with client during meals. support and encouragement. 30
  31. 31. Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Disturbed body At the end of  Observed emotional May indicate acceptance After 8 hours of“Ang panget image related to 8 hours of changes. or non-acceptance of nursingkong tignan, increased nursing situation. intervention thepara na akong production of intervention  Assess mental and physical influence of clientspongebob” as Bilirubin as the client will present condition on the client’s To determine factors verbalizedverbalized by the evidenced by verbalize emotional state influencing emotional understandingpatient jaundice understanding state of body of body  Established therapeutic nurse-client changes. changes. relationshipObjective:  Regognized behaviours indicative of Conveys an attitude of Verbalization over concern with body and it’s process caring and to develop a of negative sense of trust perception to  Encourage verbalization of concerns of self disease process, future expectations. Serves as objective cues to With determine extent of jaundice and  Invovle patient in planning care and enteric sclera scheduling activities Provides opportunity to  Assessed clients current level of identify fears/mis-concept adaptation and progress. and deal with them directly.  Assist with grooming needs as necessary. Enhances of feeling of competency/self worth. Encourages independence and participation in therapy To determine coping abilities and skills Maintaining appearance enhances self-image. 31
  32. 32. Cues/Needs Nursing Planning Implementation Rationale Evaluation DiagnosisSubjective: Risk for After 2 weeks  Determined  Adverse reaction of After 2 weels of nursing“Matatagalan pa bago situational low of nursing individual factors that medicating Isoniazid intervention, the patientbumalik ang kulay ko” as self-esteem intervention, would contirbute in has caused yellowish verbalizedverbalized by the patient related to the patient will diminishing self- discoloration of skin acknowledgement of disturbed body acknowledge esteem factors that contributes toObjective: image as factors that feelings of low self-esteem With Jaundice, Enteric evidenced by lead to  Determined client  To detemine Sclera and Yellowish Jaundice possibility of awareness of own awareness of Nail beds feelings of low responsibility for situation to detemine self-esteem dealing with the individual’s situation, personal coping skills growth and so forth  Assessedfore  Contributes to view presence of negative of situation as attitudes or self-talk hopeless/ difficult  Observed non-verbal  Incongruencies languanges between verbal and non-verbal communication requires clarification  Assesed family  To determine dynamics and support adequate spport of client system of the patient Provide information about disease process, To help the patient prognosis, and alleviate the emotional treatment needs. disturbances that he’s Enhance self-concept, feeling and for the acceptance of situation patient’s faster recovery and will do no further harm. 32
  33. 33. MEDICAL-SURGICAL MANAGEMENT i. Pharmacotherapeutics DRUG NAME MECHANISM OF ACTION INDICATION SIDE NURSING EFFECTS IMPLICATIONBrand Name: Among the pharmacodynamic Acute, subacute & Abdominal pain, Do not use Essentiale properties were reported chronic nausea, diarrhea in hypersensitivity or all hepatoprotective effects found in hepatitis; toxic and allergic ergy to any ingredientsBrand Name: numerous experimental models into metabolic liver reaction(skin of the preparation.Essential Forte acute liver damage eg, induced by diseases, intoxications rash) ethanol, alcyl alcohol, carbon (eg fromClassification: tetrachloride, paracetamol and drugs); infection, fattyHepatic Protectors galactosamine. Moreover, in degeneration of the liverDosage: chronic models (ethanol, due to thioacetamide, organic solvents), alcohol, hypernutrition,1 tab the inhibition of steatosis and DM, fibrosis was also seen. As active kwashiorkor, pregnancy; principle has been suggested cholestasis; pre- & post- accelerated membrane regeneration op care, and stabilisation, inhibited lipid esp in liver/gallbladder peroxidation and inhibited collagen surgery synthesis. 33
  34. 34. DRUG NAME MECHANISM OF ACTION INDICATION SIDE NURSING EFFECTS IMPLICATIONGeneric Name: Contains fat soluble vitamins (A, D Treatment and GU: Urine Assess patient for signs ofTheravim and E) and most water-soluble prevention of vitamin Discoloration nutrition deficiency prior to vitamins (B-Complex vitamins B1, deficiencies. MISC: Allergic and throughout therapy.Brand Name: B2, B3, B5, B6, B12, Vit. C, biotin Dietary supplement for reactions to Instruct to notify side effects and folic acid). These vitamins are a the treatment and preservatives, of medication to physician.Multivitamin diverse group of compounds prevention of vitamin additives or Encourage to comply on necessary for normal growth and deficiencies. These colorants. medication.Classification: development. Many act as vitamins are necessary Encourage patient to comply coenzymes or catalysts in numerous for normal growth and Contraindicated with physiciansVitamins and metabolic processes. Liquid development. Many act in ypersensitivity recommendations. ExplainSupplements products do not contain folic acid. as coenzymes or to preservatives, that the best source of catalysts in numerous colorants, or vitamins is a well balancedDosage: metabolic processes additives, diet with foods from the 4 including basic food groups.1 tab tartrazine, saccharin, and aspartame 34
  35. 35. DRUG NAME MECHANISM OF ACTION INDICATION SIDE NURSING EFFECTS IMPLICATIONBrand Name: Liver Cell Growth-Silymarin from -Liver Diseases, acute, Common: milk thistle appears to promote the chronic hepatitis Diarrhea caused Know the 10 rights in givingSilymarin growth of some types of cells in the - Protect liver from by mild laxative medication liver. Milk thistle is not used to prevent toxins, heavy metals, effect, uterine Hepatitis C Virus from causing liver alcohol, poisons and menstrualBrand Name: disease. Rather, milk thistle is used - Cholagogue stimulation. Observe proper position in with the hope that it would minimize - Fatty degeneration of taking medication to preventLiveraide the damage to the liver that HCV can the liver Case report: One aspiration cause. - Jaundice report of a Antihepatotoxic Activity-Studies - Psoriasis patient who Encourage patient drinkDosage: - Uterine tonic, experienced plenty of water to enhance suggest that silymarin from milk thistle menstrual difficulties intermittent absorption can block various types of toxins from1 tab - Spleen, kidney, gall episodes of entering and injuring liver cells. bladder tonic sweating, Encourage patient to comply Antioxidation-Milk thistle Silymarin - Varicose veins nausea, to the physicians may be an effective "antioxidant," vomiting, recommendation concerning which means milk thistle may help diarrhea, about the drug. fight a destructive chemical process in abdominal pain, the body known as "oxidation." In weakness and oxidation, harmful substances collapse that produced in the body (called free resolved after radicals) can damage cells. Some discontinuation studies suggest that milk thistle of supplement. silymarin can prevent these substances from damaging liver cells. Inflammation Inhibition-Milk thistles Silymarin is thought to prevent inflammation (swelling) of the liver; this may be described as displaying anti-inflammatory properties. 35
  36. 36. DISCHARGE HEALTH TEACHING Content StrategyM-medication To adhere in prescribed  Instruct patient to take the prescribed  Multivitamins therepautic regimen for health medications as ordered by the  Silymarine maintainance and resistance. physician.  Liveraid.  Instruct patient to avoid taking OTC drugs unless given with medical adviceE-exercise To promote a healthy  Encourage patient to include atleast 30 lifestyle, maximizing the minutes of walking or jogging or level of health and increase perfrom tolerated and preferred the body’s immunity. activities as a means of exerciseT-treatment  Encourage patient to attend follow up Attending the follow up check up of Liver Function Tests to check up. determine the progression or aggravation of disease 36
  37. 37. Health teaching about the  Instruct the patient toavoid all formsH-health teaching disease, exercise and diet. of vices that could affect his health status especially such habits that are hepatotoxic liver like smoking cigarettes and drinking alcohol beverages. Instruct that they need to have  Emphasize the importance of adheringO-OPD a health check up. to medications and attending follow- up check up.  Instruct patient to eat in small frequent Maintain and ensure adequateD-diet feeding to reduce work load of liver intake for noursihment,  Instruct patient to avoid consumption of salty and fatty foods. .  Advise patient to refer to health care If any signs of symptoms areS-signs and symptoms professional if jaundice, right upper present go to the nearest pain and other discomforts persists. hospital for check up. 37
  38. 38. VI. ONGOING APPRAISAL Patient B.R, a 25 year old male, has been admitted to Ospital ng Makati last October 31,2011 with the chief complaint of jaundice and on and off fever. Upon assessment, it wasobserved that the patient is conscious, with generalized jaundice and with enteric sclera.Thus, was diagnosed to have a drug-induced hepatitis. The client is admitted in EmergencyRoom and inserted of D5LR 1 L x 125cc/hr at left metacarpal vein with laboratory testsrendered such as HbsAg taken on October 31, 2011 and resulted as non-reactive, butobserved to have elevated AST of 3603 u/L (n= 15-37), ALT of 3933 u/L (n=30-65),Alkaline Phosphatase of 190u/L (n=50-165 u/L). ECG taken on same date reveals to haveAV block I, CBC, Na, K, BUN, ultrasound and Chest X-Ray are taken likewise. Blood coagulation test done at November 1, 2011 with an increase of Prothrombin timeof 27.7 sec (n=10.4-14 sec), INR (2.78 n= 0.88-1.21), PTT of 75 sec (n =30.4-41.2 sec). Theclient is ordered for low salt and low fat diet. Abdominal ultrasound reveals liver to be likelycontracted, suggests follow-up scan after 3 days. . By November 2, 2011, Blood Coagulation tests were repeated and ordered for TPAG.The client is prescribed with Vitamin K 1 amp Q8 x 3 doses; regulate IVF for 1 L x 100cc/hrand for repeat of ultrasound. From the subsequent weeks upon admission the The clientcomplaints of body malaise, fever and loose of appetite By November 5, latest ultrasound reveals same result like before. By November 15,2011, patient claims to have pricking right upper quadrant pain and was given Tramadol 500mg tab. by November 16, 2011 the client was ordered for chest x-ray Postero-Anterior ViewLateral, and chest CT scan and Repeat AFB Presently, the client is for discharge with latest liver function test taken last November19, 2011. The client appears jaundice, with enteric sclera and yellosih nail beds with vitalsigns of Temp.: 36.1°c RR: 14cpm PR: 64cpm BP: 110/70mmHg. 38
  39. 39. 39