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Generic Name: Paracetamol

Brand Name: Aeknil

Classification: Analgesics (Non-Opioid) & Antipyretics

Indication: Pyrexia of unknown origin. Fever & pain associated w/ common

childhood disorders, tonsillitis, upper resp tract infections post-immunization
reactions, after tonsillectomy & other conditions. Prevention of febrile
convulsion. Headache, cold, sinusitis, muscle pain, arthritis & toothache.
Contraindication: Nephropathy.

Mode of Action: Decreases fever by inhibiting the effects of pyrogens on the

hypothalamic heat regulating centers and by a hypothalamic action leading to
sweating and vasodilation.

Relieves pain by inhibiting prostaglandins synthesis at the CNS but does not
have anti-inflammatory action because of its minimal effect on the peripheral
prostaglandin synthesis.

Side/ Adverse Effect: Anorexia, nausea, vomiting, constipation, hepatic


Nursing Responsibilities: Assess patient’sfever or pain:type of


Assess allergic reactions: rash, urticaria; if theseoccur, drug mayhave to


Give with food ormilk if GI upsetoccurs

Generic Name: Ketoanalogues & essential amino acids

Brand Name: Ketosteril® [Film-coated tab]

Classification: Other Drugs Acting on the Genito-Urinary System

Indication: Prevention & therapy of damages due to faulty/deficient protein

metabolism in chronic renal insufficiency.

Contraindication: Hypercalcemia, disturbed amino acid metabolism.

Mode of Action: Normalizes metabolic process, promotes recycling product

exchange. Reduces ion concentration of potassium, magnesium and

Side/ Adverse Effect: Hypercalcemia.

Nursing Responsibilities: Evaluate for any contraindications
Warn the patient about possible side effects and how to recognize them
Frequently assess for hypercalcemia
Give with food if GI upset occurs

Generic Name: Ciprofloxacin

Brand Name: Quinosyn

Classification: Quinolones

Indication: Infections of the resp tract, middle ear, sinuses, eyes, kidneys
&/or UTI, genital organs (including gonorrhea), abdominal cavity (eg bacterial
infections of the GIT, biliary tract, peritonitis), skin & soft tissues, bones &
joints; septicemia, infections in patients w/ reduced host defenses, selective
gut decontamination.

Contraindication: Hypersensitivity to quinolones. Childn, adolescents.

Pregnancy & lactation.

Mode of Action: Inhibition of topoisomerase(DNA gyrase)enzymes,which

inhibitsrelaxation ofsupercoiledDNA andpromotesbreakage

Side/ Adverse Effect: Nausea, diarrhea, vomiting, abdominal pain, flatulence

& anorexia. Dizziness, headache, tiredness, agitation & trembling. Skin
rashes, pruritus & drug fever. Joint pains. Photosensitivity & transient renal
impairment. Stevens-Johnson syndrome, Lyell syndrome.

Nursing Responsibilities: Instruct patient not to take ciprofloxacin with dairy

products such as milk or yogurt, or with calcium-fortified juice. He may eator
drink dairy products or calcium-fortified juice with a regular meal, but do
notuse them alone when taking ciprofloxacin. They could make the
medication less effective.

Tell patient that Ciprofloxacin can cause side effects that may impair his
thinking or reactions. Tell patient to be careful if he plans to drive or do
anything that requires him to be awake and alert.

Instruct patient to take ciprofloxacin with a full glass of water (8 ounces).

Generic Name: Potassium Chloride

Brand Name: Kalium® [durule]

Classification: Electrolytes
Indication: Hypokalemia. Prophylaxis during treatment w/ diuretics.

Contraindication: Renal insufficiency, hyperkalemia, untreated Addison's

disease, constriction of the esophagus &/or obstructive changes in the
alimentary tract.

Mode of Action: Provides a direct replacement of potassium in the body.

Side/ Adverse Effect: Diarrhea, nausea, stomach pain, discomfort or gas


Nursing Responsibilities: Watch out for levels of potassium electrolyte level

to prevent hyperkalemia.

Observe 10 rights of giving medication.

Watch out for possible adverse reaction of the patient.

Generic Name: Domperidone

Brand Name: Motilium® [film-coated tab]

Classification: Antiemetics / GIT Regulators, Antiflatulents & Anti-


Indication: Dyspeptic symptom complex associated w/ delayed gastric

emptying, GERD, esophagitis eg epigastric sense of fullness, early satiety,
feeling of abdominal distension, upper abdominal pain; bloating, eructation,
flatulence; heartburn w/ or w/o regurgitations of gastric contents in the mouth.
Nausea & vomiting of functional, organic, infectious or dietetic origin or
induced by radio- or drug therapy.

Contraindication: GI hemorrhage, mechanical obstruction or perforation; in

patients w/ prolactin-releasing pituitary tumor (prolactinoma). Known
intolerance to the drug.

Mode of Action: Domperidone is a dopamine-receptor blocking agent. Its

action on the
dopamine-receptors in the chemo-emetic trigger zone produces an anti-
emetic effect.

Side/ Adverse Effect: Rarely, increased prolactin levels. GI disorders. Very

rare, transient intestinal cramps. Galactorrhea. Gynecomastia. Amenorrhea.
Nursing Responsibilities: Assess for extra-pyramidal effects such as jerking
and tongue protrusion.

Check for hypotension.

Generic Name: Omeprazole

Brand Name: Acifre® [cap]

Classification: Antacids, Antireflux Agents & Antiulcerants

Indication: Conditions where inhibition of gastric acid secretion may be

beneficial including aspiration syndromes, dyspepsia, GERD, peptic ulcer
disease, Zollinger-Ellison syndrome.

Contraindication: Headache, diarrhea & skin rash.

Mode of Action: Inhibits activity of acid (proton) pump and binds to hydrogen
potassium adenosine triphosphatase at secretory surface of gastric parietal
cells to block formation of gastric acid.

Side/ Adverse Effect: diarrhea, abdominal pain, nausea, vomiting,

constipation, flatulence. Back pain. Cough upper respiratory tract infection.

Nursing Responsibilities: Dosage adjustments may be necessary in Asian

patients and patients w/ hepatic impairment.

Advise patient that drug is only for short-term use and to consult prescriber if
giving to children for longer than 5 days/ adults for longer than 10 days

Tell patient not to use for marked fever (temperature higher than 103.1 F
(39.5C), fever persisting longer than 3 days, or recurrent fever unless directed
by prescriber.

Generic Name: Amlodipine besilate

Brand Name: Aforbes® [tab]

Classification: Anti-Anginal Drugs / Calcium Antagonists / Other


Indication: Management of HTN & for prophylaxis of angina.

Contraindication: Known sensitivity to dihydropyridines.

Mode of Action: InhibitsCalciumionfluxacrosscardiacandsmooth-musclescells,
t Usdecreasing myocardia lcontractilit y
andoxygendemands;alsodilatescoronaryarteries and artirioles.
Side/ Adverse Effect: Headache, edema, fatigue, somnolence, nausea,
abdominal pain, flushing, palpitation & dizziness.

Nursing Responsibilities: Glucose monitoring

check for drug allergies

check for BP

Generic Name: Piperacillin

Brand Name: Zosyn

Classification: Penicillins

Indication: Mild or uncomplicated infections, Severe infections, Surgical


Contraindication: Hypersensitivity.

Mode of Action: It is similar to that of other penicillins. Interfere with bacterial

cell wall synthesis promotes loss of membrane integrity and leads to death of
the organism.

Side/ Adverse Effect: GI disturbances; hypersensitivity reactions;

eosinophilia, hyponatraemia, hypokalaemia. Injection-site related reactions
such as pain, erythema and induration.

Nursing Responsibilities: Obtain history of hypersensitivity to penicillins,

cephalosphorins, or other drugs prior to administration,

Obtain specimen for culture and sensitivity prior to first dose of the drug; start
drug pending results. Periodic CBC with differential, platelet count, Hgb & Hgt,
and serum electrolytes.

Monitor for hemorrhagic manifestations because high dose may induce

coagulation abnormalities.

Instruct family/significant others to report significant, unexplained diarrhea.

Generic Name: Tramadol HCl

Brand Name: Amaryll® [vial]

Classification: Analgesics (Opioid) / Supportive Care Therapy

Indication: Moderate to severe pain & post-op pain.

Contraindication: Acute alcohol intoxication. Hypnotics, centrally-acting

analgesics, opioids or psychotropic drugs. Treatment w/ MAOIs or w/in 2 wk
from w/drawal. Childn <12 yr.

Mode of Action: Binds to mu-opioid receptors.

Inhibits reuptake of serotonin and norepinephrine in the CNS

Side/ Adverse Effect: Nausea, vomiting, diarrhea, constipation. Tiredness,

drowsiness, dizziness, headache, confusion, hallucinations. Skin rashes,
tachycardia, orthostatic hypotension, bradycardia, flushing, allergic reactions.

Nursing Responsibilities: • Assess type, location, and intensity of pain

before and 2-3 hr (peak) after administration.

Assess bowel function routinely. Assess previous analgesic history.

Tramadol is not recommended for patients dependent on opioids or who
have previously received opioids for more than 1 wk; may cause opioid
withdrawal symptoms.

Generic Name:

Brand Name: Mitodex® [vial]

Classification: Cardiac Drugs / Cholagogues, Cholelitholytics & Hepatic


Indication: Treatment of acute & chronic hepatitis, fatty liver, hepatic cirrhosis
& intoxication by drug or chemical substance; mitochondrial dysfunctions.


Mode of Action:

Side/ Adverse Effect:

Nursing Responsibilities:

Generic Name: Clonidine HCl

Brand Name: Catapin® [amp]

Classification: Other Antihypertensives

Indication: Hypertensive crisis, Severe HTN, Severe cancer pain

Contraindication: Hypersensitivity. Disorders of cardiac pacemaker
activity and conduction. Pregnancy and lactation.

Mode of Action: Clonidine stimulates alpha- 2 receptors in brain stem

which results in reduced sympathetic outflow from the CNS and a
decrease in peripheral resistance leading to reduced BP and pulse
rate. It does not alter normal haemodynamic response to exercise at
recommended dosages.

Side/ Adverse Effect: Drowsiness, dry mouth, dizziness & headache.

Constipation, depression, anxiety, fatigue, nausea, anorexia, parotid pain,
sleep disturbances, vivid dreams, impotence & loss of libido, urinary retention
or incontinence, slight orthostatic hypotension, dry itching or burning
sensations in the eye.

Nursing Responsibilities: Do not discontinue prior to surgery; monitor

BP carefully during surgery; have other BP-controlling drugs readily
available. Store epidural injection at room temperature; discard any
unused portions. Reevaluate therapy if clonidine tolerance occurs;
giving concomitant diuretic increases the antihypertensive efficacy
of clonidine.

Generic Name: Ceftriaxone Na

Brand Name: Acrexon® [vial]

Classification: Cephalosporins

Indication: Treatment of susceptible infections, eg chancroid, endocarditis,

gastroenteritis (invasive salmonellosis, shigellosis), gonorrhea, Lyme disease,
meningitis (including meningococcal meningitis prophylaxis), septicemia,
surgical infection (as prophylaxis), syphilis, typhoid fever & Whipple's disease.

Contraindication: History of shock, hypersensitivity to cephalosporins,

penicillins, anilide local anesth.

Mode of Action: Inhibits bacterial cell wall synthesis, rendering cell wall
osmotically unstable, leading to cell death.
Side/ Adverse Effect: Shock, hypersensitivity, blood abnormality. Liver &
kidney failure, GI & resp disturbances, superinfection, vit deficiency.

Nursing Responsibilities: Assess pt.’s previous sensitivity reaction to

penicillin or other cephalosporins.

Assess pt. for s/sx of infection before and during treatment.

Obtain C&S before beginning drug therapy to identify if correct treatment has
been initiated.
Generic Name: bacillus clausii

Brand Name: Erceflora

Classification: Antidiarrheals

Indication: Acute diarrhea with duration of ≤14 days due to infection, drugs or
poisons. Chronic or persistent diarrhea with duration of >14 days.

Contraindication: Not for use in immunocompromised patients (cancer

patients on chemotherapy, patients taking immunosuppressant meds)

Mode of Action: Contributes to the recovery of the intestinal microbial flora

altered during the course of microbial disorders of diverse origin. It produces
various vitamins, particularly group B vitamins thus contributing to correction
of vitamin disorders caused by antibiotics & chemotherapeutic agents.
Promotes normalization of intestinal flora.

Side/ Adverse Effect: No known effects

Nursing Responsibilities: Shake drug well before administration.

Administer drug within 30 minutes after opening container.
Dilute drug with sweetened milk, orange juice or tea.

Generic Name: Repaglinide

Brand Name: NovoNorm® [tab]

Classification: Antidiabetic Agents

Indication: Type 2 diabetes where hyperglycemia can no longer be controlled

satisfactorily by diet, wt reduction & exercise. NovoNorm can also be used w/
metformin in type 2 diabetes who are not satisfactorily controlled on metformin

Contraindication: Hypersensitivity. Type 1 diabetes. Diabetic ketoacidosis.

Pregnancy & lactation.

Mode of Action: Inhibits alpha-glucosidases, enzymes that convert

oligosaccharides and disaccharides to glucose. This inhibition lowers blood
glucose level, especially in postprandial hyperglycemia.

Side/ Adverse Effect: Mild hypoglycemia & hyperglycemia, transient visual

disturbances, GI disorders eg diarrhea or nausea. Mild & transient elevation in
liver enzyme levels.

Nursing Responsibilities: Monitor blood glucose and glycosylated

hemoglobin levels.
Monitor patient's meal pattern. Consult prescriber about adjusting dosage if
patient adds or misses a meal.
Assess for angina, shortness of breath, or other discomforts.
Watch for signs and symptoms of bronchitis and upper respiratory, urinary,
and EENT infections.

Generic Name: Mupirocin

Brand Name: Bactroban Ointment® [oint]

Classification: Topical Antibiotics

Indication: Primary skin infections eg impetigo, folliculitis, furunculosis &

ecthyma. Secondary infections eg infected eczema, infected traumatic lesions
including abrasions, insect bites, minor wounds & burns. Bacterial
contamination prophylaxis.

Contraindication: Not suitable for opth or intranasal use. Do not use at the
site of central venous cannulation nor in conjunction w/ cannulae.

Mode of Action: Systemic absorption of mupirocin through intact human skin

is minimal. The systemic absorption of mupirocin was studied following
application of BACTROBAN CREAM three times daily for 5 days to various
skin lesions (greater than 10 cm in length or 100 cm 2 in area) in 16 adults
(aged 29 to 60 years) and 10 children (aged 3 to 12 years). Some systemic
absorption was observed as evidenced by the detection of the metabolite,
monic acid, in urine. Data from this study indicated more frequent occurrence
of percutaneous absorption in children (90% of patients) compared to adults
(44% of patients); however, the observed urinary concentrations in children
(0.07 - 1.3 mcg/mL [1 pediatric patient had no detectable level]) are within the
observed range (0.08 - 10.03 mcg/mL [9 adults had no detectable level]) in
the adult population. In general, the degree of percutaneous absorption
following multiple dosing appears to be minimal in adults and children. Any
mupirocin reaching the systemic circulation is rapidly metabolized,
predominantly to inactive monic acid, which is eliminated by renal excretion.

Side/ Adverse Effect: Burning sensation, stinging, itching. Cutaneous

sensitization reactions.

Nursing Responsibilities: Avoid contact to eyes

If any irritation is seen/felt discontinue the use of cream

If no improvement is seen when used from 3-5 days consult physician.

Generic Name: Amikacin sulphate

Brand Name: Amikacide® [amp]

Classification: Aminoglycosides

Indication: Bacterial septicemia including neonatal sepsis. Serious infections

of the resp tract. Infections of the bone & joints. Intra-abdominal infections
including peritonitis. Burns & post-op infections. Serious & complicated UTI
due to susceptible organisms. As initial therapy in suspected gm-ve infections
before the results of susceptibility testing are obtained. In mixed, gm-ve, staph
infections & other gm+ve organism eg Strep & pneumococci.

Contraindication: Hypersensitivity to aminoglycosides.

Mode of Action: Inhibits protein synthesis by binding directly to the 30S

ribosomal subunit; bactericidal
Side/ Adverse Effect: Auditory, vestibular, renal toxicity & neuromuscular
blockade. Rash, drug fever, headache, paresthesia, tremor, nausea &
vomiting, eosinophilia, arthralgia, anemia & hypotension.

Nursing Responsibilities: Obtain specimen for culture and sensitivity test

before giving first dose. Therapy may begin while awaiting the results.

Evaluate patient’s hearing before and during therapy if he will be receiving

drug for longer than 2weeks. Notify prescriber if patient has tinnitus, vertigo,
or hearing loss.

Weigh patient and review renal function studies before therapy begins.

Generic Name: Montelukast Na

Brand Name: Brecare® [film-coated tab]

Classification: Antiasthmatic & COPD Preparations

Indication: Management of chronic asthma & allergic rhinitis. Prophylaxis for

exercise-induced asthma.

Contraindication: Hepatic impairment or cirrhosis. Treatment of acute

asthma attacks.

Mode of Action: Montelukast inhibits bronchoconstriction due to antigen

challenge. Montelukast is a selective leukotriene receptor antagonist of the
cysteinyl leukotriene CysLT 1 receptor. The cysteinyl leukotrienes (LTC 4, LTD
4, LTE 4) are products of arachidonic acid metabolism that are released from
various cells, including mast cells and eosinophils. They bind to cysteinyl
leukotriene receptors (CysLT) found in the human airway. Binding of cysteinyl
leukotrienes to leukotriene receptors has been correlated with the
pathophysiology of asthma, including airway edema, smooth muscle
contraction, and altered cellular activity associated with the inflammatory
process, factors that contribute to the signs and symptoms of asthma.
Montelukast binding to the CysLT 1 receptor is high-affinity and selective,
preferring the CysLT 1 receptor to other pharmacologically important airway
receptors, such as the prostanoid, cholinergic, or beta-adrenergic receptor.
Montelukast inhibits physiologic actions of LTD 4 at the CysLT 1 receptors,
without any agonist activity

Side/ Adverse Effect: Headache, resp tract infection, GI disturbances,

generalized pain, arthralgia, myalgia, fever, dizziness, elevated liver enzymes;
hypersensitivity reactions including rashes, urticaria & angioedema.

Nursing Responsibilities: Administer in the evening without regard to food.

Ensure that drug is taken continually for optimal effect.

Do not administer for acute asthma attack or acute bronchospasm.

Avoid the use of aspirin or NSAIDs in patients with known sensitivities while
they are using this drug.

Ensure that patient has a readily available rescue medication for acute
attacks or situations when a short-acting inhaled agent is needed.

Generic Name: Salbutamol sulphate

Brand Name: Activent® [syr]

Classification: Antiasthmatic & COPD Preparations

Indication: Relief of bronchospasm in bronchial asthma, chronic bronchitis,

emphysema & other reversible obstructive pulmonary diseases.

Contraindication: Pregnancy. β-blockers.

Mode of Action: Synthetic sympathomimetic amine

and moderately selective beta2-adrenergicagonist with comparatively long
action. Acts more promimently on beta2receptors (particularly smooth
muscles of bronchi, uterus, and vascular supply to skeletal muscles) than
onbeta1(heart) receptors. Minimal or no effect on alpha-adrenergic receptors
inhibition of leukocyte infiltration at the site of inflammation, interference in the
function of mediators of inflammatory response, and suppression of humoral
immune responses.

Side/ Adverse Effect: Fine skeletal muscle tremor, tachycardia, headache,

dizziness & arrhythmias (rare).
Nursing Responsibilities: Position patient onhigh backrest

Do back tappig after younebulize thepatient

Do not give foodimmediately. Itcan causevomiting

Generic Name: Cefuroxime

Brand Name: Aeruginox® [Film-coated tab]

Classification: Cephalosporins

Indication: Lower resp tract infections, uncomplicated gonorrhea, Pre-op


Contraindication: Hypersensitivity. GI absorption difficulties. Childn <5 yr.

Mode of Action: Bactericidal Inhibits synthesis of bacterial cell wall, causing

cell death.

Side/ Adverse Effect: Thrombophlebitis, GI disturbances. Skin rash, itching,


Nursing Responsibilities: Determine history of hypersensitivity reactions

to cephalosporins

Monitor signs of infection

Report onset of loose stools or diarrhea.

Generic Name: Cetirizine HCl

Brand Name: Aforvir® [tab]

Classification: Antihistamines & Antiallergics

Indication: Symptomatic relief of allergy eg hay fever & urticaria.

Contraindication: Neonates.

Mode of Action: Cetirizine, a human metabolite of hydroxyzine, is an

antihistamine; its principal effects are mediated via selective inhibition of
peripheral H1 receptors. The antihistaminic activity of Cetirizine has been
clearly documented in a variety of animal and human models. In vivo and ex
vivo animal models have shown negligible anticholinergic and
antiserotonergic activity. In clinical studies, however, dry mouth was more
common with Cetirizine than with placebo. In vitro receptor binding studies
have shown no measurable affinity for other than H1 receptors.
Autoradiographic studies with radiolabeled Cetirizine in the rat have shown
negligible penetration into the brain. Ex vivo experiments in the mouse have
shown that systemically administered Cetirizine does not significantly occupy
cerebral H1 receptors.

Side/ Adverse Effect: Slight drowsiness to deep sleep.

Nursing Responsibilities: Give without regard to meals.

Provide syrup form for pediatric use if needed.

Arrange for use of humidifier if thickening of secretions, nasal dryness

bothersome; encourage adequate intake of fluids.

Provide skin care for urticaria.

Generic Name: Probiotic

Brand Name: Gastro Flora Probiotics

Classification: Supplements & Adjuvant Therapy

Indication: Promotion of general wellness & normal intestinal function.


Mode of Action:

Side/ Adverse Effect:

Nursing Responsibilities: Check for signs of hypersensitivity

Generic Name: Phytonadione

Brand Name: Vitamin K

Classification: Anti Coagulant

Indication: This was given to our client for prophylaxis and therapy of
hemorrhagic disease
and causes a decrease in bleeding tendency to post operative client

Contraindication: Severe liver disease

Mode of Action: Required for hepatic synhesis of blood coagulation factors II
(Prothrombin) , VII, IX and X
Side/ Adverse Effect: rapid pulse, chills and fever, hypotension, cyanosis
and hemoglobinuria.

Nursing Responsibilities: assess for sulfites sensitivity

Monitor for side effects and adverse reactions.

Patients receiving vitamin K therapy should be cautioned not to take over-the-

counter drugs medications without the advice of health professionals.

Generic Name: Zn sulfate monohydrate

Brand Name: E-Zinc® [drops]

Classification: Electrolytes, Vitamins & Minerals (Paediatric)

Indication: Supplement to correct Zn deficiency eg malabsorption syndromes

& in conditions w/ increased body losses.

Contraindication: Allergy to any component of E-Zinc.

Mode of Action: E-Zinc contains zinc. Zinc helps the body's natural defense
against damaging free radicals (antioxidant effect) and helps boost immune
function. Free radicals are highly reactive and unstable chemicals generated
during normal body activities that require oxygen (eg, respiration, digestion,
blood circulation, immune system response, etc) and after exposure to
ultraviolet (UV) light, cigarette smoke and various pollutants. One major effect
of zinc is on the ability of cells to properly replicate the deoxyribonucleic acid
(DNA), which is required for cells to multiply. Hence, zinc is needed for normal

Zinc has other known functions/effects:

Cofactor of various enzymes in cell division and growth.

Required for the normal development and maintenance of the immune

system; helps regulate the activity of cells involved in immune function.

Functions as an antioxidant by being a cofactor of the enzyme superoxide

dismutase, which is involved in the removal of harmful free radicals.

Zinc is also recommended by the World Health Organization (WHO) and

UNICEF as an adjunct in acute diarrhea management together with reduced
osmolarity oral rehydration salts (ORS).

Side/ Adverse Effect: Gastrointestinal side effects eg, nausea and vomiting
are seen with doses of elemental zinc >30 mg.
Nursing Responsibilities: Check for hypersensitivity to drugs.

Melencio Santino-Acute Asthma

S > “inuubo pa ang anak ko at may plema” as verbalized by the pt father.
O >received patient awake and cradle by father.
2:45 >with IVF #4 D5NSS 500cc x 14hrs regulated at 35 gtts/min; 50cc
>with productive cough
>PR=128; tachycardia
>alar flaring
>with wheezes @ auscultation of left and right lower lobe of lungs.
A >airway clearance ineffective r/t secretions in the bronchi.
P >after the interventions pt will improve airway patency.
I >established rapport
3:00 >replaced IVF #4 with IVF #5 D5NSS 500cc x 14hrs regulated at 35
>auscultated breathe sounds; wheezing on left and right lower lobe of
>demonstrated proper back tapping.
> elevated head
E >goal partially met; pt improved air way patency but still cough is

Escorilla Adrianne-Tonsilopharyngitiss

S >”nilalamig po ako” as verbalized by the pt.

O >received pt awake and coherent
2:45 >IVF #1 D5NSS 1000cc x 8hrs;950cc
>temp=38.9 deg C
>flushed appearance
>warm skin
>with reddish tonsils
A >hyperthermia r/to illness
P > after the shift pt will decrease temp from 38.9 deg to normal range.
I >established rapport
4:00 >VS taken T=38.9 P=128 R=34 BP=110/70
>demonstrated TSB
>advised to wear more comfortable clothes
>advised to increase fluid intake
>advised CBR
E >goal partially met; pt decreased in temp but not equal to any of the
normal ranges