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Benguet State University COLLEGE OF NURSING La Trinidad, Benguet

A Case Study on

Colonic Carcinoma
Presented to the Faculty of the College of Nursing, Benguet State University In Partial Fulfillment of the Requirements in Related Learning Experience 105

Submitted by: Group 8 Audray Kyle Saydoven Noreen Paligpig Kathleen Mae Panagan Graile Pinas Aaron Rafael Perkins Shiki Charelle Reforba Warren Jae Sandoval Ma. Lorena Gabrielle Sanqui Corazon Sepulchre Marsha Sepulchre Jo-anne Bray Siadto Marinel Tabarejos Bherly Frank Tamid-ay Submitted to: Jon Erik Saluta, RN January 2011

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I.

II.

Patients Information Name: Felipe Dacnas Alunday Sr. Address: Allaguia, Pinukpok, Kalinga Birthdate: June 11, 1947 Age: 63 years old Nationality: Filipino Religion: Roman Catholic Date of Admission: January 3, 2011 Time of Admission: 4.05 pm Admitting Physician: : Mathew B. Bawayan Attending Physician: Ponadon, Besarino, Douglas Admitting Diagnosis: Colonic Carcinoma S/P Anterior Resection (July 23, 2011) S/P Third Cycle Chemotherapy Principal Diagnosis: Colonic Carcinoma S/P Anterior Resection (July 23, 2011) S/P Fourth Cycle Chemotherapy Clinical History Chief Complaint: For fourth chemotherapy Review of systems: (+) Body Weakness, (-) Nausea and vomiting, (+) Anorexia, (-) Abdominal pain, (-) Constipation, (-) Diarrhea, (-)Diziness, (-) HA History of Present Illness: Present condition started when the patient was diagnosed with colon cancer last July 2010. Patient underwent colonic resection on July 2010 and was advised to undergo chemotherapy. Previous chemotherapies were done in BGHMC institution. There was associated nausea and vomiting. Patient was scheduled for his fourth chemotherapy hence admitted. Past medical History: (-) Other Hospitalization (+) HPN 2010 (-) Accidents or trauma in the past (-) Allergies Family History: (+) Hypertension, (-)DM, (-) BA, (-) CAD, (-) PTB Social and Environmental History Smoker, Non alcoholic beverage drinker

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III.

Anatomy and Physiology COLON The colon is the last part of the digestive system in most vertebrates; it extracts water and salt from solid wastes before they are eliminated from the body, and is the site in which flora-aided (largely bacteria) fermentation of unabsorbed material occurs. Unlike the small intestine, the colon does not play a major role in absorption of foods and nutrients. However, the colon does absorb water, potassium and some fat soluble vitamins. In mammals, the colon consists of four sections: the ascending colon, the transverse colon, the descending colon, and the sigmoid colon (the proximal colon usually refers to the ascending colon and transverse colon). The colon, cecum, and rectum make up the large intestine. The location of the parts of the colon are either in the abdominal cavity or behind it in the retroperitoneum. The colon in those areas is fixed in location. Arterial supply to the colon comes from branches of the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA). Flow between these two systems communicates via a "marginal artery" that runs parallel to the colon for its entire length. Historically, it has been believed that the arc of Riolan, or the meandering mesenteric artery (of Moskowitz), is a variable vessel connecting the proximal SMA to the proximal IMA that can be extremely important if either vessel is occluded. However, recent studies conducted with improved imaging technology have questioned the actual existence of this vessel, with some experts calling for the abolition of the terms from future medical literature. Venous drainage usually mirrors colonic arterial supply, with the inferior mesenteric vein draining into the splenic vein, and the superior mesenteric vein joining the splenic vein to form the hepatic portal vein that then enters the liver. Lymphatic drainage from the entire colon and proximal two-thirds of the rectum is to the paraaortic lymph nodes that then drain into the cisterna chyli. The lymph from the remaining rectum and anus can either follow the same route, or drain to the internal iliac and superficial inguinal nodes. The pectinate line only roughly marks this transition. Ascending colon The ascending colon, on the right side of the abdomen, is about 25 cm long in humans. It is the part of the colon from the cecum to the hepatic flexure (the turn of the colon by the liver). It is secondarily retroperitoneal in most humans. In ruminant grazing animals, the cecum empties into the spiral colon.

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Anteriorly it is related to the coils of small intestine, the right edge of the greater omentum, and the anterior abdominal wall. Posteriorly, it is related to the iliacus, the iliolumbar ligament, the quadratus lumborum, the transverse abdominis, the diaphragm at the tip of the last rib; the lateral cutaneous, ilioinguinal, and iliohypogastric nerves; the iliac branches of the iliolumbar vessels, the fourth lumbar artery, and the right kidney. The ascending colon is supplied by parasympathetic fibers of the vagus nerve (CN X). Arterial supply of the ascending colon comes from the ileocolic artery and right colic artery, both branches of the SMA. While the ileocolic artery is almost always present, the right colic may be absent in 515% of individuals. Transverse colon The transverse colon is the part of the colon from the hepatic flexure to the splenic flexure (the turn of the colon by the spleen). The transverse colon hangs off the stomach, attached to it by a wide band of tissue called the greater omentum. On the posterior side, the transverse colon is connected to the posterior abdominal wall by a mesentery known as the transverse mesocolon. The transverse colon is encased in peritoneum, and is therefore mobile (unlike the parts of the colon immediately before and after it). Cancers form more frequently further along the large intestine as the contents become more solid (water is removed) in order to form feces. The proximal two-thirds of the transverse colon is perfused by the middle colic artery, a branch of SMA, while the latter third is supplied by branches of the IMA. The "watershed" area between these two blood supplies, which represents the embryologic division between the midgut and hindgut, is an area sensitive to ischemia. Descending colon The descending colon is the part of the colon from the splenic flexure to the beginning of the sigmoid colon. The function of the descending colon in the digestive system is to store food that will be emptied into the rectum. It is retroperitoneal in two-thirds of humans. In the other third, it has a (usually short) mesentery. The arterial supply comes via the left colic artery. Sigmoid colon The sigmoid colon is the part of the large intestine after the descending colon and before the rectum. The name sigmoid means S-shaped (see sigmoid).

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The walls of the sigmoid colon are muscular, and contract to increase the pressure inside the colon, causing the stool to move into the rectum. The sigmoid colon is supplied with blood from several branches (usually between 2 and 6) of the sigmoid arteries, a branch of the IMA. The IMA terminates as the superior rectal artery. Sigmoidoscopy is a common diagnostic technique used to examine the sigmoid colon. Redundant colon One variation on the normal anatomy of the colon occurs when extra loops form, resulting in a longer than normal organ. This condition, referred to as redundant colon, typically has no direct major health consequences, though rarely volvulus occurs resulting in obstruction and requiring immediate medical attention.[4] A significant indirect health consequence is that use of a standard adult colonoscope is difficult and in some cases impossible when a redundant colon is present, though specialized variants on the instrument (including the pediatric variant) are useful in overcoming this problem. Standing gradient osmosis Water absorption at the colon typically proceeds against a transmucosal osmotic pressure gradient. The standing gradient osmosis is a term used to describe the reabsorption of water against the osmotic gradient in the intestines. This hypertonic fluid creates an osmotic pressure that drives water into the lateral intercellular spaces by osmosis via tight junctions and adjacent cells, which then in turn moves across the basement membrane and into the capillaries. Functions of the Colon There are differences in the large intestine between different organisms, the large intestine is mainly responsible for storing waste, reclaiming water, maintaining the water balance, absorbing some vitamins, such as vitamin K, and providing a location for flora-aided fermentation.Vitamin K is essential as a coagulation factor. By the time the chyme has reached this tube, most nutrients and 90% of the water have been absorbed by the body. At this point some electrolytes like sodium, magnesium, and chloride are left as well as indigestible parts of ingested food (e.g., a large part of ingested amylose, protein which has been shielded from digestion heretofore, and dietary fiber, which is largely indigestible carbohydrate in either soluble or insoluble form). As the chyme moves through

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the large intestine, most of the remaining water is removed, while the chyme is mixed with mucus and bacteria (known as gut flora), and becomes feces. The ascending colon receives fecal material as a liquid. The muscles of the colon then move the watery waste material forward and slowly absorb all the excess water. The stools get to become semi solid as they move along into the descending colon. The bacteria break down some of the fiber for their own nourishment and create acetate, propionate, and butyrate as waste products, which in turn are used by the cell lining of the colon for nourishment. No protein is made available. In humans, perhaps 10% of the undigested carbohydrate thus becomes available; in other animals, including other apes and primates, who have proportionally larger colons, more is made available, thus permitting a higher portion of plant material in the diet. This is an example of a symbiotic relationship and provides about one hundred calories a day to the body. The large intestine produces no digestive enzymes - chemical digestion is completed in the small intestine before the chyme reaches the large intestine. The pH in the colon varies between 5.5 and 7 (slightly acidic to neutral).

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IV.

Colonic Carcinoma / Colon Carcinoma / Colon Cancer Definition: It is a disease in which malignant (cancer) cells form in the tissues of the colon. The colon is part of the body's digestive system. The digestive system removes and processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) from foods and helps pass waste material out of the body. The digestive system is made up of the esophagus, stomach, and the small and large intestines. The first 6 feet of the large intestine are called the large bowel or colon. The last 6 inches are the rectum and the anal canal. The anal canal ends at the anus (the opening of the large intestine to the outside of the body). Risk Factors: Age and health history can affect the risk of developing colon carcinoma . Risk factors include the following:  Age 50 or older.  A family history of carcinoma of the colon or rectum.  A personal history of carcinoma of the colon, rectum, ovary, endometrium, or breast.  A history of polyps in the colon. Signs and Symptoms:  A change in bowel habits.  Blood (either bright red or very dark) in the stool.  Diarrhea, constipation, or feeling that the bowel does not empty completely.  Stools that are narrower than usual.  Frequent gas pains, bloating, fullness, or cramps.  Weight loss for no known reason.  Feeling very tired.  Vomiting. A specimen removed from a patient with colonic carcinoma

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V. General:

Pathophysiology of Colonic Carcinoma

Age: above 50 y.o Diet Colon Polyps Gender: More common in males Alcohol Intake

Physical Inactivity Ulcerative Colitis Genetics

Cells that line the colon are very active, constantly dividing and creating buds known as polyps. Most polyps are small, benign growths that usually stop growing.

But a tiny percentage of these polyps keep growing, sometimes for 10 years or more. Various genetic mutations can transform them into cancerous tumors. The most commonly
mutated gene in all colorectal cancer is the APC gene, which produces the APC protein. The APC protein is the "brake" on the -cateninprotein. Without APC, -catenin translocates (moves) into the nucleus, binds to DNA, and activates the expression of more proteins. (If APC is not mutated in colorectal cancer, then -catenin itself is.)

As these tumors grow larger, they gather more mutations and begin to burrow deeper into the muscle wall that lines the colon.

Once the cancer invades the blood and lymph systems, malignant cells can break off and spread to other organs.

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Patient Based: The patient is a 63 year old male, suffering from colon cancer (Colonic carcinoma). He was diagnosed last July 2010 after having a check-up. As stated by his daughter, the patient has high fiber but low protein intake. Also, he has suffered from peptic ulcer. He is a smoker but not alcoholic. Moreover, based from the tests done to the patient, polyps were present in his intestines.
History of ulcer 63 year old Smoker Male

Formation of Polyps (intramucosal epithelial lesion)

Cancers grow.

Cancers invade the muscularis mucosa, lymphatic structures, and vascular structures and involve regional lymph nodes, adjacent structures, and distant sites.

Colonic Carcinoma

VI.

Diagnostics Procedures or Tests for Colonic Carcinoma The following tests and procedures may be used: y Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else

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that seems unusual. A history of the patient's health habits and past illnesses and treatments will also be taken. Fecal occult blood test: A test to check stool (solid waste) for blood that can only be seen with a microscope. Small samples of stool are placed on special cards and returned to the doctor or laboratory for testing. Digital rectal exam: An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the rectum to feel for lumps or anything else that seems unusual. Barium enema: A series of x-rays of the lower gastrointestinal tract. A liquid that contains barium (a silver-white metallic compound) is put into the rectum. The barium coats the lower gastrointestinal tract and x-rays are taken. This procedure is also called a lower GI series.

Barium enema procedure. The patient lies on an x-ray table. Barium liquid is put into the rectum and flows through the colon. X-rays are taken to look for abnormal areas. Sigmoidoscopy: A procedure to look inside the rectum and sigmoid (lower) colon for polyps, abnormal areas, or cancer. A sigmoidoscope is inserted through the rectum into the sigmoid colon. A sigmoidoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.

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Sigmoidoscopy. A thin, lighted tube is inserted through the anus and rectum and into the lower part of the colon to look for abnormal areas. Colonoscopy: A procedure to look inside the rectum and colon for polyps, abnormal areas, or cancer. A colonoscope is inserted through the rectum into the colon. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.

Colonoscopy. A thin, lighted tube is inserted through the anus and rectum and into the colon to look for abnormal areas.
y y

Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. Virtual colonoscopy: A procedure that uses a series of x-rays called computed tomography to make a series of pictures of the colon. A computer puts the pictures together to create detailed images that may show polyps and anything else that seems unusual on the inside surface of the colon. This test is also called colonography or CT colonography.

VII.

Laboratory Finding Ultrasonogaphy: Left hemidiaphragm is opacified. Heart is enlarged. Right hilar fullness. Bones are unremarkable. Well defined opacity measuring 3 X 2.5 cm at the right pleural base margin. Impression: Pleural base mass to consider metastasis. Pleural Effusion left. Right hilar fullness.

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VIII.

Surgical and Medical Treatment Surgery Surgery is the most common treatment for all stages of colon cancer. The cancer is removed using one of the following types of surgery: Local excision: If the cancer is found at a very early stage, the doctor may remove it without cutting through the abdominal wall. Instead, the doctor may put a tube through the rectum into the colon and cut the cancer out. This is called a local excision. If the cancer is found in a polyp (a small bulging piece of tissue), the operation is called a polypectomy. Resection: If the cancer is larger, the doctor will perform a partial colectomy (removing the cancer and a small amount of healthy tissue around it). The doctor may then perform an anastomosis (sewing the healthy parts of the colon together). The doctor will also usually remove lymph nodes near the colon and examine them under a microscope to see whether they contain cancer.

Colon cancer surgery with anastomosis. Part of the colon containing the cancer and nearby healthy tissue are removed, and then the cut ends of the colon are joined. Resection and colostomy: If the doctor is not able to sew the 2 ends of the colon back together, a stoma(an opening) is made on the outside of the body for waste to pass through. This procedure is called a colostomy. A bag is placed around the stoma to collect the waste. Sometimes the colostomy is needed only until the lower colon has healed, and then it can be reversed. If the doctor needs to remove the entire lower colon, however, the colostomy may be permanent.

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Colon cancer surgery with colostomy. Part of the colon containing the cancer and nearby healthy tissue is removed, a stoma is created, and a colostomy bag is attached to the stoma. Radiofrequency ablation: The use of a special probe with tiny electrodes that kill cancer cells. Sometimes the probe is inserted directly through the skin and only local anesthesia is needed. In other cases, the probe is inserted through an incision in the abdomen. This is done in the hospital with general anesthesia. Microwave ablation destroys liver tumors using heat generated by microwave energy. Cryosurgery: A treatment that uses an instrument to freeze and destroy abnormal tissue, such as carcinoma in situ. This type of treatment is also called cryotherapy. Even if the doctor removes all the cancer that can be seen at the time of the operation, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to increase the chances of a cure, is called adjuvant therapy. Adjuvant Therapy Even if all the cancer that can be seen at the time of the operation is removed, some patients may be given radiation therapy or chemotherapy after surgery to kill any cancer cells that are left. Treatment given after surgery to increase the chances of a cure is called adjuvant therapy. Chemotherapy Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic

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chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). Chemoembolization of the hepatic artery may be used to treat cancer that has spread to the liver. This involves blocking the hepatic artery (the main artery that supplies blood to the liver) and injecting anticancer drugs between the blockage and the liver. The liver's arteries then deliver the drugs throughout the liver. Only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on what is used to block the artery. The liver continues to receive some blood from the hepatic portal vein, which carries blood from the stomach and intestine. The way the chemotherapy is given depends on the type and stage of the cancer being treated. Radiation Therapy Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated. IX. Nursing Considerations NURSING GOAL 1) Support the patient in managing, pain, nutrition, dehydration, fatigue etc. 2) Improve quality of life by promoting rehabilitation for survivals of cancer. 3) Maintain the dignity. POSSIBLE DIAGNOSIS 1) ANXIETY  Assess level of anxiety  Establish therapeutic relationship  Encourage to express feelings (develop rapport)  Improve specific information  Provide Safe environment  Crisis Intervention (expect for the worse) 2) DISTURBED BODY IMAGE  Discuss the meaning of the loss and change  Observe and evaluate the interaction with the relatives.

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3)

4)

5)

6)

7)

 Allow denial but do not participate in the denial. ( do not argue, or do not favor)  Assist the client ( significant others to cope with the changes in appearance)  Teach way to reduce the alopecia enhance the appearance until the hair grows back.  Teach the client to participate to the care of afflicted body area. ANTICIPATORY GRIEVING  Use therapeutic communication skills with provide an open environment for the client or significant others to discuss their feelings realistically.  Answer question about illness and prognosis honesty but always encourage hope.  Encourage the dying client to make funeral, burial plans ahead of time, be sure that the will is in order.  Encourage client to continue taking past in activity he enjoys including maintaining employment as long as possible. RISK FOR INFECTION  Monitor Vital signs  Monitor WBC  Teach to avoid crowded places and practice personal hygiene.  Protect skin and mucous membrane from injury.  Encourage increase protein, vitamins, and vitamin C. RISK FOR INJURY  Assess for sign and symptoms of obstruction.  Teach to differentiate minors to serious problem.  Monitor laboratory results. ENHANCED NUTRITION LESS THAN BODY REQUIREMENTS  Assess current eating pattern.  Teach the principles of good nutrition.  Manage problem that interfere feeding  cold drinks  soft blend, soft liquid  Teach to supplement meals with nutritional supplements  Teach to make food diary.  Parenteral Nutrition.  IMPAIRED SKIN TISSUE INTEGRITY  Oral, pharyngeal, esophageal, mucous membrane.  Signs and Symptoms y Ulcers tongue, mucous membrane in mouth, throat y Lesides ulcerations y Fungal Infections y Red swollen gums

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y Xerostomia excessive dryness mucous membrane  Carefully assessment , evaluate the tissue impairment  Teach measured to prevent infection.
X. Drug Study a. Ranitidine hydrochloride Brand Name: Zantac Indications:

1. Short-term treatment of active duodenal ulcer. Most patients heal within 4 weeks. Studies available to date have not assessed the safety of ranitidine in uncomplicated duodenal ulcer for periods of more than 8 weeks. 2. Maintenance therapy for duodenal ulcer patients at reduced dosage after healing of acute ulcers. No placebo-controlled comparative studies have been carried out for periods of longer than 1 year. 3. The treatment of pathological hypersecretory conditions (e.g., ZollingerEllison syndrome and systemic mastocytosis). 4. Short-term treatment of active, benign gastric ulcer. Most patients heal within 6 weeks and the usefulness of further treatment has not been demonstrated. Studies available to date have not assessed the safety of ranitidine in uncomplicated, benign gastric ulcer for periods of more than 6 weeks. 5. Maintenance therapy for gastric ulcer patients at reduced dosage after healing of acute ulcers. Placebo-controlled studies have been carried out for 1 year. 6. Treatment of GERD. Symptomatic relief commonly occurs within 24 hours after starting therapy with ZANTAC 150 mg twice daily. 7. Treatment of endoscopically diagnosed erosive esophagitis. Symptomatic relief of heartburn commonly occurs within 24 hours of therapy initiation with ZANTAC 150 mg 4 times daily. 8. Maintenance of healing of erosive esophagitis. Placebo-controlled trials have been carried out for 48 weeks. Side Effects Central Nervous System Rarely, malaise, dizziness, somnolence, insomnia, and vertigo. Rare cases of reversible mental confusion, agitation, depression, and hallucinations have been reported, predominantly in severely ill elderly patients. Rare cases of reversible blurred vision suggestive of a change in accommodation have been reported. Rare reports of reversible involuntary motor disturbances have been received. Cardiovascular

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As with other H2-blockers, rare reports of arrhythmias such as tachycardia, bradycardia, atrioventricular block, and premature ventricular beats. Gastrointestinal Constipation, diarrhea, nausea/vomiting, abdominal discomfort/pain, and rare reports of pancreatitis. Hepatic There have been occasional reports of hepatocellular, cholestatic, or mixed hepatitis, with or without jaundice. In such circumstances, ranitidine should be immediately discontinued. These events are usually reversible, but in rare circumstances death has occurred. Rare cases of hepatic failure have also been reported. In normal volunteers, SGPT values were increased to at least twice the pretreatment levels in 6 of 12 subjects receiving 100 mg intravenously 4 times daily for 7 days, and in 4 of 24 subjects receiving 50 mg intravenously 4 times daily for 5 days. Musculoskeletal Rare reports of arthralgias and myalgias. Hematologic Blood count changes (leukopenia, granulocytopenia, and thrombocytopenia) have occurred in a few patients. These were usually reversible. Rare cases of agranulocytosis, pancytopenia, sometimes with marrow hypoplasia, and aplastic anemia and exceedingly rare cases of acquired immune hemolytic anemia have been reported. Endocrine Controlled studies in animals and man have shown no stimulation of any pituitary hormone by ZANTAC and no antiandrogenic activity, and cimetidineinduced gynecomastia and impotence in hypersecretory patients have resolved when ZANTAC has been substituted. However, occasional cases of impotence and loss of libido have been reported in male patients receiving ZANTAC, but the incidence did not differ from that in the general population. Rare cases of breast symptoms and conditions, including galactorrhea and gynecomastia, have been reported in both males and females. Integumentary Rash, including rare cases of erythema multiforme. Rare cases of alopecia and vasculitis. Respiratory A large epidemiological study suggested an increased risk of developing pneumonia in current users of histamine-2-receptor antagonists (H2RAs) compared to patients who had stopped H2RA treatment, with an observed adjusted relative risk of 1.63 (95% CI, 1.072.48). However, a causal relationship between use of H2RAs and pneumonia has not been established. Other

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Rare cases of hypersensitivity reactions (e.g., bronchospasm, fever, rash, eosinophilia), anaphylaxis, angioneurotic edema, acute interstitial nephritis, and small increases in serum creatinine.
NURSING IMPLICATIONS/RESPONSIBILITIES  Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate.  Nurse should know that it may cause false-positive results for urine protein; test with sulfosalicylic acid.  Inform patient that it may cause drowsiness or dizziness.  Inform patient that increased fluid and fiber intake may minimize constipation.  Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly.  Inform patient that medication may temporarily cause stools and tongue to appear gray black. b. dexamethasone Brand Name: Decadron Indications: Allergic States Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity reactions, perennial or seasonal allergic rhinitis, and serum sickness. Dermatologic Diseases Bullous dermatitis herpetiformis, exfoliative erythroderma, mycosis fungoides, pemphigus, and severe erythema multiforme (Stevens-Johnson syndrome). Endocrine Disorders Primary or secondary adrenocortical insufficiency (hydrocortisone or cortisone is the drug of choice; may be used in conjunction with synthetic miner-alocorticoid analogs where applicable;in infancy mineralocorticoid supplementation is of particular importance), congenital adrenal hyperplasia, hypercal-cemia associated with cancer, and nonsuppurative thyroiditis. Gastrointestinal Diseases To tide the patient over a critical period of the disease in regional enteritis and ulcerative colitis. Hematologic Disorders Acquired (autoimmune) hemolytic anemia, congenital (erythroid) hypoplastic anemia (Diamond-Blackfan anemia), idiopathic thrombocytopenic purpura in adults, pure red cell aplasia, and selected cases of secondary thrombocytopenia. Miscellaneous

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Diagnostic testing of adrenocortical hyperfunction, trichinosis with neurologic or myocardial involvement, tuberculous meningitis with subarachnoid block or impending block when used with appropriate antituberculous chemotherapy. Neoplastic Diseases For the palliative management of leukemias and lymphomas. Nervous System Acute exacerbations of multiple sclerosis, cerebral edema associated with primary or metastatic brain tumor, craniotomy, or head injury. Ophthalmic Diseases Sympathetic ophthalmia, temporal arteritis, uveitis, and ocular inflammatory conditions unresponsive to topical corticosteroids. Renal Diseases To induce a diuresis or remission of proteinuria in idiopathic nephrotic syndrome or that due to lupus erythematosus. Respiratory Diseases Berylliosis, fulminating or disseminated pulmonary tuberculosis when used concurrently with appropriate antituberculous chemotherapy, idiopathic eosinophilic pneumonias, symptomatic sarcoidosis. Rheumatic Disorders As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in acute gouty arthritis, acute rheumatic carditis, ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy). For the treatment of dermatomyositis, polymyositis, and systemic lupus erythematosus. Side Effects Allergic Reactions Anaphylactoid reaction, anaphylaxis, angioedema. Cardiovascular Bradycardia, cardiac arrest, cardiac arrhythmias, cardiac enlargement, circulatory collapse, congestive heart failure, fat embolism, hypertension, hyper-trophic cardiomyopathy in premature infants, myocardial rupture following recent myocardial infarction (see WARNINGS: Cardio-Renal), edema, pulmonary edema, syncope, tachycardia, thromboembolism, thrombophlebitis, vasculitis. Dermatologic Acne, allergic dermatitis, dry scaly skin, ecchymoses and petechiae, erythema, impaired wound healing, increased sweating, rash, striae, suppression of reactions to skin tests, thin fragile skin, thinning scalp hair, urticaria. Endocrine

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Decreased carbohydrate and glucose tolerance, development of cushingoid state, hyperglycemia, glycosuria, hirsutism, hypertrichosis, increased requirements for insulin or oral hypoglycemic agents in diabetes, manifestations of latent diabetes mellitus, menstrual irregularities, secondary adrenocor-tical and pituitary unresponsiveness (particularly in times of stress, as in trauma, surgery, or illness), suppression of growth in pediatric patients. Fluid and Electrolyte Disturbances Congestive heart failure in susceptible patients, fluid retention, hypokalemic alkalosis, potassium loss, sodium retention. Gastrointestinal Abdominal distention, elevation in serum liver enzyme levels (usually reversible upon discontinuation), hepatomegaly, increased appetite, nausea, pan-creatitis, peptic ulcer with possible perforation and hemorrhage, perforation of the small and large intestine (particularly in patients with inflammatory bowel disease), ulcerative esophagitis. Metabolic Negative nitrogen balance due to protein catabolism. Musculoskeletal Aseptic necrosis of femoral and humeral heads, loss of muscle mass, muscle weakness, osteoporosis, pathologic fracture of long bones, steroid myopathy, tendon rupture, vertebral compression fractures. Neurological/Psychiatric Convulsions, depression, emotional instability, euphoria, headache, increased intracranial pressure with papilledema (pseudotumor cerebri) usually following discontinuation of treatment, insomnia, mood swings, neuritis, neuropathy, paresthesia, personality changes, psychic disorders, vertigo. Ophthalmic Exophthalmos, glaucoma, increased intraocular pressure, posterior subcapsular cataracts. Other Abnormal fat deposits, decreased resistance to infection, hiccups, increased or decreased motility and number of spermatozoa, malaise, moon face, weight gain. Nursing considerations: Assessment: (1) history for systemic administration renal/hepatic disease, hypothyroidism,ulcerative colitis. (2) fistory for ophthalmic preparations vaccinia, varicella, ocular TB. (3)Physical for systemic admin. blood glucose, serum electrolytes, R, adventitious sounds. (4)physical for topical dermatologic preparations: affected area for infections, skin injury. Interventions:

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 Dont give drug to nursing mothers since drug is secreted in the breast milk forsystemic admin.  Dont use intranasal product with untreated local nasal infections, epistaxis,nasal trauma.  Use caution when occlusive dressings, tight diapers over covered areas; these canincrease systemic absorption for topical dermatologic prep. Teaching points:  Avoid exposure to infection. Administer decongestant nose drops first if nasal passages are blocked. Avoid contact with eyes. Report worsening of condition c. cefuroxime Brand Name: Cefuroxime Indications: 1. Lower Respiratory Tract Infections, including pneumonia, caused by Streptococcus pneumoniae, Haemophilus influenzae (including ampicillin-resistant strains), Klebsiella spp., Staphylococcus aureus (penicillinase- and non-penicillinase-producing strains), Streptococcus pyogenes, and Escherichia coli. 2. Urinary Tract Infections caused by Escherichia coli and Klebsiella spp. 3. Skin and Skin-Structure Infections caused by Staphylococcus aureus (penicillinaseand non-penicillinase-producing strains), Streptococcus pyogenes, Escherichia coli, Klebsiella spp., and Enterobacter spp. 4. Septicemia caused by Staphylococcus aureus (penicillinase- and non-penicillinaseproducing strains), Streptococcus pneumoniae, Escherichia coli, Haemophilus influenzae (including ampicillin-resistant strains), and Klebsiella spp. 5. Meningitis caused by Streptococcus pneumoniae, Haemophilus influenzae (including ampicillin-resistant strains), Neisseria meningitidis, and Staphylococcus aureus (penicillinase- and non-penicillinase-producing strains). 6. Gonorrhea: Uncomplicated and disseminated gonococcal infections due to Neisseria gonorrhoeae (penicillinase- and non-penicillinase-producing strains) in both males and females. 7. Bone and Joint Infections caused by Staphylococcus aureus (penicillinase- and nonpenicillinase producing strains). Side Effects: Local Reactions: Thrombophlebitis has occurred with IV administration in 1 in 60 patients. Gastrointestinal: Gastrointestinal symptoms occurred in 1 in 150 patients and included diarrhea (1 in 220 patients) and nausea (1 in 440 patients). The onset of pseudomembranous colitis may occur during or after antibacterial treatment Hypersensitivity Reactions:

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Hypersensitivity reactions have been reported in fewer than 1% of the patients treated with cefuroxime and include rash (1 in 125). Pruritus, urticaria, and positive Coombs' test each occurred in fewer than 1 in 250 patients, and, as with other cephalosporins, rare cases of anaphylaxis, drug fever, erythema multiforme, interstitial nephritis, toxic epidermal necrolysis, and Stevens-Johnson syndrome have occurred. Blood: A decrease in hemoglobin and hematocrit has been observed in 1 in 10 patients and transient eosinophilia in 1 in 14 patients. Less common reactions seen were transient neutropenia (fewer than 1 in 100 patients) and leukopenia (1 in 750 patients). A similar pattern and incidence were seen with other cephalosporins used in controlled studies. As with other cephalosporins, there have been rare reports of thrombocytopenia. Hepatic: Transient rise in SGOT and SGPT (1 in 25 patients), alkaline phosphatase (1 in 50 patients), LDH (1 in 75 patients), and bilirubin (1 in 500 patients) levels has been noted. Kidney: Elevations in serum creatinine and/or blood urea nitrogen and a decreased creatinine clearance have been observed, but their relationship to cefuroxime is unknown. Postmarketing Experience with Cefuroxime: In addition to the adverse events reported during clinical trials, the following events have been observed during clinical practice in patients treated with cefuroxime and were reported spontaneously. Data are generally insufficient to allow an estimate of incidence or to establish causation. Neurologic: Seizure. Non-site specific: Angioedema. Cephalosporin-class Adverse Reactions: In addition to the adverse reactions listed above that have been observed in patients treated with cefuroxime, the following adverse reactions and altered laboratory tests have been reported for cephalosporinclass antibiotics: Adverse Reactions: Vomiting, abdominal pain, colitis, vaginitis including vaginal candidiasis, toxic nephropathy, hepatic dysfunction including cholestasis, aplastic anemia, hemolytic anemia, and hemorrhage. Several cephalosporins, including cefuroxime, have been implicated in triggering seizures, particularly in patients with renal impairment when the dosage was not reduced.If seizures associated with drug therapy should occur, the drug should be discontinued. Anticonvulsant therapy can be given if clinically indicated. Nursing Considerations Body as a Whole:

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 Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history of allergies, particularly to drugs, before therapy is initiated.  Inspect IM and IV injection sites frequently for signs of phlebitis.  Report onset of loose stools or diarrhea.  Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes. d. ambroxol Classification: Mucolytic Adverse effect Occasional gastrointestinal side effects may occur but these are almost invariably mild. Indication Adjuvant therapy in patients with abnormal, viscid, or inspissated mucous secretions in acute and chronic bronchopulmonary diseases, and in pulmonary complications of cystic fibrosis and surgery, tracheostomy, and atelectasis. Also used in diagnostic bronchial studies and as an antidote for acute acetaminophen poisoning. Assessment & Drug Effects  Monitor for S&S of aspiration of excess secretions, and for  Bronchospasm (unpredictable); withhold drug and notify physician immediately if either occur.  Lab tests: Monitor ABGs, pulmonary functions and pulse oximetry as indicated.  Have suction apparatus immediately available. Increased volume of respiratory tract fluid may be liberated; suction or endotracheal aspiration may be necessary to establish  and maintain an open airway. Patient & Family Education  Report difficulty with clearing the airway or any other respiratory distress.