A Clinical Vignette in Pharmacology,

Therapeutics and Diagnostics

Submitted To:
The Faculty of the College of Nursing
Pharmacological Team:

Mr. Mark Anthony Artaba

Mr. Domino B. Puson
Mr. Jerald T. Ugdoracion
Mrs. Elaine Eina T. Lim
Mr. Alvin Cloyd H. Dakis

Submitted By:
Francis B. Robles, Jr.
BSN III-C
Batch 2011
 A Clinical Vignette in Pharmacology,
Therapeutics and Diagnostics

Analgesics and Antipyretics

A case of Ms. Janine Samora, Female, 17 years old, living at Mandaue, Cebu, went to
the clinic last one week ago due to reasons of dysmenorrhea. She asked her physician for
medications to relieve this and was prescribed celecoxib, taken orally, 200mg twice a day.
Without knowing, Mrs. Samora, mother of Janine, advices her to take in garlic and gingko
because she heard from her friends that this is effective in treating dysmenorrhea. 8 days later,
Janine returns to her physician and notifies him that her menstruation is heavier than usual and
has not stopped.

Assessment:
Subjective:
> “Ning-samot man akong dugo,pila na man ni ka-adlaw, lahi ra man ni sa akong ubang
regal” as verbalized by client
Objective:
> received client sitting bench, conscious, coherent, awake, and afebrile and eupneic
> generalized weakness noted
> client has taken celecoxib for more than 5 days straight
> use of herbal medications: garlic and gingko noted
> use of perineal pads: 3 times per hour
> pallor noted
> poor skin turgor noted
> slow capillary venous return noted: 3-4 seconds
> with VS of: T: 37.3°C, P: 93bpm, R: 21cpm, BP:100/60mm Hg
Diagnosis:
Fluid Volume Deficit r/t active fluid volume loss secondary to decreased platelet
aggregation
Planning:
Short Term:
After 5 hours of therapeutic nursing interventions, client will be able to verbalize
realization of drug interaction resulting to increased bleeding tendency
Long Term:
After 5 days of effective therapeutic nursing interventions, client will be able to show
effective management as evidenced by decreased output, corrections on errors of
lifestyle/habits that impede further bleeding.
Interventions:
1. Appropriately educate client regarding drug and drug interactions. Emphasize that
drug is not for long term use and should be limited to 3 days maximum.
2. Teach patient signs and symptoms of bleeding, including those symptoms not
associated with present conditions, such as that of the GI tract. Symptoms may take
form in black tarry stools, blood in vomit, and in the urine.
3. Assess patient for other complications brought by drug such as liver toxicity, urinary
retention, and hypersensitivity.
4. Tell patient that drug may harm the liver. Advice patient to stop therapy and notify
prescriber if she experiences signs and symptoms of liver toxicity, including nausea,
fatigue, lethargy, itching, yellowing of skin or eyes, right upper quadrant tenderness,
and flulike syndrome.
5. Tell patient to increase fluid intake. Educate the importance of increasing fluid intake
in relation to blood loss.
6. Educate patient regarding other adverse reactions of drug.
7. Tell patient that this drug may cause drowsiness, dizziness, and blurring of vision.
Advice client to avoid activities that requires mental alertness.
Evaluation:
The patient demonstrates an understanding of the treatment regimen and adverse
reactions of the drug. Client incorporates proposed interventions to lifestyle changes resulting to
corrected adverse reactions.
 A Clinical Vignette in Pharmacology,
Therapeutics and Diagnostics
Anesthetics

A case of Mr. Arvin Malbos, Male, 23 years old, currently occupying an apartment at
Bogo, Cebu was admitted last Tuesday due to fracture on the right tibia. He is scheduled for an
open reduction internal fixation procedure tomorrow, Friday. On the day of operation, Mr.
Malbos was inducted with Propofol (Diprivan), an IV anesthetic agent. He had good Vital Signs
at the beginning until he had a sudden drop of respiratory rate and poor results of the pulse
oxymetry.

Assessment:
Subjective:
> “No Verbal Cues” noted
Objective:
>client is lying on bed, unconscious, and dyspneic with intervals of apnea noted
> with anesthetic infusion via IV attached to left arm
>client is cyanotic
> with VS of T: 35.8°C, P: 72bpm, R:11cpm, BP:110/70mm Hg.
>irregular RR noted
>increased chest diameter, excessive use of accessory muscles noted
>low pulse oxymeter reading: 88% noted
Diagnosis:
Ineffective breathing pattern r/t depression of the respiratory center of the medulla
secondary to induction of the anesthetic agent
Planning:
Short Term:
After 30 minutes of effective therapeutic regimen, client will be able to restore a level of
breathing pattern within boundaries considered as better or normal as evidenced by an increase
in: pulse oxymeter reading, regular respiratory rate; and a change in the tinge of skin color
from bluish to a shade of pink.
Long Term:
After 3 days of nursing interventions, client will be able to resume normal breathing
pattern as evidenced by stable VS, a reading of pulse oxymeter within normal range (98-100%),
and good skin color.
Interventions:
1. Provide pre-operative education to Mr. Malbos and his significant others about the
induction process to minimize fears of anesthesia. If questions or clarifications are
asked regarding the ORIF, give overviews.
2. Assess patient for a history of hypersensitivity to propofol, soybean oil, glycerol, or
egg phospholipids. This is usually the cause of respiratory depression in relation to
adverse reaction to propofol.
3. Visually inspect the propofol preparation for particular matter and discoloration
before administration. If the emulsion appears to be separated, tell anesthesiologist
regarding the matter for proper disposal.
4. Prepare materials for intubation. Manual ventilation equipments of oxygenation may
be used. Oxygen administration should be at the lowest concentration or as
prescribed by surgical team.
5. In a worse to come scenario, resuscitation may be necessary. Prepare resuscitation
equipments. Be alert when this happens. Take note for any unusualities and resolve
the matter according to protocols of profession.
6. Maintain a calm attitude while dealing with the situation. A clouded mind decreases
performance and critical thinking.
7. Post-operatively, monitor patient’s status. Let patient perform post-operative
exercises that maintains and improves respiratory function. Closely monitor progress
especially in the first 24 hours.
Evaluation:
The patient maintains effective breathing despite respiratory depression by
administration of oxygen as appropriate.
 A Clinical Vignette in Pharmacology,
Therapeutics and Diagnostics
Antimicrobials

A case of Mickie Reyes, Female, 15 years of age, living at Pajo, Lapu-Lapu, was
brought to the clinic because her mother was worried regarding her feet that had foul odors,
scaling and maceration, specifically at the interdigital areas. Her physician prognosed Mickie of
having Intertrigenous tinea pedis. With this, Mickie was prescribed to use an oral anti-fungal:
itraconazole (Sporanox) 200mg daily for 2 weeks. After a week, Mrs. Reyes came back with
Mickie, lethargic, and having yellowish tinge of the eyes and skin. She wanted to now regarding
the medication.

Assessment:
Subjective:
> “Nagluya lage akong bata dong, Unya, lain na kayo iyang panit ug color.” As
verbalized by mother of client
> “Naunsa naman ko? Sakit akong tiyan.” as verbalized by client
Objective:
> received client sitting on bench, conscious and coherent
> without IVF attached
> untimely healing of macerations of interdigitalis of both feet noted
> generalized weakness noted
> nausea, vomiting, and anorexia reported and noted
> tenderness to the right upper quadrant of abdomen noted
> jaundice noted
> Pain Noted:
P: Moderate Pain
Q: Sharp throbbing pain
R: RUQ of abdomen
S: 4/10
T: during movement
> increased AST, ALT, and platelet levels
Diagnosis:
Risk for impaired liver function r/t increased toxicity secondary to drug medication
Planning:
Short Term:
After 4 hours of nursing interventions, client and significant other will be able to verbalize
understanding of the current status in relation to drug medication’s adverse effects
Long Term:
After 5 days of effective therapeutic interventions, client will be able to demonstrate
lifestyle changes that will impede and reduce the risk of liver toxicity and timely healing of foot
will be observed.
Interventions:
1. Inform Physician to change therapeutic regimen that appropriate for client. He may
be giving drugs too strong for client.
2. Appropriately educate client regarding drug and drug interactions.
3. Teach patient to recognize and report signs and symptoms of further liver disease,
such as dark urine, pale stools, and unusual fatigue.
4. Instruct patient that oral solutions can never be used interchangeably with prescribed
capsules.
5. Encourage client to avoid fatty foods. Fats interfere with the normal function of liver
cells and can cause additional scarring of liver cells where they cannot regenerate
anymore.
6. Stress necessity of follow-up care and adherence to therapeutic regimen.
7. Assist with medical treatment of underlying condition to support organ function and
minimize liver damage.
Evaluation:
Client is free of the signs of liver failure as evidenced by liver function studies within
normal levels, and absence of jaundice, hepatic enlargement, and level of energy.
 A Clinical Vignette in Pharmacology,
Therapeutics and Diagnostics
Gastro Intestinal:

A case of Ms. Devian Te, Male, age 45, currently a resident of Sanciangko, Colon was
admitted due to reasons of abdominal pain. He said that this has already been present for 2
months, and had worsened ever since. No abnormal findings were noted on the physical
examination or in the results of gastrointestinal endoscopy. He was diagnosed as having IBS.
He was prescribed for a treatment of Calcium Carbonate and was given instructions for and out
patient case. After a week, he went back complaining that besides from the chalky taste, he had
diarrhea since the third day he took the drug.

Assessment:
Subjective:
> “Nagkalibanga naman ko ana dong, galuya gud akong lawas” as verbalized by client
Objective:
> received client lying on the chair
> body weight less is 10% less than that of last visit
> poor skin turgor noted
> watery stools reported
> more than 3 defecation per day noted
> hypotension noted: 100/60mm Hg
> generalized weakness noted
Diagnosis:
Hypertonic Fluid Volume Deficit r/t inability to absorb required electrolytes secondary
increased peristalsis on irritated stomach lining
Planning:
Short Term:
After 4 hours of nursing interventions, client will be able to show immediate replenish of
fluids lost as evidenced by an increase in skin turgor.
Long Term:
After 7 hours of nursing interventions, client will resume activities that were impaired by
drug side effects.
Interventions:
1. Notify prescriber regarding diarrhea and side effects of drug.
2. Initiate intravenous infusion to replenish fluids and electrolytes lost.
3. Assess vital signs taking note of temperature, and blood pressure changes.
4. Establish a 24 hour replacement needs and routes to be used.
5. Monitor laboratory values that indicate nutritional well-being/deterioration such as the
serum albumin, transferrin, RBC and WBC counts, and serum electrolyte values.
6. Suggest liquid drinks for supplemental nutrition.
7. Discourage beverages that are caffeinated or carbonated.
8. Encourage exercise. Metabolism and utilization of nutrients are enhanced by activity.
Evaluation:
Client will maintain a fluid volume at a functional level as evidenced by individually
adequate urinary output, stable vital signs, moist mucus membranes and good skin turgor.
 A Clinical Vignette in Pharmacology,
Therapeutics and Diagnostics

Respiratory System:

A case of Ms. Franchesca Lumber, Female, 35years of age, living at Capitol Cebu, went
to the ER due to tachypnea, and acute shortness of breath with audible wheezing. She has a
history of asthma and has taken her ventolin nebule at home before coming to the hospital. At
the ER, the physical exam revealed the following: HR 112, RR 40 with signs of accessory
muscle use. Ausculation revealed decreased breath sounds with inspiratory and expiratory
wheezing and pt was coughing up small amounts of white sputum.

Assessment:
Subjective:
> “Naglisod kog ginhawa, *cough*, sakit pa gyud akong dughan” as verbalized by client.
Objective:
> received client sitting,conscious, coherent, tachypneic and afebrile
> acute episodes of starvation for air noted
> wheezing noted
>coughing noted
>white sputum noted
> signs of accessory muscle use noted
> with vital signs of: T: 36.9°C, P: 112bpm, R: 43cpm, BP: 120/80mm Hg.
Diagnosis:
Ineffective Breathing Pattern r/t spasm of the bronchial tree
Planning:
Short Term:
After immediate nursing care, client will be able to breathe clearly as evidenced by lower
RR and minimized used of accessory muscles.
Long Term:
After 3 days of nursing interventions, client will have a be able to show signs of effective
breathing patterns as evidenced by clearance from the Cardio-Pulmonary test and stable VS.
Interventions:
1. Educate patient on the correct way of using a puffer. Teach about meter dose
inhalers. When tow puffs are required, 1-3 minutes should lapse between two puffs.
A spacer may be used to increase the delivery of the medication.
2. Be alert and watch out for status astmaticus after giving drug.
3. Tell patient to avoid caffeine or products that increases heart rate, it can cause
severe tachycardia if given with Ventolin.
4. Tell patient to use only the recommended nebulizer and compressor for treatment
and not to mix drug with other drug.
5. Remind patient that drug is for maintenance treatment only and shoudn’t be used to
stop an asthma attack or bronchospasm.
6. Inform patient that she may feel palpitations, chest pain, rapid heart beat, tremors, or
nervousness.
7. Caution patient to notify prescriber if she notices a decrease in symptom control or
more frequent use of her rescue inhaler.
Evaluation:
Paitent exhibits normal breathing pattern. Patient copes up effectively and
efficiently.
 A Clinical Vignette in Pharmacology,
Therapeutics and Diagnostics

Cardiovascular:

A case of Mr. Gerald Pastoriza, Male, 54 years old, living at Talisay Cebu, was
rushed to the ER yesterday because of myocardial infaction and high blood pressure. A few
minutes after he came in, he had a stroke attack. He was given his usual antihypertensive drug.
The doctor gave him Heparin Sodium via IV infusion. Two days later, blood sample was taken
from him. Later that afternoon, the site where blood was drawn was bleeding.

Assessment:
Subjective:
> “Nagdugo man ni ang kamot sa akong bana!” as verbalized by wife
Objective cues:
> received client lying in bed, conscious and coherent
> with #4 NSS infusing well on Left arm
> with injection site bleeding noted
> client is till under heparin therapy noted
> increased clotting time
> pallor noted
> poor skin turgor noted
> slow capillary venous return noted: 3-4 seconds
> with VS of: T: 37.3°C, P: 90bpm, R: 18cpm, BP:110/50mm Hg
Diagnosis:
Risk Fluid Volume Deficit r/t active blood loss secondary to decreased coagulating
capability of white blood cells
Planning:
Short Term:
After 6 hours of nursing interventions, client will be able to manage bleeding within
level of capability and enumerate ways to reduce risk of further bleeding.
Long Term:
After 5 days of effective therapeutic interventions, client will be able to incorporate
the proposed nursing interventions that decreases risk for bleeding into lifestyle.
Interventions:
1. Keep cannulated extremity still. Use soft restraints or arm boards as needed.
Movement may cause trauma to artery.
2. Do passive range-of-motion (ROM) exercises to unaffected extremity every 2 to
4 hours. Exercise prevents venous stasis.
3. Prepare for removal of arterial catheter as needed. Circulation is potentially
compromised with a cannula. It should be removed as soon as therapeutically
safe.
4. If cast causes altered tissue perfusion, anticipate that physician will bivalve the
cast or remove it. This restores perfusion in affected extremity.
5. Keep away sharp objects from patient. This would help ensure safety for the
patient.
6. Tell patient to avoid in contact sports. Such activities increase the risk for
bruising and bleeding.
7. Keep Protamine Sulfate ready at all times
Evaluation:
Client has maintained being unhurt at all times. Client has showed lifestyle changes
on bleeding precaution methods.
 A Clinical Vignette in Pharmacology,
Therapeutics and Diagnostics

Central Nervous System

A case of Harold Levi, age 59, living alone after his wife had a stroke and was placed in
a nursing home. He has had problems with tremors at rest for quite some time, but attributes it
to nerves. He has been retired for over 5 years now, and spends time looking after his two dogs
and playing cards and bingo. He notices that he is getting clumsy and dropping things. When
his son came to visit, he noticed his father had a shuffling, propulsive type of gait and made a
doctor’s appointment for him. Mr. Levi is diagnosed as having Parkinson’s disease. The health
care provider tells him that his stooped posture is part of the process, along with the
monotonous, indistinct speech that he has recently developed. The health care provider
explains that to get the muscle problems under control, he wants to start Mr. Mckinley on two
drugs that work well together. He prescribes carbidopa-levodopa (Sinemet 10-100) twice a day.

Assessment:
Subjective:
“Sa ako ra man ning pagkatiguwang, kahibaw na mo. Dili na ing-ana kamaayo
atong lihok” as verbalized by client.
Objective:
> received client lying on bed
> client is ambulatory, with shuffling, propulsive gait
> tremors noted
> stooped posture noted
> slurred speech noted
Diagnosis:
Risk for falls r/t side effects of anti-Parkinson drugs
Planning:
Short Term:
After 4 hours of nursing intervention, client’s support system would be able to
enumerate at least 10 possible situations where client could be at risk for injury in his present
condition.
Long Term:
After 5 days of effective nursing interventions, client and SO will be able to
incorporate lifestyle changes appropriate for patient’s well being.
Interventions:
1. Assess gait & balance
2. Risk identification, Surveillance safety
3. Assess patient or caregiver’s knowledge of immobility and its implications. Even
patients who are temporarily immobile are at risk for effects of immobility such
as skin breakdown, muscle weakness, thrombophlebitis, constipation,
pneumonia, and depression.
4. Facilitate transfer training by using appropriate assistance of persons or devices
when transferring patients to bed, chair, or stretcher.
5. Allow patient to perform tasks at his or her own rate. Do not rush patient.
Encourage independent activity as able and safe. Hospital workers and family
caregivers are often in a hurry and do more for patients than needed, thereby
slowing the patient’s recovery and reducing his or her self-esteem.
6. Keep side rails up and bed in low position. This promotes a safe environment.
7. Teach energy-saving techniques. These optimize patient’s limited reserves.
8. Instruct patient or caregivers regarding hazards of immobility. Emphasize
importance of measures such as position change, ROM, coughing, and
exercises.
Evaluation:
Client moves about safely & experiences no falls or injuries. Client’s SO participates in
the programs intended for client’s safety.
 A Clinical Vignette in Pharmacology,
Therapeutics and Diagnostics

EENT:

A case of MAC, a 16 year old, Male, was brought to the hospital because of an eye
injury which was scheduled for an emergency surgery. He was well taken care of by the staff
and was discharged after 3 days. A week later, MAC’s mother called up the hospital and
reported that her son’s eyes were very red and swollen. That afternoon, they went to see the
physician specializing in EENT for a check up. Dr. Antenor Cruz concluded that it was a sign of
an infection and was caused by a strain of bacteria. The renounced doctor assumed that it was
caused by too much scratching of the eyes with an unclean hand and possibly exposed to an
environment wherein presence of bacteria is abundant. The handsome and intelligent doctor
prescribed an antibiotic medication specifically erythromycin to treat the disease, which has to
be taken 3 times with a day of only 2-3 drops each time for 1 week.

Assessment:
Subjective:
> “Namuwa jud ang mata sa akong bata” as verbalized by patient’s mother
Objective:
> reddish eyes noted
> itchiness over the left eye reported
> excessive secretions of the eye observed
> superinfection
> photophobia and tearing
> decrease in visual acuity, possibly leading to blindness
> diarrhea
> nausea
> vomiting
Diagnosis:
Fluid Volume Deficit related to increased motlin secretion secondary to
adverse effect of medication as evidenced by vomiting and diarrhea
Planning:
Short Term:
After 4 hours of nursing interventions, client will be able to show immediate replenish of
fluids lost as evidenced by an increase in skin turgor.
Long Term:
After 7 days of nursing intervention, client will be able to maintain electrolyte levels in the
body as evidenced by normal serum levels.
Interventions:
1. Increase oral fluid intake
2. Administer anti – emetic medications
3. Increase sodium in diet
4. Administer pain relievers
5. Encourage patient not to do activities requiring visual acuity
6. Encourage patient to wear sunglasses during outdoors and daytime
7. Wipe secretions with sterile gauze
8. Tell patient to complete the treatment with no lapses
9. Encourage hand washing
10. Encourage proper environmental care
Evaluation:
Patient’s eye was free from sings of inflammation and infection. Patient’s electrolyte
levels remained at the normal. Abdominal pain was relieved and patient was able to see things
better.