Intr oductio n

The rising incidence of tuberculosis has economic

repercussions not only for the patient’s family but also for the
country. Eighty percent of people afflicted with tuberculosis are in
the most economically productive years of their lives, and the
disease sends many self-sustaining families into poverty. The rise
in the incidence of tuberculosis has been due to the low priority
accorded to anti-tuberculosis activities by many countries. The
unavailability of anti-TB drugs, insufficient laboratory networking,
poor health infrastructures, including a lack of trained health
personnel, have also contributed to the rise in the incidence of the
diseases.
According to the World Health Organization, the Philippines ranks
sixth in the world for the number of cases of tuberculosis and has
the highest number of cases per head in Southeast Asia. Almost
two thirds of Filipinos have tuberculosis, and up to five million
people are infected yearly in our country.
Tuberculosis At A Glance
Tuberculosis (TB) is an infection, primarily in the lungs caused by bacteria called
Mycobacterium tuberculosis. It is spread usually from person to person by breathing
infected air during close contact. TB can remain in an inactive (dormant) state for
years without causing symptoms or spreading to other people. When the immune
system of a patient with dormant TB is weakened, the TB can become active
(reactivate) and cause infection in the lungs or other parts of the body. The risk factors
for acquiring TB include close-contact situations, alcohol and IV drug abuse, and
certain diseases (for example, diabetes, cancer, and HIV) and occupations (for
example, health-care workers). The most common symptoms of TB are fatigue, fever,
weight loss, coughing and night sweats.
The diagnosis of TB involves skin tests, chest x-rays, sputum analysis (smear and
culture), and PCR tests to detect the genetic material of the causative bacteria.
Inactive tuberculosis maybe treated with an antibiotic to prevent the TB infection from
becoming active. Active TB is treated, usually successfully with combination of one or
more of several drugs.
Drug-resistant TB is a serious, as yet unsolved, public health problem, especially in
Southeast Asia, the countries of the former Soviet Union, Africa, and in prison
populations.
Poor patient compliance, lack of detection of resistant strains, and unavailable therapy
are the key reasons for the development of drug-resistant TB.
The occurrence of HIV has been responsible for an increased frequency of
tuberculosis. Control of HIV in the future, however, should substantially decrease the
frequency of TB.
 History
 * 1882
 * “Consumption”
 * 1940s
 * mid 80s-90s
 * March 24, 1997
 * (1963)- May 2007

 Global Impact of Tuberculosis

One third of the world’s population is infected with
the TB bacillus. There are 8 million new cases of TB
each year and 3 million people die of the disease
(170,000 cases are children). TB is the leading cause
of death in HIV-infected persons.
 PAT IE NT’ S PROF IL E
 Name: LML
 Address: PLC Poblacion, Muntinlupa City
 Date of Birth: October 27, 1959
 Age: 49 years old
 Sex: Female
 Civil Status: Married
 Nationality: Filipino
 Religion: Roman Catholic
 Occupation: Housewife
 Admission Date/Time: August 25, 2008 - 2:00 pm
 Attending Physician:Dr. E.S.
ADMI TTI NG HI ST ORY:
This is a case of a 49 year old, female, diabetic-
type 2, non-hypertensive patient who was admitted at
Alabang Medical Clinic last August 25, 2008 around
2:00 pm, with complains of difficulty of breathing and
body weakness.
Two months prior to admission, the patient
experienced progressive body weakness, decreased
appetite, with productive coughing, and pleuritic chest.
The husband was prompted to bring her to the
hospital for further evaluation, since the patient was
known to have DMII, lost to follow up for the entire 8
months and had stopped taking her medications.
Ph ysic al Asse ssm ent:

>GS: conscious, coherent

>Skin: pale
>HEENT: pinkish palpebral conjunctivae, palpable
lymph nodes
>C/L: symmetrical chest expansion, harsh crackles
breath sound heard on upper lobe of left lung
>Heart: Normal Rate Regular Rhythm, (-) murmurs
>Abdomen: Unremarkable
>GUT/Genitalia: Unremarkable
>IE: Unremarkable
>Extremities: Unremarkable
Admitting Impression: Diabetes Mellitus
2, poorly controlled
r/o Pneumonia
t/c Pulmonary Tuberculosis

Final Diagnosis: Pulmonary Tuberculosis,

Category 2, stage3
Past Medical History:
>4x hospitalization- gave birth (normal delivery)
>4x hospitalization- due to illnesses (DM, PTB)
>initiates self-medication on simple illnesses such as colds,
cough, and fever(paracetamol, alaxan, tuseran forte).
Family History:
FATHER MOTHER
DIABETES (-) (+)
HYPERTENSION (-) (-)
ASTHMA (-) (+)
The patient had family history of diabetes, as well as
respiratory disease such as asthma.
According to the patient, she had no childhood immunizations
particularly BCG vaccine, which made her susceptible to acquire
respiratory diseases such as Tuberculosis.
Social History:
The patient resides in a congested environment, unemployed
since the birth of her first child and lives a sedentary lifestyle.
Ana tom y a nd
Phy si ol og y
URT

LRT
 Is a membraneous tube
that consists of dense
regular connective and
smooth muscle
reinforced with 15-20
"C"-shaped pieces of
cartilage.
 Cartilages form the
anterior and lateral sides.
 Protect the trachea
and maintain an open
passageway for air.
 Posterior wall contains no
cartilage and consists of
a ligamentous membrane
and smooth muscle
which can alter the
diameter of the trachea.
 Esophagus lies
immediately posterior to
the cartilage-free
posterior wall of the
trachea.
 · Trachea is lined with
pseudostratified ciliated
columnar epithelium that
contains numerous
goblet cells.
 Bronchi
 Trachea divides into the
right and left primary
bronchi.
 Right bronchus is shorter
and wider and is more
vertical than the left
bronchus.
 Primary bronchi extend
from the mediastinum to
the lungs.
 The lining of the bronchi
is the same as the
trachea and the bronchi
are supported by
"C"-shaped cartilage
rings.
How Does Lungs protect themselves:
◙ First, the nose acts as a filter when breathing in, preventing
large particles of pollutants from entering the lungs.

◙ If an irritant does enter the lung, it will get stuck in a thin layer of
mucus (also called sputum or phlegm) that lines the inside of the
breathing tubes.

◙ Mucus is "swept up" toward the mouth by little hairs called cilia
that line the breathing tubes.

◙ The last of the common methods used by the lungs to protect

themselves can also create problems. The airways in the lungs
are surrounded by bands of muscle. When the lungs are irritated,
these muscle bands can tighten, making the breathing tube
narrower as the lungs try to keep the irritant out. The rapid
tightening of these muscles is called bronchospasm
◙ Cough and sneeze reflex: Irritant touches the surface
of the glottis, Trachea or bronchus.
↓
Sensory signals are transmitted
to the medulla.
↓
Motor signals are transmitted
Back to the respiratory system.
↓
Respiratory muscles contract very rapidly
Generating high pressures in the lungs while
The vocal cords remain tightly closed.
↓
Vocal cords open suddenly, allowing
pressurized air in the lungs to flow out in a blast
Muscles involved in respiration

Quiet Forced (in addition to muscles involved

in quite respiration)

Inspiration Diaphragm (contraction) Sternocleidomastoid muscle

Intercostal muscles (to Pectoralis muscles
prevent inward bellowing) Serratus anterior muscle
Scalene muscles Erector spinae
Quadratus lumborum

Expiration Elastic recoil of the lungs Abdominal muscles

Intercostal muscles (to Latissimus dorsi
prevent outward bellowing)
Diaphragm (relaxation)
Laboratory Re sults
 RESULT NORMAL VALUES

WBC

RBC
He matolo gy 0 8-2 5
15.1 x 10 9/L

3.0 x 10 12/L
5-10 x 10 9/L

M 4.5-5.5
F 4.0-5.0

DIFFERENTIAL COUNT

NEUTROPHIL SEG 0.88 0.55-0.70

LYMPHOCYTE 0.12 0.20-0.35

EOSINOPHIL 0-0.01

MONOCYTE 0.03-0.05

PLATELET COUNT 603.00 142-424,000 UL

HGB 86 g/l M 130-160

F 120-140

HCT 0.26 M 0.42-0.50

F 0.37-0.47

OTHERS Hgt 144 mg/dl

 RESULT NORMAL VALUES

WBC
He matolo gy 0 8-2 6
9.6 5-10 x 10 9/L

RBC 3.85 M 4.5-5.5

F 4.0-5.0

DIFFERENTIAL COUNT

NEUTROPHIL SEG 0.83 0.55-0.70

LYMPHOCYTE 0.13 0.20-0.35

EOSINOPHIL 0-0.01

MONOCYTE 0.04 0.03-0.05

PLATELET COUNT Adequate 142-424,000 UL

HGB 110 g/l M 130-160

F 120-140

HCT 0.33 M 0.42-0.50

F 0.37-0.47
 Blo od Ch em 0 8-2 6
RESULTS UNITS NORMAL VALUES

LU 90 Mg/dl 70-105

HOL 101 Mg/dl 140-310

G 107 Mg/dl 35-160

RIC 425.14 Umol/l 155.00-428.00

UN 4.98 Mmol/l 2.90-8.20

LT 7 IU/L 10-40

ST 14 IU/L 10-42

DLD 13.63 Mg/dl 29.00-71.54

DL 66.0 Mg/dl 66.0-178.0

LDL 21.40 Mg/dl 0.00-40.00

ABG 08-27

RESUL NORMAL
T VALUES

pH 7.46 7.35 – 7.45

PAO2 73.4 95 – 100 mmHg
PACO2 31.7 35 – 45 mmHg
HCO3 22 22 – 26 mEq/L
TCO2 23 25 - 30 mmol/l
BE -1.8 -2 to +2 mmol/l
O2 SAT 95.60% 96% - 98%
X-r ay
Chest x-ray
The left lung is hyper aerated. Both lobes have multiple, thin-walled,
lucent structures with no bronchovascular structures. Thick pleura
covers the lung from apex to base, including the sinuses. The right
upper lobe has soft densities. The rest of the right lung fields are
clear.
The heart size cannot be assesses. The left hemidiaphragm is
indisctinct. A long horizontal fluid interface is projected on it.
The right hemidiaphragm is normal. The thoracic cage is normal.

Impression:
Extensive PTB with destroyed left lung.
Empyema in the legt hemithorax is suspected. Suggest doing a left
lateral decubitus film.
Sp utu m te st 08-2 8
AFB Stain
Day 3
Greater than 25 polymorphonuclear cells
Less than 25 epithelial cells
Positive for acid fast bacilli: 3+
More than 10 AFB/OIF in at least 20 visual fields
Day 2
Greater than 25 polymorphonuclear cells
Less than 25 epithelial cells
Positive for acid fast bacilli: 3+
More than 10 AFB/OIF in at least 20 visual fields
Day 1
Greater than 25 polymorphonuclear cells
Less than 25 epithelial cells
Positive for acid fast bacilli: 3+
More than 10 AFB/OIF in at least 20 visual fields
He moglobin A1 C

RESUL NORMAL
T VALUES

A1C 5.7% 3.82%-6.52%

CONCENTRATION
Ult raso und 0 8-25

Chest ultrasound
Real time scanning of the left lung shows
fluid with estimate volume of 157cc.

Impression:
Pleural effusion, left.
Blo od c hem 0 8-2 6

RESUL NORMAL
T VALUES

POTASSIU 4.05 3.5-5.3 mmol/L

M
Blo od c hem 0 8-2 5

RESULT UNITS NORMAL VALUES

S

NA 130.3 Mmol/l 135.0-145.0

K 2.54 Mmol/l 3.60-5.00
CREA 96.82 Umol/l 53.00-115.00
Cr oss-ma tching report
08-2 5
Patients ABO Type “O” RH+
Donor’s ABO Type “O” RH+
 RESULT NORMAL RESULTS

PHYSICAL

Ur in alysi s 0 8-2 5
COLOR
TRANSPARENCY
Yellow
Hazy
Straw - Dark yellow
Clear - Hazy
pH 6.0 4.5-7.8
SPECIFIC GRAVITY 1.020 1.003-1.029

MICROSCOPIC

EPITHELIST CELLS Moderate small amounts

PUS CELLS 35-40/hpf

RBC 0-3/hpf male: 0-3/hpf

female: 0-5/hpf
BACTERIA Few Negative
OTHERS Ketones (-) Negative

CHEMICAL

SUGAR Negative Negative

ALBUMIN trace
Tr oponin t est

Troponin – 1 negative
Med ical
Man age me
nt
  Admit to room of choice under Dr.
August 25, 2008 Jarcia
 Secure consent
Hgt: 214mg/dl  TPR every shift
 Diabetic diet
 Complete Blood Count
 Accurate Platelet Count
 Hemoglucotest
 Electrocardiogram
 Chest x ray
 Urinalysis with urine ketones
 Stat serum sodium, potassium
 Creatinine
 Fasting Blood Sugar
 Glycosylated hemoglobin
 Blood Urea Nitrogen
 Uric acid
 Lipid profile
 Alanine Aminotransferase (ALT),
Aspartate Aminotransferase (AST)
 IVF: Plain NSS 1 L to run for
8 hours
 Plain NSS 1 L to run for 12
hours
 Humulin R 5 units
subcutaneous
 Vital sign every 1 hour and
record
 Refer accordingly
 Esomeprazole (Nexium)
ampule 40 mg once a day IV
 Erdosteine (Ectrin) 300 mg
tablet twice a day by mouth
 Cefuroxime 750 mg every 8
hours IV After negative skin
test
 1 Nebule Salbutamol every 4
hours
August 25, 2008  Prepare and
4:55 pm transfuse 2 units
Packed Red Blood
Cell properly typed
and cross matched
to run 5 hours each
with 2 hours interval
 Benadryl 1 ampule
prior to each blood
transfusion
 Oxygen at 4
liters/minute as
needed for dyspnea
August 25  Refer to Dr. Jennie
Estrada for co-
management
 Incorporate 40 mEq
Potassium Chloride to
the present IVF
 Kalium Durule 1 tablet
twice a day
 hemoglucotest every 6
hours and record
 Transderm patch 5 mg
anterior chest wall once
a day
7:35 pm  Incorporate 40 mEq
Potassium Chloride
to the next IVF
 Plain NSS 1 L x KVO
once on blood
transfusion. Please
insert another line
8:20 pm  Paracetamol tablet
500 mg tablet
every 4 hours as
needed for
temperature ≥
37.6 C
August 26, 2008  Please do chest
9:15 am ultrasound with
marking
1:30 pm  IVF to follow: Plain
NSS 1 L + 40 mEq
Potassium Chloride x
10 hours
August 26  Repeat Complete
Blood Count 6 hours
post blood
transfusion
August 26  For hemoglucotest
twice a day pre
meals
8:00 pm
 IVF to follow Plain
NSS 1L + 40 mEq
Potassium Chloride x
10 hours
 August 27, 2008  No need for now
3:48 am  Discontinue on the
Attending physician left (IVF)
informed IVF to
follow x KVO
8:45 am  IVF to follow 1L Plain
NSS 1L x KVO
August 27  Please maintain
oxygen at 5
liters/minute
August 27  Please maintain
oxygen at 5
liters/minute
5:20 pm  Decrease
nebulization to every
6 hours
August 27  Glimepiride 1 mg 1
tablet pre breakfast
 Transfer service to
Dr. Jennie Estrada
August 28, 2008  Culture and
12:30 pm sensitivity and
sputum acid fast
bacilli smear results
 Ferrous Sulfate
(United Home) 325
mg 1 tablet twice a
day
 5:30 pm  Please advise her to
Informed of Hgt: 54 eat on schedule.
mg/dl Increase Hgt
Asked if for repeat Hgt monitoring to three
afterwards times a day
 8:30 pm  Hold Nitroglycerin
Informed of blood patch for now
pressure: 90/60
Asked if Nitroglycerin
patch should be
continued
 August 29, 2008  Let the patient eat
5:00 am then re-check after 1
Attending physician’s hour
informed regarding
61 mg/dl and
resident on duty
informed
 6:30 am
Attending physician
regarding the latest
Hgt result 71 mg/dl
9:30 am  To follow: Plain NSS
1 L x KVO
10:45 am  Hemoglucotest:35
 Please give D50-50
IV now
 Repeat
hemoglucotest after
1 hour
 11:00 am  Hold antibiotic
Attending physician medications
informed  Give D50-50 IV PRN
hemoglucotest:35 for hemoglucotest
and that D50-50 IV is <80mg/dl
ongoing
 12:00 pm  Let patient eat her
 Hemoglucotest :53 lunch first
mg/dl (premeals)
 Referred to resident
on duty
August 29, 2008  To consume tablets if
Kalium durule then
discontinue
 Hold Glimeperide
 IVF to follow D5NSS 1 L
to run for 12 hours
 Start Myrin P Forte 3
tablets OD(before
breakfast)
 Please incorporate
Benutrex-C 1 ampule to
present IVF for 3 cycles
 5:30 pm  Please advise patient
 Hemoglucotest : to eat. Repeat
54mg/dl hemoglucotest
 Asked if D50-50 is to afterwards. If still low
be given. may give due D5050
1 vial
 Attending physician  Ok. Thanks
informed of
hemoglucotest:
58mg/dl
 Patient was asked to
eat
 11:30 pm  Give SERC 8mg/tab
 Resident on duty  Ok give 16mg/tab
informed regarding
patient complaints
 Avail stocks 16mg
 August 30, 2008  Do ECG, then do
2:20 am hemoglucotest,if the
 Resident on duty result is 80 mg/dl
informed about give D50-50
patient’s condition,
cold and clammy BP-
90/60mm/Hg
 Hemoglucotest: 38  Give D50-50 again
mg/dl
9:00 am  Repeat
Hemoglucotest
11:00 am  Refer to
Endocrinologist
 Follow up blood c/s
 12:30 pm  Please elevate left
 Resident on duty and leg with 2 pillows
attending physician  FD 800 cc then
informed of BP increase hour to 6
80/50. hours
Endocrinologist not
available
 2:20 pm  To follow: D5NSS to
 Resident on duty run for 6 hoursLet
informed of patient the patient eat her
Hemoglucotest: 76 lunch May not repeat
mg/dl as of 7 am hemoglucotest
9:30 pm  Please follow blood
c/s result
9:50 pm  Problem: BM 8 times
since am, small
amount
 For stool examination
 Kindly update
attending physician
11:15 pm  IVF to follow: D5NSS
1L + Benutrex-C 1
ampule to run for 6
hours
August 31,2008  Facilitate fecalysis
1:30 am
7:00 am  IVF to follow: D5NSS
1L + Benutrex-C
1ampule to run for 6
hours
 3:40 pm  Please do fecalysis
 Attending Physician now
informed of 4 times  Start Erceflora 1 vial
BM TID
6:35 pm  TF: D5NSS 1 L + 1
ampule Benutrex-C
to run for 6 hours for
2 cycles.
11:00 pm  TF blood c/s formal
report
 To consume tablets
of Kalium durule then
discontinue
 Facilitate fecalysis
 Start Streptomycin
1.5 mg (ANST) IM 3
times a week (M-W-
R)
September 1, 2008  To consume stocks
2:13 pm of Tazocin then to
Unasyn 750
mg/tablet; 1 tablet
BID
 To consume stocks  Let the relative look
of Tazocin then to on other drugstores
Unasyn 750  IVF TF: D5NSS + 1
mg/tablet; 1 tablet ampule Benutrex-c to
BID run for 8 hours in 2
cycles
  To consume IVF then discontinue
9:15 pm  May go home for request tomorrow
am
 Therapeutics:
4. Unasyn 750 mg in 2 daysLevox
500 mg OD in 8 days
5. Myrin P Forte 3 tablets OD in 5-7
days
6. Streptomycin 1.5 mg IM 3 times a
week (M-W-R) (ANST)
 To consume tablets of other
medications and discontinue.OPD
to follow on September 18, 2008,
Thursday, 10:00 am
11:00 pm  Thanks. Discontinue
HGT monitoring
Drug S tudy
Ethambutol

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Ethambutol -Ethambutol -Initial phase -Alcoholism, optic -Disorders of the -Perform visual
interferes with RNA treatment & re- neuritis, impaired blood & lymphatic acuity and color
synthesis, causing treatment of all forms hepatic function, system, immune descrimination test
suppression of of TB in category I & severe renal system, metabolism before and during the
Mycobacteria II patients caused by insufficiency, & nutrition, CNS, eye, therapy.
multiplication. It also susceptible strains of hyperuricemia, gouty GI, hepatobiliary, skin -Assess liver and
has bacteriostatic mycobacteria. arthritis, jaundice, & SC tissues, renal function before
Brand Name action against M retrobulbar neuritis. musculoskeletal, and during the
tuberculosis by acting Pregnancy & connective tissue & therapy.
-Myrin P Forte
on rapidly growing lactation. bone, renal/urinary, -Assess patient
pathogens in cavity reproductive system mental status often:
walls and is also & breast. Fever, affect mood,
effective in slow- malaise, flu-like behavior change.
Classification growing pathogens. syndrome, dryness of watch out for
mouth. confusion and
-Anti-TB Agents
hallucination
-Assess patient for
visual disturbance
that may indicate
optic neurisyis

Dosage

-3 tab OD in 5 to 7
days before
breakfast.
Streptomycin

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Streptomycin -Inhibits protein -Part of combination -Pregnancy; -Abnormal skin -Assess patient with
synthesis in bacterial therapy of active hypersensitivity sensation around the previous sensitivity
cell by building direct tuberculosis; use in face; vertigo; fever reaction.
to 30S ribosomal combination with -Severe allergic -Assess patient with
subunits, causing other agent for reactions (rash; signs and symptoms
inaccurate peptide treating of hives; difficulty of infection including
sequence to form In streptococcus or breathing; tightness characteristic of
Brand Name protein chain, enterococcal in the chest; swelling sputum, urine, stool,
resulting in bacterial endocarditic, of the mouth, face, WBC>10,000/mm3
-Streptomycin
death. mycobacterial lips, or tongue); -Obtain baseline
infection, plague, decreased urination; information before
tularemia, and dizziness; headache; and during treatment
brucellosis hearing loss; hives; -Identify urine output,
Classification lightheadedness; If decrease, notify
loss of balance; physician.
Aminoglycosides
muscle weakness; -Assess over growth
nausea; numbness of infection: perineal
or tingling; ringing or itching, fever
roaring in the ears; redness, pain
skin rash or itching; swelling, drainage,
vaginal irritation or rash, diarrhea, chain
Dosage discharge; vomiting in cough sputum.
-Monitor input and
-1.5G ANST(-) IM output, report sudden
3TYMS 2 WEEK change
(M-W-F0
Levofloxacin

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Levofloxacin -The levorotatory - Treatment of adults -Hypersensitivity to - Diarrhea, - Store in a dry place
isomer of ofloxacin ≥18 yr w/ mild, quinolones. IV abdominal at temperatures not
which inhibits DNA moderate & severe Epilepsy, history of discomfort, nausea, more than 30°C.
topoisomerase, more infections caused by tendon disorders anorexia, abdominal - Should be used with
commonly referred to susceptible strains of related to pain, vomiting, caution in patients
as the DNA gyrase. microorganisms in fluoroquinolone stomatitis & with a known or
DNA gyrase is the following therapy. Childn, heartburn; insomnia, suspected CNS
Brand Name necessary for conditions: pregnancy & headache & disorder that may
bacterial DNA Community-acquired pneumonia
lactation. dizziness; rash, predispose to
-Levaquin
replication and some , acute bacterial pruritus & eczema; seizures or lower
-Quixin
aspects of exacerbation of muscle & joint pain; seizure threshold
transcription, repair, chronic bronchitis, bone marrow -Take the oral
recombination and acute depression. solution 1 hr before
Classification transposition. maxillary sinusitis, Increased liver or 2 hrs after eating.
Inhibition of DNA complicated & enzymes. Pain, -Avoid multivitamins
- Antibiotic
gyrase in susceptible uncomplicated skin & reddening at the inj with zinc, iron
-Fluoroquinolone
microorganisms skin structure site, phlebitis. products, sucralfate,
results in the infections, acute and Mg- or Al-
inhibition of ATP- pyelonephritis, containing antacids 4
dependent negative complicated & hr before and after
supercoiling of DNA, uncomplicated UTI, dose.
Dosage inhibition of ATP- nosocomial
independent pneumonia, chronic
-500 mg OD in 8 relaxation of bacterial prostatitis.
days. supercoiled DNA and
promotion of double-
stranded DNA
breakage resulting in
bacterial cell death.
 Ampicillin

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Ampicillin -synthetic, broad -respiratory tract - Hypersensitivity; -hypersensitivity -Take 1 hr before or
Salbactam spectrum antibiotic infections due to non- infectious -nausea 2 hr after meals; food
suitable for gram- penicillinase- mononucleosis. -vomiting may interfere with
negative bacteria. producing -gastritis absorption
Acid resistant, Haemophilus -stomatitis -Take for prescribed
destroyed by influenzae number of days
penicillinase. -GI infections -Ampicillin chewable
Brand Name -GU infections tablets should not be
-use of the injection swallowed whole
-Unasyn
only for bacterial -May decrease
-Ampicillin Sodium
meningitis effectiveness of oral
-use of the injection contraceptives
for septicemia and -Do not save for
Classification endocarditis future use or share
with family
-Antibiotic
members/friends
-Penicillin
who have similar
symptoms

Dosage

-750 mg 1 tab BID

for 11 days
Cefuroxime

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Cefuroxime -Cefuroxime binds to -Treatment of -Hypersensitivity to -Diarrhea; -Give Cefuroxime at
one or more of the infections caused by cephalosporins. -nausea & vomiting same time each day.
penicillin-binding Staphylococcus, -abdominal pain -Do not give if the
proteins (PBPs) Strepcoccus, patient have
which inhibits the pneumococci, diarrhea, a stomach
final transpeptidation meningococci & or intestinal infection,
step of peptidoglycan other susceptible or a blood clotting
Brand Name synthesis in bacterial microorganisms. problem
cell wall, thus -Assess for severe
-Romicef
inhibiting allergic reaction.
biosynthesis and -Check the patency
arresting cell wall of IV line before
assembly resulting in administration.
Classification bacterial cell death.
Cephalosporins

Dosage

-750mg IV q 8
ANST (-)
Piperacillin + Na Tazobactam

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
- Piperacillin + Na -The combination - Treatment of -Hypersensitivity to -Upset stomach, - May prolong
Tazobactam has activity against infections in the lower penicillins, vomiting, unpleasant bleeding time when
many Gram-positive resp tract eg severe cephalosporins & β- or abnormal taste, used with
and Gram-negative community-aquired lactam inhibitors. diarrhea, gas, anticoagulants
pathogens and pneumonia & headache, - Assess
anaerobes, including healthcare constipation, hematopoietic
Pseudomonas pneumonia; insomnia, rash, function periodically.
Brand Name aeruginosa. uncomplicated & itching skin, swelling, - Perform periodic
-Triggering of the complicated skin & shortness of breath, electrolyte
-Tazocin
pneumococcal skin structure unusual bruising or determinations in
autolytic enzyme by infections; intra- bleeding. patients with low K
inhibitors of cell wall abdominal infections reserves.
synthesis. w/ peritonitis eg - Increased risk of
Classification complicated fever and rash in
appendicitis; patients with cystic
-Penicillins
complicated & fibrosis. Increased
uncomplicated UTI; risk of bleeding
gynecologic infection manifestations.
eg postpartum Prolonged treatment
endometritis or pelvic may increase risk of
inflammatory superinfections.
Dosage disease; bacterial
infection in
- 750 mg per tablet, neutropenic patients
1 tablet BID
Erdosteine

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Erdosteine -Peak plasma levels -Acute -Hepatic cirrhosis & -No gastrointestinal -Monitor the effect of
are reached after 30- bronchitis, chronic cystathionine- nor systemic side the drugs.
60 min. Ectrin has bronchitis & its synthetase enzyme effects due to Ectrin -Watch out for the
subsequent complete exacerbations. Resp deficiency. have been observed.. adverse reaction.
metabolism in similar disorders Phenylketonuria -monitor RR
metabolites. characterised by (susp only).
abnormal bronchial
Brand Name secretions &
impaired mucus
-Ectrin
transport

Classification
-Mucolytics

Dosage

-300mg 1 cap. 1
cap BID PO
USW c Salbutamol

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Salbutamol -Bronchodilator. -Indicated in the -Patients with a -A small increase in -Salbutamol 2.5-mg
-Salbutamol is a β- treatment of acute history of heart rate may occur nebules should be
adrenergic stimulant severe asthma & in hypersensitivity to in patients who inhale used with care in
which has a highly routine management any of the a large dosage of patients known to
selective action on of chronic components of Aero- salbutamol. This is have received large
the receptors in bronchospasm Vent. not usually doses of other
bronchial muscle and unresponsive to accompanied by any sympathomimetic
Brand Name in therapeutic doses, conventional therapy. changes in the drugs. It should be
it has little or no electrocardiogram. administered
-Aero Vent
action on the cardiac Other side effects cautiously to patients
receptors. which occur with very suffering from
high doses of thyrotoxicosis.
salbutamol by -Great care is also
Classification inhalation are needed in patients
peripheral with cardiovascular
-Antiasthmatic
vasodilatation and disease
-COPD Preparation
the fine tremor of -An increased risk of
skeletal muscle. arrhythmias may also
occur if
sympathomimetic
agents are given
Dosage -the potential for
paradoxical
-1 nebule bronchospasm
Salbutamol every 4 should be kept in
hrs mind
Nitroglycerin

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Nitroglycerin -Glyceryl trinitrate -Prophylaxis of -Acute circulatory -Headaches may -Assess for chest
dilates the peripheral angina pectoris. failure (shock), develop initially but pain before
blood vessels thus Long-term treatment severe hypotension, usually, these will administration of
reducing the of CHD. Treatment of acute myocardial disappear after a few drugs.
workload of the chronic heart failure infarction. days. There is also -Monitor V/S
heart. Deponit NT in combination w/ the possibility of -Should not be used
5/10 is designed to digitalis &/or reflex tachycardia, during the first 3
Brand Name release a constant diuretics. postural hypotension, months of pregnancy
amount of glyceryl nausea and unless advised by the
-Nitro 5TT
trinitrate onto the skin dizziness. Allergic physician.
and then by skin reactions may -It increases the
transdermal occur in sensitive antihypertensive
absorption directly patients. properties of
Classification into the systemic vasodilators, calcium
circulation. The once- antagonists,
-Anti-Anginal Drugs
daily application will antihypertensives,
ensure that the tricyclic
patient receives antidepressants and
sufficient glyceryl alcohol.
trinitrate for -Not suitable for
prophylaxis against acute anginal attacks
Dosage attacks for 24 hrs.

-Transderm patch
5 mg anterior chest
wall once a day
Humulin R

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Humulin R Neutral human -Treatment of Hypoglycemia. Sweating, dizziness, -If the insulin
insulin of diabetes mellitus for palpitation, tremor, substance (the
recombinant DNA the control of hunger, restlessness, cloudy material)
origin. A short-acting hyperglycemia. tingling in the hands, settles at the bottom
preparation that may feet, lips or tongue, of the bottle, the
be administered by lightheadedness, bottle must be
SC or IV injection. inability to carefully rotated
Brand Name Onset of action concentrate, before the injection.
occurs at headache, -Should not be used
-Eli Lilly
approximately 30 drowsiness, sleep if it is cloudy,
min, with a duration disturbances, unusually viscous,
of about 5 hrs and anxiety, blurred precipitated or even
peak activity at 1-3 vision, slurred slightly colored.
Classification hrs. speech, depressive -Always examine the
mood, irritability, appearance of the
-Insulin
abnormal behavior, insulin before
Preparations
unsteady movement administering a dose.
and personality -Do not use if the
changes. insulin substance
-Hypoglycemia (the white material)
remains visibly
Dosage separated from the
liquid after mixing.
-Humulin R, 5 units -Hold if there is signs
SQ. of hypoglycemia
Glimepiride

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Glimepiride -Blood glucose -Type 2 DM when -Hypersensitivity to -Hypoglycemia -Assess for allergies
lowering through hyperglycemia sulfonylureas. chest pain or prior to start of the
stimulation of insulin cannot be adequately Impaired renal irregular heartbeat; therapy
release from the controlled by diet & function. Insulin- confusion; dark urine;
pancreas and insulin exercise alone. dependent (type 1) fainting; -Assess for potential
sensitivity at receptor -Combination therapy DM. Ketoacidosis (w/ inter action with other
site; reduction of w/ metformin & or w/o coma). Severe prescription, OTC
Brand Name basal hepatic insulin when the use infection, trauma. medication or herbal
glucose secretion; of either of these Pregnancy & products the patient
-Acotril tab
ineffective if patients agents alone is lactation. may be take
lacks functioning inadequate to control -Monitor CBC,
beta-cell hyperglycemia. glcosylated Hgb
(baseline every 3
Classification months) while
ongoing treatment
-Oral anti diabetic
check liver test
agent
function periodically.
AST,LDH and renal
studies
-Hold if there are
signs of
Dosage hypoglycemia.

-1mg/tab 1tab pre-

breakfast
Esomeprazole

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Esomeprazole -Inhibits the -Treatment of gastro- -Hypertensive -Headache, -Assess patients
H+K+ATPase pump esphageal reflux -Metabolic Alkalosis abdominal pain, condition before and
(proton pump) in disease (GERD) as constipation, during the therapy.
gastric parietal cells an alternative to oral diarrhea, -Assess hepatic
effectively blocking therapy in patients flatulence, function because
the final step in acid when oral therapy is nausea & vomiting. drug is extensibly
production, thereby not appropriate. metabolized in the
Brand Name reducing gastric -Hyperacidity liver.
acidity. -Report for adverse
-Nexium iv
reaction.

Classification
-Antacid
-Antireflux agents
-Antiulcerants

Dosage

-IV vial 40 mg OD
Bacillus clausii

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Bacillus clausii -a preparation -Treatment of acute -None -No side effects have -Should be
consisting of diarrhea w/ duration been reported, up to administered in the
suspension of of ≤14 days due to the present time, with interval between 1
Bacillus clausii infections, drugs or the use of the drug. dose of antibiotic and
spores, normal poisons or for chronic the next.
inhabitants of the or persistent diarrhea -Does not interfere
intestine, with no w/ duration of >14 with the ability to
Brand Name pathogenic powers. days. drive or use
Administered orally, machinery.
-Erceflora
Bacillus clausii -No contraindications
spores, due to their regarding the use of
high-resistance to Erceflora during
both chemical and pregnancy and
Classification physical agents, lactation.
cross the barrier of
-Antidiarrheals
the gastric juices
reaching unharmed
the intestinal tract
where they are
transformed into
metabolically active
Dosage vegetative cells.

-1 vial TID
Serc

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Serc -Exerts a relaxant -Meniere's disease, -Hypersensitivity to -Mild gastric - Patients with
action on the Meniere betahistine diHCl or complaints have phaeochromocytoma
precapillary -like syndrome to any of the been reported. They or bronchial asthma
sphincters of the characterized by excipients of Serc. can often be should be treated
microcirculation of attacks of vertigo, eliminated by with extra care.
the inner ear, and tinnitus & reducing the dosage. - It is recommended
thereby increases the sensorineural Also, skin rashes to use Serc with
Brand Name blood supply to the deafness, peripheral have been reported. caution in patients
stria vascularis of the vertigo. with a history of
-Solvey Pharma
labyrinth. peptic ulcer.
Investigations into - There is insufficient
the acute, subacute data on the use of
and chronic effects of this drug during
Classification betahistine in pregnancy to
animals have evaluate possible
-Antivertigo Drugs
demonstrated the low harmful effects.
toxicity and safety of
the drug.

Dosage

- 8 mg 1-2 tab. To
be taken tid.
Paracetamol

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Paracetamol -Decrease fever by -Fever -Hypersensitive -Hypothermia -Assess patients
inhibiting the effect of -headache dark urine or pale fever of pain,
pyrogens on the -muscle pain stools; unusual location, intensity,
hypothalamic heat fatigue; yellowing of duration,
regulating center and -toothache the skin or eyes. temperature,
by hypothalamic -colds
action leading to
Brand Name sweating and
vasodilation.
-Tempra
-Relieving of pain by
inhibiting
prostaglandin
synthesis at the CNS
Classification but does not have
anti-inflammatory
-Analgesics (Non-
action because of its
Opioid) &
minimal effect on the
Antipyretics
peripheral
prostaglandin
synthesis.

Dosage

- PRN 500mg/tab
every 4 hrs for
T≥37.6
Ferrous Sulfate

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Ferrous Sulfate -Provides/replace -Iron deficiency -Hypersensitivity -Constipation; -Obtain baseline
elemental iron, an darkened or green assessment of iron
essential component stools; diarrhea; deficiency before
in formation of nausea; stomach starting the therapy.
hemoglobin in red upset.Severe allergic -Monitor for adverse
blood cell reactions (rash; reaction.
development hives; itching; -Assess bowel
Brand Name difficulty breathing; elimination; increase
tightness in the water, bulk and
-Ferrous Sulfate
chest; swelling of the activity constipation
( United Homes)
mouth, face, lips, or occurs.
tongue); black, tarry -Assess patients and
stools; blood or family knowledge of
Classification streaks of blood in drug therapy.
the stool; fever; -Evaluate
-Vitamins and
vomiting with hemoglobin;
minerals (pre and
continuing sharp hematocrit and
post natal)/
stomach pain reticulocyte count
antianemic
during therapy.
-Assess diet and
nutrition amount of
Dosage iron diet.
-Identify cause of iron
-325mg/tab 1 tab loss or anemia
BID
Kalium Durule

Generic Name Mechanism of Indication Contraindication Side effects Nursing

Action Consideration
-Kalium Durule - Potassium is Hypokalemia. -Renal insufficiency, - - This medicine must
needed to maintain Prophylaxis during -hyperkalemia be diluted in at least
good health. treatment w/ -untreated Addison's one-half glass (4
Although a balanced diuretics. disease ounces) of cold water
diet usually supplies -constriction of the or juice to reduce its
all the potassium a esophagus &/or possible stomach-
person needs, obstructive changes irritating or laxative
Brand Name potassium in the alimentary effect.
supplements may be tract. - f on a salt (sodium)-
-AstrZeneca
needed by patients restricted diet, check
who do not have with the doctor
enough potassium in before using tomato
their regular diet or juice to dilute
Classification have lost too much medicine. Tomato
potassium because juice has a high salt
Electrolytes
of illness or treatment content.
with certain - Swallow the tablets
medicines. whole with a full (8-
ounce) glass of
water. Do not chew
or suck on the tablet.
Dosage -Assess for signs of
hyperkalemia.
-1 tab TID -Monitor PR
 Nu r si ng
Man a ge men t
 Promoting Oxygenation / ineffective airway clearance

Intervention Rationale

•Assess respiratory status. Note depth, rate, and character of ►symptoms may be masked by chronic respiratory conditions
breathing.
►it becomes frequent and productive, maybe accompanied with chest pain
•Assess cough ( productive, weak, or hard )
►hemoptysis maybe present in advanced cases
•Assess nature of secretions: color, amount, consistency

•Auscultate lungs for presence of normal and abnormal lung ►Bronchial breath sounds and crackles maybe present
sounds
►low- grade fever occurs
•Monitor vital signs

•Monitor oxygen saturation through arterial blood gas/ pulse ►decreased oxygen saturation and increased PaCo2 are signs of hypoxia and
oximetry respiratory compromise

•Position the client on fowler’s/ orthopneic
•Encouraging or providing frequent changes in position every 2
hours
•Encouraging ambulation
►to allow for maximum chest expansion
►to keep the lungs open and clear of secretions
►help shift respiratory secretions in the airway

•Deep breathing and coughing exercises ►allows for the removal of secretions from the airway

•Hydration ►maintains the moisture of the respiratory mucous membrane

used to treat respiratory problems
•Provide respiratory medications including bronchodilators, ►for reducing excessive mucus and provide patent airway
expectorants etc. as doctor’s ordered
►to maintain the patient’s oxygen
•Oxygen therapy ►mechanical aspiration of the airways involving the used of catheter inserted
•Suctioning through nose, mouth of tracheal tube
 Infection
Intervention
•Induce sputum with heated aerosol if needed to expedite
diagnosis and start early treatment
•Monitor sputum cultures
•Have patient cover mouth when coughing or sneezing
•Teach patient hand washing techniques to use after handling
sputum
•Provide a high- protein, high- calorie, increased- fluid diet
•Refer patient contacts to be assessed for possible infection and
for chemoprophylactic treatment
•Administer medications as ordered.
•Report all confirmed TB cases to the health department
rationale
►precautions to prevent airborne transmission are important
during and after procedures that stimulate coughing
►indicated until the patient responds to the medication
►this decreases airborne contaminants
►friction and running water effectively remove microorganisms
from hands
►This maintains optimal nutritional status
►this prevents spread or development of infection
►anti- TB drugs treatment should be promptly initiated for
patients with TB disease.
►coordination of follow-up care and contact investigation to
facilitate propylaxis for patient contacts.
 Nutrition, Altered , Less than Body requirements

intervention rationale

•Document patient’s nutritional status on admission, ►useful in defining degree/ extent of problem and appropriate
noting skin turgor, current weight and degree of weight choice of interventions
loss, integrity of oral mucosa, ability/ inability to
swallow, presence of bowel tones, history of nausea/
vomiting or diarrhea

•Ascertain patient’s usual dietary pattern, likes/ dislikes ►helpful in identifying specific needs.

•Monitor intake/ output and weight periodically ►Useful in measuring effectiveness of nutritional
and fluid support
•Encourage and provide for frequent rest periods. ►Helps to conserve energy

•Investigate anorexia, nausea and vomiting and note ►May affect dietary choices and identify areas for problem
solving, to enhance intake
possible correlation to medication

•Provide oral care before and after respiratory treatment

►For oral hygiene

•Encourage small frequent meals with foods high in ►Maximize nutrient intake
protein and carbohydrates

•Encourage SO to bring foods from home and share ►Creates a normal social environment
meals with patient
Nu r si ng Ca r e
Pla n
 Nursing Care Plan
Name: L. L.
Age/Sex: 49/F
Medical Diagnosis: Pulmonary Tuberculosis Stage III Category II
Nursing Diagnosis: Ineffective airway clearance related to accumulation of excessive mucus secretions on tracheobronchial as evidence by difficulty of
Short term goal: At the end of intervention, the patient will expel secretions easily to promote airway clearance.
Long term goal: The patient will maintain patent airway with decrease presence of secretions after hospitalization.

Cues Problem Scientific Reason Interventions Rationale Evaluation

S ► “nahihirapan Difficulty in The airway parts of ► Assessed patients ► Patient education will Goal met.
akong huminga” as breathing the respiratory knowledge about her vary on disease as well The patient was
verbalized by the system which air condition. as the patient’s cognitive able to expelled
patient. flows, was blocked level. secretion easily.
to get from the ► Monitored for vital signs ► To gather baseline
O ► RR=38cpm external data and noted changes.
► (+)productive environment to the ► Positioned head midline ► To maintain open
cough alveoli by the with flexion. airway at rest.
► with greenish excessive mucus
phlegm secreted by the ► Elevated head of ► To take advantage of
► weak in goblet cells. bed/change position every gravity decreasing
appearance Ref. two hours. pressure on diaphragm.
► (+) crackles on Medical-Surgical ► Encouraged deep ► To maximize effort in
upper left lung Book breathing and coughing mobilization of
exercises. secretions.
► Increase oral fluid intake ► To promote
to at least 2000 ml/day. systematic hydration
and to help liquefy
secretions,
► Discourage use of oil ► To prevent aspiration
based products around nose. into lungs.
► Monitor vital signs and
observed for signs of ► To assess changes and
respiratory distress. noting complications.
► Provided with ► For the patient to be
information about the aware of the importance
Ref. necessity of expectorating of expectorating
Medical- Surgical secretions. secretions.
book ► Given bronchodilators as ► For mobilization of
ordered by doctor. secretions.
Nursing Care Plan
Name: L. L.
Age/Sex: 49/F
Medical Diagnosis: Pulmonary Tuberculosis Stage III Category II
Nursing Diagnosis: Social isolation related to disease process as evidenced by accommodation on an isolation room.
Short term goal: At the end of my intervention, the patient will be able to verbalize understanding about the purpose of isolation process.
Long term goal: After hospitalization, the patient will express increase sense of self-worth even undergoing isolation process.

Cues Problem Scientific Reason Interventions Rationale Evaluation

S► “Mga pamilya ko loss of self- esteem Tuberculosis is very ►Identified blocks to ►To prevent Goal met.
na lang ang contagious, spread by social contacts. contributing factors The patient
dumadalaw sa’kin” as airborne droplet to problem verbalized
verbalized by the nuclei that are ►Listened to ►To be able to deeply understanding about
patient. produce when an comments of client understand patient’s the purpose of
O► hostile behavior infected person regarding sense of thoughts and isolation process.
►moody coughs or sneezes isolation. condition.
►irritable .Clients with this ►Established ►Promotes trust and
►withdrawn eye condition must be therapeutic nurse- establish rapport.
contact during treated carefully, client relationship.
conversation. some of them were ►Explained the ►To provide client’s
isolated to prevent the nature of disease and awareness.
transmission of mode of transmission.
microorganisms. As a ►Encouraged open ►To maintain
result, the patient’s visitation when involvement with
enduring personality possible and/or others.
characteristics were telephone contact.
decreased. ►Provided positive ►Encouraged client’s
Ref. reinforcement when continuation of efforts
Medical-Surgical patient’s makes move and to enhance self-
Book towards others. esteem.
►Provided with clean ►To provide comfort
and comfortable measures for the
environment. patient.
Nursing Care Plan
Name: L.L.
Age/Sex: 49/F
Medical Diagnosis: Pulmonary Tuberculosis Stage III Category II
Nursing Diagnosis: Risk for activity intolerance related to generalize weakness as evidenced by verbal report of fatigue.
Short term goal:` At the end of my intervention, the patient will be able to walk on short distances with assistance as tolerated by the patient.
Long term goal: After hospitalization, the patient will be able to perform self care activities with minimal assistance.

Cues Problem Scientific Reason Interventions Rationale Evaluation

S► “Nanghihina ako“ body weakness Tuberculosis maybe ► Determined the ► Assessments guide Goal met
as verbalized by the extra- pulmonary and patient’s perception of treatment. The patient walked on
patient. affect organs / tissues causes of fatigue. a short distance with
O► RR=38cpm other than the lungs. ► Assessed the ►To define what the assistance.
► weak in This process causes patient’s level of patients is capable of,
appearance reduction in muscle mobility. which is necessary
► refuse to perform strength and its before setting realistic
daily activities. function, which leads goals.
►functional level to generalized ► Assessed nutritional ►Adequate energy
4 – dyspnea and weakness and impairs status. reserves are required
fatigue at rest the ability to maintain for activity.
activity. ► Assessed emotional ►Depression resulting
Ref: response to change in from the inability to
medical- surgical book physical status. perform required
activities can further
aggravate activity
intolerance.
► Establish guidelines ►Motivation is
and goal of activity enhance if the patient
with the patient. participates in goal
setting.
► Encouraged ►Provides time for
adequate rest periods. energy conservation
and recovery.
► Encouraged ►This promotes a
physical activity sense of autonomy
consistent with the while being realistic
patient’s energy about capabilities.
resources.
► Encouraged active ►Exercise maintains
range of motion muscle strength and
exercises. joint range of motion.
► Provide emotional ►Patient may be
support will fearful of
increasing activity. overexertion and
potential damage to
the heart.
► Encouraged ►Physically inactive
patients to choose patients need to
activities that improve functional
gradually build capacity through
endurance. repetitive exercises
over a longer period
of time.
►Teach the patient to ►Promotes
recognize signs of awareness of when to
physical over activity. reduce activity.
► Involve the patient ►Setting small,
in goal setting and attainable goals can
care planning. increase self
confidence and self-
esteem.
Th e end