SURIGAO EDUCATION CENTERCollege of NursingKm. 2, Surigao City

A case presentationOn

Plasmodium falciparum

Presented to:Mr. Edsel Paler RN

Mrs. Jecel R. Eupeňa, RNMr. Ian Tristan Abedejos, RN

Ms. Vivian Cereyn Cabuga, RNMs. Louella Ursua, RNMr.Jose P. Ramos RN

Mrs. Lady Mabelle M. Gesta,RNMrs. Czarina Mae F. Lumague, RN

Mr. Neil John Plaza,RN

Presented by:Abarico, Giza MarieAlsong, Donna Ros

Balicog, HarveyBorgonia, Glorigin Mary

Donoso, JeanLao Singuan, Lara MaeLisondra, Raem GraceNarciso, Stefanny MaeRuaya, Arhvee Kristine

Tisang, MaricarDEDICATION

We would like to dedicate this case presentation, first of all to our Almighty God, who gave the knowledge, strength and wisdom to us at all times.

To our parents who genuinely loved us, by giving their full support that encourage us and inspire us so much to continue and do our best for this case presentation and for all our finances we used to make this case presentation possible.

To our clinical instructors, whose support and help is there for the accomplishment of this case study.

And to all of us, may this case study help us to know deeper about this disease, as part of our learning in our profession.

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ACKNOWLEDGEMENT

We wholeheartedly acknowledge the following persons who helped and untiringly supported us to make this case presentation possible:

To Mrs. Reflorvic P. Dotillos, one of our clinical instructor who gave us this case we are presenting;

To our patient, Mr. ˝Facebook˝ who is diagnosed with malaria, for trusting and believing in us student nurses; for cooperating and generously provided us information and answered all our questions.

To the Surigao Medical Center staff nurses assigned in station 2, for entertaining us in gathering pertinent data from the patient’s chart;

To our clinical instructors who gave us ideas and direction in making this output. Who patiently and thoughtfully taught us important things that we have to know as part of our profession, and all the knowledge you imparted to us. Rest assured that we will cherish all those lessons in our hearts, for a life time.

To all our families for their kind understanding when we were away from our houses while making this case. To their undying support financially and morally, which inspired us to pursue and do our best for this case presentation.

To Mr. and Mrs. Narciso, as well as Mrs. Balicog for accommodating us in their house to make our case presentation.

To all my group mates, for the efforts and patience, that they spent sleepless nights in making this case presentation. It’s such a pleasure to have all of you in this unusual and first time experience we all had.

Above all, to our Almighty God for His unconditional love, and whose infinite wisdom gave us the capability to come up with this output.

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Introduction

Malaria is considered as the most important parasitic disease affecting man, as it is responsible for million deaths annually. It has been identified by the World Health Organization as one of the three major infectious disease threats, along with HIV and tuberculosis, which together, cause more than 5 million deaths each year. Despite such high figures in mortality, the disease is curable if it is promptly and adequately treated.

The nature of malaria as a public health problem requires sustained and systematic efforts toward two major strategies, namely prevention of transmission through vector control and the detection and early treatment of cases to reduce morbidity and prevent mortality.

The group of parasites causing malaria belongs to the genus Plasmodium that is normally transmitted by the bite of an infected female mosquito belonging to the genus Anopheles. Majority of us do not know how does this parasitic disease affect us human through the carrier mosquito that can cause malaria.

This was the case of our patient Mr. Facebook, a construction worker in South Africa for two years, who was diagnosed of Malaria (P. falciparum). He is a 40-year old, male residing at Purok-2 Brgy. Cayutan, Surigao City. He was admitted in Surigao Medical Center last September 26, 2009.

We choose this case, because it is interesting and because of its popularity worldwide, and the fact that it has million of deaths each year especially in South Africa. Although malaria is not common in our country, it is important to know about the nature of this disease. Many countries are seeing an increasing number of imported malaria cases due to extensive travel and migration, and we all know that many of our fellowmen are working in different countries worldwide. We would also like to know and understand what this disease was all about. The pathology and physiology of malaria, its signs and symptoms, its treatments, prevention and its complications if not treated immediately. Because of these reasons, this case study was made.

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Review of Related Literature__________________________________

Malaria is a vector-borne infectious disease caused by a eukaryotic protist of the genus Plasmodium. It is widespread in tropical and subtropical regions, including parts of the Americas, Asia, and Africa. Each year, there are approximately 350–500 million cases of malaria, killing between one and three million people, the majority of whom are young children in Sub-Saharan Africa. Ninety percent of malaria-related deaths occur in Sub-Saharan Africa.

Malaria is one of the most common infectious diseases and an enormous public health problem. Five species of the plasmodium parasite can infect humans; the most serious forms of the disease are caused by Plasmodium falciparum. Malaria caused by Plasmodium vivax, Plasmodium ovale and Plasmodium malariae causes milder disease in humans that is not generally fatal. A fifth species, Plasmodium knowlesi, causes malaria in macaques but can also infect humans. This group of human-pathogenic Plasmodium species is usually referred to as malaria parasites.

Usually, people get malaria by being bitten by an infective female Anopheles mosquito. Only Anopheles mosquitoes can transmit malaria, and they must have been infected through a previous blood meal taken on an infected person. When a mosquito bites an infected person, a small amount of blood is taken, which contains microscopic malaria parasites. About one week later, when the mosquito takes its next blood meal, these parasites mix with the mosquito's saliva and are injected into the person being bitten. The parasites multiply within red blood cells, causing symptoms that include symptoms of anemia (light-headedness, shortness of breath, tachycardia, etc.), as well as other general symptoms such as fever, chills, nausea, flu-like illness, and, in severe cases, coma, and death.

Although some are under development, no vaccine is currently available for malaria that provides a high level of protection; preventive drugs must be taken continuously to reduce the risk of infection. These prophylactic drug treatments are often too expensive for most people living in endemic areas. Most adults from endemic areas have a degree of long-term infection, which tends to recur, and also possess partial immunity (resistance); the resistance reduces with time, and such adults may become susceptible to severe malaria if they have spent a significant amount of time in non-endemic areas. They are strongly recommended to take full precautions if they return to an endemic area.

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Symptoms

Symptoms of malaria include fever, shivering, headache, nausea, fatigue, tiredness, vomiting, hemoglobinuria, retinal damage, and convulsions. The classic symptom of malaria is

cyclical occurrence of sudden coldness followed by rigor and then fever and sweating lasting four to six hours. P. falciparum can have recurrent fever every 36–48 hours or a less pronounced and almost continuous fever. For reasons that are poorly understood, but that may be related to high intracranial pressure, children with malaria frequently exhibit abnormal posturing, a sign indicating severe brain damage. Malaria has been found to cause cognitive impairments, especially in children. It causes widespread anemia during a period of rapid brain development and also direct brain damage. This neurologic damage results from cerebral malaria to which children are more vulnerable. Cerebral malaria is associated with retinal whitening, which may be a useful clinical sign in distinguishing it from other causes of fever.

Severe malaria is almost exclusively caused by P. falciparum infection and usually arises 6–14 days after infection. Consequences of severe malaria include coma and death if untreated—young children and pregnant women are especially vulnerable. Splenomegaly (enlarged spleen), severe headache, cerebral ischemia, hepatomegaly (enlarged liver), hypoglycemia, and hemoglobinuria with renal failure may occur. Severe malaria can progress extremely rapidly and cause death within hours or days. In the most severe cases of the disease fatality rates can exceed 20%, even with intensive care and treatment. In endemic areas, treatment is often less satisfactory and the overall fatality rate for all cases of malaria can be as high as one in ten. Over the longer term, developmental impairments have been documented in children who have suffered episodes of severe malaria.

Chronic malaria is seen in both P. vivax and P. ovale, but not in P. falciparum. Here, the disease can relapse months or years after exposure, due to the presence of latent parasites in the liver. Describing a case of malaria as cured by observing the disappearance of parasites from the bloodstream can, therefore, be deceptive. The longest incubation period reported for a P. vivax infection is 30 years. Approximately one in five of P. vivax malaria cases in temperate areas involve overwintering by hypnozoites (i.e., relapses begin the year after the mosquito bite).

Malaria parasites

Malaria parasites are members of the genus Plasmodium (phylum Apicomplexa). In humans malaria is caused by P. falciparum, P. malariae, P. ovale, P. vivax and P. knowlesi. P. falciparum is the most common cause of infection and is responsible for about 80% of all malaria cases, and is also responsible for about 90% of the deaths from malaria. Parasitic Plasmodium species also infect birds, reptiles, monkeys, chimpanzees and rodents.

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Diagnosis

Microscopic examination of blood films

The most economic, preferred, and reliable diagnosis of malaria is microscopic examination of blood films because each of the four major parasite species has distinguishing characteristics. Two sorts of blood film are traditionally used. Thin films are similar to usual blood films and allow species identification because the parasite's appearance is best preserved in this preparation. Thick films allow the microscopist to screen a larger volume of blood and are about eleven times more sensitive than the thin film, so picking up low levels of infection is easier on the thick film, but the appearance of the parasite is much more distorted and therefore distinguishing between the different species can be much more difficult. With the pros and cons of both thick and thin smears taken into consideration, it is imperative to utilize both smears while attempting to make a definitive diagnosis.

Prevention

Malaria transmission can be reduced by preventing mosquito bites with mosquito nets and insect repellents, or by mosquito control measures such as spraying insecticides inside houses and draining standing water where mosquitoes lay their eggs. Work has been done on malaria vaccines with limited success and more exotic controls, such as genetic manipulation of mosquitoes to make them resistant to the parasite have also been considered.

Methods used to prevent the spread of disease, or to protect individuals in areas where malaria is endemic, include prophylactic drugs, mosquito eradication, and the prevention of mosquito bites. The continued existence of malaria in an area requires a combination of high human population density, high mosquito population density, and high rates of transmission from humans to mosquitoes and from mosquitoes to humans. However, unless the parasite is eliminated from the whole world, it could become re-established if conditions revert to a combination that favors the parasite's reproduction.

Treatment

Active malaria infection with P. falciparum is a medical emergency requiring hospitalization. Infection with P. vivax, P. ovale or P. malariae can often be treated on an outpatient basis. Malaria infections are treated through the use of antimalarial drugs, such as quinine or artemisinin derivatives. Treatment of malaria involves supportive measures as well as specific antimalarial drugs. When properly treated, someone with malaria can expect a complete recovery. Malaria infections are treated through the use of antimalarial drugs, such as quinine or artemisinin derivatives.

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Plasmodium falciparum is a protozoan parasite, one of the species of Plasmodium that cause malaria in humans. It is transmitted by the female Anopheles mosquito. P. falciparum is the most dangerous of these infections as P. falciparum (or malignant) malaria has the highest rates of complications and mortality. As of 2006 it accounted for 91% of all 247 million human malarial infections (98% in Africa) and 90% of the deaths. It is more prevalent in sub-Saharan Africa than in other regions of the world; in most African countries, more than 75% of cases were due to P.falciparum, whereas in most other countries with malaria transmission, other Plasmodial species predominate.

Mosquito vectors and the Plasmodium life cycle

The parasite's primary (definitive) hosts and transmission vectors are female mosquitoes of the Anopheles genus. Young mosquitoes first ingest the malaria parasite by feeding on an infected human carrier and the infected Anopheles mosquitoes carry Plasmodium sporozoites in their salivary glands. A mosquito becomes infected when it takes a blood meal from an infected human. Once ingested, the parasite gametocytes taken up in the blood will further differentiate into male or female gametes and then fuse in the mosquito gut. This produces an ookinete that penetrates the gut lining and produces an oocyst in the gut wall. When the oocyst ruptures, it releases sporozoites that migrate through the mosquito's body to the salivary glands, where they are then ready to infect a new human host. This type of transmission is occasionally referred to as anterior station transfer. The sporozoites are injected into the skin, alongside saliva, when the mosquito takes a subsequent blood meal.

Only female mosquitoes feed on blood, thus males do not transmit the disease. The females of the Anopheles genus of mosquito prefer to feed at night. They usually start searching for a meal at dusk, and will continue throughout the night until taking a meal. Malaria parasites can also be transmitted by blood transfusions, although this is rare.

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III. TABLE OF CONTENTS____________________________________

I. Dedication iII. Acknowledgement iiIII. Introduction iiiIV. Review of Related Literature

Malarial Infection (Plasmodium falciparum) 1-4 V. Anatomy and Physiology 5-7 VI. Patient’s Health History (initial data)

A. Biographic Data 8 B. History of Present Illness 9

C. Past Health History 10a. Family Health History 10b. Genogram 11c. Personal Health History 12

1. Lifestyle 121.1 Personal Habits 121.2 Diet 121.3 Sleep and Rest Patterns 121.4 Elimination Patterns 121.5 Activities of Daily Living 131.6 Instrumental Activities of Daily Living

d. Social Data 132. Family Relationships/ Friendships 133. Ethnic Affiliation 13 4. Educational Level 135. Economic Status 136. Psychological Data 13

e. Patterns of Health Care 13 V11. Physical Examination and Review of Systems

A. General Survey 14B. Integument

a. Skin 14 b. Hair 14 c. Nails 14

C. Head, Eyes, Ears, Nose and Throat (HEENT) a. Skull and Face 14

b. Eyes and Vision 15 c. Ears and Hearing 15 d. Nose and Sinuses 15

D. Oropharynx 15E. Neck 15F. Thorax and Lungs 16G. Cardiovascular 16H. Breast and Axillae 16I. Abdomen 16

J. Musculoskeletal System 16K. Lower Extremities 16L. Neurological Systems

Level of Consciousness 16 M. Cranial Nerves 17

a. Languageb. Orientationc. Memoryd. Attention Span Demonstrated Several Errors

N. Reproductive System 1X. Laboratory Data

A. HematologyX. Medication SheetXI. Drug Study XII. Pathology and Physiology of DiseaseXIII. Nursing Care Plan (NCP) XIV. Discharge Plan

A. MedicationsB. Environmental ConcernsC. TreatmentD. Health TeachingsE. Out Patient Check-upF. Diet

XV. Appendices IVF Chart Input and Output

XVI. Definition of Terms XVII. References

VI. PATIENT’S HEALTH HISTORY_____________________________

A. Patient’s Profile/Biographic Data

Hospital : Surigao Medical CenterCase Number : 40086Fiscal Year : 2009Name : Mr.FacebookGender : MaleBirth date : January 22, 1969Birth place : Purok-2 Brgy. Cayutan, Surigao CityHome Address : Purok-2 Brgy.Cayutan, Surigao CityCivil Status : MarriedReligion : Roman CatholicNationality : FilipinoOccupation : Construction workerEducational Attainment : High School GraduateHeight : 5’5’’Weight : 67 kg

B. ADMISSION DATA: Mode of Admission : AmbulatoryDate of Admission : September 26, 2009 Time of Admission : 3:00 pmVital Signs upon Admission

Temperature: 39˚C Pulse Rate: 110bpm Respiration Rate: 26cpm Blood pressure: 110/90 mmHg

Admitting Physician : Dr. ZuluetaAttending Physician : Dr. Fuentes, AlpinianoChief Complaint : FeverRoom : PR6Date of Discharge : October 1, 2009

PRESENT ILLNESS: Present condition started 2 days PTA as low-med grade fever (-) dysuria, (-) odynophagia, (-) cough and colds

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IMPRESSION: Dengue Fever vs. MalariaFINAL DIAGNOSIS: Malarial Infection (P. falciparum)

Sources of data gathered: the patient himself and his wife the patient’s chart

BMI= weight (kg)/ height (m)2 = 67kg/ (1.65m)2 = 67kg/ 2.7 = 24.8 Normal

C. History of Present Illness_____________________________________

For the last two years, patient worked as a construction worker in South Africa- where Malaria is epidemic. Last September 18, 2009, patient arrived here in Surigao City due to finished contract. Five days after the arrival, 2 days prior to admission, patient had fever. According to him, it was only treated with paracetamol. He also felt nauseated and had experienced headache. He lost his appetite, and so he doesn’t like to eat. His fever lasted for three days, and noticed his skin became yellowish. Thus, prompted him and his wife to seek medical care in Surigao Medical Center.

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D. Past Health History__________________________________________

a. Childhood Illnesses

According to patient, he had experienced chicken pox at the age of 9 years old, mumps at the age of 12 years old.

b. Immunizations

According to patient, he was immunized with BCG,DPT,OPV,Hepatitis A, Hepatitis B, and MMR but he could not recall the exact dates the immunization were given. He was immunized of Hepatitis B vaccine before going to Africa.

c. History of Hospitalization

He had his circumcision when he was 9 year old and never had any accidents and injuries experienced. The patient was never been hospitalized before; hence, this was his first hospitalization.

d. Allergies

The patient had no allergic reactions in any foods and drugs, as what he had stated.

e. Medications Since patient had not been hospitalized before, he had not received any prescribed medications. However, his usual non-prescription drugs were Paracetamol (Biogesic) 500mg 2 tablets twice a day for fever and headache, Neozep for common colds.

f. Family Health History:

Our patient Mr. Facebook is the third child among the five children of Mr. and Mrs. E. He had one elder brother and sister, one younger brother and two younger sisters. His father died because of alcoholism, while his mother is still alive. As of his brothers and sisters, he claimed that no one has illness or disease. All his brothers and sisters are in healthy condition. He was married and has one child.

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FAMILY GENOGRAM:

Legends:

: Father : Patient : Brother : Mother : Sister

Father Mother (Deceased) alcoholism (69 yrs old)

48 yrs old 47 yrs old 40 yrs old 38 yrs old 36 yrs old 31 yrs old

11g. Personal Health History:

o Lifestyle Personal Habits- Patient claimed that never in his life he had smoked, took

prohibited drugs. But he drinks alcoholic beverages/ liquors.

Diet- Before hospitalization, patient’s typical diet for the day would consist of rice, ˝tinola˝, fried fish, ˝ paksiw˝, and vegetables. The patient usually eats 3 times a day and sometimes when there is extra money he will have his snack.

o Sleep and rest pattern

Before hospitalization, patient sleeps around 8:00 pm, and wakes up at around 5:00 am. During hospitalization, he felt uncomfortable with the environment thus, he can’t sleep well. He only sleeps about 1-2 hours and wake up again.

o Elimination Pattern

Before hospitalization, patient urinates 5-6 times a day. He only defecates twice a day usually with soft, formed brown stool. He claimed that he has no history of difficulties of defecating. During hospitalization the patient defecated twice a day, and urinates regularly.

o Activities of Daily Living (ADL)

Patient had no difficulty in eating, grooming, dressing, and fecal elimination. He can perform well in terms of his personal hygiene, such as tooth brushing every after meal, taking a bath, and washing his hands.

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o Instrumental Activities of Daily Living

Patient had no difficulties experienced in food preparation infact; he used to cook for their meal. He is also able to used cell phone and even handles finances.

h. Social Data

1.1 Family relationship/friendship Patient has good relationships to his family and friends. They help each other in time of stress or any problems the encounter especially during his hospitalization.

1.2 Ethnic AffiliationThe patient is a native Surigaonon. He claimed that he believed in quack doctors.

1.3 Educational Level The patient is a high school graduate and did not continued college education because of financial problem.

1.4 Economic StatusThe patient is not a Phil Health member. He claimed that he is the one paying the medical bill and also with the help of his relatives.

1.5 Psychological DataThe patients experienced major stressor when his father died. He felt depressed and managed it by talking to his wife and relatives, until he recovered.

Patterns of health care:

If there is any of the family members of their family suffered from illness, they used herbal medicine for treatment and if does not cured, they immediately seek medical help from the health center.

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VII. PHYSICAL EXAMINATION_______________________________

(September 28-29, 2009)

GENERAL APPEARANCE:

The patient was lying on bed on a semi-fowlers position with IVF of PLR at the level of 500cc running @ 40gtts. / min. infusing well at the left metacarpal vein. He looks pale, weak and his skin is slightly yellowish. He is conscious and cooperative in answering our questions.

Vital Signs: Temperature: 38.4°C Respiratory Rate: 28 cpm Pulse Rate: 93 bpm Blood Pressure: 110/90 mmHg

Integument:

Skin Patients skin is dry Skin color is brown and slightly yellowish Warm to touch No lesions Intact dermis

Hair Hair is evenly distributed No presence of lice Black hair; no dandruff noted

Nails Normal curvature Smooth texture Intact skin surrounding nails Prompt return of usual color ‘pink’ ( 3 seconds after performing ‘blanch test’)

Head, Eyes, Ears, Nose and throat (HEENT)

Skull Rounded in shape and symmetrical Smooth skull contour Absence of masses

Face Symmetric facial features Symmetric facial movement

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Eyes and vision

Skin intact No discharge; no discoloration Symmetrical eye brows Equally distributed eye lashes Black color of pupils; equal in size Pupils constrict when looking at near object; dilate when looking at far object When looking straight ahead, client can see objects in the periphery. Both eyes coordinated

Ears and Hearing Symmetrical Color same as facial skin Mobile firm and not tender Able to hear taking of the clock in both ears while performing ‘watch tick test’

Nose and Sinuses

Symmetric and straight No discharge Uniform color Not tender Air moves freely as the client breathe through the nares

Oropharynx (Mouth and Throat) Lips is slightly darker No dentures Teeth color is slightly yellowish Slightly dark gums Tongue moves freely Pink and smooth tonsils Dry mouth

Neck Muscle equal in size Coordinated movements with no discomfort Equal strength

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Thorax and Lungs Chest symmetric

Spine vertically aligned Absence of adventitious breath sounds No tenderness, absence of masses

Cardiovascular Pulsations noted Presence of audible sounds ( S1, S2 ) Blood Pressure = 110/90 mmHg

Breast and Axillae Skin uniform in color No tenderness and masses noted Round nipples, similar in color

Abdomen Absence of rashes or lesions Uniform in color Presence of pain on the right side when palpated

Musculoskeletal System Firm muscles, weakness noted at lower extremities Muscles in the arm and foot were equal in size No contractures noted No deformities noted No tenderness; no swelling

Neurological System

Level of Consciousness:

The patient was conscious on the day of admission until he was discharged.

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Cranial Nerves

I. Olfactory Patient was able to smell.II.Optic Patient can able to read newsprint at a distance.

III.Oculomotor

Patient’s pupils constricted when looking at near objects and dilated when looking at far objects. Patient’s pupils also converged at the center of both eyes when penlight was moved.

IV. Trochlear

Patient’s both eyes were coordinated and moved simultaneously with parallel alignment when penlight was moved at six cardinal fields of gaze using the six ocular muscles, namely: Superior Rectus, Inferior Rectus, Lateral Rectus, Superior Oblique, Inferior Oblique, and Medial Rectus.

V. TrigeminalPatient elicited blink reflex when sclera of the eye was slightly touch using a wisp of cotton while looking upward.

VI.Abducens Patient was able to move eyeballs laterally and parallel alignment using the six ocular muscles.

VII. Facial Patient could identify sharp and dull using. He could also smile and frown.

VIII. AuditoryPatient was able to hear normal voice tones

IX. Glossopharyngeal

Patient was able to move his tongue from side to side and up and down when asked to do so.

X. Vagus Patient had presence of swallowing reflex.XI. Accessory Patient was able to shrug shoulders.XII. Hypoglossal Patient could protrude her tongue at midline.

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VIII. Review of Systems(September 30, 2009)

General Survey

Feels weak Restless Conscious With IVF of PLR 1000cc at level of 500cc running @ 40gtts/min hooked well in

the left arm.

Integumentary System:

According to the patient he had no history of itching, lesions, abrasion and bruises. He said that he has no allergies from fury animals, plants and foods.

The patient stated that he uses efficascent oil in relieving mosquito bites, muscle pain, and “panuhot”.

HEENT (Head, Eyes, Ears, Nose, Throat):

Patient claimed that he experienced headache during worked especially when he’s having an overtime, and take an analgesic (Paracetamol, biogesic).The patient claimed that he has no visual hearing problem. The patient claimed that he always experience cold especially during rainy seasons.

Neck:The patient said that he doesn’t have any neck lumps, goiter, stiffness, and diagnosis of any

thyroid problem.

Thorax and Lungs:The patient didn’t experienced emphysema, pneumonia, tuberculosis and asthma. The

patient claimed that he has no problem in his breathing.

Cardiovascular System:According to patient, he has no history problem in his cardiovascular system such as

hypertension, rheumatic fever, heart failure, varicosities and fatigue. He claimed that he used to drink alcohol beverages occasionally, but he doesn’t smoke.

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Gastrointestinal tract:The patient claimed that he has no history of difficulty in swallowing and gastric ulcer. He

also claimed that he has no history of hematemesis. During hospitalization, patient claimed that he feels nauseated before and after he took his meal.

Musculoskeletal: Patient claimed that he doesn’t experience any muscle/joint pain. He also claimed that he

has no arthritis.

Urinary System:The patient claimed that he urinates 5-6 times a day and 2-3 times at night.

Neurological System

A. LanguageThe patient speaks slowly but clear in answering our questions.

B.OrientationThe patient was able to identify himself, the name of significant others who are always

with him, and is oriented to time and place.

C. Memory The patient was able to recall the things happened to his life months or years ago. He was

able to answer our questions immediately.

D. Attention SpanThe patient counting from 1 to 50, indicating that the patient had an ability to focus on such

mental task.

Reproductive System

There are no inflammations, swelling or discharges on his reproductive organ as claimed by the patient.

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HEMATOLOGY

DATE: 9/26/09 TIME: 1:24 PM

EXAM NAME RESULT UNIT NORMAL VALUE

SIGNIFICANCE

HGB 16.69 g/L 12.O-17.0 Normal

RBC 3.01 X 10 ^12/L 4.0-6.0 Anemia

HCT 49.12 % 37-54 Normal

MCV 85.06 U^3 87+-5 Normal

MCH 28.9 pg 29+-2 Normal

MCHC 33.97 g/dl 34+-2 Normal

RDW 12.15 11.6-14.6 Normal

PLATELET COUNT

52 L 150-450 Thrombocytopenia

WBC 7.34 L 4.5-10.0 Normal

DIFFERENTIAL COUNT;

LYMPHOCYTES 35.4 % 20-40 Normal

MONOCYTES 15.7 % 0-7 Infection

EOSINOPHILS 1.7 % 0-5 Normal

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HEMATOLOGY

09-26-09 11:34 PM

Requesting Physician :Dr. FuentesExam name Result Unit Normal value Significance

HGB 13.64 g/L 12.0-17.0 Normal

HCT 39.08 % 37-54 Normal

Platelet Count 58 ×10^9/L 150-450 Thrombocytopenia

HEMATOLOGY

09-27-09 06:03pmRequesting Physician :Dr. Fuentes

Exam name Result Unit Normal value Significance

HGB 13.57 g/L 12.0-17.0 Normal

HCT 39.89 % 37-54 Normal

Platelet Count 59 ×10^9/L 150-450 Thrombocytopenia

HEMATOLOGY

09-28-09 12:02amRequesting Physician :Dr. Fuentes

Exam name Result Unit Normal value Significance

HGB 13.77 g/L 12.0-17.0 Normal

HCT 40.09 % 37-54 Normal

Platelet Count 43 ×10^9/L 150-450 Thrombocytopenia

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COMPLETE BLOOD COUNT

9-26-09 6pm

TEST NORMAL VALUES RESULTS SINIFICANCE

Hemoglobin 120-170gm/L 165gm/L Normal

Hematocrit 37-52gm/L 47.8gm/L Normal

Platelet count 150- 350,000/Cu.mm.

48,000mm3 Thrombocytopenia

Blood type B+

COMPLETE BLOOD COUNT

9-27-09 6pm TEST NORMAL VALUES RESULTS SIGNIFICANCE

Hemoglobin 120-170gm/L 164.6gm/L Normal

Hematocrit 37-52gm/L 49.14gm/L Normal

Platelet count 150- 350,000/Cu.mm. 41,000mm3 Thrombocytopenia

COMPLETE BLOOD COUNT

9-27-09 6pmTEST NORMAL VALUES RESULTS SIGNIFICANCE

Hemoglobin 120-170gm/L 143gm/L Normal

Hematocrit 37-52gm/L 42.2gm/L Normal

Platelet count 150- 350,000/Cu.mm. 54,000mm3 Thrombocytopenia

22TEST RESULT UNIT REFERENCE SIGNIFICANCE

Glycosylated Hgb

5.5 % 4.5-6.3 Normal

CHEMISTRY RESULT FORM

09-27-09 6pmTEST RESULT UNIT REFERENCE SIGNIFICANCE

Total Bilirubin 8.92 mg/dl 0 - 1.3 Liver produced more than the required amount.

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MISCELLANEOUS

Patient’s Temperature 39.2 c

BSMP Result (2nd) (+) for malarial parasite

MEDICATION SHEET

Drugs Frequency and Dosage

Godex DS 1 tab. OD PO

Coartem 2 tab now then 2 tabs after 8hrs. then 2 tabs BID 2x a week

Paracetamol 500mg 1 tab now then q 4° PRN for fever

above 38°C

Mobic 15 mg 1 tab. OD PO PRN for headache

Ursofalk 250 mg/tab 1 tab BID PO

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X. DRUG STUDY_____________________________________________

Godex

Classification:Liver therapy

Route/ Dosage:1 tab once a day per orem

Indication:Acute & chronic hepatitis, drug-induced hepatitis, fatty liver

Ursofalk

Classification: Cholelitholytics & Hepatic Protectors

 Route/Dosage:

250mg / tab, 1 tab bid per orem

Indication:Cholestatic liver disease

Contraindication:Acute inflammation of the gallbladder, bile duct or of cystic duct. Pregnancy & lactation.

Adverse Drug Reactions:Porridge-like stools.

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References:

Medical Surgical Nursing 8 th Edition by: Joyce M. Black Public Health Nursing in the PhilippinesBurton’s Microbiology for the Health Sciences 8 th Edition by: Lippincot Williams and WilkinsEssential’s of Human Anatomy & Physiology 8 TH Edition by: Elaine N. Marieb

www.yahoo.comwww.ask.comwww.malaria.comwww.wikipedia.comwww.healthline.comwww.medline.com

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Coartem

Classification: Anti malarial

Dosage:2 tab now then 2 tabs after 8 hrs. then 2 tabs BID 2x a week

Indication:Treatment, including stand-by emergency, of adults & children due to P. falciparum or

mixed infections including P. falciparum. Also recommended for malaria infections acquired in areas where the parasites may be resistant to other antimalarials.

Contraindications:Severe malaria. Family history of congenital prolongation of the QTc interval or sudden

death, history of symptomatic cardiac arrhythmias, w/ clinically relevant relevant bradycardia or w/ severe cardiac diseases. 1st trimester of pregnancy. Patients w/ known disturbances of electrolyte balance eg hypokalemia or hypomagnesemia. Not indicated for treatment of malaria due to P. vivax, P. malariae or P. ovale.

Special PrecautionsDehydration, electrolyte imbalance. Pregnancy & lactation.

Adverse Drug ReactionsHeadache, dizziness, asthenia, palpitation, sleep & GI disturbance, pruritus, rash, cough,

arthralgia, myalgia.

26

XI. PATHOLOGY AND PHYSIOLOGY____________________

31

Develop Schizonts (liver cells containg numerous merozoites)

Schizonts rupturereleases merozoites

Merozoites enter red blood cells & invade erythrocytes

Sporozoites (mature sporoblast-enter the mosquito salivary glands)

Predisposing factors: Age Sex Race

Precipitating factors: Environment

P. falciparum Anopheles mosquito (carrier of sporozoites)

Sporozoites (injected into the subcutaneous tissue)

Travel into the blood steam

Travel into the liver and invade liver cells (hepatocytes)

32

Within an erythrocyte, the merozoite transforms into a trophozoite (in RBC)

Trophozoite mature & produce male & female gametocyte (in RBC)

Male gametocyte (in RBC)

Female gametocytes (in RBC)

Ingested by a female anopheles mosquito while taking a blood meal from the infected person.

Male & female gametocytes (ingested by mosquito)

Male & Female gametocytes mature into male & female gametes (within mosquito’s stomach)

Male & female gametes fuse within mosquito stomach (within mosquito’s stomach)

Zygote is produce (within mosquito stomach)

Ookinete (mature zygote)

Oocyst (escaped from the mosquito’s stomach by squeezing between cells in the stomach wall & encysts on the outer wall)

Sporoblast (develop within oocyst)

The RBC ruptures and signs & symptoms are evidenced, such as: headache, fever, chills & shivering.

Sweating occurred

NURSING CARE PLAN 2(September 28, 2009)

Subjective cues: Taghilantan ako sir", as verbalized by the patient.

Objective cues: Skin is warm to touch Vital signs:

Temperature: 38.4 ˚c Pulse rate: 100 bpm

Respiratory rate: 28 cpm Blood pressure: 110/90mmHg

Diagnosis: Hyperthermia related to underlying infection.

Planning: Within four hours of giving appropriate nursing intervention, patients Temperature will return within normal range (36.5- 37.5°c).

Interventions

Monitored body temperature periodically

Maintained bed rest

Tepid sponge bath provided

Encouraged patient to increase fluid intake

Provided client safety

Remove excess bed linens

Health Teaching imparted:

Encouraged increase fluid intake

Encouraged to eat nutritious foods such as green leafy vegetables & fruits

Rationale

Fever pattern may aid in diagnosis e.g. 38.9-41˚ c suggest in infectious disease process.

To reduced metabolic demands/ oxygen consumption

May help reduced fever through heat loss or by conduction

To replace the loss of fluid

To prevent in patient from injury

To reduced heat and prevent increase in temperature.

To prevent patient from dehydration

To help patient achieve fast recovery and gain energy from foods

35

Collaborative: Administered antipyretic such

as paracetamol 500 mg P.O. as prescribed.

May relieve fever by direct action on the hypothalamus, the center of heat regulator.

Evaluation:Goal was met as evidence by the patient’s temperature that was normalized, from 38.4 ۫ C to

37.3◦C.

36

NURSING CARE PLAN 5(September 28, 2009)

Subjective cues:“Sakit ako uyo”, as verbalized by the patient.

Objective cues: Guarding behavior Facial grimacing Pain scale of 6/10

Diagnosis:Acute pain related to infectious process.

Planning: Within 8 hours of giving appropriate nursing intervention, patient pain will reduce or lessen

from pain scale of 6/10 to 3/10.

Interventions Rationale Observed nonverbal cues/pain.

Monitored skin color/ temperature and patient’s vital sign.

Provided comfort measures, quiet environment, and calm activities.

Instructed/ encouraged use of relaxation techniques such as focused breathing, imaging, CDs/tape.

Encouraged adequate rest periods.

Collaborative: Provided for individualized

physical therapy/exercise program that can be continued by the client after discharge.

Observation may/may not congruent with verbal reports or may be only indicator present when client is unable to verbalize.

Which are usually altered in acute pain.

To promote non-pharmacological pain management.

To distract attention and reduce tension.

To prevent fatigue.

Promotes active not passive, role and enhances sense of control.

Evaluation: Goal met:

The patient’s pains were reduced from the scale of 6/10 to 3, as evidenced by patient’s feeling of comfort and absence of facial grimacing.

39

NURSING CARE PLAN 4(September 28, 2009)

Subjective cues: “Dili ko katuyog”, as verbalized by the patient.

Objective cues: He easily get mad if there is unnecessary noise Sleeps only for 1-2 hours Inability to concentrate

Diagnosis:Sleep pattern disturbance related to uncomfortable sleeping environment.

Planning: After 8hrs. of providing appropriate nursing interventions, patient will be able to report

improvement in sleep/ rest pattern.

Interventions Rationale Determined client’s usual sleep pattern

and expectations. Promoted adequate physical exercise

activity during day.

Recommended quite activities, such as reading or listening to soothing music in the evening.

Instructed in relaxation techniques.

Discussed/ implemented effective age-appropriate bedtime rituals (ex. Drinking warm milk).

Provide calm, quiet environment and manage controllable sleep disturbing factor.

Provides comparative baseline.

Enhances expenditure of energy or release of tension so that client feels ready for sleep/rest.

To reduce stimulation so client can relax.

To decrease tension, prepare for rest /sleep.

To enhance client’s ability to fall asleep.

To enhance client to fall asleep.

Evaluation:Goal was met, progress towards desired outcome. Patient can sleep well within normal pattern.

38

NURSING CARE PLAN 3(September 28, 2009)

Subjective cues: “Kasukaon ko”, as verbalized by the patient.

Objective cues: Aversion toward food

Diagnosis: Nausea related to disease process.

Planning: Within 8 hours of giving appropriate nursing interventions, patient will be able to lessen or be free of nausea.

Interventions: Rationale

Checked vital signs and note signs of dehydrations.

Advised client to drink water after 30 minutes before or after meals, instead of with meal.

Encouraged client to eat small meals spaced throughout the day instead of large meals.

Instructed client to eat slowly, chewing food well

Avoid offending odors, such as cooking, smoke, perfumes, mechanical emissions when possible

Encouraged deep, slow breathing

Nausea may occur in the presence of postural hypotension/ fluid volume deficit.

So stomach does not feel excessive fully.

To enhance digestion.

As they may stimulate or worsen nausea.

To promote relaxation and refocus attention away from nausea.

Evaluation: Goal met, Patient feels comfortable and free from nausea.

37

XII. NURSING CARE PLAN

NURSING CARE PLAN 1(September 29, 2009)

Subjective cues:“Wala koy gana mo kaon”, as verbalized by the patient.

Objective cues: Fatigue Loss of appetite Didn’t like to eat

Nursing Diagnosis:Imbalanced nutrition less than body requirements related to lack of interest in food.

Planning:Within 8 hours of rendering appropriate nursing intervention, patient will regain his

appetite and/or interest in food.

INTERVENTIONS RATIONALE Weighed daily or as indicated.

Ascertained patient’s dietary program and usual pattern compared with recent intake.

Provided liquids continuing nutrients and electrolytes as soon as patient can tolerate oral fluids progress to more solid foods as tolerated.

Included SO in meal planning as indicated.

Discuss eating habits, including food preferences/ intolerances.

Encourage client to choose foods or have family members bring foods that seam appealing

Promote pleasant, relaxing environment, including socialization when possible.

Assess adequacy of nutritional intake.

Identifies deficit and deviations from therapeutic needs.

Oral rate is preferred when patient is alert and a bowel function is restored.

Provide re use of involvement; provide information for SO to understand nutritional needs.

To appeal to client’s likes or dislikes.

To stimulate appetite.

To enhance intake.

33

Prevent/ minimize unpleasant odors. May have a negative effect on appetite/ eating.

Evaluation:Goal was met. Patient regains his appetite and interest in food.

34

NURSING CARE PLAN 6(September 29, 2009)

Subjective cues:“Tagkuyba ako sa ako sakit”, as verbalized by the patient.

Objective cues: Restless Poor eye contact Dry mouth Weak Loss of appetite

Nursing Diagnosis:Anxiety related to disease process

Planning:After 8hrs. of giving appropriate nursing interventions, the patient will be able to verbalize

awareness of feelings of anxiety.

INTERVENTIONS RATIONALE Monitored Vital Signs

Observed behaviors

Bedside Care rendered

Provided comfort through resting

Establish a therapeutic relationship, conveying empathy and unconditional positive regard

Provide accurate information about the situation.

To identify physical responses associated with both medical & emotional conditions.

Which can point to the client’s level of anxiety

Patient to be comfortable

To promote relaxation

To avoid the contagious effect/transmission of anxiety

Helps client to identify what is reality based

Evaluation: Goal was met. Patient was able to verbalized awareness of feelings of anxiety.

40

XIII. DISCHARGE PLAN______________________________________Date of discharged: October 1, 2009 Condition upon discharged: Improved

(METHODS)

Medications Advice patient and SO to facilitate in taking medications on time and in proper

administration, as prescribed. Point out the importance of completing the duration of take home medications even if the

patient shows wellness. Instructed patient to take the maintained medications as prescribed, such as: Godex and

Nexium.

Environmental Concern Encouraged patient and SO to maintain proper sanitation. Encouraged patient and SO to clean their house and surroundings, especially with those

areas that mosquitoes can live.

Treatment Instructed patient as well as the SO to continue his medicines for the entire length of

prescribed period. Advised patient or SO to always read the label of the medication and be aware of the date

of expiration of the drug. Always follow doctor’s order or instruction.

Health Teachings Encouraged patient to eat nutritious foods such as vegetables and fruits. Advised the importance of cleanliness at all times. Encouraged patient to take enough rest and sleep. Advised patient to have daily exercise, only those activities which he can tolerate. Encourage patient to maintain proper hygiene.

Out Patient Check-up Instructed patient to report for follow up check-up, as ordered by the physician. Instructed patient to consult the physician immediately, if any complications occur.

Diet Advised patient to eat nutritious foods such as fruits and vegetables such as pineapple,

carrots, legumes, grains. Encouraged patient to have adequate fluid intake.

Spiritual Encouraged patient and SO to attend mass once a week or every Sunday and encouraged to

pray and thank God always.41

XIV. APPENDICES___________________________________________

INRAVENOUS FLUID CHART

Date Bottle No.

Type of fluid/ Volume

Flow Rate Time Started

9-26-09

9-27-09

# 1

# 2

#3

#4

#5

#6

#7

#8

#9

#10

D5LR 1L

D5LR 1L

D5LR 1L

D5LR 1L

PLR 1L

PLR 1L

PLR 1L

PLR 1L

PLR 1L

PLR 1L

60gtts/min. SR @↓ 40 gtts/min

@40gtts/min

@60gtts/min.

@60gtts/min.

@60gtts/min

@60gtts/min.

@60gtts/min

@60gtts/min

@60gtts/min.

↓ 40gtts/min.

3:00am

8:50 pm

6am

11:35am

5:45pm

10:00pm

2:35am

6:00 am

.10:30am

3:00pm

42

INTAKE AND OUTPUT

DATE SHIFT IVF Oral FluidsTaken

Total intake

UrineOutput

Vomitus

BM TotalOutputCredit Consumed

09-26-09 7-33-11 700 1,300 1,600 2,900 2,000 - 2x 2,000+

2x BM11-7 NH 1,000 2,000 3,000 2L - - 2L

TOTAL INTAKE IN 24 HRS. = 5,900 TOTAL OUTPUT IN 24 HRS.

4,000 + 2x BM

DATE SHIFT IVF Oral FluidsTaken

Total intake

UrineOutput

Vomitus

BM TotalOutputCredit Consumed

09-27-09 7-3 500 1,500 2,000 3,500 2,000 - 2x 2,000+ BM 2X

3-11 900 1,600 1,000 2,600 1,450 - - 1,45011-7 NH 1,900 1,000 2,900 2,500 - - 2,500 +

BM 2XTOTAL INTAKE IN 24 HRS. = 8,800 TOTAL OUTPUT IN

24 HRS.5,900 + 2x BM

DATE SHIFT IVF Oral FluidsTaken

Total intake

UrineOutput

Vomitus

BM TotalOutputCredit Consumed

09-28-09 7-3 470 1,530 2,000 3,530 2,700 - 2x 2,700+ BM 2X

3-11 650 820 1,000 1,820 1,500 - 1x 1,500+ 1x BM

11-7 NH 650 1,500 2,150 1,500 - - 1,550 TOTAL INTAKE IN 24 HRS. = 7,500 TOTAL OUTPUT IN

24 HRS.5,750 + 3x BM

43Definition of Terms

1. Sporozoites - one of the many cells formed as a result of * sporongony during the life cycle of a sporozoan. In “plasmodium sporozoites are formed by repeated division of the contents of the oocyst inside the body of the mosquito.

2. Hepatocytes- the principal cell type in the liver, a large cell with many metabolic functions, including synthesis, storage, and detoxification and bile production.

3. Schizonts - one of the stages that occurs during the asexual phase of the life cycle of a sporozoan

4. Merozoite- stage in the life cycle of the malaria parasite. Many merozoites are formed during the asexual division of the schizonts.

5. Erythrocyte (red blood cell) - blood cell containing the red pigment, hemoglobin, the principal function of w/c is the transport of oxygen.

6. Trophozoite – stage4 in life cycle of the malarial parasite (plasmodium) that develops from merozoite in the red blood cells.

7. Gametocytes – any of the cells that are in the process of developing into gametes by undergoing “gametogenesis”

8. Zygote – fertilized ovum before cleavage begins. It contains both male and female pronuclei.

9. Ookinete – the motile elongated “zygote” of the malarial parasite (plasmodium), formed after fertilization of the macrogamete.

10. Encyts – enclosed in a cyst.

11. Sporoblasts – An early stage in the development of a sporocyst, prior to differentiation of the sporozoites.

12. Parasitemia – is the quantitative content of parasites in the blood. It is used as a measurement of parasite load in the organism and an indication of the degree of an active parasitic infection.

13. Paroxysms – sudden violent attack, especially a spasm or convulsion the abrupt worsening of symptoms or recurrence of disease.

14. Epidemic- occurs when new cases of a certain disease, in a given human population, and during a given period, substantially exceed what is "expected," based on recent.

15. Plasmodium falciparum is a protozoan parasite, one of the species of Plasmodium that cause malaria in humans. It is transmitted by the female Anopheles mosquito.

44

V. Anatomy and Physiology

The liver, weighing roughly 1.2-1.6 kg, performs many of the functions necessary for staying healthy. It is located in the right side of the body under the lower ribs and is divided into four lobes of unequal size. Two large vessels carry blood to the liver. The hepatic artery comes from the heart and carries blood rich in oxygen. The portal vein brings the liver blood rich in nutrients absorbed from the small intestine. These vessels divide into smaller and smaller vessels, ending in capillaries. These capillaries end in the thousands of lobules of the liver. Each lobule is composed of hepatocytes, and as blood passes through, they are able to monitor, add, and remove substances from it. The blood then leaves the liver via the hepatic vein, returns to the heart, and is ready to be pumped to the rest of the body.

5

Among the most important liver functions are:

· Removing and excreting body wastes and hormones as well as drugs and other foreign substances. These substances have entered the blood supply either through production by metabolism within the body or from the outside in the form of drugs or other foreign compounds

· Synthesizing plasma proteins, including those necessary for blood clotting. Most of the 12 clotting factors are plasma proteins produced by the liver. If the liver is damaged or diseased, it can take longer for the body to form clots.

· Producing immune factors and removing bacteria, helping the body fight infection The phagocytes in the liver produce acute-phase proteins in response to microbes. These proteins are associated with the inflammation process, tissue repair, and immune cell activities.

Other important but less immediate functions include:

· Producing bile to aid in digestion. Bile salts aid in fat digestion and absorption. Bile is continuously secreted by the liver and stored in the gallbladder until a meal, when bile enters the beginning of the small intestine. Bile production ranges from 250 mL to 1 L per day depending of amount of food eaten.

· Excretion of bilirubin. Bilirubin is one of the few waste products excreted in bile.. Bilirubin then results from the breakdown of the hemoglobin in the red blood cells and is excreted into bile by hepatocytes. Jaundice results when bilirubin cannot be removed from the blood quickly enough due to gallstones, liver disease, or the excessive breakdown of red blood cells.

· Storing certain vitamins, minerals, and sugars .The liver stores enough glucose in the form of glycogen to provide about a day's worth of energy. The liver also stores fats, iron, copper, and many vitamins including vitamins A, D, K, and B12.

· Processing nutrients absorbed from digestive tract. The liver converts glucose into glycogen, its storage form. This glycogen can then be transformed back into glucose if the body needs energy. The fatty acids produced by the digestion of lipids are used to synthesize cholesterol and other substances. The liver also has the ability to convert certain amino acids into others.

One of the liver's most interesting abilities is self-repair and the regeneration of damaged tissues. In clearing the body of toxins, the liver is damaged by exposure to harmful substances, demonstrating why this capability is important. It also gives hope that if a failing liver can be supported for a certain period of time, it might regenerate and allows the patient to survive and regain a normal life.

6Meloxicam

Brand Name: Mobic

CLASSIFICATION: Therapeutic Effects: non steroidal anti-inflammatory agents

Pharmacologic: non opioid analgesics

Prescribed, Recommended Dosage, Frequency, and Route of Administration15mg 1 tab OD PO PRN for headache

MECHANISM OF ACTION:Inhibit prostaglandin synthesis, probably by inhibiting the enzyme

cyclooxegenase.Therapeutic effects: Decreased pain and inflammation associated with osteoarthritis.Also decreases fever.

INDICATION:Relief signs and symptoms of osteoarthritis and rheumatoid arthritis (including juvenile

rheumatoid arthritis).

CONTRAINDICATIONS:Contraindicated in: Hypersensitivity. Cross sensitivity may occur with other NSAID’s

including aspirin. Severe renal impairment. Concurrent use of aspirin ( increased risk of adverse reactions). Peri-operative pain from coronary artery bypass graft (CABG) surgery. ADVERSE REACTION

CV: edema

GI: GI bleeding, abnormal liver function tests, diarrhea, dyspepsia, nausea

DERM: Exfoliative dermatitis, Stevens-johnson syndrome, toxic epidermal necrolysis, pruritus

HEMAT: anemia, leucopenia, thrombocytopenia.

NURSING IMPLICATIONAdvise patient to take this medication with a full glass of water and to reman in an upright position for 15-30 min after administration.

Instruct patient to take medication as directed. Take missed doses as soon as remembered but not if almost time for the next dose. Don not double doses.

Caution patient to avoid concurrent use of alcohol, aspirin, acetaminophen, or other OTC medications without consulting healthcare professional.

27

Advise patient to inform healthcare professional of medication regimen prir to treatment or surgery.

Advise patient to consult healthcare professional if rash, itching, visual disturbances, weight gain, edema, black stools, or signs of hepatotoxicity (nausea, fatigue, lethargy, jaundice, upper right quadrant tenderness, flu-like symptoms) occur.

28

AcetaminophenBrand Name:

Paracetamol

Classification: Therapeutic: antipyretics, non opioid analgesics

Prescribed, Recommended Dosage, Frequency, and Route of Administration 500 mg 1 tab now then q 4 prn ≥ 38˚ c

MECHANISM OF ACTION:Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever,

primarily in the CNS.Has no significant anti-inflammatory properties or GI toxicity. Therapeutic Effects: Analgesia. Antipyresis.

INDICATIONSMild pain. Fever.

CONTRAINDICATIONSContraindicated in: Previous hypersensitivity. Products containing alcohol, aspartame,

saccharin, sugar, or tartrazine should be avoided in patients who have hypersensitivity or intolerance to these compounds.

ADVERSE REACTIONS: GI: Hepatic failure, hepatotoxicity(overdose)

GU: renal failure( high doses/ chronic use).

Hemat: neutropenia, pancytopenia, leucopenia

Derm: rash, urticaria

NURSING IMPLICATIONS:Advise patient to take medication exactly as directed and not to take more than the recommended amount. Chronic excessive use of >4g/day (2 g in chronic alcoholics) may lead to hepatotoxicity , renal or cardiac damage. Adults should not take acetaminophen longer than 10 days and children not longer than 5 days unless directed by healthcare professional.Short-term doses of acetaminophen with salicylates or NSAIDs should not exceed the recommended daily dose of either drug alone.

Advise patient to avoid alcohol (3 or more glasses per day increases the risk of liver damage) if taking more than an occasional 1-2 doses and to avoid taking concurrently with salicylates or NSAIDs for more than a few days, unless directed by healthcare professional.

29

Pedi: Advise parents or caregivers to check concentrations of liquid preparations. Errors have resulted in serious liver damage. Have parents or caregivers determine the correct formulation and dose for their child(based on the child’s age/weight), and demonstrate how to measure it using an appropriate measuring device.

Inform patients with diabetes that acetaminophen may alter results of blood glucose monitoring. Advise patient to notify health care professional if changes are noted.

Caution patient to check labels on all OTC products. Advise patients to avoid taking more than one product containing acetaminophen at a time to prevent toxicity.

Advise patient to consult healthcare professional if discomfort or fever is not relieved by routine doses of this drug or if fever is greater than 39.5 degree celcius or lasts longer than 3 days.

30

RED BLOOD CELLS

Red blood cells (also referred to as erythrocytes) are the most common type of blood cell and the vertebrate body's principal means of delivering oxygen to the body tissues via the blood. They take up oxygen in the lungs or gills and release it while squeezing through the body's capillaries. The cells are filled with hemoglobin, a biomolecule that can bind to oxygen. The blood's red color is due to the color of oxygen-rich hemoglobin. In humans, red blood cells develop in the bone marrow and live for about 120 days; they take the form of flexible biconcave disks that lack a cell nucleus and organelles and they cannot synthesize protein.

7