NURSING CASE STUDY(Myocardial Infarxtion

University of Perpetual Help – Molino Campus

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COLLEGE OF NURSING Nursing Case Study Admission/ Final Diagnosis I. Health History A. DEMOGRAPHICAL DATA Client’s Initials: Gender: Age:

D. G. B

Female 80

Religion: Iglesia ni Cristo Occupation: Self - employed Usual Source of Medical Care: Hospital Date of Admission: June 18, 2011 Initial Diagnosis: T/C AMI, DM Type 2

B. SOURCE AND RELIABILITY OF INFORMATION Information that was obtained came from the patient's chart. The patient at the time was unconscious and unable to speak.

C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS Chest Pain Difficulty in breathing Infection

D.HISTORY OF PRESENT ILLNESS/ OR PRESENT HEALTH The patient was admitted on June 18, 2011. The initial diagnosis of the patient was Acute Myocardial Infarction, DM Type 2. The patient was

E. DEVELOPMENTAL HISTORY

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COLLEGE OF NURSING Erik Erikson labeled the crisis of this period as Integrity vs Despair. Rather than focus on the external adjustments related to the series of physical social losses experienced by the elderly, Erikson focused on an internal struggle. As death approaches, people begin a life review that involves deciding whether or not their lives have been worthwhile. This opens them to the ultimate despair in the view that their lives have not been what it could or what should have been, and that it is now too late to do anything about it. The resulting disgust is actually contempt for themselves, when facing such despair invokes the search for ego integrity. Ego integrity involves acceptance of one and only life cycle as something that had to be and that, when necessity permitted no substitution. It includes accepting the mistakes that were made, while recognizing the good things that were accomplished, developing a sense of inevitable order of the past it also involves a feeling of companionship, “with an ordering way of distant times and different pursuits” or a detached, philosophical wisdom about life in general rather than only one’s own in particular.

F. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. ROS and PE

SYSTEM

REVIEW OF SYSTEM

A. General/ Overall health status

No verbal cues

B. Integument (skin, hair, nail)

No verbal cues

PHYSICAL EXAMINATION OBJECTIVE DATA

COMMON SIGNS AND SYMPTOMS

Unconscious

Weakness

Cyanotic

Fatigue

SIGNIFICANCE

Unconsciousnes s: Inadequate cerebral perfusion and cardiogenic shock Cyanosis: Inadequate oxygenated blood circulation

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COLLEGE OF NURSING C. Head

No verbal cues

D. Eyes

No verbal cues

E. Ears

No verbal cues

F. Nose and Sinuses

No verbal cues

G. Mouth and Throat

No verbal cues

H. Neck

No verbal cues

I. Breast and Axillary

No verbal cues

J. Respiratory

No verbal cues

K. Cardiovascula r

No verbal cues

L. Gastrointestin al

No verbal cues

M. Urinary

No verbal cues

N. Genitalia

No verbal cues

O. Musculoskelet al

No verbal cues

(+) Gasping

Weak Heart rate

Shortness of Breath

Gasping: associated with a drop of the body’s oxygen level

Heartburn

Weak Heart rate: Not enough blood being pumped by the heart.

(+) Chest pain

(+) Edema

Musculoskeletal

(+) Infected wound (Left

Arm pain (Commonly on left

Edema: Fluid retention in the body

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COLLEGE OF NURSING arm) Foot)

Upper Back Pain

Infection: Increased WBC

General Malaise P. Neurologic

No verbal cues

Q. Hematologic

No verbal cues

R. Endocrine

No verbal cues

(+) DM Type 2

High blood glucose in the context of insulin resistance and relative insulin deficiency.

2. LABORATORY STUDIES / DIAGNOSTICS

Implications Procedur e

Procedure Date

Chest Xray

6/23,25/1 1 7/3/11

Indication

Normal Values

A projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are among the most common

The lungs look normal in size and shape, and the lung tissue looks normal. No growths or other masses can be seen within the lungs. The pleural spaces (the spaces

Actual Findings/ Results Further Progression in Pulmonary Edema with possible underlying pneumonia.

ABNORMAL

Evidence of consolidation on the left upper lobe, subcutaneaus emphysema as

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COLLEGE OF NURSING surrounding the lungs) also look normal.

films taken, being diagnostic of many conditions.

The heart looks normal in size, shape, and the heart tissue looks normal. The blood vessels leading to and from the heart also are normal in size, shape, and appearance.

seen with the tracheostomy tube in place. Heart is enlarge in size, with left ventricular prominence.

The diaphrag m looks normal in shape and location. All tubes, catheters, or other medical devices are in their correct positions in the chest. Gram Staining

6/23/11

An empirical m Negative ethod of infection differentiating b acterial species into two large groups (Grampositive and Gr am-negative) based on the chemical, primarily the presence of

Positive cocci in ABNORMAL singly +1

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COLLEGE OF NURSING high levels of peptidoglyca n, and physical properties of their cell walls. [1] The Gram stain is almost always the first step in the identification of a bacterial organism.

ABG

CBC

7/5/11

7/3/11

A blood test that is performed using blood fro m an artery. It involves puncturing an artery with a thin needle and syringe and drawing a small volume of blood. The most common puncture site is the radial artery at the wrist, but sometimes the femoral artery in the groin or other sites are used.

pH – 7.35 – 7.45

Also known as full blood count (FBC) or full blood exam(FBE) or blood panel,

Hemoglobin (g/dl) - 12.0 15.0

pO2 – 80 – 100 mm Hg pCO2 – 35 – 35 mm Hg HCO3 – 22 -26 mEq/liter BE - -2 - +2 mEq/liter

pH = 7.62 pO2 = 111.2 mm Hg pCO2 = 23.2 mm Hg HCO3 = 23.3 mEq/liter BE= 3.9 02 sat. = 98.9%

ABNORMAL

O2 Sat. – 95 – 100%

Hematocrit (%) - 36 – 44

Hgb = 9.60 g/dl

ABNORMAL

Errythrocytes = 28.40% WBC = 9400

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COLLEGE OF NURSING is a test panel requeste d by a doctor or other medical professional th at gives information about the cells in a patient's blood. A scientist or lab technician performs the requested testing and provides the requesting medical professional with the results of the CBC. Alexander Vastem is widely regarded as being the first person to use the complete blood count for clinical purposes.

Urinalysis 7/2/11

An array of tests performed on urine and one of the most common methods of medical diagnosis. A part of a urinalysis can

RBC's ( x 106 /ml) - 4.0 4.9 WBC (cells/ml) 4,500 - 10,000 Basophils - 0 1 (0 - 0.75%)

RBC = 2.97 Neutrophil = 82% Lymphocyte = 9%

Eosinophils - 0 Monocyte = 4% - 3 (1 - 3%) Lymphocytes 24 - 44 (25 33%)

Eosinophil = 4% Basophil = 1%

Monocytes - 3 - 6 (3 - 7%)

Color - Pale yellow to amber Turbidity Clear to slightly hazy

Color = Yellow

ABNORMAL

Transperancy = Hazy Reaction = 6.0 Gravity = 1.030

Specific Gravity -

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1.015-1.025

be performed by using urinedipsticks, in which the test results can be read as color changes.

Chem. Exam.

pH - 4.5-8.0

Albumin = Trace

Glucose – Negative

Sugar = Regular

RBC – Negative

Pus = 12-15 HPF

Albumin – Negative

RBC = 4-6 HPF

Epithelial cells – Negative or Rare

Epithelial cells = Moderate Others = Yeast cells Abundant

3. OTHER ASSESSMENT TOOLS

Date Taken

Comprehensive Actual Content/ Legend

Actual Result

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COLLEGE OF NURSING Eyes Response – Eye opening spontaneously (4)

June 18, 2011

Verbal Response – No verbal response (1)

Motor Response – No response (1)

GCS – 6 Severe head injury

ANATOMY AND PHYSIOLOGY THE HEART Function and Location of the Heart The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest. Structure of the Heart The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point and about 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it to move as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle. Chambers of the Heart The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and a bottom chamber.

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COLLEGE OF NURSING The two top chambers are known as the left and right atria(singular: atrium). The atria receive blood from different sources. The left atrium receives blood from the lungs and the right atrium receives blood from the rest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles pump blood out to different parts of the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. The ventricles have much thicker walls than the atria which allows them to perform more work by pumping out blood to the whole body. Blood Vessels Blood Vessel is tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries are blood vessels which carry blood from the heart to the body. There are also microscopic blood vessels which connect arteries and veins together called capillaries. There are a few main blood vessels which connect to different chambers of the heart. The aorta is the largest artery in our body. The left ventricle pumps blood into the aorta which then carries it to the rest of the body through smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries which take the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain into the inferior vena cava (IVC) or the superior. These two large veins then take the blood from the rest of the body into the right atrium. Valves Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates which prevent blood from flowing in the wrong direction. They are found in a number of places. Valves between the atria and ventricles are known as the right and left atrioventricular valves, otherwise known as the tricuspid and mitral valves respectively. Valves between the ventricles and the great arteries are known as the semilunar valves. The aortic is found at the base of the aorta, while the pulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body. However, there are no valves found in any of the other arteries besides the aorta and pulmonary trunk. What is the Cardiovascular System The cardiovascular system refers to the heart, blood vessels and the blood. Blood contains oxygen and other nutrients which your body needs to survive. The body takes these essential nutrients from the blood. At the same time, the body dumps waste products like carbon dioxide, back into the blood, so they can be removed. The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive. Veins deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as the body has unloaded it back into the blood). All the veins drain into the superior and inferior vena cava which then drain into the right atrium. The right atrium pumps blood into the right ventricle. Then the right ventricle pumps blood

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COLLEGE OF NURSING to the pulmonary trunk, through the pulmonary arteries and into the lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen which the body can use. From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta which then distributes it to the rest of the body through other arteries. The main arteries which branch off the aorta and take blood to specific parts of the body are: Carotid arteries, which take blood to the neck and head Coronary arteries, which provide blood supply to the heart itself Hepatic artery, which takes blood to the liver with branches going to the stomach Mesenteric artery, which takes blood to the intestines Renal arteries, which takes blood to the kidneys Femoral arteries, which take blood to the legs The body is then able to use the oxygen in the blood to carry out its normal functions. This blood will again return back to the heart through the veins and the cycle continues.

Blood Flow of the Heart The heart is completely divided into a right and left halves. These 2 halves of the heart act as separate pumps, and there is no mixing of blood between them. Each is in charge of pumping blood through one of the two blood vessel circuits.

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COLLEGE OF NURSING

The right heart pumps blood to the pulmonary circuit, where the blood picks up oxygen from the lungs. The left heart then pumps it into the systemic circuit, where the blood delivers oxygen to the tissues that need it. Finally, the blood returns to the right heart and the cycle repeats itself.

Blood always leave the heart through arteries, which include the aorta and pulmonary arteries. Conversely, blood enters the heart through the veins, the largest being the pulmonary veins the vena cava.

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COLLEGE OF NURSING

PATHOPHYSIOLOGY of Myocardial infarction

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COLLEGE OF NURSING

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MEDICAL – SURGICAL MANAGEMENT 1. Procedure (Surgery) Procedure/ Date

Indication/ Analysis

Tracheostomy / July 5 2011

A tracheostomy is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube.

A tracheostomy is usually done for one of three reasons: (1) to bypass an obstructed upper airway (an object obstructing the upper airway will prevent oxygen from the mouth to reach the lungs); (2) to clean and remove secretions from the airway; and (3) to more easily, and usually more safely, deliver oxygen to the lungs. • • •

• •

Need for further and more aggressive surgery Infection Air trapping in the surrounding tissues or chest. In rare situations, a chest tube may be required Scarring of the airway or erosion of the tube into the surrounding structures (rare). Need for a permanent tracheostomy. This is most likely the result of the disease process which made the a tracheostomy

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COLLEGE OF NURSING

• •

necessary, and not from the actual procedure itself. Impaired swallowing and vocal function Scarring of the neck

NURSING RESPONSIBILITIES Preparatory Nursing Measures. In addition to routine preparation of the patient unit for postoperative care, the following measures should be planned in advance. (1) The patient will require constant attendance for at least the first 48hours. The nursing personnel must remember two important things: the patient's life depends upon a clear airway and the patient will have a temporary loss of voice. Therefore, the patient must be observed closely for airway patency and immediate action taken when any adverse signs or symptoms are present. The patient wills feel anxious about his inability to communicate with his voice. Always have the call bell available to the patient. Devise a temporary means of communication such as writing notes or (2) For the first few days postoperatively, the patient should be kept in a room where the temperature and humidity can be maintained at optimum levels. Increased temperature and humidity will help to reduce the tracheal irritation that results when inspired air has bypassed the natural warming and moisturizing of the nasopharyngeal airway. (3) The patient's room should be supplied with a variety of equipment necessary to the care of the patient. Such things include suction equipment, a sparetracheostomy tube set, and

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COLLEGE OF NURSING sterile dressing material. b. Postoperative Nursing Measures. In addition to routine postoperative nursing care, the following nursing actions should be noted. (1) Always apply basic principles of aseptic technique when caring for the incision and the airway. When suctioning, use separate set-ups for pharyngeal and tracheostomy suctioning.(2) Constantly observe the patient for signs of respiratory obstruction such as restlessness, cyanosis, increased pulse, or gurgling noises during respiration

Central Venous Pressure / July 5 2011

Wound debridement / July 5 2011

Central venous pressure is considered a direct measurement of the blood pressure in the right atrium and vena cava. It is acquired by threading a central venous catheter (subclavian double lumen central line shown) into any of several large veins. It is threaded so that the tip of the catheter rests in the lower third of the superior vena cava. The pressure monitoring assembly is attached to the distal port of a multilumen central vein catheter.

An open wound or ulcer can not be properly evaluated until the dead tissue or foreign matter is removed. Wounds that contain necrotic and ischemic (low oxygen content) tissue take longer to close and heal. This is because necrotic tissue provides an ideal growth medium

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COLLEGE OF NURSING for bacteria, especially for Bacteroides spp. and Clostridium perfringens that causes the gas gangrene so feared in military medical practice. Though a wound may not necessarily be infected, the bacteria can cause inflammation and strain the body's ability to fight infection. Debridement is also used to treat pockets of pus called abscesses. Abscesses can develop into a general infection that may invade the bloodstream (sepsis) and lead to amputation and even death. Burned tissue or tissue exposed to corrosive substances tends to form a hard black crust, called an eschar, while deeper tissue remains moist and white, yellow and soft, or flimsy and inflamed. Eschars may also require debridement to promote healing.

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COLLEGE OF NURSING

Generic Name/ Brand Name, Classification, Stock Diazepam(VALI UM)

Anti-anxiety agent, Anticonvulsant

Indication, Frequency, Dosage

Side-effects/ Adverse Reaction

INDICATION:

-Dizziness -Drowsiness

-Adjunct in the management of: Anxiety, Preoperative sedation, conscious sedation. -Provide light anesthesia and Anterograde amnesia. -Treatment of status epilepticus/ uncontrolled seizures. -Skeletal muscle relaxant. -Management of the symptoms of

-Lethargy -Hangover -Headache -Paradoxical Excitation -Blurred Vision -Respiratory Depression -Hypotension

Special Consideration/ Nursing Responsibility

-Monitor BP, PR, RR prior to periodically throughout therapy and frequently during IV therapy. - Assess IV site frequently during administration, diazepam may cause phlebitis and venous thrombosis. - Prolonged highdose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient. Observe depressed patients closely for suicidal tendencies. - Observe and record intensity, duration and location of seizure activity. The initial dose of diazepam offers seizure control for 15-20 min after administration.

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COLLEGE OF NURSING - IM injections are painful and erratically absorbed. If IM route is used, inject deeply into deltoid muscle for maximum absorption. - Caution patient to avoid taking alcohol or other CNS depressants concurrently with this medication. - Effectiveness of therapy can be demonstrated by decrease anxiety level; control of seizures; decreased tremulousness.

Alcohol withdrawal.

Omeprazole(LO SEC)

Proton-pump Inhibitors, Antiulcer Agent

INDICATION:

-Dizziness

Assessment:

-Drowsiness

1. History: Hypersensitivity to Omeprazole or any of its components; pregnancy, lactation 2. Physical: skin lesions; reflexes; urinary output; abdominal examination; respiratory auscultation

-Maintenance of healing erosive esophagitis. -Duodenal Ulcers.

-Fatigue

-Short-term treatment of active benign gastric ulcer. -Pathologic hyposecretor y condition, including zollingerellison

-Abdominal Pain

-Headache -Weakness -Chest pain

-Acid Regurgitation -Constipation -Diarrhea -Flatulence -Nausea and Vomiting.

Interventions: 1. Administer before meals. 2. Administer

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COLLEGE OF NURSING antacids with, if needed. 3. Have regular medical follow-up visits. 4. Report severe headache, worsening of symptoms, fever, chills.

syndrome. -Reduction of risk of GI bleeding in critically ill patient.

-Dizziness, -Encephalopathy INDICATION:

Lasix(FUROSE MIDE)

Diuretics

-Edema due to: CHF, Hepatic or Renal Disease.

-Headache -Insomnia -Nervousness -Hearing loss -Tinnitus -Hypotension -Constipation

-Diarrhea Hypertension. -Dry mouth -Dyspepsia

Furosemide is a very potent medication. Using too much of this drug can lead to serious water and salt/mineral loss. Therefore, it is important that you are closely monitored by your doctor while taking this medication. Tell your doctor right away if you become very thirsty or confused, or develop muscle cramps/weakness.

-Nausea and Vomiting.

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COLLEGE OF NURSING

Common: -Nausea

-Assess pt for previous sensitivity reaction.

-Diarrhea -Vomiting INDICATION: Ciprofloxacin(CI PROBAY)

GI Drug “Laxative”

Infections of the resp. tract, middle ear, paranas al sinuses, eyes, kidneys, urinary tract

-Rash Uncommon: -Anorexia -Headache -Dizziness -Fever

-Assess pt for any s/s of infection before & during treatment.

-Assess for adverse reactions.

-GI and Abdominal pain, -Flatulence -Confusion

-Assess pt. & family’s knowledge of drug therapy.

-Vertigo

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COLLEGE OF NURSING Imdur

INDICATION:

Imdur Tablets are indicated for the prevention of angina pectoris due to coronary artery disease. The onset of action of oral isosorbide mononitrate is not sufficiently rapid for this product to be useful in aborting an acute anginal episode.

Imdur Tablets are contraindicated in patients who have shown hypersensitivity or idiosyncratic reactions to other nitrates or nitrites.

-Patients should be told that the antianginal efficacy of Imdur Tablets can be maintained by carefully following the prescribed schedule of dosing.

Discontinued: Autonomic Nervous System Disorders: Dry mouth, hot flushes. Body as a Whole: Asthenia, back pain, chest pain, edema, fatigue, fever, flu-like symptoms, malaise, rigors. Cardiovascular Disorders, General: Cardiac failure, hypertension, hypotension.

–For most patients, this can be accomplished by taking the dose on arising.

-Most patients develop true physical dependence which can be severe.

Central and Peripheral Nervous System Disorders: Dizziness, headache, hypoesthesia, migraine, neuritis, paresis, paresthesia, ptosis, tremor, vertigo. Gastrointestinal System Disorders: Abdominal pain, constipation, diarrhea, dyspepsia, flatulence, gastric ulcer, gastritis, glossitis, hemorrhagic gastric ulcer, hemorrhoids, loose stools, melena, nausea, vomiting. Hearing and Vestibular Disorders: Earache,

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COLLEGE OF NURSING tinnitus, tympanic membrane perforation. Heart Rate and Rhythm Disorders: Arrhythmia, arrhythmia atrial, atrial fibrillation, bradycardia, bundle branch block, extrasystole, palpitation, tachycardia, ventricular tachycardia. Liver and Biliary System Disorders: SGOT increase, SGPT increase. Metabolic and Nutritional Disorders: Hyperuricemia, hypokalemia. Musculoskeletal System Disorders: Arthralgia, frozen shoulder, muscle weakness, musculoskeletal pain, myalgia, myositis, tendon disorder, torticollis. Myo-, Endo-, Pericardial and Valve Disorders: Angina pectoris aggravated, heart murmur, heart sound abnormal, myocardial infarction, Q wave abnormality. Platelet, Bleeding and Clotting Disorders: Purpura, thrombocytopenia. Psychiatric Disorders: Anxiety, concentration impaired, confusion, decreased libido, depression, impotence,

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COLLEGE OF NURSING insomnia, nervousness, paroniria, somnolence. Red Blood Cell Disorder: Hypochromic anemia. Reproductive Disorders, Female: Atrophic vaginitis, breast pain. Resistance Mechanism Disorders: Bacterial infection, moniliasis, viral infection. Respiratory System Disorders: Bronchitis, bronchospasm, coughing, dyspnea, increased sputum, nasal congestion, pharyngitis, pneumonia, pulmonary infiltration, rales, rhinitis, sinusitis. Skin and Appendages Disorders: Acne, hair texture abnormal, increased sweating, pruritus, rash, skin nodule. Urinary System Disorders: Polyuria, renal calculus, urinary tract infection. Vascular (Extracardiac) Disorders: Flushing, intermittent claudication, leg ulcer, varicose vein. Vision Disorders: Conjunctivitis, photophobia, vision abnormal. Pharmaton

CONTRAINDI -There are no known side CATIONS: effects.

A yellow coloration of the urine after

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COLLEGE OF NURSING

-In disturbances of calcium metabolism, such as hypercalcae mia and hypercalciuria

-In case of hypervitamin osis D

-Up to now no interactions with other drugs or foods are known.

Overdose -In renal insufficiency

-During therapy with vitamin D

-In case of phenylketonu ria

The toxicity of the product in large overdoses will be that of the liposoluble vitamin D. Prolonged daily intake of larger amounts can cause symptoms of chronic toxicity such as vomiting, headache, drowsiness and diarrhoea. Acute symptoms are only seen at even higher doses.

taking is caused by the vitamin B2 content (natural color of vitamin B2). Such staining is absolutely harmless.

-In case of known hypersensitivi ty to any ingredients of the compound.

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COLLEGE OF NURSING Diflucan(FLUCO INDICATION: NAZOLE) Fluconazole is used for the treatment of oropharyngea l, esophageal, and vaginal candidiasis; serious systemic candida infections; Cryptococcus neoformans meningitis. It is also used as a preventive measure for candidiasis in bone marrow transplants. Fluconazole is used in the treatment of coccidioidom ycosis, cryptococcosi s, onychomycos is, fungal pneumonia, septicemia, and ringworm of the hand.

Side Effects: -Hypersensitivity reaction (fever, chills, rash, pruritus) -Dizziness -Drowsiness -Headache -Constipation -Diarrhea -Nausea -Vomiting -Abdominal pain

ADVERSE REACTION: -Exfoliative skin disorders -Serious hepatic effects -Blood dyscrasias (eosinophilia, thrombocytopenia, anemia, leukopenia)

-Give without regards to meals. -PO and IV therapy equally effective. -Do not use parenteral form if solution is cloudy, precipitate forms, seal is not intact, or is discolored. -Establish baseline for CBC potassium, and hepatic function studies. -Assess for hypersensitivity reaction (chills, fever). -Monitor for liver or renal function tests, potassium, CBC, and platelet count. -Report rash or itching promptly. -Monitor temperature at least daily. -Determine pattern of bowel activity and stool consistency. -Assess for dizziness; provide assistance as needed.

PATIENT

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COLLEGE OF NURSING TEACHINGS: -Do not drive car or use machinery if dizziness or drowsiness occurs. -Notify physician of dark urine, pale stool, yellow skin or eyes,rash with or without itching. -Patients with oropharyngeal infections should be taught good oral hygiene. -Consult physician before taking any other medication.

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