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7/29/2019 Case Presentation Out Put 2
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University of La Salette
College of NursingSantiago City
Philippines
BronchopnuemoniaLucas Paguila Medical Clinic Hospital
August 07, 2012
Prepared by:
BSN-3A Bracket C
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Introduction
Bronchopneumonia is an illness of lung, which is caused by different organism likebacteria, viruses, and fungi and characterized by acute inflammation of the walls of the
bronchioles. It is also known as pneumonia. It is common in women and causes to the 6% deaths.Streptococcus pneumoniae (pneumococcus) and Mycoplasma pneumonia both are the common
bacterium, which causes bronchopneumonia in the adults and children.
CAUSESBacteria
Virus
Bacterial pneumonias tend to be the most serious and, in adults, the most common causeof pneumonia. The most common pneumonia-causing bacterium in adults is Streptococcus
pneumonia (pneumococcus).
RISK FACTOR
ElderlyHospitalizationImmobilization
Immune Deficiency
Long Term Illness
Smoking
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Lung abscess is an acute or chronic infection of the lung, marked by a localized collection
of pus, inflammation, and destruction of tissue. Lung abscess is the end result of a number ofdifferent disease processes ranging from fungal and bacterial infections to cancer.
DIAGNOSTIC TEST
1. ABG is a test done to measure how much oxygen and carbon dioxide is in your blood. It also
looks at the acidity (pH) of the blood. Usually, blood gases look at blood from an artery. In rarer
cases, blood from a vein may be used.
2. CBC
Complete blood count (CBC) test measures the following:
The number of red blood cells (RBCs)The number of white blood cells (WBCs)
The total amount of hemoglobin in the blood
The fraction of the blood composed of red blood cells (hematocrit)
The mean corpuscular volume (MCV) -- the size of the red blood cellsCBC also includes information about the red blood cells that is calculated from the other
measurements:
MCH (mean corpuscular hemoglobin)
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Anatomy and Physiology
Respiratory System:
- Consists of the external nose, the nasal cavity, the Pharynx, the Larynx, the Trachea, theBronchi and the Lungs.
Function:
Gas exchange Filters inspired air Voice production Olfaction Regulate blood pH
Upper Respiratory Tract: (Nose-Larynx)
Nose -the external opening of the Respiratory System-Consist of External nares /nostrils and Nasal Cavities
RESPONSIBILITY:-Rich supply of capillaries warm the inspired air
-Olfactory mucosa
-Respiratory Mucosa
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-Supported by a framework of nine pieces of cartilage (Three individual pieces
and three cartilage pairs ) that area held in place by ligaments and muscles
*Trachea (Wind pipe)-Is a membranous tube consists of connective tissue and smooth Muscle,
Reinforced with 16-20 C shaped pieces of cartilage
-Adult: about 1.4-1.6 cm in diameter and about 10-11 cm long.
*Bronchi
-The trachea divides the left and right main (primary) bronchi each of which
connects to the lung.-The left main bronchus is more horizontal than the right main bronchus because
it displaced by the Heart. Foreign objects that enter the trachea usually logged in
the right main Bronchus; because it is more it is more vertical than the left mainBronchus and therefore more indirect line with the trachea. The trachea is lined
with psuedostratified ciliated columnar epithelium and are supported by C
shaped pieces of cartilage.
*Lungs
-Are the principal organs of respiration.
-Each lung is cone shaped, with its base resting on the diaphragm and its apexextending superiorly to a point about 2.5 centimeters above the clavicle.
-The lung has three lobes: the superior, middle and inferior lobe.
-Includes the Bronchioles, and the alveoli.
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Demographic Data
Name: Pt. Honey Pooh
Gender: Female
Age: 4 y/oBirthdate: December 20, 2007
Birthplace: Ipil, Echague Isabela
Address: Paddad, Alicia, IsabelaReligion: Roman Catholic
Nationality: FilipinoEthnicity: IlocanoAdmission
Date: July 31, 2012
Time: 4:30 pm
Attending Physician: Dra. PaguilaChief Complaint: cough for 3 days, dyspnea, and fever for 1 day
Initial Vital Signs:Temp: 38. 9 C
PR: 148bpm
RR: 48 cpm
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Nursing History
History of Present Illness
According to the patient's mother, the patient was hospitalized at Lucas-Paguila with a
diagnosis of bronchopneumonia on June 26, 2012. Three days prior to admission, the patient
experienced cough & dyspnea. On July 31, 2012 the patient had a fever in the morning so theyadmitted her at Lucas-Paguila Medical hospital at 4:40PM.
History of Past Illness
According to the patients mother, this is the 4th
time that her daughter has been admitted
to the hospital. The first time that the patient was admitted to the hospital was at the age of 9
months; the patient had a chief complaint of cough and fever. At the age of 1 year and 2 months,the patient was admitted to Lucas-Paguila due to loose bowel movement. She has completed all
her vaccines. The patient has no known food allergies.
Family Health History
The patient has a family health history of asthma, diabetes mellitus, and hypertension.
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Gordon's Functional Health Pattern
PRIOR TO ADMISSION DURING ADMISSION
Health perception - Health
Management Pattern
According to the mother,
the patient has a healthy
body.
The child is unaware of
her condition.
Nutritional - Metabolic
pattern
According to the patients
mother, the patient eatsthree times a day. She eats
fatty foods but also eatsvegetables and fruits likesquash and apple. She
drinks 1 glass of water a
day and 5-10 7-ounce
bottles of milk a day. Shealso drinks soft drinks.
During admission, the
patient does not eatregularly. She only drinks
1/2 glass of water in themorning. During one shift,the patient consumed 1 1/2
bottles of milk.
Elimination Pattern According to the patients
mother, the patientdefecates daily every
noon. The patient urinates4-5 times a day.
The patient did not
defecate since the first dayof her admission. During
the shift, the patienturinated twice.
Activity - Exercise Pattern According to the patientsmother, the patient wakes
The patient was dependenton her mother for her
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Coping Stress Tolerance
Pattern
According to the mother,
the patient has a close
relationship with themother. The mother would
help solve all the problemsthat the patient may have.
The relationship between
the mother and the patient
is still strong. The patienttalks with the mother for
any needs.
Value - Belief Pattern The patient is a RomanCatholic. She was baptized
at Our Lady of Atochia
Church when she was a
year old. According to themother, the patient and
mother prays together
every day.
The mother and patientprays together.
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1st
Physical Assessment
Date: August 01, 2012
Time: 1:00PM
Vital Signs:
Temp: 38. 9 CPR: 148 bpm
RR: 48 cpm
General Appearance: Received patient lying on bed with an ongoing D5 .03 NaCl 500ml regulated at
30ugtts/min hooked at right arm, patent and infusing well.
Mood: responsive, alert, awake
Behavior: acting with appropriate behavior
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Physical Assessment
AREA ASSESSED METHODS FINDINGS INTERPRETATION
1. SKINCOLOR
TEXTURE
TEMPERATURE
MOISTURE
TURGOR
INSPECTION
INSPECTION
ANDPALPATION
PALPATION
PALPATION
PALPATION
Light brown
skin color
Smooth
Normally
warm
Smooth
Snacks back
to previous
state
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COLOR
PUPIL (PERRLA)
INSPECTION
INSPECTION
Pink red
Responds to
pen light
NORMAL
NORMAL
6. EXTERNALAUDITORY CANAL
HEARING INSPECTION Hearing
equally in
both ears
NORMAL
7. NOSESYMMETRY
COLOR
INSPECTION
INSPECTION
Symmetrical
Same color as
the face
NORMAL
NORMAL
8. LIPS AND MOUTH
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12.UPPEREXTREMITIES
SYMMETRY
ROM
INSPECTION
INSPECTION
Symmetrical
(+) Full range
of motion
NORMAL
NORMAL
13.LOWEREXTREMITIES
SIZE
SYMMETRY
ROM
INSPECTION
INSPECTION
INSPECTION
Equal in size
Symmetrical
(+) Full range
of motion
NORMAL
NORMAL
NORMAL
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Laboratory ResultsDate: August 31,2012, 12:05pm
CBC RESULTS NORMAL INTERPRETATION
RBCHct
Hgb
WBC
4.430.35
128
10.9
4-60.4-0.54
130-180
5-10
NORMALNORMAL
NORMAL
NORMAL
DIFFERENTIAL
LymphocytesMonocytes 0.240.06 0.25-.350.03-0.14 NORMAL
BLOOD INDICES
MCV (mean cell volume)
MCH (mean corpuscularhemoglobin)MCHC (Mean Cell
Hemoglobin Concentration)
79.5
28.9
36.4
86-110
26-38
31-37
NORMAL
NORMAL
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Pathophysiology
Predisposing Factors Etiologic Agent Precipitating Factors- Age - Streptococcus pneumonia - immunocompromise
- Sex - Staphylococcus aureus - underlying lung disease- Escherichia coli - alcoholism
-Mycoplasma pneumonia - malnutrition
- altered consciousness
Aspiration of microorganism
Adherence to alveolar
macrophages; exposure of cell
wall components
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Pathophysiology
Aspiration of oropharyngeal secretions is the most common route of lower respiratorytract infection; thus the nasopharynx and oropharynx constitute the first line of defense for most
infectious agents. Another route of infection is through the inhalation of microorganisms thathave been released into the air when an infected individual coughs, sneezes, or talks, or form
aerosolized water, such as that from contaminated respiratory therapy equipment. In healthy
individuals, pathogens that reach the lungs are expelled or held in check by mechanisms of self-
defense (First line: Physical, Mechanical, and Biochemical Barriers, Second line: InflammatoryResponse, Immunity, cough reflex, mucociliary clearance). If a microorganism gets past the
upper airway defense mechanisms, the next line of defense is the alveolar macrophage. Thisphagocyte is capable of removing most infectious agents without setting off significantinflammatory or immune responses. However, if the microorganism is virulent or present in large
enough numbers, it can overwhelm the alveolar macrophage and result in a full-scale activation
of the bodys defense mechanism, including the release of multiple inflammatory mediators,
cellular infiltration, and immune activation. These inflammatory mediators and immunecomplexes can damage bronchial mucous membranes and alveolocapillary membranes, causing
the acini (cluster of cells that resembles a many-lobed "berry"; the berry-shaped termination of
an exocrine gland, where the secretion is produced, is acinar in form, as is the alveolar saccontaining multiple alveoli in the lungs) and terminal bronchioles to fill with infectious debris
and exudate. In addition, some microorganisms release toxins from their cell walls that can cause
further lung damage. The accumulation of exudate in the acinus leads to dyspnea and to V/Q
mismatching and hypoxemia. The immune response includes complement activation and theproduction of antibodies which are crucial for opsonizing the encapsulated bacterium
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Course in the Ward
Date Doctors Order
July 31, 2012
4:35pm
- Admit to ROC- V/S q 4- For CBC- D5 0.3 NaCl 500 ml at 30 ggts/min- Paracetamol 120 mg q 4h for T- 38 C-
Hydrocortisone 25 mg IV q 8- Aerosol with salbutamol- Cefuroxime 250mg IV q 6 ANST- Oxygen at 2-36 for dyspnea- Refer for any signs and symptoms
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Nursing Care Plan
Date: August 01, 2012
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: none
Objective:
RestlessnessProductive cough
(+) Rhonchi on rightlower lobe
Temp: 38. 9 CPR: 148 bpm
RR: 48 cpm
Risk for
ineffective airwayclearance r/taccumulation of
tracheobronchialsecretions
After 3-4 hours of
nursing intervention,the patient will be ableto maintain patent
airway clearance AEBreduction of congestion
with breath soundsclear
Monitor V/s Elevate HOB and
encourage frequent
positioning
Auscultate breathsounds and assessair movement
Keep back dry andloosen clothingand teach deep
breathing andcoughing exercises
Instruct the motherto increase fluid
intake
Provide adequaterest periods
Givebronchodilators as
ordered Administer oxygen
therapy and othermedications as
ordered
For baseline data Ventilation to different
lung segment
To ascertain status andnote progress
To promote comfortand adequateventilation and promote
pulmonary hygiene
To liquefy secretions
Rest will preventfatigue and decrease
oxygen demands
To clear airway whensecretions are blocking
the airway To increase oxygen
saturation
After 3-4 hours of
nursing intervention,the patientmaintained a patent
airway AEB areduction of
congestion withclear breath sounds.
GOAL MET
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Date: August 01, 2012
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: none
Objective:
Restlessness(+) Rhonchi on right
lower lobe
Temp: 38. 9 CPR: 148 bpm
RR: 48 cpm
Risk for impaired
Gas Exchange r/tinflammation of
airways and
accumulation ofsputum affecting
O2 and O2transport
After 4-5 hours of nursing
intervention, the patient willdemonstrate improvement
in gas exchange AEB a
decrease in respiratory rateto normal (22-34 cpm)
Monitor V/S Observe color of skin,
mucous and nail beds
Elevate HOB andencourage frequent
position changes Encourage deep
breathing andcoughing exercises
Keep back dry andloosen clothing
Provide adequate restperiods
Instruct mother toincrease fluid intake
of the child
Administer oxygentherapy as ordered
For baseline data To note in any
changes of the
status of your gasexchange
To facilitate thediaphragm
To promote goodpulmonary
hygiene
To promotecomfort and
adequate
ventilation Rest will preventfatigue anddecrease oxygen
demands formetabolic
demands
To liquefysecretions
To increaseoxygen saturation
After 4-5 hours of
nursing intervention, thepatients respiratory rate
decreased to 42 cpm
GOAL NOT MET
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Date: August 01, 2012
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: none
Objective:
Warm to touch
Body weaknessLack of appetite
V/S:
Temp: 38. 9 C
PR: 148 bpmRR: 48 cpm
Hyperthermia r/tinflammatory process
After 30 minutes to 1hour of nursing
intervention, the
temperature of the pt.will decrease from
38.9C to at least 37.5C
Establish rapport Monitor V/s Perform TSB
Promote surfacecooling by means
of undressing
Encourage fluidintake
Maintain patentairway and
provide blanket
Maintain bed restand adequate rest
periods
Administerantipyretics asordered
To gain trust For baseline data TSB promotes
heat loss throughevaporation and
conduction To provide
comfort and
prevent chills
To supportcirculating
volume and tissueperfusion
To promotepatients safety
and to avoidchills
To reducemetabolic
demands andoxygen
consumption
To decreasecirculating
pyrogens
After 30 minutes to 1hour nursing
intervention, the
temperature decreasedfrom 38.9 C to 37.8 C
GOAL PARTIALLYMET
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Date: August 01, 2012ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
Objective:
(+) Rhonchi in rightlower lobeProductive cough
RestlessnessCough
Tachypnea
V/S:Temp: 38. 9 C
PR: 148 bpmRR: 48 cpm
Risk for infection r/t
suppressed inflammatoryresponse
At the end of the shift,
the patient will be freefrom possible spread of
infection.
Monitor V/S Encourage the
mother to
perform goodhand-washingtechniques
Encourageadequate rest
periods
Stress theimportance ofincreasing the
childs nutritionalintake
Instruct mother toprovide goodhygiene for thechild
Instruct mother toprovide adequate
safe drinkingmilk/water for the
child
Instruct mother tokeep the childwarm and to
provide a blanket
To establishbaseline data
To reduce spreador acquisition of
infection
To enhance fastrecovery and
regain strength
Good nutritionintake canstrengthen the
bodys immunesystem
To prevent entryof microbes
To prevent GIdisturbance
To avoid chillsand to prevent thechild from having
a fever
At the end of the shift,
the patient has been freefrom possible spread of
infection.
GOAL MET.
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Date: August 01, 2012
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
Objective:
Lack of appetite
Lack of interest to foodoffered
Risk for imbalancednutrition r/t decrease
nutrient absorption
At the end of theshift, the patient
will consume at
least 65% of thefood offered
Monitor vital signs Assess for difficulty of
swallowing and the
ability to swallow
Encourage familymembers to prepare
food of patientspreferences- develop
meal plan with thepatient
Ask the mother to jointhe child during meal
time
Instruct client to avoidcaffeinated beverages
Promote adequate andtimely fluid intake bylimiting fluids 30
minutes prior to meal
Encourage small butfrequent feedings
Instruct the client to eata bland diet, low in
roughage, avoiding hot,spicy, or very acidic
foods
To have baseline data Can be factors that
can affect ingestion
and causative ofaltered nutrition
To maintain adequatecaloric intake
To meet thenutritional needs of
the client
It stimulates gastricmotility
To reduce possibilityof early satiety
May reduce fatigueand thus enhanceintake while
preventing gastricdistention
This reduces thestress on the
gastrointestinal tract
The patient only ate 50%of foods offered.
GOAL NOT MET.
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Drug Study
DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NSG.
CONSIDERATION
Generic Name:
Hydrocortisone
Classification:Adrenal Cortical steroid
CorticosteroidGlucocorticoid
Therapeutic Class:Hormone
Enters target cells and
binds to cytoplasmicreceptor; initiates manycomplex reactions that are
responsible for itsanti-inflammatory,
immunosuppressive(glucocorticoid), and salt-
retaining
(mineralocorticoid)actions. Some actions
maybe undesirable,depending on drug use
-Replacement therapy in
adrenal corticalinsufficiency-Allergic states
Severeorincapacitating allergic
conditions-Hematologic disorders
-Ulcerative colitis
-Allergy to any component
of the drug-Fungal infections-Amebiasis
-Hepatitis B-Vaccinia or varicella
-Antibiotic-Resistant infections
-Immunosuppression
CNS:
Vertigo, headache,paresthesias, insomnia,seizures, psychosis
CV:Hypotension,shock,HPN
and heart failuresecondary to fluid
retention,
thromboembolism,thrombophlebitis, fat
embolism, cardiacarrhythmias
Dermatologic:Thin, fragile skin,
petechiae, ecchymosis,
purpura, striae,
subcutaneous fat atrophy
EENT:Cataracts, glaucoma,increased IOP
Endocrine:Amenorrhea, irregular
mens, growth retardation,decreased carbohydrate
tolerance and DM,cushingoid state, HPA
suppression systemic,
Before
- Assessforcontraindications.- Assess body weight,
skincolor, V/S,urinalysis, serum
electrolytes, X-rays, CBC.- Arrange for increased
dosage when patient is
subject to unusual stress.- Do not give live
vaccines withimmunosuppressive
dosesofhydrocortisone.- Observe the 15 rightsof drug administration.
During- Give daily before 9amto mimic normal peak
diurnalcorticosteroidlevels.
- Space multiple dosesevenly throughout the
day.- Use minimal doses for
minimal duration tominimize adverse
effects.
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hyperglycemia
GI:Peptic or esophagealulcer, pancreatitis,
abdominal distention,nausea, vomiting,
increased appetite and
weight gainHematologic:
Na and fluid retention,
hypocalcemia, increasedblood sugar, increased
serum cholesterol,decreased T3 and T4
levels
Hypersensitivity:Anaphylactoidorhypersensitivity
reactions
Musculoskeletal:Muscle weakness, steroidmyopathy and loss of
muscle mass,osteoporosis, spontaneous
fractures
Other:Immunosuppression,aggravation or masking
ofinfections, impairedwound healing
- Do not give IMinjections if patient has
thrombocytopenicpurpura.
- Taper doses whendiscontinuing high-dose
orlong-term therapy.
After
- Monitor client for at
least 30minutes.- Educate client on the
sideeffects ofthemedication and what to
expect.- Instruct client to report
pain at injection site.- Instruct client to take
drug exactly as
prescribed.- Dispose ofusedmaterials properly.
- Document that drughas been given
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DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NSG.CONSIDERATION
Generic Name:
Cefuroxime
Classification: antibioticCephalosporin
Dosage: 250 mg PO bid
Route: oral
Bactericidal: inhibits
synthesis of bacterial cellwall, causing cell death.
Acute bacterial maxillary
sinusitis caused bystreptococcus pyrogens.
Lower respiratoryinfections caused by
streptococcus
pneumonia, H. influenza
Contraindicated with
allergy to cephalosporinsand penicillins.
Use cautiously with renalfailure, lactation,
pregnancy
CNS: headache,
dizziness, lethargy,paresthiasis.
GI: nausea and
vomiting, diarrhea,anorexia, abdominal
pain, flatulence.
HEMATOLOGIC:bone marrow depression(WBC, decreased
platelets, decreasehematocrit.)
HYPERSENSITIVITY: Ranging rush to fever to
anaphylaxis: serum
sickness reaction.
Assessment:
History: hepatic andrenal impairment,
lactation, pregnancy.
Physical: Skin Status,culture of affected area.
Oral Drug:
Give oral drug with food
to decrease GI upset andenhance absorption.
Discontinue ifhypersensitivity
occurred.
Parenteral Drug:
Report severe diarrhea,difficulty of breathing,unusual tiredness or
fatigue, pain at injection
site
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DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NSG.
CONSIDERATION
Generic
Name: SalbutamolSulfate AlbuterolSulfate
Brand
Name: AccuNeb,Airomir, Proventil,
Proventil HFA, ProventilRepetabs, Ventolin,
Ventolin HFA, VentolinObstetric Injection,
Ventolin Rotacaps,
Volmax, VoSpire ER
Available
Forms: Capsules forinhalation: 200mcgInjection: 1 mg /ml Solution forinhalation: 0.083%,
0.5%, 0.63 mg / ml, 1.25mg / 3 ml Syrup: 2 mg /5 ml Tablets: 2 mg, 4mg Tablets (extended-release): 4 mg, 8 mg
Relaxes bronchial,
uterine, and vascularsmooth muscle by
stimulating beta2
receptors.
* To prevent or treat
bronchospasm in patientswith reversible
obstructive airway
disease * To prevent exercise-
induced bronchospasm * Acute asthma * Symptom relief duringmaintenance therapy of
asthma and otherconditions with
reversible or irreversibleairways obstruction
(including COPD and
bronchitis)
* Contraindicated in
patients hypersensitive to
drug or its ingredients. * Use with caution in
patients with CV
disorders (includingcoronary insufficiency
and hypertension),hyperthyroidism,
diabetes mellitus, and
those who are unusuallyresponsive to
adrenergics * Use extended-releasetablets cautiously in
patients with GI
narrowing.
. CNS: tremor,
nervousness, dizziness,insomnia, headache,
hyperactivity, weakness,
CNS stimulation,
malaise CV: tachycardia,
palpitations,
hypertension EENT: dry and irritatednose and throat with
inhaled form, nasalcongestion, epistaxis,
hoarseness GI: heartburn, nausea,vomiting, anorexia,altered taste, increased
appetite
* Drug may
decrease sensitivityof spirometry used
for diagnosis of
asthma.* When switching
from regular toextended-release
tablets, keep inmind that a regular
2 mg tablet every 6hours is equivalent
to an extended-release 4 mg tablet
every 12 hours.* Syrup may etaken by children as
young as age 2; itcontains no alcohol
or sugar.* Rarely, erythema
multiforme orStevens-Johnson
Syndrome has beenlinked to use of
syrup in children.
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DRUG NAME ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NSG.CONSIDERATION
Generic Name:
Paracetamol
Brand Name:
Classification:
Analgesic, Anti pyretics
Dose: 1ampFrequency: for PRN
meds q 4-6 hours
Route: oral
Indicated in conditions
like Ear pain, Headache,Malaise, Migraine, mild
to moderate pain, Pain,
Post-vaccine reaction,Short bowel syndrome,
Toothache.
Paracetamol exhibits
analgesic action byperipheral blockage pain
impulse generation. It
produces antipyresis byinhibiting the
hypothalamic heat-regulating center. Its
weak anti-inflammatoryactivity is related to
inhibition ofprostaglandin synthesis
in the CNS
Contraindicated in
conditions like
hypersensitivity
Nausea, allergic reaction,
skin rashes, acute renaltubular, necrosis.
Potentially fatal: Liverdamage
If sensitivity reaction
occurs, discontinue useof paracetamol
If pain persist more than10 days and arthritic and
rheumatic conditionaffecting children,
immediately consult
physician.