OVERVIEW OF THE DISEASE
INTRODUCTION
A hypertensive emergency is severe hypertension (high blood pressure ) with acute impairment of organ system 9 especially the central nervous system , cardiovascular system and/or renal system ) and the possibility of irreversible organ damage. In case of hypertensive emergency, the blood pressure should be lowered aggressively over minutes to hours with a hypertensive agent. Several classes of hypertensive agents are recommended and the choice of hypertensive agent depends on the cause for the hypertensive crisis, the severity of elevated blood pressure and the patient’s usual blood pressure before the hypertensive crisis. In most cases, the administration of an intravenous Sodium Nitroprusside injection which has an almost immediate anti hypertensive effect is suitable but in many cases, oral agents are given like Captopril, Clonidine, Labetalol, Prazosin, which all have a delayed onset of action by several minutes compared to Sodium Nitroprusside, can also be used.
DEFINITION
Generally, the terminology describing hypertensive emergencies can be confusing. Terms such as hypertensive crisis, malignant hypertension, hypertensive urgency, accelerated hypertension and severe hypertensions are all used to=in the literature and often overlap.
As a specific term hypertensive emergency is primarily used as a crisis with a diastolic pressure of 120 mm hg and above plus end organ damage (Brain, Cardiovascular, renal) as described above in contrast to hypertensive urgency where as yet no end organ damage has developed. The former requires immediate lowering of blood pressure as with Sodium Nitroprusside infusions.
SIGNS AND SYMPTOMS Headache High blood pressure usually 140/100 and above Shortness of breath Convulsion Changes in vision Nausea Vomiting
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Heart palpitations
DIAGNOSTIC EXAM Blood pressure monitoring using sphygmomanometer Electrocardiogram (ECG) Complete Blood Count(CBC) Physical Examination LDL-HDL Ratio
TREATMENT
The usual treatment is to reduce blood pressure using anti –hypertensive drugs, it includes:
ACE inhibitors;
ARBs;
Diuretics;
Beta-blockers;
Calcium- blockers
Diuretics are usually recommended as the first line of therapy for most people who have high blood pressure. If one drug doesn’t work or is disagreeable, other types of diuretics are available.
NURSING INTERVENTION
The primary responsibility of the nurse is to assess the condition of the patient during the treatment. It includes the following but are not limited to;
Vital signs monitoring specifically blood pressure, Assessment for possible and sudden drop of blood pressure, Monitoring of adverse reactions to drugs, Tabulation of Input and Output when ordered and carrying out doctor’s order.
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A. Client’s profile:Name: Mr. AMAddress: Abbay Maddela QuirinoAge: 26 years oldSex : MaleCivil status : MarriedNationality : FilipinoReligion : Born AgainBirthDate : November 5,1983Occupation : BaKerDate of admission: May 4, 2010Time of admission: 2:45PMChief Complaint: body weakness and pale lookingDiet : DATDiagnosis: Anemia to consider Blood DyscrasiaPhysician: Dr.X
MEDICAL HISTORY:• Present health history of illness:
- Two weeks prior to admission the patient suffered body weakness associated with pale looking. According to the patient he also felt dizziness and severe headache; he take paracetamol to relieve the pain but then he was not relieve that’s why they decided to have his check up at QPH and his Physician advised him for confinement with a diagnosis of Anemia. Admitted last May 4, 2010 @ 2:45pm
• Past medical history:- He is not fully immunized that’s why he occasionally experienced Childhood
diseases like; cough,colds and fever. His last confinement was on October 2009 at Dundayong Hospital at part of Maddela Quirino. Also Last December 28, 2009 at QPH with an admitting diagnosis of Idiopathic thrombocytopenia Purpura . Last April 16-22, 2010 he was confined at SIGH and was diagnosed with Anemia.
• Family health history:
Father Possible hereditary Mother+ HPN +- Asthma -- Cancer -- DM -
II GORDONS HEALTH FUNCTIONAL PATTERN
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1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN
BEFORE HOSPITALIZATION: the Pt. verbalized that he is healthy. He can actually maintain his body healthy without any problems.
DURING HOSPITALIZATION: when he was admitted at QPH he still thinks that he is okay because he feel good still but easily feel tiredness.
2. NUTRITIONAL-METABOLIC PATTERN
BEFORE HOSPITALIZATION: Pt.AM prefers vegetables than meat. He rarely eats meat because he thinks those are the reason that’s why he is suffering anemia.
DURING HOSPITALIZATION: the doctor ordered DAT diet. And the hospital usually serves meat as their vian.
3. ELIMINATION PATTERN
BEFORE HOSPITALIIZATION: PTA, the pt. urinates 7-8x a day with colorless - light yellow urine with no foul odor.
DURING HOSPITALIZATION: when he was admitted, he urinates 6-7x a day. And perspires at all times bec.of warm environment in the hospital.
4. ACTIVITY-EXERCISE PATTERN
BEFORE HOSPITALIZATION: The pt. is fun of playing basketball and this serve as his exercise.
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DURING HOSPITALIZATION: He can’t play basketball because of his condition .
5. SLEEP-REST PATTERN
BEFORE HOSPITALIZATION: Sometimes his number of sleep ranges from 6-7 hours a day. But mostly he has hard time on getting his sleep with unknown cause.
DURING OSPITALIZATION: he mentioned that, since his confinement here in QPH, he felt as though he was refreshed than that as compared with before because he had enough time to sleep without any interruptions. he had no more worries about his routine activities.
6. COGNITIVE PERCEPTUAL PATTERN
Pt. AM is only a high school undergraduate but he can read and write. He can easily understood and respond to our questions directly.
7. SELF PERCEPTION/ SELF CONCEPT PATTERN
BEFORE HOSPITALIZATION: He sees himself as a very busy person and responsible father on his two child.
DURING HOSPITALIZATION: Because of her stay at QPH, his anxiety about his daily routines/activities at home is temporarily relieved.
8. ROLE RELATIONSHIP PATTERN
BEFORE HOSPITALIZATION: He is a responsible father and husband. He is a baker on a small bakery at Zamora.
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DURING HOSPITALIZATION: he can’t work anymore because of his condition.
9. SEXUALITY-REPRODUCTIVE PATTERN
He was 7 years old when he was circumcised by what they call “de pok-pok”before.
10. COPING STRESS MANAGEMENT
BEFORE HOSPITALIZATION: Due to his routine Activities, he was not aware that he was under stress. he had been encountering it every day which may trigger the disease.
DURING HOSPITALIZATION: he now understand that having enough rest when he is tired and stressed is very indispensable to overcome his condition. He also recognizes though our health teachings are the essence of taking of multivitamins rich in iron to strengthen his immune system.
11. VALUE BELIFE PATTERN
BEFORE HOSPITALIZATION: He was a devoted Born again. He sometimes attends mass together with his wife and children at their nearby church.
DURING HOSPITALIZATION: Now that he is confined, he can’t attend mass anymore but still prays all the time.
PHYSICAL ASSESSMENT
Date: May 06,2010@10:00am
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General Appearance: conscious
BODY PARTS TECHNIQUE FINDINGS
INTERPRETATION
HEAD Hair Inspection Black in
colorNo lice
Normal
Scalp InspectionPalpation
No presence of dandr
uffNo masse
sNo tenderness
NormalNormal
Ears Inspection With norma
l hearin
g
Normal
Earlobes Inspection Bean-shape
d
Normal
Ear Canacl Inspection No abnormal
discharges
Normal
Eyes(Conjunctiva)
Inspection PERRLAWith pale
conjunctiva
NormalDue to lack of red
blood cell
Lips Inspection Pale in color
(white)
Due to lack of red blood cell
Teeth Inspection With presence of dental carrie
s
Due to poor hygiene
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Gums Inspection Pinkish in color
Normal
Tongue Inspection Moist NormalFACE Inspection
PalpationPale in
colorNo masse
s
Due to lack of red blood cell
Normal
NECK Inspection Symmetrical and pale in
color
Normal
Due to present condition
UPPER EXTREMITIES
InspectionPalpation
No lesion and pale in
colorSymmetri
cal, no
bones dislocated
Due to present condition
Normal
Fingernails Inspection
Palpation
Clean and prope
rly cut
Slightly poor capillary
refill
Normal
Due to lack of red blood cell
Shoulder Inspection symmetrical and pale in
color.
Normal
Due to present condition
Heart Auscultation 115 bpm Normal
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Thorax and lungs
Palpation
Auscultation
No tenderness
No wheez
ing sound
Normal
Normal
Abdomen Inspection
Auscultation
Palpation
Percussion
Flat, Sym
metrical
slightly pale
in color
Normoactive
soundNo tenderness
Resonant
Due to present condition
Normal
Normal
Normal
LOWER EXTREMITIES
Inspection
Palpation
Symmetrical
Pale in color
Normal
Due to lack of red blood cell
Legs Inspection Hairy and slightl
y pale. And with
complain of pain
on the left leg.
Due to lack of red blood cell
Due to basketball accident.
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II. ANATOMY & PHYSIOLOGY
The heart pumps oxygenated blood to the body and deoxygenated to the lungs. In the human heart there is one atrium and one ventricle for its circulation, and with both a systemic and pulmonary circulation there are four chambers in total; left atrium, left ventricle, right atrium and right ventricle. The right atrium is the upper chamber of the right side of the heart. The blood that is returned to the right atrium is deoxygenated (poor in oxygen) and passed in to the right ventricle to be pumped through the pulmonary artery to the lungs for re-oxygenation and removal of carbon dioxide. The left atrium receives newly oxygenated blood from the lugs as well as the pulmonary vein which is passed into the strong ventricle to be pumped through the aorta to the different organs of the body.
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III. PATHOPHYSIOLOGY
HYPERTENSIVE EMERGENCY
ETIOLOGIC FACTOR: RISK FACTORS:
Obesity Age Stress
IV. COURSE IN THE WARD
DOCTOR’S ORDER RATIONALE5/4/102:45 pm>pls. admit to male medicare Ward> Record TPR
>To treat underlying condition> for baseline data
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Stressor initiated
Reni is released by the
Angiotensin is produced
Angiotensin I is converted to Angiotensin II
Increased BP
>DAT>CBC>BT>PNSS1L- 25 gtts/min>Secure 4 units of FWB type O+ & transfused
after crossmatching> refer accordingly
5/5/1010:10 am>TF: PNSS1L at KVO> For Peripheral blood smear> for referral to Hematologist> continue for BT> refer
5/6/109:30am Continue BT
5/7/10 Still for BT Continue IVF PNSS1L x 24hrs
5/7/103:00pm For referral to Hematologist D5NM1L x 25 gtts/min Multivit. + Iron 1 capsule TID refer
> applicable diet to the patient> to check any abnormalities> to replace components of blood loss> for electrolytes and fluid balance>to check for compatibility of blood
to evaluate the condition
for electrolytes and fluid balance to check abnormalities of blood for further evaluation and management To replace components of blood loss To evaluate condition
To replace components of blood loss
To replace components of blood loss
For further evaluation and management For electrolytes and fluid balance To boost immune system For further evaluation
V. LABORATORY RESULTS
Name: Mr AM
Result Normal values
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WBC 3.5
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URINALYSIS
Date: 11- 30- 09
Chemical Examination
Color: yellow
Clarity: clear
MICROSCOPIC EXAMINATIONS:
Pus cells: 0-2/hpf
Red cells: 5-7/hpf
Epithelial cells: moderate/hpf
Amorphous urates: few/hpf
Mucus threads: +/hpf
Bacteria: +/hpf
Dr. Nathanael B. Vidad, MD, FPSP
Photologist ( 59251)
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CHEMISTRY
Date: Nov. 30, 2009
TEST REFERENCE VALUE
Fasting blood sugar: 5.97 mmol/L 3.89-5.83 mmol/L
Cholesterol: 7.33 mmol/L 3.87-6.71 mmol/L
Triglycerides: 1.35 mmol/L up to 1.7 mmol/L
Blood urea Nitrogen: 5.78 mmol/L 2.5-6.5 mmol/L
Creatinine: 87.9 mmol/L 150-357 mmol/L
Dr. Nathanael B. Vidad, MD, FPSP
Photologist ( 59251)
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SERUM ELECTROLYTES
Date: Nov. 30, 2009
Test Reference Value
Sodium: 133.7 mmol/L 135.0-155.0 mmol/L
Potassium: 2.89 mmol/L 3.60-5.50 mmol/L
Dr. Nathanael B. Vidad, MD, FPSP
Photologist ( 59251)
HEMATOLOGY
DATE: Nov. 29, 2009 Reference Value
WBC: 7.6 3.5-10
RBC: 5.14 3.80-5.80
HGB: 152 110-165
HCT: .470 .350-.500
PLT: 289 150-390
PCT: .198 .100-.500
WBC FLAGS: G3 Reference Value
LYM- 23-8% 17.0-48.0%
MON- 7.0-% 4.0-10.0%
GRA- 69.2% 43.0-76.0%
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XII. VITAL SIGNS
Admitted: November 29, 2009Initial vital sign bp- 220/140
November 29, 20098am-4pm
• 9:25 am bp-160/ 100 PR-90bpm• 10:30 am bp-160/100 PR-86bpm• 11:40 am bp-160/100 PR-86bpm• 12:50pm bp-130/90 PR-86bpm• 2:00pm bp-160/100 PR-88bpm• 3:45pm bp-170/100 PR-98bpm•
November 29, 20094pm-12am
• 5:00pm bp-190/110 PR-96bpm• 6:30pm bp-200/130 PR-102bpm• 8:15pm bp-200/120 PR-98bpm• 9:50pm bp-180/120 PR-100bpm• 11:00pm bp-210/130 PR-98bpm •
November 30, 200912am-8am
• 1:00 bp-190/120 PR-96bpm• 2:00 bp-220/110 PR-98bpm• 3:00 bp-200/110 PR-84bpm• 5:30 bp-180/120 PR88bpm• 7:30 bp-190/120 PR-80bpm •
November 30, 20098am-4pm
• 9:30am bp-190/120 PR-72bpm• 12:00pm bp-190/130 PR-84bpm• 1:00pm bp-200/120 PR-89bpm• 2:30pm bp-180/130 PR-83bpm• 3:30pm bp-190/120 PR-68bpm
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November 30, 20094pm-12am
• 6:00pm bp-150/100 PR-58bpm• 8:30pm bp-170/100 PR-64bpm• 9:40pm bp-140/100 PR-60bpm• 10:40pm bp-140/100 PR-57bpm• 11:30pm bp-160/100 PR-60bpm •
December 1, 200912am-8am
• 1:30am bp-170/110 PR-62bpm• 2:30am bp-160/110 PR-64bpm• 3:30am bp-180/120 PR-57bpm • 4:30am bp-170/100 PR-58bpm• 5:30am bp-170/110 PR-62bpm
December 1, 20098am-4pm
• 9:00am bp-160/100 PR-80bpm• 10:00am bp-180/110 PR-86bpm• 10:15am bp-170/100 PR-83bpm• 10:30am bp-160/100 PR-86bpm• 10:45am bp-160/100 PR-85bpm• 11:00am bp-170/100 PR-80bpm• 11:15am bp-160/100 PR-66bpm• 11:30am bp-160/100 PR-64bpm• 11:45am bp-170/110 PR-63bpm• 12:30pm bp-160/110 PR-60bpm• 1:00pm bp-160/110 PR-68bpm• 1:15pm bp-160/110 PR-67bpm• 2:00pm bp-160/110 PR-65bpm• 2:30pm bp-160/110 PR-64bpm• 3:30pm bp-170/110 PR-66bpm
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December 1, 20094pm-12am
• 5:00pm bp-170/110 PR-66bpm• 6:45pm bp-180/110 PR-68bpm• 9:30pm bp-180/110 PR-61bpm• 10:00pm bp-140/110 PR-64bpm• 11:00pm bp-170/110 PR-65bpm
December 2, 200912am-8am
• 1:00am bp-180/120 PR-72bpm• 2:30am bp-180/90 PR-70bpm• 5:30am bp-160/110 PR-80bpm• 7:30am bp-160/100 PR-79bpm
December 2, 20098am-4pm
• 9:00am bp-160/110 PR-62bpm• 10:00am bp-150/90 PR-64bpm• 11:00am bp-160/100 PR-66bpm• 12:00pm bp-150/100 PR-62bpm• 2:00pm bp-150/100 PR-63bpm
December 2, 20094pm-12am
• 6:30pm bp-170/110 PR-80bpm• 7:00pm bp-160/110 PR-94bpm• 9:00pm bp-140/90 PR-87bpm• 10:00 bp-150/110 PR-92bpm
December 3, 2009
12am-8am
• 1:30am bp-140/100 PR-98bpm• 5:30am bp-150/110 PR-84bpm• 7:00am bp-140/100 PR-84bpm
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December 3, 20098am-4pm
• 9:30am bp-140/100 PR-89bpm• 10:30am bp-140/100 PR-87bpm• 11:30am bp-160/100 PR-90bpm• 12:30pm bp-140/100 PR-93bpm• 1:30pm bp-140/90 PR-86bpm• 2:00pm bp-140/90 PR-78bpm• 2:30pm bp-140/100 PR-68bpm
December 3, 20094pm-12am
• 6:00pm bp-140/90 PR-66bpm• 10:00pm bp-130/90 PR-68bpm
December 4, 200912am-8am
• 12:30am bp-160/120 PR-85bpm• 1:15am bp-150/120 PR-86bpm• 1:30am bp-140/100 PR-89bpm• 1:45am bp-140/100 PR-86bpm• 2:00am bp-140/100 PR-83bpm• 2:15am bp-140/100 PR-86bpm• 6:00am bp-140/100 PR-79bpm
December 3, 20098am-4pm
• 10:00am bp-140/100 PR-86bpm
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VI. NURSING CARE PLAN
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Assessment Diagnosis
Planning
Intervention
Rationale
Evaluation
SUBJECTIVE:• “Lagi
sumasakit ulo ko.” as verbalized by the pt.
OBJECTIVE:• Body
weakness• Irritable• Oily face
elevated blood pressure
After 1-4° of nursing intervention the pts headache will be relieved.
Independent:-Established
rapport
-Monitored BP and PR
-Instructed pt on proper deep breathing
-Positioned the pt on a comfortable position
Dependent:
-Due meds given
-On low fat, and low salt diet
-To gain pt trust and cooperation
-For baseline data
-To lessen anxiety and stress
-For pts comfort
-To relief headache
-To lessen fat deposit and retention of NaCl ions.
Goal met as evidence by the pts verbalization of “hindi na masakit ulo ko.”
NURSING CARE PLAN
Assessment Diagnosis
Planning
Intervention
Rationale
Evaluation
SUBJECTIVE:-Ø
OBJECTIVE:-guarded
behavior-diaphoretic
Knowledge deficit r/t self care
After 1-2° of nursing intervention the pt will be able to demonstrate all increasing
Independent:-Established
rapport-Monitored
v/s
-Instructed pt to have adequate rest periods
-Emphasized the importance of proper hygiene, grooming and feeding
-To gain pt trust and cooperation
-For baseline data
-For comfort and relaxation.
-To promote cleanliness
Goal met as evidence by the pts verbalization of “ gagawin ko yung itinuro mo.”
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interest / participation of self care.
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NURSING CARE PLAN
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Assessment Diagnosis
Planning
Intervention
Rationale
Evaluation
SUBJECTIVE: “limang araw na
akong hindi ngdudume,kaya nanghihina ako” ask verbalized by the pt.
OBJECTIVE:-facial grimace-minimal
movement
Constipation
After 1-3° of nursing intervention the pt. will be able to defecate and regain strength.
Independent:-Established
rapport
-Monitored v/s
-Palpated abdomen
-Instructed to increased fluid intake
-Encouraged pt to eat nutritious foods.
Dependent: administered
Bisacodyl as ordered.
-To gain pt trust and cooperation
-For baseline data
-To check for presence of distention.
-to promote hydration
-To promote moist/ soft stool.
Goal met as evidence by the pts verbalization of “”nagdumi na ako.
VII. DRUG STUDY
DRUG NAME CLASSIFICATION
INDICATION/ACTION
SIDE EFFECTS NSG. RESPONSIBILITIES
Generic name:Ketorolac
Brand name:
Stock:
Generic name: Ranitidine
Brand Name:
Stock:
Generic Name:metoclopramide
Brand name:plasil
Stock:10mg/2ml
Generic name:Furosemide
Non- steroidal anti-inflammatory
Doctor’s order:
Anti ulcer drugs
Doctor’s order:
Anti-emetics
Doctor’s order:1 amp IV now then
q8° PRN
Diuretics
Short term management of moderately severe, acute pain for single dose treatment
Gastric irritation
Nausea and vomiting
Headache Dyspepsia GI pain Constipation Flatulence
Anaphylaxis Headache Blurred vision
Bradycardia,supravetricular tachycardia
Neuroleptic malignant syndrome,seizures, suicide ideation.
Vertigo, headache, dizziness.
Correct Hypovolemia before giving. Alert: Maximum Combined duration of
parenteral and oral therapy is 5 days. When appropriate, give by deep IM
injection. Pt may feel pain at the injection site which can be relieve by applying cold bags.
Assess pt for abdominal pain. Note presence of blood in emesis, stool or gastric aspirate.
Drug may be added to total parenteral solutions.
Monitor bowel sounds. Safety and effectiveness of drug haven’t been
established for therapy lasting longer than 12 weeks.
To prevent nocturia, give P.O. and IM
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Brand name:
Stock:
Generic name:Paracetamol
Brand name:
Stock:
Generic name:Losartan
potassium
Brand name: getzar
Generic name: Bisacodyl
Brand name:Dulcolax
Doctor’s order:1 amp IV now then
OD
Non opiod analgesic and anti pyretics
Doctor’s order:1 amp IV stat
Anti hypertensives
Diphenyl methane derivative
Hypertension
Mild pain and/or fever
For hypertension
Chronic constipation
Panceatitis, thrombocytopenia.
Neutropenia, leucopenia, pancytopenia and hypoglycemia
Headache, dizziness, fatigue, abdominal pain, nausea, back pain or leg pain, cough and respiratory infection
Dizziness, faintness, muscle weakness with
preparations in the morning. Give 2the early afternoon.
Watch for signs of hypokalemia such as muscle weakness and cramps.
Alert: Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose.
Drugs can be used alone or with other antihypertensives.
Monitor patient’s BP to evaluate effectiveness of therapy and monitor patients who are also taking diuretics for symptomatic HpN.
Give drugs at times that don’t interfere with scheduled activities or sleep.
Before giving for constipation, determine whether patient has adequate fluid intake, exercise and
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excessive useAbdominal crampsElectrolyte
imbalance
diet.
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