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The document provides a patient's profile and summarizes the doctor's orders and medications for Henorio C. Credo, including Ranitidine Hydrochloride, Cefuroxime, Omeprazole, Metoclopramide, and Paracetamol to treat his conditions of CAP, UTI, and fever resulting from injuries sustained from a fallen tree. The profile outlines the patient's personal details, admission details, diagnoses, medical history and present illness.

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Luwefe Dagayloan
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52 views4 pages

Patient

The document provides a patient's profile and summarizes the doctor's orders and medications for Henorio C. Credo, including Ranitidine Hydrochloride, Cefuroxime, Omeprazole, Metoclopramide, and Paracetamol to treat his conditions of CAP, UTI, and fever resulting from injuries sustained from a fallen tree. The profile outlines the patient's personal details, admission details, diagnoses, medical history and present illness.

Uploaded by

Luwefe Dagayloan
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Patient’s Profile

Name: Henorio C. Credo

Age: 56 years old

Sex: Male

Birth date: December 30, 1995

Birth place: Pinan Zamboanga del Norte

Address: Olingan Dipolog City

Religion: Roman Catholic

Nationality: Filipino

Occupation: Fisherman

Name of Spouse: Rita Credo

Date and Time of admission: September 20, 2010 @ 4:55pm

Attending physician: Dr. Galaretta


Admitting Physician: Dr. A. Hamsirani

Diagnosis: CAP T/C UTI


Chief Complain: Fever, cough and vomiting

History of past illness:

The patient doesn’t have any illness that has been diagnosed by the physician, is first
time to be admitted in the hospital. In the past years, the patient had colds, cough and fever
but is just for a short time and was not a serious condition.

History of present illness:

The patient is working as a tree logger, at 9am in the morning he was cutting a large
gemilina tree, when he was nearly done with cutting tree, the tree fell and unexpectedly hit the
branch of another tree, so instead of the falling away from him, it fell towards him. The patient
ran away but unfortunately the tree still hit him on the back, then he rolled unconsciously and
when he woke up, the trunk of the tree was already in his legs. He stayed in that position for an
hour, he was rescued at around 10 am. He arrived at the hospital at around 10.30 am. Both his
legs were injured, especially his left leg, the tibia and fibula were broken.

Drug Study
DOCTOR’S ORDER: Ranitidine Hydrochloride 50 mg IVTT Q 8 hr
GENERIC NAME: Ranitidine Hydrochloride
BRAND NAME: Zantac
CLASSIFICATION: Antiulcer drug/ histamine2 antagonist
ACTION: competitively inhibits the action of histamine at the H 2 receptors of the parietal cells of the
stomach, inhibiting basal gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic
agonist, gastrin and pentagastrin.
INDICATION: active duodenal and gastric ulcer; treatment of erosive esophagitis; treatment of
heartburn, acid indigestion, sour stomach.
CONTRAINDICATION:
• Hypersensitivity to drug
• Use cautiously in patient with hepatic dysfunction and pregnancy
DOSAGE: 50mg q 6-8 hr
ADVERSE EFFECTS:
CNS: headache, malaise, vertigo
GI: constipation, diarrhea, nausea, vomiting
EENT: blurred vision
Hepatic: Jaundice
Other: Anaphylaxis, angioedema, burning and itching at injection site
NURSING RESPONSIBILITIES/CONSIDERATIONS:
 Take drug with meals and at bedtime.
 Drug may be added to TPN solutions.
 Instruct patient to avoid cigarette smoking because this may increase gastric acid secretion and
worsen disease
 Advise patient to report abdominal pain and blood in stool or emesis.
 

DOCTOR’S ORDER: Cefuroxime 750 mg IVTT now then q 8 hrs. ANST (-)
GENERIC NAME: Cefuroxime
BRAND NAME: Cefaclor
CLASSIFICATION: second generation cephalosporin/ antibiotic
ACTION: second-generation cephalosporin that inhibits cell-wall synthesis, promoting osmotic
instability, usually bactericidal
INDICATION: bacterial exacerbations of chronic bronchitis or secondary bacterial infection of acute
bronchitis; serious respiratory tract infection, UTI, skin-skin structure infections, bone or joint infections
CONTRAINDICATION:
 Contraindicated to patient hypersensitivity to drug and other cephalosporin
 Use cautiously in patient hypersensitive to penicillin
DOSAGE: 750 mg
ADVERSE EFFECTS:
CNS: seizures
GI: diarrhea, nausea and vomiting
DERM: rashes, urticaria
HEMAT: bleeding, blood, dyscrasias
Other: anaphylaxis, serum sickness, allergic reactions
NURSING RESPONSIBILITIES/CONSIDERATIONS:
 Tell patient to take drug as prescribed
 Avoid alcohol while taking this drug and for 3 days after because severe reactions often occur.
 Instruct patient to notify prescriber about rash
 Report severe diarrhea, difficulty breathing, unusual tiredness or fatigue, pain at injection site.

DOCTOR’S ORDER: omeprazole 20 mg cap; I cap BID PO


GENERIC NAME: omeprazole
BRAND NAME: losec
CLASSIFICATION: Proton pump inhibitor
ACTION: suppresses secretion of serotonin and gastroeneterohepatic peptides. Increase absorption f
fluid and electrolytes from the GI tract and increase transmit time. Decreased levels of serotonin
metabolites. Also suppresses growth hormone insulin and glucagon
INDICATION: management of GERD. That has nt been responded t cnventinal therapy with hi9stamine
H2 receptor blocking agents. Shorterm management f active duodenal ulcers.
CONTRAINDICATION:
 Hypersensitivity to drug
 Use cautiously in pregnant women and children
DOSAGE: 20 mg cap
ADVERSE EFFECTS:
headache, dizziness, fatigue, weakness, somnolence, chest pain, abdominal pain, acid regurtation,
constipation, diarrhea, flatulence, nausea and vomiting
NURSING RESPONSIBILITIES/CONSIDERATIONS:
 Instruct patient t take medications as directed to the finish the drug completely even if fling
better.
 May cause drowsiness. Caution patient to avid driving or there activities requiring alertness until
response to med is known.
 Advise patient to report onset of black tarry stools, diarrhea abdominal pain r persistent
headache the physician promptly
 Advise patient to avid alcohol , products containing aspirin, ibuprofen, naproxen, ketoprofen,
and foods that may cause increase G.I irritation.

DOCTOR’S ORDER: Metoclopramide I amp IVTT q 8 hrs. PRN for vomiting


GENERIC NAME: metoclopramide
BRAND NAME: clopra
CLASSIFICATION: antiemetic
ACTION: Stimulates motility of upper GI tract, blocks dopamine receptor at the chemoreceptor trigger
zone
INDICATION: To prevent nausea and vomiting and gastroesophangeal reflux
DOSAGE: I amp IVTT q 8 hrs. PRN
ADVERSE EFFECTS:
Restlessness, anxiety, drowsiness, hypotension, bradycardia
NURSING RESPONSIBILITIES/CONSIDERATIONS:
 Monitor bowel sound
 Advice patient to not to drink alcohol during therapy
 Avoid any activities that require alertness for 2 hrs. after doses

DOCTOR’S ORDER: Paracetamol 500mg I tab q 4 hrs. for fever


Generic Name: paracetamol
Brand Name: Tylenol
Classification: Acetaminophen
Action: Analgesic & antipyretic, a drug that reduces fever
Indications: For treatment of mild or moderate pain & antipyretic in colds and influenza
Contraindications: contraindicated with allergies to NSAID
 Adverse Effects:
 Dizziness
 Digestive Upset
 Pancytopenia
 Anorexia
Nursing Interventions:
 explain to the patient the drug’s side effects
 instruct patient to report signs of severe experience of the side effects
 Advice patient to eat frequent small amounts of food

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