INTRODUCTION UPPER GASTROINTESTINAL BLEEDING Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract.

The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon. Presentation Patients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, or hematochezia (maroon coloured stool) if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage. Patients may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath. Causes Upper gastrointestinal bleeding: Upper GI bleeding originates in the first part of the GI tractthe esophagus, stomach, or duodenum (first part of the small intestine). Most often, upper GI bleeding is caused by one of the following: Peptic ulcers Gastritis Esophageal varices Mallory-Weiss tears Gastrointestinal cancers Inflammation of the gastrointestinal lining from ingested materials Peptic ulcer disease: Peptic ulcers are localized erosions of the mucosal lining of the digestive tract. Ulcers usually occur in the stomach or duodenum. Breakdown of the mucosal lining results in damage to blood vessels, causing bleeding. Gastritis: General inflammation of the stomach lining, which can result in bleeding. Gastritis also results from an inability of the gastric lining to protect itself from the acid it produces. NSAIDs (nonsteroidal anti-inflammatory drugs), steroids, alcohol, burns, and trauma can cause gastritis. Esophageal varices: Swelling of the veins of the esophagus or stomach usually resulting from liver disease. Varices most commonly occur in alcoholic liver cirrhosis. When varices bleed, the bleeding can be massive, catastrophic and occur without warning. Mallory-Weiss tear: A tear in the esophageal or stomach lining, often as a result of vomiting or retching. Mucosal tears also can occur after seizures, forceful coughing or laughing, lifting,

straining, or childbirth. Physicians often find tears in people who have recently binged on alcohol. Cancer: One of the earliest signs of esophageal or stomach cancers may be blood in the vomit or stool. Inflammation: when the mucous membranes break down, they are unable to counteract the harsh effects of stomach acid. Nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, alcohol, and cigarette smoking promote gastric ulcer formation. Helicobacter pylori are a type of bacteria that also promotes formation of ulcers. Gastrointestinal Bleeding Symptoms Acute gastrointestinal bleeding first will appear as vomiting of blood, bloody bowel movements, or black, tarry stools. Vomited blood may look like "coffee grounds." Symptoms associated with blood loss can include: Fatigue Weakness Shortness of breath Abdominal pain Pale appearance Vomiting of blood usually originates from an upper GI source. Bright red or maroon stool can be from either a lower GI source or from brisk bleeding from an upper GI source. Long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black stools, or a positive test for microscopic blood. Diagnosis The diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age < 50 years, and blood urea nitrogen/creatinine ratio 30 or more. In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using the Gastroccult test.

PATIENTS PROFILE Name Age Gender Birthday Address Religion Nationality Civil Status Occupation : : : : : : : : : H.Y.I 68 years old Male November 06, 1944 San Pedro, Laguna Roman Catholic Filipino Married Retired Real Estate Broker

Admitting Date Admitting Time Attending Physician

: : :

November 13, 2012 12:09pm Dr. CF

Final Diagnosis Tuberculosis ongoing treatment

Upper Gastrointestinal Bleeding, Pulmonary

Chief complaint

Weakness and Difficulty of Breathing

Vital Signs upon Admission

Blood Pressure Respiratory Rate Pulse Rate Temperature

: : : :

140/80 mmHg 38 cpm 102 bpm 37.2 C

PATIENTS HISTORY General Data This is a case of H.Y.I., 65 years of age, male, catholic, Filipino, presently residing at San Pedro, Laguna, admitted for the first time in this institution, on November 13, 2012 at 12:09 in the afternoon. Chief complaint: Difficulty of Breathing History of Present Illness: Twenty seven days prior to admission, the patient was admitted in Asian hospital due to DOB, weakness, and persistent fever, history for gastritis, pneumonia, PTB, COPD, DM2, he was discharged improved EGD done, given Myrine P. Forte, Seretide, but mark only 7 days patients condition return the same with weakness, medications are continued until 4 days prior to confinement, he was brought for consult at their family physician where he prescribed Clindamycin, Myrine P. Forte and salbutamol neb. One day prior to confinement (+) vomiting of coffee ground material, stool looked to be black and tarry, he was now with distress and (+) DOB when being seated Past Medical History: (+) Hospitalization on Oct 20, 2012 Gastritis Pneumonia PTB COPD DM type 2 Myeloproliferative Disease Diagnosis: Gastritis, Asthma Personal and Social History: (+) smoker for 25 pack years, stopped at the age of 40 (-) drinker of any alcoholic beverages

Family History: The patient has a no history of DM, HPN, asthma, cancer, heart disease, lung disease, and kidney disease.

PHYSICAL ASSESSMENT ACTUAL FINDINGS PR- 102 RR 38 NORMAL FINDINGS T- 37.2 C O2 sat- 98% - Normocephalic - Smooth - No lumps - Absence of modules or masses - No area of tenderness - Symmetrical with protrusions on the lateral part of parietal forehead and occipital bone. - Whitish - No nits, lice and dandruff - No baldness - Black or brown in color - Hair is evenly distributed - No area of baldness - Thick - Fine - Curly/kinky/straight - Dry/oily/shiny hair

VS: BP 140/80 Head - Normocephalic Skull - No lumps

Scalp

- No nits, lice and dandruff - No baldness

Hair - Straight, black with white hair, oily hair

Face

- Symmetrical with movement - Expressions appropriate to situations - Symmetrical - No cloudiness - No Lacrimation

- Symmetrical with movement - Expressions appropriate to situations - Symmetrical - No protrusions - Dear or no Cloudiness - No excessive Lacrimation - Moves symmetrically - Hair evenly distributed - Skin Intact - Equally distributed - Curved slightly outward - Skin intact

Eyes

Eyebrows

Symmetrical

Eyelashes Eyelids

- Equally distributed - Curved slightly outward - Skin intact

- No discharge - No discoloration - Lids close symmetrically - Approximately 15-20 involuntary blinks per minute; bilateral blinking Lid margins - No secretions - No erythema - No redness

- No discharge - No discoloration - Lids close symmetrically - Approximately 15-20 involuntary blinks per minute; bilateral blinking - No scaling - No secretions - No erythema - No redness - Pink, shiny, with visible blood vessels - No discharges

Lower palpebral - Pink, shiny, with visible blood vessels conjunctiva - No discharges

Sclera

- White in color - Clear - No redness

- White/yellowish in black Americans - Clear, no cloudiness - No redness - Flat - Brown - Even coloration - Symmetrical - Round - Transparent/Shiny - PERRLA(Pupils Equally Round, Reactive to Light & Accommodation

Iris

- Flat - Brown - Round - Transparent/Shiny

Pupils

- PERRLA

Eye Movement

- Moves in unison - coordinated

- Moves in unison - Coordinated

Field of vision *Visual acuity Ear

- Good peripheral vision - 20/20 in both eyes - Parallel with outer canthus of the eyes - Same as the color of the face

- Same as the color of the face

- No swelling

- No swelling - No tenderness - Firm cartilage - Yellowish - Dry/waxy cerumen - Presence of cilia - No foreign body

Ear Canal

- Waxy cerumen - Presence of cilia

Hearing acuity Nose

- With good hearing acuity in both ears - No lesions - Presence of cilia

- With good hearing acuity in both ears - Symmetric and straight - No discharge or flaring - Uniform color - No tenderness - No lesions - Presence of cilia - Uniform pink color(darker, e.g, Bluish hue, in Mediterranean groups and dark-skinned clients) - Soft, moist, smooth texture - Symmetry of contour - Ability to purse lips - No tenderness - Pink, moist - No swelling - No tenderness - No discharges - No retraction(lower and upper) - 32 in number - White - Upper teeth over-rides lower teeth - Pink, even, rough dorsal surface and moist

Lips

- Darker lips - Ability to purse lips - Dry

Gums

- Pink, dry - No swelling - No tenderness - No discharges

Teeth

- Yellowish, 29 in number

Tongue Frenulum

- Pink, even, rough dorsal surface and dry

- Midline

- Midline

- Pinkish - With visible veins Soft Palate Hard Palate Uvula Pink, dry, no swelling/no tenderness -Bony, light pink in color, dry

- Pinkish - With visible veins - Pink, moist, no swelling/no tenderness -Bony, Llght pink in color, moist

-Midline moves when the client says Aah

-Pink, moist -Midline moves when the client says Aah - Pinkish - No discharge - No inflammation - Erect & midline - Same as the skin color - No tenderness - No lymphs, No mass - Symmetrical - Muscles equal in size; head centered - Coordinated, smooth movements with no discomfort - Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive - No edema - No abrasions or other lesions - Freckles, some birthmarks, some flat and raised nevi - When pinched, skin springs back to previous state

Tonsils

- Pinkish - No discharge - No inflammation - Same as the skin color - No lymphs, No mass

Neck

Upper Extremities Skin

- Pale in color, sag and wrinkled - No abrasions or other lesions

Hair

- Black in color, evenly distributed, dandruff noted

Nails

Nails appeared thickened,

- Convex curvature

dirty, yellow in color, > 2 capillary refill

- Smooth texture - Highly vascular and pink in light-skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal streaks - Intact epidermis - Prompt return of pink or usual color(generally less than 4 seconds)

Chest and back Posterior Thorax

- No tenderness - No masses

- Chest symmetric - Skin Intact; uniform temperature - Chest wall intact - No tenderness - No masses - Full and symmetric chest expansion - Vesicular and bronchovesicular sounds - Quiet, rhythmic, and effortless respirations - Full symmetric excursion - Bronchial and tubular breath sounds in the trachea - Vesicular and bronchovesicular breath sounds - Unblemished skin - Uniform color - Silver-white striae or surgical scars - Flat, rounded(convex),or scaphoid (concave) - Symmetric movements caused by respiration - Audible bowel sounds - No tenderness - Relaxed abdomen with smooth, consistent tension

Anterior Thorax

- Full expansion - Tachypnea

Abdomen

- Unblemished skin - Uniform color

 Lower extremities Skin - Brown in color - No abrasions or other lesions - Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive - No edema - No abrasions or other lesions - Freckles, some birthmarks, some flat and raised nevi - when pinched, skin springs back to previous state - Concave curvature - Smooth texture - highly vascular and pink in light-skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal streaks - Intact epidermis - Prompt return of pink or usual color (generally less than 4 seconds)

Nails

- Nails appeared thickened, dirty, yellow in color, > 2 capillary refill

Motor functions:

- Repeatedly and rhythmically touches the nose - Rapidly touches each finger to thumb with each hand - Can readily determine the position of fingers and toes

- Has upright posture and steady gait with opposing arm swing; walks unaided, maintaining balance - May sway slightly but is able to maintain upright posture and foot stance. - Maintain stance for at least 5 seconds - Maintains heel-toe walking along straight line - Repeatedly and rhythmically touches the nose - Rapidly touches each finger to thumb with each hand - Can readily determine the position of fingers and toes

Anus and Rectum

-Anal opening appear hairless, moist, and tightly closed, no redness and swelling noted - Black stool noted (melena) about 6 diapers soaked

ANATOMY AND PHYSIOLOGY

ANATOMY & PHYSIOLOGY Anatomy is the scientific discipline that investigates the structure of the body. The word anatomy means to dissect, or cut apart and separate, the parts of the body for study while physiology is the scientific discipline that deals with the processes or functions of living things. UPPER GASTROINTESTINAL TRACT The gastrointestinal (GI), or digestive, tract extends from mouth to anus. The division of the GI tract into upper and lower is a matter of some confusion and debate. On embryologic grounds, the GI tract should be divided into upper (mouth to major papilla in the duodenum), middle (papilla to mid-transverse colon), and lower (mid-transverse colon to anus) according to the derivation of these 3 areas from the foregut, midgut, and hindgut, respectively. Nevertheless, the GI tract is conventionally divided into upper (mouth to ileum) and lower (cecum to anus). From the point of view of GI bleeding, however, the demarcation between the upper and lower GI tract is the duodenojejunal (DJ) junction; bleeding above the DJ junction is called upper GI bleeding, and that below the DJ junction is called lower GI bleeding. For the purposes of endoscopy, the upper GI tract includes the esophagus, stomach and duodenum (esophagogastroduodenoscopy [EGD] or upper GI endoscopy), and the lower GI tract includes the anus, rectum, colon, and cecum (anoproctocolonoscopy or lower GI endoscopy) Mouth, oral cavity, and pharynx The mouth leads to the oral cavity, which has a vestibule lying between the lips, the cheeks and gums (gingivae), and the teeth. The main oral cavity also lies between the hard and soft palate above, the tongue below, and the alveoli and teeth. The oral cavity leads to the pharynx through the fauces, which contain pharyngeal tonsils (adenoids) and palatine tonsils. Salivary glands (parotid, submandibular, and sublingual) open into the oral cavity. The pharynx extends from the base of the skull above to the cricoid cartilage (at the level of C6) below. It has 3 parts: the nasopharynx (from the base of the skull above to the soft palate below), the oropharynx (from the soft palate above to the hyoid bone below), and the laryngopharynx (from the hyoid bone above to the cricoid cartilage below). The nasal cavity,

oral cavity, and larynx open into the nasopharynx, oropharynx, and laryngopharynx, respectively. The laryngopharynx also has a piriform fossa on either side. Esophagus The esophagus (gullet) is one of the few organs traversing 3 regions of the body--namely, the neck, thorax, and abdomen. Accordingly, it is divided into 3 parts: cervical, thoracic, and abdominal. The esophagus is a 25-cm-long vertical muscular tube that which normally remains collapsed and that runs from the laryngopharynx (throat or hypopharynx) in the neck through the thorax (chest) to the stomach in the abdomen. The cervical esophagus begins at the lower border of the cricoid cartilage (at the level of C6); it is very short (only 5 cm long) and lies in front of C6 and C7 (covered with prevertebral fascia), slightly to the left of the midline. In the neck, the esophagus, along with the trachea (in front of the esophagus) and the thyroid (covering the trachea and the esophagus), is enclosed in a sheath of visceral (deep cervical) fascia. The carotid sheath (containing the common carotid artery, internal jugular vein, and vagus nerve) is on the side of the esophagus; the recurrent laryngeal nerves lie in the tracheoesophageal grooves, and the thoracic duct is to the left of the esophagus. The cervical esophagus continues as the thoracic esophagus at the suprasternal notch. In the superior mediastinum, the esophagus continues to run in front of the vertebral column and behind the trachea and lies behind the aortic arch and to the right of the descending thoracic aorta. The azygos vein crosses the esophagus on the right. In the posterior mediastinum, the esophagus continues behind the left main bronchus and right pulmonary artery and comes to lie in front of the descending thoracic aorta at the esophageal hiatus of the diaphragm; the thoracic duct lies behind it in the posterior mediastinum and to its left in the superior mediastinum. Mediastinal pleurae lie laterally, and the pericardial sac lies anterior to the esophagus. The thoracic esophagus enters the abdomen via the esophageal hiatus in the diaphragm at the level of T10 (see the image below) and has a small (2-3 cm) intra-abdominal length. The esophagogastric junction (cardia), therefore, lies in the abdomen below the diaphragm to the left of the midline at the level of T11. Stomach The cardiac notch (incisura cardiaca gastri) is the acute angle between the intra-abdominal esophagus and the gastric fundus (the part of the stomach above a horizontal line drawn from the cardia). The body (corpus) of the stomach leads to the pyloric antrum (at the incisura angularis), which joins the duodenum at the pylorus, lying at the L1-L2 level (transpyloric plane) to the right of the midline.

Duodenum The duodenum has 4 parts: superior, descending, horizontal, and ascending. The first (superior) part, or bulb (5 cm), is connected to the undersurface of the liver (porta hepatis) by the hepatoduodenal ligament (HDL), which contains the proper hepatic artery, portal vein, and common bile duct (CBD); the quadrate lobe of the liver and gallbladder are in front, and the CBD), portal vein, and gastroduodenal artery (GDA) are behind. The second (descending) part, or C loop (10 cm), which has an upper and a lower genu (flexure), is composed of the transverse mesocolon and colon in front and the right kidney and inferior vena cava (IVC) behind; the head of the pancreas lies in the concavity of the C. The third (horizontal) part (7.5 cm) runs from right to left in front of the inferior vena cava (IVC) and aorta, with superior mesenteric vessels (the vein on the right and the artery on the left) in front. The fourth (ascending) part (2.5 cm) continues as the jejunum. The duodenum continues into the jejunum at the duodenojejunal flexure. The rest of the small bowel is a convoluted tube about 4-6 m long that occupies the center of the abdomen and the pelvis, surrounded on 2 sides and above by the colon. The ileum continues into the large intestine at the ileocecal junction. Gastrointestinal physiology Gastrointestinal physiology is a branch of human physiology addressing the physical function of the gastrointestinal (GI) system. The major processes occurring in the GI system are that of motility, secretion, regulation, digestion and circulation. The function and coordination of each of these actions is vital in maintaining GI health, and thus the digestion of nutrients for the entire body. Motility The GI tract generates motility using smooth muscle subunits linked by gap junctions. These subunits fire spontaneously in either a tonic or a phasic fashion. Tonic contractions are those contractions that are maintained from several minutes up to hours at a time. These occur in the sphincters of the tract, as well as in the anterior stomach. The other type of contractions, called phasic contractions, consist of brief periods of both relaxation and contraction, occurring in the posterior stomach and the small intestine, and are carried out by the muscularis externa.

Stimulation The stimulation for these contractions likely originates in modified smooth muscle cells called interstitial cells of Cajal. These cells cause spontaneous cycles of slow wave potentials that can cause action potentials in smooth muscle cells. They are associated with the contractile smooth muscle via gap junctions. These slow wave potentials must reach a threshold level for the action potential to occur, whereupon Ca2+ channels on the smooth muscle open and an action potential occurs. As the contraction is graded based upon how much Ca 2+ enters the cell, the longer the duration of slow wave, the more action potentials occur. This in turn results in greater contraction force from the smooth muscle. Both amplitude and duration of the slow waves can be modified based upon the presence of neurotransmitters, hormones or other paracrine signaling. The number of slow wave potentials per minute varies based upon the location in the digestive tract. This number ranges from 3 waves/min in the stomach to 12 waves/min in the intestines. Contraction Patterns The patterns of GI contraction as a whole can be divided into two distinct patterns, peristalsis and segmentation. Occurring between meals, the migrating motor complex is a series of peristaltic waves cycles in distinct phases starting with relaxation followed by an increasing level of activity to a peak level of peristaltic activity lasting for 5 15 minutes.This cycle repeats every 1.52 hours but is interrupted by food ingestion. The role of this process is likely to clean excess bacteria and food from the digestive system. Peristalsis Peristalsis Animation Peristalsis is one of the patterns that occur during and shortly after a meal. The contractions occur in wave patterns traveling down short lengths of the GI tract from one section to the next. The contractions occur directly behind the bolus of food that is in the system, forcing it toward the anus into the next relaxed section smooth muscle. This relaxed section then contracts, generating smooth forward movement of the bolus at between 225 cm per second. This contraction pattern depends upon hormones, paracrine signals, and the autonomic nervous system for proper regulation. Segmentation Segmentation also occurs during and shortly after a meal within short lengths in segmented or random patterns along the intestine. This process is

of

carried out by longitudinal muscles relaxing while circular muscles contract at alternating sections thereby mixing the food. This mixing allows food and digestive enzymes to maintain a uniform composition, as well as to ensure contact with the epithelium for proper absorption. Secretion Every day, seven liters of fluid are secreted by the digestive system. This fluid is composed of four primary components: ions, digestive enzymes, mucus, and bile. About half of these fluids are secreted by the salivary glands, pancreas, and liver, which compose the accessory organs and glands of the digestive system. The rest of the fluid is secreted by the GI epithelial cells. Ions The largest component of secreted fluids is ions and water, which are first secreted and then reabsorbed along the tract. The ions secreted primarily consist of H+, K+, Cl-, HCO3- and Na+. Water follows the movement of these ions. The GI tract accomplishes this ion pumping using a system of proteins that are capable of active transport, facilitated diffusion and open channel ion movement. The arrangement of these proteins on the apical and basolateral sides of the epithelium determines the net movement of ions and water in the tract. H+ and Cl- are secreted by the parietal cells into the lumen of the stomach creating acidic conditions with a low pH of 1. H+ is pumped into the stomach by exchanging it with K +. This process also requires ATP as a source of energy; however, Cl- then follows the positive charge in the H+ through an open apical channel protein. HCO3- secretion occurs to neutralize the acid secretions that make their way into the duodenum of the small intestine. Most of the HCO3- comes from pancreatic acinar cells in the form of NaHCO3 in an aqueous solution.This is the result of the high concentration of both HCO3- and Na+ present in the duct creating an osmotic gradient to which the water follows. Digestive Enzymes The second vital secretion of the GI tract is that of digestive enzymes that are secreted in the mouth, stomach and intestines. Some of these enzymes are secreted by accessory digestive organs, while others are secreted by the epithelial cells of the stomach and intestine. While some of these enzymes remain embedded in the wall of the GI tract, others are secreted in an inactive proenzyme form. When these proenzymes reach the lumen of the tract, a factor specific to a particular proenzyme will activate it. A prime example of this is pepsin, which is secreted in the stomach by chief cells. Pepsin in its secreted form is inactive (pepsinogen). However, once it reaches the gastic lumen it becomes activated into pepsin by the high H+ concentration, becoming an enzyme vital to digestion. The release of the enzymes is regulated by neural, hormonal, or paracrine signals. However, in general, parasympathetic stimulation increases secretion of all digestive enzymes.

Mucus Mucus is released in the stomach and intestine, and serves to lubricate and protect the inner mucosa of the tract. It is composed of a specific family of glycoproteins termed mucins and is generally very viscous. Mucus is made by two types of specialized cells termed mucus cells in the stomach and goblet cells in the intestines. Signals for increased mucus release include parasympathetic innervations, immune system response and enteric nervous system messengers. Bile Bile is secreted into the duodenum of the small intestine via the common bile duct. It is produced in liver cells and stored in the gall bladder until release during a meal. Bile is formed of three elements: bile salts, bilirubin and cholesterol. Bilirubin is a waste product of the breakdown of hemoglobin. The cholesterol present is secreted with the feces. The bile salt component is an active non-enzymatic substance that facilitates fat absorption by helping it to form an emulsion with water due to its amphoteric nature. These salts are formed in the hepatocytes from bile acids combined with an amino acid. Other compounds such as the waste products of drug degradation are also present in the bile. Regulation The digestive system has a complex system of motility and secretion regulation which is vital for proper function. This task is accomplished via a system of long reflexes from the central nervous system (CNS), short reflexes from the enteric nervous system (ENS) and reflexes from GI peptides working in harmony with each other. Long Reflexes Long reflexes to the digestive system involve a sensory neuron sending information to the brain, which integrates the signal and then sends messages to the digestive system. While in some situations, the sensory information comes from the GI tract itself; in others, information is received from sources other than the GI tract. When the latter situation occurs, these reflexes are called feed forward reflexes. This type of reflex includes reactions to food or danger triggering effects in the GI tract. Emotional responses can also trigger GI response such as the butterflies in the stomach feeling when nervous. The feed forward and emotional reflexes of the GI tract are considered cephalic reflexes. Short Reflexes Control of the digestive system is also maintained by ENS, which can be thought of as a digestive brain that can help to regulate motility, secretion and growth. Sensory information from the digestive system can be received, integrated and acted upon by the enteric system

alone. When this occurs, the reflex is called a short reflex. Although this may be the case in several situations, the ENS can also work in conjunction with the CNS; vagal afferents from the viscera are received by the medulla, efferents are affected by the vagus nerve. When this occurs, the reflex is called vagovagal reflex. The Myenteric plexus and Submucosal plexus are both located in the gut wall and receive sensory signals from the lumen of the gut or the CNS. GI peptides GI peptides are signal molecules that are released into the blood by the GI cells themselves. They act on a variety of tissues including the brain, digestive accessory organs, and the GI tract. The effects range from excitatory or inhibitory effects on motility and secretion to feelings of satiety or hunger when acting on the brain. These hormones fall into three major categories, the gastrin and secretin families, with the third composed of all the other hormones unlike those in the other two families. Further information on the GI peptides is summarized in the table below. RESPIRATORY SYSTEM Breathing is necessary because all living cells of the body require oxygen and produce carbon dioxide. The respiratory system allows the exchange of these gases between the air and the blood. And the cardiovascular system transports them between the lungs and the cells of the body. The capacity to carry out normal activity is reduced without healthy respiratory and cardiovascular systems. Function: 1. Gas Exchange. The respiratory system allows oxygen from the air to enter the blood and carbon dioxide to leave the blood and enter the air. The cardiovascular system transports oxygen from the lungs to the cells of the body and carbon dioxide from the cells of the body to the lungs. Thus, the respiratory and cardiovascular systems work together to supply oxygen to all cells and to remove carbon dioxide. 2. Regulation of blood pH. The respiratory system can alter blood pH by changing blood carbon dioxide levels. 3. Voice Production. Air movement past the vocal folds makes sound and speech possible. 4. Olfaction. The sensation of smell occurs when airborne molecules are drawn into the nasal cavity. 5. Protection. The respiratory system provides protection against some microorganisms by preventing their entry into the body and by removing them from the respiratory surfaces.

Upper Respiratory system The upper respiratory system consists of the nostrils (external nares), nasal cavity, nasal vestibule, nasal septum, both hard and soft palate, nasopharynx, pharynx, larynx and trachea. Within the nostrils, course hairs protect us from dust, insects and sand. The hard palate serves to separate the oral and nasal cavities. There is a protective mucous membrane that lines the naval cavities and other parts of the respiratory tract. It is secreted over the exposed surfaces and then the cilia sweep that mucus and any microorganisms or debris to the pharynx, so it is swallowed and then destroyed in stomach acids. Lower Respiratory system The trachea branches off into what is known as the bronchi (more commonly called bronchial tubes). These two main bronchi have branches forming the bronchial tree. Where it enters the lung, there is then secondary bronchus. In each lung, the secondary bronchi divide into tertiary bronchi and in turn these divide repeatedly into smaller bronchioles. The bronchioles control the ratio of resistance to airflow and distribution of air in our lungs. The bronchioles open into the alveolar ducts. Alveolar sacs are at the end of the ducts. These sacs are chambers that are connected to several individual alveoli, which make up the exchange surface of the lungs. The Lungs

The human respiratory system has two lungs, which contain lobes separated by deep fissures. Surprisingly, the right lung has three lobes while the left one has only two lobes. The lungs are made up of elastic fibers that gives it the ability to handle large changes in air volume. The pleural cavity is where the lungs are located. The diaphragm is the muscle that makes up the floor of the thoracic cavity and plays a major role in the pressure and volume of air moving in and out of the lungs.

How they work Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vesselcalled capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Travelling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

Blood Supply The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs. The Pleurae The lungs are covered by smooth membranes that we call pleurae. The pleurae have two layers, a 'visceral' layer which sticks closely to the outside surface of your lungs, and a 'parietal' layer which lines the inside of your chest wall (ribcage). The pleurae are important because they help you breathe in and out smoothly, without any friction. They also make sure that when your ribcage expands on breathing in; your lungs expand as well to fill the extra space.

The Diaphragm and Intercostal Muscles When you breathe in (inspiration), your muscles need to work to fill your lungs with air. The diaphragm, a large, sheet-like muscle which stretches across your chest under the ribcage, does much of this work. At rest, it is shaped like a dome curving up into your chest. When you breathe in, the diaphragm contracts and flatten out, expanding the space in your chest and drawing air into your lungs. Other muscles, including the muscles between your ribs (the intercostal muscles) also help by moving your ribcage in and out. Breathing out (expiration) does not normally require your muscles to work. This is because your lungs are very elastic, and when your muscles relax at the end of inspiration your lungs simply recoil back into their resting position, pushing the air out as they go.

PATHOPHYSIOLOGY

MEDICAL MANAGEMENT

DATE & TIME November 13, 2012 (1:30pm)

PROGRESS NOTES BP: 100/70 mmHg PR: 135 bpm RR: 30 cpm T: 37 C CBG: 183

DOCTORS ORDER Please admit to ICU under the service of Dr. CF Please secure consent for admission and management

RATIONALE

NURSING RESPONSIBILITIES

Informed Make sure that consent stems the patient from the legal understood the and ethical consent and he right the signed it. patient has to decide what is done to his or her body, and from the physician's ethical duty to make sure that the patient is involved in decisions about his or her own health care to monitor vital signs

TPR q shift and record please

To obtain baseline data and to know the present condition of the patient

Check patients vital signs accurately and record. Relay any abnormalities to the physician

NPO temporarily IVF: PNSS 1L x 40 cc/hr To maintain balance between the Maintain the flow of the IV Fluid. Place the patient

fluid and electrolytes. To prevent dehydration.

on the proper position to prevent obstruction on the IV flow. Assist and inform patient about the needed preparation in every procedure. Relay the samples needed to medical technologist and inform the doctor once the result is available or if there is any abnormalities Observe the ten rights in giving medications

Labs: CBC with PLT, Na K Creatinine ALT PT& PTT ABO blood typing CBC now then q 4 hours while on NPO, UA, 12L ECG, CXR PA

To help the physician confirm diagnosis and to check other patients condition

Impression: UGIB prob 2 DM 2, newly diagnosed

Medications: - Give Pantoloc 80mg IV now then start Pantoloc drop: D5W 200cc + 80mg Pantoloc x 12 hours - Sucralfate g/tab - Humulin N 10 u SC 30mins BS, hold for CBG < 100 - Humulin N 6 u SC 30mins BS, hold for CBG <110 Continue pt. meds: myrin p forte 4 tabs BB Transfuse 4 units FWB properly typed and cross matched to run for 4 hours

For pharmacologic management and continuity of care

For the rapid The nurse is and effective responsible for restoration of insuring that the an adequate right unit of blood blood volume is to be and to administered to maintain blood the right patient composition after typing and within safe crossmatching by limits with the lab. Before

regard to homeostasis, oxygen carrying capacity, oncotic pressure and biochemistry

administering the unit, the nurse has to get consent forms signed by the patient or a qualified representative of the patient. The nurse has to take a complete set of vital signs for a baseline. After starting the transfusion, the vital signs must be checked after 15 minutes, then 30 minutes from then, then at one hour. Then vital signs must be checked every hour. If a reaction occurs, then the transfusion must be stopped immediately and normal saline infused. Properly identify the patient and check for proper blood type and crossmatching

Stand by 3 u PRBC properly typed and cross matches

For possible blood transfusion

O2 inhalation via nasal cannula @ 2lpm

Provide adequate oxygen

Administer O2 with caution and carefully assess its effect on patient

Hook to cardiac monitor and pulse oxymeter

 V/S q 1 hour

To assess any changes in the patients condition

Obtained and record v/s ; report if there are some changes

Accurate I & O q shift and record please

Maintaining fluid balance

Report for any abnormal findings

WOF hypotension, change in sensorium

Signs that patient is in shock

Assess patients blood pressure and level of consciousness Explain to patient the need and the procedure to be done on him.

Insert NGT do gastric lavage

For cleaning out the contents of stomach and for collecting stoma acid for test For proper documentatio n

Complete patient database c/o MICC

AP informed of this admission via phone call Refer accordingly. To treat any possible complications or problems Refer to the physician properly and have the right documentation towards the patient

3:00pm

For PBS (save smear pls.) prior to BT Repeat CXR To check if there is any Inform the patient about the

changes in patients condition and compare it to the previous result

procedure and properly drape the patient during the procedure for patients privacy.

Transfuse 1 u FWB & 3 u PRBC properly typed and cross matched to run for 4 hours

For the rapid The nurse is and effective responsible for restoration of insuring that the an adequate right unit of blood blood volume is to be and to administered to maintain blood the right patient composition after typing and within safe crossmatching by limits with the lab. Before regard to administering the haemostasis, unit, the nurse has oxygen to get consent carrying forms signed by capacity, the patient or a oncotic qualified pressure and representative of biochemistry the patient. The nurse has to take a complete set of vital signs for a baseline. After starting the transfusion, the vital signs must be checked after 15 minutes, then 30 minutes from then, then at one hour. Then vital signs must be checked every hour; If a reaction occurs, then the transfusion must be stopped

immediately and normal saline infused. Tranexamic acid 500mg IV q 8 hours CBR with no BRP To decrease oxygen demand of body Instruct properly the patient

Increase IVF rate to 80cc/hr, decrease KVO during BT

Maintain the flow of the IV Fluid. Place the patient on the proper position to prevent obstruction on the IV flow.

For Hgba1c defer (+) anemia Facilitate blood transfusion ASAP

5:20pm

Facilitate BT stat Repeat CBC with platelet at 12mn To check if there is any changes in patients condition and compare it to the previous result

NPO Vitamin K 1amp IV q 8 hours x 3 doses Salbutamol nebulization q 1 x For Advise patient not

3 doses

bronchodilatio n

to eat before and after nebulization

Repeat K at 12mn

6:00pm

Instead of Salbutamol, use Ipratropium + salbutamol nebulization

(+) melena 120cc

2 more u PRBC on standby @ all time

For possible blood transfusion

Properly identify the patient and check for proper blood type and crossmatching

Increase IVF rate to 12-cc/hr KVO during BT NPO except meds Amoxicillin 500mg 2 caps BID Clorithromycin 500mg/tab BID Intensive PPI

10:10pm

PR: 130 bpm RR: 20 cpm (-) DOB, crackles Flat neck veins

Transfuse next blood product after 2 hours Coralan 5mg tab BID hold for HR <60 IVF to ff: D5NSS 1L x 60cc/hr shift to PNSS 500cc x KVO during BT To maintain balance between the fluid and electrolytes. To prevent dehydration. Maintain the flow of the IV Fluid. Place the patient on the proper position to prevent obstruction on the IV flow.

 o o o o o

Start Humulin R sliding scale Hum R SC CBG 2 u > 160 3 u > 180 4 u > 200 5 u > 250

Relay labs at 12mn. Please facilitate Pantoprazole drip TF: D5W 250cc + 80mg Pantoprazole x 12 hours Save smear for PBS for future review pls. Refer

November 14, 2012 (7:00am)

BP: 130/90 mmHg PR: 115 bpm RR: 20 cpm (+) pallor (-) epigastric pain (+) melena 5x total of 200cc Dry lips Ongoing 3rd unit of blood (1st FWB, 2nd PRBC)

Please give another Pantoprazole 40 mg IV now Insert another line and hook PNSS 1L x 40cc/hr To maintain balance between the fluid and electrolytes. To prevent dehydration. Maintain the flow of the IV Fluid. Place the patient on the proper position to prevent obstruction on the IV flow.

Monitor Hgb, Hct q 12 hours, start serial monitoring after 3rd unit of blood was transfused Increase IVF with PNSS 1L to 120cc/ht ALL IVF to KVO during BT

 Fast drip 200cc PNSS now Make stand by PRBC 4 u instead of 2u PRBC Refer AP updated

12:10pm

Hold Humulin N temporarily IVF TF: D5NSS 1L x 10 u Humulin R to run for 100cc/hr

Give Humulin R 4 u SC for CBG >200 mg/dL D/C Humulin R sliding scale Decrease CBG to q 6 hours Maintain on NPO strictly

Transfuse another 2 units PRBC properly typed and cross matches Will assessed pt. first after the 3rd PRBC BT before BT of another unit

6:15pm

Rounds with Dr. B. Go ahead with 2 u PRBC BT Maintain on NPO shift antibiotic to: o Levofloxacin 500g IV OD

o Metronidazole 500mg IV q 8 hours ANST (-) Stand by another 2 u PRBC (4 u) PRBC

November 15, 2012 (7:30am)

BP: 150/90 mmHg PR: 107 bpm Total of 5 - FWB - PRBC (-) chest pain, abdominal pain

Transfuse another 2 u PRBC each unit to run for 4 hours with blood of 2 hours Stand by 4 u PRBC Refer for BT reaction or congestion AP updated Refer accordingly

8:30am

BP: 150-170/80- Start of T160 C200 P80 F53 90 mmHg divided into 4 equal feedings PR: 103 bpm RR: 20 cpm Once OF is started Clear breath o Shift mainline IVF to PNSS sounds 1L x 60cc/hr Decrease pallor o BT line to keep on KVO Hgb 85-93 o Continue Hum R 4 u SC q 6 hours to CBG >200 o Start Humulin N 10 u SC BB, BS, hold for CBG <120 mg/dL Start Losartan 25mg OD hold for SBP <110 Hold Ampicillin, Clorithromycin Follow up PBS present and relay - done

LABORATORY EXAMINATION November 13, 2012 URINALYSIS o Also known as Routine and Microscopy (R&M) is an array of tests performed on urine, and one of the most common methods of medical diagnosis. TEST Color Transparency Reaction (pH) Protein Glucose Specific Gravity Pus cells RBC Mucus Threads RESULT Yellow Slight Hazy 5.0 Negative Negative 1.020 1 3 / HPF 0 - 2 / HPF Few NORMAL VALUES Clear Straw Yellow Clear - Hazy 4.5 - 8 Negative Negative 1.003 1.030 0 -10 mm3 0 3 HPF INTERPRETATION NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

BLOOD TYPING AND CROSSMATCHING o Blood typing is a laboratory test done to determine a person's blood type. If the person needs a blood transfusion, another test called cross matching is done after the blood is typed to find blood from a donor that the person's body will accept.

Patients name: H.Y.I Patients Blood Type: O Rh (D) Positive Donors Blood Type: O Rh (D) Positive Blood Component: Whole Blood Blood Serial #: UPH-12-1490 Date of Extraction: 10-31-12 @ 10:30am Date of Expiration: 12-05-12 @ 10:30am Date Crossmatched: November 13, 2012 Cross matched by: D. RMT Major Cross matching: No agglutination seen/compatible Minor Cross matching: No agglutination seen/compatible

ARTERIAL BLOOD GAS o ABGs measure how well the lungs can provide adequate oxygen to the body and subsequently remove carbon dioxide. Analysis of blood gases helps evaluate a person's respiratory and metabolic status. ABGs also measure blood pH and the integrity of the body's acid-base balance.

12:00nn TEST RR Temperature Site pH pCO2 RESULT NORMAL VALUES 35 cpm 38.3 C RBA 7.580 21.4 mmHg DECREASED 7.35 7.45 35 45 mmHg INTERPRETATION

pO2

135 NORMAL

80 100 (<60y/o) Respiratory Alkalosis Partially Compensated

HCO3 BE O2Sat

19.9 mmol/L DECREASED -2 99

22 26 mmol/L

+/-3 95 - 100

NORMAL

COMPLETE BLOOD COUNT AND PLATELET HEMATOLOGY o The branch of internal medication that is concerned with the study of blood. It is used to determine any abnormalities in the patients blood components.

1:19pm TEST NAME Hemoglobin RESULT 57.4 gm/L NORMAL VALUES 120 150 gm/L INTERPRETATION DECREASED (patient suffers from anemia due to upper GI bleeding) DECREASED (patient suffers from anemia due to upper GI bleeding)

Hematocrit

0.176 L/L

0.400 0.540 L/L

RBC WBC Segmenters Neutrophils Eosinophils Lymphoctyes Monocytes Basophils MCV MCH MCHC Platelet

2.19 x 10 /L 8.24 x 109/L .78 x 109/L 6.61 x 109/L 0.002 x 109/L 1.43 x 109/L 0.133 x 109/L 0.060 80.4 fl 26.2 pg 326 g/L 835 x 109/L

12

4 5.6 x 10 /L 5.0 10.0 x 109/L 0.50 - 0.70 x 109/L 1.63 6.96 x 109/L 0.030 0.440 x 109/L 1.09 2.99 x 109/L 0.240 0.790 x 109/L 0.00 0.80 x 109/L 80 98 fl 26 32 pg 32 360 g/L 150 - 400 x 109/L

12

DECREASED (patient suffers from anemia due to upper GI bleeding) NORMAL INCREASED (due to a presence of bacterial infection) NORMAL DECREASED (due to a presence of bacterial infection) NORMAL DECREASED (due to a presence of bacterial infection) NORMAL NORMAL NORMAL NORMAL INCREASED (indicates that there is a systemic response that forms clot to the bleeding site

FECALYSIS o Fecalysis is also known as stool analysis. It refers to a series of laboratory tests done on fecal samples to analyze the condition of a person's digestive tract in general. Among other things, a fecalysis is performed to check for the presence of any reducing substances such as white blood cells (WBCs), sugars, or bile and signs of poor absorption as well as screen for colon cancer. 1:48pm TEST NAME Color Cosistency RESULT Reddish brown Watery NORMVAL VALUES Brown Soft and bulky, small and dry, depends on diet None 0 HPF INTERPRETATION Due to upper gastro intestinal bleeding Due to diarrhea

Ova/Parasite Prese

None found 0 3 / HPF

NORMAL Presence of infection

RBC CLINICAL CHEMISTRY REPORT

1 2 / HPF

0 HPF

Indicates bleeding

BLOOD CHEMISTRY o Part of a diagnostic work up with the blood being analyzed to check for specific elements which could contribute clues to the diagnostic

3:14pm TEST NAME RESULT NORMAL RANGE INTERPRETATION INCREASED (BUN level because of absorption of degraded blood during intestinal transit) NORMAL INCREASED (indicates hyperkalemia) DECREASED (indicates hyponatremia and body weakness) NORMAL

BUN

15.07 mmol/L

2.5 6.4 mmol/L

Creatinine Potassium

99.88 mmol/L 5.59 mmol/L

53 133 mmol/L 3.5 5.1 mmol/L

Sodium ALT November 14, 2012

133.24 mmol/L 21.00 u/L

136 145 mmol/L 10 40

COMPLETE BLOOD COUNT AND PLATELET HEMATOLOGY o The branch of internal medication that is concerned with the study of blood. It is used to determine any abnormalities in the patients blood components.

1:04am TEST NAME Hemoglobin Hematocrit RESULT 58 gm/L 0.174 L/L NORMAL RANGE 120 150 gm/L 0.400 0.540 L/L INTERPRETATION DECREASED patient suffers from anemia due to upper GI bleeding) DECREASED patient suffers from anemia due to upper GI

RBC WBC Neutrophils Eosinophils Lymphoctyes Basophils Monocytes MCV MCH MCHC Platelet

2.17 x 1012/L 10.2 x 109/L 7.48 x 109/L 0.036 x 109/L 0.14 x 109/L 0.111 0.220 x 109/L 80.4 fl 26.8 pg 333 g/L 746 x 109/L

4 5.6 x 1012/L 5.0 10.0 x 109/L 1.63 6.96 x 109/L 0.030 0.440 x 109/L 1.09 2.99 x 109/L 0.00 0.80 x 109/L 0.240 0.790 x 109/L 80 98 fl 26 32 pg 320 360 g/L 150 - 400 x 109/L

bleeding) DECREASED patient suffers from anemia due to upper GI bleeding) SLIGHTLY INCREASED (due to a presence of bacterial infection) INCREASED (due to a presence of bacterial infection) NORMAL DECREASED (due to a presence of bacterial infection) Normal DECREASED (due to a presence of bacterial infection) NORMAL NORMAL NORMAL INCREASED (due to a presence of bacterial infection)

CLINICAL CHEMISTRY REPORT BLOOD CHEMISTRY o Part of a diagnostic work up with the blood being analyzed to check for specific elements which could contribute clues to the diagnostic

1:27am TEST NAME Potassium RESULT 4.54 mmol/L NORMAL RANGE 3.5 5.1 mmol/L INTERPRETATION NORMAL

HEMATOLOGY o The branch of internal medication that is concerned with the study of blood. It is used to determine any abnormalities in the patients blood components. RESULT 93.5 gm/L 0.315 L/L NORMAL RANGE 120 150 gm/L 0.400 0.540 L/L INTERPRETATION DECREASED patient suffers from anemia due to upper GI bleeding) DECREASED patient suffers from anemia due to upper GI

TEST NAME Hemoglobin Hematocrit

bleeding)

DIAGNOSTIC EXAMINATION

DRUG STUDY

DRUG NAME Generic name: pantoprazole Brand name: Pantoloc Classification: Proton pump inhibitor Dosage: 40 mg Route: IV Frequency: Stat

ACTION Inhibits both basal and stimulated gastric acid secretion by suppressing the basic step in acid production, through the inhibition of the proton pump by binding to and inhibiting hydrogenpotassium ATP, the enzyme system located at the secretory surface of the gastric parietal cell.

INDICATION Duodenal and gastric ulcer, moderate and severe reflux esophagitis. Symptomatic improvement and healing of mild reflux esophagitis. Prevention of gastroduodenal ulcers induced by NSAID in patients at risk with a need for continuous NSAID treatment.

CONTRAINDICATION Hypersensitivity. Moderate to severe hepatic or renal dysfunction.

ADVERSE REACTION Headache, insomnia, diarrhea, abdominal pain, flatulence, rash, hyperglycemia

NURSING CONSIDERATION Monitor hepatic enzymes: AST, ALT, alkaline phosphatase during treatment. Instruct patient to take drug as prescribed and approximately the same time each day. Tell patient to swallow tablet whole, not crushed, split or chewed. Inform patient that antacid do not affect drug absorption. Advice patient to report persistence of symptoms diarrhea, bleeding and tarry stools. Advice patient not to drink alcohol, eat food or take drugs (aspirin, NSAIs) that could cause gastric irritation.

DRUG NAME Generic name: Metronidazole Brand name: Flagyl Classification: Antiprotozoals; Amebicides Dosage: 500 mg Route: IV Frequency: q 8

ACTION Direct-acting trichomonacide and amebicide that works inside and outside the intestines. Its thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis, causing cell death.

INDICATION Infections in the intra-abdominal, skin structure, bacterial septicemia, lower respiratory system and endocarditis. Treatment of susceptible protozoal infections in the treatment and prophylaxis of anaerobic bacterial infections.

CONTRAINDICATION Blood dyscrasias. Hypersensitivity to imidazole

ADVERSE REACTION Headache, seizure, fever, dizziness, edema, nausea, abdominal cramping, vomiting, diarrhea

NURSING CONSIDERATION Assess for allergic reactions: rash, uticaria, pruritus. Monitor renal function and bowel pattern. Inform client that drug can cause metallic taste and urine may appear dark. Instruct patient not to take alcohol or drugs that contain alcohol during therapy and at least 48 hrs after therapy is completed because of disulfiram-like reaction to alcohol ingestion. Report severe GI upset, dizziness, unusual fatigue or weakness, fever or chills.

DRUG NAME

ACTION

INDICATION

CONTRAINDICATION

ADVERSE REACTION

NURSING CONSIDERATION Advice patient to continue taking drug as prescribed for the length of time ordered. Advice patient to take drug with plenty of fluids at least 2 L per day Inform patient that toxicity may result if drug is used with theophylline. Advice patient to rinse mouth frequently and use sugarless candy or gum for dry mouth Instruct diabetic patient to monitor glucose levels, hypoglycemic reaction may indicate need to stop medications. Advice patient to avoid sun exposure to prevent phototoxicity.

Generic name: Levofloxacin Brand name: Levox Classification: Quinolones Dosage: 500 mg Route: IV Frequency: OD

Semisynthetic antibacterial agent that inhibits anti bacteria DNA gyrase, necessary for supercoiling of the DNA, thereby preventing DNA replication, transcription, repair and recombinationin susceptible bacteria.

Infections cause by susceptible strains of microorganisms in acute maxillary sinusitis, actibacterial exacerbation of chronic bronchitis, CAP, nosocomial pneumonia, uncomplicated skin and uncomplicated urinary tract infection and acute pyelonephritis.

Epilepsy History of tendon disorders related to fluoroquinolone therapy. Hypersensitivity to levofloxacin

Nausea, Diarrhea, Headache, Dizziness, Insomnia, Musculoskeletal effects, Pain, Reddening of infusion site , Phlebitis, increase in fungal overgrowth

DRUG NAME Generic name: Losartan Brand name: Lifezar Classification: Antihypertensive; angiotensin II antagonist Dosage: 25 mg Route:PO Frequency: OD

ACTION Selectively blocks the binding of angiotensin II to receptor sites in many tissues, especially the vascular smooth muscles and adrenal glands. This prevents the vasoconstricting and aldosteronesecreting effects of angiotensin II on these tissues.

INDICATION Treatment of hypertension. Renal protection in type 2 diabetic patients with protenuria.

CONTRAINDICATION Renal artery stenosis, hyperkalemia, hypersensitivity, anuria,

ADVERSE REACTION Dizziness, orthostatic hypotension, impaired renal function, hyperkalemia, facial edema, fever, angina pectoris

NURSING CONSIDERATION Assess patients blood pressure, hold for SBP <110 Obtain baseline liver and renal function before therapy Assess for hydration status Tell patients to avoid sodium substitutes because they may contain potassium which can cause hyperkalemia in taking the drug Inform patient that drug may cause dizziness, fainting or light headedness, caution patient to rise slowly to sitting or standing to prevent orthostatic hypotension

DRUG NAME Generic name: Ivabradine Brand name: Coralan Classification: Anti-anginal Dosage: 5 mg, tab Route:PO Frequency: BID

ACTION Ivabradine is a pure heart rate-lowering agent, acting by selective and specific inhibition of the cardiac pacemaker If current that controls the spontaneous diastolic depolarization in the sinus node and regulates heart rate. The cardiac effects are specific to the sinus node with no effect on intra-atrial, atrioventricular or intraventricular conduction times, nor on myocardial contractility or ventricular repolarization.

INDICATION Treatment of CAD: Symptomatic treatment of chronic stable angina pectoris in coronary artery disease patients with normal sinus rhythm. Indicated in patients unable to tolerate or with a contraindication to the use of -blockers or in combination with -blockers in patients inadequately controlled with an optimal -blocker dose and whose heart rate is >60 bpm.

CONTRAINDICATION Hypersensitivity to ivabradine or to any excipients of Coralan; resting heart rate of <60 bpm prior to treatment; cardiogenic shock; acute myocardial infarction; severe hypotension (<90/50 mm Hg); severe hepatic insufficiency; sick sinus syndrome; sino-atrial block

ADVERSE REACTION Luminous Phenomena, Bradycardia, Sinus arrhythmia, unstable angina, aggravated angina pectoris, atrial fibrillation, myocardial ischemia, myocardial infarction and ventricular tachycardia, Nausea, constipation and diarrhea

NURSING CONSIDERATION Assess patients HR, hold for HR <60bpm Monitor regularly for atrial flutter occurrence while taking this medication. Inform patient that this drug may cause blurred vision, do not drive a car or operate machinery while taking this medication.

DRUG NAME Generic name: Amoxicillin Brand name: Amoxil Classification: Antibiotics; penicillin Dosage: 500mg, 2caps Route:PO Frequency: BID

ACTION Prevents bacterial cell wall synthesis during replication. Bactericidal

INDICATION Treatment of infections of respiratory tract, skin structures, GUT and bacterial endocarditis prophylaxis

CONTRAINDICATION Hypersensitivity to penicillins, cephalosporins. Not used to treat severe pneumonia, empyema, pericarditis , purulent or septic arthritis suring acute stage.

ADVERSE REACTION Dizziness, fatigue, insomnia, reversible hyperacidity, urticaria, maculopapular to exfoliative dermatitis, neuropathy, anorexia, nausea, vomiting, abdominal pain/cramps, bloody diarrhea

NURSING CONSIDERATION Obtain patients history of allergy Assess patients signs and symptoms of infection Assess for bowel patterns for possible bloody diarrhea Advice patient to watch for and report signs of superinfection like loose fouls smelling stools or furry tongue If GI upset occur, take this drug with meals

DRUG NAME Generic name: Phytomenadione Brand name: Konakion MM Classification: Hemostatics Dosage: 1 amp Route:IV Frequency: q 8hrs x 3 doses

ACTION Synthetic analog of Vitamin K whch is essential in clotting factors II, VII, IX, X.

INDICATION

CONTRAINDICATION

ADVERSE REACTION Hypotension, cyanosis, headache, dizziness.

NURSING CONSIDERATION Assess bleeding: bruising, hematuria, black tarry stools and hematemesis Monitor prothrombin-time suring the treatment Stress the need for periodic lab tests to monitor coagulation levels Instruct patient to avoid use of hard toothbrush, flossing, razors and sharp objects until treatment id terminated Instruct patient to report symptoms of bleeding: bruising, nosebleed, blood in urine or black tarry stool

Vitamin K compounds Pronounced allergic are used in the diathesis. treatment and prevention of hemorrhage associated with vitamin K deficiency. The dose of Vitamin K should be carefully controlled by prothrombin-time estimations. It is the only vitamin K compound used to reverse hypoprothrombinemia and hemorrhage caused by anticoagulant therapy.

DRUG NAME Generic name: Rifampicin/isoniazid/ Pyrazinamide/ ethambutol Brand name: Myrin-P forte Classification: Anti tuberculois Dosage: 4 tabs Route:PO Frequency: Before breakfast

ACTION Ethambutol interferes with RNA synthesis, causing suppression of Mycobacteria multiplication. It also has bacteriostatic action against M tuberculosis by acting on rapidly growing pathogens in cavity walls and is also effective in slowgrowing pathogens

INDICATION Initial phase treatment & retreatment of all forms of TB in category I & II patients caused by susceptible strains of mycobacteria.

CONTRAINDICATION Hypersensitivity. Alcoholism, optic neuritis, impaired hepatic function, severe renal insufficiency, hyperuricemia, gouty arthritis, jaundice, retrobulbar neuritis.

ADVERSE REACTION Leukopenia, thrombocytopenia, hypersensitivity syndrome, eosinophilia, fever, anorexia, elevations of serum uric acid conc; dizziness, paresthesia; epigastric distress, constipation, nausea, vomiting, anorexia; hepatic impairment, jaundice; pruritus, rash, acute gout; malaise; headache

NURSING CONSIDERATION Perform visual acuity and color discrimination test before and during the therapy. Assess liver and renal function before and during the therapy. Assess patient mental status often: affect mood, behavior change. watch out for confusion and hallucination Assess patient for visual disturbance that may indicate optic neuritis.

DRUG NAME Generic name: Salbutamol Brand name: Activent Classification: Sympathomimetics Dosage: Route: neb Frequency: q 1 hr x 3 doses

ACTION Stimulated beta 2 receptors of bronchioles by increasing levels of cAMP which relaxes smooth muscles to produce bronchodilation.

INDICATION Relief of bronchospasm in bronchial asthma, chronic bronchitis, emphysema and other reversible, obstructive pulmonary diseases. Also useful for treating bronchospasm in patients with coexisting heart disease of hypertension.

CONTRAINDICATION Hypersensitivyty to salbutamol, also atropine and its derivatives. Cardiac arrhythmia associated with tachycardia caused by digitalis intoxication.

ADVERSE REACTION Fine skeletal muscle tremor, leg cramps, palpitations, tachycardia, hypertension, headache, nausea, vomiting, dizziness, insomnia, hypotension, peripheral vasodilation, flushing, feeling of nervousness, mouth and throat irritation

NURSING CONSIDERATION Assess cardiorespiratory function: BP, HR, rhythm and breath sounds Monitor for evidence of allergic reactions and paradoxical bronchospasm Teach patient to use inhaler; to avoid getting aerosol in eyes or blurring may result Instruct patient not to eat 30 mins before and after the nebulization Instruct the patient to limit caffeine products such as chocolate, coffee, tea, cola, avoid smoking.

DRUG NAME Generic name: Tranexamic Acid Brand name: Hemostan Classification: Cardioactive drugs; Hemostatics Dosage: 500 mg Route: IV Frequency: q 8 hrs

ACTION Inhibits breakdown of fibrin clots. It acts primarily by blocking the binding of plasminogen and plasmin fibrin; direct inhibition of plasmin to fibrin; direct inhibition of plasmin occurs only to a limited degree.

INDICATION Treatment and prophylaxis of hemorrhage associated with excessive fibrinolysis. Prophylaxis of hereditary angioedema.

CONTRAINDICATION Hypersensitivity. Patients with active intravascular clotting because of the risk of thrombosis. Severe renal insufficiency. Patients with microscopic hematuria.

ADVERSE REACTION GI disturbances. Nypotension, particularly after rapid IV administration. Thrombotic complications have been reported, transient disturbances in color vision associated with its use.

NURSING CONSIDERATION Assess patients history if with active intravascular clotting, predisposed thrombosis, and hemorrhage. Monitor anticoagulant cover Perform eye exams Perform liver function tests Perform blood tests Obtain prothrombin time of the patient May be mixed with most solutions but not with penicillins Advice patient to report visual abnormalities

DRUG NAME Generic name: Clarithromycin Brand name: Claranta Classification: Antibiotics; macrolides Dosage: 500mg Route: PO Frequency: BID

ACTION Inhibits or interferes with bacterial protein synthesis by binding to the 50s ribosomal subunits of bacterial chromosome.

INDICATION Treatment of respiratory tract infections. Treatment of leprosy and for prophylaxis and treatment of opportunistic mycobacterial infections.

CONTRAINDICATION Hypersensitivity to macrolides. Concomitant therapy with cisapride, primozide and terfenadine in patients with preexisting cardiac abnormalities of electrolyte disturbances. Severe lever damage. Impaired kidney function. Hypokalemia.

ADVERSE REACTION GI disturbances (nausea, diarrhea, abnormal taste, dyspepsia). Taste disturbances, stomatitis, tooth discoloration.

NURSING CONSIDERATION Assess patients infection before therapy and regularly thereafter. Monitor hepatic and hematologic status. Assess bowel pattern, discontinue drug if severe diarrhea occurs. Advice patient not to chew or crush extended released tablets. Advice patient to report any adverse reaction. Advice patient to contact physician if loose foul-smelling stools or furry tongue is observed this may indicate superinfection.

DRUG NAME Generic name: Sucralfate Brand name: Iselpin Classification: Acid- peptic disease drugs; cytoprotective Dosage: Route: Frequency:

ACTION Protects GI lining against peptic acid, pepsin and bile salts by binding with positively-charged proteins in exudates forming a viscous paste-like adhesive substance thus forming a protective coating.

INDICATION Prophylaxis of gastrointestinal hemorrhage from stress ulceration

CONTRAINDICATION Contraindicated with allergy to sucralfate, chronic renal failure or dialysis, not intended for IV administration

ADVERSE REACTION Constipation, diarrhea, nausea, dizziness, dry mouth, GI disturbances, rash, pruritus, headache, vertigo, back pain, drowsiness.

NURSING CONSIDERATION Monitor gastric pH, blood in stools Monitor patient for severe constipation Monitor patient with renal insufficiency for aluminum toxicity. Give drug on empty stomach 1 to 2 hrs. before meals Monitor pain; use antacid to relieve pain Report severe gastric pain Do not crush, chew tablets. Advice patient to avoid cigarette smoking which may increase gastric acid secretions and worsen disease.

DRUG NAME Generic name: Insulin, human isophane suspension (recombinant DNA origin) Brand name: Humulin N Classification: Intermediate acting insulin Dosage: 10 u Route:SC Frequency: 30 mins BS

ACTION Increase glucose transport across muscle and fat cell membranes to reduce blood glucose level. Promotes conversion of glucose to its storage form, glycogen; triggers amino acid uptake and conversion to protein in muscle cells and inhibits protein degradation; stimulates triglyceride formation and inhibits release of free fatty acids from adipose tissue; and stimulates lipoprotein lipase activity, which converts circulating lipoproteins to fatty acids.

INDICATION Diabetic ketoacidosis, Type I diabetes, adjunct to type II diabetes inadequately controlled by diet and oral antidiabetic agents.

CONTRAINDICATION Hypoglycaemia, insulinoma, hypersensitivity reactions, diabetic coma.

ADVERSE REACTION Lipoatrophy, lipohypertrophy, rash, hypoglycemia, ketoacidosis, redness, swelling, pruritus

NURSING CONSIDERATION
Hold for CBG <100mg/dl Do not give insulin injection concentrated IV Be aware that some patients may develop insulin resistance and require large insulin doses to control symptoms of diabetes. To mix insulin suspension, swirl vial gently or rotate between palms or between palm and thigh. dont shake vigorously: this causes bubbling and air in syringe Note that switching from separate injections to a prepared mixture may alter patient response. Whenever NPH or lente in mixed with regular insulin in the same syringe, give it immediately to avoid loss of potency.

DRUG NAME Generic name: Regular insulin Brand name: Humilin R Classification: Short acting insulin Dosage: 4 u Route:SC Frequency: PRN

ACTION Short-acting, clear, colorless solution of exogenous unmodified insulin extracted from beta cells in pork pancreas or synthesized by recombinant DNA technology (human). Enhances transmembrane passage of glucose across cell membranes of most body cells and by unknown mechanism may itself enter the cell to activate selected intermediary metabolic processes. Promotes conversion of glucose to glycogen.

INDICATION It indicated as an adjunct to diet and exercise to improve glycemic control in adults and children with type 1 and type 2 diabetes mellitus.

CONTRAINDICATION Hypersensitivity to insulin animal protein, renal impairment, hepatic impairment and older adults. Safety and efficacy in children <2 y are not established.

ADVERSE REACTION Sweating, hunger, headache, nausea, tremulousness, tremors, palpitation, tachycardia, weakness, fatigue, nystagmus, localized allergic reactions at injection site; generalized urticaria or bullae, lymphadenopathy.

NURSING CONSIDERATION
Give Humilin R for cbg >200mg/dl Give maintenance doses subcutaneously, rotating injection sites regularly to decrease of lipodystrophy. Do not give insulin injection concentrated IV Use caution when mixing two types of insulin, In general, when an intermediate-acting insulin (e.g., NPH insulin isophane suspension) is mixed with short-acting soluble insulin (e.g., regular), the shortacting insulin should be drawn into the syringe first. Carry some form of fast-acting carbohydrate (e.g., lump sugar, LifeSavers or other candy) at all times to treat hypoglycemia.

NURSING CARE PLAN