Case Scenario:

Child Denis 9 year old boy playing with his friends outside their home stopped for a
while to void on a transparent container which he found inside the bathroom. His mother notice a
small amount and cola colored urine.

The next day, he informed his mother that he complains of mild headache and feels weak.
In addition, mother noticed that child Denis had no interest to eat. The condition became worse
when child Denis experienced shortness of breath the following day. This symptoms prompted
the mother to bring him to a Mandaluyong City Medical Center.

Question No. 1

Formulate three (3) nursing diagnosis, prioritize based on identified theory using the
template below. (6 points)

Prioritization Nursing Diagnosis Theory based explanation

1 Ineffective breathing pattern
related to the inflammatory
process as evidenced by the
shortness of breath.
2 Excess Fluid Volume related
to compromised regulatory
mechanisms (renal
Insufficiency) as evidenced
by edema, pulmonary
congestion on x-ray, and
specific gravity changes.
3 Risk for infection related to
renal impairment.
Maslow's Hierarchy ,
respiration which under the
biological and physiological
needs was one of the highest
level of priority.
Maslow's Hierarchy,
“Nutrition (elimination, skin
care)” Biological and
Physiological needs was one
of the highest level of priority
next to respiration.
Maslow's Hierarchy
“Protection/Free from
infection” which was under
the safety and security needs,
was one of the level 2 or
Moderately high priority next
 to biological & physiological
needs.

Question No. 2

Based on the above scenario, formulate two (2) drug study using the suggested format.
(30 points)

Drug Classific Mechani Indicati Contraindic Adverse Nursing

Data ation sm of ons ation Reaction Responsibilities
Action
Generic Pharma Inhibits Treatme Hyper Hyper Baseline assess
Name co bacterial nt of sensitivity to sensitivity ment
therapeu cell wall susceptib any reaction
Penicillin tic: synthesis le penicillin. ranging Question for
G Penicilli by infection from rash, history of
potassium n binding s Caution: fever, allergies,
to one or including chills to particularly
Brand Clinical: more of sepsis, Renal/heptic anaphylaxi penicillins,
Name Antibioti the meningit impairment, s occur cephalosporins.
c penicillin is, seizure occasional
Pfizerpen binding endocard disorder, ly. Intervention/eval
proteins itis, hypersensiti uation
Route and of pneumon vity to
frequency bacterial. ia. cephalospori Promptly report
Active ns, pts with rash
300, 000 Therape against asthma. (hypersensitivity)
units IM, utic gram diarrhea (with
o.d. Effect: positive fever, abdominal
organism pain,
Bacterici s (except mucus, or blood
dal S. in stool, may
aureus). indicate
Some antibiotic
gram- colitis). Monitor
negative I&O, urinalysis
organism electrolytes, renal
s (e.g. N. function tests for
gonorrho nephrotoxicity
eae) and
some
anaerobe
s and
spirochet
es.
Generic Pharma Enhance Treatme Contraindic Vigorous Baseline
name co s nt of ations: diuresis assessment
Therape excretion edema may lead
Furosemid utic: of associate Hypersensiti to Check vital sign,
e sodium, d with vity to profound esp. B/P, pulse,
Loop chloride, HF and furosemide. water for hypotension
Brand diuretic. potassiu renal/hep Anuria. loss/electr before
Name m by atic olyte administration.
Clinical: direct disease: Caution: depletion,
Lasix Diuretic action at acute resulting Asses baseline
ascendin pulmona Hepatic in renal function,
Route & g limb of ry cirrhosis, hypokalem serum
frequency loop of edema. hepatic ia, electrolytes, esp.
Henle. Treatme coma, hyponatre serum sodium,
2 mg/kg nt of severe mia, potassium.
p.o. daily Therape hyperten electrolyte dehydratio
utic sion (not depletion, n. Assess skin
Effect: recomme prediabetes, turgor, mucous
nded as diabetes, Sudden membranes for
Produces initial systemic volume hydration status;
diuresis, treatment lupus depletion observe for
lower ). erythematos many edema.
B/P us. Pts with result in
prostatic increased Assess muscle
hyperplasia/ risk of strength, mental
urinary thrombosis status.
stricture. ,
circulatory Note skin
collapse temperature,
sudden moisture.
death.
Obtain baseline
Acute weight initiate
hypotensiv I&O monitoring.
e episodes
may occur, Auscultate lung
sometimes sounds
several
days after In pts with
beginning hepatic cirrhosis
therapy. and ascites,
consider giving
Ototoxicit initial doses in a
y hospital setting.
(deafness,
vertigo, Intervention/eval
tinnitus) uation
may occur,
esp in pts Monitor B/P,
with vital signs, serum
severe electrolytes,
renal weight
impairmen
t. Note extent of
diuresis
Can
exacerbate Watch for
diabetes symptoms of
mellitus, electrolyte
systemic imbalance
lupus hypokalemia may
erythemat result in changes
osus, in muscle
pancreatiti strength, tremor,
s muscle cramps,
altered mental
Blood status, cardiac
dyscrasias arrhythmias;
have been hyponatremia
reported. may result in
confusion, thirst,
cold/clammy
skin.
Consider
potassium
supplementation
if hypokalemia
occurs.

Patient/family
teaching

Expect increased
frequency,
volume of
urination.

Report
palpations, signs
of electrolyte
imbalances
(noted
previously),
hearing
abnormalities
(sense of fullness
in ears, tinnitus)

Eat foods high in

potassium such
as whole
grains(cereals),
legumes, meat,
bananas, apricots,
 orange juice,
potatoes(white,
sweet) raisins.

Avoid sunlight,
sunlamps.

REFERENCES:

https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-
Guide/51345/all/furosemide

https://www.drugs.com/furosemide.html#:~:text=Furosemide%20is%20a%20loop
%20diuretic,disorder%20such%20as%20nephrotic%20syndrome.

https://nurseslabs.com/antibiotics/#penicillins_and_penicillinaseresistant_antibiotics