The document summarizes a case study of a 25-year-old male patient who experienced an adverse drug reaction to anti-TB medication. He developed jaundice, fever, and hemoptysis after taking Isoniazid for 23 days. On admission, he was jaundiced with a temperature of 36.6°C. Laboratory tests and examinations were performed. The case provides details on the patient's history, symptoms, physical assessments, and initial lab results.

1. A care for client with client with adverse drug reaction
secondary to Anti-TB medication.
In partial fulfillment of Related Learning Experience (R.L.E)
Submitted By:
Portugal, Marc
Prodigalidad, Jhonelle
Quiambao, Bianca
Rambaud, David
Redoble, Arlie
Reyel, Arby
Reyes, Jennelyn
Roderos, Mitch Angela
Rojero, Catherine Mae
BSN 4C GROUP II S.Y 2011-2012
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2. SCOPE AND LIMITATION
For the two weeks of rotation of BSN 4C Group 2 in Ospital ng Makati, the group was
able to handle the case of a client with adverse drug reaction secondary to Anti-TB medication.
However during that time, the duties and responsibilities ought to be done by the student nurses
had serves as a hindrance to give way for an intensive nursing patient interaction. Aside from the
time constraints, the patient is scheduled for discharge during that time. But we were fortunate
enough to gather data that has provided us knowledge and to support our case study which is to
be presented on this day. The group would like to apologize beforehand for the limited amount
of information. Yet rest assured that the case presented reflects our utmost learning extracted
from the information available.
INTRODUCTION
We BSN group 2 find this case as an interesting one because it is our first time to
encounter this kind of case and it leaves some questions on our mind that let us come to a
decision to choose this case for our case study.
Isoniazid has rarely caused very serious (possibly fatal) liver disease. The risk of liver
disease is increased in people who are 35 years and older, who use alcohol or illegal injection
drugs, or who currently have long-term liver problems. Tell your doctor immediately if you
develop symptoms of liver disease, including persistent nausea/vomiting, severe
stomach/abdominal pain, unusual weakness/tiredness, dark urine, yellowing eyes/skin.
Hepatic effect
Hepatitis has been reported in less than 5% of patients receiving isoniazid alone. Jaundice
is usually preceded by a prodromal illness with fatigue, nausea, malaise, abdominal pain, and
anorexia. Asymptomatic increases in liver function tests may occur. Isoniazid should be
discontinued if hepatotoxicity occurs, usually defined as SGOT greater than four times normal
The mechanism of hepatic injury is unknown but may be related to the acetyl metabolite
of isoniazid. Patients exhibiting hepatotoxicity are more likely to be fast acetylators of isoniazid.
Eight cases of severe hepatitis resulting in death or transplantation have been evaluated by the
Department of Health of New York. Duration of isoniazid use before onset of hepatitis ranged
from 21 to 142 days, and seven patients continued use of isoniazid at least 10 days after onset of
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3. symptoms. Massive hepatic necrosis was a common finding and cholestasis was present in two
of five cases.
The risk is age related with a greater occurrence reported in patients who are 35 years or
older. The risk of hepatitis is also increased in patients who consume alcohol daily, in women,
and in minorities. In a study of 2651 women beginning isoniazid preventive therapy during
pregnancy or postpartum, 5 cases of isoniazid-induced hepatitis were identified, including two
fatalities. In another review of deaths due to isoniazid, eight of 21 women between 15 and 44
years old were within one year postpartum. In general, death due to isoniazid hepatotoxicity
occurs more frequently in women than men.
Fulminate hepatitis, characterized by jaundice, disorders of consciousness and elevated
serum transaminases up to 80 times the upper limit of normal, has occasionally occurred in
patients receiving isoniazid with rifampin. Rifampin, by virtue of its enzyme-inducing activity,
likely increases the reactive metabolite of isoniazid thought to be responsible for the
hepatotoxicity associated with isoniazid.
Monthly monitoring and interviewing of patients should take place. Patients should be
fully informed regarding the risk of hepatotoxicity associated with isoniazid, educated about the
signs and symptoms of liver damage, and instructed to contact their physician immediately if
they develop signs or symptoms.
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4. DEMOGRAPHIC DATA
Client’s name : Patient B.R
Gender: Male
Age, Birth date and Birth place: 25years old, April 5,1986 at Makati
Marital Status: Single
Nationality: Filipino
Religion: Islam
Address: 4565 Jerry St. Pio Del Pillar Makati City
Educational Background: College Graduate
Occupation: Financial and Corporate Relations
Usual Source of Medical Care: Ospital ng Makati
A. SOURCE AND RELIABLITY OF INFORMATION
 Patient’s Chart
 Patient’s Mother
 Patient Himself
B. REASON FOR SEEKING CARE
“Naninilaw ang buong katawan”
“pababalik balik na lagnat”As verbalized by the patient
C. HISTORY OF PRESENT ILLNESS
23 days Prior to admission From the patient’s interview, Patient B.R has undergone
physical examination as requirement for his new job, when the company physician
detected a bullae from his CT Chest Scan.thus, the patient was prescribed to take in
Isoniazid with Vitamin B complex
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5. 2 weeks Prior to admission – Patient B.R complaints of experiencing easy fatigability,
anorexia and generalized weakness
4 days Prior to admission – Patient B.Radditionally developed fever,jaundice and
hemoptysis. Hence persistence of symptoms has lead the patient for subsequent
admission
Upon Admission - Patient’s vital signs was taken and recorded of blood pressure of
120/80, PR: 86, RR: 21, Temp: 36.6 c with a general survery of jaundce and ecteric
scelera. The patient was hooked with D5LR 1 L x 125cc/hr at left metacarpal vein with
laboratory tests rendered such as HbsAg, LFT, ECG, CBC, Na, K, BUN, ultrasound and
Chest X-Ray are taken likewise.
D. PAST MEDICAL HISTORY
Pediatric/Childhood/ Adult Illness: Patient has has a history of drug reaction secondary to
anti-tubercular drugs especifically Isoniazid when he was 1 years old. at that time,
patient had jaundice, hepatomegaly and purpura examination for work, a granuloma was
noted on CAT.
Injuries or accidents: The client recieved multiple injuries due to stampede (10 y/0)
Serious/ Chronic Illnesses: PTB primary complex (1 y/o)
Hospitalizations: Patient was hospitalized due to Viral Infection last 2007
Operations: No known operations
Obstetric history: Not applicable
Immunizations: The client verbalized of having complete immunization of DPT,
OPV, BCG and Measles vaccine.
Allergies: The client stated to have food allergies in Eggplant, Egg and Shrimp
Medications prior to confinement: The client recieved 23 days of Isoniazid Medication
with unrecalled dosage but of an approximate of less than 25 mg
Last Examination Date: October 31,2011
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6. E. FAMILY HISTORY
Father Mother
(+) HPN (+) HPN
(+) DM (+) DM
(
?? Age ?? Age
?? Age ?? Age 25 y/o
LEGEND
Male Female Client
Heredo-Family Illness
Maternal –
The Mother side of Patient’s B.R is known to be hypertensive and with Diabetes
Mellitus. The client recalled no other inherited illness besides the one indicated above.
Father-
The Father side of Patient’s B.R is known to be hypertensive and with Diabetes Mellitus.
The client recalled no other inherited illness besides the one indicated above.
F. SOCIO-ECONOMIC
The client consists of a nuclear family and lives together with his parents and
siblings. The client states that he contributes for the family financial expenses. Financial
Resources are adequate enough to provide for them for the expenses of their everyday
living that is by means of his father and with and the help of his siblings who were
working likewise though the occupation was not identified. Prior to admission, the client
was hired to be a Financial and Corporate Relations at the company with an average
income of 18,000 php per month.
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7. G. DEVELOPMENTAL HISTORY
Erik Erickson
Psychosocial Theory Age Task Patient’s Description
IntimacyVs. Isolation 19 – 30 Young adults The client is presently single for 6
y/o need to form months and does not comit in
intimate, loving intimate relationships.
relationships with moreover,there was an observed
other people. conflict between the family
Success leads to members as suported by the
strong patient’s verbaliztion that they are
relationships, presently facing a a problem
while failure between their family. The client is
results in at risk for loneliness and Isolation
loneliness and if inadequate support that may
isolation. affectt his development if
problems are left unresolved.
H. REVIEW OF SYSTEMS
1. Regional Examinations
(Nov. 24, 2011, 10:30 am)
Vital Signs:
Temp : 36.1°c RR: 14cpm PR: 64cpm BP: 110/70mmHg
General Assessment:
 Patient was conscious and coherent; lying on bed and both feet secured. Skin is clean
and smooth but it was yellow in color, also has a good or normal skin turgor. Nails
are long but not dirty and with normal capillary refill. Patient has an abdominal pain
in right lower quadrant when eating with heplock inserted at left metacarpal vein.
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8. Date of System Normal Findings Actual Findings
Assessment
November 24, Integumentary Smooth and good skin I:
2011 turgor, no lesions or any
discoloration, no  Yellowish complexion, no lesion,
clubbing, no breaks no swelling and edema.
&abnormal curvature.  Normal looking
 Visible veins on both arms
 Has a temperature of 36.2°c.
In nails:
 Long and clean nails and round
nails.
 Nailbed yellowish in color
P:
 Warm, soft, smooth, and has a good
skin turgor.
In nails:
 Hard, immobile, and smooth.
November 24, Hair and Head No lesion, no I:
2011 tenderness, no pain on
palpation, no masses, no -His hair color is black, hair is evenly
lumps, no nodules or distributed,
depression, symmetrical
-Has thick hair.
-No presence of parasite and dandruff.
-In scalp: Symmetrical and round and
no lesion.
P:
-Hair texture is smooth and soft.
-In head the texture is smooth and
firm.
November 24, Eyes Eyelid intact, no I:
2011 redness, swelling,
discharge or lesions. -Lid margins moist and light pink,
Eyeballs are moist & lashes short, evenly spaced and curled
glossy, conjunctiva outward.
numerous small blood
vessels. Sclera white. -Bulbar conjunctiva is clear with tiny
Good eye contact. vessels visible, palpebral conjunctiva
is light pink with no discharge and the
color of the sclera is yellowish.
- In PERRLA:
*Cornea is transparent and the shape
of the iris and pupil is round and
equal.
*The left and right eye has a good
reaction to light (constrict and dilate)
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9. -In extra ocular movements:
*Both eyes coordinated well in all
directions.
November 24, Ears Ears are symmetrical I:
2011 with 10 degrees angle.
Color is same in facial -Equal size and similar appearance.
with no tenderness or
any nodule and without -No lesions, color yellow same with
any presence of his complexion.
discharge.
P:
-Warm, smooth, no nodules and no
tenderness in auricle and tragus.
November 24, Mouth and 32 adult teeth are I & P:
2011 Throat present with moist and
pink mucous membrane -Lips and surrounding tissue relatively
without any lesions or symmetrical.No lesions, swelling and
swelling. drooping.
-Lip is light pink; moist, smooth and
with no lesions.
-Buccal mucosa is light pink, moist
and without lesions.-Gums are light
pink, and moist.
-In tongue:
*Moist, some papillae present,
symmetrical appearance, midline
fissures present and the color is pink
and color white at the center and no
lesions as well as the sides of the
tongue.
*Hard palate: slightly pink. *Soft
palate: pink, -Has 32 teeth and
yellowish in color.
November 24, Neck No tenderness on I:
2011 palpation, no pain,
symmetrically align, no -Neck is symmetric with head
enlarged lymph nodes, centered and without bulging masses.
no tracheal lateral
deviation. P:
-Smooth skin, firm, and none tender
and none enlarged nodules.
November 24, Breast and No palpable nodules and I:
2011 Axillae lesions. Breast is firm -Nipples have no discharges and not
and round. cracked.
November 24, Respiratory Intercostals spaces are I:
2011 even and relaxed; chest
symmetry is equal, no -The color of his chest is similar to his
pain or tenderness, and complexion.
no abnormal breath
sound. -Intercostals spaces are even and
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10. relaxed.
-Chest symmetry is equal
-Thorax: is straight.
-The RR of the patient is 14cpm.
P: No pain or tenderness.
A: Lung is clear to auscultation on
inspiration and expiration.
November 24, Cardiovascular No fatigue on simple PR : 64 bpm
2011 activities, no
arrhythmias and heart BP: 110/70 mmHg
murmurs. PR=60-
100bpm. I:-Neck veins are not distended.
P:
-No vibrations or palpitation in aortic,
pulmonic, or tricuspid area.
A:-No murmur sound heard.
November 24, Abdominal No pain, No palpable I:
2011 masses and tenderness,
Flat and round. -Flat abdomen
P:
-Upon palpation patient experienced
mild pain right lower quadrant.
November Musculoskeletal Have good range of -Does not need assistance to stand and
24,2011 motion and no limitation toes point straight ahead. Able to
of movements. shrug shoulders against resistance.
November 24, Neurologic Have no tremors -No presence of tremors, oriented, no
2011 paralysis. Oriented, no history of seizures, mental dysfunction
history of seizures, or hallucinations.
mental dysfunction or
hallucinations.
November Lympathic Has no bleeding No swollen lymph nodes.
24,2011 tendencies, normal
lymph nodes.
2. Laboratory Studies/Diagnostics
Laboratory (Date) Normal Value Result Interpretation/Significance
10/31/11
M - 14-18 g/dl 15.5 Normal
Hemoglobin F – 12 -16 g/dl
Hematocrit M – 0.40 – 0.54 0.47 Normal
F – 0.37 – 0.37
White Blod Cells 4.0 – 11.0 7.6 Normal
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11. Red Blood Cells M – 5.0 -6.4 4.8 Below Normal
Indicates anemia, bone marrow
failure, erythropoietin deficiency,
hemolysis or transfusion reaction
hemorrhage.
DIFFERENTIAL COUNT
Segmenters 0.5 – 0.7 0.62 Above Normal
Lymphocytes 0.2 – 0.4 0.31 Above Normal
Increased in presence of
infection
Monocytes 0.02 – 0.05 0.07 Above Normal
Seen in chronic inflammation,
stress
response,hyperadrenocorticism ,
and immune-mediated disease
Platelet 150- 300 145 Normal
Laboratory (Date) Normal Value Result Interpretation/Significance
11/04/11
M - 14-18 g/dl 15.4 Normal
Hemoglobin F – 12 -16 g/dl
Hematocrit M – 0.40 – 0.54 0.43 Normal
F – 0.37 – 0.37
White Blod Cells 4.0 – 11.0 6.9 Normal
Red Blood Cells M – 5.0 -6.4 4.5 Below Normal
Indicates anemia, bone marrow
failure, erythropoietin deficiency,
hemolysis or transfusion reaction
hemorrhage.
DIFFERENTIAL COUNT
Segmenters 0.5 – 0.7 0.67 Above Normal
Lymphocytes 0.2 – 0.4 0.26 Above Normal
Increased in presence of
infection
Monocytes 0.02 – 0.05 0.07 Above Normal
Seen in chronic inflammation,
stress
response,hyperadrenocorticism ,
and immune-mediated disease
Platelet 150- 300 155 Normal
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12. 10/31/11
Clinical S.I Unit Range Conversion Unit Result Interpretation
Chemistry Result Result
Section
AST (SGOT) 3603 u/L 15-37 3603 u/L 15-37 Above Normal
ALT (SGPT) 3933 u/L 30-65 3933 u/L 30-55 Above Normal
Alkaline 190 u/L 50-165 190 u/L 50-165 Above Normal
Phosphtase Above normal
indicates
response of
cholestatic
liver disease
Sodium 133 u/L 136-145 133 meq/L 136-145 Below Normal
Potassium 4 u/L 3.5-5.1 4 meq/L 3.5-5.1 Normal
11/19/11
Clinical S.I Unit Range Conversion Unit Result Interpretation
Chemistry Result Result
Section
Above Norma
AST (SGOT) 104 u/L 15-37 104 u/L 15-37 Serum AST
and ALT
increased in
liver damage,
ALT (SGPT) 268 u/L 30-65 268 u/L 30-55 Above Normal
11/13/11
Clinical S.I Unit Range Conversion Unit Result Interpretation
Chemistry Result Result
Section
Total Protein 104 g/L 64-82 6.20 g/dL 6.4-8.1 Above Normal
May indicate
Chronic infection
(including
tuberculosis), Liver
dysfunction,
Dehydration,
Alcoholism
Albumin 268 g/L 34-50 3.10 g/dL 3.4-5.0 Above Normal
May indicate
Dehydration, Poor
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13. protein utilization
Globulin 31 g/L 30-32 3.10 g/dL 3-3.2 Normal
/C Ratio - 1.1-1.6 1.00 1.1-1.5 Normal
11/07/11
Clinical Chemistry Section
Billirubin Results Interpretation
Total 0-20-52 umol/L 433.50 Above Normal
Direct 0-8.55 umol/L 201.70
Indirect 0-11.97 umol/L 231.80
11/1/11
Clinical S.I Unit Range Conversion Unit Result Interpretation
Chemistry Result Result
Section
BUN 3.3 mmol/L 2.5-6.4 9.24 mg/dL 7.0-18.0 Normal
Creatinine 54 umol/L 53-115 0.61 mg/dL 0.60- Normal
1.30
11/01/11
Blood Coagulation Tests Range Results Interpretation
Prothrombin Time 10.4 – 14.0 sec 27.7 sec Above Normal
% Activity 73 -127 % 27.6 % Normal
INR 0.88 – 1.21 sec 2.78 sec Above Normal
PTT 30.4 – 41.2 sec 75 sec Above Normal
11/07/11
Blood Coagulation Tests Range Results Interpretation
Prothrombin Time 10.4 – 14.0 sec 29 sec Above Normal
% Activity 73 -127 % 26 % Normal
INR 0.88 – 1.21 sec 2.93 sec Above Normal
PTT 30.4 – 41.2 sec 93.2 sec Above Normal
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14. 10/31/11
URINALYSIS
DATE:
LAB NO.
PATIENT’S NAME:
ROOM
AGE: SEX: MALE
PHYSICAL CHMICAL
Color Dark Yellow Protein +3
Transparency Slightly Hazy
pH 6.0 Sugar NEGATIVE
Specific Gravity 1.030
MICROSCOPIC
CRYSTALS
Amorphous Urates FEW
CELLS
White Blood cells 7 – 10 hpf
Red blood cells 3 – 5 hpf
Epithelial cells MODERATE
OTHERS
Bactaeria & Mucus Threads: OCCASIONAL
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15. 3. Other Assessment Tools
Procedure Indication Results Nursing intervention
11/22/11 The acid-fast stain is an Microscopic Pre
Examination :
especially important test Advise patient to drink a lot of fluids
the night before the test. It makes the
Acid Fast Stain for the test more accurate if it's done first
Specimen Negative
thing in the morning.
genus Mycobacterium, to
Advised patient not to take
rule out pulmonary antibiotics and some sulfonamides
because it may interfere with test
tuberculosis. results, causing the results to be
falsely negative.
Prior to breakfast, the patient will be
asked to provide a 5-10 mL
specimen of sputum delivered into a
sterile cup with a screw top lid.
11/18/11 Intra
Asked patient to cough deeply and
spit
Acid Fast the substance that comes up from the
lungs (sputum) into a container.
Stain Specimen Microscopic
Examination: Patient may be asked to inhale a mist
of salty steam in order to cough
Negative more deeply and produce sputum.
Post
Place it in a sterile container, label
appripiately and immdiately forward
in the laboratory.
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16. Procedure Indication Results Nursing intervention
11/19/11 CT scanning or (+) Small Pre
sometimes called CAT Bullae, both
Remove all Metal objects including
scanning is a noninvasive apices minimal jewelry, eyeglasses, dentures and
CT Chest Scan hairpins. Patient may also be asked
medical test that helps fibrosis left to remove hearing aids and
removable dental work.
physicians diagnose and upper lung
Instruct not to eat or drink anything
treat medical conditions. normal for several hours beforehand,
especially if a contrast material will
parenchyma be used in exam.
CT scanning combines
(-) opacities or Intra
special x-ray equipment
A chest ct scan takes about 30
with sophisticated densities mins., which includes preparation
time
computers to produce Patient mat lie on a narrow table
that moves through the hole
multiple images or While inside the scanner, an x-ray
pictures of the inside of tube moves around your body. You
will wear soft buzzing, clicking or
the body. These cross- whirring noises as the scanner takes
pictures
sectional images of the The technician will ask you to lie
still and hold your breath for short
area being studied can
periods. these measures help make
then be examined on a the picture as clear as possible the
scan itself
computer monitor, printed
Post
or transferred to a CD. CT exams are generally painless,
fast and easy.
After a CT exam, you can return to
your normal activities.
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17. Procedure Indication Results Nursing intervention
11/1/2011 An Gall bladder not Pre
Abdominal abdominal ultrasound visualized likely Instruct patient on NPO prior to
procedure
Ultrasound uses reflected sound contracted. Suggest For a study of the liver, gallbladder,
spleen, and pancreas, you may be
waves to produce a follow-up scan after 3 asked to eat a fat-free meal on the
evening before the test
picture of the organs days. Explain that the procdure is non-
invasize and painless
and other structures in Instruct patient to wear
comfortable, loose-fitting clothing
the upper abdomen. Instruct to remove all clothing and
jewelry in the area to be examined.
Sometimes a
Intra
specialized ultrasound
Assist patient in proper positioning
Instruct that There will be little
is ordered for a
discomfort. The conducting gel may
feel slightly cold and wet.
detailed evaluation of
a specific organ
Post
Assist patient in cleaning the gel
and Aftercare of materials
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18. Procedure Indication Results Nursing intervention
10/31/11 HBsAG stands for Pre Interventions
HbsAg hepatitis B surface Non-Reactive Explain the procedure to the
(qualitative) patient.
antigen. It
Specimens submitted for testing
indicates current are handled according to the HRL
SOP entitled "Sample Handling"
Hepatitis B
No special instructions such as
infection. fasting or special diets are
required. Diurnal variation is not a
major consideration.
Specimens may be serum,
recalcified plasma, or plasma.
Serum specimens may be
collected using regular red-top or
serum-separator Vacutainers.
Intra Interventions
Required sample volume is 10 μL
for the assay; 1.0 mL will permit
repeat analyses as well as other
testing.
Post Interventions
Specimens should be stored in
plastic vials and sealed tightly to
prevent desiccation of the sample.
Serum or plasma samples are
collected aseptically to minimize
hemolysis and bacterial
contamination.
Samples are stored in labeled 2
mL Nalgene cryovials or
equivalent.
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19. Procedure Indication Results Nursing intervention
10/31/11 Electrocardiogram A.V Block I Pre
Electrocardiogram (ECG) provides 12 Explain the procedure to the
patient.
vector views of the Cannot rule out Instruct patient to wear
comfortable, loose-fitting clothing
heart’s electrical lateral Instruct to remove all Metal
objects including jewelry,
activity as reflected by infarction eyeglasses, dentures and hairpins.
Patient may also be asked to
electrical potential remove hearing aids and
removable dental work.
differences between In some instances, men may
require the shaving of a small
positive and negative amount of chest hair to obtain
optimal contact between the leads
electrodes placed in the and the skin
limbs and chest wall. Intra
ECG is crucial for EKG leads are attached to the
body while the patient lies flat on
establishing many a bed or table. Leads are attached
to each extremity (four total) and
cardiac diagnoses, to six pre-defined positions on the
front of the chest. A small amount
especially arrhythmias of gel is applied to the skin, which
allows the electrical impulses of
and myocardial the heart to be more easily
transmitted to the EKG leads.
ischemia. Instruct that the test takes about
five minutes and is painless.
I. FUNCTIONAL ASSESSMENT
HEALTH PERCEPTION-HEALTH MANAGEMENT
Prior to admission, the patient tells his stressful schedule he had from his previous work.
The patient works everyday in midnight shift of from 12:00 am – 9:00 am or up to 3:00 am –
12:00 noon, in which has affected his health in general. Furthermore, the patient does not
consume multivitamins but does not experienced colds in the past 3 months as far as he could
remember.
The client is aware of the etiology of his illness and positively adheres to medical
advices. The client feels well unlike his first admission. That “sobrang dilaw ko” verbalized
by the patient as he exclaims his disbelief from the extent of his disease process. The client
19

20. claims that he acquired his disease during his infant years being exposed to PTB and learned
to exhibit an adverse reaction to Isoniazid back then. Presently, the Patient does not find any
difficulty on the advices given by doctors and nurses to him,he believes that by cooperating
and adhering on the medications would continually make her better and soon to be
discharged. The client adheres to therapeutic regimen of taking Essential Forte 1 tab T.I.D
and Silymarin Capsule T.I.D
SELF-ESTEEM, SELF CONCEPT/SELF PERCEPTION PATTERN
Before the patient was admitted, he sees himself being able to do things according to
the manner he wants it. He does not mind his health not until the manifestation of discomfort
brought from his disease. Presently, the client verbalized difficulty of being sick; he stated
that he will find it hard to adjust from it. The client admitted that his self-perception in his
body has changed, as he needs to be more conscious in taking care of himself such as
refraining from stressful situations, refraining from alcoholic beverages and smoking. The
client honestly verbalized a change of perception about self. That because of his condition,
job opportunities are lessened because of it’s permanent effects. Despite of it, though
“Matatagalan nga lang ang pagkakawala ng paninilaw ko” as verbalized by the client but He
affirms a positive prognosis to his health, the patient stated that he is looking forward to be at
home, and to make up the responsibilities that he had missed due to his absence.
ACTIVITY/EXERCISE PATTERN
Prior to confinement, the client describes his previous activities as stressful. the client
takes his OJT as being recently hired from that certain company. The client usually works
midnight around 12:00 am – 9:00 am or 3:00am – 12:00 pm . The client remarks his previous
activities as a form of exercise. His favorite sports are basketball and . But he prefers to
stay at home and rest during his free time.
Presently, the patient is confined in the primary holding unit. The client assumes full
self care on himself. The client is on bed rest and does minimal activities. He states that he
would play games in his cell phone or listen to music to let the time pass. The client is noted
to be sleeping most of the time.
20

21. Feeding 0 Grooming 0
Bathing 0 Gen. Mobility 0
Toiling 0 House 0
maintenance
Bed mobility 0 Dressing 0
Legends:
Level 0 – Self Care
Level I – Use of equipments
Level II– Assistance from another person
Level III –Requires assistance from another person or device
Level IV – Dependent and does not participate
SLEEP/REST PATTERN
The client has 9 hours of sleep and sleeps around 10 o’clock in the evening and wakes up
around 8’oclock in the morning. The client states that he feels full rested upon waking up. The
client has no difficulty of sleeping except from some external factors such as the noise of other
patients that he shares the ward with. The client does not use any sleeping pills but prefers to
play music in his radio to induce sleep. The client frequently naps in the morning.
NUTRITIONAL-METABOLIC PATTERN
The client eats three times a day with low salt and low fat diet, the client prefers to eat in
small frequent meals to prevent the pricking pain in his right upper quadrant and for the reason to
minimize the workload of his liver to digest nutrients. The client has poor appetite and
experienced weight loss of 3kg, from 58 kg to 55kg. There client is has food allergy in Eggplant,
Egg and Shrimp. The client drinks 7-8 glasses of water.
ELIMINATION PATTERN
The client states that he defecates once a day usually in the morning in soft brown stool
without difficulty and use of laxatives. The client urinates 4x day or more varying in his fluid
intake; he verbalizes no difficulty in voiding.
SEXUALITY/REPRODUCTIVE
The client is presently single for 6 months and is sexually inactive. He was circumcised
by the age of 11.
INTERPERSONALRELATIONSHIPS/RESOURCES
The client is the youngest son among his 3 siblings. The client verbalized that there has been
a problem faced by the family from the previous months, the presently affects the interpersonal
21

22. relationships between his siblings and parents. In terms of decision making, the client assumes
full responsibility of himself in terms of his personal issues. But when in terms to health and
other concerns affecting the family, the client considers the opinions of his family as well.
COPING & STRESS MANAGEMENT/ TOLERANCE PATTERN
The client states that whenever he feels frustrated, he would initially avoid the stressful
situation to deliberately think before making out judgments. He stated that he perceive problems
positively and would joke about it to help him relieve stress. .
VALUES/ BELIEFS
The client is an Islam since birth. However, he states that he does barely attend their
church and practice due to preoccupation to other things.
As of the present time, the client stated that his condition will eventually pass and he will
recover quickly.He stated that he will abstain from drinking alcoholic beverages, smoking, and
from over abusing his body.
J, PERSONAL/SOCIAL HISTORY
Habits: The client has the habit of smoking to past time, improve concentration or to help him
relive from experiencing anxiety and stress.
Vices: The client started drinking at the age of 13 of Beer as his alcoholic preference. The client
started smoking 4 packs of green Malboro cigarettes at age 13
Lifestyle: The client was known to live in a stressful lifestyle.
Client’s usual daily life: The client’s typical day is working as financial and corporate relations
in midnight then goes straight home for rest and preparation his next shift. the client would
watch DVD’s or rest during his day offs.
Rank/Order in the family: the Client is ranked as the youngest son to his 3 siblings.
Travel: The client’s known travel is from his home and to his work. The client has no previous
local and intonation travel for the past 6 months.
22

23. J. ENVIRONMENTAL HISTORY
The client lives together with his parents and siblings. The client describes his residency as a
compound where his extended relative’s family lives. The client described their house as
bungalow type which is well ventilated and and adequate to live for household members of five.
The client stated that their home is adequately supplied by water, electricity and near from
establishments such as market, church and school. Environmental problems that were identified
are the presence of by standers who frequently drinks alcoholic beverages, and a semi talyer that
brings polluted air.
K. PEDIATRIC HISTORY
Maternal and Birth history
Birth date: April 5, 1986 Hospital: Not assessed
Birth Weight: Unrecalled
Type of Delivery: Normal Spontaneous Delivery
Condition after Birth: The client is born stable in condition
Mother:
Complications of Delivery: No known complications
Anesthesia during Labor: No known usage of anesthesia
Exposure to Teratogenic agents during pregnancy: No known exposure to teratogenic
agents
23

24. I. PATHOPHYSIOLOGY
Adverse Drug Reaction 2 to anti-TB medications
PREDISPOSING PRECIPITATING
II. FACTORS FACTORS
Age Immunity History of TB Prim0ary Lifestyle
Complex (1 y.o)
History of
hepatomegaly,purpura and Smoking
granuloma
Alcoholic
Stress
23 days of Medicating Isoniazid
AV BLOCK I
HEPATOXICITY
Elevated Liver
Function Tests
Impaired Liver Function
Impaired ability to Impaired water Insufficient Impaired Bilirubin
emulsify fat regulation coagulating factors excretion
Right Upper Imbalance in water Delayed Blood Elevated bilirubin
Quadrant Pain and sodium Clotting levels
Hyponatremia Jaundice
Adverse Reaction 2 to Anti-TB medication
24

25. III. CONCEPT MAPPING
1. Impaired liver function related to
hepatotoxic medication as evidenced
adverse reaction of Isoniazid
Adverse Reaction 2 to Anti-TB medication
Patient B.R; 25 y/o Male.
4. Disturbed body image Temp.: 36.1°c RR: 14cpm PR: 64cpm BP: 110/70mmHg 2. Acute pain related to
 23 days of taking isoniazid medications
related to increased  Jaundice inflammation and swelling of
production of Bilirubin as  Enteric sclera the liver as evidenced by
evidenced by jaundice  Weight Loss from 58 to 55 kg pain in right upper quadrant
 BMI of 18.5 (undewrweight)
 Elevated Liver function tests, Bilirubin
 CT Chest Scan result:
 UZ result: Liver is likely contracted
 Complaints of right upper quadrant pain after eating (P/S of 6/10)
 Facial Grimace
 Verbalization of negative perception to self
3. Imbalance Nutrition: Less than
body requirements related to
inability to digest adequate
25
nutrients

26. IV. PROBLEM LIST
Actual
Problem Problem Remarks
Number
Impaired liver function related The client exhibited an abnormally elevated
1 to hepatotoxic medication as Liver Funtion tests, indicating an impaired
evidenced adverse reaction of liver funtion.
Isoniazid
2 Acute pain related to Patient has complaints of right upper quadrant
inflammation and swelling of pain after eating or belching. The problem is
the liver as evidenced by pain in suspected to persist to impairment of the liver.
right upper quadrant
3 Imbalance Nutrition: Less than There is a decrease in weight due to feeding
body requirements related to modifications caused by his present liver
inability to digest adequate impairment. Thus, the client is unable to
nutrients nourish his body in desireable range (BMI of
18. 5) Weight loss is clearly evident due to
the fall of his weight from to 58 kg to 55kg
26

27. 4 Disturbed body image related to Impairement in the liver has caused difficulty
increased production of excretion of metabolic waste such as
Bilirubin as evidenced by bilirubin, such excessive amount of bilirubin
jaundice manifested from the client’s yellowish
discoloration of skin, sclera and nail beds.
27

28. V. NURSING CARE PLAN
Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Impaired liver After 2 weeks Review results by obtaining Indicates presence of hepatotoxic After 2 weeks of
“ kahit ng bata pa ako, function of nursing previous Liver Function medication and need for medical nursing
naninilaw ako sa pag related to intervention, Tests such as SGPT, treatment. intervention,
umiinom ako ng hepatotoxic there will be a SGOT, Creatinine, Alkaline Liver function
Isoniazid” as medication as decrease Phosphtase test taken last
verbalized by the evidenced manifestation of October 31.2011
patient adverse liver failure as Emphasize the importance To reduce incidence of cirrhosis decreased as of
reaction of evidenced by an of abstaining any forms of or severity f liver damage/failre result taken last
Isoniazid improvement in alchoholic beverages November
Objective: liver function 19,2011
 With history of of results from
taking isoniazid previous Encouraged client to avoid To prevent aggravation of AST = 104 (n:
for23 days examinations. eating deep fried foods, disease. Liver is responsible for 15-37)
medications chicken skin, chicharon fat emulsification ALT =268 (n:30-
 Jaundice which are high in fats 65)
 Enteric sclera
 Elevated Liver
function tests, Administered hepato To promote pharmacologic
AST =3603 u/L protectors and treatment of disease
ALT = 3933 u?L multivitamins as orderesd
 Bilirubin: 433.50 a.) Silymarin
umol/L b.) Essential Forte
 UZ result: Liver is c.) Mutivitamns
likely contracted
Emphasized the need for To monitor and determine
follow-up check-ups and effecitiveness of therapeutic
ahering to monitoring of regimen
Liver function tests such as
SGPT, SGOT, Creatinine,
Alkaline Phosphtase .
28

29. Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Acute pain By the end of  Monitored Vital signs q 30 until Baseline data is important to help
By the end of
“ Sumasakit ang related to 8 hours of the patient stable especially Determine patient’s current health
8 hours of
tsyan ko sa tuwing inflammation nursing respiratory rate and blood status and evaluate efficacy of nursing
nakain ako” as and swelling intervention, pressure nursing interventions rendered intervention,
verbalized by the of the liver as the the
patient evidenced by Patient will  Assess the patient’s pain by using The client’s report of pain is the Patient will
pain in right verbalize a the 10 point pain rating scale q4 single most reliable indicator of verbalized a
upper decrease in hrs or PRN during the 2-10pm pain. decrease in
Objective: quadrant pain scale shift. pain scale from
from 6/10 to 6/10 to 0/10
 Pain Scale of 0/10  Performed comprehensive Pain is a subjective experience and
6/10 assessment to pain include must be described by the client in
 With complaints location , characteristic, onset, order to plan effective treatment
of pain after duration, frequency,
meal or during quality, intensity or severity
 Facial grimace
 Provided nonpharmacologic pain Relaxation techniques decrease
relief methods, such as breathing oxygen consumption, respiratory
exercises, music therapy, rate, heart rate, and muscle tension,
distraction and progressive which interrupt the cycle of pain–
relaxation before, after, and if anxiety–muscle tension.
possible during painful activities.
 Kept side rails up and bed in low
position. To reduce likelihood of falls and to
promote a safe environment.
 Administered Pain medications as
ordered such as Tramadol To promote pharmacologic
measures in relieving pain
29

30. Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Imbalance After 4 hours of Assessed the present weight of the Provides baselinedata about the After 4 hours
“Ang lake pa ng Nutrition: nursing client by the use of weighing scale client. of nursing
katawan ko dati Less than intervention, the intervention,
kumpara sa body patient will Determined the client’s attitude Psychological factors towards the patient
ngayon. ang lake requirements verbalize towards eating. eating may affect one person’s verbalized
talaga ng related to understanding on appetite and also to know the understanding
pinangayat ko” inability to the importance client’s eating habits. on the
as verbalized by digest of proper diet importance
the patient adequate Educated the client regarding the Education provides ample of proper diet
nutrients as importance of eating healthy foods information that the client may
Objective: evidenced in terms of benefits to his body not be aware 8of, hence leading
by BMI of such as green leafy to the kind of eating habits and
 Weight Loss 18.5 vegetablesfoods, citrus fruits such diet he is following.
from 58 to 55 as dalandan, orange, calamansi
kg juice, bayabas to increase the
 BMI of 18.5 body’simmunity
(undewrweight
) Instructed the client to avoid Caffeinated beverages may
 Complaints of caffeineated beverages like coffee, decrease the appetite and will
right upper tea, softdrinks and energy drinks. make the client feel full easily
quadrant pain
after eating Encourged the client to eat in small To minimize occurances of
frequent feeding right upper quadrant pain by
reducing the workload of the
Instructed the patient to avoid foods liver
rich in fats found in deep fried
foods, chicken skin, chicharon and To prevent aggravation of
foods rich in salt such as disease. Liver is responsible for
Canned goods and procesed meats fat emulsification and water
Seasoned foods sodium-regulation
Dried fish
To assist as needed and to offer
Stayed with client during meals. support and encouragement.
30

31. Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Disturbed body At the end of  Observed emotional May indicate acceptance After 8 hours of
“Ang panget image related to 8 hours of changes. or non-acceptance of nursing
kong tignan, increased nursing situation. intervention the
para na akong production of intervention  Assess mental and physical influence of client
spongebob” as Bilirubin as the client will present condition on the client’s To determine factors verbalized
verbalized by the evidenced by verbalize emotional state influencing emotional understanding
patient jaundice understanding state of body
of body  Established therapeutic nurse-client changes.
changes. relationship
Objective:
 Regognized behaviours indicative of Conveys an attitude of
 Verbalization over concern with body and it’s process caring and to develop a
of negative sense of trust
perception to  Encourage verbalization of concerns of
self disease process, future expectations. Serves as objective cues to
 With determine extent of
jaundice and  Invovle patient in planning care and
enteric sclera scheduling activities
Provides opportunity to
 Assessed clients current level of identify fears/mis-concept
adaptation and progress. and deal with them
directly.
 Assist with grooming needs as necessary.
Enhances of feeling of
competency/self worth.
Encourages independence
and participation in
therapy
To determine coping
abilities and skills
Maintaining appearance
enhances self-image.
31

32. Cues/Needs Nursing Planning Implementation Rationale Evaluation
Diagnosis
Subjective: Risk for After 2 weeks  Determined  Adverse reaction of After 2 weels of nursing
“Matatagalan pa bago situational low of nursing individual factors that medicating Isoniazid intervention, the patient
bumalik ang kulay ko” as self-esteem intervention, would contirbute in has caused yellowish verbalized
verbalized by the patient related to the patient will diminishing self- discoloration of skin acknowledgement of
disturbed body acknowledge esteem factors that contributes to
Objective: image as factors that feelings of low self-esteem
 With Jaundice, Enteric evidenced by lead to  Determined client  To detemine
Sclera and Yellowish Jaundice possibility of awareness of own awareness of
Nail beds feelings of low responsibility for situation to detemine
self-esteem dealing with the individual’s
situation, personal coping skills
growth and so forth
 Assessedfore  Contributes to view
presence of negative of situation as
attitudes or self-talk hopeless/ difficult
 Observed non-verbal  Incongruencies
languanges between verbal and
non-verbal
communication
requires clarification
 Assesed family  To determine
dynamics and support adequate spport
of client system of the patient
Provide information
about disease process, To help the patient
prognosis, and alleviate the emotional
treatment needs. disturbances that he’s
Enhance self-concept, feeling and for the
acceptance of situation patient’s faster
recovery and will do
no further harm.
32

33. MEDICAL-SURGICAL MANAGEMENT
i. Pharmacotherapeutics
DRUG NAME MECHANISM OF ACTION INDICATION SIDE NURSING
EFFECTS IMPLICATION
Brand Name: Among the pharmacodynamic Acute, subacute & Abdominal pain, Do not use Essentiale
properties were reported chronic nausea, diarrhea in hypersensitivity or all
hepatoprotective effects found in hepatitis; toxic and allergic ergy to any ingredients
Brand Name:
numerous experimental models into metabolic liver reaction(skin of the preparation.
Essential Forte acute liver damage eg, induced by diseases, intoxications rash)
ethanol, alcyl alcohol, carbon (eg from
Classification:
tetrachloride, paracetamol and drugs); infection, fatty
Hepatic Protectors
galactosamine. Moreover, in degeneration of the liver
Dosage: chronic models (ethanol, due to
thioacetamide, organic solvents), alcohol, hypernutrition,
1 tab
the inhibition of steatosis and DM,
fibrosis was also seen. As active kwashiorkor, pregnancy;
principle has been suggested cholestasis; pre- & post-
accelerated membrane regeneration op care,
and stabilisation, inhibited lipid esp in liver/gallbladder
peroxidation and inhibited collagen surgery
synthesis.
33

34. DRUG NAME MECHANISM OF ACTION INDICATION SIDE NURSING
EFFECTS IMPLICATION
Generic Name: Contains fat soluble vitamins (A, D Treatment and GU: Urine Assess patient for signs of
Theravim and E) and most water-soluble prevention of vitamin Discoloration nutrition deficiency prior to
vitamins (B-Complex vitamins B1, deficiencies. MISC: Allergic and throughout therapy.
Brand Name: B2, B3, B5, B6, B12, Vit. C, biotin Dietary supplement for reactions to Instruct to notify side effects
and folic acid). These vitamins are a the treatment and preservatives, of medication to physician.
Multivitamin diverse group of compounds prevention of vitamin additives or Encourage to comply on
necessary for normal growth and deficiencies. These colorants. medication.
Classification: development. Many act as vitamins are necessary Encourage patient to comply
coenzymes or catalysts in numerous for normal growth and Contraindicated with physicians
Vitamins and metabolic processes. Liquid development. Many act in ypersensitivity recommendations. Explain
Supplements products do not contain folic acid. as coenzymes or to preservatives, that the best source of
catalysts in numerous colorants, or vitamins is a well balanced
Dosage: metabolic processes additives, diet with foods from the 4
including basic food groups.
1 tab tartrazine,
saccharin, and
aspartame
34

35. DRUG NAME MECHANISM OF ACTION INDICATION SIDE NURSING
EFFECTS IMPLICATION
Brand Name: Liver Cell Growth-Silymarin from -Liver Diseases, acute, Common:
milk thistle appears to promote the chronic hepatitis Diarrhea caused Know the 10 rights in giving
Silymarin growth of some types of cells in the - Protect liver from by mild laxative medication
liver. Milk thistle is not used to prevent toxins, heavy metals, effect, uterine
Hepatitis C Virus from causing liver alcohol, poisons and menstrual
Brand Name: disease. Rather, milk thistle is used - Cholagogue stimulation. Observe proper position in
with the hope that it would minimize - Fatty degeneration of taking medication to prevent
Liveraide the damage to the liver that HCV can the liver Case report: One aspiration
cause. - Jaundice report of a
Antihepatotoxic Activity-Studies
- Psoriasis patient who Encourage patient drink
Dosage: - Uterine tonic, experienced plenty of water to enhance
suggest that silymarin from milk thistle
menstrual difficulties intermittent absorption
can block various types of toxins from
1 tab - Spleen, kidney, gall episodes of
entering and injuring liver cells.
bladder tonic sweating, Encourage patient to comply
Antioxidation-Milk thistle Silymarin - Varicose veins nausea, to the physicians
may be an effective "antioxidant," vomiting, recommendation concerning
which means milk thistle may help diarrhea, about the drug.
fight a destructive chemical process in abdominal pain,
the body known as "oxidation." In weakness and
oxidation, harmful substances collapse that
produced in the body (called free resolved after
radicals) can damage cells. Some discontinuation
studies suggest that milk thistle of supplement.
silymarin can prevent these substances
from damaging liver cells.
Inflammation Inhibition-Milk
thistle's Silymarin is thought to prevent
inflammation (swelling) of the liver;
this may be described as displaying
anti-inflammatory properties.
35

36. DISCHARGE HEALTH TEACHING
Content Strategy
M-medication To adhere in prescribed  Instruct patient to take the prescribed
 Multivitamins therepautic regimen for health medications as ordered by the
 Silymarine maintainance and resistance. physician.
 Liveraid.  Instruct patient to avoid taking OTC
drugs unless given with medical
advice
E-exercise To promote a healthy
 Encourage patient to include atleast 30
lifestyle, maximizing the
minutes of walking or jogging or
level of health and increase
perfrom tolerated and preferred
the body’s immunity.
activities as a means of exercise
T-treatment  Encourage patient to attend follow up
Attending the follow up
check up of Liver Function Tests to
check up.
determine the progression or
aggravation of disease
36

37. Health teaching about the  Instruct the patient toavoid all forms
H-health teaching
disease, exercise and diet. of vices that could affect his health
status especially such habits that are
hepatotoxic liver like smoking
cigarettes and drinking alcohol
beverages.
Instruct that they need to have  Emphasize the importance of adhering
O-OPD
a health check up. to medications and attending follow-
up check up.
 Instruct patient to eat in small frequent
Maintain and ensure adequate
D-diet
feeding to reduce work load of liver
intake for noursihment,
 Instruct patient to avoid consumption
of salty and fatty foods. .
 Advise patient to refer to health care
If any signs of symptoms are
S-signs and symptoms
professional if jaundice, right upper
present go to the nearest
pain and other discomforts persists.
hospital for check up.
37

38. VI. ONGOING APPRAISAL
Patient B.R, a 25 year old male, has been admitted to Ospital ng Makati last October 31,
2011 with the chief complaint of jaundice and on and off fever. Upon assessment, it was
observed that the patient is conscious, with generalized jaundice and with enteric sclera.
Thus, was diagnosed to have a drug-induced hepatitis. The client is admitted in Emergency
Room and inserted of D5LR 1 L x 125cc/hr at left metacarpal vein with laboratory tests
rendered such as HbsAg taken on October 31, 2011 and resulted as non-reactive, but
observed to have elevated AST of 3603 u/L (n= 15-37), ALT of 3933 u/L (n=30-65),
Alkaline Phosphatase of 190u/L (n=50-165 u/L). ECG taken on same date reveals to have
AV block I, CBC, Na, K, BUN, ultrasound and Chest X-Ray are taken likewise.
Blood coagulation test done at November 1, 2011 with an increase of Prothrombin time
of 27.7 sec (n=10.4-14 sec), INR (2.78 n= 0.88-1.21), PTT of 75 sec (n =30.4-41.2 sec). The
client is ordered for low salt and low fat diet. Abdominal ultrasound reveals liver to be likely
contracted, suggests follow-up scan after 3 days.
. By November 2, 2011, Blood Coagulation tests were repeated and ordered for TPAG.
The client is prescribed with Vitamin K 1 amp Q8 x 3 doses; regulate IVF for 1 L x 100cc/hr
and for repeat of ultrasound. From the subsequent weeks upon admission the The client
complaints of body malaise, fever and loose of appetite
By November 5, latest ultrasound reveals same result like before. By November 15,
2011, patient claims to have pricking right upper quadrant pain and was given Tramadol 500
mg tab. by November 16, 2011 the client was ordered for chest x-ray Postero-Anterior View
Lateral, and chest CT scan and Repeat AFB
Presently, the client is for discharge with latest liver function test taken last November
19, 2011. The client appears jaundice, with enteric sclera and yellosih nail beds with vital
signs of Temp.: 36.1°c RR: 14cpm PR: 64cpm BP: 110/70mmHg.
38

39. 39