Dengue

CASE STUDY
OF
DENGUE HEMORRHAGIC FEVER
GRADE III

Introduction

Dengue fever, also known as breakbone fever, is an infectious tropical disease caused by the dengue virus. Symptoms include fever, headache, muscle and joint pains, and a characteristic skin rash that is similar to measles. It is a life threatening condition resulting in bleeding, low levels of blood platelets and blood plasma leakage, or into dengue shock syndrome, where dangerously low blood pressure occurs. In a small portion of these cases the virus causes increase vascular permeability that lead s to bleeding diathesis or disseminated intravascular coagulation (DIC) known as dengue Hemorrhagic Fever. Typically, people infected with dengue virus are asymptomatic (80%) or only have mild symptoms such as an uncomplicated fever. Others have more severe illness (5%), and in a small proportion it is life-threatening. The incubation period (time between exposure and onset of symptoms) ranges from 3–14 days, but most often it is 4–7 days. Therefore, travelers returning from endemic areas are unlikely to have dengue if fever or other symptoms start more than 14 days after arriving home. Children often experience symptoms similar to those of the common cold and gastroenteritis (vomiting and diarrhea), and generally have less severe symptoms than adults, but are at greater risk of severe complications.
The course of infection is divided into three phases: febrile, critical, and recovery.
In febrile phase involves high fever, often over 40 °C (104 °F), and is associated with generalized pain and a headache; this usually lasts two to seven days.
In critical phase, this follows the resolution of the high fever and typically lasts one to two days. During this phase there may be significant fluid accumulation in the chest and abdominal cavity due to increased capillary permeability and leakage. This leads to depletion of fluid from the circulation and decreased blood supply to vital organs.
In recovery phase occurs next, with resorption of the leaked fluid into the bloodstream. This usually lasts two to three days. The improvement is often striking, but there may be severe itching and a slow heart rate.
The reason for studying or knowing more about Dengue Hemorrhagic Fever is, the diseases is very fatal when it is not discovered immediately, so we must be all aware about the s/Sx so that the disease can be easily detected to avoid different risk and complication and also death.

Patient’s Profile

Name: Child X
Age: 5 years old
Address: Alagao, Bauan Batangas
Birthday: may 22, 2007
Nationality: Filipino
Religion: roman catholic
Date of admission: October 9, 2012
Time of Admission: 8:00 pm
Chief complain: fever cough and colds
Admitting diagnosis: to consider dengue hemorrhagic fever
Final diagnosis: dengue hemorrhagic fever grade 3

Patient’s history

Clinical appraisal
Child x admiited for the first time at Bauan General Hospital on October 9, 2012 complaining of
Fever,cough and colds with the diagnosis of dengue hemorrhagic fever.

Present Health History Client’s condition started 3 days prior to admission. Patient had an on an off fever with cough and colds. Then 2 days prior to admission, patient still have fever accompanied by abdominal pain and vomits twice at home. One day prior to admission, patient is a febrile, but few hours later there is recurrence of fever and there is decrease of appetite. Patient was brought to his pediatrician’s clinic for consultation. Different tests were performed like CBC, and urinalysis. Then after that, he has been referred to Bauan General Hospital for further evaluation and examination. Then he has been admitted here at Bauan General Hospital.

Past Health History According to the parents of the patient, the child did not experienced having serious health problems other than fever, cough and colds. He had a complete immunization and no known allergies. He had no previous hospitalization.

Family History Patient X is the youngest child of his parents among their three children. The client has no history of asthma, diabetes mellitus, tuberculosis, cancer, and hypertension.

Personal History During free time, the patient loves to watch television especially cartoons and he also plays outside with his brother and neighbors. With regards to his sleep and rest pattern, he usually took a nap in the afternoon during weekends at approximately 2-3 hours and during at night, he sleeps early at around 7-8 pm. His usual diets are just the common foods prepared by his mother like, rice with meat or fish, fruits and seldom he eat vegetables. He loves to eat candies, chocolates and ice cream.

Social History Patient X has a close and harmonious relationship with all the members of the family. They usually celebrate feast of different patron saints. He also use’s po and opo to elders. He is currently studying as a kindergarten in the school near them. Patient X family live in a small Bungalow house and regards to availability of community resources they have a health center, church and school.

PHYSICAL ASSESSMENT

Date Assessed: October 10, 2012
General Assessment: Conscious and Coherent
Initial Vital Sign: CR- 102bpm, Temp- 38.10C, RR-23/min, BP- 80/60mmHg Area assessed | Technique | Findings | Evaluation | Skin color | Inspection | > brown skin, evenly distributed> Slightly dry skin> Warm to touch | >> due to elevated body temperature(38.10c) | Head Hair Face | Inspection | > With short hair, evenly distributed> (-) lice> Slightly Puffy Face | > due to increase number and size of pores in the capillaries | Eyes | Inspection | > symmetrically aligned with pupils equally round reactive to light and accommodation | | Ears | Inspection | > Symmetrically aligned> sounds equally perceived in both ears | | Nose | Inspection | > Symmetrically aligned without discharged | | Mouth Lips Teeth | Inspection | >slightly dry lips> presence of tooth decay | >Due to decrease fluid intake> Due to improper hygiene or Vit. C deficiency | Chest and lungs | inspectionauscultation | > equally rise and fall> There are fuzziness on both infrahilar area | > Due to infrahilar pneumonitis, Bilateral | Heart | Auscultation | >Heart and other chest structure are normal | | Abdomen | > Palpation | > (+) colic> (+) Ascites | > Due to increase number and size of pores in the capillaries | Upper Extremities Pulses Nails Nails Bed | PalpationInspection | >Bouncing pulsesTransparent, smooth And convex>pale | > Due to decrease blood flow | Lower Extremities Distal pulses | Palpation | > | | Musculoskeletal system | Inspection | > Equal on both sides of the body>muscle weakness | > due to presence of present illness |

PATHOPYSIOLOGY

Precipitating | Environmental conditions (open spaces with water | | | pots, and plants) | Immunocompromise | Mosquito carrying dengue virus |

Predisposing | | Geographical area – tropical islands in the | Pacific (Philippines) and Asia |

Aedes aegypti (dengue virus carrier): 8-12 days of viral replication on mosquitos’ salivary glands

Bite from mosquito (Portal of Entry in the Skin)

Allowing dengue virus to be inoculated towards the circulation/blood (Incubation Period: 3-14 days

Virus disseminated rapidly into the blood and stimulates WBCs including B lymphocytes that produces and secretes immunoglobulins (antibodies), and monocytes/macrophges, neutrophils

Antibodies attach to the viral antigens, and then monocytes/macrophages will perform phagocytosis through Fc receptor (FcR) within the cells and dengue virus replicates in the cells

Entry to the bone marrow

Entry to the spleen Recognition of dengue viral antigen on infected monocyte

Release of cytokines which consist of vasoactive agents such as interleukins, tumor necrosis factor, urokinase and platelet activating factors which stimulates WBCs and pyrogen release

Dengue

Cellular direct destruction and infection of red bone marrow precursor cells as well as immunological shortened platelet

Virus ultimately targets liver and spleen parenchymal cells where infection produces apoptosis/cell death

Hepatosplenomegaly

Thrombocytopenia

Dengue Hemorrhagic

Increase number and size of the pores in the capillaries which leads to a leakage of
Fluid from the blood to the interstitial fluid (capillary leakage)

Ascite

Pleural effusion

Complications:
Intense bleeding
Pulmonary Edema
Shock
Very low blood pressure Liver cirrhosis
Death

Recovery

ANATOMY AND PHYSIOLOGY

CIRCULATORY SYSTEM
The Circulatory System is responsible for transporting materials throughout the entire body. It transports nutrients, water, and oxygen to your billions of body cells and carries away wastes such as carbon dioxide that body cells produce. It is an amazing highway that travels through your entire body connecting all your body cells.
Parts of the Circulatory System
The circulatory System is divided into three major parts: 1. The Heart 2. The Blood 3. The Blood Vessels
The Heart
The Heart is an amazing organ. The heart beats about 3 BILLION times during an average lifetime. It is a muscle about the size of your fist. The heart is located in the center of your chest slightly to the left. Its job is to pump your blood and keep the blood moving throughout your body.
It is your job to keep your heart healthy and there are three main things you need to remember in order to keep your heart healthy. 1. Exercise on a regular basis. Get outside and play. Keeps that body moving (walk, jog, run, bike, skate, jump, swim). 2. Eat Healthy. Remember the Food Pyramid and make sure your eating your food from the bottom to top. 3. Don't Smoke! Don't Smoke! Don't Smoke! Don't Smoke! Don't Smoke!
The Blood
The blood is an amazing substance that is constantly flowing through our bodies. * Your blood is pumped by your heart. * Your blood travels through thousands of miles of blood vessels right within your own body. * Your blood carries nutrients, water, oxygen and waste products to and from your body cells. * A young person has about a gallon of blood. An adult has about 5 quarts. * Your blood is not just a red liquid but rather is made up of liquids, solids and small amounts of oxygen and carbon dioxide.
Blood Cells * Red Blood Cells are responsible for carrying oxygen and carbon dioxide. Red Blood Cells pick up oxygen in the lungs and transport it to all the body cells. After delivering the oxygen to the cells it gathers up the carbon dioxide(a waste gas produced as our cells are working) and transports carbon dioxide back to the lungs where it is removed from the body when we exhale(breath out). There are about 5,000,000 Red Blood Cells in ONE drop of blood.

* White Blood Cells help the body fight off germs. White Blood Cells attack and destroy germs when they enter the body. When you have an infection your body will produce more White Blood Cells to help fight an infection. Sometimes our White Blood Cells need a little help and the Doctor will prescribe an antibiotic to help our White Blood Cells fight a large scale infection.

* Platelets are blood cells that help stop bleeding. When we cut ourselves we have broken a blood vessel and the blood leaks out. In order to plug up the holes where the blood is leaking from the platelets start to stick to the opening of the damaged blood vessels. As the platelets stick to the opening of the damaged vessel they attract more platelets, fibers and other blood cells to help form a plug to seal the broken blood vessel. When the platelet plug is completely formed the wound stops bleeding. We call our platelet plugs scabs. Plasma * Plasma is the liquid part of the blood. Approximately half of your blood is made of plasma. The plasma carries the blood cells and other components throughout the body. Plasma is made in the liver.
The Blood Vessels
In class we talked about three types of blood vessels: 1. Arteries 2. Capillaries 3. Veins
Arteries
Arteries are blood vessels that carry oxygen rich blood AWAY from the heart. Remember, A A Arteries Away, A A Arteries Away, A A Arteries Away.
Capillaries
Capillaries are tiny blood vessels as thin or thinner than the hairs on your head. Capillaries connect arteries to veins. Food substances (nutrients), oxygen and wastes pass in and out of your blood through the capillary walls.
Veins
Veins carry blood back toward your heart.

LYMPHOCYTE

A lymphocyte is a type of white blood cell in the vertebrate immune system. In the circulatory system they move from lymph node to lymph node. This contrasts with macrophages, which are rather stationary in the nodes.
By their appearance under the light microscope, there are two broad categories of lymphocytes can be divided into large lymphocytes and small lymphocytes. Large granular lymphocytes include natural killer cells (NK cells). Small lymphocytes consist of T cells and B cells.
MONOCYTE
Monocytes are produced by the bone marrow from hematopoietic stem cell precursors called monoblasts. Monocytes circulate in the bloodstream for about one to three days and then typically move into tissues throughout the body.
NEUTRROPHIL GRANOLUCYTES
In general, they are referred to as either neutrophils, the most abundant type of white blood cells in mammals and form an essential part of the innate immune system. These phagocytes are normally found in the bloodstream. However, during the acute phase of inflammation, particularly as result of bacterial infection, neutrophils leave the vasculature and migrate toward the site of the inflammation in a process called chemotaxis.

EOSINOPHILS GRANULOCYTES

Eosinophil granulocytes, usually called eosinophils, are white blood cells that are one of the immune system components responsible for combating multicellular parasites and certain infections in vertebrates. Along with mast cells, they also control mechanisms associated with allergy and asthma. They are granulocytes that develop during hematopoiesis in the bone marrow before migrating into blood.

BASOPHIL GRANULOCYTES

Basophil granulocytes, mostly referred to as basophils, are the least common of the granulocytes, Basophils appear in many specific kinds of inflammatory reactions, particularly those that cause allergic symptoms. Basophils contain anticoagulant heparin, which prevents blood from clotting too quickly. They also contain the vasodilator histamine, which promotes blood flow to tissues.

CIRCULATORY SYSTEM

Laboratory Results

October 8, 2012 ( 10:25 am )
URINALYSIS
MICROSCOPIC | NORMAL VALUE | RESULT | ANALYSIS | Color | Straw-dark Amber | Light Yellow | Normal | Transparency | Clear | Slightly turbid | Normal | Specific Gravity | 1.005-1.025 | 1.025 | Normal | pH | 4.8 – 6.5 | 6.5 | Normal | WBC | 0-1/hpf | 1-2/hpf | | RBC | 0-1/ hpf | 0-2/ hpf | | Epithelial cells | Few | Few | Normal | Amorphous Urates | Few | Few | Normal | CHEMICAL TEST | Protein | Negative | Negative | Normal | Sugar | Negative | Negative | Normal |

October 9, 2012
DENGUE NS1AG and IgG/IgM Examination | RESULT | ANALYSIS | DENGUE NS1Ag | POSITIVE | Indicate presence at high concentrations in the sera of DV infected patients during the early clinical phase of the disease | DENGUEIgGIgM | NEGATIVE | Its confirming the high specificity of this assay |

HEMATOLOGY
Date: October 8, 2012 PARAMETERS | NORMAL VALUES | RESULTS | ANALYSIS | Erythrocytes | 4.6-6.2 10^6/uL | 4.44 | Normal | Hemoglobin | 140- 180 g/L | 134.00 | Slightly Decrease | Hematocrit | 0.40- 0.54 | 0.40 | Normal | Leukocytes | 4.5 – 11 10^3/uL | 4.20 | Normal | Neutrophils | 0.45 – 0.65 | 0.68 | Slightly elevated | Lymphocytes | 0.02 -0.35 | 0.20 | Normal | Monocytes | 0.02 – 0.35 | 0.12 | Normal | Eosinophils | 0.02 – 0.04 | 0 | | Basophils | 0-0.1 | 0 | | Platelet | 150 – 250 10^3/uL | 230 | Normal |

Date: October9, 2012 PARAMETERS | NORMAL VALUES | RESULTS | ANALYSIS | Erythrocytes | 4.6-6.2 10^6/uL | 5.01 | Normal | Hemoglobin | 140- 180 g/L | 130 | Decrease: Indicates a reduction in either the number or the size of red blood cells. | Hematocrit | 0.40- 0.54 | 0.37 | Decrease; indicates there is bleeding | Leukocytes | 4.5 – 11 10^3/uL | 4.09 | Normal | Neutrophils | 0.45 – 0.65 | 0.62 | Normal | Lymphocytes | 0.02 -0.35 | 0.29 | Normal | Monocytes | 0.02 – 0.35 | 0.08 | Normal | Eosinophils | 0.02 – 0.04 | 0 | | Basophils | 0-0.1 | 0 | | Platelet | 150 – 250 10^3/uL | 169 | Normal: But there’s a decrease in no. from the previous exam |

DATE: October 10, 2012 PARAMETERS | NORMAL VALUES | RESULTS | ANALYSIS | WBC | 5.0- 10.0 | 6.40 | Normal | RBC | MALE: 4.6 - 6.2Female: 4.2 – 5.4 | 4.50 | Normal | HEMOGLOBIN | MALE: 140-160FEMALE: 120-140 | 133.0 | Decrease: Indicates a reduction in either the number or the size of red blood cells | HEMATOCRIT | MALE: 0.40- 0.54FEMALE: 0.37- 0.47 | 0.39 | Decrease: indicates that there is bleeding | Neutrophils | 0.45 – 0.65 | 0.64 | Normal | Lymphocytes | 0.02 -0.35 | 0.30 | Normal | Monocytes | 0.02 – 0.35 | 0.06 | Normal | Platelet | 150 – 250 10^3/uL | 158 | Normal: But there is a continuous reduction from the previous exam |

DATE:October 11, 2012 PARAMETERS | NORMAL VALUES | RESULTS | ANALYSIS | WBC | 5.0- 10.0 | 8.7 | Normal | HEMOGLOBIN | MALE: 140-160FEMALE: 120-140 | 112 | Decrease: Indicates a reduction in either the number or the size of red blood cells | HEMATOCRIT | MALE: 0.40- 0.54FEMALE: 0.37- 0.47 | 0.34 | Decrease: indicates that there is bleeding | Neutrophils | 0.45 – 0.65 | 0.47 | Normal | Lymphocytes | 0.02 -0.35 | 0.37 | Increase; indicates that the immune system are affected | Monocytes | 0.02 – 0.35 | 0.16 | Normal | Platelet | 150 – 250 10^3/uL | 186 | Normal: But slightly increase from the previous exam |

DATE: October 12, 2012 PARAMETERS | NORMAL VALUES | RESULTS | ANALYSIS | WBC | 5.0- 10.0 | 12.30 | Increase; indicates that there is infection | RBC | MALE: 4.6 - 6.2Female: 4.2 – 5.4 | 4.77 | Normal | HEMOGLOBIN | MALE: 140-160FEMALE: 120-140 | 143.0 | Normal | HEMATOCRIT | MALE: 0.40- 0.54FEMALE: 0.37- 0.47 | 0.43 | Normal | Neutrophils | 0.45 – 0.65 | 0.43 | Decrease: an indication of some underlying condition | Lymphocytes | 0.02 -0.35 | 0.47 | Increase: indicates that diseases affect the immune system | Monocytes | 0.02 – 0.35 | 0.10 | Normal | Platelet | 150 – 250 10^3/uL | 60 | Decrease: indicates that there is bleeding |

DATE: October 13, 2012 Hematocrit | 0.40 – 0.54 | 0.40 | Normal | Platelet | 150 – 350 | 88 | Decrease: slightly increase from previous exam still there is an indication of bleeding |

DATE: October 14, 2012 Hematocrit | 0.40 – 0.54 | 0.38 | Decrease: indicate that there is bleeding | Platelet | 150 – 350 | 125 | Decrease; continuously increase from the previous exam, indicates that the patient is recovering |

Nursing Care Plan

Assessment | | | | | | Subjective;“Nung isang araw dumugo ilong ng anak ko pero konting konti palang naman”as verbalized by the mother.Objectives:Weakness andirritability.· Restlessness.· V/S taken asfollows:BP= 120/80 mmHgCR= 90bpmPR= 20cpmTemp: 37.8c. | | | | | |

ASSESSMENT | DIAGNOSIS | PLANNING | NURSING INTERVENTION | RATIONALE | EVALUATION | Subjective:“Hanggang ngayon nga nilalagnat pa sya”as verbalized byher motherObjective: * Flushed skin, * warm totouch. * Slightly dry skin * Restlessness.V/S taken asfollows:T: 38.1P: 70R: 19BP: 110/90 | Increase body temperaturerelated toviral infection | After 4 hrs. Ofnursinginterventions,the patient willmaintain coretemperaturewithin normalrange. | Independent:Monitor vital signs especially temperatureRecord allsources of fluidloss such asurine, vomitingand diarrhea.Promotesurface coolingby means oftepid spongebath.Wrapextremities withcotton blankets.Providesupplementaloxygen. | Dysrhythmiasand ECGchanges arecommon dueto electrolyteimbalanceanddehydrationand directeffect ofhyperthermiaon blood andcardiactissues.To monitor orpotentiatesfluid andelectrolyteloses.To decreasetemperatureby meansthroughevaporationandconduction.To minimizeshivering.To offsetincreasedoxygendemands andconsumption. | After 4 hrs.Of nursinginterventions, thepatient wasablemaintaincoretemperaturewithinnormalrange |

ASSESSMENT | DIAGNOSIS | PLANNING | NURSING INTERVENTION | RATIONALE | EVALUATION | Subjective:“No verbal cues”Objective: * thin body * with muscle weakness * with poor muscle tone * lack of interest in food * Pale conjunctiva and mucus membrane.V/S taken asfollows:T: 36.6P: 98R: 18Bp: 110/90 | Imbalanced nutritionless thanbodyrequirementsrelated weakness of the body secondary to the presence of disease | After 8 hoursOf nursinginterventions,the client willbe able to increase food intake and gained enough energy | Independent:Determine ability to chew, swallow and taste Noted total daily intakeEliminate smellsfrom theenvironment.Avoid foods thatmight cause orexacerbateabdominalcramping likecaffeinatedbeverages,chocolate, orangejuice.Measureabdominal girth.Observe skin ormucousmembranedryness, andturgor. Noteperipheral edema and sacraledema.Assess abdomenfrequently forreturn to softness,appearance ofnormal bowelsounds, andpassage of flatus.Weigh daily.Collaborative:Monitor BUN,protein,prealbumin oralbumin, glucose,nitrogen balanceas indicated.Advance diet astolerated.Collaborative:Refer to physicaltherapy. | To determine if there is any factors that can affect ingestion or digestion of nutrientsTo reveal changes that should be made in clients dietary intakeReduces gastricstimulation andvomitingresponse.Might increaseabdominalcramping.Providesquantitativeevidence ofchanges ingastric orintestinaldistention.Hypovolemia,fluid shifts andnutritionaldeficitscontribute topoor skin turgor,edematoustissue.Indicates returnof normal bowelfunction andability toresume oralintake.Initial losses orgains reflectchanges inhydration.Reflects organfunction andnutritionalstatus andneeds.Carefulprogression ofdiet whenintake isresumedreduces risk ofgastric irritation | After 8 hours Ofnursinginterventions, the clientwas able to increase food intake and gained enough energy |

DRUG STUDY

NAME OF DRUG | CLASSIFICATION & MECHANISM OF ACTION | INDICATION | ADVERSE REACTION | CONTRAINDICATION | NURSING CONSIDERATION | MONITORING PARAMETERS | GENERIC NAME: ParacetamolBRAND NAME:Biogesic DOASAGE:5mlFREQUENCY:Every 4 hours for Temp> 37.8 C | Non –opioid analgesics Antipyretics Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or if other substances that synthesize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat regulating center. | Mild pain and fever | Hematologic: haemolytic anemia, leukopenia, neutropenia, pancytopeniaHEPATIC:JaundiceMetabolic: hypoglycaemiaSKIN: rash & uticaria | Contraindicated hypersensitive to drugUse cautiously in patient with long term alcohol use because the therapeutic doses cause hepatotoxicity | May use OTC & prescription products contain acetaminophen.Be aware of these when calculating daily doses Use liquid from the children and patient who have difficulty in swallowing In children , don’t exceed 5 doses in 24 hrs. | May decrease glucose, haemoglobin and hematocritMay decrease neutrophil, WBC, RBC and platelet |

NAME OF DRUG | CLASSIFICATION & MECHANISM OF ACTION | INDICATION | ADVERSE REACTION | CONTRAINDICATION | NURSING CONSIDERATION | MONITORING PARAMETERS | Generic Name:ClarithromycinBrand Name:KlazDosage:3.5mlRoute:P.O.Frequency:Every 12 hours | Anti- infectivesBinds to the 5OS subunits of bacterial ribosomes blocking protein synthesis; bacteriostatic or bacteriocidal, depending on consentration. | Community- acquired pneumonia caused by S. pnuemoniae, C. pnuemoniae, or M. pnuemoniae | CNS: headacheGI: diarrhea, nausea, taste pervertion, abdominal pain, vomiting (in children)Hematology: leukopenia, coagulation abnormalitiesSkin: rash in children | Contraindicated to patient hypersensitive to clarithromycin and erythromycin or other macrocides and those receiving pinozides or other drug that prolong QT interval or cause cardiac arrthythmiasUse cautiously in patient with hepatic or renal impairement | The safety and effectiveness to the ER from haven’t been established for treating other infections for which the original from has been approved.Monitor patient for infection.Obtain specimen for culture and sensitivity test before giving. | May decrease alkaline phosphatise, ALT, AST, billirubin, BUN, creatinine, GGT, LDH levelMay decrease neutrophil, thrombocyte and WBC counts |

NAME OF DRUG | CLASSIFICATION & MECHANISM OF ACTION | INDICATION | ADVERSE REACTION | CONTRAINDICATION | NURSING CONSIDERATION | MONITORING PARAMETERS | BRAND NAME:OmeprazoleBRAND NAME:Omsec DOSE:20 mgROUTE : IVFREQUENCY:Once a day | Anti-UlcerInhibits activity of acid (proton) pump and binds to hydrogen potassium adenosine triposphate and secretory surface of gastric parietal cells to block formation of gastric acids | | CNS: Dizziness, headacheG.I.: abdominal pain, constipation, diarrhea, flatulence, nausea & vomitingMUSCULOSKELETAL:Back painRESPIRATORY: cough, URTISKIN: rash | Contraindicated in patient hypersensitive to drug and its componentUse cautiously in patient in Barter’s Syndrome, hypocalemia, alkalosisLong term administration of bicarbonate with calcium or milk can cause milkalkali syndrome | Dosage adjustment maybe necessary in Asians and patient with hepatic impairmentDrug increase its own bioavailability with repeated doses.drug is unstable in gastric acid less drug is lost to hydrolysis because drug increase gastric pH | None reported |

NAME OF DRUG | CLASSIFICATION & MECHANISM OF ACTION | INDICATION | ADVERSE REACTION | CONTRAINDICATION | NURSING CONSIDERATION | MONITORING PARAMETERS | | | | | | | |

NAME OF DRUG | CLASSIFICATION & MECHANISM OF ACTION | INDICATION | ADVERSE REACTION | CONTRAINDICATION | NURSING CONSIDERATION | MONITORING PARAMETERS | | | | | | | |

NAME OF DRUG | CLASSIFICATION & MECHANISM OF ACTION | INDICATION | ADVERSE REACTION | CONTRAINDICATION | NURSING CONSIDERATION | MONITORING PARAMETERS | | | | | | | |