CASE STUDY:

Staphylococcal Scald Skin Syndrome

(SSSS)

Immanuel SyBSN III-IGroup 3

Mrs. Jeorjet EvangelistaSeptember 3, 2009

INTRODUCTION

A. Background of the Study

The client is a 1-year old female who was admitted last August 23, 2009 at 5:50 in the evening due to ulcerated wounds in the body. Staphylococcal scalded skin syndrome (SSSS), also known as Ritter von Ritterschein disease (in newborns), Ritter disease, and staphylococcal epidermal necrolysis, encompasses a spectrum of superficial blistering skin disorders caused by the exfoliative toxins of some strains of Staphylococcus aureus. It is a syndrome of acute exfoliation of the skin typically following an erythematous cellulitis. Severity of staphylococcal scalded skin syndrome varies from a few blisters localized to the site of infection to a severe exfoliation affecting almost the entire body.

B. Rationale of the Study

The researcher decided to choose this case because I want to acquire knowledge about Staphylococcal scalded skin syndrome that may cause severe damage of our skin, thus making us more prone to external acquisition of infection. I want to use the knowledge that I acquired in promoting awareness and sharing my knowledge to the people. With this information, people would not neglect simple wounds to become a threat for their own safety and health.

C. Significance of the Study

This study can help Nurses in providing information about proper management and care for patient who has the said disease. It also benefits us nursing students in gaining extra knowledge and information that we can use in the future. It can also educate people who lacks in information about the disease and also those people who are already experiencing or have the possibility of having it. Every individual is vulnerable in acquiring the disease, so everyone should be educated the importance of having a healthy lifestyle and clean environment to decrease the number of cases of SSSS.

BIOGRAPHIC DATA

Name: Ms. A.C Age: 1 year old Weight: 11.5 kgBirthday: October 2, 2007 Gender: FemaleCivil Status: Single Religion: Roman CatholicAddress: Brgy. Punta, Calamba City

Date of Confinement: Aug, 23 2009Time 5:50 pm

NURSING HISTORY

I. History

Ms. A.C. is a 1 year old female. She was born on October 2, 2007. Prior to her confinement she lives with her parents at Punta, Calamba Laguna. A Filipino citizen & her religious orientation is Roman Catholic. She has a medical insurance from Panasonic.

II. Past History

Ms. AC experienced past illnesses such as cough and colds. According to her mother, she had a complete vaccination (BCG, OPV, DPT, AMV, and AHB). She has no identified allergic response. There was no incident of any injuries and hospitalization in the past.

III. Present Illness

Ms. AC experienced the scaling of her skin four days prior to admission. She was not febrile. Three days prior to admission, wounds have started to appear. They bought ointments to apply on the infected area for two days. Ms. AC manifested signs of fever and was rushed to Emergency Room. IV. Chief Complaint

Ms. AC’s chief complaint was skin lesions and fever. According to her mother, three (3) days prior to admission, Ms. A.C. had skin lesions in the upper back, legs, buttocks and nose. Ms. A.C. also experienced fever the day prior to admission.

V. Family History

According to Ms. AC’s father, they have history no known history of family illnesses while Hypertension is a family illness in her maternal side.

Functional Health Pattern

A. Health Perception Pattern

Ms. AC’s mother stated that this is her baby’s first confinement. The mother states that they self medicate using OTC drugs and will settle for hospitalization if no progress results.

B. Nutritional-Metabolic Pattern

Ms. AC his typical daily meals before his illness begun was rice, chicken, vegetable and commercial milk. She eats 3 times a day; morning afternoon and merienda. She usually does not eat for supper. According to her mother, Ms. AC drinks 1 bottle of commercial milk and 1 bottle of water per day. The mother states that “hindi pa ngtutoothbrush yan”. Her weight was 11.5 kg. She was taking a vitamin C supplement in syrup form.

C. Elimination Pattern

Ms. AC’s usual bowel elimination pattern was twice a day. It’s yellow in color and not form. The frequency of urination is unidentified because she is still wearing diapers. She usually changes diapers three times a day. There was no presence of blood in the stool and urine.

D. Activity-Exercise Pattern

Ms. AC daily activity was playing inside and outside the house. Her exercise includes walking in the morning and playing in the afternoon. She was very active and alert.

E. Sleep-Rest Pattern

Mr. AC sleeps at night for 8 hours. He sleeps at 10:00 pm and rise at 6:00 am. She sleeps continuously with no disturbances. When she needs to sleep, her mother feed her with milk and sings lullaby. She does not take naps in the morning.

F. Role-relationship Pattern

Ms. AC lives with her parents. She is the only daughter of the family. Her needs were supplemented by her parents. According to her parents, Ms. AC serves as their happiness in life.

Physical Assessment

Name: Ms. A.C Age: 1 year oldGender: Female Weight: 11.5 kilograms

Vital SignsTemp: 36.3◦ CRespiratory Rate: 27 Cardiac Rate: 132

AREA TECHNIQUE NORMS FINDINGSANALYSIS and

INTERPRETATION

SKULL

Size, shape and symmetry of the skull

Inspection Palpation

Normocephalic and symmetrical, with frontal, parietal, and occipital prominences; Smooth skull contour

Rounded, normocephalic; smooth skull contour symmetrically

Normal

Presence of nodules, masses, and depressions

Palpation Inspection

Smooth, uniform consistence; absence of nodules or masses

Has no tenderness; no masses nor nodules

Normal

HAIR

Evenness of growth, thickness, or thinness of hair

Inspection Palpation

Evenly distributed and covers the whole scalp; maybe thick or thin

Evenly distributed hair but few; does not cover the whole scalp

Normal

Texture and oiliness over the scalp

Inspection Palpation

Silky; resilient hair

Silky; smooth and resilient hair.

Normal

Presence of infection and infestation

Inspection Palpation

No infection and infestation

No infection and infestation

Normal

EYES

EYEBROWS

Hair distribution, alignment, skin quality and movement

Inspection

Symmetrical and in line with each other; maybe black, brown or blond depending on race; evenly distributed

Symmetrical and aligned with each other; black; evenly distributed, movements are symmetrical.

Normal

EYELASHES

Evenness of distribution and direction of curl

Inspection

Evenly distributed; turned outward

Turned outward eyelashes: hair equally distributed.

Normal

EYELIDS

Surface characteristics and position (in relation to the cornea, ability to blink, and frequency of blinking)

Inspection

Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes open; eyelids meet completely when the eyes are closed; symmetrical

Able to close the eyes and has the ability to blink.

Normal

SCLERA

Color and clarity

Inspection

White in color; clear; no yellowish discoloration; some capillaries maybe visible

White sclera with some visible capillaries

Normal

PUPILS

Color, shape, and symmetry of size

Inspection Color depends on the person’s race; size ranges from 3-7 mm, and are equal in size; equally round

Pupil equally round.

Normal.

Light reaction and accommodation

Inspection Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual

Dilates when looking at far objects and constrict when looking at near objects.

Normal

EXTRAOCULAR MUSCLE

Eye alignment and coordination

Inspection Both eyes coordinated movement in unison, with parallel alignment

Eyed moves with parallel alignment.

Normal

EARS

Color, Inspectio Color same Same color Normal

symmetry of size and position

n as facial skin; symmetrical; auricle aligned with outer canthus of eye, about 10 degrees from vertical

as the facial skin; tip of auricle aligned at the outer canthus of the eye.

Texture, elasticity and areas of tenderness

Palpation Mobile, firm, and not tender; pinna recoils after it is folded

Smooth in texture, flexible and elastic pinna; no tenderness.

Normal

NOSE

Any deviation in shape, size, or color and flaring or discharge from the nares

Inspection

Symmetric and straight; no discharge or flaring; uniform color

Symmetric and straight; uniform color with no nasal flaring.

Normal

Nasal septum

Inspection Palpation

Nasal septum intact and in middle

Nasal septum intact and in midline.

Normal

Tenderness, masses and displacements of bone and cartilage

Palpation Not tender; no lesions

No tenderness wound present

Wounds can attribute to increase susceptibility to infection

MOUTH

LIPS

Symmetr Inspection Uniform Symmetrical; Dry and crack lips

y of contour, color and texture

Palpation pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips

dry lips and crack lower lip

may indicate deficient fluid intake or improper oral hygiene

BUCCAL MUCOSA

Color, moisture, texture, and the presence of lesions

Inspection Uniform pink color; moist, smooth, soft, glistening, and elastic texture

Uniform pink color; moist, smooth, soft

Normal

TEETH

Color, number and condition and presence of dentures

Inspection Teeth are starting to grow; white, shiny

Teeth are starting to grow; white, shiny

Normal

GUMS

Color and condition

Inspection Pink gums Pink gums. Normal

TONGUE

Color and texture of the mouth floor and frenulum

Inspection Pink color; moist; slightly rough; thin whitish coating; moves freely; no tenderness

Pink color; moist; thin whitish coating; moves freely; no tenderness

Normal

Position, color and texture, movement and base of the tongue

Inspection Central position; pink color; smooth tongue base with prominent veins

Geographical tongue with patches, central position

Patches in tongue may indicate deficient fluid intake or improper oral hygiene

THORAX

ANTERIOR THORAX

Breathing pattern

Inspection Quiet, rhythmic, and effortless respirations

Rhythmic, quiet breathing.

Normal

Temperature, tenderness, masses

Palpation Skin intact; uniform temperature; chest wall intact; no tenderness; no masses

Has intact skin; has equal warmth on both sides. No masses.

Normal

POSTERIOR THORAX

Shape, symmetry, and comparison of anteroposterior thorax to transverse diameter

Inspection Palpation

Anteroposterior to transverse diameter in ratio 1:2; chest symmetric

Symmetrical chest.

Normal

Spinal alignment

Inspection

Spine vertically aligned

Spine vertically aligned

Normal

Temperature, tenderness, masses, lesions

Palpation Skin intact; uniform temperature; chest wall intact; no tenderness; no masses ; no lesions

No masses nor tenderness: has equal warmth on each side; skin not intact with lesions

Wounds can cause increase susceptibility to infection

AXILLAE

Axillary, subclavicular, and supraclavicular lymph nodes

Inspection

No tenderness, masses, or nodules

No tenderness, masses, or nodules

Normal

ABDOMEN

Skin integrity

Inspection Unblemished skin; uniform color

Uniform color.

Normal

Abdominal contour

Inspection Flat, rounded (convex)

Has a flat and concave abdomen

Normal

Symmetry of contour

Inspection Symmetric contour

Has a symmetrical abdominal contour.

Normal

MUSCLES

Muscle size and comparison on the other side

Inspection Proportionate to the body: even in both sides

Proportionate to the body; in both sides.

Normal

Tremors in the muscles

Inspection No tremors No tremors. Normal

Muscle tonicity

Palpation Even and firm muscle tone

Firm muscle tone

Normal

JOINTS

Joint swelling

Inspection No swelling, no warmth, no redness, no pain

Absence of swelling, pain or redness.

Normal

Extremities Inspection Palpation

No swelling, no warmth, no redness, no pain.

Absence of swelling, redness or pain.

Normal

Neurological Assessment

Category Normal Findings Actual Findings

Mental Status

Level of Consciousness

Orientation

Awake

Oriented

Awake

Oriented

Laboratory Results

UrinalysisNormal Findings Interpretations

Color Colorless-dark yellow

Yellow normal

Transparency Clear Clear normalReaction 4.6-8.0 pH Alkaline Alkalinity may be

caused by disease and infection

Specific Gravity 1.005-1.030 1.010 NormalAlbumin absent Negative NormalSugar absent Negative NormalPus Cells 0-4 hpf 0-2/hpf NormalRBC 0-3 hpf 0-2/hpf Normal

ANATOMY AND PHYSIOLOGY

Skin

In zoology and dermatology, skin is an organ of the integumentary system made up of a layer of tissues that guard underlying muscles and organs. As the interface with the surroundings, it plays the most important role in protecting against pathogens. Its other

main functions are insulation and temperature regulation, sensation and vitamin D and B synthesis. Skin is considered one of the most important parts of the body.

Skin has pigmentation, melanin, provided by melanocytes, which absorbs some of the potentially dangerous radiation in sunlight. It also contains DNA repair enzymes which reverse UV damage, and people who lack the genes for these enzymes suffer high rates of skin cancer. One form predominantly produced by UV light, malignant melanoma, is particularly invasive, causing it to spread quickly, and can often be deadly. Human skin pigmentation varies among populations in a striking manner. This has sometimes led to the classification of people(s) on the basis of skin color.

The skin is often known as "the largest organ in the human body", weighing approximately 4.5 kilograms. This applies to exterior surface, as it covers the body, appearing to have the largest surface area of all the organs. Moreover, it applies to weight, as it weighs more than any single internal organ, accounting for about 15 percent of body weight. For the average adult human, the skin has a surface area of between 1.5-2.0 square meters; most of it is between 2-3 mm thick. The average square inch of skin holds 650 sweat glands, 20 blood vessels, 60,000 melanocytes, and more than a thousand nerve endings. Being the outer protective covering of the body, and being exposed to the environment, the skin is very vulnerable to growths, rashes, discolorations, cysts, burns, injuries, infections, and other disorders. Damaged skin will try to heal by forming scar tissue, often giving rise to discoloration and depigmentation of the skin.

Layers

The skin has two major layers which are made of different tissues and have very different functions.

Skin is composed of the epidermis and the dermis . Below these layers lies the hypodermis or subcutaneous adipose layer, which is not usually classified as a layer of skin.

EPIDERMIS

The outermost epidermis consists of stratified squamous keratinizing epithelium with an underlying basement membrane. It contains no blood vessels, and is nourished by diffusion from the dermis. The main type of cells which make up the epidermis are keratinocytes, with melanocytes and Langerhans cells also present.

The epidermis can be further subdivided into the following strata (beginning with the outermost layer): corneum, lucidum, granulosum, spinosum, basale. Cells are formed through mitosis at the innermost layers. They move up the strata changing shape and composition as they differentiate, inducing expression of new types of keratin genes. They eventually reach the corneum and become sloughed off (desquamation). This process is called keratinization and takes place within about 30 days. This layer of skin is responsible for keeping water in the body and keeping other harmful chemicals and pathogens out.

Blood capillaries are found beneath the epidermis, and are linked to an arteriole and a venule. Arterial shunt vessels may bypass the network in ears, the nose and fingertips.

DERMIS

The dermis lies below the epidermis and contains a number of structures including blood vessels, nerves, hair follicles, smooth muscle, glands and lymphatic tissue. It consists of loose connective tissue otherwise called areolar connective tissue - collagen, elastin and reticular fibers are present. Erector muscles, attached between the hair papilla and epidermis, can contract, resulting in the hair fiber pulled upright and consequentially goose bumps. The main cell types are fibroblasts, adipocytes (fat storage) and macrophages. Sebaceous glands are exocrine glands which produce, a mixture of lipids and waxy substances: lubrication, water-proofing, softening and antibactericidal actions are among the many functions of sebum. Sweat Glands open up via a duct onto the skin by a pore.

The dermis is made of an irregular type of fibrous connective tissue consisting of collagen and elastin fibers. It can be split into the papillary and reticular layers. The papillary layer is outermost and extends into the epidermis to supply it with vessels. It is composed of loosely arranged fibers. Papillary ridges make up the lines of the hands giving us fingerprints. The reticular layer is denser and is continuous with the hypodermis. It contains the bulk of the structures (such as sweat glands). The reticular layer is composed of irregularly arranged fibers and resists stretching.

The hypodermis is not part of the skin, and lies below the dermis. Its purpose is to attach the skin to underlying bone and muscle as well as supplying it with blood vessels and nerves. It consists of loose connective tissue and elastin. The main cell types are fibroblasts, macrophages and adipocytes (the hypodermis contains 50% of body fat). Fat serves as padding and insulation for the body.

FUNCTIONS

1. Protection: Skin gives an anatomical barrier between the internal and external environment in bodily defense; Langerhans cells in the skin are part of the immune system

2. Sensation: Skin contains a variety of nerve endings that react to heat, cold, touch, pressure, vibration, and tissue injury; see somatosensory system and touch.

3. Heat regulation: The skin contains a blood supply far greater than its requirements which allows precise control of energy loss by radiation, convection and conduction. Dilated blood vessels increase perfusion and heat loss while constricted vessels greatly reduce subcutaneous blood flow and conserve heat. Erector pili muscles are significant in animals.

DRUG STUDY

Drug’s Name Indication Contraindication Side effects Action Nursing

ConsiderationBrand name:Bactocil

Generic name:Oxacillin sodium

Therapeutic Class:Anti-infective

Pharmacologic class:Penicillins

Systemic infections caused by staphylococci

Contraindicated in patients hypersensitive to drug or other penicillins

CNS: neuropathy, irritability, lethargy, dizziness, fatigue

CV: thrombophlebitis.

GI: oral lesions, nausea, vomiting, diarrhea

GU: nephropathy

Penicillinase-resistant penicillin that inhibits cell-wall synthesis during microorganism multiplication.

Bacteria resist penicillin by producing penicillinase-enzymes that convert penicillin to inactive penicillic acid. Oxacillin resists these enzymes and inhibits the formation of the cell wall preventing binding sites of cells, thus prevents multiplication.

Before giving drug, as patient if there is allergic reaction to penicillin.

Give drug 1-2 hours before meals or 2-3 hours after meals.

Drug’s Name Indication Contraindication Side effects Action Nursing Consideration

Brand name: Treatment Contraindicated Skin: skin Bactericidal Restrict use of

Gentamycin

Generic name:Gentamicin sulfate

Therapeutic Class:Local anti-infective

Pharmacologic class:Topical drugs

and prophylaxis of superficial infections

Treatment of superficial burns of the skin caused by susceptible bacteria

in patients that are hypersensitive

irritation, allergic dermatitis

drug that disrupts bacterial protein synthesis by binding to ribosomes. Disruption of the protein mechanism of the bacterial cell prevents the development and growing of the cell leading to death, thus, prevents further multiplication

drug to selected patients; widespread use may lead to resistant organism

Prolonged use may result to overgrowth of non-susceptible organisms

Drug’s Name Indication Contraindication Side effects Action Nursing Consideration

Brand name:Bactifree

Generic name:Bacitracin

Therapeutic Class:Local anti-infective

Pharmacologic class: Topical drugs

Topical infections, abrasions, cuts, minor burns or wounds

Contraindicated in patients hypersensitive to drug and patients with atopy

Skin: rash, pruritis, allergic dermatitis

Bactericidal or Bacteriostatic depending on organism and concentration of drug. Inhibits cell-wall synthesis by disrupting the formation of the cell wall preventing binding sites of bacterial cells, thus prevents multiplication.

Clean skin before applying the ointment

Prolonged use may caused overgrowth of non-susceptible organisms, particularly Candida species

NURSING CARE PLAN

ASSESMEN DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

TS: “lage nyang kinakamot yung sugat nya” stated by the mother of the client

O: scratching of skin Open wounds

Risk for Infection

Risk Factor: Broken skin

The client will be able to be free from infection after shift via interventions

> Encourage bed rest

> Encouraged mother to wash hands frequently when attending her daughter

>check vital signs every 4 hours

> Resting restores body energy, thus, increasing body’s immune system >NANDA

> Hand washing is the best way to prevent transmission and acquiring of microorganism. >Fundamentals of Nursing 8th Ed. Taylor

>monitoring for risk factors >Nursing Process: A Clinical Guide. Sam

Client is free from infection

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONS: “1 bote lang ng gatas at

Risk for deficient

After health teaching, the

> monitor I/O every shift

> to have a picture of the

The client demonstrates

tubig ang iniinom nya sa isang araw” as stated by the mther of the client

O: dry scaly skin poor skin turgor dry lips

Fluid Volume

Risk Factor: Low fluid intake

client will be able to demonstrate willingness to follow interventions.

> Provide a sheet of paper where the family members can list the I/O of the client

> advised the client to drink at least 2 bottles of water per day

> Advised the relatives to not use alcohol in cleaning the client’s body

>advised to change positions frequenly

fluid status of the client

> promotes awareness and cooperation between the family members of the client

> to increase and maximize fluid intake

> alcohol when applied to skin can easily evaporate including the fluids, making skin drier

> dry skin are more prone to injuries when pressured

>NANDA

compliance with the interventions applied

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONS: “madami pa syang sugat

Impaired Skin Integrity R/T

After hospitalization,

> keep the affected body parts clean

> moisture is best breeding

The client’s skin lesions were

eh” “kinakamot nya lage yan sugat nya”

as stated by the mother of he client

O: open wounds Redness Swollen area around the wound

mechanical factors(lesions)

the client’s skin lesions will heal without an complications

and dry

> stimulate circulation to affected area

> Periodically measure the wound and see if complications occur.

> administer ointments prescribed

ground for microorganism >Fundamentals of Nursing 5th Ed. Taylor

> blood circulation containing WBC in the affected area increases body’s process of repairing

> to monitor the progress of wound healing

> for quick and better healing process

>NANDA

healed

ASSESMENT

DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S: “may kakulitan nga

Risk for Fall The client will be able

> Raise side rails > serves as guard to

The client was free from injury

yan bata na yan” as stated by the mother of the client

O: side rails not raise Client sleeping near the edge of the bed 1 year old

Risk Factors: <2 years of age

to be free from injury during shift > Assist client to

sit or sleep far from the edge of the bed

>Instruct the SO on how to manipulate (raising/lowering) side rails

> Advised the SO to always watch the client

prevent falling

>to decrease chances of falling

>learning safety measures promotes safe environment

> Infants are at greater risk for falling because of developmental issues

>NANDA

ASSESMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONS: “konti lang sya uminom”

Impaired Oral Mucous

The client will be able

> Advised to drink at least 3-4 bottles

> to prevent dehydration of

The client’s oral mucousa was

“hindi pa nagtutoothbrush” as stated by the mother of the client

O: Dry lips Geographical tongue Desquamation of lower lip Crack on lips

Membrane R/T ineffective oral hygiene

to restore integrity of oral mucosa before discharge

of fluid everyday

> Wet lips frequently

> Promote oral hygiene

> Encourage use of pacifier

he body

>lubricating the skin of the lips decrease the possibility of disruptions > early initiation of proper oral health practices lessens oral problems

> for the stimulation of the saliva to lubricate the oral mucousa

>NANDA

restored

ANTIBIOTIC&

DRUG STUDY:Immanuel Sy

BSN III-IGroup 3

Mrs. Jeorjet EvangelistaSeptember 3, 2009

INTRODUCTION

Antibiotic (from the Ancient Greek: anti, "against", and bios, "life") is a substance or compound used to treat infections caused by bacteria and other microorganisms. It usual action is that it kills or inhibits the growth of bacteria. Originally, an antibiotic was a substance produced by one microorganism that selectively inhibits the growth of another. Synthetic antibiotics, usually chemically related to natural antibiotics, have since been produced that accomplish comparable tasks.

RANGE OF ANTIBIOTIC EFFECTIVENESS

1. Narrow-spectrum antibiotic is effective against only specific families of bacteria.

2. Broad-spectrum antibiotic refers to an antibiotic with activity against a wide range of disease-causing bacteria. It is also means that it acts against both Gram-positive and Gram-negative bacteria.

In some species of bacteria, the cell wall consists primarily of a thick layer of peptidoglycan. Other species have a much thinner layer of peptidoglycan and an outer as well as an inner membrane. When bacteria are subjected to Gram's stain, these differences in structure affect the differential staining of the bacteria with a dye called gentian violet. The differences in staining coloration (gram-positive bacteria appear purple and gram-negative bacteria appear colorless or reddish, depending on the process used) are the basis of the classification of bacteria into gram-positive (those with thick peptidoglycan) and gram-negative (those with thin peptidoglycan and an outer membrane), because the staining properties correlate with many other bacterial properties.

Kinds of Antibacterial Effects and Modes of Actions

I- BACTERICIDAL EFFECT

1. Cell wall synthesis inhibitors Cell wall synthesis inhibitors generally inhibit some step in the synthesis of bacterial peptidoglycan. Generally they exert their selective toxicity against eubacteria because human cells lack cell walls.

Example:

Bacitracin is a polypeptide antibiotic produced by Bacillus species. It prevents cell wall growth by inhibiting the release of the muropeptide subunits of peptidoglycan from the lipid carrier molecule that carries the subunit to the outside of the membrane Teichoic acid synthesis, which requires the same carrier, is also inhibited. Bacitracin has a high toxicity which precludes its systemic use. It is present in many topical antibiotic preparations, and since it is not absorbed by the gut, it is given to "sterilize" the bowel prior to surgery.

2. Cell membrane inhibitors disorganize the structure or inhibit the function of bacterial membranes. The integrity of the cytoplasmic and outer membranes is vital to bacteria, and compounds that disorganize the membranes rapidly kill the cells. However, due to the similarities in phospholipids in eubacterial and eukaryotic membranes, this action is rarely specific enough to permit these compounds to be used systemically.

II- BACTERIOSTATIC EFFECT

1. Protein synthesis inhibitors Many therapeutically useful antibiotics owe their action to inhibition of some step in the complex process of translation. Their attack is always at one of the events occurring on the ribosome and rather than the stage of amino acid activation or attachment to a particular tRNA. Most have an affinity or specificity for 70S (as opposed to 80S) ribosomes, and they achieve their selective toxicity in this manner.

Example:

The aminoglycosides are products of Streptomyces species and are represented by streptomycin, kanamycin, tobramycin and gentamicin. These antibiotics exert their activity by binding to bacterial ribosomes and preventing the initiation of protein synthesis.

DRUG STUDY

Drug’s Name

Indication Contraindication Side effects Action Nursing Consideration

Brand name:Seretide

Generic name:fluticasone propionate

Maintenance treatment of asthma as prophylactic therapy

For patients requiring oral corticosteroid treatment for chronic asthma

Contraindicated in hypersensitive patients

Patient with acute episodes of asthma in which intensive measures are needed

CNS: headache, dizziness, nervousness, migraine

GI: abdominal discomfort, nausea, vomiting,

GU: irregular menstrual cycle, inflammation of the pelvis

Resp: chest congestion, dyspnea

Skin: dermatitis, urticaria

Others: fever, influenza

Synthetic glucocorticoid with potent anti-inflammatory activity. Inflammation is an important component in the pathogenesis of asthma. Glucocorticoid inhibits many cell types and mediator production or secretion involved in the asthmatic response. These anti-inflammatory actions of fluticasone may contribute to the efficacy in asthma.

> Use cautiously in breastfeeding client

> monitor client, especially post-operative or during period of stress, for evidence of inadequate adrenal response

Drug’s Name

Indication Contraindication Side effects Action Nursing Consideration

Brand name:Spiriva

Generic name:Tiotropium bromide

For the long-term, once-daily, maintenance treatment of bronchospasm associated with (COPD), including chronic bronchitis and emphysema.

Contraindicated in patients with a history of hypersensitivity to atropine or its derivatives, including ipratropium, or to any component of this product.

EENT: dry mouth, blurred vision,

GU: constipation, urinary difficulty & retention.

Others: increased heart rate.

Tiotropium is a long-acting, antimuscarinic agent, which is often referred to as an anticholinergic. It has similar affinity to the subtypes of muscarinic receptors, M1 to M5. In the airways, it exhibits pharmacological effects through inhibition of M3-receptors at the smooth muscle leading to bronchodilation

>Do not swallow capsules.

>Keep capsules away from heat and cold (do not freeze)

>Throw away any unused capsules that have been open to air.

Drug’s Name Indication Contraindication Side effects Action Nursing Consideration

Brand name:Avelox

Generic name:moxifloxacin hydrochloride

Acute Bacterial Sinusitis

Acute Bacterial Exacerbation of Chronic Bronchitis

Community Acquired Pneumonia

Uncomplicated Skin and Skin Structure Infections

Complicated Intra-Abdominal Infections

Complicated Skin and Skin Structure Infections

Contraindicated in persons with a history of hypersensitivity to moxifloxacin or any member of the quinolone class of antimicrobial agents.

Cardiac: arrhythmia

GI: vomiting, abnormal liver function test, dyspepsia, dry mouth, flatulence, oral moniliasis, constipation, increased, anorexia, stomatitis, glossitis

HEMIC AND LYMPHATIC: leukopenia, eosinophilia, prothrombin decrease

METABOLIC: increased, amylase increased

MUSCULOSKELETAL arthralgia, myalgia

CNS: insomnia, nervousness, vertigo, somnolence, anxiety, tremor

SKIN: rash pruritus, sweating, urticaria

GU: vaginal moniliasis, vaginitis

Interferes with action of enzymes necessary for bacterial replication. Inhibits topoisomerases of DNA gyrase (is an enzyme that super coils DNA) therefore impairing processes of bacterial DNA replication, transcription, repair, and recombination

> Drug may be given without regards to meal

> Give at he same time each day

> use cautiously with patients who has history of seizure or CNS disorders

Drug’s Name Indication Contraindication Side effects Action Nursing Consideration

Brand name:Medrol

Generic name:Methylprednisolone

Symptomatic sarcoidosis

Berylliosis

Loeffler's syndrome

Fulminating or disseminated pulmonary tuberculosis

Aspiration pneumonitis

Systemic fungal infections and known hypersensitivity to components.

Cardiac: Congestive heart failure in susceptible patientsHypertension

GI: Peptic ulcer with possible perforation and hemorrhagePancreatitisAbdominal distention

MUSCULOSKELETAL Muscle weaknessLoss of muscle mass

CNS: ConvulsionsVertigoHeadache

SKIN: Impaired wound healing.May suppress reactions to skin tests,Thin fragile skin,Facial erythema,Increased sweating

Metabolism: Fluid retentionPotassium lossHypokalemic alkalosis

Naturally occurring glucocorticoids (hydrocortisone and cortisone), which also have salt-retaining properties, are used as replacement therapy in adrenocortical deficiency states. Their synthetic analogs are primarily used for their potent anti-inflammatory effects in disorders of many organ systems.

Glucocorticoids cause profound and varied metabolic effects. In addition, they modify the body's immune responses to diverse stimuli.

Medical advice should be sought without delay for patients exposed

Persons who are on immunosuppressant, doses of corticosteroids should be warned to avoid exposure to chickenpox or measles.

Drug’s Name Indication Contraindication Side effects Nursing Consideration

Brand name:Duavent

Generic name:ipratropium bromide-salbutamol

Management of reversible bronchospasm

bronchial asthma,

COPD.

Contraindicated in patients hypersensitive to drug and in those hypersensitive to soy lecithin or related foods such as soybeans and peanuts

Cardiac: arrhythmia

GI: nausea

MUSCULOSKELETAL: arthralgia, myalgia

CNS: Headache

RESP: sinusitis, rhinitis.dyspnea, coughing

> take care to avoid leakage around he mask

> use cautiously in patients with angle-closure glaucoma, prostatic hyperplasia, or bladder neck obstruction

DRUG ACTION:

Ipratropium bromide is a potent bronchodilator, particularly in large bronchial airways; however, some evidence suggests that it also has bronchodilator activity in small airways. Bronchodilation results from relaxation of smooth muscles of the bronchial tree. The extent of bronchodilation produced by ipratropium appears to be determined by the level of cholinergic parasympathetic bronchomotor tone and by inhibition of bronchoconstriction resulting from neural reflex activation of cholinergic pathways.

Salbutamol: Salbutamol stimulates adenyl cyclase, the enzyme which catalyzes the formation of cyclic-3', 5'-adenosine monophosphate (cAMP) from adenosine triphosphate (ATP). The cAMP thus formed mediates the cellular response eg, bronchial smooth muscle relaxation. Salbutamol has been shown in most controlled studies to have more effect on respiratory tract, in the form of bronchial smooth muscle relaxation, than isoproterenol at comparable doses while producing fewer cardiovascular effects.

Rationale of Combination: Ipratropium bromide-salbutamol fixed-dose combination maximizes the response to treatment in patients with bronchial asthma and chronic obstructive pulmonary disease (COPD) by increasing bronchodilation through 2 distinctly different mechanisms ie, anticholinergic (parasympatholytic) and β2-agonist (sympathomimetic) effects. Simultaneous administration of both an anticholinergic (ipratropium bromide) and a β2-sympathomimetic (salbutamol sulfate) produces a greater bronchodilator effect than when either drug is used alone.

Drug’s Name Indication Contraindication Side effects Action Nursing Consideration

Brand name:Clexane

Generic name:enoxaparin

deep vein thrombosis

pulmonary embolism

angina

Kidney failure

Allergy to heparin or other low molecular weight heparins

Bacterial infection of the heart valves and the lining surrounding the heart

Active major bleeding.

Recent stroke caused by bleeding in the brain

CARDIAC: thrombocytopenia, bleeding

MUSCULOSKELETAL osteoporosis

CNS: Blood clots in the spinal cord

SKIN: Death of skin cells (necrosis) at the site of injection

METABOLISM: hyperkalaemia

Contains the active ingredient enoxaparin, which is a type of medicine called a low molecular weight heparin. It is used to stop blood clots forming within the blood vessels.

Blood clots normally only form to stop bleeding that has occurred as a result of injury to the tissues. The clotting process is complicated and begins when blood cells called platelets clump together and produce chemicals that activate the clotting process. The final part of this process involves a substance called thrombin being activated to produce a protein called fibrin. Fibrin binds the platelets together, forming a blood clot. This is the body’s way of repairing itself

USE WITH CAUTION IN:

People over 80 years of age

People who are underweight or overweight

Decreased kidney function

Decreased liver function

People with problems stopping bleeding

Diabetes

People having spinal or epidural anesthesia

Drug’s Name Indication Contraindication Side effects Action Nursing Consideration

Brand name:Ansimar

Generic name:Doxofylline

Asthma Hypersensitive with ansimar and hypotension

CARDIAC: palpitations, tachycardia

CNS: dizziness, drowsiness nervousness

METABOLISM: diaphoresis

GI: Nausea and vomiting,

adenosine-non-blocking anti-asthmatic drug with potent bronchodilator activity

Monitor V/S

Check for chest pains

Monitor if tachycardia occurs