2023 Urinary Elimination Scientific Knowledge Base Urinary elimination is the last step in the

Urinary Elimination

Scientific Knowledge Base

Urinary elimination is the last step in the removal and elimination of excess water and by products of body metabolism. Adequate elimination depends on the coordinated function of _________________________, __________________, ___________________, and _________. The kidneys filter waste products of metabolism from the blood. The ­­­­­­­­­­­­______________________

________________ from the kidneys to the bladder. The bladder holds urine until the volume in the bladder triggers a sensation of urge indicating the need to pass urine. Micturition occurs when the brain gives the bladder permission to empty, the bladder contracts, the urinary sphincter relaxes, and urine leaves the body through the urethra.

Kidney

The kidneys lie on either side of the vertebral column behind the peritoneum and against the deep muscles of the back. Normally the left kidney is higher than the right because of the anatomical position of the liver.

Nephrons, the functional unit of the kidneys, remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance. The normal range of urine production is ______________________________. Please convert to CC/day.  Erythropoietin, produced by the kidneys, stimulates red blood cell (RBC) production and maturation in bone marrow. The kidneys play a major role in blood pressure control via the renin-angiotensin system, release of aldosterone and prostacyclin. The kidneys also affect calcium and phosphate regulation by producing a substance that converts vitamin D into its active form. 

Ureters

A ureter is attached to each kidney pelvis and carries urinary wastes to the bladder. 

Bladder

The urinary bladder is a hollow, distensible, muscular organ that holds urine. The bladder has two portions, a fixed base called the trigone and a distensible body called the detrusor. The bladder expands as it fills with urine. How much urine can the bladder hold?

Urethra

Urine travels from the bladder through the urethra and passes to the outside of the body through the urethral meatus. The urethra passes through a thick layer of skeletal muscles called the pelvic floor muscles. These muscles stabilize the urethra and contribute to urinary continence. The external urethral sphincter, made up of striated muscles, contributes to voluntary control over the flow of urine. The female urethra is approximately 3 to 4 cm (1 to 1.5 in) long and the male urethra is about 18 to 20 cm (7 to 8 in) long. The shorter length of the female urethra increases risk for urinary tract infection due to close access to the bacteria contaminated perineal area. 

Act of Urination

Brain structures influence bladder function.

Voiding: Bladder contraction + urethral sphincter and pelvic floor muscle relaxation

Bladder wall stretching signals micturition center.

Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control.

When a person is ready to void, the central nervous system sends a message to the micturition centers, the external sphincter relaxes and the bladder empties.

Factors Influencing Urination (See Box 46-1)

Growth and development­­­­­­­­­­­_____________________________­­­____________________________

Sociocultural factors_____________________________­­­____________________________

Psychological factors_____________________________­­­____________________________

Personal habits_____________________________­­­____________________________

Fluid intake_____________________________­­­____________________________

Pathological conditions_____________________________­­­____________________________

Surgical procedures_____________________________­­­____________________________

Medications_____________________________­­­____________________________

Diagnostic Examinations_____________________________­­­____________________________

Common Urinary Elimination Problems

The most common problems involve _____________________________________________ or ________________________________________. Problems can result from 

1. I_____________________________­­­____________________________

2. I_____________________________­­­____________________________

3. O_____________________________­­­____________________________

4. I_____________________________­­­____________________________

5. I_____________________________­­­____________________________

Urinary retention_____________________________­­­____________________________

Urinary tract infection_____________________________­­­____________________________

CAUTIs

Urinary incontinence_____________________________­­­____________________________

Common forms of UI are: (See Table 46-1)

1. T_____________________________­­­____________________________

2. F_____________________________­­­____________________________

3. U/O_____________________________­­­____________________________

4. S_____________________________­­­____________________________

5. U_____________________________­­­____________________________

6. R_____________________________­­­____________________________

Urinary diversion­­­­­­­­­­­­­­­­­­­______________________________________________________________

Two types: _____________________________________________________________

A ureterostomy or ileal conduit 

Nephrostomy tubes 

Nursing Knowledge Base:________________________________________________________________

Infection control and hygiene______________________________________________________

Growth and development_________________________________________________________ (Focus on older adult Box 46-2)

Psychosocial considerations________________________________________________________

Critical thinking________________________________________________________________________

Nursing Process: Assessment (Box 46-5)

Through the patient’s eyes_________________________________________________________

Self-care ability_______________________________________________________________

Cultural considerations____________________________________________________________

(Box 46.4 cultural aspects of care)

Health literacy_______________________________________________________________

Nursing history_______________________________________________________________

(Box 46.5 Nursing assessment questions)

Pattern of urination _____________________

Symptoms of urinary alterations: (table 46-2) ___________________________________

Physical assessment

Kidneys___________________________________

Bladder___________________________________

External genitalia and urethral meatus___________________________________

perineal skin___________________________________

Assessment of urine

Intake and output___________________________________

Characteristics of urine___________________________________

Color___________________________________

Clarity___________________________________

Odor___________________________________

External genitalia and urethral meatus

Perineal skin

Laboratory and Diagnostic Testing

Diagnostic Examination (Table 46.5 Common diagnostic tests of urinary Tract)

Nursing responsibilities before testing:

1. ___________________________________

2. ___________________________________

3. ___________________________________

4. ___________________________________

Responsibilities after testing include:

1. ___________________________________

2. ___________________________________

3. ___________________________________

Nursing Diagnosis: Nursing diagnoses common to patients with urinary elimination problems: 

Functional urinary incontinence 

Stress urinary incontinence

Urge urinary incontinence

Risk for infection

Toileting self-care deficit

Impaired skin integrity

Impaired urinary elimination

Urinary retention

Planning

Goals and outcomes

Set realistic and individualized goals along with relevant outcomes

Collaborate with the patient

Setting priorities___________________________________________________________

Patient’s immediate physical and safety needs

Patient expectations and readiness to perform some self-care activities

Teamwork and collaboration______________________________________________________

Implementation

Health promotion_____________________________________________________

Patient education_____________________________________________________

Promoting normal micturition_______________________________________________

• Maintaining elimination habits

• Maintaining adequate fluid intake

Promoting complete bladder emptying______________________________________________

Preventing infection____________________________________________________

Acute care

Catheterization____________________________________________________­­­­­______________

Skill 46-2, Inserting and Removing a Straight (Intermittent) or Indwelling Catheter

Types of catheters _____________________________________________________________________

Catheter sizes_____________________________________________________________________

Catheter changes_____________________________________________________________________

Catheter drainage systems____________________________________________________________________

Routine catheter care_____________________________________________________________________

Preventing catheter associated infection (Box 46-10) _____________________________________________________________________

Catheter irrigations and instillations_______________________________________________________

Removal of indwelling catheters__________________________________________________________

Alternatives to catheterization____________________________________________________________

Suprapubic catheters External catheters

Urinary diversions

Ø Incontinent diversions

Changing a pouch

Gently cleanse the skin surrounding the stoma 

Measure the stoma and cut the opening in the pouch

Remove the adhesive backing and apply the pouch 

Press firmly into place over the stoma. 

Observe the appearance of the stoma and surrounding skin. 

Continent diversions

Orthopic neobladder

Medications

Antimuscarinics: treat urgency, frequency, nocturia and urgency UI

Bethanechol: treat urinary retention

Tamsulosin and silodosin: relax smooth muscle

Finasteride and dutasteride: shrink the prostate

Antibiotics: treat urinary tract infections

Be familiar with the medications and indications for all medications your patient is taking. 

Continuing and restorative care

Lifestyle changes

Pelvic floor muscle training

Bladder retraining

Toileting schedules

Intermittent catheterization

• Skin care

Evaluation

Through the patient’s eyes

Assess the patient’s self-image, social interactions, sexuality, and emotional status

Patient outcomes

Use the expected outcomes developed during planning to determine whether interventions were effective

Evaluate for changes in the patient’s voiding pattern and/or presence of symptoms 

Evaluate patient/caregiver compliance with the plan

Safety Guidelines for Nursing Skills

Follow principles of surgical and medical asepsis as indicated

Identify patients at risk for latex allergies 

Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.

Bowel Elimination

Scientific Knowledge Base_______________________________________________________________

Mouth_____________________________________________________________________

Esophagus_____________________________________________________________________

Stomach_____________________________________________________________________

Small intestine__________________________________________________________________

Large intestine__________________________________________________________________

Anus_____________________________________________________________________

Defecation_____________________________________________________________________

Nursing Knowledge Base: Factors Affecting Bowel Elimination

Age_____________________________________________________________________

Diet_____________________________________________________________________

Fluid intake_____________________________________________________________________

Physical activity_____________________________________________________________________

Psychological factors___________________________________________________________________

Personal habits_____________________________________________________________________

Position during defecation_______________________________________________________________

Pain_____________________________________________________________________

Pregnancy_____________________________________________________________________

Surgery and anesthesia_________________________________________________________________

Medications_____________________________________________________________________

Diagnostic tests_____________________________________________________________________

Common Bowel Elimination Problems_____________________________________________________

Constipation (Box 47-1) ________________________________________________________________

Impaction____________________________________________

Diarrhea_____________________________________________________________________

Incontinence_____________________________________________________________________

Flatulence_____________________________________________________________________

Hemorrhoids_____________________________________________________________________

Bowel Diversions

Temporary or permanent artificial opening in the abdominal wall. Stoma­­­­­­­­­___________________

Surgical opening in the ileum or colon. Ileostomy or colostomy

Ostomies

Sigmoid colostomy 

Transverse colostomy

Ileostomy

Loop colostomy

End colostomy

Other Approaches

Ileoanal pouch anastomosis

Continent ileostomy

Antegrade continence enema 

Critical Thinking

Integrate the knowledge from nursing and other disciplines to understand the patient’s response to bowel elimination alterations.

Experience in caring for patients with elimination alterations helps you provide an appropriate plan of care.

Use critical thinking attitudes such as fairness, confidence, and discipline. 

Apply relevant standards of practice when selecting nursing measures

Nursing Process: Assessment

Through the patient’s eyes_________________________________________________________

Nursing history_________________________________________________________________

What a patient describes as normal or abnormal is often different from factors and conditions that tend to promote normal elimination. 

Identifying normal and abnormal patterns, habits, and the patient’s perception of normal and abnormal with regard to bowel elimination allows you to accurately determine a patient’s problems.

Elimination factors

(Box 47.3 Nursing assessment questions)

Elimination pattern

Stool characteristics

Routines

Bowel diversions

Appetite changes

Diet history

Daily fluid intake 

Surgery or illness

Medications

Emotional state

Exercise

Pain or discomfort

Social history

Mobility and dexterity

Physical assessment

Mouth

Abdomen 

Rectum 

Laboratory tests: Fecal specimens

Diagnostic examinations:

Direct visualization

Indirect visualization

Bowel preparation 

Nursing Diagnosis: Some diagnoses that apply to patients with elimination problems include:

Disturbed body image

Bowel incontinence

Constipation

Perceived constipation

Risk for constipation

Diarrhea

Nausea

Deficit knowledge (nutrition)

Planning

Goals and outcomes

Incorporate elimination habits or routines

Reinforce routines that promote health

Consider preexisting concerns

Setting priorities

Patients often have multiple diagnoses

Teamwork and collaboration

Implementation: Health Promotion

Routine

Colorectal cancer

Promotion of normal defecation

Sitting position

Privacy

Positioning on bedpan

Prevent muscle strain and discomfort 

Elevate head of the bed 30 to 45 degrees

Wear gloves when handling bedpans

Acute Care

Environment

Cathartics and laxatives

Ø Cathartics have a stronger and more rapid effect on the intestines than laxatives

Ø Suppositories may act more quickly than oral medications

Antidiarrheal agents

Opiates used with caution

Enemas

Cleansing enemas

Tap water

Normal saline 

Hypertonic solutions

Soapsuds

Oil retention

Other types of enemas

Carminative and Kayexalate

Enema administration

Sterile technique is unnecessary.

Wear gloves.

Explain the procedure, positioning, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation.

Digital removal of stool

Use if enemas fail to remove an impaction.

Last resort in managing severe constipation

Inserting and Maintaining a Nasogastric Tube

Purposes

• Decompression, enteral feeding, compression, and lavage

Categories of nasogastric (NG) tubes

• Fine- or small-bore for medication administration and enteral feedings

• Large-bore (12-French and above) for gastric decompression or removal of gastric secretions

Clean technique

Maintaining patency

Continuing and restorative care 

Care of ostomies______________________________________________________

Irrigating a colostomy______________________________________________________

Pouching ostomies______________________________________________________

Nutritional considerations______________________________________________________

Psychological Considerations______________________________________________________

Bowel training______________________________________________________

Maintenance of proper fluid and food intake_________________________________________

Promotion of regular exercise______________________________________________________

Management of the patient with fecal incontinence or diarrhea__________________________

Maintenance of skin integrity ______________________________________________________

Evaluation

Through the patients eyes­­­­­­­­­­­­­_______________________________________________________

Patient outcomes ____________________________________________________________ 

1. Medication Orders

a. What are the nursing responsibilities for acknowledging or checking orders?

b. List the components of a correctly written medication order. 

c. Explain and define the different types of orders

i. Standing

ii. Stat

iii. PRN

iv. Single

2. Routes of Administration – define and discuss nursing considerations for each:

a. Enteral

i. Oral

ii. Sublingual

iii. Buccal

iv. G-Tube/NGT

v. Rectal

b. Parenteral 

i. SQ

· Angle of insertion:

· Sites of administration:

ii. IM

· Angle of insertion:

· Sites of Administration:

iii. ID

· Angle of insertion:

· Sites of Administration:

iv. IV

v. What is the purpose of the Z-track method? When is it performed?

c. Topical

i. Eye Drops

ii. Eardrops

iii. Nasal drops

iv. Inhalers

v. Lotion/cream/ointment/powder

vi. Transdermal

vii. Vaginal

Critical Thinking Scenario:

The patient, Mr. Koop, has deteriorated over the shift. His temp is now 39.2 C, he is complaining of nausea and is not able to tolerate oral fluids. The nurse checks the orders for Mr Koop and finds that he is ordered acetaminophen 650mg po q4hrs for temps >38.5 C. Based on the assessment of the patient, what would be the nurse’s next action?

3. Define each of the Rights of Administration:

a. Medication

b. Dose

c. Patient

d. Route

e. Time

f. Documentation

g. Indication

h. Response

i. Refuse

4. Explain the Checks of Medication Administration 

a. First

b. Second

c. Third

Critical Thinking Scenario:

A patient is complaining of severe pain and has orders for morphine sulfate. The nurse knows that the route that would give the slowest pain relief would be which route?

5. Define medical reconciliation and explain when it would occur.

6. When would a nurse refuse to administer a drug?

Critical Thinking Scenario:

The healthcare provider enters an order a new medication, Acetaminophen 2g po q4hrs prn pain into the EMAR. Pharmacy fills the order and sends it to the floor. The patient is requesting pain meds for a pain level of 4/10. The nurse reviews the order and questions it. Why does the nurse question the order? What would the nurse do next? 

7. Developmental Considerations

a. Infants/Children

b. Elderly

8. Other Considerations for Med Administration

a. How does the nursing assessment figure into med administration?

Critical Thinking Scenario:

A patient is prescribed ibuprofen 200 mg PO every 4 hours as needed for pain. The pharmacy sends up enteric-coated tablets, but the patient refuses the tablets, stating that she cannot swallow pills. What will the nurse do?

Critical Thinking Scenario:

The patient’s medication administration record lists two antiepileptic medications that are due at 0900, but the patient is NPO for a barium study. The nurse’s coworker suggests giving the medications via IV because the patient is NPO. What will the nurse do?

9. Name at least 5 ways a medication error can occur. What is the priority when a medication error happens?

10.  Name at least 5 assessment questions the nurse should ask before giving medication?

11. How do you draw up two medications? Please write the steps.

12.  What do you have to be cautious of when crushing oral medication?

13. Name the parts of a syringe.

14. Needles come in various gauges. The ___________the gauge number, the smaller the needle.

15. How do you remove medication from a vial? Ampule?

16. In what part of the eye are eye drops applied?

17. How do you hold the ear when applying ear drops in infants? How do you hold the ear when applying ear drops in an adult?

18. Does the nurse need to put on gloves when applying a transdermal patch? Why?

19. When giving a subcutaneous injection (SQ) in the abdomen, be sure to choose a site at least ____ inches away from the umbilicus.

20. Why do you need to rotate sites when applying transdermal patches?

Critical Thinking Scenario:

The nurse is preparing to administer a transdermal patch to a patient and finds that the patient already has a medication patch on his right upper chest. What will the nurse do?

Critical Thinking Scenario:

The nurse is giving a medication that has a high first-pass effect. The health care provider has changed the route from PO to IV. What can the nurse expect with the IV dose?

Critical Thinking Scenario:

The nurse answers a patient’s call light and finds the patient sitting up in bed and requesting pain medication. What will the nurse do first?

Class Prep Guide Part I

1. Define:

a. Pharmacology

b. Pharmacotherapeutics

c. Pharmacokinetics

d. Pharmacodynamics

2. How are Drugs Classified?

· What is the difference between them?

· Why do nurses need to know about pharmacology?

3. Define:

a. Absorption

b. Distribution

c. Metabolism

d. Excretion

4. Factors affecting Absorption

a. Dosage

b. Dosage Form

i. Enteric coated

ii. Extended release

c. Define the Routes

i. Parenteral

ii. Enteral

iii. Topical

d. GI function 

Identify the administration route (be specific):

____ Injection just below the dermis of the skin

____ Drops placed directly into the eye or ear

____ Medication placed in the mouth against the mucous membrane

____ Injection into a vein

____ Medication placed under the tongue

____ Medicated packing placed in rectum

____ Injection into the muscle

____ Ointment placed directly on the skin

____ Injection into the dermis just under the epidermis 

5. Factors affecting Distribution

a. Blood Flow

b. Blood Brain Barrier

6. Factors affecting Metabolism

a. First pass effect

i. Which medication, oral Tylenol or IV Tylenol, has a higher bioavailability level? Why? 

b. Protein Binding

7. Drug Action on the Cell

a. Stimulate cell function

b. Inhibits cell function

8. Identify the following potential problems/impairment as affected by absorption (A), distribution (D), metabolism (M), or excretion (E):

____ Impaired blood flow

____ End stage renal disease

____ Elderly population

____ Medication given with a large meal

____ Liver disease

____ Blood-brain barrier

____ Continuous gastric suctioning

9. A patient who has had gastric bypass surgery may have difficulty with which aspect of pharmacokinetics? 

10. Define the Phases of Clinical Trials

a. Phase I

b. Phase II

c. Phase III

d. Phase IV

Identify the clinical trial phase for the following:

– A larger number of patients receive the medication at a higher dose ______

– Medication is given to a large number of patients and results are compared with the standard-of-care medication_____

– A small number of patients receive a low dose of medication to evaluate its safety________

– Medication is made available to the general public and effectiveness and side effects of the drug are tracked _____

11. Sources of Drugs

12. Names of Drugs

a. Chemical

b. Generic

c. Trade/Brand

13. Provide the chemical, generic, and a trade name for the following:

· azithromycin

· diphenhydramine

· meloxicam

Critical thinking exercise:

Sarah Hawkins, an older woman who lives on a fixed income, is on multiple medications. She says that all her friends are taking the generic form of their medications. While you, the nurse, are visiting her, she asks, “What do you think of generic medications? Are they safe? Are they as good? Are they worth it?” Answer the following questions:

How do generic equivalent drugs differ from a trade name drug?

What would you, the nurse, recommend that Sarah do about accepting generic drugs?

14. Drug Standards

a. FDA

b. US Pharmacopeia

c. National Formulary

d. Hospital Formulary

e. Physician’s Desk Reference

f. Prescription

g. OTC (Over the Counter)

· What is the role of the FDA? 

· What role does the FDA play in regulating herbal and dietary supplements? 

15. Drug Monitoring

a. Therapeutic drug monitoring

b. Half-life

c. Onset

· Why is a drug’s half life listed in a drug reference book?

· When is the use of drugs with short half lives indicated? 

d. Peak & Trough

e. Minimum Effective Concentration

f. Therapeutic Range

g. Toxicity

· Scenario: 2 mg of IV Morphine is given to an adult at 1000 for severe 10/10 pain. The patient starts to feel the effect at 1005. At 1020 the patient reports their pain as 3/10 and reports relief of pain until 1430. 

What is the onset? _____________ When is the peak? _____________

What is the duration? ___________ 

· Scenario: IV Vancomycin infusion is started at 0800 and is infused over 1 hour. 

When would the nurse measure the trough level? ________ 

When would the nurse measure the peak level? __________

· Scenario: Acetaminophen has a half-life of 3 hours for adults. 

If 500 mg is given at 0800, how much of the drug will have been excreted at 1100? ____ 

How much at 1400? ____ 

When would the drug be completely excreted from the system? _____

16. Pharmacodynamics

a. Potency

b. Efficacy

c. Agonist

d. Partial agonist

e. Antagonist

· Scenario: A 26-year old patient takes 20 tablets of oxycodone by mouth. The nurse gives the patient naloxone. 

· What is the agonist? The antagonist? How does the antagonist work?

· How would you teach the patient the difference between potency and efficacy?

f. Drug to Drug Interactions

i. Additive effect 

ii. Antagonistic effect

iii. Synergistic effect

iv. Incompatibility

· Differentiate between additive, synergistic and antagonistic drug effects. 

g. Drug Diet Interactions

17. Identify the food the patient should avoid when taking the following medications and why should it be avoided:

· Ciprofloxacin

· Atorvastatin

· Warfarin

18. Variable affecting Drug action

a. Age

b. Gender

c. Disease process

d. Ethnicity

e. Genetic

f. Dosage

· Scenario: John Kessler has been ill for a long time and his prognosis is poor. He is 84 yrs old with multiple debilitating and chronic conditions. He has had uncontrolled diabetes for more than 20 yrs and has experienced many complications due to this condition. Three years ago, he developed chronic kidney disease and requires dialysis 3 times a week. To further complicate his condition, John has continued to consume alcohol every day and smokes one pack of cigarettes per day. He has a long history of both alcohol and tobacco use. 

Five days ago, his daughter noticed he was becoming increasingly weak and lethargic. Last night when his temp reached 38.8C ( 102F) and he became confused, he was taken to the ER and admitted to the hospital. A chest xray this morning revealed bilateral pneumonia. John is receiving multiple medications through both the IV and inhalation route. 

What factors may influence drug metabolism or excretion in this patient?

How would drug elimination for this patient possibly complicate the pharmacotherapy?

How will IV or inhalation drug therapy affect the absorption of his medications?

John will receive a loading dose of IV antibiotics and then receive a maintenance doses every 6 hrs. What is the purpose of this regimen? 

· Scenario: Percocet is given to an 89- year old female, weighing 98 lbs. with a history of end-stage renal disease, hypertension, and arthritis is admitted for pain management following a fall. Identify the variables which might influence absorption of the po medication. What else would the nurse want to know?

19. Pregnancy Categories

a. Define each category:

i. A

ii. B

iii. C

iv. D

v. X

b. Teratogenic effects

20. Drug Effects: Define each term: 

a. Therapeutic effect

b. Side effect

c. Adverse effect

d. Drug toxicity

e. Drug allergy

f. Anaphylaxis

g. Drug tolerance

h. Drug dependence

i. Cumulative effect

j. Idiosyncratic effect

k. Addiction

21. Identify the following as a therapeutic effect (TE), a side effect (SE), a drug allergy (DA), an anaphylactic reaction (AR), or an idiosyncratic effect (IE)

____ Sudden constriction of the bronchiolar muscles and edema of 

 the larynx

____ Administration of Benadryl results in unexpected 

hyperactivity in a child 

____ Antihypertensive medication lowers blood pressure to WNL

____ Administration of antibiotic medication results in nausea

____ Administration of IV morphine results in hives and itching

22. Pharmacotherapeutics

a. Maintenance therapy

b. Prophylactic therapy

c. Therapeutic index

· Scenario: A patient who takes warfarin for chronic atrial fibrillation and is going in for a knee replacement. 

· What test might the doctor order to check the therapeutic index?

· What type of medication might the doctor order prior to surgery? 

· Is warfarin considered maintenance therapy? Why or why not?

· Scenario: As the triage nurse in a busy ER, you determine the patient’s chief complaint, obtain vital signs, collect past medical history and ask about food and drug allergies. While assessing a patient with a suspected ankle fracture, the patient says that they are allergic to codeine because it makes them sleepy and nauseated. 

· What further questions would you ask the patient about drug allergies?

· Differentiate between an adverse effect, a side effect and a drug allergy. Which does this patient have?

· Is this patient experiencing an idiosyncratic reaction?