DAY 1
Shift/Time
7/3
/
10:30am
Baseline data
10:35am
Fluid deficiency
Administration of IV Venoclysis as
fluid #1 PNSS 1L @ ordered
80cc/hr. Increase
OFI
Fluid deficiency
IVF regulated @
desired rate
3:00pm
Medical
Management
IVF regulation as
ordered
6am
Supportive
management
Omeprazole 40mg
IVTT OD was given
6-12-6
Supportive
management
Clonidine 75mg 1
Antihypertensive as
tab Q6hrs was given ordered
Supportive
management
Supportive
management
Combivent 1neb
Q4hrs
6-10-2-6
Proton pump as
ordered
Nebulization w/
bronchodilators as
ordered
DAY 2
IVF followed up #2
PNSS 1L @
160cc/hr
V/S q4 monitored
and recorded
V/S q4 as ordered
I&O has ordered
balance
were recorded q
shift
Crumpled linen
Difficulty of
performing ADL
Patient assisted in
feeding and taking
medicine
Fluid Deficiency
IVF followed up #3
PNSS 1L @
160cc/hr
Prevent embolism
and pneumonia
Assisted on sit up
on bed
Fluid deficiency
IVF regulated @
desired rate
IVF regulation as
ordered
6:00am
Anti-infective as
ordered
6:00am
Supportive
management
Losartan 100mg
1tab OD was given
Antihypertensive as
ordered
6:00am
Supportive
management
Supportive
management
Clonidine 75mg 1
tab Q6hrs D/C
Supportive
management
Supportive
management
Combivent 1neb
Q4hrs
11pm
6-10-2-6
IVF PNSS 1L as
ordered
D/C as ordered
Nebulization w/
bronchodilators as
ordered
6:00am
6:00am
6:00am
6-10-2-6
and recorded
Fluid and electrolyte Intake and output
balance
were recorded q
shift
Crumpled linen
Bed side care done
Long and dirty
Trimmed and
finger nails
cleaned finger nails
Uncombed hair
Combing hair done
Fluid deficiency
IVF regulated @
desired rate
Risk for injury
Side rails raised
Supportive
management
Supportive
management
Supportive
management
Supportive
management
Supportive
management
IVF regulation as
ordered
Anti-infective as
ordered
Antihypertensive
as ordered
Proton pump as
ordered
D/C as ordered
Losartan 100mg
1tab OD was given
Omeprazole 40mg
IVTT OD was given
Clonidine 75mg 1
tab Q6hrs D/C
Paracetamol 500mg Antipyretics as
Q4hrs PRN was
ordered
given
Combivent 1neb
Nebulization w/
Q4hrs
bronchodilators as
ordered
NORMAL
VALUE
RESULT
FBS
Adult: 4.11-5.28
mmol/L
69-90yrs: 4.366.38mmol/
5.94mmol/L
Male: 59 109
umol/L
Female: 45-84
umol/L
89.90mmol/L
CREATININE
INTERPRETATI
NSG.
ON
IMPLICATION
NORMAL
The increase in
serum
creatinine is
relatively minor
at the earliest
stages of
1.Provide the
patient a Low
Protein diet
R: To muscle
wasting
2.
disease due to
mathematical
reasons (eg, a
patient whose
baseline
creatinine is 0.6
would have to
lose more than
50% of his GFR
before the
creatinine would
increase to 1.3
and first be
noted to be
"abnormal" by
most reference
intervals).
Iinterindividual
differences in
muscle mass
that are related
to gender, age,
and ethnicity
(among other
things) are the
cause.
SGPT(ALT)
[ up to 32 u/L ]
15u/mL
NORMAL
TOTAL
[150 200
CHOLESTERO mg/dL
L
208mg/dL
Levels between
200 mg/dL and
239 mg/dL
(5.176.18
mmol/L) are
considered
borderline for
high
cholesterol.
71mg/dL
Triglyceride
levels should be
below 150
mg/dL (1.69
mmol/L).
NORMAL
HDL (High
density
lipoprotein)
[45 65 mg/dL
32mg/dL
Low HDL-C is
associated with
poor memory and
decline in
memory in
middle aged
adults.
161.8mg/dL
NORMAL
Provide the
patient food rich
in HIGH
DENSITY
LIPOPROTEIN
foods s/a nuts,
seafoods like
salmon and
mackerel are
highest in
omega-3 fatty
acid, olive oil,
avocado,
oatmeal.
Encouraged to
perform passive
ROM
R: To help
elevate HDL
level
EXAMINATION
RESULTS
ELECTROLYTES
NORMAL
INTERPRETATION
S. SERUM
143
VALUES
135-145mmol/L
S. POTASSIUM
3.45
3.50-5.00mmol/L
Low potassium
(hypokalemia)
refers to a lower
than normal level
of potassium in
your bloodstream.
S.
CALCIUM(ionized)
S. CHLORIDE
1.21
1.12-1.32mmol/L
NORMAL
96.00106.00mmol/L
40220mmol/24hour
s
25125mmol/24hour
s
URINE SODIUM
URINE
POTASSIUM
NORMAL
NURSING
IMPLICATIONS
1.Have a diet
rich in potassium
such
as
bananas,
apples, oranges,
milk
and
tomatoes.
R:
To
help
maintain
postassium
imbalance
2.Administer
potassium
supplement as
ordered
R:
To
help
correct
postassium
everyday
cells indicates
that a person
is more
susceptible to
an infection.
Decreased
lymphocytes in
blood causes a
condition
known as
lymphocytopen
ia.
Monocytes
0.05
Eosinophils
Basophils
Stabs
Thrombocytes
0.02
357.8
0.01-0.12
NORMAL
0.01-0.05
NORMAL
0.005
0.01-0.05
150.00-440.00 x
NORMAL
10^g/L
Blood Type
Rh Type
(http://www.nurseslearning.com/courses/nrp/labtest/course/section3/index.htm
AUGUST 31,2013 )
(4, 2013)