Anda di halaman 1dari 7

G.

COURSE IN THE WARD


Date: August 18, 2013

DAY 1

Shift/Time

Nurse's Assessment Nurse's Intervention

7/3
/
10:30am

Baseline data

V/S monitored and


recorded q 4 hr

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

Fluid and electrolyte Intake and output


I&O has ordered
imbalance
were recorded q shift
Assessment of LOC Glasgow coma scale Neurological
done
Assessment 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

Paracetamol 500mg Antipyretics as


Q4hrs PRN was
ordered
given

Supportive
management

Combivent 1neb
Q4hrs

6-10-2-6

Date: August 19, 2013


Shift/Time
3/7
/
7pm

Proton pump as
ordered

Nebulization w/
bronchodilators as
ordered

DAY 2

Nurses Assessment Nurses Intervention Medical


Management
Fluid Deficiency

IVF followed up #2
PNSS 1L @
160cc/hr

Base line data

V/S q4 monitored
and recorded

Fluid and electrolyte Intake and output

V/S q4 as ordered
I&O has ordered

balance

were recorded q
shift

Crumpled linen

Bed side care done

Long and dirty finger Trimmed and


nails
cleaned finger nails
Uncombed hair

Combing hair done

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

Risk for injury

Side rails raised

Anti-infective as
ordered

6:00am

Supportive
management

Losartan 100mg
1tab OD was given

Antihypertensive as
ordered

6:00am

Supportive
management

Omeprazole 40mg Proton pump as


IVTT OD was given ordered

Supportive
management

Clonidine 75mg 1
tab Q6hrs D/C

Supportive
management

Paracetamol 500mg Antipyretics as


Q4hrs PRN was
ordered
given

Supportive
management

Combivent 1neb
Q4hrs

11pm

6-10-2-6

Date: August 20, 2013 Day 3


Shift/Time
Nurse's
Assessment
7/3
Fluid Deficiency
/
8:46am
Base line data

IVF PNSS 1L as
ordered

D/C as ordered

Nebulization w/
bronchodilators as
ordered

Nurse's Intervention Medical


Management
IVF followed up #2
PNSS 1L @
160cc/hr
V/S q4 monitored
V/S q4 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

I&O has ordered

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

III. LABORATORY AND DIAGNOSTOC EXAMINATIONS


BLOOD CHEMISTRY
LAB EXAM

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.

TRIGYCERIDE <65yrs: <200


mg/dL
>65yrs: <325
mg/dL

71mg/dL

Triglyceride
levels should be
below 150
mg/dL (1.69
mmol/L).
NORMAL

HDL (High
density
lipoprotein)

[45 65 mg/dL

LDL -calculated [66 178


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

(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2581752/ September 4, 2013)

( http://emedicine.medscape.com/article/2054342-overview#aw2aab6b3 August 31,


2013 )
(http://emedicine.medscape.com/article/127943-overview August 31, 2013)
RADIOGRAPHIC X-RAY
Chest AP: HEART ENLARGED, PATCHY INFILTRATES AND NOTED IN THE
LOWER LOBE, REST OF LUNG FILEDS ARE CLEAR, AN ATHEROSCLEROTIC
AORTA IN NOTED
IMPRESSION:
~CARDIOMEGALY
~RIGHT BASAL PNEUMONIA

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

(http://www.mayoclinic.com/health/low-potassium/MY00760 August 31, 2013 )


HEMATOLOGY
EXAMINATION
RESULT
NORMAL
INTERPRETA
NURSING
VALUES
TION
IMPLICATION
Hemoglobin
130
120.00NORMAL
150.00g/L
Hematocrit
0.39
0.36-0.45
NORMAL
Leucocytes No.
10.9
5.00-10 x 10^g/L
NORMAL
Concentration
Segmentation
0.81
0.40-0.60
Lymphocytes
0.12
0.25-0.40
1.Encourage
Decreased
count of these the patient to

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

eat rich in vit.


C
R: To boost the
immune
system
2.As a nurse
you observe
the 5 moments
of
handwashing
R: To be able
to prevent the
spread of
microorganism
from person to
person

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)

Anda mungkin juga menyukai