V.

THE PATIENT AND HIS CARE

1. Medical Management

a. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy

Medical Date Ordered General Indication & Client Response

Management Description Purpose to Treatment

IVF Date Ordered 5% dextrose in D5NM is The patient

November 15, lactated ringers administered by responded well

D5LRS 1L
2008 solution intravenous with no signs of
30gtts/min
(Osmolarity of infusion for irritation and
Date d/c
527-hyprtonic, parenteral adverse reactions.
November 20,
pH of 4.9) maintenance of
2008
-provides routine daily fluid

calories and free and electrolyte

water, provides requirement with

electrolytes. minimal

Also contains carbohydrates

sodium lactate calories and to

which is used in correct or replace

treating mild to fluid losses due to

moderate change in the

metabolic patient’s diet

acidosis. (NPO) and during

the cesarean

operation.

Nursing Responsibilities:

 Check the doctor’s order

 Explain the procedure to the patient

 Tell the patient that she might feel a discomfort from the tourniquet and the IV

insertion

 Check and monitor IVF regulation and level of fluid

 Check if there is a need for removal and replacement of fluid

 Check if the tube is in the vein and signs of edema

 Check if there is a back-flow of blood

 Check if there is bubbles present in the tube

 Always Monitor V/S.

b. Pharmacotherapy

Brand name and Date ordered/ Route of General action Client response

Generic name Date started/ Administration,

Date changed/ Dosage and

Frequency of

Administration
Mefenamic 11-19-08 P.O., 500mg, Inhibits Patient was

Acid TID for pain prostaglandin relieved from

synthesis by pain.

decreasing the

activity of the

enzyme,

cyclooxygenase,

which results in

decreased

formation of

prostaglandin

precursors
Cephalosporin 11-19-08 I.V., 750mg, q8 Inhibits bacterial The patient did

Cefuroxime cell wall not acquire

sodium synthesis by infection and

binding to one or did not

more of the experience any

penicillin- adverse

binding proteins reaction.

(PBPs) which in

turn inhibits the

final

transpeptidation

step of

peptidoglycan

synthesis in

bacterial cell

walls, thus

inhibiting cell

wall

biosynthesis.

Bacteria

eventually lyse

due to ongoing

activity of cell

wall autolytic

enzymes

(autolysins and

murein

hydrolases)

while cell wall

assembly is

arrested.
Ferrous Sulfate 11-19-08 P.O., O.D. Replaces iron, The patient

found in responded well

hemoglobin, to treatment

myoglobin, and and did not

other enzymes; experience any

allows the adverse

transportation of reaction.

oxygen via

hemoglobin.
Nifedipine 11-19-08 P.O., 10mg, BID Inhibits calcium The patient

ion from responded well

entering the to treatment

"slow channels" and did not

or select experience any

voltage-sensitive adverse

areas of vascular reaction.

smooth muscle

and myocardium

during

depolarization,

producing a

relaxation of

coronary

vascular smooth

muscle and

coronary

vasodilation;

increases

myocardial
 oxygen delivery

in patients with

vasospastic

angina

c. Diet

Type of Diet Date Ordered, General Indication & Client

Date Performed, Description Purpose Response to

Date Administer Treatment

NPO 11-17-08 The patient is not This is done to The patient

11-19-08 allowed to take prevent complied with

any oral food or alteration of the the prescribed

liquid result of the diet.

fasting blood

sugar.bcs intake

of food can

increase

glucose level
Clear Liquid 11-19-08 A diet of clear This diet reduce The patient

Diet 11-20-08 liquids maintains stimulation of complied with

vital body fluids, the digestive the prescribed

salts, and system, and diet.

minerals; and also leave no residue

gives some energy in the intestinal

for patients when tract. This is

normal food intake why a clear

must be liquid diet is

interrupted. Clear often prescribed

 liquids are easily in preparation

absorbed by the for surgery, and

body. by mouth is generally the

(NPO) for a long first diet given

time. This diet is by mouth after

also used in surgery. Clear

preparation for liquids are

medical tests such given when a

as sigmoidoscopy, person has been

colonoscopy, or without food by

certain x-rays. mouth (NPO)

for a long time.

d. Exercise

Activity General Purpose Date Order Client

Description Response

Complete Bed Prescribed To provide 11-18-08 The client

Rest maternal adequate rest adhered to the

complication of order without

pregnancy complaints.