Dengue Part Qo
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Transcript of Dengue Part Qo
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II. NURSING ASSESSMENT
A. Personal History
1. Demographic data
Johnny (not his real name) is a single 19 year old naturally born
Filipino and currently studying at UST, Manila taking a course of _______.
Johnny was born last May 11 1991 via Natural Spontaneous delivery in a
hospital at Angeles City. He is a Roman Catholic and presently residing at
77- 76 Verbena Street Don Bosco, Mabalacat Pampanga. Johnny stays at a
dormitory in Manila; he usually goes home in Pampanga every weekend
to bond with his family. Johnny lives with his parents, Mommy Yumi (51
years old) and Daddy Andrew (56 years old), together with his two elder
sisters, Jenny (31 years old) and Shirley (22 years old). Shirley and Jenny
are also born via natural spontaneous delivery. Johnny was admitted at
AUFMC last Aug 25 at around 7: 22 pm due to his chief complaint of body
ache, and on and off fever for 3 days.
Johnny belongs to a nuclear family since he lives with his parents
together with his two sisters. Daddy Andrew and Mommy Yumi were both
college graduates. His father, Daddy Andrew, already retired in his work
he gets a monthly pension of P 15, 000. While Mommy Yumi works as an
Assistant Manager in Clark Development Corporation earning P 50, 000
per month. When it comes to decision making, both parents help each
other especially when it comes to decisions about health care and
budgeting. According to Johnny, there is no dominant member to take
charge on every decision. Their parents make sure to talk about every
matter together and solve their problems together as well. Jenny and
Shirley were both working as a call center agent earning P 10 000 per
month. The family has a total monthly income of P 85, 000. According to
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them their income is more than enough for their expenses. Their total
expenses per month reach P 40- 50, 000 which includes: electric and
water bill, LPG, food, allowance of Johnny etc. The family is considered
not poor since every member of the family receives P 17, 000 per month.
According to Johnny, their dormitory in Manila is not that clean, there
are presence of empty cans and bottles around, and full of garbage outside.
There is also presence of open canal outside their dormitory. Their bathroom
has presence of mosquitoes because it was dirty. Johnnys cousin who also
lives in that dormitory got dengue fever recently and was admitted in a
hospital in Manila. Meanwhile, their house their house here in Pampanga is a
concrete type of house, which has four rooms and two bathroom (with toilet
flush). Garbage collection is done everyday. There is no presence of empty
cans or bottles in their house. According to Mommy Yumi, she always makes
sure to clean their house everyday. However there is still some presence of
insects and rodents, like flies, mosquitoes, cockroaches in their house which
predisposes the family in acquiring diseases. The family uses a mechanical
means (insect spray) of killing these rodents; their source of water is from
the Mabalacat water services, the sources of their drinking water are thenearby water stations selling mineral water, to ensure the potability of their
drinking water.
Johnny wakes up everyday at around 5 am in the morning. Sometimes
he tends to forgot to eat breakfast due to lack of time preparing for
school. He goes to school at 7 am until 4 in the afternoon. He always
makes sure to take a bath before and after going to school. Johnny always
sleeps at around 10: 30 11: 00 in the evening.
Johnnys family was affiliated to Roman Catholic. They go to church
every Sunday, Johnny said that he always pray at night to thank God for
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the blessings that he received. Johnny said that he loves to eat vegetables
like carrots, ampalaya, cabbage, tomatoes etc, and fruits like apple,
oranges and banana. He also loves to eat junk foods and soft drinks. He
seldom drinks water but every night he drinks milk before going to sleep.
Johnny says that he is not smoking but he drinks alcohol occasionally.
Johnnys usual hobbies during available time are playing basketball,
surfing the internet, watching movies etc.
Their family believes in Hilots and albularyos. They also make use of
some herbal medicines like oregano for cough and colds, Lagundi for
cough, and guava leaves for treating wounds. When one member of a
family is sick, they first buy over the counter drugs. But when the disease
is not relieved, they will bring the patient to the nearest clinic or hospital.
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B. Family Health Illness History
Grandfather(72)-deceased dueto heart attack and
kidney disease
GrandfatherGrandmother
(68)
Grandmother
Auntie
1
Daddy
Andrew
-HPN, HyperK,
Ulcer
Auntie
2
Mommy
Yumi
HPN
Johnny
-DF
Jenny
Bronchitis,
PNAShirley
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Family Health Illness History
According to Johnny, they dont have any information about their
grandparents in their Fatherss side, they also dont know if they are still
alive. With regards to their grandparents on Mother side, Johnnys
grandfather died at the age of 72 due to heart attack and kidney disease, he
was diagnosed of having kidney disease when he was 55 years old, they
believe that eating fatty foods, smoking and drinking alcohol are the reasons
why their Grandfather develops a heart disease. Meanwhile their
grandmother was still alive, she dont have any history of any disease since
she practice a healthy lifestyle.
Johnnys father is also presently admitted in AUFMC due to
Hypertension and Hyperkalemia. Daddy Andrew (56 years old) has a history
of Ulcer since he was 25 years old. He will feel abdominal pain when he did
not eat any food. This is the 3rd time that Daddy Andrew was hospitalized due
to hypertension. He starts smoking when he was just teenager, he also
frequently drinks alcohol but he stops when he was 45 years old. Mommy
Yumi (51 years old) also has a history of hypertension; she acquired this
when she was just 40 years old. Mommy Yumi is not smoking or drinking but
she loves to eat fatty foods.
Johnny sister, Shirley, was never been hospitalized and she dont have
any history of serious illness. She had chickenpox when she was 16 years
old. Meanwhile Jenny was hospitalized twice due to Bronchitis and
Pneumonia. She said that shes not smoking and drinking alcohol. She got
chickenpox when she was only 1 year old.
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History of Past Illness
Johnny got chickenpox when he was first year high school (16 years
old), however he did not got mumps or measles since he was born. Johnny
has an allergy to some foods like eggs, chicken, shrimps, etc. He said that he
will manifest itchiness, redness and swelling in his skin when he eat some of
this foods.
Johnny was first hospitalized when he was 5 years old; his diagnosis is
T/C Dengue Fever. He manifested high fever however his platelet count is
just normal and his condition is just stable. Johnny was hospitalized for the
second time when he was 2nd year high school due to a fracture in his left
knee, he undergo a procedure called Open Reduction Internal Fixation. He
got his fracture when he was playing basketball with his friends and he fell to
the ground with his left knee.
Johnny says that he seldom got fever, or cough and colds. But when he
got any of those, he will buy some over the counter drugs like Paracetamol
but when it is not relieved that is the time that he will go to a clinic.
This is the third time that he was hospitalized; he has a chief complaint
of body ache, and on and off fever. His final diagnosis was Dengue Fever.
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F. Diagnostic and Laboratory Procedures
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Diagnostic/
Laboratory
Procedure
Date
ordered/
Date results
in
Indication or
purposeResults
Normal
Values
Analysis/Interpre
tation
Complete
Blood
Count
1st:
Date Ordered:
Aug 25, 2010
Date
Performed:
Aug. 25,
2010
Date Result:
Aug. 25,
2010
It is a basic
screening and is
one of the most
frequently ordered
laboratory
procedures. It
helps in the
management of
disease that
originated in other
body system.
Generally includes
absolute numbers
or percentages of
erythrocytes,
leukocytes,
platelets,
hemoglobin, and
hematocrit in the
blood sample.
Hemoglobin
Major cellular
element of thecirculatin
It measures the
amount of
hemoglobin
164 140 - 175 g/L The patients
hemoglobin level is
within the normal
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Diagnostic/
Laboratory
Procedure
Date
ordered/
Date results
in
Indication or
purposeResults
Normal
Values
Analysis/Interpre
tation
Complete
Blood
Count
1st:
Date Ordered:
Aug 25, 2010
Date
Performed:
Aug. 25,
2010
Date Result:
Aug. 26,
2010
2nd:
Date Ordered:
Aug 26, 2010
Date
Performed:
Aug. 26,
2010
Date Result:
Aug 26 2010
It is a basic
screening and is
one of the most
frequently ordered
laboratory
procedures. It
helps in the
management of
disease that
originated in other
body system.
Generally includes
absolute numbers
or percentages of
erythrocytes,
leukocytes,
platelets,
hemoglobin, and
hematocrit in the
blood sample.
Hemoglobin
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Diagnostic/
Laboratory
Procedure
Date
ordered/
Date results
in
Indication or
purposeResults
Normal
Values
Analysis/Interpre
tation
Complete
Blood
Count
1st:
Date Ordered:
Aug 26, 2010
Date
Performed:
Aug. 26,
2010
Date Result:
Aug. 27,2010
2nd:
Date Ordered:
Aug 27, 2010
It is a basic
screening and is
one of the most
frequently ordered
laboratory
procedures. It
helps in the
management of
disease that
originated in other
body system.
Generally includesabsolute numbers
or percentages of
erythrocytes,
leukocytes,
platelets,
hemoglobin, and
hematocrit in the
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Date
Performed:
Aug. 27,
2010
Date Result:
Aug 27 2010
blood sample.
Hemoglobin
Major cellular
element of the
circulating
blood and
transport
oxygen as its
principal
function.
It measures the
amount of
hemoglobin
present in a
deciliter of whole
blood. Hemoglobin
level correlates
closely with the
red blood cell
count and affects
the hemoglobin-to-
red blood cell ratio
(mean corpuscular
hemoglobin [MCH]
and mean
corpuscular
!st: 158 g/L
2
nd
: 158 g/L
1st: 140 175
g/L
2
nd
: 140 175g/L
The patients
hemoglobin levels
on both results are
within the normal
range, The patient is
not dehydrated or
anemic. It could
suggest that there is
enough number of
circulating hemoglobin,
thus no deprivation of
oxygen supply to the
different body organs.
The patient did not
manifest bleeding.
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hemoglobin
concentration
[MCHC]). It is used
to measure the
severity of anemia
or polycythemia
and to monitor thepatients response
to therapy as well
as to measures the
oxygen carrying
capacity of the
blood.
Hematocri
t
Measures
percentage by
volume of
packed red
blood cells
(RBC) in a whole
blood sample.
.
It measures
percentage or
concentration of
packed red blood
cells in a whole
blood sample or
blood volume.
Hematocrit
Ist: 0.45 gm/L 1st: 0.41
0.50 gm/L
The patients
hematocrit level is
within the normal
range indicating
that patient has no
presence of
dehydration,
polycythemia or
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indicates the
proportion of cells
and fluids in the
blood. It is useful
in evaluating
dehydration and
hypovolemia..
2nd: 0.46
gm/L
2nd: 0.41
0.50 gm/L
anemia. The
patient has pink
palpebral
conjunctiva and
moist lips
Leukocyte
Part of a
complete blood
that indicates
the number of
WBCs in a micro
liter of whole
blood
Blood component
that
reports the
possible presence
and severity of
infection or
inflammatory
response. It is theabsolute numbers
of white blood cell
circulating in the
cubic millimeter of
blood. It acts as a
defense against
microorganism
1st: 1.33 g/L
2nd: 1.43 g/L
1st: 4.50 11
X 10 g/L
2nd: 4.50 11
X 10 g/L
The patients has
decreased level of
WBC indicating
viral infection and
inflammatory
response. The
patient had a
temperature of 37.2 C in the
morning, however
it increase to 38.1
C in the afternoon.
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through
phagocytosis and
produces or
transport and
distributes
antibodies to help
maintainimmunity.
Its purpose was to
determine
infection of
inflammation.
Neutrophils The primary
function of
neutrophil is
phagocytosis(killi
ng and digestion
of
microorganisms).
Acute bacterial
infections and
1st: 0.60 g/L 1st: 0.18
0.70 g/L
The patient has
normal levels of
Neutrophils. The
rashes of the
patient decreased.
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trauma
stimulates
neutrophil
resulting in
increased WBC
count.
2nd: 0.30g/L 2nd: 0.18
0.70 g/LLymphocytes The primary
function oflymphocytes isfighting chronicbacterial infectionand acute viralinfections . Itindicates theamount oflymphocytesparticipating withmacrophages at a
site of local injury.Used to assess &monitor geneticand acquiredimmunodeficiencystatus.
1st: 0.29 g/L
2nd: 0.56 g/L
1st: 0.10 -0.48
g/L
2nd: 0.10
The patients
lymphocytes is
within the normal
range on the first
result indicating a
good immune
system .
While on the
second result the
level increases due
to viral infection
which is dengue
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0.48 g/L Fever.
Monocytes Are usually thelargest of theWBCs (12-20 m)and are oftenreferred to asscavenger cells
(phagocytes). Theycan ingestparticles such ascellular debris,bacteria, or otherinsoluble particles.
1st: 0.05 g/L
2nd: 0.07 g/L
1st: 0.00
0.04 g/L
2nd: 0.0 0.04
g/L
The patients
monocytes is
slightly high
indicating infection
due to Dengue
fever. The patient
is febrile with
temperature of
38.1 C
Eosinophils Eosinophils are
involved in Allergicreaction. Parasiticinfections are alsocapable ofstimulating theproduction ofthese cells. Thesecells are capable ofphagocytosis ofantigen antibodycomplexes. They
Ist : 0.06
2nd: 0.07
Ist: 0.00 0.
03 g/L
2nd: 0.00
0.03 g/L
The patients
eosinophils are bothabove the normal
range . The patient
still manifest rashes
on trunk and arms
however it was
lessened.
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do not respond tobacterial or viralinfection.
Platelet
Count
Platelets are a
type of bloodcell. They play a
key role in
normal blood
clotting. During
the clotting
process, platele
ts clump
together to plug
small holes in
damaged blood
vessels. The
purpose of
clotting is
to stop
bleeding.
It determines
ability of
patients blood to
clot normally. Itis used to
evaluate platelet
production, to
assess the
effects of
chemotherapy or
radiation therapy
on platelet
production, to
diagnose and
monitory severe
thrombocytosis
or
thrombocytopeni
a and to confirm
a visual estimate
1st: 110
2nd: 117
1st: 150 400
X 10 g/L
2nd: 150 400
X 10 g/L
The patients
platelet is both
below the normal
limits, which implies
problem intactness
of clotting ability.
Patient is at risk for
bleeding. The
platelet count
decreased due to a
viral infection
(Dengue Fever)
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of platelet
number and
morphology from
a stained blood
film.
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Diagnostic/
Laboratory
Procedure
Date
ordered/
Date results
in
Indication or
purposeResults
Normal
Values
Analysis/Interpre
tation
Complete
Blood
Count
Date Ordered:
Aug 27, 2010
Date
Performed:
Aug. 27,
2010
Date Result:
Aug. 28,
2010
It is a basic
screening and is
one of the most
frequently ordered
laboratory
procedures. It
helps in the
management of
disease that
originated in other
body system.
Generally includes
absolute numbers
or percentages of
erythrocytes,
leukocytes,
platelets,
hemoglobin, and
hematocrit in the
blood sample.
Hemoglobin
Major cellular
element of thecirculatin
It measures the
amount of
hemoglobin
165 g/L 140 - 175 g/L 1st: The patients
hemoglobin levelsis within the
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Nursing Responsibilities for Complete Blood Count
Prior:
Check doctors order.
Check the clients name or Identification band.
Explain to the client the purpose of the procedure.
Inform the patient that the test requires a blood sample and who will
perform the venipuncture and when.
Inform the patient how the procedure is performed, the equipment to
be used.
Explain to the patient that she may feel some discomfort from the
needle puncture.
Prepare the materials necessary for the test.
During:
Maintain sterile technique.
Tell the patient when to insert the needle for him to be prepared.
Encourage the patient to remain calm during the test.
Assist the patient if necessary.
Ensure a sterile blood sample from the patient.
Provide comfort to the patient.
Do not leave the patient while the procedure is ongoing.
After:
Handle the sample gently to prevent hemolysis. Apply direct pressure to the
venipuncture site until bleeding stops.
Send the blood sample to the laboratory immediately.
Proper documentation.
Instruct patient that if hematoma results or develops at the venipuncture
site, apply warm compress.
Document.
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Diagnostic/
Laboratory
Procedure
Date
ordered/
Date results
in
Indication or
purposeResults
Normal
Values
Analysis/Interpreta
tion
Dengue NS1
Antigen
Test
Date Ordered:
August 25
2010
Date
Performed:
August 25
2010
Date Result:
Aug 25 2010
Dengue viruses are
enveloped, single-
stranded, positive-
sense RNA viruses
that, among other
components,
contain seven non-
structural proteins.
One of them is
known as NS1.
Although its
specific role has notbeen completely
elucidated, NS1
has been used as
a target in a kit
developed for the
diagnosis of
Reactive Non reactive The result for
Dengue NS1 Antigen
Test for the patient
is Reactive
indicating he is
positive for Dengue
Fever
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acute dengue
infection
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Nursing Responsibilities
Prior:
Check the doctors orders.
Explain to the patient that small amount of blood will be drawn from
him and that blood will be tested to measure if her blood cells are
within normal values and to detect some blood abnormalities such as
anemia, polycythemia or detect infections.
Inform the client that there are no fluid restrictions or fasting.
Inform the patient that he will experience mild pain at the site of
extraction during collection.
Ensure that the patient understands the procedure.
Prepare laboratory request and inform laboratory.
Inform the client of the scheduled extraction.
During:
Provide comfort measures to decrease the clients anxiety.
Place the client in a comfortable position.
Maintain aseptic technique.
Assist medical technologist if necessary.
After:
Instruct patient to apply slight pressure at the site of extraction for a
few minutes.
Place the patient in a comfortable position and leave his room quietly.
Document the time and procedure done. Then, obtain results and
secure it in the patients chart. Refer
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Diagnostic/
Laboratory
Procedure
Date
ordered/
Date results
in
Indication or
purposeResults
Normal
Values
Analysis/Interpreta
tion
Urinalysi
s
Date ordered:
August 25,
2007
Date of
results:
August 25,
2007
- To screen
patients urine for
renal or urinary
tract disease
- To help
detect metabolic
or systemic
disease
unrelated to
renal disorders
Color: yellow
Sugar:
negative
Appearance:
Clear
pH: 7.0
Color: yellow-
amber
Sugar:
negative
Appearance:
Clear
pH: 5.5 6.5
The result is normal
which indicates that
the patient did nothave any kidney
problem.
This indicates that
there is no presence of
sugar in the urine.
It indicates that theres
no infection present in
the patients urine.
pH is within the
normal range
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Specific
Gravity:
1.005
Albumin:
negative
Red Cells:
None
Epithelial
cells : Rare
Specific
Gravity:
1.001 1.035
Albumin:
negative
Red Cells:
none
Epithelial
cells : Rare
Pus cells: none
inducating absence
of infection in the
urine.
The patient is not
dehydrated and has
no fluid overload .
The result is normal
which means patient
has no infection in
kidney.
There is no presence
of bleeding in the
urine.
The result is normal
which means patient
has no infection in
kidney.
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Pus cells: 0-1
The result is normal
which means patient
has no infection in
kidney.
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Nursing Responsibilities for Urinalysis:
Prior:
Check the doctors order.
Check the right client.
Encourage the patient to increase fluid intake.
Apply warm compress on hypogastric region.
During:
Provide privacy.
Allow adequate time to decrease discomfort, and anxiety,
Tell the patient to assume a normal voiding position.
Introduce stimuli for voiding.
Pour warm water over the perineum.
Collect a clean catch urine sample during midstream urination.
After:
Ensure that the specimen label and laboratory requisitionform are filled out correctly.
Securely attach the label to the container.
Send the specimen to the laboratory at once.
Document what you have done.
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Laboratory
Procedures
Date
Ordered
Date Results
In
Indications
or
Purposes
Result
s
Normal
Values
Analysis and
Interpretation of
Results
Sodium Date Ordered:
August 26
2010
Date
performed:
August 26
2010
Date Result:
August 27,
2010
It measures serum
level of sodium in
relation to amount of
water in the body. It
evaluates fluid-
electrolyte and acid-
base balance and
related
neuromuscular, renal
and adrenal functions.
138.10 135 - 150
mmol/L
The result is within
the normal range.
The patient has
normal acid base
balance and has no
neuromuscular,
renal and adrenal
alterations.
Potassium Date Ordered: It evaluates clinical
signs of potassium
3.42 3.5 5.50 The result is within
below the normal
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August 26
2010
Date
performed:
August 26
2010
Date Result:
August 27,
2010
excess or potassium
depletion. It is used to
monitor renal
function, acid-base
balance and glucose
metabolism. It
evaluates
neuromuscular and
endocrine disorders
and detect the origin
of arrhythmias.
mmol/L range. The patient
has alteration acid
base balance and
has neuromuscular,
renal and adrenal
alterations. The
patient manifested
body weakness.
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Nursing Responsibilities (Serum Electrolytes)
Prior:
Explain to the patient that the serum sodium test determines the
sodium content of the blood.
Explain to the patient that the serum potassium test determines the
potassium content of the blood.
Tell the patient that the test requires a blood sample. Explain who will
perform the venipuncture and when.
Explain to the patient that he may feel slight discomfort from the
tourniquet and the needle puncture.
Inform the patient that he need not restrict food and fluids.
Notify the laboratory and physician of drugs the patient is taking that
may affect test results; they may need to be restricted.
During:
Perform a venipuncture and collect the sample in a 3 to 4 ml clot-
activator tube. Handle the sample gently to prevent hemolysis.
After:
Apply direct pressure to the venipuncture site until bleeding stops.
Instruct the patient to resume any medications stopped before the
test.
In the patient with increased sodium levels and loss of water, observe
for signs of thirst, restlessness, dry and sticky mucous membranes,
flushed skin, oliguria and diminished reflexes.
Observe the patient with hypokalemia for weakness, malaise, nausea,
diarrhea, colicky pain, muscle irritability progressing to flaccid
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paralysis, oliguria and bradycardia. The ECG reveals flattened P waves,
prolonged PR interval, a wide QRS complex, tall, tented T waves and
ST segment depression. Cardiac arrest may occur without warning.
If increased total body sodium causes water retention, observe for
hypertension, dyspnea, edema and heart failure.
In the patient with decreased sodium levels, watch for apprehension,
lassitude, headache, decreased skin turgor, abdominal cramps and
tremors that may progress to seizures.
Secure results.
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V. THE PATIENT AND HER CARE
A. MEDICAL MANAGEMENT
a. IVF
Medical
management/
Treatment
Date ordered
date
performed
date changed
General Description Indication(s) or
Purposes
Clients
response to
the treatment
#1 4 D5LRS
1L X 200 cc/
hour
Date ordered:
August 25, 2010
Date Performed:
August 25,2010
Date Changed:
August 26, 2010
D5LRS is a hypertonic
solution that have a
higher concentration of
particles in solution
compared to plasma.
Used to balance the
concentration of fluid
and particles across fuil
compartments, fluid
shifts out of the
intracellular space into
the extracellular space,
causing cellular
It is an efficient and
effective method of
supplying fluids to
the body
Use as a route in
administration of
Intravenous medications.
The patient has
No allergic
response.
The patient
Hydrationmaintained as
evidenced by
good skin turgor,
and moist moist
oral mucus
membrane. The
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# 6- 8 D5LRS
1L X 150 cc/
hour
Date ordered:
August 26, 2010
Date Performed:
August 26 - 28,
2010
shrinkage or
dehydration.
patients body
weakness was
relieved
#5 D5NM 1L X
200 cc/ hour
Date ordered:
August 25, 2010
Date Performed:
August 25,
2010
D5NM is a hypertonic
solution that have a
higher concentration of
particles in solution
compared to plasma.
Used to balance the
concentration of fluid
and particles across fuil
compartments, fluid
It is an efficient and
effective method of
supplying fluids to
the body
Use as a route in
administration of
The patient has
No allergic
response.
The patient
Hydration
maintained as
evidenced by
good skin turgor,
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Date Changed:
August 26, 2010
shifts out of the
intracellular space into
the extracellular space,
causing cellular
shrinkage or
dehydration.
Intravenous medications. and moist moist
oral mucus
membrane. The
patients body
weakness was
relieved
#1 3 KCL
drip 30 meqs
+ 90cc PNSS
(soluset) to
run for 8 hrs
Date ordered:
August 27, 2010
Date Performed:
August 27 - 28,
2010
To maintain Fluid and
electrolyte imbalance and
for hypokalemia
It is an efficient and
effective method of
supplying fluids to
the body
Use as a route in
The patient has
No allergic
response.
The patients
body weakness
was relieved
The patient
Hydration
maintained as
evidenced by
good skin turgor,
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administration of
Intravenous medications.
and moist moist
oral mucus
membrane
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NURSING RESPONSIBILITIES: FOR INTRAVENOUS FLUID (IVF)
Prior:
Verify doctors order.
Explain the procedure to SO.
Obtain the necessary materials.
Select a suitable vein for venipuncture.
During:
Check IVF level.
Check for patency of tubing.
Check if IVF is infusing well.
Practice aseptic technique.
After:
Adjust the rate of fluids appropriate to needs of pt. as ordered.
Monitor IV flow and pt.s response.
Monitor pt. for evidence of IV infiltrations r/t complication such as pain,
swelling and tenderness.
Check for presence of air in the tubing if there is, remove immediately.
Record all procedure done
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b. Drugs
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Name of the
Drug; Generic
Name
Brand Name
Date Ordered
Date Taken or
Given
Date Changed
or Discontinue
Route of
Administratio
n
Dosage and
Frequency ofAdministratio
n
General
Action
Functional
Classification
Mechanism of
Action
Indications or
Purposes
Client
Response to
the
Medication
with Actual
Side Effects
Generic Name:
Acetaminophen
Brand Name;
Paracetamol
Date Ordered:
August 25,
2010
Date Taken or
Given:
August 25 27,
2010
Date Changed
or Discontinued:
Not changed
500 mg/tab
every 4 hours
PRN X fever
General Action:
Antipyretic,
analgesic
Specific Action:
-Reduces fever
by acting
directly on the
hypothalamic
heat-regulating
center to cause
vasodilation
and sweating
which help
dissipate heat.
For viral
infections
with pain
and Fever
The clients
temperature
decreased from
38.5 C to 37.2
C.
The patient has
no allergic
reactions to the
drug.
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Nursing Responsibilities for Paracetamol
Prior:
Perform proper hand washing.
With long-term therapy, monitor CBC, liver and renal function studies.
Check the patients identity Checks for the doctors order
Get the temperature of the client.
Assess fever; note presence of associated signs (diaphoresis, tachycardia, malaise).
Make sure that the 10 rights are applied.
During:
Check if your giving the right dosage.
Check patients name by asking the complete name.
Identify the patient expresses any doubt about the medication; alwaysrecheck the order, drug label and dosage on the container.
After:
Provide opportunities for rest.
Maintain a quiet environment.
Instruct client or significant others to increase fluid intake.
Report paleness, weakness and heart beat skips; s/sx of hemolytic anemia.
Report for any symptoms of abdominal pain, yellow discoloration of skin and
eyes, dark urine, itching or clay-colored stools because it may indicate
liver toxicity.
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Name of the
Drug; Generic
Name
Brand Name
Date Ordered
Date Taken or
Given
Date Changed
or Discontinue
Route of
Administratio
n
Dosage and
Frequency of
Administratio
n
General
Action
Functional
Classification
Mechanism of
Action
Indications or
Purposes
Client
Response to
the
Medication
with Actual
Side Effects
Generic Name:
Pantoprazole
Sodium
Brand Name;
Pantoloc
Date Ordered:
August 25,
2010
Date Taken or
Given:
August 25 28,
2010
Date Changed
or Discontinued:
Not changed
40 mg IV OD General Action:
Proton Pump
inhibitor, Anti-
secretory drug
Specific Action:
Supresses
gastric acid
secretion by
specific
inhibition of the
hydrogen
potassium
ATPase enzyme
system at the
secretory
surface of the
gastric parietal
cells; blocks thefinal ste of
Preventionand
treatment of
gastro
duodenal
ulcers and
stress ulcers
The patient
complied to the
treatment
regimen, he has
no allergic
reactions
towards the
drug. He did not
manifest any
signs ofduodenal or
stress ulcers
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Nursing Responsibilities for Pantoloc:
Prior:
Perform proper hand washing.
Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the
stool, emesis, or gastric aspirate.
Check contraindications
Make sure that the 10 rights are applied.
Check the patency of the IV tube.
During:
Check if your giving the right dosage.
Clean the IV insertion site for medications with a cotton ball with alcohol.
Gradually inject the drug into the port.
After:
Provide opportunities for rest.
Maintain a quiet environment.
Instruct client or significant others to increase fluid intake.
Monitor side effects or reactions.
Document all necessary information.
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Name of the
Drug; Generic
Name
Brand Name
Date Ordered
Date Taken or
Given
Date Changed
or Discontinue
Route of
Administration
Dosage and
Frequency of
Administration
General Action
Functional
Classification
Mechanism of
Action
Indications or
Purposes
Client
Response to
the Medication
with Actual
Side Effects
Generic Name:
Brand Name:
Iterax
Date Ordered:
Aug 26, 2010
Date Taken or
Given:
Aug 26, 2010
10 mg/ tab now General Action:
Antihistamine
Specific Action:
Potent specific
histamine (H1)
receptor
antagonist;
inhibits histamine
release and
eosinophil
chemotaxis
during
inflammation,
Symptomatic
relief of perennial
and seasonal
allergic rhinitis,
vasomotor
rhinitis, allergic
conjunctivitis and
,mild
uncomplicated
urticaria
.
The patients
rashes was
lessened. The
itchiness and
redness was
relieved.
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leading to
reduced swelling
and decrease
inflammatory
response, has
anti pruritic
effects.
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Nursing Responsibilities for Iterax:
Prior:
Document all necessary information.
Perform proper hand washing.
Checks for the doctors order
Check the patients identity
During:
Provide opportunities for rest.
Maintain a quiet environment.
Advise patient not to scratch the rashes
Instruct client or significant others to increase fluid intake.
After:
Document all necessary information.
Monitor for adverse effects of the drug
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Name of the
Drug; Generic
Name
Brand Name
Date Ordered
Date Taken or
Given
Date Changed
or Discontinue
Route of
Administration
Dosage and
Frequency of
Administration
General Action
Functional
Classification
Mechanism of
Action
Indications or
Purposes
Client
Response to
the Medication
with Actual
Side Effects
Generic Name:
Bisacodyl
Brand Name:
Dulcolax
Date Ordered:
August 26, 2010
Date Taken or
Given:
August 26 2010
10 mg / supp now General Action:
Laxatives
Specific Action:
Increase the
osmotic pressure
in the colon and
slightly acidify
the coloniccontents,
resulting in an
increase in stool
water content,
stool softening,
laxative action.
Treatment of
Constipation and
abdominal pain
.
The patients
abdominal pain
was relieved. The
patient defecated
on July 27 2010.
His stool was
formed, without
blood and soft.
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Nursing Responsibilities for Dulcolax
Prior to:
Check the written medication order for completeness. It shouldinclude the drug name, dosage, frequency, and duration of thetherapy.
Check to see if there are any special circumstances surroundingadministration of the dose to the patient.
Be certain that you know the expected action, safe dosage range,special instructions for administration and adverse effects associatedwith drug orders.
Prepare the necessary equipment.
Wash your hands. Prepare the dosage as ordered.
During:
Check patients name by asking the complete name.
Identify the patient expresses any doubt about the medication; alwaysrecheck the order, drug label and dosage on the container.
After:
Document date and time
Monitor adverse effect
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C. Diet
Type of
diet
Date ordered
Date started
Date changed
General
description
Indication (s)
Or Purpose (s)
Specific
food
taken
Clients
response and/ or
reaction to diet
DAT (Diet as
tolerated)
except dark
Colored
Foods
Date Ordered :
August 25,
2010
Date Started:
August 25, 2010
Date Changed:
Not changed
The patient can eat
foods rich in CHO,
CHON, Vitamin C,
especially foods
rich in Iron (Fe) ,
and drink fluids as
tolerated.
He needs to eat food rich
in CHO, CHON, Vitamin C,
and adequate intake of
fluids to increase energy
and to prevent infection
and for tissue repair for
immediate healing and
damaged cells. Dark color
foods should be avoided
since it can mask the
color of the stools.
Presence of blood in the
stool is checked in
patients with dengue
Fever
Banana,
Rice, Milk,
Fish,
Apple,
Orange
The patient
complied with the
diet regimen. The
patients energy
levels increased
AEB decreased
body malaise.
The patients did
not manifest blood
in the stool.
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Nursing Responsibilities (Diet)
Prior:
Checks for the doctors order
Check the patients identity
Monitor the client and assess for signs of weakness.
Explain to the patient the purpose of the dietary recommendation tohis current condition.
During:
Be sure that the patient is taking or eating foods he can tolerate.
Assess patients condition and how he responded on the foods he is
taking.
Try to give fruits especially banana and vegetables.
Stress the importance on complying with the diet.
Monitor if the patient adapts or complies with the prescribed diet
After:
Assess the health status of the patient.
Compare previous health status from the present.
Document all necessary information.
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d. Activity / Exercise
Type of
Exercise
Date ordered Date
performed
Date changed
General Description Indication(s) or Purposes
Clients response and/or
reaction to the
activity/exercise
Complete
Bed RestDate Ordered:
August 25 2010
Date Performed:
August 25 28 2010
Date Changed:
Not Changed
Patient is restricted to go
out of bed or to perform any
activity that could increase
workload of the heart.
Movement is permitted as
tolerated by the patient.
Adequate rest is encouraged
and activity according to the
patients tolerance is
allowed.
To decrease oxygen
demand, provide
adequate energy
stores, and to prevent
injuries.
It is also indicated to
hasten recovery and to
prevent pain that
aggravated by
movement.
Promotes lung
expansion and
improves breathing.
The patient complied
with the physician's
order. He became less
irritable and the body
weakness that he
complains upon
admission was relieved.
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The patients tolerated
well in the activity AEB
the patients continuous
recovery.
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Nursing Responsibilities (Activity/ Exercise)
Prior to:
Checks for the doctors order
Check the patients identity
Explain to the SO the need for the said activity/exercise.
During:
Provide safety precaution Provide comfort measures
Promote a quite environment conducive for rest.
Provide adequate rest periods
After:
Monitor the position/activity of the patient every 2 hours.
Obtain initial assessment about the progress of the activity.
Encourage verbalization of feelings about the activity.
Assess for patients condition, how he responds to the activity.
Document all necessary information.