dengue part qo

8/8/2019 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.


20/57

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


21/57


22/57

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.


23/57

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


24/57

acute dengue

infection


25/57

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


26/57

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 .


which means patient

has no infection in

kidney.

There is no presence

of bleeding in the

urine.


which means patient

has no infection in

kidney.


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Pus cells: 0-1


which means patient

has no infection in

kidney.


29/57

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.


30/57

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


31/57

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


35/57

# 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


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,


36/57

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


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,


37/57

administration of

Intravenous medications.

and moist moist

oral mucus

membrane


38/57

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


39/57

b. Drugs


40/57

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.


41/57


42/57

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.


43/57


44/57

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


45/57


46/57

Nursing Responsibilities for Pantoloc:

Prior:


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:




Monitor side effects or reactions.

Document all necessary information.


47/57

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.


48/57

leading to

reduced swelling

and decrease

inflammatory

response, has

anti pruritic

effects.


49/57

Nursing Responsibilities for Iterax:

Prior:



Checks for the doctors order

Check the patients identity

During:



Advise patient not to scratch the rashes


After:


Monitor for adverse effects of the drug


50/57

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.


51/57

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


52/57


53/57

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.


54/57

Nursing Responsibilities (Diet)

Prior:



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.



55/57

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.


56/57

The patients tolerated

well in the activity AEB

the patients continuous

recovery.


57/57

Nursing Responsibilities (Activity/ Exercise)

Prior to:



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.


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