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DESCRIPTION
Nursing: Physical AsTRANSCRIPT
San Lorenzo Ruiz College of Ormoc
College of Nursing
Ormoc City
Name of Patient: Serenio, Olympio Lota Hospital No.: 39096- 2011
Diagnosis: Post-gliotic seizure secondary to CVA Room No.: MM8
Diabetes Mellitus, type 2 Physician: Dr. Honey Alcantara/
Essential Hypertension, stage I Dr. Dennis Daniel Roa
Hypokalemia
PHYSIOLOGIC BODY PARTS
INSPECTION PALPATION PERCUSSION AUSCULTATION
Head and Neck
Head Normocephalic and symmetrical
Normal skull which looks smooth, no masses non-tender, and depressions, no pain felt
Hair White and gray, no scars noted, lighter skin color than complexion
Flat shaft, brittle, moist from perspiration/ oily, thin
Scalp Lighter in color than skin complexion, moist from perspiration, no scars, free from dandruff
Without masses, no pain felt, no lumps
Forehead No wounds/ scars, color is even which is light brown, lentigens (brown age spots) slightly noted
No pain felt, without lesions and depressions, no masses, no pain felt, , temporal pulse= 61 bpm synchronized on both sides with normal strength, warm to touch
Face Oval, , symmetrical facial features, dry skin, poor skin turgor, facial grimace and facial wrinkles noted
No masses, no pain felt, no swelling
Eyes In line with each other/ symmetrical, non-protruding
Eyebrows Bilateral, grayish and white in color, evenly distributed, symmetrically aligned, parallel
No masses, no lumps, no nodules
PHYSIOLOGIC BODY PARTS
INSPECTION PALPATION PERCUSSION AUSCULTATION
Eyelashes Evenly distributed, slightly curved outward, black, blink reflex= 15 times per minute
Active blink reflex, thin
Eyelids UPPER LIDS: Involuntary
Symmetrical, Intact, able to open and close, pale pink in color, dry, drooping eyelids
LOWER LIDS:Symmetrical, intact, able to open and close, pale pink in color, dry
when blinking
Involuntary when blinking
Sclera white, absence of lesions, small veins are visible
Conjunctivae Not inflamed; pale pink in color, moist
Cornea Transparent and glossy, teary looking, clear
Iris Equal in size of both eyes and brownish in color, appears flat with a regular shape
Pupil Black, Equally round, reactive to light and accommodation
Muscle Function Both eyes are well coordinated, it moves smoothly and symmetrically
and follows the 6 fields of gaze.
Muscle Balance Constricting during light reflex and simultaneously during consensual light reflex
Visual Acuity 20/20 (Normal Vision); Upon admission,, patient experienced blurring of vision and gradually returns to normal
Peripheral Vision Able to see the stimulus at about 90 degrees temporally, 50 degrees superiorly, 70 degrees inferiorly, and 60 degrees nasally
Nose Found in the midline of the face with no lesions and no presence of discharges
No masses, no lumps, no pain felt
Frontal Sinus Evidence of swelling around the eyes and nose, gray during transillumination
Slightly tender upon palpation
Dull sound
Maxillary Sinus Evidence of swelling around the eyes and nose, grayish color during transillumination
Slightly tender Dull sound
Mouth
Lips Pallor, pale pink in color, cracked and dry
Non-tender, no pain felt, soft, no lumps
Gums Pale pink in color, no bleeding, smooth
No pain felt
Teeth Yellowish, 27 teeth, 2 extracted, and dentures for molars noted, presence of dental plaques also noted
Tongue Pink in color and is in the midline of the mouth. It moves freely and the dorsal and ventral surface is moist.
Frenulum Attached to the tongue, pink in color
Sublingual Pink in color, absence of lesions, blood vessels visible
Hard Palate Slightly whitish Hard
in color and dome-shaped with ridges, no lesions, dry
Soft Palate Light pink in color, concave, no lesions, moist
Soft
Uvula Hanging in the midline of soft palate, pink in color, slightly dry
Tonsils
Speech
Pink, moist, not inflamed
Slightly slurred
No pain felt
EARS Bilaterally equal, without swelling, light brown in color consistent with the patient’s facial skin, no discharges, laterally aligned with the outer canthus of the eye, symmetrical, and pendulous
Firm, absence of lumps, no pain felt
Auditory Acuity Able to perceived the words and sounds equally in both ears
Neck Able to move the head in full range of motion without complaints or
Smooth, absence of lesions, no pain felt, carotid pulse= 61 bpm synchronized and strong pulse
discomforts, able to move neck with full ROM: flexion= 45°, hyperextension= 60°, lateral abduction= 40°, rotation=10°
Lymph Nodes Not inflamed No pain felt during palpation
Trachea Appears in midline
Placed centrally in midline, spaces are equal on both sides, not deviated
Thyroid Gland Moves up when swallowing, no visible masses
No enlargement, masses and tenderness
Thorax
Chest Anterior Lighter in color, equal rise and fall, breathing route is 18 cycles per minute, moist with perspiration
Equal chest expansion, full symmetric excursion, warm skin, axillary temperature= 37.8°C
Resonance on lung area, flat on ribs
Clear sounds on both lobes of the lungs
Lungs Respiratory rate= 18 cycles per minute, bilateral symmetry
Resonant sound on intercostals spaces, flat on ribs
Clear sounds on both lobes of the lungs
Heart Nonpalpable, heartbeats=61 bpm
Dull Sound Apical pulse= 61 bpm
Chest Posterior Spine vertically align, symmetrical
Warm to touch, no pain felt, full and symmetric expansion
Resonant sound heard
Clear sounds on both lobes of the lungs
Abdomen Color is the same with the body, flat, umbilicus in the midline and non-protruding
No pain felt no lumps, absence of masses, and lesions
Tympanic sound over the stomach, dullness over the liver and spleen
High pitched sound/ gurgles: 8 times/minute
Liver No pain felt, lightly palpable
Dull sound
Spleen Non palpable Dull soundKidney Non palpable, no
painDull sound
Extremities
Upper Even in color, hairy, slight age spots noted, numbness and difficulty moving left hand, with ongoing IVF #4 of PNSS 1L @ 20 gtts/min at the level of 150 cc infusing well @ right hand; unable to perform gross and fine motor skills at left hand
No pain felt, capillary refill less than 3 seconds, brachial and radial/ulnar pulse palpable, T= 37.8 degrees CelsiusPR= 61 bpm
BP= 120/80 mmhg
Muscle tone
Muscle strength
Color is even, poor skin turgor, wrinkles, and unable to resist the force exerted on his left hand and was able to resist force
no pain felt, no lumps, non-tender, warm and moist from perspiration.Patient has weak resistance to force exerted to him
Reflexes
exerted on the right hand
Biceps= flexion of the forearmTriceps= extension of the elbowBrachioradialis= supination and flexion of forearm
Lower Equal in size, brown in complexion, even skin tone, hairy legs
No pain felt, popliteal/dorsalis pedis and tibal pulse palpable
Muscle Strength Weak resistance to force exerted on him
Muscle tone
Reflexes
Color is even, unable to move left leg, symmetrical, age spots and wrinkles noted
No pain felt, non-tender, no lumps, warm to touch
Patellar= extension of the kneeAchilles= planter flexion of the feetPlantar= toes curved/plantar flexion of the toes
Gait Patient is confined to bed (non-ambulatory) due to left-sided weakness. Gait
was not assessed.
Balance Patient is confined to bed (n0n-ambulatory) due to left-sided weakness. Balance was not assessed.
Coordination Patient is confined to bed. Coordination was not assessed.
San Lorenzo Ruiz College of Ormoc
College of Nursing
Ormoc City
Name of Patient: Serenio, Olympio Lota Hospital No.: 39096- 2011
Diagnosis: Post-gliotic seizure secondary to CVA Room No.: MM8
Diabetes Mellitus, type 2 Physician: Dr. Honey Alcantara/
Essential Hypertension, stage I Dr. Dennis Daniel Roa
Hypokalemia
DRUG THERAPEUTIC RECORD
Drug/ Dose/ Frequency/
Route
Classification/ Mechanism of
Cction
Indications/ Contraindica-
tions/Side Effects
Principles of Care
Treatment Evaluation
Metformin
HCl
Dose:
500mg
Route:
Oral
Frequency:
BID
Classification:
Antidiabetic
Mechanism of
Action:
Exact
mechanism is
not understood
which possibly
Indications:
-Adjunct to diet to
lower blood
glucose with type 2
DM
-As part of
combination
therapy with
insulin wherein
1. Do not
discontinue
this
medication
without
consulting
healthcare
provider.
2.
Monitor
urine or
serum
glucose
levels
frequently to
determine
effectiveness
of drug and
Medications
taken at
ordered dose,
date and time.
Desired
effects
obtained.
Timing:
10 am
10 pm
increases
peripheral
utilization of
glucose,
decreases.
either drug alone
cannot control
glucose levels in
patients with type 2
DM
Contraindications:
-Hypersensitivity to
the drug, CHF;
diabetes
complicated by
fever, severe
infections, major
surgery
Side Effects:
Gastrointestinal:
Nausea, vomiting,
anorexia,
heartburn, diarrhea
and flatulence
Hypersensitivity:
-allergic skin
Monitor
blood
glucose and
ketone as
prescribed.
Swallow
extended-
release
tablets
whole; do
not crush or
chew.
Do not use
this drug
during
pregnancy.
Avoid
using
alcohol
while
dosage.
Arrange for
transfer to
insulin
therapy
during
periods of
high stress.
Use IV
glucose if
severe
hypoglycemi
a occurs as a
result of
overdose.
Increased
risk of
hypoglycemi
a occurs as a
result of
reactions, eczema,
pruritus, erythema,
urticaria
taking the
drug.
Report your
fever, sore
throat,
unusual
rash or
bruising,
dark-urine,
light-
colored
stools,
hypo- or
hyperglyce
mic
reactions.
overdose.
.
Amlodipine
desylate
(Norvasc)
Dose:
Classification:
Calcium-
Channel
Blocker
Indications:
-Hpertension
Contraindications:
-Hypersensitivity
-Monitor
patient
carefully.
-Monitor
-Caution
patient to
continue
taking drug,
even when
Medications
taken at
ordered dose,
date and time.
Desired
500 mg
Route:
Oral
Frequency:
TID
Timing:
6 am
2 pm
10 pm
Mechanism of
Action:
Inhibits
calcium ion
influx across
cardiac and
smooth muscle
cells, thus
decreasing
myocardial
contractility
and oxygen
demand; also
dilated
coronary
arteries and
arterioles.
-used cautiously to
patients receiving
other peripheral
vasodilators
Side effects:
CNS:
-headache, fatigue,
dizziness, light-
headedness,
paresthesia
CV:
-edema, flushing,
palpitations
Gastrointestinal:
-nausea, abdominal
pain
Genitourinary:
-sexual difficulties
Musculoskeletal:
-muscle pain
blood
pressure
frequently
during
initiation of
therapy.
-Notify
prescriber
if signs of
heart failure
occur, such
as swelling
of hands
and feet or
shortness of
breathing.
-Alert:
Don’t
confuse
with
Amiloride.
feeling
better.
-Tell the
patient SL
Nitroglycrei
n may be
taken as
needed when
angina
symptoms
are acute. IF
patient
continues
nitrate
therapy
during
adjustment
of
amlodipine
dosage, urge
continued
compliance.
effects
obtained.
Citicoline
Dose:
500 mg
Route:
Oral
Frequency:
TID
Timing:
6 am
2 pm
10 pm
Classification:
-Neurotonics
-Nootropics
Mechanism of
Action:
Increases
blood flow and
oxygen
consumption in
the brain. It is
also involved
in the synthesis
of lecithin.
Increases the
neurotransmiss
ion levels
because it
favors the
synthesis and
production
Indications:
-Parkinson’s
disease
-Head acute
cerebral injury
-Cerebrovascular
disease
Contraindications:
-Parasympathetic
hypertonia
Side Effects:
-diarrhea
-hypertension/
hypotension
-blurred vision
-chest pain
-tachycardia
-restlessness
-body temperature
-May be
taken
without
food. With
or without
meals.
-Should not
be taken in
the late
afternoon
because it
can cause
difficulty in
sleeping.
-Should be
started
within 24
hours of a
stroke.
Administer
this
medication
without
regard to
meals.
-Observe
closely or
monitor
patient’s
neurologic
status.
-Report
physician for
unusualities
such as
rashes and
chest
tightness
Medications
taken at
ordered dose,
date and time.
Desired
effects
obtained.
speed of
dopaminergic
antagonist
through the
inhibition of
tyrosine
hydroxylase.
elevation -Monitor
neurostatus
while
taking the
drug.
-Contact
physician
immediatel
y if allergic
reaction
such as
hives,
rashes and
chest
tightness
occurs.
occurs.
-Slowly
injexct over
3- 5 minutes
into a vein
or into a Y-
port.
Phenytoin
(Dilantin)
Dose:
100 mg
Classification:
Anticonvulsant
/ Antiepileptic
Mechanism of
Indications:
-to control tonic-
clonic (grandmal)
and complex partial
(temporal lobe)
-
REquireme
nts usually
increase
during
-Tell the
patient to
notify
prescriber if
skin rash
Medications
taken at
ordered dose,
date and time.
Desired
Route:
Oral
Frequency:
TID
Timing:
6 am
2 pm
10 pm
Action:
Unknown. A
hydantoin
derivative that
probably
stabilizes
neuronal
membranes
and limits
seizure activity
by either
increasing
influx of
sodium ions
across cell
membranes in
the motor
cortex during
nerve impulses
generation.
seizures
-for patient
requiring a loading
dose
-to prevent and
treat seizures
during
neurosurgery
-status epilepticus
Contraindications:
-Hypersensitivity to
the drug
-Sinus bradycardia,
SA block, 2nd- and
3rd- degree AV
block, or Adam-
Stokes syndrome
-Used cautiously to
those with hepatic
dysfunction,
hypotension
-Elderly
pregnancy.
-Use only
clear
solution for
injection.
-Don’t give
IM unless
dosage
adjustments
are made.
-Divided
doses given
with or
after meals
may
decrease
adverse GI
reactions.
-Stop drug
develops.
-Advise
patient to
avoid
driving and
other
potentially
hazardous
activities
that require
mental
alertness
until drug’s
CNS effects
are known.
-Advise
patient not to
change
brands or
dosage
forms once
effects
obtained.
Side Effects:
CNS:
-ataxia, slurred
speech, dizziness,
mental confusion,
twitching,
nervousness,
headache
CV:
-periateritis, nodosa
EENT:
-nystagmus,
diplopia, blurred
vision
Metabolic:
-osteomalacia
Hepatic:
-toxic hepatitis
if rash
appears.
-Don’t stop
drug
suddenly
because this
may worsen
seizures.
-Monitor
drug level
in blood.
-Monitor
CBC and
calcium
level every
6 months
and
periodically
onitor
hepatic
he’s
stabilized on
therapy.
-Tell patient
not to use
capsules that
are
discolored.
-Advise
patient to
control
alcohol.
-Warn
patient and
parents not
to stop drugs
abruptly.
-Stress the
importance
function.
.
of good oral
hygiene and
regular
dental
examination.
Glimepiride
Dose:
3 mg
Route:
Oral
Frequency:
OD
Timing:
8 am
Classification:
-Medium to
long-acting
sulfonylurea
Antidiabetic
drug
Mechanism of
Action:
Unknown.
Lowers
glucose level
possibly by
stimulating
Indications:
-Adjunct to diet
and exercise to
lower- blood
glucose level in
patients with tpe 2
DM whose
hyperglycemia
can’t be managed
by diet and exercise
alone
-Adjunct to diet
and exercise in
conjunction with
-May be
used
together
with insulin
for patients
who lose
glucose
control
after first
responding
to therapy.
-Monitor
fasting
-Tell patient
to take the
drug first
meal of the
day.
-Make sure
patient
understands
that the
therapy
relieves
symptoms
but does not
Medications
taken at
ordered dose,
date and time.
Desired
effects
obtained.
release of
insulin from
functioning
pancreatic beta
cells and may
lead to
increased
sensitivity of
peripheral
tissues to
insulin.
insulin or
metformin therapy
in patients with
type 2 DM whose
hyperglycemia
cannot be managed
by glimepiride-
alone maximum
dosage.
Contraindications:
-hypersensitivity to
the drug
-Pregnant or
elderly clients
-breastfeeding
patients
-debilitated or
malnourished
patients
Side Effects:
CNS:
glucose
level
periodically
to
determine
therapeutic
response.
-Use of oral
hypoglyce
mics may
carry higher
risk of CV
mortality
than use of
diet alone
or diet and
insulin
therapy.
-When
changing
patient
cure the
disease.
-Stress the
importance
of adhering
to diet,
weight
reduction
exercise and
personal
hygiene
programs.
-Advise
patient to
wear/ carry
identificatio
n at all
times.
-Advise
woman to
-dizziness,
asthenia,, headache
EENT:
-changes in
accommodation,
Gastrointestinal:
-nausea
Hematologic:
-leukopenia,
hemolytic anemia
Skin:
-pruritus, erythema,
urticaria,
photosensitivity
reactions
Hepatic:
-cholestatic
jaundice
from other
sulfonylure
ases to
glimepiride,
transition
period is
not needed.
consult
prescriber
before
planning
pregnancy.
Dexamethas
one
Dose:
Classification:
Corticosteroid
Mechanism of
Indications:
-crebral edema
-inflammatory
conditions
-Determine
whether the
patient is
sensitive to
-Tell patient
not to stop
drug
abruptly or
Medications
taken at
ordered dose,
date and time.
4 mg tab
1 tab
Route:
Oral
Frequency:
BID
Timing:
8 am
6 pm
Action:
Not clearly
defined.
Decreases
inflammation,
mainly by
stabilizing
leukocyte
lysomal
membranes;
suppresses
immune
response;
stimulates
bone marrow;
& influences
protein,
fat ,and
carbohydrate
metabolism.
-shock
-adrenocortical
insufficiency
Contraindications:
-Hypersensitivity to
the drug
-recent MI
-patients with GI
ulcer, renal disease,
hypertension,
osteoporosis, DM,
hypothyroidism,
cirrhosis,
diverticulitis,
seizures, heart
failure
Side Effects:
CNS:
-euphoria,
insomnia, vertigo,
headache,
other
corticostero
ids.
-For better
results and
less
toxicity,
give once-
daily dose
in the
morning.
-Give oral
dose with
food when
possible.
-Give IM
injection
deeply into
gluteal
muscle.
without
prescriber’s
consent.
-Instruct
patient to
take drug
with food or
milk.
-Teach
patient the
signs and
symptoms of
early adrenal
insufficiency
, fatigue,
muscle
weakness,
joint pain,
fever,
anorexia,
nausea,
Desired
effects
obtained.
paresthesia,
seizures
CV:
-heart failure,
hypertension,
edema, arrthymias,
thrombophlebitis,
thromboembolism
EENT:
-cataracts,
glaucoma
Route
injection
sites to
prevent
muscle
atrophy.
-Always
adjust to
lowest
effective
dose.
-Watch for
depression
pr
psychotic
episodes
especially
in high-
dose
therapy.
shortness of
breath,
dizziness,
and fainting.
-Warn
patient about
easy
bruising.
-Advise
patient to
avoid
exposure in
infections
(such as
measles and
chicken pox)
and to notify
the
prescriber if
such
exposure
-Diabetic
patient may
need
increased
insulin;
monitor
glucose
levels.
occurs.