V. THE PATIENT AND HIS CARE

V. THE PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT

a. IVF (Intravenous Fluid Therapy)

MEDICAL

MANAGEMENT /

TREATMENT

DATE ORDERED/

DATE PERFORMED/

DATE CHANGED

GENERAL

DESCRIPTION

INDICATIONS/

PURPOSE

CLIENT’S

RESPONSE TO

TREATMENT

IVF No. 1

D5 0.3NaCl 500cc x

30 ugtts/min

Date ordered:

January 22, 2011

Date performed:

January 22, 2011

Time Started:

11:15AM

Time Consumed:

5:45AM

D5 0.3NaCl is a

hypertonic solution

owing to the higher

than normal amount

of Na and Cl ions. It

pulls fluid and

electrolytes from

the intracellular and

interstitial

compartments into

the intravascular

compartments.

To compensate

cellular dehydration

and corrects

moderate fliud loss,

prevents alkalosis

provides calorie and

NaCl.

The treatment

resulted to a good

skin turgor and

capillary refill and

decreased risk for

deficient fluid

volume.

IVF No. 2

D5 0.3NaCl 500cc x

30 ugtts/min

Date ordered:

January 23, 2011

Date performed:

January 23, 2011

Time Started: 5:45AM

Time Consumed:

12:45PM

D5 0.3NaCl is a

hypertonic solution

owing to the higher

than normal amount


pulls fluid and

electrolytes from


interstitial

compartments into

the intravascular

compartments.

To compensate


and corrects


prevents alkalosis


NaCl.

The treatment

resulted to a good

skin turgor and


decreased risk for

deficient fluid

volume.

IVF No. 3

D5 0.3NaCl 500cc x

30 ugtts/min

Date ordered:

January 24, 2011

Date Performed:

January 24, 2011

Time Started:

12:45PM

D5 0.3NaCl is a

hypertonic solution

owing to the higher

than normal amount


pulls fluid and

electrolytes from


To compensate


and corrects


prevents alkalosis


NaCl.

The treatment

resulted to a good

skin turgor and


decreased risk for

deficient fluid

volume.

Time Consumed:

8:30AM

interstitial

compartments into

the intravascular

compartments.

IVF No. 4

D5IMB 500cc x 40-

41 ugtts/min

Date Ordered:

January 25, 2011

Date Performed:

January 25, 2011

Time Started: 8:30AM

Time Consumed: N/A

D5 IMB is a

hypertonic solution,

which makes the

cell shrink. It is

composed of water

and carbohydrates

as source of energy

and both cations

and anions.

It is used to supply

the necessary

nutrients to the

patient.

The patient was

compliant to the

treatment given.

NURSING RESPONSIBILITIES:

Before:

1. Verify the doctor’s order indicating the type of solution, the amount to be

administered, the rate of flow of the infusion and any allergies.

2. Explain the procedure and prepare the client.

3. Prepare the equipments needed.

4. Wash hands thoroughly.

5. Obtain IV solution and check for the sediments and any crack or leak from

the container.

6. Check also for the expiration date.

7. Check fluid discoloration or defect. If noted, dispose the defected tubing

and get another.

8. Assess client’s vital signs for baseline data, skin turgor, bleeding

tendencies, disease, or injury to the extremities, status of vein to

determine the appropriate puncture site.

During:

1. Explain the importance and purpose of IVF.

2. Place the patient in a comfortable position to facilitate easy

insertion of the IV line.

3. Use the smallest gauge needle possible.

4. Maintain aseptic technique throughout the procedure.

5. Follow proper procedures in infusing IV solution.

6. Watch out for fluid overload.

7. Secure the needle properly after insertions. Always check the

needle of the IV, if it is in the vein:

- Bring the IV bottle lower than the patient arm.

- Pinch the IV tubing.

- Observe the backflow of the blood in the distal portion of

the IV tubing.

8. Avoid or remove air from the tubing as it may cause embolism.

After:

1. Check for swelling around the site for IV infiltration. Assess for any

signs of edema or bulging of vein if it is not properly inserted.

2. Regulate IVF as ordered. Apply a medication label on the solution if

a medication is added.

3. Observe for the reaction of the patient to the solution given.

4. Document related data.

5. Chart the procedure including time, name, dosage and the patient

response to the administration.

6. Properly dispose used materials after insertion

b. Drugs

NAME OF

DRUGS/

GENERIC

NAME/

BRAND

NAME

DATE

ORDERED/

DATE TAKEN/

DATE GIVEN/

DATE

CHANGED

ROUTE OF

ADMINISTRATION,

DOSAGE,

FREQUENCY OF

ADMINISTRATION

GENERAL ACTION;

CLASSIFICATION; MECHANISM

OF ACTION

INDICATION(s)

OR PURPOSE

(s)

(PATIENT

CENTERED)

CLIENTS’S

RESPONSE

TO THE

MEDICATION

WITH ACTUAL

SIDE

EFFECTS

Generic

Name:

Cefazolin

Brand

Name:

Ilocef

Date Ordered:

January 22,

2011

Date Taken:

January 22-24,

2011

Discontinued:

January 24,

2011

Cefazolin (Ilocef)

250mg q°6 ANST(-)

Route: IV

General Action:

Cefazolin is a first-

generation cephalosporin antibioti

c.

Mechanism of action:

It inhibits bacterial cell wall

synthesis by binding to one or

more of the penicillin-binding

proteins (PBPs) ,thus inhibiting cell

wall biosynthesis.

Bacteria eventually lyse due to

It was ordered

to treat

infection

caused by

staphylococci,

streptococci or

E.coli, species.

The client was

complaint with

the medication

prescribed.

http://en.wikipedia.org/wiki/Antibiotic

http://en.wikipedia.org/wiki/Antibiotic

http://en.wikipedia.org/wiki/Cephalosporin

ongoing activity of cell wall autolytic

enzymes (autolysins and murein

hydrolases) while cell wall

assembly is arrested.


Before:

Check doctor’s order.

Right drug, dosage and frequency must be observed.

Explain the purpose of the drug.

Assess patient allergy to penicillin or cephalosporin.

Assess patient for infection (vital signs; appearance of surgical site, urine; WBC) at beginning and during

therapy.

Culture infection site before the therapy.

During:

Maintain aseptic technique.

Avoid or remove air to prevent embolism.

After:

Observe patient for signs and symptoms of anaphylaxis (rash, pruritis, laryngeal edema, wheezing).

Change sites every 48-72 hr to prevent phlebitis.

Instruct patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or

discharge, loose or foul-smelling stools) and allergy.

Document related information.

NAME OF

DRUGS/

GENERIC

NAME/

BRAND

NAME

DATE

ORDERED/

DATE TAKEN/

DATE GIVEN/

DATE

CHANGED

ROUTE OF

ADMINISTRATION

, DOSAGE,

FREQUENCY OF

ADMINISTRATION

GENERAL ACTION;

CLASSIFICATION;

MECHANISM OF ACTION

INDICATION(s

) OR

PURPOSE (s)

(PATIENT

CENTERED)

CLIENTS’S

RESPONSE TO

THE

MEDICATION

WITH ACTUAL

SIDE EFFECTS

Generic

Name:

Metoclopra

mide

Brand

Name:

Reglan

Date Ordered:

January 22,

2011

Date Taken:

January 22-24,

2011

½ amp q°8 PRN

for vomiting

Route: IV

General Action:

Antiemetic

Mechanism of Action:

Metoclopramide inhibits gastric

smooth muscle relaxation

produced by dopamine, therefore

increasing cholinergic response

of the gastrointestinal smooth

muscle.

For the

treatment

vomiting

The client was

compliant with

the medication

and no further

vomiting was

noted after

administration.


Before:


Right drug, dosage and frequency must be observed.

Explain the purpose of the drug.

Assess patient for allergy to metaclopramide.

Check the medication’s compatibility with IV.

During:

Monitor for extrapyramidal reactions, and consult physician if the occur.

Give IV doses slowly over 1-2 minutes.

Avoid or remove air to prevent embolism.

After:

Dispose used materials properly.

Observe patient for any adverse reaction to therapy.

Tell the patient to take sugarless candies or gums to relieve dry mouth.

Instruct patient to take drug exactly as prescribed.

Chart the time drug was given.

Document properly.

NAME OF

DRUGS/

GENERIC

NAME/

BRAND

DATE

ORDERED/

DATE TAKEN/

DATE GIVEN/

DATE

ROUTE OF

ADMINISTRATION

, DOSAGE,

FREQUENCY OF

ADMINISTRATION

GENERAL ACTION;


OF ACTION

INDICATION(

s) OR

PURPOSE (s)

(PATIENT

CENTERED)

CLIENTS’S

RESPONSE TO

THE

MEDICATION

WITH ACTUAL

NAME CHANGED SIDE EFFECTS

Generic

Name:

Ampicillin

Brand

Name:

Omnipen

Date Ordered:

January 24,

2011

Date Taken:

January 24,

2011

250 mg q°8

ANST(-)

Route: IV

General Action:

Antibiotic; Penicillin


Destroys bacteria by inhibiting

bacterial

cell-wall synthesis during

microbial multiplication. Addition

of sulbactam enhances drug’s

resistance to beta-lactamase, an

enzyme that can inactivate

ampicillin.

To treat

patient

gastrointestina

l infection

The patient

reported relief

from abdominal

pain caused by

Bacteria.


Before:


Prepare medication and materials needed.

Perform necessary hand hygiene before administering drugs.


Calculate medication dosage properly.

Assess patient allergy to penicillin or cephalosporins.

During:

Explain the procedure and purpose of the medication.

Clean the port and maintain aseptic technique.

Inject medication slowly.

After:

Observe for any signs of hypersensitivity.

Assess client’s reaction.

Properly dispose materials used.

Document all relevant data.

NAME OF

DRUGS/

GENERIC

NAME/

BRAND

DATE

ORDERED/

DATE TAKEN/

DATE GIVEN/

DATE

ROUTE OF

ADMINISTRATION

, DOSAGE,

FREQUENCY OF

ADMINISTRATION

GENERAL ACTION;


OF ACTION

INDICATION(

s) OR

PURPOSE (s)

(PATIENT

CENTERED)

CLIENTS’S

RESPONSE TO

THE

MEDICATION

WITH ACTUAL

NAME CHANGED SIDE EFFECTS

Generic

Name:

Metronidazo

le

Brand

Name:

Flagyl

Date Ordered:

January 24,

2011

Date Taken:

January 24,

2011

30cc q°8 x 3 doses

(IV) then shift to

250mg/5ml 3ml

TID(ORAL)

General Action:

Amebicide, Antibacterial,

Antibiotic, Antiprotozoal


Inhibits DNA synthesis in specific

anaerobes causing cell death

To treat

patient acute

gastrointestina

l infection with

susceptible

anaerobe

organisms.

The patient

reported relief

from abdominal

pain and

cramping

caused by

bacteria


Before:


Prepare medication.


Calculate medication dosage properly.

During:

Explain the purpose of medication and how it will help; Include relevant information about the effects of

medication

Inject medication slowly.

For Oral medication, take it with foods to prevent GI upset.

Instruct not to drink alcohol (beverages, or preparations containing alcohol, cough syrups), severe

reactions may occur.

After:

Instruct that urine may be a darker color than usual.

Assess patient reaction to the medication.

Document all relevant information.

NAME OF

DRUGS/

GENERIC

DATE

ORDERED/

DATE TAKEN/

ROUTE OF

ADMINISTRATION

, DOSAGE,

GENERAL ACTION;


OF ACTION

INDICATION(

s) OR

PURPOSE (s)

CLIENTS’S

RESPONSE TO

THE

NAME/

BRAND

NAME

DATE GIVEN/

DATE

CHANGED

FREQUENCY OF

ADMINISTRATION

(PATIENT

CENTERED)

MEDICATION

WITH ACTUAL

SIDE EFFECTS

Generic

Name:

Diphenhydr

amine

Hydrochlori

de

Brand

Name:

Benadryl

Date Ordered:

January 24,

2011

Date Taken:

January 24,

2011

12.5 mg/5ml TID

Route:

Oral

General Action:

Antihistamine


It competes with histamine at H1

receptor site, thus preventing or

reversing the effect of histamine.

Prevention

and treatment

of nausea and

vomiting

The patient was

compliant with

the medication.

Patient didn’t

experience

further vomiting.


Before:


Explain the use of the medicine.

Compute for the right dose.

Do hand hygiene before administering the drug.

During:

Give the medication on time.

Take each dose with a full glass of water.

It can also be taken with or without food.

After:

Assess patient for drowsiness, dry mouth, and motion-sickness.

Monitor and observe patient reaction or response to the medicine.

Document the time, and date of administration.

NAME OF

DRUGS/

GENERIC

NAME/

DATE

ORDERED/

DATE TAKEN/

DATE GIVEN/

ROUTE OF

ADMINISTRATION

, DOSAGE,

FREQUENCY OF

GENERAL ACTION;


OF ACTION

INDICATION(

s) OR

PURPOSE (s)

(PATIENT

CLIENTS’S

RESPONSE TO

THE

MEDICATION

BRAND

NAME

DATE

CHANGED

ADMINISTRATION CENTERED) WITH ACTUAL

SIDE EFFECTS

Generic

Name:

Pyrantel

Brand

Name:

Quantrel

Date Ordered:

January 24,

2011

Date Taken:

January 24-25,

2011

10 cc HS

Route:

Oral

General Action:

Anti-helminthic; Anti-infectives


Pyrantel is a depolarizing

neuromuscular blocking agent

that causes spastic paralysis of

Enterobius vermicularis and

Ascaris lumbricoides.

Treatment of

patient’s

bacterial

invasion in the

gastrointestina

l tract

The patient

reported relief

from abdominal

pain and

cramping

caused by

bacteria.


Before:


Explain the use of the medicine.

Culture for ova and parasites,

Strict hand washing and hygiene measures are important.

During:

Administer drug with fruit juice or milk.

Ensure that entire dose is taken once.

After:

Disinfect toilet facilities after patient use.

Advise SO to launder bed linens, towels, nightclothes, and undergarments (pinworms) of the patient

daily.

Instruct the SO that he should also be treated for total eradication of the pinworms.

c. Diet

TYPE OF DIET DATE ORDERED/ GENERAL

DESCRIPTION

INDICATION(s) SPECIFIC

FOODS

CLIENTS’S

RESPONSE

DATE TAKEN/

DATE CHANGED

OR PURPOSE (s)

(PATIENT

CENTERED)

TAKEN AND/OR

REACTION TO

DIET

1. NPO

(Nothing Per

Orem/ Nothing

by Mouth)

Date Ordered:

January 22, 2011

Date Started:

January 22, 2011

Discontinued:

January 23, 2011

No food in any

form and

liquids will be

taken by

mouth.

It was ordered to

prevent gastric

irritation and

secretions related

to pain; to

eliminate nausea

and vomiting.

None The patient

complied by not

eating or having any

food by mouth or

per Orem.


Before:


Assure IV fluid therapy if patient is NPO>

Instruct SO not to give anything through the mouth.

During:

Assess client’s condition.

Assure that nothing is taken through the mouth( either liquid or solid.

Place “NPO” sign on bed where the patient or SO can always see it.

Remove foods or drinks on patient’s bedside.

After:

Observe patient’s response on the diet.

Monitor client’s condition.

TYPE OF DIET DATE

ORDERED,

DATE

GENERAL DESCRIPTION INDICATIONS

OR

SPECIFIC

FOODS

CLIENT’S

RESPONSE

AND/OR

STARTED,

DATE

CHANGED

PURPOSES TAKEN REACTION TO

DIET

2. Soft

Bland Diet

Date ordered:

January 23,2011

Date started:

January 23,

2011

Discontinued:

January 25,

2011

This diet includes foods that

are moderately low in

fiber, have a soft texture and

are moderately seasons.

It does not contain whole grain

cereals or salads with raw,

fresh fruits and vegetables.

Serving sizes are small to

provide a gradual increase in

the amount of food from the

NPO diet.

To prepare the

clients

stomach after

eating nothing

by mouth and

to limit foods,

that stimulate

the production

of gastric acid

that causes

irritation.

Lugaw,

Water,

Milk,

Biscuit,

Client easily

tolerated the

ordered die and

was relieved

from hunger and

thirst.


Before:


Inform patient and the SO that the client may have a soft diet.

Explain the purpose of the Bland diet.

Provide the SO with some examples of soft diet foods.

Inform SO that foods may be softened by cooking or mashing.

During:

Assess the patient’s condition.

Assure that the patient or SO eliminates food that are hard to chew or swallow such as raw fruits and

vegetables, tough meat.

Restrict the patient not to drink highly acidic beverages such as coffee, chocolate, carbonated sodas.

Instruct patient to have small frequent meals (6 meals/day) to help reduce gastric irritation.

Instruct patient to eat slowly and chew foods well.

After:

If the patient had reflux, instruct not do to lie down after eating and eat the last small meal at east two hours

before bedtime.

TYPE OF DIET DATE

ORDERED/

GENERAL

DESCRIPTION

INDICATION(s)

OR PURPOSE

SPECIFIC

FOODS TAKEN

CLIENTS’S

RESPONSE

AND/OR

DATE TAKEN/

DATE CHANGED

(s)

(PATIENT

CENTERED)

REACTION TO

DIET

3. DAT

(Diet As

Tolerated)

Date Ordered:

January 25, 2011

Date Started:

January 25, 2011

Date Changed:

-------

Regular diet of

an individual as

long as it is

tolerated and

appropriate to

individual’s

health.

It was ordered

because the

client can now

tolerate any food

he desires that is

nutritious, that

will not lead to

any

complications.

Rice with

dish(Sinigang)

The patient was

able to eat in his

regular eating

pattern

consisting of

healthy foods

and fruits.


Before:

Check the Doctor’s Order.

Explain the Indication and purpose of the diet to the patient.

Explain the Importance of Right Nutrition to the patient / SO.

Check the client’s choice of food.

During:

Encourage the patient to eat nutritious foods and fruits.

Recommend the patient to avoid eating junk foods and not to drink carbonated beverages.

After:

Recommend the Patient to perform Oral Hygiene every after meal.

d. Exercise

TYPES OF

EXERCISE

DATE ORDERED,

DATE PERFORMED,

DATE CHANGED

GENERAL

DESCRIPTION

INDICATION OR

PURPOSE(S)

CLIENT’S

RESPONSE TO

TREATMENT

Complete bed rest

with Bathroom

Privileges

Date ordered:

January 22, 2011

Date performed:

January 22-25, 2011

A medical treatment

involving a period of

consistent

recumbence in bed.

It is used as a

treatment for an

illness or medical

condition by relaxing

the body to enhance

recovery of health.

It helps to conserve

energy, promote recovery

and rest, and prevent

fatigue.

The patient was

seen on bed

throughout the day

and was able to

regain energy as

evidenced by

becoming non-

irritable during

nurse-patient

interaction.


Before:

Assessed the patient’s condition before introducing the exercise

Explain the type and how the exercise should be done.

Explain the need and purpose of the exercise.

During:

Observe the patient.

Provide comfort with the aid of pillows.

Provide safety measures to facilitate health.

After:

Report any abnormal findings.

Take note of the patient’s improvement on her health

Documents

V. THE PATIENT AND HIS CARE