V.

THE PATIENT AND HIS CARE

A. MEDICAL MANAGEMENT

Medical Date ordered, General Indications Clients

management/ performed, Description or Purpose Response to
Treatment changed treatment

D5 Lactated DO: Aug. 21, It is an For Electrolyte

Ringer’s 2006 hypertonic replacement imbalance
Solution DP: Aug. 21- solution that of fluids and was
22, 2006 causes the electrolytes. prevented.
cell to shrink.
Each 100 ml
consists of 5g
of dextrose
monohydrate,
600 mg NaCl,
30mg of Na
Lactase
Anhydrase,
30 mg of
potassium
chloride. It
has a pH of
4.0- 6.5.

NURSING RESPONSIBILITIES

PRIOR:
o Check the doctor’s order for the correct IVF to be infused.
o Check for the IVF regulation.
o Explain the purpose and importance of IV fluids to the patient and
SO.

DURING:
o Check for the integrity of the infusion.
o Regulate and monitor the IV rate of fluid.
o Assess the site for any redness, swelling, tenderness or infiltration.

AFTER:
o Check for the patency of the line always.
o Monitor the level of IV fluid.
o Place an IV tag.
Medical Date ordered, General Indications Clients
management/ performed, Description or Purpose Response to
Treatment changed treatment

Oxygen DO: Aug. 22, Oxygen is a It was given Pt. was well-
Inhalation 2006 transparent, post oxygenated
DP: Aug. 22, odorless dry operatively to AEB absence
2006 gas that is patient to of nasal
slightly prevent flaring,
heavier than respiratory difficulty of
air. distress. breathing, no
pallor or
cyanosis.

NURSING RESPONSIBILITIES

PRIOR:
o Check chart for the Oxygen regulation and monitor vital signs.
o Prepare the equipments; oxygen supply, humidifier with distilled
water, nasal cannula and tubing.
o Assess skin and mucous membrane, breathing patterns and chest
movements.
o Wash hands.

DURING:
o Determine need for oxygen therapy and verify order.
o Prepare client and SO and explain the procedure’s importance.
o Set up oxygen and humidifier.
o Turn on oxygen at the prescribed rate and ensure proper
functioning. Check oxygen if flowing freely through the tubing.
There should be no kinks and connections should be airtight. There
should be no bubbles in the humidifier as oxygen flows through.
o Put the cannula over the clients face with the outlet prongs fitting
into the nares.
o Assess for the nares’ encrustation and irritations.

AFTER:
o Report any significant deviations from normal.
Medical Date ordered, General Indications Clients
management/ performed, Description or Purpose Response to
Treatment changed treatment

Surgical Skin DO: Aug. 21, Involves the To reduce the There were no
Preparation 2006 cleansing of risk of post noted signs
DP: Aug. 21, the surgical operative and symptoms
2006 site, removing wound of infection
hair if only infection. after the
necessary operation.
and applying
anti- microbial
agent, PRN.

NURSING RESPONSIBILITIES
• Ensure that the operative site and surrounding areas are clean, have the
patient take a shower, wash the operative site and apply anti- microbial
agent.
• Inspect for growth, moles, rashes, pustules, irritations, abrasions, bruises
or broken or ischemic areas.
• Determine whether client is allergic to any solutions used in the skin prep.
• Hair removal at the operative site is not recommended unless the hair
interferes with the surgical procedure.
Medical Date ordered, General Indications Clients
management/ performed, Description or Purpose Response to
Treatment changed treatment

Bulb syringe DO: Aug. 22, Suction drains To drain Blood and
attached to a 2006 are used in serum from serum was
drainage tube DP: Aug. 22, every case of the operative drained at the
2006 subcutaneous site operative site.
operation over To promote There were no
the muscles wound healing noted signs
and in the sub and decrease and symptoms
muscular the potential of infection.
pocket. for infection.

NURSING RESPONSIBILITIES

• Determine color, consistency and amount of drainage from the tube and
suction apparatus. Record the volume of the drainage.
• Check for the patency and tubes and suction should be functioning.
• Bulb syringe should be hanging properly. Drain should be secured and
labeled properly.
• Check any leakage of fluid at the drainage insertion site.

Medical Date ordered, General Indications Clients

management/ performed, Description or Purpose Response to
Treatment changed treatment

Wound The doctor of A thin white To prevent There were no

dressing the patient cloth that is infection. noted signs
was the one autoclaved for and symptoms
who changed sterilization. of infection
the first
wound
dressing.

NURSING RESPONSIBILITIES

• In many instituitions, the physician changes the initial post operative

dressing. The doctor orders the type and frequency of dressing changes.
Assess the dressing if it is soiled and check for the doctors order.
• Specify type of dressing to be used, clean or sterile.
• Use aseptic technique in examining the wound.
• Report changes in the color, character and quantity of the drainage from
the drain or around the drain site. Any sign of swelling, redness,
tenderness, warmth, bleeding, discharge or separation of wound edges
should be reported.
• Make sure that the dressing is intact.