PHINMA- Cagayan de Oro College

Max Suniel Street, Carmen, Cagayan de Oro City

College of Nursing

GENERAL OBJECTIVE
(KNOWLEDGE, SKILLS, ATTITUDE)

At the end of 12 hours duty, I will be able to:

KNOWLEDGE:

 Know the proper procedures in doing and conducting care to a 75-year-old man with type
2 diabetes presented to the Emergency Room with epigastric pain that radiates to his
back.

 Determine the tools needed in caring for a 75-year-old man with type 2 diabetes
presented to the Emergency Room with epigastric pain that radiates to his back.

 Assess a 75-year-old man with type 2 diabetes with the used of the correct equipment and
methods to address the existing health needs of the patient.
SKILLS:

 Together with the client formulate a plan of care to provide his needs and problems.
 To address the patient’s needs and problems
 Implement safe and quality nursing interventions.
 Basing on the identified nursing problems, prepare and make a health education
activities.
 Manage resources (human, physical, financial, time) efficiently and effectively

ATTITUDE:

 With the client and significant others, evaluate the health outcomes of nurse –client
working relationship.
 Ensure a working relationship with the patient  based on trust, respect and shared
decision-making using appropriate communication/interpersonal techniques/strategies
 PHINMA- Cagayan de Oro College
Max Suniel Street, Carmen, Cagayan de Oro City

College of Nursing

SPECIFIC OBJECTIVE
(KNOWLEDGE, SKILLS, ATTITUDE)

At the end of 12 hours duty in the Emergency Room, I will be able to:

KNOWLEDGE:

 Identify and document the signs and symptoms displayed by a 75-year-old man.
 Note the remarkable laboratory results and refer directly to his attending physician. 
 Distinguish nursing diagnosis base on the recognized subjective and objective
information.
 Identify the important nursing considerations when administering medications

SKILLS:

 Reassess the 75-year-old man during nursing rounds

 Perform accurately the following nursing procedures  vital signs and administration of
medication as ordered by the physician
 Refer abnormal laboratory and diagnostic results to the attending physician

ATTITUDE:

 Properly communicate requests for laboratory examinations and diagnostic procedures

such  to Medtech and RADTech.
 Develop and adopt a good attitude towards doing the procedures.
 DAILY PLAN OF ACTIVITY:

Time  Activity 

6:15 am Time for the gathering

6:00 AM  Arrival in the area we have assigned

6:15 -  Pre conference 

7:00AM  Prayer 
 Attendance Checking
 Paraphernalia Inspecting

7:00 -  Courtesy call to nurses manager and staff

7:30AM  Nurses orientation to emergency room
 Associate with endorsement and nursing rounds

7:30 - 9:00  Check IVF level and regulate at prescribed rate

am   Monitor vital signs
 Apply standard and quality intervention
 Physical Assessment
 Determine of patient have allergies
 Administer glipizide, hydrochlorothiazide, enteric-coated aspirin, and occasional
ibuprofen, intravenous ranitidine, bottle of magnesium citrate, and a dose of
azithromycin appropriate dosage for weight 

9:00 am  Continue nursing rounds/ rotations

-10:00 am

9:00 -10:00  Report signs of infection

am  Inform the patient to express or clarifications of needs, unknowns, and questions
 Tell the patient to verbalize fears and concerns.
 Teach the patient to recognize the signs and symptoms that need to be reported to
the nurse.

10:00- BREAK TIME

10:30am

10:30 -  Assist clients for follow-up result and refeR

12:00

12:00 - 1:00 LUNCH BREAK

1:00 - 3:00  Reassess patient

3:00 pm   Nursing Round for afternoon shift

 Check the IVF level and regulation 
 Take Vital signs, BP

3:00-4:00 BREAK TIME

4:00-5:00  Continue nursing rounds

5:00- 7:00  Recording of monitoring results

pm   Polish the working area
 Check IV fluid level , site and regulation
Assessment
I. Current Job
A. What is your current job title?
N/A = NOT MENTIONED IN THE CASE STUDY

B. How long have you had this job?

N/A = NOT MENTIONED IN THE CASE STUDY

C. What specific tasks you perform on the job?

N/A = NOT MENTIONED IN THE CASE STUDY

D. Are exposed on any of the following on your present job?

N/A Chemicals N/A Infectious agents N/A Stress

N/A Dusts N/A Loud Noise N/A Vapors, Gases

N/A Extreme N/A Radiation N/A Vibrations

Temperature changes: 

E. Do you think you have any work-related problems?

If so, describe N/A = NOT MENTIONED IN THE CASE STUDY

F. How would you describe your satisfaction with your job?

N/A Very satisfied   N/A Satisfied N/A Somewhat satisfied

N/A Dissatisfied   N/A Very Dissatisfied

G. Have there been any recent changes in your job? N/A = NOT MENTIONED IN THE
CASE STUDY

H. Do you use protective equipment/clothing on your job? N/A = NOT MENTIONED

IN THE CASE STUDY

If so, list items used: N/A = NOT MENTIONED IN THE CASE STUDY
II. Pas Work Experience:

Please provide the following Information, starting with your first job:

         Job Title                    Dates Hired                   Brief description of

job               Exposures                      Injuries/Illnesses

N/A = NOT N/A = NOT N/A = NOT N/A = NOT N/A = NOT
MENTIONED MENTIONED MENTIONED MENTIONED MENTIONED
IN THE CASE IN THE CASE IN THE CASE IN THE CASE IN THE CASE
STUDY STUDY STUDY STUDY STUDY

HEALTH HISTORY

Name N/A = NOT MENTIONED IN THE CASE STUDY Date JULY 29,2021
Time N/A = NOT MENTIONED IN THE CASE STUDY
Demographic Data: N/A = NOT MENTIONED IN THE CASE STUDY Gender MALE
Marital Status N/A = NOT MENTIONED IN THE CASE STUDY
Reason for Seeking Health Care
Epigastric pain that radiates to his back
Previous Illness/Hospitalization/Surgeries: 

Hypertension and peptic ulcer disease and his current medications were glipizide,
hydrochlorothiazide, enteric-coated aspirin, and occasional ibuprofen for arthritis pain.
Client/Family Medical History:
Addiction (drugs/alcohol) N/A          Diabetes N/A
Mental Disorders N/A

Arthritis N/A Heart Disease N/A Sickle cell anemia N/A

Cancer N/A Hypertension N/A Stroke N/A Chronic Lung N/A
Disease N/A Kidney Disease N/A Other N/A

Immunization/Exposure to Communicable Disease: N/A = NOT MENTIONED IN THE

CASE STUDY

Allergies N/A = NOT MENTIONED IN THE CASE STUDY

Home Medications:    A dose of azithromycin

Developmental Level:

ADULT

Psychosocial History: Alcohol use:  N/A = NOT MENTIONED IN THE CASE STUDY
Tobacco use: N/A = NOT MENTIONED IN THE CASE STUDY
Drug use: N/A = NOT MENTIONED IN THE CASE STUDY
Caffeine intake: N/A = NOT MENTIONED IN THE CASE STUDY
Self- perception/Self-concept:    N/A = NOT MENTIONED IN THE CASE STUDY

Sociocultural History: Family structure                                        

 

Role in family N/A = NOT MENTIONED IN THE CASE STUDY

Cultural Ethnic group N/A = NOT MENTIONED IN THE CASE STUDY

Occupation/work role N/A = NOT MENTIONED IN THE CASE STUDY

Relationships with others N/A = NOT MENTIONED IN THE CASE STUDY

Activities of Daily Living:

Nutrition: Type of diet N/A = NOT MENTIONED IN THE CASE STUDY

Usual weight N/A = NOT MENTIONED IN THE CASE STUDY
Eating patterns N/A = NOT MENTIONED IN THE CASE STUDY

Type of snacks N/A = NOT MENTIONED IN THE CASE STUDY

Food likes/dislikes N/A = NOT MENTIONED IN THE CASE STUDY

Fluid intake: Type N/A = NOT MENTIONED IN THE CASE STUDY

Amount N/A = NOT MENTIONED IN THE CASE STUDY

Elimination (usual patterns): Urinary N/A = NOT MENTIONED IN THE CASE STUDY
Bowel N/A = NOT MENTIONED IN THE CASE STUDY

Sleep/rest:
Usual sleep patterns N/A = NOT MENTIONED IN THE CASE STUDY

Relaxation tecniques/patterns N/A = NOT MENTIONED IN THE CASE STUDY

Activity/Exercise:

Usual exercise patterns N/A = NOT MENTIONED IN THE CASE STUDY

Ability to perform self-care activities N/A = NOT MENTIONED IN THE CASE STUDY

Review of Systems:

Respiratory N/A = NOT MENTIONED IN THE CASE STUDY

Circulatory N/A = NOT MENTIONED IN THE CASE STUDY

Integumentary N/A = NOT MENTIONED IN THE CASE STUDY

Musculoskeletal N/A = NOT MENTIONED IN THE CASE STUDY

Neurosensory N/A = NOT MENTIONED IN THE CASE STUDY

Reproductive/Sexuality N/A = NOT MENTIONED IN THE CASE STUDY

Health Maintenance Activities:

Usual source of health care N/A = NOT MENTIONED IN THE CASE STUDY

Date of last exam (physical, dental, eye) N/A = NOT MENTIONED IN THE CASE STUDY

Other health maintenance activities N/A = NOT MENTIONED IN THE CASE STUDY