Jose Rizal University

College of Nursing and Health Sciences

Grand Case Presentation

Submitted By: Group 1-302N

Ahito, Hazel Grace P.
Alba, Jasmine Grace
Alverne, Chloie Dominique S.
Andrade, Felicity Louise C.
Aragones, Anne Mikael F.
Bang-i, Judy Ann M.
Bang-i, Rachael M.
Barba, Kristine Marie G.
Belonio, Mary Catherine Ann S.
Bernarte, Claroze Lou V.
Bianito, Danica Mae B.
Biñas, Glemma Rose V.
Calugas, Jian Kaye C.
 TABLE OF CONTENTS

Chapter I Assessment
A. Nursing Health History
a. Personal Data …………………………………………………………...…… 03
b. Chief Complaint/s ……………………………………………………….…… 03
c. History of Present Illness ………………………………………………….... 03
d. Past Medical History ……………………………………………………...…. 03
e. Family Health History (Genogram) ………………………………………… 04
f. Social History ……………………………………………………………….... 04
g. Review of System
i. Pearson’s Gordon Approach (Adult) ………………………………... 04

B. Physical Examination
a. Head to Toe Assessment …………………………………………………....
05

C. Diagnostic Procedure
a. Name of Diagnostic Procedure …………………………………………….. 13
b. Definition / Description ………………………………………………………. 13
c. Specific Indication ………………………………………………………...…. 13
d. Nursing Responsibilities ………………………………………………..…… 14

D. Comprehensive Definition & Description of the Disease

a. Pathophysiology (book base) ………………………………………….…… 25
b. Schematic Diagram includes Signs & Symptoms, Predisposing
Factors regarding the presented data (patient base) ……………………. 26

Chapter II Planning
A. List of Prioritized Nursing diagnosis (3 NCP) ………………………………… 27
B. Nursing Care Plan ……………………………………………………………….…. 28

Chapter III Implementation

A. Medical Management
a. Drug Study ……………………………………………………………………. 40
b. Treatment …………………………………………………………………….. 56
c. Diet / Activity / Exercise ……………………………………………………... 56
B. Surgical Management ……………………………………………………………... 56
C. Patient’s Daily Progress Note ………………………………………………….… 57

Chapter IV Evaluation

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 A. Discharge Planning Instruction
a. Medication ………………………………..…………………………….…….. 64
b. Exercise ……………………..…………....……..…………………………… 64
c. Treatment ………………………………………………………..…………… 64
d. Health Teaching ………………………………..………………….………… 65
e. Outpatient Department (follow up check-up) ……………………..……… 65
f. Diet ………………………………………………………..……..…………… 65

Chapter V Final Output

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 CHAPTER I ASSESSMENT

A. Nursing Health History

a. Personal Data

Name: F. J. C.
Age: 80 yrs old
Birthdate: September 29, 1942
Gender: Female
Religion: Methodist
Birthplace: Tarlac
Nationality: Filipino
Marital Status: Married
Ward No: 249 (Medical Ward/St.Therese)
Admission Date: November 25, 2022
Discharge Date: -
Diagnosis: Electrolyte Imbalance, Hypertension, S/P CVD Infarct
Occupation: N/A
Height:152.4cm
Weight: 50kg

b. Chief Complaints

Generalized body weakness and decreased appetite.

c. History of Present Illness

Patient is on cardiac rehabilitation therapy due to CVD infarct and on November 8, the
patient was noted to have Bipedal Edema.
On November 14, 2022 the patient experienced SOB hence, admitted at a private
hospital where she was admitted as a case of MI/ACS and 1. She also underwent
thoracentesis bilateral where pleural fluid studies were sent but no result yet. During
the admission, the patient was also diagnosed and managed as a case of COVID (+)
and given a reminder after 1 week, the patient was discharged but she claimed to be
weak and had decreased in appetite.
During the interim, she consulted a neurologist due to an episode of delirium. Patient
was given medication.
Due to persistent symptoms of generalized body weakness and decreased appetite,
the patient was brought to the ER.

d. Past Medical History

(✔) Hypertension ( ) Skin Disease

(✔) Coronary Disease ( ) Allergy
( ) Heart Failure ( ) Cancer

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(✔) Bronchial Asthma (✔ ) Diabetes
( ) COPD ( ) Blood Dyscrasia
( ) Tuberculosis ( ) Arthritis
( ) Kidney Disease ( )Neuro-psychiatric
( ) Liver Disease ( ) Surgeries
( ) Thyroid Disease (✔) Others: ________

e. Family Health History (Genogram)

f. Social History

(✖) Smoking ( Pack years): __________

(✖) Alcohol ( Type and Frequency): ___________
(✖) Prohibited Substances:______
(✖) Other: ________

g. Gordon’s Functional Health Pattern

Prior to admission, the patient was compliant with medication regimen for previous
diagnosis such as maintenance for HTN: Losartan. Patient had no vices of drinking
alcohol or smoking. She was also immunized for COVID-19 prevention: 2 doses
Astrazeneca, 2 doses Pfizer. Moreover, the patient attends regular check-ups
especially during observation of adverse reactions. For nutritional - metabolic, the
patient was reported to have decreased appetite. Patient had poor skin turgor,
presence of edema, and dry skin which were signs of dehydration. For elimination, the

4
patient had normal bowel movement. For activity-exercise, the patient had body
weakness and due to old age, she had low activity level. For cognitive-perceptual, she
visited a neurologist due to an episode of signs of delirium. For role-relationship, the
patient is living with husband and daughter. She was not sexually active. There was
no recorded assessment for sleep-rest, self-perception, and coping/stress tolerance.

In the latest assessment, the patient had an altered level of consciousness, but
compliant with the treatment when awake. The patient was prescribed a low salt low
fat diet, Glucerna 1200 kcal 6 equal feeding via NGT with 50 cc flushing. Patient still
had bipedal edema, edema on right hand which appears shiny and described by the
patient as itchy and painful. Patient had a foley catheter for voiding and wore a diaper
for defecation. As the patient was ordered to be on CBR without BRP, she had no
activity or exercise. The sleep pattern of the patient was observed to be irregular due
to indefinite time of awake and sleeping time. For cognitive-perceptual, the patient
was unable to verbalize time and place, but has awareness of the pain experienced in
the body. The patient was constantly accompanied by daughter during the hospital
stay. She was not sexually active. There was no recorded assessment for sleep-rest,
self-perception, coping/stress tolerance, and values/pattern due to inability to
verbalize.

B. Physical Examination

During the assessment, our patient was on complete bed rest without bathroom
privileges. The patient was interviewed on the current pain she felt to be considered
during the physical assessment. She was conscious during the examination on
11/29/22, and reported pain on throat and right hand. The reported areas were not
assessed to provide comfort to the patient.

a. Head to Toe Assessment

ASSESSMENT ANALYSIS FINDINGS

GENERAL SURVEY

Posture and gait, standing, Not Assessed Patient is on complete

sitting bed rest.

Overall hygiene and Clean and neat Normal finding

grooming

Body and breath odor No body and breath odor Normal finding

Signs of distress in posture Not Assessed Patient is on complete

bed rest.

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Obvious signs of health or Pallor (paleness), Abnormal finding since
illness weakness, edema on being pale and weak
extremities indicates a health
problem.

Client's attitude Cooperative Normal finding

Affect/mood, Appropriate to the situation Normal finding

appropriateness of
responses.

Quality of speech, quality, Non-verbal Abnormal finding since

and organization it indicates a health
issue.

Relevance and organization Makes sense, has a sense Normal finding

of thought of reality.

THE INTEGUMENT

General color and texture Pallor Abnormal finding since

skin pallor indicates
that there is a loss or
decrease of blood flow
to the skin.

Uniformity of skin Generally uniform Normal finding

Lesions Freckles, some birthmarks Normal finding

that have not changed since
childhood, no abrasions or
other lesions

Moisture Dry skin Abnormal finding

because it indicates
dehydration and other
health issues.

Temperature Uniform; within normal Normal finding

range.

Skin turgor Skin stays pinched or tented Abnormal finding since

or moves back slowly. Poor it can indicate severe
dehydration.

THE HEAD

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Configuration Rounded (normocephalic Normal finding
and symmetric, with frontal,
parietal, and occipital
prominences); smooth skull
contour

Facial features Slightly asymmetric facial Normal finding

features, thin eyebrows,
high hairline

Facial movements Symmetric facial Normal finding

movements

Scalp Dry scalp Normal finding

HAIR

Evenness of growth Patches of hair loss over the Normal finding

scalp

Hair thickness or thinness Thin hair Normal finding

Texture and oiliness Brittle hair Normal finding

Presence of infestation or No presence infection or Normal finding

infection infestation

Amount of body hair Variable Normal finding

NAILS

Fingernail plate shape Convex curvature Normal finding

Fingernail and toenail Dull and brittle Normal finding for

texture geriatric patients

Fingernail and toenail bed Pallor Abnormal finding since

color it indicates that the
client has a low red
blood cell count and
maybe a sign of lack of
nutrients in the body.

Tissues surrounding nails Presence of inflammation Abnormal finding since

it indicates lack of
protein and vitamin C.

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Blanch test of capillary refill. Delayed return of usual Abnormal finding since
color (3-4 seconds) it is a sign of
circulatory
insufficiency.

THE EYES

Eyebrows Thin eyebrows, skin intact Normal finding

Eye lashes Thin lashes Normal finding

Eyelids surface Skin intact; no discharge; no Normal finding

characteristic discoloration

Bulbar conjunctiva color, Transparent, sclera appears Normal finding

texture, and presence of white with small brown
lesions macules

Palpebral Conjunctiva Pale Abnormal finding since

it may indicate a sign
of anemia and loss of
red blood cell
production

Lacrimal gland No edema or tenderness Normal finding

over the lacrimal gland

Lacrimal sac and No drainage when palpating Normal finding

nasolacrimal duct

Cornea texture and clarity Transparent, slightly shiny Abnormal finding since
and sunken sunken eyes indicates
dehydration.

Pupils color, shape, and The iris is round , flat and Normal finding
symmetry of size. evenly colored and 2-3 mm
equally reactive to light

Direct and consensual Illuminated pupil constricts Normal finding

reaction to light
(Oculomotor &Trochlear)

Assess each pupil's reaction Pupils constrict when Normal finding

to accommodation. looking at a near object,

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 pupils dilate when looking at
a far object.

Six ocular movements (CN Both eyes are coordinated, Normal finding
3,4,6) move in unison and with
parallel alignment

Location of light reflex Light falls symmetrically at 6 Normal finding

o'clock on both pupils

Rosenbaum Eye Chart Test Not Assessed Patient is weak and on

complete bed rest so
she can't do the
procedure. Plus there's
no snellen chart
available.

Visual fields Not Assessed Not eligible to do the

step since the patient
is weak and on CBR.
Plus the snellen chart
is also not available.

Visual Acuity Not Assessed Not assessed since the

patient is weak and on
CBR .

THE EARS

Auricles: color, symmetry of Color of the auricles is the Normal finding

size, and position same as the facial skin and
symmetrical

Auricles: texture, elasticity, Mobile, firm, no tenderness Normal finding

and areas of tenderness and pinna recoils after being
folded.

External ear canal, cerumen, No cerumen, distal third Normal finding

skin lesions, and blood contains follicles and glands

Gross hearing (Whisper Not Assessed Non-verbal

test)

THE NOSE

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External Nose Not Assessed Patient is on NGT

Patency of nasal cavities Not Assessed Patient is on NGT

Mucosa Not Assessed Patient is on NGT

Nasal septum Not Assessed Patient is on NGT

Maxillary and frontal Not Assessed Patient is on NGT

sinuses tenderness

LIPS AND BUCCAL MUCOSA

Outer lips symmetry of Pallor and dry Abnormal finding since

contour, color, and texture dry lips means
dehydrated and poor
nutrient-intake

Inner lips and buccal Not Assessed Patient is on CBR

mucosa
color, moisture, texture, and
presence of lesions

Teeth and gums Not Assessed Patient is on CBR.

Tongue movement Not Assessed Patient is on complete

bed rest.

Base of the tongue Not Assessed Patient is on complete

bed rest.

Presence of nodules, lumps, Not Assessed Patient is on complete

or excoriated areas bed rest.

Hard and soft palate Not Assessed Patient is on complete

bed rest.

Uvula and tonsils Not Assessed Patient is on complete

bed rest .

THE NECK

Neck muscles Muscles in equal size, head Normal finding

centered

Head movement Coordinated ,smooth Normal finding

movements with no

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 discomfort

Muscle strengths Equal strength in both right Normal finding

and left

Lymph nodes Not Assessed Patient is not

comfortable

Trachea Central placement in midline Normal finding

of neck

Carotid arteries and jugular Not Assessed Patient's neck is

veins painful.

THORAX AND LUNGS

Breathing pattern Quiet, rhythmic respirations Normal finding

Chest shape Not Assessed Patient is on CBR

Breath sounds With normal breath sounds, Normal finding

without dyspnea

Diaphragmatic excursion Symmetrical excursion Normal finding

THE HEART

Heart sound Not Assessed Patient is on complete

bed rest.

Lifts and heaves Not Assessed Patient is on complete

bed rest.

BREAST AND AXILLAE

Breasts size, symmetry, and Not Assessed Patient is on complete

contour or shape bed rest.

Presence of discharge Not Assessed Patient is on complete

bed rest.

Axillary lymph nodes Not Assessed Patient is on complete

bed rest.

ABDOMEN

Appearance and contour Not Assessed Patient is on complete

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 bed rest.

Umbilicus Not Assessed Patient is on complete

bed rest.

Bowel sounds Not Assessed Patient is on complete

bed rest.

Pain and tenderness Not Assessed Patient is on complete

bed rest.

BACK AND EXTREMITIES

Alignment of the Spine Not Assessed Patient is on complete

bed rest.

Upper and lower extremities With pain and tenderness Abnormal finding since
it maybe a sign of
edema and other
health issues.

ROM Not Assessed Patient is on complete

bed rest.

Muscle size and Not Assessed Patient is on complete

characteristics bed rest.

Muscle strength Not Assessed Patient is on complete

bed rest.

Peripheral pulses Pulse rate range is normal Normal finding

MOTOR FUNCTION

Romberg's Test Not Assessed Patient is on complete

bed rest.

Standing on one foot with Not Assessed Patient is on complete

eyes closed bed rest.

Heel-toe walking Not Assessed Patient is on complete

bed rest.

C. Diagnostic Procedure

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● Name of Diagnostic Procedure:

1. Complete Blood Count (CBC)

2. X-ray
3. Urinalysis
4. Ultrasound
5. Blood Chemistry

● Definition/Description

1. COMPLETE BLOOD COUNT (CBC)

● A complete blood count, also known as a full blood count, is a set of medical
laboratory tests that provide information about the cells in a person's blood.
The CBC indicates the counts of white blood cells, red blood cells, and
platelets, the concentration of hemoglobin, and the hematocrit.
2. X-RAY
● An x-ray is a form of radiation used to take an image of the inside of the body.
Images are produced by using how different body structures, including bones
and soft tissues, absorb x-ray rays as they traverse through the body.
Radiography is another term for X-ray imaging.
3. URINALYSIS
● A urinalysis is a test of your urine. It's used to detect and manage a wide range
of disorders, such as urinary tract infections, kidney disease and diabetes. A
urinalysis involves checking the appearance, concentration and content of
urine. For example, a urinary tract infection can make urine look cloudy instead
of clear. Increased levels of protein in urine can be a sign of kidney disease.
Unusual urinalysis results often require more testing to find the source of the
problem.
4. ULTRASOUND
● A process that examines inside organs and tissues using high-energy sound
waves. On a computer screen, the echoes created by the sound waves create
images of the tissues and organs (sonogram). Diseases like cancer may be
diagnosed with the help of ultrasound.
5. BLOOD CHEMISTRY
● A procedure to evaluate the presence of specific chemicals in the body using a
sample of blood. These substances include lipids, proteins, glucose (sugar),
enzymes, and electrolytes (such as sodium, potassium, and chloride).

● Specific Indication

1. CBC
● Indicated for anemia, infection and leukemia.
● To review the overall health of the patient.
● To diagnose and monitor a medical condition.
● To monitor a medical treatment

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2. X-RAY
● Identify the cause of symptoms, such as pain and swelling.
● Look for foreign objects in the body.
● Look for structural problems in the bones, joints or soft tissues.
● Plan and evaluate treatments.
● Provide routine screenings for cancer and other diseases.
3. URINALYSIS
● Checking the appearance, concentration and content of the urine.
● This is requested if the patient has abdominal pain, frequent or painful
urination, back pain, blood in the urine or other urinary problems.
4. ULTRASOUND
● Evaluate blood flow
● Guide a needle for biopsy or tumor treatment
● Check the thyroid gland
● Find genital and prostate problems
● Assess joint inflammation (synovitis)
5. BLOOD CHEMISTRY
● Assess the function of specific organs, such as the thyroid, liver, and
kidneys
● Examine the electrolyte balance of the body.
● Help in disease and condition diagnosis
● Provide the chemical levels (a baseline) for future blood chemistry tests
to compare.
● Examine the impact of a treatment on certain organs.
● Keep an eye on any health issues (as a part of follow-up).

● Nursing Responsibilities

1. Complete Blood Cells (CBC)

● Explain the test procedure. Explain how skin punctures might cause some
minor discomfort.
● Encourage the patient to try to avoid stress as much as she can because
stress affects and alters normal hematologic values.
● Explain why it is not necessary to fast. However, because of lipidemia, fatty
meals may change the results of various tests.

2. X-RAY
● Remove all metallic objects.
● No preparation is required.
● Ensure the patient is not pregnant or suspected to be pregnant.
● Assess the patient’s ability to hold her breath.
● Provide appropriate clothing
● Instruct patient to cooperate during the procedure.

3. URINALYSIS

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 ● Instruct the patient to void directly into a clean, dry container.
● Collect specimens from the patient into a disposable collection apparatus
consisting of a plastic bag with an adhesive backing around the opening that
can be fastened to the perineal area or around the to permit voiding directly to
the bag.
● Cover all specimens tightly, label properly and send immediately to the
laboratory.
● Observe standard precautions when handling urine specimens.
● If the specimen cannot be delivered to the laboratory or tested within an hour, it
should be refrigerated or have an appropriate preservative added.
4. ULTRASOUND
● During the procedure the nurse must help the endoscopist and, when
indicated, the anesthesist.
● After the completion of the procedure, the nurse must carry-on with the
reprocessing of the endoscopic instrument and of the devices.
5. BLOOD CHEMISTRY
Before:
● Inform the patient about the procedure; how is it done and its purpose.
● Inform the patient that he will feel a bit pain when needle is inserted.
● Advise the patient that she should feel relax as possible while blood is being
drawn out
● Advice the patient not to pull her hands during the procedure
● Clean the site where the needle will be pricked.
During:
● Assist the patient during the procedure.
● Monitor the patient’s condition.
● Provide comfort measures to divert her attention to pain or discomfort

After:
● Apply pressure dressing to the puncture site.
● Observe the vein punctured site for bleeding.
● Remind/inform the patient that she can only eat and drink after the procedure.

Observe for neurological deficits

● Monitor neurovital signs regularly
● Monitor vital signs regularly
● Provide a quiet environment with the head of the bed elevated
● Elevate bed rails to prevent falls.

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16
 VITAL SIGNS AND HOURLY MONITORING RECORD

VITAL SIGNS
Date Time BP Temp. Pulse RR O2 Sat.
Rate

11-25-22 4PM 150/80 36.2 81 20 100%

5PM 150/90 36 85 20 100%

6PM 140/70 36 88 20 100%

7PM 140/70 36.5 84 20 100%

8PM 140/80 36.9 91 20 100%

9PM 150/80 36.4 87 20 100%

10PM 110/70 36.5 82 20 100%

11-26-22 12AM 110/70 36.0 90 20 100%

1AM 100/70 36.5 87 20 100%

2AM 100/70 36.9 81 20 100%

3AM 100/70 36.1 105 20 100%

4AM 100/70 36.9 112 20 100%

5AM 100/70 36.1 97 20 100%

6AM 100/60 36.4 89 19 97%

11-26-22 7AM 120/70 36.4 92 19 98%

8AM 120/70 36.5 100 20 99%

9AM 120/70 36.6 98 20 98%

10AM 100/60 36.9 96 20 97%

11AM 100/60 37.2 88 20 99%

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11-27-22 7AM 120/80 37.1 98 21 98%

8AM 120/80 37.4 99 21 99%

9AM 90/60 36.9 114 21 96%

10AM @2D-ECHO

11AM 120/70 36.8 109 20 96%

12PM 110/70 37.0 111 21 97%

1PM 110/70 36.9 100 21 98%

2PM 120/70 37.0 105 21 98%

3PM 120/80 36.9 87 20 97%

4PM 120/80 37.0 90 21 98%

5PM 120/80 37.2 87 22 98%

6PM 120/70 36.7 85 21 97%

7PM 120/70 36.6 82 20 97%

8PM 120/60 37.5 71 21 97%

9PM 110/60 37.0 103 20 97%

10PM 110/60 36.7 83 19 98%

11PM 100/60 37.3 83 19 98%

11-28-22 12AM 100/60 37.6 90 20 100%

1AM 110/60 37.5 71 19 100%

2AM 120/60 37.1 86 19 98%

3AM 100/60 37.1 88 19 98%

4AM 100/60 37.4 82 20 98%

11-29-22 2AM 120/70 36.2 83 19 100%

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 3AM 100/60 36.6 76 19 100%

4AM 120/70 36.0 82 18 99%

5AM 100/60 36.3 78 19 100%

6AM 120/70 36.4 87 19 100%

7AM 120/70 36.4 88 20 99%

8AM 120/70 36.2 84 20 99%

SECTION OF HEMATOLOGY AND COAGULATION

Procedure Date Normal Values Obtained Clinical

Values Interpretation

PROCEDURE COMPLETE BLOOD TEST (CBC)

1. Red Blood Cell 11-25-2022 5.18 x 10¹²/L Abnormal

(RBC) (1st Day) (Elevated)

11-26-2022 4.70 x 10¹²/L Normal

( 2nd Day)

11-27-2022 4.70 - 5.00 x 10 4.24 x 10¹²/L Abnormal

(3rd Day) 12/L (Decreased)

11-28-2022 3.79 x 10 12/L Abnormal

(4th Day) (Decreased)

2. Hemoglobin 11-25-2022 148 g/L Normal

125 - 160 g/L
11-26-2022 135 g/L Normal

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 11-27-2022 123g/L Abnormal
(Decreased)

11-28-2022 110 g/L Abnormal

(Decreased)

3. Hematocrit 11-25-2022 0.50L Abnormal

(Elevated)

11-26-2022 0.46L Normal

0.37 - 0.47 L
11-27-2022 0.41L Normal

11-28-2022 0.36 L Abnormal

(Decreased)

RED BLOOD CELL INDICES

11-25-2022 95.8/L Normal

11-26-2022 97.0 fL Normal

4. Mean Corpuscular
Volume (MCV) 11-27-2022 78.0 - 100.0 fL 97.4 fL Normal

11-28-2022 96.0 fL Normal

(femtoliters)

11-25-2022 28.6 pg Normal

5. Mean Corpuscular 11-26-2022 28.7 pg Normal

Hemoglobin 11-27-2022 29.0 pg Normal
27.0 - 31.0 pg
(MCH)
11-28-2022 29.0 pg Normal
(picograms)

6. Mean Corpuscular 11-25-2022 29.8 g/dL Abnormal

Hemoglobin 31. 0 - 37.0 g/dL (Decreased)
Concentration
(MCHC) 11-26-2022 29.6 g/dL Abnormal
(Decreased)

20
 11-27-2022 29.8 g/dL Abnormal
(Decreased)

11-28-2022 30.2 g/dL Abnormal

(Decreased)

11-25-2022 13.9 % Normal

7. Red Cell 11-26-2022 14.3% Normal

Distribution Width 11-27-2022 14.4% Normal
11.60 - 14.60 %
(RDW)
11-28-2022 14.4 % Normal

11-25-2022 19.4 x 10 9/L Abnormal

(Elevated)

11-26-2022 24.8 x 10 9/L Abnormal

8. White Blood Cell (Elevated)
Count (WBC) 11-27-2022 4.4 -10.0 x 10 9/L 17.1 x 10 9/L Abnormal
(Elevated)

11-28-2022 12.5 x 10 9/L Abnormal

(Elevated)

11-25-2022 0.88 Abnormal

(Elevated)

9. Neutrophils 11-26-2022 0.89 Abnormal

(Elevated)

11-27-2022 0.35 -0.66 0.88 Abnormal

(Elevated)

11-28-2022 0.87 Abnormal

(Elevated)

10. Lymphocytes 11-25-2022 0.08 Abnormal

0.24- 0.44 (Decrease)

11-26-2022 0.06 Abnormal

(Decrease)

11-27-2022 0.07 Abnormal

(Decrease)

11-28-2022 0.08 Abnormal

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 (Decrease)

11-25-2022 0.01 Abnormal

(Decrease)

11-26-2022 0.03 Normal

11. Monocytes
11-27-2022 0.03 - 0.06 0.02 Abnormal
(Decrease)

11-28-2022 0.03 Normal

11-25-2022 0.03 Abnormal

(Decrease)

11-26-2022 0.02 Abnormal

(Decrease)
12. Stabs 11-27-2022 0.05 - 0.11 0.03 Abnormal
(Decrease)

11-28-2022 0.02 Abnormal

(Decrease)

11-25-2022 70 x 10 9/L Abnormal

(Decreased)

11-26-2022 75 x 10 9/L Abnormal

(Decrease)
13. Platelet Count 150 - 400 x 10 9/L
11-78-2022 67 x 10 9/L Abnormal
(Decrease)

11-28-2022 47 x 10 9/L Abnormal

(Decrease)

PROCEDURE: X-RAY

1. Fibrotic Densities Seen in both Normal

upper lobes

2. Heart Not enlarged Normal

3. Pulmonary Unremarkable Normal

Vasculature
11-25-2022
4. Aortic Knob Calcific To be monitored

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 5. Trachea Seen midline Normal

6. Costophrenic sulci Both intact Normal

7. Esophagogastric NGT is seen Normal

junction (Repositioning is
suggested)

PROCEDURE: ROUTINE URINALYSIS

Physical Analysis

Color 11- 25-2022 yellow Normal

Transparency 11-25-2022 slightly cloudy Normal

Chemical Analysis

Specific Gravity 11-25-2022 1.015 - 1.025 1.020 Normal

pH 11-25-2022 4.8 - 7.8 5.5 Normal

Glucose 11- 25-2022 Negative ++ Abnormal (Findings)

Ketone 11-25-2022 Negative Negative Normal

Bilirubin 11-25-2022 Negative Negative Normal

Urobilinogen 11-25-2022 0.01 - 1 0.1 Normal

Protein 11-25-2022 Negative + Abnormal (Findings)

Blood 11- 25-2022 Negative Trace Abnormal (Findings)

NItrite 11-25-2022 Negative Negative Normal

Leukocytes 11-25-2022 Negative Negative Normal

Microscopic Analysis

RBC 11-25-2022 0 - 2 /hpf 1-3 /hpf Abnormal

WBC 11- 25-2022 0 - 3 /hpf 6-8 /hpf Abnormal

Epithelial Cells 11-25-2022 few

Mucus Threads 11-25-2022 few

Bacteria 11-25-2022 some

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Cast 11-25-2022 1.0200 - 1 /lpf /lpf

Hyaline cast/s: 1-3

Fine granular cast/s: 0-1

PROCEDURE: ULTRASOUND REPORT (Whole Abdomen: Liver, GB, HBT, Pancreas, Spleen, Aorta,
Kidneys, Urinary Bladder, Pelvi)

Impression:

1. Renal Cortical Cysts, Bilateral 11-28-2022

2. Ultrasonically Normal Liver, Gallbladder, Biliary Tree,
Pancreas, Spleen, and Proximal Abdominal Aorta
3. Non visualized mid to distal abdominal aorta due to
obscuring bowel gas
4. S/P Foley catheter insertion
5. Atrophic uterus
6. Negative adnexae
7. Minimal hepatorenal ascites

PROCEDURE: BLOOD CHEMISTRY

Lactate Dehydrogenase 11-25-2022 125.0 - 220.0 U/L 400.00 U/L Elevated

(units per liter)

D-DIMER 11-25-2022 100.0 -446.80 1174.48 ng/mL Elevated

ng/ml (nanograms
per milliliter)

Ferritin 11-25-2022 4.63 -204.00 2559.55 ng/mL Elevated

ng/mL

Creatinine 11-25-2022 49.00 - 9.00 101.20 umol/L Elevated

umol/L (micromoles
per liter)

Blood Urea Nitrogen 11-25-2022 3.50 - 7.20 mmol/L 26. 62 mmol/L Elevated
(BUN) (millimoles per
liter)

Fasting Plasma Glucose 11-26-2022 3.9 - 5.5 mmol (70 SI: 12.87 Elevated plasma
-99 mg/dL) mmol/L Glucose

Prediabetes Conventional:
(Impaired fasting 233.97 mg/dL
glucose): 5.6 - 6.9
mmol/L (100-125

24
 mg/dL)

Diabetes: Greater
than 7.0 mmol/L
(126 mg/dL

Potassium 11- 27- SI: 3.50 - 5.10 SI: 2.68 Decreased

2022 mmol/L mmol/L

Conventional: Conventional:
3.50 - 5.10 meq/L 2.68 meq/L

Sodium 11-27-2022 SI: 136 - 146 SI:158. 1 Elevated

mmol/L mmol/L

Conventional: 136 Conventional:

- 146 meq/L 158. 1 meq/L

D. Comprehensive Definition & Description of the Disease

25
a. Pathophysiology (Book based)

b. Schematic Diagram includes Signs & Symptoms, Predisposing Factors

regarding the presented data (patient based)

26
 CHAPTER II PLANNING

A. List of Prioritized Nursing Diagnosis

27
 Prioritized Nursing Diagnosis
Electrolyte imbalance (Hypernatremia)
related to deficient dietary and fluid
intake
Electrolyte Imbalance (Hypokalemia)
related to medication regimen,
decreased dietary and fluid intake
Decreased cardiac output related to
altered preload as evidenced by
generalized weakness and Bipedal
Edema.
Acute pain related to the irritation of the
pharyngeal mucosa secondary to
insertion of the NGT as evidenced by
demonstration of the patient.
Risk for Infection related to
compromised immune system
Rationale
NANDA defined Electrolyte imbalance
as At risk for a change in serum
electrolyte levels that may compromise
health.
NANDA defined Electrolyte imbalance
as At risk for a change in serum
electrolyte levels that may compromise
health.
NANDA defined decreased cardiac
output as Inadequate blood pumped by
the heart to meet metabolic demands of
the body.
According to NANDA, acute pain is
Unpleasant sensory and emotional
experience arising from actual
or potential tissue damage or described
in terms of such damage
(International Association for the Study
of Pain); sudden or slow
onset of any intensity from mild to
severe with anticipated or
predictable end and a duration of !6
months.
Risk for Infection was defined by
NANDA as At risk for being invaded by
pathogenic organisms.
28
 NCP 1: Electrolyte imbalance (hypernatremia) related to deficient dietary and fluid intake

Cues Nursing Analysis Objective of Intervention Rationale Evaluation

Diagnosis Care

Subjective: Electrolyte With aging, the After 8 hours Independent Independent Partially met
“Hindi po sya gaano imbalance kidney of nursing
nainom ng tubig at (hypernatremi experiences interventions, Raise bed side rails To reduce the risk After 8 hours of
mahina kumain degenerative the client will be of falls while patient nursing
a) related to
nagsasabi na wala changes just able to is on CBR interventions, the
raw gana.” as deficient like other maintain client was
verbalized by the dietary and organs. The Electrolyte Reposition patient This may aid in somehow able
daughter of patient. fluid intake kidney's Balance as at least every 2-4 circulation and to maintain
histologic and evidenced by hours prevents the Electrolyte
Objective: functional the following development of balance as
alterations with indicators: pressure ulcer evidenced by the
● Weak in age may following
appearance contribute to ● exhibit good Maintain activity Prevent indicators:
the elderly's skin turgor restrictions, e.g. overstimulating the
● Eyes appear a bit electrolyte and moist complete bed rest; patient and offer ● improved
sunken. imbalances. lips. schedule plenty of rest good skin
The severity of uninterrupted rest periods with minimal turgor and
● Dry lips these ● appear periods; assist the interruptions. somewhat
anomalies rested and patient with self- moist lips.
● Decreased skin depends on a comfortable care activities as
turgor variety of needed. And ● appeared
variables, such ● normal provide a calm rested
Basal Metabolic as underlying serum environment.
Panel: illnesses, levels: ● normal
Sodium: mental Sodium(Nor Provide and Promotes interest in serum
SI: 158. 1 mmol/L capacity, mal range: encourage oral drinking and levels of
Conventional: drugs, and 3.5- care. reduces discomfort potassium

29
158. 1 mEq/L kidney 5.2mmol/L) e. due to dry lips and
function. and prevents further ● sodium
Dehydration drying of it. (Normal
and aberrant range: 3.5-
electrolytes 5.2mmol/L)
can affect older Review the patient's A review of all e.
persons for a medication regimen medications the
variety of and laboratory data patient is currently
reasons, from using in order to
physical identify any
limitations that potential adverse
make it difficult effects and drug
to consume reactions, including
enough fluids ineffective drug
to iatrogenic therapy, significant
factors side effects and
including drug interactions.
polypharmacy The laboratory
and results will portray
unmonitored the internal
diuretic use. conditions
This nutritional status of
susceptibility is the patient such
made more as the Basic
likely by renal Metabolic Panel
senescence as results and other
well as laboratory data
physical and
mental aging. Provide health To help regain and
Additionally, teaching to restore normal fluid
water retention companion of volume and
and associated patient about the electrolyte balance
electrolyte importance of in patient’s body

30
imbalances are
more common
in older
persons and
are aggravated
by
physiological
stress.
REFERENCE:
El-Sharkawy, A. M.,
Sahota, O., Maughan, R.
J., Lobo, D. N., Ron, &
Dileep. (2013). The
pathophysiology of fluid
and electrolyte balance in
the older adult surgical
patient. Clinical Nutrition.
https://www.sciencedirect.
com/science/article/pii/S0
261561413003166
hydration. Remind
the companion to
encourage patient
to drink prescribed
amount of fluids
Inform patient and Ice chips are a way
patient’s companion to stay hydrated, it
about the benefits can ease dry mouth
of ice chips and if while providing
ever they agree refreshing and
provide ice chips to cooling sensation
patient
Monitor frequently Patient vital signs
the patient's vital will provide baseline
signs, and notify the data of their
physician of any condition
unusual deviation
Monitor patient's Alteration of the
status regarding body's exchange of
their respiratory oxygen may
and muscle occur due to
strength electrolyte
imbalance
Monitor skin turgor, Water-deficit
color, and hyponatremia
31
temperature and manifests by signs
mucous membrane of dehydration.
moisture.

Monitor level of Sodium imbalances

consciousness and may cause changes
neuromuscular that vary from
function, noting irritability and
movement, confusion to
strength, and seizures and coma.
sensation. In the presence of a
water deficit, rapid
rehydration may
cause cerebral
edema.

Monitor and To determine if the

evaluate the medications are
effects of the taking effect on the
medication on patient, or if these
the patient's medications are
condition worsening the state
of the patient.

Monitor IV site for

patency, signs of To prevent
infiltration such as complications of IV
redness or therapy
indurations.

Dependent Dependent

32
Administer Administration of
parenteral fluids parenteral fluids
(D5W 500 + D5 0.9 ordered by the
NaCL x 12° ) as physician will aid
prescribed by the in promoting the
physician balance of the
patient's
electrolytes.

Collaborative Collaborative

Initiate referral of To determine the

the patient's Basic correct nutritional
metabolic Panel needs of the
to the nutritionist patient to promote
the occurrence of
electrolyte balance.

33
 NCP 2: Electrolyte Imbalance (Hypokalemia) related to medication regimen and decreased dietary and fluid intake

Cues Nursing Analysis Objective of Intervention Rationale Evaluation

Diagnosis Care

Subjective: Electrolyte Potassium is an After 8 hours Independent Independent Partially met

“Hindi po sya Imbalance electrolyte of nursing
gaano nainom (Hypokalemia) needed primarily intervention, Review the patient's A review of all After 8 hours of
ng tubig at related to for muscle and the patient will medication regimen medications the nursing
mahina kumain medication nerve tissue be able to: and laboratory data patient is currently interventions,
nagsasabi na regimen and function. Large using in order to the goal was
wala raw gana.” decreased amounts of ● normal identify any potential met. The patient
as verbalized by dietary and potassium found serum adverse effects and was able to:
the daughter of fluid intake in the intestinal levels: drug reactions,
patient. fluids are Potassium including ineffective ● normal
excreted during (Normal drug therapy, serum
episodes of range: 3.50 significant side effects levels:
Objective: diarrhea.Depleti - 5.10 and drug interactions. Potassium
on of potassium mmol/L The laboratory results (Normal
● Weak in occurs and then will portray the range: 3.50 -
appearance leads to altered internal conditions 5.10 mmol/L
electrolyte ● exhibit nutritional status of
● Eyes appear balance in the good skin the patient such
a bit sunken. body. turgor and as the Basic ● exhibit good
moist lips. Metabolic Panel skin turgor
● Dry lips REFERENCE:
results and other and
● appear laboratory data somewhat
● Loss appetite rested and moist lips.
comfortable
● Decreased Raise bed side rails To reduce the risk of ● appeared
skin turgor falls while patient is rested
on CBR

34
● CRT of 3 Reposition patient at This may aid in
seconds least every 2-4 hours circulation and
prevents the
Basal development of
Metabolic pressure ulcer
Panel:

Potassium: Provide a calm Prevent

SI: 2.68 mmol/ environment. overstimulating the
Conventional: patient and offer
2.68 mEq/L plenty of rest periods
with minimal
interruptions.

Provide health To help regain and

teaching to restore normal fluid
companion of patient volume and
about the importance electrolyte balance in
of hydration. Remind patient’s body
the companion to
encourage patient to
drink prescribed
amount of fluids

Inform patient and Ice chips are a way to

patient’s companion stay hydrated, it can
about the benefits of ease dry mouth while
ice chips and if ever providing refreshing
they agree provide and cooling sensation
ice chips to patient

35
Monitor input and To determine if there's
output abnormal losses.

Monitor capillary refill This may help

evaluate patient’s
hydration status

Monitor frequently Patient vital signs will

the patient's vital provide baseline data
signs, and notify the of their condition
physician of any
unusual deviation

Dependent Dependent

Administer parenteral Administration of

fluids (D5W 500 + D5 parenteral fluids
0.9 NaCL + KCI 40 ordered by the
mEq x 12°) as physician will aid in
prescribed by the hydration and
physician promote the
balance of the
patient's electrolytes.

Collaborative Collaborative
Initiate referral of the To determine the
patient's Basic correct nutritional
metabolic Panel to needs of the patient

36
 the nutritionist to promote the
occurrence of
electrolyte balance.

NCP 3: Decreased cardiac output related to altered preload as evidenced by generalized weakness and bipedal Edema

Cues Nursing Analysis Objective of Intervention Rationale Evaluation

Diagnosis Care

Objective: Decreased Decreased After 8 hours Independent Independent After 8 hours of

cardiac output cardiac of nursing nursing
● Generalized related to altered output is a interventions, Maintain fluid Patients with low interventions, the
weakness preload as state in the patient will restriction and/or cardiac output are goal was met. The
evidenced by which an be able to: sodium restriction. more prone to patient was able to:
● Presence of generalized inadequate retaining additional
edema weakness and amount of ● demonstrates fluids and can be ● demonstrates
Bipedal Edema. blood is adequate very sensitive to adequate cardiac
● Pallor being cardiac output sodium. A fluid output as
pumped by as evidenced and/or sodium evidenced by
● BP: 140/90 the heart to by blood restriction may be blood pressure,
mmhg meet the pressure, necessary to pulse rate and
body’s pulse rate and minimize fluid rhythm within
● PR: 81 bpm metabolic rhythm within retention. normal limits E.g.
demands. normal limits BP: 120/80 mmhg
● O2 Sat: 100% E.g. BP: Lessens physical PR: 60-100 bpm

37
 120/80 mmhg Maintain activity stress and tension
PR: 60-100 restrictions, e.g. that affect blood ● participate in
bpm complete bed rest; pressure and the activities that
schedule course of reduce the
● participate in uninterrupted rest hypertension. workload of the
activities that periods; assist the heart, e.g. Stress
reduce the patient with self-care management,
workload of activities as needed. therapeutic
the heart, e.g. medication
Stress Can reduce regimen program,
management, Instruct in relaxation stressful stimuli, and rest plan.
therapeutic techniques, guided and produce a
medication imagery, and calming effect,
regimen, and distractions. E.g. by thereby reducing
rest plan. watching Television BP.
or by pumping a
glove with water
inside.

Cardiac
Place the patient on arrhythmias are
a cardiac monitor. common with
decreased cardiac
output. It is
important to be
able to monitor for
these and then
treat as
appropriate should
an arrhythmia
develop.

Low cardiac output

38
Monitor heart rate can stimulate the
and blood pressure. sympathetic
nervous system.
This is done to
compensate for
the low cardiac
output and can
result in increased
heart rates and
initially an
increased blood
pressure. Later on,
blood pressures
may drop and the
patient can
become
hypotensive.

Dependent

Various
Dependent medications may
be ordered for
Administer patients with
prescribed decreased cardiac
medications as output (i.e. ACE,
ordered. E.g. ACE, ARBs, CCB, etc.).
ARBs, Beta These will help to
blockers, Calcium improve heart
channel Blockers. function and
decrease patient’s
symptoms and

39
 cardiac workload.

Collaborative

A cardiologist has
Collaborative special training in
identifying,
Refer to cardiologist preventing, and
treating diseases
of the heart and
blood vessels.

40
 CHAPTER III IMPLEMENTATION

A. Medical Management

a. Drug Study

Drug Dose Classificat Mechanism of Indication Contraindicati Side Effect Nursing

Generic Route ion Action on Responsibilities
Trade Name Frequen
cy

Pantoprazole Dose: Proton Inhibit both Treat damage ● Known ● Nausea ● Assess the underlying
40 mg / Pump basal and from hypersensitivit condition before
tab Inhibitors stimulated gastroesopha y to any of the ● Vomiting therapy and thereafter
gastric acid geal reflux constituents of to monitor drug
Route: secretion by disease pantoloc or of ● Headache effectiveness.
Oral suppressing (GERD), a the
the final steps condition in combination ● Joint pain ● Assess GI symptoms:
Frequen in acids which partners. epigastric/ abdominal
cy: production, backward flow ● Diarrhea pain, bleeding and
Once a through the of acid from ● Mild anorexia.
day inhabitation of the stomach gastrointestin ● Dizziness
the proton causes al complaints ● Monitor possible drug
pump by heartburn and eg. Nervous ● Loss of induced adverse
binding to and possible injury dyspepsia. appetite effects.
inhibiting of the
hydrogen- esophagus ● Pantoloc must
potassium (the tube not be used in
adenosine between the combination
triphosphatase, throat and treatment for
the enzyme stomach) in eradication of
system located adults and H. Pylori in
at the children 5 patients with

41
 secretory years of age moderate and
surface of the and older. severe
gastric parietal hepatic or
cell. renal
dysfunction.

Tranexamic Dose: Antifibrinoly The binding of Tranexamic ● Patient with ● Nausea Before:
acid 500 mg tics this receptor acid is Hypersensitivi
prevents indicated for ty ● Vomiting ● Monitor blood
Route: plasmin the treatment pressure, pulse, and
IV (activated form of hereditary ● Women using ● Diarrhea respiratory status as
of angioedema, combination indicated by severity
Frequen plasminogen) cyclic heavy hormonal ● Hypotensi of bleeding.
cy: from binding to menstrual contraceptive on
every 8 and ultimately bleeding in s ● Monitor for overt
hours stabilizing the premenopaus ● Thromboe bleeding every 15–30
fibrin matrix al females, ● Active mbolic, min.
and other thromboembo e.g.,
instances of lic arterial, ● Monitor neurologic
significant disease(e.g., venous, status (pupils, level of
bleeding in the DVT embolic;N consciousness, motor
context of pulmonary eurologic, activity) in patients
hyperfibrinolys embolism, or e.g., visual with subarachnoid
is. cerebral impairmen hemorrhage.
thrombosis t,
convulsion ● Assess for
● History of s, thromboembolic
thrombosis or headache, complications.
thromboembo mental (especially in patients
lism , status with history).
including changes; ● Notify physician of
retinal vein or myoclonus positive Homans’
artery ; sign, leg pain

42
occlusion hemorrhage, edema,
● Rash hemoptysis, dyspnea,
or chest pain.

● Monitor platelet count

and clotting factors
prior to and
periodically
throughout therapy in
patients with systemic
fibrinolysis.

During:

● Stabilize IV catheter to
minimize
thrombophlebitis.
Monitor the site
closely.

After:

● Instruct the patient to

notify the nurse
immediately if
bleeding recurs or if
thromboembolic
symptoms develop.

43
 ● Advise the patient to
make position
changes slowly to
avoid orthostatic
hypotension.

Dexamethason Dose: Corticoster Dexamethason It is used to ● Patients who ● Upset ● Observe signs of
e 20mg oids e's effect on treat a number are stomach. adverse reactions.
the body of different hypersensitiv
Route: occurs in a conditions, e to any ● Stomach ● Monitor blood
IV variety of such as components irritation pressure 2 - 3 times
ways. It works inflammation of this daily.
Frequen by suppressing (swelling), product. ● Vomiting.
cy: OD x the migration severe ● Test for glycosuria
4 days of neutrophils allergies, ● Systemic ● Headache. daily. If urine is
and decreasing adrenal fungal positive for sugar,
lymphocyte problems, infections, ● Dizziness. check each urine.
colony arthritis, cerebral ● Insomnia.
proliferation. asthma, blood malaria, ● Observe gastric
or bone tuberculosis ● Restlessn aspirates and stools
marrow disease of the ess. for bleeding.
problems, eye.
kidney ● Depressio ● Observe closely for
problems, skin n signs of infection.
conditions,
and flare-ups ● Loss of
of multiple appetite .
sclerosis

44
ipratropium/ Dose: Adrenergic Ipratropium is Is used to ● Contraindicate ● Feeling
salbutamol 20mcg - s with an treat d in treatment shaky
100 mcg anticholiner acetylcholine conditions of threatened ● Assess lung sounds,
gics antagonist via where abortion or ● Nervousne PR, and BP before
Route: blockade of breathing is a premature ss drug administration
MDI muscarinic problem, such labour. and during peak of
cholinergic as COPD, ● Tremor medication
Frequen receptors. chronic ● Bronchodilat
cy: 2 Blocking bronchitis and ors should ● Headache ● Use a nebulizer
puffs cholinergic emphysema. not be the mouthpiece instead
receptors They work by only or main ● Muscle of a face mask to
decreases the relaxing and treatment in cramps avoid blurred vision
production of opening up patients with or aggravation of
cyclic the air severe or ● Problems narrow angle
guanosine passages, unstable sleeping glaucoma.
monophosphat making asthma
e (cGMP). This breathing ● Dry mouth
decrease in the easier and ● Ensure adequate
lung airways improving ● Sore hydration, control
will lead to shortness of throat environmental
decreased breath, chest temperature to
contraction of tightness and ● A change prevent
the smooth wheezing. in voice hyperpyrexia.
muscles (hoarse
voice) ● Have the patient void
before taking
● A different medication to avoid
taste in urinary retention.
your
mouth ● Advise patient to
Report rash, eye
● Difficulty pain, difficulty
urinating voiding, palpitations,
(peeing) vision changes

45
 Apidra Dose: antidiabetic Insulins lower To improve APIDRA is ● Hypoglyce ● Assess patient for
Route: blood glucose glycemic contraindicated: mia signs and symptoms
subcuta by stimulating control in during episodes of hypoglycemia
neous peripheral adults and of ● Insulin
injection glucose uptake pediatric hypoglycemia resistance ● Monitor body weight
by skeletal patients with in patients who periodically. Changes
Frequen muscle and fat, diabetes are ● Lipodystro in weight may
cy: QID and by mellitus hypersensitive phy necessitate changes
inhibiting to APIDRA or in insulin dose.
hepatic to any of its ● Lipohypert
glucose excipients rophy ● Assess patient for
production When used in signs of allergic
patients with ● Local reactions (rash,
known allergic rxn shortness of breath,
hypersensitivity wheezing, rapid
to APIDRA or ● Hypokale pulse, sweating, low
its excipients, mia BP) during therapy
patients may
develop
localized or
generalized
hypersensitivity
reactions

Losartan Dose: angiotensin Inhibits Treatment of Contraindicated BEFORE

(Cozaar) 50mg II receptor vasoconstrictiv hypertension, with patient CNS: ● Monitor blood
antagonist e and alone or in hypertensive to pressure
Route: aldosterone- combination drugs ● dizziness,
Oral secreting with other insomnia ● Use cautiously in
action of antihypertensi patients with
Frequen angiotensin II ve agents. EENT: impaired renal or
cy: once by blocking hepatic function.
● Nasal
daily angiotensin lI

46
receptors on ● Tell the patient to
the surface of congestion avoid salt
vascular , sinusitis. substitutes; these
smooth muscle products may contain
and other GI: potassium, which
tissue cells. can cause
● Diarrhea, hyperkalemia in
dyspepsia patients taking
losartan.
● Musculosk
eletal: DURING
muscle ● Ensure to observe
cramps, the following rights of
myalgia, the patient (right
back or leg medication, right
pain. route, right patient,
right time and right
● Respirator dosage).
y: cough,
upper ● Monitor blood
respiratory pressure closely to
tract evaluate
infection. effectiveness of
therapy.
● Loss of
appetite ● When losartan is
used alone, the
effect on blood
pressure is notably
less in black patients
than in other races.

● Regularly assess the

47
 patient's renal
function (via
creatinine and BUN
levels).

● Monitor patients who

are also taking
diuretics for
symptomatic
hypotension.

AFTER

● Advise patient to
report swelling of
face, eyes, lips, or
tongue or any
breathing difficulty
immediately.

Azithromycin Dose: macrolide Azithromycin Azithromycin ● Azithromycin ● Diarrhea ● Obtain specimens for
500mg/t antibiotics binds to the is is or loose culture and sensitivity
ab 235 rRNA of indicated to contraindicate stools test before giving first
the bacterial the d to the dose, therapy may
Route: 50S ribosomal people with people with ● Nausea begin pending results.
oral subunit. It the community hypersensitivit
stops bacterial acquired y to ● Abdominal ● Give 2 max 1 hour
Frequen protein pneumonia. erythromycin pain before or 2 hours after
cy: OD synthesis by Pharyngitis/ or other a meal tablets and
inhibiting the tonsillitis, macrolide or ● Stomach single-dose packets
transpeptidatio uncomplicated ketolide upset, for oral suspension
n /translocation skin/skin antibiotics. can be taken with or
step of protein structure, without food. Don't

48
synthesis and acute bacterial ● Use ● Vomiting give with antacids.
by inhibiting exacerbation cautiously in
the assembly of patients with ● Constipati ● Monitor pt. for
of the 50S chronic impaired on superinfection. Drug
ribosomal obstructive hepatic may cause
subunit. pulmonary function. ● Dizziness overgrowth of
disease, nonsusceptible
acute bacterial ● Tiredness bacteria fungi
sinusitis,
● Headache
genital ● Reconstitute
ulcer disease.. ● Vaginal suspension with 2
itching or ounces (60ml) water
discharge after taking, pt. should
rinse glass with
● Nervousne additional 2 ounces of
ss water & drink it to
ensure she has taken
● Sleep an entire dose.
problems Packets aren't for
(insomnia) children.

● Skin rash ● If pt. vomits within 60

or itching min. of taking Zmax,
notify prescriber;
● Ringing in additional or different
the ears therapy may be
needed.
● Hearing
problems

● Decreased
sense of
taste or

49
 smell.

Ciprofloxacin Dose : Quinolone It produces its Is used to Contraindicated ● Nausea. ● Ensure that the
400 mg antibiotics action through treat or in persons with patient is well
inhibition of prevent a history of hydrated.
● Vomiting.
Route: bacterial DNA certain hypersensitivity ● Stomach
P.O gyrase and infections to ciprofloxacin ● Give antacids at least
pain.
topoisomerase caused by or any of the 2 hr after dosing.
Frequen IV bacteria such quinolones
cy: BID as pneumonia; ● Heartburn ● Monitor clinical
(2x a gonorrhea); response; if no
day) typhoid fever ; ● Diarrhea. improvement is seen
infectious or a relapse occurs,
diarrhea repeat culture and
● Vaginal sensitivity.
itching
and/or ● Encourage the patient
discharge. to complete a full
course of therapy.
● Pale skin.

● Unusual
tiredness

● Loss of
appetite

Toujeo Route : Antidiabetic Insulin glargine To improve Contraindicated ● Cold ● Monitor patient

50
 SQ s; insulin reduces blood glycemic in patients who symptoms response to therapy
glucose by control in have (stabilization of blood
Frequen stimulating adults with hypersensitivity ● Upper glucose levels).
cy : OD peripheral diabetes reactions to respiratory
glucose uptake mellitus insulin glargine tract ● Monitor for adverse
and inhibiting infection. effects
hepatic
glucose ● Evaluate patient
● Low blood
production. understanding on
sugar
drug therapy by
(hypoglyce
asking the patient to
mia)
name the drug, its
indication, and
● Allergic
adverse effects to
reactions
watch for
● Injection
site
reactions.

● Body fat
redistributio
n
(lipodystrop
hy)

● Itching

● Rash

Piperacillin Dose : penicillins Inhibits cell To treat ● Hypersensitivi ● Diarrhea ● Monitor signs of
/tazobactam 45 mg and beta- wall synthesis bacterial ty to allergic reactions and

51
(Piptaz) lactamase by binding to infections in piperacillin/taz ● Constipati anaphylaxis, including
Frequen inhibitors bacterial cell many different obactam, on pulmonary symptoms
cy : Q8 membranes. parts of the penicillins, (tightness in the throat
body (eg, cephalosporin and chest, wheezing,
● Nausea
Route : stomach or s, or beta cough dyspnea) or
IV bowel, lungs, lactamase skin reactions (rash,
skin, female inhibitors ● Vomiting pruritus, urticaria).
reproductive such as
organs). clavulanic ● Heartburn ● Notify physician or
acid and nursing staff
sulbactam immediately if these
● Stomach reactions occur.
● used pain
cautiously in
kidney failure ● Fever

● Headache

● Loss of
appetite

Vildagliptin Dose : dipeptidyl Vildagliptin has Is indicated as Should not be ● Headache -Monitor urine or serum
(proglin) 50mg 1 peptidase-4 been shown to an adjunct to taken by people glucose levels
tab (DPP-4) stimulate diet and who are in a ● Nasophary frequently to determine
inhibitor insulin exercise to state of ngitis effectiveness of drug
Frequen secretion and improve ketoacidosis and dosage.
cy : BD inhibit glycaemic ● Cough
glucagon control in
Route : secretion in a adults with ● Constipati
Oral glucose- type 2 on
dependent diabetes

52
 manner mellitus ● Dizziness
and
increased
sweating

Furoxemide Dose: Diuretics Inhibits Treatment of ● History of ● low blood Safe Administration:
40mg reabsorption of hypersensitivity pressure,
edema to ● Thoroughly monitor
sodium and
chloride associated furosemide or patient medical
Route: Sulfonamide ● dehydratio
primarily in with CHF, history for any
Oral loop of n and
cirrhosis of electrolyte conditions
Henle and also ● Increasing
Frequen in liver, and oliguria, depletion contraindicated for
cy: BID proximal and kidney anuria, fluid (for use of Furosemide.
distal disease, and example,
renal tubules; electrolyte sodium,
including depletion ● Monitor patient's
an potassium
antihypertensiv nephrotic States intake and output
e syndrome. constantly. Changes
that decreases ● Hepatic coma ● Jaundice
May be in output may indicate
edema and
intravascular used for ● ringing in fluid volume loss or
volume management the ears dehydration
of (tinnitus)
hypertension, ● Monitor vital signs
alone ● sensitivity before and after
to light
or in administering
(photopho
combination bia),rash,P Furosemide.
w/ ancreatitis-
other nausea,dia ● Check patient's labs
antihypertensi rrhea,abdo and Electrolyte levels
ve minal periodically
agents, & for pain,and throughout the course
dizziness.

53
treatment of of treatment.
hypercalcemia ● Increased
. Has blood Patient Education:
sugar and
been used ● Encourage patient to
uric acid
concomitantly levels have an intake of
with potassium rich foods
mannitol for i.e. bananas to help
treatment of replace potassium
severe loss.
cerebral
edema, ● Instruct patient to
particularly in monitor for signs of
meningitis. Hypokalemia and
immediately notify
Physician or Nurse for
muscle weaknesses.

● Instruct patient to
move
slowly when changing
positions to avoid
injuries as a result of
loss of balance or
muscle weakness

● Instruct patient to
avoid
sudden consumption of

54
 large amounts of fluids

b. Treatment

● Provide antihypertensive drugs- to maintain blood pressure

● Provide antibiotics- to treat certain types of bacterial infection
● Antidiabetic drugs (Insulin)- stabilize and control blood glucose level

c. Diet/Activity/Exercise

Diet:
● Low fat, low salt
● Glucerna 1200 kcal in 6 equal feedings- help manage blood sugar, when used as meal or snack replacements.

Activity/Exercise:
● Complete bed rest

B. Surgical Management

● No surgical treatment was provided.

C. Patient’s Daily Progress Notes

Date Procedure Diet Activity Drugs Treatment Surgery Nursing Problem

11/25 - received on NPO CBR -Ipratropium/ N/A N/A Impaired gas

55
bed bath Salbutamol exchange
-Apidra
- O2 support -Ciprofloxacin
via nasal
cannula at
2pm
- saturation at
100%

- With ongoing
venoclysis
infusion well

- With
norepinephrine
orem 82mps x
0.5 with BP of
150/100 mmhg

- With
indwelling
foley catheter
- draining well

- assessed
patient
-Vitals signs
recorded -
Waiting rt pcr
results
R- endorsed

56
11/25 D- received pt. NPO CBR -Apidra N/A N/A Deficient fluid
Asleep -ipratropium/ volume
-with ongoing Salbutamol
venoclysis and -Ciprofloxacin
infusing well
-Afebrile
-With Ngt
intact and
patient foley
catheter
connect to
urine bag
A- assessed
patient
condition
-provide safe
and warm
environment
-IVF regulated
as ordered
-Vitals signs
take and
recorded
-Positioned
comfortably
-Due meds
given as
ordered
-Watch out for
any untoward
signs and
symptoms-
Monitored

57
 intake and
output
-Needs
attended
R- endorsed

11/26 -instructed to low salt, CBR -Apidra N/A N/A Risk for infection
used the call low fat -Toujeo
light when -Azithromycin
need -piperacillin/
assistance tazobactam
-Proglin
-Placed in high
backrest

-Kept
monitored-Oral
care done

-Change of
antibiotic
ordered by the
physician, skin
testing of
antibiotic
done, Run Ns.
negative by
intern Ibay—-

-noted oral
sores,
physician
informed

58
 R- latest bp
-for continuity
of care
-endorsed

11/26 -received low salt, CBR -ipratropium/ N/A N/A Risk for infection
patient lying in low fat Salbutamol
bed -Apidra
-With ongoing -Proglin
venoclysis
-With ongoing
NGT intact
-Foley catheter
to urine bag
-With O2
simponi @
2pm via nasal
cannula

11/27 A- assisted low salt, CBR -Apidra N/A N/A Imbalanced

and monitored low fat nutrition
-Encourage
low fat, low
salt
-place in high
backrest
-checked
properly of
NGT
-Feeding given
-Due
medication
given

59
 -Maintain in
high back rest,
ATM feeding
-CBG
monitoring
-Oral care
done

11/27 -Received low salt, CBR -Apidra N/A N/A Deficient fluid
patient lying in low fat -ipratropium/ volume
bed Salbutamol
- with ongoing -pantoprazole
venoclysis
- with NGT
- With O2
simponi at
2pm
- No aspiration
10 PM

11/28 -Assisted and Low salt, CBR -Apidra N/A N/A Deficient fluid
monitored low fat -pantoprazole volume
- place in high -tranexamic acid
backrest - Dexamethasone
- checked
properly of
NGT
- feeding given
- CBG
monitoring
- Oral care

60
 done

11/28 D - place Low salt, CBR -Dexamethasone N/A N/A

patient in low fat -Apidra
fowler’s
position -With
NGT in place
and foley
catheter
A - assessed
the patient
-Maintained on
contraceptives
-Maintained on
intravenous
hydration
-Fed the
patient through
NGT strict
aspiration
precautions
R- no
aspiration
signs/
symptoms
soon

61
 Chapter IV Evaluation

A. Discharge Planning Instruction

a. Medication

● Losartan (Cozaar)- Its purpose is to lower blood pressure or to treat hypertension which was classified as
angiotensin II receptor antagonists .
● Amlodipine(Norvasc)- A drug under calcium channel blockers which helps to decrease blood pressure.
● Apixaban (Eliquis)- An anticoagulant used for prevention of blood clots and prevents thickening of blood.
● Atorvastatin(Lipitor)- Classified as antilipemics which helps to lower bad cholesterol and fats that were released
by the liver and raise good cholesterol.
● Haloperidol (Haldol)- Classified as an antipsychotics which helps to prevent delirium, nervousness and
excitement problems in the brain.

b. Exercise

● Wrist and Hand Stretch- This movement stretches the ligaments in the wrist and forearms to maintain range of
motion and reduce joint pain.
● Standing Knee Raises- Strengthens hips, and back. It also helps with posture, balance, and coordination.
● Walking- Helps to strengthen muscles, bones and lowers the risk of heart disease and stroke.
● Zumba dancing- Improves balance, posture and reduce stress.
● Water aerobics-Water helps to reduce stress and increase strength, flexibility, and balance.

c. Treatment

● Diet. Instruct the patient to enforce a diet rich in all nutrients and electrolytes that she needs.
● Fluid intake. The amount of fluid taken must follow the doctor's recommendations.
● Follow-up. The patient must come back for a follow-up examination to assess her electrolyte and fluid levels one
week after being discharged.
● Medications. To prevent a recurrence of the disease, rigorous adherence to recommended drugs is important.

d. Health Teaching

62
● Educate patient to take safety precautions against risk for falls.
● Teach home monitoring of blood pressure, where indicated, and obtain return demonstration of ability to take
blood pressure and medications accurately.
● Recommend the client to keep a diary of pressure readings taken at different times of the day and noting any
associated symptoms.
● Instruct client/SO in healthy eating and adequate fluid intake.
● Take your medications with water. Avoid taking them with grapefruit juice since it may alter how your body
absorbs some medications.

e. Discharge Planning Instruction

● Emphasize the importance of regular medical follow-up care. Review “danger” signs requiring immediate
physician notification.
● Discuss significant signs/symptoms that require prompt reporting to healthcare providers.

f. Diet

● Low salt, low fat diet - HTN

● Increase intake of potassium rich food such as banana, green leafy vegetables.
● Instruct the patient to make liberal use of powdered, low sodium milk, and milk product
● Introduce the Mediterranean diet to the client. This diet emphasizes fresh fruits and vegetables, grains, legumes,
fish, beans, and healthy fats. This type of diet has many heart-healthy advantages that may reduce the risk of
heart disease and stroke.

63
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https://www.prmc.org/assets/site/documents/direct-access-lab-tests.pdf

Blood chemistry tests. (n.d.). Canadian Cancer Society. Retrieved December 4,

2022, from https://cancer.ca/en/treatments/tests-and-procedures/blood-

chemistry-tests

Complete blood count (CBC). (2020, December 22). Mayo Clinic. Retrieved

December 4, 2022, from https://www.mayoclinic.org/tests-procedures/complete-

blood-count/about/pac-20384919

Electrolyte Imbalance: Types, Symptoms, Causes & Treatment. (2022, August

13). Cleveland Clinic. Retrieved December 4, 2022, from

https://my.clevelandclinic.org/health/symptoms/24019-electrolyte-imbalance

Heilman, J. (n.d.). 15.6 Applying the Nursing Process – Nursing Fundamentals.

WI Technical Colleges Open Press. Retrieved December 4, 2022, from

https://wtcs.pressbooks.pub/nursingfundamentals/chapter/15-6-applying-the-

nursing-process/

Urinalysis. (2021, October 14). Mayo Clinic. Retrieved December 4, 2022, from

https://www.mayoclinic.org/tests-procedures/urinalysis/about/pac-20384907

X-ray: Imaging test quickly helps diagnosis. (2022, February 11). Mayo Clinic.

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https://www.mayoclinic.org/tests-procedures/x-ray/about/pac-20395303

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