PERSONAL Physical

DATA
Patho Drugs
Assessment

CUMC- ICU
RLE 8
MTW 3-11PM
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INTRODUCTION:
Cholelithiasis is a prevalent disorder
in developed countries, where
incidence is 10% to 20%, although
many individuals are asymptomatic.
Gallstones are of two types:
Cholesterol and pigmented.
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Cholesterol stones are the most

common. Risk factors include
obesity, middle age, female gender,
native American ancestry, and
gallbladder, pancreatic, or ileal
disease. Gallstone formation is
termed cholelithiasis.
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Cholecystitis can be acute or

chronic, but both forms are almost
always caused by a gallstone
lodged in the cystic duct. The
gallbladder becomes distended and
inflamed, with pain similar to the
caused by gallstones.
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Pressure against the distended

wall of the gallbladder
decreases blood flow and may
result in ischemia, necrosis,
and perforation.
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Fever, leukocytosis, rebound

tenderness, and abdominal
muscle garding are common
findings. Serum bilirubin and
alkaline phosphatase levels
may be elevated.
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The acute abdominal pain of

cholecystitis may be differentiated
from that caused by pancreatitis,
myocardial infarction and acute
pyelonephritis of the right kidney.
Cholangiography or radioactive
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Hematochezia is the passage

of bright red, bloody stools from
the rectum also called thusly
,

(bright red blood per rectum)

and abbreviated BRBPR.
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It is distinguished from melena,

which is stool with blood that has
been altered by the gut flora and
appears black/"tarry".
Hematochezia is commonly
associated with lower GI bleeding.
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In adults, the most common

causes are hemorrhoids and
diverticulosis, both of which are
relatively benign; however, it can
also be caused by colorectal
cancer, which is frequently fatal.
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In a newborn infant (neonate),

hematochezia may be the result of
swallowed maternal blood at the
time of delivery, but can also be
an initial symptom of necrotizing
enterocolitis, a serious condition
affecting premature infants.
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In adolescents and young adults,

inflammatory bowel disease,
particularly ulcerative colitis, is a
serious cause of hematochezia
that must be considered and
excluded.
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Hematochezia can be due to

upper gastrointestinal bleeding.
However, as the blood from such
a bleeding is usually chemically
modified by action of acid and
enzymes, it presents more
commonly as melena.
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Hematochezia from an upper

gastrointestinal source is an
ominous sign, as it suggests a
very brisk bleed which is life
threatening. The study is to provide
quality nursing care to the assigned
patient,
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utilizing the knowledge based on

nursing process and critical
thinking skills. This cases study
aims to guide the student nurses
in providing client-centered
nursing care while applying critical
thinking in all phases of
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nursing care from assessment to

evaluation. Moreover, awareness and
knowledge of the patient’s disease
condition and its corresponding
pathophysiology is vital in providing
suitable intervention to the client.
Thus, with accurate application of
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physical assessment, actual and

potential health problems are being
detected and resolved through the
nursing care plan. This study is
directed towards health maintenance
and rehabilitation, by utilizing the
skills and knowledge,
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the client is being protected from

any complications and potential
severity of the disease condition.
Thereby, rendering proper
interventions and nursing actions,
could certainly alleviate the client’s
health problem.
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Personal Data
Patient X is a 31 years old male and
he is single. He is presently residing
at Manticao, Cagayan de Oro City.
He is a Filipino citizen and belongs to
a Roman Catholic religious affiliation.
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Patient was admitted last August

12, 2010 around 8:20am at
Capitol University Medical Center
with a diagnosed of
Hematochezia.
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During our assessment his vital

signs were stable with a
temperature of 36.5 oC, pulse rate
of 82bpm, respiratory rate of
22cpm and a blood pressure of
120/70 mmHg. HPI
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 History of Present Illness

Patient was admitted last July
28, 2010 at Northern Mindanao
Medical Center due to obstructive
jaundice secondary to
choledocholithiasis with
cholecystolithiasis.
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Under went cholecystectomy,

common bile ducts exploration,
choledochodenostomy last July
29, 2010. Exlaparotomy done
due to bleeding at operative
site.
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Four hours prior to admission

noted Hematochezia with
hematemesis and thus referred
to CUMC for further
management.
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History of Past Illness

In 1998, patient was diagnosed
of having ulcer. Admitted and
undergone endoscopy and
medications were given.
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PHYSICAL ASSESSMENT:
HEALTH PERCEPTION - Health Management Pattern
Patient was referred to CUMC for further
management because of Hematochezia and
hematemesis 4hours after the operation at
NMMC. Patient was conscious and responsive.
Upon assessment he was noted jaundice to his
both eyes.
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He drinks softdrinks once or twice a

day and he do not drink coffee.
Patient X is none smoker, none
alcoholic and no food and drug
allergies.
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NUTRITIONAL AND METABOLIC PATTERN

During confinement, patient was on
strict NPO with a supplement of Kabiven
60cc/hr and NGT was in placed as lavage.
Nutritional state was well-nourished.
Patient's lips were pallor so with the
mucosa and gums. Tongue was in midline
and teeth were complete.
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Uvula was on the midline, tonsils were not

inflamed and the posterior pharynx was
no inflammation. Trachea was on the
midline and thyroids are non-palpable.
The general color of the skin was pallor,
texture is rough, turgor is supple and skin
temperature is warm to touch. He had
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Uvula was on the midline, tonsils were not

inflamed and the posterior pharynx was
no inflammation. Trachea was on the
midline and thyroids are non-palpable.
The general color of the skin was pallor,
texture is rough, turgor is supple and skin
temperature is warm to touch.
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He had an abdominal wound due

to exlaparotomy with multiple IV's
attached at right brachial area.
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ELIMINATION PATTERN
Patient X never defecated during
our shift. His usual urinary pattern
is 1,200cc with urine color yellow.
There was no excessive
perspiration or nocturnal sweats
noted.
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ABDOMEN:
There was a surgical scar at the
midline of the abdomen due to
exlaparotomy and the
configuration of the abdomen is
flat.
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ACTIVITY EXERCISE PATTERN

Patient X exercise pattern were
passive-active ROM exercise to his
both hands and feet. Leisure activities
were to sleep and rest. Breathing
pattern was regular; lung expansion was
symmetrical and non-productive cough.
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There was a decreased ROM on his

hands and feet and spine was in midline.
He was totally dependent on bathing,
meal preparation, cleaning, laundry,
toileting, bed mobility, chair/toilet transfer,
and ambulation. And he was assist with
person when feeding dressing, grooming
and ROM.
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COGNITIVE PERCEPTUAL PATTERN

Patient X was conscious and oriented to
time, place and person. Emotional state
was calm and answers the questions
being asked properly. His head was
normocephalic, facial movement was
symmetrical, fontanels were closed, hair
was fine and the scalp was clean.  
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Patient X eyes were both symmetrical

and the conjunctiva was pale. Sclera
was icteric with uniform constriction of
the pupils. The visual acuity was grossly
normal and full peripheral vision.
External pinnae were normoset,
external canal has no discharges.
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Tympanic membrane was intact with

normal gross hearing. Septum was in
the midline, mucosa was pale, no
discharges noted and both were patent
and gross smell was normal. The
primary languages that the patient usually
used were English, Tagalog and Bisaya.
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He was a college graduate from Capitol

University last 1995 taken up BSMT. He
has no pain reported during the shift
because there was patient control
analgesia (PCA) provided. But as what he
had stated, there were pain if he coughs
and he can manage the pain felt on the
operative site.
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SELF PERCEPTION CONCEPT PATTERN

Patient X felt differently upon
hospitalization and was not able to
go to work because of his
condition.
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ROLE RELATIONSHIP PATTERN

Patient X is single. There were no
known illnesses in his family. He lives
with his family and the people who
supported him most of the time during
his hospitalization and the one who
paid his bills were his relatives and family.
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SEXUALITY-REPRODUCTIVE PATTERN
According to the patient, he has no
sexual problem. There was no
prostate problem, no penis
discharges and the scrotum were
equal in shape with left is lower than
right.
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COPING-STRESS TOLERANCE PATTERN

Patient experienced stressful
situation upon hospitalization due
to being hospitalized and he was
not able to work. He manages his
stress by relaxing and sleeping.
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VALUES-BELIEF PATTERN
Patient X is a Roman Catholic.
According to him, it is important to his
life because it is where we had grown
up and it is what we believed. He
usually goes to church every
Sundays. Anatomy
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Liver
Produce substances that break down
fats, convert glucose to glycogen,
produce urea (the main substance of
urine), make certain amino acids (the
building blocks of proteins), filter
harmful substances
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from the blood (such as alcohol),

storage of vitamins and minerals
(vitamins A, D, K and B12) and
maintain a proper level or glucose
in the blood. The liver is also
responsible for producing cholesterol.
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It produces about 80% of the cholesterol

in your body.
Stomach. Food enters the stomach from
the esophagus. The connection between
the stomach and the esophagus is called
the cardiac sphincter. The cardiac
sphincter prevents food from passing
back to the esophagus.
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Heart burn is the sensation when

stomach juices (gastric juice) is allowed to
seep through the sphincter into the
esophagus. Once the food enters the
stomach, gastric juices are used to break
down the food. Some substances are
absorbed muscle lining of the stomach.
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One of the substances the stomach

absorbs is alcohol. The other end of the
stomach empties into the duodenum. The
duodenum is the first section of the small
intestine. The pyloric sphincter separates
the stomach from the duodenum.
The stomach is composed of five layers.
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Starting from the inside and working our

way out, the innermost layer is called the
mucosa. Stomach acid and digestive
juices are made in the mucosa layer. The
next layer is called the submucosa. The
submucosa is surrounded by the
muscularis, a layer of muscle that moves
and mixes the stomach contents.
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The next two layers, the subserosa and

the serosa are the wrapping for the
stomach. The serosa is the outermost
layer of the stomach.
Gallbladder
Gallbladder is to store bile and
concentrate. Bile is a digestive liquid
continually secreted by the liver.
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The bile emulsifies fats and

neutralizes acids in partly digested
food. A muscular valve in the common
bile duct opens, and the bile flows
from the gallbladder into the cystic duct,
along the common bile duct, and into the
duodenum (part of the small intestine).
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Spleen
The human spleen is an organ that
creates lymphocytes for the destruction
and recycling of old red-blood cells. The
spleen is also a blood reservoir. It
supplies the body with blood in
emergencies such as a bad cut. The
spleen is also the location where while
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blood cells rap organisms.

The average weight of an adult spleen is
0.44 lbs. During and after digestion, the
size of the spleen increases. Infection of
malaria or mono can also cause the
spleen to increase in size.
If the increase in size is significant, the
spleen can rupture. If the spleen ruptures,
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immediate medical care is necessary.

You may need emergency surgery to
control the bleeding.
Other diseases that causes enlargement
of the spleen are: rheumatoid arthritis,
systemic lupus, sickle cell anemia,
leukemia, lymphoma.
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Pancreas
The pancreas contains enzyme producing
cells that secrete two hormones. The two
hormones are insulin and glucagon.
Insulin and glucagon are secreted directly
into the bloodstream, and together, they
regulate the level of glucose in the blood.
Insulin lowers the blood sugar level and
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increases the amount of glucagon (stored

carbohydrate) in the liver. Glucagon
slowly increases the blood sugar level if it
falls too low. If the insulin secreting cells
do not work properly, diabetes occurs.
The pancreas produces the body's most
important enzymes.
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The enzymes are designed to digest

foods and break down starches.
The pancreas also helps neutralize chyme
and helps break down proteins, fats and
starch. Chyme is a thick semifluid mass of
partly digested food that is passed from
the stomach to the duodenum. If the
pancreas is not working properly to
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neutralize chyme and break down

proteins, fats and starch, starvation may
occur.
Small and Large intestines
The small and large intestines perform
different functions. The small intestine is
where the most extensive part of digestion
occurs. Most food products are absorbed
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in the small intestine. The large intestine

is responsible for absorption of water and
excretion of solid waste material. Food
and waste material are moved along the
length of the intestine by rhythmic
contractions of intestinal muscles; these
contractions are called peristaltic
movements. Waste is solid because most
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of the water has been removed by the

intestines as it travels through them.
If the intestines are not working
properly, green stool, Crohn's
disease, constipation, Irritable Bowel
Syndrome, or Tapeworms may be
present.
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Sometimes the intestine can

protrude through an abnormal
opening in the body and cause a
hernia.
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Choledocholithiasis:
About 15% of people with
gallstones will develop stones in
the common bile duct. The
common bile duct is a small tube
that carries bile from the
gallbladder to the duodenum.
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Obstruction of the common bile

duct may also lead to obstruction
of the pancreatic duct because
these ducts are usually connected.
If the pancreatic duct is also
obstructed, pancreatitis will likely
develop.
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DRUG ORDER NURSING

(Generic name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS RESPONSIBILITIES/
brand name, ACTION OF THE DRUG PRECAUTIONS
classification,
dosage, route,
frequency)

Generic Name: Bactericidal Treatment of Containdicate CNS: Headache, 1. Arrange for

dizziness, insomia, culture and
Ciprofloxacin uncomplicate
Brand Name: ; interferes d with allergy fatigue, depression,
blurred visions,
sensitivity test
before begnning
rwith DNA d UTIs to
Cipro ataxia. the therapy.
Classification: caused by E. CV: Arrhythmias, 2. Ensure that the
replication ciprofloxacin, hypotension, angina patient is well
Antibacterial Coli, K. EENT: Dre eye, eye hydrated
in Pneumoniae norfloxacin or
Dosage: pain, keratopathy 3. Take V/S before
200mg susceptible as a one-time other GI: Nausea, and after thrapy
vomiting, dry mounth, 4. Monitor and
Route: bacteria dose in fluoroquinolon diarrhea, abdominal record I/O
IV preventing patients at es.
pain 5. Apply eye
GU: Renal failure irritation
Frequency:
cell low risk of Use cautiously Hematologic: solution.
Every 12 hours Elevated BUN, 6. Monitor cardiac
reproductio nausea, with renal serum creatinine and status.
diarrhea. alkaline phophatase
n impairement. Other: Fever, rash
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DRUG ORDER NURSING

(Generic name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS RESPONSIBILITIES/
brand name, ACTION OF THE DRUG PRECAUTIONS
classification,
dosage, route,
frequency)
Treatment of
Generic Bactericida moderate to History of CNS: Headache; 1. Culture
insomnia; infection before
Name: severe infections allergic reactions starting the
Tazocin l: Inhibits caused by agitation; anxiety,
treatment.
to penicillins, dizziness
Brand Name: synnisms, piperacillin-
cephalosporins, CV: Hypertension
2. Take V/S
resistant, before and
Tazobactam causing or beta-lactamase EENT:Rhinitis after therapy.
piperacillin/tazob
Classification inhibitors; GI: Diarrhea; 3. Monitor and
: cell wall of actam–
constipation; record I/O.
susceptible, hypersensitivity to
sensitive 4. Frequent
Antibiotic beta-lactamase– any component of
nausea; mouth care.
Dosage: organisms, producing strains dyspepsia, sore 5. Monitor serum
the product. mouth; vomiting;
50mg of electrolytes
Route:
causing microorganisms Use cautiously stool changes; and cardiac
cell death. in the with renal abdominal pain, status.
IV GU: Interstitial 6. Apply hot and
nosocomial impairement
Frequency: pneumonia nephritis, renal
cold compress
on the
Every 8 hours (moderate to failure inflammation
severe). site.
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DRUG ORDER NURSING

(Generic name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS RESPONSIBILITIES/
brand name, ACTION OF THE DRUG PRECAUTIONS
classification,
dosage, route,
frequency)
Anticholinergic, Bronchodilator CNS: Nervousness, 1. Ensure
Generic Name: Contraindicat dizziness, adequate
chemically , treatment for
Ipatropium related to
bronchospasm
ed with headache, fatigue,
insomia, blurred 2.
hydration
Control the
bromide atropine which
Brand Name: associated hypersensitivit vision. temperature of
blocks vagally GI: Nausea, GI the
Combivent mediated with COPD y to atropine distress, dry mouth environment to
Classification: reflexes by (solution, Respiratory: prevent
Bronchodilator or its Dyspnea, bronchitis, hyperpyrexia.
antagonizing the aerosol),
Dosage: action of chronic derivatives, bronchospasm, URI, 3. Have patient
18mg cough, exacerbation void before
acethycholine.
Route: bronchitis, and soybean or of symptoms, taking
Causes hoarseness, medication to
Nebulization bronchodilation emphysema. peanut pharyngitis. avoid urinary
Frequency: and inhibits Others: Back pain, retention.
Every 6 hours
allergies chest pain, allergic- 4. Monitor the RR
secretions from
serous and (aerosol). type reactions, after
seromucous palpitations, rash nebulazation.
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DRUG ORDER NURSING

(Generic name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS RESPONSIBILITIES/
brand name, ACTION OF THE DRUG PRECAUTIONS
classification,
dosage, route,
frequency)
Nalbuphine Relief of CNS: Sedation, 1. Monitor V/S
Generic Name: Contrindicated clamminess, before and
Nalbuphine acts as an moderate to with sweating, headache, after theraphy.
hydrochloride agonist at severe pain. hypersensitivity restlessness, 2. Check RR
specific opoid depression, before and
Brand Name:
to nalbuphine confusion, faintness, after giving the
Nubain receptors in hallucination, drug
Classification: the CNS to and sulfites. floating feeling, 3. Reassure the
Opoid agonist- produce feeling of heaviness, patient about
antagonist numbness, tingling, addiction
analgesia and flushing, warmth, liability,most
Analgesic
Dosage: sedation but blurred vision. patient who
also acts to CV: Hypotension, recieve opiates
5mg hypertension, for medical
Route: cause bradycardia, reasons
IV hallucinations tachycardia doesn’t
Frequency: develop
and is an
Every 4 hours dependence
antagonist at syndrome.
(PRN)
mu receptors.
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DRUG ORDER NURSING

(Generic name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS RESPONSIBILITIES/
brand name, ACTION OF THE DRUG PRECAUTIONS
classification,
dosage, route,
frequency)

Generic Name: Contraindicated Fatigue,

1. Monitor for
Metochlopramid Stimulate GI motility allergy
e the motility disturbances to patients with drowsiness
2.
reaction.
Assess patient
Brand Name:
of the hypersensitivity and for nausea and
Plasil to this drug vomiting,
Classification: upper GI restlessness, abdominal
Antiemitics distension and
tract insomia bowel sounds
Dosage:
andstric before and
1 ampule after
Route: emptying. medication.
IV 3. Inform the
Frequency: accelate g patient that this
Every 6 hours drug may
cause
drowsiness.
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DRUG ORDER NURSING

(Generic name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS RESPONSIBILITIES/
brand name, ACTION OF THE DRUG PRECAUTIONS
classification,
dosage, route,
frequency)

Generic Protect Treatment Contraindicated Nausea, 1. Monitor vital

signs before
Name: against for to patients with vomiting and and after
Acetylcysteine acetamenoph medications. If
respiratory hypersensitivity bronchospasm,
Brand Name: en overdose- their is a
Fluimucil affections to this drug. headache, rash positive
induced reaction, stop
Classification hepatoxicity characterize the medication
: by d by thick and inform the
physician.
Mucolytic maintaining or and viscous 2. Small frequent
Dosage: restoring hyper meals.
½ ampule hepatic secretions .
3. Provide skin
care.
Route: concentration 4. Instruct patient
IV of glutathione. to report
Frequency: difficulty of
breathing.
Every 6 hours
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DRUG ORDER NURSING

(Generic name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS RESPONSIBILITIES/
brand name, ACTION OF THE DRUG PRECAUTIONS
classification,
dosage, route,
frequency)

Generic Name: Provides 1. Monitor for

Kabiven Parenteral Hypersensitivi Raise in body
essential and any
Brand Name:
non-essential
nutrition, ty to egg and temp., sensitivity.
Glucose 2. Monitor vital
Classification: long-chain soy protein. shivering, signs before
Parenteral fatty acids for and after the
chills, nausea
nutritional energy therapy.
product methabolism and vomiting 3. Provide tepid
Dosage: and structural sponge bath.
97g 4. Increase fluid
integrity of
Route: intake atleast
IV cell
3-4 liters.
Frequency: membrane. 5. Monitor
Every 6 hours serum
glucose.
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DRUG ORDER NURSING

(Generic name, MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS RESPONSIBILITIES/
brand name, ACTION OF THE DRUG PRECAUTIONS
classification,
dosage, route,
frequency)
 
Generic Name: Essential Prevent Blood Chest pain, 1. Monitor
Vitamin k vital signs
Brand Name: step and treat disorders, flushing, every pre
Aqua-Mephyton leading to hypoprothr allergies strange and post
Classification:
carboxylati ombinemia movements, medication.
Vitamins and
2. Provide
supplement on and rapid pulse,
Dosage: safety
1 amp activation tightness of precaution
Route: of the the chest, 3. Passive
IV range of
Frequency: blood- cramps.
motion
Every 6 hours clotting 4. Provide
proteins. antiembolic
stoking
NCP
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ASSESSMENT DATA Nursing Diagnosis GOALS AND NURSING EVALUATION

(Subjective and Objective (Problem and Etiology) OBJECTIVES INTERVENTIONS AND
Cues) RATIONALE
INDEPENDENT:
Subjective: Impaired At the end of Goal’s met.
 Performed ROM.
“Dili kayo ko  After
makalihok tungod sa
physical 8 hours of
R: To help strengthen the
muscles.
mobility related  Place patient in semi- thorough
akong tahi” as nursing fowler’s position.
nursing care
verbalized by the to post- R: To facilitate

patient.
intervention, comfortably. patient
operative  Turn from side to side.
performed
Objectives: patient will be R: To avoid any skin

 Limited range of wound at the breakdown.

ROM.
abdominal are able  Elevate body parts
motion exercise especially the weak part.

 Guarded secondary to performed R: To promote venous

return.
movement
exlaparotomy. ROM  Encourage deep-breathing
exercise.
 With ADL of 2
 Pain when according to R: To promote lung
expansion.

moving to the his physical 

DEPENDENT:
Administer medication/s as
other side ordered by the physician.
 Facial grimace
therapist. R: So that patient will be
able to treat easily.
noted
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ASSESSMENT DATA Nursing Diagnosis GOALS AND NURSING EVALUATION

(Subjective and Objective (Problem and Etiology) OBJECTIVES INTERVENTIONS AND
Cues) RATIONALE
INDEPENDENT: Goal’s met.
Subjective: Acute pain in At the end of  Monitor the vital signs
 After
“Sakit the abdominal 30 minutes of of the patient.
R: To note for any thorough
akong samad” area related to nursing unusualities. nursing care,
 Divert the attention
as verbalized post-operative the patient’s
intervention, upon onset of pain.
R: To lessen the pain. pain was
by the patient. wound
patient will  Provide comfort to the
alleviated
secondary to patient.
with the pain
Objectives: cholecystectom lessen the R: To lessen the
trigger of the pain. scale from
 Swelling y and pain.  Assess when moving to
sides
7/10 to 4/10
 Patient can
 Guarding choledochecto R:To relief comfort
DEPENDENT: now rest and
movement my/  Administer Tramadol as
sleep
ordered by the
at the site exlaparotomy physician comfortably
R: To lessen the pain
 Pain Scale=
7/10
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ASSESSMENT DATA Nursing Diagnosis GOALS AND NURSING EVALUATION

(Subjective and Objective (Problem and Etiology) OBJECTIVES INTERVENTIONS AND
Cues) RATIONALE
Subjective: INDEPENDENT: Goal’s partially
Risk for At the end of 8  Perform hand hygiene
Objectives: met
infection hours nursing when doing some
 After
procedures.
related to post intervention, R: To prevent thorough
contamination to the
operative the patient will patient.
nursing care,
wound at the be  Perform wound the patient is
dressing. partially free
abdominal area  Free from R: To prevent from infection
secondary to infection. 
microorganism.
Monitor vital signs.
as evidenced
Exlaparotomy  Perform R: to note any by sanitizing
unusuality. the
hand DEPENDENT: surroundings
hygiene by  Administer antibiotics
medications as  Patient had
itself ordered by the performed
physician hand hygiene
R: to prevent spread
of infection
Discharge
Plan
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HEALTH TEACHINGS/DISCHARGE PLAN

MEDICATIONS:
Explain to the significant others the
importance of:
• drug medications
• adverse effect
• contraindications
• the importance of continuing medications
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 Rationale: to be able for the

significant others to have
knowledge about the medication
that the client is taking and to
report if there is presence of
adverse reaction
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 ECONOMICS:
Explain to significant others that the
rehabilitation may be prolonged to be able
for the family to prepare financial needs
Have physical therapist to re-learn function
as transferring, walking and other gross
motor functions
Have occupational therapist to help re- learn
everyday activities or ADL
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TREATMENTS:
Maintain adequate oxygenation to have
proper oxygenation or to prevent brain
damage
Teach significant others about the
importance in the completion of treatment to
have faster recovery
Teach family to facilitate recovery of the
client to promote self-esteem
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HEALTH TEACHINGS:
Have range of motion exercise to build
strength and tone of the muscle
Need for good hygiene to promote
cleanliness To maintain patent airways and
promote drainage of saliva from the airway to
have proper oxygenation
Teach significant others that client needs
supportive care to maintain self-esteem
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OUTPATIENT:
Have a regular follow-up check up at
the nearest hospital or health center to
prevent recurrence of further
complications
Consult physician for follow-up check
up to prevent recurrence of further
complications
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DIET:
Maintain diet of preference or as
ordered
Increase fluid intake
Eat nutritious foods such as fruits
and vegetables
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Emotional Aspects:
1. Advise family that the patient will tire easily,
will become irritable and upset by small events
and is likely to show less interest in things.
2. Discuss patient’s depression with the
physician in relation to anti-depressant therapy.
3. Encourage the family to support the patient
and give reinforcement.
 
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Home Modifications:
Have occupational therapist make
a home assessment and
recommendations to help the
patient become more
independent. Related
Experience
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RELATED LEARNING EXPERIENCE

As the popular saying goes “Experience is the best teacher”,
once you only read it, you will just forget it, once it’s only being
thought unto you, it will no longer be remembered later, but
once tried, it will never be forgotten.
Same as what we have experienced with our 4-week hospital
exposure at the intensive care unit in Capitol University City
Hospital. We have experienced how to it feels like being
nervous of doing some procedures and we just trying hard not
to commit mistakes. Truly it was a great experience for all of us
were learning takes a big role for each and every one of us.
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But sometimes we do have shortcomings, we commit mistakes

and being reprimanded by our action, yet we’re still grateful
because it had made us a better person and becoming
competent in performing nursing care. But as we go along with
the case study we have learned to manage our time wisely to
be able to finish our requirements as well as giving time for
other subjects. By this case study, we also became more
responsible, to be diligent and organize with our work.
Moreover, thorough analysis, further readings and research,
meeting of our ideas and suggestions, and patience brought us
in this final output of this case study.
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In later clinical exposure it would be a great help since it has

already given us some information in addition to our knowledge
most specifically about this case study project. Through this, we
could be able to provide quality the best care we could give to
the patient. As the prevalence saying goes “people don’t care
how much you know until they know how much you care”.
People must also realize that nursing is a high position of
profession with its main purpose - “no matter how hard it is, no
matter how much you are being paid for it and wherever you
are, it is life that nurses dealing with. Nurses bring life. “
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And lastly, this study wouldn’t be possible without the help of

our Clinical Instructor who allowed us to soar to greater
heights. His strict teachings yet gentle in approach had helped
us not to be afraid and be confident of the knowledge that our
school and teachers had equipped us. His teachings will always
mark in our minds and hearts. And we will always remember
the days we had learned so much from him.
To our families for their kind understanding when we were
away from our homes while doing this study. And above all, to
our Almighty God whose infinite wisdom gave us the capability
to come up with a study that our nursing colleagues could
 
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Thank you!