FOCUSED CLINICAL CASE STUDY

CHAPTER 1
ASSESSMENT
A. NURSING HEALH HISTORY
Personal Data
The client is 80 years old, female.
Chief Complaint
Decreased level of responsiveness
Medical Diagnosis
CV Infarct vs Bleed; Complicated UTI
History of Present Illness
June 19 to July 2, client was previously admitted at OSMAK due to decrease in
sensorium and decrease in appetite for 3 days. Managed as case of CVD infarct vs
bleed; complicated UTI; Post gliotic seizure; HPN Stage 2; S/R cerebellum infarct with
residuals and Pott’s disease. Client was discharged with NGT.
3 days PTA, the patient in bed has spontaneous eye opening, but no verbal
output or spontaneous movement
1 day PTA, there was a note of decrease in sensorium and edema on both upper
and lower extremities. Persistence of the symptom prompted consult & subsequent
admission.
Past Medical History
 S/P CVD Bleed, Left Basal Ganglia (March 2018)
 S/P CVD (cerebellar) infarct with residuals
 S/P biliary exploration (2012)
Social History
Client is non-smoker and non-alcoholic
 B. FOCUSED ASSESSMENT
BP: 113/46 mmHg
HR: 78 bpm
RR: 16 cpm
02: 100%
General Appearance
Client’s has a medium body frame. Maintained on moderate high back rest.
Client is on right lateral position.
Mental Status
Client’s GCS is 3 (E1M1V1); no spontaneous eye opening, unresponsive to name
calling, no verbal response and no movement.
Skin
Skin is pallor and skin turgor is wrinkle loss of elasticity. Client has a grade 2
bedsore in the sacral area. Scar on right middle finger. Client is on contact
precaution.
Eyes
Client has no spontaneous eye opening and unresponsive to name calling.
Nose
Client has a nasogastric tube in the left nostril.
Mouth
Hooked on mechanical ventilator; ventilator modes SIMV BUR 16
PS 16
FiO2 40%
Chest and Lungs
Chest hooked on cardiac monitor. Crackles was heard upon auscultation.
Upper and Lower Extremities
Client has a non-invasive blood pressure on right arm. IVF of 250 cc D5W + 2
amp of dopamine x 14 cc/hr on left arm. Grade 2 pitting edema on both hands and
grade 3 pitting edema on both feet.
Genitalia
Client has a foley catheter draining @ 200 cc (dark yellow urine) and diaper.

C. DIAGNOSTIC PROCEDURES
1.Complete blood count (CBC) is a blood test used to evaluate your overall health and
detect a wide range of disorders, including anemia, infection and leukemia.
A complete blood count test measures several components and features of your blood,
including:
 Red blood cells, which carries oxygen
 White blood cells, which fights infection
 Hemoglobin, the oxygen-carrying protein in red blood cells
 Hematocrit, the proportion of red blood cells to the fluid component, or plasma, in
your blood
 Platelets, which help with blood clotting
Nursing Responsibilities
 Identify the patient by asking the patient to state his/her name. Also check the
client’s identification band. ( confirm patient’s identity using two patient identifiers,
based on the hospital protocol)
 Explain test procedure. Explain that slight discomfort may be felt when the skin is
punctured.
 Encourage to avoid stress if possible because altered physiologic status influences
and changes normal hematologic values.
 Explain that fasting is not necessary. However, fatty meals may alter some test
results as a result of lipidemia.
 Apply manual pressure and dressings over puncture site on removal of dinner.
 Monitor the puncture site for oozing or hematoma formation.
 Instruct to resume normal activities and diet.

CBC Results (July 09, 2018)

Values Reference
Test Clinical Interpretation
Obtained Range
Decreased Hgb indicates anemia due to CVD
12.0-16.0
Hemoglobin 9.1 (L) Bleeding, where the weakened blood vessels
g/dL
ruptures causing blood loss.
Decreased Hgb indicates anemia due to CVD
38.00 –
Hematocrit 26.6 (L) Bleeding, where the weakened blood vessels
47.00%
ruptures causing blood loss.
Decreased RBC indicates anemia due to CVD
4.00 – 6.00
RBC count 2.94 (L) Bleeding, where the weakened blood vessels
10^6/uL
ruptures causing blood loss.
80.00 –
MCV 90.5 Normal
100.00fL
26.00 –
MCH 31.0 Normal
34.00pg
31.00 –
MCHC 34.2 Normal
37.00g/dL
4.50 – 11.00
WBC Count 8.20 Normal
10^3/gL
fIncreased neutrophil may indicate a response
Neutrophil 77.9 (H) 50 – 70% to bacterial infection or acute inflammation
Low lymphocytes count indicates that the
Lymphocyte 13.5 (L) 20 – 40% body is low on infection resistance.
Monocyte 6.7 0.0 – 7.0% Normal
Eosinophil 1.5 0.0 – 5.0% Normal
Basophil 0.4 0.0 – 1.00% Normal
Increase in number of platelet is called
Platelet 150 – 400 thrombocytosis. Symptoms can include blood
419 (H)
count 10^3/uL clots that form and block blood supply to the
brain or the heart.
2. Blood urea nitrogen (BUN) test measures the amount of nitrogen in your blood that
comes from the waste product urea. Urea is made when protein is broken down in your
body. Urea is made in the liver and passed out of your body in the urine. A BUN test
isdone to see how well your kidneys are working.
Creatinine is a waste product in your blood that comes out from muscle activity. It is
normally removed from your blood by your kidneys, but when kidney function slows
down, the creatinine level rises.
Glomerular Filtration Rate (GFR) tells how much your kidneys function. It maybe
estimated from your blood level of creatinine.
Nursing Responsibilities
 Identify the patient by asking the patient to state his/her name. Also check the
client’s identification band. (ssconfirm patient’s identity using two patient identifiers,
based on the hospital protocol)
 Explain the procedure to the patient or parents (if patient is a child) to gain
cooperation. Tell the patient that the test is used to evaluate kidney function.
 Inform the patient that he need not to restrict food and fluids, but should avoid diet
high in meat.
 Tell the patient that the test requires a blood sample. Explain who will perform the
venipuncture and when.
 Explain to the patient that he may experience slight discomfort from the tourniquet
and needle puncture.
 Notify the laboratory and physician of medications the patient is taking that may
affect test results; they may need to be restricted.
BUN Creatinine EGFR Result (July 06, 2018)
Specimen: Serum
Test Result Reference Range Interpretation
Increased BUN level means
10.27
BUN 2.76 – 8.07 mmol/L kidney are not able to remove
(H)
rea from the blood normally.
45.00 – 84.00
Creatinine 52 Normal
umol/L
EGFR (Estimated
60.00 – 120.00
Glomerular 87 Normal
mL/min/1.73m^2
Filtration Rate)

3. Chest x-ray is the most commonly performed diagnostic x-ray examination. A chest
x-ray produces images of the heart, lungs, airways, blood vessels and the bones of the
spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps
physicians diagnose and treat medical conditions.
Nursing Responsibilities
 Identify the patient by asking the patient to state his/her name. Also check the
client’s identification band. ( confirm patient’s identity using two patient identifiers,
based on the hospital protocol)
 Explain the procedure to the patient or parents (if patient is a child) to gain
cooperation.
 Gown cannot have snaps or pins
 Tell patient they will be asked to take deep breath and hold during the procedure.
CHEST XRAY RESULTS (July 06, 2018)
Lungs are hyperaerated.
Reticular densities are seen scattered in both lungs with conference in the left lower
lung obscuring the ipsilateral hemidiaphragm and costophrenic sulcus.
Heart is not enlarged.
Pulmonary vascular markings are unremarkable. Atherosclerotic aorta.
Trachea is skewed on the left, like positional.
Right hemidiaphragm I s intact. Right costophrenic sulcus is blunted.
Marginal osteophytes are seen at the endplates of the thoracic vertebrae.
There is rightward curvature of the thoracic spine which may real or positional in nature.
An endotracheal tube is seen in place with its tip 1.25cm from the carina. Repositioning
is recommended.
Feeding tube is noted with its tip not delineated in this study.
Impression:
Hyperaerated lungs.
Consider bilateral Pneumonia with signs of consolidation at the left lower lung.
Atherosclerotic aorta.
Thoracic spondylosis
4. Random Blood Sugar is a blood sugar test is a procedure that measures the
amount of sugar, or glucose, in your blood. Indications
Random blood sugar test provides accurate information about how the body is
controlling glucose metabolism. It is indicated in a range of conditions including:
 Diabetes; Seizures; Enteral and parenteral feeding; Liver disease or pancreatitis;
Head injury or unconciousnes; Stroke; Alcohol or drug intoxification; Sepsis
Nursing Responsibilities:
 Identify the patient by asking the patient to state his/her name. Also check the
client’s identification band. (confirm patient’s identity using two patient identifiers,
based on the hospital protocol)
 Explain the procedure to the patient or parents (if patient is a child) to gain
cooperation.
 Choose the puncture site. For adults and children fingertips and earlobe can be use.
For infants, the tip of the great toe or heel can be the site of puncture.
 Wash hands and don clean gloves.
 If glucometer is used, load the strip into the device beforehand.
 Swab alcohol pad to the chosen puncture site. Use sterile/clean gauze to dry it
thoroughly. Piecing the skin with a wet skin (alcohol) allows the chemical to pass
through the outer layer of the skin thus, causing the procedure more painful and
uncomfortable.
 To collect a blood sample, position the lancet (pricking needle) at the side of the site.
To minimize pain and patient’s anxiety pierce the skin sharply and briefly. This
technique also increases blood flow. For better results, some agencies are using a
lancing device (mechanical blood-letting device) wherein the lancets are simply
loaded in the spring of the equipment. (It’s like using a spring-loaded pen, once you
click the button the spring releases the lancet and immediately retracts it after
piercing the skin). However, be sure to load an unused lancet before using to
prevent spread of blood-transmitted diseases.
 Don’t squeeze the puncture site to prevent diluting the sample with fluids from
tissues.
 Cover the entire patch of strip with blood.
 Place gauze over the punctured area and briefly apply pressure until the bleeding
stops. Ask the parents of a child to do this.
 Read and Document result.
Random Blood Sugar Result (July 06, 2018)
Specimen: Blood
RESULT REFERENCE RANGE INTERPRETATION
227.0 mg/dL 79-160 mg/dL Increased RBS means increase in glucose in
the blood indicating Diabetes Mellitus.

5. Blood Typing is a test that determines a person’s blood type. The test is essential if
you need a blood transfusion or are planning to donate blood. Not all blood types are
compatible, so it’s important to know your blood group. Receiving blood that’s
incompatible with your blood type could trigger a dangerous immune response.
Nursing Responsibilities:
 Identify the patient by asking the patient to state his/her name. Also check the
client’s identification band. ( confirm patient’s identity using two patient identifiers,
based on the hospital protocol)
 Explain the procedure to the patient or parents (if patient is a child) to gain
cooperation.
 Choose the puncture site.
 Swab alcohol pad to the chosen puncture site. Use sterile/clean gauze to dry it
thoroughly. Piecing the skin with a wet skin (alcohol) allows the chemical to pass
through the outer layer of the skin thus, causing the procedure more painful and
uncomfortable.
 Collect a blood sample by pricking the puncture site.
 Put blood sample in a glass slide and label with patient’s information including date
of collecting the sample.
 Apply pressure to punctured site.

Blood Typing (July 09, 2018)

(-)ABO (+)RH : “O” Rh (O) positive
Interpretation:
Type O individuals can donate blood to anyone, because their blood has no antigens.
However, they can only receive blood from other type O individuals (because blood with
any antigens is seen as foreign).
Rh-positive: People with Rh-positive blood have Rh antigens on the surface of their red
blood cells. People with Rh-positive blood can receive Rh-positive or Rh-negative blood.
6. Lactate Dehydrogenase (LDH) test looks for signs of damage to the body’s tissues.
Indication:
 To measure whether you have tissue damage and its severity
 To monitor severe infections or conditions like hemolytic or megaloblastic anemias,
kidney disease, and liver disease
 To help evaluate certain cancers or your cancer treatment
Nursing Responsibilities
 Identify the patient by asking the patient to state his/her name. Also check the
client’s identification band. ( confirm patient’s identity using two patient identifiers,
based on the hospital protocol)
 Explain the procedure to the patient or parents (if patient is a child) to gain
cooperation.
 Choose the puncture site.
 Swab alcohol pad to the chosen puncture site. Use sterile/clean gauze to dry it
thoroughly. Piecing the skin with a wet skin (alcohol) allows the chemical to pass
through the outer layer of the skin thus, causing the procedure more painful and
uncomfortable.
 Collect a blood sample by pricking the puncture site.
 Put blood sample in a tube and label with patient’s information including date of
collecting the sample.
 Apply pressure to punctured site.
LDH Result (July 06, 2018)
Specimen: Serum
REFERENCE
RESULT INTERPRETATION
RANGE
Increased LDH indicates a sign of tissue damage or
disease.extreme high levels indicate multiple organ
135.00 – dysfunction.
355 (H)
214.00 u/L if your LDH levels are elevated, ALT, AST, or ALP tests
are to be ff. to determine which organs are involved.

7. Electrolyte Determination is an electrolyte test can help determine whether there's

an electrolyte imbalance in the body. Electrolyte measurements may be used to help
investigate conditions that cause electrolyte imbalances such as dehydration, kidney
disease, lung diseases, or heart conditions. Repeat testing may then also be used to
monitor treatment of the condition causing the imbalance.
Electrolytes are salts and minerals, such as sodium, potassium, chloride and
bicarbonate, which are found in the blood. They can conduct electrical impulses in the
body.
Nursing Responsibilities
 Identify the patient by asking the patient to state his/her name. Also check the
client’s identification band. ( confirm patient’s identity using two patient identifiers,
based on the hospital protocol)
 Explain the procedure to the patient or parents (if patient is a child) to gain
cooperation.
 Choose the puncture site.
 Swab alcohol pad to the chosen puncture site. Use sterile/clean gauze to dry it
thoroughly. Piecing the skin with a wet skin (alcohol) allows the chemical to pass
through the outer layer of the skin thus, causing the procedure more painful and
uncomfortable.
 Collect a blood sample by pricking the puncture site.
 Put blood sample in a tube and label with patient’s information including date of
collecting the sample.
 Apply pressure to punctured site.
Electrolyte Determination Na, K, Cl (July 09, 2018)
Specimen: Serumss
EFERENCE
ELECTROLYTES RESULT NTERPRETATION
RANGE
 Decreased Sodium level indicates excess
136.00- fluid accumulation in the body (evidenced by
Na 130(L) 145.00 edema that is caused by heart failure,
mmol/L cirrhosis, and kidney diseases that cause
protein loss.
3.50 –
K 3.65 5.10 Normal
mmol/L
Decreased Chloride level indicates
88.0 98.00 – hypochloremia which occurs with any disorder
Cl
(L) 107.00 that causes low blood sodium. Hypochloremia
also occurs with congestive heart failure.

8. Stain for Acid Fast Bacilli is a differential stain used to identify acid-fast organisms
such as members of the genus Mycobacterium. Detection of acid-fast bacilli (AFB) in
stained and acid-washed smears examined microscopically may provide the initial
bacteriologic evidence of the presence of mycobacteria in a clinical specimen.
Nursing Responsibilities
 Identify the patient by asking the patient to state his/her name. Also check the
client’s identification band. ( confirm patient’s identity using two patient identifiers,
based on the hospital protocol)
 Explain the procedure to the patient or parents (if patient is a child) to gain
cooperation.
 Choose the puncture site.
 Swab alcohol pad to the chosen puncture site. Use sterile/clean gauze to dry it
thoroughly. Piecing the skin with a wet skin (alcohol) allows the chemical to pass
through the outer layer of the skin thus, causing the procedure more painful and
uncomfortable.
 Collect a blood sample by pricking the puncture site.
 Put blood sample in a tube and label with patient’s information including date of
collecting the sample.
 Apply pressure to punctured site.
Stain for Acid Fast Bacilli Result (July 08, 2018)
- No acid fast bacilli seen
9. Urinalysis. A set of screening tests that can detect some common diseases. It may
be used to screen for and/or help diagnose conditions such as UTI, kidney disorders,
liver problems, diabetes and other metabolic conditions.

Indication:
- To evaluate presence of ketones, albumin and sugar in the urine.
- To evaluate the pH level of the urine.
- To detect genitourinary infections.

Nursing Responsibilities:
- Instruct the patient to void directly into a clean, dry container. Sterile,disposable
containers are recommended.
- Instruct the patient on how to do midstream clean catch of the urine.
- Cover all specimens tightly, label properly and send immediately to the
laboratory.
- Observe standard precautions when handling urine specimens.

Result: July 07, 2018

Macrosopic Referen
Result Interpretation
exam ce Value
light
Color yellow Normal
yellow
Cloudy or foamy urine may occur occasionally
due to mild dehydration; It may also be a cause
of excess protein or crystalline substances in
slightly the urine. Additionally, in numerous cases,
Transparency clear
hazy Infections anywhere in the urinary tract (UTI),
including the bladder or urethra, in both men
and women, can cause pus to appear in the
urine, giving it a cloudy/hazy appearance.
A highly alkaline urine occurs in: Urinary tract
obstruction, Pyloric obstruction, Salicylate
intoxication, Renal tubular acidosis, Chronic
renal failure, Respiratory diseases that involve
Reaction 8.5 (H) 4.6 – 8.0 hyperventilation. Most of the bacteria
responsible for urinary tract infections make the
urine more alkaline because the bacteria split
urea into ammonia and other alkaline waste
products.
Low specific gravity may indicate the presence
of diabetes insipidus, a disease caused by
Specific 1.016 – impaired functioning of antidiuretic hormone
1.011 (L)
Gravity 1.022 (ADH). Low SG also may occur in patients with
glomerulonephritis, pyelonephritis, and other
renal abnormalities.
Chemical Referen
Result Interpretation
Exam ce Value
Infections or obstruction in the urinary tract or
Leukocyte 3+ (H) negative bladder may cause to have an increased
amount of leukocytes in the urine.
Nitrite negative negative Normal
Urobilinogen normal normal Normal
Having trace albumin in your urine means that
your kidneys are abnormally spilling a tiny
amount of
protein into
Protein trace negative the urine from the blood. Protein in the urine
may be an indication of a Kidney disease, UTI
and other conditions such as: congestive heart
failure, a first warning
of eclampsia in pregnancy.
Suggestive of Microscopic hematuria that is
may be caused by a calculus in the urinary
tract. It also may indicate other conditions such
Blood 1+ (H) negative
as: infection in the bladder,kidney
or prostate, viral illness, such as hepatitis, and
endometriosis.
The presence of ketones in the urine indicates
that the body is using fats rather than
carbohydrates or energy. May be present in the
Ketone trace negative urine of individuals with uncontrolled diabetes or
during conditions of physiological stress such as
fasting, rapid weight loss, frequent strenuous
exercise or prolonged vomiting.
 Bilirubin negative negative normal
Glucose negative negative normal

Remarks: Assay verified; bi-level controls are within reference range.

10. Electrocardiogram (ECG) It is a diagnostic tool that is routinely used to assess the
electrical and muscular functions of the heart.

Indication:
- To help identify primary conduction abnormalities, cardiac arrhythmias, cardiac
hypertrophy, pericarditis, electrolyte imbalances, myocardial ischemia, and the site
and extent of myocardial infarction.
- To evaluate the effectiveness of cardiac medications.
- To test for evaluating cardiac status, graphically records the electrical current
(electrical potential) generated by the heart.

Nursing Responsibilities:
- Explain to the patient the need to lie still, relax, and breathe normally during the
procedure.
- Note current cardiac drug therapy on the test request form as well as any other
pertinent clinical information, such as chest pain or pacemaker.
- Explain that the test is painless and takes 5 to 10 minutes.

Result:July 08, 2018

Vent rate: 83bpm P-R-T axes: 58-45

PR int: 144ms Avg. RR: 716ms
QRS dur: 132ms QTcB: 473ms
QT/QTc: 401/441ms QTcF: 448ms
11. SGPT/ALT (Serum Glutamic-Pyruvic Transaminase / Alanine
Aminotransferase)This blood test measures an enzyme called alanine transaminase
(ALT). ALT is an enzyme made in the liver. It is released into the blood when tissues are
damaged.

Indications:
- checks for and measures damage to the liver.
- to check medical treatments that may affect the liver.

Nursing Responsibilities:
- Determine medications being taken by the patient and inform physician as physician
may need to ask the patient to avoid taking certain medicines before the test
because they might affect the test result.

Result: July 06, 2018

Specimen: Blood
REFERENCE
RESULT INTERPRETATION
RANGE
SGPT is released into blood when the liver or heart
are damaged. The blood SGPT levels are thus
120.3 (H) 0.00 – 33.00 u/L
elevated with liver damage or with an insult to the
heart Some medications can also raise SGPT levels.

12. Prothrombin Time Test. It is a blood test that measures how long it takes blood to
clot.
Indications:
- Use to check for bleeding problems.
- To monitor the effectiveness of heparin or thrombolytic agents.

Nursing Responsibilities:
- Explain to the patient that the procedure determines whether their blood clots
normally.
- Determine and notify the laboratory and physician of drugs the patient is taking that
may affect test results; it may be necessary to restrict them before performing the
procedure.
- Explain to the patient that he may feel slight discomfort from the tourniquet and the
needle puncture.

Results: July 06, 2018

Specimen: Blood

REFERENCE
RESULT INTERPRETATION
RANGE

Prothrombin
10-14
Time (PT) 13.0 normal
seconds
Patient

Control 11.0
Activity 75.2 70-100% normal
An INR result above 1.1 means your blood
is clotting more slowly than normal.
INR This may indicate conditions such as:
(International Bleeding disorders in which there is a
1.09 (H) 0.8 to 1.1
Normalized problem with the body's blood clotting
ratio) process, disorder in which the proteins that
control blood clotting become over active,
Liver disease, low level of Vitamin K.

REFERENCE
RESULT INTERPRETATION
RANGE
Partial Thromboplastin Time
25-35
(APTT) 28.7 normal
seconds
Patient
Control 27.0

13. Total Protein. This test measures the total amount of two classes of proteins found
in the fluid portion of your blood. These are albumin and globulin.

Indications:
- To help diagnose a number of health conditions such as kidney and liver diseases
and malnutrition.

Nursing Responsibilities:
- Determine and notify the laboratory and physician of drugs the patient is taking that
may affect test results; it may be necessary to restrict them before performing the
procedure as many medications can affect the total protein test results.
- Determine possibility of pregnancy as Total protein measurement may be increased
during pregnancy.

Result:July 06, 2018

Specimen: Serum
REFERENCE
RESULT INTERPRETATION
VALUE
A low total protein level can suggest a liver or
kidney disorder, or a disorder in which protein is
not digested or absorbed properly. Low levels
Total 66.00 - 87.00
53.4 (L) may be seen in severe malnutrition and with
Protein g/L
conditions that cause malabsorption, such as
celiac disease or inflammatory bowel disease
(IBD).
A low albumin can suggest liver disease. It can
also be seen in inflammation, shock, and
malnutrition. They may be seen with conditions
in which the body does not properly absorb and
39.70 – 49.40
Albumin 24.4 (L) digest protein, such as Crohn’s disease or
g/L
celiac disease, or in which large volumes of
protein are lost from the intestines. It may also
be seen in other conditions such as: infection,
cancer, hypothyroidism,and diabetes.
Globulin 29.0 20 - 35g/L normal
A/G Ratio 0.8 0.8-2.0 normal

14. SGOT / AST (Serum Glutamic-Oxaloacetic Transaminase / Aspartate

Aminotransferase) test This test is a blood test that’s part of a liver profile. It measures
one of two liver enzymes, called serum glutamic-oxaloacetic transaminase. This
enzyme is now usually called AST, which stands for aspartate aminotransferase.

Indications:
- To evaluate how much of the liver enzyme is in the blood.
- Used to help your doctor diagnose liver damage or liver disease.
- To evaluate liver health for people who are already known to have
- conditions that affect the liver, such as hepatitis C.

Nursing Responsibilities:
- Instruct patient to avoid taking any over-the-counter (OTC) medications,
including acetaminophen (Tylenol), in the two days before the test. If the patient did
take medications containing acetaminophen and/or other medications, notify the
physician.

Result:July 07, 2018

REFERENCE
RESULT INTERPRETATION
RANGE
High SGOT means one of the organs or muscles containing
the enzyme could be damaged. These include your liver,
but also the muscles, heart, brain, and kidneys. Extremely
0.00 – 33.00 high levels of AST indicate conditions that cause severe
100.8 (H)
u/L liver damage. These conditions include: acute viral hepatitis
A or hepatitis B, shock, or collapse of the circulatory
system, and or extensive liver damage that’s likely caused
by toxins.

15. Gram stain for bacteria. It is a dyeing technique that helps in detecting the
presence of bacteria or fungi in a fluid/cell sample, obtained from a site of suspected
infection.
Indications:
- When the possibility of a bacterial (or sometimes fungal) infection is suspected.
- Used to identify the presence of microorganisms in normally sterile body fluids
(cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid).
- Helps in a preliminary classification of the bacteria, which helps a physician initiate
appropriate antibiotic therapy.

Nursing Considerations:
- Determine certain medications that patients may currently be taking that may
influence the outcome of the test. Inform your physician, the complete list of
medications (including any herbal supplements) that the patient is currently taking.
This will help to interpret your test results more accurately and avoid unnecessary
chances of a misdiagnosis.

Result:July 08, 2018

Findings:
Occasional pus cells seen.
Many epithelial cells seen.
Occasional gram positive cocci in pairs seen.
Many gram positive bacilli seen.
Occasional gram negative bacilli seen.
Fungal elements seen.
 CHAPTER 2
PLANNING

A. LIST OF PRIORITIZED NURSING DIAGNOSES

RANK NURSING DIAGNOSIS JUSTIFICATION

It is the 1st prioritized nursing
problem because Circulation must

1
Ineffective Cerebral Tissue be given immediate action before
Perfusion related to interruption breathing and airway according to
of blood flow as evidenced by the CAB principle. Proper blood
GCS 3 circulation provides oxygen to the
different parts of the body in order
for it to function in its optimum level.
It is the 2nd prioritized nursing
Excess Fluid Volume related problem because Circulation must

2
renal insufficiency as evidenced be given immediate action before
by pitting edema both upper and breathing and airway according to
lower extremities and high BUN the CAB principle. Proper blood
of 10.27mmol/L circulation provides oxygen to the
different parts of the body in order
for it to function in its optimum level.
It is the 3rd prioritized nursing
diagnosis because according to
CAB principle, Airway must be given
the 2ndimportance after Breathing.

3
Ineffective Airway Clearance
Since oxygen is our main source of
related to increased mucus
life, and exhalation is the main way
production as evidenced by
to expel toxins from our bodies, poor
crackles upon auscultation
breathing may further lead to a
multitude of health problem that
slows the recovery of patient and
may even lead to death.
 It is the 4th prioritized nursing
Impaired Tissue Integrity related

4
diagnosis. It must be given
to altered circulation as
immediate intervention to prevent
evidenced by bedsore at sacral
infection and other complications
area grade 2
that may further slow the recovery of
patient.

Mobility is needed in order to

accomplish physiological needs of
individuals. Physiological needs are
thought to be the most important
Impaired Physical Mobility

5
and should be met first in the
related to neuromuscular
hierarchy of needs according to
involvement as evidenced by
Maslow. Physiological needs are the
inability to purposely move
physical requirements for human
involved body parts.
survival. If these requirements are
not met, the human body cannot
function properly and will ultimately
fail.
 B. NURSING CARE PLAN 1
ASSESSMENT NURSING DX PLANNING INTERVENTION RATIONALE EVALUATION
Objective Data Ineffective Short term 1. Monitor V/S q15 - Baseline data Short term
- GCS 3 Cerebral Tissue After 8 hours of 2. Assess for signs of - Particular clusters of signs Outcome Partially
- With NGT Perfusion related Nursing decreased tissue and symptoms occur with Achieved. After 8
- With Mechanical to interruption of Interventions, perfusion. differing causes. Evaluation hours of Nursing
Ventilator SIMV blood flow as primary care giver provides a baseline for Interventions, the
BUR 16 evidenced by will be able to future comparison. patient’s primary
PS 16 GCS 3 verbalize the 3. Review laboratory - Blood clotting studies are caregiver
FiO2 40% patient’s condition data (prothrombin being used to conclude or verbalized the
- No spontaneous and therapy time) patient’s condition
make sure
eye opening, regimen and the and therapy
that clotting factors stay
unresponsive to patient’s O2 regimen and the
name calling, no saturation will within therapeutic levels. patient’s O2
verbal response remain within Gauges of organ perfusion saturation is 97%
and no normal range. or function. Irregularities in which is within
movement. coagulation may occur as normal range.
- Input – 484cc Long Term an effect of therapeutic
- Output – 380cc Upon trans out, measures. Long term
- V/S the patient will 4. Periodically check - For comparative baseline Outcome partially
- BP:113/46mmHg maintain data.
mental status and achieved. Upon
- HR: 78 bpm maximum cerebral
perform neurologic trans out, the has
- RR: 16 cpm tissue perfusion,
- 02: 100% as evidenced by assessment (GCS) not yet achieved
Glasgow Coma 5. Keep the patient on a - This promotes venous outflow the goalto maintain
Scale of 15, warm high back rest from brainand helps reduce maximum cerebral
and dry skin, vitals pressure tissue perfusion, as
within normal Collaborative - Proton pump inhibitor evidenced by
1. Esomeprazole 40
Reference: range and ability
mg/vial, 1 vial, IV, Glasgow Coma
Doenges M. E., to swallow,
OD Scale of 12, warm
et al., Nurse’s mentally alert and - Blood Derivative or Plasma
2. Albumin 12.5/50 ml 1 Volume Expande and dry skin, vitals
Pocket Guide, oriented, and
vial IV QID
pages 618 – 621. normal motor and - Neutrotopic. to increase blood within normal
3. Citicoline 1 gram/
sensory function tab, 1 tab, BID, NGT flow and O2 consumption in the range and ability to
brain. to increase blood flow swallow, mentally
and O2 consumption in the alert and oriented,
brain.
and impaired motor
4. Clopidogrel 75 - Antiplatelet Agents; Platelet
mg/tab, 1 tab, OD, Aggregation Inhibitors Inhibits and sensory
NGT platelet aggregation it function.
decreases the occurrence of
atherosclerotic events in
patients at risk.
5. Lactulose 30cc syrup - Laxatives
OD HS, NGT
 NURSING CARE PLAN 2
ASSESSMENT NURSING DX PLANNING INTERVENTION RATIONALE EVALUATION
Objective Data: Excess Fluid Volume Short term 6. Monitor V/S q15 - Baseline data Short term
- Grade 2 pitting related to renal After 8 hours of 7. Perform hand - To prevent Outcome Partially
edema on both insufficiency as Nursing Intervention, hygiene and wears transmission of Achieved
hands and grade 3 evidenced by the patient’s edema PPE when going to microorganism After 8 hours of
pitting edema on pittingedema both will decrease from patient’s room Nursing interventions,
both feet. upper and lower grade 2 to 1 on the 8. Auscultate breath - For presence of the patient had a
- High BUN result of extremities and high upper extremities and sounds crackles, decrease size of
10.27mmol/L with a BUN of 10.27mmol/L from grade 3 to grade congestion. edema from grade 2 to
normal range of 1 of lower extremities. 9. Note for presence - Indicates fluid 1 on the upper
2.76 – 8.07 mmol/L of edema and retention and extremities and from
- Pulmonary crackles Long Term measure the area provides grade 3 to grade 2 of
upon auscultation Upon trans out, the periodically comparative lower extremities.
- Input – 484cc patient will have a baseline
- Output – 380cc balanced Intake and Long Term
- V/S Output, free of signs of 10. Observe skin and - For presence of Outcome Partially
- BP:113/46mmHg edema. mucous ulceration Achieved. Upon trans
- HR: 78 bpm membranes out, the patient had a
- RR: 16 cpm 11. Record I and O balance I and O, and
- 02: 100% accurately free of signs of edema
12. Elevate edematous - Reduce tissue
extremities pressure and risk
of skin breakdown
Collaborative - Antihypertensive;
Loop Diuretic
13. Administer
Reference: Doenges Furosemide 20
M. E., et al., Nurse’s mg/vial, 1 vial, with - Proton Pump
Pocket Guide, pages albumin, IV Inhibitor
376 - 379 14. Esomeprazole
40 mg/vial, 1 vial,
IV, OD
 CHAPTER 3
IMPLEMENTATION

A. DRUG STUDY
Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Meropenem is a synthetic Hypersensitivity to CNS: seizures, headache.

Meropenem Carbapanem carbapenem β-lactam antibiotic meropenem, other 1) Monitor periodically liver and kidney function,
Antibiotic that exerts its bactericidal carbapenems. History of CV: phlebitis, thrombophlebitis, especially seizures in older adults and those with renal
Brand Name Indication activity by inhibiting bacterial cell anaphylactic reaction to peripheral vascular disorder. insufficiency.
wall synthesis in gm+ve and gm- β-lactams (e.g. 2) Determine history of hypersensitivity reactions to
Merrem Complicated skin & ve bacteria through binding to penicillins, other beta-lactams, cephalosporins, penicillins, or
several penicillin-binding cephalosporins). EENT: oral candiasis, glossitis. other drugs.
skin structure
infections proteins (PBPs). 3) Discontinue drug and immediately report S&S of
GI: clostridium difficile- hypersensitivity.
Frequency, Dose and Route associated diarrhea, constipation, 4) Report S&S of superinfection or
diarrhea, glossitis, nausea, pseudomembranous colitis.
1g/vial, IV, q8 vomiting

GU: RBCs in urine

Hematologic: anemia

Resp.: apnea, pneumonia

Skin: injection-site inflammation,

pruritis, rash

Other: anaphylaxis, sepsis,

hypersensitivity reactions,
inflammation, pain.
Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Suppresses gastric acid Contraindicated with CNS: Headache, vertigo, 1) Assess for hypersensitivity to any proton pump
Esomeprazole Proton Pump Inhibitor secretion by specific inhibition of hypersensitivity to Dizziness, insomnia,apathy, inhibitor or hepatic impairment.
the hydrogen potassium ATPase omeprazole, anxiety, paresthesias, dream 2) Obtain baseline liver function tests and monitor
Brand Name Indication enzyme system at the secretory esomeprazole, or other abnormalities Respiratory: URI periodically during the course of therapy.
surface of the gastric parietal proton pump inhibitors. symptoms Sinusitis Cough, 3) Instruct patient to take drug at least 1 hr before
- Short-term treatment cells; blocks the final step of the Use cautiously with epistaxis Dermatologic: Rash, meals.
S-Omipin for erosive acid production. hepatic dysfunction, inflammation Urticaria, pruritus 4) Monitor for severe headache, worsening of
esophagitis pregnancy, and lactation. symptoms, fever, chills, darkening of the skin,
 - Treatment of GERD Frequency, Dose and Route Alopecia, dry skin changes in color of urine or stool.
5) For GI symptoms such as nausea and vomiting,
GI: Diarrhea, nausea,abdominal instruct patient to have small, frequent meals.
40 mg/vial IV, OD
pain,vomiting, constipation, dry 6) Instruct patient to limit activities to those that do not
mouth, tongue atrophy,flatulence require alertness and precision as the drug may cause
vertigo and dizziness.
Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Conditions whereby CNS: reduced salivation and 1) Monitor electrolytes, ECG, liver and renal function
Sodium Electrolyte Sodium chloride is the major admin of sodium chloride lachrymation, fever, headache, studies.
Chloride extracellular cation. It is would be detrimental. Not dizziness, restlessness, irritability 2) Note LOC
important in electrolyte and fluid to be used to induce and weakness 3) Assess heart and lung sounds.
Brand Name Indication balance, osmotic pressure emesis. Sustained 4)Observe S&Sx of hypernatremia, flushed skin,
control and water distribution as release tablets: GI Hematologic: tachycardia, elevated temperature, rough dry tongue, and edema.
Rhea Sodium Fluid end electrolyte it restores sodium ions. It is disorders associated with hypertension 5) Monitor V/S and I&O.
Chloride replacement in used as a source of electrolytes strictures or diverticula. 6) Assess urine specific gravity and serum sodium
hyponatremia and water for hydration, levels.
treatment of metabolic acidosis, Other: hypernatremia, thirst
Prophylaxis of muscle priming solution in
cramps during routine haemodialysis and treatment of
haemodialysis hyperosmolar diabetes.

Frequency, Dose and Route

1g/tab, 1 tab, TID, NGT

Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Hypersensitivity to any In very rare cases it can cause: 1) Do not use essentiale in hypersentive or pt’s
Essentiale Hepatic protectors Works by improving the components of the drug. Abdominal pain, nausea, diarrhea allergic to any of the ingredients of the drug.
Forte synthesization of liver Newborns and and allergic reaction (skin rash). 2) Check the medication sheet and the doctor’s order
phospholipids, promotes cell prematurely born before medicating.
Brand Name Indication membrane regeneration, children. 3) Secure a copy of the client’s history to drug
Nutritional support in reactivates different enzyme interactions and allergies.
sanofi-aventis the management of systems and receptors, 4) Provide enough knowledge to the patient of what
damaged liver increases detoxification ability of drug he/she would be taking and what are the
(chronic disease, liver the liver and through that expected therapeutic and side effects.
cirrhosis, fatty liver mechanism normalizes liver 5) Monitor V/S after administration of medication and
and intoxication of function. observe for adverse reactions
hepatotoxic
substances). Frequency, Dose and Route
 300 mg/tab, 1 tab, NGT, BID

Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

It is osmotically equivalent to an Hypersensitivity to Mild reactions such as flush, x1) Monitor BP, pulse and respiration, and IV albumin
Albumin Plasma Volume equal volume of normal human albumin preparations or urticaria, fever, and nausea occur flow rate. Adjust flow rate as needed.
Expander plasma and will increase to any of the excipients. rarely. These reactions normally 2) Lad tests: Monitor dosage of albumin using plasma
circulating plasma volume by an disappear rapidly when the albumin (normal: 3.5-5 g/dL); total serum protein
Brand Name Indication amount approximately equal to infusion rate is slowed down or (normal: 6-8.4 g/dL); Hgb; Hct; and serum electrolytes.
the volume infused. It provides the infusion is stopped. Very 3) Observe closely for S&Sx of circulatory overload
colloidal oncotic pressure, which rarely, severe reactions such as and pulmonary edema. If S&Sx appear, slow infusion
Albunorm 25% Restoration & serves to mobilize fluid from shock may occur. In case of rate just sufficiently to keep vein open, and report
maintenance of extravascular tissues back into severe reactions, the infusion immediately to physician.
circulating blood vol the intravascular space should be stopped and an 4) Observe for bleeding points that did not bleed at
where vol deficiency Frequency, Dose and Route appropriate treatment should be lower BP with injuries or surgery and as BP rises.
has been initiated. 5) Monitor I&O ratio and pattern. Report changes of
12.5/50 ml 1 vial IV QID
demonstrated & use urinary output.
of a colloid is 6) Report chills, nausea, headache, or back pain to
appropriate. physician immediately.

Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities
Phenytoin stabilizes neuronal Patients w/ severe CNS: headache, tremor, 1) Continuously monitor vital signs and symptoms
Phenytoin Anticonvulsant membranes and decreases damage to the blood cells dizziness, insomnia, transient during and after administration of drugs for an hour
seizure activity by increasing and bone marrow, grade nervousness. afterward.
efflux or decreasing influx of Na II and III AV block or GI disturbances: nausea, 2) Observe patient closely for neurologic adverse
ions across cell membranes in Stokes-Adams syndrome, vomiting, constipation, gum effects
the motor cortex during sick sinus syndrome, tenderness and hyperplasia, 3) Reduce dosage, discontinue phenytoin, or
generation of nerve impulses. sinus bradycardia, sino- acne, hirsutism, coarsening of the substitute other antiepileptic medication gradually;
atrial block; w/in the first 3 facial features. abrupt discontinuation may precipitate status
mth after MI and in case epilepticus.
of cardiac output failure Phenytoin toxicity manifestation: 4) Monitor hepatic function periodically during long-
(LVEF <35%). Cerebellar syndrome, vestibular term therapy; monitor blood counts and urinalysis
Concomitant use w/ and ocular effects, nystagmus, monthly.
delavirdine. diplopia, slurred speech, ataxia, 5) Maintain good oral hygiene to prevent gum disease
mental confusion, dyskinesia, 6) Use caution and monitor for early signs of toxicity;
Brand Name Indication
seizure frequency exacerbation, phenytoin is metabolized in the liver.
 hyperglycaemia.
Dilantin Epilepsy, Seizures
associated w/
neurosurgery Frequency, Dose and Route

100 mg/cap, 1 cap, TID, NGT

Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

A derivative of choline and History of hypersensitivity Shock, hypersensitivity, 1) Monitor blood pressure, pulse and heart rate.
Citicoline Neurotropic cytidine involved in the to citicoline sodium or to hypotension, insomnia, 2) Assess allergic reaction like GI disturbances.
biosynthesis of lecithin. It is any of the ingredients of excitement. 3) Only give prescribed dose.
Brand Name Indication claimed to increase blood flow Citicoline. 4) Advise relative to consult the physician if any
and O2 consumption in the problems occur to the patient during medication.
brain. In addition, 5) WOF hypotensive effects.
Zynapse Cerebrovascular Citicoline should not be 6) The supplement should not be taken in the late
disorders, Head Frequency, Dose and Route used if you have the afternoon or at night because it can cause difficulty
injury, Parkinsonism following conditions: sleeping.
• Patients with 7) Citicoline therapy should be started within 24 hours
1 gram/ tab, 1 tab, BID, NGT Hypertonic of the of a stroke. The physician will prescribe the correct
parasympathetic dosage and the length of time it should be taken for a
medical condition.

Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Clopidogrel Antiplatelet Agents; Inhibits platelet aggregation by - Hypersensitivity to CNS: Depression, Dizziness, 1) Assess pt for symptoms of stroke, peripheral
Platelet Aggregation irreversibly inhibiting the binding platelet aggregation Fatigue,Headache. vascular disease, or MI periodically
Inhibitors of ATP of platelet receptors. inhibitors. EENT: Epistaxis. 2) Monitor pt. for signs of thrombotic thrombocytic
Brand Name Indication Therapeutically, it decreases the - Pathologic bleeding Resp: Cough, Dyspnea. purpura
occurrence of atherosclerotic (peptic ulcer, intracranial CV: Chest Pain, Edema, 3) If dose is missed, administer as soon as possible
events in patients at risk. hemorrhage) Hypertension. unless almost time for next dose, do not do double
Prophylaxis of
- Lactation GI: GI Bleeding, Abdominal Pain, doses.
Plavix thromboembolic Frequency, Dose and Route
 disorders 75 mg/tab, 1 tab, OD, NGT Diarrhea, Dyspepsia, Gastritis. 4) Note for the ff after administration of medication:
Use Cautiously in: Derm: Pruritus, Purpura, Rash. fever, chills, unusual bleeding or if bruising occurs.
Acute coronary - Patients at risk for Hemat:
syndrome bleeding (trauma, Bleeding, Neutropenia,
surgery, or other Thrombotic Thrombocytopenic
pathologic conditions) Purpura.
- History of GI Metabolism:
bleeding/ulcer disease. Hypercholesterolemia.
- Severe hepatic
impairment

Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Lactulose Laxative Lactulose promotes peristalsis Galactosaemia, GI Abdominal discomfort (e.g. 1) Assess for history of allergy to lactulose, low-
by producing an osmotic effect obstruction, digestive flatulence, cramps), nausea and galactose diet, diabetes, pregnancy, and lactation.
Brand Name Indication in the colon w/ resultant perforation or risk of vomiting. 2) Do not freeze laxative form. Extremely dark or
distention. In hepatic digestive perforation. cloudy syrup may be unsafe; do not use.
encephalopathy, it reduces Patient on low galactose 3) Give laxative syrup orally with water to increase
Lilac Constipation
absorption of ammonium ions diet. Galactosaemia, GI palatability.
and toxic nitrogenous obstruction, digestive 4) Monitor for adverse drug effects. Report diarrhea,
compounds, resulting in reduced perforation or risk of severe belching, abdominal fullness.
blood ammonia concentrations. digestive perforation. 5) Do not administer other laxatives while using
Frequency, Dose and Route Patient on low galactose lactulose.
diet. 6) Monitor serum ammonia levels.
30cc syrup OD HS, NGT
7) Not that bowel movements will be increased 2-3
days.

Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Furosemide Anti-hypertensive; Inhibits sodium and chloride Contraindicated in CNS: vertigo, headache, 1) Monitor fluid I&O and electrolyte, BUN, and CO2
Loop diuretic reabsorption at the proximal and patients hypersensitive to dizziness, paresthesia, levels frequently.
distal tubules and the ascending drug and those with weakness, restlessness, fever. 2) Watch for signs of hypokalemia, such as muscle
loop of Henle. anuria CV: orthostatic hypotension, weakness and cramps.
Brand Name Indication thrombophlebitis w/ I.V. 3) Monitor glucose level in diabetic patients.
Caution: Use cautiously administration. 4) Drug may not be well absorbed orally in patients w/
Lasix Acute pulmonary
 edema; Frequency, Dose and Route in patients w/ hepatic GI: abdominal discomfort and severe heart failure.
Edema; 20 mg/vial, 1 vial, with albumin, cirrhosis and in those pain, diarrhea, anorexia, nausea, 5) Make position changes slowly because high doses
Hypertension IV allergic to sulfonamides. vomiting, constipation, of antihypertensive drugs taken concurrently may
pancreatitis. produce episodes of dizziness or imbalance.
GU: azotemia, nocturia, polyuria, 7) Avoid replacing fluid losses with large amounts of
frequent urination, oliguria. water.
Hematologic: agra-nulocytosis, 8) Observe older adults closely during period of brisk
aplastic anemia, leukopenia, diuresis. Sudden alteration in fluid and electrolyte
thrombocytopenia anemia. balance may precipitate significant adverse reactions.
Musculoskeletal: muscle spasm. Report symptoms to physician.
Skin: S-J syndrome
Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Levetiracetam Anticonvulsants The exact mechanism of Contraindicated in CNS: asthenia, headache, 1) Assess pt’s mental status.
anticonvulsant effect is patients hypersensitive to somnolence, amnesia, anxiety, 2) Assess duration, location and characteristics of
unknown. May act by inhibiting drug. ataxia, depression, dizziness, seizure activity.
simultaneous neuronal firing that emotional lability, hostility, 3) Confirm medication from doctor’s orders.
leads to seizure activity. Caution: Use cautiously nervousness, paresthesia, pain, 4) Monitor for changes in phenytoin blood levels with
in patients with history of vertigo. coadministered drugs.
psychiatric symptoms, EENT: diplopia, pharyngitis, 5) Monitor patients closely for such adverse reactions
Brand Name Indication especially psychotic rhinitis, sunisitis. dizziness, which may lead to falls.
symptoms and behavior. GI: anorexia. 6) Seizures can occur if drug is stopped abruptly.
Hematologic: leukopenia, Tapering is recommended.
Keppra XR Adjunct in seizures neutropenia.
Frequency, Dose and Route Respiratory: cough
Monotherapy for Other: Infection.
partial seizures with 500 mg/tab, 1 tab, BID, NG
or without secondary
generalisation

Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Contraindicated to CNS: anxiety, fatigue, headache, 1) Assess patient’s fever or pain: typeof pain, location,
Paracetamol Analgesic; Exhibits analgesic action by patients with insomnia, pyrexia. intensity, duration, temperature, and diaphoresis.
Antipyretic peripheral blockage of pain hypersensitivity,
impulse generation. It produces intolerance to tartrazine CV: hypertension, hypotension, 2) Assess allergic reactions: rash, urticaria; if these
antipyresis by inhibiting the (yellow dye #5), alcohol, peripheral edema, periorbital occur, drug may have to be discontinued.
Brand Name Indication hypothalamic heat-regulating table sugar, saccharin edema, tachycardia (I.V.).
centre. Its weak anti- 3) Teach patient to recognize signs of chronic
inflammatory activity is related to Contraindicated with overdose: bleeding, bruising, malaise, fever, sore
inhibition of prostaglandin allergy to acetaminophen GI: nausea, diarrhea, vomiting, throat.
Biogesic Mild to moderate pain abdominal pain, diarrhea,
and fever synthesis in the CNS.
Frequency, Dose and Route 4) Notify physician for pain/ fever lasting for more than
 constipation (I.V.). 3 days
500 mg/tab, 1 tab, q4, NGT PRN
fever Hematologic: hemolytic anemia,
leukopenia, neutropenia,
pancytopenia, anemia (I.V.).

Hepatic: jaundice

Metabolic: hypoglycemia,
hypokalemia, hypervolemia,
hypermagnesemia,
hypophosphatemia (I.V.)

Muscu: muscle spasms, extremity

pain (I.V.)

Drug Name Classification Mechanism of Action Contraindication Adverse Effects Nursing Responsibilities

Anorectal Emollient/Skin Promotes would Contraindicated w/ Skin:rash; hives; 1) Cleanse the affected
Ointment protectives granulation and re- allergy to itching; red, swollen, area with mild soap and
epithiliazation. calmoseptine blistered, or peeling warm water and rinse
skin with or without thoroughly.Gently dry by
CNS: fever; patting or blotting with to
Respiratory: before applying ointment
wheezing; tightness in 2) Monitor for adverse
the chest or throat;
Brand reactions.
Indication trouble breathing,
Name 3) Discontinue if site
swallowing, or talking;
unusual hoarseness; worsens or does not
Calmoseptine Protects, or swelling of the improve or if bleeding
Ointment soothes & mouth, face, lips, occurs
helps promote tongue, or throat.
healing in Frequency, Dose and
Route
those w/
impaired skin BID, apply on sacral
integrity area
related to: Bed
Sores
 B. NURSING MANAGEMENT
 Monitor Input and Output (q1)
 Monitor Vital Signs (q1)
 CBG Monitoring (TID)
 Tracheal Care
 Suctioning (EndoTracheal) (PRN)
 NGT Feeding (1200 kcal in 6 equal feeding) (q4)
 Check the level of consciousness of the patient
 Asses for the Neuroassessment of the patient
 Check if there is any presence of bleeding
 Maintain present mechanical ventilator setting decrease the FiO2 to 40%
 Apply Calmoseptin on the the sacral ulcer (BID)
 Check for the IV Fluid and keep vein open
 Assess the patient’s neurologic status; observe for CVA progression and level of
consciousness (LOC) change as evidenced by decreasing numerical score on the
GLASGOW COMA SCALE.
 Begin bedside range-of-motion exercise to preserve mobility and prevent deformities

C. Treatment
 IVF PNSS 1L x KVO – IV Fluid Therapy is used to maintain homeostasis when
enteral intake is insufficient and to replace any additional losses, these losses may
occur from the GI tract or Urinary Tract may be caused by blood loss.
Indication:
Fluid & Electrolyte replenishment
Hydration
Nursing Responsibilities:
 Check for any signs of phlebitis
 Condition of the catheter
 Check and regulate the drop rate
 Change IVF bottle if needed
 Check for any sign of infiltration

 Blood Transfusion (Transfuse 2 units Packed RBC)-Are done to replace blood lost
during surgery or due to a serious injury. A transfusion also may be done if your
body can't make blood properly because of an illness.
Indication:
Increase Circulating Blood Volume
Nursing Responsibilities:
 Check for any Septic Reaction (Rapid onset of chills, vomiting, high fever)
 Remain at bedside for 10-15 minutes
 Use needle gauge 18-19 to allow easy flow of blood
 Check for any Allergic Reaction (Flushing, Pruritus, Rashes)

 Mechanical Ventilation (Maintain present mech vent setting decrease FiO2 to 40%)
– It helps patients breathe by assisting the inhalation of oxygen into the lungs and
the exhalation of carbon dioxide. And it can also help support and control of
breathing.
Indication:
Ability to maintain airway patency
Helps in oxygenation
Use of Hyperventilation
Nursing Responsibilities:
 Suction if needed
 Prevent from infection
 Manage the airway of the mech vent
 Monitor for any complication

 Suctioning (EndoTracheal) before NGT feeding and PRN –It is used to maintain a
clear airway and optimise respiratory function and It is carried out when a patient
with an artificial airway such as a endotracheal tube cannot cough and void
pulmonary secretions.

Indication:
Clears secretion
Maintains airways patency
Nursing Responsibilities
 Remove any clothing covering the tracheostomy tube
 Check the patency of the inner cannula
 Check the tube position to ensure patent airway
 Re assess clients oxygenation
 Place the patient in a sims position in the drainage o secretion in the mouth.

D. DIET
 Nasogastric Tube Feeding –It is a special tube that carries food and medicine to
the stomach through the nose. It can be used for all feedings or for giving a person
extra calories.
 Low Fat and High Fiber Diet – It’s the one that restricts saturated fat and
cholesterol while high fiber diet promotes regularity with a softer, bulkier and regular
stool pattern and slows the absorption of blood sugar and so helps regulate the
sugar in the blood.

E. ACTIVITY AND EXERCISE

 Passive Range of Motion -involves someone else moving a joint for you. It helps in
improving your circulation and Exercising the joint helps to keep them limber, which
reduces pain caused by stiffness. Individuals who cannot move on their own or do
not have the strength to do so may benefit from passive range of motion exercise
that prevents contractures.
 Encourage to rest with head slightly elevated to maintain airway patency.

F. CLIENT’S DAILY PROGRESS CHART

Date Diagnostic Diet Activity Medication Treatment
July  Serum Glutamic –  NGT start  Vital  Meropenem 1g IV  Decrease
6, Pyuvic Transaminase/ 1200 kcal in signs q1 q8 FiO2 to
2018 Alanin 6 equal  Input and  Vancomycin 1g IV 50%
Aminotransferase feeding q4 Output OD  PNSS IV
(SGPT/ALT)  1400 kcal in q1  S. Omipin 40mg IV 8ml/g
 Prothrombin Time Test 6 equal OD  Decrease
(PTT) feedings (1:1  NaCl 1 tab IVF to
 Total Protein dilution) TID/NGT KVO
 Blood Urea Nitrogen  Essential Forte 1  PNSS 1L
(BUN) tab TID x KVO
 Chest X-ray  Albumin Infusion
 Random Blood Sugar 25% BID
 Lactate Dehydrogenase
(LDH)
July  Urinalysis  Increase of  Decrease  Furosemide 20mg  FiO2 at
7,  Serum Glutamic- feeding to CBG TID post albumin 50%
2018 Oxaloacetic 1500kcal/da monitorin infusion (2nd cycle)
Transaminase/Aspartat y with equal g to TID  Citicholine 1g tab
e Aminotransferase feeding (1:1)  Apply BID
Test (SGOT/AST)  Add 6 egg Calmose  Phenytoin 100g
 2D echo whites in ptin on TID
 Place 20 EEG OF/day the  Clopidogrel
sacral 75mg/tab 1 tab OD
ulcer  Start Lactulose
twice a 30cc OD if BM ≥
day 2x/day
 Continue  Start low dose
Na Dopamine drip
connectio @4mcg 1mg/min
n double
concentration
 Discontinue
Vancomycin
 Decrease Albumin
Infusion OD
 Echocardiogram (ECG)  For  Increase Dopamine  Shift to
July  Gram Stain for Bacteria repeat drip to 6mcg/kg/min SIMV
8,  Stain for Acid Fast electrolyt to run for 11cc/hr  Maintain
2018 Bacilli e @ 1pm  Increase Dopamine present
 Follow up cultures  Please drip to 7mcg/kg/min mechvent
(Urine, Blood, Sputum) facilitate (14cc/hr) setting
 Facilitate 2D echo with EEG and  Levetriracetam decrease
Doppler continue 500g tab BID FiO2 to
 For repeat CBC, meds  Phenytoin 100g tab 40%
Electrolyte today @  For TID  Transfuse
1pm standard  Follow up 2 units
and Lactulose 30cc Packed
contact RBC
precautio
n

July  Complete Blood Count  Paracetamol

9, (CBC) 500mg 1 tab q4
2018  Blood typing PRN for fever
 Electrolyte
Determination (Na, K,
Cl)
July  For repeat 12 LED ECG  Please give  For
10, Dulcolax 1 dose repeat 12
2018 LED ECG

 PNSS
KVO
250cc D5
Water

CHAPTER 4
EVALUATION
A. NARRATIVE EVALUATION OF NURSING PROBLEMS
 All of the identified goals were partially achieved. The first nursing problem is
Ineffective Cerebral Tissue Perfusion related to interruption of blood flow as
evidenced by GCS 3 which is managed with the help of medications and
interventions. The patient partially achieved the goal of primary care giver to
verbalize the patient’s condition and therapy regimen and the patient’s O2 saturation
is 97% which is within normal range. The patient partially achieved the goal upon
trans-out to maintain maximum cerebral tissue perfusion, as evidenced by Glasgow
Coma Scale of 12, warm and dry skin, vitals within normal range and ability to
swallow, mentally alert and oriented, and normal motor and sensory function
The second nursing problem is Excess Fluid Volume related to renal insufficiency
as evidenced by pitting edema both upper and lower extremities and high BUN of
10.27mmol/L which is managed with the use of interventions. The patient partially
achieved the goal of the patient will have a decrease size edema from grade 2 to 1 on
the upper extremities and from grade 3 to grade 2 lower extremities. The patient
partially achieved the goal of the patient to have a balanced Intake and Output, and free
of signs of edema.

.
B. DISCHARGE PLANNING INSTRCUTIONS

MEDICATIONS
 Paracetamol (Biogesic)500 mg/tab, 1 tab, every 4 hours, through NGT as needed
for mild to moderate pain and fever.
 Levetiracetam 500 mg/tab, 1tab, twice a day through NGT for monotherapy for
partial seizures with or without secondary generalisation.
 Lactulose 30cc syrup once a day at bedtime through NGT for constipation.
 Phenytoin 100 mg/cap, 1 cap, three times a day through NGTfor Epilepsy, Seizures
associated with neurosurgery.
 Clopidogrel 75 mg/tab, 1 tab, once a day through NGT for acute coronary
syndrome.
 Citicoline 1 gram/ tab, 1 tab, twice a day through NGT for cerebrovascular
disorders.
 Essentiale Forte 300 mg/tab, 1 tab, twice a day through NGT for nutriotional
supplement.
 Sodium Chloride 1g/tab, 1 tab, three times a day through NGTfor prophylaxis of
muscle cramps during routine haemodialysis.

EXERCISE
 The client was advised to have Passive Range of Motion to avoid strenuous
exercise. It helps in improving the circulation and exercising the joint, helps to keep
them limber, which reduces pain caused by stiffness, such as stretching both arms
and legs to prevent injury and muscle strain are fit to his physical activities are highly
recommended while adjusting back to his normal lifestyle. Individuals who cannot
move on their own or do not have the strength to do so may benefit from passive
range of motion exercise that prevents contractures.
 The client is advised to rest in a moderate high back rest to help maximize lung
expansion and to avoid risk for aspiration when feeding via NGT.

TREATMENT
 IV fluids such as Plain Normal Saline Solution (PNSS) will not be used after
discharge.

HEALTH TEACHINGS
 Instruct the relatives to wash hands thoroughly before starting your feeding.
 Before feeding begins, check to see that the stomach is empty.
 Insert the tip of an empty syringe into the end of the NG tube.
 Pull back to withdraw the contents of the stomach.
 Don’t begin the feeding if more than 100 ml remains from the previous feeding.
 Fill the feeding bag with the prescribed amount of formula and run the fluid to the
end of the tube. Clamp the tube.
 Connect the end of the feeding bag tubing to the NG port.
 Open the clamp and allow the formula to flow into the NG tube.
 Then allow the prescribed amount of water to flow in.
 After each feeding, rinse the bag and tubing. Every 24 hours, wash with soapy
water. Rinse thoroughly.
 The patient was also taught ROM exercise to be used when exercising muscles.
 Change positions every 2 hours, for example, if you have been lying on back for a
while, turn to side. If unable to switch positions on your own, ask a family member or
caregiver to help.
 Instruct the relatives to keep skin clean and dry,the cleaner and drier your skin is,
the less likely it will develop bed sores. Dip a wash cloth in a bucket of warm water
and mild soap and clean your skin with it. Then, pat your skin dry with a towel. If you
rub too hard, it can lead to skin irritation.
 Use pillows, another effective way to prevent bed sores is to put pillows between
parts of your body that press against each other such as under the tailbone,
shoulders, heels and elbows. If lying on the side, it is better to put the pillow between
knees and ankles.
 Avoidance of smoking and strenuous exercises to prevent shortness of breath or
weakened.
 Proper oral hygiene to prevent bacteria spread past the mouth that may cause
respiratory diseases.
 Maintenance of proper hygiene
 Instruct the patient to do deep breathing exercise.

DIET
 The client was advised to have Nasogastric Tube Feeding1500 kilocalories per day
in 6 esqually feeding.