PATIENT’S NAME: Morillo, Feddie CHIEF COMPLAINT’S: RLQ pain,

Vomiting and fever

AGE: 36 y.o. DIAGNOSIS: Systemic viral infection, R/o
amoebiasis R/o UGB
ROOM: MMW- station 2 ATTENDING PHYSICIAN: Dr. Diosana

GENARAL OBJECTIVES: To recognize the physiologic responses of the body to disease conditions
DATA NURSIN PATHOTHYSIOL SPECIFIC INTERVENTION RATIONALE EVALUATIO REFERENCE
DIAGNOSIS OGY OBJECTIVES N
SUBJECTIVE Infection After 4 days INDEPENDENT After 4 days Nurses Pocket
related to of duty I will of nursing guide 2010
The patient presence of be able to: • Asses • Provide interventio
verbalizes systemic contributing baseline n, duty NCP 11th
“ga sakit microorganis 1. Reduce factor and data, and goals are edition
ang akon ms infection. vital signs. data’s met as
kilid sa to’o 2. Elimina needed for evidence Drug
kag gina te fever. further care by: handbook
hilanat ko”. 3. Patient will • Stress and
demonstrat proper hand managemen Patient Medical
OBJECTIVE e washing to t. demonstrat surgical
Vital signs techniques, the patient. es changes nursing 7th
T-37.9 ‘C and • Maintain • To avoid in lifestyle edition
P- 79 bpm lifestyle sterile cross and clean
R- 24 cpm habits to technique in contaminati technique
BP-110/90 reduce the invasive on. like
mmHg cross procedure cleaning his
contaminati such as IV • Prevent utensils
WBC-4.7 x on. insertion. further before
109 /L 4.Promote • Perform TSB damage to eating.
safe and when temp the patient.
clean rises. Patient do
environmen hand
t. • To reduce washing
• Instruct
5.Patient will fever/ lower properly
patient to
verbalize temperatur and
clean
about his e. correctly
understandi environment • To provide after using
ng properly, safer and the CR.
regarding environment clean
his health al sanitation. environment Patient
status • Provide . verbalizes
related to health causes of
his teaching to infection
infection. the patient and ways to
regarding • Patient may prevent it.
the causes able to
of infection, understand
risk factors, where, how
complication he acquires
s and infection
preventive and how to
techniques. prevent it.

DEPENDENT

Administer
medication as
prescribed:

Paracetamol
500 mg PO Q4
RTC Treatment for
pain and
Ampicillin 500 fever.
mg IVTT Anst
Q6 Use to teat
bacterial
infection
 LABORATORY RESULT
DATA NORMAL VALUES LABORATORY RESULT IMPLICATION NURSING
CONSIDERATION
HBsAg Negative Positive Patient is positive to Refer to the physician
hepatitis B
Instruct patient to take
the antibiotics properly
as prescribed.

Instruct patient to
increase fluid, vit. C,
exercise and proper
diet to facilitate good
immune system.
Hgb 136-163 g/L 136
Hct .40-.48 .41 Normal Instruct patient to
RBC 4.0-5.0 x 1012 / L 5.0 Normal maintain the normal
Normal level.
Instruct patient to eat
WBC 5.0-10.0 x 109 /L 4.0 foods rich in iron.
Infection
Refer to the physician
Instruct patient to
increase fluid, vit. C,
Creatinine 62-125 umol/L 109 umol/L exercise and proper
Na+ 135-148 mmol/L 136.8 mmol/L Normal diet to facilitate good
K+ 4.0-5.3 mmol/L 4.0 mmol/L Normal immune system.
 STOOL Normal Instruct patient to
Color maintain normal level
Consistency by proper diet,
Brown Brown exercise, and rest.
Soft Soft Normal
-no ova or parasite Normal
found
Instruct patient to
facilitate normal level
by eating proper diet,
proper exercises, good
rest, and clean
preparation of foods.

DISCHARGE PLAN
PROBLEM HEALTH TEACHING LEVEL RATIONALE
 DRUG STUDY
GENERIC AME, CLASSIFICATI INDICATION MECHANISM ADVERSE NURSING PATIENT REFERENCE
BRAND NAME, ON OF ACTION EFFECT CONSIDERATI TEACHING
DOSAGE, ON
ROUTE &
TIMING
paracetamol Antipyretic Fever Reduces fever Headache, Asses patient Tell patient
(no brand Analgesic Pain by acting hepatic if he have any not to use if Drug
name) directly to the toxicity, chest allergy to this he has no handbook
500 mg hypothalamic pain, dyspnea drug. fever. 2005
PO heat
Q4 RTC regulating Advice
center to patient that
cause this drug is
vasodilation only for short
and sweat, term use
w/c help because it
dissipate can damage
Anti ulcer Heartburn heat. the liver.
ranitidine drugs Vertigo, Assess
hydrochloride malaise, patient for
(brand name headache, abdominal
not available blurred pain. Note Instruct
in patients Competitively vision, presence of patient to
chart) inhibits action jaundice. blood in take without
50 g of histamine emesis, stool, regard to
IVTT on the H2 at or gastric meals
Q8 receptor sites aspirate. because
of parietal absorption
cells, isn't affected
decreasing by food.
gastric acid
secretion. Urge patient
to avoid
cigarette
smoking
because this
may increase
gastric acid
secretion and
Bacterial worsen
Penicillin infection disease.
ampicillin
sodium Advise
(brand name Lethargy, Asses patient patient to
not available thrombophleb for the allergy report
in patients itis, nausea of this drug. abdominal
chart) and vomiting, pain and
500 mg Inhibits cell diarrhea, blood in stool
IVTT Anst wall synthesis abdominal or emesis.
Q6 during pain,
bacterial nephropathy.
multiplication
. Inform
patient to
notify
prescriber if
rash, fever, or
chills develop.
Tell patient to
take entire
quantity of
drug exactly
as prescribed.