c

cc
GENERIC NAME
c

 c
BRAND NAME Kalium Durule
CLASSIFICATION Potassium salt
SUGGESTED DOSE 

c
Adults: Initally, 20 mEq of Potassium Supplement P.O. Daily, in divided
doses. Adjust doses, as needed, based on potassium levels
ORDERED DOSE 1 tab TID
MODE OF ACTION Replaces potassium and maintains potassium level.
INDICATIONS ë Hypokalemia
ë acute MI
CONTRAINDICATIONS patients with cardiac disease and severe renal impairment
DRUG INTERACTION Increases effects:
ACE inhibitors, digoxin, potassium sparing diuretics
SIDE EFFECTS Paresthesia of limbs, flaccid paralysis, nausea, vomitting, abdominal
pain, hypotension
ADVERSE EFFECTS Arrythmias, hyperkalemia, respiratory paralysis, cardiac arrest
NURSING è Monitor VS
RESPONSIBILITIES
è Check potassium level after repeated doses.
è Inform patient of short-term need for drug and answer any
questions and address concerns
è Review potential adverse reactions and instruct patient to
promptly report any occurrences.
c
c
c
c
c

c  c
 c
c
On February 17, 2010, Wednesday, at the Gyne Ward, Bed 3 of Davao del Sur
Provincial Hospital at around 10:00 a.m., assessment is conducted to Ms. Amelita
Botod, Female, 44 years of age, single, to ascertain her level of health and physiologic
functioning. She was admitted due to preterm labor and was later given a final diagnosis
of _____ as G4P4 (2010). She is in the Taking-In Phase of the process of maternal role
adaptation.

c  
c c
c
She is received on bed, awake conscious and coherent with an IVF of D5LR
1000cc regulated at KVO rate, infusing well at her left metacarpal vein. She has an
endomorphic body built. Weight and height. She is wearing a big dark pink shirt and a
blue shorts, although her hair was not properly combed. She is able to stand and go to
the comfort room and walk; at this time, it was already 3 days after giving birth to her 4th
child. Upon talking to her, we observe that she is slouching while sitting. Body odor is
noted; however, s4igns of distress are not seen on her. She is not restless and not in
any respiratory distress. She answers back our query presentably; she is cooperative,
calm and smiles at times. She is able to explain her experience in giving birth in an
understandable and clear and audible voice.

c
cc
c
Vital Signs Actual value Normal Value
Temperature (Axilla) 36.8°C 35.6°C-36.7°C
Pulse Rate 83 bpm 70-80 bpm
Respiratory rate 19 cpm 16-20 cpm
Cardiac Rate 85 bpm PR is not greater than/ or
equal to AP
Blood Pressure 170/100 mmHg 110/70 mmHg-130/90 mmHg

cc

Upon inspection, blackheads are noted on the sides of the nose. Skin on the face
is oily. Color of skin is brownish and even in proportion. A small edema is seen on her
right arm due to previous IV insertion. Scars are noted on her lower extremities due to
previous lesions. Upon palpation, her skin is warm to touch. Skin on hands and feet are
both dry. Has a good skin turgor which when pinched back, the skin then springs back
to its previous state.

c c
c
Upon inspection, she has a normocephalic head. Dandruff and lice are not noted.
Hair is evenly distributed. Her facial features are symmetrical as evident when she
smiles. Edema or hollowness in her face is not observed. She is also able to perform all
facial movements such as raising and lowering her brows, closing her eyes tightly,
puffing the cheeks, smile and show teeth. Upon palpation, forehead is smooth and oily.
Hair is coarse and oily in texture. No nodules and hollow masses are palpated.

† Eyebrows and Eyes

Upon inspection, it is symmetrical and with equal movement. Eyelashes are

everted in position. Palpebral conjuntiva is pinkish in color and moist. No presence of
lesions and discharges are noted. Pupils are isocoric with a pupil size of 3mm which
has a brisk reaction to light. Both constricts at 2mm. When looking straight ahead, the
patient can see objects in the periphery and able to move her eyes in unison with
parallel alignment. She is also able to read at near and slightly far distance.

† Ears

Both the pinnae are symmetrical, aligned with the outer canthus of the eye, and
have the same skin tone with the facial skin upon inspection. Color of the ears is
brownish. No discharges are noted upon examining the ear canal with the use of the
penlight. She is able to hear normal voice tone on both ears. Upon palpation, ears are
firm and not tender.

† Nose

Upon inspection of the nose, the septum is located at the midline and nasal
flaring is not noted. The mucosa is pinkish in color upon examining with the use of
penlight. Presence of hair inside the mucosa is noted. Upon palpation, no tenderness is
noted on the frontal and maxillary sinuses.
† Mouth

Upon inspection of the mouth, lips are dark-red in color and slightly dry. No
inflammations are noted. Mucosa is pinkish and free from lesions. Gums are also pink in
color. She has an incomplete set of teeth for her age, her left upper premolar tooth is
missing and cavities were seen on her upper and lower second and third molars.
Tongue and uvula is at midline with no deviations. Tonsils are free from inflammation.

c c
c
It has a uniform color the same as the tone of her facial skin. No masses or
lesions are observed. No discomforts or uncoordinated movements are observed during
movement of the neck when asked. Submandibular, Submental, Superficial cervical
chain, Posterior cervical chain, deep cervical chain and Supraclavicular lymph nodes of
the neck are not palpable. c

c c

Both are noted to be engorged upon inspection. Color of the skin of the breast is
the same with the tone of the facial skin. Any presence of lesions, edema or hollowness
is not noted. Dimpling is not noted upon retraction. The areolas are large, round and
dark brown in color. Each nipple is located at the center of each areola; both are noted
to be round and everted. Her breast is warm to touch and moist with some wet milk
discharges, it was firm and no tenderness and masses were noted as verbalized by the
patient.

c ccc

c
Upon inspection, chest is seen as symmetrical, uniform in color and intact. She
has a respiration rate of 19 cycles per minute. Some papules are seen on the upper
portion of the chest. Skin on chest was warm to touch, moist and no tenderness or
hollow disproportions noted upon palpation. Symmetrical lung expansion was noted with
symmetrical tactile fremitus. Adventitious breath sounds were absent during
auscultation and breathing pattern was quiet, rhythmic and effortless during
respirations.

c c

Our patient has a cardiac rate of 85 beats per minute with regular heart sounds
of ³lub-dub´ heard upon auscultation. No presence of lifts and heaves are noted upon
palpation. Point of maximal impulse is felt at the 5th intercostal space at left
midclavicular line just below the breast.

 c!
 c
c c
Upon inspection, abdominal binder is noted to be dry and intact. Her incision site
is vertical in position, at the midline under the umbilicus as verbalized by our client.
Striae gravidarum is seen beneath the binder which has a slight deviation of color from
the abdominal skin tone. Palpation was not performed due to the presence of abdominal
binder.

c 
"c

c
c She is able to defecate and urinate freely. She is wearing a sanitary napkin with
lochia rubra present at minimal amount. No other lacerations or inflammations are noted
as what the patient has verbalized. Her buttocks are noted to be brown in color and
typically have the same skin tone in the back.

ccc#$  c

c c
The back is noted to be equal in color which is noted to be brownish upon
inspection. There are some papules noted on the upper portion of the back. Her
muscles are of equal size on both sides of the body. She demonstrated no signs of
contractures, fasciculation and tremors. The patient can move in a smooth coordinated
movement evident of a firm, not flaccid muscles in the upper and lower extremities. Her
bones and joints have no swelling and deformities, thus, able to move smoothly. Her
range of movement is limited due to complaint of abdominal pain in the incision site. Her
lower extremities are noted to have scars from previous lesions.

c 

cc
c
c She is able to recognize other persons such as her partner. She is aware of the
time and the place she is currently at, and distinguishes herself among the others. She
is responsive and able to answer questions related to her recent condition and about
the prescriptions the doctor made earlier in the day. She is also able to remember
remote memories when asked about her childhood days. She can maintain balance
while sitting in the interview conducted.

She has a Reactive Level Scale (RLS) and Glasgow Coma Scale (GCS) score of
1 and 15 respectively.
c
c%#&'c
Eye Opening ± Spontaneous: 4; Motor Response ± To verbal command: 6; Verbal
Response ± Oriented: 5

%c 
c
c(c

c  c )
c 


c   c
)
c
I Olfactory Sensory Smell When asked to
state what kind of
material she was
instructed to smell
on with her eyes
covered, she was
able to identify the
smell of soap
without any
difficulty.
II Optic Sensory Vision & visual She was asked t
fields read on the paper
with the word
³DIGOS´ on it at
approximately 14
inches away from
her. She was able to
read this clearly and
without any felt
difficulty.
III Oculomotor Motor Extraocular eye She was able to
movement move her eyes up,
down, and side to
side when she was
asked to do so.
IV Trochlear Motor Extraocular eye She was able to
movement move her eyes up,
down, and side to
side without any felt
difficulty or
uncoordinated eye
movement.
V Trigeminal Sensory and motor Sensation of skin in Her blinking
the face and cornea reflex is quite
responsive when
the penlight goes
near to her eyes.
VI Abducens Motor Extraocular eye Her eyes are
movement able to move from
up to down or vice
versa and from left
to right or vice versa
without any
uncoordinated
movement of the
eyes noted.
VII Facial Motor and Sensory Facial Expression She is able to
perform all facial
movements such as
closing the eyes
tightly, raising and
lowering brows,
puffing the cheeks
and smile. No
difficulty or
uncoordinated facial
 movements, or
depressions are
noted.
VIII Auditory Sensory Hearing and As the
equilibrium assessment was
going on, she was
not able to have any
difficulty in hearing
the spoken words
even at a one-meter
distance.
IX Motor and Sensory Swallowing and Swallowing is
Glossopharyngeal tongue movement visible when
drinking a glass of
water and move her
tongue side to side
and up and down
without any difficulty
felt.
X Vagus Motor and Sensory Swallowing Swallowing is
visible when
drinking a glass of
water. No difficulties
were felt by the
client.
XI Accessory Motor Head movement Able to perform
and shrugging of head flexion and
shoulders extension and
shoulder shrugging
completely even
with resistance.
XII Hypoglossal Motor Protrusion of the She is able to
tongue and tongue protrude her tongue
movement from an up to down
motion or even from
side to side without
any felt difficulties.
c
c
c


c
c
c Generally, the client was responsive and cooperative of the nurse¶s instructions
and concerns related to her current status. During her whole stay in the hospital, she
was not yet able to have a bath and her hygiene is not also that well maintained- which
must be badly needed to be focused on. Not only to avoid body odor but also to
prevent complications and infections to set in due to insufficient care towards cleansing
the body.

In her physiological state, her blood pressure is noted to be high. However, she
did not complain of any alterations or pain from other body parts, except for the
abdominal pain in the incision site, while the assessment is going on. Papules are
prominently noted on her upper chest and upper back. Scars were also noted on her
lower extremities which show signs of previous lesions. All other assessment done
showed normal results and it could imply that patient¶s health status is getting better.
She has a full range of motion. RLS/GCS score of 1/15 distinct of a generally alert
sensory-neural status with well-functioning cranial nerves.
c