II.

NURSING ASSESSMENT

A. Personal History

1. Demographic data

Johnny (not his real name) is a single 19 year old naturally born
Filipino and currently studying at UST, Manila taking a course of _______.
Johnny was born last May 11 1991 via Natural Spontaneous delivery in a
hospital at Angeles City. He is a Roman Catholic and presently residing at
77- 76 Verbena Street Don Bosco, Mabalacat Pampanga. Johnny stays at a
dormitory in Manila; he usually goes home in Pampanga every weekend
to bond with his family. Johnny lives with his parents, Mommy Yumi (51
years old) and Daddy Andrew (56 years old), together with his two elder
sisters, Jenny (31 years old) and Shirley (22 years old). Shirley and Jenny
are also born via natural spontaneous delivery. Johnny was admitted at
AUFMC last Aug 25 at around 7: 22 pm due to his chief complaint of body
ache, and on and off fever for 3 days.

Johnny belongs to a nuclear family since he lives with his parents

together with his two sisters. Daddy Andrew and Mommy Yumi were both
college graduates. His father, Daddy Andrew, already retired in his work
he gets a monthly pension of P 15, 000. While Mommy Yumi works as an
Assistant Manager in Clark Development Corporation earning P 50, 000
per month. When it comes to decision making, both parents help each
other especially when it comes to decisions about health care and
budgeting. According to Johnny, there is no dominant member to take
charge on every decision. Their parents make sure to talk about every
matter together and solve their problems together as well. Jenny and
Shirley were both working as a call center agent earning P 10 000 per
month. The family has a total monthly income of P 85, 000. According to
 them their income is more than enough for their expenses. Their total
expenses per month reach P 40- 50, 000 which includes: electric and
water bill, LPG, food, allowance of Johnny etc. The family is considered
not poor since every member of the family receives P 17, 000 per month.

According to Johnny, their dormitory in Manila is not that clean, there

are presence of empty cans and bottles around, and full of garbage outside.
There is also presence of open canal outside their dormitory. Their bathroom
has presence of mosquitoes because it was dirty. Johnny’s cousin who also
lives in that dormitory got dengue fever recently and was admitted in a
hospital in Manila. Meanwhile, their house their house here in Pampanga is a
concrete type of house, which has four rooms and two bathroom (with toilet
flush). Garbage collection is done everyday. There is no presence of empty
cans or bottles in their house. According to Mommy Yumi, she always makes
sure to clean their house everyday. However there is still some presence of
insects and rodents, like flies, mosquitoes, cockroaches in their house which
predisposes the family in acquiring diseases. The family uses a mechanical
means (insect spray) of killing these rodents; their source of water is from
the Mabalacat water services, the sources of their drinking water are the
nearby water stations selling mineral water, to ensure the potability of their
drinking water.

Johnny wakes up everyday at around 5 am in the morning. Sometimes

he tends to forgot to eat breakfast due to lack of time preparing for
school. He goes to school at 7 am until 4 in the afternoon. He always
makes sure to take a bath before and after going to school. Johnny always
sleeps at around 10: 30 – 11: 00 in the evening.

Johnny’s family was affiliated to Roman Catholic. They go to church

every Sunday, Johnny said that he always pray at night to thank God for
the blessings that he received. Johnny said that he loves to eat vegetables
like carrots, ampalaya, cabbage, tomatoes etc, and fruits like apple,
oranges and banana. He also loves to eat junk foods and soft drinks. He
seldom drinks water but every night he drinks milk before going to sleep.
Johnny says that he is not smoking but he drinks alcohol occasionally.
Johnny’s usual hobbies during available time are playing basketball,
surfing the internet, watching movies etc.

Their family believes in Hilots and albularyos. They also make use of
some herbal medicines like oregano for cough and colds, Lagundi for
cough, and guava leaves for treating wounds. When one member of a
family is sick, they first buy over the counter drugs. But when the disease
is not relieved, they will bring the patient to the nearest clinic or hospital.
 B. Family Health Illness History

Grandfather
Grandmother Grandmother
(72)-deceased due Grandfather
to heart attack and (68)
kidney disease

Auntie Daddy
Mommy Auntie
1 Andrew
Yumi 2
-HPN, HyperK,
HPN Ulcer

John Jenny
ny Bronchitis, Shirl
PNA
-DF ey
Family Health Illness History

According to Johnny, they don’t have any information about their

grandparents in their Fathers’s side, they also don’t know if they are still
alive. With regards to their grandparents on Mother side, Johnny’s
grandfather died at the age of 72 due to heart attack and kidney disease, he
was diagnosed of having kidney disease when he was 55 years old, they
believe that eating fatty foods, smoking and drinking alcohol are the reasons
why their Grandfather develops a heart disease. Meanwhile their
grandmother was still alive, she don’t have any history of any disease since
she practice a healthy lifestyle.

Johnny’s father is also presently admitted in AUFMC due to

Hypertension and Hyperkalemia. Daddy Andrew (56 years old) has a history
of Ulcer since he was 25 years old. He will feel abdominal pain when he did
not eat any food. This is the 3rd time that Daddy Andrew was hospitalized due
to hypertension. He starts smoking when he was just teenager, he also
frequently drinks alcohol but he stops when he was 45 years old. Mommy
Yumi (51 years old) also has a history of hypertension; she acquired this
when she was just 40 years old. Mommy Yumi is not smoking or drinking but
she loves to eat fatty foods.

Johnny sister, Shirley, was never been hospitalized and she don’t have
any history of serious illness. She had chickenpox when she was 16 years
old. Meanwhile Jenny was hospitalized twice due to Bronchitis and
Pneumonia. She said that she’s not smoking and drinking alcohol. She got
chickenpox when she was only 1 year old.
History of Past Illness

Johnny got chickenpox when he was first year high school (16 years
old), however he did not got mumps or measles since he was born. Johnny
has an allergy to some foods like eggs, chicken, shrimps, etc. He said that he
will manifest itchiness, redness and swelling in his skin when he eat some of
this foods.

Johnny was first hospitalized when he was 5 years old; his diagnosis is
T/C Dengue Fever. He manifested high fever however his platelet count is
just normal and his condition is just stable. Johnny was hospitalized for the
second time when he was 2nd year high school due to a fracture in his left
knee, he undergo a procedure called Open Reduction Internal Fixation. He
got his fracture when he was playing basketball with his friends and he fell to
the ground with his left knee.

Johnny says that he seldom got fever, or cough and colds. But when he
got any of those, he will buy some over the counter drugs like Paracetamol
but when it is not relieved that is the time that he will go to a clinic.

This is the third time that he was hospitalized; he has a chief complaint
of body ache, and on and off fever. His final diagnosis was Dengue Fever.
F. Diagnostic and Laboratory Procedures
 Date
Diagnostic/ Analysis/Interpre
ordered/ Indication or Normal
Laboratory Results tation
Date results purpose Values
Procedure
in

1st: It is a basic
Complete
Date Ordered: screening and is
Blood
Aug 25, 2010 one of the most
Count frequently ordered
laboratory
Date
procedures. It
Performed:
helps in the
Aug. 25,
management of
2010 disease that
originated in other
Date Result: body system.
Aug. 25, Generally includes
2010 absolute numbers
or percentages of
erythrocytes,
leukocytes,
platelets,
hemoglobin, and
hematocrit in the
blood sample.

Hemoglobin
Major cellular It measures the 164 140 - 175 g/L The patient’s

element of the amount of hemoglobin level is

circulating hemoglobin within the normal

 Date
Diagnostic/ Analysis/Interpre
ordered/ Indication or Normal
Laboratory Results tation
Date results purpose Values
Procedure
in

1st: It is a basic
Complete
Date Ordered: screening and is
Blood
Aug 25, 2010 one of the most
Count frequently ordered
laboratory
Date
procedures. It
Performed:
helps in the
Aug. 25,
management of
2010 disease that
originated in other
Date Result: body system.
Aug. 26, Generally includes
2010 absolute numbers
or percentages of

2nd: erythrocytes,
leukocytes,
Date Ordered:
platelets,
Aug 26, 2010
hemoglobin, and
hematocrit in the
Date
blood sample.
Performed:
Aug. 26,
2010

Date Result:
Aug 26 2010
Hemoglobin
 Date
Diagnostic/ Analysis/Interpre
ordered/ Indication or Normal
Laboratory Results tation
Date results purpose Values
Procedure
in

1st: It is a basic
Complete
Date Ordered: screening and is
Blood
Aug 26, 2010 one of the most
Count frequently ordered
laboratory
Date
procedures. It
Performed:
helps in the
Aug. 26,
management of
2010 disease that
originated in other
Date Result: body system.
Aug. 27, Generally includes
2010 absolute numbers
or percentages of

2nd: erythrocytes,
leukocytes,
Date Ordered:
platelets,
Aug 27, 2010
hemoglobin, and
hematocrit in the
 Date blood sample.
Performed:
Aug. 27,
2010

Date Result:
Aug 27 2010
Hemoglobin
Major cellular It measures the !st: 158 g/L 1st: 140 – 175 The patient’s

element of the amount of g/L hemoglobin levels

circulating hemoglobin on both results are

present in a within the normal
blood and
deciliter of whole range, The patient is
transport
blood. Hemoglobin not dehydrated or
oxygen as its
level correlates anemic. It could
principal
closely with the suggest that there is
function. red blood cell
2 : 158 g/L
nd
2 : 140 – 175
nd
enough number of
count and affects g/L circulating hemoglobin,
the hemoglobin-to- thus no deprivation of
red blood cell ratio oxygen supply to the
(mean corpuscular different body organs.
hemoglobin [MCH] The patient did not
and mean manifest bleeding.
corpuscular
 hemoglobin
concentration
[MCHC]). It is used
to measure the
severity of anemia
or polycythemia
and to monitor the
patient’s response
to therapy as well
as to measures the
oxygen – carrying
capacity of the
blood.

Hematocri Ist: 0.45 gm/L 1st: 0.41 – The patients

t It measures 0.50 gm/L hematocrit level is
Measures percentage or
within the normal
percentage by concentration of
range indicating
volume of packed red blood
that patient has no
packed red cells in a whole
presence of
blood cells blood sample or
blood volume.
dehydration,
(RBC) in a whole
Hematocrit polycythemia or
blood sample.
 indicates the anemia. The
proportion of cells patient has pink
and fluids in the 2nd: 0.46 2nd: 0.41 – palpebral
blood. It is useful
gm/L 0.50 gm/L conjunctiva and
in evaluating
moist lips
dehydration and
hypovolemia..

Leukocyte 1st: 1.33 g/L 1st: 4.50 – 11 The patients has

Part of a Blood component X 10 g/L decreased level of
complete blood that
WBC indicating
that indicates reports the
viral infection and
the number of possible presence
inflammatory
WBCs in a micro and severity of
response. The
liter of whole infection or
inflammatory
patient had a
blood
response. It is the temperature of
absolute numbers 37.2 C in the
of white blood cell morning, however
circulating in the it increase to 38.1
cubic millimeter of 2nd: 1.43 g/L 2nd: 4.50 – 11 C in the afternoon.
blood. It acts as a X 10 g/L
defense against
microorganism
 through
phagocytosis and
produces or
transport and
distributes
antibodies to help
maintain
immunity.
Its purpose was to
determine
infection of
inflammation.

Neutrophils The primary

function of 1st: 0.60 g/L 1st: 0.18 – The patient has
neutrophil is 0.70 g/L normal levels of
phagocytosis(killi Neutrophils. The
ng and digestion rashes of the
of patient decreased.
microorganisms).
Acute bacterial
infections and
 trauma
stimulates
neutrophil
resulting in
increased WBC
count.
2nd: 0.30g/L 2nd: 0.18 –
0.70 g/L
Lymphocytes The primary
function of
lymphocytes is 1st: 0.29 g/L 1st: 0.10 -0.48 The patients
fighting chronic g/L lymphocytes is
bacterial infection
and acute viral within the normal
infections . It
indicates the range on the first
amount of result indicating a
lymphocytes
participating with good immune
macrophages at a
site of local injury.
system .
Used to assess &
monitor genetic
and acquired While on the
immunodeficiency
second result the
status.
level increases due
to viral infection
2nd: 0.56 g/L 2nd: 0.10 – which is dengue
 0.48 g/L Fever.

Monocytes Are usually the

largest of the
WBCs (12-20 µm) 1 : 0.05 g/L 1st: 0.00 – The patients
st

and are often 0.04 g/L monocytes is

referred to as
scavenger cells slightly high
(phagocytes). They
can ingest indicating infection
particles such as due to Dengue
cellular debris,
bacteria, or other fever. The patient
insoluble particles.
is febrile with
temperature of
38.1 C

2nd: 0.07 g/L 2nd: 0.0 – 0.04

g/L
Eosinophils Eosinophils are Ist : 0.06 Ist: 0.00 – 0. The patients
involved in Allergic eosinophils are both
reaction. Parasitic 03 g/L
above the normal
infections are also
range . The patient
capable of
stimulating the 2nd: 0.07 2nd: 0.00 – still manifest rashes
production of on trunk and arms
these cells. These 0.03 g/L however it was
cells are capable of lessened.
phagocytosis of
antigen – antibody
complexes. They
 do not respond to
bacterial or viral
infection.

Platelet It determines 1st: 110 1st: 150 – 400 The patient’s

Count ability of X 10 g/L platelet is both

Platelets are a patient’s blood to below the normal

type of blood limits, which implies

clot normally. It
cell. They play a problem intactness
is used to
key role in of clotting ability.
evaluate platelet
normal blood Patient is at risk for
production, to 2nd: 117 2nd: 150 – 400
clotting. During bleeding. The
assess the X 10 g/L platelet count
the clotting
effects of decreased due to a
process, platele
ts clump
chemotherapy or viral infection

together to plug radiation therapy (Dengue Fever)

small holes in on platelet

damaged blood production, to
vessels. The diagnose and
purpose of monitory severe
clotting is thrombocytosis
to stop
or
bleeding.
thrombocytopeni
a and to confirm
a visual estimate
of platelet
number and
morphology from
a stained blood
film.
 Date
Diagnostic/ Analysis/Interpre
ordered/ Indication or Normal
Laboratory Results tation
Date results purpose Values
Procedure
in

Date Ordered: It is a basic

Complete
Aug 27, 2010 screening and is
Blood
one of the most
Count frequently ordered
Date
laboratory
Performed:
procedures. It
Aug. 27,
helps in the
2010
management of
disease that
Date Result: originated in other
Aug. 28, body system.
2010 Generally includes
absolute numbers
or percentages of
erythrocytes,
leukocytes,
platelets,
hemoglobin, and
hematocrit in the
blood sample.

Hemoglobin
Major cellular It measures the 165 g/L 140 - 175 g/L 1st: The patients
element of the amount of hemoglobin levels
circulating hemoglobin is within the
 Nursing Responsibilities for Complete Blood Count

Prior:

• Check doctor’s order.

• Check the client’s name or Identification band.
• Explain to the client the purpose of the procedure.
• Inform the patient that the test requires a blood sample and who will
perform the venipuncture and when.
• Inform the patient how the procedure is performed, the equipment to
be used.
• Explain to the patient that she may feel some discomfort from the
needle puncture.
• Prepare the materials necessary for the test.
During:

• Maintain sterile technique.

• Tell the patient when to insert the needle for him to be prepared.
• Encourage the patient to remain calm during the test.
• Assist the patient if necessary.
• Ensure a sterile blood sample from the patient.
• Provide comfort to the patient.
• Do not leave the patient while the procedure is ongoing.
After:

• Handle the sample gently to prevent hemolysis. Apply direct pressure to the
venipuncture site until bleeding stops.
• Send the blood sample to the laboratory immediately.
• Proper documentation.
• Instruct patient that if hematoma results or develops at the venipuncture
site, apply warm compress.
 Document.
 Date
Diagnostic/ Analysis/Interpreta
ordered/ Indication or Normal
Laboratory Results tion
Date results purpose Values
Procedure
in
Date Ordered: Dengue viruses are
August 25 enveloped, single- Reactive Non reactive The result for
Dengue NS1 2010 stranded, positive- Dengue NS1 Antigen
Antigen sense RNA viruses Test for the patient
Test Date that, among other is Reactive
Performed: components, indicating he is
August 25 contain seven non- positive for Dengue
2010 structural proteins. Fever
One of them is
Date Result: known as NS1.
Aug 25 2010 Although its
specific role has not
been completely
elucidated, NS1
has been used as
a target in a kit
developed for the
diagnosis of
acute dengue
infection
 Nursing Responsibilities
Prior:

 Check the doctor’s orders.

 Explain to the patient that small amount of blood will be drawn from
him and that blood will be tested to measure if her blood cells are
within normal values and to detect some blood abnormalities such as
anemia, polycythemia or detect infections.
 Inform the client that there are no fluid restrictions or fasting.
 Inform the patient that he will experience mild pain at the site of
extraction during collection.
 Ensure that the patient understands the procedure.
 Prepare laboratory request and inform laboratory.
 Inform the client of the scheduled extraction.

During:

 Provide comfort measures to decrease the client’s anxiety.

 Place the client in a comfortable position.
 Maintain aseptic technique.
 Assist medical technologist if necessary.

After:

 Instruct patient to apply slight pressure at the site of extraction for a

few minutes.
 Place the patient in a comfortable position and leave his room quietly.
 Document the time and procedure done. Then, obtain results and
secure it in the patient’s chart. Refer
 Date
Diagnostic/ Analysis/Interpreta
ordered/ Indication or Normal
Laboratory Results tion
Date results purpose Values
Procedure
in
Color: yellow Color: yellow- The result is normal
Date ordered: amber which indicates that
the patient did not
Urinalysi August 25, - To screen
have any kidney
2007 patient’s urine for
s problem.
renal or urinary
Date of tract disease Sugar: Sugar:
results: - To help negative negative
This indicates that
August 25, detect metabolic
there is no presence of
2007 or systemic
sugar in the urine.
disease
unrelated to Appearance: Appearance:
renal disorders Clear Clear It indicates that there’s
no infection present in
the patients urine.
pH: 7.0 pH: 5.5 – 6.5

pH is within the
normal range
 inducating absence
of infection in the
Specific Specific urine.
Gravity: Gravity:
1.005 1.001 – 1.035 The patient is not
dehydrated and has
Albumin: no fluid overload .
Albumin: negative
negative The result is normal
which means patient
has no infection in
kidney.
Red Cells:
Red Cells: none
None There is no presence
of bleeding in the
Epithelial urine.
Epithelial cells : Rare
cells : Rare The result is normal
which means patient
has no infection in
Pus cells: none kidney.
Pus cells: 0-1
The result is normal
which means patient
has no infection in
kidney.
Nursing Responsibilities for Urinalysis:

Prior:

 Check the doctor’s order.

 Check the right client.

 Encourage the patient to increase fluid intake.

 Apply warm compress on hypogastric region.

During:

 Provide privacy.

 Allow adequate time to decrease discomfort, and anxiety,

 Tell the patient to assume a normal voiding position.

 Introduce stimuli for voiding.

 Pour warm water over the perineum.

 Collect a clean catch urine sample during midstream urination.

After:

 Ensure that the specimen label and laboratory requisition

form are filled out correctly.

 Securely attach the label to the container.

 Send the specimen to the laboratory at once.

 Document what you have done.

 Date Indications Analysis and
Laboratory Ordered Result Normal
or Interpretation of
Procedures Date Results s Values
Purposes Results
In

Sodium Date Ordered: It measures serum 138.10 135 - 150 The result is within
level of sodium in mmol/L the normal range.
August 26
relation to amount of The patient has
2010
water in the body. It normal acid base
Date evaluates fluid- balance and has no
performed: electrolyte and acid- neuromuscular,
base balance and renal and adrenal
August 26
related alterations.
2010
neuromuscular, renal
Date Result: and adrenal functions.

August 27,
2010

Potassium Date Ordered: It evaluates clinical 3.42 3.5 – 5.50 The result is within
signs of potassium below the normal
 August 26 excess or potassium mmol/L range. The patient
2010 depletion. It is used to has alteration acid
monitor renal base balance and
Date
function, acid-base has neuromuscular,
performed:
balance and glucose renal and adrenal
August 26 metabolism. It alterations. The
2010 evaluates patient manifested
neuromuscular and body weakness.
Date Result:
endocrine disorders
August 27, and detect the origin
2010 of arrhythmias.
Nursing Responsibilities (Serum Electrolytes)

Prior:

 Explain to the patient that the serum sodium test determines the
sodium content of the blood.
 Explain to the patient that the serum potassium test determines the
potassium content of the blood.
 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 feel slight discomfort from the
tourniquet and the needle puncture.
 Inform the patient that he need not restrict food and fluids.
 Notify the laboratory and physician of drugs the patient is taking that
may affect test results; they may need to be restricted.

During:

 Perform a venipuncture and collect the sample in a 3 to 4 ml clot-

activator tube.
 Handle the sample gently to prevent hemolysis.

After:

 Apply direct pressure to the venipuncture site until bleeding stops.

 Instruct the patient to resume any medications stopped before the
test.
 In the patient with increased sodium levels and loss of water, observe
for signs of thirst, restlessness, dry and sticky mucous membranes,
flushed skin, oliguria and diminished reflexes.
 Observe the patient with hypokalemia for weakness, malaise, nausea,
diarrhea, colicky pain, muscle irritability progressing to flaccid
 paralysis, oliguria and bradycardia. The ECG reveals flattened P waves,
prolonged PR interval, a wide QRS complex, tall, tented T waves and
ST segment depression. Cardiac arrest may occur without warning.
 If increased total body sodium causes water retention, observe for
hypertension, dyspnea, edema and heart failure.
 In the patient with decreased sodium levels, watch for apprehension,
lassitude, headache, decreased skin turgor, abdominal cramps and
tremors that may progress to seizures.
 Secure results.
V. THE PATIENT AND HER CARE

A. MEDICAL MANAGEMENT

a. IVF

Date ordered
Medical Client’s
management/ date Indication(s) or
General Description response to
performed Purposes
Treatment the treatment
date changed

Date ordered: D5LRS is a hypertonic

solution that have a
August 25, 2010 It is an efficient and The patient has
higher concentration of
effective method of No allergic
particles in solution
#1 – 4 D5LRS supplying fluids to response.
compared to plasma.
1L X 200 cc/ Date Performed: the body
The patient
hour Used to balance the
August 25, Hydration
concentration of fluid
2010 maintained as
and particles across fuil Use as a route in
evidenced by
compartments, fluid administration of
good skin turgor,
shifts out of the Intravenous medications.
Date Changed: and moist moist
intracellular space into
oral mucus
August 26, 2010 the extracellular space,
membrane. The
causing cellular
 shrinkage or patients body
dehydration. weakness was
relieved
Date ordered:
# 6- 8 D5LRS
1L X 150 cc/ August 26, 2010
hour

Date Performed:

August 26 - 28,
2010

D5NM is a hypertonic
solution that have a
#5 D5NM 1L X Date ordered: higher concentration of
It is an efficient and The patient has
effective method of No allergic
200 cc/ hour August 25, 2010 particles in solution
supplying fluids to response.
compared to plasma.
Date Performed: the body
The patient
Used to balance the
August 25, Hydration
concentration of fluid
2010 maintained as
and particles across fuil Use as a route in
evidenced by
compartments, fluid administration of
good skin turgor,
 Date Changed: shifts out of the Intravenous medications. and moist moist
intracellular space into oral mucus
August 26, 2010
the extracellular space, membrane. The
causing cellular patients body
shrinkage or weakness was
dehydration. relieved

#1 – 3 KCL Date ordered: To maintain Fluid and

electrolyte imbalance and
drip 30 meqs August 27, 2010 The patient has
for hypokalemia
+ 90cc PNSS No allergic

(soluset) to response.
Date Performed:
run for 8 hrs The patients
August 27 - 28, It is an efficient and body weakness
2010 effective method of was relieved
supplying fluids to
The patient
the body
Hydration
maintained as
evidenced by
Use as a route in
good skin turgor,
administration of and moist moist
Intravenous medications. oral mucus
membrane
NURSING RESPONSIBILITIES: FOR INTRAVENOUS FLUID (IVF)

Prior:

 Verify doctor’s order.

 Explain the procedure to SO.
 Obtain the necessary materials.
 Select a suitable vein for venipuncture.


During:

 Check IVF level.

 Check for patency of tubing.
 Check if IVF is infusing well.
 Practice aseptic technique.

After:

 Adjust the rate of fluids appropriate to needs of pt. as ordered.

 Monitor IV flow and pt.’s response.
 Monitor pt. for evidence of IV infiltration’s r/t complication such as pain,
swelling and tenderness.
 Check for presence of air in the tubing if there is, remove immediately.
 Record all procedure done
b. Drugs
 Route of General
Date Ordered Administratio Client
Name of the Action
n Response to
Drug; Generic Date Taken or
Functional Indications or the
Name Given Dosage and Classification Purposes Medication
Date Changed Frequency of with Actual
Brand Name Mechanism of
or Discontinue Administratio Side Effects
n Action

Date Ordered:
August 25,
Generic Name: 500 mg/tab General Action: For viral The client’s
2010 infections
Acetaminophen every 4 hours temperature
Antipyretic, with pain
PRN X fever and Fever decreased from
analgesic
38.5 C to 37.2
Date Taken or
Brand Name; Specific Action: C.
Given:
Paracetamol -Reduces fever The patient has
August 25 – 27,
by acting no allergic
2010
directly on the reactions to the
hypothalamic drug.
heat-regulating
Date Changed
center to cause
or Discontinued:
vasodilation
Not changed and sweating
which help
dissipate heat.
Nursing Responsibilities for Paracetamol

Prior:

 Perform proper hand washing.

 With long-term therapy, monitor CBC, liver and renal function studies.
 Check the patient’s identity
 Checks for the doctor’s order

• Get the temperature of the client.

• Assess fever; note presence of associated signs (diaphoresis, tachycardia, malaise).
• Make sure that the 10 rights are applied.

During:

• Check if your giving the right dosage.

• Check patient’s name by asking the complete name.
• Identify the patient expresses any doubt about the medication; always
recheck the order, drug label and dosage on the container.

After:

• Provide opportunities for rest.

• Maintain a quiet environment.
• Instruct client or significant others to increase fluid intake.

• Report paleness, weakness and heart beat skips; s/sx of hemolytic anemia.
• Report for any symptoms of abdominal pain, yellow discoloration of skin and
eyes, dark urine, itching or clay-colored stools because it may indicate
liver toxicity.
•
 Route of General
Date Ordered Administratio Client
Name of the Action
n Response to
Drug; Generic Date Taken or
Functional Indications or the
Name Given Dosage and Classification Purposes Medication
Date Changed Frequency of with Actual
Brand Name Mechanism of
or Discontinue Administratio Side Effects
n Action

Date Ordered:
August 25,
Generic Name: 40 mg IV OD General Action: Prevention The patient
2010 and
Pantoprazole complied to the
Proton Pump treatment of
Sodium gastro treatment
inhibitor, Anti-
duodenal regimen, he has
Date Taken or secretory drug
ulcers and no allergic
Given: stress ulcers
Brand Name; Specific Action: reactions
August 25 – 28, towards the
Pantoloc Supresses
2010 drug. He did not
gastric acid
manifest any
secretion by
signs of
specific
Date Changed duodenal or
inhibition of the
or Discontinued: stress ulcers
hydrogen
Not changed potassium
ATPase enzyme
system at the
secretory
surface of the
gastric parietal
cells; blocks the
final step of
Nursing Responsibilities for Pantoloc:

Prior:

 Perform proper hand washing.

 Assess patient routinely for epigastric or abdominal pain and frank or occult blood in the
stool, emesis, or gastric aspirate.
• Check contraindications
• Make sure that the 10 rights are applied.
• Check the patency of the IV tube.

During:

• Check if your giving the right dosage.

• Clean the IV insertion site for medications with a cotton ball with alcohol.
• Gradually inject the drug into the port.

After:

• Provide opportunities for rest.

• Maintain a quiet environment.
• Instruct client or significant others to increase fluid intake.
• Monitor side effects or reactions.
• Document all necessary information.
•
 Date Ordered Route of General Action
Name of the Client
Date Taken or Administration Functional Response to
Drug; Generic Indications or
Name Given Dosage and Classification the Medication
Purposes
Frequency of with Actual
Brand Name Date Changed Mechanism of
Administration Side Effects
or Discontinue Action

Generic Name: Date Ordered: .

Aug 26, 2010
10 mg/ tab now General Action: Symptomatic The patient’s
relief of perennial rashes was
Brand Name: Antihistamine and seasonal
allergic rhinitis, lessened. The
Date Taken or
Iterax vasomotor itchiness and
Given: rhinitis, allergic redness was
Specific Action: conjunctivitis and
Aug 26, 2010 relieved.
,mild
Potent specific uncomplicated
histamine (H1) urticaria

receptor
antagonist;
inhibits histamine
release and
eosinophil
chemotaxis
during
inflammation,
leading to
reduced swelling
and decrease
inflammatory
response, has
anti pruritic
effects.
Nursing Responsibilities for Iterax:

Prior:

 Document all necessary information.

 Perform proper hand washing.
 Checks for the doctor’s order
 Check the patient’s identity

During:

• Provide opportunities for rest.

• Maintain a quiet environment.
• Advise patient not to scratch the rashes
• Instruct client or significant others to increase fluid intake.

After:

 Document all necessary information.

 Monitor for adverse effects of the drug

 Date Ordered Route of General Action
Name of the Client
Date Taken or Administration Functional Response to
Drug; Generic Indications or
Name Given Dosage and Classification the Medication
Purposes
Frequency of with Actual
Brand Name Date Changed Mechanism of
Administration Side Effects
or Discontinue Action

Date Ordered: .
August 26, 2010
Generic Name: 10 mg / supp now General Action: Treatment of The patient’s
Constipation and abdominal pain
Bisacodyl Laxatives abdominal pain
was relieved. The
Date Taken or
Specific Action: patient defecated
Given:
on July 27 2010.
Brand Name: Increase the
August 26 2010 His stool was
osmotic pressure
Dulcolax formed, without
in the colon and
blood and soft.
slightly acidify
the colonic
contents,
resulting in an
increase in stool
water content,
stool softening,
laxative action.
Nursing Responsibilities for Dulcolax

Prior to:

 Check the written medication order for completeness. It should

include the drug name, dosage, frequency, and duration of the
therapy.
 Check to see if there are any special circumstances surrounding
administration of the dose to the patient.
 Be certain that you know the expected action, safe dosage range,
special instructions for administration and adverse effects associated
with drug orders.
 Prepare the necessary equipment.
 Wash your hands.
 Prepare the dosage as ordered.

During:

 Check patient’s name by asking the complete name.

 Identify the patient expresses any doubt about the medication; always
recheck the order, drug label and dosage on the container.

After:

 Document date and time

 Monitor adverse effect
C. Diet

Type of Date ordered

Indication (s) Specific Client’s
diet General
Date started food response and/ or
description Or Purpose (s) taken reaction to diet
Date changed

DAT (Diet as Date Ordered : The patient can eat He needs to eat food rich Banana, The patient
tolerated) foods rich in CHO, in CHO, CHON, Vitamin C, Rice, Milk, complied with the
August 25, Fish,
except dark CHON, Vitamin C, and adequate intake of diet regimen. The
2010 Apple,
Colored especially foods fluids to increase energy Orange patients energy
Foods rich in Iron (Fe) , and to prevent infection levels increased
and drink fluids as and for tissue repair for AEB decreased
Date Started:
tolerated. immediate healing and body malaise.
August 25, 2010
damaged cells. Dark color
The patients did
foods should be avoided
not manifest blood
since it can mask the
in the stool.
color of the stools.
Date Changed: Presence of blood in the
stool is checked in
Not changed
patients with dengue
Fever
Nursing Responsibilities (Diet)

Prior:

 Checks for the doctor’s order

 Check the patient’s identity

 Monitor the client and assess for signs of weakness.

 Explain to the patient the purpose of the dietary recommendation to
his current condition.

During:

 Be sure that the patient is taking or eating foods he can tolerate.

 Assess patient’s condition and how he responded on the foods he is
taking.
 Try to give fruits especially banana and vegetables.
 Stress the importance on complying with the diet.
 Monitor if the patient adapts or complies with the prescribed diet

After:

 Assess the health status of the patient.

 Compare previous health status from the present.
 Document all necessary information.
d. Activity / Exercise

Date ordered Date Client’s response and/or

Type of performed General Description Indication(s) or Purposes reaction to the
Exercise
Date changed activity/exercise

Complete
Bed Rest
Date Ordered: Patient is restricted to go To decrease oxygen The patient complied
out of bed or to perform any demand, provide with the physician's
August 25 2010
activity that could increase adequate energy order. He became less
workload of the heart. stores, and to prevent irritable and the body
injuries. weakness that he
Date Performed:
complains upon
August 25 – 28 2010 It is also indicated to admission was relieved.
Movement is permitted as hasten recovery and to
tolerated by the patient. prevent pain that
Adequate rest is encouraged aggravated by
Date Changed:
and activity according to the movement.
Not Changed patient’s tolerance is
allowed.

Promotes lung
expansion and
improves breathing.
The patient’s tolerated
well in the activity AEB
the patient’s continuous
recovery.
Nursing Responsibilities (Activity/ Exercise)

Prior to:

 Checks for the doctor’s order

 Check the patient’s identity
 Explain to the SO the need for the said activity/exercise.

During:

 Provide safety precaution

 Provide comfort measures
 Promote a quite environment conducive for rest.
 Provide adequate rest periods

After:

 Monitor the position/activity of the patient every 2 hours.

 Obtain initial assessment about the progress of the activity.
 Encourage verbalization of feelings about the activity.
 Assess for patient’s condition, how he responds to the activity.
 Document all necessary information.