Lab Study

PATTERNS OF
CLINICAL EXAMINATION
JANUARY 25, 2016
JANUARY 19, 2016
FUNCTIONING
OTHER SOURCES
JANUARY 26, 2016
N/A
1. RESPIRATORY
According
mother,
he
to
the
had
patients
history
of
difficulty of breathing associated
he was still 14 y/o due to his
by Dr. Josefina J. Goh-Cruz in
20
Patient has nasal cannula
as of now as told by his mother.

His mother remembered when
Marlow experienced common
No
use
of
accessory
oxygen saturation of 92 %
as well as dyspnea
Chest
expanding
is
inhalation and expiration
time and never reoccurred again
muscles during breathing
some prescribed medication yet
the drugs. This only happen one
to run at 2L/m with
symmetrically
Respiratory rate of 20
cpm
Brookes Point, PPC. He took
his mother forgot the name of
cpm
with chest pain last 2013, when
heart enlargement as diagnosed
Respiratory rate of
Irritable
during
during
Can
breathe
first
Chest
is
Chest
is
symmetrically
expanding
during
without
Bronchial
sounds
oxygen support
Respiratory rate of 23 cpm
Vesicular
heard
during
auscultation
expanding
symmetrically
during
assessment
No nasal discharge upon
Bronchial
assessment
sounds
Vesicular
heard
No dyspnea or orthopnea
noted upon assessment
No nasal secretions upon

assessment
during
auscultation
32
cough and colds, the patient

would
immediately
drink
Calamansi juice, approximately

4
Calamansi
Fruit
with
tablespoon of sugar in one glass

and he drinks it 3 times a day.
When he has a colds he took
OTC drug specifically 1 tab of
Neozep, 500mg every 8 hours.
No history of respiratory
illnesses such as; TB, Asthma,
Pneumonia, COPD and other
upper
or
lower
respiratory
diseases.
2. CIRCULATORY
Has history of heart enlargement
BP of 120/90mmHg
BP of 90/70mmHg
BP:90/70mmHg
Refer to Hematology
32
last 2013 when he was 14 y/o as
PR of 58 bpm, Full in
PR of
54 bpm, Full in
PR: 54 bpm, Full in
diagnosed by Dr. Josefina J.

Goh-Cruz. He was not admitted
but he was given medications
and advised to go home to rest.
According to his mother he did
he
stopped
consuming
taking
the
it
strength, measured from
the radius
the radius
the radius
capillary refill <4 secs
Nails are pale and no
Nails are pale and no
clubbing noted
clubbing noted
not experience it again after he

took prescribed medications yet
Pale conjunctiva
during
Capillary refill in <4 sec
Pallor Skin and warm to
prescribed
are
pale
with
capillary refill of <3 sec

and no clubbing noted
after
assessment
Nails
touch poor skin turgor
Pinkish
conjunctiva
during assessment
noted
medicine
The patient has no history of
fainting,
palpitation,
seizures
and convulsion
3. FOOD
AND
FLUID
INTAKE
Patients eat 3 a day usually
January 19,2016
Diet: NPO
Patient is on NGT feeding
Patient is on NGT feeding
IVF of PNSS 1L x 12 hours
32
consumed 3-4 cups of rice every
(1,200
Total IVF intake of 638
meal especially when their viand

was ginataang labong with
ml
susu as stated by his mother.

He approximately consumes 2L
of water per day
No food allergy. Doesnt take
any alcohol beverages. Drinking
1 cup of coffee once a day every
kcal/day
(1,200
kcal/day
6 @ 21 gtts/min
Received at the level of 450
feedings) of Milk
feedings) of Milk
ml
ml
Absence of Gag reflex as
Absence of Gag reflex as
ml @7:00am
Change bottle @ 12:00 noon
PNSS 1L x 12 hours @ 21
gtts/min
noted
noted
Mannitol 50 cc IV every 6
hours
morning during breakfast.

January 25,2016
IVF of D5W 500ml x 4 hours
@ 30 gtts/min received at the
Level of 500ml @ 7:00 am
Change bottle @ 11:00am
D5W 500ml x 4 hours @ 30
gtts/min
32
Mannitol 50 cc IV every 6
hours
January 26,2016
IVF of D5W 500ml x 4 hours
@ 30 gtts/min received at the
level of 340ml @ 7:00am
Change bottle @ 10:30am
D5W 500ml x 4 hours @ 30
gtts/min
N/A
4. ELIMINATION
According to the mother she is
Has IFC inserted during
not sure if how many times did
assessment with an output
the patient defecate but she
of 450 ml amber in color
of 750ml amber in color
of 340ml yellowish in color
notice he goes to comfort room

to defecate once a day every
time he was on their home.
No bowel movement
Has IFC noted during Has
No bowel movement
IFC
noted
during
Did not defecate for 9 days

No vomiting noted during
32
He took Loperamide capsule

usually
500
mg
as
assessment
his
medication every time he had

diarrhea as stated by his mother
His mother is not sure if how
many times did the patient void
yet she estimated that Marlow
voids 3-4 times a day when their
at home
N/A
5. REGULATORY
MECHANISM
Marlow
seldom
experience
Has temperature of 36.8
Has Axilla temperature of
Has Axilla temperature of
C taken at axilla
35.6 C
35 C
Intact skin with good skin
Has stage II pressure ulcer
turgor of >2 sec
on lumbar area fresh Boil
Has stage II pressure ulcer
mark noted on the same
no open wounds noted
mother mixed sambong and
Cold clammy skin
lagundi for him to drink after
Pale conjunctiva
fever, but when he does, his
eating
and
before
bed
for
on lumbar area fresh Boil
therapeutic management as said
mark noted on the same
by his mother
location
location
Pale conjunctiva
32
He takes a bath when he feels
Perspiration noted during
that his fever is not severe and

assessment
can be relieved by doing so.

Marlow
completed
his
childhood
history
of
immunization.
No
convulsions
and
Pale conjunctiva
syncope.
N/A
6. HYGIENE
Marlow takes a bath every day.
Unkempt in appearance
No allergies in any shampoo and
Short greasy hair
soap. Using clear shampoo and

safeguard.
Changes clothes once a day and
brush his teeth once a day

usually
at
morning
after
Halitosis and foul body
Well-groomed
and
Well-groomed
and
dressed appropriately to
dressed appropriately
his age
to his age
Short shiny hair
Short shiny hair
Halitosis noted
Halitosis noted
Short clean nails
Short clean nails
odor noted
Long dirty nails
breakfast.
N/A
7. ACTIVITY
AND
32
EXERCISE
Every weekend he help his
father in doing work such as
plowing and planting in the
farm.
He plays basketball with his
Patient sleeps all the time
during the first assessment

unable to sit and stand
Unable to sit and stand

independently
Continue
turning
schedules
Patient received Passive
Change position every 2

Rom exercises
hours
friends every afternoon.
to
prevent
progression of pressure
ulcer
N/A
8. REST AND SLEEP
He sleeps usually at 9:00 in the
Patient appears drowsy
Patient is lethargic upon
Remains lethargic during
evening and rise at 7:00 in

morning. Refers to side lying
and prone position; uses two
during the shift

Requires more vigorous
assessment
Sleeps
frequently
assessment
but
Sleeps
frequently
but
pillows and mosquito net during
stimulation to awake and
awakens to spoken word
awakens to spoken word
sleep
He naps about 2 hours after
stays awake for a few
and gentle shake
and gentle shake
minutes at a time only
Appears calm
lunch or after working on farm
32
9. COMMUNICATION
N/A
AND SPECIAL
Patient
SENSES
uses ilonggo
and
Patient was Stuporous;
tagalog for communication.
responds
unintelligibly
No visual, Auditory and speech
and awakens briefly only
disturbances according to his
to
mother.
Patient is right handed.
stimulation
repeated
Altered
hearing
vigorous
Unable to speak clear and

understandable word
Uses
moaning
signs
to
communicate
ability
(requires repetitive words

to respond)
Aphasia
Patient
was
able
to
respond rapidly on painful
Difficulty on hearing that

requires
Vision: follow six cardinal
repetitive
questions and instruction

usually 3-4 times for him
to respond
Vision: Unable to respond
Patient was not able to
to 6 cardinal signs of gaze
respond rapidly on painful
stimulus
less
than
second (a single pinch on

all extremities.)
Hearing: hear sounds on
both ears within 4 feet
stimulus (a single pinch

on the Left and Right
32
Brachial, Left and Right

Legs) for about 3 seconds.
10. COGNITION
AND
PERCEPTION
Loss of consciousness for 6 days
after vehicular accident.
No history of convulsion,
Patient
was
Stuporous
during assessment
epilepsy and fainting
Sometimes
he
look
GCS score of 9
having
difficulty
in
comprehending
CT-Scan
GCS score of 11
having
Report
(January
12,2016)
in Impression:
Soft tissue swelling:
difficulty
Left
comprehending
restless and irritable after
instructions and questions
temporal area
instructions and questions Mucosal Swelling:
awakens
GCS score of 6
that had been ask to him
that had been ask to him
Right
Nasal Cavity
N/A
11. PAIN AND
DISCOMFORT
Patient complaint body pain and
tiredness after helping on farm
and also after school
His mother gave him back
Irritable
whenever
mother wakes him up
his
Patient
experienced
Experienced
muscle
muscle cramps on his
cramps
on
lower extremities usually
extremities
2-3 times in a day that is
during the shift that is
1-2
lower
times
32
massage and advised him to
relieved by massage
relieved by massage
Moaning and crying noted
sleep early so he could rest
with facial grimace rated

as 9/10 in pain scale
N/A
12. RECREATION
AND
DIVERTION
Marlow
likes
watching
TV
during at home, he also played
Sleeps frequently during

the shift

the shift

the shift
basketball together with his
When awake, he just look
When awake, he just look
friend after school or after
around and sleep again.
around and sleep again.
working in the farm.

N/A
13. RELIGIOUS LIFE
Patient is a Pentecostal. He
seldom go to church every
No religious medal worn
N/A
N/A
during assessment
Sunday.
14. COPING
32
MECHANISM
N/A
N/A
N/A
N/A
According to his mother Marlow

sings every time he has problem.
15. ROLES AND
N/A
RELATIONSHIP
According to his parents he is
Patient
is
irritable
He rely to his mother
industrious, jolly and reliable
whenever his mother talks
whenever
son and he has many friends

His mother stated that his son is
to him
uncomfortable
previous
representative
high
in
school
Supreme
he
feel
He rely to his mother

whenever
he
feel
uncomfortable
Patient was cooperative

during assessment
Student Government at their

school.
Precipitating Factors
Age (17 y.o)
Gender (male)
32
Predisposing Factors
Riding a motorcycle
Road intersection
Rough road
Unaware of incoming vehicle
Vehicular Accident
Direct head impact
Brain collide at high velocity with

the bony skull
Cortical injury occurs in the left

temporal lobe
Stretched or injured neuronal

axon
Acute traumatic damage to the brain
32
Blood extend bidirectionally to

white matter, subdural and
subarachnoid spaces
Influx of calcium
into axons
Efflux of
potassium into the
extracellular space
Brain
Herniation
Subdural
Hematoma
Increase ICP
Release of excessive
glutamate level in
extracellular spaces
The Na+/K+ ATP-dependent

pump overworks to restore
ionic balance
Left untreated
Death
excitotoxic cascade
Causing the cells to increase
permeability
Energy depletion
Oxidative dysfunction:
Hypotonia
Muscle weakness
32
Large amount of sodium

entered the cell
accompanied by an inrush
of water
Increase Na level:
148.7 mmol/ L (Jan. 16, 2016)
158.8 mmol/ L (Jan. 20, 2016)
165.5 mmol/ L (Jan.22, 2016)
Swelling on left temporal area
Swelling squeezes the

neighboring blood vessels
Axonal dysfunction
32
Impaired functional communication

within left temporal lobe and other
body parts
Decreased blood
circulation
Insufficient supply of oxygen

and glucose
Oxygen saturation: 92%
Altered hearing ability

Agitation
Irritability
Childish behavior
Receptive/ sensory aphasia.
Decreased ability to
comprehend language
LEGEND:
Precipitating factors
Predisposing factors
Signs and symptoms
Disease/complications seen in patient
Pathophysiologic process
PALAWAN STATE UNIVERSITY

College Of Nursing and Health Sciences
32
Puerto Princesa City
CT- Scan Report

Patients Name: Marlow
Examination: Head cranial
Age: 17 years old
Ward: Surgical Ward

Date: January 12, 2016
Attending Physician: Dr. Del Rio
History: Vehicular accident; loss of consciousness

Multiple tomographic axial scans of the cranium demonstrated:
-Thickened soft tissue over the left temporal area.
-The interhemispheric fissure is centered along the midline. The cerebrum and cerebellum showed normal cortical sulcation.
-The ventricles are of normal sizes and are symmetrical. There are no signs of increased intracranial pressure.
-there is normal development of the white matter and cortex with normal attenuations of the periventricular white matter.
-Gray-white matter differentiation is maintained.
-The basal ganglia, internal capsule, corpus luteum, thalamus, sella and pituitary appear normal. Parasellar structures are unremarkable.
-The brain stem and cerebellum also appear normal. There are no abnormalities in the cerebellopontine angle areas on both sides.
-Osseous structures appear intact. Sutures are not unusually widened.
-The paranasal sinuses and mastoid air cells are normally developed, clear and pneumatized.
32
-The orbits and intraorbital structures are unremarkable.

-Thickened mucosa in the right nasal cavity.
IMPRESSION: SOFT TISSUE SWELLING: LEFT TEMPORAL AREA
MUCOSAL SWELLING: RIGHT NASAL CAVITY
No other significant or unusual findings were seen

32

DATE
EXAMINATION
January 12,
2016
Age: 17 years old

RESULT
Ward: Surgical Ward

NORMAL VALUES
INTERPRETATION
WBC
15.9 x 109/L
5.0 -10.0 x 109 /L
HGB
121 g/L
135-180 g/L
HCT
34 %
40-54%
PLATELET
178 109/L
150-450 x 109/L
SIGNIFICANCE
The result is above normal range. This

indicates that the patient have increase
fighting defense of the body due to the
patients
current
condition
and
underlying causes. It indicates that there
is some kind of infection or
inflammation inside the body.
The result is below normal range, this
indicates that the supply of oxygen in
the blood is insufficient therefore the
organs and tissues inside the body
received deficient oxygen supply.
Producing antibodies
to
develop
immunity against infections. It defends
the body against bacteria, parasites,
viruses and tumors.
Below normal. A low hematocrit means

the percentage of red blood cell is below
the normal limits. Another term for low
hematocrit is anemia.
Normal platelet count indicates that it is
able to protect intact blood vessels from
damage and initiate repair through the
formation of platelet plugs when blood
The hematocrit measure the percentage

of RBCs in the blood plasma.
Hemoglobin are main intracellular

protein of erythrocytes. It carries
oxygen and remove carbon dioxide.
Needed for normal blood clotting;

initiating clotting cascade by clinging
to turn area; helps to control blood loss
32
vessel walls are damaged.
NEUTROPHILS
80 %
50-70%
Above normal. There is a presence of Phagocytes in the blood. These are the
pathogenic microbes and it indicates bodys first line of defense against
infection traps and kills it.
infection and bacteria.
LYMPHOCYTES
18 %
25-40%
Below normal. Below normal. It

indicates
that
the
patient
is
immunocompromised and wasnt able to
fight the possible presence of microbes
or infection in the blood.
Responsible for immune response

against microbial invasion. They are
also responsible for fighting tumors
and viruses and inactivation of B cells.

32

Age: 17 years old
EXAMINATION
Electrolytes
Sodium
RESULT
REFERENCE VALUE
INTERPRETATION
SIGNIFICANCE
148.7 mmol/ L
135-148 mmol/ L
Theres an increase sodium

level in the body that indicates
muscle malfunction.
3.46 mmol/ L
3.5-5.3 mmol/ L
Below normal potassium level

indicates decre ase muscle
function.
Helps maintain fluid balance

and works on nerve impulse
transmission. Too much or too
little sodium in the blood can
cause muscle malfunction.
and works on nerve and
muscle function. If potassium
level is too low may result to
muscular
weakness,
and
fatigue.
Potassium
Ward: Surgical Ward


32
LABORATORY STUDY
Name of Patient: Marlow
Diagnosis: Cerebral Contusion
DATE
January 17,
2016
Sex: Male
Age: 17 years old

Attending Physician: Dr. Lazo
URINALYSIS
Color
RESULT
Yellow
NORMAL VALUES
Straw to dark yellow
Transparency
Slightly hazy
clear
CHEMICAL EXAM
Glucose
negative
negative
pH
6.0
5.0-7.5
INTERPRETATION
A dark brown or tea-colored urine may
indicate liver disorder or a side effect
of certain medicine. The bile excretion
in the urine may give the dark color.
SIGNIFICANCE
Color of urine is affected by eating
certain food or the presence of bile or
blood in the urine. To determine if the
urochrome, a pigment that result from
the bodys destruction of hemoglobin
still in its normal state.
Cloudiness may be caused by excessive To determine if there is more solutes in
cellular material.
the urine resulting to deepest yellow
color.
Theres no presence of sugar/glucose in To determine presence of sugar in the

the urine of the patient
urine. When too much glucose is found
in the urine, the most common culprit is
diabetes.
The result is within the normal range of The pH is governed by the H ions
Ph. This means his pH is not too acidic concentration of the urine. Disorders
or alkaline.
such as diabetes mellitus, dehydration,
diarrhea, emphysema and starvation
make the urine acidic. Chronic renal
32
Specific gravity
The result is within the normal values.

The urine is diluted and normally
concentrated.
failure, renal tubular acidosis, UTI

salreylate poisoning cause the urine to
be alkaline.
Urea and uric acid have the greatest
influence on specific gravity of urine.
The specific gravity increases with
conditions that increase the loss of
fluids from the body. Decreases in the
specific gravity result from renal
disease.
1.015
1.010-1.030
Puss cells
0.2 /hpf
0-5 /hpf
The result is negative which indicates To determine if there is infection in the

no presence of pus and infection in the urine.
urine.
RBC
2-4 /hpf
0-6 /hpf
The result is normal which indicates no To determine if there is bleeding in the

presence of bleeding in the urinary urinary tract that is due to trauma,
tract.
kidney stones and infection.
A Urates
none
None
It means that there are no presence of Urates should not be seen at the urine.
urates in the urine and it indicates that Presence of urates at the urine indicates
the patients has no gout or other gout.
autoimmune disease.
MICROSCOPIC
EXAM
32

32

Age/ Sex: 17 years old / male
Examination Requested: THORACIC CAGE
Ward: Surgical
Attending Physician: Dr. Nayal
RADIOGRAPHIC REPORT
The bones of the thoracic cage are intact and normal in density texture and modeling
No evidence of fracture, dislocation
Joint spaces are within normal limits
CONCLUSION:
NORMAL BONE OF THE THORACIC CAGE

32

EXAMINATION
Glucose
Creatinine
Electrolytes
Sodium
Potassium
Age: 17 years old
Ward: Surgical Ward

RESULT
REFERENCE VALUE
INTERPRETATION
SIGNIFICANCE
81.2 umol/ L
79-132 umol/ L
The kidney normally filter

creatinine out of the blood and
send them out of the body
through urine.
Creatinine
levels
help
determine how well your
kidneys
function.
When
creatinine levels increase, your
kidney function may be
impaired.
158.8 mmol/ L
135-148 mmol/ L

muscle malfunction.
4.22 mmol/ L
3.5-5.3 mmol/ L

transmission. Deficiency may
result to muscle cramps and
reduced appetite while if
excess could result to high
blood pressure.
There is normal potassium Helps maintain fluid balance
level electrolyte which is and works on nerve and
essential to proper muscle and muscle function. If potassium
32
nerve function.

muscular
weakness,
and
fatigue.
32

LABORATORY STUDY
Sex: Male
EXAMINATION
Glucose
Creatinine
RESULT
REFERENCE VALUE
INTERPRETATION
SIGNIFICANCE
87.5 umol/ L
79-132 umol/ L
The kidney normally filter

creatinine out of the blood and
send them out of the body
through urine.
Creatinine
levels
help
determine how well your
kidneys
function.
When
creatinine levels increase, your
kidney function may be
impaired.
165.5
135-148 mmol/ L

muscle malfunction.
4.33
3.5-5.3 mmol/ L
There is normal potassium

level electrolyte which is

transmission. Deficiency may
result to muscle cramps and
reduced appetite while if
excess could result to high
blood pressure.
Electrolytes
Sodium
Potassium
Age: 17 years old

32
essential to proper muscle and

nerve function.

muscular
weakness,
and
fatigue.
32

LABORATORY STUDY
EXAMINATION
Electrolytes
Potassium
Sex: Male
Age: 17 years old
RESULT
REFERENCE VALUE
INTERPRETATION
SIGNIFICANCE
2.09 mmol/ L
3.5-5.3 mmol/ L
There is normal potassium

level electrolyte which is
essential to proper muscle and
nerve function.

muscular
weakness,
and
fatigue.
32
RANDOM BLOOD SUGAR EXAMINATION

DATE
RESULT
8:00am
12:00noon
4:00pm
112mg/dl
Jan 15,2016
70- 100 mg/dl
Normal
Above Normal
Normal
70- 100 mg/dl
Above Normal
Above Normal
70- 100 mg/dl
Normal
Normal
70- 100 mg/dl
Normal
Normal
Normal
70- 100 mg/dl
Normal
Above Normal
Normal
88mg/dl
102mg/dl
Jan 17,2016
8:00am
12:00noon
107mg/dl
8:00am
12:00non
4:00pm
87mg/dl
8:00am
12:0noon
4:00pm
91mg/dl
86mg/dl
Jan 18,2016
79mg/dl
85mg/dl
Jan 19,2016
91mg/dl
102mg/dl
Jan 20,2016
12:00am
8:00am
4:00pm
INTERPRETATION
Above Normal
93mg/dl
109mg/dl
Jan 16,2016
12:00am
4:00pm
NORMAL VALUES
70- 100 mg/dl
102mg/dl
102mg/dl
97mg/dl
Above Normal
Normal
32
Jan 21, 2016

8:00am
12:00noon
4:00pm
76mg/dl
8:00am
12:00noon
4:00pm
103mg/dl
8:00am
12:00noon
108mg/dl
8:00am
103mg/dl
12:00am
104mg/dl
70- 100 mg/dl
Normal
70- 100 mg/dl
Normal
Normal
Above Normal
70- 100 mg/dl
Above Normal
Normal
Above Normal
70- 100 mg/dl
Above Normal
Above Normal
70- 100 mg/dl
Above Normal
86mg/dl
87mg/dl
Jan 22,2016
105mg/dl
87mg/dl
Jan 23,2016
102mg/dl
Jan 24,2016
Jan 25,2016
SIGNIFICANCE:
Random blood sugar test is performed to monitor blood sugar level it measures the amount of circulating glucose in blood. Blood sugar or glucose is a major
source of energy for most cells of the body and provides nutrients in bodys organs, muscles and nervous system (including brain cells). Hormones made in the body
help control glucose level.
When RBS increased it indicates hyperglycemia, diabetes, hypothyroidism and nephriris. .The decreased blood sugar level (hypoglycemia) can cause brain
damage.
32

DRUG STUDY
Name of Drug
Generic
Name:
Ciprofloxacin
Brand name:
Quinosyn
Classification:
Antibacterial
Dose,
Frequency
and Route
Dosage:
500mg
Frequency:
BID
Route:
Per Orem
Sex: Male
Mechanism of
action
Age: 17 years old

Indication
Inhibition
Ciprofloxacin is
of topoisomerase
(DNA
gyrase)
used to treat
enzymes, which
infections of the
inhibits
skin.
relaxation
of supercoiled
DNA
and promotes bre
akage of double
Contraindication
Adverse effects
Ciprofloxacin is
Nausea
contraindicated
in persons with a
history
of hypersensitivi
ty to
ciprofloxacin,
any member of
the quinolone
Vomiting
Stomach pain
Heartburn
Diarrhea
Nursing implication
Nursing responsibilities
C Antibacterial
H Prevention or
treatment
of infection;
signs
and symptoms of
infection like fever
and pain are reduced.
E Twice a day
exactly at 6 am and
12 noon; Make sure
Instruct patient not to

take ciprofloxacin with
dairy products such as
milk or yogurt, or with
calcium-fortified juice.
He may eat or drink dairy
products
or calciumfortified juice with a
regular meal, but do not
use them alone when
32
stranded DNA.
class
of antimicrobial
agents, or any of
the product
components.
Coadministration of
ciprofloxacin
with other drugs
primarily
metabolized by
CYP1A2 results
in increased
plasma
concentrations
of these drugs
and could lead to
clinically
significant
adverse events of
the coadministered
drug.
Contraindicated
Feeling an
urgent need to
urinate
Headache
Hives
Difficulty
breathing or
swallowing
Hoarseness or
throat
tightness
Rapid,
irregular,
or pounding
heartbeat
Fainting
Fever
to drink plenty of
water or other fluids
everyday
while
taking Ciprofloxacin;
Do not take or eat a
lot
of
caffeine
products such as
coffee, tea, energy
drinks,
cola
or
chocolate within 6
hours
before
or
2hours after you take
ciprofloxacin.
C -Instruct client to
report any adverse
reaction
to
the physician
or
nurse. Tell patient
that antacids and
mineral supplements
may decrease the
absorption
of
Ciprofloxacin which
makes it less effective
when taken at the
same time.
taking
ciprofloxacin.
They could make the
medication less effective.
Tell
patient
that
Ciprofloxacin can cause
side effects that may
impair his thinking or
reactions.
Instruct patient to take
ciprofloxacin with a full
glass of water (8 ounces).
Instruct patient to avoid
taking antacids, vitamin
or mineral supplements,
sucralfate
(Carafate),
or didanosine
(Videx)
powder or
chewable
tablets within 6 hours
before or 2 hours after
you take ciprofloxacin.
These other medicines
can make ciprofloxacin
much less effective when
taken at the same time.
Instruct patient to stop
taking ciprofloxacin and
32
for the treatment

Joint or
of certain
sexually
muscle pain
transmitted
diseases by some
Unusual bruisi
experts due to
bacterial
ng or bleeding
resistance.
Extreme
Concomitant
tiredness
administration
Lack
with tizanidine is
contraindicated
of energy
of appetite
K -Do not take the

medication in larger
amounts, or take it
for
longer
than
recommended by
your doctor.
call the doctor at once if

he has sudden pain,
swelling,
tenderness,
stiffness,
or movement
problems in any of his
joints.
Also instruct patient to
rest his joint until he
receive medical care
or instructions.
Seizures
Dizziness
Confusion
Nervousness
Restlessness
Anxiety
32
Difficulty
falling asleep
or staying
asleep
Pain in the
upper
right part of
the stomach
Yellowing
of the skin
or eyes
Dark urine
32

DRUG STUDY
Name of Drug
Gneric name:
Omeprazole
Brand name: Losec
(CAN)
Sex: Male
Dosage,
Frequency,
Route
DOSAGE: 40g
FREQUENCY:
OD
ROUTE: IVTT
DRUG
CLASSIFICATION:
Age: 17 years old

Mechanism of
action
Gastric acid-pump
inhibitor: Suppresses
gastric acid secretion
by specific inhibition
of the hydrogenpotassium ATPase
enzyme system at the
secretory surface of
Indication
Contraindication
Short-term treatment
Contraindicated
of active duodenal
ulcer; First-line
with
therapy in treatment
hypersensitivity to
of heartburn or
omeprazole or its
symptoms of gastrocomponents;
esophageal reflux
Use cautiously
disease (GERD).
Adverse effects
CNS: Headache,
dizziness, asthenia,
vertigo, insomnia,
apathy, anxiety,
paresthesia, dream
abnormalities
Dermatologic:
Rash, inflammation,
Nursing implication
C: Antisecretory
drug;Proton pump
inhibitor
H: IVTTE: decrease
gastric acid secretion
C: Take the drug
beforemeals. Report
severe
32
Anti-secretory drug
Proton pump inhibitor
the gastric parietal

cells; blocks the final
step of acid
production.
Short-term
treatment of active
benign gastric ulcer;
GERD, severe
erosive esophagitis,
poorly responsive
symptomatic GERD;
Long-term therapy:
Treatment of
pathologic
hypersecretory
conditions
(Zollinger-Ellison
syndrome, multiple
adenomas, systemic
mastocytosis);
with pregnancy,
and/or lactation
urticaria, pruritus,
alopecia, dry skin
GI: Diarrhea,
abdominal pain,
nausea, vomiting,
constipation, dry
mouth, tongue
atrophy
Respiratory: URI
symptoms, cough,
epistaxis
Other : Cancer in
preclinical studies,
back pain, fever
headache,worsening
of symptoms, fever,
chills.
K: Swallow
thecapsules whole; do
not chew, open, or
crush them.
Eradication of H.
pylori with
amoxicillin or
metronidazole and
clarithromycin;
32
Name of Drug
Classification
Generic name:
Ketorolac
Antipyretic
Non Opioid
analgesic
Brand name:
Toradol
Dose,
Frequency
and Route
20 mg IV q
12
Mechanism of
Action
Indication
Anti-inflammatory
and analgesics
activity, inhibits
prostaglandins and
leukotrine synthesis.
Short term
management of
pain
Contraindications
Side effects and

Adverse Reactions
Nursing
Responsibilities
Headache, dizziness,
Dont forget to
insomnia, fatigue,
patients who have a
rash, sweating,
assess first the
history of
nausea, dyspepsia,
patient before
gastrointestinal
GI pain, diarrhea,
administering this
bleeding or peptic ulcer. dyspnea.
drug: know the
history (e.g.
Contraindicated to
allergies, renal
patients who are
impairment, etc.)
suspected or confirmed
and physical
cerebrovascular
condition of the
bleeding.
patient (reflexes,
ophthalmologic and
This drug should be use
audiometric
cautiously with patients
evaluation,
who have impaired
orientation, clotting
hearing, allergies, and
times, serum
cardiovascular/gastroint
electrolytes, etc.)
Contraindicated to
32
estinal/hepatic
conditions.
Report any signs of

itching, swelling in
the ankles, sore
throat, easy
bruising, etc.
Be aware that
patient be at
increased risk for
CV events, GI
bleeding, renal
toxicity, monitor
accordingly.
Generic Name:
Paracetamol,
Acetaminophen
Brand
Name: Biogesic,
Panadol, Tylenol
Non-narcotic
analgesic,
Antipyretic
Dose:30 mg
Decreases fever by
1 amp
Frequency:
a hypothalamic
q4
effect leading to
Route: IV
sweating and
vasodilation
Inhibits pyrogen
Suitable
substitute for
aspirin &
recommended
to be given if
the fever is
38.5C and
above
Renal Insufficiency
Minimal GI upset.
Anemia
Neutropenia
Thrombocytopenia
Leukopenia
Do not exceed
4gm/24hr. in adults
and 75mg/kg/day in
children.
Do not take for

10 days for pain in
32
effect on the
hypothalamic-heatregulating centers
adults, or more than

3 days for fever in
adults.
Urticaria
CNS stimulation
Hypoglycemic
fecal occult blood

and nephritis.
coma
Jaundice
Avoid using
OTC drugs with
Acetaminophen.
Drowsiness
Liver Damage
Assess for
Take with food

or milk to minimize
GI upset.
Report N&V.
cyanosis, shortness
of breath and
abdominal pain as
these are signs of
toxicity.
Report
paleness, weakness
and heart beat skips
32
Report
abdominal pain,
jaundice, dark urine,
itchiness or claycolored stools.
Report pain
that persists for
more than 3-5 days
This drug is
not for regular use
with any form of
liver disease.
Generic Name:
Mannitol
Brand Name:
Osmitrol
Diuretics
150 cc IV q
6
In large doses,
increases rate of
electrolyte excretion
by the kidney,
particularly sodium,
chloride, and
potassium.
To promote
diuresis in
prevention and
treatment of
oliguric phase
of acute
kidney failure
following
cardiovascular surgery,
Anuria; marked pulmonary

congestion or edema;
severe CHF; metabolic
edema; organic CNS
disease, intracranial
bleeding; shock, severe
dehydration, history of
allergy;
Pulmonary congest
ion.
Fluid and
electrolyte
imbalance,
Dry mouth
Observe the IV
site regularly for
infiltration.
Administration
rate for oliguria
should be titrated to
produce a urine
output. (about 30-50
32
severe
traumatic
injury.
Also used to
reduce
elevated
intraocular
(IOP) and
intracranial
pressure (ICP),
to promote
excretion of
toxic
substances.
Thirst,
Headache,
Blurred vision
Dizziness,
Nausea
Chest pain.
ml/hr in adult
Take care to avoid
extravasation.
Observe injection
site for signs of
inflammation or
edema.
Measure I&O
accurately and
record to achieve
proper fluid
balance.
Monitor vital
signs closely.
Report significant
changes in BP and
signs of CHF.
Monitor for
possible indications
of fluid and
electrolyte
32
imbalance (e.g.,
thirst, muscle
cramps or
weakness,
paresthesias, and
signs of CHF).
Be alert to the
possibility that a
rebound increase in
ICP sometimes
occurs about 12 h
after drug
administration.
Patient may
complain of
headache or
confusion.
Take accurate
daily weight.
32

NURSING CARE PLAN
Name of patient: Marlow
Age: 17 yrs. old
Attending Physician: Dr. Lazo /Dr. Nayal

Ward: Surgical
32
ASSESMENT
Objective:
DIAGNOSIS
Ineffective
cerebral
tissue perfusion related
-Altered LOC;
to interruption of blood
-Changes in motor flow
or
sensory
responses;
- restlessness
-speech
abnormalities
intellectual
-Capillary refill of
4 seconds
T- 35.0 oC
RR- 20 cpm
PR- 54 bpm
BP- 90/70 mmHg
RATIONALE
Swelling on left
temporal area
Swelling squeezes
the neighboring
blood vessels
Decreased blood
circulation
Insufficient oxygen
supply
Ineffective tissue
perfusion
PLAN
INTERVENTION
RATIONALE
Short term goal:
Independent:
1. Monitor vital signs: 1. To have baseline
After 6 hrs. of
Hypertension or
data,
nursing
hypotension
Hypertension
or
interventions,
the
hypotension may have
patient will be able
been a precipitating
to have an improve
factor.
tissue perfusion as
Hypotension
may
evidence by decrease
follow stroke because
capillary refill in 2
of circulatory collapse.
seconds.
2. Assess for signs of 2. To determine S&S
decrease tissue
occurs in patient
Long term goal:
perfusion
Within 3 days of 3. Measure urine
providing
nursing
output on a regular
interventions,
the
basis.
patient will:
Maintain usual or 4. Assist in
improved
LOC,
ambulation and
cognition, and motor
positioning
and sensory function
5. Promote adequate
EVALUATION
After 6 hrs. of
nursing
interventions, the
to have an improve
tissue perfusion as
evidence
by
decrease capillary
refill in 2 seconds.
3. To monitor patients
hydration
4. To limit energy
consumption
and
respiratory effort.
5. To prevents stasis of
32
fluid intake
the body fluids.
6. Note the skin color

and feel the
temperature of the
skin
6. Skin pallor, cold skin

temperature or an
absent pulse can
signal
arterial
obstruction.
7. Measure the
capillary refill
7. To
determine
complications such
as
hypoxia to
provide
early
interventions
8. Provide relaxation
and bed rest.
8. It importance of
nonpharmacological
interventions
to
improve functional
capacity.
9. Position
with
head
slightly 9. Reduces
arterial
elevated and in
pressure
by
neutral position.
promoting
venous
drainage and may
improve
cerebral
32
circulation
perfusion.
and
10. Administer
supplemental
10. Reduces
oxygen,
as
hypoxemia
indicated.(nasal
cannula 3 lpm)
Dependent:
1. Administer
medications
needed.
as 1. To have therapeutic
effect.
2. Drugs
use
to
improve
tissue
perfusion

32
NURSING CARE PLAN

Age: 17 yrs. old

Ward: Surgical
ASSESMENT
DIAGNOSIS
RATIONALE
Objective:
Hindi pa po sya
nakakatayo, di nya pa
po kaya as verbalized
by the mother
Impaired
Physical
mobility r/t muscle
stiffness in lower
extremities 2 VA
Trauma(vehicle
accident)
Limited physical
PLAN
INTERVENTION
RATIONALE
EVALUATION
Short term Goal:
-Established rapport -To build trust and Short term goal:

with patient
cooperation
At the end of 2 hrs
At the end of 2
hours patient
to
-Monitor Vital Sign
-Serve as baseline
participated in
cooperate/participate
data
activity that will
32
movement
Objective:
unable to sit,
walk and turn
side by side
without
assistance
with NGT and
IFC noted
experienced
muscle
stiffness on
lower
extremities
Functional
level # 4
dependent,
does not
participate in
activity.
VS taken
RR= 20CPM
BP=90/70
T=35
PR=54
Stimulates
inflammatory
response
Increased capillary
permeability fluid
and cellular
exudation.
-To maintain position

of
function
and
reduce
risk
of
pressure ulcer
help to promote
mobility as
evidenced by
moving his arms
and feet.
Long term goal:

-To maintain joint
mobility,
improve At the end of 2
circulation,
and days intervention
prevent contractures
patient
remain
unable
to
sit
-To reduce risk of independently
pressure on sensitive
area
-Assist with activities -To provide support

of
hygiene,
and to the patient and
feeding as indicated
prevent injury
Pain
Impaired
mobility
in activity that will

help him to promote
mobility such as -Assisted
patient
passive ROM.
position on regular
schedule
(turning
Long term Goal:
side to side- every 2
hrs)
At the end of 2 days
nursing intervention -Applied
passive
patient will be able ROM exercises on
to
demonstrate lower extremities
improvement
in
mobilization
-Perform regular skin
examination
for
excoriated area
physical
- Used side rails of -To prevent possible

bed.
fall
that
might
happen.
-Maintain
semi- - Patient need to find
32
fowlers position and the

comfortable
rest on bed
position
-Determine
the - To assess
presence
of presence
complications related complications.
to
immobility
(pneumonia,
and
elimination
problems).
Administer
medication prior to
activity as needed for
pain relief
the
of
-To permit maximal

effort
and
involvement
in
activity
32


Age: 17 yrs. old
NURSING CARE PLAN

Ward: Surgical
32
ASSESMENT
Subjective:
hindi
makapagsalita,
verbalized by
mother.
DIAGNOSIS
Impaired
verbal
siya communication
as related
to
the neuromuscular impair
ment as evidenced by
absence
of responding.
Objective:
slurred speech
inability to
speak
dominant
language
used of nonverbal
cues(hand
gestures, hea
turning
pleading eyes)
aphasia(difficul
ty expressing
thoughts
verbally)
difficulty
of forming
RATIONALE
PLAN
Swelling in left
temporal area
After 3 days
of nursing
interventions, the
client will
be
able to establish
method
of communication
in which his needs
can beexpressed.
Axonal
dysfunction
Impaired
functional
communication
within the
temporal lobe and
other body parts
Impaired ability to
comprehend
language
INTERVENTION
RATIONALE
EVALUATION
-Monitored vitalsigns with -Establishesbaseline

After
3
days
emphasisto BP
data for review of of nursing
existingconditions
interventions, the
client
will
-Provided
anatmosphere -to facilitate/ improve establish method
of acceptance
andprivacy good communication of communication
throughspeaking slowly andin
in which his needs
a normal tone, notforcing the
can be expressed.
client tocommunicate
-Taught techniques to improve
speechby
initially
askingquestions
that
clientcan answer with
ayes or no
-Used strategies toimprove

the
clientscomprehension
byusing touch andbehavior
tocommunicatecalmness
andadding other non verbal
methods
-Deliberate actionscan
be taken toimprove
speech. Asthe clients
speechimproves,
hisconfidence
willincrease
and
shewill
make
moreattempts
atspeaking.
-Improving
the
clients comprehension
can help to decrease
frustration
and
increase trust. Clients
32
words noted
restlessness
noted
GCSJanuary
19,2016- 6severe
traumatic brain
injury
January
25,2016 -9moderate
traumatic brain
injury
January
26,2016-11moderate
traumatic brain
injury
LOC- lethargic
of communication suchas;
usingpantomime.
with aphasia can

correctly
interpret
tone of voice.
-Educated
relativesto
establish
amethod -Imparts thought and
of communicationthrough
answers the needs of the
signlanguage
client with lessened
difficulty
32

NURSING CARE PLAN

Age: 17 yrs. old

Ward: Surgical
32
ASSESMENT
DIAGNOSIS
Impaired swallowing
Subjective:
related to decreased
Hindi
makalunok
gag reflex
ang anak ko as
verebalized patients
mother.
Objective:
-Difficulty
of
swallowing
-Cough/gagging before
a swallow
- VS taken
RR= 20cpm
BP=90/70 mmHg
T=350 C
PR=54 bpm
RATIONALE
PLAN
Decreased gag
reflex
At the end of 1 hr.

of
nursing
interventions, the
to
prevent
aspiration.
Coughing before
swallowing
Difficulty of
swallowing
Impaired
swallowing
INTERVENTION
RATIONALE
EVALUATION
Independent:
At the end of 1 hr.
-Establish
good -To gain the trust of of
nursing
rapport to patient and family and patient.
interventions, the
family.
patient was able to
prevent aspiration
- Monitored vital -To
monitor
the as evidenced by
signs.
baseline data.
patient has NGT.
- Assessed the gag -To ascertain strength
reflex of patient of presence of gag
using
tongue reflex.
depressor.
- Assessed sensory- -To assessed causative
perceptual status.
factors and degree of
impairment
- Auscultated the
gurgling sound for -To assessed the proper
NGT feeding.
placement
of
the
parenteral tube.
- Kept HOB elevated
to 30-45 minutes -To reduce risk of
after feeding.
regurgitation/aspiration.
32
- Encouraged rest
period before meals. -To
minimize
the
fatigue.
- Monitored intake
and output.
-To identify the fluid
volume of the patient.
-Provide oral hygiene
following
each To
promote
feeding.
cleanliness
and
minimize bacteria.


Age: 17 yrs. old
NURSING CARE PLAN

Ward: Surgical
32
ASSESMENT
Subjective:
Nahihirapang
huminga ang aking
anak as verbalized by
the patients mother.
Objective:
- Patient has nasal
cannula with O2 of
2L/m
-RR: 20 cpm / regular
-restlessness,
pale
noted
-lethargy
- Capillary refill<4 sec
DIAGNOSIS
RATIONALE
PLAN
Impaired
gas
exchange related to
altered oxygen supply
Decrease blood flow
After 6 hrs., of
nursing intervention
the patient will be
able to tolerate the
use
of
oxygen
support via nasal
cannula.
Decrease oxygen
circulation to body
parts
INTERVENTION
Dependent
-Monitor skin and
mucous membrane
-Elevate head of the
bed, assist patient to
moderate high back
rest position to ease
work of breathing.
RATIONALE
EVALUATION
After 6 hrs., of
nursing
- To indicate cyanosis. intervention
the
patient was able to
tolerate the use of
- Oxygen delivery oxygen support via
may be improved by nasal cannula.
upright suctioning.
Airflow limitations
Impaired gas
exchange
-Use
of
oxygen - Provide oxygen
support via nasal therapy and easy to
cannula at level of absorbed oxygen.
2L/min.
-Monitor vital signs - To have baseline
every 2hrs.
data.
-promote calm/restful - To consume the
environment,
also oxygen properly
encourage to have
adequate rest.
-positioned the client -To promote optimal
32
to change position chest expansion and

frequently
drainage of secretion.
Monitor
oximetry
pulse - To identify hypoxia

is present

NURSING CARE PLAN
32

Age: 17 yrs. old
ASSESMENT
Objective:
-Pain scale of
evidence by
facial grimace
-Restlessness noted
-crying, moaning

Ward: Surgical
DIAGNOSIS
RATIONALE
PLAN
INTERVENTION
Independent:
Acute pain related to Fluid and electrolyte Short term:

muscle spasm
imbalance
After 6 hrs. of -Assessed for
9
nursing
location of pain
intervention,
the
Low potassium level to reduce the pain at
tolerable level of
RATIONALE
EVALUATION
-To help determine

possibility of
underlying the
condition or requiring
treatment
After 6 hrs. of
nursing
intervention, the
patient
was
partially able to
reduce the pain at
tolerable level as
32
Appears
weak;
patient cannot perform
ADL
-Shows
guarding
behavior
-Irritable at times
-potassium level: 2.09
mmol/L
VS taken:
RR= 20cpm
BP=90/70 mmHg
5/10.
Calcium dominates
potassium level
Long term:
After 1-2 weeks of
Increase
muscle nursing
contraction
intervention,
the
to demonstrate use
of relaxation skills
Unpleasant sensory and
diversional
experience.
activities.
T=350 C
PR=54 bpm
Activation of pain
receptors
Send signal to the

brain
-Noted clients
attitude toward pain.
-Help to determine
appropriate pain
management
-Used pain rating

scale for age and
cognition
-To evaluate level of

pain
-Provided comfort
measures like
massage back rub
and deep breathing
exercise.
-To promote nonpharmacological pain

management
-Vital signs were

monitored every 2
hrs.
-To monitored
baseline data.
- Provide rest
periods, sleep and
relaxation.
- Fatigue on the
patient may
exaggerate on the
pain he experienced.
evidenced
by
facial grimace of
7/10.
-May not be
32
Perception of pain
-Observed non-verbal congruent with verbal

cues
reports or maybe only
indicator present
when client is unable
to verbalize
-Elevate bed covers;
keep linens off toes.
Dependent:
- Administration of
analgesics as
prescribed by the
physician.
Ketorolac (Toradol)
30 mg IV q12hrs. x 3
- Maintains body
warmth without
discomfort due to
pressure of bed
clothes on affected
area.
-To relieve pain.
Ketorolac have
proved it to be
effective in alleviate
bonepain, with longer
action and fewer side
effects than narcotics
agents.
32
32

Lab Study

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PATTERNS OF

JANUARY 19, 2016

difficulty of breathing associated

he was still 14 y/o due to his

by Dr. Josefina J. Goh-Cruz in

Patient has nasal cannula

as of now as told by his mother.

inhalation and expiration

time and never reoccurred again

muscles during breathing

some prescribed medication yet

the drugs. This only happen one

to run at 2L/m with

Brookes Point, PPC. He took

his mother forgot the name of

with chest pain last 2013, when

heart enlargement as diagnosed

inhalation and expiration

Respiratory rate of 23 cpm

inhalation and expiration

No nasal discharge upon

No nasal secretions upon

cough and colds, the patient

Calamansi juice, approximately

tablespoon of sugar in one glass

last 2013 when he was 14 y/o as

PR: 54 bpm, Full in

diagnosed by Dr. Josefina J.

strength, measured from

strength, measured from

capillary refill <4 secs

Nails are pale and no

Nails are pale and no

not experience it again after he

strength, measured from

Capillary refill in <4 sec

Pallor Skin and warm to

capillary refill of <3 sec

touch poor skin turgor

Patient is on NGT feeding

Patient is on NGT feeding

IVF of PNSS 1L x 12 hours

consumed 3-4 cups of rice every

Total IVF intake of 638

meal especially when their viand

susu as stated by his mother.

Total IVF intake of 905

Total IVF intake of 560

Absence of Gag reflex as

Absence of Gag reflex as

morning during breakfast.

Has IFC inserted during

not sure if how many times did

assessment with an output

assessment with an output

assessment with an output

the patient defecate but she

of 450 ml amber in color

of 750ml amber in color

of 340ml yellowish in color

notice he goes to comfort room

Has IFC noted during Has

Did not defecate for 9 days