Diagnostic/ Date ordered Indications or Analysis &

Laboratory and Date Purposes Results Normal Values Interpretation

Procedure of results
Hematology 7/30/10 This test is used to WBC: 9.9 g/L HCT: 0.359-0.446 Mid cells may
evaluate anemia, LYM: 2.1, Neutrophils: 0.50 – include less
leukemia, reaction 20.9%L 70 frequent
to inflammation and MID: 0.5, LYM: 0.20 – 0.40 occurring and
infections, 5.1%m rare cells
GRAN: 7.3, correlating to
peripheral blood
74%g monocytes,
cellular characters, RBC: 4.01 T/L eosinophils,
State of hydration Hgb: 119 g/L basophils, blasts
and dehydration, HCT: .374 L/L and other
Polycythemia, MCV: 93.3 fL precursor white
Hemolytic disease MCH: 29.7 pg cells.
of the newborn, to MCHC: 318 g/L
manage PLT 296 g/L
chemotherapy
decisions.

1. MEDICAL MANAGEMENT
 DATE ORDERED,
MEDICAL PERFORMED, GENERAL INDICATIONS CLIENT REACTIONS
MANAGEMENT CHANGED, DESCRIPTION
DISCONTINUE

Solution that is Used for fluid Mr. X feels

5% Dextrose in isotonic with blood resuscitation after a comfortable after
Lactated Ringer’s and intended for blood loss due to receiving the
Solution intravenous trauma, surgery, or a medication
administration. burn injury.
Veterinary Previously, it was
administration may used to induce urine
also be output in patients
subcutaneous. with renal failure.
 DATE ROUTE OF GEN. ACTION,
NAME OF ORDERED, ADMIN. & MECH. OF INDICATION CLIENT’S
DRUG TAKEN, DOSAGE & ACTION REACTION
CHANGED FREQUENCY
OF ADMIN.
Generic 2g IVP q 6 nhibits bacterial Used for treating After giving the
Name: cell bacterial medication the
Ampicillin wall synthesis by infection client’s feel ok.
Brand Name: binding to one or
Omnipen, more of the
Polycillin, penicillin
Principen binding proteins
(PBPs); which in
turn inhibits the
final
transpeptidation
step
of peptidoglycan
synthesis in
bacterial
cell walls, thus
inhibiting cell
wall
biosynthesis.
Bacteria
eventually
lyse due to
ongoing
activity of cell
wall
autolytic
enzymes
(autolysins and
murein
 hydrolases)
while cell wall
assembly is
arrested.

DATE ROUTE OF GEN. ACTION,

NAME OF ORDERED, ADMIN. & MECH. OF INDICATION CLIENT’S
DRUG TAKEN, DOSAGE & ACTION REACTION
CHANGED FREQUENCY
 OF ADMIN.
Generic 5g on each Cofactor of suitable After giving the
Name: buttocks many enzymes for replacement medication the
Magnesium systems therapy in client’s feel ok.
sulfate involved in magnesium
deficiency,
Brand Name: neurochemical
transmission
and muscular
excitability

DATE ROUTE OF GEN. ACTION,

NAME OF ORDERED, ADMIN. & MECH. OF INDICATION CLIENT’S
DRUG TAKEN, DOSAGE & ACTION REACTION
CHANGED FREQUENCY
 OF ADMIN.
Generic 50mg q 6 IVP Inhibits Used for After giving the
Name: prostaglandin treating medication the
Ketorolac synthesis by inflammation client’s feel ok.
Brand Name: decreasing the and pain in
Toradol activity of the the operation
enzyme, site.
cyclooxygenase,
which results in
decreased
formation of
prostaglandin
precursors,
chemicals that
cells
of the immune
system make that
cause the redness,
fever, and pain of
inflammation and
that also are
believed to be
important in the
production of non-
inflammatory pain

DATE ROUTE OF GEN. ACTION,

NAME OF ORDERED, ADMIN. & MECH. OF INDICATION CLIENT’S
 DRUG TAKEN, DOSAGE & ACTION REACTION
CHANGED FREQUENCY
OF ADMIN.
Generic 50mg q 8 IVP Competitive Used to After giving the
Name: inhibition of prevent ulcer medication the
Ranitidine histamine at H2- while patient is client’s feel ok.
Brand Name: receptors of the on NPO.
Zantac gastric parietal
cells, which
inhibits
gastric acid
secretion, gastric
volume, and
hydrogen ion
concentration are
reduced. Does
not
affect pepsin
secretion,
pentagastrin-
stimulated
intrinsic
factor secretion,
or
serum gastrin.

TYPE OF DIET DATE GENERAL INDICATIONS SPECIFIC FOOD CLIENT’S

ORDERED, DESCRIPTION TAKEN RESPONSE
 STARTED &
CHANGED
The clear liquid The purpose of Water, juice, jelly
diet is composed clear liquid is to
of foods with low rest the G.I tract
residue content and maintain
Clear Liquid Diet which are liquid fluid balance.
in form to
minimize the load
of food needing
digestion in the
intestines.
The Full Liquid The traditional Milk, cooked
Diet is a diet indication for the refined cereals
which is full liquid diet is
Full liquid Diet intermediate for short term
between the use as transition
clear liquid and step between
mechanical soft clear liquid and
diet in soft diet.
characteristics.
Mechanical Soft Soft diet is used Lugaw,
Diet provides as a transition champorado and
foods which can diet between full noodles
Soft Diet be ingested with and regular diet.
a minimum of
chewing but
provides more
calories and bulk
than the Full
Liquid Diet.
Low salt diet Indicated to pt. High in fiber food
provides food with high blood
Low sodium Diet which are low in pressure.
sodium content,
to manage
 individual with
hypertension

TYPE OF EXERCISE DATE ORDERED, GENERAL INDICATIONS CLIENT’S REACTION

STARTED & DESCRIPTION
CHANGED
Exercises are done for Indicated to pt. that
a person by a helper. are in bed to maintain
Passive ROM The helper does the their joints and muscle
exercise range of motion healthy
exercises because the
person cannot do them
by himself.
Deep Breathing The pt. either sits in a Deep breathing helps
Exercise chair or sits upright in expand the lungs and
bed inhales, pushing force better
the abdomen out to distribution of the air
force maximum into sections of the
amounts of air into the lungs.
lungs

NAME OF DATE PERFORMED BRIEF DESCRIPTION INDICATIONS CLIENT’S REACTION

PROCEDURE
Cesarean Section A cesarean section is Performed whenever
a surgical procedure abnormal conditions
in which incisions are complicate labor and
made through a vaginal delivery,
woman’s abdomen threatening the life of
and uterus to deliver the mother or the
baby. baby. Dystocia or
difficult labor is the
other common cause
of cesarean section.
RECOMMENDATION

A. Student Nurse

As a student nurse, to enhance our skills and knowledge is important that’s

why we doing a research about a particular disease is important for us.
Searching for a particular disease such as “Pre-eclampsia” may lead us to
expand our ideas about the condition of the disease. Through this, we can
encourage our co-student nurse to gather more information for them to
broaden their knowledge by sharing of gathered data especially about the
cause and effect of this disease together about the health teachings on how
to avoid a certain illness, so that they can allocate it to other individuals to
prevent diseases and to promote health.

B. Community

For the community, having knowledge about Pre- eclampsia is important. The
community must be aware for the signs and symptoms of disease. They must
determine the cause and effect of the disease. So as a community, they may
help each other to prevent its cause such as alleviating eating salty foods,
eating fatty foods so that the community may take action to avert risk factors
for the health of the whole community. The community should also
participate in the programs that are related for the promotion of health.

C. Patient

Patient health condition will be better if he follows the recommendation that

we have given to him, such as preventing eating foods that are high in salt
and cholesterol.. To promote health, Mrs. X should maintain a healthy
lifestyle; Mrs. X should stop eating foods that are high in sodium and fats for
the sake of his condition. Mrs. X should have proper exercise everyday for the
good circulation of blood. Mrs. X should also monitor his intake of food and
prevent foods that contains low dense lipoprotein such as fatty meats,
instead take foods contain high dense lipoprotein such as fruits and
vegetables, to promote a healthy diet
D. Health Workers

Health providers must broaden their knowledge in order to promote healthy

conditions of the client. They must be responsible for the improvement of
client’s health by teaching the client on how to properly manage his
condition. Health teachings are important to prevent risk factors. Promoting
health must be developing in the community, and most especially in the
hospital which is the most essential role of the health care providers. They
must enhance more of their knowledge, such as research and studies, to
have capability to impart right health teachings for individuals, family and
community.