6.

Laboratory and Diagnostic Procedure PROCEDURE Hematology DATE 02-212012 INDICATION This test is used to evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characters, State of hydration and dehydration, Polycythemia, Hemolytic disease of the newborn, to manage chemotherapy decisions. RESULT PLT: 270,000 NORMAL FINDINGS 150000-450000 INTERPRETA TION Normal

HCT: 0.424 vol 0.415-0.504 vol% Normal % HGB: 137 g/L 140-170 g/L Decreased

RBC: 4.16 WBC: 7.2 g/L POLYS: 0.853 LYMPHO: 0.0885

3.5-4.7x1012L 4.5-11x109/L 0.55-0.63 %

Normal Normal Increased

0.23-0.35%

Decreased

Procedure Blood Chemistry

date 02-21-2012

Indication

Result

Normal Interpretation findings FBS: 5.9-6.1 mmol/ Increased 10.88mmol/ L L Cholesterol: 7.20mmol/L HDL: 95.64mg/dl LDL: 159.62mg/ dl 3.88-6.47 mmol/L Increased

30-75mg/dL

Increased

66-178mg/dL

Normal

02-21-2012 6:00 am 12:00 nn

RBS: 9.85mmol/L 9.35 mmol/L

2.5-7.2 mmol/L

Increased Increased

02-22-2012 6:00am 12:00nn 02-23-2013 05:00am

9.02mmol/L 11.1 mmol/L 7.65.mmol/L

Analysis: Nursing Responsibilities for Blood Chemistry: Before: 1.) Inform the patient about the procedure; how is it done and its purpose. 2.) Inform the patient that he will feel a bit pain when needle is inserted. 3.) Advise patient that he should feel relax as possible while blood is being drawn out. 4.) Advice the patient not to pull his hands during the procedure. 5.) Clean the site where the needle will be pricked. During: 1.) Assist the patient during the procedure. 2.) Monitor the patients condition. 3.) Provide comfort measures to divert his attention from pain or discomfort After: 1.) Apply pressure dressing to the puncture site. 2.) Observe the vein punctured site for bleeding. 3.) Remind/inform the patient and SO that the patient can already eat and drink after the procedure. Procedure Date General Result Normal Descrition Description Electrolytes 02-21-2012 Sodium: 136-142 Decreased 122.8mmol/L mmol/L Pottasium: 3.23mmol/L Chloride: 104.4meq/ L 3.8-50 mmol/L 104 meq/L Decreased

Increased

Diagnostic/ Laboratory Procedure

Date

Indications Purposes

or

Impression Results

October 5, 2011

CT SCAN Computed Tomography

Brain studies. Brain CT scans can detect hematomas (blood clotted mass), tumors, strokes, aneurysms (a blood vessel that ruptures), and degenerative or infected brain tissue. The introduction of CT scanning, especially spiral CT, has helped reduce the need for more invasive procedures such as cerebral angiography (inserting a wire through an artery to where it will reach brain vessels for visualization in real time).

Cerebrovascular disease parenchymal hemorrhage (subcortex right temporal Plain head scan shows lobe;small old of parenchymal hemorrhage the infarct ) measuring about 8.0cm.x 5.0 in the subcortex of the left temporal lobe with surrounding edema. No extracerebral hemorrhage noted. There is minimal shift of the midline stuctures to the right. The basal ganglia, cerebellum and brain stem are unremarkable..

C. IMPLEMENTATION 1. Medical Management DATE MEDICAL ORDERED, MANAGEME PERFORMED, NT CHANGED, DISCONTINUE PNSS Plain Normal Saline Solution 1L 20-21gtts/min October 3, 2011

GENERAL DESCRIPTION

INDICATION S

CLIENT REACTIO NS

Is a sterile, nonpyrogenic solution for fluid and electrolyte reple nishment and caloric supply in a single dose container for intravenous admi nistration.

Administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolytes requirement with minimal carbohydrate, calories and to correct or replace fluid looses due to change in patients diet (NPO).

Mr. CVD was able to maintain electrolyte s and nutrients balance

2. Drugs Route, Dosage, Frequency of Administration 1gm IVP q 12

Name of Drug Generic Name: Citicoline Brand Name: Citicholine Classification: Neurotonics, Nootropics

Date October 3, 2011

Action increase a brain chemical called phosphatidylcholine. decrease brain tissue damage when the brain is injured.It is usually known that phospholipid, especially lecithin, decreases following decline in brain activity with cerebral trauma. Citicoline, which is a co-enzyme, accelerates the biosynthesis of lecithin in the body. enhances the action of the brain stem ciliary body especially the ascending ciliary body activating system, which is closely related to consciousness, but does not exert effort on the extrapyramidal system. increases cerebral blood flow and oxygen consumption of the brain and improves cerebral circulation and metabolism.

The goals of pharmacotherapy are to reduce morbidity, to prevent complications, and to maintain nutritional status. Standard Nursing Responsibilities in Administering Drugs: 1. Observe the 10 Rights of drug administration: *right patient identify patient by: Checking ID Band, asking him to state his name *right drug read label three times *right route- check the route of administration *right dosage- calculates the correct amount *right time *right documentation- sign medication sheet *right approach, *right attitude, *patients right to be informed, *right to refuse 2. Practice asepsis. Practice proper hand washing. 3. Do not leave the medication at the bedside. Stay with the client until he actually takes the medications. 4. The nurse who prepares the drug administers it. DO not accept endorsement of medications.

Nursing Responsibilities: Citicoline may be taken with or without food. Take it with or between meals. The supplement should not be taken in the late afternoon or at night because it can cause difficulty sleeping. Contact the physician immediately if allergic reaction such as hives, rash, or itching, swelling in your face or hands, mouth or throat, chest tightness or trouble breathing are experienced. Citicoline therapy should be started within 24 hours of a stroke. The physician will prescribe the correct dosage and the length of time it should be taken for a medical condition.

Name of Drug

Date

Route, Dosage, Frequency of Administration

Action

Indication

Clients Reaction

Generic Name: Mannitol

October 3, 2011

100cc IV q 12

In the oliguric phase of acute renal failure, Mannitol increases osmotic

Cerebral edema Icreassed

Brand Name: Osmitrol Classification : Osmotic diuretic

pressure (pressure needed to stop the absorption of something or osmosis) of the glumerular filtrate, thereby,promoting diuresis (treating the oliguric phase of renal failure) and excretes toxic materials (management for toxic overdose). It also elevates blood plasma osmolality thus, inhibiting the reabsorption of water and electrolytes (for relief of edema) and mobilizing fluids in the cerebral and ocular spaces(lowers intracranial or intraocular pressure).

intracrania l pressure

Nursing Responsibilities: Monitor the following: Vital signs Intake and output Central venous pressure Pulmonary artery pressure Signs and symptoms of dehydration (e.g. poor skin turgor, dry skin, fever, thirst) Signs of electrolyte imbalance/deficit (e.g. muscular weakness, paresthesia, numbness, confusion, tingling sensation of extremity and excessive thirst) (for increase ICP) Neurologic status and intracranial pressure readings. (for increase IOP) Elevating eye pain or decreased visual acuity. Laboratory Tests Renal function (BUN and Creatinine) Serum Electrolyte (Sodium and Potassium)

Name of Drug Generic Name: Atorvastatin Brand Name: Lipitor Classification: HMG CoA reductase inhibitors

Date October 3, 2011

Route, Dosage, Frequency of Administration 10mg 1 tab OD

Action inh.ibits HMG CoA, the enzyme that catalyzes the first step in the cholesterol synthesis pathway, resulting in a decrease in serum cholesterol, serum LDLs and increases serum HDLs: increases hepatic LDL reuptakes and catabolism of LDL: lowers triglyceride levels.

Indication Adjunct to diet to reduce elevated LDL, total cholesterol levels to increase HDL level.

Clients Reaction

Nursing Responsibilities: Monitor patients lipid and liver function lebels at baseline and periodically thereafter. Monitor patient for signs of mabdomyolyis, especially if taking more than one class of lipid lowering drugs. Assess patients and familys knowledge of drug therapy. Route, Dosage, Frequency of Action Administration

Name of Drug

Date

Indication

Generic Name: October 3, 2011 Acetaminophen or Paracetamol Brand Name: Tylenol Classification: Antipyretic Analgesic (nonopioid)

300mg IVP T 37.8C

Reduces Fever fever by acting directly on the hypothalamic -heat regulating center to cause vasodilation and sweating, which helps dissipate heat

Nursing responsibilities Do not exceed the recommended dosage Give drug with food if GI upset noted Disconitue drug if hypersensitivity reactions occur Report rash, unusual bleeding or brusing, yellowing of skin or eyes, changes in voiding patterns

Diet TYPE DATE OF ORDERED, DIET STARTED & CHANGED Soft diet 09-27-11

GENERAL INDICATIONS DESCRIPTION

SPECIFIC FOOD TAKEN

CLIENTS RESPONSE

Nursing Responsibility: Explain the purpose of diet. Perform ways to increase patients appetite and compliance to diet D. Activity/ Exercise

TYPE OF EXERCISE Passive ROM exercise

DATE

GENERAL DESCRIPTION Exercises are done for a person by a helper. The helper does the range of motion exercises because the person cannot do them by himself.

Purpose

January 2012

To maintain joints and muscle healthy

Nursing Responsibility Assess the patients stamina and response to exercise to gauge the degree of gradual activity progression. Assess vital signs before and after exercise. Encourage a gradual increase in activity within the limits of the patients condition. D. EVALUATION 1. Discharge Planning Dear Patient/ Family, You are now for discharge. The following are instructions which you should always remember to follow: a. MEDICATION Medication Dosage, Route and Frequency 1gm IVP q 12 Timing Indications Nursing Consideration May be taken with or without food. Take it between meals.

Citicoline

6:0 0 am ; 9:0 0 pm

Cerebral vascular disease

Mannit ol

100c c IV q 12

6:0 0 am ; 6:0 0 am 6:0 0 am ; 6:0 0 pm

Cerebral edema

Atorvastatin

10m g1 tab OD

Reduce elevated LDL, total cholester ol levels to increase HDL level

Oliguria should be titrated to produce a urine output. (about 3050 ml/hr) Monitor lipid and liver function lebels at baseline and periodical ly

b. Exercise

c. Treatment

Limit strenuous activities for 3 to 5 days No heavy lifting of anything greater than 20 lbs for 3 days Do deep breathing and coughing exercise at least once a day for 30 minutes. Perform active ROM exercises once a day for 1 hour such as flexion and extension of upper and lower extremities. It is advisable to exercise for 30-45 minutes, if tolerated. Increase the progression of activity as tolerated. Exercise in well lighted pace. Monitor the clients response to activity.

Health Teachings /Hygiene Emphasize the importance of applying the given recommendation to him to promote health status. Encourage patients significant others to comply with the prescribed home medications as instructed. Explain the importance of follow up care, to monitor his condition.

On Hygiene Keep environment clean Maintain cleanliness at all times Take a bath daily Regularly trim fingernails and toenails

d. Out Patient Follow-Up See the doctor on the scheduled date of follow-up .In case of emergency, call your doctor and dont hesitate to visit your nearest clinic in the community. e. Diet Follow low salt and low fat diet Eat foods that are high in fiber like vegetables and fruits. Be conscious of the food labeling and read its content Foods to Example Avoid Salty Foods High preservative foods like tuyo, daing and dilis. Fast Food Instant noodles Processed meat (hotdogs, tocino) Canned goods Chips High Fat/ High Anything fried Cholesterol Butter Foods Chips Fast food Processed meat (hotdogs, tocino)

I have fully understood the discharge instructions given to me and will comply to it for my fast recovery.

______________________________________________ Patient Signature above Printed Name ______________________________ Date