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Date ordered: D5 0.3NaCl is a To compensate The treatment

January 22, 2011 hypertonic solution cellular dehydration resulted to a good
D5 0.3NaCl 500cc x owing to the higher and corrects skin turgor and
30 ugtts/min Date performed: than normal amount moderate fliud loss, capillary refill and
January 22, 2011 of Na and Cl ions. It prevents alkalosis decreased risk for
pulls fluid and provides calorie and deficient fluid
Time Started: electrolytes from NaCl. volume.
11:15AM the intracellular and
interstitial
Time Consumed: compartments into
5:45AM the intravascular
compartments.
c

'
Date ordered: D5 0.3NaCl is a To compensate The treatment
January 23, 2011 hypertonic solution cellular dehydration resulted to a good
D5 0.3NaCl 500cc x owing to the higher and corrects skin turgor and
30 ugtts/min Date performed: than normal amount moderate fliud loss, capillary refill and
January 23, 2011 of Na and Cl ions. It prevents alkalosis decreased risk for
pulls fluid and provides calorie and deficient fluid
Time Started: 5:45AM electrolytes from NaCl. volume.
the intracellular and
Time Consumed: interstitial
12:45PM compartments into
the intravascular
compartments.

c

(
Date ordered: D5 0.3NaCl is a To compensate The treatment

January 24, 2011 hypertonic solution cellular dehydration resulted to a good
owing to the higher and corrects skin turgor and
D5 0.3NaCl 500cc x Date Performed: than normal amount moderate fliud loss, capillary refill and
30 ugtts/min January 24, 2011 of Na and Cl ions. It prevents alkalosis decreased risk for
pulls fluid and provides calorie and deficient fluid
Time Started: electrolytes from NaCl. volume.
12:45PM the intracellular and
 interstitial
Time Consumed: compartments into
8:30AM the intravascular
compartments.

c

)
Date Ordered: D5 IMB is a It is used to supply The patient was
January 25, 2011 hypertonic solution, the necessary compliant to the
D5IMB 500cc x 40- which makes the nutrients to the treatment given.
41 ugtts/min Date Performed: cell shrink. It is patient.
January 25, 2011 composed of water
and carbohydrates
Time Started: 8:30AM as source of energy
Time Consumed: N/A and both cations
and anions.


$


#
*
+

*,+

1. Verify the doctor¶s order indicating the type of solution, the amount to be
administered, the rate of flow of the infusion and any allergies.
2. Explain the procedure and prepare the client.
3. Prepare the equipments needed.
4. Wash hands thoroughly.
5. Obtain IV solution and check for the sediments and any crack or leak from
the container.
6. Check also for the expiration date.
7. Check fluid discoloration or defect. If noted, dispose the defected tubing
and get another.
8. Assess client¶s vital signs for baseline data, skin turgor, bleeding
tendencies, disease, or injury to the extremities, status of vein to
determine the appropriate puncture site.

-+

1. Explain the importance and purpose of IVF.

2. Place the patient in a comfortable position to facilitate easy
insertion of the IV line.
3. Use the smallest gauge needle possible.
4. Maintain aseptic technique throughout the procedure.
5. Follow proper procedures in infusing IV solution.
6. Watch out for fluid overload.
7. Secure the needle properly after insertions. Always check the
needle of the IV, if it is in the vein:
- Bring the IV bottle lower than the patient arm.
- Pinch the IV tubing.
- Observe the backflow of the blood in the distal portion of
 the IV tubing.
8. Avoid or remove air from the tubing as it may cause embolism.
,+

1. Check for swelling around the site for IV infiltration. Assess for any
signs of edema or bulging of vein if it is not properly inserted.
2. Regulate IVF as ordered. Apply a medication label on the solution if
a medication is added.
3. Observe for the reaction of the patient to the solution given.
4. Document related data.
5. Chart the procedure including time, name, dosage and the patient
response to the administration.
6. Properly dispose used materials after insertion
 ]
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4

#+
Cefazolin (Ilocef) 
4+
It was ordered The client was
5+
January 22, 250mg q°6 ANST(-) ,7 is a first- to treat complaint with
Cefazolin 2011 generation cephalosporin antibiotic. infection the medication
Route: IV caused by prescribed.
*

6+
45
,
4+
—


5+
January 22-24, It inhibits bacterial cell wall —  



Ilocef 2011 synthesis by binding to one or 

——.
more of the penicillin-binding
4+
proteins (PBPs) ,thus inhibiting cell
January 24, wall biosynthesis.
2011
Bacteria eventually lyse due to
ongoing activity of cell wall autolytic
 enzymes (autolysins and murein
hydrolases) while cell wall
assembly is arrested.



$


#
*
+

*,+

ë Check doctor¶s order.

ë Right drug, dosage and frequency must be observed.
ë Explain the purpose of the drug.
ë Assess patient allergy to penicillin or cephalosporin.
ë Assess patient for infection (vital signs; appearance of surgical site, urine; WBC) at beginning and during
therapy.
ë Culture infection site before the therapy.
-+

ë Maintain aseptic technique.

ë Avoid or remove air to prevent embolism.
,+

ë Observe patient for signs and symptoms of anaphylaxis (rash, pruritis, laryngeal edema, wheezing).
ë Change sites every 48-72 hr to prevent phlebitis.
ë Instruct patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or
discharge, loose or foul-smelling stools) and allergy.
ë Document related information.
  
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4+
For the The client was
4

#+
½ amp q°8 PRN Antiemetic treatment compliant with
5+ January 22, for vomiting vomiting the medication
Metoclopra 2011 45
,
4+
and no further
mide Route: IV Metoclopramide inhibits gastric vomiting was

6+
smooth muscle relaxation noted after
*
January 22-24, produced by dopamine, therefore administration.
5: 2011 increasing cholinergic response
Reglan
of the gastrointestinal smooth

muscle.

$


#
*
+

*,+

ë Check doctor¶s order.

ë Right drug, dosage and frequency must be observed.
ë Explain the purpose of the drug.
ë Assess patient for allergy to metaclopramide.
ë Check the medication¶s compatibility with IV.
-+

ë Monitor for extrapyramidal reactions, and consult physician if the occur.

ë Give IV doses slowly over 1-2 minutes.
ë Avoid or remove air to prevent embolism.
,+

ë Dispose used materials properly.

ë Observe patient for any adverse reaction to therapy.
ë Tell the patient to take sugarless candies or gums to relieve dry mouth.
ë Instruct patient to take drug exactly as prescribed.
ë Chart the time drug was given.
ë Document properly.




 
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4+
The patient
4

#+
250 mg q°8 Antibiotic; Penicillin To treat reported relief
5+ January 24, ANST(-) patient from abdominal
Ampicillin 2011 45
,
4+
gastrointestina pain caused by
Destroys bacteria by inhibiting l infection Bacteria.
*

6+
Route: IV bacterial


5: January 24, cell-wall synthesis during 
Omnipen
2011 microbial multiplication. Addition 
of sulbactam enhances drug¶s 

resistance to beta-lactamase, an 

enzyme that can inactivate

ampicillin.




$


#
*
+

*,+

ë Check doctor¶s order.

ë Prepare medication and materials needed.
ë Perform necessary hand hygiene before administering drugs.
ë Check the medication¶s compatibility with IV.
ë Calculate medication dosage properly.
ë Assess patient allergy to penicillin or cephalosporins.
-+

ë Explain the procedure and purpose of the medication.

ë Clean the port and maintain aseptic technique.
ë Inject medication slowly.
,+

ë Observe for any signs of hypersensitivity.

ë Assess client¶s reaction.
ë Properly dispose materials used.
ë Document all relevant data.




 
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4+
To treat The patient
4

#+
Amebicide, Antibacterial, patient acute reported relief
5+ January 24, Antibiotic, Antiprotozoal gastrointestina from abdominal
Metronidazo 2011 30cc q°8 x 3 doses l infection with pain and
le (IV) then shift to 45
,
4+
susceptible cramping

6+
250mg/5ml 3ml Inhibits DNA synthesis in specific anaerobe caused by
*
January 24, TID(ORAL) anaerobes causing cell death
organisms.
bacteria

5: 2011
Flagyl





$


#
*
+

*,+

ë Check doctor¶s order.

ë Prepare medication.
ë Check the medication¶s compatibility with IV.
ë Calculate medication dosage properly.
-+

ë Explain the purpose of medication and how it will help; Include relevant information about the effects of
medication
ë Inject medication slowly.
ë For Oral medication, take it with foods to prevent GI upset.
ë Instruct not to drink alcohol (beverages, or preparations containing alcohol, cough syrups), severe
reactions may occur.
,+

ë Instruct that urine may be a darker color than usual.

ë Assess patient reaction to the medication.
ë Document all relevant information.


 
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4+
Prevention The patient was
4

#+
Antihistamine and treatment compliant with
5+ January 24, of nausea and the medication.
Diphenhydr 2011 12.5 mg/5ml TID 45
,
4+
vomiting
Patient didn¶t
amine It competes with histamine at H1 experience
Hydrochlori 
6+
Route: receptor site, thus preventing or further vomiting.

de January 24, Oral reversing the effect of histamine.

2011
*

5:

Benadryl

$


#
*
+

*,+

ë Check doctor¶s order.

ë Explain the use of the medicine.
ë Compute for the right dose.
ë Do hand hygiene before administering the drug.
-+

ë Give the medication on time.

ë Take each dose with a full glass of water.
ë It can also be taken with or without food.
,+

ë Assess patient for drowsiness, dry mouth, and motion-sickness.

ë Monitor and observe patient reaction or response to the medicine.
ë Document the time, and date of administration.
  
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4+
Treatment of The patient
4

#+
Anti-helminthic; Anti-infectives patient¶s reported relief
5+ January 24, bacterial from abdominal
Pyrantel 2011 10 cc HS 45
,
4+
invasion in the pain and
Pyrantel is a depolarizing gastrointestina cramping
*

6+
Route: neuromuscular blocking agent l tract
caused by
5: January 24-25, Oral that causes spastic paralysis of bacteria.

Quantrel 2011  —

— and
—
—
—



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#
*
+

*,+

ë Check doctor¶s order.

ë Explain the use of the medicine.
ë Culture for ova and parasites,
ë Strict hand washing and hygiene measures are important.
-+

ë Administer drug with fruit juice or milk.

ë Ensure that entire dose is taken once.
,+

ë Disinfect toilet facilities after patient use.

ë Advise SO to launder bed linens, towels, nightclothes, and undergarments (pinworms) of the patient
daily.
ë Instruct the SO that he should also be treated for total eradication of the pinworms.


4


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January 22, 2011 No food in any It was ordered to None The patient
#5"
-
form and prevent gastric complied by not
]
!


+ liquids will be irritation and eating or having any
January 22, 2011 taken by secretions related food by mouth or
mouth. to pain; to per Orem.
4+
eliminate nausea
January 23, 2011 and vomiting.



$


#
*
+

*,+

ë Check doctor¶s order.

ë Assure IV fluid therapy if patient is NPO>
ë Instruct SO not to give anything through the mouth.

-+

ë Assess client¶s condition.

ë Assure that nothing is taken through the mouth( either liquid or solid.
ë Place ³NPO´ sign on bed where the patient or SO can always see it.
ë Remove foods or drinks on patient¶s bedside.

,+

ë Observe patient¶s response on the diet.

ë Monitor client¶s condition.







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,

+
This diet includes foods that To prepare the Lugaw, Client easily
*

January 23,2011 are moderately low in clients Water, tolerated the

fiber, have a soft texture and stomach after Milk, ordered die and

+
are moderately seasons. eating nothing Biscuit, was relieved
January 23, It does not contain whole grain by mouth and from hunger and
2011 cereals or salads with raw, to limit foods, thirst.

fresh fruits and vegetables. that stimulate
4+
Serving sizes are small to the production
January 25, provide a gradual increase in of gastric acid
 2011 the amount of food from the that causes
NPO diet. irritation.

$


#
*
+

*,+

ë Check doctor¶s order.

ë Inform patient and the SO that the client may have a soft diet.
ë Explain the purpose of the Bland diet.
ë Provide the SO with some examples of soft diet foods.
ë Inform SO that foods may be softened by cooking or mashing.

-+

ë Assess the patient¶s condition.

ë Assure that the patient or SO eliminates food that are hard to chew or swallow such as raw fruits and
vegetables, tough meat.
ë Restrict the patient not to drink highly acidic beverages such as coffee, chocolate, carbonated sodas.
ë Instruct patient to have small frequent meals (6 meals/day) to help reduce gastric irritation.
ë Instruct patient to eat slowly and chew foods well.

,+

 ë If the patient had reflux, instruct not do to lie down after eating and eat the last small meal at east two hours
before bedtime.

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#+ Regular diet of It was ordered
 

January 25, 2011 an individual as because the Rice with The patient was
!
long as it is client can now dish(Sinigang) able to eat in his


+ tolerated and tolerate any food regular eating
January 25, 2011 appropriate to he desires that is pattern
individual¶s nutritious, that consisting of
Date Changed: health. will not lead to healthy foods
------- any and fruits.
complications.


$


#
*
+

*,+

ë Check the Doctor¶s Order.

ë Explain the Indication and purpose of the diet to the patient.
ë Explain the Importance of Right Nutrition to the patient / SO.
ë Check the client¶s choice of food.

-+

ë Encourage the patient to eat nutritious foods and fruits.

ë Recommend the patient to avoid eating junk foods and not to drink carbonated beverages.

,+

ë Recommend the Patient to perform Oral Hygiene every after meal.




84

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5
]


+
A medical treatment It helps to conserve The patient was
:
*5
January 22, 2011 involving a period of energy, promote recovery seen on bed
-
and rest, and prevent throughout the day
consistent
recumbence in bed. fatigue.
and was able to

,5+

It is used as a regain energy as
January 22-25, 2011
treatment for an evidenced by
illness or medical becoming non-
condition by relaxing irritable during
the body to enhance nurse-patient
 recovery of health.
interaction.

$


#
*
+

*,+

ë Assessed the patient¶s condition before introducing the exercise

ë Explain the type and how the exercise should be done.
ë Explain the need and purpose of the exercise.

-+

ë Observe the patient.

ë Provide comfort with the aid of pillows.
ë Provide safety measures to facilitate health.

,+

ë Report any abnormal findings.

ë Take note of the patient¶s improvement on her health