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UTI (Domo-os,Belenda)

A. NAME OF DRUG: Paracetamol

B. FUNCTIONAL CLASSIFICATION:Non-narcotic Analgesic and Anti-Pyretic


C. THERAPEUTIC ACTION: Unknown. Thought to produce analgesia by

blocking generation of pain impulses, probably by inhibiting prostaglandin
synthesis in the CNS or the synthesis or action of other substances that
synthesize pain receptors to mechanical or chemical stimulation. It is
thought to relieve fever by central action in the hypothalamic heat-
regulating center.

D. INDICATION: Mild pain or fever.

E. SIDE-EFFECTS- May cause a false-positive test result for urinary 5-

hydroxyindoleacetic acid or interfere with home glucose testing.

HEMATOLOGIC: hemolytic anemia, leucopenia, neutropenia and

HEPATIC: severe liver damage (with toxic doses) and jaundice.
Skin: rash and urticaria.
Other: hypoglycemia

F. ACTUAL DOSAGE: 1ml IV q 4 h

G. USUAL DOSAGE: 325-650mg P.O. q4-6hours; 1g P.O.t.i.d., q.i.d.,p.r.n.

• Maximum dosage should not exceed 4g daily. Dosage for long-
term therapy should not exceed 2.6g daily.
H. CONTRAINDICATION: Contraindicated in patients hypersensitive to


-Use cautiously in px with history of chronic alcohol use because hepato-

toxicity has occurred after therapeutic dosages.
-Many OTC products contain acetaminophen; be aware of this when
calculating total daily dosage.
-Liquid form is recommended for children and for all patients who have
difficulty swallowing.
-Know that acetaminophen may produce false-positive decreases in blood
glucose levels in home monitoring systems.
• Because of the pain experience in the abdominal area, he has a hard time resting; the bed
has no side rails thus prone to fall. The only thing that provides his safety is her wife and
other SO that accompanies him when asleep.

Rest and Comfort:

• Past: Usually he sleeps for 8 hours @ night without any interruptions and has 30 minutes
naptime in the afternoon.
• Present: He sleeps with interruptions due to experience pain and presence of healthcare
team that provides the necessary interventions. He sleeps for about 6 hours, and seldom
takes nap in the afternoon.

C. Oxygenation:
• Past: has no difficulty of breathing, has no hereditary illness (e.g. Asthma)
• Present: has no difficulty of breathing, RR= 19 bpm; bed found along the alley

D. Sexuality
• He is identified as male; portrays masculine sexuality; and is happily married for 7 years.

E. Spirituality
• Client professes the faith of Roman Catholic; seldom goes to church with his family.
Believes that faith alone could save a person.

F. Communication:
• He has no difficulty in communicating his needs or discomfort; he is conscious and coherent;
has no difficulty to speak and understand Tagalog.

G. Elimination:
• Past: He usually eliminates approximately 500 - 800cc in a day, voiding about 10 times a day.
His defecates once a day every morning.
• Present: He eliminates approximately 250 cc within shift.Defecates once a day.

H. Fluid & Nutrition

• Past: He only eats meals that are composed of rice and meat each 3 meals per day ranges
about 300cc of meals measurement. His fluid intake is about 2000 cc a day.
• Present: He consumes 3 meals a day; sometimes consumes ½ of the meal served
approximately 180cc in amount and his fluid intake is approximately 1000cc in a day; he has
a IVF of D5LR 1L @ 20gtts/min.

3. Assessment:
Head: Hair is curly, well distributed; symmetrical
Ears: Symmetrical, both ears can hear well or has no defect; pinna recoils when folded
Eyes: Reddesh conjunctivae ; Responsive to light stimulus; symmetrical in size, PERRLA.
Nose: Nasal septum firm and placed in the center
Throat: tartar deposits on teeth and gums noted
Chest and lungs:


Skin & Extremities:

• Has scars at arms; has no difficulty moving. Skin warm to touch; sweating noted.



(Complete Blood
Hemoglobin 140 g/L 120-160g/L The result of hemoglobin test -To determine the
is Ñ which may indicate no hemoglobin value in
sign of anemia; the blood; and to
Also indicates sufficient determine capacity
oxygen supply in the blood. to carry oxygen to
body tissues.

WBC 6.60 x 10g/l 5.0-10.0 x g/l Result shows normal or within * To determine the
normal value there’s no sign presence of
of infection infection.
* To check WBC for
diagnostic health
*Assess WBC as
past of complete
blood count
Neutrophils 76% 50-70 % Result shows elevated To determine the
Neutrophils or abnormal presence of
value, there is sign of bacterial infection
bacterial infection.
Lymphocytes 24% 25-40% Result shows Below Normal, To detect
there is sign of infection; autoimmune disease
inadequate body’s defenses / such as lymphoma
mmune system and lymphatic


TYPE OF DIET: DAT (Diet as Tolerated)

DATE ORDERED: July 1, 2007

Rationale: to provide needed vitamins and minerals necessary in nourishing the

systems in the body and strengthening resistance especially during disease process.


NAME OF SOLUTION: D5LR 1 L @ 20 gtts/min.

TYPE OF SOLUTION: Hypertonic Solution

DATE ORDERED: July 1, 2007

Rationale: It contains multiple electrolytes for caloric replacement, mainly for

rehydration, and maintenance of fluid volume; has free water and salt.


Objective: After discharge, the patient and significant others will:

M- Follow prescribed home medication such as take home medication as prescribed

by the Pediatrician.

E-If instructed by the Physician to perform several independent interventions as

demonstrated by the nurses such as TSB, back rubbing, bedside care, the
significant others should perform above-said simple interventions to alleviate
health condition of patient and exercise within tolerance.

T- Perform simple treatment such as checking of body temperature as necessary.

Also advice to take adequate rest and increase oral fluid intake.

H- Advise patient and significant others to provide cheap and economical but
nutritious food such as green leafy vegetables. Always consider the health
teachings provided by the nursing students such as boiling of drinking water for
safety measures.

O- Visit the physician for follow up consultations. If bleeding occurs visit the
D- Follow the Doctor’s Order with regard to patient’s diet. Instruct daily intake of
adequate and well balanced diet. Should include full range of food groups. Never
disregard the order, and consult the Doctor first before making changes in the
patient’s diet.