Mindanao State University

COLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student _________Section B_________________________ Clinical Instructor _Sir Rambe Ramel Jr.___________________

Area of Assignment Medicine ward (Male senior citizen ward) Date Submitted __July 12, 2012_________________________

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name Patient X______ Address Lacob, Dalipuga, Iligan City Age 76 years old

Sex male Religion Roman Catholic Civil Status Widow Occupation farmer

HEALTH HABITS

Frequency Amount Period/Duration

1. Tobacco 5x a week 1 pack 62 years

2. Alcohol 3x-4x a week 1-3 bottles 62 years
3. OTC-drugs/ non-prescription drugs every onset of pain/fever 1 tablet/cap 30 years

A. CHIEF COMPLAINTS

Difficulty of Breathing

B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and
vocational responsibilities, affected diagnoses}.

Present condition started 15 days prior to admission; patient experienced an onset of cough, productive with yellowish phlegm, associated with dysphagia, difficulty opening the
mouth, difficulty speaking due to lockjaw which later associated with difficulty breathing, until patient seek consultation to Mindanao Sanitarium Hospital, and was subsequently
admitted, patient was diagnosed with Tetanus, nosocomial infection, S/P Tracheostomy & stage II hypertension, then he was referred after 14 days to GregorioT. Lluch Memorial
hospital or GTLMH.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth
and developmental history, nutrition- for pedia)

Patient has no history of infectious disease or major illness, he was hospitalized before at Mindanao Sanitarium Hospital due to cough in 2002 and he had an operation performed
on his eye to remove cataract in 1988, he has no major illness, no known allergies, and he was taking multivitamins which cannot be recall by the SO.

FAMILY HISTORY WITH GENOGRAM

Acquired Diseases: Heredo- familial Diseases:

Hypercholesterolemia __×___ Diabetes ___/__
Kidney Disease __×___ Heart Diseases __×___
Tuberculosis __×___ Hypertension ___/__
Alcoholism __×___ Cancer __×___
Drug Addiction __×___ Asthma __×___
Hepatitis A __×___ Epilepsy __×___
B __×___ Mental Illness __×___
C __×___ Rheuma/Arthritis ___/__
Others (pls. specify) Others (pls. specify)

D. PATIENT’S PERCEPTION OF:

1. Present Illness

N/A

2. Hospital Environment

N/A

E. SUMMARY OF INTERACTION

The interaction with the so and the patient was a very challenging one, the patient was unable to talk, he can only respond or answer to the student-nurse by nodding his head, so all if
not, most of the information were from the SO, the So was so cooperative and was really willing to provide the answers to the student-nurse’s question, she was very cooperative in answering
the questions asked by the student-nurse, thought there is a language barrier the Student-nurse was able to get the necessary information from the SO and the patient as well. In general the
interaction was a very informative one.
 REVIEW OF SYSTEMS

Name MR. X Date

Vital Signs: Height
Temperature 38 ⁰C Weight
Pulse 118 bpm Observation ____________________________________

Respiration 40 cpm
Blood Pressure

110/70 mmHg
The patient is generally weak, conscious but not oriented to time, place and person. Patient is lying on the bed
most of the time and is wearing white pajamas that cover his extremities. Patient skin was dry with some
rashes noted. There are many tattoos on his body, he looks old with white hair and with not firm skin, Facial
1.GENERAL
grimace noted when moving extremities even if it’s just too little movement. Poor grooming noted. With
tracheoostomy inserted and nasogastric tube.

H- head is normocephalic, with lesion noted, px hair become white due to aging. Patient had no previous head
injury, hair is not combed. Presence of scars noted, some dandruffs noted.
E- Eyes are symmetric in shape, pale palpebral conjunctiva, pupils are equally round and not reactive to light
and accommodation, patience could not able to follow 6 cardinal gaze, he is not wearing any eye glasses or
any eye wear. And with Presence of lesions and discharges.
2. HEENT E- ears are symmetric in shape on both sides, and in line with outer canthus of eyes, no lesions noted , no ear
ache reported, small cerumen formation was inspected during inspection, and with no presence of swelling
N-patient’s nose was inserted with naso gastric tube, (-) discharges and secretion. Patient’s ability to smell
and distinguish odor were not assessed.
T- throat was inserted tracheostomy to facilitated easy expulsion of secretion, patient cannot masticate foods
and suffering from dysphagia.

Patient skin is dry, no hair noted on the skin of the extremities just tiny hairs, patient skin is warm to touch,
hair of the head is white-black in color,
Patient nails are not cut and dirty
Edema presence on the lower extremities
3. INTEGUMENTARY
Patient had freckles noted on the face.
 RR 4O with adventious breath sound(crackles) heard upon auscultation, patient experience cough and difficulty of breathing,
4. RESPIRATORY Equal chest expansion and crackles breath sound heard upon auscultation, no deformities in chest, patient sometimes is tachypnic.

Pulse palpated on both hands with the same rate, Pulse rate is 99bpm with strong palpable pulse appreciated at both hands, BP 120/80mmhq.
5. CARDIOVASCULAR Pulse pressure of 40 mmHg, capillary refill of 2 seconds, temporal was not heard upon auscultation, Patient had a hypertension stage 2

Patient was on a “Full Adult diet”, he only consume foods prepared by the hospital, he has lesions on his oral mucosa, due to lockjaw, patient’s
6. DIGESTIVE oral mucosa is dry because it is always expose to air, no denture was observed, patient’s teeth are yellow in color with some brown portion noted,
since patient can’t move he was in a diaper , no abdominal mass was palpated, Abdomen is flat and soft, patient’s stool is usually yellow to brown
in color, and is semi-formed to watery in texture.

Patience is not diaphoretic

Patient defecate semi formed stool to watery, color is yellow to brown.
7. EXCRETORY Patient urinate freely on the FBC , urine is amber in color and transparent

Patient generally weak, Patient is not ambulatory, patient was not able to move,
Patient is lying on bed at all times,
8. MUSCULOSKELETAL Muscle strength of 1/5 on the upper and lower extremities,
(+) muscle spasm
Patient is awake but not oriented to time, place, and person.
9. NERVOUS Some of the 5 senses are still functioning while other are not assessed due to the condition of the patient
EYES: unable to follow 6 cardinal gaze but patient gaze at his SO whenever the SO touches his
EARS: patient respond to verbal question by nodding head
NOSE: not assesses
TASTE: unable to masticate food, not assessed
SKIN: warm to touch, patient stares at the SO and SN whenever they touch him.
Weight and height are not taken
No history of goiter.
10. ENDOCRINE No enlargement of thyroid
Skin is slightly warm to touch; no eyeball protrusion skin color is no yellowish but is brown in complexion.

DRUG STUDY
BRAND NAME GENERIC Prescribed and Mechanism
NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

B: Cipro P: 2oo mg IVTT q 12 hours Inhibits bacterial DNA Indicated for treating Contraindicated in Headache, dizziness,  Check culture and
synthesis, mainly by infections like UTI, patients with known insomnia, depression, sensitivity reports
G: Ciprofloxacin R: 400 mg IVTT q 12 hours blocking DNA gyrase; allergy to any fever, rash, to ensure that
respiratory tract infection,
bactericidal fluoroquinolone and in photosensitivity this is the drug of
C: Antibacterial and skin infections that
pregnant or lactating choice for the
(Fluoroquinolone) are caused by susceptible women and cautions patient.
strains of gram-negative should be used in the
bacteria including E. coli, presence of renal  Monitor renal
K. pneumoniae, P. dysfunction function tests
aeruginosa, group D. before initiating
therapy to
streptococci etc.
appropriately
arrange for
dosage reduction
if necessary

 Be aware of drug-
interactions, to
avoid decreasing
drug’s effects.

 Long-term
therapy nay result
in overgrowth of
organisms
resistant to
ciprofloxacin

Inhibits cell wall synthesis Contraindicated in Headache, insomnia,

Indicated for treating
B: Merrem IV P: 500 mg IVTT q 8 hours in bacteria. It readily
penetrates cell wall of
G: Meropenem R: 1 g IVTT q 8 hours most gram positive and
negative bacteria to reach
C: Anti-infective
penicillin-binding protein
targets.
intra-abdominal infections
caused by E.coli, klebsiella
pneumoniae,
pseudomonas aeruginusa
etc.
patients hypersensitive to
components of drug or
other drugs in same class
and in patients who have
had anaphylactic
reactions to beta-lactams.
dizziness, drowsiness,
weakness, seizures,
hypotension,rash,
dyspnea
 Monitor patient
 Collect specimens
for culture and
sensitivity testing
as needed
for
hypersensitivity
reaction or
anaphylaxis, if
either occurs stop
infusion
immediately

Fluid and electrolyte

Replaces deficiencies of replacement in Contraindicated in
B: Minims sodium chloride P: 1 g 2 tabs PO TID
sodium and chloride and hyponatremia and patients with normal or
 Instruct patient to
G: Sodium chloride R: 1 g PO with each glass maintains these hypochloremia caused by elevated electrolyte levels
fast for 12 hours
of water electrolytes at adequate electrolyte loss or in and fluid retention.
C: Electrolyte replacement before therapy
levels. severe salt depletion starts
Edema, heart failure
exacerbation, fluid and  Don’t administer
electrolyte disturbances in pregnant
women
Increases serum calcium
P: 1 tab PO OD level through direct effects Hypocalcemic tetany Hypersensitivity to drug,
B: Cal-Lac on bone, kidney, and GI ventricular fibrillation,
R: 4.5 mEq to 16 mEq IV hypercalcemia and  Monitor calcium
tract
G: Calcium lactate prn hypophosphatemia, levels frequently
pregnancy or
C: Electrolyte replacement
breastfeeding
Hypercalcemia, joint pain,
back pain

Mild to moderate pain

Hypersensitivity to drug Hypersensitivity reactions
Unclear. Pain relief may caused by headache,
B: Paracetamol P: 300mg 1 amp q 4 hours result from inhibition of muscle ache, common such as fever
prn prostaglandin synthesis in cold
G: Acetaminophen CNS. Fever reduction may  Observe for acute
R: 325 to 650 mg PO q 4-6 result from vasodilation toxicity and
C: Analgesic, Anti-pyretic hours overdose
and increased peripheral
blood flow in
hypothalamus, which
dissipates heat and lowers
body temperature

.
Mucolytic agent in
Decreases viscosity of adjunctive treatment of
B: Acetadote P: 600 mg in 1\2 glass of secretions, promoting Hypersensitivity to drug Headache, hypotension,
acute and chronic hypertension, chest
water\NGT OD @ HS secretion removal through
G Acetylcysteine coughing, postural bronchopulmonary tightnss
R: drainage and mechanical disease like pneumonia
C: Mucolytic,  Instruct patient to
means. In acetaminophen
acetaminophen antidote: report worsening
overdose, maintainsand
restores hepatic cough, and other
glutathione, needed to respiratory
inactivate toxic symptoms
metabolites

Produces osmotic effect, constipation

B: Apo-lactulose P: 30 cc OD @ HS which increases water
content in colon and Patients requiring low- Diarrhea, intestinal
G: Lactulose galactose diet  Watch for adverse
enhances peristalsis. cramps, abdominal
GI reactions
distention, flatulence
C: Laxative
 Check stool
consistency and
frequency

Inhibits the enzyme DNA Community- acquired Hypersensitivity to drug,

gyrase in susceptible pneumonia its componenets Backpain, photosensitivity
B: Tavanic P: 500mg tab OD gram- negative and gram- Nosocomial pneumonia  Check vital signs
positive aerobic and esp. BP,
G: Levofloxacin anaerobic bacteria
C: Anti-infwctive

:
 NURSING ASSESSMENT II

Name Patient X_______ Age 76 y/o____ Sex Male__

Chief Complaint DOB _________________________________
Impression/Diagnosis Tetanus _____________
Date/Time of Admission June 14, 2012 Inclusive Dates of Care June 29-30 &July 3-4, 2012_
Diet: Full adult diet ___________________ Allergies N/A _______ __
Type of Operation (if any) Tracheostomy insertion __________

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

DAY 1 DAY 2

The 76 years old patient was a very

active person, every day he usually
1.ACTIVITIES- REST
goes to town at early in the morning
a. Activities and go back home at the evening,
he is fond of visiting his relatives
b. Rest
around the town according to the
c. Sleeping pattern SO. He usually sleep early in the
evening and wakes up early to work
at their farm or to go to the city.
The patient was not active, he was
confined on his bed due to his
present condition, he spends most of
his time on bed, he spends most of
his time sleeping or resting, but due
to the hospital setting or the
medication administration, his
sleeping was always disturbed.
The patient was not active, he was
confined on his bed due to his
present condition, he spends most of
his time on bed, he spends most of
his time sleeping or resting, but due
to the hospital setting or the
medication administration, his
sleeping was always disturbed.
The patient was not active, he was
confined on his bed due to his
present condition, he spends most of
his time on bed, he spends most of
his time sleeping or resting, but due
to the hospital setting or the
medication administration, his
sleeping was always disturbed.

2.NUTRITIONAL- METABOLIC
a. Typical intake(food, fluid)
b. Diet
c. Diet restrictions
d. Weight
e. Medications/supplement
food
3. ELIMINATION
The patient has no diet restriction,
he just eat what he wants, and he is
fond of fruits and vegetables, he
eats a lot of rice, he is also fond of
eating meat such as chicken, pork
and cow meat
(Weight was not taken)
Patient was taking multivitamins
which can’t be recalled by the SO.
The patient usually urinate three to
The patient’s diet is “Full Adult Diet”,
he only consume foods (Ensure)
prepared by the hospital, he is being
fed via NGT or nasogastric tube
because patient has difficulty
swallowing, due to lockjaw.
(Weight was not taken)
Patient was given medication via
NGT, and the medication is
sucralfate.
The patient’s diet is “Full Adult Diet”,
he only consume foods (Ensure)
prepared by the hospital, he is being
fed via NGT or nasogastric tube
because patient has difficulty
swallowing, due to lockjaw.
(Weight was not taken)
Patient was given medication via
NGT, and the medication is
sucralfate.
The patient’s diet is “Full Adult Diet”,
he only consume foods (Ensure)
prepared by the hospital, he is being
fed via NGT or nasogastric tube
because patient has difficulty
swallowing, due to lockjaw.
(Weight was not taken)
Patient was given medication via
NGT, and the medication is
sucralfate

a. Urine (frequency, color,
transparency)
b. Bowel (frequency, color,
consistency)
4. EGO INTEGRITY
a. Perception of self
b. Coping Mechanism
c. Support System
d. Mood/Affect
four times a day, usually the color of
the urine according to the SO is
amber in color and is transparent.
The patient usually defecates one to
two times a day, and the waste or
stool is usually yellow to brown in
color, sometimes the stool is quite
watery but most of the time it is
formed.
The patient was a very active 76
year old man, he is a very caring
grandfather according to the SO,
and when every time he is sad, he
just plays with his grandchildren or
drink with his friends. The patient is
also supported by his family
members such as his children,
nieces, nephews and grandchildren
The patient had a urine at 300 mL;
urine is amber in color and is
transparent.
The patient has not defecated
during the shift.
The patient perception of self was
not assesses because patient can’t
talk. Though it can be seen that he’s
sad and having hard time due to his
condition and his family members
are acting as his support system
since his wife is gone.
The patient had a urine output of
200 mL; urine is amber in color and
is transparent.
The patient has not defecated
during the shift.
The patient perception of self was
not assesses because patient can’t
talk. Though it can be seen that he’s
sad and having hard time due to his
condition and his family members
are acting as his support system
since his wife is gone.
The patient had a urine output of
500 mL; urine is amber in color and
is transparent.
The patient has defecated once
during the shift, the stool is slightly
watery and yellow and brown in
color.
The patient smiles when ever his SO
jokes around or asks him funny
things. His family members are
acting as his support system since
his wife is gone. He is starting to
have brighter facial expression.

5. NEURO-SENSORY
Patient is mentally capable, there
a. Mental state were no visible abnormalities
reported or discovered according to
the SO.
b. Condition of five senses:
According to the SO, before
(sight, hearing, smell, taste,
hospitalization the patient has no
touch) impairment in five senses reported
or discovered, so all five senses are
functioning
Patient is lethargic, he only respond
to painful or sudden touch by the
SO,
Senses were not assessed
Patient is awake but drowsiness
noted.
The sense of touch, sight, and
hearing are functioning he responds
to touch, movement of hand (sight)
and voice of the SO and the student-
nurse.
Smell and taste were not assessed
Patient is awake and respond to
verbal stimuli (questions) by
nodding, he also respond to visual
stimuli (hand movement) assesses
by asking patient if he has seen a
hand, then patient respond by
nodding means yes, the patient also
respond to touch, because he always
have facial grimace whenever SO
suddenly move a limb of the patient.
6. OXYGENATION

a. Vital signs

Temperature Not Taken 37.6 ⁰C 38 ⁰C 38

Respiratory rate Not Taken 36 cpm 40 cpm 29

Heart rate Not Taken 118 bpm 119

92 bpm
Blood pressure Not Taken 110/70 mmHg 120/70
120/70 mmHg
b. Lung sounds Not Taken Crackles auscultated over lung fields Crackles auscultated over lung fields
No history of respiratory problems,
c. History of Respiratory No history of respiratory problems, except for cough cases No history of respiratory problems, No history of respiratory problems,
except for cough cases except for cough cases except for cough cases
Problems

7. PAIN-COMFORT The patient shows facial grimace The patient shows facial grimace
According to the SO the patient The patient shows facial grimace whenever the SO suddenly move a whenever the SO suddenly move a
a. Pain (location, onset,
usually experience headache and whenever the SO suddenly move a limb of the patient. limb of the patient.
character, intensity, duration,
muscle aches. It is usually alleviated limb of the patient.
associated symptoms,
by sleeping or taking mefenamic Pain is alleviated through Pain is alleviated through
aggravation)
acid or paracetamol Pain is alleviated through touch(gentle tapping) of the touch(gentle tapping) of the
touch(gentle tapping) of the patient’s daughter. patient’s daughter.
patient’s daughter.
b. Comfort
Medication taken by the patient
measures/Alleviation
were multivitamins, mefenamic ND Medications:
Paracetamol.
c. Medications

The patient is confined on his bed The patient is confined on his bed
8. HYGIENE AND ACTIVITIES The patient usually wake up early to The patient is confined on his bed due to his present condition, he due to his present condition, he
 OF DAILY LIVING
9. SEXUALITY
a. female (menarche, menstrual
cycle, civil status, number of
children, reproductive status)
b. male (circumcision, civil
status, number of children)
work or visit his relatives around the
town, then goes back home in the
evening, he takes a bath once a day,
and changes clothes every day too,
he is the one attending to his
hygiene, he usually sleep early in the
evening, according to the SO the
patient spends too much time
grooming before going outside their
house.
A case of seventy six years old male,
widow and circumcised at the age of
14.
LABORATORY AND DIAGNOSTIC PROCEDURES
due to his present condition, he
spends most of his time on bed, he
spends most of his time sleeping or
resting.
The personal hygiene of the patient
is performed and maintained by the
patient’s SO, the SO helps the
patient change clothes.
A case of seventy six years old male,
widow and circumcised at the age of
14.
spends most of his time on bed, he
spends most of his time sleeping or
resting.
The SN provided afternoon care and
helped the patient change clothes.
A case of seventy six years old male,
widow and circumcised at the age of
14.
spends most of his time on bed, he
spends most of his time sleeping or
resting.
The SN provided afternoon care,
while the SO helped the patient
change clothes.
A case of seventy six years old male,
widow and circumcised at the age of
14.
 DATE NAME OF THE PROCEDURE RESULT NORMAL VALUE NURSING IMPLICATION

June 27, 2012 HEMATOLOGY

Hgb 97 135-160g/L Below:anemia, infection

 Maintain adequate nutrition
 Be alert and report hemorrhage
which could decreased Hgb.
Hct 0.30 0.40-0.48g/L Below: anemia, infection
 Promote adequate fluid intake
 Promote adequate rest
RBC 3.5 4.0-5.5x1012/L Below: anemia
 Promote proper nutrition such as
eating foods like vegetables,fruits
and meat
WBC 17.7 5-10x1012/L Above: infection,leukemias,inflammatory
disorders,anemias.
 Monitor s/sx of infection
 Teach SO the proper handwashing
technique
 Encouraged SO to keep pt. away
from other people with
communicable disease

DIFF. COUNT:
Neutro 0.78 0.55-0.65 Above: acute infection
 Monitor pts condition and and
assess further aggravation of
infection
 Promote proper handwashing and
 proper disposal of waste
Lympho 0.15 0.25-0.40
Below: immunodeficiency
 Have respiratory precautions in
handling pt.
 Keep pt. away from other pts with
Eosino 0.05 0.01-0.05 infection
Within normal range
Platelet count 563 140-440x1012/L
Above: injury
 Observe for signs of bleeding
 Encourage adequate nutrition and
fluid intake
BLOOD CHEMISTRY

Creatinine 0.7mg/dl 0.6-1.2

SGPT 223U/L Up to 35 Within Normal Range
Sodium 126.3mmol/L 135-148mmol/L
Potassium 5.06mmol/L 3.5-5.3mmol/L Below:
Within Normal Range

June 29, 2012 HEMATOLOGY

Hgb 103g/L 135-160g/L

Below:anemia, infection
 Maintain adequate nutrition
 Be alert and report hemorrhage
which could decrease Hgb.

Hct 0.31g/L 0.40-0.48g/L

Below: anemia, infection
  Promote adequate fluid intake
12
WBC 11.5 5-10x10 /L  Promote adequate rest
Above: infection,leukemias,inflammatory
disorders,anemias.
 Monitor s/sx of infection
 Teach SO the proper handwashing
technique
 Encouraged SO to keep pt. away
from other people with
DIFF. COUNT: communicable disease
Neutro 0.81 0.55-0.65
Above: acute infection
 Monitor pts condition and and
assess further aggravation of
infection
 Promote proper handwashing and
proper disposal of waste
Lympho 0.18 0.25-0.40
Below: immunodeficiency
 Have respiratory precautions in
handling pt.
 Keep pt. away from other pts with
infection
Eosino 0.01 0.01-0.05
Within normal range
12
Platelet count 210.0 140-440x10 /L
Above: injury
 Observe for signs of bleeding
 Encourage adequate nutrition and
fluid intake
 SUMMARY OF INTRAVENOUS FLUID

DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED

JULY 4,2012; 7:50am # 10 D50.3NaCl ;L KVO 25 JULY 5,2012; 10:45 pm

JULY 5,2012; 10:45pm # 11 D50.3NaCl ;L KVO 25 JULY 7,2012; 6:45 am

COMPUTATION:

# of hours to run = volume in cc x drop factor

drops/min x 60 min

# of hours to run = 1000cc x 15gtts/min

10gtts/min x 60 min/hr

= 25 hours

SUMMARY OF MEDICATION
 DATE MEDICATIONS- dosage, frequency, route Remarks

July 3-6, 2012 Ciprofloxacin 2oo mg IVTT q 12 hours GIVEN, Taken and Tolerated

July 3-5, 2012 Meropenem 500 mg IVTT q 8 hours GIVEN, Taken and Tolerated

July 3-6,2012 Sodium chloride 1 g 2 tabs PO TID GIVEN, Taken and Tolerated

July 3-6,2012 Calcium lactate 1 tab PO OD GIVEN, Taken and Tolerated

July 3-6,2012 Acetaminophen 300mg 1 amp q 4 hours prn GIVEN, Taken and Tolerated

July 3-6,2012 Acetylcysteine 600 mg in 1\2 glass of water\NGT OD @ HS GIVEN, Taken and Tolerated

July 3-6,2012 Lactulose 30 cc OD @ HS GIVEN, Taken and Tolerated

Amikacin 300mg IVTT q 8 hours ANST(-) ___(revised) GIVEN, Taken and Tolerated
July 3-4,2012
Levofloxacin 500mg tab OD GIVEN, Taken and Tolerated
July 3-6,2012
Amikacin 1amp IVTT q 8 hours ANST(-) GIVEN, Taken and Tolerated
July 4-6,2012
Paracetamol 300mg IVTT q 4h (PRN for fever) GIVEN, Taken and Tolerated
July 3-6,2012
Ipratropium bromide + albuterol SO4 GIVEN, Taken and Tolerated
July 3-6,2012
Clonidine 75mg ~ tab q 8h GIVEN, Taken and Tolerated
July 3-6,2012
Baclofen 10mg ~tab BID GIVEN, Taken and Tolerated
July 3-6,2012
Domperidon ~ tab TID GIVEN, Taken and Tolerated
July 3-6,2012
Sucralfate ~ gm q 6h per NGT GIVEN, Taken and Tolerated
July 3-6,2012
Muperocin BID GIVEN, Taken and Tolerated
July 3-6,2012
Azithromycin 500mg tab OD per NGT GIVEN, Taken and Tolerated
July 3-6,2012
Ranitidine 50mg IVTT q 8h GIVEN, Taken and Tolerated
 ANATOMY AND PHYSIOLOGY
The respiratory system is an intricate arrangement of spaces and passageways that conduct
Air from outside the body into the lungs and finally into the blood as well as expelling waste
gases. This system is responsible for the mechanical process called breathing with the average
adult breathing about 12 to 20 times per minute.
Alveoli
Are tiny sacks that are enveloped in a network of capillaries.
Nostrils/Nasal Cavities
During inhalation, air the nostrils and passes into the nasal cavities where foreign bodies
are removed, the air is heated and moisture before it is brought further in the body.
Sinuses
Are small cavities that are lined with mucous membrane within the bones of the skull.
Pharynx/Throat
Carries food and liquid into the digestive tract and air in the respiratory tract.
Larynx/Voice Box
Located between pharynx and trachea. It is the location of adam’s apple, which is the
Thyroid gland and houses the vocal cords.
Trachea/ Wind Pipe
Is a tube that extends from the lower edge of the larynx to the upper part of the chest
And conducts air between the larynx and lungs.
Lungs
Organ which the gases takes place. At the lungs, the bronchi subdivide becoming
smaller as they branch through the lung tissue, until they reach the air sacks called
alveoli.
Bronchi

The trachea divides into two parts called bronchi which enters the lungs.

Bronchioles

Bronchi subdivided creating a network of small braches with the smallest

One being the bronchioles.

 The Brain
Three cavities, called the primary brain vesicles, form during the early embryonic development of the brain. These are the forebrain (prosencephalon), the midbrain
(mesencephalon), and the hindbrain (rhombencephalon).

During subsequent development, the three primary brain vesicles develop into five secondary brain vesicles. The names of these vesicles and the major adult structures that
develop from the vesicles follow (see Table 1):

 The telencephalon generates the cerebrum (which contains the cerebral cortex, white matter, and basal ganglia).
 The diencephalon generates the thalamus, hypothalamus, and pineal gland.
 The mesencephalon generates the midbrain portion of the brainstem.
 The metencephalon generates the pons portion of the brainstem and the cerebellum.
 The myelencephalon generates the medulla oblongata portion of the brainstem.
 The cerebrum consists of two cerebral hemispheres connected by a bundle of nerve fibers, the corpus callosum. The largest and most visible part of the brain, the
cerebrum, appears as folded ridges and grooves, called convolutions. The following terms are used to describe the convolutions:
o A gyrus (plural, gyri) is an elevated ridge.

o A sulcus (plural, sulci) is a shallow groove.

o A fissure is a deep groove.

The deeper fissures divide the cerebrum into five lobes (see Figure 1; most lobes are named after bordering skull bones): the frontal lobe, the parietal lobe, the temporal
lobe, the occipital lobe, and the insula. All but the insula are visible from the outside surface of the brain.

A cross section of the cerebrum shows three distinct layers of nervous tissue (see the list below and Figure 2):

o The cerebral cortex is a thin outer layer of gray matter. Such activities as speech, evaluation of stimuli, conscious thinking, and control of skeletal muscles occur
here. These activities are grouped into motor areas, sensory areas, and association areas.
o The cerebral white matter underlies the cerebral cortex. It contains mostly myelinated axons that connect cerebral hemispheres (association fibers), connect gyri
within hemispheres (commissural fibers), or connect the cerebrum to the spinal cord (projection fibers). The corpus callosum is a major assemblage of association
fibers that forms a nerve tract that connects the two cerebral hemispheres.
o Basal ganglia (basal nuclei) are several pockets of gray matter located deep inside the cerebral white matter. The major regions in the basal ganglia—the caudate
nuclei, the putamen, and the globus pallidus—are involved in relaying and modifying nerve impulses passing from the cerebral cortex to the spinal cord. Arm
swinging while walking, for example, is controlled here.
 The diencephalon connects the cerebrum to the brainstem. It consists of the following major regions:
o The thalamus is a relay station for sensory nerve impulses traveling from the spinal cord to the cerebrum. Some nerve impulses are sorted and grouped here before
being transmitted to the cerebrum. Certain sensations, such as pain, pressure, and sensitivity to temperature, are also evaluated here.
o The epithalamus contains the pineal gland. The pineal gland secretes melatonin, a hormone that helps regulate the biological clock (sleep-wake cycles).

o The hypothalamus regulates numerous important body activities. It controls the autonomic nervous system and regulates emotion, behavior, hunger, thirst, body
temperature, and the biological clock. It also produces two hormones (antidiuretic hormone or ADH, and oxytocin) and various releasing hormones that control
hormone production in the anterior pituitary gland.

The following structures are either included or associated with the hypothalamus:

o The mammillary bodies relay information related to eating, such as chewing and swallowing.
o The infundibulum connects the pituitary gland to the hypothalamus.

o The optic chiasma passes between the hypothalamus and the pituitary gland. Here, portions of the optic nerve from each eye cross over to the cerebral hemisphere
on the opposite side.
 The brainstem connects the diencephalon to the spinal cord. The brainstem resembles the spinal cord in that both consist of white matter fiber tracts surrounding a core of
gray matter. The brainstem consists of the following four regions, all of which provide connections between various parts of the brain and between the brain and the spinal
cord. (Some prominent structures of the brainstem regions are listed in Table 2 and illustrated in Figure 3, which also illustrates the relationship of the cranial nerves to the
brainstem.)
 Anatomy and physiology of urinary system

The urinary system comprises the kidneys, ureters, bladder, and urethra. A thorough understanding of the urinary system is necessary for assessing individuals with acute or
chronic urinary dysfunction and implementing appropriate nursing care.
Anatomy of the Upper and Lower Urinary Tracts The urinary system—the structures of which precisely maintain the internal chemical environment of the body—perform various
excretory, regulatory, and secretory functions.
The kidneys are a pair of brownish-red structures located retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen from the 12th thoracic
vertebra to the 3rd lumbar vertebra in the adult
An adult kidney weighs 120 to 170 g (about 4.5 oz) and is 12 (about 4.5 inches) long, 6 cm wide, and 2.5 cm thick. The kidneys are well protected by the ribs, muscles, Gerota’s fascia,
perirenal fat, and the renal capsule, which surround each kidney.
The kidney consists of two distinct regions: Renal Parenchyma Renal Pelvis
The renal parenchyma is divided into the cortex and the medulla. The cortex contains the glomeruli, proximal and distal tubules, and cortical collecting ducts and their adjacent
peritubular capillaries. The medulla resembles conical pyramids. The pyramids are situated with the base facing the concave surface of the kidney and the apex facing the hilum, or pelvis
Renal Parenchyma
The hilum, or pelvis, is the concave portion of the kidney through which the renal artery enters and the renal vein exits. The renal artery (arising from the abdominal aorta) divides into
smaller and smaller vessels, eventually forming the afferent arteriole. Renal Pelvis
The afferent arteriole branches to form the glomerulus , which is the capillary bed responsible for glomerular filtration. Blood leaves the glomerulus through the efferent arteriole and
flows back to the inferior vena cava through a network of capillaries and veins. Renal Pelvis
Each kidney contains about 1 million nephrons, the functional units of the kidney. Each kidney is capable of providing adequate renal function if the opposite kidney is damaged or
becomes nonfunctional. Nephrons
The nephron consists of a glomerulus containing afferent and efferent arterioles, Bowman’s capsule, proximal tubule, loop of Henle, distal tubule, and collecting ducts. Collecting ducts
converge into papillae, which empty into the minor calices, which drain into three major calices that open directly into the renal pelvis. Nephrons
Nephrons are struturally divided into two types: cortical and juxtamedullary.
The glomerular membrane normally allows filtration of fluid and small molecules yet limits passage of larger molecules, such as blood cells and albumin. Kidney function begins to
decrease at a rate of approximately 1% each year beginning at approximately age 30.
The glomerulus is composed of three filtering layers: the capillary endothelium, the basement membrane, and the epithelium.
Kidneys • Urine formation • Excretion of waste products • Regulation of electrolytes • Regulation of acid–base balance • Control of water balance • Control of blood pressure • Renal
clearance • Regulation of red blood cell production • Synthesis of vitamin D to active form • Secretion of prostaglandins
 Ureters Urine, which is formed within the nephrons, flows into the ureter, a long fibromuscular tube that connects each kidney to the bladder. The ureters are narrow, muscular
tubes, each 24 to 30 cm long, that originate at the lower portion of the renal pelvis and terminate in the trigone of the bladder wall.
There are three narrowed areas of each ureter: ureteropelvic junction ureteral segment ureterovesical junction
The angling of the ureterovesical junction is the primary means of providing antegrade, or downward, movement of urine, also referred to as efflux of urine. This angling prevents
vesicoureteral reflux, which is the retrograde, or backward, movement of urine from the bladder, up the ureter, toward the kidney. ureterovesical junction
The angling of the ureterovesical junction is the primary means of providing antegrade, or downward, movement of urine, also referred to as efflux of urine. This angling prevents
vesicoureteral reflux, which is the retrograde, or backward, movement of urine from the bladder, up the ureter, toward the kidney. ureterovesical junction
During voiding ( micturition), increased intravesical pressure keeps the ureterovesical junction closed and keeps urine within the ureters. As soon as micturition is completed,
intravesical pressure returns to its normal low baseline value, allowing efflux of urine to resume. Therefore, the only time that the bladder is completely empty is in the last seconds of
micturition before efflux of urine resumes.
The angling of the ureterovesical junction is the primary means of providing antegrade, or downward, movement of urine, also referred to as efflux of urine. This angling prevents
vesicoureteral reflux, which is the retrograde, or backward, movement of urine from the bladder, up the ureter, toward the kidney. ureterovesical junction
The left ureter is slightly shorter than the right” Did Y OU k now ?
The lining of the ureters is made up of transitional cell epithelium called urothelium. As in the bladder, the urothelium prevents reabsorption of urine. The movement of urine
from the renal pelves through the ureters into the bladder is facilitated by peristaltic waves (occurring about one to five times per minute) from contraction of the smooth muscle in the
ureter wall (Walsh, Retik, Vaughan & Wein, 1998).
Ureters functions as tubes that actively convey urine from the kidneys to the bladder.
The urinary bladder is a muscular, hollow sac located just behind the pubic bone. The bladder is characterized by its central, hollow area called the vesicle, which has two inlets
(the ureters) and one outlet (the urethrovesical junction), which is surrounded by the bladder neck.
Adult bladder capacity is about 300 to 600 mL of urine. In infancy, the bladder is found within the abdomen. In adolescence and through adulthood, the bladder assumes its position in
the true pelvis.
The wall of the bladder comprises four layers: adventitia detrusor lamina propria urothelium
The urothelium layer is specialized, transitional cell epithelium, containing a membrane that is impermeable to water. The urothelium prevents the reabsorption of urine stored in the
bladder urothelium
The bladder neck contains bundles of involuntary smooth muscle that form a portion of the urethral sphincter known as the internal sphincter. The portion of the sphincteric mechanism
that is under voluntary control is the external urinary sphincter at the anterior urethra, the segment most distal from the bladder (Walsh et al., 1998).
The urinary bladder functions as a muscular sac that expands as urine is produced by the kidneys to allow storage of urine until voiding is convenient.
The urethra arises from the base of the bladder: In the male, it passes through the penis; in the female, it opens just anterior to the vagina. In the male, the prostate gland, which lies
just below the bladder neck, surrounds the urethra posteriorly and laterally.
The urethra is a muscular tube that drains urine from the body; it is 3–4 cm long in females, but closer to 20 cm in males.
The cardiovascular system is a continuation of that oxygenation process. The heart pumps blood through a closed system of blood vessels in order to bring oxygen and other nutrients to the cells
throughout the body.

In part I of the cardiovascular system we will gain an understanding of the various parts of this system and then put these organs together to gain an understanding of how blood is circulated
through the body.

In part II we will learn more about the blood itself.

The cardiovascular system consists of:

 The heart
 Blood vessels including arteries, capillaries, and veins
 Blood
The Heart

The heart is a muscular organ made up of involuntary striated muscle tissue. It is located in the thoracic cavity in between the lungs and just above the diaphragm. It is covered in protective
membranes called the pericardium. Besides forming a protective layer, these membranes also secrete a fluid that helps to reduce friction as tissues rub together during heart contractions.
The next layer of the heart is a thick layer of cardiac muscle tissue called the myocardium. It is the contraction of the myocardium that creates the force necessary to pump blood through the
body.

Attached to the outer surface of the myocardium is the epicardium. This membrane consists of blood vessels that nourish the heart.

Blood Supply

The heart is supplied blood through the coronary arteries, which come off of the aortic artery. Blockage of the coronary artery is what causes a heart attack.

The Heart Chambers

There are four chambers in the heart. The two upper chambers are called the atria. They receive blood from the veins. The two lower chambers are the ventricles. Blood is pumped from the
ventricles to the arteries and to the rest of the body. The heart consists of two pumps. The left atrium and left ventricle is the left pump. The right atrium and the right ventricle is the right pump.
There is no opening between the atria or between the ventricles. Instead, there are valves in between the atria and the corresponding ventricles.

The Heart Valves

There are two types of valves located in the heart: the atrioventricular valves and the semilunar valves. The atrioventricular valves are located between each atrium and its corresponding
ventricle. These valves allow blood to flow from the atrium to the ventricle without allowing any blood to flow backwards from the ventricle to the atrium. The two atrioventricular valves are the
tricuspid valve and the mitral valve.

Semilunar valves are located in the arteries that carry blood from the ventricles to the rest of the body. The two semilunar valves are called the pulmonary semilunar valve and the aortic
semilunar valve.

The sound we associate with the heartbeat is actually the closing of the heart valves. “Lub-dub” is the sound often used to describe the sound of the heartbeat. The first sound, “lub”, is the sound
of the atrioventricular valves closing. The second sound, “dub”, is the sound of the semilunar valves. If any of the heart valves are not working correctly then another sound might be heard. This
is referred to as a heart murmur.

Blood vessels

There are three main types of blood vessels. Arteries, capillaries, and veins form a system of tubes that carry blood to and from the heart. The blood vessels form an incredible network of tubes
throughout the body. An adult has as many of 100,000 miles of blood vessels in their body.

Arteries

These large blood vessels are made of a thick muscular layer to withstand higher blood pressure. They carry blood from the heart to the capillaries.

Capillaries
Capillaries form a vast network of very small vessels that enable the exchange of materials between blood and the tissue cells. The term capillary bed refers to a network of capillaries that supply
blood to an organ.

Veins

Veins return blood from the capillaries back to the heart. They are made up of a relatively thin muscular layer and contain internal valves to keep the blood from ever flowing backwards. About
60% of the blood volume is located in the veins at any given time.

Blood Flow

Deoxygenated blood from the body flows from the superior and inferior vena cava veins to the right atrium. This blood is pumped to the right ventricle and then proceeds to the pulmonary trunk
where it is oxygenated by the act of inhalation. This newly oxygenated blood then flows through pulmonary veins to the left atrium and is pumped to the left ventricle to continue to the aorta and
the rest of the body. These are referred to as the pulmonary and systemic circuits.

Assists deoxygenated blood from the right ventricle to the lungs and then
Pulmonary Circuit assists newly oxygenated blood from the lungs to the left atrium. (This is the
flow of blood between the heart and lungs.)

Assists oxygenated blood to all parts of the body (except the lungs) and then
Systemic Circuit returns deoxygenated blood to the right atrium. (This is the flow of blood
from the heart to the rest of the body.)
 PATHOPHYSIOLOGY

Precipitating Factors of Tetanus:

>Work (Farming)

>Exposure to bacteria (wounds/lacerations)

Clostridium Tetani bacteria containing virulence plasmids enter wound

Toxins are produced

Spores germinate under anaerobic conditions

Vegetative Spore

Cell Lysis

Production of exotoxins (Tetanolysin &Tetanospasmin)

Tetanolysin Tetanospasmin

Potentiating of infection spread via

Release of biochemical mediators of inflammatory response Blood vessels Lymphatics Neural Pathy

Inflammatory response Endocellar damage Depress immune system Blocks the release of inhibitory transmitters

Endothelia permeability Excitatory activities

Capillary Phagocytosis and removal of debris
Platelet & Fibrin deposition Generalized tonic muscle spasm occur
Blood flow Release of pyrogens
 Blood Pressure
Swelling Redness Stimulation of hypothalamus to
Increase body temperature Tissue ischemia

Fever end organ dysfunction A

Pharynx Cranial Facial Masseter Glottis Respiratory muscles

Aspiration of oral secretions Rapid firing of impulses Fixed smile & elevated Lock Jaw
Eyebrows Failure to speak Chest wall muscle Diaphragm
or cry

Pneumonia Asphyxiation

Hypoxemia

Cardiac arrest Respiratory Distress

Death
 MEDICAL MANAGEMENT

IDEAL

Medical Management: Tetanus

1. Antibiotics, including penicillin, clindamycin, erythromycin, and metronidazole

2. Bed rest with a nonstimulating environment ( dimlight, reduced noise, and stable temperature)

3. Tetanus immune globulin- to reverse the poison

4. Muscle relaxants such as diazepam

5. Sedatives

6. Breathing support with oxygen, a breathing tube, and breathing tube and a breathing machine

Medical Management: Pneumonia

1. Maintaining adequate oxygenation

2. Sputum specimen for culture and sensitivity should be obtained prior to initiating antibiotic therapy

3. Antiviral agents

4. Prophylactic antibiotic therapy

5. Bronchodilators

6. Mucolytic agents

7. Expectorants

8. Cough suppressants and pain relievers

9. Pneumococcal vaccine
Diet: Adequate Hydration

Medical Management: Hypertension

1. Diuretic

2. Beta-adrenergic blocking agents

3. Alpha1-receptor blockers

4. Angiotensin- converting enzyme inhibitors

5. Calcium channel blockers

6. Centrally acting alpha2-agonists

7. Peripherally acting adrenergic antagonists

8. Direct vasodilators

Diet: Low fat, Low cholesterol, and Low sodium diet

Medical Management: Pseudomonas

1. Aminoglycosides

2. Antipseudomonal Agents( tirarcillin, piperacillin, mezlocillin, ceftazidine)

ACTUAL

June 27, 2012

Hematology
Differential count
Blood chemistry
June 29, 2012
 Hematology
Differential count

Diet: Full adult Diet

July 3-4,2012

Amikacin 300mg IVTT q 8 hours ANST(-) ___(revised)

July 3-5, 2012

Meropenem 500 mg IVTT q 8 hours

July 3-6, 2012

Ciprofloxacin 2oo mg IVTT q 12 hours

Sodium chloride 1 g 2 tabs PO TID

Calcium lactate 1 tab PO OD

Acetaminophen 300mg 1 amp q 4 hours prn

Acetylcysteine 600 mg in 1\2 glass of water\NGT OD @ HS

Lactulose 30 cc OD @ HS

Levofloxacin 500mg tab OD

Paracetamol 300mg IVTT q 4h (PRN for fever)

Ipratropium bromide + albuterol SO4

Clonidine 75mg ~ tab q 8h

Baclofen 10mg ~tab BID

Domperidon ~ tab TID

Sucralfate ~ gm q 6h per NGT

Muperocin BID

Azithromycin 500mg tab OD per NGT

 Ranitidine 50mg IVTT q 8h

July 4-6,2012

Amikacin 1amp IVTT q 8 hours ANST(-)

July 4, 2012

IVF # 10 D50.3 1L@KVO

July 5,2012

IVF # 11 D50.3 1L@KVO

 NURSING MANAGEMENT

IDEAL:

Nursing Interventions: Pneumonia

1. Maintain a patent airway and adequate oxygenation.
2. Obtain sputum specimens as needed.
3. Use suction if the patient can’t produce a specimen.
4. To prevent aspiration during nasogastric tube feedings, check the position of tube, and administer feedings slowly.
5. To control the spread of infection, dispose secretions properly.
6. Provide a quiet, calm environment, with frequent rest periods.
7. Assess the patient’s respiratory status. Auscultate breath sounds at least every 4 hours.
8. Monitor fluid intake and output.
9. Evaluate the effectiveness of administered medications.
10. Explain all procedures to the patient and family.

Nursing Interventions: Hypertension

1. Vital signs should be checked 2 hourly with emphasis on Blood pressure and pulse rate.
2. Monitor patient's weight daily and keep proper record. This is to help detect edema or weight loss.
3. Patient should be advised to avoid stress and tension.
4. Constipation should be avoided because it makes the patient strain at defecation thereby further elevating the blood pressure.
5. Encourage relaxation techniques
6. Give fluid restriction and sodium diet as indicated.

Nursing Interventions: Tetanus

1. Inspect the patient for neuromuscular changes.
2. Provide and maintain patent airway.
3. Provide comfort measures.
4. Provide good nutritional support.
5. Protect patient from injuries.
6. Have intubation and suction equipment immediately available at the bedside should the patient require.
7. Turn the patient every 2 hours.

8. Provide emotional support to the patient as well as to the patient’s family.

Nursing Interventions: Pseudomonas Infection
1. For respiratory infection, maintain a patent airway by suctioning secretions whenever necessary and provide adequate oxygen.
2. Administer ordered analgesics as needed.
3. Protect immune compromised patients from exposure to infection.
4. Use strict sterile technique when changing dressings that involve infected wounds.
5. Reinforce the importance of completing the course of antibiotic therapy as prescribed.
6. Tell the patient to avoid drinking water when traveling to endemic areas.
7. Avoid using humidifiers in the patient’s room.

ACTUAL:

1. Monitored and recorded vital signs.

2. Checked and regulated IVF at prescribed flow ratwe.
3. Provided bed side care.
4. Provide comfort measures.
5. Monitored patient’s five senses and mental status.
6. Assisted SO in positioning the patient every 2 hours.
7. Gave fluid and diet restrictions as ordered by the physician.
8. Maintained patent airway.
9. Provided patient time to sleep and rest.
10. Provided a calm, cool environment.
11. Auscultated breath sounds to notify for any changes.
12. Monitored intake and output.
13. Encouraged patient to use mask and clean gloves as much as possible during interaction with the patient.
14. Provided health teaching on:

 Infection control
 Proper diet
 Proper hygiene
 SURGICAL MANAGEMENT

IDEAL

Surgical Management: Tetanus

1. Debridement - to clean the wound and remove the source of poison

-removal of dead tissue by mechanical surgical or autolytic means

Surgical Management: pneumonia

1. Thoracotomy - standard surgery for pneumonia. It requires general anesthesia and an incision to open the chest and view the lungs.

2. Chest tubes – used to drain infected pleural fluid.

Surgical Management: Hypertension

No surgical management

Surgical Management: Pseudomonas

1. Debridement of necrotic tissue

2. Removal of infected medical devices if possible

3. Malignant otitis requires for bowel necrosis, perforation, obstruction, or abscess drainage

4. Vitrectomy may be needed in cases of endophthalmitis

-is an intraocular procedure in which 1- to -4 mm incisions are made at the pans plana

ACTUAL
 TRACHEOSTOMY- a surgical procedure in which an opening is made into the trachea.

DISCHARGE PLAN

NAME ______DAUG, Jorge M.______________________________ DATE OF DISCHARGE: ____________________

CONDITION UPON DISCHARGE Must be well _________ Nature: Home per request ( ) Discharge against medical advice ( )

 Encourage SO not to forget to let patient take medications at right time, dosage, and route and always check for
expiration.
1. MEDICATIONS  Encourage SO to keep drugs at dry, cool place.
 Encourage SO not to double dose if forgotten to take medications on scheduled time.
 Encourage SO to let the patient eat before taking the medications to lessen GI irritation, unless otherwise
prescribed.
 Encourage SO to help monitor the medications taken.
 Encourage SO to exercise the body parts of the patient.
 Encourage SO to raise and elevate the legs of the patient when lying on bed to promote venous blood return.
2. EXERCISE  Encourage SO to provide passive ROM.
 Encourage SO to reposition patient every two hours to prevent bed sores.
 Encourage adequate periods of rest and sleep to prevent fatigue.
 Encourage SO to let the patient eat healthy foods such as vegetables and fruits to promote faster recovery.
 Encourage increased intake of fluid to promote hydration.
3. DIET  Encourage SO to follow recommended diet for the patient.

 Teach SO about the importance of Infection Control such as proper hand washing.
 Teach SO about the importance of practicing proper hygiene.
4. HEALTH TEACHING  Provide demonstration on deep breathing exercises.
 Discuss the proper way of coughing and the DO’s and DON’T’s when coughing.

 Encourage SO and the patient to visit physician on the scheduled appointment.

 Encourage SO to report to the physician if severe adverse effects of medications are experienced.
5. SCHEDULE FOR THE NEXT VISIT  Encourage SO to always seek for medical advice for any problems.
 Encourage SO and the patient to visit the hospital 1- 2 weeks after discharge.
 Recommend for follow- up care for the benefits of the patient.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “basin mag bara ang
tracheostomy kay permi
daghan plema na mugawas”,
as verbalized by the SO.
O: 3:00pm, received patient
lying in bed in a supine
position, uncoscious, with #8
D5 0.3 NaCl, 400 cc level left,
regulated @ 10 gtts/min,
hooked @ the right arm, FBC
is @50cc level and also with
tracheostomy insertion
connected with oxygen with
flow rate of 1.5L/min.
 With initial v/s:
T-37.5 degree Celsius
P- 100bpm
R- 30 cpm
BP- 120/80 mmHg
 With tracheostomy noted
 With NGT noted
 DOB noted
 Coughing noted
 Tachypnea noted
 Exessive mucus secretion
noted
 Lock-jaw noted
 Crackles auscultated on
left and right upper lobes
of the lungs noted
 Weakness noted
 Lathargy noted
Risk for aspiration r/t
excessive mucus secretion
and impaired swallowing due
to lock jaw secondary to
Tetanus
Within my 8 hours of nursing
care, I will be able to identify
factors risk for aspiration so
that the patient’s risk for
aspiration will be decreased
as a result of early
intervention.
Monitor v/s
Provide bedside care
Monitor and regulate IVF
Monitor level of
consciousness
Observe for food particles
in tracheal secretions at
the tracheostomy
Clean excreted mucus at
tracheostomy
Keep suction set up
available at bedside
Explain to the SO the need
for proper positioning
Instruct on proper feeding
techniques
Place IVF in a side where
the patient can’t see
 To obtain baseline
data
to promote comfort
 to prevent cardiac
and fluid overload
 a decreased LOC is a
prime risk factor for
aspiration
 presence of food
particles is a sign of
aspiration
 for this can
contribute to
aspiration
 this is necessary to
maintain patent
airway
 to decrease the risk
of aspiration

 to reduce the risk of
aspiration
 patient with tetanus
may have or develop
hydrophobia

CUES
S: “laayan man ko magbantay,
gapahangin ko sahay sa
gawas”, as verbalized by the
SO.
O: 3:00pm, received patient
lying in bed in a supine
position, uncoscious, with #8
D5 0.3 NaCl, 400 cc level left,
regulated @ 10 gtts/min,
hooked @ the right arm, FBC
is @50cc level and also with
tracheostomy insertion
connected with oxygen with
flow rate of 1.5L/min.
 With initial v/s:
T-37.5 degree Celsius
P- 100bpm
R- 30 cpm
BP- 120/80 mmHg
 Patient is
unconscious
 Patient’s watcher is
not always at the
patient’s bedside
noted
 Restlessness noted
 Lock-jaw noted
NURSING DIAGNOSIS
Risk for injury r/t presence of
disease process,
neuromuscular impairment,
secondary to tetanus
NURSING CARE PLAN
OBJECTIVES
Within my 8 hours of nursing
care, the patient’s
environment will be modified
as indicated to enhance
safety and free of injury.
INTERVENTIONS
Monitor v/s
Provide bedside care
Monitor and regulate IVF
Assess patient’s muscle
strength
Encourage SO to
participate
teach SO to control the
environment such as
dimming or turning off
lights
teach SO to control the
environment such as
reducing the noise
production
ask SO to stay at patient’s
side at all times
make sure that the side
rails are up
discuss to SO the
importance of monitoring
of condition or emotions
RATIONALE EVALUATION
 To obtain baseline
data
to promote comfort
 to prevent cardiac
and fluid overload
 to identify risk for
falls
 to enhance
commitment to plan
 patient’s with tetanus
are irritable, it may
stimulate seizure
 patient’s with tetanus
are irritable, it may
stimulate seizure
 to prevent possible
injuries
 to prevent falls
 fatigue, anger,
irritability can
contribute to
occurrence of injury

CUES
S: “murag ga lisud siya pag
ginhawa”, as verbalized by
the SO.
O: 3:00pm, received patient
lying in bed in a supine
position, uncoscious, with #8
D5 0.3 NaCl, 400 cc level left,
regulated @ 10 gtts/min,
hooked @ the right arm, FBC
is @50cc level and also with
tracheostomy insertion
connected with oxygen with
flow rate of 1.5L/min.
 With initial v/s:
T-37.5 degree Celsius
P- 100bpm
R- 30 cpm
BP- 120/80 mmHg
 DOB noted
 Tachypnea noted
 Cough noted
 Grunting noted
NURSING DIAGNOSIS
Ineffective breathing pattern
r/t presence of disease
process, neuromuscular
impairment, secondary to
tetanus
NURSING CARE PLAN
OBJECTIVES
Within my 8 hours of nursing
care, I will be able to identify
factors that affects patients
breathing pattern
INTERVENTIONS RATIONALE EVALUATION
Monitor v/s  To obtain baseline
data
Provide bedside care to promote comfort
Monitor and regulate IVF
 to prevent cardiac
and fluid overload
Auscultate chest  to evaluate presence
or character of breath
sounds and
secretions
 Evaluate cough
 to indicate possible
 Assess for obstruction
concomitant pain or  that may restrict
discomfort respiratory effort
 Encourage  to promote proper
positioning breathing
 Stress importance of
good posture to SO  to facilitate deeper
respiratory effort
 Modify environment  to prevent
(noise reduction, irritability
dimming of light)
 Encourage adequate  to prevent fatigue
rest periods