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REVIEW OF SYSTEM

Name: Patient X Date: October 3, 2011

Vital SignsTemperature: 37.9 CPulse: 92 bpm Height: 165 cmRespiration: 19 cpm Weight: 67 kgBlood Pressure: 130/80 mm Hg Observation: Received patient, sitting on bed, conscious, alert and coherent with

#3 PNSS 1Lregulated @ 20gtts/min, infusing well on the left arm with IV left of

820 cc.

1. General

Pt is awake and conscious; sitting on bed with an IV hooked at the left arm. Pt was wearing a splint made by scarf and has a bandage placed at the fracturesite. Blisters were seen around the portion of the fractured site. Pt appears at his age. Skin is intact and even in color. Facial features are symmetric in theenvironment. Keloids were present. Ht and wt appears within normal range. Dress is appropriate to climate, looks clean and fits to the body well. Pt smellsunpleasantly.

2. HEENT

Normocephalic, position at the midline, erect and still; head is without lesions and nodules. Hair is unkempt; symmetric facial expressions; no observed facialweakness; pt has good focus on objects. Eyebrows preset bilaterally and eyeglasses are evenly distributed. Hair color is gray and white and not evenlydistributed. Eyelashes aligned normally and no sunken appearance. Conjunctiva is pink and has anicteric sclera. Ears equal in size and ears skin color isinconsistent with facial color, nose is symmetric in the midline and in proportion to other features. Throat is pink and moist; no swelling and inflammation.

3. IntegumentaryHair color is gray and white and moustache and beard is present. No lesions found on the scalp. Nails are firmly attached to nailbed. Surface is smooth andregular. Left hand is pale; nails are pail and are cold to touch. Capillary refill time ate the right arm is >3 sec. Nails are uniform in thickness but is dirty. Pt hasgood skin turgor w/c is right for his age except for the right arm where fracture is present. Swelling and edema is present on the right arm.

4. RespiratoryEqual and symmetric chest expansion. Spinous process appears in straight line. Scapulae are placed symmetrically and pt is related when breathing. Chestskin color is consistent and even. Chest surface has no lesions, no lumps cyst on the chest; has clear breath sounds; no adventitious sounds noted. Ptsfacial expression when breathing is relaxed and breathing is automatic, effortless, regular, even and produces no noise. (-) cyanosis (-) nasal flaring

5. Cardiovascular PMI is located at the 5th

ICS Left MCL; without murmurs. S1 and S2 is clear. Pulse at the right arm (radial pulse) is not pal[able because edematous skin.Radial pulse at the Left arm is palpable. CRT

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6. DigestiveLips is dark, moist and symmetrical. (-) cracking,(-) lesions. Gums is pink and moist. Tongue is even in color and pink. Saliva is present. No white patches orlesions ar observed around the oral cavity. Buccal mucosa is pink smooth and moist. Uvula is at the midline. Abdomen is warm, smooth and symmetric andis even in color. Umbilicus is at the midline, abdomen is soft and nontender with normal active bowel sounds.

7. ExcretoryPt has micturated ate least 7x a day with a pale yellow urine. Patient has also defecated once with a yellow, semi-solid stool. Pt admits no pain duringmicturition or defeation.

8. MusculoskeletalSkin over the joint at the right arm is pale; pt has a closed fracture at the right elbow. Swelling and tenderness are noted over the joints upon palpation. Ptwas able to move his right fingers but feels pain when he moves his arm/elbow. Extremities are warm with joints intact. Unequal grips and strength on botharms. Muscle strength at right arm =1/5. Muscle strength at left arm is 4/5.

9. NervousPt is full alert, conscious and facial appearance is symmetrical. Pt was able to focus on objects. Pt is oriented to time, date and place. Articulations clear andunderstandable. All 5 senses were working properly. Pt was able to recall information.

10. EndocrinePt is not diaphoretic; skin is warm to touch except at the right arm. His growth appears on his age, has heat/cold intolerance. Sweat glands are responsive totemperature. Pt has no abnormal pigmentation on skin. Ht and wt is appropriate for his age. Pt has type 2 DM: non-insulin dependent.

11. Reproductive Pt is a male, circumcised; is married with 5 children (2 girls and 3 males). He is the eldest ; he is 5 years old.

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REVIEW OF SYSTEM

Name: Patient X Date: October 4, 2011

Vital SignsTemperature: 36.50 CPulse: 89 bpm Height: 165 cmRespiration: 19 cpm Weight: 67 kgBlood Pressure: 130/90 Observation: Received pt. sitting on bed, conscious, alert and coherent

with #4 PNSS 1 L regulated at 20 gtts/min infusing well on the left arm with IVF left 820 cc.

11. General

Pt is awake and conscious, sitting on bed with IVF hooked at left arm. Pt appears his age; sexual development is appropriate for his gender; skin color iseven and intact. Facial features are symmetric with environment,(-) skin lesions; ht and wt appears within normal range. Pt has a splint made by a scarf.Presence of blisters can be found at the R arm where fracture is located; edematous and pale skin; cool to touch keloids were also present on some areas ofthe body.

12. HEENT

Head-normocephalic, position at midline,erect and still; no lesions and nodules;hair is kept properly;symmetric facial expressions, presence of facialweakness,Eyes- not good on focusing objects. Eyebrows are present bilaterally, eyeballs are normally aligned in their sockets, have big eyebags,conjunctiva is pink with anicteric sclera; Ears- equal in size bilaterally, skin color is consistent with facial skin color; Nose- no redness, swelling or lesions arepresent, symmetric, at the midline and in proportion with other facial features;nostrils are patent.Throat- pink and moist, no inflammation.

13. IntegumentaryHair is properly kept; scalp hair is uniform in texture and color, hair is thin, unevenly distributed to the scalp;gray and white in color;no lesions can be foundover the scalp; on R arm, nails are pale with CRT of >3 secs; (+) edema and tenderness upon palpation; on L arm, nails are smooth, strong and is firmlyattached to nail bed, uniform in thickness. Skin is warm to touch, wrinkles is present on the face.

14. RespiratoryEqual and symmetric expansion of the chest; spinous process appear in straight line; scapule are placed symmetrically in each hemithorax,relaxed posturewhen breathing; no adventitious lung sounds are heard/ noted, (-)dyspnea; patients breathing is automatic and effortless and produces no noise; (-)retraction; does not use any accessory muscles when breathing; (-)cyanosis;(-)nasal flaring;(-)clubbing.

15. CardiovascularPMI is at the 5th ICS LMCL; without murmurs; S1 and S2 can be heard upon auscultation. Pulse at the right arm is not palpable due to fracture at the site;radial pulse at the L arm is palpable. R arm CRT= >3secs.

16. DigestiveLips is dark, moist, and symmetrical;(-)cracking,(-)lesions. Gums is pink and moist, teeth is free from food debris and is evenly spaced. Tongue is pink andeven in color; saliva is present and there is no white patches or lesions around oral cavity;bucal mucosa is pale and moist; uvula at the midline; tonsils is pink;(+)gag reflex;(+)halitosis; abdomen is warm and symmetric, flat and is consistent in color;(-)lesions; umbilicus is in midline and with NABS.

17. ExcretoryPatient had micturated at least 4x a day with a pale yellow urine, with an estimated amount of 240 cc every time patient urinates. Pt had also defecated oncewith a pale yellow semi-solid urine. No pain during micturation and defecation. Pt admits there is no any burning sensation or pain felt when urinating.

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18. MusculoskeletalSkin over the joint at the right arm is pale; unable to flex his right elbow due to bone fracture at the site but is able to move his fingers; tenderness are notedaround the site;spine is straight; symmetric neck and hips; extremities are warm to touch with joints intact; unequal grips and strength on both hands; R arm-muscle strength= 1/5; L arm muscle and strength on both hands;L arm-muscle strength=4/5.

19. NervousPt is full alert, conscious and coherent; facial expression is symmetrical;has ability to maintain gait and balance; able to focus on objects;can maintain eye-to-eye contact; pt is oriented to tome, date, and place; regards to own name upon hearing someone calling him; able to distinguish hot and cold; all 5 sensesare intact and functioning well. Pt can still recall events; articulation is clear; no mood swings.

20. EndocrinePt is not diaphoretic and sweat glands are responsive to temperature; skin is warm to touch; pt has tolerance to heat; physical growth is appropriate for his

age. ht and wt is appropriate for his age. pt is a type 2 DM non-insulin dependent.

21. Reproductive Pt is a male, circumcised, and has 5 children(2 female, 3 male); he is the eldest among his siblings; he is 56 yrs. old.

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REVIEW OF SYSTEMSName: Patient X Date: October 05, 2011

Vital SignsTemperature: 36.5 C Height: 165 cm.

Pulse: 85 bpm Weight: not takenRespiration: 21 cpm Observation: Received pt. sitting on bed, conscious, coherent,

Blood Pressure: 130/90 mmHg and alert with IVF #5 PNSS 1L with 450 cc left @20 gtts/min.

Infusing well at the left arm.

1. General Patient is awake and conscious; sitting on bed; patient feels pain when his arm will be moved. Pt. appears of his age; sexual development is

appropriate for his age and gender. Skin is intact and is even in elbow. Facial features are symmetric to environment; Height and weight appearswithin normal range. Maintains eye contact, articulation is clear and understandable. Dress is appropriate to climate. Pt. has a closed fracture at theright elbow and was using a sling elbow support.

2. HEENT Normocephalic, position at midline, erect and still; hair is kept properly; symmetric facial expression; has facial weakness but has good focus inobjects. Eyebrows are present bilaterally, eyelashes are evenly distributed. Conjunctiva is pink, anicteric sclera. Ears equal in size bilaterally, earskin color is consistent with facial skin color, no redness or swelling around the ears. Nose is symmetric, midline and is in proportion to other facialfeatures, nostrils are patent; throat is moist and no lesions at all.

3. Integumentary Hair is properly kept; scalp hair is not uniform in color, thin, gray and white; unevenly distributed to the scalp; nails are smooth and look pale. CRT> 2 secs. Nails are cut but some debris is present. Skin is warm to touch on the unaffected area. Pt. has dead tissues, has 2 stiches and has blisters onthe right elbow. Pt. has a close fracture, keloids are present t some of the areas of the body.

4. Respiratory Equal and symmetric chest expansion; spinous process appear in a straight line; relaxed posture when breathing and has no lesions over the chest.No adventitious lung sounds are heard. Pt.s breathing is automatic and effortless, regular and even and produces no noise. Pt. is not in respiratorydistress; not using accessory muscles when breathing, (-) cyanosis, (-) nasal flaring.

5. Cardiovascular PMI is at the 5th

intercostal mid-clavicular line, without murmurs. S1 and S2 are audible. Radial pulse is hardly palpable. Left radial pulse is strong,bounding and palpable. CRT > 2 sec. Pt. has edema on the right arm; bruit is not noted.

6. Digestive Lips is dark, dry and is symmetrical; (-) lesions. Gums is pink and moist; tongue is pinkish and even in color; saliva is present; no white patches orlesions are observed around the mouth; buccal mucosa is pink and moist; uvula is at the midline; abdomen is warm, smooth and symmetric and is

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even in color, umbilicus at midline, abdomen is soft, nontender and is flat with normal active bowel sounds.

7. Excretory Patient has micturated at least 3x a day with pale yellow urine amounting to at least 3 glasses of water. Pt. was able to defecate once with a yellow,formed stool. Pt. admits no pain during micturition and defecation.

8. Musculoskeletal Skin over the joint is even in color; edema is present at the fractured site and tender upon palpation; spine is straight; mandible is symmetrical and atthe midline; symmetric neck and hips; extremities are warm to touch with joints intact except for the right elbow. Unequal grip and strength on both

hands; right arm muscle strength: 1/5; left arm muscle strength 4/5.

9. Nervous Pt. is alert and conscious; facial expression is symmetrical; has ability to maintain gait and balance; gait is smooth and coordinated, able to focus onobjects; pt. is oriented to time, date and place; regards to own name upon hearing someone calling him; able to determine what is hot and cold ; all 5senses were intact and functional. Pt. can recall recent activities; articulation is clear and understandable.

10.Endocrine Pt. is not diaphoretic; skin is warm to touch except for the right arm; physical growth appears on his age, has heat/cold tolerance; sweat glands areresponsive to temperature; no abnormal pigmentation on skin. Height and weight appropriate for his age; pt. has type 2 diabetes mellitus and is oncontinuous monitoring.

11.Reproductive Patient is a male; married with children ( 2 girls and 3 males); Pt. is 56 years old.

Laboratory and Diagnostic Procedures

NAME OFPROCEDURE

INDICATION NORMALVALUE

RESULT NURSINGIMPLICATION

NURSINGRESPONSIBILITIES

1. URINALYSIS -to detectnormal versusabnormal urinecomponents-to detectglycosuria-to aid in thediagnosis of

renal disorders.

Color: lightstraw to dark

amber

Sp. Gravity:1.025-1.030

Sugar: (-)

Albumin: (-)

Yellow

1.020

Negative

Negative

Normal

Normal

Normal

Normal

Pretest: Explain the purpose and procedureof the test; withhold diuretics for 3 daysbefore test., avoid excessive intake of waterand salt.Posttest: patient can resume normal fluidand dietary intake and medications.

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2. HEMATOLOGY -to monitor hgbvalue in RBCs-to checkvolume of RBCin the blood

-

Hgb: 135-160g/l

Hct: 0.40-0.48

WBC-5-10 x 10

Neutrophil:

0.55-0.65

120

0.37

8.8

0.50

Low;

Low;

Normal

Low;

Pretest: Explain test procedure that slightdiscomfort may be felt whenvenipunctured; avoid stress; avoiddehydration and overhydration; avoid fat

laden meals.

Posttest: Apply manual pressure anddressing to the puncture site. Monitor sitefor oozing and hematoma. Resume normalactivities and diet.

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3. CREATININE

4. GLUCOSE (FBS)

5. HGT

-to diagnoserenal function

Lymphocyte:0.25-0.40

Eosinophil:0.01-0.05

Creatinine:0.6-1.4 mg/dl

70-105 mg/dl

72-128 mg/dl

0.32

0.18

0.9

56.2 mg/dl

9-30-11/7:25 pm191 mg/dl

10-1-11/5 am176 mg/dl

Normal

High;

Normal

Low;

High;

High;

Pretest: explain procedure; assess diet andprotein intake

Posttest: monitor as appropriate forimpaired renal function.

Pretest: explain procedure; ensure to fastfrom all foods except water as directed.Posttest: resume normal diet and activity.Interpret results and counsel appropriately.

Pretest: Explain test procedure that slightdiscomfort may be felt when

venipunctured; avoid stress; avoiddehydration and overhydration; avoid fatladen meals. Posttest: Apply manual

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6. ECG

Pulse: 72 bpmRhythm:Regular

QRS complexelevated S I-II

5 pm-196 mg/dl

10-2-11/5 am84 mg/dl

5 pm-76 mg/dl

10-3-11/ 5 am295 mg/dl

5 pm-78 mg/dl

10-4-11/5 am122 mg/dl

5 pm-196 mg/dl

10-5-11/5 am178 mg/dl

5 pm-98 mg/dl

60-100 bpmConsisitetent and

regular

Normal QRS axis

High;

Low;

Normal

High;

Normal

Normal

High;

High;

Normal

Normal

High

pressure and dressing to the puncture site.Monitor site for oozing and hematoma.Resume normal activities and diet

Pretest: Explain the procedure, purpose

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7. Blood Chemistry

PR interval:0.016 sec.

P waves-upright

T waves-upright

ST segmentRemarks:

Sinus rhythmwith right

bundle branchblocks

Cholesterol-119 mg/dl

Triglycerides-34 mg/dl

HDLCholesterol- 38

mg/dl

LDLCholesterol-

74.2 mg/dl

Glycosulated-

0.12 to 0.20 s (3 -5 small squares)

Normal upright

Deflections

140-200 mg/dl

30-150 mg/dl

30- 65 mg/dl

66-176 mg/dl

4.2- 6.2 %

Normal

Normal

High

Low

Normal

Normal

Normal

Normal

and interfering factors; have patient relaxedand rest ideally 15 minutes before the test;emphasized that ECG is painless and doesnot deliver electrical current to the body;have the patient avoid heavy meals andsmoking for at least 30 minutes before the

test.

Posttest: recognize the limitation of anECG; interpret results and counsel andmonitor the patient appropriately.

Pretest: Explain test procedure that slightdiscomfort may be felt whenvenipunctured; avoid stress; avoiddehydration and overhydration; avoid fatladen meals.

Posttest: Apply manual pressure anddressing to the puncture site. Monitor sitefor oozing and hematoma. Resume normal

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8. CXR-AP Sitting

6.2 %

Lung filed areclear. Heart isnot enlarged.

Aorta isprominent with

knobcalcifications

Costrophenicsulci and

diaphragm areintact.

The rest of theincluded

membranesareunremarkable.

Impression:Atheroscleroti

c Aorta

Clear andnormally shaped

Normal

High

Normal

Normal

High

activities and diet.

Pretest: Explain the purpose and procedureof the test; assure that there will be nodiscomfort, screen for pregnancy status offemale patients; if positive, advise theradiology department; remind patients ofthe need to remain motionless and tofollow all breathing instructions during theprocedure.

Posttest: interpret test outcome andmonitor for pulmonary disease and chestdisorders; explain changes in therapybased on chest- x ray results.

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NURSING ASSESSMENT II

Name of Patient: Patient X Age: 56 Y.O Sex: MaleChief Complaints: For medical management of increased blood glucose level Inclusive Dates of Care: October 3-5, 2011Impression/Diagnosis: Diabetes Mellitus Type II; Fracture at the right elbow 2 to VA Allergies: NoneDate of Admission: September 30, 2011Diet: Low Salt, Low Cholesterol Diabetic DietType of Operation (if any): None

Normal Pattern Before HospitalizationClinical Appraisal

Initial Day 1 Day 2

1. Activities Rest

a. Activities

b. Sleeping pattern

a.) Pt. is a businessman, ownsand runs a bakery in their town,Bacolod. He had a bakeshop anda small sari-sari store. His

a.) Pt. only sits or lies at bed andonly talks to his son and wife. Hesometimes walks at the corridor ifhe likes to.

a.) Pt. usually stays in bed, sittingand talks to his wife. Unable toperform ADLs such as bathing,toothbrushing and change

a.) Pt. usually stays on bedbut admits he was able towalk around corridors, ableto perform some ADLs

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c. Rest activities were repairing furniture,scrub the floor and clean theirstores. Limited to do or lift heavyobjects such as supplies in theirstore. His forms of exercise werebrisk walking in the morning andafternoon if not busy, punch bagsand lift dumbbells. He seldom

watched teleseryes but prefer towatch news and boxing. Pt. alsodo household chores.b.) Pt. sleeps at 11pm and wakesup at 4am and feels rested whenhe sleeps for at least 6 hours.c.) Pt. admits he was able to restfor 6 hours in the morning if notbusy or if all chores were done.Pt. admits he seldom sleeps in theafternoon for he is not comfortableto sleep.

b.) Pt. sleeps at 12 midnight andwakes up at 6 am. Sometimesdisturbed when his right elbowhurts every time he moves it.

Awakens when the MedicationNurse administers his medicine.c.) Pt. was able to rest in theafternoon and took afternoon

naps for at least 30 minutes.

clothing and relies assistancefrom his wife or son.b.) Pt. sleeps at least 8 hours,sleeps at 9 pm and wakes up at 5am. Sometimes disturbed whenhis right elbow hurts or when theMedication Nurse administers hismedicine.

c.) Pt. wasnt able to get enoughrest in the afternoon because ofthe hot environment where healways sweats and feelsuncomfortable about the smell ofthe surroundings.

such as going to thebathroom, change clothingor and brushing his teeth.b.) Pt. sleeps at 9 pm andwakes up at 4 am but isable to wake up betweensleeping hours because ofpain he felt when he move

his right elbow.c.) Pt. had not takenenough rest in the morningbut able to take afternoonnaps for at least 30minutes.

2. Nutrition Metabolic

a. Typical intake (food or

fluid)

b. Diet

c. Diet restriction

d. Weight

e. Medication / Supplement

food

a.) Pts. intake of food at usuallyconsists of a cup of rice, fish,

vegetables and sometimes meat.Took 3 meals a day and neverskips a meal. Took his snacks atleast twice a day at 11 am and 3pm which consist of a coke andan ensaymada or any availablebread at his bakery. Drinks plentyof liquids and admits a pitcher ofwater is not enough for him toquench his thirst. Drinks coca colafor at least 5 times a week. Pt.had no food or drug allergies orfood intolerance.b.) Regular diet. Patient admits he

is not choosy when it comes tofood. Eats what is being servedon the table.c.) pt. admits he was restricted to

a.) Pts. intake of food usuallyconsists of a cup of rice, fish

tinola, banana and waterb.) Low Salt, Low CholesterolDiabetic Dietc.) Restricted diet: soft drinks andsweets, high in fat and cholesterold.) Not takene.) Ciprofloxacin BID 500g,Gliclazide mg 1 tab

a.) Pts. intake of food usuallyconsists of a cup of rice, chicken,

vegetables and soupb.) Low Salt, Low CholesterolDiabetic Dietc.) Restricted diet: soft drinks andsweets, high in fat andcholesterol.d.) Not takene.) Ciprofloxacin PO BID 500g

a.) Pts. intake of foodconsists of a cup of rice,

fish tinola, chicken andbananab.) Low Salt, LowCholesterol Diabetic Dietc.) Restricted diet: foodsthat are high in fats,cholesterol and sweetsd.) Not takene.) Cefuroxime 750 mgIVTT

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eat any sweets or drinks softdrinks but he does not adhere tothe advise of othersd.) weight:e.) Multivitamins 3x/day


Initial Day 1 Day 2

3. Elimination

a. Urine (frequency, color,

transparency)

b. Bowel (frequency, color)

a.) pt. admits during his middleaged years he micturated for atleast 15 urinations for 24 hours.Wakes up at midnight or dawn tourinate. Pt. admits that his urinevolume changes.b.) Defecated once a day with aformed, yellow stool. Usual bowelpattern is every morning. Patientis not constipated.

No associated pain duringmicturition and defecation

a.) Usually micturates 4x/day witha pale yellow urine with anaverage amount of 520ccb.) Defecated once a day withsemi-solid stool. Usual bowelpattern at morning.


a.) Pt. admits he micturated4x/day with a pale yellow urinewith an average amount of atleast 240ccb.) Pt. admits he defecated onlyonce a day in the morning with asemi-solid, pale yellow stool.


a.Pt admits he urinates forat least 3x a day with anaverage volume of 600 ccwith a pale yellow urine.b. Admits he defecatedonce in the morning with ahard, yellow stool.


4. Ego Integrity

a. Perception of self

b. Coping Mechanism

c. Support Mechanism

d. Mood / Affect

a.) Before the onset of the

disease, pt. admits and perceivedhimself as a healthy person evenwhen he has DM because heperform exercises such aspunching bags and lifteddumbbells. Confidence boostabout his health because headmits his hypertension wasminimized after the operation.b.) His coping mechanism wasrepairing and fixing furniture orbakes at his own bakery in theirtown. His ways of handling stresswas to stay put at his house, took

a rest or watch his favoritemovies.c.) Support mechanism is his wifeand children

a.) Pt. perceived himself as a not-

so-healthy person because of hiscondition: closed fracture at theright elbow with type 2 DM.b.) sometimes patient talks to hisroommate; he sometimes sleepsand no recreational form ofactivities were done.c.) his support mechanism washis wife and his family.d.) patient was not irritable; facialweakness was observed.

a.) Pt. only sits on bed, talks to his

wife. He does not perceive himselfas a healthy person because ofhis debilitating illnessb.) No recreational activities weremade inside the room. Sometimeshe talks to his roommates.c.) his support mechanism washis wife and his familyd. patient admits he gets irritatedbecause of the foul environmentand sometimes cannot maintaineye contact when asked.

a.) Pt perceives himself as

a not-so-healthy personbecause of his illnessb.) patiet communicateswith his roommates insidethe room, took naps if thereis time or if he feels sleepyand walks into the corridorsif he gets bored.c.) His wife is always at hissided.) patient can maintain eyecontact when asked. Nomood swings observed.

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d.) patient is not irritable;becomes grumpy when problemsuch as financial crisis or supplyproblems arises.

5. Neuro Sensory

a. Mental sate

b. Condition of 5 sense:

(sight, hearing, smell,

taste, touch)

Pt. admits he is always happy;active, alert and responsive;oriented to time, date and place.b.) All 5 senses are intact and

functioning well.

a.)pt. is conscious, articulation isclear and is coherent. Pt. canrecall past events and answersthe question deliberately when

asked; oriented to time, date andplace. Pt. is anxious at timesbecause of his condition and thesurgical procedure to be done.b.) All 5 senses were intact andfunctioning well.

a.) Pt. is conscious, alert,coherent, and oriented to time,date and place. Able to respondwhen asked questions and can

recall past events.b.) All 5 senses were intact andfunctioning well.

a.) Pt. is conscious, alert,coherent, and oriented totime, date and place. Ableto recall information and

events related with to hishealthb.) All 5 senses were intactand functioning well.


Initial Day 1 Day 26. Oxygenation and Vital signs

a. Respiratory rate

b. Pulse rate

c. Heart rate

d. Blood pressure

e. Lung sounds

f. History of respiratory

problems

Pts. vital signs were not taken

No history of respiratory problems

T: 37.9P: 92 bpmR: 19 cpmBP: 130/80 mmhg

Pt. has clear breath sounds


T: 36.5P: 89 bpmR: 19 cpmBP: 130/90 mmhg



T:P:R:BP:


No history of respiratoryproblems

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7. Pain comfort

a. Pain (location, onset,

intensity, duration,

associated symptoms,

aggravation)

b. Comfort measure /

alleviation

c. Medication

a.) Before the onset of vehicularaccident, pt. had felt no pain at allb.) No comfort measures donec.) No medications taken

a.) his main focus was pain at theright arm, painful when touchedand moved.pt. admits a sharppain when palpated at theaffected arm, radiating to the mid-

upper right arm to wrist. Painscale= 10/10; pain last only forminutes; aggravated whenmoved. Non-pitting edema notedat the right arm.b.) A splint was used for supportand feels relieved when nottouched or movedc.)

a.) Pain at the right elbow, painfulwhen touched and moved. Ptadmits pain is minimized butadmits tender upon palpation,non-pitting edema is still present

at the affected arm. Pain scale:8/10. Aggravated when movedb.) Splint was used to minimizepain and no other comfortmeasures were notedc.) Prophylactic antibiotic(cefuroxime) was given

a.) Pain at the right armdue to vehicular accident,sharp pain, with non=pittingedema at the affected arm,tender upon palpation and

aggravates more whenmovedb.) sling was used forsupportc.) medication wasntchecked for pain.

Normal Pattern Before Hospitalization Clinical AppraisalInitial Day 1 Day 2

8. Hygiene and activities of daily living Before hospitalization, pt. waswell-groomed, takes a bathdaily(preferred time bath is 4 am)brushes his teeth and combs hishair neatly.

Able to perform ADL such asfixing furniture, do exercises, ableto work-out like carryingdumbbells, and punch bags.

Pt. admits he usually stays on bedsitting or lying. Asked assistancefrom his wife for his hygiene;unable to brush his teeth alone.Mustache and beard were notshaved. He wasnt able to take abath but was given sponge bath.

Able to change clothing once aday. Able to walk in the corridorsbut assistance is needed.

Pt. admits he was always givensponge bath by his wife. Wasntable to brush his teeth, but waswas able to comb is hair andchange clothing. Mustache andbeard were not shaved Pt. usuallysits on bed. Pt. smellsunpleasantly. Can walk withoutassistance.

Pt. admits he was givensponge bath at themorning. Able to brush histeeth and combs his hair.Mustache and beard werenot shaved. Pt. admits hewalks at the corridors andable to perform some ADLssuch as eating, standingand going to bathroomwithout assistance.

9. Sexuality

a. Female (menarche,

menstrual cycle, civil

a.) Pt. is a circumcised male and

the eldest in his 5 siblings; He ismarried with 5 children (2 femalesand 3 males)

No significant changes No significant changes No significant changes

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status, number of children,

reproductive status)

b. Male (circumcision, civil

status, number of children)

SUMMARY OF MEDICATION

Date Medication Dosage Route Frequency Remarks

09/30/11to 10/02/11

Cefuroxime

Ciprofloxacin

Mixtard

Gliclazide

750 mg

500 mg

24 u prebreakfast10 u presupper

60 mg

IVTT

P.O.

SQ

P.O.

q 80

BID

BID (prebreakfast,presupper)

OD

Given andtolerated

Given andtolerated

Given and

tolerated Given and

tolerated

SUMMARY OF INTRAVENOUS FLUID

DateIntravenous Fluids

& VolumeDrop Rate

Time Started Time Ended

Indication

09/30/11 #1 PNSS T L 30 gtts/min 8:45 PM 10/01/11

Isotonic- has the samesalt concentration as thenormal cells of the body

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10/01/11

10/02/11

10/03/11

10/4/11

10/05/11

#2 PNSS T L

#3 PNSS T L

#4 PNSS T L

#5 PNSS T L

#6 PNSS T L

20 gtts/min

30 gtts/min

20 gtts/min

20 gtts/min

20 gtts.min

8:15 AM

9:10 AM

5:30 AM

1:30 AM

5:15 AM

10/01/118:15 PM

10/02/115:45 PM

10/03/115:30 PM

10/04/111:30 PM

and the blood

Isotonic- has the samesalt concentration as thenormal cells of the bodyand the blood

Isotonic- has the samesalt concentration as thenormal cells of the bodyand the blood

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NURSING CARE PLAN

Cues Nursing Diagnosis Objective Intervention Rationale Evaluation

Subjective:Sakit-sakit pa gihaponakong kamot pag ilihokgahubag pa gihapon siya.

Impaired skin integrityrelated to physical

immobilization at the rightarm secondary to bone

Short-Term Objective:Within 8 hours of duty,patient will be able tomaintain physical well-

1. Assess bloodsupply andsensation ofaffected area.

1. To evaluateimpairment ofcirculation toextremities

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As verbalized by thepatient.

Objective:- Closed fracture

at the rightelbow

- Presence ofedema at theentire right arm

- Tender uponpalpation

V/S:

T: 36.5C

P: 85 bpmR: 21 cpm

BP: 130/90 mmHg

fracture due to vehicularaccident

being

Long-Term Objective:After 3 days of duty,patient will be able toparticipate in preventionmeasures and treatment

program.

2. Monitor vitalsigns and MIOevery 2 hours andevery shiftrespectively.3. Inspect skin ondaily basis,

describing paincharacteristics andchanges observed4. Keep the areaclean and dry,prevent infectionand supportfracture.5. Repositionclient every 2hours or asindicated.6. Encourage

early ambulationor mobilization7. Providedoptimum nutritionand adequatefluids.8. Provide a quiet,restfulenvironment9. Encourageverbalization offeelings10.Review

laboratory results

2. To comparedata to baselinevalues and tomonitor output ofthe patient.3. To assist clientin correcting or

minimizingcondition andpromote optimalhealing.4. To assist bodysnatural healingprocess.5. To enhanceunderstanding andcooperation.6. Promotescirculation andreduces risks

associated withimmobilization.7. To preventdehydration and tomaintain generalgood health.8. To decreaseoxygen demand toavoid fatigue.9. To enhanceself-esteem andadhere totreatment

regimen.10.To determineabnormal values

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that may hinderwound healing.

CP_GROUP I

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