TABLE OF CONTENTS

I. INTRODUCTION A. Overview of the Case B. Objective of the Study C. Scope and Limitation II. HEALTH HISTORY A. Profile of the Patient B. Family and Personal Health History a. History of Present Illness b. Chief Complaint III. DEVELOPMENTAL DATA IV. MEDICAL MANAGEMENT A. Medical Orders B. Drug Study V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY VI. NURSING ASSESSMENT VII. NURSING MANAGEMENT A. Ideal Nursing Management (NCP) B. Actual Nursing Management ( SOAPIE ) VIII. REFERRALS AND FOLLOW-UP IX. EVALUATION AND IMPLICATIONS X. DOCUMENTATION Organization/ Grammar/ Bibliography i

VI. MEDICAL MANAGEMENT

Medical Orders with Rationale Date and Time December 9, 2011 y 12:30pm y y y DAT TPR q 4hrs Labs: CBC y y y To have/ achieve nutritional needs To identify and monitor changes in v/s May identify hematological factors causing the any complications. To determine its normal and abnormal value. For electrolytes and fluid supplement Secure consent to care y For legal purposes Medical Orders Rationale

Start venoclysis with PNSSiL @ 30gtts/min Meds follow Intake and output q shift

y y

y y

To have effective treatment Fluid intake must supplement the fluid loss in the body

To secure and stand by 1 u of PRBC of patients blood type properly screened and cross-matched Give Diphenhydranide 50 mg -1hr prior to each unit

To know correct blood type/ Rh and or for possible BT & replacing blood components

y 10:00pm

Acts on bloodvessels, GI,respiratory system by antagonizing theeffects of histaminefor H1-receptor site. causes increasedheart rate,vasodilatation,secretions;Signifi cant CNSdepressant andanticholinergic properties

12-10-11 2:10am y Insert straight catheter and measure I&O Repeat Cbc, crea, 6hrs after Bt y Aids in urination , monitor fluid loss

10:45am

May identify hematological factors causing the any complications. To determine its normal and abnormal value.

12-11-11 10:05am y Insert foley catheter and measure I&O q 4hrs IVF to follow : PNSSil @ 25 gtts/min y Aids in urination , monitor fluid loss

For electrolytes and fluid supplement

12-12-11 12:00nn y Give metroclopramide I amp, now Ok for Cystoscopy y

y 12-13-11 12nn y

5:50am 12-14-11

Follow up IV of PNSSiL@ 25 gtts/min Give plasil I amp IVTT now

y y

For electrolytes and fluid supplement

Scheduled for cystoscopy with start insertion @12nn under Dr. Logno