MEDICAL MANAGEMENT

Date
October 3, 2013

Medical Regimen
Secure consent

Rationale
Consent to treatment is the principle
that

person

must

give

their

permission before they receive any

type of medical treatment.

DAT with SAP

The recommendation for aspiration

precautions is made because the
patient may have difficulties in
swallowing food or liquid correctly or
have a history of having food travel into
the lungs, causing a choking hazard,
instead of into the stomach. Simply,
aspiration, or choking, can occur when
food or liquid mistakenly go down the
wrong pipe, ending up in the lungs,
hence the need to take precautions

Vital signs every shift

Measuring and recording a patients

vital signs accurately is important as
this gives an indication of the patients
physiological state

CBC

A complete blood count (CBC) gives

important information about the kinds
and numbers of cells in the blood,
especially red blood cells, white blood
cells, and platelets. A CBC was
ordered for the doctor to be able to
diagnose conditions, such as anemia,
infection, or any other disorders.

D5LR 1L x

It is a hypertonic solution useful for

30gtts/min

daily maintenance of body fluids and

nutrition, and for rehydration. These

solutions are used to correct fluid
imbalances in the body.
Paracetamol

It is a pain reliever and a fever reducer.

It was ordered if ever in case the
patient had fever.

Urinalysis

Urinalysis is the physical, chemical,

and microscopic examination of urine.
It involves a number of tests to detect
and measure various compounds that
pass through the urine. Urinalysis can
reveal diseases that have gone
unnoticed because they do not
produce striking signs or symptoms.

FBS

This measures blood glucose after you

have not eaten for at least 8 hours. It is
often the first test done to check for
prediabetes

and

diabetes.

It

is

determined by taking a sample of

venous blood after at least eight hours
of fasting. The sugar level is then
evaluated in the blood sample.
BUN (Blood Urea

This measures the amount of nitrogen

Nitrogen)

in your blood that comes from the

waste product urea. A BUN test is done
to see how well your kidneys are
working. If your kidneys are not able to
remove urea from the blood normally,
your BUN level rises.

Crea

It reveals important information about

your kidneys. If your kidneys aren't
functioning properly, an increased level
of creatinine may accumulate in your

blood.

serum

creatinine

test

measures the level of creatinine in your

blood and gives you an estimate of
how well your kidneys filter (glomerular
filtration rate). A creatinine urine test
can measure creatinine in your urine. A
normal result is 0.7 to 1.3 mg/dL for
men and 0.6 to 1.1 mg/dL for women.
Cholesterol

This helps determine your risk of the

build up of plaques in your arteries that
can lead to narrowed or blocked
arteries

throughout

(atherosclerosis).

your

High

body

cholesterol

levels usually don't cause any signs or

symptoms, so a cholesterol test is an
important tool. High cholesterol levels
often are a significant risk factor for
heart disease.
Chest XRAY

A chest x ray is a painless, noninvasive

test used to detect abnormalities in the
lungs,

but

can

also

detect

abnormalities in the heart, aorta, and

the bones of the thoracic area. It can
be used to diagnose many conditions
and

diseases

pulmonary

as

edema,

bronchitis,
asthma,

such

cysts,

pleurisy,

pneumonia,

tumors,

pericarditis,

cancers,

cardiomegaly,

heart failure, and fractures.

D5 W 1L x 8 hrs

D5W is mostly used to treat patients

with

fluid

loss,

hypernatremia

(too

dehydration,
much

or

sodium.)

When D5W is initially infused, it is an

isotonic

solution,

but

when

the

dextrose is metabolized, the solution

actually becomes hypotonic, a solution
where osmotic pressure causes fluid to
shift into cells. D5W is not good for
patients with renal failure or cardiac
problems since it could cause fluid
overload. Also, patients at risk for
intracranial pressure should not receive
D5W since it could increase cerebral
edema (swelling.)
October 4, 2013

For serum NA

Measurement of serum sodium is

routine in assessing electrolyte, acidbase, and water balance, and renal
function.

The

reference

range for

serum sodium is 135-145 mmol/L. A

doctor may order this test, along with
other

electrolytes,

electrolyte

to

imbalance.

identify
It

may

an
be

ordered to determine if a disease or

condition involving the brain, lungs,
liver, heart, kidney, thyroid, or adrenal
glands is causing or being exacerbated
by a sodium deficiency or excess.
Serum K

This test measures the amount of

potassium in the fluid portion (serum)
of the blood. Potassium (K+) helps
nerves and muscles communicate. It
also helps move nutrients into cells and
waste products out of cells. Doctor may
order this test to diagnose or monitor
kidney

disease

and

high

blood

pressure.
SGPT

This test is used to determine if a

patient has liver damage. The normal

range is 10 to 40 international units per

liter (IU/L).
Omperazole 40g IV This drug belongs to group of drugs
OD

called

proton

decreases

pump

the

inhibitors.

amount

of

It

acid

produced in the stomach. It is used to

treat symptoms of gastroesophageal
reflux

disease

(GERD)

and

other

conditions caused by excess stomach

acid. It is not for immediate relief of
heartburn symptoms. It is also used to
promote healing of erosive esophagitis
(damage to your esophagus caused by
stomach acid).
Aspiration Precaution

Aspiration precautions are measures

taken

to

prevent

person

from

aspirating, or choking. Choking can

occur in debilitated patients who have
a

diminished

swallowing

reflex.

Aspiration occurs when the swallowed

contents do not pass through the
esophagus, but go directly into the
lungs.
Bed sore precaution

Bed sore are injuries to skin and

underlying tissues that result from
prolonged
Pressure

pressure
ulcers

are

on

the

skin.

much

more

common among patients who are

unable to move because of paralysis,
illness or old age. Sustained pressure
can cut off circulation to vulnerable
parts of the body, especially the skin of
the buttocks, hips and heels - the
affected tissue dies if it does not

receive an adequate flow of blood.

October 6, 2013

Atrovastatin (Lipitor) Atorvastatin is in a group of drugs

20g/tab

called HMG CoA reductase inhibitors,

or "statins." Atorvastatin reduces levels
of

"bad"

cholesterol

(low-density

lipoprotein, or LDL) and triglycerides in

the blood, while increasing levels of
"good"

cholesterol

(high-density

lipoprotein, or HDL). Atorvastatin is

used to treat high cholesterol, and to
lower the risk of stroke, heart attack, or
other

heart

complications.

It

was

ordered because the patient had a high

level of LDL (176.13mg/dL) and low
level of HDL (34.47mg/dL)
For NGT insertion

By inserting a nasogastric tube, you

are gaining access to the stomach and
its contents. This enables you to drain
gastric

contents,

decompress

the

stomach, obtain a specimen of the

gastric

contents,

or

introduce

passage into the GI tract. This will

allow you to treat gastric immobility,
and bowel obstruction. It will also allow
for drainage and/or lavage in drug
overdosage or poisoning. In trauma
settings, NG tubes can be used to aid
in the prevention of vomiting and
aspiration.
O2 per nasal cannula

Without adequate oxygen, hypoxia, a

condition in which insufficient oxygen
reaches the cells, will occur

Foley catheter hook A Foley catheter is a thin, sterile tube

to urine bag

inserted into the bladder to drain urine.

It is held in place with a balloon at the
end, which is filled with sterile water to
prevent

the

catheter

from

being

removed from the bladder. It was

ordered to be able to monitor the urine
output of the patient and to prevent
retention of urine leading to urinary
hesistancy.

ABG

Blood gas is a measurement of how

much oxygen and carbon dioxide is in
your blood. It also determines the
acidity (pH) of your blood. The test is
used to evaluate respiratory diseases
and conditions that affect the lungs. It
helps determine the effectiveness of
oxygen therapy. The test also provides
information about the body's acid/base
balance, which can reveal important
clues about lung and kidney function
and the body's general metabolic state.

October 8, 2013

Ensure

gold

5 Ensure Gold has a well-balanced

scoops in 200cc h2o proportions of macronutrients in accord

x 5 feedings; 50cc with guidelines for Dietary Reference
water flushing

Intake developed jointly by US and

Canadian Authorities and conforms to
the very latest American Heart
Association Guidelines for Healthy
Dients. Protein 15% ,Carbohydrate
55% and Fat 30% . Ensure Gold can
be used as a sole source of nutrition

when consumed and reconstituted in

appropriate amounts. It (reconstituted
with water) can also be used as a
supplement between or with meals.

Clonidine

Clonidine

is

used

alone

or

in

combination with other medications to

treat high blood pressure. Clonidine is
in

class

of

medications

centrally

acting

hypotensive

agents.

called

alpha-agonist
It

works

by

decreasing your heart rate and relaxing

the blood vessels so that blood can
flow more easily through the body.

Amlodipine 10mg tab

Amlodipine

is

used

alone

or

in

combination with other medications to

treat high blood pressure and chest
pain (angina). Amlodipine is in a class
of medications called calcium channel
blockers. It lowers blood pressure by
relaxing the blood vessels so the heart
does not have to pump as hard. It
controls chest pain by increasing the
supply of blood to the heart.

October 9,2013

Myrin p forte 3 tabs It is an anti-TB agent that contains

OD

Ethambutol, Rifampicin, Isoniazid and

Pyrazinimide, commonly used to treat
Tuberculosis infections. Initial phase
treatment & re-treatment of all forms of
TB in category I & II patients caused by
susceptible strains of mycobacteria.

IVF PNSS 1L @ 15 It is a isotonic solution. Used because it has

gtss/min

little to no effect on the tissues and

make the person feel hydrated
preventing hypovolemic shock
or hypotension

Clopidogrel

75g/tab Clopidogrel is used alone or with

1tab OD

aspirin to prevent serious or lifethreatening problems with the heart

and blood vessels in people who have
had a stroke, heart attack, or severe
chest pain. Clopidogrel is in a class of
medications

called

antiplatelet

medications. It works by preventing

platelets from collecting and forming
clots that may cause a heart attack or
stroke.
Bed sore precaution

Bedsores also called pressure sores or

pressure ulcers, are injuries to skin and
underlying tissues that result from
prolonged

pressure

on

the

skin.

Bedsores most often develop on skin

that covers bony areas of the body,
such as the heel, ankles, hips or
buttocks. It was ordered because the
patient is unable to move and change
position.

October 13,2013

Losartan 50mg tab Losartan

OD (am feeding)

is

used

alone

or

in

combination with other medications to

treat high blood pressure. Losartan is
also used to decrease the risk of stroke
in

people

who

have

high

blood

pressure and a heart condition called

left

ventricular

hypertrophy

(enlargement of the walls of the left

side of the heart) Losartan is in a class
of medications called angiotensin II
receptor

antagonists.

It

works

by

blocking the action of certain natural

substances that tighten the blood
vessels, allowing the blood to flow
more smoothly and the heart to pump
more efficiently.
Amlodipine

50mg Amlodipine

(pm feeding)

is

used

alone

or

in

combination with other medications to

treat high blood pressure and chest
pain (angina). Amlodipine is in a class
of medications called calcium channel
blockers. It lowers blood pressure by
relaxing the blood vessels so the heart
does not have to pump as hard. It
controls chest pain by increasing the
supply of blood to the heart.

October 19, 2013

RBS

It measures blood glucose regardless

of when you last ate. Random testing is
useful

because

glucose

levels

in

healthy people do not vary widely

throughout the day. Blood glucose
levels that vary widely may mean a
problem.
Check

residual Before each bolus feeding, gastric

before feeding

contents should be suctioned out and

returned to the stomach before a new
feeding is administered to ensure that
minimal residue remains from the
previous feeding. Residual volume
should be checked every 3-5 hours

when feeding is by continuous drip.

Excess residual volume (>100 -150
mL) may indicate an obstruction or
some other problem that must be
corrected before feeding can be
continued. This could also protect
patient against aspiration pneumonia.
Domperidone

This medication increases movement

through the digestive system. It is used
to

treat

symptoms

of

stomach

disorders. It may also be used to

prevent nausea and vomiting.
October 23, 2013

Plasil 10mg IV
Skip

one

Used to treat nausea and vomiting.

feeding, Because there is (+) vomiting

next feeding will be

tomorrow.
October 26, 2013

Suction

oral To maintain patent

airway and to

secretions

remove excess secretions

Salbutamol

Salbutamol works by opening up the

air passages in the lungs so that air
can flow into the lungs more easily. In
doing

so

it

can

help

to

relieve

symptoms such as coughing, wheezing

and shortness of breath.