Date

Order

Rationale
Well-balanced diet containing all of the
essential nutrients needed for optimal

August 4,

Please admit
Full Diet

2014

growth, tissue repair, and normal functioning

of the organs. Such a diet contains foods
rich in proteins, carbohydrates, high-quality

4:15pm

fats, minerals, and vitamins in proportions

that meet the specific caloric requirements
of the individual.
Vital signs are obtain and recorded to obtain
VS every 4 hours

the patients baseline data and be useful for

further management.
These are common routine laboratory tests

LABS:

in the hospital.

Complete blood count CBC - blood test used to evaluate your

Chest Xray

overall health and detect a wide range of

Serum electrolyte

disorders, including anemia, infection.

Urinalysis

Chest Xray this is to diagnose conditions

affecting the chest, its contents, and nearby
structures.
S. electrolyte - Tests that measure the
concentration of electrolytes in the blood.
Urinalysis test for
general evaluation of health
diagnosis of metabolic or systemic diseases

that affect kidney function.

5% Dextrose in Lactated Ringer's is a

Start IV D5LR 1L

plasma expander. It is given to our client

@140cc/ hour

because of dehydration.

.
MEDS:
Paracetamol 500g

Paracetamol for fever

1 tab RTC x 3 doses

Ampicillin sulbactam

Ampicillin for infection

q 8 1.5g IVTT
(ANST)

ANST ( After Negative Identifying avoidable allergens is an

Skin Test )

important part of allergy management.

Allergy testing helps your doctor to confirm
your sensitivity so that appropriate
avoidance advice can be given. Results of
skin allergy tests are available within 15 20
minutes. It is important to note that all test
results must be interpreted in the context of
a careful history.

Tepid sponge bath

Intake and output q

To reduce body temperature of our patient

To monitor the intake and output of our client

shift
D5NM solution is indicated for parenteral
10:20pm

IVF TF D5NM

maintenance of routine daily fluid and

@140cc/ hr

electrolytes requirements with minimal

carbohydrate calories from dextrose.

Generic Name: Paracetamol

Brand Name: Biogesic
Classification: Antipyretic
Ordered dose: 500 mg/tab, 1 tab q4 1 tab RTC x 3 doses;
PRN
Date ordered: august 4, 2014
Mode of Action:
Exhibits analgesic action by peripheral blockage of pain impulse generation
- Produces antipyresis by inhibiting the hypothalamic heat-regulating centre
Suggested Dose: 325 650 mg
Indications:
Mild pain, fever
Contraindications:
- Previous hypersensitivity
- Analgesic nephropathy
- Renal and hepatic impairment
Drug Interaction:

Drug drug
Reduced absorption of cholestyramine within 1 hour of administration
Accelerated absorption with metoclopramide
Paracetamol may increase effect of warfarin

Drug food
- Chronic, excessive consumption of alcohol may increase the risk of acetaminophen-induced
hepatotoxicity
Adverse Effects:

GI: hepatotoxicity, hepatic failure

GU: renal failure

Derm: rash, urticaria

Nursing Responsibilities:

1. Assess fever; note presence of associated signs (diaphoresis, tachycardia and malaise)
Rationale: This assessment will serve as basis for evaluation of effectivity of medicine against fever.
2. Assess liver function studies.
Rationale: Medication may cause hepatotoxicity.
3. Administer with full glass of water.
Rationale: This helps to prevent irritation.
4. Give drug with meals or antacids.
Rationale: This will minimize gastric irritation.
5. In case of overdose, acetylcysteine should be readily available.
Rationale: Acetylcysteine is the antidote for acetaminophen toxicity.

Generic Name: Ampicillin Sulbactam

Brand Name: Unasyn
Classification: Anti-infectives Anti-bacteria
Ordered dose: 1.5 g IVTT q8
Date ordered: august 4, 2014
Mode of Action:
By binding to specific penicillin-binding proteins (PBPs) located inside the bacterial cell wall, Ampicillin inhibits the third
and last stage of bacterial cell wall synthesis. Cell lysis is then mediated by bacterial cell wall autolytic enzymes such
as autolysins; it is possible that Ampicillin interferes with an autolysin inhibitor.
Suggested Dose: 1.5 3 g
Indications:
Treatment of infections causedby susceptiblestrains of Shigella, Salmonella, E.Coli, Haemophilusinfluenzae,
S.typhosa, N.Gonorrhea, enterococci, gram-positiveorganisms
Contraindications:
Allergies topenicillins, cephalosporins, or otherallergens and Use cautiously with renal disorders
Drug Interaction:

Drug drug
- Increased risk of rash with allopurinol
- Increased bleeding effect with heparin, oral anticoagulants
- Decreased effectiveness with tetracyclines, chloramphenicol

Decreased efficacy of hormonal contraceptives, atenolol with ampicillin

Increased ampicillin effect with probenecid

Adverse Effects:

CNS: Lethargy, hallucinations, seizures

CV: CHF

GI: Glossitis, stomatitis, gastritis, sore mouth, furry tongue, black "hairy" tongue, nausea, vomiting,
diarrhea, abdominal pain, bloody diarrhea, enterocolitis, pseudomembranous colitis, nonspecific hepatitis

GU: Nephritis

Hematologic: Anemia, thrombocytopenia, leukopenia, neutropenia, prolonged bleeding time

Hypersensitivity: Rash, fever, wheezing, anaphylaxis

Local: Pain, phlebitis, thrombosis at injection site (parenteral)

Other: Superinfectionsoral and rectal moniliasis, vaginitis

Nursing Responsibilities:

Culture infected area before treatment; reculture area if response is not as expected.

Check IV site carefully for signs of thrombosis or drug reaction.

Do not give IM injections in the same site; atrophy can occur. Monitor injection sites.

Administer oral drug on an empty stomach, 1 hr before or 2 hr after meals with a full glass of water; do not give with
fruit juice or soft drinks.

Take this drug around-the-clock.

Take the full course of therapy; do not stop taking the drug if you feel better.

Take the oral drug on an empty stomach, 1 hr before or 2 hr after meals; the oral solution is stable for 7 days at
room temperature or 14 days refrigerated.

This antibiotic is specific to your problem and should not be used to self-treat other infections.

You may experience these side effects: Nausea, vomiting, GI upset (eat frequent small meals), diarrhea.

Report pain or discomfort at sites, unusual bleeding or bruising, mouth sores, rash, hives, fever, itching, severe
diarrhea, difficulty breathing.