NURSING CARE PLAN 1: INEFFECTIVE AIRWAY CLEARANCE (July 25, 2019)

NURSING SCIENTIFIC NURSING

ASSESSMENT OBJECTIVES RATIONALE EVALUATION
DIAGNOSIS EXPLANATION INTERVENTIONS
Subjective: Ineffective airway Ineffective Airway After 2 hours of - Assessed level of - This information is essential for Goal is met.
“Nahihirapan siyang clearance related to Clearance is the nursing consciousness/cognition and identifying potential for airway
ilabas ang plema” as airway spasm as inability to clear interventions, the ability to protect own airway. problems, providing baseline After 2 hours of
verbalized by wife. evidenced by secretions or patient’s level of care needed and nursing
presence of crackles obstructions from the secretions are influencing choice of intervention interventions, the
Objective: and rhonchi and an respiratory tract to mobilized, and patient’s
- presence of crackles increased maintain a clear airway is free of - Monitored respirations and - Indicative of respiratory distress secretions were
and rhonchi respiratory rate of 26 airway. excessive breath sounds, noting rate and/or accumulation of secretions mobilized, and
- intercostal count per minute. secretions. and sounds. airway was free of
retractions were noted Clostridium tetani excessive
- dyspnea enters the body - Elevated head of bed and - To take advantage of gravity secretions as
- restlessness through the wound changed client’s position decreasing pressure on the evidenced by:
- Vital Signs: ↓ every 2 hours. diaphragm and enhance
T: 36.7°C Spores release drainage/ventilation to different -clear lung sounds
P: 72 bpm bacteria that spreads lung segments. through
R: 26 cpm in the body auscultation
BP: 120/70 mmHg ↓ - Encouraged deep breathing -To maximize effort and improve - (-) intercostal
O2: 94 Tetanospasmin is and coughing exercises. productivity of the cough. retractions
produced -absence of
↓ -Performed endotracheal -To clear airway by removing dyspnea
Nerve signals are suctioning. excessive or viscous secretions -ability to
blocked from spinal effectively cough
cord to muscles -Educated patient to maintain -Fatigue is a contributing factor to up secretions.
causing spasm ( planned rest periods. ineffective coughing. - RR: 18
including respiratory
muscle spasm) - Assessed SO’s knowledge - To determine educational and
↓ of contributing causes, support needs.
Diaphragm and treatment plan, specific
laryngeal muscles are medications and therapeutic
affected + profuse procedures.
amounts of secretions
- Administered oxygen - The provision of adequate
therapy with nasal cannula at oxygen can supply and provide
2 LPM as per doctor’s order. backup oxygen, thus preventing
hypoxia.

- This drug can thin the thick

- Administered Acetylcysteine secretions making it easy to
600 mg/tab OD HS. expectorate.
 NURSING CARE PLAN 3: RISK FOR INJURY (July 25, 2019)

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTIONS
Subjective: Risk for injury Impaired physical mobility is After 2 hours of -Assessed client’s -To determine presence of Goal is met.
“Hindi pa rin related to the limitation in independent, nursing developmental level. Motor characteristics of client’s
masyadong neuromuscular purposeful physical interventions, the skills, ease and capability of unique impairment and After 2 hours of
movement of the body or of
makagalaw ang asawa impairment as one or more extremities.
patient and/or moving, posture and gait. guide choice of nursing
ko” as verbalized by evidenced by significant others interventions. interventions, the
wife. muscle rigidity and Clostridium tetani enters the will be able to patient and/or
spasm. body through the wound demonstrate -Assisted with the treatment -To maximize the potential significant others
Objective: safety measures of underlying condition for mobility and function. demonstrated
-slow spastic to minimize causing pain or dysfunction. safety measures
movement Toxins produced by growing potential for injury. to minimize
-decrease range of -Turned and positioned the -To optimize circulation potential for
motion Spores germinate under patient every 2 hours or as and relieves pressure. injury as
-difficulty in turning anaerobic conditions needed. evidenced by:
-Vital signs:
T: 36.7 -Supported affected body -To maintain position of -SO ensured that
PR: 72 bpm Tetanospasmin produced by parts or joints using pillow, function and reduce risk of side rails are up
RR: 26 cpm causative bacteria in the rolls, pads etc. pressure ulcer. all the time.
organism
BP: 120/70 mmHg -Using of pillows
02: 94 -Kept side rails up and bed -To promote a safe to support body
Tetanus toxins enters the in low position. environment. parts or joints.
nerve terminals through the -SO ensured that
lower motor neuron -Maintained limbs in -Maintaining proper limbs alignment
functional alignment with the alignment of extremities is maintained.
use of pillows. Supported prevents contractures -Performed
Neurotransmitter is blocked
feet in dorsiflex position. such as foot drops and/or passive and
excessive plantar flexion active motion
An ability to inhibit lower or tightness. exercises.
motor neurons is disrupted -SO maintained
-Performed passive or active -To promote/increase the client’s skin
assistive range of motion venous return, prevents clean, dry and
Which can result in muscle exercises to all extremities stiffness and maintain moisturized.
rigidity and spasm
like moving or lifting the muscle strength and
extremities. endurance.
Risk for injury
- Clean, dry and moisturized - These measures reduce
the skin. skin breakdown from
prolonged immobility.

-Involved the significant -To help the client improve

others in care, assisting from the condition.
them to learn ways of
managing the problems of
immobility.
 NURSING CARE PLAN 2: IMPAIRED VERBAL COMMUNICATION (July 26, 2019)

NURSING SCIENTIFIC NURSING

ASSESSMENT OBJECTIVES RATIONALE EVALUATION
DIAGNOSIS EXPLANATION INTERVENTIONS
Subjective: Impaired verbal Clostridium tetani After 2 hours of -Established rapport with the -To gain the client’s trust and Goal is met.
“Hindi makapag salita communication enters the body nursing client and significant others. cooperation.
ang asawa ko” as related to structural through the wound interventions, the After 2 hours of
verbalized by wife. problem secondary patient will be able -Assessed the patient’s - Patients may have skills with nursing
to tracheostomy tube Spores release to use a form of primary and preferred means many forms of communications, interventions, the
Objective: . bacteria that spreads communication to of communications like verbal yet they will favor one method for patient was able to
- Difficulty of vocalizing in the body get needs met and , written or gestures. important communication. use a form of
words. to relate effectively communication to
- Difficulty in Tetanospasmin is with people and - Assessed the ability to -A way to be certain if get needs met and
communicating produced his environment. understand written words, communication has been to relate effectively
-Difficulty in pictures and gestures. productive is through with people and
expressing thoughts Nerve signals are understanding of information from his environment as
verbally blocked from spinal both sides of the discussion. evidenced by:
-Difficulty expressing cord to muscles
needs causing spasm ( - Provided writing pad and -An alternative means of -Using of hand
including respiratory pencil as an alternative communication can help the gestures
muscle spasm) means of communication. patient express ideas and -Using of eye
communicate needs. blinks when
Diaphragm and answering a yes or
laryngeal muscles are - Educated the patient to use -This is helpful for intubated and no question
affected + profuse eye blinks or finger tracheal patients. -Writing on a
amounts of secretions movements for yes or no paper when he
responses. wants to say
Unsecured airway something or when
- Involved significant others in -Enhances participation and he needs
Placement of plan of care as much as commitment to plan. something.
tracheostomy tube possible.

Impaired verbal -Educated significant others -To maximize patient’s sense of

communication to placed important objects independence.
within the patient’s reach.

- Provided the patient with -It may be difficult for patient to

ample time to respond. respond under pressure; patient
needs extra time to organize
responses.
 DRUG STUDY

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION

Generic Name: Acts mainly at the For muscle relaxant Drowsiness • Monitor periodic
Diazepam limbic system and adjunct for the relief hepatic, renal, and
reticular formation; of reflex skeletal Possible side effects: hematopoietic
may act in spinal cord muscle spasm due to -nausea function studies in
Brand Name: and at supraspinal local pathology. -slurred speech patients receiving
Valium sites to produce Treatment of tetanus. repeated or prolonged
skeletal muscle therapy.
relaxation.
Classification:
• Monitor elderly
Benzodiazepines
patients for dizziness,
ataxia, mental status
Dosage: changes. Patients are
D5W 250 + 60 mg q6 at an increased risk
Started on June 20, for falls.
2019
•Use of drug may
lead to abuse and
addiction. Don’t
withdraw drug
abruptly after long-
term use; withdrawal
symptoms may occur.
 DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING
ACTION CONSIDERATION

Generic Name: Clopidogrel selectively Use to prevent blood None seen on patient. • To report any unusual
Clopidogrel bisulfate inhibits adenosine clot formation. bruising, bleeding to
diphosphate (ADP) Other possible side prescriber, that it may
Brand Name: from binding to its effects: take longer to stop
Plavix platelet P2Y receptor -dizziness. bleeding.
and subsequent -nausea.
Classification: activation of -diarrhea or • To take with food or
Antiplatelet glycoprotein GPIIb/IIIa constipation. just after eating to
complex thus reducing minimize GI discomfort
Dosage: platelet aggregation. .
75 mg/Tab
1tab OD • To report diarrhea,
Started on June 20, skin rashes,
2019 subcutaneous bleeding
, chills, fever, sore
throat.
 DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING
ACTION CONSIDERATION

Generic Name: Inhibits Treatment of None seen on patient. • Monitor patient’s

Losartan Potassium vasoconstrictive and hypertension. blood pressure prior to
aldosterone secreting Possible side effects: administration of
Brand Name: action of angiotensin II -upper respiratory medication
Cozaar by blocking infections, such as the
angiotensin II receptor common cold Monitor patient BP
Classification: on the surface of the -dizziness closely to evaluate
Antihypertensives vascular smooth -stuffy nose effectiveness of
Angiotensin II muscle and other therapy.
Receptor Blocker tissue cells.
Monitor patient’s input
and output.
Dosage:
50mg/tab Monitor patient’s
1tab OD regularly for possible
Started on June 20, side effects.
2019
• Regularly assess the
patient’s renal function
(via creatinine and
BUN levels

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION
Generic Name: Inhibits beta lactamase
Piperacillin + and prevents the
Tazobactam destruction of piperacillin.
Therefore, tazobactam is
Brand Name: given with piperacillin to
Tazocin enhance the activity of
piperacillin in eradicating
Classification: bacterial infections.
Antibiotic Piperacillin kills bacteria
extended spectrum by inhibiting the synthesis
penicillin, beta- of bacterial cell walls.
lactamase inhibitor
-For treatment of gram None seen on patient. •Obtain skin test for
-positive and gram- hypersensitivity
negative bacteria. Possible side effects: reaction to penicillin
-injection site pror to administration
-Hospital Acquired reactions like swelling of medication.
Pneumonia. , redness, pain,
soreness or. irritation If large doses are
-agitation given or if therapy is
-trouble sleeping prolonged, bacterial or
fungal superinfection
may occur, especially
in elderly

• Monitor hematologic
Dosage: and coagulation
4.5g/TIV parameters.
Q6
Started on June 22, • Tell patient to report
2019 adverse reactions
promptly.

• Tell patient to alert a

health care
professional about
discomfort at the I.V.
site.

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION

Generic Name: None seen in patient.

Azithromycin Blocks transpeptidation -Treatment of lower Obtain Skin Testing for
by binding to 50s respiratory infection. Possible side effects: hypersensitivity
Brand Name: ribosomal subunit of -diarrhea or loose reaction to azithrmycin.
Zithromax susceptible organisms -Hospital Acquired stools
and disrupting RNA- Pneumonia. -nausea • Administer on an
Classification: dependent protein -abdominal pain empty stomach1 hour
Antibiotic synthesis at the chain before or 2-3 hours
Macrolide elongation step. after meals. Food
affects absorption of
Dosage: drugs
500mg/tab
1tab OD • Advice patient to take
Started on June 22, drug as prescribed,
2019 even after he feels
D/C: June 26, 2019 better.

• Advice patient to
report adverse
reactions promptly

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION

Generic Name: Bactericidal: Inhibits For treatment of None seen in patient. • Obtain Skin Testing
Amikacin Sulfate protein synthesis in bacterial infections. for hypersensitivity
 susceptible strains of Possible side effects: reaction to amikacin.
Brand Name: gram-negative bacteria -diarrhea
Amikin , and the functional -hearing loss Correct dehydration
integrity of bacterial -spinning sensation ( before therapy
Classification: cell membrane vertigo) because of increased
Antibiotic appears to be risk of toxicity.
Aminoglycoside disrupted, causing cell
death. •Due to increased risk
of nephrotoxicity,
monitor renal function.
Dosage:
1 gram IV • Instruct patient to
OD promptly report
Started on June 23, adverse reactions to
2019 prescriber.
D/C June 29, 2019
• Encourage patient to
maintain adequate fluid
intake.

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION
Generic Name: Promotes hepatic Prevention and None seen in patient. •Assess skin for
Phytonadione Vitamin formation of treatment of ecchymoses,
K coagulation factors II, hemorrhage. Possible side effects: petechiae.
VII, IX, X Essential for -unusual or unpleasant
Brand Name: normal clotting of blood taste in your mouth •Assess gums for
Mephytone . -a light-headed feeling gingival bleeding.
-blue colored lips
•Assess for decrease
Classification: in BP, increase in
Coagulant pulse rate, complaint of
abdominal/back; pain,
severe headache.

Dosage: •Monitor PT,

1 ampule then Q8 international
Started on June 24, normalized ratio (INR)
2019 routinely in those
D/C on June 27, 2019 taking anticoagulants.

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION
Generic Name: Bactericidal: Inhibits -For treatment of None seen in patient. • Obtain Skin Testing
Metronidazole DNA synthesis in bacterial infections. for hypersensitivity
specific (obligate) Possible side effects: reaction to
Brand Name: anaerobes, causing -Preferred antibiotic for -nausea, vomiting, loss metronidazole
Flagyl cell death; tetanus (WHO) of appetite
antiprotozoal- -diarrhea Tell patient to report to
Classification: trichomonacidal, -constipation prescriber immediately
Antiprotozoal amoebicidal. -headache any neurologic
Antibacterial symptoms.
Nitroimidazole
• Contraindicated in
Dosage: patients hypersensitive
500mg TID to drug.
Q6x10days
Started on June 20, • Instruct patient to
2019 take oral form with
D/C on June 30, 2019 meals to minimize
reactions.

• Monitor liver function

test results carefully in
elderly patients

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION
Generic Name: Tetanus toxoid To prevent tetanus and None seen on patient. •Shake well the vial
Tetanus Toxoid adsorbed induces indicated for booster before withdrawing
active immunity to injection. Possible Common side each dose.
Brand Name: tetanus antigen by effects:
Imatet stimulating the immune -mild fever •Monitor for
system to produce -joint pain hypersensitivity.
Classification: specific antigen. -muscle aches
Vaccine

Dosage:
0.5ml IM
Given June 25, 2019

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION

Generic Name: Reduces the viscosity To liquify phlegm. None seen on patient. • Instruct the significant
Acetylcysteine of pulmonary person to dissolve the
 secretions by splitting Possible Side effects: drug in water before
Brand Name: disulfide linkages -inflammation of the administration.
Fluimucil between mucoprotein mouth
molecular complexes. -nausea Monitor cough type
Classification: -vomiting and frequency.
Mucolytic
•Report difficulty
Dosage: breathing or nausea.
600 mg/tab
disooleve in 50 ml of Report any side effects
water that might occur in
patient.
OD HS
Started on July 25,
2019

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION

Generic Name: Inhibits fibrinolysis by To control bleeding. None seen on patient. • Conduct a skin
Tranexamic Acid blocking the binding of Short-term testing prior to
plasminogen and management of Possible side effects: administration of drug.
Brand Name: plasmin to fibrin, thus hemorrhage. -nausea
Lysteda preventing dissolution -vomiting Unusual change in
of the hemostatic plug. -diarrhea bleeding pattern
Classification: should be immediately
Antifibrinolytic reported to the
physician.
Dosage:
500mg IV q8 •Inform the client that
PRN for bleeding he/she should inform
Started on June 26, the physician
2019 immediately if severe
D/C: June 30, 2019 side effects occur.

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION
Generic Name: Albumin is responsible Temporary None seen on patient. •Monitor vital signs,
Human Albumin for 75-80% of the replacement of albumin intake and output
colloid osmotic in diseases associated Possible side effects: before and frequently
Brand Name: pressure with low levels of -nausea & vomiting throughout therapy.
Buminate of normal plasma. plasma proteins -fever and chills
Albumin stabilizes resulting in relief or -fast heart rate •Assess for signs of
Classification: circulating blood reduction of associated vascular overload (
Plasma expanders volume and is a carrier edema. elevated CVP,
of rales/crackles,
Dosage: hormones, enzymes, dyspnea, hypertension,
20% OD medicinal products and jugular venous
Started on June 26, toxins. distention) during and
2019 after administration.
D/C: July 10, 2019
•Monitor serum sodium
levels; may cause
increase concentration.

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION

Generic Name: Inhibits reabsorption of Treatment of None seen on patient. •Monitor weight, blood
Furosemide sodium and chloride hypertension and pressure, and pulse
from the proximal and edema. Possible side-effects: rate routinely with long-
Brand Name: distal tubules and -nausea or vomiting term use.
Lasix ascending limb of the -diarrhea
loop of Henle, leading -constipation • Monitor fluid intake
Classification: to a sodium-rich and output.
Antihypertensive diuresis.
Loop diuretic • Advise patient to
immediately report
Dosage: ringing in ears, severe
20mg IV OD abdominal pain, or
Started on June 26, sore throat and fever;
2019 these symptoms may
D/C: July 10, 2019 indicate toxicity.

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION
Generic Name: Depresses subcortical Midazolam is suitable None seen on patient. • Conduct a skin
Midazolam levels in CNS may act drug in long-term testing prior to
hydrochloride on limbic system, sedation of patient with Possible side effects: administration of drug.
reticular formation. tetanus. -headache
Brand Name: May potentiate γ- -nausea • Monitor blood
Midazolam aminobutyric acid ( -vomiting pressure, heart rate
GABA) by binding to and rhythm,
Classification: specific respirations, airway
Benzodiazepine (short- benzodiazepine integrity, and arterial
acting) receptors. oxygen saturation
CNS depressant during procedure.

Dosage: • Monitor
D5W 250cc + 15mg Hypersensitivity to
Midazolam x 10cc/hr. benzodiazepines.
Started on June 28,
2019 •Monitor level of
D/C: July 10, 2019 consciousness before,
during for at least 2-6
hours after
administration of drug.

•Carefully monitor PR,

BP, and respirations
during administration.
 DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING
ACTION CONSIDERATION

Generic Name: It inhibits both To treat muscle None seen on patient. • Watch for sensitivity
Baclofen monosynaptic and spasticity and for reactions, such as
polysynaptic reflexes at muscle relaxant. Possible side effects: fever, skin eruptions,
Brand Name: spinal level. -drowsiness and respiratory distress
Lioresal -dizziness .
-weakness
-fatigue • Don’t withdraw drug
Classification: -headache abruptly after long term
Skeletal muscle -sleep problems use unless severe
relaxant adverse reactions
demand it.
Dosage:
10mg/tab • Report frequent or
TID painful urination,
Started on June 20, constipation, nausea,
2019 headache, insomnia, or
D/C: July 11, 2019 confusion that persists
or is severe.
 DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING
ACTION CONSIDERATION

Generic Name: Bactericidal interferes For the treatment of None seen on patient. • Conduct a skin
Ciprofloxacin with DNA replication in infections. testing prior to
susceptible bacteria Possible side effects: administration of drug.
Brand Name: preventing cell -diarrhea
Cipro reproduction. -dizziness • Monitor patient’s
-drowsiness intake and output and
Classification: observe patient for
Antibiotic signs of crystalluria.

Dosage: • Advise patient to

500mg/tablet drink plenty of fluids to
BID reduce risk of urine
Started on July 19, crystals.
2019
• Advise patient that
hypersensitivity
reactions may occur.
 DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING
ACTION CONSIDERATION

Generic Name: Elevates the serum Prevention and -Black stools • GI upset may be
FeSO4 iron concentration and treatment of iron related to dose.
Ferrous Sulfate is then converted to deficiency anemias. Other possible side
Hgb or trapped in the effects: • Enteric-coated
Brand Name: reticuloendothelial cells -Constipation products reduce GI
Feoso for storage and -Diarrhea. upset but also reduce
eventual conversion to amount of iron
Classification: a usable form of iron. absorbed.
Iron supplement
• Monitor hemoglobin
Dosage: level, hematocrit, and
1tab OD reticulocyte count
Started July 25, 2019 during therapy.

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION

Generic Name: None seen on patient.

Omeprazole Gastric acid-pump To prevent excessive • Tell patient to
inhibitor: Suppresses acid formation in the Possible side effects: swallow tablets whole
Brand Name: gastric acid secretion GIT. -headache and not to open, crush,
Prilosec by specific inhibition of -abdominal pain or chew them.
the hydrogen- -diarrhea
Classification: potassium ATPase • Instruct patient to
Proton pump inhibitor enzyme system at the take drug at least 1
secretory surface of hour before meals.
Dosage: the gastric parietal
40mg/capsule cells; blocks the final
1tab OD step of acid production.
Started on July 31,
2019

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION
Generic Name: Budesonide controls To reduce irritation and None seen on patient. •Monitor for
Budesonide the rate of protein swelling of the airway. hypersensitivity.
synthesis, depresses Possible Side effects:
Brand Name: the migration of -thinning skin, easy •Taper systemic
Pulmicort Respules polymorphonuclear bruising, increased steroids carefully
leukocytes, fibroblasts, acne or facial hair. during transfer to
Classification: reverses capillary inhalational steroids;
Corticosteroid permeability and -ankles swelling. deaths from adrenal
lysosomal stabilization insufficiency have
Dosage: at the cellular level to occurred.
200 mcg/dose q12 prevent or control
through nebulization inflammation. •Monitor patient for
Started on July 31, signs of hypercorticism
2019 -acne, bruising, moon
face, swollen ankles,
hirsutism, skin striae,
buffalo hump -which
could indicate need to
decrease dosage.

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION
Generic Name: Reduces fever by To decrease fever. - Assess patient’s fever
None seen on patient.
Paracetamol acting directly on the or pain: type of pain,
hypothalamic heat- location, intensity,
Brand Name: regulating center to duration, temperature,
Biogesic cause vasodilation and and diaphoresis.
Possible side effects:
sweating, which helps
Classification: dissipate heat. -low fever -Assess allergic
Analgesic -nausea reactions: rash,
-stomach pain urticaria; if these
Dosage: -loss of appetite occur, drug may
300mg TIV have to be
Started on June 20, discontinued.
2019
-Give drug with food to
prevent GI upset.

DRUG NAME MECHANISM OF DRUG RATIONALE SIDE EFFECT NURSING

ACTION CONSIDERATION
 Generic Name: Inhibits cell wall For treatment of None seen in patient. -Hypersensitive to
Ceftriaxone synthesis, promoting bacterial infections. cephalosporins,
osmotic instability that Possible side effects: penicillins and related
Brand Name: is usually bactericidal -Fever antibiotics.
Forgram -Dizziness
-Nausea/vomiting -Obtain C&S before
Classification: beginning drug therapy
3rd generation to identify correct
cephalosporin treatment has been
initiated.
Dosage:
2g OD -Report signs such as
Started on July 17, petechiae, ecchymotic
2019 areas, epistaxis or
D/C: July 23, 2019 other forms of
unexplained bleeding.

LABORATORY & DIAGNOSTIC PROCEDURES

EXAM Result Result Result Result Result Result Result Result REMARKS
NAME
 06/24/201 06/27/201 07/01/201 07/04/201 07/09/201 07/12/201 07/12/201 07/15/201
9 9 9 9 9 9 9 9
15:42:16 17:25:09 17:35:22 11:21:58 19:45:34 10:57:26 09:30:33 10:05:51
White
blood cell
Normal 10.84 ( 14.42 ( 10.96 ( 10.7 (High 11.85 ( 15.47 ( 15.47 11.78 ( Presence of
Value: High) High) High) ) High) Hight) (High) High) infection
4.10-10.0 x due to C.
10^9/L tetani, K.
pneumoniae
, P.
aeruginosa
Red blood
cell
Normal 3.24 (Low) 3.65 (Low) 3.27 (Low) 3.68 (Low) 3.73 (Low) 3.90 (Low) 3.90 (Low) 4.05 (Low) RBC is low
Value: due to
4.5-6.2 x tetanolysin
10^12/L
Hematocrit
Normal
Value: 0.29 (Low) 0.32 (Low) 0.29 (Low) 0.32 (Low) 0.33 (Low) 0.34 (Low) 0.34 (Low) 0.35 (Low) When
0.40-0.50 hematocrit
g/L level is low
the color of
RBC
become
hypochromi
c
Hemoglobi When
n 92.0 (Low) 103.0 ( 93.0 (Low) 104.0 ( 107.0 ( 110.0 ( 110.0 ( 116.0 ( hemoglobin
Normal Low) Low) Low) Low) Low) Low) level is low
Value: the color of
130-180 RBC
 g/L become
hypochromi
c

MCV When MCV

Normal is below the
Value: 79.9 80.6 79.1 78.8 81.5 75.7 77.4 76.3 normal
82-98 Fl range, it
means that
the size of
RBC is
small or
what we
called
microcytic
MCH When
Normal hemoglobin
Value: 27.4 26.2 26.9 25.1 26.4 26.1 27.2 26.8 level is low
28-33 % the color of
RBC
become
hypochromi
c
MCHC When
Normal hemoglobin
Value: level is low
33-36 % 31.9 (Low) 32.6 (Low) 32.5 (Low) 32.2 (Low) 32.4 (Low) 32.5 (Low) 32.5 (Low) 32.5 (Low) the color of
RBC
become
hypochromi
 c

Platelet
count
Normal Associated
Value: 162 459 (High) 635 (High) 651 (High) 491 (High) 434 (High) 434 (High) 377 with
150-400 x tracheal
10^9/L trauma and
bleeding

RDW When RDW

Normal 15 (High) 15 (High) 15 (High) 15 (High) 15 (High) 14 14 14 is high and
Value: MCV is low
11.4-14.0 it suggests
% microcytic
anemia
Neutrophil
Normal 77.7 (High 77.7 (High 73.5 (High 72.3 (High 68.8 (High 72.8 (High 72.8 (High 72.2 (High Presence of
Value: ) ) ) ) ) ) ) ) infection
55-65 % due to C.
tetani, K.
pneumoniae
, P.
aeruginosa

Presence of
Lymphocyt 11.3 (Low) 10.3 (Low) 14.1 (Low) 16.2 (Low) 16.3 (Low) 13.7 (Low) 13.7 (Low) 13.7 (Low) infection
e due to C.
Normal tetani, K.
Value: pneumoniae
25-35 % , P.
aeruginosa
 Eosinophil
Normal 1.1 (Low) 2.8 2.9 2.4 3.8 3.2 3.2 3.2 Normal
Value:
2.0-4.0 %
Monocyte
Normal 9.8 (High) 9.1 (High) 9.2 (High) 8.6 (High) 10.7 (High 10.0 (High 10.0 (High 10.0 (High Presence of
Value: ) ) ) ) infection
3.0-8.0 % due to C.
tetani, K.
pneumoniae
, P.
aeruginosa
Basophil
Normal 0.1 0.1 0.3 0.5 0.4 0.3 0.3 0.3 Normal
Value:
0-1.0 %

EXAM Result Result Result Result Result Result Result Result REMARKS
NAME 07/15/201 07/18/201 07/18/201 07/23/201 07/24/201 07/25/201 07/25/201 07/30/201
9 9 9 9 9 9 9 9
01:17:04 14:33:59 09:53:05 20:45:51 01:26:30 20:34:57 12:01:58 11:37:06
White Presence of
blood cell infection due
Normal 11.78 ( 10.44 ( 10.44 ( 18.32 ( 18.32 ( 9.28 9.28 10.83 ( to C. tetani, K
Value: High) High) High) High) High) High) . pneumoniae
4.10-10.0 x , P.
10^9/L aeruginosa
Red blood
cell
Normal 4.05 (Low) 3.44 (Low) 3.44 (Low) 3.42 (Low) 3.42 (Low) 3.35 (Low) 3.35 (Low) 4.10 (Low) RBC is low
Value: due to
tetanolysin
4.5-6.2 x
10^12/L
Hematocrit When
Normal hematocrit
Value: 0.35 (Low) 0.30 (Low) 0.30 (Low) 0.30 (Low) 0.30 (Low) 0.29 (Low) 0.29 (Low) 0.35 (Low) level is low
0.40-0.50 the color of
g/L RBC become
hypochromic
Hemoglobi When
n 116.0 ( 95.0 (Low) 95.0 (Low) 97.0 (Low) 97.0 (Low) 94.0 (Low) 94.0 (Low) 111.0 ( hematocrit
Normal Low) Low) level is low
Value: the color of
130-180 RBC become
g/L hypochromic
MCV
Normal 81.4 81.1 81.3 80.7 81.4 81.7 84.2 86.3 Microcytic to
Value: Normocytic
82-98 Fl

MCH
Normal 26.6 (Low) 27.6 (Low) 27.6 (Low) 27.4 (Low) 27.4 (Low) 27.7 (Low) 28.1 28.6 Hypochromic
Value: to
28-33 % Normochromi
c
MCHC
Normal
Value: 32.2 (Low) 31.4 (Low) 31.4 (Low) 32.8 (Low) 32.8 (Low) 32.2 (Low) 33.2 33.5 Hypochromic
33-36 % to
Normochromi
c

Platelet
count Associated
 Normal 377 354 354 397 397 429 (High) 429 (High) 501 (High) with tracheal
Value: trauma and
150-400 x bleeding
10^9/L
RDW
Normal 15 15 15 15 15 15 14 14 Microcytic to
Value: Normocytic
11.4-14.0
%
Neutrophil Presence of
Normal infection due
Value: 72.2 (High 67.3 (High 67.3 (High 90.8 (High 90.8 (High 50.2 (Low) 50.2 (Low) 46.4 (Low) to C. tetani, K
55-65 % ) ) ) ) ) . pneumoniae
, P.
aeruginosa
Lymphocyt Presence of
e infection due
Normal 15.2 (Low) 17.4 (Low) 17.4 (Low) 5.2 (Low) 5.2 (Low) 30.7 30.7 35.5 (High to C. tetani, K
Value: ) . pneumoniae
25-35 % , P.
aeruginosa
Eosinophil Presence of
Normal infection due
Value: 3.0 5.2 (High) 5.2 (High) 0.1 (Low) 0.1 (Low) 6.5 (High) 6.5 (High) 4.6 (High) to C. tetani, K
2.0-4.0 % . pneumoniae
, P.
aeruginosa
Monocyte Presence of
Normal infection due
Value: 9.2 (High) 9.6 (High) 9.6 (High) 3.7 3.7 12.2 (High 12.2 (High 12.8 (High to C. tetani, K
3.0-8.0 % ) ) ) . pneumoniae
, P.
aeruginosa
Basophil
Normal
Value: 0.4 0.5 0.5 0.2 0.2 0.4 0.4 0.7 Normal
0-1.0 %

DATE AND TIME REQUESTED: 07/14/2019 12:21:30

URINALYSIS (MICROSCOPIC/CHEMICAL EXAMINATION)
ROUTINE
PHYSICAL RESULT REFERENCE
EXAMINATION
Color DARK YELLOW Light yellow –
Amber
Transparency ( TURBID Clear
Clarity)
CHEMICAL RESULT REFERENCE CHEMICAL RESULT REFERENCE
ANALYSIS ANALYSIS
Glucose NEGATIVE < 5.5 mmol/L pH 8.5 5.00 – 8.00
Bilirubin NEGATIVE < 5 umol/L Protein > 4.0 g/L 0.1 g/L
Ketone NEGATIVE < 0.4 mmol/L NEGATIVE
Urobilinogen < 4 umol/L
Specific gravity 1.035 1.005 – 1.035 Nitrite
POSITIVE NEGATIVE
Blood > 280 /uL < 9 /uL > 625 /uL (+4)
Leukocytes < 14 /uL
Ascorbic acid NEGATIVE < 0.5 mmol/L 150 mg/dL (+3)
MicroAlbumin < 10 mg/L
Creatinine > 26.5 mmol/L < 1.0 mmol/L 2.5 mmol/L (
Calcium < 2.4 mmol/L
TRACE)
URINE SEDIMENT ANALYSIS BY AUTO PARTICLE RECOGNITION
SEDIMENT RESULT UNIT REFERENCE
RANGE
RBC 655 (+4/MANY) /HPF 0-2
 WBC 275 (+4/MANY) /HPF 0-4
Squamous epithelial cells 20 (NORMAL) /LPF 0 - 82
Amorphous urate/phosphate 16622 (+4/MANY) /LPF 0 - 80
Mucus threads 31 (NORMAL) /LPF 0 – 82
Bacteria 14 (TRACE/RARE /HPF 0 - 10
)

DATE AND TIME REQUESTED: 06/20/2019 09:17:57

URINALYSIS (MICROSCOPIC/CHEMICAL EXAMINATION)
ROUTINE
PHYSICAL RESULT REFERENCE
EXAMINATION
Color YELLOW Light yellow –
Amber
Transparency ( SLIGHTLY Clear
Clarity) TURBID
CHEMICAL RESULT REFERENCE CHEMICAL RESULT REFERENCE
ANALYSIS ANALYSIS
Glucose NEGATIVE < 5.5 mmol/L pH 6.0 5.00 – 8.00
Bilirubin NEGATIVE < 5 umol/L 0.2 g/L (TRACE)
Protein 0.1 g/L
Ketone NEGATIVE < 0.4 mmol/L 17 umol/L (+1)
Urobilinogen < 4 umol/L
Specific gravity 1.025 1.005 – 1.035 Nitrite NEGATIVE NEGATIVE
Blood 200 /Ul (+3) < 9 /uL 15 /uL (TRACE)
Leukocytes < 14 /uL
Ascorbic acid NEGATIVE < 0.5 mmol/L 150 mg/dL (+3)
MicroAlbumin < 10 mg/L
Creatinine 4.4 mmol/L (+1) < 1.0 mmol/L Calcium 2.5 mmol/L ( < 2.4 mmol/L
TRACE)
URINE SEDIMENT ANALYSIS BY AUTO PARTICLE RECOGNITION
SEDIMENT RESULT UNIT
 REFERENCE
RANGE
RBC 32 (+ /HPF 0-2
3/MODERATE)
WBC 5 (TRACE/RARE) /HPF 0-4
Squamous epithelial cells 9 (NORMAL) /LPF 0 - 82
Non-Squamous epithelial cells 3 (NORMAL) /LPF 0 – 18
Amorphous urate/phosphate 198 (+ /LPF 0 – 80
1/OCCASIONAL)
Mucus threads 9 (NORMAL) /LPF 0 - 82

BLOOD TYPING RESULT

Date Requested: 06/21/2019
09:27:55

ABO Rh

A POSITIVE

COAGULATION STUDIES RESULT

Date Requested: 07/09/2019
09:33:54
 EXAM NAME RESULT UNIT REFERENCE RANGE
Prothrombin Time
Patient 12.40 Seconds 11.5 – 15.5
Control
% Activity 110.00 % 70 - 120
INR 0.94

Thromboplastin Time
Patient 28.50 Seconds 28 – 38
Control

ARTERIAL BLOOD GAS ANALYSIS RESULT

TEST RESULT RESULT RESULT RESULT RESULT RESULT RESULT RESULT

NAME 07/10/19 07/15/19 07/19/19 07/20/19 07/22/19 07/23/19 07/25/19 07/30/19
07:06:00 18:41:33 18:21:30 16:38:00 18:01:40 20:41:15 13:49:15 14:23:30

Ph
Normal 7.459 7.448 7.447 7.460 7.443 7.405 7.393 7.419
Value:
7.380-7.
460

pCO2
Normal 35.4 mmHg 35.1 mmHg 41.0 mmHg 38.7 mmHg 38.0 mmHg 39.0 mmHg 37.6 mmHg 34.7 mmHg
Value:
32-46
mmHG
 pO2 86.2 mmHg 105.2 188.9 248.0 33.8 mmHg 173.5 94.7 mmHg 58.4 mmHg
Normal mmHg mmHg mmHg (Low) mmHg (Low)
Value: (High) (High) (High) (High)
70-100
mmHg

SO2
Normal 96.8% 98.0% 99.5% 99.7 67.5% 99.4% ( 97.2% 90.5%
Value: (High) (High) (Low) High) (Low)
92-98.5%

HCO3
Normal 28.4 23.9 27.9 27.5 25.6 24.0 22.5 22.1
Value: mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L
21-28
mmol/L

Normal Normal Normal Normal Normal Normal Normal Normal

ABG Acid-Base Acid-Base Acid-Base Acid-Base Acid-Base Acid-Base Acid-Base Acid-Base
Analysis Balance Balance Balance Balance Balance Balance Balance Balance

Result Result Result Result Result REMARKS

Test name 06/20/2019 06/22/2019 06/27/2019 07/01/2019 07/09/2019
12:07:44 08:01:11 18:13:56 17:41:18 09:33:54
Creatinine
Normal Value: 101 umol/L 95 umol/L 85 umol/L 65.00 umol/L 71.00 umol/L Associated with
71-133 umol/L (Low) low muscle mass
 Result Result Result Result Result REMARKS
Test name 07/09/2019 07/12/2019 07/12/2019 07/18/2019 07/18/2019
19:29:35 21:51:16 23:19:13 09:53:05 14:46:53
Creatinine
Normal Value: 71 umol/L 56 umol/L (Low) 56 umol/L (Low) Associated with
71-133 umol/L low muscle
mass
Sodium
Normal Value: 140 mmol/L 140 mmol/L Normal
137-145 mmol/L
Potassium
Normal Value: 4.40 mmol/L 4.40 mmol/L 4.00 mmol/L 4.00 mmol/L Normal
3.5-5.1 mmol/L

Result Result Result REMARKS

Test name 07/23/2019 07/24/2019 07/30/2019
20:45:51 06:45:28 11:37:06
Creatinine
Normal Value: 62 umol/L (Low) Associated with low
71-133 umol/L muscle mass
Sodium
Normal Value: 139 mmol/L 139 mmol/L 138 mmol/L Normal
137-145 mmol/L
Potassium
Normal Value: 4.80 mmol/L 4.80 mmol/L 4.30 mmol/L Normal
3.5-5.1 mmol/L

SI Unit SI Unit
 Result Result REFERENCE REMARKS
Test Name 06/20/2019 06/20/2019 RANGES
08:56:52 11:43:33
Blood Urea 8.30 mmol/L 3.2-7.1 Indicative of
Nitrogen 8.20 mmol/L (High) (High) Dehydration

Creatinine 95.00 umol/L 101.00 umol/L 71-133 Normal

SI Unit
Test Name Result REFERENCE Remarks
RANGES
Random Blood 8.00 mmol/L Below 11.1 mmol/L Normal
Sugar
Blood Urea 8.20 mmol/L (High) 3.2-7.1 Indication of
Nitrogen dehydration
Creatinine 95.00 umol/L 71-133 Normal
Total Cholesterol 3.70 mmol/L < 5.17 Normal
Total Protein 45.00 g/L (Low) 63-82 Associated with
aging process
Albumin 29.00 g/L (Low) 35-50 Associated with
aging process
Globulin 16 g/L 15-35 Normal
A/G Ratio 1.81 0.0-2.0 Normal
SGOT/AST 54.00 U/L 17-59 Normal
SGPT/ALT 37.00 U/L < 50 Normal
 MICROBIOLOGY REPORT
DATE and 06/20/2019 06/20/2019 06/20/2019 07/13/2019 07/13/2019
TIME 02:18:28 06:34:33 11:35:51 09:25:00 09:25:00
requested
Specimen BLOOD BLOOD Transtracheal Aspirate BLOOD Tracheal Aspirate
Type (left arm) (right arm) (right arm)
Final Report: No Final Report: No Initial Report: No
Culture growth after 5 growth after 5 Klebsiella pneumoniae growth after 24 hours Pseudomonas aeruginosa
Isolate days of days of incubation of incubation
incubation
- Amikacin
- Amoxicillin
- Cefepime
- Cefoxitin - Ciprofloxacin
- Cefuroxime axetil - Gentamicin
- Ceftazidime
Sensitivity - Ceftriaxone
Test (Disk - Cefuroxime (oral)
diffusion - Ciprofloxacin
method) - Ertapenem
Antibiotic - Gentamicin
(Sensitive) - Imipenem
- Meropenem
- Piperacillin/
Tazobactam
- Trimethoprim /
Sulfamethoxazole
Sensitivity - Amikacin
Test (Disk - Cefepime
- Ampicillin - Ceftazidime
diffusion
- Imipenem
method)
- Meropenem
Antibiotic - Piperacillin/
(Resistant) Tazobactam

DATE and 07/13/2019 07/13/2019 7/14/2019 07/23/2019

TIME 13:55:57 13:55:57 12:21:54 09:25:00
requested
Specimen Type BLOOD BLOOD URINE BLOOD
(left arm) (left arm) (right arm)
Final Report: No Initial Report: No
Culture Isolate growth after 5 growth after 24 hours Proteus mirabilis Final Report: No growth after 5
days of incubation of incubation days of incubation

- Amikacin
- Amoxicillin
- Cefepime
Sensitivity Test - Cefotaxime
(Disk diffusion - Cefoxitin
method) - Cefuroxime axetil
Antibiotic - Ceftazidime
(Sensitive) - Ceftriaxone
- Cefuroxime (oral)
- Ciprofloxacin
- Ertapenem
- Gentamicin
- Meropenem
- Piperacillin/ Tazobactam
Sensitivity Test
(Disk diffusion - Ampicillin
- Trimethoprim /
method)
Sulfamethoxazole
Antibiotic
(Resistant)