C O U R S E I N T H E W A R D

DOCTOR’S ORDER RATIONALE NURSING RESPONSIBILITIES

06-26-11
06:30 PM

Please admit to pedia ward >to provide closed supervision >fill the necessary documents
under the supervision of Dra. and to further monitor the >prepare the chart of the
Marcelo. patient patient
>assist the patient to be at
the ward
>admit the patient to PEDIA
>take initial VS
Secure consent for admission >acts as a legal basis of the >present self as a witness
S.O’s awareness and >stand as a witness in
acceptanceof medical securing of the consent
servicesto be rendered to the >validate understanding of
patient the patient’s SO about the
importance of signing a
consent
TPR q shift >acts s a baseline and to >monitor and record it
monitor any deviation from >refer any deviation
normal
NPO >this is to prevent aspiration >emphasize the need to
since the patient is restrict giving of fluid and
experiencing DOB breast feeding to the patient
Diagnostic:
CBC with APC >to note for its baseline and >obtain and fill a laboratory
to note for any deviation from request form and forwarded it
normal blood count to the lab.
component >follow up the result and
attach to the patient’s chart
Na, K, Cl >to detemine electrolyte >obtain and fill a laboratory
imbalances request form and forwarded it
to the lab.
>follow up the result and
attach to the patient’s chart
U/A with SG >to determine alteration in > collect urine specimen
urine components
CXR-APC >to visualize the underlying > remove jewelries or
organ within the chest anything that may alter the
result
Tx: hook to D5 0.3 NaCL 500 cc >for hydration and serve as an >obtain and prepare aan
@ 50 ugtts/min. access for IV medications infusion set
>select a venipuncture
site,insert the catheter and
initiate the infusion
>maintaain the patency of the
tube
>hook the IV fluid and
regulate @the given infusion
rate and label it

Cefuroxime 270mg IV q 8hrs
ANST(-)
Ipratropium+ salbutamol neb.
1 neb q 8
Salbutamol neb. 1 neb now
then q 25 min. x 2 doses/ neb
Paracetamol 80 mg/ IV q 4 for
fever
Monitor fever
>this is an antibiotic; >check for the drug allergy
>administer the drug
following the 10R’s
>this promotes >assess the respiratory rate of
bronchodilation the patient
>instruct the S.O in proper
use of neb.
>instruct the S.O to give neb.
at the right time
>intsuct S.O to report any
adverse effect
>this promotes >assess the respiratory rate of
bronchodilation the patient
> give neb. at the right time
>instruct S.O to report any
adverse effect
>to lower the body >monitor the VS of the
temperature of the patient patient
>observe 10 R’s when
administering
O2 inhalation@ 1-2 Lpm/
cannula
>this is provide adequate
Oxygen and to alleviate DOB
>verify doctor’s order
>fill the humidifier bottlewith
distilled water
>attach the humidifier to the
base of flow meter and attach
the tubing
>regulate the flow meter @
the given level
>monitor the regulation of
the oxygen

Place on moderate high back
rest
Perform CPT every after
nebulization
Monitor VS q2 and record
Monitor I and O q shift and
record
Refer
>to promote lung expansion >instruct the mother to
cuddle the child in an upright
position or to elevate the
head of the bed
>to mobilize the secretion and >instruct S.O to do this after
to promote expectoration of neb.
secretion >demonstrate the proper way
of doing CPT
>to note for any deviation >monitor and record it
>refer if it is not normal
>to assess fluid balance in the >monitor and record
body and to monitor if I and
O is within normal
>to note for any untoward sx >refer if untoward symptoms
that may experience by the occur
patient in order to provide
immediate mng’t
06-26-11
10:40 pm

Please transfer under the service

of Dr. Mallillin
Breastfeeding with aspiration >this is to provide >instructed the mother to
precaution nourishment to the patient continue breastfeeding right
away aand emphasized the
need to prevent aspiration
through burping the child
right after breastfeeding
Follow up labs
Monitor vital signs and record >to note for any deviation >monitored and recorded
from normal values >referred for any deviation
Monitor intake and output q >to note if the patient’s I&O is >monitor and record
shift and record within normal
Refer >to provide immediate mng’t >refer accordingly.
if untoward symptoms occur
Decrease salbutamol neb. q 4 >to improve breathing pattern >verified doctor’s order
>instructed the S.O to give
nebulization every after 4
hours.
>instructed S.O to give neb. @
the right time
>instructed S.O in proper use
of neb.
Refer >to provide immediate mng’t >refer accordingly
if untoward symptoms occur
06-27-11
02:30 pm

IVF to follow D5 IMB 500cc to
run @ 33 ugtts/min.
Decrease nebulization to q 6
For fecalysis
Refer CXR
>to replenish fluid and
electrolyte and to provide
route for IV meds.
>to promote bronchodilation
thus improves breathing of
the patient
>to visualize the underlying
organ within the chest and for
further observation.
>maintained patency of IV
tubings
>infused and regulated IVF @
the given rate
>instructed S.O to give neb. at
the right time.
>instructed S.O in proper use
of neb.
> remove jewelries or
anything that may alter the
result
IVF to follow D5 IMB 500cc to
run @ 30 ugtts/min.
Meptin syrup 2.0 ml BID
06-28-11
08:55pm
Start cefuroxime drops 0.8 ml
BID
Klaricid 2.5 ml BID
IVF to follow D5 IMB 500cc to
run for 8 hours.
>to provide adequate
hydration and acts as a route
for IV meds.
>To promote bronchodilation
>this is an antibiotic.
>this is an antibacterial.
>to replenish fluid and
electrolyte and to provide
>maintained patency of IV
tubings
>infused and regulated IVF @
the given rate
>verified doctor’s order
>administer following the
10r’s
>verified doctor’s order
>administer following the
10r’s
>verified doctor’s order
>administer following the
10r’s
>infuse the ordered IVF and
regulate it
 P E A R S O N S

PSYCHOPHYSIOLOGICAL:

The patient is 7 months old. This indicates that in the theory of Psychoanalysis he
belongs to Oral Stage in which the mouth is the source of pleasure. In Erickson’s theory, the
central task that he manifests is the trust vs. mistrust. In Piaget’s Cognitive theory, he is in
sensorimotor in which interpret the environment by mental image and uses make- believe and
pretend play. He usually cries when he is not comfortable, not feeling well or when he wants
something that is not given.

ELIMINATION:

Before Hospitalization:

According to his mother, the patient usually consumes 1 diaper per day, fully soaked.
The color of his urine is light yellow. He has no history of kidney or bladder disease. He
defecates twice a day with brownish in color with formed consistency without using any aid in
defecating.

During Hospitalization:

According to the mother, the patient wore diaper and consumed 2-3 diapers in a day,
fully soaked. He still defecates twice a day with soft in consistency.

ACTIVITY AND EXERCISE

Before Hospitalization:

According to the mother, the child is very active. He loves crawling with the supervision
of his mother most of the time. He performs activities such as clapping, and “close open” of his
hands.

During Hospitalization:

According to the mother, the patient is lying on his bed most of the time, sometimes
cuddled by her mother when he is crying or uncomfortable. He has no toys to play with, so he is
being cheered up by his parents to stop or avoid him in crying.
REST AND SLEEP

Before Hospitalization:

According to the mother, the patient has no difficulty in sleeping at night. He usually
sleeps 11hours a day from 8pm to 7am. His mother usually breastfed him before he sleeps at
night. He sleeps 3 hours during daytime as a form of his rest.

During Hospitalization:

According to the mother, the patient cannot sleep in his usual sleeping pattern during
night time because he is still having difficulty of breathing, and easily awaken by the nurses
rounds or when they are having vital signs monitoring. He rests for an hour during daytime.

SAFETY AND SECURITY

Before Hospitalization:

According to the mother, she together with her husband always supervises the patient
during his playtime to ensure his safety. They placed all sharp objects that the child cannot
reach nor find.

During Hospitalization:

According to the mother, the patient is on bed guarded by his parents. They always
assured not to leave him unattended. Cuddled and cheered him when he is crying.

OXYGENATION

Before Hospitalization:

According to the mother, her baby is already experiencing cough and colds which
impairs his oxygenation.

During Hospitalization:

According to the mother, the patient has rapid and difficulty of breathing due to
persistent cough and colds with presence of clear nasal discharge. Crackles and wheezes upon
auscultation noted. Most of the time cuddled by her mother or lying on bed positioned in
modified high back rest. His respiratory rate is 65cpm. The doctors ordered salbutamol and
oxygen therapy 1-2 LPM via nasal cannula to manage his underlying condition but he removes it
every time they place it due to irritation.

NUTRITION

Before Hospitalization:

According to the mother, the patient is fully breastfed. His mother gives him
paracetamol (tempra syrup) when he has fever and oregano extract when experiencing cough.
He loves drinking water especially when it is placed in a baby bottle. His height is 68cm
weighing 10kgs.

During Hospitalization:

According to the mother, the patient is still breastfed but not frequently. He is also been
infused of D5 IMB 500cc IVF with the infusion rate of 30 ugtts per minute. His height is 68cm
and weighs 8 kgs.

SPIRITUALITY

Before Hospitalization:

According to the mother, they seldom go to church because of its distance from their
house but they attend the yearly mass of Our Lady of Piat. He is a roman catholic. They have a
relics and pictures of holy family, Mama Mary, and Papa Jesus in their house.

During Hospitalization:

According to the mother, they pray for the fast recovery of their son. They keep their
faith with God and their relationship becomes stronger.