VII.

Course in Ward / Treatments / Intervention

Medical Management
1. Doctor’s Progress Notes
Date Physician’s Order Rationale
10/21/2021  VSq4  Provide baseline data

 I&O q4  This is to indicate the fluid balance of

the patient.
 IVF: D5IMB 500mg then
fast drip 200cc then  To give nutritional support to patient
regulate @60 cc and at the same time to eliminate
dehydration
 TF: D5IMB 500ML
@60cc  For maintenanace of fluid and
electrolytes especially to patients who
LABS:
need calories and hydration.

 CBC (complete blood

 This measures the numbers of
count)
different types of cells that make up

 UA (urinalysis) your blood to check for anemia,

infection and your blood-clotting
 CXR (chest x-ray) ability.

 ECG  Urine test helps in assessing the

(electrocardiogram) patient’s if there are possible kidney
or bladder infection.
 S. Elec (Na, K)

 It can aids to keep patient’s

 Stool exam
healthcare provider see how well your
MEDS: lungs and heart are working.

 Paracetamol 250mg/5ml  used to check your heart's rhythm

and electrical activity.
 Racecadtoril 10mg
mixed with milk or water  a blood test that measures levels of
PO TID the body's main electrolytes. Sodium,
which helps control the amount of
 Erceflora 5mL/Amp
 1Amp PO q4 fluid in the body. It also helps your
nerves and muscles work properly.
 O2 2L-4L via nasal
Cannula PRN for  to help diagnose certain conditions
dyspnea affecting the digestive tract. 

 Increase OFI (oral fluid  Aids in alleviating patient’s body

intake) temperature

Continue Meds:  Use to treat diarrhea

 IVF D5IMB 500mL  Treatment for gastrointestinal

@70cc disorders

 TF D5NSS 500mL  the aim of reducing sensations of

@70cc dryness in the upper airways.

 Aids in providing the patient to

eliminate fluid loss

10/23/2021  Discharge paln  Provide patient instructions with

regards to the meds, provide patient
 Proper hygiene/
teaching about his or her condition.
handwashing
 Deter the spread of microorganism.

Eliminate bacterial transfer from one
place to another.
 Laboratory / Diagnostic Examination
Procedure Purpose Normal Range Result Nursing
Management

>CBC > The complete WBC: 4.0- WBC: 11.6 () >Inform the patient
blood count 10.5mcL
10-21-2021 about the mild
(CBC) is a RBC: 5.27
10:00 AM
RBC:4.10-5.60 discomfort due to
gathering of tests
cells/mcL
that assess the punctured skin.
Hemoglobin:
cells that circle in Hemoglobin: 15.4 > Explain the test
blood, including 12.5-17.0 gm/dL
procedure to the
red blood cells Hematocrit:
(RBCs), white Hematocrit: 44.1 patient.
blood cells 36%-50%
> Inform patient that
(WBCs), and MCV: 84
MCV: 80-98 fL fasting is not
platelets (PLTs). MCH: 29
The CBC can necessary.
MCH: 27.0- 34.0
assess your picograms (pg) >Encourage to
general avoid stress if
wellbeing and MCHC: 34.9
identify an MCHC: 32- 36 possible because
grams/deciliter (g/
assortment of altered physiologic
dL)
 sicknesses and status influences
conditions, such RDW: 13.7
and changes
as infections, RDW: 11.7% -
15.0% normal hematologic
anemia,
PLATELETS:
leukemia, values.
PLATELETS: 268
bleeding disorder 140 -415 (g/dL) > Educate patient
or disease.
that fatty meals
NEUTROPHIL
NEUTROPHILS: S: 47 may alter some test
40%-74%
results as a result
LYMPHS:
LYMPHS: 46 of lipidemia.
14%-46%
MONOCYTES:
MONOCYTES: 6
4%- 13%
EOS: 1%
EOS: 0%- 7%
BASOS: 0%
BASOS: 0%- 3%

CHEST Chest x-rays can NORMAL NORMAL >Assess the

X-RAY be used to study patient’s ability to
10-21-2021 the lungs, heart hold his or her
10:00 AM and surrounding breath. Holding
structures. It one’s breath after
helps to know inhaling enables the
what this imaging lungs and heart to
study evaluates. be seen more
An x-ray clearly in the x-ray.
machine >Provide
provides a two- appropriate
dimensional clothing. Patients
image of the are instructed to
body’s internal remove clothing
structures. from the waist up
and put on an X-ray
gown to wear
during the
 procedure.
>Instruct patient to
cooperate during
the procedure. The
patient is asked to
remain still because
any movement will
affect the clarity of
the image.

Electrocardio The 110 bpm to 160 NORMAL >Explain the

bpm
graphy (ECG) electrocardiogra procedure to the
10-21-2021 m (ECG or EKG) patient. Inform the
10:00 AM is a noninvasive patient that
routine echocardiography
examination of is used to evaluate
the electrical the size, shape,
activity of the and motion of
heart that is used various cardiac
to reflect structures. Tell who
underlying heart will perform the
conditions. test, where it will
Regular heart take place, and that
movements are it’s safe, painless,
controlled by a and is noninvasive.
complex set of >Ensure to empty
electrical the bladder. Instruct
impulses that patient to void prior
direct the upper and to change into
and lower heart a gown.
chambers to
contract and
relax
rhythmically.
Electrolytes Electrolytes are SODIUM: 135- SODIUM: 130 > Nurses may use
147 mmol/L
Test important for a effective teaching
10-21-2021 host of bodily POTASSIUM: 3.5 POTASSIUM: and communication
-5.2 mmol/L 3.5
10:00 AM functions skills to help
including CHLORIDE: 95- CHLORIDE: prevent and treat
107 mmol/L 100
hydration of the various fluid and
body, the CO2: CO2: electrolyte
regulation of 22-30 mmol/L 24 disturbances.
nerve and
muscle function, UREA UREA
NITROGEN
the balancing of NITROGEN
(BUN): 20
blood acidity and (BUN): 7-20
pressure levels, mg/dL
and the CREATININE: CREATININE:
rebuilding of 0.5- 1.2 mg/dL 1.2
damaged
tissues. An GLUCOSE: 60- GLUCOSE:
electrolytes 110 mg/dL 100
blood test is
used to identify
problems caused
by electrolytes
imbalance in the
body.
Stool Exam A stool test is Test Particulars >Assess the
10-21-2021 conducted to patient’s level of
MACROSCOPIC
10:00 AM Help diagnose EX- comfort. Collecting
any disease of stool specimen may
Colour Greenish
the digestive Brown produce a feeling of
tract, the liver or embarrassment and
Consistency Semi Solid
the pancreas. discomfort to the
Reaction Alkaline
The evaluation of patient.
enzymes such as Blood Absent >Encourage the
elastase and patient to
trypsin present in Mucus Present (+) urinate. Allow the
the stool may patient to urinate
MICROSCOPIC
help gauge the EX.- before collecting to
functioning of the avoid contaminating
Ova of Hook Absent
pancreas. worm the stool with urine.

Larva of S. Absent
Stercoralis

Ascarris Absent
lumbricoides

E. Histolytica Absent

E. Coli Absent

Giardia Lamblia Absent

Trichomonas Absent

RBC NIL

Pus Celis Plenty

Macrophages Absent

Vegetable Cells Present

Yeast Cells Absent

Fat Globules Absent

Bacterial Flora Present

Epithelial Cali 1-2

Crystals Absent