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LAB RESULT/ DIAGNOSTIC FINDINGS

CBC 1/30/2006
TEST RESULTS REFERENCE
HEMOGLOBIN MASS C 140-160 g/L
MCH 27.5-33.2 pg
HEMATOCRIT 40-54 %
MCV 80-94 fl
MCHC 32-37 %
RBC 4.5-5.0 x10^12/L
WBC 5-10x10^9/L
DIFFERENTIAL COUNT
NEUTROPHILS 40-75%
LYMPHOCYTES 20-45%
PLATELETS 140-440 x 10^9/L
RBC MORPHOLOGY

SERUM ELECTROLYTES 1/30/2006


TEST RESULTS REFERENCE
SODIUM 135-155 mmol/L
POTASSIUM 3.5-5.3 mmol/L
CHLORIDE 103-116 mmol/L
UREA NITROGEN 3.2-6.8 mmol/L
SUBSTC
CREATININE SUBSTC 44-106 umol/L

ABGs 1/30/2006
TEST RESULT REFERENCE
pH 7.5-7.45
PCO2 35-45 mmHg
PO2 80-100 mmHg
HCO3 22-26 meq/L
BE(ecf) +/-2
O2 Sat 94-100%
Total CO2
FiO2
Temp
URINALYSIS 1/30/2006
TEST RESULT REFERENCE
COLOR Yellow
TURBIDITY Clear
REACTION Acidic
SPECIFIC GRAVITY 1.015
PROTEIN Negative
SUGAR ++
RBC /H.P.F.
WBC 0-1/H.P.F.
CASTS none
BACTERIA
EPITHELIAL CELLS
CRYSTALS

SPUTUM CULTURE 1/30/2006

MICROSCOPY
WBC Gram+cocci
EPITHELIAL CELLS Gram-rods

CHEST X-RAY 1/30/2006


De Leon, Elaine S. BSN IV-B 07/26/06
Px: DE, A 43 y/o male was admitted to POC and was diagnosed of pathologic fracture femoral neck left distal femur
ASSESSMENT NSG. DX RATIONALE PLAN INTERVENTIONS RATIONALE EVALUATION

Subjective: Partial Traction is applied After 8 hours of 1. Assess Degree of 1. px may be restricted by self- fter 8 hours of NI,
“hindi ko nga masyado Impaired to the extremity of NI, client will be immobility produced by view/self-perception out of Patient will be able to
magawa yung mga Physical a px with a able to increase/ treatment and note proportion with actual physical increased and
normal na ginagawa ko Mobility r/t fracture, the maintain mobility patient’s perception of limitations maintain mobility at
dahil nga sa naka- immobilization purpose of this is at the highest immobility the highest possible
traction ako.” As patient by traction first, to lessen the possible level 2. instruct and assist px 2. increase blood flow to level
verbalized. muscle spasm and with active/passive ROM muscles and bones to improve
to reduce the exercises of affected and muscle tone, maintain joint
Objective: inability to fracture and then to unaffected extremities mobility; prevent contractures/
move purposefully provide atrophy and calcium resorption
within the physical immobilization and from disuse
environment; imposed to maintain the
restrictions; unable to corrected position
perform ADL’s: unable to the affected part 3. encourage use of 3. isometric contract mucles
to bathe and dress self of the body. isometric exercises without bending joints or
without assistance; able starting with the moving limbs and help maintain
to feed self; muscle unaffected limb. muscle strength and mass
strength: RUE,LUE, Reference:
RLE: 5/5, balance Orthopedic nursing
skeletal traction on the by: Larson and
4. instruct in/encourage 4. facilitates movement during
lower left extremity; Gould
use of trapeze and post hygiene/skin care and linen
medical dx: pathologic
position for lower limb changes
fracture femoral neck left
fractures.
distal femur
5. assist with/encourage 5. improves muscle strength and
self-care activities such as circulation,promotes self-
bathing or shaving directed wellness
6. prvide diet high in 6. in the presence of
CHON, CHO, Vitamins musculoskeletal injuries,
and minerals nutrients required for healing are
rapidly depleted, often resulting
in a weight loss as much as
20/30 lb during skeletal traction.
This can have profound effect on
muscle mass, tone and strength

Reference: Nursing Care Plans


by: Doenges et.al

ASSESSMENT NSG.DX RATIONALE PLAN INTERVENTIONS RATIONALE EVALUATION


Subjective: “eto wala Risk for Bowel Decrease in After 8 hour of NI, 1. Auscultate abdomen for 1. This will reflect bowel activity After 8 hours of Ni,
masyadong ginagawa Incontinence activity level may px wil be able to presence, location and patient will be able to
kundi maupo, mahiga, r/t change in reduce GI motility Maintain normal characteristics of bowel maintain normal
sanay akong palaging activity level in which results in bowel elimination sounds bowel elimination
naglalakad at me constipation which and demonstrate 2. Discuss usual 2. determine normal bowel and demonstrate
ginagawa.”; “ dumudumi is one of the behaviors or elimination pattterns movement behaviors or lifestyle
ako 1 beses sa isang potential lifestyle changes to changes to prevent
3. instruct in/encourage 3. to improve consistency of
araw.”, “Pag dumudumi complications of a prevent developing developing problems
balanced fiber and bulk in stool and facilitate passage
dito lang din, syempre patient in traction. problem.
diet through the colon
hindi naman ako
pwedeng tumayo.”, 4. promote adequate fluid 4. to promote moist/soft stool
“Kung ano ang binibigay intake, including water
nila(POC) sa aking and high-fiber juices;
pagkain, un ang kinakain suggest warm,stimulating
ko.” As verbalized by Reference: Brunner fluids
patient and Suddarth’s
Textbook of 5. Encourage active 5. to stimulate contractions of
Objective: Medical-Surgical exercise on the unaafected the intestines
Normal Bowel sounds Nursing by: part and passive exercise
heard every 20 s; Smeltzer and Bare on the affected part
inadequate toileting, lack
of privacy, recent 6.provide privacy by 6. facilitates normal bowel
environmental changes, covering the Balkan function
insufficient physical frame with linen and in
activity, balance skeletal routinely scheduled time
traction on left lower
extremity 7. Ascertain frequency, 7. Provides a baseline for
color, consistency, amount comparison, promotes
of stools. recognition of changes

Reference:
Nurse’s Pocket Guide by
Doenges et. al

ASSESSMENT NSG.DX RATIONALE PLAN INTERVENTIONS RATIONALE EVALUATION


S: “Nahulog kasi ako Risk for Patient in Traction After 8 hours of 1. Inspect the skin for 1. Pins or wires should not be After 8 hours of NI,
nung isang linggo nun sa Infection r/t have high risk in NI, px will be able preexisting irritation or inserted through skin infections, px will be able to be
bangko, nauna ang skeletal acquiring infection be free of purulent breaks in continuity rashes, or abrasions which may free of purulent
puwitan ko, nabalian traction due to the direct drainage or lead to bone infection. drainage or erythema
ako, mula bulacan dinala insertion of erythema, and 2. Assess pin site, noting May indicate onset of local and remain to be
ako dito sa orthopedic” Steinman pin into remain to be presence of edema, infection/tissue necrosis, which afebrile
as patient verbalized the bone. afebrile erythema, foul odor or can lead to osteomyelitis
drainage
Objective: Vital
signs:BP:130/90, T: 37.2 3. Provide sterile pin care 3. may prevent cross-
C, HR: 80bpm, RR: with hydrogen peroxide contamination and possibility of
22bpm, patient is Reference: and betadine and exercise infection
afebrile, balanced Orthopedic meticulous handwashing
skeletal traction Nursing by: Larson
application on the left and Gould 4. instruct patient not to 4. Minimize opportunity for
lower extremity, no signs touch the insertion sites contamination
of imflammation and
drainage of the skin on 5. Monitor V/S. note Hypotension, confusion may be
pin site; medical dx of presence of chills, fever, seen with gas gangrene;
pathologic fracture malaise, change in tachycardia and chills/fever
femoral neck left distal mentation reflect developing sepsis.
femur, intact level of
consciousness, (-)chills
and diaphoreses
6. Investigate abrupt onset 6. May indicate development of
of pain/limitation of osteomyelitis
movement with localized
edema/erythema in
injured extremity
GENERIC NAME MECHANISM INDICATION ADVERSE DRUG-DRUG NURSING RESPONSILBILITIES
OF ACTION REACTION INTERACTION
Amikacin Inhibits protein Treatment of EENT: ototoxicity Inactivated by
synthesis in serious gram- (vestibular, cochlear) penicillin,
bacteria at level negative bacillary
of 30S ribosome. infections GU: nephrotoxicity

Therapeutic F and E:
effects: Hypomagnesemia
Bacterial action
MS: muscle paralysis
Spectrum: most
aminglycosides Misc: hypersensitivity
notable for reaction
activity against:
P. aureginosa,
klebsiella
BRAND NAME pneumoniae, DOSAGE COTRAINDICATION DRUG-FOOD
Amikin Escherichia coli, INTERACTION
proteus, serratia, IV: 300 mg Hypersensitivity, most
acinetobacter, s. parenteral products
aureus contain bisulfites and
should be avoided in
patients with known
intolerance, cross-
sensitivity among
aminoglycosides may
occur.

GENERIC NAME MECHANISM INDICATION ADVERSE DRUG-DRUG NURSING RESPONSILBILITIES


OF ACTION REACTION INTERACTION
BRAND NAME DOSAGE COTRAINDICATION DRUG-FOOD
INTERACTION

GENERIC NAME MECHANISM INDICATION ADVERSE DRUG-DRUG NURSING RESPONSILBILITIES


OF ACTION REACTION INTERACTION
BRAND NAME DOSAGE COTRAINDICATION DRUG-FOOD
INTERACTION
GENERIC NAME MECHANISM INDICATION ADVERSE DRUG-DRUG NURSING RESPONSILBILITIES
OF ACTION REACTION INTERACTION

BRAND NAME DOSAGE COTRAINDICATION DRUG-FOOD


INTERACTION
GENERIC NAME MECHANISM INDICATION ADVERSE DRUG-DRUG NURSING RESPONSILBILITIES
OF ACTION REACTION INTERACTION

BRAND NAME DOSAGE COTRAINDICATION DRUG-FOOD


INTERACTION

GENERIC NAME MECHANISM INDICATION ADVERSE DRUG-DRUG NURSING RESPONSILBILITIES


OF ACTION REACTION INTERACTION
BRAND NAME DOSAGE COTRAINDICATION DRUG-FOOD
INTERACTION

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