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8/4/2019 Part 10 Discharge Plan- Appendices
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XI. Discharge Plan
Medication
• Discuss all take home medications to the primary caregiver such
as the brand, generic name dosages , frequency and as well as
the action of the drug.
Tramadol 50mg 1cap PO q6
FeSO4 I tabPO OD
Paracetamol 500mg PO PRN
Multi Vitamins 1tab PO OD
• Encourage and instruct the patient to comply with the full course
of medication prescribed by the regimen.
• Inform the primary caregiver of the side effects of the
medications and teach significant others on how to watch for
those side effects
• Encourage to take drugs with food if not contraindicated or take
them one hour or two hours after meal.
• Inform family about food and other medications that cause
interactions with the drugs the patient is currently taking.
• Instruct the primary caregivers not to stop the medications
abruptly or even adjust the dosage without consulting the
physician.
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Exercise
• Maintain a good and safe environment.
• Encourage enough rest for the client right after discharge.
• Instruct significant others/primary care giver to not let the client
engage self into strenuous activities.
• Encourage doing simple and non-strenuous range of motion
exercises such as walking and stretching.
• Instruct primary caregiver to assist patient in doing passive ROM.
• Instruct primary care giver to let the patient gradually increase
acrivities.
• Ambulation if tolerated also is encouraged.
• Increase intensity, duration and frequency of exercise every
week to gain more strength
• Encourage SO to provide appropriate amount of rest to the client
• Advise patient not to engage in strenuous activities
Treatment
• Instruct patient to always maintain good hygiene
• Instruct patient on proper wound dressing
• Encourage client to increase intake of fluid at least 2500ml a day
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• Encourage the primary caregiver to provide comfort to the
patient
• Instruct client to have adequate rest
• Explain the importance of following the complete therapeutic
regimen prescribed by the Physician.
• Explain also the purpose of continuing the treatment even after
discharge.
• Teach the primary caregiver necessary procedures in caring for
the client.
Health Teaching
• Instruct patient to avoid doing strenuous activities
• Encourage client to comply medications
• Teach client the importance of proper lifestyle
• Teach patient and primary caregiver regarding the importance of
developing good coping skills and emotional support
• Teach client to decrease intake of fibers
• Encourage the family of the client to maintain proper sanitation.
•
Encourage the family of the client to bath the client everyday.
• Instruct the significant others to groom the client properly.
• Instruct the significant others of the client to keep the client’s
back dry.
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Out - patient: Follow up Visit
• Remind patient to commit with the scheduled follow-up check up
with client’s physician
• Stress out the importance of seeking immediate consultation if
any signs of abnormalities
• Encourage primary caregiver to make sure that the patient has a
safe place to live after discharge
• Stress out to the primary caregivers to seek immediate
consultation if adverse reactions of drugs occur.
• Encourage primary caregivers to carry out follow up diagnostic
regimen.
• Inform primary caregivers to report any signs of abnormalities
such as sudden increase of blood pressure, respiratory rate,
pulse rate, and contractures as soon as possible.
Diet
• Encourage increase intake of oral fluid intake
• Advise patient not to skip his meals and eat a regular intervals
• Instruct patient not to eat the foods that are contraindicated to
patient
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• Encourage primary caregiver to provide food for the patient that
has the essential vitamins and minerals so as to boost the
patient’s immune system
• Encourage family members to prepare and have the client eat
foods rich in protein, calorie, vitamin C, iron, carbohydrates and
high in fiber.
• Maintain a well-balanced diet.
• Advise significant others on how to properly handle and prepare
food so as to prevent contamination.
Spirituality
• Instruct patient to continue having faith to God and to continue
praying
• Encourage patient to attend mass every Sunday
• Encourage to verbalized thoughts to the family to provide
support
• Encourage to have faith to the Superior and perform rituals
according to ones religion and belief.
• Encourage to go to church regularly and participate on the
activities of the church.
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X. Prognosis
Good Fair Poor
/ A. Response of the patient regarding the presence
of the pain after its management
/ B. Physiologic response of the body to disease
process/ C. Relief of symptoms associated with the disease
condition/ D. Performance of the daily living of the patient
during confinement (e.g. eating, toileting, dressing,
etc.)/ E. Compliance of the patient to the medication and/
or therapy/ F. Adequacy of rest periods and sleep
/ G. Consumption of the patient with nutrition
/ H. Patient’s significant others’ behavior regarding
the health teaching given by the health caregiver
and the physician/ I. Attitude
/ J. Duration of Illness
/ K. Precipitating Factor
/ L. Nature of Problems
/ M. Predisposing Factors
/ N. Family Support
/ O. Level of Consciousness
CALCULATIONS:
Formula: amount # of (good/fair/poor) x 100 = % (Percentile)
15
Amount of Percentile
Good = 4 26.67%
Fair = 5 33.33%
Poor = 6 40.00%
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INTERPRETATION:
The patient is more likely to have a poor prognosis because of the
severity and the nature of her disease. Immediate management was not
done to the client which led to the metastasis of cancer cells to surrounding
tissues. Another factor that contributed to the poor prognosis is physiologic
response of his body to the medical and surgical treatments which is poor
due to the quick growth of cancer cells and which eventually contributed to
the long duration of hospital stay of the client. The client has also a strong
genetic predisposition from his relatives. The client is also engaged to
smoking and drinking alcohol. Thus, a strong precipitating factors.
The patient has a greater chance of living if proper management of the
condition is compensated and if cancer cells did not metastasize, with
religious compliance to the chemotherapy, adequate nutrition and
environment is fully achieved. These would include the consistency in the
chemotherapy, avoidance of exposure to stress, and continuous monitoring
of metastasis and laboratory results including the significant factors affecting
the condition of the patient’s condition.
The table above shows the good effects and bad effects that can be
manifested by the patient during and after the treatments and interventions
being rendered.
XI. Conclusion
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The group has concluded that the client, with the significant others’
participation and help in giving nursing care and also with strict compliance
to the plan of care, has a poor chance of improved condition.
The health care teams including the nurses and attending physician,
were able to render appropriate care to the patient and provide health
education such as proper nutrition, healthy lifestyle, and most especially
strict medication compliance and adherence to nursing management but still
the client manifested poor physiologic response to the management. Being a
health care advocate, provider and a front-liner of taking care of patient’s
condition, emphasis on client’s education is stressed.
The client's part in strict adherence to treatment and vigilance in
promoting optimum health such as avoiding tobacco smoking and alcohol
drinking will most probably help improve patient’s condition. Significant
others' support also is needed to promote client’s emotional well-being.
As for the student nurse assigned to the patient, knowing the case
including its risk factors and interventions is more important in order to
impart proper education and able to provide proper care needed for the
promotion of client’s health and wellness. This case study also paved a way
to nurture and foster the group’s learning and thus promote critical thinking
skills.
XII. Recommendations
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We recommend this study to the incoming fourth year nursing
students of Xavier University Ateneo de Cagayan who will be assigned at the
Surgical Ward for their clinical exposure especially in catering oncology
concepts – which this may be a means for them to improve their skills,
knowledge, and attitude towards facilitating of excellent health care to their
patients.
We propose to have enough time for assessment and noting down
every significant finding day by day to really come up with exceedingly
applicable nursing diagnoses. Prioritize all the recognized nursing diagnoses
according to the intensity of need to be addressed and still giving
importance to the perceived problems of the patient himself. Hint properly
the disease process to attach all the cues, complications and possible
outcome and also to designate accurate drugs and interventions to be given.
We suggest further venture of critical thinking perseverance in order to
spot the problems and complications present in their preferred patient so
that they can supply necessary nursing interventions with the best quality of
care. Lastly, teamwork and agreement in the group is of great substance.
Concepts on leadership and management can be applied to facilitate proper
division of labor, collaboration, etc. Through this, they will able to finish all
the obligatory requirements for this case study.
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XIII. Bibliography
American Cancer Society (2002).Cancer facts and figures 2002.
Atlanta:
American Cancer Society.
American Pain Society. (1999). Principles of analgesic use in the
treatment
of acute pain and chronic cancer pain: A concise guide to
medical practice (4th ed.). Skokie, IL: American Pain Society.
Barraclough, J. (1999). Cancer and emotion: A practical guide to
Psychooncology. Philadelphia: J. B. Lippincott.
Boik, J. (1995). Cancer and natural medicine: A textbook of basic
science
and clinical research. Princeton, MN: Oregon Medical Press.
Broder, S. (1991). Molecular Foundations of Oncology. Williams and
Wilkins:
Baltimore, Maryland, USA. p. 393-400.
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DeVita, V. T., Hellman, S., & Rosenberg, S. A. (Eds.). (1995). Biologic
therapy of cancer (2nd ed.). Philadelphia: J. B. Lippincott.
Green, F., et al. (2002). AJCC cancer staging manual (6th ed.). New
York: Springer-Verlag.
Groenwald, S., Hansen-Frogge, M., Goodman, M., & Henke Yarbro,
C. (Eds.). (1998). Comprehensive cancer nursing review (4th
ed.).
Boston: Jones and Bartlett.
Heath, C. W., &Fontham, E. (2001).Cancer etiology. In: Clinical
oncology.
Atlanta: American Cancer Society.
Huber, E. B., &Magrath, I. (Eds.) (1998). Gene therapy in treatment of
cancer: Progress and prospects. New York: Cambridge University
Press.
Lenhard, R. E., Osteen, R. T., &Gansler, T. (Eds.).(2001). Clinical
oncology.
Atlanta: American Cancer Society.
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Kumar, V., Cotran, R., Robbins, S. (1997). Basic Pathology. 6 th ed. W.B.
Saunders Company: Philadelphia.
Lever, W. and Lever, G. (1990). Histopathology of the Skin. 7th ed.
Lippincott Company: Philadelphia. p.676-679.
Loeser, J. D. (Ed.) (2001). Bonica’s management of pain (3d ed.).
Philadelphia: Lippincott Williams & Wilkins.
Miaskowski, C. (1997). Oncology nursing: An essential guide for patient
care. Philadelphia: W. B. Saunders.
Nouri, K. (2008). Skin Cancer. McGrawHill Companies, Inc.: China. p.
205-
206.
Pazadur, R., Coia, L. R., Hoskins, W. J., &Wagman, L. D. (Eds.).
(2001). Cancer management: A multidisciplinary approach.
Melville, NY: PRR, Inc.
Porth, C. Pathophysiology: Concepts of Altered Health States. 7th ed.
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Lippincott Williams and Wilkins: Philadelphia.
Smith, R. A., et al. (2001). American Cancer Society guidelines for the
early detection of cancer: Cancer Journal forClinicians, 51(1), 38–
76.
Smeltzer, S., Bare, B. et al. (2010). Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing. 12th ed. Lippincott Williams and Wilkins:
Philadelphia.
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XIV. Appendices
A. Doctor’s Order
Date Progress Notes Doctors Order7/1/11 Wt=55kg -pls admit pt. to male
surgical ward under the
service of Dr. S-secure consent to care-TPR & BP q4°-start venoclysis with
PNSS 1L @ 30gtts/min
-high protein diet-attach labs (available)
to charts-start Cloxacillin 500mg
IVTT ( ) ANST q6°-multivitamins 1 tab OD-ferrous sulphate 1 tab
OD-dressing BID with
Daikins solution-refer accordinglyDr. P.
7/1/11 8PM -for CBC,pH count, NA+
& K determination-CT-BT, albumin, FBS-ECG 12 leads pls-CXR-PA viewDr. P.
7/2/11 6.0mg/dl -pls prepare 4 units of
PRBC18.0mg/dl -transfuse after cross
matching-txt order Dr. P.-for daily dressing with
betadine OD-ERROR
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Dr. P.7/3/11 -for below elbow
amputation-secure consent-refer to Dietary for
nutrition supportDr. U.
7/4/11 -IVF TF: D5LR 1L @
30gtts/minD5NSS 1L @
30gtts/minD5LR 1L @ 30
gtts/min
PNSS 1L @30gtts/min x 3 cyclesDr. U.-3PM diphenhydramine
1g IV nowDr. U.
7/5/11 -for below elbow
amputation once cp
cleared
-IVF TF: PNSS 1L @
30gtts/minPNSS 1l @
30gtts/minPNSS 1L @ 30
gtts/minDr. U.
7/7/11 -pls transfuse PFRB 2L
unit after cross
matchingDr. U.
7/8/11 -for schedule of surgery
on TuesdayHgb= 8.6 - for BT 2 units of
available blood after
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proper screening &
crossmatchingDr. P.
7/9/11 Pre BT temp 37.8 -pls give paracetamol
500mg P.O. prior to BTDr. G.
7/10/11 Painful bladder upon
urination
-for UA on Monday
Dr. G.7/10/11 -pls change dressing
-refer to SROD-pls change IV site,
tubings-gentamycin 80 mg IVTT
ANST q8°-for CBC, Crea, NA,& K
in AMDr. A.
7/10/11 -reschedule for below
elbow amputation
tomorrow-pls prepare PRBC 3
units of pts blood type &
transfuse 2 units prior to
operation-secure consentDr. A.
7/10/11 -NPO PMN-full course body
hygiene-Vit. K 10g IVTT q 8°
-for protime-prepare blood as
orderedDr. A.
7/11/11 (+) H/o DM x 4yrs -pls refer to another
anaesthesiologist Ty-opt FBS and RBS, Crea
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Dr.A.-refer protime-Postpone surgeryDr. G.
7/12/11 -for below elbow
amputation-NPODr. G.-pls prepare 4 units FWB
of pt’s type &
crossmatched pls-pls prepare 2 units
fresh frozen plasma-once blood is available
transfuse 1 unit before
ORDr. P.
POSTOP6:15 PM -o2 inhalation 3L/min
until fully awake-vital signs q15 min until
stable-DAT once fully awake-IVF @ 20gtts/min;
follow-up 1 D5LR 1L @
same rate-continue gentamycin &
cloxacillin-tramadol 50mgs IVTT-
stat dose only-tramadol 50mgs P.O.
q6°,-6hrs after IV doseDr. U.
7/14/11 -cont meds-pls remove foley
catheterDr.G.
Hgb=2.6mg/dl -pls transfuse FWB 3
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units (settled)-rpt CBC after BTDr. P.
7/15/11 -for dressing todayDr.G.
7/16/11 (+)SOB -D/c cloxacillin-cefuroxime 700mg IV
q8°-dressing & draining
today-for rpt CBCDr.G.
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B. Nurse’s Notes
07/01/11
11-7
07/02/11
7-3
3-11
11-7
>Received on bed with IVF of D5LR @ 30 gtts/min
>v/s taken and recorded
>with mass @ anterior forearm-noted
>foul-smelling
>dressing done
>due meds given
>adequate bed rest
>cared for
>needs attended
>endorsed
>Received on bed with ongoing IVF of PNSS 1L @ 30 gtts/min
>v/s taken and recorded
>due meds given
>adequate rest provided
>needs attended
>endorsed
>Received awake on bed with PNSS @30 gtts/min
>v/s taken & recorded
>due meds given
>needs attended
>kept comfortable
>endorsed
>Received asleep lying on bed with IVF of PNSS, regulated @
30 gtts/min
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07/03/11
7-3
3-11
11-7
07/04/11
>With mass @ left forearm; secured with bandage
>v/s taken & recorded
>due meds given
>provided with adequate rest
>cared for
>endorsed
>received awake on bed with PNSS 1L @ 30 gtts/min
>v/s taken & recorded
>due meds given
>still for OR once CP cleared
>needs attended
>endorsed
>received awake on bed IVF of D5LR 1L @30 gtts/min
>with dressing @ left forearm-foul smelling
>due medications given
>needs attended
>v/s taken & recorded
>endorsed
> received awake on bed with IVF of D5LR 1L regulated @ 30
gtts/min
>with mass @ left forearm
>v/s taken & recorded
>due medications given
>febrile- TSB encouraged
>comfort and safety measures
>Cared for
>Endorsed
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7-3
3-11
11-7
>Received awake lying on bed with ongoing IVF of PNSS 1L @
600 cc level regulated at 30 gtts/min @ right hand
>dry sclera noted
>Pale nail beds, with mass @ left forearm
>Morning care done such as fixing bed and bedside table
>Adequate rest provided
>9:00 AM : wound dressing done aseptically
>High protein and low calorie: served and consumed half of
share of meal with poor appetite
>9:50 AM: blood transfusion started with “1” unit fresh whole
blood type “B+” with serial # 272434 regulated @ 20 gtts/min
>11:15 AM: chills noted
>Febrile : T= 38.3
>Tepid sponge bath done
>Above blood transfusion discontinue
>1:00 PM: temperature rechecked 40.3
>1:30 PM: referred to ROD with orders of diphenhydramine 1
amp given
>Watcher reinstructed to continue doing tepid sponge bath
>Kept watch for any unusualities
>Endorsed with latest v/s of T= 39 C, P= 92, R=20, BP=170/60
>Received awake on bed with ongoing PNSS @ 30gtts/min
> v/s taken and recorded
>due medications given
>watchful for abnormalities
>endorsed
>Received awake on bed with D5LR @20gtts/min
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07/05/11
7-3
3-11
3:15
High protein
diet
>afebrile
>v/s taken and recorded
>due meds given
>needs attended
>kept comfortable
> endorsed
>Received on bed with ongoing IVF of PNSS 1L @ 30 gtts/min
>v/s taken and recorded
>due meds given
>adequate rest provided
>needs attended
>endorsed
>Received awake, sitting on a chair with ongoing IVF PNSS @
200cc level regulated @
30gtts/min infusing well on right hand
>Conscious and coherent
>Pail nail beds noted
>Pale and dry lips noted
>With tender movable whitish gangrenous mass with foul
odor @ left forearm
>Initial v/s taken and recorded as follows: T= 36.4C P=
82bpm, R= 18cpm, Bp=120/70mmHg
>above IVF consumed and followed up with PNSS IL regulated
@ some rate infusing well @
right hand
>Afternoon care done such as tucking in of bed linens
>Encourage to increase fluid intake within cardial tolerance
>Wound dressing done aseptically @ left forearm
>Served and consumed full share with good appetite
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1:45
1:50
11-7
07/06/11
7-3
High protein
diet
9:15
>Health teachings given to SO with emphasis on:
• Medication compliance to promote early recovery
• Instruct patient to immobilize the left arm
•
Encourage intake of iron rich food such as greenleafy vegetables
>febrile; T=38.0
>TSB done
> above blood transfusion consumed and followed up c PNSS
1L @ 200 cc level
regulated @ 30 gtts/min
Kept watch for any unusualities
Endorsed with latest v/s of : T-37.3 C, P-85, R-20, BP- 110/60
>Received with PNSS IL @ 30gtts/min
>v/s taken and recorded
>due meds given
>rest provided
>cared for
>endorsed
>received awake, sitting on bed with ongoing IVF of PNSS IL
@ 850cc level , regulated @ 30gtts/min, infusing well on left
forearm
>with mass @ left forearm, gangrenous, foul odor with pus>generalized body weakness noted
>initial v/s taken and recorded as follows: T=37.6 C, P=
90bpm, R=20cpm, Bp=120/70mmHg
>served and consumed whole share with good appetite
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3-11
11-7
07/07/11
7-3
3-11
>bedside care done such as changing of linens
>seen and examined by Dr. XY
>Health teachings imparted with emphasis on
1. Strict compliance to medication regimen
2. Proper diet – increase in protein and caloric intake
3. Aseptic wound dressing
>Endorsed with latest v/s T= 37.2C, P= 79bpm, R= 20cpm,
Bp= 100/70mmHg
received on bed with IVF of PNSS IL @
30gtts/min-infusing well
>with mass @ left forearm, with foul odor –
noted
>v/s taken and recorded
>due meds given
>Cared for
>endorsed
>Received asleep on bed with ongoing IVF of PNSS IL @
30gtts/min
>With swelling and redness on left forearm with foul odor
>v/s taken and recorded
>due meds given as ordered
>cared for
>needs attended
>endorsed
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11-7
07/08/11
7-3
3-11
11-7
>received awake on bed with PNSS @ 30gtts/min
>with mass on left forearm
>v/s taken and recorded
>due meds given
>needs attended
>endorsed
>received awake on bed with IVF of PNSS, regulated @
30gtts/min
>v/s taken and recorded
>due meds given
>kept watched for abnormalities
>cared for
>endorsed
>received asleep on bed with PNSS IL @ 30gtts/min
>v/s taken and recorded
>due meds given
>needs attended
>cared for
>endorsed
>received awake on bed with PNSS @30gtts/min
>BT – started
>Afebrile
>v/s taken and recorded
>due meds given
>needs attended
>endorsed
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07/09/11
7-3
3-11
11-7
7/10/11
7-3
>received awake on bed with IVF of PNSS, regulated @
30gtts/min
>v/s taken and recoded
>due meds given
>cared for
>endorsed
>received asleep on bed with PNSS IL @ 30gtts/min
>v/s taken and recorded
>due meds given
>needs attended
>cared for
>endorsed
>received awake on bed with IVF of PNSS, regulated @
30gtts/min
>v/s taken and recorded
>due meds given
>cared for
>endorsed
>received with PNSS @ 30gtts/min
>v/s taken and recorded
>due meds given
>rest provided
>cared for
>endorsed
>received asleep on bed with PNSS IL @ 30 gtts/min
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3-11
11-7
7/11/11
7-3
8:30am
>v/s taken and recorded
>due meds given
>adequate rest provided
>needs attended
>endorsed
>Received on bed with ongoing HBT of RBC type BT S# 2010-
271400 @
@ 15-20gtts/min
>with wound dressing over right forearm-slightly soaked
> v/s taken and recorded T=37.1 C
> due meds given
> for below elbow amputation tomorrow – still for CP
evaluation tomorrow
> cared for
>NPO @ midnight-instructed
>endorsed
>received asleep on bed with PNSS @ 15-20 gtts/ min
>afebrile
>v/s taken and recorded
>due medications given
> needs attended
>endorsed
>Received awake on bed with D5LR @20gtts/min
>afebrile
>v/s taken and recorded
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9:30am
3-11
Soft diet
>due meds given
>needs attended
>kept comfortable
> endorsed
>Received awake, sitting on bedside chair with ongoing IVF
PNSS IL @ 200cc level
Regulated @ 30gtts/min infusing well @ right hand
>conscious and coherent
> pail lips and nail beds noted
> with mass @ left hand with soiled dressing, with foul odor
> initial v/s taken T =37.6C, P =78bpm, R= 21cpm, Bp=
120/80mmHg
>bedside care done- linens tucked
>wound dressing done aseptically
> seen and examined by Dr. xy
>above IVF consumed and followed up with PNSS IL regulated
@ 30gtts/min
>rest periods provided
>health teachings maintained and reinforced
> for below elbow amputation today
> CP cleared
> Surgery postponed
>BT started with 1 unit FWB as RBC type “B” RH(+) with
serial # 272237
regulated @ 20 gtts/min
>Kept watched for unusualities
> endorsed with latest v/s T=37.9C, P=95bpm, R=16cpm, Bp=
120/70mmHg
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11-7
7/12/11
7-3
3-11
febrile
High protein
diet
>Received awake, sitting on bedside chair, with IVF of PNSS IL
@660cc level on
Right arm
>with ongoing 1U FWB 058RBC type “B” Rh(+) with serial#
272327a side drip on Y port
Regulated @ 20gtts/min
>conscious and coherent
>with mass on left forearm covered with soiled dressing
>with initial v/s taken and recorded as follows T= 36.5C P=
86bpm, R= 19cpm Bp=
110/60mmHg
>afternoon care done like tucking in of linens
>rest period provided
>encouraged to verbalized discomfort
>maintained and instructed
>health teachings given with emphasis on
a. high-protein diet
b. high calorie diet
c. proper hygiene
d. ROM exercise
>endorsed to next shift with latest v/s T=36.5C, P= 89bpm,
R=20cpm, Bp= 110/70mmHg
>received awake on bed with ongoing PNSS regulated @
30gtts/min
>v/s taken and recorded
> comfort provided
>watchful for unusualities
>endorsed
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11-7
7/13/11
7-3
3-11
>received with PNSS @ 30gtts/min
>v/s taken and recorded
> due meds given
> morning care given
>rest provided
>cared for
> endorsed
>received awake , sitting on bedside chair with ongoing IVF
of PNSS
IL @600cc level regulated @ 30gtts/min infusing well on
right arm
>conscious and coherent
> with mass of left forearm covered with dressing –soiled
> with initial v/s taken and recorded as follow: T= 38.4C,
P=95bpm, R= 20cpm,
Bp=110/70mmHg
>tepid sponge bath done
> temperature rechecked after 30minutes 38.3C
>continues TSB done
>temperature rechecked after 30minutes 37.6C
>adequate rest provided
> served and consumed whole share with good appetite
>health teaching given with emphasis on:
a. high calorie diet
b. high protein diet
c. ROM exercise
d. adequate fluid intake
e. proper hygiene
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11-7
7/14/11
7-3
9am
10am
>endorsed with latest v/s of: T= 36.6C, P= 86bpm, R= 15cpm,
Bp= 120/60mmHg
>received awake on bed with IVF of PNSSIL @30gtts/min
> with mass on left forearm-soiled and foul smelling
> due medications given
>adequate rest provided
>needs attended
> v/s taken and recorded
>endorsed
>received awake on bed with ongoing IVF of PNSS IL
@30gtts/min
>v/s taken and recorded
>with foul smelling and slightly bleeding wound on left arm
>due medications given as ordered
> dressing done
>NPO started
>for below elbow ampuitation on call
>needs attended
> endorsed
>received awake on bed with ongoing IVF of PNSS IL
@30gtts/min
>v/s taken and recorded
> due meds given
>afternoon care given
>rest provided
>cared for
> endorsed
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3-11
11-7
7/15/11
7-3
9am
11am
3-11
>received asleep on bed with IVF of PNSS regulated @ 30
gtts/min
>S/P below elbow amputation with post operative site dressing
keptdry and intact
>v/s taken and recorded
>due meds given
> provided adequate rest
>cared for
>endorsed
>receive awake, lying on bed with ongoing IVF of D5LR IL
@740cc level regulated @
20gtts/min –infusing well @ right arm
>with FBC attached to UROBAG draining a yellow colored
urine
> conscious and coherent
>dry and cracked lips
> with complaint of sharp , throbbing pain in the amputated
limb @ a level
Of 8 in a pain scale of 1 -10 with 10 being the most painful
>s/p below elbow amputation –postoperative site dressing
kept dry and intact
>pail nail beds
>initial v/s taken , T=36.2C, P= 82bpm, R=16cpm
>bedside care done such as changing of linens
> adequate rest provided
>amputated limb kept elevated
>seen and examined by Dr. XY with new orders carried out by
NOD
>folley bag catheter removed with 200cclevel of urine
>back kept dry
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11-7
7/16/11
7-3
3-11
>served and consume half share with fair appetite
>health teachings imparted with emphasis on:
a. strict compliance to medication regimen
b. proper wound dressing and cleaning
c. high intake of protein to aid in healing process
>endorsed with latest v/s T=37.7C. P= 80bpm, R=17cpm, Bp=
110/60mmHg
>Received awake on bed with D5LR @20gtts/min
>afebrile
>v/s taken and recorded
>due meds given
>needs attended
>kept comfortable
> endorsed
>received awake on bed with ongoing PNSS @KVO
>afebrile
>due meds given
> blood transfusion done with s#272294
>v/s taken and recorded
>kept watched for any unusualities
>endorsed
>received on bed with PNSS @ KVO
>v/s taken and recorded
>started BT @ 15-20gtts/min
>febrile
>due meds given
>cared for
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11-7
7/16/11
7-3
07/17/11
3-11
> endorsed
>received on bed with PNSS @KVO- changed IV to D5LR @
20gtts/min
>still for BT#3 (+) chills
>v/s taken and recorded
>afebrile
>due meds given
>care for
>endorsed
>received awake on bed with ongoing D5LR @ 20gtts/min
>afebrile
>due meds given
>v/s taken and recorded
>adequate rest provided
>cared for
>endorsed
>received awake on bed with IVF D5LR IL @ 20gtts/min-
dislodge
>with post-operative dressing –soiled and with foul smell noted
and referred to SROD
>v/s taken and recorded
> afebrile
>above IVF reinserted
>seen and examined by SROD with orders
>dressing changed by SROD
>instructed to elevate post-op stump @ all time
>needs attended
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