edited case pres s.p
TRANSCRIPT
OUR LADY OF FATIMA UNIVERSITY
COLLEGE OF NURSING
REGALADO, FAIRVIEW, QUEZON CITY
CASE PRESENTATION
ACUTE GLOMERULONEPHRITIS
PRESENTED BY:
BSN 4A1-A
Group 1
Almerino, Ma. Alfie Rose J.
Apostol, Gloria G.
Bacnis, Arjay Aezon
Banza, Heidee Marie B.
Fajardo, Veronica Kaychelle T.
Galeno, Josefina
Moreno, Beryl Jean Z.
Ostia, Quenz Chavyrrie
Pasos, Dianne O.
Ramos, Messalea B.
Romero, Robert Bryan O.
PRESENTED TO:
Ms. Teresita Joyce O. Ayala, R.N, RM, MAN
January 26, 2011
Ospital ng Lungsod ng Sapang Palay
(OLSP)
TABLE OF CONTENTS
I. INTRODUCTION
II. OBJECTIVE
III. PATIENT’S PROFILE
IV. PHYSICAL ASSESSMENT
V. THEORETICAL FRAMEWORK
VI. LABORATORY/ DIAGNOSTIC FINDINGS
VII. ANATOMY AND PHYSIOLOGY
VIII. PATHOPHYSIOLOGY
IX. COURSE IN THE WARD
X. NURSING CARE PLAN
XI. DRUG STUDY
XII. DISCHARGE PLANNING
INTRODUCTION
Acute glomerulonephritis is an active inflammation in the glomeruli, it refers to a specific
set of renal diseases in which an immunologic mechanism triggers inflammation and
proliferation of glomerular tissue that can result in damage to the basement membrane,
or capillary endothelium. In acute glomerulonephritis, the kidneys are normal in size or
enlarged and edematous, and the surface of the kidney may show punctate
hemorrhages.
Symptoms of acute glomerulonephritis include the following: Hematuria is a universal
finding, even if it is microscopic. Gross hematuria is reported in 30% of pediatric
patients. Edema (peripheral or periorbital) is reported in approximately 85% of pediatric
patients; edema may be mild (involving only the face) to severe, bordering on a
nephrotic appearance. Headache may occur secondary to hypertension; confusion
secondary to malignant hypertension may be seen in as many as 5% of
patients. Shortness of breath or dyspnea on exertion secondary to heart failure or
pulmonary edema; usually uncommon, particularly in children. Possible flank pain
secondary to stretching of the renal capsule. Hypertension is seen in as many as 80%
of affected patients. Hematuria, either macroscopic (gross) or microscopic, may be
noted. Skin rashes (ie, malar rash frequently seen with lupus nephritis) may be
observed. Abnormal neurologic examination or altered level of consciousness occurring
because of malignant hypertension or hypertensive encephalopathy. Arthritis may be
noted.
A doctor can diagnose AGN by performing Urinalysis, CBC, Electrolytes, including BUN
and creatinine (to estimate the glomerular filtration rate [GFR). Procedure like renal
biopsy is required for definitive diagnosis. Primary diseases that solely affect the
kidneys and cause AGN, are Immunoglobulin A nephropathy (IgA nephropathy,
Berger’s disease), membranoproliferative nephritis (type of kidney inflammation), post
infectious GN (GN that results after an infection).
Glomerulonephritis may be a temporary and reversible condition, or it may get worse.
Progressive glomerulonephritis may lead to chronic kidney failure and end-stage kidney
disease.
The goal of treatment is to stop the ongoing inflammation and lessen the degree of
scarring that ensues. Depending on the diagnosis, there are different treatment
strategies. Often the treatment warrants a regimen of immunosuppressive drugs to limit
the immune system’s activity. This decreases the degree of inflammation and
subsequent irreversible scarring.
Most epidemic cases follow a course ending in complete patient recovery as many as
100%. Most cases occur in patients aged 2-12 years. Only 10% of cases occur
in patients older than 40 years Less than 5% of cases occur in patients younger than 2
years old. Male to female ratio is 2:1. In children, most common is post infectious AGN,
the majority of which is post streptococcal AGN.
The DOH had recorded a total of 19,475 cases last year.
As a group, we decided to study this kind of disease for us to know more about the
complications. As a nursing students, we must not only focus to one corner or merely by
just taking care of our patients but to know their underlying condition as well for the
better and good nursing intervention done to promote maximum living ability.
Furthermore, we have chosen this case study in order to identify and determine the
general health problems and needs of the patient with an admitting diagnosis of acute
glomerulonephritis. This study also intends to help patient as well as its significant
others to promote health and medical understanding of such condition through the
application of the nursing theories and nursing skills.
OBJECTIVES
General Objective:
The group aims to have a better understanding about Acute Glomerulonephritis (AGN)
for us to be an effective nurse in this course condition.
Specific Objectives:
At the end of the case study, the students must able to:
Define and recognize AGN and to describe its pathophysiology, clinical
manifestation and medical management.
Incorporate nursing process and promote appropriate nursing interventions.
Know and promote preventive measures such as healthy lifestyle and
management.
PATIENT’S PROFILE
Biographic Data
Name : Patient RL
Age : 13 years old
Gender : Male
Address : Bulacan
Birthday : September 10 1997
Religion : Roman Catholic
Civil Status : Single
Nationality : Filipino
Source of information : RL and his Auntie
Room : 21
Bed no. : 7
Date of Admission: January 14, 2011
Time of Admission: 11:39 am
Chief Complaint : Pain (Radial area)
ADMITING DIAGNOSIS: AGN
PHYSICAL ASSESSMENT
DATE PERFORMED JANUARY 24 AND 25, 2010
PART OF THE BODY
MEASUREMENT NORMS ACTUAL FINDINGS
ANALYSIS
Initial Vital Signs
Temperature
Cardiac Rate
Respiratory Rate
Blood Pressure
General appearance
Body built
Over – all hygiene and
grooming
36.5 – 37.0°C
55 – 85 bpm
12 – 18 cpm
110 – 135 / 65 – 85 mmhg
Height: 5’3”Weight: 107 – 130
lbsBMI: 19 – 23
(G&A notes 2005)
Clean and neat
37.5°C
25 cpm
120 / 90 mmhg
4’2”68 lbs
BMI:
Clean and neat (morning care
done)
Febrile(abnormal)
Abnormal due to fear
Normal
AbnormalAbnormal
Clean and neat
Mental Status
Attitude
Effect/ mood appropriateness
of response
Cooperative
Appropriate in situation
Cooperative
Sometimes inappropriate
Normal
Abnormal due to he wants to
go home
Quantity, quality & organization of
speech
Relevance and organization of
thoughts
Understandable, moderate, exhibit
thought association
Logical sequence, make sense of
reality
UnderstandableModerate, exhibit
thought association
Logical sequence, make sense of
reality
Normal
Normal
SKIN Color appropriate to genetic
background
Color appropriate to genetic background
Edematous skin Abnormal due to lack of protein
thiamine & excess sodium
HAIR Evenness of growth
Texture and thickness
Evenly distributed hair
Fine thick hair
Short hair blackish w/ gold hair w/c is evenly distributed
Fine thick hair
Normal
Normal
HEAD Size, shape and symmetry
Symmetry of facial movement
Facial features
Rounded(normocephalic)
Symmetry of facial movement
Symmetry or asymmetrical facial
features
Normocephalic
Symmetry of facial movement
Symmetry of facial features
Normal
Normal
Normal
EYES Color, texture and presence of
lesion of palpebral
conjunctiva
Clarity and
Shiny, smooth and pink conjunctiva with ( - ) lesion
Transparent, shiny
Smooth and pink or red conjunctiva
with ( - ) lesion
Shiny, smooth and
Normal
Normal
EARS
NOSE
texture of cornea
Presence of edema in the
eyelids
Auricles; color, symmetry of size
and position
Auricles; texture elasticity; areas of tenderness
Hearing acuity response to
normal
External nose: shape, size, color
flaring or discharge from
nares
Patency of both nasal cavities
& smooth details of iris is available
No edema and hallowness
Color uniform to face; symmetry
position
Mobile, firm and not tender; pinna
recoils after it is folded
Normal voiceTune audible
Symmetry and straight, no
discharge or flaring, uniform color
without contraptions
Air moves freely as the client breathes through the nares
details of iris is available
Presence of edema
Color uniform to face; symmetry
position
Firm and not tender; pinna
recoils after it is folded
Normal voiceTune audible
Symmetric and straight, uniform
color, no discharge and without contraptions
Both nares is patent
Abnormal due to edema
Normal
Normal
Normal
Normal
Normal
MOUTH
LIPS
TEETH
Symmetry of contour and
texture of oral mucous
membrane
Color, and condition and presence of
dentures
Uniform pink color, soft, moist, smooth
texture; symmetry of contour, ability to
purse lips
Smooth, white shiny tooth enamel; smooth intact
dentures
Pink in color and slightly dry
Smooth, white shiny tooth
enamel; smooth intact dentures
Abnormal, may suggest dehydration
because strict fluid intake
Normal
ANTERIOR
THORAX
POSTERIOR
THORAX
Breathing patterns
Anterior thorax auscultation
Quiet, rhythmic, and effortless
respirations
Broncho vesicular and vesicular breath
sounds
Vesicular and broncho vesicular
breathSounds
Quiet, rhythmic and effortless respirations
Broncho vesicular and vesicular breath sounds
Vesicular and broncho vesicular
breath sounds
Normal
Normal
Normal
UPPER EXTREMITIES
Shoulder
Elbow
Performs internal and external rotation
of the arms
Perform flexion and extension, pronation
and supination of forearm
Can perform internal & external
rotation of the arms
( but pain during ROM)
Can perform flexion &
extension, pronation & supination of
forearm
Abnormal due presence of
edema
Abnormal due to presence of
edema
ABDOMEN
Hands and fingers
Wrist
Contour and symmetry
Performs flexion, extension, abduction
and adduction
Perform flexion and extension, radial and ulnar flexion
Flat, rounded or scaphoid, no
abnormal enlargement, no bulges or ridges
( but pain during ROM)
Can perform flexion, extension,
abduction & adduction
( but pain during ROM)
Can perform flexion &
extension, radial & ulnar flexion
( but pain during ROM)
Flat, rounded, no abnormal
enlargement, no bulges or ridges
Abnormal due to presence of
edema
Abnormal due to presence of
edema
Normal
LOWER EXTREMITIES
Knees (Right knee)
(Left knee)
No presence of inflammation, lesion. Can flex and rotate
No presence of inflammation, lesion. Can flex and rotate.
No presence of inflammation
lesion. Can flex & rotate
No presence of inflammation
lesion. Can flex and rotate
Normal
Normal
DEVELOPMENTAL TASK
According to Erik Erikson who adapted Freud’s theory, people continue to develop
throughout life. He describe eight stages of development, each stages must be
accomplished in order to reach the level of achievement. The resolution of the task can
be complete, partial successful or unsuccessful, success to complete any development,
the healthier the personality is failure to complete can be viewed as a series by crises,
damages the ego. Both positive and negative aspects of the critical life periods.
Patient X is under adolescent in the stage of development task, he is 13 y/o (12-20 y/o)
an identity vs. role of confusion, a coherent sense of self plans to actualize once
abilities, feelings of confusion, in decisiveness and possible anti-social behavior.
According to patient X, he is living with his aunt for almost four years now. The reason is
his parents are separated since he was born. He shows positive reaction regarding on
his health condition by being cooperative to health care providers. Negative aspects of
his life, helps him to feel brave enough to become independent
Based on Gordon functional patterns, which provide a framework to signify the
sequences of recurring behavior. Patient X, during our interaction describes normal
sleeping rest pattern, exercise by walking when he go to school and do some household
chores assigned to him. Cognitive and self perception including relationships shows
lack of development, a little bit stress seen but still tolerable, acts of being tough
despites of living with his family was noticeable on his values belief pattern.
LABORATORY / DIAGNOSTIC FINDINGS
URINALYSIS
DATE EXAMINATION NORMS RESULT INTERPRETATION
ANALYSIS
1/15/11
Color
Transparency
Reaction
Specific gravity
Protein
Sugar
RBC
Pus cells
Epithelial cells
Mucus threads
Amorphous
urates
Straw/amber
Clear
Acidic
1.005–1.030
Negative
Negative
< 2 / hpf
few
few
few
Yellow
Hazy
Acidic
1.03
+++
Negative
100 > /hpf
10-12/hpf
+
++
+++
Not normal
Not normal
Normal
Normal
Not normal
Normal
increased
increased
Normal
Normal
positive
Concentrated
Measures urine density, or the ability of the
kidney to concentrate or dilute the urine over that
of plasma.
Increase in concentration due to
kidney problem
Due to decreased
glomerular filtration/
indications kidney problem
indicates inflammation in the urinary tract
indicates kidney/urinary tract infection
due to kidney disease, the urine is concentrated
that made amorphous urates form
Coarse granular
cast
negative
None
1-2/hpf positive indicates urinary tract infection
BLOOD CHEMISTRY
DATE EXAM NORMS RESULT INTERPRETATION
ANALYSIS
1/15/11
BUN
Creatinine
2.5-6.4 mmol/L
35.4-123.8
mmo/L
9.9 mmol/L
83.3 mmol/L
increased
Normal
due
to decreased
glomerular filtration rate due to kidney problem
HEMATOLOGY
DATE EXAMINATION NORMS RESULT INTERPRETATION
ANALYSIS
1/14/11
Hgb
Hct
WBC count
140-170 g/L
0.4-0.5
5-10x109
82 g/L
0.26
24.5x109
decreased
increased
increased
Due to malnutrition
Indicates anemia
Indicates inflammation in the urinary tract
Indicates infection
Differential
Count
Segmenters
Lymphocytes
Eosinophils
0.55-0.65
0.25-0.35
0.00-0.05
0.9
0.06
0.04
decreased
decreased
Normal
indicates Infection
Patient
Is susceptible in infection
1/20/11
Hgb
Hct
WBC count
Differential
count
Segmenters
Lymphocytes
140-170 g/L
0.4-0.5
5-10x109
0.55-0.65
0.25-0.35
76 g/L
0.24
10.6x109
224x103
0.81
0.19
decreased
Not normal
Slightly increased
Not normal
Not normal
Due to malnutrition
due to presence of
infection
infection
Deficiency in
immune
response
indicates infection
KUB SONOGRAM
Right kidney 8.08 x 4.8 x 4.3 cm
Left kidney 8.8 x 5.8 x 5.4 cm
Size normal
Findings slightly echogenic kidneys
Ureters non-dilated
Urinary bladder findings normally filled, smooth wall
Impression diffuse parenchymal changes of kidneys
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM
Functions:
Help maintain the homeostasis by controlling the composition, volume and
pressure of the blood.
Excrete the waste products of the body.
Regulation of the blood pH.
Contributions to metabolism.
Composition of the Urinary System
Kidney
1. The two reddish kidney beans are said to be retroperitoneal organs.
2. The right kidney is slightly lower than the left kidney.
3. The three layers surround each kidney: Renal Capsule (deep layer), Adipose
capsule or the Perirenal fat (intermediate layer), Renal Fascia (superficial layer).
4. Renal Hilus > it is where the blood and lymphatic vessels and nerves enters and
exit the kidney. It is also through which the ureter leaves the kidney.
5. Renal Sinus > it is a cavity within the kidney and also entrance of the renal hilus.
6. Within the kidney are three distinct regions: Renal Cortex (a superficial reddish
area), Renal Medulla (a deep reddish brown
region) and Renal Pelvis (formed by the 2
calyces)
7. within the renal medulla lies the Renal
Pyramids
8. Major Calyx > is formed by the union of 2 or
more calces.
9. Minor Calyx > receives the urine from several renal papilla.
Nephron
I. (from Greek νεφρός - nephros, meaning "kidney")
II. It is the basic structural and functional unit of the kidney.
III. Parts:
* Glomerulus > is a capillary tuft that receives its blood supply from an afferent
arteriole of the renal circulation.
> it is like a ball of yarn
>The glomerular blood pressure provides the driving force for water and solutes
to be filtered out of the blood and into the space made by Bowman's capsule.
* Renal Tubule > is the portion of the nephron containing the tubular fluid filtered
through the glomerulus.
>The components of the renal tubule are:
Proximal convoluted tubule
Loop of Henle
o Descending limb of loop of Henle
o Ascending limb of loop of Henle
Distal convoluted tubule
Mechanism of Urine Formation:
1. Glomerular Filtration
2. Tubular Re-absorption
3. Tubular Secretion
Ureter
There are two uterine tubes that carry urine from the kidneys to the bladder.
Each ureter is about ten to twelve inches long. Urine flows down partly by gravity,
but mainly by waves of contractions which pass several times per minute through
the muscle layers of the urethral walls.
Each ureter enters the bladder through a tunnel in the bladder wall, which is
angled to prevent the urine from running back into the ureter when the bladder
contracts.
Urinary Bladder
is the organ that collects urine excreted by the kidneys before disposal by
urination
A hollow muscular, and distensible (or elastic) organ, the bladder sits on the
pelvic floor. Urine enters the bladder via the ureters and exits via the urethra.
It stores for about 1000mL of urine.
Urethra
It is a tube that connects the urinary bladder to the genitals for removal out
of the body.
In males, the urethra travels through the penis, and carries semen as well
as urine. In females, the urethra is shorter and emerges above the vaginal
opening.
The external urethral sphincter is a striated muscle that allows voluntary
control over urination.
In the human female, the urethra is about 1.5–2 inches (4–5 cm) long and
exits the body between the clitoris and the vagina, extending from the
internal to the external urethral orifice.
In the human male, the urethra is about 8 inches (20 cm) long and opens
at the end of the penis.
NEPHRON
PATHOPHYSIOLOGY OF ACUTE GLOMERULONEPHRITIS
Post Streptococcal Infection
(Group-A, Beta-Hemolytic)
Antigen-Antibody Complex form
It deposits in the Glomeruli
Inflammatory Response
(Inflammation of Glomerulus)
Production of Endothelial Cells
-Increase permeability of -Blocking of the Capillaries Hematuria
Basement membrane of Glomeruli &
-Vasospasm of Afferent Proteinuria
Edema Arterioles
Oliguria Glomerular Filtration Rate
decreases
Retention of Water and Sodium
Hypervolemia
Hypertention
COURSE IN THE WARD
January 14, 2011
A 13 year old male patient was admitted in the ER, accompanied by his mother, with a
chief complaint of shortness of breath and dizziness. Patient is weak looking upon
admission and has had seizure. He was seen and examined by Dr. Enriquez, with
orders of low salt, low fat diet; fluid intake limitation to 645 mL for 24 hours; CBC,
blood typing, BUN, creatinine, C3, ESR, ASO, chest x-ray (posterior, antero-lateral),
KUB UTZ; I/O monitoring. Patient was hooked with D5W 1L inserted as venoclysis at
KVO regulation. Medications ordered were amlodipine 5 mg PO OD; furosemide 30 mg
TIV q 120; diazepam 5 mg TIV for seizure; penicillin G 750 mg TIV q 60; phenobarbital
300 mg TIV q 80 as loading dose then shift to 50 mg TIV q 80. Dr. Enriquez also
ordered for O2 inhalation via nasal cannula at 5 L/min. Patient was febrile (38.2 0C) at
1:45 pm and was given paracetamol 300 mg TIV at 2 pm. CBC was done and relayed to
the physician. Consent for admission was secured and signed.
In the afternoon, Dra. Dungca seen and examined the patient and ordered for
ceftriaxone 1.5 g TIV q 120; captopril 25 mg tab ½ tab BID (12 hours apart); for
urinalysis; BP strict monitoring q 20; UO monitoring; discontinue penicillin G; heplock
insertion. Patient was febrile (38.7 0C), paracetamol given TIV.
January 15, 2011
The doctor seen and examined the patient and was ordered with the same diet – low
salt, low fat, soft diet and fluid intake limitation. The patient had blurring of vision,
headache, weak in appearance, conscious and coherent, febrile (38.4 0C). The patient
was instructed to do TSB and was given paracetamol. At 2:30 pm, the doctor changed
the patient’s fluid intake limitation to 1L for 24 hours. The result of BUN, creatinine, and
urinalysis was relayed to Dr. Enriquez, while urinalysis was referred to Dr. Lim.
In the afternoon, the patient complained of headache and dizziness, was febrile and
given paracetamol. The patient was positive for tea colored urine.
January 16, 2011
Patient appears weak with blurring of vision. He was transferred to Room 21. Upon
endorsement for the shift (7-3pm), the patient was still weak in appearance and
complains pain at the IV site. He was given O2 inhalation 5 L/min via nasal cannula.
BP was 90/60 at 12 pm, a febrile, without dizziness and without blurring of vision. Due
medications were given and needs were attended.
January 17, 2011
The patient was negative for dizziness, blurring of vision, difficulty of breathing the
whole day, still with O2 inhalation 5 L/min via nasal cannula. During the 7am-3pm shift,
O2 inhalation was temporarily stopped and IVF was removed due to phlebitis at IV site,
and again reinserted on the other arm. Medications were given and needs were
attended.
January 18, 2011
The patient was seen and examined by Dr. Flores and gave new order for furosemide to
start at 20 mg tablet BID for 3 days. Reminded the patient’s watcher to facilitate KUB
UTZ, C3, ASO, ESR; ordered for BP monitoring q 20 and I/O monitoring. Heplock was
removed, during the shift of 11pm-7am, because of phlebitis at insertion site, and was
again reinserted aseptically during the 7-3pm shift. The patient was again slightly
febrile and was instructed to do TSB.
January 19, 2011
The patient was again febrile and instructed watcher to do TSB. Patient experienced
pain at IV insertion site. IVF terminated and reinserted at 1:10 pm. He was febrile, with
readings of 38 0C and 38.4 0C, and was given paracetamol TIV with BP readings of
120/80 mmHg on 7-3pm shift and 120/90 mmHg on the next shift.
January 20, 2011
The doctor ordered for Sumapen 500 mg q 60 for 5 days; D5 0.3 NaCl regulated at 20-25
gtts/min; to secure 2 units of packed RBC of blood type B; paracetamol 1 ampule q 60
prn for temperature > 38 0C. The result for CBC with pH was referred to Dra. del
Rosario. The patient was given paracetamol TIV for fever and was instructed to do TSB.
Heplock was removed during 7-3pm shift. Hematology result was referred to Dr.
Maghoo. The patient had fever again, instructed the watcher to facilitate availability of
IVF and abhocath for BT. Reason for having blood transfusion was discussed and
request for BT of 2 units of PRBC was given to the watcher. D5 0.3 NaCl 500 cc IVF
inserted and regulated at 25-26 gtts/min. Another paracetamol 300 mg 1 ampule was
given prn TIV.
January 21, 2011
The patient was febrile and given paracetamol 300 mg 1 ampule TIV. Seen and
examined by Dr. Lim, and reminded the watcher to have C3, ASO, ESR performed.
Another physician ordered for chest x-ray; continue ceftriaxone 1.5 gm q 120 TIV; start
ciprofloxacin 250 mg tab, 1 tablet BID; V/S monitoring q 40. The patient was reminded
on oral restriction and for PPD. IV medications not met, only oral medications were
given (amlodipine, furosemide, Sumapen). Needs were attended.
January 22, 2011
Advised patient to limit OFI. The patient was seen and examined by Dr. Lim and
ordered for chest x-ray. IVF was dislodged during 7-3 pm shift, hooked with D5 0.3 NaCl
1L, but then again it was terminated d/t phlebitis at IV insertion site. The patient had tea
colored urine. Medications were given. Furosemide 20 mg tab BID for 5 days was
completed. Needs were attended.
January 23, 2011
The patient was hooked with D5 0.3 NaCl 1L regulated at 25 gtts/min. Seen and
examined by physician. Medications were given and needs were attended.
January 24, 2011
The patient has a standing order for C3, ASO, ESR, PPD, and chest x-ray. The
physician ordered for OFI limitation. Medications were given and needs were attended.
BP AND UO MONITORING
DATE SHIFT TIME TEMPERATURE (0C) BP (mmHg) UO (cc)
1-14-11 7-3
3-11
12126810
37.638.837.838.738.6
150/90140/80140/80130/90130/80130/90
350
1-15-11 11-7 246
37.737.537.7
130/90130/90
130/100350
7-3 810122
37.237.837.138.2
130/70130/80130/80120/80
510
3-11 4:30610
38.138.538.9
120/80110/80110/70
160
1-16-11 11-7 26
37.136.9
110/70120/80
550
7-3 10122
36.436.437
110/7090/6090/60
600
3-11 610
36.236.4
100/70110/80
700
1-17-11 11-7 26
36.636
110/70110/70
1500
7-3 102
36.336.1
110/70120/80
3-11 610
3837.5
120/80110/80
1-18-11 11-7 26
36.937.1
120/80110/80
500
7-3 810122
37.537.137.538.4
110/80110/80110/80110/70
200
3-11 468
37.837.437.4
110/70100/70100/60
350
1-19-11 11-7 1026
37.538.535.9
110/80110/80100/80
300
DATE SHIFT TIME TEMPERATURE (0 C) BP (mmHg) UO (cc)
1-19-11 7-3 810122
36.336.236.838
110/80110/80110/80120/80
300
1-20-11 11-7 1226
39.336.3
120/80120/80110/60
400
7-3 810122
37.437
37.837
100/80100/80110/80110/80
300
3-11 46810
38.138
37.937.5
110/80120/80120/80110/80
1-21-11 11-7 1226
37.137.237.1
120/80110/80110/80
300
7-3 810122
38.336.536.436.4
110/70110/70110/70110/70
200
1-22-11 7-3 810122
36.536.436.937
120/80120/80120/70120/70
250
1-23-11 11-7 246
36.836.736.7
130/90120/80120/80
300
7-3 810122
36.136.636.937.4
110/80110/80110/70110/70
3-11 46810
37.137.737.337.4
120/80110/80110/80120/80
1-24-11 11-7 12246
37.137.336.936.8
120/70110/70110/70110/70
200
7-3 810122
36.936.936.936.8
110/80110/80110/80110/80
150
IV FLUID
DATE SHIFT KIND OFSOLUTION
VOL gtts/min
TIME STARTED
TIMEENDED
REMARKS
1-14-11 7-3 D5 W 1 L KVO 11:00
1-14-11 3-11 shifted to heplock
1-20-11 7-3 heplockterminated
1-20-11 3-11 D5 0.3 NaCl 500cc 25-26 8:00 1:30
1-21-11 7-3 D5 0.3 NaCl 1L 25-26 7:00 5:30 followup
1-23-11 3-11 D5 0.3 NaCl 1L 25 9:50 8:20 Followup
MEDICATION LIST
DRUG / DOSAGE
DATE AND TIME GIVEN14 jan 15 jan 16 jan 17 jan 18 jan 19 jan 20 jan 21 jan
amlodipine 5 mg PO OD
11:30 pm
am am 6 am 6 am 6 am 6 am 6 am
furosemide30 mg TIV q 120
11:30 pm
12 am12 pm
12 am12 pm2 pm8 pm
8 am6 pm
6 am
DC
diazepam5 mg IV for seizure
12:15 pm3 pm
paracetamol300 mg TIV q 40
2 pm10 pm
2am6 am 6 pm
2 pm6 pm
2 am2 pm10 pm
2 am
penicillin G750 mg IV q 60
(-) ANST
DC
phenobarbital50 mg IV q 80
9 pm 6 am2 pm4:35
12 am8 am6 pm
2 am10 am10 pm
6 am6 pm
2 am10 am
2 am10 am
6 am2 pm10 pm
ceftriaxone1.5 gm q 120
10 pm 10 am10 pm
10 am10 pm
10 am 12 am12 pm
2 am2 pm
6 am 6 am6 pm
captopril25 mg tab ½ tabBID
9 pm 9 am9 pm
9 am10 pm
10 am10 pm
10 am 10 am 10 am
DRUG /
DOSAGE
DATE AND TIME GIVEN18 jan 19 jan 20 jan 21 jan 22 jan 23 jan 24 jan
furosemide20 mg tab ½ tab BID for 3 days
6 am6 pm
6 am8 pm
6 am6 pm
6 am10 pm
6 am12 pm Completed
Sumapen500 mg/cap q 60
12 pm6 pm
12 am6 am12 pm
12 am6 am12 pm6 pm
12 am6 am12 pm6 pm
2 am8 am2 pm
paracetamol300 mg 1 ampQ 60 prn T > 380 C
8 pm 8 am8 pm
ciprofloxacin250 mg tab BID
6 am6 pm
6 am6 pm
6 am
BLOOD TRANSFUSION BP MONITORING
TIME BP (mmHg) REMARKS
10:5011:0511:2011:5012:202:203:30
120/70120/90
150/100150100130/90
130/100130/100
prior to BT15 min15 min30 min30 min2 hourspost BT
expiration date: 24 hours after packing
date/time packed: 21 jan 2011 / 9:40 pm
DISCHARGE PLANNING
Medication are explained to the patient and family members the importance of taking
medicines.
Discuss to the patient and family the dosage, frequency and adverse effects of the
drugs.
Encourage/instruct to keep the edematous extremities to elevate as often.
Provide warm environment.
Tell the patient that she should have self-monitoring by checking his vital signs and
weighing regularly.
Temperature
Respiratory Rate
Pulse Rate
Blood Pressure
Limit of water intake, monitor intake and output.
Hygiene should be proper for comfort.
Proper hand washing.
Improve Nutritional Status.
Out -patient schedule for follow check-up must be followed.
Instruct the patient to seek regular check-up.
Diet should be low fat and low sodium foods that will help not worsen his condition.
Eat five or more servings of vegetables and fruit daily.
Intake of fluids 8-10 glasses a day to avoid constipation.
Spiritual health affects the wellness of an individual greatly.