I. PATIENT AND HIS CARE A. MEDICAL MANAGEMENT

Medical Managemen

t

General Description

Indications

DATEOrdered/Performe

d

Client’s Response

IVF #1 D5LRS 1L x

8°

IVF #2 D5NM 1L x

8°

5% Dextrose in Lactated Ringer's Injection provides electrolytes and calories, and is a

source of water for hydration. It is

capable of inducing diuresis depending

on the clinical condition of the

patient. This solution also contains lactate

which produces a metabolic alkalinizing

effect. Sodium, the major cation of the extracellular fluid,

functions primarily in the control of water

distribution, fluid balance and osmotic

pressure of body fluids.

Normosol-M and 5% Dextrose injection is

nonpyrogenic and

It is indicated

for restoring

electrolytes and

replacing fluids in the

body especially in the case

of the patient who

has had dehydration

from Typhoid Fever.It also

serves as a route for

medication.

01/23/14

01/24/14

Client manifested no adverse reactions to

the treatment,

but it helped by

rehydrating the body

and providing

electrolytes and

calories.

Client manifested no adverse reactions to

the

is a nutrient replenisher. It provides water and electrolytes

(with dextrose as a readily available

source of carbohydrate) for maintenance of daily fluid and

electrolyte requirements, plus

minimal carbohydrate calories. The electrolyte

composition approaches that of the principal ions of normal plasma

(extracellular fluid).

It serves as a

maintenance of daily fluid and

electrolyte levels for

the patient. The

dextrose (sugar) restores glucose

levels and provides minimal

carbohydrate calories

treatment, but it

helped by rehydrating

the body and

providing electrolytes and calories

NURSING RESPONSIBILITIES:

Before the Procedure Check the doctor’s order regarding to what type of IVF to be used and

also its volume and rate.

Explain the procedure to the patient.

Gather all materials needed for the insertion of IVF to save time and not

to waste time for looking for other materials.

Wash hands before and after the procedure to prevent contamination

from insertion site.

 During the Procedure Place patient in a comfortable position to facilitate easy insertion of IV

line and to decrease patient’s fear about the procedure.

Make sure that we give the proper IV fluid and drop rate accurately

because patient may experience fluid overload or dehydration.

Check for its patency by observing the backflow of blood upon insertion.

 After the Procedure

Press the site where the needle was inserted and secure it with

micropore.

Check the site of hand where the needle is inserted if bulging is not

visible. If so, reinsertion is to be undertaken.

Advice patient to avoid scratching the site less movement of the hand

where the needle was inserted to keep it in place.

Instruct patient and significant others to inform the nurse on duty if

bulging of the site is visible, if there is back flow of blood of if IVF is not

infusing well.

Observe the IV site at least every hour for signs of infiltration or other

complications fluid or electrolyte overload and air embolism.

IVF regulation should be checked and monitored upon receiving patient.

Always check the doctor’s order for new orders regarding the IVF

supplement of the patient.

Always check if the IVF is infusing well and intact.

B. PHARMACOLOGICAL MANAGEMENT

Generic Name(brand name)

Mechanism of

Action

Date Ordered/Administ

ered

Indications

Contraindication

s

Client’s Response

to Treatmen

t

NURSING RESPONSIBILITIES

PARACETAM

OL

(biogesic)

Adult: PO 5

00 mg/tab

q4 RTC/

PRN(T>37.

5)

ANTIPYRETIC,

ANALGESICS(NON-

OPIOID)

Decreases

fever by a

hypothalam

ic effect

leading to

sweating

and

vasodilation

.

Inhibits

pyrogen

effect on

the

hypothalam

ic-heat-

regulating

01-23-14 For

temporary

relief of

pain and

discomfort

from

headache

and fever.

For

relieving

fever.

.

Hypersen

sitivity to

paraceta

mol

The

patient

didn’t

manifest

any

allergic

reaction to

Paracetam

ol. The

fever

subsided

from 38.6

to 37.3

degrees

Celsius

Before the administration of

drug

Check for medical order

Determine if patient is allergic to

the drug

Explain the procedure and

reasons for giving the drug, to

gain patient cooperation

Explain possible side effects

During drug administration

Maintain aseptic technique

Check medication, right route,

dosage, storage, etc

Stay with the patient while she

takes in the drug

Do not exceed the

recommended dosage

centers

Inhibits CNS

prostagland

in

synthesis.

After the administration of drug

Monitor any untoward effects of

the drug

Instruct SO’s to report to the

attending nurse if any unusual

effects occur

Provide comfort for the patient.

Report and record as

appropriate.

Generic Name(brand name)

Mechanism of

Action

Date Ordered/Administ

ered

Indications

Contraindications

Client’s Response

to Treatment

NURSING RESPONSIBILITIES

CIPROFLOXA

CIN

(ciprobay xr)

Adult: PO

1gm/tab

B.I.D

ANTI-BACTERIAL

Bactericidal

; interferes

with the

DNA

replication

in

susceptible

bacteria

preventing

cell

reproductio

n.

01-23-14 For Gram-

negative

bacteria like

Salmonella

typhi

Hypersensitivity.

Not to be used

concurrently with

tizanidine. Avoid

exposure to strong

sunlight or

sunlamps during

treatment.

The patient

didn’t

manifest

any allergic

reaction to

ciprofloxaci

n

Before the

administration of drug

Check for medical

order

Determine if patient is

allergic to the drug

Explain the procedure

and reasons for giving

the drug, to gain

patient cooperation

Explain possible side

effects

During drug

administration

Maintain aseptic

technique

Check medication,

right route, dosage,

storage, etc

Stay with the patient

while she takes in the

drug

Do not exceed the

recommended dosage

After the administration

of drug

Monitor any untoward

effects of the drug

Instruct SO’s to report

to the attending nurse

if any unusual effects

occur.

Report and record as

appropriate.

Generic Name(brand name)

Mechanism of

Action

Date Ordered/Administ

ered

Indications

Contraindications

Client’s Response

to Treatment

NURSING RESPONSIBILITIES

CEFTRIAXON

E

(xtenda)

Adult: IV

Inhibits

bacterial

cell wall

synthesis,

rendering

01-23-14 Typhoid

fever’s

causative

agent is

Salmonella,

Contraindicated in

patients with

known allergy to

the cephalosporin

class of antibiotics.

The patient

didn’t

manifest

any allergic

reaction to

Before the

administration of drug

Check for medical

order

Determine if patient is

inf. ST(-)

1gm q8

ANTIBACTERIAL

cell wall

osmotically

unstable

leading to

cell death.

a gram-

negative

bacilli, this

medication

inhibits this

bacteria to

multiply by

inhibiting

cell wall

synthesis.

ceftriaxone. allergic to the drug

Explain the procedure

and reasons for giving

the drug, to gain

patient cooperation

Explain possible side

effects

During drug

administration

Maintain aseptic

technique

Check medication,

right route, dosage,

storage, etc

Stay with the patient

while she takes in the

drug

Do not exceed the

recommended dosage

After the administration

of drug

Monitor any untoward

effects of the drug

Instruct SO’s to report

to the attending nurse

if any unusual effects

occur.

Report and record as

appropriate.

Generic Name(brand name)

Mechanism of

Action

Date Ordered/Administ

ered

Indications

Contraindications

Client’s Response

to Treatment

NURSING RESPONSIBILITIES

OMEPRAZOL

E

(risek)

Adult: PO

40mg/cap

HS

PROTON PUMP

Gastric-acid

pump

inhibitor;

suppresses

gastric acid

secretion at

the

secretory

surface of

the gastric

01-23-14 To decrease

further

irritation of

the gastric

mucosal

lining.

Contraindicated in

patients with

known

hypersensitivity to

substituted

benzimidazoles or

to any component

in the formulation.

The patient

didn’t

manifest

any allergic

reaction to

Omeprazole

. Verbalized

reduced

abdominal

Before the administration of drug Check for medical

order Determine if patient is

allergic to the drug Explain the procedure

and reasons for giving the drug, to gain patient cooperation

Explain possible side effects

INHIBITOR parietal

cells; blocks

the final

step of acid

production.

cramps.During drug administration

Give before food, preferably breakfast; capsules must be swallowed whole

Maintain aseptic technique

Stay with the patient while she takes in the drug

Do not exceed the recommended dosage

After the administration of drug

 Monitor urinalysis for hematuria and proteinuria. Periodic liver function tests with prolonged use.

Advise patient to report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine.

Instruct SO’s to report to the attending nurse

if any unusual effects occur

Provide comfort for the patient.

Report and record as appropriate.

Generic Name(brand name)

Mechanism of

Action

Date Ordered/Administ

ered

Indications

Contraindications

Client’s Response

to Treatment

NURSING RESPONSIBILITIES

HYDROCORT

ISONE

(solu-cortef)

Adult: IV

100mg q6 x

3 doses

STEROID

Hydrocortis

one is a

short-acting

synthetic

steroid with

both

glucocortico

id and

mineralocor

ticoid

properties

that affect

nearly all

systems of

01-23-14 Hydrocortis

one is used

to reduce

inflammatio

n. It

reduces

swelling.

Contraindicated in

patients with

known

hypersensitivity to

substituted

benzimidazoles or

to any component

in the formulation.

The patient

didn’t

manifest

any allergic

reaction to

Hydrocortis

one.

Before the administration of drug Assess for

contraindications. Assess body weight,

skin color, V/S, urinalysis, serum electrolytes, X-rays, CBC.

Arrange for increased dosage when patient is subject to unusual stress.

Observe the rights of drug administration.

During drug administration

the body.

By

inhibiting

the

formation,

storage and

release of

histamine

from mast

cells, it

reduces the

effects of

an allergic

response. It

also

increases

the body’s

response to

circulating

catecholami

nes.

Give daily before 9am to mimic normal peak diurnal corticosteroid levels.

Space multiple doses evenly throughout the day.

Use minimal doses for minimal duration to minimize adverse effects.

Do not give IM injections if patient has thrombocytopenic purpura.

Taper doses when discontinuing high-dose or long-term therapy.

After the administration of drug Monitor client for at least

30minutes. Educate client on the

side effects of the medication and what to expect.

Instruct client to report pain at injection site.

Instruct client to take drug exactly as prescribed.

Dispose of used materials properly.

Document that drug has been given

C. DIET

Type of Activity

General Description

Indications/ Purpose

Date Ordered/ Performe

d

Examples of food

Client’s Response

Soft Diet A diet that is

soft in

texture, low

in residue,

easily

digested,

and well

tolerated. It

provides the

essential

nutrients in

the form of

liquids and

semisolid

foods.

A soft diet

food can

easily be

digested by

the body. As

the digestive

system of

the patient

becomes

weak during

typhoid, the

typhoid

remedies do

not

recommend

a patient to

eat any food

that may be

high in tough

fibers.

01/23/14 Soup,

eggs,

yoghurt,

breads,

cereals,

mashed

potato,

oatmeal

The patient

complied to the

given diet.

SOFT DIET

NURSING RESPONSIBILITIES BEFORE, DURING, AND AFTER 

 Before the Procedure

Check the doctor’s order.

Check the right client.

Be sure that the diet is properly instructed.

Explain the reason for type of diet

 During the Procedure

Monitor if the client complies with the given diet.

Be sure patient is taking or eating food he/she can tolerate

 After the Procedure

Assess for patient’s condition; how he responded to the diet.

A. ACTIVITY and EXERCISE

NURSING RESPONSIBILITIES

Educate client regarding his activity

Assisting client to his bathroom privileges

Explain the purpose of restrictions in activity and position in bed as

ordered.

Assist the patient to maintain the prescribed position.

Encourage the patient to adhere to ordered activity.

Accomplish necessary documentation of patient’s reaction to the ordered

activity restrictions.

Type of Activity

General Description

Indications/ Purpose

Date Ordered/ Performe

d

Client’s Response

Bed Rest

with

Bathroom

Privilege

with

assistanc

e

It is a

restriction of

a patient's

activities,

either

partially or

completely ,

but permitted

to use the

bathroom

with

assistance.

One of the

symptoms of

Typhoid Fever is

dehydration and

weakness.

Therefore,

patient must be

assisted in using

the bathroom to

prevent any

injury.

01/23/14 Patient complied

to the prescribed

activity. It

provided

assistance to

ease the effort in

using the

bathroom by

saving energy

and preventing

exhaustion.

II. NURSING CARE PLANS

NURSING PROBLEM: Hyperthermia related to infection of systemic effects of endotoxins and bacterial products of salmonella typhi

CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONOBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:

“Halos 2 weeks

nakong

nilalagnat” as

verbalized by

the patient

Objective:

Restlessne

ss

Malaise

Headache

Warm to

touch

Elavated

WBC (14.6)

Typhidot

(presence

Hyperthermi

a

related to

infection of

systemic

effects of

endotoxins

and

bacterial

products of

salmonella

typhi.

Body

temperature

elevated above

normal level

that is usually

caused by

several factors

related to

illness. As

inoculation

occurs, prolifer

ation of

bacteria follows

and

multiplication

occurs. Once

the bacteria

starts to grow

in number, it

After 4 hours

of nursing

intervention

client will be

able to

maintain

core

temperature

within

normal range

as evidenced

by:

Body

temperat

ure

reduced

lowered

to 38.6°C

to 37.5°C.

Monitor patient

temperature

degree and

patterns.

Observe for

shaking chills

and profuse

diaphoresis

Provide tepid

sponge baths

and avoid the

Fever

pattern

may aids

in

diagnosing

underlying

disease.

Chills often

precede

during

high

temperatu

re and in

presence

of

generalize

d infection.

Goal met

After 4 hours of

nursing

intervention

goals and

objectives was

met as

evidenced by

body

temperature of

37.3°C

of IgM)

V/S taken

are as

follows:

T = 38.6 °C

RR = 22

PR = 92

BP = 90/60

will soon reach

it pathogenic

level that will

result

into pyrexia or

fever as a

defense

mechanism of

the body.

use of ice

water and

alcohol.

Remove excess

clothing and

covers

Maintain bed

rest or

minimize

movement.

May help

reduce

fever. Use

of ice

water and

alcohol

may cause

chills and

can

elevate

temperatu

re

This

decreases

warmth

and

increases

evaporativ

e cooling

To reduce

metabolic

Encourage

client to

increase fluid

intake.

INDEPENDENT:

Administer

Paracetamol as

prescribed by

the physician ,

utilizing 10Rs

in giving

medication.

demands

of oxygen

consumpti

on.

If patient is

dehydrate

d or

diaphoretic

, fluid loss

contribute

s to fever.

Antipyretic

s acts on

the

hypothala

mus,

reducing

hyperther

mia.

NURSING PROBLEM: Acute Pain R/T irritation of intestinal mucosa AEB facial grimace, guarding position, restlessness,

and 7/10 pain scale secondary to Typhoid Fever

ASSESSMENTNURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIO

N

OBJECTIVESINTERVENTIO

NRATIONALE EVALUATION

Subjective

Cues:

“Masakit tiyan

ko.”

Objective

Cues:

(+) facial

grimace

(+)

guarding

position

(+)

restlessne

ss

7/10 Pain

Scale

Acute Pain

R/T irritation

of intestinal

mucosa AEB

facial

grimace,

guarding

position,

restlessness,

and 7/10

pain scale

secondary to

Typhoid

Fever

Once the

Salmonella

typhi that

causes typhoid

fever is

consumed, it

travels initially

through the

digestive

system.

Therefore,

causing

irritation that

will eventually

trigger

diarrhea or

constipation,

weight loss,

and abdominal

Short

Term:

After 4 hours

of nursing

interventions

, the patient

will verbalize

relief from

pain.

Long Term:

After 24

hours of

nursing

intervention,

the patient

will show

signs of

comfort and

Assess the

level of pain,

location,

duration,

intensity and

characteristi

cs of pain.

Give warm

compresses

on the area

of pain.

Provide a

quiet

environment

Changes in

the

characterist

ics of the

pain may

indicate the

spread of

disease or

any

complicatio

n.

Warm can

help ease

the pain.

Promotes

Goal met

After 4 hours of

nursing

interventions,

the patient

verbalized

reduced pain

from pain scale

of 7 to 5/10.

Reported relief

from and have

rested and slept

comfortably.

V/S taken are

as follows:

T = 38.6 °C

RR = 22

PR = 92

BP = 90/60

pain. will be able

to rest and

sleep.

and reduce

stressful

stimuli.

Place in

position of

comfort.

Provide

diversional

activities,

and

relaxation

technique

Administered

Omeprazole

as

prescribed

by the

rest that

may

alleviate

the pain

May lessen

associated

discomfort

Helps with

pain

manageme

nt by

redirecting

attention to

such

activities.

Omeprazole

is a proton

physician pump

inhibitor

which

decreases

acid

secretion to

prevent

further

irritation of

mucosa

which

contributes

to the

abdominal

pain.

NURSING PROBLEM: Activity Intolerance r/t muscle weakness

CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONOBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:

“Masaki tang

Activity

Intolerance

r/t muscle

Activity

Intolerance is

insufficient

After 2-3

hours

of nursing

Assess

patient’s level

of mobility.

This aids

defining

what pati

Goal met.

After 2-3 hours

of nursing

mga

kasukasuhan

ko,

nahihirapan

ako

gumalaw” as

verbalized

by patient.

Objective:

Febrile

(38.6)

body

weakness

restlessne

ss

increased

RR (22

cpm)

low hgb

count

(11.9g/L)

fatigue

prefers to

weakness physiological or

psychological

energy, poor

endure or

complete

required or

desired daily

activities.

Because of low

hct level there

will be decrease

oxygen being

delivered to the

tissues of the

body since the

hgb is

responsible for

the oxygenation

of tissue. As a

compensatory

mechanism, the

body will

increase its

demand of

interventions

and giving

health

teachings,

the patient

will be able

to :

Follow

energy

conservati

on

technique

s to

lessen

fatigue

Perform

ADL as

tolerated.

Assess ability

to stand and

move about

and the

degree

of assistance

necessary.

Provided

adequate rest

ent is

capable of

which is

necessary

before

setting

realistic

goals.

To

determine

current

status

and needs

associate

d

with parti

cipation in

needs

or desired

activities.

Rest

between

interventions the

patient was able

to perform

comfort measure

to minimize

energy

consumption like

refraining from

doing non

essential

procedures and

placing

frequently used

items within

reach.

lie down

on bed

oxygen by

increasing

respiratory rate

of the patient

which results

then to fatigue.

Because of this

there will be fast

consumption of

ATP leading to

weaker

contractions

thus causing

muscle

weakness and if

the patient has

muscle

weakness there

will be activity

intolerance.

periods,

especially

before meals,

other ADLs,

and

ambulation.

Instruct

patient to eat

nutritious

foods and

drink adequate

fluid intake.

Teach comfort

measure to

conserve

energy by: 1.)

Changing

position

frequently; 2.)

Placing

activities 

provides

time

energy

conservati

on and

recovery.

Promotes

well-being

and

maximize

s energy

production.

This

distribute

s work to

the

different

muscles

to avoid

fatigue

frequently

used items

within reach;

3) Bedside

commode

Instruct

patient to

promote /

have

ambulation

and reposition

as necessary.

To

prevent

skin

breakdow

n and

maximize

s energy

productio

n.

NURSING PROBLEM: Risk for Imbalance Nutrition: Less than body requirements r/t loss of appetite and altered absorption of nutrients

CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONOBJECTIVES

NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective:

“Minsan

wala ako

gang kumain

kasi

masyadong

masakit” as

Risk for

Imbalance

Nutrition:

Less than

body

requirements

r/t loss of

Lack of appetite

is a common

symptom of

many diseases.

Brief periods of

anorexia are life

threatening but

After 2 hours

of nursing

interventions

the patient

will be able

to:

Maintain

Assess

appetite

changes.

Frequency and

amount of

food intake

Indicates

health

status

and effect

of illness

which

require an

Goal met.

After 2 hours

of nursing

interventions the

patient was able

to verbalized

understanding of

verbalized

by patient.

Objective:

Poor skin

turgor

body

weakness

Pale

conjuncti

va

Diaphoret

ic

appetite and

altered

absorption of

nutrients

can cause

temporary

nutrition.

Prolonged

anorexia may

lead to serious

consequences

such as

malnutrition.

During reduced

food

consumption,

people use up

their stored

glycogen which

provides energy

through

glycgenolysis.

Prolonged

reduced food

consumption

may minimize or

consume all

stored glycogen

hydration

status

State

importanc

e of meal

intake to

meet

metabolic

needs

Have

adequate

amount of

food

intake

Ask SO to

provide

companionship

during meal

Suggested

liquid drinks

for

supplemental

increased

nutritional

needs and

appetite

affected

by illness

Attention

to the

social

aspects of

eating is

important

in both

hospital

and home

setting

Such

suppleme

nts can be

used to

increase

calories

the importance

of food intake to

sustain the

nutrients of the

body and for

faster recovery.

thus improper

diet occurs.

nutrition

Instruct

patient to eat

nutritious

foods high in

calories and

protein that

will promote

weight gain.

Explain to

patient that

nutritional

needs during

the course of

and

proteins

without

interfering

voluntary

food

intake.

Maintains

and

promotes

health

status

To aid in

the

understad

ing of

patient of

the

importanc

e of

nutrition

illness also

increase so it

is imperative

to take in food.

Advised

patient to take

small frequent

feedings

Administered

intravenous

fluid D5NM 1L

for faster

recovery

To

increase

energy

levels at

regular

intervals

To

maintain

hydration

status of

the

patient

NURSING PROBLEM: Deficient Fluid volume related to diarrhea.

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNINGINTERVENTIO

NRATIONALE EVALUATION

Subjective

Cues:

“Nauuhaw

ako lagi

prang

nanunuyo

ang

lalamunan

ko.”

Objective

Cues:

o Dry

mucous

membrane

o Dry skin

and lips.

o Pale

Conjunctiv

a.

o Frequent

Diarrhea 3-

Risk for

deficient

Fluid volume

related to

excessive

fluid loss

through

frequent

passage of

stools

When there is

insufficient fluid

intake, and

excessive fluid

loss from and

diarrhea it

indicates

imbalance in

fluid volume in

which the body

can’t

compensate by

an adequate

intake of water.

Decreased

volume in the

intravascular

compartment is

called

hypovolemia.

Since water

moves freely

between the

After 2-4

hours of

nursing

intervention,

the client will:

o Learn ways

on how to

keep body

hydrated

o Comply

with the

prescribed

soft diet

o Demonstra

te clinical

signs of

adequate

hydration

o Assess and

document

amount,

color and

characteristi

cs of vomitus

and

diarrhea.

o Assess skin

turgor and

oral mucous

membrane;

o Provide for

changes in

dietary

intake

o Increase oral

fluids

o Determine

Fluid

replaceme

nt.

o To

evaluate

changes

as related

to fluid

status.

o To avoid

foods that

precipitat

e diarrhea

o To replace

fluid loss

After 4 hours of nursing intervention the client was able to:

o Maintain normal hydration as evidenced by moist skin

o Comply with the given diet

o Increase fluid intake

5x a day compartments,

extracellular

fluid deficit

causes

intracellular

fluid deficit

(cellular

dehydration),wh

ich leaves the

cells without

adequate water

to carry on

normal function.

o Recommend

products

such as

normal

fibers, plain

yoghurt

o Restrict solid

food intake

as indicated

o Assess

presence of

postural

hypotension,

tachycardia,

o To restore

normal

flora of

bowel

o To allow

bowel to

rest and

reduce

intestinal

workload

o To watch

out

warning

signs of

dehydrati

on