CLIENTS DAILY PROGRESS CHART

DAYS NURSING PROBLEMS JULY 23, 2011 (Admission) JULY 24, 2007 JULY 25, 2007 JULY 26, 2007 (Discharge)

1. Altered nutrition: Less than body requirements 2. Deficient Fluid Volume r/t Active Fluid Loss 3. Diarrhea r/t inflammation, irritation 4. Hyperthermia 5. Risk for Infection
VITAL SIGNS TEMPERATURE RESPIRATORY RATE PULSE RATE DIAGNOSTIC / LAB PROCEDURE 7-3 37.4 28 118

y y y y

| | | |

3-11 38.1 26 114

11-7 | 7-3 | 3-11 40.2 | 37.8 | 39 28 | 24 | 38 120 | 102 | 118

11-7 | 7-3 | 3-11 39 | 36.2 | 25 | 22 | 120 | 86 |

11-7 | 7-3 | | |

Hematology Complete Blood Count

*Hemoglobin 120 *Hematocrit 0.36 *WBC 11.0 DIFFERENTIAL COUNT *Segmenters .88 *Lymphocytes .12

Urinalysis Color: yellow Transparency

turbid pH: 5.0

Specific gravity:

1.020
Pus cells/HPF: 1-3

Sugar (-)

Albumin (+) A. Urates Many Mucus thread Many Bacteria (+)

Fecalysis

Color: yellow Consistency: loose Pus cells/HPF: 8-14 Entamoeba histolytica: Cyst 0-1 RBC 1-2

MEDICAL MANAGEMENT D5LRS 500 cc x 61-62 ugtts DRUGS

Metronidazole q 8

Paracetamol rtc Cotrimoxazole for antibacterials q 12 PO

DIET NPO BRAT Diet

y y

y y

*1st 6 hours *