V. THE PATIENT AND HIS CARE A.

MEDICAL MANAGEMENT Medical Date ordered, General management/ performed, Description Treatment changed D5 Lactated Ringer’s Solution DO: Aug. 21, 2006 DP: Aug. 2122, 2006 It is an hypertonic solution that causes the cell to shrink. Each 100 ml consists of 5g of dextrose monohydrate, 600 mg NaCl, 30mg of Na Lactase Anhydrase, 30 mg of potassium chloride. It has a pH of 4.0- 6.5. Indications or Purpose For replacement of fluids and electrolytes. Clients Response to treatment Electrolyte imbalance was prevented.

NURSING RESPONSIBILITIES PRIOR: o Check the doctor’s order for the correct IVF to be infused. o Check for the IVF regulation. o Explain the purpose and importance of IV fluids to the patient and SO. DURING: o Check for the integrity of the infusion. o Regulate and monitor the IV rate of fluid. o Assess the site for any redness, swelling, tenderness or infiltration. AFTER: o Check for the patency of the line always. o Monitor the level of IV fluid. o Place an IV tag.

Medical Date ordered, General management/ performed, Description Treatment changed Oxygen Inhalation DO: Aug. 22, 2006 DP: Aug. 22, 2006 Oxygen is a transparent, odorless dry gas that is slightly heavier than air.

Indications or Purpose It was given post operatively to patient to prevent respiratory distress.

Clients Response to treatment Pt. was welloxygenated AEB absence of nasal flaring, difficulty of breathing, no pallor or cyanosis.

NURSING RESPONSIBILITIES PRIOR: o Check chart for the Oxygen regulation and monitor vital signs. o Prepare the equipments; oxygen supply, humidifier with distilled water, nasal cannula and tubing. o Assess skin and mucous membrane, breathing patterns and chest movements. o Wash hands. DURING: Determine need for oxygen therapy and verify order. Prepare client and SO and explain the procedure’s importance. Set up oxygen and humidifier. Turn on oxygen at the prescribed rate and ensure proper functioning. Check oxygen if flowing freely through the tubing. There should be no kinks and connections should be airtight. There should be no bubbles in the humidifier as oxygen flows through. o Put the cannula over the clients face with the outlet prongs fitting into the nares. o Assess for the nares’ encrustation and irritations. o o o o AFTER: o Report any significant deviations from normal.

Medical Date ordered, General management/ performed, Description Treatment changed Surgical Skin Preparation DO: Aug. 21, 2006 DP: Aug. 21, 2006 Involves the cleansing of the surgical site, removing hair if only necessary and applying anti- microbial agent, PRN.

Indications or Purpose To reduce the risk of post operative wound infection.

Clients Response to treatment There were no noted signs and symptoms of infection after the operation.

NURSING RESPONSIBILITIES • Ensure that the operative site and surrounding areas are clean, have the patient take a shower, wash the operative site and apply anti- microbial agent. • Inspect for growth, moles, rashes, pustules, irritations, abrasions, bruises or broken or ischemic areas. • Determine whether client is allergic to any solutions used in the skin prep. • Hair removal at the operative site is not recommended unless the hair interferes with the surgical procedure.

Medical Date ordered, General management/ performed, Description Treatment changed Bulb syringe attached to a drainage tube DO: Aug. 22, 2006 DP: Aug. 22, 2006 Suction drains are used in every case of subcutaneous operation over the muscles and in the sub muscular pocket.

Indications or Purpose To drain serum from the operative site To promote wound healing and decrease the potential for infection.

Clients Response to treatment Blood and serum was drained at the operative site. There were no noted signs and symptoms of infection.

NURSING RESPONSIBILITIES • • • • Determine color, consistency and amount of drainage from the tube and suction apparatus. Record the volume of the drainage. Check for the patency and tubes and suction should be functioning. Bulb syringe should be hanging properly. Drain should be secured and labeled properly. Check any leakage of fluid at the drainage insertion site.

Medical

Date ordered, General

Indications

Clients

management/ performed, Treatment changed Wound dressing The doctor of the patient was the one who changed the first wound dressing.

Description A thin white cloth that is autoclaved for sterilization.

or Purpose To prevent infection.

Response to treatment There were no noted signs and symptoms of infection

NURSING RESPONSIBILITIES • • • • In many instituitions, the physician changes the initial post operative dressing. The doctor orders the type and frequency of dressing changes. Assess the dressing if it is soiled and check for the doctors order. Specify type of dressing to be used, clean or sterile. Use aseptic technique in examining the wound. Report changes in the color, character and quantity of the drainage from the drain or around the drain site. Any sign of swelling, redness, tenderness, warmth, bleeding, discharge or separation of wound edges should be reported. Make sure that the dressing is intact.