Appendix C (Discharge Plan)

1. Recapitulation of stay.

Day 1 (February 27, 2018)

I receive patient L.J.Q. lying on bed ,sleeping with on going IVF PNSS

with a drop rate of KVO 40cc/hr, right arm. CBC, Blood typing, urinalysis . Second blood

transfusion was administered with the following vital signs :Temperature 36.5°C, Pulse

Rate 64 bpm, Respiration 20 cpm, Blood Pressure 120/80 mmHg ; given furosemide

Day 2 (February 28, 2018)

Received endorsement and had nursing rounds, seen patient on bed

awake, afebrile, and coherent with an IVF of PNSS 1L @ KVO 40cc/hr, right arm.

Blood pressure of 120/80 mmHg, temperature of 36.6°C, pulse rate of 76 bpm, and

respiration of 20 cpm. Doctor ordered Diet as Tolerated (DAT) for the patient.

Assessed general status of the patient; V/S taken every hour and charted.

Conducted Physical Assessment and interviewed the patient utilizing the Gordon’s

Functional Health Pattern Guide. Time taping of IVF. Bedside care done. I and O

measured and recorded at the end of shift.

Day 3 (March 1, 2018)

Received endorsement and had nursing rounds, seen patient on bed,

awake, afebrile, and coherent, with an IVF of PNSS 1L @ KVO 40cc/hr. Assessed

general status of the patient and observed for any unusualities. V/S taken every 4 hours
and charted. IVF of PNSS was terminated. Bedside care done. Assisted patient’s need

Promote verbalization of feelings and emotions. I and O measured and recorded at the

end of the shift.

2. Lab and Diagnostic Summary

Complete Blood Count

Test name Result Reference Range Significant Findings

Hemoglobin 3.44 10.8-14.2 Low

Hematocrit 12.9 37.7-53.7 Low

RBC 1.50 3.60-4.69 Low

WBC 8.47 3.70-10.1 Normal

Blood type 0+

Platelet count 60.1 155-366 Low

HBS Ag Non- reactive

Lymphocytes 2.41 1.09-2.99 Normal

Monocytes .208 .240-.790 Low

Eosinophils .098 .030-.440 Normal

Basophils .071 0.00-0.80 Normal

MCV 86.2 81.1-96.0 Normal

MCH 22.6 27.0-31.2 Low

Total

Urinalysis
Test Reference Value Results

Macroscopic

Color Amber/straw Yellow

Appearance Clear Hazy

Specific Gravity 1.005-1.025 1.025

pH 4.5-7 6.0

Glucose Absent NEGATIVE

Protein NEGATIVE

Microscopic

RBC 0-5/HPF 0-3

WBC 0-5/HPF 3-6

Amorphous Rare FEW

Epithelial cells Rare FEW

Bacteria None FEW

FUNCTIONAL STATUS

ADL’s Independent Requires Assistance Type of Assistance

Ambulation /

Transfer /

Toileting /

Eating /

Dressing /

Bathing /

Grooming /

3. Nutritional Diet

Diet Diet as Tolerated and iron -rich foods

Height and Weight 5’4’’ and 67kg

NUTRITIONAL INTAKE AND EATING HABITS

Eat foods that are rich in iron such as camote tops,fish, shellfish and liver. Intake

of iron supplement is needed as it helps the immune system and is needed for

increase hemoglobin.
4. Sensory and Physical Impairment

Type of Impairment Complete Loss

Prosthesis /

Sight /

Hearing /

Speech /

Paralysis /

Bladder Incontinence /

5. Psychological Status

The patient is conscious and well oriented to time, place and date and events that

has happened yesterday. She responds to questions being asked, expresses her feelings

and concerns regarding her hospitalization. She communicates to the health care

provider and significant others regarding her needs.

6. Special Treatment

Patient is not having any special treatment or any procedure upon discharging.

7. Dental Status

Teeth Yes No Upper Lower

Dentures Yes No

Condition of teeth/ gums

Patients gums are in good condition, gums are pale. She has no dentures and

has presence of decay in upper and lower molar.

8. Activity potential and Rehabilitation potential

Encouraged patient to walk, sit and bed side lying. Instructed patient to do deep

breathing exercise and take medications prescribed by the physician. Patient is

collaborative during the care.

9. Cognitive Status

Patient’s cognitive status is stable. She is able to understand health teachings,

instructions and answers questions being asked. She is able to ask questions for

further understanding.
10. Discharge Drug Therapy

11. Post discharge Plan of Care

-Health Teachings

M.E.T.H.O.D.S

Medications

-Instruct patient to take the medications prescribed by the physician and to take

note on the dosage, action, contraindications and its side effects.

-Proper timing and dosage of ferrous sulfate is important for the drug to be

effective. It should be taken once a day 15-30 minutes after meal.

-Take missed doses as soon as remembered within 12 hr; otherwise, return to

regular dosing schedule. Do not double doses.

-Warn the patient for side effects such as stools may be dark green or black

-Instruct the patient to report if there are any adverse effects observed

Environment and Exercise

-Tell patient to avoid doing any strenuous activities

-Instruct patient to have proper bed rest and stay in a quiet place for fast

recovery
Treatment

-Discuss the purpose of medications

-Tell patient to submit self to diagnostic examination to make sure ones health

status and to make sure that she is not having any complication

-Instruct the patient to follow physicians orders and any health care team that

aims for the promotion of health.

Health Teaching

-Encourage patient to provide adequate rest and have 8 hours of sleep every day

-Instruct not to do any strenuous activities

-Encourage to eat healthy foods especially foods that are rich in iron

-Educate patient to perform proper hygiene

-Advise patient to have follow up check ups

-Proper timing of Ferrous Sulfate, It should be taken once a day 15-30 minutes

after meal.

Outpatient Referral

-Remind patient to have follow up check-ups to monitor patients health status

and to maintain optimum balance of wellness.

 -Inform patient to report if there are any side effects or abnormalities observed

at home to avoid any further complications.

Diet

-Advised patient to healthy foods , especially those rich in iron

-Encourage to eat healthy foods such as green leafy vegetables, liver , shellfish

-Having vitamin C with iron-rich foods will help to absorb the iron more easily. -

Serve up meals with plenty of vegetables and fruit or have a glass of orange

juice with your meal.

-Drink 8-10 glasses of water everyday

Spiritual

-Advised patient to attend regular masses every Sunday

13. Aid provided to Client/ Family in Arranging Post-Discharge Plan

Client/ Patient Name Medical Record # Attending Physician

L.J.Q. 00000000072914 Dr. Swiert B. Lorenzo