Fluid Therapy

Kinds of
Nursing Intervention and
Date Ordered: Fluid Types and Purpose of Fluid:
Responsibilities:
(ml/L):

1. August 10, 1. PLRS 1. Isotonic 1. Use sterile technique in venipuncture

2010 2. PNSS 2. Uses: and equipment assembly, with all
2. August 13, a. Used mainly to supply water. venipunctures.
2010 b. Vehicle for mixing medications for 2. Do not administer quantity in excess of
I.V. delivery for all age groups. that required to keep vein open or
c. Replaces fluid and electrolytes. administer appropriate dose of
medication.
3. Do not use solution if outdated, cloudy
or the seal is not intact, as with all IV
solutions.
4. Monitor blood pressure, pulse rate and
respiratory rate frequently.
5. Regulate IV drip.
Diet Therapy
Date Ordered: Type of Diet: Purpose of Diet:
Augus 10, 2010 DAT  To meet the nutritional
needs of the client by
supplementing foods that
the patient can tolerate.
 Helps the client to easily
digest the food
 It provides the essential
nutrients in the form of
liquids and semisolid
foods, such as milk and
fruit juices, it is commonly
recommended for people
who have gastrointestinal
(GI) disturbances
XIII. Laboratory Studies
Nursing Responsibilities and
Intervention:
 The nurse should remind or
guide for the right food intake
of the client such as mashed,
boiled, or baked potatoes,
wheat, corn, or rice cereals.
 Advise the client to avoid
ketchup and other tomato
products, citrus fruits,
chocolate, mint, spicy foods,
alcohol, and caffeine.
 The nurse should explain to
the client what soft diet is.
 Educate the patient of the
purpose and importance of
the diet.
 Type of Nursing
Date Normal Values: Result: Significance:
Laboratory Test: Interventions:
Ordered:

June 28, Hgb M: 14 – 16.5g/dl 20.6 g/dl Elevated  Discomfort or

2010 bruising may
F: 11.5 – 15. 5g/dl
occur at the
Hct M: 0.42 – 0.52 0.62 High puncture site.
 Applying
F: 0.37 – 0.47
pressure to the
o
RBC M: 4.5-6.5x10/L 6.85 x10 /L High puncture site
until the
(Erythrocyte No. F: 3.9-5.6x10o/L
bleeding stops
Conc.)
helps to
WBC reduce
5-10 x10o/L *No result *No result
bruising
(Leucocyte No.
Conc)  Apply warm
packs to
relieve
discomfort.
Differential Count: 0.40-0.60 0.96 Increased due to
inflammatory
 Segments
response

Elevated
0.10-0.20 0.40

 Lymphocyte
s

0.01-0.03 *No result *No result

 Eosinophils 0.02-0.05 *No result *No result

 Stabs
0.02-0.06 *No result *No result
 Monocyte
 Basophil 150-450 x10o/L 202 Normal

Platelet

M: 0-9mm/hr *No result *No result

 ESR F:0-20 mm/hr *No result *No result

3-5 min 6 mins Prolonged due to

decreased vit. K
Clotting Time

*No result *No result

Bleeding Time

Type of Normal Values: Result: Significance: Nursing

Laboratory Test: Interventions:
Date
Ordered:

June 30, Hgb M: 14 – 16.5g/dl 22.0 g/dl Elevated  Discomfort or

2010 bruising may
F: 11.5 – 15. 5g/dl
occur at the
Hct M: 0.42 – 0.52 0.67 High puncture site.
 Applying
F: 0.37 – 0.47
pressure to the
o
RBC M: 4.5-6.5x10/L 6.92 x10 /L High puncture site
until the
(Erythrocyte No. F: 3.9-5.6x10o/L
bleeding stops
Conc.)
helps to
WBC reduce
5-10 x10o/L *No result *No result
bruising
(Leucocyte No.
Conc)  Apply warm
packs to
relieve
discomfort.

Differential Count:
  Segments 0.40-0.60 0.94 Increased due to
inflammatory
response

Elevated
 Lymphocyte 0.10-0.20 0.35
s

 Eosinophils 0.01-0.03 *No result *No result

 Stabs
0.02-0.05 *No result *No result
 Monocyte
 Basophil 0.02-0.06 *No result *No result

150-450 x10o/L 202 Normal

Platelet

M: 0-9mm/hr *No result *No result

ESR
 F:0-20 mm/hr *No result *No result

Clotting Time 3-5 min 5.4 mins Prolonged due to

decreased vit. K

Bleeding Time *No result *No result

Type of Normal Values: Result: Significance: Nursing

Laboratory Test: Interventions:
Date
Ordered:

June 28, Prothrombin Time 14.2 -18.2 secs 20.2 secs Prolonged  Explain the
2010 importance of
the procedure
Control 0.85 – 1.15 secs 1.65 secs Prolonged
to the client
 Discomfort or
INR 0.l86 – 1.15 secs 1.16 Prolonged bruising may
occur at the
puncture site.
Activity % 82 – 100% 76% Prolonged
 Apply warm
packs to
relieve
discomfort.

Type of Normal Values: Result: Significance: Nursing

 Date Laboratory
Interventions:
Ordered: Test:

June 29, FBS 3.9-5.8 mmol/L 8.7mmol/L Increased (may  Explain the
2010 indicate DM) importance of
the procedure
to the client
Creatinine 5.3-115 ummol/L 127.6 ummol/L Increased (Poor  Discomfort or
kidney function) bruising may
occur at the
puncture site.
Elevated (Poor
BUN 2.6 – 6.5 7.21  Apply warm
kidney function)
packs to
relieve
Potassium 3.5 – 5.31 4.22
Normal discomfort.

Sodium 135 – 148 mmol/L 141.2 mmol/L

Normal
 Type of
Nursing
Date Laboratory Normal Values: Result: Significance:
Interventions:
Ordered: Test:

June 28, Color Straw-amber Yellow Normal  Send the urine

2010 to the
laboratory
Transparency Clear Slight turbid Normal
within 5 – 10
mins after
Reaction Acidic Acidic Normal voiding
 Explain the
importance of
Specific Gravity 1.010-1.020 1.030 Elevated
the procedure
to the client
WBC 0 – 2hpf 2 – 4hpf Normal  Educate the
client on
importance of
Albumin 0–2 4–6 Elevated
getting mid-
stream urine.
 RBC 0-2hpf 1-2 hpf Normal

Glucose Negative Negative Normal

Epithelial cells Negative Positive Abnormal

Cast None-few Coarse Granular Abnormal

Amorphous 0–2 1-4 Normal

urates
 Type of
Nursing
Date Laboratory Normal Values: Result: Significance:
Interventions:
Ordered: Test:

June 28, SGOT/AST 40 U/L 126 U/L Elevated  Explain the

2010 importance of
(May indicate
the procedure
Liver
to the client
inflammation or
 Discomfort or
MI)
bruising may
occur at the
puncture site.
SGPT/ALT 38 U/L 54.7 U/L Elevated
 Apply warm
(May indicate packs to
Liver relieve
inflammation or discomfort.
MI)