نسخة Weekly Report Nur 423 2021

King Saud University
College of Nursing
2ND
Semester SY 1441 – 1442
(2020– 2021)
NURS 423 CLINICAL PACKAGE
Weekly report
(To be submitted before the next class)
Student Name: ______________Area __________Room/bed No._________
Diagnosis: ____________________________ Date: __________________ Week#_________
Marks Student
marks
1. Physical assessment sheet 2
2. Laboratory and Diagnostic 1
Tests
3. Nursing care plan 4
4. Medication 3
TOTAL 10
/2=5
Physical assessment
RM # Area Critical \ ER ----- bed# Admission Unit: CCU(coronary care Wt: 85KG
-------- Sex: male M\F day: unit) Height: 170CM
Age: 58Y/O 02 BMI: 29 (overweight)
MARCH 2020 @
13:08 pm Triage level in ER dep.:
DX: Isolation: Allergies: un known allergies

Acute Stander precaution
coronary syndrome, heart failure
.
Lines: CVP: V/S 0800 0900 1000 1100 1200
NUR 423 Medical-Surgical Dept.

College of Nursing
2ND
(2020– 2021)
Art lines: PA pressure: T 36.9 C

PA cath:
HR 70b/m
IV Site:
PICC: 118\76mm
CVC: BP
of mm Hg
Note:
Location, the condition of them, and when the SPO2 Spo2: 98%
dressings were last changed
Orders to flush central/hep FSBS
Neuro: Cardio: Pulse: 80 b/m O2. 95%
Cognitive: alert and oriented Strength: bounding +3 RA …… NC ……L
Patient is oriented to time, place and person Rhythm: rregular Lung Sounds
SR rhythm with ST elevation Rate: 20 cycle/min
BP: 124/81 mmHg
Rhythm: regular rhythm
Mental: age appropriate Heart sound: Pattern: no more tachypnea
Behavior: Normal facial expression, comfortable rregular or bradypnea, Crackles arepresent, respiration
mode and normal speech arerelaxed, effortless, and quiet
Tele (ECG): yes Breathing Sound: adventitious sounds hear in both
lower lung crackles
Secretion:
clear secretion no more Oder, thick
Speech: normal , time speaks, clearly Edema - 2+Slight indentation,15
without seconds to rebound
any difficulty.
PUPILS: R___ pupil equal round reacts to Cough

Location of edema:
light and a commands. In booth feet
Trach
Suction
L ___ pupil equal round reacts to Ventilation mood setting
light and a commands.

College of Nursing
2ND
(2020– 2021)
Peripheral pulse: Chest tube:

(Strength/Regularity)
GCS 15/15 UR LR
ABG:
Eye opening :4
Best verbal response:5oriented to
person, time, and place
Best motor response obeys commands :6 UL LL PH: 7.12 ( low , acidosis)
HCO3 : 21 mmol/l(low, acidosis metabolic)
PCO2: 45 MMHg( normal)
Grades of Best Motor Response
6 Carrying out request ('obeying
command') -patient does simple things Interpretation: uncompensated acidosis metabolic
you ask.
5 Localising response to pain.
4 Withdrawal to pain - pulls limb away
from painful stimulus.
3 Flexor response to pain - pressure on
nail bed causes abnormal flexion of
limbs - decorticate posture.
2 Extensor posturing to pain - stimulus
causes limb extension - decerebrate
posture.
1 No response to pain.
Grades of Best Verbal Response

5 Oriented - patient knows who and
where they are, and why, and the year,
season and month.
4 Confused conversation - patient
responds in conversational manner, with
some disorientation and confusion.

College of Nursing
2ND
(2020– 2021)
3 Inappropriate speech - random or

exclamatory speech, with no
conversational exchange.
2 Incomprehensible speech - no words
uttered, only moaning.
1 No verbal response.
Eye Opening
4 Spontaneous eye opening.
3 Eye opening in response to speech -
that is, any speech or shout.
2 Eye opening in response to pain.
1 No eye opening.
GI Diet: orally normal diet. GU Skin

Urine color
PO. Intake: Color
NPO Output: -- ml\kg\hr Brown, sun exposed area is darker, dry, clean
NPO w/Meds Balance:
NGT FOLEY: Condition
Clean and odor less, poor skin turgor
Fluid Restrictions 24/HR Warm equally.
Last BM: Strict I/O ’s
Dialysis:
Wound
uniformity thin Old scar in the ICD site
Dressing
Drain output…….
College of Nursing
2ND
(2020– 2021)
M/S (Strong, week, par thesis, paralysis) Activity PAIN (PQRSTU)

RU RL LU LL :PT P- stress and not relief by anything, Q- as Pt said sharp like
stabbing, R-left side of chest radiating to left shoulder and left
full mobility for arm, S-8 from 10 in pain scale with dizziness, SOB, diaphoresis,
Brace Cane Walker Wheelchair each joint Range lOC for 1min T- started 11:00a.m. suddenly and
of motion in all continues, U- patient during pain not apple to move or breath
muscle within
normal range,
smooth and
coordinated.
With activity
intolerance.
ECG strip-----------------------------------HR: ----------------- PR interval: -------------- QSR duration: ------------------

Interpretation: --------------------------------------------------

College of Nursing
2ND
(2020– 2021)
______________ Area ______________ Date Submitted______________
Laboratory and Diagnostic studies
I – Laboratory Test Normal Result Significance (your interpretation)

Value
WBC 7.800
A bacterial or viral infection
3,500 to 10,500 * An inflammatory disease such as rheumatoid
cells/mcl arthritis
* An allergy
* Leukemia or Hodgkin disease
* Tissue damage from a burn injury or surgery
If Low
Cancers that affect the bone marrow

* An autoimmune disorder, such as lupus (or SLE)
* HIV/AIDS
Bone marrow damage.
RBC 4,0 TO 5,5 5.3 If high :

million/cu mm
blood congenital heart disease
* dehydration (for example, from severe diarrhoea)

College of Nursing
2ND
(2020– 2021)
* low blood oxygen levels (hypoxia)

* pulmonary fibrosis (a lung condition that
* causes scarring of the lungs)
* Polycythemia vera
If low :
anemia
* bone marrow failure
* erythropoietin deficiency, which is the primary
cause of anemia in patients with chronic kidney
disease
* hemolysis, or RBC destruction caused by
transfusions and blood vessel injury
* internal or external bleeding
* leukemia
* malnutrition
* multiple myeloma, a cancer of the plasma cells
in bone marrow
* nutritional deficiencies, including deficiencies in
iron, copper, folate, and vitamins B-6 and B-12
* pregnancy
* thyroid disorders

College of Nursing
2ND
(2020– 2021)
HGB 120 TO 160 140

Low hemoglobin levels may be a sign of:
* Different types of anemia
* Thalassemia
* Iron deficiency
* Liver disease
* Cancer and other diseases
High hemoglobin levels may be a sign of:
* Lung disease
* Heart disease
* Polycythemia vera,
MCV 80 to 96 fl/red 90
cell in adult
ESR 20mmlh 46
If your ESR is high, it may be related to an

inflammatory condition, such as:
* Infection
* Rheumatoid arthritis
* Rheumatic fever
* Vascular disease
* Inflammatory bowel disease
* Heart disease
* Kidney disease
* Certain cancers
Sometimes the ESR can be slower than normal. A
College of Nursing
2ND
(2020– 2021)
slow ESR may indicate a blood disorder, such as:

* Polycythemia
* Sickle cell anemia
* Leukocytosis, an abnormal increase in white
blood cells
Troponin
0.1mg\ml 1.843.40
If even a small level of troponin is found in your
blood, it may mean there is some damage to your
heart. If high levels of troponin are found in one or
more tests over time, it probably means you had a
heart attack. Other reasons for higher than normal
troponin levels include:
* Congestive heart failure
* Kidney disease
* Blood clot in your lungs
Chol 5.2mmol\L 8.20
HDL
1.0mmol\l 1.21
LDL 5.18
2.6mmol\l
Trig 1.69 1.78
Albumin 40g\l 30.42

If your albumin levels are lower than normal, it
may indicate one of the following conditions:
* Liver disease, including cirrhosis
* Kidney disease
College of Nursing
2ND
(2020– 2021)
* Malnutrition
* Infection
* Inflammatory bowel disease
* Thyroid disease
Higher than normal levels of albumin may indicate
dehydration or severe diarrhea.
Alk phos 211
19-146 iu\l
from. High alkaline phosphatase levels in the liver
can indicate:
Cirrhosis
Hepatitis
A blockage in the bile duct
Mononucleosis, which can sometimes cause
swelling in the liver
There are several other types of blood tests that
check your liver function. These include bilirubin,
aspartate aminotransferase (AST), and alanine
aminotransferase (ALT) tests. If these results are
normal and your alkaline phosphatase levels are
high, it may mean the problem is not in your liver.
Instead, it can indicate a bone disorder, such as
Paget's Disease of Bone, a condition that causes
your bones to become abnormally large, weak, and
prone to fractures.

College of Nursing
2ND
(2020– 2021)
Moderately high levels of alkaline phosphatase

may indicate conditions such as Hodgkin
lymphoma, heart failure, or a bacterial infection.
Low levels of alkaline phosphatase may indicate

hypophosphatasia, a rare genetic disease that
affects bones and teeth. Low levels may also be
due to a deficiency of zinc or malnutrition. To
learn what your results mean, talk to your health
care provider.
BUN 0.7mg\dl 8.2
Higher BUN levels can indicate:
heart disease
congestive heart failure
a recent heart attack
gastrointestinal bleeding
dehydration
high protein levels
kidney disease
kidney failure
dehydration
obstruction in the urinary tract
stress
shock
Keep in mind that some medications, such as
College of Nursing
2ND
(2020– 2021)
certain antibiotics, can raise your BUN levels.
Lower BUN levels can indicate:
liver failure
malnutrition
severe lack of protein in the diet
overhydration
Potassium 4.8mmol\l 4.5
Too much potassium in the blood, a condition
:known as hyperkalemia, may indicate
* Kidney disease
* Burns or other traumatic injuries
* Addison's disease, a hormonal disorder that can
cause a variety of symptoms including weakness,
dizziness, weight loss, and dehydration
* Type 1 diabetes
* The effect of medicines, such as diuretics or
antibiotics
* In a rare instances, a diet too high in potassium.
Potassium is found in many foods, such as
bananas, apricots, and avocados, and is part of a
healthy diet. But eating excessive amounts of
potassium-rich foods can lead to health problems.
Too little potassium in the blood, a condition
:known as hypokalemia, may indicate
College of Nursing
2ND
(2020– 2021)
* A diet too low in potassium

* Alcoholism
* Loss of bodily fluids from diarrhea, vomiting, or
use of diuretics
* Aldosteronism, a hormonal disorder that causes
high blood pressure
Sodium 135mmol\l 140
If your results show higher than normal sodium

levels, it may indicate:
* Diarrhea
* A disorder of the adrenal glands
* A kidney disorder
* Diabetes insipidus, a rare form of diabetes that
happens when the kidneys pass an unusually high
volume of urine.
If your results show lower than normal sodium
levels, it may indicate:
* Diarrhea
* Vomiting
* Kidney disease
* Addison disease, a condition in which your
body's adrenal glands don't produce enough of
certain types of hormones
* Cirrhosis, a condition that causes scarring of the
College of Nursing
2ND
(2020– 2021)
liver and can damage liver function

* Malnutrition
* Heart failure
Date Finding:
II – Diagnostic Test
Chest XRAY Chest show mild plural effusion a
.
ECG
Echocardiogram
No thrombus, sever LV dysfunction, EF15%
CT brain Normal
may indicate hypertrophy, ischemic change, infraction, or tachycardia.

reveal left ventricle hypertrophy, dilation, & abnormal contractility, EF≤15%.
List of actual nursing diagnosis (priority):
1-
2-
3-
4-
5-

College of Nursing
2ND
(2020– 2021)
Nursing Care Plan 1(actual)

Patient Name: _____________________ Room/Bed NO: ____________ Diagnosis: ________________________
Assessment Nursing diagnosis Goals Interventions Evaluation
Subjective data. -Patient will -Record urine output. Determine -
demonstrate how often the patient urinates.
 -Blood pressure
adequate
-Monitor electrocardiogram (ECG) within a normal
Objective data. cardiac output range for the
for, rate, rhythm, and ectopy.
patient
Check the pulse  Pulse steady
and within 60-
Measure heart rate 100 beats per
-Assess mental status and level minute
of consciousness.  Breathing is
-Measure oxygen saturation with pulse unlabored
oximetry  Urine output at
least 30 ml/hour
-Assess the skin's appearance and  Patient feels less
temperature weak and
fatigued
-Note respiratory rate, rhythm and  No dizziness or
breathing sounds confusion
 Skin is warm
-Check blood pressure and usual color

College of Nursing
2ND
(2020– 2021)
- -
- -
- -
-
-
-
-
-
-
Nursing Care Plan 2(actual)

Patient Name: _____________________ Room/Bed NO: ____________ Diagnosis: ________________________
Subjective data. - - -Assess respirations: note quality, rate, -
pattern, depth, and breathing effort. -
-
-Monitor vital signs. -
Objective data. -Assess for changes in -
orientation and behavior. -
-.Monitor arterial blood gases (ABGs) -
and note changes. -
-Use pulse oximetry to monitor O2 -
saturation and pulse rate continuously. -
-
-Use pulse oximetry to monitor
O2 saturation and pulse rate
continuously.
-
-Position with proper body alignment for
College of Nursing
2ND
(2020– 2021)
optimal respiratory excursion (if tolerated,

head of bed at 45 degrees).
-Suction as needed.
-Encourage deep breathing, using

incentive spirometer as indicated.
Nursing Care Plan 3(actual )

Patient Name: _____________________ Room/Bed NO: ____________ Diagnosis: _____________

College of Nursing
2ND
(2020– 2021)
Subjective data. - - - -
- -
- -
- -
Objective data. - -
- -
- -
- -
- -
- -
- -
Nursing Care Plan 4 (potential)


College of Nursing
2ND
(2020– 2021)
- -
- -
- -
Objective data. - -
- -
- -
- -
- -
- -
- -
Nursing Care Plan 5 (potential)


College of Nursing
2ND
(2020– 2021)
- -
- -
- -
Objective data. - -
- -
- -
- -
- -
- -
- -
List of patient medication:
1-
2-
3-
4-
5-
6-
7-

College of Nursing
2ND
(2020– 2021)
Medication sheet 1
Patient Name &ID: …………………………………….. Room/bed NO: …………… Diagnosis: …………………..……

Name of dug Classification / Indication Side effects Nursing role Evaluation
dose Action of the
route drug
frequency
- -Chemical class: CNS: Confusion, Advise adult patient
Salicylate It is used to CNS depression taking low-dose
- Therapeutic EENT: Hearing aspirin not to also
treat
class: Anti- loss, tinnitus take ibuprofen
- inflammatory, rheumatic GI: Diarrhea, GI because it may
antiplatelet, fever. bleeding, reduce the
antipyretic, heartburn, cardioprotective and
nonopioid It is used to hepatotoxicity, stroke preventive
analgesic ease pain nausea, stomach effects of aspirin.
and fever. pain, vomiting •Instruct patient to
HEME: Decreased take aspirin with food
It is used to blood iron level, or after meals
leukopenia, because it may cause
-Blocks the
treat some prolonged GI upset if taken on
activity of types of bleeding time, an empty stomach.
cyclooxygenase arthritis. shortened life •Caution patient not
, the enzyme span of RBCs, to take Durlaza

College of Nursing
2ND
(2020– 2021)
needed for It is used to thrombocytopenia 2 hours before or 1

prostaglandin RESP: hour after consuming
protect
synthesis. Bronchospasm alcohol. Also advise
Prostaglandins, bypass SKIN: him to take the
important grafts and Ecchymosis, capsule with a full
mediators in the stents in rash, urticaria glass of water at the
inflammatory Other: same time every day
the heart.
response, cause Angioedema, and to swallow the
local It is used to Reye’s syndrome, capsule whole.
vasodilation salicylism (CNS •Instruct patient to
with swelling lower the depression, stop taking aspirin
and pain. With chance confusion, and notify prescriber
blocking of of heart diaphoresis, if any symptoms of
cyclooxygenase attack, diarrhea, difficulty stomach or intestinal
and inhibition of hearing, bleeding occur such
prostaglandins, stroke, and dizziness, as passage of bloody
inflammatory death in headache, or tarry stools or if
symptoms some hyperventilation, patient is coughing
subside. Pain is people. lassitude, tinnitis, up blood or vomit
also relieved and vomiting) that looks like coffee
because grounds.
prostaglandins •Advise patient with
play a role in tartrazine allergy not
pain to take aspirin.
transmission •Tell patient to
from the consult prescriber
periphery to the before taking aspirin
spinal cord. with any prescription
Aspirin inhibits drug for blood
platelet disorder, diabetes,

College of Nursing
2ND
(2020– 2021)
aggregation by gout, or arthritis.

interfering with •Tell patient not to
production of use aspirin if it has a
thromboxane strong vinegar-like
A2, a substance odor.
that stimulates
platelet
aggregation.
Aspirin acts on
the heat-
regulating
center in the
hypothalamus
and causes
peripheral
vasodilation,
diaphoresis, and
heat loss.
Medication sheet 2
Patient Name &ID: …………………………………….. Room/bed NO: …………… Diagnosis: …………………..……

Name of Classification / Indication Side effects Nursing role Evaluation
drug Action of the
dose Drug
route
frequency
- -Chemical class: To control CNS: Asthenia, peripheral
Nonselective hypertension depression, vascular disease

College of Nursing
2ND
(2020– 2021)
beta- adrenergic dizziness, fatigue, because it may

- blocker with As adjunct to fever, headache, aggravate
alpha1- treat mild to hypesthesia, symptoms of
adrenergic severe heart hypotonia, arterial insuf-
- blocking activity failure of insomnia, light- ficiency. In
Therapeutic ischemic or headedness, patients with
class: cardiomyopathi malaise, diabetes mellitus it
Antihypertensive c paresthesia, may mask signs of
, heart failure origin somnolence, hypoglycemia,
treatment stroke, syncope, such as
adjunct vertigo tachycardia, and
CV: Angina, AV may delay
block, recovery.
bradycardia, •Monitor patient’s
edema, heart blood glucose
-Reduces cardiac failure, level, as ordered,
output and hypertension, during carvedilol
tachycardia, hyper- therapy because
causes triglyceridemia, drug may alter
vasodilation, and orthostatic blood glucose
decreases hypotension, level.
peripheral palpitations, warning Avoid
vascular peripheral stopping drug
resistance, which vascular disorder abruptly in
reduces blood EENT: Blurred patients with
pressure and vision, dry eyes, hyperthyroidism
cardiac periodontitis, because thyroid
workload. When pharyngitis, storm may occur,
given for at least rhinitis and in patients
4 weeks, ENDO: with angina

College of Nursing
2ND
(2020– 2021)
carvedilol Hyperglycemia, because it may

reduces plasma hypoglycemia worsen or MI may
renin activity. GI: Abdominal occur.
pain, diarrhea, •Know that if
elevated liver patient has heart
enzymes, failure, expect to
jaundice, melena, also give digoxin,
nausea, vomiting a diuretic, and an
GU: Albuminuria, ACE inhibitor.
hematuria, •Be aware that
elevated BUN and chronic beta
creatinine levels, blocker therapy
impotence, such as carvedilol
incontinence, is not routinely
renal with- held prior to
insufficiency, UTI major surgery
HEME: Aplastic because the
anemia, decreased benefits outweigh
PT, the risks
thrombocytopenia, associated with its
unusual bleeding use with general
or bruising anesthesia and
MS: Arthralgia, surgical
arthritis, back procedures.
pain, muscle
cramps
RESP: Dyspnea,
increased cough,
inter- stitial
pneumonitis

College of Nursing
2ND
(2020– 2021)
SKIN: Erythema
multiforme,
pruritus, purpura,
Stevens–Johnson
syndrome, toxic
epidermal
necrolysis,
urticaria
Other:
Anaphylaxis,
angioedema, fluid
overload, gout,
hyperkalemia,
hyper- uricemia,
hyponatremia,
hypovolemia, viral
infection, weight
gain or loss
Medication sheet 3
Patent Name &ID: …………………………………….. Room/bed NO: …………… Diagnosis: …………………..……
Name of Classification / Indication Side effects Nursing role Evaluation
Drug Action of the
Dose Drug
Route
Frequency
- -Chemical To treat erosive CNS: Anxiety, Ensure the
class: esophagitis asthenia, confusion, continuity of
Substituted associated with depression, gastric acid
benzimidazole gastroesophagea dizziness, fatigue, suppression

College of Nursing
2ND
(2020– 2021)
- Therapeutic l reflux disease fever, hallucinations, during transition

class: (GERD) short- headache, hypertonia, from oral to I.V.
Antiulcer, term hypokinesia, pantoprazole (or
- gastric acid insomnia, malaise, vice versa)
proton pump To treat migraine, because even a
inhibitor pathological somnolence, speech brief interruption
hypersecretion disorder, vertigo of effective
associated with CV: Chest pain, suppression can
Zollinger–Ellison elevated triglycerides, lead to serious
syndrome or hypercholesterolemia complications.
-Interferes with other neoplastic , hyperlipidemia •Don’t give
gastric acid conditions EENT: Anterior pantoprazole
secretion by ischemic optic within 4 weeks of
inhibiting the neuropathy, blurred testing for
hydrogen- To maintain vision, dry mouth, Helicobacter
potassium- healing of erosive increased salivation, pylori because
adenosine esophagitis and pharyngitis, rhinitis, antibiotics,
triphosphatase reduce relapse of sinusitis, taste bismuth
(H+-K+- daytime and disorder, tinnitus preparations,
ATPase) nighttime ENDO: and proton pump
enzyme symptoms in Hyperglycemia inhibitors
system, or patients with GI: Abdominal pain, suppress H.
proton pump, GERD atrophic gastritis, pylori and may
in gastric Clostridum difficile– lead to false-
parietal cells. associated diarrhea, negative results.
Normally, the constipation, Drug also may
proton pump diarrhea, elevated cause false-
uses energy liver enzymes positive results
from HEME: in urine
hydrolysis of Agranulocytosis, screening tests

College of Nursing
2ND
(2020– 2021)
ATPase to leukopenia, for tetrahydro-

drive H+ and pancytopenia, cannabinol.
chloride (Cl–) thrombocytopenia Consult
out of parietal MS: Arthralgia, back guidelines for
cells and into or neck pain, bone pantoprazole use
the stomach fracture, myalgia, before testing.
lumen in rhabdomyolysis
exchange for RESP: Bronchitis,
potassium dyspnea, increased Expect to
(K+), which cough, upper monitor PT or
leaves the respiratory tract INR during
stomach infection SKIN: therapy if patient
lumen and Cutaneous lupus takes an oral
enters parietal erythematosus, anticoagulant
cells. After this erythema multiforme,
exchange, H+ photosensitivity, . Monitor patient
and Cl– pruritus, rash, for bone fracture,
combine in the Stevens–Johnson especially in
stomach to syndrome, toxic patients
form epidermal necrolysis receiving
hydrochloric multiple daily
acid (HCl). doses for more
Pantoprazole than a year
irreversibly because proton
inhibits the pump inhibitors,
final step in such as
gastric acid pantoprazole,
production by increase risk of
+ blocking the osteoporosis-
exchange of related fractures

College of Nursing
2ND
(2020– 2021)
intracellular H of the hip, spine,

and or
extracellular wrist.
K+, thus
preventing H+
from entering
the stomach
and additional
HCl from
forming.

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King Saud University

DX: Isolation: Allergies: un known allergies

Lines: CVP: V/S 0800 0900 1000 1100 1200

NUR 423 Medical-Surgical Dept.

Art lines: PA pressure: T 36.9 C

PUPILS: R___ pupil equal round reacts to Cough

NUR 423 Medical-Surgical Dept.

Peripheral pulse: Chest tube:

Grades of Best Verbal Response

NUR 423 Medical-Surgical Dept.

3 Inappropriate speech - random or

GI Diet: orally normal diet. GU Skin

M/S (Strong, week, par thesis, paralysis) Activity PAIN (PQRSTU)

ECG strip-----------------------------------HR: ----------------- PR interval: -------------- QSR duration: ------------------

NUR 423 Medical-Surgical Dept.

______________ Area ______________ Date Submitted______________

Laboratory and Diagnostic studies

I – Laboratory Test Normal Result Significance (your interpretation)

Cancers that affect the bone marrow

RBC 4,0 TO 5,5 5.3 If high :

NUR 423 Medical-Surgical Dept.

* low blood oxygen levels (hypoxia)

NUR 423 Medical-Surgical Dept.

HGB 120 TO 160 140

If your ESR is high, it may be related to an

slow ESR may indicate a blood disorder, such as:

Trig 1.69 1.78

Albumin 40g\l 30.42

NUR 423 Medical-Surgical Dept.

Moderately high levels of alkaline phosphatase

Low levels of alkaline phosphatase may indicate

certain antibiotics, can raise your BUN levels.

Lower BUN levels can indicate:

* A diet too low in potassium

Sodium 135mmol\l 140

If your results show higher than normal sodium

liver and can damage liver function

may indicate hypertrophy, ischemic change, infraction, or tachycardia.

List of actual nursing diagnosis (priority):

NUR 423 Medical-Surgical Dept.

Nursing Care Plan 1(actual)

NUR 423 Medical-Surgical Dept.

Nursing Care Plan 2(actual)

optimal respiratory excursion (if tolerated,

-Encourage deep breathing, using

Nursing Care Plan 3(actual )

NUR 423 Medical-Surgical Dept.

Nursing Care Plan 4 (potential)

NUR 423 Medical-Surgical Dept.

Nursing Care Plan 5 (potential)

NUR 423 Medical-Surgical Dept.

List of patient medication:

NUR 423 Medical-Surgical Dept.

Patient Name &ID: …………………………………….. Room/bed NO: …………… Diagnosis: …………………..……

NUR 423 Medical-Surgical Dept.

needed for It is used to thrombocytopenia 2 hours before or 1

NUR 423 Medical-Surgical Dept.

aggregation by gout, or arthritis.

Patient Name &ID: …………………………………….. Room/bed NO: …………… Diagnosis: …………………..……

NUR 423 Medical-Surgical Dept.

beta- adrenergic dizziness, fatigue, because it may

NUR 423 Medical-Surgical Dept.

carvedilol Hyperglycemia, because it may

Area Date Submitted__