RAD RLE Guide

Name of Student : AGOT ANGEL MAY P. Section : BSN 2-2-4

Concept : ________________
Name of Clinical Instructor : JESSEL SEBOA Occupation:Teacher Religion:Roman Catholic
Patients Data: Nationality: Filipino
Name::Celeste Empuerto Maraguinot Source Data:
Gender: Female Date&Time of Admission:2/18/20 7:15 PM
Birth Date: May 16, 1999 Attending Physician:Dr.Seboa
Birth Place: Cebu City Diagnosis:
Age: 21
Address: Canduman, Mandaue City
Educational Level : College_
Marital Status: Married
Chief Complaint:Headache 2 days
LMP: 6/5/19
EDC: 3/8/20
AOG: 36 ³/₇
S: 2 days PTA patient felt mild headache, dizzy and light headed, she did not check her blood pressure. No medication taken,
condition tolerated, duration only in minutes.
1-day PTA patient was at work (elementary teacher) when she suddenly felt light headed, dizzy, with headache, now more
intense, she took her blood pressure and it was 140/90. Patient went home and had rest.
3H PTA sought consult with a private doctor, BP:150/90 and was advised for admission.

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O: awake, alert, pink palpebral conjunctiva, clear breath sounds, equal chest expansion, dynamic precordium, no murmur,
gravida linea nigra, no contractions, FH: 33 cm, FHT 128 BPM
A: G₁P₀ PU 36 ⁶/₇ weeks AOG, LMP, Mild Preeclampsia
Anatomy & Physiology
(This will show a drawing of the organ affected related to the diagnosis of the patient.)

Followed by:
HEAD
Head, in human anatomy, the upper portion of the body, consisting of the skull with its coverings and contents, including the lower jaw. ... The term
also is used to describe the anterior or fore part of animals other than humans. human skull. (Left) Lateral and (right) frontal views of the human skull.
MIGRAINE
Migraine is a neurological condition that can cause multiple symptoms. It's frequently characterized by intense, debilitating headaches. Symptoms may
include nausea, vomiting, difficulty speaking, numbness or tingling, and sensitivity to light and sound. Migraines often run in families and affect all ages.

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LABORATORY TEST
Date Type of exam Patient’s Result Normal Values Significance / Interpretation

12/03/2020 CBC WBC: 13.3 4.4-11.0 HIGH WBC LEVEL

RBC:4.03 4.5-5.1
HGB: 12.4 12.3-15.3
HCT:38.3 35.9-44.6
MCV:95 80-90 HIGH MCV LEVEL
MCH:30.8 27.5-33.2
MCHC:32.4 32.0-36.0
RDW:12.1 11.6-14.8
12/03/2020 Urinalysis MICROSCOPIC
Color: YELLOW Yellow
Volume :30
Transparancy: HAZY Clear /transparent Hazy Urine may Indicate Mild Dehydration.
Specific Gravity: 1.010 1.003-1.035
CHEMICAL EXAMINATION
Albumin: NEGATIVE
pH:6.5 4.5-8.0
Ketone:3+
Blood: NEGATIVE
Glucose: NEGATIVE
Nitrite: NEGATIVE
Bilirubin: NEGATIVE
Urobilinogen:NORMAL

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Diagnostic Tests

Date Type of test Patient’s result Significance/ interpretation

12/03/2020 HGT 103mg/dL The 103 mg/dL blood sugar level was from a Fasting Glucose Test,
then it may indicate prediabetes.

Problem List

Number of Priority Focus / Nursing Diagnosis

1
Felt mild headache, dizzy and light headed

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Drug Study

Drug name Classification Mechanism of action Indication Contraindication Adverse reaction Nursing
responsibilities
o Generic Name cephalosporin Cephalosporins exert Susceptible mild to patients with CNS: Headache. Before:
Ceferoxime antibiotics bactericidal activity by moderate infections cephalosporin CV:Shortness of breath. - taken on an empty
o Brand Name interfering with bacterial including hypersensitivity or Gastrointestinal: stomach 1 hour before
Ceftin cell wall synthesis and pharyngitis/tonsillitis, cephamycin Abdominal pain, or 2 hours after meals,
o Actual dosage, inhibiting cross-linking of acute maxillary sinusitis, hypersensitivity. abdominal cramps, but may be taken with
route, frequency the peptidoglycan. The chronic bronchitis, acute Cefuroxime should be flatulence, indigestion, food to reduce
500 mg cap BID cephalosporins are also otitis media, used cautiously in mouth ulcers. stomach upset.
thought to play a role uncomplicated skin and patients with Skin and Subcutaneous During:
Tissue Disorders: Rash, -if your symptoms do
skin structure, UTIs, hypersensitivity to
itch. not improve or if they
gonorrhea, early Lyme penicillin.
Renal and Urinary get worse call your
disease
Disorders: Dysuria. doctor.
Reproductive System and After:
Breast Disorders: -Follow the directions
Vaginitis, vulvar itch. on your prescription
OTHERS: Chills, sleepiness, label carefully, and ask
thirst. your doctor or
pharmacist to explain
any part you do not
understand.
-monitor patients
atleast 30minutes.

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Drug Study
Drug name Classification Mechanism of Indication Contraindication Adverse reaction Nursing
action responsibilities
o Generic Name nonsteroidal anti- Mefenamic acid has used for the short-term patients with salicylate CNS:Headache,Dizziness Before:
Mefenamic Acid inflammatory drugs analgesic, anti- treatment of mild to hypersensitivity or NSAID CV: chest pain -Take mefenamic acid
o Brand Name (NSAIDs). inflammatory, and moderate pain from hypersensitivity who shortness of breath with food. This will
Ponstel antipyretic properties. various conditions. It is have experienced weakness on one side of your help to protect your
o Actual dosage, The mechanism of action also used to decrease asthma, urticaria, or body stomach from side-
route, of mefenamic acid, like pain and blood loss from other allergic reactions slurred speech. effects such as
frequency that of other NSAIDs, is menstrual periods.. after taking aspirin or GASTROINTESTINAL GI: indigestion.
500 mg q6 not completely other NSAIDs. Severe, Diarrhea,Stomach During:
understood but involves rarely fatal, Cramps,Vomiting and -if your symptoms do
inhibition of anaphylactoid reactions Nausea. not improve or if they
cyclooxygenase (COX-1 to mefenamic acid have HEPATIC:yellowing of your get worse call your
and COX-2). Mefenamic been reported in such skin or whites of your eyes doctor.
acid is a potent inhibitor patients. flu-like symptoms, such as After:
of prostaglandin fever, chills, and -Follow the directions
synthesis in vitro body ,aches,tiredness,nausea, on your prescription
pain in the upper part of your label carefully, and ask
stomach,Itching your doctor or
MUSCULOSKELETAL: pharmacist to explain
Inflammation Of The ,Tissue any part you do not
Lining The Sinuses ,Joint Pain understand.
DERMATOLOGY: -monitor patients
Reddening, blistering, or atleast 30minutes.
peeling skin..

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Drug Study
Drug name Classification Mechanism of Indication Contraindication Adverse reaction Nursing
action responsibilities
Generic name: Iron Products An essential mineral Prevention and treatment of an overload of iron in CNS:seizures,dizziness, Before:
Ferrous Sulfate found in iron vitamin and dietary the blood. a type of Headaches,syncope Assess for level of
(Beniforte) hemoglobin,myoglobin deficiency anemias;used in blood disorder where pain relief and
Brand name: and many enzymes. anemia due to blood loss the red blood cells burst CV: hypotension administer prn dose
Slow FE, Fer-In- Enters the bloodstream during menstruation,infections called hemolytic anemia. Hypertension,tachycardia as needed but not to
Sol, Feratab, and is transported to the surgery, an ulcer from too much exceed the
Iron, Mol-Iron, organs of the delivery,intoxication,parasitosis stomach acid. a type of recommended total
Feosol, and
reticuloendothelial or other causes and anemias stomach irritation called GI: daily dose.
MyKidz Iron 10
system(liver,spleen,bone during pregnancy gastritis. nausea,constipation,dark
marrow) where it is Stools, diarrhea vomiting During:
Actual dosage,
route, frequency separated out and -if your symptoms do
1 Cap OD becomes part of iron DERMATOLOGIC: flushing, not improve or if they
stores. urticaria get worse call your
doctor.
After:
-wear a medical
bracelet in giving
medications.
-Monitor vital signs
atleast 30 minutes.

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Drug Study
Drug name Classification Mechanism of action Indication Contraindication Adverse reaction Nursing
responsibilities
o Generic Name Vitamins and helps to regulate the calcium is indicated for Patient with arcoidosis. CNS: A Migraine Before:
calcium minerals. release and storage of hypocalcemia (e.g. in increased activity of the Headache,Dizziness,Stroke. Educate patient about
o Brand Name neurotransmitters and neonates and for parathyroid gland. GASTROINTESTINAL GI: the medications and
Citracal + D, Os- hormones, the uptake hypocalcemic tetany). high amount of calcium in Stomach upset, flatulence the name of the drugs.
Cal, Oyster Shell + and binding of amino Intravenously the blood. or bloating. During:
D. acids, absorption of administered calcium is Dehydration, DERMATOLOGY: -if your symptoms do
o Actual dosage, vitamin B 12, and gastrin also used for Constipation,kidney Itchy skin rashes over your not improve or if they
route, frequency. secretion. hyperkalemia, stones are unable to take whole body. get worse call your
1 tab BID hypermagnesemia, and this vitamins. doctor.
during bypass operations. After:
-Follow the directions
on your prescription
label carefully, and ask
your doctor or
pharmacist to explain
any part you do not
understand.
-monitor patients
atleast 30minutes.

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Nursing Care Plan

Defining Nursing Diagnosis Scientific Analysis Goal of Care Intervention Rationale

Characteristics
Vital Signs: Felt mild headache, dizzy and Headaches that are accompanied by To ease the Independent: To determine the
T:37.1 light headed related to chemical fever, stiff neck, confusion, decreased pressure of head Monitor temperature, pulse, underlying cause of pain
RR:24 activity in the brain. alertness or memory, or neurological respiration, and white blood and treat accordingly.
BP:150/90 symptoms such as visual disturbances, cells as indicated.
HR:94 slurred speech, weakness, numbness, To assist in evaluating
O2 Sat: 98 or seizures. Dependent: impact of pain on client’s
Make evaluation and assist the life.
patient
Collaborative:
If the headache is getting worse .
you may call the physician to
examine the cause .

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FDAR

It is a method of charting nurses use, along with other disciplines, to help focus on a specific patient problem, concern, or event. It is
geared to save time and decrease duplicate charting. It is a great charting method for nurses who have a lot of patients and is easier read by
other professionals. It gives other professionals a snapshot of what went on during your shift in a concise manner.

Date Focus Time DAR

12/03/2020 7:15PM D: patient complaints 2days headache.
Felt mild headache, dizzy and light Vital Signs:
headed T:37.1
RR:24
BP:150/90
HR:94
O2 Sat: 98
A:encourage the patient to verbalize feelings

R : Encouraged adequate rest,Encouraged adequate oral fluid intake and

monitor vital signs.

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Discharge Planning (SAMPLE)

AMETHOD of discharge planning was developed and modified to provide a systematic method for ensuring client’s needs during the
termination phase of hospitalization. The AMETHOD represent areas the nurse should consider before the client goes home. The Discharge plan
follows the FDAR format. AMETHOD is placed in the Implementation.

Date Focus Time DAR

12/03/2020 Discharges instructions 7:15PM D: With discharge order from attending physician Dr.Seboa

A: A ctivity: Bed rest: You may need to stay in bed all the
time. You will be allowed to get up briefly to go to the
bathroom.
M – advised SO to give the ff. meds at the right time,
dose, frequency and route
E – encouraged to maintain cleanliness of the house and
surroundings
T – advised to go to follow-up consultations on the
prescribed date
H – encouraged to do chest tapping to facilitate
mobilization of secretion
O – observed for signs of super infections such as fever,
black fury tongue and foul odor discharges
D – encouraged to eat fresh vegetables and fish
R:patient will be able to go back to doing her ADL without
uneasiness.

Bibliography (a summary of all the resources used)

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