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Personal Data My patient¶s name is C.T.B she is 54 years old, female. She was born on July 9, 1943. Her civil status is widowed. the family is currently living at Caloocan city.The patient¶s educational attainment is college graduate. the patient and her family are pure Filipino. She and her family are devoted Roman Catholic in religion. The source of information is C.T.B the patient herself. Interviewed was conduct last January 31,2011. I. Chief Compliant ³Nahihirapan akong lumunok kaya hindi ako makakain´ as stated.´ Medical Diagnosis: PeritonsilarAbcess/ Acutetonsilar pharyngitis
History of Present Illness:
Four days prior to admission the patient experienced difficulty of swallowing and inability to eat properly but no actions done. Three days prior to admission the patient still experienced difficulty of ingesting food, she ate soft foods only. Two days prior to admission the patient had phlegm, yellowish secretion and still complains of difficulty in swallowing cough. Prior to admission the patient experienced weakness, difficulty of swallowing and inability to ingest food and the patient has a fever of 37.2 Celsius.
Past Medical History
Client remembered to have experienced measles and chicken pox when she was a child , but she failed to recall the treatment used.she had not experienced serious illness, and hospitalization. Client has no allergies in environment, she also have a complete vaccine of immunization. Client has a vices like drinking alcohol occasionally. She also drink 1 cup of coffee every morning. She take Fern-C to served as her vitamins
INTERPRETATION There are no hereditary disease that the client could acquire from her parents and grandparents. The client could have acquired her disease within their community.
ELIMINATION The patient defecates once a day every morning.V. their income is sufficient in their daily needs and they have children that helps them out in times of difficulties. and there were no difficulties in urination. The patient is Roman Catholic. she doesn¶t use eye glasses. She is not smoking. The patient does not perspire excessively. Role Relationship pattern The patient is widowed . doesn¶t have a work. The patient¶s menarche was when she was 15 years old and she got menopause at 43. the whole family attends mass every Sunday. She is happy and contented in her life. She and her daughter lives in one home. She doesn¶t have any body odor. She urinates 5 to 6 times a day. but she sometimes forget things that she has previously done. There are no religious practices and beliefs that can affect the treatment for her. Her stool is black and has moderate amount. II. Social History The patient is a college graduate. IV. There were no complications when the client gave births and delivered them via NSD. When there are situations that make her angry and worried her husband help him to handle those things and make her calm. a good mother. she doesn¶t have any difficulty defecating. III. y . Self perception-Self concept Pattern She is a simple woman. There are no changes in her memory in the past. Coping Stress Tolerance Pattern When she feels tense and anxious she alleviate them by being relaxed and she talks it with and and sometimes when he¶s not home she just watches comedy movies. Values Belief Pattern The patient is satisfied in her life. Cognitive Perceptual Pattern The patient¶s hearing is quiet impaired but she doesn¶t use any devices. Her family is the most important to her. she also has difficulty visualizing things 12ft away. understanding and loving partner. but they have a small business and that was their source of income. V. she also have some friends who she can talk occasionally. REVIEW OF SYSTE Person¶s Review of System y PSYCHOLOGICAL I. VI. they are her source of energy and inspiration in life. she go to the church every Sunday together with her family. a disciplinarian. Sexuality and Reproductive Pattern the client said that they are old enough for those things.
OXYGENATION The patient has no difficulty in breathing. For her dinner. He has no allergies in food. Their community is well organized. she also takes a nap for about 2-3 hours in the mid afternoon. She does walking before she was admitted in the hospital. She doesn¶t have difficulty sleeping. She doesn¶t cook. SAFETY-ENVIRONMENT The patient lives in urban community. NUTRITION The patient¶s diet is in soft diet. She always watches TV before she sleeps. For her lunch she just has rice soaked in soup and a glass of water. that was the time that she has difficulty in sleeping because of too much thinking then she¶ll talk with her husband and children to have that problem solved. she takes a bath every morning and shower before having a sleep. y y y . her daughter cooks for them. environment and medication. She just ate lugaw for her breakfast and a glass of water. When their family is having problem. she ate II. She eats 3 times a day sometimes with snacks in between. Sleep Rest Pattern She sleeps at about 10:00 o¶clock in the evening and wakes up at 6:00 o¶clock in the morning. REST AND ACTIVITY Activity Exercise Pattern Patient doesn¶t do any form of exercise.y I.
The distal third contains hair follicles and glands with dry cerumen. NAILS The client¶s nail plate shape is convex 160. client can see objects in the periphery. sclera appears white. equal in size. There were no physical deformities noted. smooth and pink in color. When looking straight ahead. Pupil is black in color. Illuminated and nonilluminated pupil constricts. Eyelashes equally distributed. There are no masses. no discharges. and round. Nail bed color is pink and capillary refills within 3 seconds and there is no beau¶s line. the contour is round and symmetrical. Eyelids skin intact. She uses simple words in communicating. Client blinks when the cornea is touched. MENTAL STATUS The client is conscious and well oriented of the time. The client is well groomed. no fouls odor and appropriately dressed. She is able to follow directions and respond when called and he is emotionally cooperative. curled slightly outward. The gait is smooth and rhythmic. smooth and the skin turgor is poor.Physical Assessment GENERAL APPEARNACE Patient has a small frame body build and upright posture. firm and not tender and pinna recoils after it is folded. She has difficulty on recognizing words on her left ear with normal voice and difficulty in both ears in whispered voice. SKIN The skin is light brown in color. Consistency is smooth. warm to touch. She has difficulty in visualizing things12 feet away from her. Pupils constrict when looking at near objects and pupils dilate when looking at far objects. There are no masses on the maxillary and frontal sinuses. mobile. HEAD AND FACE The client¶s skull is appropriate to her body size. with parallel alignment. No leision noted. . Bulbar conjunctiva is transparent. Face is symmetrical and does easy movements. She has a long nails and some what dirty. eyelids close symmetrically. EARS The client¶s ear auricle color is normal racial tone. Hair is evenly distributed and there were no edemas noted. Both eyes coordinate move in unison. place and person around her. Palpebral conjunctiva is shiny. no discoloration. Face shape is round EYES The client¶s eyebrows are evenly distributed with skin intact.
trachea is in the midline and thyroid gland is not palpable. . Muscles have equal strength. Heart sounds are audible on four anatomic sites. smooth and has a regular texture. She defecates everyday and urinates 6 times for the whole day. deformities or tenderness noted. pink with whistish spots. lung expansion is symmetrical both anterior and posterior. Muscle tone is normal racial color.Tongue is in central position. UPPER EXTREMITIES The client¶s upper extremities¶ muscle strength is 3of 5. dry and symmetrical. HEART The client's has no abnormal pulsation. MOUTH AND PHARYNX Lips is pale in color. and both nasal cavities are patent. Uvula is position in the midline of the soft palate. gag reflex is present. There is no lesion. LOWER EXTREMITIES The client¶s motor strength is good with a scale of 4 of 5. Pperipheral pulses are present. Muscle tone is normal racial color. There is no dimpling.She complain for a bit difficulty upon swallowing. Spinal column is straight. The client breath sounds is crackles upon auscultation. right and left shoulder and hips are at the same height. Tonsils are inflamed. the color of the mucosa is pink.NOSE The clients external nares a normal racial tone. The peripheral pulses have symmetrical pulse volume with full pulsation. the septum is at the midline. tongue moves freely and has no tenderness. There are tenderness in the maxillary and frontal sinuses there are no observes redness and swelling. Liver and bladder are not palpable. There is a lesion on his knee right part and on the right legs. There are no physical deformities. no lesions and lingual frenulum is in the midline. Hard and soft palate is pink in color. BREAST AND AXILLA The client¶s breast is equal in size generally asymmetrical. Lymph nodes are not palpable. ABDOMEN The client¶s abdomen has a normal racial tone and symmetric contour and shape is flat and round. There is no tenderness on the lymph nodes. Chest well intact and there is no tenderness. no masses. Audible bowel sounds. LUNGS AND THORAX The client¶s lungs is AP to lateral ratio 1:2. NECK The client¶s muscles Equal in size and head centered. lymph nodes are not palpable.
She is at menopausal stage.00 . It is concern to the composition of blood and used to determine if blood components are within normal values. which is the blood-forming tissue. Indication The CBC provides valuable information about the blood and to some extent the bone marrow. bleeding tendencies.FEMALE GENITALS Not assessed.66 X 10¶g/L Normal Range 4. The CBC is used for the following purposes: y as a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis y y y to identify persons who may have an infection to diagnose anemia to identify acute and chronic illness.50-11. According to her there is no discharges on her genitalia. It is frequently performed by a medical technician. DIAGNOSTIC PROCEDURE Hematology Hematology is a study of blood. and white blood cell disorders such as leukemia y y to monitor treatment for anemia and other blood diseases to determine the effects of chemotherapy and radiation therapy on blood cell production Nursing Responsibilities Identify the patient Explain the procedure Position the patient in comfortable position Label the specimen properly Report abnormal result in the physician Use a correct procedure in obtaining the specimen y y Hematology 1-25-11 Result WBC Differential Counts 13.
Eos. but it can also be used to detect disorders that affect the body's production of uric acid and to help measure the level of kidney functioning. 2.Neu.7 0.0-40.Perform venipuncture by entering the skin with needle at approximately a 15-degree angle to the skin. the patient will have too much uric acid in the blood. Supersaturated uric acid in the urine (uricosuria) can crystallize to form kidney stones that may block the tubes that lead from the kidneys to the bladder (the ureters).Apply tourniquet several inches above intended venipuncture site 3. RBC HGB HCT MCV 71. If the liver produces too much uric acid or the kidneys excrete too little.3 4. The urine test is used most often to monitor patients already diagnosed with kidney stones.0-7.0 20. allow area to dry). needle bevel up.0 0.0 2.0- Interpretation: The client has a infection.Clean venipuncture site (with povidone iodine or alcohol. Uric Acid Tests Definition Uric acid tests are tests that are done to measure the levels of uric acid in blood serum or in urine.7 fL 50.0-70.9 16. Nursing Responsibilities Prior: 1. During: 1. This condition is called hyperuricemia. the client has a allergy. Uric acid is a waste product that results from the breakdown of purine.50-5.50 120-100 0.Select vein for venipuncture (usually antecubital space). . Purpose The uric acid tests are used to evaluate the blood levels of uric acid for gout and to assess uric acid levels in the urine for kidney stone formation. and when the basophil is above the normal range.) Uric acid is made in the liver and excreted by the kidneys.1 4.0-3.6 7. Bas.380-0.470 80.5 3.0-0.351L 84.0 0. Lym. Mon. (Nucleic acids are the building blocks of DNA.14 x 10¶12/L 124g/l 0. a nucleic acid.
Attach a label to each blood tube.40 mg/dl (149.01 mg/dl 10. 2.41-5. After: 1.09 umol Conventional Unit 142.38) 0.If using a Vacutainer. withdraw the needle and exert pressure. Uri c Test 1-28-11 SI units Uric Acid (enzymatic) 273.81-238.75 mmol/L > 15 Desirable level that puts you at lower risk for coronary heart disease. If using a syringe.13 mmol/L HDL Interpretation: L 0.00-200.40 Trigllcerides(enzymatic) 1.Record the date and time of blood collection.After the blood is drawn. Apply bandage if needed.Properly dispose contaminated materials. URINALYSIS Urinalysis is a diagnostic physical. 4. and microscopic examination of a urine sample (specimen). even tension as blood fills the syringe.Relay results to the doctor. place cotton ball over site.11-2.88-6.74 mmol/ L Conventional Unit 3.2. 3. 3.80-339.73 Interpretation: Excess serum accumulation of uric acid can lead to a type of arthritis known as gout Lipid Prof. chemical.Release tourniquet when the blood begins to flow.20 144. Purpose Routine urinalyses are performed for several reasons: y y y general health screening to detect renal and metabolic diseases diagnosis of diseases or disorders of the kidneys or urinary tract monitoring of patients with diabetes .26 (100.62 mg/dl 2. SI unit Cholesterol L 3.01) 20. ease tube forward in holder once in the vein.96 mg/dl F>44.2 (4. pull back on the barrel with slow. Specimens can be obtained by normal emptying of the bladder (voiding) or by a hospital procedure called catheterization. A cholesterol level of 200 mg/dL or higher raises your risk.
quantitative urinalysis tests may be performed to help diagnose many specific disorders. Immerse all the regent area in the specimen and remove the strip immediately. The urinary microalbumin test measures the rate of albumin excretion in the urine using laboratory tests. GravityReactionAlbuminGlucoseWbcRbc Mucous threadEpithelial cellBacteria1.In addition.015 acidic negative negative 3-5/hpf 2-4/hpf moderate moderate moderate yellow hazy INTERPRETATION When the WBC count in urine is high. Precise timing is essential ± use a watch with a second hand. Ensure storage instructions are adhered to ± the date of opening should be recorded on the bottle. Hold the strip horizontally and compare the test areas closely with the colour chart on the bottle label for the length of time specified. it means that there is inflammation in the urinary tract or kidneys. . the excretion of greater than 200 g/mL albumin is predictive of impending kidney disease. Quantitative analysis often requires the use of a timed urine sample. Record the results in nursing records and report any abnormal findings. In diabetics. The most common cause for WBCs in urine (leukocyturia) is a bacterial urinary tract infection (UTI). Urinalysis 1-26-11 ColorTransparencySP. such as endocrine diseases. Always test fresh urine. collected in a clean dry container ± if the urine is left standing for more than four hours. Remove excess urine. osteoporosis. Nursing considerations y y y y y y y y Check the expiry date of the test strips on the bottle label. bladder cancer. and porphyrias (a group of disorders caused by chemical imbalance). leading to false readings. such as a bladder or kidney infection. there may be contaminants. This test is used to monitor the kidney function of persons with diabetes mellitus.
needle bevel up. Attach a label to each blood tube.38 mmol/L 73. After: 1.Select vein for venipuncture (usually antecubital space).18-8. 2.Perform venipuncture by entering the skin with needle at approximately a 15-degree angle to the skin. Urea Nitrogen SI units Urea Nitrogen Creatinine H 10. pull back on the barrel with slow. blockage of urine flow. The body uses larger than normal amounts of protein following serious burns. Urea is made when protein is broken down in your body. During: 1. 2. blockage of the urinary tract by a kidney stone or tumor. even tension as blood fills the syringe. 3. fever. abnormal loss of water from the body (dehydration). 4. Urea is made in the liver and passed out of your body in the urine INDICATION The BUN level may be checked in order to assess or monitor: y y y y y the presence or progression of kidney or liver disease. ease tube forward in holder once in the vein. 3. .Apply tourniquet several inches above intended venipuncture site 3.Relay results to the doctor.UREA NITROGEN A blood urea nitrogen (BUN) test measures the amount of nitrogen in your blood that comes from the waste product urea.Clean venipuncture site (with povidone iodine or alcohol. recovery from severe burns. allow area to dry). shock.Release tourniquet when the blood begins to flow. or bleeding in the digestive tract. place cotton ball over site. mental confusion. Apply bandage if needed.Properly dispose contaminated materials. Patients with kidney failure are sometimes disoriented and confused.After the blood is drawn.If using a Vacutainer.72 umol/L Normal Range 2. a heart attack or congestive heart failure.33 45-84 INTERPRETATION High levels of BUN may indicate kidney disease or failure. withdraw the needle and exert pressure. NURSING RESPONSIBILITIES Prior: 1. 2.Record the date and time of blood collection. If using a syringe. dehydration.
SOFT PALATE: soft palate (also known as velum or muscular palate) is the soft tissue constituting the back of the roof of the mouth. to the esophagus. and trachea.larynx.ANATOMY AND PYSIOLOGY TONSILS : are two clumps of tissue. or superior. embedded in a pocket at the side of the palate (roof of the mouth). and cranial. on either side of the throat. PATHOPHYSIOLOGY Risk factor y y Tonsillitis Pharyngitis Causative agent y Most of these true abscesses are polymicrobial y Group A -hemolytic streptococci (GABHS) y -Hemolytic streptococci y Staphylococcus aureus y Haemophilus influenzae y Anaerobic bacteria play an important role: y y y y y Prevotella Porphyromonas Fusobacterium Peptostreptococcus Possible synergy between anaerobes and GABHS . TONGUE: tongue is a muscular hydrostat on the floors of the mouths of most vertebrates which manipulates food for mastication PHARYNX is the part of the throat situated immediatelyposterior to (behind) the mouth and nasal cavity. UVULA: is of course the little piece of flesh that hangs down from the rear portion of the soft palate.
Tonsillar and peritonsillar edema may lead to compromise of the upper airway. and eventually extends around the tonsil. The infection starts in the intratonsillar fossa. pain with opening the mouth (trismus). involving the soft palate. Signs and symptoms y Fever and sore throat: y Most common initial complaints y Trouble swallowing.infectious tonsillopharyngitis progresses from cellulitis to abscess. The abscess is a suppuration outside the tonsillar capsule. Purulence usually collects within one tonsillar fossa. in proximity to the upper pole of the tonsil. which is situated between the upper pole and the body of the tonsil. but it may be bilateral. muffled (³hot potato´) voice: y Classic presenting symptoms y Unilateral neck or ear pain: y Other common presenting symptoms .
CHAPTER 2 .
2 celcius. . 5 Readiness for enhanced knowledge The last to be prioritized because this only needs an improvement and conducting health teachings.Nursing Diagnosis Acute pain related to inflamed tonsils as evidenced pain scale of 9/10 Rank 1 Justification This is the actual problem based on Maslow¶s Hierarchy of Needs the physiologic needs of the patient this must be given an immediate treatment/action to lessen the pain. 3 Hyperthermia related to elevated wbc secondary to peritonsillar as evidence by temperature of 37. The third prioritized because an elevated temperature can cause other complication. 4 Readiness for enhanced comfort The fourth priority because it is already on the wellness stage and needs only to maintain by the client. 2 Impaired swallowing related to acute peri-tonsilar abscess as evidenced by pain when swallowing This is the second prioritized problem based on Maslow¶s Hierarchy of Needs the physiologic needs of the patient this must be given an immediate treatment.
g.Determine clients acceptable level of pain/ pain control goals. use of heat/cold packs. and calm activities.Proviede comfort measures (e. Upon discharge. the client will be able to decrease perceive pain from 4/10 to 2/10 without complication. CD¶s/tapes (e. . quiet environment. music instructional) 4. complication. repositioning.SSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING IMPLEMENTATION SCIENTIFIC RATIONALE 1. and reduce tension. the client was able to decrease perceived pain from 4/10 to After 2 hours of nursing intervention.Promote nonpain from 4/10 to pharmacological pain 0/10 without management. imaging.g. DISCHARGE: GOAL ACHIEVED Release of chemical mediators Objective: P: when she swallows it already hurts Q: aching pain R: extend through the neck S:pain scale is 9/10 T: every after she swallows Stimulating the pain receptor SHORT-TERM: After 8 hours of nursing intervention. nurse¶s presence).Instruct in/ encourage use of relaxation techniques such as focused 3. Recommendation: TERMINATE THE PLAN Transmission of impulse Transmission of nociceptors to other part of spinal cord 3. EVALUATION Subjective: ³Ang sakit pag lumulunok ako´ ±as verbalized by the client Acute pain related to inflamed tonsils as evidenced by pain scale of 9/10 Tissue injury DISCHARGE: Upon discharge. SHORT-TERM: GOAL ACHIEVED After 8 hours of nursing intervention. 2.Work with client to prevent pain.Distract attention breathing. white noise.Varies with individual and situation. the client was able to decrease perceived 2. the client will be able to decrease perceived pain from 4/10 to 0/10 without complication. touch. 1.
. Notify physician if regimen is inadequate to meet pain control goal.As timely intervention is more likely to be successful in alleviating pain. 2/10 without complication. as indicated maximum dosage as ordered by the doctor.231-237 After 2 hours of nursing intervention.Localized pain Perception of pain the client will be able to demonstrate use of relaxation skills and diversional activities as indicated for individual situation. the client will be able to demonstrate use of relaxation skills and diversional activities as indicated for individual situation. therapeutic interventions response and length of time before pain recurs. 4. Recommendation: TERMINATE THE PLAN COLLABORATIVE: Maintain acceptable level of pain. COLLABORATIVE: Administer analgesics. Reference: Medical Surgical by: Brunner pp.
-Verbalize 2/3 interventions that will promote client¶s comfort.Assessment Nx Diagnosis Scientific Explanation Planning Intervention Rationale Evaluation Subjective: ³Hirap ako lumunok´ as stated Impaired swallowing r/t acute peri-tonsilar abscess as evidenced by difficulty in swallowing After 8 hours of Nx intervention. Long term: -To promote After 1 week of Nx . -Encourage to avoid milk products and chocolate Long term: After 1 week of Nx -Determine food preferences ofclient -To incorporate as possible enhancing food intake. After 8 hours of Nx intervention. client will be able to: -Identify factors that affect present condition Objective: -difficulty in swallowing -pain while swallowing -facial grimace -Verbalize 2/3 interventions that will promote client¶s comfort. client will be able to: -Assess client¶s swallowing condition -to have a baseline data and to assess client¶s present condition. -Identify factors that affect present condition -to prevent thickening of oral secretions.
jelly. client will be able to: swallowing . client will be able to: -Demonstrate behaviors that will promote good swallowing -Demonstrate behaviors that will promote good swallowing -To establish optimum dietary plan. . -to promote client¶s well being and to be able for the patient to ingest medications. intervention. -Feed one consistency and/or texture of food at a time. pudding. Collaborative: Refer patient to dietitian Administer medications as prescribed and place the medication in gellatin.intervention.
CHAPTER 3 .
FREQUENCY Ceftriaxone 1g/IV OD. ROUTE. route and frequency Administer the drug on the time order Monitor the v/s of the patient Monitor for the side effect of the drug Monitor for the hydration status of the patient Instruct the patient to report if she experience any of the side-effect of the drug Instruct pt. otic and bone. CONTRAINDICATION y Hypersensi tivity to cephalospo rins. GIT. soft tissue and post-op infection. DOSE. MECHANISM OF ACTION Act by inhibiting cell wall synthesis in bacteria. SIDE-EFFECT NURSING MANAGEMENT y GENERIC NAME: Ceftriaxone BRAND NAME: Rocephin INDICATION: Respiratory. GUT. endocarditis. to take plenty of rest note. record and document the drug administration y y y y y y y y y .Drug Study DRUGS CLASSIFICATION AND INDICATION CLASSIFICATION: Cephalosporins 3rd generation. skin. y y Diarrhea Abnormal liver and renal function test Hypoprothr ombinemia Thrombopl ebitis y Check the history of the pt. especially the allergy Check the physicians order regarding the dose.
Drug Study DRUGS CLASSIFICATION AND INDICATION MECHANISM OF ACTION acetaminophe CLASSIFICATION: n appears to Miscellaneous produce analgesics analgesia by INDICATION: elevation of For fever and the pain discomfort associated threshold. y y y y y y y y y Check the history of the pt. FREQUENCY Acetaminophen 30mg PO q6. DOSE. ROUTE. mechanism headache. and may involve condition involving inhibition of musculoskeletal pain. especially the allergy Check the physicians order regarding the dose. route and frequency Administer the drug on the time order Monitor the v/s of the patient Monitor for the side effect of the drug Offer plenty of water during administration Monitor for the hydration status of the patient Instruct the patient to report if she experience any of the side-effect of the drug Instruct pt. the nitric oxide pathway mediated by a variety of neurotransmit ter receptors including Nmethyl-Daspartate and substance P. CONTRA-INDICATION SIDEEFFECT y y Haemat ological Skin and other allergic reaction NURSING MANAGEMENT GENERIC NAME: acetaminophen BRAND NAME: Tylenol y y y y y Hypersensitivity to the drug Anemia cardiac and pulmonary disease Hepatic or severe renal disease. to take plenty . The with bacterial and potential viral infections.
record and document the drug administration .y of rest note.
However. making them easy to chew and swallow. the kinds of foods his or her stomach can tolerate will be different. A List of Soft Foods The soft diet food list will vary slightly depending on the reason for resorting to the same.TREATMENT Intravenous Therapy y D5 NM ILX10hrs. he or she cannot chew and swallow hard foods.20 gtts/min Definition Intravenous therapy is giving of fluid/liquid substance directly to the vein for fluid and electrolytes replacement and supplement. he can very well digest all foods. On the other hand. Thus. Evaluate for patient response and report s/sx of fluid overload Advise patient to report pain at IV site Label the IV container properly Check for its patency Check for any back flow of blood Check for presence of bubbles Make sure that you are giving the right IVF to the right patient . Besides being soft in texture. pureed and mashed foods come in his list of soft foods after tooth extraction. for a person who has just had a gastritis bypass. Mostly people with chewing and swallowing problems or those who have just undergone a surgery will need to be on a soft food diet. the soft food umbrella also entails foods that are not high in fiber content and also those that conduce to gas. Indication/Purpose y y y For fluid replacement Foe severe water depletion requiring rapid replacement Isotonic solution that expands intravascular volume Precaution y y use water solution only in patient with severe water loss and fluid imbalances use cautiously in generic or post operative patient because fluid retention may worsen Nursing Considerations y y y y y y y y y Diet Soft foods as the name suggests are foods that are soft in texture. The check for IV site for any redness or infiltration check for proper flow rate of IV. Regulate frequency as needed. For example. Let's have a look at the soft diet food list to get a greater understanding of which are the foods that come under this soft food category. if a person has just had an oral surgery.
de-skinned and pureed) Vegetables There are only some vegetables that are permitted to be eaten. pinto beans. depending on one's condition the list will vary. cabbage. are gas forming vegetables. Let's have a look at the general soft diet food list. Fried foods and spicy or highly seasoned foods are also not good for post-operative or immobile patients. most raw foods. eating raw vegetables is forbidden. Moreover. Moreover. Fruits All fruits containing skin and seed should be avoided. Thus. onions. as vegetables like broccoli. cooked cereals are soft and easy to chew and swallow. etc. The cooked grains one is permitted to have are: y y y y y y Oatmeal Grits Cream of wheat Cooked pasta Macaroni Smooth peanut butter Meat and Eggs y Ground meat . breads and cereals are eliminated from their diet as well. The fruits one is permitted to have are: y y y Bananas Apple sauce Pureed berries (de-seeded. The vegetables one is permitted to have are: y y y y y y Avocados Skinned tomatoes Skinned and mashed potatoes Asparagus Mashed pumpkin Baked beans Breads y y y Soft breads without crust Pancakes French toast without crust Grains In the grain category.gradual progression from a completely pure liquid diet to a soft food diet and then to a general diet is to be made.
salmon or white fish without bones Broiled or stewed turkey or chicken Soft boiled or scrambled eggs Dairy Products y y y y y y y y Yogurt Tofu Cottage cheese Mild cheeses Cream cheese Butter Cream Mayonnaise Beverages y y y y y y y y y y Milk Coffee Tea Herbal tea Chocolate milk Milk shakes Fruit juices Vegetable juices Soups (creamed soups) Broth People recovering from gastritis should drink only caffeine-free drinks and should also have low acid juices such as apple. Desserts Desserts with coconut and nuts should be avoided. grape or pear juice. The desserts one is permitted to have are: y y y y y y y y Ice-cream Pudding Custard Gelatin desserts Honey Home made trifle7 Fruit mousse Cream pies 24 Hour Recall . lamb or veal Tender cooked liver Cooked tuna.y y y y y Tender cooked beef.
Ceftriaxone 1g/IV D5 NM OD. passive rom Day 02 Jan.Breakfast Lunch Dinner Food intake 1 slice of fish 2cups of rice 1 small banana 1 small bowl monggo 2 cups of rice ¼ cup of rice 1 slice of adobo Fluid intake 2 glasses of water 2 glasses of water of 1 glass of water Biochemical Appraisal Rich in carbohydrates Rich in protein High in potassium Rich in carbohydrates Rich in protein Rich in carbohydrates Rich in protein Activity/Exercise Permit activity as tolerated. 2011 Flat on none bed.gtts/min mg PO q6.2011 Flat on None bed. 30. . Daily Progress Chart Diagnostic Procedure Urinalysis Hematology Uric test Urea nitrogen Hematology Uric test Urinalysis Urea nitrogen Activity Flat bed Surgery Medication Treatment Admission Jan.gtts/min mg PO q6. Day 01 Jan.gtts/min mg PO q6. Urinalysis Urea nitrogen Hematology Urinalysis Flat on none bed.1. ILX10hrs. 2011 Hematology Uric test 31. ILX10hrs. passive rom Ceftriaxone 1g/IV D5 NM OD.20 Acetaminophen 30.gtts/min mg PO q6.20 Acetaminophen 30.28. 2011 on NONE Ceftriaxone 1g/IV D5 NM OD. ILX10hrs. passive rom Ceftriaxone 1g/IV D5 NM OD.20 Acetaminophen 30.20 Acetaminophen 30. Discharge Day 03 Feb. ILX10hrs.
CHAPTER 4 .
The client was also having the amount of rest and relieves discomfort.CHAPTER 4: EVALUATION A. The patient was also advice to take a rest for a couple of days to boost the immune system and gain easily the strength. Avoid eating of acidic and sweets which can stimulate the salivary glands. Instruct patient to eat soft diet. Instruct patient to report or have a check up if there is an increase in body temperature. Instruct patient to avoid smoking that can lead to further complications. 2011 upon discharge. . Permit activity as tolerated. OUT PATIENT DEPARTMENT Instruct the patient to have followed up check-up on February 9. NARRATIVE EVALUATION OF ACTUAL NURSING PROLEM ACUTE PAIN The client was able to decrease perceived pain form 4/10 to 0/10 without complication. Instruct patient to increase fluid intake at least 2-3L/day. Instruct the patient to maintain the fluid volume of the body. y Tonsillectomy should be considered after severe or recurrent peritonsillar abscesses HEALTH TEACHINGS y y y y y y y Instruct the patient to continue the take home medication and take it on time. DISCHARGE PLANNING INSTRUCTION MEDICATIONAdvice the patient to take Ceftriaxone 250mg OD. and acetaminophen (Tylenol) 30-mg PO q6 for 7 days. Advice also the patient to take the medication as prescribed. Instruct the patient for proper oral hygiene to avoid infection. DIET y y y The patient was advice for soft diet. listening soft music and reading a book. B. High fibers and low fat diet. TREATMENT y Patients may be discharged on oral antibiotics to complete a 10±14-day course when afebrile and peritonsillar swelling has subsided. The client was able to demonstrate the use of relaxation techniques and diversional activities like watching TV. EXERCISE The patient was advice foe passive ROM for at least 2-3 days.
pinto beans. making them easy to chew and swallow. de-skinned and pureed) Vegetables There are only some vegetables that are permitted to be eaten. depending on one's condition the list will vary. However. Besides being soft in texture. On the other hand. A List of Soft Foods The soft diet food list will vary slightly depending on the reason for resorting to the same. if a person has just had an oral surgery. breads and cereals are eliminated from their diet as well. Moreover. Fried foods and spicy or highly seasoned foods are also not good for post-operative or immobile patients. pureed and mashed foods come in his list of soft foods after tooth extraction. Thus. for a person who has just had a gastritis bypass. most raw foods. he or she cannot chew and swallow hard foods. onions. the soft food umbrella also entails foods that are not high in fiber content and also those that conduce to gas. The fruits one is permitted to have are: y y y Bananas Apple sauce Pureed berries (de-seeded. The gradual progression from a completely pure liquid diet to a soft food diet and then to a general diet is to be made. etc. cabbage. Let's have a look at the general soft diet food list. he can very well digest all foods. For example. Fruits All fruits containing skin and seed should be avoided. Mostly people with chewing and swallowing problems or those who have just undergone a surgery will need to be on a soft food diet. Moreover. eating raw vegetables is forbidden. The vegetables one is permitted to have are: y y y y y y Avocados Skinned tomatoes Skinned and mashed potatoes Asparagus Mashed pumpkin Baked beans Breads y y y Soft breads without crust Pancakes French toast without crust . Let's have a look at the soft diet food list to get a greater understanding of which are the foods that come under this soft food category. Thus. as vegetables like broccoli.Soft foods as the name suggests are foods that are soft in texture. the kinds of foods his or her stomach can tolerate will be different. are gas forming vegetables.
The cooked grains one is permitted to have are: y y y y y y Oatmeal Grits Cream of wheat Cooked pasta Macaroni Smooth peanut butter Meat and Eggs y y y y y y Ground meat Tender cooked beef. grape or pear juice. Desserts . cooked cereals are soft and easy to chew and swallow. lamb or veal Tender cooked liver Cooked tuna.Grains In the grain category. salmon or white fish without bones Broiled or stewed turkey or chicken Soft boiled or scrambled eggs Dairy Products y y y y y y y y Yogurt Tofu Cottage cheese Mild cheeses Cream cheese Butter Cream Mayonnaise Beverages y y y y y y y y y y Milk Coffee Tea Herbal tea Chocolate milk Milk shakes Fruit juices Vegetable juices Soups (creamed soups) Broth People recovering from gastritis should drink only caffeine-free drinks and should also have low acid juices such as apple.
The desserts one is permitted to have are: y y y y y y y y Ice-cream Pudding Custard Gelatin desserts Honey Home made trifle7 Fruit mousse Cream pies .Desserts with coconut and nuts should be avoided.