NURSING HISTORY

Name: Patient A
Age: 61 y/o

History of Past illness:

MEDICAL HISTORY: The patient had a history of rheumatoid arthritis for 6 years
SURGICAL HISTORY: There is no previous surgical history listed.
ACCIDENT: No accident reported related to the present condition.
TRAUMA: No history of trauma mentioned
MEDICINE: The patient was taking pain relievers due to painful attacks which gets worsen
mostly in cold months of November to February.
ALLERGIES: No allergies have been identified.

History of Present illness:

2 hours prior to admission in the emergency room, Patient A looks pale, weak, and very thin
weighing 44kgs. Thus, the patient GCS was (E3V4M5) Vital signs as follows: BP-80/50mmHg;
HR-106bpm; RR-24cpm; and temp-35.4ᵒ C with SPO2 of 93%

DIAGNOSTIC AND LABORATORY PROCEDURES

Complete Blood Count (CBC) - is a blood test used to evaluate your overall health and detect
a wide range of disorders, including anemia, infection, and leukemia. A complete blood count
test measures several components and features of your blood, including: Red blood cells, which
carry oxygen.
X-ray- use invisible electromagnetic energy beams to produce images of internal tissues,
bones, and organs on film or digital media.
Stool Test- is to determine whether a type of bacteria or parasite may be infecting the
intestines. Many microscopic organisms living in the intestines are necessary for normal
digestion.
CASE No. 2
PATIENT: Mrs. W AGE: 62 y/o

MEDICAL MANAGEMENT

Indication:
 The nasal cannula is a device
used to deliver supplemental
oxygen or increased airflow to a
patient or person in need of
OXYGEN THERAPY respiratory help. This device
consists of a lightweight tube
(NASAL CANNULA)
which on one end splits into two
prongs which are placed in the
nostrils and from which a mixture
of air and oxygen flows.

Purpose:
 Nasal cannulas and face masks
are used to deliver oxygen to
people who don't otherwise get
enough of it. They are commonly
used to provide relief to people
with respiratory disorders

Indication:
 The most commonly used
crystalloid worldwide is normal
INTRAVENOUS FLUID THERAPY saline which is used in the
management and treatment
of dehydration (e.g., hypovolemia,
shock), metabolic alkalosis in the
presence of fluid loss, and mild
sodium depletion.

Purpose:
 The main purpose of IV Therapy is
to deliver fluids, medications, or
vitamins directly into the veins of
the body. It is the fastest way to
deliver blood products, vitamins,
medications, or other necessary
fluids directly into a person's
circulatory system.
FDAR CHARTING

DATE & TIME FOCUS PROGRESS NOTE

2/10/2022 Acute pain related to D: On a pain scale of 1-10,

epigastric pain the patient rates 6/10;
present with discomfort,
5PM body malaise and is pale in
appearance.
VS as follows:
BP=80/50mmHg;
HR=106bpm;
RR=24cpm;
Temp=35.4 ᵒ C
SPO2 of 93%.

A:
- Provided comfort
measures (nasal cannula
administration)
- Monitored Vital signs
- Documented location,
scale (0-10) and character
of the pain
- Notified physician
- Labs requested
- Order meds started
- IV line started
- Secured Lab results

R: On a pain scale of 6/10

patient was relieved to
3/10.
DRUG STUDY

Indication:
 Most effective agent for treatment
of erosive and non-erosive reflux
disease; It is used to treat gastric
and duodenal ulcers, erosive
OMEPRAZOLE esophagitis, and
gastroesophageal reflux disease
Brand name: Prilosec
(GERD). It works by decreasing
(Proton Pump Inhibitor) the amount of acid produced by
the stomach.
 ; peptic ulcer disease; non-ulcer
dyspepsia; stress-related mucosal
bleeding

Side effects:
More common
 Black, tarry stools
 Bleeding gums
 Headache
 Abdominal pain
 Diarrhea
 Nausea
 Vomiting
 Gas (flatulence)
 Dizziness
 Upper respiratory infection
 Acid reflux
 Constipation
 Rash
 Cough
 - is used for Stomach acid, Heartburn,
Stomach pains, Stomach upset, Acid
indigestion, Increases water in the intestines
Gelmalicid and other conditions.

Brand Name: SIDE EFFECTS:

AlternaGEL, Amphojel, and Nephrox.  Constipation
 Black stools
Drug Classification:  Mood changes
Antacid  Pain during urination
 Stomach or abdominal pain
 Vomit
 Loss of appetite
 Muscle weakness
 Nausea
 Slow reflexes
 Vomiting
 Diarrhea