RELATED LEARNING EXPERIENCE

REQUIREMENTS FOR
CARE OF OLDER ADULT

Name
Section:
Concept: Care of Clients with problems in Oxygenation, Fluid and Electrolyte
Balance, Infectious, Inflammatory and Immunologic Response, Cellular
Aberrations – Acute and Chronic
Clinical Instructor:
I. GENERAL AND SPECIFIC OBJECTIVES

A. General Objectives

After 4 hours of case study with a concept of “Care of Clients

with problems in Oxygenation, Fluid and Electrolyte Balance,
Infectious, Inflammatory and Immunologic Response,
Cellular Aberrations – Acute and Chronic” the student nurses
will be able to demonstrate knowledge, regarding health and
disease condition of the patient, understand the disease
processes, familiarize the possible complication, assimilate
treatment plans, and use appropriate nursing interventions.

B. Specific Objectives

1. Acquire knowledge and familiarization of each disease.

2. Determine the signs and symptoms of the particular
diseases.
3. Review anatomy and physiology of the affected parts of
the diseases.
4. Analyze and understand the pathophysiology of each
disease.
5. Interpret laboratory and diagnostic studies.
6. Integrate all drugs being used for the patient’s treatment.
7. Present nursing care plans that identify the patient’s
needs and be able to use nursing interventions accordingly.
II.
PATIENT’S DEMOGRAPHIC DATA

Patient’s Initials: A.M.B.

Sex: Male Age: 77 Date of Birth: Marital Status:

JUNE 12, 1943 MARRIED
Address: LAWAAN, TALISAY

Occupation: NOT STATED Religion: ROMAN CATHOLIC

Weight (kg): NOT STATED Height (m): NOT STATED
Date and Time of Admission: 8/13/20 4:01 PM

Chief Complaint: Left Sided Weakness, Slurring of Speech

Admitting Diagnosis: CV Bleed, HCVC, Type 2 DM, CKD Stage 5 Secondary to Hypertensive
Nephrosclerosis

Admitting Physician: DR. QUIJANO

III. PATIENTS MEDICAL HISTORY

A. History of Present Illness ( A narrative detail of the current admission in
chronological order)

Patient came to the hospital on 8/13/2020 at 4:01PM. He was complaining of left

sided weakness and slurring of speech. The doctor decided to admit the patient
in the COVID unit and instructed that the patient is NPO temporarily except
meds. Laboratory test were made and medications were given.

B. Past Health History

Previous Hospitalizations/Surgery/Ilness (include date, hospital, diagnosis, procedure):

1. Not stated
2. Not stated
3. Not stated
4. Not stated
5. Not stated
Diagnosed Chronic Illness (specify):
CV Bleed, HCVC, Type 2 DM, CKD Stage 5 Secondary to Hypertensive Nephrosclerosis
Immunizations (complete or incomplete, specify): Not stated
Obstetric History (if applicable): None

Allergies (specify): None

Other Important Information: None

C. Family Health History (Genogram with brief narrative explanation)

Family Health History cause was not stated.

 D.
Psychosocial History

Brief Description of Lifestyle and Relationship with Family and Peers: NOT STATED
Vices and Addictions (Provide a brief history, including smoking, alcohol, illegal drugs):
NOT STATED
Employment History (all employment from beginning to the current): NOT STATED
Current Stage in Erickson’s Psychosocial Theory:
Patient is currently in 8th stage of the theory which is Integrity vs. Despair. Since
information with regards to this was not mentioned, this was based on his age. During this
stage, people reflect back on the life they have lived and come away with either a sense of
fulfilment from a life well lived or a sense of regret and despair over a life misspent. Those
who feel proud of their accomplishments will feel a sense of integrity. Successfully
completing this phase means looking back with few regrets and a general feeling of
satisfaction. These individuals will attain wisdom, even when confronting death. Those
who are unsuccessful during this phase will feel that their life has been wasted and will
experience many regrets. The individual will be left with feelings of bitterness and despair.

IV. PHYSICAL ASSESSMENT/EXAMINATION (Encircle and/or provide the

information based from your assessment findings)
Vital Signs
Temperature:36.7 °C Pulse:89bpm Respiration:38cpm Blood pressure: O2 Saturation: 97% Pain Score:
160/100mmHg NOT STATED
GENERAL SURVEY
How does the Age: 77 DOB: 6/12/1943
client look like? Sex: Male Body Build: Thin Cachectic Obese Within Normal Limits
Height: _________ Weight: ______________
Well groomed Poorly Groomed
Facial Expression: Anxious Happy Sad Angry

NEUROLOGICAL
(LOC) Level of Alert Awake Lethargic Obtunded Stuper Comatose Confused
Consciousness Decerebrate Decorticate
Oriented x 4: Person Place Time Event
Response to touch/voice
Eyes Unaided sight Glasses Contact lens Implants Prosthesis
Snellen 20/ Blind
Pupils Equal Round Reactive to light Accommodates Sluggish Brisk
Nonreactive to light Consensual
Pupil size before light ______mm Pupil size after light ______mm
Ears Unaided hearing Hard of hearing Deaf Hearing aid
Implant Cerumen Drainage
Extremities Hand grips +1 +2 +3 +4 +5 equal unequal
Foot pushes +1 +2 +3 +4 +5 equal unequal
Cranial Nerves I (smell)
II(vision)
III+IV+VI (eye movement)
V (sensation of face/oral)
VII (facial movement/taste)
VIII (hear/balance)
IX (taste/swallow)
X (chew/gag/speech)
XI (shrug/turn head)
XII (tongue movement)
Pain Character Onset
 (COLDSPA) Location Duration
Severity Pattern
Associated Factors
CARDIOVASCULAR
Skin/Mucous Pink Pale Cyanotic Jaundiced Ruddy
Membranes Flushed Diaphoretic
Radial and Radial: Palpable (L/R) Absent (L/R) Pedal: (DP PT) Palpable (L/R)
Pedal Pulses Absent (L/R)
Apical R (2 people simultaneously) Apical and Radial Pulse Deficit
adial Pulses
Carotid Pulses (DO NOT TAKE AT SAME TIME) Right Left
Thrill Bruit
Capillary Refill Normal (<3 Sec) ______sec
Jugular Neck Not visible Visible
veins
Edema Absent Present: location +1 +2 +3 +4
Anasarca Pitting Non Pitting
Calf Tenderness Denies Positive Homan’s sign R L calf size R____ L_____ (team leader or charge nurse
notified)
Heart Regular Irregular Murmur Extra sounds
Rhythm/Sounds Strong Faint Muffled
-S12
Telemetry: rhythm ___________________ Pacemaker Defibrillator
location
IV Fluids Solution: PNSS Rate 20gtts/min Infusion Pump
Site location (be specific) _________
Site appearance: Clear Edema Erythema Tender
Pallor
Dialysis access: type __________ Thrill Bruit Location:___________
Appearance:____________
RESPIRATORY
Respirations Regular Irregular Even Uneven Unlabored Labored
Symmetrical Asymmetrical
Lung Sounds Clear LUL RUL LLL RLL RML Anterior
Posterior
Wheezes location__________ Rales/crackles location__________
Rhonchi location ________
Nasal flaring Sternal retraction Intercostal retraction
Do lung sounds improve with cough and deep breath (y/n)?
Cough None Nonproductive Dry
Moist Productive
Sputum: amount _______________ color_______________
frequency___________
Oxygen Room air: Negative Pressure Pulse ox 97% O2 at 2-3L/min
Nasal Cannula Mask Tent
CPAP BIPAP
Respiratory Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds # of times______
Treatments HHN medication Bipap
Ventilator? TV rate
02% other
GASTROINTESTINAL
Oral Teeth Dentures Caries Dysphagia
Mucous Membranes: intact moist dry pale
leukoplakia
Abdomen: Inspect Soft Round Flat Scaphoid Obese
Auscultate Percuss Firm Hard Nondistended Distended
Palpate Tender Non Tender
Location:
Bowel Sounds RLQ RUQ LUQ LLQ Normoactive Hypoactive
Hyperactive Absent
NGT/GT/JT None Type of tube: NGT patent nonpatent
Suction: low high Color of drainage ______________
Amount____________________
Bowel Movement Continent Incontinent last BM______________
Color Size_________________ Consistency Ostomy Stool
Nutrition Diet % eaten Breakfast____ Lunch_____ NPO?
Why___________
Self feed Needs assistance Thickened liquids: honey nectar pudding Tube
Feed_________________
GENITOURINARY
Urine Continent Incontinent Catheter type _______________ Patent Nonpatent
Color Clear Sediment Burning Frequency
Intake and Output PO/Oral/Tube Feed intake 180ml IV intake 60ml Urine output 5ml Other output
Fluid restriction Total I&O + /- ________________
Genitalia Male Female vaginal discharge LMP
Post partum
MUSCULOSKELETAL
Mobility ADLs independent or assisted with _________________________________________________
Muscle Treatment None Cast Brace Splint Location
Elevate Traction – type:
_________________________ Traction weight: _________________________
CMST Circulation: color, pulses, cap refill Motion Sensation
Temperature
RA LA
RL LL
Antiembolitic Hose:knee/thigh
Contractures Not present Present – which extremity? What %
decreased?
Amputation No Yes Location _______________________________
ROM AROM AAROM PROM CPM
Limited location___________________
Mobility Turns self Sits independently Dangles Stands independently
Walks independently
Ambulatory assistance: Gait belt Cane Walker Crutches Braces
Wheelchair Gerichair
Walks: distance frequency tolerance PT OT
RNA
Risk for falls Bed alarm Chair alarm 1 or 2 Person Transfer Floor pad Side Rails
Mechanical Lift Slide Board

INTEGUMENTARY
Appearance Intact Color___________ Pallor Rash Bruise Lesions Scar
Location __________________
Turgor_____ seconds Site___________
Skin Warm Hot Cool Cold
Dry Moist
Wound Dressing None Surgical site – Location Well approximated
Sutures Staples Steristrips
Dressing: Dry/intact Non-intact Change: Yes
Pressure Ulcers
No
Drainage: Color Amount___________
Odor_________
Wound appearance: Drain type _________
Amount______

Stage Location Size

Tunneling Eschar Slough
Stage Location Size
Tunneling Eschar Slough
Stage Location Size
Tunneling Eschar Slough
ISOLATION (if applicable)
Type Culture
Site

PSYCHOSOCIAL
Behavior Cooperative Uncooperative Pleasant Withdrawn Combative
Other_______________
Restraints None Chemical Physical: type
location

CMST of extremity
RA
LA
RL
LL
Frequency Checked________________
Language Spoken _______________________

B. General Summary of Physical Assessment/Examination Findings (Provide

a narrative summary of all the findings and correlate with the diagnosis of
the patient)

Patient A.M.B. is a male. Based on the data provided, patient is stuper and reactive
to light.
Patient was infused with PNSS with a rate of 20gtts/min. Respirations are irregular.
He is placed at a negative pressure room with oxygen via nasal cannula at 2 -3 lpm.
Client was on NGT and his feed intake is 180ml with IV intake of 60ml and a urine
output of 5ml.
 V. ANATOMY AND PHYSIOLOGY

The epicardium or the visceral and outermost layer is actually a part of the heart wall.
The myocardium consists of thick bundles of cardiac muscle twisted and whirled into ringlike
arrangements and it is the layer that actually contracts.
The endocardium is the innermost layer of the heart and is a thin, glistening sheet of endothelium that
lines the heart chambers.
Superior and inferior vena cava. The heart receives relatively oxygen-poor blood from the veins of
the body through the large superior and inferior vena cava and pumps it through the pulmonary trunk.
Pulmonary arteries. The pulmonary trunk splits into the right and left pulmonary arteries, which
carry blood to the lungs, where oxygen is picked up and carbon dioxide is unloaded.
Pulmonary veins. Oxygen-rich blood drains from the lungs and is returned to the left side of the heart
through the four pulmonary veins.
Aorta. Blood returned to the left side of the heart is pumped out of the heart into the aorta from which
the systemic arteries branch to supply essentially all body tissues.
Atrioventricular or AV valves are located between the atrial and ventricular chambers on each side,
and they prevent backflow into the atria when the ventricles contract.
The left AV valve- the bicuspid or mitral valve, consists of two flaps, or cusps, of endocardium.
The right AV valve, the tricuspid valve, has three flaps.
The second set of valves, the semilunar valves, guards the bases of the two large arteries leaving the
ventricular chambers, thus they are known as the pulmonary and aortic semilunar valves.
KIDNEY
VI. PATHOPHYSIOLOGY

CVD

HCVD
 VII. LABORATORY AND DIAGNOSTIC STUDY

Date Type of Exam Patient’s Results Normal Significance/

Values Interpretation
URINE ANALYSIS Color:Light Yellow Hazy transparency of urine
Transparency: maybe an indication for
Hazy Albumin: dehydration and infection
Albumin: +1 NEGATIVE Positive result in albumin,
Blood: 2+ Blood: blood and glucose is an
Glucose: 2+ NEGATIVE indication for kidney
Glucose: damage.
NEGATIVE
CBC WBC: 13.1 4.4 – 11.0 Elevated WBC and
NEU: 9.99 1.80 – 7.80 neutrophil indicates
HBG: 10.8 14.0 – 17.5 inflammation or infection
HCT: 32.8 g/dL along the urinary tract,
41.5 – 50.4% often in the bladder or
kidney. Low hemoglobin
and hematocrit indicates
anemia.
BLOOD HGT: 253 mg/dL 72 – 99 mg/dL Poorly Controlled Diabetes
GLUCOSE
BLOOD GAS pH: 7.250 7.350 – 7.450 Metabolic acidosis
ANALYSIS pC02: 46.4 35.0 -45.0 uncompensated
p02: 120.7 80.0 – 100.0
HC03: 20.1 22.0 – 26.0
02: 97.5% >95.0
pH: 7.356 7.350 – 7.450 Metabolic Acidosis
pC02: 39.6 35.0 -45.0 uncompensated
p02: 245.8 80.0 – 100.0
HC03: 21.7 22.0 – 26.0
02: 99.5% >95.0
COVID-19 RAPID igG: NEGATIVE NEGATIVE Not suspected to COVID-
ANTIBODY TEST IgM: NEGATIVE NEGATIVE 19 Infection
PROTHROMBIN INR: 1.32 0.84 – 1.11 Indication for blood clot
TIME and bleeding
CLINICAL Creatinine: 3.66 0.51 – 0.95 Kidney damage
CHEMISTRY BUN: 45.1 6.0 – 20.0 Diabetes
BUA: 9.20 2.4 – 5.7
HBA1C: 7.50 4.0 – 6.0
 VIII. DRUG STUDY
Name of Drug Action Indication/s Side Effects Nursing
Responsibilities
Generic Name: Inhibits -Primary Headache. BEFORE:
HMG-CoA prevention of Myalgia -Check doctor’s order or
reductase, cardiovascular Rash MAR.
the enzyme disease Pruritus, -Prepare medication.
that -Reduces risk Allergy -Double check the
catalyzes of stroke and Flatulence medication before going
Atorvastatin the early heart attack in Dyspepsia to the client.
step in pts with type 2 Depression. -Verify patient
cholesterol diabetes with -Explain the procedure
Brand Name: synthesis. or without and route of medication.
Lipitor evidence of -Assess baseline lab
Therapeutic heart disease. results: cholesterol,
Effect: triglycerides, hepatic
Classification: Decreases function tests.
Antihyperlipidemic LDL and DURING:
VLDL, -Wash hands before
Dosage: plasma administration.
80 mg/ tab, 1 tab triglyceride -Monitor for headache
Route: levels; Contraindicati Adverse Effect -Monitor for headache,
increases on/s pruritus, malaise.
PO/ NGT HDL  Active Myalgia -Monitor cholesterol,
concentratio hepatic Rhabdomyolysis triglyceride lab values for
Frequency: n. disease . therapeutic response.
OD  Unexplaine Cataracts -Monitor hepatic function
d elevated Photosensitivity, tests, CPK.
Timing: hepatic AFTER:
8pm function test -Periodic lab tests are
results. essential part of therapy
-If dark urine, muscle
fatigue, bone pain is
present report
immediately to the
physician.
-Document
Name of Drug Action Indication/s Side Effects Nursing Responsibilities
Generic Irreversibly  Stress ulcer  Dizziness BEFORE:
Name: binds to, prophylaxis in  Pruritus  Check doctor’s order or
Pantoprazole inhibits critically ill pts.  Rash MAR.
hydrogen  Diarrhea  Prepare medication.
potassium  Headache,  Double check the
Brand Name: adenosine  Nausea medication before going to
Protonix IV triphosphate, the client.
an enzyme on  Verify patient
surface of  Explain the procedure and
Classification: gastric parietal route of medication.
Proton pump cells. Inhibits  Obtain baseline lab values,
inhibitor hydrogen ion including serum creatinine,
Dosage: transport into cholesterol.
40 mg gastric lumen.  Wash hands before
Route: Contraindication/s Adverse Effect administration.
IVTT Hypersensitive to Hyperglycemia DURING:
proton pump occurs rarely
 Monitor patients vital signs
inhibitors (e.g.,
 Monitor for GI discomfort
Frequency: omeprazole).
AFTER:
STAT
 Evaluate for therapeutic
response
 If headache, onset of black,
tarry stools, diarrhea is
Timing: present refer to the
q24 H physician
 Document accordingly

Name of Drug Action Indication/s Side Effects Nursing Responsibilities

Generic Name: Inhibits Hypertension Headache BEFORE:
Nicardipine calcium ion Facial flushing -Check doctor’s order or MAR.
movement Peripheral edema -Prepare medication.
across cell Light-headedness -Double check the medication
Brand Name: membranes Dizziness before going to the client.
Cardene , depressing Asthenia (loss of -Verify patient
contraction strength, energy) -Explain the procedure and
of cardiac, Palpitations, route of medication.
Classification: vascular Angina DURING:
Antianginal, smooth Tachycardia -Monitor B/P during and
antihypertensive muscle. Nausea following IV infusion.
Dosage: Abdominal cramps -Monitor serum hepatic enzyme
10mg + cc PNSS Dyspepsia (heartburn, results
at 20 cc/hr indigestion, epigastric -Regulate exact titration
pain), -Assess for peripheral edema
Dry mouth behind medial malleolus
Rash. -Assess skin for facial flushing,
Route: Contraindication Adverse Effect dermatitis, rash.
/s AFTER
IVTT - -confusion, -Avoid tasks requiring motor
Hypersensitivi -slurred speech skills, alertness until response
ty to drug. -drowsiness to drug is established.
Frequency: -Advanced -marked hypotension -Document
STAT aortic -bradycardia
stenosis
 Name of Drug Action Indication/s Side Effects Nursing Responsibilities
IV FLUID: Sodium Water and -Fever BEFORE:
Normal Saline Chloride is fluid -Injection site swelling, -Obtain history of the patient’s
(Sodium source of replacement redness fluid and electrolyte status
Chloride)--- 0.9% water and -Infection before therapy.
SODIUM electrolytes. -Hypertension -Check for the correct patient to
CHLORIDE It is capable be administered.
SOLUTION of inducing -Check doctor’s order if it is the
diuresis right drug and right dose to be
depending given.
Classification: on the DURING:
Isotonic clinical -Correct flow rate.
condition of AFTER
Dosage: the patient. -Monitor for continued signs of
1L @ 30 It is a hypovolemia, including poor
GTTS/MIN crystalloid skin turgor, tachycardia, weak
given pulse, and hypotension.
Route: intravenousl Contraindicati Adverse Effect -Monitor for signs of
y in case of on/s hypervolemia such as
IV shock, -Heart failure febrile response, hypertension, bounding pulse,
dehydration -Pulmonary infection at the site pulmonary crackles, dyspnea,
, and edema of injection, venous shortness of breath, peripheral
Frequency: diarrhoea to -Renal thrombosis or phlebitis edema, jugular vein distension
STAT increase the impairment extending from the site (JVD) and extra heart sounds
plasma -Sodium of injection, such as S3
volume. retention extravasation, and -Check for any adverse
hypervolemia reactions and report
immediately to the physician.
-Document baseline vital signs,
edema, lung sounds, and heart
sounds, and continue
monitoring after the infusion.
Name of Drug Action Indication/s Side Effects Nursing
Responsibilities
Generic Increases Edema prevention -Dizziness BEFORE:
Name: osmotic -Headache -Obtain history of the
MANNITOL pressure of -Blurred Vison patient’s fluid and
plasma in -Nausea electrolyte status before
glomerular -Vomiting therapy.
Brand Name: filtrate, -Skin Rash -Check for the correct
OSMITROL inhibiting -Fever patient to be
tubular administered.
reabsorption of -Check doctor’s order if it
Classification: water and is the right drug and right
OSMOTIC electrolytes dose to be given.
DIURETIC (including -Monitor I.V. site
sodium and carefully to avoid
Dosage: potassium). extravasation and tissue
200 cc These actions necrosis
enhance water -Assess for evidence of
Route: flow from Contraindication/s Adverse Effect circulatory overload,
IV various tissues Anuria secondary polyuria, urinary including pulmonary
and ultimately to severe renal retention, osmotic edema, water
decrease disease nephrosis, intoxication, and heart
Frequency: intracranial and Progressive heart pulmonary failure
Q4H intraocular failure, pulmonary congestion, DURING:
pressures; congestion, renal edema, -Administer drug as
serum sodium damage, or renal extravasation with Indicated.
level rises dysfunction after edema and tissue AFTER
Timing:
while mannitol therapy necrosis, seizure, -Monitor renal function
8am-12nn-
potassium and begins Severe chest pain, tests, urinary output, fluid
8pm- 12mn
blood urea pulmonary thrombophlebitis balance, central venous
levels fall. Also congestion or pressure, and electrolyte
protects pulmonary edema levels
kidneys by Severe dehydration -Check for any adverse
preventing reactions and report
toxins from immediately to the
forming and physician if unusualities
blocking are noted.
tubules. -Document and Record
time the drug taken
Name of Drug Action Indication/s Side Effects Nursing
Responsibilities
Generic Citicoline is a Cerebrovascular -Fleeting and BEFORE:
Name: naturally occurring disorders discrete -Check for the
CITICOLINE endogenous hypotension correct patient to be
nucleoside involved effect administered.
in the biosynthesis -Increased -Check doctor’s
Brand Name: of lecithin. It parasympathetic order if it is the right
PREGABLIN increases the effects drug and right dose
synthesis of -Hypotension to be given.
phosphatidylcholine -Itching or hives -Be cautious that this
Classification: (main neuronal -Swelling in face drug may cause low
membrane or hands blood volume,
phospholipid) and -Tingling in headache and
Dosage: enhances mouth and excessive thirst to
1 gm acetylcholine throat the patient
production. It is -Headache DURING:
also claimed that it -Nausea -Administer drug as
Route: increases blood Contraindication/s Adverse Effect Indicated
IVTT flow and oxygen Hypersensitivity to -Bradycardia, AFTER
consumption in the drug Hypertonia of tachycardia, -Check for any
brain. the diarrhoea, adverse reactions
Frequency: parasympathetic epigastric and report
Q8H nervous system discomfort, immediately to the
stomach pain, physician if
fatigue unusualities are
Timing noted and persist.
8am-4pm- -Document and
12mn Record time the drug
taken.
 Name of Action Indication/s Side Effects Nursing
Drug Responsibilities
Generic -Lower blood -Management of Occasional: Localized BEFORE:
Name: glucose by non-insulin-de redness, swelling, -Check doctor’s order
Regular increasing pendent diabetes itching (due to improper or MAR.
Insulin transport into mellitus (type 2) insulin injection -Prepare medication.
cells and unresponsive to technique), allergy to -Double check the
Brand Name: promoting the treatment with insulin cleansing medication before
Humulin R conversion of diet and/or oral solution. Infrequent: going to the client.
glucose to hypoglycemic Somogyi effect -Verify patient
glycogen agents (rebound -Assess for s/sx of
Classification: -Promote the hyperglycemia) with hypoglycemia before
Anti-diabetic/ conversion of chronically excessive administration of
hormones amino acids to insulin dosages. medication.
proteins in Systemic allergic -Inform patient about
muscle and reaction (rash, the medication and
Dosage: stimulate angioedema, its route.
6U triglyceride anaphylaxis), DURING:
formation lipodystrophy -Wash hand and
Inhibit the (depression at injection wear gloves.
release of free site due to breakdown -Do not mx insulin
fatty acids. Contraindication/s of adipose tissue), glargine with any
Route:
-Sources lipohypertrophy other insulin or sol’n.
SQ -Allergy or
include pork, (accumulation of -Administer through
hypersensitivity to
beef/ pork subcutaneous tissue at SQ at the same time
a particular type
combinations, injection site due to each day.
of insulin,
semisynthetic, inadequate site -Instruct patient not
preservatives, or
biosynthetic, rotation). Rare: Insulin to massage site.
Frequency: other additives.
and resistance. After:
STAT recombinant ADVERSE EFFECTS -Wash hands and
DNA. Severe hypoglycemia driscard gloves
(due to hyperinsulinism) properly.
may occur with insulin -Discard sharps in
overdose, the proper bin for
decrease/delay of food sharps.
intake, excessive -Monitor glucose
exercise, those with level as ordered.
brittle diabetes. Diabetic-Document
ketoacidosis may result
from stress, illness,
omission of insulin
dose, longterm poor
insulin control.
Reference: Deglin, J. H., PharmD, & Vallerand, A. H., PhD, RN. (n.d.). Davis's DRUG
GUIDE FOR NURSES (9th ed.). Robert Martone.
 Name of Drug Action Indication/s Side Effects Nursing Responsibilities
Generic Appears to Fever Rare: BEFORE:
Name: inhibit Hypersensitivity -Check doctor’s order or MAR.
Acetaminophen prostaglandin reaction. -Prepare medication.
synthesis in -Double check the medication
Brand Name: the CNS and, before going to the client.
Paracetamol to a lesser ADVERSE -Verify patient
extent, block EFFECTS -Inform patient about the
pain -Early Signs of medication and its effect
Classification:
impulses Acetaminophen -Assess fever, note presence
antipyretics
through Toxicity: of associated signs
peripheral Anorexia, (diaphoresis, tachycardia, and
Dosage: action. Acts nausea, malaise)
500 mg/ tab, 1 centrally on diaphoresis, DURING:
tab hypothalamic fatigue within -Wash hands before
heat- first 12–24 hrs. administation
Route: regulating Contraindication/s -Later Signs of -Administer with a full glass of
PO center, -Pervious Toxicity: water.
producing hypersensitivity Vomiting, right -If overdose occurs,
peripheral -Products upper quadrant acetylcysteine is the antidote.
Frequency:
vasodilation containing tenderness, AFTER:
PRN- q 4h alcohol,
(heat loss, elevated -May be taken with food or on
skin aspartame, hepatic an empty stomach.
Timing: erythema, saccharin, sugar, function tests -Notify the physician if
NOTE: For diaphoresis) or tartazine within 48–72 discomfort or fever is not
>38. 0 ° should be hrs after relived by routine doses of this
avoided in ingestion. drug.
patients who Antidote: -Document
have Acetylcysteine
hypersensitivity or (see Appendix
intolerance to K for dosage).
these
compounds.
Name of Drug Action Indication/s Side Effects Nursing
Responsibilities
Generic Dissociates to -Management of -Frequent: Before:
Name: provide metabolic Abdominal -Check doctor’s order
Sodium bicarbonate acidosis distention, or MAR.
Bicarbonate ion. flatulence, belching. -Prepare medication.
-Double check the
Brand Name: Therapeutic ADVERSE medication before going
Citrocarbonate, Effect: EFFECTS to the client.
Neut, baking Neutralizes -Metabolic alkalosis -Verify patient
soda hydrogen ion (irritability, twitching, -Assess patient for
Classification: concentration, paresthesia, epigastric or abdominal
Antacid raises blood, cyanosis, slow or pain and frank on occult
urinary pH. shallow respirations, blood in the stool,
Dosage: headache, thirst, emesis, or gastric
200 mg nausea). aspirate.
-Fluid overload -Inform patient about
results in headache, the medication and its
Route: Contraindication/s
weakness, blurred effect
PO -Metabolic or vision, behavioral During:
repiratory changes, -Administer medication
Frequency: alkalosis incoordination, with a full glass of
STAT -Hypocalcemia muscle twitching, water.
-Excessive elevated B/P, -Administer medication
chloride loss bradycardia, as directed.
-Patient is tachypnea, -Review with the patient
sodium restricted wheezing, coughing, the symptoms of
diet. distended neck electrolyte imbalance.
-Renal Failure veins. After
-Severe -Extravasation may -Notify physician if
abdominal pain occur at the IV site, indigestion is
of unknown resulting in tissue accompanied by chest
causes, necrosis, ulceration. pain, difficulty
especially if breathing, or
associated with diaphoresis or if stools
fever. become dark or tarry.
-Document
Reference: Deglin, J. H., PharmD, & Vallerand, A. H., PhD, RN. (n.d.). Davis's
DRUG GUIDE FOR NURSES (9th ed.). Robert Martone.
Name of Drug Action Indication/s Side Effects Nursing
Responsibilities
Generic Name: It allows the CKD Nausea, BEFORE:
Ketoanalogue intake of vomiting -Check doctor’s order
essential amino or MAR.
acids while -Prepare medication.
Brand Name: minimizing the -Double check the
Ketobest amino- nitrogen medication before
intake. going to the client.
Following -Verify patient
Classification: ingestion, the -Explain the route of
Supplement ketoanalogues medication and what
are the medication is for.
Dosage: transaminated -Assess patient’s
600 mg by taking electrolyte levels
Route: nitrogen from Contraindication/s Adverse Effect DURING:
Oral non-essential -Hypercalcemia Hypercalcemia -Administer as
amino acid, -Disturbed amino acid directed
Frequency: thereby metabolism -Administer with food
TID decreasing the to prevent GI upset
formation of the AFTER
Timing urea by reusing -Monitor the patient
the amino for hypercalcemia
8am- 1pm- 6pm
group. -Monitor vital signs
-Document
accordingly

Name of Drug Action Indication/s Side Effects Nursing Responsibilities

Generic Inhibits Treatment for -Drowsiness BEFORE:
Name: burst firing partial seizures -Asthenia (loss -Assess for hypersensitivity to
levetiracetam without of strength, levetiracetam, renal function tests.
affecting energy) -Check doctor’s order or MAR.
Brand Name: normal -Headache -Prepare medication.
Levipil 500 neuronal -Infection -Double check the medication before
excitability. -Dizziness going to the client.
Classification: -Pharyngitis -Verify patient
Anticonvulsant -Pain -Explain the route of medication and
-Depression what the medication is for.
Dosage: -Anxiety DURING:
500 mg/ tab -Vertigo -Administer as indicated
-Rhinitis -Monitor renal function tests
-Anorexia -Observe for suicidal ideation,
-Sinusitis depression, behavioral changes.
-Anorexia -Assist with ambulation if dizziness
-Diplopia occurs.
Route: Contraindication/s Adverse Effect AFTER
Oral Hypersensitivity -Acute psychosis, -Report mood swings, hostile
to drug or its seizures have behavior, suicidal ideation, unusual
Frequency: components been reported. changes in behavior.
Sudden -Drowsiness usually diminishes with
BID
discontinuance continued therapy. Instruct the patent
increases risk of
Timing to avoid tasks that require alertness,
seizure activity.
motor skills until response to drug is
8am- 6pm
established.
-Document accordingly
 IX. PROBLEM PRIORITIZATION
Problem Justification
1. Impaired Gas Exchange Rapid breathing

2. Ineffective Cerebral tissue perfusion CVD as evidenced by sensory, language,

intellectual, and emotional deficits
3. Impaired Urinary Elimination Patient had urinary retention

4. Fatigue Patient is lethargic and has decreased

performance

5. Deficient Knowledge DM 2 as evidenced by ineffective self-health

management

X. NURSING CARE PLANS

Problem 1: Impaired Gas Exchange

Defining Nursing Scientific Goal of Care Nursing Rationale

Characteristics
Diagnosis Analysis Intervention
Subjective: Impaired Gas is exchanged SHORT TERM: Independent Independent
“Nakabant gas between the alveoli After 30 minutes of 1.Monitor vital -All vital signs are
ay ko nga exchange and the pulmonary nursing intervention, signs regularly and impacted by
paspas capillaries via the patient will: note cardiac changes in
related to
kayo iya diffusion. Diffusion >Maintain optimal rhythm oxygentation.
ginhawa,” CKD stage 2.Note respiratory -This provides
of oxygen and gas exchange as
as 5 as rate, depth, and insight into the
carbon dioxide evidenced by
verbalized evidenced occurs passively, unlabored effort in breathing. work of breathing
by the SO by rapid and adequacy of
according to their respiration at 12-20
breathing alveolar ventilation
concentration cycles per minute
3.Elevate head of -Elevation or
differences across >Verbalize and
bed and position upright position
OBJECTIVES: the alveolar- manifest sense of
client facilitates
-Rapid capillary barrier. comfort and
breathing appropriately respiratory
These concentration relaxation evidenced function by gravity
-Nasal
flaring differences must be by absence of rapid 4.Teach patient -This will help
-Use of maintained by breathing, nasal deep breathing patient learn how
accessory ventilation of the flaring, using of exercises and to maintain
muscles
alveoli and accessory muscles relaxation optimal gas
-Cold
clammy skin perfusion of the and cold clammy techniques exchange
pulmonary skin 5.Attend patient -This will help
T: 36.7C capillaries. A needs and provide provide comfort.
P:89bpm
balance between the LONG TERM: a quiet and Quiet and
R: 38cpm
BP: two normally exists After 8 hours of comfortable comfortable
160/100mm but certain nursing intervention, environment. environment will
Hg conditions can alter the patient will: help in achieving
O2 Sat: 97% overall patient
this balance between >Demonstrate
the two normally continuous use of wellness.
exists but certain relaxation skills Dependent Dependent
1.Administer -Oxygen
conditions can alter >Demonstrate or
oxygen therapy as administration
this balance, participate in
ordered by helps alleviate and
resulting in Impaired treatment regimen
physician compensate
Gas Exchange. like breathing
 exercises patient’s unusual
breathing pattern
2.Administer -Medication
medications as indicated
prescribed by depending on the
doctor etiological factor
Collaborative will help subside
Reference: and alleviate
https://nurseslabs.com breathing problem.
/impaired-gas-
exchange

Problem 2: Ineffective Cerebral tissue perfusion

Defining Nursing Scientific Goal of Care Nursing Rationale

Characteristics Diagnosis Analysis Intervention
Subjective: Ineffective Due to SHORT TERM: Independent
“Wan-a siya’y Cerebral decreased After 4 hours of nursing 1.Establish -To promote
mabati sa tissue cardiac output, intervention, the patient rapport cooperation
iyang left side 2.Monitor vital -To have
perfusion there is will be able to:
og mag lisod signs baseline data,
sad siya ug related to decreased >Display decrease signs assess changes
lihok”, as CVD as preload and of ineffective tissue in neurologic
verbalized by evidenced stroke volume perfusion status
SO. by sensory, thus there is 3.Check -Determine
language, decreased blood LONG TERM: capillary refill blood
intellectual, pumped out After 4 days of nursing and conjunctiva circulation
OBJECTIVES: for paleness
-Slurring of and from the blood. intervention, the patient
4.Elevate head -Promote
speech emotional Decrease in will be able to: of bed to 30 circulation
-Left sided deficits stroke volume >Gradually improve degrees
weakness decreases tissue perfusion AEB 5.Advise patient -To conserve
-Altered level perfusion good capillary refill and to have enough energy
of throughout the pink conjunctive. rest
consciousness 6.Avoid neck -To avoid
-Chanes in body. >Display no further
flexion and obstruction of
motor/sensory deterioration/ recurrence
extreme hip/ arterial and
responses; Reference: of deficits knee extension venous blood
Doenges, E.,
restlessness >Maintain usual/ flow
Moorhouse, F. M.,
-Cyanotic lips & Murr A. 2010. improved level of Dependent
-Pale Nursing Care consciousness, 1.Provide and -Aids in
conjunctiva Plans: Guidelines maintain difficulty of
for Individualizing cognition, and
and nail beds oxygen as breathing.
Client Care Across motor/sensory function.
the Life Span ordered.
2.Administer -Promote
medications as wellness.
ordered.
 Problem 3: Impaired Urinary Elimination

Defining Nursing Scientific Analysis Goal of Care Nursing Rationale

Characteristics Diagnosis Intervention
Subjective: Impaired Renal failure is a SHORT TERM: Independent Independent
“Kapoy man Urinary problem which results After 8 hours of 1. Determine 1. To assess
ilihok, way Elimination to loss of kidney nursing client’s pattern degree of
gana” as of elimination interference
related to functions and as GFR intervention, the
verbalized by 2. Determine 2. To help
the patient. decrease decreases, the kidney patient will: client’s usual determine level
glomerular cannot excrete >Achieve daily fluid intake of hydration
filtration nitrogenous products normal urinary 3. Observe for 3. To help in
rate and fluid causing elimination signs of infection treating urinary
impairment in urinary pattern alterations
OBJECTIVES:
elimination. >Verbalize 4. Emphasize 4. To promote
-Urinary importance of wellness
retention understanding of
having good
-Intake: 1,220 condition hygiene
ml; Urinary Reference: Doenges, E., 5. Encourage to 5. To allow
output: 340 ml Moorhouse, F. M., & Murr
A. 2010. Nursing Care
LONG TERM: verbalize client to deal
Plans: Guidelines for After 4 days of concerns with feelings
Individualizing Client Care nursing and begin
Across the Life Span problem
intervention, the
solving
patient will:
Collaborative Collaborative
>Identify 1. Collaborate 1. To prevent
causative factors with dietitian to aggravation of
>Demonstrate review proper disease
behaviors or dietary plan for condition
techniques to patient
2. Administer 2. To manage
cope with
medications as symptoms and
condition indicated treat
properly underlying
conditions.

Problem 4: Fatigue

Defining Nursing Scientific Goal of Care Nursing Rationale

Characteristi Diagnosis Analysis Intervention
cs
Subjective: Fatigue Fatigue, as a SHORT TERM: Independent Independent
“ related to nursing diagnosis, After 4 hours of 1. Note stage of 1. To assess
decreased is referred to as the nursing disease process, possible cause and
nutrition state, fluid severity of
metabolic overwhelming intervention, the
OBJECTIVE balance patient’s condition
S: energy sustained sense of patient will: 2. Determine ability 2. To aid in
-Lethargic production exhaustion and >Report to participate in creating an
or listless; decreased capacity improved sense activities individualized
drowsy for physical and of energy treatment regimen
-Decreased 3. Note daily energy 3. To determine
mental work at >Participate in
performanc patterns pattern/timing of
e usual level. recommended
activity
treatment
 Reference: Doenges, program 4. Encourage client to 4. To increase
E., Moorhouse, F. M., do whatever possible activity level as
& Murr A. 2010.
Nursing Care Plans: LONG TERM: tolerated
Guidelines for 5. Provide 5. To reduce
After 4 days of
Individualizing Client environment stressors that
Care Across the Life nursing conducive to relief of might trigger
Span intervention, the fatigue fatigue
patient will: Collaborative Collaborative
>Identify basis 1. Review medication 1. To identify
of fatigue and regimen/use which drugs cause
individual areas fatigue
2. Refer to PT/OT for 2. To
of control
programmed daily maintain/increase
>Perform ADLs exercises and strength and
and participate in activities muscle tone and to
desired activities enhance sense of
at level of ability well-being
3. Refer to counseling 3. To provide
or psychotherapy as psychological and
indicated emotional support

Problem 5: Deficient Knowledge

Defining Nursing Scientific Goal of Care Nursing Intervention Rationale

Characteristics
Diagnosis Analysis
Subjective: Deficient Absence or SHORT TERM: Independent
“Wa ko 1. Discuss essential 1. Provides knowledge
kahibaw
Knowledge deficiency of After 4 hours of
ngano naka related to cognitive nursing elements, such as the base from which client
sakit ko following: Explain the can make informed
Diabetes information intervention the
ani”, as normal blood glucose lifestyle choices.
verbalized Mellitus related to patient and/ or range and how it
by patient. Type 2 as specific topic SO: compares with client’s
OBJECTIVES:
evidenced [Lack of >Will verbalize level, the type of
-History by specific understanding of diabetes the client has,
of past ineffective information the disease and the relationship
illness Self-health necessary for process and between insulin
deficiency and a high
Manageme clients/SO(s) potential
glucose level
nt to make complication. 2. Review client’s type 2. Verifies
informed >Identify of basal insulin understanding and
choices relationship of correctness of
regarding s/sx to the disease procedure. Identifies
condition/tre process and potential problems, so
atment/lifest correlation that alternative
solutions can be found
yle changes. symptoms with
for insulin
Reference: causative factors. administration.
Nursing Care
Plans
>Participate in 3. Review self- 3. Confirms that client
Guidelines for learning process, administration of is proficient in skills or
Individualizing as well as the S.O insulin, either will require assistance
Client Across injection or pump, and or full care in managing
the Life Span by correctly
care of equipment. procedures and
Doenges, performs
APRN, BC- Have client equipment.
necessary demonstrate
Retired, et.al.
 procedure and procedure: drawing up
explains reasons and injecting insulin,
for the action. insulin pen technique,
or use of continuous
pump.
LONG TERM: 4. Reasons for the 4. Knowledge of the
After 2 weeks of ketoacidotic episode precipitating factors
nursing may help avoid
intervention, the recurrences.
patient will: 5. Acute and chronic 5.Acute and chronic
> Present absence complications of the complications of the
disease, including disease, including
of any other
visual disturbances, visual disturbances,
complications neurosensory and neurosensory and
cardiovascular cardiovascular changes,
changes, renal renal impairment, and
impairment, and hypertension
hypertension 6. Frequent (up to 6 to
6. Demonstrate 8 times daily) self-
fingerstick testing, or monitoring of blood
similar procedure, glucose (SMBG) is the
such as palm or foundation of intensive
armstick, or diabetes management.
continuous glucose
monitoring system.
Have client and SO
return demonstration
of obtaining sample
and operating blood
glucose until
proficient. Collaborative
Collaborative 1. To determine if there
1. Arrange for follow are any complications
check -ups. develop.

XI. DISCHARGE PLANNING

Patient Data
Patient Initials: A.M.B.
Age: 77 years old
Sex: Male
Diagnosis: CVD BLEED, HCVD, TYPE 2 DM, CKD STAGE 5 SEC TO HYPERTENSIVE
NEPHROSCLEROSIS VS URATENEPHROPATHY
Subjective Data “Bisag maningkamot pa ko, maglisod gihapon ko’g lihok”, as
verbalized by the patient.
Objective Data T – 36.7 °C
P – 89 bpm
R – 38 cpm
BP – 160/100 mmHg
O2 – 97%
Assessment/Nursing Impaired physical mobility related to neuromuscular impairment
secondary to hemorrhagic stroke
Diagnosis
Planning Demonstrate techniques/behaviors that enable resumption of
activities
Intervention
Activity Advice patient to have complete bed rest until strength is
regained. Have the patient turn to side to prevent bed sores.
 If tolerated, do light exercises such as walking.
Encourage the patient to do range of motion exercises with
patient’s capabilities to promote good circulation and to
enhance body function.
Medication Instructed to take prescribed medications by the physician as
directed.
Instruct SO to monitor patient ability to take medication.
Environment Encourage SO to maintain a safe, clean and quiet environment.
Encourage to maintain cleanliness of the house and
surroundings.
Inform patient and SO to limit visitors.
Treatment Instruct patient and SO that treatment should be continued at
home according to the doctor’s instructions.
Encourage patient to take medications prescribed by the
physician.
Health Teachings Educate patient on how to have a healthy lifestyle, right foods
to eat and foods to avoid.
Instruct patient and SO to maintain safe environment.
Advise patient to take medicines as directed.
Encourage to begin an exercise program.
Encourage to control cholesterol level.
Provide stress management methods to deal with stress at
home or work.
Advise patient to assist with movement and exercises using
unaffected extremity to support and move weaker side.
Instruct patient to report to the doctor immediately if
unusualities occur.
Outpatient Referral Instruct patient to keep all follow-up appointments and to
comply with the scheduled check-up.
Diet Changes in diet may include:
Reducing the amount of fat and cholesterol you eat
Reducing the amount of salt (sodium) in your diet
Eating more fresh vegetables and fruits
Eating more lean proteins, such as fish, poultry, and beans and
peas (legumes)
Eating less red meat and processed meats
Using low-fat dairy products
Limiting vegetable oils and nut oils
Limiting sweets and processed foods such as chips, cookies,
and baked goods
Not eating trans fats.
Spiritual Encourage patient to always pray and seek guidance to his God
and to always have faith in him.

XII. Further Readings

Hemorrhagic Stroke Treatment & Management, 22 April 2019

Management begins with stabilization of vital signs. Perform endotracheal intubation for patients with a decreased
level of consciousness and poor airway protection. Intubate and hyperventilate if intracranial pressure is elevated,
and initiate administration of mannitol for further control. Rapidly stabilize vital signs, and simultaneously
acquire an emergent computed tomography (CT) scan. Glucose levels should be monitored, with normoglycemia
recommended. [1] Antacids are used to prevent associated gastric ulcers.
The treatment and management of patients with acute intracerebral hemorrhage depends on the cause and severity
of the bleeding. Basic life support, as well as control of bleeding, seizures, blood pressure (BP), and intracranial
pressure, are critical. Medications used in the treatment of acute stroke include the following:
Anticonvulsants - To prevent seizure recurrence
Antihypertensive agents - To reduce BP and other risk factors of heart disease
Osmotic diuretics - To decrease intracranial pressure in the subarachnoid space

No effective targeted therapy for hemorrhagic stroke exists yet. Studies of recombinant factor VIIa (rFVIIa) have
yielded disappointing results. Evacuation of hematoma, either via open craniotomy or endoscopy, may be a
promising ultra-early-stage treatment for intracerebral hemorrhage that may improve long-term prognosis.
Reference:
https://emedicine.medscape.com/article/1916662-treatment