JH CERILLES STATE COLLEGE

Pagadian Annex
West Capitol Road, Balangasan District
Pagadian City

In consortium with
WESTERN MINDANAO STATE UNIVERSITY
Zamboanga City

Name of Student Group 2 Clinical Instructor Mrs. Warqueen Factor Vedra

Area of Assignment Medical Ward Date Submitted November 18, 2023

NURSING ASSESSMENT I

I. DEMOGRAPHIC DATA

Name Patient J Address Purok Malambuon, Balangasan P.C. Age 54 years old

Sex Female Religion Roman Catholic Civil Status Widowed Occupation Cashier

II. HEALTH HISTORY

A. Chief Complaint/s:
Shortness of breath

B. Impression/Admitting Diagnosis:
To consider Community Acquired Pneumonia Moderate Risk vs Pulmonary Tuberculosis, to consider Type II Diabetes Mellitus, Newly Diagnosed
Stage II Hypertension.

C. History of Present Illness {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, include obstetrical history,
LMP and EDC for OB patient; affected diagnosis}.
1 month prior to admission noted acute onset of non--productive cough. Tolerated condition. No consult sought. In the interim, noted progression of cough from non-
productive to productive. Self-medicated with salbutamol, with noted partial relief. Persistence of cough associated with shortness of breath, thus sought consult and subsequuently admitted.

D. History of Past Illness (previous hospitalization, injuries, procedures, infectious disease, immunization, health maintenance, major illnesses, allergies, medications, habits, birth and
developmental history, nutrition- for pedia)
 Patient has no history of hospitalization, fully immunized; patient has maintenance medication of Losartan 50 mg; no known allergies; taken OTC drugs such as
Paracetamol.

E. Habits

Frequency Amount/Dose Period/Duration

 Smoking √ 1 pack 1 year

 Drinking √ 500 ml occasionally
 OTC Medications Paracetamol 500 mg prn

F. Family History with Genogram

Legend: Acquired Diseases:

Hypercholesterolemia ×
Kidney Disease ×
Tuberculosis ×
Alcoholism ×
Drug Addiction ×
Hepatitis A ×
B ×
C ×
Others (pls. specify) ×
Determine which side (or specific member of the
Heredo- familial Diseases: family. Ex. Paternal, Maternal, Sibling, Self
Diabetes √ paternal
Heart Diseases × ×
Hypertension √ self, maternal
Cancer √ paternal
Asthma × ×
Epilepsy × ×
Mental Illness × ×
Arthritis √ self
Others (pls. specify) × ×
 GENOGRAM

X X X X

Grandfather Grandmother Grandmother

Grandfather

X
X
Mother Father

LEGEND:

Male X Deceased Hypertension

Female Diabetes Lung cancer

Patient Lung Cancer

 IV. LABORATORY AND DIAGNOSTIC PROCEDURES
PATIENT’S NAME: Patient J DATE:

DATE NAME OF THE RESULT NORMAL VALUE NURSING IMPLICATION NURSING CONSIDERATION
PROCEDURE (before and /or after procedure)

11/05/2023 HEMATOLOGY BEFORE:

White Blood Cell 12.10 5.0 - 10.0 High WBC indicates infection.  Explaining any necessary preparation, such
Red Blood Cell 5.17 4.2 - 5.4 High RBC can be a sign of dehydration or as fasting or discontinuing certain.
heart disease.  Assessing for any known allergies or
MCV 79.5 80.0 - 96.0 Low MCV indicates microcytic anemia sensitivities to contrast agents or other
MCH 27.1 33.0 - 36.0 Low MCH indicates hypochromic anemia substances used in specific hematology test.
RDW- SD 38.2 39.0 - 46.0 Low RDW- SD means that Red Blood Cells  Ensuring the patient understands the
are not very different in size from typical purpose, procedure and potential risks of
measurements. hematology before obtaining informed
Differential Count consent.
Eosinophils 9.2 0.5 -1 High Eosinophils may indicate allergies.
AFTER:
 Assisting with any discomfort/ pain at the
11/05/2023 ELECTROCARDIOGRAM Sinus rhythm Normal site where the blood sample was taken.
LAD, no  Observing for any immediate complication
hypertrophy, such as bleeding, hematoma formation or
no ischemia allergic reactions.

BEFORE:
11/05/2023 BLOOD CHEMISTRY  Ensure accurate patient identification by
HbA1C 10.99 4.5 - 6.5 % High HbA1c means you have too much sugar checking their name, date of birth and other
in blood. identifiers.
Blood Urea Nitrogen (BUN) 5.5 <8.3 mmol/L (<65 y.o) Low BUN may be caused by a diet very low  Confirm that the patient has followed any
<11.9 mmol/L (>65 y.o) in protein. fasting requirements if applicable and
Creatinine 105.9 Male= 59 - 104 umol/L High Creatinine may indicate Kidney’s aren’t educate them about the purpose and
Female= 45 - 84 umol/L working well. procedure at the test.
Uric Acid (BUA) 375.2 umol/L Male= 202.3- 416.8 umol/L High Uric Acid indicates hyperuricemia.
Female= 142.8- 339.2
umol/L
 AFTER:
11/06/2023 BLOOD CHEMISTRY  Regularly assess vital signs to ensure the
Lipid Profile < 5.2 mmol/L patient’s stability post- procedure.
Cholesterol 5.28  Observe the patient for any signs of
<2.3 mmol/L complication such as excessive bleeding or
Triglycerides 2.78 High triglyceride often a sign of other fainting and take appropriate action if
conditions that increase risk of heart disease needed.
Male: >1.145 mmol/L and stroke.
HDL 0.92 Female: >1.68 mmol/L Low HDL increased risk of heart disease.
<5.159 mmol/L
LDL 3.08 Low LDL increased risk of hemorrhagic
stroke.

11/06/2023 ARTERIAL BLOOD GAS 7.35- 7.45 BEFORE:

ph 7.40 34- 48 mmHg Normal Range  Expalin the procedure. ABG analysis
PCO2 40.5 83- 108 mmHg Normal Range evaluates how well the lungs are delivering
p02 92.0 21- 28 mmol/L Normal Range the oxygen to the blood.
CHC03 24.8 -2 - 3 mmol/L Normal Range  Instruct patient to breath normally during
BE 0.2 94- 98% Normal Range the procedure.
CSO2 97 Normal Range  Monitor Vital Signs and observe for signs of
circulatory impairment.
 V. SUMMARY OF MEDICATION

PATIENT’S NAME: ____________Patient J__________________________ DATE: ______________

DATE MEDICATIONS DOSAGE ROUTE FREQ REMARKS NURSING RESPONSIBILITIES

11/06/2023 Ceftriaxone 2g IV OD Given and Recorded  Use Cautiously in patients that is
hypersensitive to penicillin because of
possible cross- sensitivity with other beta-
lactum antibiotics.
 Monitor patient for signs and symptoms of
super infection.
 Obtain specimen for culture and sensitivity
before giving first dose.

Azithromycin 500mg PO OD Given and Recorded  Use cautiously in patients with impaired
hepatic function.
 Monitor patient for super infection. Drug
may cause overgrowth of non- susceptible
bacteria or fungi.

Human Recombinant 4 units SQ Given and Recorded  Assess patient’s glucose level before starting
Insulin (HRI) theraphy and regularly after.
 Monitor patient’s glycosylated hemoglobin
level regularly.

INH Q4h Given and Recorded

Ipratropium Bromide 500mcg  Use cautiously in patient with angle closure
glaucoma prostatic hyperplasia or bladder-
neck obstruction.
 If using a face mask for a nebulizer, take
care to avoid leakage around the mask; eye
pain or temporary blurring of vision may
occur.

Clonidine 100 mg PO  Monitor blood pressure and pulse rate

BID Given and Recorded frequently. Dosage is usually adjusted to
patient’s blood pressure and tolerance.
 Observe patient for tolerance to drugs
therapeutic effects which may require
increase dosage.

PO
Losartan OD Given and Recorded  Use cautiously in patients with impaired
50 mg
renal or hepatic function.
 Monitor patient’s blood pressure closely to
evaluate effectiveness of therapy.
 VI. SUMMARY OF INTRAVENOUS FLUID

INTRAVENOUS FLUID &

DATE/TIME NO. OF NUMBER DATE/TIME
VOLUME DROP RATE COMPUTATION
STARTED BOTTLE OF HOURS CONSUMED
11/06/2023 1 PNSS 1L 20 gtts/min. 12 hrs. and 30 11/06/2023 Total Volume (ml)
8:30 am mins. 9:00 pm
Prescribed rate x 4ml
11/06/2023 2 PNSS 1L 20 gtts/min. 12 hrs. and 30 11/07/2023
9:00 pm mins. 9:30 am 1000ml

11/07/2023 3 PNSS 1L 20 gtts/min. 12 hrs. and 30 11/07/2023 20 gtts/min. x 4ml

9:30 am mins. 10:00 pm
1000 ml
11/07/2023 4 PNSS 1L 20 gtts/min. 12 hrs. and 30 11/08/2023
10:00 pm mins. 10:30 am 80 gtts/min.

11/08/2023 5 PNSS 1L 20 gtts/min. 12 hrs. and 30 11/08/2023 = 12. 5 hrs. or 12 hrs. and 30 mins.
10:30 am mins. 11: 00 pm

VII. INTAKE AND OUTPUT MONITORING SHEET

PATIENT’S NAME: ___________Patient J___________________________ DATE: _____________

INTAKE OUTPUT

SHIFT URINE NGT/DRAINS PTT/CTT BM OTHERS TOTAL

11/06/2023 240 0 240

11/07/2023 720 0 720

11/08/2023 720 0 720

TOTAL:
1680 0 1680
 VIII. VITAL SIGNS AND NEUROLOGICAL OBSERVATION SHEET
PATIENT’S NAME: ________________________________ AGE/SEX: __________ BED/ROOM NO./ WARD:
________________

BLOOD
PULSE RATE
PRESSURE
REMARKS (LOC; Handgrip;
OXYGEN PUPIL GCS
DATE/ TEMPERAT RESPIRATO Muscle, Strength; Limp
ARTERI SATURA SIZES (E,M,V=
TIME URE RY RATE Movement; Breathing; UO;
RADI APIC AL TION (R,L) TOTAL)
CUFF BM; etc)
AL AL CATHET
ER

E= 4 LOC: awake, responsive,

oriented, body weakness
11/06/2023 36.3 71bpm 140/90 17cpm 98% 3,3 M= 6 =15
mmHg UO: 0 , BM: 0
V= 5

E= 4 LOC: awake, responsive,

oriented, body weakness
150/90
11/06/2023 36.5 70bpm mmHg 20cpm 98% 3,3 M= 6 =15 UO: 240 ml, BM: 0

V= 5

E= 4 LOC: awake, responsive,

oriented, body weakness
11/07/2023 36.7 69bpm 160/90 21cpm 96% 3,3 M= 6 =15
mmHg UO: 0 , BM: 0
V= 5

11/07/2023 36.5 83bpm 170/90 20cpm 96% 3,3 E= 4 LOC: awake, responsive,
mmHg oriented, body weakness
M= 6 =15 UO: 720 ml, BM: 0
V= 5

11/08/2023 36.8 82bpm 160/90 21cpm 97% 3,3 E= 4 LOC: awake, responsive,
mmHg oriented, body weakness
M= 6 =15 UO: 0 , BM: 0
V= 5

11/08/2023 36.9 81bpm 160/90 20cpm 96% 3,3 E= 4 LOC: awake, responsive,
mmHg oriented, body weakness
M= 6 =15 UO: 720 ml , BM: 0
V= 5
A. Anatomy and Physiology
B. Illustration (drawing of organs(s) / system(s) involved with appropriate labels of its structure)

The pancreas is a long, slender organ, most of which is located posterior to the bottom half of the stomachAlthough it is primarily
an exocrine gland, secreting a variety of digestive enzymes, the pancreas also has endocrine cells. Its pancreatic islets—clusters
of cells formerly known as the islets of Langerhans—secrete the hormones glucagon, insulin, somatostatin, and pancreatic
polypeptide (PP).

Alpha Cells
(glucagon Production)
Decreases blood glucos
level
Alpha cells release
glucagon intothe
bloodstream
Glucagon stimulates the
liver to convert stored
glycogen into glucose.
Raising blood sugar level
BLOOD SUGAR REGULATION
PANCREAS
Islets of Langerhans
Beta Cells Delta Cells
(insulin Production) (Somatostatinn Prooduction)
Increase blood glucose Delta cells release somatostatin
level
Somastotatin inhibits the
Beta cells release insulin release of both insulin and
into the bloodstream glucagon, contributing to fine
Insulin facilitates tube blood sugar reggulation
glucose uptake by cells
for energy or storage
Insulin promotes glucose
Increases blood glucose Postprandial (after meal) Fasting or between meals
uptake, reducing blood Thoracic volume decreases
stimulates insulin release
sugar levels
Air is expelled from
Decreased bloodthe lungs back
glucose
NEGATIVE FEEDBACK
into the atmosphere
stimulates glucagon
release.
GAS EXCHANGE IN TISSUES
Balancing Act
The diaphragm contracts and flattens
Glucagon
Oxygen promotes from
dessociates the
Intercostal muscle expand the ribcage release ofinglucose
hemoglobbin systemicfrom the
capilliaries,
Local Regulation
liver, increasing
enterinng tissues forblood
cellular
Thoracic volume decreases
glucose homeostasis
respiration
Air is drawn into the lungs through
the airways
Paracrine Action Fine tuning
Carbon dioxide enters systemic
GAS EXCHANGE IN ALVEOLI
capillaries
Inhaled air reaches the alveoli

Oxygen from the alveoli diffuses into

TRANSPORT OF CARBON
the pulmonary
Lungs capillaries
facilitatesthe exchange of DIOXIDE
gases,binds
Oxygen ensuring the body recieves
to hemoglobin in RBC
oxygen and expels carbon dioxide Deoxygenated blood, carrying carbon
TRANSPORT OF OXYGEN dioxide, returns to the right atrium of
INHALATION the heart
Oxygenated blood is carried by the
pulmonary veins to the left atrium of From the right atrium, blood is
the heart pumped into the pulmonary
circulation, reaching the lungs
From the left atrium,oxygenated
blood is pumped into systemic GAS EXCHANGE IN ALVEOLI
circuulation
Carbon dioxide diffuses from the
EXHALATION pulmonary capilliaries into the alveoli

The diaphragm relaxes and intercostal During exhalation, carbon dioxide is

muscles return to their resting expelled from the lungs.
position
 Heart involves a series of coordinated
steps to pump blood throughout the body,
ensuring oxygen and nutrient are
delivered to tissue and waste products are
removed.
BLOOD RETURN TO THE HEART
Deoxygenated blood returns to the right
atrium
ATRIAL CONTRACTION
The right atrium contracts pushing blood
through the tricuspid valve into the right
ventricle
VENTRICULAR COONTRACTION
The left ventricle contracts, sending
oxyygenated blood through the aortic
valve into the aorta
SYSTEMIC CIRCULATION
Oxygenated blood is pumped into the
systemic circulation through the aorta
Blood travels through arteries, arterioles
and capilliaries to deliver oxygen and
nutrients to body tissues
TISSUE OXYGENATION
Oxygen and nutrients are exchanged for
waste products in capilliaries within
tissues
Deoxygenated blood returns to the heart
through venules and veins
PULMONARY CIRCULATION
Deoxygenated blood enter the right
atrium
Blood is pumped into the pulmonary
circulation
GAS EXHANGE IN THE LUNGS
In the lungs, carbon dioxide is expelled,
and oxygen is taken up by RBCs
Oxygenated blood returns to the left
atrium through pulmonary veiins
REPEATING THE CYCLE
The entire cardiac cycle repeats, with
coordinated atrial and ventricular
contractions, ensuring continous blood
circulation.
 XI. PATHOPHYSIOLOGY

A. Pathophysiology

B. Diagram and Illustration (drawing & diagram/ flow chart of disease process)
 XIII. MEDICAL MANAGEMENT

Ideal:

COMMUNITY ACQUIRED PNEUMONIA based on the severity of symptoms, the patient’s health and

The management of CAP- MR often involves antibiotics, local resistance patterns.

rest and supportive care. The specific treatment may vary

PHARMACOLOGIC THERAPY NUTRITIONAL THERAPY

Administration of antibiotics Nutrition, meal planning, weight control and increased activity are
the
In patients should be switched from IV to Oral Therapy foundation of diabetes management.

Focus on complex carbohydrates with a low glycemic index such as

OTHER THERAPEUTIC REGIMEN whole grains, legumes and vegetables.
Hydration is necessary part of therapy. Eating smaller, balanced meals throughout the day can stabilize
Antipyretic may be used to treat headache and fever. glucose levels.

Warm, moist inhalations are helpful in relieving bronchial irritation. PHARMACOLOGIC THERAPY

Insulin may be necessary on a long term basis to control glucose

levels, if meal planning and oral agents are ineffective or when
insulin
deficiency occurs.

Thiazolidinediones are a class of oral anti diabetic medications that

reduces insulin resistance in target tissues enhancing insulin action
without directly
DIABETES MELLITUS TYPE II stimulating insulin secretion.

The main goal is to normalize insulin activity and blood glucose Anti diabetic agents include second- generation sulfonylureas,
levels biguanides, alpha- glucosidase inhibitors, dipeptide peptidase
to reduce the development of complications. 4 inhibitors.

HYPERTENSION The goal is to prevent complications and death by maintaining

a blood pressure lower than 130/80 mmHg. Medications used
to treat high blood pressure includes:
Angiotensin- Converting Enzyme (ACE) inhibitors Medications prescribed by the Physician:

Angiotensin II Receptor Blockers (ARBS) * Ceftriaxone 2g IV, OD

* Azithromycin 500 mg PO, OD
Calcium Channel Blockers * Human Recombinant Insulin 4 units, SQ
* Ipatropium Bromide 500 mcg, INH, q4h
* Clonidine 10 mg PO, BID
* Losartan 50 mg PO, OD
* Omeprazole 40 mg IVTT, OD
*Isosorbide Dinitrate 10mg PO, OD
Actual:

PHARMACOLOGICAL THERAPY
 XIV. SURGICAL MANAGEMENT

Ideal:

COMMUNITY ACQUIRED PNEUMONIA

While most patients with pneumonia do not require

surgery, it may be necessary if complications such as
lung abscess.

Chest Tube
- chest tube insertion to place a flexible, hollow
drainage tube in to the chest in order to remove
an abnormal collection of air and allow the lungs
to fully expand. It is place between the ribs and
into the space between the ribs and into the space
between the inner and outer lining of the lung.

Thoracotomy
- which involves an incision to open the chest and
view the lungs so that dead and damaged lung
tissue can be removed.

Lobectomy

- removing a part of the lung.

 XV. NURSING MANAGEMENT

Ideal:
COMMUNITY ACQUIRED PNEUMONIA

Improve patent airway. Checked and recorded patient vital signs for baseline data.

Monitor for respiratory changes. Auscultated breath sounds to notify for any changes.

Maintaining nutrition. Provided comfort measures.

Promote adequate rest. Instructed patient to have adequate rest and increase fluid intake.

Encourage movement and positioning. Provided health teaching on proper ways of coughing and breathing.

Increase fluid intake Assessed patients response to treatment.

Manage pain and cough

DIABETES MELLITUS TYPE II

Limiting salt and fat intake

Engage on physical activity

Monitor blood glucose levels and blood pressure. Checked blood glucose levels by performing capillary blood glucose monitoring.

Limit alcohol intake Checked and recorded patients vital signs for baseline data.

Keeping a record of blood glucose levels to detect patterns and Instructed patient to limit salt and fat intake
abnormalities.
Instructed patient to eat more fruits and vegetables.
Instructed patient to engage on physical activity and exercise. Instructed patient to take maintenance medication prescribed by the doctor.

HYPERTENSION

Educate a patient about managing blood pressure and providing
assistance with social support.
Provide written information about the expected effects and side effects
of medication.
Checked and recorded vital signs.
Instructed patient to report any changes, signs and symptoms of
hypertension like headaches, fatigue or confusion, dizziness and difficulty
breathing.

Educate about how a change of lifestyle and medications can control Provided comfort measures
hypertension.
Monitored intake and output.
Advice to limit alcohol intake, tobacco and nicotine should be avoided.
Regulated IV flow rate.
Regular follow up care so that blood pressure control can be achieve.
 XVI. NURSING CARE PLAN

SCIENTIFIC
NURSING EXPLANATION OF EXPECTED
CUES OBJECTIVES INTERVENTIONS RATIONALE
DIAGNOSIS THE PROBLEM OUTCOME
(DIAGNOSIS
Subjective: Elevated body A fever is a temporary After 8 hours of nursing  Monitor core ‒ Monitoring core After 8 hours of nursing
“Init akong pamati, temperature rise in the body intervention, the patient temperature temperature can intervention, the patient
tibuok jud nakong temperature. It’s one part will be able to: help detect disease were able to:
lawas,” as verbalized by of an overall response  Achieve a normal or infection early
the patient. from the body’s immune body temperature  Increase oral fluid ‒ To replace the  Achieve a normal
system. A fever is usually range from 36.5 ℃ intake body’s fluid loss body temperature
Objective: caused by an infection. to 37.5℃ range from 36.5 ℃
T: 38.3 ℃ Sometimes the occurence  Provide tepid sponge ‒ To promote to 37.5℃.
RR: 21 cpm of fever may also be due bath dispersal of body
BP: 130/90 mmHg to noninfectious factors, heat and to have a
PR:88 bpm like injury, heat stroke or cooling effect.
 Hot flushed skin dehydration.  Promote surface ‒ Heat is loss by
 Skin warm to cooling, loosen evaporation and
touch clothing and coool conduction
environment

 Raise the side rails ‒ Helps ensure

and lower bed at all patient’s safety
times
 Administer ‒ To reduce body
antipyretics as temperature
prescribed by the
physician
 Monitor and record ‒ Potential fluid and
all sources of fluid electrolyte losses
loss such as urine
output.

XVI. NURSING CARE PLAN

SCIENTIFIC
NURSING EXPLANATION OF EXPECTED
CUES OBJECTIVES INTERVENTIONS RATIONALE
DIAGNOSIS THE PROBLEM OUTCOME
(DIAGNOSIS
Subjective: Ineffective airway Ineffective airway After 8 hours of nursing  Assess and record ‒ It is important to After 8 hour of nursing
“Gahi kaayo akong ubo clearance related to clearance is the inability interventions, the respiratory rate. take action when interventions, the
mao nang inag ubo obstructed airway to clear secretions or patient will be able to: there is an patient was able to:
nako sakit. Naa pod from retained obstructions from the  Patient will avoid alterartion in  Verbalize to avoid
plema mugawas inag secretions respiratory tract. specific behaviors or breathing patterns cigarette smoking as
ubo nako.” factors that worsen to detect early signs it worsen secretions
secretions and of compromise and airway
Objective: airway clearance  Evaluated patiient’s respiratory system. clearance
T: 38.3 ℃  Expectorate cough, amount and ‒ To determine ability  Demonstrate
RR: 21 cpm secretions type of secretions. to protect own reduction of
BP: 130/90 mmHg  Demonstrate  Instruct patient to airway congestion.
PR:88 bpm absence/reduction have adequate rest ‒ Extra activity can
of congestion with worsen shortness of
 Fatigue breath sounding  Maintain an elevated breath
 Dyspnea clear head of bed as ‒ To help preventt
 Restlessness tolerated. Sliding secretions from
down in the bed or a accumulation
slumped posture
prevents proper lung
expansion and can
reduce coughing
effectiveness.
 Teach coughing and
deep breathing
exercises, if coughing ‒ To mobilize
is painful the patient secretions
can splint the
abdomen with a
pillow
 Administer
bronchodilators,
mucolytics or ‒ Bronchodilators help
expectorants and open the airway,
antibiotics as mucolytics or
ordered. expectorants help
thin mucus and
make easier to
cough up, antibiotics
 Drinking plenty of treats respiratory
 fluids infections.
‒ Thins secretions
and prevents
dehydration.

XVI. NURSING CARE PLAN

SCIENTIFIC
NURSING EXPLANATION OF EXPECTED
CUES OBJECTIVES INTERVENTIONS RATIONALE
DIAGNOSIS THE PROBLEM OUTCOME
(DIAGNOSIS

Subjective: Elevated blood Hypertension is the After 8 hours of  Monitor blood ‒ Changes in blood After 8 hours of
“Malipong ko pressure term used to describe nursing interventions, pressure pressure may nursing intervention,
usahay,” as manifested by high blood pressure. the patient will be able indicate changes in the patient was able
verbalized by the dizziness Hypertension is to: patient status to:
patient. repeatedly elevated  Maintain blood requiring prompt  Maintain blood
blood pressure pressure within attention pressure within
Objective: exceeding 140 over 90 acceptable limits  Recommend ‒ Provides acceptable limits
T: 37.2℃ mmHg.  Verbalize patient to keep opportunity to  Verbalized
PR: 82 bpm understanding of diary of pressure follow trends and understanding of
RR: 21 cpm condition, readings taken at indentifyy the condition,
BP:180/90 mmHg therapeutiic different times of contributing therapeutic
regimen and the day and noting factors such as regimens and
 dizziness preventive any associated medication effects preventive
measures symptoms measures.
 Provide calm, ‒ It helps lessen
restful sympathetic
surroundings, and stimulation;
minimize promotes
environmental relaxation.
activity and noise.
Limit the number of
 visitors and length
of stay.
 Educate patient to ‒ Promotes patient’s
understand the general well-being
disease process and
how lifestyle
changes and
medications can
control
hypertension
 Instruct patient to ‒ Consumption of
restrict foods high foods rich in salt,
in salt, sugar and sugar and fats may
fats increase blood
pressure

 Emphasize increase ‒ Healthy diet may

consumption of help regulate the
fruits and blood pressure
vegetables

XVII. DISCHARGE PLAN

NAME: Patient J AGE/SEX: 54 y.o / F ADDRESS: Purok Malambuon Balangasan, Pagadian City
DATE/TIME OF ADMISSION: _____________________ FINAL DIAGNOSIS: ____________________________________
DATE/TIME OF DISCHARGE: ____ OPERATION/PROCEDURE DONE: ___________ ATTENDING PHYSICIAN: _______________________
CONDITION UPON DISCHARGE: Well and Recovered ( ) With Slightly Improved Condition ( ) Unstable and Needs More Medical Management ( ) Dead ( )
NATURE: May Go Home ( ) Home per Request ( ) Discharged Against Medical Advise ( ) Transferred to Hospital of Choice ( ) Referred to Another Facility ( ) Death ( )
  Encourage SO to help monitor the medications taken.
 Teach patient regarding the names of the drugs, its dosage, time of administration, contraindication and side effects.
1. MEDICATIONS
 Instruct patient to check for expiration date before taking the medication.
 Instruct patient to eat before taking the medications that may irritate the Gastrointestinal Tract.
 Instruct patient to reposition every 2 hours to prevent bed sores.
2. ENVIRONMENT &
 Encourage patient to have a proper rest in a well- ventilated and comfortable environment.
EXERCISE / ACTIVITY LEVEL/
 Avoid exposure to smoke.
RESTRICTIONS
 Avoid abruption of medication.

3. TREATMENTS
 Provide patient with oxygen therapy if prescribed by the physician.
 Nebulizer/ Nebulizing session as needed.
Instruct patient to follow a healthy diet.
Instruct patient to take medication on time
4. HEALTH TEACHING Encourage and instruct SO to monitor patients ability to take medications.
Explain complications that may arise if not taking medication accordingly.
Instruct family members to keep patient on their watch as the patient may not totally recovered.
5. OUTPATIENT/ INPATIENT  Instruct patient to come back for follow-up check up.
REFERRALS  Instruct patient to visit a doctor when there is any unusual noted.

 Keep low salt and low fat diet.

6. DIETARY INSTRUCTIONS
 Encourage patient to eat more fruits and vegetables.