A.

Actual Medical Management

The Patient and Her Care IVF used/consumed D5 LRS (5% Dextrose Lactated Ringers Solution) 1L General Description Hypertonic solution that has higher osmolarity than the serum. It pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. It is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply administered intravenously. Indication or purpose Since the patient was on NPO upon admission, she was given D5 LRS as her IVF administered intravenously to serve as a source of water, electrolytes, and calories. It also serves as a route for medication administration.

D5 0.3 NaCl (5% Dextrose 0.3 Sodium Chloride) 500cc

To maintain rehydration and to replace fluid loss, patient was given this IVF.

Hypotonic solution that has Also, for medication administration. greater concentration of free water molecules that are found inside the cell.

c. Diet

Type Of diet Soft Diet ( low low diet)

General description

Indication

Very similar to regular diet except fat, that the textures of salt foods have been modified.

This was ordered to provide a transitional diet between liquids and regular food for (vegetable soup) patients who have difficult in swallowing or who undergone surgery. 30

Specific Foods Taken Lugaw, soup

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d. Positioning Type Of General description exercise Moderate high A position wherein the back rest patient is kept on bed with the head of bed held at at least 45 with limitations to other activities.

Indication To reduce oxygen demand and prevent fatigue. Rest decreases body metabolic rate. Since the patient is old, she is prone to have pressure ulcers and she is more likely to manifest fatigue.

F. Diagnostic and Laboratory Procedures (Listed only those results that are abnormal) DIAGNOSTIC OR LABORATORY PROCEDURES INDICATIO NS OR PURPOSES

RESULT S

NORMAL VALUES

ANALYSIS AND INTERPRETATION

Used to estimate risk of developing a disease specifically heart disease. Because CHOLESTEROL high blood cholesterol has been associated with hardening of the arteries, heart disease and a raised risk of death

351 mg/dL

140250mg/dL

The client has an increased cholesterol level which is one of the precipitating factor of the clients Hypertension.

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LDL

Triglycerides

WBC

Neutrophils/ Segmenters

from heart attacks. The LDL test measures how much low-density lipoprotein (LDL) you have in your blood. Too much LDL in the blood can clog arteries. A test to determine the cholesterol level circulating in the bloodstream The test is performed to find out how many white blood cells you have. Your body produces more white blood cells when you have an infection or allergic reaction, even when you are under general stress To detect presence of infection in the body

219 mg/dL

<178 mg/dL

This is also one of the factors that aggravates or triggers the clients hypertensive episodes.

209 mg/dL

10-190mg/dL

This is also one of the factors that aggravates or triggers the clients hypertensive episodes.

4900/ cu. mm

5-10 x 103mm

The WBC count is below the normal limits a decrease or increase in the WBC count denotes infection or inflammation.

76%

50-70%

The Neutrophils is above the normal limits indicating infection.

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Lymphocytes

To detect presence of infection within the body.

24%

25-40%

The number of lymphocytes is slightly decreased which indicates infection

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