REVIEW OF SYSTEM

Name: Patient X Vital Signs Temperature: 37.9 C Pulse: 92 bpm Respiration: 19 cpm Blood Pressure: 130/80 mm Hg #3 PNSS 1L 820 cc. Pt is awake and conscious; sitting on bed with an IV hooked at the left arm. Pt was wearing a splint made by scarf and has a bandage placed at the fracture site. Blisters were seen around the portion of the fractured site. Pt appears at his age. Skin is intact and even in color. Facial features are symmetric in the environment. Keloids were present. Ht and wt appears within normal range. Dress is appropriate to climate, looks clean and fits to the body well. Pt smells unpleasantly. Normocephalic, position at the midline, erect and still; head is without lesions and nodules. Hair is unkempt; symmetric facial expressions; no observed facial weakness; pt has good focus on objects. Eyebrows preset bilaterally and eyeglasses are evenly distributed. Hair color is gray and white and not evenly distributed. Eyelashes aligned normally and no sunken appearance. Conjunctiva is pink and has anicteric sclera. Ears equal in size and ears skin color is inconsistent with facial color, nose is symmetric in the midline and in proportion to other features. Throat is pink and moist; no swelling and inflammation. Hair color is gray and white and moustache and beard is present. No lesions found on the scalp. Nails are firmly attached to nailbed. Surface is smooth and regular. Left hand is pale; nails are pail and are cold to touch. Capillary refill time ate the right arm is >3 sec. Nails are uniform in thickness but is dirty. Pt has good skin turgor w/c is right for his age except for the right arm where fracture is present. Swelling and edema is present on the right arm. Equal and symmetric chest expansion. Spinous process appears in straight line. Scapulae are placed symmetrically and pt is related when breathing. Chest skin color is consistent and even. Chest surface has no lesions, no lumps cyst on the chest; has clear breath sounds; no adventitious sounds noted. Pts facial expression when breathing is relaxed and breathing is automatic, effortless, regular, even and produces no noise. (-) cyanosis (-) nasal flaring PMI is located at the 5th ICS Left MCL; without murmurs. S1 and S2 is clear. Pulse at the right arm (radial pulse) is not pal[able because edematous skin. Radial pulse at the Left arm is palpable. CRT <3sec at the right arm. Date: October 3, 2011

Height: 165 cm Weight: 67 kg Observation: Received patient, sitting on bed, conscious, alert and coherent with regulated @ 20gtts/min, infusing well on the left arm with IV left of

1. General

2. HEENT

3. Integumentary

4. Respiratory

5. Cardiovascular

6. Digestive

Lips is dark, moist and symmetrical. (-) cracking,(-) lesions. Gums is pink and moist. Tongue is even in color and pink. Saliva is present. No white patches or lesions ar observed around the oral cavity. Buccal mucosa is pink smooth and moist. Uvula is at the midline. Abdomen is warm, smooth and symmetric and is even in color. Umbilicus is at the midline, abdomen is soft and nontender with normal active bowel sounds.

7. Excretory

Pt has micturated ate least 7x a day with a pale yellow urine. Patient has also defecated once with a yellow, semi-solid stool. Pt admits no pain during micturition or defeation.

8. Musculoskeletal

Skin over the joint at the right arm is pale; pt has a closed fracture at the right elbow. Swelling and tenderness are noted over the joints upon palpation. Pt was able to move his right fingers but feels pain when he moves his arm/elbow. Extremities are warm with joints intact. Unequal grips and strength on both arms. Muscle strength at right arm =1/5. Muscle strength at left arm is 4/5.

9. Nervous

Pt is full alert, conscious and facial appearance is symmetrical. Pt was able to focus on objects. Pt is oriented to time, date and place. Articulations clear and understandable. All 5 senses were working properly. Pt was able to recall information.

10. Endocrine

Pt is not diaphoretic; skin is warm to touch except at the right arm. His growth appears on his age, has heat/cold intolerance. Sweat glands are responsive to temperature. Pt has no abnormal pigmentation on skin. Ht and wt is appropriate for his age. Pt has type 2 DM: non-insulin dependent.

11. Reproductive

Pt is a male, circumcised; is married with 5 children (2 girls and 3 males). He is the eldest ; he is 5 years old.

REVIEW OF SYSTEM
Name: Patient X Vital Signs Temperature: 36.50 C Pulse: 89 bpm Respiration: 19 cpm Blood Pressure: 130/90 with #4 PNSS 1 L regulated at 20 gtts/min infusing well on the left arm with IVF left 820 cc. Date: October 4, 2011

Height: 165 cm Weight: 67 kg Observation: Received pt. sitting on bed, conscious, alert and coherent

11. General

12. HEENT

13. Integumentary 14. Respiratory 15. Cardiovascular 16. Digestive 17. Excretory

Pt is awake and conscious, sitting on bed with IVF hooked at left arm. Pt appears his age; sexual development is appropriate for his gender; skin color is even and intact. Facial features are symmetric with environment,(-) skin lesions; ht and wt appears within normal range. Pt has a splint made by a scarf. Presence of blisters can be found at the R arm where fracture is located; edematous and pale skin; cool to touch keloids were also present on some areas of the body. Head-normocephalic, position at midline,erect and still; no lesions and nodules;hair is kept properly;symmetric facial expressions, presence of facial weakness,Eyes- not good on focusing objects. Eyebrows are present bilaterally, eyeballs are normally aligned in their sockets, have big eyebags, conjunctiva is pink with anicteric sclera; Ears- equal in size bilaterally, skin color is consistent with facial skin color; Nose- no redness, swelling or lesions are present, symmetric, at the midline and in proportion with other facial features;nostrils are patent.Throat- pink and moist, no inflammation. Hair is properly kept; scalp hair is uniform in texture and color, hair is thin, unevenly distributed to the scalp;gray and white in color;no lesions can be found over the scalp; on R arm, nails are pale with CRT of >3 secs; (+) edema and tenderness upon palpation; on L arm, nails are smooth, strong and is firmly attached to nail bed, uniform in thickness. Skin is warm to touch, wrinkles is present on the face. Equal and symmetric expansion of the chest; spinous process appear in straight line; scapule are placed symmetrically in each hemithorax,relaxed posture when breathing; no adventitious lung sounds are heard/ noted, (-)dyspnea; patients breathing is automatic and effortless and produces no noise; (-) retraction; does not use any accessory muscles when breathing; (-)cyanosis;(-)nasal flaring;(-)clubbing. PMI is at the 5th ICS LMCL; without murmurs; S1 and S2 can be heard upon auscultation. Pulse at the right arm is not palpable due to fracture at the site; radial pulse at the L arm is palpable. R arm CRT= >3secs. Lips is dark, moist, and symmetrical;(-)cracking,(-)lesions. Gums is pink and moist, teeth is free from food debris and is evenly spaced. Tongue is pink and even in color; saliva is present and there is no white patches or lesions around oral cavity;bucal mucosa is pale and moist; uvula at the midline; tonsils is pink ;(+)gag reflex;(+)halitosis; abdomen is warm and symmetric, flat and is consistent in color;(-)lesions; umbilicus is in midline and with NABS. Patient had micturated at least 4x a day with a pale yellow urine, with an estimated amount of 240 cc every time patient urinates. Pt had also defecated once with a pale yellow semi-solid urine. No pain during micturation and defecation. Pt admits there is no any burning sensation or pain felt when urinating.

18. Musculoskeletal 19. Nervous 20. Endocrine 21. Reproductive

Skin over the joint at the right arm is pale; unable to flex his right elbow due to bone fracture at the site but is able to move his fingers; tenderness are noted around the site;spine is straight; symmetric neck and hips; extremities are warm to touch with joints intact; unequal grips and strength on both hands; R armmuscle strength= 1/5; L arm muscle and strength on both hands;L arm-muscle strength=4/5. Pt is full alert, conscious and coherent; facial expression is symmetrical;has ability to maintain gait and balance; able to focus on objects;can maintain eyeto-eye contact; pt is oriented to tome, date, and place; regards to own name upon hearing someone calling him; able to distinguish hot and cold; all 5 senses are intact and functioning well. Pt can still recall events; articulation is clear; no mood swings. Pt is not diaphoretic and sweat glands are responsive to temperature; skin is warm to touch; pt has tolerance to heat; physical growth is appropriate for his age. ht and wt is appropriate for his age. pt is a type 2 DM non-insulin dependent. Pt is a male, circumcised, and has 5 children(2 female, 3 male); he is the eldest among his siblings; he is 56 yrs. old.

REVIEW OF SYSTEMS Name: Patient X Vital Signs Temperature: 36.5 C Pulse: 85 bpm Respiration: 21 cpm Blood Pressure: 130/90 mmHg 20 gtts/min.
1. General

Date: October 05, 2011 Height: 165 cm. Weight: not taken Observation: Received pt. sitting on bed, conscious, coherent, and alert with IVF #5 PNSS 1L with 450 cc left @ Infusing well at the left arm.

2. HEENT

3. Integumentary 4. Respiratory 5. Cardiovascular 6. Digestive

Patient is awake and conscious; sitting on bed; patient feels pain when his arm will be moved. Pt. appears of his age; sexual development is appropriate for his age and gender. Skin is intact and is even in elbow. Facial features are symmetric to environment; Height and weight appears within normal range. Maintains eye contact, articulation is clear and understandable. Dress is appropriate to climate. Pt. has a closed fracture at the right elbow and was using a sling elbow support. Normocephalic, position at midline, erect and still; hair is kept properly; symmetric facial expression; has facial weakness but has good focus in objects. Eyebrows are present bilaterally, eyelashes are evenly distributed. Conjunctiva is pink, anicteric sclera. Ears equal in size bilaterally, ear skin color is consistent with facial skin color, no redness or swelling around the ears. Nose is symmetric, midline and is in proportion to other facial features, nostrils are patent; throat is moist and no lesions at all. Hair is properly kept; scalp hair is not uniform in color, thin, gray and white; unevenly distributed to the scalp; nails are smooth and look pale. CRT > 2 secs. Nails are cut but some debris is present. Skin is warm to touch on the unaffected area. Pt. has dead tissues, has 2 stiches and has blisters on the right elbow. Pt. has a close fracture, keloids are present t some of the areas of the body. Equal and symmetric chest expansion; spinous process appear in a straight line; relaxed posture when breathing and has no lesions over the chest. No adventitious lung sounds are heard. Pt.s breathing is automatic and effortless, regular and even and produces no noise. Pt. is not in respiratory distress; not using accessory muscles when breathing, (-) cyanosis, (-) nasal flaring. PMI is at the 5th intercostal mid-clavicular line, without murmurs. S1 and S2 are audible. Radial pulse is hardly palpable. Left radial pulse is strong, bounding and palpable. CRT > 2 sec. Pt. has edema on the right arm; bruit is not noted. Lips is dark, dry and is symmetrical; (-) lesions. Gums is pink and moist; tongue is pinkish and even in color; saliva is present; no white patches or lesions are observed around the mouth; buccal mucosa is pink and moist; uvula is at the midline; abdomen is warm, smooth and symmetric and is

even in color, umbilicus at midline, abdomen is soft, nontender and is flat with normal active bowel sounds. 7. Excretory 8. Musculoskeletal 9. Nervous 10.Endocrine 11.Reproductive Patient has micturated at least 3x a day with pale yellow urine amounting to at least 3 glasses of water. Pt. was able to defecate once with a yellow, formed stool. Pt. admits no pain during micturition and defecation. Skin over the joint is even in color; edema is present at the fractured site and tender upon palpation; spine is straight; mandible is symmetrical and at the midline; symmetric neck and hips; extremities are warm to touch with joints intact except for the right elbow. Unequal grip and strength on both hands; right arm muscle strength: 1/5; left arm muscle strength 4/5. Pt. is alert and conscious; facial expression is symmetrical; has ability to maintain gait and balance; gait is smooth and coordinated, able to focus on objects; pt. is oriented to time, date and place; regards to own name upon hearing someone calling him; able to determine what is hot and cold ; all 5 senses were intact and functional. Pt. can recall recent activities; articulation is clear and understandable. Pt. is not diaphoretic; skin is warm to touch except for the right arm; physical growth appears on his age, has heat/cold tolerance; sweat glands are responsive to temperature; no abnormal pigmentation on skin. Height and weight appropriate for his age; pt. has type 2 diabetes mellitus and is on continuous monitoring. Patient is a male; married with children ( 2 girls and 3 males); Pt. is 56 years old.

Laboratory and Diagnostic Procedures NAME OF PROCEDURE

1. URINALYSIS

INDICATION -to detect normal versus abnormal urine components -to detect glycosuria -to aid in the diagnosis of renal disorders.

NORMAL VALUE Color: light straw to dark amber Sp. Gravity: 1.025-1.030 Sugar: (-) Albumin: (-)

RESULT Yellow

NURSING IMPLICATION Normal

NURSING RESPONSIBILITIES Pretest: Explain the purpose and procedure of the test; withhold diuretics for 3 days before test., avoid excessive intake of water and salt. Posttest: patient can resume normal fluid and dietary intake and medications.

1.020 Negative Negative

Normal Normal Normal

120
2. HEMATOLOGY

-to monitor hgb value in RBCs -to check volume of RBC in the blood -

Hgb: 135-160 g/l

Low; Pretest: Explain test procedure that slight discomfort may be felt when venipunctured; avoid stress; avoid dehydration and overhydration; avoid fat laden meals. 0.37 Low; Posttest: Apply manual pressure and dressing to the puncture site. Monitor site for oozing and hematoma. Resume normal activities and diet.

Hct: 0.40-0.48

8.8 WBC5-10 x 10 Normal

0.50 Neutrophil: 0.55-0.65 Low;

0.32 Lymphocyte: 0.25-0.40 Normal

0.18 Eosinophil: 0.01-0.05 0.9

3. CREATININE

High;

-to diagnose renal function

Creatinine: 0.6-1.4 mg/dl

Normal

4. GLUCOSE (FBS)

56.2 mg/dl 70-105 mg/dl Low;

Pretest: explain procedure; assess diet and protein intake Posttest: monitor as appropriate for impaired renal function. Pretest: explain procedure; ensure to fast from all foods except water as directed. Posttest: resume normal diet and activity. Interpret results and counsel appropriately. Pretest: Explain test procedure that slight discomfort may be felt when venipunctured; avoid stress; avoid dehydration and overhydration; avoid fat laden meals. Posttest: Apply manual

5. HGT

72-128 mg/dl

9-30-11/7:25 pm 191 mg/dl

High;

10-1-11/5 am 176 mg/dl

High;

5 pm-196 mg/dl High; 10-2-11/5 am 84 mg/dl 5 pm-76 mg/dl Normal 10-3-11/ 5 am 295 mg/dl 5 pm-78 mg/dl Normal 10-4-11/5 am 122 mg/dl 5 pm-196 mg/dl High; 10-5-11/5 am 178 mg/dl 5 pm-98 mg/dl Normal
6. ECG

pressure and dressing to the puncture site. Monitor site for oozing and hematoma. Resume normal activities and diet

Low;

High;

Normal

High;

Pulse: 72 bpm Rhythm: Regular QRS complex elevated S I-II

60-100 bpm Consisitetent and regular Normal QRS axis

Normal

High Pretest: Explain the procedure, purpose

PR interval: 0.016 sec. P wavesupright

0.12 to 0.20 s (3 5 small squares) Normal upright

Normal Normal

Deflections T wavesupright ST segment Remarks: Sinus rhythm with right bundle branch blocks
7. Blood Chemistry

and interfering factors; have patient relaxed and rest ideally 15 minutes before the test; emphasized that ECG is painless and does not deliver electrical current to the body; have the patient avoid heavy meals and smoking for at least 30 minutes before the test. Posttest: recognize the limitation of an ECG; interpret results and counsel and monitor the patient appropriately.

High

140-200 mg/dl Cholesterol119 mg/dl 30-150 mg/dl Triglycerides34 mg/dl 30- 65 mg/dl HDL Cholesterol- 38 mg/dl 66-176 mg/dl LDL Cholesterol74.2 mg/dl 4.2- 6.2 % GlycosulatedNormal Normal Normal Pretest: Explain test procedure that slight discomfort may be felt when venipunctured; avoid stress; avoid dehydration and overhydration; avoid fat laden meals. Posttest: Apply manual pressure and dressing to the puncture site. Monitor site for oozing and hematoma. Resume normal Normal Low

6.2 %
8. CXR-AP Sitting

activities and diet. Clear and normally shaped Normal High Pretest: Explain the purpose and procedure of the test; assure that there will be no discomfort, screen for pregnancy status of female patients; if positive, advise the radiology department; remind patients of the need to remain motionless and to follow all breathing instructions during the procedure. Posttest: interpret test outcome and monitor for pulmonary disease and chest disorders; explain changes in therapy based on chest- x ray results.

Lung filed are clear. Heart is not enlarged. Aorta is prominent with knob calcifications Costrophenic sulci and diaphragm are intact. The rest of the included membranes are unremarkable. Impression: Atheroscleroti c Aorta

Normal

Normal

High

NURSING ASSESSMENT II
Name of Patient: Patient X Chief Complaints: For medical management of increased blood glucose level Impression/Diagnosis: Diabetes Mellitus Type II; Fracture at the right elbow 2 to VA Date of Admission: September 30, 2011 Diet: Low Salt, Low Cholesterol Diabetic Diet Type of Operation (if any): None Age: 56 Y.O Sex: Male Inclusive Dates of Care: October 3-5, 2011 Allergies: None

Normal Pattern 1. Activities Rest a. Activities b. Sleeping pattern

Before Hospitalization a.) Pt. is a businessman, owns and runs a bakery in their town, Bacolod. He had a bakeshop and a small sari-sari store. His

Initial a.) Pt. only sits or lies at bed and only talks to his son and wife. He sometimes walks at the corridor if he likes to.

Clinical Appraisal Day 1 a.) Pt. usually stays in bed, sitting and talks to his wife. Unable to perform ADLs such as bathing, toothbrushing and change

Day 2 a.) Pt. usually stays on bed but admits he was able to walk around corridors, able to perform some ADLs

c.

Rest

2. Nutrition Metabolic a. Typical intake (food or fluid) b. Diet c. Diet restriction d. Weight e. Medication / Supplement food

activities were repairing furniture, scrub the floor and clean their stores. Limited to do or lift heavy objects such as supplies in their store. His forms of exercise were brisk walking in the morning and afternoon if not busy, punch bags and lift dumbbells. He seldom watched teleseryes but prefer to watch news and boxing. Pt. also do household chores. b.) Pt. sleeps at 11pm and wakes up at 4am and feels rested when he sleeps for at least 6 hours. c.) Pt. admits he was able to rest for 6 hours in the morning if not busy or if all chores were done. Pt. admits he seldom sleeps in the afternoon for he is not comfortable to sleep. a.) Pts. intake of food at usually consists of a cup of rice, fish, vegetables and sometimes meat. Took 3 meals a day and never skips a meal. Took his snacks at least twice a day at 11 am and 3 pm which consist of a coke and an ensaymada or any available bread at his bakery. Drinks plenty of liquids and admits a pitcher of water is not enough for him to quench his thirst. Drinks coca cola for at least 5 times a week. Pt. had no food or drug allergies or food intolerance. b.) Regular diet. Patient admits he is not choosy when it comes to food. Eats what is being served on the table. c.) pt. admits he was restricted to

b.) Pt. sleeps at 12 midnight and wakes up at 6 am. Sometimes disturbed when his right elbow hurts every time he moves it. Awakens when the Medication Nurse administers his medicine. c.) Pt. was able to rest in the afternoon and took afternoon naps for at least 30 minutes.

clothing and relies assistance from his wife or son. b.) Pt. sleeps at least 8 hours, sleeps at 9 pm and wakes up at 5 am. Sometimes disturbed when his right elbow hurts or when the Medication Nurse administers his medicine. c.) Pt. wasnt able to get enough rest in the afternoon because of the hot environment where he always sweats and feels uncomfortable about the smell of the surroundings.

such as going to the bathroom, change clothing or and brushing his teeth. b.) Pt. sleeps at 9 pm and wakes up at 4 am but is able to wake up between sleeping hours because of pain he felt when he move his right elbow. c.) Pt. had not taken enough rest in the morning but able to take afternoon naps for at least 30 minutes.

a.) Pts. intake of food usually consists of a cup of rice, fish tinola, banana and water b.) Low Salt, Low Cholesterol Diabetic Diet c.) Restricted diet: soft drinks and sweets, high in fat and cholesterol d.) Not taken e.) Ciprofloxacin BID 500g, Gliclazide mg 1 tab

a.) Pts. intake of food usually consists of a cup of rice, chicken, vegetables and soup b.) Low Salt, Low Cholesterol Diabetic Diet c.) Restricted diet: soft drinks and sweets, high in fat and cholesterol. d.) Not taken e.) Ciprofloxacin PO BID 500g

a.) Pts. intake of food consists of a cup of rice, fish tinola, chicken and banana b.) Low Salt, Low Cholesterol Diabetic Diet c.) Restricted diet: foods that are high in fats, cholesterol and sweets d.) Not taken e.) Cefuroxime 750 mg IVTT

eat any sweets or drinks soft drinks but he does not adhere to the advise of others d.) weight: e.) Multivitamins 3x/day Normal Pattern 3. Elimination a. Urine (frequency, color, transparency) b. Bowel (frequency, color) Before Hospitalization a.) pt. admits during his middle aged years he micturated for at least 15 urinations for 24 hours. Wakes up at midnight or dawn to urinate. Pt. admits that his urine volume changes. b.) Defecated once a day with a formed, yellow stool. Usual bowel pattern is every morning. Patient is not constipated. No associated pain during micturition and defecation a.) Before the onset of the disease, pt. admits and perceived himself as a healthy person even when he has DM because he perform exercises such as punching bags and lifted dumbbells. Confidence boost about his health because he admits his hypertension was minimized after the operation. b.) His coping mechanism was repairing and fixing furniture or bakes at his own bakery in their town. His ways of handling stress was to stay put at his house, took a rest or watch his favorite movies. c.) Support mechanism is his wife and children Initial a.) Usually micturates 4x/day with a pale yellow urine with an average amount of 520cc b.) Defecated once a day with semi-solid stool. Usual bowel pattern at morning. No associated pain during micturition and defecation Clinical Appraisal Day 1 a.) Pt. admits he micturated 4x/day with a pale yellow urine with an average amount of at least 240cc b.) Pt. admits he defecated only once a day in the morning with a semi-solid, pale yellow stool. No associated pain during micturition and defecation Day 2 a.Pt admits he urinates for at least 3x a day with an average volume of 600 cc with a pale yellow urine. b. Admits he defecated once in the morning with a hard, yellow stool. No associated pain during micturition and defecation

4. Ego Integrity a. Perception of self b. Coping Mechanism c. Support Mechanism d. Mood / Affect

a.) Pt. perceived himself as a notso-healthy person because of his condition: closed fracture at the right elbow with type 2 DM. b.) sometimes patient talks to his roommate; he sometimes sleeps and no recreational form of activities were done. c.) his support mechanism was his wife and his family. d.) patient was not irritable; facial weakness was observed.

a.) Pt. only sits on bed, talks to his wife. He does not perceive himself as a healthy person because of his debilitating illness b.) No recreational activities were made inside the room. Sometimes he talks to his roommates. c.) his support mechanism was his wife and his family d. patient admits he gets irritated because of the foul environment and sometimes cannot maintain eye contact when asked.

a.) Pt perceives himself as a not-so-healthy person because of his illness b.) patiet communicates with his roommates inside the room, took naps if there is time or if he feels sleepy and walks into the corridors if he gets bored. c.) His wife is always at his side d.) patient can maintain eye contact when asked. No mood swings observed.

5. Neuro Sensory a. Mental sate b. Condition of 5 sense: (sight, hearing, smell, taste, touch)

d.) patient is not irritable; becomes grumpy when problem such as financial crisis or supply problems arises. Pt. admits he is always happy; active, alert and responsive; oriented to time, date and place. b.) All 5 senses are intact and functioning well.

a.)pt. is conscious, articulation is clear and is coherent. Pt. can recall past events and answers the question deliberately when asked; oriented to time, date and place. Pt. is anxious at times because of his condition and the surgical procedure to be done. b.) All 5 senses were intact and functioning well.

a.) Pt. is conscious, alert, coherent, and oriented to time, date and place. Able to respond when asked questions and can recall past events. b.) All 5 senses were intact and functioning well.

a.) Pt. is conscious, alert, coherent, and oriented to time, date and place. Able to recall information and events related with to his health b.) All 5 senses were intact and functioning well.

Normal Pattern 6. Oxygenation and Vital signs a. Respiratory rate b. Pulse rate c. Heart rate d. Blood pressure e. Lung sounds f. History of respiratory problems

Before Hospitalization Pts. vital signs were not taken No history of respiratory problems

Initial T: 37.9 P: 92 bpm R: 19 cpm BP: 130/80 mmhg Pt. has clear breath sounds No history of respiratory problems

Clinical Appraisal Day 1 T: 36.5 P: 89 bpm R: 19 cpm BP: 130/90 mmhg Pt. has clear breath sounds No history of respiratory problems

Day 2 T: P: R: BP: Pt. has clear breath sounds No history of respiratory problems

7. Pain comfort a. Pain (location, onset, intensity, duration, associated symptoms, aggravation) b. Comfort measure / alleviation c. Medication

a.) Before the onset of vehicular accident, pt. had felt no pain at all b.) No comfort measures done c.) No medications taken

a.) his main focus was pain at the right arm, painful when touched and moved.pt. admits a sharp pain when palpated at the affected arm, radiating to the midupper right arm to wrist. Pain scale= 10/10; pain last only for minutes; aggravated when moved. Non-pitting edema noted at the right arm. b.) A splint was used for support and feels relieved when not touched or moved c.)

a.) Pain at the right elbow, painful when touched and moved. Pt admits pain is minimized but admits tender upon palpation, non-pitting edema is still present at the affected arm. Pain scale: 8/10. Aggravated when moved b.) Splint was used to minimize pain and no other comfort measures were noted c.) Prophylactic antibiotic (cefuroxime) was given

a.) Pain at the right arm due to vehicular accident, sharp pain, with non=pitting edema at the affected arm, tender upon palpation and aggravates more when moved b.) sling was used for support c.) medication wasnt checked for pain.

Normal Pattern 8. Hygiene and activities of daily living

Before Hospitalization Before hospitalization, pt. was well-groomed, takes a bath daily(preferred time bath is 4 am) brushes his teeth and combs his hair neatly. Able to perform ADL such as fixing furniture, do exercises, able to work-out like carrying dumbbells, and punch bags. a.) Pt. is a circumcised male and the eldest in his 5 siblings; He is married with 5 children (2 females and 3 males)

Initial Pt. admits he usually stays on bed sitting or lying. Asked assistance from his wife for his hygiene; unable to brush his teeth alone. Mustache and beard were not shaved. He wasnt able to take a bath but was given sponge bath. Able to change clothing once a day. Able to walk in the corridors but assistance is needed. No significant changes

Clinical Appraisal Day 1 Pt. admits he was always given sponge bath by his wife. Wasnt able to brush his teeth, but was was able to comb is hair and change clothing. Mustache and beard were not shaved Pt. usually sits on bed. Pt. smells unpleasantly. Can walk without assistance. No significant changes

9. Sexuality a. Female (menarche, menstrual cycle, civil

Day 2 Pt. admits he was given sponge bath at the morning. Able to brush his teeth and combs his hair. Mustache and beard were not shaved. Pt. admits he walks at the corridors and able to perform some ADLs such as eating, standing and going to bathroom without assistance. No significant changes

status, number of children, reproductive status) b. Male (circumcision, civil status, number of children)

SUMMARY OF MEDICATION Date 09/30/11 to 10/02/11 Medication Cefuroxime Ciprofloxacin Mixtard Gliclazide Dosage 750 mg 500 mg 24 u prebreakfast 10 u presupper 60 mg Route IVTT P.O. SQ P.O. Frequency q 80 BID BID (prebreakfast, presupper) OD Remarks Given and tolerated Given and tolerated Given and tolerated Given and tolerated

SUMMARY OF INTRAVENOUS FLUID Intravenous Fluids & Volume Time Started Drop Rate Time Ended Indication Isotonic- has the same salt concentration as the normal cells of the body

Date

09/30/11

#1 PNSS T L

30 gtts/min

8:45 PM

10/01/11

5:15 AM 8:15 AM 10/01/11 #2 PNSS T L 20 gtts/min 9:10 AM 10/02/11 #3 PNSS T L 30 gtts/min 5:30 AM
10/03/11

10/01/11 8:15 PM 10/02/11 5:45 PM

and the blood Isotonic- has the same salt concentration as the normal cells of the body and the blood Isotonic- has the same salt concentration as the normal cells of the body and the blood

#4 PNSS T L 20 gtts/min 1:30 AM #5 PNSS T L

10/03/11 5:30 PM 10/04/11 1:30 PM 20 gtts/min

10/4/11 #6 PNSS T L 10/05/11

20 gtts.min

NURSING CARE PLAN

Cues Subjective: Sakit-sakit pa gihapon akong kamot pag ilihok gahubag pa gihapon siya. Nursing Diagnosis Impaired skin integrity related to physical immobilization at the right arm secondary to bone Objective Short-Term Objective: Within 8 hours of duty, patient will be able to maintain physical wellIntervention 1. Assess blood supply and sensation of affected area. Rationale 1. To evaluate impairment of circulation to extremities Evaluation

As verbalized by the patient. Objective: - Closed fracture at the right elbow - Presence of edema at the entire right arm - Tender upon palpation V/S: T: 36.5C P: 85 bpm R: 21 cpm BP: 130/90 mmHg

fracture due to vehicular accident

being Long-Term Objective: After 3 days of duty, patient will be able to participate in prevention measures and treatment program.

2. Monitor vital signs and MIO every 2 hours and every shift respectively. 3. Inspect skin on daily basis, describing pain characteristics and changes observed 4. Keep the area clean and dry, prevent infection and support fracture. 5. Reposition client every 2 hours or as indicated. 6. Encourage early ambulation or mobilization 7. Provided optimum nutrition and adequate fluids. 8. Provide a quiet, restful environment 9. Encourage verbalization of feelings 10. Review laboratory results

2. To compare data to baseline values and to monitor output of the patient. 3. To assist client in correcting or minimizing condition and promote optimal healing. 4. To assist bodys natural healing process. 5. To enhance understanding and cooperation. 6. Promotes circulation and reduces risks associated with immobilization. 7. To prevent dehydration and to maintain general good health. 8. To decrease oxygen demand to avoid fatigue. 9. To enhance self-esteem and adhere to treatment regimen. 10.To determine abnormal values

that may hinder wound healing.