Name of Patient: S.T.

C Diagnosis: Cerebral Concussion, lacerated wound left frontal area secondary to vehicular accident Age/Sex: 39y.o. Physicians Name: Dr. Baldivinos Chief complaints: LOC and lacerated wound left forehead secondary to vehicular accident Medications Ranitdine C Antacid Prevention of gastric ulcer formation H Patient states that she didnt have any GI discomfort Patient states that GI discomfort is relieve E 50 mg IVTT q8h C Teach patient of drug adverse reaction and to be alert if any are present K Assess patients GI Exercise *Passive Range of Motion -the nurse or another person moves each of the clients joints through heir complete range of movement, maximally stretching all muscle groups within each plane over each joint *Active-Assistive Range of Motion -carried out with client and the nurse participating. The client is encouraged to carry out as much of each movement as possible, within the limitations of strength and immobility *Temporomandibular Joint -open mouth -close mouth Treatment *Complete blood count (CBC), also known as full blood count (FBC) or full blood exam (FBE) or blood panel -is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood. Abnormally high or low counts may indicate the presence of many forms of disease, and hence blood counts are amongst the most commonly performed blood tests in medicine, as they can provide an overview of a patient's general health status. *Urinalysis Hygiene *Bed bath - to promote cleanliness, to provide comfort and relaxation, to improve the clients self-image, to condition the skin, to stimulate peripheral circulation of the client. * Physical Care -Cleanliness of body -Shaving -Washing face -Nail Trimming *Washings of hands *Oral care - to maintain the intactness *Follow up Consultation to monitor the changes of the patients condition. *Instruct the client to 39 *Inform significant others to report signs of pain, heat to site, foul odor, and fever because it signifies infection. Outpatient Referral *Stoma care -Daily care of the trach site is needed to prevent infection and skin breakdown under the tracheostomy tube and ties. Care should be done at least once a day; more often if needed to prevent odor, irritation and infection. Diet *Diet as tolerated -This particular diet is only given when client can now tolerate any food he desires that is nutritious, if this will not lead to any complications.

condition before starting therapy and regularly thereafter to monitor drug effectiveness Be alert for any drug interaction and drug adverse reaction Dont use aluminum base needle when giving drug parenterally because drug is incompatible with aluminum Dont confuse ranitidine with rimantidine Tramadol C analgesic patient experiencing moderate to severe pain H Patient states that he is free from pain E 50 mg IVTT q8h

*Shoulder -abduction -adduction (anterior & posterior) -horizontal flexion and extension -internal & external rotation *Elbow -rotation for supination and pronation *Wrist -flexion, extension & hyperextension -circumduction -radial flexion & ulnar flexion

-it involves examining the appearance, concentration and content of urine. It is used to detect and assess a wide range of disorders, including urinary tract infection, kidney disorders and diabetes. *Cranial CT Scan -is an imaging method that uses x-rays to create crosssectional pictures of the head, including the skull, brain, eye sockets, and sinuses.

and health of the oral mucosa, to prevent oral infections, to clean and moisten the membranes of the mouth and lips *Tracheostomy care - cleaning the trach- to prevent infection clean the inner cannula at least 1/day

comply with home medications and maintenance drugs in order to promote and hasten recovery. *Encourage client to perform regular exercises and maintain a healthy lifestyle. *Continue wound care to promote wound healing and

*Suctioning of the tracheostomy tube

*Chest X-ray, Skull APL X-ray, Right Elbow X- to secrete mucous ray, Cervical Spine X-ray formation *Hands and Fingers -is an x-ray of the structures - flexion, extension & inside the chest, elbow and hyperextension the cervical spine. An x-ray -abduction & adduction is a type of high-energy radiation that can go *Foot through the body and onto -internal & external rotation film, making pictures of areas inside the chest,elbow *Ankle and cervical spine which -plantar flexion & can be used to diagnose 39

C Teach patient of drug adverse reaction and to be alert if any are present K Assess patients pain before starting therapy and regularly thereafter to monitor drugs effectiveness Monitor cardiovascular and respiratory status Closely monitor patient at risk for seizures; drug may reduce seizure threshold Monitor patient for drug dependence. Drug can produce drug dependence similar to that of codeine or dextropropoxyphene and thus has potential for abuse Be alert for any drug adverse reaction For better analgesic effect, give drug before the onset of intense pain

dorsiflexion -eversion & inversion *Deep breathing exercises -a relaxation technique that can be self-taught. Deep breathing releases tension from the body and clear the mind, improving both physical and mental wellness.

disease or deformities. *Tracheostomy -is an operative procedure that creates a surgical airway in the cervical trachea. -it is for improving the airway. -it is indicated to provide a long-term route for mechanical ventilation in cases of respiratory failure. *Intravenous therapy or IV therapy -is the giving of liquid substances directly into a vein. -it is the fastest way to deliver fluids and medications throughout the body. *Wound dressing *Intravenous Therapy -PNSS isotonic solution good for replacing fluids in the body. 39

*Change in position q2h using log roll technique - Change of position can prevent client in bed rest from developing pressure ulcers - Log roll technique is use to prevent patient sustaining further damage in his spinal cord

 If RR is belo 12 cpm, withhold drug and notfy physician Dont confuse tramadol and trazodone Contraindicated to patients hypersensitive to drug or any of its components, and those with acute intoxication with alcohol Use cautiously in patient at risk for seizures and RR depression: those with traumatic head injury and increase intracranial pressure

*Medications 1. Ranitidine 2. Tramadol 3. Paracetamol 4. Dexamethasone 5. Cefuroxime 6. Neural B

Paracetamol C antipyretic, analgesic mild pain or fever H Reports pain relief and reduction of fever with drug 39

E 500mg IVTT prn for fever q4h C Teach patient of drug adverse reaction and to be alert if any are present: Teach patient that drug is contraindicated to patient hypersensitive to drug Teach to use drug cautiously if patient has history of chronic alcohol abuse Tell patient that long term use of drug can cause liver damage K Assess patients pain or temperature before and during therapy Be alert for adverse reaction and drug interaction 39

 Dont use drug if fever higher than 39.5C, last longer than 3 days or recur Drug is for short terms use contact prescriber if patient takes drug longer than 10 days Dexamethasone C anti-inflammatory, immunosuppressant Cerebral Edema H Patient condition improves with drug therapy E 50mg/ tab p.o. stat 50mg IVTT stat if on NPO 50mg/tab TID p.o. 50mg TID IVTT if on NPO C Teach patient of drug 39

adverse reaction and to be alert if any are present: Tell patient to have a low Na in the diet. Tell patient to have high CHON and K in diet Tell patient not to abruptly stop drug because this may be fatal Teach patient early signs of adrenal insufficiency (fatigue, muscle weakness, joint pain, fever, anorexia, nausea, dyspnea, dizziness, and fainting) Warn patient of long term use about cushingoid symptoms and need to notify prescriber about weight gain and swelling Warn patient about easy bruising

K Obtain history of patients underlying condition before 39

therapy Monitor patients blood pressure, weight, glucose level and electrolyte level Look for adverse reaction and drug interaction Watch for dosage dependence and psychotic behavior Give with food when possible Always adjust to the lowest effective dose When stopping drug in long term use. Gradually reduce the dosage Give low sodium, high CHON and HIGH K in the diet. If patient has adverse drug reaction notify prescriber, treat the symptoms and provide supportive therapy Dont confuse dexamethasone with desoximetasone 39

Cefuroxime C antibiotic prophylactic purposes H Patient is free from any signs and symptoms of infection E 50 mg/cap p.o. BID C Teach patient of drug adverse reaction and to be alert if any are present: Tell patient if taking with diuretics may increase risk of adverse renal reaction Instruct patient to take drug exactly as prescribed, even after he feels better Advise patient to take oral suspension with food to enhance 39

absorption K Assess patients infection before starting therapy Before giving first dose, obtain specimen of culture and sensitivity test Before giving first dose, ask patient of hypersensitivity to cephalosporins and penicillin Be alert for adverse drug reaction Neural B C vitamin supplements improvement of nerve function, acute alcohol intoxication H Patient regains normal vitamin B1,6,12 level Improvement of nerve 39

function E 1 cap OD C Teach patient to take drug exactly as prescribed Drug should be taken preferably in the morning K Make sure that paitent takes drug exactly as prescribed

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