VIII.

Review of System
ROS
General

1st day
-no chills
-afebrile
Temp:
4pm- 36.5 degree Celsius
8pm- 36.8 degree Celsius

2nd day
-no chills
-afebrile
Temp:
4pm- 35.5 degree Celsius
8pm- 37.0 degree Celsius

HEENT

Head:
-(+) Grimacing

Head:
-no facial grimace

Eyes:
-pink conjunctiva
-no itch
-PERRLA

Eyes:
-pink conjunctiva
-no itch
-PERRLA

Ears:
-no discharges
-no pain
-no tenderness

Ears:
-no discharges
-no pain
-no tenderness

Nose:
-no discharges

Nose:
-no discharges

Throat:
-no bleeding gums
-no mouth ulcers

Throat:
-no bleeding gums
-no mouth ulcers

Skin

-no rashes
-skin is not warm to touch

-no rashes
-skin is not warm to touch

Respiratory

Respiratory rate:
4pm- 18 cpm
8pm- 20 cpm

Respiratory rate:
4pm- 19 cpm
8 pm- 20 cpm

Cardiovascular

Cardiac rate:
4pm - 62bpm
8pm- 71 bpm

Cardiac rate:
4pm - 73 bpm
8pm- 69 bpm

Gastrointestinal
Genitourinary

- acute pain(pain scale of 9/10)

Urine:
-2-4 times this day (200ml)

-acute pain(pain scale of 3/10)

Urine:
- 2- 4 times this day (200ml)

XV. Discharge Plan (January 10, 2014)

I.

MEDICATION

1. Take medications as ordered.

2. Inform the patient to take medications on time or as directed for the full course
of therapy even if feeling better.
3. Inform the client about the adverse effects and possible side effects of the
medications.
4. Inform the client about the importance of taking prescribed medications and the
consequences of not following the treatment regimen.
5. Encourage the patient to report or inform the health team if any of these side
effects occur. Inform and explain to the client that other drugs that he is taking will
probably have effects with the medication given. Moreover, emphasize the right
time interval of these drugs to maximize its effects and avoid further
complications.
6. Provide information for better understanding regarding therapeutic regimen.
II.

EXERCISE

1. Promote regular light exercise and exercise as tolerated.

2. Encourage exercise in lower and upper extremities to promote good circulation.
3. Inform patient about proper exercise regimen to avoid injury.
4. Alternate rest periods with activity.
5. Encourage walking exercise.
III. TREATMENT
1. Instruct the patient to continue drug therapy as ordered.
2. Inform the patient as well as family the dangers of non compliance to treatment
regimen.
3. Discuss to the patient the complications and other problems that might arise
from the condition.
4. Inform the patient to exercise and do breathing exercises.
5. Instruct the patient to report to the health team promptly about any changes on
health condition.
6. Encourage patient to strictly comply with the doctors orders, especially in
taking prescribed medications.
7. Encourage the patient to have followed up visitations to the physician after
discharge.

IV.

H EALTH TEACHINGS

1. Encourage patient to avoid strenuous activities.

2. Improving nutritional intake; meal planning is implemented with High fiber
moderate calorie, low fat and low salt as the primary goal.
3. Encourage to balance diet and intake of nutritious food such as vegetables and
lean meat, avoiding high fat foods.
4. Check with healthcare provider to evaluate progress of the condition.
5. Encourage to have adequate hydration. Water is the best source of fluid that is
needed by the body to maintain its function.
6. Instruct to avoid alcoholic beverages due to a compromised hepatic system.
7. Encourage to have a restful and quiet atmosphere at home.
8. Encourage patient to use relaxation skills when in pain.
9. Encourage patient to seek emotional and social support especially to family and
friends to promote strength and comfort.
10. Check the condition with a healthcare provider to evaluate progress of the
condition.
V.

OUTPATIENT

1. Remind patient on the arrangements to be made with the physician for followup checkups.
2. Follow-up checkup regularly in order to monitor and properly manage
patients illness.
3. Inform to continue medication as ordered.
4. Instruct to have a follow-up checkup or refer to the physician if the patient is
uncomfortable.
5. Instruct the patient and significant others to report for any irregularities.

VI. DIET
1. The diet recommended for the client is High fiber moderate calorie, low fat and
low salt
2. Encourage patient to increase nutritious foods intake by eating fresh fruits and
vegetables, whole grain products, and lean meat.
3. Recommend eating 5 or more servings of vegetables and fruits each day.
4. Encourage to choose whole grain foods instead of white flour and sugars.
5. Advise to try to limit meats that are high in fat and cut back on processed meats
like hot dogs and bacon.
6. Inform patient to avoid food such as salted, cured, smoked, or canned meat.
7. Increase oral fluid intake. Hydration is needed by the body to transport nutrients
needed by the body.
8. Instruct to avoid drinking of alcoholic beverages as much as possible.
9. Encourage not to forget to get some type of light exercise because the
combination of good diet and regular exercise will help in the maintenance of
healthy weight and the feeling of more energetic.

Table of Contents
I.

Demographic Data
a. Clients name
b. Sex
c. Age
d. Birth date
e. Birth Place
f. Race/nationality
g. Address
h. Chief Complaint
i. Diagnosis
j. Surgical Procedure
k. Date of Admission
l. Hospital
m. Physician
n. Room no.
o. Hospital

II.
III.
IV.
V.
VI.
VII.

Sources of reliability
Reason for seeking care/chief complaint
History of Present Illness
Past medical History
Family History
Functional Assessment
a. Health Perception/ Health Maintenance
b. Self Esteem/Self-concept/Self-perception pattern
c. Activity/exercise pattern
d. Sleep/Rest Patterns
e. Nutritional/Elimination
f. Sexuality/Reproductive
g. Interpersonal Relationship
h. Coping Stress Management/Tolerance Pattern
i. Personal Habits

4
4
4
5
6
7

VIII.
IX.
X.
XI.
XII.
XIII.
XIV.
XV.

Review of System
Anatomy and Physiology
Pathophysiology
Laboratory Study
Drug Study
Problem List
Nursing care plan
Discharge Plan

10
11
12
13
14
21
22
30

XI. Diagnostics and Laboratory Study

Hematology
Test

Result

WBC
Diff. Count
Neutrophils
lymphocytes
Monocytes
Test

N-Value

10.3

5.10x109/1

0.80
0.15
0.05

0.50-0.62
0.25-0.40
0.03-0.07

Result

RBC
Hemoglobin
Platelet count
Sedimentation rate
Hematocrit

N-Value

Significance

Increased
Decreased

Significance

3.67
88
241

(m) 4.5-5.5x10
Decreased
(m) 140-170 gm/L Decreased
150-400x10-9/L
Normal

0.27

(m) .39-.54

Decreased

Blood Chemistry
Test Name
Sodium
Potassium

Result

Normal values

133.8 mmol/L
2.43 mmol/L

135-148mmol/L
3.4-5.3 mmol/L

Significance
Decreased
Decreased

Clinical Microscopy
Physical &
Chemical
Examination
Color

Result

Significance

Yellow

Ph
Albumin
Sugar

Slightly
turbid
60.5
Trace
Not normal
Negative

Sp. gravity

1.010

Transparency

Microscopic
Examination
Epithelial
cells
Mucous
threads
Puss cells
RBC
Bacteria
Amor.
Urates/
phosphate

Result

significance

Few
Few
8.12
2-4
Few
moderate

Not normal
Not normal
Not normal