CHAPTER

Personal Data
My patients name is C.T.B she is 54 years old, female. She was born on July
9, 1943. Her civil status is widowed. the family is currently living at Caloocan city.The
patients educational attainment is college graduate. the patient and her family are pure
Filipino. She and her family are devoted Roman Catholic in religion.
The source of information is C.T.B the patient herself. Interviewed was
conduct last January 31,2011.
I.

Chief Compliant
Nahihirapan akong lumunok kaya hindi ako makakain as stated.
Medical Diagnosis: PeritonsilarAbcess/ Acutetonsilar pharyngitis

II.

History of Present Illness:

Four days prior to admission the patient experienced difficulty of swallowing and
inability to eat properly but no actions done.
Three days prior to admission the patient still experienced difficulty of ingesting
food, she ate soft foods only.
Two days prior to admission the patient had phlegm, yellowish secretion and still
complains of difficulty in swallowing cough.
Prior to admission the patient experienced weakness, difficulty of swallowing and
inability to ingest food and the patient has a fever of 37.2 Celsius.
III.

Past Medical History

Client remembered to have experienced measles and chicken pox when she
was a child , but she failed to recall the treatment used.she had not experienced serious
illness, and hospitalization.
Client has no allergies in environment, she also have a complete vaccine of
immunization.
Client has a vices like drinking alcohol occasionally. She also drink 1 cup of
coffee every morning. She take Fern-C to served as her vitamins

FAMILY HISTORY

LEGEND:

PATIE
NT
MAL
E
FEMA
LE
DECEAS
ED

INTERPRETATION
There are no hereditary disease that the client could acquire from her parents and
grandparents. The client could have acquired her disease within their community.

V. Social History

The patient is a college graduate. She is not smoking, she go to the church every
Sunday together with her family.
REVIEW OF SYSTE
Persons Review of System
PSYCHOLOGICAL
I.

Self perception-Self concept Pattern

She is a simple woman, a good mother, a disciplinarian, understanding and loving
partner. She is happy and contented in her life. When there are situations that
make her angry and worried her husband help him to handle those things and
make her calm.

II.

Role Relationship pattern

The patient is widowed , doesnt have a work, but they have a small business and
that was their source of income, their income is sufficient in their daily needs and
they have children that helps them out in times of difficulties. She and her
daughter lives in one home,

III.

Sexuality and Reproductive Pattern

the client said that they are old enough for those things. The patients menarche
was when she was 15 years old and she got menopause at 43. There were no
complications when the client gave births and delivered them via NSD.

IV.

Cognitive Perceptual Pattern

The patients hearing is quiet impaired but she doesnt use any devices, she also
has difficulty visualizing things 12ft away, she doesnt use eye glasses. There are
no changes in her memory in the past, but she sometimes forget things that she
has previously done.

V.

Coping Stress Tolerance Pattern

When she feels tense and anxious she alleviate them by being relaxed and she
talks it with and and sometimes when hes not home she just watches comedy
movies.

VI.

Values Belief Pattern

The patient is satisfied in her life. Her family is the most important to her, they are
her source of energy and inspiration in life, she also have some friends who she
can talk occasionally. The patient is Roman Catholic, the whole family attends
mass every Sunday. There are no religious practices and beliefs that can affect the
treatment for her.

ELIMINATION
The patient defecates once a day every morning. Her stool is black and has
moderate amount, she doesnt have any difficulty defecating. The patient does not
perspire excessively. She urinates 5 to 6 times a day, and there were no difficulties
in urination. She doesnt have any body odor.

REST AND ACTIVITY

I.

Activity Exercise Pattern

Patient doesnt do any form of exercise. She does walking before she was
admitted in the hospital. She always watches TV before she sleeps. She eats 3
times a day sometimes with snacks in between; she takes a bath every morning
and shower before having a sleep. She doesnt cook, her daughter cooks for them.
II.

Sleep Rest Pattern

She sleeps at about 10:00 oclock in the evening and wakes up at 6:00 oclock in
the morning; she also takes a nap for about 2-3 hours in the mid afternoon. She
doesnt have difficulty sleeping. When their family is having problem, that was
the time that she has difficulty in sleeping because of too much thinking then
shell talk with her husband and children to have that problem solved.

SAFETY-ENVIRONMENT
The patient lives in urban community. Their community is well organized. He has
no allergies in food, environment and medication.

OXYGENATION
The patient has no difficulty in breathing.

NUTRITION
The patients diet is in soft diet. She just ate lugaw for her breakfast and a glass of
water. For her lunch she just has rice soaked in soup and a glass of water. For her
dinner, she ate

Physical Assessment
GENERAL APPEARNACE

Patient has a small frame body build and upright posture. The gait is
smooth and rhythmic. The client is well groomed, no fouls odor and appropriately
dressed. There were no physical deformities noted.
MENTAL STATUS
The client is conscious and well oriented of the time, place and person
around her. She uses simple words in communicating. She is able to follow directions
and respond when called and he is emotionally cooperative.
SKIN
The skin is light brown in color, warm to touch, smooth and the skin
turgor is poor. No leision noted. Hair is evenly distributed and there were no edemas
noted.
NAILS
The clients nail plate shape is convex 160. Nail bed color is pink and capillary
refills within 3 seconds and there is no beaus line. She has a long nails and some what
dirty.
HEAD AND FACE
The clients skull is appropriate to her body size; the contour is round and
symmetrical. There are no masses. Face is symmetrical and does easy movements.
Consistency is smooth. Face shape is round
EYES
The clients eyebrows are evenly distributed with skin intact. Eyelashes equally
distributed, curled slightly outward. Eyelids skin intact, no discharges, no discoloration,
eyelids close symmetrically. Bulbar conjunctiva is transparent; sclera appears white.
Palpebral conjunctiva is shiny, smooth and pink in color. Client blinks when the cornea is
touched. Pupil is black in color, equal in size, and round. Illuminated and nonilluminated
pupil constricts. Pupils constrict when looking at near objects and pupils dilate when
looking at far objects. When looking straight ahead, client can see objects in the
periphery. Both eyes coordinate move in unison, with parallel alignment. She has
difficulty in visualizing things12 feet away from her.
EARS
The clients ear auricle color is normal racial tone, mobile, firm and not tender and pinna
recoils after it is folded. The distal third contains hair follicles and glands with dry
cerumen. There are no masses on the maxillary and frontal sinuses. She has difficulty on
recognizing words on her left ear with normal voice and difficulty in both ears in
whispered voice.

NOSE

The clients external nares a normal racial tone, the septum is at the midline, the color of
the mucosa is pink, and both nasal cavities are patent. There are tenderness in the
maxillary and frontal sinuses there are no observes redness and swelling.
MOUTH AND PHARYNX
Lips is pale in color, dry and symmetrical.Tongue is in central position, pink with
whistish spots, no lesions and lingual frenulum is in the midline, tongue moves freely
and has no tenderness. Hard and soft palate is pink in color, smooth and has a regular
texture. Uvula is position in the midline of the soft palate. Tonsils are inflamed, gag
reflex is present.
NECK
The clients muscles Equal in size and head centered. Muscles have equal strength,
lymph nodes are not palpable, trachea is in the midline and thyroid gland is not
palpable.She complain for a bit difficulty upon swallowing.
LUNGS AND THORAX
The clients lungs is AP to lateral ratio 1:2, lung expansion is symmetrical both anterior
and posterior. Spinal column is straight, right and left shoulder and hips are at the same
height. Chest well intact and there is no tenderness, no masses. The client breath sounds
is crackles upon auscultation.
HEART
The client's has no abnormal pulsation. Heart sounds are audible on four anatomic sites.
The peripheral pulses have symmetrical pulse volume with full pulsation.

BREAST AND AXILLA

The clients breast is equal in size generally asymmetrical. There is no dimpling.
There is no tenderness on the lymph nodes.
ABDOMEN
The clients abdomen has a normal racial tone and symmetric contour and shape is flat
and round. Audible bowel sounds. Liver and bladder are not palpable. She defecates
everyday and urinates 6 times for the whole day.
UPPER EXTREMITIES
The clients upper extremities muscle strength is 3of 5. Muscle tone is
normal racial color. There is no lesion, deformities or tenderness noted. Lymph nodes are
not palpable.
LOWER EXTREMITIES
The clients motor strength is good with a scale of 4 of 5. Muscle tone is
normal racial color. There is a lesion on his knee right part and on the right legs. There
are no physical deformities. Pperipheral pulses are present.
FEMALE GENITALS

Not assessed. According to her there is no discharges on her genitalia. She is at

menopausal stage.
DIAGNOSTIC PROCEDURE
Hematology
Hematology is a study of blood. It is frequently performed by a medical technician. It is
concern to the composition of blood and used to determine if blood components are
within normal values.
Indication
The CBC provides valuable information about the blood and to some extent the bone
marrow, which is the blood-forming tissue. The CBC is used for the following purposes:

as a preoperative test to ensure both adequate oxygen carrying capacity and

hemostasis

to identify persons who may have an infection

to diagnose anemia

to identify acute and chronic illness, bleeding tendencies, and white blood cell
disorders such as leukemia

to monitor treatment for anemia and other blood diseases

to determine the effects of chemotherapy and radiation therapy on blood cell

production

Nursing Responsibilities
Identify the patient
Explain the procedure
Position the patient in comfortable position
Label the specimen properly
Report abnormal result in the physician
Use a correct procedure in obtaining the specimen

Hematology

1-25-11

WBC

Result

Normal Range

13.66 X 10g/L

4.50-11.00

Differential Counts
Neu.

71.9

50.0-70.0

Lym.

16.6

20.0-40.0

Mon.

7.5

2.0-7.0

Eos.

3.7

0.0-3.0

Bas.

0.3

0.0-0.1

RBC

4.14 x 1012/L

4.50-5.50

HGB

124g/l

120-100

HCT

0.351L

0.380-0.470

MCV

84.7 fL

80.0-

Interpretation:
The client has a infection, and when the basophil is above the normal range, the client has
a allergy.
Uric Acid Tests
Definition
Uric acid tests are tests that are done to measure the levels of uric acid in blood serum or
in urine.
Purpose
The uric acid tests are used to evaluate the blood levels of uric acid for gout and to assess
uric acid levels in the urine for kidney stone formation. The urine test is used most often
to monitor patients already diagnosed with kidney stones, but it can also be used to detect
disorders that affect the body's production of uric acid and to help measure the level of
kidney functioning.
Uric acid is a waste product that results from the breakdown of purine, a nucleic acid.
(Nucleic acids are the building blocks of DNA.) Uric acid is made in the liver and
excreted by the kidneys. If the liver produces too much uric acid or the kidneys excrete
too little, the patient will have too much uric acid in the blood. This condition is called
hyperuricemia. Supersaturated uric acid in the urine (uricosuria) can crystallize to form
kidney stones that may block the tubes that lead from the kidneys to the bladder (the
ureters).
Nursing Responsibilities
Prior:
1.Select vein for venipuncture (usually antecubital space).
2.Apply tourniquet several inches above intended venipuncture site
3.Clean venipuncture site (with povidone iodine or alcohol, allow area to dry).
During:
1.Perform venipuncture by entering the skin with needle at approximately a 15-degree

angle to the skin, needle bevel up.

2.If using a Vacutainer, ease tube forward in holder once in the vein. If using a syringe,
pull back on the barrel with slow, even tension as blood fills the syringe.
3.Release tourniquet when the blood begins to flow.
After:
1.After the blood is drawn, place cotton ball over site; withdraw the needle and exert
pressure. Apply bandage if needed.
2.Properly dispose contaminated materials.
3.Record the date and time of blood collection. Attach a label to each blood tube.
4.Relay results to the doctor.
Uri c Test
1-28-11

Uric Acid (enzymatic)

SI units

Conventional Unit

273.09 umol

142.80-339.2 (4.62 mg/dl

2.41-5.73

Interpretation:
Excess serum accumulation of uric acid can lead to a type of arthritis known as gout

Lipid Prof.
SI unit

Conventional Unit

Cholesterol

L 3.74 mmol/ L

3.88-6.20 144.40 mg/dl

(149.81-238.38)

Trigllcerides(enzymatic)

1.13 mmol/L

0.11-2.26 (100.01 mg/dl

10.00-200.01)

HDL

L 0.75 mmol/L > 15

20.96 mg/dl F>44.40

Interpretation:
Desirable level that puts you at lower risk for coronary heart disease. A cholesterol level
of 200 mg/dL or higher raises your risk.

URINALYSIS
Urinalysis is a diagnostic physical, chemical, and microscopic examination of a urine
sample (specimen). Specimens can be obtained by normal emptying of the bladder
(voiding) or by a hospital procedure called catheterization.
Purpose
Routine urinalyses are performed for several reasons:

general health screening to detect renal and metabolic diseases

diagnosis of diseases or disorders of the kidneys or urinary tract

monitoring of patients with diabetes

In addition, quantitative urinalysis tests may be performed to help diagnose many specific
disorders, such as endocrine diseases, bladder cancer, osteoporosis, and porphyrias (a
group of disorders caused by chemical imbalance). Quantitative analysis often requires
the use of a timed urine sample. The urinary microalbumin test measures the rate of
albumin excretion in the urine using laboratory tests. This test is used to monitor the
kidney function of persons with diabetes mellitus. In diabetics, the excretion of greater
than 200 g/mL albumin is predictive of impending kidney disease.
Nursing considerations

Check the expiry date of the test strips on the bottle label;
Ensure storage instructions are adhered to the date of opening should be
recorded on the bottle;
Precise timing is essential use a watch with a second hand;
Always test fresh urine, collected in a clean dry container if the urine is left
standing for more than four hours, there may be contaminants, leading to false readings;
Immerse all the regent area in the specimen and remove the strip immediately;
Remove excess urine;
Hold the strip horizontally and compare the test areas closely with the colour
chart on the bottle label for the length of time specified;
Record the results in nursing records and report any abnormal findings.
Urinalysis
1-26-11
Color-

yellow

Transparency-

hazy

SP. Gravity-

1.015

Reaction-

acidic

Albumin-

negative

Glucose-

negative

Wbc-

3-5/hpf

Rbc

2-4/hpf

Mucous thread-

moderate

Epithelial cell-

moderate

Bacteria-

moderate

INTERPRETATION

When the WBC count in urine is high, it means that there is inflammation in the urinary
tract or kidneys. The most common cause for WBCs in urine (leukocyturia) is a bacterial
urinary tract infection (UTI), such as a bladder or kidney infection.
UREA NITROGEN
A blood urea nitrogen (BUN) test measures the amount of nitrogen in your blood that
comes from the waste product urea. Urea is made when protein is broken down in your
body. Urea is made in the liver and passed out of your body in the urine
INDICATION
The BUN level may be checked in order to assess or monitor:

the presence or progression of kidney or liver disease.

blockage of urine flow.
mental confusion. Patients with kidney failure are sometimes disoriented
and confused.
abnormal loss of water from the body (dehydration).
recovery from severe burns. The body uses larger than normal amounts of protein
following serious burns.
Urea Nitrogen
SI units

Normal Range

Urea Nitrogen

H 10.38 mmol/L

2.18-8.33

Creatinine

73.72 umol/L

45-84

INTERPRETATION
High levels of BUN may indicate kidney disease or failure; blockage of the urinary tract
by a kidney stone or tumor; a heart attack or congestive heart
failure; dehydration; fever; shock; or bleeding in the digestive tract.
NURSING RESPONSIBILITIES
Prior:
1.Select vein for venipuncture (usually antecubital space).
2.Apply tourniquet several inches above intended venipuncture site
3.Clean venipuncture site (with povidone iodine or alcohol, allow area to dry).
During:
1.Perform venipuncture by entering the skin with needle at approximately a 15-degree
angle to the skin, needle bevel up.
2.If using a Vacutainer, ease tube forward in holder once in the vein. If using a syringe,
pull back on the barrel with slow, even tension as blood fills the syringe.
3.Release tourniquet when the blood begins to flow.
After:
1.After the blood is drawn, place cotton ball over site; withdraw the needle and exert

pressure. Apply bandage if needed.

2.Properly dispose contaminated materials.
3.Record the date and time of blood collection. Attach a label to each blood tube.
4.Relay results to the doctor.

ANATOMY AND PYSIOLOGY

TONSILS : are two clumps of tissue, on either side of the throat, embedded in a pocket
at the side of the palate (roof of the mouth).
SOFT PALATE: soft palate (also known as velum or muscular palate) is the soft tissue
constituting the back of the roof of the mouth.
UVULA: is of course the little piece of flesh that hangs down from the rear portion of
the soft palate.
TONGUE: tongue is a muscular hydrostat on the floors of the mouths of most
vertebrates which manipulates food for mastication
PHARYNX is the part of the throat situated immediatelyposterior to (behind)
the mouth and nasal cavity, and cranial, or superior, to the esophagus,larynx,
and trachea.

PATHOPHYSIOLOGY
Risk factor

Tonsillitis

Pharyngitis

Causative agent
Most of these true abscesses are polymicrobial
Group A -hemolytic streptococci (GABHS)
-Hemolytic streptococci
Staphylococcus aureus

 Haemophilus influenzae
Anaerobic bacteria play an important role:

Prevotella

Porphyromonas

Fusobacterium
Peptostreptococcus

Possible synergy between anaerobes and GABHS

infectious tonsillopharyngitis progresses from cellulitis to abscess.

The infection starts in the intratonsillar fossa, which is situated between the upper pole and the
body of the tonsil, and eventually extends around the tonsil.
The abscess is a suppuration outside the tonsillar capsule, in proximity to the upper pole of the
tonsil, involving the soft palate.
Purulence usually collects within one tonsillar fossa, but it may be bilateral.
Tonsillar and peritonsillar edema may lead to compromise of the upper airway.
Signs and symptoms
Fever and sore throat:

Most common initial complaints

Trouble swallowing, pain with opening the mouth (trismus), muffled (hot potato) voice:

Classic presenting symptoms

Unilateral neck or ear pain:

Other common presenting symptoms

CHAPTER
2

Nursing Diagnosis

Rank
1

Acute pain related to

inflamed tonsils as
evidenced pain scale of 9/10

Justification
This is the actual problem
based on Maslows
Hierarchy of Needs the
physiologic needs of the
patient this must be given an
immediate treatment/action
to lessen the pain.

2
Impaired swallowing related
to acute peri-tonsilar abscess
as evidenced by pain when
swallowing

This is the second prioritized

problem based on Maslows
Hierarchy of Needs the
physiologic needs of the
patient this must be given an
immediate treatment.
3

Hyperthermia related to
elevated wbc secondary to
peritonsillar as evidence by
temperature of 37.2 celcius.

The third prioritized because

an elevated temperature can
cause other complication.

4
Readiness for enhanced
comfort

The fourth priority because it

is already on the wellness
stage and needs only to
maintain by the client.

5
Readiness for enhanced
knowledge

The last to be prioritized

because this only needs an
improvement and conducting
health teachings.

SSESSMENT

DIAGNOSIS

SCIENTIFIC
EXPLANATION

Subjective:
Ang sakit pag
lumulunok ako as
verbalized by the
client

PLANNING
DISCHARGE:

Acute pain related to

inflamed tonsils as
evidenced by pain
scale of 9/10

Tissue injury

Release of chemical
mediators

Upon discharge, the

client will be able to
decrease perceived
pain from 4/10 to
0/10 without
complication.

Objective:
P: when she
swallows it already
hurts
Q: aching pain
R: extend through
the neck
S:pain scale is 9/10
T: every after she
swallows

Stimulating the pain

receptor

Transmission of
impulse

Transmission of
nociceptors to other
part of spinal cord

SHORT-TERM:
After 8 hours of
nursing intervention,
the client will be
able to decrease
perceive pain from
4/10 to 2/10 without
complication.

After 2 hours of
nursing intervention,

IMPLEMENTATION
1.Determine clients
acceptable level of
pain/ pain control
goals.
2.Proviede comfort
measures (e.g. touch,
repositioning, use of
heat/cold packs,
nurses presence),
quiet environment,
and calm activities.

SCIENTIFIC
RATIONALE
1.Varies with
individual and
situation.

DISCHARGE:
GOAL ACHIEVED

Upon discharge, the

client was able to
decrease perceived
2.Promote nonpain from 4/10 to
pharmacological pain 0/10 without
management.
complication.

3.Instruct in/
encourage use of
relaxation techniques
such as focused
3.Distract attention
breathing, imaging,
and reduce tension.
CDs/tapes (e.g. white
noise, music
instructional)
4.Work with client to
prevent pain,

EVALUATION

Recommendation:
TERMINATE THE
PLAN

SHORT-TERM:
GOAL ACHIEVED
After 8 hours of
nursing intervention,
the client was able to
decrease perceived
pain from 4/10 to
2/10 without

Localized pain

Perception of pain

the client will be

able to demonstrate
use of relaxation
skills and diversional
activities as
indicated for
individual situation.

therapeutic
interventions
response and length
of time before pain
recurs.

COLLABORATIVE:

Reference:
Medical Surgical by:
Brunner pp.231-237

Administer
analgesics, as
indicated maximum
dosage as ordered by
the doctor.

complication.

4.As timely
intervention is more
likely to be
successful in
alleviating pain.

After 2 hours of
nursing intervention,
the client will be able
to demonstrate use of
relaxation skills and
diversional activities
as indicated for
individual situation.
Recommendation:
TERMINATE THE
PLAN

COLLABORATIVE:
Maintain acceptable
level of pain. Notify
physician if regimen
is inadequate to meet
pain control goal.

Assessment
Subjective:
Hirap ako
lumunok as stated

Nx Diagnosis
Impaired swallowing
r/t acute peri-tonsilar
abscess as evidenced
by difficulty in
swallowing

Scientific
Explanation

Planning
After 8 hours of Nx
intervention, client
will be able to:

Intervention
-Assess clients
swallowing
condition

-Identify factors that

affect present
condition
-Determine food
preferences ofclient

Objective:
-difficulty in
swallowing
-pain while
swallowing

-Verbalize 2/3
interventions that
will promote clients
comfort.

-facial grimace

Rationale
-to have a baseline
data and to assess
clients present
condition.

-To incorporate as
possible enhancing
food intake.

-to prevent
thickening of oral
secretions.

Evaluation
After 8 hours of Nx
intervention, client
will be able to:

-Identify factors that

affect present
condition

-Verbalize 2/3
interventions that
will promote clients
comfort.

-Encourage to avoid
milk products and
chocolate
Long term:
After 1 week of Nx

Long term:
-To promote

After 1 week of Nx

intervention, client
will be able to:

-Demonstrate
behaviors that will
promote good
swallowing

-Feed one
consistency and/or
texture of food at a
time.

Collaborative:
Refer patient to
dietitian

Administer
medications as
prescribed and place
the medication in
gellatin, jelly,
pudding.

swallowing .

intervention, client
will be able to:

-Demonstrate
behaviors that will
promote good
swallowing
-To establish
optimum dietary
plan.

-to promote clients

well being and to be
able for the patient to
ingest medications.

CHAPTER
3

Drug Study
DRUGS

CLASSIFICATION
AND INDICATION

MECHANISM
OF ACTION

DOSE, ROUTE,
FREQUENCY

GENERIC
NAME:

CLASSIFICATION:
Cephalosporins 3rd
generation.

Act by inhibiting
cell wall synthesis
in bacteria.

Ceftriaxone 1g/IV
OD.

CONTRAINDICATION

SIDE-EFFECT

NURSING MANAGEMENT

Ceftriaxone
BRAND
NAME:
Rocephin

INDICATION:
Respiratory, GIT, GUT,
otic and bone, skin,
soft tissue and post-op
infection, endocarditis.

Hypersensi
tivity to
cephalospo
rins.

Diarrhea
Abnormal
liver and
renal
function
test
Hypoprothr
ombinemia
Thrombopl
ebitis

Check the history of the pt.

especially the allergy
Check the physicians order
regarding the dose, route
and frequency
Administer the drug on the
time order
Monitor the v/s of the
patient
Monitor for the side effect
of the drug
Monitor for the hydration
status of the patient
Instruct the patient to report
if she experience any of the
side-effect of the drug
Instruct pt. to take plenty of
rest
note, record and document
the drug administration

Drug Study
DRUGS

GENERIC
NAME:
acetaminophen
BRAND
NAME:
Tylenol

CLASSIFICATION
AND INDICATION

MECHANISM
OF ACTION
acetaminophe
CLASSIFICATION: n appears to
Miscellaneous
produce
analgesics
analgesia by
INDICATION:
elevation of
For fever and
the pain
discomfort associated threshold. The
with bacterial and
potential
viral infections,
mechanism
headache, and
may involve
condition involving
inhibition of
musculoskeletal pain. the nitric
oxide pathway
mediated by a
variety of
neurotransmit
ter receptors
including Nmethyl-Daspartate and
substance P.

DOSE, ROUTE,
FREQUENCY
Acetaminophen 30mg PO q6.

CONTRA-INDICATION

Hypersensitivity to
the drug
Anemia
cardiac and
pulmonary disease
Hepatic or severe
renal disease.

SIDEEFFECT

Haemat
ological
Skin
and
other
allergic
reaction

NURSING MANAGEMENT

Check the history of the

pt. especially the allergy
Check the physicians
order regarding the dose,
route and frequency
Administer the drug on
the time order
Monitor the v/s of the
patient
Monitor for the side effect
of the drug
Offer plenty of water
during administration
Monitor for the hydration
status of the patient
Instruct the patient to
report if she experience
any of the side-effect of
the drug
Instruct pt. to take plenty
of rest
note, record and

document the drug

administration

TREATMENT
Intravenous Therapy

D5 NM ILX10hrs.20 gtts/min

Definition
Intravenous therapy is giving of fluid/liquid substance directly to the vein for fluid
and electrolytes replacement and supplement.
Indication/Purpose

For fluid replacement

Foe severe water depletion requiring rapid replacement
Isotonic solution that expands intravascular volume

Precaution

use water solution only in patient with severe water loss and fluid imbalances
use cautiously in generic or post operative patient because fluid retention may
worsen

Nursing Considerations

check for IV site for any redness or infiltration

check for proper flow rate of IV. Regulate frequency as needed.
Evaluate for patient response and report s/sx of fluid overload
Advise patient to report pain at IV site
Label the IV container properly
Check for its patency
Check for any back flow of blood
Check for presence of bubbles
Make sure that you are giving the right IVF to the right patient

Diet
Soft foods as the name suggests are foods that are soft in texture, making them easy to
chew and swallow. Besides being soft in texture, the soft food umbrella also entails foods
that are not high in fiber content and also those that conduce to gas. Mostly people with
chewing and swallowing problems or those who have just undergone a surgery will need
to be on a soft food diet. Let's have a look at the soft diet food list to get a greater
understanding of which are the foods that come under this soft food category.
A List of Soft Foods
The soft diet food list will vary slightly depending on the reason for resorting to the same.
For example, if a person has just had an oral surgery, he or she cannot chew and swallow
hard foods.
However, he can very well digest all foods. Thus, pureed and mashed foods come in his
list of soft foods after tooth extraction. On the other hand, for a person who has just had a
gastritis bypass, the kinds of foods his or her stomach can tolerate will be different. The

gradual progression from a completely pure liquid diet to a soft food diet and then to a
general diet is to be made. Fried foods and spicy or highly seasoned foods are also not
good for post-operative or immobile patients. Moreover, most raw foods, breads and
cereals are eliminated from their diet as well. Thus, depending on one's condition the list
will vary. Let's have a look at the general soft diet food list.
Fruits
All fruits containing skin and seed should be avoided. The fruits one is permitted to have
are:

Bananas

Apple sauce

Pureed berries (de-seeded, de-skinned and pureed)

Vegetables
There are only some vegetables that are permitted to be eaten, as vegetables like broccoli,
cabbage, pinto beans, onions, etc. are gas forming vegetables. Moreover, eating raw
vegetables is forbidden. The vegetables one is permitted to have are:

Avocados

Skinned tomatoes

Skinned and mashed potatoes

Asparagus

Mashed pumpkin

Baked beans

Breads

Soft breads without crust

Pancakes

French toast without crust

Grains
In the grain category, cooked cereals are soft and easy to chew and swallow. The cooked
grains one is permitted to have are:

Oatmeal

Grits

Cream of wheat

Cooked pasta

Macaroni

Smooth peanut butter

Meat and Eggs

Ground meat

Tender cooked beef, lamb or veal

Tender cooked liver

Cooked tuna, salmon or white fish without bones

Broiled or stewed turkey or chicken

Soft boiled or scrambled eggs

Dairy Products

Yogurt

Tofu

Cottage cheese

Mild cheeses

Cream cheese

Butter

Cream

Mayonnaise

Beverages

Milk

Coffee

Tea

Herbal tea

Chocolate milk

Milk shakes

Fruit juices

Vegetable juices

Soups (creamed soups)

Broth

People recovering from gastritis should drink only caffeine-free drinks and should also
have low acid juices such as apple, grape or pear juice.
Desserts
Desserts with coconut and nuts should be avoided. The desserts one is permitted to have
are:

Ice-cream

Pudding

Custard

Gelatin desserts

Honey

Home made trifle7

Fruit mousse

Cream pies

24 Hour Recall
Food intake

Fluid intake

Biochemical Appraisal

Breakfast

1 slice of fish
2cups of rice
1 small banana

Lunch
Dinner

2 glasses of water
2 glasses of water

1 small bowl
monggo
2 cups of rice
cup of rice
1 slice of adobo

of 1 glass of water

Rich in carbohydrates
Rich in protein
High in potassium
Rich in carbohydrates
Rich in protein
Rich in carbohydrates
Rich in protein

Activity/Exercise
Permit activity as tolerated.
Daily Progress Chart

Admission
Jan.28,
2011

Day 01
Jan.
30,2011

Day 02
Jan.
2011

Hematology
Uric test
31, Urinalysis
Urea
nitrogen

Discharge
Day 03
Feb.1,
2011

Diagnostic
Procedure
Urinalysis
Hematology
Uric test
Urea
nitrogen
Hematology
Uric test
Urinalysis
Urea
nitrogen

Hematology
Urinalysis

Activity

Medication

Treatment

Ceftriaxone 1g/IV
OD.
Acetaminophen 30
-mg PO q6.

D5
NM
ILX10hrs.2
0 gtts/min

Flat on None
bed,
passive
rom

Ceftriaxone 1g/IV
OD.
Acetaminophen 30
-mg PO q6.

D5
NM
ILX10hrs.2
0 gtts/min

Flat on none
bed,
passive
rom

Ceftriaxone 1g/IV
OD.
Acetaminophen 30
-mg PO q6.

D5
NM
ILX10hrs.2
0 gtts/min

Flat on none
bed,
passive
rom

Ceftriaxone 1g/IV
OD.
Acetaminophen 30
-mg PO q6.

D5
NM
ILX10hrs.2
0 gtts/min

Flat
bed

Surgery

on NONE

CHAPTER
4

CHAPTER 4: EVALUATION
A. NARRATIVE EVALUATION OF ACTUAL NURSING PROLEM
ACUTE PAIN
The client was able to decrease perceived pain form 4/10 to 0/10 without complication.
The client was able to demonstrate the use of relaxation techniques and diversional
activities like watching TV, listening soft music and reading a book. The client was also
having the amount of rest and relieves discomfort.
B. DISCHARGE PLANNING INSTRUCTION
MEDICATIONAdvice the patient to take Ceftriaxone 250mg OD, and
acetaminophen (Tylenol) 30-mg PO q6 for 7 days. Advice also the patient to take the
medication as prescribed.
EXERCISE
The patient was advice foe passive ROM for at least 2-3 days. The patient was also
advice to take a rest for a couple of days to boost the immune system and gain easily the
strength. Permit activity as tolerated.
TREATMENT
Patients may be discharged on oral antibiotics to complete a 1014-day course when afebrile
and peritonsillar swelling has subsided.
Tonsillectomy should be considered after severe or recurrent peritonsillar abscesses

HEALTH TEACHINGS

Instruct the patient to continue the take home medication and take it on time.
Instruct the patient for proper oral hygiene to avoid infection.
Instruct the patient to maintain the fluid volume of the body.
Instruct patient to increase fluid intake at least 2-3L/day.
Instruct patient to report or have a check up if there is an increase in body
temperature.
Instruct patient to eat soft diet.
Instruct patient to avoid smoking that can lead to further complications.

OUT PATIENT DEPARTMENT

Instruct the patient to have followed up check-up on February 9, 2011 upon discharge.
DIET

The patient was advice for soft diet.

High fibers and low fat diet.
Avoid eating of acidic and sweets which can stimulate the salivary glands.

Soft foods as the name suggests are foods that are soft in texture, making them easy to
chew and swallow. Besides being soft in texture, the soft food umbrella also entails foods
that are not high in fiber content and also those that conduce to gas. Mostly people with
chewing and swallowing problems or those who have just undergone a surgery will need
to be on a soft food diet. Let's have a look at the soft diet food list to get a greater
understanding of which are the foods that come under this soft food category.
A List of Soft Foods
The soft diet food list will vary slightly depending on the reason for resorting to the same.
For example, if a person has just had an oral surgery, he or she cannot chew and swallow
hard foods.
However, he can very well digest all foods. Thus, pureed and mashed foods come in his
list of soft foods after tooth extraction. On the other hand, for a person who has just had a
gastritis bypass, the kinds of foods his or her stomach can tolerate will be different. The
gradual progression from a completely pure liquid diet to a soft food diet and then to a
general diet is to be made. Fried foods and spicy or highly seasoned foods are also not
good for post-operative or immobile patients. Moreover, most raw foods, breads and
cereals are eliminated from their diet as well. Thus, depending on one's condition the list
will vary. Let's have a look at the general soft diet food list.
Fruits
All fruits containing skin and seed should be avoided. The fruits one is permitted to have
are:

Bananas

Apple sauce

Pureed berries (de-seeded, de-skinned and pureed)

Vegetables
There are only some vegetables that are permitted to be eaten, as vegetables like broccoli,
cabbage, pinto beans, onions, etc. are gas forming vegetables. Moreover, eating raw
vegetables is forbidden. The vegetables one is permitted to have are:

Avocados

Skinned tomatoes

Skinned and mashed potatoes

Asparagus

Mashed pumpkin

Baked beans

Breads

Soft breads without crust

Pancakes

French toast without crust

Grains
In the grain category, cooked cereals are soft and easy to chew and swallow. The cooked
grains one is permitted to have are:

Oatmeal

Grits

Cream of wheat

Cooked pasta

Macaroni

Smooth peanut butter

Meat and Eggs

Ground meat

Tender cooked beef, lamb or veal

Tender cooked liver

Cooked tuna, salmon or white fish without bones

Broiled or stewed turkey or chicken

Soft boiled or scrambled eggs

Dairy Products

Yogurt

Tofu

Cottage cheese

Mild cheeses

Cream cheese

Butter

Cream

Mayonnaise

Beverages

Milk

Coffee

Tea

Herbal tea

Chocolate milk

Milk shakes

Fruit juices

Vegetable juices

Soups (creamed soups)

Broth

People recovering from gastritis should drink only caffeine-free drinks and should also
have low acid juices such as apple, grape or pear juice.
Desserts
Desserts with coconut and nuts should be avoided. The desserts one is permitted to have
are:

Ice-cream

Pudding

Custard

Gelatin desserts

Honey

Home made trifle7

Fruit mousse

Cream pies

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