Table of content

Page:
|. Objectives……………………………………………………
||. Overview of the study…………………………………
|||. Nursing health History………………………………..
A. Demographic data………………………………..
B. Past history…………………………………………..
C. Present illness………………………………………
D. Family History………………………………………
V. Physical assessment………………………………………
V||. Diagnosis laboratory result………………………..
V||. Discharge Planning…………………………………….
 Labarotory Findings
Patient name: X Age: 52 yrs/old
Requested labaratory: feb. 10,2020 Female

Hematology
Test Result
Hemoglobin 9.0 (L) 11.00-16.00g/dL
Hematocrit 29.1 (L) 37.00-47.00percent
RBC Count 4.01 4.00-6.00x10^6/vL
WBC Count 8.2 5.00-10.00x10^3vL
Platelet 2.6 150.00-400.00x10^1/vL
MCV 72.6 (L) 82.50-98.00Fl
MCN 22.4 (L)26.10-32.80g
MCHC 30.9 30.70-35.90g/dL
Segmenters 58 50.00-65.00percent
Lymphocyte 34 25.00-35.00percent
Monocyte 06 2.00/7.00percent
Eosinophils 02 1.00-3.00percent

Urinalysis
Rout Yellow WCC 3. 5/hpf
Collon
Transparency Hazy RBC D. 1/Hpf
Specific gravity 1.005 Epithelial cells Occasional
PH 6.0 Amorphous urates. Ocasional
Protein Negative Amorphous urates
Glucose Negative Mucus threads. Rare
Ketone Bacteria. FEW
Casts Pregnancy test.
Cystals Urine micral
Remarks
 Crossmatching
Panors screening
ABO&Typing ‘A’RH+ Slide/Direct Crossmatching
Hemoglobin Passed Blood Dgg number 3600-001334T
Malaria Negative Date of extraction 1-31-20
Hbsag Nonreactive Date of expiration 03-06-20
RPR(syphilis) Nonreactive Major
HCV Ab Nonreactive Minor
HIV 1&2AB Nonreactive Remarks 300mL

Remarks:
1unut of WB/CO Pre ifugao
Tube/ortho spectrum
Salive phase No agglutination
AHG/Phase No Agglutination
Bovine Phase No Agglutination
Crossmatching result
Compatible
 Patient profile

Patient name: Ptient Y

Age: 52
Birthdate: March 9
Birthplace: Villacis, Santiago City
Civil Status: Married
Gender: Female
Nationality: Filipino
Religion: Methodist
Address: Villacis, Santiago City
Fathers Name: Mr. R.
Mothers Nmae: Mrs. C.
Date of administration: February 8,2020
Time of administration: 1:30pm
Chief Complaint: Fever, Body weakness
Admiting Diagnosis: Anemia
Attending physician: Dr. C
Room: Female Ward
Assessment Diagnosis Planning Intervention Rationale Evaluation

“Nang hihina •Activity After 4hours of •assess patient •influences Goal met
ako, kadalasan intolerance nursing ability to choice of Patient
hindi ko related to intervention perform interventions reaveals an
matapos ang imbalance the patient will normal task or or needed increased in
trabaho ko” as between able to: activities of assisstance. activity
verbalized by oxygen supply daily living. tolerance and
the patient (delivery) and •report an •recommended •enhance rest demonstrated
demand increase in a quiet to lower body’s a decreased in
activity atmosphere, oxygen psychological
Objective: tolerance and bed rest if requirements signs of
Fatigue including indicated and reduce intolerance
Body weakness activite of daily strain on the
Pale living heart lungs
Vs/ taken •demonstrate •Elevated the •Emhance lung
BP: 80/60 a decrease in head of the bed expansion to
HR: 88 psychological as tolerated maximize
RR: 21 signs of oxygenation for
intolerance cellular uptake
•provide or •although help
recommend may be
assisstance necessary, self
with activities esteem is
enhanced
when patient
does
something for
self.
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Hyperthemia After 4hours of •monitor vital •vital signs Goal met, After
“Parang mainit related to nursing signs provide more 4hours of
ang mama bacterial intervention accurate nursing
ko”as infection the patient indication of intervention
verbalized by temperature core the patient
the relative of will decrese temperature temperature
the parient •remove •these will decresed
excess clothing decrease and the
Objective: and covers warmth and temperature is
Temp:38.2 increase 37.5
BP: 80/60 evaporative
HR: 88 cooling
RR: 21 •promote a •to decrease
well ventilation warmth and to
area to a increase
patient evaporative
cooling
•encourage •it helps
patient TSB lowering the
body
temperature
•take adequate •helps to
fluid intake normalize body
temperature
Assessment Diagnosis Planning Intervention Rationale Evaluation

“Masakit ang Acute pain After 4hours of •monitor vital •alteration from Goal met
mga kamay related to nursing sign normal maybe After 4hours of
ko” as spasm at intervention signs of infection nuring
cerbalized by upper the patient will intervention
the parient extremities able to: •provide •to promote the patient feel
Pain scale •the patient comfort Non- more
8/10: feel more meassures, pharmachological comfortable,
Body weakness comfortable, quiet pain less pain and
And evidence less pain and environment management decrease the
of pain decrease the and calm pain scale from
Restless pain scale activities 8/10 to 4/10
Irritability •encourage •it helps suit the
VS taken: hot compress pain
BP: 80/60 •encourage •to promote
HR: 88 relaxiational relaxiation
RR: 21 activity like
diversional
activity and
relaxiation
such as
listening music
 Dischrge planning
M-edication
• the patient is advised to follow and take the prescribe medication regimen needed for
Effective treatment and fast recovery
E-xercise
• Instruct the patient to exercise regularly like stretching
T-reatment
• Encouraged patient to have adequate rest
• Encouraged patient to drink 2-3 litters of water everyday
H-ygiene
•Educated patient about propper hygiene and its importance
• Encourage patient to practice good hygiene
O-ut patient
• Instructed the patient to have follow up check up after 7 days
• Advise to notify physician physician if there is any problem or complications arises
D-iet
• Instructe the patient to eat atleast 2 fruits and 2 vegetable
•Instruct the patient to drink plenty of water
• Advised the patient to avoid eating junk foods and refrain from drinkinh sodas
• Advised patient to avoid foods that are rich in fat
S-pirituity
•Encouraged patient to go to Church every Sunday
• Instructed to patient o pray for fast recovery
• Instruct the patient to have faith in God
• Advised to patient to always thanks God
Patient history

History of present illness

A 52 years old female patient and 2days ago prior to administration the ptient is a p was on her way
home after s

M
 Republic of the phillipines
Isabela State University

Drug name Classification Action Indication Adverse effect Nursing responsibility

 Antibacterial Treatment •hematologic toxicity:
Cotrimoxazole of infections neutropenia,
due thrombocytopenia,
Sulfamethoxazole tosuceptible agranulocytosis,
and organism appasticanemi
trimethoprim, •contraindicated in
cotrimoxazole patient with known
Hypersensitivity
Totrimethoprim
Or sulfonamides
•use with caution in
patients with
Impairedrenal or
hepatic function
Or with possible folate
or G6PD deficiency

Dissage
Drug name Classification Action Indication Adverse effect Nursing
responsibility

Dissage
Drug name Classification Action Indication Adverse effect Nursing
responsibility

Dissage
Drug name Classification Action Indication Adverse reaction Nursing
Brande name: Dietary Provide a Procut used to •Constipation
nutricap supplement comprehensi treat or •Diarrhea or
ve prevent upset stomach
Array of vitamindefivie may occur
essential ncy due to These effect
Generic name: vitamins and poor diet, ussually
Multivitamins mineral certain illness temporary and
+mineral+Ginkgo designed to or during amy disappear as
+Lycopene+Lutein enhance a pregnancy your body adjust
+Ginseng+ healthy to this medication
Lecithin+Ginkgo+ lifestyle,
Biloba+Zeaxanthin promote
+Zink vitality and
improve
Dassage: mental
Available in function
Tablets
100s per box