Formatlabresults.ncp.Drugana

LAB RESULT/ DIAGNOSTIC FINDINGS CBC 1/30/2006 TEST HEMOGLOBIN MASS C MCH HEMATOCRIT MCV MCHC RBC WBC DIFFERENTIAL COUNT NEUTROPHILS LYMPHOCYTES PLATELETS RBC MORPHOLOGY

RESULTS

40-75% 20-45% 140-440 x 10^9/L

SERUM ELECTROLYTES 1/30/2006 TEST RESULTS SODIUM POTASSIUM CHLORIDE UREA NITROGEN SUBSTC CREATININE SUBSTC

ABGs 1/30/2006 TEST pH PCO2 PO2 HCO3 BE(ecf) O2 Sat Total CO2 FiO2 Temp

REFERENCE 140-160 g/L 27.5-33.2 pg 40-54 % 80-94 fl 32-37 % 4.5-5.0 x10^12/L 5-10x10^9/L

RESULT

REFERENCE 135-155 mmol/L 3.5-5.3 mmol/L 103-116 mmol/L 3.2-6.8 mmol/L 44-106 umol/L

REFERENCE 7.5-7.45 35-45 mmHg 80-100 mmHg 22-26 meq/L +/-2 94-100%

URINALYSIS 1/30/2006 TEST COLOR TURBIDITY REACTION SPECIFIC GRAVITY PROTEIN SUGAR RBC WBC CASTS BACTERIA EPITHELIAL CELLS CRYSTALS

RESULT

SPUTUM CULTURE 1/30/2006 MICROSCOPY WBC EPITHELIAL CELLS

CHEST X-RAY 1/30/2006

Gram+cocci Gram-rods

REFERENCE Yellow Clear Acidic 1.015 Negative ++ /H.P.F. 0-1/H.P.F. none

De Leon, Elaine S. BSN IV-B 07/26/06 Px: DE, A 43 y/o male was admitted to POC and was diagnosed of pathologic fracture femoral neck left distal femur ASSESSMENT

NSG. DX

RATIONALE

Subjective: “hindi ko nga masyado magawa yung mga normal na ginagawa ko dahil nga sa nakatraction ako.” As patient verbalized.

Partial Impaired Physical Mobility r/t immobilization by traction

Traction is applied to the extremity of a px with a fracture, the purpose of this is first, to lessen the muscle spasm and to reduce the fracture and then to provide immobilization and to maintain the corrected position to the affected part of the body.

Objective: inability to move purposefully within the physical environment; imposed restrictions; unable to perform ADL’s: unable to bathe and dress self without assistance; able to feed self; muscle strength: RUE,LUE, RLE: 5/5, balance skeletal traction on the lower left extremity; medical dx: pathologic fracture femoral neck left distal femur

PLAN After 8 hours of NI, client will be able to increase/ maintain mobility at the highest possible level

Reference: Orthopedic nursing by: Larson and Gould

INTERVENTIONS

RATIONALE

1. Assess Degree of immobility produced by treatment and note patient’s perception of immobility 2. instruct and assist px with active/passive ROM exercises of affected and unaffected extremities

1. px may be restricted by selfview/self-perception out of proportion with actual physical limitations

3. encourage use of isometric exercises starting with the unaffected limb.

3. isometric contract mucles without bending joints or moving limbs and help maintain muscle strength and mass

4. instruct in/encourage use of trapeze and post position for lower limb fractures. 5. assist with/encourage self-care activities such as bathing or shaving

4. facilitates movement during hygiene/skin care and linen changes

6. prvide diet high in CHON, CHO, Vitamins and minerals

6. in the presence of musculoskeletal injuries, nutrients required for healing are rapidly depleted, often resulting in a weight loss as much as 20/30 lb during skeletal traction. This can have profound effect on muscle mass, tone and strength

2. increase blood flow to muscles and bones to improve muscle tone, maintain joint mobility; prevent contractures/ atrophy and calcium resorption from disuse

EVALUATION fter 8 hours of NI, Patient will be able to increased and maintain mobility at the highest possible level

5. improves muscle strength and circulation,promotes selfdirected wellness

Reference: Nursing Care Plans by: Doenges et.al ASSESSMENT

NSG.DX

RATIONALE

PLAN

INTERVENTIONS

RATIONALE

EVALUATION

Subjective: “eto wala masyadong ginagawa kundi maupo, mahiga, sanay akong palaging naglalakad at me ginagawa.”; “ dumudumi ako 1 beses sa isang araw.”, “Pag dumudumi dito lang din, syempre hindi naman ako pwedeng tumayo.”, “Kung ano ang binibigay nila(POC) sa aking pagkain, un ang kinakain ko.” As verbalized by patient

Risk for Bowel Incontinence r/t change in activity level

Decrease in activity level may reduce GI motility in which results in constipation which is one of the potential complications of a patient in traction.

After 8 hour of NI, px wil be able to Maintain normal bowel elimination and demonstrate behaviors or lifestyle changes to prevent developing problem.

Reference: Brunner and Suddarth’s Textbook of Medical-Surgical Nursing by: Smeltzer and Bare

Objective: Normal Bowel sounds heard every 20 s; inadequate toileting, lack of privacy, recent environmental changes, insufficient physical activity, balance skeletal traction on left lower extremity

1. Auscultate abdomen for presence, location and characteristics of bowel sounds

1. This will reflect bowel activity

2. Discuss usual elimination pattterns 3. instruct in/encourage balanced fiber and bulk in diet

2. determine normal bowel movement 3. to improve consistency of stool and facilitate passage through the colon

4. promote adequate fluid intake, including water and high-fiber juices; suggest warm,stimulating fluids 5. Encourage active exercise on the unaafected part and passive exercise on the affected part

4. to promote moist/soft stool

6.provide privacy by covering the Balkan frame with linen and in routinely scheduled time

6. facilitates normal bowel function

7. Ascertain frequency, color, consistency, amount of stools.

7. Provides a baseline for comparison, promotes recognition of changes

After 8 hours of Ni, patient will be able to maintain normal bowel elimination and demonstrate behaviors or lifestyle changes to prevent developing problems

5. to stimulate contractions of the intestines

Reference: Nurse’s Pocket Guide by Doenges et. al

ASSESSMENT

NSG.DX

RATIONALE

PLAN

INTERVENTIONS

RATIONALE

EVALUATION

S: “Nahulog kasi ako nung isang linggo nun sa bangko, nauna ang puwitan ko, nabalian ako, mula bulacan dinala ako dito sa orthopedic” as patient verbalized Objective: Vital signs:BP:130/90, T: 37.2 C, HR: 80bpm, RR: 22bpm, patient is afebrile, balanced skeletal traction application on the left lower extremity, no signs of imflammation and drainage of the skin on pin site; medical dx of pathologic fracture femoral neck left distal femur, intact level of consciousness, (-)chills and diaphoreses

Risk for Infection r/t skeletal traction

Patient in Traction have high risk in acquiring infection due to the direct insertion of Steinman pin into the bone.

Reference: Orthopedic Nursing by: Larson and Gould

After 8 hours of NI, px will be able be free of purulent drainage or erythema, and remain to be afebrile

1. Inspect the skin for preexisting irritation or breaks in continuity 2. Assess pin site, noting presence of edema, erythema, foul odor or drainage

1. Pins or wires should not be inserted through skin infections, rashes, or abrasions which may lead to bone infection. May indicate onset of local infection/tissue necrosis, which can lead to osteomyelitis

3. Provide sterile pin care with hydrogen peroxide and betadine and exercise meticulous handwashing

3. may prevent crosscontamination and possibility of infection

4. instruct patient not to touch the insertion sites

4. Minimize opportunity for contamination

5. Monitor V/S. note presence of chills, fever, malaise, change in mentation

Hypotension, confusion may be seen with gas gangrene; tachycardia and chills/fever reflect developing sepsis.

6. Investigate abrupt onset of pain/limitation of movement with localized edema/erythema in injured extremity

6. May indicate development of osteomyelitis

After 8 hours of NI, px will be able to be free of purulent drainage or erythema and remain to be afebrile

GENERIC NAME Amikacin

MECHANISM OF ACTION Inhibits protein synthesis in bacteria at level of 30S ribosome.

INDICATION Treatment of serious gramnegative bacillary infections

Therapeutic effects: Bacterial action

ADVERSE REACTION EENT: ototoxicity (vestibular, cochlear)

DRUG-DRUG INTERACTION Inactivated by penicillin,

NURSING RESPONSILBILITIES

GU: nephrotoxicity F and E: Hypomagnesemia MS: muscle paralysis

BRAND NAME Amikin

GENERIC NAME

Spectrum: most aminglycosides notable for activity against: P. aureginosa, klebsiella pneumoniae, Escherichia coli, proteus, serratia, acinetobacter, s. aureus

MECHANISM OF ACTION

Misc: hypersensitivity reaction

DOSAGE

COTRAINDICATION

IV: 300 mg

Hypersensitivity, most parenteral products contain bisulfites and should be avoided in patients with known intolerance, crosssensitivity among aminoglycosides may occur.

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