LABORATORY EXAMS

Laboratory Test and Normal value Patient’s value Significance

Date
Serology Test
ASO=Negative ASO=Negative No significance; normal
11-17-10

Hematology Test
11-17-10
Hemoglobin 120 – 150 g/L 132 g/L No significance; normal
Hematocrit 0.36 – 0.46 0.39 No significance; normal
WBC 4.5 – 11.0 x 109/L 13.9 x 109/L Increased; Infection
Platelet 150 – 300 x 109/L 294 x 109/L No significance; normal
Differential Count
Segmenters 0.31 – 0.76 0.82 No significance; normal
Lymphocytes 0.14 – 0.44 0.13 Decreased; Indicates diseases that affect the immune
Monocytes system
0.02 – 0.11 0.05 No significance; normal

NURSING CARE PLAN

Acosta, Janette Cuevas 30/F Room 309 Chief complaint: Fever, headache and difficulty swallowing

CUES NURSING DIAGNOSIS SCIENTIFIC RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Independent

An individual’s health status 1. Encourage diet The soft diet is easily

greatly affects eating habits modification as chewed and swallowed.
and nutritional status. indicated--- soft diet.
Subjective Difficulty in swallowing
(dysphagia) due to painfully 2. Encourage rest period To minimize fatigue when
“Masakitay tak but-ol tak inflamed throat can prevent before meals. taking meals and promote
pagkaon, amo gutiay la tak a person from obtaining restoration of health.
kinakaon, yana kay nagasa adequate nourishment.
na ak.” As verbalized by the (Fundamentals of 3. Instruct to do oral care Promotes oral hygiene.
patient. Nursing by Kozier, At the end of the 8-hour before/ after meals.
> Pain rating scale of 3 7th edition, page duty the patient will be able
when swallowing 1178). to swallow foods with 4. Give health teaching with Promotes wellness.
Inadequate nutrition reduced or without emphasis on importance of
Imbalanced nutrition: Less
Objective is associated with pain/discomfort in order to well-balanced and
than body requirements
marked weight loss, restore optimum nutritional nutritional intake.
related to pain in
> Pain in swallowing generalized status, to meet the body
swallowing
>Reddened tonsils with pus weakness, altered requirements and to 5. Monitor I &O and body To determine adequacy of
> Dry skin, lips and oral functional abilities, promote health. weight. fluid and caloric intake.
mucosa increased
> Whitish tongue susceptibility to Dependent & Collaborative
> Fair skin turgor infection, impaired
> Pale conjunctiva pulmonary 1. IVF of D5NM regulated at Helps in achieving adequate
> Mildly faint equal pulses function, and 20gtts/min. nutritional intake.
> Minimal weakness prolonged length of
> (+) Hoarseness hospitalization 2. Provide analgesic prior to To enhance comfort.
> Palpable cervical nodes (Fundamentals of feeding as prescribed by the
Nursing by Kozier, physician.
7th edition, page
1190) 3. Administer antibacterial Fights bacteria causing
medication as prescribed by inflammation, pain and
the physician. redness of the tonsils.

PHARMACOLOGICAL SHEET
 DRUG GENERAL ACTION SPECIFIC ACTION INDICATION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILITY
-Observe signs of allergic
-Active Peptic Ulcer response.
Paracetamol Headache, drowsiness,
Inhibition of prostaglandin -Hypersensitivity to drug -Instruct pt. To avoid
1amp IVTT q4, Analgesic/ Anitpyretic Fever, muscle pain dizziness, palpitation,
synthesis -Children < 2 yrs old alcohol that may be of
temp >38⁰ C tinnitus, rash
-Lactating increased risk of GI
ulceration and bleeding.
-When giving IV, check site
daily for phlebitis and
Clindamycin -Hypersensitivity to drug
Fever, diarrhea, skin irritation.
30mg IVTT q6 ANST (-) mix Suppresses protein -Pregnancy & Lactation
Antibiotic Serious infections rashes, nausea and -Warn patient that
w/ D5W infuse w/in synthesis of bacteria -Infants < 1months
vomiting, swelling of face injection might be painful.
30mins as side drip -GI disease
-Never give undiluted
bolus.
Prevacid -Reduce risk of NSAID- -Hypersensitivity to drug -Do not crush or chew
Suppresses gastric acid Diarrhea, headache, rash,
30mg to be dissolved at related ulcer in patients -Lactation & Infants capsules.
Antiulcer secretion by inhibiting the nausea and abdominal
top of tongue before -Short-term treatment of -Severe hepatic -Give once daily dose
acid proton pump pain
breakfast active duodenal ulcer impairment before breakfast.
-Give w/ meals, food, or
milk to minimize adverse
effects
-Hypersensitivity to drug Severe diarrhea, -Discontinue drug if
Mefenamic Acid Inhibition of prostaglandin Short term relief of mild to -GI inflammation ulceration, bleeding, rash, diarrhea, dark stools or
Analgesic
500mg q6 synthesis moderate pain -Children <14 yrs old nausea & vomiting, rash occur. Contact
-Pregnancy or Lactation headache physician.
-Do not use for a period
exceeding 1 week.

-Give oral drug with food.

-Establish baseline on BP
and weight
-Hypersensitivity to drug Anaphylactic reaction, -Instruct to avoid alcohol
Hydrocortisone Corticosteroid/ Anti- Suppresses immune
Severe inflammation -Children <2 yrs old weight gain, nausea, & caffeine; may contribute
200mg IVTT q8 x 3doses inflammatory response
susceptibility to infection to steroid-ulcer therapy
-Tell patient not to stop
drug abruptly or without
prescriber’s consent