BSN3-G2-NEURO-Grand-Case-Presentio-Study.pdf

This study covered the neurological condition.

1. MindanaoStateUniversity
COLLEGEOFHEALTHSCIENCES
MarawiCity
ACASEOFA26-YEAR-OLDMALEPATIENTWITHMULTIPLEPHYSICALINJURIESSECONDARYTOFALLSECONDARYTOELECTRICALINJURY
PRESENTEDTOTHECOURSEINSTRUCTOR,PROF.IMANU.MATUMADIANDTHEFACULTYOFMINDANAOSTATEUNIVERSITY-MAINCAMPUSCOLLEGEOF
HEALTHSCIENCESINPARTIALFULFILLMENTOFREQUIREMENTSINTHECOURSECAREOFCLIENTSWITHPROBLEMSINNUTRITION,AND
GASTROINTESTINAL,METABOLISMANDENDOCRINE,PERCEPTIONANDCOORDINATION–NSG126.4
SUBMITTEDBY:
Gayongan,ArlynneMoira
Manahan,RoldanJay
Molama,LizbethDiahn
Murillo,MariaKatherine
Nicolas,KyleRitchell
Palaganas,AngelineL.
Panganiban,Estephanie
Saari,Casandra
Sahibol,Mersia
JULY26,2024

2. INTRODUCTION
Electricalinjuriesareasignificantpublichealthconcernworldwide.AccordingtotheElectricalSafetyFoundationInternational(ESFI),electricalincidentsaccountedfornumerousworkplace
fatalitiesandinjurieseachyear.In2020,therewere126electricalfatalitiesintheUnitedStates,markinga24%decreasefrom2019,butstillhighlightingthedangersassociatedwithelectrical
hazards​(ElectricalSafetyFoundation)​.Nonfatalelectricalinjuriesalsoincreasedby17%inthesameyear,with2,220casesinvolvingdaysawayfromwork​(ElectricalSafety
Foundation)​.
InthePhilippines,electricalinjuriesarealsoprevalentduetothecountry'stropicalclimateandfrequentexposuretooutdoorelectricalhazards.Asignificantproportionoftheseinjuriesoccurin
agriculturalandruralsettingswhereindividualsmaycomeintocontactwithliveelectricalwireswhileengagingindailyactivities,suchasharvestingorclimbingtrees.Theseinjuriesoftenresult
insevereconsequences,includingburns,neurologicaldamage,andfracturesfromassociatedfalls.
Thiscasestudyfocusesona26-year-oldmalepatientwhosustainedmultiplephysicalinjuriessecondarytoafallcausedbyanelectricalinjury.TheincidentoccurredonOctober7,2024,at
approximately2:40PMinPinamungajan,Cebu,whenthepatientencounteredaliveelectricalwirewhileclimbingamangotree.Theelectrificationledtoalossofbalanceandafallfroma
heightofapproximately30meters,resultinginsignificantinjuries.ThepatientsoughtconsultationatVicenteSottoMemorialMedicalCenter(VSMMC)13hourspost-injury.
Uponinitialassessmentbythestudentnurse,thepatientreportedextremepain(10/10onthepainscale),tinglingsensations,andaninabilitytomovehislowerlegs,suggestingpossiblespinal
involvement.ThepatientwasaliveandconsciousuponarrivalatVSMMC,withaGlasgowComaScale(GCS)scoreof15,indicatingfullalertnessandorientation.Despiteasmallheadtrauma
intherightparietalarea,therewerenosignsofimpairedconsciousness.
Thepatient'smedicalhistorywasnotablyunremarkable,withnoprevioushospitalizations,significantillnesses,orknownallergies.Hisimmunizationstatuswascomplete,includingtheCOVID-
19vaccine,underscoringhisoverallgoodhealthpriortotheincident.
Thiscasestudywillexplorethecircumstancesleadingtothefall,thepatient’sinitialpresentation,andthesubsequentmanagementandtreatmentrequiredforhisrecovery.Understandingthe
complexitiesandoutcomesofsuchinjuriescanprovidevaluableinsightsintothepreventionandmanagementofelectricalinjuriesinsimilarsettings.

3. NURSINGASSESSMENT1
PATIENT’SPROFILE
NameofPatient:PatientX Address:CebuCity,Cebu Age:26
Sex:Male Religion:RomanCatholic CivilStatus:Single Occupation:None
HABITS
Frequency Amount Period/Duration
1.Tobacco Thriceaday 2-3sticks 12years
2.Alcohol Onceaweek 250mL 8years
3.OTC-drugs/non-prescriptiondrugs:
Paracetamol Thriceaday 500mg/tab 18years(intermittent)forfever
A.CHIEFCOMPLAINTS
ThepatientsoughtconsultationatVicenteSottoMemorialMedicalCenter(VSMMC)duetoelectricalinjuryresultingfromfallingfromamangotree.
B.HISTORYOFPRESENTILLNESS
Thepatientpresentedtothemedicalfacility13hoursaftersustaininganinjury.Theincidentoccurredwhilehewasclimbingamangotree,duringwhichheencounteredalive
electricalwire.Theelectrificationledtoalossofbalanceandsubsequentfallfromasignificantheightofapproximately30meters,resultinginmultiplepotentialinjuries.
Uponthestudentnurseassessment,thepatientreportedthatduringthattime,heexperiencedapainlevelof10/10onthepainscale,indicatingextremediscomfortanddistress.He
describedthesensationnotonlyasintensepainbutalsoastingling.Notably,thepatientexpressedconcernabouthisabilitytomovehislowerlegs,indicatingpotentialneurological
involvementorinjurytothespinalarea.Hestronglybelievesthathemayhavesustainedaspinalfractureduetothefallandthetraumaendureduponlanding.
●NameofIllness:Fall
●TimeofIllness:2:40PM
●DateofIllness:October7,2024
●PlaceofIllness:Pinamungajan,Cebu

4. ●IntentofInjury:Unintentional/Accidental
●FirstAid:Nofirstaidmeasuresweregivenpriortoarrivalatthehospital.
UponreachingtheVicenteSottoMemorialMedicalCenter(VSMMC),thepatientwasassessedandfoundtobealiveandconscious.Thisisapositiveindicatorofhisimmediate
neurologicalandphysicalstatus.HisGlasgowComaScale(GCS)scorewasassessedtobe15,whichindicatesthatthepatientisfullyalertandoriented.Thoughhehadasmallhead
traumaintherightparietalarea,therewerenosignsofimpairedconsciousnessatthetimeofevaluation.
Overall,thecombinationofcircumstancesleadingtothisfall,coupledwiththepatient’scurrentcondition,willbecriticalindeterminingtheappropriatenextstepsfortreatment
andmanagementofanyinjuriessustainedduringthefall.
C.HISTORYOFPASTILLNESS
Thepatientreportedthathehadanotablyunremarkablemedicalhistory.Hestatedthathehasneverbeenhospitalized,whichindicateshehasnotrequiredanyinpatientmedical
careforseriousillnessesorcomplications.Additionally,hementionedexperiencingnoinjuriesthatwouldnecessitatemedicalattention,norhasheundergoneanysurgicalproceduresor
interventionsinthepast.
Intermsofinfectiousdiseases,thepatientclarifiedthathehasnosignificantillnesses,includingcommonailmentssuchascoughsorcolds,whichsuggestsarobustimmuneresponseand
overallgoodhealth.Furthermore,therearenoreportsofanymajorillnessesorchronicconditionsthatcouldimpacthiscurrenthealthstatus.
Thepatientalsoconfirmedthathehasnoknownallergies,whichisanimportantaspectofhismedicalhistoryasitimplieshehasnothadanyadversereactionstomedications,foods,or
environmentalagents.Inregardtomedications,heindicatedthatheisnotcurrentlyonanyprescribedorover-the-counterdrugs,andthereisnohistoryofmedicationusethatwouldraise
concerns.
Moreover,thepatient’shealthmaintenancepracticesappeartobethorough,consideringthathisimmunizationstatusiscomplete.Thisincludestheadministrationofallnecessaryvaccines,
notablytheCOVID-19vaccine,underscoringaproactiveapproachtohishealthandwellness.Overall,thepatient'shistoryindicatesalackofsignificantmedicalconcerns,contributingtohis
currentstateofgoodhealth.

5. FamilyHistorywithGenogram
AcquiredDiseases: Heredo-familialDiseases:
Hypercholesterolemia  Diabetes 
Kidneydisease  Heartdisease ☑
Tuberculosis  Hypertension ☑
Alcoholism ☑ Cancer 
Drugaddiction  Asthma 
HepatitisA  Epilepsy 
B  Mentalillness 
C  Rheuma/Arthritis☑
Others:  Others: 
D.PATIENTPERCEPTIONOFILLNESS
1.Presentillness
Thepatientexpressedhisthoughtsabouthiscurrentillness,stating,"It'sgoodthatIwenttothehospitalrightaway."Thisindicatesthatherecognizestheimportanceoftimely
medicalinterventioninaddressinghishealthconcerns.Healsomentioned,"Ifeelthatmyconditionhasimproved,"whichsuggeststhatheperceivesapositivechangeandprogressinhis
healthstatussincereceivingtreatment.Thisself-assessmentmayreflecthisreliefandhopefulnessregardinghisrecovery,signalingthatheisengagedinhishealingjourneyandtakingan
activeroleinmonitoringhissymptoms.Overall,thepatient'scommentaryhighlightshisawarenessofthesituationandhisappreciationforthecarehehasreceived.
2.Hospitalenvironment
Thepatient'sperceptionofthehospitalenvironmentislargelypositive.Heexpressedsatisfactionwiththequalityofserviceprovidedbythestaffnurses,highlightingtheir
professionalismandattentiveness.Additionally,heemphasizedthatthehospitalmaintainsahighstandardofhygiene,whichcontributedtohisoverallfeelingofsafetyandwell-
being.Thecleanlinessofthefacilitiesreassuredhimthatproperhealthprotocolswerebeingfollowed,furtherenhancinghisoverallexperienceinthehospital.Thispositivefeedback
aboutthestaffandthecleanlinessoftheenvironmentisindicativeofthehospital'scommitmenttoprovidingqualitycareandasupportiveatmosphereforpatients.

6. E.SUMMARYOFINTERACTION
ThepatientwasadmittedtoVSMMConJuly10,2024,at12:00pm.Thechiefcomplaintofthepatientwaselectricalinjuryduetoafall.Uponconductingaphysicalexaminationofthe
teammembersupontheadmissionofthepatient,itbecameevidentthatthesignificantabnormalitiesidentifiedwasthelowerextremities,whichpresentedaconcerningmotorfunctionscoreof
0/5,suggestingaprofounddegreeofweaknessorparalysis.Additionally,therewasanoticeablelacerationonthepatient'shead,whichraisedconcernsregardingpossibletraumaticbraininjury
orcontusionsthatcouldfurthercompromiseneurologicalfunctionorexacerbatedswelling.Theadmittingdiagnosismadewasmultiplephysicalinjuriessecondarytothefallsecondaryto
electricalinjurytoconsiderspinalcordinjuryandlaceratedwound,3cmattheparietalarea.Inresponsetothesituation,theattendingphysicianorderedaseriesoflaboratoryexaminations,
proceduralinterventions,andamedicationregimentailoredtoaddressthepatient’scondition.Subsequently,thepatientunderwentasurgicalprocedureinvolvingalaminectomyfromT12toL2,
accompaniedbyatensorfascialata(TFL)graftoverlay;duringsurgery,apositivefindinginthetransrectalareaatT12wasnoted,whereasthedurawasevaluatedandfoundtobenormalatthe
T10andL1spinallevels,indicatingacarefulconsiderationofanypotentialcomplicationsassociatedwithspinaltrauma.
OnJuly22,2024,at2:30pm,astudentnursemadeherinitialencounterwiththepatient.Duringthisfirstinteraction,sheconductedaninitialinterviewtogatherdetailedhistoryand
assessthepatient’scurrentcondition,followedbyathoroughphysicalexamination.
Throughoutthefollowingdays,thestudentnursewasresponsibleformonitoringthepatient’svitalsignsonaregularbasisandadministeringprescribedoralmedicationsaspartofher
patientcareresponsibilities.
Thestudentnursecontinuedtoengageincomprehensivemanagementofthepatient'scare,conductingadditionalinterviewsandperformingfollow-upphysicalexaminations,thereby
buildingupontheinitialassessmentsmadeduringherfirstshift.ThisongoingcareandevaluationpersisteduntiltheconclusionofhershiftonJuly24,2024.

7. PHYSICALEXAMINATION
Name:PatientX Date:July22,2024
ChiefComplaint:Electricalinjuryduetoafall Height:168cm Weight:76kg
VitalSigns:Temp:36.0CRR:20cpmPR:71bpm02:97%BP:110/70mmHgPainScore:0/10 BMI:26.9kg/m2(Overweight)
GENERAL Patientpresentsnotwearingclothesbutwithablanket.Heislyingonbedwithaheplockonrighthand;withspinalbracesupport,with
diaperandfoleycatheterinserted.Heisparaplegic,unabletomovehislowerextremities.Skinishairythroughouthisbody.Hisnailsare
cleanandtrimmed.Appearsalertandisinnoacutedistress.Vitalsignsarestable,withbloodpressure,heartrate,respiratoryrate,and
temperaturewithinnormallimits.Thepatientisorientedtoperson,place,andtimeandisabletocommunicateeffectively,Cebuanobeing
thefirstlanguage.
HEENT
Head:Hairisthickandinblackcolor.Nopresenceofdandrufforinfestationsobserved.A3cmsuturedwoundontherightparietalarea
noted.Thewoundedgesarecleananddrywithnobleeding.Therearenosignsofhematomaorsignificantedemasurroundingtheinjury.
Eyes:Eyebrowsarethickandalignedwiththeeyes.Thescleraisanictericandthepalpebralconjunctivaappearspink.Pupilsareequal,
round,andreactivetolight.Extraocularmovementsareintact.Nosignsofoculartrauma.Visualacuityis20/20.
Ears:Thepatientdeniesanyhistoryofearinfectionsorhearingloss.Bothearsappearsymmetricalwithnodischargeorsignsoftrauma.
Auriclesandmastoidprocessesarenon-tender,withnolesions,discolorations,ordischarge.Hearingisintactonbothsides.Rinne'stestis
positive,indicatingbetterairconductionthanboneconduction,andWeber'stestrevealsmidlinelocalization.
Nose:Noobviousdeformitiesorsignsoftrauma.Mucousmembranesaremoist.Thereisnonasalflaring,drainage,orasymmetry.Thecolor
ofthenosematchesthatoftherestoftheface.
Throat/Mouth:Mustacheandbeardisthick.Therearenotongueormouthsores,bleeding,redness,swelling,orpaininthemouthorgums.
Teethiscompleteandslightlyyellowishincolor.Thepatientcanswallowproperlywithoutdifficulty.Tonsilsarenotenlarged.
INTEGUMENTARY Theskinisexaminedinallareasnotcoveredbythelacerationnorbedsores.Skinishairy.Therearenorashes,lesions,orsignsofinfection.
Theskiniswarm,dry,andintact,withnormalturgor.Therearenosignsofdehydrationobserved.Twoelongatedverticalsuturedwounds
havebeennotedfromrecentsurgeries:onelocatedonthelowerbackandtheotherontheleftouterthigh.Bothwoundsarebeingmaintained
inacleananddrycondition,withnoindicationsofinfectionobservedatthesurgicalsites.

8. CARDIOVASCULAR Thechestwallissymmetricalwithoutdeformity,andthereisnotendernessuponpalpation.Pulserateis71beatsperminute.Thepatient
denieschestpain,shortnessofbreath,ordifficultybreathing.Heartsoundsareregularwithnomurmurs,gallops,orrubsnoted.Temporal,
carotid,apical,brachial,radial,femoral,popliteal,posteriortibial,anddorsalispedispulsesareintactandequalbilaterally.Capillaryrefillis
lessthan2seconds.
RESPIRATORY Theanteriorandposteriorthoraxaresymmetrical,witharespiratoryrateof20breathsperminuteandequalchestexpansion.Nodifficultyof
breathing,chestpainandshortnessofbreathwasobserved.Thepatientdemonstratesclearlungsoundsbilaterallywithnowheezing,
crackles,ordiminishedbreathsoundsuponauscultation.Respiratoryeffortisunlabored,andoxygensaturationiswithinnormalrange.
GASTROINTESTINAL Thepatientdeniesabdominalpain,indigestion,nausea,orvomiting.Theabdomenissymmetricwithbrownskincolor,noscars.The
abdomenissoft,non-distended,andnontendertopalpation.Bowelsoundsarepresentinallquadrants.Nohepatosplenomegalyormassesare
notedduringpalpation.
NEUROLOGICAL Thepatientisconscious,alert,orientedtotimeandplace,andspeechisclear,withaGCSscoreof15.Thepatientshowsnormalresponsesto
lighttouchandpainstimuliintheupperbody,indicatingthatsensoryfunctionsareintactinthisregion.However,inthelowerbody,both
extremitiesareunresponsivetosensorystimuliandareunabletomove.Sensoryfunctions(taste,hearing,smell)areintact.CranialnervesI-
XIIareintact.Thepatientdemonstratesnormalmotorstrengthinupperextremities,whilelowerextremitiespresentwithweakness,unableto
moveandambulate.
MUSCULOSKELETAL Thereisnoevidentswelling,deformity,ortendernessintheextremities.Rangeofmotioninallupperjointsisfullandpain-free.Rangeof
motionislimitedinlowerjoints.Upperextremitiesexhibitnormalmusclesizeandstrength(Grade5),demonstratingfullrangeofmotion
(ROM)againstgravityandresistance.Lowerextremitiesexhibitnomusclecontraction;demonstratingparalysis(Grade1).
REPRODUCTIVE Uponexaminationofthereproductivesystem,thepatient,whowascircumcisedatage8,showsnovisibleabnormalities,lesions,orsignsof
swellingintheexternalgenitalia.Thereisnoabnormaldischargeorevidenceofinfection.Palpationrevealsnotendernessorpalpable
massesinthepelvicregion.Thepatienthasalive-inpartnerandhasonechild,andreportsnoconcernsorsymptomsrelatedtosexualhealth.
AFoleycatheterisinplacewithaurineoutputof600cc,andtherearenosignsofurinarytractinfectionorabnormalitiesnotedintheurine.
Overall,thereproductiveexaminationisnormal,withnosignificantabnormalitiesorconcerns.
EXCRETORY Uponexaminationoftheexcretorysystem,thepatienthasaFoleycatheterinplacewithaurineoutputof600cc,andtheurineisclearand
yellow,indicatingadequatehydrationandnormalkidneyfunction.Therearenosignsofurinarytractinfection,suchasblood,unusualodor,
orcloudiness.Thebladderisfunctioningnormally,withnosignsofdistensionordiscomfort.Thepatientusuallydefecateseveryotherday,1
to2timesadaywithnormalstoolconsistencyandcolor.Therearenocomplaintsofflankpainordiscomfort,andnosignsofedemaor
abnormalfluidretentionarepresent.Overall,theexcretorysystemisfunctioningwell,withnormalurinaryandboweloutputs.

9. NURSINGASSESSMENT2
Name:PatientX Age:26yrsold Sex:Male
Admitting/ChiefComplaint:Electricalinjuryduetoafall Diet:DAT
Impression/Diagnosis:Multiplephysicalinjuriessecondarytothefallsecondarytoelectricalinjurytoconsider1)spinalcordinjuryand2)laceratedwound,3cmattheparietalarea
Date/TimeofAdmission:07/10/24 InclusiveDatesofCare:07/22-24-24
TypeofOperation(ifany):Laminectomyandtensorfascialata(TFL)graftoverlay Allergies:None
NORMALPATTERN BEFOREHOSPITALIZATION INITIAL
July22,2024
DAY1
July23,2024
DAY2
July24,2024
1.ACTIVITIES-RESTPriortothepatient’shospital
admission,hededicatedhistimeto
caringforanimalsonthefarm.His
morningswerefilledwithroutine
chores,whichincludedfeedingthe
animals,checkingtheirwater
supply,andensuringthattheir
livingspaceswerecleanand
comfortable.Hetypicallytakesa
two-hournapduringlunchtime.In
theearlyevening,hegoestobed
around9PMandrisesat4AM.
Whileheenjoysrestfuland
uninterruptedsleep,hedoestendto
snore.
Duringhospitalization,thepatientfaced
significantphysicalrestrictionsthat
severelylimitedhismobility.Asaresult,
hefoundhimselfconfinedtohisbedfor
thedurationofhisstay,unabletomove
aroundfreely.Thisrestrictionwas
largelyduetoalimitedrangeofmotion
(ROM)resultingfromhismedical
condition,whichmadeitchallengingfor
himtoengageinanyactivitiesthat
requirephysicalmovement.
Inadditiontothephysicalconstraints,
thepatientreportedexperiencing
frequentdisruptionsinhissleeppatterns.
Heattributedthisissuetothe
medicationsadministeredbythenursing
staff.
Thiscombinationofphysicalimmobility
andinterruptedsleepcreateda
challengingenvironmentforthepatient,
affectingbothhisphysicalandmental
well-beingduringhishospitalstay.
Duringthistimeofhospitalization,the
patientremainsstableandhasno
immediatehealthconcerns.However,
heencountersdifficultieswith
purposefulmovement,whichimpacts
hismobilityandindependenceduring
rehabilitation.Specifically,hehas0/5
motorfunctioninhislower
extremities,preventinghimfrom
movingfreely.Inaddition,thepatient
reportedexperiencingfrequent
disruptionsinhissleeppatterns.He
attributedthisissuetothenursing
staffwhogavehimmedications.He
usuallygoestobedearly,around6
PMandexperiencesabrief
interruptioninhissleepwhenheis
awakenedforhismedicationsat10
PMand4AM.
Duringthistimeofhospitalization,
thepatientremainsstableandhasno
immediatehealthconcerns.However,
heencountersdifficultieswith
purposefulmovement,whichimpacts
hismobilityandindependenceduring
rehabilitation.Specifically,hehas0/5
motorfunctioninhislower
extremities,preventinghimfrom
movingfreely.Inaddition,thepatient
reportedexperiencingfrequent
disruptionsinhissleeppatterns.He
attributedthisissuetothenursing
staffwhogavehismedications.He
usuallygoestobedearly,around6
PMandexperiencesabrief
interruptioninhissleepwhenheis
awakenedforhismedicationsat10
PMand4AM.

10. 2.NUTRITIONAL-
METABOLIC
Priortohospitalization,thetypical
mealsconsistedofthefollowing:
●Breakfast:Ricewithsalted
driedfish
●Lunch:Riceaccompaniedby
vegetables
●Dinner:Ricepairedwith
cannedfoods
●Ifnoothersidedishwas
available,aneggwasthe
preferredchoice.
Therewerenospecificdietary
restrictionsorspecialdiets
followed,andnomedicationsor
dietary supplements were
consumedasidefromOTCdrugs.
Thepatientfeelsthathewas
heavierpriortobeinghospitalized.
Duringthepatient'shospitalization,a
structured mealschedulewas
implementedtoensurehereceived
necessarynutrientswhilemaintaininga
balanceddiet.
●Breakfast:Ricepairedwithbeef
●Lunchtime:Ricepairedwithchicken,
withpancitandapieceofmelon
●Dinner:Ricepairedwithfish
Thepatientwasona"dietastolerated"
status,withmealspreparedbasedonhis
healthneedsandpreferences.
Throughouthishospitalization,hethinks
someweightloss,attributingittodietary
changesandthehealthcareenvironment.
Asformedications,hewasgiventhese
medicationsasordered:
●Paracetamol600mg
●Cefuroxime750mg
●Tramadol50mg(completed)
●Omeprazole40mg
●ChlorexidineoralgargleBID
Aspartofthepatient'sdailyroutine,
heconsumesthemealsprovidedby
thehospitalwhilebeingonDATdiet.
●Breakfast:Ricepairedwithcrispy
friedfish,alongwithasliceof
melonthat
●Lunch:Ricepairedwithbeef,
plusanothersliceofmelon
●Dinner:Ricepairedwithawarm,
flavorfulsoup,alongwithbanana
andpapaya.
Asformedications,hewasgiven
thesemedicationsasordered:
●Paracetamol600mg
●Cefuroxime750mg
●Omeprazole40mg
●ChlorexidineoralgargleBID
Aspartofpatient’sdailyroutine,he
consumesthemealsprovidedbythe
hospitalwhilebeingonDATdiet.
●Breakfast:Ricepairedwithfish
andegg
●Lunch:Ricepairedwithfish,,
plusanothersliceofmelon
●Dinner:Ricepairedwithbeef,
alongwithpineapple
Asformedications,hewasgiven
thesemedicationsasordered:
●Paracetamol600mg
●Cefuroxime750mg
●Omeprazole40mg
●ChlorexidineoralgargleBID
3.ELIMINATION Typically,thepatientexperiences
urinationthreetimesthroughoutthe
day,eachtimeproducingastrong,
steadystreamofurinethathasa
noticeableyellowishtint.This
frequencysuggestsawell-
functioningurinarysystem.In
additiontourinaryhabits,the
patientgenerallyhasonebowel
movementeachday.Thesebowel
movementsarecharacterizedbya
firmconsistency,indicatinga
healthydigestiveprocess,andthey
aredistinguishedbyagreenish
Thepatientreportedatotalof750mLof
dark-yellowurineoutputthroughoutthe
SN’sshift(2-9pm)whichcouldindicate
potentialdehydrationorotherunderlying
issues.Additionally,withintheassigned
shiftoftheSN,therewerenooccurrences
ofbowelmovements.
Thepatientreportedatotalof700mL
ofdark-yellowurineoutput
throughouttheSN’sshift(2-9pm)
whichcouldindicatepotential
dehydrationorotherunderlying
issues.Additionally,withinthe
assignedshiftoftheSN,therewasno
occurrenceofbowelmovement.
.Thepatientreportedatotalof
700mLofdark-yellowurineoutput
throughouttheSN’sshift(2-9pm)
whichcouldindicatepotential
dehydrationorotherunderlying
issues.Additionally,withinthe
assignedshiftoftheSN,therewas
oneoccurrenceofbowelmovement,
thatisgreenishandformedstool.

11. color,whichcouldbeinfluencedby
dietaryfactorsorother
physiologicalprocesses.
4.EGOINTEGRITY Thepatientmaintainsastrongself-
imageandviewshimselfas
healthy,boostinghisoverallwell-
being.Whenfacedwithdifficulties,
hecopesbyreachingouttohis
friendsforsupportandusually
drinksalcohol.Intermsofhis
emotionalstate,hemaintainsa
cheerfuldisposition.Overall,the
patient’sself-perceptionofhealth,
coupledwithhissupportive
relationshipsandcheerfulattitude,
contributestohiseffectivecoping
strategiesandresilienceintheface
ofadversity.
Thepatientexpressedasenseof
vulnerability,perceivinghimselfasweak
duetohisrelianceonassistancewhile
ambulating.Thisfeelingofweaknesswas
compoundedbythefactthathewason
bedrest,whichlimitedhismobilityand
independence.Healsosharedthathis
parentswereplayingacrucialroleby
financinghisfoodandmedicine,which
indicatesarelianceonfamilysupport
duringthischallengingtime.When
approachedbytheSN,patientmaintained
acalmdemeanorandengagedin
conversationpleasantly.Hisabilityto
communicatenicelydespitehis
circumstancessuggestsresilienceanda
willingnesstoconnectwiththose
providinghiscare.
Thepatientexpressedasenseof
vulnerability,perceivinghimselfas
weakduetohisrelianceonassistance
whileambulating.Thisfeelingof
weaknesswascompoundedbythe
factthathewasonbedrest,which
limited his mobility and
independence.Heisalsouncertain
aboutwhetherhewillbeabletowalk
againafterhisforthcomingfinal
operation.Whenapproachedbythe
SN,patientmaintainedacalm
demeanorand engaged in
conversationpleasantly.Hisabilityto
communicatenicelydespitehis
circumstancessuggestsresilienceand
awillingnesstoconnectwiththose
providinghiscare.
Thepatientexpressedasenseof
vulnerability,perceivinghimselfas
weakduetohisrelianceonassistance
whileambulating.Thisfeelingof
weaknesswascompoundedbythe
factthathewasonbedrest,which
limited his mobility and
independence.Hequestionsifthe
surgerywillrestorehismobilityorif
itwillleavehimfacingfurther
challenges.Whenapproachedbythe
SN,patientmaintainedacalm
demeanorandengagedin
conversationpleasantly.Hisabilityto
communicatenicelydespitehis
circumstancessuggestsresilienceand
awillingnesstoconnectwiththose
providinghiscare.
5. NEURO-SENSORYThepatientdemonstratesfull
alertness,iswell-oriented,andis
awareofwhoheisandwhereheis,
aswellasthetimeofday.Allofhis
sensoryfaculties—suchassight,
hearing,touch,taste,andsmell—
arefunctioningoptimally,allowing
themtoeffectivelyengagewithhis
environment and respond
appropriatelytoexternalstimuli.
Thisindicatesastablecognitive
stateandastrongconnectionto
bothhisimmediatesurroundings.
Thepatientisfullyalertandoriented,
demonstratingawarenessofhisidentity,
location,andthecurrenttime.Allofhis
sensoryfaculties—sight,hearing,touch,
taste,andsmell—areworkingeffectively,
enablinghimtointeractmeaningfully
withhisenvironmentandreact
appropriatelytoexternalstimuli.This
reflectsastablecognitivestateandasolid
connection to his immediate
surroundings.
Thepatientisfullyalertandoriented,
demonstratingawarenessofhis
identity,location,andthecurrent
time.Allofhissensoryfaculties—
sight,hearing,touch,taste,and
smell—areworkingeffectively,
enablinghimtointeractmeaningfully
withhisenvironmentandreact
appropriatelytoexternalstimuli.This
reflectsastablecognitivestateanda
solidconnectiontohisimmediate
surroundings..
Thepatientisfullyalertandoriented,
demonstratingawarenessofhis
identity,location,andthecurrent
time.Allofhissensoryfaculties—
sight,hearing,touch,taste,and
smell—areworkingeffectively,
enablinghimtointeractmeaningfully
withhisenvironmentandreact
appropriatelytoexternalstimuli.This
reflectsastablecognitivestateanda
solidconnectiontohisimmediate
surroundings.

12. 6. OXYGENATIONBeforeadmission,therewereno
recordedvitalsignsorlungsounds
indicating the patient's
physiologicalorrespiratorystatus.
Nohistoryofrespiratoryissueswas
reportedbythepatientornoted
during initial assessments,
suggestingnopriorsignificant
respiratoryconcerns,chronic
conditions,oracutedistress.
Novitalsignsweretakenbecausethe
primarytaskassignedtothestudentnurse
(SN)onthisparticulardaywasfocused
onconductinganinterviewand
performingaphysicalexaminationofthe
patient.Theemphasiswasongathering
detailedinformationaboutthepatient's
medicalhistory,currentsymptoms,and
overallconditionthroughdirect
questioning and observational
assessment.
Vitalsignstakenasfollows;
temperature=36.0C,respiratoryrate
=20cpm,pulserate=73bpm,blood
pressure=120/80mmHg,O2
saturation=96%andpainscore=
0/10.
Overall,therecordedvitalsigns
reflectastableandhealthy
physiologicalstate,withnoimmediate
medical concerns requiring
intervention.Thepatientisnot
currentlyreceivinganyoxygen
support,furtheremphasizingtheir
adequaterespiratoryfunction.
Vitalsignstakenasfollows;
temperature=36.1C,respiratoryrate
=19cpm,pulserate=80bpm,blood
pressure=120/80mmHg,O2
saturation=97%andpainscore=
0/10.
Overall,therecordedvitalsigns
reflectastableandhealthy
physiologicalstate,withno
immediate medicalconcerns
requiringintervention.Thepatientis
notcurrentlyreceivinganyoxygen
support,furtheremphasizingtheir
adequaterespiratoryfunction
.
7.PAINAND
COMFORT
Beforehisadmissiontothe
hospital,theonlydiscomforthe
encounteredwasaheadache
localizedinthetemporalregionof
hishead.Thisheadachetypically
manifestsitselfwhenhemissesa
meal,suggestingapossiblelink
betweenhiseatingpatternsandthe
onsetofthispain.Torelievethe
headache,heresortstotaking
paracetamolandalsofindsthat
restinghelpstoeasehissymptoms.
Bydoingso,heisabletomanage
thediscomforteffectively.
Thepatienthasexplicitlystatedthatheis
notexperiencinganypainordiscomfort
atthistimebutbruisesfromtheinjuryare
stillvisible.SNhasnotedthatheoften
appearstobeuneasyinhiscurrent
position.Thisobservationsuggeststhat
whilehemaynotbeinpain,heisnot
completelycomfortable.
Thepatienthasclearlyindicatedthat
heiscurrentlynotexperiencingany
painordiscomfortwithapainscore
of0/10.Thisobservationimpliesthat
painisabsent.
Thepatienthasclearlyindicatedthat
heiscurrentlynotexperiencingany
painordiscomfortwithapainscore
of0/10.Thisobservationimpliesthat
painisabsent.
8. HYGIENEAND
ACTIVITIESOFDAILY
LIVING
Priortoadmission,thepatient's
dailyhygieneroutineconsistedof
bathingandbrushingtheirteeth
onceaday.Thisregimeninvolved
takingashowerorbatheachdayto
maintaincleanlinessandpersonal
hygiene,alongwithbrushingtheir
Thepatientisexperiencingmobility
issuesthathinderhisabilitytoperform
theADLsindependently.Consequently,
hedependsonhissignificantother(SO)
forhelpwithpersonalhygiene.Although
thepatientcannotbatheinthe
conventionalway,hisSOsupportshimby
Thepatientisfacingmobility
difficultiesthatimpedehisabilityto
performactivitiesofdailyliving
(ADLs)onhisown.Asaresult,he
exhibitsunusualbodyodorsincehe
didnottookabedbath.SNnoted
poorhygieneatthisday.
Thepatientisexperiencingmobility
issuesthathinderhisabilitytodothe
ADLsindependently.Consequently,
hedependsonhissignificantother
(SO)forhelpwithpersonalhygiene.
Althoughthepatientcannotbathein
theconventionalway,hisSO

13. teethatleastoncedailytoensure
oralhealthandfreshbreath.
gentlywipinghimdown,allowinghimto
maintaincleanlinessandcomfort.
supportedhimbygentlywipinghim
allthewaydown,allowinghimto
maintaincleanlinessandcomfort.
9.SEXUALITY Patientindicatedthatheunderwent
acircumcisionprocedurewhenhe
was8yearsold.Inaddition,he
liveswithhispartner,withwhom
hehasacloseandsupportive
relationship.Together,theyhavea
daughter,whichaddsanotherlayer
tohispersonalcircumstancesand
familydynamics.
Patientisanindividualwhoisafatherof
onechildrenandcohabilitateswithhis
live-inpartner.Heunderwent
circumcisionattheageof8.Throughout
hismedicalhistory,therehavebeenno
documentedsurgeriesinvolvingthe
reproductiveorgans.Thissuggeststhat,to
date,hehasnotexperiencedanysurgical
interventionsthatwouldaffecthis
reproductivehealthorcapabilities.
Patientisanindividualwhoisafather
ofonechildrenandcohabilitateswith
hislive-inpartner.Heunderwent
circumcisionattheageof8.
Throughouthismedicalhistory,there
havebeennodocumentedsurgeries
involvingthereproductiveorgans.
Thissuggeststhat,todate,hehasnot
experiencedanysurgicalinterventions
thatwouldaffecthisreproductive
healthorcapabilities.
Patientisanindividualwhoisa
fatherofonechildrenand
cohabilitateswithhislive-inpartner.
Heunderwentcircumcisionattheage
of8.Throughouthismedicalhistory,
therehavebeennodocumented
surgeriesinvolvingthereproductive
organs.Thissuggeststhat,todate,he
hasnotexperiencedanysurgical
interventionsthatwouldaffecthis
reproductivehealthorcapabilities.

14. LABORATORYANDDIAGNOSTICPROCEDURES
DATE NAMEOFTHE
PROCEDURE
RESULT NORMALVALUE NURSINGIMPLICATION
7/10/14 HEMATOLOGYSECTION
CBC
WBC 17,600 4,000-10,000/mm^3 Highwhitebloodcellcountsoftenindicateaninfectionorinflammatoryresponse.
Regularlyassessthepatientforsymptomsofinfection,suchasfever,chills,and
localizedrednessorswelling.Promptidentificationandtreatmentofinfectionsare
crucial.
RBC 4.00×10^6 4.7-6.10×^6/mm^3 Monitorforinflammationorinfectionsuchasfever,redness,swelling,orpain.
Hemoglobin 14.00 14-17gm% Withinnormalrange
Hematocrit 37.00 40-50vol% Withinnormalrange
DifferentialCount
Neutrophils 73 45-65% Elevatedneutrophilindicatesanacutebacterialinfection,inflammation,stress
response,orpossiblyamyeloproliferative.
Lymphocytes 30 20-35% Withinnormalrange
Monocytes 7 2-9% Withinnormalrange
PlateletCount 440/mm^3 150,000-450,000mm^3Regularlyassessforsignsofbleedingorbruising,suchaspetechiae,purpura,or
spontaneousbleedingfromgumsorthegastrointestinaltract.
7/10/24 Creatinine 0.82 0.8-1.3mg/dL Withinnormalrange

15. BUN 29.69 12-42mg/dL Withinnormalrange
7/10/24 Electrolytes
Sodium 139.0 135-145mmol/L Withinnormalrange
Potassium 3.69 3.5-5.5mmol/L Withinnormalrange
7/10/24 ECG Sinusrhythmwithin
normallimits
Sinusrhythmwithin
normallimits
Provideanynecessarypost-procedurecareinstructions,suchashowtocarefortheskin
afterelectroderemoval,andscheduleanyfollow-upappointmentsifneeded.
07/16/24
10:58
AM
CHEMISTRYSECTION
Sodium 134.70 135.00-145.00mmol/LWithinnormalrange
Potassium 4.16 3.5-5.10mmol/L Withinnormalrange
Chloride 98.30 98-107mmol/L Withinnormalrange
IonizedCalcium 1.16 1.12-1.32mmol/L Withinnormalrange
HEMATOLOGYSECTION
07/16/24
9:33AM
WBCCount 12.30×10^9/L 3.95-11.21 Continueregularmonitoringandensureadequatehydration.
RBCCount 2.96×10^12/L 3.81-5.81 Monitorforinflammationorinfectionsuchasfever,redness,swelling,orpain.
HEMATOLOGYSECTION
Hemoglobin 99.80 121.4-179.8g/L Regularlyassessforsignsandsymptomsofanemia,suchasfatigue,pallor,shortness
ofbreath,dizziness,tachycardia,andchestpain.

16. Hematocrit 29.00 36.85-54.32% Monitorsymptomsofanemiaandtheirimpactondailyactivities.
MCV 98 78.89-101.00fL ChangesinMCVcanindicatetheeffectivenessoftreatmentincorrectingthe
underlyingcauseofanemia.
MCH 33.70 26.10-33.97pg Aslightlyelevatedmayindicatemacrocyticanemia,redbloodcellsarelargerthan
normal.conditionslikevitaminB12orfolatedeficiencycouldbecaused.
MCHC 344.0 320.0-362.0g/L Withinnormalrange,suggestingnormalhemoglobinconcentrationwithinredblood
cells.
RDW-CV 13.00 12.20-16.38% Withinnormalrange.
PlateletCount 474.00×10^9/L 118-365 Regularlyassessforsignsofthrombosissuchasdeepveinthrombosis,pulmonary
embolism,orstroke.
DifferentialCount
Neutrophil 82.9 55-65% Elevatedneutrophilindicatesanacutebacterialinfection,inflammation,stress
response,orpossiblyamyeloproliferative.
Lymphocyte 6.590 25-35% Lowlymphocyteindicateslymphocytopenia,couldbeduetoacuteinfections,
immunosuppressivestates,orbonemarrowsuppression.
Monocyte 10.400 3-11% Withinnormalrange.
Eosinophil 0.011 2-4% Theeosinophilscountisnotablylow.Eosinophilstypicallyincreasewithallergic
reactions,parasiticinfections,orcertainautoimmunediseases.
Basophil 0.203 0-1% Withinnormalrange.

17. 7/16/24
1:31AM
CHEMISTRYSECTION
FiO2 100.00 21-100% Thepatientisreceiving100%oxygen,whichcouldindicateacriticalneedfor
supplementaloxygen,oftenseeninsevererespiratorydistress.
pH 7.341 7.35-7.45 Slightlybelowthenormalrange,indicatingaconditioncalledmildacidosis.Regular
monitoringofvitalsigns,respiratoryfunction,renalfunction,neurologicalstatus,and
electrolytelevelsiscrucial.
pCO2 51.10 35.0-45.0mmHg ElevatedpCO2suggestsrespiratoryacidosis,indicatinghypoventilation.Thiscould
beduetocentralnervoussystemdepression.Regularassessmentofrespiratorystatus,
includingrate,depth,andeffort,isessential,alongsidemonitoringforsignsof
respiratorydistressandchangesinmentalstatus,suchasconfusionordrowsiness.
pO2 148.80 83-108mmHg TheelevatedpO2isconsistentwithreceiving100%oxygen,highlevelsof
supplementaloxygencanincreasepO2significantly.
HCO3 28.00 21.0-28.0mmol/L HCO3isslightlyelevated,whichmightindicateacompensatoryresponseto
respiratoryacidosis,suggestingthekidneysareretainingbicarbonatetobufferthe
excessacid.Regularmonitoringofthepatient’srespiratorystatus,includingrate,
depth,andeffort,isessential,alongwithvigilantobservationforneurological
symptomssuchasconfusionordizziness.
TCO2 29.60 22.0-29.0mmol/L Slightlyabovethenormalrange,suggestingapotentialmetabolicalkalosisor
compensationforarespiratoryacidosis.Monitoringthepatient'srespiratorystatus,
includingrate,depth,andeffort,iscrucial,alongwithregularassessmentofvitalsigns
andneurologicalstatusforanysignsofconfusionorlethargy.
BE(ecf) 2.00 -3.0-2.0mmol/L BEiswithinnormalrange.Acloseobservationtothepatientforsignsofmetabolicor
respiratorycompensationisessential,especiallyifotherlabvaluesorclinical
symptomssuggestanunderlyingdisorder.
SO2 99.10 95.0-98.0mmol/L Slightlyabovenormalrange.Ensurethatthepatientisreceivingthecorrectamountof
supplementaloxygentopreventhyperoxia,whichcanbeharmful,particularlyin
patientswithchroniclungdiseases

18. SUMMARYOFINTAKEANDOUTPUT
INTAKE
OUTPUT
Date/shift Oral Parenteral Others Total Urine Emesis Drainage Others Total
7/12/24
(Admission)
6am-2pm
2pm-10pm
10pm-6am
300
900
1700
500
600
2660
0
0
0
800
1500
4360
300
300
1690
0
0
0
0
0
0
0
0
0
300
300
1690
7/12/24
6am-2pm
2pm-10pm
10pm-6am
0
0
200
2280
700
3860
0
0
0
2280
700
4060
200
450
1780
0
0
0
0
0
0
0
0
0
200
450
1780
7/13/24
6am-2pm
2pm-10pm
10pm-6am
0
0
0
880
880
2640
0
0
0
880
700
2640
500
480
1580
0
0
0
0
0
0
0
0
0
0
480
1580

19. 7/14/24
6am-2pm
2pm-10pm
10pm-6am
0
700
1200
880
880
2680
0
0
0
880
1580
3540
620
450
1670
0
0
0
0
0
0
0
0
0
620
450
1670
07/15/24
6am-2pm
2pm-10pm
10pm-6am
(post-op)
0
-
0
880
-
1360
0
-
480
880
-
1840
500
-
1030
0
-
0
0
-
0
0
-
0
500
-
1030
07/16/24
6am-2pm
2pm-10pm
10pm-6am
920
NPO
0
-
320
1880
80
0
80
1000
320
1960
900
-
2080
0
-
0
0
-
0
0
-
0
900
-
2080
07/17/24
6am-2pm
2pm-10pm
10pm-6am
600
450
1750
300
200
600
0
0
0
900
650
2350
600
700
1950
0
0
0
0
0
0
0
0
0
600
700
1950

20. 07/18/24
6am-2pm
2pm-10pm
10pm-6am
700
475
1,225
320
320
960
0
0
0
1020
795
2185
900
-
2080
0
0
0
0
0
0
0
0
0
900
0
2080
07/19/24
6am-2pm
2pm-10pm
10pm-6am
810
700
200
240
-
2800
0
0
0
1050
700
3000
650
580
1,930
0
0
0
0
0
0
0
0
0
650
580
1930
07/20/24
6am-2pm
2pm-10pm
10pm-6am
850
750
2050
0
0
0
0
0
0
850
750
2050
500
680
1780
0
0
0
0
0
0
0
0
0
500
680
1780
07/21/24
6am-2pm
2pm-10pm
10pm-6am
650
700
2150
0
0
0
0
0
0
650
700
2150
330
600
1530
0
0
0
0
0
0
0
0
0
330
600
1530

21. 07/22/24
6am-2pm
2pm-10pm
10pm-6am
1000
750
2400
0
0
0
0
0
0
1000
750
2400
750
600
2050
0
0
0
0
0
0
0
0
0
750
600
2050
7/23/24
6am-2pm
2pm-10pm
10pm-6am
900
700
2080
0
0
0
0
0
0
900
700
2080
700
600
200
0
0
0
0
0
0
0
0
0
700
600
200
7/24/24
6am-2pm
2pm-10pm
800
450
0
0
0
0
800
450
500
500
0
0
0
0
0
0
500
500

22. SUMMARYOFINTRAVENOUSFLUID
DATE&TIME INTRAVENOUSFLUIDANDVOLUME DROPRATE
July11,2024
12:00pm
#1Aminoacid+Sorbitol5%500mL 42cc/hr
July12,2024
10:00am
#2Aminoacid+Sorbitol5%500mL 42cc/hr
July12,2024
10:00pm
#3Aminoacid+Sorbitol5%500mL 42cc/hr
July13,2024
10:00am
#4Aminoacid+Sorbitol5%500mL 42cc/hr
July13,2024
10:00pm
#5Aminoacid+Sorbitol5%500mL 42cc/hr
July14,2024
10:00am
#6Aminoacid+Sorbitol5%500mL 42cc/hr
July14,2024
10:00pm
#7Aminoacid+Sorbitol5%500mL 42cc/hr
July15,2024
10:00am
#8#7Aminoacid+Sorbitol5%500mL 42cc/hr

23. July15,2024
10:00pm
#8Aminoacid+Sorbitol5%500mL 42cc/hr
July15,2024
7:15am
#1PNSSIL 20cc/hr
July16,2024
2:30pm
#2PNSS1L 20cc/hr
July17,2024
12;00pm
#3PNSS1L 30gtts/hr
July18,2024
8:00am
#4PNSS1L 30gtts/hr

24. SUMMARYOFMEDICATIONS
DATE MEDICATIONS REMARKS
7/11/24 Paracetamol600mgIVTTQ6
Cefuroxime750mgIVTTQ2
Tramadol50mgIVTTQ8
Omeprazole40mgIVTTQ24
ChlorexidineOralGargleBID
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.
7/12/24 Paracetamol600mgIVTTQ6
Cefuroxime750mgIVTTQ2
Tramadol50mgIVTTQ8
Omeprazole40mgIVTTQ24
ChlorexidineOralGargleBID
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.
7/13/24 Paracetamol600mgIVTTQ6
Cefuroxime750mgIVTTQ2
Tramadol50mgIVTTQ8
Omeprazole40mgIVTTQ24
ChlorexidineOralGargleBID
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.

25. 7/15/24 Paracetamol600mgIVTTQ6
Cefuroxime750mgIVTTQ2
Tramadol50mgIVTTQ8
Omeprazole40mgIVTTQ24
ChlorexidineOralGargleBID
Omeprazole40mgODQ24
Ceftriaxone2gIV
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.
7/16/24 Ceftriaxone1gIVTTQ12
Omeprazole40mgODQ24
Paracetamol600mgIVQ6
Tramadol50mgIVTTQ8inbetweendoseofPara
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.
7/17/24 Ceftriaxone1gIVTTQ12
Omeprazole40mgODQ24
Paracetamol600mgIVQ6
Tramadol50mgIVTTQ8inbetweendoseofPara
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.
7/18/24 Ceftriaxone1gIVTTQ12
Dexamethasone5mgIVQ12x5days
Omeprazole40mgODQ24
Tramadol50mgIVTTQ8inbetweendoseofPara
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.

26. 7/19/24 Ceftriaxone1gIVTTQ12
Dexamethasone5mgIVQ12x5days
Omeprazole40mgODQ24
Tramadol50mgIVTTQ8inbetweendoseofPara
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.
7/20/24 Ceftriaxone1gIVTTQ12
Dexamethasone5mgIVQ12x5days
Omeprazole40mgODQ24
Tramadol50mgIVTTQ8inbetweendoseofPara
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.
7/21/24 Paracetamol600mgIVTTQ6
Ceftriaxone19mgIVTTQ12
Dexamethasone5mgIVQ12x5days
Omeprazole40mgIVTTQ24
Tramadol50mgIVTTQ6inbetweendoseofPara
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.
7/22/24 Paracetamol600mgIVTTQ6
Ceftriaxone19mgIVTTQ12
Dexamethasone5mgIVQ12x5days
Omeprazole40mgIVTTQ24
Tramadol50mgIVTTQ6inbetweendoseofPara
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.

27. 7/23/24 Paracetamol600mgIVTTQ6
Ceftriaxone19mgIVTTQ12
Omeprazole40mgIVTTQ24
Tramadol50mgIVTTQ6inbetweendosesofPCM
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.
7/24/24 Paracetamol600mgIVTTQ6
Ceftriaxone19mgIVTTQ12
Omeprazole40mgIVTTQ24
Tramadol50mgIVTTQ6inbetweendosesofPCM
Administeredandgiventothepatientasscheduledandprescribedafterverificationfromnurse-on-duty,
andpermissionfromthepatient.Noadversereactionsnoted.

28. ANATOMYANDPHYSIOLOGY
ElectricalInjury
●CellsInvolved:
○EpithelialCells:Normallyprotectunderlyingtissuesandorgans,provideabarrieragainstmechanicalinjury,pathogens,andfluid
loss.Electricalinjurydisruptsthesecells,causingburnsandlossofbarrierfunction.
○MuscleCells(Myocytes):Facilitatemovementthroughcontraction.Electricalinjurycancauseinvoluntarycontractionsandcell
damage,leadingtomusclenecrosis.
○NerveCells(Neurons):Transmitsignalsforsensation,motorfunction,andautonomiccontrol.Electricalinjurycancause
depolarizationandnervedamage,leadingtosensoryandmotordeficits.
●TissuesInvolved:
○EpidermalandDermalTissues:Provideprotectivebarriersandsensation.Electricalburnsdisrupttheselayers,leadingtoskin
damageandpotentialinfection.
○MuscleTissue:Responsibleformovementandposture.Electricalinjurycausesmusclebreakdown,whichcanreleasemyoglobin,
potentiallyleadingtokidneydamage(rhabdomyolysis).
○NervousTissue:Essentialforsignaltransmissionwithinthenervoussystem.Electricalinjurycandisruptthesepathways,leading
todysfunction.
●OrgansInvolved:
○Heart:Pumpsbloodthroughoutthebody.Electricalcurrentscandisrupttheheart'srhythm,causingarrhythmiasorcardiacarrest.
○Muscles:Responsibleformovement.Damagedmusclesmaylosefunctionandintegrity.
○Skin:Protectsinternalstructures.Burnscompromisethisprotection,increasinginfectionrisk.
●BodySystemsInvolved:
○IntegumentarySystem:Protectsagainstenvironmentalhazards.Electricalburnscompromiseskinintegrity.
○MuscularSystem:Facilitatesmovement.Damageimpairsmobilityandcanleadtomusclenecrosis.
○NervousSystem:Coordinatesbodyfunctionsandresponses.Electricalinjurycancausenervedamageandlossoffunction.

29. ○CardiovascularSystem:Circulatesblood.Arrhythmiascanimpairbloodflowandoxygendelivery.
ImpactoftheFall
○CellsInvolved:
■Osteocytes:Maintainbonetissue.Fracturesdisruptboneintegrityandhealingrequiresremodeling.
■Chondrocytes:Maintaincartilageinjoints.Dislocationscandamagethesecells,impairingjointfunction.
■Myocytes:Enablemusclecontraction.Impactcancausebruisingandmuscletears.
○TissuesInvolved:
■BoneTissue:Providesstructuralsupport.Fracturescompromisestabilityandrequirehealing.
■CartilageTissue:Facilitatessmoothjointmovement.Dislocationsdamagecartilage,leadingtopainanddysfunction.
■MuscleandConnectiveTissues:Supportmovementandstability.Traumacausesbruising,tears,andinflammation.
■OrganTissues:Performessentialfunctions.Impactcancauseinternalbleedinganddamage.
○OrgansInvolved:
■Bones:Providestructureandsupport.Fracturesdisruptthesefunctions.
■Joints:Facilitatemovement.Dislocationsimpairjointfunctionandstability.
■InternalOrgans:Maintainvitalfunctions.Impactcancauseorgandamageandinternalbleeding.
○BodySystemsInvolved:
■SkeletalSystem:Providesstructuralsupport.Fracturesanddislocationsimpairthissystem.
■MuscularSystem:Enablesmovement.Traumacancausemuscleinjuryandlossoffunction.
■InternalOrganSystems:Ensurevitalfunctions.Damagecanimpairorganfunctionandcausesystemiceffects.
●PotentialSpinalCordInjury
○CellsInvolved:
■Neurons:Transmitsignalsbetweenthebrainandbody.Spinalcordinjurydisruptsthesepathways,leadingtolossof
sensationandmotorcontrol.
■GlialCells:Supportandprotectneurons.Injurytothesecellscanexacerbateneuraldamage.

30. ○TissuesInvolved:
■NervousTissue:Facilitatescommunicationwithinthenervoussystem.Damagedisruptssignaltransmission.
■BoneTissue:Protectsthespinalcord.Fracturescompromisethisprotection.
○OrgansInvolved:
■SpinalCord:Transmitssignalsbetweenthebrainandbody.Injurycancauseparalysisandlossoffunction.
■Vertebrae:Protectthespinalcord.Fracturesordislocationscanleadtospinalcordcompression.
○BodySystemsInvolved:
■NervousSystem:Coordinatesbodyfunctions.Spinalcordinjurydisruptsthesefunctions,causingparalysisandsensory
loss.
■SkeletalSystem:Providesprotectionforthespinalcord.Injurytovertebraecompromisesthisprotection.
●LaceratedWoundintheParietalArea
○CellsInvolved:
■Keratinocytes:Formtheouterlayeroftheskin.Lacerationsdisruptthesecells,leadingtoopenwounds.
■Neurons:Inthebrain'sparietallobe,processsensoryinformation.Damagecanimpairsensoryfunctions.
○TissuesInvolved:
■EpidermalandDermalTissues:Provideprotectionandsensation.Lacerationscauseopenwoundsandpotentialinfection.
■NervousTissue:Processessensoryinformation.Damagecanimpairthesefunctions.
○OrgansInvolved:
■Skin:Protectsinternalstructures.Lacerationsdisruptthisprotection.
■Skull:Protectsthebrain.Lacerationscanexposetheskull,increasinginfectionrisk.
■Brain(ParietalLobe):Processessensoryinformation.Injurycanimpairsensoryperceptionandintegration.
○BodySystemsInvolved:
■IntegumentarySystem:Protectsagainstenvironmentalhazards.Lacerationscompromiseskinintegrity.
■NervousSystem:Processessensoryinformation.Damagetotheparietallobecanimpairsensoryfunctions.

31. PATHOPHYSIOLOGY

32. Thepatientisa26-year-oldmalewhosustainedmultiplephysicalinjuriesasaresultofafallfromamangotree,whichwasfurthercomplicatedbyanelectricalinjury.Notableinjuries
includeapotentialspinalcordinjuryandasignificant3cmlacerationintheparietalareaoftheskull.Theoccurrenceofmultiplephysicalinjuriesfromafalloffamangotree,compoundedby
electricalinjury,canbeattributedtobothprecipitatingandpredisposingfactors.Precipitatingfactorsareimmediatecircumstancesoractionsthatdirectlycontributetotheincident.Inthiscase,
environmentalhazardssuchastheproximityofpowerlinestothetree,alackofawarenessaboutthesedangers,andinadequatesafetyprecautionsplayedsignificantroles.Additionally,climbing
behaviorandrisk-takingtendenciesfurtherheightenedthedanger,makingthefallmorelikelyandsevere.Ontheotherhand,predisposingfactorsareunderlyingconditionsthatmakean
individualmoresusceptibletosuchaccidents.Inthisscenario,beingmale,comingfromalowsocioeconomicbackground,andadheringtocertainculturalpracticescanincreasevulnerability.
Menmightbemorelikelytoengageinriskybehaviors,whilesocioeconomicandculturalfactorscouldinfluencetheawarenessandsafetymeasuresadopted,therebyindirectlycontributingto
thelikelihoodofsustainingsevereinjuriesfromsuchaccidents.
Electricalinjuriesandfallsfromaheightcanresultinacomplexinterplayoftraumaticinjuriesandmedicalemergencies,requiringamultifacetedapproachtotreatment.Asthepatient
touchesalivewire,theelectricalcurrentdisruptscellularmembranesthroughelectroporation,makingthempermeabletoionsandmolecules.Thisleadstocellulardysfunctionandnecrosis,with
visibleburns,pain,andmusclespasmsastypicalsignsandsymptoms.Thehighenergyfromthecurrentgeneratesheat,causingthermalburnsthatdamageskin,muscle,andothertissues.
Laboratoryresultsoftenshowelevatedmuscleenzymeslikecreatinekinase(CK),indicatingmuscledamage.Severecomplicationscanincludeextensivetissuenecrosis,potentiallyrequiring
debridementorevenamputation.
Muscledamageandrhabdomyolysisarealsosignificantconcernsfollowinganelectricshock.Theelectricalcurrentcausesinvoluntarymusclecontractions,leadingtomusclefiber
breakdownandthereleaseofmyoglobinintothebloodstream,whichcandamagethekidneys.Symptomsofrhabdomyolysisincludemusclepain,weakness,anddarkurine,withlaboratorytests
showingelevatedCKandmyoglobinlevels.Earlyinterventionwithaggressivehydrationiscrucialtopreventkidneydamage,butwithoutit,thepatientcoulddevelopacutekidneyinjury,
potentiallynecessitatingdialysis.Additionally,theelectricalcurrentcaninterferewiththeheart’selectricalconductionsystem,causingarrhythmiasorevencardiacarrest.Symptomsinclude
palpitations,irregularheartbeats,orchestpain,withelectrocardiograms(ECGs)usedtodetectthesearrhythmias.Immediatetreatmentwithanti-arrhythmicdrugsordefibrillationmaybe
requiredtopreventpotentiallyfataloutcomes.
Theimpactofthefallfromaheightcancausefracturesanddislocations,leadingtopain,swelling,deformity,andaninabilitytomovetheaffectedlimb.X-raysandCTscansareessential
fordiagnosingtheseinjuries,withtreatmentinvolvingimmobilization,reductionofdislocations,andpossiblysurgery.Complicationscanincludenon-unionoffracturesorchronicpain.Internal
injuriestoorganssuchastheliver,spleen,andkidneysarealsopossible,withsignsincludingabdominalpain,tenderness,andindicationsofinternalbleedinglikelowbloodpressureand
tachycardia.CTscansandultrasoundareusedfordiagnosis,withsurgicalinterventionnecessarytorepairorgandamage.Untreatedinternalbleedingcanleadtoshockandorganfailure.

33. Bruisingandcontusionsresultfromdirectimpactduringthefall,causingpain,swelling,anddiscoloration.Theseinjuriesaretypicallymanagedwithrest,ice,compression,andelevation(RICE),
althoughseverebruisingmayrequiremoreintensivecare.
Potentialspinalcordinjuriesresultingfromvertebralfracturesordislocationsinthefallarecriticaltoassessandmanage.Signsincludebackpain,lossofsensation,andmotor
dysfunctionbelowtheinjurysite.MRIandCTscansareessentialfordiagnosis,withimmediatestabilizationandpossiblysurgicalinterventionrequired.Rehabilitationincludesphysicaland
occupationaltherapy,butcomplicationscanincludepermanentparalysisandlossoffunction.Earlyneurologicalassessmentiscrucialtodeterminetheextentofspinalcordinjury,withtreatment
optionsincludingcorticosteroidstoreduceinflammationandsurgerytodecompressthespinalcord.Long-termoutcomesdependontheseverityandlocationoftheinjury,withsomepatients
potentiallyrecoveringpartiallywithintensiverehabilitation,whileothersmaysufferpermanentdisability.Additionally,the3cmlacerationintheparietalareaposesrisksofbleeding,infection,
andpotentialdamagetounderlyingbraintissue.Initialmanagementincludescleaning,suturing,andantibioticprophylaxis,withCTscansassessingforunderlyingskullfractures.Withoutproper
care,thewoundcanbecomeinfectedorleadtolong-termneurologicaldeficits.Theparietallobeisinvolvedinprocessingsensoryinformationandspatialorientation,soinjuryinthisareacan
resultindeficitssuchasimpairedsensation,difficultywithspatialtasks,andcognitivechanges,necessitatingongoingneurologicalevaluationandneurorehabilitation.

34. MEDICALMANAGEMENT
DATE ORDERS
7/11/24
●PleaseadmittotraumateamundertheclientsserviceofDr.Opato
●Labs:CBC,bloodtyping,creatinine,electrolytes,serumcreatininekinase,urinemyoglobin
●IVF:PLR1L@100cc/hr
●Diet:DAT
●Meds:
○Paracetamol600mgIVTTQ6
○Cefuroxime750gIVTTQ8
○Tramadol50gIVTTQ8
○Omeprazole40mgIVTTQ24
○ChlorexidineoralgargleBID
○StartAminoacid＋Sorbitol5%500mL@42cc/hr
●VSQ4
●I&OQshift
●RefertoNSforcomfort
●Maytransporttowardoncew/vacancy
●RefertoIMforbaselineevaluation
12:39PM
●Patientseenandexamined
●Facilitatependinglabs
●CarereferraltoGenIM,Dr.Inanu
●Referforanyunusualities
9:00PM
●ReverseIVFtoPLR1L@285cc/hr

35. 7/12/24
7/13/24
7/14/24
8:53AM
●ForCTwabw/contrastnow
●MaintainonNPO
●D5LR@110cc/hr
●MonitorCBGQ8
4:45AM
●ForCXRPA(sitting)now
●ForsputumAFBandGSCS
●NoimmediatesurgicalinterventionGSwise
●MayhaveDATw/SAP
●IVFPLR@110cc/hr
●FollowupTOStoNSS
●MonitorCBGQ8whileonNPO
3:15PM
●DirecttoOR
●Forlaminectomy
●Meds:
○Ceftriaxone2gIV
○Omeprazole40gIVOD
10:55PM
●Post-operativeorders
●DietNPO
●IVF:PNSS1L×30drops/min
●Labs:CBC,serumelectrolytes,BUN,creatinine
●Meds:
●Ceftriaxone2gIVTT

36. 7/15/24
7/16/24
7/17/24
7/18/24
7/19-20/24
7/21/24
7/22/24
●Cefuroxime750mgIVTTQ8
●Omeprazole40mgIVTTQ24
●Tramadol50mgIVTTQ6
●Paracetamol600mgIVTTQ6
5:00PM
●ForExpansionduraplastyw/tensorfascialatagraft
5:50AM
●Patientextubatedsecretionssuctioned
●AttachO2cannula@2Lpm
●Referfordesaturation≤92%
●Maintainlumbarvest
●RemoveJPdraintomorrow
●TurntosideQ2
NONE
NONE
●Continuepresentmanagement
●ForORscheduling,awaitingimplants
●Awaitingimplants
●ForORoverw/implants
●TurntosidesQ2

37. 7/23/24
7/24/24
●Bedsorepreventions
●ForORscheduling
●Referfordesaturation
●ForORscheduling
●Awaitingimplants
●TurntosidesQ2
●Bedsorepreventions

38. NURSINGMANAGEMENT
DATE/TIME FOCUS DATA,ACTION,RESPONSE
7/23/24
2:00-10:00PM
Self-careDeficit D>Receivedpatientlyingonbedonroomair;takingorally;withheplockgauge20onrighthand;withlumbarvest;withdiaper;with
foleycatheterattached;notwearingclothesbutwithblanket;poorhygienenoted;awake,alert,andoriented;GCS=15;paraplegicand
immobile;afebrile;notinpainordistress;VStakenandrecorded:T=36.0°C,P=73bpm,R=20cpm,BP=120/80,O2sat=96%,PS=0/10
A>Assessedpatient’scondition;VStakenandrecorded;repositionedatintervals;instructedtopreserveself-caredespitelimitation;
performedandassistedonADLsandROMexercise;instructedonhowtouseweight-shiftingtechniques;advisedtokeepheadinneutral
positionandmaintainimmobilityofthespinebymeansofbedrest;encouragedtheuseofrelaxationtechniques;encouragedtoincrease
fluidintake;providedrestandsleepperiods;providedassistanceasneeded;performedbedsidecare;needsattended;raisedsiderails;
ensuredsafetyandcomfort;watchedoutforanyunusualities
R>Aftermynursinginterventions,thepatientandSOdemonstratedproperhygienemeasuresaswellastechniquestopreventfurther
injury
7/24/24
2:00-10:00PM
PhysicalImmobility D>Receivedpatientlyingsupineonbedonroomair;takingorally;withheplockgauge20onlefthand;withlumbarvest;withdiaper;
withfoleycatheterattached;notwearingclothesbutwithblanket;awake,alertandoriented;GCS=15;paraplegicandimmobile;unableto
doADLsindependently;callsforassistance;afebrile;notindistress;VStakenasfollows:T=36.1°C,P=80bpm,R=19cpm,BP=120/80,
O2sat=97%,PS=0/10
A>Assessedpatient’scondition;VStakenandrecorded;repositionedatintervals;performedandassistedonADLsandROMexercise;
assistedwithself-careandpersonalhygiene;instructedonhowtouseweight-shiftingtechniques;advisedtokeepheadinneutralposition
andmaintainimmobilityofthespinebymeansofbedrest;encouragedtheuseofrelaxationtechniques;encouragedtoincreasefluidintake;
providedrestandsleepperiods;providedassistanceasneeded;performedbedsidecare;needsattended;raisedsiderails;ensuredsafetyand
comfort;watchedoutforanyunusualities
R>Aftermynursinginterventions,thepatientverbalizedtechniquestopreventfurtherinjury

39. DISCHARGEPLAN
Patient’sName:PatientX DateofDischarge:N/A
ConditionUponDischarge:Mustbewell Nature:☑Homeperrequest
Thisdischargeplanaimstoensurecomprehensivecareandsupportforthepatient'srecoveryfrommultiplephysicalinjuriessustainedduetoanelectricalinjury.
Medication MedicationEducation
✔Educatethepatientabouttheimportanceofadheringtothemedicationregimen.Advisethepatienttocompletethefullcourseevenifhefeelsbetter.
✔Discusspotentialsideeffectsandtheneedtoreportadversereactions.Discussthepotentialneedformedicationsthatpromotehealing,suchastopicalointmentsfor
woundhealingorvitaminsthatsupportrecovery(e.g.,VitaminCandZinc).
✔Provideclearinstructionsondosages,timings,andmethodsofadministration.Stresstheimportanceoftakingmedicationsasprescribed,andkeepamedicationlogto
avoidconfusion.
Exercise RehabilitationExercises
Developaphysiotherapyplantailoredtothepatient'sinjuries,including:
✔RangeofMotion(ROM)Exercises:Topreventstiffnessandpromotemobility.
✔StrengthTraining:Focusonrebuildingstrengthininjuredareas.
✔BalanceTraining:Particularlyimportantafterfallstopreventfutureincidents.
Provideatailoredhomeexerciseplanfocusingongentlerange-of-motionexercises,strengthtrainingastolerated,andactivitiesthatpromotebalanceandcoordination.
✔PerformgentleROMexercisesforaffectedlimbsdailytopreventstiffnessandimproveflexibility.
✔Startwithshortwalksindoors,graduallyincreasingdurationandintensityastoleratedtoregainmobility.
Clearlyinstructthepatienttoavoidhigh-impactactivitiesandheavyliftinguntilclearedbytheirhealthcareprovider.
Treatment WoundCare
✔Instructonpropercareforanyopenwounds,includingcleaningwithsaline,applyingnewdressings,andmonitoringforsignsofinfection(redness,swelling,or
discharge).
✔Schedulenecessarytreatments,suchasfollow-upappointmentsforwoundassessmentorfurtherimagingasindicated.Ifapplicable,explaintheneedforspecialty
consultations(e.g.,withaneurologistororthopedicsurgeon).PainManagementStrategies
✔Recommendnon-pharmacologicalpainmanagementtechniquessuchasheattherapyandTENS(TranscutaneousElectricalNerveStimulation)andDeepbreathing
exercise.

40. HealthteachingInjuryPrevention
✔Discusshomesafetymeasurestopreventfuturefalls,especiallyfocusingonminimizingelectricalhazards(e.g.,checkingsocketsandusingproperinsulation).
SignsofComplication
✔Educatethepatientonrecognizingsymptomsthatnecessitateimmediatemedicalattention,suchasworseningpain,fever,excessivebleeding,ornoticeablechangesto
theirwounds.
LifestyleModifications
✔Provideinformationaboutlifestylechangesthatcansupportoverallhealthandwell-being.
UnderstandingElectricalInjuries
✔Provideeducationalresourcestohelpthepatientcomprehendthepotentiallong-termeffectsoftheirinjuries,includingrehabilitationrequirements.
FollowupvisitSchedulingAppointments
✔Schedulefollow-upvisitswithprimarycareandspecialists(orthopedic,neurologist,psychologist)asnecessary.
✔Ensurethepatientunderstandstheimportanceofattendingtheseappointmentsforongoingevaluationandcare.
✔Providethepatientwitharemindercardcontainingimportantfollow-updatesandcontactinformationforquestionsorconcerns.
MonitoringRecovery
✔Discussthetimelineforrecoveryandwhatthepatientshouldexpectduringtherehabilitationprocess.
Diet NutritionalGuidance
Emphasizetheimportanceofabalanceddietrichinvitaminsandmineralstopromotehealing.Outlineadietplanthatincludes:
✔Protein:Fortissuerepair(e.g.,leanmeats,legumes,dairy).
✔FruitsandVegetables:Forvitaminsandantioxidants(especiallyVitaminC-richfoods).
✔WholeGrains:Toprovidesustainedenergy.
Hydration
✔Instructthepatienttomaintainadequatehydration,particularlyifmedicationsareprescribedthatcanleadtodehydration.
Spirituality Spirituality
EmotionalandSpiritualWell-Being
✔Encouragethepatienttoexplorespiritualpracticesthatresonatewiththem,whetherthroughreligiouscommunity,meditation,orrestorativepracticessuchasyogaor
mindfulness.
✔Recommendconnectingwithchaplaincyservicesifthepatientdesiresspiritualcounselingtoprocesstheirexperienceandsupportemotionalhealing.
SupportSystems
✔Discusstheimportanceofhavingastrongsupportnetwork,consistingoffamily,friends,andcommunityresourcesthatcanprovideencouragementand
companionshipduringrecovery.

41. NURSINGCAREPLAN
ASSESSMENT DIAGNOSISPLANNING INTERVENTION RATIONALE EVALUATIO
N
Subjective:
“Dikonamaramdaman
yangpaako,kayahindi
dinakomakalakad”as
verbalizedbythepatient.
Objective:
VS:
T=36°C
P=72bpm
R=20cpm
BP=110/80mmhg
02Sat=96%
PS=0/10
●Paraplegic
●Unabletoambulate
●Inabilitytomove
purposefullywithin
physicalenvironment
●Limitedrangeof
motion(ROM)
Impaired
Physical
Mobilityr/t
Musculoskele
tal
impairment
After8hoursof
nursing
intervention,
thepatientwill
be freeof
complications
ofimmobility,
asevidenced
by:intactskin,
absence of
thrombophlebiti
s,andnormal
bowelpattern
Independent
✔Establishrapportwiththepatient.
✔Monitorpatient’svitalsigns.
✔Assessthepatient'sabilitytoperformADLs
effectivelyandsafelyonadailybasis.
✔Assessfordevelopingthrombophlebitis(calfpain,
Homans'sign,redness,localizedswelling,andrisein
temperature).
✔Evaluateneedforassistivedevices.
✔Evaluatethesafetyoftheimmediateenvironment.
✔Encourageandfacilitateearlyambulationandother
ADLswhenpossible.
✔Educatetheappropriateuseofassistivedevicesin
thehomesetting.
✔Providepositivereinforcementduringactivity.
✔Allowpatientstoperformtasksathisorherown
rate.Donotrushthepatient.Encourageindependent
activityasableandsafe.
✔Keepsiderailsupandbedinlowposition.
✔Turnandpositionevery2hours,orastolerated.
✔Maintainlimbsinfunctionalalignment(e.g.,with
pillows,sandbags,wedges,orprefabricatedsplints).
✔PerformpassiveoractiveassistiveROMexercisesto
allextremities.
✔Useprophylacticantipressuredevicesas
✔Togaintrustandcooperation
✔Forbaselinedata
✔Restrictedmovementaffectstheabilitytoperform
mostADLs.Safetywithambulationisanimportant
concern.
✔Bedrestorimmobilitypromotesclotformation.
✔Properuseofwheelchairs,canes,transferbars,and
otherassistancecanpromoteactivityandreduce
dangeroffalls.
✔Obstaclessuchasthrowrugs,etc.canfurtherimpede
one'sabilitytoambulatesafely.
✔Thelongerthepatientremainsimmobilethegreater
thelevelofdebilitationthatwilloccur.
✔Mobilityaidscanincreaselevelofmobility.
✔Patientsmaybereluctanttomoveorinitiatenew
activityfromafearoffalling.
✔Hospitalworkersandfamilycaregiversareoftenina
hurryanddomoreforpatientsthanneeded,thereby
slowingapatient'srecoveryandreducinghisorher
self-esteem.
✔Topromoteasafeenvironment.
✔Tooptimizecirculationtoalltissuesandtorelieve
pressure.
✔Topreventfootdropand/orexcessiveplantarflexion
ortightness.
✔Topromoteincreasedvenousreturn,preventstiffness,
andmaintainmusclestrengthandendurance
After8hoursof
nursing
intervention,
thepatientwas
free of
complications
ofimmobility,
asevidenced
by:intactskin,
absence of
thrombophlebiti
s,andnormal
bowelpattern

42. appropriate.
✔Encourageincreasedfluidintake.
✔Teachenergysavingtechniques.
Dependent
✔Administermedicationsasperdoctor'sorder.
✔Consultwiththemultidisciplinaryteam.
✔Topreventtissuebreakdown.
✔Tooptimizehydrationstatusandpreventhardeningof
stool.
✔Tooptimizepatient'slimitedreserves.
✔Tofacilitatemanagementandtreatment.
✔Patientmayrequiresupportfromphysiotherapistor
occupationaltherapist

43. ASSESSMENT DIAGNOSISPLANNING INTERVENTION RATIONALE EVALUAT
ION
Subjective:
“Hindinaakonakakaligo
attoothbrushkayhindi
manakomakakilosng
ayos,dimakalakad”as
verbalizedthepatient.
Objective:
VS:
T=36.0°C
P=73bpm
R=20cpm
BP=120/80mmhg
02Sat=96%
PS=0/10
●Paraplegic
●Unabletoambulate
●Limitedrangeof
motion(ROM)
●Unabletoperform
ADLsandpersonal
hygiene
independently
●Bodyodornoted
●Longnailsobserved
Self-care
Deficitr/t
physical
immobility
After8hoursof
nursing
intervention,
thepatientwill
beableto
identify
resourceswhich
areusefulin
optimizing
autonomyand
independence.
Independent
✔Establishrapportwiththepatient.
✔Monitorpatient’svitalsigns.
✔AssessabilitytocarryoutADLsonaregularbasis.
Determinetheaspectsofself-carethatare
problematictothepatient.
✔Encourageindependence,butintervenewhena
patientcannotperform.
✔Useconsistentroutinesandallowadequatetimefor
patientstocompletetasks.
✔Providepositivereinforcementforallactivities
attempted;notepartialachievements.
✔Providefrequentencouragementandassistanceas
neededwithdressing.
✔Encourageuseofclothingonesizelarger.
✔Assistinperformingpersonalhygienesuchas
changingdiapersandclothesbutallowhimto
performalone.
✔Ensurethatneededutensilsarecloseby.
✔Instructpatientstoselectbedbathtimewhenthey
arerestedandunhurried.
✔Offerfrequentencouragement.
✔Assistpatientsinremovingorreplacingnecessary
clothing.
✔Keepsiderailsupandbedinlowposition.
✔Turnandpositionevery2hours,orastolerated.
✔Maintainlimbsinfunctionalalignment(e.g.,with
pillows,sandbags,wedges,orprefabricatedsplints).
✔PerformpassiveoractiveassistiveROMexercisesto
allextremities.
✔Useprophylacticantipressuredevicesas
appropriate.
✔Togaintrustandcooperation
✔Forbaselinedata
✔Thepatientmayonlyrequireassistancewithsomeself-
caremeasures.
✔Tofacilitatelearninganddecreasefrustration.
✔Thishelpspatientsorganizeandcarryoutself-careskills.
✔Thisprovidesthepatientwithanexternalsourceof
positivereinforcement.
✔Toreduceenergyexpenditureandfrustration.
✔Toensureeasierdressingandcomfort.
✔Toprovidehelptothepatientinmoving,andtoensure
thepatient'scomfort,dignity,andoverallwell-being.
✔Toconserveenergyandoptimizesafety.
✔Hurryingmayresultinaccidentsandtheenergyrequired
fortheseactivitiesmaybesubstantial.
✔Patientsoftenhavedifficultyseeingprogress.
✔Clothingthatisdifficulttogetinandoutofmay
compromiseapatient'sabilitytobecontinent
✔Topromoteasafeenvironment.
✔Tooptimizecirculationtoalltissuesandtorelieve
pressure.
✔Topreventfootdropand/orexcessiveplantarflexionor
tightness.
✔Topromoteincreasedvenousreturn,preventstiffness,
andmaintainmusclestrengthandendurance
✔Topreventtissuebreakdown.
✔Tooptimizehydrationstatusandpreventhardeningof
stool.
✔Tooptimizepatient'slimitedreserves.
After 8
hoursof
nursing
intervention,
thepatient
wasableto
identify
resources
whichare
usefulin
optimizing
autonomy
and
independenc
e.

44. ✔Encourageincreasedfluidintake.
✔Teachenergysavingtechniques.
Dependent
✔Administermedicationsasperdoctor'sorder.
✔Consultwiththemultidisciplinaryteam.
✔Tofacilitatemanagementandtreatment.
✔Patientmayrequiresupportfromphysiotherapistor
occupationaltherapist

45. ASSESSMENT DIAGNOSISPLANNING INTERVENTION RATIONALE EVALUATIO
N
Subjective:
“Putol-putoltulogkokay
nagabigaypanggamotsa
gabi”asverbalizedthe
patient
Objective:
VS:
T=36.1°C
P=80bpm
R=19cpm
BP=120/80mmhg
02Sat=97%
PS=0/10
●Yawning
●Dozing
●Awakeningearlier
thandesired
●Interruptedsleep
●Complaintsofnot
feelingrested
Disturbed
Sleeping
Patternr/t
medi
cation
administratio
n
After8hoursof
nursing
intervention,
thepatientwill
beableto
achieveoptimal
amounts of
sleep as
evidencedby:
rested
appearance,
verbalizationof
feelingrested
and
improvementin
sleeppattern.
Independent
✔Establishrapportwiththepatient.
✔Monitorpatient’svitalsigns.
✔Assesspastpatternsofsleepinanormal
environment:amount,bedtimerituals,depth,length,
positions,aids,andinterferingagents.
✔Instructpatientstofollowasconsistentadaily
scheduleforretiringandarisingaspossible.
✔Instructtoavoidheavymeals,alcohol,caffeine,or
smokingbeforeretiring.
✔Increasedaytimephysicalactivitiesasindicated
✔Discouragepatternofdaytimenapsunlessdeemed
necessarytomeetsleeprequirementsorifpartof
one'susualpattern.
✔Suggestuseofsoporificssuchasmilk.
✔Explaintheneedtoavoidconcentratingonthenext
day'sactivitiesoronone'sproblemsatbedtime.
✔Providenursingaids(e.g.,backrub,bedtimecare,
painrelief,comfortableposition,relaxation
techniques).
✔Encourageincreasedfluidintake.
✔Teachenergysavingtechniques.
Dependent
✔Administermedicationsasperdoctor'sorder.
✔Consultwiththemultidisciplinaryteam.
✔Togaintrustandcooperation
✔Forbaselinedata
✔Sleeppatternsareuniquetoeachindividual.
✔Thispromotesregulationofthecircadianrhythm,
andreducestheenergyrequiredforadaptationto
changes.
✔Thoughhungercanalsokeeponeawake,gastric
digestionandstimulationfromcaffeineandnicotine
candisturbsleep.
✔Toreducestressandpromotesleep.
✔Nappingcandisruptnormalsleeppatterns.However
theelderlydobetterwithfrequentnapsduringthe
daytocountertheirshorternight-timesleepschedule.
✔WhichcontainsL-tryptophanthatfacilitatessleep.
✔Obviously,thiswillinterferewithinducingarestful
state.
✔Topromoterest.
✔Tooptimizehydrationstatusandpreventhardening
ofstool.
✔Tooptimizepatient'slimitedreserves.
✔Tofacilitatemanagementandtreatment.
✔Patientmayrequiresupportfromphysiotherapistor
occupationaltherapist
After8hoursof
nursing
intervention,the
patientwasable
to achieve
optimalamounts
ofsleepas
evidencedby:
rested
appearance,
verbalizationof
feelingrested
and
improvementin
sleeppattern.

46. DRUGSTUDY
BrandName
GenericName
Classification
Dosage
Frequency
Route
Mechanismof
Action
Indication Contraindic
ation
AdverseReaction NursingResponsibilities
Prilosec
Omeprazole
Protonpump
inhibitor
40mgOD
IVTTQ12
Anantisecretory
compoundthatisa
gastricacidpump
inhibitor.
Suppressesgastric
acidsecretionby
inhibitingtheH+,
K+-ATPase
enzymesystem
[theacid(proton
H+)pump]inthe
parietalcells.
Duodenalandgastriculcer
Gastroesophageal reflux
diseaseincludingsevere
erosiveesophagitis(4to8
wktreatment)
Long-termtreatmentof
pathologichypersecretory
conditionssuchasZollinger-
Ellisonsyndrome,multiple
endocrineadenomas,and
systemicmastocytosis
In combination with
clarithromycintotreat
duodenalulcersassociated
withHelicobacterpylori.
Long-term
use for
gastroesoph
agealreflux
disease,
duodenal
ulcers;
lactation.
CNS:Headache,
dizziness,fatigue
GI:Diarrhea,
abdominal pain,
nausea, mild
transientincreasesin
liverfunctiontest
Urogenital:Hematuri
a,proteinuria
Skin:Rash
✔Checkandverifywiththedoctor'sorder.
✔Observerightsinmedicationadministration.
✔Educatepatientontheprocedureandthe
medication
✔Givebeforefood,preferablybreakfast
✔Checkthatthevial/ampoule/syringe/bagisintact,
checkmedicationforintegrityandpresenceof
particulatematter.
✔Asepticallycleaninjectionportwithalcoholswab
andallowittodry.
✔InspectIVsiteandassessforsignsofredness,
inflammationorswelling.
✔DonotpushIVmedtoquicklytoavoidadverse
effects
✔EnsureIVispatent
✔InstructpatienttonotadjustordisconnecttheIV
✔Informthepatientsregardingthesideeffects
suchasdizzinessandheadache.
✔Monitorforadverseeffectssuchasrash,
swelling,ordifficultybreathing.
✔Advicetoreportanychangesinurinary
eliminationsuchaspainordiscomfortassociated
withurination,orbloodinurine.
✔Advicetoreportseverediarrhea;drugsmayneed
tobediscontinued.
✔Monitorurinalysisforhematuriaandproteinuria.
Periodicliverfunctiontestswithprolongeduse.

47. BrandName
GenericName
Classification
Dosage
Frequency
Route
Mechanism
ofAction
Indication Contraindication AdverseReaction NursingResponsibilities
Dexamethasone
Sodium
Phosphate
Dexamethasone
Corticosteroid,
Glucocorticoid,
Hormone
5mgOD
TIV
×5doses
Dexamethas
oneisa
synthetic
glucocortico
idwhich
decreases
inflammatio
n by
inhibiting
the
migrationof
leukocytes
andreversal
ofincreased
capillary
permeability
. It
suppresses
normal
immune
response
Hypercalcemiaassociatedwithcancer
Short-termmanagementofvarious
inflammatoryandallergicdisorders,
suchasrheumatoidarthritis,collagen
diseases(SLE),dermatologicdiseases
(pemphigus),statusasthmaticus,and
autoimmunedisorders
Hematologic disorders:
Thrombocytopenic purpura,
erythroblastopenia
Trichinosiswithneurologicor
myocardialinvolvement
Ulcerativecolitis,acuteexacerbations
ofMS,andpalliationinsome
leukemiasandlymphomas
Cerebraledemaassociatedwithbrain
tumor,craniotomy,orheadinjury
Testingadrenocorticalhyperfunction
Unlabeleduses:Antiemeticfor
cisplatin-inducedvomiting,diagnosis
ofdepression
Intra-articular or soft-tissue
administration:Arthritis,psoriatic
plaques
Respiratoryinhalant:Controlof
bronchial asthma requiring
corticosteroidsinconjunctionwith
othertherapy
Hypersensitivity;
activeuntreated
infections;
ophthalmicusein
viral, fungal
diseaseoftheeye.
Growth retardation,
osteoporosis, peptic
ulcer,glaucomaand
subcapsularcataracts,
vertebralcompression
fractures.Cushing-like
features, pancreatic
dysfunction and
pancreatitis,GIupsets,
increased appetite,
increasedfragilityofthe
skin. Increased
susceptibility to
infection.
PotentiallyFatal:HPA
supression;CVcollapse
onrapidIVadmin.
✔ Checkandverifywiththedoctor's
order.
✔ Observerightsinmedication
administration.
✔ Educatepatientontheprocedureand
themedication.
✔ Checkthatthe
vial/ampoule/syringe/bagisintact,check
medicationforintegrityandpresenceof
particulatematter.
✔ Asepticallycleaninjectionportwith
alcoholswabandallowtodry.
✔ InspectIVsiteandassessforsignsof
redness,inflammationorswelling.
✔ PreventphlebitisbychagingIVsite
every72hours
✔ DonotpushIVmedtoquicklyto
avoidadverseeffects
✔ EnsureIVispatent
✔ Advisepatienttonotadjustor
disconnecttheIV
✔ WARNING:Givedailydosesbefore
9AMtomimicnormalpeak
corticosteroidbloodlevels.
✔ Donotstoptakingtheoraldrug
withoutconsultinghealthcareprovider.
✔ Avoidexposuretoinfection.
✔ Advisetoreportunusualweight
gain,swellingoftheextremities,muscle
weakness,blackortarrystools,fever,
prolongedsorethroat,coldsorother
infections.

48. Intranasal:Reliefofsymptomsof
seasonalorperennialrhinitisthat
respondspoorlytoothertreatments
Dermatologicpreparations:Reliefof
inflammatory and pruritic
manifestationsofdermatosesthatare
steroid-responsive
Ophthalmic preparations:
Inflammationofthelid,conjunctiva,
cornea,andglobe

49. BrandName
GenericName
Classification
Dosage
Frequency
Route
Mechanism
ofAction
Indication Contraindication AdverseReaction NursingResponsibilities
Ultram
Tramadol
Analgesic
50mgIVTT
Q6
Therapeutic
actions
Bindsto
mu-opioid
receptors
andinhibits
thereuptake
of
norepinephri
neand
serotonin;
causesmany
effects
similarto
the
opioids—
dizziness,
somnolence,
nausea,
constipation
—butdoes
nothavethe
respiratory
depressant
effects.
Reliefofmoderatetomoderately
severepain
Reliefofmoderatetoseverechronic
paininadultswhoneedaround-the-
clocktreatmentforextendedperiods
(ERtablets)
Unlabeleduses:Premature
ejaculation;restlesslegssyndrome
Allergyto
tramadolor
opioidsoracute
intoxicationwith
alcohol,opioids,
orpsychoactive
drugs.
Usecautiously
withseizures;
concomitantuse
ofCNS
depressants,
MAOIs,SSRIs,
TCAs;renal
impairment;
hepatic
impairment.
CNS:Sedation,
dizzinessorvertigo,
headache,confusion,
dreaming,sweating,
anxiety,seizures
CV:Hypotension,
tachycardia,
bradycardia,
vasodilation,syncope,
orthostatichypotension
Dermatologic:Sweating,
pruritus,rash,pallor,
urticaria
GI:Nausea,vomiting,
drymouth,constipation,
flatulence
Other:Potentialfor
abuse,anaphylactoid
reactions
✔ Checkandverifywiththedoctor's
order.
✔ Observerightsinmedication
administration.
✔ Educatepatientontheprocedureand
themedication.
✔ Checkthatthe
vial/ampoule/syringe/bagisintact,check
medicationforintegrityandpresenceof
particulatematter.
✔ Asepticallycleaninjectionportwith
alcoholswabandallowtodry.
✔ InspectIVsiteandassessforsignsof
redness,inflammationorswelling.
✔ PreventphlebitisbychagingIVsite
every72hours
✔ DonotpushIVmedtoquicklyto
avoidadverseeffects
✔ EnsureIVispatent
✔ Advisepatienttonotadjustor
disconnecttheIV
✔ Assessthepatientforlossof
consciousness(LOC),somnolenceand
arousaldifficulties.
✔ Assessthesource,location,and
characteristicsofpain.
✔ Seizuresshouldbeobservedclosely.
Whennecessary,employseizure
precautions.
✔ Takethismedicationexactlyas
directed.
✔ Tramadolcanbetakenwithor
withoutmeals,buttakeitconsistently

50. withinaspecifiedtimeorperiod.
✔ Advisetosideeffects:Dizziness,
sedation,drowsiness,impairedvisual
acuity(avoiddrivingorperformingtasks
thatrequirealertness);nausea,lossof
appetite(liequietly,eatfrequentsmall
meals).
✔ Advisetoreportseverenausea,
dizziness,severeconstipation,thoughtsof
suicide.

51. BrandName
Generic
Name
Classification
Dosage
Frequency
Route
Mechanismof
Action
Indication ContraindicationAdverseReaction NursingResponsibilities
Amcetam
Paracetamol
Analgesic
600mgIVTT
Q6inbetween
dosesofPCM
Antipyretic:
Reducesfeverby
actingdirectlyon
thehypothalamic
heat-regulating
centertocause
vasodilationand
sweating,which
helpsdissipateheat.
Analgesic:Siteand
mechanismof
actionunclear.
Analgesic-antipyreticin
patientswithaspirin
allergy,hemostatic
disturbances,bleeding
diatheses,upperGI
disease,goutyarthritis
Arthritisandrheumatic
disordersinvolving
musculoskeletalpain(but
lacksclinically
significantantirheumatic
andanti-inflammatory
effects)
Commoncold,flu,other
viralandbacterial
infectionswithpainand
fever
Unlabeleduse:
Prophylacticforchildren
receivingDPT
vaccinationtoreduce
incidenceoffeverand
pain
Contraindicated
withknownG-6-
PDdeficiency
Hypersensitivity
Usecautiously
withimpaired
hepaticfunction,
chronic
alcoholism,
pregnancy,
lactation.
CNS:Headache
CV:Chestpain,
dyspnea,myocardial
damagewhendosesof
5–8g/dayareingested
dailyforseveralweeks
orwhendosesof4
g/dayareingestedfor
1yr
GI:Hepatictoxicity
andfailure,jaundice
GU:Acutekidney
failure,renaltubular
necrosis
Hematologic:
Methemoglobinemia
—cyanosis;hemolytic
anemia—hematuria,
anuria;neutropenia,
leukopenia,
pancytopenia,
thrombocytopenia,
hypoglycemia
Hypersensitivity:
Rash,fever
✔Checkandverifywiththedoctor'sorder.
✔Observerightsinmedicationadministration.
✔Educatepatientontheprocedureandthe
medication
✔Checkthatthevial/ampoule/syringe/bagisintact,
checkmedicationforintegrityandpresenceof
particulatematter.
✔Asepticallycleaninjectionportwithalcohol
swabandallowtodry.
✔InspectIVsiteandassessforsignsofredness,
inflammationorswelling.
✔PreventphlebitisbychagingIVsiteevery72
hours
✔DonotpushIVmedtoquicklytoavoidadverse
effects
✔EnsureIVispatent
✔AdvisepatienttonotadjustordisconnecttheIV
✔Advisepatientofsideeffectssuchasdizziness
andheadache
✔Monitorforadverseeffectssuchasrash,
swelling,ordifficultybreathing
✔Advisetoperformcomfortmeasurestoalleviate
discomfortfromGIeffectsandheadache.
✔Advisetoreportifpainorrecurrentfeverpersists
despitemedicationuse.
✔Advisetoavoidalcoholasthiscanincreasethe
riskofliverdamageorimpairedliverfunction.
✔Providepainandfevermanagementthroughnon-
pharmacologicalmethods,suchascold
compressesorrest

52. BrandName
GenericName
Classification
Dosage
Frequency
Route
Mechanismof
Action
Indication Contraindicati
on
AdverseReaction NursingResponsibilities
Rocephin
Ceftriaxone
Antibiotic,
Third
generation
cephalosporins
1gIVTTQ12
Inhibitsbacterial
cellwallsynthesis
bybindingtooneor
moreofthe
penicillin-binding
proteins(PBPs)
whichinturn
inhibitsthefinal
transpeptidationstep
ofpeptidoglycan
synthesisin
bacterialcellwalls,
thusinhibitingcell
wallbiosynthesis
Gonorrhea:Single250-mg
IMdose
Meningitis:1–2gIMorIV
onceadayorinequal
divideddosesbidfor4–14
days.
Perioperativeprophylaxis:
Give1gIV30–120min
beforesurgery.
Contraindicated
withallergyto
cephalosporins
orpenicillins.
Usecautiously
withrenal
failure,
lactation,
pregnancy
CNS:Headache,
dizziness,lethargy,
paresthesias
GI:Nausea,vomiting,
diarrhea,anorexia,
abdominalpain.
Hematologic:Bone
marrowdepression—
decreasedWBCcount,
decreasedplatelets,
decreasedHct.
Hypersensitivity:
Rangingfromrashto
fevertoanaphylaxis;
serumsicknessreaction
Local:Pain,abscessat
injectionsite;phlebitis,
inflammationatIVsite
✔Checkandverifywiththedoctor'sorder.
✔Observerightsinmedicationadministration.
✔Educatepatientontheprocedureandthe
medication
✔Checkthatthevial/ampoule/syringe/bagis
intact,checkmedicationforintegrityand
presenceofparticulatematter.
✔Asepticallycleaninjectionportwithalcohol
swabandallowtodry.
✔InspectIVsiteandassessforsignsof
redness,inflammationorswelling.
✔PreventphlebitisbychagingIVsiteevery
72hours
✔DonotpushIVmedtoquicklytoavoid
adverseeffects
✔Advisepatientofsideeffectssuchas
dizziness,headacheorGIupset
✔Monitorforadverseeffectssuchasrash,
swelling,ordifficultybreathing
✔Advisetoperformcomfortmeasuresto
alleviatediscomfortfromGIeffectsand
headache.
✔Advisetoavoidalcoholasthiscan
increasetheriskofliverdamageor
impairedliverfunction.
✔Advisetoreportseverediarrhea,difficulty
breathing,unusualtirednessorfatigue,
painatinjectionsite