"Acute Coronary Syndrome Non ST Elevation Myocardial Infarction, Hypertensive Cardiovascular Disease, Diabetes Mellitus Type 2, and Community Acquired Pneumonia" Med MNGT

IV.
PATIENT AND HIS CARE
A. Medical Management
a) IVF, Condom Catheter, Oxygen Therapy

Date ordered
Date performed Client’s response to the
Type of IVF General description Indication(s) or Purpose(s)
Date change treatment
D/C
PNSS 1L Date Ordered: An isotonic type of solution thatTo provide hydration and The patient responded well
X 100 cc/hr November 25, 2009 exerts the same osmotic pressureelectrolyte to the patient. to the treatment without
that can be found in plasma. It is any abnormal signs and
Date Performed: used to supply water calories andTo provide route for medicine symptoms felt.
November 25, 2009 electrolytes to the body. administration. Maintenance of fluid
Plain normal saline solution volume was noted as
Date Changed: contains 308 mosm/L PNSS was given to prevent evidenced by no signs of
November 26, 2009 further increase in blood dehydration. No further
to D5W 500 cc glucose levels increase in blood glucose
levels was noted.
Nursing Responsibilities:
BEFORE:
• Verify prescriptions for IV therapy

• check solution label and identify patient
• Explain procedure to the patient
• Carry out hand hygiene and put on disposable non-latex gloves
• Apply a tourniquet 4-6 inches above the sites apply identify a suitable vein
• Choose site. Use distal veins of hands and arms first
• Raise bed for comfortable working height and position for patient and adjust lighting
96
DURING:
• Explain to the client what you are going to do, why it is necessary, and how she can cooperate
• Question the patient carefully about sensitivity to latex, use blood pressure cuff rather than latex tourniquet if there
is sensitivity
• Apply a new tourniquet for each patient and palpate for a pulse distal to the tourniquet
• With hand not holding the venous access devise, steady patient’s arm and use finger to pull skin taut
• Hold needle bevel up and at 5-25 degree angle, depending on the depth of vein
• If backflow of blood is visible, straighten angle and advance needle. Additional steps for catheter is inserted over
the needle:
• Hold needle hub, and slide catheter over the needle and vein
o Remove while pressing lightly on the skin over the catheter tip
o Release tourniquet and attach infusion tubing: open clamp enough to allow drip
o Cover and tape the small loop of IV tubing onto the dressing
o Calculate infusion rate and regulate flow of infusion
AFTER:
• Document date and time therapy initiated

• Monitor vital signs
• Check the level of the IV as per hospital policy
• Tape the IV lines
• Dress and label the venipuncture according to the hospital policy
• Instruct the client to inform the health care professionals should there be any swelling or redness on insertion site
which may be a sign for dislodged IV line
• Regularly check regulation of IVF
97
Date ordered
Type of IVF General description Indication(s) or Purpose(s)
D/C
D5W 500 cc Date Ordered: It is used to supply water andPatient needs D5W for fluidThe patient did not
X 20 cc/hr November 26, 2009 calories to the body. It is also usedvolume maintenance and formanifest a sudden
as a mixing solution (diluent) forthe prevention of suddendecrease in blood glucose
Date Performed: other IV medications. Dextrose isdecrease in blood glucoselevels.
Novemeber 26, 2009 a natural sugar found in the bodylevels.
and serves as a major energy
Date Discontinued: source. When used as an energy
December 02, 2009 source, dextrose allows the body
to preserve its muscle mass.
BEFORE:
• Check the doctor's order.

• Check the expiration date of Intravenous fluid.
• Inform the patient's SO about the IV fluid to be given.
• Explain the procedure to the SO.
DURING:
• Check the IVF level.

• Check the patency of the tube
• Select an appropriate site.
• Use aseptic technique.
98
AFTER:
• Regulate the IVF as ordered.

• Monitor the response of the patient.
• Check for any presence of infiltrations.
• Check if there is presence of air.
• Record all procedures done
Date ordered
Date performed Indication(s) or Client’s response to
Catheter General description
Date change Purpose(s) the treatment
D/C
Condom Catheter Date Ordered: The use of catheters can Since patient had DM for The patient was able to
Novmber 26, 2009 be under patient control 5 years, catheterization maintain urine output
and can be designed to was performed to AEB no bladder
Date Performed: fit into their lifestyle.This accurately monitor urine distension noted.
November 26, 2009 device should be applied output of the patient for
to clean, dry skin. The possible nerve damage
condom is commonly that affects renal
made from a latex excretion of waste
material and attaches to products.
the penis with adhesive.
A plastic tube is attached Also due to restriction on
to the condom, which the patient’s activity and
leads to a bag taped to continuous cardiac
the leg or a pouch monitoring in which in
surrounding the penis. this case needs not be
The attached bag removed.
accumulates all the urine
until it is emptied. The
bag must be emptied
every 30 minutes and the
condom device must be
changed and cleaned at
least every other day to
protect the skin of the
penis.
99
BEFORE:

• Inform the patient's SO about the condom catheter to be used.
• Explain the procedure to the SO.
DURING:
• The penis should be gently washed and dried. Make sure the penis is dry before you put on the condom catheter.
• Make sure the condom catheter is inserted securely.
• The condom catheter should fit snugly without being too tight.
• Make sure the skin does not show any signs of damage such as sores or cuts.
AFTER:

• Check for any presence of skin breakdown.
• regular cleaning of any leakage is very important
100
Date ordered
O2 Flow Rate General description Indication(s) or Purpose(s)
D/C
2LPM Date Ordered: Oxygen therapy usually suppliedIt was given to the patient toThe patient was able to
November 25, 2009 via a nasal cannula regulated inmaintain the effective level ofcope up and respond
accordance to the amount ofoxygen saturation in thepositively to the therapy as
oxygen the patient needs. body. The patient isevidenced by patient was
Date Discontinued: experiencing dyspnea AEBable to show an absence
Novemeber 28, 2009 with a RR: 25 uponof signs and symptoms of
admission he was given O2respiratory distress AEB a
inhalation to relieve fromdecrease in RR of 25 to 18
dyspnea. cpm.
BEFORE:

• Check the patency of the nasal cannula
• Inform the patient regarding the purpose of the therapy
DURING:
• Check whether the O2 flow rate is within the desired level.

• Restrict smoking. Put a no smoking sign on the patient’s room.
• Recheck patency of the tubing.
AFTER:
• Regulate O2 flow rate as ordered

101
b) Drugs
Name of Drugs, Date ordered Route of Admin., General action Indication(s) or Clients response to
generic name Date taken/given Dosage & frequency Functional Purpose(s) the medications with
Brand name Date changed/ D/C of admin. Classification actual side effects
Mechanism of action
Generic Name: Date Ordered: 1 ampule IV Anticholinergic Agent Atropine sulfate is The patient’s heart
Atropine sulfate November 25, 2009 indicated to the rate increased from
patient to increase the 60 bpm to 200 bpm.
Brand Name: heart rate of the
Atropen Date Discontinued: patient and to prevent
November 25, 2009 bradycadia.
BEFORE:
• Check the doctor’s order.

• Check the drug label, contents, and appearance.
• Check the right dosage, route and time of administration.
• Explain to the client what the purpose of the drug.
DURING:
• Observe proper medical asepsis.

• May be taken with or without food.
102
AFTER:
• Monitor the client’s reaction to the drug.

• Document the findings.
General action
Name of Drugs, Date ordered Route of Admin., Clients response to
Functional Indication(s) or
generic name Date taken/given Dosage & frequency the medications with
Classification Purpose(s)
Brand name Date changed/ D/C of admin. actual side effects
Mechanism of axn.
Generic Name: Date Ordered: 7.5mg/hr via lidocaine Antiarrhythmic Upon admission the The patient
Lidocaine November 25, 2009 drip patient’s initial ECG responded well on the
shows marked ST drug as evidenced by
Brand Name: Date Consumed: segment depression patient has normal
Xylocard November 26, 2009 (11-25-09/9:00 pm), sinus rhythm as
then when it was reflecte from the
repeated the patient patient’s ECG as of
had atrial fibrillation 11-26-09 (8:00 am).
with rapid ventricular
response (11-25-
09/9:30 pm). The drug
is indicated to the
patient to relieve the
patient from
arrhythmia.
BEFORE:

103
• Explain to the client what the purpose of the drug
DURING:

• May be taken with or without food.
AFTER:

General action
Name of Drugs, Date ordered Route of Admin., Clients response to the
generic name Date taken/given Dosage & frequency medications with
Mechanism of axn.
Generic Name: Date Ordered: 1 ampule nowq then, 40Loop Diuretics It is used forThe pt. manifested a
Furosemide November 25, 2009 mg 1tab X 3 days hypertensive crisis. Useddecreased in blood
Inhibits the reabsorptionto lowers down bloodpressure AEB blood
Brand Name: (Lasix) Date Performed: 25mg/tab BID of Na and Cl from thepressure AEB bloodpressure from 190/130
November 25, 2009 loop of henle and distalpressure of 190/130mmHg to 100/70 mmHg.
renal tubule. Increasesupon admission.
renal excretion of h2o,
Date Shifted: Na, Cl, Mg, H2, and Ca.
November 27, 2009 to
Aldazide
104
BEFORE:
• Assess signs of metabolic acidosis.

• Assess signs of hypokalemia
• Assess rate, depth, rhythm of respiration
• Assess skin turgor and edema
• Note rashes, temperature elevation.
• Weight, and I & O to determine fluid loss.
• Check BP prior giving of medication
DURING:
• Give early in the day to prevent sleeplessness.

• Administer via SIVP
AFTER:
• Check BP of the patient

• Note for any side effects of the drug.
• Monitor the patient after taking the drug.
• Prepare the client in his comfortable position after giving the medication.
• Document or chart that the medicine was given.
General action
Mechanism of axn.
Generic Name: Date Ordered: 25 mg/tab ¼ tab q12 ACE inhibitor Patient has hypertensionThe patient manifested a
Captopril November 25, 2009 due to diabetes mellitusdecreased in BP from
for 5 years. Diabetes190/130 to 100/70
causes continued andmmHg.
105
Brand Name: Capoten consistently high blood
glucose levels. Because
of the viscosity of the
blood, the blood flow is
restricted, the blood
*Home Medication pressure increases. The
drug is given to promote
decrease in blood
pressure.
Nursing Responsibilities
BEFORE:
• Check the written medication order for completeness. It should include the drug name, dosage, frequency, and
duration of the therapy.
• Check to see if there are any special circumstances surrounding administration of the dose to the patient.
• Be certain that you know the expected action, safe dosage range, special instructions for administration and
adverse effects associated with drug orders.
• Prepare the necessary equipment.
• Wash your hands.
• Prepare the dosage as ordered.
• Check the label on the medications three times before administering any drug.
• Never prepare a dosage of medication, which is discolored, has precipitated, and is contaminated or outdated.
• Make sure that the patient has taken her meal before giving the medication.
DURING:
• Identify the patient expresses any doubt about the medication; always recheck the order, drug label and dosage on
the container.
AFTER:
106
• Following administration, be certain that the patient is comfortable, then immediately record the procedure.
• Note for any allergic reactions.
General action
Mechanism of axn.
Generic Name: Date Ordered: 40 mg IV shifted toProton Pump InhibitorThe patient vomited Patient was relieved from
Pantoprazole November 25, 2009 40mg Drug twice on the 26th of heartburn.
1 tab OD November causing
Brand Name: Pantoloc Date Shifted: heartburn to the patient.
November 26, 2009 To treat heartburn felt by
patient this drug was
Date Discontinued: given.
December 30, 2009
BEFORE:
107
DURING:
the container.
AFTER:
General action
Mechanism of axn.
Generic Name: Date Ordered: 4 mg IV now then 2mgOpioid analgesic Patient has developed Patient was relieved from
Morphine Sulfate November 25, 2009 PRN chest pain due to the chest pain.
disease condition. Acute
Brand Name: Avinza, M- Last given: November Coronary Syndrome
Eslon 28, 2009 causes inadequate blood
flow and oxygen supply
Date Discontinued: to the myocardial cells of
Dember 02, 2009 the heart resulting to
chest pain. The drug is
given to the patient to
promote relief from chest
pain. Also, compared to
Meperidine, which is
commonly used, this
drug does not decrease
the oxygen consumption
of the patient. That is
why it is chosen to be
108
administered rather than
Meperidine.
BEFORE:
DURING:
the container.
AFTER:
General action
Mechanism of axn.
109
Generic Name: Date Ordered: D5W 90 cc + isoketAnti-angina As patient was admittedPatient was relieved from
Isosorbide Dinitrate November 25, 2009 10g/soluset to the hospital, he waschest pain.
@ 1.5mg/hr already experiencing
Brand Name: Date Performed: chest pain. This drug
Isoket drip November 25, 2009 was given in order to
treat chest pain felt by
Date consumed: 11-26- the patient.
09
Isordil Date Performed: SL

November 27, 2009
Date Discontinued:
November 28, 2009
Nursing responsibilities:
BEFORE:
• Check and confirm the order (Dosage, frequency and route)

• Check and recheck the drug indication and computation
• Check patient’s identity
• Explain the importance of strict compliance to medical regimen.
DURING:
• Give oral preparations on an empty stomach, 1 h before or 2 h after meals; take with meals if severe, uncontrolled
headache occurs.
• Give sublingual preparations under the tongue or in the buccal pouch; encourage the patient not to swallow.
• Give chewable tablets slowly, only 5 mg initially because severe hypotension can occur; ensure that patient does
not chew or crush sustained-release preparations.
110
AFTER:
• Maintain life support equipment on standby if overdose occurs or cardiac condition worsens.
• Gradually reduce dose if anginal treatment is being terminated; rapid discontinuation can lead to problems of
withdrawal.
General action
Mechanism of axn.
Generic Name: Date Ordered: 0.4 cc SQ now then qAntithrombotic Patient is at risk toPatient did not develop
Enoxaparin sodium November 25, 2009 12 develop thrombusformation of thrombus.
because of plaque
Brand Name: Clexane Date Discontinued: rupture due to CAD. With
November 29, 2009 this drug it helps in
preventing the formation
of clots and extension of
existing clots within the
blood.
BEFORE:
111
DURING:
the container.
AFTER:
General action
Mechanism of axn.
Generic Name:Date Ordered:10ml TID Antacid On the 26th of November, Patient was relieved from
Magnesium November 26, 2009 the patient vomited hyperacidity.
hydroxide/aluminum resulting to acid
hydroxide Date Discontinued: accumulation thus
November 27, 2009 causing hyperacidity
Brand Name: Maalox onto the patient. To treat
the hyperacidity this drug
was ordered.
112
BEFORE:
DURING:
the container.
AFTER:
113
generic name Date taken/given Dosage & Functional Purpose(s) the medications with
Brand name Date changed/ D/C frequency of admin. Classification actual side effects
Mechanism of axn.
Generic Name Date Order: 50 mg/tab ½ tab BID Beta Adrenergic The patient when The patient’s blood
Metoprolol November -25-09 Blocking Agent admitted had a blood pressure decreased
pressure of 190/30, to from 190/30 to 120/70.
Brand Name Date Change: decrease the blood
Lopressor November -25-09 pressure Metoprolol
was administered.
BEFORE:
• Check the doctor’s order

• Check the drug labels, contents and appearance.
• Check the right dosage, route, and time of administration.
• Explain to the patient what the purpose of the drug.
• Monitor BP and pulse before therapy, during dose titration, and periodically during therapy
• Monitor intake and output ratios and daily weight.
• Instruct to take food before taking the drugs.
DURING:
• Explain the effects of the medication to the patient and SO .

• Instruct to avoid activities that require mental alertness.
• Report for symptoms of fluid overload such as sudden weight loss, SOB and swelling of extremities.
• Avoid activities that require mental alertness.
114
AFTER:
• Monitor for the patient’s reaction to the drug.

• Document the procedure in the patient’s chart.
• Observe proper storage of drug.
• Monitor Vital Sign
Mechanism of axn.
Generic Name: Date Order: 30cc PO OD Stool softener Patient is at risk to The patient
Lactulose November -25-09 develop constipation responded well as
Frequency: HS due to prolong evidenced by passage
Brand Name: Date Change: ( hour of Sleep) immobilization. This of stool.
Lilac November -25-09 drug is indicated to
the patient to prevent
constipation and to be
able to passage stool
BEFORE:
• Check the Doctor’s order before giving the medication.

• Observe the ten (10) rights in giving a medication.
• Explain the procedure and purpose of giving the medication.
• Assess for galactosemia, intestinal obstruction.
DURING:
115
• Be alert for drug’s adverse reactions and drug interactions.
• Monitor vital signs especially blood pressure.
• Tell patient the possible side effects that may occur.
• Be alert for side effects such as diarrhea, vomiting and hypokalemia
AFTER:
• Watch out for dependent.

• Document the dosage, route and frequency of the drug to the patient’s chart.
General action
Name of Drugs, Date ordered Route of Admin., Clients response to
generic name Date taken/given Dosage & frequency the medications with
Mechanism of axn.
Generic Name: Date Order: 75mg/tab OD Anti-coagulant Patient is at risk to The patient did not
Clopidogrel November -25-09 develop formation of develop clot
clot due to due to the formation.
Brand Name: Date Started: plaque rupture. And
Plavix November -26-09 so this drug is ordered
to prevent the
unwanted blood clot
formation.
*Home Medication
BEFORE:

• Explain to the client what the purpose of the drug
116
DURING:

• Administer the drug before meals
AFTER:

General action
Mechanism of axn.
Generic Name: Aspirin Date Order: 80 mg/tab OD Analgesic As patient was admitted,Patient was relieved from
November -26-09 he was evidently havingchest pain.
Brand Name: Aspirin chest pain, Aspirin was
Date Change: immediately given in
November -26-09 order to relieve pain.
BEFORE:
117
DURING:
the container.
AFTER:
General action
Mechanism of axn.
Generic Name:Date Order: 60 mg/tab ½ tab OD Nitrates Patient was known to Patient did not manifest
Isosorbide mononitrate November -26-09 experience angina from angina attacks.
the day he was admitted.
Brand Name: Imdur Date Change: Imdur was administered
November -26-09 to the patient. It is a drug
used principally in the
treatment of angina
pectoris. By dilating the
vessels, it lowers the
blood pressure therefore,
leads to a reduction of
*Home Medication myocardial oxygen
requirement thus
promoting relief from
angina pectoris.
118
BEFORE:
DURING:
the container.
AFTER:
119
Mechanism of axn.
Mixtard Date Order: Sliding Scale Treatment for Upon checking the The patient’s
November -26-09 diabetes mellitus. initial HGT level the responded to drug
20 “u” SC am patient glucose level AEB decrease in
> anti-diabetics is high the result is blood glucose level of
10 “u” SC pm 131mg/dl, this would 71mg/dl as of 11-27-
indicate that the 09
patient have diabetes
mellitus. Mixtard was
given to the patient to
Home Dosage decrease the blood
*Home Medication glucose level.
22 “u” Sc am
12”u” pm
BEFORE:

• Check the drug labels, contents and appearance.
• Check the right dosage, route, and time of administration.
• Explain to the patient what the purpose of the drug.
• Assess patient for signs and symptoms of hypoglycemia and hyperglycemia.
• Monitor blood glucose and ketones every 6 hrs every therapy.
DURING:
120
• Give the mediation to patient once a day for her strength and strong body tissue.
• Use only insulin syringes to draw up dose.
• When mixing insulin draw regular insulin into syringe first to avoid contamination of regular insulin vial.
AFTER:
• Monitor for the patient’s reaction to the drug.

• Document the procedure in the patient’s chart.
• Observe proper storage of drug.
• Insulin should be stored in a cool place but does not need to be refrigerated.
General action
Mechanism of axn.
Generic Name:Date Order: 35 mg/tab BID By preserving the energyTreatment of long termThe client’s chest pain
Trimetazidine November -26-09 metabolism in cellscoronal insufficiency:was relieved.
exposed to hypoxia,angina pectoris. To
Brand Name: VastarelDate Started: trimetazidine prevents adecrease the frequency
MR November -26-09 decrease in intracellularof angina attacks.
ATP levels, thereby
ensuring the proper
functioning of ionic
pumps and
transmembranous
sodium-potassium flow
whilst maintaining
cellular homeostasis.
*Home Medication
121
BEFORE:

• Check the drug label, contents and appearance.
• Obtain information about the drug before giving it.
DURING:

• Prepare the client and explain the procedure.
• Explain the purpose of the medication.
AFTER:

122
General action
Mechanism of axn.
Generic Name:Date Order: 15 mg 1 tab OD, HS Anxiolytic Indicated for the patientThe client responded
Bromazepam November -26-09 to relieve the patient’swell AEB the patient fell
In low dosage,anxiety which mayasleep an hour and there
Brand Name: Lexotan Date Started: selectively reducesaggravate the patient’sis no episode of vomiting
November -26-09 tension and anxiety. Incondition. after administration.
high dosage, sedative
and muscle relaxant
Date Change: properties appear.
November -27-09
BEFORE:

• Check the drug label, contents and appearance.
• Obtain information about the drug before giving it.
DURING:

• Prepare the client and explain the procedure.
• Explain the purpose of the medication.
AFTER:
123
• Document or chart that the medicine was given
General action
Mechanism of axn.
Generic Name:Date Order: 80 mg/tab OD, HS Antilipemic Adjunct to dietaryThe patient’s cholesterol
Simvastatin November -26-09 therapy in thelevel remains normal
20 mg/tab OD, HS Inhibitor of 3-hydroxy-3management of primaryand blood pressure
Brand Name: zocor Shifted to Atorvastatin: methylglutarylcoenzyme hypercholesterolemia decreases from 190/130
November -26-09 Areductase, similarand mixed dyslipidemias. to 100/70 mmHg. It was
actions to lovastatin but shifted to Atorvastatin
more potent HMGCoA decrease the side effect
reductase inhibitor of the drug such a upper
increase HDL cholesterol respiratory infection.
and decrease LDL
cholesterol synthesis.
BEFORE:

• Check the drug label, contents, and appearance
• Check the right dosage, route and time of administration
• Explain the purpose of the medication to the client
DURING:
• Avoid large amounts of grapefruit juice during therapy; may increase risk of toxicity
• Witness the intake for oral medications.
124
AFTER:

General action
Mechanism of axn.
Generic Name:Date Order: 20 mg/tab OD, HS It competitively inhibitsTo lowers downThe patient cholesterol
Atorvastatin November-26-09 HMG-CoA reductase, thecholesterol in the body. Itlevel remains normal.
enzyme that catalysesstabilizes plaques and
Brand Name: Date Started: the conversion of HMG-prevents stroke.
Lipitor November-26-09 CoA to mevalonic acid.
This results in the
induction of the LDL
receptors, leading to
lowered LDL-cholesterol
concentration.
*Home Medication
BEFORE:
125
• Check the drug label, contents, and appearance
• Check the right dosage, route and time of administration
• Explain the purpose of the medication to the client
DURING:
• Avoid large amounts of grapefruit juice during therapy; may increase risk of toxicity
• Witness the intake for oral medications.
AFTER:

Mechanism of axn.
Generic Name: Date Order: 25mg/tab BID potassium-sparing The patient was given The patient
Spironolactone November -27-09 diuretic aldazide to treat fluid responded on the
retention AEB mild drug as evidenced by
Brand Name: Date Change: pulmonary congestion a decreased sign and
Aldazide December -01-09 seen on chest x-ray. It symptoms of
was also given to pulmonary edema
maintain the AEB diminished
potassium level, to adventitious breath
counter act the sounds.
potassium wasting
effect of the other
diuretics the patient is
126
taking.
BEFORE:

• Assess fluid status.
• Check blood pressure.
• Explain to the client what the purpose of the drug.
DURING:

• Check the patency of the IV site.
AFTER:

• Assess for daily weight, intake and output ratios, amount and location of edema, skin turgor.
• Observe for any discomfort at the IV site.

127
c) Activity
Date Ordered
Indication(s) or Client's response and/or
Type of Activity Date started General Description
Purpose(s) reaction to the activity
Date changed/ D/C
CBR without BRP Date Order: Patient is remained atThe patient instructed toThe patient complied with the
November -25-09 rest with a total activityhave CBR without BRP toordered activity and remained
restriction to preventprevent further increase inon the bed.
Date Change: further increase in thecardiac workload.
November -28-09 cardiac workload.
Patient was instructed to

May walk on Corridor Date Order: Patient is encouraged tostart activities specificallyThe patient was able to tolerate
November -28-09 do activities to gain thewalking to promoteslight walking since he feels
normal function of thecirculation and exercise thetired easily.
Date Started: heart again. cardiac muscle.
November -29-09
BEFORE:

• Explain the purpose of the activity restriction.
DURING:
• Stay with the patient, monitor client

AFTER:
• Record patient’s response to activity.
128
d) Diet
Date Ordered
Indication(s) or Client's response and/or
Type of Diet Date started General Description Specific foods taken
Purpose(s) reaction to the diet
Date changed
Low fat Date Order: This diet reduces the concentrations ofThis was ordered toFruits, vegetables andPatient started to exhibit
11-25-09 serum lipids, especially the cholesterolthe client since she isfish, unsaturated andstabilizing blood pressure
concentrations. Decreasing dietaryhypertensive. Infatty foods are highlyand tolerated the diet.
Date Started: saturated fatty acids, increasing theaddition, to preventrestricted.
11-25-09 proportion of polyunsaturated areatherosclerosis.
believed to retard the development of
atherosclerosis.
Fruits, vegetables, fish
Low salt This diet decreases or prevent havingIt was ordered sinceand flakes, foods withPatient started to exhibit
blood pressure the patient ishigh content of Na arestabilizing blood pressure
hypertensive. highly restricted. and tolerated the diet.
Before:
• Explain the purpose and importance of the diet and what specific foods are allowed for the patient.
• Explain also the appropriate foods not to be taken.
During:
• Assist the patient when eating

• As much as possible promote independence
129
After:
• Monitor the reaction of the patient.
130

"Acute Coronary Syndrome Non ST Elevation Myocardial Infarction, Hypertensive Cardiovascular Disease, Diabetes Mellitus Type 2, and Community Acquired Pneumonia" Med MNGT

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IV.

PATIENT AND HIS CARE

a) IVF, Condom Catheter, Oxygen Therapy

• Verify prescriptions for IV therapy

• Document date and time therapy initiated

• Check the doctor's order.

• Check the IVF level.

• Regulate the IVF as ordered.

• Check the doctor's order.

• Monitor the response of the patient.

• Check the doctor's order.

• Check whether the O2 flow rate is within the desired level.

• Regulate O2 flow rate as ordered

• Check the doctor’s order.

• Observe proper medical asepsis.

• Monitor the client’s reaction to the drug.

• Check the doctor’s order.

• Observe proper medical asepsis.

• Monitor the client’s reaction to the drug.

• Assess signs of metabolic acidosis.

• Give early in the day to prevent sleeplessness.

• Check BP of the patient

Isordil Date Performed: SL

• Check and confirm the order (Dosage, frequency and route)

• Check the doctor’s order

• Explain the effects of the medication to the patient and SO .

• Monitor for the patient’s reaction to the drug.

• Check the Doctor’s order before giving the medication.

• Watch out for dependent.

• Check the doctor’s order.

• Observe proper medical asepsis.

• Monitor the client’s reaction to the drug.

• Check the doctor’s order

• Monitor for the patient’s reaction to the drug.

• Check the doctor’s order.

• Use aseptic technique.

• Note for any side effects of the drug.

• Check the doctor’s order.

• Use aseptic technique.

• Check the doctor’s order

• Note for any side effects of the drug.

• Check the doctor’s order

• Note for any side effects of the drug.

• Check the doctor’s order.

• Observe proper medical asepsis.

• Monitor the client’s reaction to the drug.

• Monitor the client’s reaction to the drug.

Patient was instructed to

• Check the doctor's order.

• Stay with the patient, monitor client

• Record patient’s response to activity.

• Assist the patient when eating

• Monitor the reaction of the patient.

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