DISCHARGE PLAN

NURSING ORDERS

DISCHARGE INSTRUCTIONS  Advised Patient to continue taking medication and provided information on how the drug should be taken including route, dosage, and frequency. Provide health teaching about the side effects in signal of need for a drug, dose, or administration frequency.  Emphasized the importance of taking the medication as prescribed. Instructed the patient to consult health provider before taking OTC drugs.  Emphasized that antibiotics must be taken in the right time without prior prescription never stop taking the drug so that the bacteria may not restrain to anti-biotics.  Paracetamol should be taken every 4 hours when fever is present. However, cefuroxime must be taken 3x a day.  Maintained the optimum physical function through program of positioning, ROM exercise.  Provide health teaching to have simple exercise like walking and also encouraged the patient to ambulate and perform exercise 30 minutes to 1 hour daily for good body circulation and jogging to enhance capacity of the heart muscles.  Encouraged to avoid heavy work and have adequate rest.  Promoted understanding of the treatment regimen. Including the prescribed/ recommended medications, exercises and proper diet, well balanced and adequate fluid intake at least 1500- 2000 ml/day.  Encourage the client to put hot and cold compress alternately to her abdomen or its lower parts if she experienced abdominal pain to reduce risk of elevated blood pressure and dizziness.

RATIONALE

 To avoid drug toxicity and avail the desired effects of the drug.  To provide adequate information that may be necessary to the patient.

MEDICATION

 To avoid fatigue and regain normal strength.

EXERCISE

 To avoid complications

TREATMENT

NURSING ORDERS 

DISCHARGE INSTRUCTIONS

RATIONALE

Encouraged regular self-care activities such as nail trimming, oral care and daily bathing and changing clothes.

HYGIENE

 A general hygiene practice promotes healthy well be8ing and reduces the risk of acquiring bacteria/virus in the body.  To monitor conditions and to provide support and assist with problem solving if needed.

 Encouraged to have a regular check up to monitor condition to promote the continuity of care and be treated accordingly. OUT-PATIENT  Instructed to have post check up, return for any abdominal signs and complications, and follow doctor s order.  Encourage to eat foods that are high and rich in: - Vitamin C like green vegetables, citrus, fruits, and calamansi juice to help strengthen the immune system for fighting infections. - Iron like green leafy vegetables like malunggay to give RBC and transport O2 carbon dioxide.  Encourage and maintain proper intake of foods that are high and rich in:  Protein like eggs, milk, meat, fish and vegetables to facilitate building and repairing body tissues.  Encouraged to increase intake of fluid more than 8 glasses a day.  Encouraged the Client to have strong personal relationship with God and strengthen his spiritual growth, and pray for a fast recovery and complete healing.  Advised the patient do not forget to thank God for everything especially for the life he gave every day. Smile, God is in Control.

 To facilitate good healing.  To prevent anemia and promote normal blood formation.

DIET

 To increase emotional stability and immense faith in God.

SPIRITUAL

LABORATORY STUDY

DATE January 7, 2011 Color

LABORATORY EXAMINATIONS URINALYSIS

RESULT

NORMAL VALUES

INTERPRETATION Indicates that the urine color of the patient is concentrated and it can be altered by drugs or food s she is taking. There is a presence of bacteria, WBC or PUS in the urine. There is an increase presence of proteins, which signifies that the patient may have hypertension.

SIGNIFICANCE It is done to determine if there is a presence of infection or a damage kidney. It is done to determine if there is a presence of infection or inflammation in the kidneys. It is done to determine if the patient ids hypertensive or not. It is done to know if the patient has diabetes or not.

Light Yellow

Straw- Amber

Trans0parency

Hazy

None

Alb4umin

Trace

Not Present

Glucose pH Specific Gravity PUS Cells RBC

8.0 1.005 0-3/hpf 0-4/hpf

It is done to determine presence of blood in the urine caused by infection in the body. Not Present Not Present It is done to determine whether the bladder mucosa is shredding normally due to infection.

Squamous Epithelial Cells Bacteria

Rave Few

DATE

LABORATORY EXAMINATIONS CBC Exam Hemoglobin

RESULT

NORMAL VALUES

INTERPRETATION Hemoglobin count is within the normal range

January 1, 2011

113 grams/liter

135-18=0 grams/liter

SIGNIFICANCE To determine amount of blood carrying oxygen to tissues and find out the presence of hemorrhage.

Hematocrit

34 vol %

40-54 liter

The WBC is above the normal range. WBC 12.0 x 109 /L 5.0-10.0 x 109 /L

To determine occurrence of the infection and inflammation

Neutrophils

49%

50-70%

To determine variation in WBC s that may signifies infection or suppression of immune system or response.

Eosinophils

0.6

2-4% To determine the type of infection present in the body either bacterial or viral.

Lymphocytes

45

24-40%

Ultrasound
IMPRESSION: -Pneumoperitoneum is a possibility. Please suggest either an upright view of the abdomen to include the diaphragm (after 30 minutes of sitting) or a left lateral decubitus view with x-ray of the liver and the upper hepatic gutter(after 30 minutes of decubitus position) to confirm Pneumoperitoneum. - Free from abdominal fluids or contusions of the visualized organs were seen.