part 10 discharge plan- appendices

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XI. Discharge Plan

Medication

• Discuss all take home medications to the primary caregiver such

as the brand, generic name dosages , frequency and as well as

the action of the drug.

Tramadol 50mg 1cap PO q6

FeSO4 I tabPO OD

Paracetamol 500mg PO PRN

Multi Vitamins 1tab PO OD

• Encourage and instruct the patient to comply with the full course

of medication prescribed by the regimen.

• Inform the primary caregiver of the side effects of the

medications and teach significant others on how to watch for

those side effects

• Encourage to take drugs with food if not contraindicated or take

them one hour or two hours after meal.

• Inform family about food and other medications that cause

interactions with the drugs the patient is currently taking.

• Instruct the primary caregivers not to stop the medications

abruptly or even adjust the dosage without consulting the

physician.

140



Exercise

• Maintain a good and safe environment.

• Encourage enough rest for the client right after discharge.

• Instruct significant others/primary care giver to not let the client

engage self into strenuous activities.

• Encourage doing simple and non-strenuous range of motion

exercises such as walking and stretching.

• Instruct primary caregiver to assist patient in doing passive ROM.

• Instruct primary care giver to let the patient gradually increase

acrivities.

• Ambulation if tolerated also is encouraged.

• Increase intensity, duration and frequency of exercise every

week to gain more strength

• Encourage SO to provide appropriate amount of rest to the client

• Advise patient not to engage in strenuous activities

Treatment

• Instruct patient to always maintain good hygiene

• Instruct patient on proper wound dressing

• Encourage client to increase intake of fluid at least 2500ml a day

141



• Encourage the primary caregiver to provide comfort to the

patient

• Instruct client to have adequate rest

• Explain the importance of following the complete therapeutic

regimen prescribed by the Physician.

• Explain also the purpose of continuing the treatment even after

discharge.

• Teach the primary caregiver necessary procedures in caring for

the client.

Health Teaching

• Instruct patient to avoid doing strenuous activities

• Encourage client to comply medications

• Teach client the importance of proper lifestyle

• Teach patient and primary caregiver regarding the importance of

developing good coping skills and emotional support

• Teach client to decrease intake of fibers

• Encourage the family of the client to maintain proper sanitation.

•

Encourage the family of the client to bath the client everyday.

• Instruct the significant others to groom the client properly.

• Instruct the significant others of the client to keep the client’s

back dry.

142



Out - patient: Follow up Visit

• Remind patient to commit with the scheduled follow-up check up

with client’s physician

• Stress out the importance of seeking immediate consultation if

any signs of abnormalities

• Encourage primary caregiver to make sure that the patient has a

safe place to live after discharge

• Stress out to the primary caregivers to seek immediate

consultation if adverse reactions of drugs occur.

• Encourage primary caregivers to carry out follow up diagnostic

regimen.

• Inform primary caregivers to report any signs of abnormalities

such as sudden increase of blood pressure, respiratory rate,

pulse rate, and contractures as soon as possible.

Diet

• Encourage increase intake of oral fluid intake

• Advise patient not to skip his meals and eat a regular intervals

• Instruct patient not to eat the foods that are contraindicated to

patient

143



• Encourage primary caregiver to provide food for the patient that

has the essential vitamins and minerals so as to boost the

patient’s immune system

• Encourage family members to prepare and have the client eat

foods rich in protein, calorie, vitamin C, iron, carbohydrates and

high in fiber.

• Maintain a well-balanced diet.

• Advise significant others on how to properly handle and prepare

food so as to prevent contamination.

Spirituality

• Instruct patient to continue having faith to God and to continue

praying

• Encourage patient to attend mass every Sunday

• Encourage to verbalized thoughts to the family to provide

support

• Encourage to have faith to the Superior and perform rituals

according to ones religion and belief.

• Encourage to go to church regularly and participate on the

activities of the church.

144



X. Prognosis

Good Fair Poor

/ A. Response of the patient regarding the presence

of the pain after its management

/ B. Physiologic response of the body to disease

process/ C. Relief of symptoms associated with the disease

condition/ D. Performance of the daily living of the patient

during confinement (e.g. eating, toileting, dressing,

etc.)/ E. Compliance of the patient to the medication and/

or therapy/ F. Adequacy of rest periods and sleep

/ G. Consumption of the patient with nutrition

/ H. Patient’s significant others’ behavior regarding

the health teaching given by the health caregiver

and the physician/ I. Attitude

/ J. Duration of Illness

/ K. Precipitating Factor

/ L. Nature of Problems

/ M. Predisposing Factors

/ N. Family Support

/ O. Level of Consciousness

CALCULATIONS:

Formula: amount # of (good/fair/poor) x 100 = % (Percentile)

15

Amount of Percentile

Good = 4 26.67%

Fair = 5 33.33%

Poor = 6 40.00%

145



INTERPRETATION:

The patient is more likely to have a poor prognosis because of the

severity and the nature of her disease. Immediate management was not

done to the client which led to the metastasis of cancer cells to surrounding

tissues. Another factor that contributed to the poor prognosis is physiologic

response of his body to the medical and surgical treatments which is poor

due to the quick growth of cancer cells and which eventually contributed to

the long duration of hospital stay of the client. The client has also a strong

genetic predisposition from his relatives. The client is also engaged to

smoking and drinking alcohol. Thus, a strong precipitating factors.

The patient has a greater chance of living if proper management of the

condition is compensated and if cancer cells did not metastasize, with

religious compliance to the chemotherapy, adequate nutrition and

environment is fully achieved. These would include the consistency in the

chemotherapy, avoidance of exposure to stress, and continuous monitoring

of metastasis and laboratory results including the significant factors affecting

the condition of the patient’s condition.

The table above shows the good effects and bad effects that can be

manifested by the patient during and after the treatments and interventions

being rendered.

XI. Conclusion

146



The group has concluded that the client, with the significant others’

participation and help in giving nursing care and also with strict compliance

to the plan of care, has a poor chance of improved condition.

The health care teams including the nurses and attending physician,

were able to render appropriate care to the patient and provide health

education such as proper nutrition, healthy lifestyle, and most especially

strict medication compliance and adherence to nursing management but still

the client manifested poor physiologic response to the management. Being a

health care advocate, provider and a front-liner of taking care of patient’s

condition, emphasis on client’s education is stressed.

The client's part in strict adherence to treatment and vigilance in

promoting optimum health such as avoiding tobacco smoking and alcohol

drinking will most probably help improve patient’s condition. Significant

others' support also is needed to promote client’s emotional well-being.

As for the student nurse assigned to the patient, knowing the case

including its risk factors and interventions is more important in order to

impart proper education and able to provide proper care needed for the

promotion of client’s health and wellness. This case study also paved a way

to nurture and foster the group’s learning and thus promote critical thinking

skills.

XII. Recommendations

147



We recommend this study to the incoming fourth year nursing

students of Xavier University Ateneo de Cagayan who will be assigned at the

Surgical Ward for their clinical exposure especially in catering oncology

concepts – which this may be a means for them to improve their skills,

knowledge, and attitude towards facilitating of excellent health care to their

patients.

We propose to have enough time for assessment and noting down

every significant finding day by day to really come up with exceedingly

applicable nursing diagnoses. Prioritize all the recognized nursing diagnoses

according to the intensity of need to be addressed and still giving

importance to the perceived problems of the patient himself. Hint properly

the disease process to attach all the cues, complications and possible

outcome and also to designate accurate drugs and interventions to be given.

We suggest further venture of critical thinking perseverance in order to

spot the problems and complications present in their preferred patient so

that they can supply necessary nursing interventions with the best quality of

care. Lastly, teamwork and agreement in the group is of great substance.

Concepts on leadership and management can be applied to facilitate proper

division of labor, collaboration, etc. Through this, they will able to finish all

the obligatory requirements for this case study.

148



XIII. Bibliography

American Cancer Society (2002).Cancer facts and figures 2002.

Atlanta:

American Cancer Society.

American Pain Society. (1999). Principles of analgesic use in the

treatment

of acute pain and chronic cancer pain: A concise guide to

medical practice (4th ed.). Skokie, IL: American Pain Society.

Barraclough, J. (1999). Cancer and emotion: A practical guide to

Psychooncology. Philadelphia: J. B. Lippincott.

Boik, J. (1995). Cancer and natural medicine: A textbook of basic

science

and clinical research. Princeton, MN: Oregon Medical Press.

Broder, S. (1991). Molecular Foundations of Oncology. Williams and

Wilkins:

Baltimore, Maryland, USA. p. 393-400.

149



DeVita, V. T., Hellman, S., & Rosenberg, S. A. (Eds.). (1995). Biologic

therapy of cancer (2nd ed.). Philadelphia: J. B. Lippincott.

Green, F., et al. (2002). AJCC cancer staging manual (6th ed.). New

York: Springer-Verlag.

Groenwald, S., Hansen-Frogge, M., Goodman, M., & Henke Yarbro,

C. (Eds.). (1998). Comprehensive cancer nursing review (4th

ed.).

Boston: Jones and Bartlett.

Heath, C. W., &Fontham, E. (2001).Cancer etiology. In: Clinical

oncology.

Atlanta: American Cancer Society.

Huber, E. B., &Magrath, I. (Eds.) (1998). Gene therapy in treatment of

cancer: Progress and prospects. New York: Cambridge University

Press.

Lenhard, R. E., Osteen, R. T., &Gansler, T. (Eds.).(2001). Clinical

oncology.

Atlanta: American Cancer Society.

150



Kumar, V., Cotran, R., Robbins, S. (1997). Basic Pathology. 6 th ed. W.B.

Saunders Company: Philadelphia.

Lever, W. and Lever, G. (1990). Histopathology of the Skin. 7th ed.

Lippincott Company: Philadelphia. p.676-679.

Loeser, J. D. (Ed.) (2001). Bonica’s management of pain (3d ed.).

Philadelphia: Lippincott Williams & Wilkins.

Miaskowski, C. (1997). Oncology nursing: An essential guide for patient

care. Philadelphia: W. B. Saunders.

Nouri, K. (2008). Skin Cancer. McGrawHill Companies, Inc.: China. p.

205-

206.

Pazadur, R., Coia, L. R., Hoskins, W. J., &Wagman, L. D. (Eds.).

(2001). Cancer management: A multidisciplinary approach.

Melville, NY: PRR, Inc.

Porth, C. Pathophysiology: Concepts of Altered Health States. 7th ed.

151



Lippincott Williams and Wilkins: Philadelphia.

Smith, R. A., et al. (2001). American Cancer Society guidelines for the

early detection of cancer: Cancer Journal forClinicians, 51(1), 38–

76.

Smeltzer, S., Bare, B. et al. (2010). Brunner and Suddarth’s Textbook of

Medical-Surgical Nursing. 12th ed. Lippincott Williams and Wilkins:

Philadelphia.

152



XIV. Appendices

A. Doctor’s Order

Date Progress Notes Doctors Order7/1/11 Wt=55kg -pls admit pt. to male

surgical ward under the

service of Dr. S-secure consent to care-TPR & BP q4°-start venoclysis with

PNSS 1L @ 30gtts/min

-high protein diet-attach labs (available)

to charts-start Cloxacillin 500mg

IVTT ( ) ANST q6°-multivitamins 1 tab OD-ferrous sulphate 1 tab

OD-dressing BID with

Daikins solution-refer accordinglyDr. P.

7/1/11 8PM -for CBC,pH count, NA+

& K determination-CT-BT, albumin, FBS-ECG 12 leads pls-CXR-PA viewDr. P.

7/2/11 6.0mg/dl -pls prepare 4 units of

PRBC18.0mg/dl -transfuse after cross

matching-txt order Dr. P.-for daily dressing with

betadine OD-ERROR

153



Dr. P.7/3/11 -for below elbow

amputation-secure consent-refer to Dietary for

nutrition supportDr. U.

7/4/11 -IVF TF: D5LR 1L @

30gtts/minD5NSS 1L @

30gtts/minD5LR 1L @ 30

gtts/min

PNSS 1L @30gtts/min x 3 cyclesDr. U.-3PM diphenhydramine

1g IV nowDr. U.

7/5/11 -for below elbow

amputation once cp

cleared

-IVF TF: PNSS 1L @

30gtts/minPNSS 1l @

30gtts/minPNSS 1L @ 30

gtts/minDr. U.

7/7/11 -pls transfuse PFRB 2L

unit after cross

matchingDr. U.

7/8/11 -for schedule of surgery

on TuesdayHgb= 8.6 - for BT 2 units of

available blood after

154



proper screening &

crossmatchingDr. P.

7/9/11 Pre BT temp 37.8 -pls give paracetamol

500mg P.O. prior to BTDr. G.

7/10/11 Painful bladder upon

urination

-for UA on Monday

Dr. G.7/10/11 -pls change dressing

-refer to SROD-pls change IV site,

tubings-gentamycin 80 mg IVTT

ANST q8°-for CBC, Crea, NA,& K

in AMDr. A.

7/10/11 -reschedule for below

elbow amputation

tomorrow-pls prepare PRBC 3

units of pts blood type &

transfuse 2 units prior to

operation-secure consentDr. A.

7/10/11 -NPO PMN-full course body

hygiene-Vit. K 10g IVTT q 8°

-for protime-prepare blood as

orderedDr. A.

7/11/11 (+) H/o DM x 4yrs -pls refer to another

anaesthesiologist Ty-opt FBS and RBS, Crea

155



Dr.A.-refer protime-Postpone surgeryDr. G.

7/12/11 -for below elbow

amputation-NPODr. G.-pls prepare 4 units FWB

of pt’s type &

crossmatched pls-pls prepare 2 units

fresh frozen plasma-once blood is available

transfuse 1 unit before

ORDr. P.

POSTOP6:15 PM -o2 inhalation 3L/min

until fully awake-vital signs q15 min until

stable-DAT once fully awake-IVF @ 20gtts/min;

follow-up 1 D5LR 1L @

same rate-continue gentamycin &

cloxacillin-tramadol 50mgs IVTT-

stat dose only-tramadol 50mgs P.O.

q6°,-6hrs after IV doseDr. U.

7/14/11 -cont meds-pls remove foley

catheterDr.G.

Hgb=2.6mg/dl -pls transfuse FWB 3

156



units (settled)-rpt CBC after BTDr. P.

7/15/11 -for dressing todayDr.G.

7/16/11 (+)SOB -D/c cloxacillin-cefuroxime 700mg IV

q8°-dressing & draining

today-for rpt CBCDr.G.

157



B. Nurse’s Notes

07/01/11

11-7

07/02/11

7-3

3-11

11-7

>Received on bed with IVF of D5LR @ 30 gtts/min

>v/s taken and recorded

>with mass @ anterior forearm-noted

>foul-smelling

>dressing done

>due meds given

>adequate bed rest

>cared for

>needs attended

>endorsed

>Received on bed with ongoing IVF of PNSS 1L @ 30 gtts/min


>due meds given

>adequate rest provided

>needs attended

>endorsed

>Received awake on bed with PNSS @30 gtts/min

>v/s taken & recorded

>due meds given

>needs attended

>kept comfortable

>endorsed

>Received asleep lying on bed with IVF of PNSS, regulated @

30 gtts/min

158



07/03/11

7-3

3-11

11-7

07/04/11

>With mass @ left forearm; secured with bandage


>due meds given

>provided with adequate rest

>cared for

>endorsed

>received awake on bed with PNSS 1L @ 30 gtts/min


>due meds given

>still for OR once CP cleared

>needs attended

>endorsed

>received awake on bed IVF of D5LR 1L @30 gtts/min

>with dressing @ left forearm-foul smelling

>due medications given

>needs attended


>endorsed

> received awake on bed with IVF of D5LR 1L regulated @ 30

gtts/min

>with mass @ left forearm



>febrile- TSB encouraged

>comfort and safety measures

>Cared for

>Endorsed

159



7-3

3-11

11-7

>Received awake lying on bed with ongoing IVF of PNSS 1L @

600 cc level regulated at 30 gtts/min @ right hand

>dry sclera noted

>Pale nail beds, with mass @ left forearm

>Morning care done such as fixing bed and bedside table

>Adequate rest provided

>9:00 AM : wound dressing done aseptically

>High protein and low calorie: served and consumed half of

share of meal with poor appetite

>9:50 AM: blood transfusion started with “1” unit fresh whole

blood type “B+” with serial # 272434 regulated @ 20 gtts/min

>11:15 AM: chills noted

>Febrile : T= 38.3

>Tepid sponge bath done

>Above blood transfusion discontinue

>1:00 PM: temperature rechecked 40.3

>1:30 PM: referred to ROD with orders of diphenhydramine 1

amp given

>Watcher reinstructed to continue doing tepid sponge bath

>Kept watch for any unusualities

>Endorsed with latest v/s of T= 39 C, P= 92, R=20, BP=170/60

>Received awake on bed with ongoing PNSS @ 30gtts/min

> v/s taken and recorded


>watchful for abnormalities

>endorsed

>Received awake on bed with D5LR @20gtts/min

160



07/05/11

7-3

3-11

3:15

High protein

diet

>afebrile


>due meds given

>needs attended

>kept comfortable

> endorsed

>Received on bed with ongoing IVF of PNSS 1L @ 30 gtts/min


>due meds given


>needs attended

>endorsed

>Received awake, sitting on a chair with ongoing IVF PNSS @

200cc level regulated @

30gtts/min infusing well on right hand

>Conscious and coherent

>Pail nail beds noted

>Pale and dry lips noted

>With tender movable whitish gangrenous mass with foul

odor @ left forearm

>Initial v/s taken and recorded as follows: T= 36.4C P=

82bpm, R= 18cpm, Bp=120/70mmHg

>above IVF consumed and followed up with PNSS IL regulated

@ some rate infusing well @

right hand

>Afternoon care done such as tucking in of bed linens

>Encourage to increase fluid intake within cardial tolerance

>Wound dressing done aseptically @ left forearm

>Served and consumed full share with good appetite

161



1:45

1:50

11-7

07/06/11

7-3

High protein

diet

9:15

>Health teachings given to SO with emphasis on:

• Medication compliance to promote early recovery

• Instruct patient to immobilize the left arm

•

Encourage intake of iron rich food such as greenleafy vegetables

>febrile; T=38.0

>TSB done

> above blood transfusion consumed and followed up c PNSS

1L @ 200 cc level

regulated @ 30 gtts/min

Kept watch for any unusualities

Endorsed with latest v/s of : T-37.3 C, P-85, R-20, BP- 110/60

>Received with PNSS IL @ 30gtts/min


>due meds given

>rest provided

>cared for

>endorsed

>received awake, sitting on bed with ongoing IVF of PNSS IL

@ 850cc level , regulated @ 30gtts/min, infusing well on left

forearm

>with mass @ left forearm, gangrenous, foul odor with pus>generalized body weakness noted

>initial v/s taken and recorded as follows: T=37.6 C, P=

90bpm, R=20cpm, Bp=120/70mmHg

>served and consumed whole share with good appetite

162



3-11

11-7

07/07/11

7-3

3-11

>bedside care done such as changing of linens

>seen and examined by Dr. XY

>Health teachings imparted with emphasis on

1. Strict compliance to medication regimen

2. Proper diet – increase in protein and caloric intake

3. Aseptic wound dressing

>Endorsed with latest v/s T= 37.2C, P= 79bpm, R= 20cpm,

Bp= 100/70mmHg

received on bed with IVF of PNSS IL @

30gtts/min-infusing well

>with mass @ left forearm, with foul odor –

noted


>due meds given

>Cared for

>endorsed

>Received asleep on bed with ongoing IVF of PNSS IL @

30gtts/min

>With swelling and redness on left forearm with foul odor


>due meds given as ordered

>cared for

>needs attended

>endorsed

163



11-7

07/08/11

7-3

3-11

11-7

>received awake on bed with PNSS @ 30gtts/min

>with mass on left forearm


>due meds given

>needs attended

>endorsed

>received awake on bed with IVF of PNSS, regulated @

30gtts/min


>due meds given

>kept watched for abnormalities

>cared for

>endorsed

>received asleep on bed with PNSS IL @ 30gtts/min


>due meds given

>needs attended

>cared for

>endorsed

>received awake on bed with PNSS @30gtts/min

>BT – started

>Afebrile


>due meds given

>needs attended

>endorsed

164



07/09/11

7-3

3-11

11-7

7/10/11

7-3


30gtts/min

>v/s taken and recoded

>due meds given

>cared for

>endorsed

>received asleep on bed with PNSS IL @ 30gtts/min


>due meds given

>needs attended

>cared for

>endorsed


30gtts/min


>due meds given

>cared for

>endorsed

>received with PNSS @ 30gtts/min


>due meds given

>rest provided

>cared for

>endorsed

>received asleep on bed with PNSS IL @ 30 gtts/min

165



3-11

11-7

7/11/11

7-3

8:30am


>due meds given


>needs attended

>endorsed

>Received on bed with ongoing HBT of RBC type BT S# 2010-

271400 @

@ 15-20gtts/min

>with wound dressing over right forearm-slightly soaked

> v/s taken and recorded T=37.1 C

> due meds given

> for below elbow amputation tomorrow – still for CP

evaluation tomorrow

> cared for

>NPO @ midnight-instructed

>endorsed

>received asleep on bed with PNSS @ 15-20 gtts/ min

>afebrile



> needs attended

>endorsed


>afebrile


166



9:30am

3-11

Soft diet

>due meds given

>needs attended

>kept comfortable

> endorsed

>Received awake, sitting on bedside chair with ongoing IVF

PNSS IL @ 200cc level

Regulated @ 30gtts/min infusing well @ right hand

>conscious and coherent

> pail lips and nail beds noted

> with mass @ left hand with soiled dressing, with foul odor

> initial v/s taken T =37.6C, P =78bpm, R= 21cpm, Bp=

120/80mmHg

>bedside care done- linens tucked

>wound dressing done aseptically

> seen and examined by Dr. xy

>above IVF consumed and followed up with PNSS IL regulated

@ 30gtts/min

>rest periods provided

>health teachings maintained and reinforced

> for below elbow amputation today

> CP cleared

> Surgery postponed

>BT started with 1 unit FWB as RBC type “B” RH(+) with

serial # 272237

regulated @ 20 gtts/min

>Kept watched for unusualities

> endorsed with latest v/s T=37.9C, P=95bpm, R=16cpm, Bp=

120/70mmHg

167



11-7

7/12/11

7-3

3-11

febrile

High protein

diet

>Received awake, sitting on bedside chair, with IVF of PNSS IL

@660cc level on

Right arm

>with ongoing 1U FWB 058RBC type “B” Rh(+) with serial#

272327a side drip on Y port

Regulated @ 20gtts/min


>with mass on left forearm covered with soiled dressing

>with initial v/s taken and recorded as follows T= 36.5C P=

86bpm, R= 19cpm Bp=

110/60mmHg

>afternoon care done like tucking in of linens

>rest period provided

>encouraged to verbalized discomfort

>maintained and instructed

>health teachings given with emphasis on

a. high-protein diet

b. high calorie diet

c. proper hygiene

d. ROM exercise

>endorsed to next shift with latest v/s T=36.5C, P= 89bpm,

R=20cpm, Bp= 110/70mmHg

>received awake on bed with ongoing PNSS regulated @

30gtts/min


> comfort provided

>watchful for unusualities

>endorsed

168



11-7

7/13/11

7-3

3-11

>received with PNSS @ 30gtts/min


> due meds given

> morning care given

>rest provided

>cared for

> endorsed

>received awake , sitting on bedside chair with ongoing IVF

of PNSS

IL @600cc level regulated @ 30gtts/min infusing well on

right arm


> with mass of left forearm covered with dressing –soiled

> with initial v/s taken and recorded as follow: T= 38.4C,

P=95bpm, R= 20cpm,

Bp=110/70mmHg

>tepid sponge bath done

> temperature rechecked after 30minutes 38.3C

>continues TSB done

>temperature rechecked after 30minutes 37.6C


> served and consumed whole share with good appetite

>health teaching given with emphasis on:

a. high calorie diet

b. high protein diet

c. ROM exercise

d. adequate fluid intake

e. proper hygiene

169



11-7

7/14/11

7-3

9am

10am

>endorsed with latest v/s of: T= 36.6C, P= 86bpm, R= 15cpm,

Bp= 120/60mmHg

>received awake on bed with IVF of PNSSIL @30gtts/min

> with mass on left forearm-soiled and foul smelling

> due medications given


>needs attended

> v/s taken and recorded

>endorsed

>received awake on bed with ongoing IVF of PNSS IL

@30gtts/min


>with foul smelling and slightly bleeding wound on left arm

>due medications given as ordered

> dressing done

>NPO started

>for below elbow ampuitation on call

>needs attended

> endorsed

>received awake on bed with ongoing IVF of PNSS IL

@30gtts/min


> due meds given

>afternoon care given

>rest provided

>cared for

> endorsed

170



3-11

11-7

7/15/11

7-3

9am

11am

3-11

>received asleep on bed with IVF of PNSS regulated @ 30

gtts/min

>S/P below elbow amputation with post operative site dressing

keptdry and intact


>due meds given

> provided adequate rest

>cared for

>endorsed

>receive awake, lying on bed with ongoing IVF of D5LR IL

@740cc level regulated @

20gtts/min –infusing well @ right arm

>with FBC attached to UROBAG draining a yellow colored

urine

> conscious and coherent

>dry and cracked lips

> with complaint of sharp , throbbing pain in the amputated

limb @ a level

Of 8 in a pain scale of 1 -10 with 10 being the most painful

>s/p below elbow amputation –postoperative site dressing

kept dry and intact

>pail nail beds

>initial v/s taken , T=36.2C, P= 82bpm, R=16cpm

>bedside care done such as changing of linens

> adequate rest provided

>amputated limb kept elevated

>seen and examined by Dr. XY with new orders carried out by

NOD

>folley bag catheter removed with 200cclevel of urine

>back kept dry

171



11-7

7/16/11

7-3

3-11

>served and consume half share with fair appetite

>health teachings imparted with emphasis on:

a. strict compliance to medication regimen

b. proper wound dressing and cleaning

c. high intake of protein to aid in healing process

>endorsed with latest v/s T=37.7C. P= 80bpm, R=17cpm, Bp=

110/60mmHg


>afebrile


>due meds given

>needs attended

>kept comfortable

> endorsed

>received awake on bed with ongoing PNSS @KVO

>afebrile

>due meds given

> blood transfusion done with s#272294


>kept watched for any unusualities

>endorsed

>received on bed with PNSS @ KVO


>started BT @ 15-20gtts/min

>febrile

>due meds given

>cared for

172



11-7

7/16/11

7-3

07/17/11

3-11

> endorsed

>received on bed with PNSS @KVO- changed IV to D5LR @

20gtts/min

>still for BT#3 (+) chills


>afebrile

>due meds given

>care for

>endorsed

>received awake on bed with ongoing D5LR @ 20gtts/min

>afebrile

>due meds given



>cared for

>endorsed

>received awake on bed with IVF D5LR IL @ 20gtts/min-

dislodge

>with post-operative dressing –soiled and with foul smell noted

and referred to SROD


> afebrile

>above IVF reinserted

>seen and examined by SROD with orders

>dressing changed by SROD

>instructed to elevate post-op stump @ all time

>needs attended

173

part 10 discharge plan- appendices

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