UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION

COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF NURSING
Salinas Drive, Lahug Cebu City

na

A Care of a 17-year-old Patient with

Cellulitis, Left Arm

Submitted by:

Jade Catherine N. Matuguinas

BSN - IV

Clinical Instructor:

Mr. Peter Arnold T. Tubayan, RN, MAN

 TABLE OF CONTENTS

i. Title Page i
ii. Table of Contents ii
A. Introduction 1
B. Patient's Profile 2
C. Patient History
a) History of Present Illness
3
b) Past Health History
3
c) Family Health History 3
d) Environmental History
3
D. Developmental Task 4
E. Pediatric Health Assessment 5
F. Physical Examination 21
G. Laboratory and Diagnostic Studies 29
H. Summary of Significant Findings 36
I. Anatomy and Physiology 38
J. Pathophysiology 41
K. Nursing Care Plan
NCP # 1 44
NCP # 2 57
NCP # 3 67
L. Discharge Plan 81
M. Health Teaching / Teaching Plan
HTP #1 84
HTP #2 89
HTP #3 93
N. Drug Study
DS # 1 98
DS # 2 101
DS # 3 103
DS # 4 107
O. Bibliography 110
P. Curriculum Vitae 112
 1

INTRODUCTION

Cellulitis is the most common infectious cause of limb swelling. Cellulitis can occur as a
single isolated event or a series of recurrent events. It is sometimes misdiagnosed as recurrent
thrombophlebitis or chronic venous insufficiency (Hinkle & Cheever, 2018).
Cellulitis occurs when an entry point through normal skin barriers allows bacteria to enter
and release their toxins in the subcutaneous tissues. The etiologic pathogen of cellulitis is
typically either Streptococcus species or Staphylococcus aureus (Horseman & Bowman, 2013).
The acute onset of swelling, localized redness, warmth, and pain is frequently associated
with systemic signs of fever, chills, and sweating. The redness may not be uniform and often
skips areas and eventually develops a pitting “orange peel” appearance. Regional lymph nodes
may also be tender and enlarged (Horseman & Bowman, 2013).
Mild cases of cellulitis can be treated on an outpatient basis with oral antibiotic therapy.
If the cellulitis is severe, the patient is treated with IV antibiotics. The key to preventing
recurrent episodes of cellulitis lies in adequate antibiotic therapy for the initial event and in
identifying the site of bacterial entry. Cracks and fissures that occur in the skin between the toes
must be examined as potential sites of bacterial entry. Other locations include drug use injection
sites, contusions, abrasions, ulceration, ingrown toenails, and hangnails (Hinkle & Cheever,
2018).
The incident rate of cellulitis is estimated to be 24.6 cases per 1000 person-years wherein
the incidence was higher in males and in those individuals aged 45-64 years (Herchline, 2022).
Another study found a 40%–50% prevalence rate of cellulitis among Asian patients (Park, 2016).
In the Philippines, he period prevalence of CA-MRSA among children with SSTI was 0.36
(PIDSP, 2016).
This case study aimed to discuss about cellulitis, including its risk factors, causes, signs
and symptoms, how it affects the patient and the significant others, and the corresponding
nursing diagnosis and interventions. Also, having this case study would be an excellent platform
for the student nurse to develop necessary assessment and critical thinking skills which would be
beneficial in caring for a patient with cellulitis.
 2

PATIENT’S PROFILE

Name: U.L.B

Age: 17 years old

Date of Birth: 11/18/05

Sex: Female

Status: Single

Address: Nivel Hills, Cebu City

Name of Hospital: Cebu City Medical Center

Date of Admission: 11/9/22

Case N: 132406

Ward and Bed No: Pediatric Ward – Bed 10A

Chief Complaint: Swelling on the Left Arm

Medical Diagnosis: Cellulitis, Left Arm

Physician: Dr. Jezer Nerj Berden Salo

 3

PERTINENT NURSING HEALTH HISTORY & PHYSICAL ASSESSMENT

HISTORY OF PRESENT ILLNESS

Days prior to admission, the patient was suspectedly bitten by a mosquito on the left
knee. She scratched the mosquito bite and it became bigger. At night, she laid down on her left
side as it was her position of comfort. In the morning, she felt pain on her left arm but she
thought it was only due to improper sleeping position. Then she exercised her arm to relieve the
pain.

On November 8, 2022, the pain became severe that was why she went to CCMC for
check-up and her physician prescribed her Amoxiclav and a pain reliever (she forgot the name of
the drug). Then, she was advised to return if the pain is not relieved. On November 9, 2022, the
lesion on her knee ruptured and the pain on her left arm became more severe thus she was
admitted.

PAST HEALTH HISTORY

The patient was admitted to CCMC hospital multiple times due to her asthma but it was
her first time to experience swelling on his leg and arm.

FAMILY HISTORY

The patient’s mother developed cellulitis around her breast and her eldest sister also
developed cellulitis on her left arm. Both were managed by surgical drainage of the site of
inflammation at Community Hospital. In addition to that, the patient’s aunt died due to the same
case because the swollen area ruptured which was located above her buttocks.

ENVIRONMENTAL HISTORY

The patient stated that their surroundings are very unsanitary both in her parent (Nivel
Hills) and partner’s house (Upper Torralba, Apas). Though houses are far from each other, the
garbage is found everywhere outside their house, and there where many chickens, dogs, and cats
in their surroundings.
 4

DEVELOPMENTAL TASK

In ages 12 - 18 years old, Erik Erikson believed that in this group of age, adults face
identity vs. role confusion. During this stage, adolescents search for a sense of self and personal
identity, through an intense exploration of personal values, beliefs, and goals (Mcleod, 2018).
The adolescent mind is essentially a mind or moratorium, a psychosocial stage between
childhood and adulthood, and between the morality learned by the child, and the ethics to be
developed by the adult (Erikson, 1963, p. 245). During adolescence, the transition from
childhood to adulthood is most important. Children are becoming more independent, and begin
to look at the future in terms of career, relationships, families, housing, etc. The individual wants
to belong to a society and fit in (Mcleod, 2018).

According to Bee (1992), what should happen at the end of this stage is “a reintegrated
sense of self, of what one wants to do or be, and of one’s appropriate sex role”. During this stage
the body image of the adolescent changes. Erikson claims that the adolescent may feel
uncomfortable about their body for a while until they can adapt and “grow into” the changes.
Success in this stage will lead to the virtue of fidelity. On the other hand, failure to establish a
sense of identity within society can lead to role confusion. Role confusion involves the
individual not being sure about themselves or their place in society. Also, pressuring someone
into an identity can result in rebellion in the form of establishing a negative identity, and in
addition to this feeling of unhappiness (McLeod, 2018).

The patient is living happily with her live-in partner and 1 year old daughter. Before she
got pregnant at age of 15, she tended to hang out with her friends and drink alcohol occasionally.
Now that she already has a baby, she goes home earlier and spent less time with her friends as
her priorities have changed.

Therefore, the patient has achieved identity rather than confusion.

 5

PEDIATRIC HEALTH ASSESSMENT

Introduction: Patient was brought to hospital due to pain and swelling on the left arm. He was
diagnosed with cellulitis.

Name: ULB Age: 17 years old Sex: Female Date of Birth: 11/18/05 Birthplace: Cebu City

Religion: Roman Catholic Nationality: Filipino Date of Admission: 11/9/22

Address: Nivel Hills, Cebu City

Informant: __ Parent/s __ Guardian/s __ Child/Patient __ Others

Medical Diagnosis: Cellulitis, Left Arm Attending Physician: Dr. Salo

History of Present Illness

Onset of complaint prior to admission: November 2, 2022

Manner of Onset: __ acute __ chronic __ intermittent

Progress of Condition: __ better __ unchanged __ worsen

Medications given to alleviate condition:

OTC: Celecoxib Prescribed: Amoxiclab

NEWBORN/INFANT HEALTH HISTORY

A. Prenatal History

Prenatal Checkup done at what AOG: 5 months

Frequency of Prenatal Checkup: Mother forgot already. However, she said she followed the
schedule given to her by the physician in their Brgy. Health Center.

Prenatal done in/by: __ hospital __ health center __ private doctor

Illness incurred during course of pregnancy: None

Medications taken during pregnancy (OTC or prescribed): Vitamins, Clusivol OB, Iberet
 6

B. Obstetric History

G 3 P3 T3 P 0 A 0 L 3

Use of tobacco: None Use of alcohol: None Use of drugs: None

C. Labor and Delivery

AOG during labor: 37 weeks Duration of Labor: 30 minutes Type of Delivery: NSVD

Type of Anesthesia: Local anesthesia​​- Pudendal block

Place of Delivery: Cebu City Medical Center Complications: None

Assisted by: __ Obstetrician __ Midwife __ Trained Hilot

D. Birth History

Respiratory effort of newborn: __ unassisted __ assisted

Character of cry: __ loud __ high pitched __weak

Medications administered: BCG, Hep B, Vit. K

Presence of congenital anomalies: None Length of baby’s hospital stay: 1 day

E. Feeding History

First feeding was started at how many minutes/hours after birth: 30 min.

Method of Feeding: __ breastfeeding __ bottle-fed __ NGT __ mixed

Type of formula for bottle fed: N/A

Amount and frequency: q2h Age of Weaning: 5 months

Age of supplemental feeding started: 5 months

Composition of supplemental feeding: Porridge (with salt, carrots, & potato)

Vitamins taken: Celine and Tiki-tiki

Appetite: __ good __ fair __ poor Diet Restrictions: None

Prescribed diet: Breastfeeding

 7

F. Health History

Previous illness, injuries, operations: Asthma

OTC medications taken: Salbutamol

Prescription medications: None

Allergies: food shrimp drug none Others (please specify): none

I. Immunization

Immunization Received:

Table 1. Immunizations Received

VACCINE DOSE DATE HOSPITAL/BRGY.

HEALTH CENTER

BCG 1 Mother can’t Brgy. Busay Health

remember Center

Hep B 1 Mother can’t Brgy. Busay Health

remember Center

2 Mother can’t Brgy. Busay Health

remember Center

3 Mother can’t Brgy. Busay Health

remember Center

DPT 1 Mother can’t Brgy. Busay Health

remember Center

2 Mother can’t Brgy. Busay Health

remember Center

3 Mother can’t Brgy. Busay Health

remember Center
 8

OPV 1 Mother can’t Brgy. Busay Health

remember Center

2 Mother can’t Brgy. Busay Health

remember Center

3 Mother can’t Brgy. Busay Health

remember Center

1 Mother can’t Brgy. Busay Health

AMV remember Center

1 Mother can’t Brgy. Busay Health

Hib remember Center

Note: The mother stated that she strictly followed her daughter’s immunization schedule at the
barangay health center. But she already forgot the dates.

Approximate weight (in kg) at: 6 months 5.0 kg 1 year: 6.8kg

Approximate height (in inches) at:1 year: 75 cm 3 years: 3 feet

Age of onset of primary teeth: 5 months Age of eruption of permanent teeth: 6 years old

Present number of teeth in: upper 14 lower: 15

G. Family History (Focus only in the immediate family members)

Table 2. Family History

Name Relationship Age Health Status Education Occupation

A.B Mother 41 Good College Level Vendor

Laborer (accepts
Congenital
J.B Father 40 High School any small work at
Heart Problem
the market)
 9

(Enlarged heart
with a hole)

College
Graduate
J.A.B Sister 19 Good Cashier
(2 years
program)

C.B Sister 10 Good Grade 6 Pupil

Live in Production
C.Q 20 Good SHS Graduate
partner worker

A.C.B Daughter 1 Good --- ---

Family History of: __ heart disease __ stroke __ cancer

Other health conditions: Cyst, hypertension, DM

H. Developmental Milestones (Write the age when this milestone was achieved)

3 months smile 3 month sit with support 5 months stand with support 6 month say first word
5 months hold head steadily 6 months sit unsupported 7 months stand alone 9 months talk in
sentence 5 months roll over 7 months walk around 1 year old toilet training

Education: Present grade: Grade 11

 10

General Survey: Please encircle, check, or provide additional information as necessary.

Integumentary: Are there any abrasions, lacerations, or birthmarks? Swelling on the left
arm and circular wound measuring around 1 inch on the left knee. Presence of longitudinal scar
on the abdomen due to cesarean birth.

Head and Neck: Are there masses on the head or neck? There were no masses on the head &
neck.

Eyes, Ears, Nose, Mouth, and Throat: Is there exudates in the eyes? There were no exudates
in the patient’s eyes

Is the baby blinking? Yes, the patient is blinking

Do his/her eyes follow an object within 8 inches? Yes, her eyes followed an object within 8
inches

Is there discharge from the ears, nose, and throat, or nose congestion? There were no
discharges from the ears and nose

Does the newborn respond to sound? Yes, she responded to sound

Respiratory Characteristics, Lungs, and Breathing:

Is the newborn’s lungs congested or gasping for breath? No.

Cardiovascular Characteristics: Is there cyanosis? There was no cyanosis noted.

Temperature Regulation: Is body temperature maintained? Yes, he was able to maintain a

normal body temperature.

Hepatic Regulation:Does the newborn have jaundice? The newborn doesn’t have a jaundice

Gastrointestinal Adaptation: Has the newborn passed stool? Yes, the patient passed stool
within 24 hours.

Has he/she vomited? She didn’t vomit

Genitourinary Adaptation:Has the baby voided? Yes, she voided. But the mother couldn’t
calculate the first time he voided.
 11

Neurological Characteristics: How are the extremities moving? The extremities were moving
bilaterally. Primitive Reflexes were present. He displayed startle, grasp, and tonic neck reflexes.

How does cry sound? The baby’s cry was loud & strong

Endocrine Characteristics:Is there evidence of fetal or maternal endocrine disease? There

was no evidence of fetal or maternal endocrine disease.

Is the newborn jittery? Jittery of arms & legs were noted when the baby cries but, the baby is
not jittery when at rest / is not crying.

Immunologic Adaptation: Are defenses maintained? Yes

Sleep and Rest Pattern: What is the sleep pattern? The baby slept from time to time, the baby
could sleep calmly & woke up & cried when he feels hungry.

Relationships, Psychosocial Profile, and Cultural/Ethnic Variations: How are family

members relating to the newborn? They are all immediate family of the baby. Both parents are
Asian - Filipino & Roman Catholic. The infant is said to developed trust to all his family
members.

Typical Day

What is the child’s typical day like? The infant usually wakes up at around 6 AM and sleeps at
7 PM. The mother will breastfeed the infant at waking hours, then the baby will go back to sleep.

Does he/she have a babysitter or go to day care or preschool? If so, does he/she enjoy it?
She doesn’t have a babysitter at school.

What kind of day care situation is it? (e.g. day care center, child care in private home, baby
sitter in own home) Day care center

How is the child doing in school? Doing good

What subjects does the child likes and dislikes? Patient likes science and hates math

Is he/she having a problem with a particular subject? Has he/she sought help? Math

How many days of school does he/she usually miss every term? 1-3 days
 12

Nutritional Patterns

Is the child still nursing or bottle feeding? If yes, how often? Not anymore

24- hr diet recall:

Breakfast: Milo and Slice Bread

Lunch: Chicken and rice

Dinner: Utan Bisaya and rice

Ask the child to name his/her favorite food/snack: Ice cream & Adobong baboy

Eating Patterns: “How often do you eat breakfast?” “What do you usually have for
lunch?”

Patient eats breakfast every day and she usually goes to Chowking during lunch time.

Elimination Patterns

Stool: Frequency: 0-1x a day Time period of day: anytime of the day Color: brown
Consistency: formed

Amount: with an estimated amount of 240 ml per defecation.

Urination: Frequency: 4 - 6 times per day Time period of day: anytime of the day

Color: yellow Amount: Estimated amount of 210 ml per void

Problems with elimination: The child doesn’t have a problem with urination.

Activity and Exercise Patterns

Is the child very active? Yes, the patient was active

What does he/she enjoy doing? Singing and watching K-drama

Is he/she supervised during activities? Not anymore

 13

Ask what the child enjoys doing outside home: Hang-out with friends

Does he/she play any sport? Yes Is so, what? Badminton

Does he/she wear protective equipment? No

What does the child like to do with his/her friends? Talk and eat with them

How often does he/she watch TV during the week? About 1 hr per day

How much time does he/she spend in the computer? N/A

Recreation/Hobbies

Ask about the parents’ hobbies: His mother loves cook and clean the house

What does the child do for fun? Play cellphone

What hobbies does he/she have? Singing & watching K-drama

Sleep and Rest Patterns

Ask about sleep patterns and naps, bedtime rituals: No bedtime rituals before sleeping.

The child usually goes to bed at: 11 PM and he/she awakens at: 8 AM

Sleep Problems: __ nightmares __ night terrors __ somnambulism

__ enuresis Others: _______________

- the patient doesn’t have a sleep problem

How many hours does the child sleep? Estimated hour was 9 hours

Personal Habits

Ask parents about their and other caregiver’s personal habits. Do they smoke, drink
alcohol, or use drugs? Parents don’t smoke and drink.

If they smoke cigarettes, how many do you smoke in an average day? N/A

If you use alcohol, how much do you usually drink during the week? N/A
 14

If you use drugs, what type and what method? Her parents don’t use drugs

Roles/Relationships/Self-Concept

Is there are siblings, ask the parent about the relationship: She is not so close with her
siblings. They fight most of the time.

Ask the child, “Who lives at home with you?”: She lives with her family - with her mother,
father, 2 siblings, live-in partner, and her baby.

If he/she has siblings, ask about their relationship: Not so close

Also ask, “Is there an adult in your life whom you feel comfortable talking to?”: She’s
comfortable talking with her partner.

Ask about peer relationships. Does the child have a special friend, and what do they like
doing together? N/A

Ask the child to describe herself/himself by asking “Tell me about yourself”: She’s a
naughty girl and bends her parents’ rules most of the time.

Sexuality

Observation: No observable sexual behavior or abused had been observed.

Does the child masturbate? Yes but privately.

Stress and Coping

Does the child behave aggressively? No.

Ask the child: “What makes you angry?” When she doesn’t get what she wanted.

Ask the child: “What do you do when you get angry?” – Talk her heart out (“Mag yaw-yaw”)

Ask the child: “What do you do to have fun or relax?”: Sleep or watch K-drama
 15

DEVELOPMENTAL TASK

According to Erickson:

The patient is in the stage of “Identity v.s. confusion”. The patient is living happily with
her live-in partner and 1 year old daughter. Before she got pregnant at age of 15, she tended to
hang out with her friends and drink alcohol occasionally. Now that she already has a baby, she
goes home earlier and spent less time with her friends as her priorities have changed.

According to Freud:

The patient is in the “Genital Stage”. The Erogenous Zone is maturing sexual interests.
The patient is attracted to her opposite sex and the source of her sexual pleasure is her live-in
partner.
 16

HEAD-TO-TOE PHYSICAL ASSESSMENT

General Survey:

Posture: __ flexed __ limp __ erect __ relaxed __ tensed

Head Circumference: 53 cm Chest Circumference: 81 cm

Abdominal Circumference: __85 cm__ Length/Height: 153 cm

Weight: 40.5 kg T: 36.5 c PR: 99 bpm RR: 19 cpm BP: -- O2 sat: 97% Pain: 9

Location left arm Onset when she moves Duration: short Characteristics: patient can’t
describe Aggravating factor: movement Relieving Factor: Rest

Skin, Hair, Nails

Skin color and appearance: Brown Skin, moist and warm to touch. Swelling on the left arm
with localized redness around the area & circular crusted wound on the left knee measuring
around 1 inch.

Lesions: Swelling on the arm Skin Turgor: Good skin turgor

Hair Appearance: Black, short

Distribution: Well-distributed
 17

Lice: None

Appearance of nails: Nails were trimmed. Clean. Immobile. Intact.

Head and Neck

Head: __ symmetric Scars: None____ Lesions: None Others:

Lymph nodes palpable: Not Palpable thyroid: nonpalpable

Anterior Fontanelle: closed Posterior Fontanelle: closed

Facial Movement: Proportionate and symmetric. Movements are equal bilaterally.

Facial Features: The patient has small oval face, a big round eyes, double eye-lids, longer and
darker lashes, narrow nose and mole on the top of the nose.
Tonic Neck Reflex: absent

Eyes and Ears

Inspect eyes: Tracks moving object to midline without difficulty. Pupils are equal, round and
symmetric and reactive to light. Cornea is moist and the sclera is white. Eyelashes are equally
distributed and curls outward. No presence of lesions and swelling in the eyelids.

Visual Acuity: 20/20

Ear: minimal amount of earwax noted. Ears are bilaterally equal in size and non- tender. No
presence of palpable mass. Placement of pinnae is parallel with eye canthi bilaterally.

hearing intact: Intact hearing.

Mouth, Nose, and Throat

Appearance of mucous membranes, lips, tongue, and palate: Lips are symmetrical, pale, dry,
and has minimal cracks. Minimal caries noted in teeth and the gingiva is pinkish and not dry.
Buccal mucosa is not pale. Tongue is pinkish in color and positioned midline; there were no
tremors noted in the tongue. Tonsils are pink, no lesions, swelling, and exudates noted. The uvula
is positioned midline.
 18

__ sucking reflex __ rooting reflex __ gag and swallowing reflex

__ extrusion reflex

Number of teeth: 29 wisdom teeth:1

clear patent nostrils: Patent nostrils Condition of sinuses: Good

Chest and Back

General Appearance: Smooth, rounded, & symmetric

Chest expansion: good Shape: Cylinder shaped

Percussion Findings: ---

Breath Sounds: Normal

Heart

Heart sounds: Normal Heart rate: 98 bpm

Capillary Refill:1 sec Peripheral pulse: 98 bpm

Abdomen

Appearance of abdomen: flat abdomen with longitudinal scar (due to cesarean birth)

Appearance of umbilical cord: Umbilicus is pink, no discharge, odor, redness or herniation.

Palpation: Abdomen is soft to palpation & without masses or tenderness

Percussion: ---

Bowel Sounds: Sounds heard every 25 seconds

Other findings: None

Genitalia and Anus __ Patent Rectum __ Anal Reflex

__ urinary meatus at midline __ edema Other Findings: ___

 19

Extremities: Number of fingers _10_ Toes _10_ __ Full ROM

__ Normal curvature of spine __ equal muscle tone

__ no weakness

__ arms and legs symmetrical in size and movement

Other findings: _______________

Neurologic

__ responds to noise __ responds to touch __ good balance

__ coordinated movement

Current developmental assessment

A. Gross motor skills

- The patient has a coordinated gross motor ability together with greater physical strength and
prolonged endurance. She can already play sport such as badminton. Also, she can already
perform everything she wanted to such as jumping, dancing, climbing, and many more.

B. Fine motor adaptive skills

- The patient can manipulate small objects comfortably. She can write for long time, draw, do
crafts and arts, play instruments, and many more.

C. Language skills
- The patient is fluent in Bisaya, English, and Tagalog. She has no difficulty in communication.

D. Personal and social skills

- The patient likes to be with her partner and baby. At school, she hangs out with her friend and
after school, she goes home and perform her duties and responsibilities as a teenage mom.
 20

Identified Nursing Diagnosis (prioritized):

- Hyperthermia related to invasion of pathogens on the skin

- Impaired Tissue Integrity related to inflammation on the left arm
- Acute Pain related to inflammation on the left arm
- Activity Intolerance related to acute swelling of left arm
- Impaired Comfort related to acute swelling of left arm

Assessed by:

Matuguinas, Jade Catherine N.

Name and Signature of Student Nurse

Validated by:

Mr. Peter Arnold Tubayan, RN, MAN

Date of Assessment: November 17, 2022

21
 22

PHYSICAL EXAMINATION
Table 3. Physical Examination
ASSESSMENT DATA NORMAL FINDINGS ABNORMAL FINDINGS MANIFESTED BY THE
MANIFESTED BY THE PATIENT PATIENT

GENERAL SURVEY

INSPECTION Received patient lying supine on bed, awake, and

alert; with an ongoing IVF #5 D5LR 1L at 33gtts/min
with remaining fluids of 700mL infusing well at the
left foot.

PALPATION Patient has a baseline VS of T: 36.5 c; P: 99 PS: 9; T: 38.6 c (at 10:00 AM)
bpm; R: 19 cpm; & O2: 97%.
SKIN, HAIR AND NAILS
INSPECTION • Skin is evenly brownish-colored, not pale, • Presence of purulent swelling on left arm with pus
moist. inside. Redness was also noted on the site supported
• Hair is black and is evenly distributed. No by arm sling.
dandruffs and lice noted. • Presence of circular dry crusted wound on the knee
• Nails are clean and kept short with pink measuring around 1 inch in diameter.
tones at 160-degree angle between the • Flushed skin
 23

nail base and skin. No signs of clubbing

noted.

PALPATION • Skin is moist and soft Warmth, tenderness, and pain were noted on the left
• Good skin turgor arm.
• Scalp is smooth and oily and there were
no lesions noted.
• The nails are hard and immobile. Nails are
smooth and firm
• CRT 2 sec

HEAD, NECK AND CERVICAL LYMPH NODES

INSPECTION • Head is hard and smooth. Head size is
symmetric, round and in midline with no
involuntary movements.
• The neck is symmetric, with head
centered and without bulging masses.
• No lesions and swelling noted on the
neck. Patient is able to freely move his
neck.
• There is no presence of lesions in both
head and neck
 24

PALPATION • Temporal artery is palpable (2+) bilateral

• Full ROM of the neck
• Trachea is midline
• Thyroid was non palpable and no
enlargements noted
• Carotid pulse is palpated with strong
bounding pulse
• The temporomandibular joint has no
swelling.
• The preauricular, tonsillar, submandibular,
submental, superficial, posterior, deep
cervical chain, and supraclavicular nodes
of the neck are not palpable.

AUSCULTATION • Carotid arteries no blowing or swishing

sound

MOUTH, NOSE AND SINUSES

INSPECTION • Complete set of teeth, with minimal • Lips were pale, dry, and with minimal cracks.
dental caries noted.
• Oral mucosa is not pale and dry. No
lesions were noted.
 25

• Gingiva is pink and dry. No lesions and

bleeding noted. No inflammation noted
• Tonsils not swollen.
• Nose is symmetrical with the nasal
septum at the midline.

• No lesions and ulcerations noted on the

mouth
• No lesions and masses noted on the nose
• Nasal tenderness not noted.
PALPATION • Sinuses are non-tender and are trans
illuminated by the penlight.
• Frontal and maxillary sinuses tenderness
can’t be assessed. No crepitus is evident.

EYES AND EARS

INSPECTION • Iris is black in color.
• Sclera is cloudy white in color.
• Cornea is moist.
• Eyelashes are evenly distributed and curls
outward.
 26

• No lesions noted on the ears and the skin

is intact.
• Ears are not aligned.
• Size of ears are symmetrical and
proportional to the head.
• Ear canal is brownish in color
• PERRLA

PALPATION • No palpable masses noted on the ears

• The auricle, tragus and mastoid processes
tenderness not noted.

THORACIC AND LUNGS

INSPECTION • Side to side symmetric chest shape
• Regular respiratory rate & pattern
• The thorax is the same color as the rest of
the body with no presence of lesion.
• Equal Chest Expansion noted
• No retractions or bulging of ICS are noted.
 27

PALPATION • No lumps and nodules felt upon

palpation. Tenderness not noted.

AUSCULTATION • No adventitious sounds noted

CARDIOVASCULAR
INSPECTION • Jugular Venous pulse is not visible and
distended
• No prominent venous patterns on the
peripheral extremities

PALPATION • Extremities are bilaterally symmetrical

• Extremities are equally not warm to touch
• Extremities have equal bilateral pulse
strength (2+)

AUSCULTATION • Pulse rate is 99 bpm

• No blowing and swishing sounds noted on
jugular arteries
• Regular heart rhythm
• Audible heart sound Absence of extra
heart sound
 28

BREAST
INSPECTION • Patient’s breast is symmetrical and round
in shape
• The areola is rounded with dark brown in
color.
• Nipples are round, same size and equal in
color.
• Pendulous breast

PALPATION • No lesions and masses noted Axillary lymph nodes were palpable

ABDOMEN
INSPECTION • Flat abdomen
• Umbilicus is located midline
• Skin not pale.
• No ascites noted.
• Presence of longitudinal scar on the
abdomen due to caesarean birth.

PALPATION • Abdomen soft upon palpation

• No masses noted
• No Tenderness noted.
 29

AUSCULTATION • Active bowel sound noted on all 4

quadrants
• 18 bowel sounds noted per minute

GENITOURINARY-REPRODUCTIVE
INSPECTION • Pubic hair noted
• No swelling of external structures of vulva
(labia majora, minora, and clitoris) were
noted.

MUSCULOSKELETAL
INSPECTION • Both lower extremities are equal in size • Left arm is severely swollen and severe pain upon
• Have the same contour with prominences movement.
of joints.
• No involuntary movements noted
• Has equal contraction and is even.

PALPATION • No Tenderness noted.

• No crepitus noted on joints.
• Full ROM noted
• Sensations are intact.
• CRT = 1 sec
 30

NEUROLOGIC
INSPECTION • Sensations are intact.
• GCS = 15

PALPATION • Reflexes present.

• Plantar grasp reflex noted.
• Temporal Artery pulse is present (2+)
 31

LABORATORY & DIAGNOSTIC TEST

COMPLETE BLOOD COUNT

Table 4. CBC result

TEST NAME RESULT RESULT RESULT UNIT REFERENCE INTEPRETATION

(November (November 11, (November 15, RANGE
11, 2022 @ 2022 @ 4:35 2022 @ 9:33
9:11 AM) PM) PM)
CBC
WBC 18.2 17.8 14.1 109/L 4.0-11.0 High. WBC increases in
infection and
inflammation such as in
case of cellulitis (CDC,
2022).
RBC 4.3 4.4 3.0 1012/L 3.8-5.4 Low. Teens are
susceptible to anemia
due to menstrual
periods which causes
the loss of red blood
cells and a lot of iron
(Komaroff, 2014).
 32

Hgb 127 136 106 g/L 115-148 Low. Teens are

susceptible to anemia
due to menstrual
periods which causes
the loss of red blood
cells and a lot of iron
(Komaroff, 2014).
Hct 0.40 0.41 0.32 % 0.38-0.44 Low. Teens are
susceptible to anemia
due to menstrual
periods which causes
the loss of red blood
cells and a lot of iron
(Komaroff, 2014).
MCV 94.3 93.9 93.9 fL 80-100 Normal
MCH 29.6 29.7 30.4 pg 27-31 Normal
MCHC 31.4 31.7 32.4 g/dL 31-36 Normal
RDW 0.138 0.127 0.138 --- 0.115-0.150 Normal
Platelet 271 244 341 109/L 150-450 Normal

Segmenters 0.92 0.88 0.83 % 0.45 - 0.55 High. Increase level

 33

happens when there is

an infection (CDC, 2022).
Lymphocyte 0.05 0.07 0.11 % 0.38 - 0.45 Low. Bacterial infection
is one of the common
causes of
lymphocytopenia. This
may also happen in
cases of bacteremia
(Iftikhar, 2022).
Monocyte 0.03 0.04 0.05 % 0.03 -0.06 Normal
Eosinophil 0.00 0.01 0.01 % 0.02 – 0.05 Low. A low number of
eosinophil in the blood
can occur in
bloodstream infections
(Territo, 2022).
Basophil 0.00 0.00 0.00 % 0.00 – 0.01 Normal
Blood Typing A+ Normal
34
 35

MICROBIOLOGY

DATE: 11/11/2022 TIME: 2:30

PM

CULTURE & SENSITIVITY TEST

Sample: Blood

Site of Collection: Right Arm

Result (11-14-2022 @ 10:07 AM)

Final Report: (+) for staphylococcus aureus after 19 hours of incubation.

Identified Organism: (7) Staphylococcus aureus

Sensitives

1. Daptomycin – S
2. Mocifloxacin – S
3. Gentamycin – S
4. Rifampin – S
5. Clindamycin – S
6. Erthromycin – S
7. Linezolid – S
8. Ampicillin – R
9. Oxacillin – R
10. Penicillin – R
11. Chloramphenicol – I
12. Levofloxacin – S
13. Tetracycline - S

Legend:
S: Sensitivity I: Intermediate R: Resistant
 36

CLINICAL CHEMISTRY

Date: 11-11-22 Time: 1:03 PM

Table 5. Clinical Chemistry

TEST RESULT UNIT RANGE INTERPRETATION

CREATININE 1.22 mg/dL 0.6-1.1 High. Kidney
infections and intake
of certain drugs such
as vancomycin may
raise the level of
creatinine (Schulman,
2019).

IMMUNOLOGY

Date: 11-11-22 Time: 1:03 PM

Table 6. Immunology Result

TEST RESULT UNIT RANGE INTERPRETATION

Procalcitonin 7.98 mg/dL 0–5 High. A high level of
procalcitonin in the
blood occurs due to a
serious infection
(MedlinePlus, n.d.)
CRP 273.00 mg/L 0-5 High. Elevation of CRP
(Quantitative) happens in acute
inflammation or
serious infections
 37

(Mayo Clinic, 2021).

URINALYSIS

Table 7. Urinalysis

TEST NAME Result Result Unit Reference Interpretation

(11/11/2 (13/11/2 Range
2 @ 1:03 2@
PM) 9:25AM)
Physical Properties
Color Yellow Yellow Normal
Transparency Hazy Hazy Hazy urine may happen due to
urinary infection and dehydration
(Johnson, 2022).
Chemical Properties
pH 5.5 5.5 Normal
Specific 1.025 1.025 Normal
Gravity
Protein Trace +1 Normal. Protein in the urine is a
sign that the kidneys are damaged.
However, short term protein in
urine occurs in fever, high stress,
and dehydration (American Kidney
Fund, 2022).
Glucose - - Normal

Microscopic Exam
RBC 1-3 76-100 /hpf 0-2 High. An infection in the urinary
tract, bladder, and kidneys can
 38

cause inflammation and irritation

that lead to RBCs appearing in
urine. Also, recent sexual activity
can cause irritation of the tissues
around the urinary tract (Nall,
2019).
WBC 4-6 5-10 /hpf 0-2 High. Increase in WBC count is
associated with infection (CDC,
2022).
Epithelial Moderat Moderat /hpf Moderate number of epithelial
Cell e e cells in the urine happens in
urinary infections (CDC, 2022).
Bacteria Few Few /hpf Few number of bacteria in urine is
associated with infection (CDC,
2022).
Mucus Rare Rare /hpf Normal
Thread
Types of Cast Crystals
Pregnancy Negative
Test

SARS – COV-2 RT-PCR TEST

DATE: November 11, 2022

Result: NEGATIVE
 39

SUMMARY OF SIGNIFICANT FINDINGS

Table 8. Summary of Significant Findings

PEDIATRIC LABORATORY & DIAGNOSTIC THERAPEUTIC KEY NURSING

HEALTH ASSESSMENT/ STUDIES MANAGEMENT PROBLEMS
PHYSICAL ASSESSMENT
- Skin is warm to touch --- - Paracetamol 300 Hyperthermia
- T: 38.6 c (at 10:00 AM) mg IVTT q4H PRN related to
- Flushed skin for temp >/= 38c invasion of
- Lips are pale, dry, and - Tepid Sponge Bath pathogens on the
minimally cracked skin

- Presence of purulent swelling - WBC: 14.1 109/L - Vancomycin, 810 mg, Impaired Tissue
on left arm with pus inside. - Segmenters: 0.83 % IV Drip q8H Integrity related
Redness was also noted on the - Lymphocyte: 0.11% - Meropenem, 1g IV drip to inflammation
site. - Eosinophil: 0.01% q8H on the left arm
- Presence of circular dry crusted - (+) for staphylococcus aureus after 19
wound on the knee measuring hours of incubation.
around 1 inch in diameter. - Procalcitonin: 7.98 mg/dL
- Warmth, tenderness, and pain - CRP (Quantitative): 273.00 mg/L
were noted on the left arm. - creatinine: 1.22 mg/dL
- PS: 9/10 - RBC: 76-100 /hpf - Ibuprofen, 200mg/capgel, Acute Pain
- WBC: 5-10 /hpf 1 capgel q6h PRN related to
 40

- severe pain on the left - Epithelial Cell: Moderate/hpf - Vancomycin, 810 mg, inflammation on
arm upon movement - Bacteria:few/hpf IV Drip q8H the left arm

Meropenem, 1g IV drip
q8H
- Application of Arm
Sling

- PS: 9/10 - Application of Arm Activity

- Left arm swollen with severe Sling Intolerance
pain upon movement - Adequate Rest related to acute
swelling of left
arm/ Impaired
Comfort related
to acute swelling
of left arm
 41

ANATOMY & PHYSIOLOGY

THE INTEGUMENTARY SYSTEM (SKIN)

Functions of the Integumentary System
The integumentary system, also called the integument (in-teg9u-ment), which simply
means “covering,” performs a variety of functions; most, but not all, of which are protective. It
insulates and cushions the deeper body organs and protects the entire body from mechanical
damage (bumps and cuts), chemical damage (such as from acids and bases), thermal damage
(heat and cold), ultraviolet (UV) radiation (in sunlight), and microbes.

Structure of the Skin

EPIDERMIS

The outer epidermis

(ep0ı˘-der9mis) is made up of stratified
squamous epithelium that is capable of
becoming hard and tough.

The deepest cell layer of the

epidermis, the stratum basale (stra9tum
ba-sah9le), lies closest to the dermis and is
 42

connected to it along a wavy border that resembles corrugated cardboard. As they move away
from the dermis and become part of the more superficial layers, the stratum spinosum and then
the stratum granulosum, they become flatter and increasingly keratinized. As these cells leave
the stratum granulosum, they die, forming the clear stratum lucidum. The outermost layer,
the stratum corneum (kor9ne-um), is 20 to 30 cell layers thick, but it accounts for about
three-quarters of the epiderm al thickness.

DERMIS

The underlying dermis is made up mostly of dense connective tissue. The epidermis and
dermis are firmly connected and the dermis is fairly tear resistant.

The papillary layer is the superficial dermal region. The reticular layer is the deepest
skin layer. It contains dense irregular connective tissue, as well as blood vessels, sweat and oil
glands, and deep pressure receptors.

SUBCUTANEOUS

Deep to the dermis is the subcutaneous tissue, or hypodermis, which essentially is

adipose (fat) tissue. It is not considered part of the skin, but it does anchor the skin to underlying
organs and provides a site for nutrient storage.

APPENDAGES OF THE SKIN

The skin appendages include cutaneous glands, hair and hair follicles, and nails.

Cutaneous Glands

The cutaneous glands are all

exocrine glands that release their secretions
to the skin surface via ducts. They fall into
 43

two groups: sebaceous glands and sweat glands.

Hairs

A hair is a flexible epithelial structure. The part of the hair enclosed in the hair follicle is

called the root, and the part projecting from the surface of the scalp or skin is called the shaft.

Hair Follicles

Hair follicles are actually compound

structures. The inner epithelial root sheath is
composed of epithelial tissue and forms the hair.
The outer fibrous sheath is actually dermal
connective tissue.

Nails

A nail is a scalelike
modification of the epidermis
that corresponds to the hoof or
claw of other animals. Each
nail has a free edge, a body
(visible attached portion), and
a root (embedded in the skin).

REFERENCE:

Marieb, E. and Keller, S., 2018. Essentials of Human Anatomy & Physiology. 12th ed. Pearson

Education Limited.
 44

PATHOPHYSIOLOGY
45
 46

REFERENCES
Evans, T. & Yakaback, S. (2020). Cellulitis: Pathogenesis, clinical findings, and complications. Retrieved from
https://calgaryguide.ucalgary.ca/cellulitis/
Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing
(14th ed.). Philadelphia: Wolters Kluwer.

EXPLAINATION:
The vast majority of cases of cellulitis are likely caused by Streptococcus pyogenes and, to a lesser degree, by Staphylococcus
aureus. Cellulitis usually follows a breach in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound. Organisms on
the skin and its appendages gain entrance to the dermis and multiply to cause cellulitis.
Signs and symptoms include redness of the skin, swelling of the skin, tenderness, warm skin, pain, bruising, blisters, fever,
headache, chills, weakness, red streaks from the original site of the cellulitis, and swelling of lymph nodes. It may complicate to
permanent swelling, gangrene, blood infection and sepsis, infection in other regions.
Medical management includes use of antibiotics, surgical drainage of pus, pain relivers, warm & cold compress, and
amputation for severe cases. As for this patient, her treatment includes Paracetamol 300 mg IVTT q4H PRN for temp >/= 38c,
Vancomycin, 810 mg, IV Drip q8H, Meropenem, 1g IV drip q8H, Ibuprofen, 200mg/capgel, 1 capgel q6h PRN, adequate sleep, rest,
nutrition, & fluids, tepid sponge bath, and warm & cold compress.
Identified nursing problems for the patient are Hyperthermia, Impaired Tissue Integrity, Acute Pain, Activity Intolerance, and
Impaired Comfort. In addition, Nursing management include promotion of adequate rest and sleep, promotion of adequate nutritional
and fluid intake, keeping the area clean and dry, providing TSB and monitoring for any complications.
 47

NURSING CARE PLAN # 1

Nursing Diagnosis: Hyperthermia related to invasion of pathogens on the skin

Table 9. Nursing Care Plan # 1

ASSESSMEN SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

T BASIS
SUBJECTIVE Fever is an SHORT TERM SAFE & QUALITY After 2 hours of
DATA: elevated body GOAL: NURSING CARE nursing
“Iniit kaayo temperature that Within 1-2 hour ✔ Obtained and ✔ To provide interventions, the
akong occurs when the of nursing monitored VS baseline data patient
paminaw” as body's thermostat interventions, the especially the demonstrated a
verbalized by (located in the patient will be temperature temperature within
the patient hypothalamus) able to and endorsed normal range as
resets at a higher demonstrate for any evidenced by
OBJECTIVE temperature, temperature abnormalities. temperature of
DATA: primarily in within normal ✔ Measured I & ✔ to measure the 37.5c.
- T: 38.6 c at 10 response to an range as O upon I& O of the
AM. infection. evidenced by receiving and patient
- Skin is warm Pyrogens are temperature closing the
to touch. substances that between 36.5 – chart
- Flushed skin cause fever. 37.5 °C. ✔ Assessed ✔ High fever
Exogenous neurological manifest
 48

- Lips are pale, pyrogens are LONG TERM responses, different

dry, and usually microbes GOAL: noted the level neurological
minimally or their products. After 3-7 hours of signs and
cracked (Bush, 2022). of nursing consciousness symptoms.
interventions, the and
REFERENCES patient will be orientation,
Bush, L. (2022). able to maintain reaction to
Fever. Retrieved a temperature at stimuli,
from a reaction of
https://www. normal/functiona pupils and
Msdmanuals l level. presence of
.com/professional posturing or
/ seizures.
infectious-disease ✔ Provided tepid ✔ Enhances heat
s/biology-of-infec sponge bath loss by
tious-disease/feve evaporation &
r conduction
✔ Promoted surface ✔ Promote heat loss
cooling by
removing extra
clothing and cool
environment.
 49

MANAGEMENT
OF RESOURCES &
ENVIRONMENT
✔ Raised side ✔ to prevent fall
rails
✔ Lessened ✔ to avoid
environmental distractions to
noises sleep & rest
✔ Provided ✔ to promote rest
patient with a & sleep
comfortable
mattress and
blanket.
✔ Observed ✔ To prevent
protocols on transmission of
pollution-contr microbes from
ol & observed one place to
proper another
disposal of
wastes
 50

✔ Adhered to ✔ To adhere
policies, practices in
procedures and accordance with
protocols on nursing law and
prevention and other relevant
control of legislation
infection

HEALTH
EDUCATION ✔ Identifies own
✔ Determined learning needs
patient & SO
readiness as
well as her
barriers to
learning

LEGAL
RESPONSIBILITY ✔ for legal
✔ Informed S/O purposes
about any
procedures
 51

performed &
obtained
informed
consent ✔ To practice
✔ Accomplished professionalism
accurate
documentation
in all matters
concerning
client care in
accordance to
the standards
of nursing
practice. ✔ To respect
✔ Acted in patient’s rights
accordance
with the
established
norms of
conduct of the
institution /
organization/legal
 52

and regulatory
requirements

ETHICO-MORAL
RESPONSIBILITY
✔ Rendered ✔ To respect the
nursing care rights of the
consistent with patient
the client’s bill
of rights
✔ Provided ✔ To respect the
patient’s rights of the pt
privacy
✔ Provided ✔ To render
confidentiality updated pt. care
to patient’s
data and
records

PERSONAL &
PROFESSIONAL
DEVELOPMENT
 53

✔ Applied ✔ To practice
learned professionalism
information
for the
improvement
of care
✔ Demonstrated ✔ To practice
good manners professionalism
and right
conduct at all
times

QUALITY
IMPROVEMENT
✔ Encouraged ✔ Questions
the SO to raise facilitate open
feedback and communication
questions between patient
and health care
professionals and
allow
verification of
 54

understanding of
given
✔ Solicited information
feedback from ✔ To verify the
SO regarding quality of care
care Rendere given.
✔ Shared with
the team ✔ To provide
relevant holistic patient
information care.
regarding
clients’
condition and
significant
changes in
clients’
environment

RESEARCH
✔ Specified
researchable
problems
 55

regarding ✔ To provide
client care and solution to the
community problem
health

RECORD
MANAGEMENT
✔ Completed
updated
documentation
of client care ✔ to record the care
✔ Applied given to patient
principles of and to respect
record patient’s right
management ✔ To accurately
✔ Monitored and record the data
improves
accuracy,
completeness ✔ For legal
and reliability purposes &
of relevant ensure holistic &
data
 56

collaborative pt
✔ Made record care
readily
accessible to
facilitate client ✔ To provide
care accurate data &
✔ Maintained confidentiality
integrity,
safety, access
and security of ✔ To provide
records accurate data &
✔ Followed confidentiality
protocol in
releasing
records and ✔ To protect
other patient’s dignity
information
COMMUNICATIO
N
✔ Built rapport
to SO & gain
patient trust ✔ to build trust
 57

✔ Spoke with the

patient & SO
with a ✔ to facilitate in
well-modulate understanding
d voice the words
✔ Provided an
atmosphere of
respect, ✔ Conveying
openness, respect is
trust, and especially
collaboration important when
providing
education to
patients with
different values
and beliefs about
● Interpreted and health and illness
validate the d
client’s body ✔ Non verbal cues
language and are form of
communication.
 58

facial
expressions
✔ Provided
reassurance ✔ To provide
through emotional
therapeutic support.
touch, warmth
and
comforting words
of encouragement
✔ Ensured good
communicatio ✔ To avoid
n within misunderstandin
healthcare g & ensure
team patient safety

COLLABORATION
& TEAMWORK
✔ Regulated &
monitored IVF as ✔ To avoid
prescribed. dehydration & for
fluid replacements.
 59

✔ Paracetamol given ✔ To lower down

via IVTT as temperature
prescribed.
✔ Reviewed ✔ To determine the
laboratory studies status of the patient’s
condition.
✔ Collaborated with
✔ To provide a holistic
all the HCP care for the patient’s
involved in the needs
patient care

REFERENCES
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket Guide. (15th ed.). Philadelphia:
F.A. Davis Company
Bush, L. (2022). Fever. Retrieved from https://www.Msdmanuals.com/professional/infectious-diseases/biology-of-infectious-
disease/fever
 60

NURSING CARE PLAN # 2

Nursing Diagnosis: Impaired Tissue Integrity related to inflammation on the left arm

Table 10. Nursing Care Plan # 2

ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BASIS
SUBJECTIVE Cellulitis is the SHORT SAFE & QUALITY After 8 hours of
DATA: most common TERM NURSING CARE nursing
“Hubag kaayo ako infectious cause of GOAL: ✔ Obtained and ✔ To provide baseline interventions,
left arm, ug kani limb swelling. Within 8 hours monitored VS and data the patient’s left
ako samad sa tuhod The acute onset of of nursing endorsed for any arm showed no
kay mao ni ang swelling, localized interventions, abnormalities. changes (left
nibuto nga hubag” redness, warmth, the patient will ✔ Measured I & O ✔ to measure the I& O arm is still
and pain is display timely upon receiving and of the patient inflamed).
OBJECTIVE frequently healing of the closing the chart However,
DATA: associated with swollen area ✔ Assessed general ✔ to assess for any patient
- Presence of systemic signs of as evidenced condition of the abnormalities demonstrated
purulent swelling fever, chills, and by no signs of skin, noting any behaviors to
on left arm with pus sweating. The exacerbation swelling, redness, display timely
inside. Redness was redness may not be of infection and tenderness. healing as
uniform and often and actively ✔ Evaluated ✔ To evaluate evidenced by
skips areas and participate in peripheral pulses potential for patient actively
 61

also noted on the eventually her treatment impairment in participating in

site. develops a pitting regimens. circulation. her prescribed
“orange peel” ✔ Maintained proper ✔ to avoid treatment
- Presence of
appearance LONG position of arm exacerbation of regimen.
circular dry crusted condition and
(Horseman & TERM sling reduce pain.
wound on the knee
Bowman, 2013). GOAL: ✔ Promoted adequate ✔ To allow tissues to
measuring around 1
After 3-7 days rest and sleep heal timely and
inch in diameter.
of nursing limit metabolic
- Warmth, REFERENCES interventions, MANAGEMENT OF demands.
tenderness, and Hinkle, J.L. & the patient will RESOURCES &
pain were noted on Cheever, K.H. maintain ENVIRONMENT
the left arm. (2018). Brunner & tissue integrity ✔ Raised side rails ✔ to prevent fall
Suddarth's and be free ✔ Lessened ✔ to avoid distractions
- WBC: 14.1 109/L
Textbook of from any environmental to sleep & rest
- Segmenters:
Medical-Surgical infections as noises
0.83 %
Nursing (14th ed.). evidenced by ✔ Provided patient ✔ to promote rest &
- Lymphocyte:
Philadelphia: absence of with a comfortable sleep
0.11%
Wolters Kluwer. swelling/ mattress and
- Eosinophil:
redness/ blanket.
0.01%
fever, and pus. ✔ Observed protocols ✔ To prevent
- (+) for
on pollution-control transmission of
staphylococcus
 62

aureus after 19 & observed proper microbes from one

hours of disposal of wastes place to another
incubation. ✔ Adhered to ✔ To avoid
- Procalcitonin: policies, procedures cross-contamination
7.98 mg/dL and protocols on
- CRP prevention and
(Quantitative): control of infection
273.00
mg/L HEALTH
- creatinine: 1.22 EDUCATION
mg/dL ✔ Determined ✔ Identifies own
- RBC: 76-100 patient’s barriers to learning needs
/hpf learning
- WBC: 5-10 /hpf
- Epithelial Cell: LEGAL
Moderate/hpf RESPONSIBILITY
- Bacteria:few/hp ✔ Informed S/O about ✔ To adhere practices
f any procedures in accordance with
performed & nursing law and
obtained informed other relevant
consent legislation
 63

✔ Accomplished ✔ for legal purposes

accurate
documentation in
all matters
concerning client
care in accordance
to the standards of
nursing practice.
✔ Acted in ✔ To practice
accordance with the professionalism
established norms
of conduct of the
institution /
organization/legal
and regulatory
requirements

ETHICO-MORAL
RESPONSIBILITY
✔ Rendered nursing ✔ To respect patient’s
care consistent with rights
the client’s bill of
 64

rights
✔ Provided patient’s ✔ To respect the rights
privacy of the pt
✔ Provided ✔ To respect the rights
confidentiality to of the pt
patient’s data and
records

PERSONAL &
PROFESSIONAL
DEVELOPMENT
✔ Applied learned ✔ To render updated
information for the pt. care
improvement of
care
✔ Demonstrated good ✔ To practice
manners and right professionalism
conduct at all times

QUALITY
IMPROVEMENT
 65

✔ Encouraged the SO ✔ Questions facilitate

to raise feedback open
and questions communication
between patient and
health care
professionals and
allow verification of
understanding of
given information
✔ Solicited feedback ✔ To verify the quality
from SO regarding of care given.
care
Rendered
✔ Shared with the ✔ To provide holistic
team relevant patient care.
information
regarding clients’
condition and
significant changes
in clients’
environment
 66

RESEARCH
✔ Specified ✔ To provide solution
researchable to the problem
problems regarding
client care and
community health

RECORD
MANAGEMENT
✔ Completed updated ✔ to record the care
documentation of given to patient and
client care to respect patient’s
rights
✔ Applied principles ✔ To accurately record
of record the data
management
✔ Monitored and ✔ For legal purposes
improves accuracy, & ensure holistic &
completeness and collaborative pt care
reliability of
relevant data
Made record
 67

readily accessible
to facilitate client
care ✔ To provide accurate
✔ Maintained data &
integrity, safety, confidentiality
access and security
of records ✔ To protect patient’s
✔ Followed protocol dignity
in releasing records
and other
information

COMMUNICATION ✔ to build trust

✔ Built rapport to SO
& gain patient trust ✔ to facilitate in
✔ Spoke with the SO understanding the
with a words
well-modulated ✔ Conveying respect
voice is especially
✔ Provided an important when
atmosphere of providing education
respect, openness, to patients with
 68

trust, and different values and

collaboration beliefs about health
and illness
✔ Non verbal cues are
form of
✔ Interpreted and communication.
validated client’s
body language and ✔ To provide
facial expressions emotional support.
✔ Provided
reassurance through
therapeutic touch,
warmth and
comforting words ✔ To avoid
of encouragement misunderstanding &
✔ Ensured good ensure patient safety
communication
within the health
care team
COLLABORATION ✔ To avoid
& TEAM WORK dehydration & for
fluid replacements
 69

✔ Regulated & ✔ For treat infections

monitored IVF as
prescribed.
✔ Ensured
Meropenem
medication is ✔ To determine the

infusing well via status of the

soluset. patient’s condition.

✔ Reviewed ✔ To provide a holistic

laboratory studies care for the patient’s

needs

✔ Collaborated with
all the HCP
involved in the
patient care

REFERENCES
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket Guide. (15th ed.). Philadelphia:
F.A. Davis Company
Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth's Textbook of
Medical-Surgical Nursing (14th ed.). Philadelphia: Wolters Kluwer.
 70

NURSING CARE PLAN # 3

Nursing Diagnosis: Acute Pain related to inflammation on the left arm

Table 11. Nursing Care Plan # 3

ASSESSMENT SCIENTIFIC BASIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE Inflammation on SHORT TERM SAFE & QUALITY After 8 hours of
DATA: the skin typically GOAL: NURSING CARE nursing
“Sauna sakit causes pain because After 1 – 4 hrs of interventions,
kaayo bisag dili the swelling and nursing the patient
✔ Obtained and ✔ To provide
mo lihok, karon buildup of tissue interventions, the reported a
monitored VS and baseline data
dili na sakit starts pressing patient will report decrease of
endorsed to CI for any
kaayo ig against nerve pain relief and pain score from
abnormalities.
ipahuway nako endings. This control as 9 to 5 out of 10.
pero sakit pressure sends pain evidenced by ✔ Performed ✔ To check for any
hapon kaayo ig signals to the brain, verbalization of a
comprehensive abnormalities
mulihok ko ug causing discomfort decreased pain
physical assessment
kung pisliton” as (Garden State Pain score (from a PS
✔ Identified contributing ✔ These conditions
verbalized by & Orthopedics, of 9 to not more
 71

the patient 2017). than 5) and factors to pain can cause,

demonstrate precipitate, and
nonverbal cues. exacerbate
OBJECTIVE LONG-TERM persitent pain.
DATA: GOAL:
• PS: 9 After 24-72 hours
✔ Evaluated client’s ✔ Passive and
• Presence of of nursing
pattern of coping, and avoidant
purulent REFERENCES interventions, the
locus of control behavioral
swelling on Garden State Pain & patient will follow
(internal or external). patterns
left arm Orthopedics (2017). prescribed
or lack of active
with pus How Inflammation pharmacologic
engagement in
inside. causes pain. regimen to relief
self-management
Redness was Retrieved from pain and
activities can
also noted https://www.garde demonstrate the
contribute to
on the site. nstatepain.com/pos use of relaxation
perpetuation of
• Warmth, t/how-inflammation skills and
chronic pain
tenderness, -causes-pain#:~:text diversional
and pain =While%20the%20s activities as ✔ Determined relevant ✔ Pain is accepted
were noted ensation%20is%20a indicated for
cultural and and expressed in
on the left ,to%20the%20brain individual
spirituality factors different ways
arm. %2C%20causing%20 situation & report
 72

• Pain is more discomfort. PS of no greater affecting

severe upon than 3. pain response
movements
✔ Noted gender and age ✔ There may be

of client differences
between how
women and men
perceive and/or
respond
to pain.

✔ Evaluated pain ✔ Pain behaviors

behavior, noting past can include the

and current pain same ones
experience, present in acute
using pain rating scale pain. Pain
or diary, and including complaints may
functional be exaggerated
effects and because of client’s
psychological factors. perception that
pain
 73

reports are not

believed or
because client
believes
caregivers
are discounting
reports of pain.
✔ Provided
✔ The
comprehensive
assessment of pain pathophysiology
problem, noting its of chronic pain is
duration, who has multifactorial.
been consulted, and
what therapies have
been used

✔ Ascertained impact of
✔ May impact the
condition on
functioning and quality of life
lifestyle

✔ Evaluated pain
 74

reports, noting
✔ To evaluate pain
associated symptoms
on the area.
✔ Encouraged

participation in
✔ to set goals for
multidisciplinary pain
pain relief, and to
management
develop an
plan.
individualized
treatment and
✔ Recommended or
evaluation plan.
employ
✔ To promote
nonpharmacological
relaxation and
comfort measures and
helps refocus
diversional activities.
attention.

MANAGEMENT OF
RESOURCES &
ENVIRONMENT

✔ Raised side rails.

 75

✔ To promote
✔ Lessened
comfort and
environmental noises safety and prevent
falls.

✔ Provided patient with ✔ To avoid

a comfortable distractions to
mattress and blanket. sleep and rest.

✔ Observed protocols ✔ To promote rest

on pollution-control & and sleep.

observed proper
disposal of wastes
✔ To promote and
✔ Adheres to policies,
maintain
procedures and cleanliness.
protocols on
prevention and
✔ To promote safety.
control of infection

HEALTH EDUCATION
 76

✔ Determined patient’s

readiness as well as
his barriers to learning

✔ Provided information
✔ To help patient
to patient and SO
identify own
about what to expect
learning needs.
of particular therapies
✔ A wide range of

LEGAL RESPONSIBILITY discomforts are

common
✔ Informed client and
depending on the
S/O about any
procedure being
procedures
used.
performed &
obtained informed
✔ To adhere
consent.
practices on
accordance with
✔ Accomplished
nursing law and
accurate
other relevant
 77

documentation in all legislation.

matters concerning
✔ For legal purposes
client care in
accordance to the
standards of nursing
practice.

ETHICO-MORAL
RESPONSIBILITY

✔ Rendered nursing

care consistent with

the client’s bill of
rights
✔ To adhere

practices on
accordance with
nursing law and
✔ Provided patient’s
other relevant
privacy legislation.

✔ To respect
 78

patient’s rights.
✔ Provided

confidentiality to
✔ To respect the
patient’s data and
records. rights of the
patient.
PERSONAL &
PROFESSIONAL
DEVELOPMENT

✔ Applied learned

information for the

✔ To deliver
improvement of care
appropriate
nursing care to
✔ Demonstrated good
the patient.
manners and right
✔ To respect patient
conduct at all times
QUALITY IMPROVEMENT and improve
rapport.
✔ Encouraged the pt. to

raise feedback and

 79

questions
✔ Questions

facilitate open
communication
between patient
and health care
professionals and
allow verification
✔ Solicited feedback
of understanding
from client and given information.
significant others
✔ To help identify
regarding care
improvements in
rendered
the delivery of
✔ Shared with the team
healthcare.
relevant information
regarding clients’
✔ allow verification
condition and
of understanding
significant changes in
given information
clients’ environment
and give
appropriate
 80

RESEARCH healthcare
interventions
✔ Specified researchable

problems regarding
✔ To improve
client care and
community health delivery of
RECORD MANAGEMENT healthcare
interventions.
✔ Completed updated

documentation of
client care (to record
✔ To record the care
the care given to
patient and to respect given to patient
patient’s rights) and respect their
rights.
✔ Applied principles of

record management

✔ Monitored and
✔ To adhere to
improved accuracy,
hospital protocols.
completeness and
✔ Makes record
reliability of
 81

relevant data readily accessible

to facilitate client
✔ Maintained integrity,
care.
safety, access and
security of records
✔ Makes record

readily accessible
to facilitate client
care and ensures
✔ Followed protocol in
safety of patient’s
releasing records and
records.
other information
✔ To ensure safety

COMMUNICATION of patient’s data.

✔ Built rapport to

patient & SO

✔ Spoke with the client

✔ To build trust and
with a well-modulated
rapport.
voice and slow pace.
✔ To facilitate
 82

understanding of
✔ Provided an
the patient.
atmosphere of
✔ Conveying respect
respect, openness,
trust, and is especially
collaboration important when
providing health
teaching to
patients with
different values
and beliefs about
health and illness
and a calm
environment
allows the patient
to concentrate
and focus.
✔ Interpreted and
✔ To monitor
validated client’s
body language and patient’s current
facial expressions status.
 83

✔ Provided reassurance
✔ To promote
through therapeutic
touch, warmth and patient comfort.
comforting words of
encouragement

✔ Utilized informatics to
✔ To improve
support the delivery
of healthcare delivery of
information and
COLLABORATION & TEAM healthcare.
WORK

✔ Regulated and ✔ To keep

monitored IVF as electrolytes

prescribed by the balanced and
physician. route for possible
medication
administration.
✔ Ibuprofen given as
✔ To reduce pain
prescribed.
 84

✔ Reviewed lab results

✔ To determine the
with HCP
status of the
patient.
✔ Developed an
✔ An organized plan
individualized pain
management plan beginning with
with the patient and the simplest
physician. Discussed dosage schedules
plan to patient and and least invasive
SO/ family. modalities
improves chance
for pain control.
✔ Assisted family in
✔ Positive
developing a program
of coping strategies reinforcement,
encouraging
SO/family to use
own control can
aid in focusing
energies on more
 85

productive
activities

✔ Emphasized to pt &
✔ To evaluate
SO the need for
regular medical and disease status and
laboratory follow-up response to
therapies.

REFERENCES
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket Guide. (15th ed.). Philadelphia:
F.A. Davis Company
Garden State Pain & Orthopedics (2017). How Inflammation causes pain. Retrieved from
https://www.gardenstatepain.com/post/how-inflammation-causes-pain#:~:text=While%20the%20sensation%20is%20a,to%20t
he%20brain%2C%20causing%20discomfort.
 86

DISCHARGE PLAN

Table 12. Discharge Plan

● Continue taking home meds as prescribed by the physician.
o Folic Acid + Ferrous Sulfate + Vit. B complex tab, 1 tab,
Medication PO, OD
o Ascorbic Acid + Zinc Chewable Tab, 1 Tab, OD
o Ibuprofen, 1 tab, as needed
● Educate the patient of the expected therapeutic effect of the
meds
● Advice patient to follow these general guidelines:
o Take medication as directed.
o Do not change the amount or the schedule.
o Do not stop taking prescription medication without
talking to the doctor.
o Do not share prescription medication.
o Ask what results and side effects to expect. Report them
to your doctor.
o Some medications can be dangerous when mixed.
o Talk to a doctor or pharmacist if you are taking more
than one medication. This includes over-the-counter
medication and herb or dietary supplements.

● Advice patient and SO to maintain a clean environment to avoid

recurrence of infection
Environment ● Encourage patient and SO to stay in a well-ventilated area
● Advice patient and SO to maintain an environment conducive
for rest and sleep

● Advise patient and SO to comply with follow-up schedules

o Return to CCMC at OPD on 11/30/2022
Treatment ● To help prevent infection:
 87

o Keep the patient’s surroundings clean.

o Wash hands frequently

Health Teaching Teach patient the following:

• Apply warm compress on the left arm, thrice a day, for 15
minutes.
• Do not scratch bug bites or areas of injury.

Call 911 if:

• You have sudden trouble breathing or chest pain.

Seek care immediately if:

Observable
• Your wound gets larger and more painful.
signs & symptoms
• You feel a crackling under your skin when you touch it.
• You have purple dots or bumps on your skin, or you see bleeding
under your skin.
• You have new swelling and pain in your legs.
• The red, warm, swollen area gets larger.
• You see red streaks coming from the infected area.

Contact your healthcare provider if:

• You have a fever.
• Your fever or pain does not go away or gets worse.
• The area does not get smaller after 2 days of antibiotics.
• Your skin is flaking or peeling off.
• You have questions or concerns about your condition or care.

Diet • Encourage patient to consume healthy foods rich in vitamins and

minerals such as fruits and vegetables.
 88

• Encourage patient to consume foods rich in proteins such as

pork, beans, chicken, and eggs to promote wound healing.
• Encourage patient to drink adequate amount of water.

● Put God in the center of the family

Spirituality
● Pray for faster recovery and continuous healing
● Always be grateful of all the blessings received

REFERENCES
Drugs.com (2022). Cellulitis. Retrieved from https://www.drugs.com/cg/cellulitis-discharge-
care.html
 89

HEALTH TEACHING # 1

TOPIC: CELLULITIS AND PREVENTION OF RECURRENCE

GENERAL OBJECTIVES: After 20 minutes of nurse-patient interaction at CCMC pediatric ward, the patient will gain knowledge
about cellulitis and apply ways to prevent its recurrence.
Table 13. Health Teaching Plan No. 1

LEARNING LEARNING CONTENT LEARNING TIME TEACHING EVALUATION

OBJECTIVES ACTIVITY ALLOTED STYLE
After 20 minutes of After 20 minutes of
nurse-patient nurse-patient
interaction the interaction the
patient will be able patient was able
to: to: correctly
explain what is
- Explain her - Cellulitis is a common bacterial I. Introduction 2 minutes Question and cellulitis including
understanding skin infection that causes What is Answer, its causes, risk
about Cellulitis redness, swelling, and pain in the cellulitis? sharing factors, signs and
infected area of the skin. symptoms, and
demonstrate the
ways to prevent its
- Identify the risk Causes. Staphylococcus and
recurrence.
factors and streptococcus bacteria. When there
 90

causes of is a break in the skin, these bacteria

cellulitis can cause a skin infection. II. Lecture 15 minutes Pamphlet,
Proper One-on-one
Risk factors for cellulitis include: - Definition discussion,
- Cracks or peeling skin between of cellulitis demonstration
the toes - Causes and
- History of peripheral vascular risk factors
disease of cellulitis
- Injury or trauma with a break in - Signs and
the skin (skin wounds) symptoms
- Insect bites and stings, animal of cellulitis
bites, or human bites - Ways to
- Ulcers from certain diseases, prevent
including diabetes and vascular recurrence
disease of cellulitis
- Use of corticosteroid medicines
or other medicines that suppress 3 minutes Demonstration
III. Evaluation
the immune system , Q&A, sharing
1. Explain your
- Wound from a recent surgery
learnings
about cellulitis
 91

- Identify the Symptoms of cellulitis include: 2.

signs and - Fever with chills and sweating Demonstrate
symptoms of - Fatigue the ways on
cellulitis - Pain or tenderness in the affected how to prevent
area recurrence of
- Skin redness or inflammation that cellulitis
gets bigger as the infection
spreads
- Skin sore or rash that starts
suddenly, and grows quickly in
the first 24 hours
- Tight, glossy, stretched
appearance of the skin
- Warm skin in the area of redness
- Muscle aches and joint stiffness
from swelling of the tissue over
the joint
- Nausea and vomiting

- Demonstrate
and apply the Protect your skin by:
ways to
 92

prevent - Keeping your skin moist with

recurrence of lotions or ointments to prevent
cellulitis cracking
- Wearing shoes that fit well and
provide enough room for your
feet
- Learning how to trim your nails to
avoid harming the skin around
them
- Wearing appropriate protective
equipment when participating in
work or sports

Whenever you have a break in the

skin:
- Clean the break carefully with
soap and water. Apply petroleum
jelly every day.
- Cover with a bandage and change
it every day.
 93

- Watch for redness, pain,

drainage, or other signs of
infection.

Others:
- Wash your hands frequently
- Maintain a sanitary environment
- Avoid scratching insect bites
- Practice good hygiene

REFERENCES

CDC (2022). Cellulitis: All You Need to Know. Retrieved from https://www.cdc.gov/groupastrep/diseases-

public/Cellulitis.html#:~:text=Cellulitis%20is%20a%20common%20bacterial,are%20important%20for%20preventing%20cell
ulitis.

Penn Medicine (2021). Cellulitis. Retrieved from https://www.pennmedicine.org/for-patients-and-visitors/patient-

information/conditions-treated-a-to-z/cellulitis
 94

HEALTH TEACHING # 2

TOPIC: HOW TO PREVENT WOUND INFECTION

General objectives: After 20 minutes of student nurse – patient interactive lecture demonstration at CCMC Pedia Ward, the patient
will be able to know and apply the learned ways on how to prevent wound infection.
Table 14. Health teaching # 2

LEARNING LEARNING CONTENT LEARNING TIME TEACHING EVALUATION

OBJECTIVES ACTIVITY ALLOTED STYLE
After 20 minutes I-Attention After 20 minutes of
of student Catching Activity student nurse-
nurse-patient - How do you 3 minutes Questioning & patient lecture
interactive lecture perform wound sharing demonstration the
demonstration dressing? patient was able
they will be to: to:
- Explain the
- Explain the A wound infection occurs when I-Lecture Proper Demonstratio meaning of
meaning of germs such as bacteria gain access 12 minutes n and wound
wound to and grow within the damaged interactive infection
infection skin of a wound. lecture using - Determine
creative ppt when to call a
presentation.
 95

- Determine doctor for sign

when to call a When to call the Doctor. Call your Giving of and symptoms.
doctor (sign doctor if you have any of these brochure - Enumerate &
and symptoms changes around your wound. about proper demonstrate
to be reported) ● warm skin around the II-Video wound care the ways to
wound Showing prevent wound
● yellow or green discharge 3 minutes infection &
coming from the wound Video showing promote timely
● the wound giving off an wound healing.
unpleasant odor III- Learning
● red streaks on the skin Assessment
around the wound -Proper 2 minutes Q & A, &
● fever and chills demonstration sharing
● aches and pains of on how to
● nausea and vomiting properly change
the wound
1. Ensure that all necessary dressing
- Enumerate &
equipment is clean. - Questioning
demonstrate
2. Thoroughly wash the hands the client of the
the ways to
with soap and warm water, things he/she
prevent wound
then rinse and dry them. learned about
 96

infection & 3. If there is active bleeding, hold the wound

promote timely a clean bandage or gauze to infection.
wound healing. the wound and apply pressure
until it stops.
4. Clean the cut or scrape by
running warm water over it for
several minutes. Use warm,
soapy water to clean the
surrounding skin, but avoid
getting soap in the wound.
5. Apply a thin layer of antiseptic
ointment.
6. Allow the skin to air-dry before
covering it with gauze or a
bandage. There is usually no
need to cover minor cuts and
scrapes.
7. Change the wound dressing at
least once a day. Replace it
immediately if it gets damp or
dirty.
 97

8. Keep a close eye on your

wound in case it does get
infected.
9. Encourage intake of
protein-rich and calorie-rich
foods and encourage a
balanced diet.
10. Educate clients and SO
(significant other) about
appropriate cleaning,
disinfecting, and sterilizing
items.

REFERENCES
Megan et. al. (2022). How to recognize and treat an infected wound. Medical News Today
retrieved from https://www.medicalnewstoday.com/articles/325040
 98

HEALTH TEACHING # 3
TOPIC: PROPER WOUND CARE
General objectives: After 20 minutes of student nurse – patient interactive lecture demonstration at CCMC Pedia Ward, the patient
will be able to demonstrate how to properly perform wound care.

Table 15. Health Teaching # 3

LEARNING LEARNING CONTENT LEARNING TIME TEACHING EVALUATION

OBJECTIVES ACTIVITY ALLOTED STYLE
After 20 minutes After 20 minutes of
of student student nurse-
nurse-patient I-Attention 2 minutes Questioning & patient interactive
interactive lecture Catching sharing lecture
demonstration, Activity demonstration, the
the patient will be - How do you patient was able to:
able: usually take - acquire
care of your knowledge on
- Acquire Wound care- refers to specific types wound? proper wound
knowledge of treatment wounds. This care
about proper procedure is done when the - Identify the
wound care patient’s normal skin integrity is 10 minutes Demonstration different
II. Lecture
damaged. This type of treatment is and interactive materials
Proper
performed in order to promote the lecture using needed for
 99

patient’s skin repair and creative ppt wound care and

-Identify the regeneration. presentation. demonstrate
different MATERIALS NEEDED FOR WOUND Giving of how to properly
materials needed CARE brochure remove an old
for simple wound - Medical gloves about proper dressing, clean
care & explain its - Disposable face mask wound care. the wound and
uses - Apron change wound
- Alcohol pads dressing.
- Cotton balls III. Video 3 minutes Video showing
- Cotton tipped applicators Showing
- Gauze sponges
- Non-Woven sponges
- Dressing bandage
- Medical tape 5 minutes Q & A, &
IV - Learning
- Ointments and medicines such as sharing,
Assessment
betadine demonstration
-Proper
demonstration
-Demonstrate Removing the old Dressing
of simple wound
how to properly Follow these steps to remove your
care
remove an old dressing:
- Questioning
dressing
 100

- Wash your hands thoroughly the client of the

with soap and warm water things he/she
before and after each dressing learned about
change. the simple
- Put on a pair of non sterile wound care
gloves.
- Carefully remove the tape.
- Remove the old dressing. If it is
sticking to your skin wet it with
warm water.
- Remove the gauze pads or
packing tape from inside your
wound.
- Put the old dressing, packing
material, and your gloves in a
plastic bag. Set the bag aside.
- Demonstrate
how to
Cleaning the Wound
properly clean
Follow these steps to clean your
the wound
wound
 101

- Put on a new pair of non sterile

gloves
- Use a clean soft washcloth to
gently clean your wound with
warm water and soap. Your
wound should not bleed much
when you are cleaning it. A small
amount of blood is OK.
- Rinse your wound with water.
Gently pat it dry with a clean
towel. DO NOT rub it dry.
- Check the wound for increased
redness, swelling or bad odor.
- Pay attention to color and
amount of drainage from your
wound. Look for drainage that
gas become darker or thicker.
- After cleaning the wound remove
your gloves.
- Demonstrate - Wash your hands again.
how to
 102

properly
change the Changing your dressing
wound Follow these steps to put a new
dressing dressing on:
- Put on a new pair of non sterile
gloves.
- Pour saline into a clean bowl.
- Squeeze the saline from the
gauze pad until it is no longer
dripping.
- Place the gauze pads in your
wound. Carefully fill the wound
and any spaces under the skin.
- Cover the wet gauze with a large
dry dressing pad. Use rolled
gauze to hold this dressing in
place.
- Put all used supplies in the
plastic bag. Close it securely the
put it in a second plastic bag, and
 103

close that bag securely. Put it in

the trash.
- Wash your hands again when you
are finished.

REFERENCES
How Should I Clean a Wound? (n.d.). WebMD. Retrieved September 25, 2022, from https://www.webmd.com/first-aid/relieving-
wound-pain?fbclid=IwAR04LCIDKKCbLXL-SEnhSkqBayNh753JXWl016dVNc7wZWORodpvtXpnuQs
 104

DRUG STUDY # 1

Table 16. Drug Study No. 1

Name of Classification Mechanis Indication Contraindication Adverse Nursing

Drug m of Reactions Responsibilities
Action
Generic General Bactericidal General  Hypersensitivity to CNS: Chills, Before
Name: Classification action is Indication: vancomycin depression, - Assess for
Vancomycin Tricyclic due to  Parenterally  allergy to corn or dizziness, contraindications
glycopeptide inhibition of for corn products fatigue, fever, - Monitor IV site
Trade derivative cellwall potentially life  Previous hearing headache, closely; necrosis and
Name: biosynthesis threatening loss insomnia, tissue sloughing will
Vancocin Functional and infections in vertigo result from
Classification: alteration of patients CV: Hypotension, extravasation.
Antibiotic bacterial allergic, peripheral edema, - Store parenteral
cell-membra nonsensitive, or vasculitis solutions in
Patient’s ne resistant to EENT: Ototoxicity refrigerator for up to
Dose: 810 permeability other less GI: Abdominal 14 days; after further
mg, IV Drip and toxic pain, dilution, parenteral
q8H ribonucleic antimicrobial constipation, solution is stable 24 h
acid (RNA) drugs Clostridium at room temperature.
Maximum synthesis.  Used orally difficile associated - Assess hearing. Drug
 105

Dose: Active only in diarrhea, may cause damage to

3,000mg against Clostridium diarrhea, flatulence, auditory branch (not
many difficile nausea, vomiting vestibular branch) of
Minimum gram-positiv colitis and GU: eighth cranial nerve,
Dose: e staphylococcca Nephrotoxicity, with consequent
10mg organisms. l UTI deafness, which may be
enterocolitis HEME: Anemia, permanent
(not eosinophilia, During
effective by neutropenia, - To reconstitute properly
oral thrombocytopenia - Avoid rapid infusion,
route for MS: Back pain R which may cause
treatment ESP: Dyspnea, sudden hypotension.
of systemic wheezing - Monitor BP and heart
infections) SKIN: Exfoliative rate continuously
dermatitis; drug through period of drug
Patient’s rash administration.
Indication: with eosinophilia After
Cellulitis and • Monitor patient
systemic symptoms response to therapy
(DRESS); • Monitor for adverse
exfoliative effects
dermatitis; • Evaluate patient/SO
 106

extravasation with understanding on drug

pain, tenderness, therapy by asking
thrombophlebitis, patient to name the
and drug, its indication, and
tissue necrosis; adverse effects to watch
pruritus; rash; for.
StevensJohnson • Monitor patient
syndrome; compliance to drug
toxic epidermal therapy
necrolysis; urticaria • Notify prescriber
Other: Anaphylaxis, promptly of ringing in
drug-induced fever, ears.
hypokalemia,
injection-site
inflammation,
superinfection
Sources:
BOOK
Karch, A. M. (2017). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer
 107

DRUG STUDY # 2

Table 17. Drug Study No. 2

Name of Classification Mechanism Indication Contraindicatio Adverse Nursing

Drug of Action n Reactions Responsibilities
Generic General Paracetamol Temporary - hypersensitivity to Hematologic: Before
Name: Classification exhibits relief of pain drug hemolytic anemia, • Assess for the cautions and
Paracetamo analgesic andand leukopenia, contraindications (e.g. drug
l Non-opioid antipyretic discomfort neutropenia, allergies, CNS depression,
Analgesics activity by from pancytopenia, cv disorders, etc.) to
Trade Antipyretics inhibiting headache, thrombocytopenia. prevent any untoward
Name: prostaglandi fever, cold, Hepatic: complications.
Functional n synthesis. flu, minor liver damage, • Perform a thorough
Pfizer Classification: It produces muscular jaundice physical assessment &
Analgesics analgesia by aches, Metabolic: obtain VS
Antipyretics elevating the overexertion, hypoglycemia
pain menstrual Skin: rash, urticaria During
threshold andcramps, • Administer appropriate
antipyresis toothache, dosage at right route and
Patient’s through minor frequency
Dose: 300 action on the arthritic • Educate client/SO on drug
 108

mg IVTT hypothalami pain. therapy to promote

q4H PRN c understanding and
for temp heat-regulati Patient’s compliance.
>/= 38c ng center. Indication: • Assess for hypersensitivity
Fever
Maximum After
Dose: • Monitor patient response
4000mg to therapy
• Monitor for adverse effects
Minimum • Evaluate patient/SO
Dose: understanding on drug
10mg therapy by asking patient
to name the drug, its
indication, and adverse
effects to watch for.
• Monitor patient
compliance to drug therapy

Sources:
BOOK
Karch, A. M. (2017). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer
 109

DRUG STUDY #3

Table 18. Drug Study No. 3

Name of Classificatio Mechanism of Indication Contraindicatio Adverse Nursing

Drug n Action n Reactions Responsibilitie
s
Generic General Inhibits -Relief of -Contraindicated with CNS: Before
Name: Classification prostaglandin signs and allergy to ibuprofen, Headache, • Assess for the cautions
Ibuprofen synthesis by symptoms of NSAID, salicylates Dizziness, and contraindications to
Non-opioid decreasing the rheumatoid (common in patients Somnolence, prevent any untoward
Trade Analgesics activity of the arthritis with Insomnia, fatigue, complications.
Name: Antipyretics enzyme, -Relief of asthma, rhinitis, Tinnitus, • Perform a thorough
Advil cyclooxygenase mild to chronic Ophthalmologic physical assessment &
Functional , which moderate urticaria, and nasal Effects obtain VS
Patient’s Classification: results in pain polyps)
Dose: Non – Narcotic decreased -Treatment of - To be used Respiratory: During
200mg/capge Analgesics formation of primary cautiously Dyspnea, rhinitis, • Administer drug
l prostaglandin dysmenorrhe with hypertension, GI Hemoptysis, with food or meals
1 capgel q6h precursors. a bleeding, peptic ulcer, Pharyngitis, if GI upset occurs.
PRN -Fever impaired renal or Bronchospasm • Administer appropriate
 110

reduction hepatic dosage at right route

function, pregnancy, and frequency
Maximum or lactation. CV: • Educate client/SO on
Dose: 3200 Patient’s Hypertension, drug therapy to
mg Indication: Palpitations, promote understanding
- For Pain Arrhythmia and compliance.
Minimum • Assess for
Dose: Hematologic: hypersensitivity
200mg Bleeding,
Platelet inhibition After
in higher doses, • Monitor patient
Neutropenia, response to therapy
Leukpenia, • Monitor for adverse
Pancytopenia, effects
Thrombocytopenia • Evaluate patient/SO
, understanding on drug
Agranulocytosis, therapy by asking
Aplastic anemia, patient to name the
Decreased Hgb drug, its indication, and
and Hct adverse effects to watch
for.
Dermatologic: • Monitor patient
 111

Rash, pruritus, compliance to drug

Sweating, therapy
Dry mucous • Arrange for
Membranes, periodic
Stomatitis ophthalmologic
examination for
long term drug use.
• Discontinue drug if
eye changes,
symptoms of liver
dysfunction or renal
impairment occur.
• Instruct patient to
use the drug as
suggested and to
avoid over-the
counter medications
(many OTC drugs
contain similar
components which
may lead to
overdose).
 112

• Instruct patient to
report mouth sores,
fever, chills, weight
gain, changes in
vision, swelling in
ankles or fingers,
and black, tarry
stools.
• Instruct patient to
limit activities to
those that do not
require alertness
and precision.
Sources:
BOOK
Karch, A. M. (2017). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer
 113

DRUG STUDY #4

Table 19. Drug Study No. 4

Name of Classification Mechanis Indicatio Contraindica Adverse Nursing Responsibilities

Drug m of n tion Reactions
Action
Generic General -. Exert  Serious - allergy to the  GI: diarrhea, Before
Name: Classification bactericidal intra-abdo drug or nausea, vomiting, • Assess for the cautions and
Meropene Carbapenems effect by minal, betalactams dehydration and contraindications
m inhibiting urinary - seizure disorders electrolyte • Perform a thorough physical
Functional cell tract, skin - lactation imbalance assessment
Classification: membrane and skin  CNS: • Perform culture and sensitivity
Antibiotics synthesis in structure, headache, tests at the site of infection to
Trade susceptible bone dizziness, altered ensure appropriate use of the
Name: bacteria, and joint, mental state drug.
Meronem leading to and  • Conduct orientation and reflex
cell death. gynecolog Superinfections assessment, as well as auditory
Patient’s ical testing to evaluate any CNS
Dose: 1g infections. effects of the drug
IV drip  (aminoglycosides)
q8H Infections: During
S.pneumo • Check culture and sensitivity
 114

Maximum niae, reports.

Dose: 2 g H.influenz • Administer drug with appropriate
ae, E.coli, dosage at the right route.
Minimum K.pneumo • Ensure that patient receives full
Dose: 0.25 niae, course.
mg B.fragilis, • Monitor infection site and
P.mirabilis presenting signs and symptoms
, throughout course of drug therapy.
P.aerugino • Provide safety measures to protect
sa, and the patient if CNS effects occur.
P.bivia. • Educate client on drug therapy to
promote understanding and
compliance.
Patient’s • Provide the following patient
Indication teaching on safety precautions (e.g.
: changing positions, avoiding
Cellulitis hazardous tasks, ec.), drinking lots
of fluids and to maintain nutrition
even though nausea and vomiting
may occur, report difficulty
breathing, severe headache, fever,
diarrhea, and signs of infection.
 115

After
• Monitor patient response to therapy
• Monitor for adverse effects
• Evaluate patient understanding on
drug therapy by asking patient to
name the drug, its indication, and
adverse effects to watch for.
• Monitor patient compliance to drug
therapy
Sources:
BOOK
Karch, A. M. (2017). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer
 116

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