Student Name: Es-esa, Shierly Ann Roman

Kiw-is, Karl Kristian B.

Kiblasan, Cristina S.

Year and Group Group IV-A

Level Offering 2st Semester AY 2021-2022

Clinical area of Orthopedic CS

assignment

Date of Exposure February 6-7, 2022

No. of hours 24 hours

II. PATIENTS PROFILE

Name of Patient: Z
Sex: Male
Age: 40 years old
Birthday: January 25, 1982
Birthplace: Ambiong, La Trinidad Benguet
Religion: Roman Catholic
Civil Status: Married
Educational Attainment: College Graduate
Occupation: Teacher
Number of Sibling: 3
Nationality: Filipino
Date of Admission: February 1, 2021
Time of Admission: 8:00@am
Informant: Wife
Blood Pressure: 140/90 mmHg
Temperature: 37.6 C
Pulse Rate: 76 bpm
Respiration: 20 cpm
Attending Physician: Dr. XYZ
Chief Complaint: Pain thus, he experienced limitation of movement at lower
extremities specifically in the right foot.
Admitting Diagnosis: Gout athritis
Final Diagnosis: Gout arthritis

lll.History of Present Illness

Present Medical History

Patient usually doing his lesson plan at 9pm. He seldom experience pain over
his right foot and observed slightly swollen. With this, he experience minimal
movements of extremities. After a sudden he cannot tolerate the pain in the morning
thus, he requested to his wife to bring to the hospital because the pain aggravates and
subsequently admitted.
Past Health History and Family History

In an interview with patient Z, he claimed that he has a hypertension and

take amlodipine as maintenance. He had experienced common childhood illnesss such
as chicken pox and mumps. He also experienced cough,colds,sore throat and fever. He
was able to manage it through bed rest and buying over the counter drugs. He also
took OTC drugs such as biogesic for headache and paracetamol for fever. He had
complete immunization from birth to childhood.
According to patient Z, they had a history of asthma on maternal side &
hypertension on both sides. They don’t have any history of Diabetes Mellitus, Cancer
& any other diseases which are hereditary.
Social, Environmental History

For his social and environmental history, patient Z is teaching for almost 20
years from his respective school. He actively participates in school activities with
colleagues and students like in sports and technology livelihood education such as
gardening. He usually drinks alcohol at night. He smoke usually takes 3-5 stick a day.
He lives with his wife and children in their own house.

IV. 13 AREAS OF ASSESSMENT

1. Psychosocial and Psychological Status

Patient Z is 40 years old, born on January 25,1982. He lives in a two-story

house with 4 rooms together with his wife and 3 children. He is a teacher and can
understand Kankana-ey, ibaloi and Ilokano. The patient and her family is Roman
Catholic and have no practices or beliefs which might affect to providing health care.
Watching the television, eating and singing is his way in spending her leisure time. He
has positive outlook in his life.
2. Mental and Emotional Status

He is conscious and coherent, oriented to time, date, place and person. He is

able to understand instructions and acts according to his age. He is responsive to
verbal commands, touch, and pain stimuli. He is cooperative and responded to the
question being asked. He is also mentally affected because of present illness however
his wife and children became more loving and supportive to him.
3. Environmental Status

He is oriented that he is in the hospital. Patient is knowledgeable about his

conditions. There is steady pattern of activity, light noise and color in his environment
and it does not distract him. The food and water are at the side table and is placed at
the right side of the patient, it is accessible to him.
4. Sensor Status

A. Visual Status. Cloudiness in the right pupil is present, able to read

with reading glasses, pupils are equally round, reactive to light and
accommodation, able to follow penlight with gaze.

B. Auditory. Ears are parallel, symmetrically proportional to the size of

the head. Patient has no difficulty hearing the spoken words when the whisper
test was conducted.
C. Olfactory Status. His nose has no deviation in terms of shape and
size. Upon palpation, no tenderness, no inflammation or nodules on the frontal,
sphenoid, ethmoid, and maxillary sinuses were noted. No discharges were seen
during the assessment. He was able to distinguish the different smells since his
admission.
D. Gustatory Status. No lesions seen upon inspection. Patient was able
to identify the different tastes such as oranges and banana.

E. Tactile Status. He can distinguish light from firm touch on his body
and is able to perceive hot and cold sensations in proportion to stimulus and
there are no aberrant sensations. With skin turgor of 20 seconds.
5. Motor Status
Motor strength is assessed. His movements are limited since he is connected to
an IV line and uncomfortable due to pain. The patient was able to move without
assistance. He can move all his joints slowly and carefully.
6. Thermoregulatory Status
Patient’s body temperature ranges from (36.5°C) to 99.5°F (37°C). The patient’s
temperature levels all falls on the normal range. There is no sign of profuse sweating.

DATE TIME TEMPERATURE

8 AM 37 °C
February 7,2022 11 AM 36.5°C
3 PM 36°C
8 AM 36.1°C
February 8,2022 11 AM 36.6°C
3 PM 36.5°C
February 9,2022 8 AM 36.5°C
 11 AM 36.4°C
3 PM 36°C

7. Respiratory Status
Patient’s respiration rate ranges from 15 to 23 breaths per minute. The
patient’s respiratory rate falls on the normal range while the SPO2 ranges from 95-
99%. No sign of use of accessory muscle.

DATE TIME RR SPO2

7AM 18 BPM 98%
February 7,2022 10 AM 20 BPM 97%
2 PM 23 BPM 9o%
8 AM 21 BPM 99%
February 8,2022 11 AM 18 BPM 96%
3 PM 17 BPM 97%
8 AM 20 BPM 96%
February 9,2022 11 AM 22 BPM 97%
3 PM 20 BPM 99%
8. Circulatory Status
Patient’s heart rate ranges from 60 to 100 beats per minute. The patient’s
cardiac rate falls within the normal range. Blood pressure has a systolic reading of
130-140 mmHg and a diastolic reading of 80-90 mmHg. The patient’s BP has had high
systolic and diastolic readings. Capillaryrefill is2 seconds.

CAPILLIARY
DATE TIME HR BP
REFILL
8AM 65 BPM 2 SECONDS 140/ 90mmHg
February 7, 2022 11 AM 80 BPM 2 SECONDS 130/90 mmHg
3 PM 79 BPM 2 SECONDS 140/ 90mm/Hg
8 AM 88 BPM 2 SECONDS 130/80 mmHg
February 8, 2022 11 AM 75 BPM 2 SECONDS 130/80mmHg
3 PM 90 BPM 2 SECONDS 140/60mm/Hg
8 AM 87 BPM 2 SECONDS 120/80mmHg
February 9, 2022 11 AM 90 BPM 2 SECONDS 130/80mmHg
3 PM 78 BPM 2 SECONDS 140/90mmHg
9. Nutritional Status

The patient’s food is being served in the hospital. The patient’s appetite is good.
There is no change in the appetite for food during the hospitalization and health
deviation. There is no culture or religious dietary restrictions reported by the patient.
The patient is able to swallow in her food and medication as well and eat orally by
himself.
10. Elimination Status
Before hospitalization, the patient usually defecates once a day and voids 7-10
times a day. There is no change in his output.
11. Sleep, Rest and Comfort Status

The patient claims that he normally sleeps for 8-9 hours in a day. But during
admission the patient claims that he sleeps less than normal which is 3-5 hours in a
day because he is not comfortable due pain and sometimes being disturbed when
nurses have to get vital signs or give medication.
12. Fluids and Electrolytes Status

Prior to hospitalization the patient usually drinks 2-3 L a day coming from
water, buko juice, coffee and carbonated beverages and urinates 7 times a day.He has
an ongoing IVF of PNSS 1L regulated at 18 gtts/min to replace fluid and electrolyte
loss. The patient denies the feeling of thirst. The patient’s capillary refill is 1-2
seconds, with good skin turgor.
13. Integumentary Status

Skin color is brownish and with a good skin turgor. Swelling on right foot was
noted.
V. Anatomy and Pathophysiology
 Alcohol intake , hypertension,
age, and diet

Catabolized into ketones

and lactic acid

Ketones and lactic acid complete

with uric acid for execration in
urine, increase excretion of uric
acid. Repetitive trauma to the metatarsophalangeal
joint (toe) due to weight bearing provides
Increase uric acid concentration
nidus for crystals deposition.
in blood, easily leaks into joints Big toe
Crystallization occurs more easily ,uncle or
in cooler areas, i.e. peripheral knee
Uric acid crystalizes in a peripheral joints, as opposed to proximal
joints.
joint

Activation of complement cascade

results in leukocytes chemotaxis.
Properties unique to uric acid
crystals on polarizing Negatively birefringent (blue)
Neutrophils enter joint to phagocytes the
microscopy. Uric acid crystals seen on
crystals.
synovial fluid analysis
Needle-shapes uric acid crystals puncture Pain, warm, Foot may
Inflammatory
neutrophils, releasing degradative swollen joint become
cascade
enzymes into joint space. (sudden paralyzed
onset) due to pain

Gout arthritis
 HEMATOLOGY RESULT

TEST RESU NORM Interpretat TEST RESU NORM Interpretat

LT AL ion LT AL ion
VALUE VALUE
WBC 10.5 4.5- Normal Hemoglo 133 Male: Normal
COUNT 11.0 bin 130-
180,
Female
: 120-
160
RBC 4.28 3.6-6.0 Normal Hematoc 0.40 Male: Normal
COUNT rit 0.41-
0.51,
Female
: 0.36 -
0.45
Neutroph 0.61 0.35 - Normal Platelets adequ 150- Normal
ils 0.71 ate 450
Lymphoc 0.39 0.24 – Normal
yte 0.44
Uric acid 9.8 3.5 to High level
blood 7.2 of uric acid
test (mg/dl) in the blood

URINALYSIS:

Appearance and Chemical Characteristics:

Color: Sugar: Negative Reaction (pH):
Yellow 6.0
Transparency: Protein: Negative Specific Gravity:
Hazy 1.005

MICROSCOPIC EXAMINATION:
Pus Cells: None Mucous Threads: few
Red Blood Cells: 0-1hpf Bacteria:
occasional
Epithelial Cells: 0-1lpf Cast: none
Amorphous Urates/Phosphates: Others:
Rare
 I. DRUG STUDY
MECHANISM OF INDICATION/ SIDE EFFECTS/ NURSING
NAME OF THE ACTION CONTRAINDICA ADVERSE EFFECTS IMPLICATION
DRUG TION:

GENERIC ACTION: Indication CNS: Headache, Assessment &

NAME: Prototype of the Chronic, dizziness, light- Drug Effects
IBUPROFEN propionic acid symptomatic headedness, anxiety,
NSAIDs (cox-1) rheumatoid Monitor for
emotional lability,
inhibitor with arthritis and therapeutic
osteoarthritis; fatigue, malaise, effectiveness.
BRAND NAME: nonsteroidal anti- drowsiness, anxiety,
relief of mild to Optimum
Advil, Amersol inflammatory confusion, depression,
moderate pain; response
activity and primary aseptic generally occurs
significant dysmenorrhea; within 2 wk
CLASSIFICATI meningitis. CV: Hyperte
antipyretic and reduction of (e.g., relief of
ON: nsion, palpitation,
analgesic fever. pain, stiffness,
CENTRAL congestive heart failure
properties. Blocks or swelling; or
NERVOUS prostaglandin Unlabeled Uses (patient with marginal improved joint
SYSTEM synthesis. Gout, juvenile cardiac function); flexion and
AGENT; NSAID Ibuprofen activity rheumatoid peripheral strength).
(COX-1); also includes arthritis, edema. Special Observe patients
ANALGESIC; modulation of T- psoriatic Senses: Amblyopia with history of
ANTIPYRETIC cell function, arthritis, (blurred vision, cardiac
ankylosing decompensation
inhibition of decreased visual acuity,
spondylitis, closely for
inflammatory cell vascular scotomas, changes in evidence of fluid
chemotaxis, headache. color vision); retention and
decreased release nystagmus, visual-field edema.
of superoxide Contraindicatio defects; tinnitus, Lab tests:
radicals, or ns impaired Baseline and
increased Patient in whom periodic
hearing. GI: Dry mouth,
scavenging of these urticarial, severe evaluations of
gingival ulcerations, Hgb, renal and
compounds at rhinitis,
dyspepsia, heartburn, hepatic
inflammatory sites. bronchospasm,
nausea, vomiting, function, and
angioedema, auditory and
anorexia, diarrhea,
nasal polyps are ophthalmologic
constipation, bloating,
precipitated by examinations
flatulence, epigastric or
FREQUENCY/ aspirin or other are
abdominal discomfort
DOSAGE/ NSAIDs; active recommended in
or pain, GI patients
ROUTES peptic ulcer,
ulceration, occult blood receiving
Inflammatory bleeding
Disease loss. Hematologic: Thr prolonged or
abnormalities. high-dose
Adult: PO 400–800 ombocytopenia,
Safe use during therapy.
mg t.i.d. or q.i.d. neutropenia, hemolytic
(max: 3200 mg/d) pregnancy Monitor for GI
or aplastic anemia,
distress and
Child: PO <20 kg, (category B), leukopenia; decreased S&S of GI
up to 400 mg/d in lactation, or Hgb, Hct; transitory rise bleeding.
divided doses; 20– children <6 mo is in AST, ALT, serum Note: Symptoms
30 kg, up to 600 of acute toxicity
not established. alkaline phosphatase;
mg/d in divided in children
doses; 30–40 kg, rise in (Ivy) bleeding include apnea,
up to 800 mg/d in time. GU: Acute renal cyanosis, and
divided doses failure, polyuria, response only to
azotemia, cystitis, painful stimuli,
Mild to Moderate hematuria, dizziness, and
Pain, nephrotoxicity, nystagmus.
Dysmenorrhea
decreased creatinine
Adult: PO 400 mg Patient &
q4–6h up to 1200 clearance. Skin: Maculo Family
mg/d papular and Education
vesicobullous skin
Fever eruptions, erythema Notify physician
Adult: PO 200–400 multiforme, pruritus, immediately of
mg t.i.d. or q.i.d. rectal itching, passage of dark
(max: 1200 mg/d) tarry stools,
acne. Body as a
Child: PO 6 mo–12 "coffee ground"
Whole: Fluid retention emesis, frankly
y, 5–10 mg/kg q4–
with edema, Stevens- bloody emesis,
6h up to 40
Johnson or other GI
mg/kg/d
syndrome, toxic distress, as well
hepatitis, as blood or
protein in urine,
hypersensitivity
and onset of
reactions, anaphylaxis, skin rash,
bronchospasm, serum pruritus,
sickness, SLE, jaundice.
angioedema. Do not drive or
engage in other
potentially
hazardous
activities until
response to the
drug is known.
Do not self-
medicate with
ibuprofen if
taking
prescribed drugs
or being treated
for a serious
condition
without
consulting
physician.
Do not give to
children
younger than 3
mo or for longer
than 2 d without
consulting
physician.
Do not take
aspirin
concurrently
with ibuprofen.
Avoid alcohol
and NSAIDs
unless otherwise
advised by
physician.
Concurrent use
may increase
risk of GI
ulceration and
bleeding
tendencies.
Do not breast
feed while
taking this drug
without
consulting
physician.
 MECHANISM INDICATION/ SIDE EFFECTS/ NURSING IMPLICATION
NAME OF OF ACTION CONTRAINDIC ADVERSE EFFECTS
THE ATION:
DRUG

GENERIC ACTION: Indication Body as a Assessment & Drug

NAME: Potent Palliative Whole: Hypersensitivi Effects
INDOMET nonsteroidal treatment in ty (rash, purpura,  Monitor for
active stages of
HACIN compound with pruritus, urticaria, therapeutic
moderate to
BRAND antiinflammato severe angioedema, angiitis, effectiveness: In
NAME: ry, analgesic, rheumatoid rapid fall in blood acute gouty
Indameth, and antipyretic arthritis, pressure, dyspnea, attack, relief of
Indocid effects similar ankylosing asthma syndrome in joint tenderness
CLASSIFI to those of rheumatoid aspirin-sensitive and pain is
CATION: aspirin. spondylitis, patients), edema, usually apparent
acute gouty
CENTRAL Appears to weight gain, flushing, in 24–36 h;
arthritis, and
NERVOUS reduce motility osteoarthritis of sweating. CNS: Heada swelling generally
SYSTEM of hip in patients che, dizziness, vertigo disappears in 3–5
AGENT; polymorphonuc intolerant to or , light-headedness, d. In rheumatoid
ANALGESI lear leukocytes, unresponsive to syncope, fatigue, arthritis: Reduced
C, development of adequate trials muscle weakness, fever, increased
ANTIPYRE cellular with salicylates ataxia, insomnia, strength, reduced
and other
TIC; exudates, and nightmares, stiffness, and
therapy. Also
NSAID vascular used IV to close drowsiness, relief of pain,
permeability in patent ductus confusion, coma, swelling, and
injured tissue arteriosus in convulsions, tenderness.
resulting in its the premature peripheral  Question patient
antiinflammato infant. neuropathy, psychic carefully
ry effects. disturbances regarding aspirin
Contraindicati
ons (hallucinations, sensitivity before
Allergy to depersonalization, initiation of
FREQUENCY/ indomethacin, depression), therapy.
DOSAGE/ aspirin, or other aggravation of  Observe patients
ROUTES epilepsy, carefully; instruct
NSAID; nasal
Rheumatoid
polyps parkinsonism. CV: El to report adverse
Arthritis
Adult: PO 25– associated with evated BP, reactions
50 mg b.i.d or angioedema, palpitation, chest promptly to
t.i.d. (max: 200 history of GI pains, tachycardia, prevent serious
mg/d) or 75 mg lesions; bradycardia, and sometimes
sustained CHF. Special irreversible or
pregnancy
release 1–2 Senses: Blurred fatal effects.
times/d (category B; D
in third vision, lacrimation,  Lab tests: Monitor
Pediatric trimester), eye pain, visual field renal function,
Arthritis lactation, changes, corneal hepatic function,
Child: PO 1–2 children (14 y). deposits, retinal CBC with
mg/kg/d in 2–4 disturbances differential, BP
divided doses
including and HR, visual
(max: 4
mg/kg/d) or macula, tinnitus, hear and hearing
150–200 mg/d ing disturbances, acuity
epistaxis. GI: Nausea, periodically.
Acute Gouty vomiting, diarrhea,  Monitor weight
Arthritis anorexia, bloating, and observe
Adult: PO/PR 5 abdominal distention, dependent areas
0 mg t.i.d. until
ulcerative stomatitis, for signs of edema
pain is
tolerable, then proctitis, rectal in patients with
rapidly taper bleeding, GI underlying
ulceration, cardiovascular
Bursitis hemorrhage, disease.
Adult: PO 25– perforation, toxic  Monitor I&O
50 mg t.i.d. or hepatitis. Hematolog closely and keep
q.i.d. (max: 200
ic: Hemolytic physician
mg/d) or 75 mg
sustained anemia, aplastic informed during
release 1–2 anemia (sometimes IV administration
times/d fatal), agranulocytosis for patent ductus
, leukopenia, arteriosus.
Close Patent thrombocytopenic Significant
Ductus
purpura, inhibited impairment of
Arteriosus
Premature platelet renal function is
neonate: IV <48 aggregation. Urogenit possible; urine
h, 0.2 mg/kg al: Renal function output may
followed by 2 impairment, decrease by 50%
doses of 0.1 hematuria, urinary or more. Also
mg/kg q12– frequency; vaginal monitor BUN,
24h; 2–7 d, 0.2
bleeding, breast serum creatinine,
mg/kg followed
by 2 doses of changes. Skin: Hair glomerular
0.2 mg/kg q12– loss, exfoliative filtration rate,
24h; <7 d, 0.2 dermatitis, erythema creatinine
mg/kg followed nodosum, tissue clearance, and
by 2 doses of irritation with serum
0.25 mg/kg extravasation. Metab electrolytes.
q12–24h
olic: Hyponatremia, Patient & Family
hypokalemia, Education
hyperkalemia,  Notify physician of
hypoglycemia or S&S of GI
hyperglycemia, bleeding, visual
glycosuria (rare). disturbance,
 tinnitus, weight
gain, or edema.
 Do not take
aspirin or
other NSAIDs;
they increase
possibility of
ulcers.
 Note: Frontal
headache is the
most frequent
CNS adverse
effect; if it
persists, dosage
reduction or drug
withdrawal may
be indicated. Take
drug at bedtime
with milk to
reduce the
incidence of
morning
headache.
 Do not drive or
engage in other
potentially
hazardous
activities until
response to drug
is known.
 Do not breast feed
while taking this
drug.
NAME OF MECHANISM INDICATIO SIDE NURSING IMPLICATION
THE DRUG OF ACTION N/ EFFECTS/
CONTRAIN ADVERSE
DICATION: EFFECTS
GENERIC ACTION: Uses GI: Nausea, Assessment & Drug Effects
NAME: Alkaloid of the Prophylacti vomiting,  Lab tests: Baseline and periodic
COLCHICINE plant Colchicum cally for diarrhea, determinations of serum uric
BRAND autumnale with recurrent abdominal acid and creatinine are advised,
NAME: antimitotic and gouty pain, anorex as well as CBC, including Hgb,
Novocolchine indirect arthritis ia, platelet count, serum
antiinflammator and for hemorrhagi electrolytes, and urinalysis.
CLASSIFICA y properties. acute gout,  Monitor for dose-related
c
TION: either as gastroenteri adverse effects; they are most
ANTIGOUT single agent tis, likely to occur during the initial
AGENT or in steatorrhea, course of treatment.
FREQUENCY/ combinatio hepatotoxici  Monitor for early signs of
DOSAGE/ n with a ty, colchicine toxicity including
ROUTES uricosuric pancreatitis weakness, abdominal
Acute Gouty such as . Hematolo discomfort, anorexia, nausea,
Attack
probenecid, gic: Neutro vomiting, and diarrhea,
Adult: PO 0.5–
1.2 mg followed allopurinol, penia, bone regardless of administration
by 0.5–0.6 mg or marrow route. Report to physician. To
q1–2h until pain sulfinpyraz depression, avoid more serious toxicity,
relief or one. thrombocyt drug should be discontinued
intolerable GI Contraindi openia, agra promptly until symptoms
symptoms (max: cations nulocytosis, subside.
4
Blood aplastic  Monitor I&O ratio and pattern
mg/attack) IV 2
mg followed by dyscrasias; anemia. CN (during acute gouty attack):
0.5 mg q6h until severe GI, S: Mental High fluid intake promotes
relief or renal, confusion, excretion and reduces danger of
intolerable GI hepatic, or peripheral crystal formation in kidneys
symptoms (max: cardiac neuritis, and ureters.
4 mg/attack) disease; syndrome of  Keep physician informed of

Prophylaxis use of IV muscle patient's progress. Drug should

Adult: PO 0.5 or colchicine weakness be stopped when pain of acute
0.6 mg every in patients (accompanie gout is relieved. Therapeutic
night or every with both d by response: articular pain and
other night as renal and elevated swelling generally subside
needed (up to hepatic serum within 8–12 h and usually
1.8 mg/d may
dysfunction creatine disappear in 24–72 h after PO
be needed for
severe . Severe kinase). Ski therapy, and 6–12 h after IV
cases) IV 0.5–1 local n: Severe administration.
mg 1–2 times/d irritation irritation Patient & Family Education
 Surgical can result and tissue  If taking colchicine at home,
Patients from SC or damage if IV withhold drug and report to the
Adult: PO 0.5 or IM use; administrati physician the onset of GI
0.6 mg t.i.d.
pregnancy on leaks symptoms or signs of bone
starting 3 d
before surgery (category around marrow depression (nausea,
and continuing C). Safe use injection sore throat, bleeding gums,
for 3 d after in children site. Urogen sore mouth, fever, fatigue,
surgery not ital: Azotem malaise, unusual bleeding or
established. ia, bruising).
Renal proteinuria,  Keep colchicine on hand at all
Impairment
hematuria, times to start therapy or
Clcr 10–50
mL/min: oliguria. increase dosage, as prescribed
prolonged use is by physician, at the first
not suggestion of an acute attack.
recommended.  Physician may prescribe
Clcr <10 sodium bicarbonate, or sodium
mL/min: reduce or potassium citrate, to
recommended
maintain alkaline urine and
dose by 50%
thus prevent formation of urate
stones.
 Avoid fermented beverages
such as beer, ale, and wine as
they may precipitate gouty
attack. The physician may
allow distilled alcoholic
beverages in moderation.
 Do not breast feed without
consulting physician.

NAME OF MECHANISM INDICATIO SIDE NURSING IMPLICATION

THE DRUG OF ACTION N/ EFFECTS
CONTRAIN /ADVERSE
DICATION: EFFECTS
GENERIC ACTION: Indications CNS: Eupho Assessment & Drug Effects
NAME: Immediate- May be ria,  Establish baseline and
PREDNISON acting synthetic used as a headache, continuing data regarding BP,
E analog of single agent insomnia, I&O ratio and pattern, weight,
BRAND hydrocortisone. or confusion, fasting blood glucose level, and
NAME: Effect depends conjunctive psychosis. sleep pattern. Start flow chart
Deltasone, on ly with CV: CHF, as reference for planning
Meticorten, biotransformatio antineoplas edema. GI: individualized
Orasone, n to tics in Nausea, pharmacotherapeutic patient
Panasol prednisolone, a cancer vomiting, care.
CLASSIFICA conversion that therapy; peptic  Check and record BP during
TION: may be impaired also used in ulcer. Musc dose stabilization period at
HORMONES in patient with treatment uloskeletal: least 2 times daily. Report an
AND liver of Muscle ascending pattern.
SYNTHETIC dysfunction. myasthenia weakness,  Monitor patient for evidence of
SUBSTITUTE Less gravis and delayed HPA axis suppression during
S; ADRENAL mineralocorticoi inflammato wound long-term therapy by
CORTICOST d activity than ry healing, determining plasma cortisol
EROID; hydrocortisone, conditions muscle levels at weekly intervals.
GLUCOCOR but sodium and as an wasting,  Lab tests: Obtain fasting blood
TICOID retention and immunosup osteoporosis glucose, serum electrolytes, and
potassium pressant. , aseptic routine laboratory studies at
depletion can Contraindi necrosis of regular intervals during long-
occur. cations bone, term steroid therapy.
Systemic spontaneou  Be aware that older adult
fungal s patients and patients with low
FREQUENCY/ infections fractures. E serum albumin are especially
DOSAGE/ and known ndocrine: C susceptible to adverse effects
ROUTES hypersensit ushingoid because of excess circulating
Antiinflammato ivity; features, free glucocorticoids.
ry pregnancy growth  Be alert to signs of
Adult: PO 5–60 (category suppression hypocalcemia (see Appendix F).
mg/d in single C), in children, Patients with hypocalcemia
or divided doses lactation. carbohydrat have increased requirements
Child: PO 0.1– e for pyridoxine (vitamin B6),
0.15 mg/kg/d in intolerance, vitamins C and D, and folates.
single or divided hyperglyce  Be alert to possibility of masked
doses mia. Specia infection and delayed healing
l (antiinflammatory and
Acute Asthma Senses: Cat immunosuppressive actions).
Child: PO <1 y, aracts. Hem Prednisone suppresses early
1–2 mg/kg/d atologic: Le classic signs of inflammation.
times 3–5 d or ukocytosis. When patient is on an extended
10 mg q12h; 1–4 Metabolic: therapy regimen, incidence of
y, 20 mg Hypokalemi oral Candida infection is high.
q12h; 5–13 y, 30 a. Inspect mouth daily for
mg q12h; >13 symptoms: white patches, black
y, 40 mg q12h furry tongue, painful
times 3–5 d membranes and tongue.
 Monitor bone density.
Compression and spontaneous
fractures of long bones and
vertebrae present hazards,
particularly in long-term
corticosteroid treatment of
rheumatoid arthritis or
diabetes, in immobilized
patients, and older adults.
 Be aware of previous history of
psychotic tendencies. Watch for
changes in mood and behavior,
emotional stability, sleep
pattern, or psychomotor
activity, especially with long-
term therapy, that may signal
onset of recurrence. Report
symptoms to physician.
 If a patient is receiving aspirin
concomitantly with a
corticosteroid, salicylism may
be induced when the
corticosteroid dosage is
decreased or discontinued.
 Be aware that long-term
corticosteroid therapy is
ordinarily not interrupted when
patient undergoes major
surgery, but dosage may be
increased.
 Monitor for withdrawal
syndrome (e.g., myalgia, fever,
arthralgia, malaise) and
hypocorticism (e.g., anorexia,
vomiting, nausea, fatigue,
dizziness, hypotension,
hypoglycemia, myalgia,
 arthralgia) with abrupt
discontinuation of
corticosteroids after long-term
therapy.
Patient & Family Education
 Take drug as prescribed and do
not alter dosing regimen or stop
medication without consulting
physician.
 Be aware that a slight weight
gain with improved appetite is
expected, but after dosage is
stabilized, a sudden slow but
steady weight increase [2 kg (5
lb) per wk] should be reported
to physician.
 Avoid or minimize alcohol and
caffeine may contribute to
steroid-ulcer development in
long-term therapy.
 Report symptoms of GI distress
to physician and do not self-
medicate to find relief.
 Do not use aspirin or other
OTC drugs unless they are
prescribed specifically by the
physician.
 Report slow healing, any vague
feeling of being sick, or return
of pretreatment symptoms.
 Be fastidious about personal
hygiene; give special attention
to foot care, and be particularly
cautious about bruising or
abrading the skin.
 Report persistent backache or
chest pain (possible symptoms
of vertebral or rib fracture) that
may occur with long-term
therapy.
 Tell dentist or new physician
about prednisone therapy.
 Carry medical information at all
 times. It needs to indicate
medical diagnosis,
medication(s), physician's
name(s), address(es), and
telephone number(s).
 Do not breast feed while taking
this drug without consulting
physician.

MECHANISM INDICATIO SIDE NURSING IMPLICATION

NAME OF OF ACTION N/ EFFECTS/
THE DRUG CONTRAIN ADVERSE
DICATION: EFFECTS

GENERIC ACTION: Indications CNS: Drows Assessment & Drug Effects

NAME: Allopurinol To control iness,  Monitor for therapeutic
ALLOPURIN reduces primary headache, effectiveness which is
OL endogenous uric hyperurice vertigo. GI: indicated by normal serum
BRAND acid by mia that Nausea, and urinary uric acid levels
NAME: selectively accompanie vomiting, usually by 1–3 wk (aim of
Alloprin A , inhibiting action s severe diarrhea, therapy is to lower serum uric
Alloprim, of xanthine gout and to abdominal acid level gradually to about 6
Apo- oxidase, the prevent discomfort, mg/dL), gradual decrease in
allopurinol-A enzyme possibility indigestion, size of tophi, absence of new
CLASSIFICA responsible for of flare-up malaise. He tophaceous deposits (after
TION: converting of acute matologic: ( approximately 6 mo), with
ANTIGOUT hypoxanthine to gouty Rare) Agran consequent relief of joint pain
AGENT xanthine and attack; to ulocytosis, and increased joint mobility.
xanthine to uric prevent aplastic  Monitor for S&S of an acute
acid (end recurrent anemia, gouty attack which is most
product of calcium bone likely to occur during first 6
purine oxalate marrow wk of therapy.
catabolism). Has stones; depression,  Lab tests: Monitor serum uric
no analgesic, prophylacti thrombocyt acid levels q1–2wk to check
antiinflammator cally to openia. Ski adequacy of dosage. Perform
y, or uricosuric reduce n: Urticaria baseline CBC, liver and kidney
actions. severity of or pruritus, function tests before therapy
hyperurice pruritic is initiated and then monthly,
mia maculopapu particularly during first few
associated lar rash, months. Check urinary pH at
FREQUENCY/ with toxic regular intervals.
DOSAGE/ antineoplas epidermal  Monitor patients with renal
ROUTES tic and necrolysis. disorders more often; they
Treatment
radiation Other: Hep tend to have a higher
Hyperuricemia
Adult: PO 100 therapies, atotoxicity, incidence of renal stones and
mg/d, may both of renal drug toxicity problems.
increase by 100 which insufficienc  Report onset of rash or fever
mg/wk (max: greatly y. immediately to physician;
800 mg/d), increase withdraw drug. Life-
divide doses plasma uric threatening toxicity syndrome
>300
acid levels can occur 2–4 wk after
mg/d IV 200–
400 mg/m2/d by initiation of therapy (more
(max: 600 mg/d) promoting common with impaired renal
in 1–4 divided nucleic acid function) and is generally
doses degradation accompanied by malaise,
Child: PO 10 y, . fever, and aching, a diffuse
10 mg/kg/d in . erythematous, desquamating
2–3 divided
Contraindi rash, hepatic dysfunction,
doses (max: 800
mg/d) IV 200 cations eosinophilia, and worsening of
mg/m2/d in 1–4 Hypersensit renal function.
divided doses ivity to Patient & Family Education
allopurinol;  Drink enough fluid to produce
Treatment as initial urinary output of at least
Secondary
treatment 2000 mL/d (fluid intake of at
Hyperuricemia
Adult: PO 200– for acute least 3000 mL/d). (Note that
800 mg/d for 2– gouty 1000 mL is approximately
3 d or longer, attacks; equal to 1 quart.) Report
divide doses idiopathic diminishing urinary output,
>300 mg/d hemochrom cloudy urine, unusual color or
Child: PO 6–10 atosis (or odor to urine, pain or
y, 100 mg
those with discomfort on urination.
t.i.d., <6 y, 50
mg t.i.d. family  Report promptly the onset of
history); itching or rash. Stop drug if a
Renal children skin rash appears, even after
Impairment (except 5 or more wk (and reportedly
(based on those with as long as 2 y) of therapy.
ClCr range) hyperurice  Minimize exposure of eyes to
Clcr: 80 mL/min
mia ultraviolet or sunlight which
= 250 mg/d; 60
mL/min = 200 secondary may stimulate the
mg/d; 40 to development of cataracts.
mL/min = 150 neoplastic  Do not drive or engage in
mg/d; 20 disease and potentially hazardous
mL/min = 100 chemothera activities until response to
mg/d; 10
 mL/min = 100 py). Safety drug is known.
mg q2d; 0 during  Remain under medical
mL/min = 100 pregnancy supervision while taking
mg q3d;
(category C) allopurinol (generally
removed by
hemodialysis. or lactation continued indefinitely); drug
is not can cause severe adverse
established. reactions.
 Do not breast feed while
taking this drug without
consulting physician.

MECHANISM INDICATIO SIDE NURSING IMPLICATION

NAME OF OF ACTION N/ EFFECTS/
THE DRUG CONTRAIN ADVERSE
DICATION: EFFECTS

GENERIC ACTION: Indications Body as a Assessment & Drug Effects

NAME: Sulfonamide- Hyperurice Whole: Flus  Decrease daily dosage with
PROBENECI derivative renalmia in hing, caution by 0.5 g q6mo to
D tubular blockingchronic dizziness, lowest effective dosage that
BRAND agent. In gouty fever, maintains stable serum
NAME: sufficiently high
arthritis anaphylaxis urate levels when gouty
Benemid, doses, and . CNS: Head attacks have been absent for
Benuryl , competitively tophaceous ache. GI: Na 6 mo or more and serum
Probalan, inhibits renal gout. usea, urate levels are controlled.
SK- tubular Contraindi vomiting,  Lab tests: Periodic serum
Probenecid reabsorption of cations anorexia, so urate levels, Hct and Hgb,
CLASSIFICA uric acid, Blood re and urinalysis. Determine
TION: thereby dyscrasias; gums, hepat acid–base balance
ANTIGOUT promoting its uric acid ic necrosis periodically when urinary
AGENT; excretion and kidney (rare). Urog alkalinizers are used. Some
SULFONAMI reducing serum stones; enital: Urin physicians prescribe
DE; urate levels. during or ary acetazolamide at bedtime to
URICOSURI within 2–3 frequency. keep urine alkaline and
C AGENT wk of acute Hematologi dilute throughout night.
gouty c: Anemia,  Patients taking sulfonylureas
FREQUENCY/ attack; over hemolytic may require dosage
DOSAGE/ excretion of anemia adjustment. Probenecid
ROUTES uric acid (possibly enhances hypoglycemic
Gout
(>1000 related to actions of these drugs
Adult: PO 250
mg b.i.d. for 1 mg/d); G6PD (see DIAGNOSTIC TEST
wk, then 500 mg patients deficiency), INTERFERENCES).
b.i.d. (max: 3 with aplastic  Expect urate tophaceous
g/d) creatinine anemia deposits to decrease in size.
clearance (rare). Musc Classic locations are in
Adjunct for
<50 uloskeletal: cartilage of ear pinna and big
Penicillin or
Cephalosporin mg/min; Exacerbatio toe, but they can occur in
Therapy use with ns of gout, bursae, tendons, skin,
Adult: PO 500 penicillin in uric acid kidneys, and other tissues.
mg q.i.d. or 1 g presence of kidney Patient & Family Education
with single dose known stones. Ski  Drink fluid liberally
therapy (e.g., renal n: Dermatiti (approximately 3000 mL/d)
gonorrhea)
impairment s, to maintain daily urinary
Child: PO 2–14
y or <50 kg, 25– ; use for pruritus. Re output of at least 2000 mL or
40 mg/kg/d in 4 hyperurice spiratory: R more. This is important
divided doses mia espiratory because increased uric acid
secondary depression. excretion promoted by drug
to cancer predisposes to renal calculi.
chemothera  Physician may advise
py. Safety restriction of high-purine
during foods during early therapy
pregnancy until uric acid level
(category stabilizes. Foods high in
B), purine include organ meats
lactation, or (sweetbreads, liver, kidney),
in children meat extracts, meat soups,
<2 y is not gravy, anchovies, and
established. sardines. Moderate amounts
are present in other meats,
fish, seafood, asparagus,
spinach, peas, dried
legumes, wild game.
 Avoid alcohol because it may
increase serum urate levels.
 Do not stop taking drug
without consulting
physician. Irregular dosage
schedule may sharply elevate
serum urate level and
precipitate acute gout.
 Be aware that lifelong
therapy is usually required
in patients with symptomatic
hyperuricemia. Keep
scheduled appointments
 with physician and for
kidney function and
hematology lab work.
 Report symptoms of
hypersensitivity to physician.
Discontinuation of drug is
indicated.
 Do not take aspirin or other
OTC medications without
consulting physician. If a
mild analgesic is required,
acetaminophen is usually
allowed.
 Do not breast feed while
taking this drug without
consulting physician.

II. NCP PROPER (2 ACTUAL PROBLEMS AND 1 RISK /POTENTIAL

PROBLEM)

PROBLEM / EPLANAT NURSING INTERVENTI SCIENTIFIC EVALUATIO

NURSING ION OF GOAL (USE ON RATIONALE N
DIAGNOSIS THE THE SMART)
PROBLE
M
SUBJECTIVE Gout STO: DIAGNOSTIC DIAGNOSTICS: Goal fully
: “nagsakit j occurs wh After 4 hours S: 1. The patient met
ay sakak “ en urate of effective 1. Performed a experiencing STO:
After 4 hours
crystals nursing comprehensiv pain is the most
of effective
Pain rate accumula intervention e assessment reliable source nursing
scale of 8/10 te in the the patient of pain. of information intervention
joint, will report Determine the about their the patient
OBJECTIVE: causing relieved/cont location, pain. Thus, report
(+) guarding the rolled of characteristics assessment of relieved/cont
behavior inflammat pain. , onset, pain by rolled of
pain.
(+) facial ion and As duration, conducting an
As
grimace intense manifested frequency, interview helps manifested
High level of pain of a by quality, and the nurse in by
uric acid gout (-)guarding severity of planning (-)guarding
Swollen attack. behavior pain via optimal pain behavior
Joints Urate (-)facial assessment. management (-)facial
Vital signs: crystals grimace strategies.. grimace
PR: 98 bpm, can form Goal partially
RR: 20 cpm,, when 2. Using charts met
BP:120/90, there is a LTO: or drawings of LTO:
After 3 days
SPO2: 96%, high After 3 days 2. Assessed the body can
of effective
T: 36.5 levels of of effective for the help the nursing
uric acid nursing location of the patient, and the intervention
pain by asking
in the intervention nurse the patient
to point to the
NDX: blood. the patient determines incorporate
site that is
Acute Pain The body will specific pain relaxation
discomforting.
related to produces incorporate locations. skills and
diversional
distension of uric acid relaxation
activities into
tissues by the when it skills and 3. Additionally, the pain
accumulation breaks diversional the nurse control
of down activities into should ask the program.
fluid/inflam purines the pain 3. Performed following As
matory — control history questions manifested
process, substance program. during pain by
assessment of
Decreased
destruction of s that are As pain; (4) assessment to
reports of
joint as found manifested allergies or determine its
pain or
manifested by naturally by known side history: (1)
discomfort
Reports of in our Decreased effects to effectiveness of
pain/discomf body. reports of medications. previous pain
ort, fatigue pain or treatment or
secondary to discomfort management;
Gout Arthritis (2) what
medications
were taken and
when; (3) other
medications
being taken

4. In taking a
pain history,
provide an
opportunity for
4. Determined the client to
the client’s express in their
perception of own words how
pain.. they view the
pain and the
situation to
gain an
understanding
 of what the pain
means to the
client

5. Many health
facilities set
pain
assessment as
the ―fifth vital
sign‖ and
5. Pain should should be
be screened added to
every time routine vital
vital signs are signs
evaluated. assessment.

6. Some
patients may be
hesitant to try
the
effectiveness of
nonpharmacolo
6. Assess the
gical methods
patient’s
and may be
willingness or
willing to try
ability to
traditional
explore a
pharmacologica
range of
l methods (i.e.,
techniques to
use of
control pain.
analgesics).

THERAPEUTI
THERAPEUTIC
CS:
S:
1. Provide
1. It is
measures to
relieve pain preferable to
before it provide an
becomes analgesic before
severe. the onset of
pain or before it
becomes severe
when a larger
dose may be
required.

2.Acknowledg 2. Nurses have

ed and the duty to ask
accepted the their clients
client’s pain. about their pain
and believe
their reports of
pain.

3.Nonpharmaco
3. Provided
logical methods
nonpharmacol
ogical pain in pain
management. management
may include
physical,
cognitive-
behavioral
strategies, and
lifestyle pain
management.

4.Recommend 4. Soft and

ed or provide sagging
a firm mattress, large
mattress or pillows prevent
bedboard, maintenance of
small pillow. proper body
Elevate linens alignment,
with bed placing stress
cradle as on affected
needed. joints. Elevation
of bed linens
reduces
pressure on
inflamed or
painful joints.

5. Encouraged 5. Prevents
frequent general fatigue
changes of and joint
position. stiffness.
Assist the Stabilizes joint,
patient to decreasing joint
move in bed, movement and
supporting associated pain.
affected joints
above and
below,
avoiding jerky
movements.

6. Provided 6. Promotes
gentle relaxation and
massage. reduces muscle
tension.
7. Encouraged
7. Promotes
the use of
relaxation,
stress
provides a
management
sense of control
techniques
and may
such as
enhance coping
progressive
abilities.
relaxation,
biofeedback,
visualization,
guided
imagery, self-
hypnosis, and
controlled
breathing.
Provide
Therapeutic
Touch

8., Administer
8. Relives pain.
pain
medication as
prescribed

EDUCATIVE/
EDUCATIVE/
HEALTH
HEALTH
TEACHINGS:
TEACHINGS:
1. In severe
1. Suggested
disease or acute
patient
exacerbation,
assume a
total bedrest
position of
may be
comfort while
necessary (until
in bed or objective and
sitting in a subjective
chair. Promote improvements
bedrest as are noted) to
indicated. limit pain or
injury to joint.

2.Recommend 2. Heat
ed that patient promotes
take a warm muscle
bath or relaxation and
shower upon mobility,
arising or at decreases pain,
bedtime. and relieves
Apply warm, morning
moist stiffness.
compresses to Sensitivity to
affected joints heat may be
several times diminished and
a day. Monitor dermal injury
water may occur.
temperature of
compress,
baths, and so
on.
3. Instructed
3. Refocuses
to Involve in attention,
diversional provides
activities stimulation and
appropriate enhances self-
for individual esteem and
situation. feelings of
general well-
being.
PROBLEM EPLANATI NURSING INTERVENTI SCIENTIFIC EVALUATION
/ NURSING ON OF GOAL (USE ON RATIONALE
DIAGNOSI THE THE SMART)
S PROBLEM
SUBJEC Gout is a STO: DIAGNOSTIC DIAGNOSTIC Goal fully met
TIVE: disorder of After 6 hours S: S: STO:
“ purine of effective Assessed and Level of After 6 hours
metabolis
hindi ko nursing continuously activity and of effective
m
maigala characteriz intervention monitor exercise nursing
w ang ed by the patient will degree of joint depends on intervention
aking elevated maintain a inflammation the the patient
paa uric acid position of and pain. progression maintain a
dahil levels with function with and position of
sobrang deposition absence/limita resolution of function with
of urate
sakit tion of the absence/limita
crystals in
“ joints and contractures. inflammatory tion of
other As manifested process. contractures.
tissues. by adequate As manifested
High uric range of Assessed the This by adequate
acid levels motion strength to assessment range of
result from perform ROM provides data motion
decreased
LTO: to all joints. on extent of
excretion
OBJECTI of uric acid After 2-3days any physical Goal partially
VE: ( 90% of of effective problems and met
Limited r cases) due nursing guides LTO:
ange of to a wide intervention therapy. After 2-3days
motion. variety of the will be able Testing by a of effective
causes. to maintain or nursing
Reluctanc physical
The increase the intervention
e to disorder therapist may
strength and the was able to
attempt may be needed.
function of the maintain or
movemen progress
affected increase the
t from an Assessed Examines
and/or strength and
Decrease asymptom compensatory presence or development
function of the
d muscle atic stage body part. degree of or recession
through affected
strength. exercise- of
acute As evidenced and/or
Inability gouty related pain complications compensatory
to by and changes . May require
arthritis, to body part.
purposef chronic Increased in joint to delay
ully move tophaceous muscle mobility. augmenting As evidenced
within gout. That strength exercises and by
the could leave hold until Increased
to impaired
physical further muscle
physical
environm mobility. healing strength
ent Complicati occurs.
Disintere ons
st in include Assessed the Acceptance of
erosive
ADLs due emotional temporary or
deforming.
to pain, response to more
verbalizat the disability permanent
ion of or limitation. limitations
tiredness can vary
and broadly
generalize between
d individuals.
weakness Each person
V/S take has his or her
n as personal
follows: interpretation
T: 36.5 of acceptable
PR: 86 quality of life.
RR:
20BP: THERAPEUTI THERAPEUTI
120/80 CS: CS:
SPO2: Maintain Systemic rest
95% bedrest or is mandatory
chair rest during acute
NDX: when exacerbations
Impaired indicated. and
Physical Schedule important
Mobility activities throughout
related to
providing all phases of
Skeletal
deformity frequent rest disease to
and periods and reduce
Pain, uninterrupted fatigue,
discomfor nighttime improve
t as sleep. strength.
manifeste
d by Assist with Maintains
Reluctanc active and and improves
e to passive ROM joint function,
attempt and resistive muscle
movemen exercises and strength, and
t isometrics general
secondar when able. stamina.
y to Gout Note:
Arthritis Inadequate
 exercise leads
to joint
stiffening,
whereas
excessive
activity can
damage
joints.

Repositioned Relieves
frequently pressure on
using tissues and
adequate promotes
personnel. circulation.
Demonstrate Facilitates
and assist self-care and
with transfer patient’s
techniques independence
and use of . Proper
mobility aids transfer
such as a techniques
walker, cane, prevent
trapeze. shearing
abrasions of
the skin.

Positioned Promotes
with pillows, joint stability
sandbags, (reducing risk
trochanter of injury) and
roll. Provide maintains
joint support proper joint
with splints, position and
braces. body
alignment,
minimizing
contractures.

Provided foam Decreases

or alternating pressure on
pressure fragile tissues
mattress. to reduce
risks of
 immobility
and
development
of decubitus.

EDUCATIVE/ EDUCATIVE/
HEALTH HEALTH
TEACHINGS: TEACHINGS:
Encouraged Maximizes
patient to joint function,
maintain maintains
upright and mobility.
erect posture
when sitting,
standing, and
walking.

Discussed Helps prevent

and provide accidental
safety needs injuries and
such as falls.
raised chairs
and toilet
seat, use of
handrails in
the tub,
shower and
toilet, proper
use of
mobility aids
and
wheelchair
safety.
Prevents
Suggested flexion of the
using a small neck.
or thin pillow
under the
neck.
PROBLEM / EPLANATION NURSING INTERVENTION SCIENTIFIC EVALUATION
NURSING OF THE GOAL (USE RATIONALE
DIAGNOSIS PROBLEM THE
SMART)
SUBJECTIVE: A fall is an STO: Completed a fall The use of a Goal fully met
event that After 8 hours risk assessment. standard tool STO:
OBJECTIVE: occurs when of nursing *Factors will help After 8 hours
contributing to identify the
Limited range a person at intervention of nursing
falls risk. status of the
of motion. rest the patient *Functional patient’s risk intervention
Reluctance to accidentally will be able ability. for falling and the patient
attempt comes to the to maintain *Use of mobility will help was able to
movement ground or a the ability to devices determine the maintain the
Decreased lower area. perform factors ability to
muscle activities of contributing perform
to the high
strength. daily living activities of
risk for falls.
Inability to without daily living
purposefully having a fall. without
move within Evaluated Improper use having a fall.
the physical patient’s of mobility
environment understanding devices may
Disinterest in LTO: of the use of cause more Goal partially
mobility harm than
ADLs due to After 3 days met
assistive devices good.
pain, of nursing such as zimmer LTO:
verbalization intervention frame and After 3 days
of tiredness the patient crutches. of nursing
and will be able intervention
generalized to maintain Assessed the Using the the patient
proper size and wrong size on
weakness safe and was able to
height of the mobility
V/S taken as promoting mobility device devices does maintain safe
follows: T: environment. to the patient’s not give full and
36.5 PR: 86 physique. mobility promoting
RR: 20BP: support to environment
120/80 SPO2: patients and
95% may even
cause further
problems
such as falls
and fall-
NDX: related
Risk for fall injuries.

Assessed the Pain leads to

need for pain unstable gait
medications. and mobility.
Referral to Patients with
physiotherapy problem may
and need
occupational therapies to
therapy. help them
regain
independence
and lower
their risk of
falling.

Provided This will help

identification to healthcare
alert every one staff, families
of the high risk and friends
for fall. acknowledge
the need for
caution when
dealing with
the patient.

Put the bed at Low set beds

the lowest level. reduce the
possibility of
falls and
serious
injuries
related to
falls.

Explained the Allowing

bed settings to patients to
the patient set their own
including how bed
bed remote minimizes
controls works. the risk of
them
jumping off
the bed while
it is at a
higher
position.

Placed items Items far

within the away from
patient’s reach. the patient’s
reach may
contribute to
falls and fall-
related
injuries.