A Group Case Protocol Entitled:
S/P Exploratory laparotomy, Evacuation of Peritoneum, Perihepatic Packing,
Central Venous Catheter Insertion via Right Femoral Vein
Presented to the Faculty of the
School of Health and Natural Sciences
In Partial Fulfillment of the Requirements in
Intensive Nursing Practicum
(NCM 122)
Submitted by:
Labasan, Vhea Jocel
Araneta, Marsha Lianne
Fillag, Veannie
Mejia, Julie Ann
Oreña, Marian
BSN 4B
February 2023
TABLE OF CONTENTS
PARTS
PAGE
I.
3P’s
page 3
II.
Brief Description
page 6
III.
Anatomy and Physiology
page 9
IV.
Pathophysiology
page 13
V.
Laboratory Results and Diagnostic Studies
page 16
VI.
PERSON Assessment
page 50
VII.
Drug Study
page 61
VIII.
Course in the Ward
page 80
IX.
Nursing Care Plan
page 99
X.
References
page 105
3P’s
I.
A. PERSONAL PROFILE
Name: Mr. N
Gender: Male
Age: 46 years old
Birthday: September 23, 1976
Place of Birth: Bayombong, Nueva Vizcaya
Address: Magsaysay, Bayombong, Nueva Vizcaya
Civil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Ethnicity: Ilocano
Dialect: Ilocano, Tagalog
Educational Attainment: College Graduate
Occupation: Foreman
Weight: 85 kg
Height: 5’8”
BMI: 24.8 kg/m2
SIGNIFICANT OTHER
Name: Mrs. M
Relationship to the Patient: Husband
Age: 45 years old
Civil Status: Married
Address: Magsaysay, Bayombong, Nueva Vizcaya
Educational Attainment: College Graduate
Occupation: Housewife
DATA PRIOR TO HOSPITALIZATION
Chief Complaint: Patient was driving a motorcycle and bumped himself into a tree, wherein his
abdomen, particularly his right upper abdomen, was the part that got slammed into the tree.
NOI: Motor Accident
TOI: 9:30 PM
POI: Busilac, Bayombong, Nueva Vizcaya
DOI: January 23, 2023
Admitting Diagnosis: Motor Vehicular Accident
Final Diagnosis: S/P Exploratory laparotomy, Evacuation of peritoneum, Perihepatic Packing,
Central Venous Catheter insertion via right femoral vein
Admitting Physician: Dr. A
Date of Admission: January 23, 2023
Time of Admission: 10:00 PM
Date of Discharge: January 29, 2023
Time of Discharge: 10:00 AM
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B. HISTORY OF PRESENT ILLNESS
Mr. N is a 46-year-old male who was rushed into Region II Trauma Medical Center,
Bayombong, Nueva Vizcaya, via ambulance due to a motor vehicle accident on January 23, 2023,
at around 10:00 in the evening. According to the patient’s significant other, his wife, Mrs. M, stated
that her husband works at the TAM-AN Resort in Busilac, Bayombong, Nueva Vizcaya, as a
contractual foreman in the renovation of the said resort. On Sunday evening, Mr. N informed his
wife that he would be going home late because there would be a simple celebration with his coworkers after they worked, and they had a good conversation until they did not notice it was
already late in the evening. Following that, at around 9:00 PM, they decided to call it a day. Mr. N
decided to drive home with his motorcycle since he had no work to do the following day. On his
way home, it suddenly began to rain, yet Mr. N still continued to drive home and drive fast at 80
kilometers per hour to pass through the rain, even though it was already a heavy rain. Then, on
the road between Busilac Barangay Hall and Busilac Resort, there was a truck on the opposite
road whose headlight was set on high beam. Mr. N got dazzled by the light and was confused
about where he should drive his motorcycle, and since it was raining on that day while driving his
motorcycle at 80 km/hr., he passed through a deep manhole cover and suddenly braked after
passing through it and bumped himself into a tree, wherein his abdomen, particularly his right
upper abdomen, was the part that got slammed into the tree. The vendors of the fruit stand that
was near the accident area and who witnessed the accident immediately called the emergency
rescue team.
Upon arrival in the hospital at around 10:00 PM, the patient was in a groggy state with
some abrasions on his right hand, both arms, right upper leg, left lower leg, and on his right cheek.
He was immediately resuscitated by the nurses on duty following the ABC procedure. Initial vital
signs were also taken, with a temperature of 35.8 °C, a respiratory rate of 38 counts per minute,
a pulse rate of 129 beats per minute, an oxygen saturation of 90%, and a blood pressure of 60/40
mmHg. The patient suddenly became pale and had cool skin when touched. The patient was in
hypovolemic shock, which is why the physician came up with the decision to transfuse one pack
of red blood cells with a blood type of O+ through a central venous catheter by way of the patient’s
right femoral vein for an emergency and fast access for blood administration. An oxygen was also
administered at 10 lpm through a face mask as ordered by the Physician. The nurse on duty also
administered 1 liter of PNSS to the patient’s right cephalic vein and was set on a fast drip. Upon
central venous catheter insertion, the physician noticed that Mr. N was grimacing while holding
his abdomen, and upon checking his abdomen, there was the presence of a large, bluish-purplish
bruise. Upon assessment, the patient’s abdomen was swollen, and Mr. N rated it as 8/10 on the
pain rating scale. Mr. N was immediately tested with a FAST ultrasound to determine the extent
of the trauma to the patient’s abdomen. The ultrasound indicates that there was bleeding on his
abdomen, but the physician cannot rule out where the source of the bleeding was due to the large
amount of blood present in the patient's peritoneal cavity. The nurse on duty assessed the
patient’s eye, verbal, and motor responses using the Glasgow coma scale with a score of 12, in
which, in the eye opening response, the patient’s eyes open to verbal stimuli, command, and
speech, in the verbal assessment, Mr. N responded in a conversational manner but with some
disorientation and confusion, and in the motor response, the patient pulls his limb away from the
painful stimulus. Following that, a complete blood count was ordered by the physician, and an
electrocardiogram was also done on the patient.
Due to the result of the FAST ultrasound, the physician came up with the decision to
undergo the patient for an emergency exploratory laparotomy. After an hour of transfusion, at
12:00 in the morning, the patient was transferred to the operating room for an emergency
exploratory laparotomy to perform the evacuation of blood in the peritoneal cavity of the patient
and to locate where the source of the bleeding came from. During the procedure, the surgeon
was able to evacuate the blood with a total volume of 980 ml and was also able to locate the
source of the bleeding, wherein the liver got damaged, particularly on the right hepatic artery,
which he graded as V with laceration and parenchymal disruption involving 75% of the hepatic
lobe. That is why the surgeon came up with an intervention to perform perihepatic packing on the
right upper quadrant of the liver to temporarily stop the bleeding using gauze laparotomy sponges.
After packing, the patient was closed, and the pack was left on the patient’s liver for 48 hours.
After the surgery, the patient was transferred to the ICU to be closely monitored and evaluated.
An arterial blood gas test was also performed, and the result indicated that the blood pH was
7.20, which was decreased from the normal range. Vital signs were also taken, including a
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temperature of 36.8 °C, a respiratory rate of 26 counts per minute, a pulse rate of 110 beats per
minute, an oxygen saturation of 96%, and a blood pressure of 100/70 mmHg, which indicate that
the patient is having metabolic acidosis. A sodium bicarbonate was then ordered and
administered to the patient through an intravenous line. One pack of red blood cells was then
again transfused to the patient through a central venous catheter by way of the patient’s right
femoral vein.
On January 26, 2023, at 8:00 a.m., vital signs were stable, with a temperature of 36.8 °C,
a respiratory rate of 19 counts per minute, a pulse rate of 89 beats per minute, an oxygen
saturation of 97%, and a blood pressure of 110/80 mmHg. Metabolic acidosis was resolved, and
the patient’s prothrombin time was 12.5 seconds. The surgeon scheduled the patient for a
second-look laparotomy at 10:00 AM for the removal of the packing from the patient’s liver. In the
operating room, the abdomen was washed out, the packing was carefully removed from the right
upper quadrant, and the right hepatic artery was avulsed and ligated. After the procedure, the
patient was transferred to the surgery ward for recovery and further monitoring.
C. HISTORY OF PAST ILLNESS
According to the patient, he has a history of a motor vehicle accident when he was in his
early twenties, which he describes as a minor accident when he rides a tricycle, in which he got
a minor abrasion on his legs and arms.
FAMILY HEALTH HISTORY
According to Mr. N, their family has no history of liver disease. Although his father was an
alcoholic, he drinks three times a week. On the other hand, her mother was diagnosed with
hypertension in 2018 and is currently on a maintenance dose of Lisopril. Other than that, no other
genetic or hereditary problems were mentioned.
SOCIAL HEALTH STATUS
The patient is a 46-year-old male in Erikson's psychosocial development stages of
generativity vs. stagnation. The patient is a foreman. He was married to Mrs. M, a housewife, and
they had three children together. The patient is an alcoholic, wherein he drinks three times a week
to the extent that he will be exhausted, but he does not smoke. He sleeps for 5–6 hours, goes to
bed at 11:00 PM, and wakes up at around 5:00–6:00 AM. The patient's body mass index is 24.8
kg/m2, which classifies him in a healthy weight range. According to him, he is fond of eating fatty
foods and some vegetables. He also just drinks water—3–5 glasses a day. Mr. N got her first
dose of the Aztrazeneca vaccine for COVID-19 disease on July 15, 2021, and his second dose
the following month. He got his booster shot from Pfizer at the Capitol on May 2022.
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II.
BRIEF DESCRIPTION
Definition
The liver is the most regularly injured organ in blunt abdominal trauma. Given its large size
in the abdominal cavity, it can also be frequently injured with penetrating abdominal injuries. Liver
trauma can run the gamut of minor lacerations or capsular hematomas with minimal morbidity
and mortality to hepatic avulsions with high mortality. Most hepatic injuries are minor and can be
graded with the American Association for the Surgery of Trauma Hepatic Injury Scale.
VI is Hepatic Avulsion
Incidence
Liver injuries make up approximately 5% of all trauma admissions. The liver is the most
common solid organ injured in blunt trauma, and patients with hepatic injury usually have other
concomitant injuries. Mortality from hepatic trauma depends on the degree of injury. Minor liver
injuries make up most hepatic trauma, with 80% to 90% being grades 1 or II. Mortality increases
with the grade of injury, and grade VI liver injuries are often fatal. Liver injury is the primary cause
of death in severe abdominal trauma and has a 10% to 15% mortality rate.
Etiology
A traumatic liver injury is common in both blunt and penetrating abdominal injuries. The
liver’s anterior location in the abdomen, its fragile parenchyma, and the relative ease in which
Gleeson’s capsule is violated makes it susceptible to injury from blunt forces. Its fixed location
under the diaphragm also makes it susceptible to shear forces from deceleration injuries. The
vasculature in the liver is made up of large but thin-walled vessels with high blood flow. The
mechanism of injury for blunt abdominal trauma is often due to motor vehicle accidents,
pedestrian accidents, and falls. Farming and industrial accidents can also lead to a number of
liver injuries. In addition, the anterior location and large size relative to other abdominal organs
make it prone to injury in penetrating abdominal penetrating trauma from gunshot or stab wounds.
The right lobe of the liver is the most commonly injured portion in both blunt and penetrating
injuries.
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Predisposing Factors
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Alcohol
Drugs
Distracted Driving
Risky Driving
Seat Belt Use
Male Gender
Clinical Manifestation
An injured liver results in hemorrhaging (bleeding). The signs and symptoms of an injured liver
include:
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Drop in blood pressure
Tachypneic
Tachycardic
Pale
Abdominal pain
Guarding (holding hand over the area)
Tenderness in the upper right part of the abdomen
Right shoulder pain and signs of shock and blood loss
Complications
The overall incidence of complications is < 7% but can be as high as 15 to 20% in highgrade injuries. Deep parenchymal lacerations can lead to a biliary fistula or biloma formation. In
biliary fistula, bile leaks freely into the abdominal or thoracic cavity. A biloma is a contained
collection of bile similar to an abscess. Bilomas are typically treated with percutaneous drainage.
For
biliary
fistulas,
biliary
decompression
through
endoscopic
retrograde
cholangiopancreatography (ERCP) is highly successful.
Abscesses develop in about 3 to 5% of injuries, often because of devitalized tissue being
exposed to biliary contents. Diagnosis is suspected in patients in whom pain, temperature, and
white blood count (WBC) increase in the days after injury; confirmation is by CT. Abscesses are
usually treated with percutaneous drainage, but laparotomy may be necessary when
percutaneous management fails.
Diagnostic Procedures
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Ultrasonography- Ultrasonography is a noninvasive procedure and highly operatordependent. Focused assessment by ultrasound for trauma (FAST) has been advocated
in initial trauma evaluation. The purpose of this exam is to provide a quick bedside
assessment.
Computed tomography scan- CT scan is the first imaging study which gives relatively
detailed delineation of solid organ injuries and retroperitoneal injuries as well. CT scan is
the standard imaging study for patients following blunt trauma
Focused assessment with sonography (FAST)- in trauma is a rapid bedside ultrasound
examination performed by surgeons, emergency physicians, and paramedics as a
screening test for blood around the heart or abdominal organs after trauma.
Laboratory Procedures
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Rapid Antigen Test- Antigen tests are immunoassays that detect the presence of a
specific viral antigen, which indicates current viral infection.
Complete Blood Count- A complete blood count (CBC) is a blood test used to evaluate
your overall health and detect a wide range of disorders, including anemia, infection and
leukemia.
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Hepatitis B Surface Antigen Test (HBsAg)- A "positive" or "reactive" HBsAg test result
means that the person is infected with hepatitis B. This test can detect the actual presence
of the hepatitis B virus (called the “surface antigen”) in your blood.
PT/PTT- The prothrombin time (PT) test measures how quickly blood clots. The partial
thromboplastin time (PTT) is mainly used to monitor a person's response to anticoagulant
therapies.
Blood typing- Blood typing is a fast and easy way to ensure that you receive the
right kind of blood during surgery or after an injury.
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Serum Electrolytes- An electrolyte panel, also known as a serum electrolyte test, is a
blood test that measures levels of the body's main electrolytes: sodium, chloride,
potassium and bicarbonate.
Urinalysis- Urinalysis is a test of your urine. It's used to detect and manage a wide range
of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis
involves checking the appearance, concentration, and content of urine.
Fecalysis- The stool will be checked for color, consistency, amount, shape, odor, and the
presence of mucus. The stool may be examined for hidden (occult) blood, fat, meat fibers,
bile, white blood cells, and sugars called reducing substances. The pH of the stool also
may be measured.
Liver Function Test- also referred to as a hepatic panel, are groups of blood tests that
provide information about the state of a patient's liver.
Surgical Procedures
Exploratory laparotomy is surgery to open up the belly area (abdomen). This surgery is
done to find the cause of problems (such as belly pain or bleeding) that testing could not diagnose.
It is also used when an abdominal injury needs emergency medical care. This surgery uses one
large cut (incision). The provider can then see and check the organs inside the abdomen. If the
cause of the problem is found during the procedure, then treatment is often done at the same
time.
Perihepatic packing is a surgical procedure used in connection with trauma surgery to
the liver. In this procedure the liver is packed to stop non arterial bleeding, most often caused by
liver injury.
A central venous catheter (CVC) is a catheter placed into a large vein. It is a form of
venous access. Placement of larger catheters in more centrally located veins is often needed in
critically ill patients, or in those requiring prolonged intravenous therapies, for more reliable
vascular access.
Pharmacologic Management
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Sodium Bicarbonate- treatment of metabolic acidosis which may occur in severe renal
disease and severe primary lactic acidosis.
Epinephrine- Epinephrine injection is indicated in the emergency treatment of type I
allergic reactions, including anaphylaxis. It is also used to increase blood pressure in adult
patients with hypotension.
Norepinephrine- Norepinephrine injection is used to raise blood pressure in patients with
severe, acute hypotension (short-term low blood pressure).
Dopamine- Dopamine is a peripheral vaso stimulant used to treat low blood pressure, low
heart rate, and cardiac arrest.
Dobutamine- Dobutamine's inotropic effect increases contractility, leading to decreased
end-systolic volume and, therefore, increased stroke volume. The increase in stroke
volume leads to an augmentation of the cardiac output of the heart.
Acetaminophen- This drug is used to treat mild to moderate pain
Benzylpenicillin- Treatment of severe infections caused by penicillin G-susceptible
microorganisms when rapid and high penicillin levels are required such as in the treatment
of septicemia, meningitis, pericarditis, endocarditis and severe pneumonia.
Tranexamic Acid- Tranexamic acid (sometimes shortened to txa) is a medicine that
controls bleeding
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III.
ANATOMY AND PHYSIOLOGY
Digestive System
The digestive system is made up of the gastrointestinal tract—also called the GI tract or
digestive tract—and the liver, pancreas, and gallbladder. The GI tract is a series of hollow organs
joined in a long, twisting tube from the mouth to the anus. The hollow organs that make up the GI
tract are the mouth, esophagus, stomach, small intestine, large intestine, and anus. The liver,
pancreas, and gallbladder are the solid organs of the digestive system.
Liver
The liver is the largest organ in your body. It weighs about 3 pounds and is about the size
of a football. It performs many functions essential for good health and a long life. Liver is an organ
with many functions, your liver’s two main responsibilities in the process of digestion are to make
and secrete bile and to process and purify the blood containing newly absorbed nutrients that are
coming from the small intestine. Bile has two main purposes: to help absorb fats and to carry
waste from the liver that cannot go through the kidneys.
Functions of the Liver
The liver is an essential organ of the body that performs over 500 vital functions. These
include removing waste products and foreign substances from the bloodstream, regulating blood
sugar levels, and creating essential nutrients. Here are some of its most important functions:
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Albumin Production: Albumin is a protein that keeps fluids in the bloodstream from
leaking into surrounding tissue. It also carries hormones, vitamins, and enzymes through
the body.
Bile Production: Bile is a fluid that is critical to the digestion and absorption of fats in the
small intestine.
Filters Blood: All the blood leaving the stomach and intestines passes through the liver,
which removes toxins, byproducts, and other harmful substances.
Regulates Amino Acids: The production of proteins depend on amino acids. The liver
makes sure amino acid levels in the bloodstream remain healthy.
Regulates Blood Clotting: Blood clotting coagulants are created using vitamin K, which
can only be absorbed with the help of bile, a fluid the liver produces.
Resists Infections: As part of the filtering process, the liver also removes bacteria from
the bloodstream.
Stores Vitamins and Minerals: The liver stores significant amounts of vitamins A, D, E,
K, and B12, as well as iron and copper.
Processes Glucose: The liver removes excess glucose (sugar) from the bloodstream and
stores it as glycogen. As needed, it can convert glycogen back into glucose.
Anatomy of the Liver
The liver is reddish-brown and shaped approximately like a cone or a wedge, with the
small end above the spleen and stomach and the large end above the small intestine. The entire
organ is located below the lungs in the right upper abdomen. It weighs between 3 and 3.5 pounds.
9
Structure
The liver consists of four lobes: the larger right lobe and left lobe, and the smaller caudate
lobe and quadrate lobe. The left and right lobe are divided by the falciform (“sickle-shaped” in
Latin) ligament, which connects the liver to the abdominal wall. The liver’s lobes can be further
divided into eight segments, which are made up of thousands of lobules (small lobes). Each of
these lobules has a duct flowing toward the common hepatic duct, which drains bile from the liver.
Parts
The following are some of the most important individual parts of the liver:
Common Hepatic Duct: A tube that carries bile out of the liver. It is formed from the intersection
of the right and left hepatic ducts.
Falciform Ligament: A thin, fibrous ligament that separates the two lobes of the liver and
connects it to the abdominal wall.
Glisson’s Capsule: A layer of loose connective tissue that surrounds the liver and its related
arteries and ducts.
Hepatic Artery: The main blood vessel that supplies the liver with oxygenated blood.
Hepatic Portal Vein: The blood vessel that carries blood from the gastrointestinal tract,
gallbladder, pancreas, and spleen to the liver.
Lobes: The anatomical sections of the liver.
Lobules: Microscopic building blocks of the liver.
Peritoneum: A membrane covering the liver that forms the exterior.
10
The liver can be damaged as a result of impact (for example, a motor vehicle crash) or
penetrating trauma (such as a knife or gunshot wound). Injuries may range from relatively small
collections of blood (hematomas) within the liver to large tears that go deep into the liver. Because
the liver has many large blood vessels, the main problem resulting from liver injury is severe
bleeding.
People with liver injury and severe bleeding have symptoms of shock, including a rapid
heart rate, rapid breathing, and cold, clammy, pale or bluish skin. People also have abdominal
pain and tenderness because blood in the abdomen irritates the abdominal tissue. When bleeding
is severe, the abdomen may also be swollen.
Cardiovascular system
The cardiovascular system is sometimes called the blood-vascular, or simply the
circulatory system. It consists of the heart, which is a muscular pumping device, and a closed
system of vessels called arteries, veins, and capillaries. As the name implies, blood contained in
the circulatory system is pumped by the heart around a closed circle or circuit of vessels as it
passes again and again through the various "circulations" of the body.
Blood
Blood is a constantly circulating fluid providing the body with nutrition, oxygen, and waste
removal. Blood is mostly liquid, with numerous cells and proteins suspended in it, making blood
"thicker" than pure water. The average person has about 5 liters (more than a gallon) of blood.
Components of Blood
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Plasma is the main component of blood and consists mostly of water, with proteins, ions,
nutrients, and wastes mixed in.
Red blood cells are responsible for carrying oxygen and carbon dioxide.
Platelets are responsible for blood clotting.
White blood cells are part of the immune system and function in immune response.
Functions of the Blood
Blood is unique; it is the only fluid tissue in the body.
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Carrier of gasses, nutrients, and waste products. Oxygen enters blood in the lungs
and is transported to cells. Carbon dioxide, produced by cells, is transported in the blood
to the lungs, from which it is expelled. Ingested nutrients, ions, and water are carried by
the blood from the digestive tract to cells, and the waste products of the cells are moved
to the kidneys for elimination.
Clot formation. Clotting proteins help stem blood loss when a blood vessel is injured.
Transport of processed molecules. Most substances are produced in one part of the
body and transported in the blood to another part.
Protection against foreign substances. Antibodies help protect the body from
pathogens.
Transport of regulatory molecules. Various hormones and enzymes that regulate body
processes are carried from one part of the body to another within the blood.
Maintenance of body temperature. Warm blood is transported from the inside to the
surface of the body, where heat is released from the blood.
pH and osmosis regulation. Albumin is also an important blood buffer and contributes
to the osmotic pressure of blood, which acts to keep water in the blood stream.
Bleeding is the loss of blood. Bleeding may be:
● Inside the body (internally)
● Outside the body (externally)
Bleeding may occur:
● Inside the body when blood leaks from blood vessels or organs
● Outside the body when blood flows through a natural opening (such as the ear, nose,
mouth, vagina, or rectum)
● Outside the body when blood moves through a break in the skin
When blood is lost, the body quickly pulls water from tissues outside the bloodstream in
an attempt to keep the blood vessels filled. As a result, the blood is diluted, and the hematocrit
(the percentage of red blood cells in the total amount of blood in the body, or blood volume) is
redu
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IV.
PATHOPHYSIOLOGY
14
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V.
LABORATORY RESULTS AND DIAGNOSTIC PROCEDURES
A. RAPID ANTIGEN TEST
Disease Reporting Unit Department of Pathology Region II Trauma and Medical Center
Date conducted: January 23, 2023
Patient name: Mr. N
Age: 46 years old
Address: Magsaysay, Bayombong, Nueva Vizcaya
Gender: Male
__ Case, confirmed outbreak
__ Close contact, confirmed
outbreak
__ Case, closed or semiclosed institution
__ Close contact or semiclosed institution
✔ Case, Limited RTPCR Capacity
__ Close contact, limited RTPCR capacity
__ Covid-19 symptomatic suspects who are eligible for admission to our facility
Result: Negative
Date/Time done: January 23, 2023
Nursing Consideration:
BEFORE:
● Identifies the indication for RAT swab to be collected (to assist in the detection or
surveillance of the COVID-19 virus)
● Collects the appropriate equipment required for procedure; swab, test device,
extraction tube, buffer solution, facial tissues
● Performs hand hygiene and don correct PPE to perform procedure- gloves, gown,
N95 mask, eye wear
● Engages with the patient and family using appropriate communication and personcentered care to discuss the procedure and ask COVID-19 screening questions
● Positively identifies the patient, explains procedure and gains consent for specimen
collection +/- clinical holding using appropriate communication and person-centered
care principles
● Check expiry dates on device and test solution. Remove the test device from the foil
pouch prior to use. Place on a flat, horizontal and clean surface. Hold the buffer bottle
vertically and fill the extraction tube with buffer fluid until it flows up to the “fill line” of
the extraction tube (300 μl)
● Positions the patient appropriately. Utilized appropriate supports/and or therapeutic
holding during the procedure
DURING:
● Tilt the patient’s head back 70 degrees. Using a pencil grip insert swab less than one
inch (about 2 cm) into nostril (until resistance is met at the turbinates)
● Rotate the swab five times against the nasal wall then slowly remove from the nostril.
● Using the same swab repeat the collection procedure with the second nostril
● Swirl the swab tip in the buffer fluid inside the extraction tube, pushing into the wall of
the extraction tube at least five times and then squeeze out the swab by squeezing the
extraction tube with your fingers
● Break the swab at the breakpoint and close the cap of extraction tub
● Open the dropping nozzle cap at the bottom of the extraction tube
● Dispense 5 drops of extracted specimens vertically into the specimen well (S) on the
device. Do not handle or move the test device until the test is complete and ready for
reading.
AFTER:
● Close the nozzle and dispose of the extraction tube containing the used swab
● Start timer. The test takes 15 minutes to return a result and must be accurately timed
using a timer (mobile phone or other). Do not interpret the test result BEFORE 15
mins or AFTER 20 min of starting the test. Dispose of the used device according to
your local regulations and biohazard waste disposal protocol.
● Negative result: The presence of only the control line (C) and no test line (T) within the
result window indicates a negative result
● Positive result: The presence of the test line (T) and the control line (C) within the
result window, regardless of which line appears first, indicates a positive result.
●
Invalid result: If the control line (C) is not visible within the result window after
performing the test, the result is considered invalid.
B. ROUTINE HEMATOLOGY
Patient Name: Mr. N
Age: 46
years old
TEST
Gender:
Male
RESULT
Hgb
120 g/L
Hct
30 vol %
RBC Count
4.71x10^12/L
WBC Count
pH
6.9 x10^9/L
7.20
DIFFERENTIAL COUNT
RESULT
0.57
0.34
0.06
0.03
TEST
Nuetrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Band/Stabs
Immature cells
Platelet count
NRBC
300 x10^9/L
RBC INDICES
86.7 fl
29.1 pg
336 g/L
13.7 %
MCV
MCH
MCHC
RDW
Date/Time
conducted:
January 23, 2023
REFERENCE RATE
M: 135-180 g/L
F: 120-160 g/L
M: 40-50 vol %
F: 37-47 vol %
4.5-5.9X10^12/L
5-10 x10^9/L
7.35-7.45
REFERENCE RATE
0.40-0.70
0.20-0.40
0.00-0.06
0.00-0.07
0.00-0.01
0.00-0.01
150-450 x10^9/L
82.0-95.0 fl
27.0-31.0 pg
320-360 g/L
11.6-14.6%
C. SEROLOGY IMMUNOLOGY
Patient Name: Mr. N
Age: 46
years old
Gender:
Male
Requesting Physician:
Hospital no: 33958
ASSAY
HBsAG
METHOD
I.C.T
Date/Time
conducted:
January 23, 2023
Area: ER General
Surgery
RESULT
Non-reactive
D. CLINICAL HEMATOLOGY
Patient Name: Mr. N
Age: 46
years old
TEST
Gender:
Male
RESULT
Bands/Stabs
Immature Cells
Platelet Count
Clotting Time
Bleeding Time
TEST
Reticulocyte Count
Date/Time
conducted: January
23, 2023
REFERENCE RATE
0.00-0.05
150-450x10
3-6 min
1-5 min
SPECIAL HEMATOLOGY
RESULT
17
REFERENCE RATE
0.3-3.0%
ESR
Prothrombin Time
Reactivated Partial Thromboplastin
Time
Aspartate Aminotransferase
ALT
TPAG
D-Dimer
12.5sec
27.8 sec
M: 0-20 mm/hr
F: 0-30 mm/hr
11.7-15.3 sec
24-35 sec
45 U/L
47 U/L
8-33U/L
4-36U/L
0.40 ug/ml
0-0.50 ug/ml
E. BLOOD TYPING
Patient Name: Mr. N
Age: 46
years old
Gender: Male
Requesting Physician:
Test
Blood Typing (ABO Forward + Rh)
Date/Time Done:
Med Tech
Hospital no: 33958
Date
conducted:
January 23,
2023
Area: ER
Result
“O” Rh Positive
Head, Blood Bank Section
F. CLINICAL CHEMISTRY
Patient Name: Mr. N
Age: 46 years
old
Test
Gender: Male
Result
BUN
Creatinine
Sodium
Potassium
5.96 mmol/L
54.90 mmol/L
143.0 mmol/L
4.5 mmol/L
Date
conducted:
January 23,
2023
Reference
Value
2.5-6.1
46.0-92.0
135.0-145.0
3.5-5.5
Nursing Consideration:
BEFORE:
● Tell the patient that the test requires a blood sample.
● Explain to the patient, who will perform the arterial puncture, when it will occur, and
where the puncture site will be; radial, brachial, or femoral artery.
● Inform the patient that he may not need to restrict food and fluids.
● Instruct the patient to breathe normally during the test, and warn him that he may
experience a brief cramping or throbbing pain at the puncture site.
DURING:
● Use a heparinized blood gas syringe to draw the sample.
● Perform an arterial puncture or draw blood from an arterial line.
● Eliminate air from the sample, place it on ice immediately, and prepare to transport for
analysis.
AFTER:
● After applying pressure to the puncture site for 3 to 5 minutes and when bleeding has
stopped, tape a gauze pad firmly over it.
● If the puncture site is on the arm, don’t tape the entire circumference because this may
restrict circulation.
● If the patient is receiving anticoagulants or has a coagulopathy, apply pressure to the
puncture site longer than 5 minutes if necessary.
● Monitor vital signs and observe for signs of circulatory impairment.
18
G. ROUTINE URINALYSIS
Patient Name: Mr. N
Test Components
Color
Transparency / Appearance
Age: 46 years old
Gender: Male
Date
conducted:
January 23,
2023
Macroscopic Examination
Result
Normal
Pathophysiological Basis
Values
Red
Straw Yellow Indication: Abnormal Finding
tinged
to Amber in Significance: Many foods and
medicines can affect the color of the
Color
urine. Urine with no color may be
caused by long-term kidney disease
or uncontrolled diabetes. Red urine
can be caused by blood in the urine.
Implication: Patient Mr. N, urine
color has an abnormal finding of
having a red tinged in color urine. This
may indicate an abdominal injury
Indication: Abnormal Finding
Hazy
Clear
Significance: Cloudy urine can be
caused by pus, blood, sperm,
bacteria, yeast, crystals, mucus, or a
parasite
infection,
such
as
trichomoniasis
Implication: Patient Mr. N, has a urine
transparency
of
having
hazy
appearance, this may indicate
concentrated urine.
pH
3
4-5.8
Indication: Below the normal values
Significance: Some foods and
medicines can affect urine pH. A high
pH can be caused by severe vomiting,
a kidney disease, some urinary tract
infections and asthma. A low pH may
be caused by severe lung disease,
uncontrolled
diabetes,
aspirin
overdose,
severe
diarrhea,
dehydration, starvation, drinking too
much alcohol, or drinking antifreeze.
Implication: Patient Mr. N, has a
below the normal findings of the pH
level of the urine which indicates of an
acidosis urine.
Protein
Negative
Negative
Indication: Normal
Significance: Protein in the urine
may mean that kidney damage, an
infection, cancer, systemic lupus
erythematosus
(SLE),
or
glomerulonephritis is present.
Implication: Patient Mr. N found out
that there is no trace of protein which
indicates having no proteinuria.
19
Glucose
Test Components
RBC / hpf
WBC / hpf
Epithelial Cells
Urates / Phosphate
90
mg/dl
80-140
mg/dL
Indication: normal values
Significance: Glucose is the type of
sugar found in blood. Normally there
is very little or no glucose in urine.
When the blood sugar level is very
high, as in uncontrolled diabetes, the
sugar spills over into the urine.
Glucose can also be found in urine
when the kidneys are damaged or
diseased
Microscopic Examination
Result
Normal
Pathophysiological Basis
Values
Indication: Below the normal value
3.20
4.20-6.10
Significance: Red blood cells in the
urine may be caused by kidney or
bladder injury, kidney stones, a
urinary
tract
infection
(UTI),
inflammation
of
the
kidneys
glomerulonephritis, a kidney or
bladder tumor, or systemic lupus
erythematous (SLE).
Implication: Patient Mr. N, has low
normal value findings of which had an
indication of internal bleeding
Indication: Abnormal Finding
1.32
Puss cells Significance: The presence of
cells,
urates
and
and bacteria epithelial
Phosphates
may
mean
that
the
should be
sample is not as pure as it needs to
absent in
be. These cells do not mean there is
urine
Moderate
a medical problem, but the doctor
may ask the patient to give another
urine sample.
Implication: Patient Mr. N has a
moderate to few findings. An
indication of having a presence of
Few
puss cells, a sign of infection and
inflammation.
Nursing Consideration:
BEFORE:
● Tell the patient that the test requires a urine sample
● Explain to the patient the procedure and instruct the patient to void directly into a clean,
dry container. Sterile, disposable containers are recommended. Women should always
have a clean-catch specimen if a microscopic examination is ordered. Feces,
discharges, vaginal secretions and menstrual blood will contaminate the urine specimen
DURING:
● Collect specimens into a disposable collection apparatus consisting of a plastic bag with
an adhesive backing around the opening that can be fastened to the perineal area
Depending on hospital policy, the collected urine can be transferred to an appropriate
specimen container
● Cover all specimens tightly, label properly and send immediately to the laboratory
AFTER:
● If a urine sample is obtained from an indwelling catheter, it may be necessary to clamp
the catheter for about 15-30 minutes before obtaining the sample. Clean the specimen
port with antiseptic before aspirating the urine sample with a needle and a syringe.
● Observe standard precautions when handling urine specimens.
● If the specimen cannot be delivered to the laboratory or tested within an hour, it should
be refrigerated or have an appropriate preservative added
20
H. ROUTINE FECALYSIS
Patient Name: Mr. N
MACROSCOPIC
EXAMINATION
Color
Consistency
MICROSCOPIC
EXAMINATION
Fat neutral fat crystals
and soaps
Yeast
TEST
Ova or Parasite
Occult Blood
Malarial Smear
Age: 46
years old
RESULT
Brown to
Green
ish Brown
Gender: Male
NORMAL
FINDINGS
Brown to
Greenish Brown
Formed
Formed
Colorless
18% and
non-fatty
acid stool
Colorless 18%
and non-fatty acid
stool
Date conducted: January 23,
2023
PATHOPHYSIOLOGICAL BASIS
Indication: NormalFinding
Significance: Normal, healthy
stool ranges from a shade of
brown to greenish brown. This
may vary of food intake and lots of
colorful foods. The color is the
result of what a person eat and
how much bile is it in stool.
Implication: Patient, has a normal
finding
Indication: Normal Finding
Significance: Healthy stool is
usually considered a soft, formed
bowel movement. The consistency
changes could be caused by an
infection, nutrients not being
digested due to celiac disease or a
problem with the pancreas, such
as pancreatic cancer or
pancreatitis
Implication: Patient, has a normal
finding
None
RESULT
NORMAL
FINDINGS
None
Negative
Negative
NURSING CONSIDERATIONS
BEFORE:
⮚ Assess the patient’s level of comfort. Collecting stool specimen may produce a feeling of
embarrassment and discomfort to the patient.
⮚ Encourage the patient to urinate. Allow the patient to urinate before collecting to avoid
contaminating the stool with urine.
⮚ Avoid laxatives. Advise patient that laxatives, enemas, or suppositories are avoided three
days prior to collection.
Instruct a red-meat free and high residue diet. The patient is indicated for an occult blood test,
must follow a special diet that includes generous amounts of chicken, turkey, and tuna, raw and
uncooked vegetables, and fruits such as spinach, celery, prunes and bran containing cereal for
two (2) days before the test.
DURING:
● Instruct the patient to collect small amount directly into a clean, dry container. Sterile,
disposable containers are recommended
● Depending on hospital policy, the collected urine can be transferred to an appropriate
specimen container
Cover all specimens tightly, label properly and send immediately to the laboratory
AFTER:
⮚ Instruct patient to do hand washing. Allow the patient to thoroughly clean his or her hands
and perianal area.
Resume activities. The patient may resume his or her normal diet and medication therapy
unless otherwise specified.
21
I.
FAST ULTRASOUND
Patient Name: Mr. N
Age: 46
Gender: Male
years old
Access No: E22101500055
Procedure: Whole Abdomen
Health Record: 039958
Requesting Physician:
Clinical Info:
Liver Blunt Trauma
Findings:
Date conducted:
January 23, 2023
Ward: Surgery
Modality: DR
- The lungs are clear
- The heart is not enlarged
- The aorta is unremarkable
- Diaphragm and sulci are intact
- Other chest structures are intact
Impression:
-
Unremarkable Cardio Pulmonary Findings
Ms. RM, RT
Rad Tech
RD, MD
Radiologist
Nursing Considerations:
BEFORE:
 Explain to the patient the purpose of the test. Tell him who will perform the test and where
it will take place.
 Inform the patient that he will need to lie flat on a narrow bed, which slides into a large
cylinder that houses the MRI magnets. Explain to the patient that MRI is painless and
involves no exposure to radiation from the scanner. A radioactive contrast dye may be
used, depending on the tissue being studied.
 Advise the patient that he will have to remain still for the entire procedure.
 Explain to the patient who is claustrophobic or anxious about the test’s duration that he
will receive a mild sedative to reduce his anxiety or that he may need to be scanned in an
open MRI scanner, which may take longer but is less confining. Tell him that he will be
able to communicate with the technician at all times and that the procedure will be
stopped if he feels claustrophobic.
 If contrast media will be used, obtain a history of allergies or hypersensitivity to these
agents. Mark any sensitivities on the chart and notify the practitioner.
 Instruct the patient to remove all metallic objects, including jewelry, hairpins, and watches.
 Ask the patient if he has any implanted metal devices or prostheses, such as vascular
clips, shrapnel, pacemakers, joint implants, filters, and intrauterine devices. If so, the test
may not be able to be performed.
 Make sure that the patient or a responsible family member has signed an informed
consent form.
 Administer the prescribed sedative if ordered.
 At the scanner room door, recheck the patient one last time for metal objects.
DURING:
 Remind the patient to remain still throughout the procedure.
 Assess how the patient responds to the enclosed environment. Provide reassurance if
necessary.
 Monitor the cardiac function for signs of ischemia (chest pressure, shortness of breath, or
changes in hemodynamic status).
AFTER:
 The nurse should be aware of these post-procedure nursing interventions after magnetic
resonance imaging:
 Tell the patient that he may resume his usual activities as ordered.
 If the test took a long time and the patient was lying flat for an extended period, observe
him for orthostatic hypotension.
22


Provide comfort measures and pain medication as needed and ordered because of
prolonged positioning the scanner.
Monitor the patient for the adverse reaction to the contrast medium (flushing, nausea,
urticaria, and sneezing).
J. CLINICAL CHEMISTRY
Patient Name: Mr.
N
Requesting
Physician: Dr.
Yabres, MD
TEST
Age: 46 years Gender:
old
Male
Hospital no: 33958
RESULT
Date: January 23, 2023
Area: Surgery Ward
REFERE
NCE
VALUE
14-0-36.0
U/L
Aspertate
Aminotransferase
59 U/L
Alanine
Aminotransferase
65 U/L
0.0-35.0
U/L
Total Bilirubin
99.7 umol/L
Direct Bilirubin
68.7 umol/L
Bilirubin
Unconjugated
31.0 umol/L
3.4222.23
umol/L
0.0-6.84
umol/L
0.0-18.81
umol/L
23
PATHOPHYSIOLOGIC
AL BASIS
Indication: Above the
normal values
Significance: ALT is an
enzyme found in the
liver that helps convert
proteins into energy for
the liver cells. When the
liver is damaged, ALT is
released into the
bloodstream and levels
increase. Aspartate
transaminase (AST).
AST is an enzyme that
helps metabolize amino
acids.
Implication: Patient,
has an above the normal
value findings which
may have an indication
of elevated aspartate
aminotransferase and
alanine
aminotransferase as
enzymes that indicates
liver damage or fatty
liver and high
concentrations in the
blood.
Indication: Above the
normal values
Significance: Bilirubin
attached by the liver to
glucuronic acid, a
glucose-derived acid, is
called direct, or
conjugated, bilirubin.
Bilirubin not attached to
glucuronic acid is called
indirect, or
unconjugated, bilirubin.
All the bilirubin in blood
together is called total
bilirubin. This is to
examine an elevated
plasma bilirubin
Implication: Patient,
has an above the normal
value findings which
may have an indication
of higher levels of direct
bilirubin in blood an
indication that the liver
isn't clearing waste and
bilirubin properly and
has common bile duct
obstruction
Alkaline Phospate
104.40 U/L
38.0126.0 U/L
Nursing Considerations:
BEFORE:
⮚ Tell the patient that the test requires a blood sample.
⮚ Explain to the patient, who will perform the arterial puncture, when it will occur, and where
the puncture site will be; radial, brachial, or femoral artery.
⮚ Inform the patient that he may not need to restrict food and fluids.
⮚ Instruct the patient to breathe normally during the test, and warn him that he may
experience a brief cramping or throbbing pain at the puncture site.
DURING:
● Use a heparinized blood gas syringe to draw the sample.
● Perform an arterial puncture or draw blood from an arterial line.
● Eliminate air from the sample, place it on ice immediately, and prepare to transport for
analysis.
AFTER:
⮚ After applying pressure to the puncture site for 3 to 5 minutes and when bleeding has
stopped, tape a gauze pad firmly over it.
⮚ If the puncture site is on the arm, don’t tape the entire circumference because this may
restrict circulation.
⮚ If the patient is receiving anticoagulants or has a coagulopathy, apply pressure to the
puncture site longer than 5 minutes if necessary.
⮚ Monitor vital signs and observe for signs of circulatory impairment.
A. ELECTROCARDIOGRAM
24
Patient Name:
Mr. N
Age: 46 years old
Gender: Male
Date/Time conducted:
January 23, 2023
BEFORE:





Verify the order for the ECG in the client's chart, confirm the client's Identity.
Provide privacy and explain the procedure to the client.
Emphasize that no electrical current will enter the body.
Tell the client that the test typically takes about 5 minutes.
Place the ECG machine close to the client's bed and plug the cord into the wall outlet
or, battery-operated, ensure that it is functioning. Turn on the machine and input
required client information.
DURING:





Verify the order for the ECG in the client's chart Confirm the client's Identity.
Provide privacy and explain the procedure to the client.
Emphasize that no electrical current will enter the body.
Tell the client that the test typically takes about 5 minutes.
Place the ECG machine close to the client's bed and plug the cord into the wall outlet
or, battery operated, ensure that it is functioning. Turn on the machine and input
required client information.
AFTER:
 When the machine finishes recording the 12-lead ECG, remove the electrodes and
clean the client's skin.
 After disconnecting the lead wires from the electrodes, dispose of the electrodes.
Indication:
Sinus
Tachycardia
 Assist
the client
to a comfortable position.
 Remove any remaining equipment and wash your hands.
Significance:
An in
electrocardiogram
records
in the
heart. It's
common
 Document
your notes the test's
datethe
andelectrical
time andsignals
significant
responses
byathe
client.
and painless test used to quickly detect heart problems and monitor the heart's health. The
Verify the date, time, client's name, and assigned ID number on the ECG itself.
test also help diagnose and monitor conditions affecting the heart. It can be used to investigate
symptoms of a possible heart problem, such as chest pain, palpitations (suddenly noticeable
heartbeats), dizziness and shortness of breath.
Interpretation:
Alongside with presence of hemorrhage. ECG notes a sinus tachycardia is characterized by a
sinus P wave at a rate of more than 100 per minute, usually followed by a QRS complex that is
usually narrow (but may be wide in the presence of an underlying BBB). Associated with
widened blood pressure, decrease heart rate (129 bpm) and irregular pulse rate.
Nursing Considerations
K. ROUTINE HEMATOLOGY
25
Patient Name: Mr. N
Age: 46
years old
Hgb
Gender:
Male
RESULT
130 g/L
Hct
35vol %
TEST
RBC Count
WBC Count
pH
4.60x10^12/L
5x10^9/L
7.35
DIFFERENTIAL COUNT
RESULT
0.57
0.34
0.06
0.03
TEST
Nuetrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Band/Stabs
Immature cells
Platelet count
NRBC
300 x10^9/L
RBC INDICES
86.7 fl
29.1 pg
336 g/L
13.7 %
MCV
MCH
MCHC
RDW
Date/Time conducted:
January 25, 2023
REFERENCE RATE
M: 135-180 g/L
F: 120-160 g/L
M: 40-50 vol %
F: 37-47 vol %
4.5-5.9X10^12/L
5-10 x10^9/L
7.35-7.45
REFERENCE RATE
0.40-0.70
0.20-0.40
0.00-0.06
0.00-0.07
0.00-0.01
0.00-0.01
150-450 x10^9/L
82.0-95.0 fl
27.0-31.0 pg
320-360 g/L
11.6-14.6%
L. SEROLOGY IMMUNOLOGY
Patient Name: Mr. N
Age: 46
years old
Gender:
Male
Requesting Physician:
Hospital no: 33958
ASSAY
HBsAG
METHOD
I.C.T
Date/Time
conducted:
January 25, 2023
Area: ER General
Surgery
RESULT
Non-reactive
M. CLINICAL HEMATOLOGY
Patient Name: Mr. N
Age: 46
years old
TEST
Gender:
Male
RESULT
Bands/Stabs
Immature Cells
Platelet Count
Clotting Time
Bleeding Time
TEST
Reticulocyte Count
ESR
Date/Time conducted:
January 25, 2023
REFERENCE RATE
0.00-0.05
150-450x10
3-6 min
1-5 min
SPECIAL HEMATOLOGY
RESULT
Prothrombin Time
Reactivated Partial Thromboplastin
Time
Aspartate Aminotransferase
ALT
TPAG
26
12.5sec
27.8 sec
REFERENCE RATE
0.3-3.0%
M: 0-20 mm/hr
F: 0-30 mm/hr
11.7-15.3 sec
24-35 sec
45 U/L
47 U/L
8-33U/L
4-36U/L
D-Dimer
0.40 ug/ml
0-0.50 ug/ml
N. CLINICAL CHEMISTRY
Patient Name: Mr. N
Test
BUN
Creatinine
Sodium
Potassium
Age: 46 years
old
Result
5.96 mmol/L
54.90 mmol/L
143.0 mmol/L
4.5 mmol/L
Gender: Male
Date conducted:
January 25, 2023
Reference Value
2.5-6.1
46.0-92.0
135.0-145.0
3.5-5.5
Nursing Consideration:
BEFORE:
⮚ Tell the patient that the test requires a blood sample.
⮚ Explain to the patient, who will perform the arterial puncture, when it will occur, and where
the puncture site will be; radial, brachial, or femoral artery.
⮚ Inform the patient that he may not need to restrict food and fluids.
⮚ Instruct the patient to breathe normally during the test, and warn him that he may
experience a brief cramping or throbbing pain at the puncture site.
DURING:
●
●
●
Use a heparinized blood gas syringe to draw the sample.
Perform an arterial puncture or draw blood from an arterial line.
Eliminate air from the sample, place it on ice immediately, and prepare to transport for
analysis.
AFTER:
⮚ After applying pressure to the puncture site for 3 to 5 minutes and when bleeding has
stopped, tape a gauze pad firmly over it.
⮚ If the puncture site is on the arm, don’t tape the entire circumference because this may
restrict circulation.
⮚ If the patient is receiving anticoagulants or has a coagulopathy, apply pressure to the
puncture site longer than 5 minutes if necessary.
⮚ Monitor vital signs and observe for signs of circulatory impairment.
O. ROUTINE URINALYSIS
Patient Name: Mr. N
Test Components
Color
Age: 46 years old
Gender: Male
Date conducted:
January 25,
2023
Macroscopic Examination
Result
Normal
Pathophysiological Basis
Values
Straw
Straw Yellow Indication: Normal Finding
Yellow
to Amber in Significance: Many foods and
medicines can affect the color of the
to
Color
urine. Urine with no color may be
Amber
caused by long-term kidney disease or
in Color
uncontrolled diabetes. Red urine can
be caused by blood in the urine.
Implication: Patient Mr. N, urine color
has a normal finding
27
Transparency / Appearance
pH
Protein
Glucose
Test Components
RBC / hpf
WBC / hpf
Indication: Normal Finding
Significance: Cloudy urine can be
caused by pus, blood, sperm, bacteria,
yeast, crystals, mucus, or a parasite
infection, such as trichomoniasis
Implication: Patient Mr. N, has a clear
urine transparency which indicates a
normal finding.
Indication: Normal
4
4-5.8
Significance: Some foods and
medicines can affect urine pH. A high
pH can be caused by severe vomiting,
a kidney disease, some urinary tract
infections and asthma. A low pH may
be caused by severe lung disease,
uncontrolled
diabetes,
aspirin
overdose,
severe
diarrhea,
dehydration, starvation, drinking too
much alcohol, or drinking antifreeze.
Implication: Patient Mr. N, has a
normal finfing
Indication: Normal
Negative
Negative
Significance: Protein in the urine may
mean that kidney damage, an
infection, cancer, systemic lupus
erythematosus
(SLE),
or
glomerulonephritis is present.
Implication: Patient Mr. N found out
that there is no trace of protein which
indicates having no proteinuria.
Indication: normal values
90
80-140
Significance: Glucose is the type of
mg/dl
mg/dL
sugar found in blood. Normally there is
very little or no glucose in urine. When
the blood sugar level is very high, as in
uncontrolled diabetes, the sugar spills
over into the urine. Glucose can also
be found in urine when the kidneys are
damaged or diseased.
Microscopic Examination
Result
Normal
Pathophysiological Basis
Values
Indication: Below the normal value
4
4.20-6.10
Significance: Red blood cells in the
urine may be caused by kidney or
bladder injury, kidney stones, a urinary
tract infection (UTI), inflammation of
the kidneys glomerulonephritis, a
kidney or bladder tumour, or systemic
lupus erythematous (SLE).
Implication: Patient Mr. N, has low
normal value findings of which had an
indication of internal bleeding
Indication: Abnormal Finding
1.32
Puss cells Significance: The presence of
and bacteria epithelial cells, urates and Phosphates
may mean that the sample is not as
should be
pure as it needs to be. These cells do
absent in
not mean there is a medical problem,
urine
but the doctor may ask the patient to
give another urine sample.
Clear
Clear
28
Implication: Patient Mr. N has a
moderate to few findings. An indication
of having a presence of puss cells, a
sign of infection and inflammation.
Nursing Considerations:
BEFORE:
● Tell the patient that the test requires a urine sample
● Explain to the patient the procedure and instruct the patient to void directly into a clean,
dry container. Sterile, disposable containers are recommended. Women should always
have a clean-catch specimen if a microscopic examination is ordered. Feces, discharges,
vaginal secretions and menstrual blood will contaminate the urine specimen.
DURING:
● Collect specimens into a disposable collection apparatus consisting of a plastic bag with
an adhesive backing around the opening that can be fastened to the perineal area
Depending on hospital policy, the collected urine can be transferred to an appropriate
specimen container
● Cover all specimens tightly, label properly and send immediately to the laboratory
AFTER:
● If a urine sample is obtained from an indwelling catheter, it may be necessary to clamp
the catheter for about 15-30 minutes before obtaining the sample. Clean the specimen
port with antiseptic before aspirating the urine sample with a needle and a syringe.
● Observe standard precautions when handling urine specimens.
● If the specimen cannot be delivered to the laboratory or tested within an hour, it should
be refrigerated or have an appropriate preservative added
P. ROUTINE FECALYSIS
Patient Name: Mr. N
MACROSCOPIC
EXAMINATION
Color
Age: 46
years old
RESULT
Brown to
Greenish
Brown
Gender: Male
NORMAL
FINDINGS
Brown to
Greenish Brown
Date conducted: January 25,
2023
PATHOPHYSIOLOGICAL BASIS
Indication: NormalFinding
Significance: Normal, healthy stool
ranges from a shade of brown to
greenish brown. This may vary of
food intake and lots of colorful
foods. The color is the result of
what a person eat and how much
bile is it in stool.
Implication: Patient, has a normal
finding
Consistency
MICROSCOPIC
EXAMINATION
Fat neutral fat crystals
and soaps
Formed
Formed
Colorless
18% and
non-fatty
acid stool
Colorless 18%
and non-fatty acid
stool
29
Indication: Normal Finding
Significance: Healthy stool is
usually considered a soft, formed
bowel movement. The consistency
changes could be caused by an
infection, nutrients not being
digested due to celiac disease or a
problem with the pancreas, such
as pancreatic cancer or
pancreatitis
Implication: Patient, has a normal
finding
Yeast
TEST
RESULT
Ova or Parasite
Occult Blood
Malarial Smear
None
NORMAL
FINDINGS
None
Negative
Negative
Q. CT SCAN
Patient Name: Mr. N
Health Record: 039958
Requesting Physician:
Clinical Info:
Liver Blunt Trauma
Findings:
The lungs are clear
The heart is not enlarged
The aorta is unremarkable
Diaphragm and sulci are intact
Other chest structures are intact
Impression:
Unremarkable Cardio Pulmonary Findings
Ms. RM, RT
Rad Tech
Age: 46
Gender: Male
years old
Access No: E22101500055
Procedure: Whole Abdomen
Date conducted:
January 25, 2023
Ward: Surgery
Modality: DR
RD, MD
Radiologist
R. CLINICAL CHEMISTRY
Patient Name: Mr.
N
Requesting
Physician: Dr.
Yabres, MD
TEST
Age: 46
Gender: Date: January 252023
years old
Male
Hospital no: 33958
Area: Surgery Ward
Aspertate
Aminotransferase
Alanine
Aminotransferase
RESULT
20U/L
REFERENCE
VALUE
14-0-36.0 U/L
PATHOPHYSIOLOGICAL
BASIS
Indication: normal values
30 U/L
0.0-35.0 U/L
Significance: ALT is an
enzyme found in the liver
that helps convert proteins
into energy for the liver
cells. When the liver is
damaged, ALT is released
into the bloodstream and
levels increase. Aspartate
transaminase (AST). AST
is an enzyme that helps
metabolize amino acids.
Total Bilirubin
3.42 umol/L
Direct Bilirubin
6.80 umol/L
3.42-22.23
umol/L
0.0-6.84 umol/L
30
Implication: Patient, has a
normal finding
Indication: normal values
Bilirubin
Unconjugated
18.0 umol/L
0.0-18.81 umol/L
Significance: Bilirubin
attached by the liver to
glucuronic acid, a
glucose-derived acid, is
called direct, or
conjugated, bilirubin.
Bilirubin not attached to
glucuronic acid is called
indirect, or unconjugated,
bilirubin. All the bilirubin in
blood together is called
total bilirubin. This is to
examine an elevated
plasma bilirubin
Implication: Patient, has a
normal finding
Alkaline Phospate
Remarks:
Med Tech
104.40 U/L
38.0-126.0 U/L
Time Done:
Head, Anatomic & Clinical
Laboratory Section
Nursing Consideration
BEFORE:
● Tell the patient that the test requires a blood sample.
● Explain to the patient, who will perform the arterial puncture, when it will occur, and
where the puncture site will be; radial, brachial, or femoral artery.
● Inform the patient that he may not need to restrict food and fluids.
● Instruct the patient to breathe normally during the test, and warn him that he may
experience a brief cramping or throbbing pain at the puncture site.
DURING:
● Use a heparinized blood gas syringe to draw the sample.
● Perform an arterial puncture or draw blood from an arterial line.
● Eliminate air from the sample, place it on ice immediately, and prepare to transport for
analysis.
AFTER:
● After applying pressure to the puncture site for 3 to 5 minutes and when bleeding has
stopped, tape a gauze pad firmly over it.
● If the puncture site is on the arm, do not tape the entire circumference because this may
restrict circulation.
● If the patient is receiving anticoagulants or has a coagulopathy, apply pressure to the
puncture site longer than 5 minutes if necessary.
● Monitor vital signs and observe for signs of circulatory impairment.
B. ELECTROCARDIOGRAM
31
Patient Name:
Mr. N
Age: 46 years old
Gender: Male
Date/Time conducted:
January 23, 2023
BEFORE:





Verify the order for the ECG in the client's chart, confirm the client's Identity.
Provide privacy and explain the procedure to the client.
Emphasize that no electrical current will enter the body.
Tell the client that the test typically takes about 5 minutes.
Place the ECG machine close to the client's bed and plug the cord into the wall outlet
or, battery-operated, ensure that it is functioning. Turn on the machine and input
required client information.
DURING:





Verify the order for the ECG in the client's chart Confirm the client's Identity.
Provide privacy and explain the procedure to the client.
Emphasize that no electrical current will enter the body.
Tell the client that the test typically takes about 5 minutes.
Place the ECG machine close to the client's bed and plug the cord into the wall outlet
or, battery operated, ensure that it is functioning. Turn on the machine and input
required client information.
AFTER:
 When the machine finishes recording the 12-lead ECG, remove the electrodes and
clean the client's skin.
 After disconnecting the lead wires from the electrodes, dispose of the electrodes.
Indication:
Normal
 Assist
the client to a comfortable position.
 Remove any remaining equipment and wash your hands.
Significance:
An in
electrocardiogram
records
in the
heart. It's
common
 Document
your notes the test's
datethe
andelectrical
time andsignals
significant
responses
byathe
client.
and painless test used to quickly detect heart problems and monitor the heart's health. The
Verify the date, time, client's name, and assigned ID number on the ECG itself.
test also help diagnose and monitor conditions affecting the heart. It can be used to investigate
symptoms of a possible heart problem, such as chest pain, palpitations (suddenly noticeable
heartbeats), dizziness and shortness of breath.
Interpretation:
Heart is beating at an even rate of 60 to 100 beats per minute
Nursing Considerations
S. ROUTINE HEMATOLOGY
32
Patient Name: Mr. N
Age: 46
years old
TEST
Gender:
Male
Hgb
RESULT
140g/L
Hct
45vol %
RBC Count
WBC Count
pH
4.5x10^12/L
6x10^9/L
7.35
DIFFERENTIAL COUNT
RESULT
0.57
0.34
0.06
0.03
TEST
Nuetrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Band/Stabs
Immature cells
Platelet count
NRBC
300 x10^9/L
RBC INDICES
86.7 fl
29.1 pg
336 g/L
13.7 %
MCV
MCH
MCHC
RDW
Date/Time
conducted:
January 29, 2023
REFERENCE RATE
M: 135-180 g/L
F: 120-160 g/L
M: 40-50 vol %
F: 37-47 vol %
4.5-5.9X10^12/L
5-10 x10^9/L
7.35-7.45
REFERENCE RATE
0.40-0.70
0.20-0.40
0.00-0.06
0.00-0.07
0.00-0.01
0.00-0.01
150-450 x10^9/L
82.0-95.0 fl
27.0-31.0 pg
320-360 g/L
11.6-14.6%
T. SEROLOGY IMMUNOLOGY
Patient Name: Mr. N
Age: 46
years old
Gender:
Male
Requesting Physician:
Hospital no: 33958
ASSAY
HBsAG
METHOD
I.C.T
Date/Time
conducted:
January 25, 2023
Area: ER General
Surgery
RESULT
Non-reactive
U. CLINICAL HEMATOLOGY
Patient Name: Mr. N
Age: 46
years old
TEST
Gender:
Male
RESULT
Bands/Stabs
Immature Cells
Platelet Count
Clotting Time
Bleeding Time
TEST
Reticulocyte Count
ESR
Date/Time conducted:
January 29, 2023
REFERENCE RATE
0.00-0.05
150-450x10
3-6 min
1-5 min
SPECIAL HEMATOLOGY
RESULT
Prothrombin Time
Reactivated Partial Thromboplastin
Time
Aspartate Aminotransferase
ALT
D-Dimer
12.5sec
27.8 sec
REFERENCE RATE
0.3-3.0%
M: 0-20 mm/hr
F: 0-30 mm/hr
11.7-15.3 sec
24-35 sec
30 U/L
33 U/L
0.40 ug/ml
8-33U/L
4-36U/L
0-0.50 ug/ml
33
V. CLINICAL CHEMISTRY
Patient Name: Mr. N
Test
BUN
Creatinine
Sodium
Potassium
Age: 46 years
Gender: Male
old
Result
5.96 mmol/L
54.90 mmol/L
143.0 mmol/L
4.5 mmol/L
Nursing Consideration:
Date conducted:
January 25, 2023
Reference Value
2.5-6.1
46.0-92.0
135.0-145.0
3.5-5.5
BEFORE:
⮚ Tell the patient that the test requires a blood sample.
⮚ Explain to the patient, who will perform the arterial puncture, when it will occur, and where
the puncture site will be; radial, brachial, or femoral artery.
⮚ Inform the patient that he may not need to restrict food and fluids.
⮚ Instruct the patient to breathe normally during the test, and warn him that he may
experience a brief cramping or throbbing pain at the puncture site.
DURING:
● Use a heparinized blood gas syringe to draw the sample.
● Perform an arterial puncture or draw blood from an arterial line.
● Eliminate air from the sample, place it on ice immediately, and prepare to transport for
analysis.
AFTER:
⮚ After applying pressure to the puncture site for 3 to 5 minutes and when bleeding has
stopped, tape a gauze pad firmly over it.
⮚ If the puncture site is on the arm, don’t tape the entire circumference because this may
restrict circulation.
⮚ If the patient is receiving anticoagulants or has a coagulopathy, apply pressure to the
puncture site longer than 5 minutes if necessary.
⮚ Monitor vital signs and observe for signs of circulatory impairment.
W. ROUTINE URINALYSIS
Patient Name: Mr. N
Test Components
Color
Transparency / Appearance
Age: 46 years old
Gender: Male
Date conducted:
January 29, 2023
Macroscopic Examination
Result
Normal
Pathophysiological Basis
Values
Straw
Straw Yellow Indication: Normal Finding
Significance: Many foods and
Yellow to to Amber in
Amber in Color
medicines can affect the color of the
Color
urine. Urine with no color may be
caused by long-term kidney disease or
uncontrolled diabetes. Red urine can
be caused by blood in the urine.
Implication: Patient Mr. N, urine color
has a normal finding
Indication: Normal Finding
Clear
Clear
Significance: Cloudy urine can be
caused by pus, blood, sperm, bacteria,
yeast, crystals, mucus, or a parasite
infection, such as trichomoniasis
Implication: Patient Mr. N, has a clear
urine transparency which indicates a
normal finding.
34
pH
Protein
Glucose
Test Components
RBC / hpf
WBC / hpf
Indication: Normal
Significance: Some foods and
medicines can affect urine pH. A high
pH can be caused by severe vomiting,
a kidney disease, some urinary tract
infections, and asthma. A low pH may
be caused by severe lung disease,
uncontrolled diabetes, aspirin
overdose, severe diarrhea,
dehydration, starvation, drinking too
much alcohol, or drinking antifreeze.
Implication: Patient Mr. N, has a
normal finding
Indication: Normal
Negative Negative
Significance: Protein in the urine may
mean that kidney damage, an
infection, cancer, systemic lupus
erythematosus (SLE), or
glomerulonephritis is present.
Implication: Patient Mr. N found out
that there is no trace of protein which
indicates having no proteinuria.
Indication: normal values
90
80-140
Significance: Glucose is the type of
mg/dl
mg/dL
sugar found in blood. Normally there is
very little or no glucose in urine. When
the blood sugar level is very high, as in
uncontrolled diabetes, the sugar spills
over into the urine. Glucose can also
be found in urine when the kidneys are
damaged or diseased.
Microscopic Examination
Result
Normal
Pathophysiological Basis
Values
Indication: normal value
5.10
4.20-6.10
Significance: Red blood cells in the
urine may be caused by kidney or
bladder injury, kidney stones, a urinary
tract infection (UTI), inflammation of
the kidneys glomerulonephritis, a
kidney or bladder tumour, or systemic
lupus erythematous (SLE).
Implication: Patient Mr. N, has a
normal value findings
Indication: normal Finding
1.32
Significance: The presence of
1-5
epithelial cells, urates and Phosphates
may mean that the sample is not as
pure as it needs to be. These cells do
not mean there is a medical problem,
but the doctor may ask the patient to
give another urine sample.
Implication: Patient Mr. N has a
normal finding
4
4-5.8
35
X. ROUTINE FECALYSIS
Patient Name: Mr. N
MACROSCOPIC
EXAMINATION
Color
Consistency
MICROSCOPIC
EXAMINATION
Fat neutral fat crystals
and soaps
Age: 46
years old
RESULT
Brown to
Greenish
Brown
Ova or Parasite
Occult Blood
Malarial Smear
NORMAL
FINDINGS
Brown to
Greenish Brown
Formed
Formed
Colorless
18% and
non-fatty
acid stool
Colorless 18%
and non-fatty acid
stool
Yeast
TEST
Gender: Male
RESULT
Date conducted: January 29,
2023
PATHOPHYSIOLOGICAL
BASIS
Indication: Normal Finding
Significance: Normal, healthy
stool ranges from a shade of
brown to greenish brown. This
may vary of food intake and lots
of colorful foods. The color is the
result of what a person eat and
how much bile is it in stool.
Implication: Patient, has a
normal finding
Indication: Normal Finding
Significance: Healthy stool is
usually considered a soft, formed
bowel movement. The
consistency changes could be
caused by an infection, nutrients
not being digested due to celiac
disease or a problem with the
pancreas, such as pancreatic
cancer or pancreatitis
Implication: Patient, has a
normal finding
None
NORMAL
FINDINGS
None
Negative
Negative
Nursing Consideration:
BEFORE:
● Assess the patient’s level of comfort. Collecting stool specimen may produce a feeling
of embarrassment and discomfort to the patient.
● Encourage the patient to urinate. Allow the patient to urinate before collecting to avoid
contaminating the stool with urine.
● Avoid laxatives. Advise patient that laxatives, enemas, or suppositories are avoided
three days prior to collection.
● Instruct a red-meat free and high residue diet. The patient is indicated for an occult
blood test, must follow a special diet that includes generous amounts of chicken, turkey,
and tuna, raw and uncooked vegetables and fruits such as spinach, celery, prunes and
bran containing cereal for two (2) days before the test.
DURING:
● Instruct the patient to collect small amount directly into a clean, dry container. Sterile,
disposable containers are recommended
● Depending on hospital policy, the collected urine can be transferred to an appropriate
specimen container
● Cover all specimens tightly, label properly and send immediately to the laboratory
AFTER:
● Instruct patient to do hand washing. Allow the patient to thoroughly clean his or her
hands and perianal area.
36
●
Resume activities. The patient may resume his or her normal diet and medication
therapy unless otherwise specified.
Y. CT SCAN
Patient Name: Mr. N
Age: 46
Gender: Male
years old
Access No: E22101500055
Procedure: Whole Abdomen
Health Record: 039958
Requesting Physician:
Clinical Info:
No more Liver Blunt Trauma
Findings:
The lungs are clear
The heart is not enlarged
The aorta is unremarkable
Diaphragm and sulci are intact
Other chest structures are intact
Impression:
Unremarkable Cardio Pulmonary Findings
Ms. RM, RT
RD, MD
Rad Tech
Radiologist
Date conducted:
January 29, 2023
Ward: Surgery
Modality: DR
Nursing Consideration:
BEFORE:
 Explain to the patient the purpose of the test. Tell him who will perform the test and
where it will take place.
 Inform the patient that he will need to lie flat on a narrow bed, which slides into a large
cylinder that houses the MRI magnets. Explain to the patient that MRI is painless and
involves no exposure to radiation from the scanner. A radioactive contrast dye may be
used, depending on the tissue being studied.
 Advise the patient that he will have to remain still for the entire procedure.
 Explain to the patient who is claustrophobic or anxious about the test’s duration that he
will receive a mild sedative to reduce his anxiety or that he may need to be scanned in
an open MRI scanner, which may take longer but is less confining. Tell him that he will
be able to communicate with the technician at all times and that the procedure will be
stopped if he feels claustrophobic.
 If contrast media will be used, obtain a history of allergies or hypersensitivity to these
agents. Mark any sensitivities on the chart and notify the practitioner.
 Instruct the patient to remove all metallic objects, including jewelry, hairpins, and
watches.
 Ask the patient if he has any implanted metal devices or prostheses, such as vascular
clips, shrapnel, pacemakers, joint implants, filters, and intrauterine devices. If so, the test
may not be able to be performed.
 Make sure that the patient or a responsible family member has signed an informed
consent form.
 Administer the prescribed sedative if ordered.
 At the scanner room door, recheck the patient one last time for metal objects.
DURING:
 Remind the patient to remain still throughout the procedure.
 Assess how the patient responds to the enclosed environment. Provide reassurance if
necessary.
 Monitor the cardiac function for signs of ischemia (chest pressure, shortness of breath, or
changes in hemodynamic status).
AFTER:
 The nurse should be aware of these post-procedure nursing interventions after magnetic
resonance imaging:
 Tell the patient that he may resume his usual activities as ordered.
37



If the test took a long time and the patient was lying flat for an extended period, observe
him for orthostatic hypotension.
Provide comfort measures and pain medication as needed and ordered because of
prolonged positioning the scanner.
Monitor the patient for the adverse reaction to the contrast medium (flushing, nausea,
urticaria, and sneezing).
Z. CLINICAL CHEMISTRY
Patient Name: Mr.
N
Requesting
Physician: Dr.
Yabres, MD
TEST
Aspertate
Aminotransferase
Alanine
Aminotransferase
Total Bilirubin
Direct Bilirubin
Bilirubin
Unconjugated
Age: 46
Gender: Date: January 29, 2023
years old
Male
Area: Surgery Ward
Hospital no: 33958
RESULT
20U/L
REFERENCE
VALUE
14-0-36.0 U/L
PATHOPHYSIOLOGICAL
BASIS
Indication: normal values
30 U/L
0.0-35.0 U/L
Significance: ALT is an
enzyme found in the liver
that helps convert proteins
into energy for the liver
cells. When the liver is
damaged, ALT is released
into the bloodstream and
levels increase. Aspartate
transaminase (AST). AST
is an enzyme that helps
metabolize amino acids.
3.42 umol/L
6.80 umol/L
18.0 umol/L
Implication: Patient, has a
normal finding
3.42-22.23 umol/L Indication: normal values
0.0-6.84 umol/L
0.0-18.81 umol/L Significance: Bilirubin
attached by the liver to
glucuronic acid, a glucosederived acid, is called
direct, or conjugated,
bilirubin. Bilirubin not
attached to glucuronic acid
is called indirect, or
unconjugated, bilirubin. All
the bilirubin in blood
together is called total
bilirubin. This is to
examine an elevated
plasma bilirubin
Implication: Patient, has a
normal finding
Alkaline Phospate
Remarks:
Med Tech
104.40 U/L
Time Done:
38.0-126.0 U/L
Head, Anatomic & Clinical
Laboratory Section
38
Nursing Consideration
BEFORE:
⮚ Tell the patient that the test requires a blood sample.
⮚ Explain to the patient, who will perform the arterial puncture, when it will occur, and where
the puncture site will be; radial, brachial, or femoral artery.
⮚ Inform the patient that he may not need to restrict food and fluids.
⮚ Instruct the patient to breathe normally during the test, and warn him that he may
experience a brief cramping or throbbing pain at the puncture site.
DURING:
● Use a heparinized blood gas syringe to draw the sample.
● Perform an arterial puncture or draw blood from an arterial line.
● Eliminate air from the sample, place it on ice immediately, and prepare to transport for
analysis.
AFTER:
⮚ After applying pressure to the puncture site for 3 to 5 minutes and when bleeding has
stopped, tape a gauze pad firmly over it.
⮚ If the puncture site is on the arm, don’t tape the entire circumference because this may
restrict circulation.
⮚ If the patient is receiving anticoagulants or has a coagulopathy, apply pressure to the
puncture site longer than 5 minutes if necessary.
⮚ Monitor vital signs and observe for signs of circulatory impairment.
VI.
PERSON ASSESSMENT
39
Demographic and Biological Data
Mr. N
46 years old
September 23, 1976
Patient initials
Age
Date of birth
Place of birth
Sex
Bayombong, Nueva Vizcaya
Male
Address
Magsaysay, Bayombong, Nueva Vizcaya
Civil Status
Married
Chief complaints
NOI: Motor Accident
TOI: 9:30 PM
POI: Busilac, Bayombong, Nueva Vizcaya
DOI: July 23, 2023
Admitting Diagnosis
Final Diagnosis
Admitting Physician
Date of Admission
Date of Discharge
Current Health Problems
Motor Vehicle Accident
S/P Exploratory laparotomy, Evacuation of
peritoneum, Perihepatic Packing, Central
Venous Catheter insertion via right femoral
vein
Dr. A
January 23, 2023
January 29, 2023
HEALTH HISTORY
⮚ Mr. N is a 46-year-old male who rushed
into Region II Trauma Medical Center,
Bayombong, Nueva Vizcaya, via
ambulance car due to a motor vehicle
accident on January 23, 2023, at
around 10:00 in the evening.
Past Health Problems

Surgical History
⮚ Mr. N did not undergo any surgical
procedures.
Accidents
⮚ According to the patient, he was also
hospitalized in his early twenties
because of a minor car accident.
Family Risk Factors
Medications
⮚ Hypertension
⮚ The patient has no maintenance drugs
taking.
According to the patient, he has a history of
a motor vehicle accident when he was in his
early twenties, which he describes as a
minor accident when he rides a tricycle, in
which he got a minor abrasion on his legs
and arms.
PSYCHOSOCIAL
Significant Others
Wife
The wife, Mrs. M,
accompanied her
husband to region 2
Trauma Medical Center
all throughout the
hospitalization.
Mrs. M
40
Structure of Family
Nuclear
Coping Mechanism
He received support from his wife and
children.
Mr. N has a traditional
family structure which
composed of husband,
wife, and children.
He is expressing how he feels to his wife
and spending time with his children.
Religion
Primary language
Primary source of
healthcare
Financial
Resources Related
to Health Care
Occupation
Educational
Attainment
General
Appearance
Level of
Consciousness
Coping strategies is used
to overcome stressful
events that people face in
every day because it
helps to relieve stress and
regain control over that
stressful event.
Roman Catholic
Ilocano and Tagalog
Region II Trauma Medical Center (R2TMC)
PhilHealth & SSS
Foreman
College graduate
PRE-ASSESSMENT
POST-ASSESSMENT
PATHOPHYSIOLOGI
January 23, 2023
January 29, 2023
CAL BASIS
10:30 PM
8:00 AM
Patient is lying at the bed Patient is wearing a sando The abrasions and
wearing a hospital gown.
lacerations were
and short pants.
He is not well groomed
caused by the
Patient is awake and
and has multiple
vehicular
crash he
coherent.
abrasions and a large
experienced.
bruise on his stomach
was noted.
Eye opening: 3 (to verbal Eye opening:
stimuli, command, and
4(spontaneously)
speech)
Verbal Response:
Verbal Response: 4
5(Confused)
(Confused)
Motor Response: 6(Obeys
Motor Response: 5
command)
(moves to localized pain)
GCS-15
GCS-12
Eye opening:
4- spontaneously
3-to speech
2- to pain
1-no response
Verbal response
5-oriented
4-confused
3-inappropriate words
2-incomprehensible
sound
1-no response
Motor response
6-obeys command
5-moves to localized
pain
4-flex to withdraw
from pain
3-abnormal flexion
2-abnormal extension
1-no response
41
Affect
Orientation
The patient has an
The patient has an
appropriate affect with appropriate affect. The client
his current condition.
shows appropriate
The patient shows worry
facial expressions in
about his current
relation to emotions.
condition.
The patient has difficulty Mr. N is aware of the date,
concentrating and
time and who was with
delayed response on the
him.
questions asked by the
nurse.
Questions
Time:
Question: Alam nyo po
ba kung anong petsa po
ngayon?
Answer: January 23,
2023 (delayed response)
Place:
Question: Alam niyo po
ba kung saan kayo
ngayon?
Answer:
Oo
nasa
hospital ako ngayon
Date:
Question: Sir, alam nyo
po ba kung anong araw na
po ngayon?
Answer: Opo, Linngo na
po ngayon. January 29,
2023 po
Time:
Question: Sir, alam nyo
po ba king anong oras na
ngayon?
Answer: (looks to the wall
clock) 8:00 na po ng
umaga
Person:
Question: Kilala nyo po
ba kung sino kasama nyo
ngayon sir?
Answer: Opo, yung Mrs.
ko po (looks to his wife)
The client’s memory is
The client’s memory is
intact but has a delayed
intact.
response
Memory
•
•
Immediate memory:
Patient instructed to
repeat the numbers
“1,3,5,8,15”
⮚ Question: Sir
pakiulit po yung
sasabihin ko
“1,3,5,8,15”
⮚ Answer: Patient
repeat number
“1.3,58,15”
Recent memory:
Patient recent
memory was intact,
Mr. N remembered
•
•
Immediate memory:
Patient instructed to
repeat the numbers
“1,3,5,8,15”
⮚ Question: Sir pakiulit
po yung sasabihin ko
“1,3,5,8,15”
⮚ Answer: Patient
repeat number
“1.3,58,15”
Recent memory: Patient
recent memory was
intact, Mr. N remembered
what he was doing before
the accident.
42
It is natural for the
patient to exhibit
restrictive emotion
as a result of worry
and fatigue
associated with his
current condition, as
evidenced by his
facial expression
and body
language/movement
.
Checking orientation
of the client help the
nurses to evaluate
mental status and
help to diagnose
other condition
caused by the
incident.
what he was doing
before the accident.
⮚ Question: Sir
naalala nyo po ba
yung ginagawa
nyo bago po kayo
naaksidente?”
⮚ Answer: “nagsalosalo po kami ng •
mga katrabaho
ko”
•
Remote memory:
Patient remote
memory was intact
because he
remembers the date
of his birthday.
⮚ Question: Sir naalala
nyo po ba yung
ginagawa nyo bago
po kayo naaksidente”
⮚ Answer: “nagsalosalo po kami ng mga
katrabaho ko”
Remote memory: Patient
remote memory was
intact because he
remembers the date of his
birthday.
⮚ Question: Kaylan po
birthday nyo sir?
⮚ Answer: September
23, 1976
⮚ Question: Kaylan
po birthday nyo
sir?
⮚ Answer:
September 23,
1976
Speech
Client speaks and
responds with a clear
and modulated voice
with normal pace.
Nonverbal behavior The patient was looking
on the ceiling, facial
grimace was noted upon
assessment.
Client speaks and responds
with a clear and modulated
voice with normal pace.
He is smiling and he keeps Due to the pain on his
eye contact. Patient was
abdomen, facial
nodding when he agrees to grimace was noted
the questions.
upon assessment.
ELIMINATION
PREASSESSMENT
January 23, 2023
10:30 PM
POSTASSESSMENT
January 29, 2021
8:00 AM
STOOL
Frequency
Patient usually
defecate once a
day in the morning
Once a day
Pattern
Every morning
around 6:00 AM –
7:00 AM
Early in the morning
Consistency
and shape
Soft to Hard and
well formed
Soft and well formed
Presence of
unusual
odor
None
None
43
PATHOPHYSIOLOGICAL BASIS
Color
Yellow to brown
Yellow to brown
30 ml
URINE
1200 ml
15-30 minutes
every after drinking
water
Patient usually
urinate every 4
hours.
None
None
Pale yellow
Pale yellow
With
difficulty or
with pain
upon
urination
No difficulty and no
pain upon
urination.
No difficulty and no
pain upon urination.
Toileting
Ability
Patient can sit/stand
upright on toilet to
urinate and defecate
and can undress his
self without any
assistance.
Urinates and
defecates in the toilet
with minimal
assistance upon
walking ahead to the
toilet.
Due to post-surgical incision and
abrasion, patient needs minimal
assistance.
Abdomen
Patient’s abdomen
was swollen and
has a large, bluishpurplish bruise that
is 5 inches in
diameter
Patient abdomen has
a post-surgical
vertical midline
incision.
Due to the trauma from the
accident, his abdomen got
slammed into the tree resulting in
swollen abdomen with a presence
of large bruise.
Amount
Frequency
Presence of
unusual
odor
Color
REST AND ACTIVITY
Current
Activity
Level
ADL’s
The client
can:
• Groom
Himself
• Feed
Himself
• Move
PREASSESSMENT
January 23, 2023
10:30 PM
Mr. N was lying in
bed, can perform
hand gestures but
cannot tolerate to
reposition his self.
POSTASSESSMENT
January 29, 2022
8:00 AM
The patient can
reposition his self in
bed with minimal
assistance.
The patient cannot
groom himself
independently.
The patient spends
most of his time
resting in his bed.
Mr. N was not able
to eat as he was
undergone for
emergency E-lap.
Mr. N needs
assistance when
wearing his clothes
44
PATHOPHYSIOLOGICAL BASIS
Limited movement due to the pain on
pre assessment and post-surgical
incision.
•
Communicat
e
The patient cannot
walk due to pain
from his abdomen.
He can
communicate
effectively but not
instantly.
Sleep
Pattern
Body Frame
Posture
Gait
Coordinatio
n
Balance
Motor
Function
Muscle
Strength
and perform his
personal hygiene.
The patient need
assistance when
moving in his bed.
The patient speaks
with a modulated
voice with a normal
pace.
Duration: 6-7 hours Duration: 6-7 hours.
from 11 pm to 5 am. Patient has disturbed
No sleep during the
sleeping pattern
day.
because of the pain
from his incision
sight.
Endomorph
The patient’s posture
was not assessed
because he was
brought in the ER
lying in a stretcher
Endomorph
Endomorphs are rounded, with lots of
muscle and body fat, a stockier
structure, and a slower metabolism.
Patient can finally sit
but slouchy.
The patient walks
The patient’s gait was slowly with minimal
not assessed
support from his
because he was
wife. Arm swing
brought in the ER
through foot and
lying in a stretcher move forwards at the
same time.
Coordinated using
nose to finger test
with slow response.
N/A
Coordinated using
nose to finger test.
Patient needs
minimal assistance
when walking and
sitting.
Gross: Mr. N can flex
Gross: Mr. N can
upper extremities and
flex upper
lower extremities. extremities and lower
Can bend his head at
extremities. Can
all sides.
bend his head at all
sides.
Fine: Mr. N can hold
light material like a Fine: Mr. N can hold
ball pen and can
light material like a
write
ball pen and can
write
Patient has no
Patient has no
involuntary
involuntary
movements like
movements like
twitching and spasms
twitching and
or a y uncoordinated
spasms or a y
movement.
45
0- Complete absence of muscle
movement
1- No movement, contraction of
the muscle is palpable
2- Full muscle movement
against gravity with support
uncoordinated
movement.
Muscle strength
grade - 4
Muscle strength
grade - 4
Mobility/ use Patient does not use
of assistive
assistive device for
devices
mobility. Patient
assisted with his
wife.
3- Full range of motion against
gravity
4- Full range of motion against
gravity and minimal
resistance
5- Full range of motion against
gravity and full resistance
Patient used
wheelchair upon
discharge from the
ward to the car.
SAFE ENVIRONMENT
Allergies
Eyes/
Vision
Pre-Assessment
Post- Assessment
(January 23, 2023)
(January 29, 2023)
No allergies to food,
drug, and
environment.
No allergies to food,
drug, and
environment.
PATHOPHYSIOLOGICAL
BASIS
Pupils are equal and Pupils are equal and
round, reactive to
round, reactive to
light, and
light, and
accommodate. He is accommodate. He is
not using eyeglasses. not using eyeglasses.
Hearing
He is not using
hearing aids.
He is not using
hearing aids
Skin
Integrity
Skin is brown in color
and feels cold and
clammy.
Skin is brown in color
and feels warm and
dry.
• Abrasions that are
superficial in depth
and with a size of:
Abrasions that are
superficial in depth
and with a size of:
>Left cheek: 2cm
>Left cheek: 2cm
>Right hand: 2cm
>Right hand: 2cm
>Right arm: 3.5cm
>Right arm: 3.5cm
>Left arm: 3cm
>Left arm: 3cm
>Right upper leg:
3.5cm
>Right upper leg:
3.5cm
46
The patient sustained multiple
abrasions from getting involved
in a motor vehicular accident
>Left lower leg: 3cm
>Left lower leg: 3cm
>5” surgical vertical
midline incision
Breast
No masses and
tenderness upon
No masses and
tenderness upon
palpation
palpation
Nose
The nasal septum is
in the midline,
mucosa is moist
The nasal septum is
in the midline,
mucosa is moist
Neck
Neck muscles are
equal in size. No
tenderness and
masses upon
palpation.
Neck muscles are
equal in size. No
tenderness and
masses upon
palpation.
Dry mucous
membranes
Mucous membranes
are moist and intact.
The patient was having active
bleeding leading to decreased
blood volume, thereby causing
a decrease in blood flow to
peripheral tissues
35.8°C
36.7°C
The temperature was
decreased due to energy deficit
Mucous
Membrane
Temperature
47
OXYGENATION
Activity
Intolerance
Airway
Clearance
Respiratory
Rate
Pre-Assessment
Post- Assessment
(January 23, 2023)
(January 29, 2023)
The patient cannot
perform activities
independently due
to pain and
weakness
The patient’s
movement
is
minimal due to the
surgery.
Clear and open
airways. No
blockages or
obstruction noted
Clear and open
airways. No
blockages or
obstruction noted
38 cpm
20 cpm
48
PATHOPHYSIOLOGICAL BASIS
Movement is minimal due to the
trauma
The patient is tachypneic due to
poor perfusion of tissues from
loss of too much blood
Capillary
Refill
Patient’s capillary
refill takes more
than 3 seconds.
Patient’s capillary
refill is normal, as it
goes back to its
pinkish color within
2 seconds.
Oxygen
Saturation
90%
97%
Pulse Rate
129 bpm
86 bpm
Blood
Pressure
60/40 mmHg
110/80 m
Low oxygen saturation is due to
poor perfusion of tissues
attributed to the hypovolemic
shock
The patient is experiencing
tachycardia due to decreased
blood volume from massive
bleeding
A drop in blood pressure is a
result of the patient’s decreased
cardiac output
NUTRITION
Pre-Assessment
(January 23, 2023)
Diet
Restrictions
Post- Assessment
(January 29, 2023)
PATHOPHYSIOLOGICAL
BASIS
NPO
DAT
Fluid Intake
Not assessed
500ml of water
Height and
Weight
Weight: 85 kg
Weight: 85 kg
Height: 5’8”
BMI: 24.8 kg/m2
Height: 5’8”
The patient was placed on NPO
for emergency surgery
BMI: 24.8 kg/m2
Tissue
Turgor
Recoil of skin takes
more than 3 seconds
to return to its original
state
An immediate recoil
of skin that goes
back in less than 2
49
The blood flow to peripheral
tissue is reduced causing poor
skin turgor
Ability
-
Che
w food
-
Swall
ow
-
Feed
self
Not assessed
Patient is able to
chew food, swallow,
and feed himself
50
The patient was placed on NPO
for emergency surgery
VII.
Name of
Medication
Generic
name:
Sodium
bicarbonate
Brand name:
Date given:
January 23,
2023
Date
Discontinued:
Classification
Doctor’s Order
Alkanizing Agents Time:
5:35AM
Route:
IV
Frequency:
Q4
Form:
2-5 mEq/kg IV
infusion over 4-8
hr
DRUG STUDY
Mechanism of Action
Bicarbonate reacts with H+ ions to
form water & carbon dioxide. It
acts as a buffer against acidosis by
raising blood pH
Side effects
Frequent urge to urinate
headache (continuing)
loss of appetite
(continuing)
mood or mental changes
muscle pain or twitching
nausea or vomiting
nervousness or
Indication:
restlessness
slow breathing
Treatment of metabolic acidosis, swelling of feet or lower
which may occur in severe renal legs
disease, and severe primary lactic unpleasant taste
acidosis.
unusual tiredness or
weakness
January 29,
2023
Adverse effects
Aggravated CHF
Cerebral hemorrhage
Edema
Hypernatremia
Hypocalcemia
Hypokalemia
Tetany
Metabolic alkalosis
Belching
Gastric distension
Pulmonary edema
Hypernatremia
Hyperosmolality
Intracranial acidosis
Milk-alkali syndrome
Nursing consideration
1.
2.
3.
Contraindication:
Hypersensitivity
Injection
● Chloride loss due to vomiting
or from continuous
gastrointestinal suction
● Currently treated with
diuretics
4.
5.
Assess the client’s
fluid balance
throughout the
therapy. This
assessment includes
intake and output,
daily weight, edema
and lung sounds.
Symptoms of fluid
overload should be
reported such as
hypertension, edema,
difficulty breathing or
dyspnea, rales or
crackles and frothy
sputum.
Sigs of acidosis
should be assessed
such as
disorientation,
headache, weakness,
dyspnea and
hyperventilation.
Assess for alkalosis
by monitoring the
client for confusion,
irritability,
paresthesia, tetany
and altered breathing
pattern.
Hypernatremia
clinical manifestations
should be assessed
and monitored which
includes: edema,
weight gain,
hypertension,
tachycardia, fever,
flushed skin and
mental irritability.
6. Hypokalemia should
also be assessed by
monitoring signs and
symptoms such as:
weakness, fatigue, U
wave on ECG,
arrhythmias, polyuria
and polydipsia.
7. IV sites should be
observed closely.
Extravasation should
be avoided as tissue
irritation or cellulitis
may occur when
taking sodium
bicarbonate.
8. If infiltration occurs,
the physician should
be notified
immediately. Confer
with the doctor or
other health care staff
regarding warm
compresses and
infiltration site with
lidocaine or
hyaluronidase.
52
9. Monitor the client’s
serum calcium,
sodium, potassium,
bicarbonate
concentrations,
serum osmolarity,
acid-base balance
and renal function
before and
throughout the
therapy.
10. Tablets must be
taken with a full glass
of water.
11. For clients taking the
medication as a
treatment for peptic
ulcers it may be
administered 1 and 3
hours after meals and
at bedtime.
Name of
Medication
Generic
name:
Epinephrine
Brand name:
Adrenalin
Classification Doctor’s
Order
alpha- and
betaadrenergic
agonists
Time:
Route:
IV
Frequency:
PRN
Mechanism of Action
Side effects
Adverse effects
Epinephrine acts on alpha and betaadrenergic receptors. Epinephrine
acts on alpha and beta-receptors
and is the strongest alpha-receptor
activator. Through its action on
alpha-adrenergic receptors,
epinephrine minimizes the
vasodilation and increased the
vascular permeability that occurs
Fast/pounding heartbeat,
nervousness,
sweating,
nausea,
vomiting,
trouble breathing,
headache,
dizziness, anxiety,
shakiness, or pale skin
Tachycardia,
hypertension,
headache,
anxiety, apprehension,
palpitations,
diaphoresis, nausea,
vomiting,
weakness,
tremors.
53
Nursing consideration
▪
Monitor BP, pulse,
respirations, and
urinary output and
observe patient
closely following IV
administration.
Epinephrine may
widen pulse
pressure. If
Date given:
January 23,
2023
Date
Discontinued:
January 29,
2023
Form:
0.3 milligram
(mg)
during anaphylaxis, which can cause
the loss of intravascular fluid volume
as well as hypotension. Epinephrine
relaxes the smooth muscle of the
bronchi and iris and is a histamine
antagonist, rendering it useful in
treating the manifestations of allergic
reactions and associated conditions.
This drug also produces an increase
in blood sugar and increases
glycogenosis in the liver. Through its
action on beta-adrenergic receptors,
epinephrine leads to bronchial
smooth muscle relaxation that helps
to relieve bronchospasm, wheezing,
and dyspnea that may occur during
anaphylaxis
▪
▪
▪
Indication:
Epinephrine injection is indicated in
the emergency treatment of type I
allergic
reactions,
including
anaphylaxis. It is also used to
increase blood pressure in adult
patients with hypotension.
▪
▪
Contraindication:
There are no absolute
contraindications against using
epinephrine. Some relative
contraindications
include hypersensitivity to
sympathomimetic drugs, closedangle glaucoma, and anesthesia with
54
▪
disturbances in
cardiac rhythm occur,
withhold epinephrine
and notify physician
immediately.
Keep physician
informed of any
changes in intakeoutput ratio.
Use cardiac monitor
with patients
receiving epinephrine
IV. Have full crash
cart immediately
available.
Check BP repeatedly
when epinephrine is
administered IV
during first 5 min,
then q3–5min until
stabilized.
Advise patient to
report to physician if
symptoms are not
relieved in 20 min or
if they become worse
following inhalation.
Advise patient to
report bronchial
irritation,
nervousness, or
sleeplessness.
Dosage should be
reduced.
Monitor blood
glucose & HbA1c for
halothane. Another unique
contraindication to be aware of is
catecholaminergic polymorphic
ventricular tachycardia.
Name of
Medication
Generic
name:
Norepinephrine
Brand name:
Levophed
Date given:
Jnuary23,
2023
Date
Discontinued:
January 29,
2023
Classification
Doctor’s Order
sympathomimetic Time:
Route:
IV
Frequency:
PRN
Form:
Mechanism of Action
Side effects
Norepinephrine functions as
a peripheral vasoconstrictor
by acting on alphaadrenergic receptors. It is
also an inotropic stimulator
of the heart and dilator of
coronary arteries because
of its activity at the betaadrenergic receptors.
Indication:
8-12 mcg/minute
intravenous (IV)
infusion; titrate to
effect
loss of glycemic
control if diabetic.
Norepinephrine injection is
used to raise blood pressure
in patients with severe, acute
hypotension (short-term low
blood pressure)
Contraindication:
Generally, norepinephrine
should be avoided in
patients with mesenteric or
55
Adverse effects
●
●
Blurred vision
●
chest pain or
discomfort
●
headache
●
●
lightheadedness,
dizziness, or
fainting
●
●
nervousness
●
pounding in the
ears
●
slow, fast, or
irregular heartbeat
●
unusual tiredness
or weakness
●
Allergic reactions like
skin rash, itching or
hives, swelling of your
face, lips or tongue.
Difficulty breathing,
wheezing.
Irregular heartbeats,
palpitations or chest
pain.
Pain, redness or
irritation at site where
injected.
Nursing consideration
▪
▪
Monitor constantly while
patient is receiving
norepinephrine. Take
baseline BP and pulse
before start of therapy,
then q2min from
initiation of drug until
stabilization occurs at
desired level, then every
5 min during drug
administration.
Adjust flow rate to
maintain BP at low
normal (usually 80–100
mm Hg systolic) in
normotensive patients.
In previously
hypertensive patients,
systolic is generally
maintained no higher
peripheral vascular
thrombosis as the
subsequent vasoconstriction
will increase the area of
ischemia and infarction.
▪
▪
▪
▪
56
than 40 mm Hg below
preexisting systolic level.
Observe carefully and
record mental status
(index of cerebral
circulation), skin
temperature of
extremities, and color
(especially of earlobes,
lips, nail beds) in
addition to vital signs.
Monitor I&O. Urinary
retention and kidney
shutdown are
possibilities, especially
in hypovolemic patients.
Urinary output is a
sensitive indicator of the
degree of renal
perfusion. Report
decrease in urinary
output or change in I&O
ratio.
Be alert to patient’s
complaints of headache,
vomiting, palpitation,
arrhythmias, chest pain,
photophobia, and
blurred vision as
possible symptoms of
over dosage. Reflex
bradycardia may occur
as a result of rise in BP.
Continue to monitor vital
signs and observe
patient closely after
cessation of therapy for
clinical sign of circulatory
inadequacy.
Name of
Medication
Generic
name:
Dopamine
Brand name:
Intropine
Date given:
Janyary 23,
2023
Date
Discontinued:
January 29,
2023
Classification Doctor’s
Order
Adrenergic
Time:
Route:
IV
Frequency:
PRN
Form:
5 mcg/kg per
minute (5
mcg/Kg/min)
Mechanism of Action
Dopamine is a precursor
●
to norepinephrine in ●
noradrenergic nerves and
●
is also a neurotransmitter
●
in certain areas of the ●
central nervous system.●
Dopamine produces ●
positive chronotropic and
●
inotropic effects on the
myocardium, resulting in
increased heart rate and
cardiac contractility. This
is accomplished directly
by exerting an agonist
action on betaadrenoceptors and
indirectly by causing
release of norepinephrine
from storage sites in
sympathetic nerve
endings. In the brain,
dopamine acts as an
agonist to the five
dopamine receptor
subtypes (D1, D2, D3,
D4, D5).
Side effects
Irregular heartbeats
Nausea
Vomiting
Anxiety
Headache
Chills
Goosebumps
Shortness of breath
Adverse effects
●
●
●
●
●
●
●
●
●
●
●
57
lightheadedness,
chest pain,
fast, slow, or pounding heartbeats,
shortness of breath,
cold feeling,
numbness,
blue-colored appearance in your
hands or feet, and
darkening or skin changes in your
hands or feet
Heart arrhythmias that can be lifethreatening
Kidney damage
Gangrene of digits at the higher
doses.
Nursing consideration
Monitor hemodynamics
closely: BP, HR, EKG,
CVP, and PAOP if
available
• Obtain parameters for
hemodynamic values
• Titrate to obtain
appropriate BP (more
potent vasoconstrictors
may be required)
• Irritation may occur at
IV site
• Beta blockers may
counteract therapeutic
effects
Indication:
Dopamine is a peripheral
vaso stimulant used to
treat low blood pressure,
low heart rate, and cardiac
arrest.
Contraindication:
Patients
with pheochromocytoma
or uncorrected
tachyarrhythmias
including ventricular
fibrillation and ventricular
tachycardia. Reduce the
dopamine dose if an
increased number of
ectopic beats is observed.
Correct hypovolemia
before dopamine
administration.
Name of
Medication
Classification Doctor’s
Order
Mechanism of Action
Side effects
58
Adverse effects
Nursing consideration
Generic
name:
Dobutamine
Brand name:
Inotrex
Inotropic
Agent
Time:
Route:
IV
Frequency:
Dobutamine directly
stimulates beta-1
receptors of the heart to
increase myocardial
contractility and stroke
volume, resulting in
increased cardiac output.
Indication:
Date given:
January 23,
2023
Date
Discontinued:
January 29,
2023
PRN
Form:
0.5 to 1.0
mcg/kg/min
●
●
●
●
●
low blood
pressure,
chest pain
(angina),
fast or slow
heartbeat,
shortness of
breath, and
trouble breathing
Dobutamine's
inotropic
effect
increases
contractility, leading to
decreased
end-systolic
volume and, therefore,
increased stroke volume.
The increase in stroke
volume leads to an
augmentation
of
the
cardiac output of the
heart.
●
●
●
●
●
●
●
●
●
increased heart rate and
increased blood pressure,
ventricular ectopic activity,
nervousness,
headache,
nausea,
vomiting,
palpitations,
low platelet counts
(thrombocytopenia),
swelling at the injection site.
●
●
●
●
●
●
Contraindication:
The medication is
contraindicated in
patients with acute
myocardial infarction,
unstable angina, left main
stem disease, severe
hypertension,
arrhythmias, acute
myocarditis or
pericarditis, hypokalemia
and idiopathic
59
Observe IV site
closely and avoid
extravasation.
Dobutamine can
cause inflammatory
response and tissue
ischaemia.
Monitor for adverse
reactions.
Continuous blood
pressure monitoring.
Continuous
cardiorespiratory
monitoring.
Document vital signs
hourly and PRN.
Monitor fluid balance.
hypertrophic sub-aortic
stenosis.
Name of
Medication
Generic
name:
Dopamine
Brand name:
Classificatio Doctor’s Order
n
Adrenergic
Time:
Route:
IV
Frequency:
Date given:
Date
Discontinue
d:
Form: 5 mcg/kg
per minute (5
mcg/Kg/min)
Mechanism of Action
Dopamine is a precursor
●
to norepinephrine in ●
noradrenergic nerves ●
and is also a
●
neurotransmitter in ●
certain areas of the ●
central nervous system.●
Dopamine produces ●
positive chronotropic and
inotropic effects on the
myocardium, resulting in
increased heart rate and
cardiac contractility. This
is accomplished directly
by exerting an agonist
action on betaadrenoceptors and
indirectly by causing
release of
norepinephrine from
storage sites in
sympathetic nerve
endings. In the brain,
dopamine acts as an
agonist to the five
dopamine receptor
Side effects
Irregular heartbeats
Nausea
Vomiting
Anxiety
Headache
Chills
Goosebumps
Shortness of breath
Adverse effects
●
●
●
●
●
●
●
●
●
●
●
60
lightheadedness,
chest pain,
fast, slow, or pounding
heartbeats,
shortness of breath,
cold feeling,
numbness,
blue-colored appearance in
your hands or feet, and
darkening or skin changes in
your hands or feet
Heart arrhythmias that can be
life-threatening
Kidney damage
Gangrene of digits at the
higher doses.
Nursing consideration
Monitor hemodynamics
closely: BP, HR, EKG,
CVP, and PAOP if
available
• Obtain parameters for
hemodynamic values
• Titrate to obtain
appropriate BP (more
potent vasoconstrictors
may be required)
• Irritation may occur at IV
site
• Beta blockers may
counteract therapeutic
effects
subtypes (D1, D2, D3,
D4, D5).
Indication:
Dopamine is a peripheral
vaso stimulant used to
treat low blood pressure,
low heart rate, and
cardiac arrest.
Contraindication:
Patients
with pheochromocytoma
or uncorrected
tachyarrhythmias
including ventricular
fibrillation and ventricular
tachycardia. Reduce the
dopamine dose if an
increased number of
ectopic beats is
observed. Correct
hypovolemia before
dopamine administration.
61
Name of
Medication
Generic
name:
Acetaminoph
en
Brand name:
tylenol
Date given:
January 23,
2023
Date
Discontinue
d: January
29, 2023
Classificatio Doctor’s Order
n
Analgesics
Time:
7:00AM
Route:
IV
Frequency:
Q4
Form:
500mg/50ml
Mechanism of Action
According to its FDA
labeling,
acetaminophen's exact
mechanism of action has
not been fully established
despite this, it is often
categorized alongside
NSAIDs (nonsteroidal
anti-inflammatory drugs)
due to its ability to inhibit
the cyclooxygenase
(COX) pathways. It is
thought to exert central
actions, which ultimately
lead to the alleviation of
pain symptoms.
Indication:
Side effects
●
red, peeling or blistering
skin
●
rash
●
hives
●
itching
●
swelling of the face,
throat, tongue, lips,
eyes, hands, feet,
ankles, or lower legs
●
hoarseness
●
difficulty breathing or
swallowing
Adverse effects
●
Skin rash,
hypersensitivity
reactions
●
Nephrotoxicity
(elevations in BUN,
creatinine)
●
Hematological: anemia,
leukopenia,
neutropenia,
pancytopenia
●
Metabolic and
electrolyte
●
o
Decreased
serum
bicarbonate
o
Decreased
concentrations
of sodium and
calcium
o
Hyperammone
mia
o
Hyperchloremia
o
Hyperuricemia
o
Increased
serum glucose
This drug is used to treat
mild to moderate pain.
Contraindication:
Hypersensitivity to
acetaminophen, severe
hepatic impairment, or
severe active hepatic
disease.
62
Nursing consideration
1. Assess for an allergy
to acetaminophen.
2. Assess for pain by
having the patient rate
on a scale of 1-10, and
describe
characteristics,
duration, and
frequency. Assess for
chronic conditions that
warrant the use of
acetaminophen such
as arthritis.
3. If given as an
antipyretic, assess
temperature.
4. Assess
for pregnancy or
lactation.
Acetaminophen is a
category B risk
meaning the risk of
fetal harm is possible
but unlikely.
Administration is safe
under the prescription
and supervision of a
healthcare provider.
5. Assess for
acetaminophen
toxicity: nausea,
vomiting, abdominal
pain, elevated bilirubin
and liver enzymes.
o
Name of
Medication
Generic
name:
Benzylpenicillin
Brand name:
Bicillin
Date given:
January 24,
2023
Date
Discontinued:
Classification Doctor’s
Order
Beta-lactam
Antibiotic
Time:
6:00AM
Route:
IV
Frequency:
Q6
Form:
125mg
Mechanism of Action
By binding to specific
penicillin-binding
proteins (PBPs)
located inside the
bacterial cell wall,
penicillin G inhibits the
third and last stage of
bacterial cell wall
synthesis. Cell lysis is
then mediated by
bacterial cell wall
autolytic enzymes
such as autolysins; it
is possible that
penicillin G interferes
with an autolysin
inhibitor.
Side effects
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
nausea,
vomiting,
diarrhea,
rash,
abdominal pain,
urticaria.
muscle spasms,
fever,
chills,
muscle pain,
headache,
tachycardia,
flushing,
tachypnea,
hypotension.
63
Increased
bilirubin and
alkaline
phosphatase
Adverse effects
●
Hypersensitivity
Reactions: The commonly
encountered adverse drug
reaction with penicillin is
hypersensitivity of immediate
onset or delayed onset.
o
Immediate onset:
This kind of reaction
occurs within 20
minutes postadministration. It is
characterized by
urticaria, pruritis,
edema,
laryngospasm,
Nursing consideration
●
●
Watch for seizures;
notify physician
immediately if patient
develops or increases
seizure activity.
Monitor signs of allergic
reactions and
anaphylaxis, including
pulmonary symptoms
(tightness in the throat
and chest, wheezing,
cough dyspnea) or skin
reactions (rash, prurits,
urticaria). Notify
physician or nursing staff
immediately if these
reactions occur.
January 29,
2023
Indication:
bronchospasm,
hypotension,
vascular collapse,
and death.
Treatment of severe
infections caused by
penicillin G-susceptible
microorganisms when
rapid and high penicillin
levels are required
such
as
in
the
treatment
of
septicemia, meningitis,
pericarditis,
endocarditis
and
severe pneumonia.
o
Contraindication:
●
A previous history of
severe allergic
reactions or penicillin
and its derivatives.
Penicillin is also
contraindicated in
patients who have had
Stevens-Johnson
syndrome after
administering penicillin
or a penicillin
derivative.
●
64
Delayed onset: This
reaction occurs
within 1 to 2 weeks of
treatment. It is rare
and is characterized
by fever, malaise,
urticaria, myalgia,
arthralgia, abdominal
pain, and skin
rashes.
Gastrointestinal
System: GI symptoms were
the most common and were
reported in over 1% of
patients, including nausea,
vomiting, stomatitis, which
are commonly observed with
oral administration.
Pseudomembranous colitis
is also observed during or
after the treatment.
Hematologic Reactions: If
the dose is exceeded 10
million units/day and if a
patient has received a higher
dose previously, then those
patients can precipitate
Coombs positive hemolytic
anemia and neutropenia,
●
●
●
Assess muscle aches
and joint pain (arthralgia)
that may be caused by
serum sickness. Notify
physician if these
symptoms seem to be
drug related rather than
caused by
musculoskeletal injury or
if muscle and joint pain
are accompanied by
allergy-like reactions
(fever, rashes, etc.)
Monitor signs of
eosinophilia (fatigue,
weakness, myalgia) or
leukopenia (fever, sore
throat, signs of
infection); report these
signs to the physician.
Monitor injection site for
pain, swelling, and
irritation. Report
prolonged or excessive
injection site reactions to
the physician.
which is resolved when
therapy is stopped.
Name of
Medication
Generic name:
Tranexamic Acid
Brand name:
Hemostan
Date given:
January 23, 2023
Classification
Doctor’s Order
Anti-fibrinolytic, Time:
antihemorrhagic
Route:
IV
Frequency:
PRN
Form:
Mechanism of Action
Tranexamic acid is an ●
antifibrinolytic agent that
inhibits the breakdown of
fibrin clots. It blocks the●
lysine binding sites of
●
plasminogen and impairs
●
the endogenous fibrinolytic
process, thus preserving
and stabilising the fibrin●
matrix structure.
●
Additionally, it reduces
inflammation associated
65
●
Metabolic Reactions: The
salt form of penicillin G may
cause electrolyte
imbalances, i.e.,
hyperkalemia when given IV
in a large dose.
●
Nervous
System: Neurological
manifestations include
hyperreflexia, myoclonic
twitches, seizures, and coma
after IV doses and are more
likely in patients with
impaired renal function.
Side effects
Abdominal or stomach
pain, discomfort, or
tenderness.
chills or fever.
difficulty with moving.
headache, severe and
throbbing.
joint or back pain.
muscle aching or
cramping.
Adverse effects
Nursing consideration
Significant: Visual
defects (e.g. changes in
color vision, visual loss),
retinal
venous
and
arterial
occlusions,
ligneous conjunctivitis;
convulsions (particularly
with high doses of IV
inj),
severe
hypersensitivity
reactions
(e.g.
1. Unusual change in
bleeding pattern should
be immediately
reported to the
physician.
2. For women who are
taking Tranexamic acid
to control heavy
bleeding, the
medication should only
be taken during the
menstrual period.
Date
Discontinued:
January 29, 2023
50mg/min
with hereditary
●
angioedema by inhibiting
the proteolytic activity of
plasmin which decreases
the activation of
complement and
consumption of C1
esterase inhibitor (C1INH).
Indication:
Tranexamic acid
(sometimes shortened to
txa) is a medicine
that controls bleeding. It
helps your blood to clot
and is used for nosebleeds
and heavy periods. If
you're having a tooth taken
out, using tranexamic acid
mouthwash can help stop
bleeding.
Contraindication:
Hypersensitivity. Active
thromboembolic disease
(e.g. pulmonary embolism,
DVT, cerebral thrombosis),
history or risk of
thromboembolism
(including retinal vein or
artery occlusion);
fibrinolytic conditions after
consumption coagulopathy
(unless predominant
66
muscle pains or
stiffness.
anaphylaxis
or
anaphylactoid reaction),
venous and arterial
thrombosis
or
thromboembolism;
cerebral oedema and
infarction (particularly in
women
with
subarachnoid
haemorrhage),
dizziness.
Blood and lymphatic
system
disorders: Anaemia.
Gastrointestinal
disorders: Nausea,
vomiting,
diarrhoea,
abdominal
pain.
General disorders and
administration
site
conditions: Fatigue.
Musculoskeletal
and
connective
tissue
disorders: Musculoskele
tal pain, back pain,
muscle
cramps
or
spasm,
arthralgia.
Nervous
system
disorders: Headache,
migraine.
Respiratory,
thoracic
and
mediastinal
disorders: Nasal
and
sinus
symptoms.
Skin and subcutaneous
3. Tranexamic Acid
should be used with
extreme caution in
CHILDREN younger
than 18 years old;
safety and
effectiveness in these
children have not been
confirmed.
4. The medication can be
taken with or without
meals.
5. Swallow Tranexamic
Acid whole with plenty
of liquids. Do not break,
crush, or chew before
swallowing.
6. If you miss a dose of
Tranexamic Acid, take
it when you remember,
then take your next
dose at least 6 hours
later. Do not take 2
doses at once.
7. Inform the client that
he/she should inform
the physician
immediately if severe
side effects occur
activation of the fibrinolytic
system with acute severe
bleeding), history of
convulsions; acquired
disturbances of color
vision. Severe renal
impairment. Concomitant
use with combined
hormonal contraceptives.
67
tissue disorders: Allergic
dermatitis.
VIII.
DATE AND TIME
COURSE IN THE WARD
DOCTOR’S ORDER
January 23, 2023
FOCUS
Admission
10:00PM
DATA, ACTION,
RESPONSE
D: The patient was
rushed to the
emergency room
due to a motor
vehicular accident.
The patient was in
a groggy state with
some abrasions on
his right hand, both
arms, right upper
leg, left lower leg,
and on his right
cheek.
T: 35.8
PR: 129 bpm
RR: 38 bpm
BP: 60/40 mmHg
O2Sat: 90%
GCS: E3V4M5
A: The patient was
immediately
resuscitated by the
nurses on duty
following the ABC
procedure. Oxygen
was also
administered at 10
lpm via face mask
as ordered by the
physician.
10:20PM
-
PNSS 1L
1 PRBC
Laboratory and
Diagnostics:
-
Blood Typing and
crossmatching
RAT
Blood Transfusion
D: The patient was
seen pale and had
cool skin when
touched.
D:. Blood type: O+
A: A pack of RBC
was transfused to
the patient via the
CVC right femoral
vein.
A: PNSS 1L fast
drip was also
administered
through the right
cephalic vein.
D: The patient was
grimacing while
holding his
abdomen. A large,
bluish-purplish
bruise was seen on
the patient’s right
upper abdomen
with a pain scale of
8/10.
10:30PM
A: A FAST
ultrasound was
done on the
patient.
R: The ultrasound
indicates that there
was a large amount
of blood present in
the patient’s
peritoneal cavity.
10:40PM
A: Orders were
carried out
Laboratory and
Diagnostics:
-
R: CBC result
showed
hemoglobin of 120
g/L, hematocrit of
30%, WBC of 6.9
x10^9/L, and blood
pH of 7.20.
CBC
ECG
Blood Che
A: Medico-Legal
was assessed and
done
11:00PM
R: The patient has
multiple abrasions
on his right hand,
arms, right upper
leg, left lower leg,
and right cheek. A
large, bluishpurplish bruise on
his right upper
quadrant of the
abdomen was also
seen.
January 24, 2023
-
12:00AM
-
For emergency
exploratory
laparotomy
Administer
anesthetics
Preoperative care
D: The patient was
transferred to the
OR for an
emergency
exploratory
laparotomy.
A: Oriented to the
OR unit, OR
69
consent form was
secured. surgical
checklist was
assessed and
done, IFC was
inserted aseptically,
preoperative
medications were
administered, seen
and examined by
the surgeon and
anesthesiologist,
VS was carefully
monitored.
D: 980 ml of blood
was evacuated in
the patient’s
peritoneal cavity.
The surgeon
located the source
of bleeding which
was the liver
particularly on the
right hepatic artery,
which graded as V
with laceration and
parenchymal
disruption involving
75% of the hepatic
lobe.
1:00AM
A: Perihepatic
packing on the right
upper quadrant of
the patient’s liver
was done.
R: The pack was
left on the patient’s
liver for 48 hours.
3:30AM
-
Transfer to PACU
PACU transfer and
Monitor VS every 15 continuous monitoring
minutes
Keep NPO until
return of peristalsis
D: The procedure
was done. The
patient was
transferred to the
PACU.
T: 36.6
PR: 100 bpm
RR: 23 bpm
BP: 110/80 mmHg
O2Sat: 97%
3:45AM
Continuous Monitoring
70
D: The patient was
still groggy,
positioned flat on
bed. VS monitored
closely, assessed
for signs of
anesthesia wearing
off like return of
peristalsis and
ability to move feet.
IFC was intact,
draining well,
above IVF was
infusing well.
T: 36.6
PR: 100 bpm
RR: 23 bpm
BP: 110/80 mmHg
O2Sat: 97%
4:00AM
-
Discontinue oxygen
10 lpm via
facemask
A: Oxygen was
discontinued.
A: VS monitored
closely, assessed
for signs of
anesthesia wearing
off like return of
peristalsis and
ability to move feet.
R: The patient was
able to raise his
both feet to a
desirable level.
5:00AM
-
Transfer to ICU
D: The patient was
transferred to the
ICU for close
monitoring.
5:30AM
-
Laboratory Test:
ABG
D: The patient was
seen sleeping. IFC
was intact, draining
well, above IVF
was infusing well.
T: 36.8
PR: 125 bpm
RR: 23 bpm
BP: 110/70 mmHg
O2Sat: 97%
A: Orders were
carried out.
71
R: Blood pH was
decreased to 7.20,
HCO3: 18. The
patient was
experiencing
metabolic acidosis.
5:35AM
-
-
6:00AM
-
A: Sodium
bicarbonate IV was
administered to the
patient. 1 PRBC
was transfused to
the patient via CVC
right femoral vein.
Sodium bicarbonate
2-5 mEq/kg IV over
4-8 hrs
1 PRBC
Benzylpenicillin
125mg, IV, Q6
Continuous Monitoring
D: The patient was
asleep. IFC was
intact, draining well,
above IVF was
changed
aseptically.
T: 36.8
PR: 100 bpm
RR: 21 bpm
BP: 110/80 mmHg
O2Sat: 97%
A: Administered
Benzylpenicillin
125mg, IV ANST (-)
as ordered by the
physician
7:00AM
-
Acetaminophen
500mg/50ml, IV
Surgical Pain
D: “Nararamdaman
po sumasakit yung
tahi ko” as
verbalized by the
patient. Pain scale
of 7/10, face mask
of pain,
restlessness.
A: Instructed use of
distraction imagery,
deep breathing
exercises,
Acetaminophen
500mg/50ml, IV
was administered
as ordered by the
physician.
R: Patient stated
“hindi na po gaano
masakit”. Pain
72
scale of 3/10
9:00AM
Wound Care
D: The patient was
conscious, lying
comfortably on the
bed.
A: Wound care
done, IFC was
intact, draining well,
above IVF was
infusing well.
10:00AM
Continuous Monitoring
D: The PRBC bag
of the patient was
already consumed.
T: 36.6
PR: 89 bpm
RR: 20 bpm
BP: 110/80 mmHg
O2Sat: 97%
A: Blood
transfusion line of
the patient was
removed
aseptically
R: 1 PRBC was
transfused to the
patient.
12:00AM
-
Benzylpenicillin
125mg, IV, Q6
A: Administered
Benzylpenicillin
125mg, IV as
ordered by the
physician
1:00PM
-
Acetaminophen
500mg/50ml, IV
Sodium bicarbonate
2-5 mEq/kg IV over
4-8 hrs
D: The patient was
seen lying on his
bed. IFC was
intact, draining well,
above IVF was
infusing well.
-
A: Administered
Acetaminophen
500mg/50ml, IV,
and Sodium
bicarbonate 2-5
mEq/kg IV, as
ordered by the
physician.
73
2:00PM
Continuous Monitoring
D: The patient was
asleep. IFC was
intact, draining well,
above IVF was
changed
aseptically.
T: 36.8
PR: 92 bpm
RR: 20 bpm
BP: 110/80 mmHg
O2Sat: 97%
6:00PM
-
D: The patient was
seen lying on his
bed. IFC was
intact, draining well,
above IVF was
infusing well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
physician.
10:00PM
Continuous Monitoring
D: The patient was
asleep. IFC was
intact, draining well,
above IVF was
changed
aseptically.
T: 36.7
PR: 87 bpm
RR: 20 bpm
BP: 110/80 mmHg
O2Sat: 97%
January 25, 2023
-
12:00AM
-
D: The patient was
seen lying on his
bed. IFC was
intact, draining well,
above IVF was
infusing well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
74
physician.
6:00AM
Continuous Monitoring
D: The patient was
asleep. IFC was
intact, draining well,
above IVF was
changed
aseptically.
T: 36.7
PR: 87 bpm
RR: 20 bpm
BP: 110/80 mmHg
O2Sat: 97%
6:15AM
-
D: The patient was
seen lying on his
bed. IFC was
intact, draining well,
above IVF was
infusing well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
physician.
D: The patient was
seen and examined
by Dr. A.
9:30AM
A: Wound care
done, assisted on
early ambulation.
IFC was intact,
draining well,
above IVF was
infusing well.
10:00AM
-
A: All orders were
carried out.
Laboratory Test:
PT, PTT, CBC
R: Laboratory test
shows PT: 12.5
sec, PTT: 27.8 sec.
Hgb: 130 g/L, Hct:
35%, WBC:
5x10^9/L, blood
pH: 7.35
10:30AM
Continuous Monitoring
75
D: The patient was
seen conscious,
lying on his bed.
IFC was intact,
draining well,
above IVF was
infusing well.
T: 36.8
PR: 92 bpm
RR: 20 bpm
BP: 110/70 mmHg
O2Sat: 97%
12:00PM
-
D: The patient lying
on his bed. IFC
was intact, draining
well, above IVF
was infusing well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
physician.
2:00PM
Continuous Monitoring
D: The patient was
asleep. IFC was
intact, draining well,
above IVF was
changed
aseptically.
T: 36.7
PR: 87 bpm
RR: 20 bpm
BP: 110/80 mmHg
O2Sat: 97%
6:00PM
-
D: The patient lying
on his bed. IFC
was intact, draining
well, above IVF
was infusing well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
physician.
76
10:00PM
-
D: The patient was
seen lying on his
bed. IFC was
intact, draining well,
above IVF was
infusing well.
NPO for 8 hours
T: 36.8
PR: 89 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
A: Instructed the
patient to eat
nothing by mouth
until tomorrow for
the scheduled
surgery.
R: The patient
understood the
instructions.
January 26, 2023
-
12:00 am
-
D: The patient lying
on his bed. IFC
was intact, draining
well, above IVF
was infusing well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV, as
ordered by the
physician.
8:00 am
-
D: The patient was
seen lying on his
bed. IFC was
intact, draining well,
above IVF was
infusing well.
Remain NPO
Laboratory Test:
ABG
T: 36.8
PR: 89 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
A: Orders were
carried out.
R: ABG result
77
showed blood pH
of 7.37, HCO3 of
25.
10:00AM
-
For second-look
laparotomy
Preoperative care
D: The patient was
transferred to the
OR for a secondlook laparotomy.
A: Oriented to the
OR unit, OR
consent form was
secured. surgical
checklist was
assessed and
done, IFC was
inserted aseptically,
preoperative
medications were
administered, seen
and examined by
the surgeon and
anesthesiologist;
and VS was
carefully monitored.
D: The patient’s
abdomen was
washed out, the
perihepatic packing
was carefully
removed, the right
hepatic artery was
avulsed and
thrombosed, and it
was ligated.
11:30AM
12:00PM
-
Benzylpenicillin
125mg, IV, Q6
A: Administered
Benzylpenicillin
125mg, IV, as
ordered by the
physician.
12:30PM
-
Transfer to PACU
PACU transfer and
Monitor VS every 15 continuous monitoring
minutes
Keep NPO until
return of peristalsis
D: The procedure
was done. The
patient was
transferred to the
PACU.
-
T: 36.8
PR: 89 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
78
12:45PM
Continuous Monitoring
D: The patient was
positioned flat on
bed. VS monitored
closely, assessed
for signs of
anesthesia wearing
off like return of
peristalsis and
ability to move feet.
IFC was intact,
draining well,
above IVF was
infusing well.
T: 36.6
PR: 100 bpm
RR: 23 bpm
BP: 110/80 mmHg
O2Sat: 97%
2:00PM
Continuous Monitoring
D: The patient was
positioned flat on
bed. VS monitored
closely, IFC was
intact, draining well,
above IVF was
infusing well. The
patient was able to
raise his both feet
at a desired level.
T: 36.6
PR: 100 bpm
RR: 22 bpm
BP: 110/80 mmHg
O2Sat: 97%
2:30PM
-
Transfer to surgery
ward
Monitor VS every 4
hours
D: The patient was
transferred to the
surgery ward. IFC
was intact, draining
well, above IVF
was infusing well.
T: 36.6
PR: 100 bpm
RR: 23 bpm
BP: 110/80 mmHg
O2Sat: 97%
79
5:00PM
-
Acetaminophen
500mg/50ml, IV
Surgical Pain
D: The patient was
seen conscious,
with a facial mask
of pain,
restlessness,
“Medyo
nararamdaman ko
yung sakit sa opera
ko” as stated by the
patient. Pain scale
of 7/10
A: Instructed use of
distraction imagery,
deep breathing
exercises,
Acetaminophen
500mg/50ml, IV
was administered
as ordered by the
physician.
R: Patient stated
“hindi na po gaano
masakit”. Pain
scale of 3/10
6:00PM
-
Benzylpenicillin
125mg, IV, Q6
Continuous Monitoring
D: The patient was
lying on his bed.
VS monitored
closely, IFC was
intact, draining well,
above IVF was
infusing well.
T: 36.6
PR: 100 bpm
RR: 22 bpm
BP: 110/80 mmHg
O2Sat: 97%
A: Benzylpenicillin
125mg, IV was
administered.
6:30PM
-
A: All orders were
carried out.
Laboratory Test:
CBC, Serum
Electrolytes test,
Blood Chemistry
10:00PM
Continuous Monitoring
80
D: The patient was
asleep. VS
monitored closely,
IFC was intact,
draining well,
above IVF was
infusing well.
T: 36.6
PR: 100 bpm
RR: 22 bpm
BP: 110/80 mmHg
O2Sat: 97%
January 27, 2023
-
12:00AM
-
D: The patient lying
on his bed. IFC
was intact, draining
well, above IVF
was infusing well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
physician.
6:00AM
Continuous Monitoring
D: The patient was
still asleep. IFC
was intact, draining
well, above IVF
was changed
aseptically.
T: 36.7
PR: 87 bpm
RR: 20 bpm
BP: 110/80 mmHg
O2Sat: 97%
6:30AM
-
D: The patient lying
on his bed. IFC
was intact, draining
well, above IVF
was infusing well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
physician.
7:00AM
-
A: Diet was
implemented.
Clear liquid diet
9:30AM
Wound care
81
D: The patient was
conscious, lying
comfortably on the
bed.
A: Wound care
done, IFC was
intact, draining well,
above IVF was
infusing well.
R: Patient’s
abrasion wounds
started to dry and
heal.
10:00AM
Continuous Monitoring
D: The patient was
lying on his bed.
IFC was intact,
draining well,
above IVF was
infusing well. .
T: 36.7
PR: 87 bpm
RR: 20 bpm
BP: 110/80 mmHg
O2Sat: 97%
A: Instructed and
assisted the patient
for early
ambulation.
R: The patient
understood the
instructions.
12:00PM
-
D: The patient lying
on his bed. IFC
was intact, draining
well, above IVF
was infusing well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
physician.
1:00PM
-
A: IFC was
removed
aseptically.
Remove IFC
aseptically after
return of voiding
sensation
2:00PM
Continuous Monitoring
82
D: The patient was
using his phone,
above IVF was
infusing well. .
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
6:00PM
-
D: The patient lying
on his bed., above
IVF was infusing
well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
physician.
10:00PM
Continuous Monitoring
D: The patient was
asleep, above IVF
was infusing well. .
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
January 28, 2023
-
12:00AM
-
D: The patient lying
on his bed., above
IVF was infusing
well.
Acetaminophen
500mg/50ml, IV
Benzylpenicillin
125mg, IV, Q6
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
83
O2Sat: 97%
A: Administered
Acetaminophen
500mg/50ml, IV
and Benzylpenicillin
125mg, IV as
ordered by the
physician.
6:00AM
-
Benzylpenicillin
125mg, IV, Q6
Continuous Monitoring
D: The patient was
asleep, above IVF
was infusing well. .
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
A: Administered
Benzylpenicillin
125mg, IV as
ordered by the
physician.
9:00AM
-
Discontinue
Acetaminophen
500mg/50ml, IV
Wound care
D: The patient was
seen and examined
by Dr. A.
A: Wound care
done, draining well,
above IVF was
infusing well.
10:00AM
Continuous Monitoring
D: The patient was
asleep, above IVF
was infusing well. .
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
12:00PM
-
A: Administered
Benzylpenicillin
125mg, IV as
ordered by the
physician.
Benzylpenicillin
125mg, IV, Q6
84
2:00PM
Continuous Monitoring
D: The patient was
watching on his
phone, above IVF
was infusing well. .
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
6:00PM
-
D: The patient was
watching on his
phone, above IVF
was infusing well. .
Benzylpenicillin
125mg, IV, Q6
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
A: Administered
Benzylpenicillin
125mg, IV as
ordered by the
physician.
10:00PM
Continuous Monitoring
D: The patient was
watching on his
phone, above IVF
was infusing well. .
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
January 29, 2023
12:00AM
-
A: Administered
Benzylpenicillin
125mg, IV as
ordered by the
physician.
Benzylpenicillin
125mg, IV, Q6
6:00AM
Continuous Monitoring
85
D: The patient was
watching on his
phone, above IVF
was infusing well. .
T: 36.7
PR: 87 bpm
RR: 19 bpm
BP: 110/80 mmHg
O2Sat: 97%
8:00AM
-
A: All orders were
carried out.
Laboratory Test:
CBC, Serum
Electrolytes test,
Blood Chemistry,
Urinalysis, Fecalysis
9:30AM
Wound care
A: Wound care
done, draining well,
above IVF was
infusing well.
10:00AM
Discharge Planning
D: All laboratory
results shows
normal values.
A: The patient was
seen and examined
by Dr. A with orders
made and carried
out, with may go
home order,
instructed SO to
settle hospital bills,
gave instructions
on home
medications,
emphasized checkup after 1 week,
above IVF removed
aseptically.
R: Acceded to all
instructions, settled
bills, and went
home accompanied
by his SO.
86
IX.
NURSING CARE PLAN
ASSESSMENT
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING
NURSING
INTERVENTION
Subjective Data:
"Hindi ako
makahinga ng
maayos", as
verbalized by the
patient.
Ineffective
tissue
perfusion
related to
blood loss
Major bleeding
⬇
Decreased venous
return
⬇
Decreased preload
⬇
Decreased cardiac
output
⬇
Poor tissue
perfusion
Short term goal:
After 8 hours of nursing
interventions, the
patient will demonstrate
increased perfusion as
evidenced by an
increasing blood
pressure and
decreasing pulse and
respiratory rate
Independent:
Objective Data:
•Tachypneic
•Capillary refill
greater than 3
seconds
•Poor skin turgor
•Vital signs:
>T: 35.8°C
>P: 129 bpm
>R: 38 cpm
>BP: 60/40
>O2: 90%
Long term goal:
After 1 week of nursing
interventions, the
patient will have
optimal perfusion as
evidenced by:
. vital signs within
normal limits
. capillary refill
within 2
seconds
. normal skin
turgor
1. Monitor oxygen and
arterial blood gas
RATIONALE
EVALUATION
1. As shock progresses,
lactic acidosis occurs
resulting in the increased
level of carbon dioxide and
decreasing pH.
Short term goal:
After 8 hours of nursing
interventions, the goal
was met as evidenced
by a blood pressure of
90/60, pulse rate of 104
bpm, and respiratory
rate of 25 cpm
2. Restrict the patient’s
activity and maintain the
client on bed rest.
2. Minimizes oxygen
demand
3. Administer IV fluids
3. Sufficient fluid intake
maintains adequate filling
pressures and optimizes
cardiac output needed for
tissue perfusion
Dependent:
1. Provide 10 lpm via
face mask, as indicated.
1. To support oxygenation
and perfusion
Long term goal:
After 1 week of nursing
interventions, the goal
was met as evidenced
by:
. blood
pressure:110/80
mmHg, pulse
rate: 86 bpm,
respiratory rate
of 20cpm, and a
temperature of
36.7°C
. capillary refill
within 2 seconds
. normal skin
turgor
ASSESSMENT
Subjective data:
• "Masakit sa
bandang tyan
kong may
pasa", as
verbalized by
the patient
Objective Data:
• Decreased
urine output:
30ml
• Dry mucous
membranes
• Cool, clammy
skin
• Poor skin turgor
• Capillary refill
greater than 3
seconds
• Vital
signs
> T: 35.8°C
> P: 129 bpm
> R: 38 cpm
> BP: 60/40
> O2: 90%
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING
Deficient Fluid
Volume related to
active fluid loss
secondary to
vehicular
accident
Vehicular Accident
⬇
Blunt trauma on upper
abdominal cavity
⬇
Rupture of veins and
capillaries
⬇
Major bleeding
⬇
Fluid volume deficit
Short term goal:
After 8 hours of
nursing intervention
the patient will able to
have increased fluid
volume as evidenced
by an increasing blood
pressure and
decreasing pulse and
respiratory rate
Long term goal:
After 1 week of
nursing intervention
the patient will able to
have adequate fluid
volume as evidenced
by:
. stable vital
signs
. warm and dry
skin
. moist mucous
membranes
. normal skin
turgor
. capillary refill
within 2
seconds
88
NURSING
INTERVENTION
Independent:
1. Monitor vital signs
2. Auscultate heart
tones and inspect
jugular veins
3. Assess mental status
Dependent:
1. Start intravenous fluid
replacements, as
ordered
2. Administer 1 PRBC,
as ordered.
RATIONALE
EVALUATION
1. Serve as baseline
data and for
comparison,
especially with
active blood loss
Short term goal:
After 8 hours of nursing
intervention the goal was
met as evidenced by a
blood pressure of 90/60,
pulse rate of 104 bpm,
and respiratory rate of 25
cpm
2. Abnormally
flattened jugular
veins and distant
heart tones are
signs of ineffective
circulation
Long term goal:
After 1 week of nursing
intervention the goal was
met as evidenced by:
. blood
3. Loss of
pressure:110/80
consciousness
mmHg, pulse
accompanies
rate: 86 bpm,
ineffective circulating
respiratory rate of
blood volume to the
20cpm, and a
brain
temperature of
36.7°C
.
warm and dry
1. Parenteral fluids
skin
are necessary to
.
moist mucous
restore volume
membranes
quickly.
.
normal skin turgor
.
urine output of
2. Blood and blood
1200ml
products will be
.
ASSESSMENT
Subjective Data:
“Ang dami kong
gasgas sa
katawan”, as
verbalized by the
patient.
Objective Data:
• Abrasions that are
superficial in depth
and with a size of:
>Left cheek: 2cm
>Right hand: 2cm
>Right arm: 3.5cm
>Left arm: 3cm
>Right upper leg:
3.5cm
>Left lower leg: 3cm
normal urine
output per
hour
necessary to replace
blood loss
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING
NURSING
INTERVENTION
Impaired
skin integrity
related to multiple
abrasions
secondary to
vehicular
accident
Vehicular Accident
⬇
Friction against a
rough surface
⬇
Multiple abrasion
⬇
Damaged skin
tissue
⬇
Impaired skin
integrity
Short term goal:
After 1 hour of nursing
interventions, the
patient will
demonstrate
measures to heal and
protect wound,
including wound care
Independent:
1. Monitor the site of
impaired tissue integrity
at least once daily for
color changes, redness,
swelling, warmth, pain,
or other signs of
infection.
Long term goal:
After 1 week of
nursing interventions,
the patient's wound
will decrease in size
2. Encourage a diet that
meets nutritional
needs.
3. Teach skin and
wound assessment and
ways to monitor for
signs and symptoms of
infection, complications,
and healing.
89
RATIONALE
1. Systematic inspection
can identify impending
problems early.
2. A high-protein, high
calorie diet may be
needed to promote
healing (ex. Yogurt,eggs,
mashed potatoes, soft
cooked beans etc.)
3. Early assessment and
intervention help prevent
the development of
serious problems.
EVALUATION
Short term goal:
After 1 hour of nursing
interventions, the goal
was met as evidenced by
demonstration of
measures to heal and
protect wound, including
wound care
Long term goal:
After 1 week of nursing
interventions, the goal
was met as evidenced by
a decrease in wound size
4. Instruct the patient
and significant other the
proper care of the
wound including hand
washing, wound
cleansing, dressing
changes, and
application of topical
medication.
5. Educate the patient
on the need to notify
physician.
ASSESSMENT
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING
Subjective Data:
"Masakit yung tahi
ng tyan ko", as
verbalized by the
patient with a rate of
6/10
Acute pain related
to surgical incision
site as evidenced
by pain scale of
6/10, facial grimace
and guarding
behavior
Surgical incision of the
abdomen
Short term goal:
After 2 hours of nursing
interventions, the patient
will verbalize a decrease in
pain as evidenced by
decrease in pain scale
from 6/10 to 1-2/10
Objective Data:
•Abdominal incision
•Facial grimace
•Guarding behavior
⬇
Tissue trauma
⬇
Pain perception
Long term goal:
After 5 days of nursing
intervention, the patient will
be relieved from pain as
evidenced by:
90
4. Accurate information
increases the patient’s
ability to manage therapy
independently and
reduce risk for
infection.
5. This is to prevent
further complications.
NURSING
INTERVENTION
Independent:
1. Observe and
document location
and severity of pain.
RATIONALE
1. Assist in
differentiating
cause of pain, and
provides
information about
disease
progression,
development of
complication and
effectiveness of
intervention.
EVALUATION
Short term goal:
After 2 hours of nursing
interventions, the goal
was met as evidenced
by decrease in pain
scale from 6/10 to 2/10
Long term goal:
After 5 days of nursing
intervention, the goal
was met as evidenced
by:
.
verbal report of
pain absence
.
verbal report of
pain absence
.
relaxed
appearance with no facial
grimace and guarding
behavior
2. Note response to
medication and report
to physician if pain is
not being relieved.
3. Provide a quiet
environment and
encourage patient to
rest.
1. Perform
nonpharmacol
ogic pain relief
methods such
as relaxation
techniques
and provision
of distractions
Dependent:
1. Administer
acetaminophen
500mg/50ml IV, as
prescribed.
91
2. Severe pain not
relieved by routine
measures may
indicate developing
complication or
need for further
intervention.
3. Additional
stressors can
intensify the
patient’s perception
and tolerance of
pain.
3. To provide
optimal comfort to
the patient.
1. To alleviate and
relieve pain
.
relaxed
appearance with no
facial grimace and
guarding behavior
ASSESSMENT
NURSING DIAGNOSIS
SCIENTIFIC
EXPLANATION
Subjective Data:
• “Katatapos lang
ako inoperahan,
may tahi ako dito
sa tyan", as
verbalized by the
patient
Risk for infection
related to break in skin
integrity secondary to
surgical procedure
Surgical incision
⬇
Pathogens may
invade the incision
⬇
Pathogens will multiply
at the site of surgical
wound
⬇
Infection
Objective Data:
• Surgical incision
on abdomen
PLANNING
Short term goal:
After 30 minutes of
nursing interventions,
the patient will be able
to demonstrate proper
wound cleaning and
dressing.
Long term goal:
After 1 week of nursing
interventions, the
patient will remain free
of infection
NURSING
INTERVENTION
Independent:
1. Assess signs and
symptoms of infection,
especially temperature
1. Increase in
temperature may
indicate infection
EVALUATION
Short term goal:
After 30 minutes of
nursing
interventions, the
goal was met as
evidenced
by demonstration of
proper wound
cleaning and
dressing.
2. Emphasize the
importance of
handwashing
technique
2. It serves as first line
of defense against
infection
3. Maintain aseptic
technique when
changing dressing or
caring for wound, and
in disposing
contaminated waste.
3. Regular wound
dressing promotes fast Long term goal:
After 1 week of
healing and drying of
nursing
wound.
interventions, the
goal was met as
evidenced by the
4. Wet area can be
client remaining free
lodge area for bacteria
of infection
4. Keep wound area
clean and dry
5. Encourage
nutritional intake rich in
calories and protein,
vitamins, and
carbohydrates
Dependent:
1. Administer
Benzylpenicillin 125 mg
IV q8, as prescribed.
92
RATIONALE
5. An adequate
amount of calories
helps the body use
nutrients to build a
strong immune system
and protein helps with
wound healing
1. Aids in preventing
the client from
acquiring infection
X.
REFERENCES
Exploratory Laparotomy. (2023). Saint Luke’s Health System.
https://www.saintlukeskc.org/health-library/exploratory-laparotomy
Wikipedia Contributors. (2022, September 21). Perihepatic packing. Wikipedia; Wikimedia
Foundation. https://en.wikipedia.org/wiki/Perihepatic_packing
Wikipedia Contributors. (2023, January 29). Central venous catheter. Wikipedia; Wikimedia
Foundation. https://en.wikipedia.org/wiki/Central_venous_catheter
Doklestić, K., Stefanović, B., Gregorić, P., Ivančević, N., Lončar, Z., Jovanović, B.,
Bumbaširević, V., Jeremić, V., Vujadinović, S. T., Stefanović, B., Milić, N., & Karamarković, A.
(2015). Surgical management of AAST grades III-V hepatic trauma by Damage control surgery
with perihepatic packing and Definitive hepatic repair–single centre experience. World Journal
of Emergency Surgery, 10(1). https://doi.org/10.1186/s13017-015-0031-8
Caruso, D. M., Battistella, F. D., Owings, J. T., & Samaco, R. C. (1999, October). Perihepatic
Packing of Major Liver Injuries: Complications and Mortality. ResearchGate; American Medical
Association.
https://www.researchgate.net/publication/12811805_Perihepatic_Packing_of_Major_Liver_Injuri
es_Complications_and_Mortality
and, D. (2023, February). Your Digestive System & How it Works. National Institute of Diabetes
and Digestive and Kidney Diseases; NIDDK | National Institute of Diabetes and Digestive and
Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/digestivesystem-how-it-works
Liver Functions, Location, Anatomy and Disease | Columbia Surgery. (2022).
Columbiasurgery.org. https://columbiasurgery.org/liver/liver-and-its-functions
Philbert Yuan Van. (2021, June 7). Liver Injury. MSD Manual Consumer Version; MSD Manuals.
https://www.msdmanuals.com/home/injuries-and-poisoning/abdominal-injuries/liver-injury
Introduction to the Cardiovascular System | SEER Training. (2023). Cancer.gov.
https://training.seer.cancer.gov/anatomy/cardiovascular/
Hoffman, M. (2010, April 27). Picture of Blood. WebMD; WebMD.
https://www.webmd.com/heart/anatomy-picture-of-blood
Belleza, M. (2017, August 15). Blood Anatomy and Physiology: Study Guide for Nurses.
Nurseslabs. https://nurseslabs.com/blood-anatomy-physiology/
Khan Academy. (2023). Khanacademy.org.
https://www.khanacademy.org/science/biology/human-biology/circulatorypulmonary/a/components-of-the-blood
Bleeding: MedlinePlus Medical Encyclopedia. (2014). Medlineplus.gov.
https://medlineplus.gov/ency/article/000045.htm
Taghavi, S., & Askari, R. (2022, July 19). Liver Trauma. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK513236/#:~:text=Liver%20trauma%20can%20run%20t
he,of%20Trauma%20Hepatic%20Injury%20Scale.
Philbert Yuan Van. (2021, July). Hepatic Injury. MSD Manual Professional Edition; MSD
Manuals. https://www.msdmanuals.com/professional/injuries-poisoning/abdominaltrauma/hepatic-injury
Health, U. (2020, December 22). Liver Injuries & Home Care. Ucsfbenioffchildrens.org; UCSF
Health. https://www.ucsfbenioffchildrens.org/education/liver-injuries-and-home-care
Ahmed, N., & Vernick, J. (2011). Management of liver trauma in adults. Journal of Emergencies,
Trauma, and Shock, 4(1), 114. https://doi.org/10.4103/0974-2700.7684
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