Beruflich Dokumente
Kultur Dokumente
Date
and Doctors Order Nursing Intervention Rationale
Time
1/16/
17
1:50 AM
Admit to ICU under the
service of Dra. Nerissa
Reyes
Receive consent for
admission
Diet: NPO
IVF PNSS 1 L x 16
Monitor v/s q 1, I & O q
1
Diagnostics
CBG: 155 mg/dL
CBC
Na, K, Crea, BUN
PT, PTT
12 Lead ECG
CxR, AP high
UA
CT scan plan with BW
Cervical APL
Pelvis AP
LS spine APL
Therapeutics:
Nicardipine drip 90 cc
PNSS+ 10 mg
Nicardipine to run at
15 cc/hr
titrate at 5 cc/hr to
maintain at 140-150
SBP
Omeprazole 40 mg 1
OD
Mannitol 150 cc IV
now then 100 q 6
Tranexamic acid 1 g IV
now then 500 g IV q 8
x 6 doses
Tramadol 50 g IVP PRN
for pain q 8
Metoclopramide 10 IV
q 8 for n/v
O2 via nasal cannula 2-3
L/min
CBG q 6 and record
Addendum
1:50 AM For 2D Echo with Doppler Inform the intensivist on An intensivist, also known as a
admission critical care physician, is a
Hold temperature - medical doctor with special
Anastrozole training and experience in treating
critically ill patients.
7:25 PM
IVF to follow PNSS 1 L x Operate the mechanical Mechanical ventilator is a machine
16 ventilator with the given that generates a controlled flow of
settings gas into a
Neuro
Hold Dexamethasone in
AM
Mannitol 125 cc q 4
Pass transout in AM if ok
with other APs
6:30 PM Okay to transfer out of Verbal agreement signifies
ICU understand on the significant
others part
9:25 PM IVF to follow PNSS 1 L x Administer Piperacillin + Antibiotic, based on ETA GS/CS
16 x 2 cycles Tazobactam as ordered (9/19/16)
10:00 No objection for transout Continue to monitor BP as Systolic reading of 100 is in the
PM
to ICU ordered Normal range. Diastolic reading of
90 is in the High Blood Pressure
(Hypertension) Stage 1 range.
1/22/
17
6:23 AM Transfer Servida to room Administer Fluimicil as ordered Mucolytic agent, presence of
near station pseudomonas aeruginosa on ETA
GS/CS according on yesterdays
Reduce dosage of Vigocid as results
ordered Dosage of Vigocid must be
reduced in moderate to severe
impairment
3:48 PM Start Amlodipine (Norvasc
or Vasalat) 5 mg/tab Inform the lab technician for the To compare the ordered tests from
To consume Nicardipine ordered laboratory tests the previous results for
drip Shift Omeprazole IV to capsule developments
Inform once Dra. N. Reyes as ordered Parenteral omeprazole should be
order laboratory works Inform Nephrology on deck for shifted to oral omeprazole as soon
consult as feasible
Dr. Guce updated on patients
status. Data given will be used as
Inform radiologic technologist to baseline
perform diagnostic imaging
To compare the cranial CT scan
from the previous results for
developments
8:00 PM Neuro Increase Ketosteril To decrease serum creatinine level
Refer to rehab in AM administration as ordered
If fully awake try gelatin
per orem with SAP in AM
1/23/
17
12:10 IVF to follow PNSS 1 L x Inform AP on patients status Dr. Pena updated on patients
PM
16 status. Data given will be used as
Refer PRN baseline
2:10 PM Watch out for DOB, chest Decrease administration of Dosage of Vigocid must be
pain and episodes of Vigocid as ordered reduced in moderate to severe
desaturation for O2 impairment
saturation < 95%
Hook to oxygen via nasal
cannula at 2-3 L/min
Refer PRN
7:00 AM Please facilitate the Inform TCVS on deck for IJ Dr. Dizon updated on patients
following lab exams catheter creation. Notify OR. status. Data given will be used as
tomorrow 1/24/2017 baseline
CBC
Na, K, BUN, Crea
CXR portable high
setting
AP updated
Refer PRN
11:30 Neuro Notify OR for IJ catheter Intrajugular access allows the
AM
Facilitate lab in AM insertion. placement of various types of
Mannitol q 6 in AM intravenous (IV) lines to facilitate
Start bladder training the infusion of fluids, blood
products, and drugs
Inform anesthesiologist on deck Dr. Dizon updated via phone on
for the ordered procedure patients status. Data given will be
Significant others are aware used as baseline
regarding on the referral As a general rule, medical or
surgical procedures may not be
carried out without the informed
consent of the patient.
1/24/
17
7:30 AM Kindly relay CXR results Transfuse available PRBC as Low RBC count requires BT
once available ordered
IVF to follow PNSS 1 L at
60 cc/hr
No objections to start
bedside patient rehab
7:20 PM Neuro
Mannitol q 8 in AM Hold all anti-hypertensive meds Blood pressure drops after
Remove oxygen in AM as ordered hemodialysis due to fluid being
quit as PRN pulled off, when combined with all
Start Melatonin 3 mg at of the anti-hypertensive
HS medication, the BP will bottom out
10:20 Neuro Inform the lab technician for the To be used on the patient for
PM
Patient seen and ordered laboratory tests baseline data
examined, however
limited neuro PE done due
to patient is drowsy
Noted with spontaneous
(n) of RF, RL
Hemiparesis (L)
Lenings test
Will start bedside rehab
for tomorrow then will
bring the patient to rehab
gym on the next session
Strict aspiration
precaution
Encourage HBR
Will follow up
1/25/
17
10:00 V/S noted
AM
IVF to follow PNSS 1 L x
60 cc/hr
Neuro
Mannitol 75 cc q 8 in
AM
Start bladder training
If with urge, remove foley
catheter in AM
Last day of Piptazo
tomorrow then start
9:40 PM Silgram 750 mg 1 tab BID
Plan: MRI of the brain with
gado by next week as
OPD
Norgesic forte 1 tab now
per q 6 prn
1/26/
17
12:10 IVF to follow 1 L x 60 cc/hr
AM
6:30 AM Maintain on moderate
back rest
Turn patient side to side q
2
IVF to follow PNSS 1 L x
60 cc/hr
1/27/
17
Neuro
Try soft diet in AM c SAP,
hold OF. If tolerated,
remove NGT
Consume present stock of
Mannitol
For repeat CT scan brain
plain today
Possible discharge next
week
10:20 IVF to follow PNSS 1 L x
PM
60 cc/hr
1/28/ May also give Norgesic
17 forte 1 tab for cervical
12:15 pain/spasm
AM
1:30 AM Neuro
Repeat CT showed
minimal resolution of
hemorrhage, (+)
perilesional edema
Continue Mannitol for now
For MRI of the brain c
gado (+) MRS (Magnetic
Resonance Spectroscopy
c/o Makati Med or
Perpetual
Repeat area prior to MRI
1:55 PM Hold MRI for now
Inform relatives that will
do MRI after 2 weeks
IVF to follow PNSS 1 L x
60 cc/hr
1/29/
17
10:00 IVF to follow PNSS 1 L x
AM
60 cc/hr
10:35 Clonidine 75 mcg 1 tab
AM
OD post lunch
4:55 PM IVF to follow PNSS 1 L x
60 cc/hr
1/30/
17
7:40 AM IVF to follow PNSS 1 L x
60 cc/hr
11:00 OF to 1400/1400
AM divided by 6 equal
feedings
Repeat CBC, Na, today
2:00 PM Start K-Lyte 1 tab TID
4:50 PM Rehab
Will start tilt table if
tolerated
9:20 PM Encourage oral feeding c
SAP
Start teaching relatives
regarding receiving care
Suggest to hold tilt table
for now
Will do MRI c qado as OPD
Tentative plan for
discharge within the week
IVF to follow PNSS 1 L x
600 cc/hr
1/31/
17
7:55 AM No objections to
discharge patient from CV
standpoint
Agree to hold tilt table
testing
Inform me on final
discharge plans for home
meds
2/1/1
7
11:55 Will discharge patient
AM
with NGT
Change present NGT to
siliconized NGT
7:15 PM Neuro
Teach relatives regarding
feeding
Ask dietician to instruct
relatives regarding
feeding preparating