Beruflich Dokumente
Kultur Dokumente
Kkkkkkkkkk Tx:
kkkkk D5 LRS 1L x 8 - to pull the fluids into the - Properly label the IV
12/07/13 vascular by osmosis Fluid and regulated it
- Observe aseptic
technique when
Ceftriaxone
-To reduce bacteria because changing IV fluid
1.5g/IV now
the - Determined for
then 750 mg/ IV history of
patient has high percentage
q8 (-)ANST hypersensitivity
of neutrophil and positive for
reactions
bacteria - Prepared and
administered drug
Tramadol according to 10 Rs if
50mg/IV q8 ANST is negative
- To relieve pain he felt in - monitor vital signs
the RUQ - Assessed patient
level of pain before
and after
administering
analgesics
12/07/13 Monitor v/s q 1 - To detect changes in the - Assessed the
patients physical status patients vital signs
12/07/13 I and O q shift - To know if the patients -Asked the patient how
kidney is functional many times he void in
- To assess fluid balance every shift
-Recorded intake and
output every shift
12/07/13 WOF untoward - To manage signs and - Reported any
S/Sx symptoms immediately untoward signs and
- To know more about the
disease symptoms
12/07/13 Refer - For proper management - referred
accordingly
- Inform the
attending physician
to know patients
condition
12/07/13 Give paracetamol - To decrease the - Kept patient at rest
10:00pm 300mg/IV q4 RTC temperature of the patient to while
Temp: 38.1 temperature is
C elevated
- Check doctors
order
- Administered the
drug using 10 Rs
- Clean the IV port
prior to
administration of
drugs
- Assessed patients
fever
ROS: No DOB
No anginal chest
pain
No asthma
No adema
12/08/13 P:
for CBC - To look for signs of an - Record the time
infection or signs of that the blood is
gallbladder problems drawn
- Instruct patient to
apply pressure in
the venipuncture
for Blood CS site
- to know if there is growth
for CXR RA of microorganism
increased
ceftriaxone 2g
IV q12 - to increase the efficacy of
stat - Determined for
the drug history of
azithromycin
hypersensitivity
500mg tab OD - to reduce the worsening of
paracetamol reactions
infection
300mg IV q4
- To decrease the
RTC
temperature of the patient - Kept patient at rest
for transfer to
medical ward to while
- To treat the patient temperature is
once
through medication elevated
cholecystitis is
- Transferred patient
ruled out
- For transferring the when cholecystitis
Please facilitate
patient with complete is ruled out
all labs ordered
data - Reported lab orders
prior to transfer
refer and completed the
- For proper management chart of the patient
- referred
accordingly
- Inform the
attending physician
to know patients
condition
12/10/13 Facilitate ULTZ - To know the result earlier - Checked the result
(HBT/KUB) and for proper of ULTZ
management
12/10/13 DAT - To improve nutritional - Instructed the
status of the patient patient to eat small
frequent meals
12/11/13 - to pull the fluids into the - Properly label the IV
D5 LRS 1L x 8 vascular by osmosis Fluid and regulated it
- Observe aseptic
technique when
changing IV fluid
-
12/11/13 Facilitate ULTZ - -
HBT/KUB