Date/Time 7/2/2011 5:30am

Doctors Order Admit under white SVC

Rationale For proper monitoring, management and evaluation

Remarks Done

Secure consent

Patient has the right to be consented in all procedures to be done

Done

TPR with BP q4

To monitor vital signs so that any unusualities will be referred as follows.

Done

DAT

Diet as tolerated to maintain nutritional status of patient.

Done

PNSS 1L @ 100cc/hour

Plain Normal Saline Solution. To maintain fluid and electrolyte balance. 100cc/hr is the appropriate rate computed by the physician.

Done

Labs: CBC PC

CBC with PC determines the quantity of each quantity of blood cell in a given specimen of blood, often including the amount of hemoglobin, hematocrit, and the proportion of various white blood cells. To know any deviations or abnormalities in the blood

Done

Creatinine

Checking Creatinine levels is important because it is a measurement of renal function.

Done

Sodium

to determine clients hydration status and the kidney's ability to conserve or remove sodium

Done

Potassium

To determine amount of potassium in the blood of the client.

Done

RBS

To determine/monitor blood glucose level

Done

U/A

to detect and measure various compounds that pass through the urine of the client.

Done

PA

Physical Assessment, to assess client from head to toe

Done

CXR

Chest x-ray is done for internal visualization of the chest to check for any unusualities and to see if other vital organs has already been affected

Not Done

ECG 12L

To evaluate the functionality of the heart.

Done

Meds: Cefotaxime 1gm IVTT of q8H ANST()

Antibiotic

Done

Paracetamol 500mg tab q4 RTC x 24h. then PRN for T>38 C

It is commonly used for the relief Done of fever, headaches, and other minor aches and pains. Given every hours for 24 hours. And as needed if temperature is greater than 38 C.

Domperidone 10 mg tab TID

to suppress nausea and vomiting

Done

Omeprizole 40mg cap OD

To decrease the amount of acid produced in the stomach.

Done

I and O qShift

INTAKE AND OUTPUT gauge fluid balance and give valuable information about clients condition.

Done

TSB for fever

It is effective in relieving fever by reducing high temperature and also helpful in alleviating pain or discomfort.

Done

Refer

This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

Date/Time 7/3/11

Doctors order CT scan

Rationale CT scans allow doctors to inspect the inside of the body without having to operate or perform unpleasant examinations.

Remarks Not Done

Cefotaxime 2gm IVTT

Cefotaxime is used for infections of the respiratory tract, skin, bones, joints, urogenital

Done

system, meningitis, and septicemia. Transfer to CP ward For proper monitoring, management and evaluation Dx: Cervical Xray to find injuries or diseases that affect the discs or joints in your spine and to check the curve of patients spine. refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Not Done Not Done

Date/Time 7/4/11 1:30pm

Doctors Order Dx: S/F Xray Cervical APL-provide request

Rationale to find injuries or diseases that affect the discs or joints in your spine and to check the curve of patients spine.

Remarks Done

EEG- provide request

The EEG is an important aid in the diagnosis and management of epilepsy and other seizure disorders

S/F Cranial CT scan

Allows the doctor to inspect the inside of the body without having to operate or perform unpleasant examinations.

Not Done

S/F GS/CS

To determine what kind of organism is causing the infection and find out what commonly used antibiotic it is resistant and sensitive

Done

Meds: 1.) Ceftriazone 2g. IVTTOD

Antibiotic

ANSTC 2.) Paracetamol 5mg tab q4h, PRN for fever It is commonly used for the relief of fever, headaches, and other minor aches and pains. PRN refers to the dosage of prescribed medication that is not scheduled; instead Done

administration is left to the caregiver or the patient's 3.) Diazepam 5mg IVTT PRN for active seizures only IVF: PNSS 1L @ 120 cc/hr To maintain fluid and electrolyte balance. 120cc/hr is the appropriate rate computed by the physician. Seizure precaution Client has a risk for trauma/suffocation related to possible occurrence of seizures I and O q shift INTAKE AND OUTPUT gauge fluid balance and give valuable information about your patient's condition. refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Done Done Done Done Done

Date/Time 7/5/11

Doctors Order Dx: TSH

Rationale To test TSH levels of the client and to assess if client is suffering from excess or defieciency of thyroid

Remarks Done

hormone. T4 To measure amount of thyroxine in the blood of the client. Cranial CT scan To allow doctors to inspect the inside of the body without having to operate or perform unpleasant examinations. EEG The EEG is an important aid in the diagnosis and management of epilepsy and other seizure disorders Done Not Done Done

Follow up x ray of cervical spine

to take a picture of the bones in the back of the neck

Not Done

Captopril 25mgtab, 1 tab every now and then for BP >160/100 Compliance to ceftriaxone

To lower blood pressure if it reaches BP of greater than 160/100 Compliance with meds will avert any complications.

Done

Done

Cont. other meds

Compliance with meds will avert any complications.

refer

This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client.

Done

Date/Time 7/6/11

Doctors Order S/F compliance to all labs

Rationale Compliance with labs will help monitor clients present condition

Remarks Done

Please retrieve Chest X ray and Cervical x-ray and place at bedside today.

To Evaluate the heart, Lungs, chest wall and the back of the neck. Placement in bedside will help the

doctor in assessing the results. Continue all meds. Compliance with meds will avert any Done complications. Refer to consultant This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Done

Date/Time 7/7/11 Dx:

Doctors Orders

Rationale CT scans allow doctors to inspect the inside of the body without having to operate or perform unpleasant examinations. Helps in

Remarks Not Done

S/F CT scan

S/F creatinine

Checking Creatinine levels is important because it is a measurement of renal function.

Done

Continue all meds

Compliance with meds will avert any complications.

Done

Continue supportive care

To help alleviate anxiety of the client

Done

Refer accordingly

This may create a collaborative treatment among the client and health providers; thus it

Done

also makes a good coordination in the treatment of the client.

Date/Time 7/811

Doctors orders Dx: Facilitate clinical CT scan today

Rationale CT scans allow doctors to inspect the inside of the body without having to operate or perform unpleasant examinations.

Remarks

1:30pm

Repeat U/A

To screen patient's urine for renal/ urinary detect substances

Tramadol 50 mg. IVTT q8h

Opiod analgesic for pain management

Epinisume 1 tab TID Paracetamol 500 mg q6h It is used for the relief of fever, headaches, and

other minor aches and pains. hours. Given every 6

Secure Consent

Patient has the right to be consented in all procedures to be done

Date/Time 7/9/11

Doctors orders Dx 1 PR xp ( ) S. cen results CP (undecided)

Rationale

Remarks

Patient has the right to be consented in all

procedures to be done. client is in sepsis Continue Meds Compliance with meds will avert any complications. TSB for fever It is effective in relieving fever by reducing high temperature and also helpful in alleviating pain or discomfort. Refer This may create a collaborative treatment among the client and health providers; thus it also makes a good coordination in the treatment of the client. Done Done Done

Acknowledgement The proponents of this case study would like to extend their warmest gratitude to all the people who made the success of this undertaking a reality. First and foremost, to the almighty Father, for his unceasing love and blessings; for giving us enough power and fortitude to face all the hardships in the making of this work. To him be all glory and praise. To Maam Jenifer Ocampo, RN MN for giving us the appropriate orientation and facilitation on our first exposure in the med. Extension ward. She had been very patient and understanding to us, and gave us an enjoyable and unforgettable experience. To the staff and personnel of Southern Philippines Medical Center, especially in medical extension ward for giving us the opportunity to complete this study. To our dear families and friends, for their never ending support and understanding; for always being there to guide and care for us after the long days of duty. To the patients of Ricardo limso medical center and southern Philippines medical center, for challenging us to do more and for pushing us to our limits to maintain their normal vital signs, to appease their restlessness and sometimes to endure their unexplainable behavior; we will never forget you. Lastly, to each and every one who helped realize this study into completion, may it be direct or indirect, no matter how minimal, the gratitude and pleasure fir this achievement of this task is ours to share.