c) Client’s daily Progress Chart

Admission 26 27 28 29 30 Dec. 1 2 3
Nov.25 Discharged
Acute Pain
Ineffective Airway
Clearance
Impaired Gas
Exchange
Ineffective Tissue
Perfusion
Decreased
Cardiac Output
Risk for
Aspiration
Anxiety
Fatigue
Risk for infection
Activity
intolerance
Self care Deficit
Vitals signs 36.8 35.8 35.5 36 36 36 36.3 36.9
Temperature
Pulse Rate 105 76 67 77 65 70 73 71
Respiratory Rate 25 18 20 20 21 20 18 19
Blood Pressure 190/130 100/70 100/70 100/70 130/80 130/80 120/90 120/70
Diagnostics

Chest (PA) view

ECG
2D
Echocardiogram
with Doppler

155
 Laboratory
procedures

Blood
Chemistry
CK-MB 47.4 mg/dl
Troponin T <0.05ng/ml
Blood
hematology

Hemoglobin 124 g/dl

Hematocrit 0.39
White Blood Cells 6.9
Neutrophils 0.65
Lymphocytes 0.30
Eosinophils 0.01
Monocytes 0.04
Platelet count 218,000/µL
Prothrombin Time
13.7 s
(PTT)
Activated partial
thromboplastin 34.8 s
time (aPTT)
FBS 192.91mg/dl
HBAIc 10.9%
Serum
electrolytes
Sodium
139.3 mEq/L
Potassium 3. 83 mEq/L 4.25mEq/L 4.1mEq/L
Creatinine 1.39 mg/dl
Magnesium 0.65mg/dl
Calcium 4.35 mg/dl
Lipid profile

HDL 77.52 mg/dl

156
 LDL 46.51 mg/dl
Triglycerides 46.90 mg/dl
Cholesterol 133.33 mg/dl
HGT 9:45pm (6am) (12mn) (12mn) (12mn) (6am) (6am) (6am)
301mg/dl 179 mg/dl 153 mg/dl 153mg/dl 160mg/dl 148mg/dl 120mg/dl 120mg/dl

159mg/dl
(12nn) (6am) (6am) (6am) (6pm) (6pm) (6pm)
148 mg/dl 148 mg/dl 140mg/dl 155mg/dl 98mg/dl 93mg/dl 130mg/dl

(6pm) (12nn) (12nn) (12nn)

156 mg/dl 75 mg/dl 75mg/dl 80mg/dl
(6pm) (6pm) (6pm)
71 mg/dl 112mg/dl 120mg/dl
IVF

PNSS 1L TS: 9:35pm 6am – 9:40am

(interrupted)
D5W 500cc 9:40am
DRUGS
Furosemide
Trimetazidine
Bromazepam
Simvastatin Shifted to
atorvastatin
Atorvastatin
Isosorbide
Dinitrate
Isordil SL
Isosorbide
Mononitrate
Metoprolol
Captopril
Lactulose
Clopidogrel
Spironolactone
157
 Lidocaine
Atropine sulfate
Pantoloc
Shifted to oral
Aspirin
Morphine Sulfate
Maalox
Mixtard
Enoxaparin
Sodium
O2 2LPM
Condom
Catheter
Low fat, Low
salt diet
CBR without
BRP
May walk on the
corridor

158