Evaluation

On our first duty at General Emilio Aguinaldo Hospital, we were assigned to patient RM. He was
involved in a vehicular accident the night of July 15, 2014. His admitting diagnosis was multiple soft
tissue injury 2 to VA. During our first duty, patient was hooked on D5NSS1L 8. He was also hooked on
4 liters of oxygen. The initial vs was: BP: 80/60, RR: 22, PR:71, T:37.1. The staff nurse mentioned that
this patient was disoriented and didnt know who he was with during that time. He could not recall his
wife that was present during our shift. Upon limited physical examination, we observed that the patient
was restless and wanting to get out of bed. Also during the examination, we noticed that the patient
has multiple soft tissue damage on his arms including his legs. He wasnt cooperative during the
examination, so it was very limited. He was wide awake during the examination but unable to respond
to the questions that were asked such as the current place he is at and if he know who is he with at the
moment. His current medications are: Risperdone tab ODHS 1mg, Paracetamol via IV PRN if
temperature is >38.3, Cefuroxime 2gms OD iv via solucet for 30 minutes, Ranitidine 50 mg Q8 and
Citicoline 500mg via iv. His current diet that time was soft diet. Ct scan was done on 7/29/14 and
according to the result; present study shows complete regression of the small contusion hemorrhages in
the right frontal lobe. RM was monitored every 4 hours during that shift. Vs were within normal range.
O2 level was in the 95% level. Nasal cannula kept intact to maintain great flow of 02 intake. Patient was
repositioned every time he slides down from bed. IV was regulated to 30-31 gtts.
The following week of our duty in GEAM, he was again assigned to our group. During that time,
he was having chills. Initial vs was: BP: 70/50, RR: 44, PR 106 T: 40.1, O2 sat was 95%. Tsb was given
hourly and paracetamol via iv. After the intervention, his temperature decreased from 40.1 to 39.3, and
the next hours, stayed at 38.2. Dopamine was given to RM by the staff nurse to increase bp, however,
his bp did not elevate that much. It went from 70/50 80/60. By the end of the shift, RMs
temperature remained at 38.2, RR:25, PR:87, O2:95%. The following night, he was once again assigned
to our group. His initial temperature was 38.4, BP: 70/50, RR:40, PR:95, O2:95%. He was once again on
Q1 monitoring. Tsb was given hourly but the temperature remained at 38.0 range. Doctor visited him
that same shift and suspected that he may have acquired septicemia. Skin test for piperacillin given to
RM around 10:30PM that night and after 30 minutes, he had a negative reaction. Prescription for
pipercillin was given to the live-in partner to buy. However, she wasnt able to get the medication due to
financial reason. At the end of the shift, his temperature remained constant at 38.0.