VII.

COURSE IN THE WARD

Date and time Physicians order Nursing responsibility

July 31, 2017 1400H Confirm diet with 1960 Diet was confirm by
(-) Dyspnea kcal/day nutritionist
(-) desaturation Maintain on heplock Heplock was maintained
(+) green sputum Diagnostics Refer for the diagnostic
- CBC PC procedure
(-) desaturation
Therapeutic
(-) fever - Start sulfadiazine, Given medication on time
(-) edema apply affected area. with right dosage
120/70 Continue
100 bpm imipenem/ cilastatin
20 cpm 250 mg TIV
- Continue other
medications
- Monitor VS every 4 Input & output and vital
hours and I and O signs monitored every 4
every shift hours and recorded
- Mechanical Mechanical vent was set on
ventilator the right order
N560
FiO2 30%
BUN
July 31,2017 For head turning every 2 Range of motion was done
1600H hours Provided a wound care
For daily wound care every shift
Watch out for: Note and record if dyspnea
- Dyspnea appear
- Hypotension
Refer
 August 1, 2017 -Ward receiving notes-
1400H Respectfully receiving Received patient and note
patient X, 85 years all baseline data
old/Male admitted since
Height: 170cm
June 3,2017 currently
Weight: 70 kg
managed on septic shock
secondary ventricular
CHON (0.8) 56 g- 224 kcal(11%)
assist device in
CHO 264-1054 kcal (54%) respiratory failure.
FATS 78g-702 kcal (35%) Diet:TRC= 1890 Kcal/day
using nutrient optimum Refer diet to nutritionist
1:1 dilution divided into 6
equal feeding with the
FF8 macronutrient
distribution CHON (08)
56 grams,CHO 264
grams, Fats 78 grams
Maintain heplock

Diagnostics Heplock was maintained

- Chest X-ray in right hand
portable today with Refer client for
request diagnostics procedures
- BUN, creatinine,
Na, K, phosphate
tomorrow AM
- CBC PC tomorrow
AM

Medications:
1. Impinem/cilastatin 250
mg/250 mg TIV every 12
hours
2. IV acetylcysteine 600 Observe the 10 rights of
mg/tab 1 tab + glass giving medication
water once at bedtime
3. Revise nebulization to
salbutamol + ipratropium
+ IV acetylcysteine
every 4 hours and as
needed for difficulty of
breathing
4. Daxofulline 400mg/tab, 1
tab, twice a day
5. Pantropazole 40 mg/tab
before breakfast
6. Lactulose 30 cc OOHS,
noted if Bowel movement
>3x/day
7. Human albumin 20% TIV
to complete to day 5 then
discontinue ( Q12 )
8. Chlorhexetidine oral
gargle for oral care TID
Maintain to moderate to
high back rest
Monitor vital signs, 02sat
every 4 hours
Facilitate bed turning
every 2 hours
Client maintained high
back rest
Given 02 sat every 4
hours and document
ROM every 2 hours was
done