Time and date

Focus For whole abdomen ultrasound

Data Action Response D> with orders of for whole abdomen ultrasound by Dr. X, with the diet of Nothing Per Orem Post midnight on the previous shift, with no contraptions noted A>checked the doctors order, checked if the Nothing per Orem diet is strictly followed, explained the procedure to the client and relatives, informed and Checked to radiology department the schedule of the procedure, accompanied patient to radiology department. R>whole abdomen ultrasound done and to secure results. D>with admitting diagnosis of Cerebro vascular disease: bleed, with body temperature of 38.8, flush skin, increase respiratory rate; 25breathes per minute. A>Vital signs taken and recorded, administer PRN medication; given 250 mg of paracetamol orally, perform tepid sponge bath, inform the Resident on Duty about the situation, rechecked the vital signs especially the temperature R> temperature decrease to the normal limits;37.2 D>on diabetic diet, with glucose monitoring Three times a day with sliding scale of insulin HR subcutaneous, with CBG results of 138 mg/dl A>checked the doctors order regarding the sliding scale of insulin, explained the procedure to the client, prepare the materials needed, administered 2units of insulin subcutaneously, reassure the patient after the procedure. D> with orders of for 2D echo by Dr.X, with admitting diagnosis of Anemia secondary to upper gastrointestinal bleeding A>Verify doctors order, informed and checked from the radiology department the schedule of the procedure explain to the patient and relatives the procedure, accompanied the patient to the radiology department R> proceedure done and results to secure

Elevated body temperature

Hyperglycemia

For KUBP ultrasound

Titration of inotropes: noradrenaline

D>with admitting diagnosis of community acquired pneumonia moderate risk, status post hemodialysis ongoing titration of noradrenaline 5 is the minimum and 60 is the maximum decrement by 3s; on 15 microdrops per minute, with ideal blood pressure of 90/60 mmHg as ordered by Dr. X A>checked doctors order, explained the procedure to the patient and relatives ,vital signs taken and recorded: vital signs while ongoing to titration, place on safe and comfortable position and all health care needs attended. R> on 5 micro drops per minute, with latest blood pressure of 100/60mmHg

Time and date

focus For referral to rehabilitation Medicine

For potassium correction

Data Action Response D> with orders of for referral to rehab by Dr. X, with admitting diagnosis of Cerebro vascular disease, infarct left , on diet as tolerated with Glasgow coma scale of 15;4:5:6. A>checked the doctors order ,explain the order to the patient and relatives, forward the referral form to rehabilitation medicine department. R>Rehab Residents on duty noted on the chart D>with orders of potassium correction, kalium durule 250 mg/tablet 2tablets three times a day in three doses and repeat potassium after the last dose by Dr. X, with latest serum potassium result of 1.35mg/dl. A> verify doctors order, inform the patient about the order, procure the needed medication, transcribed the medication to the medication sheet, kardex and standing order sheet. R> initial dose of potassium started still for repeat potassium after the correction. D>with orders of IVF to consume and shift to heplock by Dr. X, with ongoing IV Fluid of Plain NSS 1 liter to run for 12 hours at 100 cc level. A> verify doctors order, explain the procedure to the client, prepare materials needed, consumed the IV Fluid and shifted to heplock flushed 3cc of Plain NSS in the heplock, reassure the patient R>Shifted to heplock; intact and patent D> with difficulty and fast breathing noted; 28 Breaths per minute, with admitting diagnosis of CVD infarct Left, with O2 saturation decrease to 95% A> Vital signs taken and recorded, elevated the head of the bed, place the patient on side lying position, administered PRN medication; ipratropium+ salbutamol via nebulization, perform chest physiotherapy after the nebulization, encouraged to cough, R>Decreased respiratory rate;21 breaths per minute

Shift IV fluid to heplock

Difficulty of breathing

Health teaching
D>received awake on bed conscious and coherent,on diet as tolerated, no contraptions noted with admitting diagnosis of Pleural effusion secondary to paraneumonic process vs pulmonary tuberculosis A>Vital signs taken and recorded, encouraged deep breathing exercise and instructed to do blow bottle exercises, emphasized the importance of following the medication regimen for the betterment of the health status, encouraged to ask queries related to the topic of the teaching. R> verbalized understanding about the health teaching rendered