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  • Patient's Daily Progress Chart: RD RD RD

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    ethens
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    This patient chart summarizes a 10-day hospital stay in May 2008 for a patient admitted to the ICU. It includes daily records of vital signs, nursing problems, diagnostic tests and results, medications, diet, activity levels and other medical management. Key findings included abnormal lipid and glucose levels, positive cardiac enzymes, ECG showing ST elevation and sinus bradycardia. The patient was treated with IV fluids, oxygen, monitoring, various cardiac and other drugs and progressed from complete bed rest to sitting up with limited activity and visitors by day 10 when they were discharged.

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    Patient Progress

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    This patient chart summarizes a 10-day hospital stay in May 2008 for a patient admitted to the ICU. It includes daily records of vital signs, nursing problems, diagnostic tests and results, medications, diet, activity levels and other medical management. Key findings included abnormal lipid and glucose levels, positive cardiac enzymes, ECG showing ST elevation and sinus bradycardia. The patient was treated with IV fluids, oxygen, monitoring, various cardiac and other drugs and progressed from complete bed rest to sitting up with limited activity and visitors by day 10 when they were discharged.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    47 views5 pages

    Patient's Daily Progress Chart: RD RD RD

    Uploaded by

    ethens
    This patient chart summarizes a 10-day hospital stay in May 2008 for a patient admitted to the ICU. It includes daily records of vital signs, nursing problems, diagnostic tests and results, medications, diet, activity levels and other medical management. Key findings included abnormal lipid and glucose levels, positive cardiac enzymes, ECG showing ST elevation and sinus bradycardia. The patient was treated with IV fluids, oxygen, monitoring, various cardiac and other drugs and progressed from complete bed rest to sitting up with limited activity and visitors by day 10 when they were discharged.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 5

    1.

    Patient’s Daily Progress Chart

    Days (Month of May Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10
    2008) Admissio (10-08-09) 10-09- (10-10- (10-11-09) (05-12-09) (10-13-09) 3rd NPIe 3rd NPI 3rd NPI
    n (ICU) 09) 09) (ICU) (ICU) (ICU) (10-14-09) (10-15- Discharge
    (10-07-09) (ICU) (ICU) (Med 09) (10-16-09)
    (ICU) Ward) (Med (Med Ward)
    Ward)
    NURSING
    PROBLEMS
    1.Acute Pain
    2. Ineffective
    Breathing
    Pattern
    3.Decreased
    Cardiac Output
    4.Ineffective
    Tissue Perfusion
    (Cardiopulmonary
    )
    5.Activity
    Intolerance
    VITAL SIGNS
    Blood Pressure 140/100 140/100 130/10 130/10 130/90 110/90 110/80 100/80 100/80 140/100
    (mmHg) 0 0
    Temperature 36.5 36.9 38.1 36.5 36.8 36.7 36.9 36.8 36.7 36.5
    (°C)/axilla
    Pulse Rate (bpm) 109 106 107 97 102 92 89 88 89 109
    Respiratory Rate 36 38 34 25 24 22 22 20 22 36
    (bpm)
    Oxygen Saturation 97 98 97 97 97 97 97
    (%)
    GCS 15
    DIAGNOSTIC
    PROCEDURES:
    Complete Blood
    Count
    Hemoglobin(g/L) 143 g/L 143 g/L
    Hematocrit 0.40 0.40
    Leukocytes (109/L) 8 7
    Lymphocytes 0.42 0.36

    Serum
    electrolytes
    Serum 0.9
    Creatinine(umol/L)
    Sodium (mmol/L) 120.8

    Patassium 4.2
    (mmol/L)
    Lipid Profile
    Cholesterol 5.8↑ 5.8↑
    (mmol/L
    Triglycerides 1.54 ↑ 1.54 ↑
    ((mmol/L)
    High Density 29 1.15
    Lipoprotein (HDL)
    (mmol/L)

    Low Density 5.67 5.0 ↑


    Lipoprotein (LDL)
    (mmol/L)
    Glucose (FBS) 6.21 6.81 ↑
    (mmol/L)
    Cardiac Enzymes
    Troponin (Cardiac positive
    T) (ng/ml)

    Chest X-ray (AP


    Sitting)
    Twelve (12) Lead
    Electrocardiogram
    (ECG)

    P-R (sec) 0.20

    QT (sec) 0.36
    QRS (sec) 0.06
    Analysis and ST-
    Interpretation segment
    elevation
    , sinus
    bradycar
    dia.

    MEDICAL
    MANAGEMENT
    IVF
    D5W
    Oxygen therapy at
    via nasal cannula
    Pulse Oximeter

    Cardiac
    Monitoring
    DRUGS
    Isoket
    Clexane
    Plavix
    Morphine Sulfate
    Lasix
    Metoprolol
    Capoten
    Risek
    Vidastat
    Vastarel MR
    Aspirin
    Lanoxin
    Omeprazole
    Paracetamol
    Lactulose
    Aldactone
    DIET
    Nothing Per Orem
    (NPO)
    Temporarily
    Soft diet
    Low salt diet
    Low fat diet
    DAT
    Activity/Exercise
    Complete Bed
    Rest without
    Bathroom
    Privilege
    May sit-up on bed,
    but without
    bathroom
    privileges

    Limit Visitors to 2
    persons only

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