Course in the Ward

DATE and TIME FOCUS DATA/ACTION/REACTION

January 15, 2017 DOB D>brought to PhicWard a 82y/o male per stretcher; BP
200/100 CR 79 RR 26 Wt. 60kg
A>moved on HBR, oxygen administration 3-9Lpm
2:46am Admission A>S/E by Calacal
>consent secured. IVF PNSS 1L started with side drip
90cc PNSS + 1amp nicardipine to titrated
>CBC with APC, Na, K, BUN, Crea, SGPD, SGOT -ref
>CXR, CT scan pls. ff.up result
NGT & IFC Insertion R>BP 130/100
>consent for insertion secured.
>IFC inserted aseptically then connected to urine bag with
yellowish urine output
>NGt inserted then secured
>assisted to ward
3:41am D>awake on bed
>S/E by Dr. Calacal
A>oxygen inhalation: Oxygen saturation 74%
>explained patient procedure to watcher
>watcher secure waiver for DNR
7am D>on bed moderate HBR with intact IFC and NGT
A>tube feedings done
>needs attended monitored
11am A>carried out new orders
>for repeat cranial CT-Scan with contrast after 48hrs
>endorsed to incoming shift schedule. Of Ct-Scan with
contrast
>referred result of CT-Scan to Dr. Calacal with telephone
orders;carried out new orders
D>for repeat cranial CT-Scan with contrast tomorrow as
ordered by Dr. Calacal
3pm D>recieved patient awake; intact IVF
A>health needs attended; monitored accordingly
>ensured safety
11pm D>on bed awake with E4 V1 M4
A>listed & recorded
>with DNR waiver & signed as endorsed
>continuity of care recorded
January 16, 2017 D>recieved patient with intact NGT& IVF line
8am A>health needs attended; monitored VS accordingly
D>for cranial CT-Scan with contrast
A>refused with waiver signed by the daughter
>referred to Dr. Calacal
12:50pm Rounds D>S/E by Dr. Calacal with orders made
A>carried out
3pm D>on bed with intact IVF
A>tube feeding done
>needs attended, monitored
11pm D>on HBR position with intact NGT & IFC with IVF on
A>continuity of care rendered: monitored accordingly
January 17, 2017 D>on bed with intact NGT & IFC
7am A>maintained NGT & IFC
>tube feedings done
12:29am Rounds A>S/E by Dr. Gina with orders made & carried out
3pm D>received on bed with NGT & IFC
>GCS (E2 V1 M6)
>CBG 129mg/dL
A>continuity of care endorsed
11pm D>on bed with intact IVF line
A>continue monitoring VS & recorded
>ensured safety
January 18, 2017 D>on bed with NGT & IFC
7am >GCS (E2 V1 M6)
A>maintained IFC & oxygen inhalation
>calls attended