Course in The Ward H.Injury

COURSE IN THE WARD
September 21, 2020 (1st week)

6 am – Admission
The patient was admitted on September 21, 2020 at 6:00 am with a chief complaint of
cuts and deep wound in the face. Initial vital signs were BP of 170/90 mmHg, Temp of 37.2C,
RR of 14 cpm, and PR of 58 bpm. ICP value is 25 mmHg. He admitted directly to the OR for an
emergency operation which lasted for 4 hrs. Intubation was still intact unless the patient regained
consciousness or if he will have the ability to breathe independently.
11 am – SICU
He was transferred to the SICU at around 11 am, hooked to D5NSS 1L X 16 hours with
drop factor of 20. Neuro vital signs done with a result of GCS: 0 due to anesthesia; BP 150/90;
Temperature 36.1 C; RR 14 cpm; PR 68 bpm. ICP MONITORING / Measurement = 19 mmHg
The doctored ordered of strict NPO diet and requested the following laboratory and
diagnostic exams which are CT scan stat, CBC with platelets, Na, K, Creatinine, RBS, Lipid
Profile, ABG, Urinalysis, CXR, ECG, PT, PTT. He also ordered for this medications: (1)
Mannitol 100cc every 4 hours as side drip, fast drip initially of 100cc, (2) Dexamethasone
(Decadron) 8 mg IVP now the 4 mg IVP every 6 hours, (3) Ranitide (Zantac) 50mg IVP
now then every 8 hours, (4) Captopril (Capoten) 25 mg tab (pulverized) SL, (5) Nicardipine
drip 10ml/ 1 amp incorporated to present IV with MAP of equal or greater than 160 and
target BP is 150/90, (6) phenytoin (Dilantin) 100 mg PO TID, (7) Acetamenophen
(Tylenol) 1 tab 500 mg every 4 hours PO. And an IVF to follow: D5NSS (3X) X 30 cc/hr.
Oxygen therapy via nasal cannula is administered and urinary rubber catheter was placed intra-
op. Kept the patient warm and thermoregulated.
12 nn
Neuro vital signs done with a result of GCS: 0 due to anesthesia; BP 145/90; Temperature 37.1;
RR 15 cpm; PR 78; O2 Sat: 92; ICP MONITORING / Measurement = 18 mmHg; Pupillary
reaction:absent constrication; Motor function: absent. Suction was done to prevent aspiration of
excessive fluids due to anesthesia.
1 pm
Neuro vital signs done with a result of GCS: due to anesthesia; BP 142/90; Temperature 36.8;
RR 14 cpm; PR 76; O2 Sat: 92; ICP MONITORING / Measurement = 18mmHg; Pupillary
reaction: minimal constriction and absent activity upon stimulation.
2 pm Normal dapat
Neuro vital signs done with a result of GCS: 9 ; BP 143/84; Temperature 37.1; RR 14 cpm; PR:
71; O2 Sat: 92; ICP MONITORING / Measurement = 19 mmHg; Upon assessment the client
uses accessory muscles in breathing.
The patient woke up but still lethargic. Educated the client about deep breathing exercise for 15
minutes 3x a day.
3 pm
Neuro vital signs done with a result of GCS: 9; BP 142/96; Temperature 36.8; RR 16 cpm; PR
79 bpm; O2 Sat: 93; ICP MONITORING / Measurement = 18 mmHg;
Medication given were: (1) Mannitol 100cc side drip Q4, Acetaminophen 500 mg Q4 PO
4 pm
Neuro vital signs done with a result of GCS: 9; BP 142/91; Temperature 36.7 C; RR 14 cpm; PR
5 pm
Medication given was: Dexamethasone 4 mg IVP Q6
6 pm
82 bpm; O2 Sat: 93; ICP MONITORING / Measurement =16 mmHg;
7 pm
82 bpm; O2 Sat: 93; ICP MONITORING / Measurement = 18 mmHg; Pain scale: 1/10
Medication given were: (1) Mannitol 100 cc side drip Q4, (2) Ranitidine 50 mg IVP Q8, (3)
Phenytoin 100 mg PO TID, (4) Acetaminophen 500 mg Q4 PO
8 pm
Neuro vital signs done with a result of GCS: 9; BP141/86; Temperature 36.7 C; RR 14 cpm; PR
9 pm
10 pm
11 pm
Medications given were: (1) Mannitol 100 cc side drip Q4, (2) Dexamethasone 4mg IVP Q6, (3)
Acetaminophen 500 mg Q4 PO
September 22, 2020
12 mn
ICP MONITORING / Measurement = 17 mmHg
Neuro vital signs done with a result of GCS: 10; BP 143/84 mmHg; Temperature 36.8 C; RR: 12
cpm; PR: 73 bpm; O2 Sat: 94
1 am
cpm; PR: 73 bpm; O2 Sat: 94; ICP MONITORING / Measurement = 17 mmHg;
2 am
3 am ((Dito dapat yung Cushing Triad))
First IV D5NSS was consumed. Another D5NSS was hooked @30 cc/hr
Medications given were: (1) Mannitol 100 cc side drip Q4, (2) Ranitidine 50 mg IVP Q8, , (3)
Phenytoin 100 mg PO TID, (4) Nicardipine drip 10ml / 1 amp, (5)Acetaminophen 500 mg Q4
PO
4 am
5 am
Medications given was: (1) Dexamethasone 4 mg IVP Q6
6 am
7 am
8 am
Neuro vital signs done with a result of GCS: 10; BP 147/82; Temperature 36.8 C; RR: 12 cpm;
PR: 73 bpm; O2 Sat: 95; ICP MONITORING / Measurement = 16 mmHg;
9 am
10 am
11 am
Medication given were: (1) Mannitol 100cc side drip Q4, (2) Dexamethasone 4 mg IVP Q6, (3)
Ranitidine 50mg IVP Q8, (4) Nicardipine drip 10ml / 1 amp incorporated to present IV with
MAP of equal or greater than 160 and target BP is 150/90, (5) Phenytoin 100 mg PO TID, (7)
Acetaminophen 1 tab 500 mg Q4 PO.
12 nn
cpm; PR: 73 bpm; O2 Sat: 96;
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm
September 23, 2020
12 mn (Cushing Triad)
Neuro vital signs done with a result of GCS: 11; BP: 200/100 mmHg; Temperature 36.8 C; RR:
10 cpm; PR: 57 bpm; O2 Sat: 98;
Administer Nicardipine drip 10 ml/1 amp IV as ordered.
1 am
2 am
3 am
Medications given were: (1) Mannitol 100 cc side drip Q4, (2) Ranitidine 50 mg IVP Q8, (3)
4 am
5 am
Medications given was: (1) Dexamethasone 4 mg IVP Q6
6 am
Neuro vital signs done with a result of GCS: 12; BP 144/80 mmHg Temperature 36.8 C; RR: 12
7 am
8 am
9 am
10 am
11 am
Medication given were: (1) Mannitol 100cc side drip Q4, (2) Dexamethasone 4 mg IVP Q6, (3)
Ranitidine 50mg IVP Q8, (4) Phenytoin 100 mg PO TID, (5) Acetaminophen 1 tab 500 mg Q4
PO.
12 nn
cpm; PR: 73 bpm; O2 Sat: 99; Pain scale: 2/10
1 pm
1st D5NSS 1 L at 30 cc/hr was consumed. Another D5NSS 1 L was hooked at 30 cc/hr.
Administer Nicardipine drip 10 ml/ 1 amp as ordered.
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
Phenytoin 100 mg PO TID, Acetaminophen 500 mg Q4 PO
8 pm
9 pm
10 pm
11 pm
September 24-27, 2020

Continues medications and interventions was given to the client together with Neuro vital signs
Q1. Still the patient’s LOC was lethargic. GCS score is 13. Continuous oxygen therapy was
being administered. ICP value = 17 mmHg
September 28 – October 4, 2020 (2nd week)
Q1. From lethargic, the patient’s LOC became alert on September 30 but still his strength is not
yet recovered. With the help of the nurse or PT, they will assess pt’s strength, balance, and
mobility, and give suggestions for exercises to do in the hospital. GCS score of 13, improvement
on the client can now be seen. Continuous oxygen therapy was being administered. Continuous
deep breathing exercise. ICP value = 17 mmHg
October 5 – 25, 2020 (3rd – 5th week)
Q1. Patient’s LOC was still alert, GCS score is 14, he is now regaining his strength and
continuous oxygen therapy was being administered to the client. Catheter was also removed. On
the 5th week the nasal cannula was removed. Continuous deep breathing exercise. ICP = 17
mmHg
October 26 – November 2, 2020 (6th week)
The patient was admitted to rehabilitation 6 weeks after his injury. He was alert, with short-term
memory difficulties, subtle difficulties with word finding and higher-level tasks. CT scan of his
head demonstrated bilateral inferior frontal lobe and left temporal lobe confusions with
hypodensity of the brain compatible with enchephalomalacic change in addition to an extradural
fluid collection in the right frontal region, which indented the underlying brain. ICP value = 17
mmHg

Course in The Ward H.Injury

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COURSE IN THE WARD

September 21, 2020 (1st week)

September 24-27, 2020

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