NURSING KARDEX

Name: LDB Age: 42 Gender: Male Religion: Roman Catholic

Diagnosis: Cystolithiasis Attending physician: Dr. Vlad Alukard/ Dr. Khaleed Hussain
Ward & Bed: Surgical Pavilion; Bed No. 10

Date & Time Remarks Date & Time IV Fluids Date &
Started Time
Terminated
5/24/2021 @ Admitted to urology; attending urologist Dr. 5/24/2021 @ PNSS iL
5:20 am Vlad Alucard/ Dr. Khaleed Hussain; secured 5:20 am @30gtts/min
consent for management; referred to Dr.
Aldous Badang, Urology Resident.
5/24/2021 @ Followed- up Swab result; followed-up UTZ- 5/25/2021 @ PNSS iL
10:20 am KUB c/o SO 8:00 am @30gtts/min
5/25/2021 @ referred to IM department c/o Dr. Selena 5/26/2021 @ PNSS iL
5:30 am Pharsa; informed Uro department once seen 10:00 am @30gtts/min
by IM
5/25/2021 @ referred accordingly;
9:30 am
5/25/2021 @ referred urine output less than 30 ml/hr
12:00 pm
5/26/2021 @ Plan: Cystolithotripsy; inform IM for CP
2:00 pm clearance; referred to Dr. Rafaela Estes once
urine c/s is in.
5/27/2021 @ May go ahead with planned surgery; Inform
1:30 am IM resident for CP clearance; referred to Dr.
Aldous Badang once seen by IM.
5/27/2021 @ For “E” cystoscopy, cystolithotripsy possible
8:00 am diversion of urine; referred to IM for pre-op
management; schedule emergency once with
CP clearance.
5/27/2021 @ Seen by Dr. Layla Lesley; Patient stratified as
10:00 am low risk to develop major adverse cardio-
pulmonary events in a low risk type of
procedure; Repeat serum crea and BUN
24hrs post- op; get blood c/s 2x sites and
procalcitonin;
5/27/2021 @ Transport to OR
11:20 am

Date Medications Date Examinations/labs Date Diet

5/23/2021 Swab Test 5/24/2021 DAT
5/24/2021 Cefuroxime 5/24/2021 Creatinine/ BUN 5/25/2021 DAT
Tramadol CBC
Paracetamol Urinalysis
Serum Electrolytes
FBS
12 leads ECG
Protime
CT/BT
Blood Typing
HbsAg
HbA1c
Chest X-ray
UTZ- KUB
5/25/2021 Amlodipine 5/26/2021 Urine Culture 5/26/2021 DAT
Ranitidine PSA
5/27/2021 Blood Culture 5/27/2021 NPO

Treatments
5/24/2021 - FBC insertion
- TPR q4h
- I&O q shift
5/25/2021 - Continued management
- Encouraged ambulation
- Monitored I&O in absolute figure
- Continued current medications
5/26/2021 - Encourage oral fluids
- Continue I&O monitoring
- Change FBC
- Continue current management