ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

Date Admitted: October

______________
25, 2021 Mode of Admission: ___________
Spine Board HMO: __________
PhilHealth Hospital No. ______
54321
Level of Care Needed: ( ) Minimal ( ) Moderate ( ) Intensive ( / ) Critical Care
None
Allergies to Food/Drug*: _________________ A
Blood Type*: _______ Positive
Rh: _______________ K.T.
RN Sig: __________
Nutrition/Diet Contraption Started: Disc* Others:
Frequently ordered items: Activities:
:

Temp: 36C CR: Others: ( /) CBR (/) IVF Lines 10/25/21 10/30/21 02@ ___L/min

PR: 49 bpm BP: 100/60 mmHg ( ) Assisted (/) NGT 10/25/21 10/30/21 ( ) Cannula

RR: 18 cpm MIO: ( ) Ambulatory (/) Urinary Cath 10/25/21 10/30/21 ( ) Face Mask

WT: 85 kg ( ) Respirator

Date & Time

Date/Time Diagnostic, Laboratories, Procedures
Date/Time R.N R.N Date/Time R.N
Ordered Medications Timing Carried
Sig. Sig. Taken/Done Sig
Out Ordered
Carried & Referrals
Out

10/25/21 Dexamethasone IV 8 10/25/21 K.T. 10/25/21 10/25/21 K.T. MRI 10/25/21 K.T.

Methylprednisolone 500mg x 2 doses slow

10/25/21 8 10/25/21 K.T. 10/25/21 10/25/21 K.T. Serum Sodium (Na) 10/25/21 K.T.
IVTT for 15mins STAT

Methylprednisolone 125mg by continuous

10/25/21 8:40 10/25/21 K.T. 10/25/21 10/25/21 K.T. Serum Potassium (K) 10/25/21 K.T.
IV infusion

10/25/21 Solu Medrol 40 mg IVTT Q8h 8-4-12 10/25/21 K.T. 10/25/21 10/25/21 K.T. Bicarbonate 10/25/21 K.T.

Falgan 1gm/vial x 100 ml IV infusion for 15 12-6-12-

10/25/21 10/25/21 K.T. 10/25/21 10/25/21 K.T. Creatinine 10/25/21 K.T.
mins Q6H RTC 6-12

10/25/21 Omeprazole 40 mg IVTT OD x 3 doses 8 10/25/21 K.T. 10/25/21 10/25/21 K.T. WBC 10/25/21 K.T.

10/25/21 Zegerid 40mg OD ac 5:30 10/25/21 K.T. 10/25/21 10/25/21 K.T. Hemoglobin 10/25/21 K.T.

Kiara Denise Tamayo

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

10/25/21 Biocobal 500mcg IVTT OD x 5 days 8 10/25/21 K.T. 10/25/21 10/25/21 K.T. Hematocrit 10/25/21 K.T.

10/25/21 Cefotazime 1gm IV Q8H ANST (-) 8-4-12 10/25/21 K.T. 10/25/21 10/25/21 K.T. Coagulation Studies 10/25/21 K.T.

10/25/21 Lactulose 30cc at HS 8 10/25/21 K.T 10/25/21 10/25/21 K.T. Blood Glucose Level 10/25/21 K.T.

10/25/21 Baclofen 5mg/tab, give one tab TID x3days 8-1-6 10/25/21 K.T. 10/25/21 10/25/21 K.T. NGT 10/25/21 K.T.
Mr. W.C. Dr. Yohan Go Unable to move his arms and legs
10/25/21 10/25/21 K.T. Urinary Catheter 10/25/21 K.T.
M Single Roman Catholic
28 April 29, 1993 10/25/21 Dr. Yohan K.T.
10/25/21 Go Traumatic
Cervicothoracic laminectomy Spinal Cord Injury10/25/21 K.T.

Iloilo City K.T.

10/28/21 10/28/21 K.T. Spinal Angiogram 10/28/21 K.T.
ICU
10/29/21 10/29/21 K.T. Histopathologic Analysis 10/2/21 K.T.

Patient Name: _______________ Physician: _____________ Chief Complaint: ___________________________

Sex: ___ CS: ________ Religion: ______________
Age: ____ Date of Birth: _______________ Resident on Duty/in Charge: ___________ Impression: ___________________________
Address: ____________________________________ Primary Nurse: ______
(* Red Ink) Department/ Room No.: ____

Kiara Denise Tamayo

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

Name: Mr. W.C Name: Mr. W.C Name: Mr. W.C Name: Mr. W.C Name: Mr. W.C
RM: ICU RM: ICU RM: ICU RM: ICU RM: ICU
Physician: Dr. Yohan Go Physician: Dr. Yohan Go Physician: Dr. Yohan Go Physician: Dr. Yohan Go Physician: Dr. Yohan Go

RX RX RX RX RX
#1 D5LR 1L x 100 cc/hr Dexamethasone IV Methylprednisolone 500mg x 2 Methylprednisolone 125mg by Solu Medrol 40 mg IVTT Q8h
8-6 8 doses slow IVTT for 15mins continuous IV infusion 8-4-12
STAT 8:40
8

Flaggings:
10/25/21 K.T.
10/25/21 K.T. 10/25/21 K.T. 10/25/21 K.T.
10/25/21 K.T.

Name: Mr. W.C Name: Mr. W.C Name: Mr. W.C Name: Mr. W.C Name: Mr. W.C
RM: ICU RM: ICU RM: ICU RM: ICU RM: ICU
Physician: Dr. Yohan Go Physician: Dr. Yohan Go Physician: Dr. Yohan Go Physician: Dr. Yohan Go Physician: Dr. Yohan Go

RX RX RX RX RX
Falgan 1gm/vial x 100 ml IV Omeprazole 40 mg IVTT OD x Biocobal 500mcg IVTT OD x 5 Cefotazime 1gm IV Q8H Cefotazime 0.1 mixed with 0.9
infusion for 15 mins Q6H RTC 3 doses days /ANST (-) distilled water for skin test.
12-6-12-6-12 8 8 8-4-12 / ANST (-)
10/25/21 to 10/30/21

10/25/21 K.T. 10/25/21 K.T. 10/25/21 K.T. 10/25/21 K.T. 10/25/21 K.T.

Kiara Denise Tamayo

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

Name: Mr. W.C Name: Mr. W.C Name: Mr. W.C Name: Mr. W.C
RM: ICU RM: ICU RM: ICU RM: ICU
Physician: Dr. Yohan Go Physician: Dr. Yohan Go Physician: Dr. Yohan Go Physician: Dr. Yohan Go

RX RX RX RX
Zegerid 40mg OD ac Lactulose 30cc at HS Baclofen 5mg/tab, give one tab /MRI
5:30 8 TID x3days /Serum Na
8-1-6 /Serum K
10/25/21 to 10/28/21 /Serum Bicarbonate
/ Serum Creatinine
/ CBC
/ Coagulation
/ Blood Glucose Level
10/25/21 K.T.

10/25/21 K.T. 10/25/21 K.T. 10/25/21 K.T. / Spinal Angiogram

10/28/21 K.T.
Name: Mr. W.C Name: Mr. W.C
RM: ICU RM: ICU
Physician: Dr. Yohan Go Physician: Dr. Yohan Go / Histopathologic Analysis
10/29/21 K.T.
RX RX
Neurosurgical Treatment Cervicothoracic Laminectomy
Arterial Line Insertion
NGT insertion
Blood Glucose Monitoring
Urinary Catheter insertion
Transfer to ICU
10/25/21 K.T.

Ambulated with Physical Therapy 10/25/21 K.T.

Trial of Void
Replacement of Bladder Catheter
10/28/21 K.T.

Kiara Denise Tamayo

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

Kiara Denise Tamayo