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  • CITW Hyperthyroidism

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    Paola Cruz
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    The document contains doctor and nurse notes from a 3-day hospital admission for a patient presenting with palpitations, fatigability, and body weakness. On day 1, the patient was admitted and started on medications, IV fluids, and diagnostic testing. Throughout the admission, vital signs were taken regularly and medications were administered as ordered. By day 3, labs were stable and the doctor determined the patient was ready for discharge. The nurse discussed the discharge plan and continuity of care with the patient.

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    CITW-hyperthyroidism

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    The document contains doctor and nurse notes from a 3-day hospital admission for a patient presenting with palpitations, fatigability, and body weakness. On day 1, the patient was admitted and started on medications, IV fluids, and diagnostic testing. Throughout the admission, vital signs were taken regularly and medications were administered as ordered. By day 3, labs were stable and the doctor determined the patient was ready for discharge. The nurse discussed the discharge plan and continuity of care with the patient.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    30 views6 pages

    CITW Hyperthyroidism

    Uploaded by

    Paola Cruz
    The document contains doctor and nurse notes from a 3-day hospital admission for a patient presenting with palpitations, fatigability, and body weakness. On day 1, the patient was admitted and started on medications, IV fluids, and diagnostic testing. Throughout the admission, vital signs were taken regularly and medications were administered as ordered. By day 3, labs were stable and the doctor determined the patient was ready for discharge. The nurse discussed the discharge plan and continuity of care with the patient.

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    of 6

    DATE AND TIME DOCTOR’S NOTES NURSE’S NOTES

    Day 1
    December 20, 2020 Admitted to hospital - Patient was seen and
    3:00 AM CC: Palpitations, fatigability and examined by the doctor
    body weakness. with orders.
    - Admitted the patient,
    Admit to the ff order: consent was served and
    attached to the chart.
    Diet: DAT - Routine admission care
    Vital signs: Every 4 hours and was provided
    IVF to follow: PLR (3X) X 8 hours - Assessed vital signs
    with drop factor of 20. - Patient was informed
    Diagnostics: CBC with platelet regarding tests to be
    count, T3, T4, TSH, Na, K, Ca, done.
    Urinalysis, CXR - Diet ordered by the
    Monitor: T3, T4, TSH, Ca doctor was informed to
    Therapeutics: Medical the patient.
    Management Carried out the doctor’s orders
    1. Medications: and sent a request to the
    Propylthiouracil (Philusa laboratory for the following
    Propylthiouracil) 50 mg tests:
    tab PO every 8 hours, - CBC with
    Propanolol (Inderal) 10 platelet count
    mg PO QID, Potassium - T3, T4, TSH, Na,
    250 mg tab PO TID, K, Ca
    Diazepam (Valium) 5 mg - Urinalysis
    PO every 6 hours PRN, - CXR
    Paracetamol (Biogesic) - Hooked PLR 1L regulated at
    500 mg 1 tab PO for 125 cc/hr
    fever.
    2. Watch out for
    complication

    Vital signs were done with


    7AM normal results except
    temperature of 38.4 C
    -Administered Paracetamol 500
    mg
    - Patient was sent to the
    Radiology Department for Chest
    X-ray

    Administered
    Propanolol (Inderal) 10 mg PO
    9AM Diazepam (Valium) 5 mg PO

    Administered:
    11AM Propylthiouracil 50 mg tab
    Potassium 250 mg tab PO
    Hooked PLR 1L regulated at 125
    cc/hr

    12PM Took VS
    VITAL SIGNS
    Temperature 38.3
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    -Administered Paracetamol 500
    mg

    3PM Administered
    Propanolol (Inderal) 10 mg PO
    Diazepam (Valium) 5 mg PO

    4PM
    Vital Signs
    All Normal
    Temp: 37.3 C
    BP: 120/100 mmHg
    PR: 107 bpm
    RR: 18 cpm
    O2 Sat: 98%
    7PM Administered:
    Propylthiouracil 50 mg tab
    Potassium 250 mg tab PO
    Hooked PLR 1L regulated at 125
    cc/hr

    8PM Took VS
    VITAL SIGNS
    Temperature 37.5
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 130/80 mm/hg

    9PM Administered
    Propanolol (Inderal) 10 mg PO
    Diazepam (Valium) 5 mg PO

    Day 2 Took VS
    December 21, 2020 VITAL SIGNS
    12:00 am Temperature 37.3
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    3:00 AM
    Administered:
    Propylthiouracil 50 mg tab
    Potassium 250 mg tab PO
    Hooked PLR 1L regulated at 125
    cc/hr

    4:00 am Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg
    7AM
    Requested laboratory Took VS
    examinations of the following: VITAL SIGNS
    Temperature 37.4
    - CBC with Platelet count Pulse Rate 91 bpm
    - T3, T4, TSH, Na, K, Ca Oxygen Saturation 99%
    - Urinalysis Respiratory Rate 19 cpm
    CXR Blood Pressure 110/80 mm/hg

    Carried out laboratories as


    instructed.

    9AM Administered
    Propanolol (Inderal) 10 mg PO
    Diazepam (Valium) 5 mg PO

    11AM
    Administered:
    Propylthiouracil 50 mg tab
    Potassium 250 mg tab PO
    Hooked PLR 1L regulated at 125
    cc/hr

    12PM

    Took VS
    VITAL SIGNS
    Temperature 37.1
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    3PM
    Administered
    Propanolol (Inderal) 10 mg PO
    Diazepam (Valium) 5 mg PO
    4PM

    Vital Signs
    All Normal
    Temp: 37.3 C
    BP: 120/100 mmHg
    PR: 107 bpm
    RR: 18 cpm
    O2 Sat: 98%

    7PM
    Administered:
    Propylthiouracil 50 mg tab
    Potassium 250 mg tab PO
    Hooked PLR 1L regulated at 125
    cc/hr

    8PM
    Took VS
    VITAL SIGNS
    Temperature 37.5
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 130/80 mm/hg
    9PM
    Administered
    Propanolol (Inderal) 10 mg PO
    Diazepam (Valium) 5 mg PO

    Day 3 Took VS
    December 22, 2020 VITAL SIGNS
    12:00 am Temperature 37.3
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    3:00 AM
    Administered:
    Propylthiouracil 50 mg tab
    Potassium 250 mg tab PO
    Hooked PLR 1L regulated at 125
    cc/hr

    4:00 am Took VS
    VITAL SIGNS
    Temperature 36.4
    Pulse Rate 91 bpm
    Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    7AM Doctors rounds, Took VS


    All labs stable VITAL SIGNS
    The doctor ordered that the Temperature 37.4
    patient was ready to Pulse Rate 91 bpm
    discharge. Oxygen Saturation 99%
    Respiratory Rate 19 cpm
    Blood Pressure 110/80 mm/hg

    9AM Continuity of care

    Nurse and client summarize


    outcome of care (Termination
    Phase)

    Advised of Discharge plan and


    recommendations

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