COURSE IN THE WARD

Date Doctors Order Rationale Nursing

Responsibilities
12/07/13 Please admit to - For proper medical - Completed and filled
8:05 pm surgery ward treatment and management up necessary data in
under the service and for further evaluation the chart.
of team II - Positioned patient
comfortably on bed
and ensured safety.
12/07/13 Secure consent for - Acts as legal basis to - served as a witness
admission and patients awareness and - validated
management acceptance of medical understanding of the
services to be rendered. patient & SO about the
importance of signing
consent.
12/07/13 DAT - To improve nutritional - Instructed the
status of the patient patient to eat small
frequent meals
12/07/13 v/s q shift and - To provide basis on which - measured and
record to compare patients vital recorded the vital
signs and evaluate signs every shift
- reported untoward
patients status
signs and
symptoms
12/07/13 Dx:
CBC - To look for signs of an - Recorded the time
infection or signs of that the blood is
drawn
gallbladder problems.
- Instructed patient
to apply pressure in
Na the venipuncture
K site
- to determine if a medical - Monitored I and O
condition is improving or - Regulated IVF
Creatinine worsening
U/A
- Instructed the
- To indicate renal function
patient to catch
- To provide information
midstream urine
about the body system and taught him
function how to catch urine
in aseptic manner
CXR RA
- Explained the
significance of the
diagnostics and
assisted the patient

Kkkkkkkkkk Tx:
kkkkk D5 LRS 1L x 8 - to pull the fluids into the - Properly label the IV
12/07/13 vascular by osmosis Fluid and regulated it
- Observe aseptic
technique when
Ceftriaxone
-To reduce bacteria because changing IV fluid
1.5g/IV now
the - Determined for
then 750 mg/ IV history of
patient has high percentage
q8 (-)ANST hypersensitivity
of neutrophil and positive for
reactions
 bacteria - Prepared and
administered drug
Tramadol according to 10 Rs if
50mg/IV q8 ANST is negative
- To relieve pain he felt in - monitor vital signs
the RUQ - Assessed patient
level of pain before
and after
administering
analgesics
12/07/13 Monitor v/s q 1 - To detect changes in the - Assessed the
patients physical status patients vital signs
12/07/13 I and O q shift - To know if the patients -Asked the patient how
kidney is functional many times he void in
- To assess fluid balance every shift
-Recorded intake and
output every shift
12/07/13 WOF untoward - To manage signs and - Reported any
S/Sx symptoms immediately untoward signs and
- To know more about the
disease symptoms
12/07/13 Refer - For proper management - referred
accordingly
- Inform the
attending physician
to know patients
condition
12/07/13 Give paracetamol - To decrease the - Kept patient at rest
10:00pm 300mg/IV q4 RTC temperature of the patient to while
Temp: 38.1 temperature is
C elevated
- Check doctors
order
- Administered the
drug using 10 Rs
- Clean the IV port
prior to
administration of
drugs
- Assessed patients
fever

12/08/13 Refer transfer of - for collaborative - referred accordingly

(+) ataxia service management
Chest pain
12/08/13 S: 40/m

1 week of fever, - For baseline data - Performed TSB for

intervals elevated
(+) cyanosis with temperature
yellow sputum - Encourage patient
(+) RUQ pain, to increase fluid
 excruciating by intake
sign - Administered
ULTZ: outer antipyretic and pain
abdomen reliever
gallbladder with
polyps

ROS: No DOB
No anginal chest
pain
No asthma
No adema

12/08/13 O: alert, AS, PC, SCE

BP 110/
80mmhg
PR 105 bpm
Temp 35.1
12/08/13 A: CAP, MR r/o
cholecystitis

12/08/13 P:
for CBC - To look for signs of an - Record the time
infection or signs of that the blood is
gallbladder problems drawn
- Instruct patient to
apply pressure in
the venipuncture
for Blood CS site
- to know if there is growth
for CXR RA of microorganism

increased
ceftriaxone 2g
IV q12 - to increase the efficacy of
stat - Determined for
the drug history of
azithromycin
hypersensitivity
500mg tab OD - to reduce the worsening of
paracetamol reactions
infection
300mg IV q4
- To decrease the
RTC
temperature of the patient - Kept patient at rest
for transfer to
medical ward to while
- To treat the patient temperature is
once
through medication elevated
cholecystitis is
- Transferred patient
ruled out
- For transferring the when cholecystitis
Please facilitate
patient with complete is ruled out
all labs ordered
data - Reported lab orders
prior to transfer
refer and completed the
- For proper management chart of the patient
- referred
accordingly
- Inform the
attending physician
 to know patients
condition

12/09/13 Transfer to medical - For proper management - Endorsed the

Abdomen ward as previously to meet patients needs patient to medical
flat ordered ward
Soft non- - Completed the
tender chart before
on 4 transferring
quadrants - Assessed the
patient before
Febrile transferring
(-) jaundice
12/09/13 Please inform the - For collaborative - referred
ROD management accordingly
- Inform the
attending physician
to know patients
condition
12/09/13 For upper - To know the patient - Explained the
abdominal ULTZ diagnosis procedure clearly

12/09/13 Request for alkaline - for liver disease or - Explained he

phosphatase damage to the liver procedure to the
patient
12/09/13 Start Ketorolac - To relieve pain he felt in - Assessed pain
30mg IV q6 the RUQ (note type,
location, and
intensity) prior to
and after 1-2 hr of
administration.
12/09/13 For KUB/ HBT - To diagnose intra- - Obtained a
abdominal diseases such history of the
as intestinal obstruction, patients
complaints,
masses, tumors, ruptured
including a list
organs, abnormal gas of known
accumulation, and ascites. allergens,
especially
allergies and
sensitivities to
latex.

12/10/13 Facilitate ULTZ - To know the result earlier - Checked the result
(HBT/KUB) and for proper of ULTZ
management
12/10/13 DAT - To improve nutritional - Instructed the
status of the patient patient to eat small
frequent meals
12/11/13 - to pull the fluids into the - Properly label the IV
D5 LRS 1L x 8 vascular by osmosis Fluid and regulated it
- Observe aseptic
technique when
changing IV fluid
-
12/11/13 Facilitate ULTZ - -
HBT/KUB

12/11/13 D/C azithromycin - To shift for other - Discontinued

Cut ceftriaxone IV medication administering the
drug
- Recorded
discontinuing of
drugs
12/11/13 Start metronidazole - To minimize risk for - Start administering
500mg Iv q 8 infection metronidazole
according to 10 Rs
12/11/13 Cut tramadol/ - To avoid any alteration - Record all the
ketorolac IV prior to exam medications that
should not be
administered
12/11/13 Soft diet - To digest the food easily - Instructed patient
and to reduce contraction not to eat meat and
of the bladder that can high cholesterol
cause pain foods
12/11/13 For upper - To diagnose patients - Explained
abdominal CT scan disease procedure and its
purpose to patient
to obtain patients
cooperation with
the procedure
- Instructed patient
to minimize any
body movements
- Encourage patient to wear
comfortable, loose-fitting
clothes
- Instructed patient to
remove any metal object
including jewelry, dentures,
hearing aid, and
eyeglasses
12/11/13 For CEA/ AFP - To determine presence of - Explained the
tumor procedure to the
patient
12/12/13 Facilitate CT scan - To prepare the patient -
of upper abdominal prior CT scan
with consent

12/12/13 DAT - To improve nutritional - Instructed the

status of the patient patient to eat small
frequent meals
12/12/13 Cut IV meds - Patient will undergo CT - Stopped all IV
scan and he is NPO medications of the
Patient
- Record it in
medication sheet
12/12/13 Preparation for
12:00nn abdominal CT scan:
Soft diet at 1 pm - To digest the food easily - Instructed patient
to avoid meats and
 foods that is not
soft

12/12/13 Give 2 dulcolax tab - To promote elimination for - Instructed client to

at 8pm preparation for CT scan take the medication
on time
12/12/13 Give 1 bottle castor - To have a clear - Explained to the
oil 60cc at 9:00pm visualization of the organ patient the purpose
that is affected of giving castor oil
12/12/13 May drink water - To prevent dehydration of - Instruct the patient
until 12:00mn the patient not to drink water
beyond 12:00mn
12/12/13 Give 1 dulcolax - For easy elimination - Instruct patient to
sup/ rectum at before the examination inhale when
4:00am and for clear visualization inserting the
dulcolax in the
rectum
12/12/13 NPO post-midnight - For CT scan - Instruct the patient
not to eat or drink
after 12mn
12/12/13 Please bring patient - To prepare him for - Encourage the
to CT scan room at incoming CT scan patient to relax
7:00am
12/13/13 Facilitate - To know the result earlier - Checked the result
Abdominal CT scan and for proper of CT scan
management
Continue meds - For continuity of meds and - Prepared and
management administered drugs
according to 10 Rs
Refer - For proper management - referred
accordingly
- Inform the
attending physician
to know patients
condition
12/14/13 Facilitating CT scan - To know the result earlier - Checked the result
results and for proper of CT scan
management
DAT - To improve nutritional - Instructed the
status of the patient patient to eat small
frequent meals
Refer - For proper management - referred
accordingly
- Inform the
attending physician
to know patients
condition
12/16/13 Facilitating CT scan - To know the result earlier - Checked the result
results and for proper of CT scan
management
DAT - To improve nutritional - Instructed the
status of the patient patient to eat small
frequent meals
 Refer - For proper management - referred
accordingly
- Inform the
attending physician
to know patients
condition
12/16/13 For AFP, CEA- done - To determine presence of - Explained the
12:30 am tumor procedure to the
patient
12/17/13 MGH
Home meds as
ordered: - to provide continuity of - Prepared the
Cefuroxime meds and management patient for
500mg 1 cap discharge by
TID providing
Metronidazole instruction about
500mg 1 tab symptoms
TID management, signs
Algesia 1 tab and symptom that
TID prn (+) pain should be reported
to the physician
and the importance
of taking antibiotics
as prescribed
Follow up after 1 - to provide close supervision - Filled necessary
week documents
- Explained the
importance of
having a follow up
check up