COURSE IN THE WARD

Date/Time of shift Doctor’s Order Nurses Response Evaluation

September 15-

23,2012

Patient seen and examined at 12:35pm.(sept.15)

Triage to critical bed. For C BG: 195mg/dL Hook to cardiac monitor and

pulse oximeter. Start IVF: PNSS 1L x 100cc/hr. Please give lidocaine 50g TIV For intubation now. Using ET

tube size 1.5cm, hook to monitor for continuous Ambubag.

Mannitol (20%) 250ml Citicoline 2gm TIV now, then

ofloxacinLabs: for 12 led ECG CBC, PT, PTT CxR, protein,

creatinine, serum NaCl ABG, CT scan, urinalysis. For insertion of NGT, keep end

open at bedside bottle. For insertion of individually

foley catheter attached to urine bag.

Hook to mechanical ventilator with the following set up:o FiO2- 100%o TV- 350

NPO temporary CBG q8 while on NPO. ASA 80mg/tab 1tab OD Atorvastatin 40mg/tab ODHS Lactulose 30ml ODHS Start of feeding 1750 kcal/day

o CHO: 218.75gm/dayo CHON: 131.25 gm/dayo Fats: 38.9

Ofloxacin 20mg TIV BID (-) ANST

Omeprazole 40g TIV OD Paracetamol 300mg TIV q4

PRN for fever T: 37.8 Paracetamol 300mg TIV q4

PRN for fever T: 37.8

Kalium durule 75g/tab 1tab BID

Paracetamol 300mg TIV q4 PRN for fever T: 37.8

Kalium durule 75g/tab 1tab BID

ICU TTRANSFER (September 16, 2012 4:00pm) Patient and examined. IVF to ff: PNSS 1L x 40cc/hr.

o ROM Citicoline 2gm TIV q8 Atorvastatin 40g/tab 1tab

ODHS Omeprazole 40g/tab 1tab

ODHS Lactulose 30cc ODHS, hold if

BM > 3x/dayMechanical Ventilator settings as follows:

- AC mode- PR- 40- TV- 350- PBBP- 5- BUR- 16- FiO2- 70%

For repeat ABG prior to ICU transfer.

Please inform MROD once results available.

Relative informed regarding patient’s status and prognosis.

Monitor and maintain back rest.

For carotid duplex 3am once stable.

Hook to cardiac monitor and pulse oximeter.

ICU RECEIVING (September 16,2012 8:00pm) For 12 LED ECG with long LED

II. Attach to mechanical

ventilatoro Mode: ACo TV: 360o BUR: 16

o TF: 40o Deep: 5

Decrease FiO2 by 10% every hour to reach 30%

Repeat ABG in AM out 30% FiO2

Strict aspiration precaution oral care w/ hexetidine

solution swab the oral cavity TID

for fecalysis revise lactulose o 30cc prn at

bedtime if no BM x 3 days or w/o constipation

moderate high back rest Please replace current

mechanical ventilator bemet or Newport

o TV : 360o FI O2 : 30%o PF : 40o RR: 8o PS: 10

Facilitate turning of patient Q2

To secure egg crate mattress To secure anti-embolic

stocking Start mannitol :

o 9/19 150cc Q6o 9/20 150cc Q8o 9/21 160cc Q8o 9/22 160cc Q12o 9/23 discontinue

Please continue NVS monitoring

Start amlodipine 10mg/tab 1 tab

Moderate high back rest

September 24,

2012

Please apply warm and cold compress to all affected area

ABG in arm

(6am-2pm)

(2pm-10pm)

Discontinue CBG monitoring Give acetycylsitiene Shift omeprazole to

pantoprazole cap 40g 1 cap ODHS

Continue physical therapy Please do gentle suctioning

Patient extubated because unable to tolerate weaning : diazepam 5mg IV now

Re etubated w/ ET tube size 7 at level 22

Hook to mechanical ventilator Hold aspirin