Course in the Ward
Doctor’s Order Rationale Nursing Responsibility
June 23, 2010
7:50am
Please admit to medical For proper Admitted to medical
ward under the service of management ward
the yellow team/ Dr.
Tugade, Dr. Rugnao
Secure consent for For legal purposes Assured that the
admission patient understood the
explanation done by
the doctor and secured
patient’s signature.
Soft, low salt, low fat diet For nutritional Instructed patient to
purposes. Should be eat porridge or soup
soft to prevent and noodles.
increase oxygen Instructed client that
demand. Low salt, he can still eat foods
low fat to prevent with sodium but
further increase in minimal only.
blood pressure, Encouraged client to
prevent metabolic eat vegetables and
acidosis and fruits instead of fatty
maintain sodium foods.
level.
Insert IFC Before inserting,
provided privacy first.
Cleaned the head and
shaft of the penis
properly.
IFC inserted
aseptically and
connected to urine bag
CBR without BRP To prevent further Instructed client to be
increase in cardiac on complete bed rest.
work load Instructed also client
that he need not to go
to the bathroom for
urination because an
IFC was already
inserted.
Diagnostics
CBC APC To determine Hgb Explained to the
count, RBC, WBC patient the procedure.
and Platelet count. Told patient that blood
WBC to detect sample will be taken.
infection. RBC and Explained to the client
Hgb to assess for that he might feel
oxygen content of slight discomfort
the blood and during needle
Platelet to assess for puncture. Instructed
blood clot. patient that he need not
BUN To measure the restrict food and fluids.
nitrogen fraction of Cleaned the
urea and would aid venipuncture site with
in the diagnosis of anti-septic before
Acute aspirating blood
glomerulonephritis sample. Ensured
Crea To assess creatinine aseptic technique
levels that would during collection of
diagnose presence blood sample. Sent lab
of Acute request form with the
glomerulopehritis blood sample to the
Na laboratory.
K Potassium is crucial
to heart function
and plays a key role
in skeletal and
smooth muscle
contraction.
U/A This test evaluates Explained to the client
physical that the urinalysis
characteristics of reveals urine
urine. Determines characteristics. Inform
specific gravity of the patient that he need
urine and pH; not restrict food and
detects and fluids. Perform hand
measures protein, washing first and wear
glucose and ketone sterile gloves.
bodies Obtained urine
specimen by clamping
first the urinary
catheter and removing
the urine bag then
unclamp the urinary
catheter and place the
urine to the specimen
bottle. Sent lab request
form with the urine
specimen to the
laboratory.
Hgt To determine sugar Explained the
level in the blood procedure and its
importance to the
client. Explained to the
client that he might
feel slight discomfort
during needle
puncture. Check for
the availability of the
strip. Prepare the
materials.
Handwashing first.
Cleaned the puncture
site with cotton balls
soaked with alcohol.
12L ECG To assess electrical Explained the
conductivity of the procedure and its
heart importance to the
client. Placed the leads
properly and provided
privacy inn doing such
procedure.
CXR-PA To visualize lungs Explained procedure
and size of the and its importance to
heart. the client.
Facilitated request
2D-ECHO To determine the Explained procedure
presence of diseases and its importance to
of heart muscles, the client.
valves and Facilitated request
pericardium, heart
tremors and
congenital heart
disease
Thearapeutic
IVF D5W 100cc x KVO Adult I.V. solution Hooked IVF and
to keep vein open regulated at 10gtts/min
for I.V. medication
delivery.
Lanoxin 0.5mg IV now It helps make the Monitored heart rate.
then 0.25mg IV OD heart beat stronger Administered
with a more regular effectively and
rhythm efficiently by
observing the 10R’s of
giving medication.
Furosemide 20mg IV now Diuretic treatment Monitored blood
with BP precaution for heart failure and pressure.
drug of choice for Administered
pulmonary edema effectively and
efficiently by
observing the 10R’s of
giving medication
Watch out for
hypotension
Clopidogrel 75mg/tab OD Decreases platelet Administered
to prevent blood effectively and
clot efficiently by
observing the 10R’s of
giving medication
Watched for any signs
of bleeding
ASA 80mg/tab OD It is an anti- Administered
coagulant drug to effectively and
prevent blood clot efficiently by
observing the 10R’s of
giving medication
Watched for any signs
of bleeding
Metoprolol 50mg IV then To decrease blood Administered
OD pressure effectively and
efficiently by
observing the 10R’s of
giving medication
Advise patient to
change position slowly
to minimize orthostatic
hypotension
Captopril 25mg tab ¼ tab To decrease blood Administered
BID pressure effectively and
efficiently by
observing the 10R’s of
giving medication
Watched for any signs
of hypotension
O2 inhalation of To facilitate Placed nasal canula
6LPM/NC oxygenation properly. Regulated
oxygen @ 6 LPM.
High Back Rest To promote lung Positioned patient on
expansion high back rest.
Please admit to medical The patient is Ensured safety of
ICU already under client in transferring to
critically ill patients the medical ICU.
and so intensive
care and careful
monitoring is
needed.
8:30 am For hypoglycemia Checked for blood
Start D5050 50 ml now glucose before
administering.
Administered
effectively and
efficiently.
10:50am
Give Lanoxin 0.5mg IV It helps make the Administered
now heart beat stronger effectively and
with a more regular efficiently.
rhythm Monitored heart rate.
11:20 am Administered
Lanoxin 6.5mg IV now effectively and
efficiently.
Increased dose from
0.5mg to 6.5mg
Monitored heart rate.
Furosemide 40mg/IV Diuretic treatment Administered
now for heart failure and effectively and
drug of choice for efficiently.
pulmonary edema. Monitored blood
pressure.
Increase O2 to 8LPM/ O2 To facilitate Placed face mask
face mask oxygenation properly and increased
O2 inhalation from
6LPM to 8LMP
1:40pm Diuretic treatment Administered
Give Furosemide for heart failure and effectively and
40mg/IV now drug of choice for efficiently.
pulmonary edema Monitored blood
pressure.
Start Intubation The endotracheal tube Prepared materials for
Epinephrine 1amp/IV serves as an open intubation such as
passage through the
CPR laryngoscope, ET tube,
upper airway. The
Epinephrine 1amp/IV purpose of ambo bag, oxygen
CPR endotracheal intubation tank, leukoplast, 10cc
Epinephrine 1amp/IV is to permit air to pass syringe.
freely to and from the Ensured proper
CPR lungs in order to placement of the ET
Epinephrine 1amp/IV ventilate the lungs.
CPR is used on people
tube.
CPR
in cardiac arrest in Performed ambo
Epinephrine 1amp/IV
order to oxygenate the bagging properly
CPR blood and maintain Performed CPR
a cardiac output to properly.
Epinephrine 1amp/IV keep vital organs alive
CPR Drug of choice for Checked for ECG
Epinephrine 1amp/IV cardiac arrest tracing.
CPR Post mortem care :
ECG flat -Removal of all
Pronounce dead 3:45pm contraptions.
-Before removing ET
tube, aspirate first air.
-Placed cadaver slip.
-Covered the patient
properly
