course in the ward output
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7/24/2019 Course in the Ward Output
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COURSE IN THE WARD
DATE/TIME DOCTORS ORDER SCIENTIFIC RATIONALE NURSING INTERVENTION
10/14/15
7:30 am
BP: 100/70
mmHgHR: 110 bpm
RR: 18 pm
T!mp: "7#"$C
P%!&'! &(m)* *+ OB ,&-(
S!.-! +'!*
TPR ')2*
DAT D)&g+'*)':
C+mp%!*! B%++( C+.*T3CBC45B%++( *!'*5P%&*!%!*5 H!p&*)*)'B '.-2&! &*)g! 3HB'AG4
5U-)&%6')' ,)*U-)! C+-)+)G+&(+*-+p)5 C&!- &*)g! 19 3CA 1945C&!- &*)g! 1 3CA 145T-&';&g)&% U%*-&'+.(5S!-.m g%.*&m)p6-.;)*-&'&m)&'! 3SGPT4/ &%&)!
&m)+*-&'2!-&'! 3ALT4 5S!-.mG%.*&m) O
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7/24/2019 Course in the Ward Output
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!%p ,)* b%++(%+**)g
$latelet %o!t)' .'!(*+ (!*!* *! .mb!- +2p%&*!%!*' ) *! b%++(#Hepat&t&' B '()a%e
a!t&*e! "HB'A+#D!*!*' p-+*!) *&* )'p-!'!* + *! '.-2&! +2*! ;)-.' T+ '-!! 2+-5 (!*!*5&( !%p ()&g+'! &.*!&( -+) HBV)2!*)+' !&-%)!'*-+.*)! )()&*+- +2 &.*!!p&*)*)' B &(2-!.!*%6 )(!*)?!')2!*!( p!+p%! b!2+-!
'6mp*+m' &pp!&-.(!*!*&b%! ) *!b%++( (.-)g *!-!+;!-6 p!-)+( )* )' *!p-)m&-6 ,&6 +2)(!*)26)g *+'! ,)*-+) )2!*)+'5)%.()g HBV &--)!-'*&*!#Ca!%e( a!t&*e! ,1-5
"CA 1-5#b%++( *!'* )'
.'!( *+ m!&'.-! *!&m+.* +2 CA19
p-+*!) ) *!
b%++('*-!&m#
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7/24/2019 Course in the Ward Output
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S*&-* PNSS IL VO -&*!
T+ '!.-! 1 .)* +2 p&=!(
Ca!%e( a!t&*e! 1.,
."CA 1.,.#)' .'!( *+
!%p ()!-!*)&*!
b!*,!! &!- +2
*!p&-!&'&( +*!-
+()*)+'5 &' ,!%% &' *+
m+)*+- *-!&*m!*-!'p+'! &( -!.--!!#
T(a!'a*&!al
lt(a'o!d )' & *6p! +2
p!%;) .%*-&'+.( .'!(
b6 (+*+-' *+ !
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7/24/2019 Course in the Ward Output
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10:00 pm
10/19/19
9:00 &m
-!( b%++( !%%'
T-&'2.'! b%++( +!
&;&)%&b%! ,&-(
>&* +.* 2+- BT -!&*)+
M+)*+- VS -'
M+)*+- I 0 -'
T+ ,&-(
P&-&!*&m+% "00mg IVTT
+,
TSB p%!&'!
M&6 *-&'2.'! &;&)%&b%!
b%++( +,
C%+-p!)-&m)! m&%!&*!
1 &mpIM p-)+- *+ B%++(
*-&'2.')+
C!= VS p-)+- &2*!-
b%++( *-&'2.')+
Blood U(ea
N&t(o*e!"BUN #
'-!!)g *!'* 2+- *!
!;&%.&*)+ +2 =)(!6
2.*)+# $ota''&m
te't,)' .'!( *+ m!&'.-!
*! &m+.* +2 p+*&'').m) 6+.- b%++( &(
.*-)!*' )*+ !%%'.
Ce't ,(a !%p 'p+*
&b+-m&%)*)!' +- ()'!&'!'
+2 *! &)-,&6'5 b%++(
;!''!%'5 b+!'5 !&-*5
&( %.g'#
2+- m!()&*)+&(m))'*-&*)+ &('!-;!' &' BT %)!
D!-!&'! HbH*
*+ p-!;!* +mp%)&*)+'
*+ p-!;!* 2.-*!-
)?%*-&*)+5')g' +2 p%!b)*)'/)2!*)+# C!= *! %!;!% +2 *! IVF
C!= &( -!g.%&*! *! (-+p -&*!
C&g! *! IVF'+%.*)+ )2 !!(!(
C!= 1'**! *!mp# +2 *! p*# b!2+-! g);)g *
D+ +* !
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7/24/2019 Course in the Ward Output
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10:00 am
BP: 100/0
mmHg
HR:80 bpm
RR: pm
T!mp:"#$C
34 p&%%+-34 ;&g)&%
b%!!()g
>&* +.* 2+- B%++(
*-&'2.')+ -!&*)+
IVF *+ # PNSS 1L VO
-&*!
S*)%% *+ '!.-! b%++( &'
+-(!-!( *-&'2.'! +!
&;&)%&b%!
F+- ,+%! &b(+m!
.%*-&'+.( )%.(! P!%;)
&-!&
F+%%+, .p &!- &*)g!
195 &!- &*)g! 1
-!'.%*
F2# .p %&b -!'.%*
M+)*+- VS -'
ADD:
FESO 1 &p BID
L&*.%+'! "0 HS
IVF *+ # PNSS 1L VO
+mp%)&*)+'
*+ &''!'' =)(!6
2.*)+
T-!&*m!* +2 2!;!-
(!-!&'! Hb*
m&&g!m!* +2 '!;!-!
&%%!-g) +-
6p!-'!')*);)*6 -!&*)+5
)%.()g &&p6%&
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7/24/2019 Course in the Ward Output
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10/1/15
10:00 am
BP: 0/0
mmHg
HR: 80 bpm
RR: pm
T!mp: "7$C
10/17/15
7:00 am
BP: 0/0mmHgHR: 7 bpm
RR: " pm
-&*!
S*&-* C!2.-+
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7/24/2019 Course in the Ward Output
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T!mp: "#8$C
7:"0 pm
10/16/156:00 am
BP: 0/0mmHg
HR:80 bpm
RR:0pm
T: "7$C
34 ',!%%)g +2
L!2* %!g
10/1./15
7:30 am34 p&%%+-
34;&g)&%
IVF *+ : PNSS 1L &* +.* 2+- *-&'2.')+
&''!'' =)(!6 2.*)+
-!(.! '*)m.%&*)+ +2*! ()g!'*);! '6'*!m
2+- !&-%6
&mb.%&*)+5p-!;!* p+'*
+p +mp%)&*)+
b+,!% m+;!m!* -!*.-
*+ +-m&%
A''!'' p*# 2+- &b(+m)&% ()'*!*)+5 p-!'!!
'+.(' +-m&% p&**!- +2 b+,!% 2.*)+# A''!'' +%+-5 +')'*!6 &m+.* +2 '*++% p
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7/24/2019 Course in the Ward Output
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11/0/11
-!&*)+
*+ p-!;!* p+'* +p
+mp%)&*)+'
*-!&*m!* +2
+'*)p&*)+#
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7/24/2019 Course in the Ward Output
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11/07/19
11/08/19
11/0/19
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7/24/2019 Course in the Ward Output
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11/10/19
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7/24/2019 Course in the Ward Output
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C%!&-
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