course in the ward output

7/24/2019 Course in the Ward Output

1/24

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


2/24

!%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%++( *!'* )'

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p-+*!) ) *!

b%++('*-!&m#


3/24

S*&-* PNSS IL VO -&*!

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p!%;) .%*-&'+.( .'!(

b6 (+*+-' *+ !


4/24

10:00 pm

10/19/19

9:00 &m

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T-&'2.'! b%++( +!

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D+ +* !


5/24

10:00 am

BP: 100/0

mmHg

HR:80 bpm

RR: pm

T!mp:"#$C

34 p&%%+-34 ;&g)&%

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>&* +.* 2+- B%++(

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F+%%+, .p &!- &*)g!

195 &!- &*)g! 1

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FESO 1 &p BID

L&*.%+'! "0 HS

IVF *+ # PNSS 1L VO

+mp%)&*)+'

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2.*)+

T-!&*m!* +2 2!;!-

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6p!-'!')*);)*6 -!&*)+5

)%.()g &&p6%&


6/24

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.-+


7/24

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


20/24

11/0/11

-!&*)+

*+ p-!;!* p+'* +p

+mp%)&*)+'

*-!&*m!* +2

+'*)p&*)+#


21/24

11/07/19

11/08/19

11/0/19


22/24

11/10/19


23/24

C%!&-


24/24

course in the ward output

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