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VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL 1) Clients Daily Progress Chart DAYS NURSING PROBLEMS 1.)Hyperthermia 2.

) Decreased cardiac output 3.) Ineffective peripheral tissue perfusion 4.)Acute pain 5.) Impaired physical mobility 6.) Impaired Skin integrity 7.)Risk for injury ADMISSSION (February 4, 2013) 5 6 7

VITAL SIGNS Temperature Pulse Rate Respiratory Rate Blood Pressure 36.6C 78bpm 18cpm
160/100mmHg

36C 97bpm 20cpm 140/80mm Hg

36.2C

36.3 77bpm 17cpm 130/80mm Hg

73bpm 16cpm 120/80mm Hg

DX/LAB PROCEDURES 1.) URINALYSIS 2.) LDH 3.) CBC Hematocrit Hemoglobin Leukocyte count Neutrophils Lymphocytes Monocytes Eosinophils Platelet Count MEDICAL MANAGEMENT 1. IVFs D5LRS 1L D5LRS 1L + 10 U Oxytocin

0.35 119 7.86 0.68 0.26 0.05 0.01 187

DRUGS

Standing Order
1. Magnesium Sulfate 2. Aldomet

REVISED

3. Buscopan 4. Diclofenac 5. Tramal 6. Cefuroxime 7. Mefenamic Acid 8. Losartan


NOT GIVEN

D/C

Stat Medications
1. 2. 3. 4. Catapres Hydralazine Magnesium sulfate Ampicillin DIET 1. Nothing per orem 2. General liquid diet ACTIVITY 1. Complete Bed Rest with Bathroom Privileges 2. Ambulation

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