Date / Progress Nurses Laboratory Doctors’ Treatment Nursing

Time Notes Assessment Exams Orders Done Intervention

s
First day ER *Conscious and *conscious and *pls admit *Venoclysis *V/S taken and
Stay responsive responsive under the started with recorded
*afebrile *afebrile service of Dr. PNSS 1 LITER *Referred to
June 28, 2009 *skin warm to * T= 37oC Diagan then regulated ROD
5:30pm touch *Appears weak *TPR every 4 at KVO Rate *Labs
*(+) harsh (+)DOB hours and requested
breath sounds (+)nasal flaring record pls *medications *Blood
BLF noted *DAT but NPO started extraction cone
* (+) body Poorly once dysneic by medtech
weakness nourished *Labs: CBC,UA, * Provided O2
noted (+)systolic SE,ECG, Serum Inhalation
(+) Nasal murmur Creatinine,
Flaring Flat abdomen Chest X-ray To
(+)difficulty of return Plate,
breathing FBS, HGT
*PNSS 1 LITER
AT KVO RATE
*Meds:
Furosemide 20
mg 1 tab now
Con. Myrin P 3
TABS OD
Hydrocortisone
100 mg IV now
O2 Inhalation at
3-4L/min
inform AP
June 29, 2009 *refer Medications
2 Day
nd
(8:30 am) accordingly started
June 29, 2009 conscious and FBS- 70.81
5:20am (-)DOB responsive mg/dl normal
*afebrile (70-151mg/dl) TF. PNSS at KVO
* T= 37 C
o
Creatinine-1.14 Rate
*Appears weak mg/dl normal Ranitidine 50
(0.9-1.5mg/dl) mg IVTT Q12
WBC= 7.4 x 10 hours PRN
9/L normal:(5-
10 10 9/L )
Hct= 0.43
normal: (0.40-