Chapter 6

CLIENT’S DAILY PROGRESS IN THE HOSPITAL

1. Client’s Daily Progress Chart

Nursing Problems 11- 11-28- 11- 11- 12-01- 12- 12-03- 12-04- 12-05- 12- 12-
27-10 10 29-10 30-10 10 02-10 10 10 10 06-10 07-10

Impaired gas √ √ √ √
exchange
Acute pain √ √ √ √ √ √

Decrease cardiac √ √
output
Excess fluid volume √ √ √ √

Activity Intolerance √ √ √ √ √ √ √ √ √ √

Diagnostic Procedure

Creatinine 1.5
mg/dl

Sodium 156.6
mg/dl
Potassium 3.60
mg/dl
HEMATOLOGY 133
Hemoglobin
g/L
Hematocrit 0.40
 L/L
Red Blood Cell Count 4.65 x
1012/L

252,00
Platelet count 0

WBC 25.7/L

Urinalysis Macrosco
pic
Analysis

Color :
straw

Transpar
ency:
cleat

Reaction
:
6.0

Specific
gravity:
1.015

Sugar:
Negative
Albumin:
Negative

Microsco
pic
Analysis

RBC: 0-1
 Pus cells:
0-2

Epithelial
cells:
Few
Cholesterol 295
mg/dl

Medical Management

A. IVF
√ √ √
PNSS 1L x KVO √ √
√
PNSS 80ccx KVO +
KCLx6 hrs.
√ √ √ √
PNSS 1Lx12hrs. √

D5W 500xKVO

B. Drugs
Furosemide √ √ √ √
Combivent Nebule √ √ √ √

Ranitidine √

Digoxin √ √ √

Clopidogrel √ √ √
Ceftriaxone √ √ √ √
Levofloxacin √ √ √
Ambroxol √ √ √

Omeprazole √ √ √
 Heparin √ √ √ √

Atorvastatin √ √ √ √
Bivalirudin √ √

Spironolactone √ √

Losartan √ √

C. Diet
Nothing Per Orem √ √ √ √

Soft diet √ √ √ √ √ √ √