DOCTOR’S ORDER(S

)

Date/Time June 1, 2011 4PM

Order

Rationale

>Please admit at P1F3 – Reverse >Admission in the area will protect a patient from Isolation infectious organisms that
might be carried by the staff, other patients, or visitors or on droplets, in the air or on equipment or materials. Hence, the medical stuff and personnel will be able to monitor the patient’s condition.

>Secure consent management

to

care

and >To insure that all procedures
and treatmentt done are in accordance to patient’s will and/or consent.

>DAT (Diet as tolerated) with strict >Able to take foods as wished with strict aspiration precaution Aspiration Precaution to prevent choking. >Venoclysis of PNSS iL @ 30 gtts/min; IVTF of PNSS iL @ 3o gtts/min
> It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

> Diagnostics: - CBC with platelet
>To test for loss of blood, abnormalities in the production or destruction of blood cells, acute and chronic infections, allergies, and problems with blood clotting and bleeding.

- Blood typing

>Done to determine a person's blood type for blood transfusion or transplant purposes, because not all blood types are compatible with each other.

- Na+, K+, Crea, BUN

>To screen for an electrolyte imbalances.

-U/A

>A screening to detect renal and metabolic diseases.

- Chest X-ray –PA

>Used to help find some problems with the organs and structures inside the chest.

- ECG

>A noninvasive procedure for recording electrical changes in the heart and also used to evaluate symptoms such as chest pain, shortness of breath, and palpitations.

>Therapeutics: 1) Hydroxyurea tab, 2 tabs B.I.D.
>An antineoplastic agent and treats cancer by slowing or stopping the growth of cancer cells.

2)

Allupurinol 100mg tab O.D.

> Used for treating gout caused by excessive levels of uric acid in the blood (hyperuricemia).

3)

NaHCO3 1 tab T.I.D.

>An antacid used to relieve heartburn and acid indigestion, and help make blood or urine less acidic in certain conditions.

4) Cloxacillin 500mg IVTT q.6h

>An antibiotic in the class of drugs called penicillins. It fights bacteria and used to treat many different types of infections caused by staphylococcus bacteria ("staph" infections).

5)Paracetamol 500mg q.4h PRN for Temp > 37.8 0C

>To relieve fever and for pain management.

> Nursing: 1) Monitor V/S q.2 hours, refer if: BP: >150/90 or < 90/60 HR: > 100 or < 60 RR: > 22 or < 16
>To monitor and identify any abnormalities from the patient’s normal state, and to establish basis for the effect of the treatment and medications.

2) Intake and output every shift

>Evaluate client's fluid and electrolyte balance, also influence the choice of fluid therapy; document client's ability to tolerate oral fluids;

and recognize significant fluid losses

3)Refer: Shortness of breath, chest pain

>To be able to treat possible probelms and/or complications that may occur.

4)To patient’s secured transfuse apart

secure 3 “u” PRBC of blood type. Properly and cross-matched, to in 4-6 hours, q.8 hours

>The most commonly transfused blood component which can restore the blood's oxygen-carrying capacity, specially for patient’s with bleeding problem and anemia.

By Dr. Sarmiento/Casino

June 2, 2011 12 PM >Transfuse blood once available

>To replace lost components of blood in the patient’s body.

>Continue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min # 2 PNSS iL @ 30 gtts/min # 3 PNSS iL @ 30 gtts/min # 4

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

June 3, 2011 11 AM >Still for Blood Transfusion

>To replace lost components of blood in the patient’s body.

>Continue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min # 3 PNSS iL @ 30 gtts/min # 3 PNSS iL @ 30 gtts/min # 5

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

June 4, 2011 11 AM >Continue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

June 5, 2011 12 PM >Diagnostics: - CBC with platelet
>For monitoring purposes and thus help determine the general health status of the patient. Also help reflects whether patient is healthy and if cell populations are within normal limits.

- U/A

>To monitor renal fuunction and any unusualities in the urinary system while patient is under treatment.

- Na+, K+, Crea

>To monitor electrolytes balances and imbalances.

- Repeat Chest X-ray – PA

>Proper diagnpstic evaluation for appropriate management.

>Summary of Medications: 1)Cloxacillin q.8hours 500mg IVTT
>An antibiotic in the class of drugs called penicillins. It fights bacteria and used to treat many different types of infections caused by staphylococcus bacteria ("staph" infections).

2)Hydroxyurea 500mg, 2 tabs >An antineoplastic agent and B.I.D. treats cancer by slowing or
stopping the growth of cancer cells.

3) Allupurinol 100mg, 1 tab OD
> Used for treating gout caused by excessive levels of uric acid in the blood

(hyperuricemia). 4)

Paracetamol 500mg tab, q.4hours PRN for Temp > 38 o C.

>To relieve fever and for pain management.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

By Dr. Valleja

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

June 6, 2011 3 PM >Continue medications

>For maximum therapeutic effects, and prevention of complications.

>Transfuse blood once available

>To replace lost components of blood in the patient’s body.

IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

June 7, 2011 9:30 AM >Continue medications

>For maximum therapeutic effects, and prevention of complications.

>Transfuse blood once available

>To replace lost components of blood in the patient’s body.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

1:30 PM

>Retrieve Chest X-ray film and place at bedside >Hold Cloxacillin IVTT as ordered >Please carry out: 1)Cefuroxime 750mg IVTT q.8hours ANST ( )
>An antibiotic from the group of drugs called cephalosporin and is used to treat many kinds of bacterial

infections, including severe or life-threatening forms. Thus, skin testing is done to determine petient’s allergic reaction.

2) Levofloxacin 500mg, 1tab OD

>Is in a group of antibiotics called fluoroquinolones and is used to treat bacterial infections of the skin, sinuses, kidneys, bladder, or prostate. Thus, used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.

3)Hydroxyurea 500mg, 2 tabs B.I.D.

>An antineoplastic agent and treats cancer by slowing or stopping the growth of cancer cells.

4) Allupurinol 100mg, 1 tab OD

>Used for treating gout caused by excessive levels of uric acid in the blood (hyperuricemia).

5) NaHCO3 1 tab T.I.D.

>An antacid used to relieve heartburn and acid indigestion, and help make blood or urine less acidic in certain conditions.

6) Paracetamol 500mg, 1 tab q.4 hours PRN for Temp >38 o C

>To relieve fever and for pain management.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

June 9, 2011 >Refer to ENT

>To be able to examine and treat possible complications.

>Continue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

June 10, 2011 5 PM >Diagnostics: - Repeat CBC with platelet
>For monitoring purposes and thus help determine the general health status of the patient. Also help reflects whether patient is healthy and if cell populations are within normal limits.

>Conitnue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

June 11, 2011 10 AM >Continue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

June 12, 2011 11 AM >Diagnostics: - Repeat CBC with platelet
>For monitoring purposes and thus help determine the general health status of the patient. Also help reflects whether patient is healthy and if cell populations are within normal limits.

>Conitnue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

June 13, 2011 7 AM >To secure 4 “u” PRBC of patients blood type and complete crossmatching

>The most commonly transfused blood component which can restore the blood's oxygen-carrying capacity, specially for patient’s with bleeding problem and anemia.

>Transfuse once available, q. 6 of blood in the patient’s body. hours

>To replace lost components

>Conitnue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

11 AM

>Hold Cefuroxime IVTT and Levofloxacin p.o. >Start Cloxacillin 500mg IVTT q.6 hours, ANST ( )
>An antibiotic in the class of drugs called penicillins. It fights bacteria and used to treat many different types of infections caused by staphylococcus bacteria ("staph" infections).

>Start Clindamycin 300mg IVTT q.6 hours, ANST ( )

>Used to treat certain types of bacterial infections, including infections of the lungs, skin, blood, bones, joints, female reproductive organs, and internal organs.

>Omeprazole 40mg tab OD

>Help to decrease the amount of acid produced by the stomach, and prevent upper gastrointestinal tract bleeding.

>PCM 500mg tab, RTC for fever

>To relieve fever and for pain management.

>Repeat Chest X-ray – PA

>Proper diagnpstic evaluation for appropriate management.

By Dr. Villaren

11 PM

>Please give Omeprazole 40mg cap with strict Aspiration Precaution now

>Help to decrease the amount of acid produced by the stomach, and prevent upper gastrointestinal tract bleeding.

>PCM 300mg IVTT now June 14, 2011 12 PM >Summary of Medications: 1) Clindamycin 300mg IVTT q.6h

>To relieve fever and for pain management.

>Used to treat certain types of bacterial infections, including infections of the lungs, skin, blood, bones, joints, female reproductive organs, and internal organs.

2) Cloxacillin 500mg IVTT q.6h

>An antibiotic in the class of drugs called penicillins. It fights bacteria and used to treat many different types of infections caused by staphylococcus bacteria ("staph" infections).

3) Hydroxyurea 500mg, 2 tabs T.I.D.

>An antineoplastic agent and treats cancer by slowing or stopping the growth of cancer cells.

4) NaHCO3 1 tab T.I.D.

>An antacid used to relieve heartburn and acid indigestion, and help make blood or urine less acidic in certain conditions.

5) Allupurinol 100mg, 1 tab OD

>Used for treating gout caused by excessive levels of uric acid in the blood (hyperuricemia).

6) PCM 500mg, 1 tab q.4hours for Temp >38 oC

>To relieve fever and for pain management.

>It is indicated as a source of water and electrolytes. In

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

general, used for fluid replenishment or medication administration.

June 15, 2011 8 AM >Give Calcium Gluconate i amp slow IVTT
>Used as an antacid for heartburn; treatment of hypocalcemia in those conditions requiring prompt increases in plasma calcium; and for emergency cardiotonic effect

>Continue Medications

>For maximum therapeutic effects, and prevention of complications.

>Diagnostics: - Na+, K+,Crea
>To monitor electrolytes balances and imbalances.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

By Dr. Valleja

2 PM

>Retrieve Chest X-ray film and place at bedside >For U/A
>To monitor renal fuunction and any unusualities in the urinary system while patient is under treatment.

>Continue Medications

>For maximum therapeutic effects, and prevention of complications.

>Facilitate blood transfusion

>To continuously replace any lost components of blood in the patient’s body. >To treat any possible complications or problems.

>Refer

By Dr. Villaren

June 16, 2011 1 PM >Continue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration. >To treat any possible complications or problems.

>Refer accordingly

By Dr. Valleja

June 17, 2011 5 PM >Change present IVF with PNSS iL + 60 meq KCL to run @ 30 gtts/min x 2 cycles >Give: 1) Kalium Durule i tab T.I.D.

>For hydration purposes plus potassium chloride to prevent or to treat low blood levels of potassium (hypokalemia).

>A generic for Potassium chloride and has many uses such as being a sodium-free substitute for table salt (sodium chloride) and as a supplements that is used to prevent hypokalaemia.

2) Ciprofloxacin 2oomg IVTT q.12 >An antibiotic which is used to kill all the unhealthy bacteria hours

by interfering with the process and functioning of enzymes, which ends the synthesis of protein and bacterial DNA.

>Continue other medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

>Refer accordingly

>To treat any possible complications or problems.

By Dr. Valleja

June 18, 2011 12 PM >Diagnostics: -Na+, K+ - CBC with platelet
>For monitoring purposes and thus help determine the general health status of the patient. Also help reflects whether patient is healthy and if cell populations are within normal limits. >To monitor electrolytes balances and imbalances.

>Continue medications

>For maximum therapeutic effects, and prevention of complications.

>IVTF: PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min PNSS iL @ 30 gtts/min

>It is indicated as a source of water and electrolytes. In general, used for fluid replenishment or medication administration.

>Refer accordingly

>To treat any possible complications or problems. By Dr. Valleja

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