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Therapeutic Management

Date/Time August 16, 2010 Order DAT(Diet As Tolerated) Significance Patients that are newly admitted will be given a diet that he/she can tolerate. 9:45 pm CBC(Complete Blood Count) done This test is a protocol in the hospital, this is to check the blood components and to diagnose certain problems.

Start Venoclysis PNSS 1L @ 90cc/hr

IV administration is performed to replace fluids, administer medications and to provide water and electrolyte.

Intake and Output cc/cc q shift and record.

This is to monitor closely the intake and output of the patient. It will allow the health team to identify if the patients systems concerning excretion and absorption is functioning well

Laboratory 4am tomorrow CCBC, Serum Creatinine, SGPT, Alkaline Phosphatase, PT/APTT, Lipid profile blood typing

For baseline data and to diagnose other complications and disorders that can be seen through the results of the laboratory exams.

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ECG(Electrocardiogram) now

Is a transthoracic interpretation of the electrical activity of the heart over time captured and externally recorded by skin electrodes.

Secure 1 unit PRBC

To be used for blood transfusion.

Bed Rest

To strengthen the bodys immune system. To condition the body for blood transfusion.

August 17, 2010

Serve another 1 unit PRBC of patients blood type divided into 2 aliquot.

Patient is transfused with blood because he has a low level of Hemoglobin.

2 am

Transfuse 1 aliquot in 2 hours. Increase VS monitoring to q30 minutes while on BT. Refer for congestion and any transfusion reaction.

For close monitoring of the condition of the patient. To monitor if there are allergic reactions within the transfusion of blood.

3:55 pm

O2 inhalation 2Lpm per nasal cannula.

This is indicated to patient since he is having difficulty of breathing.

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August 18, 2010

Decrease IVF to 50cc/hr.

IVF is decreased since patient has already a satisfactory hydration status.

5 pm Transfuse recorded 1 aliquot PRBC for 2 hours. IVF to KVO while BT is ongoing. Secure 2 units PRBC (pts blood type) cross matched. (standby) Blood should be transfused within 2 hours because there is a possibility that the blood will be destroyed. IVF is placed on KVO to facilitate the transfusion of blood. PRBC is secured and standby for the next blood transfusion. Transfuse 1 unit PRBC in AM for 2 hours. Monitor VS and refer for unusualities.

August 19, 2010

Patient is transfused with PRBC many times since he is anemic. His hemoglobin level is very low. His last result is 42.

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