MEDICAL MANAGENT

August 22, 2010

The patient was admitted under the service of Dr. E. he was placed on NPO temporarily for 4
hours then DAT with SAP. The doctor ordered IVF of D5NM 1L to run for 8 hours to be followed by D5LR.
The doctor also ordered the following laboratory exams: CBC, UA, ECG, CXR, Crea, and Trop T.
Medications are as follows: Combivent neb now, Flixotide neb now, Risek 40mg IVP now then OD, and
Ansimar 400mg ½ tab BID. The patient was hooked to oxygen inhalation via nasal cannula at 1-2 LPM.

The doctor ordered to have serous amylase now and to relay result. He also ordered the
following meds: Maalox suspension 1 tbsp every 6 hours, Grendis 30 mg 1 cap BID, Angirel 20mg 1 tab
TID and to continue combivent every 6 hours. The patient was placed on soft diet and to be on complete
bed rest without bathroom privileges. IVF was shifted to KVO. The doctor ordered CPK MB, LDH and to
relay result.

August 23, 2010

The doctor ordered to relay official reading of chest x-ray. He also ordered Hydrocortisone
100mg IV every 8 hours, to shift Risek IV to Ranitidine 50mg IV every 8 hours, and to give combivent neb
PRN only.

August 24, 2010

The doctor ordered to continue meds, and to hook patient to O2 at 2-3 LPM PRN for dyspnea.

August 25, 2010

The doctor ordered to reduce Hydrocortisone 100mg IVP and Ranitidine 50mg IVP to every 12
hours. The patient was instructed on full diet, low salt, low fat. Plasil 10mg IV was given due to presence
of hiccups. Patient was placed on moderate high back rest due to DOB and was given combivent neb for
2 doses due to DOB and occasional wheezes.

August 26, 2010

The doctor ordered to decrease O2 inhalation to 1-2 LPM and to consume Ranitidine IV. He also
ordered Zertin 300mg 1 amp BID due to presence of phlegm.

August 27, 2010

The doctor ordered to give O2 PRN only, and to reduce hydrocortisone 100mg IV to OD starting
tomorrow. He also ordered Seretide inhaler 25mg/125mg 2 puff BID and Spiriva 18mcg 1 cap OD to be
used with handinhaler.

August 28, 2010

The doctor ordered to consume Hydrocortisone IV.

NURSING MANAGEMENT

August 22, 2010

The patient was instructed on NPO for 4 hours then on DAT with strict aspiration precaution. He
was hooked to O2 inhalation via nasal cannula at 1-2 LPM. IVF of D5NM 1L was regulated at 31 gtts/min.
Due meds were given. In the afternoon, the patient was instructed on soft diet. He was also instructed
to be on complete bed rest without bathroom privileges. IVF was regulated at KVO.

August 23, 2010

Patient was encouraged to have adequate rest periods and to verbalize feelings of discomfort
and pain. Due meds were given. IVF of D5LR was regulated at 31 gtts/min. Patient was instructed on soft
diet and to perform deep breathing exercise.

August 24, 2010

Patient was encouraged to verbalize feelings of discomfort and pain. Vital signs were taken and
recorded. Due meds given. O2 inhalation via nasal cannula regulated at 1-2 LPM. IVF of D5LR 1L was
regulated at 31 gtts/min. Instructed patient to perform deep breathing exercise. Head of bed kept
elevated.

August 25, 2010

Patient was instructed on full diet with low salt and low fat. He was placed on moderate high
back rest. O2 inhalation regulated at 2-3 LPM. IVF regulated at same rate. Due meds were given. Patient
was instructed to perform deep breathing exercise. Head of bed kept elevated.

August 26, 2010

Patient was encouraged to have adequate rest periods. O2 inhalation was reduced to 1-2 LPM.
Due meds were given. IVF regulated at same rate. Patient was instructed to maintain adequate
hydration to liquefy secretions.

August 27, 2010

IVF regulated at same rate. Due meds were given. Head of bed kept elevated.