COURSE IN THE WARD

Date and Time Focus Doctor’s Order Nurses note

August 28, 2018 Admission Please secure consent D: seen and examined by Dr.
3:50PM for admission and V with admitting orders made,
management initial VS taken and recorded
Vital Signs: Please admit to as follows.
T: 36.2 medical ward
BP: 150/90mmHg A: carried out Doctor’s order,
To monitor intake and
PR: 98bpm consent for hospitalization
output every shift and
RR: 26cpm secured, admission care
record
rendered, heplock inserted
(+) DOB VS every 4 hours and
aseptically, low salt diet
(+) Edema record
advice
Low salt Diet (Of
limited and 700cc)
Diagnostics DIAGNOSTICS: D: chest xray, BUN, crea,
CBC, Na, K, Ca, ALT and
Chest X-ray
AST
CBC
Na, K, Ca
AST, ALT
BUN, Creatinine
TREATMENT:
Hook to heplock
Furosemide 4g IV
every 12 hours
Start Digoxin 0.25g 1
tab OD
Start aspirin 8g 1 tab
OD
Omeprazole 4g 1 tab
OD
Refer accordingly

D: transferred to ward
Transfer accompanied by IW and
watcher
5PM Post D: received patient from ER
Admission via wheelchair, weak in
Care appearance conscious and
coherent with intact
venoclysis
A: assisted to bed
comfortably, VS taken and
recorded, needs attended
due meds started and inform
Dr. B regarding admission
5:45PM DIAGNOSTICS:
CC: DOB
2D echo – January c/o
watcher ------
 scheduled for
determine for albumin
TREATMENT:
D/c aspirin
Plan to start warfarin
once patient D/c
omeprazole
Digoxin 0.25mg 1 tab
OD
Monitor intake and
output
10:25PM Start warfarin 5g 1 tab
OD
Possible phlebotomy
CBC in am
T/c TOF
T/c pulmonary stenosis
Rounds with Dr. D
D/c furosemide
Start spironolactone
25g 1 tab OD
For 2Decho
D/c warfarin
August 29, 2018 Continuity of DIAGNOSTICS: D: on bed, conscious not in
10AM Care distress
Refer 2Decho
Vital Signs: A: monitored, advised to limit
TREATMENT:
BP: 120/80mmHg strenuous activity
PR: 85bpm Digoxin 0.25mg 1 tab
R: understood
OD
500mL – Input Spironolactone 25g 1
200mL – Output tab OD

Decreased Edema
(+) DOB

3PM Continuity of D: on bed awake with O2

Care support
A: health needs attended due
meds given, VS taken and
monitored
11PM D: lying, (-) DOB and chest
pain
A: keep rested with O2
August 30, 2018 Continuity of DIAGNOSTICS: D: on bed, sitting (-) DOB and
12:50PM Care chest pain, for 2Decho as
For 2Decho
ordered, rounds done by Dr.
Vital Signs: TREATMENT: B
BP:
140/110mmHg Heplock A: monitored, attended health
PR: 87bpm Digoxin 0.25mg 1 tab needs and facilitated 2Decho
OD
Intake – 700mL Spironolactone 25g 1
Output – 1,000mL tab OD
 Monitor intake and
output
3PM Continuity of D: on bed, (-) DOB
Care
A: meds given
11PM Monitoring D: conscious
A: meds attended
August 31, 2018 Continuity of DIAGNOSTICS: D: on bed, heplock
12NN Care
For 2Decho A: due meds given, health
Vital Signs: needs attended
TREATMENT:
BP: 130/100mmHg D: for Na, P and Ca in AM
PR: 84bpm Start aspirin 8mg 1 tab
OD A: request forwarded
Intake – 1,200mL Digoxin 0.25mg 1 tab
Output – 1,300mL D: for phlebotomy
OD
Decreased Edema Spironolactone 25g 1 A: coordinated with laboratory
tab OD department
(+) DOB
For phlebotomy
Follow up:
Crea, K
5:45PM S/p phlebotomy 500cc
PNSS 400cc infused
CBC in morning
6PM D: phlebotomy done, for CBC
in AM
A: forwarded
11PM D: hooked to O2 support via
nasal cannula (4lpm)
A: continuously monitored
and needs attended
September 1, Continuity of DIAGNOSTICS: D: on bed with intact IV line
2018 Care (heplock)
For 2Decho
Vital Signs: A: monitored, needs attended
TREATMENT:
BP: 130/90mmHg due meds given
PR: 70bpm D/c aspirin
R: awaits accordingly
Continue Digoxin
(-) DOB 0.25mg 1 tab OD and
Decreased Edema Spironolactone 25g 1
tab OD
Intake - 700
Output – 800
4PM D: on bed, lying with O2
A: maintained O2 via Nasal
Cannula 4lpm
11PM D: received ambulatory, (-)
DOB
A: continuously monitored,
encouraged to sleep
September 2, May go home D: may go home
2018 For WAB as OPD
8:45AM A: facilitated discharge
For 2Decho as OPD
Retrieve CD of
January 2Decho c/o
patient
Limit oral fluid intake to
1-1.5L/drink (watch out
for edema and DOB)
Ff. September 3 for the
CD
Ff. September 7 2pm
at the OPD
HOME MEDS:
Digoxin 0.25mg 1 tab
OD
Spironolactone 25g 1
tab OD
2:40PM D: may go home with settled
bills
A: IV line removed, home
meds ordered and Follow up
check-up carried
R: went home