KRSITIAN KARL B.

KIW-IS
BSN IV-A
Republic of the Philippines
Department of Health
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
Baguio City

PATIENT’S KARDEX

Diet: NPO temp. Feed: Self Bath: Self Activity: Complete

Assist Partial B.R.P.
To be fed Complete
Ambulatory
 Laboratory B.: U.S. T.P.R. TPR q shift and record
CBC, CXR-APL, U/A Repeat

Vital sign
T° = 39.8°C
RR = 67 cpm
PR = 156 bpm
WT = 75 kg Misc
X-ray I&O
Financial
Stat Orders & Test I.V. Fluids
CBC, CXR-APL, U/A 1.PNSS 1L x 24°
Increase OFI. IVF to follow PNSS 1L x 12 hours

Watch out for DOB, dizziness

For sputum culture this AM.

Standing Order
Allergies
Date Date
Injections Time Medicine Time
Ordered Ordered
February Cefazolin 1 gm IV every 6° 8:00 AM
5, 2021 ANST ( )

Paracetamol 900 mg per IV 8:00 AM

every 4 hours RTC

Amikacin 50 mg IV OD ANST 8:00 AM

()
February Shift cefazolin to cefuroxime 10:00
6, 2021 750 mg IV every 8 hours AM
ANST ( )
KRSITIAN KARL B. KIW-IS
BSN IV-A
Date
TREATMENT
Ordered
Salbutamol 1 nebule + 2cc
February PNSS every 15 minutes for
5, 2021 three doses then every 4 8:00 AM
hours

Suction secretion PRN 8:00 AM

Oxygen inhalation at 3-4
8:00 AM
LPM/NC
TSB PRN for fever
8:00 AM
February Decrease Salbutamol
10:00
6, 2021 nebulization to every 6 hours
AM
Decrease paracetamol 600
mg every 4 hours RTC to
10:00
every 4 hours then PRN for
AM
fever

February 5, 2021
Date
February 6, 2021
Adm.

Name: STEVE ROGERS Hospital Number: 010110

Ward: MEDICAL WARD ( PRIVATE ROOM) Bed No. 12

Dx: PNEUMONIA( BACTERIAL)