UNIVERSITY OF NORTHERN PHILIPPINES

COLLEGE OF NURSING
Website: www.unp.edu.ph

Mail: unp_nursingvc@yahoo.com CP# 09177148749, 09175785986 

DOCTOR’S ORDER AND PROGRESS NOTES SHEET

Name:______________Nathan Delavin__________________Age/Sex/CS:____25/M/S__Ward/Room:__206___
DATE PROGRESS NOTES DOCTOR’S ORDER C A R E D
08-23-21 COMPLAINTS: complaints of
7:00 AM pain in the upper right side of Doctors Order: 
his chest that is 7 out of 10 in Please admit to ROC of choice /
intensity, the patient under the service of Dr. Kho Langot
verbalized “Nasakit unay toy (Orthopedic) Secure consent for /
barukong ko”. admission 
NPO  
VS: Monitor TPR q shift and record  /
BP – 153/74 Please insert a large bore needle PTOR  / /
mmHg  IVF: PNSS 1L x 8 hours  / /
• HR – 112 Dx: CBC 
beats/minute   Serum Electrolytes (Na, K, Mg ,
•RR 22 Cl) 
breaths/minute   Urea, Crea 
• T – 37.9°C  PT, PTT  
• SpO2 – 96% ECG 
with no CXR-AP 
supplemental
Pelvic X-ray 
oxygen.
Left limb X-ray 
Spinal X-ray/ Spinal CT Scan
(plain) 

Treatment: 
Give Tramadol 50 mg IV q 8 / /
hours for pain 
Administer Omeprazole 40 mg IV / /
now then OD in AM
Daily wound dressing  / /
Start Tranexamic Acid 500 mg IV / /
q8 
Please include blood / /
typing and cross matching
in the laboratory request 
Secure 2 units of PRBC / /
(450cc) properly blood
typed, and crosses
matched and transfuse 1
unit once available. 1 unit
for possible OR use 
Give 10 mg IV Diphenhydramine / /
and 300 mg IV Paracetamol 30
mins prior to BT.
Keep the affected leg immobile / /
and maintain splint 
Schedule for ORIF Plating 3 PM / /
today

Skin test Ketorolac / /

30 mg IV and
Cefuroxime 1.5 / /
grams IV 30 mins
prior to ORThen
start Cefuroxime
1.5 grams IV
ANST as loading
dose  
Refer accordingly  /
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  UNP-CN 

UNIVERSITY OF NORTHERN PHILIPPINES COLLEGE OF NURSING Website: www.unp.edu.ph Mail:

unp_nursingvc@yahoo.com CP# 09177148749, 09175785986 

 C–Carried A-Administered R-Requested E-Endorsed D-Discontinued 

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  UNP-CN