Davao Doctors College Nursing Program Progress Notes

Davao Doctors College, Inc.
Gen. Malvar St., Davao City

College of Allied Health Sciences | Nursing Program
PROGRESS NOTES DOCTORS ORDER RATIONALE

February 15, 2021 Please admit under the service of
@ 9:45 AM Dr. Dumaguit.
 Secure consent to care  The informed consent
(+) bilateral edema process makes sure that
@ lower extremities your health care provider
BP= 140/90 has given you information
No BM for 4 3 days about your condition along
(+) spider angioma with testing and treatment
options before you decide
what to do.
 LSLF diet  It is often recommended to
limit sodium to 2,000 mg a
day. Ascites is an
accumulation of fluid in the
abdominal area. Lowering
the sodium, you eat will
lessen your body's tendency
to retain fluid.
 V/S q4/ I&O qS  To obtain baseline data of
VS and monitor condition of
patient intake and output
until stable.
 IVF w/ PNSS 1L @ KVO  Prescription medicine used

for fluid and electrolyte
replenishment for
intravenous administration.
 WOF Unusualities.
Daily abdominal girth  Important precaution used to

Measurement diagnose and monitor the
following: Buildup of fluid in
the abdomen, most often
caused by liver failure, heart
failure, or any cancer that
has spread widely
throughout the abdomen.
LABORATORIES:
CBC  Ordered to evaluate a
person's red and white blood
cells and platelets; anemia
may be present if bleeding
has occurred, and platelets
are often decreased
with cirrhosis.
U/A
 Urinalysis (Midstream
Clean Catch). Used for a
routine urinalysis, urine
culture, or other urine test
that require
uncontaminated urine for
accurate result.
CXR-PA  Posteroanterior chest x-ray

view examines the lungs,
bony thoracic cavity,
mediastinum and great
LP vessels.
 Lipid profile parameters can
use in all the cirrhotic
patients to assess severity
of disease.
SGPT  SGPT means Serum

Glutamic Lactulose 30cc
OD qHS Pyruvic
Transaminase. This test is
done to measure the
amount of Glutamate
Pyruvate Transaminase
(GPT) in blood serum.
BUA  This test measures the
amount of uric acid in your
blood or urine.
SERUM CREATININE  Elevation in serum
creatinine is a common
laboratory finding for
patients with cirrhosis and
can indicate the presence
of either an acute kidney
injury (AKI) or chronic
kidney disease (CKD).
ECG 12 LEADS  To assess your heart
rhythm, diagnose poor
blood flow to the heart
muscle (ischemia),
diagnose a heart attack,
and diagnose abnormalities
of your heart, such as heart
chamber enlargement and
abnormal electrical
conduction.
MEDICATIONS
Spironolactone 25mg 1Tab OD
Furosemide 40mg IVTT q12 hrs
w/ BP precautions
Calmoseptine cream apply tom
affected area
Losartan 50mg 1tab OD @ AM
FeSO4 1tab OD @ AM
Paracetamol 1tab q4 PRN
February 15, 2021  Increase Furosemide to 40mg

@ 12:30 PM IVTT q8 hrs w/ BP precaution
(+) Ascites (hold if BP < 100mmHg)
 Increase Spironolactone
25mg/tab 1tab BID
 Clindamycin 300mg IVTT q6

hrs
 VSq4/I&O qS  To obtain baseline data of

VS and monitor condition of
patient intake and output
until stable
 Refer accordingly  To have accurate
documentation and
assessment.
February 16, 2021  For CT scan w/ contrast of  Help highlight the areas of
1: 25 PM whole abdomen your body being examined.
 HBsAg  Hepatitis B surface antigen
(HBsAg) is a blood test
ordered to determine if
someone is infected with the
hepatitis B virus. If it is
found, along with specific
antibodies, it means the

person has a hepatitis B
infection.
 For ultrasound of whole  It is used to help diagnose
abdomen w/ marking for pain or distention
paracentesis (enlargement) and evaluate
the kidneys, liver,
gallbladder, bile ducts,
pancreas, spleen and
abdominal aorta.
 Shift IV to Heplock  This medication is used to
keep IV catheters open and
flowing freely. Heparin helps
to keep blood flowing
smoothly and from clotting in
the catheter by making a
certain natural substance in
your body (anti-clotting
protein) work better.
 For possible paracentesis  Performed to obtain a small
sample of or drain ascitic
fluid for both diagnostic or
therapeutic purposes.
February 17, 2021  For whole abdomen CT scan

as OPD
 Paracentesis Done  Test used to detect bacteria
in a sputum sample.
 Diagnostics:  It is a urine test that
Bottle 1: GS/CS measures the amount of
Bottle 2: Sugar, Albumin albumin in your urine.
Bottle 3: Cell differential, cell  Describing populations of
count white blood cells in
peripheral blood
 Apply abdominal binder  Helps to reduce
postoperative pain, distress,
and hemorrhage after
operation.
 Decrease Furosemide 20mg
IVTT q8 Hypotension
 Vit. K 10mg IVTT q8x 3
 Continue current  To have effective nursing

management and medical intervention.
 WOF: Bleeding, Hypotension  This is for further precaution.
Also, to prevent bleeding
and hypotension.
 Refer accordingly  For accurate documentation
 Transfer back to ward and management.
II. LABORATORY/DIAGNOSTIC EXAMINATIONS
PROCEDURE PURPOSE NORMAL RESULT NURSING

RANGE MANAGEMENT
Urinalysis: A urinalysis is Volume: 600 to Color: Light 1.) Instruct the
February 15, used to detect 2500 mL in 24 Yellow patient to void
2021 @ 11:00 and manage a hours, Transparency: directly into a clean,
AM wide range of Color: Pale Hazy dry container.
disorders, such yellow to Sp. Gravity: Sterile, disposable
as urinary tract amber, 1.01 0 containers are
infections, Transparency: Ph: 6.0 recommended.

kidney disease clear to slightly Sugar: Negative Women should
and diabetes. A hazy, Albumin: always have a
urinalysis Specific gravity: Negative clean-catch
involves 1.005 to 1.025 RBC:2-5 /hpf specimen if a
checking the with a normal Pus Cells: 2- microscopic
appearance, fluid intake, 5/hp examination is
concentration pH: 4.5 to 8, Bacteria: ordered. Feces,
on and content Albumin: MANY/hpf discharges, vaginal
of urine. negative, Epithelial Cells: secretions and
Glucose: Moderate/hpf menstrual blood will
negative, Mucus threads: contaminate the
Blood: Few /hpf urine specimen.
negative, Cast remarks: 2.) Collect
Protein: WBC +++ specimens form
negative, infants and young
Bilirubin: children into a
negative, disposable
Nitrate for collection apparatus
bacteria: consisting of a
negative, plastic bag with an
Casts: adhesive backing
negative, around the opening
occasional that can be
hyaline casts, fastened to the
Red blood perineal area or
cells: negative around the penis to
or rare, permit voiding
Crystals: directly to the bag.
negative or Depending on
none, hospital policy, the
White blood collected urine can
cells: negative be transferred to an
or rare appropriate
Epithelial cells: specimen
few; hyaline container. 3.) Cover
casts: 0-1/lpf all specimens
tightly, label
properly and send
immediately to the
laboratory. 4.) If a
urine sample is
obtained from an
indwelling catheter,
it may be necessary
to clamp the
catheter for about
15-30 minutes
before obtaining the
sample. Clean the
specimen port with
antiseptic before
aspirating the urine
sample with a
needle and a
syringe. 5.)
Observe standard
precautions when
handling urine
specimens.
6.) If the specimen
cannot be delivered
to the laboratory or
tested within an
hour, it should be
refrigerated or have
an appropriate
preservative added.
Chest X-ray: It is an imaging Hollow Negative Nursing

February 02, test that uses structures cardiopulmonary interventions prior
X-ray s to look containing nary findings. to chest x-ray:
2021 @ 1:00
at the mostly air, Elevated dome 1.) Remove all
PM
structures and normally of the right metallic objects.
organs in your appear dark. In hemidiaphragm. Items such as
chest. It can a normal chest Considerations jewelry, pins,
help your X-ray, the chest are: buttons etc. can
healthcare cavity is Diaphragmatic hinder the
provider see outlined on muscle and visualization of the
how well your each side by phrenic nerve chest.
lungs and heart the white bony pathology. 2.) No preparation
are working. structures that is required. Fasting
Certain heart represent the or medication
problems can ribs of the chest restriction is not
cause changes wall. On the top needed unless
in your lungs. portion of the directed by the
Certain chest are the health care
diseases can neck and the provider.
cause changes collar bones 3.) Ensure the
in the structure (clavicles). On patient is not
of the heart or the bottom, the pregnant or
lungs. chest cavity is suspected to be
bordered by the pregnant. X-ray s
diaphragm are usually not
under which is recommended for
the abdominal pregnant women
cavity. On unless the benefit
either side of outweighs the risk
the chest wall, of damage to the
the bones of mother and fetus.

the shoulders 4.) Assess the
and arms are patient’s ability to
easily hold his or her
recognizable. breath. Holding
Inside the chest one’s breath after
cavity, the inhaling enables the
vertebral lungs and heart to
column can be be seen more
seen down the clearly in the x-ray.
middle of the 5.) Provide
chest, splitting appropriate
it nearly in clothing. Patient is
equal halves. instructed to
On each side of remove clothing
the midline, the from the waist up
dark appearing and put on an X-ray
lung fields are gown to wear
seen. The white during the
shadow of the procedure.
heart is in the 6.) Instruct patient
middle of the to cooperate during
field, atop the the procedure. The
diaphragm, and patient is asked to
more to the left remain still because
side. The any movement will
trachea affect the clarity of
(windpipe), the image. Nursing
aorta (main interventions after
blood vessel chest x-ray 1.)
exiting the Nonspecial care.
heart), and the Note that no special
esophagus care is required
descend down following the

the middle, procedure.
overlapping the 2.) Provide comfort.
vertebral If the test is
column. facilitated at the
bedside, reposition
the patient properly.
CBC: February It is a test that Hemoglobin: Hemoglobin g: 1. Explain test

15, 2021 @ evaluate the 12.0-16.5 g/dl 8.5 g/dl ( ) procedure. Explain
1:00 PM cells that Hematocrit:3 8- Hematocrit: that slight
circulate in 54% Red Cell 25.5%( ) Red discomfort may be
blood and can Count:4.2-6. cell count: felt when the skin is
evaluate your 2x105 ul White 3.64x105ul ( ) puncture.
overall health blood Cell:5.0- White blood 2. Encourage to
and detect a 10.0 x103ul cell:8.7x103 avoid stress if
variety of Platelet ul(normal) possible because
diseases and count:150,00 0- Platelet count: altered physiologic
conditions, 450,000 ul 432,000ul status influences
such as Differential (normal) and changes
infections, Count: Segmenters : normal hematologic
anemia and Segmenters: 76%( ) values.
leukemia. 55-65% Lymphocyte 3. Explain that
Lymphocytes: s:18%( ) fasting is not
25-35% Monocytes: 6% necessary.
Monocytes: 2- ( ) However, fatty
4% meals may alter
some test results as
a result of lipidemia.
4. Apply manual
pressure and
dressings over
puncture site on
removal of dinner.
5.Monitor the
puncture site for
oozing or
hematoma
formation.
6. Instruct to
resume normal
activities and diet.
ECG: February A medical test Normal sinus Interpretation: Prior the procedure
2, 2021 @ 8:00 that detects rhythm each P Sinus 1. Explain the
AM heart problems wave is Tachycardia procedure to the
by measuring followed by a patient. Inform the
the electrical QRS P waves patient that
activity normal for the echocardiography
generated by subject P wave is used to evaluate
the heart as it rate 60 - 100 the size, shape,
contracts. bpm with and motion of
various cardiac
structures. Tell who
will perform the
test, where it will
take place, and that
it’s safe, painless,
and is noninvasive.
2. No special
preparation is
needed. Advise the
patient that he
doesn’t need to
restrict food and
fluids for the test.
3. Ensure to empty
the bladder. Instruct
patient to void prior
and to change into
a gown.
4. Encourage the
patient to
cooperate. Advise
the patient to
remain still during
the test because
movement may
distort results. He
may also be asked
to breathe in or out
or to briefly hold his
breath during the
exam.
5. Explain the need
to darkened the
examination field.
The room may be
darkened slightly to
aid visualization on
the monitor screen,
and that other
procedure (ECG
and
phonocardiography)
may be performed
simultaneously to
time events in the
cardiac cycles.
6. Explain that a
vasodilator (amyl
nitrate) may be
given. The patient
may be asked to
inhale a gas with a
slightly sweet odor
while changes in
heart functions are
recorded.
During the
Procedure:
1. Inform that a
conductive gel is
applied to the chest
area. A conductive
gel will be applied
to his chest and
that a quarter-sized
transducer will be
placed over it. Warn
him that he may
feel minor
discomfort because
pressure is exerted
to keep the
transducer in
contact with the
skin.
2. Position the
patient on his left
side. Explain that
transducer is
angled to observe
different areas of
the heart and that
he may be
repositioned on his
left side during the
procedure.
After the procedure:
1. Remove the
conductive gel from
the patient’s skin.
When the
procedure is
completed, remove
the gel from the
patient’s chest wall.
2. Inform the patient
that the study will
be interpreted by
the physician. An
official report will be
sent to the
requesting
physician, who will
discuss the findings
with the patient.
3. Instruct patient to
resume regular diet
and activities.
There is no special
type of care given
following the test.
Whole Imaging of the Organs should Impression: Before exam:

Abdomen abdomen uses not inflame -Liver cirrhosis 1. You must not eat
Ultrasound: sound waves to (normal) -Moderate to or drink for eight
February 17, produce massive ascites hours before your
2021 @ 10:00 pictures of the -Subcutane ous exam. Water and
AM structures edema of the taking medication is
within the anterior wall of okay.
upper the abdmen. 2. If ultrasound
abdomen. It is -Bilateral renal pelvis is also being
used to help parenchyma l done, for female
diagnose pain disease. patients, please
or distention -Mild drink 32 ounces of
(enlargement) hydronephrosis water one hour
and evaluate and hydro- before the scan.
the kidneys, ureter, left to You can go to the
liver, rule out a distal bathroom to relieve
gallbladder, bile ureteral yourself, as long as
ducts, obstructing you keep drinking
pancreas, calculus. water. Male
spleen and -Normal patients do not
abdominal ultrasound of the need to have a full
aorta. GB, pancreas bladder.
and spleen. 3. If your doctor
gave you an order,
please bring it with
you.
During exam:
1. You will be asked
to change into a
gown.
2. A diagnostic
medical
sonographer will
explain your exam
and answer any
questions you may
have.
3. Your procedure
will be performed
with you lying flat
on your back on the
examination table.
4. Your exam will
take between 30
and 45 minutes.
After exam:
5. You may resume
your regular diet,
unless told
otherwise by your
doctor.
6. Your study will
be reviewed by an
imaging physician
and the results sent
to your doctor. Your
doctor will discuss
these results with
you and explain
what they mean in
relation to your
health.

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Davao Doctors College, Inc.

Gen. Malvar St., Davao City

PROGRESS NOTES DOCTORS ORDER RATIONALE

 IVF w/ PNSS 1L @ KVO  Prescription medicine used

Daily abdominal girth  Important precaution used to

CXR-PA  Posteroanterior chest x-ray

SGPT  SGPT means Serum

February 15, 2021  Increase Furosemide to 40mg

 Clindamycin 300mg IVTT q6

 VSq4/I&O qS  To obtain baseline data of

antibodies, it means the

February 17, 2021  For whole abdomen CT scan

 Continue current  To have effective nursing

II. LABORATORY/DIAGNOSTIC EXAMINATIONS

PROCEDURE PURPOSE NORMAL RESULT NURSING

infections, Transparency: Ph: 6.0 recommended.

Chest X-ray: It is an imaging Hollow Negative Nursing

the bones of mother and fetus.

descend down following the

CBC: February It is a test that Hemoglobin: Hemoglobin g: 1. Explain test

Whole Imaging of the Organs should Impression: Before exam:

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