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  • Surgery Ward 3 Phase 3

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    Ryrey Abraham Pacamana
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    The patient was on the AM shift from 7AM to 3PM. At 7AM the patient's vital signs were taken and they reported a pain level of 7/10. Throughout the day doctors visited and provided orders to the patient. The orders included removing the NGT at 7:50AM, starting a soft diet, continuing medications, monitoring vital signs, bladder training then removing the IFC at 2:45PM, and referring the patient accordingly. Additional orders included starting new medications, decreasing CBG checks, following up IV fluids, completing other medications, and removing a BT line at 10:35PM. The patient's pain level decreased to 4/10 by the end of the shift and their vital signs and intake

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    The patient was on the AM shift from 7AM to 3PM. At 7AM the patient's vital signs were taken and they reported a pain level of 7/10. Throughout the day doctors visited and provided orders to the patient. The orders included removing the NGT at 7:50AM, starting a soft diet, continuing medications, monitoring vital signs, bladder training then removing the IFC at 2:45PM, and referring the patient accordingly. Additional orders included starting new medications, decreasing CBG checks, following up IV fluids, completing other medications, and removing a BT line at 10:35PM. The patient's pain level decreased to 4/10 by the end of the shift and their vital signs and intake

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    27 views4 pages

    Surgery Ward 3 Phase 3

    Uploaded by

    Ryrey Abraham Pacamana
    The patient was on the AM shift from 7AM to 3PM. At 7AM the patient's vital signs were taken and they reported a pain level of 7/10. Throughout the day doctors visited and provided orders to the patient. The orders included removing the NGT at 7:50AM, starting a soft diet, continuing medications, monitoring vital signs, bladder training then removing the IFC at 2:45PM, and referring the patient accordingly. Additional orders included starting new medications, decreasing CBG checks, following up IV fluids, completing other medications, and removing a BT line at 10:35PM. The patient's pain level decreased to 4/10 by the end of the shift and their vital signs and intake

    Copyright:

    © All Rights Reserved
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    Flag for inappropriate content
    of 4

    PHASE 3

    OCTOBER 28, 2021

    YOUR SHIFT IS AM SHIFT (7AM-3PM)

    At 7AM. You visited the patient, the complaint is pain on operative site with PAIN SCALE of 7/10

    INITIAL V/S BP: 140/90 PR:83 RR:19 TEMP:37.8C O2 Sat:99% GCS 15/15

    At 7:30AM. Dr. Viado visited the patient and gave doctor’s order.

    At 8AM. Dr. Butardo visited the patient and gave doctor’s order.

    At 10:30AM. Dr. Plete visited the patient and gave doctor’s order.

    At 12:00PM. Vital Signs: BP:130/80 PR:98 RR:18 TEMP:37.0C CBG:189mg/dl O2 Sat:99%

    At 3PM. You assessed the patient condition. With bearable pain at post op-site, Pain scale of 4/10 Latest
    VS: BP: 130/90 PR:96 RR:16 TEMP:37.3C O2 Sat:99% GCS 15/15

    The patient’s intake and output:

    Intake: IVF consume: (COMPUTE) MAIN line L2:104cc Oral intake:980cc

    Output: Urine IFC:(1830cc) stool: once jp:67cc

    ACTIVITY REQUIREMENTS: 1 NCP, 1 DRUGSTUDY, FILL UP PATIENT’S CHART, MEDICATION CARDS, VS


    DAILY.

    ------------------------------------------------------------------------------------------------------------------------------------------

    DOCTORS ORDER

    10/28/2021

    7:30AM

    >remove NGT (remove NGT at 7:50AM)

    >soft diet

    >Continue meds

    >NVS Q shift

    >IFC Bladder training (started at 7:35AM) then remove IFC (remove IFC at 2:45PM)

    >Refer accordingly
    DR. VIADO

    8AM

    Feboxustat 40mg/tab, 1 tab OD PM (to start at 12PM)

    Losartan 50mg/tab, 1 tab OD AM (to start at 8:35AM)

    Decrease CBG to TID PRE-MEALS

    DR. BUTARDO

    10:30AM

    >Follow up IVF PNSS1L for 20 hours after consume of D5NM.

    >To complete other meds.

    >remove BT LINE.(REMOVE BT LINE AT 10:35PM)

    DR. PLETE
    Date Progress
    TIME POSTED
    Doctor’s Order AND
    And time Notes SIGNATURE

    10/28/2021 ⮚ remove NGT (remove NGT at 7:50AM)


    ⮚ soft diet
    7:30AM
    ⮚ Continue meds
    ⮚ NVS Q shift
    ⮚ IFC Bladder training (started at 7:35AM) then
    remove IFC (remove IFC at 2:45PM)
    ⮚ Refer accordingly

    DR. VIADO

    ⮚ Feboxustat 40mg/tab, 1 tab OD PM (to start at


    12PM)
    ⮚ Losartan 50mg/tab, 1 tab OD AM (to start at
    8AM 8:35AM)
    ⮚ Decrease CBG to TID PRE-MEALS
    DR. BUTARDO

    ⮚ Follow up IVF PNSS1L for 20 hours after consume


    of D5NM.
    ⮚ To complete other meds.

    ⮚ remove BT LINE.(REMOVE BT LINE AT 10:35PM)


    DR. PLETE
    10:30AM

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