UNIVERSITY OF MINDANAO

MEDICAL CENTER
Nursing Kardex

Name: Nadine A. Lustre Rm/Bed #: Hosp. #: Date and Time of Admission: 9-21-21
Age: 50 y/o Sex: F CS: Address: Physician: James B. Reid, MD
CC: Non-healing wound left foot Admitting Dx: Infected wound, Left foot, CKD 5, DM, CAD, HCVD

Date Diet Date Lab / Diagnostics Date/Time Remarks Date Procedure and Treatment Remarks

9-21-21 Low salt, Low fat 9-21- ➢ CBG NOW 9-21-21 304mg/dl 9-21- ➢ Monitor VS q4
21 then TID @7:50am 21 ➢ I & O shift
@7:50
pre meals ➢ Conferred with Dr.
am
Reid
➢ Blood GCCS
➢ Refer patient to Dr.
x 2 sites
Kris B. Aquino for
➢ Serum
Co-Management,
Creatinine
please inform me
@ 8am
once aware
➢ -Serum
➢ Continue
electrolytes
Old septal wall maintenance
(NA, K, Ca, 9-21-21
@7:50am MI medications:
Mg )
➢ Inform MROD once
➢ -ECG 12
results of labs are in
leads
➢ ABG @ 8am
➢ AV Dupler
Scan of 9-22-
lower Left 21@6 ➢ Rounds with Dr.
foot am Reid
➢ Wound Kleibsella
9-22- ➢ D/C Clindamycin
GSCS done 21@6am pneumoniae,
and Ciprofloxacin
8/19/21 to sensitive to
➢ Proceed on Dupler
await result ciprofloxacin
and of lower extremities
after 72 tomorrow AM
meropenem
hours, refer
9-21- once
21@ 12pm ➢ Please follow up
available foot Xray result
8am
➢ CXR PA ➢ If for debridement,
➢ Lipid profile No objection ID
➢ Blood wise, send intra op
typing @ 9-23- tissue specimen for
8am 21@8 GSCS
➢ -CBC am ➢ Continue
➢ -HBAIC Meropenem
➢ -Serum ➢ Follow-up initial
Albumin blood CS
 ➢ For Xray, ➢ Flamazine dressing
left foot done
APO/L
➢ TT, HTIG

9-22- ➢ CBG CBG 205 mg/dl

21 9-22- ➢ Shift to microset
21@6am
➢ Follow up blood and
wound GSCS
Date IV Fluids Date Medications Remarks ➢ Continue IV
9-21-21 ➢ Venoclysis: 9-21- ➢ Clindamycin 300mg antibiotics
@7:50 PNSS 1L to run 21 1cap TID X 7 days ➢ IVF to KVO
am @ 40cc/hr ➢ Ciprofloxacin 500 ➢ Elevate foot with 1
➢ Decrease mg TID 1 tab BID x to 2 pillows
present IVF to 10 days
9-21-21 KVO rate
@8am Maintenance Meds:

➢ Losartan 100mg 1
tab OD in AM
➢ -Amlodipine 10 mg
1 tab OD in AM
➢ -NACHO3 1 tab TID
➢ Ketoanalogue
600mg 1 tab TID
➢ -EPO 4000 units SQ
2X a week
➢ -Atorvastatin 40 mg
1 tab OD
➢ -CaCO3 500 mg 1
tab TID
➢ -Humulin 70/30 15
units SQ in AM and
10 units SQ in PM

9-22- ➢ Meropenem 1gm IVTT

21 loading dose now then
500mg q 12h

maintenance medications:

➢ -Losartan 100mg 1 tab

OD in AM
➢ -Amlodipine 10 mg 1
tab OD in AM
➢ -NACHO3 1 tab TID
➢ -Ketoanalogue 600mg 1
tab TID
➢ -EPO 4000 units SQ
2X a week
 ➢ -Atorvastatin 40 mg
1 tab OD
➢ -CaCO3 500 mg 1
tab TID
➢ Humulin 70/30 15
units SQ in AM and
10 units SQ in PM

9-23-
21 ➢ NACHO3 1tab to BID
➢ Meropenem 1gm IVTT
loading dose now
then 500mg q 12h

maintenance medications:

➢ -Losartan 100mg 1 tab

OD in AM
➢ -Amlodipine 10 mg 1
tab OD in AM
➢ -NACHO3 1 tab TID
➢ -Ketoanalogue 600mg
1 tab TID
➢ -EPO 4000 units SQ 2X
a week
➢ -Atorvastatin 40 mg 1
tab OD
➢ -CaCO3 500 mg 1 tab
TID
➢ Humulin 70/30 15 units
SQ in AM and 10 units
SQ in PM

➢
 VITAL SIGNS SHEET
Name: Nadine A. Lustre Room No.: Age/Gender: 50 /F Allergies:
Attending Physician: James B. Reid, MD Date: 9-21-21 Birth Date: Patient ID:

ROOM # DATE TIME BP PULSE RESP TEMP REMARKS SIGNATURE

9-21-21 7:50 am 110/80mmhg 99bpm 22cpm 36.5
degree
celcius
 IV FLOWSHEET/ADDITIVES/IV DRUG SUPPORT

Name: Nadine A. Lustre Room No.: Age/Gender: 50 /F Allergies:

Attending Physician: James B. Reid, MD Date: 9-21-21 Birth Date: Patient ID:

DATE IV TIME IV ADDITIVES RATE SIGNATURE TIME REMARKS SIGNATURE

BOTTLE FLUID CONSUMED
NO.
STARTED
September 1 7:50am PNSS 40cc/hr
21, 2021 1L @

PIGGYBACKS:
DATE IV TIME IV ADDITIVES RATE SIGNATURE TIME REMARKS SIGNATURE
BOTTLE STARTED FLUID CONSUMED
NO.
 FLUID BALANCE SHEET
Name: Nadine A. Lustre Room No.: Age/Gender: 50 /F Allergies:
Attending Physician: James B. Reid, MD Date: 9-21-21 Birth Date: Patient ID:
INTAKE OUTPUT
6-2
ENTERAL DRAIN
shift IVF 1 IVF 2 OTHERS BLOOD TPN URINE STOOL OTHERS
TUBE ORAL
7 40cc/hr
8 40cc/hr
9 40cc/hr
10 40cc/hr
11 40cc/hr
12 40cc/hr
1 40cc/hr
2 40cc/hr
TOTAL 320cc
TOTAL per shift: TOTAL per shift:
Sheila C.
Saclot
NOD: SN, UM Balance per shift:
INTAKE OUTPUT
2-10
ENTERAL DRAIN
shift IVF 1 IVF 2 OTHERS BLOOD TPN URINE STOOL OTHERS
TUBE ORAL
3
4
5
6
7
8
9
10
TOTAL
TOTAL per shift: TOTAL per shift:
NOD: Balance per shift:
INTAKE OUTPUT
10-6
ENTERAL DRAIN
shift IVF 1 IVF 2 OTHERS BLOOD TPN URINE STOOL OTHERS
TUBE ORAL
11
12
1
2
3
4
5
6
TOTAL
TOTAL per shift: TOTAL per shift:
NOD: Balance per shift:

FINAL
TOTAL

NOD: 24 hour total INTAKE 24 hour total OUTPUT

24 hour BALANCE
 MEDICATION ADMINISTRATION RECORD

Name: Nadine A. Lustre Room No.: Age/Gender: 50/F Allergies:

Attending Physician: James B. Reid, MD Date: _Sept. 21, 2021 Birth Date: _ Patient ID:
DATE MEDICATION DATE/ 6/21 6/22 6/23 REMARKS
ORDERED TIME
7-21-21 Losartan 100 mg 1 tab 6 am
@7:50 am OD in AM
8am
Amlodipine 10mg 1 tab 6 am
OD in PM
8am
NaHCo3 1-tab TID 6 am

8am
2 pm
10 pm

Atorvastatin 40 mg 1 6 am
tab OD
8am
CaCO3 500 mg 1 tab 6am
TID
8am
2 pm
10 pm
Humulin 70/30 15 units
SQ in AM and 10 units
SQ in PM

Clindamycin 300mg 6 am
1cap TID X 7 days
8am
2pm

10pm

Ciprofloxacin 500 mg 6 am
TID 1 tab BID x 10 days
8am
2pm
10pm
 Ketoanalogue 600mg 1 6am
tab TID
8am
2pm

10pm

EPO 4000 units SQ 2X a

week
Atorvastatin 40 mg 1 6am
tab OD
8am
CaCO3 500 mg 1 tab 6 am
TID
8am
2pm
10pm

Meropenem 500mg 6am

IVTT q 12h
7 am
6 pm

PRN
DATE MEDICATION DATE/ REMARKS
ORDERED TIME

SINGLE ORDER/STAT
Full Name of Staff
DATE MEDICATION DATE/ INITIALS Initials Nurse
ORDERED TIME
GIVEN Sheila C.
September Meropenem 1gm IVTT loading September S.C.S Saclot UM,
22, 2021 dose 22, 2021 @ S.C.S SN
@ 6am 6am

Legend:
1. Please put (*) at the box if medicine is not available/not given; (R) if patient refused medication.
2. Affixing signature for 12 midnight medications should fall on the same date.