ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

July 10, 2021

Date Admitted: _____________ Ambulatory
Mode of Admission: ___________ PhilHealth
HMO: __________ 20873
Hospital No. ______
Level of Care Needed: ( ) Minimal ( / ) Moderate ( ) Intensive ( ) Critical Care
None
Allergies to Food/Drug*: _________________ B
Blood Type*: _______ Positive
Rh: _______________ K.T.
RN Sig: __________
Nutrition/Diet Contraption Started: Disc* Others:
Frequently ordered items: Activities:
:

Temp: 38.6C (q2h) CR: Others: ( ) CBR (/) IVF Lines 02@ ___L/min

PR: 115 bpm (q2h) BP: 130/80 mmHg ( ) Assisted ( ) NGT ( ) Cannula
(q2h)

RR: 23 cpm (q2h) MIO: (/) Ambulatory ( ) Urinary Cath ( ) Face Mask

WT: 80 kg ( ) Respirator

Date & Time

Date/Time Diagnostic, Laboratories, Procedures &
Date/Time R.N R.N Date/Time R.N
Ordered Medications Timing Carried
Sig. Sig. Taken/Done Sig
Out Ordered
Carried Referrals
Out

7/10/21 Tramadol 100 mg Q6H for 2 days 8-2-8-2 7/10/21 K.T. 7/10/21 7/10/21 K.T. CT Scan of abdomen 7/10/21 K.T.

Metoclopramide (Plasil) 10 mg IV Q8H for 5

7/10/21 8-4-12 7/10/21 K.T. 7/10/21 7/10/21 K.T. Plain Chest X-ray 7/10/21 K.T.
days

Ciprofloxacin 400 mg IV Q8H for 5 days. IV

7/10/21 8-4-12 7/10/21 K.T. 7/10/21 7/10/21 K.T. Ultrasound 7/10/21 K.T.
ANST (-)

Metronidazole 500 mg/100ml IV infusion 5

7/10/21 8 7/10/21 K.T. 7/10/21 7/10/21 K.T. CBC 7/10/21 K.T.
ml/minute for 2 days. IV ANST (-)

Omeprazole 40 mg vial dissolved in 100 ml

7/10/21 through IV infusion for 20-30 minutes for 2 8 7/10/21 K.T. 7/10/21 7/10/21 K.T. Biochemical Analysis 7/10/21 K.T.
days.

7/14/21 Octreotide 50 mcg for 2 weeks, thrice a day 8-1-6 7/14/21 K.T. 7/10/21 7/10/21 K.T. LDH 7/10/21 K.T.
Kiara Denise Tamayo
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

IV.

Piperacillin – Tazobactam 4.5g TID IV

7/14/21 8-1-6 7/14/21 K.T. 7/10/21 7/10/21 K.T. Glucose Test 7/10/21 K.T.
ANST (-)

PRN 7/10/21 7/10/21 K.T. Adenosine Deaminase (ADA) Test 7/10/21 K.T.

07/13/21 Tramadol 100 mg Q6H PRN for pain 07/13/21 K.T. 7/10/21 7/10/21 K.T. Pleural Fluid Cultures 7/10/21 K.T.

Metronidazole 500 mg /100 ml Intravenous

infusion OD 5 ml /minute PRN
07/13/21 07/13/21 K.T 7/10/21 7/10/21 K.T. Ascitic fluid Analyses 7/10/21 K.T.
ANST (-)

Mrs. V.S. Dr. Salazar

7/10/21 7/10/21 K.T. Amylase and Lipase Test Severe Abdominal Pain7/10/21 K.T.
F Married Roman Catholic
7/10/21 7/10/21 K.T. Blood urea nitrogen (BUN) 7/10/21 K.T.
58 April 6, 1963 Dr. Salazar
Brgy. Salong, Balasan, Iloilo K.T.
7/10/21 7/10/21 K.T. Creatinine Test 7/10/21 K.T.

7/10/21 7/10/21 K.T. Thoracentesis 7/10/21 K.T.

7/12/21 7/12/21 K.T. Thoracentesis 7/12/21 K.T.

7/14/21 7/14/21 K.T. Thoracentesis 7/14/21 K.T.

Insert Left-sided underwater seal intercostal

7/14/21 7/14/21 K.T. 7/14/21 K.T.
drainage tube.

Patient Name: _______________ Physician: _____________ Chief Complaint: _______________________

Sex: ___ CS: ________ Religion: ______________
Age: ____ Date of Birth: _______________ Resident on Duty/in Charge: ___________ Impression: ___________________________
Address: ____________________________________ Primary Nurse: ______
Kiara Denise Tamayo
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

(* Red Ink) Department/ Room No.: ____

Name: Mrs. V.S Name: Mrs. V.S Name: Mrs. V.S Name: Mrs. V.S Name: Mrs. V.S
RM: 233 RM: 233 RM: 233 RM: 233 RM: 233
Physician: Dr. Salazar Physician: Dr. Salazar Physician: Dr. Salazar Physician: Dr. Salazar Physician: Dr. Salazar

RX
#1 Lactated Ringer’s 1 L x 25
gtts/min for hydration.
7:30-3:30
RX RX RX RX
Metoclopramide (Plasil) 10 Ciprofloxacin 400 mg IV Metronidazole 500 mg /100 Omeprazole 40 mg vial
mg IV Q8H for 5 days. Q8H for 5 days ml Intravenous infusion OD 5 dissolve in 100 ml through IV
8-4-12 ANST (-) ml /minute for 2 days infusion for 20-30 minutes for
8-4-12 ANST (-) 2 days.
8 8

Flaggings:
07/10/21 K.T. 07/10/21 K.T. 07/10/21 K.T. 07/10/21 K.T. 07/10/21 K.T.

Name: Mrs. V.S Name: Mrs. V.S Name: Mrs. V.S Name: Mrs. V.S Name: Mrs. V.S
RM: 233 RM: 233 RM: 233 RM: 233 RM: 233
Physician: Dr. Salazar Physician: Dr. Salazar Physician: Dr. Salazar Physician: Dr. Salazar 233 Dr. Salazar
Physician:

RX RX RX RX RX
Octreotide 50 mcg for 2 Piperacillin-tazobactam 4.5g Tramadol 100 mg Q6H for 2 NPO Thoracentesis
weeks thrice a day thrice a day intravenously. days. Insert Left- sided underwater
intravenously. ANST (-) 8-2-8-2 seal intercostal drainage tube.
8-1-6 8-1-6

07/10/21 K.T.
07/10/21 K.T. 07/12/21 K.T.
07/10/21 K.T. 07/10/21 K.T. 07/10/21 K.T. 07/14/21 K.T.

Kiara Denise Tamayo

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

Name: Mrs. V.S Name: Mrs. V.S Name: Mrs. V.S Name: Mrs. V.S Name: Mrs. V.S
RM: 233 RM: 233 RM: 233 RM: 233 RM: 233
Physician: Dr. Salazar Physician: Dr. Salazar Physician: Dr. Salazar Physician: Dr. Salazar Physician: Dr. Salazar

RX RX RX RX RX
/CT scan of abdomen /Ascitic fluid analyses /LDH Tramadol 100 mg Q6H PRN Metronidazole 500 mg /100
/Plain Chest X-Ray /Amylase and Lipase tests /Glucose test for pain. ml Intravenous infusion OD 5
/Ultrasound /Blood urea nitrogen /Adenosine Deaminase ml /minute PRN
/CBC (BUN) (ADA) ANST (-)
/Biochemical Analysis /Creatinine tests /Pleural Fluid Cultures
/Serum Troponin test

07/10/21 K.T.
07/10/21 K.T. 07/10/21 K.T. 07/13/21 K.T. 07/13/21 K.T.

Kiara Denise Tamayo

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

NURSING SERVICE - KARDEX

Kiara Denise Tamayo