Case 2

Mr. G, a 72-year-old male patient was rushed to the Emergency Room of Bukidnon General Hospital at
around 11 o’clock in the evening of September 28, 2021. The witness stated that he was driving his car
when it collided with a 4x4 pick up truck coming in the opposite direction, which had swerved to avoid
the driver who was attempting to overtake. As a result, Mr. G sustained pulmonary contusion in the
diagnostic imaging test and head trauma which leads to the alteration of the level of his consciousness.
He is admitted under the service of Dr. Roa and was referred to Dr. Faller for co-management.

You are the student nurse on duty at Surgical station for that shift (11- 7) for 2 consecutive nights
starting from September 28, 29. You are to receive the admission from the ER and eventually facilitate
referral to the ICU. You become the primary nurse on duty for the particular patient.

Instructions:

Refer to the doctor’s orders provided below to do the following tasks. You may ask assistance of your
Instructor in transcribing/reading the written doctor’s order of the actual chart. Make use of the actual
hospital forms to reflect your output.

1. Carry out admission orders by reflecting it on the chart monitoring sheet:

1.1 Vital signs and Neuro Vitals Signs sheet

1.2 Medication Sheet

1.3 I and O Monitoring sheet

1.4 Oxygen Monitoring sheet

1.5 IVF Sheet

2. Make your nurses notes before the shift will end.

3. Accomplish the patient’s Kardex

4. Prepare a referral note to the ICU.

5. Update the monitoring sheets ( 1.1 to 1.5) as initially started during the admission.

6. Make your nurses notes and endorsement before ending your shift.