CENTRO ESCOLAR UNIVERSITY

SCHOOL OF NURSING
RECORDING SHEET

KARDEX
DATE INTRAVENOUS FLUID + SIDE DATE MEDICINE DOSAGE
DRIP AND TPN FREQUENCY
10/08/2021 PNSS 1L regulated at 20 gtts/min 10/08/2021 Hydrocortisone 200 mg IVTT now,
then q 4h

10/08/2021 Rapid Salbutamol + ipratropium

nebulization 1 neb alternated with
Budesonide 1 neb q 20 min x 3
cycles

BLOOD TRANSFUION

NURSING INTERVENTIONS
10/08/2021 Secure consent for care & mgt

10/08/2021 TPR q4h & record done

10/08/2021 Place on moderate high back rest

DIAGNOSTIC PROCEDURES 10/08/2021 O2 inhalation via face mask at
8L/min done
10/08/2021 CBC 10/08/2021 Monitor O2 saturation
10/08/2021 Plt 10/08/2021 Suction PRN
10/08/2021 Blood chem 10/08/2021 Monitor I&O 1 shift
10/08/2021 CXR 10/08/2021 Relay lab and diagnostics done
10/08/2021 ABG 10/08/2021 For close watch
10/08/2021 Pulmonary Function Studies 10/08/2021 Refer accordingly
CONTRAPTIONS
10/08/2021 O2 inhalation via face mask

Operation Procedure DIET

10/08/2021 DAT with SAP

Name: Budoy Age: 55 Sex: Male

CS: worsening of cough associated with tightness all over the chest, with profuse expectoration of
mucoid sputum, and difficulty of breathing more markedly during moderate to severe exertion.
 Address: Birthday:

Diagnosis: Productive cough associated with chest tightness & difficulty of breathing.

Attending Physician: Referrals:

Allergy:

Admission Date/Time 10/08/2021 2:00 pm Trans. in/out date and time:

Ward: Medical ward Room No.