NCM 119 Clinical RLE

Patient’s Kardex- the proprietary name for a filing system for nursing records and orders that was held
centrally on the ward and contained all the nursing details and observations of patients that had been
acquired during their stay in hospital. It is also contain patient information, such as name and
demographics, allergies, chief complaints or reason for admission, resuscitation code, list of
medications, and plan of care. Furthermore, Kardex is used during nurses’ endorsement.
A medical chart is a complete record of a patient's key clinical data and medical history, such as
demographics, vital signs, diagnoses, medications, treatment plans, progress notes, problems,
immunization dates, allergies, radiology images, and laboratory and test results.

Parts of the Medical chart/ Patient’s chart:

Standing Order Sheet

Vital Signs Graphic Sheet
Doctor’s Sheet
Laboratory results
Diagnostics exam results
Fasting Blood Glucose Monitoring Sheet
Surgical Treatment Record (Post op)
Anesthesia Record
Vital Signs Monitoring Sheet
Intravenous Fluid Sheet
Intake and output sheet
Medication Record
Nurses’ Notes Sheet
Medical and nursing history record/ Health Assessment Record
Inform Consent- admission/ hospitalization, surgical treatment, medical and diagnostic procedures
Medical Abstract
Demographic profile
Professional Fee form
Philhealth Form and other forms.

Activities:
One for each group (3 and 4)

Instructions:

Head Nurse: Application of head nursing skills:

1. Design and organize a unit wherein facilities are properly placed.

2. Create an emergency cart. Identify all its content and make an inventory
3. Collaborate with staff nurses (staff nurses in your group) in making different forms needed in the
unit

Staff nurse: Application of nursing skills:

1. Admission of patient by using the kardex and medical patient’s chart.

2. Develop patient’s kardex and write all the necessary information from the given scenario.
 3. Design a medical chart and transcribe all the data/information from the admission orders/s of
patient (given scenario).
4. Application of Nursing process- physical assessment, administering medications, charting
(FDAR), referrals(SBAR) and documentation.

Group 3 Case study

A 48-year-old man is brought to the emergency department (ED) by his wife complaining of a 5-day
history of worsening dyspnea, chest pain, and fever. He has a history of hypertension for which he is on
an ACE inhibitor, and diet-controlled diabetes. He has no allergies. He works in the financial industry and
is normally well. He smokes 3–4 cigars a day. On initial assessment, he is noted to be clammy and
appears pale. He is short of breath at rest. Observations taken during triage are as follows: heart rate
118 regular, BP 96/49mmHg, temperature 38.8 °C, respiratory rate 28 breaths per minute, oxygen
saturation 87% on room air. The potential diagnosis of sepsis is recognized and he is moved to the
resuscitation room for further assessment and interventions.

A focused history reveals no recent travel, a cough producing purulent green sputum and right-sided
pleuritic chest pain. Sputum is obtained and sent for culture. Intravenous access is sited and blood is
taken and sent for blood cultures, haematology and biochemistry. A 12-lead ECG shows a sinus
tachycardia. An arterial blood gas (ABG) sample is taken on 40% oxygen which shows the following:

pH 7.32
pO2 9.1kPa
pCO2 2.8kPa
HCO3 15mmol/l
BE −7mmol/l
Lactate 5.1mmol/l

A chest X-ray is taken which demonstrates right lower lobe consolidation with effusion. A diagnosis of
severe sepsis secondary to a community-acquired pneumonia is made. A 20ml/kg fluid bolus is given at
the same time as the first dose of antibiotics in accordance with the hospital antibiotic policy. His initial
blood tests demonstrate the following:

Hb 14.1g/dL. Sodium 148mmol/.L WCC 18.2×109/L. Potassium. 3.8mmol/L Neutrophils. 17.8×109/L Urea
16.5mmol/L. Platelets 420×109/L. Creatinine 198micromol/L. CRP 370mg/L. Glucose 11.4mmol/l.

Despite fluid resuscitation, his blood pressure is 87/44mmHg. Intensive care is contacted and a review of
the patient requested. Central venous, arterial, and urinary catheters are placed. Further fluid boluses
are administered against his central venous pressure (CVP) up to a total of 40ml/kg but he remains
hypotensive. A noradrenaline infusion is started and titrated to maintain a mean arterial blood pressure
(MAP) of greater than 65mmHg. Over the next hour, he appears drowsier and a repeat ABG on 60%
oxygen at this point shows the following:

pH 7.21 .pO2 10.1kPa. pCO2 6.1kPa. HCO3 15mmol/L. BE −6mmol/L. Lactate 3.8mmol/L.

The patient undergoes a rapid sequence intubation and lung-protective mechanical ventilation is
commenced. While waiting for transfer to the ICU, a sliding scale is commenced to maintain tight
glycemic control. Thromboprophylaxis and gastric protection are prescribed.
Group 4 Case study

A 27-year-old woman presents to the ED with a 24-hour history of right lower quadrant abdominal pain.
The pain was sudden in onset, not migratory, and has gradually worsened, associated with nausea and
vomiting but no diarrhea. She denies any fever, back pain, dysuria, or frequency of micturition. There is
no vaginal discharge or bleeding and her last menstrual period was 2 weeks earlier. There is no history
of similar pain in the past. There is no history of previous abdominal surgery and she is otherwise fit and
well. She is not on any medication, has no known allergies, and does not smoke. Her partner looked on
the internet earlier and feels her symptoms suggest acute appendicitis and hence brought her to the ED.
On examination her temperature is 37.4 °C and her heart rate and blood pressure are normal. She
exhibits tenderness in the right iliac fossa with a positive psoas sign. There is no rebound tenderness
with both Rovsing’s and obturator signs being negative. A urine pregnancy test is also negative.
The patient has analgesia and undergoes laboratory tests. Her urinalysis has a trace of blood, CRP is 28,
white cell count 9.7, and all other tests are within normal limits. She is referred to the surgical resident
and is keen to discharge her home with analgesia with a suspected diagnosis of a ruptured ovarian cyst.
The ED consultant advises otherwise.
The patient is admitted to a surgical ward for observation and further evaluation. Radiological imaging is
warranted but is awaiting whether an ultrasound scan (US) or a computed tomography scan (CT) is most
appropriate.