STANDING ORDER SHEET

Date/Time Medication Remarks

4-29-2021 9: AM Ketorolac 15 mg TIV q6
PRN
4-29-2021 1:00 PM Advil 500 mg OD
4-30-20219:00 AM Ampicillin Sulbactam 500mg
IV q12 ANST
4-30-2021 12:00 NN Diclofenac Sodium 500mg IV
q6
5-01-2021 9:15 AM 2 amps of Tramadol
5-01-2021 9:30 AM Mupiroxin ointment OD
5-01-2021 11 AM Cefatoxin 1 gm IV q8 ()
ANST
5-01-2021 Vitamin B complex capsule
500 mg ODHS
 DR’ ORDER SHEET

DATE/TIME PROGRESS NOTES DOCTOR’S ORDER

4-29-2021 Admit patient to Male
7 AM medical Surgical Room
under the service of Dr.
Shiva

Secure consent for

admission

Hooked O2 inhalation via

nasal cannula at 3-5 LPM
PRN for SPO2 < 92%

Hooked D5LR 1L to run at

24-25 gtts/min.

For CBC,pt, X-ray of the right

hand

For possible wrist splinting

care of Dr. Alday, secure
consent

Lessen activities of the right

hand

May apply cold compress for

swelling

For possible wrist splinting

care of Dr. Alday, secure
consent

Monitor V/S q4 hour

Refer accordingly

4-30-2021 8 Patient seen, for open

AM surgery tomorrow morning
8AM, secure consent

Inform OR team

Inform Dra. Luna for

 Cardiopulmonary Clearance

Inform Dr. Fajarillo for

anethesiology

NPO post midnight

Shift IVF to PNSS 1L @28-

29gtss/min

Start Ampicillin Sulbactam

500mg IV q12 () ANST

Shift Advil tab to Diclofenac

Sodium 500mg IV q6

For MRI of right arm secure

consent

Refer accordingly.

05-01-2021 S/P open surgery

Monitor VS q1 for 4 hours
Shift to D5NSS + 2 amps
Tramadol to n for 34-
35gtts/min.
Change dressing OD
To shift Ampicillin Sulbactam
to Cefatoxin 1gm IV q8
()ANST
Start vitamin B Complex
capsule 500 mg ODHS
Monitor I and O q4
NPO- MTFO
For repeat CBC, pt
Refer accordingly.
 IV FOW SHEET

DATE IVF KIND OF LEVEL NO OF TIME REMAR NURSE

/ NO. SOLUTION OF IVF DROPS/ KS SIGNAT
SHIF OR MIN URE
T INCORPOR
ATION
4-29- 1 D5LR 1L 24-25 7:00 AM Hooked GREYE
2021 gtts/min. S

4-30- 2 PNSS 1L 28- 7:00 AM Hooked GREYE

2021 29gtss/ S
min

5-01- 3 D5NSS+ 2 1L 7:00 AM Hooked GREYE

2021 amps 34- S
tramadol 35gtts/
min.
 INTAKE AND IUTPUT SHEET

DATE SHIFT ORAL IV TOTAL URINE EMESI TOTAL SIGNATUR

S E
4-29- 07-03 - 576cc 576cc 300cc 300cc GREYES
2021 GGCSN202
1
03-11
11-07
Total
4-30- 07-03 350 cc 672cc 1022cc 600cc 600cc GREYES
2021 GGCSN202
1
5-01- 03-11 - 408cc 408cc 365cc 365cc GREYES
2021 11-03 - 408cc 408cc 365cc 365cc GGCSN202
1
11-07
Total
07-03
03-11
11-07
Total
07-03
03-11
11-07
Total
07-03
03-11
11-07
Total
07-03
03-11
11-07
Total
07-03
03-11
11-07
Total
07-03
03-11
11-07
Total
07-03
03-11
11-07
Total
07-03
03-11
11-07
 Total

MEDICATION RECORD

PATIENT’S NAME: Rosalinda B. Hiroshima HOSPITAL CASE NO:

____________
AGE: 40 SEX: FEMALE CIVIL STATUS: WARD NO. Male Medical-Surgical Ward

DATE 4-29- 4-30- 5-1-2021

2021 2021
DAYS OF WEEK Thurs. Fri. Sat.
KETOROLAC 15 mg 11 - 07
q6 PRN Cefatoxin 1 07 - 03 REYES
gm IV q8 () ANST 03 - 11

ADVIL 500 mg OD 11 - 07
07 - 03 REYES
03 - 11
Ampicillin Sulbactam 11 - 07
500mg IV q12 () 07 - 03 REYES
ANST 03 - 11

Diclofenac Sodium 11 - 07
500mg IV q6 07 - 03 REYES
03 - 11
Mupiroxin ointment 11 - 07
OD 07 - 03 REYES
03 - 11
Cefatoxin 1 gm IV q8 11 - 07
() ANST 07 - 03 REYES
03 - 11
Vitamin B complex 11 - 07
capsule 500 mg 07 - 03 REYES
ODHS 03 - 11
11 - 07
07 - 03
03 - 11
11 - 07
07 - 03
03 - 11
11 - 07
07 - 03
03 - 11
11 - 07
07 - 03
03 - 11
 11 - 07
07 - 03
03 - 11

NURSE’S NOTES

DATE/TIME FOCUS DATA ACTION RESPONSE

April 29, 2021 Acute Pain on Subjective 1. Admitted 1. Patient

7:00am - the right hand data: “Nanakit patient to Male painscale
3:00pm talaga itong medical changed from
kanang kamay Surgical Room 8/10 to 0/10.
ko, parang under the 2. Patient is
may natusok” service of Dr. not
as verbalized Shiva demonstrating
by the patient. physiologic
2. Secured sign of pain as
Objective consent for evidenced that
data: admission the patient is
Informed Dr. no longer
PR/HR- Shiva of the experiencing
108bpm admission pain, tingling
RR- 33cpm sensation,
BP:130/80 3. Hooked O2 weakness,
mmHg inhalation via irritability,
SPO2- 99% nasal cannula tachypnea ,
at 3-5 LPM tachycardia,gu
(+)pain, PRN for SPO2 arded
(+)tingling < 92% behavior,
sensation, weak and pale
(+)weakness 4. D5LR 1 L in apperance
(+)less range received and anxiety and
of motion of regulated at facial grimace
the right hand 24-25 gtts. connotes pain.
(+)Irritabilty
(+)guarded 5. Vital signs 3. The patient
behavior on taken and vital signs are
right hand recorded. within normal
(+)weak in limits.
appearance 6. Assisted
(+) pale in patient in
appearance comfortable
(+)Anxious position.
(+)Tachypnea
(+)facial 7. Perform a
grimace comprehensiv
connotes pain e assessment
of pain. 

8. Applied cold
compress for
swelling.

9. Reassesse
d patient for
pain,
PAINSCALE:
7/10

10. Performed
skin test.

11. Patient is
Negative in
skin test.

12. Gave
patient
Ketorolac 15
mg TIV q6
PRN for
severe pain

13. Advised
patient to
lessen
activities
of the right
hand

14. Assisted
patient for
CBC and, X-
ray of the right
hand

15. Provided
rest to patient.

16. Reassess
 ed patient
regarding pain

17. Pain
lessened from
pain scale of
8/10 to 3/10
.
18. Vital signs
taken and
recorded.

19. Referred
patient
accordingly.

20. Gave
patient Advil
500 mg.

21. IV
checked and
regulated
.
22. Reassess
ed patient for
pain.
PAINSCALE:
0/10

23. I and O
shift recorded.

24. Provided
patient rest
and
comfortable
environment.

4-30-2021 Preparation Subjective 1. Secured Scheduling of

7:00 AM-3:00 for open data: patient’s patient’s
PM surgery “Okay, I’ll go consent. operation is
with the done.
surgery.” as 2. Called and
verbalized by informed the
the patient. OR team.

3. Called and
informed Dra.
Luna for
Cardiopulmon
ary Clearance

4.Called and
Infored Dr.
Fajarillo for
anethesiology

5.Shifted IVF
to PNSS 1L
and regulated
@28-29gtss/m
in

6. Vital signs
taken and
recorded.

7. Informed
patient about
ANST.

8. Performed
ANST at 8:30
AM

9. Informed
patients not to
eat or
drink after
midnight, the
night before
surgery.

10. Checked
patient for
ANST, and the
result is
negative.

11. Informed
the patient
about what to
administer and
started
Ampicillin
Sulbactam
500mg IV q12
at 9 AM

9.Shifted Advil
tab to
Diclofenac
Sodium
500mg IV q6

7. Informed
patient about
the new
medication.

8. Gave
patient
Diclofenac
Sodium
500mg IV q6
at 12PM.

9. Secured
patient’s
consent for
MRI of the
right arm.

10. Called and

scheduled an
MRI to the
radiologist.

11. Provided a
health
 education to
patient.

12. Checked
and regulated
IVF @28-
29gtts/min.

13. Vital signs

taken and
recorded.

14. I and O
taken and
recorded.

15. Provided
patient
adequate rest.

5-01-2021 Post-operative Subjective 1. Physician Provided

7am-3pm care data: “Ayus visited at 8:45 patient
naman AM. comfort
pakiramdam throughout
ko after 2. Assisted post-operative
surgery” as patient in a phase.
verbalized by comfortable
the patient. position.

Objective 3. Informed
data: patient not to
VS eat or drink
until there is a
9 AM doctor’s order.
BP:110/70
PR: 88 bpm 4. Vital signs
RR: 23 bpm taken and
TEMP: 37 recorded at 9
O2 SAT: 99% AM.

10 am 5. Shifted IVF
BP:110/80 to D5NSS + 2
PR: 84 bpm amps
RR: 25 bpm Tramadol and
TEMP: 36.8 run @ 34-35
O2 SAT: 99% gtts/min at
9:15 am.
11 am
BP: 110/70
PR: 88bpm 6. Changed
RR: 23 bpm dressing OD
TEMP: 37 at 9:30 AM
O2 SAT: 99%
7. Applied
12 nn Mupirocin
BP: 120/70 ointment to
PR: 98 bpm operative OD
RR: 33 bpm at 9:30.
TEMP: 37
O2 SAT: 91 8. Gave
patient a
(+) wound health
dressing teaching about
wound care.
(+)wound
stitches 9. Vital signs
taken and
recorded at 10
AM.

10. Informed
patient about
new
medication to
administer,
and performed
ANST at 10:30
AM.

11. Patient is
(-)ANST.

12. Administer
ed Cefoxin 1
gm IV q8 ()
ANST at 11
am.

13. Vital signs

taken and
reorded at
11am.

14. I and O
taken and
recorded at 11
am.

15. Called
laboratory and
scheduled a
CBC for
patient.

16. Assisted
patient on her
needs.

17. Vital signs

taken and
reorded at 12
nn

18. Provided a
patient an
adequate rest.

19. I and O
taken and
recorded at 3
pm.