Time and Date Doctor’s Order Rationale Nursing

Responsibilities

10/ 01/ 23, 11:00 AM Please admit patient • Admit the patient as
to ward of choice For Further ordered
(+) fever Management • Prepare all necessary
(+) swelling of left foot documents
(+) tenderness • Obtain initial VS
(+) difficulty in
ambulating

Secured consent for • For documentation • Serve as witness in

admission and mngt and records keeping. securing Consent
• Protect the patient’s • Explain Patient’s
Right Rights
Low salt low fat diet • To avoid further • Advice Low Salt Diet
complication caused by to patient and educate
excessive intake of him
Sodium • Inform the Dietician
regarding the Patient’s
diet
IVF : PNSS 1L x 42 To replenish Electrolyte Assessing the patient's
gtts/min condition (medical
history, allergies, fluid
balance, and overall
clinical status)
• Document baseline
data
• Observe for signs of
fluid overload and
manifestations
• Check for the
patency of the IV line
• Regulate the IV
Diagnostics: cbc w/ pc • To Obtain Baseline • Explain the
Data and to determine Procedure to the
whether the level of patient
Blood Component is in • Facilitate lab request
normal range • Refer relevant
findings
Creatinine To measures the level Explain the procedure
of creatinine in the to the patient and
blood answer queries of the
patient • Assist and
accompany the patient
12 L ecg To rule out • Carryout the Doctor’s
Cardiovascular order • Confirm the
 problem since the identity of the patient •
patient is already 52 Inform the Radiologist
years old • Explain the
procedure to the
patient • Position and
Assist the patient
Therapeutics: Assess
Clindamycin 600mg iv Monitor
q8 Educate
Note for adverse
Ketorolac 30mg iv q8 x effects
3 doses

Paracetamol 500mg 7
tab, q4 prn

Ats 3000 iu/ ml () ast

Tt 0.5 ml IM
Diosalin+hesperidin

To monitor patient Take Patients VS q4

Vs q4 and record progress Note patient progress

Refer • For continuous • Refer accordingly

monitoring
10/ 01/ 23 , 1:20 PM Start allopurinol
300mg 1 tab OD

Start renalog tab, 1

tab BID
3: 57 PM IVF to follow PNSS 1L X To replenish Electrolyte Assessing the patient's
42 gtts/min condition (medical
history, allergies, fluid
balance, and overall
clinical status)
• Document baseline
data
• Observe for signs of
fluid overload and
manifestation
s • Check for the
patency of the IV line
• Regulate the IV
10/02/23, 8:15 PM
(+) swelling of left foot Eterocoxib 120mg 1
(-) fever tab 1 tab OD

Start hydrocortisone
50mg iv q8

Ivf tf: PNSS 1L X To replenish Electrolyte Assessing the patient's

28gtts/ min condition (medical
history, allergies, fluid
balance, and overall
clinical status)
• Document baseline
data
• Observe for signs of
fluid overload and
manifestation
s • Check for the
patency of the IV line
• Regulate the IV
Refer • For continuous • Refer accordingly
monitoring