August 26, 2011 11:45pm

DAY 0

1:25 pm

3:00 pm

August 27, 2011

Patient received via stretcher carried by NOD of ER Complains of extreme muscle weakness Was conscious and coherent Admitting vital signs: BP 90/60 mmHg PR 77 bpm RR 35 cpm T 36.5 degree centigrade Upon receiving from ER, venocyclysis was already started D5NM 1L X KVO with side drip of PNSS 80 cc + 40 mEq KCL X 25 cc/hr on the 1st cycle to run for 3 cycles at the right arm He was transferred safely on bed Instructed on DAT, high K diet Laboratory examination was requested CBC, Na, K, ABG and urinalysis Another cycle of KCL drip was administered via soluset with 80 cc of PNSS + 40 mEq KCL Urine specimen was collected and submitted to the laboratory for urinalysis (+)vomiting 6x q shift 300ml-500 ml per vomit DAY 1 Was conscious and not in distress With ongoing IVF of PNSS 80 cc + 40 mEq KCL X 25 cc/hr on the 1st cycle to run for 3 cycles at the right arm Vital signs were taken and recorded hourly: Ranges: BP 90/60 mmHg PR 75-80 bpm RR 20-21 cpm T 36.4-36.6 degree centigrade Still instructed on DAT, high K diet for maintenance Laboratory examination CBC, Na, K, and urinalysis was done at the ER ward reminded to be secured Still requested for ABG Requested for TSH and FT4 Patient was encouraged to rest and sleep Was kept safe and comfortable Patients per orem intake was a total of 2300 mL and IVF was 1660 mL

August 28, 2011

Urine output is light yellow and slightly turbid without particle and have aromatic smell He urinated 8 times in large volume approximately 275 ml everytime he urinates (+)vomiting 3x q shift 150ml per vomit Client urinates without pain He defecated once Stool was semi-formed and have no particles Due medications were given: ranitidine metoclopramide kalium durule DAY 2 Still conscious and not in distress With ongoing IVF of PNSS 1L + 80 mEq KCl to run for 10 hours at the level of 600 cc, 33 gtts/min infusing well at the right arm Vital signs were taken and recorded hourly: Ranges: BP 90/60 mmHg PR 76-90 bpm RR 20-22 cpm T 36.2-36.8 degree centigrade Still instructed on DAT, high K diet for maintenance Was seen and examined by Dr. Villegas with orders noted and carried ot Was still encouraged to rest and sleep Was kept safe and comfortable Was also encouraged deep breathing His BP reached 80/80 mmHg and was referred to Dr. Cordova The result of K- 2.91 mEq/L was relayed to Dr. Cordova Fast drip of PNSS 200 cc was given then the remaining 300 cc was incorporated with 40 mEq KCl PNSS to run for 10 hours Patients per orem intake was a total of 3000 mL and IVF was 2450 mL Urine output is light yellow and slightly turbid without particle and have aromatic smell He urinated 14 times in large volume approximately 286 ml everytime he urinates Client urinates without pain He does not defecated Due medications were given: ranitidine

9:00 am

12:00 am 12:15 am

metoclopramide kalium durule August 29, 2011 Still conscious and not in distress With ongoing IVF of PNSS 1L 80 mEq KCl at the level of 750 cc to run for 8 hours, 41-42 gtts/min Vital signs were taken and recorded every 4 hours: Ranges: BP 80-/50-100/70 mmHg PR 70-92 bpm RR 20-22 cpm T 36-36.7 degree centigrade Still instructed on DAT, high K diet for maintenance Laboratory examination ABG, TSH and FT4 was not done Was seen and examined by Dr. De Sagun with orders noted and carried out, for serum K after the 3rd cycle due at 8:00 am Patient was provided with safety measures, raising the side rails of the bed Was still encouraged to rest and sleep Was kept safe and comfortable Patients per orem intake was a total of 2000 mL and IVF was 2560 mL Urine output is light yellow and slightly turbid without particle and have aromatic smell He urinated 11 times in large volume approximately 236 ml everytime he urinates Client urinates without pain He defecated once Stool was semi-formed and have no particles Due medications were given: ranitidine metoclopramide kalium durule No signs of nausea and vomiting shown by the patient

9:10 am