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Date/ shift
Aug 10, 2010
6:00am-2:00pm
9:20am
- Please admit to
pedia ward B
- Please secure
consent for
admission
management
- TRP q4 include Bp
and record please
- Monitor I&O cc/cc
q shift record
please
- Diet as Tolerated
- IVF D5 0.3 NaCl
1liter to run KVO
- Diagnostics:
Chest x-ray
CBC
Urinalysis
ECG
- Place water out
for respiratory
distress and any
informed s/sx and
please refer to
PROD
- Please inform
PROD readmission
once at ward.
- Please Refer
accordingly
10:20am
- Admitted a 13y/o
girl with a chief
complaint of
edema on low
extremities
- Conscious
- Vital signs taken
and recorded
- Seen and
examined
- Consent for
admission and
management
secured
- D50.3NaCl 1L to
run at KVO
hooked and
regulated at
desired rate
- DAT die
- CXR PA follow up
results
- CBC P follow up
results
- Urinalysis Follow
up results
- ECG don result
attached to chart
- Medication
prescribed
3. - Therapeutics:
Furosemide 25mg
thru IV q8
Cefuroxime 750mg
TIV q8
- Monitor Vital signs
include Bp and
record
- Monitor I&O cc/cc
q shift and record
- Pedia ward nurse
on duty informed
- Fixed and brought
to ward
- Needs attended
- Endorsement
10:40am
- Include egg whites
– 3 egg whites to
be mixed with milk
3x/day
- Strict I &O
monitoring cc/cc
- Lab results BUN,
CREA
12:30pm
- Trans. in patient
PROD per via
stretcher
accompanied by
NOD
- w/ IVF 900cc
- Conscious
- O2 inhaler 3-4
LAM via face mask
- Cont. on DAT diet
- CXR PA follow up
results
- CBC P follow up
results
- Urinalysis Follow
up results
- ECG don result
attached to chart
- endorsed
2:00pm-10:00pm 2:45pm
- received patient
on bed with IVF @
4. 50cc
- conscious
- on DAT diet
- O2 inhalation w/
ongoing @3lpm
via facemask
- CXR PA ff up
results
- CBC PC ff up
results
- Urinalysis ff up
results
- ECG tracing
attached to chart
for efficient
reading
- Vital signs take
and recorded
- afebrile
- Due meds given
- Needs attended
- endorsed
10:40pm
- received on bed
w/ IVF @940cc
- conscious
- DAT diet; include 3
egg whites to be
mixed with milk 3x
a day
- O2 inhalation
ongoing @ 3-
4LPM via
5. facemask
- endorsed
- CXR PA ff up
results
- CBC PC ff up
results
- Urinalysis ff up
results
- ECG tracing
attached to chart
for efficient
reading
- BUN, CREA for w/
request
- Vital signs take
and recorded
- Due meds given
- Needs attended
Aug. 11,2010
6:00am-2:00pm
10:15 am
- May mean off to
O2 inhalation
- Please facilitate
pending labs
- Continue present
meds and
management
- Please refer
7:00am
- Received o bed w/
ongoing IVF 800cc
- Conscious
- DATT diet include
3 egg whites 3x a
day to be mixed
w/ milk
- w/O2 inhalation 3-
4Lpm via
facemask
- CXR PA ff up
results
- ECG tracing
attached to chart
6. - BUN, CREA ff up
results
2:00pm-10:00pm 2:50pm
- Received o bed w/
ongoing IVF 110cc
- Conscious
- DATT diet include
3 egg whites 3x a
day to be mixed
w/ milk
- w/O2 inhalation 3-
4Lpm via
facemask
- CXR PA ff up
results
- ECG tracing
attached to chart
- BUN, CREA ff up
results
- Vital signs
recorded
- needs attended
- Endorsed
10:00pm
- Received o bed w/
ongoing IVF 780cc
- Conscious
- DAT diet include 3
egg whites 3x a
day to be mixed
w/ milk
- w/O2 inhalation 3-
4Lpm via
facemask
7. - CXR PA ff up
results
- ECG tracing
attached to chart
- BUN, CREA ff up
results
- Vital signs
recorded
- afebrile
- due meds given
- needs attended
- Endorsed
Aug 12, 2010
6:00am-2:00pm
9:00 am
- Revised present Iv
to PNSS 500cc +
30mcg NaCl to run
for 24hrs x 2 doses
- Continue present
meds and
management
- Please refer
6:25am
- Received o bed w/
ongoing IVF 720cc
- Conscious
- DAT diet include 3
egg whites 3x a
day to be mixed
w/ milk
- ECG tracing
attached to chart
- BUN, CREA ff up
results
- Seen and
examined by Dr.
Velasco
2:00pm-10:00pm 2:30pm
- Received o bed w/
ongoing IVF 720cc
- Conscious
- DAT diet include 3
egg whites 3x a
day to be mixed
8. w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Afebrile
- Needs attended
10:00pm-6:00am 10:30pm
- Received o bed w/
ongoing IVF 200cc
- Conscious
- DAT diet include 3
egg whites 3x a
day to be mixed
w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Afebrile
- Needs attended
Aug. 13,2010
6:00am-2:00pm
8:10am
- Continue DAT diet
- Lanoxin ).25mg/ta
b ½ tab 2x a day-
hold for HR<80
- Start Salbutamol
NEB INED every
12hrs.
- Continue present
meds and
management
- Please refer
6:00am
- Received pt. on
bed w/ IVF @
270cc level
- Conscious
- On DAT diet to
include 3 egg
whites 3x a day to
be mixed w/ milk
- ECG tracing
attached to chart
- Repeat Na+
9. correction for
request
8:10am
- Seen and
examined by Dra.
Velasco order
meds and
continue
management
- Vital signs taken
and recorded
- Needs attended
- endorsed
2:00pm-10:00pm 2:40pm
- received on bed
w/ IVF @ 130cc
level
- conscious
- on DAT diet to
include 3 egg
whites 3x a day to
be mixed w/ milk
- ECG tracing for w/
request
- Vital signs taken
and recorded
- #3PNSS
500c+30mcg NaCl
X24 hook as to
follow
- Due meds given
- Needs attended
- Endorsed
10:00pm-6:00am 10:00pm
10. - received on bed
w/ IVF @ 470cc
level
- conscious
- on DAT diet to
include 3 egg
whites 3x a day to
be mixed w/ milk
- ECG tracing for w/
request
- Repeat serum Na+
correction
- Vital signs taken
and recorded
- Due meds given
- Needs attended
- Endorsed
Aug. 14, 2010
6:00am-2:00pm
8:50am
- Continue present
meds and
management
- Please refer
6:00am
- Received patient
on bed w/ IVF of
390cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Request serum
Na+ correction for
w/ request
10:30am
- Salbutamol neb
8:50am
- Seen and
11. 1nebule for 1 dose
- Re-assessment
after 30mins
- Please refer
examined by Dr.
Macapulay w/
order made and
carried out
- Vital signs taken
and recorded
10:30am
- Referred to
Dr.Velasco w/
order made and
carried out
- Due meds given
11:20am
- Informed
Dr.Velasco
- Needs attended
2:00pm-10:00pm 3:10pm
- IVF: D5 0.3 NaCl
500cc to run at
KVO
- Refer
2:30pm
- received patient
on bed w/ IVF @
200cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Request serum
Na+ correction for
w/ request
- Vital signs taken
and recorded
- Due meds given
12. - Needs attended
10:00pm
- Received pt. on
bed @140cc level
- Asleep
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat serum Na+
correction for
request due
@3:30am
(8/15/2010) ff up
result
Aug. 15,2010 12:00pm
- D/c Cefuroxime
- Start ceftazidime
770mg TIV q8
ANST
- Cont. Other meds
and management
- Refer
6:00am
- Received pt. on
bed w/ IVF @
490cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat serum Na+
correction ff. up
result
12:00nn
13. - Seen and
examined by Dr.
Aganiza w/ new
orders made and
carried out
- Vital signs taken
and recorded
- Due meds given
- Needs attended
2:10pm
- Received pt. on
bed w/ IVF @
100cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat serum Na+
correction ff. up
result
10:30pm
- Received pt. on
bed w/ IVF @
290cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
14. - ECG tracing
attached to chart
- Repeat serum Na+
correction ff. up
result
- Vital signs taken
and recorded
- Afebrile
- Needs attended
Aug. 16,2010 9:00am
- start with
pediasure
2glasses/day
- start with
multivitamins +
Iron cap 1cap daily
- rpt CXR(APL) today
compare w/
previous result
done
- cont. Ceftazidime
IV & other oral
meds
- refer
7:00am
- Received patient
on bed w/ IVF @
400cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
9:00pm
- ECG tracing
attached to chart
- Seen and
examined by Dr.
Aganiza w/ order
made and carried
out
- Rpt. CXR for w/
request today;
15. compare w/
previous plate
(8/10/10)
- Afebrile
- Due meds given
- Needs attended
2:00pm-10:00pm 2:00pm
- received pt. on
bed w/ IVF @
340cc level
- conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk;
include pediasure
2glasses daily
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended
10:00pm
- Received patient
on bed w/ IVF @
850cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
16. attached to chart
- Afebrile
- Due meds given
- Needs attended
Aug.17,2010 - ff up rpt CXR (APL)
- cont. Present
meds and
management
- refer
6:00pm
- Received patient
on bed w/ IVF @
400cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
9:30am
- Seen and
examined by Dr.
Aganiza w/ order
made and carried
out
- Needs attended
2:00pm-10:00pm 2:00pm
- received pt. on
bed w/ IVF @
800cc level
- conscious
- On diet as
tolerated to
include 3egg
17. whites TID to be
mixed w/ milk;
include pediasure
2glasses daily
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended
10:00-6:00pm 10:00pm
- received pt. on
bed w/ IVF @
300cc level
- conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk;
include pediasure
2glasses daily
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended
Aug. 18,2010
6:00am-2:00pm
9:40am
- may reinsert IV
- continue present
meds and
management
- please refer
6:00am
- Received patient
on bed w/ IVF @
350cc level
- Conscious
- On diet as
tolerated to
include 3egg
18. whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
9:00am
- Seen and
examined by Dr.
Aganiza w/ order
made and carried
out
- Needs attended
2:00pm-10:00pm 3:10pm
- IVF to ff: D5 0.3
NaCl 500cc to run
at KVO
- Please refer
2:10pm
- Received patient
on bed w/ IVF @
100cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
10:00pm-6:00am - Received patient
on bed w/ IVF @
50cc level
- Conscious
- On diet as
19. tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
12:30am
- #5 D5 0.3
NaCl@KVO
hooked as to
follow
- Meds attended
Aug.19,2010
6:00am-2:00pm
6:00am
- Received patient
on bed w/ IVF @
450cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Seen and
examined by Dra.
Velasco w/ orders
made and carried
out
- Repest k+ for
request
20. - Vital signs taken
and recorded
- Due meds given
2:00pm-10:00pm 8:55pm
- For repeat K+
- Cont. meds and
management
- Please refer
2:00pm
- Received patient
on bed w/ IVF @
400cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
10:00pm-6:00am 10:00pm
- Received patient
on bed w/ IVF @
340cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Request K+ for
request; result is
relayed to Dra.
Concepcion
21. - Vital signs taken
and recorded
- Due meds given
Aug.20,2010
6:00am-2:00pm
9:35am
- Start Vit.B
complex 1 tab OD
- Cont. meds and
management
- Please refer
6:15am
- Received patient
on bed w/ IVF @
260cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
9:30am
- ECG tracing
attached to chart
- Seen and
examined by Dra.
Velasco
- Vital signs taken
and recorded
- Due meds given
2:00pm
- Received patient
on bed w/ IVF @
180cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
22. - Vital signs taken
and recorded
- Due meds given
11:15pm
- Received patient
on bed w/ IVF @
135cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
- Needs attended
Aug.21,2010
6:00am-2:00pm
8:05am
- For issuance of
clinical abstract
- Cont. meds and
management
- Please refer
6:00am
- Received patient
on bed w/ IVF @
60cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
8:00am
- Seen and
examined by Dra.
23. Macapulay w/
orders made and
carried out
- Vital signs taken
and recorded
- Due meds given
2:00pm
- Received patient
on bed w/ IVF @
10cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Due meds given
- Needs attended
10:00pm-6:00am 4:00pm
- IVF to ff.
D50.3NaCl 500cc
as KVO
10:35pm
- Received patient
on bed w/ IVF @
490cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
24. - Vital signs taken
and recorded
- Due meds given
- Needs attended
Aug.22,2010 10:30am
- For repeat CXR
APL tom. 7:00am
- Cont. meds and
management
- Please refer
6:35am
- Received patient
on bed w/ IVF @
450cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
-
10:30am
- Seen and
examined by Dra.
Velasco orders
made and carried
out
- Repeat CXR APL
w/ request
- Vital signs taken
and recorded
- Due meds given
- Needs attended
2:00pm-10:00pm 2:55pm
- Received patient
on bed w/ IVF @
500cc level
- Conscious
25. - On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Vital signs taken
and recorded
- Instructed pt. and
mother not to
drink colas
- Due meds given
- Needs attended
10:00pm-6:00pm 10:00pm
- Received patient
on bed w/ IVF @
340cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat CXR APL
tom. @ 7:00am
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended
Aug.23,2010 6:30am 6:00pm
26. 6:00pm-2:00pm - Cont. meds and
management
- Please refer
- Received patient
on bed w/ IVF @
500cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
mixed w/ milk
- ECG tracing
attached to chart
- Repeat CXR APL
for w/ request,
due today; done
follow
6::30pm
- Seen and
examined by Dra.
Velasco orders
made and carried
out
- Vital signs taken
and recorded
- Due meds given
- Needs attended
2:00pm-10:00pm 2:35pm
- Received patient
on bed w/ IVF @
210cc level
- Conscious
- On diet as
tolerated to
include 3egg
whites TID to be
27. mixed w/ milk
- ECG tracing
attached to chart
- Repeat CXR APL
follow up results
- Vital signs taken
and recorded
- Afebrile
- Due meds given
- Needs attended