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MEDICAL MANAGEMENT
Doctor’s Order Rationale
8/25/2010
4pm
please admit under the service of Dr. Judy Suarez Chua
Secure client to care
problem dizziness
condition stable
activity complete bed rest with toilet privileges. - to prevent further injuries due to the clients condition of
allergies none dizziness
full low fat, low salt diabetic diet 1800kcal/ day in 3 main - standardize diabetic diet therapy for the client, in order to
meals with snacks in between 60% CHO but no simple adjunct the client drug therapy
sugars,20%CHON of HBV, the rest as fats mainly MUFAs
and PUFAs
venoclysis with PNSS 1L @120ml/day - provide hydration
nursing care
1. TPR q 4 -Standardize hospital protocol for vital signs
2. BP monitoring q 2
3. strict I & o monitoring - to monitor client’s hydration status
4:10pm
labs:HGT now, ECG 12leads now
CBC, U/A, Na, K, creatinine, SGPT, FBS,HBAIC,lipids panel, -monitor clients glucose levels and cardiovascular function
BUN -to monitor clients blood, urine, serum potassium, kidney and liver
Meds: functioning and adherence to therapy
1. captopril 25mg 1 tab sublingual now -decrease client’s blood pressure
2. Humulin R 4 units subcutaneously now -decrease client’s glucose levels
3. insulin lispro 25% +insulin lispro protamine suspension
25%(Humalog mix 25) 10 units 15 mins pre breakfast and 15
mins. Pre dinner subcutaneously.
HGT monitoring 3 times daily pre meals -to monitor clients glucose levels
refer for worsening, dizziness, onset of neurologic
deficits,chest pain,dyspnea and other unsualities.
will inform attending physician
8/26/10
3:53am
give captopril 25mg tab SL now -to decrease client’s blood pressure
9:50am
- to decrease client’s client’s blood pressure
amlodipine 5mg tablet once a day orally @8pm
2pm
give humulin R 3 units subcutaneously now -to decrease client’s glucose levels
7pm
7:40pm
-to monitor for the client’s unstable bp
secure BP monitoring to q 4 and chart please
9/1/10
6Am
Laboratory Results
HEMATOLOGY RESULT
BLOOD INDICES
MCV 95.0 81-99 fl
MCH ↑31.7 27.0-31.0 pg
CHEMISTRY REPORT
ELECTROCARDIOGRAPHIC REPORT
Interpretation
Sinus rhythm with acute anteroseptal wall myocardial infarction. Suggest follow-up tracing, cardiac enzyme studies and clinical correction.
CHEMISTRY REPORT