MEDICAL MANAGEMENT

Date and Doctors Order Time 09-10-2010 Please admit patient 1:00 am to P1F3 Please secure consent to care Insert NGT #16

Laboratory Results

Normal Values

Rationale

To prevent aspiration since patient is having a neuromuscular impairment To prevent aspiration should patients condition deteriorates To limit energy consumption since patient has body weakness and for accurate monitoring of urine output In critical care setting, it is important that the client is closely monitored for effective management of sudden changes in the clients status To monitor patients fluid status 110.0 150-400 (10^3/uL) Reflects the normal clotting ability of the blood To detect substances

NPO temporarily

Insert FBC #16 and attach to urobag

VS q2 refer if BP >140/90 or <90/60

I and O q4 and document please LABS: CBC with PLT

U/A

Color: dark

yellow Clarity:hazy pH: 8.0 Specific Gravity:1.005 Na 159.9 mEq/L (134-149 mEq/L)

and other cellular materials in the urine associated with different metabolic disorders To detect hypernatremia associated with edema To detect hypokalemia To evaluate kidney function To evaluate liver function To evaluate liver function In conjunction with other lab tests for a patient with history of excessive alcohol intake

2.6

(3.4-5.4 mEq/L) (4.6-23.4 mg/dl) (F: 0-31 u/L) (F: 0-32 u/L) (0.2-1.2 mg/dl)

BUN

48.1

SGOT/AST

283.2

SGPT/ALT

53.0

Total Bilirubin

16.14

Chest PA ECG 12 lead UTZ-WA PTPA

46.3

(10.2-15.2 secs)

Reflects the normal clotting ability of the blood For fluid replacement and parenteral access of medications Please refer to drug study

Start venoclysis of D5W 500cc at KVO rate

Meds: Vit K i amp IVTT q8 (4-12-8) Aminoleban sachet q12 (6-6)

Spironolactone 25mg i tab BID (8-6) Ciprofloxacin 500mg i tab BID (8-6) Metronidazole 500mg i tab TID (8-1-6) Omeprazole 20mg i cap BID (8-6) Lactulose 30cc q2 (810-12-2) Please chart frequency, characteristics, color, and volume of stool BM 2x watery stool, brownish in color with minimal amount

Please record separately Refer with signs of bleeding, chest pain, change in sensation and any unusualities Refer to Dr. Echalico (Gastro sub-------rotanil) for comanagement Refer accordingly Bisacodyl adult suppository now Give Lactulose 30cc now Continue meds Refer accordingly To secure 3 U PRBC of patients blood type, properly screened and crossmatched, q8 apart Manifestations of drug effects

07:30am

To facilitate bowel movement To facilitate bowel movement

09-11-10 11:00 am

To replenish fluid loss

Furosemide 20mg IVTT after each transfusion VS monitoring qH with 02 sat UTZ monitoring D5W 500cc at KVO rate Refer to Dr. Echalico for co-management T: 38 C Give Paracetamol 300mg IVTT q4 PRN for fever <38 C Repeat PTPA For CBC with PLT monitoring q12 (6-6) For procurement of meds Please check amount, frequency and characteristic of stool D5W 500cc at KVO rate Lactulose 30cc q2

To facilitate excretion

01:00 pm

To decrease temperature

09:00 pm

09-13-10 09:30 am

To facilitate bowel movement To check nutritional status To avoid aspiration

Serum albumin

May have general liquid with aspiration precaution Diet OF 1600 kcal 1:1 dilution in 4 equal

To provide daily nutritional

feedings Omeprazole 20mg i cap BID (6-6) D5LR iL at 20gtts/min Carry out order Please start OF For procurement of meds Still for BT For UTZ of whole abdomen Summary of meds For UTZ Serum albumin determination, CBC, repeat PTPA Refer Hold feeding for now

requirement To minimize gastric secretions

11:00 am

09-14-10 11:00 am

K09:15 pm

For further observation

Stat CBC, Na, and K Give Omeprazole 40mg IVTT now Defer present IVF, shift to PNSS iL + 20mEq KCl at 20gtts/min Start Kalium Durule i tab TID Suppository for rectum now VS monitoring q2 KCl as potassium supplement

As potassium supplement

Continue meds Refer accordingly Remove NGT

09-16-10 10:30 am

To test for oral tolerance To test for gag reflex

May have soft diet with strict aspiration precaution Elevate head 90 degrees before feeding and 90 degrees after For procurement of meds IVF follow-up D5W 500cc at KVO rate Continue VS monitoring Repeat Na, K, Crea, BUN, PTPA, CBC with PLT Strict fluid aspiration precaution please D5W 500cc at KVO rate Continue meds Turn to sides q2

To prevent aspiration

09-17-10

09-18-10

To prevent bed sores and pulmonary complications To facilitate freeflowing urine

DC FBC

09-19-10

Refer accordingly CBC with PLT, Na, K, Crea, BUN, PTPA

Procurement of meds D5W 500cc at KVO rate