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. Merza
Rationale
Nursing Respondibilities
Admitted patient to pedia ward Filled up necessary documents needed Oriented SO to the physical set up of the area Explained to the clients SO the significance of the consent Act as a witness in the signing of the consent
That the patients SO adhere to whatever treatment and management the hospital could give.
DAT
Promote restoration & meet body requirement Brought request form in the laboratory department Explained procedure to the SO Instructed to the SO proper urine collection To note any abnormalities in the results thus proper management and treatment will be given for such.
Explained to the clients SO the significance of the consent Act as a witness in the signing of the consent Refer to Dr. R. Santos for co-management
That the patients SO adhere to whatever treatment and management the hospital could give.
Monitored v/s every shift and monitored patients condition. Referred accordingly
To have a baseline data for clients present condition For further monitoring and management To sedate the pt.
Refer accordingly July 24, 2012 Refer to Dr. J. Merza for Anesthesia Pre-operative order July 24, 2012 For complete thyroidectomy under General Anesthesia Secure consent for anesthesia NPO 6hours prior to OR IVF D5LRS 1L X 8Hours once NPO Metaclopramide 1ampule, 30min. prior to OR
Administered drug as ordered following the 10Rs, Explained to patient SO possible side effects and purpose of the drug. Administered drug as ordered following the 10Rs, Explained to patient SO possible side effects and purpose of the drug. Administered drug as ordered following the 10Rs, Explained to patient SO possible side effects and purpose of the drug. Monitored v/s every shift and monitored patients condition. Instruct pt. to void before transrefing to OR To have a baseline data for clients present condition Instruct the pt. to empty the bladder prior to OR transfer
Pls. inform me of schedule if once CP cleared Refer 8:42pm Pls. schedule OR tomorrow NPO post 7am July 25 2012 Refer to Dr. A. Cureg 8:54am For FT4 stat 12:30pm Normal FT4 1.7
Referred accordingly
May undergo surgery Post Operative Order July 25 2012 1:15pm Status post completion thyroidectomy under GA O2 @ 3L/min
Prepare the pt. for the incoming surgery Explain & inform the pt. about the safety precaution connected w/ the O2 use Regulate at the ordered saturation
To treat the disease per se Increase O2 availability & for cardiac functioning & tissue perfussion
V/S every 15min until stable DAT once fully awake IVF PLRS 1L X 8 hours D5NR 1L X 8 hours D5NSS 1L X 8 hours Ketorolac 30mg IV now every 6 hours X 3 doses Then start Mefenamic acid5oomg/tab(ponstansf) 1tab every 8hours PRN Nalbufine 10mg IV now every 4hours PRN for pain Cefalexin 500mg/cap TID/orem
Moderate high back rest Refer July 25 2012 Oral pain medications as order 11:15am Resume Euthyrox 50mg/tab 1tab before breakfast