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Doctors Order July 24 2012 Admit pt. to room of choice under the service of Dr. N. Delos Santos/N. Chan/J.

. 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

For further management, treatment and evaluation of the disease

Secure consent for admission

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.

For CBC, Blood typing, Chest X-ray T4, TSA

For completion thyroidectomy once cleared for surgery

Please secure consent

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.

Refer to Dr. R. Delos Santos for co-management

TPR every shift & record

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

Refer pt. to Dr. J. Merza for anesthesia

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

Diphemhydramine 1ampule 3omin prior to OR

Medazolam 10mg IV on call to OR

V/S prior to and after pre medications

Pls. instruct to urinate 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

For further monitoring and management

Refer pt. to Dr. Cureg

For futher management To note if there a abnormal value

Inform the pt. about the laboratory examination

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

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