REVIEW OF SYSTEM

Name: _________________________________ Date: _____________________

Vital Signs
Temperature: 36.5 degrees Celsius
Pulse: 105 bpm Height: not taken
Respiration: 22cpm Weight: not taken
Blood Pressure: 140/90mmHg
Observation: received patient unconscious with GCS1o (E4, M6, Vt), IVF of D 5NaCl at left arm with drop rate of 30gtts per minute and 90cc PNSS with 10mg of nicardipine at 10cc per hour

Patient is unconscious with GCS score of 10 (E4 M6 Vt); IVF PNSS 90cc +10 mg of nicardipine @ 10cc per hour; with tracheostomy tube attached to
1. General
mechanical ventilator (40%); FBC attached to urobag and NGT for feeding.
Head: craniotomy is done and have sutures in parietal area of the head
Ears: no palpable lymph nodes noted
2. HEENT Eyes: pupils react to light
Nose: Naso-Gstric Tube is attached for feeding
Throat: patient is on Tracheostomy tube attached to mechanical ventilator

3. Integumentary Skin is warm to touch, senile turgor and mobility

4. Respiratory Equal chest expansion, (+) rales and stridor

5. Cardiovascular No murmur, distracted heart sounds

6. Digestive Abdomen is soft, NBS,

7. Excretory Patient is on FBC and collected urine output of 1270cc in 8hours, haven’t defecated for 5 days

8. Musculoskeletal Patient is unconscious and have weak muscle strength and cannot move without assistance

9. Nervous FGCS OF 10 (E4, V1, M5)

10. Endocrine No lymphodenophathies, non-distended neck vein