G.

COURSE IN THE WARD

Date/Shift

Medical Management

Rationale

Nursing Intervention

Rationale

12/28/16
8:00 am

VS q 4 as ordered

-Baseline
data
and --For Vs Monitoring q 4
information
for -Vs monitored & recorded.
comparison of changes.
-VS within normal range

8:10 am

NVS q 4 as ordered

-To determine whether -NVS

checked
the nervous system is recorded
impaired.
Total NVS of 11/15
-To detect the presence
of neurological disease or
injury and monitor its
progression,
determine
the type of care to
provide, and gauge the
patient's response to the
interventions.

12:00 noon

VS q 4 as ordered

-Baseline
data
and -For Vs Monitoring q 4
information
for -Vs monitored & recorded.
comparison of changes.
-VS within normal range

12:10pm

NVS q 4 as ordered

-To determine whether -For NVS q 4

the nervous system is -NVS
checked

-To monitor vital signs and

checked for any unusualities.

and -To do assessment of sensory

neuron and motor responses,
especially reflexes (Pupil size
and reaction, Handgrip, leg
movement, eye opening, best
verbal response and best motor
response Glasgow coma Scale.

-To monitor vital signs and

checked for any unusualities.

-To do assessment of sensory

and neuron and motor responses,

impaired.
recorded
-To detect the presence Total NVS of 11/15
of neurological disease or
injury and monitor its
progression,
determine
the type of care to
provide, and gauge the
patient's response to the
interventions.

especially reflexes (Pupil size

and reaction, Handgrip, leg
movement, eye opening, best
verbal response and best motor
response with the use of the
Glasgow coma Scale.

1:30pm

Intake
and
Monitoring q shift

Output - To monitor progress of -For I&O monitoring qShift -To know how much fluids are
urinary retention and -I&O summed up and loss/added in the course of care
edema.
recorded

Date/Shift

Medical Management

Rationale

12/29/2016
7:30 AM

PNSS 1 L @ 120 cc/hr X2

-Serves as a source of -IV tube checked if To control the amount of fluids a

securely attached to IV patient receives while having a
water and electrolytes
cannula.
therapy.
-IV site checked for any
discoloration & swelling.
-IVF regulated, monitored
and recorded.

8:00 am

VS q 4 as ordered

-Baseline
information

Nursing Intervention

data

Rationale

and -Vs monitored & recorded. -To monitor vital signs and
(BP of 150/90 mmHg)
checked for any unusualities.
- placed on MHBR,
provided good ventilation,
instructed
to
avoid

strenuous activities
- BP rechecked
-still (BP of 150/90 mmHg)
8:15am

NVS q 4 as ordered

-To determine whether

the nervous system is
impaired.
-To detect the presence
of neurological disease or
injury and monitor its
progression,
determine
the type of care to
provide, and gauge the
patient's response to the
interventions.

12:00 noon

VS q 4 as ordered

-Baseline
information

12:05noon

NVS q 4 as ordered

-To determine whether

the nervous system is
impaired.
-To detect the presence
of neurological disease or
injury and monitor its
progression,
determine
the type of care to
provide, and gauge the
patient's response to the
interventions.

data

-For NVS q 4
-NVS
checked
recorded
Total NVS of 11/15

-To do assessment of sensory

and neuron and motor responses,
especially reflexes (Pupil size
and reaction, Handgrip, leg
movement, eye opening, best
verbal response and best motor
response with the use of the
Glasgow coma Scale.

and -Vs monitored & recorded.

-For NVS q 4
-NVS
checked
recorded
Total NVS of 11/15

-To monitor vital signs and

checked for any unusualities.

-To do assessment of sensory

and neuron and motor responses,
especially reflexes (Pupil size
and reaction, Handgrip, leg
movement, eye opening, best
verbal response and best motor
response with the use of the
Glasgow coma Scale.

1:30pm

Intake
and
Monitoring q shift

Output - To monitor progress of -For I&O monitoring qShift -To know how much fluids are
urinary retention and -I&O summed up and loss/added in the course of care
edema.
recorded