COURSE IN THE WARD

Date
and Doctors Order Nursing Intervention Rationale
Time
1/16/
17
1:50 AM
Admit to ICU under the
service of Dra. Nerissa
Reyes
Receive consent for
admission
Diet: NPO
IVF PNSS 1 L x 16
Monitor v/s q 1, I & O q
1
Diagnostics
CBG: 155 mg/dL
CBC
Na, K, Crea, BUN
PT, PTT
12 Lead ECG
CxR, AP high
UA
CT scan plan with BW
Cervical APL
Pelvis AP
LS spine APL
Therapeutics:
Nicardipine drip 90 cc
PNSS+ 10 mg
Nicardipine to run at
15 cc/hr
 titrate at 5 cc/hr to
maintain at 140-150
SBP
Omeprazole 40 mg 1
OD
Mannitol 150 cc IV
now then 100 q 6
Tranexamic acid 1 g IV
now then 500 g IV q 8
x 6 doses
Tramadol 50 g IVP PRN
for pain q 8
Metoclopramide 10 IV
q 8 for n/v
O2 via nasal cannula 2-3
L/min
CBG q 6 and record

10:11 NGT, IFC insertioin

PM
Cervical collar
Inform AP of patients
whereabouts
11:00 Pls send plates of CT scan
PM

Addendum

Continue Mannitol at 125

cc q 4
Lasix 20 mg IV after every
3rd dose Mannitol
1/17/
17
7:00 AM Hold Furosemide
9:00 AM Ept, K, Ica, Mg
1:40 PM IVF to follow PNSS 1 L x
16
5:00 PM Neuro
Try giving gelatin per
orem with SAP
Start Losartan 50 mg 1
tab OD
Lipid profile, FBS, SGPT,
SGOT in AM
Start K-Lyte 1 tab TID
Shift IV Omeprazole to
Pantoprazole 20 mg OD
If gelatin is tolerated may
try lugaw with SAP
Lactulose 30 cc q v/s
For cervical spine and
pelvic X-ray (AP Lat-
oblique)
Start CaCO3 1 tab OD
Start Cefuroxime 500 mg
cap BID
Refer accordingly
1/18/
17
7:00 AM May have soft diet with
SAP
May not re-insert NGT
IVF to follow PNSS 1 L x
16
2:00 PM For HBA1C
Remove cervical collar
2:50 PM Neuro
Mannitol 100 cc q 4
Pass trans out in AM
Order in room
Refer to Rehab
For repeat CBC, Na, K,
Crea in AM
CBG OD before
breakfast
6:00 PM PNSS 1 L x 16 as IVF to
follow
1/19/
17
4:00 AM Give Paracetamol 500
mg/IV now then
Paracetamol 500/tab q 4
PRN per temp 37.8 C
above
10:34 Repeat CT-Scan with
AM
contrast
If with fever, repeat CBC
May re-insert NGT
12:57 IVF to follow PNSS 1 L x
PM
16 x 2 cycles
4:00 PM Start OF 1600 cal in 1600
cc divided into 6 equal
feedings
8:00 PM Refer to other oncologist
Will reassess patient
tomorrow
8:30 PM Inform relatives requiring
referral to oncologist
9:30 PM Refer to Dr. Villavicencio
for NS consult and
 evaluation
11:30 Neuro
PM
Patient seen and
examined
History and CT scans
reviewed
No neurological indication
for evacuation at ICH
Will standby
1/20/
17

1:50 AM For 2D Echo with Doppler Inform the intensivist on An intensivist, also known as a
admission critical care physician, is a
Hold temperature - medical doctor with special
Anastrozole training and experience in treating
critically ill patients.

7:25 PM
IVF to follow PNSS 1 L x Operate the mechanical Mechanical ventilator is a machine
16 ventilator with the given that generates a controlled flow of
settings gas into a

12:23 Give Clonidine (Catapres)

PM
75 mg SL now
3:00 PM Neuro
No available oncologist
Consulted with another
oncologist
Ok to resume Anastrozole
 Start Dexamethasone 4
mg IV OD
K-Lyte OD
For repeat CBC, NA, K, in
AM
IVF PNSS 1 L 16
1/21/
17
8:20 AM Start Piperacillin Inform the lab technician for the To compare the ABG from the
Tazobactam 4.5 g q 8 ordered laboratory tests while previous results for developments
Repeat chest X-ray and setting FiO2 at 40% while on the given FiO2 setting
urinalysis
Refer to cardio of choice
for co-management
8:35 AM Hold Cefuroxime Replace solution and regulate PNSS helpful to replace Na+
Refer to Dr. Villareal for for 20-21 gtts/min
co-management
8:40 PM Continue Losartan
Start PNSS 80 cc + 20 g Decrease FiO2 by 35% Decreasing FiO2 will be justified
Nicardipine initially at 5 through weaning can be gradually
mg/hr via infusion pump attempted by lowering its
titrate accordingly to concentration for a fixed period
achieve SBP 140 and re-evaluating the clinical
parameters.
1:21 PM Cardiology
Vital signs: BP: 140/80; Update significant others on To provide update on patients
CR: 80; O2 sat: 100%; patients status status
awake and responsive
Patient seen and
examined. History,
physical examination and
clinical course reviewed
Continue Losartan 100 mg
1 tab OD AM
 Continue K-lyte 1 tab TID
x 6 doses
Review 2D echo results

Neuro
Hold Dexamethasone in
AM
Mannitol 125 cc q 4
Pass transout in AM if ok
with other APs
6:30 PM Okay to transfer out of Verbal agreement signifies
ICU understand on the significant
others part
9:25 PM IVF to follow PNSS 1 L x Administer Piperacillin + Antibiotic, based on ETA GS/CS
16 x 2 cycles Tazobactam as ordered (9/19/16)
10:00 No objection for transout Continue to monitor BP as Systolic reading of 100 is in the
PM
to ICU ordered Normal range. Diastolic reading of
90 is in the High Blood Pressure
(Hypertension) Stage 1 range.

1/22/
17
6:23 AM Transfer Servida to room Administer Fluimicil as ordered Mucolytic agent, presence of
near station pseudomonas aeruginosa on ETA
GS/CS according on yesterdays
Reduce dosage of Vigocid as results
ordered Dosage of Vigocid must be
reduced in moderate to severe
impairment
3:48 PM Start Amlodipine (Norvasc
or Vasalat) 5 mg/tab Inform the lab technician for the To compare the ordered tests from
To consume Nicardipine ordered laboratory tests the previous results for
 drip
Inform once Dra. N. Reyes
order laboratory works
8:00 PM Neuro
Refer to rehab in AM
If fully awake try gelatin
per orem with SAP in AM
1/23/
17
12:10 IVF to follow PNSS 1 L x
PM
16
Refer PRN
2:10 PM Watch out for DOB, chest
pain and episodes of
desaturation for O2
saturation < 95%
Hook to oxygen via nasal
Shift Omeprazole IV to capsule
as ordered
Inform Nephrology on deck for
consult
Inform radiologic technologist to
perform diagnostic imaging
Increase Ketosteril
administration as ordered
Inform AP on patients status
Decrease administration of
Vigocid as ordered
developments
Parenteral omeprazole should be
shifted to oral omeprazole as soon
as feasible
Dr. Guce updated on patients
status. Data given will be used as
baseline
To compare the cranial CT scan
from the previous results for
developments
To decrease serum creatinine level
Dr. Pena updated on patients
status. Data given will be used as
baseline
Dosage of Vigocid must be
reduced in moderate to severe
impairment
 cannula at 2-3 L/min
Refer PRN
7:00 AM Please facilitate the Inform TCVS on deck for IJ Dr. Dizon updated on patients
following lab exams catheter creation. Notify OR. status. Data given will be used as
tomorrow 1/24/2017 baseline
CBC
Na, K, BUN, Crea
CXR portable high
setting
AP updated
Refer PRN
11:30 Neuro Notify OR for IJ catheter Intrajugular access allows the
AM
Facilitate lab in AM insertion. placement of various types of
Mannitol q 6 in AM intravenous (IV) lines to facilitate
Start bladder training the infusion of fluids, blood
products, and drugs
Inform anesthesiologist on deck Dr. Dizon updated via phone on
for the ordered procedure patients status. Data given will be
Significant others are aware used as baseline
regarding on the referral As a general rule, medical or
surgical procedures may not be
carried out without the informed
consent of the patient.

1/24/
17
7:30 AM Kindly relay CXR results Transfuse available PRBC as Low RBC count requires BT
once available ordered
IVF to follow PNSS 1 L at
60 cc/hr
No objections to start
bedside patient rehab
7:20 PM Neuro
 Mannitol q 8 in AM Hold all anti-hypertensive meds Blood pressure drops after
Remove oxygen in AM as ordered hemodialysis due to fluid being
quit as PRN pulled off, when combined with all
Start Melatonin 3 mg at of the anti-hypertensive
HS medication, the BP will bottom out

10:20 Neuro Inform the lab technician for the To be used on the patient for
PM
Patient seen and ordered laboratory tests baseline data
examined, however
limited neuro PE done due
to patient is drowsy
Noted with spontaneous
(n) of RF, RL
Hemiparesis (L)
Lenings test
Will start bedside rehab
for tomorrow then will
bring the patient to rehab
gym on the next session
Strict aspiration
precaution
Encourage HBR
Will follow up
1/25/
17
10:00 V/S noted
AM
IVF to follow PNSS 1 L x
60 cc/hr

Neuro
Mannitol 75 cc q 8 in
AM
Start bladder training
If with urge, remove foley
 catheter in AM
Last day of Piptazo
tomorrow then start
9:40 PM Silgram 750 mg 1 tab BID
Plan: MRI of the brain with
gado by next week as
OPD
Norgesic forte 1 tab now
per q 6 prn
1/26/
17
12:10 IVF to follow 1 L x 60 cc/hr
AM
6:30 AM Maintain on moderate
back rest
Turn patient side to side q
2
IVF to follow PNSS 1 L x
60 cc/hr
1/27/
17
Neuro
Try soft diet in AM c SAP,
hold OF. If tolerated,
remove NGT
Consume present stock of
Mannitol
For repeat CT scan brain
plain today
Possible discharge next
week
10:20 IVF to follow PNSS 1 L x
PM
60 cc/hr
1/28/ May also give Norgesic
17 forte 1 tab for cervical
12:15 pain/spasm
AM
1:30 AM Neuro
Repeat CT showed
minimal resolution of
hemorrhage, (+)
perilesional edema
Continue Mannitol for now
For MRI of the brain c
gado (+) MRS (Magnetic
Resonance Spectroscopy
c/o Makati Med or
Perpetual
Repeat area prior to MRI
1:55 PM Hold MRI for now
Inform relatives that will
do MRI after 2 weeks
IVF to follow PNSS 1 L x
60 cc/hr
1/29/
17
10:00 IVF to follow PNSS 1 L x
AM
60 cc/hr
10:35 Clonidine 75 mcg 1 tab
AM
OD post lunch
4:55 PM IVF to follow PNSS 1 L x
60 cc/hr
1/30/
17
7:40 AM IVF to follow PNSS 1 L x
60 cc/hr
11:00 OF to 1400/1400
 AM divided by 6 equal
feedings
Repeat CBC, Na, today
2:00 PM Start K-Lyte 1 tab TID
4:50 PM Rehab
Will start tilt table if
tolerated
9:20 PM Encourage oral feeding c
SAP
Start teaching relatives
regarding receiving care
Suggest to hold tilt table
for now
Will do MRI c qado as OPD
Tentative plan for
discharge within the week
IVF to follow PNSS 1 L x
600 cc/hr
1/31/
17
7:55 AM No objections to
discharge patient from CV
standpoint
Agree to hold tilt table
testing
Inform me on final
discharge plans for home
meds
2/1/1
7
11:55 Will discharge patient
AM
with NGT
Change present NGT to
siliconized NGT
7:15 PM Neuro
Teach relatives regarding
feeding
Ask dietician to instruct
relatives regarding
feeding preparating