XI.
DOCTOR’S ORDER
Date Ordered Doctor’s Order Rationale Remarks
01/21/24 Admit pt For proper Done
1:24 PM monitoring,
management and
evaluation
Secure consent to care Patient has the right Done
to be consented in all
procedures to
bedone
TPR with BP q4 To monitor vital signs Done
so that any
unusualities will be
referred as follows
Start venoclysis: Done
IVF:
● PNSS 1L, fluid IV: PNSS - A normal
drop 300cc now saline solution; a
then regulate to 20 mixture of salt
cc/hr (sodium chloride) and
water with a
concentration of
0.9% sodium
chloride. For fluid
replacement and
electrolyte balance
Laboratory: CBC with PC Done
CBC PC determines the
quantity of each
quantity of blood cell
in a given specimen
of blood,often
including the amount
of hemoglobin,
hematocrit, and the
proportion of various
white blood cells. To
know any deviations
or abnormalities in
the blood
Urinalysis To screen patient's Done
urine for renal/urinary
detect substance
Random Blood Sugar To measure glucose Done
(RBS) levels in the
bloodstream at any
given time,
regardless of when
the individual last ate.
Fasting Blood Sugar To measure the Done
(FBS) glucose
concentration in the
blood after an
overnight fast and
are commonly used
to diagnose diabetes
or monitor blood
sugar levels in
individuals with the
condition.
Blood Test: A test that examines Done
● SGPT, the cells, chemicals,
● S. Urea proteins or other
● S. Uric Acid substances in the
blood.
CXR AP Chest x-ray is done Done
for internal
visualization of the
chest to check for
any unusualities and
to see if other vital
organs has already
been affected
12-lead electrocardiogram A medical test that is Done
(ECG) recorded using leads,
or nodes, attached to
the body. To capture
the electrical activity
of the heart and
transfer it to graphed
paper.
Medication: Done
● Omeprazole 40 mg To reduce the
IVTT now amount of acid in the
stomach and to treat
indigestion and
heartburn, and acid
reflux.
● Omeprazole To reduce the Done
40mg/cap, 1 cap amount of acid in the
OD PO stomach and to treat
indigestion and
heartburn, and acid
reflux.
● Rebamipide Helps in replacement Done
100mg/ tab, 1 tab of lost tissue by
TID PO increasing the
expression of
epidermal growth
factor (EGF) and
EGF receptors.
These EGF causes
angiogenesis,
increased production
of granulation tissue
and epithelialization
of ulcer healing.
● Eposis 4000IU A medicine that helps Done
inject route SQ your bone marrow to
produce more red
blood cells. It is used
to treat a type of
anemia caused by
kidney disease. It is
also used to treat
anemia caused by
cancer chemotherapy
and by taking
medicines to treat
HIV.
● Propanolol 10 It is used to treat Done
mg/tab, 1 tab OD heart problems, help
with some of the
symptoms of anxiety
and prevent
migraines.
I/O every shift To indicate the fluid Done
balance for the
patient
Done
Watch out for any unusual
s/s; Report always
01/21/24 To secure 2 units of whole To treat patients who Done
4:35 PM blood need all the
components of blood,
such as those who
have sustained
significant blood loss
due to trauma or
surgery.
01/22/24 One Algina Sachet now For the treatment of Done
12:20 AM symptoms of
gastroesophageal
reflux such as acid
regurgitation,
heartburn, and
indigestion due to
reflux of stomach
contents.
01/23/24 Stat CBC PC CBC with PC Done
3:50 PM determines the
quantity of each
quantity of blood cell
in a given specimen
of blood,often
including the amount
of hemoglobin,
hematocrit, and the
proportion of various
white blood cells. To
know any deviations
or abnormalities in
the blood
Refer Done
01/23/24 Plan: Done
7:10 PM
● CT Scan of whole to assess the
abdomen with abdomen and its
contrast organs for tumors
and other lesions,
injuries, intra-
abdominal bleeding,
infections,
unexplained
abdominal pain,
obstructions, or other
conditions
● Endoscopy, to collect tissue
Colonoscopy samples (biopsy) to
test for diseases and
conditions that may
be causing anemia,
bleeding,
inflammation or
diarrhea.
Colonoscopy is used
to look for colon
polyps or bowel
cancer and to help
diagnose symptoms
such as unexplained
diarrhea, abdominal
pain or blood in the
stool
Continue meds Done
Medication: Done
● Suggest to start It helps to make
Vitamin K amp various proteins that
IVTT Q8H are needed for blood
clotting and the
building of bones.
● Tranexamic Acid To indicate the fluid Done
500 mg IVTT Q8H balance for the
patient
01/24/24 For CT Scan of whole Done
9:30 PM abdomen
