VIII.
COURSE IN THE WARD
DATE AND TIME Doctor’s Order FOCUS DATA, ACTION,
RESPONSE
April 26, 2025 -Please Admit to ICU Admission D: Into ER admitted a 17
3:15 pm -Secure Patient consent years old male with CC
for admission and of Persistent high-grade
management fever, abdominal pain,
-IV fluids PNSS 1L to run gum bleeding, GI
for 12 hours bleeding, generalized
- TPR every shift and weakness for 3 days
record
- DAT
-Blood transfusion: 1 VS taken:
unit PRBC T: 39.2 degrees Celsius
-oxygen mask @ 8-10
Liter per minute BP: 80/60 mmHg
O2:95 %
Medications HR: 124 bpm
-Acetaminophen RR: 22 bpm
350mg q4 IV for pain
H: 5’6” (167 cm)
and fever
-Omeprazole 40mg IV W: 128 lbs (58 kg)
od
-Dopamine 5
A: Secured consent for
µg/kg/min/ IV infusion
admission
-Norepinephrine 0.016
Seen and examined by
mg/mL, diluted in 250 Dr. A. and referred to
ml of dextrose 5% in the attending physician
PNSS. with admitting orders
made and carried out.
R: All endorsed to the
Laboratory nurse on duty.
-CBC
-PT/INR
-ApTT
-Blood typing &
crossmatching
-Dengue NS1 antigen
-IgM
-ECG
April 26, 2025 For IFC insertion Trans IN to ICU ward D: Received from ER via
3:55 pm IFC insertion wheelchair with ongoing
Uric output after IFC IVF, level patent and
infusing well (+)
abdominal pain, GI
bleeding
A:
-Explained the
procedure to the pt and
SO in a calm and
reassuring manner
-Provided privacy
-Inserted IFC aseptically
and secured it in placed,
hanged at the bedside
below the level of the
pt.
Placed in bed
comfortably, Assessed
patient condition.
Routine admission care
done. Advised SO not to
leave the patient
unattended.
R: All endorsed
April 26, 2025 Blood transfusion D: Blood type A+ with a
positive Rh factor;
Laboratory results: Hb-
7.5 g/Dl, Hct: 22 %; no
previous transfusion
reactions or
complications
A: Verified doctor’s
order; Obtained consent
signed by the SO;
Secured 1 unit of PRBC
properly screened and
cross – matched;
Explained the purpose
of the procedure.
Recorded baseline vital
signs then monitored
q15 mins for the first
hour then q hour
during blood
transfusion.
R: No signs of
transfusion reactions
noted.
April 26, 2025 -Administer Fever D: Received patient on
Paracetamol 300mg IV bed awake, with
q4 ongoing IVF,
temperature of 39.2
-Continue Monitoring of degrees Celsius
temperature
A:
V/S monitored and
recorded
Encourage SO to do TSB
to the patient.
Administer
acetaminophen __ as
ordered by the
physician, provide
comfort measure. All
due meds given, all
health needs attended.
R: Patient still have
persistent high body
temperature.
April 27 Laboratory Vomiting D: Received patient on
7 am – 11 pm -Repeat CBC, PT/INR, bed conscious and
aPTT responsive, reports of
vomiting 3 times in the
- Urinalysis past hour, associated
with abdominal pain
Administer A:
Ondansetron 4mg IV V/S monitored and
push q6 for nausea and recorded
vomiting
Provide hydration,
monitored patient’s
condition and assessed
for signs of dehydration
R: Decreased frequency
of vomiting
11pm - 7am Fluids and electrolytes D: With an IVF of NaCl
replacement of 900 cc level 50cc/hr ,
moderately dehydrated
due to vomiting
A:
V/S monitored and
recorded
Hydration continued
orally and
intravenously, above IVF
regulated accordingly,
due medications given.
R: For further hydration
April 28, 2025 Administer Omeprazole Abdominal pain D: Received patient
7 am – 11 pm 40mg IV od lying on bed with on
going IVF with
complaints of
abdominal pain
Pain scale: 8/10
A: Assessed the
patient’s current
condition. Provided
comfort measure, all
due meds were given.
R: Continuity of care
April 29, 2025 Administer Dizziness D: Weak as seen
7 am – 11 pm Ondansetron 4mg IV Altered Comfort
push q6 for nausea and A:
vomiting Advised for adequate
rest. Raised the side
rails of the patient’s bed
to prevent falls and
ensure safety at all
times.
A: Encouraged patient
to drink fluids regularly,
Promote clean
11 pm- 7 am Health teaching environment to reject
Monitor Vital Signs habitat for vector.
R: For further care
April 30, 2025 -transfer to Pedia Ward Continuity of care D: Received patient on
7 am – 11 pm bed with on going IVF
ICU to Pedia Ward with a temperature of
36.5 degrees Celsius
and BP of 90/60 mmHg
A:
Meds Attended,
All needs attended
accordingly
R: Continue monitoring
May 1, 2025 Monitor Vital Signs Health teaching D: Received patient on
7 am – 11 pm bed and conscious
A:
.
Encourage rest and
relaxation, promote
hydration and nutrition
R: For further care and
management
May 2, 2025 Continue other Discharge planning D: Seen and examined
7 am – 11 pm medication at home by Dr. L.R. with may go
home orders.
Vital signs are stable t:
36.4, BP: 120/80, RR:
18, PR: 89, O2 sat: 96%
A:
-Bills facilitated and fully
accomplished
- Advised for a balanced
and nutritious diet
essential to support
recovery. Recommend
regular, gentle exercises
R: The patient improved
and recovered. For
follow up check up May
9, 2025 R2TMC OPD
- Bills Settled.
