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    Date/time Doctor's Order Rationale

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    james pasion
    1. The doctor examined the patient and reviewed their history of chest pain, admission to the local hospital, and medical history of hypertension. 2. Diagnostic tests were ordered including bloodwork, ECG, echocardiogram, and chest x-ray to evaluate the patient's condition. Medications were started or continued for pain, edema, hypertension, and infection prevention. 3. Over the next few days, the orders focused on IV fluids and electrolyte replacement. Additional diagnostic tests including troponin, HbA1c, blood typing, and repeat echocardiogram were ordered. Medications were continued and adjusted to prevent blood clots and treat underlying conditions. Strict intake and output monitoring was maintained

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    Date/time Doctor's Order Rationale

    Uploaded by

    james pasion
    39 views2 pages
    1. The doctor examined the patient and reviewed their history of chest pain, admission to the local hospital, and medical history of hypertension. 2. Diagnostic tests were ordered including bloodwork, ECG, echocardiogram, and chest x-ray to evaluate the patient's condition. Medications were started or continued for pain, edema, hypertension, and infection prevention. 3. Over the next few days, the orders focused on IV fluids and electrolyte replacement. Additional diagnostic tests including troponin, HbA1c, blood typing, and repeat echocardiogram were ordered. Medications were continued and adjusted to prevent blood clots and treat underlying conditions. Strict intake and output monitoring was maintained

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    Doctors Order

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    1. The doctor examined the patient and reviewed their history of chest pain, admission to the local hospital, and medical history of hypertension. 2. Diagnostic tests were ordered including bloodwork, ECG, echocardiogram, and chest x-ray to evaluate the patient's condition. Medications were started or continued for pain, edema, hypertension, and infection prevention. 3. Over the next few days, the orders focused on IV fluids and electrolyte replacement. Additional diagnostic tests including troponin, HbA1c, blood typing, and repeat echocardiogram were ordered. Medications were continued and adjusted to prevent blood clots and treat underlying conditions. Strict intake and output monitoring was maintained

    Copyright:

    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    39 views2 pages

    Date/time Doctor's Order Rationale

    Uploaded by

    james pasion
    1. The doctor examined the patient and reviewed their history of chest pain, admission to the local hospital, and medical history of hypertension. 2. Diagnostic tests were ordered including bloodwork, ECG, echocardiogram, and chest x-ray to evaluate the patient's condition. Medications were started or continued for pain, edema, hypertension, and infection prevention. 3. Over the next few days, the orders focused on IV fluids and electrolyte replacement. Additional diagnostic tests including troponin, HbA1c, blood typing, and repeat echocardiogram were ordered. Medications were continued and adjusted to prevent blood clots and treat underlying conditions. Strict intake and output monitoring was maintained

    Copyright:

    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    of 2

    Date/time Doctor's Order Rationale

    Sept. 1,
    2018
    1. To determine the general status of the pt.
    9:21 AM 1. Patient seen and reexamined
    2. History reviewed
    • 4 days PTA: chestpain (ps 9-
    10/10) radiating to the scapular
    area
    (+) diaphoresis
    consult at local hosp, admitted
    • 2 days PTA: transferred for
    further evaluation
    • Hours PTA – admitted
    • (+) HPN (2010): Metropolol 50
    mg tab OD PO
    • (-) Hx of previous admission
    4. Diagnostics
    • CBC, platelet • Measures several components and features of blood
    • Crea, BUN • To evaluate kidney function
    • Na, K+, Ca, Mg • Measures level of electrolytes
    • Blood culture • Identifies specific bacteria/fungi causing the infection
    • Trop I, please facilitate • Measures the levels of troponin T or troponin I in the
    blood
    • ECG – 12 leads • Measures heart's electrical activity
    • 2D echo, please follow up • Ultrasound technique to take pictures of the heart
    • Repeat CXR-PAL • Projection radiograph of the chest used to diagnose
    tomorrow 6 am conditions affecting the chest
    5. Therapeutics
    1. increase aspirin to 100 mg tab 1. For mild to moderate pain or fever, to prevent blood clots
    OD PO
    2. Furosemide 40 mg IV q 8hrs 2. For edema due to heart failure, hepatic impairment or renal
    disease. Hypertension
    3. continue other meds
    3. To continue treatment

    6. Ffup requested blood units, to


    transfuse 1 unit q 8hrs with BT
    precautions
    - Furosemide 20 mg IV port BT • prophylactic administration of loop diuretics is common
    esp. among pts who are at risk for circulatory overload ,
    pulmonary edema, or both
    7. Strict I and O q shift 6. To help evaluate pt.'s fluid and electrolyte balance, any imbalance
    may affect pt.'s output
    8. Moderate high back rest 8. For proper lung expansion and to promote breathing
    9. Deck to ICU/CCU depending on
    vacancy (Deck 2)
    10. Refer accordingly
    Sept. 2,
    2018
    1. For fluid and electrolyte replenishment and caloric supply
    7:07 Am 1. IVF: D5W 500 cc @ 10cc/hr
    2. Continue other meds 2. To continue treatment
    Sept. 3,
    2018
    1. For fluid and electrolyte replenishment and caloric supply
    7:01 AM 1. IVF: D5W 500 cc @ 10cc/hr #4
    2. Diagnostics:
    • For Trop I • Measures the levels of troponin T or troponin I in the blood
    • Hba1c (glycated haemoglobin) • Used to reflect average blood glucose levels
    • Blood typing • To tell the type of blood
    • CBG q6 (5-11, 5-11) • Reveals individual patters of blood glucose changes
    • For 2D echo w/ Doppler, please • Measures the speed and direction of the blood flow within
    do ffup the heart
    3. Therapeutics:
    Summary of Meds:
    1. Enoxaparin 6cc SQ q12 – D3 1. Used to prevent blood clots in pt.s who are in bedrest. Also
    used in combination with aspirin to prevent complications
    from angina and heart attacks
    2. Aspirin 100mg tab OD PO 2. For mild to moderate pain or fever, to prevent blood clots
    3. Clopidogrel 75 mg tab PO OD 3. Reduction of atherosclerotic events in pts at risk for such
    events including recent MI or acute coronary syndrome
    4. Atorvastatin 80 mg tab OD PO 4. Reduction of risk of stroke an heart attacks
    @HS
    5. Enalapril 5 mg ½ tab OD PO 5. For renal hypertension. Reduces systolic and diastolic BP
    by 15- 20%
    6. Carvedilol 6. 25 mg ½ tab BID 6. For hypertension
    PO
    7. Ceftriaxone 2 g IV q 24 7. To prevent growth of bacteria that cause infection
    8. Azithromycin 500 mg tab BID 8. Treatment of different types of infections caused by
    bacteria (respiratory, skin, ear, and STD)
    9. N-Acetylcysteine 600 mg tab 9. Treatment of respiratory affections by thick & viscous
    BID hypersecretions
    10. Start NaHCO3 tab TID PO 10. Management of metabolic acidosis. Used to alkalinize
    urine
    11. Omeprazole 40 mg tab OD PO 11. To treat conditions caused by too much acid production in
    the stomach
    4. Please do ffup Blood transfusion 4. to replace lost components of blood
    • Secure blood units as
    previously ordered
    • transfuse once available
    5. Ffup Decking to CCU as ordered
    6. Refer accordingly
    7. Strict I and O q shift 7. To help evaluate pt.'s fluid and electrolyte balance, any imbalance
    may affect pt.'s output
    8. Moderate high back rest 8. For proper lung expansion and to promote breathing

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