DATE DOCTOR’S ORDER RATIONALE NURSING RESPONSIBILITIES

3/25/23 - Admit patient to ICU -For further patient medical - Admitted the patient as ordered
under the service of DR. condition monitoring and -Prepared and filled out the necessary documents
Reyes then take over assessment -Obtained initial vital signs and recorded
DR. E Reyes -Assisted the patient to room of choice
-Informed assigned doctor regarding re-admission
-Secure consent for -To have consideration and -Explained to patient’s /SO about risks, benefits, and alternatives
admission and respect patient’s autonomy to of a given procedure or intervention
management make health care decisions -Addressed client /SO question about the procedure to be
performed
-Facilitated patient’s SO for documentation of consent
-NPO temporarily while -Nothing by mouth means -Explained to SO the importance of making the patient on NPO
dyspneic prohibit patient in taking foods Status
and fluids. This is to prevent -Patient was placed on NPO Status
patient from aspiration while -Positioned the patient on his bed into more comfortable height
dyspneic
-IVF: PNSS 1L x 24 hrs -For hydration and to facilitate -Verified doctor’s order
fluid and electrolytes -Regulated IVF accurately
replacement and to serve as an
access for IV medication
-CBC, BUN, Creatinin, -Checking of laboratory results -Verified doctor’s order
K if there are some abnormal -Informed the patient about the diagnostic exams
findings from normal results -Filled out necessary request form
-Apical view to check the -Followed-up results and attached it to the patient’s charts
extent of damage of the lungs
-CxR-AP, R-L, ECG
-Therapeutics -Verified doctor’s order
-Observed rights of drug administration
-Hydrocortisone -is used to treat immune, 1. Right Drug
100mg/dl /IV inflammatory, and neoplastic 2. Right Dosage
conditions. 3. Right Patient
4. Right Route
-Salbutamoln + -is used for Acute asthmatic 5. Right Time
ipratropium attacks & exacerbations of 6. Right Documentation
chronic bronchitis. 7. Right Education
Management of bronchospasm 8. Right Assessment
-Omeprazol 40mg
in COPD. 9. Right to Refuse
10. Right Evaluation
11. Monitored vital signs
>Continue present
-omeprazole is a proton-pump
mendication
inhibitor, used to treat gastric
-Amlodipine 100mg acid-related disorders.

-Trimetazidine 35 mg
-Amlodipine is a calcium
channel blocker used to treat
hypertension and angina.

-Trimetazidine is a piperazine
derivative indicated as an
-Losartan 100 mg adjunct therapy in
symptomatic treatment of
stable angina pectoris.

-Rosuvastatin 10mg -Losartan is an angiotensin

receptor blocker used to treat
 hypertension and diabetic
nephropathy, and is used to
reduce the risk of stroke.

-used to lower the risk of

-Clonidine 75mg cardiovascular disease and
manage elevated lipid levels by
inhibiting the endogenous
production of cholesterol in the
liver

-Clonidine is an alpha-2
adrenergic agonist used to treat
hypertension and severe cancer
pain, among other conditions,
-Clopidogrel 75 mg and to treat withdrawal
symptoms from various
substances. It is also used to
aid in the diagnosis of
pheochromocytoma and to
prevent migraines
-Doxofylline 400mg

-is an antiplatelet agent used to

prevent blood clots in
peripheral vascular disease,
coronary artery disease, and
cerebrovascular disease.
 -used in the treatment of
asthma

3-25-2023 Start amikacin R: To treat serious bacterial NR: Give amikacin to treat the infection
infection in many different
For intubation once a parts of the body Insert intubation to help support breathing
day
To look for minute ventilation to give an accurate volume to the
If intubation look to MV patient.
10:25am For intubation To give appropriate dosage to Identify the patient
the patient
Diacystein 5g, IV Interpret the doctors order

Diaphydine 50g, IV Prepare exact dosage of prescribed drug

Monitor the patients response for desired and possible adverse

effects
3-27-2023 Refer to Dr. E. Battung To remove fluid that’s built up Explain the procedure to the patient
in the airways
Tracheostomy insertion Provide qtracheostomy care for clients with new or recent
tracheostomy to maintain patency of the tube and minimize the
risk for infection

Verify that an inner cannula is in place.

Change the tracheostomy tube every week.

Clean the tracheostomy once a day.

 Verify that a low-pressure cuff is in place.
3-28-2023 CXR-AP Portable today Rationale: To minimize Assess the patient’s ability to hold his or her breath
magnification of the cardiac
silhouette. To ensuring the patients comfort while at the xray room

Provide appropriate clothing

9:31am Decrease To maintain the normal blood Monitor BP continuously if possible or every couple of minutes.
Norepinephrine drip to J. pressure to the patient
Microdrops
3-28-23 Shift piptaz to zepim 2
grams IV q 12 hours
1:39 pm
4:00 pm NPO at 7pm. Tomorrow - Nothing by mouth is a Verify and carry out doctor’s order.
a surgery will be done as medical instruction meaning to
on call basis withhold food and fluids.

- To lower the risk of Instruct the patient not to eat or drink.

aspiration of gastric contents
during general anesthesia,
which is due in part to
suppression of laryngeal
reflexes from anesthesia.
3-29-23 Transfuse 2 units of -Blood transfusion reduces -Verify doctor’s order. Inform the client and explain the purpose
 PRBC minute ventilation and work of of the procedure.
breathing
7:23 am -Obtain and record baseline vital signs

4:23pm Lactulose 30cc at -To relief constipation -Verified doctor’s order.

ODHS.
-Decreased blood ammonia -Observed 10 rights of drug administration.
levels with improved mental
status in portal-systemic 1. Right drug
(hepatic) encephalopathy
(PSE). 2. Right dosage

3. Right patient

4. Right route

5. Right time

6. Right documentation

7. Right education

8. Right assessment

9. Right to refuse
 10.Right evaluation

4:25 pm - For tracheostomy tube - to create an artificial airway - explain the procedure to the patient and their family.
insertion at 8pm tonight.
- - use a standard aseptic technique using non-touch technique.
- Refer to Dr. Baquiran
for anesthesia -Refer accordingly.

3-30-23 -Transfuse 4 units of -To prevent hypoventilation to -Monitoring patient vital sign every 5 minutes during the first 15
platelets concentration, the patient minutes
7:30 pm type, specific each unit
to run for 30 mins.
3-31-23 -For possible exploration -To a significant reduction of -Administer fluids and blood as prescribed
and control bleeders both the minute ventilation and
5:27 pm tomorrow at 7 am/ GA. the WOB 

-Secure consent -To have ethical consideration -Facilitated documentation of consent.

and also to protect patients
freedom to make healthcare
decisions.
-Inform OR To review the patients identity, -Identify and explain the procedure to the patient
the procedure, and the surgical
 site before surgical incision or
the start of the procedure. -Check for the doctors order

Inform Dr. Baquiran To review the medical -Check of the patient's chart and explain needs of the patient to
condition and history to plan the doctor before performing the surgery
the appropriate anesthetic for
surgery. 

NPO post midnight Nothing by mouth is a medical -Verify and carry out doctor’s order.
instruction meaning to
withhold food and fluids. -Instruct the patient not to eat or drink.

- To lower the risk of

aspiration of gastric contents
during general anesthesia,
which is due in part to
suppression of laryngeal
reflexes from anesthesia.
5:42 pm Once available, transfuse -To attain the normal value of -Patient should be correctly identified and consent where
4 units platelet RBC applicable explained and signed
concentrate, type,
specific, each unit to run -Explain the procedure or to the guardian of the patient.
for 30 mins.
-Monitor the vital signs
 -Observe the rights of the patient

Give diphenhydramine To prevent febrile -Verified doctor’s order.

50 mg IV before platelet nonhemolytic transfusion
transfusion. reactions and minor allergic -Observed 10 rights of drug administration.
transfusion reactions.
1. Right drug
2. Right dosage
3. Right patient
4. Right route
5. Right time
6. Right documentation
7. Right education
8. Right assessment
9. Right to refuse
10.Right evaluation