COURSE IN THE WARD
July 28, 2017 patient EGY 52-year-old male was transferred from ER to
neuro ward with an admitting diagnosis of Acute Hemorrhagic Stroke. Received
patient on stretcher awake and coherent, with ongoing IVF PNSS 1Liter 90cc/hr
flow rate at 550cc level infusing well, indwelling foley catheter noted. Patient
complained of body weakness and inability to move left side of his body. Patient
was transferred from stretcher to bed properly and kept comfortable in bed, on
moderate high backrest, side rails up, vital signs checked and recorded
(BP=160/90 Temp=36.8oc Pulse=80 bts/min Resp=20 cycle/min), advised watcher
not to leave patient alone. Physician’s order noted and carried out, Mannitol
100cc q8 TIV x 3 doses bolus, Nicardipine 10mg 10cc plus 90cc PNSS to run at
90cc/hr side drip, Telmisartan 80mg tablet per orem OD after breakfast,
Omeprazole tablet 40mg per orem OD, Due medications given, needs attended.
July 29, 2017. 7:00 am, seen patient lying on bed conscious and coherent,
on moderate high backrest, left side body weakness noted, with ongoing IVF PNSS
at 90cc/hr plus Nicardipine 10mg at 10cc/hr infusing well, indwelling foley
catheter noted, vital signs monitored and recorded (BP=140/90 Temp=36.6oc
Pulse=75 bts/min Resp=18 cycle/min), new physician’s order Carvedilol 25mg
1tablet oral once a day after lunch, order carried out. Due medications given,
ensured safety precaution, advised watcher to not leave the patient alone, needs
attended.
July 30, 2017. 7:00 am, patient was on bed sleeping, maintained on
moderate high backrest, with ongoing IVF PNSS 1liter at 90cc/hr plus Nicardipine
10mg at 10cc/hr infusing well, indwelling foley catheter noted, vital signs
monitored and recorded (BP=140/80 Temp=36.8oc Pulse=76 bts/min Resp=20
cycle/min), advised the watcher not to leave patient alone, due medication given,
new physician’s order carried out, start Telmisartan 80mg 1 tablet oral once a day
after breakfast.
July 31, 2017. 6:00 am Neuro Ward Orientation, 7:00 am first visit with
patient EYG, seen patient lying on bed awake and coherent, established rapport,
left side body weakness noted, on moderate high backrest, with ongoing IVF PNSS
1liter at 90cc/hr drip rate at 700cc fluid level infusing well, indwelling foley
catheter noted with 400cc urine level slightly turbid yellow in color, asymmetry of
face noted sluggish on the left side, placed patient on comfortable position, vital
signs checked and recorded (BP=130/80 Temp=36.8oc Pulse=80 bts/min Resp=20
cycle/min), morning care done, due medication given, physical assessment,
cranial nerve assessment and cerebellar function assessment done except
Romberg and Tandem gait test, interview, Gordon’s and health teaching done,
ensure safety precaution, instructed watcher not to leave patient alone, CBG
done, needs attended, NCP 1 applied.
August 1, 2017. 7:00 am seen patient in supine lying on bed awake and
coherent, on moderate high backrest, left side body weakness noted, with
ongoing IVF PNSS 90cc/hr at 900cc level infusing well, indwelling foley catheter
noted with 200cc urine level, morning care done, vital signs checked and recorded
(BP=130/80 Temp=37.0oc Pulse=82 bts/min Resp=20 cycle/min), side rails up,
health teaching done, emphasized importance of body hygiene, no new
physician’s order, due medication given, NCP 2 done, instructed watcher not to
leave patient alone, needs attended.
August 2, 2017. 7:00 am seen patient lying on bed awake and coherent, left
side body weakness noted, complained of itchiness, body odor noted, with
ongoing IVF PNSS 90cc/hr at 300cc level infusing well, no indwelling folley
catheter noted, morning care done, vital signs checked and recorded (BP=130/80
Temp=36.8oc Pulse=79 bts/min Resp=18 cycle/min), side rails up, health teaching
done, emphasized the importance of compliance to medication and body hygiene
especially perineal area, due medication given, NCP 3 done, needs attended. May
go home, discussed Discharge Plan to the patient and significant others, advised
strict compliance to instructions.
