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Art Christian M. Ramos July 26, 2013
BSN 4 – 3
1. Nurse’s Progress/Narrative Notes
July 19, 2013 6 – 2 pm Shift
Date Hours
July 19, 2013 0700 Admitted a 60 year old male client with diagnosis of bladder cancer, stage III via stretcher. Conscious,coherent, oriented, not in any form of distress at 7am.On O2 Nasal Cannula at 2 – 4 liters per minute intact.With IVF of #1 PNSS 1L at 10gtts/mins (Keep VeinOpen), infusing well. With Indwelling Catheter connected to Urobag, draining to yellowish urinaryoutput at 250cc level. Initial Vital Signs taken at 7amand recorded as follows: BP= 130/90 mm/Hg; PR= 86bpm; RR= 22cpm; T= 37.5 °C, Afebrile----------------------
July 19, 2013 1300 Seen by Dr. Castro at 1:00pm, with the following ordersmade: to start bottle #2 D5 NSS 1L to run for 8 hours,To follow bottle #3 D5 NSS 1L to run for 8 hours, tofollow bottle #4 D5NSS 1L to run for 12 hours. To starton the following medications: Ondansetron 50mg/IV,every 6 hours; Tramadol 10mg/IV, every 8 hours asneeded; Calcium Carbonate 1 tablet once a day;Potassium Dorol 2 tablet, three times a day; IronSupplement at 2pm. For Nasogastric Tubing insertion,put on nothing per Orem (NPO) – To follow orders.Monitored accordingly. Maintain on low fat, low salt dietwith strict aspiration precaution. Watch out for signs of hematuria, nausea and vomiting, change in levels of consciousness, and difficulty of breathing. Supportivenursing care and management, rendered. Endorsedwith follow up on Blood results and Chest X-ray, strictintake and output monitoring. For TransurethralRetrogade Pyelogram on July 22, 2013 at 9:00 amunder the service of Dr. Castro. OR request sent,Informed Consent Signed. -------Art Christian M. Ramos----------------------------------------------SN, PLM Batch 2014
Addendum: Schedule at OR department of Sta. AnaHospital at 2:30pm------------------Art Christian M. Ramos----------------------------------------------SN, PLM Batch 2014
2. Compute for the cc/hr of the ff IV bottles: 2, 3 & 4 only
HOURS=
cc/hr
Bottle # 2: D5NSS 1 L to run for 8 hours
1000 cc
8 hours=
125 cc/hr
Bottle # 3: D5NSS 1 L to run for 8 hours
1000 cc
8 hours=
125 cc/hr
Bottle # 4: D5NSS 1 L to run for 12 hours
1000 cc
12 hours=
83.3 cc/hr
3. Give the rationale for ondansetron administration
The rationale for giving the patient ondansetron is that Ondansetron (Zofran)blocks the actions of chemicals in the body that can trigger nausea and vomiting. AlsoOndansetron is used to prevent nausea and vomiting that may be caused by surgery or by medicine to treat cancer (chemotherapy or radiation) which in case of the patient thathas bladder cancer may be in a treatment of chemotherapy and the side effects of it areNausea and Vomitting.
