MEDICAL MANAGEMENT

ReferraI Note
Date Notes RationaIe NURSING
RESPONSIBILITIES
Oct.8,2011
5:30pm














O Refer to FS: head
trauma
O Refer to FM: fever










O >Suicide, homicide,
escape precaution








O >Refer accordingly.






O Respectfully referring
patient to your service
for further evaluation
and management.
Thank you!


O For close monitoring
of the patient and
proper management
of his condition.







O This is ordered so
that the patient will
be monitored closely
and to avoid the
harming of patient's
life or others.




O This may create a
collaborative
treatment among the
client and the health
care providers; thus
it also makes a good
coordination on the
treatment of the
client.





O Assist patient.













O Observe and
monitor for
patient's
behavior to
prevent
harmful acts
of the patient.


O Refer to the
AP about the
patient's
condition
accurately.











O NO: head trauma
secondary to fall
O TO: 1pm
October.8,2011,
Montalban Rizal

O O> BP: 140/80
O (+)confusion
O HR: 98bpm
O RR: 20cpm
O Head trauma
secondary to fall
O Fever etiology to be
determined.
O P>Refer to FS





















O This may create a
collaborative
treatment among the
client and the health
care providers; thus
it also makes a good
coordination on the
treatment of the
client.



















O Refer to the
AP about the
patient's
condition
accurately
Oct.8,2011
7:20pm

















O >Please admit to FSW










O >Routine ward care






O For close monitoring
of the patient and
proper management
of his condition.



O To prevent patient
from acquiring
infections.





O Assist the
patient in
admission,
secure
consent.






O Do daily ward
care.

























Oct.9,2011
9:50am


Oct.10,2011
10:35am






10pm

O >NPO















O >VS and NVS q1, then
q4 if stable



















O >Diagnostic
O -CBC stat
O -For cranial CT Scan
O Urinalysis stat

O >D5NM 1Lx8hrs.

O >Paracetamol 300gms

O To prevent
aspiration and to
prepare for a test.













O Vital signs are
important for
baseline assessment
and to monitor
patients condition
which evaluates the
whole treatment
course, especially
the medications she
receives that could
be a contributing
factor in the variation
results of the vital
signs.
O To evaluate client's
further condition.







O Advised pt
not to eat and
drink anything
as ordered by
the doctor.
The
alternative
way for
patient's thirst
is to wet lips
by a cotton
ball soaked in
water.


O Monitor and
record vital
signs to
evaluate
further
conditions.
















O Follow up lab
results.





TV 1 amp now then q4
< 37.8C
Please refer if
there is still
vomiting, fever.
O >ce compress affected
area for 1
st

24hours/occipital area.
O >Please transfer to Dr.
Montes.

O A case of a 38years old
female, Lagdamen
Nilly, married from
Montalban Rizal
O BP:130/80
O Temp: 37.6 C
O CR: 80
O RR:26
O (+)vomiting 4x
O (+)fever
O (+)dyspnea
O (+)drowsy
O (+)hematoma

O -Conscious, ambulatory
with support, febrile,
not in distress
O -Pink palpebral
conjunctiva
O (+)hematoma 4x4cm at
Occipital area
O -Cerebral concasion
with hematoma
secondary to fall


O D5NM 1Lx12hrs













































O A hypertonic solution
which aids in lost
body fluids











































O Monitor and
regulate VF
accurately
and check if it
is infusing
well.



O -D/C VF


O -Transfer to Pav3



O -WOF vomiting
O -refer accordingly.








O Restrain patient














O Chest tapping q1 then
4-6hrs with agitation



O Vs q1 and record
please.














O May be a sign of any
complications.








O Psychiatric facilities
often use medical
interventions in the
form of restraints to
reduce safety risks
posed by violent
patients and to
prevent patients
from harming
themselves and
others.




O Promotes a comfort
feeling.


O Vital signs are
important for
baseline assessment
and to monitor
patients condition
which evaluates the
whole treatment
course

O Assist in
removing V
tubing.
O Assist patient
to transfer to
Pav3

O Monitor
patient for
any
vomiting,avio
d foods or
things that
can make the
client
nauseated.


O Monitor
client's
behavior to
prevent them
from harming
themselves
and others,








O Assist patient
in doing chest
tapping.


O Monitor VS
and record it
accurately.






O Suicidal, homicidal






O Refer

O This is ordered so
that the patient will
be monitored closely
and to avoid the
harming of patient's
life or others.


O This may create a
collaborative
treatment among the
client and the health
care providers; thus
it also makes a good
coordination on the
treatment of the
client.

O Monitor for
client's
behavior to
prevent from
harming
themselves
and others.

O Refer to the
AP about the
patient's
condition

Oct.11,2011








4:15pm





0ct.12,2011
4:45pm













S> Referred due to descriptive
behavior.
O> Seen and examined an
adult female. She was on 4
patient restraint. She was
restless and agitated. She
was violent. Mood is labile
with appropriate affect.

O Chest/back tapping q2





O Vs q1 while restrained







O Refer accordingly




















O Vital signs are
important for
baseline assessment
and to monitor
patients condition
which evaluates the
whole treatment
course





















O Monitor and
record VS
accurately.













0ct.16.2011
4:40pm



O Admit to P3W2




O Vs q shift and record








O DAT with SAP





















O Haloperidol 5mg BD







O This may create a
collaborative
treatment among the
client and the health
care providers; thus
it also makes a good
coordination on the
treatment of the
client.


O For close monitoring
of the patient and
proper management
of his condition.

O For baseline data
and for close
monitoring of client's
condition.








O This is done to give
appropriate and
adequate
nourishment with the
prevention or
minimization of risk
factors in the patient
at risk for aspiration.










O Assist patient
in admission.









O Monitor and
record VS
accurately.







O Advise patient
to avoid
eating foods
that can
aspirate the
patient



O Advise client
to Stop taking




O Monitor for




























O Lab. Pregnancy test

O WOF loss of
consciousness
,vomiting, dyspnea
O Haloperidol is an
older antipsychotic
used in the
treatment of
schizophrenia.
O May be a sign of
complication of the
disease.
the client's
behavior and
consciousnes
s.



O Advise patient
to avoid
eating foods
that can
aspirate the
patient




O Assist patient
in transferring
to W1



O Administer
drugs
properly.






Oct.19,2011
9:00am







10am

S> "Mabuti naman po ako
O>Seen and examined an
adult female look appropriate
for age, fairly groomed with
good eye contact, mood
erithymic



O DAT















O May transfer to W1
once approved







O Meds: Haloperidol 5mg
BD, Biperiden HCL
2mg/tab OD






O Change ward behavior,
sleep and eating


O This is done to give
appropriate and
adequate
nourishment with the
prevention or
minimization of risk
factors in the patient
at risk for aspiration.
O For close monitoring
of the patient and
proper management
of his condition.
O These are
antipsychotic drugs
to reduce the
symptoms felt by the
patient.























































O Monitor
patient
closely for
changes in
her behavior.





pattern

O Suicidal, homicidal, and
escape precaution










O Refer




O This is ordered so
that the patient will
be monitored closely
and to avoid the
harming of patient's
life or
others.




O This may
create a
collaborative
treatment
among the
client and the
health care
providers;
thus it also
makes a good
coordination
on the
treatment of
the client.































O Refer patient
to the AP to
evaluate
further
conditions.










LABORATORY EXAMS

HEMATOLOGY
Date: Oct.8,2011

RESULTS NORMAL VALUES
HemogIobin: 1.26 FemaIe 120160g/L
MaIe 140180g/L
Hematocrit: 0.37 FemaIe 0.36
MaIe 0.400.54
RBC: 4.6 4.6x1012/L
WBC:10.1 510x109/L
DifferentiaI count
NeutrophiI: 0.77 0.450.65
Lymphocyte: 0.22 0.200.35
Monocyte: 0.01 0.020.06
PIateIet count: 212


URINALYSIS
Date: Oct.9,2011

CoIor: Light yeIIow
Transparency: SIightIy turbid
S6: 1015
Ptt: acidic
Protein: (+)
Sugar: ()



MICROSCOPIC FINDINGS
WBC: 1-3hpf
RBC: 11-15hpf
Epithelial cells: moderate
Mucus threads: few
Amorphous urates: few

PREGANANCY TEST
Date: 0ct.12,2011
Result: NEGATVE















Patient is NL, 38 years old female, married, Filipino, High school graduate, NC,
unemployed. Presently residing in Montalban Rizal brought by mother and admitted in
Oct.8,2011

HPI:
Patient was mentally ill since 2009, previous hospitalizations and medications
history are unknown to confinement.
Two hours PTA, patient attended her sister's wake. She was then observed to
have irrelevant speech shouting loudly and with crying spells. She was destructive to
properties, one physically assaulted her character. She ran out of the house and
accidentally fell her head on the concrete sidewalk, sustaining a head injury. She was
then brought to our center for consult of subsequent admission.

Covered in the ward:
Upon admission, patient was admitted to FS due to head trauma. She was given
V Paracetamol. She was then transferred to PAV 3 W2 and started on haloperidol 5mg
BD.

PE:
-Conscious, coherent, ambulatory
-BP:110/80 PR:86 RR:20 Temp: 36.1C
-Seen patient finding essentially normal
-Seen and examined an adult female, in uniform, she was seen on 4 patient restraint.
She was restless and agitated. Mood is labile with apathetic affect. Speak in violent.
Patient repeatedly says: "Gusto ko mag- Jollibee, Daddy!