KARDEX
Patient’s Name: Whaley Age: 84 Sex: M
Address: ______________________________________
Admitting Physician: _______________________ Date and Time Admitted: 11-21-2021/7:00a.m
Admitting Diagnosis: Acute hypoxemia with suspected Community Acquired Pneumonia
Surgery Done: ________________________________ Date and Time of Surgery: ________________
Mental Status Activities Diet Tubes Special Info
__ Conscious __ Ambulant __ NPO __ Foley Catheter __ Weigh Daily
__ Drowsy __ Dangle and Sit up __ DAT __Thoraco Tube __ BP q Shift
__ Stupor __ Bedrest with BRP __ Soft __NGT __ Neuro VS
__ Unconscious __ CBR w/o BRP __ Clear Liquids __ CVP __ Radiation
__ Comatose Others____________ __Ge. Liquids Others: Others: _________
Others___________ ___________
_
DATE MEDICATION DATE IV FLUIDS/BLOOD TRANSFUSION DATE & TIME
ORDERED ORDERED DISCONTINUED
Ampicillin 11/21/2021
IVF PNSS 1L x 7.5 hours @ 44-
11-21-2021 sulbactam 1.5mg Q6 11-21-2021 3:00 P.M
45gtts/min
IV
Azithromycin
500mg IV OD
Guaifenesin 1200
mg PO Q6
Metoporolol 25 mg
PO BID
ASA 81 mg PO OD
Claritin 10 mg PRN
DATE MEDICAL DATE DONE
ORDERED TREATMENT/LABORATORIES
/DIAGNOSTICS
11-21-2021 ABGs 11-21-2021
11-21-2021 Chest X-ray 11-21-2021
11-21-2021 Blood cultures 11-21-2021
INTRAVENOUS FLUID SHEET
SURNAME: Whaley M.I.: AGE: 84 HOSPITAL NO.: 007349201
GIVEN NAME: SEX: M WARD/ROOM NO.: Inpatient floor
Date Shift Bot. Kind of Volume Gtts Time Remarks Nurse’s
No. Solution started/consumed signature
11-21- 44-45 Started/Complete
7-7 1 PNSS 1L 1000 ml 7:30 a.m/ 3pm NCL
2020 gtts/min d
THERAPEUTIC SHEET
SURNAME: Whaley M.I. AGE 84 HOSPITAL 007349201
: : NO.:
GIVEN SEX M WARD/ROOM
NAME: : NO.:
NAME OF DRUG, DOSAGE, DATE AND TIME GIVEN
ROUTE, & FREQUENCY 11-21-2021
8:00 a.m
(NC
Leyaley)
Ampicillin sulbactam 1.5mg Q6 2:00 p.m
IV (NC
Leyaley)
8:00 p.m
(KC)
8:00 a.m
(NC
Azithromycin 500mg IV OD
Leyaley)
8:00 a.m
(NC
Leyaley)
2:00 p.m
Guaifenesin 1200 mg PO Q6
(NC
Leyaley)
8:00 p.m
(KC)
7:30 a.m
(NC
Leyaley)
Metoprolol 25 mg PO BID
6:00 p.m
(NC
Leyaley)
ASA 81 mg PO OD
7:30 a.m
(NC
Leyaley)
Claritin 10 mg PRN
NURSE’S NOTES
SURNAME: Whaley M.I. AGE 84 HOSPITAL 007349201
: : NO.:
GIVEN SEX M WARD/ROOM
NAME: : NO.:
Date-Shift FOCUS Data – Action – Response
11/21/2021
7-7 AM
7:30 am Admission D: admitted an 84 y/ male patient with initial VS as follows:
Assessment BP- 142/86 mmHg
HR -102 bpm
RR- 32 bpm
Temp -38.8°C
SpO2 -89% on room air
with fever, fatigue, tachypnea, cough with sputum, shortness of breath and
hypoxemia; has crackles throughout the lower lobes of his lungs; with
occasional expiratory wheezes throughout the lung fields-----------------------
(NCL)
A: place on bed; side rails; immediate caregiver to stay with patient; seen and
examined by ER Physician with orders made and carried out accordingly;
7:45 am consent to care and hospitalization secured and attached to chart; IVF of PNSS
7:50 am 1L inserted aseptically at left metacarpal vein with g.22 IV cannula @ and
7:55 am regulated to 44-45 gtts/min; administered titrate supplemental o2 as ordered
@; request for ABGs, CXR, and blood cultures; Diet as Tolerated instructed to
watcher-----------------------------------------------------------------------------------(NCL)
8:00 am
R: Transfer patient to inpatient floor via stretcher; accompanied by ER RS and
significant others; no untoward events noted---------------------------(NCL)
2:00 pm D: temperature 39°C/axilla @-----------------------------------------------------------(NCL)
Ineffective
A: initiated tepid sponge bath; loosened tight garments; encouraged adequate
thermoregulation as
oral fluid intake as tolerated @---------------------------------------------------------(NCL)
manifested by high
R: patient was closely monitored-----------------------------------------------------(NCL)
body temperature
39°C /axilla
2:00 pm D: cough with sputum; heart rate of 105 bpm; respiratory rate of 34 cpm with
Acute pain r/t episodes of difficulty of breathing @ -------------------------------------------------(NCL)
localized A: elevate head of the bed; encourage deep breathing exercise; demonstrate
inflammation and splinting chest and effective coughing while in upright position; encouraged
persistent cough adequate rest; promote adequate nutritional intake; administered Ampicillin-
3:00 pm sulbactam 1.5mg IV and Guaifenesin 1200mg PO as doctor’s
order--------------------------------------------------------------------------------------------------
------------------(NCL)
R: patient verbalized relief---------------------------------------------------------------(NCL)
