D F- Elevated Blood Pressure and titrated by

incrementsof 5 microdrips
-Received patient lying on bed asleep, D
per minute every 15
side rails up0 and locked, with on-
-Appears lethargic, cold and minutes to maintain
going IVF of PNSS 1L. at 200 cc level at
clammy skin noted, flaccid muscle systolic BP range of 120-
right antcubital vein at 30 drops
tone on the left side of the body; 150 as ordered. Arterial
infusing well, with nasogastric tube
right facial drooping noted,slurred blood specimen
Foley Bag Catheter connected to
speech, able to move all extractiondone aseptically
urobag with 200cc of tea colored
extremities per command but by Dr. Jones and sent to
urinary output; with oxygen
with left hemiparesis; eye opening laboratory.
administered at 3L/min
is appreciated upon name calling;
vianasal cannula.---------------------------- Laboratory results for
anisocoric, pupillary size of 6mm
------------------------------------------Skin CBC, S CREA, BUN and
at right eye and 3-4mm at lefteye;
cold to touch, pale looking, chilling ABG in. Relayed to
right pupil is sluggishly reactive to
sensation noted.---- Dr.Jones thru SMS,
light while left pupil is briskly
updated patient’s status
A reactive to light accommodation.
and replied
BP-160/90, HR-98 bpm,RR-23
-placed comfortably on bed with side
cpm, T-37 “ok thanks”
rails up and locked; oxygen
administered continuously at 3L/min.; A R
monitored blood pressure every 15
-Placed on bed with side rails up -BP rechecked 140/80
mins. Warm blanket applied.
and locked; head of bed elevated
Measured and recorded intake and A
at 30 degree angle; oxygen
output. Administered Tramadol 30mg
inhalation administered; hooked -Visited patient and
injected very slowly thruIVTT as per
to cardiac monitor and pulse encouraged verbalization
Doctor’s order. Administered oximeter attached; visited by of any medical problems
antibiotics initially after negative skin Medtechfor blood extraction, such as headache.
test done as post operative order by CBC, BUN, CREA. Continuous BP monitoring
the Doctor. Ceftriaxone 1gm done.
Visited by Dr. Jones. Orders given
administered slowly thru IVTT.
and carried out properly. R
Observed foradverse reaction of the
SerumNa+and K + determination
drug. -Last BP 140/80 for FBS
request sent to laboratory; 3-way
urinary catheter Fr.16 inserted and lipid profile
aseptically and obtained urine determination in AM.
specimen and brought to Endorsed to next shift
laboratory for urinalysis then Nurse J. Bataga.------------
catheter attached to urobag. Rhoda Ordinaria,RN

Mannitol 20% 500ml given 150ml

at fast drip using large boreneedle
gauge 19; Nicardipine in 80ml of D

5 Water via soluset atinitial rate of

100 microdrips per minute