Kardex in healthcare (nursing) PDF

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Summary

Kardex - is for a filing system for nursing records and orders that was held centrally on the ward and contained all the nursing details and observations of patients that had been acquired during their stay in hospital....

Description

KARDEX PATIENT NAME: C. Advincula PHYSICIAN: Dr. Betty de la Cuesta Date Admitted: July 22, 2021 Diagnosis: Asthma

AGE:3 years old HOSPITAL NO.: 010203 SEX: Male WARD/ROOM: PICU Chief Complaint: 2 weeks cough, difficulty of breathing with deep rapid breathing, with chest retraction. Allergies: No allergies to food and medications

DIAGNOSTICS CBC with Platelet count ABG Chest X-ray MEDICATIONS Hydrocortisone Cefuroxime Budesonide nebule Montelukast Paracetamol (Aeknil) IV FLUIDS D5IMB

DATE ORDERED 07/22/2021 07/22/2021 07/22/2021 DATE ORDERED 07/22/2021 07/22/2021 07/22/2021 07/22/2021 07/22/2021 DATE ORDERED 07/22/2021

NURSING ACTION Requested and taken result Requested and taken result Requested and taken result NURSING ACTION Started 50mg IV as (loading dose) now every 6 hours for 24 hours. Started 750mg / 375mgIV (ANST) every 8 hours. Started 1 dose Started 4mg 1 tablet chewable OD at 6pm, PO Started 150 mg IV every 4 hours PRN NURSING ACTION Started 500ml at 44mgtts/min

SPECIAL ENDORSEMENTS Vital signs

DATE ORDERED 07/22/2021

NURSING ACTION Obtained

TREATMENT Albuterol (Ventolin, salbutamol) Oxygen PROCEDURES Spirometry

DATE ORDERED 07/22/2021 07/22/2021 DATE ORDERED 07/22/2021

NURSING ACTION Started 5 mg in 2 ml Started via pediatric face mask at 5 LPM NURSING ACTION Obtained

DIET Plenty of fruits and vegetables

DATE ORDERED 07/22/2021

NURSING ACTION Endorsed

NURSING NEEDS

DATE ORDERED

NURSING ACTION...