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Kardex (MW 2)

1) The document contains patient kardex information including name, age, diagnosis, room/bed number, diet, laboratory results, doctor's orders, and IV/medication administration for multiple patients. 2) The kardex tracks patient information like vital signs, input/output, wound care, imaging/lab results, and medication administration over time. 3) Doctor's orders include referrals to other specialists, monitoring of symptoms, sensory/motor exams, and discharge planning pending nephrology clearance.

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Aubrey Unique Evangelista
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268 views3 pages

Kardex (MW 2)

1) The document contains patient kardex information including name, age, diagnosis, room/bed number, diet, laboratory results, doctor's orders, and IV/medication administration for multiple patients. 2) The kardex tracks patient information like vital signs, input/output, wound care, imaging/lab results, and medication administration over time. 3) Doctor's orders include referrals to other specialists, monitoring of symptoms, sensory/motor exams, and discharge planning pending nephrology clearance.

Uploaded by

Aubrey Unique Evangelista
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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KARDEX

Name: Sibonga, Romel Penones Age/Sex: 47 years old/Male HRN: 2721038

Diagnosis: Pulmonary Congestion sec to AKI on top of CKD sec to Obstructive Uropathy sec to
Nephrolithiasis (L) on top of Complicated UTI Room/Bed No.: Room 6 Bed 5

Date Diet Date Laboratory Remarks Doctor’s Order Remarks


11/12 Renal Diet w/ 11/14 Follow up: Followed 11/13
SAP -CXR PA up result -MGH
-CBC + PC will be out -Daily wound -Done
-Blood GSCS x2 – within 5 care
11/13 days -May remove FC -Done
-Urine CS once epidural is
-T/S Catheter tip CS inserted
To be done
11/16 after HD 11/15
-CBC + PC, Na, K, Crea, -For RDU -Still
BUN 6hours post HD enrollment finding
-VS q4 RDU
-I&O qshift -Done
-WOF: Dyspnea -Done
Fever -Done
Cough
-Refer -Done
Accordingly

Date IVF Date Medications Remarks 11/16


11/13 Heplock 11/16 Cefepine Day 13 Ongoing For HD today as -HD
Cefepine ordered Billing still
medication being
processed
KARDEX

Name: Mirafuentes, Michael John Merca Age/Sex: 24 years old/Male HRN: 3280046

Diagnosis: Hyperthyroidism TCVD (+) LVH (+) LVD AF in RVR FC II; Hepatic Encephalopathy Grade II Type
A, Episodic Precipitated by Infection Room/Bed No.: Room 6, Bed 4

Date Diet Date Laboratory Remarks Doctor’s Order Remarks


11/11 BF OTF 1400 11/14 S/F: Followed -Refer to Gastro -Done
KCAL -Urine GSCS AFB up to and Endo
-Blood GSCS x2 watcher
-Manage patient -Done
Crea: 65.88 as heart failure
K: 3.58 risk in storm
Na: 147
-Refer to cardio -Done
11/15 For UTZ Whole
Abdomen -MHBR -Done

11/16 Repeat PTINR (Day 3) - -O2 via face -Given if


11/17 mask @ 6-10 patient
lpm as needed is in
FF up: UTZ of Whole Followed need
Abdomen (11/15) up
-Refer -Done

-Maintain on
Date IVF Date Medications Remarks NGT and OTF
11/11 PNSS @ 60cc/hr feeding may
proceed to trial
PNSS @ feeding with jelly
11/15 100cc/hr ace

D5W 1L @
11/16 60cc/hr
KARDEX

Name: Labasano, Jovenal Jr. Ferrando Age/Sex: 34 years old/Male HRN: 3260315

Diagnosis: HCAP; GBS Room/Bed No.: Room 6, Bed 7

Date Diet Date Laboratory Remarks Doctor’s Order Remarks


11/10 BF OTF 1600 11/14 T/S: Followed -MHBR -Done
53 KG -Blood GSCS up to
-Sputum GSCS watcher -Refer to dietary -To be
referred
-Turn to sides q2 -Done

-For daily -To be


sensory and done
motor
functioning
monitoring

-For discharge,
no objections, IM
Nephro wise

Date IVF Date Medications Remarks


11/10 PNSS @ 80cc/hr

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