Comprehensive Analysis of Doctor's Orders and Patient Care

This assignment presents three different scenarios of doctor's orders, detailing patient admissions, diagnostic tests, medication administrations, and specific instructions for patient care. The first scenario involves a patient requiring intravenous fluids, medication, and vital sign monitoring. The second case outlines orders for a patient with potential appendicitis, including lab tests, IV fluids, and referral for surgery. The third scenario describes pre- and post-operative orders for a cholecystectomy, covering medication, fluid management, vital signs, and dietary instructions. The assignment requires a thorough understanding of medical terminology, treatment protocols, and patient care procedures, including the interpretation of abbreviations, dosages, and monitoring parameters. The orders highlight the importance of accurate documentation and adherence to medical directives. The provided assignment is a valuable resource for students seeking to understand medical documentation and treatment planning.

DOCTOR’S ORDER
PATIENT’S NAME: ____________________________ AGE: ______ SEX: ______ HOSP #:________
ATTENDING PHYSICIAN: ___________________________________ RM/WARD: ______________
Situation 1: Aug. 28, 2020 11:30am
Please admit patient under my service
Venoclysis: Start Plain Normal Saline Solution (PNSS) 1L @ 30 gtts/min, IVF to
follow PNSS 1L @ 20 gtts/min
Monitor vital signs every 40 and record
Monitor intake and output every 40
Diagnostics: CBC, UA, 12 Leads ECG, Chest X-ray PA view, CBG now
Medications: Ranitidine 50mg IVTT q 80
Paracetamol 300mg IVTT stat, then Paracetamol 500mg/tab q 40
Cefuroxime 750 mg IVTT q 80 ANST
TSB for temperature 39.5 0C
12nn > T = 39 0C PR – 86 beats/min RR- 32 breaths/min BP – 130/90 mmHg
Refer accordingly..
Dr. Jezra Lopez
Situation 2:
Please admit under the service of Dr. Jose Dagoc
NPO
For STAT CBC, Chest X-Ray, UA, HbSag, blood typing
Start venoclysis D5LR 1L @ 120cc/hr
REVISED MAY 2006 NSD - 4

Start Ampicillin Sulbactam 1.5 gm IV now then 750mg IV q 80
Tramadol 1 amp IVTT now
For possible Appendectomy
Refer to Dr. Abad (anesth) once consented for OR
Vs q 20
I & O q 40
Relay labs once in
Refer for any unusualities
Situation 3:
08.28.2020
8:00 am Admit patient
NPO
Amsulvex 1.5 gms q 80
CBC, UA, SE, CT-BT
For possible cholecystectomy
D5NM 1L q 80
Dr. Garcia for anesthesia
08.29.2020 S/P cholecystectomy
9am To PACU until fully awake then to room of choice
Vs q 15 mins x 2 hours then hourly x 4 then q 4 hours
NPO, DAT at 8pm
D5LR 1L to run at 120cc/hour
D5NM 1L to run at 50 cc/hr
Meds: Tramal 50mg slow IV now then q 80 PRN
Ketorolac 15 mg slow IV stat then q 20 x 4 doses
O2 inhalation @ 2LPM until fully awake
REVISED MAY 2006 NSD - 4

I & O every shift
Moderate high back rest
Refer accordingly
REVISED MAY 2006 NSD - 4