09/13/2017 - Received patient on bed

Post endorsement assessment - GCS-6

(6:00AM) - On moderate high back
rest
- With ongoing of PNSS @
Diet-NPO 200cc level
- With 02 inhalation via
nasal cannula @ 3lmp
- With IFC intact
connected to urine bag
draining yellow urine
output
- For CT scan
- Meds observed
- D- GCS-7
- With O2 inhalation via
nasal cannula of 2LMP
- With NGT intact
- With IFC intact
- Endorsed for continuity
of care
09/13/2017
Post endorsement assessment - Received patient on bed
(2:00 PM) in semi fowlers position
with ongoing IVF of PNSS
DIET: 1800KCAL 1L @ 700cc level

- Nicardipine drip @80cc

level
- GCS-7
- With o2 inhalation via
nasal cannula @2LMP
- With NGT intact
- With IFC intact
connected to urine bag
draining yellow output
- With cardiac monitor
and pulse oximeter
- A- Iv patency checked
and regulated
- Meds availability
checked
- VS taken and recorded
Pre-endorsement assessment - D- GCS-6
(10:00PM) - With o2 per nasal
cannula @2LMP
- With NGT and IFC
- Contraptions intact
 - A- due meds gives
- Endorsed to continuity
Post-endorsement assessment of care
(10:00AM) - D- received patient on
bed on semi fowlers
position
- -GCS-6
- With o2 inhalation per
nasal cannula @2LMP
- With ongoing IVF of
PNSS 1L @250cc level
- With SD of nicardipine
drip @15cc level
- With NGT intact
- With IFC intact
connected to urine bag
draining yellow output
attached to cardiac
monitor and pulse
oximeter
- Awaiting CT scan result
- A- IVF pattency checked
and regulated
- Availability of meds
checked
Pre-endorsement assessment
(6:00AM) - D- GCS-6
- With O2 inhalation via
nasal cannula @2LMP
- With NGT and IFC intact
- With episodes of
hypertension
- Awaiting for CT scan
result
09/14/2017 - D- Received patient on
Post-endorsement assessment bed
(6:00AM) - GCS-6
- On high back rest
- With ongoing IVF of
PNSS @700cc level
- With SD of Nicardipine
drip of 25cc level
- With O2 inhalation per
nasal cannula of 2LMP
- With cardiac monitor
and pulse oximeter
- With NGT intact
- With IFC intact
 connected to urine bag
draining to yellow
colored urine
- Meds checked
- D- carried out order
Pre-endorsement assessment
(2:00PM) - Received patient on bed
on semi fowlers position
- GCS-6
1,800KCAL/day - With O2 inhalation via
nasal cannula @ 2LMP
- With ongoing IVF of a
PNSS @100cc level
- With SD of Nicardipine
drip @45cc level
- With NGT intact
- With IFC intact
connected to urine bag
draining yellow colored
output
- Attached to cardiac
monitor and pulse
oximeter
- Hypertensive
- A- IVF patency checked
and regulated
- Availability of meds
checked
Pre-endorsement assessment
(10:00PM) - GCS-6
- With NGT intact
- With O2 inhalation via
nasal cannula @2LMP
- With contraption intact
- A- feeding done with
SAP
- Endorsed for continuity
of care
Post-endorsement assessment
(10:00AM) - D- received patient on
bed on high back rest
with ongoing IVF of PNSS
1L @600cc level with SD
of Nicardipine drip 10cc
+ D5W @90cc @25cc
level
- GCS-6 hypertensive
- With O2 inhalation via
 nasal cannula @2LMP
- NGT intact
- With IFC intact
connected to urine bag
draining yellow colored
urine output
- With cardiac monitor
and pulse oximeter
- A- IVF checked and
regulated
- With availability of meds
checked
- VS taken and recorded
- D- GCS-6 (E-1V-1M-4)
- With O2 via nasal
cannula @ 2-3LMP
- With NGT and IFC intact
- A- morning care rended
- Feeding done with SAP
- VS taken and recorded
Post endorsement assessment
(06:00AM) - D- GCS-6
- With O2 inhalation via
nasal cannula @ 2-3LMP
1800KCAL/DAY - With NGT and IFC intact
- A- morning care
rendered
- Endorsed for continuity
of care
09/15/2017 - Received patient on bed
Post-endorsement assessment on semi-fowlers position
(06:00AM) with ongoing IVF