History of Present Illness
Two hours prior to admission, at 4am, patient Jake was jogging along Lacson
Street when a group of bystanders had approached him and stabbed him
multiple times. He claims that he does not know these people. He tried to
defend himself resulting to multiple injuries in his upper extremities where he
had 3 lacerations, cheeks where he had a laceration on the left, right chest and
right upper abdominal quadrant.
Medications:
Tetanus Toxoid 0.5 ml/amp, give 1 ampule via deep IM,
now at right deltoid
ATS 3,000 IU/amp, give 1 ampule via deep IM, now,
ANST at left deltoid
Piperacillin Tazobactam 2.25 grams/vial, give 1 vial via IV
drip to run for 3 hours Q8H
Tramadol 50 mg/amp, give 1 ampule very slow IV push
now then Q6 PRN for pain
Omeprazole 40 mg/amp, give 1 ampule via IVTT ODHS
Latest Vital Signs :
Blood Pressure: 90/60 mmHg
Heart Rate: 121 bpm
Respiratory Rate: 26cpm
Temperature: 37.3 ⁰C
Pain Scale: 10/10
NURSING CARE PLAN
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