Các biến chứng và mất máu dự kiến (EBL): Disposition: Mô tả như thế nào bệnh nhân dung nạp các thủ vật: Mô tả bất kỳ mẫu vật thu được và các phòng thí nghiệm kiểm tra đã được đặt hàng. | 18 Discharge Note Date and time Procedure Indications Patient Consent Document that the indications risks and alternatives to the procedure were explained to the patient. Note that the patient was given the opportunity to ask questions and that the patient consented to the procedure in writing. Lab tests Relevant labs such as the INR and CBC Anesthesia Local with 2 lidocaine Description of Procedure Briefly describe the procedure including sterile prep anesthesia method patient position devices used anatomic location of procedure and outcome. Complications and Estimated Blood Loss EBL Disposition Describe how the patient tolerated the procedure. Specimens Describe any specimens obtained and labs tests which were ordered. Name of Physician Name of person performing procedure and supervising staff. Discharge Note The discharge note should be written in the patient s chart prior to discharge. Discharge Note Date time Diagnoses Treatment Briefly describe therapy provided during hospitalization including surgical procedures and antibiotic therapy. Studies Performed Electrocardiograms CT scans. Discharge medications Follow-up Arrangements Fluids and Electrolytes Maintenance Fluids Guidelines 70 kg Adult D5 1 4 NS with 20 mEq KCI Liter at 125 mL hr. Specific Replacement Fluids for Specific Losses Gastric nasogastric tube emesis D5 NS with 20 mEq L KCL. Diarrhea D5LR with 15 mEq liter KCI. Provide 1 liter of replacement for each 1 kg or lb of body weight lost. Bile D5LR with 25 mEq liter amp of sodium bicarbonate. Pancreatic D5LR with 50 mEq liter 1 amp sodium bicarbonate. Blood Component Therapy 19 Blood Component Therapy A. Packed red blood cells PRBCs . Each unit provides 250-400 cc of volume and each unit should raise hemoglobin by 1 gm dL and hematocrit by 3 . PRBCs are usually requested in two unit increments. B. Type and screen. Blood is tested for A B Rh antigens and antibodies to donor erythrocytes. If blood products are required the blood can be rapidly .
