TIME TREATMENT/MANAGEMENT NURSES NOTES

August 4, 2009

8:15am Ocular assessment  Receive on bed

 VS taken
 Warm to touch
 Has rashes all over her body
 Cachexic
 () productive cough (yellow, tenacious)
 Crackles on left lower lobe
IVF D5 IMB 500ccx 8
 Conscious but irritable and cry when touch
 GCS:
 Has a patent ongoing IVF of D5 IMB on R
hand at 100cc level running at a drop rate of
9:10am 10gtts/min infusing well
 IVF regulated to 16gtts/min

 IVF check, and was regulated

Subjective: “Medyo mainit siya ngayon, bumabalik

yong lagnat niya kaninang madaling araw”

Objective:
Temp: 38.9C
PR: 150bpm
RR : 34 breaths per min
Urine: 90cc
10:35am Stool: 1x

Assessment:
Hyperthermia r/t exposure to hot environment as
manifested by skin warm to touch

Planning:
After one hour of nursing intervention the pt. will
have a decrease in temperature within normal range
at least 37.0C

Intervention:
 Monitor VS esp. temp q30 min