DATE &TIME DATA ACTION RESPONSE / RESULT

Monday-May 9, 2011

 8:00 am  Seen patient sleeping on  Vital signs taken and  Temp: 36.5oC
bed with his mother on recorded. CR: 130cpm
the bedside. RR: 34bpm
 8:30 am  Provided with bedside
care.
 Nurse-patient  Established rapport.
interaction, done.
 11:00 am  The ileostomy bag of  Assisted the mother in
the patients is about emptying the ileostomy
two-thirds. bag.
 Noted the appearance of  Beefy red stoma.
the stoma.
 Noted the consistency,  Fluid condense-like
and odor of the effluent. effluent.
 12:00 noon
 Vital signs taken and  Temp: 36.5oC
recorded. CR: 135cpm
RR: 30bpm
 Intake and Output was  Intake: Breast feeding
documented. and 120 ml of water
Output: 90 ml ( 1 diaper
changed)
Tuesday- May 10, 2011

 8:00 am  Seen patient awake and  Vital signs taken and  Temp: 36.5oC
playing with her recorded. CR: 135ccpm
mother. RR: 30bpm
 Due medications are  Ferrous sulfate
 given. 150mg/10.6 ml/2ml,
PO, OD
Probiotics plus
prebiotics 1 sachet, OD
 Provided with bedside
care and done with
nurse-patient
interaction.
 9:00 am  Physical assessment
done.
 11:00 am
 Scheduled time for  Assisted the mother in  Fluid condense-like
ileostomy bag ileostomy bag effluent
emptying. emptying. Noted the
appearance of the
 12:00 noon stoma.
 Vital signs taken and  Temp: 36.5oC
recorded. CR: 134 cpm
RR: 30 bpm
 Documented the intake  Intake: Breast feeding
and output. and 60 ml of water
Output: 90 ml (1 diaper
change)
Wednesday- May 11, 2011

 8:00 am  Seen patient eating  Vital signs taken and  Temp: 36.5oC
cerelac for breakfast, recorded. CR: 136 cpm
with his mother feeding RR: 30 bpm
his son.
 Due medications given.  Ferrous sulfate
 Bedside care done, 150mg/10.6 ml/2ml,
nurse-patient interaction PO, OD
 done. Probiotics plus
prebiotics 1 sachet, OD
 9:00 am  CBG monitored.  68 mg/dl

 With beefy red stoma

on the lower right
quadrant of the
abdomen.
 11:00 am  Scheduled time for  Assisted the mother in  Fluid condense-like
ileostomy bag ileostomy bag effluent
emptying. emptying.

 12:00 noon  Vital signs taken and  Temp: 36.5oC

recorded. CR: 136 cpm
RR: 30 bpm
 Documented the intake  Intake: Breastfeeding
and output. and 60 ml of water
Output: 90 ml ( 1 diaper
change)
Thursday-May 12, 2011

 8:00 am  Seen patient sleeping  Vital signs taken and  Temp: 36.5oC
with his parents on the recorded CR: 136 cpm
bedside. RR: 30 bpm
.

 Bedside care done, with

nurse-patient
interaction.

 11:00 am  With beefy red stoma

on the lower right
quadrant of the
 abdomen.
 Scheduled time for  Fluid condense-like
ileostomy bag  Assisted the mother in effluent
emptying. ileostomy bag
 Scheduled time for emptying.
ileostomy care.  Assisted the mother in
providing ileostomy
 12:00 noon care.
 Vital signs taken and  Temp: 36.5oC
recorded. CR: 134 cpm
RR: 30 bpm
 Documented the intake  Intake: Breastfeeding
and 50 ml of water
and output
Output: 90 ml ( 1 diaper
change)