DIVINA GRACIA VIBAL CIELO BSM-II

DAILY JOURNAL

AUGUST 28, 2020

Mrs. Vibar arrived 8 AM at Josephine Belmonte Duran Memorial Hospital,

she’s 26 years old, was born on Novemeber 16, 1993 , female, married, live at
Bacacay, Albay and her last menstrual period was on June 10, 2020. Vital sign
were taken with the following;

Blood Pressure: 70/60

Cardiac Rate: 72
Respiratory Rate: 20
Weight: 56 kgs
Body Temperature: 37.1
02Sat: 98%

She was complaining for dizziness, difficulty of breathing, and vomiting for
3 days. She was referred by Dr. Cua to admission and to be admitted at
medical ward with admitting diagnosis of hypotension. Temperature, pulse rate,
and respiratory were taken every shift. Metocloporomide IV was given and to
be transferred to medical ward at room 221 and endorsed to nurse.

3 AM in the afternoon, patient requested for vomiting medication. The

nurse/midwife on duty administered metoclopromide tab p.o. The response of
the patient was her vomit decreased.
 DAILY JOURNAL

AUGUST 29, 2020

Mrs. Vibar is 26 years old, was born on Novemeber 16, 1993 , female,
married, live at Bacacay, Albay and her last menstrual period was on June 10,
2020. During the 8 AM round, the patient was conscious, negative in shortness
in breath, positive in slightly pale in appearance, positive in vomiting (3x) with
body weakness, positive in pain, and ambulatory.

Patient’s vital signs was taken and recorded, S/E by ROD with order
carried out. IVF regulated at desired rate and administer metoclopromide
tablet per os. Collected a urine specimen from patient and forwarded it to
laboratory. The nurse/ midwife on duty rendered health teaching about good
nutrition and proper hygiene examples are; avoid eating salty, sour, oily, and
spicy food. Also, encouraged verbalization of any untoward signs and
symptoms. It was also advised that patient will intake of ice chips/cubes to
lessen discomfort. She was kept safe and comfortable on bed, and always put
side rails.

After all actions given, Urine analysis was done with result and refer ROD.
The patient verbalized no pain and vomit decreased.

During the 2 AM round, the patient was concious, negative in shortness of

breath, negative in slightly pale in appearance, vomit (1x), negative in pain,
and ambulatory.

Patient’s vital signs was taken and recorded. IVF regulated at desired rate
and administer metoclopromide tablet per os. Random Blood Sugar was done.
Patient’s was encouraged to verbalized any untoward signs and symptoms.
She was kept safe and comfortable on bed, and always put side rails.

After all actions given, the patient respond that there’s no pain and her
vomit decreased.
 DAILY JOURNAL

AUGUST 30, 2020

Mrs. Vibar is 26 years old, was born on Novemeber 16, 1993 , female,
married, live at Bacacay, Albay and her last menstrual period was on June 10,
2020. During the 8 AM round, the patient was planning to discharged. The
patient was conscious, negative in shortness of breath, negative in pale in
appearance, negative vomiting, negative in pain, and ambulatory.

The patient’s vital sign was taken and recorded, S/E by ROD with order
carried out nurse/ midwifery on duty. IVF was removed aseptically. Home
medication/ instruction explained to patient;Advised follow-up chek-up after 7
days.

Mrs. Vibar was discharged with in good condition.