Nursing Documentation

Date Time Notes

2-19-2021 - Received patient lying on bed with D5 0.3% NSS + 20 mEq KCl at
8AM
50 mL per hour, hooked at left metacarpal vein, infusing well.
- Patient is responsive and coherent
- Vital signs checked and recorded with T =39.1 , BP = 100/ 60
mmHg, RR = 23bpm, PR = 85 bpm
- Facial Grimacing observed
- Pain assessed with pain score of 7 out of 10 as verbalized by
patient.
- IV fluid regulated to 13 drops per minute
- Reminded patient of NPO status and bed rest.
- Positioned patient in bed comfortably.
- Kept monitored for unusualities
- Instructed watchers to report any complaints.
-Bedside care done
- Administered Paracemtamol 500 mg/tab, one tablet by mouth
9 AM
with sips of water
- kept patient comfortable
10 AM -assessed patient about the pain she was feeling
-encouraged and reminded patient to observe bed rest
-monitored patient’s intake and output
-seen and examined by attending physician
-orders carried out
 repeat blood work
 stools collected to be checked for occult blood
-administered diphenoxylate/atropine sulfate (Lomotil)
11 AM
2.5mg/0.025mg/tablet, 2 tabs q6h
-Provided diversional activities such as listening to music
-Poisitoned patient comfortably
12 NOON -still on NPO status
-provided oral care to avoid complications
- VS checked and recorded as follows: T= 38.2 C; BP = 110/70 mm
Hg; RR = 19 bpm; PR = 95 bpm
-administered propantheline bromide 15 mg PO q8hr AC (30 mg PO
12:30 PM
qHS)
1 PM -administered Metronidazole 500/100 mL bottle IV q6h
1:30 PM -administered Tramadol 50 mg slow IV q6h
2 PM - promoted adequate rest for the patient
- changed patient’s position frequently, provided frequent skin care,
and maintained dry or wrinkle-free bedding to avoid bed sores
3 PM -assessed patient’s experienced pain
-provided diversional activities by encouraging her to watch movies
or listen to her favorite music
- I and O monitored and recorded

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 VS checked and recorded as follows: T= 38 C; BP = 110/80 mm Hg;
4 PM
RR = 20 bpm; PR = 97 bpm
- Endorsed to the nurse on duty of the next shift with the same IV
above running at 13 drops/min at the level of
500 mL hooked at left metacarpal vien, infusing well.
Nurse Signature: AQUINO, R
FSUU SN

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