San Pedro Hospital of Davao City, Inc.

C. Guzman St., 8000 Davao City, Philippines

Tel. No. (082) 222-6100 Fax No. (082) 226-4714
Website: www.sanpedrohospitaldavao.com
Email: sanpedrohospital@yahoo.com

NURSES’ NOTES

Name: Marquez, Steve Ward: San Lorenzo Room/Bed No.: Room 409

DATE TIME
09/09/2021 3-11 3:00 pm Received asleep on bed
Circu-oral cyanosis noted;

Tachypneic breathing noted; grunting noted

Skin is warm to touch, with capillary refill time at 3-4 seconds

With mainline IVF of D10W 48 cc + Calcium gluconate 2 cc, @ 50 cc fluid

running at 10 cc/hr via infusion pump ; infusing well on the left

great saphenous vein

Still for urinalysis and stool exam ; stool exam container provided and attached

wee bag

4:00 pm VS checked and recorded: RR 62cpm; T: 37.5 C ; CR: 63bpm ; NOD aware

Bedside care done ; linen stretched and tucked well

4: 10 pm TSB rendered

Rendered O2 support at 3 L/min

4: 30 pm Temperature rechecked: Temp: 36.5 C

5:00 pm Health teachings rendered to mother, such as

A. Maintain on NPO

B. Maintain O2 support

B. prompt referral for unusualities like, cyanosis. Increased temperatures

C. Handwashing before and after patient care

D. Facilitate proper urine specimen collection

6:00 pm Vs rechecked and noted ; afebrile

6:10 pm Seen and examined by Dr. J. Gullardo ; with orders made

7:00 pm Due medications given

 Urine specimen saved and sent to lab

7:30 pm Stool specimen saved and sent to lab

8:00 pm Mother instructed to resume breastfeeding with strict aspiration precaution as

ordered
8:30 pm Above IVF consumed and followed up eith same D10W 48 cc + 2 cc Calcium

gluconate regulated at 10 cc/hr via infusion pump

Cuddled and breastfed by mother with sucking reflex : burped thereafter

9:00 pm Cried at times

Capiilary blood glucose taken: 50 mg/dL ; NOD aware

10:00 pm Vs rechecked ; afebrile

10:30 pm Above IVF disloged ; kept set sterile

10:45 pm IVF reinserted by PGI Corpuz

11:00 pm Left lying on bed with mother at bedside

Jhulia Anne F. Gamutin, St. N / CI’s Signature / NOD’s Signature