ST.

PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
A.Y. 2nd SEMESTER 2020-2021

DATA – ACTION – RESPONSE

Date Time Data Actions Response

4/8/ 11:46 Received pt. lying in bed (11:

21 AM 47 A.M.)  capillary refill- 4 VS:
seconds T- 38
11:52  clubbing nailbeds P- 98 bpm
AM VS:  abdominal girth- 70 R- 30 cpm
T – 37.9 cm BP- 100/70 mmHg
P – 100bpm  liver- hard and firm O2- 93%
R – 30cpm  bloated noted
BP – 100/70mmhg  petechiae noted
O2 – 93%  jaundice noted VS:
 edema- pitting at T- 37.9
11:59  shortness of breath 2mm depth P-98 bpm
AM with use of accessory  neuro: irritable and R- 30 cpm
muscles when decreased BP- 100/70 mmhg
breathing  alertness O2- 93%
 nausea
 increasing level of
irritability  TSB done VS:
12:14  Yellowish  Fowler's position done T- 37.9
PM discoloration on the  O2 at 2Lpm P-120 bpm
skin  PNSS KVO R- 33 cpm
 FBC done BP- 80/50 mmhg
Lab Results:  1U of FWB O2- 88%
CBC:  prepared for
HGB- 7 g/dL paracentesis
HCT- 25 %  prepared for blood
WBC- 12,000 transfusion
Platelet- 135,000  Increased 02 at 4Lpm
VS:
Serum Electrolytes: T- 37.9
12:22 K- 3.5 mEq/L  Administered: P-120 bpm
PM Na- 130 mEq/L Spironolactone 40mg R- 35 cpm
BUN- 42 IVTT Nexium 40mg BP- 80/50 mmhg
Creatinine- 1.7 Metronidazole 500mg O2- 85%
Serum Protein- 4.5 g/dl IV drip Tolvaptan
Serum Albumin- 2.3 g/dl (Samsca) IVTT
Serum Globulin- 4.2 g/dl Vit. K 1 ampule
Serum Bilirubin- 2.5 g/dl Lactulose (Duphalac)
30 mL Albumin
Liver Enzymes: SGPT- 54 infusion and
units SGOT- 55 units Furosemide
Rifaximin (Xifaxan)
ABG:
pH- 7.32
PAO2- 70 mmhg
PCO2- 50 mmhg
HCO3- 21
Prothrombine Time- 24 secs

UTZ: atrophy of the right lobe

 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
A.Y. 2nd SEMESTER 2020-2021

and hypertrophy of the

caudate/left lobe; increased
portal vein diameter, marked
enlargement of the spleen