MSJC Nurse's Notes

Name: Rowena Reclusado Date: 4/9/21

Time Temp HR RESP B/P O2 SAT PAIN GLUC. OXYGEN
0700 97.7 86 27 113/53 97% 0 110 3 lpm
1100 97.1 85 20 110/60 98% 0 97 3 lpm

RM:2167 CODE: FC ALLERGIES :NKA HX: HTN, Hyperlipidemia AAO x 4 PERRLA: Yes

DX: Hyperbilirubenia r/t Hep C, Acute kidney failure, mass on liver

HGB 11g/dL

PNA: No FLU: No WBC 10 mcl HCT 45% PLT 200x10/L

NA 135meq/L CL 108meQ/L BUN 15mg/dL GL 117mg/dL

K:3.7meQ/L CO2 25meQ/L CR 1.0 meQ/L

LKWT: DIET: Reg

WT: 160 lbs GI/GU: with Foley cath.
SIRS: N First Fluid. amt: 500 ml LBM: 4/9/21 black, tarry stool
SKIN: gen. jaundice FEET: 2+ edema, cap refill < BOWEL SOUNDS: Active x 4
3 secs
CARDIAC: Normal sinus rhythm LUNG SOUNDS: Clear anterior and posterior
bilaterally
PERFUSION: cap refill< 3 secs upper & lower
extremities

INTAKE (PO and IV’s including IVPB) OUTPUT( including drains)

800 ml Urine 800 ml

2021
 MSJC Nurse's Notes
Name: Rowena Reclusado Date: 4/9/21

IV: 0.9 NaCl RATE: 5 ml/hr FLD.S REMAINING: 500 ml

Did I: SBAR my Nurse √ Complete Hourly rounding(5P’s): √ DAILY WTs: Assess & reass.
PAIN: √ Document I&O”s √ Correlate Med.s and Labs to diagnosis or condition √
Assess and reassess vitals and condition of patient √ Check orders and current/ new labs results √

0700 Received report from Lauren, RN. Assumed care at this

time_______________________________________________________
0845 Pt. is up and watching TV, AAO x 4. Denies any distress. Complete head
to toe assessment. Skin is jaundice. Abdomen firm and distended. IV
sites to right wrist and right forearm shows no S/S of infiltration.
Administer AM meds. Siderails up x 2, Low bed and locked. Call light
within reach-------------------------------------------------------------------------------
1045 Pt’s lying-in bed comfortably. No apparent distress at this time. 5ps
addressed------------------------------------------------------------------------------

1315 Pt’s asleep with no apparent distress. Addressed 5Ps.-----------------------

1515 Reassessed VS. Addresses 5 Ps. No s/s of distress at this time. Will
continue to monitor-----------------------------------

1700 No s/s of pain /SOB. 5Ps addressed. SBAR report given to RN Lauren-----

2021