NURSE’S NOTES

SURNAME:_____FERI______________________________ M.I.:__D____ AGE:__55____ HOSPITAL NO.:_0002345__

GIVEN NAME:____LOGAN__________________________________ SEX:__M____ WARD/ROOM NO.:_____218______

Date-Shift FOCUS Data – Action – Response

05-06-2021 Admission Care D: Admitted a 55 y/o male patient accompanied by his wife with
7:00 am initial VS as follows:
08:00 am BP: 110/70 mmHg
08:30 am PR : 97 bpm
RR: 21 cpm
Temp: 36.4
O2 sat: 97 %
Felt uneasy, weak, unpleasant pain around umbilicus with facial
asymmetry.

A: Assisted on bed and positioned to moderate high back rest ;

side rails raised; seen and examined by ER physician (Dr.
Guerrero) with orders made and carried out accordingly; consent
to care and hospitalization secured; started IVF of PNSS 1L + Vit.
B inserted aseptically at right metacarpal vein regulated to 56-57
gtts/min.@; request for laboratory and other diagnostic procedures
made, performed 12 lead ECG; forwarded and attached to chart;
other standing orders carried out accordingly; accompanied for
CXR; facilitated awaiting results, informed surgical ward nurse on
duty regarding on duty.

R: Transferred to surgical ward in a private room at 8:30 am via

wheelchair, endorsed accordingly.

9:00 am Post transferred D: Received patient via wheelchair accompanied by ER OD and

assessment significant other, with initial vital signs as follows:
BP: 110/70 mmHg
PR: 86 bpm
RR: 21 cpm
Temp: 36.4 ◦c
with body weakness, constipation and unpleasant pain around
umbilicus region, and facial asymmetry noted; with ongoing IVF
PNSS 1L + Vit. B x 6 hours regulated to 56-57 gtts/min @ 900 cc
level regulating well.

A: Transferred patient to room of choice and assisted to desired

position of comfort for safety, positioned patient high-back rest;
IVF regulated as ordered; clear liquid diet and NPO post midnight
instructed to significant other; initial VS taken accordingly; ROD
informed about the admission.)

R: Patient settled in the room; Vital signs checked and monitored

 at a normal range; monitored and secured patients safety and
wellness; waiting for laboratory and results.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

A: Rounds made by Dr. Refuerzo; consent for blood transfusion

10:00 am secured; prescribed PNSS 1L with KVO side drip at 10 gtts/min;
12:00 nn Secured 2 units of FWB x 4 hours regulated at 41-42 gtts/min;
1:00 pm monitored patient for bt reactions.
R: Vital signs checked and monitored at a normal range;
monitored and secured patient’s wellness.

A: seen and examined by Dr. Sabaten; instructed for surgery;

assessed patient; administered medications; monitored vital signs;
2:00 pm and provided information.

R: Patient’s knowledge increased for her operation; increased

patient’s satisfaction; increased collaboration between NPI.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

D: Vital signs at a normal range.

5:00 pm Bedside Care
6:00 pm A: Rounds made by Dr. Plete; assessed patient; monitored vital
7:00 pm signs; NPO post midnight instructed; oral and body hygiene before
OR endorsed; Ketorolac 30 mg IV 1 HR PTOR ANST transcribed,
changed linens; and provided information.

R: Patient’s knowledge increased for her condition; improved

patient’s satisfaction; increased collaboration between NPI.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

D: temperature of 38.4 c/axilla @ 2am.

May 7, 2021 Ineffective
2:00 am Thermoregulation A: TSB done; prescribed PRN medication of Paracetamol 300 mg
3:00 am IV give.
4:00 am
R: Patient’s temperature was back into normal; vital signs checked
and monitored at a normal range; secured patient’s safety and
wellness.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

D: Patient transferred to PACU; Informed NOD.

12:00 nn Post-operative
01:00 pm Care A: Seen and examined by Dr. Plete; hooked to o2 support via
02:00 pm nasal cannula regulated to 2-3 lpm as ordered infusing well; NPO
temporarily instructed; encouraged deep breathing exercise;
monitored VS q15 then q1 till it became stable; monitored JP drain
output q1; consumed PNSS 1L KVO side drip at 10 gtts/min at left
hand; with ongoing IVF of PNSS 1L + VIT. B x 6 hours regulated
to 56-57 gtts/min @; Ketorolac 30 mg IV q8 endorsed;
Metronidazole 500 mg IV q8 endorsed; discontinued Nubain 5 mg
IV; Tramadol 50 mg SIVP given; Cefoxitin (Monowel) 2 g IV now
given; informed next shift surgical ward nurse regarding scheduled
medications.

R: Patient’s settled in the room; vital signs checked and monitored

at a normal range; secured patient’s safety and wellness; referred.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513
 9:00 pm D: temperature of 37 c/axilla @9pm.
10:00 pm
A: assessed patient; TSB done; monitored vital signs q4 hours.

R: Patient’s knowledge increased for her operation; increased

patient’s satisfaction; increased collaboration between NPI.

NURSE’S NOTES

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________
Date-Shift FOCUS Data – Action – Response