Name: Katty Perry Age/Sex: 8months old/F RM&Bed no: 110-1

Date Time Focus Progress note (DAR:Data, Action, Response)

04/07/2021 07:00AM PRE-ASSESSMENT Received patient, lying on bed, asleep with ongoing
IVF of D5IMB 500cc at 50cc/hr infusing well at right
metacarpal vein, with heplock at left cephalic vein,
with standing order of vol/vol replacement of PNSS.
07:30AM Risk for Fluid Volume Deficit D: The watcher verbalized “Nurse, parati po syang
related to vomiting, watery nagsusuka at basa ang tae nya” noted: Dry
stool, possible evidence by lips/mouth, sunken eyeballs. Withvital signs of: BP:
dry lips, mouth, sunken eyes. 90/50 mmHg, CR: 110, RR:30, TEMP: 39C and O 2 Sat.
of 97%. ------------------------------------------------------------
08:30AM A: Established rapport; VS checked and recorded;
Assess skin turgor and oral membranes; Assess color
or urine and stool and vomit;Auscultate heart sounds
and note for rate rhythm or any abnormal findings;
Monitor fluid status relation to dietary intake and
monitor serum electrolytes and urine osmolality. -----
08:50AM Checked and Examine by Dr. Robbins, ROD
09:30AM BUN, Urine specific gravity and osomolality, done
with results. ------------------------------------------------------
10:30AM A:Urge patient to drink prescribe amount of fluid;
encourage family or watcher to assist with feedings,
as necessary. ---------------------------------------------------
11:50AM R: The watcher verbalized “Hindi na masyado sya
nagsusuka at hindi na basa ang kanyang tae, Salamat
nurse.” ------------------------------------------------------------
12:00PM Lunch is served to the watcher.
01:30PM Hyperthermia related to D: The watcher verbalized “Nurse, mainit po ang
dehydration. aking anak, may lagnat sya” noted: body
temperature above normal average, hot, flushed skin,
weakness. With vital signs of: Withvital signs of: BP:
90/50 mmHg, CR: 110, RR:30, TEMP: 39C and O 2 Sat.
of 97%. ------------------------------------------------------------
02:00PM A: VS checked and recorded.---------------------------------
02:15 PM Checked and examine by Dr. Robbins, ROD
02:30PM Paracetamol 5ml PO, LG: at home at 4am; may give
paracetamol 1/ supp for fever >38.5 every 12hrs, PO
to start once at ward; Co-Amoxiclav (AmoClav) 5ml
PO every 8hrs(6am-2pm-10pm)-----------------------------
02:50PM A:VS rechecked and recorded.-------------------------------
02:55PM R: The watcher verbalized “Okay na sya nurse, hndi
na masyado sya mainit, thank you nurse”.----------------
03:00PM POST-ASSESSMENT Left the patient lying on bed, awake, with ongoing IVF
IVF of D5IMB 500cc at 50cc/hr infusing well at right
metacarpal vein, with heplock at left cephalic vein,
with standing order of vol/vol replacement of PNSS,
not in respiratory distress. Endorsed to next shift,
NOD, Rajenne Blanche C. Kho, DMSF-----------------------