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Nurse'S Notes Name: - Cleopatra Andude - Age/Sex/CS: - 36/F/M - Ward/Room: - Obward-123 - ATTENDING PHYSICIAN - Dr. Danilo Dizon
Nurse'S Notes Name: - Cleopatra Andude - Age/Sex/CS: - 36/F/M - Ward/Room: - Obward-123 - ATTENDING PHYSICIAN - Dr. Danilo Dizon
Name:_Cleopatra Andude_______Age/Sex/CS:_36/F/M______Ward/Room:_obward-123___
ATTENDING PHYSICIAN__Dr. Danilo Dizon___________________________________________________
10-25-21 Post-transferred D – Received on bed in supine position; conscious; with initial vital signs as
8:45 am assessment follows:
BP: 160/90 mmHg
PR: 98 bpm
RR: 20 cpm
Temp: 37.2◦c
O2 Sat: 93 %
Pale and facial asymmetry noted; with ongoing IVF of D5LRS 1L x 20 hours
Regulated to 16-17 gtts/min @950 cc level, regulating well; with O2 support
Via nasal cannula, infusing well. -------------------------------------------- (RJA)
Date/ TIME FOCUS Data – Action – Response
A – Transferred patient to room of choice; assisted to desired position of
Comfort for safety, positioned patient high-back rest; initial VS taken
Accordingly; ROD informed about the admission. -----------------------(RJA)
R – Patient settled in the room; vital signs checked and monitored;
Monitored and secured patient’s safety and wellness; waiting for laboratory
Results. --------------------------------------------------------------------------(RJA)
Renea Joy M. Arruejo
UNP-CN
Stud. No. 300052120513
10-25-21 Pitting,bipedal D – Signs of edema in her ankles, onset 2 days ago. --------------------- (RJA)
9:30 edema A – Prescribed furosemide 40 mg IV; elevated her foot. ------------------(RJA)
R – Signs of edema within the patient decreased. ------------------------- (RJA)
Renea Joy M. Arruejo
UNP-CN
Stud. No. 300052120513
10:00 Dyspneic D – Shortness of breath; diminished breath sounds in the lower based of
Lungs. --------------------------------------------------------------------------- (RJA)
A – Encouraged deep breathing exercises; maintain head of the bed elevated;
monitored and secured patient’s safety and wellness. -------------------- (RJA)
R - Vital signs checked and monitored at a normal range.-------------- (RJA)
Renea Joy M. Arruejo
UNP-CN
Stud. No. 300052120513
8:00 AM A – Continued urine output monitoring, requested for repeat ABG, Crea, K,
and urinalysis. ----------------------------------------------------------------- (RJA)
R – Waiting for laboratory results. ------------------------------------------ (RJA)