OFELIA L.

MENDOZA MATERNITY AND GENERAL

HOSPITAL
MOJON, CITY OF MALOLOS , BULACAN
TEL NO. (044)794-7113
NURSES NOTES
Name: N/A
Room: N/A
Date: January 7, 2019
NURSES NOTES
Shift: 7 am to 3 pm 1/08/19
1/07/19 6: 00 AM
⮚ Received patient awake on bed.
7: 9:10 AM ⮚ With ongoing IVF D5LR 1L inserted on the
⮚ Received patient c̅ a chief complaint of right metacarpal vein and regulated at 31
epigastric pain few hours and radiating at the gtts/min to run for 8 hours as ordered.
back, prompted consult. ⮚ Rounds back/ rounds again by Dra. Mendoza
⮚ Conscious and coherent, in pain with orders made and carried out.
⮚ Vital signs taken and recorded ⮚ Vital signs taken and recorded
⮚ Seen and examined by Dra. Mendoza with ⮚ Administered Paracetamol 300 mg IV STAT as
order and carried out. prescribed by the physician.
⮚ Consent for admission and management ⮚ Due medications given
signed and secured
11: 10 AM 1:00 PM
⮚ NPO temporarily-instructed to patient ⮚ Rounds back/ rounds again by Dra. Mendoza
⮚ Requested and sent to the laboratory with new orders made and carried out.
>CBC, UA, whole abdominal ultrasound. T: 37.6c ⮚ Vital signs taken and recorded
⮚ D5LR 1L – started as venoclysis using IV ⮚ Administered Paracetamol 500mg every 4 hours
cannula gauge 24 inserted aseptically at right as needed per doctor’s order.
metacarpal vein and regulated at 31 gtts/min ⮚ Health teachings instructed
to run for 8hrs as ordered. ⮚ Health needs attended
⮚ Due medications given ⮚ Endorsed to 3-11 shift
⮚ Vital signs taken and recorded every 2 hrs
1: 10 PM
⮚ Rounds back/ rounds again by Dra. Mendoza
with new orders made and carried out.
⮚ Light meal diet (crackers) as prescribed by
the physician. Mia Zabelle V. Pascual, S.N
⮚ Vital signs taken and recorded
3:00 PM BulSU CON Batch 2022
⮚ Health teachings instructed
⮚ Health needs attended
⮚ Endorsed to 3-11 shift

Mia Zabelle V. Pascual, S.N

BulSU CON Batch 2022
 OFELIA L. MENDOZA MATERNITY AND GENERAL HOSPITAL
MOJON, CITY OF MALOLOS , BULACAN
TEL NO. (044)794-7113

VITAL SIGNS RECORD / INTAKE & OUTPUT RECORD

Name: N/A Age: 42 y/o Room no. N/A

DATE
TIME BP P R T FHT INTAKE IV NGT MISC OUTPUT STOOL EMES NG MI
ORAL URINE IS T SC
01/07/2019 130/ 90 20 36.8c - - - - - - - - - -
9:10 AM 90
11:10 AM 120/ 82 19 36.3c
90
1:10 AM 120/ 78 18 35.6c
70
01/08/19 130/ 99 18 38.4c
6:00 AM 90
1:00 PM 120/ 88 19 37.6c
90

KARDEX
Name: N/A Date of Admission: 01/07/2019 9:10 AM
Address: N/A Operation: N/A
Age: 42 y/o Gender: M Diet: Light Meal Diet
Diagnosis: Cholecystitis/UTI IVF: D5LR 1L to run for 8hrs
Attending Physician: Dra. Mendoza IVF T/F: N/A

Endorsement
⮚ Vital signs q 2hrs
⮚ Lab request done
⮚ Due medications are given
⮚ Light meal diet
Medication:
⮚ Paracetamol 300 mg IV STAT then every
4 hours as needed for T>38.5C
⮚  Paracetamol 500mg every 4 hrs as needed
for T> 37.5

Mia Zabelle V. Pascual, S.N

BulSU CON Batch 2022