PATIENT NAME: MAUREEN WROBLE

AGE: 28 Years old

GENDER: F
C.S: Single
BED#: #02
DATE / SHIFT/ TIME FOCUS NOTES (DATA, ACTION, RESPONSE)

12/05/21 Received patient lying on bed, awake, feels

3:00 PM tired, with an ongoing IV Fluid of PNSS 1L
x8hrs infusing well at her right arm.
Vital signs as follows:
Temp: 37.6
BP: 95/70
RR:22
PR: 99
Pain scale: 6/10
02 Sat: 88%
 Body weakness
 (+) Pallor
 Abdominal pain @ the epigastric region
 Hgb: 85g/dl
 Hematocrit: 0.25%
 RBC: 2.7× 10^9/L
 WBC Count: 4.4
3:30 PM Fatigue  Established trust and rapport.
 Assisted in developing a schedule for daily
activity and rest.
 Stressed the importance of frequent rest
6:30 PM periods.
 Monitored hemoglobin, hematocrit, RBC
count, and reticulocyte counts.
 Educated energy-conservation
techniques.
 Encouraged  to continue iron therapy for
a total therapy time ,even when fatigue is
no longer present.
 Educate the client and the family
regarding foods rich in iron (organ and
other meats, leafy green vegetables,
molasses, beans).

 Provided supplemental oxygen therapy
as needed
 Admininstered FeSO4 + FA 1 tab BID as
prescribed
4:30 PM Epigastric Pain  Assessed the client’s pain, including the
location, characteristics, precipitating
factors, onset, duration, frequency,
quality, intensity, and severity.
6:00PM  Encouraged the use of
nonpharmacological pain relief measures
such reading books, and music thrapy.
  Instructed to avoid NSAIDs such as
aspirin.
 Adminstered Omeprazole 40g/cap OD ac
breakfast
 Administered ampicillin -Sulbactam 1.5g
IV q6 hrs for x days as prescribed.

5:30 PM Infection  Assessed for local or systemic signs of

infection, such as fever, chills,
9:30 PM swelling, pain, and body malaise.
 Advised to wear loose and comfortable
clothes
 Instructed to avoid eating raw fruits,
vegetables, and uncooked meats.
 Encouraged to increase fluid intake
 Monitored vital signs q1 hr.
 Regulate IV fluid
 Monitored WBC count
Instructed to avoid contact with people
with existing infections.
 Stressed the importance of daily hygiene,
mouth care, and perineal care.
 Administered Paracetamol 500mg tab q4
as prescribed
5:00 PM Activity Intolerance  Allow verbalization of feelings regarding
limitations
6:00 PM  Encouraged to gradually increase activity
with active range-of-motion exercises in
bed, increasing to sitting and then
standing
 Dangled the legs from the bed side for 10
to 15 mins.
 Assisted with ADLs while avoiding patient
dependency.
 Provided bedside commode as indicated
4:30 Risk for Fluid Volume  Monitored urine color and specific gravity
Deficit and fluid intake and output.
 Monitored BP for osthostatic changes.
10:00 PM Monitored changes in pt's mental status.
 Administered PNSS as prescribed.
 Transfused 2 PRBCs 250ml x 4-6 hrs as
prescribed.

11:00 PM  Vital signs are all within normal range

 CBC and WBC count are all within normal
range
 Relieved from pain with a pain scale of
2/10
 The patient regains strength as evidenced
by reclaimed normal mobility and
functioning.
 Reports ability to perform required
activities of daily living.
 Refer accordingly

Jomark C. Orpilla,RN