APPENDIX C

DATE/TIME SOAPIE/R NURSE’S NOTES

1 – 12 – 18 S/O > received patient lying on bed with head elevated to
30-degree angle awake in sensorium GCS 10 (E4, M1,
7AM V1); irregular shape; spontaneous used power on
upper extremities; weakness noted on lower
extremities; occasionally follows command; with
ongoing venoclysis on right arm PNSS at KVO rate;
with side drip of Amiodarone drip 4amps ____ + D5W
250 at 30cc/hr; infusing well via infusion pump; (+)
backflow, (-) phlebitis, (-) inflammation; with
endotracheal tube hooked to mechanical ventilator
with the following settings: TV=450, FiO2=100,
BUR=20, LL=22, on AC mode; with crackles noted on
both lung fields; with diminished ES seams in minimal
amount and with whitish oral secretions in moderate
amount; with white patch on tongue; well saturated;
(-)DOB, (-)SOB and not in distress; with nasogastric
tube for medications and feeding; Patient (+) gurgling
sounds heard upon auscultation and well secured; with
foley catheter to urobag draining well with yellow-
colored urine; with minimal hematuria noted on
tubings; (-) bladder distention; with soft and flat
abdomen; with hypoactive bowel sounds heard upon
auscultation; skin is warm to touch; with good and
elastic skin turgor; (-) edema; (-)bedsore; (-)perineal
rash; with pink and moist mucus membranes; with
capillary refill time of 2 seconds; continually hooked to
cardiac monitor with vital signs of: BP-130/90, HR-83,
RR-21, O2Sat-100%, Temp-36.5
> Ineffective Airway Clearance related to retained
secretion.
> Impaired Gas Exchange related to insufficient
oxygen
> Ineffective Breathing Pattern related to present
condition
A > Ineffective Myocardial Tissue Perfusion related to
altered tissue perfusion
> Ineffective Cerebral Tissue Perfusion related to
altered Cerebral Tissue Perfusion
> Activity Intolerance related to present condition
 > Risk for Infection
> Risk for Injury
> At the end of 12 hours of nursing intervention, the
patient will be able to:
Maintain good oxygen
Maintain vital signs within acceptable
range
 Render safe and quality nursing care
> Cephalocaudal assessment done
> Initial vital signs taken and recorded
P
> IVF line checked for patency
> Chest tapping done and checked area q2
> decreased cordance to 10//hr as ordered
> due Aspirin 80mg tab and Exflem 1 tab
>> due Duavent neb given
I
> NGT feeding done; tolerated and with residue
> referred to Dr. Talabucon
> Midaz 2.5mg IVTT with BP prec
> due Mannitol 100cc IV bolus
> accordingly and back tapping done
> due clopidogrel 75mg tab via NGT
> seen and examined by Dr. Namaad with new orders
carried out
ALITRAQ > NGT feeding done; tolerated with residue
250CC
> due medications given
9:45 AM > seen and examined by Dr. Talabucon with new
BP 110/80 orders carried out
10 AM
> Intake and Output measured and recorded
> Updated AP of starts
12 NN
> due CombiVent 1 neb given
> perineal care done; needs attended promptly
1 PM
ALITRAQ 250 > due Dexane 0.6cc SQ BID given at right UQ
 CC > turned to sides intervals
2 PM > Intake and Output measured and recorded
> endorsed to next ROD for continuity of care

DATE/TIME SOAPIE/R NURSE’S NOTES

1-12-18 S/O > Received lying on bed, awake in sensorium; GCS
score 10 (E4, M5, V1) , pupil: 3mm briskly reactive to
7AM light on both eyes (+) isocoric , (+) corneal reflex with
spontaneous limited eye movement, with spontaneous
motor response on both upper and lower extremities ,
with ongoing IVF of PNSS IL + 20 mEqs KCL at 10
cc/hr via infusion pump, with ongoing #1 cordarone
drip 4amps + D5W 250 at 10cc/hr via infusion pump ,
(-) phlebitis,
(-) infiltration , (+) backflow , infusing well at right arm,
(-) SOB ,
(-) DOB , with endotracheal tube to mechanical
ventilator with following settings: TV 450 , FI02 60,
BUR 20, LL 22 , on AC mode, with bilateral chest
expansion , with crackles noted upon auscultation on
both lung field, with yellowish secretion upon suction
into the endotracheal tube with nasogastric tube for
medications and feeding, patency checked, (+)
gurgling sound heard upon auscultation of the
abdomen when introducing air into the nasogastric
tube, (-) abdominal distention , (-) bloatness,
With foley catheter to urobag draining well with yellow
colored
urine in moderate amount , (-) bladder distention with
good peripheral palpable pulses, (+) sinus tachycardia
 continuously attached to cardiac monitor with initial
vital signs BP :120/70, HR : 107bpm , RR: 27 cpm,
T :36.8 C, O2 sat: 100%, (-) pressure sore
>Ineffective Airway clearance related to retained
tracheobronchial secretions
>Impaired gas exchange related to insufficient oxygen
supply and demand
>Ineffective cardiac tissue perfusion related to altered
myocardial contraction
A >Risk for infection

>Risk for aspiration

8 PM >Altered comfort related to hospitalization
>Self care deficit related to present health status
>At the end of 12 hours the patient will be able to:
a. maintain patent airway
b. maintain proper oxygenation and hydration

10 PM c. maintain proper positioning and alignment

d. receive medication safely
P e. receive quality nursing care
10:45 PM
>vital signs taken and recorded
>cephalocaudal assessment done

11:45 PM >due nebulization given as ordered

>positioned comfortably and safely

1-13- >suction secretions as needed

18 ;12AM >due medications given as ordered
>Fed per nasogastric tube, tolerated with residual, with
aspiration precaution

2 AM >provided calm and restful environment

>kept closely monitored

3:45 AM >positioned comfortably and safely

4 AM >suction secretions as needed

 >intake and output measured
>updates relayed to AP’s
>kept closely monitored
5:30 AM >seen and examined by Dr. panolong with orders
carried out
>due nebulization given as ordered
6 AM
>positioned comfortable and safely
>suction secretions as needed
>provided calm and restful environment
6:45 AM
>kept closely monitored
>positioned comfortably and safely
> suction secretions as needed
>due medications given as ordered
7 AM
> Fed per nasogastric tube, tolerated with residual,
with aspiration precaution
> provided calm and restful environment
> kept closely monitored
> due nebulization given as ordered
> positioned comfortably and safely
> suction secretions as needed
> provided calm and restful environment
> kept closely monitored
>chest tapping done done
>oral and perineal care done
>bedside care done
> positioned comfortably and safely
> Suction secretions as needed
> Due medications given as ordered
> Intake and output measured
> Updates relayed to AP’s
 > kept closely monitored
>needs attended
>Endorsed to next NOD for continuity of care

DATE/TIME SOAPIE/R NURSE’S NOTES

1-13-18 S >No verbal output, patient is intubated
7 AM O > Received lying on bed, awake in sensorium; GCS
score 10 (E4, M5, V1) , pupil: 3mm briskly reactive to
light on both eyes (+) isocoric , (+) corneal reflex with
spontaneous limited eye movement, with spontaneous
motor response on both upper and lower extremities ,
with ongoing IVF of # PNSS IL + 20 mEqs KCL at 10
cc/hr via infusion pump, with ongoing #1 cordarone
drip 4amps + D5W 250 at 10cc/hr via infusion pump ,
(-) phlebitis,
>with foley catheter ……
>with skin hot to touch
>with BP 100/60 mmHg, HR 103 bpm,
RR 33 cpm, temp 38.8C
>Ineffective airway clearance related to retained
secretions
A
> Impaired gas exchange related to decreased oxygen
supply and demand
>Ineffective cardiac tissue perfusion related to
impaired contractility
>Risk for infection related to immunocompromised
>At the end of 12 hours nursing intervention the
patient will be able to :
>maintain patent airway
 P >maintain a stable hemodynamic status
> provide adequate oxygenation
>provide safe and quality nursing care
>established rapport
> Cepahalocaudal assessment done
>Perineal care done, changed diaper
>Reposition to comfort
I >Suction secretions as needed
>Oral care done
8 AM >Reinsert IV line done
>measured input and output
IV line >suctioned secretions properly
dislodged
>due meds given
8 AM >PCM 500mg tab given
OF 250 ml
9 am >monitored vital signs
10 AM >seen and examined by Dr. Panolong with new orders
carried out
12 NN
T = 38 C (+) >nebulization done
fever
>suctioned secretions properly
>Intake and output measured and recorded
2 PM T = 37.5 C
> vital signs taken and recorded
>due meds given
3 PM
>suction secretions properly
>seen and examined by Dr. Talabucon
>Endorsed to NOD
4 PM OF 200 ml
BP 100/60 mmHg, HR 80 bpm, RR 20 cpm, temp 37.1
C , O2 sat 100%, GCS 10 (E4,M5,V1) drowsy in
5 AM sensorium

6 AM E
DATE/TIME SOAPIE/R NURSE’S NOTES
1 – 13 – 18 S/O >No verbal output, patient is intubated. Received
patient lying on bed with head of bed elevated at 30
7PM degree angle. Awake with spontaneous eye opening
with isocoric pupils briskly reactive to light and
accommodation, 3mm .with normal power on all
extremities, does not follow commands. With periods
of restlessness. GCS 11 (E4M6V1)
>with endotracheal tube attached to mechanical
ventilator with settings : TV 450, FiO2 40%, BUR 20,
Lip Level 22, on AC mode with fine crackles on
bilateral lung fields. Not in distress. With whitish
tracheal secretion, minimal amount salivary oral
secretion, moderate amount.
>with nasogastric tube for medications and feeding.
NGT patent and in proper placement with (+) gurgling
on auscultation. Adbomen is soft, non tender , non
distended, no pressure sore noted.
>with foley catheter attached to urobag , draining dark
yellow urine. No visible heamturia, with (+) sediments .
Bladder is not distended.
>with ongoing IVF on left hand: #0 PNSS IL + 20
mEqs KCL at 10cc/hr.Infusing well via infusion
pump .No infiltration, no phlebitis on insertion site.
>No peripheral edema noted with good skin turgor.
Skin is warm to touch with temp 37.4 C. Attached to
cardiac monitor with initial vital signs : BP 110/70
mmHg, HR 87 bpm , RR 23 cpm, O2 sat 100%
>Impaired gas exchange r/t imbalance in O2 supply
and demand
>Ineffective airway clearance r/t retained tracheal
secretions
>Impaired physical mobility r/t bed confinement
>Activity Intolerance r/t generalized weakness
A
>Risk for further infection
>Risk for injury r/t periods of restlessness
>At the end of the shift, the patient will:
- maintain vital signs within acceptable range
 - receive safe nursing care
>Initial vital signs taken. Assessment done
>Due neb given
>Due NGT feeding given. Due meds given per
NGT .Placed on moderate high backrest
P >Referred to Dr. Talabucon with orders carried out

7PM I >Diazepam 5mg IV given as ordered

>Turned to sides, Back tapping done

8 PM 250cc >Due neb given. Due piperacillin + Tazobactam IV
ALITRAQ given

9 PM >Secretions suctioned as needed

(+) facial and >Updated AP’s via SMS
B/L upper ext
twitching >Referred to Dr. Talabucon with orders carried out

10 PM BP = 110/70 >Levetiracetam 500mg IV in 100cc PNSS to run x 15

mmHg mins given as ordered
>Tepid sponge bath done
>Secretions suctioned as needed
11 PM
>Turned to sides as scheduled
1 – 14 – 18
12AM >Monitored for unusualities
Gen. seizures >Due NGT feeding given .Tolerated well
for 5 seconds
>Morning care done. Perineal care done

1 AM >Due neb given

Warm to touch
, >Turned to sides as scheduled

T = 37.0 C >Bedside care done

2 AM 250cc > Followed with #2 PNSS IL at 10 cc/hr as odered

4 AM ALITRAQ >Due meds given

>Secretions suctioned
>output measured and recorded
>updated AP’s via SMS
>Endorsed to next shift NOD with vital signs BP
 IVF consumed 100/60 mmHg, HR 61bpm, RR 18 cpm, O2 sat 100%

6 AM
7 AM

DATE/TIME SOAPIE/R NURSE’S NOTES

1 -14-18 S >No verbal output, patient is intubated
7 AM O >Received patient on bed in supine position with head
of bed elevated
>with approximately 30 degree angle , awake in
sensorium, follows commands, GCS 11 ( E4M6V1);
with isocoric pupils at 4mm _____, both briskly
reactive to light, (+) visual threat; (+) body weakness ;
(+) twitching on Left hand noted, occasional; with
ongoing IVF of # 1 PNSS IL 10 cc/hr infusing well at
left hand, (+) backflow, (-) signs of phlebitis , (-)
infiltration
>with ET to MV with set-up: TV=450, FiO2= 40%,
BUR= 20, PEEP=0 on AC mode at 22cm lip level, with
bilateral chest expansion , fine crackles heard on both
upper lung fields , (-) signs of distress ; RR 20 cpm ,
O2 sat = 100% , CRT < 3 secs, with mouthguard in
placed , with minimal whitish tracheal secretions, with
greenish to yellowish ,loose oral secretions , moderate
in amount
>with nasogastric tube for medications and feeding , (-)
residual, (+) gurgling, with soft non-distended
abdomen with hypoactive bowel sounds heard on all
quadrants
>with foley catheter to urobag draining , amber colored
urine,
(-)hematuria, (-) sediments
>on continuous cardiac monitoring showing sinus
 bradycardia
HR= 56 bpm to sinus rhthym, HR= 64bpm , BP
100/70mmHg with palpable peripheral pulses.
>skin warm to touch T= 36.4 C with anti-embolic
stockings on both lower extremities; (-) pressure injury
>Ineffective Airway clearance r/t retained
tracheobronchial secretions
>Impaired gas exchange r/t poor lung compliance

A >Decreased cardiac output r/t decreased myocardial

contractility
>Impaired physical mobility r/t neurologic deficit
>Activity Intolerance r/t decrease in muscle strength
>self care deficit r/t present condition
>Risk for infection r/t to exposure to pathogens
>Risk for Aspiration r/t presence of tubings and
retained bronchial secretions
> Risk for Injury r/t restlessness and twitching activity
>within 12 hours shift, patient will be able to:
-maintain clear and patent airway
-maintain stable hemodynamic status
- receive efficient and quality nursing care
-remain free from any episode of aspiration
P >Introduce staff and built rapport to patient and family

>Cephalocaudal assessment done

>vital signs and neuro vital signs taken and maintained
>reinforced patient to place, date and time
>checked ongoing IVF and IV site for patency
>checked attached tubings for kinks and leaks
>checked soft restrains on hands every hour
I >due nebulisation given as ordered; back tapping
done thereafter
>due feeding and medications given via NGT with
8 AM strict aspiration precaution observed
>due Dexamethasone 5mg IV given aseptically
>suctioned ET and oral secretions , then as needed
>repositioned on right side-lying; applied powder on
pads
>relayed available labs to all AP’s
>due Levofloxacin 750mg IV aseptically
8:40 AM
>bedside care done; watched out for any unusualities
9 AM
>repositioned to supine; head of bed maintained
10 AM elevated
>maintained side rails raised for safety
11 AM >due nebulisation given; back tapping done thereafter
>oral care done with Bactidol solution
12 NN >due medications given per NGT as ordered
>referred to Dr. Panulay for co-management via SMS
12:30 PM >repositioned to left side-lying position
>due feeding and medications, given per NGT
1 PM >due Dexamethasone 5mg IV given aseptically
2 PM >due Piperacillin + Tazobactam 45mg IV given as
ordered
>intake and output measured and recorded
3 PM >updated all AP’s with patients latest status
>seen and assessed by Dr. Panulay with new orders
carried out
4 PM
>CBG taken and relayed to Dr. Panulay
>started KCl drip; ___ PNSS 1 liter + 20 mEqs KCl
25c/hr to run for 4 hours
> due nebulisation given; back tapping after suctioning
done thereafter
> seen and assessed by Dr. Talabucon with new
orders carried out
4:15 PM HgT = 305
mg/dL > perineal care done: changed diaper
 > repositioned comfortably on bed
5 PM > due medications given per NGT as ordered
> intake and output measured and recorded
6 PM > repositioned to supine with head of bed elevated
6:30 PM > seen by Dr. Natividad and Dr. Alagodan with new
orders carried out
> started weaning: hooked to T-piece at 4 LPM x 15
6:45 PM mins
7 PM > watched out for any signs of respiratory distress
> Goal met; so far tolerated weaning; (-) signs of
respiratory distress; Endorsed to next shift NOD for
continuity of care with latest vital signs: BP = 110/70,
HR = 83 BPM, RR = 20 CPM, T = 36.4 C, O2 Sat =
100%, awake in sensorium with isocoric pupils, GCS
11 (E4, M6, V1)

DATE/TIME SOAPIE/R NURSE’S NOTES

1 – 14 – 18; S/O >no verbal output. Patient is intubated. Received
7 PM patient lying on bed with head of bed elevated at 30-
degree angle. Awake. Conscious. With spontaneous
eye opening. With isocoric pupils briskly reactive to
light and accommodation, 3mm. with normal power on
all extremities. Does not follow commands
 > with endotracheal tube attached to mechanical
ventilator with settings: TV 450, FiO2 40%, BUR 20,
PEEP 0, Lip Level 22. With fine crackles on bilateral
lung fields. Whitish tracheal secretions, minimal
amount, salivary oral secretions. Not in distress.
> with nasogastric tube for medications and feeding.
NGT is patent and in proper placement with (+)
gurgling on auscultation. Abdomen is soft, non-tender,
non-distended with hypoactive bowel sounds
> with foley catheter attached to urobag draining dark
yellow urine. No visible hematuria. No sediments
noted. Bladder is not distended.
> with ongoing IVF on left hand . #1 PNSS 1 liter at
10cc/hr. with side drip of #1 KCl drip 20 mEq + 90cc
PNSS at 25cc/hr. Infusing well via infusion pump. No
infiltration. No phlebitis on insertion site
> skin is warm to touch with temp of 36.4 C with senile
skin turgor. No pressure sore noted. No peripheral
edema noted. Compression stockings worn on bilateral
lower extremities
>attached to cardiac monitor with initial vital signs BP
= 100/70 mmHg, HR = 76 bpm, RR = 24 cpm, O2 sat
100%
> Impaired gas exchange r/t imbalance in O2 supply &
demand
> Ineffective airway clearance r/t retained bronchial
secretions
> activity intolerance r/t generalized weakness
A > risk for injury r/t periods of restlessness
> at the end 12 hours of nursing intervention, the
patient will:
- maintain vital signs within acceptable range
- receive safe nursing care
> initial vital signs taken. Assessment done
> secretions suctioned as needed
P
> hooked to O2 via T-piece at 4 LPM as ordered
7 PM
> hooked back to MV with same settings. Tolerated
 weaning well
I > relayed to Dr. Panolong. Humulin R 8 “U” SC given
pre-feeding as ordered
7:15 PM
> due NGT feeding given. Due meds given per NGT
7:45 PM
> turned to sides. Gentle back tapping done
> due meds given
8 PM Hgt = 320
mg/dL > output taken and recorded
9:30 PM
> updated APs via SMS
10 PM
ALITRAQ 250 > turned to sides as scheduled
CC
> due neb given
11 PM
> oral care done
1-15-18 12
AM > due NGT feeding given. Positioned on moderate
high back rest. Tolerated well.
> morning care done. Perineal care done.
> oral care done
2 AM

> bedside care done

4 AM
ALITRAQ 250 > oral and tracheal secretions suctioned as needed
CC
> output taken and recorded
> due meds given. Due neb given
5 AM BUN XI: Dark
Brown,formed > updated APs via SMS
plenty in > hooked to T-piece at 4 LPM as ordered
amount
> monitored for unusualities
6:30 AM
> endorsed to next shift NOD with vital signs: BP =
110/70 mmHg, HR = 55 BPM, RR = 20 CPM, O2 Sat
7 AM 100%, GCS 11 (E4, M6, V1), not in distress.
 E

DATE/TIME SOAPIE/R NURSE’S NOTES

1 -15 – 18; S/O >received asleep, difficult to arouse, head of bed at 45
C; GCS 10 (E3, M6, V1), isocoric pupils 3mm brisk;
7 AM with patent IV site at left hand with ongoing PNSS 1
liter at 10cc/hr via insulin pump; with endotracheal tube
to mechanical ventilator with the following settings: TV
450, FiO2 40, BUN 20, LL 22, PEEP 0 ON AC MODE;
with secretions whitish loose in moderate amount; with
ET secretions of clear loose in minimal amount; with
equal lung expansion; with clear breath sounds; not in
respiratory distress; CRT <3 seconds; continuously
hooked to cardiac monitor on lead II; sinus rhythm;
with good palpable pulses; with soft, flat, non-
distended, non-bloated abdomen, with normo-active
bowel sounds; with foley catheter to urobag, draining
yellowish colored urine in moderate amount; (+)
sediments; (-) hematuria; (-) bladder distention; with
spontaneous movement on extremities, with anti
embolic stockings on both legs, (-) bedsore, (-) rashes,
with baseline vital signs of BP 100/70 mmHg, HR
60bpm, RR cpm, T 36.2 C, O2Sat 100%
> Ineffective airway clearance related to presence of
retained secretions
> Ineffective tissue perfusion (cerebral) related to
altered blood flow secondary to brain mets
> Ineffective breathing pattern related to decreased
lung expansion secondary to Lung CA
> Risk for injury and for possible seizure activity
> Risk for impaired skin integrity related to bed
confinement
> within our shift, patient will be able to:
- maintain clear and patent airway
- receive adequate oxygenation
- be free from signs of infection
 - receive nursing quality nursing care
- receive medications safely as ordered
- maintain vital signs at acceptable units
- able to tolerate T-piece weaning
> assessed cephalocaudally, baseline vital signs
measured and recorded; bedside care done;
> relayed HGT to Dr. Panolong; carried out orders;
A
> kept monitored for unusualities
> referred to Dr. Talabucon; carried out orders;
> Humulin R 6 “u” SC given and recorded, suctioned
secretions with due nebulisation given;
> due ALITRAQ feeding; NGT given and recorded,
P feed tolerated with residual;
> due Acetylcysteine 600mg tab, aspirin 80 mg tab,
Levoteracetam 7 mg tab given and recorded/NGT
> hooked to T-piece at 6 LPM; kept monitored for
unusualities;
> hooked back to MV with same settings for 45
minutes then 15 minutes 15 minutes in cycles;
> kept monitored for unusualities
> patient seen and examined by Dr. Talabucon; carried
out orders
> repositioned to right side-lying;
> suctioned secretions; due medications given and
recorded;
> due Clopidogrel tab via NGT given;
> relayed to Dr. Paramore; carried out orders;
> Humulin R 6 ”u” SC given aseptically; KCl drip
started;
> due feeding given and recorded ;
> drained urobag and summed up;
I
> updated AP’s of status;
> perineal care done; changed diapers; bedside care
 done;
> due nebulisation given and recorded; KCl drip
followed
> due medications given and recorded
> endorsed to next NOD for continuity of care; bedside
care done; partial goals met

DATE/TIME SOAPIE/R NURSE’S NOTES

1-16-18 S/O  Patient meds comply attended
7am  Kept watch for unsualities; refer accordingly
 Goals met: moderate APS WITH GCS 10 EV
MOV, drowsy
 Isocoric pupils 3mm; spontaneous weak arms,
endorsed nto next shift NOD monitor AS VS. BP
 Patient lying in bed, drowsy in appearance;
GCS10 (E410-v), iscoric, brisk, enable to follow
single command , with ongoing ivf of pnss
regulated at 10cc/hr infusing well at infusion
pump, with endotracheal tubed attached to
mechanical ventilator , N 450, FiO2 40% BUN
1, AC meds, + nasal flaring
 HR SOB, tem 36.2, O2sat 100
 Ineffective airway clearance due to retained
secretions
 Decreased cardiac output r/t to altered status
A  Impaired physical mobility
 Self care deficit related body weakness
 Risk for infection
 Risk for impaired skin integrity
 After 12 hours of nursing care, patient will be
able to:
 Maintain patient airway and adequate
oxygenation
 P  Vital signs at normal range
 Promote safety and comfort
 Asssist in self care activities
8am  Cepahlaucaudal assist
 Side rails up
 Position comfortably on bed
 Hooked at 4ctm

HGT – 270
9am mg/dl on NPO  Hooked to mechanical ventilator
9:15am for UTZ OF  Kept monitored for any unusualities
WA  Refer to Dr. Taldues via sms
 Valproic acid give per iv
 Turned to sides intervals
11:00am  Hooked to t-give @4Lpm
 Seen and examined by Dr, Allaydan
 Received 20g iv give

11:15am  Kept comfortable at all times

 Seen and received by Dr.Pauli

12nn (+) audable  Relayed result to Dr. Tauding

pleurysm

HGT-262  Humulin R 6
mg/dl  Hooked to T-tube @ 4lpm
 Due medications give

1pm
 Hook back to MV
1:15pm  Sustained precautions accordingly
 Hooked to MV
2:15pm  Pre medications give
 Turned to side at interval
 Reported attending physician
 Hooked to MV
3pm
 Kept closely monitored
 Meds attended
 Hooked to T-tube at 4Lpm
5pm
 Hooked to MV
 Provided care due
 Diaper changed into warm

5:15pm (+) BM,  Relayed to Dr. Paveley

 greenish , soft  Humulin R 8”u” sq
in nul out  Sustained duties

5:40pm
HGT 300  Feed patient nasogastric tube
6:00pm mg/dl  Due medications give
 Hooked to T-tube
 Hooked to MV with same settings
7:00 pm  Bedside care done
 Endorsed to next NOD

DATE/TIME SOAPIE/R NURSE’S NOTES

1-16-18 S  No Verbal Output
7pm O  Received on bed with ongoing IVF of #2 D5W
500@ 10 cc infusing well via infusion pump;
(+) backflow (-)Phlebitis (-) Infiltration
 Stupor in sensorium, Pupils of 2mm on both
eyes and brisky reactive to light, with flexion
on all extremities
 With Endotracheal tube to MV with the
following settings: TV-450 FiO2 – 40% Bunr -
16 LL-22 on AC, Mode: (+)whitish et
secretions, (+) Bilateral Lung Expansion (+)
crackles on both Lung Field (-) SOB (-)DOB (-)
Distress
 With Nasogastric tube for meds and feeding
patient in place: (+) gurgling sounds noted
upon ascultation on abdomen
 With foley catheter attached to UrogBag
draining to a yellow urine in moderate amount
 Continously hooked to cardiac monitor
 Ineffective cerebral tissue perfusion r/t
inadequate blood flow
 Ineffective airway clearance r/t retained
secretions
 Impaired physical mobility r/t neurovascular
A involvement
 Self-care deficit r/t immobility
 Risk for infection
  At the end of 12 hours, will be able to: achieve
a stable hemodynamic status, maintain patent
airway, provide quality nursing care
7pm P  Established rapport
 Cephalocaudal assessment done and
\ documented
 Vital signs taken and recorded
I  Checked IV patency
 Placed comfortably on bed
 Suctioned secretions as needed
 Due meds given
 Raised side rails for safety
8pm  Turned to side at intervals
 Gentle back-tapping done
 Provided adequate rest
10pm  Intatke and output measured and recorded
 Updated all aps via sms
 Vital signs taken and recorded
11pm  Fed per ngt with residual
 Kept closely monitored
1-19-18  Turned to side accordingly
12mn  Placed on cool and calm enviroment
 Bedside care done
2am  Cotinously monitored
 Complete bed bath rendered; changed soiled
linens and gowns
3am  Oral and perineal care done
5am  Suctioned secretions
 Ngt taken and recorded
 Fed per ngt with residual
 Due meds given
 Needs attended
6am  Kept watched
 (+)SOB (-) DOB
 (+) Deterioration
 Endorsed to next nod for continuity of care

TIME SOAPIE/R NURSE’S NOTES

1-17-18 S/O  Received patient in bed; GCS 6 (E1M4Vit);
7am stupor in sensorium; flexion motor response all
limbs; noo spontaneous eye movement; no
verbal response; intubated; isocoric pupils
brisky reactive to light and accomodation @
2mm
 With nasogastric tube inserted @ right nostril for
feeding and medication administration; (+)
gurgiling sound notes and epigastrium ; (-)
abdominal distentions; with sfot and flabby
abdomen
 With endotratcheal tube attached to T-piece
@4Lpm oxygen (+) bilateral chest expansion
noted upon each respiration; with fine crackles
noted at both lung fields
 With chest leads continously hooked to cardiac
monitor for closer monitoring with inital vital
signs BP 110/70 mmhg, hr 80 sinus rhythem;
RR 28 regular fast respiration, afebrile @37.c,
skin is warm to touch; 100% 02 saturation
 With renodysis at right arm #2 D5W 500 @ 400
cc level regulated @ 10cc/hr – infusing well via
infusion pump; (+) backflow
 With foley catheter attached to urobag-draining
well with light yiellow urine in moderate amount;
(-) hematuria; (-) bladder distention; (-)
sediments
 Ineffective breathing pattern related
A tracheobronchial obstruction
 Electrolyte imbalance related fluid imbalance
 Unstable glucose level related stress induced
 Impaired physical mobility related decrease
muscle strength and castrol
 Impaired skin integrity related extremes of age
 Activtity intolerance related imbalance oxygen
suppy and demand
 Risk for falls related episodes of seizure
 Introduced oneself to patient and family as his
nurse this morning
 Established trust and support
 Reinforce orientation to date, time, and current
P status
 Initial vital signs taken, recorded and monitored
hourly
 Initial cephalucaudal assesment done
thoroughly
8am  Due ciprofloxacin 200 mg given intravenously &
 aseptically
 Suctioned oral and et secretions as frequetly
needed
 Due levetiracetam tab and norplat s tablet give
per ngt
 Turned to sides every 2 hours; back tapping
done thereafter
10am  Due valproic acide 500 mg tab given per ngt-
toreted with residual
12nn  CBG monitoring taken, recorded and relayed to
Dr. Damolang with insulin standing order of
Humulin R 6 units given subcutaneously
 Due AlitraQ feeding given per ngt with strict
CBG =222 aspiration precaution
2pm mg/dl  Seen and examine by Dr. Pandong with new
orders carried out
 Increased present IVF to 40 cc/hr as per
ordered
 Due piptaz 4.5gm and dexamethasone given
intravenously and asepticallyty
3pm  Intake and output measured, calculated, and
recorded
 All AP’s updated of patient’s current status via
sms
4:30pm  Soiled diaper changed and perinal care done
providing privacy

6pm  CBG monitoring taken, recorded and relayed to

(+) Darkgreen Dr. Panolog with standing insulin scale; humulin
watery R 4u given subcutaenously

Stool in
moderate  Due AlitraQ given per NGT with strict aspiration
amounts precautions patency and placement checked
CBG=172 prior feeding – tolerated without residual
mg/dl  Seen and examined by Dr. Talabucan with new
Feeding =250 orders carried out
6:45pm  Seen and examined by Dr. Alagadaan with new
order
 Advised to night shift NOD for continuity of care
 No verbal output; patient is intubated
 Received patient in bed; GCS 6 (E1M4Vit);
stupor in sensorium; flexion motor response all
limbs; noo spontaneous eye movement; no
verbal response; intubated; isocoric pupils
brisky reactive to light and accomodation @
 E 2mm
 With nasogastric tube inserted @ right nostril for
S feeding and medication administration; (+)
O gurgiling sound notes and epigastrium ; (-)
abdominal distentions; with sfot and flabby
abdomen
 With endotratcheal tube attached to T-piece
@4Lpm oxygen (+) bilateral chest expansion
noted upon each respiration; with fine crackles
noted at both lung fields
 With Nasogastric tube attaced @ L nostril;
(+)patency
 (+) gurgling sound herd upon asculation, for
meds and feeding; with Alitroq: 1 sachet in
250cc H20 every 6 hours well tolerated; with
residual
 HR is within normal range; in sinus rhythm
 With ongoing #2 D5W 500 @ 40cc/hr @ R hand
 With normoactive level and heard in all four
abdominal quadrants, soft abdomen and not
distended
 With foley catheter attached to urobag draining
well with yellow colored urin in minimal to
moderated amount
 With continously hooked to cadiac monitor and
pulse oximeter with latest vs as follows: BP=
10/70mmhg, HR=72bpm, RR=26cpm, T+37c,
O2sat = 100%
 Ineffective airway clearance related retained
bronchial secretions
 Ineffective breathing pattern related decreased
lung expansions
 Impaired gas exchange related insufficient 02
supply and demand
 Ineffective cerebral tissue perfusion related
inadequate blood flow
 Self care deficit related to hospitalization
A  Risk for further infection related to presence of
invasive tubings
 After 12 hours of nursing intervention, patient
will be able to: maintain patent airway, maintain
good oxygenation, maintain proper positioning,
maintain hemodynamics within normal range
7pm  Established rapport
 History taking done
 Cephalocaudal assessment done
  Positioned patient comfortably
 Iprateopium + salbutamol given via nebulization
8pm P  Due medications given per ngt
10pm  Conefloxacin 200mg IV given
 Positioned patient @ L side – lying position
 Due Dexamethasone 5mg IV given
 Due piperacillin + Taclobatan 4.5 gm IV
I  Due Valpros 500mg+tab 2u given
11pm  Updated all AP’s s fo patient status
 Kept side rails raised
 Back tapping
12am  Due combinent given via nebulization
 Oral care done
2am  Positioned patient @ R side lying position
 Provided comfort
4am  Due medication given
5:30am  Morning care done
 Perineal care done
6am  HGT taken and relayed to AP
 Due feeding and medication given per NGT
 Due dexamethasone 5mg IV q8 given
 Due clexane 0.6cc sc given
 Due omeprazole 40mg IV open
6:30am  Bedside care done
 Provided safety and quiet enviroment
 Needs attended
 Endorsed to the next NOD for continuity of care
7am with vital signs as follows: bp: 110/60mmhg,
HGT= PR:79bpm, RR=19cpm, o2sat=100%
304mg/dl

DATE/TIME SOAPIE/R NURSE’S NOTES

1-18-18 S/O  Received patient lying on bed and head
elevated 30 angle GSCS (E1M1V1),
stuporous, isocoric pupils 2mm with brisky
inactive to light and accomodation, (+) flexion
noted on both upper and lower extremities
 With ongoing IVF of D5W 500cc AT 40cc/hr
hooked at right hand infusing well with
infusing pump (+) occlusion and (-) infiltration
 With endotrachial tube in place attaced to
mechanical ventilator with the following
settings: tv 450 FiO2 4c 3lr 16 LL=22 on AC
mode tolerated and well saturated, (+)
bilateral lung chest expansion, (+) fine
crackles heard on both lungfileds upon
 ascultation with minimal whitish endotracheal
secretions and minimal oral secretions
 With nasogastric tube in place for
medications and feeding, patency checked,
(+) gurgling sound heard upon ascultation
when introducing on via aseptic syringe, with
ongoing feeding of alitraq, sachet every 6
hours; (+) soft and flobby abdomen (-)
abdominal distentsion
 With foley catheter in place attached to
urogbag draining moderate amount of straw
juice colored urine, (-) hematuria,
(+)sediments, (-) bladder distension
 Continously hooked to cardiac monitor with
latest vital signs of bp: 120/70mmHg, hr 75
bpm, rr:22, temp: 36.4c O2sat 100%
 Ineffective airway clearance related to
retained endotrachial secretions
 Impaired breathing pattern related to
insufficient oxygen suppy and demand
 Ineffective cerebral tissue perfussion related
A to altered cerebral blood flow
 Impaired physical mobility related to
neuromuscular involvement
 Risk for infection related to presence of
invasive tubings
 Risk for falls
 At the end of my nursing interventions,
patient will be able to: maintain
hemodynamics within normal range, maintain
clean and patent airway, provide safety at all
7am times, kept monitored is unsualities
P  Thorough cephalocaudal assessment done
 Initial vital signs and neurovital signs taken
and documented
 Positioned comfortably on bed
 Done for Ct scan with contrast clearance
facilitated
I  Turned to sides at interval
 Back tapping done
6am  Suction secretions as needed
10am  Seen by Dr. Nativididad
 Seen by Dr. Pandong
 Provided adequate rest periods
12am  Suction secretions as needed
 Due HGT taken and relayed via sms
  Due medications given as ordered
 Fed per NGT with strict aspiration precaution,
1pm tolerated without residual
 Positioned comfortably on bed
 Suctioned secretions as needed
HGT=222mg/dl  Due antibiotic skin tested as ordered
 Due medications given as ordered
OF 250cc  Transported to URI department for Cranial
2pm CT scan
3pm Dark, tary, loose  Updating attending physician
in  Transported back to the unit
moderate/minimal  Positioned comfortably on bed
amount  Intake and output measured and recorded
4pm To start  Kept closely monitored for any unsualities
merganem  Due medications given as ordered
 Suctioned secretions at interval
 Turned to sides, backtapping done
 Bedside care done
6pm  Due HGT taken and relayed via sms
 Fed per NGT with strict aspiration
 Kept closely maintained
 Partial intake and output measure and
recorded
 Endorsed to IC next nurse on duty for
continuity of care

7pm  Received stupor, GCIS 6 (G2M3V1) isocoric

pupils 2mm brisk; flexion on all extremities
 With patent IV site at right arm
 With nasogastric tube for medications and
feeding inplaced attached to mechanical
ventilator
E  With endotrachial tube in place attaced to
mechanical ventilator with the following
settings: tv 450 FiO2 4O bur 16 LL=22 on
S/O AC mode tolerated and well saturated, (+)
bilateral lung chest expansion, (+) fine
crackles heard on both lungfileds upon
ascultation with minimal whitish endotracheal
secretions and minimal oral secretions
 With soft, flat, not distended, non-bloated and
nontender abdomen; active bowel sounds
 With foley catheter in place attached to
urobag draining moderate amount of straw
juice colored urine, (-) hematuria,
(+)sediments, (-) bladder distension
  With anti-embolic stockings on both legs; with
blood pressure sinus of 110/100 mmhg, PR
90bpm, RR 25bpm, T-36.7, O2sat 100%
 Ineffective airway clearance related retained
bronchial secretions
 Ineffective breathing pattern related
decreased lung expansions
 Impaired gas exchange related insufficient 02
supply and demand
 Ineffective cerebral tissue perfusion related
inadequate blood flow
 Self-care deficit related to hospitalization
 Risk for further infection related to presence
of invasive tubings
 Thorough cephalocaudal assessment done
 Initial vital signs and neurovital signs taken
and documented
A  Positioned comfortably on bed
 Done for Ct scan with contrast clearance
facilitated
 Turned to sides at interval
 Back tapping done
 Suction secretions as needed

I
DATE/TIME SOAPIE/R NURSE’S NOTES
1-19-18 S/O  Brachial tube attached to mechanical ventilator
7am with setting tv 450 FiO2=40, BUR=16, PEEP=0,
U=22CM on AC mode, tolerated and well
saturated, with clean breath sound, (-)
secretions upon function, (+) bilateral chest
expansion, (-) secretions upon function, (+)
bilateral chest expansion, (-) SOB, regular fast
respiration; with nasogastric tube for
medications and fucntion, (+) patency, with
normoactive bowel sound with flat and soft
abdomen, (-) abdominal distention, (-)BM,
(-)bedsore; foley catheter attached to uro bag,
draining to yellowish urine in moderate amount,
(+) yellowish sediment noted in tubings, (-)
bladder distention, skin warm to touch, good
peripheral pulses with pale mucous membrane,
with anti-embolic stocking applied on both legs,
capillary refill < 3 seconds continuing hooked to
cardiac monitor with normal sinus rhythm with
latest vital signs of BP: 140/90. HR:93, RR:25,
Temp:37.8c, O2sat 100%
 Ineffective airway clearance related to retained
endotrachial secretions
 Impaired breathing pattern related to insufficient
A oxygen suppy and demand
 Ineffective cerebral tissue perfussion related to
altered cerebral blood flow
 Impaired physical mobility related to
neuromuscular involvement
 Risk for infection related to presence of invasive
tubings
 Risk for falls
 At the end of my nursing interventions, patient
will be able to: maintain hemodynamics within
normal range, maintain clean and patent airway,
P provide safety at all times, kept monitored is
unsualities
 Thorough cephalocaudal assessment done
 Initial vital signs and neurovital signs taken and
documented
 Positioned comfortably on bed
 Thorough cephalocaudal assessment done
 Initial vital signs and neurovital signs taken and
I documented
  Positioned comfortably on bed
 Done for Ct scan with contrast clearance
facilitated
 Turned to sides at interval
 Back tapping done
 Suction secretions as needed

DATE/TIME SOAPIE/R NURSE’S NOTES

1-19-18  Due meds given as ordered
8am  Intake and output measured and recorded
9am T: 36.1c  Rechecked temperature
 Seen and examined by Dr. Natividad
 Diagnostic test required
10am BM:brownish  Provided privacy and perineal care
soft in large  Due meds given as ordered
 Blood chem result relayed
11:30am  Nebulized with combivent , chest tapping done
 Seen and examined by Dr. Panolog
HGT:204mg/dl  HGT taken and seen by Dr. Panolog
 Suggestion relayed to AP’S via sms
 NGT opened to drain
 Increased IVF rate to 80%
11:45am  Received text order from Dr. Natividad and carried
12nn out
 Humilin 4 unit SQ given
 Due meds given as ordered
12:10am  Received text order from Dr. Alagadon with order
2pm BM2:Brownish and carried out
3pm green in  Provided privacy , oral and perineal care
moderate  APS updated of patients status via sms
 Nebulized with combivent with nebulizer,
chesttapping care
 Valproic acid 100mg tab NGT given
 Bedside care done
 Shave and taping done
6pm Hgt:214mg/dl  HGT taken and relayed to Dr. Ponlong
 Humulin R 4 units sq given
 Due meds given as ordered
 Kept watch for any unsualities
 Needs attended
7pm  Afebrile, (-) NGT residual, drowsy in sensorium
 GCS8(E3M4V1T), isocoric pupils at 2mm brisk,
(+) distended, flexion noted on all extremities
E  Endorsed with latest v/s BP 120/80, HR:76, RR21
temp 37.0c
7pm S/O  Patient on bed with ongoing renodysis of #4 D5N
1L @80cc/hr via infusion pump, infusing well on
left hand, patent with poistive bloodback flow, (-)
phlebitis, (-) infiltration
 Drowsy in sensorium isocoric 2mm brisky reactive
to light; with spontaneous weak movement on
upper extremity; (+)flexion to pain on right lower
extremity
 Bilateral chest expansion noted; with flat
abdomen, (-) abdominal on bladder distention
 With nonreactive bowel sound on all four
quadrants of the abdomen, with capillary refil of 1
second noted
 With endotrachial tube in place attaced to
mechanical ventilator with the following settings: tv
450 FiO2 4O bur 16 LL=22 on AC mode tolerated
and well saturated, (+) bilateral lung chest
expansion, (+) fine crackles heard on both
lungfileds upon ascultation with minimal whitish
endotracheal secretions and minimal oral
secretions
 With foley catheter attached to urobag-draining
well with light yiellow urine in moderate amount;
(-) hematuria; (-) bladder distention; (-) sediments
A  Ineffective airway clearance related to retained
endotrachial secretions
 Impaired breathing pattern related to insufficient
oxygen suppy and demand
 Ineffective cerebral tissue perfussion related to
altered cerebral blood flow
 Impaired physical mobility related to
neuromuscular involvement
 Risk for infection related to presence of invasive
tubings
 Provide adequate oxygenation
P  Maintain clear and patent airway
 Provide adequate rest and sleep periods
 Maintain vital signs and neuromuscular signs at
acceptable units
 Watch for deterioration of sensorium, anisocoria,
difficulty of breathing, and any forms of
arrythmias,hypotension,hypertension,
 hyperthermia,hypoglycemia,hyperglycemia, and
other unsualities and refer to Aps immediately
 Assessed general status and recorded
I  Vital signs nuerovital signs monitored and
recorded
 Due Nebulization started
7:30pm  Turned to sides at intervals
 Back-tapping care
 Check for any signs of pressure, sores-negative
with Bradin scale II - high risk
 Suctioned secretions gently as needed; with clear
to whitish oral secretions in moderate to minimal
aount noted; (-) endotracheal tube secretions
 Oral care done
 Bedside Care done
7:30pm  Pre medications given as ordered
 Seen and examined by Dr. Talabum
8pm  Pre medications given as ordered
 Intake and output measured as recorded, vital
9pm signs and neurovital signs taken and recorded,
Aps updated via sms
11pm

DATE/TIME SOAPIE/R NURSE’S NOTES

01-20-2018 S >Patient is intubated and doesn’t respond to
questions and commands
7:00 AM
>Received drowsy in sensorium, GCS 9 (E-4,
O M-4,V-1), isocoric pupil at 2mm brisk, with
episode of visual threat at right eye, positive
corneal reflex on both eyes, flexion noted an all
extremities, positive, positive gag and cough
reflex, with intravenous fluid at left hand with # 5
D5W 1L at 80cc/hr, infusing well, positive
patency, negative infiltration, negative phlebitis,
with endotracheal tube attached to mechanical
ventilator with setting of
M=450,BUR=16,FiO2=40,U=22cm,PEEP= 0 on
AC mode tolerated and well saturated, with clear
breath sound negative secretions, positive
bilateral chest expansion with episode of
tachypnea, negative SOB, with nasogastric tube
for medications attached to bedside bottle for
 open to drain, negative drainage with safe and
flabby abdomen, with normoactive bowel sound,
negative bowel movement, negative bedsore,
negative abdominal distension, with Foley
catheter attached to urobag draining to yellowish
urine in moderate amount, negative bladder
distention, negative incontinent, with anti
embolic stocking on, with pale mucous
membrane with capillary refill > 3seconds, with
good peripheral pulses rhythm, with vital signs of
BP: 130/90, HR:83,RR:25 TEMP:36.1 degree
Celsius, O2 sat 100%.
>Ineffective cerebral tissue perfusion related to
altered blood flow
>Ineffective airway clearance related to
presence of tube/secretion
A >Impaired physical mobility related to
neuromuscular impairment
>Self care deficit related to neuromuscular
impairment
>Risk for infection related to hospitalization
>At the end of 12 hours, the patient will be able
to
-Maintain hemodynamics and vital signs states
-Maintain clean and patent airway with adequate
P support
-Maintain and improve in neurovital signs
-Free from further infection and complications
>Introduced self to the patient and family
>Cephalocaudal assessment and vital signs
taken and monitored
>IV site, patency and level checked and well
regulated
>Turned to side every 2 hours interval, chest
tapping done and secretions suctioned
>Received text order from Dr. Panolong and
7:05 AM
carried out
 >Decreased IV rate to 60cc/hr
>Received txt order from Dr. Panolong and
carried out
8:00 AM
>Nebulized with combivent 1 neb, chest tapping
done and secretions suctioned
>Due meds are given as ordered
>Intake and output measured and recorded
>Seen and examined by Dr. Panolong with
orders carried out

9:50 AM I >Diagnostic reported

>Due meds given as ordered
>Above IVF consumed and followed up with #6
D5W 50cc/hr + KCl 20meq at 60cc.hr, infusing
well
10:00 AM >HGT taken and relayed to Dr. Panolong
10:35 AM >Humulin R 4 units SQ given as indicated in
checking scale
>Nebulized with combivent 1 neb, chest tapping
done and secretions suctioned
12:00 NN
>Due meds given as ordered
>Oral and perineal care done
>APS updated of patient’s status
2:00 PM
>Received telephone order from Dr. Natividad
abd carried out
2:30 PM >Informed Dr. Gamolo’s update and carried out
>Received text order from Dr. Panolong and
carried out
2:45 PM
>Due meds given as ordered
>Bedside care done
3:30 PM
>Reviewed for any unusualities
>HGT teaken and relayed to Dr. Panolong
4:00 PM
>Due meds given as ordered
6:00 PM >Provided safe and quite environment
>Need attended
> Afebrile, drowsy in sensorium, GCS 7
(E=2,M=4,V=1), Isocoric pupils at 2mm brisk,
HGT:215mg/dl flexion noted on all extremities, negative bowel
7:00 PM movement, negative bedsore,endorsed with
latest vital signs of BP: 120/80, HR: 89, RR:26,
HGT: 156 mg/dl Temp:37 degree Celsius, O2 sat 100%.

DATE/TIME SOAPIE/R NURSE’S NOTES

01-20-2018 S >No verbal output patient is intubated
7:00 PM O >Received patient lying in bed with head of bed
at 30 degree, drowsy in sensorium, GCS 7/15
E2, M4, V1,with isocoric pupils at 2mm brisk
reacts to light, with flexion on both upper and
lower extremities not in respiratory distress,
negative shortness of breath and negative
bedsore.
>With ongoing IVF #6 D5W 50cc +KCl 20 meqs
at 60cc/hr infusing well at left hand, (-)
infiltration, (--) phlebitis, (+) backflow with edema
in both hands.
>With ET to MV: M:450, FiO2:40, BUR:16,
PEEP:0, U:22 on AC mode, with clear breath
sounds noted on both lung field with bilateral
lung chest expand noted.
>With white secretions on both oral and ET in
minimal amount.
>With nasogastric tube in placed for medications
with (+) gurgling sound heard upon auscultation,
with left non tender a non bloated abdomen
upon palpitation.
>With foley bag catheter attached to urobag
draining well into yellowish colored urine in
minimal to moderate amount, (-) rediness, (-)
 hematoma, (-) bladder distension, (-) distended
abdomen.
>With skin is warm to touch, afebrile with
capillary blood refill > 3 seconds, (-) bedsores.
>Hooked to cardiac monitor with heart rhythm
with initial vital signs BP:11/70, HR: 82, RR:20,
Temp:35.7 degree Celsius , O2 sat 100%.
>Ineffective airway clearance related to retained
secretions
>Ineffective precing pattern related to rflaed
seues

A >Decreased cardiac output related to altered

myocardial contrary
>altered comfort related to presence conclu
>Impaired physical mobility related to
neuromuscular incount
>Risk for aspiration related to presence of tube
>Risk for infection related to hospitalization
>At the end of 12 hours nursing intervention the
patient will be able to:
A. Maintain adequate patent airway
B. Maintain good oxygenation
C. Ensure safety and comfort
P
D. Provide quality nursing care
E. Exhibit proper position and body alignment
8:00 PM
>Introduced myself to patient and family
>Cephalocaudal assessment done
>Initial vital signs taken and recorded
>IV line checked for patency and occluded
>Turn to sides at intervals
>Chest tapping done
8:40 PM I
>Back kept dry
 >Suction secretions done
>Due duavent given
9:00 PM >Due medications give as ordered
10:00 PM >Seen and examined by Dr. Talabucon with new
ordered carried out
>Consumed and follow up #7 D5W 1L at 60
10:30 PM cc/hr
>Monitored for any unusualities
11:00 PM >Turn to sides at intervals
>Chest tapping done
12:00 AM >Back kept dry
>Due meropenem 500mg given
>Due dexamethasone given
>Suction secretions done
>Intake and output measured and recorded
>Updated AX AP’S in patient status
>Turn to sides at interval
>Chest tapping done
>Back kept dry
1:00 AM >Suction secretions done
2:00 AM >Due medications given as ordered
>Provided safe and quite environment
>Ensure safe at all times
>Turn to sides at interval
>Chest tapping done
3:00 AM >Back kept dry
4:00 AM >Provided adequate rest
>Turn to side at interval
HGT: 182 mg/dl >Chest tapping done
>Back kept dry
 >Morning care done
4:30 AM >Perineal care done
>Changed diaper done
>Due medications give as ordered
>ABG done
>HGT taken as ordered and relayed to Dr.
Panolong
5:00 AM
>Due humulin R given as ordered
>Suction secretions done
6:00 AM
>Drowsy in sensorium, isocoric 2-3mm brisk
reacts to light, (+) flexion to pain in all
extremities, (-) BM, afebrile, well saturated, (_)
bedsores, naked with braden scale score of 11
high risk
>Endorsed to next shift NOD for continuity of
E care with latest vital signs BP: 130/80, HR:84,
RR:25, Temp: 35,9 degree Celsius, O2 sat
7:00 AM 100%.

DATE/TIME SOAPIE/R NURSE’S NOTES

01-21-2018 S/O >Received patient lying in bed with head of the
bed elevated at 30 degree supported with pillow,
7:00 AM drowsy in sensorium, with isocoric pupils at 2mm
brisk, spontaneous limited in eye movement
inlet, with flexion noted on both arms and legs,
with ongoing IVF #7 D5W 1L + 10 meqs at
60cc/hr, hooked at left hand, (+) backflow, (-)
phlebitis, (-) infiltration
>With NGT secured and attached to left nodule
for meds on NPO status except meds, with (+)
gurgling sounds noted upon auscultation, with
soft abdomen, with hypoactive bowel sounds
with mucosal bloatnus noted, (-) abdominal
distention, (-) tenderness
>With endotracheal tube attached to mechanical
ventilator with the following settings, TV:450,
FiO2:40%, BUR:16, LL:22, on AC mode, with
clear breath sounds upon auscultation, with
 bilateral lung expansion with regular fast
breathing, (-) SOB, (-) DOB with pulmonary
secretions moist on both and ET tube.
>Continuousness hooked to cardiac monitor and
lead II, regular in rhythm (-) PVC, (-) RAC, with
good peripheral pulses noted
>With Foley catheter attached to urobag draining
well in yellowish colored urine, (-) hematuria, (-)
sediments, (-) bladder distention, skin is warm to
touch, afebrile, with phlebitis in IV site, with
dependent edema on both upper and lower
extremities, (-) pressure ulcer at backward area
notes, with baseline vital signs of BP: 120/90,
HR:72, RR:28, Temp: 36 degree celsius, O2 sat
100%
>Ineffective airway clearance related to retained
secretions
>Impaired tissue perfusion related to decreased
cardiac workload
>Ineffective breathing pattern related to poor
lung expansion
>Risk for impaired skin integrity
A
>Risk for aspiration
>Risk for infection
>At the end of 12 hours of nursing interventions
patient will be able to:
a. maintain patent airway
b. receive quality nursing care
c. maintain patent IV line
d. prevent IV cumulative complications
P e. ensure safety at all times

f. improve gradually breathing pattern

g. prevent from any complication
>Build rapport to patient
>Initial vital signs taken and recorded
 >Cepahalocaudal assessment done
>Perineal care done, changed diaper
10:00 AM >Reposition to comfort
>Suction secretions as needed
I >Oral care done
>Due IV medication given ciprofloxacin 20mg IV
drip
>Due NGT medication given fluomucil 2 tablets
11:00 AM SAMBM1X; all
greenish stool, >Repositioned to right side lying position, back
smelly minimal tapping done applied binder at the back
>Kept watch for unusualities
>Due IV meds given dexamethasone 5mg IV
>Due NGT medication given mepenem 600mg
tab, tolerated 5 residual
NPO except
12:00 NN meds >Kept watched for unusualities
>Perineal care done, changed soiled diaper
>Repositioned patient at comfort
>Examined and visited by Dr. Alagadan with
new orders carried out
>HGT taken and recorded and relayed to Dr.
Panolong for insulin carunge
>Due meds given combivent 2.5ml via inhalation
NPO except >Oral care done
meds
>Suction secfetions
12:45 PM >Due NGT meds given Acetazolamide 250mg
BM2x, tab ketosteril tab, dilantin 1 cap, tolerated
greenish,mudy without residual
1:00 PM stool abundant
>Consumed and follow up #8 D5W 1L at 60cc/hr
1:20 PM
>Repositioned patient to comfort
> Reinserted IV line at right arm upper brachial ,
HGT: 130mg/dl nenous cannula complete and extract
2:00 PM >Given due meropenem 50mg IV at 50cc IV drip
 to new for 30 minutes
4:00 PM >Repositioned to right side lying position, back
tapping done applied binder at the back
>Kept watch for unusualities
(+) Phlebitis
>Due NGT medication given mepenem 600mg
tab, tolerated 5 residual
6:00 PM >Kept watched for unusualities
>Perineal care done, changed soiled diaper
>Repositioned patient at comfor
>Drowsy in sensorium, with isocoric pupils at
2mm brisk, spontaneous limited in eye
movement inlet, with flexion noted on both arms
and legs,
>Endorsed to next shift NOD for continuity of
care with latest vital signs BP: 130/80, HR:
13/080, RR: 30 Temp: 36 degree Celsius, O2
sat 100%.
7:00 PM