San Pedro Hospital of Davao City, Inc.

C. Guzman St., 8000 Davao City, Philippines

Tel. No. (082) 222-6100 Fax No. (082) 226-4714
Website: www.sanpedrohospitaldavao.com Email:
sanpedrohospital@yahoo.com

NURSES’ NOTES

Name: De Guzman, Charizze__________ ____ Ward: Room/Bed No. : 201______________

DATE TIME

03/30/22 8:00 AM Received patient lying in bed; awake and coherent

With pale conjunctiva

With dry oral mucosa

With TPN of Combiflex at 1800 kcal and 40 mEqs KCl running at 80 mL/hr

Incorporated with KCl of 3 cycles; 2nd cycle ongoing

With side drip of Octreotide 500 mg q 12 running at 20.8 mL/hr at 228 cc and
D5W at 250 cc level

Sharp pain is located on patient’s left midepigastric region with pain scale of 7/10

Bloated

With weakness on both lower extremities

VS checked and recorded

BP- 130/80 mmHg
T- 37.7 C
RR- 22 cpm
CR- 108 bpm
O2SAT- 95%

Still for upper gastrointestinal endoscopy; with consent and with accounting
clearance; Aware Josh

Still for S. K & Na post correction

On NPO except medication

 8:30 AM TSB done

Bedside care done

10:00 AM Above mainline KCl consumed & followed up with 3rd cycle = 40 mEqs KCl
@80mL/h; regulated

Health teachings rendered

 Maintain NPO except for meds

 Encourage increase of fluid oral intake (after NPO)

 Report any signs of bleeding, hypoglycemia and abdominal pain

D5W ½ vial given as ordered

Rebamipide 100 mg given as ordered

12:00 NN VS checked and recorded; afebrile

BP- 120/80 mmHg
T- 36.9 C
RR- 21 cpm
CR- 100 bpm
O2SAT- 97%

Capillary blood glucose test while on NPO done; 90 mg/dL

2:00 PM I&O recorded with no unusualities

Patient endorsed to pm NOD with Combiflex 1800 kcal and 40 mEqs KCl at 80
mL/hr

Incorporated KCl x 3 cycles; 3rd cycle ongoing with side drip Octreotide 500 mg
q12 at 20.8 mL/hr and D5W 250 mL

3:00 PM Patient lying on bed; awake and coherent with side rails up

Denise Pamaong, St.N/Cathya Jane Morales, RN