NURSE’S NOTES
Name:_Cleopatra Andude_______Age/Sex/CS:_36/F/M______Ward/Room:_obward-123___
ATTENDING PHYSICIAN__Dr. Danilo Dizon___________________________________________________
Date/ TIME FOCUS Data – Action – Response
10-25-21 Admission Care D: Admitted a 36 y/o female client, accompanied by her husband with initial
8:20 am vital signs as follows:
BP: 180/100 mmHg
PR: 112 bpm
RR: 28 cpm
Temp: 37.3◦c
O2 Sat: 92 %
With moderate respiratory distress, sleeplessness, nausea, vomiting, and,
Diarrhea. -------------------------------------------------------------------------(RJA)
A: Assisted on bed and positioned to moderate high back rest; side rails
raised; seen and examined by ER physician (Dr.Cardenas) with orders made
and carried out accordingly; consent to care and hospitalization secured;
started IVF of D5LRS 1L x 20 hours inserted aseptically at right metacarpal
vein with g.16 IV cannula and regulated to 16-17 gtts/min @; with o2
Support via nasal cannula @2-3LPM; request for laboratory and diagnostic
procedures made; forwarded and attached to chart; other standing orders
carried out accordingly; facilitated awaiting results; informed medical nurse
on duty regarding admission. ------------------------------------------------- (RJA)
R: Transferred to OB ward in a private room @8:45 am via stretcher;
endorsed accordingly. --------------------------------------------------------- (RJA)
Renea Joy M. Arruejo
UNP-CN
Stud. No. 300052120513
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
10/26-21 Parasthesia D - rapid onset of numbness/tingling.--------------------------------------- (RJA)
7:00 AM A - Requested for repeat K; prescribed furosemide 40 mg IV; checked urine
Output; revised IVF for 60cc/hr. --------------------------------------------- (RJA)
R - Waiting for laboratory result. ------------------------------------------ (RJA)
8:00 AM A – Continued urine output monitoring, requested for repeat ABG, Crea, K,
and urinalysis. ----------------------------------------------------------------- (RJA)
R – Waiting for laboratory results. ------------------------------------------ (RJA)
