-
DATE/SHIFT/TIME
Sample 1FOCUSDATA ACTION RESPONSE08/24/2011 7-3 shift9:00 AM
9:10 AM
10:00 AM Abdominal Pain
D-Patient verbalized sakit gyod akong tiyan, pain scale 8 out of
10, facial grimacing, guarding behavior, irritable, Temperature
37.40C, pulse 70 beats per minute, respiration 18 breaths per
minute.----------A-Administered Hyoscine N-butyl bromide 20 mg
Intravenously as per doctors order, encouraged and demonstrated
deep breathing exercises, placed in semi Fowlers position with side
rails up and locked.R-Patient reports pain was relieved. Pain scale
5/10.-------------------------------------------Lysette
Bagatua,RN
-
DATE/SHIFT/TIME
Sample 2FOCUSDATA ACTION RESPONSE08/24/20117-3 shift1:00 PM
1:05 PM
2:00 PM
Elevated Body Temperature
D-Init akong lawas as verbalized. With flushed skin and warm to
touch, Temperature 38. 90C via axilla, pulse 80 beats per minute,
respiration 24 breaths per minute, blood pressure
120/80.-----------------A-Performed tepid sponge bath, applied ice
cap on forehead, administered Paracetamol 250mg intravenously as
per doctors order. Encouraged adequate oral fluids intake, provided
calm environment to keep patient comfortable.---------R-Gipaningot
na ko, as verbalized, temperature decreased to
37.20C.----------------Lysette Bagatua,RN
-
DATE/SHIFT/TIME
Sample 3FOCUSDATA ACTION RESPONSE09/15/087-3 shift9:00 AM
9:10 AM
9:20 AM
Pain at IV Site
D-Sakit man ang lugar nga naa ang dextrose as verbalized IV site
slightly swollen and with redness noted.----------A- Checked IV
site and found beginning of signs of infiltration. Closed and
removed IV aseptically, changed the whole system, reinserted the
new set aseptically into the distal portion of basilic vein, left
arm anchored, splint applied, regulated IVF as to the prescribed
drops. Advised to call nurse for any presence of
pain.-----------------------R-Wala na ang sakit sa akong
dextrose,as
verbalized---------------------------------------------------------------M.
Omamalin,RN
-
DATE/SHIFT/TIME
Sample 4FOCUSDATA ACTION RESPONSE08/25/11 7-3 shift9:10 AM
9:15 AM
ER to ORPre-Operative Assessment
D-Received from ER per stretcher with side rails up and locked
with ongoing IVF of PLR 1L. at 900ml level at left cephalic vein
using IV cannula gauge 18 regulated at 30 drops/min., with oxygen
inhalation at 3L/min. via nasal cannula, nasogastric tube attached
to drainage open bottle with bloody discharges noted, Foley Bag
Catheter connected to urobag with 100ml of tea colored urinary
output. Cold clammy skin, grimace face, gnawing abdominal pain
noted.A-Instructed patient to do deep breathing exercise. Checked
the patency of IVF drop factor, name of patient and IVF hooked,
checked the nasogastric tube and Foley Bag Catheter if dripping
well. Reviewed and checked the patient chart if all laboratory
results were attached, surgery consent signed and availability of
surgical materials and pre operative medicines. Checked and
reviewed Operating Room checklist, jewelries, dentures, nail beds,
name tag of patient applied. All surgical and pre operative
medicines checked. BP checked 100/60, HR 92 beats/min. Respiratory
rate 21 breaths/min. Skin cleaned.
------------------------------------------------------------
-
DATE/SHIFT/TIMEFOCUSDATA ACTION RESPONSE9:20 AM
9:30 AM
9:35 AM
9:45 AM10:00 AM
1:20 PM
1:35 PM
For surgical procedure (explor lap)-Transported per stretcher
side rails up and locked accompanied by circulating nurse to
Operating Room table.-------------------A-Placed comfortably on
Operating Room table on supine position both arms strapped;
orientation done on Operating Room procedures, and validated all
entries in the WHO Surgical Safety
Checklist.-------------------------------------------------------------------Skin
preparation done aseptically and applied sterile drapes to
abdominal area. Surgical instruments, needles, sponges counted and
witnessed by circulating nurse, J.
Lopez.----------------------General anesthesia induced by Dr.
Evangeline S. Ruaya.------Exploratory Laparotomy performed by Dr.
G.Realiza with Dr. C. Mata as Surgeons
Assistant.-----------------------------------------Surgical
operation ended. All surgical instruments and supplies are
accounted and declared complete. Nasogastric tube attached to
drainage bottle and Foley Bag Catheter attached to urobag draining
well.
----------------------------------------------------------------------Dressing
done aseptically on post operative site . Arm straps
removed.-------------------------------------------------------------
-
1:40 PM
-R-Responsive to stimuli and pain, with spontaneous eye opening,
BP-checked 100/60, HR-90bpm, RR-20bpm with IVF of PLR 1L ongoing
regulated at 30 drops left cephalic vein, another line PNSS 1L. at
20 drops right metacarpal vein infusing well. Accompanied and
transported to PACU per stretcher, side rails up and locked.
Endorsed to nurse K. Eguia.-----------------------------Grace
Bengua,RN
-
DATE/SHIFT/TIMEFOCUSDATA ACTION RESPONSEPACU 1:45 PM
1:50 PM
1:55 PM
D-Received patient from Operating Room per stretcher, side rails
up and locked, with on-going IVF of PLR 1L. at 200 cc level at left
cephalic vein at 30 drops infusing well, another line of PNSS 1L.
at 500cc level and regulated at 200 drops/ min with nasogastric
tube attached to open drainage bottle open to drain with bloody
discharges Foley Bag Catheter connected to urobag with 200cc of tea
colored urinary output; with oxygen administered at 3L/min via
nasal
cannula.----------------------------------------------------------------------Skin
cold to touch, pale looking, chilling sensation noted.----A-placed
comfortably on bed with side rails up and locked; oxygen
administered continuously at 3L/min.; monitored blood pressure
every 15 mins. Warm blanket applied. Hot water bag cap locked
tightly applied to both upper and lower extremities post-operative;
wound checked for bleeding. Measured and recorded intake and
output. Administered Tramadol 30mg injected very slowly thru IVTT
as per Doctors order. Administered antibiotics initially after
negative skin test done as post operative order by the Doctor.
Ceftriaxone 1gm administered slowly thru IVTT. Observed for adverse
reaction of the drug. Observed for nausea and
vomiting.---------------------
-
DATE/SHIFT/TIMEFOCUSDATA ACTION RESPONSEPACU3:35 PM
3:40PM
4:00 PM
4:15 PM
Dr. Evangeline S. Ruaya updated for patient status, BP checked
110/70, HR 92 bpm, RR 21 bpm, T- 36.50C, thru text with reply may
transport to
ward-------------------------------------------------R-Dili na kayo
sakit akong samad mam as verbalized by the patient. Able to move
both upper and lower extremities post-operative wound checked for
bleeding; sterile dressing intact and dry as
observed.---------------------------------------------------------A-Transported
to Surgical Service, per stretcher, side rails up and
locked.--------------------------------------------------------------------------Endorsed
to Surgical Service Ward Nurse on duty.----Kate Eguia,RN
-
DATE/SHIFT/TIME
Sample 5FOCUSDATA ACTION RESPONSE8/24/20113-11 shift9:15 PM
9:25 PM
9:50 PM
10:00 PM
Altered comfort related to post-operative pain
D-Sakit akong samad sa tiyan, Sir as
verbalized.-----------------Facial grimace noted, irritable,
moaning noted, pain scale of 8/10, received from PACU via stretcher
with ongoing venoclysis of PLR 1L. with 900ml level left hooked at
right cephalic vein, with nasogastric tube in place open to drain
with greenish output; and indwelling catheter in place attached to
urine bag with output of 450ml yellow tinged
urine.---------------------------------------------------------A-Placed
on bed in supine position, medication record checked for last
administration of Tramadol; instructed to do deep breathing;
supported abdomen with pillow while turning to sides, abdominal
binder
applied----------------------------------------------------------------R-Sakit
pa gihapon akong samad as verbalized. Still in pain as evidenced by
a pain scale of 7/10.
------------------------------------A-Inspected dressing for
discharges. Dressing dry and intact. Given with Tramadol 50mg as
PRN for pain intravenously, with blood pressure
precaution.--------------------------------------------------------
-
DATE/SHIFT/TIME
Sample 5FOCUSDATA ACTION RESPONSE10:35 PM
R-Arang-arang na akong pamati, Sir as verbalized, pain has
reduced as evidenced by a pain scale of 4/10. Patient understood
instructions and seen performing deep breathing. Endorsed to 11-7
shift for continuity of care.------------------------------------M.
Galvez,RN
-
DATE/SHIFT/TIME
Sample 6FOCUSDATA ACTION RESPONSE08/23/20117-3 shift 7:00 AM
7:30 AM
7:35 AM
8:00 AM
Altered comfort:Pain related to post Caesarean Section wound
D-Received on bed with on-going intravenous fluid of D5LR 1
liter at 550ml level infusing well on right cephalic vein at
20gtts/min-----------------------------------------------------------Sakit
akong samad, as verbalized. With pain scale of 8/10 BP of 130/100,
pulse 105 b/min., T-37.30C; restless, guarding behavior over
incision site, facial grimace, profuse sweating, pale
looking.---------------------------------------------------------A-Incision
site checked with no foul smell and no discharges; wound dressing
intact and dry; repositioned to Semi-Fowlers position. Encouraged
and demonstrated relaxation techniques such as deep breathing.
Applied abdominal
binder.-----------------------------------------------------------------R-Sakit
pa gihapon akong samad as verbalized; pain scale of 7/10, BP
130/90------------------------------------David Silva,RN
-
DATE/SHIFT/TIME
Sample 7FOCUSDATA ACTION RESPONSE08/23/20113-11 shift3:00 PM4:00
PM
4:20 PM4:45 PM4:50 PM
5:00 PM
Anxiety related to scheduled surgeryD-Received with IVF of D5LR
50ml at KVO at left cephalic vein.---Mahadlok ko sa operasyon nako
unya, as verbalized. Asked questions repeatedly regarding surgery.
Cold, clammy skin, looks worried, pale-looking. BP-150/90, HR-128
b/min, RR-24 c/min,
T-360C.-------------------------------------------------------------------------A-Family
members encouraged to stay with the patient. Referred to Dr. Lee
for the re-explanation of the surgical procedure. Encouraged to
verbalize feelings. Consent signed by the patient Assisted Dr. Lee
during rounds. Procurement of materials for surgery followed-up.
Provided perioperative health teachings. Allowed to ask questions
and answers provided.-------------------R-Nakasabot na ko sa
operasyon. Wala na ko nahadlok. Gipapalit na nako ang mga gamit sa
operasyon as verbalized. Appears relaxed and skin is warm to touch.
T-36.50C, RR- 18 cpm, HR-89 bpm, BP-120/90,
-------------------------------------------------Ira Lakian,RN
-
DATE/SHIFT/TIME
Sample 8FOCUSDATA ACTION RESPONSE8/25/20117-3 shift6:50 AM
6:55 AM6:57 AM
Abdominal pain Scale of 9/10
D-Nadisgrasya siya Maam, gasakit iyang tiyan as verbalized by
wife. Brought in per stretcher, pale and cold clammy skin noted, in
severe pain scale of 9/10, in moderate respiratory distress bluish
contusion 6cm observed at the right temporo-parietal and in the
left parietal areas. Abdominal pain noted as evidenced by grimaced
face, with a board-like abdomen on palpation, slightly restless,
GCS 15/15, T-360C P-110 beats/min R-42 breaths/min
BP-50/30.-----Placed on bed with side rails up and locked, with
head of bed elevated to 300 angle, 02 inhalation administered at
3-4 L/min via nasal cannula. Ice pack applied to contusions.
----------------------Seen and examined by Dr. Genesis Realiza,
consent for admission signed by wife. Started with venoclysis of
PLR 1L at fast drip for the first 500ml hooked at the left cephalic
vein using IV cannula gauge 18, then regulated to 60 gtts/min.
Another line initiated at the right metacarpal vein with PLNSS 1L
using blood transfusion set regulated at
15gtts/min.-------------------------------------------------
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE7:00 AM7:30 AM
7:50 AM
R-BP rechecked 80/40 P-120 beats/min R-44 breaths/min, sakit
kayo akong tiyan Maam, as verbalized
.--------------------------------A-Ketorolac 30mg IVTT given as
ordered stat. Brought to the X-ray and accompanied by nurse M.
Omamalin per stretcher with side rails up and locked for abdominal
x-ray flat plate and upright view; stat CBC, BT taken by Medical
Technologist Antonio Lagod. -------X-ray plates and CBC results
seen by Dr. Realiza, orders given. Scheduled for an emergency
exploratory laparotomy, consent for surgery and induction of
anesthesia signed by wife, after proper explanation of
pre-operative and post-operative procedure done by Dr. Realiza.
Nasogastric tube Fr.16 inserted at the right nostril by Dr. Realiza
and open to drain; Foley Bag Catheter Fr.16 inserted aseptically by
nurse M. Omamalin and attached to urobag with tea colored urine
output at 150ml level. Instructed the wife to secure 2 units of
blood of patients blood type A+ for possible surgical operative
use. OR nurse Mr. Mark Galvez and anesthesiologist Dr. Evangeline
Ruaya informed of the procedure. ------------------------
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE8:20 AM
8:55 AM9:15 AM
Cefuroxime 1.5gm administered as loading dose via IVTT after a
negative skin test and no adverse drug reaction noted after 30
minutes.-------------------------------------------------------------------------R-
Prescribed drugs and surgical supplies already available. Still
with abdominal pain, scale of 8/10, moderate bloody discharges in
NGT, T-36.80C, PR-12 beats/m, RR-40 breaths/min, BP-90/60---A-
Transported to OR per stretcher with side rails up and locked and
complete drugs and surgical supplies needed.----------Nesle Lim,
RN
-
DATE/SHIFT/TIME
Sample 9FOCUSDATA ACTION RESPONSE7/23/2011 7-3 shift10:00 AM
10:15 AM
11:00 AM
Constipation
D-Maam, tulo na kaadlaw wala ko nakalibang as verbalized.Stomach
distended, hypoactive bowel sound upon auscultation noted;
irritable, T-7.80C, PR-80 bpm, RR-28 bpm BP-130/90.----A-Given
suppository per Doctors order and provided privacy; advised to
increase fluid intake and eat foods high in fiber like green leafy
vegetables (kangkong, pechay, malunggay) and fruits (papaya,
pineapple), encouraged mobility------------------------------R-
Able to defecate and felt comfortable.------------------Belia
Bohol,RN
-
DATE/SHIFT/TIME
Sample 10FOCUSDATA ACTION RESPONSE8/23/20113-11 shift3:05 PM3:10
PM3:15 PM
6:00 PM11:00 PM
Ineffective air way clearance related to excessive mucous
secretions
D-Naglisod ko og ginhawa as verbalized, with labored breathing,
productive cough with mucopurulent seceretions, RR-30 bpm, with
slight flaring of
nostrils-----------------------------------------------------A-Lowered
the bed, placed on high Fowlers position with side rails up and
locked; administered Oxygen at 3 liters per minute; loosened
clothing and made comfortable------------------------------Referred
to Dr. Maurice Montecillo. Orders given; nebulized with 1 nebule as
ordered; PLR 1L started at 15gtts/min at right metacarpal vein
infusing well; demonstrated back tapping after nebulization,
encouraged and demonstrated deep breathing and coughing exercises,
encouraged increase oral fluids intake to 8-10 glasses per day;
provided a calm and well ventilated environment free from
allergen.-----------------------------------------------------------R-Verbalized
ease of breathing and tolerable cough. Understanding of
instructions noted through demonstration of proper deep breathing
and coughing exercises.
---------------------------------------Latest RR-24 cycles/min and
endorsed to next shift.---Peter Soro,RN
-
DATE/SHIFT/TIME
Sample 11FOCUSDATA ACTION RESPONSE8/25/2011 7-3 shift11:50AM
12:00 Noon
12:05 PM
12:15 PM
Elevated blood pressure
Admitted this 52 y.o. female with complaints of body malaise and
numbness at left side of the body with onset of headache prior to
admission.---------------------------------------------------------------------D-
Lain iyang pamati, bas verbalized by the daughter, Maria Realiza.
Patient is lethargic with facial drooping noted, with slurred
speech, with initial vital signs of BP 180/100, HR-132 bpm T-37.20C
per
axilla.------------------------------------------------------------------------A-Ushered
to ER bed and positioned to semi-Fowler, side rails up and locked,
initiated with humidified oxygen support at 3-4 liters per minute
via nasal cannula. Consent to care signed by the daughter, Maria
Realiza, Referred to resident on duty Dr. Lucy Itok about this
admission---------------------------------------------------------Assisted
Dr. Itok on her bedside assessment. Orders made and carried out
properly. Plain NSS 1L inserted aseptically as venoclysis at 20
gtts/minute at left metacarpal vein; Captopril 25mg. given
sublingual (not to chew nor crush the tablets) Furosemide 40mg.
given intravenously STAT. All are as ordered.
-------------------------
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE12:25 PM12:30 PM
2:00 PM-CBC, BUN, CREA, Lipid Profile, FBS requests sent to
laboratory. EKG taken and referred to Dr. Itok for
interpretation----------------------Informed the watcher about ICU
admission. Consent for ICU admission signed by daughter, Maria
Realiza. ICU informed about this admission. Request for Plain Brain
CT Scan and chest X-Ray AP view handed over to watcher for payment
at Cashiers Office. Referred to neurosurgeon, Dr. Jones for
evaluation and management thru phone call and responded will see
the patient later. CT Scan and Chest X-Ray taken as accompanied by
ER Nurse, Mark Galvez, and transported to ICU per stretcher with
side rails up and
locked.-----------------------------------------------------------Endorsed
to ICU Nurse on duty, Rhoda
Ordinaria.----------------------------------------------------------------------------------------Gerry
Zamoras,RN
-
DATE/SHIFT/TIME
Sample 12FOCUSDATA ACTION RESPONSE8/25/20113-11 shift3:00 PM
3:10 PM
4:00 PM
Elevated Blood Pressure 160/90
D-Appears lethargic , cold and clammy skin noted, flaccid muscle
tone on the left side of the body; right facial drooping noted,
slurred speech, able to move all extremities per command but with
left hemiparesis; eye opening is appreciated upon name calling;
anisocoric, pupillary size of 6mm at right eye and 3-4mm at left
eye; right pupil is sluggishly reactive to light while left pupil
is briskly reactive to light accommodation. BP-160/90, HR-98 bpm,
RR-23 cpm,
T-370C.--------------------------------------------------------A-Placed
on bed with side rails up and locked; head of bed elevated at 300
angle; oxygen inhalation administered; hooked to cardiac monitor
and pulse oximeter attached; visited by Medtech for blood
extraction, CBC, BUN, CREA.---------------------------------Visited
by Dr. Jones. Orders given and carried out properly. Serum Na+ and
K+ determination request sent to laboratory; 3-way urinary catheter
Fr.16 inserted aseptically and obtained urine specimen and brought
to laboratory for urinalysis then catheter attached to urine
bag.---------------------------------------------------------------------
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE4:15 PM
5:15 PM6:30 PM9:30 PM10:30 PM
-Mannitol 20% 500ml given 150ml at fast drip using large bore
needle gauge 19; Nicardipine in 80ml of D5Water via soluset at
initial rate of 100 microdrips per minute and titrated by
increments of 5 microdrips per minute every 15 minutes to maintain
systolic BP range of 120-150 as ordered. Arterial blood specimen
extraction done aseptically by Dr. Jones and sent to
laboratory.-------------Laboratory results for CBC, S CREA, BUN and
ABG in. Relayed to Dr. Jones thru SMS, updated patients status and
replied ok thanks---R-BP rechecked
140/80.---------------------------------------------------A-Visited
patient and encouraged verbalization of any medical problems such
as headache. Continuous BP monitoring done.R-Last BP 140/80 for FBS
and lipid profile determination in AM. Endorsed to next shift Nurse
J. Bataga.------------Rhoda Ordinaria,RN
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE8/25/201111-7 shift11:00 PM
12:00 MN
D-Received on bed awake with head of bed at 300 angle elevation,
with ongoing IVF of PNSS 1L hooked at left metacarpal vein flowing
at 20 drops/min infusing well, with 160ml level left with starting
dose of Nicardipine Drip (80ml D5W + 20mg) at 10 microdrips/min.
rate. With ongoing humidified 02 inhalation at 3-4 l/min. via nasal
cannula, with indwelling urinary catheter attached to urine bag,
patent and draining well; contains bright yellow urine with
approximately 150ml in volume. With multiparameter cardiac monitor
attachment, right facial area drooped. As noted, with pupillary
size of right eye 5-6mm, left eye 3-4mm, right pupil is sluggishly
reactive to light, while left pupil is briskly reactive to light
accommodation, able to move all extremities per command, slurred
speech, with spontaneous eye opening. -------------------D-Labad
man akong ulo Maam as verbalized while pointing at right parietal
area of the head, facial grimace is noted, irritable with pain
scale of 7/10; BP 160/100, HR-119bpm, RR-24cpm, T-37.30C, 02 sat
97%.---------------------------------------------------------
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE12:10 AM12:13 AM12:15 AM2:00 AM3:00
AM6:45 AM
A-Dim light provided, applied ice pack over the right parietal
area.---Referred to Dr. Jones thru phone call, orders made and
carried out properly. STAT dose of Tramadol 25mg given slow IV as
ordered, STAT dose of Mannitol 20% 100ml given via IV fast drip as
ordered. Unnecessary disturbance avoided and promoted a cool, calm
and quite non stimulating
environment.----------------------------------R-Nawala-wala na ang
labad sa akong ulo Maam as verbalized by patient, pain scale of
4/10. -----------------------------------------------A-Seen soundly
asleep and undisturbed.-----------------------------R-Verbalized to
be free from pain; Still for lipid profile and FBS
determination.------------------------------------------Rhoda
Ordinaria,RN
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE8/26/20117-3 shift7:30 AM
7:45 AM
7:50 AM
7:55 AM
D-Received on bed in supine position at 300 angle head of bed
elevation. With ongoing IVF of PNSS 1L at 20 drops/min at left
metacarpal vein with 520 fluid level left, with side drips of 20ml
Nicardipine and 80ml of D5W via soluset at 10 drips/min; with
humidified oxygen inhalation at 3-4 liters per minute via nasal
cannula with indwelling urinary catheter attached to urine bag with
yellow colored urine at approximately 200ml. Appears conscious with
spontaneous eye opening and pupillary size of 5mm sluggishly
reactive to light at right eye and 3mm briskly reactive to light at
left eye, patient show body weakness but able to move all
extremities per command, with slurred speech as verbal response.
Initial vital signs of BP-130/90, HR-82 bpm, RR-20 cpm,
T-36.50C.-----------A-Oatmeal diet was served to the patient and
able to consumed 8 spoonfuls of the food. On Aspiration Precaution;
assisted patient on sitting position; assisted Dr. Itok during
visit with given order of may transfer to room of choice if okay
with Dr. Jones. Informed Dr. Jones thru telephone with telephone
order of okay for me to transfer to ward.
----------------------------------------------------------
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE7:40 AM7:48 Am7:52 AM
8:00 AM8:15 AM
8:25 AM
8:28 AM
9:00 AM
9:15 AM
Knowledge deficit related to disease process, lifestyle -Visited
on bed and encouraged to verbalize feelings. Positioned to
semi-fowlers and maintained safety measures by placing side rails
up and locked. Informed the daughter regarding the transfer and
given options regarding various accommodations.
---------------Family member opted to be accommodated at suite
room. Informed station nurse on duty thru phone call on patients
transfer.------------------------------------------------------------------------D-Maam,
unsa kaayo ang ginadili nakong kan-on? as asked by patient. Appears
confused and worried.------------------------------A-Explained the
importance of lifestyle and diet modification and advantages of
compliance. Instructed also to avoid taking alcohol and smoking.
Encouraged patient to limit intake of high sodium, high fat and
high cholesterol diet, instead encouraged increased intake of green
leafy vegetables and high fiber diet.---------------R-Dili nako
manigarilyo og mu-inon og beer karon Maam. Ako na pud limitahan
akong pagkaon og mga tambok og asgad na pagkaon as verbalized. Seen
patient smiling and comfortable in
bed.-----------------------------------------------------------------------------
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE9:28 AM
10:00 AM
11:15 Am11:23 AM
A-Assisted Dr. Jones during visit. For referral to physical
therapist for further management as ordered. Request form sent to
rehab unit by the nursing attendant Ms. Nayal. Take home medication
was ordered and carried out correctly at discharge instruction
sheet.---------------------------------------------------------------------------A-Assisted
family member during visiting hour. Health teaching was imparted on
the importance of constant monitoring of blood pressure, the
compliance of medication and the importance of early consultation
for any health care related problems. Take home medications
discussed and explained to the patient and the daughter. Reminded
also regarding the patients next scheduled visit on September 21,
2011 at 8am, OPD.---------------------------R-Patient able to
enumerate all take home medications with correct dosage and timing.
Patients daughter verbalized Nakasabot nako
Maam-------------------------------------------------A-Received
phone call from ward stating that the room is ready for
transfer.--------------------------------------------------- Rhoda
Ordinaria,RN
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE11:25 AM
11:40 AM
11:57 AMPre-assessment upon patient transfer
D-Awake and responsive, free form any pain, still slurred speech
as verbal response, body weakness still noted but able to move all
extremities at times without any command. Pretransport vital signs
are BP-130/90, HR-76 bpm, RR-18 cardiac per minute, T-370C per
axilla.---------------------------------------------------------------------------A-Transported
to Suite Room per stretcher with side rails up and locked. Aided
throughout the transport.-----------------------------Informed
attending physicians Dr. Itok and Dr. Jones that patient was
transferred at Suite Room with room number 307 thru phone
call.------------------------------------------------------------------------------R-Still
awaiting to be seen by Physical Therapist for daily range of motion
exercises. Discharge instruction sheet was attached to chart and to
be given to the family prior to discharge. Endorsed to nurse on
duty.----------------------------------------------------Rhoda
Ordinaria,RN
-
DATE/SHIFT/TIME
Sample 13FOCUSDATA ACTION RESPONSE8/25/20116-2 shift6:00 AM6:05
AM
6:10 AM
7:08 AM
Hemodialysis with pulmonary congestion
Received from medical ward per wheelchair with 02 inhalation on
going at 5-6L/ml via nasal
cannula.-------------------------------------D-Naglisod ko ug
ginhawa Maam as verbalized; oriented to place, date and time;
labored breathing noted with flaring of nostrils; weight gain of
4.0kgs; BP-150/100; with heplock on right metacarpal
vein.-------------------------------------------------------------A-Assisted
comfortably to the hemodialysis chair; consent for hemodialysis
signed by wife; skin preparation of arteriovenous fistula access
done aseptically and with positive thrill upon palpation;
cannulated with
ease.---------------------------------------Hemodialysis started
scheduled for 4 hours with ultrafiltration goal of 4.0 liters and
ultrafiltration rate of 250-350 ml/min; 2000 units of regular
heparin given as IV bolus and 1000 units every hour thereafter as
anticoagulant;monitored for signs of hypotension; BP/HR monitoring
done every 15 mins.-------------------------------visited by Dr. G.
Doble with order made to discharge patient after hemodialysis once
cleared; ward nurse informed of the discharge order to facilitate
for the billing and discharge clearance of the
patient.-------------------------------------------------------------------------
-
DATE/SHIFT/TIME
FOCUSDATA ACTION RESPONSE9:00 AM9:05 AM10:10 AM
10:40 AM
Health teaching with discharge instructions
R-Puede na ko dili mag-02 Maam kay mayo na ang akong ginhawa,
patient verbalized; looks relaxed and normal breathing pattern was
observed.-----------------------------------------------------A-Reinforced
teaching given to both patient and wife to limit oral fluid intake
to 700ml/day to avoid dyspneic attack; instructed to have a
low-salt, low fat and low purine diet; reminded patient of saving
left arm to prevent potential damage to access site for future
use.----------------------------------------------------------------------Encouraged
patient to come on his next hemodialysis schedule.R-Mag-control na
ko sa akong imnon ug magbantay na ko kung unsa akong kaunon, as
verbalized by patient HD completed; cannula removed and pressure
dressing is applied; heplock removed and dressed; assisted patient
to upright position and 5 mins. to prevent orthostatic hypotension.
---------------------------Discharged ambulatory with assistance to
vehicle with clearance in fair
condition.-----------------------------------------------Prisca
Nalzaro,RN
*************************