 received awake lying in bed with __ bottle of D5LR  Admitted from E. A.

per wheel chair, accompanied by

NaCll 500 let 420 run in 12 hrs @ approximately __cc ___, with __ bottle of __ at approximately __cc inserted
level, inserted at R/L ___ vein regulated @ ___gtts/min; @ __ vein; infusing well.
infusing well.  No redn…
 …Assessment…  Placed comfortably in bed.
 …assessment…
 AM care done by S.O.; assisted
 initial v/s….
 Provided therapeutic env’t such as:
 oriented regarding physical set-up.
a. removing unnecessary things on bed
b. stretching bed linen
c. cleaning bedside table
 Seen and examined by Dr.__ with new orders made
and carried out. LABORATORY
 Health teachings provided with importance and Specimen
emphasis on:  Provided bottle for urine and stool specimen and
a. Impt. Of proper personal hygiene properly instructed…
b. Increased fluid intake  ___ specimen forwarded to lab..
c. Avoid carbonated and alcohol containing drinks
d. Importance of adequate rest period Utz
e. Encourage to adhere tx. Regimen Whole abdomen
f. Reminded on __ diet  kept on NPO then advise to take 4 glass of H2O
 Meals served such as __ and __ taken with __ appetite. gradually
 Utz of whole abdomen done
…
....INTERVENTIONS…  Avised to facilitate request for Na….
 encourage to verbalize feelings
DISCHARGE
 properly checked and regulated flow of IV and insertion
Refused referral
site.
 ….assessment…
 instructed for CBC, USTS, CXR tomorrow…
 …
 transferred to ___ ward as requested by the pt.  discharge instructions given such as:
 dressings changed aseptically (by Dr.___ assisted by a. proper intake of take home meds.
Dr.__/ ; assisted) b. ….

 tepid sponge bath rendered until fever subsided  refused referral to SROD for possible operation
 pt. requested to go home
 instructed s.o. to continue cold compressed place over  secured signature and signed by pt./S.O.
the forehead  billing facilatated
 follow up check up on ___
 followed up availability of blood for transfusion  went home(ambulatory/ per stretcher) in ___ condition,
accompanied by___
 explained to S.O. condition of the client and immediate
need for blood transfusion HAMA
 Discharge instructions given such as:….
 with 1”u” of blood wit QMH# ___, awaits in the lab blood  Requested to go home against medical advised
with cross matching result secured.  Explained impt. Of hospitalization and consequences of
 needs attended HAMA
 Secured signa…
 Follow up …
IVF
 Billing faci…
 Rciv..; with IVF out of vein
 Went home…
 Rciv… with ongoing IVF of d5LR 700cc x 80 with
soluset regulated at …. STILL MGH/ HAMA
 Above Ivf consumed and follow by the same IVF of  Still with unsettle bills
regulated at___.
Doctors order
 Above IVF not functioning wel, check with infiltration ….waver…
and pain; aseptically removed. eg. Ako po si __- ng pt. ay gusto___ sa kadahilanang___
 Above IVF of D5… re inserted at ___ by Mrs.___,
regulated at ___; assisted ____________________________
home per request/ HAMA (relation)
OXYGEN
 With O2 inhalation via nasal cannula reg. at 2L/min.

URINARY CATHETER
 With foley catheter draining to yellow-brown urine at
approximately__cc

SKIN TESTING
 Skin testing of ____ done aseptically at R/L ___ with
negative results as read by Mrs___(NOD)
 >initial dose of ___ given by ____(NOD)

ADMISSION

OB/Gyne
 Rciv lying on bed with IVF of D5LR 1L, with 10”u” of
oxytoxin inserted ….
 Health teachings provided with importance and
emphasis on:
a. Proper personal hygiene and perineal care
b. Impt. Of BF
c. Proper Breast and nipple care
d. Proper BF technique
e. Proper burping of baby after BF
f. Keep back dry
g. Reminded on ___ diet
BUBBLESHE
 …Assessment…
B > with breast slightly engorged.
>with breast engorged good in lactation
U >with firm and contracted uterus palpated at __
fingerbreath below the umbilicus.
B > voiding freely
> (+) flatus; (if not yet =NPO)
>no bowel movement
L > Lochia ___, __ in amt., used ___ perineal pad.
RUBRA 1-3 days after delivery, red – dark red color,
moderate amount
SEROSA 5-7, pink to pink brown serous, scanty
ALBA 1-3 week/ 10-14 days upper limit 21 days, cream to
yellowish maybe brown or white.
E > with episiotomy dry and intact
S> with good skin turgor
H> (-) Homan’s sign
E > discfharge instruction given regarding:
a. proper intake of take home meds.
b. return at BHC/ RHU/ OPD on __ for follow up check up
PRE-OP..
 …assessment…
 scheduled for ___
 with consent for the above procedure signed and
secured
 Pre- operative Health Teachings given such as:
a. deep breathing and coughing exercise
b. adequate rest and sleep period
c. impt. Of surgical procedure
d. have an early ambulation
e. alleviate anxiety
f. adhere to tx. Regimen
g. eat protein rich food s once normal diet resume
 skin preparation done/ Abdomino-perineal prep done.
 Dr.___ informedthat materials for OR already available.
 2nd call made and was received by ____
 Pre operative checklist accomplished
 MB HYdroxyzine HCl given through IM at R/L __
muscle./ Pre-op meds given
 Brought to O.R. per stretcher wheeled by Mr.___,
accompanied by__
 Latest BP=, CR=
POST OP…
 Received from OR per stretcher wheeled by mr._-
accompanied by ___, with 1st Post-op bottle of D5lR 1L @
appr….
 Conscious and coherent/ asleep
 Placed on bed comfortably and safety
 …assessment…
 Pale in appearance
 With slightly pale and dry lips
 With pale finger nailbeds
 Complaints of chills
 With gooseflesh skin noted
 (skin turgor? / warm or cold to touch)
 v/s taken and rec….T, PR, RR, CR, BP
 v/s monitored every 15mins q 15 mins until sdtable
 intake and ouput measured and recorded
accordingly
 with post op. orders carried out
 request for repeat hgb&hct forwarded to lab
 reminded S.O. to keep the pt. flat on bed
or
 reminded to slowly get up on bed
 instructed on gradual change on position
CS
O >dressings dry and intact on midabdominal area
supported by abdominal binder
> negative itchiness on incision site
> __ day Post CS
> pale and slightly weak in appearance
A > Risk for infection related to presence of abdominal
incision secondary to post CS operation done.
P >at the end of nsg. Intervention pt? S.O. will demonstrate
ways to (prevent/ reduce) infection
I >Assessed factors that can cause and contribute to
presence of infection
>observed for localized sign of infection especially at
surgical incision.
>noted signs and symptoms of sepsis like fever, chills
and diaphoresis.
>instructed on ways and technique to protect the
integrity of skin and prevention of infection
> stressed proper hand washing technique.
>instructed not to touch the dressingsincision site with
bare hands
>Kept dressings on mid-abdominal area dry and intact
>maintained adequate hydration
E >seen S.O. cleaning the bedside table and removing
unnecessary articles on bed.
. >with dressings dry and intact
AIRWAY CLEARANCE
S > “….
O > complaints of chest pain
>symmetric chest expansion
> with wheezing breaths sounds heard on both lung field upon
auscultation
> with non/productive cough
>with productive cough, phlegm yellowish in color and scanty
in amt.
>RR= ___bpm; dyspneic
>with complaints of DOB and shortness of breath
>…assessment…
A. > Ineffective airway clearance r/t thickened mucous secretion
in tracheobronchial tree that obstruct the airway passage.
I >Monitored v/s esp. RR and observe signs of respiratory
distress.
>auscultated chest, noted characteristics of breath sound and
presence of secretions
>assessed for concomitant pain and discomfort.
> instructed to increased fluid intake
>Assisted in semi-fowlers position with support of pillows.
>encouraged changing position and keeping back dry
>assisted in repositioning at regular interval.
>Provided restful and calm env’t and frequent rest period.
>performed chest and back physiotherapy after nebulazation
>demonstrated proper deep breathing exercise
>discouraged used of oil base product around the nose.
>provided supplemental humidification like nebulizer.
> emphasized the impt. of proper adherence to tx. Regimen.
E >seen pt. doing deep breathing exercise and effective
coughing
>seen S.O. performing percussion (cupping) and vibration
technique
PAIN
O >complaints of (characteristic, location) pain at __ area
>wit pain scale of __ in 1-10 scale
>with slightly flushed skin
> with facial grimace
>irritable at times
> slightly weak in appearance
A >Alteration in comport: Pain
P >at the end of nursing interventions pain will be lessen as
verbalized.
>At the end of nursing interventions patient will
demonstrate ways on how to lessen pain…
> At the end of nursing interventions patient will be able to
demonstrate use of relaxation technique and divertional
activities to lessen pain and discomfort.
I >assessed characteristic of pain such as:
location, pattern, duration, severity of pain
>noted presence of factors contributing to pain
>monitor vital cognitive signs watching changes in BP, PR,
RR..
>encourage to verbalize feelings
observed non-verbal cues
>assisted in comfortable position.
>ionstructed to have divertional activities such like texting,
reading newspaper, socializing to S.O.
> dev. Plan with S.O. for self care
>instructed to avoid excessive exposure to high temp
>promoted relaxing env’t , clean and well ventilated
> provided comfort measures such as changing position and
back rubbing to lessen discomfort
>provided adequate rest period.
> administered pain reliever as ordered
E> “hindi nap o madsakit” as verbalized
>pain scale of
>seen patient playing.
>seen patient texting/ reading news paper/ socializing to
S.O.
INFECTION
O > skin warm to touch: T=
> with dirty fingernails
> WBC
A> Actual infection r/t inadequate secondary defenses
increase WBC count as evidenced by lab. Result secondary
to ds. Process.
>actual infection related to presence of pyogenic organisms
in the urine as revealed by urinalysis
I >reviewed lab. Result
>assessed signs of infection like fever and chills.
>rendered TSB
>instructed to trim fingernails
> advised to change clothes
>clean bed and bedside table
>Instructed to practiced hand washing
>advised to increased fluid intake
infection in the urine
>Stressed the impt of sanitation esp. health practices like:
a. proper hand washing in every activities done especially
after toileting and before eating.
b.clean the perineum properly and keep the labia separated
during voiding
c. carefully wipe the perineum from front to back with soap
and water after defeacation
E> T=
 with trimmed fingernails
TISSUE PERFUSSION
O > hgb, hct..
.slightly weak in appearance
>with pale conjuctiva
>with capillary refill kess tha 3 sec.
A> Altered Tissue perfusion r/t decreased Hmg
concentration in the blood as seen in Lab. Exam.
P >at the end of nursing interventions pt. will able to
(improve hgb count in the bolood/ demonstrate ways and
techniques on how to improve tissue perfission)
I >monitored v/s especially BP
>noted customary baselne data such as lab. Studies e.i.
Hgb and Hct.
> measured capillary refill
> encouraged to perform within the range of motion exercise
>encouraged to ambulate.
>encouraged to elevate legs when eating
>advised to eat foods rich in Fe like organ meat and green
leafy vegetables and increase intake of vit.C
>instructed to avoid activities that may cause fatigue.
E> seen pt. eating foos rich in …
NON COMPLIANCE
S>
O > no meds in the rack
> anesthetics not yet complete
> Or materials still not complete
A > Non-Compliance to drug regimen related to financial
factor and lack of support system
P >at the end of nsg. Interventions the pt./ S.O. will
demonstrate behaviors and know the impt. Of tx. Regimen
and surgical operation.
I > assumed level of understanding
>determined reasons for alteration of therapeutic regimen
>give info. An\d help S.O. where and how to solve the
problem, asking help for SWA and NGOs
>explain the importance of hospitalizations and
undergoing___
>advised to avail medicine needed for ___
E> refered to social worker regarding condition.
 S.O. reported immediately a change in status of the pt.
KNOWLEDGE DEFICIT
S”….
O >always asking questions
>slightly irritable
>less eye contact while interacting
A >Knowledge deficit regarding lack of info. Regarding
medical condition possibly evidenced by frequent asking of
questions and misconceptions by the pt/S.O.
I >assessed clients and relative level of understanding
> identified pt.’s needs either through verbal or non verbal
expressions.
>provide env’t that is conducive for learning.
>involved S.O. in learning process.
>provided info.relevant to situation
>dev. Plan with S.O. for self care such as…
>assessed for feedback and evaluation of learning/
acquisition of skills
>encouraged verbalization of feelings.
E >seen pt./S.O. interested in teachings given