Вы находитесь на странице: 1из 17

DATE AND DOCTORS FOCUS DAR NURSES NOTES

TIME ORDER
January 20, 9:30AM Acute pain Data: 9:00AM
2019  Please admit  CC: RUQ with a pain
9:00am patient scale of 8/10,  A 41 years old female patient, wearing a maternity dress in pink slipper
 Secure  Nape pain 7/10 on, is rush in the VRH emergency room at 9:00AM on January 20, 2019.
consent  Blurring of vision She was accompanied by her husband with a chief complaints of blurring
 With Guarding behavior
 Seen by Dr. of vision, RUQ pain with a scale of 8/10 and nape pain as 7/10.
 Facial grimacing  Guarding behavior, facial grimacing, restlessness, paleness were
HB  Restlessness
 Monitor BP q  Paleness
observed. She has a BP-150/100mmHg, T-37, RR-24, PR-95 and FHT
1hr  Non-pitting Edema on of 135.
 DX: urinalysis, both lower extremities  She was place on bed comfortably with elevated feet and side rails up
CBC with for safety.
APC, baseline Action:
CTG,  Vital signs taken as 9:05am
PPT.ultrasoun follows:  BP-150/100
d whole BP-150/100mmHg,
abdomen RR-24 cpm 9:20am
 LDH, ALT, PR-95 bpm  BP-150/100
Temp-37.0 C
AST(stat)
 FHT-135 bpm
 Meds order:  SPO2-99%
 methyldopa  Position patient
250mg 2 tabs comfortably
now then TID  Promote rest
 MgSO4 4g  Elevate feet to promote
slow IV then circulation
5g IM in each  Raise side rails for
buttock safety
 Dexamethaso
ne 12mg IM 9:20 am 9:20AM
every 12hrs x  Oral meds given;
2 doses Methyldopa 250mg 2  She was seen by Dr. HB with an initial diagnosis of pre-eclampsia with
 Paracetamol tabs orders of admitting the patient, secure consent, TPR q4, BP q1, FHT q2,
 oral meds given for laboratory like urinalysis, CBC with APC, PPT, LDH, AST, ALT(STAT)
500mg q 6
Paracetamol 500mg q 6 and a baseline CTG. He ordered a medication of Methyldopa 250mg 2
RTC
RTC tabs now then TID, Magnesium sulfate 4g slow IV then 5g IM in each
 D5LR 1L x  MgSO4 4g slow IV then
8hrs buttock, Dexamethasone 12mg IM every 12 hrs. x 2 doses and
5g IM in each buttock Paracetamol 200mg q 6 RTC, D5LR 1L x 8hrs.
 Monitor BP
every 15 min
 The laboratory tests were explained to the patient, and the laboratory
Response: section was informed about the stat orders.
 The patient was able to  Consent was secured.
verbalized:  She was then hooked to D5LR 1L x 8hrs at 30-31gtts/min infusing well
 Reduced pain scale of to her left metacarpal vein.
Nape pain from 5/10,  Prior to giving mgSO4 patellar reflex was assessed with positive patellar
and 6/10 for RUQ reflex
 Absence of Guarding  After administration of mgSO4, monitor for BP,urine output,and
behavior
respiratory rate
 Absence of Facial
 She was given oral medication such as methyldopa 250mg 2 tabs now
grimacing
 Absence of then TID for her high BP, MgSO4 4g slow IV then 5g IM in each buttock,
Restlessness Dexamethasone 12mg IM every 12hrs x 2 doses for the fetus lung
 Absence of Paleness maturity, Paracetamol 500mg q 6 RTC.
 The nurse asked for a urine sample and sent it to the laboratory section
and a medical technologist drawn a blood sample for her specific
laboratory test.

10:00am

 The patient was transferred to OB ward via stretcher accompanied by


her husband. Then she was transferred to bed, and positioned to a semi-
fowler comfortably with vital signs of:
o BP- 150/90 mmHg,
o RR-24 cpm,
o PR-90 bpm,
o T-36.8
 FHT of 148.

Action:
 Notified to Dr.HB 11:00am

 CBC and urinalysis result was forwarded to the nurse station and was
notified to Dr. HB. the patient was requested for BP monitoring, q 1hr
and fetal heart tone q 2hrs.

 her vital sign was taken and recorded as follows:


o BP-140/90mmHg
o RR-22
o PR-90
o temp-36.6
 FHT-140

12:00pm
 VS taken:
o BP-140/90mmHg
o RR-23
o PR-89
o temp-36.9
2:00PM
 FHT-140
 Lab result
ALT, AST (
stat) 2:00pm
 Light meal
then NPO  The nurse station received her lab result for the AST, ALT and LDH.
midnight This was notified immediately to Dr. HB as he ordered. After he read
 Cefuroxime the result he went to the patient’s ward to explain the laboratory result
4:00PM
1.5 g/IV confirming that she has HELLP syndrome and then explain the
Data:
ANST prior to  The patient verbalize management for her disease. She was then informed to have her
elective anxiety due to her cesarean section on January 21, 2019.
LTCS disease and the  Further explanation was said about her CS and was able to understand.
 Secure procedure to be perform  Consent was secured
consent  The patient verbalize  VS taken as follows:
 FHT Q2 that she didn’t o BP-140/90mmHg
 Routine understand well how o RR-23
abdominal she got the disease. o PR-90
preparation Anxiety  The patient cannot o temp-36.9
 Please specify what to expect
inform after the operation  Oral meds given: methyldopa 250mg 2 tabs now then TID
procedure or Action:
new born  The patient was 4:00pm
care encouraged to
 ABO RH type verbalized her feeling  Received patient sitting on bed with an IVF of D5LR 1l at 375cc.she
 Please about the procedure verbalized anxiety due to her sickness
secure 1 bag  The procedure was  Vital sign taken as follows:
PRBC discussed to the patient o BP-140/90mmHg
properly  Promote relaxation o RR-22
typed and techniques o PR-90
cross Response: o temp-36.8
matched for  The patient able to
OR use verbalize understanding  Further explanation about the decrease was discussed.and she was able to
about the procedure verbalized understanding
 Stabilize pt.  The patient able to
And baby verbalize that she would  FHT-140
(continue V/S expect a cut/incision  Oral meds given: paracetamol 500mg q 6hrs
monitoring within her abdomen.
 The patient able to
verbalize that her
anxiety about the
procedure was
decreased.

6:00pm
 Patient seen lying on bed an intact IVF of D5LR at 30cc level.
 Followed by D5LR 1L x 8hrs with the same infusion rate
 She was instructed to have light meals like a cup of rice with vegetables
and instructed to have NPO after midnight as a preparation for her CS.
 VS taken as follows:
o BP-140/90mmHg
o RR-21
o PR-92
o temp-36.9
 FHT-145

 Oral meds given: methyldopa 250mg 2 tabs now then TID

8:00PM
 VS taken as follows:
o BP-140/90mmHg,
o RR-30,
o PR-95,
o temp-37.0
 FHT-145

10:00pm

 Patient seen lying on bed on bed with an IVF of D5LR 1l at 500cc.

 NPO instructed
 VS taken as follows:
o BP-140/90mmHg,
o RR-24,
o PR-92,
o temp-37.0
 FHT-149

 Oral meds given: methyldopa 250mg 2 tabs now then TID

 Second dose given: Dexamethasone 12mg IM every 12hrs x 2 doses


for the fetus lung maturity
 Paracetamol 500mg q 6hrs
DATE AND DOCTORS FOCUS DAR NURSES NOTES
TIME ORDER
January 2:00AM
21,2019
2:00am 8:00AM Data:  Patient seen on bed, conscious with an intact IVF of D5LR at 20cc
 FL “Elective  BP: 140/100  Followed by D5LR 1L x 8hrs with the same infusion rate.
LTCS”  VS taken as follows:
 Cefuroxime 1.5 o RR-21
g IV before OR o PR-93
 Secure consent o temp-37.0
 Inform OR/  FHT-148
NOD/PROD
 Routine 5:00am
abdominal Data:
preparation  BP: 140/90
 Pt on bed with an intact IVF of D5LR at 625 cc level.
 Stabilize patient  VS taken as follows:
and baby o RR-20
o PR-87
o temp-37.0
 FHT-146

Data: 7:00 AM
 BP: 140/90
 VS taken as follows:
o BP-140/90mmHg,
o RR-20
o PR-87
o T-37.0
 FHT-142

PREOPERATIVE:

8:00AM

Action:  VS:
 Procedure was o BP-140/90mmHg,
explained to the patient o RR-22
 Skin testing o PR-90
o temp-37.0
 FHT-140
 The procedure was explained to the patient and skin testing was done.

8:30 AM
Data:  Skin test result was (-) ANST
 BP-140/90mmHg  Cefuroxime 1.5 g IV was administered as prophylaxis to prevent further
complications.
 Received patient on with an intact IVF of D5LR at 375cc level.
Action:  VS:
 Cefuroxime 1.5f IV o RR-20
administration o BP-140/90
o PR-87
o temp-37.0
 FHT-142

9:30AM

 Received patient on bed with an intact IVF of D5LR 1L at 50cc level.


 Followed D5LR 1L x 8hrs with the same rate infusion
 She was examined by the surgeon and then evaluated the site of the
intended skin incision
 The patient clothes were changed to gown and instructed to lie flat on
bed.
 Perineal care and clipping of abdominal hair was performed. After that
she was transported to the OR via stretcher.

INTRAIOPERATIVE:
10:50AM Risk for injury Data:
 Induction of anesthesia 10:00AM
 To PACU (s/p
“E” LTCS+BTL Action:  Patient was assisted to fetal position,antiseptic was done and induction
under SAB)  Patient assisted to fetal of regional(spinal) anesthesia(bupivacaine50mg, midazolam,
 Flat on bed position nalbupin20mg) and the sterile draping applied. Patient was placed back
 Administer O2 at  Patient was place in
to supine position after inducted; O2 at 2lpm via nasal cannula was
2-3 l/min supine after induction of
hooked and Indwelling Foley Catheter was connected to urine bag
 Monitor vital anesthesia
inserted aseptically.
sign every 15  Bed rails up
mins till stable  IFC insertion done
 NPO aseptically
 IVF D5LRS  The operation started by Dra. S. with A.A as assist and A.M as
1L+20u oxytocin instrument. Antisepsis was done, sterile draping was applied, and
for 8 hrs To counting of needles, sponges, and instruments was done.
follow
 D5LRS 1L+10u 10:15AM
oxytocin for Risk for DATA:  The surgeon performed a 13cm pfannenstiel incision two finger-breadth above
every 8hrs times infection symphysis pubis
3doses  Incision site (13cm) 
 D5LRS 1L for
8hrs  Indwelling catheter  10:20AM
 Baby out, umbilical cord was cut. Chest x ray was done to the baby and
 Meds: Action: then transferred to NICU
 Cefuroxime
10:25AM
1.5g IV  Maintain sterile
every 8  Placenta out
technique for all
hours 10:40AM
invasive procedure
 Tranexamic  Uterus was cleanse
 Wound dressing using
acid 2mg IV  Uterine wall closed
proper technique
every 8hrs x  Abdominal closed
3 doses  Blood loss 1000ml
 Tramadol  All needles,sponges and instrument complete
50mg IV
every 8 x 3
doses
 Diclofenac POSTOPERATIVE:
75mg every
6hrs x 3
10:50AM
doses
ANST
 Ranitidine  The operation ended and procedure was done, abdomenoperineal care
50mg IV was done, sterile draping applied on the operation site, and to RR
every 8hrs endorsed.
while on  VS taken:
NPO o BP-120/90mmHg,
 May transfer o RR-22
back to ward o PR-80
when able to o T-37.0
elevate both
legs with stable  For Post Anesthesia Care, patient was on the RR. she was place in
vital sign supine position on IVF of D5LR 1l at 875cc +20U oxytocin. with oxygen
inhalation via nasal cannula at 2lpm, and hooked to pulse oximeter. The
IV meds was started and safety measures provided.
12:00PM

 May have clear 11:00am


liquid diet and  Vital sign was taken as follows:
crackers @7PM
 Repeat lab: o BP-130/90mmHg,
CBC, o RR-21
urinalysis,FL:BUN, o PR-80
CREA,PT,PPT,AST o T-37.0
,ALT,NA,K,FBI-
 IV meds given:
liquid profile
 Continue IVF
o Tramadol 50mg IV
and meds
 WOF uterine o Diclofenac 75mg IV
atony o Ranitidine 50mg IV
 CHON o Tranexamic acid 2mg IV
determined Action: 11:15am
 Continue vital
sign monitoring  Vital sign was taken as follows:
 The patient was
7:00PM assisted on bed from o BP-130/90mmHg,
 May have soft stretcher o RR-22
diet (low salt,  Maintained IFC o PR-85
 Instruct to lie flat on bed
low fat) o T-36.9
till 7pm . The patient
 May remove IFC 11:30am
was instructed on NPO
once with
and a continuous IV  Vital sign was taken as follows:
adequate flow
monitoring due
medication given o BP-130/90mmHg,
 VS monitoring q 15min o RR-23
 Monitored patient for o PR-80
bleeding o T-37.0
 Monitor urine output 11:45am
 Vital sign was taken as follows:

2:00pm o BP-130/90mmHg,
o RR-21
DATA: o PR-82
 Chief complain of pain in o T-37.0
the incision site,
 Rate the pain as 7/10
 guarding behavior
Acute pain  facial grimacing 11:50AM
related to post  paleness  The patient was lying on bed and awake with an IVf of D5LR 1l at 750cc.she
op operation  Dry lips can elevate her foot upon assessment patient was assisted back to ward via
stretcher.
ACTION:
 Vital sign taken and 12:00PM
recorded as follows:  The patient was assisted from stretcher to bed. IFC was maintained with
30cc output and was instructed to lie flat on bed until 7pm and on NPO
o BP- until 7pm lying on bed with an IVF of D5LR 1l at 675cc level
130/90mmHg,  VS:
o RR-16 o BP-130/90mmHg,
o PR-86 o RR-16
o temp-36.7 o PR-86
 Encourage the patient to o T-36.7
verbalize her feeling about
 Lochia assessed: Rubra
her condition
 Promote adequate rest  CBC, urinalysis FL: BUN,CREA, PT,PPT,AST.ALT.NA,K, FBI-liquid
 She was encourage to do profile done
breathing exercises

RESPONSE:
 The patient able to divert
her attention by watching
TV
 The patient able to report 2:00PM
that the pain is
relieved(5/10)  Received patient on bed with an IVF of D5LR 1l at 425cc level with a
urine output of 90cc .patient was complaining of pain on her incision site
rated as 7/10.facial grimacing ,guarding behavior and dry lips upon
assessment with a vital sign of:

o BP-130/90mmHg,
o RR-21
o PR-82
o T-37.0
 Patient was encouraged to do deep breathing exercise
 Her lab result was received to the nurse station.

6:00pm
 Received patient on bed with an IVF of D5LR 1l at 175cc level with a
urine output of 200cc .Vital sign was taken as follows:
DATA:
 Incision site 13cm with o BP-120/90mmHg,
drainage o RR-24
Risk for  Incision site is moist o PR-81
infection  Presence of IFC o T-36.9
ACTION:
 Instruct the patient for
 Meds due given:
proper wound care for
the incision site
 Instruct the patient to o Cefuroxime 1.5g IV
always make the area o Diclofenac 75mg IV
clean and dry at all o Tranexamic acid 2mg IV
times
RESPONSE:
 Understand the 7:00PM
importance of wound
care  Patient was received on bed with an IVF of D5LR 1l at 50 cc.IVF was
removed rehooked with D5LR 1l x 8hrs + 10U oxytocin.urine output of
230cc level and was drained. vital sign was taken as follows
o BP-120/90
o RR-16
o PR-86
o T-36.7

 Tramadol 50mg IV given

11:00pm
 Received patient lying on bed with an IVF of D5LR 1l at 500cc level with
a urine output of 120cc level .vital sign was taken as follows:
o BP-130/90
o RR-19
o PR-83
o T-36.9
 IFC was removed
DATE AND DOCTORS FOCUS DAR NURSES NOTES
TIME ORDER
January 22, 12:00am
2019  Result of ALT,  Vital sign was taken:
AST and LDH Disturbed Sleeping Data:
result Pattern o BP-120/90
 consume IVF +  Total hours of sleep at o RR-18
meds night: 4-5hrs with o PR-81
 Start interruptions o T-36.8
  Presence of eye bags
FESO4 325mg  Diclofenac 75mg IV given
OD  Lack of concentration

 Celecoxib Action:
1:00AM
200mg 1 cap  Patient on bed with an intact IVF of D5LR 1L at 40cc.
 Provide comfort measures
BID  Followed by D5LR 1L with the same rate infusion.
 such as proper positioning,
Ascorbic acid  Patient was informed about the proper ways to lessen the
80mg1 tab OD deep breathing exercises,
susceptibility to infection and was instructed for daily wound
back rub.
 Co amoxiclav care and to report any untoward signs and symptoms.
625mg 1tab  Encourage to limit intake of 2:00am
caffeine and chocolate prior
BID for 7days  Received patient on bed with an IVF of D5LR 1l at 875cc ital
to sleep.
 Amlodipine sign was taken as follows:
10mg OD
Response:
 Repeat CMC o BP-130/90
today
 Understood o RR-17
 Encourage o PR-84
early o T-36.9
ambulation  Cefuroxime 1.5g IV given
and  Tranexamic acid 2mg IV given
breastfeeding
 Continue vital 3:00am
sign  Vital sign was taken:
monitoring
o BP-120/90
o RR-20
o PR-81
o T-36.9
 Tramadol 50mg IV given

DATA:
8:00AM
risk for delayed  Verbalized discomfort  Received patient on bed awake with an IVF of D5LR 1l at 125cc
recovery related to when moving level.verbalized discomfort in moving with a pain scale of 6/10,
post op pain facial grimacing and guarding behavior.
 Pain scale of 6/10  She was encourage for early ambulation and eating foods rich
in vitamin and nutrient.vital sign was taken as follows:
 Facial grimacing o BP-120/90mmHg,
o RR-16
 Guarding behavior
o PR-86
 Difficulty in moving/turning o T-36.7
on side  Oral due meds given:
o Celecoxib 200mg 1 tab
 Incision site is moist o Co amoxiclav 625mg 1 tab
o Amlodipine 10mg 1tab
ACTION: o Ascorbic acid 80mg 1 tab
o FESO4 325mg 1 tab
 Encourage patient for
early ambulation to
promote circulation 9:00 AM

 Encourage to eat fruits  Patient was on bed with an IVF of D5LR 1l at 20cc
and adequate protein  Followed by D5LR 1L with the same infusion rate
intake  VS:
o BP-120/90mmHg,
 Demonstrate the proper o RR-16
caring for the incision site o PR-86
o T-36.7
RESPONSE: 1:00pm
 Received patient sitting on a chair with an IVF of D5LR 1l 500cc
 Understand the level. vital sign taken and recorded as follows:
importance of early o BP-130/90mmHg,
ambulation o RR-17
o PR-89
o temp-36.5
5:00pm
 Patient was on bed with an IVF of D5LR 1l at 20cc
 Followed by D5LR 1L with the same infusion rate

6:00PM

 Patient was on bed with an IVF of D5LR 1l at 875cc level. vital


sign taken and recorded as follows:
o BP-120/90mmHg,
o RR-19
o PR-84
o temp-36.9
 Celecoxib 200mg 1 tab given
 Co amoxiclav 625mg 1 tab
 Patient was taught different comfort measures and food to
avoid to promote improvement of sleep pattern.
11:00pm
 Patient was on bed with an IVF of D5LR375cc level with avital
sign taken and recorded as follows:
o BP-120/90mmHg,
o RR-16
o PR-85
o temp-37.0
 Remove IVF
DATE AND TIME DOCTORS ORDER FOCUS DAR NURSES NOTES
January 23, 2019 8:00AM Fluid overload Action: 2:00AM
 Lab result of ALT,  VS monitoring q 4hrs
 Continue pt management  Patient on bed conscious with a vital sign of:
 V/S every 4 hours Data: o BP-120/90mmHg,
 For IE and for discharge  Non-pitting edema on o RR-15
tom both lower extremities o PR-80
Action: o T-36.8
 Encourage patient to
8:00AM
 Elevate both feet
 VS:
 To use tights, or
stocking o BP-130/90mmHg,
 Do light exercises o RR-19
 Remove IVF o PR-85
o T-36.8
Response:  Patient was encouraged to do measure that could
reduce swelling on both feet.
 Understood  Encourage to ambulate
 Meds due given:
o Co amoxiclav 625mg 1 tab
o Amlodipine 10mg 1tab
o Ascorbic acid 80mg 1 tab
o FESO4 325mg 1 tab

2:00PM
 Vital sign taken:

BP-130/90mmHg
o RR-17
o PR-89
o T-36.5
6:00PM
 VS:
o BP-120/90mmHg,
o RR-19
o PR-85
o T-36.8
 Co amoxiclav 625mg 1tab given
10:00pm
 VS:
o BP-120/90mmHg, RR-15,PR-80,T-36.8

DATE AND TIME DOCTORS ORDER FOCUS DAR NURSES NOTES


January 24, 2019 May go home Readiness for Action: 8:00am
 Take home med enhanced self-care  Further health teaching
 Ferrous sulfate 325mg OD about the activities to  VS:
 Ascorbic acid 80mg 1 tab OD avoid and care for the o BP-120/90mmHg,
 Co-amoxiclav 625mg 1tab BID incision site o RR-16
 Amlodipine 1 tab OD  Encourage to avoid o PR-80
stress as possible o T-36.9
 Follow-Up check-up: January  Meds due given:
29, 2019 Response:
 Understood
o Co amoxiclav 625mg 1 tab
o Amlodipine 10mg 1tab
o Ascorbic acid 80mg 1 tab
o FESO4 325mg 1 tab

9:00AM
 Discharge planning was conducted. Patient was
ordered to may go home which was ordered by
Dr. HB.
 Patient was advised to take her home meds:

o Co amoxiclav 625mg 1 tab BID


o Amlodipine 10mg 1tab OD for 6wks
o Ascorbic acid 80mg 1ta OD
o FESO4 325mg 1 tab OD

10:00am
 The patient was discharged and instructed regarding
to her follow up checkup.

11:00am
 patient was discharged in a good condition
COURSE IN THE WARD