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Sample 1
08/24/2011
7-3 shift
9:00 AM Abdominal D-Patient verbalized “sakit gyod akong tiyan”, pain
Pain scale 8 out of 10, facial grimacing, guarding behavior,
irritable, Temperature 37.40C, pulse 70 beats per
minute, respiration 18 breaths per minute.----------
9:10 AM A-Administered Hyoscine N-butyl bromide 20 mg
Intravenously as per doctor’s order, encouraged and
demonstrated deep breathing exercises, placed in
semi Fowlers position with side rails up and locked.
10:00 AM R-Patient reports pain was relieved. Pain scale 5/10.--
-----------------------------------------Lysette Bagatua,RN
DATE/ FOCUS DATA ACTION
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Sample 2
08/24/2011
7-3 shift
1:00 PM Elevated D-“Init akong lawas” as verbalized. With flushed skin
Body and warm to touch, Temperature 38. 90C via axilla,
Temperature pulse 80 beats per minute, respiration 24 breaths
per minute, blood pressure 120/80.-----------------
1:05 PM A-Performed tepid sponge bath, applied ice cap on
forehead, administered Paracetamol 250mg
intravenously as per doctor’s order. Encouraged
adequate oral fluids intake, provided calm
environment to keep patient comfortable.---------
2:00 PM R-“Gipaningot na ko”, as verbalized, temperature
decreased to 37.20C.----------------Lysette Bagatua,RN
DATE/ FOCUS DATA ACTION RESPONSE
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Sample 3
09/15/08
7-3 shift
9:00 AM Pain at D-”Sakit man ang lugar nga naa ang dextrose” as verbalized
IV Site IV site slightly swollen and with redness noted.----------
9:10 AM 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.-----------------------
9:20 AM R-“Wala na ang sakit sa akong dextrose”,as verbalized--------
-------------------------------------------------------M. Omamalin,RN
DATE/ FOCUS DATA ACTION RESPONSE
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Sample 4
08/25/11
7-3 shift
9:10 AM ER to OR D-Received from ER per stretcher with side rails up and locked with
Pre- ongoing IVF of PLR 1L. at 900ml level at left cephalic vein using IV
Operative cannula gauge 18 regulated at 30 drops/min., with oxygen
Assessment 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
9:15 AM 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.
DATE/ FOCUS DATA ACTION RESPONSE
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PACU 1:45 D-Received patient from Operating Room per stretcher, side rails
PM 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
1:50 PM 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
1:55 PM IVTT as per Doctor’s 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/ FOCUS DATA ACTION RESPONSE
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12:25 PM -CBC, BUN, CREA, Lipid Profile, FBS requests sent to laboratory. EKG
taken and referred to Dr. Itok for interpretation---------------------
12:30 PM -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 Cashier’s 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.----------------------------------------------------------
2:00 PM -Endorsed to ICU Nurse on duty, Rhoda Ordinaria.-----------------------
-----------------------------------------------------------------Gerry Zamoras,RN
DATE/ FOCUS DATA ACTION RESPONSE
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Sample 12
8/25/2011
3-11 shift
3:00 PM Elevated D-Appears lethargic , cold and clammy skin noted, flaccid muscle
Blood tone on the left side of the body; right facial drooping noted,
Pressure slurred speech, able to move all extremities per command but with
160/90 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.--------------------------------------------------------
3:10 PM 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.--------------------------------
4:00 PM -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/ FOCUS DATA ACTION RESPONSE
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4:15 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.------------
5:15 PM -Laboratory results for CBC, S CREA, BUN and ABG in. Relayed to Dr.
Jones thru SMS, updated patient’s status and replied “ok thanks”---
6:30 PM R-BP rechecked 140/80.---------------------------------------------------
9:30 PM A-Visited patient and encouraged verbalization of any medical
problems such as headache. Continuous BP monitoring done.
10:30 PM R-Last BP 140/80 for FBS and lipid profile determination in AM.
Endorsed to next shift Nurse J. Bataga.------------Rhoda Ordinaria,RN
DATE/ FOCUS DATA ACTION RESPONSE
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8/25/2011
11-7 shift
11:00 PM 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. -------------------
12:00 MN D-“Labad man akong ulo Ma’am” 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/ FOCUS DATA ACTION RESPONSE
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12:10 AM A-Dim light provided, applied ice pack over the right parietal area.--
12:13 AM -Referred to Dr. Jones thru phone call, orders made and carried out
12:15 AM 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.----------------------------------
2:00 AM R-“Nawala-wala na ang labad sa akong ulo Maam” as verbalized by
patient, pain scale of 4/10. -----------------------------------------------
3:00 AM A-Seen soundly asleep and undisturbed.-----------------------------
6:45 AM R-Verbalized to be free from pain; Still for lipid profile and FBS
determination.------------------------------------------Rhoda Ordinaria,RN
DATE/ FOCUS DATA ACTION RESPONSE
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8/26/2011
7-3 shift
7:30 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.-----------
7:45 AM A-Oatmeal diet was served to the patient and able to consumed 8
spoonfuls of the food. On Aspiration Precaution; assisted patient
7:50 AM on sitting position; assisted Dr. Itok during visit with given order of
“may transfer to room of choice if okay with Dr. Jones”. Informed
7:55 AM Dr. Jones thru telephone with telephone order of “okay for me to
transfer to ward”. ----------------------------------------------------------
DATE/ FOCUS DATA ACTION RESPONSE
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9:28 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.---------------------------------------------------------------------------
10:00 AM 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 patient’s next scheduled
visit on September 21, 2011 at 8am, OPD.---------------------------
11:15 Am R-Patient able to enumerate all take home medications with
correct dosage and timing. Patient’s daughter verbalized
“Nakasabot nako Maam”-------------------------------------------------
11:23 AM A-Received phone call from ward stating that the room is ready for
transfer.--------------------------------------------------- Rhoda Ordinaria,RN
DATE/ FOCUS DATA ACTION RESPONSE
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11:25 AM Pre- D-Awake and responsive, free form any pain, still slurred speech as
assessment verbal response, body weakness still noted but able to move all
upon patient extremities at times without any command. Pretransport vital signs
transfer are BP-130/90, HR-76 bpm, RR-18 cardiac per minute, T-370C per
axilla.---------------------------------------------------------------------------
11:40 AM 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.------------------------------------------------------------------------------
11:57 AM 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/ FOCUS DATA ACTION RESPONSE
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Sample 13
8/25/2011 Received from medical ward per wheelchair with 02 inhalation on
6-2 shift going at 5-6L/ml via nasal cannula.-------------------------------------
6:00 AM Hemodialysis D-“Naglisod ko ug ginhawa Ma’am” as verbalized; oriented to
with place, date and time; labored breathing noted with flaring of
pulmonary nostrils; weight gain of 4.0kgs; BP-150/100; with heplock on right
congestion metacarpal vein.-------------------------------------------------------------
6:05 AM 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.---------------------------------------
6:10 AM 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.-------------------------------
7:08 AM 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/ FOCUS DATA ACTION RESPONSE
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