San Pedro HospitaI of Davao City, Inc.

C. Guzman St., 8000 Davao City, Philippines

Tel. No. (082) 222-6100 Fax No. (082) 226-4714

Website: www.sanpedrohospitaldavao.com
Email: sanpedrohospitaI@yah0Q.com

NURSES' NOTES

Name: Aguilar, Edbert Ward: Sta. Rosa Room/ Bed No. :243-1
DATE TIME
09/11/2020 7 am Patient received on bed; awake and conscious; c O2 inhalation at 3 L/min via nasal cannula; O2 sat of
90-92%; Dr Ituhat aware.

Hooked to cardiac monitor; no chest pain noted.

c IVF of D5W, @ 500 cc level @ KVO rate; @ R cephalic vein; patent and infusing well; no swelling and
no infiltration noted; regulated @ desired rate.

On LSLF diet

CBR s BRP; provided c bedside commode

Bedside care done; linen stretched and tucked well.

8 am Initial VS taken and recorded; temp. 37.4 °C; PR 75 bpm; RR 23 cpm; BP 140/100 mmHg; CR 80 bpm;
afebrile; recorded.

BP referred to AP.

Provided rest period.

8:30 am BP rechecked; 140/90 mmHg; AP aware.

Patient sent to echocardiography department via wheelchair for cardiac evaluation as ordered by Dr.
Alampayan and Dr. Cabahug.

Followed up X-ray result; done.

Patient back to room; placed on bed positioned comfortably.

IVF checked and kept well regulated.

Provided patient c comfortable and quite environment c rest period.

9 am For Trop I done by medtech c (-) result; relayed to AP.

10:37 am No chest pain noted; O2 sat checked; 92-93%; BP rechecked;140/90 mmHg; AP aware.

Encouraged patient to verbalized any discomfort.

11 am Meal served; c good appetite noted.

Monitored water intake and urine output.

 12 pm VS rechecked: temp. 37.3 °C, PR 73 bpm, RR 20 cpm, BP 130/90 mmHg, CR 75 bpm; recorded.

Instructed patient on NPO @ 10 pm for FBS and Lipid profile.

Instructed patient to collect midstream urine specimen @ tomorrow AM.

Allowed patient to have a rest period.

2:30 pm INO summed up and recorded.

Bedside care done; linen stretched and tucked well.

3 pm Patient endorsed to next NOD c on going IVF of D5W @ KVO rate @ 420 cc level; patent and intact.

ROSAREE PANTOJA MARIEL A. QUIÑANOLA

NSG - NSG - FO - 033

ID 9105016303
PHYSICAL ASSESSMENT:

General Survey

The client is in medium frame with stooped posture, the client is bedridden since he was admitted
to hospital. The client is well groomed and has no body odor. He is awake but unresponsive, he is not
cooperative.

His vital sign during the assessment

VITAL SIGNS NORMAL RANGE RESULTS
Respiratory rate 16-20 cpm 21 cpm

Temperature rate 36.5-37.5 degree Celsius 37.5 degree Celsius

Cardiac rate 60-100 bpm 80 bpm

Pulse rate 60-100 bpm 78 bpm

Blood pressure 90/60-120/80mmHg 130/100 mmHg

Skin

The client skin is normal racial tone which is brown and Unblemished and no presence of any foul
odor, the body hair is even distributed, It is dry and rough. Skin turgor is wrinkled and loss of elasticity.
He doesn’t have any edema.

Nail

The client nail shape is convex clubbing, the nail is rough and the nail bed is pink and is intact
with the epidermis. The capillary refill with 5 seconds.

Head and face

The client skull is proportionate to the body size, these were no tenderness in the scalp. These
were no presence of nodules, and infestation, his hair is not distributed well the strands are thin and
brittle. The color of his hair is a mixture of white and black. His head is round and symmetrical its
consistency is hard. He can’t control his head and the shape of his face is round and asymmetrical and
its consistency is rough.

Eyes

The condition of his eyes is normal no presences of discharges. The eye brows are evenly
distributed. An eye lid has ineffectively closure. The blink is unresponsive sometimes. Pupils are equally
round and reactive to light and accommodation. He can execute the ocular movement, he recognize
objects within 12-14 inches. The lacrimal apparatus is dry.

Ear

The color of the ear is of normal racial tone which is brown, it is symmetrical. The alignment of the
pinna is symmetrical. The pinnas are elastic and recoil when folded. Mastoid process is tender. The
auditory canal contains some cerum, the color is brown and there is an absent of discharges.

Nose

The color of the nose is racial tone which is brown. His septum is in the midline. The mucosa is
light green, nostrils are both patent. Sinuses are no tender. There’s no NGT to his both nostrils.

Mouth and oropharynx

The lips is symmetrical and brown, the consistency is rough, buccal mucosa is pink, the gum is
pink, the tongue movement are not that smooth. Its texture is rough. The color of the hard and soft
palate is pink. The tonsils are inflamed. The teeth is in complete.

Neck

The neck has involuntary movement and with resistance, maxillary lymph nodes are palpable.
The neck muscles are equal in size. The trachea is placed in the midline of the neck.

Breast

The breast of symmetrical with flat contour, shape is flat, the skin surface are rough, lymph nodes
are not palpable. The areola is color brown, shape is round and nipple is inverted. No discharges.
Chest and lungs

The color of the chest is normal racial tone which is brown. The chest wall is symmetrical and the
chest expansion is symmetrical, respiratory rhythm is irregular, the respiratory depth is shallow, the
respiratory pattern is not normal. When percussed the sound is resonance. The respiratory rate is 21
breaths per minute.

Heart

The rhythm is irregular, PMI is located in the apical pulse. Heart rate is 74 beats per minute.

Abdomen

The abdomen of the client has an unblemished skin and is uniform in color. There were
symmetrical movement caused associated with clients respiration. Peristalsis is non-visible. When
percussed the sound is tympany. When palpated he doesn’t have any tenderness. The liver are not
palpable.

Lower extremities

The client unable to stand and walk. Muscles are not palpable with absences of tremors. Bone
doesn’t have any deformities. Joint doesn’t smoothly.
 Name: Aguilar, Edbert Age: 72 Ward: Bed: 1

Chief Complaint: Chest Pain Diagnosis: Acute Pain

Physician: Dr. Alampayan & Dr. Kabahog

te/Ti Cues Nee Nursing Diagnosis Patient Nursing Implem Evaluations
ds outcome Intervention entati
s ons

Subjecti A Acute pain After 6 Establish 1 Goals completely

ve: related to hours of client’s met
decerease nursing rapport
myocardial blood interven
C flow as evidenced tion,
-“Nurse, by reports of The client
sakit pain and facial Rationale: demonstrated the
kayo grimacing. to gain relief of pain.
akong T - The client’s
dughan. patient trust and
Mura kog will be cooperation
di Rationale: able to
kaginhaw demonstr
I
a”as Coronary ate
verbaliz arteries supply relief Evaluate
ed by the heart muscles of pain reports of
the with an as pain in jaw,
patient V oxygenated blood. evidence chest, neck,
While plaque is a d by shoulder,
composition of stable arm, or hand 4
cholesterol, vital (specificall
Objectiv I calcium, fat, and signs, y on the
e: other substances absence left side)
in the blood and of
reduces the blood muscle
T flow to your tension
heart muscle. Due and
-Body Rationale:
to the build up restless
Lethargy Cardiac pain
of plaque inside ness.
radiate.
Y/ the coronary
arteries, it
results to
-Pain blockage of blood -Report Goal completely
scale of flow. This can Elevate the
anginal
3 out of E cause heart head if the
episodes met
3 attack if quick client is
decrease
treatment is not experiencing 5
d in
applied. short of The client reporte
frequenc
X breath.
y,
-Facial duration decreased in
grimace and frequency,
Reference: severity
E . Rationale: duration and
Facilitate severity
Vera, M. (2020).
Restless gas exchange
4 Angina Pectoris
ness (Coronary Artery
R Disease) Nursing . 3
-VS Care Plans. Check
taken: Retrieved client’s
C September 11,2020 meal and
Temp. : from: have 1 hr.
37 https://nurseslab rest after
s.com/4-angina- the meal.
PR I coronary-artery-
72 disease-nursing-
care-plans/
RR Rationale:
19 S to decrease
myocardial
CR workload to
74 reduce the
risk of
E anginal
BP
130/90 attack.
2

Maintain
quiet,
comfortable
environment.

Rationale:
to avoid
mental/emoti
onal stress
that may
increase the
myocardial
workload.

Nary Arlene Joy