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Nurse'S Notes: Date-Shift Focus Data - Action - Response

1) A 55-year-old male patient was admitted with abdominal pain and facial asymmetry. His vitals were taken and he was started on IV fluids and medications. 2) The following day he was transferred to the surgical ward and prepped for surgery. His vitals remained stable. 3) That evening his temperature rose to 38.4C and he was given paracetamol which reduced his fever. He underwent surgery the next day and was monitored in the PACU before being transferred back to the ward.

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116 views5 pages

Nurse'S Notes: Date-Shift Focus Data - Action - Response

1) A 55-year-old male patient was admitted with abdominal pain and facial asymmetry. His vitals were taken and he was started on IV fluids and medications. 2) The following day he was transferred to the surgical ward and prepped for surgery. His vitals remained stable. 3) That evening his temperature rose to 38.4C and he was given paracetamol which reduced his fever. He underwent surgery the next day and was monitored in the PACU before being transferred back to the ward.

Uploaded by

Renea Joy Arruejo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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NURSE’S NOTES

SURNAME:_____FERI______________________________ M.I.:__D____ AGE:__55____ HOSPITAL NO.:_0002345__


GIVEN NAME:____LOGAN__________________________________ SEX:__M____ WARD/ROOM NO.:_____218______

Date-Shift FOCUS Data – Action – Response


05-06-2021 Admission Care D: Admitted a 55 y/o male patient accompanied by his wife with
7:00 am initial VS as follows:
08:00 am BP: 110/70 mmHg
08:30 am PR : 97 bpm
RR: 21 cpm
Temp: 36.4
O2 sat: 97 %
Felt uneasy, weak, unpleasant pain around umbilicus with facial
asymmetry.

A: Assisted on bed and positioned to moderate high back rest ;


side rails raised; seen and examined by ER physician (Dr.
Guerrero) with orders made and carried out accordingly; consent
to care and hospitalization secured; started IVF of PNSS 1L + Vit.
B inserted aseptically at right metacarpal vein regulated to 56-57
gtts/min.@; request for laboratory and other diagnostic procedures
made, performed 12 lead ECG; forwarded and attached to chart;
other standing orders carried out accordingly; accompanied for
CXR; facilitated awaiting results, informed surgical ward nurse on
duty regarding on duty.

R: Transferred to surgical ward in a private room at 8:30 am via


wheelchair, endorsed accordingly.

9:00 am Post transferred D: Received patient via wheelchair accompanied by ER OD and


assessment significant other, with initial vital signs as follows:
BP: 110/70 mmHg
PR: 86 bpm
RR: 21 cpm
Temp: 36.4 ◦c
with body weakness, constipation and unpleasant pain around
umbilicus region, and facial asymmetry noted; with ongoing IVF
PNSS 1L + Vit. B x 6 hours regulated to 56-57 gtts/min @ 900 cc
level regulating well.

A: Transferred patient to room of choice and assisted to desired


position of comfort for safety, positioned patient high-back rest;
IVF regulated as ordered; clear liquid diet and NPO post midnight
instructed to significant other; initial VS taken accordingly; ROD
informed about the admission.)

R: Patient settled in the room; Vital signs checked and monitored


at a normal range; monitored and secured patients safety and
wellness; waiting for laboratory and results.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

A: Rounds made by Dr. Refuerzo; consent for blood transfusion


10:00 am secured; prescribed PNSS 1L with KVO side drip at 10 gtts/min;
12:00 nn Secured 2 units of FWB x 4 hours regulated at 41-42 gtts/min;
1:00 pm monitored patient for bt reactions.
R: Vital signs checked and monitored at a normal range;
monitored and secured patient’s wellness.

A: seen and examined by Dr. Sabaten; instructed for surgery;


assessed patient; administered medications; monitored vital signs;
2:00 pm and provided information.

R: Patient’s knowledge increased for her operation; increased


patient’s satisfaction; increased collaboration between NPI.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

D: Vital signs at a normal range.


5:00 pm Bedside Care
6:00 pm A: Rounds made by Dr. Plete; assessed patient; monitored vital
7:00 pm signs; NPO post midnight instructed; oral and body hygiene before
OR endorsed; Ketorolac 30 mg IV 1 HR PTOR ANST transcribed,
changed linens; and provided information.

R: Patient’s knowledge increased for her condition; improved


patient’s satisfaction; increased collaboration between NPI.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

D: temperature of 38.4 c/axilla @ 2am.


May 7, 2021 Ineffective
2:00 am Thermoregulation A: TSB done; prescribed PRN medication of Paracetamol 300 mg
3:00 am IV give.
4:00 am
R: Patient’s temperature was back into normal; vital signs checked
and monitored at a normal range; secured patient’s safety and
wellness.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

D: Patient transferred to PACU; Informed NOD.


12:00 nn Post-operative
01:00 pm Care A: Seen and examined by Dr. Plete; hooked to o2 support via
02:00 pm nasal cannula regulated to 2-3 lpm as ordered infusing well; NPO
temporarily instructed; encouraged deep breathing exercise;
monitored VS q15 then q1 till it became stable; monitored JP drain
output q1; consumed PNSS 1L KVO side drip at 10 gtts/min at left
hand; with ongoing IVF of PNSS 1L + VIT. B x 6 hours regulated
to 56-57 gtts/min @; Ketorolac 30 mg IV q8 endorsed;
Metronidazole 500 mg IV q8 endorsed; discontinued Nubain 5 mg
IV; Tramadol 50 mg SIVP given; Cefoxitin (Monowel) 2 g IV now
given; informed next shift surgical ward nurse regarding scheduled
medications.

R: Patient’s settled in the room; vital signs checked and monitored


at a normal range; secured patient’s safety and wellness; referred.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513
9:00 pm D: temperature of 37 c/axilla @9pm.
10:00 pm
A: assessed patient; TSB done; monitored vital signs q4 hours.

R: Patient’s knowledge increased for her operation; increased


patient’s satisfaction; increased collaboration between NPI.

NURSE’S NOTES

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________


GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________
Date-Shift FOCUS Data – Action – Response

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