NURSES' NOTES

PATIENT NAME: C. Advincula AGE: 3 years old HOSPITAL NO. N/A

PHYSICIAN: Dr. Betty de la Cuesta SEX: M WARD/ROOM: PICU

DATE/TIME FOCUS D - DATA A – ACTION R – RESPONSE NURSE SIGNATURE

07/11/2021 Ineffective breathing D- The patient’s mother verbalized “Ma’am, marigatan umanges ji anak ko”
pattern  Difficulty of breathing with deep rapid breathing
8:30 am – 4:30 pm  Chest retraction
 Sunken eyes
 Nasal mucosa is boggy with clear discharge
 Chest has increased AP diameter
 Tachypnea
 Rhonchi and wheezes are heard on auscultation with chest retractions
 Vital signs are: Temp – 38.6 °C, PR- 100 bpm, BP- 85/65 bpm, O2 Sat-
90%
8:30 am A- Monitored the patient’s vital signs especially for the breathing pattern,
sound and respiratory rate.
8:35 am  Encouraged the patient to do incentive spirometry through play.
8: 37 am  Maintained head of the bed elevated.
 Made sure the patient have a period of rest between activities during
8:40 am treatment.
8: 55 am  Administered oxygen via pediatric face mask at 5 LPM as ordered by the
8:50 am doctor
 Administered nebulization with albuterol 5mg in 2 ml of normal saline,
repeat after 15 minutes for 2 doses every 8 hours.
4:55 pm R- The patient demonstrate relaxed breathing without difficulty and deep COLLADO, K. M, S.N.
rapid breathing.
 NURSES' NOTES

PATIENT NAME: C. Advincula AGE: 3 years old HOSPITAL NO. N/A

PHYSICIAN: Dr. Betty de la Cuesta SEX: M WARD/ROOM: PICU

DATE/TIME FOCUS D - DATA A – ACTION R – RESPONSE NURSE SIGNATURE

07/11/2021 Imbalanced nutrition: D- The patient’s mother verbalized “Hindi gaanong kumakain ang anak ko”
less than body  Dry skin
8:30 am – 4:30 pm requirements  Eyes are sunken
 Skin pinch going back slowly
 Appears to be weak and lethargic
 Lack of interest in food
 Weight 13.6kg
 Height is 92.1 cm
 Vital signs are: Temp – 38.6 °C, PR- 100 bpm, BP- 85/65 bpm, O2 Sat-
90%
9:40 am A- Strictly documented and monitored the vital signs, intake and output as
well as the calorie count of the patient.
9:35 am  Fed the toddler with six small nutrient-dense meals with appetizing
appearance and taste instead of three bigger meals each day without
forcing the patient to eat.
9: 37 am  Provided pleasant environment and avoid interruptions during
mealtimes. Elevate the head of the bed.
9:39 am  Encouraged the patient to drink adequate amount of water.
9: 50 am  Administered nutritional vitamins and minerals as indicated by the
doctor.
10 am  Referred to a dietician for further assessment and recommendations
regarding food preferences of the toddler and also to support nutrition.

10:30 am R- The patient was able to consume an adequate nourishment and COLLADO, K. M, S.N.
maintained consumption of adequate nourishment and weigh gained 0.3 kg.
 NURSES' NOTES

PATIENT NAME: C. Advincula AGE: 3 years old HOSPITAL NO. N/A

PHYSICIAN: Dr. Betty de la Cuesta SEX: M WARD/ROOM: PICU

DATE/TIME FOCUS D - DATA A – ACTION R – RESPONSE NURSE SIGNATURE

07/11/2021 Hyperthermia D- The patient’s mother verbalized “Madi nga bumaba tuy gurigor na tuy
anak ko”
8:30 am – 4:30 pm  Skin are hot to touch
 Shivering
 Difficulty of breathing with deep rapid breathing
 Nasal mucosa is boggy with clear discharge
 Chest has increased AP diameter
 Rhonchi and wheezes are heard on auscultation with chest retractions
 Vital signs are: Temp – 38.6 °C, PR- 100 bpm, BP- 85/65 bpm, O2 Sat-
90%
10:30 am A- Monitored the patient’s vital signs.
10:35 am  Performed tepid sponge bath.
10: 40 am  Elevated the head of the bed.
10:45 am  Advised the parents to remove excessive clothing and blankets as well as
adjust the room temperature.
10: 55 am  Administered paracetamol (Aeknil) 150 mg IV every 4 hours prn as
ordered by the doctor.
11 am R- The patient demonstrate relaxed breathing without difficulty and deep COLLADO, K. M, S.N.
rapid breathing.