Scribd
Upload
224 views5 pages

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

Nurse's notes for 35-year-old female patient Vicky Medina admitted for thyroidectomy. Upon admission, her vitals were within normal limits and physical exam revealed signs consistent with hyperthyroidism including a fine tremor and bounding cardiac impulse. She was anxious but skin was warm and moist. Three nodules were found in her thyroid gland. She was prepared for surgery, consent was obtained, IV fluids and medications were administered, and labs were ordered. She was transferred to the surgical ward and monitored post-operatively, with temperature and vital signs remaining normal. Her knowledge and satisfaction increased through nursing care and collaboration.

Uploaded by

Renea Joy Arruejo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
224 views5 pages

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

Nurse's notes for 35-year-old female patient Vicky Medina admitted for thyroidectomy. Upon admission, her vitals were within normal limits and physical exam revealed signs consistent with hyperthyroidism including a fine tremor and bounding cardiac impulse. She was anxious but skin was warm and moist. Three nodules were found in her thyroid gland. She was prepared for surgery, consent was obtained, IV fluids and medications were administered, and labs were ordered. She was transferred to the surgical ward and monitored post-operatively, with temperature and vital signs remaining normal. Her knowledge and satisfaction increased through nursing care and collaboration.

Uploaded by

Renea Joy Arruejo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 5

NURSE’S NOTES

SURNAME:____MEDINA___________________________ M.I.:__S____ AGE:__35____ HOSPITAL NO.:_0002345__


GIVEN NAME:____VICKY__________________________________ SEX:__F____ WARD/ROOM NO.:_____218______

Date-Shift FOCUS Data – Action – Response


05-22-2021 For D: Admitted a 35 y/o female patient for Thyroidectomy,
8:00 am Thyroidecomy accompanied by her significant other with initial VS as follows:
08:30 am BP: 130/60 mmHg
08:45 am PR : 92 bpm
RR: 20 cpm
Temp: 36.4
Appeared anxious, with a smooth, warm, and moist skin, a fine
tremor, a bounding cardiac apical impulse, a pulmonic flow
murmur, couldn’t rise from deep knee bend without aid. Thyroid
contained 3 nodules, being firm consistency, and no
lymphadenopathy, eyes were not prominent, and no focal skin
thickening.

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


side rails raised; seen and examined by ER physician (Dr.
Bermudez) with orders made and carried out accordingly; consent
to care and hospitalization secured; started IVF of D5LRS 1L x 8
hours for 2 cycles inserted aseptically at right metacarpal vein
regulated to 31-32 gtts/min.@; Instructed NPO 8 hours PTOR;
Endorsed schedule for OR @ 3pm; Notified Dr. Mendoza for CP
clearance, Dr. Cruz for endo clearance, and Dr. Rose for
anesthesia; Ampicillin Sulbactam 1.5 gm ANST given; Ketorolac
for skin test prior to OR administered; changed IV cannula to
gauge 8; 1 PRBC standby in the lab and request for laboratory for
H&H.

R: Transferred to surgical ward in a private room at 8:45 am via


stretcher, endorsed accordingly.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

.
D: temperature of 37 c/axilla @9pm.

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

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy