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    Nurses Notes: General Santos Doctors' Hospital, Inc

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    Fran Lan
    The nurse's notes document the care of two patients, Sarmi Lea and Cora Lou, on August 25, 2020 at General Santos Doctors' Hospital. Sarmi Lea, age 67, was admitted for risk of dehydration from nausea and vomiting. Cora Lou, age 69, was admitted for constipation related to decreased dietary intake. Both patients received IV fluids, monitoring, health teaching, and met their nursing care goals by the end of the nurse's shift.

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    Nurses Notes: General Santos Doctors' Hospital, Inc

    Uploaded by

    Fran Lan
    121 views5 pages
    The nurse's notes document the care of two patients, Sarmi Lea and Cora Lou, on August 25, 2020 at General Santos Doctors' Hospital. Sarmi Lea, age 67, was admitted for risk of dehydration from nausea and vomiting. Cora Lou, age 69, was admitted for constipation related to decreased dietary intake. Both patients received IV fluids, monitoring, health teaching, and met their nursing care goals by the end of the nurse's shift.

    Original Title

    NURSES NOTES-NAVIDAS

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    The nurse's notes document the care of two patients, Sarmi Lea and Cora Lou, on August 25, 2020 at General Santos Doctors' Hospital. Sarmi Lea, age 67, was admitted for risk of dehydration from nausea and vomiting. Cora Lou, age 69, was admitted for constipation related to decreased dietary intake. Both patients received IV fluids, monitoring, health teaching, and met their nursing care goals by the end of the nurse's shift.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    121 views5 pages

    Nurses Notes: General Santos Doctors' Hospital, Inc

    Uploaded by

    Fran Lan
    The nurse's notes document the care of two patients, Sarmi Lea and Cora Lou, on August 25, 2020 at General Santos Doctors' Hospital. Sarmi Lea, age 67, was admitted for risk of dehydration from nausea and vomiting. Cora Lou, age 69, was admitted for constipation related to decreased dietary intake. Both patients received IV fluids, monitoring, health teaching, and met their nursing care goals by the end of the nurse's shift.

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    GENERAL SANTOS DOCTORS’ HOSPITAL, INC.

    National Highway, General Santos City

    NURSES NOTES
    Patient’s Name: SARMI, LEA Age: 67 Sex: FEMALE Hosp #:_______
    Attending Physician: DR. M Room / Ward: 145

    DATE TIME NURSING DIAGNOSIS S – subjective


    O – objective
    P – planning
    I – intervention
    E - evaluation
    08/25/20 8:00 AM  Risk for Deficient Fluid S: “Naka apat ako ng suka
    Volume related to nausea and tapos medyo basa ang tae ko at
    vomiting. mabaho”.

    O: Received patient on bed,


    awake, responsive and
    coherent; with IVF of Lactated
    Ringer 1L inserted at Left
    Metacarpal Vein, infusing @ 25
    gtts/minute and well regulated.
    Facial Grimace and dry lips
    noted.

    P: After 8 hours of nursing


    intervention there will be no
    hypovolemic shock and no
    dehydration will be noted.

    9:00 AM I: Established rapport.


    VS taken and recorded,
    Bedside care done; Bed linens
    tucked well, Meal Served and
    able to consume half of the
    meal.

    9:30 AM Due meds given by the nurse


    on duty,

    10:00 AM Emphasized to patient the


    importance of low salt, low fat.
    Monitored HGT as ordered.

    1:00 PM Health teaching is given to the


    Patient:

    - Avoid foods that can cause


    dehydration e.g. coffee, tea.
    - Encouraged to eat foods with
    high fluid content e.g.
    watermelon, grapes.
    - Encouraged to increase Fluid
    intake.
    Kept monitored; side rails up all
    2:00 PM the time, linens tucked.

    E: Goal met; Endorsed to the


    3:00 PM NOD for continuity of care.

    GENERAL SANTOS DOCTORS’ HOSPITAL, INC.


    National Highway, General Santos City

    NURSES NOTES
    Patient’s Name: LOU, CORA Age: 69 Sex: FEMALE Hosp #:_______
    Attending Physician: DR. BALAY Room / Ward:_____________________

    DATE TIME NURSING DIAGNOSIS S – subjective


    O – objective
    P – planning
    I – intervention
    E - evaluation
    08/25/20 8:00 AM Constipation related to S: “Hindi ako madalas nakaka
    decreased dietary intake. dumi nitong mga nakaraang
    araw”

    O: Received patient on bed,


    awake and responsive; with IVF
    of D5LR 1L With the IVF
    infusing well @ 25 ggts/min and
    well regulated @ Right
    metacarpal vein. Abdominal
    pain and cramping noted.
    Abdominal bloating and
    distention noted.

    8:30 AM P: After 8 hour of nursing


    interventions, the patient will
    establish or Return normal
    patterns of bowel functioning.

    9:00 AM I: Established rapport.


    VS taken and recorded Q4,
    bedside care done; linens fixed
    and tucked well.

    Determine stool color,


    consistency, frequency and
    amount.

    Instruct the patient for


    preparation for colonoscopy:

    -The patient should follow a


    special diet the day before the
    exam. E.g: plain water, tea and
    coffee without milk or cream,
    broth, and carbonated
    beverages.

    Meal served and able to consume


    10:30 AM the meal. Due meds given by the
    nurse on duty.

    IVF checked and regulated at


    prescribed rate.
    12:00 NN
    Meal Served and able to consume
    the meal.

    Health teaching is given to the


    1:00 PM patient:

    -Encourage Fluid intake of


    2500-3000 ml/day if not
    contraindicated medically.
    -Advice to take at least 20g of
    dietary fiber e.g. raw fruits, fresh
    vegetables, whole grains per
    day.
    -Advice to avoid gas forming
    foods. E.g. beans, asparagus,
    lentils.
    -Instructed the patient to NPO in
    Post-midnight for preparation on
    colonoscopy.

    Kept monitored and watched for


    2:00 PM unusualities, linens fixed and
    tucked, IVF checked and
    regulated.

    E: Goal met, evidenced by


    3:00 PM patient reported the return of
    normal patterns of bowel
    functioning. Endorsed to NOD
    for continuity of care.

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