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    Intravenous and Blood Transfusion Set

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    Mia Zabelle V. Pascual
    The document contains medical records for a 74-year-old patient admitted to Ofelia L. Mendoza Maternity and General Hospital on July 30, 2018. It includes notes from the nursing staff recording vital signs, medications, lab tests ordered, intravenous fluids administered, and instructions provided to the patient. The patient was examined by Dr. Mendoza and prescribed a low-fat diet to manage type 2 diabetes along with various oral and intravenous medications. The records document the patient's care and treatment over multiple nursing shifts.

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    © All Rights Reserved
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    Intravenous and Blood Transfusion Set

    Uploaded by

    Mia Zabelle V. Pascual
    40 views6 pages
    The document contains medical records for a 74-year-old patient admitted to Ofelia L. Mendoza Maternity and General Hospital on July 30, 2018. It includes notes from the nursing staff recording vital signs, medications, lab tests ordered, intravenous fluids administered, and instructions provided to the patient. The patient was examined by Dr. Mendoza and prescribed a low-fat diet to manage type 2 diabetes along with various oral and intravenous medications. The records document the patient's care and treatment over multiple nursing shifts.

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    Pascual, Mia-Zabelle-V._DAY1

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    The document contains medical records for a 74-year-old patient admitted to Ofelia L. Mendoza Maternity and General Hospital on July 30, 2018. It includes notes from the nursing staff recording vital signs, medications, lab tests ordered, intravenous fluids administered, and instructions provided to the patient. The patient was examined by Dr. Mendoza and prescribed a low-fat diet to manage type 2 diabetes along with various oral and intravenous medications. The records document the patient's care and treatment over multiple nursing shifts.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    40 views6 pages

    Intravenous and Blood Transfusion Set

    Uploaded by

    Mia Zabelle V. Pascual
    The document contains medical records for a 74-year-old patient admitted to Ofelia L. Mendoza Maternity and General Hospital on July 30, 2018. It includes notes from the nursing staff recording vital signs, medications, lab tests ordered, intravenous fluids administered, and instructions provided to the patient. The patient was examined by Dr. Mendoza and prescribed a low-fat diet to manage type 2 diabetes along with various oral and intravenous medications. The records document the patient's care and treatment over multiple nursing shifts.

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    OFELIA L.

    MENDOZA MATERNITY AND GENERAL


    HOSPITAL MOJON, CITY OF MALOLOS , BULACAN

    TEL NO. (044)794-7113


    Name: N/A Age: 74 y/o Room no. N/A

    INTRAVENOUS AND BLOOD TRANSFUSION SET

    BOTTLE BLOOD TYPE OR DATE/TIME/SIGNATURE TOTAL AMT REMARKS


    NAME OF IV INFUSED BY
    NO. SOLUTION STARTED DISCONTINUE OR EACH SHIFT
    CONSUMED
    NO. INCORPORATION
    PNSS 1L July 30, 500mL infused
    1 regulated at 21 2018 in 4 hours Intact and
    gtts/min for 12hrs 6:35 AM infusing well

    LEGEND:

    NO. 1,2,3 = MAIN IV LINE I,II,III Blood transfusion


    SD = A,B,C = SIDE DRIP should be written in RED
    OFELIA L. MENDOZA MATERNITY AND GENERAL HOSPITAL
    MOJON, CITY OF MALOLOS , BULACAN
    TEL NO. (044)794-7113
    NURSES NOTES

    Name: N/A
    Room: N/A
    Date: July 30, 2018

    NURSES NOTES

    Shift: 7 am to 3 pm 1: 30 PM
    7/30/18 ⮚ Rounds back/ rounds again by Dra.
    Mendoza with new orders made and carried
    7: 6:35 AM out.
    ⮚ Received diabetic patient c̅ SAP ⮚ Low fat diet - as prescribed by the
    ⮚ PTA patient reports loss of appetite and physician.
    body weakness ⮚ Vital signs taken and recorded
    ⮚ Conscious, coherent, non-ambulatory
    ⮚ Vital signs taken and recorded
    ⮚ Seen and examined by Dra. Mendoza
    with orders and carried out. 3:00 PM
    ⮚ Consent for admission and management ⮚ Health teachings instructed
    signed and secured ⮚ Health needs attended
    ⮚ Endorsed to 3-11 shift
    9: 30 AM
    ⮚ NPO temp
    ⮚ Requested and sent to the laboratory
    >CBC pc, Urinalysis, Na, K, Hqt now,
    Hba1c, Creatinine, SGPT, CXR PA, ECG
    ⮚ PNSS 1L – started as venoclysis using IV
    cannula gauge 24 inserted aseptically at Mia Zabelle V. Pascual, S.N
    right metacarpal vein and regulated at 21
    BulSU CON Batch 2022
    gtts/min to run for 12hrs as ordered.
    ⮚ Due medications given
    ⮚ Vital signs taken and recorded every 4 hrs

    OFELIA L. MENDOZA MATERNITY AND GENERAL HOSPITAL


    MOJON, CITY OF MALOLOS , BULACAN
    TEL NO. (044)794-7113

    THERAPEUTIC SHEET

    Name: N/A Age: 74 y/o Room no. N/A

    DATE 07/30/18
    PARENTERAL
    Omeprazole OD 40 mg

    Ceftriaxone TIV q 1 gm
    12 hours, ANST
    (negative)

    Citicholine TIV 1 gm
    OD

    ORAL MEDS 07/30/18


    Mosegor vita cap 1 cap
    OD

    Heraclene TID 1 mg cap

    IV MEDS

    P.R.N. MEDS
    TREATMENTS

    OFELIA L. MENDOZA MATERNITY AND GENERAL HOSPITAL


    MOJON, CITY OF MALOLOS , BULACAN
    TEL NO. (044)794-7113

    VITAL SIGNS RECORD / INTAKE & OUTPUT RECORD

    Name: N/A Age: 42 y/o Room no. N/A

    DATE
    TIME BP P R T FHT INTAKE IV NGT MISC OUTPUT STOOL EMES NG MI
    ORAL URINE IS T SC
    07/30/2018 130/ 98 18 36.8c - - - - - - - - - -
    6:35 AM 100
    9:30 AM 130/ 89 19 36.3c
    80
    1:30 PM 120/ 83 18 36.4c
    90

    KARDEX
    Name: N/A Date of Admission: 07/30/2018 6:35 AM
    Address: N/A Operation: N/A
    Age: 74 y/o Gender: M Diet: Low fat Diet
    Diagnosis: Type 2 DM IVF: PNSS 1L to run for 12hrs
    Attending Physician: Dra. Mendoza IVF T/F: N/A

    Endorsement Medication:
    ⮚ Vital signs q 4hrs ⮚ Omeprazole OD 40 mg
    ⮚ Lab request done ⮚ Ceftriaxone every 12 hours 1 gm
    ⮚ Due medications are given ⮚ Citicholine TIV OD 1gm
    ⮚ Referred accordingly ⮚ Mosegor vita cap OD 1 cap
     Heraclene TID 1mg cap
       
     
       
       
       
       
       
       
       
       
       

    Mia Zabelle V. Pascual, S.N


    BulSU CON Batch 2022

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