Scribd Logo
Upload

Welcome to Scribd!

  • 67 views

    Ofelia L. Mendoza Maternity and General Hospital Nurses Notes

    Uploaded by

    Mia Zabelle V. Pascual
    1) A patient was received at OFELIA L. MENDOZA MATERNITY AND GENERAL HOSPITAL complaining of epigastric pain radiating to the back. 2) The patient was examined, administered IVF and medications, and had lab tests requested based on orders from Dr. Mendoza. 3) Throughout the day, the patient's vital signs were monitored regularly and medications were administered as prescribed, with teaching also provided. The patient was endorsed to the next nursing shift.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Ofelia L. Mendoza Maternity and General Hospital Nurses Notes

    Uploaded by

    Mia Zabelle V. Pascual
    67 views3 pages
    1) A patient was received at OFELIA L. MENDOZA MATERNITY AND GENERAL HOSPITAL complaining of epigastric pain radiating to the back. 2) The patient was examined, administered IVF and medications, and had lab tests requested based on orders from Dr. Mendoza. 3) Throughout the day, the patient's vital signs were monitored regularly and medications were administered as prescribed, with teaching also provided. The patient was endorsed to the next nursing shift.

    Original Title

    Pascual, Mia-Zabelle-V._DAY2

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    1) A patient was received at OFELIA L. MENDOZA MATERNITY AND GENERAL HOSPITAL complaining of epigastric pain radiating to the back. 2) The patient was examined, administered IVF and medications, and had lab tests requested based on orders from Dr. Mendoza. 3) Throughout the day, the patient's vital signs were monitored regularly and medications were administered as prescribed, with teaching also provided. The patient was endorsed to the next nursing shift.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    67 views3 pages

    Ofelia L. Mendoza Maternity and General Hospital Nurses Notes

    Uploaded by

    Mia Zabelle V. Pascual
    1) A patient was received at OFELIA L. MENDOZA MATERNITY AND GENERAL HOSPITAL complaining of epigastric pain radiating to the back. 2) The patient was examined, administered IVF and medications, and had lab tests requested based on orders from Dr. Mendoza. 3) Throughout the day, the patient's vital signs were monitored regularly and medications were administered as prescribed, with teaching also provided. The patient was endorsed to the next nursing shift.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 3

    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: January 7, 2019
    NURSES NOTES
    Shift: 7 am to 3 pm 1/08/19
    1/07/19 6: 00 AM
    ⮚ Received patient awake on bed.
    7: 9:10 AM ⮚ With ongoing IVF D5LR 1L inserted on the
    ⮚ Received patient c̅ a chief complaint of right metacarpal vein and regulated at 31
    epigastric pain few hours and radiating at the gtts/min to run for 8 hours as ordered.
    back, prompted consult. ⮚ Rounds back/ rounds again by Dra. Mendoza
    ⮚ Conscious and coherent, in pain with orders made and carried out.
    ⮚ Vital signs taken and recorded ⮚ Vital signs taken and recorded
    ⮚ Seen and examined by Dra. Mendoza with ⮚ Administered Paracetamol 300 mg IV STAT as
    order and carried out. prescribed by the physician.
    ⮚ Consent for admission and management ⮚ Due medications given
    signed and secured
    11: 10 AM 1:00 PM
    ⮚ NPO temporarily-instructed to patient ⮚ Rounds back/ rounds again by Dra. Mendoza
    ⮚ Requested and sent to the laboratory with new orders made and carried out.
    >CBC, UA, whole abdominal ultrasound. T: 37.6c ⮚ Vital signs taken and recorded
    ⮚ D5LR 1L – started as venoclysis using IV ⮚ Administered Paracetamol 500mg every 4 hours
    cannula gauge 24 inserted aseptically at right as needed per doctor’s order.
    metacarpal vein and regulated at 31 gtts/min ⮚ Health teachings instructed
    to run for 8hrs as ordered. ⮚ Health needs attended
    ⮚ Due medications given ⮚ Endorsed to 3-11 shift
    ⮚ Vital signs taken and recorded every 2 hrs
    1: 10 PM
    ⮚ Rounds back/ rounds again by Dra. Mendoza
    with new orders made and carried out.
    ⮚ Light meal diet (crackers) as prescribed by
    the physician. Mia Zabelle V. Pascual, S.N
    ⮚ Vital signs taken and recorded
    3:00 PM BulSU CON Batch 2022
    ⮚ Health teachings instructed
    ⮚ Health needs attended
    ⮚ Endorsed to 3-11 shift

    Mia Zabelle V. Pascual, S.N


    BulSU CON Batch 2022
    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
    01/07/2019 130/ 90 20 36.8c - - - - - - - - - -
    9:10 AM 90
    11:10 AM 120/ 82 19 36.3c
    90
    1:10 AM 120/ 78 18 35.6c
    70
    01/08/19 130/ 99 18 38.4c
    6:00 AM 90
    1:00 PM 120/ 88 19 37.6c
    90

    KARDEX
    Name: N/A Date of Admission: 01/07/2019 9:10 AM
    Address: N/A Operation: N/A
    Age: 42 y/o Gender: M Diet: Light Meal Diet
    Diagnosis: Cholecystitis/UTI IVF: D5LR 1L to run for 8hrs
    Attending Physician: Dra. Mendoza IVF T/F: N/A

    Endorsement Medication:
    ⮚ Vital signs q 2hrs ⮚ Paracetamol 300 mg IV STAT then every
    4 hours as needed for T>38.5C
    ⮚ Lab request done ⮚  Paracetamol 500mg every 4 hrs as needed
    for T> 37.5
    ⮚ Due medications are given
    ⮚ Light meal diet
     
       
     
       
       
       
       
       
     
     
     
     

    Mia Zabelle V. Pascual, S.N


    BulSU CON Batch 2022

    You might also like