Date/ Time Focus Date, Action, Response

02/11/17 0900H Admission D>Admitted a 26 years old, female, accompanied by ER

NOD via wheelchair; on nothing per orem; with ongoing
IVF of D5LR 1L x 8 hours infusing well over right hand;
to start IV medications. ---
A>Transferred to bed safely; oriented to ward policies;
medications started; referral forwarded; kept
monitored; safety ensured; all health needs attended.---
R>Admitted at bed 613.---
1000H IMPAIRED D>with diagnosis of preseptal cellulitis OS; noted
SKIN disruption of skin around left eye--
INTEGRITY A>Assessment done; demonstrated good skin and eye
hygiene like washing thoroughly with mild soap and
patting dry; lid hygiene rendered as needed; infection
1035H control measures maintained at all times; maintained
aseptic technique when applying topical medications ---
R> verbalized understanding to instructions given; skin
care rendered.---
02/12/17 0600H Post D>Received patient awake on bed; on moderate high
endorsement back rest; on diet as tolerated; no in distress; afebrile;
assessment with an ongoing IVF of D5LR 1L x 8 hours at 750cc
level infusing well at right arm, on oral and IV
medications.---
0700 H For Final MRA D>With OPD MRA of intermediate risk.---
A>Seen and examined by Dr. Bautista; with new orders
made and carried out; intermediate risk was given by Dr.
Bautista; all health needs attended; monitored
accordingly.---
0930H R>With final MRA of intermediate risk.---
02/12/17 0800H For Diagnostic D>With admitting orders made for cranial CT scan with
Procedure contrast; with request attached to chart.---
A>Assessed patient’s condition; verified doctor’s order;
forwarded request to radiology department; secured
contrast to be used; informed resident on duty regarding
patient’s schedule; all health needs attended; kept
monitored.---
0900H R>Diagnostic procedure scheduled on 01/28/17 at
1300H.---
02/12/17 0700H Eye Care D>Status post operation of left eye.---
A>Assessed condition; advised to wear goggles at all
times; due topical and oral medications given and
instilled aseptically; encouraged proper hygiene and
handwashing; advised to avoid rubbing of the operative
site; kept safe and comforted on bed; monitored
accordingly.---
0815H R>Eye care rendered
 0815H Risk for Injury D>With visual impairment noted.---
A>Assessed condition; advised patient’s relative not to
leave patient alone or unattended; kept side rails up at all
times; kept safe and comforted; monitored from time to
time.---
R>No injury noted.---
02/11/17 0900H For operation D>For FESS today at 1100; scheduled and proposed---
A>Assessed patient’s condition; vital signs taken and
recorded; re-informed patient regarding operation;
maintained on NPO; instructed patient to wear proper
OR attire, asked to remove jewelries, dentures and
clothing; checked OR proposal, checked consent;
gathered materials for OR; coordinated with OR
regarding operation; pre-operative medications given as
ordered; accomplished pre-operative checklist; vital
signs checked before and after administration of pre-op
meds; hooked to Sterofundin 1L x 125cc/hr kept safe
and comforted on bed; kept side rails up; monitored
accordingly.---
0935H R>Endorsed to OR-NOD.---
02/12/17 0800H Oral Care D> with diagnosis of avulsed wound; lower alveolus
noted; with Barton’s bandage noted---
A>Assessed patient; vital signs taken and recorded; due
oral chlorhexidine mouthwash given; imparted the
importance of oral hygiene; educated about proper
gargling technique and proper handwashing; advised to
avoid manipulation of the operative site; encouraged
ambulation and deep breathing exercises; maintained
Barton’s bandage; all health needs attended; monitored
accordingly.---
0820H R>Oral care rendered.---
02/12/17 Post Transfer D>Received patient from PACU-nurse; on moderate
Assessment high back rest; with an ongoing IVF of D5LR 1L x 8
hours at 500cc level infusing well at right arm, status
post total thyroidectomy.---