Nurse’s Notes

Patient’s Name: Hannah Magallon Ward: St. Mary Room & Bed No: 207-B

DATE/SHIFT TIME NURSE’S NOTES

09/08/2020 7:00 am Received lying on bed, conscious, coherent and responsive to any stimuli
7-3 SHIFT
With mainline IVF of D5LR 1L at 350cc remaining on the right cephalic vein at 40
cc/hr
7:30 am VS checked: Temp: 37.9℃ , RR: 28cpm, BP: 120/80mmgH, CR: 94bpm
With cough and colds
With CC of “Miss, gipanugnaw gud ko”
With cold environment and patient is shivering and drowsy
With skin warm to touch, dry lips and weak
Provided with blanket and lowered room temperature
Provided with calibrated glass to drink lots of water
Health teachings imparted with emphasis on:
a. Changing of clothes when wet
b. Small frequent feeding with Vitamin C rich food
8:00 am Carried out TSB
8:10 am Administered ordered medication; Paracetamol 500 mg 1 tab q4h RTC
9:00 am Measured urine output at 200 cc; light yellow colored urine
9:30 am Temperature rechecked, 37.3℃

Jennifer D. Condiman, St.N./ CI’s Signature/ NOD’s Signature

 FOCUS CHARTING

DATE/TIME FOCUS PROGRESS NOTES

09/08/2020 Fever D:
7:30 am Temperature of 37.9℃
With cough and colds
Skin warm to touch
A:
Provided blanket and lowered the room temperature
Encouraged oral fluid intake
Encourage to change clothes when wet
Encourage to have small frequent meals
8:00 am Performed TBS
8:10 am Administered 500 mg Paracetamol q4h RTC as per ordered
9:30 am R:
Temperature decreased from 37.9℃ to 37.3℃

Jennifer D. Condiman, St.N./ CI’s Signature/ NOD’s Signature