DATE/TIME FOCUS D = DATA A = ACTION R= RESPONSE

October 24, Initial Assessment D - Arrived at ER, a 40-year-old female, awake,

2020 restless but coherent accompanied by sister via
8:00 AM wheelchair with chief complaints of body weakness,
abdominal pain, hematochezia, odynophagia and
purple spots inside the mouth.
A - Ushered to bed; Assisted to comfortable
position. Raised and locked siderails. Vital signs
taken and recorded as follows - BP: 80/60mmHg, PR:
65 bpm, RR: 20cpm, Temp: 36.2 C, and O2 Sat of 90%.
Seen and examined by ER ROD with orders carried
out. Secured consent for admission signed by
patient. Referred/ Facilitated CBC plt, blood typing,
APTT, PT, bleeding time, & One-stage factor Assay:
Intrinsic Coagulation System determination laboratory
and diagnostic exams STAT.
8:05 AM Started IVF of D5LR IL regulated at 20gtts/min, infusing
well with IV cannula gauge 20 at right metacarpal vein.
8:10 AM Administered Tranexamic Acid 500 mg via IV. ----------------
8:20 AM Fluid Volume Deficit D – “Nagiinuro ako hin dugo ngan nanhahagkot na
gad ako baga ako hiton mahihimatay di nala
maiha.” As verbalized. BP: 80/60 mmHg, PR: 65
bpm, Temperature: 36.2 C, O2 saturation: 90%
room air. Restless, reports of fatigue, dizziness and
light headedness. Cold, clammy skin. Capillary refill
more than 3 < seconds. Hemoglobin: 6 g/dl, Weight
65 kg. VIII inhibitor level of 59.7 bethesda units.
A - Monitored vital signs particulary BP ,HR and
Temperature; Asessed for any alteration in mental
status; provided monitoring sheet & calibrated bottle for
urine collection; Documented color and amount of urine
and noting especially for urine output less than 30
mL/hour; Identified the possible cause of the fluid
disturbance or imbalance; Monitored closely for signs of
circulatory overload; Monitored for the existence of
factors causing deficient fluid volume; Urged the patient
to increase fluid intake to at least 10 – 12 glasses or 1-2
liters per day; Encouraged SO to assist with feedings, as
necessary; Emphasized importance of oral hygiene;
Provided comfortable environment and light sheets;
8:30 AM Started Methylprednisolone 60 mg IV as ordered. ----------
8:45 AM Started Iron sucrose 200mg IV diluted to 100 mL PNSS. ---
9: 00 AM R – “Mas mauru-upay na po it akon inaabat yana.” As
verbalized. Reported decrease in restlessness, dizziness
and light headedness.
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9: 10 AM Post transfer D - Received from ER via wheelchair. Awake and
assessment slightly restless but coherent with an ongoing IVF of
D5LR IL regulated at 20gtts/min, infusing well with IV
cannula gauge 20 at right metacarpal vein. -------------------
A - Transferred to bed accompanied by sister and
placed in a comfortable position. Vitals signs taken
and recorded as follows: BP: 80/60 mmHg, PR: 65
bpm, Temp: 36.2 °C, and O2 Sat of 90%. Secured with
side rails up and locked. Oriented with regards to
hospital and ward policies. Encouraged verbalization
of feelings and concerns. ------------------------------------
9:20 AM Acute pain D - “Kanina pa ini nagsisinakit na akon tiyan, baga
hin diri nawawara” as verbalized. Dull, aching pain
on the umbilical region of the abdominal area, 9/10
on Pain Rating Scale (with 10 being the highest and
1 being the lowest), Guarding behaviors, Facial
grimace and restlessness, BP of 80/60 mmHg, HR of
65 bpm, and RR of 20 cpm, Hgb of 6 g/dL, Hct of
33%, bleeding time of 11 minutes, aPTT of 35-48
seconds, PT of 12 seconds. -------------------------------
A - Performed a comprehensive assessment of pain.
Determined the characteristics, onset, location,
duration, severity, pattern, and associated factors;
Observed for nonverbal pain cues, such as body
positioning, reluctance to move, facial expressions,
and physiological manifestations of acute pain-
elevated BP, tachycardia, and increased respiratory
rate; Explored alternative pain relief measures, such
as relaxation techniques, biofeedback, meditation,
and distraction- visual, auditory, tactile, kinaesthetic,
guided imagery, and breathing techniques; Provided
support for and careful positioning; Established a
quiet environment; Applied cold compress to
umbilical region, Monitored cardiovascular and
respiratory status prior to administration of tramadol,
a opiate analgesic; -----------------------------------------
9:35 AM Administered Tramadol 50 mg IV. ----------------------