GENERAL SANTOS DOCTORS’ HOSPITAL, INC.

National Highway, General Santos City

NURSES NOTES
Patient’s Name: SARMI, LEA Age: 67 Sex: FEMALE Hosp #:_______
Attending Physician: DR. M Room / Ward: 145

DATE TIME NURSING DIAGNOSIS S – subjective

O – objective
P – planning
I – intervention
E - evaluation
08/25/20 8:00 AM  Risk for Deficient Fluid S: “Naka apat ako ng suka
Volume related to nausea and tapos medyo basa ang tae ko at
vomiting. mabaho”.

O: Received patient on bed,

awake, responsive and
coherent; with IVF of Lactated
Ringer 1L inserted at Left
Metacarpal Vein, infusing @ 25
gtts/minute and well regulated.
Facial Grimace and dry lips
noted.

P: After 8 hours of nursing

intervention there will be no
hypovolemic shock and no
dehydration will be noted.

9:00 AM I: Established rapport.

VS taken and recorded,
Bedside care done; Bed linens
tucked well, Meal Served and
able to consume half of the
meal.

9:30 AM Due meds given by the nurse

on duty,

10:00 AM Emphasized to patient the

importance of low salt, low fat.
Monitored HGT as ordered.

1:00 PM Health teaching is given to the

Patient:

- Avoid foods that can cause

dehydration e.g. coffee, tea.
- Encouraged to eat foods with
high fluid content e.g.
watermelon, grapes.
- Encouraged to increase Fluid
intake.
 Kept monitored; side rails up all
2:00 PM the time, linens tucked.

E: Goal met; Endorsed to the

3:00 PM NOD for continuity of care.

GENERAL SANTOS DOCTORS’ HOSPITAL, INC.

 National Highway, General Santos City

NURSES NOTES
Patient’s Name: LOU, CORA Age: 69 Sex: FEMALE Hosp #:_______
Attending Physician: DR. BALAY Room / Ward:_____________________

DATE TIME NURSING DIAGNOSIS S – subjective

O – objective
P – planning
I – intervention
E - evaluation
08/25/20 8:00 AM Constipation related to S: “Hindi ako madalas nakaka
decreased dietary intake. dumi nitong mga nakaraang
araw”

O: Received patient on bed,

awake and responsive; with IVF
of D5LR 1L With the IVF
infusing well @ 25 ggts/min and
well regulated @ Right
metacarpal vein. Abdominal
pain and cramping noted.
Abdominal bloating and
distention noted.

8:30 AM P: After 8 hour of nursing

interventions, the patient will
establish or Return normal
patterns of bowel functioning.

9:00 AM I: Established rapport.

VS taken and recorded Q4,
bedside care done; linens fixed
and tucked well.

Determine stool color,

consistency, frequency and
amount.

Instruct the patient for

preparation for colonoscopy:

-The patient should follow a

special diet the day before the
exam. E.g: plain water, tea and
coffee without milk or cream,
broth, and carbonated
beverages.

Meal served and able to consume

10:30 AM the meal. Due meds given by the
 nurse on duty.

IVF checked and regulated at

prescribed rate.
12:00 NN
Meal Served and able to consume
the meal.

Health teaching is given to the

1:00 PM patient:

-Encourage Fluid intake of

2500-3000 ml/day if not
contraindicated medically.
-Advice to take at least 20g of
dietary fiber e.g. raw fruits, fresh
vegetables, whole grains per
day.
-Advice to avoid gas forming
foods. E.g. beans, asparagus,
lentils.
-Instructed the patient to NPO in
Post-midnight for preparation on
colonoscopy.

Kept monitored and watched for

2:00 PM unusualities, linens fixed and
tucked, IVF checked and
regulated.

E: Goal met, evidenced by

3:00 PM patient reported the return of
normal patterns of bowel
functioning. Endorsed to NOD
for continuity of care.