Patient’s Name: _____________________________ Ward:_________ Room & Bed No.

:__________________ Chart

No:

Date/Time Shift.Time Entry

1/18/21 7-3 7:00 am Received patient asleep lying on the bed.

With dressing on the right lower abdomen dry and intact.

With an IVF of D5LR 1L running @ 80cc/hr due 12 nn.

Intake level 700 cc infusing well over left basilic vein.

With foley catheter French 12 attached to Uro bag.

Still available 1 unit RBC blood type 0+ at laboratory as standby only.

Still for repeat CBC, electrolytes, magnesium. Tomorrow AM encoded.

With follow up chest X-ray result.

IVF to follow D5LR 1L at 60 cc/hr.

Maintain on NPO.

7:30 Bed linens well tucked. Side rails checked and locked.
8:00 am Vital signs checked and recorded: Temperature 38.8 ̊C, BP 140/90. NOD aware

Intake and output taken

Pain in the area of surgery verbalized by the patient, bleeding noted.

Facial grimacing, muscle guarding, moaning noted.

8:10 Wound cleaned, dressing changed.

Uro bag changed, drained yellow colored urine, 500 cc.

8:30 TSB rendered.

Bed elevated to semi fowler’s for comfort.

9:00 Vital signs checked: T 36.4, BP 120/80

Health teaching rendered to watcher, such as:

 Maintain on NPO
9:30
 Encourage deep breathing exercises
 Avoid touching abdomen.

10:00 Patient’s pain alleviated, no facial grimacing, muscle guarding, moaning noted.

10:30 Chest X-ray results received, NOD aware, Dr. Lim aware.

11:00 Seen and examined by Dr. Lim, with orders made.

11:20 Given cefuroxime 250 mg via IV infusion, as ordered

11:50 Checked for allergic response, none noted.

Vital signs taken,

12:00
Intake and Output taken.

12:20 IVF changed, D5LR 1L at 60 cc/hr started. With good backflow.

12:45 IVF site checked, no extravasation noted.

1:30 Assessed RLQ, site of operation, no unusualities noted.

2:15 Patient is resting comfortably in bed with no unusualities noted.

2:30 Left on bed with watcher at bedside.