COURSE IN WARD

Date and time/ Shift Focus Progress Notes

March 15, 2021 Admission D: Admitted a 55-year old female
7-3 Shift with a chief complaint of frequent
8:00 am urination, dizziness for 3 days,
fever and a non-healing wound on
her right foot.
BP: 150/90mmHg
RR: 86 bpm
PR: 29cpm
T: 39.8 C
A: Seen and examined by Dr. VS,
consent for admission secured.
Hooked PNSS 1L 20gtts/min for 10
hours. Lab request for CBC
HbA1c, Urinalysis, Fasting Blood
Glucose forwarded.
Medication:
Metformin 500mg TID
Tylenol 500 mg PO q6hr PRN.;
Clindamycin 300mg PO q6hrs;
Becaplermingel ; Simvastatin 10mg
PO OD every evening; Losartan
50mg OD
→ Monitor V/S every hour
→ For Wound Care
→ Follow up labs
→ Shift to DM Diet
All are as ordered.

R:
8:15am Wound Debridement D: Presence of pus, tenderness and
foul odor in the wound
A: The resident doctor removed the
dead skin even the infected part in
order to address the infection.
R:
9:45am Post transfer D: Endorsed to ward
10:00am Pain D: c/c of pain in her wound. Rates
the pain 3 on 1-10 scale
Pain assessment :
P-when moving/ touching
Q- aching pain
R- right lower plantar foot
S- 3/10
T- when moving
 A:Administered 500mg PO Tylenol
and assisted to position of comfort
and relaxation.
R: The patient feels much better.
Rate the pain of 3 on 1-10 scale.
12:00pm Wound Care D: Wound cleansing on her right
wound.
A: Cleaning the wound using saline
and getting a cloth a wiping all
around the wound. Keeping the
wound from being moist. After
cleaning it becaplermin gel was
applied and hydrogel dressing was
used for covering the wound. The
patient also instructed not to put
pressure on her right foot, not to
walk with bare foot. If needed to go
to the bathroom ask assistant from
SO.
R: The patient feels okay after
cleaning the wound and follow the
instructions.
3-11pm Shift D:Patient was move on her room
3:00pm and was lying on bed; awake;
conscious and coherent with an
ongoing intravenous fluid of #1
PNSS 1L regulated 20 gtts @ 350cc
level infusing on the right
metacarpal vein with an intact dry
wound dressing on the right foot;
with good skin turgor; febrile; with
pinkish palpebral conjunctiva.
Vital sign was monitored with a
data of
T- 37.9 C
PR-85bpm
RR- 20cpm
BP- 140/90mmHg

A:Administered Tylenol 500mg as

3:10pm Elevated Temperature per doctor’s order. Performed tepid
sponge bath. Provided calm
environment to keep patient
comfortable
 R:Temperature decreased to 37.5C
4:05pm
7:00pm D:Patient was lying on bed; awake,
conscious, alert and coherent. #2
PNSS 1L was regulated 20gtts/min
for 10 hours. The IV is regulating
well on her right hand well intact
and no sign of swelling or redness.
The wound dressing on her right
foot is well intact and dry and
yellow to amber in color urine.
Vital sign was monitored with a
data of
T- 37.5 C
PR-85bpm
RR- 20cpm
BP- 140/90mmHg

7:05pm
A: Administered Tylenol 500mg.

8:05pm R: The patient decreased

temperature to 37.4C
9:00pm D: Administer medications
A: Administered Simvastatin 10mg
and Losartan 50mg. Instructed the
patient to drink the Simvastatin at
night
10:00pm Temporary NPO D: Patient is for Fasting blood
glucose at 6am
A: Instructed the patient not to
drink or eat anything before 6am.
March 16, 2021 D: #3 PNSS 1L regulated @20
11-7am Shift gtts/min. Patient is lying in a supine
3:00am on bed without interrupting sleep
→Vital sign was monitored with a
data of
T- 37.6 C
PR-86bpm
RR- 19cpm
BP- 140/90mmHg

A:Placed comfortably on bed with

 side rails up
6:00 am For Fasting Blood D: For Blood Extraction
Glucose A: Instructed the patient to remain
calm to extract blood easily.
R: Patient follows the instruction
6:15am D: Pre meal CBG
A:Patient was instructed for CBG
before meals with result of
135mg/dl. And instructed the
patient that she is already allowed
to drink and eat the prescribed DM
diet for her.

R: Patient was eating the meal that

6:50am the hospital prepared and follows
all the instructions given to her.
7-3pm shift D:Patient is lying supine on bed
7:15am awake while watching television;
conscious and coherent with an
ongoing intravenous of #3 PNSS
1L regulated @ 20gtts @150 cc
level infusing well on right
metacarpal vein with an intact dry
wound dressing on the right foot;
with good skin turgor; febrile; with
pinkish palpebral conjunctiva.
Vital signs taken and recorded:
T – 37.8 C
PR – 96 bpm
RR – 22 cpm
BP – 140/90 mmHg
She has 3 of pain in a scale of 1-10

A: Mrs. DM received medications

7:25am of Metformin 500mg, Tylenol
500mg and Clindamycin 300mg
q6hrs. Patient was also given tepid
sponge bath.

R: Patient rate the pain of 2 in a

scale of 1-10 and the temperate
8:15am lowers 37.5

10:00am D: #4 PNSS IVF 1L was given and

was regulated @20gtts. Proper
hygiene was emphasized. Initial
 Vital sign was monitored with a
data of
T- 37.6 C
PR-86bpm
RR- 19cpm
BP- 140/90mmHg

A: Assisted Dr. VS for her bed side

10:30am assessment. Orders made and
carried out properly. Monitor Blood
Glucose before meal
Resume DM diet; Daily Wound
Care; Monitor V/S every hour and
record. Continuation of medication
Metformin 500mg TID; Tylenol
500 mg PO q6hr PRN and
Clindamycin 300mg PO q 6hrs;
Becaplermin gel; Simvastatin 10g
PO OD every evening; Losartan
50mg OD.
All are as ordered.
11:00am Wound Care D: Wound cleansing on her right
plantar foot wound.
A: Cleaning the wound using saline
and getting a cloth a wiping all
around the wound. Keeping the
wound from being moist. After
cleaning it becaplermin gel was
applied and hydrogel dressing was
used for covering the wound. The
patient was also instructed not to
put pressure on her right foot, not to
walk with bare foot. If needed to go
to the bathroom ask assistant from
SO.
R: The patient feels okay after
cleaning the wound and follow the
instructions given.
11:25am D: For medication

A: Mrs. DM received medication,

Tylenol 500mg. Patient side rails
was raised. Patient was given a safe
and calm environment, and was
instructed to increase fluid intake.
 11:30am Random Blood Glucose D: Pre meal CBG
A:Patient was instructed for CBG
before meals with result of
135mg/dl. Instructed the patient the
food that or the diet that she should
follow.
12:15pm R: Patient was seen eating the meal
that was prepared for her. She was
able to consume everything.
Shift 3-11pm D:The patient received alert, and
3:10pm coherent, giving full and detailed
responses to all of the questions
asked. Vital Signs were taken and
Recorded as follows
T- 36.1‘C
PR- 96 bpm
R- 20 cpm
BP – 140/90 mmHg.
A:Instructed the patient to keep the
right foot elevated and not to put
pressure on her right foot. Also
instructed the patient to ask
assistant in going to the bathroom
or use a wheel chair or crutches to
walk for assistance if no one is
around.
7:10pm A: #5 PNSS IFV 1L was given and
regulated @20 gtts/min.
9:00pm A:Simvastatin 10mg, and Losartan
50 mg was given. Patient was
instructed to drink simvastatin at
night and increase fluid intake.
March 17, 2021 D:→#6 PNSS IVF 1L was given.
11-7am shift At 7:00 am #6 IVF is still
2:00am regulating @600cc level. Patient
was on bed, awake, alert, and
coherent
Shift 7-3pm D:Patient is already afebrile. Vital
10:00am Signs were taken and recorded as
follows
T – 36.1 C
PR – 80 bpm
RR – 20 cpm
BP – 140/90 mmHg.
Monitoring Blood Glucose result
before meal is 140mg/dl.
A:

10:45am Wound Care D: Daily Wound care on her right

wound.
A: Cleaning the wound using saline
and getting a cloth and wiping all
around the wound. Keeping the
wound from being moist. After
cleaning it becamplermin gel was
applied and hydrogel dressing was
used for covering the wound. The
patient also instructed not to put
pressure on her right foot, not to
walk with bare foot. If needed to go
to the bathroom ask assistant from
SO.
R: The patient feels okay after
cleaning the wound and follow the
instructions.
11:00am D:Patient awake lying on bed;
conscious and coherent; with on-
going IVF of PNSS at 300cc level
inserted on the right metacarpal to
run for 8 hours
Initial Vital signs were check with a
data of
T – 36 C
PR – 83 bpm
RR – 20 cpm
BP – 140/90 mmHg.
A: Assisted Dr. VC for her daily
bed assessment for Mrs. DM.
Orders has made and carry out
properly. Monitor V/S every 4
 hours
Daily Wound Care
IV fluid continue
Accurate V/S and record
Continue regular DM diet
Continue prescribe meds. All as
ordered.
12:30 pm A:→#7 PNSS IVF 1L was given
and regulated @ 20gtts/min
3:00pm D:For medication and Vital Signs
were taken and recorded as follows
T – 36 C
PR – 85 bpm
RR – 20 cpm
BP – 130/90 mmHg.
A: Administered Metformin 500mg
and clindamycin 300mg PO q6hrs

Shift 3-11pm A:→#8 PNSS IVF 1L was given

8:30 pm and regulated @ 20gtts/min

9:00pm D: For medication

A:Simvastatin 10mg was given.
Patient was instructed to drink
Simvastatin at night with meals
March 18,2021 D:#9 PNSS IVF 1L was given. At
11-7am shift 7:30 am patient received Metformin
4:30 am 500mg TID, and Clindamycin
300mg PO q6hr. Proper hygiene
was emphasized and the site was
kept dry.
7-3pm shift Wound Care D: Daily wound care on her right
10:10 am foot
A:Wound was cleanse with a saline
solution and used a becaplermin gel
and a hydrogel dressing to cover
the wound. Patient was instructed
to keep foot elevated. Monitoring
Blood Glucose result before meal is
135mg/dl.
A:
R:The patient feels okay after
cleaning the wound and follow the
instructions.
12:30 pm D:#10 PNSS 1L was given.
Vital sign was check with a
 T-36.7C,
BP- 120/80mmHg
RR- 18cpm
PR- 85bpm
A: Administered Metformin 500mg
3-11pm shift D:The patient received in bed
3:15 pm sitting while watching the
television. #10 PNSS is well
regulating and well intact to the
metacarpal vein. Patient has less
pain on the wound.
A: Assisted Dr. VC for her daily
bed assessment for Mrs. DM.
Orders has made and carry out
properly. Monitor V/S every 4
hours
Daily Wound Care
IV fluid continue
Accurate V/S and record
Continue regular DM diet
Continue prescribe meds. All as
ordered.
7: 25 pm D:Patient was done eating and was
able to consume the food that was
prepared.
A: Administered Metformin 500mg
TID
8:30 pm D:#11 PNSS 1L was received and
client was reminded on her diet
which is DM diet and proper
hygiene was emphasize.
9:00 pm A:Simvastatin 10g PO, and
Losartan 50mg was given.Patient
was instructed to increase fluid
intake.
March 19, 2021 A:#12 PNSS IVF 1L was given
11-7 am shift
4 am
7:00 am D:Patient vital signs have been
monitored with a data of
T – 36.6
CPR – 89bpm
RR – 17cpm
BP – 120/80 mmHg. Monitoring
Blood Glucose result before meal is
130mg/dl.
7-3pm shift D: For medication
7: 30 am A: Administered Metformin 500mg
TID, and Clindamycin 300mg PO
q6hr
10:00 am Wound Care D: Daily wound care on her right
foot site.
A:Proper hygiene was emphasized
and the site was cleanse with saline
and used a becaplermin gel and a
hydrogel dressing to cover the
wound and it was kept dry.
R:The patient feels okay after
cleaning the wound and follow the
instructions. The site has less pain
and the discharge has lessen
11:00 am D: Patients vital signs have been
monitored with a data of
T- 36.5
CPR-85 bpm
RR- 17 cpm
BP- 120/90 mmHg
A: Administered Metformin 500mg
TID
12:00pm D:#13 PNSS 1L was given.
Monitoring Blood Glucose result
before meal 130mg/dl.
1:30 pm D:Received the patient in a supine
position, the IVF is regulating and
properly intact on right hand of the
patient
A:Assisted Dr. VC for her daily
bed assessment for Mrs. DM.
Orders has made and carry out
properly. Monitor V/S every 4
hours
Daily Wound Care
IV fluid continue
Accurate V/S and record
Continue regular DM diet
Continue prescribe meds. All as
ordered.
3-11pm shift D:Patients vital signs have been
3:15 pm monitored with a data of
T- 36.8
CPR-88 bpm
RR- 17 cpm
 BP- 120/90 mmHg
7:00 pm D:Seen the patient eating. Was able
to consume of the prepared meal
given to her. Patient was instructed
to increase fluid intake and diet was
emphasize.
9:00 pm D:#14 PNSS 1L was received and
client was reminded onher diet
and proper hygiene.
A: Administered Simvastatin 10mg
PO and
Losartan 50mg
11:00 pm D:Received the patient sitting,
listening and laughing with her
family. The wound has less
appearance of pus. IVF is well
regulating and well intact to the
right metacarpal vein.
March 20,2021
11-7 am shift D:Patient was in a supine position
2: 05 am while having an uninterrupted
sleep. Vital signs were taken and
recorded as follows:
T- 36.6
CPR-88 bpm
RR- 18cpm
BP- 120/80 mmHg
7-3pm shift D:Monitoring Blood Glucose result
7:30 am before meal is 130mg/dl
9:00 am D:Mrs. DM may go home and was
already referred for discharge

A: Assisted Dr. VC for final bed

assessment for Mrs. DM and take
note of the medications that needs
to be continued at home.
11:00 am D:Mrs. DM’s papers were already
ready for the payment. Dr. V.S.
gave her a home medication of
clindamycin 300mg PO q 6hrs and
metformin 500mg P.O. BID.
Hygiene, proper diet and wound
care was emphasized. Follow up
checkup will be on April 1, 2021.
11: 15 am D:Mrs. DM was already discharge