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NURSE'S NOTES

Family Name First Name Date Admitted Room No. Bed No. Hosp. No.
Donatella Gador 04-21-2021
Attending Physician Medical Diagnosis Age Sex CS
Hyperthyroidism and Hypokalemia 43 y/o Male
Date/Time S/O Needs/Problem: Nursing Interventions Evaluation
Identified Potential or Actual
April 22, 2021 Received patient awake, conscious, coherent, and oriented to time and place.
2pm S "tatlong araw na ako nanghihina,  Established rapport with the patient. - Goal Met
huminga"  Monitored and recorded patient’s VS -
nagtatae at nahihirapan huminga Goal Met
po” as verbalized by the patient. * Assessed patient’s general condition - Goal Met
“Parang napaka walang kwenta ko  Placed patient with proper body
alignment
dahil sa sakit ko” as verbalized by alignment for maximum
for maximum breathing
breathing pattern.
the patient.  Instructed pt to do deep breathing
O Hooked to O2 support @ 2-3 lpm exercises
via NCS  Suctioned secretions, as necessary.
Hooked cardiac monitor with rhythm  Encouraged patient to verbalize any
of atrial fibrillation concern.
C IVF D5NSS 1L x 24 hrs hooked  Helped pt with ADLs, as necessary
@ right cephalic vein  Monitored and explained to the pt
V/S: the need for IVF
T 38.5 C  Weighed patient daily
BP 90/60 mmHg  Assess capillary refill
HR 111 bpm  Instruct to avoid strenuous
RR 25 cpm activities
O2 Saturation 95%  Monitor intake and output
(+) dry skin on both upper and  Assessed skin turgor & oral mucous
lower extremities membranes for signs of dehydration.
(+) Body weakness  Monitored ventilator effort
(+) pallor  Instructed pt about food rich in Iron
(+) pale in color palpebral  Discouraged sitting/standing for long
conjunctiva periods and wearing constrictive
(+) oral mucosa is slightly dry clothing
(+) productive cough (yellowish)  Provideed optimal rest for the patient
9 crackles on both lung field
(+)  Encouraged quiet and restful
(+) Grade 4+ (bounding) pulse atmosphere
(+) hyperactive bowel sounds  Regulated IVF as ordered
LABORATORY RESULTS:  Encouraged a positive mental
perspective,
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SGPT – 15.3 U/L perspective, discourage negative

Potassium – 3.44 thoughts and brace patient for
HGB – 106 negative results.
HCT – 0.33  Encouraged the patient to recognize
RBC – 5.18 his or his
recognize her own
own strengths
strengths and
and abilities.
abilities.
WBC – 12.6 weaknesses.
PLT – 95  Acknowledged acceptance of
Segmenters – 0.79 expression
expression of feelings.
of feelings.
Lymphocytes – 0.04  Promoted an attitude of realistic
Monocytes – 0.17 hope.hope.
A1 Ineffective breathing pattern r/t  Administered the prescribed
presence of pulmonary medication by the physician
secretions as evidenced by
presence of crackles on both
lung field and dyspnea
P1 By the end of the shift, the patient
will demonstrate a decrease of
RR from 25cpm to 20-22cpm
A2 Hopelessness r/t inability to cope
with the disease process as
evidence of the patient
feeling worthless
P2 By the end of the shift, the patient
will verbalize s/sx of increasing
anxiety
A3 Ineffective tissue perfusion r/t
decreased hemoglobin
concentration in the blood
P3 By the end of the shift, the patient
will demonstrate a decrease of
HR from111bpm to 80-100bpm.
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