CHARISSE DL.

LIMOS
FOCUS CHARTING

Date/Time Focus Progress Notes

Dec. 1, 2011 D-Complained of pain at
2:00 am Epigastric Pain epigastric area with the pain scale
of 4/5

2:10 am A-Referred to Dr.Paa with orders

2:20 am Omeprazole 40 mg.given thru IV
Kept patient comfortable and safe

4:30 am R- Epigastric pain rechecked and

subsided to 1/5

1:00 am
Difficulty of breathing D- Complained of Difficulty of
breathing
With chest extraction
1:10 am
A-Oxygen administered via nasal
cannula at 2-3 LPM
Placed on moderate high back
rest
Maintained on bed rest

12 am Elevated temperature D- Temperature 39.1degrees

Celsius

12:15 am A-Referred to Dr. Manangbao

with orders
12:20 am Paracetamol 300mg given Thru IV
Tepid sponged bath done
Encouraged to increased oral fluid
intake
1:30 am
R- Temperature rechecked and
subsided to 37.8 degrees Celsius

3:00 am Headache D-“sobrang sakit po ng ulo ko”

with a pain scale of 5/5
3:15 am A-placed a warm towel over the
pain area
Placed in a comfortable position
3:20 am Referred to Dr. Ortiz with orders
Mannitol given 100 cc thru IV and
paracetamol as ordered
Maintained bed rest
5:00 am R- Headache rechecked and
subsided to a pain scale of 2/5

12:00 am
Elevated Blood Pressure D- Blood pressure 160/110mmHg
12:10 am
A-Placed on moderate high back
12:25 am rest
Clonidine given sublingually as
ordered
Maintained on Bed rest
1:35 am
R- Blood pressure rechecked and
subsided to 130/100mmHg

2:45 am Low Blood Pressure D- Blood Pressure 80/60 mmHg

A-Administered oxygen via nasal

cannula at 2-3 LMP
2:50 am Placed on Trendelenburg positon
3:00 am Referred to Dr. Paa with orders
Fludocortisone given thru IV
Maintained bed rest
4:00am
R- Blood pressure rechecked and
increased to100/70 mmHg

2:50 am Nausea and Vomiting D- Complained of nausea and

vomit 4x

2:55 am A-Placed to a fowlers with a side

lying position
Referred to Dr. Aniwasal with
orders
3:55 am Metoclopromide given thru IV
 Maintained bed rest

2:15 am R-complained of being

comfortable and not vomited at
all.

2:20 am Chest Pain D-“Sumasakit po ang dibdib ko” as

verbalized by the patient with the
pain scale of 4/5
2:20am
A-Referred to Dr. Ortiz with
orders
2:25 am
Isordil given 5mg sublingually
Maintained on bed rest

3:45 am R- Chest pain rechecked and

subsided to2/5

2:35 am
Nose bleeding D-“ Nagdudugo po ung ilong ko”
as verbalizedby the patient
2:40 am
A-applying pressure by pinching
patient’s nostril to lean forward
Placed an ice cold over the nose
and a piece of a gauze under the
lip
2:50 am Rferred to Dr. Ariola with orders
2:55 am Tranexamic acid 500 mg given
thru IV

2: 25 am
Gum Bleeding D-“Nagdudugo po yung gilagid
ko” as verbalized by the patient

A-Encouraged to rinse with salt

2:40 am water
Encouraged toapply pressure and
4:10 am advice not to brush it
Tranexamic acid 500 mg and
Vitamin K 1ampule given as
ordered
Maintained bed rest
3:00 am R- no bleeding noted

3:15 am Seizure D-Episode of seizure noted

3:20 am A-Placed on lateral position

Maintained airway
Referred to Dr. manangbao with
orders
3: 45 am
Acetazolamide given thru IV
2:20 am
R-Episode of seizure subsided

2:27 am
Numbness D-“Namamanhid po yung gawing
kanang bahagi ng hita ko” as
verbalized by the patient
2:30 am
A-Blood pressure 130/100mmHg
Placed on moderate high back
rest
Encouraged to massage the area
of numbness
Placed a warm/cold water with
towel over the numbness area
Maintained bed rest

1:45 am Dizziness D-“ Nahihilo po ako” as verbalized

by the patient
1:50 am
A-Blood pressure 130/100mmHg
Placed in a comfortable position
2:00 am
Cinnarizine1 tabgiven P.O. as
ordered
Maintained on bedrest
3:15 am
R-“ Medyo hindi na po ako
nahihilo ngayon” asverbalized by
the patient

1:10 am
Constipation D- “Ilang araw naakohindi
dumudumi as verbalized” by the
patient
 A-Encouraged to increase oral
fluid intake
Encouraged to eat nutritional

foods that are high in fiber

Encouraged to mobilized her body
2:00 am Lactulose 30 cc P.O given as
ordered

2:45 am
Frequent BM D- “Madalas poakongdumumi
saisang araw” as verbalized by the
patient

A-Encouraged to uncrease oral

fluid intake
Encouraged to eat
Banana,Rice,Apple andTea as her
diet ordered
Volume/volume replacement
dodne as ordered

12:00 am Edema D-“ Nagmamanas po yung Paa ko”

as verbalized by the patient
12:15 am
A- Blood pressure 120/70 mmHg
Encouraged to Limit salty foods
and water
Assessed pitting edema with +2
12:45 am Furosemide 40mg given thru IV as
ordered

12:00 am
Low platelet count D-Platelet count 90
12: 10 am
A-Temperature37.3 degrees
Celsius, Blood Pressure- 100/80
mmHg
Encouraged to avoid dark colored
foods
Encouraged to increase oral fluid
intake
Monitored bleeding and
hypotension done as ordered
Maintained on bed rest
2:50 am Abdominal pain D- “sumasakit po yung tiyan ko”
asverbalized by the patient with a
painscale of 3/5

A-Blood pressure-110/80 mmHg

Placed inacomfortableposition
Placed a warm towel over the
pain
2:55 am
Buscopan 1 tab P.O given as
ordered

3:15 am R- Pain scale subsided to 1/5