DATE/SHIFT/TIME FOCUS NOTES (DATA, ACTIONS, RESPONSE)

06/19/2021- 8:00 AM Pain - Received patient on semifowler’s

 Headache position, awake ; with cc of
 neck pain persistent headache and neck
pain, intermittent high fever,
cough and colds;
- hooked to ½ D5NSS + KCL at 35
ml/ hr;
- vital signs of temp – (101 F)38.3
C, HR – 104 bpm, RR – 38 cpm,
BP – 90/60 mmhg; Patient looked
pallor.
- Placed a warm towel over the pain
area.
- Assisted pt. to a position of
comfort
- Administered diclofenac 1 ml stat
- Controlled environment to
encourage rest.
- Assisted ROM exercises.
- Monitored VS
- Encourage relaxation techniques
10:00 am s/a DBE
- Patient reports headache and neck
pain was relieved
- Performed TSB q 30 min.
Fever - Encouraged pt. to wear loose
10:30 am clothes
- Started Paracetamol 500 mg oral
QID for fever, Ceftriaxone 1 g IV
BID, Amikacin 180 mg IV BID as
prescribed
-Taught proper hand washing
technique and instruct patient to keep
hands away of eyes
-Instructed patient to clean eye
Conjunctivitis discharge with tissue and dispose
11: 00 pm carefully. Teach the patient to install
eye drops and ointments correctly
without touching tip of container with
eye or lashes
-Instructed to use dark black eye
glasses to avoid bright light and
 contamination
-Advised patient to avoid rubbing eyes
–Administered Moxicip drops 2 drops
OU TID as prescribed
- Instructed to increase OFI
Ineffective A/W - Repositioned pt. q 2hr and as
clearance needed
- Encouraged DBE
1:00 pm - Started Otrivin Nasal drops 2
drops nasal TID as prescribed
- Pt.’s VS were (99.32 F) 37.4 C, HR
– 92 bpm, RR – 20 cpm, BP –
92/63 mmhg; Patient was not
pallor (lips and palm are pinkish)
3:00pm - Recoded I&O after the shift
2:00 pm - Referred

4:00 pm

DATE/SHIFT/TIME FOCUS NOTES (DATA, ACTIONS, RESPONSE)

06/20/2021- 8:00 AM Pain - Received patient awake on a semi-
 (+) Kernig’s fowler’s position ; (+) Kernig’s
sign, sign, (+) Brudzinki’s sign, vomiting
 (+) - hooked to ½ D5NSS + KCL at 35
Brudzinki’s ml/ hr;
sign - vital signs of temp – (99.32 F)
37.4 C, HR – 92 bpm, RR – 20
cpm, BP – 125/85 mmhg;
- Assisted pt. to a position of
comfort
- Elevated the head of the bed 30
degrees, and avoid neck flexion
and extreme hip flexion
- Maintained bed rest
- Continued Paracetamol 500 mg
oral QID for fever, Ceftriaxone 1 g
IV BID, Amikacin 180 mg IV BID
as ordered.
Seizure - Initiated seizure precautions.
12:00 PM - Monitored for seizure activity
 - Elevated Side rails
Vomiting - Placed the pt. to a fowler’s with a
side lying position
- Administered Syrup glycerol 10 ml
PO BID as ordered.
- Pt. reports of being comfortable
and relieved without vomiting.
3:30 PM - referred
4:00 PM