PATIENT’S NAME AGE GENDER C/S RM/BED# HOSPITAL#

R.D 76 Male

**PLEASE AFFIX SIGNATURE OVER PRINTED NAME AT THE END OF THE ENTRY
DATE/SHIFT/TIME FOCUS NOTES (DATA, ACTIONS, RESPONSE)
05/18/21/8-2 >Received patient lying on bed awake, conscious
and coherent but looks pale and weak with an on-
going IVF of ½ L D5W X KVO hooked and infusing
well at the left arm.
8:00AM
>with V/S of BP- 150/100 mmHg, PR- 114bpm, RR-
26cpm, Temp.- 36.7 °C

Decreased Cardiac >Auscultate apical pulse, assess heart rate, rhythm

Output related to
alterations in rate, >Monitor BP
rhythm and
electrical >Monitor urine output, noting decreasing output and
conduction concentrated urine

>Monitor serial ECG and chest x-ray changes

>Assess patient’s skin temperature and peripheral pulses

>Measure cardiac output and other functional parameters

as indicated

>Encourage periods of rest and assist with all activities

>Assist the patient in assuming a high Fowler’s position

>Reposition patient every 2 hours

>Instruct the SO not to leave the client unattended

>Provide quiet environment

>Administer supplemental oxygen as indicated

>Administer medication as ordered