DON - GEN – 4 – 11 - 17

Rev.00 – 00 – 00

NURSES NOTES

SURNAME FIRST NAME MIDDLE NAME ROOM/BED NO. HOSP. CASE

DELA CRUZ AISHA GARCIA RM 209 BED A NO
1-9970-901
ATTENDING PHYSICIAN AGE SEX CIVILSTATUS
8 YEARS OLD FEMALE SINGLE
DR. QUINN
DATE /
FOCUS D = DATA A = ACTION R = RESPONSE
TIME
9-16-21 Altered Body D:- Received pt lying on bed awake; “Ang lamig
11:00 am Temperature lamig Mommy” as stated by the pt to her mother;
rt bacterial inva- pt covers self w/ blanket; VS taken as follows: RR=
sion in the 18 bpm; T= 38.4℃; PR= 91 bpm; skin warm to touch;
lungs aeb produc- with crackles upon auscultation; (+) productive cough.
tive cough and A:- Nurse, pt, and parent interaction done; VS taken
Fever. and monitored; Nurse secure consent for admission
and management; Nurse inserted IVF of PNSS 1L @
right metacarpal vein intact and infusing well; IVF
check and regulated @ desired rate of 20 gtts/min;
side rails secured for pt safety; pt was assigned to a
DAT w/ strict aspiration precaution; infection control
measures observed; place pt on a position of comfort;
Nurse helped in admitting the patient to room of
choice under the service of Dr. Quinn; Nurse adminis-
tered Ceftriaxone 1gm via IV OD ANST; Nurse de-
monstrated to pt’s mother how to administer duavent
1 neb + 1 cc NSS via nebulization ever 6 hrs and how
to do bronchial tapping after nebulization; Nurse ad-
ministered Paracetamol 150 mg via IV for temp ≥
37.8℃; Nurse requested for a CBC and CX-ray AP.
R:- No other complaints noted; pt transferred to room
via wheel chair.

Beatrice Chen C. Sumadsad, SN (UB-CNM)

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 DON - GEN – 4 – 11 - 17
Rev.00 – 00 – 00

SURNAME FIRST NAME MIDDLE NAME ROOM/BED HOSP. CASE NO

NO.
ATTENDING PHYSICIAN AGE SEX CIVIL STATUS

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