Date/ Shift / Time Focus Data Action Response

October 04,2021 Risk for D: Subjective: “Nurse wala man ko nabangga pero
7:00am-3:00pm bleeding naa koy bun og sakong hita og inig toothbrush nako
mudugo man akong gums”
Objective:bruised skin and discoloration.
BP 120/80, RR -20, PR, 86, T-36.9, O2 sat95%,

7:00am A:- Positioned patient comfortably

Assessed skin and mucous membranes

8:00am Monitored vital signs and recorded

8:10 Cold compress for bruise applied

8:20am Visited by med tech for blood extraction (CBC, blood

typing and crossmatching)

9:30am Instructed patient to collect his poop and urine, stool

and urine cap given and samples collected and sent
to laboratory for testing

10:00am Monitored hematocrit (Hct) and hemoglobin (Hgb).

12:00pm Monitored vital signs and recorded

12:10pm Reviewed laboratory results referred to NOD and

ROD made aware and tranexamic acid 500mg PRN
was ordered.

1:50pm Taught patient and family members about signs of

bleeding that need to be reported to a health care
provider and advised to use a soft-bristled
toothbrush and nonabrasive toothpaste

3:00pm R: bruised and discoloration are still visible

Endorsed to next NOD patient is awake with latest
vital signs of BP: 120/80, RR: 19, PR:87, T: 37°C
O2 sat: 98%

KnumpyeonSupranes
Kirsty Marie Supranes S.N., AdDU/Melba Irene
Gabuya R.N.,M.N.