Silliman University Medical Center

Dumaguete City

Nurses Notes
Patient’s Name: Terami Su Doctor: Dr. Reyes Bed No: 314- Female Ward
DATE TIME FOCUS DATA, ACTION, RESPONSE
03/09/21 0715H Acute pain D: Received lying on bed, asleep, with #1 IVF 1L D5LR with remaining 824 mL
infusing well at left metacarpal vein. T= 37.7 ºC, PR- 70 bpm regular, RR- 16
cpm effortless, BP- 120/80 mmHg, O2 Sat- 95%. Verbalized, “I cannot tolerate
the pain. Please help.” Rated pain 10. Facial grimacing and guarding noted. ---
A: Placed on high fowler’s position, employed distraction techniques.
Administered Nalbuphine HCL (Nubain) 20 mg IM NOW and IVTT every 6hours
after. Administered Piperacillin/Tazobactam (Zosyn) 4.5 g IVTT q8h after ANST.
Administered Metronidazole (Flagyl) 1 g IV loading dose followed by 500 mg IV
q6h after ANST ----------------------------------------------------------------------------------
R: Tolerated medications. Rated pain 4. --------------------------------------------------
03/09/21 0840H Fluid volume deficit D: Verbalized, “I have been vomiting for an hour”. Feels thirsty and weak. Dry
mouth, and skin turgor is slow. 50 ml urine in the past 2 hours, dark yellow in
color. Capillary refill > 2 seconds. Vomitus green in color.----------------------------
A: Monitored intake and output. Kept comfortable and cool through
environmental manipulation. Administered Promethazine HCL (Phenergan)
25mg IVTT PRN for episodes of vomiting.-------------------------------------------------
R: Verbalized “I feel a bit better now” and tolerated medication.------------------
03/09/21 0940H Hyperthermia D: Flushed skin, profuse sweating, T- 39 ºC, diaphoretic and warm to touch.
A: Administered Acetaminophen (Ofirmev) 500mg/50ml IVTT.
R: Verbalized “I feel a little better now” and sweating was reduced. Tolerated
medication.---------------------------------------------------------------------------------------
03/09/21 0950H Altered comfort D: Verbalized, “I feel so itchy all over my body and I hardly breath.” “My skin
feels like it’s crawling and it only feels better after I scratch it.” Restlessness
and scratching noted. Redness on neck, arms, and legs.------------------------------
A: Continuous checking of allergies. Provided change of bedding and pillow
case and moisturized dry skin itchy area. Administered Methylprednisolone
(Medrol) 160 mg IVTT -------------------------------------------------------------------------
R: Verbalized “My skin isn’t as itchy but it still itches” and tolerated medication-
03/09/21 1100H Anxiety D: Verbalized, “I’m scared of what might happen to me during the surgery”.
Fidgeting noted. RR- 20 cpm, deep breaths, T=- 37.5 ºC, cool to touch, O2
Saturation-95% ----------------------------------------------------------------------------------
A: Explained to the patient the surgery and the process. Openly discussed
anxiety and feelings. Lessen environmental noise.-------------------------------------
R: Fidgeting and restlessness was reduced.-----------------------------------------------
03/09/21 1300H Pre-Operation D: Received sitting on bed, alert and awake. Scheduled for cholecystectomy
Preparation STAT------------------------------------------------------------------------------------------------
A: Secured 2 units packed RBC and crossed matched. Aseptically inserted of
Foley Catheter #18 F. Monitored vital signs and I & O. Secured surgical consent.
Administered Diphenhydramine HCL (Benadryl) 1 amp 20 mg IM. Gave pre-op
instructions. Taught the patient how to do incision care, and dressing. ----------
R: Safely transferred from bed to stretcher. Endorsed all the data recorded to
nurses on the next shift.-------------------------- MVLDizo, S.N. ; HNMSalarda, S.N.