NURSE’S NOTES

SURNAME:____MEDINA___________________________ M.I.:__S____ AGE:__35____ HOSPITAL NO.:_0002345__

GIVEN NAME:____VICKY__________________________________ SEX:__F____ WARD/ROOM NO.:_____218______

Date-Shift FOCUS Data – Action – Response

05-22-2021 For D: Admitted a 35 y/o female patient for Thyroidectomy,
8:00 am Thyroidecomy accompanied by her significant other with initial VS as follows:
08:30 am BP: 130/60 mmHg
08:45 am PR : 92 bpm
RR: 20 cpm
Temp: 36.4
Appeared anxious, with a smooth, warm, and moist skin, a fine
tremor, a bounding cardiac apical impulse, a pulmonic flow
murmur, couldn’t rise from deep knee bend without aid. Thyroid
contained 3 nodules, being firm consistency, and no
lymphadenopathy, eyes were not prominent, and no focal skin
thickening.

A: Assisted on bed and positioned to moderate high back rest ;

side rails raised; seen and examined by ER physician (Dr.
Bermudez) with orders made and carried out accordingly; consent
to care and hospitalization secured; started IVF of D5LRS 1L x 8
hours for 2 cycles inserted aseptically at right metacarpal vein
regulated to 31-32 gtts/min.@; Instructed NPO 8 hours PTOR;
Endorsed schedule for OR @ 3pm; Notified Dr. Mendoza for CP
clearance, Dr. Cruz for endo clearance, and Dr. Rose for
anesthesia; Ampicillin Sulbactam 1.5 gm ANST given; Ketorolac
for skin test prior to OR administered; changed IV cannula to
gauge 8; 1 PRBC standby in the lab and request for laboratory for
H&H.

R: Transferred to surgical ward in a private room at 8:45 am via

stretcher, endorsed accordingly.

Sig.
Renea Joy Arruejo
Stud.No.
3000052120513

.
 D: temperature of 37 c/axilla @9pm.

A: assessed patient; TSB done; monitored vital signs q4 hours.

R: Patient’s knowledge increased for her operation; increased

patient’s satisfaction; increased collaboration between NPI.

NURSE’S NOTES

SURNAME:_______________________________________ M.I.:________ AGE:________ HOSPITAL NO.:_______________

GIVEN NAME:______________________________________________ SEX:________ WARD/ROOM NO.:______________
Date-Shift FOCUS Data – Action – Response