Date and

time Focus Nurses note/ DAR

20 Received patient on wheel chair awake, weak, responsive with
October,2021 an IVF of Normal Saline regulated at 100ml/hr infusing via right
8:00am metacarpal vein----------------------------------SQN

D.”Parang giniginaw man ako” as verbalized, patient covers

3:30pm Elevated Body self with blanket,Body temp of 37.7°c, skin warm to
Temperature touch.----------SQN
3:35pm A. Explained the need to do tepid sponge bath; provided tepid
sponge bath advised wife to continue; Checked any ordered
antipyretic medications and time last given; Encouraged to------
increase oral fluid intake---------------------------------------------------
4:00pm SQN
5:40pm Impaired Skin -Rechecked body temperature with result of
integrity 37.0°c-----------------SQN
5:45pm D-with gunshot wound on left forearm; noted few pinkish
discharges on wound dressing.-----------------------------------------
SQN
A. Assessed for moderate to severe wound pain, assessed for
5:55pm numbness on left digits; noted doctors order to do wound
dressing BID; explained to patient the importance of wound
dressing-----------------------------------------------------------------------
SQN
-Provided wound dressing aseptically; Demonstrated proper
hand hygiene and explained its importance; Advised not to
11:00pm touch or scratch the wound; Advised to do range of motion
exercises on left digits; Encouraged to include vitamin C and
protein rich foods on meals. Provided teaching about the
importance of ongoing antibiotics treatment compliance;
Elevated side rails for safety---SQN
R- body temperature of 37.1°c, wound dressing intact, no
other complaints noted, seen asleep with side rails
up-------------------SQN
( Signature)