PATIENT’S NAME: MAUREEN WROBLE

AGE: 28
GENDER: FEMALE
C.S: SINGLE
BED#: 3

DATE/ SHIFT/ TIME FOCUS NOTES (DATA, ACTION, RESPONSE)

10:00 am Fluid Volume Deficit Data: Received patient conscious lying with an ongoing
IV Fluid of PNSS 1L infusing well in her right arm.
Vital signs as follows:
Temp: 37.5
10:30 am BP: 110/80
RR:22
11:00 am PR:11
12:00 pm (+) body weakness
(+) dizziness
1:00 pm (+) loss of consciousness
(+) chest and epigastric pain
1:30 pm (+) pallor
-Assesses patient’s general condition
-weigh the patient
- Monitored VS and charted
-Encouraged Fluid intake
-Monitored Intake and Output
- Monitored and regulated IVF at desired rate
-Administered medication as ordered
-Assisted patient to change position every 2hours
-Promoted proper ventilation and therapeutic
environment
-Advised SO to always stay on the patient bedside
-Provided opportunity for patient to rest
2:00 pm Acute pain -Assessed patient’s pain scale
- Promoted relaxation techniques such as massage and
diversional activities such as watching tv.
4:00 pm -Administered medication as ordered such as
Omeprazole 40g/cap, ampicillin-sulbactam 1.5 g IV and
Paracetamol 500 mg
6:00 pm - positioned the patient to her comfortable position
- Used of non-pharmacological techniques for pain
7:00 pm management as appropriate.
8:00 pm Fatigue -Encouraged patient to rest
8:30 pm - Teach energy conservation methods.
- Provided comfort such as massage, and cool showers.
9:00 pm - Offered diversional activities that are soothing.
9:30 pm - Promoted relaxation before sleep and providing for
several hours of uninterrupted sleep can contribute to
energy restoration.
10:00 pm R. the patient is conscious comfortably lying on bed and
able to maintain fluid volume at functional level with
good skin turgor with a pain scale of 0/10.