Southern Luzon State University

College of Allied Medicine

NURSE’S NOTES

Name: Donato Antonio Age: Attending Physician: Ward: Case #

60 Dr. Marla Subeldia ICU 001
Date/ Time Focus Data/ Action/ Response
09/28/2021 Risk for D> Received pt awake and in semi-fowler position on bed
7:00 am aspiration With ongoing IV-D5W @ left metacarpal vein at
approximately 500 cc x KVO. With ET tube inserted
connected to mechanical ventilator with PEEP mode.
Ventilator setting as follows; RR - 20 bpm, FiO2 -
100%, V - 80 L/min, Vt - 8 mL/kg, PIP - 20 cm H2O.
With NGT inserted. With central line at subclavian
vein. No presence of pressure ulcers. No presence of
edema. Pt communicated through writing on a white
board. Initial VS as follows: T - 37 C, BP - 130/100,
RR - 20 bpm, HR - 95 bpm, O2 sat - 96% in mech
vent ------------------------------------------------------------
A > Nurse-patient interaction and rapport established.
Assessed patient general condition. Monitored vital
signs q1. Checked NGT placement and patency.
Administered oral medications and feeding through a
nasogastric tube. Crushed and diluted on 5mL water
each tablet. Checked ET tube patency. ET care done.
Informed and explained to SO and patient about TPN
9:00 am administration and its purpose.TPN prepared and
administered through central line. Changed fully
soaked diaper. Monitored IO and vital signs ------------
2:00 pm R > Seen patient lying on bed in semi-fowler position;
latest vital signs: GCS 12 Temp - 37 C, BP - 130/90
mmHg, RR - 20 bpm, HR - 90 bpm, O2 Sat - 96%;
total intake - 1184mL, total output - 930 mL-----------

Aliyah Jewel P. Jimenez

BSN 4B
 Southern Luzon State University
College of Allied Medicine

TREATMENT RECORD
Name: Donato Antonio Ward: ICU Bed No.: 401
Date & MEDICATION TREATMENT DATE DATE DATE
Time 09/28/2021 09/29/2021 09/30/2021
Ordered COPIED ORDERED SHOULD BE SHIFT SHIFT SHIFT
SIGNED BY NURSE
6-2 2-10 10-6 6-2 2-10 10-6 6-2 2-10 10-6
09/28/ 8/
2021 Ceftriaxone 2g/ 5mL IV BID AJP
9/
Azithromycin 500mg PO OD AJP
12/
Terbutaline Neb q6 AJP

9/
Folic Acid PO OD AJP

Methylprednisolone 8 mg Per NGT 8/

AJP
Methylprednisolone 4 mg Per NGT 12/
AJP
Furosemide 10mg/mL IV OD in AM 9/
AJP
 Printed Name or Signature Printed Name or Signature Printed Name or Signature
Tro-dat Specimen Tro-dat Specimen Tro-dat Specimen

Southern Luzon State University

College of Allied Medicine

ICU/ CCU Monitoring

Name: Donato Antonio Age: 60 y/o Sex: M Civil Status: Married Bed No.: 401

Date/ Time BP CR RR Te IVF MEDS Oral Total Urine Others Total

mp Intake Intake Output Output

7 36cc Methylpr 98.5cc 95cc 95cc

+ ednisone (IVF)+
62.5cc + 10 cc 15cc =
(flush) + 113.5cc
5cc
(distilled
water)
8 36cc Ceftriaxo 125cc 98.5cc 195cc 195cc
+ ne: 5mL (IVF)+
62.5cc + 10cc 15cc+
(flush) 125cc=
238.5cc
9 36cc Furosemi 98.5cc 130cc 130cc
+ de: 1mL (IVF) +
62.5cc + 10cc 11ml
(flush)
 Azithrom
ycin: 5cc
distilled +15cc
water +
10cc
(flush)

Folic
Acid:
10cc
(flush) + +15cc
5cc
distilled =139.5
water
10 36cc 98.5cc 80cc 80cc
+
62.5cc
11 36cc 98.5cc 75cc 75cc
+
62.5cc
12 36cc 125cc 223.5cc 180cc 180cc
+
62.5cc
1 36cc Methylpr 98.5cc 95cc 95cc
+ ednisolo + 15cc
62.5cc ne: 5cc
distilled =
water + 113.5cc
10
(flush)
2 36cc 98.5cc 80cc 80cc
+
62.5cc
TOTAL 288cc 86cc 250 1,124cc 930cc 930cc
+ cc
500cc
=
788cc
3
4
5
6
7
8
9
 10
TOTAL
11
12
1
2
3
4
5
6
TOTAL