Endorsement:

R 418/ admitted 2-18-21/ Patayan C. / 3 y.o Male/ Dr.Manalo/ Admitted due to rashes possible for
measles/ SDA Diet strict isolation precautions/ Vs q4 CR- 101 RR- 29 T- 37.6 I&O qshift hydration
round q4/ W.O for difficulty in breathing, changes in sensorium/ F.U. urinalysis, S. Electrolytes and
magnesium/ survey for measles/ F.U Dr. Manalo for CXRay / IVF D5IMB 500 @40 cc/hr level due at
9:00am intake 150 cc infusing well at Right Meta Carpal Vein.

Patients Name: Patayan, Covido Age: 3 y.o

R# & Ward: 418- Pedia Ward Physician: Dr.Manalo

Date & Shift Time Entry

Time
2-19-21 7-3 Client received lying on bed
7:00 am
Skin warm to touch with good capillary refill at 2 seconds.
Ulceration in mouth or pus draining from eye, none noted.
With partial clouding of the cornea. Rashes noted on both upper
extremities.
Normal breathng pattern noted.
With an IVF of D5IMB 500 cc @40 cc/hr level
Infusing well at RMCV
8:00 am VS checked and recorded: RR- 29bpm; CR- 101; T-37.6°C; NOD aware
Administered Ibuprofen (200 mg) 5mg P.O.
Administered 1 cup of water (250 ml)
Bedside care done; linen stretched and tucked well
8:10am TSB rendered
Followed up for urinalysis
8:30 am Rechecked Temp: 36.7 °C
9:00 am Above IVF consumed and dislodged; Kept set sterile
9:20 am Client is awake and started to cry
9:30 am Rendered Health Teachings to the mother, such as;
a. Refer any unusualities like: difficulty in breathing, increase temp.
b. Proper handwashing before and after contact with the client
c. Strictly maintain proper isolation precautions
d. Maintain SDA Diet
9:40 am Followed up for CXRay
10:00 am Followed up for Serum Electrolytes
11:00 am VS rechecked and recorded: RR- 28bpm CR- 100 Temp- 37°C
11:15 am Client is eating with assistance of the mothr, SDA Diet, given 1/2cup of
Given ½ cup of mashed potato, ½ size avocado and 1 slice of bread and
Tomato soup
11:55 am Client finished his meal
12:00pm Lying comfortably on bed
12:30 pm Followed up Serum Electrolytes test
1:30 pm Followed up Magnesium Test
1:45 pm Seen and observed by Dr. Manalo, Treatment continued as ordered
2:00 pm VS rechecked and recorded: Afebrile; 36.7°C, RR- 28, CR- 98
Intake and output summed up and recorded
Left lying on bed with mother at bedside; still for strict isolation precautions.

B.L
Britney Labuson, St.N/