PATIENT NAME: LORNA DIMAGIBA

AGE: 84 Years old

GENDER: Female

C.S: Widow

BED#: 1

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

12/01/21 Received patient, awake, sitting on a

3:00 pm chair with an ongoing IV Fluid of D5
0.45% NaCl with 20 mEq KCL per liter at
60 mL’s per hour infusing well at her right
arm.

Vital signs recorded as follows:

Temp: 36.6 c
BP: 170/90 mmHg
RR: 14 cpm
PR: 76 bpm

*Quite confused
3:15 pm Acute Pain - Assessed the client’s description of pain
- Encouraged the patient to increased oral
fluid intake
3:45 pm - Avoided urinary irritants such as coffee,
tea, colas, and alcohol.
-Applied a heating pad to the supra pubic
area or lower back.
- Encouraged relaxation techniques,
4:15 pm
massage, guided imagery, or distraction
to decrease pain and provide comfort.
- Administered appropriate medication as
5:00 pm ordered such as Celecoxib 200 mg po
once a day, Ciprofloxacin 250 mg po
every 12 hours,
Acetaminophen 325 mg po q 6 hrs prn
pain or fever.

6:00 pm Fluid Volume - Assessed patient’s general condition

- Monitored VS and charted
- Encouraged Fluid intake
- Monitored and regulated IVF at desired
rate
6:30 pm - Promoted proper ventilation and
therapeutic environment
- Emphasized the relevance of
maintaining proper nutrition and
hydration..
- Offered assistance with eating and
drinking if necessary.
7:00 pm - Placed the beverage within view and
close reach at the bedside table.
- Administered appropriate medication as
ordered.
8:00 pm Acute Confusion - Oriented patient to surroundings, staff,
and necessary activities as needed.
- Allowed sufficient time for patient to
respond, to communicate, to make
decisions.
- Provided for safety needs
8:30 pm - Kept normal fluid and electrolyte
balance; establish/maintain normal
nutrition, body temperature.
- Identified self by name at each contact;
call the patient by his or her preferred
name.
9:00 pm - Provided continuity of care when
possible (e.g., provide the same
caregivers, avoid room changes).
- Assisted the family and significant
others in developing coping strategies.
- Monitored laboratory values such as
9:30 pm CBC and oxygen saturation
- Taught family to recognize signs of early
confusion and seek medical help.
10:00 pm R- Patient is awake, restfully lying on bed
and able to maintain fluid volume at well-
designed level with a good skin turgor
and a pain scale of 2/10.
PATIENT NAME: MARTIN TOTO
AGE: 76 years old
GENDER: Male
C.S: Married
BED#: 2
DATE / SHIFT/ NOTES (DATA, ACTION,
FOCUS
TIME RESPONSE)
12/01/21 Received patient lying on bed,
3:00 pm weak and coughing.

Vital signs as follows:

Temp:38
BP: 120/80 mmHg
RR: 25
PR: 98
- skin warm to touch
- restlessness
Ineffective Breathing - Assessed and record respiratory
3:30 pm Pattern rate and depth.
- Observed breathing patterns.
- Placed patient with proper body
alignment for maximum breathing
pattern.
4:30 pm - Provided respiratory medications
and oxygen, as per doctor’s order.
- Stayed with the patient during
acute episodes of respiratory
distress.
5:30 pm - Encouraged small frequent
meals.
- Educated patient or significant
other on proper breathing,
coughing, and splinting methods.

6:00 pm Hyperthermia - Monitored vital signs

- Tepid Sponge Bath (TSB) done
- Administered 500mg IV
Paracetamol as per doctor’s order
6:30 pm -Encouraged adequate oral fluid
intake
-Encouraged adequate rest
7:00 pm - Repositioned patient every 2
hours.
7:30 pm Fatigue - Encouraged patient to rest
- Taught patient energy
conservation methods.
- Provided comfort such as
8:00 pm massage, and cool showers.
- Offered diversional activities that
are soothing.
9:00 pm - Promoted relaxation before
sleep and providing for several
hours of uninterrupted sleep can
contribute to energy restoration.

10:00 pm R - Patient is awake, comfortably

lying on his bed, vital signs
returned to normal and maintains
an effective breathing pattern, as
evidenced by relaxed breathing at
normal rate and depth and
absence of dyspnea.