MEDICATION SHEET

Name of Patient: Lynelle Reyes

Address: Brgy ll Silay, City
Age: 26 y.o. Sex: Female Admission Date:

Morning shift

Complete name and initials of Pfs

medication nurse Princess Sugaton
SN-USLS

AM shift

Date September 13,2022

No. of Days 1 2
Date
Frequency Drug/Dosage/Route NOC AM PM NOC
Ordered

9/13/2022 q12h Ampicillin-Sulbactam 1G IVTT ANST 8 PFS

9/13/2022 q8h Metronidazole 500mg IVTT 8 PFS

9/13/2022 OD Omeprazole 40mg IVTT 8 PFS

8PFS
9/13/2022 q6h Nalbuphine 5mg IVTT PRN for pain
2pm PFS
8PFS
9/13/2022 Tramadole 4cc/hr 2cycles
T

Ward/Room: Woman Surgical Ward

Admission Date: 12-Sep-22

Other frequencies:

SD: Single dose

LD: Loading dose
2 3 ODAC: Once a day before meals
AM PM NOC AM PM ODPC: Once a day after meals
 INTRAVENOUS/PARENTERAL FLUID SHEET

Name of Patient: Lynelle Reyes Ward/Room:

Address: Brgy. ll, Silay City
Age: 53 y.o. Sex: Female Admission Date:

Time
Time Bottle Type of Started Amount/ Consumed/
Date
Started No. Solution By Received By Discontinued
By

9/13/2022 8:00 AM 1 PLR 1L Pfs

240cc PFS

9/13/2022 8:00 AM 1 D5lr Pfs

160cc PFS

400ccPFS
Female Surgical Ward

September 12,2022

Remarks For the remarks:

Right hand
You may write the (1) placement and (2) IVF status:

followed up (1) right hand, left leg, proximal, distal, CVP line, IJ catheter

(2) heparin lock, consumed, discontinued, shifted, followed up

followed up
 VITAL SIGNS AND INTAKE/OUTPUT FORM

Name of Patient: Lynette Reyes

Address: Brgy. ll Silayty City
Age: 52 y.o. Sex: Female

INPUT
Date Time BP T P R O2 Sat. CVP
Oral NGT IV Blood
12 am
1 am
2am
3 am
4 am
5 am
6 am
7 am

Total
Sept. 13 8 am 140/90 37 78 18 99% 0 30
Sept. 13 9 am 130/80 37.1 80 19 98% 30
Sept. 13 10 am 120/70 36.8 78 18 99% 30
Sept. 13 11 am 110/170 80 18 99% 30
Sept. 13 12 pm 100/70 36.8 78 19 99% 30
Sept. 13 1 pm 100/70 36.7 80 18 96% 30
Sept. 13 2 pm 90/60 36.7 79 18 99% 30
Sept. 13 3 pm 90/60 36.6 78 18 99% 30

Sept. 13 TOTAL 0 240

4 pm
5 pm
6 pm
7 pm
8 pm
9 pm
10 pm
11 pm

TOTAL

24 HOURS TOTAL
OUTPUT FORM

Ward/Room: Female Surgical Ward

Admission Date: September 12,2022

UT OUTPUT
Signature
Misc. Urine NGT Stool Emesis Misc.

0 0 Pfs
0 0 Pfs
0 0 Pfs
0 0 Pfs
0 0 Pfs
0 0 Pfs
0 Pfs
0 0 Pfs

0 0 Pfs
 GRAPHIC CHART

Name of Patient: Lynette Reyes Ward/Room: Female Surgical Wa

Address: Brgy II, Silay City
Age: 53 y.o. Sex: Female Admission Date:

Date 13-Sep-22 14-Sep-22 15-Sep-22

Hospital Days 1 2 3
Post-Op/Post-Partum Day 1 2 3
AM PM AM PM AM
Hour
4 8 12 4 8 12 4 8 12 4 8 12 4 8 12

Pulse
Rate
Temperature

150

140 40.0 ℃

130

120 39. 0 ℃

110

100 38.0 ℃

90

80 37.0 ℃
 80 37.0 ℃

70

60 36.0 ℃

50 35.5 ℃
Respirations 18 18
Blood Pressure 140/9 130/80
Weight (kgs.) 62 62
7a-3p 3p-11p 11p-7a TOTAL 7a-3p 3p-11p 11p-7a TOTAL 7a-3p 3p-11p
Diet NPO
Intake: Oral 0
Parenteral 30cc
TOTAL INTAKE 240
Urine (cc)/ No, of Times 0
Drainage
Emesis
TOTAL OUTPUT 0
Stool/ No. of Times 0
INITIAL
(Name, Middle, Surname) PFS
Female Surgical Ward

Septemember 12,2022

15-Sep-22
3
3
PM
4 8 12
11p-7a TOTAL
 NURSES' NOTES AND TREATMENT RECORD

Name of Patient: Lynelle Reyes

Address: Brgy ll, Silay City
Age: 53 y.o. Sex: Female

Date/
Time Focus
Post-Operative Care
Jaundice- Risk Infection
7:00AM related to disease process
8:00 AM

8:30AM
9:00AM
10:00 AM
11:00 AM

12:00PM

1:00PM

2:00 PM
NURSES' NOTES AND TREATMENT RECORD

Ward/Room: Female Surgical Ward

Admission Date: September 12,2022

Progress Notes
(D-Data A-Action R-Response)

D-Patient is admitted in post anesthesia care unit ------------------------PFS

Patient is unconsious -------------------------------------------------------------PFS

patient vital signs: 37 C, PR: 78bpm, RR: 18cmp, BP:140/90 O2sat99% PFS
A- Provide patient in comfortable position-----------------------------------PFS
Provide wound dressing for the client daily----------------------------------PFS
Provide medication to the client as prescriptions from doctors ---------PFS
Instruct patient not to take orally as Doctor ordered NPO x 4hrs -------PFS
Monitor the patients' Vital Signs and every 1hr and recorded -----------PFS

Assess the patient for any signs of hypotension, bloodycardia, nausea,

vomitting, headache, bleeding hemorage ------------------------------------PFS

Repeat the patients CBC post op and CBG for 6hrs-------------------------PFS

R: Patient is laying in bed and was able to rest and now concious she also
verbalize "nag mayo na matyag ko nurse wala na gasakit ang tiyan koPFS
Complete Name Princess F. Sugaton
SN-USLS