ION MEDICAL CENTER

J. P. Rizal Extension, West Rembo, Makati City, 1215 Telephone

No.: (+632) – 881 – 1571

NURSE’S NOTES

NAME: Alleah ‎‎ ‎‎‎‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎‎‎‎‎‎‎‎‎ ‎‎‎‎‎‎‎‎‎‎AGE: 8 y/o‎‎‎‎‎‎‎‎ ‎‎ ‎‎ ‎‎‎‎‎‎‎‎‎‎HOSPITAL NO.: ‎112222‎‎‎ ‎‎ ‎‎ ‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎
SERVICE: Pediatric ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎ SEX: Female ‎‎ ‎‎‎ ‎‎‎‎‎‎‎‎‎WARD/RM: Room 1‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎
ATTENDING PHYSICIAN: ‎Dr. Ga‎ ‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎ ‎‎‎‎‎‎‎‎

DATE/TIME FOCUS DATA, ACTION, RESPONSE

09/20/2022 Nursing Diagnosis: Data:
Altered body temperature Subj.: “Pabalik-balik po ang lagnat niya ilang araw na.” as
stated by the mother
Obj.: T: 38.7 °C BP:110/70 mmHg PR: 92 bpm
RR: 22 cpm Sp02: 89%
• ↑ capillary permeability, poor skin turgor, flushed skin,
sunken eyes, weakness, headache

Action:
• Monitored VS Q4 and assessed capillary refill
• Positioned in supine position
• Requested CBC with platelet and NS-1 test
• Provided TSB as needed to lower body temperature
• Administered Paracetamol (Tempra) 250mg (250mg/5ml)
or 5ml PO Q4 for fever 8:00 AM, Ascorbic Acid (Ceelin)
200mg (100mg/tab) or 2 tabs PO OD 8:00 AM
• Referred and endorsed accordingly

Response:
• Body temperature decreased from 38.7 °C to 37 °C and
maintained within normal range

Fluid volume deficit Data:

Subj.: “Nanghihina na po siya, nanunuyo ang labi at
mamula-mula na.” as stated by the mother
Obj.: T: 38.7 °C BP:110/70 mmHg PR: 92 bpm
RR: 22 cpm Sp02: 89%
• ↑ capillary permeability, poor skin turgor, flushed skin,
sunken eyes, weakness, headache

Action:
• Oresol and fluid replacement given and as needed
• Started IVF #1 PNSS 1L x 114cc/hr 10:00 AM
• Encouraged adequate rest
• Reviewed NS-1 test (+)
• Referred and endorsed accordingly

Response
• No deficient volume of fluid and tolerated the procedure
 Risk for bleeding Data:
Obj.: T: 38.7 °C BP:110/70 mmHg PR: 92 bpm
RR: 22 cpm Sp02: 89%
• ↑ capillary permeability, poor skin turgor, flushed skin,
sunken eyes, weakness, headache

Action:
• Reviewed NS-1 test (+), CBC; decreased platelet count
• Observed for any signs of bleeding
• Provided health-teaching about signs of bleeding and
instructed to report immediately
• Referred and endorsed accordingly

Response:
• No signs of bleeding and verbalized understanding of its
signs and symptoms
COAHS-CON2018-RLE-NN
BAUTISTA, L. G., SN