VITAL SIGNS MONITORING SHEET

Hospital no: 1234567

Name of patient: DE LA CRUZ, JUANA Age: 25 y.o. Sex: Female

DATE TIME BP C RR TEMP REMAR

R KS
5/22/2021 8:15 120/70 125 19 37.8°C IFI
AM mmHg bpm bpm
5/22/2021 10:15 115/80 129 15 37.7°C IFI
AM mmHg bpm bpm
5/22/2021 12:15 110/75 133 18 37.9°C IFI
PM mmHg bpm bpm
5/22/2021 2:15 120/80 130 20 38.0°C IFI
PM mmHg bpm bpm
5/22/2021 4:15 118/75 135 17 37.6°C IFI
PM mmHg bpm bpm
 WESTERN VISAYAS MEDICAL CENTER

VITAL SIGNS/INTAKE-OUTPUT SHEET

DATE TIME VITAL SIGNS INTAK OUTPU

E T
BP TEM CR RR I P N TOT UR ST VOMI TO
P V O GT AL IN OO TOU S TA
E L L
5/22/202 8:15 120/7 37.8° 125 19
1 AM 0 C bp bp
mmHg m m
10:15 115/8 37.7° 129 15
AM 0 C bp bp
mmHg m m
12:15 110/75 37.9° 133 18
PM C bp bp
mmHg m m
2:15 120/8 38.0° 130 20
PM 0 C bp bp
mmHg m m
4:15 118/7 37.6° 135 17
PM 5 C bp bp
mmHg m m
 INTRAVENOUS FLUID/BLOOD TRANSFUSION SHEET

Name of Patient: JUANA DE LA CRUZ Area & Bed Case No.:

Date Time Bottle no. Type Infusion/blood Rate Remarks Nurse’s

of component name and
fluid signature
5/22/2021 3:15PM 1 D5LR 1L N/A 1L x 8 Consume IFI
hours d
 MEDICATION SHEET
Name of patient: JUANA DE LA CRUZ Area and bed no: Case no:

Allergies

MEDICATION SCHEDULE ROUTE

Ceftriaxone OD PO

Paracetamol q4H PO

NURSE’S NAME AND

SIGNATURE

Nurse’s name and Time Nurse’s name and Time Nurse’s name and Time
signature signature signature
IFI 8:00AM
IFI 12NN
IFI 4:00PM

MEDICATION RECORD

SURNAME: DE LA CRUZ AGE: 25 y.o. HOSPITAL NO.: 1234567

GIVEN NAME: JUANA SEX: Female WARD/ROOM: OB Ward

O – Circle all doses not given. State reason in Nurse’s

Notes

MEDICATION Date 5/22/

Shift 2021
Ceftriaxone 7-3 8/IFI
3-11
11-7
Paracetamol 7-3 8/IFI
3-11
11-7 12/IF
I
7-3
3-11 4/IFI
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
3-11
11-7
7-3
 3-11
11-7
7-3
3-11
11-7

NURSE’S NOTES

Hospital No: 1234567

Name: JUANA DE LA CRUZ Age: 25 Sex: Female Room/Ward: OB Ward

Date & Time Focus D- Data A- Action R- Response

2:15PM Hyperthermia D – 38.0°C, client is shivering, client is warm
to touch, client feels dizzy, client feels weak.
A - Adjusted room temperature. Removed excess
clothing, blankets, and linens. Did a tepid sponge
bath.
R - 37.6°C
 PHYSICIAN ORDER SHEET

Hospital No: 1234567

Patient name: DE LA CRUZ, JUANA Age:25 y. o. Sex: _Female Civil Status: Married Ward: OB ward

DA PROGRES PHYSICIAN ORDER C A R E D NURSE’

TE S S
TI NOTES INITIA
ME L
5/22/202 (+) fever Please admit patient at OB IFI
1 ward under the

(+) foul Service of Dr. Kwok, J. IFI

Smelling TPR q 4h and record / IFI

lochia Soft diet / IFI

Laboratories:

2 days · CBC, PC, Blood typing / IFI

postpartu
m
NSVD · Urinalysis, Chest X- / IFI
ray PAview

G2P2 · S. NA, K / / IFI

· FBS, Lipid profile / IFI

Start IVF: D5LR 1L x 8 hours / / IFI

Medications:

Ceftriaxone 500 mg IVTT / IFI

ODANST

Paracetamol 300 mg IVTT / IFI

q4HPRN for Temp. > 37.8C

Special Orders:

· Vital signs q2 and record / IFI

· Monitor lochia and refer / IFI

 · Refer laboratory / IFI
results once in

· Refer PRN / IFI

Dr. Sharon Maquiran

OB-ROD

Lic No. 0123456

C-CARRIED OUT A-ADMINISTERED R-REQUESTED E-ENDORSED D-DISCONTINUED

Dr. Sharon Maquiran Ian Francine A. Inson Peter Paul Nobis, RN

OB-ROD USA-CN USA-CI Lic No.
1837738
Lic No. 0123456