Silliman University Medical Center

Dumaguete City

NURSE’S NOTES

Px’s Name: J.F. Gonzales Doctor: G. Anque Bed No. 202 FORM NO. 2019-01

DATE TIME FOCUS D= Data A= Action R= Response

09/02/22 1100H IVF Therapy D - Received lying in bed, awake, and responsive to verbal stimuli;

Complained of feeling nauseated and frequent vomiting; dry mouth and

Dryness and cracking of lips noted; appeared lethargic and tired; For IV

therapy -------------------------------------------------------------------------------

1110H A - A 22G needle was inserted at the left metacarpal vein; hooked IVF #1

PNSS 1L regulated at 33 gtts/min per order by Dr. G. Anque. —--------------

1125H R - Tolerated procedure well; No discomfort or pain reported; no signs of

Redness, swelling or infiltration, or phlebitis noted at the insertion site;

IV tubing has no kinks. -------- PRINCESS ANGEL LUCAÑAS, SUCN-SN

 Silliman University Medical Center
Dumaguete City

NURSE’S NOTES

Patient’s Name: Julie Ann Gabor Doctor: Dr. G. Anque Bed No. 202 FORM NO. 2019-01

DATE TIME FOCUS D= Data A= Action R= Response

09/09/22 0800H Persistent nausea and D – Persistent nausea and frequent vomiting reported; Potassium levels =
vomiting
3.2 mmol/L; appeared tired and lethargic; feeling weak. ---------------------

0830H A – Administered IVF #1 1L PNSS on left metacarpal vein incorporated

with 10 mEq Potassium Chloride (KCl) delivered at @22gtts/min as

ordered by Dr. G. Anque. --------------------------------------------------------

0850H R – No complaints of discomfort upon administration; No adverse reaction

to the drug noted. —---- PRINCESS ANGEL LUCAÑAS, SUCN-SN

 Silliman University Medical Center
Dumaguete City
NURSE’S NOTES

Patient’s Name: Caitlyn Pressmann Doctor: Dr. BN Sy Bed No. 202 FORM NO. 2019-01

DATE TIME FOCUS D= Data A= Action R= Response

09/16/22 0800H Chemotherapy D - Scheduled for chemotherapy at 0900H. --------------------------------------

0815H A - Due meds Metoclopramide (Plasil) 10 mg IVTT Q 8H was administered

for nausea and vomiting. -----------------------------------------------------------

0830H R - No adverse reaction to the drug administered was noted; no discomfort

noted upon administration. ----PRINCESS ANGEL LUCAÑAS, SUCN-SN

 Silliman University Medical Center
Dumaguete City

NURSE’S NOTES

Patient’s Name: Pretty Mae Colombia Doctor: Dr. BN Sy Bed No. 202 FORM NO. 2019-01

DATE TIME FOCUS D= Data A= Action R= Response

09/16/22 0900H Urinary Tract D - Complaints of burning sensation upon urination; cramping on the lower

Infection abdomen; frequent urination (urinated 6x early this morning); WBC =

15, 560 cumm/L (09/15/2022: 7:30 AM). ----------------------------------------

0910H A - Administered Ceftazidime (Fortum) 1 g/vial IV Infusion (-) ANST

incorporated in 30mL PNSS via volumetric set for 1hr as ordered by

Dr. BN Sy. ----------------------------------------------------------------------------

1010H R - No adverse effects of the drug administered was noted. —-----------------

—------------------------ PRINCESS ANGEL LUCAÑAS, SUCN-SN

 Silliman University Medical Center
Dumaguete City
NURSE’S NOTES

Patient’s Name: Cardi B. Doctor: Dr. G. Anque Bed No. 202 FORM NO. 2019-01

DATE TIME FOCUS D= Data A= Action R= Response

09/16/22 1030H Risk for Infection D - Presence of nonproductive cough; RR 24, shallow and rapid with the use

secondary to of accessory muscles; chest x-ray (09/15/22): bilateral lower lobe

Pneumonia pneumonia; WBC count (09/15/22, 6:45 AM): 14,200 cumm/L. --------------

1035H A - Administered Cefuroxime (Zegen) 750 mg IVTT (-) ANST via

Heplock as ordered by Dr. Anque. -------------------------------------------------

1045H R - No adverse reactions noted to the drug administered. —-------------------

—--------------------------PRINCESS ANGEL LUCAÑAS, SUCN-SN

 Silliman University Medical Center
Dumaguete City
NURSE’S NOTES

Patient’s Name: Byahe Malaysia Doctor: Dr. G. C. Logronio Bed No. 202 FORM NO. 2019-01

DATE TIME FOCUS D= Data A= Action R= Response

09/23/22 1000H Bladder Irrigation D - One day post-op TURP; distended bladder and tenderness noted upon

palpation on the LLQ; attached with a 3-way catheter. -------------------------

1015H A - Assisted Dr. G.C. Logronio with the continuous bladder irrigation;

attached 1L PNSS as an irrigating solution delivering at 60 gtts/min;

Irrigated a total urine output of 1500 mL, reddish in color

1100H R - Tolerated the procedure well; relieved bladder distention and

no tenderness on LLQ. —----------------------------------------------------------

—--------------------------PRINCESS ANGEL LUCAÑAS, SUCN-SN