Silliman University Medical Center

Dumaguete City

NURSE’S NOTES

Px’s Name: J.F. Gonzales Doctor: BN Sy Bed No. 2 FORM NO. 2019-01

DATE TIME FOCUS D- Data A- Action

R- Response

09/16/2022 0815 H Nausea and D - Received lying in bed, awake;

Vomiting feeling weak; feeling nauseated;
vomited twice early in the morning ( 6
and 7 am); IV present on the left
metacarpal vein; IV tubing is patent and
has no kinks; no redness, swelling, no
signs of phlebitis on the IV site noted.
A - Vital signs taken: P 75 (regular and
strong), BP 122/78, T 37°C, RR 16, O2
Sat 98%; Administered Metoclopramide
(Plasil) 10 mg through IVTT running for
1 hr. —--------------------------------------
R - Tolerated procedure well;no redness,
swelling or signs of phlebitis noted; No
reports of pain on the IV site no adverse
reaction to the drug noted. —--------------
—---------------------Princess Angel Lucañas, SN, SUCN