Southern Luzon State University

College of Allied Medicine

Lucban, Quezon

In Partial Fulfillment of the Requirements in Related Learning Experience

in Surgery 2

Submitted by:
SHIELA MAE C. ROZOL
BSN – 4B

Submitted to:

MIRASOL B. MANLAPAZ

NOVEMBER 2021
 NURSE’S NOTES

Name: Age: Attending Physician: Ward: Case #

Mr. Molina 52 Dr. Mararac Surgery 234
Date/ Time Focus Data/ Action/ Response
11-07-21 >Received lying on bed, conscious and coherent with IVF
8:00am
of D5W with 5-10 gtts/min on left cephalic vein infusing

well; Vital signs taken and recorder as: R: 40/min, PR: 90

and BP 180/160mmHg

Anxiety D> Rapid heartbeat, trembling body, sweating, upset

stomach, difficulties on concentrating, racing thoughts,

overthinking, heightened alertness, problem with sleep,

feelings of dread, dissociation and wanting to escape from

the situation that he is in.

9:00am A>Assess general condition, assess level of fear, note signs

of denial, depression or narrowed focus of attention.

Explain the procedures and care as delivered. Repeat

explanations frequently as needed. Acknowledge feelings

of normalcy feelings in this situation. Encourage patient to

share thoughts and feelings. Provide open environment in

which patient feels safe to discuss feelings. Promote calm,

quiet environment. Encourage to do deep breathing

 exercises as needed. Encourage and foster patient

interaction with support systems. Advised to do diversional

activities like watching TV or activities that can occupy

patient’s time. Convey unconditional positive regard about

the surgery.

R>Client shows relaxation and decreased the feelings of

fear, “Kalmado na ako and nakapagdecide na ako to accept

the operation, thank you!” as verbalized by the client.

SmaeRozol
Rozol, Shiela Mae
BSN-IVB - SLSU

1:00pm