Isnaira A.

Imam BSN-III
11-24-20

Daily Objectives
At the end the online duty the student nurse will be able to:
 Endorse our charting
 Present bedside clinic
 Live performance

Daily Notation
 In the sixth day of the duty, we have our endorsement
 Patient loading
 Making nurses notes
 Bed side clinic

_____________________
C.I’s Signature

Date:________________
Isnaira A. Imam BSN-III

Patient Name: Brianne Blanco Attending Physician: Dr.Monton

Room #: 262 Age: 25
Chief Complain: Cough x 1mo

NURSES NOTES
Date & time  Received patient lying on bed; awake
11-24-20  Coherent and responsive upon interaction
7:00 AM  Suctioning sputum for AFB; done
 With IVF #7 D5LR IL @30gtts/min inserted @ the
right metacarpal vein infusing well @ the level
9:00AM
of 700.
 Initial vital signs taken: T-37.2°C, P-89bmp, RR-
19brpm, BP- 110/80 mmHg, O2sat- 98%
10:00AM
 Morning care done
11:00AM
 Bed side care done
 Seen and examined by Dr. Monton with order
12:00 NN carried out.
 Vital signs rechecked and recorded: T-37.1°C, P-
12:20PM 80bpm, RR-19brpm, BP-120/80mmHg, O2sat-
97%
 Meal served; consumed share
 Health teachings instructed to patient as
follows:
-To have enough sleep and rest to regain strength.
-Limit visitors to prevent spreading of
12:40pm
microorganism.
-Advise to wear mask.
-Wear PPE before entering the room
1:00PM -Maintain negative air pressure room
-Encourage to increased fluid intake.
 Vital signs rechecked; T-37.2°C, P-85bpm, RR-20
brpm, BP- 110/80mmHg, O2sat-97%
 Needs attended
 Endorsed to NOD for continuity of care with same IVF and flow
rate.IMAM/
S.N