CHARISSE DL.
LIMOS
FOCUS CHARTING
Date/Time
Dec. 1, 2011 2:00 am 2:10 am 2:20 am 4:30 am
Focus
Epigastric Pain
Progress Notes
D-Complained of pain at epigastric area with the pain scale of 4/5 A-Referred to Dr.Paa with orders Omeprazole 40 mg.given thru IV Kept patient comfortable and safe R- Epigastric pain rechecked and subsided to 1/5
1:00 am
Difficulty of breathing
D- Complained of Difficulty of breathing With chest extraction A-Oxygen administered via nasal cannula at 2-3 LPM Placed on moderate high back rest Maintained on bed rest
1:10 am
12 am 12:15 am 12:20 am
Elevated temperature
D- Temperature 39.1degrees Celsius A-Referred to Dr. Manangbao with orders Paracetamol 300mg given Thru IV Tepid sponged bath done Encouraged to increased oral fluid intake R- Temperature rechecked and subsided to 37.8 degrees Celsius
1:30 am
3:00 am
Headache
D-sobrang sakit po ng ulo ko with a pain scale of 5/5
3:15 am 3:20 am
A-placed a warm towel over the pain area Placed in a comfortable position Referred to Dr. Ortiz with orders Mannitol given 100 cc thru IV and paracetamol as ordered Maintained bed rest R- Headache rechecked and subsided to a pain scale of 2/5
5:00 am
12:00 am 12:10 am 12:25 am
Elevated Blood Pressure
D- Blood pressure 160/110mmHg A-Placed on moderate high back rest Clonidine given sublingually as ordered Maintained on Bed rest R- Blood pressure rechecked and subsided to 130/100mmHg
1:35 am
2:45 am
Low Blood Pressure
D- Blood Pressure 80/60 mmHg A-Administered oxygen via nasal cannula at 2-3 LMP Placed on Trendelenburg positon Referred to Dr. Paa with orders Fludocortisone given thru IV Maintained bed rest R- Blood pressure rechecked and increased to100/70 mmHg
2:50 am 3:00 am 4:00am
Nausea and Vomiting 2:50 am 2:55 am
D- Complained of nausea and vomit 4x A-Placed to a fowlers with a side lying position Referred to Dr. Aniwasal with orders Metoclopromide given thru IV
3:55 am 2:15 am
Maintained bed rest R-complained of being comfortable and not vomited at all.
2:20 am
Chest Pain
D-Sumasakit po ang dibdib ko as verbalized by the patient with the pain scale of 4/5 A-Referred to Dr. Ortiz with orders Isordil given 5mg sublingually Maintained on bed rest R- Chest pain rechecked and subsided to2/5
2:20am 2:25 am
3:45 am
2:35 am 2:40 am
Nose bleeding
D- Nagdudugo po ung ilong ko as verbalizedby the patient A-applying pressure by pinching patients nostril to lean forward Placed an ice cold over the nose and a piece of a gauze under the lip Rferred to Dr. Ariola with orders Tranexamic acid 500 mg given thru IV
2:50 am 2:55 am
2: 25 am
Gum Bleeding
D-Nagdudugo po yung gilagid ko as verbalized by the patient A-Encouraged to rinse with salt water Encouraged toapply pressure and advice not to brush it Tranexamic acid 500 mg and Vitamin K 1ampule given as ordered Maintained bed rest R- no bleeding noted
2:40 am 4:10 am
3:00 am
3:15 am 3:20 am
Seizure
D-Episode of seizure noted A-Placed on lateral position Maintained airway Referred to Dr. manangbao with orders Acetazolamide given thru IV R-Episode of seizure subsided
3: 45 am 2:20 am 2:27 am Numbness
D-Namamanhid po yung gawing kanang bahagi ng hita ko as verbalized by the patient A-Blood pressure 130/100mmHg Placed on moderate high back rest Encouraged to massage the area of numbness Placed a warm/cold water with towel over the numbness area Maintained bed rest
2:30 am
1:45 am 1:50 am 2:00 am
Dizziness
D- Nahihilo po ako as verbalized by the patient A-Blood pressure 130/100mmHg Placed in a comfortable position Cinnarizine1 tabgiven P.O. as ordered Maintained on bedrest R- Medyo hindi na po ako nahihilo ngayon asverbalized by the patient
3:15 am
1:10 am
Constipation
D- Ilang araw naakohindi dumudumi as verbalized by the patient A-Encouraged to increase oral fluid intake
Encouraged to eat nutritional foods that are high in fiber Encouraged to mobilized her body Lactulose 30 cc P.O given as ordered
2:00 am
2:45 am
Frequent BM
D- Madalas poakongdumumi saisang araw as verbalized by the patient A-Encouraged to uncrease oral fluid intake Encouraged to eat Banana,Rice,Apple andTea as her diet ordered Volume/volume replacement dodne as ordered
Edema 12:00 am 12:15 am
D- Nagmamanas po yung Paa ko as verbalized by the patient A- Blood pressure 120/70 mmHg Encouraged to Limit salty foods and water Assessed pitting edema with +2 Furosemide 40mg given thru IV as ordered
12:45 am
12:00 am 12: 10 am
Low platelet count
D-Platelet count 90 A-Temperature37.3 degrees Celsius, Blood Pressure- 100/80 mmHg Encouraged to avoid dark colored foods Encouraged to increase oral fluid intake Monitored bleeding and hypotension done as ordered Maintained on bed rest
2:50 am
Abdominal pain
D- sumasakit po yung tiyan ko asverbalized by the patient with a painscale of 3/5
2:55 am
A-Blood pressure-110/80 mmHg Placed inacomfortableposition Placed a warm towel over the pain Buscopan 1 tab P.O given as ordered R- Pain scale subsided to 1/5
3:15 am
