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Nurses Notes: Student Nurse: Casas, Jannen A. Patient's Name: - N.T.M - Doctor: Bed No.

This summarizes the nurses notes for a patient being treated for excess fluid volume. The notes document the patient's condition, treatments administered including IV fluid regulation and diuretic medication, and the patient's responses. Vital signs, intake and output, lab results, and the physician were referenced in the ongoing care and monitoring of the patient's fluid management.

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Jannen Casas
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1K views2 pages

Nurses Notes: Student Nurse: Casas, Jannen A. Patient's Name: - N.T.M - Doctor: Bed No.

This summarizes the nurses notes for a patient being treated for excess fluid volume. The notes document the patient's condition, treatments administered including IV fluid regulation and diuretic medication, and the patient's responses. Vital signs, intake and output, lab results, and the physician were referenced in the ongoing care and monitoring of the patient's fluid management.

Uploaded by

Jannen Casas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Silliman University Medical Center

Dumaguete City

NURSES NOTES

Student Nurse: Casas, Jannen A.

Patient’s Name: ____N.T.M_____________ Doctor: Dr. Leo Gloria Bollos (LGB), Dr. Maria Isabelle Momongan
Arco Bed No.: _______________ Form No. 2019-01

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


10/27/2020 0800H Excess Fluid Volume D: Received lying in a semi-fowlers bed position. Awake,
responsive, comfortable, and oriented to time, place, and
people; w/ 1L IVF infused @950ml running @33gtts/min
attached to L metacarpal; Edema on both lower legs noted;
Periorbital edema on both eyes; Cough with dyspnea
when flat on bed;Gross hematuria, 2+ protein in urine;
oliguric (387 ml)-------------------------------------------------
Vital signs(in pt chart): BP: 150/100mmHg, RR:20cpm----
A: Vital signs taken gain and recorded - BP: 150/100mmHg,
RR:20cpm; noted amount/rate of fluid intake from all sources,
auscultated breath sounds ---------------------------------------------
1000H A: Review lab data like BUN, Creatinine, Serum electrolyte,
restrict sodium and fluid intake , recorded I&O accurately and
calculate fluid volume balance; strictly monitored of intake and
output---------------------------------------------------------------------
1200H A: Regulate IVF @550ml to run @15gtts/min; Instruct pt and
SO on fluid restriction; health teach on elevating edematous
extremities; instruct pt & SO on repositioning every 2 hrs -------
R: pt participated and tolerated the therapy well. Positioned to
high-fowlers and made comfortable to bed; There is still edema,
theres is still fluid volume excess; Refer to physician
accordingly.--------------------------------------------------------------
10/27/2020 0800H Excess Fluid Volume D: Received lying in a semi-fowlers bed position. Awake,
2 responsive, anxious, and oriented to time, place, and
people; w/ 1l IVF infused @460 ml running @15gtts/min
attached to Left metacarpal vein; Edema on both lower
legs noted; Periorbital edema on both eyes; Cough with
dyspnea when flat on bed;Gross hematuria, 2+ protein in
urine; oliguric (380ml)-------------------------------------------
0900H A: Vital signs taken and recorded: BP: 150/90mmHg,
RR:21cpm; note amount/rate of fluid intake from all
sources, auscultate breath sounds, Review lab data like
BUN, Creatinine, Serum electrolyte, restrict sodium and
fluid intake, record I&O accurately and calculate fluid
volume balance; strict monitoring of intake and output

>Administered due diuretics. 5mg/pptab Furosemide.


1000H Elevated BP A: administered due hypertensive; initiated relaxation
techniques; health teach on stress management
1200H R: pt participated and tolerated the therapy well;Positioned
to high-fowlers and made comfortable to bed; frequent
urination of pt recorded; refer to physician according on
IVF hourly volume and fluid restriction; endorsed.

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