NURSE’S NOTES
SURNAME: CORTEZ M.I.: V. AGE: 73 HOSPITAL NO.: 2021-10002
GIVEN NAME: ANTHONY SEX: M WARD/ROOM NO.: Private ward / 302
DATE-
FOCUS DATA – ACTION – RESPONSE
SHIFT
5/3/2021 Pain and Increased D: Received patient from ER; observed a lump over left hip causing pain
7-3pm Body Temperature and discomfort; Pain is 8 over 10 as verbalized by the patient; skin around
the lump is red and swollen; with initial vital signs of: BP= 121/82 mmHg; T=
38.6ºC; P= 79bpm; R=21cpm; O2 sat= 98%.
A: Consent to assist patient to comfort at ER; Consent to ask about the
patient’s data for admission; assessed medical history; Monitor the
patient’s HR, BP, and especially the tympanic or rectal temperature.
Given Acetaminophen 325-650 for Mild to Moderate Pain and to decrease
body temperature; referred accordingly.
R: Patient is uncomfortable but cooperative; Patients pain has decreased
by 7 over 10 as verbalized by the patient; temperature is still the same
38.6 ºC
PICC line care D: initial vital signs of: BP= 121/82 mmHg; T= 38.6ºC; P= 79bpm; R=21cpm;
O2 sat= 98% at room air.
A: Secured consent for PICC; explained the procedure to the patient;
prepared equipment’s to be used for the procedure; don gloves; PICC
line inserted and secured appropriately; kept PICC line clean; hooked
IVF PNSS 1L infusing well; Started Linezolid 600mg/300mL IV OD; IVF
regulated and infusing well; referred accordingly. Assessed the PICC
insertion site for redness, tenderness, or swelling, Assessed the dressing
to make sure it's clean and intact
R: Patient is comfortable and cooperative
5/4/2021 Pre-operative care D: Patient is scheduled for OR @10pa; CBC, FBS, lipid profile, BUN, crea,
7-3 pm SGPT, SGOT, CXR- PA, 12 lead ECG, results shows that there are no
abnormalities;
A: Explain the procedure, discussed anticipated things that may concern
patient; CP clearance done; Fondaparinux temporarily hold resume after
surgery; Anesthesia clearance done; secured consent for surgery;
informed OR; informed anesthesiologist; NPO post-midnight; removed
dentures; don gown; removed nail polish; removed underwear; IVF
regulated and infusing well; referred accordingly.
R: Patient appear relaxed, decreased fear and anxiety reduced to a
manageable level
5/5/2021 Post-operative care D: Received patient from OR; Patient is drowsy; with hemovac drain in
7-3 pm place.
A: Monitored drainage and bleeding; VS q15m for 1hr; q30min for 1
hour; then q1; kept NPO then gradually progressed diet when fully
awake with flatus; IVF regulated and infusing well; started omeprazole
40mg IV OD; wound dressing daily done using dry sterile dressing;
hydrocodone bitartrate/acetaminophen 10mg/300mg tab PO 30 min
prior to dressing change; referred accordingly. Assisted the patient to a
comfortable position
R: Patient is awake, breathing comfortably.
5/16/2021 Discharge D: Patient is conscious; (-) signs of infection from the incision site;
A: Informed patient of health teachings; explained about the things he
should and should not do; Take home meds aspirin 80mg tab OD;
Acetaminophen 325-650 mg tab q4hr PRN for mild to Moderate pain;
Docusate sodium 300mg cap OD; instructed patient for follow up after 1
week at MVH OPD at 10am; wound care daily. referred accordingly.
R: Patient is can enumerate some of the health teachings and activities
that will help him enhanced the performance of daily livings and
infection precautions.
NURSE’S NOTES
SURNAME: M.I.: AGE: HOSPITAL NO.:
GIVEN NAME: SEX: WARD/ROOM NO.:
DATE-
FOCUS DATA – ACTION – RESPONSE
SHIFT
NURSE’S NOTES
SURNAME: M.I.: AGE: HOSPITAL NO.:
GIVEN NAME: SEX: WARD/ROOM NO.:
DATE-
FOCUS DATA – ACTION – RESPONSE
SHIFT
NURSE’S NOTES
SURNAME: M.I.: AGE: HOSPITAL NO.:
GIVEN NAME: SEX: WARD/ROOM NO.:
DATE-
FOCUS DATA – ACTION – RESPONSE
SHIFT
