Patient A
You are assigned as a Medical Surgical Nurse in a tertiary hospital in Angeles City on a 6AM-
2PM shift. During the endorsement, the outgoing nurse is endorsing Patient A with following
verbatim handover information:
"Good morning Sir Z, endorsing patient Dela Cruz, Juan Santos, 62 year old male newly
admitted patient at
5AM
chief complaint:
Severe headache scale of 8/10
blurring of vision, nauseated
episodes of epistaxis
absence of chest pain but with palpitations
absence of dyspnea with oxygen saturation of 98%.
Initial vital signs are as follows:
afebrile temperature of 36.5
RR of 21 bpm
PR of 120 bpm
BP of 180/110 mmHg
given 1 dose of Catapres 75 mcg at 5:10am.
at the ER. Patient is on a low salt, low fat diet but current RBS this
6AM is 200 mg/dl.
ER initiated IVF of PLRS 1 liter X 50cc/hour inserted on the left arm, with an ongoing
o Nicardipine drip of 100 mg diluted in 100 ml via soluset in titration but currently
regulated at 10cc/hr".
Doctor's orders as follows:
CBC, Urinalysis, CXR, ECG all done at the ER still awaiting results, kindly follow up and
relay results to Dr. Tan including the room number. Additionally, additional blood
chemistry of FBS, Lipid profile, SGPT, SGOT, Creatinine, BUN to request for blood
extraction tomorrow and kindly inform the patient for preparation. Thank you Sir Z."
Upon further history taking and assessment, the patient shared that he is a chronic smoker for
20 years and has a family history of DM and hypertension. He was born and raised in Angeles
City, Pampanga, he used to work as a public school teacher. Patient also mentioned that he is
feeling better and has no current complaints. Nurse Z obtained the baseline vital signs and
informed Dr. Tan about the admission. He also reviewed the pertinent information to fill in the
patient's chart such as the patient's date of birth September 01, 1959 and hospital number of
2021-0098765.
Nurse Z updated Dr.Tan regarding his patient's admission through a text message: "Hi Dr. Tan,
patient Dela Cruz, Juan was admitted to room 801.
Vital signs as follows:
Temperature of 36.8
PR 98 bpm
RR 18 bpm
BP of 150/100 mmHg.
No current complaints, will relay laboratory and diagnostic results once available. Thank you."
At 11:30am, Dr. Tan had his rounds and made
Additional orders:
2D Echo tomorrow morning
Add NA, K on next blood extraction
Continue titration of Nicardipine drip and hold if BP is 130 mmHg systolic
Amlodipine (Norvasc) 10 mg/tab OD to start tomorrow at 8am
Start Losartan (Cozaar) 25 mg/tab OD give at 1 pm
Start Metformin (Glumet) 500 mg/tab BD to start at 8pm (8AM-8PM)
Give Glimepiride (Amaryl) 4mg/tab BID to start at 6pm
Start Atorvastatin (Lipitor) 10 mg/tab ODHS
CBG monitoring TID pre meals and relay (6AM-11AM-6PM)
Place patient of Bed Rest with Bathroom Privileges
NPO at 10PM for blood chemistry
Advice to include DM Diet
Kindly refer to Dr. Nines Bautista for DM management
IVF to follow: PNSS 1L X 80cc/hr
12:00nn
Vital signs monitoring
Temp of 36.8
PR 88 bpm
RR 16 bpm
BP 140/90 mmHg
2:00pm
Assessment:
Headache 4/10, no blurring of vision, not nauseated, no epistaxis, no chest pain, no DOB
latest 02 sat is 99%.
Total oral intake: 500m1 of water, 200 ml of orange juice
Urine (ml): Approximately 400mL
Stool (freq): lx
Before your shift ends, all doctor's orders were carried out on a given time and all patient's
needs were attended to.
Before your shift ends, as the Charge Nurse you need to accomplish a Nurse Endorsement
Sheet to be utilized during your hand over to the incoming nurse. The details of the other
patients are the following:
