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8:10pm
8:15pm
8:25pm
8:30pm Safety and
comfort
8:35pm
8:45pm
9:15pm Cough
9:50pm
10:10pm Inadequate
urine output
10:20pm
11:00pm
11:20pm
12/30/14 12:00am Safety and
comfort
12:10am Post-operative
12:20am care
1:00am
1:45am
2:10am Pain
2:15am
2:30am
2:40am
Seen
patient
resting
comfortably --------------- kbv
A
Provided
adequate
rest
periods ----------------- kbv
A Provided environment conducive for
sleep-- kbv
A
Monitored
JP
drain:
9cc----------------------------- kbv
A
Urine
output:
45cc------------------------------------- kbv
A Furosemide(Lasix)20mg IV given as
ordered- kbv
R
Urine
output:
58cc ------------------------------------ kbv
R Monitored for the further recurrence of
output
inadequacy ------------------------------------------------kbv
A
Seen
patient
asleep ---------------------------------- kbv
A Patient complaints of pain on IV site, graded
6/10,
swollen
upon
inspection ------------------------- kbv
A Placed warm compress on area for
15mins kbv
A Reassessed patient, still with 6/10
pain --------- kbv
A
Informed
MROD
through
SMS --------------------- kbv
A
Continued
present
3:10am
3:20am
4:00am
4:15am
5:00am Post-operative
care
5:40am
6:00am
Safety and
comfort
With
increasing
pain,
graded
7/10 -------------- kbv
A
Informed
MROD --------------------------------------- kbv
R Changed IV site to left hand; with IVF
infusing
well; with no complaints of pain in new site;
3/10
over
previous
site ------------------------------------------- kbv
A
Drained
JP:
8cc ---------------------------------------- kbv
A Seen patient, not in any distress, no
subjective
complaints -------------------------------------------------- kbv
A
CBG
taken:
118mg/dl ------------------------------- kbv
R With stable vital signs: 130/80mmHg,
80bpm,
19cpm, 37.4'C; With dressing dry & intact;
foley
catheter draining well; total JP output for entire
shift:
28cc,
draining
sanguineous
fluid -------------- kbv
R Patient comfortable, no untoward incident
during
entire
shift ------------------------------------------- kbv
kbvicente
Kerstin Karen B. Vicente, RN
Lic. No. 766245
R Endorsed patient to -------, RN for continuity
of
care------------------------------------------------------------ kbv