DATE/

SHIFT/
TIME

FOCUS

DATA

ACTION
RESPONSE

Sample 1

08/24/201
1
7-3 shift
Abdominal D-Patient verbalized sakit gyod akong tiyan,
9:00 AM
Pain
pain scale 8 out of 10, facial grimacing,
guarding behavior, irritable, Temperature
37.40C, pulse 70 beats per minute, respiration
18 breaths per minute.---------9:10 AM
A-Administered Hyoscine N-butyl bromide 20
mg Intravenously as per doctors order,
encouraged and demonstrated deep breathing
exercises, placed in semi Fowlers position with
10:00 AM
side rails up and locked.
R-Patient reports pain was relieved. Pain scale
5/10.------------------------------------------Lysette
Bagatua,RN

DATE/
SHIFT/
TIME

FOCUS

DATA

ACTION
RESPONSE

Sample 2

08/24/201
1
7-3 shift
1:00 PM

1:05 PM

2:00 PM

Elevated
Body
Temperatur
e

D-Init akong lawas as verbalized. With

flushed skin and warm to touch, Temperature
38. 90C via axilla, pulse 80 beats per minute,
respiration
24 breaths per minute, blood
pressure 120/80.----------------A-Performed tepid sponge bath, applied ice
cap on forehead, administered Paracetamol
250mg intravenously as per doctors order.
Encouraged adequate oral fluids intake,
provided calm environment to keep patient
comfortable.--------R-Gipaningot
na
ko,
as
verbalized,
temperature decreased to 37.20C.---------------Lysette Bagatua,RN

DATE/
SHIFT/
TIME

FOCUS

DATA

ACTION

RESPONSE

Sample 3

09/15/08
7-3 shift
9:00 AM Pain at D-Sakit man ang lugar nga naa ang dextrose as
IV Site verbalized IV site slightly swollen and with redness
9:10 AM
noted.---------A- Checked IV site and found beginning of signs of
infiltration. Closed and removed IV aseptically,
changed the whole system, reinserted the new set
aseptically into the distal portion of basilic vein, left
arm anchored, splint applied, regulated IVF as to the
9:20 AM
prescribed drops. Advised to call nurse for any
presence of pain.----------------------R-Wala na ang sakit sa akong dextrose,as
verbalized--------------------------------------------------------------M. Omamalin,RN

DATE/
SHIFT/
TIME

FOCUS

DATA

ACTION
RESPONSE

Sample 4
08/25/11
7-3 shift
9:10 AM ER to OR D-Received from ER per stretcher with side rails up and

Prelocked with ongoing IVF of PLR 1L. at 900ml level at left

Operative cephalic vein using IV cannula gauge 18 regulated at 30

Assessme drops/min., with oxygen inhalation at 3L/min. via nasal

nt
cannula, nasogastric tube attached to drainage open
bottle with bloody discharges noted, Foley Bag Catheter
connected to urobag with 100ml of tea colored urinary
9:15 AM
output. Cold clammy skin, grimace face, gnawing
abdominal pain noted.
A-Instructed patient to do deep breathing exercise.
Checked the patency of IVF drop factor, name of patient
and IVF hooked, checked the nasogastric tube and Foley
Bag Catheter if dripping well. Reviewed and checked the
patient chart if all laboratory results were attached,
surgery consent signed and availability of surgical
materials and pre operative medicines. Checked and
reviewed Operating Room checklist, jewelries, dentures,
nail beds, name tag of patient applied. All surgical and
pre operative medicines checked. BP checked 100/60, HR

DATE/
SHIFT/
TIME
9:20 AM

FOCUS

DATA

ACTION
RESPONSE

-Transported per stretcher side rails up and locked

accompanied by circulating nurse to Operating Room
9:30 AM
For
table.------------------surgical A-Placed comfortably on Operating Room table on
procedure supine position both arms strapped; orientation done
(explor on Operating Room procedures, and validated all
9:35 AM
lap)
entries
in
the
WHO
Surgical
Safety
Checklist.----------------------------------------------------------------9:45 AM
-Skin preparation done aseptically and applied sterile
10:00 AM
drapes to abdominal area. Surgical instruments,
needles, sponges counted and witnessed by
1:20 PM
circulating nurse, J. Lopez.---------------------General anesthesia induced by Dr. Evangeline S.
Ruaya.-----Exploratory Laparotomy performed by Dr. G.Realiza
1:35 PM
with
Dr.
C.
Mata
as
Surgeons
Assistant.----------------------------------------Surgical operation ended. All surgical instruments
and supplies are accounted and declared complete.
Nasogastric tube attached to drainage bottle and

1:40 PM

-R-Responsive to stimuli and pain, with spontaneous

eye opening, BP-checked 100/60, HR-90bpm, RR20bpm with IVF of PLR 1L ongoing regulated at 30
drops left cephalic vein, another line PNSS 1L. at 20
drops
right
metacarpal
vein
infusing
well.
Accompanied and transported to PACU per stretcher,
side rails up and locked. Endorsed
to nurse K.
Eguia.-----------------------------Grace Bengua,RN

DATE/
SHIFT/
TIME
PACU 1:45
PM

1:50 PM

1:55 PM

FOCUS

DATA

ACTION
RESPONSE

D-Received patient from Operating Room per stretcher,

side rails up and locked, with on-going IVF of PLR 1L. at
200 cc level at left cephalic vein at 30 drops infusing
well, another line of PNSS 1L. at 500cc level and
regulated at 200 drops/ min with nasogastric tube
attached to open drainage bottle open to drain with
bloody discharges Foley Bag Catheter connected to
urobag with 200cc of tea colored urinary output; with
oxygen
administered
at
3L/min
via
nasal
cannula.--------------------------------------------------------------------Skin cold to touch, pale looking, chilling sensation
noted.---A-placed comfortably on bed with side rails up and
locked; oxygen administered continuously at 3L/min.;
monitored blood pressure every 15 mins. Warm blanket
applied. Hot water bag cap locked tightly applied to both
upper and lower extremities post-operative; wound
checked for bleeding. Measured and recorded intake and
output. Administered Tramadol 30mg injected very slowly
thru IVTT as per Doctors order. Administered antibiotics
initially after negative skin test done as post operative

DATE/
SHIFT/
TIME
PACU3:35
PM
3:40PM

4:00 PM
4:15 PM

FOCUS

DATA

ACTION
RESPONSE

Dr. Evangeline S. Ruaya updated for patient status, BP

checked 110/70, HR 92 bpm, RR 21 bpm, T- 36.50C,
thru
text
with
reply
may
transport
to
ward------------------------------------------------R-Dili na kayo sakit akong samad mam as
verbalized by the patient. Able to move both upper
and lower extremities post-operative wound checked
for bleeding; sterile dressing intact and dry as
observed.--------------------------------------------------------A-Transported to Surgical Service, per stretcher, side
rails
up
and
locked.------------------------------------------------------------------------Endorsed to Surgical Service Ward Nurse on duty.---Kate Eguia,RN

DATE/
SHIFT/
TIME
Sample 5
8/24/2011
3-11 shift
9:15 PM

9:25 PM

9:50 PM
10:00 PM

FOCUS

Altered
comfort
related to
postoperative
pain

DATA

ACTION
RESPONSE

D-Sakit
akong
samad
sa
tiyan,
Sir
as
verbalized.----------------Facial grimace noted, irritable, moaning noted, pain
scale of 8/10, received from PACU via stretcher with
ongoing venoclysis of PLR 1L. with 900ml level left
hooked at right cephalic vein, with nasogastric tube in
place open to drain with greenish output; and
indwelling catheter in place attached to urine bag
with
output
of
450ml
yellow
tinged
urine.--------------------------------------------------------A-Placed on bed in supine position, medication record
checked for last administration of Tramadol;
instructed to do deep breathing; supported abdomen
with pillow while turning to sides, abdominal binder
applied---------------------------------------------------------------R-Sakit pa gihapon akong samad as verbalized. Still
in pain as evidenced by a pain scale of 7/10.
------------------------------------

DATE/
SHIFT/
TIME

FOCUS

DATA

ACTION
RESPONSE

Sample 5
10:35 PM

R-Arang-arang na akong pamati, Sir as verbalized,

pain has reduced as evidenced by a pain scale of
4/10. Patient understood instructions and seen
performing deep breathing. Endorsed to 11-7 shift for
continuity of care.------------------------------------M.
Galvez,RN

DATE/
SHIFT/
TIME

FOCUS

DATA

ACTION
RESPONSE

Sample 6

08/23/201
1
Altered D-Received on bed with on-going intravenous
7-3 shift
comfort:
fluid of D5LR 1 liter at 550ml level infusing well
7:00 AM
Pain
right
cephalic
vein
at
related to on
20gtts/min----------------------------------------------------post
7:30 AM Caesarea ----- n Section Sakit akong samad, as verbalized. With pain
wound scale of 8/10 BP of 130/100, pulse 105 b/min., T37.30C; restless, guarding behavior over incision

site, facial grimace, profuse sweating, pale

7:35 AM
looking.--------------------------------------------------------
A-Incision site checked with no foul smell and no

discharges; wound dressing intact and dry;

repositioned
to
Semi-Fowlers
position.

Encouraged
and
demonstrated
relaxation
8:00 AM
techniques such as deep breathing. Applied
abdominal

DATE/
SHIFT/
TIME

FOCUS

Sample 7
08/23/201
1
Anxiety
3-11 shift
3:00 PM related to
4:00 PM schedule
d surgery

4:20 PM

4:45 PM
4:50 PM

5:00 PM

DATA

ACTION
RESPONSE

D-Received with IVF of D5LR 50ml at KVO at left

cephalic vein.--Mahadlok ko sa operasyon nako unya, as
verbalized. Asked questions repeatedly regarding
surgery. Cold, clammy skin, looks worried, palelooking. BP-150/90, HR-128 b/min, RR-24 c/min,
T360C.-----------------------------------------------------------------------A-Family members encouraged to stay with the
patient. Referred to Dr. Lee for the re-explanation of
the surgical procedure. Encouraged to verbalize
feelings. Consent signed by the patient Assisted Dr.
Lee during rounds. Procurement of materials for
surgery followed-up. Provided perioperative health
teachings. Allowed to ask questions and answers
provided.------------------R-Nakasabot na ko sa operasyon. Wala na ko

DATE/
SHIFT/
TIME

FOCUS

DATA

ACTION
RESPONSE

Sample 8
8/25/2011
7-3 shift
6:50 AM Abdomin D-Nadisgrasya siya Maam, gasakit iyang tiyan as
al pain verbalized by wife. Brought in per stretcher, pale and
Scale of cold clammy skin noted, in severe pain scale of 9/10,
9/10

in moderate respiratory distress bluish contusion 6cm

observed at the right temporo-parietal and in the left

parietal areas. Abdominal pain noted as evidenced by

grimaced face, with a board-like abdomen on

6:55 AM
palpation, slightly restless, GCS 15/15, T-360C P-110

beats/min R-42 breaths/min BP-50/30.----

Placed on bed with side rails up and locked, with head
6:57 AM
of bed elevated to 300 angle, 02 inhalation

administered at 3-4 L/min via nasal cannula. Ice pack

applied to contusions. ---------------------Seen and examined by Dr. Genesis Realiza, consent

for admission signed by wife. Started with venoclysis
of PLR 1L at fast drip for the first 500ml hooked at the
left cephalic vein using IV cannula gauge 18, then
regulated to 60 gtts/min. Another line initiated at the

DATE/
SHIFT/
TIME
7:00 AM

7:30 AM

7:50 AM

FOCUS

DATA

ACTION
RESPONSE

R-BP rechecked 80/40 P-120 beats/min R-44

breaths/min, sakit kayo akong tiyan Maam, as
verbalized .-------------------------------A-Ketorolac 30mg IVTT given as ordered stat. Brought
to the X-ray and accompanied by nurse M. Omamalin
per stretcher with side rails up and locked for
abdominal x-ray flat plate and upright view; stat CBC,
BT taken by Medical Technologist Antonio Lagod. ------X-ray plates and CBC results seen by Dr. Realiza,
orders given. Scheduled for an emergency exploratory
laparotomy, consent for surgery and induction of
anesthesia signed by wife, after proper explanation of
pre-operative and post-operative procedure done by
Dr. Realiza. Nasogastric tube Fr.16 inserted at the
right nostril by Dr. Realiza and open to drain; Foley
Bag Catheter Fr.16 inserted aseptically by nurse M.
Omamalin and attached to urobag with tea colored
urine output at 150ml level. Instructed the wife to
secure 2 units of blood of patients blood type A +
for possible surgical operative use. OR nurse Mr. Mark

DATE/
SHIFT/
TIME
8:20 AM

8:55 AM

9:15 AM

FOCUS

DATA

ACTION
RESPONSE

Cefuroxime 1.5gm administered as loading dose via

IVTT after a negative skin test and no adverse drug
reaction noted after 30
minutes.-----------------------------------------------------------------------R- Prescribed drugs and surgical supplies already
available. Still with abdominal pain, scale of 8/10,
moderate bloody discharges in NGT, T-36.80C, PR-12
beats/m, RR-40 breaths/min, BP-90/60--A- Transported to OR per stretcher with side rails up
and locked and complete drugs and surgical supplies
needed.----------Nesle Lim, RN

DATE/
SHIFT/
TIME

FOCUS

Sample 9
7/23/2011
7-3 shift
10:00 AM Constipati
on

10:15 AM

11:00 AM

DATA

ACTION
RESPONSE

D-Maam, tulo na kaadlaw wala ko nakalibang as

verbalized.
Stomach distended, hypoactive bowel sound upon
auscultation noted; irritable, T-7.80C, PR-80 bpm, RR28 bpm BP-130/90.---A-Given suppository per Doctors order and provided
privacy; advised to increase fluid intake and eat foods
high in fiber like green leafy vegetables (kangkong,
pechay, malunggay) and fruits (papaya, pineapple),
encouraged mobility-----------------------------R- Able to defecate and felt comfortable.-----------------Belia Bohol,RN

DATE/
SHIFT/
TIME
Sample
10
8/23/2011
3-11 shift
3:05 PM

3:10 PM

3:15 PM

6:00 PM

11:00 PM

FOCUS

Ineffective
air way
clearance
related to
excessive
mucous
secretions

DATA

ACTION
RESPONSE

D-Naglisod ko og ginhawa as verbalized, with

labored
breathing,
productive
cough
with
mucopurulent seceretions, RR-30 bpm, with slight
flaring
of
nostrils----------------------------------------------------A-Lowered the bed, placed on high Fowlers position
with side rails up and locked; administered Oxygen at
3 liters per minute; loosened clothing and made
comfortable-----------------------------Referred to Dr. Maurice Montecillo. Orders given;
nebulized with 1 nebule as ordered; PLR 1L started at
15gtts/min at right metacarpal vein infusing well;
demonstrated back tapping after nebulization,
encouraged and demonstrated deep breathing and
coughing exercises, encouraged increase oral fluids
intake to 8-10 glasses per day; provided a calm and
well
ventilated
environment
free
from

DATE/
SHIFT/
TIME
Sample
11
8/25/2011
7-3 shift
11:50AM

12:00
Noon

12:05 PM

12:15 PM

FOCUS

Elevated
blood
pressure

DATA

ACTION
RESPONSE

Admitted this 52 y.o. female with complaints of body

malaise and numbness at left side of the body with
onset of headache prior to
admission.-------------------------------------------------------------------D- Lain iyang pamati, bas verbalized by the
daughter, Maria Realiza. Patient is lethargic with facial
drooping noted, with slurred speech, with initial vital
signs of BP 180/100, HR-132 bpm T-37.20C per
axilla.----------------------------------------------------------------------A-Ushered to ER bed and positioned to semi-Fowler,
side rails up and locked, initiated with humidified
oxygen support at 3-4 liters per minute via nasal
cannula. Consent to care signed by the daughter,
Maria Realiza, Referred to resident on duty Dr. Lucy
Itok about this

DATE/
SHIFT/
TIME
12:25 PM

12:30 PM

2:00 PM

FOCUS

DATA

ACTION
RESPONSE

-CBC, BUN, CREA, Lipid Profile, FBS requests sent to

laboratory. EKG taken and referred to Dr. Itok for
interpretation---------------------Informed the watcher about ICU admission. Consent
for ICU admission signed by daughter, Maria Realiza.
ICU informed about this admission. Request for Plain
Brain CT Scan and chest X-Ray AP view handed over
to watcher for payment at Cashiers Office. Referred
to neurosurgeon, Dr. Jones for evaluation and
management thru phone call and responded will see
the patient later. CT Scan and Chest X-Ray taken as
accompanied by ER Nurse, Mark Galvez, and
transported to ICU per stretcher with side rails up and
locked.----------------------------------------------------------Endorsed
to
ICU
Nurse
on
duty,
Rhoda
Ordinaria.---------------------------------------------------------------------------------------Gerry Zamoras,RN

DATE/
SHIFT/
TIME
Sample
12
8/25/2011
3-11 shift
3:00 PM

3:10 PM

4:00 PM

FOCUS

Elevated
Blood
Pressure
160/90

DATA

ACTION
RESPONSE

D-Appears lethargic , cold and clammy skin noted,

flaccid muscle tone on the left side of the body; right
facial drooping noted, slurred speech, able to move all
extremities per command but with left hemiparesis;
eye opening is appreciated upon name calling;
anisocoric, pupillary size of 6mm at right eye and 34mm at left eye; right pupil is sluggishly reactive to
light while left pupil is briskly reactive to light
accommodation. BP-160/90, HR-98 bpm, RR-23 cpm,
T-370C.-------------------------------------------------------A-Placed on bed with side rails up and locked; head of
bed elevated at 300 angle; oxygen inhalation
administered; hooked to cardiac monitor and pulse
oximeter attached; visited by Medtech for blood
extraction, CBC, BUN, CREA.--------------------------------Visited by Dr. Jones. Orders given and carried out
properly. Serum Na+ and K+ determination request

DATE/
SHIFT/
TIME
4:15 PM

5:15
6:30
9:30
10:30

PM

PM
PM

PM

FOCUS

DATA

ACTION
RESPONSE

-Mannitol 20% 500ml given 150ml at fast drip using

large bore needle gauge 19; Nicardipine in 80ml of
D5Water via soluset at initial rate of 100 microdrips
per minute and titrated by increments of 5 microdrips
per minute every 15 minutes to maintain systolic BP
range of 120-150 as ordered. Arterial blood specimen
extraction done aseptically by Dr. Jones and sent to
laboratory.------------Laboratory results for CBC, S CREA, BUN and ABG in.
Relayed to Dr. Jones thru SMS, updated patients
status and replied ok thanks--R-BP
rechecked
140/80.--------------------------------------------------A-Visited patient and encouraged verbalization of any
medical problems such as headache. Continuous BP
monitoring done.
R-Last BP 140/80 for FBS and lipid profile
determination in AM. Endorsed to next shift Nurse J.
Bataga.------------Rhoda Ordinaria,RN

DATE/
SHIFT/
TIME
8/25/2011
11-7 shift
11:00 PM

12:00 MN

FOCUS

DATA

ACTION
RESPONSE

D-Received on bed awake with head of bed at 300

angle elevation, with ongoing IVF of PNSS 1L hooked
at left metacarpal vein flowing at 20 drops/min
infusing well, with 160ml level left with starting dose
of Nicardipine Drip (80ml D5W + 20mg) at 10
microdrips/min. rate. With ongoing humidified 02
inhalation at 3-4 l/min. via nasal cannula, with
indwelling urinary catheter attached to urine bag,
patent and draining well; contains bright yellow urine
with
approximately
150ml
in
volume.
With
multiparameter cardiac monitor attachment, right
facial area drooped. As noted, with pupillary size of
right eye 5-6mm, left eye 3-4mm, right pupil is
sluggishly reactive to light, while left pupil is briskly
reactive to light accommodation, able to move all
extremities per command, slurred speech, with
spontaneous eye opening. -------------------

DATE/
SHIFT/
TIME
12:10 AM
12:13 AM
12:15 AM

2:00 AM

3:00 AM
6:45 AM

FOCUS

DATA

ACTION
RESPONSE

A-Dim light provided, applied ice pack over the right

parietal area.--Referred to Dr. Jones thru phone call, orders made
and carried out properly. STAT dose of Tramadol 25mg
given slow IV as ordered, STAT dose of Mannitol 20%
100ml given via IV fast drip as ordered. Unnecessary
disturbance avoided and promoted a cool, calm and
quite
non
stimulating
environment.---------------------------------R-Nawala-wala na ang labad sa akong ulo Maam as
verbalized by patient, pain scale of 4/10.
----------------------------------------------A-Seen
soundly
asleep
and
undisturbed.----------------------------R-Verbalized to be free from pain; Still for lipid profile
and FBS determination.-----------------------------------------Rhoda Ordinaria,RN

DATE/
SHIFT/
TIME
8/26/2011
7-3 shift
7:30 AM

7:45 AM
7:50 AM
7:55 AM

FOCUS

DATA

ACTION
RESPONSE

D-Received on bed in supine position at 300 angle

head of bed elevation. With ongoing IVF of PNSS 1L at
20 drops/min at left metacarpal vein with 520 fluid
level left, with side drips of 20ml Nicardipine and 80ml
of D5W via soluset at 10 drips/min; with humidified
oxygen inhalation at 3-4 liters per minute via nasal
cannula with indwelling urinary catheter attached to
urine bag with yellow colored urine at approximately
200ml. Appears conscious with spontaneous eye
opening and pupillary size of 5mm sluggishly reactive
to light at right eye and 3mm briskly reactive to light
at left eye, patient show body weakness but able to
move all extremities per command, with slurred
speech as verbal response. Initial vital signs of BP130/90, HR-82 bpm, RR-20 cpm, T-36.50C.----------A-Oatmeal diet was served to the patient and able to
consumed 8 spoonfuls of the food. On Aspiration

DATE/
SHIFT/
TIME
7:40 AM
7:48 Am
7:52 AM

FOCUS

DATA

ACTION
RESPONSE

-Visited on bed and encouraged to verbalize feelings.

Positioned to semi-fowlers and maintained safety
measures by placing side rails up and locked.
Informed the daughter regarding the transfer and
8:00 AM
given options regarding various accommodations.
8:15 AM
--------------Family member opted to be accommodated at suite
8:25 AM Knowledg room. Informed station nurse on duty thru phone call
e deficit on
patients
8:28 AM related to transfer.---------------------------------------------------------------disease -------process, D-Maam, unsa kaayo ang ginadili nakong kan-on?
lifestyle
as asked by patient. Appears confused and
worried.-----------------------------9:00 AM
A-Explained the importance of lifestyle and diet
modification
and
advantages
of
compliance.
9:15 AM
Instructed also to avoid taking alcohol and smoking.
Encouraged patient to limit intake of high sodium,
high fat and high cholesterol diet, instead encouraged
increased intake of green leafy vegetables and high

DATE/
SHIFT/
TIME
9:28 AM

10:00 AM

11:15 Am

11:23 AM

FOCUS

DATA

ACTION
RESPONSE

A-Assisted Dr. Jones during visit. For referral to

physical therapist for further management as ordered.
Request form sent to rehab unit by the nursing
attendant Ms. Nayal. Take home medication was
ordered and carried out correctly at discharge
instruction
sheet.-------------------------------------------------------------------------A-Assisted family member during visiting hour. Health
teaching was imparted on the importance of constant
monitoring of blood pressure, the compliance of
medication and the importance of early consultation
for any health care related problems. Take home
medications discussed and explained to the patient
and the daughter. Reminded also regarding the
patients next scheduled visit on September 21, 2011
at 8am, OPD.--------------------------R-Patient able to enumerate all take home
medications with correct dosage and timing. Patients
daughter
verbalized
Nakasabot
nako

DATE/
SHIFT/
TIME

FOCUS

11:25 AM
Pre assessme
nt upon
patient
transfer
11:40 AM

11:57 AM

DATA

ACTION
RESPONSE

D-Awake and responsive, free form any pain, still

slurred speech as verbal response, body weakness
still noted but able to move all extremities at times
without any command. Pretransport vital signs are BP130/90, HR-76 bpm, RR-18 cardiac per minute, T-370C
per
axilla.-------------------------------------------------------------------------A-Transported to Suite Room per stretcher with side
rails up and locked. Aided throughout the
transport.----------------------------Informed attending physicians Dr. Itok and Dr. Jones
that patient was transferred at Suite Room with room
number
307
thru
phone
call.----------------------------------------------------------------------------R-Still awaiting to be seen by Physical Therapist for
daily range of motion exercises. Discharge instruction
sheet was attached to chart and to be given to the
family prior to discharge. Endorsed to nurse on

DATE/
SHIFT/
TIME

FOCUS

DATA

ACTION
RESPONSE

Sample
13
8/25/2011
Received from medical ward per wheelchair with 02
6-2 shift
inhalation
on
going
at
5-6L/ml
via
nasal
6:00 AM Hemodialy cannula.------------------------------------ sis with D-Naglisod ko ug ginhawa Maam as verbalized;
pulmonary oriented to place, date and time; labored breathing
congestio noted with flaring of nostrils; weight gain of 4.0kgs;
6:05 AM
n
BP-150/100; with heplock on right metacarpal
vein.------------------------------------------------------------A-Assisted comfortably to the hemodialysis chair;

consent for hemodialysis signed by wife; skin

6:10 AM
preparation of arteriovenous fistula access done
aseptically and with positive thrill upon palpation;
cannulated with ease.--------------------------------------Hemodialysis started scheduled for 4 hours with
ultrafiltration goal of 4.0 liters and ultrafiltration rate
7:08 AM
of 250-350 ml/min; 2000 units of regular heparin
given as IV bolus and 1000 units every hour
thereafter as anticoagulant;monitored for signs of
hypotension; BP/HR monitoring done every 15

DATE/
SHIFT/
TIME

FOCUS

DATA

ACTION
RESPONSE

9:00 AM
R-Puede na ko dili mag-02 Maam kay mayo na ang

akong ginhawa, patient verbalized; looks relaxed and

normal
breathing
pattern
was
9:05 AM
Health
observed.---------------------------------------------------- teaching A-Reinforced teaching given to both patient and wife

with
to limit oral fluid intake to 700ml/day to avoid
discharge dyspneic attack; instructed to have a low-salt, low fat
instruction and low purine diet; reminded patient of saving left

s
arm to prevent potential damage to access site for
10:10 AM
future

use.--------------------------------------------------------------------
-Encouraged patient to come on his next hemodialysis
schedule.

R-Mag-control na ko sa akong imnon ug magbantay

10:40 AM
na ko kung unsa akong kaunon, as verbalized by
patient HD completed; cannula removed and pressure
dressing is applied; heplock removed and dressed;
assisted patient to upright position and 5 mins. to
prevent orthostatic hypotension. --------------------------