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    San Pedro Hospital of Davao City, Inc.: Nurses' Notes

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    Jhulia Gamutin
    San Pedro Hospital of Davao City, Inc. provided nursing notes for patient Steve Marquez who was admitted to the San Lorenzo Ward, Room 409. The notes document Mr. Marquez's condition and treatments over a 12 hour period on September 9, 2021, including observations of cyanosis, tachypneic breathing and grunting. He received intravenous fluids and oxygen support. His vital signs were monitored regularly and he was examined by Dr. J. Gullardo. Urine and stool specimens were also collected and sent to the lab.

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    San Pedro Hospital of Davao City, Inc.: Nurses' Notes

    Uploaded by

    Jhulia Gamutin
    1K views3 pages
    San Pedro Hospital of Davao City, Inc. provided nursing notes for patient Steve Marquez who was admitted to the San Lorenzo Ward, Room 409. The notes document Mr. Marquez's condition and treatments over a 12 hour period on September 9, 2021, including observations of cyanosis, tachypneic breathing and grunting. He received intravenous fluids and oxygen support. His vital signs were monitored regularly and he was examined by Dr. J. Gullardo. Urine and stool specimens were also collected and sent to the lab.

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    San Pedro Hospital of Davao City, Inc. provided nursing notes for patient Steve Marquez who was admitted to the San Lorenzo Ward, Room 409. The notes document Mr. Marquez's condition and treatments over a 12 hour period on September 9, 2021, including observations of cyanosis, tachypneic breathing and grunting. He received intravenous fluids and oxygen support. His vital signs were monitored regularly and he was examined by Dr. J. Gullardo. Urine and stool specimens were also collected and sent to the lab.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views3 pages

    San Pedro Hospital of Davao City, Inc.: Nurses' Notes

    Uploaded by

    Jhulia Gamutin
    San Pedro Hospital of Davao City, Inc. provided nursing notes for patient Steve Marquez who was admitted to the San Lorenzo Ward, Room 409. The notes document Mr. Marquez's condition and treatments over a 12 hour period on September 9, 2021, including observations of cyanosis, tachypneic breathing and grunting. He received intravenous fluids and oxygen support. His vital signs were monitored regularly and he was examined by Dr. J. Gullardo. Urine and stool specimens were also collected and sent to the lab.

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    San Pedro Hospital of Davao City, Inc.

    C. Guzman St., 8000 Davao City, Philippines


    Tel. No. (082) 222-6100 Fax No. (082) 226-4714
    Website: www.sanpedrohospitaldavao.com
    Email: sanpedrohospital@yahoo.com

    NURSES’ NOTES

    Name: Marquez, Steve Ward: San Lorenzo Room/Bed No.: Room 409

    DATE TIME
    09/09/2021 3-11 3:00 pm Received asleep on bed
    Circu-oral cyanosis noted;

    Tachypneic breathing noted; grunting noted

    Skin is warm to touch, with capillary refill time at 3-4 seconds

    With mainline IVF of D10W 48 cc + Calcium gluconate 2 cc, @ 50 cc fluid

    running at 10 cc/hr via infusion pump ; infusing well on the left

    great saphenous vein

    Still for urinalysis and stool exam ; stool exam container provided and attached

    wee bag

    4:00 pm VS checked and recorded: RR 62cpm; T: 37.5 C ; CR: 63bpm ; NOD aware

    Bedside care done ; linen stretched and tucked well

    4: 10 pm TSB rendered

    Rendered O2 support at 3 L/min

    4: 30 pm Temperature rechecked: Temp: 36.5 C

    5:00 pm Health teachings rendered to mother, such as

    A. Maintain on NPO

    B. Maintain O2 support

    B. prompt referral for unusualities like, cyanosis. Increased temperatures

    C. Handwashing before and after patient care

    D. Facilitate proper urine specimen collection

    6:00 pm Vs rechecked and noted ; afebrile

    6:10 pm Seen and examined by Dr. J. Gullardo ; with orders made

    7:00 pm Due medications given


    Urine specimen saved and sent to lab

    7:30 pm Stool specimen saved and sent to lab

    8:00 pm Mother instructed to resume breastfeeding with strict aspiration precaution as


    ordered
    8:30 pm Above IVF consumed and followed up eith same D10W 48 cc + 2 cc Calcium

    gluconate regulated at 10 cc/hr via infusion pump

    Cuddled and breastfed by mother with sucking reflex : burped thereafter

    9:00 pm Cried at times

    Capiilary blood glucose taken: 50 mg/dL ; NOD aware

    10:00 pm Vs rechecked ; afebrile

    10:30 pm Above IVF disloged ; kept set sterile

    10:45 pm IVF reinserted by PGI Corpuz

    11:00 pm Left lying on bed with mother at bedside

    Jhulia Anne F. Gamutin, St. N / CI’s Signature / NOD’s Signature

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