7/28/2019 With IVF

1/4

With IVF of PNSS 1L on around 480cc level and regulated at 21gtts/min and on around _____

consumed and replaced with PNSS I L on full level and regulated at same rate; with side drip of

PNSS 64 cc + 8 ampules of Furosemide on volumetric chamber on around 20 cc level and

regulated at 10 mgtts/min; with on going blood transfusion of 1 unit packed RBC typed B with

serial number 098768 and regulated at 20 gtts/min; with endotracheal tube connected to

continuous manual resuscitator with oxygen at 10LPM; with oxygen inhalation on at 2-3L/min

via nasal cannula; with Nasogastric Tube intact for feeding; with foley catheter coonectec to

urine bag draining to (color of urine)output; with chest thoracostomy tube connected to water

sealed drainage with reddish pleaural output

BP-90/70mm/Hg, CR-98, RR-25, Febrile 38.8C; Tepid sponge bath done and cold compress

placed over the forehead; on around_____ temperature rechecked and became ____

Examined by Dr. _______ with orders made

Consumed one cup of rice, one piece of fish and one glass of water

Bronchial tapping done after nebulization

BP-110/80 (1hr before the end of shift)

Endorsed for continuity of care

FC

Foley catheter Fr.16 connected to urine bag inserted aseptically with yellowish urine

output of around 300ml

With foley catheter to urine bag draining to (color of urine)output

Foley catheter removed aseptically

NGT

NGT Fr.16 inserted by Dr. ________ (and connected to bedside bottle)

With NGT for osterized feeding

With NGT connected to bedside bottle with brownish gastric output

Osterized feeding of 170 ml + 60ml of water given per NGT and well tolerated

7/28/2019 With IVF

2/4

PainD:

Reports of sharp pain on the abdominal incision area with a pain scale of 8 out of 10

Facial grimacing

Guarding behavior

Restless and irritable

A:

Administered Celecoxib 200mg IV

Encouraged deep breathing exercises and relaxation techniques

Kept patient comfortable and safe

R:

Patient reports pain was relieved

Hyperthermia

D:

Temperature of 38.9 OC via axilla

Skin is flushed and warm to touch

A:

Tepid Sponge Bath (TSB) done7:30pm

Administered 250mg IV Paracetamol as per doctors order

Encouraged adequate oral fluid intake

Encouraged adequate rest

R:

10:00pm>Temperature decreased from 38.9 to 37.1 OC

7/28/2019 With IVF

3/4

F1: Ineffective Breathing Pattern

D1: increase respiratory rate of 24 cpm

D2: use of accessory muscle to breath

D3: presence of nonproductive cough

F2: Hyperthermia

D1: skin warm and flush to touched

D2: increased body temperature of T= 38.9 degree celsius/axilla

F3: Fatigue

D1: less movement noted

A: 9:00am monitored v/s and charted

regulated IVF and charted

morning care done

assessed patient needs and performed handwashing before handling the patient

advised SO to always stay on patient bedside

promote proper ventilation and a therapeutic environment

elevated the head of the bed (moderate high back rest)

provided comfort measures and provide opportunity for patient to rest

due meds given

9:30am

tepid sponge bath done

instructed SO to provide blanket and let patient wear loose clothing

F4: Discharge Plan (12:00nn)D1: discharged order given by Dr.Name/Time

Madvised SO to give the ff. meds at the right time, dose, frequency and route

Eencouraged to maintain cleanliness of the house and surroundings

7/28/2019 With IVF

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Tadvised to go to follow-up consultations on the prescribed date

Hencouraged to do chest tapping to facilitate mobilization of secretion

Oobserved for signs of super infections such as fever, black fury tongue and foul

odor discharges

Dencouraged to eat fresh vegetables and fish

Sadvised to continue praying to God and hear mass on Sunday

2:00pmout of the room per wheelchair with improved condition