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Kristine Antonette E.

Balaba
BSN 3 – Block 1

SAMPLE CHARTING

01-18-2018 RHEUMATIC HEART DISEASE


TIME FOCUS DATA, ACTION, RESPONSE
6am Received c IV fluid of PLRS 1L @ 400cc level on
right arm
c oxygen via nasal cannula at 2L pm
BP: 100/60mmHg
A: NPO reminded and maintained
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
8am Health Teaching A: Sponge bath done assisted by the undersigned
(Hygiene) KRISTINE ANTONETTE E. BALABA
WUP – SN’19
11am A: Discussed the importance of bed rest and
encouraged proper positioning to avoid distress.
KRISTINE ANTONETTE E. BALABA
WUP – SN’19

1/19/2018 DENGUE WITH WARNING SIGNS


TIME FOCUS DATA, ACTION, RESPONSE
6am Received c IV fluid of D5LRS 1L @ full level on
right arm
BP: 100/70mmHg
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
9am Health Teaching A: Full bath done assisted by the undersigned.
(Hygiene) KRISTINE ANTONETTE E. BALABA
WUP – SN’19
11am Diet A: Emphasized the importance of avoiding dark
colored foods and increasing oral fluid intake.
R: Able to consume 350cc of water.
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
2pm A: Bed rest maintained
KRISTINE ANTONETTE E. BALABA
WUP – SN’19

1/20/2018 ACUTE GLUMERULONEPHRITIS


TIME FOCUS DATA, ACTION, RESPONSE
6am Received c heparin lock on right arm
BP: 100/60mmHg
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
8am Health Teaching A: Emphasized the importance of avoiding salty
(Diet) and fatty foods such as junk foods and instant
noodles.
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
10am Seen and examined by Dr. Dela Cruz c orders
made
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
10:30am Laboratory Procedures A: Laboratory request form forwarded to
(Cholesterol) laboratory
KRISTINE ANTONETTE E. BALABA
WUP – SN’19

1/20/2018 DENGUE WITH WARNING SIGNS


TIME FOCUS DATA, ACTION, RESPONSE
6am Received c IV fluid of D5LRS 1L @ 300cc level on
right arm
BP: 100/70mmHg
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
8am Health Teaching A: Emphasized the importance of increasing oral
(Hydration) fluid intake
R: Able to consume 350cc of water
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
9:30am Seen and examined by Dr. Dela Cruz c orders
made
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
10:00am Change of IV fluid Regulation A: Present IV fluid regulated at 5gtts/min
Bed rest maintained
KRISTINE ANTONETTE E. BALABA
WUP – SN’19

1/20/2018 ACUTE GLUMERULONEPHRITIS


TIME FOCUS DATA, ACTION, RESPONSE
6am Received c heparin lock on left arm
BP: 100/70mmHg
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
8am Fluid Volume Excess D: c facial edema
A: Educate the patient to limit the daily oral fluid
intake to 500cc daily
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
10am Seen and examined by Dr. Dela Cruz c orders
made
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
10:00am Laboratory Procedure A: Laboratory request form forwarded to
(Cholesterol) laboratory
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
1/25/2018 ACUTE GLUMERULONEPHRITIS
TIME FOCUS DATA, ACTION, RESPONSE
6am Received c heparin lock on left arm
BP: 100/80mmHg
8am Health Teaching A: Full bath done assisted by the undersigned
(Hygiene) KRISTINE ANTONETTE E. BALABA
WUP – SN’19
10am Seen and examined by Dr. Dela Cruz c orders
made
2pm A: Input and output monitored
KRISTINE ANTONETTE E. BALABA
WUP – SN’19

1/25/2018 DENGUE WITH WARNING SIGNS


TIME FOCUS DATA, ACTION, RESPONSE
6am Received c IV fluid of D5LRS 1L @ 300cc level on
left arm
BP: 90/70mmHg
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
10am Seen and examined by Dr. Dela Cruz c orders
made
10:30am Health Teaching A: Emphasized the importance of increasing oral
(Hydration) fluid intake
R: Able to consume 350cc of water
KRISTINE ANTONETTE E. BALABA
WUP – SN’19
11am Laboratory Procedure A: Blood serum extracted by MTI Camajin c
(HCT, APC) request forwarded to laboratory
11:30am Above IV fluid consumed and replaced c D5LRS
1L and regulated at 22gtts
KRISTINE ANTONETTE E. BALABA
WUP – SN’19