8/10/20 Tan,

9:50
10:00
8:15
8:20
8:00
9:35
9:05
9:39
8:10
8:55
8:40
8:30
Juana B.Na.
Azithromycin
Cefuroxime
Cefuroxime
Chest
Catapres
K,ECG
O2
Creatinine,
PNSS
x-ray
2L/min
12 75
leads
1L
750
PA
0.1
500
mcg
view
cc
BUN
mg
mg Brought
Admitted
Endorsed
Done
Given
Started
BP
Injected
Done
Given
Given
Started
rechecked
by
1by
IVTT
1as
tab
to
x-ray
as
heart
45
medical
tab
to
via
IVF
room
skin
as
staff
year
SL
nasal
technician.
at
140/80
first
station
as
test
A315
Left
nurse
old
technologist.
for
dose.
cannula
at
male
cephalic
BP
per
personnel.
right
on>149/90
Brought GAGelera
stretcher.
ambulatory
duty.
as
volar
vein.
ordered.
area.
back
mmHg.
Gtts.
Made
with CPUSN/Charisse
toRegulated
ER.
comfortable
a chief
012345 Pedroso
complain
at 88on
cc/hr.
bed. CPU CI
of cough.
Vital
mmHg.sign taken Temp.=37.4ᵒC, P = 100 beats/min, RR = 21breathe/min,
Skin
Brought
test to
to x-ray
cefuroxime
department
interpreted
per stretcher.
as negative
BP = 160/90 mmHg, Wt = 51 kg.

Assessed by Dr. Gan with orders, carried out.

09/05/20 8am Awake on bed c D5LR x 80cc/H, infusing well @ L

metacarpal, 200cc, c dressing @ RLQ soaked with
serosanguinous discharges, c foley catheter draining to
100cc of yellowish urine, NPO maintained.
9am Dr. __________ made rounds, orders noted.
Dressing Changed by same, made comfortable after.
9:15am
D5LR 1L x 80cc/hr As follow-up, gtts. Regulated.
Done, with result of 130mg/dL, SNOD_____ informed.
10:30am CBG
Afebrile, BP-110/90mmHg, PR-20bpm.
12pm
Complained of pain at the post-operative site.
12:30pm
Pain scale 8/10. Referred to SNOD___.
Given PRN as advised.
12:40pm Tramadol 100mg/tab 1tab
Relieved of pain as verbalized.
1:10pm
Resting on bed, c foley cather in place, dressing intact.
3pm
Student Signature
Robeanna M. Diesto CPUSN/ CI signature