October 24, Initial Assessment D - Arrived at ER, a 40-year-old female, awake,
2020 restless but coherent accompanied by sister via 8:00 AM wheelchair with chief complaints of body weakness, abdominal pain, hematochezia, odynophagia and purple spots inside the mouth. A - Ushered to bed; Assisted to comfortable position. Raised and locked siderails. Vital signs taken and recorded as follows - BP: 80/60mmHg, PR: 65 bpm, RR: 20cpm, Temp: 36.2 C, and O2 Sat of 90%. Seen and examined by ER ROD with orders carried out. Secured consent for admission signed by patient. Referred/ Facilitated CBC plt, blood typing, APTT, PT, bleeding time, & One-stage factor Assay: Intrinsic Coagulation System determination laboratory and diagnostic exams STAT. 8:05 AM Started IVF of D5LR IL regulated at 20gtts/min, infusing well with IV cannula gauge 20 at right metacarpal vein. 8:10 AM Administered Tranexamic Acid 500 mg via IV. ---------------- 8:20 AM Fluid Volume Deficit D – “Nagiinuro ako hin dugo ngan nanhahagkot na gad ako baga ako hiton mahihimatay di nala maiha.” As verbalized. BP: 80/60 mmHg, PR: 65 bpm, Temperature: 36.2 C, O2 saturation: 90% room air. Restless, reports of fatigue, dizziness and light headedness. Cold, clammy skin. Capillary refill more than 3 < seconds. Hemoglobin: 6 g/dl, Weight 65 kg. VIII inhibitor level of 59.7 bethesda units. A - Monitored vital signs particulary BP ,HR and Temperature; Asessed for any alteration in mental status; provided monitoring sheet & calibrated bottle for urine collection; Documented color and amount of urine and noting especially for urine output less than 30 mL/hour; Identified the possible cause of the fluid disturbance or imbalance; Monitored closely for signs of circulatory overload; Monitored for the existence of factors causing deficient fluid volume; Urged the patient to increase fluid intake to at least 10 – 12 glasses or 1-2 liters per day; Encouraged SO to assist with feedings, as necessary; Emphasized importance of oral hygiene; Provided comfortable environment and light sheets; 8:30 AM Started Methylprednisolone 60 mg IV as ordered. ---------- 8:45 AM Started Iron sucrose 200mg IV diluted to 100 mL PNSS. --- 9: 00 AM R – “Mas mauru-upay na po it akon inaabat yana.” As verbalized. Reported decrease in restlessness, dizziness and light headedness. ----------------------------------------------- 9: 10 AM Post transfer D - Received from ER via wheelchair. Awake and assessment slightly restless but coherent with an ongoing IVF of D5LR IL regulated at 20gtts/min, infusing well with IV cannula gauge 20 at right metacarpal vein. ------------------- A - Transferred to bed accompanied by sister and placed in a comfortable position. Vitals signs taken and recorded as follows: BP: 80/60 mmHg, PR: 65 bpm, Temp: 36.2 °C, and O2 Sat of 90%. Secured with side rails up and locked. Oriented with regards to hospital and ward policies. Encouraged verbalization of feelings and concerns. ------------------------------------ 9:20 AM Acute pain D - “Kanina pa ini nagsisinakit na akon tiyan, baga hin diri nawawara” as verbalized. Dull, aching pain on the umbilical region of the abdominal area, 9/10 on Pain Rating Scale (with 10 being the highest and 1 being the lowest), Guarding behaviors, Facial grimace and restlessness, BP of 80/60 mmHg, HR of 65 bpm, and RR of 20 cpm, Hgb of 6 g/dL, Hct of 33%, bleeding time of 11 minutes, aPTT of 35-48 seconds, PT of 12 seconds. ------------------------------- A - Performed a comprehensive assessment of pain. Determined the characteristics, onset, location, duration, severity, pattern, and associated factors; Observed for nonverbal pain cues, such as body positioning, reluctance to move, facial expressions, and physiological manifestations of acute pain- elevated BP, tachycardia, and increased respiratory rate; Explored alternative pain relief measures, such as relaxation techniques, biofeedback, meditation, and distraction- visual, auditory, tactile, kinaesthetic, guided imagery, and breathing techniques; Provided support for and careful positioning; Established a quiet environment; Applied cold compress to umbilical region, Monitored cardiovascular and respiratory status prior to administration of tramadol, a opiate analgesic; ----------------------------------------- 9:35 AM Administered Tramadol 50 mg IV. ----------------------