Surname: Age: Hospital Number Given Name: Sex: Room / Bed Number: Date / Time Nursing ProblemsPhilipinnes / Diagnosis

Nurses Notes Republic of the Date OR NOTES PROVINCE OF ANTIQUE Time >Received from Angel Salazar Memorial General Hospital _____ ward; conscious. >With mainline IVF of _____ 1l infusing San Jose de Buenavista at _____ gtts/min with _____ cc more to infuse at _____ vein. >With side drip #1 of _____, with _____ cc more to infuse via piggyback at mainline IVF. >With bloodline IVF of PNSS 1L infusing at _____ gtts/min with _____ cc more to infuse at _____ vein. >With NGT at _____ nostril, to gravity drain with _____ cc _____ output. >With thoracostomy tube at _____ chest, attached to water-sealed drainage bottle with ____ output at the level of _____ cc. >With indwelling catheter in place; draining to urine bag to a _____ colored urine approximately _____ cc in amount. Time >Vital signs taken and recorded; T: __C PR: __ bpm, RR: __ cpm, BP: __ mmHg. >Preoperative assessment done. Time >Dr. (Surgeon), Dr.(Assistant Surgeon), and Dr.(Anesthesiologist)in. Time >Brought to major room per stretcher. >Placed on OR table in supine position with both arms abducted. Time Multiparameter >Attached at _____ finger; SPO2: __ % Time Oxygen Inhalation >Administered via _____ at __ lpm. >Initial count of instruments, sponges, and needles done. >Placed in R lateral knee chest position Time Lumbar Skin Prep >Done aseptically by Dr. _____. >Draped aseptically. Time Spinal Anesthesia >Inducted by Dr. _____ using gauge 25 (Anesthetic Agent) spinal needle. >Placed back in supine position with both arms abducted. Time >Electrodispursive pad applied on _____. >Restraints applied on both upper and lower extremities. Time _____ Skin Preparation >Done aseptically by _____. >Draped aseptically. >Operation started. >Incision done layer by layer by Dr. ____ >Continued
NAME/IDC-SN/JOFRED M. MARTINEZ,RN-CI/ SNOD

Surname: Age: Given Name: Sex: Date / Time Nursing Problems / Diagnosis Date

Time Time

Hospital Number Room / Bed Number: Nurses Notes OR NOTES (Continuation) >Bleeders clamped and ligated / cauterized as encountered. >Vital Signs taken and recorded by Dr. _____ every 5 mins and prn _____ 1L >Followed up to above consumed IVF by _____ as ordered. Blood Transfusion _____ 450 ml >Started by _____; regulated to __ gtts/ SN: _____ minute as ordered. >Done by Dr. ____ assisted by Dr. ____. >Specimen obtained.

Republic of the Philipinnes PROVINCE OF ANTIQUE

Angel Salazar Memorial General Hospital San Jose de Buenavista

BLACK INK 7:00 AM TO 10:59 PM RED INK 11:00 PM TO 6:59 AM