Time

Focus

Data/ Action/ Response

8:00am Admission

8:15 am

8:30 am 8:40 am

Admitted a 25 year old female with chief complaint of nasal stuffiness 1 week PTA Initial BP 130/90 mmHg, T: 37.0 C, RR: 28cpm, Attended by Dr. De Leon with orders Consent for admission signed To ENT ward/ wheelchair transported by Mr. Francisco accompanied by Nurse Ramos. Ajay Ramos, RN

Time

Focus

Data/ Action/ Response

8:45 am

7-3 ENT WARD In from ER/wheelchair transported by Mr. Francisco accompanied by Nurse Ramos. With nasal stuffiness and and on and off tolerable headache BP: 130/90, RR:30 A: Placed on moderate high back rest Full diet instructed Sadam John Eclipse,RN

9:15 am

Pain

9:30 am 9:35 am 10:10am

D: Masakit ang bandang ilong ko hanggang ulo; Pain scale of 4/5 A: Examined by Dr. T.V. De Guzman with orders Ketorolac 30mg IV administered as ordered. R: Nabawasan ang sakit na nararamdaman ko.pain scale of 2/5.

Sadam John Eclipse,RN

Time

Focus

Data/ Action/ Response

10:30am Anxiety to Surgery

11:00 am 3:00pm

D: Kinakabahan po ako sa operasyon ko bukas. A: Procedure explained by Dr. T.V. De Guzman Reassurance given Consent for Polypectomy, Ethmoidectomy and Antrostomy signed and secured OR nurse notified Endorsed for continuity of care.
Sadam John Eclipse,RN

Time 3:00pm 4:00 pm 4:40 pm 6:00 pm 11:00 pm

Focus Pre-operative Management

Data/ Action/ Response 3-11 Received with nasal stuffiness A: Examined by anesthesiologist Dr. Baterina with orders. Nothing per orem starting 6am instructed. OR meds secured at bedside. Meals served, consumed one cup of rice and vegetable as viand. Endorsed for continuity of care. Mary Grace Mateo, RN 11-7 Received with nasal stuffiness A: IV fluid of D5LRS 1L connected to macroset inserted to left metacarpal vein using IV catheter gauge 20 and regulated to 42 gtts/minute. Nothing per orem instructed and maintained. Endorsed for continuity of care.

11:00pm 6:00am

7:00am

Ma. Dianne Del Rosario, RN

Time

Focus

Data/ Action/ Response 7-3 Received with patent IV Fluid on left arm at 900 cc level; With nasal stuffiness A: Nothing per orem maintained. Brought to OR/ stretcher transported by Mr. Francisco accompanied my Nurse Navida. Marieanne Macasakit, RN

7:00 am

12:00 nn 2:00pm

Time 7:00 pm

Focus Post-transfer

Data/ Action/ Response

3-11 In from PACU/ stretcher transported by Mr. Papa accompanied by RN Feriol. with patent IV fluid on left arm at 850 cc level with nasal packing intact, moderately soaked with blood BP of 110/80 mmHg A: Placed on moderate high back rest Mary Grace Mateo, RN D: Minimal blood noted at nasal area A: Maintained on moderate high back rest Cold compress applied over the nasal and frontal area R: No more bleeding noted Mary Grace Mateo, RN D: Napakasakit ng ilong ko ; pain scale of 4/5 A: Ketorolac 30mg administered per IV as ordered R: nabawasan ang sakit na nararamdaman ko.pain scale of 2/5. Endorsed for continuity of care. Mary Grace Mateo, RN

7:30 pm

Bleeding

8:30 pm

9:30 pm 10:30 pm 11:00pm

Post-operative Pain