CHARISSE DL.

LIMOS
FOCUS CHARTING

Date/Time
Dec. 1, 2011 2:00 am 2:10 am 2:20 am 4:30 am

Focus
Epigastric Pain

Progress Notes
D-Complained of pain at epigastric area with the pain scale of 4/5 A-Referred to Dr.Paa with orders Omeprazole 40 mg.given thru IV Kept patient comfortable and safe R- Epigastric pain rechecked and subsided to 1/5

1:00 am

Difficulty of breathing

D- Complained of Difficulty of breathing With chest extraction A-Oxygen administered via nasal cannula at 2-3 LPM Placed on moderate high back rest Maintained on bed rest

1:10 am

12 am 12:15 am 12:20 am

Elevated temperature

D- Temperature 39.1degrees Celsius A-Referred to Dr. Manangbao with orders Paracetamol 300mg given Thru IV Tepid sponged bath done Encouraged to increased oral fluid intake R- Temperature rechecked and subsided to 37.8 degrees Celsius

1:30 am

3:00 am

Headache

D-sobrang sakit po ng ulo ko with a pain scale of 5/5

3:15 am 3:20 am

A-placed a warm towel over the pain area Placed in a comfortable position Referred to Dr. Ortiz with orders Mannitol given 100 cc thru IV and paracetamol as ordered Maintained bed rest R- Headache rechecked and subsided to a pain scale of 2/5

5:00 am

12:00 am 12:10 am 12:25 am

Elevated Blood Pressure

D- Blood pressure 160/110mmHg A-Placed on moderate high back rest Clonidine given sublingually as ordered Maintained on Bed rest R- Blood pressure rechecked and subsided to 130/100mmHg

1:35 am

2:45 am

Low Blood Pressure

D- Blood Pressure 80/60 mmHg A-Administered oxygen via nasal cannula at 2-3 LMP Placed on Trendelenburg positon Referred to Dr. Paa with orders Fludocortisone given thru IV Maintained bed rest R- Blood pressure rechecked and increased to100/70 mmHg

2:50 am 3:00 am 4:00am

Nausea and Vomiting 2:50 am 2:55 am

D- Complained of nausea and vomit 4x A-Placed to a fowlers with a side lying position Referred to Dr. Aniwasal with orders Metoclopromide given thru IV

3:55 am 2:15 am

Maintained bed rest R-complained of being comfortable and not vomited at all.

2:20 am

Chest Pain

D-Sumasakit po ang dibdib ko as verbalized by the patient with the pain scale of 4/5 A-Referred to Dr. Ortiz with orders Isordil given 5mg sublingually Maintained on bed rest R- Chest pain rechecked and subsided to2/5

2:20am 2:25 am

3:45 am

2:35 am 2:40 am

Nose bleeding

D- Nagdudugo po ung ilong ko as verbalizedby the patient A-applying pressure by pinching patients nostril to lean forward Placed an ice cold over the nose and a piece of a gauze under the lip Rferred to Dr. Ariola with orders Tranexamic acid 500 mg given thru IV

2:50 am 2:55 am

2: 25 am

Gum Bleeding

D-Nagdudugo po yung gilagid ko as verbalized by the patient A-Encouraged to rinse with salt water Encouraged toapply pressure and advice not to brush it Tranexamic acid 500 mg and Vitamin K 1ampule given as ordered Maintained bed rest R- no bleeding noted

2:40 am 4:10 am

3:00 am

3:15 am 3:20 am

Seizure

D-Episode of seizure noted A-Placed on lateral position Maintained airway Referred to Dr. manangbao with orders Acetazolamide given thru IV R-Episode of seizure subsided

3: 45 am 2:20 am 2:27 am Numbness

D-Namamanhid po yung gawing kanang bahagi ng hita ko as verbalized by the patient A-Blood pressure 130/100mmHg Placed on moderate high back rest Encouraged to massage the area of numbness Placed a warm/cold water with towel over the numbness area Maintained bed rest

2:30 am

1:45 am 1:50 am 2:00 am

Dizziness

D- Nahihilo po ako as verbalized by the patient A-Blood pressure 130/100mmHg Placed in a comfortable position Cinnarizine1 tabgiven P.O. as ordered Maintained on bedrest R- Medyo hindi na po ako nahihilo ngayon asverbalized by the patient

3:15 am

1:10 am

Constipation

D- Ilang araw naakohindi dumudumi as verbalized by the patient A-Encouraged to increase oral fluid intake

Encouraged to eat nutritional foods that are high in fiber Encouraged to mobilized her body Lactulose 30 cc P.O given as ordered

2:00 am

2:45 am

Frequent BM

D- Madalas poakongdumumi saisang araw as verbalized by the patient A-Encouraged to uncrease oral fluid intake Encouraged to eat Banana,Rice,Apple andTea as her diet ordered Volume/volume replacement dodne as ordered

Edema 12:00 am 12:15 am

D- Nagmamanas po yung Paa ko as verbalized by the patient A- Blood pressure 120/70 mmHg Encouraged to Limit salty foods and water Assessed pitting edema with +2 Furosemide 40mg given thru IV as ordered

12:45 am

12:00 am 12: 10 am

Low platelet count

D-Platelet count 90 A-Temperature37.3 degrees Celsius, Blood Pressure- 100/80 mmHg Encouraged to avoid dark colored foods Encouraged to increase oral fluid intake Monitored bleeding and hypotension done as ordered Maintained on bed rest

2:50 am

Abdominal pain

D- sumasakit po yung tiyan ko asverbalized by the patient with a painscale of 3/5

2:55 am

A-Blood pressure-110/80 mmHg Placed inacomfortableposition Placed a warm towel over the pain Buscopan 1 tab P.O given as ordered R- Pain scale subsided to 1/5

3:15 am