Narrative Charting 1j6533

Name: CC: Rm/ bed no. Dx: AP :

7:00 am

8:00am

9:00am 11:00am 11:30am 12:00nn 12:45pm

1:00pm 3:00pm

7-3 shift -Received (lying on bed/ from itting section per stretcher/ wheelchair) (asleep/ awake); coherent; not in respiratory distress -with pupils equally round and (briskly/sluggishly) reactive to light and accommodation; with pupil size of mm -with O2 inhalation @ Lpm via (face mask/ nasal cannula) -with NGT at (left/ right) naris; patent and intact; distal end closed for feeding and medication -with (endotracheal tube/ tracheostomy) attached to mechanical ventilator with the following set-up: FiO2= ; TV;= ; mode -with symmetrical chest wall expansion -with clear breath sounds/ crackles/ wheezes) on both lung fields noted -with (pinkish/cyanotic) nailbeds noted; with good capillary refill time -with (good,senile,poor) skin turgor -with IVF of @ cc/hr infusing well @ vein @ cc level ; with side drip of @ cc/hr @ cc level -with foley catheter attached to urobag draining to a colored urine -On complete bed rest (with/without) bathroom privileges -For (urinalysis/ fecalysis/ sputum AFB) not yet saved; instructed; provided with container @ bedside -For CBC/FBS/lipid profile/serum creatinine/SUA); (encoded/ still with watcher) -For ultrasound/CT scan of ( ) ; instructed/maintained on NPO *NOTE: -Transported to 2D echo/ xray dept/ ultrasound dept per (stretcher/wheelchair; well tolerated - transported back to room per stretcher/wheelchair; well tolerated -To secure units of (PRBC, platelet concentrate), type and transfuse after proper cross matching; (still securing/with available 1 unit at lab) Initial VS checked and recorded; (afebrile/febrile) *if febrile, T= °C *NOTE: document your intervention ex. TSB done, Paracetamol 500mg 1 tab po given as orderd. Then recheck temp after 15 mins. *NOTE: document all PRN/STAT meds given NVS checked and recorded with an RLS of 1 and GCS of 15 Bedside care done; linen (changed/stretched) and tucked well Oral care done Osteorized feeding of cc given; flushed with cc of water; well tolerated Seen and examined by Dr. ; with orders made . HGT taken with a result of mg/dl; units insulin given Meal served; able to consume of the meal served VS rechecked and recorded; (afebrile/febrile) Above IVF consumed and ff. up with @ cc/hr; well regulated Health teachings rendered with emphasis on: a. b. c. d. e. f. *NOTE Hx teachings must be based on pt’s Hx condition and be congruent with medical order Intake and output summed up and recorded Watched for unusualities such as ;( none noted/ noted) Left on bed (resting/asleep) with same IVF on Discharged per wheelchair/stretcher with ing clearance

Signature over printed name