GICU: sample charting

190320131476

Date Time Focus Nurse’s Notes
March 12,2013  

 

 

 

 

 

 

 

 

 

 

3:004:00

 

 

 

 

8:00

 

 

6:00

 

7:00

7:30

8:00

 

 

 

 

9:15

9:35

10:40

 

 

 

 

 

 

11:00

 

 

 

 

 

 

 

 

 

 

 

Ineffective Airway Clearance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Elevated Serum Potassium

D>With Glascow coma scale of 9/15(E3V1M5) with eye-opening to speech, no verbal response and localizes pain, with papillary size of 3mm on both eyes reactive to light , with inhalation via face mask at 10 LPM, with nasogastric tube inserted on the left nostril clamped and intact, with symmetrical chest expansion, with distinct heart sounds, with soft abdomen , nondistended urinary bladder  connected to urine bag draining clear yellow urine, with vital signs of BP:130/80mmHg T:36.3 P: 117 O2Sat: 97%A>IVF received, checked and regulated at desired rate

>Placed on moderate high back rest

(Signature over printed name)

D> RR: 28, Crackles upon auscultation, O2Sat: 94%

A>Assessed patient condition

>Back tapping done

>Turned patient from side to side

R>Expectoration of thick greenish secretion in moderate amount with O2Sat of 99%

(Signature over printed name)

>NGT feeding of Nutren Optimum 166cc given with strict aspiration precaution

A>Seen and examined by Dr. Madrid , with orders made and carried out.

>Seen by Dr. Dimaunahan with orders made and carried out

>Bed bath done

>NGT feeding of Nutren Optimum 166cc given with strict aspiration precaution

(Signature over printed name)

D> K=5.98 mmol/L, P: 128, body weakness

A>Assessed patient condition

>Laboratory results relayed to doctor on duty with orders made and carried out.

>D5050  with 10 units of regular insulin given through slow IV as ordered by Dr. Dimaunahan

>request for repeat potassium after 1 hour forwarded to laboratory

(Signature over printed name)

R>Endorsing patient for continuity of care and management with glascow coma scale of 12/15

With the latest vital signs of BP: 130/80 T:36.4 RR:23 O2Sat:99%

(Signature over printed name)

 

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