STAFF ENDORSEMENT SHEET

Room No.: 27 Diet: DAT

Patient’s Initials: M.G.H Physician: Dr. Badajos
Age/ Sex: 20 y/o, Female
Diagnosis: T/C Pneumonia

DOCTOR’S ORDER NURSE’S NOTES

INTRAVENOUS FLUID

 Pls. relay blood chemistry
results once available
 Decrease nebulization to every
8 hrs,
 Continue IVF/ IV medication
 Pls. refer according by noted @
10:20 am
S/O: received patient awake
 With IVF on infusing well
 (+) productive cough
 lipid profile extracted
 with BP of 100/80
 afebrile
A: Ineffective Breathing Pattern R/T
Productive cough
P/I: V/S taken recorded
 IVF
 Due meds given
 On DAT
 Placed on HBR
 Encouraged deep breathing
 Rested fairly
Bottle No.: 2
Solution: D5 0.3 NaCl
Rate:15 gtts/min.
Time started:4:30 am No, I,V: 1
Amount received: 800 cc
Level endorsed to next shift: 200 cc
Medication/ Treatment
Unasen 750 ng I.V every 8 hrs. ANST ( )
Paracetamol 500 mg 1 tab. Every 4 hrs. for
Temp, > 37.8
Laboratory works/ Diagnostic
Procedures
No New Order

Prepared by: Noted by:

Mangubat, Zalonica M. Gomez, Marilyn Au Dovi

Staff Nurse Head Nurse
 STAFF ENDORSEMENT SHEET

Room No.: 29- A Diet: General liquid and crackers

Patient’s Initials: M.R Physician: Dra. Avaceña
Age/ Sex: 29 y/o, Female
Diagnosis: Ovarian new growth right endometriosis

DOCTOR’S ORDER NURSE’S NOTES

INTRAVENOUS FLUID

 General liquid and crackers
 IVF to consume, D/C IV meds
 Pull all catheter
 Start cefalexin 50 mg/ cap every
6 hrs.
 AP
S/O: received patient awake
 With IVF on and infusing
well
 With IFC on connected to
PUB
 with SD dry and intact
 with BP of 90/80
 afebrile
A: alteration in comfort: pain r/t
surgical incision
P/I: V/S taken recorded
 IVF
 Due meds given
 On general liquid and
crackers
 Encouraged deep breathing
Bottle No.: 1
Solution: D5 NL 1L
Rate:10 gtts/min.
Time started:1:30 am No, I,V: 1
Amount received: 300 cc
Level endorsed to next shift: 200 cc
Medication/ Treatment
Cefardin 1 gm on I.V every 12 hours ANST
(-)
Perocoxio (Dynastat) 40 mg slow I.V every
12 hours
Tranexamic Acid 500 mg I.V now
Skelan 550 mg tab TID
Zepharyl 500 mg/ cap every 6 hours
Cefalexin 50 mg/ cap every 6 hours
Laboratory works/ Diagnostic
Procedures
No New Order

Prepared by: Noted by:

Mangubat, Zalonica M. Gomez, Marilyn Au Dovi

Staff Nurse Head Nurse

Room No.: 21
Patient’s Initials: O.M.P
Age/ Sex: 20 y/o, Female
Diagnosis: PU 38 mts ATG, N/L: Mercs 1x CBD
DOCTOR’S ORDER
 On HBR
 Apply abdominal binder
 On GLC
 D/C IVF and IV meds
 Start cefalexin (zepharyl)
 Pull out IFC @ 9 am
Prepared by:
Mangubat, Zalonica M.
Staff Nurse
STAFF ENDORSEMENT SHEET
Diet: GLC
Physician: Dra. Avaceña
NURSE’S NOTES
INTRAVENOUS FLUID
S/O: bearable post of pain Bottle No.: 2
 BP 110/80 mmHg Solution: D5 NR 1L
 Intact dry dressing Rate: 36 gtts/min.
 Perineal mild lochia Time started:12:00 am No, I,V: 2
Amount received: 150 cc
Level endorsed to next shift: consumed
A: Medication/ Treatment
P/I: V/S taken recorded Cefazolin 1gm I.V every 12 hrs. ANST (-)
 IVF Katorolac 30 mg
 Due meds given Laboratory works/ Diagnostic
 On GLC Procedures
 Encouraged deep breathing
No New Order
Noted by:
Gomez, Marilyn Au Dovi
Head Nurse
 NURSING CARE PLAN

Patient’s Initials: G.H.M

Room No.: 27
Age/ Sex: 20 Y/O Female
Diagnosis: T/C Pneumonia

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

S: “ Nahihirapan Ineffective Breathing After 8 hours of  Vital signs  To evaluate The patient able to
akong huminga” as pattern r/t productive nursing intervention, strictly presence of rest properly and
verbalized by the cough the patient will be able monitored respiratory verbalize the
patient to demonstrate distress relieve on
compliance and breathing and
O: RR: 25 cpm understanding on the  Breath sounds  To note the decrease on
PR: 87 bpm importance of the auscultated presence of coughing
nursing intervention secretions
 (+) rendered and will
productive manifest decrease in  Comfort  To alleviate and
cough with the frequency of measures prevent anxiety
phlegm cough. provided like to be felt by the
(yellowish- proper patient
greenish) positioning following
respiratory
 (+) bronchi distress

 Dyspnea  To maintain
 Encourage hydration
 Restlessness adequate oral
fluids intake
 To maintain
 Due meds optimal
given breathing
 pattern and
improve air
exchange

Prepared by: Noted by:

Mangubat, Zalonica M. Gomez, Marilyn Au Dovi

Staff Nurse Head Nurse
 NURSING CARE PLAN

Patient’s Initials: M.R

Room No.: 29-A
Age/ Sex: 25 y/o Female
Diagnosis: ovarian new growth right endometriosis

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

S: “ ang sakit ng Alteration in comfort: After 4 hours of  Assess the  To evaluate the After 4 hours of
tahi ko” as verbalize pain r/t surgical nursing intervention, intensity of pain level of pain nursing
by the patient incision the patient will atleast intervention the
be able to verbalize  Check the  To check if its patient able to rate
O: pain scale: 8 out and demonstrate the wound still intact and the pain to 4 out of
of 10 relief pain and if there is 0 to 10.
discomfort bleeding
 irritability
 Advise the  To avoid
 Restlessness patient to put opening of the
abdominal wood and for
binder fast healing of
the wound

 To promote
 Encourage the lung expansion
patient to do
coughing
exercise
 To relieve pain
 Give prescribed
medication

Prepared by: Noted by:

Mangubat, Zalonica M. Gomez, Marilyn Au Dovi
Staff Nurse Head Nurse