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SOUTHEAST ASIAN COLLEGE INCORPORATED N. Ramirez St. E.

Rodriguez Avenue Quezon City RLE on Leadership and Management (Head Nursing) Name of Student: Balaan, Kathlein Clarrisa Ward and Bed: D17 SAMPLE CHARTING BP Due (mmHg) Medication 100/70 Date: November 26, 2012 Clnical Area:

Date/Time 8am 10am 11am Date/Shift 11/26/12 7-3pm

Temp 36.2

PR (bpm) 84

RR (cpm) 35

Dose

Frequency

Remarks

Time 7am

Nurses Notes -Received patient on bed in semi fowlers postion -with ongoing IVF of PNSS 1L times 16gtts/min on right arm at 800 level -with ongoing O2 therapy regulated @ 1-2Lpm via nasal cannula -with occasional productive cough -with bearable difficulty of breathing -vital signs taken and recorded; Afebrile -with IVP HAA 100mg q 6hrs Given @ 10am. ND 4pm -with IVP Ceftadizidine 16mg q 8hrs - Given @ 12nn -Encouraged to increased oral fluid intake -Encouraged to deep breathing exercise -For CBS, NA+ , K+, CREA Done follow up results -For Spt. AFB 2/3+, Spt. 6 S/CS for MD -CXR film @N. S. from outside -I and O q Shift -Need Attended -Endorsed to NOD

Prepared By: Eileen Joy U. Abuy Student Head Nurse

Noted By: Mrs. Helen Loresco RN Clinical Instrutor

SOUTHEAST ASIAN COLLEGE INCORPORATED N. Ramirez St. E. Rodriguez Avenue Quezon City RLE on Leadership and Management (Head Nursing) Name of Student: Balaan, Kathlein Clarrisa Ward and Bed: D17 Date/Time 8am 10am 12nn Temp 36 36.3 PR (bpm) 86 84 RR (cpm) 26 24 SAMPLE CHARTING BP Due (mmHG) medication 110/70 120/80 Date: November 28, 2012 Clnical Area: Dose Frequency Remarks

Date/Time 11/28/12 7-3pm

Time 7am

Nurses Notes -Received patient siiting on the chair -with ongoing IVP of PNSS 1L times 16gtts/min -with O2 PRN basis -with bearable DOB -Vital signs taken and Recorded; Afebrile -Bed stretching done -Encouraged to increase oral fluid intake -Advised Bed rest -Encouraged Deep Breathing and Coughing Exercise -with IVP HAA 100mg q 6hrs Given @ 10am ND 4pm -with IVP Ceftazidine 1gm q 8hrs Given @ 12nn ND 8pm -with Spt. AFB 3x ATC -Seen by Dr. Flavier with new order and carried out -D/C Hydocortisone -IVP to consume

-MGH with prescribed medications -Follow up OPD Tuesday c/o Dr. Sia -For referral to DOTS -Endorsed to NOD Prepared By: Eileen Joy U. Abuy Student Head Nurse Noted By: Mrs. Helen Loresco RN Clinical Instructor

SOUTHEAST ASIAN COLLEGE INCORPORATED N. Ramirez St. E. Rodriguez Avenue Quezon City RLE on Leadership and Management (Head Nursing) Name of Student: Balaan, Kathlein Clarrisa Ward and Bed: D17 Date/Timw 8am 10am 12nn Date/Time 11/27/12 7-3pm Temp 36.4 36 Time 7am PR (bpm) 88 86 RR (cpm) 27 28 SAMPLE CHARTING BP Due (mmHg) medications 110/70 110/70 Nurses Notes -Received patient sitting on bed -with ongoing IVF of PNSS 1L times 16gtts/min on right arm @ full level -with O2 Therapy regulated @ 1-2Lpm via nasal cannula -with occasional productive cough -with bearable difficulty of breathing -Vital signs taken and Recorded; Afebrile -with IVP HAA 10mg q 6hrs Given @ 10am ND 4PM -with IVP Ceftazidine 16mg q 8hrs. Given @ 12nn ND 8PM -Encouraged to deep breathing and coughing exercises -Encourage to oral fluid intake -Encouraged bed rest -with CXR outside for OR in Am -For Spt.AFB 2/3,3/3 -Needs Attended -Endorsed to NOD Noted By: Mrs. Helen Loresco RN Date: November 27, 2012 Clnical Area: Dose Frequency Remarks

Prepared By: Eileen Joy U. Abuy

Student Head Nurse

Clinical Instructor