With IVF of PNSS 1L on around 480cc level and regulated at 21gtts/min and on around _____ consumed and replaced

with PNSS I L on full level and regulated at same rate; with side drip of PNSS 64 cc + 8 ampules of Furosemide on volumetric chamber on around 20 cc level and regulated at 10 mgtts/min; with on going blood transfusion of 1 unit packed RBC typed B with serial number 098768 and regulated at 20 gtts/min; with endotracheal tube connected to continuous manual resuscitator with oxygen at 10LPM; with oxygen inhalation on at 2-3L/min via nasal cannula; with Nasogastric Tube intact for feeding; with foley catheter coonectec to urine bag draining to (color of urine) output; with chest thoracostomy tube connected to water sealed drainage with reddish pleaural output BP-90/70mm/Hg, CR-98, RR-25, Febrile 38.8C; Tepid sponge bath done and cold compress placed over the forehead; on around_____ temperature rechecked and became ____ Examined by Dr. _______ with orders made Consumed one cup of rice, one piece of fish and one glass of water Bronchial tapping done after nebulization BP-110/80 (1hr before the end of shift) Endorsed for continuity of care

FC
Foley catheter Fr.16 connected to urine bag inserted aseptically with yellowish urine output of around 300ml With foley catheter to urine bag draining to (color of urine) output Foley catheter removed aseptically

NGT NGT Fr.16 inserted by Dr. ________ (and connected to bedside bottle) With NGT for osterized feeding With NGT connected to bedside bottle with brownish gastric output Osterized feeding of 170 ml + 60ml of water given per NGT and well tolerated

Pain D:

Reports of sharp pain on the abdominal incision area with a pain scale of 8 out of 10 Facial grimacing Guarding behavior Restless and irritable

A:

Administered Celecoxib 200mg IV Encouraged deep breathing exercises and relaxation techniques Kept patient comfortable and safe

R:

Patient reports pain was relieved

Hyperthermia
D:

Temperature of 38.9 OC via axilla Skin is flushed and warm to touch

A:

Tepid Sponge Bath (TSB) done7:30pm Administered 250mg IV Paracetamol as per doctors order Encouraged adequate oral fluid intake Encouraged adequate rest 10:00pm>Temperature decreased from 38.9 to 37.1 OC

R:

F1: Ineffective Breathing Pattern D1: increase respiratory rate of 24 cpm D2: use of accessory muscle to breath D3: presence of nonproductive cough F2: Hyperthermia D1: skin warm and flush to touched D2: increased body temperature of T= 38.9 degree celsius/axilla F3: Fatigue D1: less movement noted A: 9:00am

monitored v/s and charted regulated IVF and charted morning care done assessed patient needs and performed handwashing before handling the patient advised SO to always stay on patient bedside promote proper ventilation and a therapeutic environment elevated the head of the bed (moderate high back rest) provided comfort measures and provide opportunity for patient to rest due meds given tepid sponge bath done instructed SO to provide blanket and let patient wear loose clothing

9:30am

F4: Discharge Plan (12:00nn)

D1: discharged order given by Dr.Name/Time

M advised SO to give the ff. meds at the right time, dose, frequency and route E encouraged to maintain cleanliness of the house and surroundings

T advised to go to follow-up consultations on the prescribed date H encouraged to do chest tapping to facilitate mobilization of secretion O observed for signs of super infections such as fever, black fury tongue and foul odor discharges D encouraged to eat fresh vegetables and fish S advised to continue praying to God and hear mass on Sunday

2:00pm out of the room per wheelchair with improved condition