Received awake(comatose) on bed with intravenous fluid of (notethe name of IVF) #(of the bottle) at 500 cc level

regulated at ___gtts/min
With O2 inhalation at ___LPM via (nasal cannula, face mask,rebreathing mask)
With endotracheal tube attached to mechanical ventilator/Manual bag resuscitator attached to O2 supply at 10LPM
Continuous manual resuscitation done
With chest thoracostomy tube at left mid-axillary line attached towater-sealed-bottle draining to bloody drainage at
____level
Fluctuation noted
With Foley bag catheter attached to urobag draining to a yellowishurine at ____level
Vital signs taken and recorded with BP:__mmHg, HR:__bpm,RR__cpm, temp:___C, O2 saturation___%
Above intravenous fluid (name of IVF, number bottle) consumedand followed up with (name of IVF, #) and regulated
at __gtts/min
Bipedal edema noted
Productive cough noted expectorating to a yellowish sputum
Crackles noted upon auscultation of the chest
Encourage deep breathing and coughing exercise
Encourage increase fluid intake
Chest physiotherapy done
Placed in semi-fowlers position
Suctioning of secretions at oral and endotracheal at 30 sec intervaldone
Body weakness noted at upper and lower extremities
Passive and active range of motion exercise done at both lower and upper extremities
Turned to sides every 2 hours
Body temperature rechecked- febrile Temp:40degrees Celsius$
Tepid sponge bath done
Body temperature rechecked Temp: 37.6 degrees Celsius
Blood transfusion started with one unit PRBC blood type ___ Rh(+/-) with serial number_______and segment
number_______ at 450cc level regulated at 10 gtts/min for the first 15minutes
Vital signs rechecked
Above blood transfusion regulated at 20 gtts/min
Seen and examine by Dr.____________with new orders----carriedout
Brought to x-ray/ ultrasound pre stretcher accompanied by_____
Brought back to ward and ushered to bed comfortably
Ate and consumed share with fair appetite
Fed through NGT with aspiration precaution
Served and consumed half of share with poor appetite
Maintained and instructed
Due meds given
Above blood transfusion consumed, mainline resumed andregulated at KVO rate
Still for CBC, serum K, Na determination---requested
For urinalysisspecimen bottle given with instructions
Intake and output monitored and recorded
Observed for any unusualities
Encouraged to verbalize discomfort
Health teachings imparted with emphasis on:
compliance of medication regimen
avoidance of dark colored foods
importance of nutritious food rich in vitamins and minerals suchas fruits and vegetables
(note: find out what causes the disease.)Endorsed sleeping on bed with latest vital signs BP:__mmHg,HR:__bpm, RR:
___cpm, Temp:____C