TIME FOCUS DATA, ACTION, RESPONSE 6am Received c IV fluid of PLRS 1L @ 400cc level on right arm c oxygen via nasal cannula at 2L pm BP: 100/60mmHg A: NPO reminded and maintained KRISTINE ANTONETTE E. BALABA WUP – SN’19 8am Health Teaching A: Sponge bath done assisted by the undersigned (Hygiene) KRISTINE ANTONETTE E. BALABA WUP – SN’19 11am A: Discussed the importance of bed rest and encouraged proper positioning to avoid distress. KRISTINE ANTONETTE E. BALABA WUP – SN’19
1/19/2018 DENGUE WITH WARNING SIGNS
TIME FOCUS DATA, ACTION, RESPONSE 6am Received c IV fluid of D5LRS 1L @ full level on right arm BP: 100/70mmHg KRISTINE ANTONETTE E. BALABA WUP – SN’19 9am Health Teaching A: Full bath done assisted by the undersigned. (Hygiene) KRISTINE ANTONETTE E. BALABA WUP – SN’19 11am Diet A: Emphasized the importance of avoiding dark colored foods and increasing oral fluid intake. R: Able to consume 350cc of water. KRISTINE ANTONETTE E. BALABA WUP – SN’19 2pm A: Bed rest maintained KRISTINE ANTONETTE E. BALABA WUP – SN’19
1/20/2018 ACUTE GLUMERULONEPHRITIS
TIME FOCUS DATA, ACTION, RESPONSE 6am Received c heparin lock on right arm BP: 100/60mmHg KRISTINE ANTONETTE E. BALABA WUP – SN’19 8am Health Teaching A: Emphasized the importance of avoiding salty (Diet) and fatty foods such as junk foods and instant noodles. KRISTINE ANTONETTE E. BALABA WUP – SN’19 10am Seen and examined by Dr. Dela Cruz c orders made KRISTINE ANTONETTE E. BALABA WUP – SN’19 10:30am Laboratory Procedures A: Laboratory request form forwarded to (Cholesterol) laboratory KRISTINE ANTONETTE E. BALABA WUP – SN’19
1/20/2018 DENGUE WITH WARNING SIGNS
TIME FOCUS DATA, ACTION, RESPONSE 6am Received c IV fluid of D5LRS 1L @ 300cc level on right arm BP: 100/70mmHg KRISTINE ANTONETTE E. BALABA WUP – SN’19 8am Health Teaching A: Emphasized the importance of increasing oral (Hydration) fluid intake R: Able to consume 350cc of water KRISTINE ANTONETTE E. BALABA WUP – SN’19 9:30am Seen and examined by Dr. Dela Cruz c orders made KRISTINE ANTONETTE E. BALABA WUP – SN’19 10:00am Change of IV fluid Regulation A: Present IV fluid regulated at 5gtts/min Bed rest maintained KRISTINE ANTONETTE E. BALABA WUP – SN’19
1/20/2018 ACUTE GLUMERULONEPHRITIS
TIME FOCUS DATA, ACTION, RESPONSE 6am Received c heparin lock on left arm BP: 100/70mmHg KRISTINE ANTONETTE E. BALABA WUP – SN’19 8am Fluid Volume Excess D: c facial edema A: Educate the patient to limit the daily oral fluid intake to 500cc daily KRISTINE ANTONETTE E. BALABA WUP – SN’19 10am Seen and examined by Dr. Dela Cruz c orders made KRISTINE ANTONETTE E. BALABA WUP – SN’19 10:00am Laboratory Procedure A: Laboratory request form forwarded to (Cholesterol) laboratory KRISTINE ANTONETTE E. BALABA WUP – SN’19 1/25/2018 ACUTE GLUMERULONEPHRITIS TIME FOCUS DATA, ACTION, RESPONSE 6am Received c heparin lock on left arm BP: 100/80mmHg 8am Health Teaching A: Full bath done assisted by the undersigned (Hygiene) KRISTINE ANTONETTE E. BALABA WUP – SN’19 10am Seen and examined by Dr. Dela Cruz c orders made 2pm A: Input and output monitored KRISTINE ANTONETTE E. BALABA WUP – SN’19
1/25/2018 DENGUE WITH WARNING SIGNS
TIME FOCUS DATA, ACTION, RESPONSE 6am Received c IV fluid of D5LRS 1L @ 300cc level on left arm BP: 90/70mmHg KRISTINE ANTONETTE E. BALABA WUP – SN’19 10am Seen and examined by Dr. Dela Cruz c orders made 10:30am Health Teaching A: Emphasized the importance of increasing oral (Hydration) fluid intake R: Able to consume 350cc of water KRISTINE ANTONETTE E. BALABA WUP – SN’19 11am Laboratory Procedure A: Blood serum extracted by MTI Camajin c (HCT, APC) request forwarded to laboratory 11:30am Above IV fluid consumed and replaced c D5LRS 1L and regulated at 22gtts KRISTINE ANTONETTE E. BALABA WUP – SN’19