Ms. Espinosa is a 90-year-old female admitted to the hospital from her assisted living facility.
She has a history of hypertension and dementia, and had a stroke three years ago. She has
also had insomnia for the past month. Ms. Espinosa is admitted due to an alteration in her
mental status. She has had a cold and a cough for a week, for which she took Coricidin
(Acetaminophen and chlorphenamine) and Tylenol PM (Acetaminophen and
diphenhydramine). Her home medications include monthly Nscobal(VitaminB12)injections;
Toprol-XL(metoprolol succinate) 100mg daily; Plendil (felodipine) 10mg daily; Allegra
(Fexofenadine) 180mg daily; Ecotrin (aspirin EC) 325mg daily; Colace(docusate sodium) 100mg
daily. She also has a very unsteady gait.
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NURSES NOTES
NAME: Patient X
AGE: 90-Year-old
SEX: Female
DATE/ TIME FOCUS DATA ACTION RESPONSE
11/12/2020 Continuity of Care D> Received patient on bed lying on supine position with on
3:00PM an ongoing IVF PNSS 1L x regulated at 27 gtts/min at 450 ml
level, there no are signs of erythematous and swelling in the iv site
…………………………………………………………………………….
3:05 pm Shift assessment A > Assessed present health status: coherent, conscious,
not in cardiopulmonary distress, complains of SOB
3:10pm Difficulty in Breathing D> “ Di po ako masyadong nakakahinga” as verbalized by the patient
Nursing interventions A > Assessed and recorded the respiratory rate, RR: 24cpm……..
A > Assisted the patient to a high fowlers
position…...............................................................................................
3:45pm Response R > RR: 24 cpm
Nursing Interventions A > continuous care and regulation on IV site………………………
Response R > No pain and distress complained by the patient
5:30pm Patient need A > Attended to health care needs of the
patient…………………………………………….………………….
A > Continuously monitored the patient
accordingly…………………………………………………………………..
6: 00pm Vital signs A > Vital signs were taken and recorded……………………………..
A > Instructed the patient to maintain O2 per nasal canula……..
A > Instructed the patient to change position every 2 hours for
better comfort ……………………………………………………………
A>Encouraged to have adequate rest………………………………
A > Advised to report immediately concerns
7: 00pm Patient concern D > “Nilalamig ako” as verbalized by the
patient………………………………………………………………………..
A > Assessed the patient’s temperature which is 35.6 ……………
A > Provided a blanket for warmth and comfort…………………….
Nursing interventions A > Administered warm water for the patient to drink to raise
temperature…………………….…………………………………………
A > Assisted on wearing extra clothing for extra warmth …………
7:30pm Monitoring A > Monitored the patient’s temperature to check for changes….
8:30pm Response R > Patients temperature is 36.9 degrees…………
9:30pm Patient need A > Attended to the patient’s needs…………………………………...
A > Continuously monitored the patient and attended needs…..
10:00pm Vital Sign A > Vital sign were taken, recorded and documented.…………..
10:10pm A > Administered Pepcid 20mg BID ……………………
10:50pm R > Patient temperature reduced to 37.5, R > RR: 20 SPO2%: 95
11: 00pm
End of shift A > Endorsed for continuity of care……………………………………
DATE/ TIME FOCUS DATA ACTION RESPONSE
11/13/2020 Continuity of Care D> Received patient on bed lying on supine position with on
3:00PM an ongoing IVF PNSS 1L x regulated at 27 gtts/min at 450 ml
level, there no are signs of erythematous and swelling in the iv site
…………………………………………………………………………….
3:05 pm Shift assessment A > Assessed present health status: coherent, conscious,
not in cardiopulmonary distress, complains of SOB
3:10pm Difficulty in Breathing D> “ Di po ako masyadong nakakahinga” as verbalized by the patient
Nursing interventions A > Assessed and recorded the respiratory rate, RR: 24cpm……..
A > Assisted the patient to a high fowlers
position…...............................................................................................
3:45pm Response R > RR: 24 cpm
Nursing Interventions A > continuous care and regulation on IV site………………………
Response R > No pain and distress complained by the patient
5:30pm Patient need A > Attended to health care needs of the
patient…………………………………………….………………….
A > Continuously monitored the patient
accordingly…………………………………………………………………..
6: 00pm Vital signs A > Vital signs were taken and recorded……………………………..
A > Instructed the patient to maintain O2 per nasal canula……..
A > Instructed the patient to change position every 2 hours for
better comfort ……………………………………………………………
A>Encouraged to have adequate rest………………………………
A > Advised to report immediately concerns
7: 00pm Patient concern D > “Nilalamig ako” as verbalized by the
patient………………………………………………………………………..
A > Assessed the patient’s temperature which is 35.6 ……………
A > Provided a blanket for warmth and comfort…………………….
Nursing interventions A > Administered warm water for the patient to drink to raise
temperature…………………….…………………………………………
A > Assisted on wearing extra clothing for extra warmth …………
7:30pm Monitoring A > Monitored the patient’s temperature to check for changes….
8:30pm Response R > Patients temperature is 36.9 degrees…………
9:30pm Patient need A > Attended to the patient’s needs…………………………………...
A > Continuously monitored the patient and attended needs…..
10:00pm Vital Sign A > Vital sign were taken, recorded and documented.…………..
10:10pm A > Administered Pepcid 20mg BID ……………………
10:50pm R > Patient temperature reduced to 37.5, R > RR: 20 SPO2%: 95
11: 00pm
End of shift
