NURSES' NOTES
PATIENT NAME: C. Advincula AGE: 3 years old HOSPITAL NO. N/A
PHYSICIAN: Dr. Betty de la Cuesta SEX: M WARD/ROOM: PICU
DATE/TIME FOCUS D - DATA A – ACTION R – RESPONSE NURSE SIGNATURE
07/11/2021 Ineffective breathing D- The patient’s mother verbalized “Ma’am, marigatan umanges ji anak ko”
pattern Difficulty of breathing with deep rapid breathing
8:30 am – 4:30 pm Chest retraction
Sunken eyes
Nasal mucosa is boggy with clear discharge
Chest has increased AP diameter
Tachypnea
Rhonchi and wheezes are heard on auscultation with chest retractions
Vital signs are: Temp – 38.6 °C, PR- 100 bpm, BP- 85/65 bpm, O2 Sat-
90%
8:30 am A- Monitored the patient’s vital signs especially for the breathing pattern,
sound and respiratory rate.
8:35 am Encouraged the patient to do incentive spirometry through play.
8: 37 am Maintained head of the bed elevated.
Made sure the patient have a period of rest between activities during
8:40 am treatment.
8: 55 am Administered oxygen via pediatric face mask at 5 LPM as ordered by the
8:50 am doctor
Administered nebulization with albuterol 5mg in 2 ml of normal saline,
repeat after 15 minutes for 2 doses every 8 hours.
4:55 pm R- The patient demonstrate relaxed breathing without difficulty and deep COLLADO, K. M, S.N.
rapid breathing.
NURSES' NOTES
PATIENT NAME: C. Advincula AGE: 3 years old HOSPITAL NO. N/A
PHYSICIAN: Dr. Betty de la Cuesta SEX: M WARD/ROOM: PICU
DATE/TIME FOCUS D - DATA A – ACTION R – RESPONSE NURSE SIGNATURE
07/11/2021 Imbalanced nutrition: D- The patient’s mother verbalized “Hindi gaanong kumakain ang anak ko”
less than body Dry skin
8:30 am – 4:30 pm requirements Eyes are sunken
Skin pinch going back slowly
Appears to be weak and lethargic
Lack of interest in food
Weight 13.6kg
Height is 92.1 cm
Vital signs are: Temp – 38.6 °C, PR- 100 bpm, BP- 85/65 bpm, O2 Sat-
90%
9:40 am A- Strictly documented and monitored the vital signs, intake and output as
well as the calorie count of the patient.
9:35 am Fed the toddler with six small nutrient-dense meals with appetizing
appearance and taste instead of three bigger meals each day without
forcing the patient to eat.
9: 37 am Provided pleasant environment and avoid interruptions during
mealtimes. Elevate the head of the bed.
9:39 am Encouraged the patient to drink adequate amount of water.
9: 50 am Administered nutritional vitamins and minerals as indicated by the
doctor.
10 am Referred to a dietician for further assessment and recommendations
regarding food preferences of the toddler and also to support nutrition.
10:30 am R- The patient was able to consume an adequate nourishment and COLLADO, K. M, S.N.
maintained consumption of adequate nourishment and weigh gained 0.3 kg.
NURSES' NOTES
PATIENT NAME: C. Advincula AGE: 3 years old HOSPITAL NO. N/A
PHYSICIAN: Dr. Betty de la Cuesta SEX: M WARD/ROOM: PICU
DATE/TIME FOCUS D - DATA A – ACTION R – RESPONSE NURSE SIGNATURE
07/11/2021 Hyperthermia D- The patient’s mother verbalized “Madi nga bumaba tuy gurigor na tuy
anak ko”
8:30 am – 4:30 pm Skin are hot to touch
Shivering
Difficulty of breathing with deep rapid breathing
Nasal mucosa is boggy with clear discharge
Chest has increased AP diameter
Rhonchi and wheezes are heard on auscultation with chest retractions
Vital signs are: Temp – 38.6 °C, PR- 100 bpm, BP- 85/65 bpm, O2 Sat-
90%
10:30 am A- Monitored the patient’s vital signs.
10:35 am Performed tepid sponge bath.
10: 40 am Elevated the head of the bed.
10:45 am Advised the parents to remove excessive clothing and blankets as well as
adjust the room temperature.
10: 55 am Administered paracetamol (Aeknil) 150 mg IV every 4 hours prn as
ordered by the doctor.
11 am R- The patient demonstrate relaxed breathing without difficulty and deep COLLADO, K. M, S.N.
rapid breathing.
