COLEGIO DE SAN JUAN DE LETRAN
SCHOOL OF NURSING
RLE/ MS 1
Patient Details
Name: Phone: Sex:
Jaimeline Marcelo 09090922014 Female
Age: 75 Address: Religion:
5th street, Coke Christian
Factory, Laguna
Citizenship: Civil Status: Birthday:
Filipino Widowed January 14, 1946
Height: Weight: Email Address:
5’2 Ft 76 KG
[email protected]Admission Date/Time: April 13, 2021/ 10:00 PM
Chief Complaint: dyspnea and Non-Productive cough
Physician: ROD
Other Healthcare Providers:
Name Disp. Last encounter Diagnosis
Murray, Jack Endocrinologist 2006 Diabetes Mellitus Type II
Linkin, Park Cardiologist 2015 Hypertension
KARDEX
Date Medication Remar Date Intravenous fluids Date Time Signature
Parenteral / ks D/C IVF /Volume x Rate started
Oral
4/13/21 Digoxin 0.25 PNSS 1L +40mEq 4/13/21 6:00 Signed
microgram OD KCl am
Furosemide D/C 4/17/21 Signed
(Lasix) 40 mg IV C/O Heplock
q8
Metformin
500mg/ BID
Captopril 25
mg/ OD.
Date / Laboratory Req Sent / In
exams taken
Special Endorsement BNP
O2@ 3 LPM via nasal canula 2D Echo
CBR s BRP BUN & Creatinine
Weigh patient daily pre-breakfast, post- CBC - RBC
void (LATEST WEIGHT
WBC
To follow up after discharge mgh Platelet count
Sodium
Potassium
FBS
HbAIC
Lipid profile
Chest Xray
Date /Treatment Freq PRN Stand by
Nebulization of Normal q 12 hours
saline
Chest Physiotherapy
CBG OD
Diet: Full ( ) DAT ( ) Liquid ( ) NPO ( ) Low salt, low fat + banana
Patient’s Name: Mrs. J.M
Doctor’s/Physician’s Order Sheet
Patient’s Name Age /sex Room
Mrs. J.M 75/ female number
144
Attending physician Admitting diagnosis: Case number
ROD Congestive heart failure 1498
Date/time Updates/observation/ Orders Date/time
progress notes carried out
4/13/21 GCS: E- 4; V- 4; M- 6 Digoxin 0.25 microgram OD 4/13/21/11:00 am
10:am (disoriented) 14/15
Crackles at the base of Furosemide (Lasix) 40 mg IV q8 4/13/21/11:00 am
the lungs
(+) S4 sounds Metformin 500mg/ BID 4/13/21/11:00 am
Bipedal Edema grade 2+ Captopril 25 mg/ OD. 4/13/21/11:00 am
Muscle strength of 3/5 potassium chloride 40 mEqs 4/13/21/11:00 am
on both lower
extremities
Physician diagnosed Oxygen at 3Lpm via nasal canula to 4/13/21/11:00 am
patient with Class III maintain O2 Saturation at above 93%
Heart Failure
DIAGNOSTIC TESTS 4/13/21/10:00 am
Cardiac markers
BUN & Creatinine 4/13/21/10:00 am
CBC 4/13/21/10:00 am
Sodium 4/13/21/10:00 am
Potassium 4/13/21/10:00 am
FBS 4/13/21/10:00 am
HbAIC 4/13/21/10:00 am
Lipid profile, Uric acid 4/13/21/10:00 am
Chest Xray 4/13/21/10:00 am
Vital signs every 4 hours for 4 days 4/13/21/10:00 am
Strict Intake and output 4/13/21/10:30 am
Weigh patient daily pre-breakfast, 4/13/21/10:30 am
post-void
IVF of PNSS 1 L to run on KVO 4/13/21/11:00 am
Nebulization of Normal saline q 12 4/13/21/11:00 am
hours
Chest physiotherapy 4/13/21/11:00 am
Complete bedrest without bathroom 4/13/21/11:00 am
privileges
Capillary blood glucose (CBG) 4/13/21/11:00 am
monitoring daily
Low salt, low fat 4/13/21/11:00 am
4/17/21 CBC, Sodium, Potassium 4/13/21/10:00 am
IVF shifted to heparin/ saline lock 4/13/21/10:00 am
Oxygen at 1LPM via nasal canula (well 4/13/21/10:00 am
tolerated)
Maintained on low salt, low fat, with 4/13/21/10:00 am
banana
Up and about, with minimal bathroom 4/13/21/10:00 am
privileges (with assistance)
Prepare discharge summary 4/13/21/10:00 am
4/18/21 : may go home with the following
instructions:
Continue medication of: Digoxin 0.25
microgram/ tab once a day
Furosemide 40 mg/ tab twice a day
Metformin 500 mg/ tab twice a day
Captopril 25 mg/ tab once a day
Diet: low salt, low fat with banana
Exercise: Minimal walking with
assistance, avoid going up and down
the stairs
Follow- up: one week after discharge
with the laboratory exam results.
Medication Administration Record
Patient’s Name: J.M Age/Sex: 75/ Female Case No. 1498
Attending Physician: ROD Room No. 144
Diagnosis: Congestive Heart Failure
Date Medication/treatm frequenc Date Date Date Date
ordere ent dose and route y Initial/Tit Initial/Tit Initial/Tit Initial/Tit
d le le le le
Digoxin 0.25 OD 13 6:00am 14 6:am
microgram 6am FM FM
Furosemide (Lasix) 40 Q8 8:00am
mg IV 8:am FM
4pm
Metformin 500mg BID 6:00am
6am- FM
6pm
Captopril 25 mg OD 6am 6:00am
FM
Nebulization of Q12 6:00am
Normal saline 6am- FM
6pm
PRN and STAT Medication
Date Time Medication/treatment Time Initial
ordered ordered dose and route given
Intravenous Fluid Sheet
Patient’s Name: J.M Age/Sex: 75/ Female Case No. 1498
Attending Physician: ROD Room No. 144
Diagnosis: Congestive Heart Failure
Date Shift Bot. Kind of Rate Time Date/time Remarks signature
No. Fluid/volume started consumed
04/13/21 6am- 1 PNSS 1L 10-11 11:00 04/13/21 Signed
2pm +40mEq KCl gtts/min am
04/14/21 6am- 2 PNSS 1L 10-11 11:00 04/14/21 Signed
2pm +40mEq KCl gtts/min am
04/15/21 6am- 3 PNSS 1L 10-11 11:00 04/15/21 Signed
2pm +40mEq KCl gtts/min am
04/16/21 6am- 4 PNSS 1L 10-11 11:00 04/16/21 Signed
2pm +40mEq KCl gtts/min am
04/17/21 6am- 1 IVF shifted to 10-11 11:00 04/17/21 Signed
2pm heparin/ saline gtts/min am
lock
Nurses Progress Notes
Patient’s Name: J.M Age/Sex: 75/ Female Case No. 1498
Attending Physician: ROD Room No. 144
Diagnosis: Congestive Heart Failure Diagnosis:
Date Time Nurses Notes
4/13/21 7 am Traditional charting
Admitted a 75-year-old female, accompanied by her son with cc taken
as easily exhausted, shortness of breath, nonproductive cough, lack of
interest in usual activities and confused to everyday situations.
Assessed and examined by AP with orders made and carried out
7:30 am Done with diagnostic test- cardiac biomarkers, BUN and Creatinine;
CBC, sodium and potassium
For Lipid Profile, uric acid
To follow 2d Echo Result
Request for Chest X-ray,
for FBS tom/ NPO post- midnight to be instructed
Done with blood test HbAIC
Vital signs every 4 hours
Strict Intake and output
Weight taken 76 kg
IVF of PNSS 1 L to run on KVO
KCl 40 mEq IV (incorporated to 1 L of PNSS) run for 24 hours
Digoxin 0.25 microgram OD
Furosemide (Lasix) 40 mg IV q 8
Metformin 500mg/ tab BID
Captopril 25 mg/ tab OD
Oxygen maintained at 3 LPM via nasal canula to maintain O2 sat of
above 93%
Nebulization of Normal saline q 12
To perform chest physiotherapy
CBR s BRP
For CBG monitoring OD
On low salt, low fat diet
2pm Still with crackles in the lungs; elevated RR and Temp
-endorsed
Sig
ned/ initial/title: FM/RN
4/14/21 6am Received sleeping on bed with IVF of PNSS + 40 mEq KCL @ 10-
11gtts/min infusing well
Slightly disoriented
w/ O2 inhalation @ 3L/min, maintained
Due meds given
Needs attended
10am
FBS; Chest X-ray results seen by AP with order to continue same
treatment
Low fat, low salt diet instructed
Chest physiotherapy done
CBR s BRP maintained
Nebulization given
Kept in comfortable position w/ legs elevated w/ pillow
1pm Still confused; RR: 23
2pm -endorsed
Signed/ initial/title: FM/RN
4/15/21 Lipid profile, uric acid, hbAIC and FBS results seen by AP with order to
continue same treatment;
Swelling on feet still present due to bipedal edema (grade 2+)
-endorsed
Signed/ initial/title: FM/RN
4/16/21 6 am With order to continue same treatment
2pm Still has limitations in movements activities, vital signs are stable;
patient little confused
Endorsed
Signed/ initial/title: FM/RN
4/17/21 6 am Received sleeping on bed with IVF of PNSS + 40 mEq KCL @ 10-
11gtts/min infusing well
w/ O2 inhalation
conscious and coherent
7:30am
S/E by AP with orders made and carried out
Request for repeat CBC, Sodium, Potassium/sent
IVF shifted to heparin/ saline lock
Oxygen levels lowered at 1LPM via nasal canula if well tolerated
Still on low salt and low-fat diet with banana
Minimal bathroom privileges w/ assistance
Secure summary for discharge;
Inform patient about discharge process
2pm Vital signs are stable; not in respiratory distress
-Endorsed
Signed/ initial/title: FM/RN
4/18/21 6 am Received sitting on bed w/ hep-lock
w/ O2 inhalation @ 1L/min via nasal cannula
conscious
7:30 am S/E by AP with orders made
MGH
Continue medication of: Digoxin 0.25 microgram/ tab OD
Furosemide 40 mg/ tab BID
Metformin 500 mg/ tab BID
Captopril 25 mg/ tab OD
Still on low salt, low fat with banana
Exercise: Minimal walking with assistance; not allowed to go up and
down stairs
Ff 1 week after discharge with the laboratory exam results
Prescription given
For billing/ sent to billing section
2pm -Endorsed
Signed/ initial/title: FM/RN
FDAR
04/13/2 F: shortness of breath
1
D: “Mabilis tsaka madalas na akong mahapo kahit konti lang ung ginagawa
ko” as verbalized by the patient
A: Placed in proper semi fowler position.
Instructed proper breathing, coughing, and splinting methods
Assisted to do some form of leg exercise
R: “hindi nako nakakaranas ng hapo katulad dati” as verbalized by the
patient
D: “Mabilis tsaka madalas na akong mahapo kahit konti lang ung ginagawa
ko” as verbalized by the patient
Vital Sign Monitoring Sheet
Patient’s Name: J.M Age/Sex: 75/ Female Case No. 1498
Attending Physician: ROD Room No. 144
Diagnosis: Congestive Heart Failure
Date/time BP PR RR T O2 sat Remarks
04/13/21/ 110/ 70 89 BPM 25 BPM 36.8 92 elevated
10:30am respiratory
rate
04/13/21/ 110/ 70 89 BPM 20 BPM 36.7
2:00 am
04/14/21/ 110/ 70 90 BPM 19 BPM 36.7
6:am
04/14/21/ 110/ 70 88 BPM 18 BPM 36.6
10:00 am
04/15/21/ 110/ 70 86 BPM 18 BPM 36.8
6:00 am
04/15/21/ 110/ 70 87 BPM 17 BPM 36.5
10:00 am
04/16/21/ 110/ 70 88 BPM 18 BPM 36.2
6:00 am
04/16/21/ 110/ 70 90 BPM 17 BPM 36.1
10:00 am
