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- Name: Feliselda AntonicaAge: 66 Sex: FemaleCC: Left side weakness and dizzinessPhysician: Dr. Pontalan & LealVSQ4: latest vital signs as follows - T: 36.5; RR: 23, PR: 90, CR: 95, BP: 150/120with IVF of PNSS 1L KVO 400ccLab: CBC, Platelet, Urinalysis, Fecalysis, and still for Cranial CT-scan at 9 AMMedication as follows: Omeprazole 40mg IVTT OD, Clopedogrel 150mg IVTT OD, nicardipine 5mg IVTT OD given and referred to Dr. VargasOxygen Inhalation via face mask 2L/min, latest O2 is 96%
- ENDORSEMENT (7:00 AM)
- medjo dili okay nurse, lipong pajud
- Hello ma'am, good morning. Ako si Joyce Panos gikan sa AdDU, ang imong student nurse for today. Kamusta man ang atong gibati ron ma'am?
- Checked the blood pressure, pulse, pupillary responses and motor functionPositioned the patient with head slightly elevatedMaintained a calm and good in lighting environment
- 7:00 AM - 7:30 AM
- Pila na ni nimo ka adlaw gibati ma'am?
- Ma'am, ipataas nato ang imong bed unya icheck nako imong blood pressure ug imong pulso, naa pud kuy icheck saimong mata ma'am ha.
- okay nurse
- gabii pa nag sugod nurse
- Put the bed side rails upEncouraged the patient to use relaxation techniques such as deep breathing exercisePatient is seen by the attending physician
- 7:30 AM - 8:00 AM
- ang vital signs mao ang sukdanan kung naga function pa ba tama imong lawas, taas pajud imong BP ma'am. ang imong temperature naa sa 36.5 normal tapos ang Pulse rate naa sa 90 bpm, normal pud kani unya ang imong respi rate naa sa 23 cpm, medjo di jud ni normal ma'am. Sige lang ma'am obserbahan lang nato kay nahatagan naman kag tambal ganina 6AM.
- Ma'am, mag check ko ug vital signs ha.
- Ma'am taas nato ang imong side rails aron di ka mahulog unya ma'am aron magaan gaan ang imong paminaw, inhale exhale ka ma'am.
- okay nurse, unsa na?
- Encouraged the patient to avoid any activity that suddenly increases blood pressureTold the significant others not to leave the patientAssessed for changes in vision such as blurring and alterations in visual fields.
- 8:10 AM- 8:30 AM
- Hello ma'am, ikaw man ang anak ni ma'am Feliceldsa ma'am no, dili lang nato byaan si patient ma'am ha theN dili sa palakaw lakawon si ma'am ha then ingna lang ko kung naa siyay gusto adtuan or mangihi siya.
- Ma'am Feliselda, dili lang sa mag lihok lihok na maka cause mutaas imong bp then ireport saako ma'am kung panglitan mag bag o ang imong panglantaw, pareha anang mag blurred ba. Salamat ma'am!
- okay nurse, salamat.
- oo ako nurse, sige nurse.
- Instructed the patient to exhale during voiding or defecationAssisted the patient in going to the bathroomClosely monitored the patient's alertness and speech.
- 8:45 AM- 9:00 AM
- Ali ma'am, assist tika. Ma'am, naa pud diay kay schedule karon para cranial CT scan, hatod tika didto ma'am after ihi nato ma'am.
- okay nurse, daghan kaayong salamat.
- nurse, mangihi daw akong mama.
- 3:00 PM
- RESPONSE:- Patient is still in Radiology Department- Patient endorsed to NOD- Absence of pallor and restlessness- Vital signs as follows=Temperature= 36.6C, PR= 92 bpm; BP= 140/100 mmHg; RR= 20 cpm; O2 sat= 97%flushing skin, pallor, and restlessness- With intact IV cannula on the right-hand metacarpal vein 18-gauge needle used with 1000 mL PNSS KVO and oxygen inhalation via face mask
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