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