Female Surgical Ward

Chai FEMALE
Yuk Hua 88.H13.A

CONTINUATION SHEET
Clinical Notes
Time of writing : 2200Hours
Actual time : 2130Hours
- New case admitted to ward using
wheelchair, escorted by ETD staff. Patient
accompanied by family member.
- Patient under room air.
- IV branula x1 insitu inserted at ETD over
right hand. No thrombophlebitis seen.
- Patient complain of epigastric pain for 7
days, vomit for 3 days and having blackish
stool for 4 days.
- Upon arrival, patient alert and able to
cooperate.
- Vital signs on admission :
BP: 90/60mmHg
PR: 112/min
RR: 24/min
Temp: 36.0 degree celsius
SPO2: 94% under room air
Pain score: 4
Morse fall score: 30
Eyes: No eyes discharge seen
Ear: No ear discharge noted
Nose: No nasal discharge noted
Lips: Dry
Abdomen: Soft, non tenderness
Malena stool seen
Skin turgor: Dry, pale looking

580709-13-5060

Date
22/3/16
ND shift

Treatment

Reported to Dr C regarding new

2145 Hours.

Ward orientation explained to pa

family members. Patient and fam
educated regarding use of call be
agree to display name in board. R
orientation checklist.

Patient changed into hospital gow

Films available: CXR x1

IVLine due 25.3.2016

IVD Normal Saline currently infu

125mls/hour from ETD.

IVI Pantoprazole 40mg in 50 mls

at 10ml/hour in progress.

Reported to Dr. C regarding SPO

reading.

Nursing Diagnosis :
1) Epigastric pain
Goal : Patient will verbalise comfort and
less pain within 24 hours.

Signed and chopped XX

Pain score charting done.
-

Encourage bed rest.

Provide comfort.

Administer analgesic medication

by doctor.

Female Surgical Ward

Chai FEMALE
Yuk Hua 88.H13.A

CONTINUATION SHEET
(Continue from previous page)
2) Fluid volume deficit.
Goal : Patient will be able to obtain
adequate fluid volume within 1-2 days.

580709-13-5060

22.3.16
ND shift

Infuse IVD as ordered by doctor.

Encourage oral intake. Small but

meals.

Strict I/O charting. Observe BO c

Administer anti-emetic medicatio

by doctor.

Inform patient to call for help when

as for toileting

Informed patient the use of call bell

Side rails pulled up.

Place basic needs near to patient

Prop up patient in bed.

Administer oxygen as ordered by

Monitor SPO2 reading and respir

hourly.

Educate patient on deep breathin

Monitor blood investigation resu

by doctor. (Eg. FBC, PT/PTT/IN
doctor if result abnormal.

Administer haematinics as ordere

Transfuse blood as ordered by do

Advice given to patient to rest in

Monitor bowel pattern for malen

3) Risk of fall
Goal : Patient will be free from fall
during hospitalization.

4) Ineffective breathing pattern.

Goal : Patient will be able to obtain
normal respiratory pattern.

5) Risk of bleeding.
Goal : Patient will not have bleeding
incident during hospitalization.

Female Surgical Ward

Chai FEMALE
Yuk Hua 88.H13.A

CONTINUATION SHEET

580709-13-5060

Monitor vital signs 2 hourly.

Signed and chopped

XX

Female Surgical Ward

Chai FEMALE
Yuk Hua 88.H13.A

CONTINUATION SHEET

580709-13-5060

Female Surgical Ward

Chai FEMALE
Yuk Hua 88.H13.A

CONTINUATION SHEET

580709-13-5060