Escolar Documentos
Profissional Documentos
Cultura Documentos
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
Nursing Diagnosis :
1) Epigastric pain
Goal : Patient will verbalise comfort and
less pain within 24 hours.
Provide comfort.
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
3) Risk of fall
Goal : Patient will be free from fall
during hospitalization.
5) Risk of bleeding.
Goal : Patient will not have bleeding
incident during hospitalization.
CONTINUATION SHEET
580709-13-5060
CONTINUATION SHEET
580709-13-5060
CONTINUATION SHEET
580709-13-5060