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Hospital Continuation Sheet Overview

A female patient was admitted to the ward with epigastric pain, vomiting, and black stool for several days. Upon admission, the patient's vital signs and physical exam were documented. Nursing diagnoses identified risks of epigastric pain, fluid volume deficit, fall, ineffective breathing, and bleeding. Treatments included IV fluids, medications, monitoring vitals and symptoms, educating the patient and family, and following doctor's orders.

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Wandy Sejeli
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1K views5 pages

Hospital Continuation Sheet Overview

A female patient was admitted to the ward with epigastric pain, vomiting, and black stool for several days. Upon admission, the patient's vital signs and physical exam were documented. Nursing diagnoses identified risks of epigastric pain, fluid volume deficit, fall, ineffective breathing, and bleeding. Treatments included IV fluids, medications, monitoring vitals and symptoms, educating the patient and family, and following doctor's orders.

Uploaded by

Wandy Sejeli
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Clinical Notes and Observations

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

Female Surgical Ward Chai Yuk Hua 580709-13-5060 FEMALE 88.H13.A CONTINUATION SHEET Clinical Notes Date Treatment Time of wri
Female Surgical Ward Chai Yuk Hua 580709-13-5060 FEMALE 88.H13.A CONTINUATION SHEET (Continue from previous page) 2) Fluid vo
Female Surgical Ward Chai Yuk Hua 580709-13-5060 FEMALE 88.H13.A CONTINUATION SHEET - Monitor vital signs 2 hourly. Signed an
Female Surgical Ward Chai Yuk Hua 580709-13-5060 FEMALE 88.H13.A CONTINUATION SHEET
Female Surgical Ward Chai Yuk Hua 580709-13-5060 FEMALE 88.H13.A CONTINUATION SHEET

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