6/10/14

7:00 AM

Received lying on bed alert and responsive with #2 PNSS 1L
at 900cc level regulated at 20 gtts/min, infusing well.
Complained of shortness of breath. Vital signs:
BP= 120/90mmHg PR= 90 bpm RR = 10 cpm T=37C
Notified attending physician. O2 therapy started at 2LPM via
nasal cannula.
7:30 AM Seen and examined by Dr. Yabres. For blood transfusion.
Consent signed. Crossmatching of 1 U PRBC Type B
requested and done.
8:00 AM Crossmatching result in and attached to chart.
Vital signs:
BP= 120/90mmHg PR= 90 bpm RR = 17cpm T=37C
1 U PRBC Type B with serial # 15436TDH started as blood
transfusion after proper crossmatching and regulated at
10gtts/minute
8:30 AM Vital signs:
BP= 120/80mmHg PR= 85 bpm RR = 16cpm T=36.5C. Blood
transfusion rate increased to 20 gtts/minute. Monitored for
blood transfusion reactions.
9:30 AM Vital signs rechecked:
BP= 120/80mmHg PR= 80 bpm RR = 16cpm T=36.5C
10:30 AM Vital signs rechecked:
BP= 110/80mmHg PR= 88 bpm RR = 20cpm T=37 C
11:30 AM Vital signs rechecked:
BP= 120/90mmHg PR= 70 bpm RR = 18cpm T=36.5C
12:00 NN





Soft liquid diet
1 U PRBC Type B consumed and discontinued. Flushed
with PNSS. Present IVF rehooked and regulated at 20
gtts/min. No adverse reaction noted.
Vital signs:
BP= 120/80mmHg PR= 90 bpm RR = 17cpm T=37C

Served and consumed half of share with poor appetite.
2:30 PM Intake and output monitored and recorded
Observed for any unusualities
Encouraged to verbalize discomfort
Health teachings imparted with emphasis on:
compliance of medication regimen
avoidance of dark colored foods
importance of nutritious food rich in vitamins and minerals
such as fruits and vegetables.
3:00 PM Made comfortable in bed. Endorsed to NOD.