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Charting Samples

The nurse received three patients - one who had undergone a cesarean section (CS), one who had a normal spontaneous delivery (NSD), and a newborn baby. The CS and NSD patients were stable on IV fluids and had indwelling catheters. The newborn was breastfeeding with precautions and awaiting newborn screening tests.

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Kaye Sanders
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112 views

Charting Samples

The nurse received three patients - one who had undergone a cesarean section (CS), one who had a normal spontaneous delivery (NSD), and a newborn baby. The CS and NSD patients were stable on IV fluids and had indwelling catheters. The newborn was breastfeeding with precautions and awaiting newborn screening tests.

Uploaded by

Kaye Sanders
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
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RECEIVING PATIENT FROM ER TO WARD, Endorsed to OR

11/24/22

7AM >In patient from ER/wheelchair accompanied by NOD.

>Afebrile, vitals stable, conscious, coherent

> With ongoing IVF of D5LRS 1L at around full level and regulated at 40gtts/min.

> With indwelling Foley catheter connected to urine bag draining to clear urine output.

>On NPO, maintained.

> For CS at 3PM, with consent signed and secured.

2:00PM > ST of Ampicilllin Sulbactam done and revealed negative result.

2:30PM > Ampicillin Sulbactam 1.5gm IV given as ordered.

>Pre Op checklist completed, OR gown on.

2:30PM Transported patient to OR/wheelchair. Endorsed to staff on duty for continuity of care.

Mary Joy J. Bernardino, RN

Receiving patient from RR to Ward ( For CS Patient)

11/24/22

10AM > Received patient from RR/stretcher accompanied by NOD.

>Afebrile, Vitals stable, Drowsy.

> S/P CS, with wound dressing dry and intact, with minimal vaginal discharge, with firm
and contracted uterus, with ongoing IVF of D5LRS 1L + 10 units oxytocin at @ 150cc level and regulated
at 40gtts/min.

> With indwelling Foley catheter connected to urine bag draining to clear urine output.

> On NPO, maintained, flat on bed maintained.

> Clear liquid diet at 4PM instructed.

11AM >Above IVF consumed and replaced with D5NM 1L and regulated at 40ggts/min.

 Seen at times. All calls and needs attended, new no complains noted. Endorsed.

Mary Joy J. Bernardino, RN


Receiving patient from RR to Ward ( For NSD Patient)

11/24/22

10AM > Received patient from RR/stretcher accompanied by NOD.

>Afebrile, Vitals stable, Drowsy.

> S/P NSD, with minimal vaginal discharge, with firm and contracted uterus, with
ongoing IVF of D5LRS 1L + 10 units oxytocin at @ 300cc level and regulated at 40gtts/min.

> On NPO, maintained.

> DAT once fully awake, instructed.

12NN >Above IVF consumed and removed aseptically.

>Voided Freel.

2PM >Seen and examined by Dra. Torres with orders made and carried out.

> Seen at times. All calls and needs attended, new no complains noted. Endorsed.
Mary Joy J. Bernardino, RN

Receiving patient on Ward ( CS Patient)

11/24/22

7AM > Received patient comfortable in bed.

>Afebrile, Vitals stable, Conscious, Coherent.

> S/P CS, with wound dressing dry and intact, with minimal vaginal discharge, with firm
and contracted uterus, with ongoing IVF of D5LRS 1L + 10 units oxytocin at @ 500cc level and regulated
at 40gtts/min.

> With indwelling Foley catheter connected to urine bag draining to clear urine output.

> On Soft diet, tolerated.

12NN >Above IVF consumed and replaced with D5NM 1L and regulated at 40ggts/min.

1PM > Seen and examined by Dra. Reyes with orders made and carried out.

3PM Seen at times. All calls and needs attended, new no complains noted. Endorsed for
continuity of care.

Mary Joy J. Bernardino, RN


Receiving baby from Nursery

11/24/22

9AM > In a baby girl from NICU/crib brought by NOD.

>Alseep, Pinkish in appearance, with good cry and good sucking reflex.

>On breastfeeding with strict aspiration precaution. Burped after feeding done.

> For Newborn Screening, Hearing test, requested.

12:30 >Seen and examined by Dra. Dela Cruz witj orders made and carried out.

>Kept warm and comfortable. Seen at times. All calls and needs attended. No new
complains noted.

3PM > Endorsed for continuity of care.

Mary Joy J. Bernardino, RN

Receiving baby on Ward

11/24/22

7AM > Received baby comfortable in bed.

>Alseep, Pinkish in appearance, with good cry and good sucking reflex.

>On breastfeeding with strict aspiration precaution. Burped after feeding done.

> For Newborn Screening, Hearing test, requested.

10:00AM >Seen and examined by Dra. Dela Cruz witj orders made and carried out.

>Kept warm and comfortable. Seen at times. All calls and needs attended. No new
complains noted.

> Endorsed for continuity of care.

Mary Joy J. Bernardino, RN

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