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6AM to 2 pm

Olga Reyes -Px.
Rm. 4
Hospital no.234
Bed no.1
Date of Admission
June 21,2024
Rcvd.aeg.on bed with IVF on of D5LR 1L x 20gtts./min.
IVF remaining 400,
At 9AM, IVF consumed and followed up,D5LR 1L x SR.
At 1:45, IVF left 600ml.
Milk given 100ml.
Juice 150ml.
NGT started at 8 AM.
OF given 350 ml.
Every 6 hours 8AM,
Ensure 100ml
Robitussin 10ml.
Water 50ml.
On BT,
Fresh whole blood 450ml consumed ,and followed up 450ml ,Remaining blood 250ml.
Defacated twice,
Vomited twice,
Oral secretions collected 200ml.
Urine collected 975.

Sagot :

Explanation:

**Patient Information and Care Summary**

*Name:* Olga Reyes

*Patient Number:* Px

*Room:* 4

*Hospital Number:* 234

*Bed Number:* 1

*Date of Admission:* June 21, 2024

**IV Fluids and Medications:**

- **Initial IV Fluids (IVF):**

- 6 AM: D5LR 1L at 20 gtts/min (400 ml remaining)

- 9 AM: New D5LR 1L started and continued

- 1:45 PM: 600 ml of D5LR remaining from the 9 AM bottle

- **Blood Transfusion (BT):**

- Fresh whole blood: 450 ml consumed

- Followed by an additional 450 ml

- 250 ml blood remaining

- **NGT (Nasogastric Tube) Feeding:**

- Started at 8 AM

- Oral Fluids (OF) given: 350 ml

- Nutritional Supplements: Ensure 100 ml every 6 hours at 8 AM

- Medications: Robitussin 10 ml

- Water intake: 50 ml

**Dietary Intake:**

- **Milk:** 100 ml

- **Juice:** 150 ml

**Other Observations:**

- **Defecation:** Twice

- **Vomiting:** Twice

- **Oral Secretions:** 200 ml collected

- **Urine Output:** 975 ml

**Summary of Events:**

- 6 AM: Initial assessment and initiation of D5LR 1L IV fluid at 20 gtts/min with 400 ml remaining.

- 8 AM: NGT started; Ensure 100 ml, Robitussin 10 ml, Water 50 ml given every 6 hours.

- 9 AM: IV fluids consumed and replenished with D5LR 1L.

- 1:45 PM: Upon follow-up, 600 ml IVF remains.

- Throughout the shift, the patient consumed 100 ml milk and 150 ml juice.

- Oral fluids totaling 350 ml were administered through the NGT.

- Patient defecated and vomited twice, with 200 ml of oral secretions collected.

- Urine output totals 975 ml.

- Blood transfusions included 450 ml consumed, followed by another 450 ml, with a remaining 250 ml.

This record ensures comprehensive documentation of patient care activities for a smooth handover and continuity of care.