Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cabanatuan City, Nueva Ecija

COLLEGE OF NURSING

Patient Name: ____________________________________ Case number: __________

Date/Tim Nurse’s Remarks

e
(DATE) 07:00 AM to 03:00 PM (DAY)
07:00 AM  Received on bed; awake
 Conscious and Coherent; conversant
 With globularly shaped abdomen
 With IV fluid of ___________ 1L (or 500mL) at around _________ mL level
and regulated at ___________________gtts/min
 (IF WITH O2) With oxygen inhalation via nasal cannula at
_________L/min
 (IF WITH NGT) With Nasogastric tube connected to bed side bottle,
draining to _________ output/intact.
 (IF WITH IFC) With foley catheter connected to urine bag draining to
_________ output
 (IF WITH WOUND/OPERATIVE DRESSING) With wound dressing, dry
and intact
 Vital signs taken and recorded
 (IF PATIENT IS FEBRILE) Temperature: ____ °C; warm skin and slightly
TIME
flushed; tepid sponge bath done
 (IF THE STAFF NURSE GAVE PARACETAMOL IV) PARACETAMOL
TIME
300mg given intravenously by NOD
TIME  (AFTER 30 MINS) Temperature subsided to _____°C
 (IF PATIENT IS HYPERTENSIVE) BP: ________ mmHg; pounding
TIME
headache noted
 (IF THE STAFF NURSE GAVE ANTIHYPERTENSIVE)
TIME
CAPTOPRIL/CLONODINE ____mg given sublingually
TIME  Latest BP: _________ mmHg
 Due meds given
 Nebulization done as prescribed
 (IF PATIENT IS FED VIA NGT) Osterized feeding done as prescribed
 Seen and examined by Dr. ________________ with orders made and
TIME
carried out
 (FOR SKIN TEST) Sensitivity skin testing of ___________ done on ______
TIME
forearm due at ___________
 (AFTER 30 MINS) Sensitivity skin testing of ___________ revealed
TIME
(negative) as interpreted by Dr. ________________
 (IF THE IV FLUID IS CONSUMED) Above IV fluid consumed and replaced
TIME
with _______ 1L/500mL and regulated at _____ gtts/min
 Intake and output measured and recorded
 All needs attended
TIME  Endorsed for continuity of care

(Student name) / (Clinical Instructor) / (Nurse on

Duty)
NEUST SN’## / /

RLE Notes
A.Y. 2019 – 2020 1st Semester
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija

COLLEGE OF NURSING

FOR BLOOD TRANSFUSION

 Present IV fluid of ______ removed aseptically and replaced with PNSS

TIME
1L and regulated at 10 gtts/min
 Pre BT meds given (30mins before transfusion) (PARACETAMOL
TIME
300mg tab, DIPENHYDRAMINE 30mg, HYDROCORTISONE 20mg
 Above IV fluid reinserted aseptically using IV needle gauge 18 into
TIME
left/right _______ vein and regulated at ________gtts/min
 Initial Vital signs as follows:
TIME
 BP: T: PR: RR:
 1 unit of PRBC type ________ properly typed and cross-matched,
TIME checked by nurses on duty with serial number _________________
hooked as side drip and initially regulated at 10 gtts/min
TIME  Present Iv fluid stopped temporarily
 Vital signs as follows:
BP: T: PR: RR:
 Vital signs as follows:
(after 5 mins)
BP: T: PR: RR:
 No BT reaction noted (if none)
 Vital signs as follows:
(after 5 mins)
BP: T: PR: RR:
 Vital signs as follows:
(after 5 mins)
BP: T: PR: RR:
 Vital signs as follows:
(after 10 mins)
BP: T: PR: RR:
 Above BT unit regulated at 25 gtts/min
 Vital signs as follows:
(after 10 mins)
BP: T: PR: RR:
 Vital signs as follows:
(after 10 mins)
BP: T: PR: RR:
 Vital signs as follows:
(after 30 mins)
BP: T: PR: RR:
 Vital signs as follows:
(after 30 mins)
BP: T: PR: RR:
 Vital signs as follows:
(after 1 hr)
BP: T: PR: RR:
 Vital signs as follows:
(after 1 hr)
BP: T: PR: RR:
 Above BT unit consumed and removed aseptically; above IV fluid
TIME
regulated at _________ gtts/min
 Latest Vital signs as follows:
TIME
BP: T: PR: RR:
 Monitored closely for delayed reactions
 (IF TRANSFUSION REACTION OCCURS) Above BT unit discontinued
TIME
temporarily; above IV fluid regulated at 10 gttss/min
 Vital signs as follows:
BP: T: PR: RR:
TIME  Seen and examined by Dr. _________ with orders made and carried out

RLE Notes
A.Y. 2019 – 2020 1st Semester
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija

COLLEGE OF NURSING

FOR DISCHARGE

Date/Time Nurse’s Remarks

 Seen and examined by Dr. __________ with orders made and carried
TIME
out
 May go home; to settle bills
 Discharge instructions given and properly explained
TIME  Above IV fluid discontinued/consumed and removed aseptically
TIME  Bills settled
TIME  Discharged via wheelchair; accompanied by SN and NOD

FOR ADMISSION

Date/Time Nurse’s Remarks

 In from Emergency Room/Ward/OR via stretcher/wheelchair
TIME
accompanied by NOD
 Transferred to bed safely; with IV fluid of _______ at around _______
mL level and regulated at _______ gtts/min
 (IF WITH O2) With oxygen inhalation via nasal cannula at
_________L/min
 Admission care done
 Vital signs taken and recorded as follows:
Temp: PR:
RR: BP:
 (other interventions)

FOR IV REINSERTION

Date/Time Nurse’s Remarks

TIME  Pain and swelling on IV site noted
 Above IV fluid discontinued and removed aseptically and saved set;
TIME
warm compress placed on the IV site
 Above IV fluid reinserted aseptically using IV needle gauge ___ into
TIME
left/right _______ vein and regulated at ________gtts/min

RLE Notes
A.Y. 2019 – 2020 1st Semester