Endorsing at room 102, Gabucbuc huberto, 28yo M in due to dyspnea and hemoptysis
Good morning! Handover for August 30, 2022. last total 12, admission 2, trans out 0, trans in 0, present total 12
ASKING QUESTIONS
Na Chest x- ray na ni sir nurse?
Na monitor na ang IO ni sir nurse?
oo humana na nag chest x ray si sir, pafollow up nalang na sa result, na monitor napud ang IO
MAINTAINING PRIVACY TO THE PATIENT
*KNOCKS*
LISTENING TO THE ENDORSEMENT AND TAKING NOTES WELL TO ENSURE THAT EVERY INFORMATION ABOUT THE PATIENT HAS BEEN RECORDED
ESTABLISH RAPPORT AND IDENTIFY THE PATIENT
Maayong buntag sad nurse!
Good morning Sir!
CLARIFY AND ASK QUESTIONS BEFORE PROCEEDING TO THE ASSIGNED PATIENT TO REDUCE THE RISK OF ERROR
ASSESSMENT
lain akong gibati nurse, maglisod kog hinga nurse, sakit pud akong dughan. dali rako kapoyon ug wa koy kusog.
akong ubo pud nurse naay kasabay na dugo
kumusta man ta karon sir?
IT IS IMPORTANT TO KNOCK BEFORE ENTERING THE ROOM OF TO ENSURE THAT THEY ARE AWARE OF YOUR PRESENCE AND TO RESPECT THEIR PRIVACY
ASSESSMENT AND MONITORING
Sir, magkuha ta ug bp, temperatura, ug pulso nimo sir ok ra?
ESTABLISHING RAPPORT TO ENSURE COOPERATION OF THE PATIENT AND IDENTIFYING HIS NAME AND DATE OF BIRTH TO MAKE SURE YOU HAVE THE RIGHT PATIENT
Ako si Huberto Gabucbuc, akong birthday diay kay November 29, 1994
Mangutana unta ko sir kung usa imong pangalan ug kanusa ka gipanganak
Ako diay si jin caballes sir, usa ko ka student nurse na taga ateneoAko diay ang nurse na naka assign saimo sir,
ASKING THE PATIENT QUESTIONS GIVES YOU MORE DATA ON HOW THE PATIENT REALLY FEELS
ganina alas kwatro ko niinom ug tambal nurse
ganina ra sir, lain jud kaayo siya sa paminaw
kanusa ra na nagsugod nga naay dugo imong ubo sir?
makihinomdom pata sir unsa orasa ta last niinom ug tambal?
ASSESSING PATIENT'S VITAL SIGN AND WEIGHT TO HAVE A BASELINE DATA WHICH CAN BE USED AS REFERENCE FOR LATER IF ANY CHANGES OCCURS IN THE CONDITION OF THE PATIENT.
ok ra kaayo nurse
Patient looks tired and weak*
Sir, pataas pud ko sa imong sanina kay akong paminawon imong paghinga
T - 37C, PR: 110, RR:28, Sp02: 86%
Adventitious breath sounds are present (wheezes and crackles)*