ADMISSION TO WARD/ POST TRANSPORT

CARE
D- Received from AS-ER per
stretcher/wheelchair, unconscious/ conscious
and coherent/ incoherent accompanied by
relative. With IVF of ___ @____remaining fluid
level, regulated @ __ via ___.With foley catheter
connected to urine bag draining into ____ output
urine. With pressure dressing/ splint on ____.
A- Assessed general status and condition. Kept
affected extremity/ limb immobilized. Reviewed
consent for admission if duly signed by the
relative. Followed-up lab work ups. Advised to
SO to secure ordered medications. Transferred
to bed safely and securely. Provided adequate
rest periods. Closely watched and attended.
TRACTION CARE
D- with ___ traction onto __ leg.
A- Assessed s-pin site for signs of infection and
other complications. S-pin care done aseptically.
Secured ropes and pulleys free from obstruction
and weight bags hanged freely.Encouraged to
do range of motion exercises within limits.
Emphasized the importance of maintaining
traction alignment to bone realignment.
Positioned comfortably in bed in-line with
traction. Provided ample time to rest.
CAST CARE
D- with ___ cast onto ___ leg/ arm.
A- Assessed casted site for signs of infection
and other complications. Assessed capillary refill
of affected extremity/ limb. Encouraged to
verbalize feeling of tightness or cooling
sensation on casted site or distal part of arm/
leg. Positioned comfortably on bed with affected
leg/ arm kept immobilized and supported with
pillow. Kept cast clean and dry. Encouraged to
do range of motion exercises as tolerated.
Provided ample time to rest.
WOUND CARE
D- with wound dressing on ___.

A- Assessed and noted wound site for signs of

infection, bleeding or discharges.Wound care
done aseptically. Encouraged to eat nutritious
foods for wound healing. Kept affected arm/ leg
immobilized. Positioned comfortably on bed.
Provided adequate rest periods.
ACUTE PAIN
D- patient verbalization; pain scale; facial
grimace; guarding behavior
A- Assessed nature and severity of pain using
pain scale. Encouraged to engage in diversional
activities. Provided proper ventilation.
Positioned comfortably on bed. Administered
pain medication as ordered.
ELEVATED BODY TEMP
D- patient verbalization; skin flushed and warm
to touch; elevated temp reading
A- Instructed to wear loose comfortable
clothing. Provided tepid sponge bath. Instructed
to increase oral fluid intake. Administered
antipyretic as ordered. Continued to monitor
temperature on regular basis.
PREPN FOR SURGERY
D- for emergency/ elective ____.
A-Assessed current status and health needs.
Followed-up availability of OR meds and
materials. Kept affected limb/ arm immobilized.
Encouraged to verbalize feelings and concerns
about upcoming procedure. Secured consent for
surgery and anesthesia. Emphasized the
importance and benefit of the procedure.
Informed AOD/OR for pre-op medications.
R- Still securing ___ NPO once ready.
FOR TRANSPORT
D- patient is ready for transport.
A- Pre-op medications given. Vital signs taken
and recorded. Informed AOD/OR.
R- transported to OR with side rails up and
locked with latest vital signs of _____.

financial assistance from MSS or other related

agencies. Emphasized compliance to treatment
regimen.
R- Chart sent to philhealth for processing/ Still in
to settle bills.
- Left ward per stretcher/ wheelchair/
ambulatory with watcher, in fair condition.
POST-OP CARE
In from OR PACU per stretcher with side rails up
and locked, with IVF of ______. With latest vital
signs of ______.
D- Post-_____, with cast/splint on ____.
A- Assessed general condition. Transferred to
bed safely and securely. Advised on DAT once
fully awake. Kept limb/ extremities elevated and
supported with pillows. Monitored Continuously
for post-op complications. Health teaching
provided regarding ___ care.

BLOOD TRANSFUSION
D- To transfuse _____as ordered.
A- Assessed patients condition. VS taken and
recorded. Maintained IV and Blood line patent.
Regulated at ordered rate. Advised to verbalize
feelings or unusualities such as difficulty of
breathing, itchiness, rashes, fever and
headache. Monitored regularly for any blood
transfusion reaction.
R- blood consumed and terminated with no post
BT reaction noted.

R- Health teaching acknowledged; no post-op

complications noted.
FOR DISCHARGE
D- With may go home orders given by ____.
A- Issued out/ Followed up clearance slip for
discharge. Health teaching about home
medications and follow-up schedule
emphasized. Followed up Philhealth card if with
complete requirements. Instructed to seek

IV Gauge colors
14- orange

16- gray

17- white

18- green

20- pink

22- blue

24- yellow/ lime

26- purple