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.
