Carl Vincent Villamor
BSN 4 Leininger
1. Patient 1 day post-appendectomy complains of severe abdominal pain (8/10) at rest. Vital
signs stable. Physician orders PRN IV analgesic.
Post-Operative Pain Management
Date/Time: 09/03/2025, 0930H
Patient ID: MRN 2025-001
Nurse: C.Villamor, RN
- S: Patient stated, "My stomach really hurts, 8/10, even when I'm just lying down."
- O: Patient appears restless, guarding abdomen. Vital signs stable (BP 120/80 mmHg, HR 88
bpm, RR 18 cpm, Temp 36.8°C). Surgical site intact.
- A: Acute post-operative pain, 8/10.
- P: Administer prescribed IV analgesic (Morphine 2 mg IV push PRN).
- I: Morphine 2 mg IV push given at 0935H. Patient monitored for side effects.
- E: At 0945H, patient reported pain decreased to 3/10. Patient resting comfortably, vital signs
remain stable. Will continue monitoring.
2025-09-03 14:00 — Recieved patient on bed awake, coherent, afebrile with IVF PNSS 500cc
hook @ R hand.Vital taken BP:120/80, PR: 89, RR: 19, T:36.9 reports "severe abdominal pain
8/10" at rest. Administer IV analgesic per PRN order. Reassess pain level in 30 minutes. Monitor
vital signs and for any signs of respiratory depression.Patient reports pain decreased to pain.
C.Villamor, RN.
2. Wound Dressing Change with Signs of Infection Scenario: Patient with surgical wound shows
redness, warmth, purulent drainage, and reports pain 6/10. Nurse needs to change dressing, take
wound culture, and call physician.
Date/Time: 09/03/2025, 1000H
Patient ID:
Nurse: C.Villamor, RN.
- S: Patient reports, "My wound is more painful today, about a 6/10."
- O: Surgical wound on lower abdomen with surrounding redness and warmth. Moderate amount
of purulent drainage noted on dressing. Wound edges approximated.
- A: Possible wound infection.
- P: Change dressing, obtain wound culture, and notify physician.
- I: 1010H: Dressing removed. Wound measured
- E: Patient tolerated dressing change well. Awaiting lab results and antibiotic administration.
Will continue to monitor wound and patient's response to antibiotics.
2025-09-03 1000H - Recieved patient on bed awake, coherent, afebrile with IVF PNSS 1000cc
hook @ L hand.Vital taken BP:110/80, PR: 79, RR: 17, T:36.4 report. Patient reports, "My
wound is more painful today, about a 6/10." Surgical wound on lower abdomen with surrounding
redness and warmth. Moderate purulent drainage noted. Wound measures 2cm x 1cm x 0.5cm.
Dressing changed, wound cleansed with sterile saline, and wound culture obtained and sent to
lab. Dr. notified at 1020H; verbal order received for Antibiotic order and transcribed. Patient
educated on infection signs/symptoms. Awaiting lab results, will monitor wound and response to
antibiotics. C.Villamor, RN.
3. Diabetic patient suddenly becomes diaphoretic, shaky, and reports dizziness. Blood glucose =
58 mg/dL. Nurse provides juice, rechecks blood sugar, and notifies doctor.
Date/Time: 2025-09-03 16:00
Patient ID:
Nurse: C.Villamor, RN
- S (Subjective): Patient reports, "I suddenly feel dizzy and shaky."
- O (Objective): Patient diaphoretic and visibly shaky. Blood glucose reading = 58 mg/dL. Alert
and oriented x 3.
- A (Assessment): Hypoglycemia in a diabetic patient.
- P (Plan): Provide fast-acting carbohydrate (juice). Recheck blood glucose in 15 minutes. Notify
physician.
- I (Implementation): 1605: Administered 4 oz of apple juice orally.
- E (Evaluation): 1620: Patient reports feeling slightly better. Blood glucose rechecked and now
85 mg/dL. Physician notified and new orders received.
2025-09-03 1600H - Recieved patient on bed awake, coherent, afebrile with IVF PNSS 700cc
hook @ R hand.Vital taken BP:115/87, PR: 68, RR: 20, T:35.9 report. Patient found diaphoretic,
shaky, reporting dizziness. CBG 58 mg/dL. 4 oz apple juice given PO at 1605H. CBG rechecked
at 1620H, now 85 mg/dL. Dr. notified, verbal orders received and transcribed. Patient resting
comfortably. CBG to be rechecked in 1 hour. Patient educated on hypoglycemia signs/symptoms
and importance of regular meals. C.Villamor, RN.
4. Elderly patient attempted to walk unassisted, slipped, and fell on the floor. Patient reports mild
hip pain but no visible fracture. Nurse assesses, informs physician, and completes incident
report.SOAPIE Note
Date/Time: 2025-09-03 1700
Patient ID:
Nurse: C.Villamor, RN
- S (Subjective): Patient states, "I tried to get up to go to the bathroom and I slipped. My hip
hurts a little."
- O (Objective): Patient found on floor next to bed. Alert and oriented x3. No visible signs of
fracture or deformity to hip. Reports mild pain (3/10) in right hip with movement. Vital signs
stable: BP [BP], HR [HR], RR [RR], Temp [Temp].
- A (Assessment): Fall with possible hip strain.
- P (Plan): Assess patient, notify physician, complete incident report.
- I (Implementation): 1705: Patient assisted back to bed. Hip assessed for range of motion,
swelling, and bruising. Ice pack applied to right hip. Dr. [Physician's Last Name] notified at
1710. Verbal order received for [Order]. Incident report completed.
- E (Evaluation): Patient resting comfortably in bed. Reports pain controlled with ice pack. Will
continue to monitor pain level, range of motion, and for any signs of complications.
2025-09-03 1700 - Elderly patient attempted to ambulate unassisted, slipped, fell. Reports mild
right hip pain (3/10), no visible fracture. Assisted back to bed, hip assessed, ice applied. Dr.
notified at 1710, verbal order received. Incident report completed. Patient resting comfortably,
pain controlled with ice. Monitor pain, ROM, and for complications. C.Villamor, RN.
5. During packed RBC transfusion, patient develops chills, fever 38.5°C, and shortness of breath.
Nurse immediately stops transfusion, maintains IV with NS, informs physician, and sends blood
bag to lab.
Date/Time: 2025-09-03 1800
Patient ID:
Nurse:C.Villamor, RN
- S (Subjective): Patient reports, "I feel cold and I'm having trouble breathing."
- O (Objective): Patient receiving packed red blood cell (PRBC) transfusion. Approximately
[Amount] of PRBCs infused. Sudden onset of chills, temperature 38.5°C, and shortness of breath
noted. Respiratory rate increased to [RR]. Auscultation reveals [Lung Sounds].
- A (Assessment): Possible transfusion reaction.
- P (Plan): Immediately stop transfusion, maintain IV access with normal saline, notify physician,
send blood bag and tubing to lab for analysis.
- I (Implementation): 1800: PRBC transfusion stopped immediately. IV line maintained with
0.9% normal saline at 120 mL/hr. Oxygen administered via canula at 0.2 LPM. Vital signs
monitored closely. Dr. notified at 1805. Verbal orders received: [Orders]. Blood bag and
transfusion tubing sent to lab with transfusion reaction form.
- E (Evaluation): Patient's condition remains guarded. Chills persist. Shortness of breath
improved slightly with oxygen administration. Awaiting further orders from physician and lab
results. Continue to monitor vital signs and respiratory status closely.
2025-09-03 1800 - During PRBC transfusion, patient developed chills, fever (38.5°C), and SOB.
Transfusion stopped immediately. IV NS infusing. O2 via canulq @ 0.2 LPM. Dr. notified,
verbal orders received: Blood bag/tubing sent to lab with transfusion reaction form. Patient's
condition guarded, chills persist, SOB slightly improved with O2. Continue to monitor VS and
respiratory status. C.Villamor, RN.
