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    Narrative Report: University of The East Ramon Magsaysay Memorial Medical Center Inc

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    Johnasse Sebastian Naval
    This narrative report describes an incident that occurred on December 3, 2021 regarding patient Elvira Goingo who was admitted to the critical care unit under Dr. Christopher Concepcion and Dr. Visvanath Espaldon with an initial diagnosis of Sellar Mass. The report details the nurse's rounds and monitoring of patients from 10:30pm to 6am, noting the patient was alert and responsive during checks. However, at 6:20am Dr. Cuanang noticed the patient was unresponsive and not following commands, prompting an assessment by Dr. Comandao.

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    Narrative Report: University of The East Ramon Magsaysay Memorial Medical Center Inc

    Uploaded by

    Johnasse Sebastian Naval
    137 views2 pages
    This narrative report describes an incident that occurred on December 3, 2021 regarding patient Elvira Goingo who was admitted to the critical care unit under Dr. Christopher Concepcion and Dr. Visvanath Espaldon with an initial diagnosis of Sellar Mass. The report details the nurse's rounds and monitoring of patients from 10:30pm to 6am, noting the patient was alert and responsive during checks. However, at 6:20am Dr. Cuanang noticed the patient was unresponsive and not following commands, prompting an assessment by Dr. Comandao.

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    This narrative report describes an incident that occurred on December 3, 2021 regarding patient Elvira Goingo who was admitted to the critical care unit under Dr. Christopher Concepcion and Dr. Visvanath Espaldon with an initial diagnosis of Sellar Mass. The report details the nurse's rounds and monitoring of patients from 10:30pm to 6am, noting the patient was alert and responsive during checks. However, at 6:20am Dr. Cuanang noticed the patient was unresponsive and not following commands, prompting an assessment by Dr. Comandao.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    137 views2 pages

    Narrative Report: University of The East Ramon Magsaysay Memorial Medical Center Inc

    Uploaded by

    Johnasse Sebastian Naval
    This narrative report describes an incident that occurred on December 3, 2021 regarding patient Elvira Goingo who was admitted to the critical care unit under Dr. Christopher Concepcion and Dr. Visvanath Espaldon with an initial diagnosis of Sellar Mass. The report details the nurse's rounds and monitoring of patients from 10:30pm to 6am, noting the patient was alert and responsive during checks. However, at 6:20am Dr. Cuanang noticed the patient was unresponsive and not following commands, prompting an assessment by Dr. Comandao.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    University of the East Ramon Magsaysay

    Memorial Medical Center Inc.


    Aurora Boulevard, Quezon City

    December 1, 2021

    Narrative Report
    This report pertains to what happened last December 3, 2021 regarding patient
    Elvira Goingo 71/F with initial diagnosis of Sellar Mass admiited at CCU-D under the
    service of Dr. Christopher Concepcion and Dr. Visvanath Espaldon.

    I arrived at the unit 9:55pm and the endorsement was on going. At about 10:15pm
    I answered a phone call from nursing office regarding pull out of one of our staff to 3
    North 2. At approximately 10:30pm, endorsement was finished and we proceeded to do
    our cubicle-per-cubicle rounds. When we entered to CCU-D, we checked the patient's
    status which includes best response which was GCS15 (spontaneous eye opening,
    oriented/good verbal output and follows command) after that we checked the
    contraptions and the settings of infusion pumps.

    At 10:35pm, we did the same routine at CCU-E.

    At 10:40pm, I was reminded by Sir Naval to report immediately any changes in


    Vital Signs, GCS, Pain score and Urine output more than 250cc in both patients. At 10:45
    I checked the medications of each of my patient and prepared the medications that is due
    in my shift. By 11pm I started to do my bedside rounds to each patient to refill materials
    for endorsement the next day. At the same time I also drained the urine output of each of
    my patient and asked them if how they are doing. Initially, I told sir Roy that we start
    providing bed bath at 11pm but pushed it to 12midnight as CCU E was in pain and thus I
    closely monitored or him at that time.

    At 12midnight I told sir Roy, our nursing aide to prepare as we have to provide
    bed bath to patient CCU D. We proceeded with the bed bath and even asked patient CCU
    D if the temperature of her bed bath is to her liking to which she responded
    At around 12am, I asked Ms Damasen if all the patients are okay then I went to 2
    patients and verified her monitoring which was accurate.

    Ms Damasen monitored the two patients hourly and I verified it hourly. I continue
    to finish my paperworks all through out our duty.

    At 5:45am, I made my rounds again for the two patients to check the status and if
    the IV levels are correct. I observed that both patients are GCS15 and matched to the
    CCU monitoring flow sheets.

    At 6am, Mr Villanueva started receiving my hand-over report.

    At 620am, Dr Cuanang arrived the check the status of CCU-D patient Goingo and
    suddenly asked Ms Damasen if the Patient was "hindi po nagigising?” no eye opening,
    has incomprehensive sound and withdraws to stimuli. Then Ms Damasen replied, "hindi
    po doc.” Dr Cuanang immediately called Dr Comandao to inform.

    At around 645am, Dr Comandao arrived and assesed the patient and asked Ms
    Damasen, "Kailan pa ganto?"

    Informed my headnurse, Ms Jovi Garibay, what happened.

    Attached to this letter is the copy of CCU endorsement logbook which indicates
    that the patient had Spontaneous Eye Opening and follow commands before my hand-off
    report to 6am-2pm duty. I wasn’t able to have a copy of CCU monitoring sheet due to the
    chart was already sent to the Medical Records.

    Please reach to me any time if you need supplementary information on the subject
    of the event. I appreciate your assistance as we work through this together.

    Sincerely yours,

    Johnasse Sebastian C. Naval, RN, MANc

    Staff Nurse, Critical Care Unit

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