Hospital,Hospital, Hospital

NURSES NOTES
Patient’s Name: Covida Mascarra Age: 50 Sex: FEMALE Hosp #:______
Attending Physician: DR. SHAUN MURPHY Room / Ward: 323

DATE TIME NURSING DIAGNOSIS S – subjective

O – objective
P – planning
I – intervention
E - evaluation
9/01/20 7:00 am Received patient lying on bed;
awake; responsive; restless noted;
with ongoing IVF of PNSSS 1L x
KVO infusig well at right
metacarpal vein.
8:00 Abdominal pain related to S- “sakit akong tiyan ma’am mga
present illness condition. 8/10 ang kasakit.” as verbalized by
patient.
O- Tense, restless, and guarding at
lower abdomen is noted.
P- Patient will verbalize relieve of
pain from 8 to 5-4/10.
10:00 am I- VS checked and recorded; VS
monitor every 4 hours thereafter;
Bed side care; Administered pain
reliever as ordered; Assist client to
use relaxation techniques such as,
-Deep breathing techniques,
guided imagery, refocusing
attention, proper positioning.
- Asses level of pain
01:30 pm -Seen and examined by Dr.
Pandemia with orders made and
carried out.
-Nurse on duty administered
Ranitidine 50mg IVTT and
 Furosemide 40mg IVTT as ordered.
2:00 pm -Intake and output summed up
and recorded.
3:00pm E- Goal met. Patient verbalized
ease of pain and rated 4/10.
Endorsed to nurse on duty for
continuity of care------------==-SN