NURSE’S NOTES

Name: Age/Sex/CS:14/F/S Ward/Room:__PEDIA C___

Date-Shift FOCUS Data – Action – Response

3/10/2021 Pain D:
3-7 (PM SHIFT)  Reports pain in the abdominal area and rated the pain 7 out of 10. Pain is felt in any position.
3:30pm  Experienced vomiting.
 Restlessness
 Muscle tension
 Decreased appetite
 Facial mask of pain
 Sleep disturbance

A:
3:45pm  Administered Omeprazole (Omepron) 20mg IV
4-6:00 pm  Kept patient in a comfortable lying position (adjusting bed) for ability to gain enough sleep and
rest.
 Demonstrated the use of appropriate diversional activities and relaxation skills.

R:
11:00pm  Patient reports relieved from pain.
 “Hindi narin po masakit ang tiyan ko.” as verbalized by the patient.

Hyperthermia D:
3:30pm  Patient temperature of 38.6C
 Experiencing fever and chills.
 Vomiting
 Sweating
 Abdominal pain
 Red skin
 weakness
A:
 Administered Paracetamol 300mg IV
3:37pm
 Performed tepid sponge bath at 5:00pm
5:00pm
 Encouraged and offered oral fluid intake every hour.
6:00pm
 Excess clothing and covers are eliminated.
 Environmental factors (bed and room temperature) was adjusted and monitored.

R:
11:00pm  Temperature decreased from 38.6C to 36.6C.
 Patient was relieved from shivering.
 “Wala na po akong lagnat.” as verbalized by the patient.