SERVICE AND PROGRESS NOTES
Date Health Condition/Nursing Problems
August 29, —Presence of Health Deficits
2021 -Hyperemesis Gravidarum
 Inability to make decisions with
respect to taking health action due
to:
a) Feeling of helplessness brought
about by the severity of the
situation
b) Inadequate knowledge regarding
pregnancy
 Inability to provide adequate
nursing care to the at risk member
of the family due to lack of
adequate knowledge and skills in
carrying out the necessary
intervention.
August 29, — Presence of Health Deficits-
2021 Hypertension
Inability to make decisions with respect to
taking appropriate health action due to:
a. Feeling of helplessness brought
about by perceived severity of the
Nursing Observations, Actions Taken, Responses and Evaluation of Progress/Outcomes Printed Name and
Signature
S - Conducted a home visit to the Dela Cruz’s residence and discovered that the daughter of Mrs.
Dela Cruz is complaining regarding her 1st pregnancy. She is experiencing nausea, vomiting and
weakness.
O- Initial assessment showed that the AOG: 11 weeks, LMP: May 20, 2021, EDC: (-), Gravida: 0,
Term: 1st Trimester, and Fundic Height: 10 cm. Vital signs taken as follows: BP: 110/80mmHg, T:
36.9, P: 92 b/min., R: 24 b/min.
A - Health threat for unwanted gestational complications with Hyperemesis Gravidarum
P – Ensure that the mother’s condition will get better before she gives birth. Encourage the
husband to be involved in the wife’s treatment and condition.
I - Educate the patient about the importance of prenatal care and how it is vital in monitoring the
baby’s condition. Discuss the risk of consequences to the mother and infant’s health. Advise the
patient to follow doctor order to take supplements and take some enough rest. Develop a diet
plan to ensure that correct nutrition is being followed.
E - On the 2nd home visit to assess the condition of the expecting mother, it was recorded that
her blood pressure is going on the normal range with 130/80 mmHg. The patient still experience
nausea but she is not vomiting anymore after she was discharged. She is also drinking the
medication prescribed to her every day. She also ask the nursing students about the schedule for
prenatal which is every Tuesday morning. She will be scheduled for the next home visit on
September 7,2021
R –Family is advised to monitor their daughter pregnancy condition the 2 nd and 3rd trimester.
S - Upon interviewing the patient, the patient verbalized, na diagnosed ako ng doctors na high
blood ako at binigyan po ako ng gamut na amlodipine 5mg na iinumin ko ng isang beses sa isang
araw.
O - Initial assessment showed that the patient is hypertensive with blood pressure reading of
130/80 mmHg, pulse rate of 91 beats per minute and a respiration of 23 breaths per minute.
 problem.
b. Inadequate knowledge to A - Health threat due to presence of risk factors of specific diseases such as hypertension.
alternative courses of action to
them. P - After 8 hours of nursing intervention, the patient will be free from pain complaints.
c. Lack of knowledge of community
resources for care. I - Instruct/explain that the normal blood pressure reading is 120/80 mmHg. Limit processed
food in diet and to restrict sodium in the diet, avoiding canned food
Encourage the patient to keep a log of food intake. Aid in the selection of appropriate food and
Inability to provide adequate nursing care DASH (Dietary Approaches to Stop Hypertension), like increasing intake of whole grains, low-fat
to the sick member of the family due to: dairy, fruits, and vegetables. Provide information regarding community resources, and support
a. Lack of knowledge about the patients in making lifestyle changes.
health condition (nature, prognosis
and management) E - Patient is aware and receptive agrees schedule visit in 2 weeks for BP and dash diet.
b. Inadequate knowledge and skill in
carrying out the necessary care R - There are no changes required for the nursing care plan since the solutions are already
(e.g., complex therapeutic regimen discussed.
or healthy lifestyle program)
c. Member’s preoccupation with own
concerns - Daughter’s (Pila Cruz)
current situation and the baby’s
welfare.

August 29, Presence of Health Deficits- Diabetes

2021 Miletus S-The verbalized that her husband was diagnosed of having diabetes mellitus type 2, but non-
compliant with the medication prescribed by the doctor instead he is using alternative herbal
 Inability to recognize the presence medication
of the condition due to lack of O- Initial assessment showed that the patient is hypertensive with blood pressure reading of
knowledge 140/90 mmHg, pulse rate of 88 beats per minute and a respiration of 23 breaths per minute.

 Inability to make decisions with
respect to taking appropriate
health action due to:
a. Fear of consequences of action,
A-Presence of Health Deficits to presence of risk factors of specific diseases Diabetes Miletus.
P- After the nursing intervention, patient should conduct an A1C Test.
I-Instruct the patients the importance of going to doctor’s check-up, for us to be able to know the
 specifically physical consequences status of the type 2 diabetes and also the possible complications of type 2
b. lack of confidence in the health Diabetes. Also explain to the client to eat healthy and have regular exercise.
personnel
E- Patient is aware about the possible complications of type 2 diabetes.

 Inability to provide adequate R- Family is advice to watch the client food intake in every day.
nursing care to the vulnerable/at-
risk member of the family due to:
a. Inadequate family resources for
care specifically financial
constraints
b. Altered role performance,
specifically role overload