COAHS MEDICAL CENTER

J. P. Rizal Extension, West Rembo, Makati City 1215

Telephone No. : (+632) – 881 – 1571

NURSE’S NOTES
Patient L 62
NAME: ________________________________ AGE: ____ HOSPITAL NO.: ______________
Inpatient Male General Ward
SERVICE: ________________________________ SEX:________ WARD/RM:
Dr. John Lazarte
ATTENDING PHYSICIAN: __________________________________________

DATE/TIME FOCUS DATA, ACTION, RESPONSE

9/25/21 8:00am Data:
-Received patient

Action:
-Assessed vital sign
-Weight and height taken and recorded
8:30am Abdominal Pain Data:
-Patient experienced abdominal pain
-Displays facial grimace
-Pain scale 8/10
- BP: 130/80 mmHg

Action:
-Monitor vital sign
-Assessed for bowel sounds
-Assessed physical examination-abdominal
assessment to patient
-Medications given as ordered
-Findings are documented
9:00am Response:
-Patient reports decreased abdominal pain
-Patient displays comfort
-Patient verbalizes pain relief
-Pain medication given as ordered
11:00am Fatigue Data:
-Patient complained of tiredness
-Patient looks weak and drowsy
- BP: 130/90 mmHg; PR: 79 bpm

Action:
-Position client in a semi fowler’s position
-Provide calm and quiet environment
- Aid the patient with developing a schedule for
daily activity and rest. Emphasize the
importance of frequent rest periods.
- Promote sufficient nutritional intake.
11:30am Response:
-Patient displays comfort
-Patient verbalizes relaxation and energy
 restoration
12:00nn \

Detablan, Aimee Kaileen, SN