Progress

note

Student Lama abdulaziz Alshehri Ward#16 TA name:

names Date:23-2-2021 RN.Johanna

Date/Time Progress Notes Sig

2-3-2021
8:30 Received patient on bed awake , alert and conscious, with GCS
15/15 , Picc line right arm , ambulatory; voiding freely and passed
stool , saturation well on room air , on regular diet , safety
precautions ; call bell within the reach , bed breaks is on , said rails
up , and bed at lowest position
9 :00 Vital sign taken as follows : Pb 137/58 mmHg , HR 79b/m , RR19
b/m , T 37 C
10 : 30 The patient had been educated as following : that insulin will make
his blood sugar lower so he must eat some food after taking insulin ,
and encourage hand hygiene regularly to prevent the germs ,
bacteria , and infection.
11:50 Conduct a head to toe assessment – taking history from the patient
12 :15 Administer medication with primary nurse lisinopril 5mg oral