NURSES PROGRESS NOTES

Patients Name: Mr. L,J Age: 70 y.o Sex: M Bed #: Hosp#:

DATA/ TIME FOCUS D= Data                A= Action                       R= Response

November 9, Airway clearance D: received patient on bed, lying and awake. With FBC. With ongoing
2020 IVF of PLNSS 1L at 30gtts/min, received at 300 cc level. With oxygen
10:01 am maintain at 4-5 LPM.
Subjective Data: Patient reorts “batio ko ug hangak kon mosulti ko unya
mosakit ako dughan ug kapoy akong lawas”.
Objective Data:
Vital Signs: T- 38.6°C P-110 bpm RR-20 bpm BP-130/70 mmHg
A:
-Vital signs were taken and documented
-Due medications were given
-Oxygen maintained at 4-5 LPM via nasal cannula
-Chest physiotherapy was done
-breathing exercise was performed
-Capillary blood sugar (CBS) monitored
R:
-Patient shows continuous breathing and respiratory rate at normal
6:01 pm levels