DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION

COLLEGE OF NURSING

NURSES PROGRESS NOTES

PATIENT NAME: KAORU T. PASYENTE AGE SEX ROOM/WARD HOSPITAL

Last Name First Name M.I. ( )M Emergency NO.
24
PASYENTE KAORU T. (/) F Room 123123

DATE/TIME FOCUS DATA/ACTION/RESPONSE

MARCH 15, 2021 Initial Assessment D – Arrived at ER, 2 months pregnant, conscious, and reports of
8:47 AM stomach pain. -----------------------------------------------------------------
A – Ushered to room of choice, transferred to bed, side rails
raised, oriented on the ward policies and protocols. Placed on
comfortable position with side rails raised and locked. Obtained
obstetric history and baseline vital signs checked and recorded
BP=130/60 mmHg, RR=20 cpm, HR= 110 bpm, and Temp at
35.5C. --------------------------------------------------------------------------
9:00 AM Acute Pain D – “The pain is getting worse; I thought it was just an upset
stomach” as verbalized, right lower quadrant rebound
tenderness upon palpation and when walking or flexing legs,
moans upon palpation, irritable, facial grimace, restlessness. --
A – Assessed the pain on its character, onset, location,
duration, severity, pattern and the associated factors,
evaluates for level of pain using the numerical pain rating scale
obtained laboratory results, keep at rest in semi-Fowler’s
position, provided image distractions, infused 1L of IV fluid
PNSS started at 20 gtts/min through right dorsal arch veins as
ordered. ------------------------------------------------------------------------
MARCH 15, 2021 R – Result of pain rating scale improved with 8/10 compared to
9:20 AM the initial pain rating of 10/10, result on CBC is leukocytosis
and ultrasound confirm appendicitis. -----------------------------------
MARCH 15, 2021 Pre-operative D – Laboratory test on CBC shows leukocytosis and ultrasound
9:25 AM confirms appendicitis. ------------------------------------------------------
A – Obtained consent form, explained the procedure and
administered Cefalexin 500mg orally and 1 tablet of Folic Acid
as ordered by the physician, informed about the medication
and its side effects such as nausea and diarrhea. ------------------
Andrea Marie B. Sevilla Vivian S. Cezar, RN Jenna Mae Tan
RTRMF – College of Nursing Clinical Instructor Staff Nurse

RLE - NCM 109 Sample Only

DATE/TIME FOCUS DATA/ACTION/RESPONSE

RLE - NCM 109 Sample Only

RLE - NCM 109 Sample Only