COAHS MEDICAL CENTER

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

Telephone No. : (+632) – 881 – 1571

NURSE’S NOTES
NAME: EE AGE: 61 y/o HOSPITAL
NO.: 34 SERVICE: Inpatient SEX: Male
WARD/RM: General Ward

ATTENDING PHYSICIAN: Dr. Delos Reyes

DATE/TIME FOCUS DATA, ACTION, RESPONSE

 Deficient knowledge
01-11-21
related to unfamiliarity with
8:00am-3:00pm disease process and/ or
transmission of disease
possibly evidenced by
Failure to
improve/recurrence
Data:
Subjective Cues:
• “Dahil sa katandaan ko hindi ko
na naalagaan yong sarili ko at
anak ko na lng yong katuwang ko
sa buhay” as verbalized by the
patient.

Objective Cues:
• Low- self esteem
• stress

Vital signs:
• BP: 120/80 mmHg
• HR:98 beats per min
• RR: 26 bpm
• T: 36.5 C
• O2 Sat: 90%

Action:
 Determine the
patient’s
understanding of
pneumonia
complications and
their treatment
regimen.
 Review normal lung
function, pathology of
the condition.
 Discuss debilitating aspects of
the disease, length of
convalescence, and recovery
expectations.

 Identify self-care and

homemaker needs.

 Assess potential home care

needs.
 Response:
 Goal Achieved, Patient and caregiver
will verbalize understanding of
condition, disease process, and
prognosis.

COAHS-CON2018-
RLE-NN COAHS-
CON2018-RLE-NN