NURSES' NOTES

PATIENT NAME: Lilibeth AGE: 36 year old HOSPITAL NO. N/A

PHYSICIAN: N/A SEX: F WARD/ROOM: N/A

DATE/TIME FOCUS D - DATA A – ACTION R – RESPONSE NURSE SIGNATURE

04/15/2021 Anemia D- The patient verbalized “Apay kasjay agkapsutak dadduma ket haan ko pay
malpas agitay ubraek tuy balayen”
D- Generalized weakness; Pale in appearance; Dizziness
V/S taken as follows: T- 37.2C; RR-19; PR- 100; O2 Sat- 96%; BP-150/89; FHT-
155 bpm
A- Told the patient to rate her perceived exertion on a scale of 0 to 10 to
assess the manifestation of activity intolerance.
A- Monitored the pulse oximeter and inform the physician if the O2
saturation is 92% or less.
A- Encouraged the patient to do deep breathing and supplement with oxygen
if required.
A- Allowed time for the patient to have undisturbed rest.
A- Assisted the patient with the gradual increase of activates to tolerance as
the patient’s strength improve.
R- The patient is able to understand and identify methods to reduce activity
intolerance such as the methods on gradual progress for activity to gradually
increase the activities to tolerance.
K.M. COLLADO, Student
Nurse