Macalalad, John Lester

Matias, Angelica Joy

Menpin, Levin
Perez, Joanne

DATE & FOCUS D (DATA) A (ACTION) R (RESPONSE)

TIME

12/10/2021 Deficient Fluid D:

8:15 AM Volume - 30 years old female CC with headache,weakness and lethargy, it has the
presence of dry lip and skin. The vital signs show low blood pressure 90/60
mmHg, elevated heart rate that is 116 bpm . The patient also shows
irritation, concentrated urine, decreased urine output, dry mucous
membranes, sunken eyeballs, and decreased skin turgor.
-

A:
- Examined the patient's vital signs, noting any irregularities in blood
pressure, heart rate, or pulse rate.
- Urinary output was observed and measured. Take note of the colour and
specific gravity.
- Fluids were placed within easy reach of the client, and the patient was
encouraged to drink.
- The signs and symptoms of dehydration were discussed, as well as measures
to avoid it from happening again.

R:
- The patient was able to keep his fluid volume at a reasonable level,
indicating appropriate intake. Vital signs are all stable. Urinary output is
typical, with a pale yellowish color and a specific gravity that is within
normal limits. The mucous membranes are moist, there are no symptoms of
weakening, and the skin turgor is good, and capillary refill is normal.

NURSES’
Medical Center
PROGRESS NOTES

LAST NAME FIRST NAME MIDDLE NAME CASE NO. REGISTRATION NO.
Dela Cruz Maurene Sotillo 2019844 244159