TIME/DATE FOCUS PROGRESS NOTE

21/03/2021 Productive cough DATA

10:54AM -received pt awake, coherent,
sitting on bed in semi-fowler &
dressed well w/an ongoing IVF
@ 1L PNSS x 24hrs w/ a side
drip of mifedipine @ 10
drops/min hooked-up, w/ an O2
via nasal cannula @ 2LPM w/ an
IFC connected to urine bag

SUBJECTIVE:
"Masakit ulo ko, nahihilo,
masakit ang dibdib ko at
nahihirapan ako huminga" as
verbalized by the patient.

OBJECTIVE:
BP-150/110
T-38’C
RR-22
PR-95

ACTION:
-established rapport to the pt
-instructed pt to avoid cold,
sweetened, & carbonated
beverages
- provided pt a quiet
environment to promote
adequate rest
-instructed pt to take
medications such as
bronchodilators and anti-
cholinergic as per doctor’s order

RESPONSE: