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  • Nurses Progress Notes Patient Name: AGE SEX Room/Ward Hospital NO. 314623 Last Name First Name M.I. M (/) F

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    Royce Vincent Tizon
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    1) The patient, Maricris Gabrintina, was a 36-year-old female admitted to the OB-Low Risk Ward room 8 of the hospital for a post-operation assessment. 2) During initial assessment, the nurse noted the patient's respiratory rate was abnormally high at 36 breaths per minute and she was experiencing pain at her incision site. 3) Later checks found the patient's breathing pattern was irregular and respiratory rate remained high, so the nurse encouraged breathing exercises and positioning changes to improve breathing and reduce discomfort.

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    TIZON, R. - FDAR

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    1) The patient, Maricris Gabrintina, was a 36-year-old female admitted to the OB-Low Risk Ward room 8 of the hospital for a post-operation assessment. 2) During initial assessment, the nurse noted the patient's respiratory rate was abnormally high at 36 breaths per minute and she was experiencing pain at her incision site. 3) Later checks found the patient's breathing pattern was irregular and respiratory rate remained high, so the nurse encouraged breathing exercises and positioning changes to improve breathing and reduce discomfort.

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    47 views1 page

    Nurses Progress Notes Patient Name: AGE SEX Room/Ward Hospital NO. 314623 Last Name First Name M.I. M (/) F

    Uploaded by

    Royce Vincent Tizon
    1) The patient, Maricris Gabrintina, was a 36-year-old female admitted to the OB-Low Risk Ward room 8 of the hospital for a post-operation assessment. 2) During initial assessment, the nurse noted the patient's respiratory rate was abnormally high at 36 breaths per minute and she was experiencing pain at her incision site. 3) Later checks found the patient's breathing pattern was irregular and respiratory rate remained high, so the nurse encouraged breathing exercises and positioning changes to improve breathing and reduce discomfort.

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    DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION

    COLLEGE OF NURSING

    NURSES PROGRESS NOTES

    PATIENT NAME: AGE SEX ROOM/WARD HOSPITAL


    Last Name First Name M.I. ( )M NO.
    GABRINTINA MARICRIS C. 36 (/)F OB-LOW
    RISK Ward 314623
    ROOM 8

    DATE/TIME FOCUS DATA/ACTION/RESPONSE


    Sept. 25, 2021 Initial Assessment D: Patient is awake and alert, complained of pain on incision site and
    7:30 AM difficulty of breathing; ongoing IV of PNSS 1 L infusing well with Human
    Albumin 20%. Patient also in CTT two-bottle system. ----------------------
    A: Vital signs gathered and noted respiratory rate to be abnormal;
    RR:36 cmp.-----------------------------------------------------------------------------
    10:00 AM Tachypnea D: Patient is on two-bottle system CTT, S/P pigtail catheter insertion.
    A: Assess the closed chest drainage system for secure connections,
    intact water seal, fluctuation of fluid, presence of air leaks, tube patency
    fluid leaks, and amount of fluid in drainage collection system. -----------
    11:00 AM Health Teaching D: Patient showed decreased activity and increase respiratory rate of
    36 cpm and noted irregular breathing pattern.--------------------------------
    A: Encouraged patient to reposition for an optimal breathing pattern to
    reduce pooling of secretions. Patient was also encouraged and taught.
    controlled breathing techniques.--------------------------------------------------
    R: Patient acknowledged health teachings.------------------------------------

    ROYCE VINCENT E. TIZON MS. VIVAN CEZAR


    STUDENT NURSE RTRMF CLINICAL INSTRUCTOR

    RLE - NCM 109 Sample Only

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