DATE/TIME FOCUS DATA ACTION RESPONSE

July 18, 2022 D: Recieved patient lying on

8:00 am bed awake but appears weak
and in pain. She has an
Acute pain secondary to onging IVF of D5LRS,
surgical procedure dripping well with the ff. Vital
(hysterectomy) signs of:
BP: 100/70 mmHg
PR: 105 cpm
RR: 40 bpm
Temp: 37 C
(+) Irritability
>facial grimaing
>Pain scale of 8/10
> on the first day post-op
A: > assessed pain regularly
noting characteristics,
location, and intensity
> identified specific activity
limitations
> repositioned the patient as
indicated
>monitored and recorded
I&O accurately
> encoureged to do
relaxation technique like
deep breathing exercise
> encouraged to increased
fluid intake
> encouraged patient to eat
iron rich foods such as green
leafy vegetables, red meat,
fish , eggs etc.
>encouraged safety at all
times
> provied divertional
activities like watching t.v or
reading books
> provided adequete rest
periods.
> administered analgesic
medication as ordered.

July 18, 2022 R: Resting in bed “medyo

12 pm Acute pain secondary to nabawasan po ang sakit ng
surgical procedure sugat ko” with the pain scale
(hysterectomy) of 5/10