NURSES PROGRESS NOTES

Patient’s Name: Marcos Jocobo Ward and Bed No. Medical Ward, Bed 1
Hospital Number: 2020-123451
Date Time Focus Data Action
Response
11/18/2020 8AM Imbalanced Nutrition D – Received patient lying in bed, awake,
(Less than body alert and conscious with an ongoing IVF of #5
requirements) PNSS 1L @ 20gtts/minute infusing well on
right arm. Appears less fatigued and more
interactive. Previous serum-potassium results
upon admission was 2.91mmol/L which is
below normal. Reports having less diarrheal
episodes and that his stool is now a bit mushy.
Reports having a better appetite today as
opposed to the previous days, but still fears
that eating too much can cause diarrhea.
Verbalized “Dili na kaayo ko permi mo adto
sa CR, dayun mas naay gana karun mo kaon
ug pagkaon kompara sa mga aging adlaw.
Pero ma hadlok gihapon ko mo kaon ug
daghan kay cguro mas ma samot nuon akong
pag kalibanga.” V/S are as follows, T: 37.1C,
PR: 72bpm, BP:130/90mmHg, RR: 26cpm
with a pain score of 1/10. ------------------------

8:30AM A – Administered Kalium Durule as

prescribed. Informed to take small frequent
meals and to keep snacks at the bedside.
Encouraged to consume a banana in every
meal. Educated on (B.R.A.T) diet to help
provide adequate nutrition, and prevent
reoccurring diarrheal episodes in the coming
weeks. Continued monitoring of diarrheal
episodes. --------------------------------------------

2PM R – Updated serum potassium levels at

3.46mmol/L and is within normal range.
Noted eating three small meals within the
shift, and has eaten two bananas. Reports
improved appetite, and that he no longer fears
that eating will cause diarrhea. Verbalized
“Busog ko dong, salamat diay sd pag ingon
nimo unsa akong angay kan’on, kay para dili
sd ko ma hadlok nga mka kalibanga balik.”
Goal for the focus of care, met. -----------------
Adrian Miguel Amil Lovelyn G. Tipon
CNU-CN Batch 2022 CNU-CN
Clinical Instructor