NURSES' NOTES AND TREATMENT RECORD

Name of Patient: J.V. Ward/Room: Medical Ward

Address: Mandalagan, Bacolod City
Age: 20 y.o Sex: Male Admission Date: August 28, 2022

Date/ Progress Notes

Time Focus (D-Data A-Action R-Response)
08/30/2022 Risk for infection r/t inadequate vaccination and low D: Received patient with #1 IV PNSS 1L at 120cc/hr right arm infusing well. Patient is
7:00am blood cell count conscious; Fever, skin rashes, and body pain verbalized by patient.
Vital Signs:
T: 38.2 C
PR: 79 bpm
RR: 21 cpm
BP: 110/70mmHg
A:
8am - Monitored Vital Signs changes Q4H
- Increased fluid intake, monitor V/S Q4 hours
- Administered Paracetamol 500mg/tablet 1tab po q4 X 24hours then PRN, Benadryl
50mg/capsule. 1 capsule TID X 2days, Vitamin A 200,000 IU 1tab po od
- Applied calamine lotion to affected area.
12pm - Monitored changes in vital signs
- Administered Paracetamol 500mg/tablet 1tab po
- Observed changes in skin color of rash and size
- Washed hands and body to avoid contamination
4pm - Monitored changes in vital signs.
- Educated patient about proper handwashing and cleaning of body to have good hygiene.
R:
- Itchiness subsided as verbalized by patient.

Signature:
Complete Name: Ruel Christian P. Dewara
SN-USLS: RCPD/MP (Name of Ci)

Date/ Progress Notes

Time Focus (D-Data A-Action R-Response)
08/31/2022 Risk for infection r/t inadequate vaccination and low D: Received patient with #2 IV PNSS 1L at 120cc/hr right arm infusing well. Patient is
3:00pm blood cell count conscious; Fever, and body pain verbalized by patient.
Vital Signs:
T: 38.1 C
PR: 79 bpm
RR: 21 cpm
BP: 120/70mmHg
A:
4pm - Monitored Vital Signs changes Q4H
- Increased fluid intake, monitor V/S Q4 hours
- Administered Paracetamol 500mg/tablet 1tab po q4 X 24hours then PRN, Benadryl
50mg/capsule. 1 capsule TID X 2days, Vitamin A 200,000 IU 1tab po od
8pm - Monitored changes in vital signs
- Administered Paracetamol 500mg/tablet 1tab po
12am - Monitored changes in vital signs.
R:
- Fever subsided as verbalized by patient.

Signature:
Complete Name: Ruel Christian P. Dewara
SN-USLS: RCPD/MP (Name of Ci)
 Date/ Progress Notes
Time Focus (D-Data A-Action R-Response)
09/01/2022 Risk for infection r/t inadequate vaccination and low D: Received patient with #1 IV PNSS 1L at 120cc/hr right arm infusing well. Patient is
7:00am blood cell count conscious; Fever, skin rashes, and body pain verbalized by patient.
Vital Signs:
T: 37 C
PR: 72 bpm
RR: 18 cpm
BP: 110/70mmHg
A:
8am - Monitored Vital Signs changes Q4H
- Increased fluid intake, monitor V/S Q4 hours, replace GI losses volume per volume.
- Administered Paracetamol 500mg/tablet 1tab po q4 X 24hours, Vitamin A 200,000 IU 1tab
po od
12pm - Monitored changes in vital signs
- Administered Paracetamol 500mg/tablet 1tab po
4pm - Monitored changes in vital signs.
R:
- Fever subsided as verbalized by patient. Temperature is at 37C

Signature:
Complete Name: Ruel Christian P. Dewara
SN-USLS: RCPD/MP (Name of Ci)