DATE AND TIME FOCUS PROGRESS NOTE

03/23/2021 PAIN D: Mrs. Cervantes is one-day

post abdominal surgery; she
continuously complains of sharp
pain on the incisional site and
1100 states that pain on the
incisional site and states that
pain is 9 on a scale of 10. She
also complains of difficulty of
breathing and often grimaces
because of the pain on
inhalation.
She is crying “I need something
for pain now!”

A: Demorol 75 mg IM in LUOQ
of the left of the buttock.
Repositioned on the right side
with pillow to abdomen to help
splint the wound. Encouraged
her to do breathing and
coughing exercises.

R: 30 minutes later the nurse

evaluates Mrs. Cervantes pain
1600 and the patient states “much
better” and rated 3 on a scale of
10.
03/ 24/2021

D: On assessment, patient’s
1100 BLOATED Abdomen is distended.
UNABLE TO PASS
FLATUS A: Repositioned (turn to sides
referred to the attending
physician with an order to insert
rectal tube.
Patient is able to pass flatus and
1700 felt relieved.

R: Patient is able to pass flatus

and felt relieved.