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1) The nurse's progress notes document a patient's condition and care on October 24th. 2) Upon assessment, the patient reported an abdominal pain level of 8/10 and was lethargic with hyperglycemia and elevated vital signs. 3) The nurse administered prescribed analgesics, provided comfort measures, and encouraged relaxation techniques, which reduced the patient's pain level to 3/10 and provided relief.

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L Rean Carmelle MAGALLONES
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1K views2 pages

Fdar

1) The nurse's progress notes document a patient's condition and care on October 24th. 2) Upon assessment, the patient reported an abdominal pain level of 8/10 and was lethargic with hyperglycemia and elevated vital signs. 3) The nurse administered prescribed analgesics, provided comfort measures, and encouraged relaxation techniques, which reduced the patient's pain level to 3/10 and provided relief.

Uploaded by

L Rean Carmelle MAGALLONES
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Nurse's Progress Notes
  • Pain Assessment and Relief

HOLY NAME UNIVERSITY SIMULATION HOSPITAL

College of Health Sciences - Nursing Department


City of Tagbilaran 6300

NURSE’S PROGRESS NOTES

Name: _______________________Age: ____ Sex: ____ Bed No. _____ Hospital No. _____________

DATE / TIME FOCUS D = Data A = Action R = Response

D-

● Received patient lying on bed ,awake.

10/24/22 Acute Pain

● Afebrile

● Not in respiratory distress

● V/S

BP-140/90 mmHg
RR- 25
PR-102bpm
Temp-35 .4 C

● Hyperglycemia: BG >180 mg/dL

● lethargic

● Patient verbalized pain on the abdominal incision area with a


pain scale of 8 /10

A-

● Assessed pain characteristics

● Determined and administered the appropriate prescribed


analgesic .

● Assisted patient in a comfortable position

● Provided comfort and safety

● Encouraged deep breathing exercises and relaxation technique

HNU-CHS-SH-DIM
April 2022
● Vital signs taken

R-

● With a pain scale score of 3/10, the patient reported pain relief.

Student’s Signature
NAME OF STUDENT
HNU-CHS-NSG

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