Republic of the Philippines

City of Cebu
CEBU CITY MEDICAL CENTER
A PHIC ACCREDITED HEALTH CARE PROVIDER
N. Bacalso Avenue corner Panganiban Street, Cebu City, Philippines 6000

NURSES PROGRESS NOTES

CAP/PTB

Name of Patient: ___________________________Area & Bed No.: ____________ Case No.:__________

DATE TIME FOCUS D-ata A-ction R-esponse

Ineffective Airway D- dyspneic RR: __ cyanotic, cough noted O2 sat:____

Clearance A- continued/started oxygen inhalation at 3LPM via nasal

cannula. Attached to pulse oximeter. Auscultated lung fields

for adventitious breath sounds crackles/wheeze noted.

Taught deep breathing exercise. Taught effective coughing.

Suctioned secretions. Due medications given. O2 saturation

monitored
R- RR: __ oxygen saturation: _____

Impaired Gas Exchange D- Dyspneic RR: ___, restlessness noted, tachycardic

PR: _____, noted change of mental status, unable to

recognize family members.

A- Started/continued oxygen inhalation at 10LPM via

facemask. Placed in semi-fowlers/fowlers position. Attached

to pulse oximeter. Assessed mental status. Observed color of

skin and nail beds. Maintained bed rest. Due medications

given

R: O2 saturation: _____, seen asleep

Risk for imbalanced D- cough noted, dyspneic, nauseated, “wala koy gana moeat”

nutrition A- encouraged small frequent meals with high calorie high

CCMC-NSD-F6 REV.0
 Republic of the Philippines
City of Cebu
CEBU CITY MEDICAL CENTER
A PHIC ACCREDITED HEALTH CARE PROVIDER
N. Bacalso Avenue corner Panganiban Street, Cebu City, Philippines 6000

protein diet consisting of soft and easy to eat foods.

Encouraged oral hygiene.

R- served meal consumed. Reported increase in appetite

Activity Intolerance D- Dyspneic RR: ____O2 saturation: ___ weak, seen lying in

bed most of the time, decreased performance

A- Explained the importance of rest in treatment plan and

necessity for balancing activities with rest. Provided quiet

and comfortable environment

R- seen asleep

Acute pain (related to D-verbalized pain with pain scale of ___, irritable, facial grimaced noted,
observed guarding behavior
inflammation of lung A- Provided comfort measures, back rubbed, placed in a

parenchyma) desired comfortable position. Encouraged deep breathing

exercise. PRN medication of Tramadol 50mg IVTT given.

R- Verbalized relief from pain. Pain scale of ___. Seen relaxed

NURSES PROGRESS NOTES

Bedridden Patients/ Patients with NGT

Name of Patient: ___________________________Area & Bed No.: ____________ Case No.:__________

DATE TIME FOCUS D-ata A-ction R-esponse

Ineffective Airway D- dypneic RR: __ cyanotic, cough noted O2 sat:____

Clearance A- continued/started oxygen inhalation at 3LPM via nasal

cannula. Attached to pulse oximeter. Auscultated lung fields

CCMC-NSD-F6 REV.0
 Republic of the Philippines
City of Cebu
CEBU CITY MEDICAL CENTER
A PHIC ACCREDITED HEALTH CARE PROVIDER
N. Bacalso Avenue corner Panganiban Street, Cebu City, Philippines 6000

for adventitious breath sounds crackles/wheeze noted.

Suctioned secretions. Due medications given. O2 saturation

R- RR: __ oxygen saturation: _____

Risk for Aspiration D- Dyspneic RR: ___, restlessness noted, tachycardic PR:
_____, noted change of mental status, unable to recognize
family members.

A- Started/continued oxygen inhalation at 10LPM via

facemask. Placed in semi-fowlers/fowlers position. Attached
to pulse oximeter. Assessed mental status. Observed color of
skin and nail beds. Maintained bed rest. Due medications
Given; Nasogastric Tube placement and patency checked
prior to feedings; placed on high back rest during feedings

R: O2 saturation: _____, seen asleep

Risk for imbalanced D- cough noted, weak and unconscious

nutrition A- fed blenderized feeding with high calorie high

protein diet as prepared by dietary team ordered by doctor

R- O2 saturation: _____, endorsed with NGT in placed- kept

tip closed

Activity Intolerance D- Dyspneic RR: ____O2 saturation: ___ weak, seen lying in

bed most of the time, decreased performance

A- Explained the importance of rest in treatment plan and

necessity for balancing activities with rest. Provided quiet

and comfortable environment; assisted and educated

watcher of passive range-of-motion exercises

R- weak and unconscious

CCMC-NSD-F6 REV.0
 Republic of the Philippines
City of Cebu
CEBU CITY MEDICAL CENTER
A PHIC ACCREDITED HEALTH CARE PROVIDER
N. Bacalso Avenue corner Panganiban Street, Cebu City, Philippines 6000

Risk for Impaired Skin
Integrity R/T Activity
Intolerance
D- Dyspneic RR: ____O2 saturation: ___ weak, seen lying in
bed weak and unconscious
A-turned to sides every two hours, assisted and educated
watcher of passive range-of-motion exercises to promote
circulation

R- thermoregulated

CCMC-NSD-F6 REV.0