Date Time Focus Data Action Response

9:00 Constant elevated blood pressure D-The patient is 26 y/o with vital signs;
temperature- 36.5, blood pressure- 160/100,
respiratory rate- 34 bpm, heart rate- 125 bpm,
oxygen saturation- 96. Received patient with an IVF
of the following: RA-PNSS LA-DSLR liter both
flowing well. The patient complains about
headache " makulogon po ang payo ko, pain scale 5
out of 10, kasubago pa po." as verbalized by the
patient. A- Established patient's rapport.
Monitored Vital Signs. Removed PNSS liter as per
Doctor's order. Referred the patient due to
elevated BP. Explained the importance of
compliance to medication. Advised patient to get
an adequate rest. R- After performing nursing
action, the patient still has an elevated BP.
1:00 Impaired Comfort due to dilatation and D- The patient's vital signs are temperature- 35.9,
curretage blood pressure- 160/110, respiratory rate- 32,
heart rate- 121, oxygen saturation- 93. The patient
looks distressed. Pain scale 6 out of 10. " Makulog
po tyaka iniinitan ako." as verbalized by the
patient. A- Assessed patient's pain scale and pain
characteristics. Advised patient to do light activities
with frequent rest period. Monitored Vital signs.
Advised patient to take soft diet for the mean time.
Explained the importance of compliance to
medication. R- After performing nursing action, the
level of pain decreased.