NURSE’S PROGRESS NOTES

SURNAME N/A AGE 65 HOSPITAL NO.

GIVEN NAME N/A SEX Female WARD Surgery
MIDDLE NAME N/A CS N/A BED NO.

DATE D – DATA DATE D – DATA

SHIFT FOCUS A – ACTION SHIFT FOCUS A – ACTION
TIME R – RESPONSE TIME R – RESPONSE
03-06-22 Nausea and D
7-3 vomiting for - Admitted patient on the ward,
several 65 years old female, conscious,
weeks; Pain with history of hypertensive
in upper disorder, arthritis, high
abdomen and cholesterol, diabetes mellitus
headache; type 2, hypothyroidism, obesity
Fever - Presented with intractable
nausea and vomiting for several
weeks
- Chief complaint of upper
abdominal pain and diffuse
headaches
- Febrile
A
- Promoted rest, positioned
comfortably in bed- semi-fowler’s
- Consent secured
- Vital signs taken and recorded
- Pain rating scale: 7/10
- Administered paracetamol IV as
prescribed
- Initiated IV rehydration as
prescribed
- Monitored intake and output
- Safety measures secured
- Comfort measures rendered
R
- Eased pain
- Temp went down to 37 C
- No further complaints

mzm
Mark Zedrix A. Mediario