Central Philippine Adventist College Alegria, Murcia,

School of Nursing Negros Occidental

Info@cpac.edu.ph
Committed to the development of the whole man

NURSES’ CODE
6A 6P
Olg- - Omega G. Albao, CPAC-SN MJP- Mary Janet L. Pinili, Cpac-SN
MJP- Mary Janet L. Pinili, Cpac-SN

Day/Shift
Focus Progress Notes (D=Data, A=Action, R=Reaction, E=Evaluation)
Time
1/26/24 6-2 F1 Fever D1 6:01 – Patient asleep, Febrile, T38.5, PR 83, skin hot to touch, dry lips, short,
shallow breathing, _______________________________________________ Olg-
A1 7 – assessed patient’s temperature, started TSB, paracetamol given per -
doctor’s order __________________________________________________ Olg
F2 Impaired skin integrity D2 8- Patient complained of itch; Pruritic rashes on skin over chest abdomen and
upper arm. ______________________________________________________ Olg-
A2 assessed skin for further signs of injury, and exacerbation of rashes, applied
zinc oxide lotion as needed, advised patient to avoid scratching.____________ Olg-
A1 9 – continued cooling measures, removed excess blankets , applied hot water
bag on feet, encouraged increased fluid intake _________________________ Olg-
A2 10- assessed for factors that trigger itch, changed and smoothened linens,
referred new outbreaks to doctor, anti-pruritic meds given per doctor’s order- Olg-
A 10– allowed patient time to rest, ensured safety and comfort of patient. ---- Olg-
A 12- Monitored vital signs, due meds give, cold compress done, assisted with
meals __________________________________________________________ Olg-
A2 1:30 - health teachings on rubella given ____________________________ Olg-
R1 1:45 - Patient resting, afebrile, T37.2 _____________________________ Olg-
R2 Still complains of itch, new pruritus outbreaks on upper thigh. _________ Olg-
E 2:00 – F1 resolved, patient afebrile since 10 am; F2 unresolved with new
outbreaks, referred and endorsed for further management____________________
______________________________________ Olg- Omega G. Albao, CPAC-SN
2-10 F2 Impaired skin integrity D2 2:15 – pruritus noted on arms, face and chest; scratch marks noted on arms and
legs verbalized itchiness___________________________________________ MJP
A2 3:00 – Instructed to avoid scratching, applied calamine on affected areas. --MJP
A: 3:15 – gave patient time to rest. ___________________________________ MJP
F1 - Fever D1 4:00 – Pt febrle T 38.4; PR 92; flushed skin teary eyes _________________ MJP
A1 4:15 - cooling measures started ; referred to AP______________________ MJP
A1 5:00 - instructed SO to continue cooling measures, prn paracetamol given as
Ordered. ______________________________________________________ MJP
F3 - Cough D3 6:30 occasional productive cough noted, fine rales heard on Left lower
lobes. RR33______________________________________________ MJP
A3 7:00 monitored respiratory status; initiated increase of fluid intake - MJP
A3 8:00 nebulization done, chest clapping applied.________________ MJP

LAST NAME FIRST NAME MI AGE SEX HOSP NUMBER

Cruz, Juanita T. 32 F 12345
Nurses’ FDARE Progress Notes

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 Day/Shift
Focus Progress Notes (D=Data, A=Action, R=Reaction, E=Evaluation)
Time
1/26/24 2-10 A1 8:30 Reassessed patient for recurrence of fever. Evening cares done. ____ MJP
A2 9:00 Reapplied calamine lotion on affected areas ___________________ MJP
R1 9:30 - Afebrile T 37.2, asleep____________________________________ MJP
R2 Pruritus still noted, verbalized existing itchiness on arms , no new scratch
marks visible ____________________________________________________ MJP
R3 – still with occasional productive cough, decreased rales, RR 24. ___MJP
E 10:00 F1 resolved, afebrile since 6 pm. F2 partially resolved. Still with itchiness
and pruritus. F3 partially resolved with occational cough and minimal rales,
endorsed to next shift for continuity of care-----------------------------------------------------
-------------------------------------------------------------------------------MJP -Mary Janet Pinili, CPAC-–SN

LAST NAME FIRST NAME MI AGE SEX HOSP NUMBER

Cruz, Juanita T. 32 F 12345

Nurses’ FDARE Supplementary Sheet

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