DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION
COLLEGE OF NURSING
NURSES PROGRESS NOTES
PATIENT NAME: AGE SEX ROOM/WARD HOSPITAL
Last Name First Name M.I. 27 ( )M SURGICAL NO.
BRAUN NATASCHA Y. (✓ ) F WARD 123456
DATE/TIME FOCUS DATA/ACTION/RESPONSE
03/15/2021 Post-transfer Assessment D = Admitted to surgical ward, a 27 year old G1P0 at 16 weeks of
7:30AM pregnancy who presented at Accident and Emergency Department
(A&E) complaining of sudden onset of localized, non-radiating pain
at suprapubic and right iliac fossa regions together with vomiting
and worsening anorexia. “Waray ako umabat hin hiranat ngan
pagdudugo ha ikinatawo labot la han bulaw na likido na nagawas.”
Vaginal speculum examination done at A&E confirmed presence of
whitish discharge without fouls smelling, healthy cervix and closed
opening (OS). Transabdominal Scan (TAS) was done showing
singleton, positive fetal heart (FH), low lying placenta without
retroplacenta clots, free fluid in pouch of Douglas (POD) and
adnexal mass. Urine Full Examination Microscopy Exam (UFEME)
revealed negative results except 3+ leukocytes.----------------------------
8:00AM A = Ushered to room of choice, transferred to bed with side rails
raised and locked. Oriented to room and floor policies. Baseline
vital signs checked and recorded: BP - 103/64 mmHg, HR - 84 bpm,
temp - 37 ०C and SPO2 - 98%.----------------------------------------------------
8:10AM Acute Pain D = “Masakit hin duro ngadi ha ubos hit ak tiyan dapit ngadi ha
tuo” as verbalized. Localized, non-radiating pain was observed in
the suprapubic and right iliac region. Positive rovsing sign.
Constantly restless and irritable.-----------------------------------------------
8:15AM A = V/S monitored. Palpated the left lower quadrant, pain rated
8/10 using the numeric rating scale. Encouraged use of behaviors
such as guided imagery, distractions, visualizations, deep breathing
exercises and relaxation techniques. Ensured safety and provided
comfort.-------------------------------------------------------------------------------
9:00AM R = Reported pain as 4/10. Experienced moderate pain.----------------
ROYCE VINCENT E. TIZON, SN MARVIE JOY B. CABIOC,RN EREN YAEGER, RN
RTRMF-CN CLINICAL INSTRUCTOR, RTRMF-CN STAFF NURSE
RLE - NCM 109 Sample Only
DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION
COLLEGE OF NURSING
NURSES PROGRESS NOTES
PATIENT NAME: AGE SEX ROOM/WARD HOSPITAL
Last Name First Name M.I. 27 ( )M SURGICAL NO.
BRAUN NATASCHA Y. (✓ ) F WARD 123456
DATE/TIME FOCUS DATA/ACTION/RESPONSE
03/16/2021 Elevated Body Temperature D = Low-grade fever. Vital signs: BP - 135/78 mmHg, HR - 88 bpm,
7:30AM temp - 38०C and SPO2 - 96%------------------------------------------------------
8:00AM A = Assessed temperature every 30 mins. Encouraged and offered
oral fluid intake every two hours. Provided tepid sponge bath.
Maintained bedrest.----------------------------------------------------------------
8:30AM Administered Paracetamol 500 mg orally as ordered for
temperatures 37.8०C and above.------------------------------------------------
9:00AM R = Temp lowered from 38०C to 37.5०C and was free from chills.
Experienced no associated complications.-----------------------------------
10:00AM Risk for Deficient Fluid D = Vomiting, worsening anorexia and increased frequency of
Volume urination. Vital signs: BP - 126/75 mmHg, HR - 85 bpm, temp - 37.5०C
and SPO2 - 95%. ---------------------------------------------------------------------
10:10AM A = Monitored intake and output (I&O). Noted urine color, and
concentration and specific gravity. Provided clear liquids in small
amounts and progressed diet as tolerated. Health teaching given
on oral hygiene, and proper nutrition and hydration.--------------------
10:30AM Administered IVF of PNSS infused at 100cc/hr.-----------------------------
12:00PM R = Maintained adequate fluid balance with normal urine output
and increased BMI from 18 to 18.3.--------------------------------------------
ROYCE VINCENT E. TIZON, SN MARVIE JOY B. CABIOC,RN EREN YAEGER, RN
RTRMF-CN CLINICAL INSTRUCTOR, RTRMF-CN STAFF NURSE
RLE - NCM 109 Sample Only
DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION
COLLEGE OF NURSING
NURSES PROGRESS NOTES
PATIENT NAME: AGE SEX ROOM/WARD HOSPITAL
Last Name First Name M.I. 27 ( )M SURGICAL NO.
BRAUN NATASCHA Y. (✓ ) F WARD 123456
DATE/TIME FOCUS DATA/ACTION/RESPONSE
03/17/2021 A = Demonstrated proper way of wound dress changing prior to
12:00PM discharge. Explained the signs and symptoms that indicate
immediate medical care. Provided follow up suture removal
instructions and schedule.-------------------------------------------------
R = Demonstrated that she is able to change her wound dressing
using aseptic technique. Able to enumerate the signs and symptoms
that indicate immediate medical care.----------------------------------------
12:10 PM A = Assessed nutritional status. Discussed the importance of proper
nutrient intake during pregnancy. Explained the importance of
healthy eating habits, proper management, and food preparation.--
R = Verbalized the importance of proper nutrient intake during
pregnancy. Gave examples of healthy eating habits, proper
management of food and preparation.----------------------------------------
ROYCE VINCENT E. TIZON, SN MARVIE JOY B. CABIOC,RN EREN YAEGER, RN
RTRMF-CN CLINICAL INSTRUCTOR, RTRMF-CN STAFF NURSE
RLE - NCM 109 Sample Only
