ANGELES UNIVERSITY FOUNDATION
COLLEGE OF NURSING
Mc Arthur Hi-way Angeles City
(045) 625-2811, Fax Number (045) 888-6000
NURSE’S PROGRESS NOTES
DATE/TIME FOCUS D - DATA A - ACTION R - RESPONSE
10/10/2020 General Survey D> Received patient on bed, alert and oriented. Patient reported prior intermittent abdominal pain in the
4:00 pm epigastric area and loss of appetite the past 2 days, and sudden onset of RLQ pain prior to admission.
Vital signs are as follows: T: 37°C, PR: 86 bpm, RR: 22 cpm, BP: 110/70 mmHg. Abdomen is soft, flat.
(+) muscle guarding. (+) direct and rebound RLQ tenderness. (+) Rovsing’s sign.-------------------------------
4:00 pm Acute RLQ Pain A> Assessed for pain and its character, onset, location, duration, severity, pattern and associated --------
factors. Provided comfort measures. Encouraged patient to verbalize pain. ---------Y.A.M. David, AUFSN
4:15 pm Diagnostic Test D> Received order of CBC and urinalysis from Dr. Cabacungan.-----------------------------------------------------
4:15 pm A> Instructed SO and patient on proper clean catch urine collection techniques. Prepared patient for-----
blood extraction.-------------------------------------------------------------------------------------- Y.A.M. David, AUFSN
5:00 pm Diagnostic Test R> Elevated WBC. Normal Urinalysis. Alvarado Score 7/[Link] results referred to ---------------------
Dr. Cabacungan. -------------------------------------------------------------------------------------Y.A.M. David, AUFSN
5:15 pm Pre-operative D> Received order of emergency appendectomy from Dr. Cabacungan.--------------Y.A.M. David, AUFSN
5:15 pm Care A> Consent form to surgery was signed and attached to chart. Pre-operative instructions were carried
(Appendectomy) out. Established, regulated and maintained IVF D5 LRS 1L X 30 gtts/min. Administered Ranitidine -------
50 mg IV q8 and Cefoxitin 2 g IV 1 hour prior to OR (ANST).---------------------------- Y.A.M. David, AUFSN
10/11/2020 Post-operative D> S/P appendectomy. Received patient on flat on bed with dressing over incision site; ongoing IVF #2
6:00 am care D5LRS 1 L at 850 cc level regulated at 30 gtts/min on left hand infusing well.-------------------------------------
6:00 am A> Assessed and recorded vital signs. Assessed incision site. Regulated and maintained IVF.--------------
Monitored and recorded urine output. Administered medication as prescribed, Cefoxitin 1gm q12, --------
Ranitidine, 50 mg IV q8 and Tramadol 50mg IV q8. Maintained NPO status. Carried out doctor’s ---------
orders.---------------------------------------------------------------------------------------------------Y.A.M. David, AUFSN
9:00 am Acute Pain D> Received patient on flat on bed with dry and intact dressing over incision site; ongoing IVF #2 ---------
D5LRS 1 L at 760 cc level regulated at 30 gtts/min on left hand infusing well. Patient verbalized “masakit
ya” while pointing at incision site. Pain scale: 8/10. Facial grimaces. Guarded movement. Vital signs are
as follows: T: 37.2°C, PR: 90 bpm, RR 30 cpm, BP: 120/80 mmHg.-------------------------------------------------
A> Assessed and recorded vital signs. Assessed for pain and its character, onset, location, duration,-----
severity, pattern and associated factors. Regulated and maintained IVF. Monitored and recorded urine --
output. Maintained NPO status until (+) flatus. Provided comfort. Instructed client to continue lying flat --
on bed. Informed client not to intake by mouth.-----------------------------------------------Y.A.M. David, AUFSN
12:00 pm Hyperthermia D> Received patient on flat on bed with dry and intact dressing over incision site; ongoing IVF #2 ---------
D5LRS 1 L at 670 cc level regulated at 30 gtts/min on left hand infusing well. Patient reported of-----------
headache. (+) chills. T: 38.9°C.------------------------------------------------------------------ Y.A.M. David, AUFSN
12:10 pm A> referred to Dr. Cabacungan. Performed tepid sponge bath. Administered Paracetamol 300 mg per IV
PRN for T= 37.8C as prescribed. Assessed and recorded vital signs. Regulated and maintained IVF.-----
Maintained NPO status until (+) flatus.----------------------------------------------------------Y.A.M. David, AUFSN
1:30 pm Hyperthermia A> Assessed and recorded vital signs. Replaced IVF bottle. Regulated and maintained IVF #3 D5LRS
1L X 30 gtts/min. Administered due medication as prescribed.--------------------------------------------------------
1:30 pm R> Temperature decreased to 37.8°C.---------------------------------------------------------Y.A.M. David, AUFSN
