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Nursing Progress Notes Example

The nursing progress notes document a patient's (Sanaa Anwar Tahir) 6-day hospital stay for complaints of hypogastric pain. On admission, the patient reported severe pain rated 7/10 that was managed with IV fluids, medications, and rest. Over the next few days, the patient's pain decreased to 5/10, 4/10, 3/10 and finally 0/10 as their condition improved. They were able to void with less pain and wanted to be discharged. Before leaving, the nurses provided health teachings around hygiene, medications, follow-up and maintaining wellness.

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ROXANNE V. LOPEZ
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2K views2 pages

Nursing Progress Notes Example

The nursing progress notes document a patient's (Sanaa Anwar Tahir) 6-day hospital stay for complaints of hypogastric pain. On admission, the patient reported severe pain rated 7/10 that was managed with IV fluids, medications, and rest. Over the next few days, the patient's pain decreased to 5/10, 4/10, 3/10 and finally 0/10 as their condition improved. They were able to void with less pain and wanted to be discharged. Before leaving, the nurses provided health teachings around hygiene, medications, follow-up and maintaining wellness.

Uploaded by

ROXANNE V. LOPEZ
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Nursing Progress Notes

PATIENT’S NAME: Sanaa Anwar Tahir HEALTH RECORD NO. :______________

SEX: F AGE: 36 Years Old WARD/ROOM NO.: Medical Ward

DATE/TIME/SHIFT FOCUS D= Data A=Action R= Response


11/27/2021 Pain D= Admitted to medical ward w/ complaints of hypogastric pain
on a pain scale of 7/10. Started venoclysis w/ PNSS
1L@20gtts/min.

A= Placed in high back rest keeping back dry. V/S monitored


and recorded. I&O monitored and recorded. Medications given
as ordered by physician.

R= Constant pain in the hypogastric region as reported by


patient. Voided 2 times with pain upon urination.
11/28/2021 Pain D= Patient reports reduced pain with a scale of 5/10.

A= IVF rate increased to 30gtts/min. Heating pad applied to


pubic area for 15 mins. I&O strictly monitored.

R= Patient reports pain is reduced w/ the help of the heating


pad. Voided 3 times with less pain upon urination.
11/29/2021 Health D= Patient able to tolerate pain upon urination.
Teaching
A= Adviced proper personal hygiene. Continue medications.
I&O strictly monitored.

R= Patient responded positively for proper personal hygiene.


Voided 3 times with less pain upon urination.
11/30/2021 10AM Patient D= Patient is able to report pain as tolerated upon urination.
Monitoring
A= Lab tests repeat for urinalysis, CBC, creatinine & BUN.
Monitored properly for any unusual findings

R= Patient tolerates pain upon urination with a pain scale of


4/10. Voided 3 times with less pain as reported by patient.
12/01/2021 9AM Patient D= Patient reports pain with a pain scale of 3/10.
Monioring
A= Regulates IV rate and decreased to 20gtts/min. Continue
medications. I&O strictly monitored.

R= Patient reports pain as reduced with a pain scale of 2/10.


Voided 3 times with less pain.
12/02/2021 11AM Patient D= Patient reports pain is gone with a pain scale of 0/10.
Monitoring
A= Changed IV to heplock. Shifted Levofloxacin to
Cotrimoxazole 800 mg 1-tab p.o. BID. Continue other
medications.

R= Patient reports pain is totally gone and wants to go home.


Voided 3 times with no pain afterall.
12/03/2021 Health D= Patient shows no pain afterall. Reports she is well.
Teaching
A= Health teachings before going home.Continue medications.
Adviced to increase fluid intake. Instructed to maintain personal
proper hygiene. Adviced to come back for follow-up check after
2 weeks.

R= Patient displays positive outlook to wellness. Voided 3 times


with no pain afterall.

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