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Nurses Progress Notes by Mikka Silveira

The nurse's progress notes document the care of a patient over three days. On the first day, the patient was conscious and oriented upon receipt, with stable vital signs. Bloodwork was taken and the patient received a blood transfusion and pain medication. On the second day, the patient reported pain and was given additional pain medication which helped them sleep. On the third day, the patient was NPO in preparation for dressing changes under sedation and continued to report pain, so more pain medication was administered.

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Dinarkram Rabreca Ecul
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42 views1 page

Nurses Progress Notes by Mikka Silveira

The nurse's progress notes document the care of a patient over three days. On the first day, the patient was conscious and oriented upon receipt, with stable vital signs. Bloodwork was taken and the patient received a blood transfusion and pain medication. On the second day, the patient reported pain and was given additional pain medication which helped them sleep. On the third day, the patient was NPO in preparation for dressing changes under sedation and continued to report pain, so more pain medication was administered.

Uploaded by

Dinarkram Rabreca Ecul
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd

Nurses Progress Notes Sheet

DATE/TIME FOCUS DATA-ACTION-RESPONSE


10/10/21 D > received patient on bed, conscious, and well oriented to
7AM-3PM time and place
DAT > with IVF D5MN 1L @ 20 gtts/min @ Left metacarpal vein,
patent, infusing well at 1000cc level
> afebrile with the ff v/s: T-37C P-121bpm R-28cpm
O2-96%
9AM > RBC – 2.71x10^6/mm^3 > T-37.7C, patient is awake
Hg – 7.50 g/dL A > v/s taken
Hct – 22.90 % > Paracetamol 1-amp IVTT given
> transfused PRBC 22OmL @ 18gtts/min @ right brachial vein
> monitored for BT reactions
> needs attended
R > Patient tolerated interventions well.
Jam Mikka G. Rodriguez
SN-SPUD
10/11/21 > Continuity of care D > received pt. lying on bed, conscious, oriented to time and
7AM-3PM place
DAT > with IVF D5NM 1L @ 20gtts/min @ Left metacarpal vein,
patent, infusing well @ 900cc level
> afebrile with the ff v/s: T-37.4C P- 137bpm R-24cpm 02-98%
> facial grimace and crying observed, reported pain scale of
> Pain in both lower legs 10/10
A > v/s taken
>due meds given: Tramadol 50mg IVTT
> health teaching done on proper breathing techniques to
relieve pain
>needs attended
> observed for any abnormalities
R > Patient is asleep.
Jam Mikka G. Rodriguez
SN-SPUD
10/12/21 > Continuity of care D > received pt. lying on bed, conscious, oriented to time and
7AM-3PM place
NPO > with IVF D5NM 1L @ 20gtts/min @ Left metacarpal vein,
patent, infusing well @ 1000cc level
> on NPO status for change of dressing under sedation
> afebrile with the ff v/s: T-35.7C P- 117bpm R-24cpm 02-
100%
> Pain in both lower legs > facial grimace and crying observed, reported pain scale of
10/10
A > v/s taken
>due meds given: Tramadol 50mg IVTT
> reinforced health teaching done on proper breathing
techniques to relieve pain
>needs attended
> observed for any abnormalities
R > Patient is asleep.
Jam Mikka G. Rodriguez
SN-SPUD

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