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.
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.
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.
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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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