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Nurses Progress Notes

Patient P.F. was admitted to the medical ward with hyperthermia. Upon initial assessment, the patient was conscious but unable to speak in full sentences and had wheezing and clubbing of the nails. Vital signs were taken. The nurse administered a tepid sponge bath and supplemental oxygen. After 30 minutes, the patient's temperature had reduced from 38.0 to 37.1 degrees celsius.

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5K views2 pages

Nurses Progress Notes

Patient P.F. was admitted to the medical ward with hyperthermia. Upon initial assessment, the patient was conscious but unable to speak in full sentences and had wheezing and clubbing of the nails. Vital signs were taken. The nurse administered a tepid sponge bath and supplemental oxygen. After 30 minutes, the patient's temperature had reduced from 38.0 to 37.1 degrees celsius.

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van
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NURSES PROGRESS NOTES

Patient’s Name: ___P.F._______________ Ward and Bed No. Medical Ward,


Bed 2
Hospital Number: __ 2020-45213_____________
Date Time Focus Data Action
Response
11/09/202 7:00AM Hyperthermia D- received patient conscious, alert, oriented
0 to time and place, ambulatory, unable to speak
in full sentences. With ongoing 1 PNSS1L @
40mL/hr at right arm, with O2 2L/min via
nasal cannula. Audible wheezing was noted
with no accessory muscle use. Chest has
increased its anteroposterior (AP) diameter.
Heart sounds are regular with no murmurs.
Patient’s nails has tar stains and clubbing.
Patient reported feeling of difficulty in
breathing and feeling cold. “Pero pag hikap
nako niya nars kay init man siya” as
verbalized by wife. Patient’s face is slightly
grimaced and restlessness was noted. Vital
signs were also taken at that time with the
following data: Temperature: 38.0° C, Pulse:
90 beats/min, Respirations: 34 cycles/min, ,
BP: 130/80 mm Hg, O2 sat: 94%
7:30AM A- Rendered tepid sponge bath (TSB);
Administered supplemental oxygen @ 3L/min
via nasal cannula. Encouraged SO to let
patient wear light clothing; maintained
bedrest. Encouraged limited water intake to 4
glasses or 1L per day, environmental care
done, monitored vital signs
8:00AM R- Patient’s temperature has reduced from
38.0 to 37.1 “Salamat mam, ni ubos ubos na
akong hilanat” as verbalized

Fritzie Vanbelle Lopez Vincent Pananganan


Student Nurse CNU CI CNU-CN

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