NURSE’S NOTES AND TREATMENT RECORD

Name: Ward/ Room: MW3

Address: Brgy. Mandalagan, Bacolod City
Age: 58 yrs old Sex: Male Admission Date: November 6, 2021

Date/ Time Focus Progress Notes

(D-Data A-Action R-Response)

Nov 15, 20121 Acute pain related to D: Received patient, conscious. Initial vital
8:00 am aching of the back and signs taken: Temp 98.5, BP: 125/73, P: 65, RR:
swelling of legs and 17. ……………………………………...AALA
ankles

Complains of dull, aching pain left lower

back………………………………….....AALA

Patient has jaundice as observed…….….AALA

Swelling of legs and ankles as shown…..AALA

Upon assessment significant left CVAT with

palpation………………………………..AALA

A: Assessed the patient for body pain to

determine possible source…………….AALA

Inspected the swelling of legs and ankle.AALA

10:00 am Ibuprofen was given to relieve pain…….AALA

Prednisone as prescribed was also given to

patient to treat arthritis…………..……..AALA

Fluid Imbalance Encouraged patient to have adequate rest and

fluids………………………………..…..AALA

Patient was positioned to moderate high back

rest………………………………….…...AALA

Continuously monitored the patient…….AALA

1:30 pm R: Aching of the back has been relieved.AALA

Swelling and pain in the legs and ankles has

been subsided……..…………...……......AALA

Patient is responsive about his condition.AALA

Endorsed………………………………AALA
Aljean Altheo L. Artillo

SN-USLS