Professional Documents
Culture Documents
The focus of this problem is pain. Notice the way how the D, A, and R are
written.
Date/Hour
Focus
Progress Notes
5/20/201
08:00pm
Pain
D:
IV
Encouraged deep breathing
A:
safe
R:
Focus
Progress Notes
5/20/2010
Hyperthermia
D:
8:00pm
axilla
Skin is flushed and warm
to touch
A:
7:30pm
Administered 250mg IV
fluid intake
Encouraged adequate rest
R:
10:00pm
Temperature decreased
from 38.9 to 37.1 OC
Alert and oriented to person, place and time. Skin pink, warm and dry.
Repirations regular and unlabored. (Or, crackles auscultated in RLL with
deep breath--productive coughing of green colored sputum upon deep
inspiration) No cough noted. Continuous O2 at 2L/min by nasal cannula.
Abdomen rounded and soft with active bowel sounds auscultated in all four
abdominal quadrants. No pain to mild palpation of abdomen. (Or, no bowel
sounds auscultated in any quadrant of abdomen after one full minute of
listening at each quadrant.) Foley catheter patent with clear yellow urine
draining. IV intact and patent in anterior aspect of left lower forearm with
1000cc D5W infusing at 100cc/hr by gravity drip (we didn't use pumps in
those days, but if we did I always mentioned that a pump was in use). No
pain, redness, or swelling at or above IV site. No calf tenderness. No pedal
edema. Knee high TED hose in place bilaterally. Side rails up. Call light in
reach
AbdominalPain
D
-Patient verbalized
A
-Performed tepid sponge bath, applied ice cap onforehead, administered
Paracetamol 250mgintravenously as per
doctors
order. Encouragedadequate oral fluids intake, provided calmenvironment
to keep patient comfortable.
R
Gipaningot na ko
,
as verbalized, temperature
decreased to 37.