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    Nurses Notes Date Focus Data Action Response: Subjective

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    GILIANNE MARIE JIMENEA
    1) Manny Fernandez, a 35-year-old male, was admitted to the hospital with a diagnosis of amoebiasis and symptoms of loose bowel movements, vomiting, and abdominal pain. 2) The nurses' notes document the patient's symptoms, vital signs, intake/output, treatments including IV fluids and pain medication, and the patient's responses over the course of the day. 3) By the end of the day the patient was responding well to health teachings on pain management and appeared more comfortable after various nursing interventions.

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    Nurses Notes Date Focus Data Action Response: Subjective

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    GILIANNE MARIE JIMENEA
    79 views2 pages
    1) Manny Fernandez, a 35-year-old male, was admitted to the hospital with a diagnosis of amoebiasis and symptoms of loose bowel movements, vomiting, and abdominal pain. 2) The nurses' notes document the patient's symptoms, vital signs, intake/output, treatments including IV fluids and pain medication, and the patient's responses over the course of the day. 3) By the end of the day the patient was responding well to health teachings on pain management and appeared more comfortable after various nursing interventions.

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    1) Manny Fernandez, a 35-year-old male, was admitted to the hospital with a diagnosis of amoebiasis and symptoms of loose bowel movements, vomiting, and abdominal pain. 2) The nurses' notes document the patient's symptoms, vital signs, intake/output, treatments including IV fluids and pain medication, and the patient's responses over the course of the day. 3) By the end of the day the patient was responding well to health teachings on pain management and appeared more comfortable after various nursing interventions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    79 views2 pages

    Nurses Notes Date Focus Data Action Response: Subjective

    Uploaded by

    GILIANNE MARIE JIMENEA
    1) Manny Fernandez, a 35-year-old male, was admitted to the hospital with a diagnosis of amoebiasis and symptoms of loose bowel movements, vomiting, and abdominal pain. 2) The nurses' notes document the patient's symptoms, vital signs, intake/output, treatments including IV fluids and pain medication, and the patient's responses over the course of the day. 3) By the end of the day the patient was responding well to health teachings on pain management and appeared more comfortable after various nursing interventions.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Fernandez Manny 35 m Dr.

    Siason

    Surname First Name M.I. Age Sex Civil Status Admission No. Attending Physician
    Amoebiasis
    Diagnosis Room/Ward

    NURSES NOTES
    Date Focus Data Action Response
    Aug.19, Loose Bowel Subjective: Vital signs taken and noted (T- Fever not noted;
    2020 Movement Patient verbalized, 37.5C, RR- 17bpm, PR- 82bpm, BP- Patient was able to
    “ga sakit man 90/70mmhg); Bedside care given; rest in a comfortable
    7:30 AM – gyapon akon tiyan Assisted patient from going to the position; Replace
    9:30 AM kag kaduwa gd ko bathroom; Encouraged to increase fluid lost from
    ma mus-on” fluid intake; Assessed for abdominal diarrhea
    discomfort, pain, cramping,
    Objective: frequency, urgency, loose or liquid
    Received patient stools, and hyperactive bowel
    awake; IVF #4 PNSS sensations.
    1L at 30gtts/min
    with remaining
    solution of 400cc,
    bottle 8; had LBM
    twice; Afebrile

    Vital signs:
    T- 37.5
    RR- 17
    PR- 82
    BP-90/70
    9:30 AM Vomiting Subjective: Measured the patient’s urinary Patient’s urinary
    Patient verbalized, output every 2 hours. Measured the output maintained at
    “Nd ko gyapon ka patient’s intake and output every 12 least 30 cc/hr.
    untat suka ” hours. Instructed the patient to Patient tolerated
    store her stool in a bedpan and his clear liquids without
    Objective: vomitus in a plastic; Bedside care vomiting; Patient will
    Lethargic; Vomited given; Assisted patient to a reported he is feeling
    2x to a 10cc whitish comfortable position. less lethargic
    saliva; Patient is
    uncomfortable;
    shows facial
    grimace
    11:00 AM – Abdominal Pain Subjective: Assessed pain; Repositioned the Patient was relieved
    12:00 PM Patient verbalized, patient; applied hot compress to of pain and was able
    “Ga sakit gd ya alleviate the pain; administered to relax; pain scale of
    gyapon akon tiyan medications 5/10
    nurse”

    Objective:
    Shows facial
    grimace; guarding
    behavior; Pain
    scale of 6/10
    1:30 PM Health Teaching: Subjective: Gave Health Teaching to the patient Patient was
    Pain Management Patient verbalized, on basic breathing exercises and responsive of the
    “Nag ayo2 akon pain management health teaching and
    palanakit sa tiyan” immediately applied
    the teachings
    Objective:
    Patient shows little
    behavior of pain
    being felt
    2:30 PM Taking of Vital Endorsed vital signs
    Signs and
    Endorsement T- 37 C
    RR- 19 bpm
    PR- 70 bpm
    BP-120/80mmhg

    -Intake and output measured


    -Replaced IV bottle 9

    Nurse printed name and signature: Gilianne Marie Jimenea SN

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