Akong Tuo Na Kamot! Napaakan Man Gud Ko Ug Putsukan" As

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Name: Romeo Dela Cruz

Age: 34
Birthday: August 12, 1987

Date/Time Focus Progress Notes

September 28, 2021 Swelling in the right hand DATA:


7:00 am ● “Nurse, namghupong
akong tuo na kamot!
Napaakan man gud
ko ug putsukan” as
verbalized by the
patient.
8:00 am ● Reddish, swelling in
the right hand.
● Vital Signs measured:
T: 36.5
BP: 160/100 mmHg
RR: 24 cpm
9:00 am
ACTION:
● Monitored Vital signs
● Past and present
medical history taken.
● Administered
Diphenhydramine 50
mg IV: as ordered
● Administered
Norgesic Forte 200
12 pm mg PO: as ordered.
● Outpatient care:
Allowed patients to be
comfortable.
● Health teachings:
Apply ice bags to
relieve swelling and
drink water as normal.

RESPONSE:
Patient showed relief of signs
and symptoms.
Name: Kim Seokjin
Age: 29
Birthday: December 4, 1992

Date/Time Focus Progress Notes

September 28, 2021 Burn in the left arm DATA:


3:00 pm ● Patient verbalized
“Napaso ko sa termos
sir! Hastang sakita!
Napaslot jud siya as
in.”
4:00 pm ● Burns in the left arm
with small blisters.
● Vital signs:
T: 36.7
RR: 26 cpm
BP: 140/100 mmHg
PR: 103 bpm
5:00 pm
ACTION:
● Monitored Vital Signs.
● Administered Silver
Sulfadiazine cream in
the burned area BID:
as ordered.
● Administered tetanus
toxoid.
● Bedside care:
Allowed patient to be
comfortable by
maintaining a clean
room conducive for
rest and sleep.
● Health teaching:
Avoid scratching of
the skin and apply
moisturizing lotion if
needed.
9:00 pm
RESPONSE:
Patient verbalized relief of
pain.

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