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    Rle - NCM 109 Sample Only

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    Faine Angela Caones
    The nurses progress notes document the care of patient Artem M. Juan, age 51, who was admitted to the hospital. His blood pressure was elevated at 125/90 mmHg in the morning so he was given Spironolactone. Later, he reported difficulty breathing so respiratory treatments and exercises were administered. By late morning, his breathing had slightly improved. An education session was then held where the importance of strictly following his prescribed medications was discussed and he demonstrated understanding.

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    Rle - NCM 109 Sample Only

    Uploaded by

    Faine Angela Caones
    46 views3 pages
    The nurses progress notes document the care of patient Artem M. Juan, age 51, who was admitted to the hospital. His blood pressure was elevated at 125/90 mmHg in the morning so he was given Spironolactone. Later, he reported difficulty breathing so respiratory treatments and exercises were administered. By late morning, his breathing had slightly improved. An education session was then held where the importance of strictly following his prescribed medications was discussed and he demonstrated understanding.

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    DAY 3 FDAR

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    The nurses progress notes document the care of patient Artem M. Juan, age 51, who was admitted to the hospital. His blood pressure was elevated at 125/90 mmHg in the morning so he was given Spironolactone. Later, he reported difficulty breathing so respiratory treatments and exercises were administered. By late morning, his breathing had slightly improved. An education session was then held where the importance of strictly following his prescribed medications was discussed and he demonstrated understanding.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    46 views3 pages

    Rle - NCM 109 Sample Only

    Uploaded by

    Faine Angela Caones
    The nurses progress notes document the care of patient Artem M. Juan, age 51, who was admitted to the hospital. His blood pressure was elevated at 125/90 mmHg in the morning so he was given Spironolactone. Later, he reported difficulty breathing so respiratory treatments and exercises were administered. By late morning, his breathing had slightly improved. An education session was then held where the importance of strictly following his prescribed medications was discussed and he demonstrated understanding.

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    © All Rights Reserved
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    of 3

    DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION

    COLLEGE OF NURSING

    NURSES PROGRESS NOTES

    PATIENT NAME: Artem M. Juan AGE SEX ROOM/WARD HOSPITAL


    Last Name First Name M.I. 51 (/) M NO.
    JUAN ARTEM M. ( )F

    DATE/TIME FOCUS DATA/ACTION/RESPONSE


    09/24/2020 Elevated blood pressure D= Increased blood pressure, BP= 125/90 mmHg
    7:30 am A= Assess blood pressure every 15 minutes and recorded.
    Administered Spironolactone 25 mg 1 tablet P.O.-------------------
    9:15 am Ineffective breathing pattern D= “Bisan waray ako ginhihimo na makapoy gin kukuri ako
    pagginhawa” as verbalized. Respiratory Rate= 22 bpm.
    A= Checked vital signs every 30 minutes. Evaluated
    respiratory rate and depth. Encouraged participation in and
    responsibility for deep – breathing exercises. Administered
    Salbutamol for continued nebulization.---------------------------------
    10:30 am R= Slight improvement in breathing as evidenced by rate depth
    of breathing. Demonstrated increased respiratory rate.------------
    11:00 am Health Education and D= Doctor’s order to continue medications
    Patient Teaching on A= Educated on the importance of strict compliance to
    Medications prescribed medication was conducted. Printed medication
    instruction visual aids provided to help in compliance and
    demonstration
    R= Comprehension on the importance of strict compliance to
    11:50 am medication administration was noted----------------------------------

    RLE - NCM 109 Sample Only


    DATE/TIME FOCUS DATA/ACTION/RESPONSE

    RLE - NCM 109 Sample Only


    RLE - NCM 109 Sample Only

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