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NURSES' NOTES

PATIENT NAME: C.H.I.N AGE: 35 HOSPITAL NO.: N/A


WARD/ROOM:
PHYSICIAN: N/A SEX: Female Obstetric

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSE SIGNATURE


Decreased cardiac output
related to increased
systemic vascular
resistance secondary to D - High blood pressure was obtained: 180/110 mmHg
PIH, as evidenced by an
140/90 mmHg
average blood pressure
level of 180/110 mmHg, 130/80 mmHg
pitting edema and
March 14, 2022 periorbital edema.
A - Assessed and monitor vital signs as well as the weight and conduct
physical examination.

 Provided emotional support


 Provided frequent rest periods with bed rest.
 Provided calm, restful surrounding, minimize environmental
activity or noise
 Administered anti-hypertensive drug as prescribed.
 Coordinated to the nutritionist for dietary sodium, fat and
cholesterol restictions.

Twinkle Mae M.
Cabading, S.N II/ Mrs.
R – The blood pressure of the client decreased. Marflor Ocampo CI

PATIENT NAME: C.H.I.N AGE: 35 HOSPITAL NO.: N/A


WARD/ROOM:
PHYSICIAN: N/A SEX: Female Obstetric
DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSE SIGNATURE
D - High blood pressure was obtained: 180/110 mmHg

140/90 mmHg

130/80 mmHg

Temp-37.0

RR-20 bpm
Nutrition imbalanced less
than the body PR of 127 bpm.
requirements related to
March 14, 2022 nausea and vomiting.
A - Determined causes of vomiting.
 Monitored the weight of the client.
 Instructed the patient to have a bed rest.
 Instructed the patient to avoid foods that might exacerbate the
situation like caffeinated beverages.
 Encouraged the client to drink plenty of water.
 Referred to dietrician for modification of diet.

Twinkle Mae M.
Cabading, S.N II/ Mrs.
R – After nursing interventions the episodes of vomiting decreased. Marflor Ocampo CI
PATIENT NAME: C.H.I.N AGE: 35 HOSPITAL NO.: N/A
WARD/ROOM:
PHYSICIAN: N/A SEX: Female Obstetric

DATE/TIME FOCUS D - ATA A - ACTION R - RESPONSE NURSE SIGNATURE


Acute pain related to D - High blood pressure was obtained: 180/110 mmHg
March 14, 2022 headache.
140/90 mmHg

130/80 mmHg

Temp-37.0

RR-20 bpm

PR of 127 bpm.
A – Performed pain assessment and evaluate characteristic of pain.
 Performed comfort measures such as positioning the patient on
a comfortable position.
 Assisted the patient to identify ways to prevent and relieve
symptoms.
 Instructed the patient to avoid exposure to radiation.
 Administered medication as ordered

Twinkle Mae M.
Cabading, S.N II/ Mrs.
R – The patient reported relief from pain. Marflor Ocampo CI

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