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Nurses Progress Notes

A 12-year-old female child was admitted to the pediatric ward with a chief complaint of elevated temperature of 39.8°C. Her vital signs and symptoms were recorded. She experienced abdominal pain and vomiting. The doctor examined her and ordered IV fluids, medications, and tests. Her temperature decreased to 37.7°C but she remained febrile. Her vital signs and needs were monitored throughout the night. By 11:00pm her temperature was normal at 37.5°C and she was ready for discharge.

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Celline Isabelle Reyes
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156 views2 pages

Nurses Progress Notes

A 12-year-old female child was admitted to the pediatric ward with a chief complaint of elevated temperature of 39.8°C. Her vital signs and symptoms were recorded. She experienced abdominal pain and vomiting. The doctor examined her and ordered IV fluids, medications, and tests. Her temperature decreased to 37.7°C but she remained febrile. Her vital signs and needs were monitored throughout the night. By 11:00pm her temperature was normal at 37.5°C and she was ready for discharge.

Uploaded by

Celline Isabelle Reyes
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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NURSES PROGRESS NOTES

SURNAME: SANDRINO AGE: 12 YEARS OLD HOSPITAL NO.: 2021-08-1942 Date: December 11, 2021
GIVEN NAME: JESSYBEL SEX: FEMALE WARD: PEDIA
MIDDLE NAME: CATINA C.S.: CHILD BED NO.: _______
ADDRESS: Purok 6, San Fransisco Bato Camarines Sur
DATE FOCUS D - DATA DATE FOCUS D - DATA
SHIFT A - ACTION SHIFT A - ACTION
TIME R - RESPONSE TIME R - RESPONSE

10/22/2021 Trans In D- Admitted a 12-year-old female


child patient with a chief
complaint of elevated temp.
T: 39.8 ˚ C
PR: 85 bpm
RR: 25
BP-120/70 mmHg
WT- 45 kgs

MA. ANGELICA BOLA

4:40 pm A – VS taken and recorded.


-patient experienced
abdominal pain & was vomiting.
-Assess and document pain
characteristics
-Encourage adequate fluid
intake
- Seen and examined by Dr.
Bolilan with orders made and
carried
- Consent for admission was
signed by Mother
- IVF of PNSS 250 mL at 225cc
to run for 1 hr., then 1L 135cc for 2
hours, then 460 mL at 90cc/hr. For
the remaining hours.
- Paracetamol 300mg TIV
given
- TSB done
- Health Teachings were provided

MA. ANGELICA BOLA

R -pt was febrile

MA. ANGELICA BOLA

10/22/2021 Dengue D- The patient’s temp. Decreased and


Fever pale appearance.
- 37.7 ˚ C
- PR: 86 bpm
- RR: 22

CELLINE ISABELLE REYES


8:40 pm A – VS was taken and recorded.
- Comfort and safety measures
were maintained
- Needs were attended.
- Paracetamol 300mg TIV given
- I & O monitored and recorded.
-Keep monitoring VS q4

CELLINE ISABELLE REYES

R- pt was endorsed
- the patient was febrile

CELLINE ISABELLE REYES

11:00 pm D-The patient’s temp. Was normal


PR: 87
RR:24
T: 37.5
A
– VS was taken and recorded.
- Comfort and safety measures
were maintained
- Health Teachings were
provided
R
-pt was back to normal
pt ready for discharge

CELLINE ISABELLE REYES

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