NURSES PROGRESS NOTES

PATIENT NAME: AGE SEX   ROOM HOSPITAL NO.

Patient X 67   F  3 xxxxx
()F
Last Name           First Name       
M.I.

1st DAY

DATE/TIME FOCUS  D=DATA       A=ACTION      R=RESPONSE     

August 2, Initial D: Arrived at ER, a 67-year old female via wheelchair

2020 Assessment accompanied by daughter; conscious and lethargic,
9:00 AM with complaint of body malaise, productive cough,
difficulty of breathing and generalized edema. Weighs
58 kg. ———————————————  GrC
A: Ushered to bed and placed in semi-Fowler’s
9:15 AM position with side rails raised and locked. Vital signs
taken are as follows: BP-150/90 mmHg, PR-72 bpm,
RR - 23 cpm, temperature - 37.2°C. Examined and
admitted by ER Medical Resident on duty with orders
carried out. Secured consent for admission signed by
daughter.   Facilitated requests for Chest X-Ray and
Blood Chemistry with Na, K & serum albumin
determination STAT. Provided container for 24-hour
urine collection, proper instruction given to the
daughter for the collection of the specimen.
Coordinated with OR for request of renal biopsy.
Informed anesthesia provider about the diagnostic
procedure. Explained the diagnostic procedure
thoroughly.————— GrC

9:25 AM Excess Fluid D: “Nanmamanas it akon mga tiil ngan bagat gin
Volume kukurian ako pag ginhawa,” as verbalized. BP: 150/90
mmHg, PR: 72 bpm, RR: 23 cpm,  Temperature -
37.2°C. Difficulty of breathing and body malaise
present. Crackles upon lung auscultation noted.
Presence of Grade 2 bipedal edema, urine output of
200 mL per urination. Hematocrit - 28.3%, Hemoglobin
- 9.3 g/dL, Serum Creatinine - 10.4 mg/dL, BUN - 16.2
mmol/L.  ————————————— GrC
A:  Placed in semi-Fowler’s position. Elevated
9:30 AM edematous extremities, and handled with care.
Loosened restrictive clothing. Continuously monitored
 vital signs. Noted presence, quality of central and
peripheral pulses. Auscultated heart and lung sounds.
————————————GrC
: Administered O2 inhalation via face mask at 2 L/min.
9:40 AM ————————————————  GrC
Monitored reports or evidence of extreme fatigue,
intolerance for activity, sudden or progressive weight
gain, swelling of extremities, and progressive
shortness of breath. Monitored weight then instructed
to weigh daily using the same scale and preferably at
the same time of the day wearing the same clothing. 
Applied warm compress on edematous areas.
Assisted with repositioning every 2 hours. Monitored
laboratory and diagnostic studies. ———— GrC
: Started IVF with PLR 1L using G 18 needle inserted
at the left metacarpal vein infusing well and regulated
9:45 AM at 20 cc/hr.  ————————GrC
: Documented BP prior to administration of
Furosemide. —————————————  GrC
9:48 AM
: Administered Furosemide 40 mg now IVTT. —
Instructed accurate I&O and noted decreased urinary
10:00 AM
output and positive fluid balance on 24-hour
calculations. Restricted fluid intake as indicated,
spacing allowed fluids throughout a 24-hour period.
Advised to avoid consuming too much sodium.
Educated on stress management, deep breathing
exercises,and  relaxation techniques.
—————————  GrC
R: Presence of grade 2 bipedal edema still noted. BP-
11:00 AM 150/80, PR - 71 bpm, RR - 23 cpm, Temperature -
37.1˚C. Improved breathing pattern.Post-furosemide
urine output .  Urine output improved from 200 mL to
250 mL per urination. Crackles upon auscultation still
noted. 

11:05 AM Pre-Transfer D: With orders to transfer to Medical Ward. Lethargic

Assessment but responsive, accompanied by daughter. With an
ongoing PNSS 1L at 975 cc level using G 18 needle
inserted at level regulated at 20 cc/hr infusing well at
left metacarpal vein. With O2 inhalation via face mask
at 2 L/min. Vital signs are as follows: BP - 130/80
mmHg, PR - 71 bpm RR - 23 cpm, temperature -
37.1˚C. Still with bipeda edema. Post-furosemide urine
output from 200 ml per urination to 2250 ml per
urination. Crackles upon auscultation still noted. 
—————— GrC
11:15 AM A: Transferred to medical ward via stretcher.
Endorsed to Medical Ward Nurse on Duty. —GrC

11:18 AM Post-Transfer D: Received from ER via stretcher accompanied by

Assessment daughter , still lethargic but responsive. With an
ongoing PNSS 1L at 975 cc level using G 18 needle
inserted at level regulated at 20 cc/hr infusing well at
left metacarpal vein. With O2 inhalation via face mask
at 2 L/min. ————————————GrC
A: Transferred to bed in a semi-Fowler’s position. Side
11:20 AM rails raised and locked. Oriented the daughter SO with
the hospital rules and policies.
————————————————GrC
: Vital signs are taken as follows: BP - 130/80 mmHg,
11:30 AM PR - 71 bpm RR - 22 cpm, Temperature - 37.0 ˚C.
Maintained O2 inhalation via face mask at 2 L/min.
Secured consent for Right Intrajugular Catheter Vein
insertion, Hemodialysis cath,  and Renal Biopsy.
Referred to Dr. X for Right Intrajugular Catheter Vein
insertion. Secured 1 “u” PRBC properly screened &
crossmatched to be infused during HD.
————————————————— GrC

12:15 PM Preparation for D: “Nasiring man po hi doctor nga bubutangan ako

Right niya han tubo,” as verbalized. With orders of
Intrajugular Intrajugular Catheter Insertion and Hemodialysis. Wt:
Catheter Vein 58 kg. Sodium 137 mmol/L, Potassium 4.1 mmol/L,
Insertion and BUN 16.2 mmol/L, Creatinine 406 umol/L.
Hemodialysis ————————— GrC
12:30 PM A: Placed in a comfortable position. Explained brief
  overview of the procedure. Attached consent for Right
  Intrajugular Catheter Vein Insertion and Hemodialysis
  consent. Obtained baseline vital signs: BP: 150/90
  mmHg, PR: 72 bpm, RR: 23 cpm, and Temperature
  37.2˚C. Noted the rate and quality of respirations and
  the heart rate and rhythm. Assessed the access site
(internal jugular vein) if functioning properly by using a
  Doppler Ultrasound. Reviewed medication history prior
to the procedure. Obtained weight. Reviewed the last
laboratory results especially the levels of sodium,
potassium, BUN, Creatinine – noting as baselines for
comparisons for post dialysis laboratory results, and
coagulation tests. Pre-operative checklist
accomplished and signed by nursing supervisor
attached to chart. Notified OR-NOD regarding the
procedure.——
 1:30 PM Pre-Transfer D: With order for Right Intrajugular Catheter insertion.
Assessment: With ongoing IVF of PNSS 1L at 20 cc/hr at left
Right metacarpal vein-infusing well. Anesthesiologist
Intrajugular informed. OR informed. Consent for procedure and
Catheter Vein anesthesia signed by patient herself. Business office
Insertion  clearance secured and attached to chart. With
accomplished pre-operative checklist signed by the
nursing supervisor attached to chart. With non-reactive
HBsAg results. With coagulation test results attached
to chart. IJ catheter secured.
———————————————  GrC
A: Placed in a comfortable position with side rails up
and locked. Vital signs taken and recorded as follows:
1:40 PM BP: 150/90 mmHg, PR: 72 bpm, RR: 23 cpm, and
Temperature 37.2˚C. Encouraged verbalization of
feelings and concerns.
——————————————— GrC
R: Wheeled to operating room per stretcher. Endorsed
2:30 PM to operating room nurse on duty.— GrC

2nd DAY

DATE/TIME FOCUS  D=DATA       A=ACTION      R=RESPONSE     

August 3, Ineffective D: “Sigidas la gihapon it akon ubo” as verbalized. With an

2020 airway ongoing PNSS 1L regulated at 20 cc/hr infusing well at
8:00 AM clearance left metacarpal vein and O2 inhalation via face mask at 2
  L/min. Productive cough and whitish phlegm noted.
  Presence of crackles on the left lung base upon
auscultation noted. Chest X-ray: Pneumonia with
consolidation at right lobe. Skin appears pallor.
————————————————  GrC
  A: Elevated the head of the bed and assisted into semi-
  Fowler’s position. Vital signs recorded as follows: BP:
 8:04 AM 120/80 mmHg RR: 18 cpm and PR: 80 bpm. Changed
  position frequently q2h. Advised to limit fluid intake, as
  indicated. Planned and scheduled activities to allow
  optimal rest periods. Performed postural drainage.
  Monitored respiration and chest movements. Encouraged
  deep-breathing and coughing exercises before and after
nebulization. —————————————  GrC
: Administered 500 mcg / 2.5 mg/25ml of Duavent
  nebulization STAT. Advised to rinse mouth after
  nebulization to prevent drying of oral mucosa. Monitored
vital signs during nebulization. Reassessed breath
8:10 AM sounds and respiratory rate. ————————————
GrC
R: “Medyo nag-upay an akon pamati kahuman
pagnebulize” as verbalized.  Crackles still noted on the
left base of the lung and productive cough with whitish
phlegm. BP - 120/80 mmHg, PR - 80 bpm, RR - 18 cpm,
8:25 AM O2 saturation - 95% (with O2).
  ———————————— GrC
 

8:40 AM Ineffective D: “Medyo maluya pa it akon lawas ngan malain it akon

Renal inaabat,” as verbalized. Pallor, pale conjunctiva, pale
Tissue mucous membrane noted. BP - 120/80 mmHg, Capillary
Perfusion refill - 3 seconds, Creatinine - 406 umol/L, BUN - 16.2
mmol/L, Serum Albumin - 1.99 g/dL, Uric acid - 9.00
mg/dL, Hgb - 9.3 g/dL, Hct - 28.3%, Grade 1 bipedal
edema. 24 - hour urine protein - 6.7 g/day. Renal biopsy
result - thickened GBM and “spike dome” pattern with
silver methanamine 
staining, immunofluoresence reveals finely granular
deposits of IgG and C3 aling capillary loops. Oliguria (600
ml/day) and cocoa-colored urine.
————————————————   GrC
A: Maintained in a comfortable position with side rails
8:50 AM raised and locked. Elevated edematous extremities to
increase venous return. Applied warm compress in
affected extremities to increase blood flow. Advised to
adhere to dietary prescription: 1740 kcal, 60%
carbohydrates, 60 grams protein, 2 grams sodium, rest
fats in 3 divided meals. Advised to limit fluid intake to
prescribed volume. Planned and scheduled activities to
allow optimal res periods. Monitored laboratory results:
BUN and creatinine. Monitored intake and output. Noted
urine characteristics: color, odor, and urine specific
gravity. ————————————  GrC
 : Administered medications as prescribed. ——
R: With increase renal tissue perfusion with manifestation
of capillary refill - 2 sec, no presence of  pallor. Grade 1
pitting edema still noted. BP - 120/80 mmHg.
9:30 AM ———————  GrC

11:10 AM Impaired D: “Tag-garagmay la iton akon naiihi”, as verbalized.

Urinary Urinates at least 2-3 times a day with 200 ml per urination
Elimination and cocoa-colored urine. Decreased hematocrit level to
28.3%. —
11:15 AM A: Maintained in a comfortable position. Advised to
adhere to dietary regimen as prescribed and limiting the
intake of alcohol and caffeine. Advised to limit fluid intake,
as indicated. Monitored intake and output. Monitored daily
weight. Noted urine characteristics. Assessed voiding
patterns: frequency and bladder distention. Instructed to
report signs and symptoms of infection, such as burning
upon urination and presence of blood in the urine.
Administered diuretic medication as prescribed.
——————————————  GrC
R: “Medyo talagudti la gihapon it akon ihi” as verbalized.
Recorded 350 ml of urine and a cocoa colored urine still
noted.  ————— GrC
12:15 PM

1:00 PM Altered D: “Makatol gad akon panit”, as verbalized. Skin warm to

Comfort touch, dryness, and pruritus noted. Frequent scratching,
related to and discomfort noticed. Serum creatinine: 406 umol/L,
pruritus BUN: 16 mmol/L. ———————————————  GrC
A: Maintained in a comfortable position with side rails
raised and locked. Assessed skin for lesions, presence of
1:10 PM excoriations, erosions, fissures, or thickening.
Recommended keeping nails short. Advised not to
scratch the affected area. Advised to keep the area clean
and dry. Instructed not to use tight clothings. Advised to
apply hypoallergenic moisturizers such as Medilan that
are alcohol free and available in cream or ointment form
as ordered. ——— GrC 
R: “Naiban ibanan naman an kakatol nak panit,” as
verbalized .Reported decrease pruritus and scratching.
2:30 PM Skin is intact with no lesions.
———————————————— GrC
       GrC
     GROUP C
 RTRMF-SN-CN
 3rd DAY

DATE/TIME FOCUS  D=DATA       A=ACTION      R=RESPONSE     

August 4, Elevated D: “Masakit iton akon ulo, baga ako hin malilinop,” as
2020 Blood verbalized. With an ongoing IVF of PNSS 1L at 900 cc
10:55 AM Pressure level inserted at the left metacarpal vein infusing well
and regulated at 20 cc/hr. Vital signs are as follows: BP-
170/90 mmHg, HR- 85 bpm. Other laboratory results:
Hemoglobin- 9.3 g/dL, Hematocrit 28.3 %, Creatinine-
406 umol/L, BUN- 16.2 mmol/L, Serum albumin-1.99
g/dL, Refer accordingly.   ———————————— 
GrC
  A: Placed in a comfortable position.  Loosened
   restrictive clothing. Provided calm, restful surroundings.
Limited the number of visitors and length of stay.
Maintained activity restrictions. Instructed relaxation
techniques, such as guided imagery, distraction and
deep breathing.   —————————————  GrC
: Terminated and reinserted IVF of PNSS 1L at 900 cc
level from left metacarpal vein to the right metacarpal
11:00 AM vein using gauge 20 infusing well and regulated at
20cc/hr. Referred to radiologist for post HD CXR PA
view.  ——GrC
: Administered Bisoprolol 5mg/tab 1 tab p.o. now as
12:00 PM
ordered. Referred and seen by Dr. F. Asanza regarding
left AVF creation but declined due to financial reasons.  
———GrC

2:10 PM Anxiety D: "Ginkukulba gad ako ma’am tungod hini na akon

Related to sakit yana," as verbalized. Anxious, restlessness,
Illness unable to eat, and disruption of sleep noted.
————————————   GrC
2:13 PM A: Encouraged verbalization of feelings and concerns.
Developed therapeutic nurse-client relationship by
listening to the client; displaying warmth, answering
questions directly, offering unconditional acceptance;
being available and respecting personal space.
Encouraged participation in relaxation exercises such
as deep breathing, guided imagery, massage, and
meditation. Acknowledged anxiety/fear, without denying
or reassuring that everything will be okay. Provided
spiritual care such as praying and asking for
forgiveness. Determined spiritual needs or conflicts and
referred to appropriate team members including clergy
and/ spiritual advisor. Assisted to identify people who
could provide financial support coming from DSWD,
PCSO, Waray, Tingog, as needed. PReProvided time
 to engage in spiritual growth/ religious activities.
Provided a calm environment. Determined support
systems available. Assisted to identify people who
could provide support as needed.———— GrC
R: Reported anxiety is reduced to a manageable level.
Latest BP of 130/80 mmHg and HR- 65 bpmExplained
brief overview of the procedure. Attached consent for
Right Intrajugular Catheter Vein Insertion and
2:30 PM Hemodialysis consent. Obtained baseline vital signs:
BP: 150/90 mmHg, PR: 72 bpm, RR: 23 cpm, and
Temperature 37.2˚C. Noted the rate and quality of
respirations and the heart rate and rhythm. Assessed
the access site (internal jugular vein) if functioning
properly by using a Doppler Ultrasound. Reviewed
medication history prior to the procedure. Obtained
weight. Reviewed the last laboratory results especially
the levels of sodium, potassium, BUN, Creatinine –
noting as baselines for comparisons for post dialysis
laboratory results, and coagulation tests. Pre-operative
checklist accomplished and signed by nursing
supervisor attached to chart. Notified OR-NOD
regarding the procedure.
——————————————GrC
A: Anxiety, restlessness, unable to eat, and disruption
of sleep are not evident. Appeared relaxed.
——————————————— GrC

2:45 pm Preparation D: “Ma pa dialysis pa kuno ako pag gawas ko ngadi

for hospital.” as verbalized. Wt: 58 kg. Sodium 137 mmol/L,
Hemodialysis Potassium 4.1 mmol/L, BUN 16.2 mmol/L, Creatinine
406 umol/L.  —
A: Explained brief overview of the procedure. Educated
2:48 PM the client in safe fluid intake, diet and how to reduce
high salt intake foods. Attached consent for
Hemodialysis. Obtained baseline vital signs: BP of
130/80 mmHg and HR- 65 bpm, RR: 23 cpm, and
Temperature 37.2˚C. Noted the rate and quality of
respirations and the heart rate and rhythm. Assessed
the access site (internal jugular vein) if functioning
2:57 pm  properly by using a Doppler Ultrasound. Reviewed
medication history prior to the procedure. Obtained
weight. Reviewed the last laboratory results especially
the levels of sodium, potassium, BUN, Creatinine –
noting as baselines for comparisons for post dialysis
laboratory results, and coagulation tests. —————
GrC
 R:”Salamat han mga impormasyon nga imo gn hatag,
kakailanganon ko gud magpa dialysis kada semana.”
as verbalized —— GrC
        GrC
     GROUP C
 RTRMF-SN-CN

4th DAY

DATE/TIME FOCUS  D=DATA       A=ACTION      R=RESPONSE     

August 5, Discharge D: “Nasiring an Doktor na pwede na ako makauli,“ as

2020 Planning verbalized. With discharge order. 
9:25 am —————————————— GrC
A: Assessed current health status. Vital signs taken and
9:28 am recorded as follows: BP: 120/80 mmHg, HR: 100 bpm, RR:
20 cpm, Temp.: 37°C, O2 sat 98%, capillary refill 2
seconds. Terminated heplock aseptically. Instructed to
religiously take the prescribed medications. Advised to do
daily exercise such as brisk walking and deep breathing
exercise as tolerated. Instructed to keep the catheter
dressing clean and dry, make sure the area of the insertion
site is clean, never remove the cap on the end of your
catheter and wear a mask over your nose and mouth
anytime the catheter is opened.  Educated regarding
natural disease progression, different dialysis modalities,
renal transplantation, and client’s option to refuse or
discontinue chronic dialysis.  Reviewed dietary
modifications or restrictions, including the following:
phosphorus, magnesium and fluid, potassium, sodium
restrictions, when indicated.  Keep a record of daily weight,
by weighing at the same time of the day and in the same
kind of clothes. Instructed in BP or glucose monitoring at
home and provide information on obtaining monitoring
equipment, as indicated. Assessed strategies to prevent
constipation, including stool softeners, bulk laxatives but
avoiding magnesium products, as indicated.  Stressed out
the importance of follow-up examinations and treatment to
the patient and family. Instructed to continue follow-up
hemodialysis upon discharge at EVRMC OPD department.t
Informed to contact physician if little or no urine output,
difficulty of breathing, and swelling of legs or ankles are
present. Recommended to allot time to engage in spiritual
 care and religious activities with family by praying daily,
reading the bible and attending masses.
——————————GrC
R: Wheeled out with improved and stable condition via
wheelchair accompanied by daughter and verbalized
understanding of health teachings imparted. ——————
GrC

           GrC
     GROUP C
 RTRMF-SN-CN

11:30 am