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    Cerj Sarigumba - Nurse's Progress Notes Fdar Template

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    Cerj Sarigumba
    1) A 5-year-old female patient was admitted with persistent coughing, purulent sputum, high respiratory rate and using accessory muscles to breathe. Salbutamol and penicillin were administered and her condition improved. 2) On the second day, the patient developed a recurrent fever with a temperature of 38.5°C and appeared uncomfortable and lethargic. Paracetamol was given and her temperature decreased to 36.4°C and she appeared comfortable. 3) The nurse's notes document the patient's condition, treatments administered, and responses over two days for persistent cough and recurrent fever.

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    Cerj Sarigumba - Nurse's Progress Notes Fdar Template

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    Cerj Sarigumba
    18 views2 pages
    1) A 5-year-old female patient was admitted with persistent coughing, purulent sputum, high respiratory rate and using accessory muscles to breathe. Salbutamol and penicillin were administered and her condition improved. 2) On the second day, the patient developed a recurrent fever with a temperature of 38.5°C and appeared uncomfortable and lethargic. Paracetamol was given and her temperature decreased to 36.4°C and she appeared comfortable. 3) The nurse's notes document the patient's condition, treatments administered, and responses over two days for persistent cough and recurrent fever.

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    Nursing

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    1) A 5-year-old female patient was admitted with persistent coughing, purulent sputum, high respiratory rate and using accessory muscles to breathe. Salbutamol and penicillin were administered and her condition improved. 2) On the second day, the patient developed a recurrent fever with a temperature of 38.5°C and appeared uncomfortable and lethargic. Paracetamol was given and her temperature decreased to 36.4°C and she appeared comfortable. 3) The nurse's notes document the patient's condition, treatments administered, and responses over two days for persistent cough and recurrent fever.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    18 views2 pages

    Cerj Sarigumba - Nurse's Progress Notes Fdar Template

    Uploaded by

    Cerj Sarigumba
    1) A 5-year-old female patient was admitted with persistent coughing, purulent sputum, high respiratory rate and using accessory muscles to breathe. Salbutamol and penicillin were administered and her condition improved. 2) On the second day, the patient developed a recurrent fever with a temperature of 38.5°C and appeared uncomfortable and lethargic. Paracetamol was given and her temperature decreased to 36.4°C and she appeared comfortable. 3) The nurse's notes document the patient's condition, treatments administered, and responses over two days for persistent cough and recurrent fever.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    HOLY NAME UNIVERSITY SIMULATION HOSPITAL

    College of Health Sciences - Nursing Department


    City of Tagbilaran 6300

    NURSE’S PROGRESS NOTES

    KC
    Name: _______________________Age: 5 Sex: ____
    ____ F Bed No. _____ 2022-8172
    3 Hospital No. _____________

    DATE / TIME FOCUS D = Data A = Action R = Response


    Persistent D= An IV is hooked at the right arm with PNSS 500 mL @ 40 gtts/min.
    April 26, 2022, 8:00 a.m. coughing
    -temperature is 37.5c via axilla

    -respiratory rate is 42 breaths per minute


    -patient is constantly coughing with purulent sputum.

    -patient is using her accessory muscles to breathe.

    A= Administer Salbutamol 1 nebule q4h via Inhalation.

    -administerePenicillinG Na 2 mil units every 8 hours IVTT.

    -sputum testing

    -blood testing

    -evaluation of blood oxygen levels

    -room humidification
    R= Improved activity of accessory muscle with a respiratory rate of 28
    breaths per minute, infrequent coughing and improved secretions.

    April 27, 2022, 4:00 p.m. Recurrent fever D= Patient’s skin is warm to touch

    -patient’s temperature is at 38.5 C via axilla

    -patient appears to be uncomfortable and lethargic.

    - respiratory rate is at 24 breaths per minute

    -infrequent coughing

    -improved secretions

    A= Administer Paracetamol 10 mL PO q4h PRN for temp ≥ 38◦C P.O.

    -Encourage patient to rest and drink fluids frequently.


    R= Patient’s temperature is at 36.4c via axilla and appears to be
    comfortable

    HNU-CHS-SH-DIM
    April 2022
    Student’s Signature

    CERJ B. SARIGUMBA
    NAME OF STUDENT
    HNU-CHS-NSG

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