DATE HOUR FOCUS PROGRESS NOTES

02-18-20 8AM Alteration in D: Received patient awake on bed in lying position, temperature
comfort R/T pain @ 36.3, blood pressure 110/80, respiratory rate 22 and pulse rate 78.
hypogastric region Patient verbalize “medyo masakit pa ang aking tahi” 1-10 (8) pain
scale.

A: Vital sign taken and recorded, IV medications for pain given by

NOD, performed palpation to the uterus, provide care such as
encouraged proper balance diet, encouraged to hold a pillow
against the incision when you laugh or cough, encouraged side
lying position as desired, performed regular walks or light exercise,
encouraged to clean wound using betadine and advise plenty or
rest.

R: Client verbalize the pain relieved at the pain scale of (10)