Date/Time Focus Progress Notes

Sept. 10, 2020 Increased body temperature D – “Mainit ang katawan ko” as verbalized
by the patient with body temperature of
1:00 pm
38.5°C----------------------------------------------SSB

A – Encouraged patient to take more fluids;

Provided a cool environment;TSB rendered

2:00 pm R – After 1 hour of nursing intervention the

temperature of the body is lowered down to
37°C------------------------------------------------SSB
1:00 pm Ineffective breathing pattern D – “Nahihirapan akong huminga” as
verbalized by the patient with RR of 25---SSB

A – Elevated head of bed; Encouraged

slower/deeper respirations; Assisted client
in the use of respiration techniques-------SSB
1:30 pm R – After 30 minutes of nursing intervention
the patient has shown a lessened difficulty
of breathing as manifested by a decrease in
RR of 25cpm to 20cpm------------------------SSB
1:00 pm Risk for deficient fluid volume D – “Nanunuyo ang labi ko” as verbalized by
the patient----------------------------------------SSB

A – Assessed skin turgor; Monitored VS

especially BP; Encouraged patient to take
more fluids---------------------------------------SSB

R – After 1 hour of nursing intervention the

patient exhibited normal limits in
VS,remained poor skin turgor and exhibited
willingness for fluid intake