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    Nurses Progress Notes Patient Name: AGE SEX Room/Ward Hospital NO. 12312 Last Name First Name M.I. (/) M F

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    Royce Vincent Tizon
    Mr. R, a 55-year-old male patient in the medical ward, was seen for ineffective cough and difficulty breathing. He was administered acetylcysteine to help with coughing and breathing difficulties. Upon reassessment, the patient reported decreased coughing and relief of breathing issues. Later, the patient complained of dyspnea and irregular breathing, so the nurse encouraged positioning and breathing techniques. Vital signs remained normal with oxygen and medications administered.

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    Nurses Progress Notes Patient Name: AGE SEX Room/Ward Hospital NO. 12312 Last Name First Name M.I. (/) M F

    Uploaded by

    Royce Vincent Tizon
    37 views1 page
    Mr. R, a 55-year-old male patient in the medical ward, was seen for ineffective cough and difficulty breathing. He was administered acetylcysteine to help with coughing and breathing difficulties. Upon reassessment, the patient reported decreased coughing and relief of breathing issues. Later, the patient complained of dyspnea and irregular breathing, so the nurse encouraged positioning and breathing techniques. Vital signs remained normal with oxygen and medications administered.

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    TIZON, R. - FDAR (RLE)

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    Mr. R, a 55-year-old male patient in the medical ward, was seen for ineffective cough and difficulty breathing. He was administered acetylcysteine to help with coughing and breathing difficulties. Upon reassessment, the patient reported decreased coughing and relief of breathing issues. Later, the patient complained of dyspnea and irregular breathing, so the nurse encouraged positioning and breathing techniques. Vital signs remained normal with oxygen and medications administered.

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    © All Rights Reserved
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    37 views1 page

    Nurses Progress Notes Patient Name: AGE SEX Room/Ward Hospital NO. 12312 Last Name First Name M.I. (/) M F

    Uploaded by

    Royce Vincent Tizon
    Mr. R, a 55-year-old male patient in the medical ward, was seen for ineffective cough and difficulty breathing. He was administered acetylcysteine to help with coughing and breathing difficulties. Upon reassessment, the patient reported decreased coughing and relief of breathing issues. Later, the patient complained of dyspnea and irregular breathing, so the nurse encouraged positioning and breathing techniques. Vital signs remained normal with oxygen and medications administered.

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    DONA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION

    COLLEGE OF NURSING

    NURSES PROGRESS NOTES

    PATIENT NAME: AGE SEX ROOM/WARD HOSPITAL


    Last Name First Name M.I. (/)M NO.
    xxx Mr. R x 55 ( )F MEDICAL
    WARD 12312
    ROOM 8

    DATE/TIME FOCUS DATA/ACTION/RESPONSE


    Oct. 4, 2020 Ineffective cough D: Patient is awake and alert, complained of dry coughs and difficulty
    8:15 AM of breathing-----------------------------------------------------------------------------
    A: Administered Acetylcysteine 600 mg 1 tablet dissolved in ½ glass of
    water OD as ordered. Assessment on client noted diminished breath
    sounds; vital signs are within normal range. ----------------------------------
    R: Upon reassessment, patient stated decreased coughing and
    relieved difficulty in breathing. ----------------------------------------------------
    9:00 AM Health Teaching D: Patient complained of dyspnea and upon assessment noted
    Irregular breathing pattern. -------------------------------------------------------
    A: Encouraged patient to reposition for an optimal breathing pattern to
    reduce pooling of secretions. Patient was also encouraged and taught.
    controlled breathing and coughing techniques. ------------------------------
    R: Patient acknowledged health teachings. -----------------------------------
    Medication A: Continuing administration of Hydrocortisone 200 mg 1 vial IVTT
    10:00 AM
    Administration and Azithromycin 500 mg 1 vial IVTT. Continue O2 inhalation via face
    mask as ordered. --------------------------------------------------------------------
    R: Monitored vital signs, revealed within normal range; assessment did
    not show any signs of respiratory distress. ------------------------------------
    ROYCE VINCENT E. TIZON IVY ROSALES, MAN, CAR, RN
    STUDENT NURSE RTRMF CLINICAL INSTRUCTOR

    RLE - NCM 109 Sample Only

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