Nursing Progress Notes

PATIENT’S NAME: Sanaa Anwar Tahir HEALTH RECORD NO. :______________

SEX: F AGE: 36 Years Old WARD/ROOM NO.: Medical Ward

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

11/27/2021 Pain D= Admitted to medical ward w/ complaints of hypogastric pain
on a pain scale of 7/10. Started venoclysis w/ PNSS
1L@20gtts/min.

A= Placed in high back rest keeping back dry. V/S monitored

and recorded. I&O monitored and recorded. Medications given
as ordered by physician.

R= Constant pain in the hypogastric region as reported by

patient. Voided 2 times with pain upon urination.
11/28/2021 Pain D= Patient reports reduced pain with a scale of 5/10.

A= IVF rate increased to 30gtts/min. Heating pad applied to

pubic area for 15 mins. I&O strictly monitored.

R= Patient reports pain is reduced w/ the help of the heating

pad. Voided 3 times with less pain upon urination.
11/29/2021 Health D= Patient able to tolerate pain upon urination.
Teaching
A= Adviced proper personal hygiene. Continue medications.
I&O strictly monitored.

R= Patient responded positively for proper personal hygiene.

Voided 3 times with less pain upon urination.
11/30/2021 10AM Patient D= Patient is able to report pain as tolerated upon urination.
Monitoring
A= Lab tests repeat for urinalysis, CBC, creatinine & BUN.
Monitored properly for any unusual findings

R= Patient tolerates pain upon urination with a pain scale of

4/10. Voided 3 times with less pain as reported by patient.
12/01/2021 9AM Patient D= Patient reports pain with a pain scale of 3/10.
Monioring
A= Regulates IV rate and decreased to 20gtts/min. Continue
medications. I&O strictly monitored.

R= Patient reports pain as reduced with a pain scale of 2/10.

Voided 3 times with less pain.
12/02/2021 11AM Patient D= Patient reports pain is gone with a pain scale of 0/10.
Monitoring
A= Changed IV to heplock. Shifted Levofloxacin to
 Cotrimoxazole 800 mg 1-tab p.o. BID. Continue other
medications.

R= Patient reports pain is totally gone and wants to go home.

Voided 3 times with no pain afterall.
12/03/2021 Health D= Patient shows no pain afterall. Reports she is well.
Teaching
A= Health teachings before going home.Continue medications.
Adviced to increase fluid intake. Instructed to maintain personal
proper hygiene. Adviced to come back for follow-up check after
2 weeks.

R= Patient displays positive outlook to wellness. Voided 3 times

with no pain afterall.