DATE/HOUR OF SHIFT FOCUS NOTE PROGRESS

Date: March 8, 2022 Frequent vomiting S: “throws up all the time like
Time: 9am to 5 pm she’s forcing all her feedings
out. She looks skinny and sick,
and she cries and is fussy all the
time.”

O:

A:
- Administered prescribed
supplemental potassium (PO,
NG, or IV) per policy.
- Monitored vital signs as
appropriate
- Gave fluids as appropriate.
- Maintained accurate intake
and output record.
- Obtained specimens for
analysis of altered potassium
levels as indicated.

R:
After 3 hours of nursing
intervention the patient has
been able to tolerated clear
liquids without vomiting
Date: March 8, 2022 Malnutrition as a health threat S: “throws up all the time like
Time: 9am to 5 pm she’s forcing all her feedings
out. She looks skinny and sick,
and she cries and is fussy all the
time.”

O:

A:
- Discussed the signs and
symptoms, possible risks and
consequences of malnutrition.
- Discussed the importance
adequate food intake both in
quality and quantity in order to
prevent acquiring of childhood
illnesses.
- Observed eating habits of the
children.
R: After 2 hours of nursing
intervention the goals set were
partially met wherein the
family will able to verbalize
understanding about
malnutrition as evidenced by
able to cite ways on how to
achieve proper nutrition.