NURSES PROGRESS NOTE

NAME OF PATIENT: _J.A_____________________________ Room/Ward: _302_______________ Doctor: ________________

HRN: ______________________

DATE/ DATE/
FOCUS DATA ACTION RESPONSE
TIME TIME
11/26/2022 Perineum pain Patient verbalization of Obtain baseline vital signs; 11/26/2022 The patient
3:00 pm pain. Pain scale of 7. facilitated nonpharmacologic 4:00 pm experienced
Restlessness and techniques such as increased comfort
irritability; Facial therapeutic touch, guided and manifest sleep
grimace and guarding imagery, and distraction with a pain scale of 4
behaviors noted; techniques by offering
Preferred entertainment.
Administered pain reliever as
ordered. Instructed to
practice slow breathing
exercises. Encouraged to try
sitz bath. Advised to clean
genitals in front to back
manner after voiding and
Administered cold and hot
therapy.

11/26/2022 Vaginal Foul-smelling discharge, Monitor Vital Signs. 11/26/2022 Lochia serosa vaginal
4:00 pm Discharge Soaked pad T= 38.3 C Administered prescribed 8:00 pm discharge with
P=73 bpm R=18 medications. Monitor vaginal minimal amount. T=
cycles/min, BP=120/70 discharge color, 37.3 C P=80 bpm
mmHg. characteristics, and amount R=18 cycles/min,
BP=120/70 mmHg

11/26/2022 Urinary Patient verbalized “Indi
4:00 pm incontinence ko mapunggan akon ihi…
wala pa ko kalab-ot sa CR
gaihi na ko”. Weakened
muscle tone. Urine
leakage in underwear or
pants/skirts
Encouraged the patient to 11/26/2022 Patient demonstrates
perform Kegel exercise. 8:00 pm fewer episodes of
Monitor consistency, color, incontinence or scant
volume, and odor of urine. urine leakage
Monitored I&O and vital sign.
Advised limitation of bladder
irritants such as coffee

11/26/2022 Sleep Patient verbalization of Provide an environment 11/26/2022 Patient acknowledged

4:00 pm deprivation having difficulty of
sleeping due to
afterpains. tired and
sleepy appearance
conducive to sleep. 4:00 pm health teachings and
Administer medication as was able to sleep
prescribed. Instructed to comfortably
schedule time for
breastfeeding periods.

11/26/2022 Breast pain Patient verbalization of Encourage the patient to. 11/26/2022 Pain scale of 4 with
4:00 pm and tenderness breast pain with a pain practice proper 6:00 pm engorgement
scale of 8 out of 10. breastfeeding. Advise to reduction of the
Facial grimace and stand under a warm shower. patient’s breast
restlessness Administer analgesic as
prescribed. Applied cold
compress. Recommend
wearing a supportive, well-
fitting bra

11/27/2022 Impaired Skin 2nd degree perineal Applied wound care. 11/27/2022 Patient verbalizes pain
3:00 pm Integrity- laceration. Pain scale of 7 Administered medications as 5:00 pm scale of 3 with no
Trauma Redness in the area. ordered. Performed routine complications
(laceration) Facial grimace skin inspections. Encouraged
ambulation. Monitor
laboratory results.

11/27/2022 Constipation Patient verbalized on
3:00 pm “nadbudlayan ko mamus-
Hypoactive bowel sound.
Absence of defecation for
4 days
Increased fiber or roughage
amount in the diet such as
papaya, camote, and green
leafy vegetables. Encouraged
the patient to ambulate as
tolerated. Educate the patient
about the importance of
having regular bowel
11/27/2022 Patient was able fecal
8:00 pm Pass out feces with
No complications and
has acknowledge
health teachings.
 movement.

11/27/2022 Enhanced Patient expressed desire Educated the mother about 11/27/2022 Patient demonstrated
3:00 pm Breastfeeding to learn about newborn latch-on and 5:00 pm effective
Breastfeeding. G1P1 with different breastfeeding breastfeeding
no prior breastfeeding position. Instructed early techniques and
experience initial breastfeeding and recognized health
exclusive breastfeeding for 6 teachings
months. Advised to fed the
infant 8-12 times a day or as
desired. Increase calorie
intake by 500 calories and
fluid intake by 500 ml.
Provided written instructions.

11/27/2022 Hyperthermia Flushed face, Hot when Assessed for presence of bath 11/27/2022 Patient’s temperature
4:00 pm touched, T= 38.5 C P=90 infection. Performed perineal 6:00 pm reduced from 38.5 C
bpm R=21 cycles/min, care. Rendered tepid sponge to 37.2 C. Stable vital
BP=130/80 mmHg for 30 min. Administered signs with no
medication as ordered. presence of infection.
Advised the patient to wear
light clothing. Monitored
vital signs q15. Increase fluid
intake. Instructed how to
perform perineal self-care.

11/27/2022 Medication Demonstrate to the patient, 11/27/2022 Patient demonstrated.

5:00 pm Education the proper administration of 6:00 pm cefuroxime
the Cefuroxime. Informed of administration
the side effects, adverse properly. Patient
effects, contraindications, verbalized the side
and precautions of effects, adverse
medication with printed effects
material. contraindications,
and precautions of
the medication.