PROGRESS NOTES

Name of Student: _Trisha Ericka Surigao BSN 4-A1

Inclusive Dates & Area: Feb. 7-9 and 14-16, 2024
CLINICAL INSTRUCTOR: Ms. Hanna Liza Mabborang, RN _

SUMMARY:

On February 15, 2024, our group continued our clinical duty in the ICU ward of Tagum Medical
City, still on a 7-to-3 shift. I was assigned, together with my duty mate Ms. Pia Relampagos, to a
73-year-old male patient with the chief complaint of (). The endorsement commenced at exactly
7:30 AM, and we received exact reports for our patient. At exactly 8:00 AM, we started our
assessment, and we found our patient on the bed, awake, responsive, coherent, and on MHBR.
He is also receiving O2 support via CPAP with the following settings: PS-6, PEEP-10, FiO2-
40%, and with chest leads attached to the monitor and a siliconized NGT at level 50. He is also
receiving #8 IVF of PNSS 1L @ 100cc/hr and #1 moxifloxacin 400mg both via an infusion pump,
which is infusing well at the left cephalic vein, with a catheter attached to a urometer. At 8:05
AM, we monitored his GCS, with a result of 15, as well as his vital signs. We noticed that his BP
is above the normal range but not symptomatic. We immediately referred it to the NOD and
continued our assessment. Upon assessment, we observed that he has no motor movements in
his right upper extremities. The patient verbalized, “paralyzed akoang right na kamot Maam
sukad atong na-stroke ko”. We also observed that the reaction of his right pupil is sluggish but
the left pupil is brisk. As part of our independent intervention, we implemented passive range of
motion with support for his right upper extremities. The patient will also be transferred out to the
rose ward, so we prepared our documentation as well as assisted the patient in preparation for
his transfer. At 9:00 AM, we closed our documentation and ushered the patient to the room of
choice together with the NOD and placed him on the bed comfortably. The NOD then endorsed
the patient to the NOD of the new ward, and we assisted in placing the IV lines, ensuring there
is no backflow and bubbles on the line that would compromise the patency of the IV site. We
also raised the side rails for the safety of the patient and ensured that he is comfortable on the
bed before leaving.

REFLECTION:

The clinical experience on February 15, 2024, at Tagum Medical City's ICU ward was a
significant learning opportunity. Partnering with Ms. Pia Relampagos, we managed the care of a
73-year-old male patient. Our shift involved thorough assessments, close monitoring of vital
signs, and prompt intervention for emergent issues. One notable aspect was addressing the
patient's post-stroke paralysis in his right upper extremities through passive range of motion
exercises. We also noted abnormal pupil reactions, warranting further assessment and
communication with the nursing officer on duty. Throughout the shift, effective communication
and teamwork were paramount as we collaborated with various healthcare professionals to
ensure comprehensive care. From coordinating with the nursing officer to facilitating the
patient's transfer to another ward, our interactions were characterized by empathy and
professionalism. This experience highlighted the importance of continuous learning and
adaptability in nursing practice. It reinforced my commitment to ongoing professional
development and providing compassionate, evidence-based care. Each encounter serves as an
opportunity to refine skills and deepen understanding, solidifying my dedication to delivering
high-quality patient care in diverse clinical settings.