DATE/ FOCUS PROGRESS NOTES 11:45am  
R-BP rechecked 120/80 mmHg,
SHIFT/
TIME
04/6/2021 Headache D – “Nadisgrasya po sya
7-3 shift Ma’am, sumasakit ulo niya” as
10:52am verbalized by mother. Brought
in ER per stretcher, pale and
clammy skin noted, pain scale 8
out of 10, in mild respiratory
distress, swelling at right
temporal lobe area. Severe
headache noted as evidenced
by grimaced face, guarding
behavior, with warm and
erythematic scalp on palpation,
slightly restless, irritable, GCS
15/15, T-36.5°C, PR-100 bpm,
RR-25 breaths/min, BP-130/90
mmHg------------------------------
11:00am   A – Placed on bed with side
rails up and locked, with head
of bed elevated to 30° angle,
O2 inhalation administered at
3L/min via nasal cannula. Ice
pack applied to swelling.--------
11:15am   Seen and examined by Dr.
Mikaela Cruz, consent for
admission signed by mother.
Started with venoclysis of PLR
1L at left cephalic vein using
gauge 18 regulated at 30
drops/min.--------------------------
PR-90 bpm, RR-20 breaths/min,
“masakit parin ulo ko Ma’am”,
as verbalized by client.----------
1:00pm   A – Ketorolac 30mg IVTT given
as ordered stat. Brought to CT
Scan as ordered and
accompanied by nurse J. Pacala
per stretcher with side rails up.;
stat CBC, BT taken by Medical
Technologist Alfieri Chua.----
2:00pm   A – CBC results seen by Dr.
Cruz, orders given. Continuous
observation for complications.
Unnecessary disturbance
avoided and promoted a cool,
calm and quite non stimulating
environment. ----------------------
2:15pm   R-“Nawala-wala na po ang sakit
ng ulo ko.” as verbalized by
patient, pain scale of 4/10.
Patient understands
instructions and seen doing
deep breathing exercises.---
2:25pm   - Patient is seen soundly asleep
and undisturbed.---------------
2:35pm   Endorsed to 3-11 shift for
continuity of care.------------------
---------------Sancha Alcazar, RN