Patient: Dizon, John Ray

Student Nurse: Alvarez, Cris Anne

Date/Time Focus Progress notes

8/17/20 Hyperthermia D: Temperature of 37.8°C via axilla

Skin is warm to touch
7:00 am
A: Monitored vital signs and recorded
Tepid Sponge Bath done
Advised to increased oral fluid intake
Encouraged to have adequate rest
Administered paracetamol 500 mg I tablet prn for temp 37,8
C
(all independent nursing action place last part of your ACTION)
9:00 R: Temperature decreased from 37.8°C to 36.9°C

9:00
Risk for fluid volume D: vomited six times for approximately 120 cc of yellow fluid
deficit related to vomiting SO stated that appetite is poor.
Headache

A: Urged to drink adequate fluid

Administered medicine as per doctor’s order- last part and
specify what specific medications
Measured intake and output q 6 hours
Educate about the possible causes of decreased fluid intake
Emphasized the importance of proper nutrition and
hydration.
11:00
R: Mucosa is moist indicating there is no sign of dehydration

11:00
Imbalanced nutrition D: SO verbalized stated “gapangluya siya tapos wala siya gana
Less than body requirements magkaon”
related to vomiting

A: Encouragedto eat adequate food and rest.

Assist patient if unable to eat without assistance or advised
SO to assist with feedings, as necessary
Advised to increased fluid intake
Administer multivitamins as per doctor’s order
2:00
R: The patient is able to eat well without assistance.