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Nurse'S Notes: Date-Shift Focus Data - Action - Response

The nurse's notes document the care provided to a 14-year-old female patient experiencing abdominal pain and fever. The nurse administered Omeprazole IV to treat the patient's abdominal pain, kept her in a comfortable position, and used diversional activities to help her gain rest. The patient's pain was relieved and she reported her stomach no longer hurt. To address fever and chills, the nurse administered Paracetamol IV and performed a tepid sponge bath. The patient's temperature decreased from 38.6C to 36.6C and she no longer had a fever.

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1K views1 page

Nurse'S Notes: Date-Shift Focus Data - Action - Response

The nurse's notes document the care provided to a 14-year-old female patient experiencing abdominal pain and fever. The nurse administered Omeprazole IV to treat the patient's abdominal pain, kept her in a comfortable position, and used diversional activities to help her gain rest. The patient's pain was relieved and she reported her stomach no longer hurt. To address fever and chills, the nurse administered Paracetamol IV and performed a tepid sponge bath. The patient's temperature decreased from 38.6C to 36.6C and she no longer had a fever.

Uploaded by

NE Tdr
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NURSE’S NOTES

Name: Age/Sex/CS:14/F/S Ward/Room:__PEDIA C___

Date-Shift FOCUS Data – Action – Response


3/10/2021 Pain D:
3-7 (PM SHIFT)  Reports pain in the abdominal area and rated the pain 7 out of 10. Pain is felt in any position.
3:30pm  Experienced vomiting.
 Restlessness
 Muscle tension
 Decreased appetite
 Facial mask of pain
 Sleep disturbance

A:
3:45pm  Administered Omeprazole (Omepron) 20mg IV
4-6:00 pm  Kept patient in a comfortable lying position (adjusting bed) for ability to gain enough sleep and
rest.
 Demonstrated the use of appropriate diversional activities and relaxation skills.

R:
11:00pm  Patient reports relieved from pain.
 “Hindi narin po masakit ang tiyan ko.” as verbalized by the patient.

Hyperthermia D:
3:30pm  Patient temperature of 38.6C
 Experiencing fever and chills.
 Vomiting
 Sweating
 Abdominal pain
 Red skin
 weakness
A:
 Administered Paracetamol 300mg IV
3:37pm
 Performed tepid sponge bath at 5:00pm
5:00pm
 Encouraged and offered oral fluid intake every hour.
6:00pm
 Excess clothing and covers are eliminated.
 Environmental factors (bed and room temperature) was adjusted and monitored.

R:
11:00pm  Temperature decreased from 38.6C to 36.6C.
 Patient was relieved from shivering.
 “Wala na po akong lagnat.” as verbalized by the patient.

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