DATE AND TIME FOCUS PROGRESS NOTE

05/16/2023 ADMISSION D: Pt complains of experiencing pain to the clinic nurse. Pt complains of

suprapubic pain that develops worse in movement. Pt claims she is not
10:34 AM pregnant as her last sexual encounter was more than two years ago; past
history, smoker with 15 pieces per day._____________________________

A: Take Pt’s vital signs. Assisted to bed provide comfort and ensures
10:48 AM
security.
10:58 AM
R: T – 37.9°C, HR – 75 beats/minute, BP – 132/71 mmHg, SaO2 – 96%
RA, RR – 14 breaths/minute, Pain score – 2/10 at rest; NB – 6/10 on
urination
____________________________________________________Nikka SN.

Phase 1

Catherine is assessed by the clinic nurse, and she informs the nurse that the abdominal pain has progressively worsened over the
last day and she is having trouble sleeping because of the frequency that she needs to urinate. She also informs the nurse that she
has been feeling unwell lately and believes that she may have had a temperature last night because she woke up during the night
feeling hot and sweaty. The nurse informs Catherine that her temperature is elevated at the

moment but her other vital signs appear within normal range. The clinic nurse assesses Catherine’s abdomen and documents the
following assessment data: no scars, bruising or discoloration; no obvious signs of injury or trauma to the abdomen. Bowel sounds
can be heard on auscultation in all four quadrants; the nurse palpates Catherine’s abdomen, which is soft and mildly tender with
normal percussive sounds. Catherine again denies being pregnant and states that she does not have a partner and is not currently
sexually active. The nurse asks Catherine if she is happy to provide a urine sample, which Catherine agrees to provide.

DATE AND TIME FOCUS PROGRESS NOTE

 05/16/23 PAIN D: abdominal pain progressively worsened over the last day with a pain score – 2/10 at
rest; NB – 6/10 on urination. Pt verbally claims not being pregnant and denies having a
02:15 PM partner and is currently not engaged in sexually active. Pt has difficulty sleeping because
of the frequent urination demands.
_________________________________________________
02:34 PM
A: abdominal assessment: inspect, auscultate four quadrants, palpates patient's abdomen;
percussion; assess pt’s vital signs; request a urine sample. ________________________

02:50 PM R: no evident evidence of trauma to abdomen, vital signs are within the normal range,
higher body temperature.  Pt consents to give a urine sample.  bowel sounds audible. Soft
and hardly painful, the abdomen makes usual percussion sound and is soft and mildly
tender._________________________________________________________ Nikka SN.

Phase 2

Catherine provides the nurse with a urine sample and notices a cloudy appearance to her urine, which she has never noticed before
when she has provided other urine samples in the past. The nurse completes her assessment of Catherine and plans to send the
urine sample off to the lab for further analysis. Catherine is asked to return tomorrow to get the results of her urine sample, which will
probably indicate the signs of an infection in her urine. Before she leaves Catherine asks what she can do to prevent a UTI from
reoccurring. The clinic nurses have a dual role, which includes both assessment and providing health information and health
promotion strategies for the clinic’s patients to support their recovery.

DATE AND TIME FOCUS PROGRESS NOTE

05/17/2023 LABORATORTY TEST D: urine test as ordered____________________________________

06:54 AM A: give SB necessary information; emphasize the significance of the

procedure; and submit the urine sample to the lab to undergo further
 evaluation.______________________________________________

R: waiting for the result of urinalysis ___________________Nikka

SN.

Phase 3
Catherine has an appointment for the next day to receive the results of her urine test. When she finally arrives, the nurse notices that
she appears uncomfortable, flushed and is mildly perspiring. She brings Catherine in early for her appointment because she looks
unwell. Catherine informs the nurse that she progressively got worse overnight and did not sleep well due to the onset of lower back
pain. Catherine informs the nurse that she went straight home after her appointment; she denies any trauma or injuries and says she
had the ‘shakes’ in bed last night.
Her vital signs are:
• T – 38.6°C
• HR – 110 beats/minute
• RR – 14 breaths/minute
• BP – 105/71 mmHg
• SaO2 – 96% RA
• Pain score – 3/10; 6/10 (on urination)

The urinalysis test results are:

• Specific gravity: 1.015
• pH: 7
• Leucocytes: +++
• Nitrites: +
• Glucose: –
• Protein: +
• Bilirubin: –
• Urobilirubin: –
• Ketones: +
• Blood: ++
DATE AND TIME FOCUS PROGRESS NOTE

05/18/2023 PAIN D: The patient seems uneasy, with flushed skin with slight perspiration. Pt claims
she had the "shakes" the previous night in bed but denies having any damage or
8:17 AM injuries. onset of lower back pain caused the Pt's conditio to gradually
worsen overnight, causing trouble in sleeping. Pt claims she had the "shakes" the
previous night in bed but denies having any injuries and trauma.
________________________________

A: assist the patient early to her appointment and assess the patient's vital signs.

R: T 38.6°C; HR 110 beats/min; BP 105/71 mmHg; SaO2 96%; RR 14

breaths/min RA; Pain score 3/10; 6/10 (on urination)__________________
Nikka SN

12:09 AM LABORATORY D: Pt has an appointment to receive the results of her urine test.________________
RESULT
A: Brings Pt in for her appointment______________________________________

R: Interpretation of results; Specific gravity: 1.015; pH: 7; Leucocytes: +++; Nitrites:

+; Glucose: –; Protein: +; Bilirubin: –; Urobilirubin: –; Ketones: +; Blood: ++;
__________________________________________________________ Nikka SN.