F> General Survey

D> Received patient sitting, conscious, coherent, oriented to time, place and
person; with an IVF of PNSS 1L received at full level, regulated @ 30 gtts/min
infusing well on the left hand; V/S as follows: Temp: 36.4 C, PR: 84 bpm, RR: 18 bpm,
BP: 110/80; with dry and intact dressing in the client's nape.
F> Impaired Skin Integrity
D> The patient has a ruptured and infected wound, purplish in color and reports of
itching on the site.
A> Provided AM care; further assessed the site; assisted in wound dressing;
instructed the patient to keep area clean and dry, and always keep it covered;
reminded the SO to drain the wound TID as per doctor's order; Emphasized to
patient not to touch the site to prevent the aggravation of infection.
R> The patient verbalized understanding of preventive measures and treatment
program; and the patient was free from signs and symptoms of infection within the
shift.

F> General Survey

D> Received patient lying, conscious, coherent, oriented to time, place and person;
with an IVF of PNSS 1L received at 900cc level, regulated @ 30 gtts/min infusing
well on the left hand; V/S as follows: Temp: 35.6 C, PR: 82 bpm, RR: 29 bpm, BP:
130/100
F> Ineffective Airway Clearance
D> Presence of ineffective cough and excessive mucus, tachypnea and periods of
DOB
A> Provided AM care; administered oral meds; monitored respirations and breath
sounds, noted rate and sounds; positioned client on semi-fowlers; encouraged deepbreathing and coughing exercises; and instructed to increase fluid intake.
R> The patient did not complain of DOB but the RR is 27.