NURSE’S NOTES

Name: Lu Fernandez Age/Sex: 25/F Rm No.: 301 Hospital No.: 100921

Date/Shift Focus Data

10-30-2020 Ineffective “It’s quite difficult to breath”, as verbalized by the patient.
AM shift (8am-4pm) breathing pattern Received patient lying on bed, awake with ongoing IVF #1
related to airway PNSS 1L @ left metacarpal vein, regulated @ 30 gtts/min.
spasm/asthma  shortness of breath
 occasional cough
 pallor
 wheezing heard
 sternal retraction
 use of accessory muscles (sternocleidomastoid) when
breathing
 Difficulty speaking
 Initial vital signs are as follows:
T: 37.7 degrees Celsius
PR: 123 bpm
RR: 28 bpm
BP: 120/80 mmHg
O2 : 94%
Within 8hrs of nursing intervention the patient will be able
to maintain optimal breathing pattern.
Interventions:
 IVF tube patency checked
 IVF regulated at prescribed rate
 Provided a clean and well-ventilated environment for
the patient.
 Initial vital signs taken and recorded q 4hrs as ordered.
 Assessed level of consciousness and ability to protect
own airway.
 Assessed the client’s level of anxiety.
 Assessed breath sounds and respiratory rate, depth,
and rhythm and color changes of the patient.
 Assessed if occasional cough of patient is productive or
unproductive and assess its amount, color, odor, and
secretion viscosity.
 Chest tapping given after nebulization as prescribe by
physician
 Planned for periods of rest between activities.
 Monitored and recorded I&O, and oxygen saturation
with the use of pulse oximeter.
 Monitored chest x-ray and laboratory results of
patient.
 Monitored for any unusualities manifested by patient.
 Administered IV fluids and other medications as
ordered.
 NURSE’S NOTES
Name: Lu Fernandez Age/Sex: 25/F Rm No.: 301 Hospital No.: 100921
 Provided passive activities to patient such as listening
to music or reading a book.
 Positioned patient appropriately (moderate high back
rest) and comfortably.
 Maintained head of bed elevated.
 Administered medication as prescribed: Salbutamol
nebulizations; 1 neb q4
 Promoted adequate rest periods to patient.
 Health teachings given with emphasis of the following:
 Encourage client to use pursed-lip breathing for
exhalation.
 Encouraged patient to do deep breathing exercises and
coughing exercises.
After 8hrs of nursing intervention the patient was able to
demonstrate appropriate coping behaviours and maintain
effective respiratory pattern, as evidenced by relaxed
breathing, normal respiratory rate, and absence of dyspnea.
-Endorsed patient to the staff on duty with latest vital signs
as follow: T - 37.5°C; PR - 97bpm; RR - 20cpm; BP -
120/80mmHg; O2 -94%-------------------------K.Josol, FSUU/SN